Patient G

G is a nice, joyful gentleman in the mid-60s, who lives with his partner with 2 cats.

The first time I ever met G was in 2020 January, the pre-covid era, when I was observing a senior colleague of mine at the university clinic. G is a bubbly and happy person, retired but worked in public affairs, and a bucket full of humour. He looks to be in a clean bill of health, with a steady gait, in fact, a bounce in his strides. That colleague of mine has now graduated and became a fully qualified osteopath.

Saved by the grace of God, I took over G’s case when I became lead practitioner this year. It is interesting to re-examine an ‘ex-patient’ of someone else’s. We were taught to take the important diagnosis, the treatments done, and patient’s responses to weigh out the patient’s expectation and our clinical reasoning of what the patient require to improve their recovery or vitality. But this gave me a chance to re-look at someone I thought I already knew, which is part and parcel of a reflective practice.

G is really interesting, he has a pre-existing asthmatic condition since young which faded away into the background during his adulthood, until, in his own words, ‘the coming of age’, which he said has been getting a little worse the last few years. Guess what his asthmatic triggers are? Cats and hay fever. He did mentioned his partner said it was either the cats or him, so he just had to deal with it.

Upon our conversation, or case history taking as one would call it professionally, G revealed a couple more interesting facts about his health which I would not have noticed. G have been living with gout but had it managed with medication, just like his hypercholestrolemia*, which was a concern for his very busy GP, which the investigation just faded away due to long waits and the multitude of tests the NHS** put him into. G did hint about not wanting to frequent hospitals or finding it hard to get an appointment at the GP, which we all can understand even though it is free and constantly subjected to abuse.

*High cholesterol levels **National Healthcare System England

G is fairly sedentary and at times surfing on the internet or some Netflix, definitely not playing around with cats. It’s interesting nothing much interests G. He does prefer to enjoy life with good food and indulge a little every evening with some wine or gin at times. Not a bad way to retire in fact since I do believe he has worked hard to get to where he is.

G originally came into the clinic presenting with pain and lack of mobility in his wrist, index finger and thumb on both sides and some issues around the right knee and calf region, for which my talented colleague took great care of and manage with G really well that this time after a whole 6 months of the clinic being closed, the leg issues has now disappeared or recovered so to speak. Also between then and now, G finally got our suspicion a little more confirmed with some imaging from the NHS, and also had a blood test for rheumatoid factors (RF)*. Imaging has confirmed arthritic changes, or simply put, bone remodeling in his thumb and index finger, thus increasing inflammation in the area and a maladaptation to the original function. But the hands were not G’s concern this time round when he came into the clinic after reopening. G came in for a curious case of shoulder issue.

*RF test measures the level of antibody protein (IgG-Fc) present in the patient’s blood produced by the immune system that attacks healthy tissues. It is normally less than 14IU/ml, RF values higher than this would associate with a higher tendency to develop rheumatoid diseases like Rheumatoid Arthritis (RA).

As G kind of know me from before, I felt that was good patient rapport built in seconds from our greetings at the reception. And because he was already comfortable, I had a simpler task for his case history as he did not feel that he has anything to hide, and also his previous impressions and experiences with us has been great which fostered this patient-practitioner partnership for the better of both of us.

G continued sharing while I listen intently, observing his fidgets in his seat, and constant adjusting of his face mask. That is when I got to know about his asthma even before screening his systemic health. Patients and practitioners are required to wear a mask to protect each other in the enclosed space of the clinic environment, unless there are clinical restrictions. G revealed that his concern instead was for his shoulder discomfort on both sides for this visit which kept me a little more on my toes. Stiffness and soreness had been bothering his left shoulder for about 3 to 4 weeks now, most probably from his sleeping posture, especially in the morning when he wakes, but did not affect his sleep much. And then 9 days ago, he had a trip on the platform at the tube station, falling onto his right shoulder, on his deltoid region, before a knock on his head, which brought on the right shoulder issue. G did not think much of it, so he did not get it checked by his GP, but also because he already had his appointment booked in with us down the line, so he thought it was not necessary to get it checked, and mentioned it would be the same protocol over again, Voltaren* for the muscle ache, and painkillers like ibuprofen, which he just does not like.

I asked a couple of cardinal questions to reduce the suspicion of a concussion. “Did you have any headaches, or fainting spells?”, “Did you experience any special senses like double vision or lost of hearing?”, “Any nose or ear bleed?”

G mentioned he noticed bruising here and there which did not raise any alarm for myself as it would be a common observable sign which is not present, neither on the arm, legs or head. He also repeated himself a couple of time on how he felt discomfort when he tried to move his neck, looking from side to side.

I stepped out of the clinic room to consult my tutor about G’s presentation, a common practice we have to do in student clinic to help us develop our clinical reasoning and skills to be fully qualified osteopaths. Because it is the first day of face-to-face with real patients, my team’s tutor were all caught up with other colleagues, so I got to present to B. I had brief interactions with B and I will say I hold her of high respect because of the multitude of experience she had, and also because I feel like she would have similar working or thinking style as myself.

Presenting to B was a breeze because I had the case history complete with ease from G because of the rapport I already have. I also came up a couple of clinical reasoning (hypotheses) for how G presented today, which was helpful to answer questions B had for me. I would say I was ready to pounce, eager like a beaver to confirm my hypotheses and get G feeling better, because that is my purpose.

Initial hypotheses:

• #1: Myofascial guarding of trapezius and muscles around the neck and shoulder region predisposed by the left side which was already sore or maladapting.
• #2: Muscle tear, if bruising is present, from the traumatic onset of the fall on the right, which would be confirmed by mechanical trigger in certain positions, and mild hyper-mobility of shoulder, instead of reduction.
• #3: The classic whiplash, which is commonly heard in a vehicular incident, affecting the mobile and unprotected column of the cervical spine (neck) when G fell side ways with an impact that travelled through the shoulder across to the midline causing some muscular guarding and irritation structures of the cervical or thoracic vertebrates.

After a short conversation with B, she gave the go-ahead.

Time to test out my hypotheses.

I came back into the room after putting on my apron and ugly gloves, which took awhile, and G was patiently waiting, still dressed, so I asked if he would like to remove his top so I can have a better look at his neck and shoulders. G automatically responded, getting up and got his top off.

Observe. Palpate. Test.

With G’s consent, I walked around him from his right to see if I can find bruising of any sort which could have been hidden by his top, and then behind him to observe any obvious asymmetry.

No bruising of any sort. -1 point for hypothesis #2.

Elevated trapezius and slight hypertonicity around the neck which means his right shoulder looks bulkier and higher than his left. +1 point for hypothesis #1.

With consent again, and also a warning that my hands might be cold due to the gloves and sanitising gel, I placed my hands to palpate this neck and shoulder region. His upper shoulders is definitely bulkier and more tart on the right. +1 point to Gryffindor yet again. But wait. The area between this shoulder blades, or scapulae as we call it medically, is interestingly soft on the touch, but has slight tenderness when I palpate more deeply. Seems like the issue is localised to this neck and above his T3 region. Slight confusion in data there. <<Cannot compute>>

Moving on, let’s assess his shoulder range of movement to cross check. Interesting enough, we see more active movement on the right than the left, which also means less muscular guarding and more activation possible on the right. That did not make any sense for now. At this point of time, B came into the treatment room to observe and make sure I was not beating up my patient into a pulp with my jiu-jitsu.

Not to worry, we still have not check the neck which was said to be the trigger of any discomfort he faced. So I got G to lie supine, facing up on the plinth. On I went with my hands behind his neck, with the full weight of his head resting on parts of my forearm, carefully and gently moving his neck into flexion, extension, segmentally rotating and side-bending and checking for any irritation or discomfort. Slight restriction on the C4–7 region, which is the lower part of the neck, but nothing significant or triggering any discomfort. So upon initial examination, nothing seems to have gone that wrong.

This is where B broke the silence in the room and said that I did really well and had a good flow and handling of G’s neck, she also expected I wouldn’t find anything obvious, and suggested I just continue to use my hands and finger tips to listen in to the structures of the neck, slowly scanning and allowing the patient and the structures to tell me what is going on. So basically, back to basics.

Superficial palpation. Deep palpation.

A few a few moments of scanning, segment by segment, still nothing. Maybe I could not make sense of what I am feeling. B asked to take over so she can show us what to focus in on. B slipped her hands onto G’s neck and in a few seconds, G’s face cringed a little. “X marks the spot.” B said. “Put your finger here and then scan around up and down the articular column and see if you can spot the difference.”

I felt a thing. Something. Something definitely different on that spot versus the higher or lower segments, but what do I make sense of it? “You felt it, didn’t you? That’s a joint capsule of a facet (zygapophyseal joint) irritation. Relax your hand and finger tips, now let me slide my hand under and guide you.” With that gentle palpation, the tissues allowed me in, and the whole sensation of my fingertips changes. I felt the specificity of the different muscles laying over the transverse processes of the cervical spine soften out and allowing me to feel through them. I felt a slight blobby bump, different from the fluidity of the other segments. I could even pinpoint which segment it was. Amazing feeling, every time the body tells you about itself.

B got G to lay side on exposing his back with his left shoulder stacked above, facing to the right. From this position, it was even more obvious, maybe because of the natural slight side bending from gravitational loading, the inflamed joint capsule was a little more pronounced, and I can safely say it was on the C5/6 facet joint, which is an irritation caused by a side-on whiplash mechanism.

B asked me about treatment plan for G for today. I suggested to be a little more specific to down neuro-modulating the trapezius off protection mode so we are able to access the deeper tissues of the cervical erector spinal group, the levator scapulae, and surrounding muscles that might influence neck movement through the upper back. At the same time, because the facet irritation is still in its acute phase of recovery and still tender on palpation after 9 days, it would be best to encourage fluid flow into the area through decompression to help the recovery process.

B suggested local area myofascial springing which she demonstrated before I took over the main bulk of the treatment process, and also traction and gentle figure-of-8 articulation of the neck to increase mobilisation.

So I took over and did some general effleurage to calm the tissues down before I did the springing technique B demonstrated, periodically asking G for feedback, which he gave his famous ‘it is a good sore’ comment when I got the correct spots or region. When I was given access to the deeper tissues, I asked G to participate with deep diaphragmatic breathing to encourage some tension from his pleural cavity and also increase the lymphatic pump which helps to stimulate the parasympathetic system to relax the structures more. I proceeded from the shoulder to the neck after, which I did some light traction to decompress the segments, specifically at the level of the irritation which G gave a nice sigh of relief and then a slight twinge which means I went a little to far. G is a very responsive and cooperative patient which made my job easier. The articulation work had a good feedback as well as G sat up and retested his neck mobility to find that I was easier to move and his shoulders felt more relaxed.

To put the cherry on top, I got G to just go through his neck rotation movement as I applied gentle reinforcement on this upper trapezius muscles to aid and re-educate the tissues to comply to the movement G was performing. Yet again an immediate effect which he said that it was not too sore and no pain triggers at all.

I left G with some advice of a warm towel over the back of his neck and shoulder whenever he feels stiffness or achy, and his response to that easy trick was good, that it’s simple enough he will give it a try.

First ever patient of my third year interviewed, examined and treated with advice given without any hesitation or doubt. Bravo Freddie, bravo. I think I was really living by grace on this first one. They say you will always remember your first patient, and it has to be G.

A note on confidentiality: The reflections that were written are from my limited clinical experience, but the patient in this has been disguised as to be unrecognisable – any similarities that remain are coincidental. Protecting confidences is an essential part of what I do: ‘Confidence’ means ‘With faith’ – we are all patients sooner or later; we all want faith that we will be heard, and that our privacy will be respected.