Low Back Pain

Case Description: Pt. is a 59 y/o male with a 30+ yr hx of lower back issues, manifesting in 3-4 profound flare-ups each year.  These flare-ups usually require him to be on bed rest for up to a week, missing work.  At his initial evaluation he was in the midst of a 2 week flare-up, reporting severe bilateral lower back pain feeling as if “he was balancing on a point in his lower back and with even small movements his back would surely ‘go out.’” He had tried physical therapy in the past and it had only served to exacerbate his symptoms.  He was very hesitant to trial more therapy, but was tired of having to “pop pills” without any long-term improvement.

Objective Measures: The patient was seen for 10 physical therapy visits over a 2 month period.

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
VAS for Pain	2-10/10	0/10
Modified ODI	64% disability	2% disability
Trunk Mobility (all very hesitant initially)	FLEX 50% expected, EXT to neutral, SB and ROT to 75%	100% of all planes without hesitation
Function	Avoiding bending/reaching tasks, taking time off work, unable to get good sleep	Back to full time work and no limitation (even lifting), feeling confident with his HEP

Summary: The patient was discharged from physical therapy with increased pain free trunk ROM to WFL, no low back pain during his normal daily activities including his work which requires frequent lifting/bending/reaching tasks.  In his course of PT he even experienced one brief flare-up, but through his provided exercises and education he was able to get through it without missing any work time.  

Sincerely,

Luke Vander Zouwen, DPT
Full Potential Physical Therapy