Abstract
A 46 year old male patient who was 5 weeks status post first time, single level microdiscectomy was seen for physical therapy treatment for 11 sessions over a 6 week period at an outpatient physical therapy clinic within a hospital under the supervision of a licensed physical therapist. The patient’s chief complaint was intermittent, right sided low back, buttocks, and burning leg pain. The patient was evaluated at the initial encounter with manual muscle testing, numeric pain rating scale, fear avoidance belief questionnaire, Oswestry disability index, patient specific functional scale, and back pain functional scale. Based on examination findings, a plan of care was established to address decreased active range of motion, strength, functional ability, and home and community participation. Main goals for the patient were decreasing pain and fear of movement, increasing lower extremity strength and range of motion, and increasing his functional ability to allow for increased participation in the home and out in the community. Primary interventions used were progressive and dynamic strength training, functional training, over ground walking, stretching, and education. He achieved true improvement in pain, range of motion, functional capabilities, home participation, and community participation as well as a meaningful improvement in fear avoidance. Although he improved, he did not achieve a true change in strength. He was discharged to home, independent with a home exercise program.