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CASE STUDYStudent nameKate TrumanSchoolExmouth Massage ClinicCourse codeMT25Submission date7 November 2019Case study number - 1, 2 or 32Category - from list of 6 - each case study must be from a different categoryAthlete (recreational or competitive)Physical disabilityAged over 70Post-acute injury or surgeryChronic injuryMedical conditionChronic injuryGeneral information - first name only, age, gender - do NOT include any personal identity informationJo; female; 48yrsOccupation - describe the physical aspects of their job and also their level of occupational stress or other relevant factorsSecondary school teacher. Jo has just changed jobs and finds her work stressful. She has a 30 minute drive to work and a full day of teaching, 5 days a week, both standing and sitting. She also has to do schoolwork in the evenings.Sport - in detail if this is in the Athlete categoryOccasional swimming, otherwise very little activityMedical history - in detail if this is in the medical condition, physical disability or over 70 categoryNot medicated for anything and no notable medical history. Possibly in peri-menopause. Slightly overweight (5ft 7 and 11st 7). She has seen her GP about her back but was told that it appears to be muscular and that massage therapy combined with something like pilates or yoga would be beneficial.Injury history - in detail if this is in one of the injury categoriesJo has experienced intermittent lumbar back pain on the left side for the last 2 years. She can think of no trauma which might have brought this on but the pain has steadily increased over the course of the last year and sometimes keeps her awake at night. Occasionally the pain is referred into her left buttock and the top of her left leg but nor further down the leg. No numbness or pins and needles. No problems with bowels or baldder.Lifestyle - family, hobbies, activities, lack of activity, diet, smoking, social life, etcJo has an extremely stressful life. She divorced 2 years ago and now lives alone as a single parent to her 2 children aged 12yrs and 15yrs both of whom have issues at school (one is dyslexic) and need a lot of support with homework. She has always been a teacher but more recently acted as a Deputy Head, which she found very stressful. She is changing to a new job in September with a return to classroom teaching where she will be on her feet for most of the day. As a single parent, when she comes home she has to do all of the home tasks as well as support her children with homework and often doesn’t get to sit down to complete her own marking and preparation work until 10pm at night. As a result, she rarely gets to bed before midnight and is up again at 5.30am so her sleep quality is poor. An additional emotional trauma this year was the early death of a much-loved family dog from cancer. She eats healthily most of the time but does comfort eat when particularly stressed and is slightly overweight. She doesn’t smoke but drinks a couple of glasses of wine 2 or 3 times a week. She drinks plenty of water. She does very little exercise since the dog died.Treatment goalsClient - what the client hopes to achievePrimary (eg treat the main injury) Secondary (eg treat another problem, get back to playing sport, lose weight and get fitterPrimary; to get rid of the back painSecondary; to sleep better and be more activeTherapistAre client’s goals achievable? How many sessions may be needed and over what timescale?If/when you would consider referring the client to a medical practitionerIf/when you would consider referring client to another discipline such as Pilates, sports coach, podiatristYes, Jo’s goals are achievableI’m confident that a big part of Jo’s back issue has arisen as a result of anxiety and stress. I think that as soon as she feels someone is helping her and giving her some positive support, she will improve quite quickly with some relief expected after the first session and continued improvement over the course of 4-6 weeks. However, she will need to take proactive steps to manage and reduce the stresses in her life. If Jo’s pain became significantly worse despite 4 weeks’ treatment and rehab I might suggest she see a physio or osteo to see whether any manipulation is required. Counselling of some kind would also be helpful for Jo to release some of the resentment she feels towards her ex-husband.I will recommend that Jo tries to make time to for a regular weekly pilates or yoga class ASAP.AssessmentCurrent symptoms - client’s account of their symptoms - pain, restricted movement etcIntermittent deep pain in left lumbar area, between spine and hip, particularly bad when sitting. Bad on rising from seated to standing position and for a while after sitting. Evenings tend to be worse and sometimes disturbs her sleep. Improves as she moves around. No pins and needles, numbness or shooting pains down the legs.Posture - neutral, lordotic/kyphotic, flat-back, sway-back or other noticeable featuresUpper body looks quite neutral but hips and knees are extended, suggesting short hamstrings. Flat-back would be the closest recognised posture. Spine - either normal or describe the degree of excessive lordotic/kyphotic curvature (cervical, thoracic, lumbar, sacral)Slightly flat, both in thoracic and lumbar. Slight cervical lordosis.Pelvis - either normal or describe the degree of excessive anterior/posterior alignment (left and right sides) and lateral alignment (one side higher than the other)Slight posterior tilt on pelvis. Lateral alignment – left iliac crest slightly higher than right.Shoulders - either normal or describe the degree of protraction/retraction, elevation/depression (right and left sides)Shoulders are not protracted. Scapulas of even height and distance from spine.Leg/arm alignment - either normal or describe any features such as hyper-extended knees, over-pronation or other foot issues Normal leg/arm alignment. Extended knees. Mobility - which joints or spinal sections appear to have a restricted range of movement or are hyper-mobile Thoracic and lumbar seem to move well in flexion. Side flexion restricted. Extension slightly restricted. Range of movement (ROM) testsThe joints or spinal sections you apply active, passive and/or resistive ROM tests (or any other tests) toConclusionsLumbar: flexion, extension and side flexionFlexion good; extension and side flexion slightly restrictedCervical: flexion, extension, lateral flexion, rotationAll within normal ROMSIJ tests: distraction, supine hip thrust, side lying ilium thrust, prone sacrum thrustAll negativeHip: flexion, extension, abduction, adduction, internal rotation, external rotationAbduction and internal and external rotation on left leg are all slightly restricted compared to right. External rotators on left leg tighter.Firing pattern tests: Obers test and glute testLeft QL firing quicker than glute med or TFL. Hamstrings firing before glutes and erector spinae on both sides.Muscle length tests for lats, hamstrings and piriformis. Thomas test and straight leg testBoth hamstrings restricted, at about 75 degrees.Left piriformis particularly restricted. Straight leg test negative. Thomas test indicates slightly short hip flexors and quads on both legs.Palpation and observation - which muscle areas look and/or feel hyper/hypo-tonic The upper lumbar area from the spine out laterally (obliques, origin of lats) felt bulky and tight. Poor tone in abdominals. Muscle atrophy in glutes. Chest breathing.Assessment summary - describe what you think the problem is, based on the above assessmentsJo’s symptoms are quite typical of someone who spends long periods sitting and does little or no exercise. Her glutes are inhibited and, as a result, hamstrings and lats are shortened and tight. Hip rotators on the left side are restricted, notably the piriformis, which is probably aggravating the left lumbar and contributing to the occasional referral of pain into the top of the left leg. It may be that the sciatic nerve is being slightly pinched. When she sits to do her schoolwork, she often sits on the sofa, rather than at a desk or table, with the laptop on her lap and also always has any paperwork to the left-hand side, so some of Jo’s problems could be as a result of poor ergonomics. The pain she feels when sitting is also symptomatic of piriformis syndrome.Shortened hip flexors suggest that the iliopsoas is implicated in the lumbar pain and the QL is hypertonic too.Finally, from a biopsychosocial point of view, she is highly stressed in most areas of her life, both at home and work, and of an anxious disposition. She is breathing from her chest and holding a lot of tension in her body so her central nervous system is in overdrive. As the thoracolumbar fascia is particularly rich in interstitial nerve endings, stress and anxiety is likely a significant factor in the level of pain she feels. Treatment planWhat measurable improvements are you hoping to make to the symptoms?I hope to make a big improvement to Jo’s symptoms. Using general massage techniques to downregulate the central nervous system should help enormously. More specific soft tissue techniques, such as myofascial release, STR and MET will help to restore hypertonic muscles to their natural resting length, in particular, the iliopsoas, QL and erector spinae. I expect to find areas of micro tension in the hip abductors that will respond to trigger point release work. Retraining breathing patterns should help to improve core stability and also downregulate the nervous system. Finally, although my role is not that of a counsellor, psychologically, I think Jo will respond favourably to having someone to listen and give positive encouragement. SESSION 1General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?Prone: - started without lotion and applied myofascial techniques all across the back (gently stretching superficial layers and skin-rolling and ‘C’ rolling) to explore for areas of particular tension and warm up the tissues for further massage work. Effleurage and petrissage across whole of back, shoulders and neck with particular attention to lower thoracic and lumbar area where Jo has a lot of muscle tightness and experiences most of her pain. Deep transverse strokes using forearms across the lower lumbar were particularly relieving.Side lying to treat left side: more general massage with particular attention to the erector spinae, lats and QL, which I believe are significant contributors to Jo’s discomfort (right side hamstring and left side lats part of posterior sling).In Jo’s second session I propose to massage and treat the legs as well as the back, in particular the hamstrings, which I believe are also contributing to Jo’s symptoms. However, in this first session, I thought it best to use the time available to try and give Jo some immediate relief from the tension in her back.Soft tissue techniquesWhere did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?Why did you pick each of these particular techniques and what were you aiming to achieve?As well as applying myofascial techniques at the outset to warm up the superficial fascia, I also used deeper skin rolling techniques, both parallel and perpendicular to the spine, aimed at releasing any adhesions that may have developed in the deeper fascia surrounding the muscles and restricting efficient movement. Active STR to erector spinae (client tilting hips into couch).Side-lying: applied passive and active STR for the lats (from origin to insertion) and active STR for QL, again to try and release tension in these muscles. Applied MET for lats (RI to avoid contracting an already hypertonic muscle) aimed at restoring normal resting length. Jo had a particularly sore point around the posterior edge of her iliac crest (attachment point for lats and QL) so I did some gentle trigger point work here to try and downregulate the nerve receptors. Supine: applied MET for QL (again, RI to avoid contracting an overactive muscle) which Obers test had identified as overactive. MET for tight piriformis. Sitting: applied active STR for erector spinae and QL to try and release these tissues further.As well as soft tissue techniques, I worked with Jo on breathing exercises. She is very much a chest breather, so we did some exercises to give her more self-awareness about breathing into her abdomen so that she engages the diaphragm properly. This should help give stability in lumbar/abdominal/pelvic area.Reassessment - describe any changes that have resulted from the treatmentLeft piriformis definitely more relaxed after MET. Jo herself felt more relaxed and positive. She stated that she felt like bursting into tears with some of the lumbar work I did as she found it so relieving.Advice - what advice or exercises did you give to the clientAlthough I’m not a counsellor, we talked about work/life balance and trying to build in some more time in the day just for her. I gave her some exercises that, initially, are focused on mobilisation of the lumbar area. These included the cat/cow stretch and flex and a variation where you lift your feet off the floor and kick them out slowly from side to side, which gives a nice stretch through the lats and into the QL area. Also, child’s pose into baby-cobra. I recommended that she repeat these 10 – 15 times 3 times a day.I gave her a breathing exercise to do in bed, first thing in the morning and last thing at night: lying supine, knees bent, using abdominal muscles to tilt the pelvis so that the small of the back is flat against the bed and then holding that position for 5 big abdominal breaths in and out. Repeat 5 times. Not only should this exercise help Jo’s breathing patterns and help release tension but should also help to strengthen the abdominal muscles. I also showed her a self MET for the posterior neck muscles that should help relieve stress.I suggested that Jo always sits at a desk or table to do her schoolwork (rather than slump on the sofa) and that she tries placing her paperwork to the right of the computer screen rather than the left. I also showed her some seated mobilisation exercises (pelvic tilts and torso rotations) that she can do every 20 mins or so. I emphasised the benefit of building regular activity/movement into her day, changing positions and stretching frequently. I recommended that she does more daily walking and also suggested she look into finding a pilates class or similar.SESSION 2How long after Session 1?4 weeksClient feedback - what client says about their condition since the last treatmentJo has been feeling much better and is a lot more positive. She has had less of her pain symptoms and it has only woken her up a couple of times at night. She has got on well with the exercises and is particularly pleased with the breathing exercises – she says it’s the first time she has been made aware of how to breathe properly and is very conscious of how helpful this is for her anxiety levels.Reassessment - describe any changes that have occurred since last treatmentMuscle length test for lats showed less restriction. QL less active too (Ober’s test) and better ROM in side flex. Hip flexors and quads (Thomas test) still showing restriction. Still some restriction in hip external rotation.General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?Prone: applied effleurage and petrissage across the whole of the back, neck and shoulders, giving particular attention to the lumbar area, the erector spinae and to the origins and insertions of the latissimus dorsi. Also applied effleurage and petrissage to the legs, in particular, the calves, hamstrings and (supine) quads, with the aim of encouraging these muscles to soften and lengthen from origins to insertions.Side lying: more general massage techniques for erector spinae, QL, lats and trapezius to further relax these muscles.Soft tissue techniquesWhere did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?Why did you pick each of these particular techniques and what were you aiming to achieve?Prone: lots of myofascial release work (steamrollering with forearms, palms and fists and stretching skin in opposite directions) across lower lumbar area, particularly cross fibre, all aimed at downregulating the nervous system and introducing new neuromuscular movement patterns to the tissues. Also deep myofascial release work at insertion of lats; gripping, squeezing and skin rolling, to try and ensure the tissues in this area are relaxed. Passive and active soft tissue release work into hamstrings to try and relax tightness here plus passive STR into glutes, starting with fist to relax the superficial muscle layers before using a soft elbow to work down to the piriformis and deeper external rotators, hoping to release tightness in these deeper muscles. Glute activation exercises to retrain neuromuscular function.Side-lying: deep myofascial gripping/rolling through left QL with the intention of further relaxing this hypertonic muscle. Active and passive STR for left lats, again, aimed at further encouraging these tissues to relax. Trigger point release work on a number of areas in the glutes and TFL that were very sensitive and may be contributing to referred pain into lower back and hip.Supine: MET for left QL – 2 iterations of PIR and 1 of RI to lengthen this muscle. PIR applied to both left and right piriformis (although left was much more restricted), again, to try and create a new resting length for this muscle. MET for hip flexors and quads on both legs (from Thomas test position) just to try and make sure the resting length of these muscles was as functional as possible.Reassessment - describe any changes that have resulted from the treatmentResting length for QL, piriformis and ilipsoas all improved. Jo reported that everything felt considerably more relaxed and ‘looser’.Advice - what advice or exercises did you give to the clientJo is continuing with the exercises from week 1. I have also introduced a basic bridge, to help strengthen her back, glutes and abdominals and a basic straight leg hip extension, lying prone, with the emphasis on contracting the glute first before raising the leg and the aim of reactivating Jo’s glutes. This will help alleviate tension in the hamstrings and lower back. I have also shown Jo the bird-dog exercise for strength and stability, with an emphasis on good form, and how to stretch her piriformis.SESSION 3How long after Session 2?4 weeksClient feedback - what client says about their condition since the last treatmentUnfortunately, Jo was not so good again today. She has struggled with her new job and is in the process of handing in her notice. She is highly stressed again and has not been diligent about doing her rehab exercises. Her pain levels are back up and she is not sleeping well.Reassessment - describe any changes that have occurred since last treatmentForward flexion being achieved largely through thoracic flexion – lumbar quite stiff. Side flexion to the right restricted. QL hypertonic (Obers). Hip flexors restricted, although not as bad as the first session. General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?I felt Jo was in need of a good deep tissue massage to downregulate the central nervous system so plenty of effleurage and petrissage across the whole of the back, neck and shoulders (both prone and side-lying), but particular emphasis to lumbar area using broad (forearms) strokes and then more specific strokes with flat knuckles and friction applied along erector spinae.Soft tissue techniquesWhere did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?Why did you pick each of these particular techniques and what were you aiming to achieve?Prone: active STR to erector spinae in prone position. MET (RI) for psoas. Side-lying: passive and active STR for left lats and QL. MET for QL (RI as hypertonic) Tried trigger point work into sensitive areas on posterior iliac crest but it was too painful for Jo so used positional release here and into hip abductors instead.Supine: MET for TFL and piriformis. Reassessment - describe any changes that have resulted from the treatmentQL no longer hypertonic and greater ROM in side flexion. Flexion easier too; erector spinae softer to palpate. Piriformis and hip flexors at a more natural resting length.Advice - what advice or exercises did you give to the clientJo realises that her regression is largely due to the increase in stress in her life and failure to commit to the rehab. She feels that once she has handed in her notice and stopped her current job she will have some time to regroup and reassess her life – and to take some responsibility for her health. With so much on her plate I have kept exercise advice functional and to a minimum: daily spinal mobilisation exercises, piriformis stretch and as much walking and/or swimming as possible, plus the breathing pattern exercises as often as possible. Conclusion - summarise results and future plans (if any) with the clientThis was a frustrating conclusion to this case study as I feel that there is so much Jo could do to improve her mobility, strength and stability but, unfortunately, I can’t control the stressful factors in her life. She feels that the soft tissue therapy is beneficial and would like to continue as a client, however, she now also understands that without addressing the negative psychosocial elements in her life and creating more time to build movement into her daily routine, the results will be limited. In the meantime, I suggested she might want to consider speaking to a life coach.ISRM use onlyMarkerinitials% mark for this case studyCommentsAverage % for three Case Studies ................
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