Reflection: 11/11/2020 Hours: 7
Today I had five patients in clinic, two with postural related neck stiffness, two with lower back pain and one with groin pain.
One of the patients with lower back pain I had seen a few weeks prior and was treating for muscular tightness in the glutes, piriformis and erector spinae and her pain was responding well to treatment. The plan for today’s session was to progress exercises and check her pelvic stability. However, she had come into clinic in severe pain which had progressed over the last few days, was an 8/10 and was on her spine, opposed to muscular. The pain was referring down her leg and was a sharp pain whenever she moved.
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 really slowly and within her pain tolerance, perform flexion and extension of the lumbar spine to assess whether the cause was soft tissue, facet joint or discogenic. I did not apply over pressure as I could see she was in a lot of pain and did not want to aggravate symptoms. 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 patients pain increased with lumbar flexion, so I tried the McKenzie approach to centralise her pain. She 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 very nervous and lacking confidence, as her pain was quite severe and she kept grimacing with pain when she moved, which made me reluctant to treat her. It has made me realise I don’t feel very confident with neurological tests which is something I need to practice.
What else I could have done/areas for improvement:
Improve my confidence and familiarise myself with neurological tests.
Practice neurological tests and revise myotomes and dermatomes to improve my confidence.
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.