Category Archives: Observational Hours

Monday 12th July 2021

Hours: 4 (Observational)

Cumulative Hours: 40 (Observational)

Patient presentations:

1. Knee Arthroscopy
2. Rotator Cuff Repair
3. Knee Replacement

Reflection Focus

• Knee Arthroscopy – Plica

Reflection Model

• The ERA cycle (Jasper, 2013)

Experience

• Patient was had a knee arthroscopy 1 month ago after conservative measures failed to help with plica syndrome.
• The patient is a keen runner and was eager to try running again with permission from the physio. The session was spent in the gym and the physio guided her through some intervals on the treadmill at increasing speeds. The patient felt no pain or discomfort and the physio was happy to allow running as long as she maintained a reduced pace and shorter distances before building back up.

 Reflection

• ‘Plicae are inward folds of the synovial lining and are present in most knees.’ (Lee, 2009, p.2378).  Problems arise when the structural properties of the plica change due to an inflammatory process. E.g. Over-use, particularly in activities that require repeated flexion and extension. This matches the patient history and suggests either over-training or an increase in training volume that the body could not cope with. Therefore, I am surprised there wasn’t any further education on managing her training load post-surgery.

• I was really interested in this case as I had never heard of plica before. The physio stated it is not a very well known condition and it is often misdiagnosed as other knee pathologies, such as PFPS. This thought aligns with current literature that states synovial plicae syndrome can be difficult to diagnose (Lee, 2018).

Action

• I was really surprised that there was an anatomical structure that I wasn’t even aware of. Therefore, I am going to update my anatomy notes to reflect my new learning and I am also going to add SPS to my knee injury notes with signs, symptoms and DDX.

Revisiting Reflection

References

• Lee, P., Nixion, A., Chandratreya, A., & Murray, J. M. (2017). Synovial Plica Syndrome of the Knee: A Commonly Overlooked Cause of Anterior Knee Pain. Surgery journal (New York, N.Y.), 3(1), e9–e16. https://doi.org/10.1055/s-0037-1598047

Monday 5th July 2021

Hours: 4 (Observational)

Patient presentations:

1. Shoulder Revision
2. Knee Replacement
3. Capsular Release
4. Calcific Tendinitis

Reflection Focus

• Knee Replacement

Reflection Model

• The ERA cycle (Jasper, 2013)

Experience

• This patient was really struggling to adhere to her rehabilitation due to a period of ill health. She had kidney stones that resulted in a kidney infection; therefore, the patient was on antibiotics.
• The patient was fearful to do ‘too much’ much in the gym as she did not want to exacerbate her infection. As a result the physio focused on balance and stability exercises such as tandem stance balance.

 Reflection

• This experience highlighted that things rarely ever go to plan and that your rehabilitation programme always needs to be flexible for the patient in front of you.  Even though there are clear rehabilitation protocols for certain pathologies you cannot blindly apply the approach without knowing the patient in front of you. Furthermore set-backs during the rehabilitation process will not always be linked to the pathology itself; therefore it is important to get an understanding of a patient’s general health and wellbeing. This aligns with the teaching we have experienced, explicitly stating rehabilitation should be patient-centred.

Action

• When designing rehabilitation programmes I need to make sure I have simple progressions and regressions in place to adapt and adjust to any patient changes. Therefore, I will be mindful to include variations at the beginning of the programme design to be as prepared as possible.

Revisiting Reflection

• When starting the COVID-19 Rehabilitation Programme, I had to teach a group class to a variety of individuals of varying abilities. Therefore, I had to include progressions and regressions. All my COVID-19 exercise sessions have a suitable regression and progression. Furthermore, I will identify any issues or concerns during participant 1-1 phone calls and adjust further if necessary – see this session for an example of adapting to seated exercises.

References

Monday 28th June 2021

Hours: 4 (Observational)

Patient presentations:

1. Total Knee Replacement
2. MUA for Adhesive Capsulitis
3. ECRB release

Reflection Focus

• ECRB Release

Reflection Model

• The ERA cycle (Jasper, 2013)

Experience

• The patient was in the early stages of rehabilitation after having surgery for lateral epicondylitis. He was happy with the progress he was making; however he was complaining of tightness in his forearm. The physio prescribed eccentric wrist extension with a 1kg dumbbell.

 Reflection

• I was unaware that there was a surgical intervention for lateral epicondylitis so was unsure of what the process entailed. However, the physio iterated that the rehabilitation process would be much like a ‘normal’ conservative approach – reducing pain, restoring ROM and strength, etc. The patient was clearly in the very early stages of rehabilitation as his current prescription was exercises to improve ROM. The eccentric wrist extension was the first exercise prescribed with load. Eccentric wrist extension is an accepted exercise prescription for the treatment of lateral epicondylitis as it is activities that require repetitive wrist extension that can result in its onset (Bahr, 2012).
• Prescribing eccentric wrist extension in this instance was not only addressing the patients complaint but it is also adhering to the acute phase on rehabilitation – normalising ROM. If the wrist extensors are restricted due to muscular tightness it would not be possible to improve ROM of the wrist without addressing this limitation.

Action

• I am not particularly confident with wrist and forearm pathologies. I would have know that an eccentric wrist extension would be an appropriate exercise for this patient due to their explicit complaint. However, I believe that my knowledge in this area is lacking. As a result, I will aim to cement my knowledge and understanding of lateral epicondylitis as this is a common injury seen in practice.

Revisiting Reflection

• Not too long after this experience, a personal training client of mine fractured her collarbone. At the time we focused on rehabilitation once she was out of her sling; however, what I overlooked was the increasing amount of load going through her other arm during ADLs. As a result, a few months down the line my client developed lateral epicondylitis at the elbow of the contralateral arm. My exercise prescription included eccentric wrist extensions; however when revising for my manual therapy exams I also found evidence to suggest that METs can be beneficial for this pathology (Thomas, et al., 2019). Therefore, once a week we complete an MET which she can also replicate at home with help from her partner. I also taught her how to apply deep transverse frictions to alleviate pain and we altered her training programme so her wrist would remain in a neutral rather than extended position.

References

• Bahr, R., Mccroy, P., Laprade, R., Meeuwisse, W., & Engebretsen, L. (Eds.). (2004). The IOC manual of sports injuries: An illustrated guide to the management of injuries in physical activity. Wiley-Blackwell.

• Thomas, E., Cavallaro, A. R., Mani, D., Bianco, A., & Palma, A. (2019). The efficacy of muscle energy techniques in symptomatic and asymptomatic subjects: a systematic review. Chiropractic & manual therapies, 27, 35. https://doi.org/10.1186/s12998-019-0258-7

Monday 21st June 2021

Hours: 8 (Observational)

Patient presentations:

1. Broken Humerus Revision
2. Total Hip Replacement
3. Capsular Release
4. Calcific Tendinitis
5. Lower Back Pain
6. Total Hip Replacement
7. Shoulder Replacement
8. Anterior Knee Pain

Reflection Focus

• Anterior Knee Pain

Reflection Model

• The ERA cycle (Jasper, 2013)

Experience

• This was the first sport related injury consultation I observed. Other patient’s with sport/activity related injuries were at least 2 or 3 session into their rehabilitation.
• The consult was initially meant to be online; however, the physio contacted the individual to inform him that he could come in if he wished. As a result the patient attended the consult in person rather than virtually.
• The patient was complaining of anterior knee pain since completing a long hike for charity over a month ago. The physio found muscle weakness of the quadricep and prescribed quad sets.

 Reflection

• The quadriceps are an active stabiliser of the knee, i.e. they help to absorb ground force reactions (GRF) (Joyce & Lewindon., 2016). Therefore, weakness of the quadriceps may result in the passive stabilisers of the knee becoming exposed to increased GFR and thus, an increased risk of injury. As the patient had completed an ‘out of the ordinary’ high load/volume task the weakness in his quadricep seems to have resulted in his knee becoming exposed to more load than tolerable which has resulted in pain.

Action

• The physio had access to a database of exercises with editable sets and reps. This allowed him to easily provide the exercises and personalise them for each patient. It may be beneficial if I have access to something similar or create my own editable database of exercises for each of exercise prescription delivery.

Revisiting Reflection

References

• Malloc, C., & Joyce, D. (2016). The athletic knee. In D, Joyce., & D, Lewindon (Eds.), Sports injury prevention and rehabilitation: Integrating medicine and science for performance Solutions. (pp.322-336). Routledge.

Monday 14th June 2021

Hours: 4 (Observational)

Patient presentations:

1. Hip Replacement and Glute Medius Impingement
2. Patella Tendinopathy
3. Calcific Tendinitis
4. Shoulder Capsular Release

Reflection Focus

• Calcific Tendinitis

Reflection Model

• The ERA cycle (Jasper, 2013)

Experience

• This was the patient’s first physio appointment since having a steroid injection administered to treat calcific tendinitis. At this stage the patient was not happy with the results as she stated her ROM was limited and painful. The clinician iterated that she still needed to give the steroid injection time to work as it was ‘early days.’ The majority of this session was spent talking to the patient about returning to work and how she was coping day to day.

 Reflection

• This was a patient who seemed to be really struggling with her pain. Her mood was low and as a result she had been offered anti-depressants by her GP. She had refused them in the interim; however, it was obvious that the patient was struggling to deal with her pain and reduced function. This is likely why the clinician spent time talking about work and her general day to day life. He didn’t necessarily offer specific guidance on these matters but he just let her air out how she was feeling. This highlighted how the psychosocial elements of MSK practice are just as important to address as the physical components. The patient left feeling much more at ease after her conversation with the clinician and iterated she would continue with the previously prescribed exercises in the hope she would be better the next time she had an appointment.
• I think it is quite possible that if the session had been lead any differently that the patient may have continued to feel particularly low about her recovery and potentially not adhere to her rehabilitation as she was not seeing any progress. As a result, I found it interesting that the clinician didn’t have a specific tool as his disposal to track adherence to rehabilitation. However on further investigation, there is a lack of agreement of high quality measurement tools for exercise adherence within MSK rehabilitation (Hall., et al. 2015; McLean., et al. 2017.)

Action

• The evidence I found for measuring adherence to rehabilitation are slightly outdated. So, I am interested to see if there have been any developments within this sphere. Equally, if I find examples of how to monitor adherence I will likely implement these into my practice. As this experience has highlighted that non-adherence could indicate a psychosocial factor that needs to be addressed.

Revisiting Reflection

References

• Sionnadh McLean, Melanie A. Holden, Tanzila Potia, Melanie Gee, Ross Mallett, Sadiq Bhanbhro, Helen Parsons and Kirstie Haywood. (2017). Quality and acceptability of measures of exercise adherence in musculoskeletal settings: a systematic review, Rheumatology, Volume 56, Issue 3, March 2017, Pages 426–438, https://doi.org/10.1093/rheumatology/kew422
• Amanda M. Hall, Steven J. Kamper, Marian Hernon, Katie Hughes, Gráinne Kelly, Chris Lonsdale, Deirdre A. Hurley and Raymond Ostelo. (2015). Measurement Tools for Adherence to Non-Pharmacologic Self-Management Treatment for Chronic Musculoskeletal Conditions: A Systematic Review,
  Archives of Physical Medicine and Rehabilitation,
  Volume 96, Issue 3, 552-562, https://doi.org/10.1016/j.apmr.2014.07.405.

Tuesday 8th June 2021

Hours: 4 (Observational)

Patient presentations:

1. Hip Replacement
2. Rotator Cuff Repair
3. Flexion Deformity of the Knee
4. Rotator Cuff Repair

Reflection Focus

• Rotator Cuff Repair

Reflection Model

• The ERA cycle (Jasper, 2013)

Experience

• Two patients were in clinic to see the physio post rotator cuff repair.
• The current aim of rehab for both patients was to restore ROM; therefore, both patients were shown active assisted ROM exercises. For example, both patients were provided a shoulder pulley to take home with them to assist shoulder flexion.
• Both patients described pain and/or discomfort approaching the end of their available range; however the clinician was quick to ease their concerns. He explained that as the shoulder had not achieved that degree of ROM in months, it was likely to feel a painful and uncomfortable until it adjusts to the new available ROM.

 Reflection

• I felt quite surprised that the clinician wasn’t concerned about the pain the patients were reporting as I recall when were taught to address pain before ROM when rehabilitating an injury. Furthermore, if a patient was still in pain that this would hinder the progress and success of rehabilitation as pain would maintain a degree of dysfunction within the injured area. However, the setting in which I am being taught, although similar, is different to physiotherapy and we haven’t specifically been taught content on post-surgical rehabilitation. Therefore, protocols and expectations are likely to differ slightly.
• On further reading, I also discovered evidence to suggest that an aggressive approach to rehabilitation may be beneficial for ROM in regards to shoulder flexion post RC repair (Bandara. 2021). Furthermore, there are post-operative complications, such as adhesive capsulitis, from prolonged immobilisation (Bandara. 2021).  Both of the patients in this instance were female and therefore the early ROM exercises they were prescribed may prevent further MSK complications as well as a restore functional ROM.

Action

• This experience has highlighted the importance on engaging with evidence for different exercise protocols and not assuming that what we are taught is the only way or the correct way to approach rehabilitation. If this patient was to be rehabilitated under the principles of what I had been taught they would have received a conservative approach. This isn’t necessarily incorrect; however, if I delivered the rehabilitation programme I wouldn’t have considered a more aggressive approach thus, the patient would not have been able to make an informed choice by discussing the pro’s and con’s of either approach.
• From this experience I am interested in understanding more about pain and whether it should be eliminated entirely before commencing other aspects of rehabilitation. Therefore, I am going to explore currently accepted protocols for rehabilitation and how pain is addressed in each of these.

Revisiting Reflection

References

• Bandara, U., An, V.V.G., Imani, S., Nandapalan, H. and Sivakumar, B.S. (2021), Rehabilitation protocols following rotator cuff repair: a meta-analysis of current evidence. ANZ Journal of Surgery. https://doi.org/10.1111/ans.17213

Monday 7th June 2021

Hours: 4 (Observational)

Patient presentations:

1. Total Hip Replacement
2. Subacromial Decrompression
3. Lumbar Decompression
4. 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

Monday 24th May 2021

Hours: 4 (Observational)

Patient presentations:

1. Knee Replacement
2. Subacromial Decompression
3. 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.

Tuesday 1st June 2021

Hours: 4 (Observational)

Patient presentations:

1. Neck Pain & Headaches
2. Rotator Cuff Repair (Post-Op)
3. Total Hip Replacement (Pre-Op)
4. 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