Low Back Pain – Radiculopathy

Case Description: 66 y/o female with an 8+ year history of persistent back pain and 2-3 years of pain and numbness radiating in to her R hip and leg.  In the 2-3 years leading up to her start of physical therapy she had also developed more and more common (several times a week) of what she described as explosive loss of bowel control that was often associated with her back pain.  She had in depth MRI imaging that showed some L5/S1 degenerative changes.  She had trialed pharmacological management through drugs including Lyrica, gabapentin, and trazadone, but nothing had provided consistent relief.  She had also tried to manage through 1-2x/wk visits to a chiropractor, with some in the moment relief, but no clear lasting resolution. 

Objective Measures: The patient was seen for 17 physical therapy visits over a 3 month period.

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
VAS for Pain	2-7/10	0-1/10
Oswestry Disability Scale	32% disability	10% disability
Radicular Symptoms	Radiating pain and numbness to her R buttock/posterior thigh and calf. Weakness in R dorsiflexors.	Full resolution of LE symptoms
Additional Symptoms	2-3x/wk with loss of bowel control	Resolution of bowel issues
General Function	Avoiding lifting/bending/twisting tasks. Sleep highly limited by pain.  Difficulty walking at times even household distances.  Unable to participate in healthy exercise routines she had previously enjoyed	Lifting up to 35 lbs without issue.  Consistent sleep without waking due pain.  Walking for general fitness without issue.  Resuming some of the exercise she had previously enjoyed

Patient Comments at Discharge: “I had been suffering with back and hip pain for so long I could not even remember what it felt like to not have pain. I had tried numerous treatments. Then I found Dr. Luke and Full Potential. I have been pain free for months. Thank you for giving me my life back.”

Sincerely,

Luke Vander Zouwen, DPT
Full Potential Physical Therapy