Therapist Name: Elizabeth Osantowski

Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

Patient Name: Michael Abbott DOB: 8/2/1977 (41 y.o.)

Date of Service: 1/25/2019

PT Diagnosis (ICD-10): R29.3 Abnormal Posture

Medical Diagnosis (ICD-10): None

BACKGROUND INFORMATION:
Referral Source: Dr. Alonzo
Referring Diagnosis: None
Other Referral Information: Dr. Alonzo did not find any skeletal abnormalities on
radiographs, but referred patient to PT for examination/evaluation, instruction in postural
correction and other appropriate exercises, and recommendations to alleviate pain.

SUBJECTIVE: Patient is a 41 y.o. Caucasian male whose main compliant is primarily

neck pain, however patient does have additional complaints of low back pain.
History of current complaint: Patient complains of neck pain centralized between
shoulder blades with gradual onset over the last 6-7 months. Pt. reports pain as “achy and
burning” and has not used any ice or heat on the area. He reports the current pain level as
a 5/10 and at best 1/10. Pt. states “in the morning my pain is better than at night. The pain
starts after 3-4 hours of working and remains constant until I get home and lay down.
When I lay down it feels better.”
Current Functional status/activity/participation level: Pt. reports his pain is
decreasing his work efficiency and impacting him from being able to take his chihuahua,
Betsie, for 1-mile walks. Pt. is currently sedentary since the onset of his pain.
Prior level of function: Patient used to be active and take 1-mile walks with his dog,
Betsie, but is unable to do this now with his pain. Pt. used to be able to work fulltime
without cervical or low back pain.
Medical/Surgical history; general health status: Pt. reported an inguinal hernia surgery
1 yr. ago and no other surgeries were reported. He states he does not have history of
smoking or drinking alcohol.

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 Therapist Name: Elizabeth Osantowski
Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

Current medications: Pt. is taking 2 OTC ibuprofen at night. He was prescribed

Metaxalone 3-4 times per day, but pt. is only taking it 2x per day.
Allergies: None to be reported.
Employment status: Pt. is a full-time administrative assistant for judge’s office. Pt.
works full time at a seated desk with minimal back support. Pt. does a lot of typing,
filing, answering phones, and keeping schedules for the judge and does not take any
breaks other than his 30 min. lunch break.
Home/Work/Other Environment: Patient lives in a house with 4 steps to enter with
railing on the R. Patient did not report where the bedroom and bathrooms in the house
were. He is divorced from his wife, but has one son, 17 y.o. who is “pushing the limits”
as a support system. Pt. stated, “I hope he goes to college soon. I’m praying he does.”
Patient has worked at the same job for 12 years. He said he got a new desk and a rolling
desk chair, but the desk is low, and the chair did not have back support or arms. Pt. is not
involved in the community or any other activities. Pt. says in his free time he likes to lay
down and watch TV.
Family health history: Pt. explained that his mother has osteoarthritis and is concerned
if he has it as well. When asked about his father, pt. said “he left when I was born. He
sucked.”
Social/Cultural history: Patient is a “devout Mormon” and is English speaking.
Patient goals: Pt. wants to be able to return to walking 1 mile with his dog, Betsie, and
increasing his work efficiency pain-free. He hopes to achieve in therapy reduced neck
and low back pain levels. He believes his problem could be from sitting and working all
day but is not confident in how to fix this problem since work is a priority.

OBJECTIVE EXAMINATION:

Systems Review:
HR: 56 bpm RR: 14 bpm BP: 118/82 taken on L arm in seated position.
Edema: None.
Other significant findings:
Cardiovascular/Pulmonary: No significant findings to report.

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 Therapist Name: Elizabeth Osantowski
Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

Integumentary: No significant findings to report.

Musculoskeletal: Patient has rounded shoulders, increased thoracic kyphosis,
flatback lumbar lordosis, and ankle plantarflexion (heels were not in contact with
ground) in standing and sitting. Gross UE and spine AROM are limited, but with
posture correction, it was WNL. Gross UE and spine strength are symmetrical and
WNL. Height: 5’8”. Weight: 180 lbs.
Neuromuscular: Gross movement including balance, transfers, and transitions
are unaffected, but locomotion is slow. Gross motor function had no significant
findings to report.
Communication/Affect/Cognition: A&O X4. No language barriers. Patient
wears glasses. Patient is a visual learner and prefers written home program with
pictures.
Other: Patient was asked red flag questions, and none were reported.

Tests and Measures:

General Anthropometric Observations/Posture: Mesomorphic, BMI: 27 Overweight.
Posture in standing shows R shoulder slightly depressed compared to the R, forward
head, increased thoracic kyphosis, IR bil. shoulders, hypo lumbar lordosis, and slight
ankle PF. Posture in sitting was slouched with rounded shoulders and upper back.
Inspection/Observation: No abnormalities to be reported.
Neurological/Sensory: UQS was preformed, but no significant findings to report.
ROM:
Cervical: AROM PROM
FLEX 20° 30° (firm end feel)
EXT 40° 45° (firm end feel)

RIGHT Joint/Motion LEFT

AROM PROM Cervical AROM PROM
65° 72° Rotation 64° 70° (firm end feel)
45° 50° SB 46° 52° (firm end feel)

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 Therapist Name: Elizabeth Osantowski
Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

Muscle Length/Flexibility:
RIGHT Muscle Length Test: LEFT
112° Latissimus dorsi MLT 110°
9” Pectoralis Major MLT 9.5”
5.5” Pectoralis Minor MLT 6”

Strength/MMT:
Muscle group tested: Grade:
Cervical Flexors: 3+
Cervical Extensors: 5
Trunk Extensors: 3
Trunk Flexors: 5
Abdominal flexors: 3

RIGHT Muscle group tested LEFT

3+ Rhomboids/Middle Trapezius 4+
5 Cervical Side Bending 5
5 Cervical Rotation 5

Palpation: Pt. has TTP between scapulae and posterior cervical region, but none reported
on low back.
Joint play assessment: Joint play was not assessed on 1/25/19; examine vertebral joints
at next visit.
Special Tests: Special tests including Spurling’s test, Compression/Distraction, Vertebral
Artery test, Alar Ligament Stress test, Anterior Shear test, and Adson’s test were
performed. All special tests were negative.
Gait: Pt. ambulated 20 ft. independently with decreased speed and UE arm swing
resulting in decreased trunk rotation and increased time spent in double limb support.
Functional Mobility: None to be reported.
Balance: WNL, no abnormalities to be reported.

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 Therapist Name: Elizabeth Osantowski
Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

Standardized Outcome Assessments: Neck Disability Index Questionnaire was

completed; patient scored of 22 out of 50, which indicates moderate disability.

INTERVENTIONS: Patient was given specific details of the POC and interventions for
treatment and was explained the anticipated benefits. He is willing to participate and
signed informed consent. He gave verbal consent for treatment today. Patient received
bilateral manual pectoralis major stretching using autogenic inhibition technique. Patient
reported decreased tension in his pectoralis muscle with this technique. Then, the patient
was shown three exercises (doorway stretch, scapular retractions, and cervical
retractions) for their HEP (see attachment). Patient completed these exercises during
today’s session with attentiveness and correctness. Patient received postural education
and adjustments that should be made, especially during work hours. Postural education
included sitting up tall, retracting shoulders and cervical, increasing lumbar lordosis, and
having feet in complete contact with the ground. Ergonomic assessment of his workplace
is recommended to make better postural adjustments including better back support for his
desk chair or a new, more supportive chair if possible and increasing the height of his
desk.

ASSESSMENT:
PROBLEMS LIST:
 Body Structure or Impairments:
1. Patient has poor posture.
2. Patient has limited cervical flexion, extension, and rotation A/PROM.
3. Patient has weak cervical flexors, trunk extensors, and abdominal flexors.
4. Patient has tight pectoralis muscles.
5. Patient has neck and low back pain 5/10.
 Activity Limitations/Participation Restrictions:
1. Patient has less work efficiency due to his pain levels.
2. Patient is unable to walk his dog for 1-mile per day.
3. Patient is unable to be in an upright position for more than 3-4 hours
without pain.

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 Therapist Name: Elizabeth Osantowski
Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

Summary-Clinical Impressions: Patient presents with abnormal posture, which causes

him to have cervical and trunk weakness, limited ROM, pectoralis major muscle
tightness, and pain. Patients pain level is preventing him from performing work duties
efficiently and participate in upright positioning throughout the day. Improvement in his
condition is dependent upon strengthening these muscles, regaining full AROM, and
increasing his pectoralis MLT. Pt needs skilled PT for posture abnormality to reduce pain
and improve work efficiency.

PT Diagnosis: Abnormal Posture.

Rehab Potential/Prognosis: Good; pt. is motivated to be pain free.

GOALS:
Short-term (to be achieved in 2 weeks):
1. The patient will increase his cervical flexors, trunk extensors, and abdominal
flexors strength to 4/5 strength by completing strengthening exercises to
improve weak postural muscles.
2. Patient will increase his AROM at least 5° and increase his pectoralis muscle
length to decrease forward head posture and thoracic kyphosis.
3. Patient will report decreased pain levels to no more than 4/10 with activity or
work to improve his work efficiency.
Long-term (to be achieved in 6-8 weeks):
1. The patient will increase his cervical flexors, trunk extensors, and abdominal
flexors to maximal 5/5 strength to improve abnormal posture.
2. Patient will increase his cervical AROM to WNL to decrease his forward head
posture and thoracic kyphosis.
3. Patient will decrease his pain levels to no more than 2/10 to be able to work a
full day efficiently.
4. Patient will decrease his pain levels to no more than 2/10 to be able to walk
his dog for 1-mile per day.

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 Therapist Name: Elizabeth Osantowski
Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

PLAN OF CARE: Patient will be seen for physical therapy treatment 3x/week for 6-8
weeks dependent on patient progression. Treatment will include neuromuscular re-
education for postural education/correction, therapeutic exercise for cervical, scapular,
and core strengthening training, therapeutic activities for functional training for work-
related tasks and ADLs, bilateral manual pectoralis major stretching using autogenic
inhibition technique, and interferential e-stim for forward head posture correctness and
pain management. Will reevaluate patient progress every month and progress program as
indicated.

____________________________________________ SPT

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 Therapist Name: Elizabeth Osantowski
Lab (AM/PM): PM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group A

Evidenced-Based Practice

AMA Citation Choi YJ, Kim HJ, Han SY, Choi BR. Effect of interferential
current therapy on forward head posture. J Phys Ther Sci.
2018;30(3):398-399.
Link to article (or doi) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857445/
doi: 10.1589/jpts.30.398
Implications for your I used this article to assist with my intervention procedure.
clinical decision-making This article showed effectiveness in using e-stim to improve
structural alignment in patients with forward head posture.
This article found interferential e-stim could induce muscle
relaxation of the shortened neck extensors to alleviate pain
from FHP while simultaneously decreasing the amount of
FHP. Since this article was effective in test subjects, I
wanted to include this modality in my intervention strategy
to help with my patient’s FHP.