General Information - Patient’s Name : E.A - Religion : Roman Catholic - Age : 40 y/o - Rehab Dr :Jolyn Ruth - Gender : Female Ambasing, FPARM - Address : Asin Rd. Baguio - Date of Referral : April 10,2018 City - Date of IE : April 11,2018 - Civil Status : Married - Diagnosis : T/C piri L>R MSC - Handedness : Right-handed strain - Occupation : Housekeeper c/c: Px c/o of intermittent radiating pain c PS 7/10, numbness on the R buttock that extends to the posterior thigh. Aggravated by prolonged sitting ~15 mins and, upon waking up in the morning c PS 8/10 and was relieved by taking self-prescribed medication(arcoxia) and doing stretching c PS 5/10.
HPI: Present condition started 2015 when px had her last birth of her last child and starts an intermittent dull aching pain on (B) lower back c PS 5/10. Px also noticed a persistent of pain p 4 hrs of travel c PS 6/10. Px managed the pain by having a masage 2x a week which ↓ the pain to 4/10. March 2018, when px felt of intermittent radiating pain c PS 7/10 on the R buttock that extends to the posterior thigh. Aggravated by prolonged sitting ~15 mins , upon waking up in the morning c PS 8/10 and was relieved by taking self-prescribed medication(arcoxia) and doing stretching c PS 5/10. April 11, 2018 d/t persistent of pain and bothers her during sleep pt went to SLU Sacred Heart hospital PT rehab and was attended and by Dr. Jolyn Ruth Ambasing, FPARM a rehab doctor. Px was requested to underwent x-ray (unrecalled). Px was then diagnosed with piriformis strain. Px recommended her to undergo PT Rehab to address her complain.
Past Medical and Surgical History:
- (+) Hospitalization @ SLU Sacred Heart hospital d/t slip disk o Pt. underwent 12 PT tx session for yr 2007-2009 @ SLU Sacred Heart hospital PT rehab o - (-) Surgery - (-) HTN - (-) Accidents - (-) Fall - (-) Trauma - (-) Heart disease - (-) Diabetes - (-) RA - (-) Asthma - (-) Scoliosis
Medications: Medication/s (Brand) Dosage/Route of Administration Indication Vitamin B complex (neurogine E) 1x a day Numbness
Personal, Social and Living Environment:
- Sedentary lifestyle - Pt has no hx of o (-) cigarette smoking o (-) alcoholic beverage drinker - Home situation: o patient lives in a 3-storey house with his mother o Pt room is located at the 2th floor (2 flight of stairs, 10 steps) o Room to CR:~6m o Room to kitchen: ~4m o Room to main door: ~4m o Room to living room: ~3m - Work situation: o Px works as a housekeeper and take care of her children o Pt. spends her time by watching television
Family History: Condition/s Mother Father HTN (-) (+) Diabetes (-) (+) RA (-) (-) OA (-) (-) Scoliosis (-) (-) Heart Disease (-) (-)
Subjective:
c/c: “kumikirot na parang may kuryente at kasamang pamamanhid sa kaliwang pwetan ko hanggang likod ng hita“ Prior level of function: Px was able to do household chores washing dishes and clothes. Pt’s goal: To be able to work pain free and can tolerate prolonged sitting
O: Vital Signs: Initial vs BP 130/80mmHg HR 88 bpm SPO2 98% Significance: for baseline data Ocular Inspection: - Ambulatory s AD - A/C/C - Endomorph - (+) 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 - (+) minimal ms spasm on B piriformis - (+) gr 1 tenderness on (B) piriformis - (+) taut band on ® Lower back - (-) ms guarding - (-) nodules - (-) contractures
Sensory:
- Dermatomal/Peripheral - Device used: pin for pain, brush for light touch and thumb for deep pressure - Findings:Px has intact sensation (100%) on R & L UE/LE - Sig: for baseline purposes
Significance: Intact reflex arc 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-75o 0o-90o 0o-62o 0o-85o 0o-120o 45o 580 30 380 empty Thoracolumbar 0o-30o 0o-35o 0o-28o 0o-30o 0o-45o 150 170 100 150 empty lateral flexion
Findings: ↓ ROM on R/L Hip flexion and thoracolumbar lateral flexion
Significance: LOM on R/L Hip flexion and thoracolumbar lateral flexion d/t tightness of piriformis
MMT:
All mm group of B UE/LE are grossly graded 5/5
Findings: N ms strength on B UE/LE Significance: For baseline purposes
SPECIAL TEST: PROCEDURE POSITIVE SIGN RESULT Significance Piriformis Test The patient is reproduction of (+) piriformis positioned sidelying. gluteal pain or tightness The test limb is radicular taken into flexion, symptoms in the adduction and distribution of the internal rotation. sciatic nerve. ELY’s Test Pt is in prone Pt hip on the same (-) To r/o tightness position, PT side also flexed of rectus passively flexes the femoris patients knee SLR 5 Pt is in supine , PT Centralize pain on (-) T/C HNP passively flex the hip the back c the knee extended the dorsiflexed the foot Prone Knee Bend Pt is in prone Pain in the anterior (-) To r/o Test position ,the thigh tight/strained examiner passively quadriceps flexes the patient's muscle or knee to end range neural tension and maintains it of the femoral there for 45 nerve seconds. The hip Pain on the To r/o lumbar should not be unilateral lumbar radiculopathy rotated. area, buttock, or of L2-L3 nerve posterior thigh roots.
Postural Analysis:
Postural landmarks are assessed in anterior/posterior and lateral views in a sitting position and are found to be in normal alignment, except for:
Landmark Anterior/Posterior Lateral
Head Midline Slightly forward Shoulder Right > Left Sh is aligned Thoracic Levelled N Kyphotic Curve Lumbar Levelled Decrease lordotic curve Pelvis Levelled Normal Hip Levelled Normal Knee Levelled Normal Ankle Levelled Normal Foot Levelled Normal
Findings: (+) postural deviation on A/P and Lateral view such slight forward head posture and flat lordotic curve Sig:: (+) postural deviation due to compensatory posture
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 Balance & Tolerance Legends: TOLERANCE BALANCE Poor- 0-15 min 1- Can assume Fair 16-30 min 2- Can assume & maintain Normal 46-60 min 3- 2+ Can assume, maintain, & weight shift 4- 3+Can assume, maintain, weight shift, & challenged
Balance Tolerance Sitting N F Standing N F
Findings: Px has normal sitting & standing balance but has fair tolerance in sitting for 20 min Significance: 2 to radiating pain A: PT Impression: - A 40 y/o female that has been diagnosed of having T/C piri L>R MSC strain, c/o of constant dull aching, numbness and radiating pain c PS 7/10 on the R buttock that extends to the posterior thigh further manifested by LOM on hip flexion and thoracolumbar lat. Flexion, minimal ms spasm on B piriformis, gr 1 tenderness on (B) piriformis L>R) , taut band on ® Lower back and postural and gait deviation.
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. constant dull aching, numbness and radiating pain c PS 7/10 on the R buttock that extends to the posterior thigh Intermittent aching, radiating pain c PS 2-3/10 on the R buttock that extends to the posterior thigh 2. Pt has ↓ AROM on trunk lat flexion, and hip flexiom 3. Fair tolerance in prolonged sitting and standing d/t pain. 4. (+) Gait deviation 5. (+) postural deviation 6. ms spasm on B piriformis 7. Tightness on of Hamstring 8. taut band on ® Lower back 9. gr 1 tenderness on (B) piriformis L>R
LTG(3x/wk for 12wks)
1. pt. will report an eliminated constant dull aching, numbness and radiating pain on the R buttock that extends to the posterior thigh. 2. Pt will be able to eliminate tightness manifested by NROM on hip flexion and thoracolumbar lateral flexion 3. To achieve N tolerance in sitting and standing 4. Pt will be able to exhibit and maintain proper posture and observe proper body mechanics 5. Pt will be able to perform N gait pattern
STG(3x/wk for 6wks)
1. Pt will report a decrease in pain by 2 increments in PS from 7/10 to 4/10
2. Pt will demonstate a decrease ms tightness manifested by an increase in ROM by 100 increments towards (L/R) hip flexion and thoracolumbar lateral flexion 3. Pt will present an eliminated ms spasm on B piriformis , taut band on ® Lower back AND gr 1 tenderness on (B) piriformis L>R
P:
PT Mx
1. HMPX 15’ on B paralumbar, piriformis and gluteus
2. US X 1.25 w/cm2 on B paralumbar, piriformis and gluteus 3. Effleurage MRT 4. Gentle stretching on B hamstring, piriformis and gluteus 5. Pt. education on proper body mechanics and proper posture to avoid complications and/or further injury
HEP 1. Self stretching techniques on hamstring, gluteus ma, and piriformis x 30 SH x 2 reps 2. Observe PBM
