INTI INTERNATIONAL UNIVERSITY

Faculty of Health and Life Sciences

Department of Physiotherapy

 Musculoskeletal Physiotherapy 2
Course Assignment

NAME: Aliya Asyiqin Binti Anuarudin IC/ I19016823

ID#:
SEM #: 6

1. Other relevant subjective & objective examinations you would perform

relevant to this condition.

Subjective Assessment
Medical history: Ask regarding any drug taken currently. Any other medical condition.
Social history: Ask regarding his activities. Does the activities can any way effect his current
condition.
Environmental history: Ask regarding living situation, any stairs in the house. Sleeping
arrangement is it comfortable.
Pain assessment: - Relieving factors: Any movement or position that lessen the pain?
Aggravating factor: What sort of movement make the pain worse or what position does the
pain increases.
24 hour behavior: What time of day does the pain worsen
Functional Assessment questionnaire: Use of Oswestry Disabilty Index
The Oswestry Index (above) is given to the patient as follows. Patient to choose what he feels
most. In this index, the score is: A=0, B=1, C=2, D=3, E=4, F=5
Calculation is as follows: (total score)/50 100%= score (in percentage)

Score interpretation is as follows:

0%-20%: Minimal disability. Still can cope with ADL
21%-40%: Moderate disability. More pain in lifting, sitting, and standing. Other ADLs are
still achievable
41%-60%: Severe. Pain is the most pressing issue, but ADLs are affected.
61%-80%: Crippled. Back pain affects all aspects of the patient’s life.
81%-100%: Bed-bound or exaggerating symptoms

Objective Assessment:

General Observation: Take note on patient built (Ectomorph, Mesomorph, Endomorph)

Observe posture: Symmetry, resting position of head on neck,Forward Head Posture (FHP),
Increase/Decrease in thoracic kyphosis
Observe gait: Start from when he enters the examination room and/or ask the patient to walk
around the room

Local Observation: Observe on pain point at lower back. Check for swelling, skin condition,
any scar present and/or any alteration of shape

Palpation: Palpate the spinous processes at the lumbar region and the connecting paraspinal
muscles. Tenderness should be found above the slip at L5, judging from the x-ray. If it
produces radicular pain, it can be confirmed as lumbar spondylolisthesis. Also palpate for any
warmth present on the lower back.
 
Sensory and motor testing: Test on both sides lower limb to compare affected and non-
affected side. Dermatome testing, using sharp or blunt sensation using a pin and are done at
areas: medial malleolus (L4), dorsum of foot at the third metatarsal (L5), lateral heel at the
calcaneus (S1) and medial popliteal fossa (S2). 

Myotome testing: testing of different movements with moderate resistance in these areas.
ankle dorsiflexion (L4), big toe extension (L5), ankle plantarflexion (S1), and ankle
plantarflexion with knee flexion (S2). These nerves are chosen to single out the level of
injury.
 
Muscle strength: Manual muscle testing on lumbar movements (flexion, extension, lateral
flexion, rotation) to check for any presence of muscle disuse and to evaluate if there are any
additional issues pertaining to the lumbar spondylolisthesis condition.
 
Special Test:

Stork test –Patient in standing position. Therapist position behind the patient and palpate at
the PSIS. The therapist keep thumb on the left/right PSIS and palpate S2 with therapist
left/right hand. Ask the patient to flex the left/right hip to 90 degrees. If normal, the PSIS of
the left/right should move downwards, past S2. Positive of sacroiliac injury if PSIS only
moves minimally or not at all.

Schober test – Patient in standing position. Therapist position behind the patient and mark the
l5 spinous process by drawing a horizontal line at the patient back. Draw a second horizontal
line 10cm above the first line. Patient then flex forward with attempting to touch the toes. The
therapist is to measure the distance between the 2 lines when patient is fully flexed. The
measurement difference between erect and flexion position is the outcome of lumbar flexion.
A positive Schober test is the outcome is less than 5cm increase in length with forward
flexion which indicate a decrease of lumbar spine ROM
Straight-Leg Raises test – Patient in supine lying. Therapists support the patient leg and
slowly elevated the leg with knee in full extension. If presence of sciatica or nerve root
irritation, patient will feel shooting pain radiating down the posterior thigh. If SLR is at 80-90
degree hip flexion indicate of hamstring tightness
Other test can also be done such as femoral nerve stretch test to indicate nerve root
compression of L2,L3 or L4. Slump test is to indicate sciatic nerve root tension same as SLR
test and Lesague test.
2. Differential Diagnosis with rationale
 

Based on the case study, the patient x-ray result shows he has pars articularis defect at the L5
level with a grade one spondylolisthesis of L5 on S1. The x-ray confirm the patient condition
but base on the complaint, history, and objective assessment that has been done other
diagnosis is also possible such as:-

Lumbar Spondylolysis

Lumbar spondylolysis we would see the patient having antalgic gait during observation.
Hamstring tightness and lumbar musculature can also be found during assessment. There
would also be sign of buttock and/or thigh pain. Lower back stiffness is also one of the
symptoms of spondylolysis which the patient might have after an injury.

However, the patient has a flattened lumbar spine with no complaints of thigh pain. During
palpation if pain and tenderness is present this would likely not apply towards spondylolysis
as it is not the finding for spondylolysis condition. Another aspect to consider regarding
spondylosis is the patient age, as spondylosis is usually due to degenerative wear and tear in
the older population.
 
 
Intervertebral Disc Prolapse (IVDP)

Intervertebral discs prolapse (IVDP) can occur due to repetitive motion of the spine, lifting
heavy lifting and being overweight. During assessment for IVDP, sign of tingling or
numbness at the leg or feet is present. Another symptom would include muscle weakness of
the lower limb and back pain.

The patient sports and injury can indicate towards IVDP but the patient does not show any
symptoms of a tingling sensation during a test and base on the x-ray finding itself it shows no
prolapse.
 
 
 
 
3.Select an evidence Based Physiotherapy Management with rationale
appropriate for this condition.
 
Pain Management

Therapeutic modalities such as TENS, Thermotherapy and Ultrasound could be used for
reducing pain.

The use of TENS help relief pain via exciting sensory nerve via Pain Gate Mechanism. The
use of Conventional TENS ( High intensity approach ) is ti activate large diameter non-
notious afferent to elicit segmental analgesia. The duration of stimulation is set at 30 min.
This is base on the study of Vance CG (2014)

Thermotherapy (the use of heat) for this management help reduce pain by increasing the
skin/soft tissue temperature with vasodilation. It also increases the metabolic rate, increases
oxygen uptake, and accelerates tissue healing.

Ultrasound is also a modalities that use thermal effect to reduce pain and improve healing
process base of a study from Noori et al. (2019).

Exercise Regime

The rehabilitation program of Watkin’s is a five-level program that gradually increases in

endurance, proprioception and strength demands on each level given. This program focus
base on athlete development and progress towards return to sport.

The exercise program starts in a neutral pain-free position with isometric exercises that train
the core muscles to protect the spine and specific stretching exercises for the legs and hips.
The focus is on neutral spine technique to reduce mechanical stress from the bony and
muscular structures in the lumbar spine. The 2nd level, is low impact exercise, level 3 begin
incorporating sports-specific exercises running, throwing and so on. On level 4 is before
returning to sports-specific exercises that involve significant force and extremes of motion
and lastly level 5 is profession athlete condonation exercises.
Exercise table

Patient Education

Proper posture correction and proper lifting techniques plays an important role to prevent
back pain injury as it helps reduce mechanical loading on the spine.

The use of bracing to help support the lumbar loading and maintain proper posture can reduce
pain by maintaining the spine from shifting

Advice on reducing hyperextension spine mobility movement

4.How would you evaluate your treatment outcome? (should be evidence
based).
Pain measures: Short-Form McGill pain questionnaire which include 1. A visual analogue pain scale
(VAS) , 2. A pain descriptor scale and 3. A pain body chart. It is to assess both intensity and quality of
pain.

The Pain Rating Index can be scored in several ways:

 Pain Rating Index - rank value
 0 = no pain
 1 = mild
 2 = discomforting
 3 = distressing
 4 = horrible
 5 = excruciating
 VAS - The pain intensity of each pain descriptor was assessed on a numeric scale in previous
research (Shafshak & Elnemr, 2021). The assigned rating can also be accepted as the score
for the pain descriptor.
 "Number of words chosen (NWC)": The number of words chosen by the patient. The higher
the total score on the MPQ, the more the pain experience for the patient increases.

Functional measures: Oswestry Disability Index, index has been found across multiple
studies that the author has come across (Vanti C. 2017), Ferrari(2016), Ferrari(2018)), and is
seen to show effective psychometric properties, as well as applicable in a variety of settings.
The procedure of ODI has been covered in the above question, hence should also be included
as one of outcome measures at the end of the treatment.
References:
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the sacroiliac joint: a systematic review of the literature. The Journal of the Canadian
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2. Lumbosacral Spondylolisthesis: Practice Essentials, Background, Etiology. (2020).
Retrieved 22 April 2021, from https://emedicine.medscape.com/article/2179163-
overview
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