LUMBAR / SACROILIAC EVALUATION - RehabEdge



Lumbar/ Sacroilliac EvaluationName___________________________ DX_______________________________________________________ Date:__________PMH_______________________________________________________________________________________________________Physician_______________________________Next Appt___________________Onset_______________Initial Evaluation:_____ Re-Evaluation:_____Pain Rating_________Funct. Rating__________*PRECAUTIONS/ CONTRAINDICATIONS:______________________________________________SUBJECTIVE: Radiating painR LNumbness/ Tingling R LPain with sitting Pain with Standing Trouble sleeping _____# Hours/ night_____ Symptoms worse in A.M. P.M. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C/c:________________________________________________________________________________________________________Occupation/Social Hx:_________________________________________________________________________________________Hobbies/Sport:_______________________________________________________________________________________________ Pt. Goals:____________________________________________________________________________________________________OBJECTIVE:Observation: _____Rounded shoulders_____Forward head mid-Thoracic Kyphosis Lumbar lordosis Gait:_______________________________________________________________________________________________________Landmarks: (Standing) ( = high, =low, = equal, R = right, L = left): _________________________________________________ROM / Strength:ActiveTrunk Flexion_____WNLPainfulTightness 75% 50%25%other_________________Trunk Ext_____WNLPainfulTightness 75% 50%25%other_________________Trunk Rot. R: _____WNLPainfulTightness 75% 50%25%other_________________ L:_____WNLPainfulTightness 75% 50%25%other_________________Trunk SB R:_____WNLPainfulTightness 75% 50%25%other_________________Trunk SB L: _____WNLPainfulTightness 75% 50%25%other_________________ MMT StrengthNon-Organic SignsTendernessDistraction (SLR) Regional SuperficialWeaknessNonanatomicSensorySimulationOverreactionAxial loadingRotation(3 / 5 positive) R LKnee ext. _____ P _____ PKnee flex _____ P _____ P DF _____ P _____ P PF_____ P _____ P Hip Flex _____ P _____ P Hip Ext. _____ P _____ PHip ABD _____ P _____ PGr. Toe ext_____ P _____ PPatient IdentifierNeurological Screen:Sensation: _____WNLOther_____________________________Reflexes: Quads R_____L_____ Achilles R_____L_____Flexibility: (NT= normal, T= tight, VT= very tight)_______________________________________________________________Palpation:___________________________________________________________________________________________________________________________________________________________________Landmarks:RLIliac Crest Level ASIS Level PSIS Level ILA Level Ischial Tub Level Malleoli Level Pubic Rami Level SacrumFlexedExtendedWNLSpecial Tests:RLRLSlump Test++● Compression Test++Gillet (Stork) Test++● Distraction Test++Standing Flexion (PSIS)++● Gaenslen Test ++Trendelenburg Test++● Sacral Thrust Test++SLR++● Thigh Thrust Test++Supine to Sit Test++ (● Cluster of ? of above + SI Sens .91, Spec .78)SPRING PIVM testing (0-6) Normal = 3 (circle)FLEXSBLSBRRLRREXTL1L2L3L4L5Fabre Test++Prone Knee Bend Test++Position Testing (lumbar): ERS: + Level________________________________ FRS: + Level________________________________ Treatment:__________________________________________________________________________________________________ASSESSMENT:_____See Initial Eval Summary/ Plan of Care ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Rehabilitation Potential:Excellent Good Fair PoorSTG/LTG:_____See Initial Eval Summary/ Plan of CarePLAN: (Circle) # Rx/ wk______ # wks______ Therex Strengthening Stretching Joint Mobs ASTYM Ultrasound EStim Manual Therapy Traction (Mechanical / Manual) HEP Lumbar Stab. Bracing/ Taping Moist Heat/ Cold Pack Other:________________Avg. Pain Rating _____Self Reported Functional Rating _____ Oswestry: _____Therapist Signature:_________________________________________Date:__________ Time:________ ................
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