week 5 post: analysis (and planning)

S: A 45 year old male presented with acute on chronic lower back pain following a fall off a ladder at work one and a half months ago. He did not experience a loss of conscioussness secondary to the fall. His xrays did not show any spinal or peripheral fractures or disclocations and no verterbral disc protrusions. He also had a second incident about 2 weeks following this where he had severe muscle spasm from his neck to his lumbar spine for up to 4 hours after walking up a flight of stairs. He was admitted to ED for this had then been referred to our clinic. He had not suffered any spasms of this sort since. He complained of a strong almost constant ache in his lower back bilaterally that almost always referred into both his hips and buttocks (pain A). This ache was often precipitated by a sharp pain in his middle lumbar region which occurred with sudden movements and primarily with functional activities which involved transitioning from lumbar flexion to extension, for example removing his T-shirt but side flexion and rotation could also sometimes bring on the pain. The patient also complained of symptoms into both of his legs and talked about two different pains in his legs that could each come on separately or together and either with or without his lower back pain. One was a pulling pain associated with pins and needles and numbness in the posterolateral thighs stopping above the knees (pain B). The second was the same pain into both his calves and into the top of his feet which occassionally referred into anteriorly (bilaterally) and was sometimes associated with cramping of the calves (pain C). The patient also reported he intermittently had mid-upper thoracic pain which he described as stiff; intermittent bilateral knee pain secondary to his osteoarthritis, general constant pain in his right foot secondary to a previous fracture and plantar fascia release and bilateral elbow pain secondary to tennis elbow! He also reported suffering from severe migraines prior to the fall however experienced a particularly bad episode one week prior to to the appointment where he had a constant migraine for 3 days. When asked special questions, he reported voiding more frequently than normal during the day and at night since the fall (up to 20 times a day and 2-3 times at night) and experienced bilateral hand numbness and tingling 2 or 3 times lasting 5 minutes or so at over the month since the fall. I noticed that in the patient questionnaire he suffered from TIIDM and post-traumatic stress disorder (PTSD) although there was no particular event or rerference to PTSD in his medical notes. I also noticed that while the patient was talking to me he could easily move his lumbar spine to indicate to me the various areas of his pains with no complaints of pain and no hesitance.
T: To perform a thorough objective examination as well as delve deeper into the patients medical notes to obtain some clarity from the patients presentation and to rule out (or rule in) any red and/or yellow flags that had come to my attention after the subjective assessment.
A: Firstly I had a discussion with my supervisor to ensure that it was safe to continue with my assessment. I conducted an active movement assessment of his lumbar spine and a functional assessment. Pain A was reproduced with some activities that the patient had reported in the subjective to be aggravating for example squatting from the floor to standing and taking his short off. He had decreased lumbar ROM into all movements and had a thoraco-lumbar pivot point with these although when moving into extension he had increased lumbar ROM and decreased thoracic extension range. Flexion, rotation and both left and right side flexion reproduced the pain A (ache) although the pain did not go into his hips only the top of his buttocks. Extension was pain free. Sustained movements did not bring on any leg symptoms and only repeated flexion to extension worsened pain A and brought on sharp pain in the middle of his lower back on the return to extension.Repeated movements did not bring on any leg symptoms either. I also performed a thorough neurological examination. I found that he was generally hyporeflexive, had diminished strength for all lumbar levels (lowest grade 3- highest 4) and had poorer sensation in a few spots mainly down his postero-lateral lower limb and top of his foot on his left side although there were some places medially and anteriorly that he reported felt different compared to his right side. Sensation to pin prick was normal and equal bilaterally. His SLR on the right was only 30 degrees and brought on pain B, pain C was reproduced with ankle dorsiflexion. Pain B was relieved with PNF although pain C wasn't. On the left pain B was reproduced at 70 degrees and the again the pains responded as above with PNF. Both his hips were clear. The PAIVM assessment of his lumbar spine did not reproduce any leg symptoms, unilaterals on L5 and S1 reproduced pain A.
After looking at his medical notes and clarifying some of the subjective, I found that he had a history of polyuria and was on medications for his diabetes which explained his bladder symptoms. He was also on a disability pension however was still working full time and had made no workers compensation claim. He only had 5 days off work altogether over the past month and a half secondary to the fall and the spasms.
R: I was reassured somewhat by my supervisor; after reading through the medical notes again and also with my subjective assessment that there were multiple yellow flags that existed. For example those relating to his behaviours (both reported and those of which I observed)- they were contradictory to some things that he had reported to me. Also, the fact that there was secondary gain i.e. he was receving money from the government despite being able to work full time. He had a heightened sense of somatic awareness as well as many more yellow flags. Despite the above, I was still anxious and left slightly confused about my findings on neurological testing as there were multiple positive findings and inconsistencies with my findings.
E: I thought I assessed the correct things with the patient, physically and in terms of picking up on various yellow flags. I felt I could have been more technically sound in my assessment skills to ensure I was testing what I thought I was testing so as to not get any false positive findings. For example, my supervisor pointed out that I may have found he was hyporeflexive although I maybe did not hit the muscle tendon hard enough with the reflex hammer and on relfection I did not! There were certain findings that were variable and did not make anatomical sense and these one cannot always control for but I think more accuracy with my testing could give me more clarity with my clinical reasoning. I also could have established a clearer history with red flags, for example he mentioned he had altered sensation in his hands however I later discovered this was only on a few occassions after prolonged use of his hands to handle objects at work and the weather was very cold on those occassions. I think obtaining a more clear pattern with these would decrease my concern and prevent me from thinking I need to triage someone off when in fact there are suitable for physiotherapy.
S: I think strategies I could use to improve on the above would be ensure my handling and technical skills are spot on before coming to any conclusions with my objective assessment. I could have asked the patient more specific questions to further assess illness behaviours that may steer me away from a red flag diagnosis and more towards a yellow flag one. For example I could have asked him what he understands as the cause of his back and leg pains. I could also be less anxious and not jump to conclusions before stopping and logically going through a patients presentation and investigating further into anything that is alarming to definitively rule it in or out.