Transcript Documentation

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Be able to document
accurately and appropriately
in scientific language.
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Use the patient’s own words
Remember to include the
functional limitation
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?
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Area 1
Burning pain 6/10
Constant pain
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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
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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)
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In: SLR (R)
Did: 60° DF +
In: ULTT 2a (L)
Did: Med rot +
In: mid-slump L = R
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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
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Muscle strength according to
Oxford scale
Muscle length – according to
ranges (0 – 60°)
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Muscles must be given where
muscle spasm occurs or where
trigger points occur.
e.g. m quadriceps
↓
Unilat ↓ Unilat ↓
(right)
(left)
→
←
L1
Gr I
3/
10
√
√
√
√
L2
√
√
Gr II
6/
10
Gr III4/
10
Gr I
1/
10
L3
√
Gr IV
1/
10
√
√
L4
Gr II
6/
10
√
√
√
√
√
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L2 ↓ Gr II 6/10
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L4 Unilat ↓ R Gr III- 1/10
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L5 Unilat ↓ L Gr I 8/10
 Main problems of the patient as indicated on
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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)
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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 quadratus lumborum L
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Referred pain in L leg (L4) 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
 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
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Use your clinical reasoning skills to determine the
true cause of the problem
What came first (chicken – egg senario)
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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
 Activity: Can not sit for prolonged periods of
time
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Participation: Can not go to church
Can not play bingo
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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
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Decrease triggerpoints in m quadratus lumborum b.m.o
triggerpoint therapy, hotpack
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Increase the mobility of n isciadicus L b.m.o
neural mobilisation techniques
Activation of abdominal stabilisers b.m.o
activation exercises
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Re-education op posture b.m.o. corrective excercices
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Home advice