Gina Palermo
July 17, 2021
TRANSITIONS IN PHYSICAL THERAPY
CASE STUDY #7
AGE:
40
DX:
L4-L5 disc bulge
P.T. EVAL:
Your patient is a 40 year old female who injured her back 3 days
ago when she bent down to pick up a basket of laundry. Patient
has had progressively increasing pain in her low back that has
begun to radiate down her (L) LE to her ankle. Her pain rates a
5/10 at rest and increases to a 8/10 when she sits to long or bends
over to pick things up. She is taking prescribed pain meds and antiinflammatory medication at this time.
Postural assessment reveals a flattened lumbar lordosis with
moderate muscle guarding in bilateral erector spinae. Trunk ROM
is limited in all planes. Trunk flexion, (L) SB and (L) rotation are
the worst. Lumbar myotomes test 5/5 throughout and reflexes are
2+ bilaterally. SLR test is (+) on the (L). Repeated flexion
increases radicular pain and repeated extension decreases radicular
pain.
P.T. DX:
Lumbar disc herniation with radicular pain; extension bias
PROBLEM LIST:
1.
2.
3.
4.
5.
LB and (L) radicular pain
Decreased trunk ROM
Muscle guarding (B) lumbar paraspinals
(+) SLR test (L)
Decreased functional abilities secondary to pain
GOALS:
1.
2.
3.
4.
5.
Decrease c/o pain to WPT
Full, painfree trunk ROM
No muscle guarding in lumbar paraspinals
(-) SLR test (L)
Return to pre-injury functional activities
PLAN:
1.
2.
3.
4.
Modalities as needed for pain relief
Lumbar traction
McKenzie extension protocol
Therapeutic exercise beginning with lumbar stabilization and
progressing to strengthening ex.
5. Patient instruction in proper back care
1. What treatment parameters would you use for treating this patient with traction.
Patient should be set up with static traction.
Reasons for using this type of traction:
 can be reduced and nerve root compression symptoms relieved
 Creates decreased intradiscal pressure (pulls protrusion in )
 Studies show disc movement to neutral at 120 lbs sustained X 20
minutes
Body Position of patient
 Flexed position at 60-75 degrees, if tolerable. This Separates
posterior structures including facet jts and intervertebral foramina
 However, patient might be experience too pain therefore can be
place in the Neutral/extended position
 Using split table using 20% of body weight (about 15-27 lbs.) along with
treatment time that is low between 8-12 minutes. Lbs will generally increase 515 per session/ treatment.
 Disc herniation with protrusion is best treated with sustained (static) traction or
long hold-rest periods (60 sec on, 20 sec off)
2. Explain the progression of McKenzie extension exercises that you would use to
treat this patient.
Patient should begin with lying on their
stomach and pushing up
Lay on stomach with arms under your
shoulders or down at your side. Head
facing down or turned to one side. Take
deep breath and relax. Hold 5 min.
Lying on pillow
Lay on stomach with arms at your side
with a pillow placed directly under chest.
Head facing down or turned to one side.
Take deep breath and relax. Hold 5 min.
Prone on elbows
Lay on stomach, place your elbows under
your shoulders so you are resting on your
forearms. Take deep breath and relax. Hold
30 sec, repeat 10 times.
Prone Press-ups
Lay on stomach, place your hands under
your shoulders. Slowly straighten elbows,
keeping lower body relax while raising the
back upwards as far as pain will allow.
3. Describe the lumbar stabilization exercises that you would choose for this patient.
Finding Pelvic Neutral- drawing belly button to spine/ Supine Abdominal Draw
In
Quadruped Opposite arm/leg
Prone Plank
Superman
Double leg bridge
Supine hip twist on physioball
Abdominal Draw In with Knee to Chest
Abdominal Draw In with Heel Slide
Prone Cobra’s
Abdominal Draw In, Seated on Physioball
4. In the chronic stage of healing, you will begin trunk strengthening. Describe the
exercises that you would choose for this patient.
Abdominal Draw In with feet on the ball
Abdominal Draw In with feet on the ball- add movement
Supine Dead Bugs
Rolling Like a Ball
Quadruped Opposite Arm/Leg, add cuff or dumbbell weights
Abdominal Crunches on Physioball
Abdominals Crunches on Physioball with rotation
Bridging with head on Physioball
Supine Bridging on Physioball
Prone Bridging- “around the world”
Quadruped Opposite arm/leg on “half foam rollers”
Seated Russian Twist with Medicine Ball
Seated on Physioball, Russian Twist with medicine ball
Bridging with Head on Physioball
5. Explain proper back care to this patient.
The patient should understand that they should maintain a good weight and be
active rather than sedentary.
Patient should be instructed on good behaviors of ADLs.
Sitting- sit up right, keep feet flat on the ground, hips in a neutral position, small
pillow can be placed in the lumbar curve of the back. Patient should avoid
slouch, or sitting for more than 60 minutes at a time in one position.
Standing- keep all in alignment! That means ears, shoulders, hips, and ankles in
alignment with each other. Relax shoulders and put weight on the middle of your
feet. Work surface can be adjusted to elbow height.
Heavy Lifting- Hold item close to your body at elbow height, bend at hips and
knees, keep back straight, lift slowly, and turn your feet to change directions. DO
not bend at the waste, lock knees or twist