Occupational Health Physio Assessment Note

Reason for referral: Referred by GP for assessment of persistent lower back pain impacting work performance. Consent status: Patient provided explicit verbal consent for assessment and treatment. HPC: Mr. John Smith, 45, presents with lower back pain radiating to his left buttock, ongoing for 3 months. Pain started insidiously with no clear mechanism of injury. It is worse with prolonged sitting and lifting, and slightly improves with walking. He describes it as a dull ache with intermittent sharp pains, particularly when bending. He has tried over-the-counter paracetamol with minimal relief. He has not sought any other professional medical advice for this condition prior to this referral. Compensation/ claim: No active compensation or insurance claims related to this condition. Understand diagnosis: Patient understands his diagnosis as 'general lower back pain' and is keen to understand the specific cause and how it affects his work. How do you feel about Rx to date: Patient feels current pain management (paracetamol) is ineffective and is frustrated by the lack of improvement. Investigations: No previous investigations (e.g., X-rays, MRI) have been performed for this complaint. PC: Lower back pain radiating to the left buttock. NRS: 5/10 at rest, 7/10 with prolonged sitting/lifting. Aggs: Prolonged sitting, bending, lifting, static postures at work. Eases: Light walking, lying down. 24hr pattern: Worse in the morning, eases slightly throughout the day with movement, but exacerbates in the evening after work. Sleep affected? Sleep is occasionally disturbed, patient reports difficulty finding a comfortable position, leading to broken sleep 2-3 nights a week. P&N/numbness/altered sensation: Reports occasional pins and needles in the left buttock, no numbness or altered sensation down the leg. Swelling/Locking/Giving way No joint swelling, locking, or giving way reported in the spine or lower limbs. Driving Driving for more than 30 minutes significantly aggravates symptoms, making his 45-minute commute challenging. ADLs Impacts ability to lift groceries, tie shoelaces, and engage in recreational gardening. DH: Paracetamol PRN (currently 1g QDS, ineffective). PMH: Asked: TB/Ca/DM/Epi/RA/CVS/Resp/Major Ops/#'s/Osetoporosis/Osteopenia /Hypertension/Circulatory Problems/Steroids/Anticoags Pt Reports: History of childhood asthma, well-controlled. No other significant past medical history. Smoker: Non-smoker. Alcohol intake: Social drinker, 3-4 units per week. General Health: Generally good, apart from current back pain. Exercises regularly before this flare-up. Mood stable: Reports stable mood, but frustrated by pain and impact on work/hobbies. Stress levels: Moderate stress levels, primarily due to work demands and concern over back pain. Home support: Lives with wife, who is supportive. What do you family think: Family is concerned and encourages him to seek professional help. Are they supportive: Yes, very supportive. Yellow flags present?: Fear-avoidance behaviours (avoiding bending, lifting), low self-efficacy regarding recovery from pain, perception that pain means damage, and frustration with work impact. Red flags: Asked: Weight loss, fever, bladder/bowel changes, saddle anaesthesia, trauma, history of cancer. Pt Reports: No red flag symptoms reported. Spondyloarthritis: No morning stiffness >30mins, no alternating buttock pain, no family history. Low likelihood. Cervical Special Questions / VBI: Asked: Dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, numbness (peri-oral). Pt Reports: No VBI symptoms reported. CES Screening Asked: Bladder/bowel incontinence/retention, saddle anaesthesia, bilateral leg weakness, progressive neurological deficit. Pt Reports: No CES symptoms reported. SH: Role: Office Administrator Hrs: 37.5 hours/week, 9am-5pm Main duties: Data entry, managing appointments, preparing reports, occasional lifting of archive boxes (up to 10kg). In work / off sick (how long): Currently in work, but struggles significantly. Has taken 3 days off in the last month due to pain. Length current fit note: N/A Barriers for RTW: Pain with prolonged sitting, difficulty with lifting tasks, reduced concentration due to pain. Enjoy job: Generally enjoys his job, finds it rewarding. Symptom impact on job: Significant impact, reports reduced productivity and concentration, fears losing his job if pain continues. What support would you expect from your colleagues?: Understanding and assistance with heavier lifting tasks. WAS: 6/10 (Patient rates his current work ability as 6 out of 10 compared to his best). Blue / Black flags present?: Lack of employer understanding regarding pain, limited ergonomic support at work, concerns about job security. Hobbies/ physical activity: Used to enjoy gardening and cycling, both now limited by pain. Meeting WHO guidelines: Currently not meeting WHO guidelines due to pain limiting physical activity. What are you hoping to get from today's consultation/ physiotherapy? Patient hopes for an understanding of his condition, pain relief, and strategies to return to full work duties and hobbies without pain. Patient perception of what they need: Believes he needs exercises to strengthen his back and advice on how to sit without pain. O. Observation: Standing: Appears comfortable, good posture, no obvious pelvic tilt or scoliosis. Walking: Normal gait pattern, no antalgic lean. Sitting: Slightly slumped posture, frequent shifting of weight. Active ROM: Lumbar Flexion: Limited to mid-range, pain at end range. Extension: Full range, pain at end range. Lateral Flexion: Full, pain to left. Rotation: Full, pain to left rotation. Passive ROM: Comparable to active ROM, no significant end-feel abnormalities. Strength: Bilateral hip flexion, extension, abduction, adduction, knee flexion, extension all 5/5. Ankle plantarflexion and dorsiflexion 5/5. Neurological Assessment: Lumbar: Myotomes Left / Right L2 5/5 5/5 L3 5/5 5/5 L4 5/5 5/5 L5 5/5 5/5 S1 5/5 5/5 Dermatomes Left / Right L2 Normal Normal L3 Normal Normal L4 Normal Normal L5 Normal Normal S1 Normal Normal Reflexes Patella L3/4 2+ (Normal) 2+ (Normal) Achilles L5/S1 2+ (Normal) 2+ (Normal) SLR: L 70 degrees (mild buttock pain) R 90 degrees (no pain) Slump test: L Positive at 45 degrees (buttock pain) R Negative PKB: L Negative R Negative Babinski: Negative Clonus: Negative Heel Shin co-ordination: Intact bilaterally Palpation: Tenderness noted over left paraspinal muscles at L4/L5 level. No significant palpable spasm or oedema. Rx. Education of findings and working diagnosis Explained findings suggest mechanical lower back pain with some neuropathic contribution to the left buttock. Emphasised that pain does not equate to damage and movement is safe. Discussed the role of prolonged static postures and lifting techniques in symptom exacerbation. Explanation of rehabilitation importance and treatment options discussed: Discussed the importance of a graded exercise program, ergonomic modifications at work, and pacing activities. Treatment options include manual therapy, specific exercises, and pain education. Emphasised active self-management approach. Exercises: Prescribed gentle lumbar mobility exercises (cat-camel, pelvic tilts), gluteal activation exercises (glute bridges), and core stability exercises (dead bugs). Advised patient to perform 3 sets of 10 repetitions, twice daily. A . Impression / working diagnosis: Mechanical lower back pain with left gluteal pain, likely exacerbated by occupational postures and lifting. No red flags identified. Presence of yellow flags (fear-avoidance, job concerns) that need addressing. Main subjective findings = 3-month history of lower back pain radiating to left buttock, NRS 5/10 at rest, 7/10 with activity. Aggravated by prolonged sitting/lifting, eased by walking. Impacting sleep, driving, ADLs, and work performance. Main objective findings = Tenderness over left L4/L5 paraspinal muscles. Limited and painful lumbar flexion, extension, and left lateral flexion ROM. Positive Left SLR and Slump test. Normal strength, sensation, and reflexes. No red flags or signs of neurological compromise. Work status = Currently in work but struggling; 3 days sick leave in the last month. Significant barriers to return to full, pain-free duties. Main obstacles to work = Prolonged sitting, heavy lifting tasks, fear of aggravating pain, and job security concerns. P. 1. Commence prescribed home exercise program. 2. Provide ergonomic advice for workstation setup and lifting techniques. 3. Discuss pacing strategies for work tasks and daily activities. 4. Education on pain physiology and reducing fear-avoidance behaviours. 5. Schedule follow-up appointment in 1 week to review progress and progress exercises. 6. Consider discussing phased return to work with employer and potential workplace adjustments if no significant improvement.