how to write a case study physiotherapy

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Standards of Practice: Case Study Template

AMA 11th Edition Citation Style Guide: Sample Case Study Papers in Physical Therapy

• Formatting your manuscript
• Reference examples
• Sample Case Study Papers in Physical Therapy

Marymount Library Physical Therapy Collection Repository

Physical Therapy students can access the Marymount Physical Therapy Collection Repository sample papers.

Below are two Physical Therapy Case report sample papers that exemplify best practices in writing in AMA style:

• Kinesiophobia and Joint Hypermobility Syndrome - Why Fear of Movement Should Matter to Movement Experts
• Patient Function Versus Time as a Driver for Rehab Progression Following Total Shoulder Arthroplasty
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New case studies are released frequently, each challenging a different aspect of clinical reasoning .

Mentor input is added to popular cases around one month later, available to registered members ( click here to join ).

To stay up to date, join us on Facebook and we’ll post new cases and mentor input as they’re released.

Upper arm pain with neurological symptoms

Final year Physio students – get a head start on the job market

Achilles pain case study #2

CPD Case study: worsening proximal calf pain in a 30 year old [10min read]

Case study: Hamstring pain in a Physiotherapist and cyclist [15min read]

CPD Case Study: Heel pain in a teenage footballer [12min read]

How to utilise physiotherapy case studies.

A case study will present an injury or condition along with some context or background information.

As Physiotherapists are well aware, no injury is as simple as the text book presentation and a patient’s situation, background and motivations must be taken into account for successful management of the case.

The world’s best rehab program is worth nothing in the hands of the world’s least motivated patient…

Each of these cases presents a different challenge – it’s not as simple as guessing the correct diagnosis, or going with your standard approach to ankle assessment.

The cases will offer slightly different challenges, from designing a successful management plan without a firm diagnosis, to considering an injury in the context of other physiological factors such as adolescent growth .

Case studies are not the resource to use to memorise different presentations and diagnoses. You could do that by reading any text book – we strongly recommend Brukner & Khan’s Clinical Sports Medicine as a great reference for sports injury info.

Once you’ve absorbed all the injury info and seen a few patients, case studies are the best way to apply that knowledge in different contexts.

Once you’ve gone through and responded to the prompt questions, it doesn’t end there.

You can match your answers against the mentor’s responses and rationale. You could match it against a colleague who has also attempted the case study. Or you could bounce your answers and reasoning off a senior colleague at work.

The goal here is not just getting the right answer – it’s about having the right reasoning behind that answer that is the key building block to a successful career .

Keen to earn a little more or kickstart a mini-business on the side? We’ve got 8 cracking ideas for Physiotherapists to diversify their interests and earn some spare cash in the process (opens in new tab) .

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Case studies and template

Case studies to help you to reflect on your practice.

These case studies will help you to reflect on your practice, and provide a summary of reflective models that can help aid your reflections and make them more effective.

Templates are also provided to guide your own activities. Remember, there is no set way to reflect and you can adapt these activities to suit your learning style and your role.

Your reflection should be about learning and improving your practice. If you’d like to see how reflection has impacted the practice of some of our registrants, watch this short video.

Getting started

Here are some tips to think about when you set out to reflect.

Sole practitioners' group

Case study: Carl is a podiatrist working in independent practise. He is a sole practitioner and has run his business for 10 years

Group reflection within a team

Case study: Munira is a physiotherapist working in private practice. She has treated her service user Russel for the last three months after he was involved in a fall at home.

Reflecting by yourself

Case study: Emily is a dietitian working in an NHS Trust hospital. She also volunteers at a local charity that raises awareness about diabetes at events and conferences

Reflective practice template

Template to help you guide your own activities

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Case studies in orthopaedics

CHAPTER SEVEN Case studies in orthopaedics Anne-Marie Hassenkamp, Diane Thomson, Sophia Mavraommatis, Kaye Walls Case study 1: Rotator Cuff Repair 166 Case study 2: Decompression/Discectomy 168 Case study 3: Fractured Neck of Femur 170 Case study 4: Total Knee Arthroplasty/Replacement 172 Case study 5: Anterior Cruciate Ligament Reconstruction 175 Case study 6: Fractured Tibia and Fibula 177 Case study 7: Achilles Tendon Repair 178 Case study 8: Idiopathic Scoliosis 180 Case study 9: Legg–Calvé–Perthes Disease 182 Case study 10: Surgical Intervention for Cerebral Palsy 185 Introduction Orthopaedics is a wide area of practice for physiotherapists and one which we encounter in most settings be it in a hospital (e.g. elective surgery, trauma or disease) or a community setting (e.g. post-operative, injury, secondary issues and long-term musculoskeletal problems). Due to the wide spectrum of orthopaedics the therapist is likely to encounter patients of all ages, from all backgrounds and with various health beliefs. Each one of these factors can have a huge influence on therapy management. Excellent communication and team working skills are essential. The orthopaedic physiotherapist is an integral member of the multidisciplinary team (MDT) and works closely with surgeons. The clinical reasoning and problem-solving approaches used are directed by the medical intervention. Clearly, a good knowledge of what is a normal change and what is a pathological one is of paramount importance. Higgs & Titchen (2000) remind us that knowledge is an essential element for reasoning and decision making, and how both of these are considered central to clinical practice. The therapist working in these settings has to have excellent anatomical, physiological and pathological background knowledge within a framework of an understanding of the psychosocial influences on rehabilitation goals. Atkinson (2005) advises the adoption of the long published movement continuum ( Cott et al 1995 ) as a good framework for orthopaedic reasoning. The changes from the person’s preferred movement capacity (PMC) to their current one (CMC) is the orthopaedic physiotherapist’s frame of reference. The process of getting from one to the other engages the therapist in educational as well as treatment situations which need the collaboration of the patient. Orthopaedic therapy goals therefore have to be patient-centred and collaborative rather than following a prescribed protocol. This makes orthopaedic physiotherapy an ideal training ground in reasoning for the starting professional. The hypothetico-deductive reasoning model ( Elstein et al 1978 ) adopted by junior physiotherapists is particularly well suited to this surgically directed arena as it stems from research in medical reasoning and hence mirrors that of the surgeon in charge of the patient. Pattern recognition ( Higgs & Jones 2000 ) – a sign of the more expert professional – allows for a quick integration into the clinical puzzle of many different pieces virtually simultaneously. Orthopaedic practice is an ideal setting for physiotherapists to become more aware of and more secure in their cognitive skills as well as honing them to expert level. CASE STUDY 1 Rotator cuff repair Subjective assessment PC 50-year-old female admitted for an arthroscopic left rotator cuff repair. The indications for surgery are: large rotator cuff tear demonstrated by MRI pain interfering with work as unable to use arm effectively above 90° night pain waking her 2–3 times per night failed course of conservative treatment including cortisone injection (twice) and physiotherapy over last 4/12 HPC Intermittent shoulder pain for about 18/12 Aggravated by reaching, particularly if sustained or repeated Patient felt excruciating pain while hanging curtains but worked through the pain for the rest of the day Was unable to sleep that night due to severe pain Attended A&E where X-ray showed no abnormality She was referred for physiotherapy which has now been ongoing for several months to no effect GP had given cortisone injections on two occasions which didn’t help Patient was then referred to an orthopaedic surgeon who organized an MRI and diagnosed a full thickness rotator cuff repair. She was listed for surgery SH Self-employed curtain maker. Has employed help for the time she will be off work Lives with husband Smoker Objective assessment Observation Increased thoracic kyphosis in relaxed standing/sitting but is able to actively correct this to a reasonable level Mild forward head posture and protracted shoulders which she can control Cervical and thoracic movements appear fine Pre-operative treatment aims Teach bed exercises for circulation Teach deep breathing exercises to maintain good chest expansion Explain post-operative management and introduce post-operative precautions. This is done with her husband present and it is explained that he will need to help with the exercises post operation Provide any written information sheets about post-operative care and discuss Post-operative treatment aims (for 0–6 week period) Monitor respiratory and circulatory status during immediate post-operative period Protect healing of soft tissues. Maximum protection phase Prevent negative effects of immobilization Monitor and assist in pain control Re-establish scapula stability Encourage good posture Arrange out patient/community physiotherapy as appropriate 1st day post-surgery Breathing exercises are checked looking for basal expansion and clearance of any sputum Patient is mobilised out of bed as soon as able wearing a blow-up abduction pillow She is taught: scapular setting exercises in side lying and sitting, scapula protraction/retraction for proprioception. Full range of neck movements passive external rotation to full range minus 20° for 3/52 in lying. Passive elevation to shoulder level for 3/52. Passive movements are preferably done by a family member or carer. This person will need to be taught this before patient is discharged that at 3/52 both elevation and external rotation can be encouraged into full passive range both in lying and in sitting. Aim for full passive range soon after 6/52 post operation ( Gibson 2007 ) good postural alignment using a mirror in sitting and standing After 6/52 Start weaning from the immobilisation device and use her arm for light use at waist level Increasing ROM in all directions including behind the back Isometric internal and external rotation in neutral can be started to strengthen the cuff Progression to resisted and anti-gravity exercises will be as stability and pain permit Correct postural positioning is important throughout Pain will be monitored and addressed by her GP if necessary Questions 1. What are the rotator cuff muscles and what is their function? 2. The rotator cuff is said to be part of a force couple. What does this mean? 3. The causative mechanisms for rotator cuff disease are divided into intrinsic and extrinsic factors. What are these? 4. Why are we concerned about the scapula position for this patient? 5. Why does this patient need good postural advice? 6. What are the complications of rotator cuff repair and what can be done to minimise the impact of these? 7. What will be included in the discharge planning for this patient? 8. What is the expected long-term outcome for this shoulder? CASE STUDY 2 Decompression/discectomy Subjective assessment PC 36-year-old male architect presents with a prolapsed intervertebral disc (PIVD) and is booked for a spinal decompression (L4/5) the next morning. The aims of surgery are to: decrease pain decompress the spinal nerve improve dural mobility to prevent adverse neural tension prevent or reduce neurological damage HPC History of recurrent back pain (but no leg pain) for many months with an insidious onset 7/52 ago, moved house and a few days later developed severe low back pain radiating into his right buttock and then, a few days later, into his right leg all the way down to his foot He was convinced that rest would alleviate this very sharp pain When this didn’t help, he was offered conservative treatment which also did not improve matters From thinking that he had a back strain he now started to worry that something quite serious was happening He also developed numbness on the outside of his lower leg A review with his consultant resulted in him being booked for surgery Objective assessment Investigations MRI – showed clear protrusion of L4/5 intervertebral disk onto the spinal nerve root and due to the worsening nature of his signs and symptoms it has been decided to decompress his lumbar spine Observation Patient has marked contralateral shift (away from his painful side) Can only sit for a very brief time Marked decrease in straight leg raise on the affected side Abnormal gait pattern of a shortened stride length on the affected side Pre-operative treatment aims Teach him bed exercises for circulation, breathing exercises and log rolling in bed Explain post-operative management and precautions Provide written information of post-operative management Fit him with a temporary lumbar corset Post-operative treatment Read operation report and check for any special instruction by surgeon Check wound if appropriate Reduce anxiety Identify and prevent any post-operative complications Monitor and restore respiratory function Check for any neurological abnormalities Get patient mobilised in his corset once muscular control of quadriceps and gluteus maximus has been demonstrated Educate patient regarding life after discharge: a. Recognition and prevention of complications b. Ergonomic advice c. Self-managed home exercise programme especially core stability and neural stretches ( Shacklock 2005 ) d. Advice on home activities including sitting, driving, working Enhance patient’s self-efficacy in his body Discharge criteria Usually discharged after 2–4 days depending on surgical procedure, wound state, neurological and muscular control Able to get dressed independently Able to use the toilet independently Sit for a minimum of 10 minutes Able to manage stairs Questions 1. What is a slipped disc? 2. What are the classic clinical features of a prolapsed intervertebral disc? 3. What is the differential diagnosis of prolapsed discs? 4. What red flag elicited in an examination of low back pain will need immediate action by a doctor? 5. Why is postural education and exercise important for this patient? 6. What psycho-social problems might influence this patient’s treatment outcome? CASE STUDY 3 Fractured neck of femur Subjective assessment PC 65-year-old very slightly built woman admitted via A&E with fractured neck of femur on the right Once the diagnosis has been confirmed by X-ray she is considered for total hip replacement (THR) The indications for surgery are: reduction of fracture reduction of pain increase of function HPC Patient fell on uneven paving stones in the street and immediately realised that she had ‘broken something’ Was in severe pain, unable to weight bear and had to be admitted to hospital by ambulance SH Lives alone, has a daughter in another city Completely independent and is a retired archivist Objective assessment Observation Her right leg appeared shortened and in external rotation in the A&E department X-ray Confirms fractured neck of femur – Garden classification stage III Pre-operative physiotherapy aims Introduce yourself to patient Find out about her anxieties Explain post-operative regime while still in bed Explain post-operative regime once she has been allowed to mobilise Breathing exercises Explain role of MDT Post-operative physiotherapy aims (rehabilitation starts on 1st day post surgery) Read operation report in notes and look for specific post-operative instructions by surgeon Reduce patient’s anxiety Check for post-operative complications Respiratory check and care as appropriate Start with vascular function maintenance (foot and ankle pumps) Introduce joint movement and muscle tone around the hip especially abduction and flexion, quadriceps and gluteus strength Bed mobility (especially bridging for toilet purposes) Keep abduction wedge when patient lies supine or lies on operated side Education about ‘do’s and don’ts (focussing on joint preservation and weight bearing) Confer with MDT (especially social worker) regarding possible hurdles to discharge (remember, she lives alone) Start mobilising with two crutches (usually by day 2–3 but check with medical colleagues) Reduce walking aid support to one stick (usually by day 4) Discharge usually by day 5 by which time she will need to be able to get in and out of bed on her own, sit to stand without help and manage to walk up and down a flight of stairs Overall aim: to enhance patient’s self-efficacy in her body Questions 1. What is the Garden classification of fractured neck of femur and how does it influence surgical management? 2. Is it typical for a fall to result in such severe injury in an elderly person? 3. What are possible post-operative complications? 4. What actions should the patient avoid until 6 weeks post operatively? 5. How would you start and then progress muscle re-education? 6. What could you do to assist this patient with her possible anxiety? CASE STUDY 4 Total knee arthroplasty/replacement Subjective assessment PC 71-year-old female admitted for an elective right total knee arthroplasty/replacement (TKR). The indications for surgery are: patello-femoral and tibia-femoral osteoarthritis demonstrated on X-ray pain interfering with and day-to-day activities including walking loss of right knee extension night pain failed course of conservative management and physiotherapy HPC Intermittent right knee pain and stiffness for at least 10 years but managed her pain with analgesia and rest Past 2 years pain has become more constant, her standing and walking tolerance has decreased and she is experiencing night pain The patient had one course of physiotherapy which included exercises, manual therapy and hydrotherapy. Therapy improved right knee extension but had no effect on pain Patient was referred by GP to an orthopaedic consultant where X-ray showed patello-femoral and tibial-femoral osteoarthritis The patient was offered an elective TKR PMH Nil of note SH Lives in a house with her husband who is fit and well No downstairs toilet and she does all the cooking and cleaning The patient is originally from Italy and still works in the family restaurant Objective assessment Gait/observation Antalgic gait, predominately weight bearing on her left lower limb Uses a stick on the right side There is a slight right knee varus deformity and a palpable patello-femoral joint crepitus There is no evidence of joint effusion or swelling Functional level Transfers independently in standing, sitting and supine positions Step-to pattern up and down stairs leading with left lower limb ROM Right knee ROM between 10° and 100° flexion All other peripheral upper and lower limb joints have normal range of movement Pre-operative treatment aims Teach bed exercises for circulation Teach deep-breathing exercises Explain post-operative management and introduce post-operative precautions Record right knee range of movement in the medical notes Teach patient to use appropriate walking aids correctly, including stairs Provide any written information sheets about post-operative care and discuss Post-operative treatment aims (day 1 and 2 post surgery) Read surgeon’s post-operative instructions regarding mobilisation Discuss with the MDT the patient’s health status and pain relief Assess bed exercises for circulation Assess deep breathing exercises to maintain good chest expansion Control post-operative knee joint swelling Commence knee joint passive and active range of movement according to the surgeons protocol Mobilize the patient according to the surgeons protocol for TKR Post-operative treatment aims (day 3 to discharge date) Discuss with patient and MDT the discharge goals Assess post-operative knee joint swelling Safe progression of all transfers between supine, sitting and standing Gait education with the appropriate use of walking aids Safe progression of stair mobility Progress active range of knee movement to 0–90° Assess the need of post-discharge physiotherapy? Education of the patient to include: a. Prevention of complications b. Self-managed home exercise programme c. Advice on home activity and gradual return to full independence Continuous passive motion machines, slings and springs and sliding boards are often used to increase the range of movement of the operative knee The discharge date is agreed when the patient can mobilise independently with or without walking aids, can mobilise on stairs independently and has achieved 90° degrees knee flexion Questions 1. What are the short-term and long-term goals for this patient and how can the therapist plan the post-discharge rehabilitation programme? 2. What is osteoarthritis? 3. What are the clinical features of osteoarthritis? 4. What can be considered conservative management for knee joint osteoarthritis? 5. Give examples of different types of total knee prosthesis 6. What are the post-operative complications of total knee replacement? CASE STUDY 5 Anterior cruciate ligament reconstruction Subjective assessment PC 35-year-old male is admitted to the ward for an elective left knee anterior cruciate ligament reconstruction (ACLR). The indications of surgery are: left anterior cruciate ligament (ACL) rupture patient is self-employed and he is not responding to conservative management HPC Patient injured his left knee 10/52 ago playing rugby when he fell forwards and sideways while the left foot remained fixed on the ground He felt immediate pain and was unable to continue with the game Pain and swelling increased over the next 2 hours X-rays taken in A&E were negative for fractures He was prescribed anti-inflammatories, referred to physiotherapy, given elbow crutches and advice on ice, rest and elevation A clinic appointment to see an orthopaedic consultant was arranged The patient had a physiotherapy assessment within 5/7 post injury and therapy focused on reduction of swelling and gentle mobility exercises 1/52 post injury the knee swelling had not reduced and the patient was still unable to weight bear on his left lower limb Soft tissue injury was difficult to assess and an urgent MRI scan was arranged which showed rupture of the left ACL and a medial collateral ligament tear The orthopaedic surgeon discussed conservative and surgical options and the patient consented to surgery as one of his main concerns was the physical requirements of his job and that he was self-employed SH Self-employed carpenter Married with two young children Plays rugby twice a week with friends and he is otherwise fit and well Objective assessment Observation Patient partially weight bearing with elbow crutches Slight muscle wasting of the left quadriceps muscles compared to the right lower limb Tenderness, heat and some swelling of the left knee joint but the patellofemoral joint is visible and palpable ROM The patient has lost 5° of knee extension and has 100° flexion Restricted by pain and swelling Knee extension is most painful movement Special tests Anterior drawer test in 70° knee flexion = positive (anterior tibial displacement) approximately 2 cm) was not conclusive due to pain and swelling Valgus stress instability was not conclusive due to pain and swelling Active Lachmans’ test was not assessed due to pain and swelling All other peripheral joints were documented as normal Pre-operative treatment aims Discuss aims and surgery procedure Explain that post-operative pain and swelling is a common presentation Discuss immediate post-operative plan Discuss and give written information of the post-operative protocol and rehabilitation programme Teach immediate post-operative knee joint exercises including patellofemoral mobilisations to maintain range of movement Teach safe mobilisation with elbow crutches Post-operative treatment aims (day 1 and 2 post surgery) Read surgeon’s post-operative instructions regarding mobilisation Minimise swelling with advice on rest, ice and elevation Advise patient on the importance of adequate pain relief Mobilise partially or fully weight bearing according to surgeon’s protocol. Encourage normal gait pattern and safe mobility on stairs. Mobilise with cricket bat splint or brace depending on surgeon’s protocol Commence active range of movement as instructed by surgeon’s protocol. Common protocols aim to achieve 0–90° of active range of movement by week 2 post surgery Encourage resting position in knee joint extension Plan discharge goals Discharge goals Reiterate ACL post-operative rehabilitation protocol and graft protection Discuss the importance of a graduated rehabilitation regime and good muscle control Discuss return to work according to surgeons protocol Review home exercise programme Review safe mobilisation on elbow crutches Re-assure the patient that immediate post-surgical pain and swelling will gradually reduce Arrange post-discharge out-patient physiotherapy appointment Questions 1. What is the role of the cruciate ligaments in knee joint stability? 2. Describe common ACL mechanisms of injury. 3. Why is reconstruction using grafts preferable to repair of torn tissue? What type of grafts can be used in ACL reconstruction? 4. Considering your patient’s profession what might be a better choice of graft for his ACL reconstruction? 5. The patient has post-operative pain and swelling and this is increasing his anxiety about his return to work. How can the therapist re-assure him and address this anxiety? 6. What is the clinical reasoning behind open and closed kinetic chain exercises in ACL reconstruction? CASE STUDY 6 Fractured tibia and fibula Subjective assessment PC 36-year-old male admitted via A&E for surgery after a motorbike accident a few hours earlier which resulted in several open transverse and crush fractures of his right tibia and fibula He also has deep friction burns on his left side from sliding on the road surface HPC Patient suffered massive blood loss due to the open nature of his fractures He was referred for immediate surgery Pedal pulses were weak but present and it was therefore decided to use an internal fixator to pin his leg After the surgery he was transferred to the high-dependency unit where his medical condition resulting from the blood loss can be monitored SH Self-employed motorcycle courier and a trained motorbike mechanic Lives with his partner and their three young children Patient and partner juggle their work schedule so that both look after their children without outside help Post-operative aims Read the operation report and check for any special post-operative instructions Check chest and start with breathing exercises Re-assure patient and advise him on process of rehabilitation Pain relief Check wounds (do not forget the left side with the burns) and distal pulses Advise patient on vascular exercises (e.g. foot and ankle pumps) for his left leg. No muscle contractions of his right lower leg yet as this may put strain on the bone ends As the patient will be non-weight bearing when he mobilises he will need to work his upper body and non-operated leg to achieve the endurance needed for this high effort walking pattern Questions 1. How are fractures classified? 2. What is an internal fixation? 3. What are the possible disadvantages of an ORIF? 4. What are the classic healing times for fractures? 5. What are the complications of fractures in general? 6. What model of rehabilitation and clinical reasoning might be useful for Mike? CASE STUDY 7 Achilles tendon repair Subjective assessment PC 41-year-old male has undergone an Achilles tendon (TA) repair 1/7 ago. You have been asked to ensure that he is safe to go home today on crutches HPC He ruptured his TA (the first time) 5/12 ago Treatment consisted of full leg plaster for 3/12 followed by out-patient physiotherapy 3/7 ago he was walking on level ground when it re-ruptured Previous diagnosis had been Achilles tendinopathy SH Lawyer working in city and travels in by underground Single and lives alone in first floor flat He plays squash at club level. Until 2 years before he had also been playing rugby at club level. From then till his TA ruptured first time he was refereeing rugby at least one game each weekend Objective assessment Observation Strong, fit looking man despite the long period of recent inactivity, with a below knee cast, the foot position being full plantar flexion Able to easily lift cast in all directions, has full mobility Circulation appeared normal Post-operative instructions Below knee cast with ankle in full plantar flexion 4/52, non-weight bearing Cast changed to reposition the foot into neutral, i.e. the ankle is at right angles, for a further 2/52, and a walking cast applied for weight bearing Cast removed 6/52 post surgery and out-patient physiotherapy to commence ( Dandy & Edwards 2003 ) Post-operative treatment aims To be clear with post-operation instructions To ensure safety with crutch walking on the flat and on stairs To support the patient psychologically Elbow crutches were supplied and fitted. Instructions for use were discussed and he was taken to the staircase for stair practice. No problems were encountered – balance, transfers and on ascending/descending the stairs. Throughout the session he revealed what an extremely difficult time he was having adapting to this long period of inactivity. This was discussed and the patient decided with help, that regular visits to the gym to work on upper body and contralateral leg (the unaffected leg) strength would give him some means of having control on this situation. He was deemed safe to go home and was discharged Questions 1. What is a tendinopathy? 2. How is a TA rupture diagnosed? 3. What muscles make up the TA and what is their function? 4. What are the stages of healing and how do they apply to this tendon? 5. Describe the progressive changes you think occur in the normal gait pattern when using crutches. 6. What are the complications of poor crutch walking? 7. What exercise therapy will likely to be incorporated into his rehabilitation once his plaster has been removed? CASE STUDY 8 Idiopathic scoliosis Subjective assessment PC 15-year-old girl admitted with idiopathic scoliosis. Scoliosis is thought to be progressing (Cobb angle 40°, Risser four) Booked in for a single stage anterior fusion in 2/7 The aim of the surgery is: to stabilise the spine to prevent further deterioration to correct the deformity HPC Change in patient’s spine was noticed by her mother 6/12 ago GP referred to consultant Pre-admission 8/52 ago – stayed overnight, met the MDT Postural advice with emphasis on symmetrical weight bearing was given Investigations including new spinal X-rays and chest X-ray, blood tests, ECG and sleep studies were carried out SH Sitting GCSE exams at the end of year and very worried about having time off school Used to play netball but lately finds it too difficult but would like to be able to play again Not involved in other sport as she feels awkward Objective assessment Observation Right rib ‘hump’ (thoracic right convex) with right shoulder protracted and a prominence of the right hip, i.e. the trunk has shifted to the left Curves well hidden under loose clothing Leg length Indicates a shortening of right leg Neurological signs Nil Single leg stance Difficult on both sides due to asymmetrical weight distribution Gait Normal Pre-operative treatment aims Respiratory assessment – record lung function in medical notes to ascertain pre-operative values Explain post-operative management and introduce post-operative precautions Provide any written information sheets about post-operative care and discuss Post-operative treatment aims Identify and prevent post-operative complications Restore respiratory function Restore active muscle control Safe, functional rehabilitation and progression of mobility Education of the patient to include: a. ergonomic advice

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Sciatica Case Study: Bringing Research Into Practice

Patient with pain in the lower back travelling down the leg. Tingling sensations.

Diagnosis: Sciatica.

Treatment: Bed rest. Traction. Piriformis stretch. Back extensions. Repeat.

This was basically my management process for anyone walking into my office claiming that they have sciatica for an alarmingly long time. This approach was insufficiently person-centered and it resulted in poor therapeutic alliances and suboptimal management.

I got over it.

I pushed myself to explore the concept of sciatica, my patients beliefs about their diagnosis and treatments, improving my assessment and management skills and not seeing every patient with a single lens and galvanising my clinical practice above the uninspired cookie-cutter method of management.

Now, in this case study blog, I’m here to tell you how Physio Network’s reviews on sciatica helped me navigate this common yet complex condition.

Sciatica: A ‘Nothing Term’ for us or a ‘Something Term’ for them?

For physios, sciatica is characterised by pain radiating down the knee from the lumbar spine associated with altered sensation and/or weakness in the leg. Sciatica is common, with 60% of patients with low back pain presenting with leg pain features (1). It’s challenging for physios to find a structural cause as it could happen from disc herniations, compression, inflammation or tumors. At times, sciatica is wrongly mixed with the term ‘lumbar radiculopathy’. By now, physios should know that sciatica is a symptom and not a specific diagnosis (2).

For patients, sciatica can be an ‘all-encompassing’ experience with ‘physically and mentally draining’ symptoms with many feeling underappreciated in their consultations with the lack of clear explanations about treatment and prognosis. This failure of understanding the patient’s whole story leads to lack of trust and poor therapeutic alliance.

The Physio Network review written by Dr. Tom Walters prepared me to understand my patient’s perspective of living with sciatica. This review advocates the importance of patient’s beliefs about their illness and the role they can play in how well they respond to treatment. One of the reasons for physios not being able to get the desired clinical outcomes could be the inability to interpret their patients’ understanding of sciatica.

The patient was a 30 year old female corporate worker referred by a consultant spine surgeon with the diagnosis of low back pain with right leg sciatica. She mentioned that a month ago she was just picking up a suitcase from her bedroom floor when she felt a catch in her lower back accompanied with excruciating pain. She collapsed to the floor and was unable to get up. She called her friend to help her out and take her to the ER.

She mentioned that she has had a similar episode of back injury two years ago where she had debilitating pain and was not able to stand up for 2 weeks. She was given pain medications at the time and was advised bed rest. She didn’t have another such episode until this one.

She didn’t have any pain in her leg at the time. After hospital admission, an MRI was done and she was advised to undergo microdiscectomy the very next day. She mentioned that the words used by the radiologists and the surgeon were “ your back is screwed up” & “you won’t be able to deal with the pain”. She was prescribed heavy doses of painkillers and physio in the form of IFT and TENS. Her surgeon kept ‘persisting’ on her getting the surgery with words like “you will get paralysed”.

Eventually, her parents intervened and they decided to not undergo the operation. After a week of bed rest, gentle physio stretches and medications, she was able to slowly move around and her back pain started to get better. She was advised to wear a lumbar belt by her physio as she returned to her work. She presented with sharp, throbbing pain down her right leg till the foot which was worse than the pain in her back. It developed after 3 weeks from the episode and she has now started to limp because of it.

‘Understanding’ the Person (Not Just the Case)

Before we go into the physical assessment of this case, I want to point out how Tom Walter’s Physio Network review helped me to navigate this clinical encounter by exploring the patient’s understanding of sciatica. I further explored my patient’s beliefs as per the four main themes stated in the review.

She mentioned her illness experience as “crippling & debilitating”. She felt “isolated” as she was not able to do the things she liked and the surgeon’s words created a lot of fear in her. She had nightmares and she would wake up in pain. She noticed that her mood became more irritable and she felt depressed. Her concept of sciatica was majorly formed by what she read on Google and she believed that the ‘nerve is getting compressed’ and ‘it can’t shrink back’. She believed if compression stops, her pain would go away.

Her treatment beliefs included that eventually she would have to undergo surgery as exercises might not help with the compression and surgery will fix it. She stopped walking and jogging and she felt Ayurvedic massage and herbal medicine was helpful. She did not want to continue with the medications. She desired credible information and valued clear explanations about her prognosis. She mentioned that what her doctor told her was exactly what she had read on Google and was concerned over its credibility.

All this information helped me navigate this clinical encounter by better understanding how to approach and manage this ‘person with sciatica’. The review states that:

“In many cases, radicular pain is not related to mechanical nerve compression and can improve without a mechanical intervention, like surgery.”

Along with this, I took the time to explain to her about the potential role inflammation/neural sensitization can have on her experience of pain. I validated her experience of pain and she was grateful for the credible explanations. She mentioned that she “felt heard and taken seriously” and it “put her mind at ease”. She believed that feeling heard was part of her healing process. This helped set the right tone from the start before beginning any physical assessments or interventions.

Assessment and Diagnosis: No More Guesswork

Differentiating sciatica from other radicular symptoms makes it challenging as clinical features are highly variable in practice (3). Dr. Mary O’ Keeffe’s research review focused on distinguishing three subsets of nerve root involvement: sciatica (radicular pain); radiculopathy, spinal stenosis. It made the differential diagnosis much less complex.

The patient complained of leg pain which was significantly greater than her back pain. Repeated extension in standing increased her symptoms. She reported a gradual increase in symptoms over the last 3 weeks with the pain being 9/10 at its worst and 3/10 at its best. Aggravating activities included sitting for long hours, lifting heavy things and twisting. Relieving activities included crook lying and forward bending stretches.

She reported pain till the right foot with right SLR of 40° and a stretch in the left posterior thigh at 70°. Upper motor neuron testing (Babinski, ankle clonus test, Hoffmann’s sign) indicated nothing abnormal. Serious pathologies (cancer, cauda equina ) were ruled out. There was no numbness present. The pain intensified with a cough or a sneeze and the pain location aligned with the dermatomal concentration along with decreased Achilles tendon reflex in the right lateral foot. Prone knee bend test and crossed lasegue test were positive and finger to floor distance was 30cm. On palpation over the right piriformis region and PSIS, she reported mild tenderness. Her Oswestry Disability Index (ODI) score was 42% indicating severe disability.

Dr. Sarah Haag’s review made me aware about the clinical guidelines which recommend a combination of history taking, a cluster of physical tests, and the StEP screening tool as being helpful clinically to identify neuropathic pain in low back related leg pain (LBLP). The 8 patient history/clinical examination signs are (4):

• Duration of disease
• Paroxysmal pain
• Pain worse in leg than back
• Typical dermatomal distribution
• Worse on coughing/sneezing/straining
• Finger to floor distance

Considering the above information, I was able to identify neuropathic pain with LBLP in my patient which directly allowed me to provide more efficient care.

Role of Imaging

The patient asked if she really needed to get another MRI done as she was scared she would be needing surgery soon to “remove the compression”. Mary O’Keeffe’s review mentions that most patients with radicular syndromes do not require immediate diagnostic imaging. Even after this clinical update, she was recommended to get an MRI done. It was important for me to match the imaging findings with the symptoms before moving forward.

This was a difficult case to manage from the start considering the high intensity of pain, its psychological impact along with levels of functional disability, and the harmful beliefs propagated by healthcare professionals. Reading the aforementioned Research Reviews set up a great foundation for me and provided me with a useful understanding of the current evidence base to optimally manage this patient.

Tom Walter’s review helped me understand the value of seeking to understand the patient’s lived ‘illness experience’ and aided in building a strong therapeutic alliance and trust (5). Listening, educating, validating, understanding her beliefs combined with a thorough physical examination assisted in better clinical outcomes.

For context – sessions were done twice a week for six weeks.

Education/Prognosis

In Mary O’Keeffe’s review , she mentioned how prognosis is normally favourable in most cases of sciatica. The pain subsides over time on its own. The first line of care should consist of reassurance, advice to stay active and resume activities as possible as well as exercise therapy.

Following reading this review, I was able to explain the nature and prognosis of sciatica and discussed the need for imaging and its ineffectiveness in determining either the conservative care or the prognosis, and was able to remove some fear. I was able to advise her regarding sciatica as a symptom, her treatment options and reducing modifiable risk factors (smoking & lack of movement). Realistic expectations were set after discussing the prognosis. It took time to convince her that surgery was not her only option.

Setting Goals

She wanted to get active again and to be able to do her job. Therefore, staying active was considered the main goal. Rather than generic exercises, I advised her to slowly get into the things she likes doing the most as a physical activity. Walking was her favourite thing to do and we decided to try that slowly along with exercise therapy. We set little targets in terms of minutes walked and slowly changed the intensity as she felt better and more confident. Painting was something that relaxed her so we slowly incorporated that in her plan for stress relief.

Exercise Therapy

Dr Sarah Haag’s review states that there is no one “best” intervention for low back pain with radiculopathy. Exercises targeted towards improving motor control, dynamic muscle strengthening and directional preference exercises along with neurodynamic mobilisation were included in the rehab program. This study also states that there’s no benefit of traction either alone or in combination with other treatment on pain intensity, functional status, or return to work.

This review showed that the addition of neurodynamic mobilization to motor control exercises may lead to a greater decrease in symptoms (6). The patient realised that exercises were safe for her as she started to enjoy ‘staying active’. She mentioned that the neurodynamic sliders “worked well for her” towards being self-sufficient in managing the pain.

The patient reported a decrease in pain to 5/10 by visit 3 and appreciated the fact that she was walking more. She stopped taking medications and was able to sit down and paint for 20 min by visit 4. By visit 7, she reported 2/10 pain in the leg and being self-sufficient with her exercises. She mentioned that even though the symptoms didn’t resolve completely, she could see she had made a lot of progress and found the rehab plan very meaningful.

By visit 15, she had pain free active range of motion in her back and her right SLR improved to 70°. She was able to walk for 5km without pain by visit 16 and was able to sit at work without pain. Her ODI score changed significantly from severe disability (42%) to no disability (0%). At 6 months follow up, she still did not have any leg pain and she was still staying physically active, working and travelling.

Sciatica can be challenging to treat in the clinic. After one year, only 55% of primary care patients reported greater than 30% improvement (7). The complexity of low back pain, lack of understanding of patients’ beliefs, limited knowledge of diagnosis, no ‘best’ intervention, no effective subgrouping of patients, confusion in the use of terminology, and failure of implementation of clinical guidelines often leave physiotherapists feeling unsure about how to navigate such clinical encounters (8). This leads to tensions in the dialogues between physios and patients. Patients are also left with higher degrees of hopelessness when physios fail to understand the impact of sciatica on their lives and identity (9).

Physio Network’s Research Reviews summarize the latest evidence for physiotherapists, to highlight optimal ways of identifying and managing patients with a range of different conditions. If you managed to make it this far and clicked on all the links along the way, then there’s just one thing left to do:

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• Hill JC, Konstantinou K, Egbewale BE, Dunn KM, Lewis M, van der Windt D. Clinical outcomes among low back pain consulters with referred leg pain in primary care. Spine.2011 Dec 1;36(25):2168-75.
• Ostelo RW. Physiotherapy management of sciatica. J Physiother. 2020 Apr;66(2):83-88.
• Jensen RK, Kongsted A, Kjaer P, Koes B. Diagnosis and treatment of sciatica. BMJ. 2019 Nov 19;367
• Mistry, J., Heneghan, N.R., Noblet, T. et al. Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back related leg pain: a systematic review and narrative synthesis. BMC Musculoskelet Disord 21, 532 (2020).
• Goldsmith R, Williams NH, Wood F. Understanding sciatica: illness and treatment beliefs in a lumbar radicular pain population. A qualitative interview study. BJGP Open. 2019 Oct 29;3(3)
• Plaza-Manzano, Gustavo PT, PhD; Cancela-Cilleruelo, Ignacio PT, MSc; Fernández-de-las-Peñas, César PT, MSc, PhD, Dr med; Cleland, Joshua A. PT, PhD; Arias-Buría, José L. PT, PhD; Thoomes-de-Graaf, Marloes PT, PhD; Ortega-Santiago, Ricardo PT, PhD Effects of Adding a Neurodynamic Mobilization to Motor Control Training in Patients With Lumbar Radiculopathy Due to Disc Herniation, American Journal of Physical Medicine & Rehabilitation: February 2020 – Volume 99 – Issue 2 – p 124-132
• Konstantinou K, Dunn KM, Ogollah R, Lewis M, van der Windt D, Hay EM; Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J. 2018 Jun;18(6):1030-1040.
• Stynes S, Konstantinou K, Dunn KM. Classification of patients with low back-related leg pain: a systematic review. BMC Musculoskelet Disord. 2016 May 23;17:226.
• Ong BN, Konstantinou K, Corbett M, Hay E. Patients’ own accounts of sciatica: a qualitative study. Spine. 2011 Jul 1;36(15):1251-6.

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If you have a question, suggestion or a link to some related research, share below!

Hi Ashish, thank you so much for this article. It is well done and well-connected with the research reviews. Great job, and thanks a lot.

yep very nice and thorough. I do think think there is a little bit of an n=1 concept to back pain patients though. Certain patients do react to soft tissue, some don’t, i have had some respond to electrotherapy in the early stages and some not and even traction. However yes, the overwhelming evidence is get them moving and strengthen and i do think lengthen.

Hi Ash, thanks for sharing your experience with this patient. Can I just ask what timeframe the 15th/16th visit were post-injury? Thanks in advance

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Rehabilitation of a Painful Shoulder – A Perspective Biomechanical Approach

Raj, V. Vijay Samuel; Ukil, Kundan Das 1 ; Shetty, Aparna 2

Department of Sports Sciences, JSS College of Physiotherapy, Mysore, Karnataka, India

1 Department of Musculoskeletal and Sports Physiotherapy, Brainware School of Medical and Allied Health Sciences, Brainware University, Barasat, West Bengal, India

2 Department of Musculoskeletal and Sports Physiotherapy, JSS College of Physiotherapy, Mysore, Karnataka, India

Address for correspondence: Dr. V. Vijay Raj, Department of Sport Science, JSS College of Physiotherapy, Mg Road, Mysore - 570 004, Karnataka, India. E-mail: [email protected]

Received March 30, 2022

Received in revised form November 16, 2022

Accepted December 16, 2022

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

The deltoid muscle is often forgotten when it comes to the evaluation and planning of treatment in shoulder conditions. Shoulder dysfunction, rotator cuff tendinopathy, and frozen shoulder are the conditions that affect functioning in major cases. The study involved an exploration of possible causes of dysfunction, especially pain and overhead activities. The patient presented with chronic pain and decreased shoulder function. A suitable shoulder rehabilitation program was designed keeping the deltoid muscle denervation into consideration. The shoulder pain, range of motion, strength, and function were evaluated at the baseline and the end of 6 weeks. The results were correlated and explored to identify the involvement of the deltoid muscle. The study showed a positive test of deltoid muscle involvement, which was identified through the strength-duration curve. There was a clinically significant improvement observed in the patients' function. Hence, the study hypothesized that along with scapular stabilization, it is important to consider deltoid equally during the assessment and treatment plan in shoulder rehabilitation program.

INTRODUCTION

The shoulder complex is an intricately designed combination of the glenohumeral joint, sternoclavicular joint, acromioclavicular joint, and scapulothoracic joint formed by the clavicle, scapula, and humerus. Shoulder articular structures are intended primarily for mobility, allowing for a wide range of motion (ROM).[ 1 ] The freedom of movement at the shoulder complex requires both mobility and stability which rely on both static and dynamic stabilization.[ 2 ] Dynamic stabilization results from a unique functional balance between mobility and stability through forces by the muscles that rely on dynamic muscular control rather than passive forces. The shoulder complex, muscles provide a stable base for the upper limb movements, it is important that the stability of scapula is essential to carry out an efficient function. When there is a loss of stabilization factors due to various reasons, the shoulder complex is susceptible to instability and dysfunction.

The common nerves that are involved in the shoulder are the axillary, long thoracic, and suprascapular and musculoskeletal nerves. The axillary nerve (AN) supplies the deltoid muscle, musculoskeletal nerve supplies the biceps, and may be entrapped or diseased. AN injury may present with axillary neuropathies caused due to various traumatic and compression injuries, also weakness of deltoid may be causative due to pathologies including subdeltoid bursa, acromion, and lateral clavicle.[ 3 ] Men are prone to AN injury than women at the ratio of 3:1.[ 4 ] Among the shoulder injuries, 9%–65% is AN injury.

The deltoid weakness can contribute to active loss of shoulder abduction, flexion, and extension and may be also caused due to AN injury, and caused due to anterior inferior dislocation, fracture, and fall on outstretched arm. The free portion of AN can be elongated due to displacement of the head of the humerus and may result in the avulsion of AN.[ 5 ] A special consideration needs to be made on the evaluation and functional diagnosis of shoulder dysfunction. The stability and mobility factors and ratio of contribution during upper limb function have to be considered in the assessment and plan of care during shoulder rehabilitation. This manuscript presents the interesting case study with an aim to present the importance of biomechanical evaluation and treatment, emphasizing on the evaluation of the auxiliary nerve involvement.

CASE REPORT

The client was a 63-year-old adult male, who visited the physiotherapy department at a tertiary hospital with complaints of pain at the left shoulder and arm for the past 6 months. He reported 1 st episode of injury during performing sumo squat, which included squats with wider base and holding a kettlebell and also later during bicep curl of 5 kg and triceps curls of 5 kg. The pain aggravated on any of the weightlifting activities since then. He consulted the orthopedic surgeon and diagnosed with partial width tear of the supraspinatus, subacromial impingement of rotator cuff, subdeltoid bursitis, and bicipital tenosynovitis. He was prescribed analgesics, advised to rest for 10 days, and referred to physiotherapy. He was treated with joint mobilization emphasizing on inferior glides with stretching of trapezius, and strengthening, and went for acupuncture. There was a 60%–70% reduction in the Visual Analog Scale (VAS) after treatment, but with a reoccurrence of pain intermittently. Three months later, during his trip abroad, with no specific reason mentioned, the pain increased in the night, for which he took therapy for 2 days from a joint specialist, where he found symptomatic relieve. The second episode occurred after lifting a suitcase of 23 kg to place it at the high head plank, which gave sudden sharp shooting pain to the patient at the left shoulder, which disabled him from lifting any weight. He had his visit to the department after this incident.

The sumo squat included standing with wide feet at shoulder width apart holding a kettlebell with both arms in front. Normally, the squat would include dropping the hips back and down, as sitting in a chair, allowing the kettlebell to swing down in between the legs, one would use the knee and hip to swing the kettlebell up and not the shoulders or one's arms. Probably, altered biomechanics would have been followed by the patient using more of his arms and shoulders, leading to a hypothesis of the shoulder muscles involvement leading to strain or AN injury.

The subjective and objective data were collected and presented with clinical reasoning form using a visual analysis. The data were plotted using Microsoft Office Excel software at baseline, before intervention and after 4 weeks of planned exercise program, and 6 weeks for discharge. Written consent was obtained from the client and the physiotherapy plan was clearly explained in his own language.

Patient evaluation and treatment planning

The client was interviewed with detailed subjective evaluation before starting of the exercise program. The client could not perform activities of daily living involving reach to the back by the left hand, and he complained about the difficulty in overhead activities and pain limiting the function. The initial evaluation of pain assessment, postural deformity, girth, muscle strength, and ROM evaluation was recorded and documented. The sensation over the neck and upper limb was intact. In the outcome measure, the Shoulder Pain and Disability Index (SPADI) of 71.53% was reported. In pain level, initial intensity of the pain was VAS 8 out of 10, the characteristics were chronic dull aching and most of the time patient experienced pain in the morning time, aggravating factor was due to stretch, weight lifting, sleeping on the affected side, and relieving factors were rest and heat application.

On observation, muscle atrophy in infraspinatus, supraspinatus, deltoid, triceps, and biceps was noticed. The posture assessment on the postural grid depicted a protracted shoulder, elevated shoulder on the left side, and winging of the scapula. The shoulder ROM during flexion, extension, abduction, and external and internal rotation was limited [ Table 1 ], with a firm end feel, pain onset (P1) followed by resistance limit (R2). The muscle strength and girth measurements were also taken shown in the table and abnormal glenohumeral rhythm (scapular dyskinesia) was noticed. Special tests for the shoulder were done to identify the underlying pathology. Empty can test, superior and inferior scratch test, Neer impingement test, speed's test, and Yergason's test, all were considered positive, these were in turn the interpretation of patient and the impingement of supraspinatus and biceps were possibly confirmed, with joint capsule involvement. Correlating the finding of special tests and kinetics, possibly a compression at the quadrilateral space may be considered for further evaluation.[ 6 , 7 ] The presenting symptoms of the patient were night pain and weakness in the shoulder–glenohumeral abduction and external rotator, without numbness to the lateral shoulder area. Thus, leading to a hypothesis of the involvement of the middle deltoid and the AN, this may be caused due to primary shoulder impingement syndrome, caused due to faulty shoulder position.

Baseline tests and follow-up were conducted before the start of the exercise program. The tests are joint ROM, muscle strength, VAS, and strength-duration curve (SDC). The follow-up tests were conducted every week and 4 weeks after to check the improvement, and with obtained results, the exercise program was changed for consecutive sessions based on the assessment using the same test methods and finally at 6 weeks for discharge. A minimal clinically important difference (MCID) for ROM of ≥9° was considered. The shoulder function was assessed using SPADI, considering a MCID of 8–13 points.[ 8 ] The muscle girth was assessed using a standard flexible inch tape and measured in centimeter (cm).[ 9 ]

Rehabilitation program

The exercise program was composed of 6 weeks [Annexure 1], planned in five phases, which included the baseline tests and every week follow-up tests. To reduce the pain at left shoulder ultrasound therapy (UST), faradic muscle stimulation for supraspinatus, biceps, and anterior and middle deltoid 30 contractions [Annexure 1].

Visual Analog Scale

The level of subjective pain was measured using VAS when the shoulder joint was moved, with 10 as the highest level of pain. Pain at the shoulder joint before the exercise was 8, and the pain level reduced to 6 in 4 days and to 4 in 2 weeks at the maximum joint range.

Muscle girth, strength, and function

The girth measurement showed an improvement with a difference of 4.5 cm in the left arm girth. Similarly, at left forearm showed a difference of 1 cm. The significant improvement in muscle strength was noted in shoulder flexors (anterior fibers of deltoid, long head of biceps, and supraspinatus) with a difference of 10 lbs and similarly in biceps muscle with a difference of 19 lbs. However, the strength of shoulder extensors, abductors, internal rotators, and external rotators showed improvement, it was negligible as the difference was <6 lbs. The results of the strength measured by handheld dynamometer are depicted in Table 1 . Improvement in function was achieved; SPADI outcome was noted at 71.53% in the baseline and 86.55% in the posttest, with a difference of improvement of 15%, with difference score of 40 points, which was far above the MCID.

The measurements were taken in the following order: shoulder flexion, abduction, internal rotation, and external rotation. Joint motion observed an increased range in all movements with an evident increase in shoulder internal and external rotation. The ROM improvement in flexion and abduction can be ignored considering the MCID and errors. The results of the ROM of shoulder joint are shown in Table 1 .

Strength duration curve

The SDC responses for the biceps muscle (AN) showed abnormal chronaxie (2.2 ms), with the curve representing a compression, showing a minimal kink [ Figure 1 ]. The posttest responses recorded a normal chronaxie (0.38 ms) representing a normal curve. An evident improvement in the strength response was observed depicting that the nerve function may be restored.

The study was conducted in five phases. In the first phase, the treatment plan was made after evaluating the patient. In the second phase, preliminary tests were conducted. In the third phase, the exercise protocol was programmed. In the fourth phase, reevaluation was done, and in the fifth phase redesigning of exercise program over 6 weeks, each of the sessions lasted for 1 h.

Historically, the assessment of musculoskeletal problems in the shoulder joint has been based on the premise that it is possible to isolate the individual structure at fault. In the differential diagnosis of shoulder dysfunction, it is essential to rule out the origin of pain, in this case, the evaluation findings hypothesized that it might be due to AN pathology involving the deltoid muscle. In this case, postexercise, there was a lag in the shoulder flexor strength, in contrary to the biceps brachii muscle showing an excellent improvement in strength, when compared with the unaffected side. This leads to the confirmation of the anterior deltoid muscle involvement. This study further concludes that in spite of strong improvement in the deltoid group of muscles, the strength was not achieved to match the unaffected side. Exercise programs of longer duration exceeding 6 weeks may be necessary to achieve actual strength with change in the resistance training programs.[ 10 ] Patient reported that the sumo squat with kettlebell exercises caused the first episode, this supports with the possibilities of abnormal kinematics and kinetics[ 11 ] of the shoulder and scapula, leading to AN injury. This study emphasizes, the biomechanical evaluation including movement analysis may aid in functional decision-making and planning an appropriate physiotherapy intervention. This may be evidently followed in sports injury management. Many times, the deltoid muscle is ignored during the shoulder evaluation. However, the shoulder stabilizers involving the scapula stability play an essential function during static and dynamic activities, it is necessary to consider the deltoid along with the scapular muscles during the assessment of shoulder dysfunction and plan an appropriate plan of care. In this study, the patients, glenohumeral accessory movements (glides) were optimal, but pain limiting the movement, and due to the reason passive mobilization techniques were not delivered. There was a significant improvement observed in the patients' function, both subjectively and objectively. The parameters such as SPADI, muscle strength, and muscle girth measurements have shown significant clinical improvement in recovery. The patient was enthusiastic and cooperative throughout the treatment session, and there were no difficulties observed by the patient to follow the exercise protocol.

The study showed a positive test of deltoid muscle involvement, which was identified through the strength-duration curve. There was a clinically significant improvement observed in the patients' function. Hence, the study hypothesized that along with scapular stabilization, it is important to consider deltoid equally during assessment and treatment plan in shoulder rehabilitation program.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Shoulder Rehabilitation Protocol:

• Passive and active stretching of pectorals and biceps muscle
• Faradic Stimulation – Deltoid inhibition techniques – Intermittent 100 Hz, 1 ms pulse duration, rest time 5–10 s. 20–30 contractions
• UST (1 Mhz, pulsed 1:1, 0.8 W/cm 2 , 4–6 min) calculated based on the standard operating procedure of the department of physiotherapy, and treatment calculation chart. (Watson, T. (2002). “Ultrasound Dose Calculations“ In Touch 101;14-17)
• Strengthening exercises comprised.
• Muscle setting exercises (isometrics)
• Resistance exercise with resistance band and dumbbells for shoulder flexors and abductors (10 rep × 3 sets) each in supine lying
• Horizontal abduction was planned to improve eccentric contraction of retractors and active stretching of pectorals (10reps × 3 sets)
• Retractor strengthening using resistance band (10 reps × 3 sets)
• Bicep curl-ups using 60%–80% 1 RM graded increment using dumbbells (10 reps × 3 sets)
• Triceps strengthening using resistance band (10 reps × 3 sets)
• Home exercise program with plans to improve the retractor strength and shoulder mobility and strength was planned for 5 days/week
• Safe lifting techniques and ergonomic measures were advised.

Axillary nerve; deltoid; physiotherapy; rehabilitation; shoulder dysfunction; shoulder pain

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 Aoife’s experience of tennis elbow

Read about how a course of physiotherapy and acupuncture resolved Aoife’s extremely painful tennis elbow

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Ankle Sprains: A Case Study

With icy sidewalks and streets, falls during the winter can become more prominent. One injury that can occur is ankle sprains.  Have you ever sprained your ankle before? Wondering if you should seek physiotherapy? Lets look at a case history of one example of an ankle sprain and what physiotherapy may involve…

Ankle Sprain: Case Study

A 35 year old woman attends the clinic after she was walking her dogs outdoors when they lunged suddenly, causing her to slip on some ice. She fell, rolling her right ankle to the side and was able to get back up and weight bear through her injured ankle, although limping back home. Her ankle was pretty sore with some noticeable swelling so she went to see her family physician the following day. X-rays were taken of the ankle and she was advised she did not have a fracture, but rather sprained her ankle. She was recommended to rest the ankle for the next 3 days and to limit her weight bearing as tolerated using a lace up brace. She was also prescribed anti-inflammatories and referred to physiotherapy.

Dance Ankles and Feet

For the assessment she was weight bearing with a lace up ankle brace. The ankle was noted as still sore but improving.

Some mild swelling over the lateral ankle and some tenderness to touch over the ankle ligaments were noted. With in-clinic testing it was determined she was dealing with a moderate ankle sprain. She was prescribed some basic neuroproprioceptive and gentle strengthening exercises. These early phase exercises set the base foundation for return to regular activity and sports and she was eager to get back to her regular routine with her dogs.

The client was seen for 6 further follow ups over the next 3 months.  During this time she was provided with some manual therapy techniques to the ankle. She was also given a progressive home exercise program which included progressive strengthening, balance and proprioceptive training. The client noted full resolution of symptoms at the conclusion of her treatment and return to her activities which included walking her dogs and her dance class.

Often people find that their ankle will feel “good enough” part way through rehabilitation but ensuring that all systems are truly “go” will help prevent a recurring injury from incomplete rehab programming.

What is the current evidence for acute lateral ankle sprains and the role of physical therapy?

If required a short period of immobilization may be used, however exercise and a functional support (either bracing or taping) is recommended over immobilization. Clinical practice guidelines support the inclusion of an active exercise rehab program following an acute lateral ankle sprain as soon as possible to help prevent recurrent lateral ankle sprains. 1

It is commonly misunderstood that someone must wait a certain period of time before attending physiotherapy, however, keep in mind that physiotherapists can assess injuries right from the moment of impact; just like when an athlete becomes injured. Coming for an appointment early in healing can give you the right tools to start with immediately. Alternatively, the body is capable of healing and change even after extended periods of time so it is also never too late to start.

If you have unfortunately sustained an ankle injury, we at Warman Physiotherapy and Wellness have trained physiotherapists who can offer a progressive rehabilitation program to help you on the road to recovery and return you to your activities/sport!

References:

• Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. BJSM. Volume 52, Issue 15. August 2018. Gwendolyn Vuurberg, et. al.

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Online romance scams: Research reveals scammers’ tactics – and how to defend against them

Assistant Professor of Criminology and Criminal Justice, University of Texas at Arlington

Disclosure statement

Fangzhou Wang does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

University of Texas Arlington provides funding as a member of The Conversation US.

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In the Netflix documentary “ The Tinder Swindler ,” victims exposed notorious con artist Simon Leviev , who posed as a wealthy diamond mogul on the popular dating app Tinder to deceive and scam numerous women out of millions of dollars. Leviev is a flashy example of a dating scammer, but criminal operations also prey on emotionally vulnerable people to gain their trust and exploit them financially.

The internet has revolutionized dating, and there has been a surge in U.S. adults using apps to find ideal matches post-pandemic. While these apps offer convenience for connecting with romantic partners, they also open the door to online romance scams. Criminals create both deceptive profiles and urgent scenarios to carry out the scam.

The Federal Trade Commission reports that nearly 70,000 Americans fell victim to online romantic scams in 2022 , with reported losses topping US$1.3 billion.

Online romance scams exploit people through calculated online social engineering and deliberately deceptive communication tactics. In a series of research projects, my colleagues from Georgia State University , University of Alabama , University of South Florida and I focused on understanding how scammers operate, the cues that may prompt changes in their tactics and what measures people can take to defend themselves against falling victim to this scam.

How online romantic scams work

Online romance scams are not coincidental. They’re carefully planned schemes that follow distinct stages. Research has identified five stages :

• Baiting victims with attractive profiles.
• Grooming victims with intimacy.
• Creating crises to extract money.
• On occasion manipulating victims with blackmail.
• Revealing the scam.

In short, scammers do not swindle victims by chance. They plan their actions in advance, patiently following their playbooks to ensure profitable outcomes. Scammers worm their way into a victim’s heart to gain access to their money through false pretenses.

In a previous study, my colleague Volkan Topalli and I analyzed victim testimonials from the website stop-scammers.com. Our research revealed scammers’ use of various social engineering techniques and crisis stories to prompt urgent requests. Scammers leveraged social norms, guilt and supposed emergencies to manipulate victims. Scammers also paid close attention to communication patterns and adapted their tactics based on victims’ responses. This interplay significantly influenced the overall operation of the scam.

Across the globe, online romance scammers use different techniques that vary across cultures to successfully defraud victims. In my recent research, for example, I looked closely into an online romance scam in China called “Sha Zhu Pan,” which loosely translates to “Pig Butchering Scam.” In Sha Zhu Pan, scammers bait and groom victims for financial exploitation through well-structured group setups. Multiple scammers across four groups – hosts, resources, IT and money laundering – persuade victims through romantic tactics to invest in fake apps or use fake gambling websites, convincing them to pay more and more without ever receiving their money back. Hosts interact with victims, resources members identify targets and collect information about them, IT creates the fake apps and websites, and the money launderers process the ill-gotten gains.

Deterrence and rewards

Like street robbers , online romance scammers can be influenced both positively and negatively by a range of situational cues that serve as incentives or deterrents.

Our investigation showed that deterrent messages can significantly affect scammers’ behavior . Here’s an example of a deterrent message: “I know you are scamming innocent people. My friend was recently arrested for the same offense and is facing five years in prison. You should stop before you face the same fate.” Based on live conversations with active scammers online, our recent analysis suggests that receiving deterrent messages reduced scammers’ response rate and their use of certain words, and increased the likelihood that when they sought further communications, they admitted they had done something wrong.

Our observations indicate that scammers not only diversify their approaches to prompt more responses, such as appealing to their romantic relationships, asking for identifying information and requesting victims switch to private chat platforms, but they also use several techniques for getting victims to overcome their misgivings about sending the scammers more money. For example, scammers subtly persuade victims to see themselves as holding more power in the interaction than they do.

Blocking scammers

There are methods that could help users defend against online romance scams.

In experimental findings, my colleagues and I suggest online apps, especially dating apps, implement warning messages. An example would be applying linguistics algorithms to identify keywords like “money,” “MoneyGram” and “bank” in conversations to alert potential victims of the scam and deter scammers from engaging further.

In addition, apps can use tools to detect counterfeit profile pictures and other types of image fraud. By concentrating on identifying scammers’ use of counterfeit profile pictures, this advanced algorithm holds the potential to preemptively hinder scammers from establishing fake profiles and initiating conversations from the outset.

How to protect yourself

Online dating app users can take precautions when talking to strangers. There are five rules users should follow to steer clear of scammers:

• Avoid sharing financial information with or sending money to strangers.
• Refrain from sending private photos to strangers.
• Pay attention to spelling and grammar because scammers often claim to reside in English-speaking countries when they actually operate in non-Western countries.
• Use image and name-reverse searches.
• Confide in family and friends if you grow suspicious.

One last piece of advice to empower those who have fallen victim to online romance scams: Don’t blame yourself.

Take the courageous step of breaking free from the scam and seek support. Reach out to your loved ones, trustworthy third-party organizations and law enforcement agencies for help. This support network is essential in helping you restart your life and move forward.

• Online dating
• Online scams
• Romance scam
• Con artists
• online dating scams

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