P4R3W4: Since I last saw you...

I'm now halfway though my MSK placement, and I'm loving almost every minute of it! When I have follow-up patients we reflect on any changes since the previous physio session. More often than not, they have dramatic changes - reductions in pain, regained normal range of movement, had multiple nights of undisturbed sleep, confidence to perform tasks at home. It's very rewarding to be apart of their journey to recovery. I have three 'magic moments' to share with you this week...

Found this on a shelf in the photocopier room... oiling up a spine. ?Peanut oil perhaps?

My supervisor made me aware of Mulligan's SWARMs technique (spinal mobilisations with arm movement), suggesting we examine the neck more thoroughly of a client who had a classic presentation of rotator cuff impingement. The neck had been cleared with active movements with over pressure at end range in a previous treatment. On closer examination there was some minor symptom replication with accessory movement to C4/5, so we decided to try SWARMs to treat the shoulder. I applied a horizontal force to C4 spinous process, away from the affected shoulder, and asked the patient to move their arm through abduction. They did, no pain. Magic. This textbook rotator cuff presentation that I suspected would take a lot of posture and muscle balance correcting was improved with one attempt of SWARMs.

Previously I have not been a big fan of K-tape. I prefer rigid taping. I have used k-tape now for two clients. The first was on an achillies tendinopathy given the person wished to stay active and taping the achillies tendon may unload the tendon (in theory... I'm sceptical). The client found the taping beneficial. We're addressing more complex issues, so I wasn't surprised that the k-tape hadn't fixed all the problems there. However the second client I used k-tape on had some significant changes. This was a young person who reported to experience regular subluxations of the shoulder. I found no evidence for anything wrong with the shoulder - I even had this client throwing and blocking a medicine ball in more vulnerable positions that may cause subluxations... still no shoulder issues. I was wondering how genuine the problem was. On follow-up, the patient reported shoulder discomfort when I done a break test with the shoulder flexed (patient holds their arm in a position and tries not to move it whilst I do my best to break their arm position). Said shoulder presented significantly weaker than the other shoulder. I decided to test the theory that it was postural and/or psychological (e.g. confidence). So I applied the K-tape to her scapula - if anything, I could clinically reason this. Posture can influence muscle force across a joint - and what teenager really cares about their posture? The client hadn't complied with their posture awareness homework. When I retested the break test they had equal and full strength... I even tried to apply more force. K-tape is magic.

The third 'magic moment' was with an elderly female who had pain with neck rotation. C2/3 was the symptomatic joint. As I was not able to physically treat this joint, I decided to treat the adjacent C0/2 joints. I used Michael Monaghan's C0-2 isolated rotation and distraction technique. This involved fixing C2 (so it didn't move) and rotating and distracting (gapping) C0-2 gently. Upon reassessing neck rotation, the lady had regained most of her neck rotation range of movement without any pain. Next session we will work on getting her neck into full extension without pain.

Okay, so there were four magic moments. This magic moment was in treating a chronic back pain presentation. The person had full back / spine pain, and in the first session all I did to treat them was a grade 1 lumbar rotation mobilisation. This is essentially a gentle rocking of the hips whilst keeping her shoulders still. The patient hadn't slept well for months and subsequently fell asleep on the table within minutes. Fast-forward one week and they had been sleeping well and gently rocking themselves to sleep. The person appeared to be more cheerful but the back pain and fatigue was still there and really disabled her day-to-day living. My treatment was gentle massage and I taught her a body-awareness and relaxation technique. The person wasn't aware they could control their body and relax themselves, thus finding this technique revolutionary. They were now able to rotate their trunk / body. Magic!! They were so pleased! For homework I gave the client one tai-chi move to practice at home. These were huge improvements for this client and I felt blessed to be in a position to help them achieve meaningful improvements in physical and psychological health.

I had a client that I clinically diagnosed as having Sever's disease. Imagine telling a child that they have a 'disease'. This was surprisingly uncomfortable for me, given that Sever's is merely a condition that when managed well during their growth spurt will have no implication on their lives. In the meantime, the condition was having a huge impact on their life and the treatment might turn into a very conservative management... which really means I will have to inform this child that they will need to forgo their Saturday and lunchtime rugby. This isn't something an aspiring All Black wants to hear.

In other cases.... I had a client with a reported 'foot drop' that was causing them to trip. I was surprised to see her foot dorsiflexors were very strong and I had to go looking elsewhere for the problem. The problem was in hip abductor and external rotator weakness... yes, the classic Gluteus Medius weakness. I'll see whether there has been any improvement in the next session. 

One common grumble from physiotherapists is that of clients not following through on advice we give... 'how have you got on with those exercises I gave you last week?' [insert excuse]. This is where we use behaviour change tactics, but it might take a few weeks to find the right tactics / to influence the correct environmental or personal factor. Identifying and targeting these factors are not easy. But they're worthwhile... one client I had last week had 'undone all the good work they had done by the physio' by returning to work, which involved lifting and driving. How will I change their work demands? Occupational physio referral?... hmmm... it's tricky when the workplace isn't invested in their workers and the workers have little option but to continue their work.

In other outpatient antics... I helped out with the Lower limb / knee class on Tuesday and hydrotherapy class on Thursday. There was also a welcome morning tea for the new receptionists on Wednesday.  I had my midway review from my supervisor on Wednesday, which was a very positive experience. I left feeling a lot more self-confidence. I also had an enjoyable week with my clinical educator. Everybody seemed to be having a good week this week.

Made a new pamphlet on core activation for the outpatient clinic...

ED on Friday was good fun too. There was an older gentleman whom had a piece of hearing-aid stuck / presumably broken in his ear. We had a quick chat to him about his balance. He gave us the story of the week...  

" I have been having a problem with my balance lately. It has got to the point that I'm thinking about giving up driving. My wife says I'm walking with a forward lean - I don't know where she got her medical certificate from. The other day I was in the shower. There's a windowsill that I use to help me balance. I was feeling unbalanced and my vision was starting to go. I was hanging on to this windowsill thinking that this was it. This was the end of me. I couldn't see a thing, everything was white and bright. My balance was bad - I was swaying around the shower. Then I reached up to feel my face and took my glasses off. I forgot to take my glasses off! "  [Fogged up glasses from the steam]

The other funny moment on Friday in ED was hearing my supervisor read back an email about Darco orthotic shoes. Between the serious communication was a punchline from the doctor asking whether the Darco shoe was a racist shoe!?