Misr University for Science & Technology

College of: PHYSICAL THERAPY

ORTHOPAEDIC
EVALUATION
SHEET

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 HISTORY TAKING

Name: Date://
Age: gender: M\F

Occupation: Referred physician:

Address: Habits:
Marital status: Activity level:

 Medical diagnosis:
cervical disc herniation
 Chief complain:
…
pain in neck and shoulder, Tingling, numbness radiate down through the both
arms, burning sensation
✓ Past history: Any previous disease operation or trauma
… nothing

✓ Present History: Out patient ( ) In patient( )

Side: Site:

Onset: gradual Duration: 2 years

course: progressive Severity: severe

Aggravating Factors: Lifting heavy objects

twisting the neck
Poor posture
Relieving Factors: pain medications
Changing positions
 ✓ Date of hospital admission: 3/12/2020

✓ Date of surgical operation: ……………………………………………

✓ Date of reduction & fixation: …………………………………………

PHYSICAL EXAMINATION

 General examination
 Level of consciousness: Awake ( ) Confused ( ) Semi coma ( ) coma( )
 Psychological status: good
 Body type: obease
 Posture & attitude: bad

Anterior view Drop shoulder

Lateral view Rounded shoulder

Posterior view kyphosis

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  Local examinations:
By inspection:

By palpation:

Skin temperature: normal

Type of swelling: none

Skin texture: normal

Soft tissue spasm: spasm around the neck

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 Pain Assessment
o Visual analogue scale:

 Special test
TEST RESULT +ve or _ve
1-Compression Test Positive

2-Distraction Test Positive

3- Spurling’s Test Positive

  Investigations: Any radiological
examinations (MRI, CT, X-RAY)

 Muscle test
A) Individual muscle test
Muscle Grade
Anterior deltoid 2

Upper trap 2

sternocleidomastoid 3

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  Test of movement (Range of Motion (ROM)

a) Active & passive ROM

JOINT MOVEMENT ACTIVE PASSIVE LIMITATION

RT/LT RT/LT

cervical range of Flexion 50 50 No

motion Extension 35 40 Limits ROM
Lat flexion 25/30 30/35 Limits ROM
Rotation 60/70 70/ 75 Limits ROM

 Gait Analysis

(Gait abnormalities)

Gait yes No comments

Waddling gait

Limbing gait

High steppage gait

Lurching gait

Circumduction gait
  Orthotic, Prosthetic, or Ambulatory aids
evaluation comments:

Plan of Treatment
1- Problem List
IMPAIREMENT FUNCTIONAL DISABILITY
LIMITATION
cervical extension Lifting
cervical lat flexion Work
cervical Rotation Personal Care

2- Goals of treatment
Short Term Relief pain
Goals Relief Tingling, numbness

Long Term Return back to normal ADL

Goals

3- Treatment plan

1- Electrotherapy, tens, ultrasound, hot backs, IR.

2-deep trigger point message technique for muscle spasm
3- mobilization for the neck
4-stretch ex for : upper trap, levator scapulae, sternocleidomastoid, Scalene
5- Isometric strengthening ex for: flexor, extensor, upper trap Protractor and
retractor muscles and for side binding and side rotation
4- Home Program
Chin Tucks

Neck Extensions (Supported with towel)

One Arm Pec Stretch – At A Wall (Do Both Sides)

Upper Trapezius Stretch

capular Retraction (Using Resistance Bands)

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