Initial Exam
Examination Date: 08/01/2019
Chief Complaints
- Bilateral Lower Back
Frequent bilateral lower back pain. Patient reports that she has had lower back pain after epidural four months ago. She regards this complaint as moderate and rated the pain as a 4 on a scale of 0 to 10 with 10 being the worst. The pain is explained as aching and dull. The pain is relieved by resting while bending and lifting worsens the condition.
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: 33
Height: 163 cm
Weight: 83 kg
BMI: 31.2
Complexion: Normal
Size: Overweight
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 Normal Pain Level
Flexion: 23 60 Moderate
Extension: 18 25 Mild
Lateral Right: 25 25 Moderate
Lateral Left: 15 25 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: L3, L4 and L5 (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
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 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 of Simply Align Technique which includes laser physiotherapy, Radio-Frequency physiotherapy and pulsewave physiotherapy. 
Intermediate Exam
Examination Date: 18/01/2019
Chief Complaint
- Bilateral Lower Back
Ms. YYYYY feels much better with almost no pain in her back now after 4 visits. She rated the pain as a 0 on a scale of 0 to 10 with 10 being the worst.
Oswestry Low Back Disability Index
The patient was asked to complete the Oswestry low back questionnaire. The disability score calculated was 0%. Their responses are as follows.
The pain comes and goes and is very mild. I would not have to change my way of washing or dressing in order to avoid pain. I can lift heavy weights without extra pain. I have no pain on walking. I can sit in any chair as long as I like. I can stand as long as I want without pain. I get no pain in bed. My social life is normal and gives me no pain. I get no pain while traveling. My pain is rapidly getting better.
Ranges of Motion
Lumbar Spine
Motion Degree Normal Pain Level
Flexion: 60 60 Moderate
Extension: 25 25 Mild
Lateral Right: 25 25 Moderate
Lateral Left: 25 25 Moderate
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 1). Braggard’s sign was negative bilaterally. Kemps was negative on the left. Kemps was negative on the right. 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 and SLR passive on both sides.
After four visits there is no residual pain reported by the patient. Oswestry Low Back Disability Index score is now 0 and patient is discharged. There is also full range of motion.
Also Read
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| Case Study: Chronic Lower Back Pain | Low Back Pain | Low Back Osteoarthritis | |