Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic, progressive low back pain localized to the lumbar region, exacerbated by prolonged sitting, standing, or physical activity. Pain is described as dull, aching, and mechanical in nature, occasionally radiating to the gluteal region without clear dermatomal distribution. No reported bowel or bladder dysfunction, saddle anesthesia, or progressive motor weakness. Symptoms are partially relieved by rest and positional changes.
Clinical Examination Findings
Lumbar spine examination reveals restricted range of motion in flexion and extension. Paraspinal muscle tenderness and hypertonicity noted at multiple lumbar levels. Neurological assessment shows intact sensation to light touch in L1-S1 dermatomes. Motor strength 5/5 in bilateral lower extremities. Deep tendon reflexes (patellar and Achilles) are symmetric and 2+. Straight leg raise (SLR) test is negative bilaterally. No evidence of focal neurological deficit or gait abnormality.
Treatment Protocol
Initiate conservative management including physical therapy focusing on core stabilization and lumbar strengthening exercises. Prescribe non-steroidal anti-inflammatory drugs (NSAIDs) for pain management. Recommend activity modification, ergonomic adjustments, and weight management. Consider referral for epidural steroid injections if symptoms persist despite conservative therapy.