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PHYSIOTHERAPY TREATMENT REPORT FORM

Patient Name: / AS / Date of Birth:
Claim Number: / Claims Rep:
Date of Injury: / 11/05/2005 / Physician: / Dr.Ranger
Occupation: / Computer Software Consultant / Vocational Status: / Working Full Hours/DutiesNot WorkingWorking Part Hours/DutiesHomemakerStudent
Referring Diagnosis: / Cervical, thoracic, and lumbar strain d/t MVA
ASSESS DATE: 11/09/2005 / RE-ASSESS DATE: Dec 6, 2005

SUBJECTIVE REPORT

(relevant history and reported symptoms)

AT ASSESSMENT

/

AT RE-ASSESSMENT

Pt. driver of honda civic, rear-ended at stop light. Head bent forward at time of impact. Back of head hit headrest, then thrown forward. Minor damage to vehicle. Immediate neck & upper back stiffness & pain. Saw GP 2 days later. Now reports burning sensation through right side of neck after sitting for long periods (>1 hr). Reports constant dull headache through forehead. / Pt. reports feeling much better lately. Has returned to the gym regularly (3x/wk) doing cardio and light weights with a trainer. Just yesterday she noticed feeling stronger than she has since prior to the accident. Still has constant dull headaches and some residual right sided neck stiffness. Low/mid back feels fine. One week ago, drove to Portland, started feeling neck stiffness after 45minutes.

OUTCOME MEASURES

(2 measures recommended)
AT ASSESSMENT / AT RE-ASSESSMENT
Type of Measure / Score / Type of Measure / Score
Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity) / 6/10 / Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity) / 3/10
Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity) / Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity)
Comments: / Comments:

OBJECTIVE CLINICAL FINDINGS

(Observation, Range of Motion, Muscle Function, Palpation, Joint Mobility, Neurological Scan, Special Tests)
AT ASSESSMENT / AT RE-ASSESSMENT
OBS: Sit slouched, fwd head posture
CSP: Decr. R Rot’n & RSF by 25% w/ pain on R side
- "tight" at base of neck with flex; incr. tone R PVM’s, SCM, Scalenes and all TOP; Stiff C5/6 R Rot’n PAVM’s.
CV: Stiff post OA glide; incr. tone suboccipitals R>L + TOP
R.SHLDR: incr. tone UFT, Lev Scap
TSP: Elevated 1ST rib; Incr. tone R Tsp PVM’s; stiff and TOP with R T2-6 PA’s.
Pelvis: R ant/L post rotated inominates / Obs: Improved posture, sits more erect
Csp: Lacks last 10% of R. Rot’n; Stiff R AA jt, improved tone through neck muscles but SCM still tight and TOP at origin
CV: Improved post glide OA; improved but still incr. tone and TOP R suboccipitals
R. Shoulder: large TP in R. Lev scap

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ASSESS DATE: Nov 9, 2005 / RE-ASSESS DATE: 12/06/2005

FUNCTIONAL ABILITY

(Work and / or Home Activities)
AT ASSESSMENT / AT RE-ASSESSMENT
Unable to do upper body gym exercises due to pain and onset of headaches.
Working full-time but increased pain reports after 1 hour of sitting. Observed to sit for 1/2 hour during assessment in slouched posture. Is required to travel both on long flights, as well as long drives frequently for work, and feels unable to manage. Cancelled work trip to toronto at end of this week. Reports low/mid back pain after 20 minutes of driving yesterday. / Has returned to gym, 3x/wk, under guidance of trainer. Doing cardio and light weights, most lower extremity, nothing overhead.
Tolerating longer periods of time at desk – pain in neck typically comes towards end of day at desk, but after 45 minutes driving.

FACTORS INFLUENCING RECOVERY

(i.e. other medical issues, complicating factors)
AT ASSESSMENT / AT RE-ASSESSMENT
None observed / None observed

TREATMENT PLAN AND RECOMMENDATIONS

(Specific Treatment Plan and Timeline)
AT ASSESSMENT / AT RE-ASSESSMENT
1. Decrease pain - education, modalities, ice,
2. Increase ROM Csp - Soft tissue work including manual therapy and stretching
3. Improve posture - exercise program, education
4. Increase tolerance to UE activity with active program
5. Increase tolerance to desk work and long travel /
  1. Progress Csp ROM – manual therapy, soft tissue work
  2. Progress UE strength/endurance to activity with progressive exercise program in conjunction with personal trainer
  3. Continue to focus on posture through education and postural exercises.

Physiotherapist: / Timberly George / Physiotherapist: / Timberly George
MSP Billing # / MSP Billing #
Clinic Name
Address / City Sports & Physiotherapy Clinic
#420 – 890 W.Pender
Vancouver / Clinic Name
Address / same
Date: / Nov 9, 2005 / Date: / Dec 6, 2005
Copy to: / Lawyer/ GP / Copy to: / Lawyer/GP

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