Therapeutic Case study 7

Case Study 7 Therapeutic skills
With your patient safely positioned on a plinth, demonstrate appropriate massage techniques to reduce oedema of the lower limb.
1. Explain the procedure to the patient
· Hello my name is...and I will be your physiotherapist today, you have been referred to physiotherapy for massage to you right ankle, this will involve lots of light, gentle movements to stimulate you circulation. This should help to reduce the swelling around the joint and hopefully enable better movement
· Are you happy with this to proceed?
2. Question patient about any contraindications
· Before I proceed, I need to check a few things with you
· Have you got high blood pressure? Do you suffer from osteoporosis? Have you got any fungi or bacterial diseases? Has this area been recently fractured? Are you allergic to anything? Is your circulation ok?
· Other contraindications (skin disorders, early bruising, open wounds, varicose veins, DVT, abnormal body temp etc can be visually seen so do not need to be asked about)
3. Collect the relevant equipment
· Dry towels to keep patient modest and wipe area after finish
· Lubricants such as talc, massage oil etc
· Extra pillows to make patient comfortable
· If patient is wearing tracksuit bottoms, as them to remove so wearing shorts
4. Position the patient
· Adjust the bed height so it is comfortable for you (the physio)
· Using pillows, support the patient comfortably
· Expose the right ankle, using towels to protect other leg and top of limb (patients will have to be wearing shorts)
5. Inspect the right ankle
· Visual contraindications
· Do some sensory tests using pin prick and brush on hammer, with the patients eyes closed (show them what to expect by doing it on their hand first, with eyes open)
6. Application
· Position yourself so you are comfortable
· Ask patients if they are comfortable
· Inform them you are going to begin the massage
· Apply you chosen lubricant
· Use long, slow strokes to distribute the lubricant and adjust the patient to your touch
· Begin the massage


Massage techniques
Need to apply soft-tissue techniques; soft-tissue includes muscles, fascia, ligaments, tendons and skin.
Stroking
· Performed with the whole hand, using a rhythmic and constant pressure for long strokes, done in direction of lymphatic and venous flow (proximal to distal)
· Superficial stroke

Effleurage
· A deeper stroke
· Use hands to pass over area with pressure and speed
· It assists fluid to flow through tissue spaces , lymph vessels and veins
· Hands move distal to proximal of limb
Kneading
· Form of petrissage
· Hands are placed onto skin and allowed to mould to the shape of the limb
· Move alternately in a circular direction with pressure applied at the top of the circle, and released towards the bottom of the circle
· Therefore hands are applying alternate pressure and release which increases circulation of area and relaxes any muscle tension
Picking up
· Form of petrissage
· Effects are similar to kneading
· Technique involves picking up (lifting) the tissues and applying a squeeze to the tissue before releasing them
· Like, kneading, it is done in a circular motion with slow, continuous and rhythmic motion
· Grasp of hand on tissue must be soft and supple
Wringing
· Same technique as picking up but a small twisting motion is applied to enhance the effect, this can be achieved by flexing and extending the wrists
· Technique mainly to be used on large loos muscle groups so probably not the ankle area
Skin Rolling
· Involves lifting and stretching the skin between the thumbs and fingers so that the skin and subcutaneous tissue are moved over each other

7. Complete the treatment
· Use towel to remove lubricant and dry the ankle area
· Remove towels from patient
· Assist patient to put on tracksuit bottoms
· Clean up the treatment area

8. Assist treatment efficacy
· Ask patient how they are feeling
· Visually inspect the area for any adverse reactions

9. Treatment is finished!

Teach this patient to use walking sticks (partial weight bearing pattern)
Background-walking sticks can be used to redistribute the transmission of load and for balance.
1. Give the patient information about why they will be given sticks to walk
· “Right, now I’m going to show you the correct way to use walking sticks, these will give you a wider base of support when walking, which makes you more stable and balanced. They will also allow you to put some weight on your affected leg.”
2. Measure the sticks
· Ulnar styloid to the ground with elbow flexed at 15degrees
3. Inform the patient of any maintenance and safety issues
· “You must take extra care when using the sticks on wet ground. Always try to maintain a straight back and look ahead when using them (posture). If the ferrules (rubber bottoms on sticks) get worn away, bring them back to us so we can change them for you.”
4. Demonstrate to the patient the correct way to stand from sitting, and also the correct gait pattern.
· This must include how to turn
· Refer to your own posture and position of imaginary affected leg
· Mention any safety issues
· Gives you the opportunity to clear the area of any obstructions
Partial weight bearing gait pattern-3 and 1
Sit to stand
· From sitting on the edge of the bed, have affected leg outstretched in front
· Have both sticks in arm on side of affected leg (in right hand)
· Use other hand to push yourself up to standing
· Use same hand to reach over and grab one of the sticks
· Position in place to make a triangle

Feet
1 stick
1 stick


Turning
· 1 stick forwards, the other stick backwards, bad leg (put pressure on sticks to take pressure of leg), good leg
Walking
· Using the 3-1 gait pattern
· Standing on good (left) leg, move both sticks forward, then bad leg forward (bad leg in middle of sticks)
Left leg (good leg)
1 stick
1 stick
Right leg (Bad leg)








· Then swing through with left leg to form another triangle, always maintaining that wide base of support ( the faster the gait, the more weight is put on the partial weight bearing limb)
To sit from standing
· Slowly walk backwards until you can feel the chair on the backs of your legs
· Take both sticks in right hand
· Use left hand to lower yourself onto the bed

5. Get patient to go from sitting to standing using the sticks
· Due a final check that the sticks are the correct height
· Make sure the patient understands everything so far, and that they are comfortable and well balanced
· Position a chair at an appropriate distance away from the patient
6. Patient practises gait pattern
· Make sure patient is balanced in standing
· 1 step first
· Then a gait cycle
· Then progress forwards towards the chair
· Stay close to the patient at all times (anticipate the unexpected e.g. a fall)
· Get them to slowly turn
· Get patient to sit down on the chair
· Important to make the patient feel safe at all times, encourage them and let them know if there posture needs to be altered, or of any other mistakes
With an emphasis on pelvic activity (lumbar region of vertebral column and hip joint) analyse the activity of sit to stand
Ask the model to do the movement a few times at normal pace, and then a few times slowly. Then explain to the examiner the four phases which are;
1. Phase 1-Preparation phase-Model is sitting on the chair with legs at right angle to trunk
2. Phase 2-Execution phase (a)- Begins as model initiates flexion of the hips, bringing the trunk forward and finishes when trunk flexion has finished and knee extension is initiated
3. Phase 3-Execution phase (b) - Begins as model initiates knee extension, and hip extension, bringing trunk backwards. It finishes with the end of hip extension
4. Phase 4-End phase-Movement has finished and model is stood up straight

Phase 1
Phase 2
Phase 3
Phase 4
Joint
Hip
Hip
Hip
Hip
Movement
Hip is in flexion
Further flexion
Extension
Hip fully extended
Plane

Sagittal
Sagittal

Axis

Frontal/Coronal
Frontal/Coronl

Angle
Appox 90degrees between trunk and thighs
90degree angle is reduced
Angle is increasing
180degrees between trunk and legs
Muscles
Trunk muscles isometrically contract to maintain a straight back
Abdominals and hip flexors concentrically contract, trunk muscles eccentrically contract
Trunk muscles and gluts concentrically contracting to pull trunk back
Hip extensors extend the hip
Slight concentric contraction of quads and trunk muscles and neck muscles to maintain a straight back
Base of Support
Large-chair and legs with feet on floor
Remains large as bum is still on seat at this point
Decreased as bum is off seat
Smaller
Centre of Gravity
At the hips
Outside of body as trunk moves forward
Outside of body
Within body
Line of Gravity
Within your body (Stable position)
Outside the body-Body is less stable
Outside of body-Body is unstable
Within body-anterior to body of 2nd sacral vertebrae-body is stable
Forces
Gravity-always present
Friction between bum and seat, and feet on floor
Greater effect of gravity-assistand downward motion of trunk
Gravity resisting upwards motion-reduced impact of friction with bum off seat
Gravity and friction between feet and floor

Hip flexors
· Sartorius,
· Pectineus
· rectus femoris
· psoas major
· iloiacus
Hip extensors
· Gluteus maximus
· Semitendinosis
· Semimembranosis
· Biceps Femoris
Trunk Muscles
· Erecta spinae
· Spinalis thoracis
· Iliocostalis lamborum
· Logissimus thoracis
Abdominals
· Rectus abdominis
· Internal obliques
· External obliques
· Aponeurosis
Gluts
· Gluteus maximus
· Gluteus medius
· Gluteus minimis
You can describe each phase in full, or describe each section for each phase, then move onto the next section. Remember to walk around and observe the models movements.