Physical Therapy Plan Of Care

Written by: [Your Name]

Date: [Date]

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I. Patient Information

Patient Name	[Patient Name]
Date of Birth	[Patient Date of Birth]
Gender	[Patient Gender]
Contact Information	[Patient Contact Number]
Address	[Patient Address]
Emergency Contact	[Patient Contact Person]

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II. Medical History

• Primary Diagnosis: Lumbar Disc Herniation

• Secondary Diagnosis (if applicable): Sciatica

• Current Medications: Ibuprofen 800mg TID, Gabapentin 300mg TID

• Past Medical History: Patient has a history of chronic lower back pain and underwent lumbar laminectomy surgery 5 years ago. No other significant past medical history.

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III. Assessment

• Physical Assessment: Limited lumbar range of motion, positive straight leg raise test on the left side, decreased sensation along the L5 dermatome on the left leg.

• Functional Limitations: Difficulty standing for prolonged periods, limited ability to bend forward without exacerbating pain.

• Pain Assessment: Patient reports sharp, shooting pain down the left leg with tingling and numbness, rated as 7/10 on the visual analog scale.

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IV. Goals

• Short-Term Goals:

  1. Improve lumbar flexibility by 20% within 4 weeks.

  2. Decrease pain intensity to 4/10 within 2 weeks.

• Long-Term Goals:

  1. Enhance core strength and stability to avoid future disc herniation.

  2. Enhance daily functioning with minimal pain.

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V. Interventions

• Therapeutic Exercises: McKenzie extension exercises - 3 sets of 10 repetitions, twice daily. Bridging exercises to strengthen gluteal muscles - 3 sets of 15 repetitions, every other day.

• Manual Therapy Techniques: Lumbar traction to alleviate pressure on the affected disc. Soft tissue mobilization to address muscle tightness in the lumbar paraspinal muscles.

• Modalities: Heat therapy for 15 minutes before therapeutic exercises to increase tissue extensibility. Ice therapy following exercises to reduce inflammation.

• Education: Patient education on proper body mechanics during activities of daily living. Ergonomic modifications for sitting and lifting to reduce strain on the lumbar spine.

• Home Exercise Program: The patient was instructed to continue McKenzie exercises and bridging exercises at home as prescribed. Emphasized the importance of consistency and proper technique.

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VI. Progress Notes

Session Date: [Date]

Progress	Description	Notes
Objective Measurements	Lumbar range of motion improved by 10% since the initial assessment. Strength in gluteal muscles increased by 25%.
Subjective Feedback	The patient reports a reduction in pain intensity to 5/10 and an improved ability to perform daily activities with less discomfort. Adhering well to a home exercise program.
Plan Adjustment	Continue current interventions with an emphasis on the progression of exercises and monitoring for any signs of exacerbation. Consideration for adding core stabilization exercises in subsequent sessions.

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