On a trip down to the coast the other day I was challenged to boil down my assessment, diagnosis and treatment into a 30-minute session. Asking patients to step out of their comfort zones and to shine light in the dark corners of their movement exploration is something I do on a daily basis, however this was my turn to have my base of support challenged. This is the space where learning and self discovery take place so with a deep breath I jumped into the treatment experiment.
“Could you grab me a piece of paper please, so I can jot down a quick case history,” I asked with an ulterior motive in mind.
As my examiner walked off to get some writing utensils I quickly watched her walking gait. I had one chance to observe her while she was unaware and pick out the major patterns missing from her movement and hang my hat on them. Her pelvis always tilted forward (anteriorly), which meant her lumbar spine never went into flexion and her feet never re-supinated as she toed off. Bingo! I am sure that there was more and usually I would have analysed this with a fine tooth comb but today it was about finding the major players and working to time.
Next was the case history. The body in its innate wisdom will always chose the posture in which it feels safest. Why in this case was re-supination of the feet being avoided and stability being achieved by compressing the facet joints of the lumbar spine instead of relying on the coordination of inner and outer core musculature? Detective hat on, we got to work.
Firstly what were her current issues?
“I’ve had over 10 years of back pain and get sciatic type pain down into my left leg”
This fitted with the movement analysis, but why? We went through her history from head to toe, with a particular interest on anything that occurred over 10 years ago and from which she might have struggled to recover. There were a number of possibilities, but multiple ankle sprains that had caused her to black out with pain seemed high on the list.
As with any piece of research, having come to a hypothesis the next step was to disprove it, otherwise it can only be described as a best guess. A little muscle testing showed that the peroneals were facilitated for a number of the major sling systems and that indeed the ankle sprains were playing a role in the presentation.
The clock was ticking. Luckily my movement assessments become the treatment as well as the homework, so we worked up the legs transitioning the feet and mobilising the fibular and cuboid bones as we went. We offered supination to the feet in a safe, pain free environment and reassessed movement as we progressed.
Finally we needed to evaluate whether treatment had indeed been effective.
“How do you feel?”
“That pain down my leg seems to have gone”
Phew. Promising so far. Time to challenge it back on the couch with a little muscle testing and indeed the previously non-existent adductors were back playing game with the rest of the body.
In true count down fashion, the bell rung and half an hour came to an end. There was more that could have been done, however pain levels had reduced, a hypothesis had been tested and confirmed, exercise homework had been set and video instruction sent later that evening and a plan created for follow up sessions.
What was my biggest take home from this experiment?
Time spent taking a case history and assessing is not time wasted. Without a case history back pain is back pain and hence treatment can only focus on the back. In this case the back was the area creating stability through joint compression and to manipulate those joints would not only have removed the area holding the body together, possibly making the situation worse, but would definitely not have addressed the root cause.
Would I like to work in half hour blocks?
In defense of a conventional 30-minute session, it forced me to work more efficiently; to not get side tracked down rabbit holes and to stick to my gut instinct and to explore it. However these rabbit holes and dead ends are valid and valuable areas of exploration both for my patients and for my own development (which then positively effects my patients in terms of more effective treatment). By working at speed things will undoubtedly get missed and the subtleties of movement that need to be coached may be left on the cutting room floor. Can it be done? To a certain degree yes. Would I want to? To be happy in what I do I would have to say no.