Date: 19/10/ 2020

Hours: 4

Total hours: 15

This session was a face to face follow up appointment from the client’s online consultation the week previous. The client was a 42-year-old woman who previously had complaints of Lx and Tx pain.

Before any treatment was provided, it was ensured that the client did not have any changes to their previous medical history or COVID-19 questions. The client had also mentioned how the exercises that were provided earlier that week had helped to decrease pain since the previous week. The client did have some low back pain due to a long walk 2 days before the session.

The client’s gait was observed when entering the room and there were no signs of an antalgic gait when walking across the room. When observing, the client had no obvious deformities, swelling or bruising or altered postures due to pain.

The client’s ROM was observed in active hip flexion, extension, and rotation. There was some pain in hip flexion from the lower back in hip flexion however no pain in any other hip movements. During Lx movements, there was no pain in Lx flexion however was some pain in extension and side flexion on both sides. The client also experienced pain in thoracic rotation. There was also some pain during active single straight leg raises with the left causing more pain than the right. All symptoms of pain had not changed since the previous appointment and ROM had not improved.

Upon palpation there was some pain at the lower back at the quadratus lumborum muscles, the left glute and hamstring muscles. The client also experienced pain on palpation at approximately L3/L4 and T12.

Some neurological tests were completed to help rule out any neurological issues due to the pain being back and spine related. During a passive straight leg raise, there was no pain in the right however in the left there was pain at 20 degrees with dorsiflexion, ROM increased without dorsiflexion, but pain proportionally increased with ROM until 45 degrees.

For treatment, soft tissue massage was applied to the lower back at the quadratus lumborum muscles at the right and left sides. There was some tightness on the right-hand side however the client was experiencing most pain at the left-hand side. This tightness may have been due to their walk they had previously completed. After massage treatment the client had felt a reduction in pain at the lower back muscles. Next, the client had asked to be shown how to complete some exercises and was also provided with additional exercises to complete. This included the book under bum, bird dog and standing pelvic tilts against a wall.

During their next session, the clients progress will be assessed and any changes to exercise prescription or if further treatment such as massage or mobilisations are needed.

It was learnt from this session that communication with the client is important, this includes describing to the client why I believe they may be experiencing pain and showing knowledge of anatomy to help them understand this. Phrasing and describing exercises in more detail will need to be worked on so that the client can follow these instructions more easily.