ProActive Training Case Study 2

Patient Name: Patient Tel No:
Patient Address: Date:

10/06/2023
PERSONAL DETAILS
Age group: Under 20 20 - 30 30 - 40 40 - 50 50 - 60 60+
Lifestyle: Active Sedentary
GP Address: No. Of children (if applicable):

0
CONTRAINDICATIONS (select if/where appropriate):

Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.
Pregnancy Any dysfunction of the nervous system (e.g. Muscular sclerosis,

Cardio vascular conditions Parkinson’s disease, Motor neurone disease)
Haemophilia Bells Palsy
Any condition already being treated by a GP or another health Inflamed nerve
professional Cancer
Medical oedema Spastic conditions
Osteoporosis Kidney infections
Arthritis Whiplash
Nervous/Psychotic conditions Slipped disc
Epilepsy Undiagnosed pain
Recent operations When taking prescribed medication
Diabetes Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever Abrasions
Contagious or infectious diseases Scar tissues (2 years for major operation and
Under the influence of recreational drugs or alcohol 6 months for a small scar)
Diarrhoea and vomiting Sunburn
Skin diseases Hormonal implants
Undiagnosed lumps and bumps Abdominal pain
Inflammation Haematoma
Varicose veins Hernia
Pregnancy (abdomen) Recent fractures (minimum 3 months)
Cuts Cervical spondylitis
Bruises Gastric ulcers
MEDICAL HISTORY
Respiratory: Gastro Intestinal

Nil Nil
Genito Urinary: Gynaecological:

Nil Nil
Musculoskeletal: Cardio Vascular:

Nil Nil
Medications: Illnesses:
Nil Nil
Worse pain Please highlight by using the tool in the ‘drawing markups toolbox’ in the comments menu (top right)
Possible
10
9
8
7
6
5
4
3
2
1
No pain
Aggravating Factors: Relieving Factors:

No aggravating factors - pre event massage No relieving factors - pre event massage
Onset:
When: How:
Hockey game- April 5, 2023 N/A
Progression: Any Treatment:

N/A Just finished off-season camp (12-weeks), first
gmae of season. Feels confident as has had pre-
event massage for similar events previously and
felt they benefitted his performance.
Radiation: Frequency:
N/A N/A
Character:
N/A
Observation: Active and Passive Movements:
Patient seem nervous, most likely due to the highly Full ROM active and passively.
anticipated game
Palpation: Special Tests:

no particular tender areas other than some minor Nil
tightness into gastroc heads.
Clinical Opinion for the Complaint:

Patient displayed clear nervousness before the event. Presented with high energy. No specific worries about
weak spots or painful areas.
Treatment:
Gentle and rapid effleurage (double hands) on quads and adductors to enhance circulation and initiate
touch. Maintained a quick pace to invigorate the patient throughout the massage, alternating between legs.
Performed tapotement (hacking, cupping, pounding) on quads and adductors to increase blood flow and
warm up the area before running.
Patient turned onto the front.
Applied the same techniques on the back of the leg, working from the calf up to the hamstring.
How patient felt after treatment:

Anxiety decreased, and the patient noticed visible redness and increased warmth in the leg muscles,
indicating improved blood flow.
Home care (FID - frequency, intensity, duration):
Stretch Strengthen Postural Heat Cold
Specific home-care advice:

Patient told to keep warm and moving between massage and event. Patient seen practicing warm up
mobility drills including skater jumps, squats, running on spot.
Reflective Practice:
It was encouraging to witness the patient's anxiety turn into excitement before the race
SOAP FORM Follow up No: 1
Patient Name: Date:
11/06/2023
Possible
10
9
8
7
6
5
4
3
2
1
No pain
Improving No Change Worsening New Contraindications
How patient has been since last treatment: Observation:

Pt had hockey game yesterday, displaying some No swelling, no abrasions, no heat or redness.
DOMS today into the lateral aspects of the quads
and calves.
Palpation: A & P Movements:

Tenderness in the quads and across the lateral head Full AROM and PROM all movements. Tenderness
of gastroc. in the quads when going into EROM knee flexion.
Functional Tests: Treatment Goals:

Nil// post-event massage Reduce symptoms of DOMS
Increases lymphatic drainage
Treatment:
In supine position, light effleurage applied to quad group. Utilized long, slow, and single-handed strokes for
a gentle massage and to enhance venous return. Transferred to double hand effleurage, maintaining a light
intensity. Employed palmar and fingerpad kneading petrissage lightly to target the tender lateral quad area.
Concluded supine techniques with double hand to single hand effleurage on the quads. Patient shifted to
prone position.
In prone position, applied effleurage across calves, up to hamstrings for bottom-up venous return. Extended
effleurage to improve blood flow, facilitating oxygen delivery to tender muscles experiencing DOMS.
Utilized light, non-reinforced finger pads for petrissage on the lateral aspect of calves. Finished prone work
with more double hand to single hand effleurage, encouraging venous return.

Pt felt that symptoms of DOMS had reduced and 'restless legs' feeling had reduced slightly.
Patient To Return After:
Day(s) 1 Week(s) Month(s)
Specific Home-Care Advice:

Patient advised to maintain proper hydration after the massage and to sustain a well-balanced diet to
replenish carbohydrate stores and support muscle repair with sufficient protein intake.
Patient given calf and quad stretches to practice between sessions.
Reflective practice:
I believe I maintained effective communication throughout the session, ensuring I understood the suitable
depth for the post-event massage. The patient expressed appreciation for my continuous inquiries about the
pressure, and they were satisifed with the massage.
SOAP FORM Follow up No: 2
Patient Name: Date:
18/06/2023
Possible
10
9
8
7
6
5
4
3
2
1
No pain
Improving No Change Worsening New Contraindications
How patient has been since last treatment: Observation:

Quad DOMS fully alleviated. Patient still Pt has no abnormal observations.
experiencing tightness in calf muscles.
Palpation: A & P Movements:

Tenderness across lateral head of gastroc. AROM & PROM = FROM
Functional Tests: Treatment Goals:

Single leg calf raise: Reduce tightness in lateral gastroc
L- 25x
R-29x
Treatment:
Effleurage from above the gastroc insertion, proceeding towards the hamstring origin. Utilized single hand,
then double hand, and back to single hand with reinforcement. Objective to enhance blood flow, mobilize
fluid, and support venous return.
Petrissage applied across both gastroc heads and soleus for tissue mobilization. Used palmar kneading and
reinforced finger pads.
Applied muscle compression technique to lateral gastroc head, held for 30 seconds, and released to improve
circulation in the area.
Performed NMT twice on lateral gastroc head of the left leg to release 1x active and 1x latent trigger points.
Conducted direct myofascial release between the lateral and medial gastroc heads to facilitate movement
between the components.

Treatment felt that calves felt 'looser' than prior to treatment.
Patient to return after:
Day(s) 2 Week(s) Month(s)
Specific Home-Care Advice:

Pt to continue with incorporating strengthening (calf raises) into exercise routine.
Pt to perform DF stetches on step 30 second hold x 3 / day.
Summary of Patient:
The patient's recovery from the hockey game has been positive. However, there is still some lingering calf
tightness. The patient is advised to maintain the stretching and strengthening routine and schedule
maintenance massages as needed. A follow-up appointment is scheduled in 2 weeks to monitor progress.
Student Name:
Daniel Vattathichirayil

ProActive Training Case Study 2

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Patient Name: Patient Tel No:

Patient Address: Date:

Lifestyle: Active Sedentary

GP Address: No. Of children (if applicable):

CONTRAINDICATIONS (select if/where appropriate):

Pregnancy Any dysfunction of the nervous system (e.g. Muscular sclerosis,

Respiratory: Gastro Intestinal

Genito Urinary: Gynaecological:

Musculoskeletal: Cardio Vascular:

Aggravating Factors: Relieving Factors:

Progression: Any Treatment:

Palpation: Special Tests:

Clinical Opinion for the Complaint:

How patient felt after treatment:

Home care (FID - frequency, intensity, duration):

Stretch Strengthen Postural Heat Cold

Specific home-care advice:

Improving No Change Worsening New Contraindications

How patient has been since last treatment: Observation:

Palpation: A & P Movements:

Functional Tests: Treatment Goals:

How patient felt after treatment:

Patient To Return After:

Day(s) 1 Week(s) Month(s)

Home care (FID - frequency, intensity, duration):

Stretch Strengthen Postural Heat Cold

Specific Home-Care Advice:

Improving No Change Worsening New Contraindications

How patient has been since last treatment: Observation:

Palpation: A & P Movements:

Functional Tests: Treatment Goals:

How patient felt after treatment:

Patient to return after:

Day(s) 2 Week(s) Month(s)

Home care (FID - frequency, intensity, duration):

Stretch Strengthen Postural Heat Cold

Specific Home-Care Advice:

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