Clinical Experience 20th September 2019 – 1.5 Hour

Shadowing Graduate Therapist, Elliot 1.5hour
Overview of patient:
Lower back pain (L3- L4 lumbar)
Suspected disc herniation

Mechanism of Injury: slipped down stairs 5 years ago, had physiotherapy which initially helped but stopped when symptoms improved.
Recently driver on very uneven building site, bouncy chair with lots of sudden suspension movements incurring sudden sharp downward movements putting much force through spine while in flexion while seated.
Subjective: Band of ache across lower back, sharp pain when driving over bumps.

Current aggravating factor cannot be rectified due to the nature of his job, although patient is only on this site for the next few weeks. The therapist advised the patient to contact occupational health with regards to the seat and equipment, as this could be a contributing factor to the worsening of his condition.
Objective: Tested joints above and below, hip and thoracic spine. Hip tests negative but slight pain in lower back, but as expected due to limited flexion of lumbar spine.
Patient slightly tense and apprehensive. Limited flexion and pain during movements, in particular flexion.

After the initial tests, we discussed how to identify disc herniation and how to differentiate between this and facet joint dysfunction. The therapist explained that pain and limited flexion would indicate disc herniation and conversely, limited extension and rotation would suggest facet joint dysfunction. I hoped to learn more about the mechanisms of these injuries and conducted further research on this to further my understanding of the assessment process of lower back pain and in particular, disc herniation.

The treatment for this patient involved the McKenzie method of prone lumbar extension. I had not seen this being performed before, so it was an excellent opportunity for me to fully understand the treatment protocol and to start to understand the effectiveness and reasons for using this method of treatment for lumbar disc herniation as opposed to any other method.
According to Lam et al. (2018), the McKenzie method is used as a treatment and assessment tool and has previously shown good inter reliability; claims that their report have supported, but only with patients with chronic issues.

Clare, Adams and Maher (2004) highlights the importance of tailoring the treatment to suit the presentation of the individual’s injury and so protocol is not the same for all patients. In this particular session, with the patient prone on the treatment couch, lumbar extension was performed to limit of pain and/or range of movement before returning back down to the couch and repeating slowly for 10 repetitions. The patient used his hands and extended elbows but if this is not possible, it could be adapted and the patient can limit the movement by using elbows instead.

Petersen et al. (2011) conducted a randomized trial and found the Mckenzie method to be of greater effect than mobilizations and manipulation techniques for patients with back pain for more than 6 weeks by way of a significant decrease in the Roland Morris Questionnaire and other measurable factors such as pain, perceived effort, general and mental health. This trial found that improvements were seen in patients who have experienced lower back pain for at least 6 weeks; the report by (Lam et al., 2018) showed the McKenzie method had moderate to high evidence of effectiveness on patients with chronic lower back pain of at least 12 weeks, as opposed to patients with lower back pain symptoms of less than 12 weeks, whereby this method has be found less effective than others. It has been suggested that other methods can be just as effective, so trying a range of treatments is advised (Lam et al., 2018) and as such I would research other treatment options for lumbar vertebral disc herniation and make an informed decision based on the individual presentation of lower back pain.

I was also made away of the importance of using markers throughout rehabilitation sessions and programs. In this instance, re-testing the patient’s lumbar flexion by way of measuring how low he can reach with his fingers in forward flexion, allowed the therapist to measure the effectiveness of the treatment in the session, which in this case was the McKenzie method and strengthening exercises. The patient had less apprehension and a further range of lumbar flexion during the re-test at the end of the session.

These are the exercises that this patient was given to perform in this session and as a continual program over the next 3 weeks.
Exercises for increasing ROM and reducing pain:
Knee hugs 3sets of 10reps 1/day
Prone extensions 3sets of 10reps 1/day
Glute bridge (add drive from going onto heels) 3sets of 12-15secs (Gold standard 20-30seconds 1/day)

Bird/dog: Perform 10x cat camels to find correct position to start.
Slide arm and leg out in opposite direction 3sets 10reps 1/day

On leaving the clinic, the patient was advised that any change or worsening of symptoms were experienced, return to clinic in 3 weeks.
NHS guidelines suggest improvements from disc herniations can around 6 weeks from start of treatment.

References –

Clare, H. A., Adams, R., & Maher, C. G. (2004). A systematic review of efficacy of McKenzie therapy for spinal pain. Australian Journal of Physiotherapy, 50(4), 209–216.

Lam, O. T., Strenger, D. M., Chan-Fee, M., Pham, P. T., Preuss, R. A., & Robbins, S. M. (2018). Effectiveness of the McKenzie method of mechanical diagnosis and therapy for treating low back pain: Literature review with meta-analysis. Journal of Orthopaedic and Sports Physical Therapy, 48(6), 476–490.

Petersen, T., Larsen, K., Nordsteen, J., Olsen, S., Fournier, G., & Jacobsen, S. (2011). The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: A randomized controlled trial. Spine, 36(24), 1999–2010.

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