Abstract

Low Back Pain (LBP) is a common complaint in Bangladesh and has many possible causes. Multiple Physical therapy interventions, including electrotherapy, traction, and lumbar stabilization exercises such as bridging and planking variations, have been shown to be very effective in reducing LBP. The purpose of this case study is to examine the Impact of Manual Physiotherapy Technics with Ultra Sound Therapy on Treatment of Chronic PLID Patient.

Case description: The patient was a 43-year-old male, who had been experiencing LBP for the past 3 year. He reported falling off a truck and landing with his hand tucked into the small of his back. The patient was very limited in activities of daily living, and was reliant on pain medication to function day-to-day. Initial physical therapy examination showed significant limitations in trunk and hip strength and Range of Motion (ROM) with severe pain on lower back. During the first few visits, the patient was unable to perform strengthening or ROM exercises effectively due to extreme levels of pain. Following application of Ultra Sound Therapy, an electrotherapeutic modality, the patient was able to actively participate in Manual therapy sessions, which included lumbar stabilization exercises, Lumber ROM Exercises, facet joint Mobilizations and Muscle Strengthening Exercises. By the end of the patient’s therapy sessions, he demonstrated normal strength in the majority of hip/trunk muscles, complained no pain in his lower back as well as full ROM in all formerly tested motions.

Discussion: It is likely that the patient’s recovery was not due to Physiotherapy application alone, but was multifactorial in nature. This case study has demonstrated that regardless of Physiotherapy’s impact on actual patient recovery, it is an effective means of reducing pain to help lead to better participation in therapeutic exercise.

Keywords: Physiotherapy; Manual therapy; Low back pain; PLID; Ultra sound therapy.

Citation: Das B, Jhumur SA. Impact of manual physiotherapy technics with ultra sound therapy on treatment of chronic PLID patient: A clinical case study of Ashulia Women and Children Hospital. J Clin Images Med Case Rep. 2024; 5(10): 3289.

Introduction

Background: Low Back Pain (LBP) is a very common complaint in the country, as it is the second most common reason people see a physician. According to Mayo Clinic, LBP may present itself in many different ways, such as muscle aching, radiating pain from the back to the legs, and decreased Range of Motion (ROM) [1]. LBP has a variety of causes, such as improper posture, improper biomechanics, falls, and overuse-such as lifting too much weight. Low back pain can happen to anybody, but those that are obese and/or sedentary tend to be at a higher risk. Possible treatments for LBP include medications, steroid injections, education, physical therapy, or surgery. Surgery is typically used as a last resort, since it can be very expensive, and may lead to greater complications. Physical therapy is an often-used conservative treatment option to treat various low back diagnoses. Various interventions include traction, electrotherapy, and therapeutic exercise, which may include lumbar stabilization exercises. It is very important to be aware of the research behind these various interventions, as well as whether they are cost-effective relative to surgical intervention. Yoon, Lee and Kim set out to examine the effects of Swiss ball lumbar stabilization exercises on pain levels of their subjects’ lower backs. The study took place over a course of 16 weeks, and they had a total of 36 patients, all of which had a diagnosis of chronic low back pain. They were split into three groups: conservative treatment, floor exercise, and Swiss ball exercise groups. Pain was measured regularly 1 using the Visual Analog Scale (VAS). Three times per week, the conservative group received different modalities such as electrical stimulation or heat. The floor group performed lumbar stabilization exercises on the floor, and the Swiss ball group performed lumbar stabilization exercises on a Swiss ball. Results came to show that stabilization exercises on a Swiss ball led to significantly lower pain on the VAS [2]. Schellenberg et al performed a study to determine the mean prone and supine bridging times in patients with and without low back pain, as well as determine the muscles that activated the most during these maneuvers. They were interested in determining whether these mean bridging times were a valuable diagnostic and progression tool. Results came to show that the primary muscles involved in supine bridging were the rectus abdominis and the external oblique. The primary muscles involved in prone bridging were the erector spinae and hamstrings. Mean bridging times were significantly different between the symptomatic and asymptomatic groups [3]. It can be concluded from this research article that bridging times are a valuable diagnostic tool. They are also potential stabilization exercises that can be incorporated into therapeutic exercise regimens for low back patients. There are many electrotherapeutic modalities available for pain relief. The one of particular interest in this study is the H-wave Instrument, which is manufactured by Electronic Waveform Labs (EWL). The company explains that TENS utilizes a squared off waveform to exert its effects, and IFC uses a sinusoidal waveform. The difference between these modalities and H-wave, is that H-wave emulates Hoffman’s Reflex, also known as the fmger flexor reflex. EWL claims that emulating Hoffman’s Reflex allows the H-wave device to penetrate deeper into tissues [2]. Representatives from EWL explained that there are two functional uses for H wave. Using low-frequency stimulation is beneficia!. For causing muscle contractions, which in turn leads to fluid shifts, and can reduce edema/swelling. In concontrast, high frequency stimulation is beneficia! For pain control A meta-analysis was performed by to determine the safety and efficacy of UST use on patients with chronic pain conditions. They found that the use of UST significantly reduced pain levels, reduced the usage of pain medications, and led to increased functionality in patients with various chronic pain conditions. There were no indications that UST could lead to unwanted side effects. It was also suggested that the use of UST can lead to a faster return to work and other activites [4]. Another study performed by Blum et al set out to determine whether repeated UST stimulation could have a positive effect on shoulder range of motion, following rotator cuff reconstruction. Patients received 1 hour of UST stimulation, 2 times per day for 90 days. Measures taken at 45 and 90 showed a significant improvement in shoulder ROM when compared to stimulation with a placebo device [5]. These findings suggest that the UST would have use in improving the range of motion in a variety of conditions not related to the shoulder. The purpose of this case study is to examine the effectiveness of lumbar stabilization exercise and electrotherapy, specifically UST effect in improving functional outcomes in a low back pain patient.

Study site: Ashulia Women and Children Hospital, which is a specialized general hospital with a fully equipped Physiotherapy Department and a team of Physiotherapy Professionals.

Case description

A 43-year-old male, came to therapy for the first time with a physician’s referral to evaluate and treat his complaint of chronic low back pain. The patient was experiencing pain in his low back that began about a year ago, and had been gradually worsening. He had fallen off a semi-truck, which he was working on, landing on his back with his hand tucked into the small of his back, which broke his hand and initiated his back pain. X -rays did not reveal any unusual findings the patient lived alone in a single bedroom apartment, on the ground level. He was unable to work due to his back pain, and reported feeling so hopeless that he didn’t feel like going out to socialize with his friends. The only thing that he was able to do was lie in bed for the majority of the day, and even that did not make it better. The patient reported having no other significant orthopedic issues, but had a history of hypertension, anxiety, and depression. He did not drink alcohol regularly, and had never smoked. The only surgical procedure was removal of wisdom teeth. Prior to his injury, he reports that he was independent in all ADLs, and was very active in work and exercise-related activities. He was limited in his tolerance to being in an upright position. He had extreme difficulty with the following tasks: moving sit to/from stand, getting inlout of a car, moving around in his bed, and cleaning his apartment. He also had difficulty with ascending/descending stairs, driving his car for any 4 longer than 30 minutes, bending over to pick up objects, and walking for any longer than 10-12 minutes. He had been using hydrocodone to reduce his pain-related symptoms. At best, his pain level was a 4/l 0 on the Visual Analogue Scale (VAS). He was experiencing a 6/l 0 at the time of evaluation, and 10/10 when the pain was at its worst. Everything made his pain worse, and could not think of anything that could relieve his symptoms, other than the pain medication that he had recently started. He denied any radiating symptoms. Observation, Examination, and Evaluation In the seated position, the patient presented with a posterior sway. In standing, posture showed increased lumbar lordosis, and a slight forward head. There was a moderate loss of cadence, and very limited motion at the hips during ambulation. Facial grimacing occurred every couple steps With palpation, there was increased tightness in the bilateral lumbar paraspinals, gluteals, and latissimus dorsi. Patient was tender to the touch-with moderate pressure, from approximately Tl O-S 1, bilateral lumbar paraspinals, Posterior-Superior Iliac Spines (PSISs), gluteals, and latissimus dorsi.

Table 1: MMT: All tested in seated position.