DOCUMENTATION Outcomes q Be able to document accurately
DOCUMENTATION
Outcomes q Be able to document accurately and appropriately in scientific language.
Subjective evaluation q q Use the patient’s own words Remember to include the functional limitation
Body chart Type of pain e. g. burning or stabbing q Intensity out of 10 e. g. 5/10 q Intermittent or constant q Do the different areas indicated on the body chart bear relevance to each other? q
Body chart Area 1 Burning pain 6/10 Constant pain
Quick active tests q q 1 High lumbar flexion ¾ range 8/10 Area 1 * (indicate comparable sign with an asterisk) Rotation L √ (clear free active) Rotation R √√ (clear with overpressure) Low lumbar extension 6/10 OP Area
Neurological examination (conduction) q q L = R (sensation is the same on both sides) Sensation: L ‹ R (L 4) – sensation is less on the left side L 4 dermatome Motor: R › L (L 5) – could break the movement on the left side L 5 miotome Reflexes: L = R (both the same) or L < R L 3, 4 (the reflex on the left side was weaker)
Neurological examination (neural dynamic tests) q q q In: SLR (R) Did: 60° DF + In: ULTT 2 a (L) Did: Med rot + In: mid-slump L = R
Other joints q q q Thoracic spine: Flex √√ Low rotation √√ Sacro-iliac joint: Compression Grade II 3/10 Area 3 1 st rib longitudinal caudad Grade 1 6/ 10 Area 1
Miofascial q q Muscle strength according to Oxford scale Muscle length – according to ranges (0 – 60°)
Palpation q q Muscles must be given where muscle spasm occurs or where trigger points occur. e. g. m quadriceps
Passive accessory intervertebral movements (PAIVM’s) ↓ Unilat ↓ (right) Unilat ↓ (left) → ← L 1 Gr I 3/ 10 √ √ L 2 √ √ Gr II 6/10 Gr III 4/ 10 Gr I 1/ 10 L 3 √ Gr IV 1/10 √ √ L 4 Gr II 6/10 √ √ √
Passive accessory intervertebral movements (PAIVM’s) q q q L 2 ↓ Gr II 6/10 L 4 Unilat ↓ R Gr III- 1/10 L 5 Unilat ↓ L Gr I 8/10
Problem list (ICF) q Main problems of the patient as indicated on q q the body chart List everything that tested positive (not the same as normal) Prioritize for the specific patient In other words – what was affected the most Impairment must be determined objectively (what can be tested)
Problem list (ICF) q Lower lumbar pain due to: painful intervertebral joint movements of L 2 – L 5 or hypomobile and painful intervertebral facet joint movements of L 2 – L 5 L muscle spasm of m erector spinae L trigger points in m quadratus lumborum L q Referred pain in L leg (L 4) due to: ↓ neural mobility of n isciadicus L trigger points in m quadratus lumborum Referred pain down the leg could be due to nerve root irritation but this is a hypothesis and not a problem – can this be tested objectively
Problem list (ICF) q Decreased mobility of n iskiadicus due to: painful intervertebral facet joint movements of L 2 – L 4 L muscle spasm of m erector spinae L poor posture q q Use your clinical reasoning skills to determine the true cause of the problem What came first (chicken – egg senario)
Problem list (ICF) q Weak abdominal stabilisers due to: painful intervertebral facet joint movements of L 2 – L 4 L muscle spasm in m erector spinae L poor posture q Muscle spasm in m erector spinae due to: painful intervertebral facet joint movements of L 2 – L 4 L poor posture poor kinetic handling / ergonomics
Problem list (ICF) q Activity: Can not sit for prolonged periods of time q Participation: Can not go to church Can not play bingo
Aims (ICF) q Decrease pain in the lumbar area b. m. o: mobilisation of the intervertebral joints / mobilisation of intervertebral facet joints q Decrease muscle spasm of m erector spinae L b. m. o. massage, specific soft tissue mobilisation, electrotherapy modalities q Decrease triggerpoints in m quadratus lumborum b. m. o triggerpoint therapy, hotpack
Aims (ICF) q q Increase the mobility of n isciadicus L b. m. o neural mobilisation techniques Activation of abdominal stabilisers b. m. o activation exercises q Re-education op posture b. m. o. corrective excercices q Home advice
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