Examination Date: 2017-02-09
Initial Exam
Chief Complaints
Frequent lower back pain. Patient reports insidious onset of the complaint. Recent MRI suggests facet degeneration at L5-S1 and moderate spinal canal stenosis. She regards this symptom as moderate and rated the pain as a 7 on a scale of 0 to 10 with 10 being the worst. The pain is reported as aching and dull and is stated as radiating into the left buttock, left foot and left hip. The pain is lessened by resting while bending and lifting aggravates the condition.
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’s gait appeared normal. Minor’s sign was negative.
Sex: Female
Age: 60
Height: 162 cm
Weight: 63 kg
BMI: 24
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). Straight leg raise was positive on the left (at 50 degrees). The patient also reported experiencing radiating pain during the test. Hoover test result was negative. Valsalva’s test was positive with pain at L5. The following lumbar orthopedic tests were positive: SLR double. 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. Milgram’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.
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.
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 or decompression 2x per week/duration of 1 month
Therapeutic Exercises 2x 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 2x 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,-10deg and20min NP
) in the lumbar region. Mona endured these treatments with mild pain. Proper use of heat or ice, sitting, standing, transferring, lifting, pushing and sleeping was explained to Ms. ZZZZZ today.
Notes: After patient was left for 2 minutes at 10 degrees of lumbar extension and side bending away form the pain side (left), patient reported less radiculopathy down the left leg. After 20 minutes of treatment at 70 lbs pattern 6, there was no radiculopathy.
Patient works as a cashier and stands all day. Recommendation of being off for two weeks was also made since her work aggravates her symptoms. Goal will be retune to work in 2 weeks.
Also Read
| Case Study: Chronic Lumbar Spinal Stenosis (3) | Case Study: Chronic Lumbar Spinal Stenosis (3) | Case Study: Chronic Lower Back Pain | Case Study: L5-S1 Disc Prolapse |
| Case Study: Subacute Lower Back Pain | Case Study: Lumbar Spinal Stenosis | Case Study: Right lateral disc protrusion at L5-S1 | Case Study: Antalgic Posture |
| Cervical Osteoarthritis / Neck Arthritis | Degenerative Disc Disease (Intervertebral Disc Pain) | Lumbar Spondylosis |