How to Write a Physiotherapy Case History and Prescription Paper

PART 1: PHYSIOTHERAPY CASE HISTORY

SECTION A - Patient Demographics (Top of the Form)

SECTION B - Chief Complaint (CC)

"I have pain in my lower back that started 3 weeks ago after lifting a heavy box."

• Location of complaint (use a body diagram if available)
• Onset: sudden or gradual
• Duration: how long it has been present

SECTION C - History of Present Illness (HPI)

• Behavior of symptoms 24 hours (24-hour pattern)
• Any previous episodes of the same complaint
• Treatment received so far and its outcome

SECTION D - Past Medical and Surgical History (PMH/PSH)

• Previous illnesses (diabetes, hypertension, osteoporosis, rheumatoid arthritis, cancer)
• Previous surgeries and dates
• Previous physiotherapy and outcome
• Hospitalizations

SECTION E - Drug/Medication History

• Current medications (painkillers, steroids, anticoagulants - important before applying electrotherapy)
• Allergies

SECTION F - Family and Social History

• Family history of relevant conditions
• Smoking, alcohol use
• Living situation (stairs at home, caregiver support)
• Recreational activities and hobbies

SECTION G - Occupational History

• Type of work (sedentary, manual, repetitive movements)
• Work hours, posture demands
• Any work-related injury (for medico-legal records)

SECTION H - Systems Review (Red/Yellow Flag Screening)

• Unexplained weight loss
• History of cancer
• Night sweats, fever
• Bilateral neurological symptoms
• Bowel/bladder dysfunction
• Constant, unremitting pain not affected by position

• Fear avoidance behavior
• Catastrophizing
• Low mood, anxiety, depression
• Poor workplace support

SECTION I - OBJECTIVE EXAMINATION

1. Observation / Inspection

• Posture (standing, sitting, lying)
• Gait analysis
• Swelling, bruising, muscle wasting, deformity, scar

2. Palpation

• Tenderness (point, diffuse)
• Temperature (warm = inflammation)
• Muscle spasm, trigger points
• Bony landmarks

3. Range of Motion (ROM)

• Active ROM (AROM) - what the patient can do
• Passive ROM (PROM) - what you can produce
• Record in degrees using a goniometer
• Note end-feel: soft, firm, hard, empty

4. Muscle Strength Testing

• Manual Muscle Testing (MMT) using the Oxford Scale 0-5
• Or dynamometer readings

5. Neurological Examination (if applicable)

• Dermatomes (sensation - light touch, pin prick)
• Myotomes (muscle power by nerve root)
• Reflexes (deep tendon reflexes - graded 0 to 4+)
• Upper/lower motor neuron signs

6. Special Tests

• Specific to the region (e.g., Straight Leg Raise for lumbar, Spurling's for cervical, McMurray's for knee, Hawkins-Kennedy for shoulder)
• Record: positive or negative with brief description of finding

7. Functional Assessment

• Activities of Daily Living (ADLs): dressing, walking, climbing stairs
• Standardized tools: Oswestry Disability Index, DASH Score, Barthel Index, Berg Balance Scale

8. Girth/Volume Measurements

• For swelling or muscle wasting

9. Postural/Biomechanical Analysis

• Spinal curvatures, limb length discrepancy, foot pronation

SECTION J - ASSESSMENT / CLINICAL IMPRESSION

1. Physiotherapy Diagnosis - the impairment-based diagnosis (e.g., "Mechanical Low Back Pain with L4-L5 nerve root irritation")
2. Problem List - list all identified impairments:
   • Pain (severity, location)
   • Reduced ROM
   • Muscle weakness
   • Functional limitation
3. Prognosis - expected recovery timeline and influencing factors
4. Short-term goals (1-2 weeks): e.g., reduce pain from 7/10 to 4/10
5. Long-term goals (4-6 weeks): e.g., return to full work duties

PART 2: PHYSIOTHERAPY PRESCRIPTION PAPER

FORMAT OF THE PHYSIOTHERAPY PRESCRIPTION

PHYSIOTHERAPY PRESCRIPTION

Patient Name: _____________________ Date: __________
Age: ________ Gender: _____________ MRD/File No: ____
Referring Physician: _______________

DIAGNOSIS: ____________________________________________

PRECAUTIONS / CONTRAINDICATIONS:
_______________________________________________________

PHYSIOTHERAPY TREATMENT PRESCRIBED:

1. ELECTROTHERAPY MODALITIES:
   □ TENS         Settings: _______ Duration: _______ mins
   □ IFT          Frequency: _____ Duration: _______ mins
   □ Ultrasound   Intensity: __ W/cm²  Mode: CW/Pulsed  Duration: ___ mins
   □ LASER        Dose: _______  Duration: _______ mins
   □ SWD/MWD      Settings: _______ Duration: _______ mins
   □ Hot pack / Ice pack      Duration: _______ mins
   □ Traction     Mode: ________ Wt: _____ Duration: ___ mins

2. EXERCISES:
   □ Active ROM exercises        Repetitions: _____ Sets: _____
   □ Passive stretching          Hold: _____ sec   Sets: _____
   □ Strengthening exercises     Load: ______      Reps/Sets: _____
   □ Proprioception/Balance training
   □ Gait training / Ambulation
   □ Breathing exercises
   □ Home Exercise Program (HEP): ___________________________

3. MANUAL THERAPY:
   □ Joint mobilization (Grade: I / II / III / IV)
   □ Soft tissue massage
   □ Neural mobilization
   □ PNF stretching

4. FUNCTIONAL TRAINING:
   □ Transfer training
   □ ADL training
   □ Ergonomic advice / Postural correction

FREQUENCY: _____ sessions per week
DURATION:  _____ weeks (Total: _____ sessions)

RE-ASSESSMENT DATE: ____________________________________

Physiotherapist Signature: __________ Reg. No.: _______
Date: _____________

KEY TIPS FOR DOCUMENTATION

1. Write legibly - or use printed/digital forms where possible.
2. Use objective, measurable terms - avoid vague words like "improved slightly." Write "knee flexion improved from 90° to 120°."
3. Date and sign every entry - include your registration number.
4. Use standardized outcome measures - these make progress trackable and defensible (VAS, Oswestry, DASH, FIM, etc.).
5. Record informed consent - note that the patient understood and agreed to the treatment.
6. Document red flags - if present, note referral made.
7. SOAP notes for every follow-up visit - brief S (any change in symptoms), O (objective findings), A (response to treatment), P (plan for next session).
8. Contraindications must be documented - especially before using electrotherapy (cardiac pacemaker, pregnancy, metal implants, malignancy, open wounds).

FOLLOW-UP / PROGRESS NOTE FORMAT

• S: "Patient reports pain reduced to 4/10, able to walk to the bathroom without support."
• O: Knee flexion 110° (was 90°). No swelling. SLR negative.
• A: Improving. On track with goals.
• P: Continue current program, add closed-chain strengthening today.

Frozen Shoulder (Adhesive Capsulitis) - Physiotherapy Intervention

Understanding the Condition

Key clinical finding with tenderness: Tenderness is most prominent in Stage 1 (freezing phase). It is typically felt over the anterior capsule/rotator interval, biceps tendon groove, and deltoid insertion. This indicates active synovial inflammation - treatment must be pain-first before any aggressive mobilization.

STAGE 1 - FREEZING / PAINFUL STAGE (Tenderness Predominant)

1. Electrotherapy Modalities (Pain Relief)

Tenderness-specific note: Over tender points, use pulsed ultrasound (not continuous), TENS electrode placement around (not directly over) the most tender area.

2. Manual Therapy (Gentle, Low Grade)

• Grade I-II Maitland joint mobilization - oscillations at beginning of range, purely for pain relief, no stretch
• Gentle soft tissue massage - to trapezius, deltoid, periscapular muscles
• Pendulum (Codman's) exercises - gravity-assisted, gravity distraction reduces pain

3. Exercises

• Pendulum/Codman's exercises - forward, sideways, circular - small circles, pain free
• Active-assisted ROM - with a stick/wand, within pain-free range only
• Shoulder shrugs and scapular retraction - maintain scapulothoracic motion
• Elbow, wrist, hand exercises - prevent disuse atrophy distally

4. Education and Positioning

• Advice: avoid lying on the affected side at night (use a pillow under the arm)
• Posture correction - correct rounded shoulder/forward head posture
• Activity modification - avoid overhead reaching, heavy lifting, overhead work
• Explain the three-stage natural history - reduces fear and anxiety

STAGE 2 - FROZEN / ADHESIVE STAGE

1. Thermal/Physical Modalities

2. Manual Therapy (Progressive, Grade III-IV)

• Maitland Grade III-IV mobilizations - sustained end-range techniques for stiffness
• Inferior glide (caudal distraction) - primary technique to restore abduction
• Posterior glide - restores internal rotation and flexion
• Anterior glide - restores external rotation (most restricted movement in frozen shoulder)
• PNF stretching (Contract-Relax) - post-isometric relaxation to gain range

3. Stretching Exercises

• Cross-body stretch (posterior capsule) - hold 30 seconds, 3-5 reps
• External rotation stretch with stick - supine, door frame or wand stretch
• Sleeper stretch - side-lying internal rotation stretch
• Wall-climbing / Finger ladder exercises - active-assisted elevation
• Pulley exercises - overhead pulley for assisted elevation

STAGE 3 - THAWING / RESOLUTION STAGE

1. Strengthening Exercises

• Rotator cuff strengthening - theraband external/internal rotation
• Scapular stabilizers - serratus anterior (wall push-up plus), lower trapezius (Y-T-W exercises)
• Deltoid strengthening - progressive resistance, side raises
• Closed-chain exercises - wall push-ups, quadruped weight-bearing

2. Proprioception and Neuromuscular Training

• Ball rolling on wall
• Perturbation training (unstable surface)
• Rhythmic stabilization techniques

3. Functional and Occupational Training

• Return to overhead reaching, ADL training
• Work-specific tasks
• Sport-specific training if applicable

JOINT MOBILIZATION GRADE GUIDE (Maitland)

TENDERNESS MANAGEMENT - SPECIFIC PROTOCOL

1. Identify tender points - biceps tendon, rotator interval, acromioclavicular joint, greater tuberosity
2. Do NOT apply deep pressure directly over tender areas - use surrounding soft tissue massage instead
3. Pulsed ultrasound is preferred over continuous when there is active tenderness
4. TENS - electrode placement around (not on) the most tender area
5. Ice before treatment (10-15 mins) to reduce acute tenderness before handling
6. Mobilization direction - use pain-free accessory glides first; avoid painful arcs
7. Corticosteroid injection co-management: when tenderness is severe, intra-articular injection (ideally ultrasound-guided) significantly reduces pain and allows physiotherapy to be more effective - as confirmed by the Rheumatology textbook (Elsevier 2022) and current clinical guidelines

CONTRAINDICATIONS TO PHYSIOTHERAPY IN FROZEN SHOULDER

• Active infection or septic arthritis
• Malignancy of the shoulder region
• Fracture or recent surgical fixation
• Severe osteoporosis (avoid high-grade manipulation)
• Uncontrolled diabetes (alters healing and response)
• Metal implant in the field (for SWD, ultrasound - adjust accordingly)

HOME EXERCISE PROGRAM (HEP)

• Stage 1: Pendulum exercises, gentle active ROM within pain-free range, ice after activity
• Stage 2: Pulley, wall climbing, cross-body stretch, external rotation with stick (10 reps x 3 sets, hold 30 sec per stretch)
• Stage 3: Theraband strengthening, full overhead activities

RECENT EVIDENCE NOTE

SAMPLE PHYSIOTHERAPY PRESCRIPTION FOR FROZEN SHOULDER (Stage 1 with Tenderness)

Diagnosis: Left Adhesive Capsulitis (Freezing Stage) with tenderness

MODALITIES:
- TENS: Conventional mode, 80 Hz, 200 µs, 30 mins
- Pulsed Ultrasound: 1 MHz, 0.8 W/cm², 1:4 duty cycle, 6 mins
- Ice pack: 15 mins post-session

MANUAL THERAPY:
- Soft tissue massage: periscapular muscles, 10 mins
- Maitland Grade I-II inferior glide and anterior glide mobilization

EXERCISES:
- Pendulum exercises: 10 circles each direction, 3x/day
- Active-assisted ROM with wand: Flexion, Abduction within pain-free range
- Scapular shrugs and retraction: 3 x 10 reps

FREQUENCY: 5 days/week
DURATION: 3 weeks, then re-assess

PRECAUTIONS:
- No forceful stretch in painful range
- Monitor for increased night pain (sign of flare)
- Refer for ultrasound-guided intra-articular injection if no improvement in 2 weeks