Postural LBP + Epilepsy On

Treatment
Milla Wildania Hakim
Preceptor:
dr. Dwi Indriani, Sp. KFR(K)
dr. Gutama Arya Pringga, Sp. KFR, M. Ked. Klin
Identity

Name : Mrs. T
Medical Record : 11552668
Age : 44 y.o.
Address : Malang
Occupation : housewife
Religion : Islam
Marital status : Married
Consulted to PMR : October 17th 2022
From : Neurology Department (LBP +Epilepsy)
Chief Complaint

Pain at low back area since 3years ago

History of Present Illness
• The patient complaint low back pain since 3 years ago
• The pain is dull, intermittent, and didn’t radiate.
• The pain worsen when the patient walk for about 4m and stands for a long time
VAS is 5
• The pain was relieved by lying/sitting position. VAS is 2
• Pain isn’t affected by coughing and sneezing
• If the patient walks, she has to stop first and then continue walking again because
of the pain
• There were numbness and tingling sensation at both of his leg
• Patient is able to feel the sensation of urinate and defecate, and able to hold
urinate and defecate.
History of Past Illness

 History of lifting heavy object (sack of rice about 10kg and grass for feeading a cow
about 3kg repetitievely 3x/day)
 History HT, DM, Stroke, Malignancy were denied

On September 27th 2022

The patient have seizure , duration 15minutes, unconsiousnes (+), when she was
watching tv
Family History

There was no history of family illness related to patient's condition

History of Medication

 Phenitoin 3x100mg
History of Functional Activity
 Patient is a housewife
 After she got sick, she got difficulty to do standing and walking for long periode
 Currently, she got difficulty to do house hold tasks and her hobby due to her
condition
Psycho-Socio-Economy

 Patient is married
 she lived with her children
 His house is 1 floor. main door to patient bedroom 3 m. There is no stair before the
entrance. The bathroom is inside and the distance from the bedroom is 5 m, with a
squatting toilet.
 Economic status: Middle Class
 Medical status: BPJS
 2 3
Barthel Index

2
3
20/20
Independent 1
2
2
2

2 1
20
 Physical Examination
GENERAL STATUS
GCS 456, Compos mentis,
Independent ambulation
Gait: Antalgic gait
BW: 62kg BH: 154 cm BMI: 26,9 obese class 1 Right hand domination

Vital sign : BP: 120/70 t: 36,8 HR: 83x/min RR: 18x/min Sp02 : 99%
Head and neck : Anemic -, jaundice -, cyanosis -, oedema -
Chest : Cor : S1,S2 single, murmur -, gallop -
Pulmonary: ves +/+ , rh-/-, wh-/-
Chest expansion : 3 – 3 – 3 cm
Breathing Count test : 30 – 30 – 30
Abdomen : Flat, soufel, hepar and lien unpalpable
Extremities : Warm acral (+/+) oedema (-/-)
 Neurological Examination
Cranial nerve : Cranial Nerve I-XII normal
Physiological Reflex : BPR +2/+2 KPR +2/+2
TPR +2/+2 APR +2/+2
Pathological Reflex : Babinski -/- Chaddock -/-
Hoffman -/- Tromner -/-
Sensory Exteroceptive : normal
Proprioceptive : normal
Spasticity : negative

Clonus : negative

Tonus : UE : normal/normal
LE : normal/normal
Musculoskeletal
Examination
NECK ROM MMT

Flexion F (0-450) 5

Extension F (0-450) 5

Lateral bending F/F (0-450) 5/5

Rotation F/F (0-600) 5/5

TRUNK ROM MMT

Flexion F (0-600) 4pain

Extension F (0-300) 5

Lateral bending F/F (0-350) 5/5

Rotation F/F (0-450) 5/5

 Local Status Lumbal
• Inspection: • Special tests
• Deformity - • SLR -/-
• Edema -
• Bragard -/-
• Erythema -
• Scar – • Sicard -/-
• Palpation : • Patrick -/-
• Tenderness -/+ at • Kontra Patrick -/-
paralumbal S • Thomas -/-
• Warmth - • Gaenslen -/-
• Paralumbal spasm -/S
• Pyriformis test -/-
• Ober -/-
• ALL: 83/83 • Ely -/-
• TLL :78/78 • Hamstring tightness -/-

• ⏀ Calf : 33/33
• ⏀ Thigh :48/48
Myotome Dermatome Dermatome Myotome

5 100% L2 100% 5

5 100% L3 100% 5

5 100% L4 100% 5

5 100% L5 100% 5

5 100% S1 100% 5
Functional Examination

Transfer
Lying to sitting : Able
Sitting to standing : Able
Standing to walking : Able

Gait pattern : Antalgic gait

Walk on heel : unable dt pain
Walk on toe : unable dt pain

Bowel and Bladder function : sensation (+) voiding (+) able to

defecate normally
Video Gait
 Problem List
Medical Postural LBP
Epilepsy on Treatment
Obesity Class I
Rehabilitation Low back pain
Gait disturbance
Difficulty prolonged sitting and standing
Difficulty to walk
Difficulty to do household task
Difficulty to pray
 Diagnosis

Clinical Diagnosis Postural LBP

Secondary Diagnosis Epilepsy on Treatment

Obesity class I
 ICF Code
 Postural LBP
 Epilepsi on treatment
 Obesity Class I

Body Function Participation

B280 Sensation of pain
Activity D649 household tasks
B530 Weight maintenance function
Body Structure D415 Maintaining a body position D930 Religion and spirituality
S760 Structure of trunk D450 walking
D530 Toileting

Personal Factor
Environmental Female , 44 yo, Housewife, Javanese, moeslem
E310 immediate Family
E580 Health services, sytems and policies
 Prognosis
Ad vitam : bonam
Ad sanationam : bonam
Ad functionam :
- Able to pray without difficulty
- Able to do Household tasks without difficulty
 Goals
SHORT TERM MID LONG TERM
TERM
- Able to change body position
1. Decreased pain 1. Improve sensory function - Able to prolonged sitting and standing without
2. Improve gait difficulty
- Able to pray without difficulty
- Able to do Household tasks without difficulty
- Reduce body Weight
 Planning
Surgical -
Medical Continue medication from neurologist, consult to nutritionist
Rehabilitation P. Dx -
P. Tx Modality :
• SWD at paralumbal, frequency 27,12 MHz, intensity as patient tolerance, duration 15
min, 2x/week.
• TENS at paralumbal, high intensity 50-100 Hz, intensity as patient tolerance, duration 15 minutes,
2x/week
Exercise:
- AROM exercise at LE S
Exercise :
WF exercise
Posture correction
Core strengthening exercise
 Planning

P. Mo Subjective, VAS, MMT

P. Ed • Explain patient condition
• Purpose & benefit of PMR therapy
• Continue exercise program at home everyday
• Routine controlled
• Proper back mechanic
• icing when pain
 Summary
Patient is Mrs. T/44 y.o/Malang/housewife. Chief complaint is pain at low back area, the
pain was dull, intermitten, and not radiating.
From physical examination we found tenderness at paralumbal S, lumbalis decrease lordotic
posture We diagnose patient with Postural LBP + Epilepsy on treatment +Obesity Class I
- We plan therapy with Modality: SWD and TENS at paralumbal D/S. Exercise: AROM
exercise at LE, WF exercise, Posture correction, Core strengthening exercise
We plan to monitor Subjective, VAS, gait, BMI.
We educate patient about the condition, PMR therapy, continue exercise program at home
everyday, routine control, and proper back mechanism and also Icing when pain.
Thank You