Hscoem Case Studies

This is a 42-year-old female with a 2/7/2015 date of injury. A specific mechanism of injury has not been described.

DIAGNOSIS: low back pain; Lumbago with sciatica right side; Myalgia

12/01/15 follow-up visit identified lower back pain. Patient rates the pain as 7/10. The pain is characterized as burning. It radiates to the neck and upper back. Condition is associated with back pain and difficulty in ambulation. It is aggravated by bending over, lifting, prolonged sitting, prolonged standing and prolonged walking. Application of cold, application of heat, bending forward, medications and rest, relieve the pain. Medication side effects include nausea and vomiting. Patient’s primary care doctor stopped her oral medication due to nausea and vomiting; and her liver function tests were elevated. She does not know names, but the sleep aid and the oral medication for pain during the day were stopped. She tolerates the medications well. Patient shows no evidence of developing medication dependency. Patient does not feel the current medication she is taking adequately addressing her pain needs and would like to try a different medication. The level of sleep for the patient has decreased due to difficulty in failing asleep and due to

General Approaches: ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 3 supports an initial course of physical therapy with objective functional deficits and functional goals. Per ODG, physical therapy indications for lumbago, backache unspecified are 9 visits over 8 weeks. The patient has tried other conservative treatments and continues with low back pain and some radicular symptoms. The requesting provider indicated that this is a mechanical axial low back pain and the patient is not a surgical candidate at this time. The provider requested 8 sessions of PT, which are supported by the guidelines. Physical therapy of the lumbar spine could help to provide additional pain relief. Recommend