Narrative (P-2)
Adequate response, which pivoted around reduction and proximation of the radicular pain, occurs after the fifth session of treatment. Only then was an acceptable prognosis established, and the patient was scheduled to continue the treatment protocol.
This patient was treated for a total of 15 sessions within a 3-week period. At the time of her release from continued care, the patient reported a 90% improvement in chief complaint.
Final physical examination also revealed normal gait and stance, fair range of motion in the lumbo-sacral spine, with mild restriction of the right Sacro-iliac articulation. Muscle strength was 5/5; even so, some hypo-tonicity of pelvic muscles had remained. SLR on the right caused mild strain at 65 degrees (non radicular) and it was negative on the left.
It is also important to note that patient received no medication during or following the treatment protocol.
The patient was placed on rehab exercises, with some restrictions left in place and she was scheduled for a follow-up examination in 4 weeks.
During the follow-up examination there was some improvement of the pelvic stabilizers following re-habilitation exercises prescribed previously, and she was scheduled for a follow-up MRI study as well.
However, due to her travel plans, the study was delayed for 8 weeks. As the result, the first follow-up MRI was performed within 16 weeks of the initial study seen here on plates 4-6/10.
She was also re-examined on this date, except for a mild localized pain in the right S.I. region, which responded well to one session of treatment. The patient was otherwise symptom free.
Because of the remaining discopathy seen on the 1st follow-up MRI study, she was scheduled for re-evaluation every 6 weeks during which time she continued to remain asymptomatic.
Unfortunately, this patient only attended the first prescheduled re-evaluation and she did not refer back for 32 weeks.
