Day 17 – Sports Therapy and Rehabilitation Clinic
Duration: 5 hours Cumulative hours: 158.15
I had two patients scheduled for appointments for my regular Friday clinic. My first patient was scheduled for a follow-up mechanical traction. I re-read her notes from the previous week and familiarised myself with the process of setting up the mechanical traction bed and the treatment settings required. This week her treatment settings would be mechanical traction at 35%. To establish the weight on the machine, I have to multiply her weight, which is 65Kg by 35%. The result was 22.5 Kg. We round down because it is always better to be a bit more conservative. So the machine would be set at 22Kg and the other settings would be static.
I did some preparatory reading of my 2nd patient’s clinical notes. I also did some reading regarding polio and how it affects individuals who had it as a child and the long-term effects after they have recovered from the virus. I found it very interesting to gain an understanding of the virus and how it impacts individuals who have had it.
Patient 1
I had a discussion with the patient to establish if there has been an improvement in her symptoms, which is numbness in the posterior right leg. She reported that there had been no change in her symptoms since her first traction treatment last week. She is continuing to keep up her physical activity because her symptoms don’t affect her ability to do exercise, despite being uncomfortable afterwards. She is currently doing resistance band exercises, static weight exercise, cardio and netball 5/7.
Her mechanical traction treatment today was 35% = 22kg in which traction with a 5-minute progression, 30 minutes of traction at a weight of 22Kg and 5 minute-regression. I now feel confident enough to set up the traction machine for another patient without the help of a supervisor.
Patient 2
My second patient seen one of my clinical supervisors earlier in the week and they had scheduled a cervical traction treatment. The patient had been experiencing aches in her wrist and numbness in her thumbs. She also experiences a dull ache in her hip, and aches and pins and needles in her calf which occurs 2-3 times per day. There is no pattern in behaviour of her pain. She is unsure what triggers it, but it can start when she is reaching for a glass, or bending over to pick something up and the pain will start. She has had to cope with the after effects of contracting polio as a child, for most of her life and is prone to falling over. She is unsure of the onset of her pain but believes it started after a fall. The pain in her wrists was describes as very achy, with numbness in her whole numb up into her wrist. The pain in her hip is described as a dull ache, and her pain in her calf is also described to be achy as well as giving her pins and needles. The patient reported that the pain in her hip was improving, however the pain in her hips weren’t.
The patient had her first cervical traction treatment 10 days ago and reported that she had no pain immediately after her treatment and could get out of a chair without wincing. The following two days she experience aches similar to those that you would feel after exercise.
My clinical supervisor helped me to set up the traction machine for cervical traction. The treatment settings are very different from lumbar treatment. The maximum amount of weight is 12.5Kg. The patient’s mechanical treatment settings for today were intermittent with 7 minutes progression, 20 minutes treatment at 7Kg and 7 minutes regression. I regularly checked on the patient throughout the treatment to ensure that she was okay.
At the end of the treatment the patient felt a little ‘whoosey’. I helped up get up from the lying position on the bed, after releasing the rope and removing the felt chin brace and bar from the patient’s chin. I encouraged her to sit on the edge of the bed for a while and then placed a chair by the side of the bed for her to sit in when she was ready to move. I also encouraged her to drink water and we chatted with her until she felt recovered and able to walk to her car. The plan for the patient’s next visit is to talk to her osteopath regarding the exercise programme that the patient is currently following and to check whether it would be advisable to add some exercises using the free weights and weight machines. The objective would be to improve the patient’s strength in her hip, upper and lower limb and to improve her endurance so that she will be able to walk more than a mile without pain or fatigue.
Patient 3
My third patient’s appointment was scheduled with one of my peers who sent home after feeling unwell, so this patient was transferred to me. It was quite an interesting case. I haven’t treated a patient with chronic LBP before but remembered from my module concerning ‘manual therapy of spine’ last year, that it is unusual for a person to have musculotendinous injury in the lumbar for longer than three months. Usually 90% of LBP cases are resolved within three months (O’Sullivan, 2015). If you have a patient who has experienced LBP for longer than three months it is important to investigate if there is a psycho-social reason for their pain that has contributed to their fear of movement. The objective of my examination of the patient was to perform specific tests to rule out discogenic, facet joint and neurological issues.
I observed the patient when she entered the cubicle and noted that she did not walk with an upright posture. My impression of her was that she was not a confident person. I went through a thorough subjective assessment with the patient. At first she seemed a bit unhappy about answering questions that she had been asked previously. I explained that it was important for me to ask the questions so that I can gain a clear understanding of her LBP. There were no red flag conditions or contraindications to treatment. She said that she had had back pain on and off for 30 years. I asked her when the current bout of LBP started and could she remember what triggered it. The patient reported that this current episode of LBP started approximately 3 months ago and the onset was gradual. The pain is not radiating and feels more like a dull ache on a level of 6-7/10 NPRS. She has to do a mobility exercise in the morning to release early morning stiffness and her ROM improves after she has been moving around a while and had a shower. Her symptoms are aggravated by standing or sitting for long periods, doing housework, walking up and downstairs, walking up hills and bending forwards. The use of heat pads help to ease symptoms as well as sitting down after standing for a long period of time.
I discussed the patient’s social and family history which was quite revealing. The patient was retired and had quite a few hobbies and interests that she enjoyed such as watercolour painting, reading, walking and swimming. She walks 2-3 times per week for approximately 40-45 minutes. Before the third UK lockdown she was swimming once a week and said that it helped to improve her range of movement and ease her symptoms. She doesn’t smoke and drinks lager very occasionally. The last time she had a drink was at Christmas 2020. When I asked her whether she had children, she said that she had one adult daughter and started to become choked up. Initially she found it difficult to talk and was very emotional. I gave her time to speak and didn’t rush her or bombard her with further questions. Eventually after composing herself she said that her daughter lived a long way away, in Essex and that she was bipolar. Her daughter had to take a lot of medication to manage her condition. The patient missed not being able to travel to see her and hasn’t seen her for 18 months because of the lockdown restrictions. She was clearly worried about her daughter. She did say that her daughter did have a partner that supported her. The patient said that I had touched on a ‘soft spot’.
During the objective assessment I went through AROM to try and reproduce the patient’s pain. None of the movements provoked pain. Initially the patient was scared to relax and move her body freely. I gave her a lot of positive feedback and encouragement. I believe that she was truly surprised that she had no pain during the whole of the objective assessment. What came to light was restricted ROM in the SLR in the hamstrings. Initially there was resistance from the patient but she relaxed when she realised that the movement did not provoke pain. The SLR was also negative for neurological symptoms.
I explained the reason why I was asking the patient to perform certain movements. I wanted to exclude discogenic and facet joint pain. When I told the patient there she did not have any injury to her lumbar spine, was truly surprised and the realisation that she could move without pain was clear to detect.
I explained that we would put together an exercise programme that would include exercises to mobilise her lower back, improve the strength in her hips and upper limbs and a stretch to improve flexibility in the hamstrings. We went through three exercises to mobilise the lumbar spine, prone knee flexion with a resistance band, seated knee extension with a resistance band and a supine hamstring stretch. I demonstrated the exercises and encouraged the patient to practise each exercise. She was able to perform each exercise. She completely surprised me by demonstrating a prone back extension exercise where she lifts her upper body and legs off of the ground at the same time. She does this exercise at home. She would not be able to perform this exercise as well as she did with back pain. I gave the patient a lot of positive encouragement and feedback. The exercises were to be completed once every day.
Patient 3 rehab exercise programme
The patient left the clinic in a more positive frame of mind than she did when she arrived. She was smiling. I felt very happy with the assessment and my clinical impression of the patient’s condition. I was so happy with the outcome. The patient was scheduled for an appointment for the following week where I will review her progress and add progressions for the exercises. I also encouraged the patient to start swimming again because the swimming pools are now open.
References
O’Sullivan, P. (2015). Back pain -separating fact from fiction. YouTube. Retrieved from https://www.youtube.com/watch?v=dlSQLUE4brQ