Marjon Clinics – 3rd November 2020 for 5 hours

During my timetabled slot in clinic this week, I treated two different clients; the first patient had a previous disc herniation so subsequent guarding of the lower back muscles and the second patient  we believe to have femoroacetabular impingement (FAI) in the left hip.

Reflective Summary

In order to optimise learning during placement, it is important to consider theories that underpin methods that promote or guide a learner’s reflection (Husebø, Regan, & Nestel, 2015). Using a reflective model can help me to focus on self-awareness after an incident and prevent the learner from describing events, thus critiquing it instead (Barksby, Butcher, & Whysall, 2015). An example of a model is Gibbs reflective cycle which is a theoretical framework comprised of six stages, that can be used to guide reflection and improve critical thinking skills (Ardian, Hariyati, & Afifah, 2019). This reflective cycle recommends that reflection should take place after experiences, so learning can be enhanced by involving feelings and thoughts, as well as recommendations for the future (Husebø et al., 2015). The six stages of Gibbs theory are as follows; describe the event, identify feelings, evaluate the experience, analyse the experience, draw conclusions and compose an action plan (Barksby et al., 2015). I will attempt to implement this model into my placement evidence, so that my reflections are critcal rather that descriptive. Subsequently, this will help me to identify the subject specifc and transferbale skills that I have improved upon.

The first client had a lumbar disc herniation, so was experiencing guarding of the lower back muscles due to centralisation. The patient previously had sciatic pain, but exercise prescription had stopped both the sciatica and the lower back pain, however since lockdown the back pain had returned due to work commitments so they did not have enough time to complete the exercises. I felt confident with this case study as I understand the biomechanics of the spine so could begin to think of exercises that could implemented, as well as the movements that should be avoided; 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). Whereas during 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 is known as the disc dynamic model. Considering this model, the first exercise I gave the client was McKenzie (prone extension) (Bo & Park, 2012), 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 (in this case extension) (Murtezani et al., 2015). The other exercises prescribed focus on improving core strength; A study by Javadian, Akbari, Talebi, Taghipour-Darzi & Janmohammadi (2015) found that patients with non-specific chronic lower back pain who completed core stability and general exercises were more effective than general exercises alone in the improvement of this condition. This is because core stabilisation exercise address intersegmental stability by facilitating neuromuscular control in the lumbar spine (Muthukrishnan, Shenoy, Jaspal, Nellikunja & Fernandes, 2010). Regarding treatment, I gave the client a lower back massage as they believe this helps there condition. Thinking ahead, as we were entering another lockdown, I recommended the use of Transcutaneous electrical nerve stimulation (TENS) machine for short term pain relief. Many studies have shown that TENs is effective for lower back pain (Bi, Chen, Li and Wang, 2015).Keskin et al. (2012) investigated the effects of TENs on lower back pain in pregnant women. They found that TENs is the most effective, easy to apply and safe treatment modality for back pain during pregnancy. Even though my client isn’t pregnant it still suggests that TENs can help with back pain.

After a thorough objective assessment, the clinical impression for the second client was FAI. The most clinically relevant special test for FAI was FADIR which is positive in 69.4% of cases (Carton and Filan, 2019). This test was positive for my client. From the clinical notes I can also recognise that in certain movements there was a reduced range of motion. The restriction is due to a mechanical block form the abnormal bony morphology of FAI (Carton and Filan, 2019). There are specific hip-related impairments in FAI which include hip muscle weakness (particularly hip adductors), lower trunk strength, poor single leg balance and lower functional task performance (Kemp et al., 2019). Therefore, I prescribed exercises that can help to improve hip strength while avoiding hip flexion as this increased the pain. Similarly, I advised them to begin cycling again so they can increase lower trunk strength, although the sit should be moved higher to prevent as much hip flexion.

Area for Improvement Action Plan
Need to be confident in my ability to perform the special tests at all the joints I will revise and then practice the different tests while considering the validity and reliability of each test so I am accurate with my selection
Perform palpations towards the end of the assessment as they can cause an undesired response of pain Next time ensure I do the palpations towards the end of the assessment
Ensure notes are as detailed as they can be Start to write the clinical notes up before the client comes into clinic so you know what you need to ask them and have a session plan in place
Consider alternative therapies (mindfulness, yoga, tai chi) as a coping mechanism for pain Look at the research into the different therapies to see which are effective

Closing the Loop

Firstly, as I have seen more clients it has given me the chance to revise the special tests at each joint, while making an evidence based decision with regards to the sensitivity (ability of the test to correctly identify those who are positive) and specificity (ability of the test to correctly identify those who are negative of the test) of the tests. For example when accessing laxity of the anterior cruciate ligament, (ACL) three tests can be used which have high sensitivity and/or specificity; Anterior draw test (SN =90-95.24, SP =86), Lachmans test (SN = 63, SP =90) and Lellis lever sign (SN = 94-98).Moreover, I always write my notes up before the client comes in, so I know what I am going to ask and have a session plan in place, but understand I may need to adapt it.

References

Al-obaidi, S., & Mahmoud, F. (2014). Immune responses following McKenzie lumbar spine exercise in individuals with acute low back pain : A preliminary study. Acta Medica Academica, 43(1), 19–29.

Ardian, P., Hariyati, R. T. S., & Afifah, E. (2019). Correlation between implementation case reflection discussion based on the Graham Gibbs Cycle and nurses’ critical thinking skills. Enfermería Clínica, 29(1), 588–593.

Barksby, J., Butcher, N., & Whysall, A. (2015). A new model of reflection for clinical practice. Nursing Times, 111(34), 21–23.

Bi, X., Lv, H., Chen, B. L., Li, X., & Wang, X. Q. (2015). Effects of transcutaneous electrical nerve stimulation on pain in patients with spinal cord injury: a randomized controlled trial. Journal of physical therapy science, 27(1), 23-25.

Bo, G. H., & Park, S. H. (2012). Kinematic Analysis of Lumbar Spine Depending on Three McKenzie ’ s Extension Exercises in Prone. Journal of Physical Therapy Science, 24(3), 271–274.

Carton, P. F., & Filan, D. J. (2019). The clinical presentation, diagnosis and pathogenesis of symptomatic sports-related femoroacetabular impingement (SRFAI) in a consecutive series of 1021 athletic hips. Hip International, 29(6), 665-673.

Husebø, S. E., Regan, S. O., & Nestel, D. (2015). Reflective Practice and Its Role in Simulation. Clinical Simulation in Nursing, 11(8), 368–375.

Kemp, J. L., King, M. G., Barton, C., Schache, A. G., Thorborg, K., Roos, E. M., … & Risberg, M. A. (2019). Is exercise therapy for femoroacetabular impingement in or out of FASHIoN? We need to talk about current best practice for the non-surgical management of FAI syndrome. British Journal Sports Medicine, 53(19), 1-9.

Keskin, E. A., Onur, O., Keskin, H. L., Gumus, I. I., Kafali, H., & Turhan, N. (2012). Transcutaneous electrical nerve stimulation improves low back pain during pregnancy. Gynecologic and obstetric investigation, 74(1), 76-83.

Murtezani, A., Govori, V., Meca, V. S., Ibraimi, Z., Rrecaj, S., & Gashi, S. (2015). A comparison of McKenzie therapy with electrophysical agents for the treatment of work related low back pain: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation, 28(2), 247–253.

Leave a Reply

Your email address will not be published. Required fields are marked *