Monthly Archives: May 2022

Knee Pain – Military Population

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Friday 22nd April 2022

Hours: 3

Patient presentations:

  1. Knee and hip Pain
  2. Knee pain – military population

Reflection Focus

  • Knee pain – military population

Reflection Model

  • Gibbs Reflective Cycle 1988

What Happened?

  • Patient presented to clinic with L side knee pain – lateral to medial.
  • Pain on flexion, IR and ER (AROM)
  • Pain on IR (PROM)
  • Nil pain during RROM
  • Special Tests = Apley -ve, McMurray +ve, Thesally -ve
  • Pain had come on since starting basic army training 6.5 weeks ago and had even resolved for around 2 weeks during this time.
  • No hx of trauma
  • PoP in joint space

 What were you thinking and feeling? 

  • My initial instinct was that the participant had sustained an injury to her meniscus. This was due to there being PoP in the joint space and pain during weight bearing. However, I was unsure due to some of the special tests coming back negative. I double checked with our clinic supervisor who agreed with my clinical impression and I could proceed with treatment.
  • As there was no mechanical locking of the joint, conservative management is an appropriate choice (Mordecai., et al., 2014). I wanted to focus on off-loading the joint and strengthening the quadriceps with minimal pain provocation of the knee.

Analysis and Evaluation

  • I prescribed heel elevated squats; however, this may have been too advanced and isometric leg extensions may have proved more beneficial, or quad sets (Mordecai., et al., 2014).
  • The patient was returning to her army base after treatment so I encouraged her to share our discussion about load and strengthening so she was given the appropriate care whilst training.

 Conclusion 

  • I am beginning to understand the importance of developing a referral network or creating documents for patients about their treatment. Particularly, in this case, the success of her rehabilitation will rely on her relaying the information I provided which may be difficult and may not be received well. However, if I had a document of some sort to give to her which explained my clinical impression, treatment and future management considerations this may make the process easier and increase the likelihood of proper care. I will work on creating a template for patients in case they require information that needs relayed to employers, etc. However, I need to check my GDPR knowledge first so I don’t break any data protection rules.

Revisiting Reflection

 

 

References

  • Mordecai, S. C., Al-Hadithy, N., Ware, H. E., & Gupte, C. M. (2014). Treatment of meniscal tears: An evidence based approach. World journal of orthopedics, 5(3), 233–241. https://doi.org/10.5312/wjo.v5.i3.233

Week 5 – Healthy Eating & Acts of Kindness

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21st February 2022

  • Hours: 2

Participants

  • 10

Education 

  • Healthy Eating
    • Foods for healthy joints
    • Foods that increase inflammation in joints
    • Portion control and a balanced diet
  • Acts of kindness
    • Small or big things you choose to do for others
    • How is an act of kindness different from feeling obligated to do something or saying ‘yes’ to everything.

Exercise Class – 2x CV circuits

CV Circuit

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 40 secs on, 20 secs rest x 3
    • Marching on the spot
    • Squats
    • Hands to toes > hands to sky
    • Boxing
    • Side Steps
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Cardiovascular

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 30 secs on, 20 secs rest x 3
    • Body Weight Squat Thrusters
    • Walking
    • Side Step with Knee Lift
    • Seated Running
    • Hands to toes > hands to sky with stability ball
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Analysis & Evaluation 

  • Reduced time on 2nd circuit due to increased complexity of movements. This was required as participants reported feeling more tired after the 2nd session than the first.
  • There has been some success in the group this week. One participant has chosen to stop using her walking stick and another has changed from a walker to a walking stick. When they discussed this with the group they spoke about having much more confidence in their body than they did previously. When asked to explain this in a bit more detail, they explicitly connected the exercise sessions to their increased confidence. This occurrence reflects findings that both aerobic conditioning and strength training can reduce pain and improve function of those living with joint pain (Rahnama & Mazloum. 2012). Strength training was found to be more effective at improving ROM; whereas aerobic conditioning was found to be more effective at improving function and walking ability.
  • Therefore, the varied nature of the exercise programme will hopefully help participants in all of these areas, with two already reporting improved walking and functionality.

Conclusion 

  • There seems to be benefit to any type of exercise (strength, aerobic and flexibility/mobility). So, it is important to encourage variety so individuals can reap the most benefits. However, some favour other types of exercise over others so I will be sure to inform them of current evidence of how different types of training could impact their joint health.

 

Revisiting Reflection

 

References

  • Rahnama, N., & Mazloum, V. (2012). Effects of strengthening and aerobic exercises on pain severity and function in patients with knee rheumatoid arthritis. International journal of preventive medicine, 3(7), 493–498.

Week 4 – Pain & How to Thrive

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14th February 2022

  • Hours: 2
  • Cumulative Hours: 2

Participants

  • 10

Education 

  • Perceptions of pain
    • What makes pain worse?
    • What makes pain better?
    • How do you feel when you are experiencing pain on a stressful day v a relaxed day?
  • Ask yourself questions to thrive
    • What are things in life you want but have not been able to obtain, e.g. a healthier relationship. Ask yourself questions about why you want that and what you would need to do in order to achieve it.

Exercise Class – CV circuit & Joint Stability

CV Circuit

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 40 secs on, 20 secs rest x 3
    • Marching on the spot
    • Squats
    • Hands to toes > hands to sky
    • Boxing
    • Side Steps
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Joint Strength

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 30 secs on, 30 secs rest x 3
    • Squats
    • Wall Push Off
    • Leg Extensions
    • Stability Ball Chest Press > Shoulder Press
    • Hamstring/Glute Kick Back
    • Banded Bicep Curl
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Analysis & Evaluation 

  • Increased time on CV circuit this week. Some found it quite a struggle, particularly those with limited mobility as they felt the rest time was not enough. This highlights the difficulty on delivering group sessions and has made me realise I need to be able to adjust timings for those who are ready to progress but also respect that timings may need to remain the same for those who are not.
  • Participants are really starting to understand the importance of EWB when it comes to their pain. I used an example of stubbing your toe – it is quite a painful thing to do but how you experience that pain depends on how you feel that day. E.g. If you have a busy day and are feeling stressed and overwhelmed, the pain you experience is likely going to be greater than on a day when you are more calm. Immediately, lots of participants shared that their pain is worse when they are stressed and need techniques to help them combat stress effectively.

Conclusion 

  • Rather than focusing on timings I should look at how to increase the intensity through exercises and shorter rest periods. E.g. Participants could complete a more demanding exercise and/or start the exercises earlier (reduced rest) but still finish at the same time as the group. This will require some clear and concise communication and coaching; hopefully, it will help maintain a group feel without pushing on before they are ready or pulling people back from progressing.
  • I will ensure I share stress management and stress avoidance techniques with the group in future sessions. Especially as stress is known to make chronic pain worse.

 

Revisiting Reflection

 

References

 

Week 3 – Emotional Wellbeing & Advice

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7th February 2022

  • Hours: 2
  • Cumulative Hours: 2

Participants

  • 10

Education 

  • Emotional Wellbeing
    • What is emotional wellbeing EWB?
    • How do you know when your EWB is low?
    • How do you improve your EWB?
  • NHS Emotional Wellbeing Advice
    • Connect, be active, keep learning

Exercise Class – CV circuit & Joint Stability

CV Circuit

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 30 secs on, 30 secs rest x 3
    • Marching on the spot
    • Squats
    • Hands to toes > hands to sky
    • Boxing
    • Side Steps
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Joint Stability

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 30 secs on, 30 secs rest x 3
    • Seated Leg Extensions
    • Hamstring/Glute kickbacks
    • Single Leg Balance
    • Calf Raises
    • Stability ball shoulder circles
    • Banded row
    • Wall supported plank
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Analysis & Evaluation 

  • Discussed 3 of the 5 steps to EWB as described by the NHS
  • Most know what improves EWB; however, everyone reported how difficult it can be to put themselves first when life is busy. We discussed how making an effort it better than not trying at all. For many, they stated that this programme has been a source for improved EWB. This gave me the opportunity to highlight that they have been able to commit 2 hours a week to the programme so that is 2 hours a week they know they can spend of exercise and improving their EWB when the programme ends.

Conclusion 

  • It is important to provide participants with the knowledge and skills to continue their joint pain management independently. I am going to continually encourage forward planning so participants know that they can achieve results independently.

 

Revisiting Reflection

 

References

 

Week 2 – Exercise & Activity Tracking

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31st January 2022

  • Hours: 2
  • Cumulative Hours: 2

Participants

  • 10

Education 

  • Why is exercise important
    • Discussed biopsychosocial model and how exercise can improve overall health which can make managing joint pain easier.
    • Different types of exercise discussed: Strength training; flexibility and; cardiovascular.
    • Most important type of exercise = the one that you enjoy.
  • Activity and exercise diary
    • Diary can be useful for identifying triggers
    • Diary can also help to monitor progress and advance exercise/activity.

Exercise Class – CV circuit & Joint Mobility

CV Circuit

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 30 secs on, 30 secs rest x 3
    • Marching on the spot
    • Squats
    • Hands to toes > hands to sky
    • Boxing
    • Side Steps
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Joint Mobility

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotation

 

  • Main Session 30 secs on, 30 secs rest x 3
    • Seated or standing side reach
    • Squats or sit to stand
    • Shoulder (horizontal flexion, flexion, extension)
    • Shoulder blade squeezes
    • Leg Circles
    • Side lunge or side steps
    • Hamstring scoops
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    •  Hamstrings
    •  Back
    •  Chest
    • Shoulders

Analysis & Evaluation 

  • Joint stability class was aimed at lower body as all participants report either hip or knee pain; however upper was included for variety and balance to the session.
  • Participants really enjoyed the discussion around why exercise was important with one reporting, ‘It is nice to talk about exercise in a way that doesn’t just focus on losing weight.’ Many agreed and shared experiences of being told to lose weight and that will solve their joint pain.  When we discussed how exercise isn’t just physically good for you but also mentally and socially many of the participants recognised that when their health is good in all these areas their joint pain is more manageable.

Conclusion 

  • During this session, I was surprised that many had been told to lose weight but hadn’t been given any further advice on how to exercise. As a result they had gone on to complete exercise that wasn’t appropriate for their current level of joint pain and exacerbated their symptoms. This resulted in many of them thinking they couldn’t exercise and likely why many were surprised at how much they could do the week previously. When we discuss exercise planning in the future I will make sure I share the principles of exercise planning and discuss appropriate exercises for their joint pain.

 

Revisiting Reflection

 

References

 

Week 1 – Introduction and Goal Setting

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24th January 2022

  • Hours: 2
  • Cumulative Hours: 2

Participants

  • 10

Education 

  • Introduction to the programme
    • Introducing yourself to the group
    • The importance of goal setting
  • What is Joint Pain?
    • Different types of joint pain
    • Risk factors for joint pain

Exercise Class –  2 x CV circuit

CV Circuit

  • Warm Up – 3 x 30s each exercise
    • Marching on the spot
    • Half Squats
    • Arm Circles
    • Chest Swings
    • Torso Rotations
  • Main Session 30 secs on, 30 secs rest x 3
    • Marching on the spot
    • Squats
    • Hands to toes > hands to sky
    • Boxing
    • Side Steps
  • Warm Down – Static Stretches, 30 secs per muscle group
    • Glutes
    • Hamstrings
    • Back
    • Chest
    • Shoulders

Analysis & Evaluation 

  • Participants all have varying capabilities so it was really important to have regressed exercise options pre-planned to ensure that the delivery of the session was smooth. Most participants were surprise, particularly those who performed more chair based options, at how much exercise they could do sat down.
  • During the education session, participants openly shared their experience of living with joint pain. As more people shared, the more individuals realised similarities with their own condition. It was easy to see that the group made strong connections very early on which I believe it was a result of sharing their personal experiences.
  • Almost all participants were surprised that a high sugar diet is a risk factor for joint pain. In the weeks that followed it then became clear that no dietary advice had ever been offered to participants in regards to trying to managing their joint pain.
    • “But more than anything, it is the Western-type diet, rich in energy intake, total and saturated fat, an unbalanced ratio of n-3 to n-6 fatty acids, high in refined carbohydrates and sugar and low in fiber and antioxidants, that might increase the risk of RA, both
      directly through increasing inflammation and indirectly through increasing insulin resistance and obesity” (Rondanelli, et al., 2020, p.677).
    • We spent some time discussing how sugar is not the only dietary risk factor; however, as many of the participants also have an obese BMI reading and high waist measurements it is important to highlight sugar as this could also help reduce risk of developing diabetes.

Conclusion 

  • Overall, the first two sessions went well. However, one participant is severely restricted with their joint pain. They are currently waiting for a hip replacement and in hindsight the programme may not have been suitable for her. In saying this, she was one of the most engaged members of the group and reported incorporating sit to stands into her days at home. I think a blended approach of education and exercise helps to make the programme more accessible, even for the most restricted, and has highlighted that patient education is just as important in rehabilitation.

 

Revisiting Reflection

 

References

  • Rondanelli, M., Perdoni, F., Peroni, G., Caporali, R., Gasparri, C., Riva, A., Petrangolini, G., Faliva, M. A., Infantino, V., Naso, M., Perna, S., & Rigon, C. (2021). Ideal food pyramid for patients with rheumatoid arthritis: A narrative review. Clinical nutrition (Edinburgh, Scotland), 40(3), 661–689. https://doi.org/10.1016/j.clnu.2020.08.020