Date: 12/10/ 2020

Hours: 4

Total hours: 11

In this session in the clinic, a 42-year-old woman with complaints of low back and thoracic pain and received an online consultation. The client has been working as a carer for the last 8 years and has experienced the pain on and off throughout her career however the pain had increased over the last 5 weeks. With hot/cold treatments no helping and the exercises she was given by her physio causing her more pain, she is looking for further treatment to help relieve pain and regain mobility.

During the subjective assessment, it became apparent that the client’s condition was affecting their daily life as she was finding it difficult to drive and do her job without any pain. It was also found that the client had been suffering a great deal with night pain, stiffness and some signs of pins and needles bilaterally down the arms. However, the client claimed that laying on their side helped to subside some of these symptoms. Overall, the client leads a healthy lifestyle however they are trying to reduce the amount that they are smoking by using a vape instead. The client shown no signs or symptoms of VBI however did have some complaints of neck pain.

During objective assessment, the client found no pain in hip flexion/extension, however flexion in the right leg did cause some pain in the left side of the lower back. During ROM testing, the client found more pain in the lower right-hand side of her back in Lx side flexion, rotation, and extension. The client found that Tx rotation was extremely painful with a NRS of 8/10. When testing Cx, the client did find some pain and aggravation during extension.

When assessing the client, it was identified that they were experiencing symptoms of pain by asking the client to pinpoint over the camera where they find the most pain. Asking the client these questions was beneficial to help with more differential diagnosis as well as helping when constructing her treatment plan.

The clinical impression was a lumbar radiculopathy of L3/L4. A differential diagnosis was given of tightness in the QL and glute muscles causing pain in the lower back and thoracic.

In the next session, a face-to-face treatment will be provided where mobility and ROM will be assessed much more specifically and provide some treatment to help relieve the pain. This treatment will involve some massage and mobilisations as well as working through some exercises which the client can continue at home. A gym plan will also be created for future sessions.

From this session, it was identified that further practice will be needed to be more precise and descriptive when asking clients questions or assessing movements. This will help with the understanding of injury and why they are being asked to complete certain movements. Confidence within the approach towards questioning the client will need to be practised and to help the client feels more relaxed.