Assess, Treat, Re-assess: Applying The Clinical Audit Process
The clinical audit process is the process of applying a test or multiple tests with a patient. Then applying an intervention or combination of interventions and then re-assessing the original test or tests. This process can be conducted over a period of minutes or months.
It is an incredibly useful methodology giving you feedback on the effect of your treatment. Further, if a patient centred test is used the patient indicates the success of the intervention himself or herself and thus there is “buy-in”.
A clinical example is shown below. The case history is edited to only the key points for brevity.
The patient attended complaining of an increase in pain to 6/10 on a verbal rating scale over the left sacro-iliac joint with occasional radiation of pain in to the anterior of the left thigh. The symptoms were aggravated with walking and getting in and out of a car. She did not report any positions of ease.
The key assessment finding was a difficulty of 4/5 in active straight leg raise (ASLR) on left and 3/5 on right as described by Mens et al (1999). With pressure to approximate the anterior superior iliac spines difficulty reduced to 4/5 and 3/5 respectively. Pressure to approximate the pelvis at the level of the greater trochanter had the same effect. However, pressure applied to approximate the posterior superior iliac spines (PSIS) reduced difficulty to 2/5 and 1/5 respectively. This test was used for the clinical audit process as it was deemed the most fundamental, prominent and functional (Liebenson 2013).
As pressure to approximate the PSIS’s was most helpfully the multifidus were targeted for neuromuscular stimulation. To do this the patient was coached through doing the horse stance vertical exercise shown in figure 1.
Figure 1. Horse Stance Vertical
Kneel down on all fours. Keep the knees under the hips and the wrists under the shoulders.
Keep the chin tucked and the elbows pointing backwards and slightly bent.
Keep the dowel rod straight along the spine and if possible parallel to the ground. (This should touch the base of the skull, the mid thoracic spine and the sacral base.)
Engage your inner unit by breathing in diaphagmatically and then pushing your diaphragm down without allowing your abdomen to expand.
Then slowly unload one hand / knee just enough to slide a piece of paper underneath – keeping the dowel rod still.
Hold this position keeping everything else static and then lower and repeat.
Aim to be able to lift one hand and the opposite knee at the same time, without shifting any other part of the body.
This exercise uses rotational loading of the spine to cause a subconscious contraction of the multifidus as well as other key spinal stabilisers.
Following four repeitions on each side of 10 second hold with 5 seconds test the ASLR was retested. After just this set the difficult was reduced to 3/5 on the left and 2/5 on the right.
After two further sets of four repetitions on each side the difficulty reduced to 2/5 on the left and 1/5 on the right.
As the patient had also had reduced difficulty on initial ASLR with ASIS and greater trochanter approximation the wall deadbug exercise was used to stimulate the pelvic floor and transversus abdominis as shown in figure 2.
Figure 2. Wall Deadbug
Start with your head 2cm’s from the wall.
Your palms should be flat on the wall, the elbows facing up.
The knees, hips and ankles should be flexed to 90 degrees and the thighs slightly external rotated.
Engage your inner unit by breathing in diaphagmatically and then pushing your
diaphragm down without allowing your abdomen to expand. This will engage the transverse abdominis, pelvic floor and diaphragm.
From here you should push off the wall to move your head a further 3-5cm’s away from the wall. This is to engage the latissimus dorsi.
Then lower alternate heel to the ground whilst maintaining the angle at your knee and ankle as well as the pressure against the wall.
Throughout your neck and lumbar spine should be in a neutral position.
Following 6 repetitions of wall deadbug on each leg at a 3-0-3 tempo the ASLR difficulty was reduced to 1/5 on the left and 0/5 on the right.
A further set each of horse stance and wall deadbug reduced the difficulty to 0.5/5 on the left. Further, at this point the verbal rating scale was reduced to a 1/10. Most importantly the patient felt much stronger when walking and was highly motivated to do her exercise programme.
Several factors need to be born in mind with this approach.
Firstly it is highly flexible. You could use an orthopaedic medicine assessment, a resisted muscle test for example. You could use a functional assessment such as an overhead squat. It works equally well with the movement-based assessments of Sahrmann (2002) and probably with whichever system you use.
Similarly you can use a variety of treatment approaches. For example in this case I could have used reflex stimulation, GUNN needling to facilitate the local stabilisers of the sacro-iliac joint, joint manipulation or mobilisation and maybe even energetic or cognitive approaches.
I can also imagine that some therapists might suggest that the response is due to placebo or even credebo as discussed elsewhere on this site. However, I suspect the majority of the treatment effect can be explained by cortical reorganisation (Tsao et al 2008).
Obviously some treatments will not have an instant effect. In some case we may be waiting weeks for a muscle to hypertrophy in response to a prolonged period of training. In others we may wait over a month for the effects of nutritional therapy protocol targeted at specific inflammatory pathways to take effect.
Nonetheless for the majority of manual and corrective exercise approaches the clinical audit process demonstrates the immediate effect these interventions can have.
The clinical audit process allows therapist and patient to get potentially instant feedback on the effect of an intervention. This can be invaluable in directing treatment and encouraging the patient to do their exercise programme. The exact mechanism is uncertain but cortical re-organisation appears most likely.
If you have any questions or ideas please comment below or feel free to email me at firstname.lastname@example.org. Skype appointments are available for people interested in consulting with me but unable to make it the UK to see me in person.
Liebenson, C. 2013. Bridging the gap. One day course. Bowskill Clinic: London.
Mens, J.M.A. Vleeming, A. Snijders, C.J. Stam, H.J. Ginai, A.Z. 1999. The active straight leg raise test and mobility of the pelvic joints. European spine journal, 8 (6), 468-473.
Sahrmann, S.A. 2002. Diagnosis and treatment of movement impairment syndromes. Mosby: St. Louis.
Tsao, H. Galea, M.P. and Hodges, P.W. 2008. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain, 131, 2161-2171.