IN-SERVICE REPORT: Mary Ann Zamora SPTA Morton College

Low Back Pain (due to Herniated Disc): Case Related Report Case: Patient is a 58 year old female came into the physical therapy clinic for the second time with complaints of pain that radiates towards the left leg rated 6/10. Upon the first visit, the physical therapist was able to do a full initial assessment of the patient. Patients past medical history includes: diabetes, hypertension, C5 and C7 herniated disc (not treated), and recurring back pain on the same region. Current medication includes antihypertensive medications, glucose altering medications, and pain medications (over the counter and prescribed). The patient has difficulty staying in prolonged positions, most commonly in supine, sitting, and standing positions. Patient exhibited near functional gait pattern, but mild antalgic gait pattern is noticeable pass 50 feet of ambulation due to radiating numbing pain on the left lower extremity. Sitting and standing balance was rated at good grade. And with pronounced pain upon ambulation; there is a reduced stride length and cadence, and also a mild wide base of support compared to normal pain free paced gait. Patient is able to perform activities of daily living (ADL), but due to pain; aerobic capacity and independent function with repetitive movement related to spinal flexion activities such as wearing socks is limited. In regards with gait activities, ambulation is only limited to short distances for up to half a mile due to increasing pain and pressure on patients back and left lower extremity. Position of comfort, as stated by the patient, is when trunk is in extended position. Summary of Assessment: It was determined by the Physical Therapist (PT) that the patient has Low Back Pain with Radiculating Symptoms (with possible Sciatica due to herniated disc) that is more pronounced on the left lower extremity as evidenced by display of pain with discomfort on the bilateral lumbosacral regions with radiating numbing pain to the left lower extremity, postural compensation on the right to relieve pressure on the left side, and range of motion limitations on the left side due to pressure and pain. Plan of care and Goals: Plan of care and goals specifically for this patient includes: reduction of pain on the lumbosacral region (pain management), improved lumbosacral and lower extremity active range of motion, strength, and flexibility (lumbar stabilization with core and lower extremity strengthening and flexibility exercises with correction for posture and normalized functional gait pattern), and lastly, to improve ADL and functional independence with little to no pain on the lumbosacral region and lower extremity. Intervention: -Hot pack on the low back area and left lower extremity for 20 min. in prone position prior to treatment and 15 min. after treatment. -Initial/Maximum phase Exercise program that is indicated specifically for this patient and was done on the second visit includes: -ankle pumps (range of motion and stretch of dorsiflexor and plantarflexor) in supine position -heel slides (range of motion) in supine position -abdominal isometrics/pelvic tilts in supine position -trunk rotation in supine position -single knees to chest (range of motion and stretch of the trunk and hip extensors) in supine position -partial straight leg raises (range of motion and stretch of the unilateral trunk and hip extensors) in supine position -Gentle massage on the low back area and left lower extremity. -Addendum on the interventions for this visit: -Conservative approach for treatment was emphasized during the first week of the patients visit to the clinic. -Hot pack and massage on the low back and lower extremity addresses one of the goals/plan of care which is pain management. -Exercise program set up on patients second visit was specifically indicated to address one of the goals/plan of care which is improved lumbosacral and lower extremity active range of motion, strength, and flexibility. -The improvement for ADL and functional independence will be addressed as patient progresses with treatment regimen and depending on patients condition, functional status, and pain tolerance. -Patient education in regards to incorporating pain management regimen and in-treatment exercise program that was modified for home use. Post-treatment assessment:
Resource: Loretto Hospital Physical Therapy Department staff Kisner and Colby. Therapeutic Exercise: Foundations and Techniques. 5th edition. 2007. F.A. Davis Company. Philadelphia, PA 19103.

IN-SERVICE REPORT: Mary Ann Zamora SPTA Morton College

Patient expressed improved function with pain reduction rated 3/10 from 6/10, and also reports the feeling of good pain. Patient demonstrated improved functional mobility and ambulation after treatment. And also, patient understood the rationale behind every intervention done for the visit and conveyed willingness to do advised modified interventions at home. Conclusion: Addressing the initial dilemma of the patient, upon visiting the physical therapy clinic, gives a sense of trust and comfort for the patient knowing that every complaints and deficits will be taken into consideration by the therapist, and will work towards a goal that will eventually provide relief and improve functional mobility in order to perform activities of daily living independently.

Resource: Loretto Hospital Physical Therapy Department staff Kisner and Colby. Therapeutic Exercise: Foundations and Techniques. 5th edition. 2007. F.A. Davis Company. Philadelphia, PA 19103.