Low Back Pain

Case Description: Pt. is a 60 y/o female who presented to physical therapy with a long history of LBP and pain in her legs. LE paresthesia was not in a dermatomal pattern.  She had a lumbar fusion sx in 2012, without significant improvement in her symptoms.  She stated at her initial evaluation, “I don’t think I can go on living with my pain like it is.  It is exhausting.”

Objective Measures: Patient was seen for 13 physical therapy visits over a 1.5 month period.

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
VAS for Pain	3-9/10	0-5/10
Oswestry Disability Scale	60% disability	22% disability
Hip Strength	Grossly 3 to 3+/5	Grossly 4+ to 5/5
Trunk ROM based on expected norms	FLEX: 50%    EXT:  10%    Sidebend R/L: 75%    Rotation R/L: 50%	100% for all and non-painful
Functional Improvements	Strong avoidance to lifting, forward bending, squatting, getting in/out of bed	Able to lift 35 lbs, bend to reach toes, pain free bed mobility, perform 20+ sit to stands

Summary:  Pt. attained full trunk ROM without LBP and reported and although continued to have LBP, stated it was no longer exhausting. LE paresthesia had improved greatly and no longer limited her daily activities.   Her treatment consisted of core control activity, patient education/training with ergonomics and functional exercise focused on daily tasks like lifting and squatting.  .  

Patient Comments at Discharge: “I am able to do normal activities with little or no pain! I can get through a full work day without being exhausted by pain!”

Sincerely,

Luke Vander Zouwen, DPT
Full Potential Physical Therapy