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Subacute Lower Back Pain

Examination Date: 2014-03-14

Intermediate Exam

Chief Complaint

1. Left Lower Back

Here is an example of a patient with subacute lower back pain.  Occasional left lower back pain.  Patient reports over all improvement, less pain and has returned to modified hours at work.   She considers this complaint as moderate and rated the pain as a 5 on a scale of 0 to 10 with 10 being the worst.  The pain is described as sharp, occurs most often after moderate physical activities and in the morning and is radiating into the left buttock, left calf and left hip.  The pain is reduced by range of motion and chiropractic treatments while bending and prolonged standing aggravates the condition.  Further concerns of this condition are tingling.

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 am restricted to social activities at home due to pain.  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.  Minor’s sign was positive.

Sex:                 Female

Age:                 33

Height:             165 cm

Weight:            70 kg

BMI:                 25.7

Complexion:    Normal

Size:                Normal

Grip strength: Normal bilaterally.

Posture

There is no indication of a head tilt in the patient’s posture.  Ms. XXXX shoulder level appeared high on the left.  There is no evidence of a forward head carriage.  Observation and inspection of the thoracic spine revealed a normal spine.  Profile view of the lumbar spine revealed normal curvature.  Romberg’s test was negative.  Adam’s sign was negative.  Left heel walk: WNL.  Left toe walk: WNL.

Ranges of Motion

Lumbar Spine

Motion                                     Degree            Normal            Pain Level

Flexion:                                   42                                60                    Mild

Extension:                               16                                25                    Moderate

Lateral Right:                           25                                25                    No

Lateral Left:                             21                                25                    No

Neurological Testing

Reflexes                                  Wexler’s Grading System

L                                  R

Patellar (L2, 3, 4)                    1+                                2+

Achilles (S1, 2)                        2                                  2

Jendrassik was not required.

Lower Extremities:

Left                                          Right

L-4                   Decrease

L-5                   Decrease

S-1                                          Equal

Lumbar Spine Evaluation

Lumbar spine evaluation provided the following results:

Palpation of the spine indicated discomfort and pain in the spinous process at: L4 and L5 (grade 3).  Straight leg raise was positive on the left (60 deg).  The patient also reported experiencing  radiating pain during the test.  Straight leg raise was negative on the right (90 deg).  Kemps was positive on the left.  Kemps was positive on the right.  Shear stability test  was positive at L4 level.

Lower Extremities Muscle Testing

Tibialis                                     5/5                               5/5

Extensor Hallucis Longus       4/5                               5/5

Hamstrings                              5/5                               5/5

Peroneous Longus                  5/5                               5/5

Ms. XXXX demonstrated  L5 (big toe extension) of 7 lbs on the right and 4 lbs on the left.

Diagnosis

M5416             Radiculopathy, lumbar region

Acute, moderate to severe traumatic joint and muscle dysfunction in the above region with associated symptoms of pain, ROM reduction and functional difficulties. Radiculopathy consitent with MRI findings of small central disc herniation at L4-L5, mild DJD of L4-L5 and L5-S1 and disc bulge at L5-S1.

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. XXXXX 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 (to stabilize lumbar spine in a pain free manner)

Lumbar stability exercises 3x per week/duration of 3 weeks (to stabilize lumbar spine in a pain free manner)

Today’s Treatments

Today’s treatment consisted of Electrical Stimulation in the lumbar region; Spinal Decompression (Pron,6,60 lbs,-7deg and20min  NP) in the lumbar region.  Proper use of heat or ice, sitting, standing, transferring, lifting, pushing and sleeping was explained to Ms. XXXXX today.

Prognosis

The prognosis for improvement of the patient’s condition is considered good.

WIN_20140314_165227 WIN_20140314_170254

Notes:

She has L4 spinous process pain during 2 lbs shear provocation test.  She has positive findings of disc herniation and DJD in lower lumbars.  Although she had more pain during extension, I still think extension is a better position for her.

DOC Settings:

Prone:  It is the go-to position

Protocol: 6 with frequent pulls at the early treatments

Force: She is 70 Kg or 154 Lbs so 60 lbs is a good starting point.

Angle:  I choose -7 to give her some centralizing extension.  Patient was asked if they have any pain or radiation or discomfort and she was ok.

Time: 20 min, to reduce muscle spasm I added Portable EMS during treatment and Ice and Biofreeze after.

Proper use of heat or ice, sitting, standing, transferring, lifting, pushing and sleeping was explained to the patient.

This patient had stopped coming in with fear of her insurance running out.  I explained that that is waste of her time and my time if she is going to come only once a while.  She understood.  We worked out a better plan for her payments and she is booked for 3 times a week for next 3 weeks.

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