Physical Therapy Initial Evaluation

Name: Alfredo Francisco MD Dx: LBP c LS radiculopathy; MPS

Age/Sex: 43/M on B paralumbars; HTN St. II
Address: Antipolo Occupation: EAC Hospital employee (utility)
Civil status: Married Dateof PTIE: November 15, 2016
Handedness: R

S:

CC/goals:
Pt. c/o dull, aching pain on the low back (VRS = 2/10) upon lifting and pushing activities performed at
work. Pt. reports to have no resting pain although pain appears when area on the low back is pressed
(VRS = 1/10). Pt. aims to be able to perform lifting and pushing activities s pain.

History of current illness:

Pt. started to feel pain on his lower back 3 years ago. Pt. went to the EAC Hospital health service
whenever he felt pain and he was prescribed pain medications there. Pain decreased since then. During
occasional emergence of back pains within the past 3 yrs, pt. just applies liniments to the painful area. Pt.
did not go to a “manghihilot” or did not massage the area.

During the last week of August 2016, the aching pain on his low back increased (VRS = 8/10). The pt.
reports that the pain had been so severe that he was not able to move his back. The said aching pain on
his back appeared the day after lifting an ~40 kg. luggage down a car on March 26. Pt. went to the
Orthopedic Department of EAC Hospital for an MD consult regarding his back pain. He was then referred
to the Rehabilitation Medicine department. He was prescribed pain medication (Celebrex), which he has
stopped taking 4 days ago, in accordance to the MD prescription. Pt. reports that the medications
improved his pain so much. Pt. was also referred for physical therapy. It is the pt.’s first time to undergo
physical therapy.

PMHx:
 (+) HTN; controlled by medications
 (+) dimoma on lungs last Dec. 2008. Resolved by excision of mass.
 (+) respiratory TB last June/July 2009. Cleared by MD.
 (-) DM
 (-) trauma
 (-) osteoporosis

FMHx:
 (-) HTM
 (-) DM

PSHx:

Pt. works as a utility worker in the psychiatry ward of the EAC Hospital. He has been working in the
hospital for 14 yrs already. He works 8 hrs a day, 5 days a week. His work involves picking up soiled
linens from a hamper that is waist-high. Height of the hamper requires him to bend over. He then carries
the ~5 kg. linens to the laundry area that is ~25 steps away. Pt. also pushes food trolleys (~5 kg.) and
wheelchairs c pts in the ward. He also transfers hospital beds c only 2 wheels (~40 kg.) in the ward. Pt.
reports that the pt.s in the hospital beds he transfer are usually unruly so it increases the effort that one
has to exert during the transfer. Sometimes he gets help during these transfers. However, most of the
time, he does them alone. In all of the said activities at work, pain (VRS = 2/10) is elicited upon lifting or
pushing.

Pt. lives with his wife, 2 children aged 15 and 11 yrs, and his father- and brother-in-law. At home, the pt.
does not do much household chores except his laundry. He washes his clothes by squatting down c the
basin on the floor. Pt. reports to feel pain on his low back after 5 – 10 mins. Pt. does not use a footstool or
chair during washing.

Pt. has no other leisure activity other than playing basketball. He does not play regularly but considers it
as his form of recreation. He feels fatigue on his low back after 1 whole game of basketball. Pt. does not
smoke but drinks alcoholic beverages (5 – 6 bottles) every night with his friends.

Pt.’s house is bungalow type c 4 steps at the front landing. Pt. reports no difficulty in negotiating in the
home.

Ancillary procedures:

TEST(S) DATE RESULTS

ECG Last week of August 2016 Results not yet known

Present medications:

MEDICATION(S) DOSAGE INDICATION FREQUENCY OF

INTAKE
Celebrex 400 mg. Pain Pt. has finished
taking the
medications 4 days
ago as per MD
prescription.

O:

VS:

BEFORE AFTER
BP 110/70 mm Hg 120/80 mm Hg
PR 100 bpm 105 bpm
RR 16 cpm 20 cpm
Temp Afebrile to touch Afebrile to touch

Sig: All VS are WNL. Pt. has HTN but reported to have taken medications during morning of the day of
therapy.

OI:
 Alert, coherent, cooperative
 Mesomorph
 Ambulatory s assistive device
 (+) postural deviations (see postural ax)
 (-) gait deviations
 (-) gross deformities
 (-) swelling of the lumbar area
 (-) erythema of the lumbar area
Palpation:
 Normothermic on all exposed areas of the body
 Grade 1 tenderness tenderness on lumbar area (VRS = 1/10)
 (+) mm. spasm of paraspinals
 (-) edema on lumbar area

MMT:
Muscles of trunk and (B) LE were grossly assessed and graded 5/5.

Sig: Mm. of the trunk and LE have normal strength.

ROM:
ROM of major jts of (B) LE and trunk are WNL, pain-free and c N end-feel except:

PROM NORMAL DIFFERENCE C ENDFEEL

VALUE NORMAL
Lumbar flexion 5 cm 7 cm 2 cm Firm c stretch pain
Lumbar ext 3 cm 4 cm 1 cm Firm c stretch pain
Lumbar (R) lateral 4 cm 5 cm 1 cm Firm c stretch pain
flexion
Lumbar (L) lateral 2 cm 5 cm 3 cm Firm c stretch pain
flexion

Sig: LOM of lumbar flexion, ext and (R) and (L) lateral flexion probably d/t mm. tightness 2 ⁰ to spasm and
overuse

Movement analysis:

TRUNK:
Fo +

L o R o o + o o

+ +
o o + +
(L) rot +

Eo ++

Active Passive Resisted

Legend:
+ : VRS = 1-4/10
++: VRS = 5-7/10
+++: VRS = 8-10/10

Pt. experienced stretch pain, s radiating pain on the LE, upon end range of all trunk motions except (R)
flexion (VRS of flexion = 2/10; extension = 4/10; (R) flexion = 2/10; (L) rot = 3/10; (R) rot = 3/10). Pt. also
felt pain on end-range of resisted trunk motions except (L) and (R) flexion (VRS of flexion = 2/10;
extension = 1/10; (L) rot = 3/10; (R) rot = 2/10). No pain was felt during active trunk movements.
Sig: Stretch pain upon end range of passive and resisted trunk movements probably d/t tight mm. 2 ⁰ to
spasm and overuse

Postural ax:

All landmarks in the anterior, lateral and posterior views are level except for:

ANTERIOR LATERAL POSTERIOR

 (L) acromion process  ↓ Lumbar lordosis  (L) acromion process
slightly higher than the slightly higher than the
(R) (R)

Sig: Higher (L) acromion
probably d/t pt.’s handedness
Sig: ↓ Lumbar lordosis probably Sig: Higher (L) acromion
d/t tight abdominals and/or tight probably d/t pt.’s handedness
hip extensors or weak hip flexors.
However hip flexors were tested
and were graded 5//5.

Special test:
 (+) Thomas test for (B) hips

Sig: (+) result indicate tightness of the hip extensors

ADL ANALYSIS:

ACTIVITY PERFORMANCE
BADLS
Dressing  Difficulty manifested by pain upon extending the back when
pulling down tshirt upon donning
Eating  Independent
Ambulation
 Level surfaces  Independent
 Unlevel surfaces  Difficulty manifested by fatigue on the low back after climbing
(Stair ambulation) 30 steps (~ 5 mins)
Toileting  Difficulty manifested by pain upon sudden standing from sitting
on the toilet
Hygiene  Difficulty manifested by pain upon extending the trunk
during bathing to scrub the back
Household chores  Difficulty manifested by fatigue upon squatting for 5-10 mins while
 Doing the laundry rinsing the clothes and pain upon bending down to rinse clothes
from the basin positioned on the floor
Shopping  Independent
Work-related tasks
 Picking up soiled  Difficulty manifested by pain upon bending down to pick up
linens from soiled hampers from a hamper that is waist-high
hamper  Difficulty manifested by pain upon carrying of ~5 kg. linens
 Carrying of linens to laundry area (25 steps)
 Difficulty manifested by pushing (~ 5kg.) food trolley in the ward
 Pushing food trolley  Difficulty manifested by pain upon pushing a wheelchair
 Pushing wheelchairs  Difficulty manifested by pain upon pushing a hospital bed (40
 Transferring hospital kg) c 2 wheels only. Sometimes pt. in the hospital bed so
beds pushing
requires more effort.
 Sig:

Difficulty in lifting objects weighing > 5 kg manifested in carrying of linens

Difficulty in pushing objects weighing > 5 kg manifested in pushing food trolleys, wheel chairs, and
hospital beds

Difficulty in sudden straightening of the back as manifested in dressing, bathing, and toileting.

Decreased tolerance to keeping the trunk erect (5-10 mins) manifested during laundry and climbing up
stairs

Difficulty in picking-up objects manifested when picking up soiled linens from a hamper and during
laundry

Assessment:
Refined Problem List

Impairments Activity Limitation Participation Restriction

PIP

NPIP

Prioritized Problem List:

1. Tightness of trunk flexors, extensors, and lateral flexors (ROM: extension = 3 cm.> (R) flexion = 4
cm. > flexion = 5 cm. > (L) flexion = 2 cm)
2. Decreased trunk mm endurance manifested by decreased tolerance to keeping trunk erect for 5 –
10 mins during laundry and when climbing up stairs
3. Difficulty in pushing objects weighing > 5 kg manifested in pushing food trolleys, wheel
chairs, and hospital beds
4. Difficulty in lifting objects weighing > 5 kg manifested in carrying of linens
5. Difficulty in picking-up objects manifested when picking up soiled linens from a hamper
and during laundry
6. Difficulty in sudden straightening of the back as manifested in dressing, bathing, and toileting.
7. LOM of lumbar spine (extension = 3 cm.> (R) flexion = 4 cm. > flexion = 5 cm. > (L) flexion =
2 cm
8. Dull aching pain (VRS = 2/10) on low back
9. Faulty posture manifested by (+) posterior pelvic tilt
10. Tightness of (B) hip extensors; (+) result for Thomas

tests

Anticipated Problem Predictive Criteria

PT Diagnosis:

Difficulty in performing ADLs that involve maintaining erect trunk for 5-10 mins, pushing and/or lifting
objects weighing 5 kg. and picking up objects probably d/t tightness of the trunk mm. Dull aching pain is
probably d/t mm. spasm 2 ⁰ to mm. tightness.
Difficulty in maintaining erect trunk for 5 – 10 mins also may be d/t decreased trunk mm. endurance.

Prognosis:
Pt. will perform his work and home activities that involve maintaining trunk erect, lifting, and pushing s
discomfort in 8 weeks. The pt.’s current problems can be addressed by physical therapy. Pain can be
relieved in 1 session, including home instructions for pain relief. Mm. extensibility and endurance can be
improved in 4 – 6 weeks, alongside with training for maintenance of proper posture. Additional 2 – 4
weeks are given d/t nature of pt.’s work, which is to expose the pt. to lifting and pushing heavy objects
everyday. Pt.’s eagerness to undergo physical therapy, free therapy for hospital employees, and physical
nearness of his workplace to the clinic will most likely increase adherence to the management program.

P:
Long-term goal:
1. Pt. will climb up and down a 30-step staircase c trunk erect (proper posture: level acromion and
pelvis, c equal WB; ROM of trunk: flexion = 6 cm, extension = 3 cm, (L) and (R) lateral flexion =
4 cm.) c basin at the level of the abdomen for 30 mins. s discomfort (VRS = 0/10) within 8
weeks.

Short-term/Anticipated goal:
 1. Pt. will rinse his dirty denim pants (~2.5 kg each) in standing (proper posture: level acromion and
pelvis, c equal WB; ROM of trunk: flexion = 7 cm, extension = 4 cm, (L) and (R) lateral flexion =
5 cm.) c basin at the level of the abdomen for 30 mins. s discomfort (VRS = 0/10) within 4
weeks.
2. Pt. will transfer hospital beds using proper biomechanics (proper posture: level acromion
and pelvis; c help from 2-3 other personnels in the ward) after 1 session.
3. Pt. will lift and carry linens (~5 kg) using proper biomechanics (proper posture: level
acromion and pelvis; flexes hips and knees upon lifting) after 1 session.

MD Prescription:
1. HMP on low back x 20 mins c pt. in prone for pain relief and mm. preparation for stretching
 Pt. was able to tolerate tx s any adverse effects. He reported that pain disappeared after
application of HMP. (-) blanching, (-) erythema
2. TENS for pain relief
 Not administered since pt. did not complain of resting pain
3. UTz for mm. preparation for stretching
 Not administered since it has same indication as HMP, and also HMP was more practical to
use because of the large area that needs to be treated (paralumbar area)
4. Stretching of TAs and hamstrings to increase motion of dorsiflexion, hip extension, and
knee flexion
 Not administered because pt. did not have LOM d/t mm. tightness. (PF PROM measurent = 48 ⁰;
Knee flexion PROM = 132⁰ ) PT was not able to administer stretching for hip extensors d/t time
constraints.
5. Lumbar stabilization techniques to increase strength of core mm.
 Not given because there was no weakness in the trunk mm.
6. Core and back strengthening to increase force generation of trunk mm.
 Not given because there was no weakness in the trunk mm.
7. Strengthening of quads, gastrocs, and hamstrings to increase force generation of said mm. for
better ambulation
 Not given because there was no weakness of the LE mm. and (-) difficulties in ambulation
8. Postural awareness to improve body alignment
 Incorporated with the other exercises in the forms of verbal, visual, and/or tactile cues to main
proper posture. Pt. was did not have difficulty c maintaining proper posture during the
exercises.
9. Proper body mechanics to protect jts. of the body, especially the back
 Pt. was able to return demonstration of proper lifting techniques and identify tasks that he has
been doing wrongly, and what he can do to improve the biomechanics in performance of
those activities.

Suggested PT management:
1. Breathing technique x 4 reps x 1 set to ↑ efficiency of breathing
 Pt. was able to perform exercise completely and correctly. Given to the pt. since it helps the pt. to
breathe efficiently and to also relax, especially since pt. has HTN.
2. Toe reaching in seating and standing x 30 secs hold x 3 reps each to ↑ extensibility of trunk
extensors
 Pt. was able to complete exercise s any report of difficulty. (-) SOB, (-) pain, (-) dizziness. Precs
for dizziness and for Valsalva maneuver.
3. Stretching of trunk rotators while holding on to || x 30 secs hold x 3 reps to ↑ extensibility
of trunk rotator mm.
 Pt. was able to complete reps s any report of difficulty. (-) SOB, (-) pain, (-) fatigue.
1. Stretching of (B) lateral flexors using dumbbells (5 kg) x 30 secs hold x 3 reps each to ↑
extensibility of trunk lateral flexors
 Pt. was able to complete reps s any report of difficulty. (-) SOB, (-) pain, (-) fatigue.

Home instructions:
 1. Maintain proper posture and apply proper biomechanics when performing activities at home
and at work.
2. Perform stretching of lateral flexors using dumbbells or improvised weights (bottle filled with sand)
x 30 secs hold x 3 reps each, BID.

Recommendations and suggestions:

1. Stretching of ant. trunk mm. by pushing back on the bed or door x 30 secs hold x 3 reps (to
increase mm. extensibility, and ROM of trunk)
2. Functional training through lifting and transferring of stacked linens x 10 reps x 3 (to improve
pt.’s functional independence in work activities)
3. Monitor if pt. will have radiculating pain. If present, perform special tests indicated for nerve
impingement in the low back to confirm.