Day 23 – Sports Therapy and Rehabilitation Clinic
Duration: 5 hours Cumulative hours: 183.45
Preparation before clinic
Patient 1
My first patient was scheduled for a triage appointment via telephone. She contacted the clinic because she has been experiencing pain and inflammation in and around her knee. She had total knee replacement (TKR) surgery approximately 7 months ago, however she was not happy that she was continuing to experience pain and inflammation so long after her operation.
I did a little bit of research regarding TKR surgery (“Total Knee Replacement Surgery, Full Knee Operation, Repair,” 2021). As with all types of surgery, the length of recovery depends upon the individual. Most quote recovery times are average and not specific. I also read that it is not unusual for patients to have swelling 7 months after surgery and in some cases 1-2 years after a TKR.
Patient 2
My second patient has been coming to the clinic on a weekly basis for cervical mechanical traction treatment. I re-read her clinic notes and history to ensure that I was clear in my mind regarding the settings for the patient’s cervical mechanical traction treatment.
Patient 3
I last saw my third patient before Easter, where I treated her for LBP. She had been recovering well from the LBP which was thought to be caused by a lumbar discogenic bulge at L4/L5 of the lumbar spine. At that time was had treated her with repeated movements in prone lumbar extension with a hip shift first to the right and then to the left to establish which was more comfortable. The patient reported the repeated lumbar extensions were less painful on the right side of the lower back. There was also an improvement in the PSLR after the treatment because patient was able to raise the left leg a further 10 degrees before experiencing symptom. Unfortunately however, the patient was experiencing LBP again due to prolonged sitting in flexion whilst study for her exams and completing her assignments.
In preparation for her appointment I reviewed her notes to familiarise myself with her case.
Friday clinic 21.05.21
Patient 1
The patient provided a brief history concerning her TKR surgery. The patient had TKR seven months ago on her left knee. This is the second time that she had had TKR surgery on her left knee. The first surgery was approximately 5 years ago, however she was in excruciating pain for 5 years and the surgery was repeated. The patient did not experience the same level of pain after the second surgery. When she is having a bad day the patient describes her pain as low-level despite reporting it as 5-6/10 NPRS and is unable to do activity. She elevates the leg and ices it for 30 minutes! This usually happens if she does too much activity.
The patient does rehabilitation exercises most days. Rehab includes ROM for flexibility of the knee – can extend the knee but does not achieve full knee extension. The patient also reported that she was able to perform a prone hamstring curl on the bed but does not achieve full EOR. She does full squats with pulses but this appears to aggravate the knee. The knee hurts and the following day and the patient is unable to perform them daily. In her own words the patient confirmed I probably do too much’. She also described the thigh muscles as being really tight and painful and asked whether it would be possible to have soft tissue massage (STM). Sometimes the patient also experiences pain in the back of the knee when she rolls over in bed. The patient has also had a TKR in the right knee and rehabilitation and recovery was successful. The patient was quite active participating in online Pilates classes three day per week and she walks, on average, 10,000 steps each day.
I felt that it was important to see the patient in clinic to see the level of inflammation around the knee and range of movement. The plan for the next appointment was to: conduct a thorough subjective and objective Ax observing the patient’s knee ROM, functional movement and level of inflammation; perform STM on quadriceps; prepare a rehabilitation programme and offer advice on exercise load.
Patient 2
The patient said that she felt a little stiff and achy in her glutes after her previous cervical traction treatment for a couple of days but after taking paracetamol the aches disappeared. The patient was very positive and said that she believes that the treatment is working because she has been sleeping much better. She is now sleeping 6-7 hours per night rather than 3-4 hours and feels much better. The patient also reported experiencing less pain in her hands. Her activity levels have improved from 2-3000 steps per day to 4-5000 steps per day.
The patient reported that she was following the exercises in the rehabilitation programme that I had designed for her.
The settings for the patient’s mechanical traction was 5 minutes progression, 20 minutes at 7Kg and 5 minutes regression on static traction. After the treatment the patient did some gentle mobilisations (cervical flexion and rotation) before getting up from the treatment table. It always takes a little time for her to recover, but that has been a good thing because it has enabled me to develop a good rapport with her and gain her trust. I love her attitude. She is so positive and is willing to try anything that will help to improve her symptoms and her mobility.
Patient 3
I carried out a full subjective and objective assessment of the patient and arrived at the same clinical impression of the patient’s condition, which was causing her pain. The patient was experiencing LBP due to a lumbar intervertabral disc bulge impinging upon the sciatic nerve within the region of L4/L5. The pain was centralised and not radiating down the legs. During the objective assessment I carried out a passive straight leg raise (PSLR) and a slump test as objective measures. The PSLR and slump tests were both positive on the left side.
I treated the patient with STM of the quadratus Lumborum and erector spinae working out trigger points on both the right and left side of the lower back. I added two additional exercises to the patient’s rehab programme which was prescribed during the previous appointment as follows:
- Pelvic tits – 2 sets of 5 reps
- Knee hugs with rotations – 2 sets of 5 repetitions
- Single knee hug – with opposite leg straight or bent – hold for 30 seconds. Repeat on opposite side. 3 sets.
- Camel Stretch – 10 repetitions
- Lateral hip rotations – 3 x 20-30 second holds at EoR
- 10 x repeated banana lumbar extensions with 10 seconds rest
- Low bridge with towel under hips – Patient to lift into low bridge – hold for 3-4 seconds and lower hips so just hovering over towel before repeating exercise
- 2 x 5 repetitions with 1 minute rest in between sets.
- Book under the bum exercise to be held as long as patient feels comfortable.
The patient also completed an Oswestry Low Back Disability questionnaire which is a patient reported outcome measure that enables us to establish if there is an improvement in the patient’s LBP in that it is not affecting her ability to carry out normal activities of daily living. The patient’s score on this occasion was 11.1% which demonstrated that her current LBP was causing minimal disruption to the patient’s activities of daily living and quality of life.
Objective measures is the one thing that my clinical supervisors have encouraged me to consider with every injury that I treat. It is important to record all findings and measurements because without them you will not be able to demonstrate if there is an improvement in the patient’s injury.
References
Total Knee Replacement Surgery, Full Knee Operation, Repair. (2021). Retrieved May 31, 2021, from https://bonesmart.org/knee/total-knee-replacement-surgery/
Areas for further improvement plus action plan
Returning to reflection at a later date