Tutorial Case #2

Lumbar Spine Region Case Presentation – Part I

History

Ororo Munroe is a 17yearold gymnast from Reston, VA. Ororo plans on attending college after high school and may seek a gymnastic scholarship during her college experience. Her family is supportive of her academic and sports careers. Ororo has had low back pain complaints for the past 6 months but has been able to manage them with stretching and icing after practice. Two days ago she had a severe episode of back pain after working out and was unable to relieve the symptoms with her usual stretches and ice. Her coach sent her to her family physician that referred her to an orthopedist who specializes in Sports Medicine. He took xrays and diagnosed a spondylolysis at L5 and a grade I spondylolisthesis at the same level. She has been referred to physical therapy for an evaluation and exercise routine. Her goal is to continue to compete at the collegiate level.

Area:Lower back

Behavior:Worsening

Aggravating Factors:sit to stand immediate severe pain (8) settles to constant ache (6) 3 hours if in semifowler position; unable to extend back secondary to severe pain. Easing Factors: lie in semifowler position; double knee to chest; ice

24 hours:

AM: awake in pain, generally stiff

Day: fatigues easily; unable to stand erect

Night: awakes if not in hooklying position

Special Questions:

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PT720/PT721 - Orthopedic Tutorial Case Presentations # 2

Tutorial Case #2

GH:nil of note

WL:

Meds:NSAIDs

Cough/sneeze:

WL:

Steroids:

Cord:

CE:

Anticoagulants: 

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PT720/PT721 - Orthopedic Tutorial Case Presentations # 2

Tutorial Case #2

Diagnostics:XRay spondylolysis; spondylolisthesis at L5S 1

Social:lives with both parents; high school senior; gymnastic/dance

Current History

Ororo Munroe is a 17yearold female gymnast. She has had low back pain for the past 6 months but has been able to manage them with stretching and icing after practice. Two days ago, Ororo had a severe episode of low back pain, and was unable to relieve the symptoms with her usual stretching and ice. Her coach sent her to an Orthopedist for an evaluation. He took xrays and diagnosed a spondylolysis and grade I spondylolisthesis at L5. She has been referred to PT for an evaluation and exercise routine. Her goal is to compete at the collegiate level.

Past History

She has a 6month history of LBP treated with ice and stretching. No formal treatment to date. Has been a gymnast since age 5.

Learning Objectives for Part I

By the end of this section the student should be able to:

  1. define all terms;
  1. define hypermobility and instability and explain how do they differ;
  1. draw the L5 vertebrae. Demonstrate where the defect in the pars interarticularis occurs;
  1. list the structures, which limit extension in the lumbar spine;
  1. understand which xray views are necessary to demonstrate a spondylolysis and know what the term "Scotty dog" refers to;
  1. identify which degenerative changes will take place over time if the spondylolisthesis continues to slip
  1. to the disk
  2. to the facet
  3. to the ligaments
  4. to the nerve roots
  5. vertebral body
  1. discuss the incidence, pathogenesis, prognosis and typical medical and surgical management and rehab course for a patient with a spondylolisthesis;
  1. use the following form to plan what you would look for in an objective examination. Fill in all of the blank spaces or circle the appropriate answers as required.

Plan The Objective Examination

The following is a representation of the type of assessment and thought process that Maitland uses during an evaluation. Try to use the following layout to assess the patient case scenario presented and determine your diagnosis and treatment protocol afterwards.

1. Name as the possible source of any part of the patient's symptoms every structure that must be examined:

Joints under the area of symptoms / Joints referring into the area of symptoms / Contractile structures underlying the area of symptoms / Other structures to be examined

1.1Circle the most probable source(s) of the symptoms.

1.2Will you do a neurological examination? Yes/No

1.2.1Segmental/peripheral/central (circle)

1.2.2Why? ______

2.0Influence Of the Symptoms of the Examination

2.1Are the symptoms minimal/moderate/severe?

2.2Does the subjective examination suggest an easily irritable disorder?

Local: Yes/No Referred:Yes/No

Give an example:______

______

______

______

Local: Activity causing symptoms______

Severity of symptoms______

Duration before symptoms subside______

Referred: Activity causing symptoms______

Severity of symptoms______

Duration before symptoms subside______

2.3. Does the nature of the symptoms indicate caution?

Yes/No – Specify: ______

2.4 Does the nature of the symptoms require specific testing?

Yes/No – Specify:______

2.5Does any other aspect of the subjective examination indicate caution, e.g. severity, irritability, stage?

Yes/No – Specify:______

2.6Are there any contraindications to any part of your examination?

Yes/No – Specify:______

3.0 The Kind of Examination

3.1. Do you think you will need to be gentle or moderately vigorous with your examination?

Local Pain / Referred Pain / Paraesthesia / Anesthesia / Dizziness or Other Symptoms
Short of pain / Short of symptoms / Short of symptoms
Pain or point of increase / Pain or point of increase / Pain or point of increase / Pain or point of increase
Active limit of movement / Active limit of movement / Partial reproduction of symptoms / Partial reproduction of symptoms
Active limit plus overpressure / Active limit plus
overpressure / ______/ ______
Sustained Repeated Combined / Sustained Repeated Combined / ______/ ______

3.2. At which point will you limit your objective examination?

3.3. Do you expect a comparable sign to be easy/hard to find?

3.4. Do you expect to be treating pain, resistance, or spasm?

4.0. Associated Examination

4.1. What associated factors must be examined?

4.1.1. Reasons why the joint, muscle, or other structure has become symptomatic

Specify:______

4.1.2. Reasons why the disorder may occur

Specify:______

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PT720/PT721 - Orthopedic Tutorial Case Presentations # 2