Review Consult

Physiotherapist Note HOPC: * Patient presents with persistent low back pain, initiated after lifting a heavy box on 15 September 2024. * Pain has progressively worsened, now radiating down the right leg to the calf. * Initial management included rest and over-the-counter paracetamol, providing minimal relief. * Aggravating factors: Prolonged sitting, bending forward, coughing/sneezing. * Easing factors: Lying flat on back with knees bent. * 24-hour symptom behaviour: Stiff and sore in the mornings, improves slightly with movement but worsens significantly by evening, especially after work. Night pain occasionally wakes patient. Goals: * Short-term: Reduce pain intensity to 3/10 by 15 November 2024; improve lumbar flexion by 20 degrees within 2 weeks. * Long-term: Return to pain-free recreational gardening within 3 months; resume hiking without discomfort within 6 months. Objective: * Lumbar Spine: * Active Range of Motion: Flexion limited to 30 degrees (normal 60), extension to 5 degrees (normal 25), right lateral flexion to 10 degrees (normal 25), left lateral flexion to 15 degrees (normal 25). Pain reported at end-range flexion and right lateral flexion. * Palpation: Tenderness over L4/L5 spinous processes and right paraspinal muscles. * Special Orthopaedic Tests: Positive Straight Leg Raise (SLR) on the right at 45 degrees, reproducing leg pain. Negative Left SLR. Femoral Nerve Tension Test negative bilaterally. * Neurological: * Sensation: Intact to light touch in L4, L5, S1 dermatomes bilaterally. * Reflexes: Patellar reflex (L4) 2+ bilaterally, Achilles reflex (S1) 2+ bilaterally. * Strength: Grossly 5/5 in bilateral hip flexors, knee extensors, ankle dorsiflexors, and plantarflexors. Decreased strength noted in right extensor hallucis longus (L5) 4/5. Treatment: * Education Provided: * Topic: Lumbar Disc Herniation and Radiculopathy. Key message: Explanation of nerve compression, importance of directional preference, and posture modification. * Topic: Pain management strategies. Key message: Encouragement for active coping, avoiding fear-avoidance behaviours. * Manual and Hands-on Treatment: * Lumbar mobilisations: L4/L5 posterior-anterior glides, Grade II, 3 sets of 30 seconds to reduce stiffness. * Soft tissue release: Right lumbar paraspinal muscles, sustained pressure, 2 minutes. * Active Therapeutic Exercises: * McKenzie Extension in Lying: Lumbar spine, 10 repetitions, 3 sets, performed slowly and controlled. * Pelvic Tilts: Lumbar spine/pelvis, 15 repetitions, 3 sets, focusing on gentle activation of core muscles. * Glute Bridge: Hips/glutes, 12 repetitions, 3 sets, holding for 3 seconds at the top. * Home Exercises Prescribed: * McKenzie Extension in Lying: 10 repetitions, 3 sets, 3 times per day. * Cat-Camel stretch: 10 repetitions, 2 sets, once per day. * Gentle walking: 15 minutes, twice per day, pain permitting. Assessment: * Primary diagnosis: Right-sided L4/L5 disc herniation with associated right L5 radiculopathy. Clinical reasoning is based on the sudden onset with lifting, radiating leg pain, positive right SLR, and specific dermatomal/myotomal weakness in L5 distribution. Objective findings align with a mechanical low back pain picture exacerbated by neural compromise. * Differential diagnoses: Lumbar facet joint dysfunction (less likely given radicular symptoms), piriformis syndrome (ruled out by negative piriformis testing and clear lumbar involvement). * Progress towards goals: Minimal progress on short-term pain reduction, but patient demonstrates good understanding of directional preference exercises. No significant change in lumbar flexion yet. Long-term goals are currently distant. * Identified barriers: Patient's occupational requirements for prolonged sitting and occasional heavy lifting are significant barriers to progress. Fear of movement also contributing to guarded posture. Plan: * Continue with a home exercise program, reinforcing McKenzie extension principles and postural awareness. Focus on nerve glide exercises to improve neural mobility. Progress core stability exercises as pain allows. * Next review: 1 November 2024. * Next appointment interventions: Re-assess lumbar spine mobility and neurological status. Progress core strengthening, potentially introducing nerve glides. Further education on ergonomic modifications for work and lifting techniques. * Referrals: Discussion with GP regarding imaging (MRI lumbar spine) if no significant improvement in radicular symptoms within 2 weeks. * Communications: Send progress update to GP via secure messaging on 1 November 2024.