Low Back Pain after Diagnosed Disc Herniation

Case Description: Pt. is a 59 y/o female who has a history of back issues as long as she can remember. She exacerbated her symptoms bending forward to pick something light off the floor several months before beginning PT and had multiple level HNP in lumbar region based on MRI results.  She had been avoiding all bending tasks for months and felt immobilized by her bilateral LE pain and lumbar spasms. She was taking gabapentin and 800 mg Motrin with regularity. 

Objective Measures: The patient was seen for 8 physical therapy visits over a 2 month period.

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
VAS for Pain	10/10 (constant)	0/10
Oswestry Disability Scale	62% disability	0% disability
Trunk Mobility	50% for FLEXT, 10% for EXT	100% all planes (no pain)
LE symptoms	Diffuse bilateral non-dermatomal pattern LE pain	No further LE symptoms

Summary: Pt. discharged from physical therapy with full resolution of her symptoms, even with lifting household weights, performing complex balance tasks, and performing all her normal daily activities.  She overcame strong fear avoidance patterns related to movement. She discharged feeling empowered, with a comprehensive home program to maintain/improve upon her results. 

Patient Comments at Discharge: “I am pain free now, without medication!  I have knowledge of the body and how every move effects each area.  I appreciate the friendliness, thoughtfulness, and concern…I could not be more pleased on how well I was treated as well as my results!”

Sincerely,

Luke Vander Zouwen, DPT
Full Potential Physical Therapy