I am currently on my musculoskeletal outpatient placement and am seeing a patient for a shoulder problem. She presented to clinic 10 days following a fall onto an outstretched hand. After a subjective assessment it was determined that the severity and irritability of her condition was very mild and so a full objective examination was indicated, with minimal caution required.
Objective examination began with AROM of the shoulder joint. The patient had demonstrated full and pain free shoulder abduction, flexion, external rotation and extension, but experienced extreme pain when returning from extension to neutral. Her pain did not settle for the remainder of the session and further accurate examination was difficult. With help from my supervisor we proposed a diagnosis of glenoid labrum tear (SLAP lesion) and decided to tape to support the shoulder joint for one week to allow the condition to settle before re-assessing.
When the patient returned for taping 3 days later she expressed that the symptoms had decreased significantly and was more than happy to have the tape reapplied for a further few days.
Upon return to the clinic for further assessment she once again noted a significant improvement in symptoms, with only mild pain performing repetitive movements (eg washing dishes or dusting) for more than 15 minutes. We therefore began further physical examination. This time, gentle palpation of her upper trapezius muscle caused severe pain and made the physical examination difficult. My supervisor decided to perform further physical assessment regardless of this – testing for impingement, instability etc. Her pain mid way through this session appeared to be extremely severe. The patient became quite teary and was very reluctant to move her shoulder. She expressed that the pain had spread to her neck and upon closer examination the cervical paravertabrals had significantly increased tone compared to the beginning of the session, with a large visible lump at the proximal attachment of her upper trapezius.
I guess you could say I freaked out. The lump honestly looked and felt like displaced bone and was very painful to palpate. My supervisor had a look but didn’t seem too concerned, and she suggested heat followed by very gentle soft tissue massage which relieved the symptoms significantly.
Afterwards my supervisor spoke to me about how my display of anxiety may have increased the patients already elevated anxiety levels. Looking back on the situation I could see how my reaction may have reinforced the patients perception of their pain being caused by a more sinister pathology.
A similar event happened the next time I saw this patient. This time I new what I had to do. I talked to the patient and explained why she was feeling the pain and that there was indeed no pathology in her neck, but rather that her muscles were trying to protect her shoulder, and in doing so were becoming very tense, causing the pain in her neck. This reassurance alone had a positive impact on her symptoms.
Though it is difficult when faced with new/ confronting situations to hide your concern I now realise that the way we react to certain things can greatly influence a patient. Next time I am faced with a patient like this I will know to take a deep breath and remain calm... for their sake and mine!
2 comments:
I think the ability to keep a patient calm during a Rx session, even if you do have some concerns regarding their condition is a skill all physios need to have. It sounds like you handled the situation really well and have 'mastered' this skill. As a student this isn't something that we can prepare for until you actually start treating a patient and are put in the situation. So I think it's great that it was brought to your attention and you were able to implement it straight away with the same patient.
Whilst it is important to stay calm and not increase a patients anxiety levels, there will always be instances in which further medical investigations for a more serious pathology may be required. In these instances I believe it is the manner in which we speak to the patient (ie our body language, tone, pitch etc) and providing them with sufficient information (but not to overload them) that will prevent increased levels of anxiety on the patient's behalf. We must always remember the 'power' that we have as a therapist. Although as a student we may not be an 'expert' in the condition that we are treating in the majority of cases our level of knowledge exceeds that of the patient - thus they are not going to question a therapist if they begin to look concerned. An anxious physio will almost always be accompanied by an anxious patient which may negatively impact upon their recovery.
From my experiences if you remain confident and calm even though you are not entirely sure what your next move is a patient will trust your abilities more and remain calm themselves. I think the best strategies to remain calm in this kind if scenario is to firstly breathe, keep smiling so you do not look stressed, explain to the patient why you have a concern and what the possible outcomes may be; i.e. if in future you have highlighted a contraindication to treatment, or whether it might be appropriate to refer the patient elsewhere. Providing the patient with an explanation of what you have uncovered in your assessment and how this will effect the direction you take with treatment and its progression will give them peace of mind that there is potential for their condition to improve. Also explaining to them that as a student you do not have the clinical experience to manage the situation independantly and seek a more experienced opinion shows that you are not incompetant but assertive enough to recognise that their presentation is beyond your level of skill at this point in time and that you want the best possible outcome for the patient
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