This week I found particularly interesting, as I had a client with possible lumbar facet joint dysfunction and restricted range of motion (ROM) of the priformis. This was my first client with a lower back problem.

Reflective Summary 

The clinical impression for the first client was facet joint dysfunction at L3-4, accompanied by tightness of the piriformis muscle belly on the same side. There were many reasons why I thought the diagnosis could be lumbar facet joint dysfunction. Firstly, with regards to palpations we can access muscle spasm which is a common cause or accompaniment of lower back pain which is common with a facet joint problem (Devereaux, 2007). This could also explain why the client had tightness within the pirformis. According to Van Kleef et al. (2010) with a facet joint problem you would expect pain/stiffness particularly in hyperextension, which was apparent in this client. Furthermore, with a facet joint problem, due to the inflammatory changes around the joint, it can compress on the spinal nerve and cause sciatica (Van Kleef et al., 2010). The client had some referred pain down into the right glute which was causing a sciatic pain.

With regards to treatment mobilisations, specifically posterior to anterior (PA) mobilisations can be used to treat a case of confirmed lumbar facet joint dysfunction. PA mobilisations are rhythmic, oscillatory movements applied to the spinous or transverse process of a vertebra, in order to decrease pain and stiffness therefore improve ROM (Snodgrass & Odelli, 2012). With the lumbar spine the pressure applied to the spinous or transverse process needs to be applied perpendicular (90 degrees). They are usually applied for 30 seconds where each vertebral level gets treated three times (Snodgrass & Odelli, 2012). Therapists select one of four grades of mobilisations, that are described by the relationship between resistance or spinal stiffness palpated and ROM perceived by the therapist (Snodgrass, Rivett, Robertson, & Stojanovski, 2010); Grade 1 = small amplitude movement near beginning of range and not in resistance, Grade 2 = large amplitude movement well into range that is free of resistance and muscle spasm, Grade 3 = large amplitude movement into resistance and muscle spasm and Grade 4 = a small amplitude movement stretching into resistance and spasm at the end of the available range (Mahakul, Singh, Sahoo, & Samant, 2017). Grade 1 and 2 are used if the patient has increased irritability if the movement causes pain that lasts, whereas grade 3 and 4 can be used on a client who has low irritability as these grades provide the most effective outcomes as it causes the treatment to have an effect. For my client we started at a grade 2 then progressed to a grade 4 in order to target pain and stiffness.

It is also suggested that one mobilisation technique may be more effective than the other when applying it to patients with a certain distribution of symptoms; for bilateral symptoms central PA should be used to begin with whereas for unilateral pain use a unilateral PA (Kanlayanaphotporn, Chiradejnant, & Vachalathiti, 2010). My client had unilateral pain therefore oscillatory movements were applied to the joints in-between the transverse processes (Snodgrass, Rivett, Robertson, & Stojanovski, 2010).

My client was also experiencing pain and tightness within the piriformis. This was identified as they had pain on palpation as well as increased pain during internal rotation of the hip at 90 degrees. Muscular Energy technique (MET) specifically Post Isometric Relaxation (PIR) was used on the piriformis. METs are a method of soft tissue manipulation that incorporates directed and controlled, patient initiated, isometric and/or isotonic contractions, that are designed to improve musculoskeletal function, pain relief and increase range of motion (ROM) (Dhinkaran, Sareen, & Arora, 2011).The technique can be applied to muscle tightness, as well as joint dysfunction and joint capsule adhesions (Chaitow & Crenshaw, 2006). There are two forms of METs: PIR and reciprocal inhibition (RI) (Agrawal, 2016).PIR, which was used on the piriformis, consists f performing a passive stretch, immediately after an isometric active contraction (Popa, 2014). A study by Agrawal (2016) concluded that although both PIR and RI are efficient techniques in improving flexibility, PIR is more effective. Physiologically, the mechanisms of METs are not known, but it may involve central and peripheral function, such as activation of muscle and joint mechanoreceptors that use centrally mediated pathways (Fryer , 2011).

I also did soft tissue release (STR) on the piriformis and prescribed the client with stretching exercises for this muscle.

What Went Well

I believe I conducted a very thorough objective assessment and ensured I included combined movements and both static and dynamic observation. I also felt confident with my technique regarding soft tissue release (STR) meaning it could be as effective as possible.

Areas for Improvement	Action Plan
Know what level of the spine I am palpating.	Revise anatomy and practice palpating the vertebra of the spine, ensuring I am aware of what level I am palpating or mobilising.
Consider what stretches are effective for particular muscles by considering biomechanics and movements that muscles control.	If I am in doubt of the muscles that the stretch targets, think about the positions that the stretch puts the client in and how that relates to muscles that control certain movements.
Understand the correct positioning when conducting muscular energy techniques (METs) on muscle.	Practice and perfect the positioning for METs on a variety of muscles.

Closing the Loop

Since writing this reflection I am more confident with the level of each vertebra and what I am palpating. As I have become more familiar with different stretches, I can understand which muscle they target.

References

Agrawal, S. S. (2016). Comparison between post isometric relaxation and reciprocal inhibition manuevers on hamstring flexibility in young healthy adults: randomized clinical trial. International Journal of Medical Research & Health Sciences, 5(1), 33-37.

Chaitow, L., & Crenshaw, K. (2006). Muscle energy techniques. Amsterdam: Elsevier Health Sciences.

Devereaux, M. W. (2007). Anatomy and Examination of the Spine. Neurologic Clinics, 25(2), 331–351.

Dhinkaran, M., Sareen, A., & Arora, T. (2011). Comparative analysis of muscle energy technique and conventional physiotherapy in treatment of sacroiliac joint dysfunction. Indian J Physiother Occup Ther, 5, 127-30.

Fryer , G. (2011). Muscle energy technique: An evidence-informed approach. International Journal of Osteopathic Medicine, 14(1), 3-9.

Kanlayanaphotporn, R., Chiradejnant, A., & Vachalathiti, R. (2010). Immediate effects of the central posteroanterior mobilization technique on pain and range of motion in patients with mechanical neck pain. Disability and Rehabilitation, 32(8), 622–628.

Mahakul, B., Singh, H., Sahoo, J., & Samant, S. (2017). Effectiveness of Maitland mobilisation technique on pain and hand functions in the postoperative management of Colles fracture. International Journal of Orthopaedics Sciences, 3(3), 397–399.

Popa , C. E. (2014). Study Regarding the Effectiveness of Muscle Energy Techniques in Treating Cervicalgias. Sports Society International Journal of Physical Education, 14(SP), 61-71.

Snodgrass, S. J., & Odelli, R. A. (2012). Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly. Physiotherapy, 98(1), 47–56.

Snodgrass, S. J., Rivett, D. A., Robertson, V. J., & Stojanovski, E. (2010). Cervical spine mobilisation forces applied by physiotherapy students. Physiotherapy, 96(2), 120–129.

Van Kleef, M., Vanelderen, P., Cohen, S. P., Lataster, A., Van Zundert, J., & Mekhail, N. (2010). Pain Originating from the Lumbar Facet Joints. Pain Practice, 10(5), 459–469.