Chiropractor Initial Consultation

Chiropractor Initial Consultation Subjective Presenting Complaint: - Right-sided lower back pain radiating into the right buttock and posterior thigh, described as a dull ache with intermittent sharp stabs. Severity is 6/10 on NRS at worst, 3/10 at best. Aggravated by prolonged sitting and bending forward, relieved by walking short distances and lying down. Symptoms have been present for 3 weeks. Personal Goals (SMART) - Specific: Reduce right-sided lower back pain to allow comfortable sitting for 30 minutes without pain. - Measurable: Achieve a pain score of 2/10 or less on the NRS after 30 minutes of sitting. - Achievable: Patient is motivated and committed to exercises, and no red flags or severe pathology were identified. - Relevant: Important for the patient to return to work as a graphic designer, which involves prolonged sitting. - Time-frame: Within 4 weeks. When did it start? How has it changed? - Onset was gradual 3 weeks ago after a long car journey, with no specific mechanism of injury. Initially mild, it has gradually worsened, becoming more constant and radiating further down the leg. The pain is stable currently but fluctuates with activity levels. Medical History / Contraindications - Past medical history: No significant history. No current medications. No known drug allergies. Previous physiotherapy 2 years ago for neck pain, which resolved. No contraindications to chiropractic care identified. Red Flag Questions: - No unexplained weight loss, fever, bladder or bowel dysfunction, saddle anaesthesia, or history of cancer reported. Personal Notes / Other - Patient is a 35-year-old graphic designer, married with two young children. Finds it difficult to manage childcare responsibilities due to pain. Enjoys gardening but has had to stop due to symptoms. Expressed frustration with the persistent pain and impact on daily life. Objective Diagnosis Exam: - Blood pressure: 120/80 mmHg - Abdominal exam for LBP patients: Soft, non-tender, no guarding. No organomegaly or masses palpated. Observation: - Mild antalgic gait, favouring the right side. Forward head posture and increased lumbar lordosis noted in standing. Slight pelvic obliquity with right ilium appearing superior. No visible swelling or bruising. Patient appears tense and guarded during movement. ROM and Function: Active / functional: - Flexion: Reduced to 45 degrees, painful at end range. Lumbar spine movement initiated with hip flexion. - Extension: Restricted to 10 degrees, pain felt in the right SI joint. - Lateral Flexion (L/R): Left lateral flexion restricted to 15 degrees with discomfort. Right lateral flexion restricted to 20 degrees, pain in right lower back. - Rotation (L/R): Left rotation restricted to 25 degrees, pain in right lower back. Right rotation restricted to 30 degrees, minimal discomfort. - Other Specific ROM: Squatting limited to half depth due to right lower back pain. Passive: - Lumbar spine PROM reveals restricted and painful end-feel in flexion and extension. Restricted right SI joint mobility with a hard, abrupt end-feel. Palpation: - Hypertonicity and tenderness noted in right quadratus lumborum, gluteus medius, and piriformis muscles. Tenderness over the right sacroiliac joint. Restricted joint play at L5-S1 and right SI joint. No oedema or significant temperature changes. Neuro/Orthopaedic Tests: Positive - Straight Leg Raise (SLR) positive on the right at 45 degrees, reproducing posterior thigh pain. Kemps Test positive on the right, reproducing right lower back and buttock pain. Right SI compression test reproduces right SI pain. Pain is reproduced with right-sided SI compression. NAD - Slump test negative. Sensory and motor examination of lower extremities within normal limits. Deep tendon reflexes (Patellar, Achilles) 2+ bilaterally. Action Manual / Exercise Therapy: - Provided diversified chiropractic adjustments to L5-S1 and right sacroiliac joint. Patient provided informed consent for adjustments, understanding the risks and benefits. Mobilisation techniques applied to the lumbar spine and pelvis to improve joint mobility. Soft tissue release techniques performed on the right quadratus lumborum and gluteus medius for 10 minutes. The aim was to reduce joint restriction and muscle hypertonicity to alleviate pain and improve range of motion. Patient tolerated treatment well with immediate subjective reduction in tension. Advice and Guidance: - Advised on appropriate sitting posture using lumbar support. Emphasised regular movement breaks, suggesting standing and walking for 2 minutes every 30 minutes of sitting. Recommended avoiding heavy lifting and twisting movements. Provided education on pain management strategies including gentle heat application. Education and Reassurance: - Reassured patient that symptoms are common and often resolve with conservative care. Explained that initial adjustments may cause some temporary soreness, but this is a normal part of the healing process. Emphasised the importance of adherence to home exercises for optimal recovery. Plan Summarised SMART goal: - Sit comfortably for 30 minutes without pain (NRS <= 2/10) within 4 weeks. Their Homework: - Pelvic tilts: 10 repetitions, 3 sets, twice daily. - Cat-cow stretches: 10 repetitions, 3 sets, twice daily. - Gentle gluteal stretches: Hold for 30 seconds, 3 sets, once daily. How to incorporate play? - Advised to reintroduce short, gentle walks with children in the park, focusing on playful movement rather than strenuous exercise. Suggested gentle stretching games with kids. For next appointment? - Re-assess lumbar and SI joint mobility. - Review home exercise adherence and progress. - Progress exercises as appropriate. - Consider further adjustments or soft tissue work based on findings. Payment and Recall made? - Payment Made? £50, paid via card. - MSK-HQ reminder / recall made? Recall scheduled for 1 November 2024 for MSK-HQ follow-up and next appointment booked for 7 days time. Summary Summary / description. Clinical Reasoning for Diagnosis Working Diagnosis: - Lumbar Facet Syndrome (L5-S1) and Right Sacroiliac Joint Dysfunction with associated muscular hypertonicity. Differential Diagnoses: - Lumbar radiculopathy (ruled out by negative Slump and normal neurological exam), Piriformis Syndrome, Disc herniation (less likely given gradual onset and lack of neurological deficit). Prognosis: - Good prognosis with consistent chiropractic care and adherence to home exercises. Expected significant improvement within 2-4 weeks, with full functional recovery anticipated within 6-8 weeks.