LBP ec HNP VL2-VL3,

VL3-VL4, VL4-VL5
Juwita Arum Mayangsari, dr

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DATABASE PEBRUARY 21,
2018
Identity
 Name : Mrs. S
 Sex : Female
 Age : 51 yo
 Address : Rusun Sombo, Surabaya
 Religion : Islam
 Occupation : Bakso Maker (husband selling bakso)
 Marital Status : Married
 Ethnic : Javanese
Referred from neurology outpatient clinic with Low Back Pain

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Chief Complaint : Nyeri pada punggung kiri bawah

History of Present Illness :

 Patient felt dull pain at lower back area, since 10 years ago, worsen
since 2 months ago. Pain radiated to right and left thigh and calf with
VAS 7-8.The pain was aggravated by position changing from lying to
sitting, from sitting to standing, walking a long distance, walking
upstairs, sitting in a long time, forward bending the trunk, sneezing and
coughing. The pain was relieved when she was in lying position or taking
medication. Muscle weakness, numbness, bowel and bladder problem
were denied.

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 History of Past Illness
The patient felt pain in the lower back area since 10 years ago, after
being hit by the cart from behind. Initially the pain was fluctuating with no
radiation pain, no tingling sensation. The pain get worsen with walking in a
long distance, walking up the stairs and lifting heavy object. The pain get
worsen since 2 years ago, and radiated to right and left thigh and calf. Due
to the pain, the patient can’t help her husband selling bakso and she get
consult to PMR clinic at Al-Irsyad, Surabaya. She got SWD twice a week and
medication. She felt a little improvement in 2 years of therapy. She had
overed to had spine surgery, but she refuse and referred to neurology out
patient clinic os RSDS for MRI and further evaluation.

The History of hipertension, diabetes mellitus, malignancy, chronic

cough and trauma were denied.

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History of Medication

From Neurologic Outpatient Clinic:

Na Diclofenac 3x50 mg
Amitriptilin 1x12,5 mg
B1 3x1

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History of sosioeconomic:
 Patient living in 4 floor building of Rusun Sombo, Surabaya. She live
in the first floor, but she frequently going to the 2nd, 3rd and 4th floor
in the diferent building to go to the marital/sircumsition ceremony
(about 2-4 x/week), sometimes 3x/day. Nowadays she unable
walking up to the upper floor to attend the ceremony. There’s no lift
nor escalator in the building.

 She prepared & cook bakso everyday from 5 kg of meat since 20

years ago. In the evening, she was helping her husband selling bakso
in front of Al-Irsyad Hospital. In the past 2 years she can’t help the
husband to sell bakso, due to the illness, but she still cooking bakso
daily.

 The patient frequently lift the pan (about 10 kg) from the floor to
the stove (±1m height) and otherwise.
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Physical Examination (20/02/2018)
General status
 Compos mentis, independent ambulation, normal gait, right handed
domination.
 Weight : 52 kg, Height : 147 cm,
 BMI : 24.06 kg/m2 (Asian criteria: overweight)
 BP : 130/90 mmHg HR : 88x/minute RR: 20 x/min

 Head and neck : anemia-, jaundice -, cyanosis -, oedema –

 Chest : heart : S1S2 single, murmur -, gallop –
lung : rh-/-, wh-/-, ves +/+
Abdomen : soepoel, hepar and lien unpalpable
Extremities : warm +/+

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Musculoskeletal Status
NECK ROM MMT

Flexion F (0-450) 5

Extension F (0-450) 5

Lateral bending F/F (0-450) 5/5

Rotation F/F (0-600) 5/5

TRUNK ROM MMT

Flexion F (0-900) Difficult to evaluate (P)

Extension F (0-300) Difficult to evaluate (P)

Lateral bending F/F (0-350) 5/5

Rotation F/F (0-450) 5/5

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 SHOULDER ROM MMT

Flexion F/F (0-1800) 5/5

Extension F/F (0-600) 5/5

Abduction F/F (0-1800) 5/5

Adduction F/F (0-450) 5/5

Internal rotation F/F (0-700) 5/5

External rotation F/F (0-900) 5/5

ELBOW ROM MMT

Flexion F/F (0-1500) 5/5

Extension F/F (1500-0) 5/5

Supination F/F (0-900) 5/5

Pronation F/F (0-900) 5/5

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 FINGERS ROM MMT
Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5
Opposition F/F 5/5
HIP ROM MMT

Flexion F/F (0-1200) 4P/4P

Extension F/F (0-300) 4P/4P

Abduction F/F (0-450) 5/5

Adduction F/F (0-300) 5/5

Internal rotation F/F (0-450) 5/5

External rotation F/F (0-350) 5/5

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 KNEE ROM MMT

Flexion F/F (0-1350) 5/5

Extension F/F (1350-0) 5/5

ANKLE ROM MMT

Dorsoflexion F/F (0-200) 5/3P

Plantarflexion F/F (0-500) 5/5

Inversion F/F (0-350) 5/5

Eversion F/F (0-150) 5/5

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 BIG TOE ROM MMT

Flexion

MTP F/F (0-300) 5/4

IP F/F (0-500) 5/4

Extension F/F (0-800) 5/4

TOES ROM MMT

Flexion

MTP F/F (0-250) 5/5

IP F/F (0-250) 5/5

Extension F/F (0-800) 5/5

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Neurological Status

N. Cranialis I –XII : Normal

Deep tendon reflex : BPR++/++ KPR ++/++ TPR+

+/++ APR++/++

Pathological Reflex : Babinski -/-, Chaddock -/-

Hoffman -/-; Tromner -/-

Sensory :

Eksteroseptive : No sensory
deficit

Proprioseptive : Normal

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Locally Status at Regio Back

Inspection :
Kyphotic posture, Redness -/-, Swelling -/-, gibbus -/-

Palpation :
Tender point + at paralumbar ~ L4 D/S
paralumbal muscle spasm +/+
Warmth -/- ; step off (-)
Knock pain (-)

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15
Chest expansion :
T2 : 3 cm
T4 : 3 cm
T6 : 3 cm
Count test : 24

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 Dermatome and Myotome
Dermatome Myotome Area Dermatome Myotome
D D S S
100% 4P L2 100% 4P
100% 5 L3 100% 5
100% 5 L4 100% 3P
100% 5 L5 100% 4
100% 5 S1 100% 5

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 Special Test Barthel index
Feeding = 10
 SLR test : +/+ Grooming =5
 Braggard test : +/+ Bathing =5
 Sicard test : +/+
Dressing = 10
 Thomas test : -/-
 Patrick test : -/- Bowels = 10

 Kontrapatrick test: -/- Bladder = 10

 Pelvic Rock test : -/- Toilet use = 10
 Ober test : -/-
Transfer = 15
 Ely’s test : -/-
Mobility = 15
 Valsava test :-
 Hamstring tightness : -/- Stairs =0
 Walk on heel : able Total  90
 Walk on toe : able
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Supporting Examination
MRI lumbosacral

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20
Degerative disease of the spine dengan gambaran:
 Spondylosis Thoracolumbalis
 Degenerative disc disease pada VL3-4
 Bulging disc yang menyebabkan slight indentasi anterior
thecal sac di level VL1-2, VL2-3, VL3-4, VL4-5

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 Problem List

R1 (Mobilization) Unable walk in a long distance

R2 (ADL) BI 90, unable to walk up the stairs
R3 (Communication) -
R4 (Psychology) Worried about her disease
R5 (Social Economy) -
R6 (Vocational) Unable to lift things and changing position frequently
R7 (Other) Low back pain with VAS 7-8
Kyphotic Posture
Overweight
Muscle weakness lower ekstremity S
Paralumbal Muscle Spasm + tender point D/S
SLR, Braggard, Sicard (+) D/S
MRI: Bulging disc in level VL1-2, VL2-3, VL3-4, VL4-5

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Clinical Diagnosis LBP ec HNP VL2-VL3, VL3-VL4, VL4-VL5

Functional Impairment Kyphotic posture

Diagnosis Paralumbal muscle spasm

Disability Difficulty in changing position because of pain

Unable to lift things and changing position
frequently
Handicap Unable to assist her husband to sell bakso
Unable to attend neighbouring ceremony in the
upper floor

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 ICF Diagnosis

Health Condition
LBP ec HNP VL2-VL3, VL3-VL4, VL4-VL5

Activities:
Participation:
Body Functions and Structures: d649: household tasks,
b530: weight maintenance function
d859: Work and
other specified and
(pre-obese) employment (Unable to lift
unspecified (difficulties in
b710: mobility of joint functions heavy object at farm)
changing positions)

External Factors: Personal Factors:

e135: products and Age
technology for employment History of previous strenous
activity

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Planning
1. Surgical : -
2. Medical : Continue medication from neurologic
outpatient clinic
3. Rehabilitation Medicine :
P. Dx :-
P. Tx :
Modality:
Laser 3J/cm² pada tender point 100% continous

Therapeutic Exercise (Physiotherapy): :

Mc Kenzie exercise
Posture correction

Orthosis : extended LS corset

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PMx:
 Clinical Findings
 MMT
 VAS
 BMI
PEx
 HE/HEP
 Explain the patient condition
 Proper back mechanic
 Icing when pain
 Continue the exercise at home

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Summary
Female 51 y.o, referred from Neurologic Outpatient Clinic with LBP ec
Degenerative disc disease.with Chief Complaint :Nyeri punggung bawah
Patient felt dull pain at lower back area, since 10 years ago, worsen
since 2 months ago. Pain radiated to right and left thigh and calf with VAS
7-8.The pain was aggravated by position changing from lying to sitting, from
sitting to standing, walking a long distance, walking upstairs, sitting in a
long time, forward bending the trunk, sneezing and coughing. The pain was
relieved when she was in lying position or taking medication.
From physical examination we found BMI 24,06 kg/m2, kyphotic posture,
paralumbal muscle spasm, weakness at ankle dorsiflexor S, and big toe
extensor.
We diagnosed with LBP ec. LBP ec HNP VL2-VL3, VL3-VL4, VL4-VL5.
Our therapy consist of Hi TENS at paralumbal area, intensity 100Hz, 20
minutes, continue medication from neurologic outpatient clinic, therapeutic
exercise, and use LS corset. We planned to monitor the clinical sign and
symptoms, VAS and MMT. We educate the patient about her disease, icing when
pain at tender area, proper back mechanic, continue exercise at home .
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TERIMA KASIH

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