MUSCULO SKELETAL ASSESSMENT

INTRODUCTION :
Patient was a 45 year old woman with lower back pain which had started three months earlier
due to her work load.
SUBJECTIVE EXAMINATION :
Patient was a 45 year old woman who was a professor in field of Engineering. She was living
together with her husband and children. Due to low back pain resulting from prolong
standing for more than one hour she came to physiotherapy department as she felt
comfortable while sitting. Her aim was to get back to work again soon. She had no previous
traumas associated with a pain.
Patient had started teaching people studying computer science Engineering program few
months earlier in order to take care of her family. During her free time she was involved in
house hold activities. A month ago she had started to experience low back pain after teaching.
One week before coming to the clinic the pain had been increased to a extent where she was
not able to stand in the lecture hall for a long time and pain was sharp and started radiating to
both legs . patient had more pain during night times.
She described that she had medications but pain was re occurred. She had family history of
Diabetes mellitus and Arthritis. The patient described pain with a 6/10 on the visual Analog
scale (VAS).

VISUAL ANALOG SCALE

After my preliminary theory I thought that symptoms could be related to Mechanical low
back pain as the patient stands for a long time during her profession.
PHYSICAL EXAMINATION :
Patient was Endomorphic. I started physical examination by assessing patient’s active range
of motion and posture. In assessing posture both shoulder and hip regions were level
anteriorly and ankles were in line. In the spinal region she had a normal kyphosis but the
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lordosis in the lumbar spine had straightened. Her lumbar flexion was normal and extension
movement was restricted and there was tightness in hamstring muscles on both sides.
I performed straight leg raise (SLR) test and slump test to detect nerve root impingement as
patient had pain radiating to both legs and SLR test was positive as the patient pain increased
when leg was lifted over 45 degrees by placing the knee straight and slump test was also
positive. Later I performed prone knee bending test to check femoral and mid lumbar
pathology as patient was having radiating pain anteriorly which was negative. I also
performed Gillet test and Patrick’s test to identify whether patient had any Sacro iliac joint
dysfunction and hip joint pathology which were negative.
During palpation I identified tenderness in medial side of the low back region. Subsequently I
performed manual muscle testing for lumbar flexors which was 3/5 and for lumbar extensors
was 3/5 according to medical research council(MRC) grading. Patient was independent in
performing her normal ADL activities. After these findings I felt patient had lumbar disc
herniation or sciatica related to physical examination results.

ANTERIOR POSTERIOR
The above diagram describing low back pain and low back pain radiating to both lower limb
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS AND PLAN :
With the subjective examination and physical examination I could say that patient was
affected by lumbar spondylolisthesis instead of lumbar disc herniation or sciatica as the
patient had low back pain mainly during prolong standing and improved by sitting .
Shamrock AG Et.al (2019) demonstrated that pain will be relieved with forward leaning or
sitting positions in low grade spondylolisthesis. Raj M. Amin Et.al(2019) demonstrated that
 MUSCULO SKELETAL ASSESSMENT

pain increases more in sitting in patients with lumbar disc herniation as it increases disc
pressure by nearly 40%. Further more MRI showed anterior slipping of L5 over S1 vertebrae
which means spondylolisthesis (L5 – S1). With these findings I finally confirmed that patient
had lumbar spondylolisthesis (L5-S1).
The prognosis would be effective if the patient followed regular physiotherapy.
TREATMENT PLAN :
The plan that I made was to address the following goals :
First of all, the short term goal was to reduce pain and to increase range of motion.
Further more, the long term goal was to improve muscle power, to correct posture and to
achieve normal activities of daily living.
WEEK 1 :
In the first week Interferential therapy (IFT) was given to lumbar spinal region with single
session every day for seven days to reduce pain and to provide relaxation. Duration : 15
minutes. I given interferential therapy for one week with out exercises as patient was unable
to perform exercises due to chronic pain.
WEEK 2 :
In the second week core strengthening exercises were given as patient felt better relief from
pain by receiving interferential therapy. Core strengthening exercises were adapted from
prentice(2011) which include :
Pelvic bridging ( bend both knees and try to raise the hips up hold it for 5 seconds and relax )
in straight lying. Repetitions – 10 to 15
Squatting ( stand against the wall . try to sit down with hips and knees bend by holding some
in front for 5 seconds and relax). Repetitions – 10 to 15
Lunges and crunches. Repetitions – 10 to 15
Draw in manoeuvre. Repetitions – 10 to 15.
In prone lying, Kneel on all fours. Try to pull abdomen in and hold for 5 seconds and relax.
Repetitions – 10 to 15.
In prone lying, Kneel on all fours. Try to lift right hand and left leg, hold for 5 seconds and
relax. Do the same exercise on alternative side. Repetitions – 10 to 15. All exercises were
performed for two sets.
Then dynamic stretching for hamstring muscles, para spinal muscles and ilio psoas muscles
was given which includes front kick, back kick, slump stretch and cat and camel stretch for 2
sets. Repetitions – 10 to 15.
Dynamic stretching routine was adapted from Cleland et al. (2006), Nelson and
kokkonen( 2006).
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HOME EXERCISES :
Core strengthening exercises should be continued regularly once a day. Repetitions – 10 to
15
2 sets.
After 6 weeks of therapeutic protocol, I received feed back from patient that core
strengthening exercises have proven to be beneficial for her and patient returned to her
profession in better shape than before.
SELF REFLECTION :
This clinical case made a important contribution in my professional growth. I had improved
my critical thinking regarding assessment and implementation of therapy to the patient. With
this study I had learnt how to do differential diagnosis for patients with low back pain
conditions.
REFERENCES :
Marcelo Baptista Dohnert jordana Peres Bauer Tiago Sebastia pavao (2015), Study of the
effectiveness of interferential current as compared to transcutaneous electrical nerve
stimulation in reducing chronic low back pain.

Ebby Waqqash Mohammed chan , Rahmat Adnan, and Ridzuan Azmi(2019) , Effectiveness
of core stability training and dynamic stretching in Rehabilitation of chronic Low back pain
patients.

Tarun Kumar, suraj Kumar, Md Nezamuddin, VP sharma (2015),Efficacy of core muscle

strengthening exercise in chronic low back pain patients.

Vrp m’kumbuzi, jt ntawukuriryayo, jd haminana, j munyanda musta, e nzakizwanimana

(2015), Accuracy of straight leg raise and slump tests in detecting lumbar disc herniation.