INITIAL EVALUATION

Name: Ethel K. Tubio

Address: Brgy 2, Siaton, Negros Oriental
Date of Birth: February 10,1995
Age: 25
Civil Status: Single
Nationality: Filipino
Gender: Female
Handedness: Right-handedness
Religion: Roman Catholic
Admitting Physician: N/A
Attending Physician: N/A
Referring Physician: N/A
Rehabilitation Physician: N/A
Medical Dx: N/A
Reason for Referral / Treating Dx: Neck pain
Date of Initial Evaluation: 11/26/2020
Informant/s and Reliability: Patient, 100%
/S/:

Problem: Pt. is a 25 y/o female with c/c of neck pain. Pain graded as 5/10 on the pain scale (0 as not pain and 10
as worst pain). Pain is aggravated by prolonged sitting with neck flexion and relieved by neck extension as well as
neck rotation. She is referred to us for PT to improve pain.

C/C: Pt. c/o significant dull, chronic pain on her neck due to prolonged sitting with improper posture. “ Musakit
siya mostly during sa akong work, especially kanang mag overtime mi." “I feel the pain mostly during work,
especially when we work overtime”, per patient’s verbal report.

HPI: Pt. started experiencing neck pain 2 years ago mostly because of her work. Pt. have been working with improper
sitting posture (neck flexion) for prolonged hours d/t their workplace not being ergonomically designed. Working
posture consists of proper work neck flexion/forward flexion.

Medications: Pt. uses salon pas and other topical ointments to alleviate pain on her neck.

Functional History:
Pt. works as an auditor for SGV, Cebu but now is currently working at home. Pt. usually works in a desk that is too
low for her height and works for almost 16 hours from 9:00 AM - 1:00 AM during busy seasons due to overtime.
During prolonged sitting, pt. would stretch 3 times in a day by extending and rotating the neck and has only two breaks
throughout her shift. Pt. is not physically active and pt. sleeps with one pillow or none.

Family History:
Father Side Mother Side
Diabetes Diabetes
Hypertension

Pt’s Goal: “Ganahan ko na ma alleviate akong pain.”

“I want my pain to be alleviated.”

/O/:

OI:
Body Type: Endomorphic
(+) postural deviation (forward neck)

V/S:

VS atx ptx Location; method; pt. position 

BP 90/70 mmHg 94/70 mmHg (R) brachial artery, auscultatory, sitting

PR 84 bpm 86 bpm (R) radial artery, palpatory, sitting

RR 16 cpm 18 cpm Diaphragmatic, sitting

O2 Sat 99% 98% (R) index finger, pulse ox, sitting

T 36.1°C 36.4°C (R) axilla, digital, sitting

ROM:
 END
NORMAL FEE
MOTION     AROM     VALUES   DIFFERENCE   L

  Cervical Flexion   0°-25°   0°-45°     20°     Firm  

  Cervical Extension   0°-42°   0°-45°     3°   Hard  

R Cervical Lat.  
Flexion       0°-35°     0°-45°     10°     Firm  

L Cervical Lat.  
  Flexion       0°-45°     0°-45°     0°     Firm  

  R Cervical Rotation       0°-60°     0°-60°       0°     Firm    

  L Cervical Rotation       0°-40°     0°-60°       20°     Firm    

Findings: Pt. has N ROM on all cervical motions except for cervical flexion, extension, ® lat. flex., & (L)
rot.
Significance: Pt has limited cervical flexion d/t pain, has limitation also on R cervical lat. flexion & L
cervical rotation d/t mm tightness.

Manual Muscle Testing:

Muscle Groups GRADE

Cervical Extensors 5/5
Capital Extensors 5/5
Combined Cervical and Capital Extensors 5/5
Cervical Flexors 4/5
Capital Flexors 5/5
Combined Capital and Cervical Flexors 5/5
R Cervical Rotators 5/5
L Cervical Rotators 4/5
R Combined capital and cervical flexors to Isolate SCM 4/5
L Combined capital and cervical flexors to Isolate SCM 4/5
Findings: Pt. has N muscle strength on all cervical mm groups except for the cervical flexors, (L) rotators, & SCM on
both sides which only has good strength.
Significance: Pt. only has good strength on cervical flexors since the mm group is weak d/t improper posture, also the
(L) cervical rotators only has good strength d/t mm tightness on the opposite side.

Special Tests:

Tests Results
Distraction Test (+) pain
Pain Scale (0-10): 4
Cervical Rotation Flexion Test Right: (+) slight pain, PS (0-10): 2
Left: (+) slight pain, PS (0-10): 1
Anterior Sheer Test (-) Pain
Foraminal Compression Test Right: (+) pain, PS (0-10): 5
Left: (+) pain, PS (0-10): 5
Findings:
Significance: The findings can be related to

Postural Analysis:
Body Type: Ectomorph
Position: Neutral standing
ANTERIOR VIEW Comments
Head (aligned, forward, flexed, extended) Aligned
Shoulders (level, uneven) Level
Rib cage (symmetric, asymmetric) Symmetric
Scoliosis (left, right, lumbar, thoracic, cervical) None
Pelvis (level, anterior/posterior tilt) Level
Hips (coxa vara, coxa valga, anteversion, retroversion Normal
Femurs (alignment, torsion) Normal
Knees (level, genu varum, genu valgum) Level
Patellar position Level
Tibias (alignment, torsions) Normal
Ankles (inversion, eversion) Normal
Rearfoot/forefoot alignment Level
Feet (pes cavus, pes planus,
supination/pronation) Normal
Toes (alignment, deformities) Level
Leg length Level
LATERAL VIEW Comments
Head (forward, flexed/extended) Forward
Mandible (resting, protracted/retracted) Resting
Scapulae (winging, elevation/depression) Level
Thoracic kyphosis (increased/decreased) Normal
Lumbar lordosis (increased/decreased) Normal
Pelvis (anterior/posterior tilt) Normal
Knees (hyperextension/flexion) Normal
Feet (longitudinal arch) Level
POSTERIOR VIEW Comments
Head (alignment, tilt) Level
Shoulder (level) Level
Scapulae (bilateral symmetry) Symmetrical
Spine C1 to sacrum (rotations, deviations) Level
Pelvis (level, tilt) Level
Sacrum (level at base and inferior lateral angles) Level
Hips (level, uneven) Level
Knees (crease level/uneven) Level
Leg (rearfoot alignment) Level
Ankle (inversion/eversion) Level
Calcaneal position (inverted/everted) Level

Findings: Pt. has significant forward head.

Significance: Pt. has forward head d/t improper head posture while working for a prolonged period of time.

Outcome Measures: Neck Disability Index Questionnaire

Section 1: Pain Intensity

I have no pain at the moment
/ The pain is very mild at the moment
 The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worst imaginable at the moment
Section 2: Personal Care (Washing, Dressing, etc.)
/ I can look after myself normally without causing extra pain
I can look after myself normally but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but can manage most of my personal care
I need help every day in most aspects of self care
I do not get dressed, I wash with difficulty and stay in bed
Section 3: Lifting
I can lift heavy weights without extra pain
/ I can lift heavy weights but it gives extra pain
Pain prevents me lifting heavy weights off the floor, but I can manage if they are
conveniently placed, for example on a table
Pain prevents me from lifting heavy weights but I can manage light to medium
weights if they are conveniently positioned
I can only lift very light weights
I cannot lift or carry anything
Section 4: Reading
I can read as much as I want to with no pain in my neck
/ I can read as much as I want to with slight pain in my neck
I can read as much as I want with moderate pain in my neck
I can’t read as much as I want because of moderate pain in my neck
I can hardly read at all because of severe pain in my neck
I cannot read at all
Section 5: Headaches
I have no headaches at all
/ I have slight headaches, which come infrequently
I have moderate headaches, which come infrequently
I have moderate headaches, which come frequently
I have severe headaches, which come frequently
I have headaches almost all the time
Section 6: Concentration
I can concentrate fully when I want to with no difficulty
/ I can concentrate fully when I want to with slight difficulty
I have a fair degree of difficulty in concentrating when I want to
I have a lot of difficulty in concentrating when I want to
I have a great deal of difficulty in concentrating when I want to
I cannot concentrate at all
Section 7: Work
I can do as much work as I want to
I can only do my usual work, but no more
/ I can do most of my usual work, but no more
I cannot do my usual work
I can hardly do any work at all
I can’t do any work at all
Section 8: Driving
I can drive my car without any neck pain
/ I can drive my car as long as I want with slight pain in my neck
I can drive my car as long as I want with moderate pain in my neck
I can’t drive my car as long as I want because of moderate pain in my neck
I can hardly drive at all
Section 9: Sleeping
 I have no trouble sleeping
/ My sleep is slightly disturbed (less than 1 hr sleepless)
My sleep is mildly disturbed (1-2 hrs sleepless)
My sleep is moderately disturbed (2-3 hrs sleepless)
My sleep is greatly disturbed (3-5 hrs sleepless)
My sleep is completely disturbed (5-7 hrs sleepless)
Section 10: Recreation
I am able to engage in all my recreation activities with no neck pain at all
/ I am able to engage in all my recreation activities, with some pain in my neck
I am able to engage in most, but not all of my usual recreation activities because of
pain in my neck
I am able to engage in a few of my usual recreation activities because of pain in
my neck
I can hardly do any recreation activities because of pain in my neck
I can’t do any recreation activities at all

Score: 10/50 Transform to percentage score x 100 = 20%points

Findings: 5-14 points (10-28%) = Mild Disability
Significance: The findings are related to the pt.’s capability in performing ADL as well as the extent to where the pt.’s
condition affects them.

ASSESSMENT:
I. Preferred Practice Pattern: Pattern 4B – Impaired Posture
II. Prognosis
A. Positive Factors
1. (+) Independence on all aspects of ADLs
2. Grades 4 & 5 for cervical & capital muscle strength
3. Pt. can efficiently communicate with PT
4. (-) Anterior Sheer Test
B. Negative Factors
1. Improper sitting posture
2. Overtime work
3. Overuse of neck flexors
4. (+) pain due to prolonged improper sitting posture
5. (+) Distraction Test
6. (+) Cervical Rotation and Flexion Test
7. (+) Foraminal Compression Test
III. PT Impression
Pt. is a home-based pt. She presented dull, chronic neck pain d/t improper posture. Pt. was able to
perform all manual muscle testing exercises with little to no difficulty. Pt. also showed little deficits
in the following ROM: cervical flex., ext., lat. flex., & rotation.
IV. PT Rehab Potential
Pain on the pt.’s neck should subside as the PTMx takes place. Pt. can opt to do stretching exercises to
help loosen the tension & lessen the pain that the pt. experiences during work.
V. Problem List
1. Dull, chronic pain on the neck
2. Pain when sitting for prolonged hours while working
VI. Long-Term Goal
Pt. should be able to work
VII. Short-Term Goal (functional, specific, measurable, achievable, realistic, and time-
bound)
Example: (usually matches the LTG/expected outcome)
a. Pt will amb. c walker 50% PWB R LE for 20 ft, x2 to progress toward amb at home
b. Pt will transfer bed <-> chair & sit <-> stand c min. assist. of 1 to progress toward
transfers at home
PLAN:
Patient will be seen as an in-patient at the Rehab dept, BID, 2 hours each session for 15 days, the following
management were performed today:
1. Example. Transcutaneous electrical nerve stimulation with conventional mode (100pps) x 15
minutes on the following painful sites: anterior deltoid area, posterior deltoid area, and anterior 2/3
of brachium.

Suggested PT Management:
1. Thermal Agent
Hot pack
Remove any jewelry and clothing form the area being treated and prepare the hot pack by wrapping
it in six to eight layers of dry towel. Place it on the bed where the neck will be resting on. Have pt.
lie in supine and provide a bell or any means for the pt. to call for assistance Check pt. for every 5
minutes for any signs of rashes or burns. Have pt. stay in that position for 20 minutes. After
treatment, check for any signs of rashes or burns.
2. Stretching Exercises
a. Neck Flexion Stretch
Begin exercise with neck in midline position. Gently bend your head forward while bringing your
chin toward your chest. Stop when a stretch is felt in the back of your neck. Hold position for 20
seconds. Return to starting position. Repeat these four more times for a total of five repetitions.
b. Neck Extension Stretch
Gently bend your head backward so that your eyes are looking up to the "sky." Stop when a stretch
is felt in the front of your neck. Hold position for 20 seconds. Return to starting position. Repeat
these four more times
3. Strengthening Exercises
a. Shoulder Scapula Squeeze
Squeeze your shoulder blades together as shown in the picture. Hold 5 seconds. Repeat 10 times.
Only squeeze hard enough to encourage good posture, not to create pain or discomfort. Perform this
exercise 2 times per day.
b. TheraBand Rows
Place Theraband around a doorknob or tie a knot in the Theraband and close it in the door. Anchor
the band at chest level. Stand tall with each end of Theraband in your hands, knees slightly bent,
abdominal muscles tight. Maintaining tight trunk muscles, pull arms back while squeezing shoulder
blades together. Focus on squeezing the shoulder blades without shrugging the shoulders up towards
the ears. Return to starting position. Do not lean back. Repeat 20 times. Perform 2 times per day.
c. Prone Rows
Lie on your stomach with your arms dangling off the side of the bed (try angling your body so your
head is facing the corner of your bed). Use a pillow under your stomach for comfort. Begin by
pulling arms back while bending elbows and squeezing shoulders blades together then slowly return
to starting position. Do not lift head up while pulling arms back. Repeat 20 times. Perform 2 times
per day.

Home Instruction:
1. Upper Trapezius Stretch
Sit up tall with good posture keeping shoulders down. Grasp the bottom of the seat with one hand.
Slightly turn your ear to your shoulder until a comfortable stretch is felt on the opposite side of the
neck. Hold that position for 20 seconds. Repeat to each side 3 times. Perform this exercise 2 times
per day.
2. Levator Scapular Stretch
Sit up tall with good posture keeping shoulders down. Grasp the bottom of the seat with one hand.
Slightly turn your chin toward your armpit until a comfortable stretch is felt on the opposite side of
the neck. Hold that position for 20 seconds. Repeat to each side 3 times. Perform this exercise 2
times per day.
3. Neck Rotation Stretch
 Rotate head gently and slowly from side to side. Do not turn head completely to either side, keep
motion small. Keep chin level with ground without letting chin drop to chest. Repeat 10 times.
Perform this exercise 2 times per day.
4. Doorway Stretch
Stand in a doorway with hands and arms out to the side as shown in picture. Keep forearms flat on
door frame. Take one step forward with one leg to feel a comfortable stretch in chest region. Hold
that position for 10-20 seconds. Repeat 3 times. Perform this exercise 2 times per day.

Prepared by:

MARIA MIKO C. SIA

BIENA K. TUBIO
SU IRS PT student batch 2022

ROSELLE FRANZ B. FELISILDA, PTRP

Clinical Instructor