Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic, mechanical low back pain localized to the lumbar region, exacerbated by prolonged sitting, standing, or forward flexion. Symptoms are described as a dull ache with intermittent episodes of stiffness. No history of trauma. Denies bowel/bladder incontinence, saddle anesthesia, or progressive lower extremity weakness. Pain intensity is rated [X]/10.
Clinical Examination Findings
Lumbar spine inspection reveals flattened lumbar lordosis with paravertebral muscle hypertonicity. Palpation demonstrates tenderness over the L4-L5/L5-S1 levels. Range of motion is restricted in flexion and extension due to pain. Neurological exam: motor strength 5/5 in bilateral lower extremities, sensation intact to light touch in all dermatomes, deep tendon reflexes 2+ and symmetric. Straight leg raise test is negative bilaterally.
Treatment Protocol
Initiate conservative management including physical therapy for core stabilization and lumbar strengthening. Prescribe NSAIDs as needed for pain control. Advise activity modification to avoid heavy lifting and repetitive bending. Consider ergonomic assessment of workspace. Follow-up in [X] weeks to assess response to therapy.