Biokinetics Assessment Follow-Up Note

DBC - Biokineticist Assessment 1. Demographic and General Information - Name, Age, Gender, Occupation: Jane Doe, 45, Female, Accountant - Sports or Hobbies: Recreational cycling, gardening 2. Current Complaint - Reason for Visit: Follow-up on persistent lower back pain impacting daily activities and exercise. - Location of Pain/Problem: Lumbar spine (L4-L5 region) with occasional left gluteal discomfort. - Onset of Pain: Approximately 3 months ago, gradual onset with intermittent sharp pain, worsening in severity over the past month. - Mechanism of Injury: No specific acute injury; pain initiated after a prolonged period of increased desk work and reduced physical activity. 3. Pain Characteristics - Pain Intensity (VAS 0-10): Varies between 4/10 at rest and 7/10 during aggravating activities. - Radiation: Occasional radiation to the left gluteal region, but not beyond the knee. - Aggravating Factors: * Prolonged sitting (more than 30 minutes) * Bending forward * Lifting light objects - Diurnal Pattern: Stiffer in the mornings for about 30-45 minutes, improves with movement, then worsens again in the late afternoon/evening. - Nocturnal Pain: Occasionally wakes her from sleep if she lies on her back for too long; relieved by changing position. 4. Past Medical and Injury History - Previous Back/Neck Pain Episodes: History of one previous episode of lower back pain 5 years ago, resolved with physiotherapy. - Chronic Conditions: * Mild Osteoarthritis in knees (managed) * Controlled hypertension - Previous Imaging: Lumbar spine X-ray 2 months ago, showing mild degenerative changes consistent with age, no acute pathology. 6. Posture and Ergonomics - Typical Daily Posture: Slumped posture observed during prolonged sitting at her desk; tends to round shoulders and anterior pelvic tilt when standing for extended periods. 7. Lifestyle Factors and General Health - Exercise and Activity Level: Previously cycled 3 times a week for 45 minutes; has significantly reduced activity due to pain. Walks for about 20 minutes daily. - Comorbidities: None directly impacting current musculoskeletal condition, other than mentioned mild OA. - Chronic Medications: * Lisinopril 10mg daily for hypertension * Occasional paracetamol for general aches 8. Current and Past Treatment - Current Pain Medications: Currently taking paracetamol as needed, 500mg, up to 4 times a day. - Previous Professional Consultations: Consulted GP 2 months ago, referred for X-ray. Saw a physiotherapist briefly 1 month ago, received general exercises but found them difficult to implement due to pain. - Treatment Efficacy: * Paracetamol provides temporary relief (2-3 hours). * Previous physiotherapy exercises were too painful to consistently perform; felt limited progress. 10. Goals and Expectations - Goals: * Reduce lower back pain to a manageable level (VAS 2/10). * Return to recreational cycling 3 times a week without pain. * Improve posture and core strength. * Be able to garden for longer periods without discomfort.