Physio Work Cover Initial

HOPC - Patient presents with lower back pain following a lifting injury at work on 01/09/2023. - Pain is aggravated by prolonged sitting and eased by lying down. - Pain is described as a constant dull ache with occasional sharp pains during movement. Radiology: - MRI scan on 05/09/2023 showed a herniated disc at L4-L5. Past Medical History - Hypertension, managed with Amlodipine 5mg QD. - No known allergies. Employment - Occupation: Warehouse Worker - Company Name: ABC Logistics, Logistics Industry - Regular hours: 40hrs a week - Duties: Heavy lifting, loading and unloading goods, physically demanding - Current work capacity certificate: GP certified for light duties only - Case Manager: John Smith - On modified hours: Yes, currently working 20hrs a week - On Modified duties: Yes, restricted to light duties such as inventory management - Return to work plan in place: Yes, see files Social History - Non-smoker, occasional alcohol use - Lives with spouse and two children - No relevant family medical history Goals - Short-term: Reduce pain and improve mobility within 4 weeks - Long-term: Return to full duties at work within 12 weeks Objective - Active range of motion: Limited flexion and extension in lumbar spine - Palpation: Tenderness over L4-L5 region - Strength: Reduced strength in lower back muscles Treatment - Pain science education provided - Mobilisation: Gr II PA R) L4/5 2x30secs - Unilateral soft tissue massage upper L) calf - Active therapy: 3x10 Single leg calf raises, 3x10 L) ankle knee to walls - Home exercise program: 3x10 bridges, 3x10 pelvic tilts, 3x/day Assessment - Diagnosis: Herniated disc at L4-L5 causing lower back pain - Differential Diagnosis: Lumbar strain - Progress: Patient shows slight improvement in pain levels - Barriers: Limited adherence to home exercise program Plan: - Continue current treatment plan - r/v 2/52 - Likely therapy: Progress to more advanced strengthening exercises - Referrals: None needed at this time - Communication: Will send progress report to GP before next session