Week 1 STARES - Kalgoorlie MSk

Situation
40 yr old male presented to the physiotherapy clinic with insidious onset of LBP that started 2/52 ago and has remained consistent throughout that period of time. The pain is localized to his left lower back and was described as an aching pain that becomes tight with certain movements and positions. The pain is worst when waking in the morning when it feels stiff and loosens up as the day progresses. The pain is aggravated by sustained standing and with walking for long distances (~20mins). It is eased with sitting or lying down. All special questions were negative and no other issues were present.
The patient has a history of LBP. 6/12 earlier he presented with LBP under the same conditions and was forced to take 3/52 off his work as a fitter working at a minesite (no time has been taken off work on this occasion). He received physiotherapy on this occasion which treated him for decreased mobility within the lumbar spine and prescription of exercises to improve lumbar muscle control.

Task
I was to conduct a thorough objective assessment to explore if this occasion was similar to previous and then treat as required to decrease his impairment and prescribe exercises to minimise the chance of this problem occurring again.

Action
The examination was begun by explaining to the patient how the session would be progressing and that with information we gained from the examination a treatment would be determined & delivered to solve his problem.
I began by assessing all active movements of the lumber spine; flexion, extension, left & right side flexion. From this it was found that flexion and RSF were restricted and thus were the asterisk movements. SLR was then tested in supine which found that L was less than R, with pain at the end of range for left SLR. This could be used as a baseline measure to be re-tested at the end of the treatment. PAIVMs were then applied to the lumber spine with the patient in prone to determine an asterisk level. It was found that L4-5 on the R, L4 central & L3-4 on the L were all stiff with L4-5 painful on the R.

Treatment was then decided to be PPIVMs to promote RSF by treating in R rotation & slight flexion of the lumbar spine. Also unilateral PAs on L3-5 on the L in lumbar spine flexion & central PAs on the same levels in the same position. Soft tissue massage was performed on the quadratus lumborum on the L to loosen the muscle that may be restricting RSF.

Result
The patient responded well to the PPIVMS and PAVIMs with increases in flexion & RSF with the patient also commenting that it felt less restricted. At the end of treatment the massage was used and this actually worked against us and returned the patient to his previous level of restriction. The previous mobilizations were repeated which gave the patient back the freedom he initially had.

Evaluation
The initial mobilizations were very effective and noticeable changes occurred in the patient’s ROM. When treating on a couple of occasions I neglected to re-measure the patients ROM after each set as I assumed they would still be having the same effect. I also didn’t re-assess the patient’s SLR which although not crucial could have been a good way of assessing the success of the treatment. I didn’t perform any clearing tests to assess the involvement of the hip or thoracic spine. It turned out that there was no involvement but I was too focused on the lumbar spine as the source of pain which it was but deficiencies in the other areas could be contributing to this issue.

Strategies
Next I will behave more systematically and work through the process in stages. Re-assessment after every single treatment is critical as may mean the treatment isn’t right or that the treatment wasn’t applied correctly. LBP is a very common occurrence (approximately 40% of cases I’ve seen are LBP related) so I need to be clear on the progression of assessment and treatment for the sake of efficiency of the session.