Physio SOAP Outpatient

Current Condition/Complaint: - The patient reports a significant reduction in pain since the last appointment. - No new symptoms or complaints have been presented. - The patient has been diligent with the home exercise program, completing exercises daily. - The patient has been using ibuprofen as needed for pain management. - A recent MRI showed mild disc bulging at L4-L5 with no nerve impingement. Objective: - Active Range of Motion (AROM): - Lumbar flexion: 70 degrees - Lumbar extension: 20 degrees - Strength Testing: - Quadriceps: 5/5 bilaterally - Hamstrings: 5/5 bilaterally - Palpation: - Tenderness noted in the lower lumbar paraspinals Treatment: - Educational Treatment: - Discussed pain management strategies and the importance of posture. - Hands-On Treatment: - Mobilisation: Gr II PA R) L4/5 2x30secs - Unilateral soft tissue massage upper L) calf - Active Therapy Treatment: - 3x10 Single leg calf raises - 3x10 L) ankle knee to walls - Home Exercise Program (HEP): - 3x15 bridges, daily - 2x20 clamshells, daily Assessment: - The patient is showing good progress with a reduction in pain and improved mobility. - The diagnosis remains consistent with lumbar strain with mild disc bulging. - The patient is progressing well towards their goal of returning to recreational running. - No significant barriers affecting progress have been identified. Plan: - Continue with the current home exercise program and add resistance band exercises. - Review in 2 weeks. - Likely therapy at the next appointment will include progression of strengthening exercises and further manual therapy. - No referrals to other professionals are needed at this time. - The therapist will send a progress update to the patient's primary care physician before the next session.