case study example physiotherapy

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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Case Studies

View the material in each Case Study and then complete the Quiz at the end to test your knowledge!

Paediatrics, Men’s & Women’s Health Case Studies

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In this section

• Blended student placements from FCP to secondary care

Primary care colleagues explain the value of FCP, Gloucestershire

• A GP's perspective on FCP
• An integrated approach to FCP
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First contact physiotherapy case studies

To support members who are considering implementing first contact physiotherapy (FCP) or are in the early stages of doing so, the CSP is collating case studies to showcase different approaches.

The people and services featured have kindly agreed to share their experiences and insight for others to learn from.

We hope the case studies will inspire and educate members by highlighting positive examples of best practice, different methods of embedding FCP, and how they are applicable to varied environments and demographics.  

This video highlights why first contact physiotherapy is a welcome addition to the primary care network, benefiting staff and patients and resulting in positive feedback.

Blended student placements from FCP to secondary care, Surrey

Sylvia Wojciechowski, from Frimley Health NHS Foundation Trust, explains how she championed placements showing the whole care pathway, from FCP to secondary care.

An integrated approach, East Sussex

Matthew Carr from Sussex MSK Partnership East explains how FCP is enabling a joined-up pathway of care for patients.

An FCP hub model, Derbyshire

An FCP hub model is giving patients convenient access to services while also ensuring integration, says Susan Buckley from Derbyshire Community Health Services.

FCP in a rural setting, North Wales

An integrated approach to FCP is enabling patients from rural areas to access the service via their local GP, says Robert Caine from Betsi Cadwaladr University Health Board.

Embedding FCPs within primary care networks, London

Kingston's model involves PCNs directly employing first contact physiotherapists who are mentored by both a GP and an FCP lead who quality assures their work.

A GP's perspective on FCP, Aylesbury

Dr Graham Jackson explains that including an FCP in a multidisciplinary team ensures patients can get access to physio referrals and advice quickly.

• Research Reviews
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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.

Don’t forget to share this blog!

Leave a comment (3).

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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Case studies in respiratory physiotherapy

CHAPTER FIVE Case studies in respiratory physiotherapy Lead author Janis Harvey, with contributions from Sarah Ridley, Jo Oag, Elaine Dhouieb, Billie Hurst Case study 1: Respiratory Medicine – Bronchiectasis Out-patient 34 Case study 2: Respiratory Medicine – Lung Cancer Patient 36 Case study 3: Respiratory Medicine – Cystic Fibrosis Patient 38 Case study 4: Respiratory Medicine – COPD Patient 41 Case study 5: Surgical Respiratory – Anterior Resection 43 Case study 6: Surgical Respiratory – Division of Adhesions 44 Case study 7: Surgical Respiratory – Hemicolectomy 46 Case study 8: Surgical Respiratory – Bowel Resection 48 Case study 9: Intensive Care – Patient for Extubation 50 Case study 10: Intensive Care – Surgical Patient 51 Case study 11: Intensive Care – Medical Patient 52 Case study 12: Intensive Care – Patient Mobilisation 54 Case study 13: Cardiothoracic Surgery – Self Ventilating Patient 55 Case study 14: Cardiothoracic Surgery – Intensive Care Patient 57 Case study 15: Paediatric Respiratory Care – Medical Patient 59 Case study 16: Paediatric Respiratory Care – Intensive Care Patient 61 Introduction The area of respiratory physiotherapy reaches a number of patient groups, both in the in-patient and out-patient settings. The case studies that follow are based predominantly in the in-patient environment; however, the components of a respiratory assessment and the subsequent identification of physiotherapy problems and treatment plan could be applied to any patient with respiratory compromise in any clinical setting. Like all other areas of physiotherapy practice, respiratory physiotherapy involves accurate patient assessment in order to identify patient problems. Respiratory assessment should include certain key elements: general observations of the patient; consideration of trends in physiological observations (e.g. HR, BP, oxygen saturations); patient position; auscultation, palpation and, where available, analysis of arterial blood gases and chest X-ray (CXR). Patient problems identified from the assessment generally fall into three main categories: loss of lung volume, secretion retention and increased work of breathing. The extent of any resulting respiratory compromise can vary greatly between patients and may not always be reflected by the ward area in which the patient is being treated. On occasion the most acutely unwell patients are in the general ward areas and not within critical care as expected. A problem-orientated treatment plan may include a combination of a number of interventions such as mobilisation, positioning, breathing techniques (e.g. ACBT, AD), manual techniques (percussion, vibrations), mechanical aids (e.g. IPPB, CPAP) or more invasive measures (e.g. airway suctioning). A respiratory assessment is mainly indicated for patients who have undergone surgery, those with medical respiratory conditions, e.g. exacerbation of COPD, and those requiring critical care. Cardiothoracic surgery and paediatrics are other specialist clinical areas that physiotherapists are involved in providing respiratory care. However, it must be remembered that patients requiring such care may not be in these ward areas exclusively. Physiotherapists working in any clinical area may be required to undertake a respiratory assessment and provide respiratory care. For example, assessment of a stroke patient who has aspirated or an oncology patient who develops respiratory failure following chemotherapy. It is important, therefore, that all physiotherapists are familiar with respiratory assessment and intervention. Another key area of work where physiotherapists are required to undertake respiratory care is in the provision of emergency duty/on-call services. Such services are available to patients who have a condition amenable to physiotherapy, which has either deteriorated or is likely to deteriorate without intervention before daytime service resumes ( Scottish Intercollegiate Guideline Network 2004 ). This can be a very challenging area of work for the physiotherapist on-call, who needs to think clearly while being faced with an acutely unwell patient who is in need of their attention, whatever the time of day. Guidance is available to support the clinician involved in providing such care and to aid ongoing assessment of competence ( Chartered Society of Physiotherapy 2002 ). CASE STUDY 1 Respiratory medicine – bronchiectasis out-patient Subjective assessment PC 35-year-old female Attending routine multidisciplinary bronchiectasis clinic appointment HPC Diagnosed 6/12 ago with bronchiectasis following an in-patient admission with community-acquired pneumonia (CAP) in her right lower lobe. This resulted in the development of bronchiectatic changes. Since diagnosis the patient reports daily production of mucopurulent secretions with excessive coughing and feelings of fatigue PMH CAP Gastric oesophageal reflux SH Married with two children Lifelong non-smoker Full-time employment as drug company representative, involving frequent travel around the United Kingdom Normally leads an active lifestyle with two to three visits a week to the gym, although this has decreased over the past 3/12 DH Omeprazole Consultant handover Patient is currently stable but is concerned about the impact of her cough and increased sputum on everyday life, especially in relation to her work, where she frequently does formal presentations Objective assessment Respiratory Ventilation SV room air SpO 2 99% RR 12 CXR Bronchiectatic changes present in right lower lobe ABG Not appropriate to be taken as stable CVS Temp 37°C HR 70 BP 120/70 CNS Nil of note Renal Nil of note MSK Nil of note Microbiology Staphylococcus aureus in sputum sample 6/12 ago Patient position Sitting in chair Observation Looks well, good colour, breathing pattern normal Patient actively trying to suppress cough and noise of secretions Auscultation Breath sounds throughout both lung fields with mid inspiratory crackles right lower lobe Questions 1. You feel this lady seems a little vague regarding her diagnosis, how will you deal with this issue? 2. Following discussion it is now evident that the patient’s knowledge about her condition is sparse. How will you resolve this issue? 3. What is the range of airway clearance techniques commonly taught to this group of patients? 4. Considering this patient’s condition and lifestyle what would be the advantages and disadvantages to each of the treatments mentioned in the previous question? 5. Your patient seems reluctant to undertake airway clearance management, how will you motivate your patient to undertake regular treatment? 6. What frequency and duration may you suggest to this patient for performing airway clearance techniques? 7. What signs and symptoms would you highlight to your patient to recognize at the start of an exacerbation? 8. Your patient asks what she should do if she has an exacerbation, what advice do you give her? 9. Why would you consider asking this patient if she has any urinary stress incontinence problems? CASE STUDY 2 Respiratory medicine – lung cancer patient Subjective assessment PC 70-year-old male Non-small-cell lung cancer (NSCLC) in the right main bronchus Admitted with an acute deterioration in condition and the family are no longer able to cope with the patient at home HPC Diagnosed 9/12 ago following a 3/12 history of increasing shortness of breath and cough. Two episodes of frank haemoptysis also reported. Following diagnosis, patient was deemed appropriate for a course of chemotherapy, but had limited response to intervention. As an out-patient he had a CT scan, which showed brain and spinal metastases, and he has been suffering uncontrollable pain. As a result he has been bed bound for the past month and has required increasing support from Macmillan oncology nurse specialists PMH Nil of note SH Lives with wife in a bungalow Smokes 40 cpd Retired teacher Close family network Until 2/12 ago independent with walking stick, able to walk to local shops approximately 100 m DH Paracetamol Co-codamol Oramorph Lactulose Build up drinks Handover Patient admitted with a decreased GCS, frail, emaciated Family very concerned, emotional and distressed by patient’s breathing pattern and audible secretions Pain management sub-optimal Objective assessment Respiratory Ventilation SV 4L O 2 via non-venturi system mask, unhumidified SpO 2 95% RR 10–22 CXR No CXR taken on admission Previous CXR (1/12 ago): white out of right lung field, secondary to bronchus obstruction ABG None available CVS Temp 39°C HR 120 BP 105/65 CNS GCS fluctuating between 5 and 8 Renal Catheterised on admission MSK Pain at lower back region in keeping with spinal metastases Microbiology None Patient position Supine Observation Flushed, drowsy, intelligible speech with audible secretions. Agitated at times, with arms flailing and pulling at oxygen mask Normal chest shape with altered breathing pattern illustrated by Cheyne–Stoking Auscultation Breath sounds diminished throughout right lung field with widespread coarse inspiratory/expiratory crackles transmitting throughout left lung field Palpation Decreased chest excursion on right with palpable secretions over trachea and left apex Questions 1. How would you describe Cheyne–Stoking? 2. If a patient is performing a Cheyne–Stoke breathing pattern, what does this indicate? 3. Prior to assessing and treating this patient, what further information do you require? 4. What are the main physiotherapy problems? 5. What are the associated problems for this patient that may affect your physiotherapy intervention? 6. How will you treat the problems that you have highlighted? 7. What outcome measures will you use to evaluate the effectiveness of your intervention? 8. In this scenario, which medical and physiotherapy interventions are inappropriate and why? 9. What do you see as the role of the palliative care team in this scenario? CASE STUDY 3 Respiratory medicine – cystic fibrosis patient Subjective assessment PC 19-year-old female Admitted with acute exacerbation of cystic fibrosis (CF) HPC Diagnosed at birth. Multiple hospital admissions over last 3 years due to exacerbation of CF. On admission patient reporting 1/52 history of increased breathlessness, sputum volume and cough. These symptoms have not responded to a 2/52 course of intravenous antibiotics. In respiratory distress. Dehydrated. Recent weight loss and current BMI 17. Under review for lung transplantation assessment. Patient previously agreed to perform twice daily ACBT in alternate side lying/supine for 20 minutes, but generally non-compliant with suggested airway clearance programme and prescribed medications PMH Asthma Osteoporosis SH Lives at home with parents and sister (non-CF) Unemployed and sedentary lifestyle due to health status DH Ventolin via nebuliser Becotide via inhaler Dnase via nebuliser Colomycin via nebuliser Azithromycin Creon Alendronate Vitamins A, D, E, K Long-term oxygen therapy Handover Patient exhausted and only able to clear small amounts of very thick, purulent bronchial secretions with difficulty. Pyrexial and requiring intravenous fluids. C/O nausea following overnight feed via PEG tube Objective assessment Respiratory Ventilation SV 28% O 2 via venturi system mask SpO 2 85% RR 34 CXR ( Figure 5.1 ) Hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally Intravenous access device in situ Figure 5.1 X-ray for Case Study 3 showing hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally. Intravenous access device in situ . ABG H + 50 nmol/L pCO 2 13 kPa pO 2 7 kPa HCO 3 − 30 mmol/L BE −9.0 CVS Temp 38.5°C HR 129 BP 100/85 CNS Nil of note Renal Nil of note MSK Kyphotic with history of osteoporosis Microbiology Pseudomonas in sputum Patient position Sitting upright in bed holding onto cot sides Observation Pale with signs of central cyanosis. Unable to speak due to SOB and excessive cough. Looks distressed. Breathing pattern shallow, apical with active expiration Auscultation Coarse inspiratory crackles transmitting throughout chest on background of high-pitched expiratory wheeze Palpation Limited chest excursion on inspiration (right = left) Secretions palpable upper, anterior chest wall Questions 1. Considering the above information, list this patient’s physiotherapy problems. 2. What information from the objective assessment led you to this problem list? 3. What does the ABG result tell you? 4. What are the specific signs of hyperinflation on this patient’s X-ray ( Figure 5.1 )? 5. During this admission, how might you initially modify this patient’s normal daily routine of alternate side lying and ACBT for 20 minutes twice a day? 6. Having decided on an acceptable airway clearance technique, what else would you include in your initial treatment plan? 7. Following two physiotherapy sessions with modified ACBT that morning, you feel that the patient is becoming more exhausted and unable to clear her secretions effectively. How might you change your physiotherapy management and with whom would you want to discuss these potential changes? 8. How might your treatment/management change if your patient was commenced on NIV? 9. Why would it be inappropriate to introduce activity/exercise at this stage? CASE STUDY 4 Respiratory medicine – copd patient Subjective assessment PC 65-year-old male Admitted to respiratory ward with acute exacerbation of COPD HPC Diagnosed 5 years ago with severe emphysema. Recent viral illness that has resulted in a dry cough, wheeze and breathlessness for 1/52. Has been house bound last few days. Normally 1–2 exacerbations per year that are managed by GP. No previous hospital admissions for COPD PMH Hypertension SH Retired engineer. Lives alone in third-floor flat. No lift. Normally manages all ADL independently. Exercise tolerance 50 m on flat – no aid required. Drives a car. No family living locally. No social services required. Smokes 30 cpd DH Salbutamol inhaler Becotide inhaler Atenolol GP letter states that patient has not picked up repeat prescription for inhalers from 1/12 ago Handover Admitted overnight. Patient noted to be drowsy but able to be roused for short periods. When awake, able to talk in short sentences but appears slightly disorientated. Breathing pattern laboured and has a dry, spontaneous cough. Dehydrated but receiving IV fluids Objective assessment Respiratory Ventilation SV 6 L O 2 via a simple face mask SpO 2 97% RR 9 CXR Hyperinflated lung fields with flattened diaphragms Emphysematous bullae upper zones No focal signs of collapse/consolidation ABG H + 58 mmol/L pCO 2 12 kPa pO 2 12 kPa HCO 3 − 30 mmol/L BE +9 CVS Temp 37.5°C HR 115 BP 130/90 CNS Drowsy but able to be roused for short periods Disorientated and confused. Moving all four limbs Renal Nil of note MSK Nil of note Microbiology None available Patient position Slumped lying in bed Observation Obese man with barrel shaped chest and large abdomen. Colour – flushed. Breathing through an open mouth. Predominately a shallow, apical breathing pattern with increased use of accessory muscles. Also demonstrating in-drawing of his lower chest wall on inspiration. Active expiration Auscultation Quiet BS generally with end expiratory polyphonic wheeze throughout Palpation Decreased expansion bi-basally (right = left). No palpable secretions Questions 1. The patient is drowsy with a RR of 9. What may be the contributing factors? 2. What is the difference between fixed and variable oxygen therapy? 3. Which type of oxygen therapy would be more suitable for the patient at this point? 4. What is this patient’s main physiotherapy problem? 5. What led you to this conclusion? 6. What factors may be contributing to this increased WOB? 7. How might your initial treatment plan address this problem of increased WOB? 8. Consider this patient’s CXR report, chest shape and breathing pattern. Would he benefit from lower lateral costal breathing exercises to improve basal chest excursion once he was less drowsy? 9. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 5 Surgical respiratory – anterior resection Subjective assessment PC 63-year-old male Day 2 post-laparotomy for anterior resection (end to end anastomosis) HPC Emergency admission yesterday with increasing abdominal pain 2/12 altered bowel habit PMH Nil of note- previously fit and well SH Lives with wife, recently retired, independent with ADL, plays golf three times a week, smoker 5 cpd DH Nil of note Handover Acute desaturation this morning. Patient has been coughing – effective and occasionally moist, nil expectorated. Otherwise stable Not been out of bed as yet Objective assessment Respiratory Ventilation SV 4 L O 2 via nasal cannulae SpO 2 90% RR 12 CXR Right basal collapse ABG None available CVS Temp 37.4°C HR 80 BP 130/60 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 4/10 on movement/coughing Morphine PCA Renal UO 20–30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Talking freely Auscultation Breath sounds throughout, fine end inspiratory crackles right base Palpation Reduced expansion right base, no secretions palpable Questions 1. Is this patient adequately oxygenated? What suggestions might you make? 2. List this patient’s physiotherapy problem(s). 3. What information from the objective assessment led you to this problem list? 4. Why are patients who have undergone surgery/anaesthetic at risk of developing respiratory compromise? 5. What are the treatment options for this patient? 6. What would your initial treatment plan include? 7. How would you progress this patient? 8. HDU patients can have many attachments including monitoring (ECG, sats probe), oxygen therapy, catheter and wound drains. What considerations would you have to give before mobilising such a patient? CASE STUDY 6 Surgical respiratory – division of adhesions Subjective assessment PC 74-year-old female Day 3 post-laparotomy and division of adhesions HPC Existing ileostomy – no output for 48 hours, vomiting and no significant fluid intake PMH Small bowel resection and formation of ileostomy 2 years previous for incarcerated hernia COPD Right axillary node clearance Previous pulmonary TB SH Lives alone, housebound, home help three times/day, smokes 10 cpd DH Ventolin inhaler Seretide inhaler Handover Initially in intensive care, intubated and ventilated. Extubated yesterday and transferred to HDU. Stable overnight, difficulty clearing secretions Objective assessment Respiratory Ventilation SV FiO 2 0.28 via face mask cold humidification RR16 SpO 2 89% CXR – taken prior to extubation ( Figure 5.2 ) Scoliosis, rotated, hyperinflated, nil focal Figure 5.2 X-ray for Case Study 6 taken prior to extubation showing the patient has a scolosis with hyperinflated lungs and nil focal in lung fields. ABG H + 36.35 nmol/L pCO 2 5.91 kPa pO 2 7.42 kPa HCO 3 − 28.2 mmol/L BE + 4.7 CVS Temp 36.5°C HR 85 BP 110/50 Noradrenaline 8 mL/hr CNS GCS E4 V5 M6 Pain score VAS 3/10 at rest 8/10 on movement/coughing Morphine PCA Renal UO 50 mL/hr +3.2 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Sitting upright in bed, frail Observation Hyperinflated chest, looks well, chatting freely, dry mouth Auscultation Breath sounds throughout, coarse expiratory crackles throughout Palpation Expansion equal, palpable secretions bilateral upper zones Questions 1. Describe the advantages and disadvantages of patient-controlled analgesia (PCA). 2. Considering this patient’s CXR ( Figure 5.2 ), what additional hardware/monitoring is visible? 3. List this patient’s physiotherapy problem(s). 4. What information from the assessment led you to this problem list? 5. From the assessment information, what suggestions should the physiotherapist make before physiotherapy care commences? 6. What would be your initial treatment plan? 7. Given this patient’s present condition and past history, how might you need to modify the treatments delivered? 8. How would you know if your treatment had been effective (outcome measures)? 9. If the initial treatment plan were to be unsuccessful in clearing secretions, how would you modify your treatment? CASE STUDY 7 Surgical respiratory – hemicolectomy Subjective assessment PC 55-year-old male Day 2 post laparotomy for right hemicolectomy (end to end anastomosis) HPC Elective admission for bowel resection – investigated 6/12 ago due to altered bowel habit and weight loss. Tumour identified and biopsy taken during colonoscopy PMH Nil of note SH Lives alone, independent with ADL, non-smoker DH Nil of note Handover Acute desaturation this morning requiring increased FiO 2 , not been out of bed as yet due to reduced blood pressure, otherwise stable Objective assessment Respiratory Ventilation SV FiO 2 0.6 via face mask cold humidification RR 12 SpO 2 96% CXR Left lower lobe collapse ABG None available CVS Temp 37.4°C HR 80 BP 80/45 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 3/10 on movement/coughing Epidural analgesia (Bupivacaine and Morphine mix) Renal UO 30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Looks well, talking freely Auscultation Breath sounds throughout, reduced at left base Palpation Reduced expansion left base, no secretions palpable Questions 1. What does the procedure of a right hemicolectomy involve? 2. Why can the presence of an epidural lead to hypotension? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. What would be your initial treatment plan? 6. After identifying an appropriate treatment plan, what information/instructions would you handover to the nursing staff caring for the patient? 7. How would you determine if your treatment plan had been effective (outcome measures)? 8. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 8 Surgical respiratory – bowel resection Subjective assessment PC 80-year-old male Day 3 post-laparotomy for bowel resection HPC Presented to A&E with painful distended abdomen. Bowels not opened for 2/7 previous. Distended loops of bowel and sigmoid volvulus on AXR. Attempted decompression by colonoscopy unsuccessful therefore proceeded to theatre for open procedure PMH Hypertension SH Lives with wife, independently mobile DH Atenolol Handover Patient confused and drowsy since return from theatre. Has a moist, ineffective cough that is not productive Objective assessment Respiratory Ventilation SV 2L O 2 via nasal cannulae RR 17 SpO 2 94% CXR ( Figure 5.3 ) Reduced lung volume bibasally Figure 5.3 X-ray for Case Study 8 showing reduced lung volume bi-basally. ABG H + 49.8 nmol/L pCO 2 4.87 kPa pO 2 10.16 kPa HCO 3 − 18.0 mmol/L BE –8 CVS Temp 37°C HR 100 BP 160/70 CVP +9 CNS GCS E3 V4 M5 Pain score – unable to score reliably Renal UO 35 mL/hr +6 L cumulative fluid balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Drowsy, audible added sounds at mouth Auscultation Breath sounds throughout reduced bibasally, expiratory crackles upper zones Palpation Expansion equally reduced bilaterally, no secretions palpable Questions 1. Explain the patient’s drug history in relation to the past medical history. 2. Why do post-operative patients tend to have a significant positive fluid balance? 3. Why is metabolic acidosis a common finding when analysing the ABG of a post-operative patient? 4. List this patient’s physiotherapy problem(s). 5. What information from the objective assessment led you to this problem list? 6. Systematically analysing this patient’s CXR ( Figure 5.3 ), what signs do you find that would confirm bibasal loss of lung volume? 7. What would be your initial treatment plan? 8. What could be suggested as a management strategy if the patient required regular suctioning and why? CASE STUDY 9 Intensive care – patient for extubation Subjective assessment PC 55-year-old female Day 7 post-laparotomy for subtotoal colectomy and extensive bowel resection, formation of ileostomy HPC Emergency admission from A&E in shock with reduced BP, abdominal pain Unwell for 3–4 days, intermittent diarrhoea and vomiting Theatre findings – patchy infarction of small and large bowel PMH Hypertension SH Lives with son, 10 cpd smoker DH Bisoprolol Handover Stable overnight Possibly for extubation. Just weaned to ASB from SIMV Objective assessment Respiratory Ventilation ASB (PEEP 5 PS 5) ETT size 7.0 FiO 2 0.35 RR 19 Tv 0.46 L SpO 2 97% M1 secretions CXR Nil focal ABG H + 39.7 nmol/L pCO 2 5.06 kPa pO 2 14.15 kPa HCO 3 − 23.1 mmol/L BE –1.5 CVS Temp 38.6°C HR 135 BP 169/88 CVP +11 CNS GCS E3 VT M4 Propofol 10 mL/hr Alfentanil 2 mL/hr Renal UO 50 mL/hr overall +500 mL MSK Nil of note Microbiology Sputum and urine – no growth Patient position Head-up tilt in bed Observation Intubated and ventilated, settled, relaxed breathing pattern Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. Define and explain the difference between SIMV and ASB modes of ventilation. 2. What would you look for in a patient assessment that might indicate to you a patient is ready for extubation? 3. The Glasgow Coma Scale (GCS) is used to assess level of consciousness. What are the components of the scoring system? 4. On assessment this patient GCS is E3 VT M5. What is the patient ‘doing’ and what are the implications of this for the patient with regard to readiness to extubate? 5. List this patient’s physiotherapy problem(s). 6. What information from the objective assessment led you to this problem list? 7. What would be your initial treatment plan? 8. How would you assess as to whether the deep breaths the patient was attempting to take were effective? CASE STUDY 10 Intensive care – surgical patient Subjective assessment PC 51-year-old female Day 1 post laparotomy – drainage of pelvic abscess and over sew of serosal tears HPC Admitted previous day with abdominal pain and distension. CT revealed free gas, fluid and faeces in the abdomen and a pelvic collection PMH Ischaemic colitis Hartmans procedure 1 year ago SH Lives with husband Independent with all ADL DH Nil Handover Problems with cuff leak on repositioning. Aiming to place NG tube then reduce sedation Objective assessment Respiratory Ventilation SIMV ETT size 7.0 FiO 2 0.35 PEEP 5 PS 10 Tv 0.419 L RR 14 SpO 2 92% HMEF brown secretions CXR Nil focal ABG H + 52.19 nmol/L pCO 2 4.6 kPa pO 2 10.96 kPa HCO 3 − 16.6 mmol/L BE –9.8 CVS Temp 36.5°C HR 100 BP 140/90 CVP +10 CNS GCS E3 VT M5 Propofol 7 mL/hr Alfentanil 2 mL/hr Renal UO 35 mL/hr +2.5 L cumulative balance MSK Nil of note Microbiology Nil of note Patient position Head-up tilt in bed Observation Intubated, ventilated, settled Auscultation Breath sounds throughout, coarse expiratory crackles right upper/middle zones Palpation Expansion equal, palpable secretions right upper zone Questions 1. Analyse the ABG presented. 2. On handover the presence of a cuff leak has been highlighted. What is the significance of this information? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. Positioning is integral to all respiratory physiotherapeutic input. Which position would you choose for this patient and why? 6. What would be your initial treatment plan? 7. If your initial treatment was unsuccessful in clearing the secretions, how might you modify your treatment? 8. What are the potential hazards associated with endotracheal suctioning? CASE STUDY 11 Intensive care – medical patient Subjective assessment PC 72-year-old male Bilateral pneumonia and sepsis, 4 hours post ICU admission HPC Presented to Acute Receiving Unit today. Poor oral intake for 1/52 – dehydrated and weak PMH Mild learning difficulties, irritable bowel syndrome SH Lives with partner, home help twice a week, otherwise independent DH Nil of note Handover Stable since admission; plan to keep sedated for at least 24 hours Objective assessment Respiratory Ventilation Uncut ETT size 8.0 SIMV FiO 2 0.65 PEEP 10 SpO 2 96% RR 25/0 mandatory/spontaneous Tv 0.55 L nil-M1 secretions CXR Collapse consolidation left lower zone, patchy changes right middle zone ABG H + 53.8 nmol/L pCO 2 6.9 kPa pO 2 10.7 kPa HCO 3 − 24 mmol/L BE –1.2 CVS Temp 38°C HR 90 BP 95/55 CVP +12 Noradrenaline 26 mL/hr CNS Pupils 2+ 2+ GCS E2 VT M4 Sedation – Propofol 10 mL/hr, Alfentanil 2 mL/hr Renal UO 30+ mL/hr +1 L balance MSK Nil of note Microbiology No result as yet, commenced on broad-spectrum antibiotics Patient position Head-up tilt in bed Observation Intubated, ventilated, sedated Auscultation Breath sounds throughout, bronchial breathing left lower zone Palpation Reduced expansion left base, no secretions palpable Questions 1. The patient is septic. What information from the objective assessment indicates this? 2. Analyse the ABG presented. 3. Describe bronchial breathing. 4. List this patient’s physiotherapy problems(s). 5. What information from the objective assessment led you to this problem list? 6. What could be your initial treatment plan for each of these problems? 7. Clinically reason through whether MHI would be appropriate for this patient. 8. What would be your short-term goals for this patient? CASE STUDY 12 Intensive care – patient mobilisation Subjective assessment PC 50-year-old male Community-acquired pneumonia Day 41 in ICU HPC Admitted via A&E drowsy, sweaty and ‘unwell’. Quickly deteriorated with respiratory failure, requiring intubation and ventilation Complicated ICU stay with ARDS and two failed extubations PMH Alcohol excess (½ bottle vodka a day) Previous IV drug abuser Previous ICU admission with pneumonia SH Lives alone, first floor flat DH Nil of note Handover Been on CPAP overnight via tracheostomy, now on speaking valve Patient is keen to mobilise Objective assessment Respiratory Ventilation Trache size 8.0 (with inner tube, non-fenestrated) Speaking valve in situ. 2 L O 2 SpO 2 96% RR 20 MP2 secretions on suction CXR No recent ABG H + 39.42 nmol/L pCO 2 5.34 kPa pO 2 11.5 kPa HCO 3 − 24.1 mmol/L BE –0.2 CVS Temp 36.5°C HR 80 BP 140/80 CNS GCS E4 V5 M6 Renal UO 100 mL/hr overall negative balance MSK Nil of note Microbiology MRSA +ve in sputum Patient position High sitting in bed Observation Looks well, strong clear voice Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. This patient developed ARDS due to severe pneumonia. What is ARDS? 2. This patient failed two attempts at extubation and so had a tracheostomy inserted to facilitate weaning. What other indications are there for tracheostomy tube insertion?

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Case Studies

Please find here a selection of cases we have assessed and treated. We hope this gives you a little more detail and understanding of what we do and how we do it.

Rib pain, Covid 19 / Coronavirus

Rib pain is common following coughing fits. The huge amount of coughing some experience with Covid 19 can lead to rib joint dysfunctions and persistent pain. This patient was in her 40’s and had previously been fit and well, a regular Pilates class attendee and an occasional jogger. Covid 19 knocked her flat. For several weeks she was bedridden, coughing constantly and feeling dreadful. Slowly over 4 weeks, the symptoms reduced and…

Covid 19 Corona Recovery

Each of us will recover at different paces and involve different strategies. If you have spent time in bed or hospital you will be much weaker and less fit than you were. You typically start to lose fitness after a few days of no activity so this has to be taken into consideration. You will find everyday jobs tiring as you didn’t before. Simple things like stairs or just short walks will…

Finger fracture

A rugby player fractured his ring finger whilst making a tackle. The fracture was re-aligned at Accident and Emergency and was splinted for a few weeks. When the splint was removed, he had stiffness and swelling in the finger and was unable to use his hand. He was a self-employed plumber and therefore needed to have a good strong grip. On the assessment of his hand,  it was established that the fracture…

Distal radius fracture (wrist fracture)

A 40-year-old gentleman fell off a ladder backwards onto his right wrist and fractured his distal radius. He is right-handed and works as a carpenter. After a period of immobilisation in a cast, his wrist and hand were very stiff and weak. He was unable to do his job and was concerned as he was self-employed. He presented with very limited movement in his fingers, thumb and wrist and with persistent sub-acute…

Boutonniere deformity of ring finger

This patient was in his late 20’s and presented with a right ring finger stuck in a flexed posture. He had a rugby injury 6 months ago when his finger was caught in someone’s jersey. At the time he thought it was just a sprain so he did not seek medical advice. However, over time he was unable to straighten the finger and it developed a deformity of flexion at the PIPJ…

Thumb arthritis

A 65-year-old lady presented with chronic pain at the base of her right thumb which she described as a constant dull ache and loss of power in her hand. She loves gardening and cooking, however, the pain in her thumb was increasingly interfering with her ability to use her hands. She has tried a variety of pain medication which has not had much effect. She saw her GP and after investigations (x-ray),…

Coronavirus, Ribs and Breathing

Ribs and Breathing If you are recovering from illness or struggling with breathlessness, or even fear, anxiety or panic, learning some simple breathing techniques can really help. It is essential to keep good lung function and breathing patterns to ventilate all the lung to reduce infection by mobilising and clearing the whole of the lung of fluids. Your lungs sit within the protective cage of your ribs, with the diaphragm – the…

Foot Stress Fracture in a Runner

Running involves a lot of aches and pains and it is hard to work out what to be worried about and what not to be. However, the dreaded ache at rest, in a bony area, such as the foot is when alarm bells go off. This club runner, ‘Jess’, had been running well for a few months with nothing more than a bit of soreness on the inside of her left shin…

Shoulder surgery, a personal view

I am Mark Buckingham, one of the Physiotherapists at WPB, and on the 1st April 2019, I had surgery on my left shoulder. The shoulder had been troublesome for over a year, with pain on lifting and overhead work such as gym, throwing or hedge cutting. There was no incident or trauma, just a build-up. Like all of us, I initially ignored it, but then it became more painful, especially after gym…

Golfer’s back pain screening

A 55-year-old gentleman presented for a golf-specific screening to help his assess for any movement issues that could be addressed to help reduce the risk of injury. He explained to me that he played off a handicap of 15 and has experienced some ongoing lower back pain on the left-hand side. He was a right-handed golfer. The pain was intermittent and would come and go but he was more aware of it…

Persistent low back pain

A 48-year-old gentleman presented to our clinic with a long history of low back pain. The pain started after lifting incident at work three years previously. Initially, he had very severe pain in his back and some pain into his right leg and he had to take time off work. He underwent a course of chiropractic and physiotherapy care, local to him, which made some small improvements however his pain remained and…

Low energy / RED-S

Elite middle distance runner – low energy availability and symptoms of RED-S by Cara Sloss Presentation: Female, 22 years, 1.65m, 47kg National level athlete – competing distances 1500m – 5km Moved to university in the past year Training load increased from 55miles – 70miles per week also started strength and conditioning twice a week. Has a supportive coach and this mileage increase was done gradually. Living in a shared house, previously living…

Nutrition through injury

Example based on a female, 46 years, 1.70m, 62kg Club level runner, regularly competing in road, cross country and fell races (up to marathon distance) Trains with a club 2x per week and have weekly mileage of around 50 miles per week Has always thought she has a good knowledge of nutrition and fuelling for her longer races Has a chronic ankle injury which she now requires surgery on which will mean…

Marathon Nutrition

Disclaimer: Case study examples are highly specific to the individual, goals set may not be right for anyone else, even if the presentation sounds similar to you. Individualised nutrition assessment is key! Athlete preparing for Marathon by Cara Sloss Presentation: Male, 49yrs, 86kg, 1.86m Has ‘good for age’ place in London Marathon Works in an office and commutes 1hr each way to work Lives at home with his wife and pre-school children…

Osteoporosis & Fracture

A 55- year old lady injured the middle of her back (thoracic spine) when she had lifted a heavy suitcase down from the garage roof to the floor. At the time she felt a severe and very sharp pain in the middle of her thoracic spine. A few days later she came in for a physio assessment. She described “deep vice like constant pain” in the middle of the spine radiating around…

Bad back and sciatica

This patient was late 30’s with a desk job but tried his best to keep fit with trips to the gym a couple of times a week. This was hard because of the kids and the increasing demands on his time. He knew that his back was tightening up for several months and simple things like putting his socks on were harder as he just didn’t bend well. The issue came just after…

Hernia in a footballer

This patient played Sunday league football and due to a limited training regime was perhaps not as conditioned as he might have been for the enthusiasm he brought to the game. It was during a sprint to try and stop the ball from going for a corner that he felt a pull in his lower tummy on the right. It was not more than a pull and he was able to finish the…

Runner’s Achilles Tendon

The main symptoms were Achilles pain in the morning, struggling to get to the bathroom which took about 30 minutes to settle down and loosen up. It could be sore after being on it for a period of time, However, it was running which was the biggest issue. Very stiff and sore to get going and took a good mile to free up. The patient was limping and was feeling aches in the…

Calf muscle tear

The issue for this patient was not the dramatic sniper shot but a rather dull gradual build-up of tightness in the inside of the left calf muscle. This was related to playing badminton specifically but it had been troubling him whilst walking the dog as well over a few weeks. There was no specific sharp pain but a gradual weakness and ache in the calf as well as a feeling of not…

Gymnast’s Hamstring

The history is of a 12-year-old female gymnast presented with a 4-week history of a painful right posterior thigh. The pain started on the run-up to a vault, towards the end of a 2-hour training session. The patient did not describe immediate pain but rather, once aggravated, she suffered a fairly rapid onset of a deep ache and sharp pain that was made worse the more running/jumping she did. Her symptoms eased after…

Keyboard Wrist Pain

History: The patient had been suffering for several years of hand, wrist and forearm pain on both sides and also some left sided shoulder pain. He is a 40-year-old professional console gamer and writer, both activities involve spending long hours either gaming or typing for various contracts. His pain had been so debilitating he had had to stop taking on new contracts for several months and decided to seek help after accepting…

Chronic Pain – Case Study

In this case study, a 23-year-old male developed Chronic Regional Pain Syndrome (CRPS) after an accident at work. (it can be called Complex regional Pain Syndrome as well.) It started as a  relatively simple strain of numerous tendons in the hand. As is typical with manual workers it is hard for them to take time off to rest the injury. Whilst most issues recover given time, some can develop into a chronic…

Heel Pain – Case Study

My client was a forty two year old lady who had a long history of Plantar Fasciopathy (Plantar Fasciitis as it is often referred to) and was referred to the clinic by her GP. The Plantar facia consists of layers of tough connective tissue that spans the underside of the foot from the toes to the heel and blends with the tendons on the underside of the foot. It contributes to supporting…

Cycling – Fractured hip

This is a case study of a 50-year-old male who was knocked off his bike and fractured his acetabulum (the socket part of the hip). He was training for a triathlon when a car clipped his rear wheel and sent him up in the air. He landed on the pavement with the outside of the hip taking the full force of the impact. An x-ray revealed that the Femoral head (ball) had…

Headache or Migraine

Postural related headache or migraine in the forehead/frontal lobe of the head. A 22 year old female presented with a two month history of Migraines that come on mid-afternoon and then stay with her until she goes to sleep that same night. She had been to see her GP and was prescribed Topamax which is used to help prevent migraines in sufferers. She found this useful, but the dose that was required…

Chest and throat pain

A patient came to see me complaining of chest pain when cycling. He is a 38 year old I.T. Consultant who is a very keen cyclist, particularly time trials. His usual very high level of fitness had been diminished over the previous 6 months and he described a feeling of chronic fatigue.

Total Knee Replacement

A 54-year-old recently retired fire fighter attended for treatment, assessment and advice regarding his long standing knee pain. In the past he had undergone multiple knee joint injections and arthroscopic (Key hole) surgery to repair torn menisci (cartilage) in both knees.

Tennis Elbow – Case Study

This is a case history of a 49 year old lady with a classical tennis elbow. This is a typical presentation at the practice and shows how it is important not to just look at the painful spot. There are often a number of additional problems that have to be dealt with to get a good result. Subjective Pain on the outside of the right elbow with referral to top of shoulder…

Shoulder – Case Study

A 43 year old police officer presented in the clinic with a one week history of right shoulder pain. It is important to undertake a thorough assessment involving questions and physical tests to determine the best way to treat a problem. The patient explained that his pain started when he woke up one morning.  He had also noticed, “a strange feeling” in his middle two fingers that came and went with no…

Neck Pain / Whip-lash

This patient was involved in a road traffic incident in June 2012. The car hit her from behind and she was in the driver’s seat with her seat belt on. As she went to get out of the car, she pushed the door open and noticed a pain in her right shoulder. That night she had pain on undressing and could not put her hand up behind her back. Then after two…

Low Back Pain – a nasty one

This is the case study of a 38- year old fit and healthy gentleman, who presented with an acute onset of severe lower back pain, an extremely common injury that will affect approximately 90% of us at one stage or another in our lives. What follows is a basic account of my management, which demonstrates the importance of a thorough assessment and a close working relationship with local Specialist Surgeons to enable…

Knee injury after skiing

A 47-year-old lady fell whilst skiing, experiencing severe knee pain and swelling and was initially taken to a hospital.  Her knee was x-rayed and she was advised that she had not broken any bones.   On her return, she was seen by an Orthopaedic Consultant and she had an MRI scan to get a more detailed assessment of her injury.  She was found to have ruptured her anterior cruciate ligament (ACL) with a smaller injury to her medial…

History Two months ago this patient slipped whilst at work on a plastic bag. He landed on his left side and twisted his hip at the same time. This was very painful and a lot of bruising came out over the next few days. He could not put any weight on the leg, so he went to have an X-ray at A&E. They reported no fracture around the hip or pelvis. But…

Hip Pain – lateral tendon

Pain on the side of the hip (lateral hip pain) Gluteus medius/minimus tendinopathy A 47-year-old woman presented with right side hip pain (on the outside of the hip). She got the pain with running, walking up hills, lying on the side of pain and crossing her Legs. She stated she had the pain for the last two months. She also stated that she started work in the gym four months ago with…

Back, rib & shoulder pain

This case study involves a 28 year old lady (Ms P) who had a 7 year history of right sided pain half way up her back and under the right shoulder blade.  The pain was not becoming worse or improving but she recently realised that she was fed up with it and wanted to see if anything could be done. She described 2 pains: Pain 1 was a diffuse ache, present most…

Treating Arthritic Joints

Arthritic Joints – “a bit of wear and tear” Pain from stiff and degenerative, “worn” joints, can be quite debilitating and interfere massively with your activities of daily living.

Ankle Sprain

An England under 21 Basketball player sprained his left ankle in March 2012, after landing on an opponent’s foot after a jump shot. His ankle went over and it was very painful.

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