Situation: On Tuesday 16th February, a middle aged female presented at the Augusta rooms with a referral from her GP. The referral stated that the woman had been granted time off work due to ongoing pain that she had been experiencing in her upper back, neck and both shoulders and that she was to be assessed by a physiotherapist to ascertain what the cause of her pains were and provide treatment if deemed appropriate. I performed a very thorough subjective examination where I discovered that her pains in order of decreasing intensity/discomfort were the thoracic spine between the medial borders of her scapulae, the left shoulder, the cervical spine and finally the right shoulder. Among other things in the subjective I found out that she was a fly-in, fly-out truck driver, working 12 hour shifts and that her shoulder pains, particularly the left were long standing, but had been gradually increasing over the previous few months as the thoracic discomfort had been developing. After reviewing notes on this woman from previous treatments, it was revealed that she had impingement of her supraspinatus tendon in the left shoulder and was still suffering from some bursitis in the same shoulder. With assistance from my supervisor I then set out to perform an objective examination of this woman. What we discovered was that her thoracic pain could be more accurately described as a ‘tightness,’ which was equally reproduced with all active movements and overpressure of the cervical and thoracic spine. All upper limb neurodynamic tests were negative. However, we discovered that her scapula position and control were very poor on both the left and right sides and that with manual scapula position correction her ‘tightness’ with movement immediately decreased. Assessment of the left shoulder revealed pain and weakness associated with the supraspinatus muscle upon testing, which was the same discomfort that she had come to see us about. There were similar symptoms with assessment of the right shoulder, but they were less marked and less intense.
Task: After a discussion with my supervisor, we decided that the first treatment aim would be to decrease the pain and ‘tightness’ in the thoracic spine by improving scapular control. This would be done through scapular stabilisation exercises, involving teaching greater activity of the rhomboids and upper trapezius muscles to retract and elevate the scapulae position on the thoracic cage. We were hoping that this exercise in itself would partly improve the supraspinatus problem by stabilising its origin on the scapula, but in addition to this, the plan was to teach isometric external rotation of the shoulder as a strengthening exercise and provide stretches for this muscle, including hand behind the back and horizontal adduction at the shoulder. So these were my tasks for this particular treatment session.
Action: I decided to teach the isometric shoulder external rotation exercise first as I felt it would be quicker and easier for the patient to comprehend than the scapula stabilisation exercises. I demonstrated the exercise in the doorway initially and explained that it was to be performed as a static hold, with no movement occurring. Then I requested the woman to perform the exercise so that I could check she understood. She performed it well, so I instructed her to do 9 more repetitions on the left side, holding each for 3-5 seconds. These were well tolerated, so I explained that this exercise would form part of her home exercise program and that she should be performing 3 sets of 10 repetitions, at least 3 times per day for each shoulder. She said she understood and was confident at being able to perform this independently. I did the same for the hand behind the back and horizontal adduction stretches of the shoulder, which the woman also said she understood were part of her home exercise program.
I began teaching the scapula stabilisation exercises, of which the first step in the process was to educate about the position of spinal and scapula neutral and how this was the optimal position to be in because it meant there was minimal stress on spinal and scapular structures. Spinal neutral was easily attainable, but unfortunately scapula neutral was not so easy and it was requiring considerable effort to actively find this position, let alone maintain it for any length of time in the initial stages. After many attempts and manual guidance from me she was able to find this position independently by the end of the session. I then gave the instructions that this would also form part of her home exercise program and that her prescription would be 10 x 2 second holds per set, performing 3 sets, 3 times per day. Again, this was well understood.
Result: I saw the woman again 2 days later on the 18th and she told me that her symptoms were greatly improved after just a few days of independently performing her exercises. So I checked she was performing the isometric external rotation correctly by viewing 1 set on the left side. She was doing well, so I told her to continue at home in the same fashion, even maintaining the contraction for longer each repetition if she felt able. I then checked her ability to find scapula neutral and hold this position, which was also much improved. I then progressed the exercise program to include scapula stabilisation through shoulder flexion range, which was accepted well and included into the home program.
The woman then presented on Tuesday the 23rd and again was happy with how her symptoms were further decreasing, but complained that her right shoulder was now giving her more trouble than the left. I asked her to perform the external rotation on the right arm so I could assess if she was performing it correctly. Her response was that she hadn’t been performing those exercises on the right side. When I quizzed her as to why not, she replied that she didn’t think she was supposed to be performing them on the right. She said that when we initially ran through her program a week earlier, we didn’t practice it on the right shoulder, so she didn’t think it was part of her home program. I was then very quick to apologise and explain that yes, I most certainly did want her performing the strength and stretching exercises on the right shoulder in addition to the left. She then told me that over the weekend as the pain was becoming more noticeable she felt she should have been performing them but was afraid to begin without getting my okay to do so first. So again, I apologised for the confusion and miscommunication on my part and insisted that she should definitely be performing the exercises for both shoulders. The woman’s next appointment with me is on Tuesday (a week after her previous session) so I will assess her symptoms and review progress then and hopefully the right shoulder pain has settled in this time, and if not I will have to re-assess and take another approach to treating the problem.
Evaluation: Overall, I thought I performed my set tasks well, but it was just the communication and education specific to the right shoulder exercises that let me and subsequently the patient down in this situation. I felt that my initial explanations, demonstrations and technique education were performed well and the woman had a good grasp on how to perform the exercises independently. Unfortunately though, I did not effectively communicate the specifics of the home exercise program, which led to the confusion and eventual non-performance of the strength and stretching exercises for the right shoulder. At the original time of technique education, I really should have got the woman to perform a set of exercises for the right shoulder in addition to the left and then really emphasised the importance of performing all the exercises for both problems and for both shoulders. The fact that the thoracic spine and left shoulder problems appeared to be responding so well to the exercises was comforting and provided some confirmation that the treatment program was appropriate and that I had taught the exercises well. The initial assessment findings for the right shoulder were very similar to those for the left shoulder, so I wait in anticipation for the next appointment to see if the problem is resolving as the left shoulder is.
Strategies: What I take from this experience is that as a therapist issuing exercises and activities to be performed independently, you cannot take it for granted that the presenting subject understands exactly what you want them to do. What may seem like a simple concept to the therapist may not be so for the patient, so it is essential to ensure that all aspects of a take home program are understood. It also reminded me that our patients have different learning styles, just like student therapists do. Some will respond best to watching a technique, others to listening to an explanation and others to performing it themselves, so it is important that you do all of these and more when teaching someone an exercise so as to ensure they know exactly what they are to do when they leave your supervision. To have a checklist or know a specific routine appears to be the way to approaching exercise education, which in my case would have lead me to demonstrating and insisting the subject performed the technique for the right shoulder at the initial time of teaching, not just explaining that this should be done. This could have gone a long way to preventing the problems that subsequently occurred, but I will know this for next time.
Sunday, February 28, 2010
Sunday, February 14, 2010
Topic One - Assessment
Sunday February 14, 2010
Situation: On the Thursday afternoon of my first week of placement I was at the Augusta clinic location for the second time (I also go to Augusta hospital and the Margaret River clinic). At this stage of the week the vast majority of clients that I had seen were follow-up cases who were returning for more treatment. I had watched my supervisor perform a couple of initial assessments to get a feel of how he goes about it but I had performed no more than half a dozen myself. A young male presented at the clinic with his mother and a referral from his GP. The referral from the GP had no diagnosis, only that the young man was to be assessed by a physiotherapist in regard to an injury sustained to the left lower leg in a basketball match the previous evening. He ambulated into my assessment room on 2 axillary crutches, non-weight bearing on his left leg and using a step-through gait.
Task: It was my task to take a subjective history and perform an appropriate physical/objective examination on the client so as to ascertain what I thought the young man’s problem was before discussing treatment possibilities with my supervisor if deemed appropriate. My supervisor was present for advice and back-up if I required it.
Action: I began my task by informing the client and his mother that I would have to ask a series of questions, so ensured that they were comfortable before the process began. I was completing the body chart and found that the boy’s pain was on the posterior aspect of his left calf at the location where another player had made contact with him. I completed the remainder of the body chart and continued on with the rest of the subjective history. When I had finished the subjective history I turned to my supervisor to see if he had any further questions to ask before I began an objective examination. His response was that I had done well, but I needed to ask if there were any other pains/problems because I had neglected to ask this when I was doing the body chart. With this instruction, I asked the boy if he did indeed have any other pains beside the one we had just run through on the back of his calf. He reported that he didn’t really think much of it, but he did have some pain around his general left hip region. After checking that he didn’t have any additional pains (which he didn’t) I directed my focus to the left hip pain and followed through with all my subjective questioning on this pain.
Result: After completing the subjective history in its entirety it turned out that the left hip pain wasn’t the most intense pain but was the more limiting and was actually a large part of why the young man didn’t feel confident weight bearing through his left leg and so was using the crutches. A very thorough objective examination of the lumbar spine, hip, knee and ankle revealed that the posterior calf pain was most likely just tenderness and inflammation from the contact made by the other basketball player. While the hip pain my supervisor and I concluded was a result of the angle of the contact which came from the other player and had caused an awkward distraction-like movement of the leg from the hip upon impact. There wasn’t marked instability around the hip, but it was certainly very painful for the boy, so I applied some ultrasound because of the acute stage of the injury and provided education about the Rest, Ice, Compression, Elevation (RICE) principle for both the hip and calf. The client was given a home exercise program of stretches and advised to return for further treatment if the problem had not resolved by the beginning of the next week.
Evaluation: I felt my performance in this situation was poor and I was very disappointed in myself for missing the secondary hip pain if it hadn’t of been for my supervisor. I must have had a lapse in concentration to skip such a vital part of the assessment and something which I definitely should have known how to do, being the body chart of the subjective assessment. Despite my self dissatisfaction, I am glad that I made this error when my supervisor was present and that it was at an early stage of my placement, because I know now that I have made such a simple mistake that I will never make it again. After the client and his mother had left I had another discussion with my supervisor and he explained that you must be very thorough with your subjective history and that he is particularly meticulous with the body chart because you don’t want to complete a whole session worth of treatment to end and find out that there are other, possibly more important pains that you need to address. He also told me not to get too down on myself because the rest of my performance was good, which was comforting when I reflected on the situation.
Strategies: I think that the obvious strategy here is that there is no substitute for a good quality subjective assessment because it really serves to guide you through your objective and that to do this; you need to know how to properly perform a subjective assessment. After this mistake, I revised in detail my history taking notes on Thursday evening and made sure I performed top quality examinations on Friday, which my supervisor complemented me on too, which was satisfying. The other strategy that I took out of this experience is to utilise my supervisors throughout the year as much as possible, because they are the ones who can identify problems with any of my skills and help me to rectify them so that mistakes and errors aren’t made in the future. A third point that I took from this experience is that you cannot take any referrals as being 100% factual and you should always conduct your own assessment of the person sitting in front of you before you decide to start treating them.
Situation: On the Thursday afternoon of my first week of placement I was at the Augusta clinic location for the second time (I also go to Augusta hospital and the Margaret River clinic). At this stage of the week the vast majority of clients that I had seen were follow-up cases who were returning for more treatment. I had watched my supervisor perform a couple of initial assessments to get a feel of how he goes about it but I had performed no more than half a dozen myself. A young male presented at the clinic with his mother and a referral from his GP. The referral from the GP had no diagnosis, only that the young man was to be assessed by a physiotherapist in regard to an injury sustained to the left lower leg in a basketball match the previous evening. He ambulated into my assessment room on 2 axillary crutches, non-weight bearing on his left leg and using a step-through gait.
Task: It was my task to take a subjective history and perform an appropriate physical/objective examination on the client so as to ascertain what I thought the young man’s problem was before discussing treatment possibilities with my supervisor if deemed appropriate. My supervisor was present for advice and back-up if I required it.
Action: I began my task by informing the client and his mother that I would have to ask a series of questions, so ensured that they were comfortable before the process began. I was completing the body chart and found that the boy’s pain was on the posterior aspect of his left calf at the location where another player had made contact with him. I completed the remainder of the body chart and continued on with the rest of the subjective history. When I had finished the subjective history I turned to my supervisor to see if he had any further questions to ask before I began an objective examination. His response was that I had done well, but I needed to ask if there were any other pains/problems because I had neglected to ask this when I was doing the body chart. With this instruction, I asked the boy if he did indeed have any other pains beside the one we had just run through on the back of his calf. He reported that he didn’t really think much of it, but he did have some pain around his general left hip region. After checking that he didn’t have any additional pains (which he didn’t) I directed my focus to the left hip pain and followed through with all my subjective questioning on this pain.
Result: After completing the subjective history in its entirety it turned out that the left hip pain wasn’t the most intense pain but was the more limiting and was actually a large part of why the young man didn’t feel confident weight bearing through his left leg and so was using the crutches. A very thorough objective examination of the lumbar spine, hip, knee and ankle revealed that the posterior calf pain was most likely just tenderness and inflammation from the contact made by the other basketball player. While the hip pain my supervisor and I concluded was a result of the angle of the contact which came from the other player and had caused an awkward distraction-like movement of the leg from the hip upon impact. There wasn’t marked instability around the hip, but it was certainly very painful for the boy, so I applied some ultrasound because of the acute stage of the injury and provided education about the Rest, Ice, Compression, Elevation (RICE) principle for both the hip and calf. The client was given a home exercise program of stretches and advised to return for further treatment if the problem had not resolved by the beginning of the next week.
Evaluation: I felt my performance in this situation was poor and I was very disappointed in myself for missing the secondary hip pain if it hadn’t of been for my supervisor. I must have had a lapse in concentration to skip such a vital part of the assessment and something which I definitely should have known how to do, being the body chart of the subjective assessment. Despite my self dissatisfaction, I am glad that I made this error when my supervisor was present and that it was at an early stage of my placement, because I know now that I have made such a simple mistake that I will never make it again. After the client and his mother had left I had another discussion with my supervisor and he explained that you must be very thorough with your subjective history and that he is particularly meticulous with the body chart because you don’t want to complete a whole session worth of treatment to end and find out that there are other, possibly more important pains that you need to address. He also told me not to get too down on myself because the rest of my performance was good, which was comforting when I reflected on the situation.
Strategies: I think that the obvious strategy here is that there is no substitute for a good quality subjective assessment because it really serves to guide you through your objective and that to do this; you need to know how to properly perform a subjective assessment. After this mistake, I revised in detail my history taking notes on Thursday evening and made sure I performed top quality examinations on Friday, which my supervisor complemented me on too, which was satisfying. The other strategy that I took out of this experience is to utilise my supervisors throughout the year as much as possible, because they are the ones who can identify problems with any of my skills and help me to rectify them so that mistakes and errors aren’t made in the future. A third point that I took from this experience is that you cannot take any referrals as being 100% factual and you should always conduct your own assessment of the person sitting in front of you before you decide to start treating them.
Sunday, February 7, 2010
Initial Entry - 07/02/2010
On the eve of my first clinical placement for the year, I feel I am much more nervous than I have been for previous placements. There is definitely still that sense of excitement at knowing I will be able to put the past 3 years worth of study into practice, but at the moment I am just fearful that I will not demonstrate my capabilities to their full potential because of the fact that I will be trying to draw on 3 years worth of material and I’m just praying there isn’t too many gaps in between.
My main concern is the new heightened perception of me as a 4th year student. In previous years there have always been comments such as “don’t worry, that’s 4th year stuff...” etc, that have been mentioned, along with others about 4th years being like new grad students. My problem is that I don’t feel like I have the capabilities of a new grad student and so I don’t want to be treated like one, certainly not in the first few weeks anyway. But I just don’t know if my supervisor will feel this way too, so this is why I’m concerned.
Another problem I have is that I would classify myself as a ‘slow starter,’ someone who prefers to ease into proceedings by listening, observing and asking questions before finally doing and performing. I don’t expect this will be taken into account on this placement, because from chats with other students it seems my supervisor likes to get students treating patients immediately on the first days on placement, which is something that I will just have to deal with as best as I can tomorrow morning.
Despite this, I do feel that there will be some allowances early on in the placement for me as a student, however I don’t think these will last for long and I’ll probably be pretty independent by the second week. Which again is a daunting prospect, but I’m hoping I’ll have a good understanding of the environment by this time and will manage well.
One other concern that I do have about this placement is that the musculoskeletal system still seems like 4 very different entities when I think about it in my head, ie. LL, UL, Lsp and Csp. I hope that I can overcome this mindset as early as possible so that I can provide the best quality of care for my patients as I can, because I feel that to achieve this I need to be thinking of the person as a ‘whole’ rather than just parts. But I’m sure that after a few patients, a few positive tests and eventually positive treatment outcomes and discussions with my supervisor that the jig-saw will begin to take form and I’ll be on my way.
I think the main thing for me to remember while I am on this placement is my goal of learning and doing as much as possible while I am still being supervised and that there is no point in getting too worked up about the thought of a poor performance.
So for now, it’s an excited, but very very nervous goodnight before day 1 tomorrow!
My main concern is the new heightened perception of me as a 4th year student. In previous years there have always been comments such as “don’t worry, that’s 4th year stuff...” etc, that have been mentioned, along with others about 4th years being like new grad students. My problem is that I don’t feel like I have the capabilities of a new grad student and so I don’t want to be treated like one, certainly not in the first few weeks anyway. But I just don’t know if my supervisor will feel this way too, so this is why I’m concerned.
Another problem I have is that I would classify myself as a ‘slow starter,’ someone who prefers to ease into proceedings by listening, observing and asking questions before finally doing and performing. I don’t expect this will be taken into account on this placement, because from chats with other students it seems my supervisor likes to get students treating patients immediately on the first days on placement, which is something that I will just have to deal with as best as I can tomorrow morning.
Despite this, I do feel that there will be some allowances early on in the placement for me as a student, however I don’t think these will last for long and I’ll probably be pretty independent by the second week. Which again is a daunting prospect, but I’m hoping I’ll have a good understanding of the environment by this time and will manage well.
One other concern that I do have about this placement is that the musculoskeletal system still seems like 4 very different entities when I think about it in my head, ie. LL, UL, Lsp and Csp. I hope that I can overcome this mindset as early as possible so that I can provide the best quality of care for my patients as I can, because I feel that to achieve this I need to be thinking of the person as a ‘whole’ rather than just parts. But I’m sure that after a few patients, a few positive tests and eventually positive treatment outcomes and discussions with my supervisor that the jig-saw will begin to take form and I’ll be on my way.
I think the main thing for me to remember while I am on this placement is my goal of learning and doing as much as possible while I am still being supervised and that there is no point in getting too worked up about the thought of a poor performance.
So for now, it’s an excited, but very very nervous goodnight before day 1 tomorrow!
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