INITIAL EVALUATION

General Information
- Patient’s Name : S.S - Religion : Roman Catholic
- Age : 63 y/o - Referring Dr : Dr. Ruyeca
- Gender : Male - Rehab Dr : Dr. Jolyn Ruth Ambasing
- Address : Quezon Hill, Baguio City - Date of Referral : April 16, 2018
- Civil Status : Married - Date of IE : April 19, 2018
- Handedness : Right-handed - Diagnosis :lumbosacral strain
- Occupation : Retired
- Precautions: Avoid lifting , activities
involving carrying heavy weights, BP and
Cardiac precuation

c/c: Px c/o Difficulty in wearing lower garments; intermittent dull aching pain on B lower back c ps 8/10,
aggravated bowing, prolonged standing, and sitting ~15’ c ps 9/10 and is relieved by rest and applying oil
liniment c ps 6/10.
HPI:
Present condition started April 3, 2018 when pt. was making a deep well which involves stooping down
and carrying heavy materials weighing ~25kg. After 2 days prior to the incident, pt. felt an intermittent dull
aching pain on B lower back c ps 8/10 and noticed a poor posture manifested by stoop posture and difficulty in
straightening his back. Pt stated that he has difficulty in wearing his lower garment and needs an assist from his
wife. Pt managed the pain by applying oil liniment every night which decreases the pain from ps 8/106/10.
On April 12, 2018 when pt. cannot tolerated the pain, he. went to Baguio Pain and Rehab Center to seek
medical consulation with Dr.Masbate, pt. was given a medication for pain relief (planax) , however it was only
effective for 1 hr. Pt. stated that no improvement was noted in his condition.
On April 16, 2018 pt. went to SLU Sacred Heart hospital ER to seek medical consultation. Pt. was
attended by Dr. Ramos and Dr. Ruyeca and was initially assessed. Pt. was then diagnosed of having lumbosacral
strain and was given medication (see medication) for pain relief. On the same day pt was reffered to SLU Sacred
Heart hospital PT rehab under Dr. Ambasing for further evaluation and tx. Pt. recommended him to undergo PT
Rehab to address his complain.

Past Medical and Surgical History:

- (+) Hospitalization @ SLU hospital d/t typhoid fever

- (+) Hernia (2010)
- (+) Goiter (2008)
- (-) Surgery
- (-) HTN
- (-) Stroke
- (-) Accidents
- (-) Fall
- (-) Trauma
 - (-) Heart disease
- (-) Diabetes
- (-) RA
- (-) Asthma
- (-) Scoliosis

Medications:
Medication/s (Brand) generic Dosage Indication
metoprolol Lopressor 1x a day To ↓BP
declofenac Voltaren As needed Pain relief

Personal, Social and Living Environment:

- Sedentary lifestyle
- Pt. stays at home watching television which involves prolonged sitting or lying for ˷ 2 hr
- Pt. does household chores involves sweeping around their yard for ˷ 1 hr
- Pt has hx of
o (-) cigarette smoking
o (-) alcoholic beverage drinker
- Home situation:
o Pt. lives in a 3-storey house with his family
o Pt room is located at the 2nd floor (4 flight of stairs, 30 steps)
o Room to CR:~6m
o Room to kitchen: ~4m
o Room to main door: ~4m
o Room to living room: ~3m

Family History:
Condition/s Mother Father
HTN (-) (+)
Diabetes (-) (+)
RA (-) (-)
OA (-) (-)
Scoliosis (-) (-)
Heart Disease (-) (-)

Subjective:

c/c: “Makirot yung bewang ko, nahihirapan din akong magsuot ng shorts ko “
Pt’s goal: “ Sana mawala na yung sakit para makapagtrabaho na ulit ako”

O:
Vital Signs:
BP 130/90 mmHg
 HR 82 bpm
SPO2 97%

Significance: for precaution of cardiac

Ocular Inspection:
- Ambulatory s AD
- A/C/C
- Mesomorph
- (+) Postural deviation (see postural analysis)
- (+) Gait deviation (see gait analysis)
- (-)Deformity
- (-) atrophy
- (-) swelling
- (-) trophic skin changes
- (-) scars/bruises/wound

Palpations:
- Normothermic on all exposed areas
- Normotonic on all 4’s
- (+)ms spasm on B low back
- (+) tightness on hamstring, , Gluteus Maximus and piriformis
- (+) gr. 1 tenderness on R piriformis
- (-) taught bands
- (-) ms guarding
- (-) contractures

Sensory Assessment:
Devices used: toothpick for pain, cotton for light touch and thumb for deep pressure
Findings: Pt has N sensation in (B) paralumbar areas, B UE/LE
Sig: For baseline data

ROM:
All major joints on B UE/LE were grossly assessed actively and passively and are WNL and Normal end-feel
except for:

Motion Right Left NROM Difference End-

feel
AROM PROM
AROM PROM AROM PROM R L R L
Hip flexion 0o-68o 0o-70o 0o-50o 0o-60o 0o-120o 52 o
700 50 o
600 Firm
Hip extension 0o- 30o 0o-35o 0o-33o 0o-35o 0o-60o 30 o
25 o 27 o
25 o Firm
Hip ER 0-30o 0-40 o 0-45o 15 o 5o Firm

Hip adduction 0-20 o 0-25 o 0-20 o 0-25 o 0-35o 15 15 10 20 Firm

Thoracolumbar 0o-30o 0o-35o 0o-35o 0o-40o 0o-45o 30 60 00 30 Firm

Rotation
AROM NROM DIFFERENCE END
FEEL
AROM
Thoracolumbar 19.5 in- 22 in ~4 in 2.5 Firm
flexion
Thoracolumbar 19.5-18 ~ 2 in 1.5 Firm
extension

Findings: ↓ ROM on R/L Hip flexion/extension/adduction, external rotation, thoracolumbar rotation, and
thoracolumbar flexion/extension
Significance: LOM on R/L R/L Hip flexion/extension/adduction, external rotation, thoracolumbar rotation, and
thoracolumbar flexion/extension d/t tightness

MMT: All major (m) groups of UE/LE and neck are assessed using break test and are grossly grade 5/5 except
the ff:
Muscle Group Grade
R L
Hip extensors 3/5 3/5
Trunk rotators 2/5 2/5
Trunk Flexors 3/5
Trunk Extensors 3/5

Findings: (m) weakness on R/L hip extensors, and trunk rotators, flexors/extensors.
Significance: decrease (m) strength on R/L hip extensors, and trunk rotators, flexors/extensors d/t inactivity

SPECIAL TEST:
PROCEDURE POSITIVE SIGN RESULT Significance
SLR Pt is in supine Sciatic pain (-) To r/o sciatic
,examiner lift the pt nerve
leg while knee is compression
straight
Yeoman’s test Pt prone, PT Pain in the lumbar (-) To r/o neural
stabilize the pelvis spine tension
while the hip is
passively extended
first while with the
knee extended then
with the knee flexed
Slump test Pt is seated upright Pain on low back (-) to r/o neural
with hands held tension
together behind his
back, the PT instruct
the pt to flex his
spine followed by
neck flexion while pt
perform knee
extension and
dorsiflexion

POSTURAL ANALYSIS:
Postural landmarks are assessed in anterior/posterior and lateral views in standing position and are found to be
in normal alignment, except for:

Landmarks Anterior/posterior Lateral

Head Slight rotated to R Forward head
Shoulders Leveled Leveled
Scapula Leveled Leveled
Thoracic Leveled  Kyphotic Curve
Lumbar Leveled ↓ Lordotic curve
Pelvis Leveled Normal
Hip Leveled Normal
Knee Leveled Normal

Findings: pt. manifests with a head slightlyrotated towards R, increase in kyphotic and decrease in lordotic
curve .
Significance: (+) postural deviation 2o habitual posture.

Sig: for baseline data

Gait Analysis:
Stance Phase R L
HS (-) (-)
FF (+) (+)
MS (+) (+)
HO (+) (+)
TO (+) (+)
Swing Phase
IS ↓ ↓
MS ↓ ↓
TS ↓ ↓
 Findings: Decrease swing phase on both Right & Left, (-) HS on both right & left feet
Sig: 20 antalgic gait

ADL analysis

Pt is independent in all aspects of ADLs such as self care, bed mobility and transfer but has min difficulty in
performing ADLS such as:

 Wearing lower garments

 Prolonged walking, sitting and standing

A:
PT Impression:
A 29 y/o male who has who has min difficulty in performing ADLS such as ambulation, activities which requires
prolonged walking and sitting further manifested by postural deviation, gait deviation, decreased (m) strength
and LOM Hip flexion/extension/adduction, external rotation, thoracolumbar rotation, and thoracolumbar
flexion/extension d/t tightness, c/o B lower back c ps 8/10 20 to lumbosacral strain.

Rehab potential: Pt. has excellent prognosis as to rehab since patient is cooperative and motivated and made
very good progress and responded well c previous PT Tx

Problem List:
1. Pt has min difficulty in performing ADLS such as ambulation, activities which requires prolonged walking
, standing and sitting
2. intermittent dull aching pain on B lower back c ps 8/10
3. LOM on R/L Hip flexion/extension/adduction, external rotation, thoracolumbar rotation, and
thoracolumbar flexion/extension
4. decrease (m) strength on R/L hip extensors, and trunk rotators, flexors/extensors.
5. (+) Gait deviation
6. (+) postural deviation
7. Ms spasm on low back
8. gr. 1 tenderness on R piriformis

LTG(3x/wk for 12wks)

1. Pt will be able to to reach highest functional ROM and m strength s pain and difficulty in performing
ADLS wearing lower garment, prolonged walking , standing and sitting
2. Pt will achieve optimum level of muscle strength of target muscles c MMT gr of 5/5
3. Pt will be able to exhibit and maintain proper posture and observe proper body mechanics
4. Pt will be able to perform optimum gait pattern
STG(3x/wk for 6wks)

1. Pt will report a decrease in pain by 2 increments in PS from 8/10 to 4/10

2. Pt will demonstate an eliminated m tightness manifested by an increase in ROM by 100 towards R/L Hip
flexion/extension/adduction, external rotation, thoracolumbar rotation, and thoracolumbar
flexion/extension
3. Pt will present an eliminated ms spasm on lower back and tenderness on R piriformis.

P:

Suggested PT Mx:

1. US x 1.5 w/cm 2 x 5’ on B PL gluteus and piriformis to decrease pt’s pain

2. HMP on B PL area and gluteal area x20’ to increase mm extensibility
3. GPMS on R Hamstring, Gluteus Maximus and piriformis to increase ROM
4. MFR on B piriformis x5’ to release mm tension
5. Pt. education on proper body mechanics and proper posture to avoid complications and/or further
injury
6. Core strengthening exercises to strengthen probably weakened muscles
7. Home exercise program that include self-stretching of the 3 muscles to increase ROM

Gurtiza Joanna Eden

Lorma Colleges PT Intern ‘18