• • Patient Profile Age, Gender, Occupation, Recreation, Family Chief complaint: (The reason the patient is seeking treatment, in their “own words”)

Patient Self Report Inventories • • • • Numeric Pain Rating Scale (NPRS) – Best in the last week: **/10 – – Worst in the last week: **/10 Average in the last week: **/10 Neck Disability Index (NDI): **% Fear Avoidance Belief Scale (FABQ): **/64 – Physical Activity Subscale: **/ 24 – Work Subscale : **/42 Depression Screen: – During the past month have you been bothered by feeling down, depressed or hopeless?

– During the past month have you been bothered by little interest or pleasure in doing things.

Patient Specific Functional Scale

Functional Impairment: Where 0 = unable and 10 = able to perform at pre-injury level

1) 2) 3) 4) 5)

Total Score **

P1: P2: P3: P4: Relationship of Areas Body Chart

1)Insert Text Box then type an x or copy and paste from existing 2) Resize auto shapes at will 3) When body chart is complete: Group symbols P1: P2: P3: P4:

X

History of Current Episode • • • • • Duration of symptoms: Mechanism of onset: Progression of symptoms since onset: Current status (improving, static, worsening): Treatment and response:

Previous History • • • • Previous Episodes: Contributing Factors: Previous Treatment: Medical History/Co-morbidities: –

Aggravating/Easing Factors

Area

P1 P2 P3 P4

Aggravating Activity Time /Pain Level Eases

Worst area: Best: Preferred Position of Rest: Easing positions or activitiesL

Time to subside

• • • Night: A.M.

Day: 24 Hour Behavior

Red Flag Screen • • • • • • • General Health Age 55 with history of cancer Cord: Clumsiness in hands, disturbance of gait suggestive of spasticity: Cauda Equina: Steroids or anticoagulants: Numbness and tingling in the hands and feet: 5 D’s (dizziness, diploplia, dysphagia, dysarthria, drop attacks)

Yellow Flag Screen • • • FABQ Score: Depression Inventory: Behaviors suggestive if depression – Use of extended rest – – – – Preference for passive treatment Withdrawal from daily activities Reports of extremely high pain Excessive reliance on aids or appliance – Self Medication

From the Body Chart: Structures to be Examined

Area

P1 P2 P3 P4 Other structures which must be ruled out Clinical Pattern/Classification

Structures Under the Area of Symptoms Structures Which Refer Into the area of Symptoms

Hypothesis

Current Hypotheses: In order of priority

Supporting Evidence Evidence Not supporting

Area

Severity Irritability Nature Stage Stability

P1

Presentation

P2 P3 P4

Plan of the Objective Examination • • • • • Does the nature of the condition or presence of co-morbidities indicate caution? Will you limit the amount of examination?

Will you limit the vigor? : – Examine to P1 – Examine to limit of active range – – Add overpressure Use repeated movements – Use sustained overpressure, combined movements Are special tests indicated? What structures will you examine on day 1?

Plan of the Objective Examination • • • • Do you expect the comparable sign to be easy or hard to find?

Why?

What test or movement do you think will reproduce the comparable sign?

Are there contributing factors which must be examined?

Objective Examination • • • Observation – Affect: – – Fitness: Gait: Posture – – – Habitual: Spinal curvature: Signs of muscle imbalance: Functional Screens –

Neurological Examination • • • • • • • • • Reflex: Dermatome: Myotome: Hoffman’s: Clonus: Babinski: Cranial Nerve examination : Upper cervical ligamentous stability – – – Tectoral Membrane: Transverse: Alar: Cervical Artery Screen:

Flexion Extension Rotation left Rotation right Lateral flexion left Lateral flexion right Retraction (dorsal glide) Active Range of Motion Cervical

Range Deviation Symptoms Limit of Range

Flexion Extension Rotation left Rotation right Lateral flexion left Lateral flexion right Active Range of Motion Thoracic

Range Deviation Symptoms Limit of Range

Other tests

Test

Spurling’s Traction CRLF (cervical rotation lateral flexion ) ULTT (upper limb tension test) Slump Tests Lower cervical quadrant Upper cervical quadrant

Symptoms Provoked Positive?/Comparable?

Palpation Findings: PPIVMS Motion Tested: Side gliding Occiput C1 C1C2 C2C3 C3C4 C5C6 C6C7 C7T1 Rib 1

Range End Feel Symptoms Reason for stop

Palpation Examination: Tissues at rest Category

Temperature and sweating: Skin and soft tissue: Muscle: Bony position and alignment:

Findings

Occiput C1 C1C2 C2C3 C3C4 C5C6 C6C7 C7T1 Rib 1

Range

Palpation Findings: PAIVMS

End Feel Symptoms Reason for stop

Reassessment following Palpation Subjective Reassessment

Pain levels: Global rating of change:

Objective Reassessment:

Hypothesis

Assessment Following the Objective: Review and re-rank your hypotheses

Supporting Evidence Question/Uncertainty

Is a clinical syndrome apparent: Classification: Associated factors which will require treatment:

Area

P1 P2 P3 P4 Select Subjection and Objective Asterisks

Subjective /Functional Asterisks Objective Asterisks

Technique/Intervention: Intention of Technique :

Treatment Day 1

Patient /tissue response during performance of technique:

Reassess Subjective /Functional Asterisks Reassess Objective Asterisks Exercise to support intervention: Trial of exercise: Result: Patient Education/Instruction:

Assessment Following the Treatment: 1)Review and re-rank your hypotheses 2) What is the impact of treatment on the working hypothesis Hypothesis Supporting Evidence Question/Uncertainty

Assessment Following Treatment • • • • • Working hypothesis: Was you initial hypothesis confirmed, clarified, modified or rejected? Can the disorder be classified or is a clinical syndrome apparent?

Did your assessment of Presentation change?

– Severity: – Irritability: – – – Nature : Stage: Stability: Did you accomplish what you wanted/needed to do in the first session??

Prognosis

• • • Expected level and rate of recovery: Time frame and number of visits: Factors which will promote or impede recovery: • Likelihood of recurrence:

Plan for the next session

Examine/Clarify/Rule Out

Working Hypothesis Rule out Contributing Factors Plan for next treatment session if the patient returns: Better Worse Unchanged

Visit # 2 Assessment at the Start of Session Subjective: Effect of the last treatment: Time from start of care: Time from last visit:

Reassess Subjective /Functional Asterisks Reassess Objective Asterisks

Technique/Intervention: Intention of Technique : Treatment Visit 2 Patient /tissue response during performance of technique:

Reassess Subjective /Functional Asterisks Reassess Objective Asterisks Exercise to support intervention: Trial of exercise: Result: Patient Education/Instruction:

Plan for the next session

Examine/Clarify/Rule Out

Working Hypothesis Rule out Contributing Factors Plan for next treatment session if the patient returns: Better Worse Unchanged Are you satisfied with patient progress to date: What obstacles to patient progress have you identified, and how will you manage them?:

Assessment Functional Asterisks and Impairments

At initial evaluation Current Status.

Reassessment Patient Self Reports

Patient Specific Functional Scale Impairment: Where 0 = unable and 10 = able to perform at pre-injury level

1) 2) 3) 4) 5)

Numeric Pain Rating Scale : Average Neck Disability Index : Total Score Outset Current Score

Global Rating of Change Scale

    A very great deal worse (-7) A great deal worse (-6) Quite a bit worse (-5) Moderately worse (-4)  Some what worse (-3)  A little bit worse (-2)  A tiny bit worse (-1)  (almost the same)  About the same (0)     A very great deal better (+7) A great deal better (+6) Quite a bit better (+5) Moderately better (+4)  Some what better (+3)  A little bit better (+2)  A tiny bit better(+1)  (almost the same)