PT Initial Evaluation:Low Back Pain 2 to Lumbar Spondylosis

Pamantasan ng Lungsod ng Maynila

College of Physical Therapy

PLM-CBR

Pt.'s Name: Dolores Liwag

Age: 61

Sex: F

Address: Manila

Civil status: Married

Handedness: ®

Occupation: Dean of PLM

Religion: Roman Catholic

Rehab Unit: PLM-CBR

Rehab Dr.: Dr. Ynion

Date of Consultation: AUG. 6, 2007

Date of IE: AUG. 12, 2007

Type of pt.: Outpt.

Informant/Reliability: Pt./Good

Dx: Lumbar Spondylosis

HPI:

Present condition started 2 months PTIE when px felt localized dull aching pain on ® low back area c PS (5/10) upon prolonged sitting while doing office works. Px was then rested after office hours and took Alaxan (see drug hx) which relieved the pain from PS (5/10) to PS (2/10). Px was able to tolerate her condition for 6 week and took same medication prn.

Two weeks PTIE, due to severity of pain PS (8/10), px seek consultation in PLM-CBR and was diagnosed to have LBP. The rehab doctor prescribed px to take Mobic (see drug hx) and was referred for PT for further evaluation and tx.

At present, px is independent in all aspects of ADL’s except in prolonged sitting during office works due to pain on ® low back area.

Ancillary Procedures

Result Date

Bone Scan decrease bone density unrecalled

MRI spinal stenosis of L4, L5 unrecalled

Drug Hx:

Indication Dosage

Alaxan pain reliever 500 mg

Mobic pain reliever unrecalled

PMHx:

(-) Htn

(-) DM

(-) heart dse.

(-) asthma

(-)arthritis on all 4’s

FMHx:

Father Mother

Htn. (-) (+)

DM (-) (-)

Heart Dse. (-) (-)

Asthma (-) (+)

PSEHx:

type A personality (px has an active lifestyle and goes to gym twice a week for fitness and work out)

non cigarette smoker

non alcohol beverage drinker

Good financial support

Px was a dean of PLM

Lives in a 2 storey house c husband

Hobbies: watching tv and going to gym

Px work almost 6-8 hrs/day and sit 4-5 hours daily

S: c/c: Pt. c/o localized dull aching pain on ® low back c PS(7/10). Px also /co min difficulty in doing office works such as prolonged sitting due to pain on ® low back.

Pt.'s Goal: To be able to work pain free and s difficulty.

O:

VS: BP: p 120/70 mmHg

a 130/90 mmHg

PR: 75 bpm 80 bpm

RR: 17 cpm 18 cpm

Temp.: Afebrile to touch

OI:

Ambulatory s assistive device

Endomorph

alert, coherent, cooperative

(-) gait deviation

(-) postural deviation

(-) swelling, erythema, hematoma, scar, wound and skin trophic changes in all 4’s face and trunk

Palpation:

Normothermic on all exposed body parts

(+) Grade 1 tenderness on ® low back area

(+) nodules on ® low back area

(+) taut bands on ® low back area

(+) mm spasm on ® low back area and ® upper quadrant of gluteal

(-) edema, subluxation,crepitition and dislocation on all 4’s

ROM:

All major jts. of (B) UE?LE are WNL, actively and passively done, painfree and c (N)

endfeel, except on (B) hip extensor noted hypermobility c firm end feel.

Significance: mm imbalances may cause the LBP

MMT:

All major mm of (B) UE/LE and trunk were grossly graded 5/5.

Significance: Px can perform exercises s difficulty

Special Test:

(+) Bragard’s Test

Findings: pain upon passive knee extension c hip extension and ankle dorsiflexion

Sig: possible nerve affectation

(+) Turyn’s Test

Findings: pain upon doing the test

Sig: possible nerve affectation

DTR

Findings: Normoreflexive on all tested areas

Sig: Intact reflex arch

Sensory Assessment:

Superficial:

STD used: pin - pain

brush - light touch

thumb - pressure

Findings: intact sensation on (B) LE

Sig: Thermal modalities may be suggested for tx

Functional Analysis

Sitting B/T: N/N

Standing B/T: N/N

ADL Analysis:

All parameters of ADL’s especially bathing, eating, dressing and housekeeping are done independently except working c min difficulty on prolonged sitting due to pain on ® low back.\

A:

PT Impression: Px’s improper posture, prolonged sitting and mm imbalances of (B) hamstring caused the LBP. This is also further manifested by MRI who revealed px has lumbar spondylosis and spinal stenosis of L5-S1.

Rehab Potential: Pt. has fair rehab potential. Pain management and proper exercise prescription may benefit but the course of the condition was due to aging. Px is not also compliant to the tx.

Problem Lists:

1. localized dull aching pain on ® low back c PS (8/10)
2. min difficulty in office works due to prolonged sitting
3. hypermobility of hip extensor
4. nodules on ® low back are
5. taut bands ® low back area
6. mm spasm on ® low back area and ® upper quadrant of gluteal
7. Grade 1 Tenderness on ® low back area

LTG: (in 2 mo.)

Px will be able to do office works c tolerated pain to pain free and s difficulty

STG: (in 1 mo):

1. To decrease pain ® low back area from PS (8/10) to PS (4/10) in 4 tx sessions
2. To be able to do office works s difficulty in 4-6 tx sessions
3. To correct px’s mm imbalance in 4-6 tx sessions
4. To decrease taut bands in 4 tx sessions
5. To decrease nodules in 4 tx sessions
6. To eliminate mm spasm in 4 tx sessions
7. To eliminate tenderness in 4 tx sessions

P:

PT Mx:

1. HMP/Tens on ® low back area x 20 mins to decrease pain and mm spasm
2. UTZ on ® low back area x 1.5 w/cm ² x 5mins prior to exercise and to decrease pain and mm spasm.
3. McKenzie Extension Exercises (1 and 2) x 30 sh x 5 reps to strengthen abdominals
4. Low back effleurage massage x 5 mins to decrease pain and mm spasm and to relax the back extensor mm
5. Hamstring, Piriformis and Rectus Femoris Stretching x 30 sh x 10 reps to increase ROM

HI:

1. Put a hot towel or hot bottle if px feel pain on ® low back
2. Proper Body Mechanics
3. Follow the exercises taught in by the PT

Dominic S. Adolfo

PLM PT Intern 2008