Monthly Archives: October 2021

Thursday 5th August 2021

Hours: 5

Patient presentations:

1. Knee pain Post-Trauma
2. STM for non-specific LBP
3. Suspected AS

Reflection Focus

• Knee Pain Post-Trauma

Reflection Model

• Gibbs Reflective Cycle 1988

What Happened?

• Patient presented with knee pain after a traumatic ‘twisting’ episode. This was the patient’s 3^rd visit and I had taken over the case from a previous practitioner. The patient was pregnant and in her 2^nd trimester. The previous practitioner was treating the patient for a quadricep weakness, and I continued on the same treatment plan.

 What were you thinking and feeling? 

• I remember thinking that treating the patient for a quadricep weakness didn’t seem to fit the MOI. Traumatic knee twisting episodes are linked to injuries to the ACL and meniscus; however, after completing the objective assessment there was no further presentation which would strongly indicate trauma to the ACL or meniscus. Furthermore, the patient presented to clinic with a reduction in their pain so, even though I was initially unsure about the diagnosis, I felt it was best to follow the plan prescribed by the previous practitioner as the patient was improving.

What was good and bad about the experience?

• During the subjective assessment the patient had made a connection between moving less and a reduction in her pain. Furthermore, she had bought a brace to wear and had altered the way she walked up and downstairs due to her pain. Taking all these behaviours into consideration I was quite concerned that the patient was, or would soon be, beginning to avoid activity. Therefore, as the patient had seen a reduction in their pain, I spent time practicing some stair walking without her brace. The patient was pleasantly surprised that she could manage this pain free.

Analysis

• Women are advised to remain active throughout their pregnancy. (UK, Physical Activity Guidelines, 2019.) Inactivity, pregnant or not, can increase the chances of health conditions such as diabetes. (WHO, 2015.)
• I believe that by taking the time to address what the patient had been avoiding not only gave them a positive outlook on their current MSK pain; but, also reduced the likelihood of continuing with this behaviour which could be detrimental, particularly during pregnancy.

 Conclusion 

• Overall, I was happy with how I handled this appointment and that I identified yellow flags that were particularly important to address considering the patient was pregnant.

Revisiting Reflection

References

• UK Chief Medical Officers’ Phsyical Activity Guidelines. (2019.) Physical Activity for Pregnant Women.
• World Health Organisation (WHO.) (2015.) Physical Acitivity Strategy for the WHO European Region 2016-2025.

Monday 2^nd August 2021

Hours: 5

Patient presentations:

1. Suspected medial meniscus tear
2. Shoulder pain localised to superior angle of scapula
3. Knee and bilateral hip pain

Reflection Focus

• Knee and bilateral hip pain

Reflection Model

• Gibbs Reflective Cycle 1988

What Happened?

• Patient’s 3^rd appointment in clinic. The patient is an amateur runner reporting diffuse anterior knee pain and bilateral hip pain after road running. When completing her runs on a treadmill there is no px present in either the knee or the hips. At this stage of the rehabilitation process the pt reported that their hips were feeling much ‘stronger’ and they wanted to focus on their knee as it was causing them the most discomfort.

 What were you thinking and feeling? 

• This session was a positive experience. The pt. was happy with their progress, so I felt confident in the exercise prescription to date. I also feel more confident in treating knee pathologies as a lot of my academic writing pieces have revolved around lower limb anatomy, biomechanics and pathologies.

What was good and bad about the experience?

• It was beneficial to identify an opportunity where I could put theory into practice. I felt I led the assessment with confidence and authority which is an element of my practice I know I struggle with. However, the highlight of this experience was certainly the patient’s optimism towards her pain. She was happy with her progress to date and seemed confident that her pain would continue to diminish. Patients who experience any form of psychological distress are at risk of poorer health outcomes and MSK pain, acute or chronic, induces some form of stress. (Jones & Rivett, 2018.) In this instance, the patient wasn’t displaying any fear-avoidance behaviours, she was eager to progress with her rehabilitation and accepted that her pain, although bothersome to her, would reduce. Overall, I believed the patient did not present with any yellow flags and that her psychological resilience to her pain would ultimately aid in her recovery.

Analysis

• This experience has highlighted that there are still many aspects of my practice where I have some theoretical understanding but haven’t necessarily been able to experience a practical application.  As a result, I don’t feel as confident in these areas. This is likely due to lack of exposure and challenging situations. For example, I am yet to treat a wrist pathology. Naturally, as I don’t have any patients with a wrist injury I haven’t done much, if any, wider reading in this area. Whereas, knee, hip, back and ankle injuries are more prevalent in the current clinical setting so my wider reading has been around helping these individuals. Although I don’t feel like this is necessarily a bad thing it has helped identify that I should still be keeping up with my theoretical knowledge and expertise in other areas that I am weaker in. I believe that having some theoretical underpinnings helped me to feel confident and self-assured in myself as a student practitioner on this day. Therefore, maintaining self-directed reading and research will be key in me feeling like a well-rounded practitioner.

 Conclusion 

• I will aim to make a conscious effort, on the occasions where I don’t have a patient, to pair up with someone who has a patient with a pathology I haven’t yet been exposed to.

Revisiting Reflection

References

• Hammerich, A., Scherer, S., & Jones, A. (2018). Influence of Stress, Coping ad Social Factors on Pain and Disability in Musculoskeletal Practice, In Mark A Jones, & Darren Rivett (Eds.), Clinical Reasoning in Musculoskeletal Practice – E-Book. (2nd ed.) (pp.47-70) Elsevier.

Monday 26^th July 2021

Hours: 5

Patient presentations

1. Shoulder pain localised to superior angle of the scapula
2. Suspected medial meniscus tear
3. Knee and bilateral hip pain
4. STM request for non-specific LBP
5. Glute pain referring to knee and foot

Reflection Focus

• Shoulder pain localised to superior angle of the scapula

Reflection Model

• Gibbs Reflective Cycle 1988

What Happened?

• Patient’s previous notes indicated treatment for suspected Metatarsalgia 2/3rd MTP. I had prepared for this; however, on arrival the patient stated that their initial injury was much better and would rather have their shoulder examined.
• The patient presented with sub-acute L sided shoulder pain – 10-11 days – localised to the superior angle of the scapula. The objective assessment revealed some ROM restrictions in cx lateral flexion, shoulder ABD and IR. All these ROM’s were +ve Px and although shoulder ER was not limited it was +Px.
• My DDX was muscular tightness of levator scapulae and the upper fibres of trapezius. I treated with STM. TrP around the scapula and upper traps and STR – pin and stretch – of upper fibres of trapezius. MET – PIR – of the scalenes. All ROM’s improved after treatment and Px had reduced.

What were you thinking and feeling?

• I felt unprepared for this patient as I was expecting to follow up on the previous injury. I frequently have to revisit shoulder anatomy and injuries as it is an area I am not very strong in, so I remember feeling quite worried that I wouldn’t know enough to treat the patient with confidence. However, after the assessment, I felt confident in my DDX and treatment.

What was good and bad about the experience?

• The patient was happy with the treatment and acknowledged that the treatment had improved their symptoms.  This is an important consequence of the treatment because, ‘The psychology of the athlete is crucial in rehabilitation, as their emotions, beliefs and thoughts all affect how their body responds to injury.’ (Joyce & Lewindon, 2016). Negative thoughts, feelings, and emotions have been shown to release hormones that are not conducive to optimal healing. Therefore, it can only be beneficial that the patient felt happy with the treatment as leaving the clinic with a negative outlook could become a psychosocial barrier to successful rehabilitation.
• However, an area to improve on would be to note down the patient’s pain using a numerical rating scale (NRS.) Although I had used ROM as an objective marker I didn’t utilise NRS which would have been useful in ascertaining if my treatment made a difference to their pain, which was their main complaint. Measuring pain according to an 11-point NRS is popular across a variety of pathologies and a 2-point reduction is considered the Minimal Clinically Important Difference (MCID.) (Michener et al., 2011; Farrar et al., 2001)

Analysis

• I believe a combination of factors led to a narrow-minded approach to my DDX and Rx in this case. I had previously completed an observational placement with a physiotherapy team where a number of patients had come in with an array of shoulder problems, e.g. post-operative subacromial decompression, frozen shoulder, and calcific tendonitis. These patients all received a form of STM, normally TrP, that was targeted towards levator scapulae, upper fibres of traps and the rotator cuff muscle group. As my patient presented with similar symptoms as these individuals, I believed that it was best to follow a similar course of action.
• However, due to this ‘tunnel vision,’ I notice that I have overlooked the patient’s +ve px on ER of the shoulder. This could indicate, in conjunction with the other px presentations, a rotator cuff pathology. Although the pt. may benefit from STM this should not be, like most other pathologies, the only course of treatment. As the pt. had functional ROM utilising a rehabilitation protocol such as the Torbay Cuff Programme may be beneficial; however, I will need to revisit rotator cuff pathology presentations before re-assessing and possibly changing the DDX.

Conclusion

• Despite there being merit to treating the symptoms the patient presented with, I don’t believe it was done under sound and valid clinical reasoning. On reflection, I believe it was the combination of a lack of confidence and a last-minute change in what I was expecting to treat that resulted in a sense of panic. As a result, I leaned on a previous experience too heavily to guide my clinical reasoning.
• This experience has highlighted that I need to find effective revision strategies for shoulder anatomy and injuries as my current strategies haven’t yet resulted in concrete knowledge. I have a lot of written notes but I will start to utilise diagrams and/or videos as a media-based approach to learning.  Furthermore, I will also look to pair up with colleagues in the clinic who have patients with shoulder pathologies to benefit from peer learning.

Revisiting Reflection

References

• Calvert T. (2016). Psychology in injury prevention and rehabilitation. In D, Joyce., & D, Lewindon (Eds.), Sports injury prevention and rehabilitation: Integrating medicine and science for performance Solutions. (pp.22-30). Routledge.
• Farrar JT., Young JP Jr., LaMoreaux L., Werth JL., & Poole RM. (2001). Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain, 94 (2), 149–158.
• Michener LA., Snyder AR., & Leggin BG. (2011). Responsiveness of the numeric pain rating scale in patients with shoulder pain and the effect of surgical status. Journal of sport rehabilitation, 20 (1), 115-128.