External Placement Exmoor Osteopaths Thursday 17th October 2019 – 4hours

During my placement today, three patients were attending follow up treatments and one was a new patient with an initial appointment. This was a great opportunity for me to get involved in the diagnostic process and getting used to performing special tests. In this instance, the patient presented with shoulder and neck pathology and presented with neurological symptoms. I am not confident in my knowledge of nerves and associated dysfunctions and as such, I was not afraid to acquire plenty of assistance from my supervisor. The notable unilateral neurological symptoms were that of pins and needles radiating from her shoulder, down the arm (Popinchalk & Schaffer, 2012).
Because of this subjective assessment, we proceeded to test for impingement of the shoulder and performed the following tests; crossover impingement test, supraspinatus “empty can test”, Neer’s, Spurling and Hawkins-Kennedy Impingement test (Bakhsh & Nicandri, 2018; Innocenti et al. 2018). Other upper limb neurodynamic tests ULNT) were performed, the reliability of which have been deemed good by Schmid et al. (2009). All of these tests were negative and my supervisor and I were unable to reproduce symptoms, however we were able to identify muscular imbalances, tenderness, tension of the shoulders and neck as well as restrictions in specific ROMs. In the absence of an exact diagnosis, we based our treatment on our thorough subjective and objective assessments and performed soft and deep tissue massage and mobilisations and exercises to increase movement in her shoulder (Dong et al., 2015; Peek et al. 2015) and neck (Lascurain-Aguirrebeña et al., 2018) with the aim to reduce any neurological symptoms that may occur due to impingement.
It has been reported that most symptoms will eventually subside regardless of treatment, however physical therapy such as soft tissue massage, stretching, strengthening and mobilisations such as traction are found to be most effective (Childress & Becker, 2016).

I am now becoming aware of the importance of objective markers in assessments and as such I made sure to test her ROM after treatment. Both measurements and patient feedback was very positive and as such felt that, although we could not give the patient a precise diagnosis, we were able to alleviate her symptoms and prescribe a stretching/exercise program to be performed at home to help maintain her ROM.

With each client, I have the opportunity to fully assess certain joint restrictions and, with the help of the supervisor, notice specific areas of restrictions, compared with previous patients and with contralateral sides. Being able to practice end feels and observing restrictions in movement on each patient and discussing findings with my supervisor has really helped me to gain experience in diagnosis not only the presence of a joint dysfunction, but more precisely, which joint (Pellecchia et al. 1996; Warth & Millett, 2015).

References – 

Bakhsh, W., & Nicandri, G. (2018). Anatomy and Physical Examination of the Shoulder. Sports Medicine and Arthroscopy Review. https://doi.org/10.1097/JSA.0000000000000202

Childress, M. A., & Becker, B. A. (2016). Nonoperative management of cervical radiculopathy. American Family Physician, 93(9), 746–754.

Dong, W., Goost, H., Lin, X.-B., Burger, C., Paul, C., Wang, Z.-L., … Kabir, K. (2015). Treatments for Shoulder Impingement Syndrome. Medicine. https://doi.org/10.1097/md.0000000000000510

Innocenti, T., Ristori, D., Miele, S., & Testa, M. (2018). The management of shoulder impingement and related disorders: A systematic review on diagnostic accuracy of physical tests and manual therapy efficacy. Journal of Bodywork and Movement Therapies. https://doi.org/10.1016/j.jbmt.2018.08.002

Lascurain-Aguirrebeña, I., Newham, D. J., Casado-Zumeta, X., Lertxundi, A., & Critchley, D. J. (2018). Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial. Musculoskeletal Science and Practice. https://doi.org/10.1016/j.msksp.2018.10.003

Peek, A. L., Miller, C., & Heneghan, N. R. (2015). Thoracic manual therapy in the management of non-specific shoulder pain: A systematic review. Journal of Manual and Manipulative Therapy. https://doi.org/10.1179/2042618615Y.0000000003

Pellecchia, G. L., Paolino, J., & Connell, J. (1996). Intertester reliability of the Cyriax evaluation in assessing patients with shoulder pain. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.1996.23.1.34

Popinchalk, S. P., & Schaffer, A. A. (2012). Physical Examination of Upper Extremity Compressive Neuropathies. Orthopedic Clinics of North America. https://doi.org/10.1016/j.ocl.2012.07.011

Schmid, A. B., Brunner, F., Luomajoki, H., Held, U., Bachmann, L. M., Künzer, S., & Coppieters, M. W. (2009). Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskeletal Disorders, 10, 1–9. https://doi.org/10.1186/1471-2474-10-11

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