Osteopathic Return Visit

Subjective

• Returns for review of R-sided LBP, onset 3 weeks ago. Pain improved since initial visit (02/05/2024); currently 3/10 (down from 7/10), described as a dull ache without radicular symptoms.
• Aggravated by prolonged sitting (> 45 mins) and lumbar flexion. Relieved by walking, heat packs, and home stretches.
• ROS: Negative for saddle anaesthesia, bowel/bladder dysfunction, fever, or unexplained weight loss.
• PMH: Mild OA bilateral knees. Appendicectomy (2012).
• Desk-based administrative worker (38 hrs/week). Walks dog 30 mins daily. High work stress currently.
• Paracetamol (Panadol®) 1,000 mg PO PRN; magnesium glycinate 300 mg PO nocte.
• Lives with partner in single-storey house; good social support.
• NKDA.

Assessment/ Findings

• BP 124/78 mmHg, HR 68 bpm, RR 14 breaths/min, Temp 36.7 °C.
• Posture: Mildly increased lumbar lordosis and anterior pelvic tilt. Gait: Normal, non-antalgic. AROM: Lumbar flexion 75% (mild tightness R QL), extension 80% (pain-free), L side-bending restricted. Palpation: Hypertonicity R quadratus lumborum (QL), R psoas, and R lumbar erector spinae. Somatic dysfunction: L4 ERS_R, R anteriorly rotated innominate, T12-L1 extension restriction.
• Neuro: Lower limb DTRs 2+ symmetrical (L4, S1). Myotomes L2-S1 5/5 bilaterally. Dermatomes intact to light touch. SLR negative bilaterally.

Working Diagnosis

• Resolving acute mechanical LBP secondary to lumbar and pelvic somatic dysfunction.
• Principal regions: Lumbar spine (L4 ERS_R), thoracolumbar junction (T12-L1), and pelvis (R anterior innominate) contributing to myofascial hypertonicity in R QL and psoas.

Plan

• Continue OMT focusing on soft tissue kneading, myofascial release (MFR), muscle energy technique (MET) to pelvis and lumbar spine, and HVLA to thoracolumbar junction.
• Review in 2 weeks (30-min session) to assess stability; taper to PRN thereafter.
• Short-term: Reduce pain to ≤ 1/10, restore full pain-free lumbar AROM within 2 weeks. Long-term: Prevent recurrence during high-workload periods and return to recreational swimming.
• Ergonomic adjustment: Use standing desk for 15 mins every hour. Continue daily walking.

Treatment/ Treatment Response

• Soft tissue massage and MFR applied to bilateral lumbar paraspinals and R QL. MET performed for R anterior innominate and L4 ERS_R. Counterstrain to R psoas. HVLA thrust to T12-L1 (cavitation achieved).
• Immediate post-treatment improvement in lumbar flexion (to 90%) and L side-bending. Patient reports decreased R flank tightness and pain reduced to 1/10.

Additional Notes:

• Educated on the importance of micro-breaks during prolonged desk work to prevent psoas shortening and lumbar loading.
• Home care: Progress HEP to include bird-dog (3 x 10 reps) and glute bridges (3 x 12 reps) daily, alongside existing cat-camel and supine piriformis stretches. Apply heat PRN for residual soreness.
• Patient expressed preference to avoid HVLA to the lower lumbar spine; utilised MET for L4 segment as preferred.