PHYSICAL THERAPY INITIAL EVALUATION

Date: August 17, 2018

Greetings of good health!

Thank you for referring your patient to our clinic for physical therapy. Please find below the PTIE
findings and our suggested PT management for your consideration.

Thank you.

GENERAL INFORMATION:
Patient’s Name: Joan Marie Manuel
Age/ Gender: 31/ Female
Diagnosis: MPS (B) trapz and lumbar strain
Request: 6 PT sessions

SUBJECTIVE:
HPI:
Present condition started 2 months prior to PTIE when pt. Felt intermittent localized dull nagging pain
(PS 5/10) and intermittent localized deep aching pain (PS 5/10) on lower back. Pt. Stated that the upper
back pain usually appear p prolonged sitting and improper posture while at work pt. took ibuprofen to
ease the pain. 1 month p when pt. carried her daughter pt. Felt deep aching pain on her lower back p
lifting her child she thought pain would be resolved by pain reliever but p a week pt. Noticed no sign of
improvement which prompted her for consultation. Pt. Was diagnosed c MPS on (B) trapz and lumbar
strain, pt. was referred to PT rehab for further PT evaluation and PT treatment.

PMHx: Meds Taken:

(-) OA/RA (+) Ibuprofen for pain relief

(-) Trauma
(-) tumor/cancer
(-) heart and lung Dse

Home/Work Environment
● Office worker
● Sedentary lifestyle
● Improper ergonomic setting

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are strictly confidential. Any part of this document may not be reproduced, republished, distributed, transmitted, displayed,
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PRESENTING PROBLEM LIST:
1. (+) Intermittent dull nagging pain on (B) upper back (PS 5/10) and lower back (PS 5/10)
2. (+) Grade 1 tenderness on (B) upper trapz
3. (+) ms spasm on (B) paracervical, trapz, rhomboids, parathoracic, paralumbar
4. (+) nodules/taut band on (B) trapz, rhomboids, lev. Scap, QL, paralumbar and parathoracic
5. (+) Muscle tightness on (B) pecs, paracervical, trapz, QL, and paralumbar
6. (+) Muscle weakness of (B) rhomboids, mid/lower trapz, and core
7. (-) LOM
8. (-) ADL difficulty
9. Postural deviation: increase; cervical lordosis, thoracic kyphosis. Decrease lumbar lordosis

LEGEND:
Lines = Taut Band ● = Trigger point
X = Ms spasm

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document are strictly confidential. Any part of this document may not be reproduced, republished, distributed, transmitted,
displayed, broadcast or otherwise exploited in any manner without the explicit written permission of Almario Physio Team.
TARGET GOALS:

After 6-8 treatment sessions:

1. Decrease pain on upper and lower back up to PS 2/10
2. Eliminated tenderness on (B) trapz
3. Eliminate ms spasm on (B) paracervical, trapz, rhomboids, parathoracic, paralumbar
4. Eliminated nodules and taut band(B) trapz, rhomboids, lev. Scap, QL, paralumbar and
parathoracic
5. Decrease ms tightness(B) pecs, paracervical, trapz, QL, and paralumbar
6. Increase ms strength(B) rhomboids, mid/lower trapz, and core
7. Improve posture on head to pelvic

After 12-24 treatment sessions:

1. Avoid recurrence of pain
2. Improve body mechanics and promote proper posture
3. Increase strength on weak ms

PT MANAGEMENT DONE: Patient Reaction:

1. HMP on (B) upper and lower back x10 mins
2. TENS on (B) upper and lower back x10 mins
3. UTZ x 1.2W/cm2 on (B) upper and lower back x
4mins each
4. STM/ART on (B) Suboccipitals, paracervical,
trapz, rhomboids, lev. Scap, parathoracic,
paralumbar, QL, glutes, and piriformis
5. GPS on (B) upper trapz, paracervical,
rhomboids, QL and paralumbar
- Pt. felt relief after the HMP and TENS
- Pt. was able to finish and endure all
modalities with no adverse effect noted
- Pt. was apprehensive during manual release
but was able to tolerate STM with no adverse
effect noted
- Pt. was advised to put ice and do stretching
on area if soreness is felt.

Note:
- All modalities applied today are included in
the Doctor’s referral

HOME EXERCISE PROGRAM

1. Self-stretching activities of (B) Paracervical, trapz, rhomboids, QL and paralumbar
2. DDBE
3. PBM

Prepared by:
Jephte C. Perucho, PTRP
Attending Physiotherapist
Lic no.: 0029604

All rights are reserved. All contents (texts, illustrations, logos, photos, graphics, designs, arrangements, etc) on this
document are strictly confidential. Any part of this document may not be reproduced, republished, distributed, transmitted,
displayed, broadcast or otherwise exploited in any manner without the explicit written permission of Almario Physio Team.