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DOCUMENTATION

DOCUMENTATION. Outcomes. Be able to document accurately and appropriately in scientific language. Subjective evaluation. Use the patient’s own words Remember to include the functional limitation. Body chart. Type of pain e.g. burning or stabbing

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DOCUMENTATION

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  1. DOCUMENTATION

  2. Outcomes Be able to document accurately and appropriately in scientific language.

  3. Subjective evaluation Use the patient’s own words Remember to include the functional limitation

  4. Body chart Type of pain e.g. burning or stabbing Intensity out of 10 e.g. 5/10 Intermittent or constant Do the different areas indicated on the body chart bear relevance to each other?

  5. Body chart Area 1 Burning pain 6/10 Constant pain

  6. Quick active tests 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 1

  7. Neurological examination (conduction) L = R (sensation is the same on both sides) Sensation: L ‹ R (L4) – sensation is less on the left side L4 dermatome Motor: R › L (L5) – could break the movement on the left side L5 miotome Reflexes: L = R (both the same) or L < R L3,4 (the reflex on the left side was weaker)

  8. Neurological examination (neural dynamic tests) In: SLR (R) Did: 60° DF + In: ULTT 2a (L) Did: Med rot + In: mid-slump L = R

  9. Other joints Thoracic spine: Flex √√ Low rotation √√ Sacro-iliac joint: Compression Grade II 3/10 Area 3 1st rib longitudinal caudad Grade 1 6/10 Area 1

  10. Miofascial Muscle strength according to Oxford scale Muscle length – according to ranges (0 – 60°)

  11. Palpation Muscles must be given where muscle spasm occurs or where trigger points occur. e.g. m quadriceps

  12. Passive accessory intervertebral movements (PAIVM’s)

  13. Passive accessory intervertebral movements (PAIVM’s) L2 ↓ Gr II 6/10 L4 Unilat ↓ R Gr III- 1/10 L5 Unilat ↓ L Gr I 8/10

  14. Problem list (ICF) Main problems of the patient as indicated on 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)

  15. Problem list (ICF) Lower lumbar pain due to: painful intervertebral joint movements of L2 – L5 or hypomobile and painful intervertebral facet joint movements of L2 – L5 L muscle spasm of m erector spinae L trigger points in m quadratuslumborum L Referred pain in L leg (L4) due to: ↓ neural mobility of n isciadicus L trigger points in m quadratuslumborum 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

  16. Problem list (ICF) Decreased mobility of n iskiadicus due to: painful intervertebral facet joint movements of L2 – L4 L muscle spasm of m erector spinae L poor posture Use your clinical reasoning skills to determine the true cause of the problem What came first (chicken – egg senario)

  17. Problem list (ICF) Weak abdominal stabilisers due to: painful intervertebral facet joint movements of L2 – L4 L muscle spasm in m erector spinae L poor posture Muscle spasm in m erector spinae due to: painful intervertebral facet joint movements of L2 – L4 L poor posture poor kinetic handling / ergonomics

  18. Problem list (ICF) Activity: Can not sit for prolonged periods of time Participation: Can not go to church Can not play bingo

  19. Aims (ICF) Decrease pain in the lumbar area b.m.o: mobilisation of the intervertebral joints / mobilisation of intervertebral facet joints Decrease muscle spasm of m erector spinae L b.m.o. massage, specific soft tissue mobilisation, electrotherapy modalities Decrease triggerpoints in m quadratuslumborumb.m.o triggerpoint therapy, hotpack

  20. Aims (ICF) Increase the mobility of n isciadicus L b.m.o neural mobilisation techniques Activation of abdominal stabilisers b.m.o activation exercises Re-education op posture b.m.o. corrective excercices Home advice

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