SOAPIE - Physiotherapy

Subjective: - The patient, a 45-year-old office worker, reports a sedentary lifestyle with limited physical activity. - The patient presents with lower back pain that has persisted for the past three weeks, exacerbated by prolonged sitting and alleviated by standing or walking. - Past medical history includes a lumbar disc herniation diagnosed two years ago, with no previous surgeries. - Recent MRI results show mild degenerative changes in the lumbar spine. - The patient is currently taking ibuprofen as needed for pain relief. - No known allergies. Objective: - Physical examination reveals tenderness in the lumbar region, reduced range of motion in forward flexion, and mild muscle spasm in the lower back. Assessment: - Clinical assessment indicates mechanical lower back pain likely due to muscle strain and poor posture. - Problems list: 1. Lower back pain 2. Reduced lumbar mobility 3. Muscle spasm Plan: - Treatment plan includes a regimen of core strengthening exercises, postural training, and manual therapy. - Patient education on ergonomics and the importance of regular physical activity was provided. - Follow-up appointment scheduled in two weeks, with a referral to a pain management specialist if symptoms persist. Intervention: - Manual therapy techniques, including soft tissue mobilization, were performed. - Demonstrated core stabilization exercises to the patient. - Adjusted treatment plan to include additional stretching exercises. - Advised the patient on maintaining proper posture during daily activities. Evaluation: - The patient reported a slight reduction in pain and improved mobility post-intervention. - Progress noted towards achieving increased range of motion. - No new issues or concerns were raised by the patient. - Treatment plan adjustments include increasing the intensity of exercises as tolerated.