| Classification | Requirements | Example |
| ACC45 Number | AB12345 | |
| Read code | S572 lumber sprain (N/A) | |
| Date of Accident | 03.11.2022 | |
| Subjective findings | ||
| Reason for visit | Lower back pain | |
| Previous surgery or fractures之前做过的手术或骨折 | N/A or lower back surgery (11.09.2020) | |
| Previous illnesses之前得过的重病 | to include chronic diseases and medications that may affect acupuncture treatment. | N/A |
| Medication and/or supplements目前服用的药物或补充营养剂 | Nurofen+Dosage | |
| Social history(ACNZ病历上没有要求) | （1）to include the type of work that they do. （2）any recreational/professional sport that they may play and. （3）home duties they normally do such as lifting babies, cutting the grass, Family medical history, etc. | |
| Subjective Findings:(patient’s description of injury)GP或physio的ACC单子上的accident发生经过描述 | Descriptions of mechanism:Sudden movement+sprained/twisted+location【examples】Lifted heavy box,sprained my lower back | |
| Onset and progressionaccident发生之后到目前病情 | 【examples】 1. Felt sharp pain after the injury for 1 day, then ongoing dull ache since then with intermittent sharp pain with certain movements. 2. The pain has remained constant since the incident, and her self-reported pain scale is 7/10. Nurofen was prescribed by her GP have not relieved the pain. She also reports difficulty sleeping, waking between 3-5 am due to discomfort. She experiences referred pain in the neck and has limited movement in her right lower back, unable to position her right arm behind her back. The pain is somewhat alleviated by the application of a heat pack. 3. The patient presents with constant sharp pain in her right lower back, a result of a fall three days ago. Pain is described as 7/10 on the Numeric Rating Scale, initially felt while digging, and has since remained consistent, not alleviated by prescribed painkillers. She reports disturbed sleep patterns, waking frequently between 3-5 am due to pain. Neck pain, suspected to be referred from the lower back, has also been noted. Notably limited motion in the right lower back, especially while trying to reach her back. She reports slight relief from the use of a heat pack. 4. The patient reports experiencing sharp, intermittent pain in the right lower back for the past two weeks. The pain is aggravated by overhead movements and lifting heavy objects. There is no history of trauma or injury. The pain has been affecting the patient’s sleep and daily activities, causing discomfort and limited range of motion (ROM). 5. The patient complains of sharp, intermittent pain in the right lower back for the past two weeks, aggravated by overhead movements and lifting heavy objects. The pain affects sleep and daily activities. 6. Following the onset of the sprain, she has been experiencing difficulty bending forward with constant sharp pain. The sprain has led to limited mobility and range of motion in her lower back. She has found relief and improvement by using a heat pack. but still feels quite sore right now. 7. The patient, a 45-year-old male, presents with complaints of lower back pain. He reports that the pain has been persistent for the past two weeks and has gradually worsened. The pain is primarily located in the lumbar area and is described as a dull, aching sensation. The patient states that the pain is aggravated by prolonged sitting and bending forward, but he denies any radiation of pain down the legs or associated numbness or weakness. | |
| 24 hour behaviour(ACNZ病历上没有要求) | This determines how the injury reacts over a typical 24-hour period, documenting the ebb and flow of the problem. | 【examples】wakes up very stiff in lower back, but without pain, after a hot shower, 30%improvement in mobility, by lunchtime, low back starts to ache, by mid-afternoon, the pain goes down the back of the leg and needs painkillers to get through the day. Needs painkillers to fall asleep. |
| Aggravated by加重因素 | Heavy lifting pain 5-7/10 if carrying any weight | |
| Relieved by减轻因素 | Heat pack, rest | |
| Yellow flags(psychological or emotional factors) | psychological or emotional factors involve psychological, social, or occupational factors that may contribute to the persistence or exacerbation of symptoms： Examples of yellow flags related to lower back pain can include: Fear or avoidance behavior: This refers to the patient’s fear of movement or avoidance of certain activities due to concerns about pain or further injury. Catastrophic thinking: Patients may have a tendency to catastrophize their pain, imagining the worst-case scenarios or believing that their condition is irreversible or untreatable. Anxiety or depression: Psychological factors such as anxiety or depression can influence the perception and experience of pain, as well as affect the ability to cope with symptoms. Work-related factors: Job dissatisfaction, high physical demands, poor ergonomics, or workplace stress can contribute to the development or persistence of lower back pain. Social support: Lack of social support or strained relationships may impact an individual’s ability to cope with and manage their condition. | N/A or fear/anxiety/depression |
| Red flags(potential serious complications) | potential serious complications In the context of healthcare, “red flags” refer to warning signs or indicators that may suggest the presence of a serious underlying condition or a potentially urgent medical situation. Red flags are used by healthcare professionals to identify symptoms or findings that require further investigation or immediate attention. When it comes to lower back pain, red flags can include: Severe or progressive neurological deficits: This may involve symptoms such as muscle weakness, numbness, or tingling that radiate down the legs, known as “sciatica.” Severe or worsening neurological symptoms could indicate nerve compression or damage. Loss of bowel or bladder control: The inability to control bowel or bladder function, including urinary or fecal incontinence, can be a sign of cauda equina syndrome, a rare but serious condition that requires immediate medical attention. Trauma or injury: If lower back pain is the result of significant trauma or injury, such as a fall, car accident, or sports-related incident, it is important to rule out fractures, spinal cord injury, or other severe injuries. History of cancer: Lower back pain in individuals with a history of cancer or a current cancer diagnosis may warrant further evaluation to rule out spinal metastasis or tumor-related complications. Unexplained weight loss: Unintentional weight loss associated with lower back pain could be indicative of an underlying systemic condition, such as cancer or infection. Fever or infection: Lower back pain accompanied by fever, chills, or other signs of infection could indicate a spinal or systemic infection. Progressive or severe night pain: Pain that worsens at night or interrupts sleep, especially if it is persistent and progressive, may require further investigation. | N/A or bladder control |
| Previous treatment之前的治疗 | Seen physio for 4 sessions， Seen GP | |
| Objective Findings治疗师诊断 | ||
| Objective Findings治疗师诊断 | ||
| Observation视诊 | Observation of a lower back sprain may involve assessing various aspects of the individual’s condition. Here are some observations that can be made: Posture: Observe the person’s posture while standing, sitting, or walking. Look for any signs of asymmetry, favoring one side, or stiffness in the lower back area. Movement limitations: Note if the person experiences difficulty or pain when bending forward, twisting, or performing specific movements that involve the lower back. They may exhibit guarded movements or avoid certain actions altogether. Facial expressions: Pay attention to their facial expressions, looking for signs of pain, discomfort, or grimacing when they move or perform specific activities that engage the lower back. Mobility: Assess their mobility and range of motion in the lower back area. Observe if they have restricted movement or if their range of motion is limited compared to normal. Muscle tension or spasm: Look for any visible signs of muscle tension or spasms in the lower back area. This may present as visible muscle contractions or palpable areas of tightness. Gait: Observe their walking pattern or gait. A person with a lower back sprain may exhibit altered gait mechanics, such as walking with a shortened stride, favoring one side, or exhibiting a stiff or guarded gait.Signs of inflammation: Notice if there are any visible signs of inflammation, such as redness, swelling, or warmth, in the lower back area. Degree of swelling: Grade 0 一切正常 No swelling or edema is observed. The affected area appears normal without any noticeable increase in size or fluid accumulation. Grade 1 轻微局部水肿，不影响活动度 Mild swelling or edema is present. There is a slight increase in the size of the affected area, but it is still within a relatively normal range. The swelling may be subtle, with minimal pitting or indentation upon pressure. Grade 2 很明显的水肿，按压明显疼痛。 Moderate swelling or edema is observed. There is a significant increase in the size of the affected area. The swelling is noticeable, and there may be moderate pitting or indentation upon pressure. The affected area may feel firm or tense. Grade 3 水肿非常明显，按压疼痛，活动度明显受影响。 Severe swelling or edema is present. There is a substantial increase in the size of the affected area. The swelling is pronounced and may extend beyond the affected area. There is marked pitting or indentation upon pressure, and the affected area may feel very firm or tense. | Walk with limping gait, back supported with both hands walking with crutch on the left difficult to lie on the back Spasm in the left side of back muscle, Reduced lumbar flexion, and side bending to the left No reddish scar Mild bruising Swelling grade2 in the affected area |
| Numerical Pain Rating Scale (NPRS)疼痛指数（0不痛，10最痛） | Video for NPRS explanation: How The Pain Scale Should Be Explained https://www.youtube.com/watch?v=jP1opUrxMR4&list=PLV4uwHHm_vvHJ9h8_UsHgqZ3u7vC6MDSX&index=4 Assessment of pain https://www.youtube.com/watch?v=2YmAdr9s0dE&list=PLV4uwHHm_vvHJ9h8_UsHgqZ3u7vC6MDSX&index=3 Numerical Pain Rating Scale (NPRS)[ask the patient to rate their pain on average over the last 24 hours on a scale of 0-10, with ‘0’ being ‘no pain’ and ‘10’ being the ‘worst possible pain’.] 0 1 2 3 4 5 6 7 8 9 10 ______________________________________________________ No pain Moderate pain Worst pain | NPRS: 7/10 |
| Patient-Specific Functional Scale (PSFS)患者特定功能评定量表 | Video for PSFS explanation: Patient-Specific Functional Scale (PSFS) https://www.youtube.com/watch?v=d9g6LbBjN0&list=PLV4uwHHm_vvHJ9h8_UsHgqZ3u7vC6MDSX&index=1 PSFS Outcomes https://www.youtube.com/watch?v=bfIdSSkCdOM&list=PLV4uwHHm_vvHJ9h8_UsHgqZ3u7vC6MDSX&index=2 Patient-Specific Functional Scale (PSFS) 问患者3个跟扭伤相关的动作并测试活动度[ask the patient to identify 3 important activities that they are unable to do or are having difficulty with as a result of the presenting problem and to score them according to the following scale] 0 1 2 3 4 5 6 7 8 9 10 _______________________________________________________________________ Unable to perform activity Able to perform the activity at the same level as before injury or problem | 非常严重，不能弯腰(worse condition)：3/10治疗3-5次后，好很多(better condition)：8/10 【examples】describe at least 3 joint-related movements, ideally one of the movements is related to their job. To be able to lift a 5kg heavy object 6/10 To be able to sleep on the affected side 6/10 To be able to place the glass on the shelf at the lower back level 6/10 |
| 4. Range of movement活动度检查 | 1.Range of motion（各大关节具体活动度数总结）: https://tcmfoundations.com/acc/8-range-of-movement/ 2.Range of motion&Orthopaedic testing（各大关节活动度及特殊检查）: https://www.youtube.com/@Physiotutors/videos?view=0&sort=p&shelf_id=0 | Lower Back Extension 25° Flexion 70° Left Lateral (flexion) 25° Right Lateral (flexion) 25° |
| 7.Neurologic evaluation.很多人不会做 | A. Sensory Deficits. | If a sensory nerve root impinges e.g. with an acute cervical or lumbar disc involvement, where there can be either hypersensitivity but usually experienced by the patient as patches of numbness with loss of feeling and a deficiency in 2-point discrimination. This should be noted on the patient’s record and re-evaluated on subsequent visits, recording changes for better or worse. |
| B. Tendon ReflexesThe Tendon Reflexes help to confirm and build up a symptom picture for a working diagnosis. Tendon reflexes are valuable as inflammation around a disc or disc hernia often resolves or reduces and reflexes along with other symptoms, can mirror this change. Sometimes there is no change, as permanent damage may exist. If in doubt refer them to their patient medical practitioner, specialist, or the appropriately qualified person. | e.g. Biceps C5 predominately, Triceps C7, Patella L4, Achilles S 1 Tendon reflexes can be recorded as increased, reduced, or absent. Compare both sides. | |
| C. Motor Deficiency | Often jointly investigated during Orthopaedic Testing can indicate a neurological impingement. | |
| 8.Muscle strength肌力检查 | compare both sides. In the case of a disc protrusion, for example, loss of power may indicate a neurologic deficiency, but this is not always the only cause. In using a Muscle-Grading Chart, the movement against resistance should not be overpowering but considered and designed so as not to aggravate the patient’s condition – as with all orthopedic tests you perform. Muscle Grading Chart. Muscle Grade&Description 5 – Normal-Complete range of motion against gravity with full resistance. 4 – Good-Complete range of motion against gravity with some resistance. 3 – Fair-Complete range of motion against gravity. 2 – Poor-Complete range of motion with gravity eliminated. 1 – Trace evidence of slight contractility. No joint motion. | |
| AssessmentACNZ病历上没有要求 | Based on the patient’s subjective report, objective findings, and the changes in symptoms, the treatment has shown positive progress in reducing pain, improving range of motion, and enhancing lower back function. The patient’s response suggests a positive response to the acupuncture intervention for lower back pain with blood stasis and qi stagnation. | 【examples】 1. The patient presents with what appears to be acute right lower back and neck pain, likely due to her recent fall. The pain has interrupted her sleep and limited her lower back mobility, impacting her quality of life. 2. Upon physical examination, palpable tension and tenderness were noted in the right lower back and neck area. Range of motion (ROM) was significantly decreased, with abduction limited to 45 degrees, flexion to 60 degrees, extension to 30 degrees, and internal rotation virtually impossible as she couldn’t position her hand behind her back. Pain response was heightened during these movements. 3. She is suffering from acute right lower back pain, likely resulting from a traumatic fall. This has resulted in interrupted sleep patterns and reduced ROM in the lower back, both of which significantly affect her quality of life. Given her symptoms and the mechanism of injury, a potential diagnosis could be a rotator cuff injury or acute lower back sprain. 4. ROM findings reveal limited lower back flexion and abduction, as well as mild pain and restricted movement in internal and external rotation. 5. Based on the subjective and objective findings, the patient presents with right lower back pain and limited ROM, indicating possible musculoskeletal dysfunction or injury. |
| Tongue Body Color Bluish Purple, Reddish, Red, Red Tip, Scarlet, Dark Red, Pale, Green Tongue body Shape Stiff, Flaccid, Swollen, Big or Enlarged Tongue, Swollen, Short, and Contracted Tongue Body Features Rough Texture, Tender Texture, Red Spots, White Spots, Black Spots, Ulcerated Tongue Body, Numb Tongue Body, Loose Tongue Body, Deviated Tongue Body, Moving, Lolling, Wagging, Playful Tongue Body， Teeth Marks on Tongue Body， Trembling Tongue Body Tongue Body Moisture Dry Tongue Body， Slightly Dry Tongue Body， Wet Tongue Body Tongue Coating White Tongue Coat， White Like Powder Tongue Coat， White Like Snow Tongue Coat， Yellow Tongue Coat， Dirty Yellow Tongue Coat， Simultaneous White and Yellow Tongue Coating， Gray Tongue Coat， Black Tongue Coat Tongue Coat Thickness Thin,Thick, Peeled, Mirrored, Shiny, No Coating | Dark Red Tongue with White Coating | |
| Superficial Pulse浮脉类 Floating부맥浮脈 Surging홍맥洪脈 soggy유맥濡脈scattered산맥散脈 Hollow규맥芤脈 Drumskin혁맥革脈 Deep Pulse沈脉类 deep침맥沈脈 Surging복맥伏脈 Hidden약맥弱脈 Firm뇌맥牢脈 Slow Pulse缓脉类 Slow지맥遲脈 Moderate완맥緩脈 Unsmooth색맥濇脈 Irregular Intermittent결맥結脈 Rapid Pulse数脉类 rapid삭맥數脈 Racing질맥疾脈 Rapid-Irregular촉맥促脈 Stirring동맥動脈 Feeble Pulse虚脉类 Feeble허맥虛脈 Thready세맥細脈 Faint미맥微脈 regularly intermittent대맥代脈 short단맥短脈 Excess Pulse實脈类 Excess실맥實脈 Slippery활맥滑脈 Wiry현맥弦脈 Tight긴맥緊脉 Long장맥長脈 | Wiry | |
| Affected Meridians受影响经络 | 肺经-LU，大肠经-LI，胃经-ST，脾经-SP，心经-HT，小肠经-SI， 膀胱经-BL，肾经-KID，心包经-PC，三焦经-SJ，胆经-GB，肝经-LIV， 任脉-REN，督脉-DU | BL(bladder meridian) |
| DiagnosisACC诊断 | read code(blood stasis and qi Stagnation) 1）因为ACC是Accident所以诊断里一般都要有-气滞血瘀blood stasis and qi Stagnation 2）伴有其他证型的参考以下例子 other patterns Zangfu/Meridian Lung(LU),Large intestine (LI),Stomach(ST),Spleen(SP),Heart(HT),Small intestine (SI),Bladder(BL),Kidney(KI),Pericardium(PC),Sanjiao(SJ),Gallbladder(GB),Liver(LR),Du Ren The Vital Substances Blood(Xue),Jin ye(Body Fluids),Jing(Essence),Qi Causes of illness 6 Evils: Wind, Cold, Damp, Heat, Summerheat, Dryness 7 Emotions: Joy, Anger,Grief, Worry and Pensiveness, Fear,Fright Condition Stagnation（气）滞，Stasis（血）瘀，Deficiency虚，Accumulation积，Rebellion气逆，sinking /prolapsed气陷/脱垂 | 1. S572(N/A) Lumber Sprain (qi stagnation&blood stasis in Bladder Meridian) 2.S572(N/A) Lumber Sprain ( qi stagnation and blood stasis in kidney channels with kidney qi deficiency) |
| Treatment Principle治疗原则 | Qi stagnation： Move Qi stagnation or regulate Qi Qi deficiency：Tonify Qi Qi rebellion： Subdue rebellious Qi or regulate Qi Qi sinking /prolapsed： Raise Qi Blood stagnation/stasis： Invigorate Blood or move blood stasis Blood deficiency： Nourish Blood deficiency or tonify blood heat： cool the Blood Accumulation of Phlegm： Transform or Resolve Phlegm Zang Fu deficiencies： Tonify or nourish or raise Qi of Zang Fu/Disperse Qi or nourish Yin Warm, supplement, or raise Yang/Subdue Yang Rising Zang Fu stagnation/rebellion： Disperse stagnation, harmonise Zangfu function Wind： Expel Wind or clear external Wind Heat： Cool/clear or reduce Heat, or clear external/exterior Heat Dryness： Moisten Dryness or clear external Dryness Cold： Warm Yang or expel Cold Damp： Transform Damp, drain damp, or expel Damp | 1. promote Qi and remove blood stasis to relieve the pain 2. promote Qi and remove blood stasis+tonify kidney qi to relieve the pain |
| Goal for treatment治疗目标，指定可以达到的目标 | ACC: This helps us to understand how well the client is progressing 1. Specific: 2. Measurable: Measurable here means being able to ascertain differences in the progress of treatment by comparing differences in the particular tests that were done in the first consultation. 3. Achievable: Within the scope of normal acupuncture practice, results need to be achievable. In some circumstances, it may not be possible to achieve a result, for example, to rejuvenate a shattered disc. It is however possible and achievable to lessen the pain associated with a shattered disc. 4. Realistic: The practitioner needs to make the patient aware that treatment and the results are realistic. 5. Timed: This is an important feature of the case history clinical notes. Objectives need to be set between the practitioner and patient as to the time frame to achieve the objectives. For example, a sprained ankle will take 7 days to heal in order so that it can be walked on comfortably without pain. However, in a ballet dancer, a sprained ankle may take 3 weeks before they can dance on it again. In the first case, treatment should cease and the patient discharged after 7 days if the goal of walking without pain has been achieved. In the second case, the ballet dancer may be able to walk after a week but still can’t dance so further treatment may be required. | 1. To be able to bend over to put on socks or shoes without pain 2. To be able to lift a 5kg heavy object without pain 3. To be able to get out of a car without pain |
| Treatment Plan治疗计划 | What are you going to do next? Rv in 1 week is only part of the story. What are you going to review and how are you going to do this? Are you intending to progress/repeat treatment/HEP etc-if so how? | Repeated treatment: acupuncture and cupping once a week review once a week |
| In many circumstances, the practitioner needs to make a change in the treatment plan. The change in Treatment Plan needs to be discussed with the patient as well as documented in the clinical notes and it must be signed. | 【examples】Discussed with the patient the probable reasons for no major change in the back pain. A different treatment strategy is going to be implemented where warm needle techniques will be used. If there is no improvement after 2 weeks with 2 treatments per week, the peer reviewer shall be consulted | |
| Estimated time frame康复预计需要时间 | 10weeks |
