SOAP Movement Perfected

Subjective: - Patient presents today with complaints of lower back pain and stiffness. - The pain is described as a dull ache, located in the lumbar region, and has been present for the past 2 weeks. The pain is worse in the morning and after prolonged sitting. - The patient reports that rest and over-the-counter pain relievers provide some relief. - The symptoms have gradually worsened over the past two weeks. - No previous episodes of similar pain. - The pain is affecting the patient's ability to sit for long periods at work. - No other associated symptoms. Past Medical History: - No significant past medical or surgical history. - The patient works as a desk clerk and spends most of the day sitting. - No family history of back pain. - No known exposures. - Up-to-date on all immunizations. - No other relevant subjective information. Objective: - Vitals signs: BP 120/80, HR 72, RR 16. - Physical examination reveals limited lumbar flexion and extension, positive slump test, and tenderness to palpation in the lumbar paraspinal muscles. - No investigations with results. Assessment: - Likely diagnosis: Lumbar strain. - Differential diagnosis: Disc herniation, facet joint dysfunction. Treatment: - Pain science education provided regarding the nature of the injury and the importance of movement. - Mobilisation: Gr II PA R) L4/5 2x30secs, Unilateral soft tissue massage upper L) calf, etc - 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc - Home exercise program [HEP] provided: Core stabilisation exercises, 3 sets of 10 repetitions, twice daily. (Include reps, sets and frequency) Plan: - No investigations planned. - Continue with physiotherapy treatment, including manual therapy and exercise. - Advised to return to clinic in one week for follow-up. Goals - changes to be achieved: - Patient will demonstrate improved lumbar range of motion and reduced pain within two weeks. - SMART Goal 2