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Manual Therapy Assessment Form

This document contains a physiotherapy assessment form for a patient with an osteoporotic vertebral fracture. It collects information on the patient's medical history, symptoms, mobility, examination findings and considers factors for physiotherapy treatment. The form guides physiotherapists in evaluating the patient and planning their rehabilitation.

Uploaded by

Praveenkumar Cr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
565 views8 pages

Manual Therapy Assessment Form

This document contains a physiotherapy assessment form for a patient with an osteoporotic vertebral fracture. It collects information on the patient's medical history, symptoms, mobility, examination findings and considers factors for physiotherapy treatment. The form guides physiotherapists in evaluating the patient and planning their rehabilitation.

Uploaded by

Praveenkumar Cr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

Physiotherapy Assessment Manual Therapy

Participant: ________________________________ Study number: _____________


Date: ________
TELEPHONE:
Home: ______________________Work/Mobile: ____________________________

DIAGNOSIS: __________________________________________________________

Patient Sticker

Physiotherapist:....
Signature: .....
Date:

1
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

Present Condition:

Worsening Unchanging Improving


Location of pain ________________________________
Constant

Intermittent

Nature ________________________________________
History of Present Condition:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

SYMPTOMS

Patient Sticker

AGGRAVATING

EASING

Physiotherapist:....
Signature: .....
Date:

2
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

24 hour pattern:
Morning

During day

Night:
Disturbed sleep? Y N
Reason:
Sleep position:

Drug History (Tick if taking):


Osteoporosis medications _____________________________________________
Anticoagulants _____________________ Pain relief ______________________
Other medications ____________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Past Medical History:


General health description: ___________________________

Heart ________

Allergy (esp to tape or massage lotions)

Alcohol

Smoke

Cauda Equina
Past illness __________________________________________________________
Past surgery _________________________________________________________
_____________________________________________________________________

Consideration to communication:
e.g hearing difficulties ___________

Social History: Living alone

Patient Sticker

visually impaired ____________

Lives with others __________________________

Physiotherapist:....
Signature: .....
Date:

3
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

Working _______________ Retired ______________________


Dependents ___________________________________________

MOBILITY ASSESSMENT: Circle relevant level of function


Walking distance
Unlimited
500m-1km
100-500m
<100m
Housebound
Unable

Stairs
Normal (reciprocal)
One step at a time
Down with rail
Up & down with rail
Unable down
Unable

Aid Use
None
Stick outdoors
Stick always
2 sticks
2 Crutches
Walking frame
Wheeled walker

Falls History (Note if any recent/new falls)


_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Expectations of physiotherapy:
_____________________________________________________________________
_____________________________________________________________________

Aims of Physiotherapy:
_____________________________________________________________________
_____________________________________________________________________

Patient Sticker

Physiotherapist:....
Signature: .....
Date:

4
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

Objective Assessment:
General observations (including posture, skin integrity, ability to lye prone etc)

Neurological testing if indicated:


Reflexes - NAD

Myotomes NAD

Dermatomes NAD

Anomalies found __________________________________________________

Active Range

In sitting

In standing

of movement:
Lumbar spine

Flexion:

Extension:

Side Flexion:

Rotation:

Patient Sticker

Physiotherapist:....
Signature: .....
Date:

5
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

Shoulders

Palpation note spasm, trigger points, allodynia and hyperalgesia

Passive Accessory Range of movement: PAIVM: Performed as indicated from active


movement assessment. Please document position of participant.

Thoracic Level

PAIVM
PA - Spinous

PA - Right

Ax findings
PA - Left

1
2
3
4
5
6
7
8
9

Patient Sticker

Physiotherapist:....
Signature: .....
Date:

6
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

10
11
12
Lumbar Level
L1
L2
L3
L4
L5

Other:

Patient Sticker

Physiotherapist:....
Signature: .....
Date:

7
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

Physiotherapy Rehabilitation of Osteoporotic Vertebral Fracture

Analysis:
Known osteoporosis affecting thoracic level________________________________
Possible dysfunction occurring at ________________________________________
Irritability:

Nil

Moderate

High

Considerations to manual therapy and treatment (e.g.: unable to lie prone, shoulder
pathology, taking anticoagulants, allergy to tape/lotions)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Patient Sticker

Physiotherapist:....
Signature: .....
Date:

8
PROVe: Physiotherapy Rehabilitation for Osteoporotic Vertebral fracture.
Manual Therapy Assessment Form Appendix 9 version1 May2013 ISTRN49117867. REC 12/SC/0411

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