Chiropractor SOAP Note

Subjective How has it been since last session? - Patient reports significant improvement in low back pain since the last session, with severity decreasing from 7/10 to 3/10. Frequency of pain episodes has also reduced from daily to 2-3 times a week, primarily after prolonged sitting. Functional limitations are less pronounced, now able to walk for longer periods without discomfort. Any post-treatment soreness? - Experienced mild, localised soreness in the lower lumbar region for approximately 24 hours after the last treatment, described as a dull ache. It resolved completely with rest and application of a heat pack. How has your homework been going? - Patient reports consistent compliance with prescribed core strengthening exercises and stretches, performing them daily as instructed. Feels the exercises have contributed to improved stability and reduced pain intensity. Progressed towards SMART goals? - Patient reports being able to tie their shoelaces and lift their grandchild without pain, which were specific goals. They also noted improved sleep quality and reduced reliance on over-the-counter pain medication. Other: - Patient mentioned an upcoming short holiday to Cornwall next month and expressed a desire to be as pain-free as possible for hiking activities. Also noted stress at work due to a new project deadline, which occasionally exacerbates their back stiffness. Objective Re-Evaluation: - Numeric Pain Rating Scale (NPRS) decreased from 7/10 at initial assessment to 3/10 today. Oswestry Disability Index (ODI) improved from 36% to 18%. Observation: - Posture: Noticeable improvement in lumbar lordosis, appears less exaggerated. Gait: Smoother and more fluid, with less guarding evident during ambulation. No visible swelling or asymmetry. ROM: Active / functional: - Flexion: Full range, smooth movement, minimal end-range discomfort. - Extension: Improved by 10 degrees compared to last session, slight stiffness at end-range. - Lateral Flexion (L/R): Left 40 degrees with mild discomfort, Right 45 degrees, pain-free. - Rotation (L/R): Left 60 degrees, pain-free. Right 55 degrees with mild restriction. - Other Specific ROM: Lumbar spine flexion-extension test showed improved segmental mobility at L4/L5. Passive: - Passive range of motion (PROM) for lumbar spine demonstrates improved elasticity and reduced capsular end-feel. Restriction pattern at L5/S1 noted to be less pronounced. Neuro-ortho tests / Palpation Positive - Minor tenderness upon palpation of the right multifidus muscle at L4/L5. Kemp's test positive on the right at end-range flexion and rotation, reproducing a dull ache. Straight Leg Raise (SLR) positive on the right at 70 degrees, eliciting a mild hamstring stretch rather than radicular pain. NAD - Slump test negative bilaterally. Femoral Nerve Stretch Test (FNST) negative bilaterally. SMART goal tracking: Patient's goal to be able to comfortably walk 5 km without pain within the next 4 weeks. This is relevant to them as they enjoy hiking and want to participate fully in their upcoming holiday. Progress is measured by their reported walking distance and pain levels. Other: - Postural assessment using a plumb line indicated continued slight anterior pelvic tilt, which will be addressed in future sessions. Action Review of Previous Plan: - Patient confirmed adherence to previous advice regarding ergonomic seating and reported no adverse reactions to the last treatment, including the mobilisation techniques applied. Manual / Exercise Therapy - Provided diversified chiropractic adjustments to the lumbar spine at L4/L5 and L5/S1, focusing on restoring segmental motion. Applied gentle soft tissue release to bilateral lumbar paraspinal muscles. Patient gave explicit verbal consent prior to treatment. The aim was to reduce joint restriction and muscle hypertonicity contributing to the reported pain and stiffness. Advice / Guidance - Advised patient on maintaining proper posture during prolonged sitting, suggesting regular micro-breaks for stretching. Educated on the importance of hydration and sleep for tissue healing. Emphasised continuing home exercises, particularly core stability work. Plan Homework: - Continue with current core strengthening exercises (plank: 3 sets of 30 seconds; bird-dog: 3 sets of 10 reps each side, daily). - Add new exercise: Cat-Cow stretch (10 repetitions, twice daily) to improve spinal mobility. - Advised to use heat pack for 15-20 minutes before performing exercises to aid muscle relaxation. To do next appointment: - Re-assess lumbar ROM and palpation findings. - Review progress on SMART goals and adjust as necessary. - Progress core strengthening exercises. - Re-evaluate postural alignment. Other: - Schedule next appointment in 1 week to monitor progress closely before holiday. Discuss strategies for managing back comfort during travel. Date: 1 November 2024