Examination Date: 13/10/2018
Initial Exam
Chief Complaints
- Bilateral Lower Back
She has a complaint of bilateral lower back pain. Patient reports that on Wednesday October 10, she was squatting and hurt her back. The next day at 2 am she attended nearby ER where she was injected with Tramadol and was recommended over counter pain medications. On Saturday morning she attended different ER due to continuation of severe pain. Tramadol given again and nausea medication. She was recommended therapies. She rated this pain as a 9 on a scale of 0 to 10 with 10 being the worst and considers this condition to be severe. The pain is constant according to the patient. The pain is described as aching and dull. The pain is made better by resting while bending and lifting exacerbates the condition.
Oswestry Low Back Disability Index
The patient was asked to complete the Oswestry low back questionnaire. The disability score calculated was 100%. Their responses are as follows.
The pain is severe and does not vary much. Because of the pain I am unable to do any washing and dressing without help. I can only lift very light weights at the most. I cannot walk at all without increasing pain. I avoid sitting because it increases pain straight away. I avoid standing because it increases pain straight away. Pain prevents (me) from sleeping at all. I have hardly any social life because of the pain. Pain prevents all forms of travel except that done lying down. My pain is rapidly worsening.
Physical Examination
Physical examination revealed an individual who was alert, cooperative and orientated.
The patient’s gait appeared normal. Minor’s sign was negative.
Sex: Female
Age: 25
Height: 173 cm
Weight: 65 kg
BMI: 21.7
Complexion: Normal
Size: Normal
Grip strength: Normal bilaterally.
Posture
There is no indication of a head tilt in the patient’s posture. Her shoulder level appeared even bilaterally. There is no evidence of a forward head carriage. Her ilium level appeared even bilaterally. 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. 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). Braggard’s sign was negative bilaterally. Hoover test result was negative. Kemps was positive on the left. The patient reported localized low back pain during the test. Kemps was positive on the right. The patient reported localized low back pain during the test. Patrick-Fabere test was negative on the left and the right. Milgram’s test was negative. Valsalva’s test was negative. The following lumbar orthopedic tests were negative: hip circumduction bilaterally. The following lumbar orthopedic tests were positive: SLR passive on both sides.
Diagnosis
M545 Low back pain
S335 Sprain and strain of lumbar spine
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.
Today’s Treatments
Today’s treatment consisted Simply Align Technique which consists of laser physiotherapy, Radio-Frequency physiotherapy and Pulsewave Physiotherapy. Proper use of heat or ice, sitting, standing, transferring, lifting, pushing and sleeping was explained to Ms. YYYYY today.
Examination Date: 18/10/2018
Progress Report
After four treatments in one week patient reported 4/10 pain scale (60% improvement) and 44% score on Oswestry Lowe Back Disability Questionnaire (about 60% improvement). Objectively improvements in ROM and reduced tenderness is noted. Patient can sit, stand and walk easier. She is now able to transfer sit to stand easier and sleep better. This is done by applying Simply Align Technique for four visits about 15 min each visit. Patient was recommended against bed rest and was told to get up and walk frequently.