SUBJECTIVE ASSESSMENT

● Name : Rekha

● Age : 48 Years

● Gender : female

● Occupation : Gyneacologist

● Address : DD colony

● Chief Complaints :
Pain in the neck from six weeks
Difficult to move the head up down & while Using mobile & head turnings.
Difficulty in bending forward.
Difficulty in moving while on bed
● Present History Patient complains of neck pain from one & half month and no
history of fall or injury.
● She had severe neck pain on the right side – pronounced in working hours –
origin bad sleep postures
● Present Medical History :
● Analgesics For neck pain
● Past Medical History : At earlier, (one yr ) she has taken analgesics for
cervical pain & underwent some sessions of physiotherapy. History of B.P.&
using medication for it.

● Surgical History : Not relevant

● Family History : Not relevant

● Socio – Economic status – Good

Pain Assessment:

● SIDE –Unilateral on right side

● SITE-sub occiput to trapezius borders

● ONSET- Slow onset-gradual

● DURATION – Sub acute

● TYPE -Aching type

● VAS -Constant with VAS score of “8”
8

● Aggravating Factors : Lifting or taking any object from Ground,on activity

● Relieving Factor : Rest

• Vital signs are normal

➢ Temperature -37°C.
➢ Respiratory rate -15 per minute.
➢ Pulse rate -70 / minute.
➢ Blood pressure -130/80mm Hg.
 OBJECTIVE EXAMINATION
On Observation :
Body Built : Mesomorphic
Posture : forward stoop posture at the cervical region
Gait : not affected
Deformities : poked chin (flexion -LCR)(extension -UCR)

On Palpation :
Warmth : not affected
Swelling : mild over trapezius
Tenderness : grade 2+
OBJECTIVE EXAMINATION
• Muscle Tone : Normal tone & No muscle wasting .
• Muscle Power : trapezius grade 3+
Sternocleidomastoid grade 2+

• Muscle Girth : Not relevant

• Reflexes : C6 (Biceps reflex),C7 (Triceps reflex)
OBJECTIVE EXAMINATION
On Examination :
Range of Motion :
Presence of pain on doing active movements.

FLEXION EXTENSION LATERAL LATERAL ROTATION ROTATION

FLEXION TO FLEXION TO TO RIGHT TO LEFT
RIGHT LEFT
AROM
45° 60° 30° 20° 45° 30°

PROM
50° 65° 30° 30° 75° 75°
INVESTIGATIONS
I
No Reports
 DIFFERENTIAL DIAGNOSIS
Distraction Test. - Neg
Jackson’s Compression Test. - Neg
Foraminal Compression (Spurling’s) Test – Neg
Upper Limb Neurodynamic (Tension) Tests - Neg
PROVISIONAL DIAGNOSIS

Frm history we can conclude that no radiating symptoms , no sign of disc

involvement
Frm spl tests – further confirms that no involvement of disc & nerve root
pathologY
Trapezitis syndrome
🠶 Functional Assessment :
Unable to do overhead activities
Feeling difficulty in clothing.
Problem list :-
-Pain
-Reduced ROM
-Poor ADLS
-Difficult to sleep
Physiotherapy Management :
Day -1
🠶 Ice application
🠶 Ultrasound
🠶 Cervical Manual Traction
🠶 Stretches in supine lying –Trapezius
🠶 Scalene, Sternocleidomastoid (SCM)
🠶 IFT
🠶 Strengthening Protocol:
🠶 Chin Tucks
🠶 Isometrics -flexors, Extensors, Side flexors & Rotators
🠶 Supine:
Chin tucks
Hand raises with chin tucks
Hands àbducted with chin tucks
Àrms abducted +IR + chintucks
Àrms pressing against the bed

Prone:
Chin tucks +hand raises