Monthly Archives: January 2022

Joint Pain Programme Training

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Monday 6th September 2021 – Monday 8th November

Hours: 6 (2 e-learns, 1 x webinar 2 x virtual classrooms)

Reflection Model

  • Gibbs Reflective Cycle 1988

What Happened?

  • Programme structure explained:
    • 2 x 1 hour supervised weekly sessions. 30. mins education followed by 30 minutes of exercise
    • Programme is for any kind of joint pain e.g. autoimmune, degenerative, fibromyalgia, gout, etc.
  • Data collection and system training
    • Outcome measures = Height, weight, BMI, Waist Hip Ratio, Blood Pressure, EQ5D and, if applicable HOOS and/or KOOS.
  • Conversation Facilitation Training and Exercise Selection
    • Developing skills on how to facilitate a group conversation
    • Exercise progressions and regressions

 

 What were you thinking and feeling? 

  • During the training process there was only 1 synchronous training session which was the conversation facilitation training and exercise selection. Other training was asynchronous but needed to be completed before hand. I found it a bit strange that we didn’t really spend much time 0n the synchronous sessions understanding joint pain; however, on reflection the asynchronous sessions were comprehensive and the expectation is if you are electing to work on the programme you will complete the pre-requisites.
  • The conversation facilitation training was interesting as we had to engage in a conversation, guided by a facilitator, and make note of what tactics they were employing. After a couple of these conversations we were then paired up and facilitated a conversation ourselves. I was fairly nervous for this; however, the session was about building up your skills so all criticism, if any, was constructive.
  • The exercise selection was quite an easy component of the programme. For example, we were asked how we may progress and regress a sit to stand.
    • Leg Extension – Regression
    • Sit to Stand – Exercise
    • Squat (Supported or Unsupported) – Progression
    • Lunge – Progression

 

What was good and bad about the experience?

  • I think the conversation facilitation training was really beneficial for my practice as even though I have experience of delivering group rehab, this programme requires an educational component in a group setting. Normally, I would be coaching a group rehab class and then spend time with patients of a 1-1 basis for the educational components of the programme. Therefore, it was important to have the skills to guide the conversation and help individuals within the group feel comfortable in contributing to the discussions.
  • There wasn’t anything particularly bad about the experience. I would have preferred more synchronous sessions as I find bouncing ideas off colleagues around me really valuable for my practice. However, with the current climate, working from home is advisable and in terms of the programme resources should be focused on the ‘pinch points.’ In other words, we could have spent hours talking about joint pain, how to manage it, how it impacts people, etc. However, if we are unable to effectively guide and facilitate a discussion then the conversations may veer off track, people may become disengaged and the atmosphere may not become conducive to a safe learning and exercise environment. Therefore, it wouldn’t matter how much ‘expertise’ we had on the topic of joint pain as those looking to benefit from that expertise may not be able to due to a facilitators lack of skill.

Analysis

  • Although comfortable with exercise selection, it was beneficial to have a discussion around this – specifically concerning joint pain. For example, in one group you may have someone waiting for a hip replacement, another with widespread pain and another with chronic lower back pain (CLBP). Therefore, it was beneficial to cement the idea that the progressions and regressions aren’t just for monitor patient progress but also for an effective and all-inclusive exercise class.
  • The table below was taken from a paper by Sullivan, et al. (2012) and highlights some of the ways exercise can be a useful tool in the rehabilitation of patients with chronic pain. For example, exercise can release endorphins and assist in weight loss, both of which have been associated with a reduction in joint pain.  Therefore, being able to adapt exercises for individuals within a group is key for them adhering to this programme and hopefully benefiting from the exercise. For example, if exercises were not regressed appropriately some may find the challenge too great or painful which may result in demotivation of consolidation on the belief that movement or exercise makes their joint pain work.

 Conclusion 

  • I start delivering on the joint pain programme 24th January 2022. Therefore, I will spend time working on facilitation skills that we have been taught but also building a 12-week programme with suitable progressions and regressions as these two factors are fundamental to the success of the programme.

Revisiting Reflection

 

 

References

  • Sullivan, A. B., Scheman, J., Venesy, D., & Davin, S. (2012). The role of exercise and types of exercise in the rehabilitation of chronic pain: specific or nonspecific benefits. Current pain and headache reports, 16(2), 153–161. https://doi.org/10.1007/s11916-012-0245-3

Hemiplegia

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Monday 11th October 2021 – Monday 13th November

Hours: 5 (10 x 30 minute sessions over 10 weeks)

Updated Hours: 15

Patient decided to continue with rehabilitation and completed a further 10 hours at 2 x 45 minutes session per week.

Patient presentation:

  • 10 year old girl with right hemiplegia
  • She has a leg length discrepancy due to excessive tone in her calves which causes tip-toe walking.
  • Parents want to focus on stretching the calf complex, strengthening the right lower limb and increasing adherence to exercises.
  • The patient wants to improve core and upper limb strength.
  • Her right upper limb is weak – she has poor grip strength and inhibited motor skills
  • The upper limb in currently not a focus at the patient has had botox and all stakeholders want to capitalise on its effects.

Reflection Model

  • Gibbs Reflective Cycle 1988

Exercise Prescription

What Happened?

  • Lots of single leg work was included in the sessions and led by the affected limb, i.e. right leg working weight was established and this was also used for the left. The aim of these exercises were to improve strength of the right hand side and improve balance and stability. Although balance and stability was not specifically mentioned by either parent or child her abnormal gait puts her at risk of falls. Backwards walking has been shown to improve balance and mobility is children with CP (Choi, et al., 2021); however, as the participant was unfamiliar we started with forwards walking, which is still beneficial for balance and mobility.
  • The patients right foot was difficult to position for certain exercises such as stretching. She has an inability to dorsiflex the foot and the ankle also falls into excessive pronation. Conservative management for treating these foot problems is stretching of the calf complex (Sees and Miller., 2013). However, interventions such as botox and splinting are required for significant changes, which the patient is due to have at Christmas time.

 What were you thinking and feeling? 

  • I felt really supported by the parents in designing a programme for this patient. After every physio appointment they would send details across of recommended exercises that we could incorporate into sessions.
  • I was quite concerned about how to make the sessions fun as the patient is very young and a commercial gym setting isn’t necessarily designed for children. However, I benefited from the novelty of her never having used a gym before. So, we would always spend time during a session doing an exercise she really enjoyed or wanted to try – even if it didn’t relate to her rehab. This may not last long and as this is going to be a long standing client, I will need to ensure I find fun and engaging tasks that still address the primary rehabilitation goals.

What was good and bad about the experience?

  • Sessions are only 30 minutes and 1 session a week – this time constraint does mean that there is less opportunity for repetition learning which helps to improve neuroplasticity.
  • The novelty of the gym can prove as a distraction at times and at 10 years old sometimes the patient is more interested in watching what is going on around her than the exercise she is currently trying to perfect.
  • The patient really enjoys the sessions and the parents are happy that she is performing some rehab exercises that she is reluctant to do for them.

Analysis

  • Repetition learning is key for helping to ‘rewire the brain’ and potentially improve function of the lower limb. However, tasks need to be repeated frequently so I need to establish a way to encourage the patient to do some exercises at home.
  • Backwards walking needs to be incorporated into the programme soon to aim for improved benefits in balance and stability. However, the patient doesn’t like to feel different and walking backwards in a gym is certainly not a normal thing to see. If she becomes uncomfortable we may need to use a different setting such as a quiet corridor or sports hall. Furthermore, going backwards on the cross trainer may have similar effects or at the very least target the quadricep of the right leg that have suffered atrophy due to her abnormal gait.

 Conclusion 

  • The patient is receiving botox over Christmas followed by 6 weeks in a splint to help address the excessive tone is her calf. Whilst the patient is not attending sessions I will focus on exploring more literature of physical therapy for children with hemiplegia. I will also work on creating an adherence diary for the patient to see if this could increase her exercise uptake.

Revisiting Reflection

 

 

References

  • Choi, J.-Y., Son, S.-M., & Park, S.-H. (2021). A Backward Walking Training Program to Improve Balance and Mobility in Children with Cerebral Palsy. Healthcare, 9(9), 1191. MDPI AG. Retrieved from http://dx.doi.org/10.3390/healthcare9091191

Morel-Lavallée Lesion

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Monday 30th August 2021 – Friday 24th August 2021

Hours: 3 (4 x 45 minute sessions over 4 weeks)

Patient presentations:

  • Large mass/swelling over the greater trochanter

  • Morel-Lavallée Lesion diagnosed in August after falling from a horse onto a brick wall.

  • The patient was struggling with pain over the greater trochanter and abnormal sensations in the area. The patient also has a painful shoulder just beyond 90 degrees of ABD, limited and painful IR (hand just able to reach illiac crest), painful flexion at EOR and painful ER. She was treated for whiplash by the NHS which has resolved but she suspects damage to her rotator cuff.
  • Previous aspiration attempt on lesion didn’t yield much fluid and the patient is now waiting for a referral to cosmetic surgery. The area has been infected twice since the injury but currently the patient is well.
  • Patient is becoming increasingly frustrated at not exercises and wants a training programme that will help with her shoulder pain and potentially her lesion. She is aware that her lesion requires surgery but doesn’t want to be sedentary in the lead up to this event

Reflection Model

  • Gibbs Reflective Cycle 1988

Exercise Prescription

2 unsupervised sessions per week, 1 supervised session.

What Happened?

  • When the patient first saw me she had to explain the details of her diagnosis as I had never heard of it before. I asked physio’s and university tutors if they had come across this pathology before but nobody knew what it was.

  • I spent a lot of time after our initial meeting, researching Morel-Lavallée Lesion. However, the literature was sparse. These lesions are common across the greater trochanter area (Miller, et al, 2014) but they can appear anywhere on the body; therefore, conservative management strategies vary. Furthermore, conservative management success depends on the severity of the injury, quick and accurate diagnosis, and if necessary aspiration (Mutuoglu, et al., 2021). There have been successful cases of conservative manage of this pathology at the knee (Doelen and Manis, 2019) and gluteal region (Harma, et al., 2004); however, the lack of an early diagnosis, excessive fluid accumulation, and lack of successful aspiration in this case indicates that surgical intervention may be the most likely resolution. Lastly, conservative management strategies appear to consist of relative rest and icing protocols rather than exercise based.

 What were you thinking and feeling? 

  • Initally, I felt as though I should turn the patient away as there was nothing I could do for her lesion. However, she expressed that she was frustrated at being sedentary and wanted to do a little bit of exercise to keep healthy. She also wanted her shoulder pain addressed and so this was what we focused on – improving pain in shoulder and shoulder ROM.
  • Light lower limb exercises were included; however, the patient knew to cease exercise if it ever resulted in a greater swelling afterwards.

What was good and bad about the experience?

  • The patient had realistic expectations about her pathology and was much more interested in improving her shoulder and also psychological wellbeing.
  • The patient was really good at communicating with me and she would message the next day and the day after a session to report her symptoms – even if there wasn’t anything new.
  • There was a slight increase in shoulder pain during week 3 because she slept with her arm above her head. She explained that her shoulder was much better but because of this her body went back into her comfortable sleeping position. As a result, her arm was held in a position it hadn’t been in for quite some time overnight and resulted in some pain and stiffness. Myself nor the patient were concerned with this and just worked within her pain tolerance on the day she came into train.
  • By the end of week 4 there was a visible reduction in her swelling; however, we never obtained an objective measure as this wasn’t something we were really focusing on. In hindsight, I should have taken a measurement to have a comparison and equally as something to monitor throughout sessions.

 

Analysis

  • The sessions really focused on what she could do as one of the main goals was just to get her moving again despite her injuries. After looking at the Torbay Shoulder Programme we assessed ROM and pain during some of the exercises described and then adapted them to make use of the gym equipment available to us. For example, Stage 3 flexion made use of the lat pulldown, where we attached a neutral grip to perform concentric and eccentric flexion. By week 3 of the programme the client was really pleased because she was able to ‘fasten her bra and tie her hair up like a normal person.’ To me this indicated that all ROM and pain had improved to a degree that the injuries were no longer disrupting her ADL’s.

 Conclusion 

  • Overall, the programme achieved its purpose. We didn’t aggravate the lesion and we improved shoulder function by reducing pain and improving ROM. I didn’t follow a specific protocol but my exercise selection was informed by the Torbay Shoulder Porgramme and how the patient was presenting. The patient intends to resume sessions post-surgery and maintain current exercise prescription until she is admitted for surgery.

Revisiting Reflection

 

 

References

  • Miller, J., Daggett, J., Ambay, R., & Payne, W. G. (2014). Morel-lavallée lesion. Eplasty, 14, ic12.
  • Mutluoglu M, De Melio J, Debrouwere T, et al
    Uncommon type of wound: Morel-Lavallée lesion
    BMJ Case Reports CP 2021;14:e243082.
  • Harma, A., Inan, M., & Ertem, K. (2004). Morel-Lavallée lezyonu: Kapali soyulma yaralanmalarinda konservatif yaklaşim [The Morel-Lavallée lesion: a conservative approach to closed degloving injuries]. Acta orthopaedica et traumatologica turcica, 38(4), 270–273.
  • Doelen, T. V., & Manis, A. (2019). Conservative management of Morel-Lavallée lesion: a case study. The Journal of the Canadian Chiropractic Association, 63(3), 178–186.

ACL-R

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Saturday 26th June 2021 – Tuesday 27th July

Hours: 8 (2 x 1 hours sessions over 4 weeks)

Patient presentation pre:

  • QASLS
    • Affected limb 4
    • Unaffected limb 2
  • Quadricep LSI
    • 87.5% with the affected limb showing weakness
  • H:Q
    • 100% both legs but affected limb weaker than unaffected
  • ACL-RSI
    • 50
  • IKDC
    • 80
  • 28-year-old female, 18 months post-operative from an anterior cruciate ligament reconstruction (ACL-r). Their goal is to fully return to hockey and would like to alter their current weight training programme to reflect this. In order to return to hockey, the client wants to improve the stability of their knee and gain the confidence needed to trust that their knee can perform at a sporting level again.

Reflection Model

  • Gibbs Reflective Cycle 1988

Exercise Prescription Examples

Session A

Session B

Session C

Session D

What Happened?

  • Client completed a 4 week rehabilitation programme. 2 supervised sessions per week and 2 unsupervised sessions per week.
  • The main goal was the correct the risky movement pattens identified  during a single leg squat. Accomplishing this goal would aid in improving the dynamic stability of the knee which in turn would allow the client to progress to more challenging/high demand tasks such as COD.
  • The client progressed smoothly throughout the programme. The only adjustment made was performing single leg RDL’s on the blue side of the BOSU. Initially, the plan was to progress from a yoga block to the black side of the BOSU; however, this increase in challenge was too great so we simplified the task.
  • At the end of the programme the client reported no more episodes of her knee giving way and feeling like returning to hockey was actually a possibility rather than a hope.

Patient presentation Post:

  • QASLS
    • Affected limb 2
    • Unaffected limb 0
  • Quadricep LSI
    • 100% with strength improvements across both limbs
  • H:Q
    • 90% both legs. Both limbs saw improvements in strength and both limbs were symmetrical in their strength values for both the quadriceps and hamstrings.
  • ACL-RSI
    • 78.3
  • IKDC
    • 100

 

 What were you thinking and feeling? 

  • I was happy with the patient’s progress despite being nervous to take on this case. Initially, when I started reading protocols on RTP for athletes who have undergone an ACL-R, I found the sheer amount of information quite overwhelming. For example, the battery of tests used to determine RTP vary quite significantly across literature (Flagg, et al., 2019). Some advocate for quadricep LSI and others argue that is over estimates function (Wellsandt, et al., 2017). Furthermore, the accepted levels for LSI and H:Q vary significantly which made it quite challenging to decide what both myself and the client would agree is an acceptable level.
  • However, as my time with the client progressed there were certain things that let me know both her knee and her confidence were improving. For example, when completing kneeling BOSU or stability ball balances the client would place herself near a walk for a safety net incase she lost balance. As the weeks progressed, she would just set up where there was available space and didn’t even think about needing a wall or any other form of external support.

What was good and bad about the experience?

  • It was good to spend a significant period of time with the client and follow her journey from the start. In clinic, we are likely to get a patient who has been in before but treated by one or more therapists beforehand. This is great for honing in note-taking and note-reading skills; however, it can be unclear if your interventions or treatment were impactful or if it is an accumulation of all of them combined. Therefore, I definitely felt a sense of pride and ownership over this rehabilitation programme as I knew the results we acquired were solely from the interventions we had put in place.
  • On reflection, there should have been some weeks where we didn’t look to advance the complexity of the task in order to allow the body to adjust to the new level it was required to work at. For example, we could have stuck with weighted walking lunges for a couple of weeks, maybe with some slight weight increases, before moving on to more complex movement patterns. Although, this didn’t impact the patient negatively, likely due to her significant weight training history, it is something to bear in mind if I do treat an ACL-R in the future.

Analysis

  • I was actually quite surprised at the quadricep strength improvements as we only ever aimed to maintain strength due to the LSI being 100%. However, this then highlights those who are critical of LSI being an overestimation of function (Chaput, et al. 2021). Clearly, the client was displaying a symmetrical weakness across the quadriceps as opposed to an LSI that would be optimal for injury prevention. Thankfully, the programme designed targeted both quadriceps to such a degree that improvements were made across both limbs but still maintained their symmetry.
  • This improvement in quadricep strength resulted in a H:Q drop; however, both hamstrings became stronger, both legs were symmetrical, and as the hamstrings are a smaller muscle group than quadriceps it is reasonable to expect hamstrings to be slightly weaker.
  • QASLS was still not optimal for the affected limb; however, 4 weeks is a short time to expect neuromuscular improvements to occur (Blanchard and Glasgow, 2014). Therefore, I am hopeful that with a continuation of rehabilitation the QASLS will align with the optimal score of 0-1.

 

 Conclusion 

  • Overall, I was happy with the outcomes of this rehabilitation programme. However, the clients goal is RTP and there are still some risky movement patterns to correct before returning to hockey training can commence. Furthermore, more demanding tasks such as COD, agility and plyometrics need to be mastered before RTP too.
  • Therefore, I will continue working with the client on these skills until it is deemed safe for her to return to hockey.

Revisiting Reflection

  • Several months after this initial rehabilitation programme, the participant strained her hamstring – the same leg which was operated on. In hindsight, I did not think about the hamstring graft that was used in her repair. Many of the exercises included, targeted the proximal hamstrings; however, I did not specifically think about incorporating distal hamstring exercises. This may have been a contributing factor to the recent injury; therefore I have made a conscious effort to target the distal hamstrings in her current rehabilitation programme, such as nordics and 1 1/2 rep RDL’s, to help protect from further injury. The client was prescribed the Askling protocol 7 days post-injury and once improvements in ROM and pain were improved we re-incorporated exercises such as deadlifts, at a lighter weight, and incorporated exercises focusing on the distal portion of the hamstrings.

 

References

  • Wellsandt, E., Failla, M. J., & Snyder-Mackler, L. (2017). Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury. The Journal of orthopaedic and sports physical therapy, 47(5), 334–338. https://doi.org/10.2519/jospt.2017.7285
  • Flagg, K. Y., Karavatas, S. G., Thompson, S., Jr, & Bennett, C. (2019). Current criteria for return to play after anterior cruciate ligament reconstruction: an evidence-based literature review. Annals of translational medicine, 7(Suppl 7), S252. https://doi.org/10.21037/atm.2019.08.23
  • Chaput, M., Palimenio, M., Farmer, B., Katsavelis, D., Bagwell, J. J., Turman, K. A., Wichman, C., & Grindstaff, T. L. (2021). Quadriceps strength influences patient function more than single leg forward hop during late-stage ACL rehabilitation. International Journal of Sports Physical Therapy, 16(1), 145–155. https://doi.org/10.26603/001c.18709
  • Blanchard. S., & Glasgow., P. (2014). A theoretical model to describe progressions and regressions for exercise rehabilitation. Physical Therapy in Sport, 15(3), 131-135. https://doi.org/10.1016/j.ptsp.2014.05.001

Medial Ankle Pain – Runner

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Monday 8th November 2021

Hours: 4

Patient presentations:

  1. Calf Strain
  2. Medial Ankle Pain

Reflection Focus

  • Medial Ankle Pain

Reflection Model

  • Gibbs Reflective Cycle 1988

What Happened?

  • Patient’s 2nd visit to clinic – Medial ankle pain, pinpointed inferior and posterior to the medial malleolus.
  • Reassessed PoP reduced from 1o to a 7/10. No longer any pain on passive DF but 2/10 on passive EV. No longer experiencing pain at rest or at night.
  • Patient is a runner and although running load had reduced it is causing pain VAS 5/10. Calf raises also cause pain 6/10 – pain lasts for an hour and eases with ice.
  • No pain when wearing trainers, but pain when walking in boots or barefoot.

 

 What were you thinking and feeling? 

  • I was really unsure on what was causing the patients pain. When I asked for support from the clinic supervisor they were also unsure.
  • The patient was experiencing pain several weeks before this session; however, she ran a marathon which resulted in a significant exacerbation in her symptoms. So, my thoughts were leaning towards an overuse/overload injury.
  • The patient didn’t feel as though their condition was improving initally; however, they were also quite down at not being able to run so this may have clouded the small improvements she had made. When we discussed other exercises such as swimming she admitted that this was something that she could do and does actually enjoy. Furthermore, when we reflected on the improvements to date she acknowledged that things were better.

 

What was good and bad about the experience?

  • As the patient’s symptoms were improving we agreed to keep the same exercise prescription. I wanted to removed calf raises due to the pain but the patient felt it was, ‘targeting the right area.’ So, we kept the calf raises but eliminated running entirely to see how this would impact her symptoms. It was good to have a discussion with the patient in this way and it also resulted in her guiding her own rehabilitation as she stated if it kept causing her pain or the pain increased she would cease and just keep up with the non-painful exercises.
  • It wasn’t great that I didn’t really know what the issue was. However, rather than get caught up in not knowing a possible diagnosis I treated the symptoms. There was a suspicion of tarsal tunnel syndrome as the patient did have numbness in her toes two weeks prior.

Analysis

  • On reflection, the patient was likely presenting with tarsal tunnel syndrome. Night pain, pain on EV and DF are all common presentations as well as numbness, tingling and pain on walking (Kiel and Kaiser, 2021). It is also possible for pain to localise to the posterior of the medial malleolus; therefore, there is a strong indication that this patient has TTS. Calf raises were a good prescription to give; however, stretching may prove more beneficial so there should be a focus on the eccentric phase if tolerable (Kiel and Kaiser, 2021) Furthermore, tibial posterior strengthening should be incorporated on her next visit to aid ankle stability and potentially offload irritated structures.

 Conclusion 

  • To benefit this patient further I will read literature on the rehabilitation of tarsal tunnel syndrome to see if there are any protocols in existence.
  • Eccentric calf raises, and tibialis posterior strengthening should be incorporated into exercise prescription

Revisiting Reflection

 

 

References

  • Kiel J, Kaiser K. Tarsal Tunnel Syndrome. [Updated 2021 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513273/

Calf Strain

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Monday 18th October 2021

Hours: 4

Patient presentations:

  1. Calf Strain
  2. Medial Ankle Pain
  3. Lateral Hip Pain

Reflection Focus

  • Calf Strain

Reflection Model

  • Gibbs Reflective Cycle 1988

What Happened?

  • 4th visit – signs and symptoms progressively improving.
  • Patient has been experience ongoing/reoccurring calf/achilles pain. The most recent episode he reported as a twinge in his calf during running that resulted in an inability to run.
  • Prior to treatment the patient did not have any warm up or warm down routines in place. Further to this, as an amateur runner little attention was paid to training volume.
  • Reassessed ROM and pain via ROM assessment and palpation. No pain on any ROM, normal end feels, 5/5 strength, proximal achilles tendon PoP reduced from 7/10 > 2/10 over 2 week period.
  • Patient adhering to exercises although not been able to attend the gym as often as he would like. Abiding by 10% rule to avoid overloading the calf complex and achilles tendon too quickly. He completed a 5km run pain free a few days before the assessment which he was really pleased with.

 

 What were you thinking and feeling? 

  • I was really happy to see the progress the participant was making – he was clearly pleased to be back running pain free and he acknowledged that his lack of S&C, warm up, and warm down strategies were likely contributing factors to his injury reoccurrence. Therefore, I felt the patient had not only benefited from the exercises but equally the education.

 

What was good and bad about the experience?

  • Good = patient improvements in pain, ROM and knowledge.
  • Needs improvement = clinical judgement on returning to running.

Analysis

  • The patient fits the demographic described by Fields and Rigby (2015), in terms of age, recreational runner status and poor conditioning. Therefore, I believe it was correct to introduce condition work for the lower limbs and also educate on loading to avoid injury and enhance performance. Providing eccentrics was popularised by Alfredon, et al. in 1998 and has a strong evidence base for achilles tendinopathy and calf strains (Fields and Rigby, 2015).
  • I never really provided goals for the patient to achieve in order to return to running. As a result, the patient returned to running within a month of the injury. The patient did not have a limp and reported no pain when running slowly; however, returning to running too soon may have cause further or re-injury.  Fields and Rigby suggest that in addition to running for 30 minutes pain and limp free, runners should also be able to perform 3 x 15 single leg calf raises, both with a straight and bent knee.

 

 Conclusion 

  • It is common to see recreational runners in clinic and therefore it is important that I have return to sport criteria to aid my clinical judgement and decision making. Therefore, I will use the approach outlines by Fields and Rigby to inform future treatment plans of runners who have sustain and injury to the calf complex.

Revisiting Reflection

 

 

References

 

  • Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American journal of sports medicine, 26(3), 360–366. https://doi.org/10.1177/03635465980260030301
  • Fields, Karl B. MD; Rigby, Michael D. DO Muscular Calf Injuries in Runners, Current Sports Medicine Reports: 9/10 2016 – Volume 15 – Issue 5 – p 320-324 doi: 10.1249/JSR.0000000000000292

Therapeutic Ultrasound

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Tuesday 26th Ocotober 2021

Hours: 3

Patient presentations:

  1. Therapeutic US
  2. Oblique Strain
  3. LBP after n0n-contact trauma

Reflection Focus

  • Therapeutic US

Reflection Model

  • Therapeutic US

What Happened?

  • A very brief treatment as the patient needed to have a COVID test before commencing training for the day.
  • Presenting with reactive achilles tendinopathy. Patient had previously received general maintenance on calves through STM, mobility and stretching exercises. Today he was in for another session of Therapeutic US.
  • 3Hz, 100%, 6 minutes.

 

 What were you thinking and feeling? 

  • Within in clinic, I have many patients who have seen a previous therapist for their current injury. However, this was the first professional sports person I had treated which means not only were there recommendations from the previous therapist but the patient would also be receiving guidance and information from multiple different coaches.
  • As this was not a day I would normally be in clinic I decided to abide by the previous therapists notes and follow the course of treatment they had planned.

What was good and bad about the experience?

  • I think I made the right decision not to offer any further advice/information as it may have resulted in information overload or even confused the patient if it conflicted with previous recommendations. However, I did reiterate that the stretching and mobility he had been prescribed previously was an important factor in his recovery. This was to ensure that he considered his exercise prescription as something as equally important as the passive treatments he was receiving.

Analysis

  • On reflection, I should have queried the Ultrasound settings used previously. As a lower pulse dose may have been enough e.g. 1:2, as the condition was only just moving into the subacute stage (Watson, 2017). However, the patient did report that his Achilles had been feeling better since his last treatment; therefore, I didn’t want to make changes to his treatment plan that may have been having a positive effect. Equally a study by Chang, et al., 2015 delivered therapeutic ultrasound in continuous mode for 8 mins on the achilles tendon and it resulted in increased tendon microcirculation via an increase in vasodilation. Vasodilation will optimise blood flow, cell permeability and nutrient delivery at the injured site, thus improving the quality and potentially rate of injury resolution.

 Conclusion 

  • I learned that it is not only important to reflect on my own treatment plans but also pre-existing treatment plans not initiated by myself. If I had seen this patient from the on-set I would have likely delivered ultrasound on a pulsed dose (1:2), which may not have been as effective as reducing the patients pain. I can’t say this with certainty as there were other contributing factors such as a mobility and stretching routine that the patient was following. I think overall I made the right decision in following the treatment plan and not changing the does; however, if the patient presented differently, e.g. worsening or static pain, I would have used a different dosage as the tissue may have been too sensitive to the continuous mode of delivery.

Revisiting Reflection

 

 

References

  • Chang, Y. P., Chiang, H., Shih, K. S., Ma, H. L., Lin, L. C., Hsu, W. L., Huang, Y. C., & Wang, H. K. (2015). Effects of Therapeutic Physical Agents on Achilles Tendon Microcirculation. The Journal of orthopaedic and sports physical therapy, 45(7), 563–569. https://doi.org/10.2519/jospt.2015.5681

Suspected Rotator Cuff Disease

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Monday 11th Ocotber 2021

Hours: 4

Patient presentations:

  1. Patella Tendinopathy
  2. Suspected Rotator Cuff Disease

Reflection Focus

  • Suspected Rotator Cuff Disease

Reflection Model

  • Gibbs Reflective Cycle 1988

What Happened?

  • Patient reporting slight discomfort in UFT and pain over the deltoid area during external rotation and abduction. Her symptoms are now intermittent rather than constant.
  • The patient received some HBE on her previous visit but as she hadn’t adhered to them as regularly as she would have liked she did not want to change these. Agreed this was a good idea as the little she has been doing was already making an impact so an increase in adherence may resolve her symptoms.
  • Patient requested STM for UFT – completed MET on UFT via PIR and NMT for TrPs.

 

 What were you thinking and feeling? 

  • I was happy with the patient’s progress. I hadn’t prescribed her HBE; however, they included stretching which has been shown to reduce pain associated with TrPs (Page 2012), which is something the patient was suffering with.

 

What was good and bad about the experience?

  • Although the treatment was appropriate in this instance I should have asked what had impacted her adherence to HBE. For example, if it was due to her being busy I may have been able to condense the prescription.

 

Analysis

  • By not asking what were her barriers to rehabilitation adherence I may have left this patient with an exercise prescription they wouldn’t benefit from as they wouldn’t do it. Adhereance to HBE is a key component to the success of many unsupervised rehabilitation programmes; however, there is a significant lack of valid a reliable tools to measure adherence (Bollen, et al., 2014).

 Conclusion 

  • I rely solely on a patient’s honesty and recall when reviewing adherence and this is likely going to produce some errors in communication. Patient’s may over or under estimate their adherence if they haven’t been noting it down. Also, patients may not be honest for fear of judgement due to lack of adherence. Therefore, I am going to search for valid and reliable tools that may be useful for assessing adherence of prescribe HBE.

Revisiting Reflection

 

 

References

  • Bollen JC, Dean SG, Siegert RJ, et al
    A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties
    BMJ Open 2014;4:e005044. doi: 10.1136/bmjopen-2014-005044

STM for LBP

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Monday 4th October 2021

Hours: 4

Patient presentations:

  1. Chronic Calf Strain
  2. STM for LBP
  3. Hip Pain

Reflection Focus

  • STM for LBP

Reflection Model

  • Gibbs Reflective Cycle 1988

What Happened?

  • Patient attends every 2 weeks for symptom management of LBP.
  • AROM is always assessed before and after treatment. The patient reports easier and pain free movement in lateral flexion and rotation.

 

 What were you thinking and feeling? 

  • I have previously provided some exercises for the participant to try at home; however, adherence is low/minimal. I get the impression from this patient that she enjoys coming in for a massage every couple of weeks and is happy with this as a treatment modality.

 

What was good and bad about the experience?

  • I treated the patient for 45 minutes with effleurage, petrissage and STR.
  • I know that massage only provides short term relief on pain and function in patients to LBP (Furlan, et al., 2015) but I felt like I wasn’t able to treat the patient with other strategies as she is fairly specific and firm with her STM request.

Analysis

  • During the massage, the patient normally engages in some general conversation. I remember a few weeks back that the participant mentioned wanting to get back to her group exercise classes that were suspended due to COVID. This may explain why adherence to HBE was low and why the patient is happy to come in every 2 weeks as she may be enjoy the social component of coming in to see someone/other people. This also means that the participant is actually avoiding exercise she is just wanting to resume the type of exercise she knows she enjoys. As a result, I was less concerned that the patient had fear avoidance beliefs (FABs) that may exacerbate her sensation of disability (Rainville, et al., 2011) Therefore, I urged the patient to look into some alternative classes that have resumed that she may enjoy.

 

 Conclusion 

  • The patients frequent visits and STM requests align with the evidence that massage is only a short term solution to LBP. I believe the patient may be in less pain if they can return to their exercise class. However, I was not able to recommend any appropriate classes as I wasn’t aware of any. Therefore, I will take them time to generate a list of community based exercise classes that some patients may benefit from.

Revisiting Reflection

 

 

References

  • Rainville, J., Smeets, R. J., Bendix, T., Tveito, T. H., Poiraudeau, S., & Indahl, A. J. (2011). Fear-avoidance beliefs and pain avoidance in low back pain–translating research into clinical practice. The spine journal : official journal of the North American Spine Society, 11(9), 895–903. https://doi.org/10.1016/j.spinee.2011.08.006
  • Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low‐back pain. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD001929. DOI: 10.1002/14651858.CD001929.pub3. Accessed 15 January 2022.

Week 5 – Phone Calls & Strength Class

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20th December – 26th December

  • Hours: 15

Main Theme Addressed During Phone Calls

  • Enjoying the holidays without exacerbating symptoms.
    • Many of the participants were concerned about how to manage the extra workload that can sometimes come with the Christmas season. Extra socialising, last minute shopping  and a lot more cooking. From the class attendance it appeared that one strategy to cope with this was to put the rehabilitation programme to the back of their mind. However, from a holistic perspective I explained to individuals that it is consistency that prevails. One skipped session will not ruin their progress and equally as we have been in and out of lockdowns I didn’t want the programme to detract from the social and emotional components of their wellbeing.
    • For those who were concerned about any extra energy expenditures we looked at ways to save energy elsewhere. For example, going to bed early, meal prepping over a number of days, leaving a rest day in-between big events. Many of the participants stated that they were already putting these strategies in place prior to our conversation. Therefore, I made a conscious effort to praise this and highlight that they were putting what they had learned into practice without my guidance.
  • Coping with other illness and managing long-covid symptoms.
    • Two participants became unwell this week. One developed a chest infection and the other a cold. Both had an exacerbation of their long covid symptoms, mainly breathlessness and fatigue. Reiterated the conversation around consistency and that missing a session or two whilst ill is not only advisable but not likely to impact their overall progress. I explained that their energy levels already weren’t 100% before getting ill so pacing, planning and prioritising are now even more key that they are suffering with another illness. I encouraged the participants to rest and keep hydrated and nourished whilst they recover. And, I advised them to return to exercise when they felt ready and at a slightly lower intensity.
    • Participants sometimes struggle to understand the concept behind pacing, planning and prioritising – so I signpost to this really useful information leaflet that also gives example on how to break tasks down in order to conserver energy. This is really important as pacing has been shown to be more effective than graded exercise therapy (GET) and actually, GET makes many people with long covid feel worse (Torjesen, 2020). This is also why my approach to exercise is symptom led. Yes, there are progressive increases each week but they are entirely optional and during my phone calls, if I feel a participant is not ready to progress I will advise them on keeping the intensity lower.
  • GP negativity towards prognosis and impact on patient.
    • One patient signed off sick with her long covid symptoms. She was shocked at his negative demeanour towards her prognosis.

Strength Class

  • (30 secs on (60 secs if singe leg), 15 seconds off (2:1) x 3, followed by a 45 second rest) x 5
  • The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Analysis & Evaluation 

  • In injury rehabilitation, psychological readiness is an important factor in RTP. This is why tools such as the ACL-RSI, I-PRRS and AFAQ all exist – to measure an athletes psychological readiness. Although this is not an injury rehabilitation programme, if a patient for any reason doesn’t feel confident or believe that they can either fully recover or make reasonable adjustments to return to their ADL’s then the likelihood is that they will struggle to progress over the course of the programme. Therefore, I was really surprised at the negativity the GP approached my participant with. Thankfully, this participant was aware that she was making progress and the outlook was not as bleak as the GP made it seem. However, if an individual didn’t possess this resilience and believed the authority figure giving them this poor prognosis, things may have been different. For example, the participant could have disengaged with the rehab believing it wouldn’t help them. Although, exercise is not appropriate for everyone managing symptoms of long covid it has been encouraged, in those not contraindicated to exercise, in order to aid with immunity, reduce inflammation and to reduce the chances of acquired MSK problems due to sedentary behaviour (Jimeno-Almazán, et al., 2021).

Conclusion 

  • I spend a lot of time trying to encourage a positive mind-set within my participants but I overlooked the external factors that could be influencing their thinking. I tend to encourage positive self-talk and praise small wins when participants have not identified them. However, external factors are something out-with my control and, to a degree, also the patients. Therefore, I am going to make a conscious effort to ask participants how they feel others have reacted/responded to their diagnosis and if that has impacted them negatively or positively.

Revisiting Reflection

References

  • Jimeno-Almazán, A., Pallarés, J. G., Buendía-Romero, Á., Martínez-Cava, A., Franco-López, F., Sánchez-Alcaraz Martínez, B. J., Bernal-Morel, E., & Courel-Ibáñez, J. (2021). Post-COVID-19 Syndrome and the Potential Benefits of Exercise. International journal of environmental research and public health, 18(10), 5329. https://doi.org/10.3390/ijerph18105329
  • Torjesen I. NICE cautions against using graded exercise therapy for patients recovering from covid-19 BMJ 2020; 370 :m2912 doi:10.1136/bmj.m2912