Chiropractor's note

Subjective

• Acute R-sided LBP, onset 3 days ago; constant dull ache (4/10) with sharp exacerbations (7/10) upon lumbar flexion and rising from seated position. No radiation into LE.
• Mechanism of injury: Lifting heavy storage boxes at home on 18/05/2024. Pain progressively worsened over 24 hrs post-incident with associated morning stiffness lasting ~30 mins.
• Negative for LE paresthesia, numbness, weakness, or saddle anesthesia. No bowel/bladder dysfunction. Hx of mild R ankle sprain (2019).
• PMH: Mild HTN. PSH: Laparoscopic appendectomy (2015). Denies prior spinal surgeries or fractures.
• Sedentary desk job (software developer, 8-10 hrs/day seated); poor ergonomic setup. Sleeps on stomach, waking 1-2x/night due to pain. Walks 2x/week; high occupational stress.
• Lisinopril 10 mg PO QD; ibuprofen (Advil®) 400 mg PO PRN for back pain; cholecalciferol (Vitamin D3) 2,000 IU PO QD.
• Father with lumbar DDD; mother with OA of the knees.

Objective

• BP: 128/82 mmHg, HR: 74 bpm, RR: 14 breaths/min, Temp: 36.8 °C, SpO2: 98 % RA.
• Antalgic lean to L. Mild R pelvic elevation. Lumbar AROM: flexion reduced by 50 % with pain, extension reduced by 25 % with local pain at L4-L5, R lateral flexion restricted and painful. Hypertonicity and spasm noted in R lumbar paraspinals and R quadratus lumborum (QL). Tenderness to palpation and restricted joint play at L4, L5, and R SI joint. Kemp's test positive on R for localized lumbar pain. SLR negative bilaterally.
• DTRs: Patellar (L4) 2+ bilaterally, Achilles (S1) 2+ bilaterally. Dermatomes L1-S2 intact to light touch bilaterally. Myotomes L2-S1 5/5 strength bilaterally.
• Lumbar X-ray (20/05/2024): Mild disc space narrowing at L4-L5, lumbar hypolordosis, no acute fracture or spondylolisthesis.

Assessment

• Acute lumbar sprain/strain with associated L4-L5 and R sacroiliac segmental dysfunction, secondary to lifting injury.
• L4, L5, and R pelvis/SI joint.
• M99.03 Segmental and somatic dysfunction of lumbar region; M99.04 Segmental and somatic dysfunction of sacral region; M54.50 Low back pain, unspecified; S39.012A Strain of muscle, fascia and tendon of lower back, initial encounter.

Plan

• Diversified HVLA chiropractic manipulative therapy (CMT) to lumbar spine and pelvis; drop-table assisted adjustment to R SI joint. Adjunctive myofascial release and interferential current (IFC) to R lumbar paraspinals/QL, followed by cryotherapy.
• 2x/week for 3 weeks, then re-evaluate for transition to 1x/week for 2 weeks.
• Short-term (2 weeks): Reduce pain to ≤ 2/10, restore pain-free lumbar AROM to ≥ 80 % normal. Long-term (6 weeks): Return to full pre-injury ADL capacity, improve core stability, and maintain ergonomic sitting posture without discomfort.
• Apply ice pack to low back 15 mins q2-3h PRN pain; perform gentle pelvic tilts and cat-camel stretches (10 reps, BID); avoid heavy lifting (> 5 kg) and prolonged sitting (> 45 mins without micro-breaks).

Interventions

• CMT (98940) performed using Diversified side-posture technique to L4 and L5, and Thompson drop technique to R PI ilium. Manual trigger point therapy (97140) applied to R QL and erector spinae for 8 mins. IFC (97014) applied to lumbar region for 15 mins with cryotherapy pack.
• Patient tolerated treatment well with audible cavitation achieved at L4-L5 and R SI joint. Immediate post-treatment reduction in resting pain (reported 3/10) and ~15 % improvement in lumbar flexion. No adverse reactions.

Evaluation

• Initial visit; baseline established. Immediate positive response to initial intervention with decreased paraspinal hypertonicity.
• Proceed with initial care plan as outlined; no modifications required at this time.

Additional Notes:

• Educated patient on proper lifting biomechanics (lifting with legs, keeping load close to body), workstation ergonomics (monitor at eye level, lumbar support), and transitioning from stomach to side-sleeping with a pillow between knees.
• Next appointment scheduled for 24/05/2024 at 10:00 America/Denver.
• Patient expressed slight apprehension regarding audible spinal adjustments; reassured and utilized gentle drop-table technique for pelvic alignment per patient comfort.