Mid and low back pain

This 37-year-old pleasant female presents today for initial evaluation regarding chronic pain she started experiencing in her lower back since September 2014. The patient states that at that time she was pregnant when she fell down some concrete stairs. The patient had two months of physical therapy with only temporary relief of symptomatology. The patient is currently five weeks pregnant at this time and she had a recent fall two days ago in which she fell down the stairs at her home. The patient states that she has been sore with increase in symptomatology from previous fall and presents to our facility for evaluation and treatment recommendations. The patient denies sustaining another injuries, trauma, or recent motor vehicle accidents. The patient describes her mid and low back complaints as a constant, throbbing, achy, pressure, stabbing pain at times with occasional numbness in her mid back on the left side which is not radiating into her lower extremities. She currently places her levels of pain at a 7/10 on the VAS scale.

ASSESSMENT:
1. Thoracolumbar muscle spasm.
2. Thoracic joint dysfunction.
3. Lumbar joint dysfunction and paresthesia, thoracic spine, left.

PLAN:
Goals of Treatment:
Short-term goals: (1-8 wks)
1. Decrease pain and inflammation in the mid and low back from constant levels of pain to intermittent levels of pain.
2. Decrease Ms spasm and myofascial hypertonicity focusing on thoracolumbar paraspinals and quadratus lumborum.
3. Decrease tingling sensation of the mid thoracic spine on the left.
4. Improve posture and body mechanics.
Long-term goals: (8-12 wks)
1. Progress into Stabilization and strengthening of core muscle groups as tolerated.
2. Teach Home exercise program and patient to become independent with use.
3. Return to previous level of functioning and maximize function.

Treatment Plan:
1. Recommend physical medicine and rehabilitation therapy directed at the thoracolumbar spine.
2. Include passive modalities of manual therapy and intersegmental spinal traction.
3. Include active rehabilitation and therapeutic exercises and activities progressing into corrective phase once tolerated.
4. Maintain pregnancy precautions.
5. Follow up in four weeks or sooner if change or worsening in condition as needed.

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