Michelle's Blog week one

Hello fellow bloggers. Before I start I just want to let you know that I’m not on placement at the moment, so if the details in my blogging sessions are a bit vague like, ages, VAS scores etc, it’s because I probably can’t quite remember.

Whilst on my musculoskeletal out-patients placement I had the opportunity to work with, at some times, a very challenging patient, but in the end it proved very rewarding of my time at SCGH. I will refer to this patient on several blogs as it was quite a complex case.

My patient was a 52 y.o female, referred for secondary impingement of the left shoulder due to trauma, resulting in RC tear or supraspinatus which was being trialled with conservative management. On my very first appointment with this patient I had spent an initial 30 minutes gaining a subjective history from the patient. The patient had an extensive PMHx and had been coming to the clinic for at least 6-8 weeks already and had seen minimal to no improvement. The patient verbalised her concerns about how she was seeing minimal improvement and her pain levels were still 8-9/10 and that she was very keen to get better because she wanted to avoid having surgery. The patient proceeded to break down into tears and was expressing her concerns about how she didn’t think that physio was working and that she didn’t like that every 4-5 weeks she would be having a different physio and thus needed to explain her situation every time. As this occurred within my very first week of prac ever, I was very overwhelmed and unsure how to proceed as this was the very first time I had seen the patient, so I hadn’t yet developed any rapport with the patient.

I discussed the situation with my supervisor and we decided that more education was needed for the patient to understand her injury and that there would be a long rehab process involved. We proceeded to use models and simple language to explain shoulder impingement and educated her on not exercising into pain.

The patient returned the following week, even though she understood the education given she presented with a very guarded posture and told me that she didn’t want to continue at SCGH and wanted to proceed with private physio where she thought she would get some more “hands on time.” Once again I discussed with the supervisor the patient’s wishes. We proceeded with the treatment session with some convincing on my behalf to at least stay for one last time. I proceeded to give her STM targeting the rotator cuff and posterior capsule, using stretching with gentle mobilisation, which she felt was one of her major impairments, and some trigger points. The patient felt immediate relief and expressed that she was extremely grateful of the treatment and listening to her concerns. She was then keen to return for an appointment the following week.

So from this I feel the dilemmas that were raised were patient’s expectations of treatment and the importance of developing strong therapist-client rapport. I know that when we are learning we need to do a full re Ax of asterix markers at the beginning and end of Rx, which for the most of it we think is very time consuming, and so does the patient. So I felt that in this patients case it was of most importance to alter my objective and minimise Ax and Re Ax to the minimum asterix markers and focus on manual treatment for patient wellbeing and patient rapport within the first few treatment sessions and to more importantly, actively listen to the patients subjective experience and think more about the psychosocial aspect of patient care.

So for future similar situations and a handy little hint for those who still have their musculo placements to come, I found that it is sometimes better to spend a bit more of your time discussing the subjective component initially to develop good rapport with your patient especially if they are a very emotional patient due to the debilitating nature of their injury. And more importantly not thinking just inside our little condition and treatment box i.e shoulder impingement in this case; graduated strengthening exercises and manual therapy to aid in joint healing and recovery. If the exercise of treatment being used is not successful, it’s ok to change tact and go on a different treatment option. In this case the previous student was treating with longitudinal glide of the gleno- humeral joint as this was the only thing that was momentarily decreasing pain, but overall pain was still 8-9/10 and there was no improvement in range or strength.

So next week I will fill you in on the more exciting part that happened with this patient regarding differential diagnosis….. Keeping you on the edge of your seat, aren’t I ???