Whilst on a Musclo prac I came across a patient, whom I felt a little tricky to deal with. She had previously been treated by a private physio, with whom she felt comfortable with, and the only person she trusted to touch her neck. She no longer went to this physio, for financial reasons. She had come for treatment of a neck problem; this made it very difficult to assess her. Subjective questioning did not help, as she did not see the point of all the questions, or what they had to do with her neck problem. I was unable to get a clear pain diagram as she was there for treatment of the left side of her neck and therefore would not give me details of the problem on the right (which was an “entirely different problem”). Pain scores were another area which she felt unable to report. Objective assessment found reduced left cervical rotation, due to pain and stiffness. She consented to a neck PAIVM assessment, which revealed several stiff segments, which I felt required mobilisation. She did not consent to neck mobilsation treatment, and therefore initial treatment consisted only of a very light and superficial neck massage. She came back the next treatment session reporting that I had made her worse in that she had been walking with a friend for a hour later that day, her friend was on her left and so she was looking towards the left for the majority of that time. Towards the end of the walk she went to look towards the left once more and felt a ‘crick’ in her neck… the kind of one you get when you move your head too quickly and causes a lot of pain. She felt as though she was going to have to be hospitalised, telling her friend to call an ambulance if need be and list her allergies. After telling me this it was decided to take a ‘hands off’ approach, concentrating on her posture, which in my opinion wasn’t the best, but she said she thought it was good, as well as specific strengthening. I left the room to chat to my supervisor about my new plan, as I left the room she shouted out ‘What no mag’s?’ As in why hadn’t I given her magazines to read whilst I was not in the room. I replied I was terribly sorry, got her the ‘mag’s’, and then proceeded towards the supervisor.
In the end I treated her for the remainder of my time on prac, at which time she was taken over by one of the senior physio’s. I decided not to push the issue of pain scores or diagram’s as this made her upset. I didn’t touch her neck for the remainder of the time, except to demonstrate deep neck flexor exercises, however I made sure to get clear consent before each time. Also I agreed that her posture was good, however the chin poke and hunched shoulders could be improved on by the exercises I gave her. Giving reason’s why this could be contributing to her pain. After a few sessions I believe there was a good physio/patient relationship, I was even asked to mobilise her neck, if I felt it appropriate... I did not. In future, with similar patient’s I don’t think I will touch the neck at all.
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2 comments:
Sounds like a very tricky patient! I have heard of similar cases with one of my other collegues already just one week into my musculo prac! It seems that these types of patients (without trying to generalise too much) may query the effectiveness of physiotherapy altogether. In which case I may have asked them 'what do you think physiotherapy can do for you?' or 'what is your idea of physio?'. Often though from building raport and improving their symptoms over time they may begin to no longer question the effectiveness of physiotherapy and place more trust in you(as I presume in your case). Given that they were at first apprehensive with recieving mobilisations to their neck after the first incident, I wonder if it may have had to do with the fact that you were a student, knowing that your experience would be limited. I would not let this one incident spoil the rest of your future treatment of neck disorders, this seems like a one off, be confident in your ability.
Wow, this patient really is challenging. I agree with what Rowan said in asking that type of patient what they think physio can do for them. This patient obviously needs a lot of education regarding what physio does and also a lot of education about her neck disorder, particulalry if it is something that needs to be managed rather than being "cured" by a physio. Don't be discouraged with other neck patients, not all will be difficult, and this patient sounds quite unusual.
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