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S
pain
S
participation restriction
S
activity limitation
O
ROM
O
jt mobilization
O
palpation
O
resistive training
O
neurological exam
O
functional assessment
A
stage of condition
A
impairment in body structure/function
A
tissue reactivity
P
manual therapy
P
therapeutic exercise
P
neuromuscular reeducation
P
biophysical agent
S
pt was referred w/ right shoulder pain
S
pt reports that pain is limiting them from reaching overhead
S
pt has no hx of trauma
S
pt works at a private volleyball instructor
O
AROM limited and pain in flex, ABD, ER
O
PROM painful w/ IR
O
resistive test strong and painful in ER and ABD
S
pt’s current complaint of limitation or impairment
S
pain scale, activity increase or decrease
S
pt reported response to treatment (pain change or limitation change)
O
treatment frequency, intensity, duration
O
positioning
O
measurements assessed during treatment
A
effectiveness of treatment
A
change in intensity/duration from previous treatment
A
change of sxs w/in treatment
A
change in objective measure w/in treatment
P
state plan to: progress, regress, maintain, or discontinue specific treatment next visit
S
pt reported that previous treatment was effective and pain-free for about a day following previous treatment.
O
treatment
O
movement analysis: step-up onto 4-in step 5/10 pain
A
TENS was effective in conjunction w/ therapeutic exercise in decreasing pt’s pain performing step-ups
P
continue w/ TENS treatment and progress to closed chain quads activation