Date: 27.11.20
Duration: 0900 – 1500- 5 hours
Marjon Sports Therapy & Rehabilitation Clinic.
Reflective Summary:
Reflection in Action (as it happens)
I had done some preparation for a follow-up appointment with a patient, who I saw last week, with a Grade 1 quadratus lumborum strain (QL). I researched different exercises to help strengthen the QL and had a substantial list. I will decide on which exercises to use depending on the patient’s ability to do them, during his appointment.
I checked my Cliniko appointments calendar yesterday evening to see if I had any new appointments, but there was only one appointment in the calendar.
I left home reasonably early to ensure that I arrived in clinic in good time. On the bus journey I checked my Cliniko appointments calendar and noted that a new appointment had been booked this morning. I did go into a little bit of a panic and if I had known about this appointment I would have left home much earlier so that I was ready and prepared in good time for the patient’s arrival. I felt a bit of stress. When I arrived in clinic I discovered that the new appointment was a transfer of a patient from another student’s calendar because they were unable to come into clinic. I quickly set up my laptop, read the clinic notes and got into PPE.
Patient 1
This appointment was a follow-up to a remote triage consultation. The patient had complained of discogenic headaches. The differential diagnosis was Upper Cross Syndrome, Cervical/Thoracic Disc Herniation – Non Radicular or Cervical/Thoracic Facet Dysfunction. The 3rd year Sports therapy student who conducted the remote triage consultation made some notes regarding the direction of the clinical investigation and treatment for the F2F appointment, based upon his differential diagnosis. The patient had also been diagnosed with mild scoliosis, which was confirmed by X-ray, in her teens (adolescent idiopathic scoliosis). I carried out a subjective and objective assessment and my findings did not suggest upper cross syndrome, but a discogenic problem at T12-T11 resulting in nerve impingement and tension in the QL muscles. It is also on the border of the lumbar region, so the impingement could stem from L1. There was muscle guarding in the upper limb due to central pathology (disc herniation). The patient did not experience pain in AROM or combined movements of the Cx. She did however experience a pulling sensation into the right lumbar region when performing combined movements to the left in cx extension and rotation and cx extension and lateral flexion. She felt a sharp, pulling sensation down into the right hip in lateral flexion of the Cx to the left side. Palpation revealed high muscle tone in the trapezius muscles on both sides of the neck, and high muscle tone in the QL on both sides – medial to the spine. During central PA of all of the vertebrae down the spine (Cx, Tx & Lx), the patient had no pain or stiffness in the cervical vertebrae but there was stiffness and pain during central PA of T12 & T11. I applied joint grade II mobilisation to T12 & T11 to reduce pain. Central PA was also applied all of the lumbar vertebrae.
I was running out of time after the assessment so I g
ave the patient advice on how to apply NMT to the trapezius and QL muscles with a massage ball to ease the high muscle tone and the headaches that the patient had been experiencing. I also put together a rehabilitation exercise programme to strengthen up the glutes, QL, erector spinae, latissimus dorsi, trapezius and rectus abdominal muscles.
CPD Exercise
The previous week we were asked to investigate the research literature in to various conditions that predominantly affect females ready for presentation between 1000 and 1100 in clinic, which had been specifically allocated for CPD if we weren’t busy with patients. I was asked to investigate Sacrococcygeal dislocation and Coccydynea. During my investigation of the literature I learned about aetiology, pathophysiology, objective markers and treatment of these conditions here and put together my powerpoint presentation here. I enjoyed learning about these conditions and didn’t know that much about them before I read the research literature. I offered to go through my presentation first as I like to get it over with. I felt reasonably comfortable going through my presentation and sharing the information that I had gathered with my peers.
Patient 2
My next appointment was a follow-up on a patient who I had seen for the first time F2F last week. After assessment I believed that he had a Grade I strain of the QL muscle on the left side of his lower back. The pain was described as localised and central in the middle of the lower back, piercing but not radiating and was experienced when sitting down or during twisting and bending movements. The pain and discomfort was eased with STM. The patient reported that the pain returned in the lumbar region over the weekend (2/7) after the patient’s visit to the clinic however the pain has eased considerably during the last three days especially during the evenings. The patient no longer has to lie on the floor when he gets home from work. Patient reports that pain level is now 1-3/10 VAS and at its worst when aggravated by movement it is 5/10 VAS. The patient is also no longer taking pain relief medication and hasn’t taken any for 5/7. The patient also reported that cycling to work is less painful. He has also been lying on a Back Stretcher Posture Massager for 15 minutes every evening and has found that it has eased his symptoms considerably.
I cleared the Tx and hip. ROM was good in all movements in the Tx and there was no pain. ROM was good in the majority of hip movements however ROM was reduced in IR & ER, but there was no pain. The stiffness in IR & ER was due to inflexibility, probably as a result of the repetitive action of cycling to and from work every day.
I progressed onto AROM of the Lx. The Patient had reasonable ROM in flexion, but could not get to end range, due to some muscle stiffness in the hamstrings. ROM was okay in extension, but the patient felt a pinching feeling when coming out of the movement. When bending to the right side the patient felt a slight pull of the QL muscle in the lower back on the left side and when bending to the left side, he also felt a slight pulling sensation in the right lumbar region. Unlike last week the patient did not feel any pain in the combined side flx, rot and ext on the left side of the lower back. This was good news. The patient also performed the sit to stand functional movement without too much discomfort, despite feeling a pulling sensation in QL muscle.
I had prepared a list of exercises that would help to strengthen the core muscles and the muscles in the lumbar and thoracic spine. I demonstrated each exercise to patient to ensure that he understood how to perform them. The patient repeated each exercise with verbal encouragement from me.
Reflection on Action (afterwards)
Patient 1
Although it felt like I was a deer in the headlights at the beginning of the F2F consultation with patient 1, I settled down as we went through the subjective and objective assessment. I feel quite confident in my final clinical impression of this patient’s injury/condition. On reflection of the experience there were a number of things that I missed during the consultation:
- I did not pay enough attention to the patient’s posture during observation. I did look for asymmetry but nothing appeared abnormal. I should have observed the patient’s posterior and lateral posture more thoroughly after she had revealed that she had mild adolescent idiopathic scoliosis, which had been confirmed by x-ray. Although the patient dismissed it as ‘not a problem’ I did wonder if there was a connection with the mild scoliosis and her current thoracic/lumbar discogenic condition.
I read some of the information regarding Scoliosis (Scoliosis Research Society, 2020) which states that adolescent curves less than 300 are unlikely to progress significantly in adulthood. I should have asked however whether she was being regularly monitored by an orthopaedic consultant.
- I should have repeated the movements that caused pain in the thoracic spine after the Grade II mobilisation of T11/T12
Patient 2
I felt that the follow-up appointment with my second patient went well. It served to remind me however, the importance of considering each patient on an individual basis. It is all very well planning and researching different rehabilitation exercises but they may need to be modified or adapted to match the patient’s capabilities.
I also need to improve my clinical note-taking so that it doesn’t take me so long so that they are ready for checking before the end of my day in clinic.
References:
Scoliosis Research Society. (2020). Scoliosis. Retrieved December 10, 2020, from https://www.srs.org/patients-and-families/conditions-and-treatments/adults/scoliosis
Areas for Further Improvement Plus Action Plan
- Explore the research literature on adults who have been diagnosed with adolescent idiopathic scoliosis and the possible impact on back pain in adulthood.
Return to Reflections at a Later Date: