Calgary Cambridge Model: Physiotherapy MSK Assessment Note

Clinician Specialty: Physiotherapist Patient's Agenda * Reduce lower back pain to be able to lift grandchildren. * Improve overall mobility and return to regular gardening activities. Information Gathered Timeline The patient, a 68-year-old female, reports that her lower back pain started approximately three months ago after a long session of gardening, specifically when she was bending and twisting to plant flowers. Initially, the pain was mild and intermittent, but it has gradually worsened, becoming more constant over the last month. She experienced a similar, but less severe, episode about two years ago which resolved with rest and over-the-counter pain relievers. Area Affected The patient describes a diffuse aching sensation across her lumbar spine, radiating slightly into her left buttock. She points to the L4-L5 region as the epicentre of her discomfort, but denies any symptoms extending below the knee or into her toes. 24-Hour Pattern Symptoms are typically worse in the morning upon waking, with significant stiffness that lasts for about an hour. Pain tends to decrease with gentle movement but can worsen again towards the late afternoon and evening, especially after prolonged standing or sitting. Sleep is often disturbed by discomfort when turning in bed. Quality/Pain Type The patient characterises her pain primarily as a dull, constant ache. Occasionally, she experiences sharp, transient pains when bending forward or lifting objects. Pain Rating Scale Patient rates her pain as 6/10 at its worst (morning stiffness, lifting) and 3/10 at its best (after gentle walking or applying a heat pack). Aggravating Factors * Bending forward * Lifting objects, even light ones * Prolonged sitting (more than 30 minutes) * Prolonged standing (more than 20 minutes) * Twisting movements Alleviating Factors * Lying flat on her back * Applying a heat pack to her lower back * Gentle walking for short durations (10-15 minutes) * Resting Other Associated Symptoms The patient reports occasional stiffness in her hips, but denies any numbness, tingling, or weakness in her legs. She has not noticed any swelling in the affected area. Patient Perspective Ideas The patient believes her pain is likely due to her age and years of gardening, suggesting it might be "wear and tear" on her spine. She's also concerned she might have "slipped a disc" due to the sudden onset after bending. Concerns Her primary concern is that the pain will prevent her from caring for her grandchildren and continuing her beloved gardening hobby. She also worries about becoming reliant on pain medication. Expectations The patient hopes to receive exercises and advice that will allow her to manage her pain effectively and regain her independence in daily activities. She expects to understand the cause of her pain and what she can do to prevent it from returning. Impact on Patient's Life The pain significantly restricts her ability to lift her grandchildren, which causes her distress. Gardening, a major source of enjoyment, is now limited to very short periods. She finds it difficult to perform household chores requiring bending or prolonged standing, such as vacuuming or doing laundry. Her social life is also affected as she avoids activities that involve prolonged sitting or walking. Feelings The patient expresses frustration with her current limitations and sadness about not being able to fully engage with her family and hobbies. She admits to feeling a bit anxious about the future if the pain persists. Other Context * No history of recent falls, trauma, or unexplained weight loss. * No bowel or bladder changes reported. * No fever or night sweats. * Social Structure: Lives with her husband, who is supportive. Two adult children live nearby and provide some assistance. Active in a local gardening club. * Occupation: Retired primary school teacher. * Past Medical History: * Hypertension (managed with Lisinopril) * Osteoarthritis in knees (mild, non-symptomatic currently) * No previous back surgeries. Physical Assessment Findings Movement Tests * Active lumbar flexion: Limited to 45 degrees, painful at end range, with a compensatory hip hinge. * Active lumbar extension: Limited to 10 degrees, painful at end range. * Active lumbar side bending (left/right): Moderately restricted and painful to both sides. * Straight Leg Raise Test (SLR): Negative bilaterally at 70 degrees. * Repeated movements: No centralisation or peripheralisation observed with repeated lumbar flexion or extension. * Gait: Antalgic gait, favouring the left side, with decreased stride length. Palpation * Tenderness to palpation over L4-L5 spinous processes and paraspinal muscles bilaterally. * Mild muscle guarding noted in lumbar erector spinae. * No significant swelling or temperature changes. Diagnosis The physiotherapist's assessment indicates that the patient is experiencing mechanical lower back pain, likely attributed to lumbar muscle strain and facet joint irritation, exacerbated by degenerative changes consistent with her age and activity history. There is no evidence of radiculopathy or neurological compromise. The presentation aligns with non-specific lower back pain. Treatment Plan The proposed treatment plan includes a combination of manual therapy, therapeutic exercises, and patient education. Initial goals are to reduce pain, improve lumbar range of motion, and increase functional capacity. Manual therapy will focus on soft tissue release for lumbar paraspinal muscles and gentle mobilisation of the lumbar spine. Therapeutic exercises will include core strengthening, hip mobility exercises, and gentle stretching. The patient will be educated on proper body mechanics for gardening and lifting, pain management strategies, and the importance of graded activity progression. A home exercise programme will be provided. The timeline for treatment is initially 6-8 weeks, with review and progression as symptoms allow. Follow-up appointments are scheduled twice a week for the first two weeks, then weekly as appropriate.