Here is an interesting case. This young lady is stuck in a lateral bend and flexed position. She has been seen by chiropractors, physiotherapists, acupuncture, massage therapists and has even received injections in her back. Some made no difference and some treatments such as steroid and Botox injections made her worse. Her condition is not resolved at our clinic but it is much better. The following is the initial exam findings and the first treatment. After a few visits we added class 4 laser and shockwave treatments as well. Do to severity of her condition not much exercises could be rendered. She was told to start walking in the swimming pool on daily basis. During spinal decompression treatments she was set up in prone position. She was flexed 5 degrees to reduce pain. Protocol 6 was chosen to reduce spasm. As mentioned before treatments on the later dates were followed by laser (350 Jules) and shockwave (1000-2000 shots at 2 bar) therapy as well. Please note the before and after 15 treatments picture.
Katrina XXXXXXX
YYYYYYYYY
Scarborough, ON MMMMM
Date of Birth: DD/MM/1988
Initial Exam
Examination Date: 28/01/2015
Chief Complaints
- Bilateral Lower Back
Constant bilateral lower back pain. Patient reports insidious onset of the complaint since November 2014. The pain is described as dull. She considers this condition as moderate and rated the pain as a 9 on a scale of 0 to 10 with 10 being the worst. The pain occurs most often during the night. The pain radiates into the right buttock, right calf, right foot and right toes. The pain is reduced by resting while bending and lifting aggravates the condition.
History
Ms. XXXXXXX states that she currently has scoliosis.
Social History
Her occupation is that of a Desk job which involves sitting while at work. Prolong hours of sitting over 12 hours at times.
Capabilities of Daily Living
The patient states that capabilities of daily living have been affected in the following areas:
I am unable to lift any objects of any weight at all. I experience SEVERE pain, which reduces my capability to perform any activity. I have CONSTANT pain occurring between 75% and 100% 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 left. Minor’s sign was positive.
Sex: Female
Age: 26
Height: 165 cm
Weight: 61 kg
BMI: 22.4
BP: 110/78
Pulse: 84/bpm
Complexion: Normal
Size: Normal
Grip strength: Normal bilaterally.
Posture
The patient’s head tilt was to the right. Ms. XXXXXXX shoulder level appeared high on the right. She had a forward head carriage. There was a high right ilium. Observation and inspection of the thoracic spine revealed decreased rounding. Profile view of the lumbar spine revealed decreased curvature. Romberg’s test was negative. Adam’s sign was negative. Left heel walk: WNL. Right heel walk: WNL. Left toe walk: WNL. Right toe walk: WNL. Trendelenberg test on the left was negative. Trendelenberg test on the right was negative.
Ranges of Motion
Lumbar Spine
Motion Degree Pain Level
Flexion: Moderately Decreased Moderate
Extension: Moderately Decreased Moderate
Lateral Right: Moderately Decreased Moderate
Lateral Left: Moderately Decreased Moderate
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). Palpation of the spine indicated discomfort and pain in the spinous process at: L4, L5 and S1 (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). Kemps was positive on the left. The patient also reported experiencing radiating pain during the test. Kemps was positive on the right. The patient also reported experiencing radiating pain during the test. The following lumbar orthopedic tests were positive: SLR passive on both sides. Kemps test was positive for possible facet and meniscoid entrapment. Straight leg raiser test caused pain at 35 to 70 degrees for possible nerve root or disc involvement. This test was followed by Maximal SLR with internal rotation, adduction, foot dorsiflexion, neck flexion and patient bearing down to further pinpoint the lesion. Slump Test in a sited position was also performed to concur with space occupying lesion such as a disc herniation or a bulge. Milgtrams’s (double leg raiser) was also caused radicular pain due to increase of intrathecal pressure. Belt test made no difference during flexion with or without supporting the pelvis. Pain was also felt at hamstrings indicating tightness.
Diagnosis
M545 Low back pain
S335 Sprain and strain of lumbar spine
M541 Radiculopathy
Acute, moderate to severe 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 patient to report 50% pain reduction and 50% increase in ROM within 2 weeks. Functionally patient should also be able to perform half of his ADL’s within these 2 weeks easier. Long Term Goals would be for patient to report over 80% pain reduction and demonstrate over 80% increase in ROM within 4 to 6 weeks. Functionally patient should also be able to perform most of his ADL’s within this period. Patient is also to be discharged with a home exercise program when the above goals have been achieved and he is over 80-90% impairment free.
Spinal Manipulation 3x per week/duration of 1 month
Therapeutic Exercises 3x per week/duration of 1 month (to improve strength, flexibility, balance, range of motion, or endurance to one or more areas of the body)
Home Exercise Program 1x (for the patient to follow a sound home exercise program to increase flexibility, strength and endurance)
Physical modalities 3x per week/duration of 1 month (Modalities such as heat, cold, electrotherapy, ultrasound, laser, acupuncture and myofascial release are used to reduce pain and inflammation and increase range of motion. )
Today’s Treatments
Today’s treatment consisted of Chiropractic Spinal Decompression (Pron,6,70 lbs,5deg and25min NP
) in the lumbar region. Katrina endured these treatments with moderate pain. Proper use of heat or ice, sitting, standing, transferring, lifting, pushing and sleeping was explained to Ms. XXXXXXX today.
A home TENS unit was also given today with instructions.
Prognosis
The prognosis for the patient’s recovery is considered fair.
Nima Pardisnia, DC #4079
Also Read
| Case Study: Acute Lumbar Radiculopathy (2) | Case Study: Chronic Lumbar Spinal Stenosis (3) | Case Study: Chronic Lower Back Pain | Case Study: Subacute Lower Back Pain |
| Case Study: Lumbar Spinal Stenosis | Case Study: Antalgic Posture | Case Study: L5-S1 Disc Prolapse | Facet Joint (Spinal) Osteoarthritis |
| Low Back Pain | Low Back Osteoarthritis |