Physiotherapy Case presentation

Case of Prolapse intervertebral Disc, lumbar disc prolapse, case, physiotherapy management, Assessment, recent Advance, orthopaedic case presentation, musculoskeletal physiotherapy case presentation, orthopaedic physiotherapy, case of a low back pain patient, lumbar radiculopathy, final year,

1. CASE PRESENTATION Syed Adil (MPT-II) Department of Orthopaedic Physiotherapy 1

2. Name: Arun kisan Chandore Age- 46 Gender- Male Occupation- Businessman Address - Shirdi Dominant side- Right Date of Assessment- 07/02/2023 Case Presentation 2

3. Chief complaint- pain in lower back radiating to left leg since 2 years Associate complaint- Tingling on posterior aspect of thigh and calf History of present illness- Case Presentation 3

4. PAIN HISTORY Onset: sudden Site: lower back region and left lower limb Side: left side Duration: 2 years Quality: dull aching and tingling Quantity: on movement:8/10 : rest 3/10 Aggravating factors: bending, lifting activities, long sitting durations Relieving factors: Rest and prone lying Case Presentation 4

5. Past medical history- none Past Surgical – None Family history- not relevant Case Presentation 5

6. PERSONAL HISTORY Diet: mixed Appetite: Adequate Bowel/Bladder : clear and continent Sleep: unaltered Addiction- none Socio-economic: Patient belongs to upper middle class Case Presentation 6

7. ENVIRONMENT HISTORY No. of family members- 6 No. of Earning Members- 1 Type of house- Pakka house and lives on ground floor Light and Ventilation is adequate Toilet Facility- western commode Case Presentation 7

8. Present drug history Tab carcikal Tab coxrella pain and spasm Tab Juviana plus neuropathic pain Raboxim DSR acid reflux Case Presentation 8

9. OBJECTIVE ASSESSMENT GENERAL EXAMINATION- BP- 130/80mmHg HR- 74 bpm RR- 19 bpm Temp- Afebrile 9 Case Presentation Height- 170 cm Weight- 70 kg BMI- 24.2 Built- mesomorphic

10. LOCAL EXAMINATION Case Presentation 10

11. INSPECTION/OBSERVATION Attitude of limb- Patient was in supine lying. Shoulder – neutral, elbows slightly flexed, wrist neutral, hip externally rotated , knees extended , ankles plantarflexed. Deformity- absent Swelling- absent External appliances- None Adaptive devices/ Aids- none Scar- absent 11 Case Presentation

12. POSTURE Case Presentation 12

13. PALPATION Warmth- Absent Tenderness- Present over L4, L5, S1 spinous process and paraspinal region (grade 2) Spasm- Present Swelling - Absent Trigger point- Absent 13 Case Presentation

14. MUSCULOSKELETAL EXAMINATION 14 Case Presentation

15. RANGE OF MOTION Lumbar spine:- Lumbar Flexion: Modified Schober's test: 4 cm Lumbar extension: 2.5 cm Right side flexion: 49.5 Left side flexion: 51.5 Combined movements: Flexion and rotation towards the left side was painful Hip Range of motion: within normal limits Case Presentation 15

16. MMT OF LOWER LIMBS Muscles Right Left Iliopsoas 4 4 Gluteus maximus 5 5 Gluteus medius 5 5 Hamstrings 5 5 Quadriceps 5 4 Tibialis anterior 5 4 Extensor hallucis longus 5 4 Gastrocnemius and soleus 5 5 Case Presentation 16

17. TRUNK MUSCLE TESTING Isometric Abdominal test: grade 3 Isometric Extensor test: grade 3 Case Presentation 17

18. LIMB LENGTH Limb Length Right Left True 89 89 Apparent 99 99 Case Presentation 18

19. GAIT ASSESMENT Step length: 35 cm Stride length: 73 cm Base width: 10 cm Cadence: 106 steps/min Case Presentation 19

20. Case Presentation 20

21. SPECIAL TEST Slump test: positive SLR test : positive Trendelenburg test: negative 90-90 test: positive Piriformis provocation test: negative Thomas test: negative Modified Ober’s test: negative Case Presentation 21

22. FUNCTIONAL SCALE Oswestry disability index Score: 15 indicating moderate disability

23. INVESTIGATIONS Case Presentation 23

24. Case Presentation 24

25. MRI SACROILIAC JOINT No significant abnormality in SI joints MRI LUMBAR SPINE At L4-L5 and L5-S1 levels: There is disc desiccation with diffuse disc bulge causing bilateral moderate neural foraminal narrowing indenting on the exiting nerve roots Case Presentation 25

26. DIFFRENTIAL DIAGNOSIS Lumbar disc protrusion Lumbar canal Stenosis Spondylolisthesis Piriformis syndrome Lumbar spondylosis Case Presentation 26

27. FUNCTIONAL DIAGNOSIS My patient Arun chandore 46 years old male businessman by occupation having chief complaint of low back pain radiating to the left leg and tingling in left lower limb is diagnosed with the lumbar disc herniation at L4-L5 and L5-S1 levels. Case Presentation 27

28. ICF My patient Vijay Gosavi 40 year old male farmer by occupation has low back pain and has difficulty bending down, lifting weight and performing his daily activities. Part1a: Impairments of body functions: b2: Sensory Functions and Pain b280: Pain- 3 b7: Neuromusculoskeletal and movement related functions b710: Mobility of joint: 2 b730: Muscle power: 3 B740: Muscle endurance 3 Case Presentation 28

29. Part1a: Impairments of body functions: S120: Spinal cord and related structures – 02 s760 Structure of trunk – 01 s770 Additional musculoskeletal structures related to movement: 02 Case Presentation 29

30. Part2: Activity limitation and participation restriction: d410 Changing basic body position – 1 d415 Maintaining a body position - 2 P Case Presentation 30

31. d4: Mobility d430: Lifting and carrying objects: 4 D450: walking: 1 D470: Using transportation: 2 D475: Driving: 2 Case Presentation 31

32. Part 3: environmental factors e3. SUPPORT AND RELATIONSHIPS e310 Immediate family e320 Friends: +4 e355 Health professionals: +4 e360 Health related professionals: +4 e4. ATTITUDES e410 Individual attitudes of immediate family members: +4 e420 Individual attitudes of friends: +2 Case Presentation 32

33. Part2: Activity limitation and participation restriction: d 2: general task and demands d 210: Undertaking a single task- 1 d 220: Undertaking multiple task- 2 Case Presentation 33

34. PROBLEM LIST Pain in low back region Tingling in left leg Difficulty performing Activities of daily living Difficulty in weight lifting Difficulty in driving and sitting for long duration Case Presentation 34

35. SHORT TERM GOALS Patient Education To Reduce Pain To maintain and improve the strength of core and lower extremity muscles To reduce tingling and radiating pain (centralize the symptoms)

36. LONG TERM GOALS Maintain Flexibility and strength of trunk muscles Improve the strength of muscles of lower limbs To improve Aerobic Capacity Ergonomics and prevention Case Presentation 36

37. PATIENT EDUCATION Educate the patient about the condition and e ngage patient in all aspects of intervention. Instruct the patient to avoid flexion activities, lifting, or any other functions that increase the pain or other symptoms Caution the patient to stop the activity immediately if the pain worsens or peripheralizes during exercises. Case Presentation 37

38. TO REDUCE PAIN HWF : hot water fomentation 15 minutes over lower back region: improve the blood circulation relaxes muscles and activates mechanoreceptors which cause pain relief. Intermittent lumbar Traction: 40 –50% of subject’s body weight, Treatment duration is 20 min with 30 second hold and 5 sec relax. Kumari A, Quddus N, Meena PR, Alghadir AH, Khan M. Effects of One-Fifth, One-Third, and One-Half of the Bodyweight Lumbar Traction on the Straight Leg Raise Test and Pain in Prolapsed Intervertebral Disc Patients: A Randomized Controlled Trial. Biomed Res Int. 2021 Sep 16;2021:2561502

39. TENS: (Conventional mode) 100 Hz, Pulse duration 125 micro seconds, 20 min Duration, electrodes placement : linear pattern once a day/4 times per week Ahmed AR, Ahmed GM, El Gohary A, Shaker E. The immediate effects of transcutaneous electrical nerve stimulation on pain intensity and H-reflex in patients with lumbosacral radiculopathy. Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2010;47(1):361-6.

40. TO ACTIVATE CORE MUSCLES Transverse abdominis Performed for 10 reps with hold of 2- 5 second initially and increase to 10 second * 2 sets Carolyn kisner , Allen colby ,. Therapeutic exercises. Foundations and Techniques . 6 th edition page 516

41. 2. MULTIFIDUS ACTIVATION Carolyn kisner , Allen colby ,. Therapeutic exercises. Foundations and Techniques . 6 th edition page 516

42. Progression in core strengthening Trunk curl-up Diagonal trunk curl Single legged extension (30 min, 3 times /week) (3 sets of 10 repetitions) (30 s rest between repetitions) (60 s rest between sets) Pattanasin Areeudomwong , Proprioceptive neuromuscular facilitation training improves pain-related and balance outcomes in working-age patients with chronic low back pain: a randomized controlled trial, Brazilian Journal of Physical Therapy, Volume 23, Issue 5, 2019

43. NEURAL MOBILIZATION FOR SCIATIC NEREVE Nerve slider technique - 3 sets of 10 reps on each treatment session Concurrent hip and knee flexion was performed dynamically with concurrent hip and knee extension. Speed and amplitude of movement were adjusted such that no pain was produced during the technique. Plaza-Manzano et.al Effects of Adding a Neurodynamic Mobilization to Motor Control Training in Patients With Lumbar Radiculopathy Due to Disc Herniation: A Randomized Clinical Trial. American Journal of Physical Medicine & Rehabilitation 99(2):p 124-132, February 2020. 

44. TO CENTRALIZE THE SYMPTOMS (McKenzie technique ) Lying in prone Prone on elbows Prone on hands Cristopher H Wise. Orthopaedic manual physical therapy. From art to evidence. Mckenzie approach, page no. 212

45. Prone on elbows with lateral shift towards unaffected side Cristopher H Wise. Orthopaedic manual physical therapy. From art to evidence. Mckenzie approach, page no. 212

46. TO IMPROVE AND MAINTAIN THE STRENGTH OF MUSCLES OF LOWER LIMBS Hip flexors Quadriceps Ankle dorsiflexors Intensity : 40 to 50 % of 10 repetition maximum (10 RM) Frequency: 2 times/day 18 to 20 repetitions per set Duration: 4 weeks Ju S, Park G, Kim E. Effects of an exercise treatment program on lumbar extensor muscle strength and pain of rehabilitation patients recovering from lumbar disc herniation surgery. Journal of Physical Therapy Science. 2012;24(6):515-8.

47. TO IMPROVE THE AEROBIC CAPACITY Aerobic exercises with Moderate intensity (50-70%) like Brisk walking, easy jogging, Walking or jogging on a treadmill elliptical trainer. Case Presentation 47

48. ERGONOMICS Squatting and reaching Load position : carry objects with equal weight on both sides Lifting and carrying objects as close to the center of gravity as possible practice carrying objects close to center of gravity Practice turning with hip rotation and minimal trunk rotation. Case Presentation 48

49. PREVENTION Check posture. Avoid any one posture for prolonged periods. If sustained postures are necessary, take frequent breaks and perform appropriate ROM exercises at least once daily. Continue flexibility, muscle endurance, and strengthening exercises appropriate for the patient to maintain ROM, muscle endurance, and strength. Case Presentation 49

50. RECENT ADVANCES Two manual therapy techniques for management of lumbar radiculopathy: a randomized clinical trial Author: Musa S Danazumi et. Al Journal: J Osteopath Med. Published: 2021 Feb Case Presentation 50

51. Method: A total of 60 patients diagnosed with unilateral lumbar radiculopathy secondary to disc herniation were randomly allocated into three groups: 20 participants each in the SMWLM, PINS, and combined SMWLM + PINS groups Two connected points, named primary and endpoints, were palpated using the index fingers of both hands. The points were areas of most and least sensitivity, respectively, found along a neuromuscular structure. Ischemic compression was given on all trigger points between 2 points for 30 seconds.

52. Conclusion: A combined SMWLM + PINS treatment protocol showed greater improvement than the individual techniques alone in the management of individuals with LR in this study. Case Presentation 52

53. THANK YOU