Regular Chiropractic Visit

Standard Consultation Subjective Report - Patient reports experiencing lower back pain and stiffness, especially after sitting for prolonged periods. - Reports pain radiating down the right leg. - Reports onset of pain approximately 2 weeks ago, following a weekend of gardening. Posture - Mildly forward head posture observed. - Slight asymmetry in shoulder height. - Lumbar spine shows a mild loss of lordosis. Cervical (Neck) ROM - Full and pain-free. Lumbar (Lower Back) ROM - Flexion: Limited to 60 degrees, pain at end range. - Extension: Limited to 10 degrees, pain at end range. - Lateral flexion: Reduced on the right side. Other ROM - Right hip internal rotation is restricted. Objective Assessment Reflexes: - Patellar reflexes 2+ bilaterally. - Achilles reflexes 2+ bilaterally. Orthopaedic Tests: - Positive straight leg raise test on the right at 45 degrees. - Positive Kemp's test on the right. Neurological Tests: - Sensory testing intact to light touch and pinprick in lower extremities. - Motor strength 5/5 in lower extremities. Functional Tests: - Difficulty with single leg stance on the right. Findings: - Palpable muscle spasm in the lumbar paraspinal muscles. - Restricted joint motion at L4-L5. - Tenderness to palpation over the right sacroiliac joint. Diagnosis: - Multi-level Neuro-Muscular-Skeletal Dysfunction (Vertebral Subluxation) with associated Myofascial Pain Syndromes. - Possible lumbar disc involvement. - Prognosis: Good with chiropractic care and adherence to home exercises. Treatment Adjustments - Verbal consent provided to proceed with current chiropractic management plan & appropriate chiropractic intervention C- - Lateral push. T- - Anterior thoracic mobilisation. L- - Side posture mobilisation. P- - Side posture mobilisation. Extremities - No abnormalities detected. STT - Upper traps, rhomboids, lumbar erectors, sub-occipitals. Vitamins/Lifestyle/Self Management - Recommend daily intake of Vitamin D 2000 IU. - Advised to maintain good posture while sitting and standing. - Instructed on proper lifting techniques. - Recommended ice application to the lower back for 20 minutes, 3 times a day. Recommendations - Continue with chiropractic care 2 times per week for the next 2 weeks. - Prescribed home exercises including pelvic tilts, cat-cow stretches, and hamstring stretches. Next Visit - Schedule follow-up appointment for 1 week from today, 8 November 2024. - Re-evaluate pain levels, range of motion, and functional status. - Adjust treatment plan as needed.