It was my first outpatient women’s physio session with a lady in the third-trimester of her pregnancy. She presented with acute, sudden onset unilateral low back pain. With detailed subjective and objective assessments, I concluded (with the guidance of my supervising physio) that the pain was due to an acute muscle spasm of the Quadratus Lumborum and Piriformis, with an underlying (R) lateral shift of L3/4. Due to the problem being highly irritable and the muscle spasm being 7/10 pain and tender on palpation (TOP), I decided to give soft tissue massage (STM) on these muscles (5 mins each) in sidelying, hoping that treatment could be more effective as the muscles settle.
During the treatment, frequent questioning of symptom response was performed. The patient felt the muscles have eased slightly as I was giving STM. After the massage, I requested for the patient to stand up for reassessment. To the surprise of both my supervisor and me, the pain levels have increased to the point where she was limping.
As the pain was so severe, I was hesitant to provide any further treatment for fear that it could get worse. However, it was also not appropriate to send her home while she was limping. As I recalled in my subjective assessment, the patient said that heat (hot shower/ hot pack) eases the pain. Immediately, I told her to lie back down and placed a hot pack over the muscle belly. Again, symptom response and erythema was checked every 5 minutes. After 20 minutes, the patient got up and the pain did not subside. She was still limping. I did not know what else to do.
After consulting the supervisor, we decided to rent out a walking frame for support in ambulation until the muscle spasm settles. In addition, I gave her advice to avoid ambulating and to rest until pain subsides.
As I reflect on the situation, I realized that my detailed objective assessment could have aggravated her symptom and the massage could have further worsened the situation. Being a novice practitioner/ an inexperienced student, it was difficult to know how far to go in the objective assessment in a highly irritable patient, as it has to be sufficient to determine the problem, yet be specific enough so that only the essential components are assessed. In the future, I would ensure to identify and discuss with my supervisor the most essential components prior to performing the objective assessment. This is so that the main problem could be identified with the unnecessary components avoided.
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2 comments:
Thats a really difficult situation to be in, especially as we are inexperienced. I'm sure alot of qualified physios have been in similar situations where the pt's pain increases, especially with acute LBP. At least the pt could still walk. Its a good reminder of the need to modify pt Ax according to the pt situation
Acute low back pain can always be a very difficult situation. Remember to reassess main AROM (1-2 movements) findings following PE. This will determine if the assessment or treatment is the aggravating factor. Also did you consider the sidelying position could have been the issue as it could have resulted in overcorrecting the shift and increasing muscle spasm. Be wary of the same situation when lying the acute LBP patient prone.
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