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Edited by Garcia-Sanchez PC

1 First Edition, 2015© Second Edition, 2016© Edited by Pablo C. Garcia-Sanchez This book pretends to be an e-book and be read through electronic devices. Think it twice if you want to print it. If you do so, be sure that it is printed using recycled paper. This book is under a Creative Commons License: Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) You are free to share — copy and redistribute the material in any medium or format. Learn more about this CC license at creativecommons.org or in our web:

physiotherapyreflectivecases.wordpress.com Notice Medical and clinical knowledge are constantly evolving and changing. Readers of this book are advised to check the most current information provided on procedures featured. It is the responsibility of the therapist, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosage and the best treatment for each patient, and to take all appropriate safety precautions. To the fullest extent of the law, the authors do not assume any liability, loss or any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The authors

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Edited by Pablo C. Garcia-Sanchez

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CONTRIBUTORS Mª Dolores Alcalá 4th year student of Physiotherapy, Universidad Europea de Madrid, Spain

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Iscia Bertrand 4th year student of Physiotherapy, Universidad Europea de Madrid, Spain Pablo C. Garcia-Sanchez Physiotherapist, Lecturer, Department of Physiotherapy and Podiatry, School of Health and Sports, Universidad Europea de Madrid, Spain Gema Gallardo Sanchez Physiotherapist, Physiotherapy Unit, Fuenlabrada University Hospital, Spain Juan Antonio Gonzalez Garcia Physiotherapist, Physiotherapy Unit, Fuenlabrada University Hospital, Spain Rossella Guido 4th year student of Physiotherapy, Universidad Europea de Madrid, Spain Marta Javier 3th year student of Physiotherapy, Universidad Europea de Madrid, Spain

Greete Kriik 2nd year student of Physiotherapy, Metropolia University of Applied Sciences, Finland Guadalupe Pérez 3th year student of Physiotherapy, Universidad del Valle de México, México Laura Ponce 3th year student of Physiotherapy, Universidad del Valle de México, México Marie-Anne Rannou 4th year student of Physiotherapy, Universidad Europea de Madrid, Spain Andrea Tiberi 4th year student of Physiotherapy, Universidad Europea de Madrid, Spain Ainhoa Uria 4th year student of Physiotherapy, Universidad Europea de Madrid, Spain Davide Violati 4th year student of Physiotherapy, Universidad Europea de Madrid, Spain

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FOREWORD TO THE FIRST EDITION La asignatura “Terapia Manual Ortopédica III” pertenece al plan de estudios del Grado en Fisioterapia de la Universidad Europea de Madrid, siendo la última asignatura a cursar dentro del itinerario curricular en “Terapia Manual Ortopédica”. Las asignaturas que lo conforman son optativas y refuerzan la formación en Terapia Manual basada en la evidencia.

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Este proyecto pretende reflejar el desarrollo del pensamiento crítico y reflexivo, tan necesario para acometer un buen diagnóstico y abordaje terapéutico del paciente a través de la Terapia Manual Ortopédica. Y qué mejor manera que comenzar con los intentos que hace el estudiante con los primeros pacientes a los que se enfrenta en la práctica clínica real. En esta experiencia vivida de forma intensa por el alumno, éste desarrolla competencias como la adaptación del tratamiento a la evolución del paciente, el replanteamiento constante de los objetivos terapéuticos, o la autocrítica, habilidades básicas para cualquier profesional de la salud. Con este proyecto no se consigue únicamente un mejor aprendizaje por parte del estudiante, sino que, nosotros los fisioterapeutas con años de experiencia clínica, tomamos conciencia y recordamos la importancia del razonamiento clínico. La metodología docente utilizada es el Método del Caso, procedimiento que se adapta especialmente bien al desarrollo de las competencias descritas anteriormente; además, la labor del docente, que ha acompañado y guiado al estudiante a través de preguntas constantes, ha permitido la adquisición de un conocimiento más profundo. Nos gustaría destacar la labor del docente, en primer lugar, por plantear este proyecto tan ambicioso y enriquecedor para todos; y en segundo lugar por acompañar y motivar permanentemente a los estudiantes. Él ha sido el motor de este proyecto, gracias a su constante inquietud en innovación de diferentes metodologías en el aula, situando siempre al alumno en el centro de su aprendizaje. Por último, nos gustaría reconocer y agradecer el esfuerzo de estos alumnos que se han implicado de forma completa y que han acometido este reto como una oportunidad de crecimiento profesional y personal; pensamos que esta actitud os permitirá tener una vida más plena. Mónica de la Cueva, Beatriz Ruiz, Raquel Díaz-Meco y PhD , Physiotherapists , Lecturers, Department of Physiotherapy and Podiatry, School of Health and Sports, Universidad Europea de Madrid, Spain

FOREWORD TO THE SECOND EDITION In this second edition of the book, we were supposed to include more case studies from the students, but the number of students attending the subject during 15-16 course were too small, that we have decided to included their work at the end of this new season. Amazing projects could be launched in Education and Health, thinking out-of-the-box, and using wisely the new tools available for physiotherapists, patients and educators. For this second edition, I have invited Juan Antonio and Gema, for writing a chapter about their lovely experience about the use of a reflective diary, and the social media in the education of our students. They are in the paramount place to teach (clinical placement) and in one of the best times to impact the student (last year of university). Thanks for accept my offering. I hope you will be delight with the reading and get inspired for your daily work. Pablo C. Garcia-Sanchez Physiotherapist, Lecturer, Department of Physiotherapy and Podiatry, School of Health and Sports, Universidad Europea de Madrid, Spain

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To our beloved patients, who open their lives to us. Pablo To our teacher, to make this happen. 2015 OMT3 students

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PART 1: INTRODUCTION

Chapter 0: Introducing the project: using case reports to improve Reflective Practice and Clinical Reasoning in Physiotherapy, Garcia-Sanchez PC. Chapter 1: Use of the reflexive diary, blog and twitter in the practicum: our experience, Gonzalez Garcia JA. and Gallardo Sanchez G. 10

INTRODUCING THE PROJECT: USING CASE REPORTS TO IMPROVE REFLECTIVE PRACTICE AND CLINICAL REASONING IN PHYSIOTHERAPY GARCIA-SANCHEZ PC.

INTRO AND CONCEPTS The ability to reflect about our actions and decisions is irrevocably linked with the basics of our improvement and learning system. This way to approach learning and practice experiences try to get beyond the bare experience as a unique improvement tool, once the therapists have

To share their own clinical experiences to teachers, clinicians and peers, could be an essential activity to develop metacognitive abilities in the learning process (Sefton, Gordon & Field, 2008). Remains in the educator to plan and create the required spaces for feedback and reflection during the course period.

started their professional work, demanding the

According to Rivett and Jones (2008) “Skills in

apprentice to critically look over their own

clinical reasoning can only be developed in the

practice, with the goal of improve it.

context of clinical cases” (Rivett, Jones, Loftus &

It is considered as a corner stone in the development of expertise within a knowledge area (Jensen, Gwyer, Hack & Shepard, 2007) and it is progressively being incorporated to the graduate and postgraduate health science curricula.

Christensen, p. 477). The use of case reports to teach clinical reasoning is well covered by Rivett and Jones in that chapter. The type of case reports carried out in this project were “written cases”, with the particularity that were peer developed with the supervision and questions prompted by another student and the educator.

Clinical reasoning and reflective practice are linked through the metacognition level of reasoning and according to Jones and Rivett (2004) reasoning could be seen as a reflective process (Jones and Rivett, 2004).

Peer learning is an educational method to improve knowledge and understanding, and is broad defined in the literature. The type of peer learning method chosen for this project was what Ladyshewsky described in 2000 and

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developed through past century, specifically

thinking and reasoning through real cases. This

using the metacognition as a reflective method

book doesn´t intend to emulate our pioneers,

(Ladyshewsky and Jones, 2008).

and probably the depth of the student´s reflections won´t be the same compared with

THE PROJECT AND INSPIRATION

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these well-noun physiotherapists. But these

This book is the final product of a collaborative

student´s reflections will be productive for them

project among international physiotherapy

and will give an instant insight about what is

students

Manual

happening in the therapist-mind during the

Therapy 3", an elective subject included in the

management. We hope this could be useful for

4th year of the Bachelor Degree in Physiotherapy

others.

attending

"Orthopaedic

at Universidad Europea de Madrid. As we seen, Reflexive Practice is a key skill to The completion of a reflective case was one of

develop Clinical Reasoning in manual therapies

the activities included in the final grade of these

and other disciplines. It is one of the tools these

subject, but the presence of their cases in the

students had learnt during their stage in the

book relied on their own decision. It was guided

university on the last courses, to improve their

by me as a teacher, but the decisions of the

understanding and practice. Giving support to

whole project were made by the students. It was

our clinical decisions will allow us to improve as

completed in 3 months on the spring of 2015.

professionals and as profession.

The project is inspired in the book "Clinical

We hope you´ll find this interesting for your own

Reasoning for manual therapists" (Jones and,

practice and be inspired to cultivate this wise

Rivett,

activity as a teacher, as a student or as a graduate

2004).

In

that

book

relevant

physiotherapist show us their knowledge,

physiotherapist.

REFERENCE LIST 1. Jensen, G. M., Gwyer, J., Hack, L., & Shepard, K. (2007). Expertise in physical therapy practice. 2. Jones, M. A., & Rivett, D. A. (2004). Clinical reasoning for manual therapists. Elsevier Health Sciences. 3. Ladyshewsky, R. K. (2000). Peer-assisted learning in clinical education: a review of terms and learning principles. Journal of physical therapy education, 14(2), 15. 4. Rivett, D., Jones, M. A., & Higgs, J. (2008). Using case reports to teach clinical reasoning. Clinical reasoning in the health professions. 3rd ed. Philadelphia: Elsevier, 477-484. 5. Sefton, A., Gordon, J., & Field, M. (2008). Teaching clinical reasoning to medical students. Clinical reasoning in the health professions. 3rd ed. Edinburgh: Elsevier, 469-78.

USE OF THE REFLEXIVE DIARY, BLOG AND TWITTER IN THE PRACTICUM: OUR EXPERIENCE 13 GONZÁLEZ GARCÍA JA. AND GALLARDO SÁNCHEZ G.

The essential philosophy of the EHEA is that

INTRODUCTION

the student becomes the centre of the system. The authors are clinical teachers of Practicum II in Fuenlabrada University Hospital ten years ago.

During

this

period,

elements

of

participation that assume the philosophy of the European Higher Education Area (EHEA) have been incorporated. This chapter explains our experience of promoting a model of effective learning.

The overall effort of the student is valued, not only physical presence in a class or practices in healthcare

settings,

as

well

as

the

management of tools of learning, rather than the

mere

accumulation

of

knowledge

(Universia Spain, 2016). It is intended that the future professional will be responsible for learning on their own, to locate, analyse,

Rey Juan Carlos University and University

manage, synthesize and transmit information

Hospital of Fuenlabrada work together in

by him/herself.

teaching students in clinical practice. Physical therapy students visit our unit in their fourth course. It was considered that the orientation of the training should be directed towards the imminent

inclusion

in

the

real

work

environment. This mean a promotion of

In this context the teaching guide of the subject Practicum II proposed as a teaching strategy “knowing in action”, which can be achieved with reflective practice. The teacher or tutor has the task of stimulating this reflection in action.

autonomy in the performance of patient care, integrating all their knowledge previously

If we understand learning as an active process,

acquired.

we need to take awareness of it. We must

know about the different kinds of strategies for

and themselves as learners in these different

learning, thinking, and problem solving.

contexts (Chick, 2016). Nevertheless, we know

Students should become aware of their

that it is not a question of an easy matter of

strengths and weaknesses as learners, writers,

practising, since we have not been educated in

readers, test-takers, group members, etc.

the habit of carrying out an exercise that leads

Students have to put metacognition into

us to introspection.

practice. The metacognition is a complex

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concept

that

has

different

definitions.

Metacognition is, put simply, thinking about one’s thinking. More precisely, it refers to the processes used to plan, monitor, and assess one’s

understanding

and

performance.

Metacognition includes a critical awareness of

With these premises since the 2012-2013 we have incorporated as elements of learning and assessment a reflective diary, a blog of the subject and the use of Twitter as social network. REFLECTIVE DIARY

a) one’s thinking and learning; and b) oneself as a thinker and learner. Major and its group of study

(Labatut

Portilho,

2004)

say

metacognition is the cognition of the cognition, that is to say, the knowledge of your own knowledge. The knowledge is the object of the cognitive activity. The way a therapist clinically

With the base of the teaching guide, different aspects were incorporated as the experience was progressing and reading about other experiences was made (Martiáñez Ramírez, 2012).

reasons their findings can strongly influence

As the name suggests, it is a chronological

how the case is interpreted. It seems clinical

account of what happened every day in the

reasoning need of the sum of the thinking and

practicum. From the beginning we emphasize

decision-making processes associated with

that the diary is voluntary, although evaluable.

clinical practice (Edwards I, 2004). The way

It

how we think it will be important to make good

discoveries,

decisions and actions. Metacognitive practices

disappointments,

increase students’ abilities to transfer or adapt

expectations, events, thoughts, reflections,

their learning to new contexts and tasks. They

suggestions, explanations, etc., experienced

do this by gaining a level of awareness above

by the student. Reflection-on-action is what

the subject matter, thinking about the tasks

gives added value to the experience. It is

and contexts of different learning situations

intended

contains

that

views,

concerns,

feelings, surprises,

the

cognitive

desires, learnings, ambitions,

effort

to

remember, process, analyze and explain in

indicated that the diary demands a richer and

writing is a way to learn.

more complex cognitive effort than the simple

It is important to emphasize the consideration that the concept of Practicum has for us. According to Guijarro Martínez (2015) we prefer the term clinical education in so far as “can contribute to [the student] development not only in doing, but also in knowing, being and living “. Reasoning, critical thinking, decision making, values, attitudes, ethical behaviors and professional socialization are involved in practice and this is considered from this broader view than simply know how (Guijarro Martínez, 2015).

description. It is noted that there is an added value in this reflection that makes it necessary and, above all, useful in their present and future learning. ACTIVITIES

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Around reflection in action and reflection deferred to the end of the day, the students carry out different activities. They search images, rating scales, variants on ways to assess and treat patients, include database search strategies, incorporate links to websites and/or videos, attach annexes with these and

TASK

other contents, etc.

The first day students are received and

In our experience the weekly reflective diary

teachers explain to them, among other things,

usually contains 6 to 12 pages. It is sent at the

the tasks to be carried out during their stay in

end of the week by email to the teacher.

the hospital. In the case of the diary they are

He/she receives two or three diaries and once

told that it has to be written on a daily basis to

read, share relevant reflections with the

achieve the objectives. They are provided with

student in writing. The teacher corrects,

information on the potential contents. They

suggests, guides or compliments. The door is

have had previous and different experiences

open to discuss all this personally, making the

with a reflective diary. Therefore, they are

process something continuous.

provided with additional written information to get what we expected.

The reflective diary is, as we said, an assessment

tool.

Since

the

2015-2016

The proposed model of reflective diary is

academic year, in an attempt to be objective, a

deliberately versatile and open. However, it

rubric based on Martiañez Ramirez et al (2015)

always contains the reflection of the students

is used.

beyond a mere description of facts. If not, we

In short, reflection is used to what we have

that has to do with something related to the

been arguing. It encourages to propose

practice. Guidelines are given and they can

alternatives, rethink what has been done, said

read some posts in health blogs as examples.

or thought, to question processes, to justify, to

Most of students did not use before this tool.

drive change, to change attitudes and values. All this means work, and time. Students have

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to work at home for a stronger learning and a

ACTIVITIES

development of criticism. It will be useful for a

We want the students to make the writing

life-long-learning.

process, adding the advantages of Internet such as easy sharing, abundant information

BLOG

and resources and unlimited communication. The writing process consists of:

Student blogging empowers students to take charge of their learning, gives their learning

Prewriting: Plan the writing. It is a time to

purpose while helping with reading, writing,

think, brainstorm ideas and organize the topic.

digital citizenship, artistic, critical thinking,

Students have questions to consider: what do I

social skills, self-expression and creativity

want to say? How do I want to say it? Who will

(Huffaker, 2005). It could also increase

read my writing? What else do I need to know

students and teachers´ motivation and

to begin? Who can I talk to about my ideas?

relationship, as well as academic achievement (Read, 2006). In our opinion blogging is perfect to use metacognitive strategies. Our

blog

write it down. Create a rough copy of the writing. Students have question to consider:

“Practicasfisio”

(https://practicasfisio.wordpress.com)

Drafting: Write your first draft. It is a time to

has

been used as a teaching tool since 2014-2015

Are my thoughts organized? Which ideas do I want to develop? In what order do I want to say them? Who can read this?

academic year. Revising: It is a time to improve the writing. Change your write to make it better. Questions TASK

to consider: Should I add or take out parts?

Students are explained the steps to publish

Have I used the best ideas and words? Are my

their posts on the blog. They must publish two

details clear?

posts in six weeks. They can choose the topic

Edit: check your writing. Questions to

that includes informative tweets, mentions

consider: Are my spelling, capitalization and

and communications to students. The author

punctuation correct? Could I use any image to

also makes a proposal for other uses: academic

complete the text? Could I use some useful

information, enrichment of the educational

links to add information?

experience,

Publish: share the writing on the Internet. We emphasise the first part of the writing process where the student must reflect.

extension

of

contents

and

“twitoria” or tutorial via Twitter. Finally, Arroyo

also

proposes

some

dynamic

integration of Twitter in the classroom. With that background we began by creating an

We have published sixty posts with 7,825 visits

account named @practicasfisio. The teachers

till the date but very few comments.

had started the use of personal and collective accounts nearly two years before. Surely that

TWITTER

previous usages led to learn utilities and

Our interest to incorporate new teaching tools

potential applications and the knowledge of

led us to put in the social network Twitter in

reference accounts in the field of Physical

the practicum at the beginning of 2014. We did

Therapy. As Twitter inherent philosophy, we

not know prior experience in clinical settings of

intend to make public the contents whose

Physical Therapy or other health discipline.

usefulness or uselessness can be decided by anyone. This means that tweets should be

Social networks can be used as a learning tool by providing information and means for integration and communication (Moreno Badajós, 2016).

respectful to people and the information should not contain personal or health information related to any person. Our uses largely coincide with those targeted by Arroyo

The study of Arroyo Sagasta (2012) addresses

Sagasta, with some particularities proper to

the presence of Twitter in a particular high

the nature of the Practicum.

education academic environment, face-toface education and very different to a clinical setting, but it was our initial reference. Its description of the use of social network for teachers is done from a primarily qualitative approach and contains a list of applications

After two years and a half using Twitter the teachers appreciate it positively. However, against our prejudices, this network was not used on a daily basis by most students. Most of them do not participate regularly in Twitter

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after the practicum (at least with the profiles

In the framework of the Extension of contents

with which they did in the Practicum II).

Tweets there are links to documents, articles, videos, websites, highlighting references to

TASK

professional blogs as a source of information

It is proposed, in the context of the practicum, participate with messages of different types. Students write spontaneous comments with

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information on topics related to what happened or they have seen. They may include links to other written content, images, videos. Teachers´ participation is considered more important because of novelty and lack of

and/or debate. Questioning tweets contain questions about different dimensions of practice (methods, techniques, illnesses, etc.). Some of them encourage enquiry about ethical codes and legal aspects of professional practice. These are responded via Twitter or students are told if the answer will be in the diary or verbally.

experience in use by many students. Students are invited to participate with tweets ACTIVITIES

about the contents of the practicum, to re-

Depending on the content we can classified

tweet,

the tweets in different types.

discussions or to answer different questions

In the

to

share

information,

to

open

Information tweets the teachers use the

that appear in the practicum.

account, since the start of each rotation, with

As in the case of diary and blog, a specific

indications about tasks, linking to content

rubric evaluates various aspects of student

about reflective diary or use of blogs in

performance.

healthcare, among other things. Other uses are information about the way of publishing

CONCLUSIONS

posts in the blog of the subject, dates or

The incorporation of teaching tools described

notifications for submission of tasks, changes

in this chapter has, as their ultimate goal, to

of teachers or teachers’ absences, exam dates,

promote more lasting and deeper learning

etc. Other informations are about professional

and habits that facilitate livelong learning. For

organizations,

the authors this is an ongoing process,

announcements,

offers,

courses/conferences that may be of interest

unfinished and subject to constant revision.

for the student or for his/her

The opinion of students is a determining factor.

immersion in the profession.

imminent

We asked them and their assessment is encouraging. However, we think it is necessary

to promote continuous efforts to improve the competences of future physical therapists.

REFERENCE LIST 1. Universia España. (Junio de 2016). http://eees.universia.es/. Recuperado el 16 de Junio de 2016, de http://eees.universia.es/preguntas-frecuentes/conceptos-basicos/#4 2. Labatut Portilho, E. (2004). Aprendizaje universitario: un enfoque metacognitivo. Madrid: Universidad Complutense de Madrid. 3. Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. (Abril de 2004). Clinical reasoning strategies in physical therapy. Physical Therapy, 312-30. 5. Chick, N. (2016). https://cft.vanderbilt.edu/. From https://cft.vanderbilt.edu/guides-subpages/metacognition/ 4. Martiañez Ramirez, N. (2012). El diario reflexivo académico como recurso de aprendizaje en las prácticas clínicas: una experiencia en el grado de Fisioterapia de la Universidad Europea de Madrid. IX Jornadas Internacionales de Innovación Universitaria. Villaviciosa de Odón. 5. Guijarro Martínez, M. (2015). La educación clínica del estudiante de fisioterapia desde la experiencia de los tutores y tutoras clínicas. Estudio fenomenológico descriptivo. Bilbao: Deusto. 6. Martiáñez Ramírez, N., Rubio Alonso, M., Terrón López, M., & Gallego, T. (2015). Diseño de una rúbrica para evaluar las competencias del Prácticum del Grado en Fisioterapia. Percepción de su utilidad por los estudiantes. Fisioterapia, 83-95.

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PART 2: REFLECTIVE CLINICAL CASES

Chapter 2: A 52 yo. man who broke his arm 9 month ago and referred pain in all movement, Alcalá MA. and Uria A.

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Chapter 3: A 32 year old woman with sore thightness in the upper posterior surface of the right leg, Bertrand I. and Rannou M-A. Chapter 4: A persistent shoulder pain and rigidity in a 51 y.o woman, Guido R. and Javier M. Chapter 5: A 45 yo. garbage collector with chronic back symptoms , Javier M. and Guido R. Chapter 6: A 23-year-old female preparing for army with lower back pain for 4 weeks , Kriik G. and Ponce l. Chapter 7: A 40 yo. man with a painful shoulder syndrome, Pérez G. and Kriik G. Chapter 8: A 16 yo. female student that suffered a 2nd grade right ankle spring, Ponce delhoyo L. and Perez-Raymundo G. Chapter 9: A 57 yo. housewife with a right hemi patellectomy and tenectomy of the patella tendon after a patella fracture and a transidesmal fracture of the right fibula bone, Rannou MA. and Bertrand I. Chapter 10: A 8-year-old boy with fractures of both legs after a fall from the eighth floor of an apartment, Tiberi A. and Violati D. Chapter 11: A too early meniscal diagnosis, Uria A. and Alcalá MA. Chapter 12: Pain causing a scapular diskinesis in a 25 yo student, Violati D. and Tiberi A.

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A 52 YO. MAN WHO BROKE HIS ARM 9 MONTH AGO AND REFERRED PAIN IN ALL MOVEMENT ALCALÀ M.D. AND URIA, A.

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INTRO A 52 yo. man who had a sedentary life and one day fell down from a stone 9 month ago and

for him to relax himself, not only like stop doing something but also he can’t calm his body.

broke his arm and since that he referred pain in

The accident affect his daily life activity due

all movement and his previous treatment

the impossibility to use the hand he couldn’t do

doesn’t work but he is stressed and tired about

all that things that he usually do and he was a

this because he wants be better as soon as

little bit overwhelmed and tired about this

possible.

situation.

SUBJECTIVE EXAMINATION

He went to another physiotherapist before I

When I first met P.N was two month ago, he

met him but the results weren’t the expected.

had a lot of pain on his distal part of the left arm.

He was treated by this therapist 20 sessions

He doesn’t had all the range of motion and he

but he wasn’t happy and his problem

told me that sometimes he doesn’t feel his

continued and also gets a little bit worst.

third, fourth and fifth fingers.

He use his hand and arm like he doesn’t have it,

He works as a lawyer and he is the boss of the

also because his predominant arm is the right

association, so his life is a little bit sedentary,

arm but he couldn’t continue with this pain.

he doesn’t like practice any sport but he love to go to the theatre, cinema and going out for

STUDENT REFLEXION AFTER S/E

dinner with his wife. We can say he likes doing

With this presentation of P.N I think that he

relaxing things, because in his work he had a

has neurogenic and muscular damage.

lot responsibility and he is stressed. He told me

The main problem is the fracture that he

he is very active: because he usually have a lot

suffered at the radio and the consequences are

of things to do at the same time, being difficult

the affectation of muscles and nerve. He has a

Q2: Didn’t you think about the possibility of the

long period development of the pathology so I

ulnar nerve being damaged too because of the

know that the fracture is solved but I have to

alteration in the sensibility of the fourth and fifth

work on all the tissue that are affected to mend

fingers?

the neurogenic problem. After S/E I think that the median nerve is affected so I will check at the elbow and the wrist.

A2: No, because the ulnar nerve’s test was negative and because in the electromyography we saw the damage of the median nerve.

For the flexors and extensors muscles I have to recuperate all the range of motions and then I can work out to improve the debility that he has.

TEACHER ADVICE Choosing high evidence-based tests will add to your reasoning better ingredients to make a good

My patient start the treatment very stressed because he wants to be better but he saw that the last treatment doesn’t work but now I can see

decision. Regarding to the neurodynamics issues, we need to discriminate among tests assessing roots, nerve trunks and main nerves.

how he is more animate and positive. So far, ULNT3 hasn´t demonstrate high sensibility The last treatment was about massage on the arms to relax the muscles and use ultrasound and

and specify. So, adding your inexperience, we need to take with precautions

laser therapy, but it doesn’t work. PHYSICAL EXAMINATION QUESTIONS TO IMPROVE REFLEXION

First of all my patient has a diagnosis before I met

Q1: How did you know that radio´s fracture was

him, so in part he knows what he has, but nobody

already cured, just because of the time that had

stopped one moment and tell him the exact

passed since the fracture took place or you had

information about which parts of his harm and

photographical evidence? And do you know if he

hand were damaged and the different part of the

used any orthotics after the fx and for how long?

treatment.

A1: I know it because I saw the MRI so I have the

Firstly I spend time to explain him exactly which

photographical evidence and I’m sure about the

are the tissue he had affected than I started with

consolidation of the fracture. No, he didn’t use

the P/E and with the medical diagnosis I build my

any orthotics after the fracture.

hypothesis and I started from the elbow and I

23

saw that he has all the range of motion and no

QUESTIONS TO IMPROVE REFLEXION

pain, so I passed to the wrist.

Q1: You´ve said you had all the information

In the clinical history of my patient I had all the information about ROM, BM, damage and all about the problem but I think that I had to explore all and plan my own treatment

24

because the one he has received doesn’t work. On the wrist I tested the range of motion and muscular balance.

about ROM and BM… but it´s no clear which joints are you talking about when referring to ROM or which muscles BM are you testing. A1: I referred to wrist’s joint and all the extensors and flexors muscles. Q2:

You´ve

said

you

started

physical

examination from the elbow. Why didn´t you start at a higher level, for example, from the

With neurodynamic technique I tested the

shoulder?

ulnar, median and radial nerve to see if the

because of the damage of someone of this.

A2: Because of his mobility and his pain I supposed that the shoulder shouldn’t suffer any injuries, so I decided started from the elbow.

STUDENT REFLEXION AFTER P/E

Q3: Did you assess any reflexes or sensations

The anterior diagnosis showed me which part I

apart from making neurodynamic techniques?

debility and the strange sensation he had were

had to test but I decide made my own P/E to start another time from the 0. I had no contraindications for P/E so I tested

A3: Yes, I assess the sensation with different type of touch on his arm and hand but the only think he feels is tingle sometimes on his hand so I decide to make neurodynamic techniques

without any problem and I saw that he had a restricted range of motion in all movement of

PATIENT MANAGEMENT

the wrist and some alteration of the sensibility on the hand. But the most important thing that

DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN

I saw is that the necessity of my patients is to

My goals are:

knows because I do one thing and no other because he was saturated and tired that people tell him what to do but not encourage

-

Improve the range of motion of the wrist

-

him and not explain him nothing.

Improve straightness of flexors and extensors muscle

-

Eliminate the pain

-

Recuperate the sensibility

-

-

Change the treatment from the

mobilizations if the pain decrease or increase

anterior

and I saw that the pain decrease.

Increase the motivation of my patient and improve self-confidence

Now I had to search a new treatment because the anterior doesn’t work.

After that I started forced the end of the movement to start improving the range of motion. To terminate the session I started stimulate

I know that my patient needs something more

the sensibility on the hand with different type

than a simple massage and I think that the

of touch and with complete extension and

ultrasound and laser didn’t have any benefice

flexion of the fingers on the active form.

in this case. After that I had to animate my patients and explain him that now we going to use new treatment and that he has to be patients and trust on me but I know that at this point maybe it can be difficult.

STUDENT REFLEXION AFTER D1 TREATMENT At the end of the session my patient referred that the pain decrease and a sort of liberation on the wrist. I saw that something change, he

First of all I focus my attention on the wrist and

was more animate than when he arrived at the

the movement of this because he had a big

session.

restriction of all movement and at the same I work on the median nerve and the sensibility.

This process was different from the previous and at the beginning the patient was a little bit

DAY_1

insecure but I could see how it works and also

I told him to take some posture of the wrist in

him could see that from the first session we

which he doesn’t feel pain and I make the same

had some results so I will continue with this

thing for the elbow to see when the pain

treatment.

appear. QUESTIONS TO IMPROVE REFLEXION After that I saw that the elbow had no restrictions and no pain so I focus on the wrist. I make mobilization fixing the radio than fixing the ulna. After that I did the mobilizations of all the bone of the hand. I make all this movement in the passive form and evaluating after all the

Q1: What happened with the sensibility? Did it improved? A1: At the moment I didn’t know because I had to wait the next sessions and see what happen in those days and text it in the next session.

25

DAY_2 Firstly I test the movement and the general state of the wrist to saw if he had maintained

days he doesn’t feel nothing strange about his fingers.

the resulted we reached in the anterior session

Now I started work on the strength of the

and it was ok.

muscles with resisted movement firstly than

After that I do the same treatment because I

26

Also the sensibility was better because in those

saw that it works, also I started work with

we use the electro stimulation of the flexors muscle with a dumbbell of 0.5 kg.

resisted movement at the same time he was

Finally I work releasing muscles in general to

with the electro stimulation and I saw that he

avoid the overload.

can do it perfectly even if with a little bit pain at the moment of mayor tension of the muscles.

On the next session I saw that the treatment work out so I continued with this and increase slowly the kg of the dumbbell.

At the end I relaxing the flexors and said him to make the same exercise at home with a little bottle of water.

I think that the prognosis is good because my patient was satisfied with this new treatment and was more animate and participate.

DAYS 3-4 After that I can say that the part of the In the next session my patient referred less

treatment

pain and more agility on the movement so I

mobilization of the ulna and radio in all

decide to continue with this treatment.

direction because after that was the moment

that

works better

was

the

in which I started to see important change in the evolution of the problem

FINAL STUDENT REFLEXION I think that at the moment in which I met my patient I had apparently all the information I need for my clinical reasoning. I had the information from the medical diagnosis, from the anterior treatment but it wasn’t enough because there was something that doesn’t work, so thanks to my examination I discovered the main point of the problem. All this means that even if you apparently had all the information you always had to search more and more to have a complete clinical reasoning that is the main point for a successful treatment.

REFERENCE LIST 1. S. Jimenez del Barrio, M. Fortun Agud, N. Pascual Lanuza. E. Bueno Garcia, E. Estebanez de Miguel and J.M. Tricas Moreno (2013). “Reliability of upper limb neurodynamic test for range of movement and symptoms localization variable”. Cuestiones de Fisioterapia 281-289.

27

A 32 YEAR OLD WOMAN WITH SORE THIGHTNESS IN THE UPPER POSTERIOR SURFACE OF THE RIGHT LEG BERTRAND I. AND RANNOU M-A.

appendix a year and a half ago and that she still

INTRO A 32 years old woman attends a physical

28

therapist due to sore tightness in the posterior surface of the right leg; ischiotibial level. High-

doesn’t feel 100 percent “good”. She feels tightness and bloated all the time in the area and has digestive discomfort since then.

level runner, the pain began and gradually

She is a very health, energetic,

worsened 8 month after being operated from

sympathetic, open minded, athletic young

the appendix.

woman

who

has

no

relevant

family

antecedents, doesn’t smoke and sporadically

SUBJECTIVE EXAMINATION

drinks alcohol in social events. She would run

A 32-year-old patient entered the

an average of 10 kilometers a day and was

consultation and started explaining her

getting ready for an important race that

condition. For a few month now, she started to

needed a lot of training. She works long hours

feel pain in the upper posterior surface of the

behind a desk and seems to be very unsatisfied

right leg while jogging; right underneath the

with her job. She loves outdoors activities and

ischium. At first she could cope with the pain

never misses an opportunity to join a group to

but as time went by it worsened to a point

participate in the event.

where it forced her to stop jogging. She would feel the pain during the terminal swing and beginning of the propulsion phase of the human running locomotion cycle and would increase when running up steep hills. The pain would also appear while she blow-dried her hair in a bending over position and occasionally, complained of lumbar pain. Continuing

to

STUDENT REFLEXION AFTER S/E About my initial hypotheses about the sources and pathobiological processes was that she could have a tendonitis of the proximal insertion of the hamstring muscle due to overuse and maybe some active trigger

gather

useful

information about her case, she mentioned that she underwent surgery to remove the

points in the gluteus area.

She didn’t present any warning for

Q3: So far, what is your thinking about the appendix-release issue in her actual clinical

examination contraindications. My first impression with her was quite optimistic. Her positive and energetic attitude

presentation? A3: It is explained further.

was quite freshening; making it easier to create a physiotherapist- patient bond of trust.

TEACHER ADVICE

Even thought I knew that her condition was

Irritability means about the property of patient´s

also affecting her psychologically, since it

current presentation reacting to any stimulus,

limited her ability to perform the activity she

and it is not directly related with the amount of

loves most well, she always managed to keep

affected activities or participation. It´s used to

a positive and open-minded attitude about it;

be more related with the severity of the

listening and cooperating with us during the

presentation. In our management it is usually

treatments and completing her “home work

linked with the quantity of mechanical stimulus

assignments”.

needed to cause patient´s symptoms and their length. This quality will suggest the extension

QUESTIONS

TO

IMPROVE

REFLEXION Q1: How does she feel about her pathology? A1:

and the level of depth of our exploration procedures.

PHYSICAL EXAMINATION

Haven’t asked her but I think she is

Although she seemed like a joyful,

annoyed about the fact that she can’t run as

optimistic and stressless person during the

long and as well as she did before and anxious

sessions, I wanted to know how she was in a

to get better.

work-like environment; to see her stress levels

Q2: So far, what is the level of severity and irritability of her clinical presentation?

and if it had an impact on her. It turned out that during her working hours she’s quite stressed out because of the bad ambience there is at

A2: The level of severity of her pathology is

work and admitted that she eats fast sugars to

minimum but the irritability is quite high since

quench her anxiety.

it’s affecting her daily life activities. I started the physical examination by palpating the right proximal insertion of the ischiotibial’s but she felt very little pain

29

compared to the one she used to while running. Like I mentioned earlier the pain appeared during the terminal swing and beginning of the propulsion phase of the human running locomotion cycle and would increase when running up steep hills. The pain also appeared while

30

performing

a

resisted

isometric

contraction of the hip in extension and of the knee flexion; to test the ischiotibial and gluteus muscle. Body chart representing her pain. She also had active trigger points in her right gluteus muscles and a blocked

STUDENT REFLEXION AFTER P/E

sacroiliac joint because of the hypertensions of

About my initial hypotheses I met

the buttocks muscles. Her pelvis was in a slight

consistent findings about the implications of

anterversion position and her body slightly

trigger points in the gluteus muscle but not

leaned forward. Sometimes she complains of

about the tendonitis of the proximal insertion

lower back pain.

of the right hamstrings.

I decided to then explore her iliopsoas,

It is clear that she has musculoskeletal

witched showed to be rather painful (both of

dysfunction for, as mentioned in the physical

them). And the scar left by the appendix’s

examination part, she has reduced muscle

surgery was ridged, fibrotic, adhered to

strength and a slight anteversion of her pelvis

connective tissues below and painful on

with a semi blocked sacroiliac joint; but I keep

palpation.

asking myself why? How is it that in less than a year, gradually, has she been feeling pain in

Muscle group

Grad (0-5)

Ischiotibial muscles

4

Hip abductors

3+

Iliopsoas

3+

the posterior part of her leg when she’s been running all her life since the age of 17? Its not like she’s not physically prepared; she is very athletic and physically strong. The pain came gradually, little by little

Muscles’ Power

since the surgery. I think that the surgery and

the scar left behind are partly the reason and

PATIENT MANAGEMENT

origin of all the simtomatology of why she is

DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN

complaining of isquion pain. Due to the aggression her body

I think the pain she’s is feeling on the posterior

underwent with surgery, I think she adapted

surface of the right leg is caused by an overload

analgesic positions wile running in order to

of the isquitibials muscles due to the pelvis

reduce the abdominal tension and pain

anteversion, gluteus weakness and lumbar

acquiring

pain; all of which is caused by an incorrect body

an

erroneous

body

position;

triggering an imbalance between muscle

position.

groups forcing some to work more than others. Since she is a young athletic woman her prognosis is good. She is willing, eager to get

QUESTIONS TO IMPROVE REFLEXION

better and does everything possible in order to

Q1: Was anything done with respect to her

achieve this goal. However she is very

digestive tract symptomatology?

impatient, and so whenever we achieve to reduce the pain, she forces her leg more and

A1: Yes, due to her digestive discomfort of tightness

and

bloatedness,

she

relapses.

was

recommended to take probiotics for a month

DAY_1 + 2

and to drink a lot of water in order to rebalance

The first day she came to get treated, I applied

her intestinal flora. (It was very useful) .

analgesic electrotherapy for 20 minutes on the upper posterior surface of the right leg to

TEACHER ADVICE

reduce the pain.

Facing a high irritable presentation as you suggest, involves to take some extra precautions

Afterwards I did massage therapy on the

during the physical examination. In your case,

iquioteibials muscles to relax the muscle as

probably this means to explore carefully the

much as I could to see if in doing so, the pain

myofascial trigger points, and do not stress the

would reduce.

common ischiotibialis tendon to the extent you couldn´t continue with the P/E routine.

I explained to her what I thought what going on and the biomechanical of her lesion. I asked her the next time she goes for a jog that she should take smaller strides to reduce the hip

31

flex/ext amplitude and the force exerted by the muscles.

DAYS 3- 5 Natalie, as expected, commented that the few

I ended the session with passive stretch of the

days following the treatment she noticed

isquioteibials muscles and the gluteus muscles.

improvement but then it went back to the original pain.

STUDENT REFLEXION AFTER D1+D2 TREATMENT 32

The patient was able to do the movement of bending over and touching the ground (movement that she couldn’t do without pain) with a 40% decrease of pain. I’m glad I managed to reduce her pain although I expect it wont last long since I didn’t treat any other areas due to lack of time.

So for the next few sessions I mostly insisted on working on reducing her pelvic anterversion with

manual

therapy

techniques

and

increasing the sacroiliac joint mobility. I would also work on her scar; reducing the fibrotic, adhered tissues and making it more flexible using “ventosas” and massage theray. Treating her iliopsoas was also important to relieve the tensions and reduce the back pain

QUESTIONS TO IMPROVE REFLEXION Q1: About the pelvic anteversion: Why did you

she would complain from time to time. I showed her how to stretch it and told her to stretch it as least once a day.

chose to treat only the joints and not for example, her abdominals?

For the isquiotibial, I gave her exercise to do at home to strengthen it. Eccentric exercise. And

A2: Interesting point, I didn’t think about it; but it would of have been an additional effective

strengthening

exercise

for

her

gluteus

muscles.

treatment. I will take it into consideration for next time.

STUDENT REFLEXION

TEACHER ADVICE

The pain reduces progressively. It seems that

A test-treatment will allow you to get invaluable

we are on the good path.

information about the condition of the presentation. Using the results of the treatment

QUESTIONS TO IMPROVE

as another piece of evaluation could inform you

REFLEXION

how to treat your patient properly

Q1: How does she feel about her treatment?

A1: She was very grateful. She knows the

To strength the tendon elastic properties will be

progress is slow and that she needs to be

a required goal in most tendon issues

patient. But as the sessions passed by, she

presentations. On the other hand we could not

would notice positive changes and that little by

forget the muscles power training. There are

little the pain reduces.

recent published evidence to relieve tendon pain using isometric, contraction, which should

TEACHER ADVICE

helped with your patient too (Rio et al. 2015)

33

FINAL STUDENT REFLEXION Natalie was improving slowly but surely. I think that the fact that she was really motivated actually helped a lot with the healing process. There were ups and downs during the duration of her rehabilitations but we managed to resolve all the problems and move forward to try and achieve a full recovery.

REFERENCE LIST 1. Daniel Cushman, Monica E. Rho et al (2015). “Conservative Treatment of Subacute Proximal Hamsting Thendinopathy Using Eccentric Exercise Performed With a Treadmil.” Journal of Orthopaedic and Sports Physical Therapy. 0;0(0):1-24 2. White, K. E. (2011). High hamstring tendinopathy in 3 female long distance runners. Journal of Chiropractic Medicine, 10(2), 93–99. doi:10.1016/j.jcm.2010.10.005 3. Sherry, M. (2012). Examination and Treatment of Hamstring Related Injuries. Sports Health, 4(2), 107–114. doi:10.1177/1941738111430197

4.

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine, bjsports-2014.

A PERSISTENT SHOULDER PAIN AND RIGIDITY IN A 51 Y.O WOMAN GUIDO R. AND JAVIER SIMON M.

34

INTRO

M. cames showing an antalgic posture that

The patient is a 51 woman that refers pain,

strikes me: aproximation and internal rotation;

especially during the night and stifness in her

holding the affected arm with the other.

left shoulder since 9 months ago. She was initially treated for a supraspinatus tendinitis, with poor results. She

came

to

consultation,

referring

a

symptom’s change and helplessness of not being able to accomplish daily things.

The symptoms have started nine months ago, when she was working in Germany. She doesn’t remember any direct trauma in the arm. She kept in mind that one day rising in the morning, she started having a not well localized acute and annoying pain in her left shoulder,

SUBJECTIVE EXAMINATION M. come to visit in November, talking about a dull and continuus pain and stifness in her left shoulder, that prevents her to carry on

especially during the night. This lack of sleep caused her a lot of tiredness and anxiety, with the consequence of not being able to work and take care at house chores.

movements of daily life, for example when she combs her hair, and paints (a passion of her).

She thought that the intake of medication was

She works as an architecht on her own and she

the only way to fight against the problem. She

is married, with a German man, for 25 years.

started taking medications (NSAIDs) to slow

Unfortunately they have no children, due to an

down the symptoms, but this forced her to be

histerectomy she underwent at 32 yo.

dependent on medications.

She’s a busy woman, who worked around the world, especially in Germany where she was living since 6 months ago. Her husband continues to work there, and being away from him, overwhelms her a lot.

After a months of acute pain, under the advice of her husband, she decided to attend to a physiotherapist. She was treated for a supraspinatus tendinitis for two months, with poor results.

The symptoms increased over time and a arm

symptoms change could be a evolution of this

rigidity began to manifest, that prevents her

first problem.

from moving it. When I asked her if the pain, after treatment and a few months later, was always the same or if she noticed change, her response was :“At the

There is also a emotional component that compromise the evolution and the mood of the patient.

beginning the pain was severe and sharp, to the

M. is feeling alone, because her husband is not

point of crying for the pain. After the treatment

with her and the pain and rigidity prevents her to

I noticed a small change in the pain quality. It

have a normal life and to perform her hobby.

wasn’t too acute and I was able to rest a bit more.” After the failed treatment, due to family reasons, she had to come back to Spain, and even she presented symptoms, she did not intend to attend to another physiotherapist. The months passed, the pain was still present,

I don’t think the disease is related with a tissue damage, instead with a progressive disease: her problem could be a tendinitis sequel and shouldn’t be related, considering her symptoms evolution, with soft tissues and bones damage surrounding the shoulder.

and rigidity even more.

She’s very disappointed with her anterior

Desperate for being unable to move her arm,

treatment and think that her problem has not

rest and have a normal life, she decided to go to

solution.

a physioterapist practice. At the present day, the patient is not motivated and thinks that her problem has not solution. M. has hypothyroidism and take daily medicine for this problem. She has been smoking a packet of cigarettes a day for 15 years, and she is an occasional drinker. STUDENT REFLEXION AFTER S/E I think her symptoms are related with the pathology diagnosis. The supraespinatus tendinitis could be a consequence of her actual presentation and the

I need to attend emotional issues in her presentation. I’ll return considering this point after the physical examination. QUESTIONS TO IMPROVE REFLEXION Q1: Do you think that could be related with a visceral problem, for example with a lung problem, like she is a smoker, and a lung problem refers pain in the shoulder? A1: I’d have considered it in the physical examination.

She was asked to do several

35

exams for discard associated diseases and, in

literature to follow routinely. Sometimes is

particular, the chest radiography was normal.

interesting to give this list to the patient in the

I think that can’t be a reffered pain of a visceral disease: M. doesn’t have related sympthoms

waiting, before entering the assessment room and check with her later the specifics.

and she refers, in the following physical

36

examination that her pains is triggered and

PHYSICAL EXAMINATION

increase with movements.

Before the physical examination, talked to me

I will deepen this thought in the rest of the issue.

that she did, a shoulder radiograph and a chest radiograph to discard other pathologies. In both

Q2. So far, which is your hypothesis about the

cases, the radiographs were normals.

pathobiological issues and pain component? A2: My hypothesis is about a nociceptive and somatic pain that starts with an inflammation presentation. With the passage of time this

I decide to ask her other questions about her life, before starting the physical examination, specially about her hobbies.

inflammatory pain become chronic and the

M. tells me that she paints since she was 20 yo,

inflammatory symptoms make space for

and it was a very strong passion for her.

stifness and a adhesion role. She used to paint, 5/6 hours a day, with both Q3. Which could be the role of hypothyroidism in

hands alternately. She’s ambidextrous.

her presentation? I start the physical examination with the visual A3: Oliva,Berardi, Misiti, Maffulli (2013) noticed that thyroid diseases should be linked to idiopathic tendinopathies and as Sardella White and Garbe (2010) found the hypothyroidism

inspection. I detected the left shoulder higher than the other one and in antepulsion, also the protracted left scapula. Muscle atrophy of the shoulder girdle was present too.

could be a risk factor for the joint. I detects also upper trapezius hypertone. Her first tendinitis could be related to her hypothiroidism

disease,

that

could

be

considered like a predisposing factor. TEACHER ADVICE Ruling out red flags in the S/E has to be a wise option. There are several list s of questions in the

The colour of the skin in general and in particular in the shoulder area is normal. Palpation produces pain of subscapularis (VAS 6/10) and deltoid (VAS 5/10).

The passive movements exploration of

left

The active movements exploration refers similar

shoulder refers limitation in all movements with

limitations and pain: 70 degrees of flexion, 25

a not well localized pain (VAS 6/10), in particular

and 35 degrees respectively of external rotation

in abduction and external rotation.

and internal rotation and 55 degrees of abduction. (Table 1) The patient isn’t able to perfom power testing because she refers so much pain and releted weakness.

Subescapularis pain: blue

Deltoid pain: red

Subsequently I perform a provocative test for cervical radiculopathy, the Jackson’s test, and the Adson’s test to discard a thoracic outlet syndrome. Both tests were negatives. I perform also any special tests that help me to

Not well localized pain

diagnose a possible disease, like the Apley Scratch Test and the Shrug Sign as McFarland and Kim (2006) shown. The negative test performed is the O'Brien's test (to exclude SLAP lesion). After the P/E, the patient refers me to be very afraid about the diagnosis and sad. I recommend her to attend to a doctor ,with the suggest to have a MRI, to better diagnose.

In passive flexion the patient can’t move beyond 85 degrees. The external and internal rotation are respectively of 30 degrees and 40 degrees; in the abduction the patient presents 60 degrees.

37

38

ROM

F

IR

ER

ABD

Passive

85°

40°

30°

60°

Active

70°

35°

25°

55°

problem have no solution, could be a problem during the treatment and the disease prognostic. QUESTIONS TO IMPROVE REFLEXION

Table 1 (F:Flexion; IR:Internal rotation; ER:

Q1: Has your patient any red flag or yellow flag

External rotation; ABD: Abduction)

regarding the physical examination procedure?

STUDENT REFLEXION AFTER P/E I discard the possibility of a visceral and referred pain. The patient doesn’t refer any related symptoms and the radiographs were normal. An important aspect is that she’s ambidextrous. Repetitive movements with her left shoulder, associated with hypothyroidism, could be related with her disease. Passive and active motion limitation makes me think in structural changes in the periarticular structures. These changes could be the results from a combination of an initial inflammation and immobilization (caused by the pain). The positives findings show me that the patient range of motion is affected, and help me to exclude pathologies like cervical radiculopathy and SLAP lesion.

A1: No, there weren’t red flags to perform the physical examination. The yellow flags are the low motivation of the patient about the treatment, the sadness for the absence of his husband and for not being able to perform her hobby and passion. Q2: So far, which is your first hypothesis with the data coming from C/O and P/E? Which is the data supporting this hypothesis? A2:

Her associated disease, the symptoms

change, and particularly the descreased passive range of motion, makes me think in a joint pathology, started with inflammation and then became chronic. I wait the MRI result that can help me to diagnose a specific disease. TEACHER ADVICE There should be findings in these 2 first steps of the clinical encounter that have to correlate

Another aspect to take into consideration is the

among them. As S/E comes firsts, usually points

emotional role in the patient disease. After the

out which areas have to be evaluate in the P/E,

physical examination I can say that there is an

and what should expect to find there. If we don´t

emotional and no only a physical aspect that

find these relationships, we need to keep going

afflict the patient. The patient’s think that the

with new questions and proceedings until we´ll reach a point to make a clinical decision. If there

are not present any severe signs or symptoms we

DAY_1

should continue this assessment into the next

My aims for the treatment are principally

session.

to release the pain and to increase the shoulder range of motion.

PATIENT MANAGEMENT

I

DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN

mobilizations in all directions. During the

MRI reveals a reduced capsular volume with

pain,

absent inflammation.

mobilization, in all movements, saying

started

with

shoulder

joint

mobilization, the patient refers a lot of especially

in

the

end-range

that she wouldn’t continue with the With this ulterior test and the P/E results I can

treatment.

say that the patient is affected by adhesive capsulitis in the “frozen phase”.

After spending time to reassure the patient, I continue the treatment with a

The symptoms show me that the patient presents a degenerative and chronic disease

soft tissue massage to reduce the stress and relax her.

that started with an inflammatory stage. The first day of treatment ends here. The initial tenditinis, the repetitives movements painting and working, with her hypotiroidism

I explain her that the prognostic could be

problem, could be risk factors of the next

good only if her works actively with me,

shoulder disease.

and that I can understand the pain she feel and can help her.

To have a good prognostic I must work the emotional role of the patient, explain the

At the end, the patient promises that will

following treatment and reassuring her.

try to have a positive role during the treatment.

However, the prognostic should be positive, if the patient follows the treatment with a positive

However, the patient feels very tired and

attitude.

negative and decides to go home.

The plan starts with a progressive treatment, helping the patient to understand her disease and treat it.

39

STUDENT REFLEXION AFTER D1 TREATMENT

motivated. The emotional role of the patient is

The first day of treatment was a disaster. The

her family is an additional drive to carry out the

patient was very negative about the treatment.

treatment.

Pain at end-range in all directions, typical of

M. was more positive and the treatment

adhesive capsulitis, prevented me to continue

continued normally.

very important, and the love and the support of

the treatment in a good way. I

40 I hope she will change her negative attitude. I must insist with the treatment and teach her to understand that the pain is part of the journey toward recovery.

started

with

shoulder

intensive

joint

mobilizations, passive, active and resistive kinesiotherapy. The patient felt pain, but she was able to withstand it. The treatment keep on with shortwave, for about 10 min/session, to increase tissues

QUESTIONS TO IMPROVE REFLEXION

temperature and improve motion and elasticy.

Q1: What do you think that you can do to motivate your patient to keep adherence of her

After one week of treatment the ROM of the shoulder improved of 15 and 10 degrees in

treatment?

flexion and abduction, while in rotational A1: To motivate my patient I can express my

movementes the degrees remain unchanged.

empathy

Anyway the patient was more motivated, than

and

explain

her

the

program

treatment and the benefits of it. The patient

the first day of treatment. (Table 2)

should have, also, the support of her family, helping her to keep adherence to the treatment and feeling motivated.

In the following treatment sessions, I added Codman’s Pendulum exercise for shoulder, to improve ROM and decrease pain; closed and

DAYS 2-4

open kinetic chain exercises, like lean the hand

The following days of treatment were different

against the wall or with a ball against the wall

compared with the first one, maybe because her

doing

husband returned to Madrid, to support her

articular stability, neuromuscular control and

wife. The husband presence influenced the

coordination.

treatment, helping M. to have an active role in the treatment program and to be more

diferents

movements,

to

improve

After 20 days of treatment the shoulder passive ROM improved of 20 degress more in flexion

and abduction, 15 degrees in internal rotation

could be: in a supine position getting the arm up

and 10 degrees in external rotation. The end-

overhead while lying down, using the opposite

range pain decreased in all movements. (Table

arm to holding it; getting the arm to externally

2)

rotate while standing, opening and closenig a door; Internal rotation could be performed using

STUDENT REFLEXION

a towel behind the back, relying on the right

The treatment’s results were good. I think this

shoulder to stretch the affected one.

treatment program is adequately and efectively in the patient presentation. Also, the emotional role of the patient changes and she’s very happy for the treatment and the results.

Q2.Which part of your management do you think has worked better and why? A2: I think the part, which was worked better was the treatment plan, especially from day 2. I planned exercises that could be appropriate for

I am very motivated and satisfied about the

the patient presentation. The anamnesis and

treatment results.

the physical examination helped me to diagnose the patient disease and to produce a treatment

I think that if the treatment will continue in this way, I will be able to improve more shoulder

plan that could be good for the patient. The

motion and decreased pain definitively.

results revealed to me that the treatment plan was good. The ROM increased, the pain

QUESTIONS TO IMPROVE REFLEXION Q1: Do you think that is useful and a good idea to recommend her to do some kind of exercises in her home? A1: Now that she begins to be motivated, I think

diminished, and the patient now is more motivated and can move forward to a symptoms improvement and a better recovery. Table 2 (F:Flexion; IR:Internal rotation; ER: External Rotation; ABD: Abduction)

it’s the better time to recommend her some

P-ROM

F

IR

ER

ABD

home exercises, because she’s more prepared to

After 1 week

+15°

/

/

+10°

keep adherence to the treatment and to have a

After 20 days +20°

+15°

+10°

+20°

Present-day

55°

40°

90°

active role in the recovery. Some exercises 120°

41

FINAL STUDENT REFLEXION This clinical case made a significant contribution in my professional and human growth. I learned to have empathy with the patient. It’s important to help the person also in her emotional issues. At the beginning was complicated to analyse the patient’s symptoms, but with the physical examination and the tests I was able to diagnose the disease. The emotional role of the patient had an important influence during the treatment.

42

I learned that the family and psychological support is very important for the patient, especially in patient with a long-term disease. The treatment results makes me think that I had plan a good treatment program for the patient, although still have a long way to go before she can be considered completely cured. REFERENCE LIST 1. Sardella White, S., & Garbe, J.R. (2010). Thyroid Disease: Understanding Hypothyroidism and Hyperthyroidism. Boston: Harvard Medical School. 2. Oliva, F., Berardi, A.C., Misiti, S., & Maffulli, N. (2013). Thyroid hormones and tendon: current views 3. and future perspectives. Concise review. Muscles Ligaments Tendons J, 3(3), 201-203. 4. McFarland, E. G., & Kim, T. K. (2006). Examination of the shoulder: the complete guide. Thieme.

A 45 YO. GARBAGE COLLECTOR WITH CHRONIC BACK SYMPTOMS JAVIER SIMON M. AND GUIDO R.

INTRO My reflective clinical case is about a 45 years old male who has pain in the cervical region, lumbar region and dizziness, didn’t suffer any direct trauma, may be related to his job,

I asked him what could be the consequences of his symptoms and he told me that his job as required gain weight because it was operator of garbage. When he described his work he commented that it was not at all satisfied.

garbage collector. The symptoms could be

He commented that did not perform any

related with a slipped disc (medical diagnosis),

hobby or sports, which can lead us to think that

and may be with other aspect like mood.

their emotional level is low, because if work

SUBJECTIVE EXAMINATION

does not satisfy you and no activity that does.

The first day the patient came to the

The most relevant symptoms was neck pain,

consultation derivative of general medicine

back pain, pain in the chest area and tingling in

with sick leave.

superior limbs. Because these symptoms were chronic, he told me that he had made some

My first impression of the patient was a sad and worried person, as he sat in the waiting room without speaking to anyone. When he started to talk to me, commented that he was married and lived with his wife and

treatments before, as Pilates, and private physiotherapy, he improve a bit, but the symptoms did not quite disappear. He hadn´t pharmacological treatment, nor had any personal history that might be related.

son. Only had a family history of osteoporosis and He had pain in the cervical and lumbar from

arthritis.

several months ago. The patient described the pain as annoying, with tension and sometimes

The patient described the pain in the morning

radiated.

with a 9/10 on the VAS scale decreased throughout the day up to 5/10.

One thing that struck me about his pain was that it hurt in any position and any movement.

43

I decided to return to this sphere during and after the physical examination (P/E). QUESTIONS TO IMPROVE REFLEXION Q1: What kind of chest pain he felt and during which movements he felt it? A1: This pain was produce by a antalgic posture,

44

in the physical examination I found that the Pectoralis minor muscles was shorted and had active Miofascial trigger points, and in the visual examination the shoulder was in internal rotation. STUDENT REFLEXION AFTER S/E About my initial hypotheses the symptoms are

I know it, because he felt pain in the stretch and palpation of these muscles.

related with the medical diagnosis, but I think that are something emotional that has been

Q2: Is there any red flag in the history you have

influenced in the perpetuation of it.

to rule out first?

I don´t think that could be related with arthritis or osteoporosis because in the medical test aren´t any signs which has any relation with

A2: No there isn´t any red flags. I can consider a yellow flag the emotional feels of patient and the relation with the pathology.

patient´s symptoms. Q3: So far, which is your guess about the At that time I did not consider the patient's

relationship between the main symptoms?

posture, but because of the knowledge acquired in other subjects this year I could associated to a string anteromedial (AM), which is related to the emotions. This is the representation of the body posture explained by Godelieve Denys-Struyf, and this string could be related with some symptoms of areas of our patients. (1)

A3: In my opinion the symptoms are related with medical diagnosis, because the pain causes by the disk alteration, has provoke some compensation that development other symptoms of patient.

TEACHER ADVICE

deviation 35º and extension 50º movements of

Relationship among symptoms often provides

the trunk, and right rotation of neck 45º.

clues about irritability, severity, and spreading pattern. Drawing a timeline introducing the starting point for signs or symptoms and their evolution, also help us to focus over one area instead of others, as the source could be the same for example.

About muscle balance he didn´t have any alteration, only the shorted Pectoralis minor muscle. And active Trigger point of Trapezius, paravertebral, lumbar quadrate muscles and psoas.

45

Sometimes, the pain in the former presentation

Other test that I realized in lumbar region was

hasn´t to be the most relevant nor the origin of

thumb-ascending test; Gillet test (2) and

the syndrome.

elasticity test and I observed an anterior

PHYSICAL EXAMINATION After know the medical diagnosis, how patient

torsion of the sacro. In dorsal region I realized the Mitchell test (3) and I found a FRSd in some vertebras.

felt his symptoms, I startet with physical examination.

I too realized Adson, Eden and Wright test to kwon if patient had any vascular alteration,

Firstly I did a static inspection, where I

and this test was negative. (2)

observed a little vascular alteration under pectoral fold.

STUDENT REFLEXION AFTER P/E

So I asked him if he had any visceral alteration

Analyzing the information got from subjective

because this could have a relation with the liver

and physical examination, I think that

or stomach.

symptoms are related with that pathology, because of hernia disc and protrusion, he

His posture was important to analysed

started to felt symptoms, and went changing

because represented AM string, antalgic

his

flexion and right lateral deviation of the trunk,

compensation that activate Trigger points,

internal rotation of shoulders, flexion of neck

and decrease the activity of some muscles.

posture.

This

could

cause

some

and extension of head. But maybe the posture was the responsible of Secondly I did the functional inspection, and I

the hernia disc, because bad posture of

found an articular limitation of the left lateral

vertebral bones, cause an alteration on disk

pressure and this could the reason of patient

Q2: So far, which is your first hypothesis with the

alterations.

data coming from C/O and P/E? Which is the

In the physical examination I hadn´t performed

46

data supporting this hypothesis?

a neurodynamic test because I didn’t know

My first hypothesis is hypertonicity because of

how to do it in this moment. After one year, I

he presents Miofascial trigger point, in my

have learned the importance and how to

opinion, activated by a bad posture and stress.

realize this test to patient how present symptoms like tingling.

The data supporting this hypothesis is the presence of Miofascial trigger point in the

So maybe I lost some important information,

palpation that reproduces his symptoms and

to plan the treatment.

the information that patient give me when he

But in this clinical case, I keep thinking that symptoms are very related with emotional state of this patient.

felt pain (for example when he has to gain weight or when he is sitting are related with a nociceptive pain). TEACHER ADVICE

QUESTIONS TO IMPROVE REFLEXION Q1: Do you think that could be useful before start or during the physiotherapy treatment, to help the patient with a psychological support by an expert? A1: In my opinion is a good idea, because our principal objective with all patient are a biopsychosocial treatment, so sometimes this must be multi-disciplinary treatment that in

Our findings during the P/E have to be meaningful for the patient. A positive finding of an unknown dysfunction or pain could lead us into a wrong path if it´s not related with the general presentation. Usually if it is found in first place of the examination. We have to check if this pain is “the kind of pain that the patient used to feel” and is related with his other main complains.

this case. But I found difficult to give patient advices about pay attention to a psychologist or other therapy to changes his mood.

PATIENT MANAGEMENT DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN After analysed the information getting in the subjective

examination

and

physical

examination my diagnosis is that patient disc

herniation, he has hypotonicity in the posterior muscles of the trunk and shortening in

STUDENT REFLEXION AFTER D1 TREATMENT

Pectoralis and Psoas.

After first day, patient presented the same symptoms and the dizziness increased.

The prognosis is positive but has some negative factors like the pathology because it,

Maybe I should choose other technique that

is irreversible without surgery treatment, the

weren´t trust technique.

chronicity of symptoms and the laboral activity. Positive factors are that after others physical treatment he has improves. The plan that I design was to address the following objectives: 

Firstly in a short-term the objective

So he had more pain the second day, so I decided to do a more relaxed session applying TENS and magnetic therapy. So after this day I learned to give more importance the mood of patient before choose any technique.

was decreased pain in cervical and 

lumbar region.

QUESTIONS TO IMPROVE REFLEXION

Secondly to medium term was to

Q1:

increase ROM at cervical region and

manipulation?

strengthen in posterior and anterior

A1: I did manipulative techniques in order to

muscles of thorax.

get the neurophysiological changes produced

DAY_1 First day I started with an osteopathic manipulation, for the dorsal region I used the “Dog-technique” and for the sacro and lumbar region I did the “lumbar roll”. To decrease tension I did a technique to relax

Why

did

you

chose

osteopathic

by these techniques. It is sought to give a stimulus to restore the SN information about the area and get so hypoalgesia short-term changes in the structures that could be affected (4). DAYS 3-4

diaphragm and other for the Pectoralis minor

The third day my patient had lumbar and

muscles that was a muscular energy technique.

cervical pain; he felts bad and told me that he had have vomit. So I decided to do a relax treatment with manual therapy, the fifth day I did the same treatment.

47

Sixth day the patient hadn´t tingling, the

hypotheses of has a relation with the mood

dizziness had been decreased, cervical pain

my patient.

had been improved but he kept feel lumbar pain.

48

In spite of I recommended him to did some active exercise to make more powerful the

So, for this session my objective was treating

back and deep muscles, because I think that is

the lumbar pain. I used a technique to relax

very important to have a good motor control

diaphragm, I did a compression treatment for

of the lumbo-pelvic region, to decrease the

Psoas Trigger points, contract-relax stretching

back symptoms.

for psoas and a active work for the deep lumbar muscles (Transverse muscle, pelvic floor and

QUESTIONS TO IMPROVE REFLEXION

Multifidus muscles).

Q1: Do you think the patient disease could be related with neurological disorders in addition to

STUDENT REFLEXION I hadn´t the final information before the patient end the treatment but while I was treat it, he had some improves like dizziness and headaches, but the outcomes after each day aren´t very representative because each day had different symptoms, I mean one day he was better of the cervical pain and worse of the

his emotional state? I think that there could be some present peripheral entrapment because I didn´t neurodynamic test and he present numbness in the arm, but he didn’t have any entrapment of Braquial plexum because the Jackson, Adson, Eden and Wright test, were negative.

lumbar pain, and the next day on the contrary,

Q2: Which part of your management do you

so the evolution was very confused.

think has worked better and why?

For me was difficult to interpreted which was

In my opinion the best treatment for this

the problem of patient´s symptoms because

patient was the relax technique a motor

the evolution was very different and when he

control (“rana al suelo” (5) adding a good

improve one symptoms get worse other and

breathing movement to relax diaphragm) and

vice versa.

manual

So I think that I have left loss some information. Maybe I was in a wrong way or this development had relation with my first

therapy.

Because

the

active

participation of patient to get a good control motor in the lumbopelvic region, and being aware how he is relax while he gets control the breath, helps him to get better results.

And the manual therapy at the Trigger point

good decision. Regarding to the neurodynamics

helps to decrease the symptoms and the

issues, we need to discriminate among tests

muscles tensions.

assessing roots, nerve trunks and main nerves.

TEACHER ADVICE

We also have special test to investigate where

Choosing high evidence-based tests will add to your reasoning better ingredients to make a

the entrapment is and its dimension, first step in the management of these presentations.

49 FINAL STUDENT REFLEXION

To conduct further analysis of this case, after a year in which I have acquired new knowledge, has helped me to realize that parts of the exploration had not taken into account and the importance of them such as neurodynamics, spinal mobilization with postero-anterior pressures, the patient's posture that can give us information of structures that are influencing their pathology. For example, in this case with an AM chain, I could choose treatment techniques and address the same depending on the patient, such as given the mood of the patient would have been better to make more moderate techniques: muscle energy techniques rather than with impulse techniques. And remember at all times the importance of the biopsychosocial treatment as in the recovery of the patient and their adherence to treatment is influenced by many factors. And some time that is necessary to do a multidisciplinary work. This has helped me to make a more complete reasoning and relating and integrating more different fields of physiotherapy I've been studying

REFERENCE LIST 1. Lucas, E., & Ángeles, M. (2009). Análisis biomecánico de las algias de raquis y su relación con la percepción del dolor y la calidad de vida. REDUCA (Enfermería, Fisioterapia y Podología), 1(2). 2. Cleland, J. (2006). Netter, exploración clínica en ortopedia: un enfoque para fisioterapeutas basado en la evidencia. Masson. 3. Ricard, F. (2007). Tratamiento osteopático de las algias del raquis torácico. Ed. Médica

Panamericana. 4. Pickar, J. G. (2011). Efectos neurofisiológicos de la manipulación vertebral. Osteopatía científica, 6(1), 2-18. 5. Souchard, P. E. (2005). RPG. Principios de la reeducación postural global (Vol. 88). Editorial Paidotribo

50

A 23-YEAR-OLD FEMALE PREPARING FOR ARMY WITH LOWER BACK PAIN FOR 4 WEEKS KRIIK G. AND PONCE L.

INTRO My client was a 23-year-old female student with lower back pain, which had started 4 weeks earlier due to heavy weight training.

where she wasn’t able to put on shoes in the locker room when leaving the gym. After this the pain had been troubling her especially on the left side of the back. Also a tendon had started snapping on her right hip.

SUBJECTIVE EXAMINATION My client was a 23-year-old woman who was in the second year of her studies in the field of physical therapy. She was living together with her boyfriend who was studying in the military academy, and it was her goal to join the army too. Due to lower back pain resulting from extensive training she came to the clinic. Her aim was to get back on track with training again soon, because the entrance test for military studies was a few months away. She was 165 cm tall and weighed 52 kg. She hadn’t had former traumas

She had tried to relieve the pain by stretching and trying to find a painless position. During the day sitting worsened the pain, and sitting through a lecture at the university was agonising. Because of this she had started to attend the lectures standing up. At home she had exchanged the sofa for a fitness ball. The pain was most severe in the evenings and after sitting down for a long period of time. Lying down eased the pain. She had found sleeping on the side with a pillow between her legs the best position for her.

associated with the pain. During her free time she was involved in many My client had started a comprehensive weight training program a few months earlier in order to pass the entry tests for the army. A month ago she had started to experience lower back pain after training. Two weeks before coming to the clinic the pain had been intensified to an extent

kinds of activities: walking her dog, going to the gym, swimming and at times also climbing. At the gym she usually trained with free weights together with her boyfriend. They trained at a “men’s gym” without contemporary adjustable gym equipment.

51

At the gym the most pain inducing exercise was

QUESTIONS TO IMPROVE REFLEXION

deadlift, which she usually did with 20 kg weights

Q1: So far, which is the level of severity and

3 x 10 repetitions. She said that she knew she was

irritability of her presentation? How is this going to

executing

impact on your plan for P/E?

performing

the a

movement squat

wrong

deep

without

enough.

She

recognized that also in her everyday life she was moving in unfavourable ways by having a habit of

52

not bending her knees while picking things up from the floor. She suspected that she had been engaging with a training program too hard for her fitness level, because she was training at the same tempo with her boyfriend.

A1: At the time of her therapy session the severity of the pain had been decreased to a level where it presented moderately in certain positions and movements. The pain affected her movements, activities and behaviour and in order to begin the healing process I felt it was extremely important not to irritate it any further. Thus I planned to be careful with the physical

STUDENT REFLEXION AFTER S/E

examination in order to avoid provoking excess

Based on the interview and her description of the

pain.

onset of the pain I suspected a disorder in

Q2: Do you think she should rest and stop lifting

neuromuscular control in the core area. My

weights?

hypothesis was that she was training with weights too heavy for her level of fitness and

A2: Yes, in order to recover she should rest for a

technique, and while she was performing the

sufficient amount of time, and afterwards

deadlift her back extensors failed to uphold her

gradually get back to weight training.

posture, resulting in a flexion in the lumbar spine,

Q3: Did you think about other forms of getting

and creating an increased torque that caused

prepared for the army?

significant pressure to the intervertebral discs and extreme tension to the surrounding tissues.

A3: She should train by doing versatile exercises. Because she already had a good selection of

I sensed that there was pressure for her to get

other physical activities she was engaging in, I

back on track to the training routine, and thus I

especially wanted to give her an alteration for

expected a challenge in motivating her to

weight training.

patiently commit to the therapeutic exercises. TEACHER ADVICE The degree of irritability and severity will drive the deepness of the P/E procedures. If we are not

cautious, a tough physical testing could ruined the

In the forward flexion the lumbar spine rounded

remaining management if we provoke elevate or

only at the end of the flexion, and up until that

severe symptoms in a highly irritable presentation,

point it was almost completely straight. In the

that avoid proper and comfortable following

modified Schober test lumbar spine lengthened

procedures.

in forward flexion 6 cm while standing and 5 cm while seated - which is within the reference

PHYSICAL EXAMINATION Day1: I started the physical examination by assessing my client’s posture and active movements.

values, but in the low end. Especially in the first forward flexions she conducted there was a visible functional scoliosis present. Her body also flexed to the right side, over her right lower extremity.

Her ankles were in line and in her feet she had symmetrical and strong longitudinal arches. There was no pronation in the ankles. Knees were slightly asymmetrical: the right ham was slightly lower than the left one. Also the right gluteal fold was a little lower than the left one. The iliac crests were horizontally aligned. Knees were directed to the back into a locked position and the pelvis had drifted to the front and tilted anteriorly. In the lumbar spine she had a normal lordosis but the kyphosis in the thoracic spine had straightened. Scapulae were symmetrically aligned, both by their distance from the spine and the height of their position. However the scapulohumeral rhythm was slightly asymmetrical: the right scapula moved smoothly but the left one did the same abruptly. In the cervical spine she had a normal lordosis.

Lateral flexions were symmetrical and the spine flexed evenly. Lateral rotation to the right was smaller than to the left. Single leg squat revealed larger weakness in the right gluteus medius than in the left one. On the right side in the anterior part of the hip a tendon was snapping as she flexed her hip. In the movement control test for the core there was no lack of control present. However, as a physical therapy student she did know what this test was about and perhaps was able to concentrate to not show positive signs. In the Straight Leg Raise Test her left leg raised smoothly over 90° but the hamstrings in the right thigh started to strain at 90°. In the Thomas Test there was no tightness in the iliopsoas muscles presented. According to palpation during a single leg hip raise the transversus abdominis muscle activation was slightly stronger on the left side than in the right side.

53

As first aid for her condition I gave her advice

medius

about a painless position. I also advised and

quadratus lumborum was not painful. While

encouraged her to actively keep up a better

conducting a stretch to the muscle, there was no

posture in which her lower back is not under

tension present and the stretch was symmetrical

stress.

on both sides. By palpation the lumbar spine was

There

During

palpation

m.

more flexible than the thoracic spine. The tonus

Day 2:

54

weakness.

in the back extensors was symmetrical in were

aspects

that

needed

closer

transversal manipulation.

examination and due to lack of time were not examined during the first session, so I decided to

STUDENT REFLEXION AFTER P/E

make a few more tests to confirm the most

My initial hypothesis during the first therapy

accurate diagnosis and management.

session was that she had a disorder in neuromuscular control in the core area. However

During the second therapy session there were no more signs of functional scoliosis present in forward flexion. It is possible that the muscle tension present before had loosened and did not pull the spine into an asymmetrical position. Lateral flexions and rotations were symmetrical. While squatting m. transversus abdominis stayed active and the lining of the knees remained. In the single leg squat m. gluteus medius failed on both sides. In forward flexion the movement of SI-joints was symmetrical. However the left side of the hip raised while raising the left knee, while the hip stayed in place when raising the right knee. There was no pain when compressing the SI-joint.

when she didn’t present any positive signs towards the lack of control, I had to change my presumption. In our first session we had gone through different factors in the core area, but did not have time to profoundly examine the pelvic area. That is why I decided I needed to conduct more tests in the second session. Between the sessions I had gone through numerous options which could be the cause for her pain, and expected to come into a conclusion after better examining her pelvic area and movements. Before the management phase I put a lot of thought into how to make therapy appealing to her. I felt like I had to balance between exercises that were not too difficult for her in order to

In the Straight Leg Raise Test hamstring stretch

maintain the right load and the therapeutic

was symmetrical and no tension presented. In

aspect, but also challenging enough for her to

the Donatelli Drop Leg Test the leg dropped ~10

stay motivated.

cm on both sides which refers to m. gluteus

QUESTIONS TO IMPROVE REFLEXION

TEACHER ADVICE

Q1. Which is the most important piece of data

No general advice could be provide to choose the

supporting your hypothesis with this patient?

most relevant information in the P/E. It has to be a

A1: The most important piece of data was the muscle imbalance presented by her poor posture and the evident weakness of her gluteus medius muscles combined with the information about the high intensity of her training and her unstable technique. Q2: Do you think she has a preference for the right

personal decision that could be shared with the expectations and feelings of the patient. Your experience and knowledge will drive you to this part of the decision-making after performed the

55

best evidence-based tests procedures. PATIENT MANAGEMENT

side of the body at the moment she performs the

DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN

movements and that it makes it stronger than the

My physical therapy diagnosis was that the client

left one on the lumbar rotation?

suffered from an unbeneficial habitual posture

A2: Based on the observations and tests I believe she has a habitual imbalance in her posture - and during heavy weight training the weaknesses in certain parts of her body have provoked an

caused by muscle imbalance, and muscle tightness and weaknesses in the pelvic region, which in high intensity weight training provoked pain into the lower back.

increasingly unbeneficial posture. Her posture

The objective for therapy for her was to correct

includes dominant elements in both right and

the posture and to learn proper movement

left side of her body, but they are unsymmetrical.

control and right movement trajectories in order

Q3: What do you think you could do to avoid her not showing the positive signs of the test you asked her to perform? A3: If she is very aware of the tests and her

to be able to train with weights. After the first physical therapy session the aim was to locate a painless

position,

avoid

pain

provoking

movements and to start practicing the right kind of posture.

performance, it could prove beneficial to ask her to describe in detail if she feels weaknesses or if one movement is harder than the other. Asking her to talk could also make the movements more natural and intuitive.

After the second therapy session the objective was to strengthen the deep postural muscles and to learn a deep, relaxed way of breathing during exercise. In order to reach a strong posture gluteus medius muscles had to be strengthened.

In the early stage of therapy the aim was to cross-

These exercises she was to do with every training

strengthen the core muscles in myofascial chains

session in order to learn to sustain core activation

both in the anterior and posterior side of her

when functioning.

body.

56

In the advanced stage of therapy the goal was to

2. EXERCISES TO STABILIZE PELVIC REGION

enable weight training. The objective was to

In order to stabilize the pelvic region I gave her

comprehensively train the musculature starting

exercises to strengthen the gluteus medius

with simple technique exercises and moving

muscles.

onto wider trajectories.

-

stepping board (3 x 10 on both sides)

In order to develop a strong muscle control I gave my client exercises to strengthen her postural

lifting the hip while standing on a

-

lateral rotation of a flexed lower limb

core muscles. In order to correct her posture I

while lying on the side (3 x 10 on both

taught her an optimal position for knees and hips,

sides)

and to stabilize her pelvic area I gave her

-

abduction of the foot while standing -

exercises for strengthening gluteus medius. In

first without a resistance and later using

order to keep her motivated I composed a

a rubber band (3 x 10 on both sides)

therapeutic training program for the advanced stage so she could witness her own improvement and not get bored with a lack of options. 1. EXERCISES FOR DEEP CORE MUSCLES To strengthen the activation of postural core

In order to keep the therapeutic training interesting and appealing she was able to choose an exercise for each session. 3. EARLY STAGE In the early stage I prescriber her

muscles I instructed her following exercises: -

vertically pulling down and bouncing a rubber band (m. transversus abdominis) (10 sec activation + 10 sec rest)

-

-

-

crossover crunches (3 x 10 on both sides)

-

by turns lifting up one hand and the opposite leg on all fours (3 x 10 on both sides)

moving the body weight onto a foot stepped forward, walking backwards

4. ADVANCED STAGE

(mm. multifidi) (5 times on both sides)

I advised her to conduct the early stage exercises

relaxed and deep breathing when

as long as she had fully learned the movements

exercising (diaphragm)

and the postural control was stable. When she

would have mastered them she could move on to

shape than before, and also to keep her

more challenging exercises. This way her training

motivated and committed into. We agreed with

was as progressive and motivating as possible. In

her that she will incorporate these exercises into

the advanced stage I gave her following

her routine and exercise independently, and

exercises:

after 6 weeks, during a follow-up contact she had

-

pulling down across to the front a pulley while crunching the opposite knee up (3 x 10 on both sides)

-

pulling down across to the back a pulley

been able to start training again with a better technique and a clear knowledge about the required movement control.

while extending the opposite leg back (3

STUDENT REFLEXION AFTER TREATMENT

x 10 on both sides)

Because my client was an active young woman

I advised her to start the advanced exercises with small resistance and moving onto heavier weights while paying strict attention to her condition and movement control.

with a concrete goal in her weight training, I didn’t want to solely give her exercises for the early stage, because she might have found it boring it could have resulted in her not sticking to it. I wanted to build a bridge between her state at

5. ALTERATIONS FOR DEADLIFT

that time and the stage she wanted to be in. I was

Because deadlift was a movement she was fond

concerned whether I was able to give her all the

of, I wanted give her an alteration to make it

information and support she needed to

possible for her to safely train the muscle groups

independently conduct the therapeutic exercise

that the movement incorporates. With the

process.

alteration she would be able to train the same muscles but in a safe and technically more simple

QUESTIONS TO IMPROVE REFLEXION

way. I instructed her:

Q1: Which part of your management do you think

-

-

squat (3 x 15), and possibly later a

has worked better and why?

telemark-squat (3 x 10)

A1: Based on the feedback I received from my

rowing both bilaterally and rotating the

client after her therapeutic practice period, the

trunk

core as well as m. gluteus medius strengthening

This progressive therapeutic exercise plan aimed to return her into the training routine in a better

exercises have proven to be the most beneficial for her. Once she was able to support a firm posture she avoided provoking pain even in

57

complicated movements. A strong core has given her the possibility to enjoy life without pain.

TEACHER ADVICE As we read previously patients’ needs to have a general idea about the length of the treatment.

Q2: What about the recovering time? Did you have

Information about this point could be found in

an idea about how many weeks the treatment

clinical reports for individual patients. Despite is

would take long?

not one best researched issues in physiotherapy, there are some populations in which these findings

58

A2: I estimated it would take her 3 months to reach the advanced level in practicing if having successfully undergone the therapy.

are extremely urgent and relevant, for example in the

professional

sports

area

where

time

constraints costs lots of money to the clubs.

FINAL STUDENT REFLEXION In order for her to properly learn the optimal movements I started the therapy plan with low-intensity training (Kisner & Colby, 2012). Especially with patients with lower back pain it is important to render activation in the deep postural muscles such as m. transversus abdominis and mm. multifidi. By increasing the activation of m. transversus abdominis the risk of generating lower back pain decreases (Miura et al. 2014). Because of this I included stabilizing exercises into every training session of her plan. In her case it was also extremely important to strengthen m. gluteus medius, which is a stabilizing muscle for the pelvic area. I chose exercises that have been proven to be the most effective in creating muscle activation in m. gluteus medius. (Bolgla & Uhl, 2005. Gowda et al. 2014.) In my opinion she comprehended the instructions well and also was committed and eager to execute the plan of therapeutic exercises. I was glad to hear her positive feedback later and excited for her recovery.

REFERENCE LIST 1. Bolgla, L. and Uhl, T. (2005). Electromyographic Analysis of Hip Rehabilitation Exercises in a Group of Healthy Subjects. JOSPT Journal of Orthopaedic & Sports Physical Therapy. 2. Gowda, A., Mease, S., Donatelli, R., Zelicof, S. (2014). Gluteus medius strengthening andthe use of the Donatelli Drop Leg Test in the athlete. JOSPT Journal of Orthopaedic &Sports Physical Therapy.

3. Kisner, C., and Colby, L. (2012). Therapeutic Exercise. Foundations and techniques.. 4. Miura, T., Yamanaka, M., Ukishiro, K., Tohyama, H., Saito, H., Samukawa, M., Takumi Kobayashi, T., Ino, T., Takeda, N. (2014). Individuals with chronic low back pain do not modulate the level of transversus abdominis muscle contraction across different postures. JOSPT Journal of Orthopaedic & Sports Physical Therapy.

59

A 40 YO. MAN WITH A PAINFUL SHOULDER SYNDROME PÉREZ G. AND KRIIK G .

INTRO

60

A 40 YO man, who handle Remotely Piloted Aircraft Systems (RPAS), in Mexico, which has a

as soon as possible to return to his daily activities. He is married and they have 2 girls with who wants to play again without pain.

painful shoulder syndrome on both sides, as a

He said that the pain on his shoulders started 2

consequence of many years working at the same

years ago but he only felt kind of discomfort and

position by long working hours.

he didn´t attended it, along of time he feels only

SUBJECTIVE EXAMINATION One day a 40 YO man, with 40 years old came to the clinical rehabilitation where I was doing my practices. He was 1.78m tall and 89 kg of weight. He handles a Remotely Piloted Aircraft System (RPAS) for a company in Mexico, almost always Monday through Saturday 8 hours with an hour of break, but he was handles the drone for 3 or 4 hours with the same position without any break to stretch or eat either. He describes his position as a super video game player, stand up, arms down, elbows 90°, and loading the control with 2kg of weight.

got worse and neurological symptoms on his arms on few times. He has token NSAID, muscular relaxants & hot water fomentations, 3 weeks felt kind of better, but 2 months later the discomfort begun again harder and his wife carried him to the doctor because the pain increase each time more, presented swollen shoulder and red zone, and sometimes cannot work but he only said ¨it will pass, I´m ok! ¨. They went first with a public doctor, where he has the insurance and take a Rx to see the acromion position, and it was good, but he said the doctor´s

diagnosis

was

¨Painful

Shoulder

Syndrome¨. Then, he went to the traumatology,

He is working on that place since he was 20 years

and he said to him the same diagnosis.

old. He had taken a course for pilot the drone to

Consequently, the doctor gives to him medical

begin work, and a long of time he has been

prescriptions to decrease the inflammation and

updated until nowadays. He was born and grew

pain, relax the muscles and the numbness

up in Mexico, he´s very sympathetic, funny,

disappears, and furthermore sends him to begun

friendly, simple, positive and waiting to recover

with physical therapy sessions.

His pain becomes chronically because he didn´t

test maybe as 1UNLT & 2UNLT to be sure that he

attend at time and at the work give to him some

hasn´t any nerve entrapment.

days to rest.

He has a good prognosis because he is very

He smoke occasionally like 1 cigar each weekend

motivated and anxious to recover full ROM to

and was an occasional social drinker.

return to his normal life, he has a very positive

He presents pain on abduction, extension, flexion (less pain with elbow flexed than with elbow extended), internal and external rotation, but in adduction he doesn´t present pain. At the

attitude and perseverant. QUESTIONS TO IMPROVE REFLEXION Q1: Which were the activities that ease his symptoms?

same time he has several limited range of motion. He presents a lot pain when try to hung out his

A1: When he applies a thermal compresses, and

clothes on the closet, brush his hair, take a

when he rested a day or two of work.

shower, dress and every activity that implicate put his arms up. He feels better when his wife put to him socks with hot rice on his shoulder. STUDENT REFLEXION AFTER S/E

Q2. Which is your opinion about central sensitization component in his pain presentation? A2: I think the main component on his pain is the muscle

overload

that

causes

a

chronic

inflammation without care on time.

About my hypothesis is a mechanical input injury,

Q3: Does he have identical pain in both of his

with possible tissue damage. He has a lot of time

shoulders? In his work, did he usually do the same

with the pain, so it comes to be a chronic disease,

task with both hands?

it could be slower to recover than a acute pain. He didn´t receive any therapy from a specialist, only the home remedies that calm a little the pain. My first impression at all was a big contracture of upper limb, back and neck. First of all, I could do explorations to verify which muscle is more damaged, and to neurological

A3: He doesn’t have the pain as a specific point he feels pain around shoulder and neck. Furthermore, he used to do the same with both hands (take a motor control). Q4: Is possible for him to work shorter periods or take a break? A4: He said that is not possible to make a break because when begin to record is hard to pause it.

61

any inflammation about bursa. And finally he

TEACHER ADVICE It´s important to cover, at least, the main issues in

refers more pain at night.

the first visit to allow you to manage all the pieces of the quiz. Missing key issues as red flags could decrease the quality of your management and set

STUDENT REFLEXION AFTER P/E About the diagnosis of doctors, I found that he has the muscles inflamed and whichever

your patient in risk

movement that he did, he presented pain,

62

PHYSICAL EXAMINATION

consequently very limited his range of motion.

He brings radiographies and the acromion

Although, he said he begun to feels better with

doesn´t indicates a possible impingement. He

de NSAID´s he want to be all right as soon as

doesn´t have a specific point with pain on his

possible. I found same kind on limited on

shoulders, so I decided realize test for the rotator

external and internal rotators (as subescapularis

cuff muscles and examine his ROM and posture.

and Infraespinatus), and on muscles as that have function of flexion, extension, abduction, the

He presents head anteversion, winged shoulder

right side has more restriction, but in adduction

blades and a little left side descending.

the rom wasn´t limited just at the end present

The range of motion on left shoulder:

pain. I think he has more restriction on his right

-Flex (L / R) 45°, 40°

shoulder because his dominant hand at business

-Left ABD (L / R) 40°, 35°

is right side, so it overloads a little bit more the

-Add (L / R) 30°, 32°

muscles. Moreover, all the test he present

-Ext (L / R) 35°,30°

positive because he continues with inflammation

-ER(L / R) 40°,40°

and overload muscles for his work , tension

-IR (L / R) 40°,40º

position and those are contributing factors. He present very good attitude and that have good

On Jobe`s test was positive both sides, Patte´s

prognosis with NSAID and therapy he going to

test was positive (same on both sides),

belly

recover but exactly I don´t know the time.

press was positive, Gerber was positive (same on

Moreover, he doesn´t presents an anatomical

both sides), Yergason was positive too (more

deformation of acromion, just muscular so it

limited on his right side). I did Neer and

becomes better for his luck.

Hawkins`s tests too, Neer was positive on both sides, but Hawkins was negative. Furthermore,

QUESTIONS TO IMPROVE REFLEXION

on the radiographies can observed that has not

Q1: Did you advise a painless position for him?

A1: He has painless when he has his arms down.

TEACHER ADVICE

Q2: Was he still working at the same time of

Getting the most reliable tests for a typical

therapy? Do you think it´ll affect your work

presentation is the key point to get a chance in

strategy?

discovering a tissue dysfunction.

A2: He continues working fewer days and fewer

PATIENT MANAGEMENT

periods of time. I think it can make slowest rehabilitation but not totally affect. Q3: Which is your second hypothesis for the data coming from P/E? Shoulder bursitis. Which is the

DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN About the diagnosis of the doctors and my point of view I met consistent findings about the painful shoulder syndrome. I had doubt then with

data supporting this hypothesis?

shoulder bursitis, because the impingement Shoulder bursitis is include the alterations of

shoulder was rule out with the radiographies, but

muscles, tendons, nerves, tendon sheaths, joint

on the radiographies has not appeared.

syndrome and neurovascular entrapment and

Furthermore he made MRI and only has

more pain at night. He has pain on all

appeared inflammation of tendons. I think he

movements

as

was good because he doesn´t present any

radiographies and magnetic resonance can rule

neurological symptom last 3 months, and he is

out impingement and bursitis.

more relax on his work and his wife is supporting

Approximately 10 % of the general adult

him, physical and psychologically.

and

with

the

studies

population experiences an episode of shoulder pain in your life (Van der Heijden, 1996) shoulder pain is the third leading cause of muscle skeletal pain extends to shoulder and back (Cailliet, 1981) .The risk that the pain persists beyond acute phase seems to be related to lack of treatment, and occupational personality factors (Van der Heijden, 1999).

The plan to reduce inflammation with help of the doctor

and

some

NSAID´s,

and

TENS,

thermotherapy, relax and therapeutic exercise. DAY_1-2 Applied TENS on his shoulders and furthermore thermotherapy with hot-wet compresses at the same time to release the pain and relax the muscles, then applied ultrasound on the area with more pain. Then told to him that he should relax for all day and don´t do any heavy work. And on the afternoon he applied an NSAID on gel.

63

STUDENT REFLEXION AFTER D1 TREATMENT

on 3rd and 4th days added pendular of Codman

The patient came with a doctor prescription. And,

mobility and muscular potency, and decrease the

he feels better with thermotherapy, so it can

pain.

exercises, and laser low potency to improve the

helps to relax the muscle and psychologically too.

potency, massage and finally 2 repetitions on

QUESTIONS TO IMPROVE REFLEXION

64

5th: add pendular Codman exercises, laser low

Q1: Did you give him instructions on how to relax

finger ladder on flexion and abduction.

his muscle at home-other than NSAID? STUDENT REFLEXION A1: only the pendular exercises.

The patient was happy because he feels his

Q2: Did you have an estimate on how many therapy sessions it would take to improve

shoulder been better and won ROM con 4 sessions. Moreover, his attitude was so positive on therapy and on house because obey all

Roberto´s state?

instructions. Furthermore, he and would gladly A2: I think near of 15 sessions.

therapy because he spoke with more people, so I think that psychologically these attitudes are

TEACHER ADVICE

best for speedy recovery.

A “test-treatment” will allow you to get invaluable information

about

the

condition

of

the

presentation. Using the results of the treatment as another piece of evaluation could inform you how to treat your patient properly. If we use a huge

QUESTIONS TO IMPROVE REFLEXION Q1: Have been your management different if you didn´t have the MRI images? Were they valuable for your results?

number of techniques in this first session, we will be less sure about which has worked better.

A1: Yes, because if we had found any abnormality as a rupture of rotator cuff, bursitis

DAYS 3-5

or even a tumor should be care with those things.

For days 3, 4 and 5 applied, TENS on his shoulders and furthermore thermotherapy with hot-wet compress at the same time to release the pain and relax the muscles, then applied ultrasound on the area with more pain. Moreover

Q2: Would he only continue his treatment at home? A2: He continues with the therapy on the clinic, but I kept giving no therapy because I was moved to another patient.

FINAL STUDENT REFLEXION All the clinical case was with help of my coordinator of practices, although we add some therapies methods. But here I would like to improve on the physical examination explore the neurological examination,

Daniel´s

scale

(muscle

strength

power).

With the treatment can be helpfully to his body but a placebo effect can be influent too. The treatment in four sessions began to show results, but those results were for the good and positive attitude for the patient, discipline at home, and he toke less hours on his job. The syndrome of shoulder pain is not exactly pathology but we can rule out other possible symptoms and treat that one. The best thing to do in all people is prevent a lesion give them some recommendations and ergonomic positions, and take a few minutes to take a break and relax on the work, in addition when we feels symptoms out of common we should go to the doctor or physiotherapist to check it and not allowed to continue advancing the affection.

REFERENCE LIST 1. Cortes V., Acosta M., Armendárez M., Domínguez M. J. Romero P. (2009). Guía de Práctica Clínica, Diagnostico y Tratamiento del Síndrome de hombro doloroso en primer nivel de atención; Delegación

Cuauhtémoc,

México:

CENETEC.

http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/085_GPC_SxHombdoloros o1NA/GPC_SHD_EVR.pdf 2. Hernández Díaz, A., Méndez, G., Orellana Molina, A., Martín Gil, J. L., & Berty Tejeda, J. (2009). Láser de baja potencia en el tratamiento de las calcificaciones de hombro. Revista de la Sociedad Española del Dolor, 16(4), 230-238. 3. SUÁREZ-SANABRIA, N. A. T. H. A. L. I. A., & OSORIO-PATIÑO, A. M. (2013). Shoulder's biomechanics and physiological basis for the Codman exercise. CES Medicina, 27(2), 205-217.

65

A 16 YO. FEMALE STUDENT THAT SUFFERED A 2 ND GRADE RIGHT ANKLE SPRING PONCE DEL-HOYO L. AND PEREZ-RAYMUNDO G.

66

INTRO A 16 yo. girl who was a football player suffered

forward position so she wanted to score the last point before the game finished.

an second grade ankle spring on the right

She was running really fast and got the ball but

limb .There had passed 3 weeks since she

suddenly one player of the other team kicked her

suffered the spring. She was immobilized during

really hard on the lateral part of her ankle and she

these 3 weeks, now she has a lot of complications

felt down and because of the velocity she was

with the functionality of her ankle.

running she felt on the ground. The pain

SUBJECTIVE EXAMINATION When my patient arrived to the clinic where I was developing my clinical stance or practices, she was using crutches because she felt pain when she supported the foot down on the floor at the moment of walking. She said on the consultation with the doctor (I was present during all the examination) that she had had an accident while she was playing football in her high school. She was part of the school’s team and she was training for the competition than is done every year between the different grades of the school. When the accident happened, the game was on the second period and her team was winning for 2-0 points, so their team was feeling kind of security against the other team. She had the

appeared just when she tried to stand up again. “I could not support my weight on my leg. Firstly I felt like if I had lost all my strength and then a lot of pain started to came to my ankle. It was insupportable. “I would not have had cried, but I could not resist, the pain was so hard” she said. When everyone noted that what had happened to was not a simple drop, all the players went to the place where she was layed dowm. They started to call the trainer and when he arrived he had already called an ambulance. He ask her what had happened but because of her crying, she said that she could not say many details of what had happened. The other player that had kicked her was how explained what had happened. Then she did not noticed exactly what happened until the ambulance arrived, and she

was taken to the hospital. In the hospital she was

proprioception, because if not, she would get

taken to the X-ray department and the

injured again. She does not have any important

traumatology discarded a possible fracture. He

antecedent. She is a healthy girl, does exercise

told her that she had had an ankle sprain and that

constantly and take a good diet. So my first

she was going to rest and take some medications.

impression was that she was going to have a

The doctor put her splint on her ankle and said

good prognostic if she follows all the therapy to

that she was going to be immobilised during 4

the letter.

weeks. She took the prescribed medications so

67

she did not feel so much pain on the next weeks.

QUESTIONS TO IMPROVE REFLEXION

The pain came back at the moment that the

Q1: Was there any deformity on her ankle?

splint was taken off. She was really surprised because her leg was so much thinner than the other one, and her foot too. She refered to had

A1: Yes, there was a relative deformity, because it was with less muscular mass and with inflammation

pain at the moment she tried to put all her weigh on his right foot. She also felt kind of restriction

Q2: Which data of the history supports your

of the movement.

hypothesis about lack of proprioception?

STUDENT REFLEXION AFTER S/E About my hypotheses of my patient´s injury is that, well she already had a certain medical diagnosis, a second grade right ankle spring. But

That she was immobilized, so she did not stand during three weeks and that makes the baroreceptors get damaged. If it is not corrected she is really exposed to have another spring.

what I could observe while she was describing

Q3: Which are going to be your precautions for the

her situation, was that she was really worry

P/E?

about if she was going to recover properly or not. She was scared because she had never seen her foot that thin and weak. I also noticed that she did not have enough proprioception because she was always seen to her ankle and moving it with her hand to be more comfortable (it due to avoid wrong positions of hes foot and avoid pain). I thought that what she needed was firstly to decrease the pain. Then gain strength and

Avoid pain is the principal precautions. The ligaments are almost recovered, (because it was a 2nd grade not 3rd) but she is still in pain. TEACHER ADVICE It´s important to remember that our physical proceedings could damage the patient. As usually passive examinations are testing tissue response, if we do not dosage them properly they could harm

that tissues. We need a proper evaluation of the

Movement

Strength

ROM

Dorsal Flexion

3

10°

Plantar Flexion

4

20°

example, missing the potential risk fall of a

Eversion

3

10°

balance test, could provoke a harsh result.

Inversion

3

10°

severity of the presentation at this point. But there are other tests for different dysfunctions that could put our patient in danger too. In

68

PHYSICAL EXAMINATION When the doctor started the physical exploration (I was just looking), the patient was kind of scare

Passive movements were the same range of movements but with a little of restriction to make the natural joint movement.

because she said that had not had a really good

He did not explore the gait because the patient

experiences with other medical processes. So

felt with insecurity at the moment of stand in

she did not wanted to know that she was going

both limbs.

to have a bar recovering. Comparing with the other limb this was the The doctor started exploring first by observation

results:

of her ankle, not her posture, because she could not stay standed up without pain. The doctor

Movement

Strength

ROM

found that the skin around the ankle was rubbish

Dorsal Flexion

5

20°

Plantar Flexion

5

40°

Eversion

5

20°

Inversion

5

35°

and warm comparing with the other ankle. Then he palpated the area, and it was swollen and inflammated. She referred her pain in level 4 in EVA scale at the moment of stand all her weight on her right foot. After that he started to evaluate the range of movements and strength in Daniel´s scale and this are the results in active mobilization:

STUDENT REFLEXION AFTER P/E I think that the Physical Exploration was kind of obvious, because the patient already had the diagnosis made at the moment she had the lesson, and it was corroborated with a radiography, so it was just to check the actual symptoms and problems she had on her ankle.

And when the doctor said the results of the test of strength, I thought it was relative, because he evaluated the movements but without causing pain, so I think the patient could have done more

TEACHER ADVICE At the end of the physical examination we need to take back a step and think for a while if data coming from S/E and P/E fits in some way.

strength even if she had felt a little of pain. If do so, it´s the moment to make out a working list The other ankle had so much more strength than the affected one because she had had to walk standing just on one foot, so she had to improve the range of movement and power of the health one to compensate the lack of the other ankle.

with the most reliable hypothesis for current patient´s presentation. At the top of this list will be the syndromes with higher likelihood to be present, and remains in the therapist ability to stablish which of them will be the working diagnostic hypothesis during the treatment session.

QUESTIONS TO IMPROVE REFLEXION Q1: Do you think your patient is going to have a fast recovering? Yes, I think she has a really good attitude and

PATIENT MANAGEMENT DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN

also positive factors to get back to play football

Thinking in my hypothesis, I beat that what she

again as soon as possible.

needs is really clear. Her ankle had suffered the consequences of the immobilization, so we need

Q2: So far, which is your first hypothesis with the data coming from C/O and P/E? Which is the data supporting this hypothesis?

to recover it as soon as possible. She had had a specific diagnosis before she came to the physiotherapy treatment so, we just had to take

My hypothesis is that is clear that she needed to

her back to her normal life. She had an

gain strength and more mobility to have a

impairment to walk normally, not just for pain,

normal gait again. The atrophy of her ankle

but also for insecurity and weakness.

makes her loose stability and muscle mass. And also the pain was the main negative factor that made her feel distrust in supporting his weight on her ankle.

The prognosis I gave her was good, I supposed she would be ok in some weeks, of course only if she follow all the instructions given during the therapy. She is young and a sportive girl, so what we have to do, also is to prevent her to have another lesion on the future, and the best way of

69

doing it is trying to recover her at 100% and

one level that were not so much painful to her.

giving her some extra points to her ankle.

She had to make 10 repetitions with an isometric

She had the same treatment during 2 weeks, and on the 3er week there were some changes, because she did not feel pain anymore. She went to therapy 3 times per week.

70

WEEK 1 AND 2

contraction in eversion, inversion, dorsiflexion and extension of the ankle. She had to keep the contraction for 10 seconds and then rest for 5 seconds between each repetition. Finally I used to give her a relax massage to avoid she was in pain after the sessions.

The treatment was given for the doctor, but I applied it to her. Firstly I used ultrasound to decrease the inflammation and pain, because if

STUDENT REFLEXION AFTER WEEK 1-2 TREATMENT

she were in pain, we could not make strength

I think the patient had good results, because we

training.

could get the pain relief. O Without pain we were

After that, I applied a hot pack for around all around her ankle for 2o minutes to relax the muscles before the stretching. Then, mobilized passively all the range of movements and stretched until the pain was of 7 in EVA scale. I explained that the therapy would be painful, but it was going to worth it.

going to be able to gain a lot of strength and proprioception to retraining the gait. WEEK 3RD During the 3er week, she was not more in pain, so all the session consisted in taught her a home program to strength all the right lower limb. I also prescribed a harder proprioceptive training

When the muscles were relaxed, we began to

and functional exercises to taker her back to

make the proprioceptive training. Being in front

football game.

of the mirror, I asked her to stand in one leg and then in the other one. I used some advisements

STUDENT REFLEXION

to make the exercises harder and raise the

She had really good results. She recovered all the

difficulty (like different surfaces with instability

range of movements, so with that factor to our

or closing her eyes at the moment she did the

favor, I think the only things she needed were get

exercises).

extra points to not get injured again.

About the strength training, I began with theraband exercises to make the resistance at

QUESTIONS TO IMPROVE REFLEXION

Q1: Do you think that is useful for her to use an

A4: I think that there wouldn´t be a lot of changes,

ankle support?

maybe I would use the kinesio-tape to help the

A1: I think that it would not be necessary, but it would give her extra support when she is playing.

peroneus muscle to do the strengthening exercises, and if the patient does not complain I could use ice instead hot. The cryo-kinetics

Q2: Does she should continue doing strengthening

exercises would have been a really good option

exercises?

too.

A2: I told her than she was going to have to do

TEACHER ADVICE

71

the exercises for a long time. Just to prevent another lesson. She needs to have more strength

For the majority of the physiotherapists I know, it

than usual in her ankle, because of the spring.

is not the ideal situation to work under the orders of other therapists or doctors, having no

Q3: Will you treat her in the same way if you have another opportunity again?

opportunity to take any decisions in the treatment you perform. In these occasions, although you

A3: Yes, absolutely. I think my management was

have to follow their prescriptions, I think that rely

good enough. The clue was in the initial

on you the capacity to dose it properly and make

subjective examination…

the necessary adjustments on patient´s benefit. And of course, they should listen to your feedbacks

Q4: How different should the treatment be if you had the opportunity to prescribe it instead of the doctor?

or reports with your own thoughts and proposals, also in that situations in which you think the treatment they prescribed is not working optimally.

FINAL STUDENT REFLEXION In my conclusion, I can say that she had a good recovering. I hope she follows all my instructions for the home program to avoid having a second lesion in the future. The treatment was successful because she was treated properly since she had the injury till the therapy program finished. The ankle spring is a very common lesson in sport people, but if it is treated properly, it doesn´t have to bring future discomforts.

REFERENCE LIST

1) Stanley Hoppenfield, (2007) Exploración física de la columna vertebral y las extremidades. (1) . Madrid. Manual Moderno

A 57 YO. HOUSEWIFE WITH A RIGHT HEMI PATELLECTOMY AND TENECTOMY OF THE PATELLA TENDON AFTER A PATELLA FRACTURE AND A TRANSIDESMAL FRACTURE OF THE RIGHT FIBULA BONE RANNOU MA. AND BERTRAND I.

imperfect osteogenesis and since then, she

INTRO

became extra careful and fearful about every A 57 yo. Housewife with a right hemi

kind of physical activity. Then, she also was

patellectomy and tenectomy of the patella

diagnosed with osteoporosis and her daughter

tendon after a patella fracture in July of 2014,

with imperfect osteogenesis too.

and a transidesmal fracture of the right fibula bone.

She’s

diagnosed

with

imperfect

She had antecedents: a right ankle fracture (a

osteogenesis and osteoporosis comes to start

fibula fracture), a right patella fracture and a

her rehabilitation with me in November after

few others in the other limbs but she couldn't

her last rehabilitation doctor’s appointment in

remember exactly how many. So, she was

August of 2014.

coming to begin her physical rehabilitation

SUBJECTIVE EXAMINATION

after her second fibula fracture (transindesmal)

I met D. at the hospital where she had a surgery for her physical rehabilitation. She was a dedicated housewife, mother of an adult daughter with whom she was very

and her second patella fracture on the right side. It happened during the summer in July, five months before I met her, first she fell and broke her patella and a week later she fell again and broke her fibula. Although her ankle fracture

close, having a lifestyle rather sedentary.

didn't need surgery as it wasn't displaced, her

Many years ago, she was diagnosed with

patella was quite bashed up and it resulted in a

hemi patellectomy and a tenectomy of the

Except for her very fragile skeletal structure

patella tendon which was in this occasion re-

which would oblige me to be extra careful, she

taunted with staples.

didn't present contraindications to the examination but, facing her fear, I decided to

The doctor prescription, of four months old in

start assessing the joints mobility and muscles

August, said that the physical therapist had to

strength in the lower limbs.

concentrate in the ankle joint but she hadn't been re-examined since then. As I spoke with

My first impression of the patient was a person

her it became clear that the ankle wasn't her

with mood swings: she often passed from a

major problem, she was disabled by it and felt

motivate, trustful and joyful state of mind to

pain but the one she had in her knee was worst.

sadness, fear, pessimism and lack of confidence

She explained to me that the pain, the

in herself as in myself. She had a tendency to

discomfort and a sensation of instability and

want to lead and control the examination,

weakness in her knee lead her to fear everyday

sometimes by fear of making it too much and

life activities such as go up and down on stairs

sometimes by laziness. It also appeared that

or go for a walk all alone even if she had

the bond she had with her daughter was very

crutches.

powerful: the fact that she inherited her

She added that because of it, she depended a

mother disease made D. feel very guilty and

lot of her daughter, feeling guilty and worry

preoccupied and worry about being a weight

about it, wanting to have a quick rehabilitation

for her.

and saying that she would do everything to

I

succeed. At the same time, she insisted a lot on

psychological sphere will be something very

the fact that I had to be very careful about her

important to include in the treatment.

understood

that,

in

this

case,

the

disease even if I didn't do anything yet. STUDENT REFLEXION AFTER S/E

QUESTIONS TO IMPROVE REFLEXION Q1: Could you find in the history any data

My initial hypotheses about the sources and

supporting that the patient should has an

patho-biological processes: a mechanic pain as

alteration of the pain modulation component in

a result of damages on bone and tendon

her pain presentation?

tissues in remodelling phase in both joints.

A1: I think that her state of mind and her

I decided to override the doctor prescription

attitude could be a proof that the patient has a

and dedicated time to the knee.

central modulation of the pain, in her case, the

psychological area has a great impact on her

she felt the more pain (Tables 2 and 3). The

pain.

mobility of the patella was quite good and the

Q2: How do you think her fear of not wanting to

cicatrisation process was going on. I made her

talk about her pathology could affect her?

walk with and without her crutch but she was so

A2: I think that this fear acts as a brake for her

focused that the walk didn’t appear very

recovery. If she doesn’t know what it is, she

natural.

can’t behave correctly to improve her condition.

TEACHER ADVICE Alteration of pain modulation system and central sensitization are two components of the pain

Right ROM Associated End-feel ankle symptoms Plantar 145° No pain Elastic flexion Dorsal 75° No pain Firm flexion Table 1. Arthrocinematics of the right ankle.

mechanisms with some overlapping and could be present at the same time. But they have to be addressed in different ways. Usually, information related with both mechanisms could be found (if present) in the subjective examination.

PHYSICAL EXAMINATION

In order to really understand what was frightening her, I tried to make her talk about her disease although I knew it. I was surprised when I discover she didn’t know much about it and wasn’t very interested in knowing more. I didn’t push her further, thinking she

Right knee Flexion

ROM

Associated Endsymptoms feel 80° Pain at the Elastic end of the movement Extension 0-1° Decreased Elastic muscle power Table 2. Arthrocinematics of the right knee.

Muscle group Grade (0-5) Ischiotibial muscles 4 Quadriceps femoris 3+ Gluteus muscles 4 Iliopsoas 4+ Flexor of ankle (DF) 4 Extensor of ankle 3+ (PF) Table 3. Muscles’ Power.

eventually could tell me and I decided to start my P/E. I started with the right ankle. She didn’t feel pain but was disturbed by a sensation of fragility and instability. I assessed her range of motion and her muscles power (Tables 1 and 3). Then, I did the same with her right knee where

At this point, she had enough so I let her go to her magnetic therapy session. Before she went out, she explained that although she was happy to start her rehabilitation and expect a lot from it, she didn’t expect very good results.

As she walked away, I finally saw how she was

exercises and that we will take care of her walk.

really walking.

My main idea was to make her participate and join her own rehabilitation by herself to then

STUDENT REFLEXION AFTER P/E

progressively lead her on a good path. She

About my initial hypotheses, my observations seemed to confirm that the real issue wasn’t in the ankle but in the knee where she suffered the more damages to the tissues. The pain finds its origin in her knee as the fact that she feels pain when moving seems to show. Also, I found interesting that she felt more pain when

seemed very relieved as she went home to know that the next session wasn’t going to be long and painful. QUESTIONS TO IMPROVE REFLEXION Q1: So far, which is your first hypothesis with the data coming from C/O and P/E? Which is the data supporting this hypothesis?

moving actively than when I executed the

A1: Noticing her pain manifests when she

movement myself. The lack of power in her

moves and go away when she rests, (associated

muscles didn’t permit her to move the way she

with a decreased ROM and muscle strength),

should as well as her fear of the pain and the fall.

my first hypothesis is a mechanical pain process

It appears that she also doesn’t know how to

as a consequence of her surgeries, in order to

use a crutch.

reduce her previous fractures. I would add that

About the narrative process, at this point I

her state of mind and her mood modulate this

understood that she didn’t want to expend

pain as shown by her attitude during the

herself on her disease or hear about it although

sessions through her obvious fear.

it had a big impact on her life and she had tendency to use it as an excuse to escape the TEACHER ADVICE

physical examination. It occurs to me that I’ll have to check again her walk as it appears that she didn’t know how to use

correctly

her

crutch

making

her

movements more difficult. I started to think that in fact, she didn’t even may need it anymore and that may have been something restraining her without her knowledge. I decided to not push her and told her that we will start the next session with some easy

There should be findings in these 2 first steps of the clinical encounter that have to correlate among them. As S/E comes firsts, usually points out which areas have to be evaluate in the P/E, and what should expect to find there. After performing the suggested tests, the therapist should could check if her first hypothesis were true or not and could move on to additional tests or questions if necessary.

avoid that she only depends on it. I noticed she

PATIENT MANAGEMENT DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN About my initial hypotheses, the exploration of

was capable to support her own weight and I asked her to try to do little walks and move in her home without it.

the patient left no doubt that the major

Finally I let her go to her electrotherapy and

problem

post-surgery

magneto therapy session because she feels

consequence and a significate lack of strength

better to end with it, saying that she took that

in the lower right limb.

as a way to relax and rest before going home.

was

indeed

a

About the narrative process, I wasn’t really sure about the implication of the daughter and her influence on her mother but I was certain that

STUDENT REFLEXION AFTER D1 TREATMENT

anyways the pathology, her history and the

She didn’t feel any pain during the treatment

rehabilitation had a strong impact on her

even if she is very attentive at every move I

participation and on her daily life sending her in

make and how far I go during the mobilizations

a vicious circle: the less she does the worst she

only to relax after a few series.

feels; and the worst she feels, the less she does.

The next day, if the treatment runs, I will

So my main goal was to break this circle and

continue with the exercises adding a little more

restore

difficulties: longer series and more resistance;

her

confidence

through

the

rehabilitation to move forward. DAY_1 We started with easy exercises: firstly big range mobilizations on both joints to show her that it could be done without pain; and then, small inner range mobilizations to start gaining ROM.

and if she has improved with her crutch I plan to try working on parallel bars with obstacles and little stairs. The goal will be to work targeting the function of her upper limb and push her to be confident about going for a walk by herself and coming back to her daily life with good bases and no fear.

I also applied a very small manual resistance during short series of movements to start

DAY_2

improving her strength slowly. The main idea is

I started assessing her progresses since the last

to show her what I expect from her and that she

session (she has a session everyday but I choose

is totally capable of doing it.

to explain the progresses and treatments each

Then, I dedicate time to show her the best way

week to really show her improvements with

to use her crutch to improve her walk and to

significates observations.), and she showed an

increased strength and a decreased pain.

obstacles and the banister and her strength

Seeing those improvements, I kept the initial

improved well so I decided to start practicing

treatment, only increasing a bit the difficulty

the stairs and to do muscular strenghting’s

with the resistance exercise and longer series of

exercise with weights.

movements.

The first exercise consisted on a flexo-

Then, we practiced on obstacles where she can

extension of her knee with a 3kg weight tied on

help herself with parallels bars and started to

her ankle, her thigh being supported by a pillow

go up and down a banister. With these two

while she was laying on her back.

exercises, we try to prepare her to go up and

The second one consisted on a flexo-extension

down the stairs, working on her joints and her

of her knee, pushing against a ball while she

muscles in a functional way which would

was sitting on the couch.

improve her symptoms.

She then continued with obstacles and banister, my intention was to slowly set up a routine,

STUDENT REFLEXION AFTER D2

with warm up, which she could easily follow so

TREATMENT

if I added exercises she won’t be lost only

I see a really significate improvement with this

removing the “old” ones when the new ones

patient. But she doesn’t seem to realize how

were totally acquired.

better she was. She tries her best to be

Finally, we started to go up and down little

enthusiastic about her treatment and I think

stairs, her two hands firmly holding on the

she manages it better when the exercises are

handtrails. The first problem was to correct her

about doing things of her daily life like trying to

posture as she was coming down the stairs

go through obstacles, working on her walk…

aside and putting both feet on each stair.

I try as much as I could to keep it entertaining

D. seemed more confident every day but

as she wished her recuperation was faster but it

started to complain about the length of the

sometimes is quite difficult to manage her

treatment showing some signs of impatience.

mood swings and to motivate her, it demands

The fact that I added some exercises didn’t

patience and inventiveness to convince her to

please her, she thought that the ones she was

work out every session but it’s an interesting

doing before were enough and I had to explain

challenge.

that the key of her progress was in the variety

DAY_3 As every session’s begun, I assessed her progresses. She was doing pretty well with the

of her treatment, increasing the difficulties. She wasn’t convinced. The next session, according to the results, I plan

to continue with the stairs, trying to improve

work more on the stairs. But to start, she

her going down so she gains in autonomy (her

warmed up with her strength exercises and

own stairs only have a handrail and she can’t

auto passive movements: we worked on every

come down without any help). We also work

movement of her hip, knee and ankle, with

out on the strength in her both legs: with auto

weights and pulleys seeking to improve the

passive exercises and more weight. Finally, we

general strength of her leg, not only her

will experiment some proprioception both for

quadriceps muscles.

her knee and ankle.

Once she finished with it, we came up and down the stairs. Last time, we didn’t manage to

STUDENT REFLEXION ABOUT D_3

change the fact that she was coming down

It’s now really difficult to keep her motivated

aside, both feet on each stairs with the two

for her therapy, she doesn’t realize her

handrails. I thought that the problem wasn’t

progresses at all, and this is why I think the

mechanic as I saw her with the obstacles and

stairs will be the solution to this problem.

she hadn’t any problem to come down from

Working and improving herself on the stairs

them. It started to appear that she feared the

will show her, with something she knows well,

stairs. She was physically capable of doing it

how much she improved.

but wasn’t confident enough.

We must continue to work with the weights for

We started slowly, with only two stairs and the

her strength even if she doesn’t see the

two handrails. Showing her that it was easier to

differences but maybe if she realize that in

come down to the next stair if she put half of

order to do the stairs exercise correctly she

her foot on the side of the stair before going

must gain strength it will be easier.

with the other on the stair of after, it was only a

The main problem with D. is her lack of trust,

question of control of her quadriceps. Solving

in herself mostly and in me a little, this is why

this, she was then able to come down frontally.

one of my objective is to give her

Very excited by this improvement, she didn’t

consciousness of all the work she managed to

even realize that she used only one handrail.

do so far, giving her exercises that put it in

These results acted as a trigger and at the end,

light, like the stairs.

she wasn’t using the handrails at all. We then tried to do little proprioception. First,

DAY_4 For this session, seeing the previous results, I decided to remove the obstacles exercises to

she had to work on a mattress, walking on it varying steps: on tiptoes, on heels, aside, crossing legs…The goal was to provoke an

adaptation of her body to the changing

was difficult for her to let her crutches aside

parameters. We then tried it on a rocker device:

because she felt like she needed it. Slowly, she

she was standing on it, on her both feet and I

decided to let them go, and admitted to me

throw her a ball in various directions to provoke

later that it was in fact easier to walk without

an unbalance.

them.

Despite her apprehension, she did it very well

Q3: Do you think that, if you ignored the

and we managed to make it more difficult

psychological aspect of the treatment, it would

asking her to stand on one feet only (she had a

had the same result?

wall to lean on if needed). She didn’t managed

A3: I think that if I hadn’t, the results would

to do it so we stayed with the more stable

have been really different, it would have been

version, for this time.

worst. I imagine she would have stop her treatment, convinced that I wasn’t seeing her

STUDENT REFLEXION AFTERDAY_4

like a person but only like a joint.

This session was quite important because she finally realized that her therapy was working, after that, it was really easier to work with her and to propose her other exercises. I think that in her case, the fear of hurting herself was the biggest brake and that all the time we took was necessary to come to this result. QUESTIONS TO IMPROVE REFLEXION Q1: Which was the role of the electrotherapy in your management? A1: The electrotherapy was TENS and was prescribed to strength her quadriceps muscles. The patient was quite enthusiastic about it as she felt a relaxing effect afterwards and insisted to have it at the end of the sessions. Q2: Did she manage to walk correctly? A2: She eventually walked in a better way but it

TEACHER ADVICE Sometimes is hard to be sure about which part of the treatment has worked better, worse or not at all, also in multi-treatment modalities. It´s the same with lots of research case reports, in which patients are treat with and elevate number of techniques and no data about confounding effect is found. At least, if patient objectives are lined with outcomes, technique effects, and these are properly performed, we could have a plan to revisit after changes are seen.

FINAL STUDENT REFLEXION The final results confirmed my initials hypotheses and even if it was a long process, the patient and I managed to see the improvements. The difficulty in this case wasn’t really the diagnosis but the management of the patient. It took a lot of patience and courage for both of us to communicate and to go through the therapy. The key of the treatment was in the psychological area of the patient, once she admitted that she was improving, it became a lot easier. She didn’t stop her mood swing but she accepted better the directions I was giving. If I had to treat her again, I wouldn’t change my treatment. It worked but maybe I’d try to be firmer, to take the lead of the treatment more quickly.

Right ROM Associated End-feel ankle symptoms Plantar 150° No pain Elastic flexion Dorsal 80° No pain Firm flexion Table 4. Final assessment of the ankle ROM

Right knee

ROM

Associated End-feel symptoms Flexion 90° No pain Elastic Extension -3° No Elastic Table 5. Final assessment of the knee ROM.

REFERENCE LIST 1. RESERVES, I. and FORIN, D. (2015). Orphanet: Ostéogenèse imparfaite. [online] Orpha.net. Available at: http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=FR&Expert=666 [Accessed 14 Jun. 2015]. 2. Root, L. (1984). The treatment of osteogenesis imperfecta. The Orthopedic clinics of North America, 15(4), 775-790.

8 YEAR OLD BOY WITH FRACTURES OF BOTH LEGS AFTER A FALL FROM THE EIGHTH FLOOR OF AN APARTMENT. TIBERI A. AND VIOLATI D.

82 The medical diagnosis was; in the left leg

INTRO

closed diafisary fracture of tibia and perone, M. is an 8 year old boy who fell off the 8th floor on the 31st of October and fractured both his legs.

treatment with a monolateral external fixator for 3 and a half months. And in the right leg open fracture of the external femoral condyle and right meseta tibial of grade IV in the Salter

SUBJECTIVE EXAMINATION

and Harris’ epifisiolisis scale. The treatment M. is an 8 year old boy who studies in a German school in Madrid. He says he doesn’t practice a particular

sport.

He

went

to

the

consists of an open reduction of the epifisiolisis with screws, cast and orthesis for the first 6 weeks.

physiotherapist the 13th of April of 2015 and says he also goes to another physiotherapist

After a MRI, it appears he had a slight

once every 2 weeks. When we met first I asked

pulmonary

how the accident happened; M. felt a little bit

neumothorax.

uncomfortable, so I decided to change the topic. After a week he confessed that on the 31st of October 2015 (Halloween night), he was playing by himself outside in the balcony, which was on the 8th floor, when he approached the border line and fell, the fall

contusion

and

a

minimum

He doesn’t present neurologic or vascular alterations, the pelvis is stable and the upper body moves without pain. He has been on a wheelchair for 5 months and after that, until today, he uses a crutch to walk. He told me he had never had any other problem before.

was diminished since he fell on a bunch of trees. He told me that that very day he went through

He does not feel any creep sensation, tingling,

surgery on both legs.

burning or allodynia; his sensibility has increased on the right knee around the patella.

He also mentions that his pain appears when

remove some fears which can interfere in the

he tries to move more the leg, and he has an

rehabilitation.

itchy sensation around the scar on the right leg. He also says he feels his legs weaker when he

QUESTIONS TO IMPROVE REFLEXION

has to walk long distances tires or taking the

Q1: Andrea, as you described, M. also has an

stairs at school

epiphysiolysis. How do you think you can deal with it?

STUDENT REFLEXION AFTER S/E M. is a little boy therefore it is complicated to get him focused for a long time, he doesn’t enjoy talking about the accident and this makes the anamnesis harder. I always try to ask

but

without

making

him

feel

uncomfortable and for that reason I was missing information during the first week in

A1: This is a point where I feel a bit doubtful, since the doctors said he has a grade IV epifisiolisis, after a few searches on this type of fractures, I saw that the prognostic is negative due to M.’s age and his growing cartilage is affected. My objectives would be to stimulate the vascularization to that zone.

the anamnesis.

Q2: What do you mean with, “a fear can

My initial hypothesis of the source and

interfere in the rehabilitation”?

pathobiological process: M. has suffered a great

trauma,

mentally and

physically.

Physically the medical diagnosis was a great help and gave a clearer picture of what he has. The fact he has a hypersensitivity or muscular weakness

could

be

related

to

the

immobilization and due to the surgery he received. I decided to evaluate only the hip and the knee of both legs and the position he has from a bipedestation. About

the narrative process, my first

impression was that M. is a Young boy and

I think that in a normal mental state where the patient feels ‘depressed’ or better said, notmotivated, due to the fear of falling for example or doing things wrong, can harden our work. If I push the line of work too much on something he does not want to do (for whichever reason), he could obtain rejection from him but at the same time if I think this line of work is appropriate but he is scared due to any reason, it can slow down the recuperation times.

luckily his improvement is faster. We have to

Q3: Which is the impact for daily life activities

pay attention to his self-confidence and try to

and participation?

84

A3: During every day activities, as we were

physiotherapists. But it doesn´t mean that a

talking, I understood that M. can do everything

wise therapist hasn´t to take it in consideration

inside certain limits. It was him who told me he

to approach these patient´s area. Disability

had difficulties to play with the other kids since

issues

he is the slowest and if he forces his legs they

presentations

start to hurt so he is scared and avoids playing.

treatment outcomes. And our work over the

The only thing he does with no problems is

dysfunction has a direct effect in disability.

being a goalkeeper during break. But generally

Physiotherapists have to know how the impact

he moves with the crutches by himself with no

is in this area and which parts of Daily Life

difficulties and can dress up by himself etc…

Activities and Participation are being affected. It

Regarding

the

is usually more significate and realistic for a

treatment M. is easily distracted, it is hard for

patient the possibility to play soccer again than

him to keep focused and he says he gets tired

to achieve the cold “knee´s full active ROM”

and doesn’t want to do certain exercises.

goal.

Q4: How was the role of his family members

PHYSICAL EXAMINATION

his

participation

during

during the anamnesis? Do they cooperate?

have

a

major

and

role

in

perspectives

patient’s for

the

One week has passed since the first time I saw

A4: The first time I met M. he was with his

M. I was at the end of the clinic’s corridor and I

grandmother; she came to me and told me in

saw him walk towards me accompanied by his

detail about M.’s accident. When I started

grandmother. After saying hello we went

talking to M. and got a bit closer he was very

inside the consult. After a few minutes talking

shy and didn’t want to answer me, so his

with his grandmother I started with the

grandmother had to answer for him. I had to

physical exploration. I ask M. if he can put his

ask his grandmother if she could leave so I

trousers, socks, shoes and shirt off, explaining

could be with M. by myself and get closer to

him that in that way I could have a clearer look

him. Since that moment he started answering

on his state. After a few jokes I asked m. if he

more questions.

could put himself on a comfortable position and look towards the front, I tried to pay

TEACHER ADVICE Following

the WHO

attention to every detail (feet position, shape the

of the tibias, height of the patellae, popliteal

International Classification of Function in 2001

hole, hip, back, and compared his muscular

(ICF),

tone). Generally he seems he goes towards a

disability

is

definitions

not

the

of

field

of

pelvic anteversion, knee flexion on the right leg,

in any other position than goalkeeper and he

and a clear division of weight towards the left

didn’t like this situation.

leg. I also evaluated his scars and the scar of the right leg, above the patella, and saw it was

STUDENT REFLEXION AFTER P/E

a queloid type; the others didn’t seem to have

When I saw M. walk I focused on his way of

any abnormal alteration.

walking, I was impressed because it looked like

- Muscle Balance:

a neurologic walk, therefore I asked my tutor for advice and he tranquilized me and told me



Right leg: grade 3/5

it wasn’t like that. My idea at first was to



Leg left: Grade 4/5

educate his walking since it looked much

- ROM the knee:

uncontrolled. After the first time I saw M. at his home, I looked for the type of fractures he



Right leg: 85 ° of flex. And 15 ° ext.

presented and made myself an idea to what I



Left Leg: Full

was dealing with. After this first P/E, I already have an idea to what I have to work with him

- VAS:

for the moment, my objectives for now is to 



Right leg: by forcing the movements of

reeducate the walk, obtain a complete knee

flexion and extension reaches an 8 (not

extension, work on the pelvic anteversion,

strive wanted more) and palpation of

strengthen the muscles and mobilize the scars

scars: supra patellar and the one in the

to avoid adherences.

popliteal hole.

I told him he’d play football again and he’ll be

Left Leg: painless movements but

stronger than before. I know inside my mind

palpation of the tibia and fibula is

that I’m facing a complicated case, mostly due

painful.

to the psychological aspect rather than the

I had the occasion to ask him some more questions, but this time focusing on his feelings after the accident. I asked him if he could play with his friends in school. He said he played as a goalkeeper and that he could stop more goals with his crutches, but he can’t play

physical.

QUESTIONS TO IMPROVE REFLEXION Q1: In the type of trauma and the postures described in the P/E, do you think that some test

pushing the femur anteriorly as the psoas iliaco or muscles that can produce this anteversion.

to assess the integrity of the nervous system

Give mobility and break scar adherences could

could be useful?

allow us obtain more elasticity in the tissues

A1: Your proposition is very interesting and in

86

work at the same time the muscles that can be

fact I thought about the same thing during the day after the exploration. Unfortunately I don’t have a lot of time to do many things, I want to focus on these types of explorations for 2

and obtain more movement of the knee. As I said earlier, always put strength work to strenghthen and reeducate the walk. I totally agree with the propioception work but it will be a line of work that I will be integrating gradually little by little according to the

reasons:

progress made on the objectives described 

Because doctors said after MRI that M. has no sort of neurologic affectation in the nerve root



I think that for a kid like him it was best

earlier. Q3: Which are the positive and negative issues for the prognosis in this patient?

to do something “faster” and simpler

A3: Positive Issues: M´s is, surely, important in

for the first day of exploration. Surely

the prognosis due to the fact that it allows us

the next time I will do some test to

to advance a quicker way, the socio-economic

discard

support of the family which allows to have

possible

neurologic

affectations. Q2: Could proprioception be an accurate goal for your patient?

physiotherapy sessions every day and 3 times a week with 2 hour sessions. The absence of other types of diseases. Negative issues: lack of concentration and doesn’t want to really do

A2: Inside my head I have an idea of what the

the exercises is a factor that makes us lose a lot

objectives are and which ones I think could be

of time to make the patient listen and do what

the most important ones. I think it is very

he is asked to, fear creates a defense response

important to work all at once with him. I will

where the muscles try to block the leg and

focus on working every day on the mobility,

difficult the exercises centered on the

paying more attention to the extension since it

increment of range of articular movement. The

is the movement that allows us to have a

type of fracture of the epifisiolisis and the age

functional walk, to work on this. I will have to

in which he did it is another important factor

since there is affectation of on the growth

for the epifisiolisis with screws, plaster and

cartilage and also it’s an age where there is

ferula for the first 6 weeks.

more bone development.

Also, after a TAC we can see a light pulmonary

TEACHER ADVICE

contusion. Minimum neumothorax.

One of the typical questions asked by the patient

He doesn’t present vascular nor neurologic

after this point is “How much time does the

affectation, the pelvis is stable and the upper

treatment need to be effective?” Therapist

limb can be moved without pain.

haven´t a crystal ball in their kit. But we could guess an approximate period of time thinking in

He has been on a wheel chair for 5 months and until today. From my point of view M. presents:

the clinical pattern, the related published evidence, the pathology and your own



Pelvic anteversion

experience treating this kind of presentation.



15° knee flexion on the right leg

Not every former point weights the same; but



Queloide-type scar on the right leg above the

you could put, in a two-plate scale, positive against negative prognostic factors and provide



an estimation. PATIENT MANAGEMENT



Muscular balance o

Right leg: grade 4/5

o

Left leg: grade 5/5

ROM: o

DIAGNOSIS, PROGNOSIS, OUTCOMES

of ext.

AND PLAN o From a medical point of view the diagnosis is clear, M. presents fractures on both legs: -

Left leg – diafisary closed fracture of

Right leg: 85° of flex. and 15°



Left leg: complete

VAS: only pain when movement and palpation o

Right leg: when forcing the

tibia and perone, treatment with an external

movements of flexo-extention

monolateral fixator for 3 and a half months.

he reaches an 8 (didn’t want to force more)

-

Right leg – open fracture of external

femoral condyle and right meseta tibial of grade IV on the Salter and Harris epifisiolisis scale, treatment consists of an open reduction

o

Left leg: the movements don’t hurt but the palpation of the tibia is painful

The prognosis of M. can be good under a

In this section I focused completely on the right

functional point of view, since he is very Young

leg:

his recuperation is faster but what upsets me is the epifisiolisis that he has on the right leg. My objectives are that M. regains his confidence on himself and that he can have once again strength, mobility and more functionality than

88

before.

I asked him if he could lay down, the attention of M during the treatment was very low, he laid down in incorrect positions and when I tried to move the leg he’d pus hit on the opposite side to avoid me from moving it. I made a deal with him: he could ask me whatever he wanted if he allowed me to move his leg. I then started with

DAY_1 Before starting with the treatment I did a quick neurologic exploration to see if there could be an entrapment on a nervous level. Both mecanosensibility test as to the nervious conduction test were negative. I asked M if he

the treatment. M was laid down facing up and the left leg was resting while I had the right leg and worked with the scar with a few massages from superficial to deep in order to break adherences, always basing on the pain M had.

could lie down on the massage table sitting. I

Then I did passive mobilizations specifically on

rapidly evaluated the ROM on both legs to

the patella to the femur and on a second place,

have a comparative mean at the end of the

passive analytic mobilizations of the knee on

treatment. I explained what I was going to do

extension

and to tell me when it’ll hurt. I explained to him

component of the tibia and tractions and

to classify his pain on a scale from 0 – 10

relaxation of the knee. On second place I

calculating 10 as an unbearable pain and 0 is

started working on the flexion from a seated

when you don’t feel anything. I started the

position

test:

component of the knee. I then did the muscle



Right leg : 85° of flex. and 15° of ext.

o

adding

an

an

external

internal

rotation

rotation

treatment of the psoas iliaco from the right

ROM: o

with

Left leg: complete

side, M was on supin position and I was holding his right leg increasing the hip flexion to better go in and palpate the iliopsoas. To the palpation of this muscle we could clearly feel

The end feel was firm and was accompanied by

an increase of the tone.

a muscular spasm as a defense mechanism due to the pain.

At the end of the treatment I re-assessed the mobility and the improvement was noticeable

since I could reach with the right leg more than

element in order to obtain his attention and

95º of flexion and nearly 5º of extension.

be able to work with him on a better way.

STUDENT REFLEXION AFTER D1

DAY_2

TREATMENT

When I saw M I asked him how he felt after the

As expected it is a child and clearly bored

treatment and he told me he felt good and that

standing still in one place and also try

he didn’t feel pain during the day. I then tried

maintaining the most attention possible with

the same treatment from the first day, giving

games and history while continuing my

me time to do a few miofascial liberation

treatment. I think it's very difficult to focus on

techniques on the quadriceps with my hands

making techniques while reassuring the

crossed on top of the muscle and realizing a

patient, this makes me wonder if what I'm

traction on the opposite side as if I wanted to

doing is really the right thing, I wish you could

enlarge the muscle and adding movements

be more relaxed and understand that what I'm

that

doing here with the I do it just for him.

restrictions. At the end of the treatment I

could

go

directed

to

miofascial

spoke with him and his grandmother who was QUESTIONS TO IMPROVE REFLEXION Q1: What types of treatment did you use to assess the iliopsoas muscle?

inside the consult and I told them that the following week we would start going to the gym, dividing the treatment on 20 minutes of manual therapy, 20 minutes of gym and 40 of

A1: I applied a pumping technique of such

swimming pool.

muscle to avoid an irritation of the muscle, which would cause an increase of the pain. Q2: Which part of your management do you

DAY_3 Same as DAY_1 and DAY 2.

think has worked better and why?

DAY_4

A2: I don’t think that there has been a part

It was the first day of gym. I started treating

during the treatment that has been more

the scars and mobilizing the patella and knee

effective. I think that the set of techniques

on flexion and extension with the same leg as

have attained this improvement. I believe my

the first day, I also focused on working on the

attitude towards the patient has played a key

hamstring muscles manually doing deep passes and stopping on miofascial conflict

90

zones and on latent trigger points. Then I went

reeducation of the gait by playing with speed

to the gym with him and we started a strength

and amplitude of the gait, controlling the trunk,

program. M was lying down and we had the

another exercise consisted on him supporting

opportunity on the clinic to do some motor

his feet on the wall of the swimming pool while

control

STABILIZE

I had to hold him from behind, positioning his

apparatus. I started with a few motor control

legs separated by a few cm’s (shoulder width)

exercises on isometric for the quadriceps, I

from this position he had to bend the legs more

positioned

the

so he could then push hard (as if he wanted to

popliteous hole and explained to M that

jump) the objective was to strengthen and

according to the orders I gave him he’d have to

work on the active mobility. For last I told him

contract only the muscle on top of the thigh

to go on a little stair that sunk M’s leg until half

and buttocks and the muscles below the thigh

of the inferior part of the thigh (above the

had to be relaxed, to make the exercise easier I

patella) and from then on he had to be on a

told him top put a hand on top of the quad and

monopodal posture and hold the position for

another one on buttocks and hamstrings. At

20 seconds.

exercises

the

with

the

STABILIZER

below

first it was hard for him to differentiate the contractions between the different muscle compartments. I did the same exercises for the hamstrings positioning the STABILIZER below

DAY_4,5,6 & 7 The treatment was always the same DAY_8

the heel and telling him to push with the heel downwards. I also worked on a propioceptive

3 weeks have passed and I did again the

level and explained to him 2 exercises, the first

physical exploration, the improvements were

one consisted on standing up on top of 2 tilts

huge.

and did charge transference from a leg to the

The pelvic anteversion, managed to have a

other without pain and the second exercise

nearly full extension from the 3º of flexion on

consisted of walking on a DYNA DISC which is

the right leg. The scars remained more or less

a disc made out of rubber, I explained to him

the same, the muscular balance improved

that he had to put more charge on the heel 

even though we could still see there was a

Little toe  thumb. We then went to some

difference between the left and right leg, with

parallel bars in order to work on the gait. After

less strength on the range of movement:

20 minutes I went down with him to the swimming pool where we focused on the

o

Right leg: 105° of flex. and 3° of ext.

up and down the stairs. On the swimming pool

o

Left leg: complete

-

VAS: pain only to movement and

palpation o

Right

leg:

when

forcing

the

the exercises were more or less the same but we increased the intensities. AFTER A MONTH AND A HALF:

movements of flexo-extention he reaches an 8

M’s treatments are still on the same line of

but he reaches greater amplitudes (didn’t want

work but increasing little by little the

to force more)

difficulties and intensities. On the third

o

Left leg: the movements don’t hurt,

evaluation I did that day M presented:

the palpation of the tibia is less painful

-

Minimum pelvic anteversion

I started as always mobilizing the scars, rotula

-

Scar on both legs were had more

and knee. That day I focused on working more

flexibility and the queloid type of scar had

with the psoas because I think it was one of the

diminished its width.

factors which was altering the gait, so I applied

-

Muscular balance

then I did an analytic stretch of that muscle. On

o

Balance muscular of the right leg:

this section I also worked on a Global Postural

grade V

the same treatment as described before and

Reeducation technique (RPG) with the posture of the dancer to stretch the posterior muscle chain, maintaining this position for 4 minutes without M feeling any pain but a slight tenseness Garrido-Marín, A. et all. 2012. On the gym I started doing a few propioception exercises which were a bit harder, such as stability on standing position on the BOSU, on the side of the half ball, he had to maintain for

o

Left leg: grade V

-

ROM:

o

Right leg: 130° of flex. and 0° of ext.

o

Left leg: complete

-

VAS: pain on the movement and at the

palpation

20 seconds, then he had to put a leg on top of

o

the BOSU and the other one in front of the

movements of flexion around the 133º/135º he

ground, and from there flexion the leg which

reaches an 8 (didn’t want to force more)

was more anteriorized by controlling the trunk. At last we were working on the gait and going

o

Right

leg:

Left leg:

painless

when

forcing

the

palpation of the tibia is

M. I realized that with the passage of time was always hearing me more, working with is not easy because you have to be always doing something that catches your attention, but I think with these types of jobs in addition to the clear improvements at the level physical, M. has greatly improved its attitude also fear. This

92

was the last day I saw M. due to the end of my clinical practice. STUDENT REFLEXION

a complete knee extension, increase of the muscle tone: gastrocnemius, soleus, popliteus, isquio-cruralis muscles, mostly on the right leg. I chose to apply an RPG treatment due to the fact that in the article (Garrido-Marín, A. et all. 7 November 2012) the effectivity or global postural reeducation was studied versus the Propioceptive Neuromuscular Facilitation, to increase the extensibility of the hamstring muscles and it concluded that the treatment

Throughout my treatments with M. my thoughts were always to look for functional exercises while at the same time entertaining him since he used to get distracted easily. During the hours of training I always looked for

with RPG is better. Therefore I surfed the web for books that talked more in depth about this treatment and which was the RPG posture most indicated for M´s presentation (Souchard, P. E. 2005).

simple exercises to strengthen, improve the propioception and functionality in order to bring it to his daily life activities. QUESTIONS TO IMPROVE REFLEXION

TEACHER ADVICE In spite of you´ve found one paper suggesting the prevalence of RPG stretching against PNF¨s, it´s no necessary true that this method is going

Q1: On the 8th day you said that you worked

to work better with your patient. Despite the

with M. a RPG stretch, the “dancer”, what is

internal and external quality of the journal

the reason that made you believe that this was

publication, we should find those which were run

a suitable stretch for him?

within a similar population compared with our

A1: During the treatment weeks, I had the

patients. If her/his profile fits properly within the

possibility to know more of M. as the days

profile of the volunteers in a research, probably

went by. There are many reasons: limitation of

you could better guess how treatment will be with your client.

FINAL STUDENT REFLEXION I’ve reached the end of the treatment with M. The case firstly really scared due to the fact that I had to put a lot of effort in every day to make him pay attention, there were days in which he came and he was really tired therefore working with him was very hard, also the fear I had when it came to do certain exercises with him blocked me a little. I think it has been a very stimulating case for me because every day I felt obliged to make up different exercises which were directed towards my goals at the same time. It has also been my first experience on working with the swimming pool so I am very happy about that, it’s a good line of work and the possibility to be able to follow the case gave me the security that what I was doing with him was the right thing because I could constantly see the improvements. It has been a difficult case but it has made me think a lot and improve my knowledge REFERENCE LIST 1. Souchard, P. E. (2005). RPG. Principios de la reeducación postural global (Vol. 88). Editorial Paidotribo. 2. Marín, A. G., Guzón, D. R., López, P. E., Serrano, M. F., & Imedio, A. S. (2013). Efectividad de la reeducación postural global frente a la facilitación neuromuscular propioceptiva, para aumentar la extensibilidad de los isquiotibiales en sujetos sanos. Estudio piloto. Cuestiones de fisioterapia: revista universitaria de información e investigación en Fisioterapia, 42(2), 98-106.

A TOO EARLY MENISCAL DIAGNOSIS URIA A. AND ALCALA L. The pain started one month ago during a paddle-

INTRO

tennis match when he made a sudden extension 31 year old man who works as a labourer in kitchen construction who complains about a continuous

94

pain above his right patella accompanied by a sense of engagement of 1 month onset…

of his right leg, but he continued playing at the time and for the next two weeks until the pain was so strong that he decided to stop. He usually went running with his dog three days a week, but he interrupted this too. The pain hasn´t hold on since

SUBJECTIVE EXAMINATION

he first noticed but has increased to the point that A.K is a 31-year-old man who works as a labourer

it hurts even at work.

in kitchen construction. He has come to a

He needs to expend a lot of time squatting at work

patella

and he feels a continuous pain, which influences

accompanied by a sense of engagement during

him in his mood and work performance. He is

certain movements, which started one month ago

annoyed about not being able to do any of his

during a paddle- tennis. He has recently started

hobbies (jogging and paddle- tennis).

physiotherapy continuous

consultation

pain

above

his

because right

of

feeling pain in the internal part of the left patella as well as an overload sensation of his left gastrocnemius.

The pain on both legs (specially the right leg) increases at the end of the day (when walking and standing for long periods of time, squatting, when

When I first met him, he walked into the

standing from a squatting position and while

consulting room limping his right foot trying not

going up and down stairs). He usually puts his

to stand on it. I noticed he was a restless person

right leg at rest, extended and with ice at the top

when he started talking to me. He didn´t stop

of the knee to reduce pain and he feels no pain at

wondering about the diagnosis before doing any

night. But when he wakes up, he feels a bit of

physical examination. He was really scared about

stiffness and discomfort on his right leg that stops

having a meniscal injury because his father was

after heating the joint.

operated twice due to his work, which is the same as his.

He had three-ankle sprain on his right leg when he

his constant fear about being operated as his

was 14 years old.

father. But during the clinical case and after the

He has a good overall health; no respiratory or circulatory or urologic dysfunction and he had

physical examination, you will see how I am going to change my mind.

good results on his latest blood test. He has not

Q3. Which

attended any doctor and has no radiographs of his

transmission in meniscus diseases? Do you think is

knee.

high enough to lead a P/E thinking in that

He is not taking any medication, just ibuprofen occasionally when working but without effect.

is

the prevalence for genetic

possibility? A3: No, there is no scientific evidence about genetic transmission in meniscus disease but I

STUDENT REFLEXION AFTER S/E

focused on that possibility because of the

Because of his family history (his father had

triggering

undergo a meniscus operation because of his

continuous aggravating situations during his work

work), my first thought has been that the same thing was happening to the son. So I have decided

mechanism

of

injury

and

the

TEACHER ADVICE

meniscus testing without thinking in other

Illness scripts are good tools for clinicians during the

options.

decision-making process. They provide therapists with the most relevant characteristics of a

QUESTIONS TO IMPROVE REFLEXION

prototype patient within a syndrome. Despite they

Q1: Didn’t you think that the pain of the left leg is

are not always the same (they evolve as the same

caused by an overload?

time as the clinician´s experience) and there is no such a thing as a “prototype patient”, having these

A1: It was my first thought, but I first wanted to

schemas in your mind prompts you with more

know what was happening with the right leg as it

chances to discover of the patient´s presentation

was the main cause for the patient visiting the

fits in that schema or not, avoiding unnecessary

consultation and his main concern.

procedures

Q2: What about the patellar tendon and the LCA and LCP? A2: Yes, you are totally right. Meniscus testing was my first step because of his family history and

PHYSICAL EXAMINATION

During

the

dynamic

examination,

active

movements are good except medial rotation of the knee and hip in both legs (especially in the right leg). Pain has been found during right leg extension starting from a squat position. Accompanied by an engagement sensation of the knee.

96

During palpation, temperature and muscular tone are normal and there is neither articular spilling nor edema. Pain has been produced at joint line palpation of the right leg and an increase in tone has been found in the calf of the left leg. Muscular balance is 3/5 in the right quadriceps. I have started with the static examination where

Trigger points have been detected at the left leg

nothing relevant has been detected except a bit of

in the internal and external gastrocnemius.

knee hyperextension and a great base of support.

Tests: Thessaly test, McMurray test. Appley test

   

The main symptom is the continuous pain

and the Sensitivity test of the joint line have been

above the right patella.

performed.

The second symptom is an engagement

All of them have been negative except the last

sensation in both sides of the right joint line.

one, which has been painful during palpation.

The third symptom is the pain at the internal

Lachman test has also been performed but has

side of the left patella.

been found to be negative too. (Harrison, B. K.,

And the fourth symptom is the overload

Abell, B. E., & Gibson, T. W. (2009), (Akseki, D.,

sensation he feels at left gastrocnemius.

Özcan, Ö., Boya, H., & Pınar, H. (2004).

His associated symptoms are a right leg block sensation and articular crunch sensation. All

STUDENT REFLEXION AFTER P/E

symptoms are related. Because of the pain in the

As all meniscal tests have been negative except

right leg, left leg has made lots of compensations,

for the joint line test. I have dismissed any

and has ended up with pain too.

meniscal injury by the limited relevance of this

last test alone. As Lachman test is also negative,

A1: The truth is that I did not think of a joint wear

LCA and LCP injuries have been dismissed too.

problem because the reason for the beginning of

I now have to make a hypothesis with all the information I have: - Pain mechanism is nociceptive and mechanical and tissue is at proliferative phase (1 month).

the pain was clear and precise: making an abrupt knee extension-playing paddle. I think that a joint wear has usually no clear beginning nor an exact reason for its appearance. Q2: I think that he should make some Rx or RMN to

Trigger mechanism: was isolated playing paddle-

see if there is some micro fracture on the patella or

tennis but was aggravated after repetitive

in the joint in general because he spends a lot of

impacts and squat positions at work time.

time in squat position, or maybe some problem in the cartilage. Don’t you think?

The source of symptoms is skeletal muscle because it affects the patella and tendons and muscles that surround it.

His main functional limitations are going up and downstairs, maintaining a squat position and standing up from a sit position. The left leg is painful after walking for a long time or after work.

A2: Yes, maybe you are right. But the reason for not doing it was because I didn´t see any neither oedema nor inflammations signs to make me suspect about micro fractures. As I didn´t find any contraindications nor red flags I decided trying some physiotherapy techniques to see if symptoms were released and patient improved before any other complementary images (which I thought were not necessary for the moment).

Because of all this information, my reflection

Q3: Have you found any symptoms on the other

about his problem after subjective and physical

limb and how do link them to the right knee

examination is that he might be suffering a

presentation?

patellofemoral pain syndrome. (Thomeé, R., Augustsson, J., & Karlsson, J. (1999). QUESTIONS TO IMPROVE REFLEXION

A3: Yes, I didn´t put enough information at first, but I´ve just revised it and as I noted, the left leg was painful during joint line palpation and had some trigger points in the external an internal

Q1: Did you think that maybe the problem started because of a joint wear?

gastrocnemius. I think there is a relation with the symptoms in the right leg because of the lots of compensation made when walking or working

that has cause an overload in his left leg because

disruption of exercise and constant overload that

of trying to avoid pain in the right leg.

will occur in the joint during his work in the future will not help the recovering process.

TEACHER ADVICE So the last of my goals is to motivate my patient The development of same symptoms on the other

to achieve better and quicker results.

limb in our patients could be related with different DAY_1

hypothesis. It could be the spread of a general

98

illness; an overused provoked by the increased

My plan starts by reducing pain and strengthening

activity of the other limb; it could be a central

the right quadriceps.

sensitization; or simply activation of mirror neurons mimicking the neural activity of the other limb. It´s

-

I have first make a passive transversal

under our scope to identify the source and the

displacement of the right patella and ask my

pattern of progression to avoid wrong targets

patient to make active flexion of the knee from

during the treatment.

a standing position, meanwhile I have continued maintaining the displacement. I´ve

PATIENT MANAGEMENT DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN My patient´s main goal is pain decreasing. So my goal table includes:

asked him to do three sets of 10 repetitions. -

Taping: medial displacement of the right patella Like this we have worked the quadriceps and the movements, which caused him pain, avoiding pain because of my passive displacement of the

-

Pain releasing

-

Strengthening right quadriceps

-

Remove load and possible contractures of the left gastrocnemius

-

Flexibilize muscles within the right knee

-

Increase or keep the articular movements limited or diminished range.

-

Restore self-confidence

As regard good prognosis factors, his interest in recovering will facilitate the process, but his fear,

patella. I have decided to apply the taping because of the good results acquired during the sessions. DAYS 2-4 My patient has come up to the next consultation with less pain so I have decided to do the same exercise as in the first session. Apart from this, I have decided to work out the internal rotation of the right hip in prone position

with a 90º-knee flexion with passive movements

A1: My idea in the first session was to reduce pain

and to work out right hip extension with anterior-

during the movements that usually caused pain to

posterior movements in standing position with

my patient. I achieved it by making a transversal

the Mulligan tape as the patient does an active

passive displacement of the patella at the same

extension of the hip.

time that he actively did his painful gesture (which

I have also recommended him to start his

was making a squat from a standing position). So

exercises and to ride in static bike for 15 minutes,

despite gaining strength in the quadriceps was

3 days per week.

not my main point, it was indirectly achieved because of the exercise itself.

In the third session, the patient has come with barely no pain, with a muscular balance of 4/5 in

Q2: Why did you work on the hip? And in this way?

the right quadriceps and with an increase in hip

A2: I decided working on the hip because, as I´ve

ROM. So I have decided to continue with the last

said in the physical examination, internal rotation

program and giving him a massage in the left leg

of the right hip was limited. I worked it in this way

to release the overload sensation of the calf.

because it was easier and had better results.

STUDENT REFLEXION

Q3: Did you do reassessment?

I really think the prognosis is this case would be

A3: I reassed my patient in the next session

great because there has been a great increase

because he came 2 days per week for just 1 hour

there has been a big improvement in all signs and

treatment so we didn´t have enough time to do

symptoms in just 3 sessions and the patient is

everything in the same day.

heavily involved. But to get our treatment to be effective, we will recommend the patient to come

Q4: What did the result from DAY1 tell you about your patient presentation?

to our clinic one day a week for the next two weeks and to begin slowly with his hobbies

A4: He was presenting an acute condition that

(running, paddle…).

was aggravated because of repetitive painful movements. As pain was alleviated while making

QUESTIONS TO IMPROVE REFLEXION Q1:

Why didn´t you work on the strength of

quadriceps in the first sessions and you didn´t focus on the range of motion firstly?

a transversal patella movement and reduced during each session, I thought about a patellofemoral dysfunction

TEACHER ADVICE

Contrasting DAY_1 results with the initial assessment of DAY_2 also provides information

Results of DAY_1 treatment usually give us a valuable information about paths of relieving

about the lasting period of the changes achieved, irritability and dosage of techniques.

symptoms and dysfunctions, if you really control the neurophysiological and biomechanical effect you are dealing with.

100 FINAL STUDENT REFLEXION I think this case has helped me to improve my clinical reasoning. In my opinion, I´ve wanted to put, too fast, the name to the disease, to make a quick diagnosis. And that is the reason why I have not progressed from the beginning. I now try to stop and pay attention to every single information about the subjective and physical examination before giving a name to the dysfunction, which I´ve learned, is not that important. REFERENCE LIST 1. Thomeé, R., Augustsson, J., & Karlsson, J. (1999). Patellofemoral pain syndrome. Sports Medicine, 28(4), 245-262 2. Harrison, B. K., Abell, B. E., & Gibson, T. W. (2009). The thessaly test for detection of meniscal tears: Validation of a new physical examination technique for primary care medicine. Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine, 19(1), 9-12. doi:10.1097/JSM.0b013e31818f1689 [doi] 3. Akseki, D., Özcan, Ö., Boya, H., & Pınar, H. (2004). A new weight-bearing meniscal test and a comparison with McMurray’s test and joint line tenderness. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 20(9), 951-958

PAIN CAUSING A SCAPULAR DISKINESIS IN A 25 YO STUDENT VIOLATI D. AND TIBERI A.

INTRO 25 years old woman, with an alteration of her right scapular girdle movement after a strange episode of pain and stiffness during the night.

She went to emergency immediately where she received the diagnosis of idiopathic subluxation. No reduction was performed and she was told to apply ice and use a sling “on and off” depending on the pain.

SUBJECTIVE EXAMINATION I just had finished to treat a patient at the clinic where I’m doing my last practices of the physical therapy career, when a colleague call me to help him with the exploration of a new patient. When I got at the “gym zone” the therapist told the patient to lift her arm to show me the problem even before to introduce me. When I saw her right scapula movement during the arm flexion I

She spent 4 days following the directions. The pain decreased but it was still strong so she decided to go back to the hospital at the emergency area where the doctor said to her it was a “cervical problem” and he diagnosed her a cervicobrachialgia. The treatment was diazepam, NSAID and superficial heat application. The doctor also gave her an appointment for two weeks later with the orthopaedic doctor.

got shocked cause I hadn’t seen something like this before. When she put her arm down we

During the 2 weeks before the appointment the

introduced to each other and we started talking.

pain decreased progressively. The orthopaedic doctor told her she has capsulitis and chronic

She was a 25 years old publicity student, she

instability of her shoulder.

have been living in Madrid all her life. She showed me all the medical reports and I She attended to physical therapy because the orthopaedic told her. She told me that the onset of the problem was day 15/03/2015; She had been

asked her for previous pathologies and she answered me it was the first time she has a health problem.

woken up by a very intense pain in her shoulder during the night and She felt it very stiff (while

I asked her if she was in pain and she told me:

she was telling me that, she simulated the

“The pain appears only when I lift my arm and it

position in which her arm was stacked).

is localized in the upper part of my shoulder. I’m

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not able to lift my arm like the other, I feel loss of

were the accurate one to describe the patient

strength when I have to take or hold something

condition.

with my hand far from my body, like a glass of water or opening the door. I don’t feel comfortable when I lay down looking up because I feel my bone (scapula) pressing the sofa or the bed, but I feel a lot better then 4 weeks ago”.

I think my first hypothesis of a mechanical problem was right but I didn’t think too much about a possible first cause of this mechanical problem. If she really suffered by a subluxation maybe an alteration of the muscular activation

She hasn’t been practicing any kind of exercise

could be provoked by a neural tissue damage or

during the last 3 years.

maybe the severe pain it self could cause it.

My

first

thinking,

putting

together

the

I also didn’t considerate the loss of strength that

information that I received and the first

the patient told me about, that could also be

impression seeing her moving, was about a

related with neurogenic problem that I didn’t ask

mechanical problem because of her “on-off” pain

questions for.

related to the last degrees of shoulder movement over the 90 degrees, provoked for the clash between the humeral head and the acromion that could compromise the tissues between them. The all thing caused by her scapula that wasn’t moving in the right way. The

My brain didn’t have the flexibility to “play” more with the information. I think it stopped working from the beginning keeping mainly the image of the patient moving. I needed to much time to get to this conclusion and start to think again.

quality of the movement that I observed made

The patient looked not worried at all for her

me think about an alteration of the sequence of

condition and she was very quiet at all time and

the muscular activation during the movement.

disposed to follow directions to improve as soon as possible.

STUDENT REFLEXION AFTER S/E I think that I forgot a lot of questions that could

QUESTIONS TO IMPROVE REFLEXION

provide me a lot more information, because of a

Q1: I would like to know if you asked your patient

lack of a mental structure to formulate them

about typical symptoms of neurogenic alterations,

orderly.

like tingling or “burning sensation”… or moments

I also didn’t considerate too much the medical diagnosis because I didn’t think that any of them

of the day in which the symptoms increase, that may help you to get a clearer idea.

A1: I didn’t ask for them and I think it was a big mistake during the first interview. Fortunately I didn’t perform the physical examination the day of the subjective examination because the patient was late for an appointment so that I had the time to reflex on it. Of course before the beginning of the physical exploration it was one of the first questions I asked the patient.

TEACHER ADVICE Contributing factors could play a key role in our patients’ presentation. Therapist tend not pay much attention to them as they are not the cause of the client´s problem. But they should be under our scope, also when they are suggested by the patients as a main issues for them. Sometimes is really challenge to eliminate their influence, for

Q2: Do you think the activation of a trigger point

example anatomic and biomechanics CF. On the

could provoke the alteration in the muscular

other hand, yellow flags or ergonomic CF will be

activation sequence of her shoulder?

targets and should be dealt within patient´s management.

A2: Actually I didn’t recognise a clear active trigger point pattern in the localization of patient

PHYSICAL EXAMINATION

pain but of course I will check it out in the

The second time I saw the patient, first thing

physical examination.

she told me was that she was getting better and

Q3: Are there any other signs supporting the neurogenic hypothesis?

her attitude was very positive from the very first moment so I thought that would be very helpful to get good results.

A3: The only signs and symptoms that could make me think about an alteration in nervous system is the loss of strength. No other signs or symptoms were reported or found.

I asked her for neurogenic symptoms and I got a “not at all” as answer. I also asked more about her strength problem and she told me it was like an uncomfortable situation in which she was

Q4: Could you identify, so far, any contributing

feeling her arm falling and tightness in her

factors for both hypotheses?

medial part of the scapula.

A4: The only contributing factor that I found is

I started with the physical examination from the

the possible subluxation she suffered because it

static observation taking the most relevant

could be the cause of both hypothesis. No other

information for me:

CF or yellow flag were found thinking in the maintenance of the condition

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



Anterior view: the humeral head looked

moment I also tried to charge the neural tissue

in a slight anterior superior position

asking a neck side bending in both sides with

compared with the other one.

the results of no changing in pain and no

Posterior view: the medial borders of

presence of other symptoms.

the scapula as well as the inferior angle of the scapula was more "detached" from the rib cage 

Side view: significant decrease of the dorsal curve (kyphosis)

The passives movements had a complete range of movement (ROM) and they didn’t provoke any pain or other symptoms.

I also tried to passively help the scapula movement during the active lifting of the arm with the result of reaching the full ROM with no pain detected but with the increased muscles activation described before. I also asked the patient to open a door to check the movement during one of the action in which she was complaining about the loss of strength;

In a posterior view, during the lifting movement

she repeated again that the movement was

of the right arm, the difference in the

uncomfortable; I observed that, during the arm

movement of the right scapula compared with

lifting, her scapula was separating from the rib

the contralateral was pretty clear: the medial

cage while maintaining the arm lifted and it

border of the scapula started to separate from

increase when she was trying to open the door.

the rib cage from the first degrees of movement (20 ° -30 °); during the lifting, the scapula present a big reduction of the ROM compared with the contralateral. When the scapula stopped to move appeared a significant

At the palpation I perceived an increased tone of the rhomboideus and intermediate region of trapezius muscles, but no trigger point that could reproduce the patient symptoms were found.

increasing in the activity of the upper trapezius, lower trapezius and also the elevator scapula.

I performed the muscular balance of the serratus anterior getting a 3-/5 (Daniel’s scale)

The conclusion was that the ROM of the physiological movements of the shoulder (arm lifting) was limited and the last degrees provoked by pain at the end of the ROM.

asking the patient an abduction of the scapula. During the test the scapula behave as described during the arm lifting and the patient was recruiting other muscles to complete the action

When the patient was in pain I used the VAS to

so that the quality of the movement was very

obtain the intensity of pain: VAS= 3. In that

poor.

STUDENT REFLEXION AFTER P/E After the P/E I considered my first hypothesis of a mechanical problem right: in this case I think the mechanical problem is the cause of patient pain. It appears only during the active movement and its nature bring me to think about a nociceptive mechanical pain because it appears with movement/ mechanical provocation (on-off) (Smart, Blake, Staines, A., & Doody, 2011) and it was localized in a specific

separated from the rib cage in a static rest position could be normal cause the patient dominant hand is the right one, that could provoke more protraction in the homolateral shoulder but it doesn’t explain why she started to have the sensation of her scapula pressing the bed or the sofa in a supine position. It also doesn’t give me information about the muscular status: the serratus anterior muscle is not active in a resting position.

site that “agreed” with my first hypothesis of a

I think the loss of strength could be due to a

clash between the humeral head and the

poor proximal stability (shoulder) that doesn’t

acromion.

allow a good “basement” for the transmission of

Analysing the muscular activation sequence, I

the forces needed for the action.

think the fact that the medial border of the

When I looked for myofascial trigger points I

scapula and the inferior angle separation from

tried to remember which muscle could provoke

the rib cage, could be due to a problem in the

the pain in the location in which the patient was

serratus anterior muscle. The serratus anterior is

feeling it. I didn’t look for them in the serratus

one of the responsible, with the trapezius

anterior cause I didn’t think in the possibility of

inferior and the trapezius superior, of the

their implication in the loss of strength.

scapula movement during the raise of the arm and also to maintain the scapula in a good relation with the rib cage during the movement. I also think that the increased activity of the rest of the muscles that permit the movement and the activation of the levatur scapulae muscle are intent of the body to reach the full movement supplying the poor action of the serratus anterior. I think the fact that the medial border of the scapula and the inferior angle were slightly

After all the previous consideration I started thinking about why the serratus anterior wasn’t activating in the right way so I started to think about a conduction problem, but I couldn’t

105

remember the innervation of the target muscle.

Another test I used in the P/E is the “scapular assistance test” that evaluates scapular and acromial involvement in subacromial impingent, probably the main cause of the mechanical nociceptive pain of the patient. The assistance for scapular elevation is provided by manually stabilizing the scapula and rotating the inferior border of the scapula as the arm moves. This procedure simulates the force-couple activity (coordination) of the serratus anterior and lower

Pain: red (VAS:3) Tightness: blue

trapezius

muscles,

the

elimination

or

modification of the impingement symptoms indicates that these muscles should be a major

QUESTIONS TO IMPROVE REFLEXION

focus in rehabilitation (Kibler & McMullen 2003).

Q1: I didn’t get your conclusion about what you found in the static observation; I mean, what do

TEACHER ADVICE

you think about the relation between her scapula

If we find during the S/E information suggesting

position and her feeling of her scapula pressing

the possibility of a neurology/neurodynamic

when she lay down supine cause as you said the

problem, neurology exam has to be conducted on

serratus anterior isn’t active in a resting position?

Day_1, prior to neurodynamic tests. Also it has to be ruled out any red flag related with these kind of

A1: I don’t have an answer yet. It could be due to the use of the sling that could affect the position

symptoms (i.e. Cauda equine or an Upper Motor Neuron Syndrome)

of the scapula girdle, or maybe a change of her shoulder posture as a result of the pain felt.

PATIENT MANAGEMENT

Q2: Have you found any coordination evidence-

DIAGNOSIS, PROGNOSIS, OUTCOMES AND PLAN

based test in the literature for this muscle?

The final diagnosis was a “Scapular dyskinesis” A2: I performed the muscular balance with a

with either flexion or abduction is rated as having

test described in (Kendall, 2007) another

obvious abnormality (dysrhythmias and winging)

effective test described in the literature is the

(McClure, Tate, Kareha, Irwin, & Zlupko, 2009).

“Wall push-ups”, used to evaluate serratus anterior muscle strength.

In the literature is described that the 5% of

that the full ROM can be reached without any

scapular diskinesis can be caused by Injury to the

pain.

long thoracic nerve that can alter muscular function of the serratus anterior muscle, and injury to the spinal accessory nerve can alter function of the trapezius muscle but no evident typical postures of these problems were found in the P/E (Kibler & McMullen 2003). Usually muscles can be also inhibited as a nonspecific response to a painful condition that in my opinion is the most possible hypothesis in the case of the patient, serratus anterior and the lower trapezius muscles are the most susceptible

I also tried to activate the serratus anterior with active exercises in a standing position and in a supine position, asking for a protraction of the scapula with the shoulder positioned in a 90 degrees flexion. I re-evaluated the ROM and pain in shoulder flexion and ABD with no significant changes in the first one and a decreased pain with an EVA of 2/10

to the effect of the inhibition (Kibler & McMullen

STUDENT REFLEXION AFTER D1 TREATMENT

2003). Inhibition is seen as a decreased ability of

My first session was planned thinking in all the

the muscles to exert torque and stabilize the

information received during the S/E and the P/E.

scapula as well as disorganization of the normal

I thought the serratus anterior muscle was the

muscle firing patterns of the muscles around the

main problem so that I chose techniques to

shoulder (Kibler & McMullen 2003).

reach a better activation of this muscle.

The superior or entire medial border may be

The treatment didn’t gave me big results maybe

painful to palpation or with motion because of

cause it was the first session and it was a very

similar tightness or scar in the levator scapulae or

short one or maybe I needed more time to apply

lower trapezius insertions, or both (Kibler &

the techniques for a longer period, or maybe

McMullen 2003), this could explain the tightness

cause I simply needed more sessions to get

that patient referred in the P/E.

better outcomes.

DAY_1

The true is that I didn’t knew protocols or other

I applied the scapular assistance test, applied in

kinds of assessment for this problem so that

several series/repetitions, as treatment to

looked for articles that describe the condition

stimulate the activity of the serratus anterior

and I took out from them some ideas to plan a

muscle and also to make the patient conscious

better treatment in the following sessions.

107

After the research I found that in the first 3 weeks

neuromuscular

of treatment the first point is avoid painful arm

techniques, of the latissimus dorsi muscle and

movements and positions and establish scapular

the pectoralis minor muscle (Kibler & McMullen

motion by proximal facilitation so that my first

2003).

technique was good (Kibler & McMullen 2003). Another point was to initiate scapular motion

facilitation

stretching

I also teach her exercises of scapula protraction using body movements previously described.

exercises without arm elevation, using trunk flexion and trunk medial rotation to facilitate

STUDENT REFLEXION

scapular protraction It could be a good idea due

After checking the muscles flexibility and tone

to the fact that the patient couldn’t activate the

related with the limitation of scapula

muscle with effectiveness and quality using arm

movements (pectoralis minor, levator scapulae,

elevation exercises (Kibler & McMullen 2003)

upper trapezius, latissimus dorsi, infraspinatus, and teres minor muscles) (Kibler & McMullen

QUESTIONS TO IMPROVE REFLEXION Q1: Do you think that activate other scapula stabilizers could be a good idea to improve the

2003), I decide to treat the muscle that appears, compared with the contralateral side, to present more tone.

quality in the shoulder movement? The result of the second session was good in A1: Yes, probably I could look for some exercises

terms of active ROM (full ROM) and pain (VAS:

to activate rhomboids and medium trapezius

1) so that I decided to follow this line for the

muscles. I’m just a little worried about charging

third session in which the patient came with

to much the superior trapezius and the inferior

better sensations but still poor movement

trapezius because as we have seen in the P/E

quality of movement but maintaining the ROM

they probably are already working too much.

and pain improving, so that I wanted to see if

DAYS 2-3

the treatment could also be useful to provoke a change in the quality of the scapular

The patient came with better sensations about

movement.

her strength and she felt she could move more than before.

What I didn’t do was retest after each technique applied so that I only know that all them

After the research I repeated the first exercise performed in day 1 and I also included the evaluation and treatment, with proprioceptive

together get to patient improvement but I don’t

know if each technique alone could lead to

technique, probably the scapular assistance test

better outcomes.

used as technique is the one that worked more cause is the only exercise I used in the first 2

QUESTIONS TO IMPROVE REFLEXION Q1: why don’t you try to activate muscles like the latissimus dorsi to see if they can help you to achieve a better scapula position in an unstable position, amid range of flexion for example?

sessions getting a better ROM and less pain. TEACHER ADVICE Physiotherapy literature is full of trials measuring the “initial effects” of lots of techniques. To be “immediately effective” doesn´t mean that the

A1: It could be a good idea to see if they can help

technique is “long-lasting” or worth it at all. Or at

me to reach a better quality of scapula

least if it is going to be accurate in each case. But

movement and position in different degrees of

re-evaluating patient´s main outcomes before

movement. I’ll try it!

and after the session, will enlighten your thinking

Q2: Which part of your management do you think has worked better and why?

and support next decisions in the management. It could also be a way to give feedback to your patient about his/her progression.

A2: I’m not pretty sure about it yet because as I said in the reflexion, I didn’t retest after each FINAL STUDENT REFLEXION My diagnosis was a scapular dyskinesis with obvious abnormality (dysrhythmias and winging) during shoulder flexion and ABD (McClure, Tate, Kareha, Irwin, & Zlupko, 2009). Causing a nociceptive mechanical pain in the patient during the 2 movements (Smart, Blake, Staines, A., & Doody, 2011). I found support that a painful condition is the most possible hypothesis in causing serratus anterior inhibition (Kibler & McMullen 2003) that is in my opinion the most affected muscle in fact a poor muscular balance during the test described in the P/E was found (Kendall, 2007); so first goal to reach was “waking up” that muscle to improve the movement quality. At this point of the treatment I didn’t find anything in the literature that could clarify me the natural process of this condition, and I also didn’t find any other paper that could help me to be more consistent during the treatment planning. I think that so far I’m missing the key treatment (exercise or manual treatment…) to improve the patient quality of movement so that I’ll keep looking for it in the literature and during the treatment sessions.

109

REFERENCE LIST 1. Smart, K. M., Blake, C., Staines, A., & Doody, C. (2011). The Discriminative validity of “nociceptive,”“peripheral neuropathic,” and “central sensitization” as mechanisms-based classifications of musculoskeletal pain. The Clinical journal of pain, 27(8), 655-663. 2. Kendall, F. P. (2007). Kendall’s Músculos Pruebas Funcionales Postura y Dolor, Editorial Marbán. 3. Kibler, W. B., & McMullen, J. (2003). Scapular dyskinesis and its relation to shoulder pain. The Journal of the American Academy of Orthopaedic Surgeons, 11(2), 142-151. 4. McClure, P., Tate, A. R., Kareha, S., Irwin, D., & Zlupko, E. (2009). A clinical method for identifying scapular dyskinesis, part 1: reliability. Journal of athletic training, 44(2), 160.

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