Physio Initial Outpatient

Physiotherapist Initial Outpatient Note HOPC - 45-year-old male presenting with left-sided lower back pain radiating into the left buttock and posterior thigh, which started 3 weeks ago after lifting a heavy box at work. Pain developed acutely after the lift. Initial management involved rest and over-the-counter paracetamol, with minimal improvement. Has been trying gentle stretching which exacerbates the pain. - Aggravating factors: prolonged sitting, bending forward, lifting, coughing/sneezing. Easing factors: lying flat on back, gentle walking. - Pain is typically 6/10 at its worst, often worse in the morning upon waking and after prolonged activity. Reduces to 3/10 with rest but rarely completely resolves. Radiology: - Lumbar spine X-ray (dated 25/10/2024): Reported as showing mild degenerative changes at L4/L5 and L5/S1, no acute fractures or dislocations. Past Medical History - Hypertension: Diagnosed 5 years ago, managed with Ramipril 5mg OD. Blood pressure well-controlled. - Previous right ankle sprain: Occurred 2 years ago, resolved with conservative physiotherapy. - No known allergies. Social History - Lives with wife and two children in a two-story house. Good family support network. Non-smoker, occasional social alcohol use (1-2 units per week). - No significant family medical history relevant to current condition. - Employed as a warehouse manager, typically working 40 hours per week. Job involves moderate physical intensity, including occasional lifting and prolonged standing/walking. Goals - Short-term physiotherapy goals: Reduce left lower back pain to 3/10 or less with daily activities within 2 weeks. Improve ability to sit for 30 minutes without significant discomfort within 2 weeks. - Long-term physiotherapy goals: Return to full work duties without pain within 6-8 weeks. Be able to lift objects up to 15kg comfortably within 8 weeks. Resume recreational cycling within 10 weeks. Objective - Posture: Mild lumbar lordosis, guarded movement. - Active Range of Motion (AROM) Lumbar Spine: Flexion limited to 30 degrees (painful), Extension limited to 10 degrees (painful), Left Lateral Flexion 15 degrees (painful), Right Lateral Flexion 20 degrees (mild discomfort), Rotation limited bilaterally (painful on left). - Palpation: Tenderness over left lumbar paraspinals and left sacroiliac joint. No obvious muscle spasm. - Neurological Exam (Left Lower Limb): Normal sensation to light touch in L2-S1 dermatomes. Motor strength 5/5 in hip flexors, knee extensors, ankle dorsiflexors, ankle plantarflexors. Reflexes: Patellar ++, Achilles ++. Straight Leg Raise (SLR): Positive at 45 degrees on left, reproducing posterior thigh pain. Negative on right. - Special Tests: Femoral nerve stretch negative bilaterally. Slump test positive on left at 30 degrees knee extension. Treatment - Educational treatment: Provided pain science education, explaining mechanical nature of pain and importance of graded activity. Discussed proper lifting techniques and ergonomic advice for sitting. - Hands-on treatment: - Mobilisation: Gr II PA L4/L5, L5/S1 2x30secs. - Soft tissue massage: Left lumbar paraspinals and gluteal muscles for 5 minutes. - Active therapy treatment: - 3x10 Cat-cow stretches. - 3x10 Pelvic tilts in supine. - 3x10 Gluteal activation exercises in prone. - Home Exercise Program (HEP) provided: - Cat-cow stretches: 10 repetitions, 3 sets, 3 times per day. - Pelvic tilts: 10 repetitions, 3 sets, 3 times per day. - Gentle walking: 10-15 minutes, 2 times per day. Assessment - Diagnosis: Acute mechanical lower back pain with left radicular symptoms, likely discogenic given mechanism of injury and positive SLR. No red flags identified. Patient is highly motivated but apprehensive about movement. - Progress towards goals: Initial session focused on pain reduction and education, with some immediate relief following manual therapy. Patient understands the importance of adherence to HEP to achieve short-term goals. - Barriers affecting progress: Patient's current work duties involving lifting pose a potential barrier to recovery if not modified. Pain apprehension. Plan: - Continue with graded exposure to movement and progressive strengthening exercises. - Next review in 1 week (r/v 1/52). - Likely therapy at next appointment: Re-assess pain and movement, progress HEP with core stability exercises, introduce McKenzie extension exercises if appropriate. - Referral to Occupational Health for ergonomic assessment at work and potential temporary work modifications. - Letter to GP detailing initial assessment and plan. Date: 1 November 2024