10.Neck 颈部 – Tcm Foundation

Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:

Subjective findings
Reason for visit:
neck pain
Previous surgery or fractures:
Nil
Previous illnesses:
Nil
Medication and/or supplements:
not known
Subjective Findings:(patient’s description of injury)
When pulling the lawnmower cord, I sprained my back.
Lifting a heavy box above the head, whilst turning the head, twisted and sprained the neck.
Whiplash to the neck after being hit in the rear by another car
Whilst playing football, I was tripped by another player and fell sideways, straining the knee.
Onset and progression:

Felt sharp pain for one day after the injury, followed by an ongoing dull ache since then, with intermittent sharp pain occurring with specific movements.

Aggravated by:
Turn around the neck
Relieved by:
rest
Yellow flags(psychological or emotional factors):
N/A
Red flags(potential serious complications):
N/A
Previous treatment:
physio for 1 session
Objective Findings:
Observation: no swelling, no bruising

Numerical Pain Rating Scale (NPRS): most of the time 5/10, 7/10 at worst

Patient-Specific Functional Scale (PSFS) :
To be able to lift 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to turn around the neck 6/10

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°

Diagnosis:
read code(blood stasis and qi Stagnation)
Treatment Principle:
promote Qi and remove blood stasis to relieve the pain
The goal for treatment:
To be able to lift 5kg heavy object without pain
To be able to sleep on the affected side without pain
To be able to turn around the neck without pain
Treatment Plan:
acupuncture and cupping 1-2times/week
Estimated time frame :
6 weeks/12 weeks
Today’s treatment:
Acupuncture 50 mins
Ashi points in the locally affected area,tianjing,hegu,wangu,shousanli,yangfu,kunlun
cupping 10 mins- in the locally affected area
Post-treatment advice:
Avoid lifting heavy objects.
Keep warm

2nd visit acc treatment

Subjective
Results/Progress:
The patient reports that
The pain has slightly diminished compared to the last visit. However, it exacerbates after extended periods of watching the computer at work. There is intermittent sharp pain accompanied by a constant dull ache, particularly noticeable during periods of inactivity.

Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst

Patient-Specific Functional Scale (PSFS):
To be able to lift 5kg heavy object 6/10
To be able to sleep on the affected side 6/10
To be able to turn around the neck 6/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°

TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashi points in the locally affected area,tianjing,hegu,wangu,shousanli,yangfu,kunlun
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm

3rd visit acc treatment

Subjective
Results/Progress:
The patient reports that
The pain has slightly decreased compared to the last visit. However, it worsens after prolonged hours of using the computer at work. The pain manifests as intermittent sharp sensations along with a constant dull ache, especially noticeable during periods of inactivity. The muscles around the neck feel noticeably tight.
Numerical Pain Rating Scale (NPRS): Most of the time 4/10, 6/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to lift a 5kg heavy object 7/10
To be able to sleep on the affected side 7/10
To be able to turn around the neck 7/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°

TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashi points in the locally affected area,tianjing,hegu,wangu,shousanli,yangfu,kunlun
cupping 10 mins- in the locally affected area
Post-treatment advice
Avoid lifting heavy objects.
Keep warm

4th visit acc treatment
Subjective
Results/Progress:
The patient reports that the pain returned one day after the last treatment, and there is still significant discomfort in the local area. However, the pain is now more localised, presenting as intermittent dull sensations.
Numerical Pain Rating Scale (NPRS): Most of the time 4/10, 6/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to lift a 5kg heavy object 7/10
To be able to sleep on the affected side 7/10
To be able to turn around the neck 7/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 55°Flexion 45°
Left
Neck (lateral bending) 35°
Neck (rotation) 70°
Right
Neck (lateral bending) 35°
Neck (rotation) 70°

5th visit acc treatment
Subjective
Results/Progress:
The patient reports that
The pain has slightly decreased compared to the last visit. It comes and goes, particularly worsening after prolonged hours of computer use at work. The sensation is not sharp, but there remains a constant dull ache. Overall, the patient reports feeling much better compared to the first visit.

Numerical Pain Rating Scale (NPRS): Most of the time 3/10, 5/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to lift a 5kg heavy object 8/10
To be able to sleep on the affected side 8/10
To be able to turn around the neck 9/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Extension 60°Flexion 50°
Left
Neck (lateral bending) 45°
Neck (rotation) 80°
Right
Neck (lateral bending) 45°
Neck (rotation) 80°