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Noorzeha   bint i   mohd   adkaa 2020897926

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Male, Malay patient with noted distended stomach came in walking independently with mild limping and misalignment of posture to the left side Patient is 38 years old, was referred for Physiotherapy when he was diagnosed by his physician as Chronic Low back pain Complaint of (c/o) nagging pain (NRS 6-7/10) at his low back, especially at the right side when in prolonged sitting. Pain will start and worsen after 20-30minutes of sitting. Pain elevates when he stands up and walk about Also c/o pain when playing golf, pain elevates when he walks but will aggravates when forward blending to swing Pt. also c/o pain significantly aggravated over the last 3 months He is a computer engineer, works at an office between 8-10hours per day, mainly sitting at his desk doing computer work No c/o radiating pain, mainly pain at his right lower back No c/o red flags symptoms  No past medical history including rehabilitation program history No serious spine-related conditions, previous falls, or  medical  issues  Took pain relief medication  Investigations (X-ray and MRI) found no spinal pathology and other abnormalities

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Observations Movement pattern : Patient able to walk independently, slightly limping with Rt. Lat. Pelvic tilt Posture (in standing) Structurally flat back without posterior pelvic tilting  (fig.1) Functional Test(s) Demonstration of pain provoking movement –  Sitting and forward bending  (fig.2) Squat Test –  Unable to hold position for more than 10secs and advance to progression position  (fig.3) Movement Testing AROM –  Able to perform AROM of all lumbar movement, pain at the end range of lumbar flexion and when getting up from flexion

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Physical Examination and Movement Impairments

Standing Forward bending Supine Hip and Knee flexion Bilateral hip and knee flexion Prone Lying Knee flexion 4 foot kneeling Rocking backwards Sitting   Spine in flexion Spine in extension Knee extension Increase symptoms when returning from bending Increase symptoms when done passively No noted increase in symptoms  No noted increase in symptoms No noted increase in symptoms

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Pain especially during prolonged static load and bending Weak abdominal and back extensor muscle and excessive anterior tilt Poor  hip flexors limiting pelvic stability Reduced trunk  endurance  Decrease postural control

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The Patient’s c/o non specific low back pain especially in prolonged sitting is due to lumbar flexion dysfunction syndrome Excessive anterior pelvic tilt is d/t weak abdominal muscle and  stabilizers Unable to perform and maintain squatting position d/t poor functioning  gluteas  and tight hamstrings

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To reduce pain and avoid pain provoking posture To improve trunk  endurance To restore movement control and correct movement  pattern To improve  posture To improve performance of ADLs ( Luomajoki  et al., 2018)

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Rest  Corrective Exercise program – Movement Control treatment High sitting and knee  extension Standing and forward bend Squat and with  progression ( Saner  et al., 2015) Abdominal hollowing (in standing and progression;  all fours, and then elevating one arm forwards and/or the contralateral leg backwards, or on standing upright and elevating one arm forwards and/or bringing the contralateral leg backwards. =Exercises in closed chain, with low velocity and low  load ) ( Saragiotto  et al., 2016 ) Correcting postural habits, movement patterns and modifications on ADLs Patient education and advice on posture awareness and back support while sitting

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Movement control training – Forward Bending

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Impairments of lumbar flexion often contribute to low back pain.  Patients with  low back pain have been shown to move more in the lumbar spine than at the  hips Repetition of specific strategies (alignment and movement) during daily activities may result in specific impairments due to recurring stress on the lumbar region that results in LBP. Modification of the strategies and exercises to change contributing factors have helped reduce symptoms, disability and recurrences of LBP

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Luomajoki , H. A.,  Bonet  Beltran, M. B.,  Careddu , S., & Bauer, C. M. (2018). Effectiveness of movement control exercise on patients with non-specific low back pain and movement control impairment: A systematic review and meta-analysis.  Musculoskeletal Science and Practice ,  36 (July 2017), 1–11. https://doi.org/10.1016/j.msksp.2018.03.008 Saner, J.,  Kool , J.,  Sieben , J. M.,  Luomajoki , H.,  Bastiaenen , C. H. G., & de  Bie , R. A. (2015). A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A  randomised  controlled trial with one-year follow-up.  Manual Therapy ,  20 (5), 672–679. https://doi.org/10.1016/j.math.2015.02.005 Saragiotto , B. T., Maher, C. G., Yamato, T. P., Costa, L. O. P.,  Menezes  Costa, L. C.,  Ostelo , R. W. J. G., &  Macedo , L. G. (2016). Motor control exercise for chronic non-specific low-back pain. In  Cochrane Database of Systematic Reviews . https:// doi.org/10.1002/14651858.CD012004

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