Physiotherapy Initial Assessment

Physiotherapy Initial Assessment Current Condition/Complaint: - The patient presents with a sharp, localised pain in the lower back, specifically in the lumbar region. The pain is exacerbated by prolonged sitting, bending, and twisting motions. The pain radiates down the left leg to the knee, but not below. - Onset was approximately 2 weeks ago, following a heavy lifting incident at work. - The injury occurred while lifting a heavy box at work. The patient felt a sudden sharp pain in their lower back. - The patient has not had any prior therapy or surgery for this condition. - The patient has not seen any other health professionals for this condition. - The pain has gradually worsened over the past two weeks. Initially, it was a dull ache, but it has intensified and now includes radiating pain. - The pain is worsened by prolonged sitting and bending. It is slightly relieved by rest and lying down. - The symptoms have progressively worsened since the onset. The patient reports increasing difficulty with daily activities. - The patient has not experienced similar symptoms in the past. - The symptoms significantly impact the patient's ability to work, as their job involves heavy lifting and prolonged standing. They also have difficulty with household chores and recreational activities. - Associated symptoms include muscle spasms in the lower back and occasional numbness in the left leg. Investigations: - X-rays of the lumbar spine were taken and showed mild degenerative changes, but no acute fractures. Medical History: - The patient has a history of hypertension, well-controlled with medication. - No previous surgeries. - No known allergies. - The patient is currently taking medication for hypertension (Lisinopril 10mg daily). - No relevant family medical history. Social History: - The patient is a smoker (10 cigarettes per day) and consumes alcohol occasionally. - The patient is employed as a warehouse worker, which involves heavy lifting. - The patient reports a low level of physical activity outside of work. - The patient reports feeling anxious about their condition and its impact on their ability to work. Patient Goals: - Short-term physiotherapy goals: Reduce pain levels to a manageable level within 2 weeks, improve mobility, and be able to sit for 30 minutes without pain. - Long-term physiotherapy goals: Return to full work duties within 6 weeks, improve core strength, and prevent future episodes. Objective: - Physical examination revealed limited lumbar flexion and extension, with pain at the end range of motion. Positive straight leg raise test at 45 degrees on the left side. Palpation revealed tenderness over the lumbar paraspinal muscles. - Measurements: Lumbar flexion: 30 degrees (normal 60 degrees). Lumbar extension: 10 degrees (normal 30 degrees). Straight leg raise: 45 degrees on the left. - Assessment findings: Muscle spasm, reduced range of motion, and pain with specific movements. Diagnosis/Impression: - Likely diagnosis: Lumbar strain with possible radicular symptoms. - Differential diagnosis: Disc herniation, facet joint dysfunction. Treatment: - Education: Provided education on proper posture, body mechanics, and pain management strategies. - Hands-on treatment: Soft tissue mobilisation to lumbar paraspinal muscles, and gentle lumbar mobilisations. - Active therapy: Core stabilisation exercises, and range of motion exercises. - Home exercise program (HEP): Instructions for performing core stabilisation exercises (e.g., pelvic tilts, abdominal bracing) 3 times a day, 10 repetitions each. Assessment: - The patient presents with a lumbar strain and associated radicular symptoms. The patient's pain levels are high, and their range of motion is limited. The patient is motivated to improve. - Prioritized problems list: Pain, limited range of motion, muscle spasm, and functional limitations. - Progress towards stated goals: The patient has shown some improvement in pain levels and mobility since the initial assessment. - Factors affecting progress and any need for modification in the plan: The patient's smoking habit may be affecting their healing process. The treatment plan may need to be modified if the patient's pain does not improve. Plan: - Detailed treatment plan: Continue with soft tissue mobilisation, lumbar mobilisations, and core stabilisation exercises. Progress exercises as tolerated. Schedule follow-up sessions twice a week for the next 2 weeks. - Anticipated goals and expected outcomes: Reduce pain levels, improve range of motion, and improve functional abilities. - Referrals to other professionals: Consider referral to a pain management specialist if pain is not controlled.