What are your top three diagnoses based on the subjective information? (ranking order)

– Myofascial strain of posterior thoracic and lumbar musculature
– Local discogenic pain thoracic, lumbar or cervical
– Dural/neural irritability in thoracolumbar region

What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)

– myofascial strain of thoracolumbar region with potential clinical instability of lumbar spine. The patient has inconsistent pain symptoms at this time that would be consistent with discogenic or facet related pain. The reason I think it is more myofascial pain is because the patient has pain in multiple directions, increased hypertonicity/guarding, improves with posture change, active hip extension is painful but not passively, tender to palpate soft tissue, deep ache, limited trunk movement with movement. I think there might be an underlying clinical instability based on hypermobile and painful lumbar segments but would probably be hard to tell at this point.

3. What subjective and objective information do you feel is missing and would have been helpful to assess with this patient?

– Any imaging? If so what kind.
– Fabq ?
– who gave her the lifting restriction?
– cranial nerves
– upper cervical ligamentous stability
– lower cervical pavim or PA’s
-rib spring
-what is her current stress level and stress level at work or home
-prone instability test
-scapular mobility / strength
-lumbar or thoracic resistive testing

How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?

– I would say something along the lines of: you have had a couple of traumatic events within a short amount of time, and it is normal to have pain afterwards, based on my exam there doesn’t seem to be anything too concerning with red flag symptoms and that your back is strong, at this point your muscles are very irritable, which is normal after an injury as they try to protect the area, but now the muscles are still very tight and get irritated when they are stretched like when your bend forward to tie shoes or slouch.
– I might have concerns with emotions and fear and how that might limit progress. However, if everything for red flag is negative, then I wouldn’t have any major concerns.

5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc.

– I would focus on decreasing her pain levels with either light movement through both lumbar and thoracic regions (cat/camel or child’s pose), and add manual massage or light mobilizations to calm the system down. Gradually progressing towards her work/home related goals