STYC01 Clinical Reflection 1/4/19 @ 10

In the second half of the open clinic session I treated a client who had postural issues, therefore experiences achiness in and around the shoulder area.

Reflective Summary 

In the subjective assessment of the form the client explained that they had a dull ache underneath the medial border and around the superior angle of the scapula. On the VAS pain scale, they scored the right side a 5 and the left a 3. The objective assessment is made up of 3 components. During observation I noticed the client had rounded shoulders and the head was tilted slightly forward which suggested they had poor posture. When I palpated the medial border more trigger points were present on the right side. I also palpated the inferior angles of the scapula and the right side was higher up. I finally tested range of movement (ROM) of the lumbar spine by using flexion (which was limited), extension and side flexion and the cervical spine by using side rotation. From this I decided to use soft tissue massage of the trapezius and rotator cuff muscles to increase blood flow, decreasing tension. I also used soft tissue release to separate fibres in order to lengthen the shorter ones.

Areas for further improvement 

In this session I believe I wasted time as I took too long to fill out the clinical consultation form. I need to improve this as it meant I did not have the time to k tape my clients back in order to adjust their posture. For next time I could save time by using more abbreviations on the form. I also could have advised the client on home exercises/stretches.

Things to remember 

  1. Use abbreviations as much as possible to speed up the process of filling in the clinical consultation form
  2. Soft tissue massage is not used all the time
  3. When performing an objective assessment of the back ensure the client has their top off

 

 

 

 

 

 

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