Sciatica

Date 15th November 2021

Posted by Laura Budd

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Monday 7th June 2021

Hours: 4 (Observational)

Patient presentations:

Total Hip Replacement
Subacromial Decrompression
Lumbar Decompression
Sciatica

Reflection Focus

Sciatica

Reflection Model

The ERA cycle (Jasper, 2013)

Experience

Patient was experiencing pain in the knee which referred down into her toe. However, on this visit this referred pain had ceased and was in the knee only.
The clinician took the time to educate the patient on the behaviour of nerve pain and reassured her that the reduction in referred pain was a sign of improvement.
The clinician did not change the exercise prescription for this patient.

Reflection

I felt a bit confused on this case as the patient wasn’t complaining of any lower back pain which I had previously thought was a pre-requisite for suspected sciatica. However, on further reading LBP may or may not be present in someone who has sciatica and, if they do, it is likely to be less severe than the referred leg pain (Koes. 2007; Konstantinou. 2012). Furthermore, pain that radiates below the knee is considered an indicator for sciatica.
This aligns with messages that have been taught to us about imaging. E.g. If you imaged 100 people without LBP a number of these could, for example, have a discongenic pathology but be asymptomatic.
The patient’s pain in this instance was centralising which is when the pain moves closer towards the spine (Albert. 2012). As the clinician stated to the patient, this is an indicator of a positive outcome. Peripheralisation on the other hand would indicate that the condition had worsened.

Action

I was clearly misinformed about how sciatica can present itself. Reflecting on this further, I clearly have some assumptions about LBP that need to be addressed. Therefore, I need to look into the possible presentations of sciatica and treatment strategies.

Revisiting Reflection

The NHS summarise sciatica as lower extremity pain and/or altered sensations with or without back pain. It has useful conservative management strategies and when to be concerned – cauda equina red flags. The most common cause of sciatica is a ‘slipped disc’ but equally an injury to the back or spinal conditions such and spondylolisthesis and spinal stenosis could be the underlying reason behind sciatic nerve irritation. Due to there being many different causes of sciatica it is really important to take a thorough subjective history, align them with patient characteristics (such as age, lifestyle, previous trauma, etc.) to determine the correct cause of treatment or if an onward referral may be required. For example, if I suspected a disc protrusion repeat extensions may be a beneficial prescription to alleviate symptoms.

References

Koes, B. W., van Tulder, M. W., & Peul, W. C. (2007). Diagnosis and treatment of sciatica. BMJ (Clinical research ed.), 334(7607), 1313–1317. https://doi.org/10.1136/bmj.39223.428495.BE
Albert, H. B., Hauge, E., & Manniche, C. (2012). Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions?. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 21(4), 630–636. https://doi.org/10.1007/s00586-011-2018-9
Konstantinou, K., Lewis, M., & Dunn, K. M. (2012). Agreement of self-reported items and clinically assessed nerve root involvement (or sciatica) in a primary care setting. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 21(11), 2306–2315. https://doi.org/10.1007/s00586-012-2398-5

Knee Replacement – Post Op

Date 12th November 2021

Posted by Laura Budd

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Monday 24th May 2021

Hours: 4 (Observational)

Patient presentations:

Knee Replacement
Subacromial Decompression
Knee Replacement

Reflection Focus

Knee Replacement – Focus on Patient Attitudes

Reflection Model

The ERA cycle (Jasper, 2013)

Experience

Two female patients were seen on this day. They were similar in age and were also the same amount of time, give or take a day or two, post-op TKR. Despite their similarities, they were at very different stages of their rehabilitation process. One was still walking with the aid of a crutch whilst the other was progressing onto single-leg glute bridges and walking unaided.

Reflection

It seemed that the patient who was progressing onto more complex tasks was more internally motivated to complete her post-op rehab exercises. She completed the exercises more often than prescribed and was asking. ‘when can I go hill walking again?’ However, when the other patient was asked by the clinician, ‘what is it you would like to get back to doing?’ she didn’t have anything in mind. The patient seemed quite reliant on her husband and stated that he was doing a lot more tasks to help her. When the clinician then iterated that the exercises would help her get back to doing some of those tasks she didn’t seem very optimistic and admitted to not completing her rehab as often as she should because she didn’t have the time. The patient expressed that she was not happy with the progress she had made to date and thought she would forever walk with a stick from now on. Although I suspected the patients lack of optimism was contributing to a slower recovery process, this was confirmed on further reading. A study by Lopez-Olivio., et al. found that low optimism, among other psycho-social factors, resulted in poorer patient reported outcomes on function and pain after a TKR (2020).
This experience highlighted the importance of psycho-social factors and their role in the recovery process. It is clearly one of the many reasons rehabilitation needs to be patient centred. The patient struggling to adhere to her rehab clearly needed further support and encouragement as she was lacking the intrinsic motivation the other patient seemed to possess.

Action

During revision sessions, I have been very focused on perfecting the objective assessment. However, this situation highlights the importance of understanding a person’s motivation and end-goals. When in clinic, I will try to spot any other behaviours that indicate a positive or negative attitude towards the rehabilitation process or injury, as these are likely going to as informative about their recovery as the objective information.

Revisiting Reflection

Upon further investigation, I found an article detailing the seven principles of rehabilitation. One of the principles is compliance and iterates that athletes should be made aware of the rehabilitation content and the expected outcome. I have been ensuring I implement this in practice but in addition I also make it a shared decision making process. By involving the client in the decision making process I am aiming for them to become intrinsically motivated to comply with their programme. This is also known as self-determination which is likely to increase adherence/compliance to a programme (Chan, et al, 2011).

References

Lopez-Olivo, M.A., Ingleshwar, A., Landon, G.C., Siff, S.J., Barbo, A., Lin, H.Y. & Suarez-Almazor, M.E. (2020). Psychosocial Determinants of Total Knee Arthroplasty Outcomes Two Years After Surgery. ACR Open Rheumatology, 2, 573-581. https://doi.org/10.1002/acr2.11178
Derwin King-Chung Chan, Martin S. Hagger, Christopher M. Spray. (2011). Treatment motivation for rehabilitation after a sport injury: Application of the trans-contextual model, Psychology of Sport and Exercise, 12(2), 83-92. https://doi.org/10.1016/j.psychsport.2010.08.005.

Neck Pain & Headaches

Date 10th November 2021

Posted by Laura Budd

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Tuesday 1st June 2021

Hours: 4 (Observational)

Patient presentations:

Neck Pain & Headaches
Rotator Cuff Repair (Post-Op)
Total Hip Replacement (Pre-Op)
Adhesive Capsulitis (Pre-Op)

Reflection Focus

Neck Pain & Headaches

Reflection Model

The ERA cycle (Jasper, 2013)

Experience

Long-standing patient of the physio. She experiences neck pain and headaches which are treated via STM. The patient’s problem is work-related and despite her DSE set-up being improved the issue persisted.

Reflection

I was surprised that there was little in the way patient education during the session; however, as this is a long-standing patient I imagine that discussions have been had previously. Equally, STM is not indicated as a form of management for headaches (NICE, 2012). However, the patient was reporting symptoms consistent with a cervicogenic headache and there is evidence that physical therapy, such as manipulations and mobilisations can help with the management of this condition (Rani et al., 2021).

Action

I knew that some headaches could be MSK related; however, I had never heard of the term cervicogenic headache. Therefore, I am going to explore the topic further – focusing on its presentation and how to manage the condition through physical therapy, exercise, and patient education.

Revisiting Reflection

NHS, Berkshire have a patient information leaflet for cerviogenic headaches which highlights common symptoms, red flags (VBI) and conservative management strategies. This may be a useful signpost to help individuals manage their symptoms at home.
A delphi study on cervicogenic headaches (CeH) iterated that manual therapy, lifestyle advice and work-related ergonomic training are useful treatment strategies for patients presenting with CeH (Pauw, et al., 2021). Interestingly exercise didn’t achieve consensus; however, it is something still to be considered when dealing with CeH.
Manual therapy and exercise was found to be effective in the treatment for headaches as opposed to either in isolation (Hidalgo, et al., 2017); therefore, techniques such as MET’s, TrP therapy, and mobilisations may all serve a purpose alongside exercises that target general ROM, deep neck flexors and the scapular muscles for CeH.

References

Rani, M., Kulandaivelan, S., Bansal, A., & Pawalia, A. (2019). Physical therapy intervention for cervicogenic headache: an overview of systematic reviews. European Journal of Physiotherapy, 21(4), 217-223. https://doi.org/10.1080/21679169.2018.1523460
National Institute for Health and Care Excellence. (2012, September 19). Headaches in over 12s: diagnosis and management. https://www.nice.org.uk/guidance/cg150
Berkshire Healthcare. (2017, November). Cervicogenic headaches Information and advice. NHS Foundation Trust. https://www.berkshirehealthcare.nhs.uk/media/168324/cervicogenic_headaches_leaflet.pdf
Hidalgo, Benjamin et al. ‘The Efficacy of Manual Therapy and Exercise for Treating Non-specific Neck Pain: A Systematic Review’. 1 Jan. 2017 : 1149 – 1169.
De Pauw, R., Dewitte, V., de Hertogh, W., Cnockaert, E., Chys, M., & Cagnie, B. (2021). Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study. Musculoskeletal science & practice, 52, 102325. https://doi.org/10.1016/j.msksp.2021.102325

Subjective Assessment Template

Subjective Assessment

Created from information provided during a clinical assessment lecture

History of Present Condition (HPC)	O – Onset Any particular event that caused the pain? Or, has is been a gradual onset? L – Location Be very specific in terms of anatomy D – Duration How long has the pain been present? Is it present all the time? How long do flare ups last? C – Characteristics Type of pain? Burning? Dull Ache? Don’t ask leading questions. A – Alleviating/Aggravating Factors What, if anything, makes the pain better or worse? Leading questions are okay here. VAS scale – be specific here too. If it is painful walking downstairs, how painful? Are they or have they received treatment in the area before. R – Radiating Is the pain local or radiating to another area or joint? Any bilateral issues? T – Temporal Pattern 24 hr behaviour, morning, afternoon, evening? How does the pain feel during these phases of the day? Does it interfere with sleep? S – Severity Do we need to manage pain relief? Or can we start strengthening/implementing weight bearing strategies?
Past Medical History (PMH)	General Health If you have seen the patient before be observant of possible changes. If you haven’t, have they noticed a recent decline and do they know a reason why? Past Illnesses & Allergies T – Thyroid H – Hypertension R – Rheumatoid Arthritis E – Epilepsy A – Asthma D – Diabetes S – Steroid Hx – Cancer Environmental Allergies – may affect when you work with them Previous Hospitalisation to Medical Appointments Related or not – decide what is relevant to include Medications Prescribed or Over the Counter, e.g. NSAID’s Diet Can help establish attitudes towards nutrition and exercise. Sleep Any problems sleeping? Related to injury or a yellow flag Family History Hx of Cancer or anything that may be of relevance to injury.
Medications	What? – Name of medication Why? – Reason for medication What dosage? Possible side effects?– could impact when you train them, how you monitor intensity, etc. Contraindications? Painkillers? How much? Could inhibit pain during assessment.
Social & Family History	What are the patients expectations? Think about age – age related pathology? Is it work related? Think about work or education.\ Home situation – marital status, children, dogs, etc. Leisure – sports, positions played, training patterns Consider – Has anyone else in the family had similar complaints?
Aggravating/Alleviating Factors	Aggravating Daily Life – stairs, driving, kettle, showering, reaching, twisting, turning, medications, etc. Work – does the problem impact work? Can work be modified to help with problem? Exercise – have they modified training in any way? ——————————————————————— Alleviating Activities – rest, moving, stretching Self-Management – ice, heat, NSAID’s, taping, bandage, etc. Lifestyle – better on weekends? If something is alleviating – How long does it take to alleviate? How long is alleviation? How frequently have they applied alleviations?
Body Chart	Identify area of pain Can indicate – paraesthesia, stiffness, weakness, referred pain. Indicate type of pain & intensity (can use VAS) Identify abnormal sensations – Red Flags
Severity & Irritability	Severity Low – Could tolerate tissue loading Moderate High – Work on managing pain ——————————————————————— Irritability Low – difficult to provoke symptoms Moderate – certain movements provoke symptoms High – very easy to provoke symptoms

Shoulder Pain Localised to Greater Tuberosity

Date 1st November 2021

Posted by Laura Budd

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Monday 23rd August 2021

Hours: 5

Patient presentations:

Knee pain post-trauma
Shoulder pain localised to greater tuberosity
Lateral Ankle Sprain

Reflection Focus

Shoulder Pain Localised to Greater Tuberosity

Reflection Model

Gibbs Reflective Cycle 1988

What Happened?

I had treated this patient previously.
The patient’s pain was sporadic. Some days the pain wouldn’t bother her and other days it would feel as though she was ‘back to square one.’
The stretches that were prescribed provided relief in the moment but were clearly not a permanent solution to her pain.
On reassessing her ROM she was pinpointing the painful/restricted area to approx. greater tubercle of the humerus. This raised my index of suspicion for a rotator cuff injury due to where the rotator cuff muscle group insert.
The patient mentioned during this session that she participates in dinghy racing from April to September. The patient stated that this sport involves pulling rope towards her and keeping tension on it for a significant period of time when training and racing.

What were you thinking and feeling?

When the patient mentioned that she participated in dinghy racing I knew I had made a mistake during my previous assessment. I had failed to take a thorough subjective history and as a result, I missed an important factor that could have been contributing to the patient’s pain. As frustrating as it was to know that I had made such an obvious mistake I was relieved that I had more information that I could use in order to support the patient.

What was good and bad about the experience? & Analysis

To have a more complete picture of the patient and her injury was extremely useful. I was able to ask further questions about dinghy racing and it turned out that she doesn’t complete any form of training in the ‘off-season.’ This once again raised my index of suspicion for an overuse injury as she had gone from doing very little sport-specific activities to training and racing at least once a week. This allowed me to provide some education to the patient about the importance of gradually increasing her training activity. Based on Cook and Purdam’s Tendinopathy Pathology Continuum (2009), I explained that overuse injuries tend to occur when the body is exposed to too much load, too often and doesn’t have enough time to repair. From this discussion, the patient could see how her training may have contributed to her pain and also disclosed that the pain started around the time she resumed dinghy racing this year.
I should have probed a little further in regards to the patient’s training pattern. I think because she mentioned new information, relevant to the case, I felt like an overuse injury made sense and started treatment based on this clinical reasoning. However, if I had more information about her training volume, load and intensity I may have been able to provide highly individualised help and support.

Conclusion

Prior to this incident I have been allowing the subjective assessment to flow quite naturally and asked further questions where I felt I needed more information. However, for the time being it seems best to follow a set protocol so I don’t miss any information. I have a template subjective assessment form that I created a year ago based from a lecture.
I will keep this template open during my note-taking so I don’t miss any significant pieces of information like I did with this patient.

Revisiting Reflection

References

Cook, J., & Purdam, C. (200(). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43, 409-416.

Knee Pain – Post Trauma

Date 25th October 2021

Posted by Laura Budd

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Monday 6th September 2021

Hours: 4

Patient presentations:

Hip Pain
Knee Pain Post Trauma

Reflection Focus

Knee Pain Post Trauma

Reflection Model

Gibbs Reflective Cycle 1988

What Happened?

Follow-up visit from the patient’s initial consultation. The patient reported that her knee pain was caused by slipping in a ‘split-like fashion.’
On the same side as her knee pain, she was reporting symptoms consistent with MTSS and she has a PMH of a LAS sustained during a game of netball 2 years ago. Furthermore, the patient had sprained her ACL on the contralateral side 2 years ago also.
I deemed the patient as active, participating in bootcamp exercise classes 4/7 and netball games 2/7.

What were you thinking and feeling?

To be sustaining multiple injuries on one side of the body not only did I want to address the patient’s current symptoms but I was also interested in trying to limit the chances of sustaining yet another injury to her right lower limb.

Analysis & Evaluation

The patient was active so she was adhering to her exercise prescription. Either as a result of the exercises, time, or both, her pain had decreased since her last visit.
The patient believed that her PMH of a LAS was likely to be partially responsible for her sustaining so many ipsilateral injuries. I was inclined to agree with the patient, especially as she noted her LAS wasn’t rehabbed particularly well. With both the patient and myself ‘on the same page’ in regards to her injuries, I felt that she was willing to put time, effort, and energy into exercises that on the surface may not look obviously linked to her sites of pain. Furthermore, when I explained the reasoning behind some of these exercises she could see the holistic benefit, i.e. the patient understood that exercises such as a single-leg balance would help with the balance and stability of the ankle which plays an important role in maintaining our bodies centre of gravity against perturbations. If our centre of gravity moves away from our support base our bodies can move into positions that place them at a higher risk of sustaining an injury. For example, excessive knee valgus and internal rotation of the hip are known risk factors for sustaining an ACL injury (Statsi, et al., 2014), something which the patient has already sustained on her contralateral side.

Conclusion

Overall, this particular case highlighted the importance of treating the root cause of a problem rather than just the symptoms. I know, for me, it can be easy to focus on just the site of injury and forget that the injury can be impacting another part of the body or, the injury arose due to a weakness in another area of the body.

Revisiting Reflection

References

Di Stasi, S., Myer, G. D., & Hewett, T. E. (2013). Neuromuscular training to target deficits associated with second anterior cruciate ligament injury. J Orthop Sports Phs Ther, 43(11), 777–A11. https://doi.org/10.2519/jospt.2013.4693

Referral for Imaging – Suspected Meniscal Tear

Date 25th October 2021

Posted by Laura Budd

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Monday 16th August 2021

Hours: 5

Patient presentations:

8 months post lateral ankle sprain
Piriformis Syndrome/Discogenic Pathology
Anterior knee pain & bilateral groin related hip pain.
Suspected MCL sprain/Meniscal tear.

Reflection Focus

Suspected MCL sprain/Meniscal tear.

Reflection Model

Gibbs Reflective Cycle 1988

What Happened?

Patient’s 3rd appointment. Complaining of knee pain, crepitus and locking after a hit to the knee during a rugby game. In previous weeks the clinic generated a referral letter for the patients GP to book an MRI.
The patient’s day-to-day pain has reduced and periods of locking have become less frequent.
The patient has family visiting at the end of next month and they want to watch him play a game of rugby. The patient wanted to know if he would be able to play by the end of September.

What were you thinking and feeling?

I was particularly concerned that this patient had become disengaged with his rehabilitation. He asked if there was any point in doing the exercises until he had his MRI. Furthermore, despite reporting that running didn’t feel normal and having no explosive movement on the affected limb he was still participating in high demand training drills, such as suicides.
I did feel empathetic towards this patient as it was clear that his family coming to watch him play meant a lot to him. However, the patient was 18 years old and with his knee still far from what he would deem normal I didn’t want to risk him playing and sustaining further damage to his knee.

What was good and bad about the experience?

I felt like I explained my concerns regarding the patients engagement with the rehabilitation process well. I was clear that the MRI may not indicate surgical intervention and that conservative management may be advised; therefore, continuing would keep him on track towards recovery (Mina., et al. 2015.) I also iterated that even if the MRI did indicate the need for surgery the outcome from this would likely be better if he engages with prehab.
I also involved the patient in a discussion about life outside of rugby. The patient noted that if he played in September and was injured further this would impact the progress he is making on his driving lessons. At this point of the assessment, I felt that the patient was starting to understand the wider implications of playing on an injury.

Analysis

I think discussing the wider implications of returning to play was important in this situation. I would not have felt comfortable advising the patient that it was safe to play given his injury and I was loosely following the StaRRT Framework to inform this decision. (Shrier, 2015.) I believed that the patient’s tissue health was not strong enough to withstand the stresses that would be placed on it during a game of rugby, especially as he would likely want to perform at 100% for his family who would be watching. Furthermore, considering the patients desire to continue playing rugby and progress to increasingly higher competitive levels the overall risk of playing seemed too great.

Conclusion

Overall, I think I handled the RTP question well but I think we didn’t handle the topic of a referral particularly well with the patient.
In the future, if a situation like this presented itself to me, I would make it clear from the very beginning what a referral for imaging entails and what the patient’s best steps are moving forward. It is possible that by generating a referral, and not explaining what this meant in any great detail at the time, the patient thought we couldn’t offer him any further help.

Revisiting Reflection

References

Shrier, I. (2015.) Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play decision-making. British Journal of Sports Medicine, (49,) 1311-1315.
Mina, D., Scheede-Bergdhal, C., Gillis, C & Carli, F. (2015.) Optimization of Surgical Outcomes with Prehabilitation. Applied Physiology, Nutrition and Metabolism.

Knee Pain – Pregnant Female

Date 25th October 2021

Posted by Laura Budd

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Thursday 5th August 2021

Hours: 5

Patient presentations:

Knee pain Post-Trauma
STM for non-specific LBP
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.

Knee and Bilateral Hip Pain

Date 25th October 2021

Posted by Laura Budd

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Monday 2^nd August 2021

Hours: 5

Patient presentations:

Suspected medial meniscus tear
Shoulder pain localised to superior angle of scapula
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.

Shoulder Pain

Date 12th October 2021

Posted by Laura Budd

Comments0

Monday 26^th July 2021

Hours: 5

Patient presentations

Shoulder pain localised to superior angle of the scapula
Suspected medial meniscus tear
Knee and bilateral hip pain
STM request for non-specific LBP
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.

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