HERNIATED DISC

• Condition during which a nucleus pulposus is displaced from

intervertebral space and is a common cause of back pain.
• Herniated disc first symptoms often are initiated with inciting event that
caused their pain often described as burning or stinging, and may
radiate into the lower extremity
• In severe cases, there can be an associated weakness or sensation
changes.
• Can compress the nerve or the spinal cord causing pain consistent
with nerve compression or spinal cord dysfunction

ANATOMY
Vertebral Column
- Axial Skeleton that supports the skull,
pectoral girdle, upper limbs, and
thoracic cage and, by way of the pelvic
girdle
- Transmits body weight to the lower
limbs.
- Protects the spinal cord & other neural
structure within
- Vertebra column has 33 vertebrae with
5 segments:
o 7 Cervical
o 12 thoracic
o 5 lumbar
o 5 sacral (fused sacrum)
o 4 coccygeal (the lower 3 are
commonly fused)
- The characteristics of Typical vertebra:

o Body – rounded and found

anteriorly
o Vertebral foramen – where spinal
cord run
o Pedicles - connects the lamina to
the vertebral body to form the vertebral
arch
o Laminae - flattened or arched part
of the vertebral arch, forming the roof of
the spinal canal
o Vertebral Arch - A circle of bone
around the canal through which the spinal
cord passes
• spinous process (1)
• Transverse process (2)
• Articular processes (4)

Intervertebral discs
- flexible fibrocartilage between two
adjacent vertebrae bodies.
- form about one-fourth the length of
the column → Shock absorbers
- thickest in the cervical and lumbar
region → greatest amount of
movements
- the vertebral body surfaces are covered with thin plates of hyaline
cartilage → Endplates
- with facet joints form the ‘functional unit of Junghans’
- Parts of the IVD:
o Anulus fibrosus - peripheral part composed of fibrocartilage and
strongly attached to the vertebral bodies and the anterior and
posterior longitudinal ligaments of the vertebral column
- composed of type I collagen, water, and proteoglycans
- characterized by extensibility and tensile strength high
collagen / low proteoglycan ratio (low % dry weight of
proteoglycans)
o Nucleus pulposus - ovoid mass of gelatinous material.
- composed of type II collagen, water, and proteoglycans
- characterized by compressibility
• low collagen / high proteoglycan ratio → retain water
• hydrated gel due to high polysacharide content and
high water content (88%)
➔ The largest avascular, anural and alymphatic organ in the body
➔ Situated slightly nearer to the posterior area
Nerve Root Anatomy
• Key difference between cervical and lumbar spine is
o pedicle/nerve root mismatch
▪ cervical spine C6 nerve root travels under C5 pedicle
(mismatch)
▪ lumbar spine L5 nerve root travels under L5 pedicle (match)
▪ extra C8 nerve root (no C8 pedicle) allows transition
o horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
▪ because of vertical anatomy of lumbar nerve root a
paracentral and foraminal disc will affect different nerve roots
▪ because of horizontal anatomy of cervical nerve root a
central and foraminal disc will affect the same nerve root

Myotomes & Dermatome

• L2: hip flexion
• L3: knee extension
• L4: ankle dorsiflexion
• L5: big toe extension
• S1: ankle plantarflexion
• S4: bladder and rectum motor supply

L1: the inguinal region and the very top of the medial
thigh.
L2: the middle and lateral aspect of the anterior thigh.
L3: the medial epicondyle of the femur.
L4: the medial malleolus.
L5: the dorsum of the foot at the third
metatarsophalangeal joint.
S1: the lateral aspect of the calcaneus.
S2: at the midpoint of the popliteal fossa.
S3: at the horizontal gluteal crease (the horizontal crease
formed by the inferior aspect of the buttocks and the
posterior upper thigh).
S4/5: the perianal area.
ETIOLOGY
• Disc herniation occurs when part or all the nucleus pulposus protrudes
through the annulus fibrous.
• The damage to the annulus of the disc appears to be associated with fully
flexing the spine for a repeated or prolonged period of time → Slouch
Posture
• Causes
➢ Most common cause of disc herniation the degenerative process
➢ The second most common cause of disc herniation is trauma →
Repetitive mechanical activities like twisting, bending, without breaks
➢ connective tissue disorders and congenital disorders such as short
pedicles.
• Risk Factors:
o Men (30’s – 40’s)
o Obesity with BMI > 30
o DM et hyperlipidemia
o Smokers
o Driving for long hours
o Physically Demanding work: manual labor or prolonged sitting with
bending et twisting motion or with vibration exposure
o Acute Trauma
o Poor Posture
o Mobility:
▪ Lumbar most common → 90% at L4-L4 and L5-S1
▪ Cervical → 60% at C6 – C7
▪ Thoracic → least common

PATHOPHYSIOLOGY
• Physiologic Changes
o Aging affects degenerations of proteoglycans in the Nucleus
Pulposus → affects the function of being Shock Absorber
o Elderly has lesser proteoglycans in the NP, thus making Nucleus
Pulposus unable to push out to the AF
• Biomechanics of loading forces
o Forces acting on the disc produced by loading: Vertical Compression,
Torsion, Bending
o Repetitive loads (Mechanical forces) along with the degenerative
cascade, over years → gradual breakdown of annular fibers with
Nucleus Pulposus pushes out
- The changes consist of nuclear degeneration, nuclear displacement and
stage of fibrosis.
Types of Herniations
• Posterolateral Disc Herniation –
(70%) Protrusion is usually
posterolateral into vertebral canal.
Protruded disc usually compresses
next lower nerve as the nerve
crosses the level of disc in its path to
its foramen.
• Central Herniation - It is less
frequent. A protruded disc above
2nd vertebra may compress the
spinal cord itself or may lead
to Cauda Equina Syndrome.
• Lateral Disc Herniation - Nerve root
compression happens above the
level of herniation. L4 nerve root is
most often involved.
Stages of Herniation

• Bulging: extension of the disc margin beyond the margins of the

adjacent vertebral endplates
• Protrusion: the posterior longitudinal ligament remains intact but the
nucleus pulposus impinges on the anulus fibrosus
• Extrusion: the nuclear material emerges through the annular fibers but
the posterior longitudinal ligament remains intact
• Sequestration: the nuclear material emerges through the annular fibers
and the posterior longitudinal ligament is disrupted. A portion of the
nucleus pulposus has protruded into the epidural space

History and Examination

Lumbar Spine
History
- can present with symptoms including sensory and motor abnormalities
limited to specific myotome.
Physical Examination
- sensory loss, weakness, pain location and reflex loss associated with the
different level are described below
Typical findings of solitary nerve lesion due to compression by herniated disc in
lumbar spine
• L1 Nerve - pain and sensory loss are common in the inguinal region.
Hip flexion weakness is rare.
• L2-L3-L4 Nerves - back pain radiating into the anterior thigh and medial
lower leg; sensory loss to the anterior thigh and sometimes medial lower
leg; hip flexion and adduction weakness, knee extension weakness;
decreased patellar reflex.
 • L5 Nerve - back, radiating into buttock, lateral thigh, lateral calf and
dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the
foot, web space between first and second toe; weakness on hip
abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot
inversion and eversion
• S1 Nerve - back, radiating into buttock, lateral or posterior thigh,
posterior calf, lateral or plantar foot; sensory loss on posterior calf,
lateral or plantar aspect of foot; weakness on hip extension, knee
flexion, plantar flexion of the foot; Achilles tendon; Medial buttock,
perineal, and perianal region; weakness may be minimal, with urinary
and fecal incontinence as well as sexual dysfunction.
• S2-S4 Nerves - sacral or buttock pain radiating into the posterior aspect
of the leg or the perineum; sensory deficit on the medial buttock,
perineal, and perianal region
Special test
1. Straight leg raise test
2. contralateral (crossed) straight leg raise test
3. Bowstring test
4. Prone knee Bending
5. Hyperextension Test

Signs & Symptoms

• Severe low back pain, radiating pain.
• Walking can be painful and difficult.
• Muscle spasm, tingling sensation, weakness or atrophy.
• loss of bladder or bowel control.
• Some people may be asymptomatic.
• Slow and deliberate, tip-toe walking.
• Spine, trunk deviation.
• Antalgic or Trendelenburg gait.
• Paraspinal muscle spasm.

Differential Diagnosis
Spondylolysis
Spondylolisthesis
Cauda equina syndrome
Muscle spasm
Mechanical pain
Myofascial pain
Spinal Cause Extraspinal causes peripheral vascular
Trauma Dse
osteomyelitis Gynacological condition
arachnoiditis, ankylosing spondylitis OA hip
Neoplasm sacroiliac joint Dse
peipheral nerve lesions
 Imaging
o X-rays → check for structural integrity for underlying probable structure
pathogenesis Narrowed disc space, loss of lumbar lordosis,
complementary scoliosis
o CT Scan → visualize bony structures in the spine that
shows calcification.
o MRI: → visualize herniated disc and totally can identify Disc protrusion
and nerve root compression

Medical Management
Non-surgical treatments: Pharmacologic Management
• NSAIDs
• Oral steroids like prednisone, methyl prednisone.
• Benzodiazepines of low dose.
• Translaminar epidural injections and selective nerve root blocks are the
second
Surgical Treatment - last resort.
• Laminectomies with discectomies, microdisectomies depending on the
cervical or lumbar area.
• Anterior cervical decompression and fusion.
• Artificial disks replacement.
• Other alternative surgical approaches to the lumbar spine include a lateral
or anterior approach that requires complete discectomy and fusion.[2]
• Intradiscal electrothermic therapy
• Nucleoplasty
• Chemonucleolysis
• Disc arthroplasty
 Initial Evaluation
July 7, 2021

This is the case John Doe a 35 y/o, male, pt from Molo, Iloilo City who was
referred for PTR 2° R Herniated Nucleus Pulposus at L5 - S1

/S/:
C/C: Pt. c/o intermittent radiating “alay” pain on R lower back to post R
thigh Gr.8/10 on PS (0 = no pain, 5 = Moderate pain, 10 = Worst pain);
aggravated at am et by prolonged sitting, trunk/hip bending, carrying heavy
loads, et prolonged walking; pain ↑ to 10/10 on PS et extends to post lat aspect
of R calf c “palamdamul” sensation on lat aspect of palmar R foot during
prolonged sitting for > 30 min; relieved by rest, stretching of legs et application of
salon pass et efficascent oil on area.
HPI: Present condition started a few months ago (unrecalled date) with
intermittent pain on R Lower back which the pt ignored due to work; Doesn’t
recall any trauma.
3 mos ago, Pt felt pain Gr. 10/10 radiating to post R thigh p carrying a
heavy load; Sx kept worsening c pain extending to post R calf c numbness on lat
aspect of palmar R foot during his driving duty; decided to temporarily stop
working fearing an accident can happen due to condition.
July 6, 2021, Pt went to visited IDH ER where he was given Tromadol for
pain of R Lower Back et was referred to Ortho department. At Ortho department,
unrecalled MD. Pt. underwent PE c Xray et MRI, results showing Herniated
Nucleus Pulposus at L5 - S1, et referred to PTR.
Past Medical Hx:
Condition Date Hospital
None

Family Medical Hx:

Condition Maternal Paternal Patient
HTN (+) (+) (+)
DM (+) (+) (+)

Food and drugs allergies: Pt. doesn’t have any allergies

Personal/Social Hx:
• Family situation: Pt lives c wife, 2 children, mother et 3 maids
• Social support: Pt. doesn’t have cultural et religious belief that may affect PT
treatment
• Home situation: Live in a 2 floored-home c ~ 20 step stairs;
Bedroom is located at the 2nd floor:
Pt Room Distance
→Main Door 50 steps
→ Dining Room 40 steps
→ upstairs Living Room 15 steps
→ Main Living Room 40 steps
• Psychological Hx
Pt is very motivated to get better, get rid of his pain et has willingness to
undergo treatment
• Lifestyle
Pt spends most of his time working but plays basketball et goes to cockpit
fight in his spare time; occasionally drink alcohol c friends
• Diet
(+) coffee drinker 3-4 cup in a day
(+) energy drink 2 bottles during work
(+) alcohol drinker
(+) Cigarette smoker of 1 pack/day

Vocational Hx:
• Educational attainment: Not assessed
• Work/Vocation Hx: Pt is a truck Driver c inconsistent driving hours Routine; Pt
usually starts driving at 12mn c driving route Iloilo to Manila et vice-versa.
Driving schedule depends on RoRos schedule c ~4 hrs continuously
driving duration but c breaks during RoRo ride or at stop overs; average of
sleep when working is 3-4 hrs but is not continuous
• Seat cushion in his truck is a bit soft. Pt’s is in a slouch position during
driving.
• Financial resources: Pt main source of income is from working as a truck driver

Ancillary Procedures:
Taken (When &
Procedure Results
Where)
(+) Herniated Nucleus Pulposus at L5 -
Xray July 6, 2021 | IDH
S1
(+) Herniated Nucleus Pulposus at L5 -
MRI July 6, 2021 | IDH
S1

Medications:
Medication (mode as
Dosage/Frequency Indication
necessary)
amiodarone 400mg qid Arrythmia
Losartan 50mg qid HTN
Metformin 500mg qid DM
Tramadol 100mg qid Pain relief
Vitamins qid Supplement

Goal: Pt goal is “madula ang sakit para makabalik gid ko sa work ngan
makapagbasketball man”
/O/:
OI:
(+) Endomorph
(+) Postural Deviation (see postural assessment)
(+) Gait Deviations (See gait Assessment)
(-) Atrophy on UE/LE et spine mm
(-) Swelling on UE/LE et spine mm
(-) Attachments

V/S:
a tx During tx p tx
BP (mmHg) 120/80 N/A 120/80
PR (bpm) 88 N/A 88
RR (cpm N/A N/A N/A
Oxygen saturation (%) 99 N/A 99
Sig: Pt has Normal and Stable VS

Palpation:
Normothermic on all exposed areas of Back et B LE
(+) Gr. 2 tenderness on R lower back
(+) Gr. 1 tenderness on R posterior buttocks and thigh
(+) mm spasm on R lower back/Buttocks/Thigh
(+) mm guarding on R lower back/Buttocks/Thigh
(+) tightness on R lower back/Buttocks/Thigh
(-) Skin Turgor on all exposed areas of B lower Back
(-) Skin Indentation on all exposed areas B Lower Back

Neurological Evaluation: (if pertinent)

Mental Status Examination:
Arousal: Pt is alert
Orientation: Pt is oriented x3 PPT
Attention: Not Assessed

Sensory Examination:
Legend: 0-absent
1- impaired sensation
2- normal sensation

Superficial sensation:
Light Touch
Area Tested L R
R lower Back 2 2
R Posterior Thigh 2 2
R Posterior Calf 2 2
 Pinprick
Area Tested L R
R lower Back 2 2
R Posterior Thigh 2 2
R Posterior Calf 2 2
Pressure:
Area Tested L R
R lower Back 2 2
R Posterior Thigh 2 2
R Posterior Calf 2 2

Deep: Not Assessed

Proprioception
Joint Tested L R

Kinesthesia: Not Assessed

Joint Tested L R

Cortical: Not Assessed

L R
UE LE UE LE
Graphesthesia
Stereognosis
Cranial Nerve Testing: Not Assessed
Cranial nerve Test Findings

Tone Assessment: Not Assessed

Legend: Modified Ashworth Scale
Muscle groups Grade

Reflex Assessment: Not Assessed

DTR: drawing
Legend:
0 Absent, no response
1+ Slight reflex, present but depressed, low normal
2+ Normal, typical reflex
3+ Brisk reflex, possibly but not necessarily abnormal
4+ Very brisk reflex, abnormal, clonus
 Superficial Cutaneous Reflex: Not Assessed
Superficial Reflex Response Findings

Coordination Assessment: Not Assessed

Non-equilibrium Test: Not Assessed
Legend:
4- Normal Performance
3- Minimal Impairment: Able to accomplish activity; slightly less
than normal control, speed, and steadiness
2- Moderate Impairment: Able to accomplish activity; movements
are slow, awkward, and unsteady
1- Severe Impairment: Able only to initiate activity without
completion; movements are slow with significant unsteadiness, oscillations
and/or extraneous movements
0- Activity Impossible
Coordination Test R L Comments

Equilibrium Test: Not Assessed

Legend:
4- Normal: Able to maintain steady balance without handhold
support (static)
Accepts maximal challenge and can shift weight easily within full
range in all directions (dynamic)
3- Good: Able to maintain balance without handhold support,
limited postural sway (static) Accepts moderate challenge; able to
maintain balance while picking object off floor (dynamic)
2- Fair: Able to maintain balance with handhold support; may
require occasional minimal assistance (static). Accepts minimal challenge;
able to maintain balance while turning head/trunk (dynamic)
1- Poor: Requires handhold support and moderate to maximal
assistance to maintain position (static). Unable to accept challenge or
move without loss of balance (dynamic)
0- Absent: Unable to maintain balance
Coordination Test R L Comments

Musculoskeletal Assessment:
Anthropometric Assessment: (if pertinent)
MBT: Not Assessed (Landmark:)
Area Tested L R Difference

LGM: Not Assessed (Landmark:)

Area Tested L R Difference
 LLD: Not Assessed
• True
L R Difference

• Apparent
L R Difference

• Segmental
Area L R Difference

ROM:
All major joints of the body are actively et passively assessed and found to
be WNL, pain-free and c N end-feel, Except:
Difference End-
Joint motion AROM PROM Normal
AROM PROM feel
R Hip Flexion c
0o – 100o 0o - 100o 0o - 120o 20o 20o Empty
Knee Flexed
R Hip Flexion C
0o - 30o 0o - 34o 0o - 90o 60o 56o Empty
Knee Extended
Sig: Pt has ↓ ROM 2° pain, mm spasm et mm guarding.
Accessory Joint Motions Assessment: Not Assessed
Legend:
0- ankylosed
1- considerable hypomobility
2- slight hypomobility
3- normal
4- slight hypermobility
5- considerable hypermobility
6- unstable
Joint Motion Grade

Sig:

MMT/FMT:
All major mm groups of (B) UE, LE, and Trunk are tested and graded 5/5,
Except:
Grade
Muscle Groups
R L
R Hip Flexion 4/5 5/5
R Knee Flexion 4/5 5/5
Sig: Pt. has ↓ mm strength 2° to pain et mm spasm
Muscle Test Grading:
Grade Value Movement
5 Normal (100%) Complete ROM against gravity c max.
resistance
4 Good (75%) Complete ROM against gravity c mod.
resistance
3+ Fair + Complete ROM against gravity c minimal
resistance
3 Fair Complete ROM against gravity no resistance
3- Fair - Some but not complete ROM against gravity
2+ Poor + Initiates motion against gravity
2 Poor Complete ROM c gravity eliminated
2- Poor - Initiates motion if gravity is eliminated
1 Trace Evidence of slight contractility but no joint
motion

Special Tests:
Test Patient’s Response Results
(+) radiating pain to Posterior
Straight Leg Leg et calf at 30° hip flexion c (+) radiculopathy
Raising Knee Extension

Sig: Pt has lumbar disc herniation at the L4-S1 nerve roots c radiculopathy

Postural Analysis:
Anterior Posterior Lateral
Not Assessed Head Leaning to L Not Assessed
R shoulder Higher than L
Lumbar Spine L R Curvature
L ASIS Higher than R
Knees are leveled
Sig: Pt has probable Scoliosis

Tolerance assessment:
Tolerance
Sitting P+
Standing N/A
Walking F
Sig: Pt. has ↓ sitting/walking tolerance 2° to pain et mm spasm, tightness

Legend:
P = < 15 minutes
P+ = 15 – 30 minutes
F = 30 - 45 minutes
G = > 1 hr
Gait Analysis: (RLA)
LEGEND: √ - Normal ↑ - Increase ↓ - Decrease (-) - Absent
STANCE (R) (L)
Initial Contact (-) ↓
Loading response √ √
Mid-Stance ↓ √
Terminal Stance (-) √
Pre-Swing (-) √
SWING
Initial Swing ↓ √
Mid Swing ↓ √
Terminal Swing ↓ √
Sig: Pt has gait deviations 2° to Pain, decreased mm strength, tightness et mm
guarding

BADL/IADL/Work/Sport and Recreational Assessment:

Activity Performance
Bed mobility Independent et c no difficulty
Moving in bed Independent et c min difficulty
Sitting up Independent et c min difficulty
Hygiene activities Independent et c no difficulty
Bathing Independent et c no difficulty
Combing hair Independent et c no difficulty
Eating activities
Using utensils Independent et c no difficulty
Managing glass and cup Independent et c no difficulty
Dressing activities
Independent et c max difficulty in putting on LE
Putting on clothes
clothes
Putting on socks and shoes Independent et c max difficulty
Transfer activities
Bed to chair Independent et c min difficulty
Getting into car Independent et c Min difficulty
Walking activities
Level surfaces Independent et c no difficulty
Unlevel surfaces Independent et c no difficulty
Sig: Pt has difficulty in ADL activities that involved bending trunk/hip 2° to Pain,
tightness et mm guarding

/A/:
PT Impression: Pt has functional difficulty in areas of bed Mobility,
dressing, transfer that involves bending of trunk/hip c ↓ tolerance sitting et
walking 2°to Pain, mm spasm et mm guarding on R lower Back to posterior
aspect of R thigh et calf, LOM et tightness of R Posterior thigh musculature, et ↓
mm strength on R hip flexors. Therefore, modalities like HMP, TENS, Traction et
US can be applied c exercise Stretching et Strengthening of B LE to ↓ pain, ↑
ROM et Strength of LE mm.

• Prognosis:
-Positive Factor
1 – Pt is motivated et willing to undergo treatment
2 – Pt is young & active
3 – Pt has a good support system
- Negative Factor
1 – Work environment et hours is not sustainable for good body mechanics
2 – Pt has comorbidities (HTN/DM)
3 – Pt lifestyle of smoking et alcohol intake

• Problem list:
1. Pain et tenderness on R Lower back to posterior R thigh
2. Difficulty in Putting on LE clothes, shoes et socks c trunk/hip bending
activities
3. ↓ Tolerance in prolonged sitting > 30 mins
4. Tightness et LOM of Posterior Thigh mm
5. Postural Deviations
6. Gait Deviations
7. Difficulty in Bed Mobility et transfers c trunk/hip bending activities
8. ↓ mm strength of Hip Flexors
9. ↓Tolerance in walking > 45 mins

LTG: Pt will be able to experience painfree full ROM on trunk et hip p 1 mo

PT rehab session to be able to tolerate prolonged sitting position for ~ 4
hrs when driving for work

STG:
1. Pt. will experience ↓ of pain on R lower back to Post R thigh from 8/10 to 4/10
on PS p 6 PT session to be able to tolerate prolonged sitting > 30min
2. Pt will demonstrate ↓ difficulty in donning/doffing of LE garments et
shoes/socks by being able to bend trunk/hip p ↓ pain and discomfort p 8 PT
session to be able to put on clothes c ease
3. Pt. will have ↑ sitting tolerance from < 30 mins → 45 min p 6 PT sessions to be
able to drive c ease et safety
4. Pt will attain ↑ ROM by 20° increment on R hip flexion c knee flexed et
extended p 6 PT session to do bed mobility activities c ease
5. Pt. will exhibit proper posture as manifested by shoulder/Hip level p 8 PT
session to be able to prevent further aggravation of condition
6. Pt will demonstrate proper gait cycle as manifested by presence of Initial
contact, Terminal Swing, pre-wing et ↑ of Swing phase on R p 8 PT session to be
able walk c ease
7. Pt. will demonstrate ↓ difficulty in Bed mobility et transfer as manifested by
ability to trunk/hip bend s pain p 6 PT session to be able to move around the
house c ease
8. Pt. will exhibit ↑ strength on Hip Flexors from 4/5 → 5/5 p 8 PT session to be
able to play basketball c ease
9. P. will exhibit ↑ tolerance of walking from 45 min → 1 hr p 8 PT session to be
able to play basketball c ease

/P:/
PTMx:
1. TENS c HMP on B Lower back to butt area x 20 minutes to  pain
2. Lumbar Traction x 25% BW x 7 SH c 7x 15 minutes to  mm spasm
3. US 1.5w/cm² on B lower back et R Butt et posterior thigh area x 5mins each
to ↑ jt extensibility
4. Mckenzie Extension Exercise to centralize et ↓ pain et ↓ tightness
a. Prone Lying x 3 min to ↓ Pain
b. Elbow Press x 10R x 2 set ↓ tightness
c. Press up x 10R x 2 set ↓ tightness
d. Curl Up x 6 SH x 5 Reps x 1 Set ↓ tightness
e. Backward Bending x 6 SH x 10 R x 1 Set ↓ tightness
5. Stretching of trunk/Hip in AP x 15 SH x 5 reps to  ROM
6. Core Exercises to ↑ core mm strength
a. Posterior Pelvic Tilts x 6 SH x 10 reps
b. Pelvic Bridging x 10 reps x 1 Set
7. Strengthening exercise on LE c 1kg Ankle wts on AP x 10 Reps x 3 sets to ↑
mm strength
8. Walking x 10 minutes to ↑ tolerance
HEP:
1. Pt education:
a. Proper Body Mechanics
1) Picking up objects, lifting et carrying heavy objects
2) Bed Mobility et Transfers
b. Proper Posture: Avoidance of slouched/flexed position
c. Importance of rest periods in between prolonged sitting/driving
d. Proper Diet and wight management
e. Risk Factors: Smoking, Alcohol et HTN/DM
f. Modification of work/home environment: Proper Seat cushion
2. Home Exercise:
a. Walking early in the morning
b. Stretching in UE/LE/Trunk X 15 SH x 3 Reps
c. McKenzie Extension (same exercise in clinic)

Claudia A . Reyes
RCI-PT Intern 2021