511 scenario 2 - completed - awaiting video links

Preparatory notes

- The problems your treatment will address

chronic soft tissue injury

reduced rom in rhs hamstring ( RHS 10% < LHS )

- The goals of your treatment

stimulate healing process

improve ROM in RHS hamstring

- The chosen measure and treatment :

measure: goniometer measure of hamstring ROM

treatment :pulsed short wave - 15minutes at 6 watts

                  deep tissue friction massage - 3 x 5 minutes sessions

- The key evidence that supports your chosen treatments


General References 
Journal 1:

Hunter D, Speed C (2007)

"The assessment and management of chronic hamstring/posterior thigh pain"

Best Practice & Research Clinical Rheumatology, Volume 21, Issue 2, Pages 261-277.

Journal 2:

Malliaropoulos N et al. (2004)

"The Role of Stretching in Rehabilitation of hamstring injuries: 80 Athletes follow-up"

Medicine & Science in Sports and Exercise, Volume 36, Issue 5.

Journal 3:

Derman W et al. ( 2011)

"Transcendence of musculoskeletal injury in athletes with disability, during major competition"

South African Journal Of Sports Medicine, Vol 23, No. 3.

Pulsed Short Wave

Journal 1:

Garret CL, Draper D, Knight K (2000)

“Heat distribution in the lower leg from leg from pulsed short-wave diathermy and ultrasound treatments”

Journal of Athletic training 35 (1) pp 50-55

Journal 2:

Val J. Roberston, Alex R. Ward, Peter Jung (2005)

“The effect of heat on tissue extensibility: A comparison of deep and superficial heating”

Archives of Physical Medicine and Rehabilitation vol 86 (4) pp 819-825

Journal 3:

John Law (1995)

“Dosage of some pulsed shortwave clinical trials”

Physiotherapy 81 (10)

Journal 4:

Draper D. Et al (2004)

“Shortwave diathermy and prolonged stretching increase hamstring flexibility more than prolonged stretching alone”

Journal Orthopaedic Sports Physical Therapy vol 34 (1) pp13-20

Website:

Watson T. (2/01/10)

http://www.electrotherapy.org/modalities/pswt.htm

DTFM

Journal 1:
Goats (1994) 
"Massage--the scientific basis of an ancient art“

Br J Sports Med 1994 28: 153-156

Journal 2:

Steven Barr et al (2009)

“Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: A systemic review”

Physiotherapy 95 (2009) pp251-265

Reference:

Beards massage 5^th Ed

Principles and practice of soft tissue manipulation, Saunders Elsevier, 2007

Treatment

introduction,explanation & consent 
(30% of marks)

- Introduction of your self

" Hello Philip, my name is _____ and I'm going to be your physio for today.

   I have been reviewing you notes and I understand you have a nagging injury in the muscle on the back of your right leg."

- Identification of patients problems

"I think the cause of your problems is a tear in your hamstrings. I expect you to make a full revovery from this injury, and your recovery should be in days and weeks rather than months.  The problems I want to work with today are 
  - the slowness of your muscle tissue to heal
  - and the tightness in your right hamstring. "

- Identification of each proposed measure and treatments as indications

"Today I would like address those problems with two treatments which both in different ways will help resolve the injury and tightness in your hamstring. "

I would like to use 
- pulsed short wave therapy
-  deep tissue massage


I would also like to measure the tightness in your right hamstring."

- justification, explanation, possible progression and description of effects of each proposed measure and treatment

Ill tell you a little more about these treatments

  First of all Pulsed short wave therapy.

- There is good evidence to suggest PSW can help increase your hamstrings ability to lengthen and heal.

- It is a painless form of painless electrical therapy. The pulsing of an electromagnetic field vibrates muscle tissue and encourages it to heal. The pulsing field also warms the tissue and so helps it to lengthen.

- We will start you on a relatively short dose today and in future treatments we will apply it for a longer duration.

- There is a small possibility you might feel some warming of your hamstring muscle but this should not be uncomfortable. But we'll do a short test before we start just so i am confident you have full sensation in your hamstrings and can notice any dramatic increase in temperature. The injury may feel a little more uncomfortable over the next few days as your tear begins to heal properly but I would expect an overall improvement in your pain and flexibility before I see you again."

"Now with regard to deep friction tissue massage.

- There is a strong belief within physiotherapy that this technique can help improve the healing process within damaged tissue and so allow the muscle to stretch more effectively.

- When you get an injury to a muscle the body responds by laying down new tissue fibres. This process can be rather haphazard emergency response by the body - with the fibres being laid in all directions. Friction massage helps break down the fibres which are not properly alligned. If you imagine the fibres being initially laid down rather like strands of dried spaghetti after injury. This technique helps line up the fibres so they are wellknit and pliable.

- Next time we do this technique we will do it for longer.

- This technique can be somewhat painful for the patient but I think the long term effects are worth the temporary discomfort."

" Regarding the measurement of your hamstrings..

- Its standard practice in physiotherapy and will help us keep track of your recovery

- I'll use  a small instrument rather like a compass called a goniometer.

- We'll take this measure each time we meet.

- All you should feel is a stretching of your hamstring as we do the test."

- Informed explanation of patients role - preparation of patient

"So what I expect of you today philip is to  take off your shoes, and jewelery and to  lie down on the bed on your back while I take the measurement of your hamstring. Ill then ask you to  turn over on the bed. We will then quickly test your skin sensation and apply the pulsed short wave machine for 15 minutes.  If for any reason you feel a strong heating sensation I want you to tell me immedietly. Ill then ask you to turn over on the bed and we will do the friction massage.If the pain is too much please tell me.Then I'll ask you to turn over again before before we measure your hamstring for the final time."

- Informed consent for treatments undertaken

"Bearing in mind what i have said. That the deep friction massage may be quite uncomfortable and that by stimulating your healing process we may temporarily cause some discomfort within you injury site. But that i expect this course of treatments will lead to a full recovery. Are you ready to proceed with these treatments"

- Check of contra indications

" Ok. Can I just check before we begin that you dont have
        -  a pacemaker, you don't have 
        -  cancer, 
        -  tb or 
        -  any severe heart problmes. You havent had any 
        -  radiation therapy in the last 6 months."

- Identification of precautions

    [not applicable in this case]

Preparation


"Ok Philip Im just going to wash my hands before we start and to gather the equipment together can you just wait while i do that."

do this - collect treatment materials [ videolink to be added ]


wash hands and collect

-thermal skin test tubes

-pillow

-goniometer

-psw (with circuplode head and straps if neccesary), put breaks on when you bring back

Safe and effective application of outcome measure and treatments
(30% of marks)

objective measure - 1st time

"Ok can you I ask you to sit on the wooden bed and take off your shoes and any jewelry and lie down on your back and we can use this pillow for you head"
"Im now going to stretch your right leg back towards you and the ceiling and measure the length of your hamstring"

do this - objective measure [ videolink to be added ]


thermal skin test and psw treatment

"great can you now turn over onto your front we will now check the sensitivity of your skin the - you might want the pillow for under your chest. Im going to press these small test tubes lightly against the skin of your back leg can you tell me when i am pressing with hot and cold".

do this - thermal test [ videolink to be added ]

" Ok. Were now going to use the pulsed short wave maching. Im going to put a towel round your right leg and you will soon feel the machine pressing lightly against your hamstring"

do this - set up psw machine [ videolink to be added ]

ensure patient comfort and make sure breaks are on, that machine is 1 metre away from anyone else, 2 metres away from other high frequency and 3 metres away from anyother psw machine. Position circuplode so it is level with the hamstring and just touching the pillow - set up machine choosing dose and frequency indicated on the machine by the diagram sheet on machine (make sure it is on continuous on older machines).

doseage > 5watts for chronic condition - with the newest machine which does interferential and ultrasound as well, set frequecy and wavelength to 20 and 20 and then switch on, and get the mean power output > 5 watts , eg 6 watts.

"Im now going to switch the machine on for 15minutes - please dont move philip and if you feel any uncomfortable warming sensation please let me know."

do this - psw switch on psw machine for examiner to see [ videolink to be added ]

then tell examiner that you are going to pretend the machine has been on for 15 minutes. and switch machine off before moving circuplode head away and remove towel, and straps


deep tissue friction massage

" Ok philip we are now going to start the deep tissue friction massage. The sensation may be uncomfotable as i massage vigourously across your hamstrings. But this sensation should become numb sometime between 30 secs to a minute. We will do this three times, taking a short rest every 5 minutes."

do this - DTFM [ videolink to be added ]


for up to one minute so examiner can see your techinque

- use two hands with four fingers each and the thumbs as a pivot - majority of hamstring tears are in biceps femoris at intersection of other hamstrings

- tell examiner you will pretend you have now completed this treatment


Objective Measure - 2nd time

"Good philip. Im pleased you coped so well with that treatment. We are now going to finish the session by taking your final hamstring measurement. Can you turn over."

do this - objective measure [ videolink to be added ]


Concluding Advice

"Excellent, today i hope weve taken the first step in your recovery.

- Next time I expect we'll extend your treatment times both with the pulsed short wave and the friction massage. We'll also give you some stretches to do at home for your hamstring. I am very hopeful we will be able to make real progress with this injury. One recent study showed athletes returning from this injury to achieve their personal best in their sport.


- As we said the injury may feel slightly worse over the next few days. If it does you can try using some gentle heat on the area - such as a hot water bottle - or possibly some ice - make sure you put the ice in a plastic bag and dont apply it directly to the skin and leave it on for around 20 minutes - see which one of these treatments works for you, if any. Failing that you could see your doctor or pharmacist about pain medication such as ibuprofen or paracetamol, but I dont think this will be neccesary. I think you will be ok.

- Do you have any questions, are you happy with everything we have done today, i look forward to seeing you again. I hope you can grow a moustache as good as mine. Thank you. "