Pain Management New Patient letter addressed to patient (Naomi)

Patient name and hospital number: Naomi Campbell, H87654321 Letter to: Patient Cc to: GP Reason for Attendance - New patient appointment Diagnosis - Chronic mechanical low back pain with radicular symptoms Current Medication - Paracetamol 1000mg four times daily - Ibuprofen 400mg three times daily (as needed) Previously Trialled Medication - Co-codamol (discontinued due to constipation) - Amitriptyline (discontinued due to daytime drowsiness) Action for GP - Continue current medication regimen; no immediate changes recommended. - Consider referral for a community pain management programme if symptoms do not improve with physiotherapy. Assessment Dear Naomi, Thank you for attending your Physiotherapy-led new patient appointment today, 1 November 2024. This letter is a summary of our consultation for your records, and I am also sending a copy to your GP and/or the original referrer. You attended alone today and used your own transport. Your primary reason for consulting us today was chronic low back pain, which you describe as a persistent, aching pain that sometimes radiates down your left leg. You also mentioned a significant impact on your daily activities and overall quality of life. Your pain started approximately 18 months ago after a gardening injury. It is a constant dull ache, rated typically at 6/10, but can flare up to 8/10 with prolonged standing or heavy lifting. You describe sharp, shooting pains down your left leg, particularly when sitting for extended periods. Heat packs and gentle stretching provide some temporary relief. The pain significantly limits your ability to walk long distances and perform household chores. You currently cope by resting when the pain becomes severe. Regarding previous treatments, you have tried over-the-counter pain relief and had a course of private physiotherapy which provided some temporary relief but no lasting improvement. You have not had any injections or psychology support related to this pain, nor have you been involved with a pain clinic previously. An MRI scan of your lumbar spine performed six months ago showed degenerative changes at L4/L5 and L5/S1 with some disc bulging, but no significant nerve compression. You understood these findings to mean 'wear and tear' and were concerned about them worsening over time. You have previously tried Co-codamol, which was discontinued due to significant constipation, and Amitriptyline, which caused excessive daytime drowsiness. You have no known allergies to pain medications or local anaesthetics. Your past medical history includes well-controlled hypertension, for which you take Ramipril, and no significant surgical history unrelated to your current condition. You live with your partner in a two-bedroom house. On a good pain day, you can manage light housework and walk for about 20 minutes. On a bad day, you are largely housebound and require assistance with washing and dressing due to stiffness and pain. Flare-up days confine you to bed for most of the day. You are able to manage basic cooking. You do not use walking aids currently. You work as a part-time administrator, which involves prolonged sitting. You find sitting aggravates your pain, and you have taken several weeks off work over the past year due to your symptoms. Your employer has provided an ergonomic chair, but this has not fully alleviated the issue. Occupational health has not yet been involved. Your pain significantly impacts your sleep. You often struggle to fall asleep due to discomfort and wake frequently during the night. You have tried over-the-counter sleep aids which offer minimal benefit, and find a warm bath before bed sometimes helps. Your pain has left you feeling frustrated and occasionally anxious, particularly about your ability to maintain your independence. You denied any thoughts of self-harm and have no history of substance use or significant mental health difficulties, nor have you had previous psychological therapy. You understand your pain is chronic and are fearful that movement might cause further damage. You are worried it will continue to worsen and prevent you from enjoying your retirement. You came to today's appointment hoping for a definitive solution to your pain and relief from your current symptoms, ideally to get back to gardening and walking. Examination Upon general examination, your gait was slightly antalgic, favouring your left side. Your posture was generally upright, and you do not use any walking aids. No obvious joint swelling or deformity was noted. Physical examination revealed tenderness to palpation over the L5/S1 paraspinal muscles. Lumbar range of motion was restricted, particularly in flexion and left-sided lateral flexion, with pain reproduction. Straight leg raise was positive on the left at 45 degrees, reproducing your radicular symptoms. Neurological examination showed intact sensation and motor power in both lower limbs, and reflexes were symmetrical. Other systems examination was unremarkable. Discussion with Patient Naomi, we discussed that your pain appears to be mechanical in nature, likely stemming from the degenerative changes in your lower back, combined with some nerve irritation. We explored the concept of persistent pain and how the body can sometimes become overprotective, even after the initial injury has healed. I explained that movement is safe and beneficial for your back, and that gradual, controlled activity is crucial for recovery. You seemed to understand that your pain does not necessarily mean ongoing damage. I provided you with information on pain physiology and chronic pain mechanisms, emphasising that your pain is real but not indicative of severe, ongoing damage. We discussed the safety of physical activity and the likelihood of chronic pain persisting if not actively managed. We specifically addressed your concerns about gardening and confirmed that with appropriate modifications and a graded approach, you should be able to return to these activities safely. Regarding medication, we discussed the effectiveness of your current regimen. I advised you to continue with your Paracetamol and Ibuprofen as needed, noting that no immediate changes to your analgesic regimen are recommended at this stage. We will review this again at your follow-up. We did not consider any interventional procedures today. We discussed the importance of non-pharmacological interventions. I recommended a tailored physiotherapy exercise programme focusing on core stability, flexibility, and graded exposure to activity. We also touched upon the potential benefits of a Pain Management Programme, which could offer further strategies for coping with chronic pain, and we can explore a referral for this if your symptoms don't improve with physiotherapy alone. We will review your progress with the exercise programme in four weeks. We covered lifestyle modifications, including pacing your activities to avoid flare-ups, maintaining good posture while sitting and standing, and incorporating regular, gentle exercise into your daily routine. We also discussed the importance of a balanced diet for overall well-being. Management Plan - No immediate investigations planned. - Continue current medication regimen; no immediate changes recommended. - Commence a structured physiotherapy exercise programme. Explore referral to community pain management programme if symptoms do not improve. Follow-Up - Follow-up appointment scheduled in four weeks to review progress with the exercise programme. It was a pleasure meeting you today, Naomi. I have every confidence that with your active participation, we can make significant progress in managing your pain. Please do not hesitate to contact us if you have any urgent concerns before your next appointment.