Robert Traph Case Summary

Lumbar radiculopathy (sciatica)and other types of back pain is one of the most frequent and essential spinal condition that a physical therapist commonly treats. Lumbar radiculopathy is a sciatic nerve root irritation or compression at the lower spine (Fuller & Goodman, 2015). A person with sciatica experiences a sudden pain, tingling sensation and weakness from the lower back radiating through the buttocks, groin and all the way own to the leg and feet depending on the affected nerve root irritation, usually from L1 to S1 ( Ropper & Zafonte, 2015).

HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year she began to complain of back pain that

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

On the objective measure (MMPI-II-RF), Mr. Cintron did not respond consistent to the tests items and therefore his protocol was invalid and uninterpretable. There was evidence of excessive inconsistency because of fixed true responding to the test item. It is possible Mr. Cintron had a difficult time comprehending the test questions as he asked for clarification from the examiner throughout the test.

Scharf utilized Diagnosis Related Estimate cervical category II and assigned an 8% Whole Person Impairment. Dr. Scharf noted the MRI study of the cervical spine right disc extrusion at C5-C6, but there are no verifiable radicular symptoms in light of the result of the EMG/NCV studies, despite the applicant’s subjective complaints of radicular symptoms into the bilateral upper extremities. Since there are no verifiable radicular symptoms, the placement into DRE category II seems appropriate.

Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

By becoming educated on the risk factors that cause back injuries, a majority of the general population can prevent agonizing and potentially disabling pain during their lifetimes. Back injuries can occur gradually over time as a result of trauma caused by repetitive activity or can result from a single traumatic event (Back). The signs and symptoms of a back injury may include pain when trying to assume a normal posture, decreased mobility, and pain when standing from a seated position (Back). Warning signs that should cause concern may include radiating pain down a leg, numbness or loss of sensation in a leg, weakness or loss of muscular strength in a leg, constant pain in the back or leg that is not affected by motion, pain in the

Method: Eleven subjects ranging in age from 18 - 65 were selected based on diagnosis of leg and low back pain. Those who participated in this study reported pain no longer than six months and no less than one month. These patients were screened using a standardized lumbar spine evaluation. Patients AROM, flexibility, medical history, strength, gait, neurology, and soft tissue were also evaluated and measured prior to testing. The test was designed using an A-B-A design where A is the baseline condition and B was intervention with the use of the PBWS. The

On admission, Ms. Kelly complained of low back pain ranging in intensity from 7 to 8, out of 10, on the pain scale where 0 is no pain and 10 is the worst imaginable pain. She subjectively describes this pain as throbbing, stabbing, burning and radiating down into both legs, left worse than right. In addition, she has sharp, stabbing, burning pain in both her arms, left worse than right, and experiences intermittent tingling and numbness sensations in both her hands. She has pain in her neck and shoulder that she defines as tension-type pain. Factors that can aggravate the pain include

Based on the progress report dated 03/01/16 by Dr. Ahmed, the patient continues to complain of constant lower back pain radiating to her left leg which she describes as sharp with pins, and needles and intermittent numbness and weakness.

As per medical report dated 3/10/2016, patient complains of low back pain rated at 7/10 with left lower