Date: 08.01.2020

Duration: 1300-1600

Individual with whom I worked with: Mick Smirthwaite

Before my placement:

Aims from today’s placement:

It is a new year and I was feeling very positive.  I was also looking forward to gaining experience of different sports injuries from those that I have had the opportunity to witness during that past couple of months.

During my placement:

I was looking forward to resuming my placement and updating my current experience.  It felt good to be back in Mick’s clinic.  We had a quick update regarding the client’s that have appointments scheduled this afternoon.  Mick had a new client visiting the clinic at 2 p.m. with back pain.  I was looking forward to observe Mick assess the client’s condition and apply the appropriate treatment.

After my placement:

Client 1 – has been a client of Mick’s for approximately 15 years after sustaining a Whiplash injury after sneezing.  During the SA She revealed that since the injury she had received acupuncture but she still has problems which have now travelled into the shoulder with occasional nerve impingement.  She also visits an Osteopath regularly and had an appointment with him yesterday.  He gave her a set of exercises to perform with the aim of strengthening the upper fibres of the Trapezius and Rhomboids.  The exercises were shoulder shrugs with dumbells, pushups performed with the shoulders retracted and straight arm rows with a theraband.  She has to visit the Osteopath next week to feedback on her progress.

When the condition is painful it does affect her sleep when she moves during the night.  At present the pain is moderate.  The common trigger appears to be stress.  The run up to the Christmas holiday was stressful and she believes that stress aggravates the condition.

With the client in prone position it was easy to see that the right shoulder and upper back appeared more raised than the left shoulder.  Upon palpation there was tension in the upper fibres of the Trapezius, Rhomboids, Supraspinatus and Levator Scapulae on the right side.  The client always has issues on the left side.  The tension in the muscles on the right side is probably as a result of compensatory movement because of the reduced ROM on the left side of the upper body.

I observed Mick perform STM of the Erector Spinae, Trapezius, Rhomboids, Supraspinatus and Levator Scapulae on the left side of the upper body.  Mick also mobilised the GHJ and stretched the supraspinatus and Levator Scapulae simultaneously during the mobilisation of the shoulder joint. He also massaged the scalenes in the neck.

Mick invited me to apply STM to the right upper back and shoulder.  I massaged the Rhomboids, upper fibres of the Trapezius and the Suprasinatus and Levator Scapulae.  I detected a trigger point in the upper fibres of the Trapezius and applied NMT to work it out.  I asked Mick for advice on variations of STM in that region of the shoulder.  He demonstrated a variation and encouraged me to repeat.  He also showed me how to mobilise the GHJ whilst simultaneously stretching the Levator Scapulae, Supraspinatus, upper fibres of the Trapezius into the upper fibres of the Deltoid.  He showed me how to perform the technique using the whole of my upper body to take the strain away from my arms and hands, adopting a comfortable seated position on the couch next to the client, with their arm internally rotated resting on my upper thigh. He also encouraged me to relax whilst performing the technique.  It was very helpful and something that I will need to practise to improve confidence as it doesn’t feel natural to me at the moment.

Client 2 – Is a cardiologist. We observed the client as he walked into the treatment room.  He was walking very slowly with a crutch.  His body was leaning more to the right side.  It was obvious from his movements that he was guarding the left side because of pain in his middle-lower back on the left side.  He had difficulty removing his jacket and shirt.  He couldn’t sit on the edge of the couch or on a chair during the SA.  He said that the onset of injury was after a 4-5 hour drive to London at New Year (approximately a week ago) and the mechanism was sitting a car for a long period of time.  He returned to work and he has to wear heavy lead tunics and skirts during work which puts extra pressure on his back.

Mick lowered the couch and the client slowly adopted the prone position.  Even before palpation it was obvious that the muscles in the lower back (Quadratus Lumborum, Gluteus Medius, Gluteus Minimus, Gluteus Maximus) were tense and in protective spasm to protect the spine. The client pointed to pain in the L4, L3, L2 and Sacroilliac Spine region.  Mick carried out mobilisation of the hip on both sides of the spine.  When initially mobilising the left hip there was very little movement due to the muscle tension.  He also applied STR with the hip in internal and external rotation.  Traction was applied to the left leg to loosen tension in the hip. He applied trigger point acupuncture to the left Gluteus Medius to relax the muscles.  After the STM, STR, mobilisations and NMT the ROM had improved and the muscles were more relaxed.  The client was still complaining of pain in the lumbar region so Mick decided to apply Electro-acupuncture to induce pain relief in much the same way that Conventional TENS would do.  Low-frequency electro-acupuncture encourages pain reduction by stimulating the release of the body’s natural analgesic chemicals such as endorphins and aids relaxation of the muscles in spasm.  The treatment lasted for approximately 20 minutes and there was a noticeable improvement in the client’s willingness to move and ROM.  The whole treatment was very interesting to observe.  A follow-up appointment for treatment was made for the next day.

How I felt through-out my placement today:

I felt good during the placement and did not feel anxious at all.  I was a little apprehensive when applying the mobilisation to the GHJ for the first client but felt more relaxed after Mick showed me the correct posture to apply the technique.  I enjoyed observing and having the opportunity to palpate and apply STM techniques for two very different cases.

Evaluate today’s placement activity:

I felt that palpating the soft tissue and applying STM techniques to client’s right shoulder went well and I feel more confident now.  I asked for advice on how to apply NMT in the upper shoulder a different way, with the correct posture in order to protect my back.  I found the advice and demonstration by Mick very helpful. During the first few weeks of my placement, I wouldn’t have had the confidence to admit that I wasn’t sure about what I was doing, but I respect Mick’s expertise and knowledge and know that I can and have learned a lot from him.

A deeper, analytical and critical approach to today’s experiences:

I have made a connection between the use of TENS and Electrotherapy with the application of acupuncture for pain relief and muscle relaxation.  The principles are very similar and the results are very similar.

Draw conclusions – what have I learned from today’s activities and my reflections:

I have been reading more about TENS lately and I made the connection regarding the use of both TENS and acupuncture for reducing pain.  The physical results are amazing.

Action plan – how will I apply what I have learned from today’s activities & my future professional and personal development:

I will read the research regarding the effectiveness of acupuncture in reducing pain.  I would consider undertaking study in the use of acupuncture after I graduate, however it is a 3-year course of study.  Reading the research will help to give me a greater understanding of this modality.

Have any questions arisen from today’s placement that I need to discuss with my Placement Tutor or University Placement Tutor:

At the end of the placement we went through both cases and discussed the treatments applied and the reasons why they were applied to consolidate my understanding.

Returning to my reflections:

During the treatment of Client 2’s lower back pain, my initial thoughts were that it was possibly a disc herniation because of the prolonged period in flexion whilst driving up to London (Adams, 2004).  I also believed at the time that there has a gradual degeneration of the disc due to the load placed on the lumbar spine from wearing protective leaded garments at work (Goldstein, Balter, Cowley, Hodgson, & Klein, 2004; Ross, Segal, Borenstein, Jenkins, & Cho, 1997).

The client was in so much discomfort and pain that it would have been to uncomfortable to go through an objective assessment, however on reflection I now wonder whether the issue was actually facet joint dysfunction.  Long periods sat in lumbar flexion can also cause facet joint dysfunction. The pain in the client’s lower back also appeared to be lateral to the spine and not originating centrally.

References:

Adams, M. A. (2004). Biomechanics of back pain. Acupuncture in Medicine, 22(4), 178–188

Goldstein, J. A., Balter, S., Cowley, M., Hodgson, J., & Klein, L. W. (2004). Occupational hazards of interventional cardiologists: Prevalence of orthopedic health problems in contemporary practice. Catheterization and Cardiovascular Interventions, 63(4), 407–411.

Ross, A. M., Segal, J., Borenstein, D., Jenkins, E., & Cho, S. (1997). Prevalence of spinal disc disease among interventional cardiologists. American Journal of Cardiology, 79(1), 68–70.