Authorisation of use of pictures

Sports Rehabilitation

Attending a talk by David Tiberio in October gave me a new insight into how to rehabilitate a patient looking to return to normal function, let a lone returning to sporting function. Tiberio discussed about loading and exploding, explaining that in order to carry out any movement, a small opposite movement occurs first. For example, when getting out of a seat, you almost sit deeper into your chair, loading the muscles needed to get you out of the chair (quadriceps, gluts etc) by applying a small stretch. This enables them to explode allowing you to carry out the movement of getting out of the chair.

I also completed a course held by Robin Lansman on Sports biomechanics and muscle chains. Here we looked at developing the standing exam, the squat test, muscle chains (open and closed chains), sport muscle chains.

I was fortunate enough to have a patient who presented with multiple inversion ankle sprains. Using these two tools, along with my knowledge as a personal trainer I carried out some rehabilitation exercises on this patient. An example of the notes can be seen below.

 Certificate of the CPD course

Gait analysis

in my attempt to grasp a better understanding of gait mechanics and how it could affect a patient I attended a Manus Sinistra talk held by Matt Harris. I also observed Matt Harris at Pure Sports Medicine, seeing him implement this into all his treatments with his patients. He also advised his patients on nutrition further strengthening my want to get a general better understanding on appropriate nutritional advice. Below are pictures of Matt assessing a fellow BSO student's gait, and my assessments of my patients gait in clinic.

Functional technique practise and clinical application

some pictures of me practising tapping the spinal segments of the thorax and moving the segment into its greatest point of ease.

clinic notes of me applying functional technique in clinic on patients, incorporating this into my routine where possible and approriate.

Obstetrics technique practise

Below are my attendance forms to my lectures in obstetrics and osteopathy,

Applying the technique used to assess leg length discrepancy with a patient, 

 the diaphragm release/stretch technique - which can be applied to pregnant women and can be beneficial due to the poor mechanisms of the diaphragm resulting from pregnancy and pressure/restriction produced due to the foetus

 the 8 finger soft tissue technique

 modified posterior SIJ high velocity thrust - as a pregnant woman would not be able to roll on to her front to carry out this technique

 seated soft tissue of the erector spinae muscles - effective and removes the need for the patient to lie prone as the patient would be pregnant and unable to do so

 periscapular muscles soft tissue, using the patients arm to reinforce and direct treatment to specific tissues, muscles and articulation of the shoulder complex

IMS practise and clinical application

Involuntary Movement System practise, attendance and clinical practise. I recently had a headache patient and have applied frontal lift technique in order to elevate his symptoms. There has been an improvement as he has been able to have no headache post treatment for upto 3 days. Prior to treatment the patient would suffer from headaches on a daily occurance.

I attempted to perform balance tension at the sacrum on a patient who experienced pain shooting along her sacrum. She had adhesions removed and this also gave me an opportunity to attempt this technique in order to see if this would relieve her symptoms. 

Study Group

We work hard to ensure we can think of all differential diagnoses, he is a little picture of me with the work my study group and I did on the knee and the mechanism behind high velocity thrusts

Nutrition and osteopathy

I had a very productive talk with a fellow student who is studying nutrition. I explained to her how I was looking to improve my knowledge of how nutrition is linked with osteopathy. She gave me a great link on recipes and the medicinal properties included in these meals

http://www.dalepinnock.com/.

I have yet to fully investigate this but from what I have seen so far it seems very interesting and could be a great help to patients with inflammatory processes going on.

Inflammation is a common cause of symptoms presented in the clinic. My tutor at BSO clinic Mike Stewart continuously mentions how low grade inflammation can be a maintaining factor for the patients symptoms. Therefore with more knowledge on how to decrease inflammation, especially through nutrition (something Mike Stewart is also keen about), then this would result in a better outcome for my patients and their symptoms.

Mike Stewart presented a slide show during a tutorial on inflammation and its underlying effect on the prevention of full recovery for patients. This linked in nicely to my knew knowledge and research into how nutrition can affect inflammation and possibly reduce the effects of inflammation.

My Contract

These are the goals I was aiming to achieve over the past year as a final year student in osteopathy:

Pre-professional learning goals	Activities and methods	Evidence	Assessment / Evaluation
Applying techniques learnt in functional technique in my treatment to patients in clinic	Attending elective class, practicing with peers, and applying when appropriate the techniques to patients	Continuation sheets highlighting specific techniques, feedback from peers, clinic tutors, blog	Feedback from patients to see if these treatments are more or less effective and self reflection. Feedback clinic assessments, CCA’s, New Patient Clinic, OSPE’s
Applying techniques learnt in obstetrics and osteopathy in my treatment to patients in clinic	Attending elective class, practicing with peers, and applying when appropriate the techniques to patients	Continuation sheets highlighting specific techniques, feedback from peers, clinic tutors, blog	Feedback from patients to see if these treatments are more or less effective and self reflection. Feedback clinic assessments, CCA’s, New Patient Clinic, OSPE’s
Applying techniques learnt in IMS in my treatment to patients in clinic	Attending elective class, practicing with peers, and applying when appropriate the techniques to patients	Continuation sheets highlighting specific techniques, feedback from peers, clinic tutors, blog	Feedback from patients to see if these treatments are more or less effective and self reflection. Feedback clinic assessments, CCA’s, New Patient Clinic, OSPE’s
Sport specific osteopathy, rehabilitation	Attend sport specialist osteopathic clinics	Letter signed by osteopath proving my attendance, blog	Apply to patients involved in sport and see their response and recovery from injury via my treatment
Improve my knowledge of gait mechanics	Attend relevant Manus lectures, read relevant books, discuss with tutors	Blog, obtain signed document showing discussions have taken place	Apply this to patients, see if I can assess their gait and possibly improve my patients gait
Improve my knowledge of nutrition and osteopathy	Attend relevant Manus lectures, courses, read relevant books	Blog, obtain signed document showing discussions have taken place	Apply this to my patients, try and improve their diet, be able to give advice on what to eat to improve their overall health
Get a better understanding into Yoga and Pilates	Attend yoga/pilates classes, talk to instructors	Blog, obtain signed document showing discussions have taken place	Enable to advice patients on whether to go to yoga/pilates, which mode of yoga/pilates is best for them, what to expect at these classes

Pilates and its core relation to osteopathy

As I moved into 3rd year at BSO I found myself promoting pilates as a great way to strengthen my patients core and that in the long run this would benefit my patient who had a weak back.

Another goal I took upon myself to get a better understanding of is the benefits and whether it was appropriate for my patients to take part in pilates. I have currently been attending classes at my local gym and have found them to be very useful and challenging. I also discussed the relationship between pilates and osteopathy with an instructor who was studying at the BSO.

The art is not to do as many repetitions as quickly as possible, but to take the time to ensure each movement is done correctly, whilst maintaining a neutral spine. Another positive aspect regarding pilates is the option to increase the level of difficulty which the teacher will explain whilst carrying out the exercise. Level one is the beginners stage but should you want to challenge yourself you can progress to level two, providing you cover the criteria to progress.

This is a great way to strengthen the core muscles, ensuring you are doing all the exercises with a neutral spine and engaging the core muscles whilst doing any exercise. The slow pace is great for anyone who may be suffering from any injuries and like with yoga, as long as you let the instructor know about any injuries they can accommodate the exercise to suit you.

To yoga or not to yoga...

One of my LPA goals is to learn more about yoga and how to incorporate it with advice for my patients. I have since been taking up yoga, and experiencing different styles of yoga in an effort to see what they offer, and whether they are appropriate for particular patients.

My first ever yoga experience I went to a Vinyasa Flow yoga session, lasting 90 minutes at my gym. This style of yoga is definitely not for beginners, or for those who experience any sort of pain. Very fast moving, and difficult regarding controlling your breathing (which is a big thing in yoga) and moving whilst controlling your breathing. The positions themselves were at times complex.

A few weeks later I tried out Iyengar yoga, which was much more simpler, slower, and easy to get into. Although some of the positions might be difficult, as long as the teacher is aware of your injuries beforehand, you can always adapt.

I managed to arrange a meeting with a yoga instructor, just to get a little more insight on yoga, its principles and if its something I should be encouraging my patients to do.

One form of yoga was developed by a man called Patanjali, who came up with the '8 limbs of yoga'. The aim was to master each limb reaching eventually enlightenment 'Samadhi'. One of the limbs needed to be mastered involved improving on ones flexibility in order to achieve a seated position (Lotus position) which you are meant to remain in, in order to mediate.

The Western world has taken this element of yoga and used it as a tool to sell and focused on the healthy aspect regarding improving ones flexibility.

Generally people practise Hatha Yoga (Hatha is divided into Ha, meaning Sun, and Tha meaning Moon). Subsections of Hatha yoga are Vinyasa (fast pace and relatively high intensity yoga), Bikram (yoga in a room at high temperatures), Iyengar (slow, relaxing, stretching) and Ashtanga (high demand on the body, very active).

With the research I have done, discussing with a yoga instructor and participating myself in different types of yoga I have concluded the following:

> Yoga is good as long as its the correct yoga (Iyengar)
> When giving yoga as advice ensure the patient knows what they're getting themselves into! My experience seemed very spiritual and that threw me a little
> Yoga is advisable for those who need to improve general flexibility
> Yoga is not advisable for those who are flexible already! Hypermobile patients do not need to further improve their range of movement!
> Yoga takes time and as such the patient needs to commit to it and give it a chance.

Applying Functional technique in clinic

One of my goals is to apply the techniques I've learnt in my electives onto patients and seeing if they are effective both to myself and my patient. So far so good! Both times when applying functional technique I felt a positive tissue response and the patient has also reported feeling a positive change. Will have to reassess next week and see how long it holds

Apparently I am good at what I do...

With the permission of a fellow 2nd year BSO Student...

[18:57:45] Emily Stern: just an ego boost for you..random as it is, but i have been hearing ur name being banded around the place a lot lately with students singing ur praise
[18:57:49] Emily Stern: good work!
[18:58:21] Tamir Grant: who have you been talking to?
[18:58:24] Tamir Grant: thats nice!
[18:58:39] Emily Stern: nah, ur name literally just keeps popping up...i think the technical term is...'arghhhhh, he's shit hot... ppl who've seen u, shadowed u

Always nice knowing people have good things to say about you behind your back!

Additionally I was given some good feedback by another student - see scrap of paper attached below!

One Monday morning we carried out an exercises where we all would write something positive about our fellow clinic team mates as we were drawing close to CCA's, this is what was said about me collectively:

New patient clinic

Yesterday morning I experienced new patient clinic (NPC). This involves taking a new patient and having one of your peers observe and make notes about how you were with the patient from general case history taking to treatment and professionalism.


Overall I was happy with my comments and in general agreed with what I needed to work on. I learnt about how to differentiate between a facet, disc and sacro-iliac joint.

This carried on nicely into my obstetrics elective where I further learnt how to differentiate between the three. Looking forward to applying my new knowledge on the next patient that presents with a lower back pain. Wonder how long I'll have to wait for that patient :oP

Leg Length Discrepancies...

Everyone has a leg length discrepancy (LLD) of some sort, whether it be 1 mm or 1 cm. An interesting way to check which leg is shorter was shown to us in our Obstetrics and Osteopathy technique class on Thursday. I later used this in clinic on Friday afternoon and it made life a little easier!

Firstly you have to obtain consent to lower the patients underwear so you can see the gluteal cleft. The cleft will point to the left or the right (unless it points straight up which means your patient does not have a LLD, but like I mentioned earlier, apparently we all have some sort of LLD!). The side which the cleft points to is the shorter leg, therefore if the cleft points to the right, the right leg is shorter. This can further be confirmed by asking the patient to bend their left knee, whilst keeping their heel on the ground, thereby leveling out the pelvis. If the were to bend their right knee you would see the pelvis dip significantly.

The diagram does not show much in way of which leg is shorter, but I thought it would be amusing to have a cleft on show to liven up this blog!

The difficulty that is the ungrateful patient

Let me set the scene. Clinic on a Wednesday PM shift, full list and unlike other days every one of my patients decided to show up, thankfully on time. My last patient is one that does not seem to feel better before, during or after treatment but nevertheless will come back to endure another 40 minutes of treatment which the patient describes as 'pokey' amongst other adjectives. Needless to say I was not looking forward to this patient at the end of the day.

I also had two first year students observing me so I had to not only be on my best behaviour but also so some level of professionalism.

The patient presented with bilateral thoracic outlet syndrome symptoms and seemed to fluctuate between having good days and bad days.

As a student osteopath I feel I need constructive criticism in order to further improve myself as a practitioner, so I can be the best osteopath I can be. But when a patient generally has nothing positive to give you, you start to question yourself and your abilities.

I don't think I am the finished product of a well rounded BSO student, as I have another 8 months to go before I finally qualify. But I definitely think I am better than what this patient perceives me to be! And the full list must mean I am doing something right with my patients (unless you look at it in a negative perspective that they keep coming back because they never get better...).

Having said all of that the patient actually felt better and thanked me for the treatment! Was a great way to end a very long afternoon. And the first years seemed to be impressed too so it was a win-win situation.

My first taste of the electives

Chose Functional technique and Osteopathy and Obstetrics which I am partaking in for this Autumn term and already they have had an effect on my technique when treating patients. We learnt to percuss (tapping?!) the vertebrae to detect a difference in tissue response, and found myself doing that the very next time I was in clinic. Obstetrics also left its mark, opening my mind to the many ways to treat patients rather than just on their back, front or sidelying. Using the 8 finger soft tissue technique too which my patients seem to respond well to. Looking forward to seeing what else will be taught!

East Street Clinic 23/09/11

Good half day in ESC. Saw two interesting patients, one was a 1500m runner who unfortunately was attacked and has since been experiencing pain in her left knee and left shoulder. The other is a semi professional footballer who pulled his hamstring. Working with people like this has further pushed me to realise how much I would love to work with sports personel and athletes.