Reg.

No: 14 March 300-U Date of Assessment/Place: 29 March 2014, OPD-1

Case Study

A 48 year old female Parminder Kaur presents with complaint of lower back pain of at least
one years duration. Patient keeps on doing household activity all the time. No significant
history of trauma or major back injury. Numbness is present most time/days and limits
activity; particularly prolong standing, walking forward bending. Current exercise level is
minimal due to pain. There are no significant complicating factors. Radiological investigation
(X-ray) was negative for significant structural abnormality (no disc herniation, disc bulge, or
osteoarthritis).

There was no any history of trauma/Injury. Patient was apparently alright before 2-3 months
back. Gradually she feels pain in his low back, and then she started to take medicine (pain
killer) without consulting any doctor. As she take medicine, pain use to subside for temporary
period of time. She uses to do home massage and get relief for some time. No any associated
problem she has a history of fall in august, 2013 and after that pain started and she was on
pain killers till then. No any kind of addict. Family history was not relevant. Pain was present
in both side of low back, were the onset of pain was gradual onset which was spasmodic type
and sub acute in nature with static course. Prolong sanding, walking, position were the
aggravating factor where as lying was relieving factor. There was not any functional
limitation as such. Pain was rated by patient herself eight on visual analog scale.

When patient was examining observationally then she was mesomorphic, no swelling any
deformity, scar or wound was present. She was not using any external appliances. While in
postural assessment from anterior view pelvis were leveled were as ASIS was anterior pelvic
tilt found. In lateral view forward head posture, in thoracic region thoraco lumber hyper
kyphosis was present. In lumber mild hyper lordosis was found, pelvis was leveled and PSIS
were anteriorly tilt. Bilateral slight knee flexion was found from side view.
On palpation tenderness was present over lower para vertebral (thoracolumabar junction and
entire lumbar vertebrae) muscles were as warmth was normal no presence of edema. Spasm
was present over lower para vertebral (thoracolumabar junction and entire lumbar vertebrae)
muscles
On examination the Range of motion (both AROM\PROM) of Lumbar Spine limited and
painful at end ranges. Combined movement examination was also limited and painful at End
range. Sensory examination (Deep & Superficial) and Reflexes (Deep and superficial) were
intact and normal respectively. Hypo Mobility was present in Thoracolumabar Junction and
on entire Lumbar Vertebrae on PAIVM. No any SI joint dysfunction, hip/ knee reported
normal after examination. On core muscle were found weak on examination. Gait pattern of
patient was Antalgic gait. In differential diagnosis Spondylolisthesis, Secondary Canal
Stenosis, Sacroiliac Strain and Lower Cross Syndrome were expected.

The special test like SLR (both right and left side) ranges 55-60 approximately actively were
as in passive its range was 60-65 approx for both leg. 5 min walk test, step sign, Faber test
pump handle test, compression / distraction test, slump test were found negative. Ober tests,
Thomas test, Elys test and Prone Knee Bend were positive in response while it was
examined. ITB tracts, piriformis muscles, hamstring and calf muscles were tight. Daniels and
Worthinghams method was used for Manual Muscle Test. Gross Testing of Muscles of the
Trunk extensor (Lumbar spine) was grade 4 (Full range of motion with having waver
sign/sign of effort.) Trunk Flexion was grade 3+ (Complete full range of motion and flexes
trunk unit inferior angle of scapula off table). Hip Flexion (Psoas Major and Iliacus) was 4+
(Thigh clear table, patient tolerates minimal resistance) and Hip Extensor (Gluteus Maximus)
were 3+ (Complete full range of motion and hold at end position with mild resistance). The
Oswestry low back pain disability questionnaire was used as measure outcome scale.

Spondylolisthesis was excluded because of negative step sign and there was No Slippage of
Vertebral Body in Radiological Examination. Secondary canal Stenosis was excluded due to
its aggravating duration time and lack of MRI investigation report. Sacroiliac Strain was
excluded because all special test of Sacroiliac joint was Negative in response. My provisional
diagnosis was Lower Cross Syndrome, Because Of Positive Finding like Postural Assessment
and Muscular Imbalance (Weak Abdominal/Glutes and Tight Hips/Erectors)

In treatment moist heat was applied before and after the exercise to get the part loose and
sedative as well. Gentle stretching of tight muscles and structure, Maitland Mobilization on
Thoracolumabar Junction and entire Lumbar Vertebrae Grade 2 to reduce pain. Electrical
Modality like IFT over the Low Back region for reduction of pain. Home exercise
programme shown & confirmed by the Patient. Gentle DTFM was added on second day over
tight muscles and Myofacial Release of paravertebral muscles.

Case was reviewed on 17
th
April 2014. Patient got relieved 60 % of her problem. There was
no more numbness, tightness in back extensors were reduced. Pain was rated 2-3 on visual
analog scale. Home exercise programme were taught like stretching of tight muscles,
strengthen exercises of core through different Pilates position shown. Breathing pattern/core
engagement activity demonstrated and ergonomic for posture was advised. A few basic
suggestions were also advised to patient like to avoid the unwanted/stressful movements.
Moist heat was advised to take regularly and if the problem re-occurs then patient was asked
to contact the doctor/therapist for management in spite of take drugs from medical shop.






Submitted By:
M. Kumar
2013-2015