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.
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.
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 Chiropractic 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. 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.
Also Read
| Case Study: Acute Lumbar Radiculopathy (2) | Case Study: Chronic Lumbar Spinal Stenosis (3) | 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 | Case Fruits: Acute Lower Back Pain |
| Case Study: Subacute Lower Back Pain | Low Back Osteoarthritis | Low Back Pain |