Failed Lumbar Surgery

Case Description: Patient is a 61 year old female who presented to physical therapy a history of lower back pain of 30+ years.  This pain led to a surgical fusion procedure 1 year prior to beginning with minimal improvements following.  She had sought out physical therapy many other times without much improvement, however had resigned to one more try, before accepting that her pain would not improve.  

Objective Measures: Patient was seen for 18 physical therapy visits over a 2.5 month

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
VAS for Pain	10/10 or higher based on patient report	0-4/10
Oswestry Disability Scale	44% disability	32% disability
Trunk ROM	All motions highly guarded with hesitancy to forward bend or rotate beyond a few degrees.  Strong fear of movement in general.	Trunk FLEX to toe-touch, sidebend hand to lateral knee, rotation 100% of expected
Home Exercise Program	Very sedentary lifestyle and quoted as saying “I hate all types of exercise.”	Performs daily routine to stretch and work on corrective exercise.  Attending open swim in Holland Aquatic center several times/week

Patient Comments at Discharge: “My body has learned that it can respond well to stretching, exercise, and breathing in a helpful way.  I can’t thank my therapists enough for teaching me everything I needed to know!”

Sincerely,

Luke Vander Zouwen, DPT
Full Potential Physical Therapy