Chapter I

INTRODUCTION

Compression fractures affect many individuals worldwide.1Vertebral

compression fractures (VCFs) of the thoracolumbar spine are common in the elderly,
with approximately 1.5 million VCFs annually in the general US population.1
Approximately 25% of all postmenopausal women in the US get a compression fracture
during their lifetime.2 The prevalence of this condition increases with age, reaching 40%
by age 80.3 Population studies have shown that the annual incidence of VCFs is 10.7 per
1000 women and 5.7 per 1000 men.4 Men older than age 65 years are also at increased
risk of compression fractures. However, their risk is markedly less than that of women of
the same age.1

In the United States, 20 million people, predominantly postmenopausal women,

have osteoporosis. Osteoporosis leads to more than 1.5 million fractures each year. One
of every two women older than 50 years will have an osteoporosis-related fracture.3
VCFs can cause severe physical limitations. Chronic back pain, which is associated with
these kinds of fractures, leads to functional limitations and significant disability.1

The most common fractures of the spine are associated with the thoracolumbar
junction. Ninety percent of all spine fractures are related to the thoracolumbar region.
Especially, the majority of thoracolumbar injuries occur at the T11 to L2 level, which is
the biomechanically weak for stress.2

Thoracolumbar spinal fractures can be divided into thoracic and thoracolumbar

fractures. They are distinguished by the anatomic and patho-mechanical characteristics
on which treatment is based. A number of systems have been used to classify
thoracolumbar spinal fractures based on the mechanism of injury. The Denis
classification, which is widely used, is based on a three-column biomechanical model of
the spine. The anterior column is composed of the anterior longitudinal ligament and the
anterior portion of the vertebral body. The middle column consists of the posterior
portion of the vertebral body and the posterior longitudinal ligament. The posterior
column is composed of the posterior elements. Based on a review of 412 cases, Denis
classified thoracic and lumbar fractures into minor and major injuries. Whatever

1
classification system is used, it is important to understand the complete nature of the
injury in order to devise an appropriate treatment plan.4

The leading causes of cervical and thoracolumbar spine injuries are motor vehicle
accidents, falls, and diving accidents. Anyone with a history of trauma who is intoxicated
or unconscious should be evaluated for spine injury. Thoracolumbar fractures can result
from minor trauma coupled with osteoporosis, which weakens the structural integrity of
individual vertebrae.4

Symptomatic vertebral compression fracture usualy present as acute thoracic or

lumbar back pain. Importantly, little correlation exists between the degree of vertebra
body collapse and pain level. Evaluating the patients risk, taking history, conducting a
physical examination and ordering radiological studies are essential parts of the
assessment and diagnosis of a suspected vertebral compression fracture. Open surgical
intervention in this frail population, with osteoporotic spinal compression fractures, is
fraught with morbidity and implant failure. Therefore, nonoperative management
including narcotic pain medication, bed rest and bracing has been historically
recommended for the vast majority of patients. Traditionally surgery has been limited to
those who have neurologic complications.5

Currently, nonoperative treatment of vertebral fractures involves the use of an

appropriate brace or cast with early mobilization of the patient as tolerated.4 Once the
pain begins to subside, the patient is encouraged to start moving. Physical therapy should
concentrate on increasing the patients knowledge of safety, posture, transfers, the
performance of daily living activities and ambulation. Gentle extension and exercises of
the trunk are useful in attaining patient mobility. Postural exercise should include
activities of the shoulder and scapulae to ensure overall strengthening and spinal stability
(Martin, 2012). Occasional wearing of either a lumbar or thoracolumbar support may be
helpful.6

Rehabilitation can be done to a patient by collaboration work of physical

medicine and rehabilitation physician, physiotherapist, occupational therapist, orthotic
prosthetic, psychologist, and medical social worker. The physician will make a
comprehensive examination to make a clear diagnosis of a patient. After that, physician
will give medication, if needed, and an instruction to the other subunit for further
treatment such as heat or cold therapy, spine orthosis, and cognitive-behavioral therapy.

2
The aim of rehabilitation are to reduce the pain, avoid reccurence, and also improving
the quality of life.7,8 Also restore functional range of motion to the (trunk) spine in all
planes without creating neurologic deficits. Restore strength of the paraspinal muscles,
latissimus dorsi, trapezius, and quadratus lumborum. The muscles of the lower
extremities may atrophy with bed rest or neurologic injury and require strengthening.
Functional Goals are Allow for pain-free sitting, standing, and walking, and develop
spinal flexibility for functional independence.4

The goals of treatment of thoracolumbar fracture are leading to early mobilization

and rehabilitation by restoring mechanical stability of fracture and inducing neurologic
recovery, thereby enabling patients to return to the workplace and protecting from the
further neural damage. However, it is still debatable about the treatment methods.4

In this case report, the writer will explain a case of a woman who suffer low back
pain which suggest to vertebral compression fracture due to trauma. The unique of this
case report are she has osteoporosis and also got into vehicle accident. The functional
status of the patient is taken by using Oswestry disability index. The Oswestry Disability
Index (ODI) is one of the principal condition-specific outcome measures used in the
management of spinal disorder.9

3
 Chapter II
CASE REPORT

I. Identity
Name : S.J
Gender / Age : Female / 56 years old
Address : Malalayang Timur
Religion : Christian
Occupational : Priest
Medical Record : 29 19 80
Examination date : January 3rd 2017

II. Anamnesis (History)

Chief complain:
Low back pain.

History of present illness:

Low back pain has felt for 11 days ago. Patient has been feeling a great sudden
pain on her lower back after vehicle accident, she was walking when a car suddenly
hit her from back and she fell. The pain is sharp pain which localized at low back (
middle side ). The pain is worst when she changes position (laying down to sitting
position, sitting to standing ), prolonged sitting or standing and feel better with rest or
laying position. She also complain about difficulty of sleeping due to pain.
At the moment of impact, she can stand up on her own and walked. Now she
needs help if she wants to stand up or walk because of the pain. She was referred
from neurologist to get further treatment with diagnosis of low back pain ec
compression fracture L1.
There is no problem for micturition and defecation. There was no history of
weight loss in the past three months. There was no history of fever. There is no
morning stiffness. There is no weakness on his leg and no numbness in the area of
bottom. No increasing pain while coughing, squeezing or defecation. This is the first
time patient has an experience like this. After this condition, patient has consumed

4
mefenamic acid for several days, but there was no significant recovery. She is
menopause since 8 years ago.

History of past illness:

- Have no history of Hypertension, diabetes, hypercholesterolemia, hyperuricemia.
- Have no history for cancer in the body.
- Have no allergic.
- She has history of TB on 1996 and completed her treatment.

History of psycologic :
Patients are open, communicative, and wise character. Patient was worried for the
disease. Because of back pain, the patient currently stay at home.

History of habitual :
She used to sleep on a spring bed using a pillow and bolster. She is a priest she
usually stand for 45 minutes - 1 hour when she was preaching, 2 3 times a month,
and sitting for hours to pray (2-4 hours) 4-5 times a week. Her work place is in
kawangkoan. She doesnt smoke nor drink alcohol.

History of socioeconomic:
Patient works as a priest, she is a widow, her husband deceased 20 years ago. Patient
lives with her older daughter. She has 2 children, the first one is already work and the
second one is a college student and study in Jogjakarta.
Currently the patient did not work because of her health physical condition. She lives
in a two floor permanent house. Her bedroom is on the first floor. The toilet is sitting
toilet. The source of water is from a PDAM. They use PLN (Perusahaan Listrik
Negara) as the source of electricity. Patient has BPJS Insurance that guarantee her
payment for medication.

III. Physical Examination

Karnofsky Performance Scale (KPS): 60 (Requires occasional assistance, but is able
to care for most of his personal needs.).
Level of Consciousness : compos mentis
Glasgow Coma Scale : Eye 4 Verbal 5 Motoric 6
5
Vital sign:
- Blood pressure : 130/90 mmHg
- Pulse : 88 pulse/minute, regular, full fill.
- Respiratory rate : 20 times/minute.
- Body temperature : afebrile
Body weight : 52 Kg
Body height : 156 cm
Body mass index : 21,3 (normal)

Visual Analoque Scale:

____________________ X_______
8
General Status:
Head : Normocephal.
Eye : No anemis on conjunctiva, no icterus on sclera, pupil isochoric.
Neck : trachea in the midline.
Thorax
Cor :
Inspection : ictus cordis not seen
Palpation : ictus cordis not palpable
Percussion : upper border: ICS III; left border: ICS V left midclavikular line;
right border right sternal line.
Auscultation : first and second heart sound normal, no murmur sound.
Pulmo :
Inspection : thoracic movement symmetric
Palpation : stem fremitus left = right
Percussion : sonor on all lung field
Auscultation : vesicular breath sound, ronchi (-/-), wheezing (-/-)
Abdomen
Inspection : no spider nevi.
Palpation : normal size of liver and spleen.
Percussion : tympani in all abdominal surface.
Auscultation : normal intestinal sound.
6
Locally Status of trunk :
Look : Front: simetris on right and left shoulder and on right and left hip;
Side: no lordotic lumbal.
Back: no scoliosis.
no swelling and redness on lower back.
No deformity on both knee.
Gait analysis: antalgic gait.
Feel : no warmth on lower back.
Prosesus spinosus position in the middle from upper to lower back.
Spasm on paravertebral muscle (right / left)
Folding skin test positif on level L1- L5.
Pain on pressure to vertebra lamina (right/left) on level L1.
Movement: pain when bending forward.

Leg length
Lower Extremity

Right Left
Apparent leg length 87 cm 87 cm

True leg length 78 cm 78 cm

Lower extremity circumference

Lower Extremity
Right Left
Tight circumference 40 cm 40 cm
Calf circumference 29 cm 29 cm

Range of motion
Trunk
Flexion - Extension Not Testetable (pain)
Lateral flexion D-S Not Testetable (pain)
Rotation D-S Not Testetable (pain)

7
 Hip
Right Left
Flexion Extension 1100 0 200 1100 0 200
Abduction-Adduction 450 0 250 450 0 250
External rotation - Internal rotation 500 0 400 500 0 400

Miotome
Right Left
L2 5 5
L3 5 5
L4 5 5
L5 5 5
S1 5 5

Dermatome
Right Left
L1 2 2
L2 2 2
L3 2 2
L4 2 2
L5 2 2
S1 2 2

Provocation test
Right Left

Valsava Negative

Laseque / SLR Negative / 800 Negative / 800

Braggard Negative Negative

Sicard Negative Negative

Patrick Negative Negative

Kontra Patrick Negative Negative

FNST Negative Negative

8
Functional Measurement:
Modified LBP disability questionnaire (Modified Oswestry Disability Index = ODI)
Section Score
1 Pain intensity 5
2 Personal care 4
3 Lifting 5
4 Walking 4
5 Sitting 3
6 Standing 3
7 Sleeping 3
8 Sex life -
9 Social life 5
10 Travelling 4
Total 36
Interpretation of scores : 36/45 x 100 % = 80 % (80% refer to crippled)

Additional Examination:
Rontgen Photo Lumbosacral :

Fergusons Angle: 450

Picture 1. Rontgen Photo Lumbosacral

9
Rontgen Photo Thoracolumbal

Picture 2. Rontgen Photo Thoracolumbal

Kyphotic Angulation : 20

IV. Diagnosis
- Clinical diagnosis : Low Back Pain
- Topical diagnosis : Corpus vertebra thoracolumbal L1
- Etiological diagnosis : Vertebral compression fracture ec trauma
- Functional diagnosis :
Back function : sensation of pain
mobility of bone function
functions of the joints and bones
Back structure: structure of trunk
Activites and Participation :
Activity Daily Living (ADL) disturbance (toileting, dressing)
Mobilization such as walking, moving, and climbing stair.
Environment : disturbance on transportation facilities
Personal factor: age 56 y.o, habit: prolonged standing
V. Problems
- Pain on low back.
- Limitation in activity due to disability (walking, toileting, dressing).
- Disturbance in vocational.
- Worried about the illness.

10
VI. Management:
Medikementosa: (from Neurology department)
- Mefenamic acid 500 mg 3x1 (prn)
- Neurosanbe 2x1
- Myonal 2x1

Medical Rehabilitation :
a. Physical Medicine and Rehabilitation Physician:
Evaluation :
- Patient has good contact and understanding
- Pain on thoracolumbal region ( VAS : 8 )
- Limitations on Activity of Daily Living
- Anxiety due to low back pain
Program :
- Bed rest for two days
- Advise patient using thick hard bed to sleep because the patient had habit
sleep on thick soft bed.
- Emphazise to the patient that during sleeping in supine position and place
small pillow below the knees.
- Emphazise to the patient to do not get out of the bed, bed rest total. Avoid
to go to bathroom and other places.
- Education: avoid activity with bending forward position, lifting heavy
object, use flat and firm bed.
- Proper Back Mechanicm
- Give an education about the problem that patient face at this time and also
give a counceling to reduce anxiety.
- Education to increase back weight by managing TKTP, consumption of
calcium and vitamin D supplementation (Cavit D3)
- Education to do exercise (after the pain is really reduced)
- Creating programs for the other sub-unit (Physiotherapy, Psychology,
Orthotic-Prosthetic, and Medical Social worker)

11
b. Physiotherapy :
Evaluation :
- Patient has good contact and understanding
- Pain on thoracolumbal region ( VAS : 8 )
- Disturbance in mobilization due to pain. The patient difficult to sit, stand
and walk.
Program :
- Transcutaneus Electrical Nerve Stimulation (TENS) on region
thoracolumbal.
- Cold compress on region thoracolumbal.

a. Occupational therapy :
Evaluation :
1. Patient has good contact and understanding
2. Pain on thoracolumbal region ( VAS : 8 )
3. Limitations on Activity of Daily Living, such as using the clothes and
bathing, need some help by her daughter, walking with towed by her
daughter.
Programs :
- Education to place the object at home appropriately so that the patient
doesnt need to bending forward his back (for example: ask the patient to
put her glass and plate in a place as high as her chest).
- Try to perform slow movement during activity.
- Maintain good posture with flat back during activity.

c. Orthotic and Prosthetic :

Evaluation :
- Patient has good contact and understanding
- Pain on thoracolumbal region ( VAS : 8 )
Program :
- Thoracolumbosacral Orthosis (TLSO)

12
 d. Psychological therapy :
Evaluation :
- Anxiety about her illness.
- The patient looks depression and passive because of pain.
Program :
- Mental support to reduce patients anxiety in coordination with family
members
- Cognitive Behavioral Therapy (CBT)

e. Medical Social Worker

Evaluation :
Patient worked as a priest, she often standing for a long period. Patient
lives with her daughter. Currently the patient did not work because of her
health physical condition.
Patient has private insurrance that guarantee his payment for medication.
Program :
- Give motivation to the patient to control in medical rehabilitation center
regularly.
- Fascilitate and giving advice to patient about alternative way to work like
sitting while preaching.
VII. Prognosis
Ad vitam : bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam

VIII. Follow-up
Follow up January 18th 2016 (2 weeks)
S 1. Pain decrease, the patient has been able to sit more than one hour.
2. Patient was able to walk > 100 m
3. Patient able to sit more than 30 minutes and walk again by herself.
4. The type of gait is antalgic gait.
5. Patient can do most personal care such as bathing, combing, but sometimes need
help from her daughter to get dress.

13
O BP: 120 / 80 VAS: 5
Spasm on paravertebral muscle at level L1-L5.
Folding skin test positif on level L1-L5.
Pain on pressure to vertebra lamina on level L1.
Section Score
1 Pain intensity 3

2 Personal care 3

3 Lifting 4

4 Walking 3

5 Sitting 3

6 Standing 3

7 Sleeping 3

8 Sex life -

9 Social life 4

10 Travelling 3

Total 29

ODI Score: (29/45) x 100% = 64%

64% refer to crippled.
The greatest problems based on ODI are lifting an object and social life.
A Low back pain et cause vertebral compression fracture L1 ec trauma
P Physiatrist:
Evaluation:
1. Pain decreasing significantly
2. Patient can sitting and standing for more than 30 minutes.
Program:
2. Proper back mechanicm
3. Emphazise the education more on how to sit, walk and lifting an object
Physiotherapy:
Evaluation:
Pain decreasing

14
 Program:
1. Continue TENS
2. Back exercise started (isometric exercise).
Occupational Therapy:
Evaluation:
1. Pain decreasing
2. Limitation on activity daily living was decreased
Program:
1. Remind the patient to maintain good posture with flat back
2. Remind the patient to do proper back mechanism when do daily activies.
Orthotic and Prosthetic:
Evaluation:
1. Pain decreasing
Program:
The thoracolumbosacral orthosis is used
Psychology:
Evaluation:
Patient little anxious and worried with her condition. She has a little depression.
Program:
1. Psychology try to meet the patient
2. Psychology explain about Cognitive Behavioral Therapy
3. Support the patient to come regularly to rehabilitation department
Medical Social Worker:
Evaluation:
Patient looks passive because of pain.
Program:
1. To explore the social factors emotional
2. Establish a plan for treatment or therapy that more intensive

Follow up January 31th 2016 (4 weeks)

S 1. Pain is decreasing. Pain is most occurred when she is changing position from
supine to lateral side or from sitting to standing position.
2. Patient able to walk longer and doing most of her activity daily living.

15
 3. Patient can do most personal care such as washing, combing and dressing by
herself.
O BP: 110 / 80 VAS: 4
Slight spasm on paravertebral muscle at level L1-L5.
Folding skin test slight positif on level L1-L5.
Slight pain on pressure to vertebra lamina on level L1.
Section Score
1 Pain intensity 3

2 Personal care 2

3 Lifting 3

4 Walking 2

5 Sitting 3

6 Standing 3

7 Sleeping 2

8 Sex life -

9 Social life 3

10 Travelling 2

Total 23

ODI Score: (23/45) x 100% = 51%

51% refer to severe disability.
The greatest problems based on ODI are still lifting an object and social life,
prolonged sitting and standing.
A Low back pain et cause vertebral compression fracture L1 ec trauma
P Physiatrist:
Evaluation:
1. Pain decreasing
Program:
1. Proper back mechanicm
2. Emphazise the education more on how to sit, walk and lifting an object
Physiotherapy:

16
 Evaluation:
1. Pain decreasing
Program:
1. TENS regio Thoracolumbal
Occupational Therapy:
Evaluation:
1. Pain decreasing
Program:
1. Remind the patient to maintain good posture with flat back
2. Remind the patient to do proper back mechanism when do daily activies
Orthotic and Prosthetic:
Evaluation:
1. Pain decreasing
Program:
1. Patient uses thoracolumbosacral orthosis most of all the day
Psychology:
Evaluation:
1. Anxious and depression is less than before.
Program:
1. Support mental the patient and her family
Medical Social Worker:
Evaluation:
1. Patient spend most of her time at home but she go out sometime for some
occasion.
Program:
1. Medical Social worker try to support the patient to back to doing daily activity and
work.

Follow up February 14th 2016 (6 weeks)

S 1. Patient able to walk and doing most of her activity daily living.
2. Patient can walk more longer than before without pain.
3. Patient can sleep at night.
4. Patient can do most personal care such as washing, combing and dressing by

17
 herself.
O BP: 120 / 80 VAS: 3 (dynamic)
No spasm on paravertebral muscle at level L1-L5.
Folding skin test negatif on level L1-L5.
No pain on pressure to vertebra lamina on level L1.
Section Score
1 Pain intensity 1

2 Personal care 1

3 Lifting 1

4 Walking 1

5 Sitting 1

6 Standing 1

7 Sleeping 1

8 Sex life -

9 Social life 1

10 Travelling 1

Total 9
ODI Score: (9/45) x 100% = 20 %
20% refer to minimal disability.
All aspects in the ODI have minimal score. The patient can cope with most living
activities. Usually no treatment is indicated apart from advice on lifting sitting and
exercise.
Rontgen Thorax : 13/2/2017
Interpretation : COR normal, suspected pulmonary TB
Pulmonologist : dx : old TB
A Low back pain et cause vertebral compression fracture L1 ec trauma
P Physiatrist:
Evaluation:
1. Pain decreasing significantly
Program:
1. Proper back mechanicm

18
2. Emphazise the patient to maintain her condition
Physiotherapy:
Evaluation:
1. Pain decreasing
Program:
1. TENS regio Thoracolumbal
Occupational Therapy:
Evaluation:
1. Pain decreasing
Program:
1. Remind the patient to maintain good posture with flat back
2. Remind the patient to do proper back mechanism when do daily activies
Orthotic and Prosthetic:
Evaluation:
1. Pain decreasing
Program:
1. Patient uses thoracolumbosacral orthosis most of all the day
Psychology:
Evaluation:
1. Anxious and depression is less than before.
Program:
1. Support mental the patient and his family
Medical Social Worker:
Evaluation:
1. Patient spend most of her time at home but she often go out sometime for some
occasion.
Program:
1. Medical Social worker try to support the patient to back to doing daily activity

19
 CHAPTER III
DISCUSSION
In this case report, we discuss about a woman, 56 years old, as a priest who got low
back pain since 11 days ago right after vehicle accident. The pain is sharp pain which
localized at low back ( middle side ) that was improved by lying in a supine position and
exacerbated by any attempt to change body position. She is menopause since 8 years
ago.
On physical examination, she exhibited local tenderness to palpation and percussion,
skin folding test positive on thoracolumbal region which mean there was a pathologic
process at vertebrae or there was an irritative muscles underneath the skin, but no
neurological deficit nor any signs of radiculopathy. She rated the pain as 8/10 on a visual
analogue scale.
Osteoporotic fractures (fragility fractures, low-trauma fractures) are those occurring
from a fall from a standing height or less, without major trauma. Vertebral compression
fractures are the most common type of osteoporotic fracture.10 They often occur at the
midthoracic (T7-T8) spine and the thoracolumbar junction (L1-L1). 11
In patients who have acute symptomatic vertebral body fracture, there is often no
history of preceding trauma. The typical patient presents with acute back pain after
sudden bending, coughing, or lifting. Occasionally, minor trauma, such as going over
speed bumps, may precipitate a fracture.12 The pain is usually well localized to the
midline spine but often refers in a unilateral or bilateral pattern into the flank, anterior
abdomen, or the posterior superior iliac spine. By contrast, radiation of pain into the legs,
as may be seen with a herniated disc, is rare with compression fractures but may herald
spinal cord or nerve root compression from retropulsed bone fragments.11
The pain from a vertebral compression fracture is variable in quality and may be
sharp or dull. Sitting, spine extension, Valsalva maneuver, and movement often
aggravate the pain and may be accompanied by muscle spasms. Sleep may be disturbed
by pain. On physical examination, the patient may experience pain upon palpation and
percussion of the corresponding spinous process and paravertebral structures.11
From anamnesis we found out that she is menopause since 8 years ago, the
majority of postmenopausal women with osteoporosis have bone loss related to estrogen
deficiency and/or age. She felt the pain right after the vehicle accident. The patient also
show the sign and symptoms that indicate a compression fracture. So we can diagnose
her with compression fracture ec trauma due to vehicle accident and she also has an
20
osteoporotic bone. The visual analog scale of pain was 8 on this patient which refer to
severe pain. Moreover, the ODI score which explain about the functional status was 80%
that refer to crippled. The form of ODI is presented on the appendix.
On radiology examination we found out that there is compression fracture of
lumbar 1 and osteoporotic vertebral. Fergusons Angle: 450 . From thoracolumbar x-ray,
we can see that this fracture is only affecting one of two of the three columns scheme
(Denis classification) and there is no severe compression (>50 percent of vertebral
height), significant fracture kyphosis (>30 degrees), a rotational component to the injury,
nor compression fractures at multiple levels. So we can assume that there is no spinal
instability.
According to the three column scheme, stability is based upon the integrity of two of
the three spinal columns. Spinal instability may be inferred when plain radiographs
demonstrate a loss of 50 percent of vertebral height or excessive kyphotic angulation
around the fracture. The angle is determined by the intersection of two lines, one
measured along the superior endplate of the vertebral body one level above the fracture
and the other along the inferior endplate of the vertebral body one level below.
Compression fractures with greater than 30 degrees and burst fractures with greater than
25 degrees angulation are generally considered unstable. The presence of a neurologic
deficit also indicates spinal instability, since the spinal column has failed to protect the
spinal cord.1

Picture 3 Three columns of the thoracolumbar spine

Compression thoracolumbar fractures are caused by forward or lateral flexion,
resulting in loss of height of the anterior column. The middle column is not involved.
When compression exceeds 50% of the vertebral height or 20 degrees of angulation, a

21
posterior ligamentous injury (supraspinous, interspinous ligaments, facet joint capsule,
and ligamentum flavum) may be present. This is due to failure of the posterior column in
tension so there is potential for instability.4
In this case report, we are emphazising on rehabilitation therapy. Physical
medicine and rehabilitation (PM&R), also referred to as physiatry, is a medical specialty
concerned with diagnosis, evaluation, and management of persons of all ages with
physical and/or cognitive impairment and disability.7,8,13
A physiatrist will work together with the other subunit such as physiotherapy,
occupational therapy, orthotic-prosthetic, psychology, and medical social worker to
achieve the best treatment for the patient.
Physiatrist found that the patient had several problems such as pain on
thoracolumbal region (VAS 8), anxiety due to low back pain, and limitations on activity
of daily living. On the acute phase we concerned more on the programs for
physiotherapy and orthotic prosthetic to decrease the pain. The program that physiatrist
gave directly to the patient were bed rest for two days, medication (mefenamic acid as an
analgesic and cavit D3 which is a supplement to prevent osteoporosis), an education
about the patients problems at this time, proper back mechanism and creating programs
for the other subunit. Proper back mechanism is very important to give an education on
how the patient should do with her lower back in many daily activities such as sitting,
sleeping, lifting an object, and cooking.
In physiotherapist program, Adjunct treatment and modalities such as TENS
might be helpful. The physiatrist prescribed cold compress and transcutaneus electrical
nerve stimulation (TENS). Cold compress can be done at rehabilitation department or as
a home program at home. The purpose of this therapy among others to control pain and
edema association with inflammation, vasoconstriction and increase blood viscosity. The
treatment time is 5-15 minutes, because longer application has been associated with
vasodilation and increase circulation. TENS is a form of electrical current that is useful
to reduce pain by gate control mechanism or by releasing endorphin. In gate control
mechanism, TENS will stimulate nerve fiber A-Beta which block pain transmission from
nerve fiber A-Delta and C. This mechanism can be conducted when TENS was set to
100150 pulse per minute with 5080 s duration. When the TENS set on 210 pulse
per minute with 200300 s duration, the endorphin will be released.7,8,14 Placement of
electrodes varies with the TENS mode used and can include positioning of a pair of
electrodes.15
22
 In orthotic and prosthetic unit, the physiatrist presicribed a thoracolumbosacral
orthosis. The thoracolumbrosacral orthosis is made of plastic and velcro. This orthosis
restricts motion in the thoracolumbar spine (lower back), increases intra-abdominal
pressure to support the spine, and helps induce good posture while allowing back
muscles to relax producing a decrease in pain. It is indicated for a patient with lumbar
pain, spondylolisthesis, excessive lordosis, spondylosis, spinal stenosis, degenerative
disc disease, lumbal strain, compression fracture, herniated nucleus pulposus, and
immobilization following lumbar surgery.9,15-18 Stable injuries can be treated with a soft
corset for symptomatic relief. Most compression fractures are amenable to nonoperative
management. Bracing is used until the patient's pain subsides at approximately 4 to 6
weeks. Occasionally, longer periods of brace immobilization are required in patients with
more severe injuries or with osteoporotic bone. 4,19

Picture 4. The patient using Thoracolumbosacral Orthosis

On January 18th 2018, physiatrist made an evaluation to the patient. The low back
pain had reduced from VAS 8 become 5. Pain decrease, the patient has been able to sit
and stand more than 30 minutes. The patient was able to walk long distance and long
time, more than 100 meters.
In this occasion, physiatrist gave an education for the patient about her current
condition, remind her again about proper back mechanism, education about caution of
osteoporosis and start to doing exercise. We suggest the patient to do the isometric back
exercise. Strenuous spinal flexion and spinal flexion exercises should be avoided in
patients with osteoporosis.7,8,20 Education about osteoporosis are important because
osteoporosis is one of factors that can cause compression fracture, beside of traumatic.
For physiotherapy, the program remained the same as before but the cold compress was
stopped.
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Picture 5 : Back extension exercise in the sitting position.

Picture 6 : I, Exercise to decrease lumbar lordosis with isometric contraction of lumbar

flexors.
J1 and J2, Isometric exercise to strengthen abdominal muscles.

For occupational therapy, physiatrist gave a prescription more on ways to modify

activities to prevent large burden to his lower back. In this case, occupational therapist
gave education to place the object at home appropiately so that the patient doesnt need
to bending forward his back (for example: ask the patient to put her glass and plate in a
place as high as her chest). This will certainly reduce the energy used for that activity
and will reduce the risk of reccurent low back pain. Another thing that can be done is try
to perform slow movement during activity. When the patient rush or hurry during
activity, it will cause fast exhaustion and consequently will give more tension to the back
and also the lumbal. Therefore, slow movement is really recommended for this patient.
Furthermore, patient should try to prefer standing instead of sitting to minimize the
burden on his lower back. Sitting will give pressure 140% on the third lumbal disc. This
is larger compare to standing, which only give pressure about 100%.21 Maintaining good
posture also important aspect that occupational therapist should taught to the patient to
reduce burden of lower back.

24
Picture 7 : Static and dynamic correct postures. (Modified from Sinaki M, Mokri B: Low
back pain and disorders of the lumbar spine. In Braddom RL, editor: Physical medicine
and rehabilitation, Philadelphia, 1996, WB Saunders, used with permission.)

Psychology subunit has an important role for this patient. The patient had anxiety
due to his lower back pain. Psychologist could do 2 things for this patient: mental
support and cognitive behavioral therapy. Mental support here was designed to support
the patient in dealing with the condition she had. Hopefully, by this effort the anxiety of
patient would reduce and make this patient focus on her treatment. Cognitive behavior
therapy (CBT) is a type of psychotherapeutic treatment that helps patients understand the
thoughts and feelings that influence behaviors. Most patients have negative statement
inside their mind about their disease. They may not be able to stop physical pain from
happening, but with practice they can control how their mind manages the pain. An
example is changing a negative thought, such as I cant do anything anymore, to a
more positive thought, such as I dealt with this before and I can do it again.13

25
 For medical social worker, the potential problems of this patient were about the
motivation to go to therapy and about the communication between patient and the place
where she works daily. The programs that could be given here were giving motivation to
the patient to control in medical rehabilitation center regularly and facilitation between
the patient and her works place about her illness especially when the patient returns to
work. We expect that by having good communication, between the patient and the
environment that around her.
The patient little anxious with his condition. However, physiatrist had try to meet
him and asked to go to psychologist to give mental support. Additionally, physiatrist also
asked the patient to continued the cognitive-behavioral therapy. The challenges here
were on medical social. For medical social worker, the problem was the patient looks
little depression because he can not back to his activity due to his pain. In this case,
medical social worker try to support the patient and provide solutions about other work
which may be doing by him.
On the follow up in February 14th 2017, the patient had more improvement. The
pain was decreasing (VAS 3) and the ODI score is minimal disability. Patient able to
walk and doing most of her activity daily living. Patient can walk more longer (1,5
kilometers) than before without pain.

26
 APPENDIX

1. Questions about low back pain and the red flag

Oswestry Disability Questionnaire

This questionnaire has been designed to give us information as to how your back pain is
affecting your ability to manage in everyday life. Please answer by checking one box in
each section for the statement which best applies to you. We realize you may consider
that two or more statements in any one section apply, but please just shade out the spot
that indicates the statement which most clearly describes your problem.
Section 1: Pain Intensity
1. I have no pain at the moment
2. The pain is very mild at the moment
3. The pain is moderate at the moment
4. The pain is fairly severe at the moment
5. The pain is very severe at the moment
6. The pain is the worst imaginable at the moment
Section 2: Personal Care (eg. washing, dressing)
1. I can look after myself normally without causing extra pain
2. I can look after myself normally but it causes extra pain
3. It is painful to look after myself and I am slow and careful
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4. I need some help but can manage most of my personal care
5. I need help every day in most aspects of self-care
6. I do not get dressed, wash with difficulty and stay in bed
Section 3: Lifting
1. I can lift heavy weights without extra pain
2. I can lift heavy weights but it gives me extra pain
3. Pain prevents me lifting heavy weights off the floor but I can manage if they are
conveniently placed (eg. on a table)
4. Pain prevents me lifting heavy weights but I can manage light to medium weights if
they are conveniently positioned
5. I can only lift very light weights
6. I cannot lift or carry anything
Section 4: Walking
1. Pain does not prevent me walking any distance
2. Pain prevents me from walking more than 1,5 kilometers
3. Pain prevents me from walking more than 750 meters
4. Pain prevents me from walking more than 100 meters
5. I can only walk using a stick or crutches
6. I am in bed most of the time
Section 5: Sitting
1. I can sit in any chair as long as I like
2. I can only sit in my favorite chair as long as I like
3. Pain prevents me sitting more than one hour
4. Pain prevents me from sitting more than 30 minutes
5. Pain prevents me from sitting more than 10 minutes
6. Pain prevents me from sitting at all
Section 6: Standing
1. I can stand as long as I want without extra pain
2. I can stand as long as I want but it gives me extra pain
3. Pain prevents me from standing for more than 1 hour
4. Pain prevents me from standing for more than 30 minutes
5. Pain prevents me from standing for more than 10 minutes
6. Pain prevents me from standing at all
Section 7: Sleeping
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1. My sleep is never disturbed by pain
2. My sleep is occasionally disturbed by pain
3. Because of pain I have less than 6 hours sleep
4. Because of pain I have less than 4 hours sleep
5. Because of pain I have less than 2 hours sleep
6. Pain prevents me from sleeping at all
Section 8: Sex Life (if applicable)
1. My sex life is normal and causes no extra pain
2. My sex life is normal but causes some extra pain
3. My sex life is nearly normal but is very painful
4. My sex life is severely restricted by pain
5. My sex life is nearly absent because of pain
6. Pain prevents any sex life at all
Section 9: Social Life
1. My social life is normal and gives me no extra pain
2. My social life is normal but increases the degree of pain
3. Pain has no significant effect on my social life apart from limiting my more energetic
interests e.g. sport
4. Pain has restricted my social life and I do not go out as often
5. Pain has restricted my social life to my home
6. I have no social life because of pain
Section 10: Traveling
1. I can travel anywhere without pain
2. I can travel anywhere but it gives me extra pain
3. Pain is bad but I manage journeys over two hours
4. Pain restricts me to journeys of less than one hour
5. Pain restricts me to short necessary journeys under 30 minutes
6. Pain prevents me from travelling except to receive treatment

29
Scoring the questionnaire
-----------------------------------------------------------------------------------------------------------
Score: patient score / total possible score x 100 = %
-----------------------------------------------------------------------------------------------------------
Scoring:
7.For each section, the total possible score is 5
8.If the first statement is marked, the section score = 0
9.If the last statement is marked, it = 5.
If all ten sections are completed the score is calculated as followed:
Example: 16 (total scored by patient)
50 (total possible score)
16/50 x 100 = 32%
10. If one section is missed or not applicable, the score is calculated as followed:
Example: 16 (total scored)
45 (total possible score)
16/45 x 100 = 35.5%
ODI Scoring:
0% to 20% (minimal disability): Patients can cope with most activities of daily living.
No treatment may be indicated except for suggestions on lifting, posture, physical fitness
and diet. Patients with sedentary occupations (ex. secretaries) may experience more
problems than others.
21%-40% (moderate disability): Patients may experience more pain and problems with
sitting, lifting and standing. Travel and social life are more difficult. Patients may be off
work. Personal care, sleeping and sexual activity may not be grossly affected.
Conservative treatment may be sufficient.
41%-60% (severe disability): Pain is a primary problem for these patients, but they may
also be experiencing significant problems in travel, personal care, social life, sexual
activity and sleep. A detailed evaluation is appropriate.
61%-80% (crippled): Back pain has an impact on all aspects of daily living and work.
Active treatment is required.
81%-100%: These patients may be bed bound or exaggerating their symptoms. Careful
evaluation is recommended.

30
 BIBLIOGRAPHY
1. Alexandru D, So W. Evaluation and Management of Vertebral Compression
Fractures. Perm J 2012 Fall;16(4):46-51

2. Kim BG, Dan JM, Shin DE. Treatment of Thoracolumbar Fracture. Asian Spine
J. 2015 Feb; 9(1): 133146.

3. Brotzman SB. Osteoporosis: Evaluation, Management, and Exercise. In : Clinical

Orthopaedic Rehabilitation. 2nd ed. Philadelphia: Mosby; 2003. P. 530

4. Lonner BS, Hoppenfeld S, Patel AI. Thoracolumbar Spine Fractures. In:

Hoppenfeld S, Murthy VL editors. Treatment And Rehabilitation Of Fractures.
Philadelphia: Lippincott Williams & Wilkins; 2000. P. 562-74

5. Godges J. Spinal Compression Fracture Repair and Rehabilitation. Available at

file:///C:/Users/asus/Downloads/26SpinalCompressionFracture.pdf

6. Metzger PC, Lombardi M. Orthopedic Trauma. In: A Comprehensive Guide

Geriatric Rehabilitation. 3rd ed. Churchill Livingstone: Elsevier; 2014. P. 175-6. 1

7. Barr KP, Harrast MA. Low Back Pain. In : Braddom RL, Chan L, Harrast MA,
Kowalske KJ, Matthews DJ, Ragnarsson KT, Stolp KA, editors. Physical Medicine
and Rehabilitation 4th ed. Philadelphia: W.B Saunders Company; 2011. P. 871
901.

8. Barr KP, Concannon LG, Harrast MA. Low Back Pain. In : Cifu DX, editors.
Physical Medicine and Rehabilitation 5thed. Philadelphia: W.B Saunders Company;
2016. p. 711 746.

9. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000; 25:2940-
2952.

10. Genant HK, Cooper C, Poor G, et al. Interim report and recommendations of the
World Health Organization Task-Force for Osteoporosis. Osteoporos Int 1999;
10:259.

11. Rosen HN, Walega DR. Osteoporotic thoracolumbar vertebral compression

fractures: Clinical manifestations and treatment. 2016 Nov. Available at
https://www.uptodate.com/contents/osteoporotic-thoracolumbar-vertebral-

31
compression-fractures-clinical-manifestations-and-
treatment?source=search_result&search=compression%20fracture%20spine&selecte
dTitle=1~150

12. Aslan S, Karcioglu O, Katirci Y, et al. Speed bump-induced spinal column injury.
Am J Emerg Med 2005; 23:563.

13. Meunier PJ. Osteoporosis: Diagnosis And Management. Martin Dunitz, 1998

14. C. J.Dy, L. E. LaMont,Q.V.Ton, and J.M. Lane, Sex andgender considerations

in male patients with osteoporosis, Clinical Orthopaedics and Related Research,
vol. 469, no.7, pp. 19061912, 2011.

15. Barr JO. Conservative Interventions for Pain Control. In : A Comprehensive

Guide Geriatric Rehabilitation. 3rd edition. Churchill Livingstone: Elsevier; 2014. P.
484-9.

16. Moore DP, Tilley E, Sugg P. Spinal Orthosis. In : Cifu DX, editors. Physical
Medicine and Rehabilitation 4th ed. Philadelphia: W.B Saunders Company; 2016. p.
359 371.

17. Norbury JW, Tilley E, Moore DP. Spinal Orthosis. In : Cifu DX, editors. Physical
Medicine and Rehabilitation 5th ed. Philadelphia: W.B Saunders Company; 2016. p.
275 288.

18. Taylor L, Lichten D, Yoo S. Orthotics. In : Maitin BI. Current Diagnosis &
Treatment Physical Medicine & Rehabilitation. New York: McGraw-Hill
Companies; 2015. P. 460-71.

19. Coppage J, Ames SE. Orthoses for Spinal Dysfunction. In : Lusardi MM, Jorge
M, Nielsen CC editors. Orthotics and Prosthetics in Rehabilitation 3th ed. Missouri:
Elsevier Saunders Company; 2013. P.378-9.

20. Siniki M, Huntoon E. Musculoskeletal Osteoporosis and Vertebral Fractures. In :

Buschbacher RM, Means KM, Kortebein PM editors. Rehabilitation Medicine Quick
Reference Geriatrics. New York: Demos Medical Publishing. 2013. P. 124-6

21. Dunn KM, Croft PR. Classication of Low Back Pain in Primary Care: Using
Bothersomeness to Identify the Most Severe Cases. Spine 2005; 30:1887-1892

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