EVERYDAY PT

REHABILITATION MEDICINE AND PHYSICAL THERAPY DEPARTMENT

Mayon Ave.,San Quintin St., Naga City, Camarines Sur
INITIAL EVALUATION

Patient Info
Name: Norman Bislumbre (N.B.)
Age: 57
Sex: Male
Address: San Vicente, Canaman, camarines Sur
Civil Status: Married
Handedness: Right
Occupation: Civil Eng.
Religion: Roman Catholic
Referring MD: Dr. jesse Joson
Date of Referral: October 10, 2023
Date of I.E.: October 12, 2023
Dx: MPS (Myofascial pain syndrome)

SUBJECTIVE

C/C: “Pirming nag kukulug ang likod kang sa may liog ko, pa dikit dikit nag kukulug siya. Pag
nagyuyuko ako, nakulog na shoulders ko, haloy na din ni sako. Si sa likod ko man, haloy na ni,
pero bihira man siya mag kulog.”

PT Translation: Pt. c/o cramping pain on Ⓑ shoulders d/t pain being experienced on Ⓑ
postero-lateral aspect of the neck. Pt also c/o pain on the lumbar area that is felt rarely.

Pt. Goal: “mahali ang kulog tapos discomfort na nafefeel ko sa may likod kang sa may neck ko
para dae na mag kulog shoulders ko”

PT Translation: Pt. goal is to eliminate discomfort and cramping pain on Ⓑ neck and
shoulders.

Precaution: N/A
HPI

Informant: Patient
Reliability: Good

Pt’s present condition started a long time ago, date was unrecalled. Pt. c/o cramping pain on
Ⓑ postero-lateral aspect of the neck and shoulders c̅ a pain scale of 6/10, aggravated during
prolonged stoop posture and excessive carrying of heavy stuff, is alleviated at rest. Pain on
Lumbar area c̅ a pain scale of 5/10 which occurs seldomly and is aggravated during prolonged
slouch sitting position and prolonged standing position. When pt. first felt pain on Ⓑ
postero-lateral aspect of the neck and shoulders, massage was the pt’s administered first aid.
Pain felt by the pt’s lumbar area was administered by rest. Pt. decided to have a check up d/t
c/o pain being felt for many years. Pt. underwent an MRI on Oct 10, 2023 at NICC Doctors
Hospital and was assessed by Dr. Jesse Joson PTRP, MD, FPOA. According to the results of
the MRI, pt’s Thoracic Spine T3/T4: Central disc protrusion with cord deformity, and disc
desiccation at T3/T4 and T6/T7. Lumbosacral results were Grade 1 isthmic Spondylolisthesis,
L5/S1 causing mild bilateral foraminal narrowing, facet joint arthrosis at L4/L5 and L5/S1, and
lumbar Spondylosis. Pt did not undergo any type of Physical therapy treatment/session prior to
the referral. Pt. was referred by Dr. Jesse Joson PTRP, MD, FPOA to have further assessments
at Everyday PT. October 13, 2023, pt. went to everyday PT, was assessed and treatment
sessions started.

Medications: Pt. has the ff. medications

Medication Dosage Frequency Indication Adverse Effects

Ancillary Procedures

Procedure Location Taken at Date Results

T3/T4: Central
disc protrusion
NICC Doctors October 10,
MRI Thoracic Spine with cord
Hospital 2023
deformity, and
disc desiccation
 at T3/T4 and
T6/T7

Grade 1 isthmic
Spondylolisthesi
s, L5/S1 causing
mild bilateral
foraminal
Lumbosacral NICC Doctors October 10, narrowing, facet
Spine Hospital 2023
joint arthrosis at
L4/L5 and
L5/S1, and
lumbar
Spondylosis.

PMHx
● (-) HTN
● (-) DM
● (-) Allergies
● (-) Asthma
● (-) Heart Dse

SHx
● Pt has a sedentary lifestyle. Pt. sits down/lays down watching TV and does not do much.
Pt. does stretching exercises seldomly to none, with limited given time.
● Pt. prefers eating fruits and vegetables with some meat and fish as a diet.
● Pt. does not smoke
● Pt. is an occasional drinker of alcoholic beverages

FMHx

Name of Dse Father Mother

Heart DSE - +

OA - +

HTN - -
 DM - -

Asthma - -
Findings: Pt’s mother has hx of Heart disease and OA
Significance: Pt. is at risk of developing Heart disease and OA

OBJECTIVE

V.S. (Vital Signs)

ā p̄ Location

BP (mmHg) 130/80 mmHg 130/90 mmhg Medial Antecubital

Fossa

PR (bpm) 78 bpm 76 bpm Index Finger

RR (cpm) 16 cpm 17 cpm Chest

Temperature 36.0° 36.2° Forehead

O.I
● Endomorph
● A/C/C (alert/coherent/cooperative)
● Ambulatory ṡ AD’s
● Well nourished - Pt’s diet is healthy and adequate
● Well developed - Pt. has appropriate body type according to age
● (+) Postural deviation (see P.A.)
● (+) Protracted scapula
● (+) ↑ Kyphotic posture of the neck
● (+) ↑ Thoracic Kyphosis

PALPATION

● Normothermic on all palpated areas of Ⓑ UEs

● (+) Nodules on Ⓑ Upper trapezius area
● (+) Taut bands on Ⓑ Upper trapezius area
● (+) Gr.1 tenderness on Ⓑ postero-latral aspect of the neck
● (-) Swelling on Ⓑ Upper trapezius
● (-) Edema on Ⓑ Upper trapezius
 ● (-) Crepitus on Ⓑ Upper trapezius
● (-) Muscle Spasms on Ⓑ Upper trapezius

Musculoskeletal Assessment

ROM (Range of Motion)

DIFFERENCE
L Ⓝ R
ARO PRO ARO PRO
End Feel
Ⓝ End
Motion Feel
M M M M

AROM PROM L R AROM PROM L L R R L R

Cervical 0°-51 0°-50 Empt

0°-49° y
Firm Firm
Rotation ° °

Cervical
0°- 0°- 0°-22 0°-22 Empt Empt
lateral 20° 25°
0°-22°
° °
0°-30° 0°-2° 0° y y
Firm
Flexion

Hip Flexion
0°- 121° Soft

DIFFERENCE
ARO Ⓝ End
MOTION M
PROM Ⓝ End Feel
Feel
AROM PROM

Cervical 0°- 0°-

25° 40°
0°- 40° 0°- 15° 0° Firm Firm
Flexion

Cervical 0°- 0°-

40° 45°
0°- 50° 0°- 10° 0°- 5° Firm Firm
Extension
MMT (Manual Muscle Testing)

MMT Grade

L R

Bilat. Shoulder Flexion 4-/5 4-/5

Bilat. Shoulder Abduction 4-/5 4-/5

Cervical Lateral Flexion 4-/5 4-/5

Cervical Extension 4-/5

Cervical Flexion 4-/5

Cervical Rotation 4-/5 4-/5

Bilat. Hip flexion 4-/5 4-/5

Findings: Pt. has ↓ MMT Strength on Ⓛ and ® shoulder flexion and abduction, cervical
mobility and Hip flexors.
Significance: Pt. has weaknesses that will affect ADL’s such as carrying stuff, head and neck
mobility, and hip strength.

Postural Analysis

LANDMARK A/P VIEW LATERAL VIEW

Head Midline Forward head posture

Neck (+) Stooping of neck ↑ Kyphotic posture

 Shoulder Slightly forward Protracted Scapula

Elbow Ⓑ Slightly flexed

Hand Functional Position Unclenched

Spine Midline Innervated lumbar Lordosis

Hips ASIS and PSIS are leveled Normal

Knees Leveled Normal

Ankle Medial and Lateral Malleoli are Normal

leveled

Outcome Measurement Tool

ADL/ Functional Assessment:

Self- Care Eating 7

Grooming 7

Bathing 7

Dressing-upper body 7

Dressing lower body 7

Toileting 7

Sphincter Control Bladder management 7

Bowel management 7

Mobility/Transfer Bed/chair 7

Toilet 7

Tub/shower 7
 Locomotion Walk 7

Stairs 7

Findings: Pt. is independent in all aspects of the assessment.

Significance: Pt. will not have difficulty in ADLs.

ASSESSMENT

PT Impression

Pt is a 57 year old male presenting c/o MPS c̅ a pain scale of 6/10 on Ⓑ postero-lateral
aspect of the neck and shoulders, c̅ presence of lumbar pain c̅ a pain scale of 6/10 in rare
occasions. Slight muscle weakness on Ⓑ shoulder flexion and abduction, cervical mobility c̅ ↓
cervical rotation, lateral flexion, flexion and extension, (+) postural deviation, (+) forward head
posture, ↑ Kyphotic neck posture, shoulders slightly forward at A/P view . Pt. also has (+)
nodules on Ⓑ Upper trapezius, (+) Taut bands on Ⓑ upper trapezius, ↓ Hip strength during
flexion.

Rehab Potential/Prognosis

Pt. has good rehab potential 2° to minimal disability, complete independence in performing
ADL’s, ability to follow instructions c̅ willingness to participate in the plan of care, very
cooperative and accommodating during treatment.

Problem List

Pt c/o Cramping pain on Ⓑ postero-lateral aspect of the neck and shoulder, Pain on Lumbar
area, (+) Nodules on Ⓑ upper Trapezius,(+) Taut bands on Ⓑ upper Trapezius, (+) Postural
deviations; (+) forward head posture, (+) Thoracic Kyphosis, MMT weakness on Ⓑ Shoulder
flexion and abduction, Cervical Mobility, MMT weakness on Hip flexors.
STG (3x/week, 4 months)

1. ↓ Cramping pain on Ⓑ postero-lateral aspect of the neck and shoulder from a pain scale
of 6/10 to at least 3/10 within 2 weeks of treatment.
2. ↓ Pain at Lumbar area from 6/10 - at least 3/10 within 2 weeks of treatment.
3. ↓ Nodules on Ⓑ upper Trapezius within 2 weeks of treatment.
4. ↓ Taut bands on Ⓑ upper Trapezius within 2 weeks of treatment.
5. To correct Postural deviations; ↓ Forward head posture, ↓ thoracic Kyphosis,↓ Protracted
scapula within 3 weeks of treatment.
6. ↑ Strength of Ⓑ Shoulder flexion and abduction, Cervical Mobility, and hip flexor
strength from 4-/5 to 4+/5 within 3 weeks of treatment.

LTG(3x/week, 10 months)

1. Eliminate cramping pain on Ⓑ postero-lateral aspect of the neck and shoulder within 3
weeks of treatment, avoiding fatigue and too much ADL’s to prevent recurrence.
2. Eliminate pain at Lumbar area within 3 weeks of treatment, avoiding too much slouch
sitting posture and excessive prolonged sitting position to prevent recurrence.
3. Eliminate Nodules on Ⓑ upper Trapezius.
4. Eliminate Taut bands on Ⓑ upper Trapezius
5. Correct postural deviations; straighten head posture, straighten back, correct scapula
position within 3 weeks of treatment.
6. Normal (5/5) strength of Ⓑ Shoulder flexion and abduction, Cervical Mobility, Hip
flexors within 4 weeks of treatment, maintain daily strengthening exercises.

PLAN

PT Mx

1. TENS on painful areas of Ⓑ Upper trapezius and Lumbar area x 15 mins

2. IRR on Ⓑ Upper Trapezius x 15 mins
3. DKM on Ⓑ Upper Trapezius x 3 mins
4. Stretching of Bilat. Trapezius x 30 secs hold x 3 sets
5. Calliet exercises x 30 secs hold x 3 sets
6. Chin Tucks x 7 secs hold x 10 reps
7. Williams flexion (1 to 2) x 10 secs hold x 5 sets each side
 8. Pelvic Bridging x 30 secs hold x 3 sets
9. Superman pose with Ⓑ arms extended while on prone position x 10 secs hold x 5 sets

Suggested PT Mx

1. Wall sliding exercises Ⓑ shoulders while standing x 10 reps x 2 sets

2. PNF exercises with cones x 10 reps x 2 sets
3. Wand exercises, all planes to Ⓑ shoulders while standing x 10 reps x 2 sets
4. Bicep curls c̅ 3 lbs dumbbells Ⓑ shoulders while sitting/standing x 10 reps x 2 sets
5. Triceps curls c̅ 3 lbs dumbbells Ⓑ shoulders while sitting/standing x 10 reps x 2 sets
6. Neck lateral flexion on Ⓑ sides x 10 reps x 2 sets
7. PRE’s on Ⓑ UEs, all planes x 7 reps x 3 sets

Home Exercise Program

1. Shoulder abduction exercises c̅ water bottles as substitute for dumbbells x 10 reps x 3

sets
2. Shoulder flexion exercises c̅ water bottles as substitute for dumbbells x 10 reps x 3 sets
3. Bicep curls c̅ water bottles as substitute for dumbbells x 10 reps x 3 sets
4. Triceps curls c̅ water bottles as substitute for dumbbells x 10 reps x 3 sets
5. Williams flexion (1 to 3) x 7 secs hold x 5 sets for each motion

Home Instruction Program

1. Pt and family education; pt’s condition, medication, preventing 2° impairments,

maintaining exercise and precautions during exercise.
2. Proper body mechanics given to pt; proper sitting, proper bed positioning, proper way of
getting up the bed and getting on the bed.

Donacao, Anton Lorenzo B.

USI - PT Intern Batch 2024