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Chronic Lower Back Pain

Examination Date: 2014-03-14

Exam

Chief Complaint

1. Right Lower Back

Below is a patient presenting chronic lower back pain.  Patient is complaining of some lower back pain for the past 7 months, with radiation down the right LE.  The pain is described as aching and dull.  She considers this condition as moderate and rated the pain as a 4 on a scale of 0 to 10 with 10 being the worst.  The pain radiates into the right buttock, right calf, right toes and right upper back.  The pain is reduced by resting while lifting, prolonged sitting and prolonged standing aggravates the condition.  Side effects of this condition are numbness.

Capabilities of Daily Living

The patient states that capabilities of daily living have been affected in the following areas:

I am unable to lift heavy objects off the floor.  However, I can manage if they are at table height.  I experience MODERATE pain, which causes a significant limitation on my physical performance of activities.  Pain is FREQUENT, and occurs between 50% and 75% of my awake time.

Physical Examination

Physical examination revealed an individual who was alert, cooperative and orientated.

The patient had a limping gait.  The limp appeared on the right.  The patient had an antalgic lean to the right.  Minor’s sign was positive.

Sex:                 Female

Age:                 51

Height:             132 cm

Weight:            62 kg

BMI:                 35.6

Complexion:    Normal

Size:                Normal

Grip strength: Normal bilaterally.

Ranges of Motion

Lumbar Spine

Motion                                     Degree            Normal            Pain Level

Flexion:                                   55                                60                    Moderate

Extension:                               8                                  25                    Moderate

Lateral Right:                           20                                25                    Moderate

Lateral Left:                             18                                25                    Moderate

Neurological Testing

Reflexes                                  Wexler’s Grading System

L                                  R

Patellar (L2, 3, 4)                    2                                  2

Achilles (S1, 2)                        2                                  2

Jendrassik was not required.

Lower Extremities:

Left                                          Right

L-4                                           Equal

L-5                                           Equal

S-1                                          Equal

Lumbar Spine Evaluation

Lumbar spine evaluation provided the following results:

Evaluation of the lumbar spinal region reveals tender areas in the lumbar region on both sides (grade 2) and erector spinae on both sides (grade 2).  Evaluation of the lumbar spinal areas indicates that trigger points are present in the erector spinae bilaterally (moderate) and quadratus lumborum bilaterally (moderate).  Straight leg raise was negative on the left (80 deg).  Straight leg raise was positive on the right (60 deg).  The patient also reported experiencing radiating pain during the test.

Lower Extremities Muscle Testing

Tibialis                                     5/5                               5/5

Extensor Hallucis Longus       5/5                               5/5

Ms. XXXX demonstrated S1 (ankle PF) of 20 lbs on the right and 25 lbs on the left.

Diagnosis

M545               Low back pain

S335                Sprain and strain of lumbar spine

Subacute, moderate traumatic joint and muscle dysfunction in the above region with associated symptoms of pain, ROM reduction and functional difficulties.

Management Plan

Short Term Goals would be for Ms. XXXX to report 50% pain reduction and 50% increase in ROM within 2 weeks.  Functionally Ms. XXXX should also be able to perform half of her ADL’s within these 2 weeks easier.  Long Term Goals would be for Ms. XXXX to report over 80% pain reduction and demonstrate over 80% increase in ROM within 4 to 6 weeks.  Functionally Ms. XXXX should also be able to perform most of her ADL’s within this period.  Ms. XXXX is also to be discharged with a home exercise program when the above goals have been achieved and she is over 80-90% impairment free.

Spinal Decompression 3x per week/duration of 3 weeks

Today’s Treatments

Today’s treatment consisted of Spinal Decompression (Supine,6,50 lbs,-2.7deg and15min  NP

) in the lumbar region.

WIN_20140314_124752

Notes:

This patient actually has lots of right knee pain.  She has been seen by her physician (who referred her to us), and another chiropractor.  Both think that her knee pain comes from her back.  I personally don’t think so.  We are currently treating her knee with U/S and exercises.   There was no spinal pain for L1-L5 upon palpation and provocation at 2lbs of force.

DOC Settings:

Supine:  Because prone aggravated her knee, otherwise I would have chosen prone

Protocol: 6 to start with frequent pulls and rests

Force: 50 lbs, She weigh’s 62 Kg, or 136 lbs, so I am comfortable to start her at 50 lbs.

Angle: -2.7 to give some flexion for comfort.  There was no different in her pain level at this angle vs flat, so I could have chose flat (0 deg) also.

Time: 15 min or 18 Cycles.  This is the minimum time my table allows me.  I have one of first tables so I only can choose time not cycles.  15 min is a good initial treatment time.  Less I find useless, and more may cause stiffness in the back.

She is to attend 3 times a week for 3 weeks. This is minimum frequency.  She has pre-paid for these sessions.  If there is significant improvement she will be asked to sign up for another four weeks.  Total of 21 visits.  If she has improvement after that, she maybe put on our wellness (once every 3 weeks continually). Why?  Because I personally believe in maintenance rehab visits.   For years I have seen patients stop treatments as soon as they were pain free to come back couple of months later with much more issues.  So I now suggest some patients, NOT ALL, to be under wellness care (once every 3 weeks).   This patient has had this pain for 7 months.  I don’t think it will be eliminated in 3 weeks.  She is deconditioned and needs lots of exercises as well.

 

Examination Date: 05/04/2014

 

 

Chief Complaint

1. Right Lower Back

Reduction of  pain to 4 on a scale of 0 to 10 with 10 being the worst is reported today. The pain is occasional according to the patient.  She feels better after decompression treatments.

Ranges of Motion

 

Lumbar Spine

Motion                                     Degree            Normal            Pain Level

 

Flexion:                                   60                                60                   Mild

Extension:                               20                                25                   No

Lateral Right:                           25                                25                   No

Lateral Left:                             25                                25                   No

 

Lumbar Spine Evaluation:

 

Palpation of the spine indicated discomfort and pain in the spinous process at: L5 and S1 (grade 2).

Management Plan

Some short-term goals have been achieved. Continuation of treatments at this time is recommended since ROM and positive orthopedic test suggest residual impairments.

 

Continue with Spinal Decompression 3x per week/duration of 3 weeks

Today’s treatment consisted of Spinal Decompression (Supine,2,60 lbs,-2.7deg and15min)  NP

Notes:

As you can see patient has improved after 10 visits.  She no longer complains of radiation of the pain down the leg.  Once again please note that we only did decompression therapy on her back.  No exercises, modalities or activity modifications were recommended so far.  Objectively ROM has improved and functionally she can transfer sit to stand and walk easier.   I am keeping the same DOC table setting but I did change protocol 6 to 2 for longer held pulls and increased the weight to 60 lbs.  This chronic lower back pain patient clearly sees the benefits of spinal decompression.  She will also be a great referral source.

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