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
1. Diet: mixed
2. Appetite: Adequate
3. Bowel/Bladder : clear and continent
4. Sleep: unaltered
5. Addiction- none
6. 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
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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
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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
1. Lumbar disc protrusion
2. Lumbar canal Stenosis
3. Spondylolisthesis
4. Piriformis syndrome
5. 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:
d2: general task and demands
d210: Undertaking a single task- 1
d220: Undertaking multiple task- 2
Case Presentation 33

34. PROBLEM LIST
1. Pain in low back region
2. Tingling in left leg
3. Difficulty performing Activities of daily living
4. Difficulty in weight lifting
5. 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 engage 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
1. 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 . 6th edition page 516

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