IDENTITY (May 19th, 2023) NIF/TWI/ dr. HY, Sp. K.F.R.

Name : Mrs. N
Age : 61 years old
Sex : Female
Religion : Moslem
Marital Status : married
Address : Surabaya
Occupation : Retired Danamon bank
Education : S1 accounting
No HP : 081235551259
Addresed : Surabaya
Referred from : Neuro OPC with LBP

AUTOANAMNESIS
II.1. Chief Complaint: Nyeri pada pinggang bawah
II.2. History of Present Illness:
Patient felt pain since 9 months ago, worsened in 3 months ago. Initially, pain localized in back area intermittently.
Then she went to the royal hospital (August 2022). There was scoliosis on therapy 1.5 months and then completely
improved. Then the pain came back in February, the patient felt radiating pain. with a characteristic sharp and burning
pain, radiating to the left heel with a tingling sensation, there is numbness on the posterior thigh to the heel.
Aggravated with upright, reduced bending. Initially WBS 10, Went to emergency room in royal hospital give
parenteral analgesia WBS 2-3. After discharge, immobilized 2.5 months. To be outpatient in Neurology OPC in Royal
Hospital. Given Citanid, celecoxib, b complex, alpentin (still not getting better). Then referred to Sutomo, (March)
neurology opc got paracetamol 400, amitriptyline, gabapentin, b-complex, do MRI. History of injecting the buttocks
muscle area 3 times the pain is reduced.
Currently, WBS 3-4 if walking. Must stop in 20 meters, resting wbs 1. Right knee pain since 2 years ago, WBS 6-7.
Local, gets worse when walking and improves wbs 0 rest. Morning stiffness is less than 15 minutes.
Crepitation (+). No complain of bowel and bladder.
II.3. History of Functional Ability
 Able to do his daily activities (eat, groom, bath, dress, going to toilet) independently.
 Unable to go up and down the stairs independently. transfer from lying to sitting, sitting to standing, standing
to chair minimal difficulty.
 Bladder and stool incontinence (-)

II.4. History of Past Illness:

 Same illness (-)
 Trauma (+), 5 y ago. Fall from seating. Retak tulang ulna.
 Hypertension (-)
 Diabetes mellitus (-)
 Tumor / cancer (-)

II.5. History of Medication and Rehabilitation:

 August 2022, Royal Hospital: Diagnosed with scoliosis in therapy for 1.5 months. Rehabilitation TENS, IR.
 February 2023: Celecosif, B-complex, Alpentin (still not getting better) reduced pain.
 Rehabilitation: TENS, IR (February-March), corset.
 Referred Sutomo, March.
 Neurology: Paracetamol 400 mg, amitriptyline, gabapentin, B-complex, MRI.
 Neurologist History of injecting the buttock muscle area 3x.

II.6. History of Hobby and Work:

• Monday-Friday Koran school cannot go
• Year 2000 doesn't work anymore

II.7. History of Psycho-Social-Economic: Lives in 2 children, brother 24 years. 1 child, male. Entrepreneur boarding
houses at home. Female, 22, assistant lecturer in Sociology, Airlangga University. Husband has died.

II.8. Family History : There is a family history of knee and hip pain
II.9. Patient’s Expectation : He hopes free normal.

PHYSICAL EXAMINATION
III.1. General Status
GCS: E4 V5 M6
BP: 110/90 mmHg, HR: 93 x/min regular, RR: 20x/min, Temp: 37.3oC, SpO2: 98-99%
Height: 160 cm
Weight: 63 kg
BMI: 24 overweight
Dominant extremity: Right-handed. Ambulation: Independent
Posture:
Gait antalgic gait

Head and neck :

Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement lymph node (-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : Soefl, peristaltic (+), tenderness (-)
Extremities : Warm acral (+|+), edema (-|-), CRT < 2 seconds.

III.2. Head/Neck/Trunk
Look : Deformity (-)
Feel : Paralumbal muscle spasm +, Adductor hip muscle spasme (+/-) Tender point gluteal, knock
pain (-), doorbell sign (-), step off (-)
Move : Pain when move (+)
Neuromuscular : Cranial nerve was normal
Sensoric : Normal
Propioceptive : Normal
Special Test : SLR -/+, Bragard -/+, Siccard -/+, Thomas -/-, Patrick -/-, Contra patrick -/+, Pelvic compression -/-,
Gaenslen test -/-, Ober test -/-, Piriformis test -/+, Freiberg test -/-, Beatty test -/-, Pace test -/-, Ely test -/-, Hamstring
tightness +/+, Reverse SLR -/-, kemp tes -/+

Movement ROM Muscles MMT

Neck Flexion (0-450) F Flexor 5
Extension (0-450) F Extensor 5
Lateral flexion (0-450) F/F Lateral flexor 5
Rotation (0-600) F/F Rotator 5
Trunk Flexion(0-850) F Flexor 5
Extension (0-300) F Extensor 5
Lateral flexion (0-350) F/F Lateral flexor 5
Rotation (0-450) F/F Rotator 5

III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-)
Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
Move : pain (-|-)
Neuromuscular :
- Muscle tone : Normal
- Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensorics : normal
- Propioceptive : normal
- Special test :-
Region Movement ROM Movement MMT
Shoulder Flexion(0-1800) F/F Flexor 5/5
Extension (0-600) F/F Extensor 5/5
Abduction(0-1800) F/F Abductor 5/5
Adduction(0-450) F/F Adductor 5/5
Internal Rotation (0-90 ) 0
F/F Internal Rotator 5/5
External Rotation (0-700) F/F External Rotator 5/5
 Elbow Flexion(0-1350) F/F Flexor 5/5
Extension (135º-0) F/F Extensor 5/5
Pronation (0-900) F/F Pronator 5/5
Supination(0-900) F/F Supinator 5/5
Wrist Flexion (0-800) F/F Flexor 5/5
Extension (0-700) F/F Extensor 5/5
Radial deviation (0-200) F/F Radial Deviator 5/5
Ulnar deviation (0-350) F/F Ulnar Deviator 5/5
Fingers Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5
Abduction F/F Abductor 5/5
Adduction F/F Adductor 5/5

III.4. Lower Extremities Region.

Look : redness (-|-), swelling (-|-), deformity (-|-), Bony enlargement (-|-), Atrophy VMO (-/-)
Feel : warmth (-|-), crepitation (+|-), tenderness (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Tonus : Normal
- Deep Tendon Reflex : KPR +2|+2; APR +2|+2
- Pathological reflex : Babinski (-|-) Chaddock (-|-)
- Sensorics : Normal
- Propioceptive : Normal
- Special Test :-
Region Movement ROM Movement MMT
Hip Flexion(0-1250) F/F Flexor 4P/4P
Extension (0-300) F/F Extensor 5/5
Abduction (0-450) F/F Abductor 5/5
Adduction (0-20 ) 0
F/F Adductor 5/5
Internal Rotation (0-450) F/F Internal Rotator 5/5
External Rotation (0-450) F/F External Rotator 5/5
Knee Flexion (0-1350) F/F Flexor 5/5
Extension (1350-0) F/F Extensor 5/5
Ankle Dorsiflexion (0-20 ) 0
F/F Dorsiflexor 4/5
Plantarflexion (0-500) F/F Plantarflexor 4P/4P
Eversion (0-150) F/F Evertor 4/5
Inversion (0-350) F/F Invertor 4/5
Big Flexion F/F Flexor 5/5
Toes Extension F/F Extensor 5/5
Toes Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5
Special test: Patellar grinding test (+|-), Varus and valgus stress test (-|-), Mc Murray test (-|-), Antrior and posterior
drawer test (-|-)
Circumference:
- 10 cm above MTP: 40/40 cm
- MTP: 35/35 cm
- 10 cm below knee: 38/38 cm
Q angle: NWB: 12°/10° varus, WB: 13°/11° varus

I.5. Functional Status

Balance : Sitting balance (static and dynamic) is good, standing balance (static and dynamic) is good
Romberg (Able), sharpened Romberg (Able), tandem walking (Able)
Transfer : Lying to sitting independent, sitting to standing independent, standing to chair independent
Coordination : Dysdiadokokinesia: negative, finger to nose: able, finger to finger: able, heel to shin: able
Count test : 40
Chest expansion : 5cm/4cm/4cm
Barthel Index : 85

Feeding 10/10 Bladder 10/10

Grooming 5/5 Toilet use 10/10
 Bathing 5/5 Mobility 10/15
Dressing 10/10 Transfer 10/15
Bowel 10/10 Stairs 0/10

Supporting Examination
Foto Lumbal Feb 2023 (RS Royal)
Kesan Skoliosis, Spondilolistesis L45 L5S1, Penyempitan discus intervertebralis L345S1. Muscle spasm

MRI Lumbosacral tanpa kontras 28/04/23

- Disc extrution disertai penebalan ligamentum flavum dan facet joint kanan kiri yang mendesak anterior
thecal sac menyebabkan severe central canal stenosis dan moderate foraminal canal stenosis kanan kiri pada
level VL 5-VS 1, disertai impingement exiting nerve root L5 dan traversing nerve root S1 kiri
- Bulging disc disertai penebalan ligamentum flavum dan facet joint kanan kiri yang mendesak anterior thecal
sac menyebabkan moderate central canal stenosis dan mild foraminal canal stenosis kanan kiri pada level VL
4-5
- Bulging disc disertai penebalan ligamentum flavum dan facet joint kanan kiri yang mendesak anterior thecal
sac menyebabkan mild central canal stenosis pada level VL 4-5
- Spondylosis thoracolumbalis

PROBLEM LIST
o Radiating low back pain
o Weakness of lower extremity
o Deficit sensoric
o scoliosis
o forward neck
o Hamstring tightness
o Paralumbal muscle spasme

ICF
Body Function:

b280. Sensation of pain (Low back pain, knee pain)

b730 Muscle power functions (Motoric weakness of leg)
b729 Function of the joints and bones (Scoliosis)
b749 Muscle tone function (hamstring tightness, paralumbal muscle spasm)

Body Structure:
s760. Structure of trunk (posture, central canal stenosis, scoliosis, spondilolistesis)

Activities and Participation:

d415 Maintaining a body position (Pain when sitting to long)
spirituality

Environmental Factors:
e310. Immediate family (Family support)
e580. Health Services, System and Policy (Patient covered by BPJS)

ASSESSMENT
Low Back Pain ec Canal stenosis VL4-5, VL5-VS1 + Right knee pain ec OA Genu + Overweight

PROGNOSIS
Ad vitam : Bonam
Ad sanactionam : Bonam
Ad functionam :
- Transfer : Independent
- Ambulation : Independent
- Other ADL : Independent
Goals:
Short Term Goals:
1. Improved pain wbs 2-3
2. Improved depression
3. Improved posture
4. Increased MMT 1-2 level
5. Maintained joint flexibility

Long Term Goals:

1. Free pain
2. Prevented worsening of condition (Increased pain scale, deficit sensory, weakness, etc)
3. Improved quality of life.

PLANNING
PDx: X ray genu D
PTx:
Modality:
 IFC at 4000-4100 Hz paralumbal area VL4-VS1 dan gluteal sinistra
 Laser 2 joule/cm2 continous at right knee

Therapeutic Exercise:
1. Kinaesthetic Awareness:
a. Pelvic tilt exercise
b. Posture correction during sitting, standing & activities.
c. Fine position that makes symptoms better and worse, learn neutral position of spine
2. Muscle performance: Core strengthening with abdominal drawing, Slr exc, bird dog, isometric strengthening
quadricep and hamstring
3. Sciatic nerve gliding exc
4. Flexibility exercise: AROM LE
5. Breathing active exercise with deep breathing diaphragmatic breathing, and relaxation technique
6. Kinesiotape at paralumbal and quadricep muscle

PEx:
1. Explain patient condition, prognosis, rehabilitation program he will get, and goal of the rehabilitation
program.
2. Fine position when sitting with cushion on chair.
3. Icing when pain, duration: 15 minutes, at tender area. Can be repeated every 2 hours if pain remained.
4. Proper back mechanic.
5. Knee joint conservative
6. Posture correction while sitting, standing and activity, postural and kinesthetic awareness.
7. Endurance exc with, F: 3-5 x/ weeks I: 11-12 borg scale T: 30 minutes1 T: lifting bottle
8. Continue exercise at home