Back Assessment

Subjective Assessment: Patient reports a gradual onset of lower back pain over the past 4 weeks, exacerbated by prolonged sitting and bending. The pain is described as a dull ache, radiating into the left buttock. The patient states that the pain is currently at a 6/10, and has been consistent over the last week. VAS: 6/10 Aggravated by: Prolonged sitting, bending, and lifting. Eased by: Rest and lying down. Mandatory questions: Night/Constant/Bilateral Pain/Weight Loss: No night pain, constant pain or weight loss reported. Pain is unilateral. Increased sweating/Night sweats: No. Power loss/Saddle numbness/Pins & needles: No power loss or saddle numbness reported. Occasional pins and needles in left leg. Bowel/Bladder Control: Normal. Sexual Dysfunction: Not applicable. Prolonged steroids/Osteoporosis: No. Anti-coagulants: No. Sleep Disturbance: Difficulty sleeping due to pain. Cough/Sneeze: No. Metal Implants: No. Past medical history: Patient has a history of mild scoliosis, diagnosed in adolescence. Patient valued outcomes: Patient wishes to return to playing golf and be able to sit comfortably at work. Objective Assessment: Posture: Forward head posture, mild lumbar lordosis. Gait: Normal gait pattern. Back movements: Flexion limited to 60 degrees, extension limited to 10 degrees, lateral flexion reduced bilaterally. SI joint: Negative findings on SI joint provocation tests. Hips: Full range of motion, no pain on hip assessment. Straight leg raise: Positive at 45 degrees on the left. Palpation: Tenderness over the left paraspinal muscles and L4/L5 region. Other issues: Patient is a smoker, and has been advised to quit. IMPRESSION: Mechanical lower back pain with possible lumbar facet joint involvement. TREATMENT: Soft tissue massage to the lumbar paraspinals, spinal mobilisations to improve lumbar range of movement, and education on posture and body mechanics. HEP (Home Exercise Programme): Prescribed core strengthening exercises, hamstring stretches, and postural correction exercises. Provided with written and visual instructions. ADVICE: Advised on proper lifting techniques, ergonomic adjustments at work, and the importance of regular exercise. Encouraged to quit smoking. Treatment PLAN: Review in one week. Continue with current treatment plan, and progress exercises as tolerated. Plan for next day: Review exercises and provide further education on posture and body mechanics.