First of all - a 20 minute consultation is ridiculous unless you're simply strapping someone, checking an exercise and adjusting, or I don't know. This is therapy people, not a sheep pregnancy van where we shuttle people in for a feel and kick them out again. If I had a psychology counselling session and I was out in 20 minutes, I'd wonder what the point is.
Nevertheless, you work for someone who wants you on those time slots.
This post is following on from yesterdays blog post about how to implement the SFMA when you are new to it, in a 40 minute new patient consultation.
Janice arrives a few days to a week after the first consultation. After initial greetings and chats, I ask her about compliance and symptoms. She says she's tried to do the hip mobilisation exercise as per the video but isn't sure if she's doing it right. And she doesn't know if she got the right band from Rebel sport.
J: It's green, "will that do?"
"No" I say, it's too light - there isn't enough tension to distract the joint enough. "Don't worry,", I say, "you can keep green for other exercise, but you'll have to get the red one otherwise you'll be coming here all the time to get me to mobilise your hips."
Ok, we have checked compliance but we have to see how she's doing it.
I check her top tier MSF which is DP and her prone hip extension range, active and passively, and it has improved on last week's initial, but regressed from post-treatment, DP actively, FN passively. I check her exercise with a red band, how she's doing it - she had the band too distal to the joint and was breath holding and wasn't directing eyes and cervical flexion towards the foot she was reaching - missing out on the better part of the roll pattern.
Once I correct it, I recheck her passive range and it's beyond 50 degrees, with no back pain. Active is FN at 45 degrees. Her MSF is DN.
While I'm there, and knowing I am in a 20 minute session, I use the same red band and set her up for a band-assisted thoracic rib grab mobilisation, emphasising the lumbar-lock element of the drill, with bilateral hip flexion, plus the eyes and cervical rotation, and diaphragmatic breathing. I get hands on to facilitate the thorax rotation in addition to the band, to help her feel what the rotation should feel like. Her MSF is DN. I take a moment with her - the reason she came in was for back pain - we haven't treated her back yet and her back pain is gone by addressing her hips and thorax. That's an important moment.
The plan now is to stress the importance of the red band, use eyes and cervical flexion and diaphragmatic breathing on the hip exercise, then add the band-assisted rib grab with eyes and cervical rotation and breathing - 3 to 5 breaths per movement.
I'll see her next week. She is to do the exercises as often as she wants through the day.
Next week I'm going to check compliance, top tier Cervical Extension, MSF, MSR, MSE and key breakouts from hip and thorax and plan from there. Time's up. Notes, breathe, smile. I wonder why I haven't done it this way up until now - I didn't know I guess, thanks uni. I wonder if there's evidence behind the SFMA approach - hey Greg, can you shed any light on that? (Am I talking to myself?)
You've just taken SFMA level 1 (and/or level 2) and you arrive at work to see a new client, your head is full, your brain is wondering how to get your clinical side of you to behave with this new person who wants your help. What do you do?
First, reset your own breathing. Then smile and check this example out:
The appointment is 40 minutes long (a typical new consultation). They are late by a couple of minutes. Don't stress. Perhaps they completed a pre-appointment questionnaire. Read it and then spend some time filling in the gaps. Your primary aim is to find out if they have a medical diagnosis, or need one, and whether they are in the right room today. If they have a medical diagnosis, this will inform you about contraindications for moving, given the first principle is to protect. Let's assume you know how to take a history and it takes you up to 10 minutes. You have 30 minutes to go. Let's assume you want to wrap it up with 5 minutes spare so they can gather themselves, head out to reception and you can finish some notes. So you're down to 25 minutes.
Second, reset your own breathing. Then smile again and proceed.
Let's assume I'm making a lot of assumptions.
Do an ortho-neuro screen of special tests - this helps you clarify the primary aim - do they have a medical diagnosis that needs referring out.
Screen their breathing.
Do a top tier and proceed.
For example, I'm 10 minutes into my consultation with Janice, a 43 year old who asked for help with left sided low back pain, no radiation, chronic. No red flags. No bowel or bladder signs. No paraesthesia. I have 25 minutes, probably, left over.
I do a top tier. 3.5 minutes later I write down my top tier findings.
I'm at about 15 minutes. 20 minutes to go.
I remember that my SFMA instructor said, in the first week after taking the course, to top tier everyone (which I've now done), then pick one breakout to master that week. My instructor said I could pick any breakout, and there will be some information, but not a complete set of findings. Nevertheless, pick one. She also said to breakout the DN's before DP's, then FP's, and not to breakout the FN's.
So, I see Janice has an FP for MSF. I won't break that out. I choose MSR which is DN. I could also have chosen MSE but Janice would have had to do cervical extension and that provoked pain so I leave that out. The MSR includes cervical rotation which was not painful.
Her MSR breakout includes seated spine rotation which was dysfunctional. While she was seated I had her do active tibial rotations which were dysfunctional both directions on both sides.
I note on her history that she's had bilateral knee ligament injuries and these still bother her, so instead of being in the lumbar lock position I keep her on the chair and ask her to do a modified lumbar lock test on the chair - it is dysfunctional bilaterally for thorax extension and rotation actively and passively so I know she has bilateral MDs. I don't have to test for prone-on-elbows lumbar extension and rotation.
I put her on the treatment table and test hip rotations in prone and find that her hip internal rotations clear 30 degress actively, so I don't need to do passive. The range is in the vicinity of mid 30's degrees. Her external rotations, actively, are less than 40 degrees. Stabilised hip ER in extension does not become functional. Passive testing is also less than 40 degrees, at 35 degrees bilaterally, and both of them provoke low back pain at R1.
In supine, her tibial rotations are bilaterally MD in both directions.
Her FABER(E) is bilaterally MD with provocation of low back pain. Stabilised FABER(E) does not change.
Her Modified Thomas Test is bilaterally MD with a lateral drift on the right side.
Another 7 minutes has passed. I'm at 22 minutes and want to have her out at 35 minutes, that leaves 17 minutes.
I write some notes on the above findings and take a moment to scan the findings. I know I haven't broken anything else out but I'm assured that my instructors have told me that in the first week I mustn't be tempted.
She has multiple findings of MD's.
In the thorax both ways into extension and rotation, so thorax MDs are 2.
The hips have MDs into extension showing up in two tests, on both sides, so that makes hips MDs for 4. Two of them provoke pain, and two don't.
At this stage I can reason that with MDs above and below the low back, this is fitting the profile of the joint-by-joint-approach. I remember that instead of just jumping to a favourite technique, I have to do a local biomechanical examination (LBE), but I'm not as confident on the thorax LBE so I go to the hips.
I test accessory joint play in supine, and find multiple direction restrictions, in posterior-anterior, and lateral-to-medial and medial-to-lateral. I'm not sure, but i'm going to make a call on my findings - multiple accessory plane MD's, thus a joint mobility dysfunction, bilaterally. I quickly check Obers test and it confirms a lateral chain MD, more so one side than the other. So, there's a tissue mobility dysfunction also.
I have spent another 2 minutes figuring that out and I'm at 24 minutes. Shit. Only 11 minutes to go.
With two joints having MDs, but one drifts laterally in the Modified Thomas Test, I choose to treat that one hip to start with. I tell Janice her hips are not accessing the movement they are supposed to, nor is the thorax, and the low back is probably the victim in the middle. The right hip has less movement so I'm starting with that.
I position her in supine, legs out straight, I pick her up lower leg just above the ankle and position her into 20 degrees flexion, 20 degrees abduction, 20 degrees external rotation to loose pack the joint. I watch the ASIS and then gently traction until it begins to move. I have her cycle a diaphragmatic breath, then resist my pull, gently, for 5 seconds, then let go, then cycle a breath. This is a muscle energy technique with joint distraction at R1. I repeat 3 times. I re-check the hip acccessory glides and thank goodness they have demonstrated better movement. I check the Obers and it has released. Phew. The Modified Thomas Test also has improved. The prone hip ER has 47 degrees to R1 and is not provoking low back pain. The opposite hip also improved to 42 degrees. I ask her to stand up and her MSR has improved in range. Her MSF improves in range and is less painful.
Another 3 minutes has passed. I'm at 27 minutes.
I point out that the brief reset has made a difference to her hips and lower back and definitely hasn't made her worse. She acknowledges and is pleased.
I get her back up, repeat the above treatment, then do it on the other side. I confirm bilateral improvement in FABER(E) and prone hip ER, plus MSF. Interestingly, Cervical Extension has improved but isn't pain-free.
I have to give her a reinforce and retraining exercise so I have her do a superband assisted hip mobility drill, with the motor control option as per this video. That's her homework to do for 5 breaths in the mobility position, and 5 repetitions in position 1 and 2. I tell her she can get a red superband from Rebel Sport for $39.95 and she's happy because her back feels so much better. I give her the link to the video and ask her to return in a week to continue work on the other findings.
I don't have time to reflect any further and I'm a bit stressed by what's just happened but the system seems to have given me a step forward. I make a note to check her exercise performance next week, plus symptoms, and breakout her thorax, in addition to repeat checking her Modified Thomas test, FABER(E), Obers, and hip ER in prone, plus hip LBE.
Bye Janice. Time for a quick cup of tea before Joe comes in.