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