Event 3: Physical Therapy Initial Evaluation

Luisa is referred to physical therapy as one of the non-pharmacological strategies to help her manage her acute neck pain.

At this event, we will look at outcome measures, subjective report, physical therapy interview with and without a medical interpreter, objective evaluation and examination, assessment, and physical therapy plan of care.

Physical Therapy – Outcome Measures

The first step of the physical therapy initial evaluation is completion of outcome measures. We will look at three main areas of information about pain and function which will include a body diagram for pain location, faces pain scale revised for pain intensity, and neck disability index for pain and function.

Body Diagram

The body diagram demonstrates pain in the upper back, posterior neck and base of the head.

Illustration of the body for the purpose of shading in the area with pain. Luisa's diagram shows pain at the back of the neck.
Luisa's body diagram

Faces Pain Scale

Luisa rates her pain for three areas: present pain 6 of 10, best 2 of 10 and worst 8 of 10.

FACES Pain Rating Scale
Faces pain scale

Luisa's Pain

Luisa rates her pain for three areas: present pain 6 of 10, best 2 of 10 and worst 8 of 10.

Numeric scale from 0 to 10 with 0 being no pain and 10 being worst. Luisa's best rates a 2, current pain a 6, and worst an 8.
Luisa's pain

Pain Manag Nurs. 2006 Sep; 7(3):117-25.Evaluatio of the Revised Faces Pain Scale, Verbal Descriptor Scale, Numeric Rating Scale, and Iowa Pain Thermometer in older minority adults. Used with permission from IASP. For clinical, educational, or research purposes, use of the FPS-R is free of charge, and permission for use is not needed, provided that the scale is not modified or altered in any way. ​​https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1519&navItemNumber=577 (Access to multiple languages on download link)

Neck Disability Index (NDI)

The Neck Disability Index (NDI) was developed by Vernon, H. & Mior, S. in 1991. This tool is used to determine the impact of pain and function.

Luisa’s NDI score is 34/50 or 68% disability at this initial physical therapy visit.

Neck disability index checklist
Neck disability index (English)
Neck disability index checklist (Spanish)
Neck disability index (Spanish)

Physical Therapy Subjective Report

Luisa’s subjective report includes her background and subjective patient report.

Past Medical History

History of hypocholesteremia, hypertension, and osteoarthritis in neck, shoulders and back. Patient is a previous smoker and occasional drinker. 

Living Environment

Patient lives in a one-story home with her husband and one daughter and 2 grandchildren.  


Patient is Hispanic, primarily Spanish speaking, high school education.

Social History

Patient is a homemaker. She participates in bowling once a week, plays cards and helps care for 2 grandchildren by driving them to/from school each day.  Patient is left hand dominant.

Patient Complaint

Patient reports pain in her posterior neck after making tamales for two days to get ready for an event at church 3 weeks ago.  She reports stiffness and pain are increased in the morning and difficulty turning her head during daily activities, especially driving and looking down; difficulty getting comfortable at night due to neck discomfort.  She is normally involved in social activities of bowling and caring for her grandchildren and is not able to complete these at this time due to discomfort.  Pain aggravated by neck and head motion, laying down on her side and driving.  Pain relief noted with use of heat and laying on her back at home.  Patient notes headache occasionally at the end of the day.

Patient notes she sleeps on her sides and has not been able sleep in that position for more than 2 hours due to neck pain.  Patient denies any numbness or tingling in neck or upper quarter.  She notes no previous injury to neck or upper back.  Patient was referred to physical therapy by her primary physician.  Patient notes she has been using intermittent Tylenol without a significant change in her pain.

Patient Goals

Return to driving, return to church activities, caring for grandchildren, playing cards, bowling and looking down to be able to read the newspaper.

Neck Disability Index

Spanish Version of the Neck Disability Index completed with a score of 68% disability.


Patient is a 69-year-old female with primary complaint of neck pain which began 3 weeks ago after making tamales for two days.

Physical Therapy – Interview– Without Interpreter

Physical Therapy – Interview– With Interpreter

Physical Therapy – Objective and Assessment

System Review

Please review the system review below for Luisa.


HR 72, sPO2 98%, BP 124/72


No visible redness, warmth or scar in upper quarter

Musculoskeletal and Neurological

See ROM and Strength

Objective Information


Patient presents with moderate forward head and rounded shoulders with left greater than right. Patient with increased lumbar lordosis and increased thoracic kyphosis. Patient with limited head motion during subjective history and discussion.

Muscle Length and Flexibility

Patient with moderate tightness in bilateral pectoralis major and minor, left biceps musculature.


WNL to light touch bilateral upper extremity dermatomes; patient denies numbness and tingling.


Patient with marked muscle guarding in bilateral upper trapezius, anterior and middle scalene and sternocleidomastoid. Patient with moderate guarding in scapular musculature and posterior cervical musculature.

Physical Therapy – Objective


Abbreviations: WNL = within normal limits; WFL = Within functional limits

Cervical Motion and Strength
Motion and Strength AROM PROM Muscle Test Grade Comments
Flexion 35 45 3 In available ROM; pain at end range
Extension 5 10 2+ In available ROM; pain at end range
Lateral flexion - Right 15 20 3 In available ROM; pain at end range
Lateral flexion - Left 10 15 3 In available ROM; pain at end range
Rotation - Right 25 35 3 In available ROM; pain at end range
Rotation - Left 15 20 3 In available ROM; pain at end rang

Upper Extremity Range of Motion

Abbreviations: WNL = within normal limits; WFL = Within functional limits


Upper Extremity Range of Motion and Strength (Shoulder)
Motion and Strength AROM PROM Muscle Test Grade
Flexion - Right WFL WFL 4+
Flexion - Left WFL WFL 5
Extension - Right WFL WFL 5
Extension - Left WFL WFL 5
External Rotation - Right WFL WFL 4+
External Rotation - Left WFL WFL 4
Internal Rotation - Right WFL WFL 4+


Upper Extremity Range of Motion and Strength (Elbow)
Motion and Strength AROM PROM Muscle Test Grade
Flexion and Extension WNL WNL 5


Upper Extremity Range of Motion and Strength (Wrist)
Motion and Strength AROM PROM Muscle Test Grade
Flexion WNL WNL 5
Extension WNL WNL 5


Upper Extremity Range of Motion and Strength (Grip)
Motion and Strength AROM PROM Muscle Test Grade
Finger Flexion WNL WNL

Right 90

Left 100


Clinical Impression

Patient presents with subacute neck pain with mobility deficits.  Patient presents with decreased active/passive range of motion and decreased strength in cervical musculature.

Patient with decreased flexibility and muscle length in muscles surrounding the shoulder in addition to changes in upper quarter posture.  Patient with limited participation in sleeping, driving, bowling, playing cards, caring for grandchildren and flexion biased cervical motions.

Patient would benefit from skilled physical therapy in order to meet patient goals for reducing pain, improving active range of motion and functional activities.

Physical Therapy Plan of Care

Following the initial evaluation and examination, the physical therapist creates a plan of care with Luisa to assist her in managing her acute neck pain. This includes establishing goals, completing acute neck pain education, non-pharmacological strategies and a home exercise program.

Physical Therapy Goals

Short Term Goals: To be met in 3 weeks

  1. Patient will tolerate looking down up to 15 minutes in the cervical region. 
  2. Patient resume normal sleeping patterns and social activities of playing cards, bowling and caring for grandchildren.
  3. Patient will complete driving without increased complaint of pain.

Long Term Goals: To be met in 6 weeks

  1. Patient will be able to resume mechanic activities for up to 4 hours without an increase in neck pain.
  2. Patient will be able to sleep 6-7 hours without awakening due to neck pain.
  3. Patient will return to bowling, playing cards, driving and caring for grandchildren without an increase in neck pain.

Physical Therapy Acute Neck Pain Education

  • Acute pain usually comes on quickly and resolves in 6-8 weeks
  • Posture and positioning for reading, sleeping, and  activity modification to improve activity level/function and decrease discomfort
  • Instruction in use of cold, heat and topical applications for pain reduction
  • Review of TENS unit as a possible strategy
  • Instruction in home exercise program and graded activity progression for pain reduction and improved upper quarter mobility and stability

Physical Therapy Neck Pain Clinical Practice Guideline

Based on Luisa’s presentation, the Neck Pain Clinical Practice Guideline (CPG) recommends the following:

Acute neck pain without radiculopathy or persistent headache summary:

  • Most episodes of acute pain resolve within 8 weeks
  • Some patients continue with ongoing symptoms or a recurrence of neck pain for more than a year
  • Monitor for red flags: changes in bowel or bladder, numbness or tingling in the upper extremities
  • Treatment Recommendations: 
  • Non-pharmacological strategies
  • Pharmacological strategies


  • Blanpied PR et al. Neck Pain: Revision 2017. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association
  • J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.030
  • Bier JD, Scholten-Peeters WGM, Staal JB, et al. Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain. Phys Ther. 2018;98:162–171.

Physical Therapy Non-Pharmacological Strategies

The physical therapist reviews non-pharmacological strategies for Luisa to try at home to help manage her acute neck pain.

Home Exercise Program

The physical therapist reviews beginning a walking program for Luisa to try at home to help manage her acute neck pain.

  • External Applications
    • Topical pain relievers: mentholated or coolant gels
    • Heat/Cold
    • Activity
    • Exercise
    • Activity modifications
  • Community of Faith
    • Support
    • Prayer
  • Relaxation/Distraction
    • Breathing
    • Meditation
    • Music
    • Prayer
    • Music

PT Interventions for Mrs. Sanchez

  • Exercise 
    • Aerobic
    • Stretching and Strengthening
  • Use heat or cold
  • Breathing

The physical therapist has Luisa begin an exercise program for stretching and strengthening of the neck and shoulders to help Luisa manage her acute neck pain.

Walking Program

Graphic showing time to invest in walking each weak and different paces, while slowly increasing the amount of time walking.
Walking program

Sample walking program.


Taylor D. Physical activity is medicine for older adults. Postgrad Med J. 2013;90(1059):26–32. doi:10.1136/postgradmedj-2012-131366

Exercises for Chronic Neck Pain

Image shows exercise descriptions for chronic neck pain.
Exercises for chronic neck pain

Efficacy of Physical Therapy Interventions

Efficacy of Physical Therapy Interventions for Acute Neck Pain
Strategy Strength Evidence in Acute Neck Pain
Massage therapy Weak Short-term effect of massage therapy including massage and myofascial release in subacute and chronic neck pain
Aromatherapy Inconclusive Evidence in chronic neck pain in conjunction with other treatments but not acute neck pain
Physical therapy Moderate Moderate evidence for acute neck pain: may include manipulation or mobilization, exercise including endurance exercises, strengthening, range of motion and mobility, acute pain education
Topical applications Moderate Topical applications with menthol increases cutaneous blood flow; acts as a counter-irritant by sensitizing nociceptors and then desensitizing nociceptors
Exercise and activity Strong Strengthening, Flexibility and Aerobic Exercise have been shown to decrease acute pain.
Social support/Community of faith Weak Weak evidence for the role of social support/community of faith in acute pain
Relaxation Weak There is not specific evidence for relaxation in acute neck pain however there is evidence in procedural pain, labor pain, TMJ disorder, fibromyalgia
TENS Weak TENS has shown benefits in acute pain with acute neck pain showing inconclusive results
Music Weak  
Reiki/Healing Touch Moderate Evidence in acute pain not specifically acute neck pain

Interactive Activity PT Treatment with and without Medical Interpreter

Without Medical Interpreter

With Medical Interpreter

No Medical Interpreter VS Medical Interpreter

Without Medical Interpreter

  • Caregiver was on the phone and distracted.
  • Luisa was not engaged in the process.
  • Therapist struggled to follow along; seemed to have difficulty knowing who to make eye contact with.

With Medical Interpreter

  • Luisa was able to answer questions.
  • Luisa and the physical therapist made eye contact, developed a rapport.
  • Conversation was faster, easier to follow along.

Language Barriers

Without Medical Interpreter
  • Luisa and caregiver had difficulty answering physical therapist’s questions.
  • The physical therapist had to repeat herself with questions to help answer questions.
  • Luisa and caregiver would talk at the same time.
  • Conversation was awkward and many pauses.
With Medical Interpreter
  • Luisa and the physical therapist made eye contact, developed a rapport.
  • Luisa was able to tell her story.
  • Luisa was able to describe her problem and goals.
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