Pain Management Rehabilitation Letter

Patient name and hospital number: John Smith, 1234567 Letter to: Dr. Jane Doe, GP Cc to: Dr. Robert Jones, Consultant Anaesthetist PLEASE ENSURE THE QR CODE LINK IS ON THE BOTTOM Reason for Attendance New patient assessment for chronic lower back pain. Diagnosis Chronic lower back pain, lumbar facet joint arthropathy. Current Medication * Paracetamol 1g four times daily * Ibuprofen 400mg three times daily * Amitriptyline 10mg at night Previously trialled Medication * Codeine - caused constipation and nausea. Action for GP Continue current medication regime. Consider referral to pain psychologist if mood deteriorates. Assessment "Thank you for referring John Smith to the Pain Centre. They were seen in a Physiotherapy-led new patient clinic." Patient presents with chronic lower back pain, radiating to the left leg, exacerbated by prolonged sitting and standing. Pain is described as a constant ache with intermittent sharp shooting pains. The patient reports that the pain has been present for 6 months and has been worsening over the last month. Patient understands the importance of a multidisciplinary approach to pain management, including physiotherapy, medication, and lifestyle modifications. Patient lives with his wife and has two adult children. He is retired and enjoys gardening. Patient worked as a carpenter for 30 years. He reports that his back pain started after lifting a heavy object at work. Pain significantly impacts sleep, with difficulty falling asleep and frequent awakenings due to pain. Patient reports mild low mood and some anxiety related to the pain and its impact on his activities. No previous history of mental health issues. Patient understands that his pain is likely multifactorial and that there is no quick fix. Patient expects to gain a better understanding of his pain and to develop strategies to manage it more effectively. Patient is motivated to improve his function and quality of life. Goal areas for rehabilitation include improving pain levels, increasing mobility, and returning to gardening. Examination General examination findings: Well-appearing, comfortable at rest. Physical examination findings for pain assessment and neurological/musculoskeletal systems: Tenderness to palpation over the lumbar facet joints. Reduced lumbar range of motion. Positive straight leg raise test on the left. Neurological examination intact. Discussion with Patient Discussed the nature of chronic pain and the importance of a biopsychosocial approach. Explained the role of physiotherapy, medication, and lifestyle modifications. Provided education on pain mechanisms and self-management strategies. Discussed the benefits of regular exercise, pacing activities, and stress management techniques. Advised on ergonomic adjustments at home and work. Management Plan Continue current medication regime. Commence physiotherapy program. Consider a trial of a TENS machine. Follow-up Review in 6 weeks with Physiotherapist and Pain Specialist. Date: 1 November 2024