Internship Case Study

1. Case Study for Health 4900 Internship
PROBLEM: Neck, shoulder, back, Treat/EX
INITIAL EVALUATION/PLAN OF CARE
 Diagnosis: Status/Post Lumbar Spondylolisthesis (What doctors did Lumbar fusion for)
 How: During post-surgery (Patient has been having pain in her right leg ever since she received
surgery for lumbar fusion. She has also been using a cane when out in public and back is tired.
Patient needs to work on pain in hip, core, and leg strength.)
 Detected: X-ray
 Treatment/Evaluation Start date: 9/13/16
- No fall prevention plan issues due to low risk of falling
- Goal: return to pain free ambulation
- Level of function: difficulty with ambulation and household duties
- No numbness or tingling
 Problem List: Increase LBP, decrease lumbar ROM, decrease lumbar strength, decreased R LE
strength
EVALUATION/CARE
 Treatment Effective:9/13/16-12/13/16
 Prognosis: Patient benefit from PT after 12-18 visits
 Goals:
- STG (3 weeks)- Independent with Initial Home Exercise Program (HEP), Increase lumbar
ROM to 50% to assist with ADL’s, household duties, and decrease back pain from 1-2/10 to
0/10
- LTG: (6 weeks)-Decrease ROQ score by greater than or equal to 10 points to demonstrate
improved function abilities, increase lumber strength to 4+/5 to assist with ambulation and
household duties, increase R LE strength to 5/5 to assist with ambulation, and patient will
be able to ambulate greater than or equal to 30 minutes without increased signs and
symptoms per patient report
 Plan: Increase lumbar ROM and strength, increase RLE strength, decrease back pain with ROM,
stretching, strengthening, manual therapy, and modalities to include ultrasound and electrical
stimulation at 2-3 times per week for 6-10 weeks
1. 9/13-Objective: Therapeutic exercises to increase strength, flexibility, and range of motion,
lumbar ultrasound, electrostimulation on lumbar with ice pack for 15 minutes, and started on
some exercises: heel/toe raises for 1 minute, side stepping 2 times around the countertop,
marching for 1 minute standing up, pillow squeezes 20 times, upper arm bike for 3 minutes,
Williams 1 5 times per leg, sways 5 times per leg, and wall stretches 10 times
Self-Evaluation -“S/P Lumbar Spondyloeistesis” -Pain=1-2

2. PT Assessment-None-reference evaluation
2. 9/15-Objective: Therapeutic exercises to improve soft tissue flexibility, decrease restriction, and
facilitate healing, SAQ/LAQ to be added for each leg for strengthening of LE and an increase in
time for the arm bike to 4 minutes
Self-Evaluation -“Did well after 1st
visit” -Pain=0-1
PT Assessment-Gradual increase in overall strength and continued LE weakness limiting
ambulation
3. 9/19-Objective: SAQ/LAQ 5 times per leg and seated marching added for LE strength -Pain=0-1
Self-Evaluation -“Did too much bending and lifting this weekend so my back and leg hurt”
PT Assessment-Continued back LE pain limits ambulation
4. 9/21-Objective: Increase in pillow squeezes to 30 times, increase in upper arm bike to 5
minutes, and added cone walks, -R Trendelenburg
Self-Evaluation -“Back is doing well today” -Pain=1
PT Assessment-Gradual increase in lumbar strength and mobility, exercise for balance, and
decrease in LBP
5. 9/22-Objective: Added standing abduction raises and supine crab
Self-Evaluation -“Feeling pretty good today” -Pain=1
PT Assessment-R hip strength- R hip weakness leading to gait abnormalities
6. 9/26-Objective: Increase to 4 pounds for SAQ/LAQ and seated marching
Self-Evaluation -“Doing better, only a little pain in leg when I walk -Pain=0-2
PT Assessment-Gradual increase in Lumbar/LE strength, increase tolerance and ambulation
7. 9/27-Objective: Increase R LE standing, Significant R Trendelenburg, SLR (Straight Leg Raises)
added for 10 reps
Self-Evaluation -“Back is better but has been aching though” -Pain=0-2
PT Assessment-Overall improvement, decrease LBP, continued R hip weakness limits ambulation
8. 9/28-Objective: SAQ/LAQ to 30 times, added mini squats for strengthening and added standing
hip abduction
Self-Evaluation -“Doing good but balance is still very bad -Pain=1
PT Assessment-Gradual increase in lumbar and decrease LE strength, continued difficulty with
ambulation
9. 10/3-Objective: R LE MMT Hip flexion 4-/5, R Trendelenburg
Self-Evaluation -“Back feels ok today but ached this weekend -Pain=1
PT Assessment-Continued R LE pain limits ambulation
10. 10/6- Objective: Lumbar ROM: flexion 50%, Revised Oswestry Questionnaire is 34%
Self-Evaluation -“Doing well today -Pain= ½
PT Assessment-Gradual increase in lumbar and LE strength, difficulty with prolonged ambulation
 Progress Report/Note
- Patient doing well, but has trouble walking still
- ½ /10 pain
- Strength- L LE=5/5, R LE Hip 4-/5, and knee flexion/Extension 4+/5, Lumbar 4/5, ROQ=34%
- Improved tolerance for ADL and household duties

3.  Assessment: Gradual improvement with Physical Therapy, decreased LBP, and improved LE
strength and tolerance for ambulation. Patient’s current impairment level of ½ /10 and her
Revised Oswestry Questionnaire score of 34%. Patient progressing toward her goal of 15%
impairment
 Plan: continue 2-3 times per week for 4 weeks
11. 10/7-Objective: Hot packs, added bike for LE, and R LE MMT hip flexion 4-/5
Self-Evaluation -“Achy today” -Pain=2
PT Assessment-Continued gait abnormalities, gradual increase in LE and lumbar strength
12. 10/10-Objective: SAQ/LAQ 15 times, seated marching increase to 5 pounds
Self-Evaluation -“Pain in the leg still” -Pain=2
PT Assessment-Gradual increase in LE strength and stability, and limitations with prolonged
ambulation
Treatment Plan-Decrease to being seen 2 times per week next week
13. 10/11-Objective: SAQ/LAQ to 20 times, R LE MMT, knee flexion 4+/5, increase bike to 5 minutes
Self-Evaluation -“Feeling good today” -Pain=1
PT Assessment-Continued gait abnormalities, gradual increase in LE strength
14. 10/12-Objective: R LE MMT hip flexion 4/5
Self-Evaluation -“Just a little pain” -Pain=1
PT Assessment-Gradual improvement, decrease R hip pain, continued limitation with
ambulation
Treatment Plan-Decrease to 2 times per week
15. 10/18-Objective: SAQ/LAQ to 30 times and R LE MMT hip flexion 4+/5
Self-Evaluation -“Felt good today” -Pain=1
PT Assessment-Continued R hip weakness limits ambulation
Treatment Plan-2 times per week
16. 10/20-Objective: R Trendelenburg, R LE MMT increase crabs to 15 times, and Hip flexion4/5
Self-Evaluation -“Back bothered me a lot yesterday, better today” -Pain=2
PT Assessment-Gradual increase in lumbar and LE strength limits ambulation
17. 10/24-Objective: Lumbar ROM flexion 50%
Self-Evaluation-“Doing pretty well, a little leg pain” -Pain=1-2
PT Assessment-Overall improvement, continued R hip weakness limiting ambulation
 Progress Note
-Gradual Improvement
-R LE MMT hip flexion 4/5, R Trendelenburg Lumbar ROM Flexion 50%, R Lateral Flexion
25%, L Lateral Flexion 50%
 Recommendation
-Continue PT-new MD (Medical Doctor) script needed to continue
18. 10/31-Objective: R Trendelenburg, R hip Flexion MMT 4/5
Self-Evaluation-“Not too bad today” -Pain=1
PT Assessment-Gradual increase in LE and lumbar strength, continued gait abnormalities

4. PT: Physical Therapy
ADL: Assisted Daily Living
ROM: Range of Motion
ROQ: Revised Oswestry Questionnaire
LBP: Low back pain
R LE: Right Leg Extension
L LE: Left Leg Extension
SAQ/LAQ: Short Arc Quadriceps/ Long Arc Quadriceps
MMT: Manual Muscle Testing