Continuation Appointment

Clinician Specialty: Osteopath Progress report: Patient reports sustained improvement in lower back pain since the last session. The initial sharp, shooting pain down the left leg (duration of 3 weeks, intensity 7/10) has reduced to a dull ache (intensity 3/10) with occasional twinges. She reports increased ability to stand and walk for longer periods without significant discomfort. Current symptoms include a persistent low-grade ache in the lumbar region, primarily on the left side, which has been present for the past 2 days. The pain is localised to the L4-L5 area. The character is a constant, dull pressure. The patient notes that prolonged sitting (e.g., at her desk job) aggravates the lower back pain, while lying down with knees bent or applying a heat pack provides relief. Specific movements such as bending forward or twisting at the waist still elicit some discomfort, but significantly less than previously. Aggravating factors: prolonged sitting, bending forward, twisting. Relieving factors: lying supine with knees bent, heat application. Examination: Vitals: Blood pressure 120/80 mmHg, Heart rate 72 bpm, Respiratory rate 16 breaths/min, Temperature 36.8°C. Physical examination findings: Postural assessment reveals a slight anterior pelvic tilt and mild left lumbar scoliosis. Palpation of the lumbar spine demonstrates tenderness and hypertonicity in the multifidus and erector spinae muscles at L4-L5 on the left. Restricted range of motion noted in lumbar flexion and left lateral flexion. Sacroiliac joint motion palpation reveals hypomobility on the left. Gait appears slightly guarded but improved compared to the previous visit. Neurological examination: Reflexes (patellar, Achilles) 2+ bilaterally and symmetrical. Sensory testing to light touch intact in bilateral lower extremities. Motor strength 5/5 in all major muscle groups of the lower extremities. Diagnostic tests reviewed: Recent lumbar MRI (dated 25 October 2024) indicated mild L4-L5 disc bulging without significant nerve root compression. Osteopathic considerations: Osteopathic diagnosis or assessment: Somatic dysfunction of L4-L5 (flexion restriction, left sidebend, right rotation), left sacroiliac joint hypomobility, and associated hypertonicity of lumbar paraspinal musculature, contributing to mechanical low back pain with radicular symptoms. Identification of key areas for osteopathic treatment: Primary focus on addressing the L4-L5 segmental dysfunction and left sacroiliac joint restriction. Secondary focus on releasing myofascial tension in the lumbar region and improving overall pelvic mechanics. Working diagnosis: Mechanical lower back pain with associated left-sided somatic dysfunctions at L4-L5 and left sacroiliac joint hypomobility, causing segmental restrictions that influence local presentation. The patient's occupation involves prolonged sitting, which is a lifestyle factor relevant to her overall postural pattern and contributes to the exacerbation of symptoms. Treatment Plan: Detailed treatment plan outlining osteopathic manipulative treatment techniques: Soft tissue techniques (effleurage, petrissage) to lumbar paraspinal muscles, myofascial release to the thoracolumbar fascia, muscle energy technique for L4-L5 flexion restriction, and gentle articulation and high-velocity low-amplitude thrust (HVLA) to address left sacroiliac joint hypomobility. Expected frequency and duration of treatment sessions: Weekly sessions for the next 3 weeks, then re-evaluate. Total duration estimated at 6-8 weeks. Short-term and long-term goals of treatment: Short-term goals include reducing current pain to 1/10, improving lumbar and SIJ mobility, and decreasing muscle hypertonicity. Long-term goals involve restoring full pain-free range of motion, preventing recurrence, and improving functional capacity for daily activities and work. Advice on lifestyle modifications, exercises, or ergonomic changes: Patient advised on ergonomic setup for her desk, including lumbar support and regular standing breaks. Home exercises prescribed include gentle pelvic tilts, cat-cow stretches, and knee-to-chest stretches to maintain lumbar mobility and strengthen core muscles. Plans for additional diagnostics or referrals to other healthcare professionals: No additional diagnostics or referrals are planned at this time, but will consider if progress plateaus or symptoms worsen. Treatment performed: Details of osteopathic manipulative treatment techniques and therapeutic interventions applied during the session: Soft tissue manipulation and myofascial release applied to lumbar and gluteal musculature. Muscle energy technique performed on L4-L5 for flexion restriction. High-velocity low-amplitude thrust applied to the left sacroiliac joint. Patient tolerated all techniques well. Immediate response to treatment and any changes in symptoms or function observed: Patient reported an immediate reduction in lumbar stiffness and improved ease of movement, particularly in bending forward. Palpation post-treatment showed reduced hypertonicity in lumbar paraspinal muscles and improved sacroiliac joint motion. Evaluation: Assessment of progress towards treatment goals based on patient feedback and clinical findings: Significant progress noted with reduction in pain intensity and frequency, improved functional ability, and objective findings of reduced muscle hypertonicity and improved joint mobility. Patient is 60% towards short-term pain relief goal. Adjustments to treatment plan based on evaluation of progress: Continue with current treatment approach, focusing on maintaining gains and progressing home exercise programme. Will introduce core strengthening exercises next session. Additional Notes: Educational information provided to patient: Discussed the importance of proper body mechanics during lifting and prolonged sitting, and explained the role of core strength in preventing future back pain. Specific instructions for home care, exercises, or follow-up activities: Encouraged daily performance of prescribed stretches and advised to use heat therapy as needed. Follow-up appointment scheduled for 1 November 2024. Patient concerns or preferences discussed during the visit: Patient expressed a preference for gentle techniques where possible due to previous negative experiences, which was acknowledged and incorporated into the treatment. Ongoing informed consent during the visit: Patient verbally consented to all treatments proposed and understood the risks and benefits. Informed consent to perform high-velocity techniques: Explicit verbal consent obtained from the patient prior to performing the HVLA technique to the left sacroiliac joint. Consent to use Scribe during the visit: Patient provided verbal consent for the use of the AI Scribe during the consultation.