Sij Dysfunction Reflection

Assessments are lumbosacral intervertebral disc disorder with radiculopathy, lumbar spondylosis without myelopathy or radiculopathy and myalgia.

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.

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

Diagnoses include failed back surgery, lumbar; degenerative disc disease, lumbar spine; back pain; lumbar radiculopathy; spondylosis without myelopathy or radiculopathy, lumbar region; impingement syndrome of bilateral shoulders; myalgia; xerostomia; erectile dysfunction; testicular hypofunction; chronic anxiety; chronic depression; and chronic insomnia.

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

O: Slow but normal gait, sitting upright on the examination table without any support, able to get up and down without any assistance on the exam table; no grimace on his face, limited lumbar spine range of motion (per TM); no muscle spasm; no impairment of NVS; no muscle atrophy noted; intact reflexes, + 5 strength to lower and upper extremities, peripheral pulses +3, sensation intact; Straight leg test was negative.

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

Positive Standing Forward Flexion test: PSIS doesn’t move or delayed & jumps superiorly, this indicates anterior rotation.

O: mild grimace on her face; sitting strait up on the exam able without the support; tender over the left side of the lumbar spine, Full lower lumbar ROM with some pain; able to perform heel and toe walks; negative straight leg raise; no impairment of NVS; DTR 2+to bilateral lower extremities

Due the patient’s symptom reproduction with the straight-leg-raise test, the SLR measurements remaining between 30-60 degrees hip flexion, the positive slump test, the described radicular pattern, and diminished Achilles DTR the therapist concluded that the examination findings were consistent with the medical diagnosis of L5/S1 disc herniation with associated nerve root involvement. (CITE) Therefore, the physical therapists diagnosis was practice pattern 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders. (CITE) Once tested, the sacroiliac (SI) tests determined SI joint dysfunction which warranted interventions to improve SI joint mobility. (CITE)

Chiu-Fang Yan, M., CNM, RN (Clinical Instructor)a, Ya-Chi Hung, MS; (Instructor, P. s. b., c, Meei-Ling Gau, PhD, CNM, RN, IBCLC (Professor)d,n,1,; Kuan-Chia Lin, P. P., Statistician), Effects of a stability ball exercise programme on low back pain and daily life interference during pregnancy. Midwifery 2014, 30,

The patient experienced the same amount of pain and felt the same as the initial assessment day. The therapist started the treatment by placing the hydrocollator on the patient’s lower back for 10 minutes. And for the next 40 minutes, Manual Massage Therapy such as Swedish massage, Joint Mobilizations, MET (muscle energy technique), and Fascial Release techniques were performed in the lower back, Gluteal region, and legs. As for the homecare, the patient was instructed to perform Hamstrings and Gluteal muscle stretches, and strengthening exercises to strengthen the Abdominal muscles (Table 2). In addition, the therapist recommended the patient to use the heat packs and to support her lower back during her daily activities.

From the biomechanical testing my client exhibits normal ability to adapt and lock his foot, as well as respond to vertical loading. He also has no issues with his knee position. However, he will want to address his postural issues. The lordotic posture could be caused by tight hip flexors, and erector spinae group. It also could be coupled with weak or lengthened abdominals and hamstrings. This is coined as Lower Cross Syndrome (Janda, 1996). Because of the lordotic posture I will want to test for muscles strength and flexibility know which muscles is most at fault and address it. Another point to note is the forward upper cross syndrome. This could be due to years of studying and looking at a computer or phone. He could have week neck deep neck flexors and lower traps while his upper traps and sternocleidomastoid could be tight.