Reflection: 26/8/2020 Hours: 6
Today I had 5 patients in clinic, 3 who were suffering from neck and shoulder tightness, one with a calf injury and another with lower back pain.
The patient with lower back pain had referral of pain down the back of her leg. I cleared her for symptoms of cauda equina and then performed subjective and objective assessment which included a dynamic and static observation. During this, I asked her to perform flexion and extension of the lumbar spine and applied over pressure to assess the end feel to identify whether the cause was soft tissue, facet joint or discogenic. Pain during flexion with a hard end feel and pain, indicates a discogenic problem, while ROM in flexion or extension with a soft end feel and no pain suggests a muscular problem. Finally pain in extension with a hard end feel indicates facet joint dysfunction. I performed neurodynamic tests to rule out sciatica due to the referred pain symptoms (Pande, 2015).
The McKenzie Approach uses repeated movements (repeated extension commonly) to treat a discogenic problem, to centralise the pain, thus improving symptoms (Donelson et al., 1990; Holdom, 1996). The patient had pain in flexion and responded successfully to repeated extension, consequently I used this for treatment and prescribed extension as home based exercises.
What I was thinking and feeling and what was good or bad:
I was feeling anxious as this was the first time I had performed a full spinal assessment on my own (with supervision), including treatment and this was also only my second week back into clinic since lockdown. However, once I began the objective assessment I felt much less anxious and became more fluent. I kept trying to think back to my spinal assessment exam at the end of second year to make sure I was on the right track.
What else I could have done/areas for improvement:
Be more confident and don’t panic when I’m unsure. I need to become more confident in my knowledge, I feel nervous doing a spinal assessment as I get confused between discogenic and facet.
- Practice more theoretical spinal case studies to build my confidence
- Review patients progress next week to see if Mckenzie approach is working
- Read more journal articles in this area to improve knowledge
- Visualise the facet and discogenic anatomy on the skeleton to improve understanding
Donelson, R., Silva, G., & Murphy, K. (1990). Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine, 15(3), 211–213.
Holdom, A. (1996). The use of the McKenzie approach to treat back pain. British Journal of Therapy and Rehabilitation, 3, 7–10.
Pande, K. (2015). The use of passive straight leg raising test: A survey of clinicians. Malaysian Orthopaedic Journal, 9(3), 44.