WOW Strain-Counterstrain really does work!!‏

Well having not had good results with S-CS it's kind of fallen off my radar of late, but this was flagged up during my CCA feed back as one of my Tutors was Jo Holmden the S-CS lecturer.

She commented that she hadn't seen much S-CS from me and was curious as to why. I explained that the real reason was because I've be concentrating on techniques that I would likely use in a CCA and that S-CS wasn't one of them as I would really struggle to justify the physiology as to how the technique works. She appeared to understand my point of view, however suggested strongly that I made the most of the tutors whilst I still had them at my disposal.

One morning whilst in clinic a gentleman presented with pain and muscle hypertonicity around his first rib among other things. Having previously had a diving accident and an X-ray showing spondyloarthoris and spondylosis it was agreed that HVT to allow the first rib to rise in inspiration more smoothly wouldn't be the most appropriate technique .... what was I to do?? Well the answer was to see Miss Holmden and ask her to demonstrate S-CS for the first rib. Miss Holmden was more than pleased to show me the technique.

After the obligatory 90 secs the pressure was released from the tender point and the patient was unwound from his position of ease and then pressure was reapplied in order for the patient to report how tender it was now, the answer was "it wasn't tender at all". Still dubious that the disappearance wasn't due to the application and reapplication of some inhibitory pressure I was keen to objectively reassess the inspiration of his first ribs, to my delight they were moving bilaterally.

I was looking forward to this gentleman returning next week to see if this movement had been maintained. Next week soon came around and I was pleased to find that the ROM had been maintained and that the patient reported a 80% improvement in his symptoms.

OSPE Nightmare !!!!

Oh my word ... I'm embarrassed with myself after today's fiasco!!!

Well it was time to take my OSPE. This year the format was slightly different as in you don't move along different lanes to different examiners but stay at the one station for a 20 minute OSPE with two examiners .... I was being examined by Chris Thomas and Valeria Ferreira (good news as they put me at ease).

So it was two questions with a part A and a part B for each of the two questions.

Question number one was concerning the examination of the upper ribs, and a treatment of the soft tissue and a HVT. So I start off my technique. I go straight into treating the upper ribs with articulation. Okay so I'm a fourth year now so I thought I should do some fancy articulation of the upper ribs ... so with the patient supine I I palpate the rib angle with the one and and the anterior portion of the rib with my other hand and start to gently articulation the models ribs ... feeling rather pleased with myself I was then asked to demonstrate another technique to work on the the upper ribs .... so I ask my patient to turn on his side ... I pause and then pause some more and pause even longer ... I cant remember what to do.



By this stage the panic has set in and I barely remember where the ribs are let alone how to work on them. The tutors try to put me at ease and suggest that there may be an easier position to have the patient in .... so I ask the patient to lay prone .... again after some more pausing I still cant do it.

Okay I get a breather by the examiners, they instruct me to carry on with the second part of the question but tell me that we will return to the question as they will need to see another technique. The second part of the question was to demonstrate how to perform a HVT to rib 2. Thankfully I can demonstrate this and even more thankfully I don't have to perform the thrust on the model ... phew lol.

Okay question two and I'm still a nervous wreck as I still cant remember how to articulate the upper ribs with another technique but I need to focus with the question at hand.

Okay question two is about working on the LS facet. Okay I know this one. I start working on the soft tissues particularly the Glutei. Having been asked the attachments of the Glutei I start to reel them off ... did I just say that Gluteus Maximus is attached to the Great Trochanter ??? I start to back track and as I do I start to get myself even more confused ... how many gluteal lines are there ... how many did I say ... oh hell I not sure what I said at this point and I still have to demonstrate how to articulate those damn ribs (I feel sick). I manage to demonstrate how to HVT the LS.

Okay come on now Steve you can do this pesky rib. Okay I get the patient side lying again and I'm sure I have to life his arm somehow .. after some fumbling with his arm I'm asked to demonstrate it with the position prone ... hence the model turns onto his back for me ... again I fumble some more with his arm. Finally as the bell rings to finish the exam I remember the technique and quickly adopt the position ... I the examiners and the model all take a big sigh of relief .... cant wait to get the result of this exam !!!!!

Oh no look at that photo ... not only am I lay on top of a skeleton in my bedroom ... but look how thin my hair is getting :-(((

UPDATE 29/04/2010

OSPE Grade

Well it wasn't all that bad ... Picked up the result of my OSPE today
and I got a C high. I'm pleased with the grade as I thought it would
be a lot worse. The feed back wasn't unexpected however. I knew that
my nerves got the better of me and that this effected my ability to
recall simple muscle origins and insertions.

The most interesting part of the feedback was that I always tried to
show the most advanced techniques that we had been taught instead of
going for the simple but effective ones and building up to mire
complicated manoeuvres when prompted to by the examiners.

The head of 4th year technique gave the group some general feedback
also that after reflection I feel applies to myself. He advised us
that we really need to make our techniques and particularly our soft
tissue work the most effective and smooth as in today's current
climate patients won't allow for us to still be learning and
developing our techniques once were qualified as the patients will
simply see other practitioners if our treatment isn't effective from the
onset.

MET Scalenes

Having been having trouble with my approach to work on Scalenes we were taught a new method of treating them (along with all other anterior neck muscles) using an MET.

The technique is really effective, but you do have to chose the patient carefully as the technique requires the patient to support the weight of their head laying supine with their head off the table, you take some of the support away by asking the patient to take the weight of their head instead of you hence you engage all of the anterior neck muscles to perform the MET, then you stretch them with a posterior shift of the head and a nodding action opposed to extension.

Ive been using this technique a lot since it was shown to us with great results. Its important to provide an appropriate and individual amount of assistance with supporting the head during the isometric phase of the technique depending on the patients strength, fitness, age, condition, presenting symptoms and diagnosis. It is also paramount that the patient fully understand how to perform the technique before it is attempted, I often found that it was a good idea to perform an MET to another muscle such as hamstrings prior to attempting it on the anterior neck muscles (even if it was only for demonstration purposes opposed to treating the hamstrings).

March CCA Success

Criteria Title Description
Criteria 1 Case History Taking
Criteria 2 Examination Skills including clinical testing
Criteria 3 Osteopathic Evaluation and Clinical Reasoning
Criteria 4 Patient management and treatment plans
Criteria 5 Professionalism

Well I cant believe my grade ... I knew that it went well and I was confident that I passed ... but a A low !!!

Having received my feedback I finally feel that my experiences as a nurse have paid dividends as it appears that I received credit for my communication and therapeutic relationship building.

The pressure is off for the final CCA ... however I now feel that its actually still a pressure but in a different way as everyone is expecting me to do well and don't seem to be giving my any support for my worries and concerns !!!

CCA Summary