STARES 1

SITUATION

A young woman had been referred by her GP for physiotherapy assessment, treatment and advice. Her presenting complaint was right-sided pain in her neck, shoulder and arm along with some pins and needles in her forearm. The onset of symptoms had been associated with her task at work, and consequently a workers compensation claim was undertaken. To qualify for workers compensation she required proof from relevant medical professionals as to the relationship between her injury and her tasks at work. The task was working at a supermarket checkout which involved reaching and lifting objects placed on her right side, just over arms length away and some weighing up to 3kg. This involved extending her right arm and twisting to the right repetitively. In the 2 years she had been with this employer she was rarely switched to an opposing till that would require her to use her left, evening out the demand on the body, rather she remained at the same till for about 90% of her employment. This had resulted in a gradual wear and tear of her right side and a consequent injury in her neck and upper limb. On examination it was found that she had sustained significant damage to her rotator cuff with positive impingement signs and tenderness on supraspinatus and supscapularis tendon palpation and stretch. Her neck was tight throughout with muscle spasms, decreased left rotation and left side flexion and her neck pain was reproduced at C3, 4 and 5. She also complained of pins and needles on abduction and elbow extension with left side flexion (stretching the nerves) and had a positive neurodynamic tests for median and ulnar nerves. From this information we agreed that the injury was work related and that the claim should be pursued. We then applied appropriate treatment to mobilise the neck into the direction of restriction, used electrotherapy to settle the swelling around the shoulder and provided stretches for the neck and shoulder.

TASK:

In the above described situation I was working with a fellow physiotherapy student from the Curtin GEM program, under the supervision of Robert Lane, the Margaret River physiotherapist. The two of us has to assess this young female, apply the relevant treatment and then present our findings to the GP and the supermarket manager to be documented on the workers claim report.

ACTION:

During this session we discussed appropriate assessments and treatment ideas and both had an attempt at applying these. I noticed that the Curtin student approached things differently and had a different understanding of the application of both assessments and treatments. For example they were doing the neurodynamic tests in one movement by putting them in the end position and then asking the patient to move their neck to change the level of pain, whereas we are shown to slowly add the components of the movement to further stress the neural tissue. I demonstrated our approach to neurodynamics to the student and the supervisor and it was shown that our method was far more sensitising. Another difference I noticed was the treatment of the neck. The Curtin student applied a side flexion PPIVM with the patients head on the pillow and swinging it from side to side as well as general PA to C3,4 and 5 with the patient in supine as they were unable to apply anything to the right side as it was too painful. Again I had to opportunity to show my clinical reasoning in this situation. I demonstrated a cradle hold PPIVM of side flexion as well as applying a side glide at EOR side flexion specifically at C3, 4 and 5.

RESULT:

From this session it was clear that there were differences in education in between the Curtin GEM program and the Notre Dame Physiotherapy course. In this situation I was able to demonstrate my learning and application of knowledge, which my supervisor was pleased with. We were able to improve our patient’s pain and available movement, as well as effectively translate our findings to the GP and supermarket manager. It was also a learning experience for both the Curtin student and myself as we were able to teach each other different approaches to assessment, treatment and clinical reasoning.

EVALUATION:

When evaluating my performance in this situation I feel I had a few strengths. Firstly I was able to demonstrate my ability and knowledge effectively to my supervisor, as well as to my patient and peer in a confident manner. This was a new experience for myself, as I have not yet felt confident in my ability to correctly assess and treat a patient. Secondly, my best strength was being able to demonstrate my approach to the Curtin student in a non-derogative way and combine it with her treatment and assessments as another option rather than a better one, even though my techniques proved to be more effective I was able to then teach the Curtin student how to do it and gave her the chance to try it. My weakness in this situation was efficiency. I have not yet established the experience to know what tests are needed and which can be disregarded in particular situations, therefore I am often very thorough, though this works to my detriment, as I am unable to see the patient in the 20minute slot provided.

STRATEGIES:

I think knowing that clinical placement is not only a learning opportunity for yourself, but also for your supervisor, patient and fellow students from other institutions changes your whole outlook on your clinical placement. Your teaching skills become just as important as your ability to learn. Also being confident in the way you present yourself and conduct the session has a large impact on how the patient perceives your ability and how they respond to your treatments. Be confident, learn and teach.