Situation
On this occasion I was to implement a session to treat a 4yr old boy with spastic hemipelgia who had just undergone botulinum toxin injections on his right hamstrings, gastroc and biceps 3 days prior. I had previously assessed and treated this boy on 2 occasions with good compliance and success with the majority of the interventions. As with many children with similar conditions his gait pattern was impaired and the use of his right arm was affected which was to be the main focus of the sessions. The main reason his gait pattern was impaired was due to his limited dorsiflexion which was also to be a target of the intervention sessions.
Task
To carry out an intervention session to treat the patient’s main impairments and teach him the correct technique to walk and also throw. The session was also be used to educate the parents on what activities and exercises should be performed at home to consolidate what occurs during the physiotherapy sessions.
Action
A full program was planned to keep the child busy and interested in the interventions that were planned to target his impairments and improve his ability to function. His mother stated that his walking pattern had improved slightly despite only receiving the Botox treatment 3 days prior so a quick assessment of his ROM into dorsiflexion could be determined. It was found that his dorsiflexion had improved slightly well ahead of the anticipated time when changes are meant to occur. No formal assessment was made of his right arm but it was evident that his ROM had improved since his elbow extension when throwing was almost to full extension.
During the session the child became very disruptive and aggravated with every activity which made keeping the session on track very difficult. I was constantly attempting different techniques to motivate the child to complete the activities as planned. I had to involve the mother to try calming him but nothing would change the situation and we had to terminate the session early.
Result
The patient was very difficult to work with and get the required results out of him so the early termination of the session was necessary. I was able to educate the mother on the importance of stretching in terms of improving and maintaining his dorsiflexion since we did manage to complete some dorsiflexion stretching prior to his behavioural changes
Evaluation
The child became very difficult to deal with and I feel that I dealt with the situation as best I could by attempting to focus in on certain activities that he became interested in at different times such as stairs or the treadmill. Unfortunately this did not appear to work. I also gave the mother and child alone time to try and calm the situation for 5minutes but this did not appear to work either. Having the session over a shorter period of time and focusing in on only 3 different activities would have been of benefit as the initial exercises were completed well with good compliance.
Strategies
Involvement of the mother and also planning a shorter program by tackling the main areas could potentially have made the session more effective and maintained the child’s interest. Also focusing on the education of the parents since at home is where most of the improvements will be made on a daily basis. Understanding how the child will respond to different exercises by targeting his interests would also give each activity a much greater chance of succeeding.
Sunday, May 30, 2010
Sunday, May 16, 2010
Week 1 STARES - TCCP
Situation
On the 4th day of my placement I was to briefly assess and treat a 4 yr old boy with spastic hemiplegia on his right but also with a slightly affected left side. He had been in on several occasions previously and had been through two treatments of Botox and was due for a third in two weeks. The main issues the boy faced were an impaired gait pattern and decreased right upper limb function. The main issue from the parents point of view was his impaired upper limb function while from the health professional’s perspective his impaired gait was the major issue. The boy was very communicative and happy to be involved in the process and the parents were very supportive and understood the importance of sessions with the centre.
Task
To determine what the individual’s issues are by performing a musculoskeletal assessment, gait analysis and functional capacity assessment. During this session it was not intended to treat the patient as such but simply get an idea of what his current limitations are.
Action
As I have found to be important when attempting to assess and treat children is the development of rapport. Fortunately the child in this case warmed very quickly to us and he was very willing to be involved in the process. Initially I assessed his lower limb range of motion and tone. The main issues found were increased tone in his right leg with dorsiflexion and knee extension. He also had decreased standing balance on his right leg. His gait showed impaired right foot clearance, circumduction, inability to extend his knee and high guard with his upper limbs. His reaching ability was also impaired predominantly when reaching to the right.
Result
This highlighted to me that the main area to work on was strength in the patient’s right lower limb, his gait pattern and also his ability to use and function with his upper limbs.
Evaluation
I believe that I conducted the musculoskeletal assessments correctly but need to improve my ability to apply and determine exactly what each of the more functional tests are inferring. I need to know what to be looking for and how it all applies to the big picture.
Strategies
On the next occasion I will know exactly what I am going to do and to keep the patient involved bring in a an incentive of some form to give him a goal. Sticking at one task for a while then completely stopping it and moving on to another would also ensure the patient is able to focus further. With time being able to find ways to keep a child involved while still keeping on task from a physiotherapy point of view will be an important skill to fine tune.
On the 4th day of my placement I was to briefly assess and treat a 4 yr old boy with spastic hemiplegia on his right but also with a slightly affected left side. He had been in on several occasions previously and had been through two treatments of Botox and was due for a third in two weeks. The main issues the boy faced were an impaired gait pattern and decreased right upper limb function. The main issue from the parents point of view was his impaired upper limb function while from the health professional’s perspective his impaired gait was the major issue. The boy was very communicative and happy to be involved in the process and the parents were very supportive and understood the importance of sessions with the centre.
Task
To determine what the individual’s issues are by performing a musculoskeletal assessment, gait analysis and functional capacity assessment. During this session it was not intended to treat the patient as such but simply get an idea of what his current limitations are.
Action
As I have found to be important when attempting to assess and treat children is the development of rapport. Fortunately the child in this case warmed very quickly to us and he was very willing to be involved in the process. Initially I assessed his lower limb range of motion and tone. The main issues found were increased tone in his right leg with dorsiflexion and knee extension. He also had decreased standing balance on his right leg. His gait showed impaired right foot clearance, circumduction, inability to extend his knee and high guard with his upper limbs. His reaching ability was also impaired predominantly when reaching to the right.
Result
This highlighted to me that the main area to work on was strength in the patient’s right lower limb, his gait pattern and also his ability to use and function with his upper limbs.
Evaluation
I believe that I conducted the musculoskeletal assessments correctly but need to improve my ability to apply and determine exactly what each of the more functional tests are inferring. I need to know what to be looking for and how it all applies to the big picture.
Strategies
On the next occasion I will know exactly what I am going to do and to keep the patient involved bring in a an incentive of some form to give him a goal. Sticking at one task for a while then completely stopping it and moving on to another would also ensure the patient is able to focus further. With time being able to find ways to keep a child involved while still keeping on task from a physiotherapy point of view will be an important skill to fine tune.
Sunday, May 9, 2010
Initial Entry - Rotation 3: TCCP
My third placement for the year will at The Centre for Cerebral Palsy. I am looking forward to becoming involved in a facility and program that helps individuals who can potentially have very significant impairments and functional limitations. I have been involved in the centre previously during 4P and took great satisfaction from helping and also being involved with people who work there who have a real passion for improving the lives of the patients.
I am expecting to be involved with the planning and implementation of individualized programs for each patient after thorough examination of their deficits and impairments. I have not been exposed to the specific nature of an examination for someone with cerebral palsy but expect that it is very similar to the standard musculoskeletal examination but with the addition of testing an individuals tone and level of spasticity.
As I found previously hydrotherapy is a large component of many of the patient’s programs and I envisage some time in the hydrotherapy pool will be involved. Onsite sessions may be at a patient’s school or education facility or possibly in their home environment. The exact nature of the treatment is not very clear to me at this stage but from lecture material I would think a lot of stretching, strengthening and conditioning work will be involved.
Due to the specialized nature of the Cerebral Palsy centre I believe that I will be observing and assisting my supervisor during the early stages but as time passes become more independent and involved in the entire of process of assessment through to implementation of a long term plan to maintain and potentially improve an individuals situation. I hope that there will be some elements of continuing education and exposure to some of the more difficult patient scenarios.
From previous reports I have found that it can be a very rewarding placement being involved in an aspect of physiotherapy that is not often considered by many following graduation. As with most placements there is a certain amount of nervousness but I expect this to dissipate rapidly as I become more and more involved.
I am expecting to be involved with the planning and implementation of individualized programs for each patient after thorough examination of their deficits and impairments. I have not been exposed to the specific nature of an examination for someone with cerebral palsy but expect that it is very similar to the standard musculoskeletal examination but with the addition of testing an individuals tone and level of spasticity.
As I found previously hydrotherapy is a large component of many of the patient’s programs and I envisage some time in the hydrotherapy pool will be involved. Onsite sessions may be at a patient’s school or education facility or possibly in their home environment. The exact nature of the treatment is not very clear to me at this stage but from lecture material I would think a lot of stretching, strengthening and conditioning work will be involved.
Due to the specialized nature of the Cerebral Palsy centre I believe that I will be observing and assisting my supervisor during the early stages but as time passes become more independent and involved in the entire of process of assessment through to implementation of a long term plan to maintain and potentially improve an individuals situation. I hope that there will be some elements of continuing education and exposure to some of the more difficult patient scenarios.
From previous reports I have found that it can be a very rewarding placement being involved in an aspect of physiotherapy that is not often considered by many following graduation. As with most placements there is a certain amount of nervousness but I expect this to dissipate rapidly as I become more and more involved.
Sunday, April 25, 2010
Final Entry - Rotation 2: Kalgoorlie
The 5 weeks I spent in Kalgoorlie proved to be easily the most challenging clinical placement thus far. I was aware that it wasn’t going to be an easy placement but being put into the environment of a private practice opened my eyes to the difficulty involved with not only being a good clinician but also aware of physiotherapy from a business point of view. I found that being able to put all the musculoskeletal learning and knowledge into practice very rewarding since for years we have been assessing and treating each other which 99% of the time means not finding any issues. So to actually assess someone, find an issue, treat the issue and improve their movement or reduce their pain was very rewarding and made it a lot easier to understand the nature of conditions and how they can be improved.
As I mentioned prior to commencing this placement one of the main difficulties I thought I would face would be diagnosis and not having access to a clear and thorough medical history as is provided at hospitals. Initially I found this particularly overwhelming with not only having to diagnose the problem but make it quick and then figure out a treatment and plan all while questioning the patient and thinking about the situation on the go. As I saw more patients this process became more effcicient and I was able to quickly diagnose but I understand that there is still a lot of work to do and this process will be refined more and more after finishing study.
I could not have anticipated the intensity of the placement and the amount of information being thrown at me. As mentioned there is always more to learn both for the rest of the year but also beyond graduation but I believe that I made some very strong and solid in roads into developing my skills and also made me aware of just how much there is to know. I also refined the process of knowledge acquisition to make learning much more efficient and enable me to accurately learn of the many different clinical conditions and how they may present to the physiotherapist.
As I gathered I began the placement from more of an observer point of view but was regularly quizzed on what was happening in the room to ensure I was clear on the session’s situation. As time went on and I began developing my skills I was able to treat patients with more and more independence. By the end I was confident with conducting an efficient and effective treatment session.
Kalgoorlie really did open my eyes as to how far physiotherapy students really have to go before they become completely proficient. The learning never stops and we need to be open to continuing this development and also strive to add more skills every time we are exposed to the clinical environment.
As I mentioned prior to commencing this placement one of the main difficulties I thought I would face would be diagnosis and not having access to a clear and thorough medical history as is provided at hospitals. Initially I found this particularly overwhelming with not only having to diagnose the problem but make it quick and then figure out a treatment and plan all while questioning the patient and thinking about the situation on the go. As I saw more patients this process became more effcicient and I was able to quickly diagnose but I understand that there is still a lot of work to do and this process will be refined more and more after finishing study.
I could not have anticipated the intensity of the placement and the amount of information being thrown at me. As mentioned there is always more to learn both for the rest of the year but also beyond graduation but I believe that I made some very strong and solid in roads into developing my skills and also made me aware of just how much there is to know. I also refined the process of knowledge acquisition to make learning much more efficient and enable me to accurately learn of the many different clinical conditions and how they may present to the physiotherapist.
As I gathered I began the placement from more of an observer point of view but was regularly quizzed on what was happening in the room to ensure I was clear on the session’s situation. As time went on and I began developing my skills I was able to treat patients with more and more independence. By the end I was confident with conducting an efficient and effective treatment session.
Kalgoorlie really did open my eyes as to how far physiotherapy students really have to go before they become completely proficient. The learning never stops and we need to be open to continuing this development and also strive to add more skills every time we are exposed to the clinical environment.
Sunday, April 18, 2010
Week 5 STARES - Kalgoorlie MSk
Situation
On the 16th of April a 25 yr old man presented with LBP and hamstring tightness following a soccer game 3 days earlier. The hamstring tightness occurred immediately following the game and the LBP presented the next morning. Since this time the pain/tightness has gotten gradually worse and he presented looking very stiff with slow movements. He felt that his left hamstring was tighter but overall the pain in his lower back, gluteals and hamstring is bilateral. This same situation has occurred on 3 other occasions but none as bad as this and all had resolved with no intervention. His pain was aggravated by activity especially with twisting and when standing or sitting for an extended period of time. The pain would ease off with rest and lying down. The patient had not had any time off work but had ceased playing sport since the incident. Prior to visiting the physiotherapist he had consulted a chiropractor who had manipulated the patient with only moderate immediate pain relief but the pain had returned worse the next day. No official diagnosis had been reported to the patient during these visits.
Task
To determine the nature of the patient’s injury by performing the required musculoskeletal examination and generate a working diagnosis to then treat the patient and reduce his symptoms to allow him operate with less pain.
Action
Initially I had the patient perform Active ROM movements to determine into what directions he is mainly deficient. He was restricted into all directions with flexion being the asterisk direction. His pain was increased when returning from any given direction to neutral position. His straight leg raise was 40° on left and 50° on the right, both very low for someone so young and active. Due to the bilateral nature of his symptoms it was necessary to perform some neural integrity testing to ascertain what neural involvement might be present. His patella tendon reflex on the right was noticeably reduced relative to the left, but all myotomes and sensation testing was negative. A slump test was then performed which produced a positive result, especially on the right where knee extension was stopped as a result of pain 5° short of full extension with the neck extended and 20° short with passive neck flexion added. After this neural testing the patient reported slight tingling in his right foot.
Result
The most important diagnosis to be made was that there were some definite neural issues which with the bilateral nature of the symptoms suggest a discal pathology impacting upon the spinal nerves, mainly on the right. As a result there is also some facet and muscle restrictions possibly as a reaction to the dysfunction being caused by the problem disc. The exact level was not clear but it is likely to be at either the L3/4 or L4/5 level.
Evaluation
Since I had never come across a patient who had diminished reflexes this was something new for me and hence had to think differently to what I had previously. I was fairly comfortable with the diagnosis but in terms of a treatment for the disc dysfunction I was not clear on which direction things had to head. Techniques to reduce the load on the disc such as traction were an option but after discussions with my supervisor we did not know the exact nature of the disc so improving the patient’s movement was the primary goal for this first session by using mobilizations techniques.
Probably the main difficulty I had with this patient was explaining to him the nature of the issue but also making him understand that having a disc problem is very common and not as debilitating as most people believe. His anxiety increased after receiving this news so limiting this became a very important factor. My supervisor was able to assist me with explaining to the patient in the best possible way the situation and that referral to a specialist could be an option.
Strategies
The most important thing I should take away from this scenario is that I need to keep the patient’s needs and limitations in mind and not hope to cure them in one session, especially with a more complex case as presented here. But in saying that some progress should be achieved to improve the patient’s function and maintain as normal as possible their ADLs. Explaining the situation to the patient and what the possible progression will be is something I need to work on and this involves me learning a lot more about the condition and what the options are for treatment.
On the 16th of April a 25 yr old man presented with LBP and hamstring tightness following a soccer game 3 days earlier. The hamstring tightness occurred immediately following the game and the LBP presented the next morning. Since this time the pain/tightness has gotten gradually worse and he presented looking very stiff with slow movements. He felt that his left hamstring was tighter but overall the pain in his lower back, gluteals and hamstring is bilateral. This same situation has occurred on 3 other occasions but none as bad as this and all had resolved with no intervention. His pain was aggravated by activity especially with twisting and when standing or sitting for an extended period of time. The pain would ease off with rest and lying down. The patient had not had any time off work but had ceased playing sport since the incident. Prior to visiting the physiotherapist he had consulted a chiropractor who had manipulated the patient with only moderate immediate pain relief but the pain had returned worse the next day. No official diagnosis had been reported to the patient during these visits.
Task
To determine the nature of the patient’s injury by performing the required musculoskeletal examination and generate a working diagnosis to then treat the patient and reduce his symptoms to allow him operate with less pain.
Action
Initially I had the patient perform Active ROM movements to determine into what directions he is mainly deficient. He was restricted into all directions with flexion being the asterisk direction. His pain was increased when returning from any given direction to neutral position. His straight leg raise was 40° on left and 50° on the right, both very low for someone so young and active. Due to the bilateral nature of his symptoms it was necessary to perform some neural integrity testing to ascertain what neural involvement might be present. His patella tendon reflex on the right was noticeably reduced relative to the left, but all myotomes and sensation testing was negative. A slump test was then performed which produced a positive result, especially on the right where knee extension was stopped as a result of pain 5° short of full extension with the neck extended and 20° short with passive neck flexion added. After this neural testing the patient reported slight tingling in his right foot.
Result
The most important diagnosis to be made was that there were some definite neural issues which with the bilateral nature of the symptoms suggest a discal pathology impacting upon the spinal nerves, mainly on the right. As a result there is also some facet and muscle restrictions possibly as a reaction to the dysfunction being caused by the problem disc. The exact level was not clear but it is likely to be at either the L3/4 or L4/5 level.
Evaluation
Since I had never come across a patient who had diminished reflexes this was something new for me and hence had to think differently to what I had previously. I was fairly comfortable with the diagnosis but in terms of a treatment for the disc dysfunction I was not clear on which direction things had to head. Techniques to reduce the load on the disc such as traction were an option but after discussions with my supervisor we did not know the exact nature of the disc so improving the patient’s movement was the primary goal for this first session by using mobilizations techniques.
Probably the main difficulty I had with this patient was explaining to him the nature of the issue but also making him understand that having a disc problem is very common and not as debilitating as most people believe. His anxiety increased after receiving this news so limiting this became a very important factor. My supervisor was able to assist me with explaining to the patient in the best possible way the situation and that referral to a specialist could be an option.
Strategies
The most important thing I should take away from this scenario is that I need to keep the patient’s needs and limitations in mind and not hope to cure them in one session, especially with a more complex case as presented here. But in saying that some progress should be achieved to improve the patient’s function and maintain as normal as possible their ADLs. Explaining the situation to the patient and what the possible progression will be is something I need to work on and this involves me learning a lot more about the condition and what the options are for treatment.
Saturday, April 10, 2010
Week 3 STARES - Kalgoorlie MSk
Situation
On the 6th of April a 45yo lady presented to me with right calf pain following a traumatic incident at a netball game 2 days prior. She had been running when she suddenly felt pain in her calf and was unable to continue playing. There was no previous history of calf injury or issues and up till consulting a physio she had been icing 2x/day and only walking on crutches due to significant pain when walking especially just prior to push off and with push of itself. From the history of incident the most likely diagnosis was likely to be a strained or torn calf muscle.
Task
To confirm the nature of the injury and rule out other possible issues by completing a thorough objective assessment. Then I was to conduct a treatment and advise the patient on home maintenance and exercises to manage & treat the injury.
Action
The examination initially involved seeing what active movements the patient could achieve. She could only dorsiflex to ~2° before pain was produced during a bilateral squat and couldn’t perform a heel raise on her right leg due to pain. Her single leg balance on her right was less than the left but she could still maintain her balance with more postural sway for 30 seconds. Passively her dorsiflexion with her leg straight was far more painful than with the knee bent. There was some bruising in the medial head of her right gastroc and her achilles tendon was slightly decreased in width relative to the left. She was very tender on palpation in her medial gastroc and a noticeable depression was felt within the medial gastroc head. She was also very tender around the medial border of the right Achilles close to the musculo-tendon junction.
From this assessment and the patient’s history it was determined that the patient had suffered a Grade 2 right medial head gastroc strain and also a strain on the structures at the musculo-tendon junction on the medial side of her achilles tendon.
The treatment in this early stage was very conservative with only ultrasound and some gentle soft tissue massage used. The main emphasis at this early stage was patient education and home exercises. She was encouraged to use her crutches when having the walk long distances, avoid use around the home and wear shoes to limit dysfunction due to an aberrant gait pattern. Some very low grade stretching using a towel and the use of hot/cold therapy to decrease swelling and pain was also prescribed.
Result
The patient seemed aware of the situation and was happy to take heed of my instructions and not cause herself anymore damage. The treatment in the practice was not designed to improve her status there and then but simply but her tissue into a better position to begin the healing process.
Evaluation
The patient was eager to follow the instructions given to her but when she returned two days later I found that she had not followed them as I had desired. Her pain had increased and she was limping noticeably. I had given her simple instructions to follow but I believe that the way I explained it to her was what caused the misunderstanding. The only exercises I gave her had been conducted correctly but she had been experiencing pain after each session but this did not deter her from repeating when the next set was required. Once again I should have explained to her to use pain as her guide and only continue if there is not pain or it is at a manageable level.
Strategies
I need to ensure that I explain clearly to the patient that pain should be used as a guide to limit her with the exercises and with ambulation. Because everyone’s ideas of pain differ I need to use more a measureable guide to limit her activity levels. In these early stages a hard and fast rule of use crutches every time you go outside would have been better than letting the patient decide when and where to use them. Using partial weight bearing and trying to imitate the movement the foot should be doing would have also been useful otherwise the patient would probably think they could walk on it normally with just some balance support from the crutches. Essentially clear and concise explanation of what the patient should be doing and exactly how much of it throughout the course of the day is required to maintain improvements in tissue structure and also limit dysfunction.
On the 6th of April a 45yo lady presented to me with right calf pain following a traumatic incident at a netball game 2 days prior. She had been running when she suddenly felt pain in her calf and was unable to continue playing. There was no previous history of calf injury or issues and up till consulting a physio she had been icing 2x/day and only walking on crutches due to significant pain when walking especially just prior to push off and with push of itself. From the history of incident the most likely diagnosis was likely to be a strained or torn calf muscle.
Task
To confirm the nature of the injury and rule out other possible issues by completing a thorough objective assessment. Then I was to conduct a treatment and advise the patient on home maintenance and exercises to manage & treat the injury.
Action
The examination initially involved seeing what active movements the patient could achieve. She could only dorsiflex to ~2° before pain was produced during a bilateral squat and couldn’t perform a heel raise on her right leg due to pain. Her single leg balance on her right was less than the left but she could still maintain her balance with more postural sway for 30 seconds. Passively her dorsiflexion with her leg straight was far more painful than with the knee bent. There was some bruising in the medial head of her right gastroc and her achilles tendon was slightly decreased in width relative to the left. She was very tender on palpation in her medial gastroc and a noticeable depression was felt within the medial gastroc head. She was also very tender around the medial border of the right Achilles close to the musculo-tendon junction.
From this assessment and the patient’s history it was determined that the patient had suffered a Grade 2 right medial head gastroc strain and also a strain on the structures at the musculo-tendon junction on the medial side of her achilles tendon.
The treatment in this early stage was very conservative with only ultrasound and some gentle soft tissue massage used. The main emphasis at this early stage was patient education and home exercises. She was encouraged to use her crutches when having the walk long distances, avoid use around the home and wear shoes to limit dysfunction due to an aberrant gait pattern. Some very low grade stretching using a towel and the use of hot/cold therapy to decrease swelling and pain was also prescribed.
Result
The patient seemed aware of the situation and was happy to take heed of my instructions and not cause herself anymore damage. The treatment in the practice was not designed to improve her status there and then but simply but her tissue into a better position to begin the healing process.
Evaluation
The patient was eager to follow the instructions given to her but when she returned two days later I found that she had not followed them as I had desired. Her pain had increased and she was limping noticeably. I had given her simple instructions to follow but I believe that the way I explained it to her was what caused the misunderstanding. The only exercises I gave her had been conducted correctly but she had been experiencing pain after each session but this did not deter her from repeating when the next set was required. Once again I should have explained to her to use pain as her guide and only continue if there is not pain or it is at a manageable level.
Strategies
I need to ensure that I explain clearly to the patient that pain should be used as a guide to limit her with the exercises and with ambulation. Because everyone’s ideas of pain differ I need to use more a measureable guide to limit her activity levels. In these early stages a hard and fast rule of use crutches every time you go outside would have been better than letting the patient decide when and where to use them. Using partial weight bearing and trying to imitate the movement the foot should be doing would have also been useful otherwise the patient would probably think they could walk on it normally with just some balance support from the crutches. Essentially clear and concise explanation of what the patient should be doing and exactly how much of it throughout the course of the day is required to maintain improvements in tissue structure and also limit dysfunction.
Friday, March 26, 2010
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.
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.
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