This was our first face to face session with the clinic team, where we had an in depth introduction to Cliniko and discussed the subjective and objective assessment for a case study.
The case study that we explored was a 42 y/o male who has RHS LBP – onset 6/12. Hx of previous LBP for 4 years. The episode related to inc. activity level. P most significant during rounds of golf (VAS 6/10) and at night, and 1/7 after playing (VAS 3/10). Slightly overweight so plays golf to stay active. P1 = RHS of lumbar region and radiates down into buttock and posterior hip. P1 inc. with forward flexion. P2 = occasional groin P normally after 2 consecutive days of golf. MRI 3/12 – degenerative disc L5.
Observation (Look) = Firstly you would observe the client statically and dynamically. Dynamically, evaluation of gait is fundamental as it can allow us to recognise if an antalgic gait is present which could imply a lumbar radiculopathy, foot slap/drop that indicates weakness of dorsiflexors that can be found with an L5 radiculopathy or a trendelenburg gait where we would suspect lower extremity weakness (Devereaux, 2007). With a lumbar spine disc herniation, a lumbar radiculopathy is common, so this is why it is essential to check gait patterns.
Clear joint above and below = All joints above and below the lumbar that can refer or influence functioning of this section of the spine should be cleared (Manske & Davies, 2016). Therefore, for the lumbar spine thoracic rotation will be actively performed by the client with overpressure as the joint above, as well as cervical movements including flexion, extension, side flexion and rotation. The joint below would be the hip so all movements at this joint should be tested including flexion, extension, abduction, adduction, internal rotation and external rotation.
Palpations (feel) =When palpating different structures, we always assess if there is any tenderness, pain, deformity, trigger points, muscle spasm/wastage and/or temperature changes (Manske & Davies, 2016). Ensure that you accurately palpate the spinous and transverse process of the lumbar vertebra. It is also vital to palpate the paraspinous muscles to assess for muscle spasm as this may be a cause or accompaniment of lower back pain which is common with a lumbar spine disc herniation (Devereaux, 2007). Lumbar disc herniations are a very common cause of LBP because of the biomechanical demands placed on these structures, as well as their inability to change due to their avascular nature (Schroeder, Guyre, & Vaccaro, 2016). Some of the muscles that should be palpated include the erector spine, quadratus lumborum, abdominals, external obliques, piriformis, psoas major and latissimus dorsi.
AROM with overpressure (move) = With a lumbar spine disc herniation you would expect an increase of symptoms during flexion rather than extension. Saleem et al. (2013) agreed that people with a lumbar disc problem are more likely to get pain in sustained flexion such as bending, sitting down and driving and experience a relief of pain during extension. This is because during lumbar extension, the nucleus pulposus migrates anteriorly, causing the nucleus to move away from the innervated annular wall, which can centralise the symptoms as the nucleus will no longer be pressing on the spinal cord (Bo & Park, 2012). Consequently, in lumbar flexion the nucleus moves posteriorly towards the ruptured annular wall, increasing the symptoms (peripheralisation), as it causes the nucleus to compress on the spinal cord. This can cause unilateral/bilateral pain. This is because the pathological reason for sciatica is nerve root compression, on the same side as the symptoms so if the disc bulges posterolaterally it will cause unilateral symptoms and if there is a central disc herniation it would cause bilateral pain (Akdenİz, Kaner, TuTkan, & Ozer, 2012). If there is referred pain in the lateral thigh this can indicate a problem with the upper lumbar, posterior thigh can be lower lumbar and L4-5, L5-S1 could cause distal lateral leg pain although this is rare (Van Kleef et al., 2010).
We would check dermatomes, myotomes and neurodynamic tests as it has been suggested that a neurodynamic examination can assist differential diagnosis of lower nerve root compression (Trainor & Pinnington, 2011). Furthermore, as a lumbar spine disc herniation can cause bilateral symptoms an upper motor neuron lesion test needs to be conducted to analyse the integrity of the nervous system when a person is suspected of having a spinal cord injury (Manella & Field-fote, 2013). The presence of Hoffman reflex, clonus or Babinski sign can indicate a myelopathy so we would need to refer (Chikuda et al., 2010).
The dermatomes assessed for the lumbar are L1 (the trochanter and groin), L2 (front of the thigh to the knee), L3 (upper buttock, anterior thigh/knee and medial lower leg), L4 (medial buttock, lateral thigh, medial leg and big toe) and L5 (posterior and lateral thigh, lateral aspect of leg, medial half of sole, first, second and third toes) (Magee, 2014).
Myotomes are assessed using the oxford scale for muscle strength (Mulcahey, Gaugan, & Betz, 2009). For L1-L2 the client performs hip flexion, L3 is knee extension, L4 is ankle dorsiflexion and L5 is big toe extension against the oxford strength scale. If a grade 5 is not achieved with any of the movements it can indicate a problem with the nerve root at that specific level.
Finally, for neurodynamic testing I would use the straight leg raise (SLR); with the patient in a supine position, the symptomatic lower limb is elevated so that the sciatic nerve is stretched, where a positive test would be indicted if pain is reproduced when the lower extremity is between 30 and 70 degrees (Devereaux, 2007). I can also use prone knee bend (PKB) where this test has been shown to place a load on the upper/mid lumbar nerve roots via movement of the femoral nerve during knee flexion.
The McKenzie approach is commonly used in the assessment and management of disc herniations, in order to reduce pain and restore spine mobility (Al-obaidi & Mahmoud, 2014). The core component of treatment consists of repeated movements (5-10 reps) or sustained postures, that are performed in specific motion directions (Murtezani et al., 2015). The aim of this method is to encourage directions of movement that centralise the pain and to avoid motions that peripheralise the symptoms (Al-obaidi & Mahmoud, 2014). Centralisation is defined as the shifting of pain from a distal to a more proximal location to the spine. Three extension exercises, prone lying, prone lying on elbows and prone press ups are particularly effective in the treatment of lumbar disc herniations (Bo & Park, 2012). However, variations of these extension exercises may be useful in the treatment of lumbar disc herniations including static lumbar extension, dynamic lumbar extension with lateral overpressure using listing/lateral shift or dynamic lumbar extension with lateral pressure and overpressure. Try dynamic extension first, if the patient struggles to hold themselves up static extension can be used. If there is no centralisation in static or dynamic extension we can use dynamic lumbar extension with lateral overpressure or dynamic lumbar extension with lateral pressure and overpressure. The key thing is to use the exercise that centralises the symptoms the most. Once you have found the exercise that allows the symptoms to become more proximal you can subscribe an at home exercise prescription. Although, it is difficult to identify the most effective exercise prescription for McKenzie exercises when concerning the intensity, frequency and duration, as a large number of studies use different exercise prescription rationales for this treatment where it has been effective (Dunsford, Kumar, & Clarke, 2011). This implies it is specific to the client and each client may react different to the treatment where improvements may be varied regarding a specific time period.
I believe one of my areas for improvement would be to consider the clients subjective and objective assessment when prescribing the number of sets and reps for an exercise programme. This can be a multidimensional approach as sets and reps can vary depending on many different factors.
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