1.10.2012 The neck patient.
Today I have used tips from last week Manus talk for the treatment of the acute neck pain patient with restricted rotation to the R. He tried to practise "bottom - up" cervical rotation and immediately we both noticed improvement in the "top - down" rotation of the neck he needs for his job as a driver. I have advised to my patient to practice at home the exercises driving the cervical rotation and side bending from bottom - up in the following 7 days before next appointment. I feel that it is very important to use the learnt skills in practice as soon as possible before they are forgotten. This was a good opportunity to try newly learnt approach to the treatment.
2.10.2012 A returning patient case
The patient I have treated since the summer clinic back on the beginning of the third year has returned for a treatment today. Pt presented with resolving LBP, neck pain that returned since 1 month ago and a very acute R TMJ pain. After presenting the case my tutor recommended to me to have a look at the neck and TMJ on that day. However I felt I wanted to check on any improvement of the muscle balance and strength in the gluteal area and VMO muscles as 2 months previously when I saw my patient for the last time, I prescribed her exercises to do. As the tutor came to the treatment room I still haven't had looked at my patient's neck or TMJ. He repeated again that he thought that the reoccurring and the new problems were the main areas to look at. I ended up massively overrunning my appointment that stressed out my patient which had other commitments somewhere else. I felt pretty unhappy about the way it went. My tutor sat down with me and explained that I have to learn to prioritise the problems. It is not acceptable to overrun by 30 minutes. He understood that I tried to be holistic and not only to look for tissues causing symptoms. In real practice I could not afford running late. I realise that I need to work on my time keeping skills.
16.10.2012 Intra oral examination
My returning patient had 2 weeks to think about the intra oral examination we proposed on her last treatment. She signed consent and I was ready with the latex gloves on to examine the pterygoids. I found the examination quite weird as I didn't feel anyones apart my own pterygoids before (and mine are pretty tight) so it was difficult to establish what the tone of the muscles was. My tutor M.S. was happy to help me and confirmed that even pterygoids are supposed to be in a healthy softish state and not too tight. My patient's pterygoids were tight and the inhibition seemed to work quite well and the deviation of the jaw on the opening was less after the treatment than before the treatment. I have learned one more thing: always ask the patient if they are not allergic to LATEX!
16.10.2012 My first successful Csp HVT in the clinic!
The patient from the new patient clinic from last week returned and felt much better. On the examination I found that the C3/4 on L did not move very well so after HVTing Tsp I attempted with confidence to HVT his neck. I was successful and this time it was not only a matter of luck. I practiced the neck HVT for a whole week and I think what helped the most was my colleague's feedback about compression I was not applying and thus I couldn't have had a good control of the neck. I tried then HVT neck of a first year student in the clinic when we had a quiet time which was successful too. I am very pleased about it.
However as every story, this one has a big BUT in it too. I wanted to check my patient's blood pressure as he reported on the first appointment that it was measured as high previously and never followed up afterwards. I completely failed as during 2 attempts the cuff on his arm was separating and it was then my patient who figured out that I put the cuff on his arm incorrectly so he put it on right and I could measure his BP successfully then. What an embarrassment! My clinic tutor found me all flustered in the treatment room, getting hot and uncomfortable. The lesson learned is that I need to practice my DCP more often!
However as every story, this one has a big BUT in it too. I wanted to check my patient's blood pressure as he reported on the first appointment that it was measured as high previously and never followed up afterwards. I completely failed as during 2 attempts the cuff on his arm was separating and it was then my patient who figured out that I put the cuff on his arm incorrectly so he put it on right and I could measure his BP successfully then. What an embarrassment! My clinic tutor found me all flustered in the treatment room, getting hot and uncomfortable. The lesson learned is that I need to practice my DCP more often!
29.10.2012 A new patient with psoriatic arthritis
What an interesting coincidence. During the break between clinic and technique class I sat down with my colleague MH and we revised spondyloarthropathies - AS, psoriatic, reactive and enteric spondyloarthropathy. With memory refreshed then few hours later I have accountered a patient which presented with pronounced kyphosis and diagnosis of psoriatic artthritis. It was interesting to see how the textbook description of the symptoms and sites of the body affected matched to the patient's presentation. However we could not for sure confirm if his kyphotic curve was a result of a sedentary life style and a bad posture or it has been a result of ankylosing due to psoriatic arthritis. The case history took 40 mins to take as it was quite extensive but all the problems (diabetes, CVS, dermatological, vit B defficiency) were monitored by a specialist or GP so the patient was safe to treat as I diagnosed him with spondyloarthritic changes and overextension of L4/5 and L/S. Lesson to learn from this experience was not to believe if the patient says that have sciatic pain. I assumed naively that GP would diagnose the pt with sciatic pain as I understand it but on the further questioning I realised that the pain he ever had was in his buttock only, never going to his LEx at all. This could represent a picture of the LSp facet or SIJ irritation. And one more thing I managed to mess up was one SIJ I forgot to examine. Still feeling flustered and nervous in front of the tutor and colleagues I guess getting absentminded/scatterbrained.
6.11.2012 A new patient with the earphones and chest pain
today i saw a patient which was supposed to be seen as a returning one but as i couldn't obtain his file from anywhere, and as he was seen 6 month ago for the last time, I saw him as a new patient on the end. He had a real attitude and was quite unhappy about the fact that instead of 40 minutes he was to have an 80 minutes appointment. He kept his earphones on while taking the case history so I asked him if he could hear me ok. he said yes, that his iPod was switched off. He really wanted only massage :0) He had a LBP but different type and intensity and location than 6 months previously. He also mentioned that since the onset of the LBP in february 2012 he started to smoke and eat a lot and decreased the exercise regime that lead to him putting on 3 stones, weighting now 19 stones being only 5 feet 9. He also complained of the chest pain and tightness and he thought it was normal. His attitude started to meld down towards the end of the case history taking. My observers reckoned it was down to the sense of humour i had with him.
He was surprised that i decided to take his blood pressure as i walked into the room with the stethoscope and sphygmomanometer. His BP and heart rate were fine. on the physical examination i found him being overweight really difficult to feel the LSp and i suspected a step in his spine that my tutor confirmed but she did not worry about it too much as it seemed to be very small. We will be keeping an eye on it. I worked on his pelvis as i found a torsion in it that helped to even out the imbalances. The guy with attitude seemed to enjoy his appointment and on the end called me his surrogate mother :-). I have advised to him to stop smoking and change the diet. I think this is what made him to feel like i was his mum.
He was surprised that i decided to take his blood pressure as i walked into the room with the stethoscope and sphygmomanometer. His BP and heart rate were fine. on the physical examination i found him being overweight really difficult to feel the LSp and i suspected a step in his spine that my tutor confirmed but she did not worry about it too much as it seemed to be very small. We will be keeping an eye on it. I worked on his pelvis as i found a torsion in it that helped to even out the imbalances. The guy with attitude seemed to enjoy his appointment and on the end called me his surrogate mother :-). I have advised to him to stop smoking and change the diet. I think this is what made him to feel like i was his mum.
13.11.2012 A new patient with anxiety, depression and bilateral knee OA
I did not do too well today when it came down to being a safe practitioner. I had a new patient that wanted to get treatment for her OA knees. she also presented with everything that could be possibly wrong so it took too long to take the case history. I asked her on the end if she had any P&N numbness or weakness anywhere in her body or any other pain. And she said yes: in feel pins and needles when sitting for too long, then it takes up to 15 minutes to move around to get rid of them. She also complained of the pain and pins and needles in her 2nd and 3rd digits of the upper extremities bilaterally, she experiences every other morning and can not straighten her fingers immediately and it takes some time to exercise them so they move fine. she also complained of the bilateral shoulder pain in the night and in the morning. I have failed to ask enough questions to make sure she was safe to treat. My tutor stressed that it does not matter how long the case history is going to take but it is important that we have good understanding of the overall health of the patient and she or he are safe to treat. I felt that it was more important to treat her knees rather than to screen for problems in the upper extremities and make sure i understood well her overall health state. Good point to remember. And another fail leading to remembering that important point...... Rather make mistakes now when you are allowed to make them. You are learning and thus you are allowed to make mistakes. More mistakes you do more you learn..... I know... This patient was a nightmare patient for me..... but it was good to experience it now rather then during the CCA exam.
Im thinking now that maybe the basket weaving she does could perhaps effect her fingers.... must ask her more details about it next time.
Im thinking now that maybe the basket weaving she does could perhaps effect her fingers.... must ask her more details about it next time.
20.11.2012 A patient with bilateral mastectomy and the right shoulder pain
Today I treated a returning patient that originally presented with LBP but today she came back to get some exercises she was promised by a different student and also complained of the right shoulder pain on swimming backstroke (but not always). I had to disregard the exercises request and examine her shoulder. I was puzzled as to she had bilateral mastectomy and her latissimus dorsi muscles were used for breast reconstruction. I couldn't appreciate what and how much effect this surgery had on the shoulder mechanics. however it was not that different to a shoulder of a patient that wouldn't have such an invasive operation undergone. The downside of the examination was I could not reproduce the symptoms!!! I palpated, did muscle resistance test, active and passive examination. the only finding was that the external rotation was slightly limited. As i finalised the examination the tutor came in and it was embarrassing for me to see how easily he could reproduce the symptoms on the biceps brachii examination that was much more firmer that what i did. He found a tendonitis of the short head of the biceps and he also found a tender point in the subscapularis muscle. I felt so stupid again as i did not think of the short head of biceps at all..
with my study group we have planned to master the shoulder joint on friday this week. hope it will help me to improve the shoulder examination technique and specifically its effectiveness.
with my study group we have planned to master the shoulder joint on friday this week. hope it will help me to improve the shoulder examination technique and specifically its effectiveness.
2.1.2013 A patient with bilateral pins and needles in hands and feet
This patient I saw today was only 19 and the case history taken 1 month ago by somebody else had some unclear areas. As she was booked for a double slot because she wanted us to look at her ankles, my tutor wanted me to clarify some missing data so we were on the safe side. This young lady suffered from the iron deficiency anaemia that has been going undiagnosed for a long time and diagnosed 3 years ago after the patient managed to sleep for 4 days due to fatigue. Her GP told her that the P&N she experienced were due to the anaemia. However one must not trust somebody's else diagnosis and I was challenged to investigate this symptom myself. I did neurological examination including tonus and clonus, babinsky response, SLRT, femoral nerve stretch, reflexes, power, pinprick and soft touch. I checked the pulses (radial, dorsalis pedis and tibialis pulse). My tutor wanted me to check her thyroid but as i have never done that before I asked him to do it. He didnt find any enlargement and I was happy to come up with the conclusion that indeed the patient has P&N due to anaemia. Afterwards I asked the tutor to teach me how to examine the thyroid. I need to find a notch of the thyroid cartilage for location, the noch of the sternum, the thyroid is located anteriorly just below the thyroid cartilage. It is not supposed to be enlarged or palpable. If it is further investigation with referal is needed.
9.1.2013 Patient with cellulitis
This elderly lady frustrated me so much as she was banging on about the previous 2 months of her life and not being concise. It took me 30 minutes to shut her up and explain to her that the cellulitis she had in her bilateral legs needs to be further treated by her GP by prescription of antibiotics. However I have to admit that I had no clue that cellulitis was a bacterial infection at all. Luckily i had with me in the treatment room my colleague that told me that. By now I have looked up more information about this infection and I suspect that my patient will probably needs to go to hospital to get intravenous treatment for the worsening cellulitis that did not react to the antibiotics she took for 7 days. I would presume that 83 year old lady will probably have immunity slightly compromised and in such cases cellulitis might be more difficult to get rid off.
9.1.2013 Patient with dropped cuboid
Apparently this condition is most common in young athletes and ballet dancers and also often caused by inversion ankle sprain. It is not very well recognised. The patient I have seen is overweight and does not do exercises as such but i have noticed that the foot where she had lateral border pain, also had pes planus (dropped medial arch). This was another condition today I did not know much about so I found it difficult to establish what I palpated and how to comprehend the findings. Normally the pain radiates into the medial foot on weight bearing and also into the fourth ray. on the palpation of the plantar surface the cuboid is tender and also palpating around the anterior ankle joint can be tender. Pt can complain of the pain on walking around the anterior ankle too. The cuboid is subluxed inferomedially due to peroneus longus musce exerting too much effort during the sport or dancing or while ankle sprain injury occurs. The tearing of the fibrous cubonavicular joint fibres and capsule surrounding the cuboid causes pain. the xray findings are usually negative as even very slight subluxation can cause a lot of pain but that amount of subluxation is not possible to spot on the xray that easily.
differential diagnosis:
Sinus tarsi syndrome
Lateral process fracture of the talus
Acute tendinitis of the peroneus longus tendon
Fracture of the anterior process of the calcaneus
Malalignment of the lateral ankle and subtalar joints
Fractures (including stress fractures)
Meniscoid of the ankle
Fracture or dislocation of the os peroneum (sesamoid bone in the tendon of peroneus longus).
Gout
Inflammatory and noninflammatory arthritis
Tarsal coalitions (in adolescents)
differential diagnosis:
Sinus tarsi syndrome
Lateral process fracture of the talus
Acute tendinitis of the peroneus longus tendon
Fracture of the anterior process of the calcaneus
Malalignment of the lateral ankle and subtalar joints
Fractures (including stress fractures)
Meniscoid of the ankle
Fracture or dislocation of the os peroneum (sesamoid bone in the tendon of peroneus longus).
Gout
Inflammatory and noninflammatory arthritis
Tarsal coalitions (in adolescents)
16.1.2013 Dropped cuboid not getting better :-(
My patient with dropped cuboid is not improving. Mr H., my clinic tutor however showed me the BLT technique today on the cuboid and the patient walked away without pain. However she was advised to get more comfortable orthotics as those she wears are too hard.
I have done BLT course last year and I think it is time to dust off some of the techniques and skills and try to use them. It seems that sometimes a gentle approach can be more beneficial that forceful HVT.
I have done BLT course last year and I think it is time to dust off some of the techniques and skills and try to use them. It seems that sometimes a gentle approach can be more beneficial that forceful HVT.
16.1.2013 New patient with IBS, asthma and TSp and LSp ache
I had a new patient today finally! She complained of the muscle fatigue in the UFT and LSp area. It was interesting to talk to Mr H., my clinic tutor that observed me while taking the case history. He noticed I am putting words into my patient's mouth, not letting them to explain what type of pain do they have but suggesting what it could be. It is apparently dangerous as when I ask them if the symptoms are worsening they usually answer yes. I need to think of asking more open questions.
As DD we thought of sheurmann's disease as she grew up quickly and played netball while teenager, somato visceral or viscero somatic reflex and effect on sympathetic outflow at lower Tsp, and muscular fatigue due to postural changes/adaptations.
She was a upper rib breather with extremely tight diaphragm that I tried to release and it was interesting to see or rather feel what was happening underneath my hands while working in the area as there were noises of the digestive organs coming out as the release was applied!
I have explained to her how she is supposed to breath and she was manipulated at T4-5 by my tutor as my HVT skills are at the moment non existant.
As DD we thought of sheurmann's disease as she grew up quickly and played netball while teenager, somato visceral or viscero somatic reflex and effect on sympathetic outflow at lower Tsp, and muscular fatigue due to postural changes/adaptations.
She was a upper rib breather with extremely tight diaphragm that I tried to release and it was interesting to see or rather feel what was happening underneath my hands while working in the area as there were noises of the digestive organs coming out as the release was applied!
I have explained to her how she is supposed to breath and she was manipulated at T4-5 by my tutor as my HVT skills are at the moment non existant.
13.2.2013 New patient that insulted everyone
This was one of the most challenging patients I have so far encountered in the clinic. This 76 yoa gentleman was bullying me, threatening me, reminding me about being slow, not answering all my questions so I could comprehend exactly what was the extent of his complain. This guy was insulting me, my tutor, my colleagues while walking down the corridor... he talked about his doctors with racist remarks. Once on the plinth he broke down and weeped quietly whole time i examined him and treated him.
On his way out he kissed me on both cheeks being greatful perhaps for the session going the way it went (2HRS!!!) He sucked all my energy and I felt unwell and developed headache as I was so focussing on his case and on handling of the whole situation. The girl from 2YrMM that was observing me was really supportive and praised me for handling such a difficult character so well. I was joking with the old guy and I showed care and interest in his problem that really helped. I did not take anything personally as I understood that this was his way of dealing with frustration and anger he had in his life (he widowed while his wife gave birth to his daughter) and i would imagine that his life was not easy. He mentioned "his Brenda" few times and i could feel that he never get over her death. very sad story. the chap mentioned 2x that he wished god would take him away from this world. some serious yellow flags here i thought.... however more that coming up with differential diagnosis and treatment plan this was a massive lesson to me how to handle a complicated personality. I still think that he will be difficult in the future but i feel that we established some kind of relationship where he feels trust towards me.
I am pleased that this was not my CCA patient! hopefully those will be a bit easier :-)
On his way out he kissed me on both cheeks being greatful perhaps for the session going the way it went (2HRS!!!) He sucked all my energy and I felt unwell and developed headache as I was so focussing on his case and on handling of the whole situation. The girl from 2YrMM that was observing me was really supportive and praised me for handling such a difficult character so well. I was joking with the old guy and I showed care and interest in his problem that really helped. I did not take anything personally as I understood that this was his way of dealing with frustration and anger he had in his life (he widowed while his wife gave birth to his daughter) and i would imagine that his life was not easy. He mentioned "his Brenda" few times and i could feel that he never get over her death. very sad story. the chap mentioned 2x that he wished god would take him away from this world. some serious yellow flags here i thought.... however more that coming up with differential diagnosis and treatment plan this was a massive lesson to me how to handle a complicated personality. I still think that he will be difficult in the future but i feel that we established some kind of relationship where he feels trust towards me.
I am pleased that this was not my CCA patient! hopefully those will be a bit easier :-)
12.3.2013 - Patient with the knee pain
This young female patient was training to run marathon when her R knee started to hurt and got swollen. On the examination there was tenderness and swelling on the anteromedial side of the knee and my tutor suggested that it might me a plica syndrome. I treated the patient very conservatively and the problem started to slowly calm down. However Mr Stewart sugested that on the third treatment we will be looking at the way our patient was walking. she had very limited dorsiflexion of the feet that disallowed her during swing phase to carry the back foot forward without dragging the toes on the groung, so she had to start to use her anterior tibial muscles to extend the toes. Her feet were very stiff and had pronounced arches. Her hips were limited in extension and her whole pelvis was posteriorly rotated with very weak gluteal minimus and medius muscles. Mr Stewart suggested exercises to stretch ant. tibial muscles and calves to start with. I was treating specifically area around hips and knees. Her symptoms disappeared completely after 7 treatments.
19.3.2013 - Strain counterstrain - unimpressed patient
I have treated today a follow up patient i have not seen before for his lower back pain. as he has been treated by HVT all the time and his back pain came back every week, i decided to use strain counterstrain techniques. During the release of the psoas muscle, i could feel a strong pulsation feeling under my palpating thumb that was a good signal. I was pretty happy with the way the treatment went but i felt the pt was not very happy what i done as he asked me if i was not going to HVT him. i said that it does not seem to be helping for long enough and i would like to try something less invasive to see if we can achieve the difference. I was so puzzled however from his HVT demanding attitude i forgot to re examine him to find out if the ROM and discomfort decreased at all... I have feeling he might not be coming back as he even did not book a follow up appointment, explaining he did not have his diary with him so he would call back later to book in....
18.4.2013 - Patient with possible retrolisthesis
This young 25 year old male presented with headaches and neck pain and also with lower back pain. he had history of the his dislocation, 5x right shoulder dislocation, multiple fractures of this upper and lower extremity and lower back pain as teenager. his headaches were a concern to me as as he complained of some blurryness when he had them, but he always self manipulated himself and it gave him instant relief. I believe that as swimmer, he might have been compensating with his neck for the right shoulder he dislocated on many occasions. this cave him left and right sided restrictions in the neck.
his lower back shown signs of scheuermann's disease and on the very base of the flexed group of segments he had very mobile segment that could have qualify for retrolisthesis. it is impossible to say for sure however as only xray can confirm the hypothesis. but we suggested to him to start with exercises like pilates to stremgthen his abdomen to help to hold the weak link together. He has been back since then and his lower back is improving (he did 5 pilates classeds in one week) but his neck is bothering him still the same.
i have noticed his breathing pattern that i will need to help him with on the next appointment.
his lower back shown signs of scheuermann's disease and on the very base of the flexed group of segments he had very mobile segment that could have qualify for retrolisthesis. it is impossible to say for sure however as only xray can confirm the hypothesis. but we suggested to him to start with exercises like pilates to stremgthen his abdomen to help to hold the weak link together. He has been back since then and his lower back is improving (he did 5 pilates classeds in one week) but his neck is bothering him still the same.
i have noticed his breathing pattern that i will need to help him with on the next appointment.
29.4.2013 - Incontinence and lower back pain - Lets try to use DNS approach!
young female of 40 yoa presented with history of lower back pain in last 7 years. She also suffered from incontinence and urinary urgency since the birth of her first child at the same time. I identified that she did not have any control over her abdominal muscles, predisposing her to recurrent lower back pain. I used the knowledge i gained in DNS course and i was teaching her how to breath into her tummy in the 4 month baby position. she did well. She felt very nervous and impatient while doing the exercises. On the end of the session (i overrun by 45 minuts with her), she was curious to understand how the back works, what hurts, and why. on the further chat she told me that every morning she does stretching exercises. she showed them to me and i was horrified! she was doing all the movements that injure the disc she had already diagnosed by MRI as prolapsed. lots of flexion and rotation for last 7 years to 'help' herself to reduce the back pain were possibly doing opposite. i told her not to do those exercises any more and when she lifts anything i taught her how to brace her tummy and gluteal muscles in order to protect her back.
I felt that extra time i got with her was so significant. not having time to chat and answer all her questions, i would never find out about her routine being detrimental to what we wanted to achieve.
I felt that extra time i got with her was so significant. not having time to chat and answer all her questions, i would never find out about her routine being detrimental to what we wanted to achieve.
2.5.2013 - Patient with lost sensation in his left heel and lower back pain
This was after a very long time I had to refer the patient to the GP for imaging as he had lower back pain for over 10 years and in last 3 years developed numbness in his left heel and foot. on the examination he had diminished pin prick sensation only in the area mentioned. As not sure what is happening in his back i sent him off for investigation to reassure us he is safe to treat. I felt a little bit angry at my tutor as he was just standing there and watching me without any attempt to help me out with examination, perhaps confirm my findings and then later to help me to write the letter. I over run massively, taking in my next patient 20 minutes late. I know i have to deal with my patients on my own but this patient was not mine (well, it was mine today) , someone just booked them with me, they never thought it was relevant to do neuro exam when pt complained of numbness in the heel, even though in the notes it was mentioned! sometimes i feel frustrated as picking up some files means i am on the edge with frustration.