Assessment In Clinic Assignment Internship

Daiana Branco
821-520-145
Thursday November 6, 2014
Andrew Clapperton

Part 1:

There are four different phases into making a clinical decision- making process;
the first phase is the evaluative phase. An evaluative phase is when the therapist has an
idea of what they think there patient may have based on what the patient had said as well
as based on assessment that would show what the patient is an isnt able to
perform.(Andrade, 2008, pg. 48) The steps to the evaluative phase include conducting a
subjective examination, generate preliminary hypothesis, conducting objective
examination, confirming clinical hypothesis, summarizing clinical findings and lastly
determining appropriateness for treatment.

Conducting a subjective examination is performed different in the event in which

a patient was referred. If the patient was referred to the RMT the therapist would either
agree or disagree with the previous health care practitioner (HCP) has diagnosed the
individual patient with. If the patients wasnt referred from another HCP then the
therapist would have to inquire about the patients health history as well as the main
reason for seeking massage therapy. The reason in which its important to conduct
subjective examination is because it helps the therapist have a better understanding of the
problem in which the patient has initially complained about. This allows for the Student
Massage Therapist (SMT) to built a picture in there mind as to what might be the nature
of their complaint. I conduct a subjective examination by asking my patient different
questions such as what they do for living, what does their job consist of doing, pain scale
and so on. By asking my patient different questions regarding their main complaint it will
allow me to have a better understanding knowing what the patient is experiencing as well
as what specific areas needed to be treated in order to help the patient. This step is linked
to the treatment plan because without understand any health issue the patient might have
the massage therapist isnt able to make a proper treatment plan in order to help the
patient.

Generating a preliminary hypothesis is when the massage therapist takes

everything theyve learned from the patient and makes an assumption on what they think

the patient may have based on what was said in the previous section. This step is
important to know as it allows the therapist to think about what the patient may have
based on the information they were given, as well as allow the massage therapist to
narrow down different test they may want the patient to perform to confirm their
suspicion. A SMT would use this step in clinical decision making to help in deciding
which tests should be conducted if they believe the patient might have positive results
based on the information that was previously provided. This steps links to the treatment
plan because it helps the SMT clarify later on during the treatment to see if there
preliminary hypothesis was correct or not. In the even that it was not the SMT would
have to go back and see where they went wrong and which other conditions could be
plausible for that patient.

Conducting objective examination is when the massage therapist performs

different assessment on the patient to clarify where and what is causing the patient pain.
This is important because by the therapist going through the different assessments such
as, postural assessment; vitals assessments; active, passive, and resisted range of motion
for muscle manual testing; and lastly orthopedic testing, all help the SMT narrow down
an individual impairment or condition. A SMT would use this step in the clinic as it
would allow the massage therapist to have a better understand on what the patient is and
isnt limited in doing, based on the results from all of the different assessments. As a
result the therapist can treat the impairment in which the patient presents with. This step
links to the treatment plan because the results that were found from the assessments will
show the massage therapist where the treatment needs to be focused. This may be certain
condition, what muscles are weak and lengthen, what tendons or bursae are impinged, or
the restrictions due to fascia etc.

Confirming clinical hypothesis is when the massage therapist looks back to their
preliminary hypothesis and determines if the initial suspicion was correct based on the
objective information that was conducted. If the clinical hypothesis werent correct then
the massage therapist would have to go back and see where they went wrong therefore
causing them to see what other tests can be performed. (Andrade, 2008, pg. 53)

Confirming the clinical hypothesis is important for a massage therapist because it allows
the massage therapist to see if there preliminary hypothesis was correct or not. If the
hypothesis was correct, it then shows the massage therapist that they are on the correct
path but leads to the next step, which is to think about what specific techniques they
would want to use in order to treat the problem. If the hypothesis was wrong then the
massage therapist would have to go back and fix what was done wrong. The SMT would
use this step in order to see if their hypothesis from the beginning was correct or not. If so
they would just have to think about what techniques they would like to perform which
directly relate to that impairment. In the event that the test were negative a secondary
hypothesis must be made further assessments must be performed to determine to
determine the underlying and as a result allow for more beneficial assessment which
directly link to the patients problem. This link to the treatment plan because by the
massage therapist knowing that there hypothesis is correct the massage therapist would
now have a better understand whats wrong with the patient.

Summarize clinical findings is when the massage therapist takes the information
from the subjective and the objective step and see what the patients impairments and
functional limitations. (Andrade, 2008, pg. 53) This step is important because it allows
the SMT to see what the patients impairments and functional limitations, which is
important to know in order to help them rehabilitate. Also its important because by the
SMT making a list of the patients impairment the massage therapist is able to use that
list to make outcomes in order to help the patient get back to their pre injury or condition
state. t. This links to treatment plan by letting the massage therapist knowing exactly
where the treatment need to be focused on in order to get the patients back to there
normal self. For example if the patient was limited in flexion, the outcome for the patient
would be to get them back into full range of motion in flexion which will be done by
treating the muscles that are shorten as well as relieve any trigger points if needed.

Determining appropriateness for treatment is when the SMT thinks back on

impairment and functional limitations and if the patient can safely be treated for the
presented condition or if they should be referred to another health care practitioner. This

step is important to know because the massage therapist doesnt want to cause more harm
to the patient. For example if the patient were to came in with elbow pain and they
werent able to flex the elbow the massage therapist would see how far the patient able to
go if there not able to perform at least one hundred and four degree then it means that
something is wrong with the patients elbow therefore causing the patient to be referred
for a x-ray. (Clapperton,2014) The student massage therapist would use this step during
clinic in order to help the massage therapist understand whether or not the patient needs
to be referred or not based on how off his range of motion is as well as response to
manual muscles testing and orthopedic testing. This links to the treatment plan because
based on the therapists findings, results and seeing how much range of motion the
patient has it will determine whether or not the patient should be referred. Also its

Part 2:

Subjective:

I had treated patient ID: 100934, she is a student at Humber studying early
childhood education (ECE). Since she was a returning student to the clinic I had asked
her if there were any chances to her health history, which there werent her health
history form was good she didnt have any health issues that I needed to be aware of as
well as any recent injuries or surgeries. Her main complain for seeking a massage was
shoulder and lower back pain. The patients short-term goal is to feel better and as for his
long-term goals is to be able to seat without feeling pain and also having no more
shoulder pain. As for pain assessment I made sure to go over the pain assessment with the
patient so I had a fully better understanding what happened as well as where she is
feeling the pain. Majority of the patients pain was located on the thoracolumbar region,
the pain had started recently after the shoulder pain had occurred the thoracolumbar pain
radiates down her leg but doesnt affect her activity daily living. She described the
quality of the pain as first dull but then sharp when its really irritating her. She ices her
lower back to help relieve the pain

Preliminary Hypothesis:

Once the subjective step was done I started to think of the different information
that I had gathered from the patient based on her health history form and all the different
information that she provided me with to the different pain questions that I had asked. I
then had thought about everything that my patient and I discussed during health history
and pain assessment that I started to build a picture in my head of possible ideas of what
the patient could possible have to be causing her lower back pain. For instance my
estimate guess is that both her right and left quadratus lumborum are both causing the
patient to have lower pain because of trigger point referral.

Objective:

Before I performed all of the different assessments on my patient in order to

confirm my preliminary hypothesis I had made sure to obtain consent for each
assessment as well as explain what I was going to, the ricks, benefits and the reason to
why its helpful. I didnt perform any vital as well as see her postural assessment because
she was a returning patient to the clinic but first time I had treated her.
I had asked my patient to perform range of motion of the thoracolumbar I had made sure
to rule out above and below. Above being the neck and below being the hip, my patient
had pain while performing flexion of the neck and knee. During her active range of
motion she had some discomfort as well as pain on her left side while performing right
lateral flexion. As for her resistance range of motion she has pain when performing
extension of the thoracolumbar of a pain scale of two. The special orthopedic test that I
asked my patient to perform was quadrants, which she was positive. I also did some joint
play and noticed that she has pain on L5- L3. I also performed some palpation to assess
the muscles and see if I found anything abnormal, I did notice that her left quadratus
lumborum has more resting tension compared to the right quadratus lumborum.

Confirm Clinical Hypothesis:

My clinical hypothesis was correct because I had guessed that her quadratus
lumborum was the issue to why my patient was experiencing lower back pain. When I
had asked my patient to perform the quadrants test she was positive on both side but felt
the pain more on her left side.

Summarize Clinical Finding:

After looking at all of the patients information the patient health history was
clear there were no changes to it. Her main complaint for seeking a massage was for
lower back pain. I had then gone through her pain assessment and learn that her back pain
had started only after a week she had shoulder and neck pain. She tends to feels her lower
back pain more when she is about to seat down or even at the stage where she is about to
stand up. Her lower back pain doesnt bother her during her active daily living, my
patients uses ice packs to relive the pains she is experiencing in her thoracolumbar. I had
noticed while my patient was performing the different ranges of motion she had pain with
flexion of the neck and hip while ruling out above and below. During active range of
motion my patient had pain on her left side while performing right lateral flexion. As for
resisted she only had pain during extension of a pain scale of 2. I also performed some
special orthopedic tests my patient was positive for only quadrants and had pain on L5L3 while I performed joint play to her thoracolumbar.

Determine appropriateness for treatment:

Based on the patients limitation I saw that the patient didnt have to be referred
everything she was limited on I was able to help her get back to some range of motion
and slowly progress into getting her back to her full range of motion.
Some techniques that I used during treatment were effleurage, c kneading, wringing,
specific kneading such as palmar and fingertip kneading and lastly trigger point
techniques. All of these techniques were important and useful helping my patient main

complaint because each technique separately helped with getting movement to the muscle
which then progressed into specific more techniques that helps the specific areas on the
muscle and muscle fibres on how to make the muscle less tense and more moveable.
Some modalities that I used on my patient was using the hydrocollator on her lower back
to help get the muscles warm so it would be easier for me to target them and relieve any
tension or trigger points thats causing the patient pain.

Reflection:

Things that I believe I did well would have to be listening to all the information
gathered from the patient in order for me to have a better understanding exactly what the
patient has and what tests can be treated for those areas. Keeping patient confidentially
just between the patient and I. As well as helping my patients get back to their full range
of motion as well as relieve any pain or tension they may be feeling. For instance I helped
relieve neck and shoulder pain that my patient was experiencing about a few week back.
This week I have been working on my patient quadratus lumborum and trying to get full
range of motion back as well as relieve any trigger points that they patients has. Things
that I would do differently would be to ask more questions, as well as when the patient
says they feel pain to ask on a pain scale one out of ten how much pain there
experiencing. I need to try and think out of the box. For instance if a patient came in with
shoulder pain, I have to think of what areas are being affected such as what needs to be
stretch and what needs to be strengthen in order to help my patient to get full range of
motion back. Also think of what areas of the body may be causing shoulder pain instead
of just focusing what is above and below the injured area.

Application of findings to the treatment plan:

After finding out the patients finding I would make a safe and effective treatment
plan for the patient by incorporating the patient in the treatment by letting the patient
know exactly what is going to be done, how its going to be done. I would first start the
treatment with assessing the patient to see if there range of motion is the same or if it has

improved. Then I will perform techniques such as effleurage, c -kneading, wringing,

specific kneading palmar and fingertip kneading and lastly relieve trigger points. Once
treatment is done I will then reassess the patient and if they gain any range of motion
back and then lastly provide them with take home exercise to help them strengthen the
affected muscle.

Reference List:

Carla-Krystin Andrade, (2008). Outcome-Based Massage-From Evidence to Practice.

2nd ed. Toronto: Paul Clifford.