Lose The Back Pain Self-Assessment Workbook

Lose The Back Pain Self-Assessment Workbook

Self-Assessment Workbook Customer Information: Name : Email: Phone Number: Best time to call / time zone: How To Use This Workbook In order to make this system as easy to use as possible and to ensure you get the best possible results, we ve created this workbook to help you document your findings and keep track of your progress. This workbook is broken down into 3 sections: Section 1 Self-Assessment Worksheet In this first section you are going to document your findings after performing the physical assessments, add your visual assessment photographs and identify which dysfunctions you have. Section 2 - Progress Checklist and Pain Scales In this section you ll use two tools to monitor your progress as you implement the various steps and strategies in this program. One is the Progress Checklist on which you ll check off and date when you complete each step and the other is the Pain Scales Chart, which you ll use to document your pain levels. Section 3 - Back Pain History Questionnaire In this section you ll answer a few questions about your condition and pain. This information is necessary only if you plan to utilize our personal support and we highly recommend you do, as you will likely have questions along the way. Helpful tips to completing the Self-Assessment worksheet! We recommend you use this workbook to document your results and findings while performing the Self- Assessments. As you complete each assessment, be sure to answer yes or no to each question. The more times you answer YES to the questions for a particular dysfunction the more likely it is that you have that dysfunction. In order to get the most out of this system you will need to do both the Visual Assessments and the Physical Assessments, they are both equally as important and when use together they offer a very compelling look at the root cause of your problem. Please refer to the Lose the Back Pain FAQ s if you have any questions along the way http://losethebackpain.com/faq.html 1

Lose The Back Pain After completing the Self-Assessments for this dysfunction please indicate if you feel you have this dysfunction or not or are not sure. If you are sure you have this dysfunction please begin the corrective exercise for this dysfunction. Use the illustrations to help you with the assessments. Forward Tipped Pelvis Dysfunction: YES NO Not Sure 1. Visual Assessments - using both a Mirror and your Self-Photos (Both Side view Photos) Do you see a downward sloping of the waistline? q YES q NO Do you see excessive curvature in the lower back? q YES q NO Do you see a forward leaning from your ankles up? q YES q NO 2. Physical Assessments Testing both Strength and Flexibility Hip Flexor Flexibility Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Do you feel tightness, pain or restriction in the upper thigh? q YES q NO Did you feel an increase in the restriction as you leaned inward? q YES q NO Did you feel the restriction on both sides? q YES q NO Lower Back Flexibility Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Do you feel tightness, pain or restriction in the lower back? q YES q NO Quadriceps Flexibility Test Was it difficult attempting to grab your foot? q YES q NO Was it difficult pulling your foot in towards your buttocks? q YES q NO Was it difficult attempting to keep your knee pointing straight down? q YES q NO Did you feel even more restriction when tipping your pelvis backwards? q YES q NO Did you feel the restriction on both sides? q YES q NO Lower Abdominal Strength Test Was it difficult attempting to bring your knees to your chest? q YES q NO Was it difficult attempting to lower your knee back to the ground? q YES q NO Did you feel pain in the lower back when doing this motion? q YES q NO Did you feel any arching on the lower back when doing this motion? q YES q NO Glute Strength Test Was it difficult attempting the get your hips off the ground? q YES q NO Was it difficult attempting to get your hip and trunk in a straight line? q YES q NO Was it difficult attempting to lift one leg off the ground? q YES q NO NOTE: The FTP is the most common dysfunction and is often times associated with a High Hip and Forward Head and Shoulder dysfunction. Your observations: 2

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Lose The Back Pain After completing the Self-Assessments for this dysfunction please indicate if you feel you have this dysfunction or not or are not sure. If you are sure you have this dysfunction please begin the corrective exercise for this dysfunction. Use the illustrations to help you with the assessments. High Hip Dysfunction: YES NO Not Sure 1. Visual Assessments - using both a Mirror and your Self-Photos (Front and Rear Photos) Which side of your pelvis is higher? q Right q Left Which side appears to have a lower shoulder? Should be HH side q Right q Left Which side appears to show that the fingers are longer? Should be HH side q Right q Left Do you see a larger skin crease in the lower back on your HH side? q YES q NO Do you see the arm on the HH side to be closer to the side of your body? q YES q NO 2. Physical Assessments Testing both Strength and Flexibility Inner Thigh Flexibility Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Did you feel a difference in the restriction between the two sides? q YES q NO Which side did you feel the restriction on more? Should be HH side q Right q Left QL Flexibility Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Did you feel a difference in the restriction between the two sides? q YES q NO Which side did you feel the restriction on more? Should be HH side q Right q Left Forward Bend Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Did your thumbs fall in to the notch? q YES q NO After attempting the position and than standing up which hip was higher? q Right q Left Did you take a photo or have someone else help? Which side was higher? q Right q Left NOTE: If you can not see the High Hip, feeling for the differences in pain, tightness or restriction between the two sides of your body, during each of the physical assessments will be one of the best ways to pin point which side the High Hip is on. Your observations: 4

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Lose The Back Pain After completing the Self-Assessments for this dysfunction please indicate if you feel you have this dysfunction or not or are not sure. If you are sure you have this dysfunction please begin the corrective exercise for this dysfunction. Use the illustrations to help you with the assessments. Forward Head + Shoulders Dysfunction: YES NO Not Sure 1. Visual Assessments - using your Self-Photos (Front and Side Photos) Is your head pushed forward? q YES q NO Are your ears forward of your shoulders? q YES q NO Do your shoulders look rounded? q YES q NO Do your shoulders look rotated inward? q YES q NO 2. Physical Assessments Testing both Strength and Flexibility Chest Flexibility Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Do you feel tightness, pain or restriction in the chest and shoulder? q YES q NO When in the position did you feel like you achieved only minimal rotation? q YES q NO Did both sides feel equally restricted? q YES q NO Upper Back Strength Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Was it difficult to get 2-3 inches off the floor? q YES q NO Was it difficult to hold that position? q YES q NO While attempting to achieve this position was there any discomfort? q YES q NO Lower Trap Strength Test Was it difficult attempting to achieve the position demonstrated? q YES q NO Was it difficult to get 2-3 inches off the floor? q YES q NO Was it difficult to hold that position? q YES q NO While attempting to achieve this position was there any discomfort? q YES q NO NOTE: Most people have a Forward Head and Shoulder to some degree, if you cannot identify it now please note that it is developing as you sit and stair at you computer monitor day after day-year after year. Your observations: 6

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Lose The Back Pain After completing the Self-Assessments for this dysfunction please indicate if you feel you have this dysfunction or not or are not sure. If you are sure you have this dysfunction please begin the corrective exercise for this dysfunction. Use the illustrations to help you with the assessments. Backward Tipped Pelvis Dysfunction: YES NO Not Sure 1. Visual Assessments - using your Self-Photos (Both side view Photos) Do you see a backward tipping of the pelvis or waistline? q YES q NO Do you see a flattening or lack of curvature in the lower spine? q YES q NO Do you see a backward leaning from the knee to the mid back area? q YES q NO 2. Physical Assessments Testing both Strength and Flexibility Flat Back Test Do you feel as if your lower back was totally flat to the floor? q YES q NO The flatter your back the more likely you have BTP Was there a lack arching or space between your back and the floor? q YES q NO The more arching and space you have the less likely you have BTP Were you unable to put some or most of your hand under your back? q YES q NO The more of your hand you can put under your back the less likely you have a BTP Glute Flexibility Test Was it difficult attempting to put the foot on to the knee? q YES q NO The easier it was for you to put your foot on your knee the less likely you have a BTP Was it difficult attempting to reach through and pull the knee to chest? q YES q NO The more you were able to pull your knees to your chest the less likely you have a BTP NOTE: Please, note that you cannot have both a Forward Tipped and a Backward Tipped Pelvis. The BTP is the least common Dysfunction and is mostly found in the older population. Tight Glutes alone do not mean that you have a BTP. Please do you best to rule out a Forward Tipped Pelvis before confirming a BTP dysfunction. Please listen to FAQ 15# before confirming BTP... http://losethebackpain.com/faq.html Your observations: 8

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Lose The Back Pain Visual Assessment Photos Photo taking tips: Stand barefoot on a hard surface with arms relaxed by your side Please wear shorts. If male without a shirt or in a jog bra or tank top if female. This allows both you and us to get the most accurate assessment. Use a plain wall as a background and ensure room is well lit and/or use a flash Turn camera to take a full length, vertical photo - hold as level as possible Ensure you get your complete body (showing head to toe) in every photo Attach Right Side Photo Here Attach Left Side Photo Here 10

Self-Assessment Workbook Attach Front Photo Here Attach Rear Photo Here NOTE: Refer to the Visual Assessment and Sample Photo section of your reference manual, to learn how you will use these photos to help identify the physical dysfunctions you have. If you request personal support we will need to see both your Self Assessment Worksheet and your Visual Assessment Photos. By emailing your info to support@losethebackpain.com or by mailing them to address below. Once we ve received your information we will contact you as quickly as possible to answer any questions you have and give you specific recommendations and guidance. The Healthy Back Institute 431 Pine Street - Suite 312, Burlington, VT 05401 USA -------------------------------------------------------------------------------------------------------------------------------------------- For Office Use Only Reviewed By: Date: 11

Lose The Back Pain Progress Checklist Use the chart below as you move thru the steps in the system to keep track of your progress. Plus, we also want to issue you a challenge Can you complete and implement all of the steps below in the first 14 days or less? We know you can and we also know that the sooner you get started and complete the steps below the sooner you ll get relief. Steps to Complete 1. Read the Welcome Letter Date Completed 2. Listen to Audio CD #1: How To Use The System 3. Watch DVD #1 Perform the self assessments Take your visual assessment photos Complete your Back Pain History Questionnaire Complete your Self-Assessment Worksheet Identify and confirm all Physical Dysfunctions 4. Watch DVD #2 Begin the corrective exercises and stretches for the dysfunctions you ve identified 5. Listen to Audio CD #2: Pain Reduction Strategies Experiment with various strategies to find the ones that work best for you 6. Listen to Audio CD #3: Condition Specific Recommendations Explore the recommendations that are relevant to your condition(s) 7. Read the Reference Manual 12

Self-Assessment Workbook Pain Scales Chart Please use the scales below to rate and monitor your pain level as you move through this program. Before Starting - Please mark the on the pain scale where you feel your pain is before starting. Little or no pain Moderate Pain Severe Pain 1 2 3 4 5 6 7 8 9 10 Week 1 - Please mark the on the pain scale where you feel your pain is now. Little or no pain Moderate Pain Severe Pain 1 2 3 4 5 6 7 8 9 10 Week 2 - Please mark the pain scale where you feel your pain is now. Little or no pain Moderate Pain Severe Pain 1 2 3 4 5 6 7 8 9 10 Month 1 - Pease mark on the pain scale where you feel you pain is now. Little or no pain Moderate Pain Severe Pain 1 2 3 4 5 6 7 8 9 10 Month 2 - Pease mark on the pain scale where you feel you pain is now. Little or no pain Moderate Pain Severe Pain 1 2 3 4 5 6 7 8 9 10 Month 3 - Pease mark on the pain scale where you feel you pain is now. Little or no pain Moderate Pain Severe Pain 1 2 3 4 5 6 7 8 9 10 Month 6 - Pease mark on the pain scale where you feel you pain is now. Little or no pain Moderate Pain Severe Pain 1 2 3 4 5 6 7 8 9 10 13

Lose The Back Pain Back Pain History Questionnaire 1. What condition have you been diagnosed with, if any? 1. How long have you been suffering from this condition? 2. Have you seen a healthcare professional for this condition? If so, which type(s): q General Physician q Physical Therapist q Chiropractor q Orthopedic Surgeon q Massage Therapist q Acupuncturist q Other Please specify 3. Which treatments have you already tried? q Anti Inflammatory Medications q Muscle Relaxants q Traction q Cortisone Injections q Ultrasound q Electrical Stimulation q Trigger Point Therapy / Injections q Surgery 4. Please tell us where your pain is located? And if it moves or travels down your leg? 6. When do you feel your pain? (ex. All day, only in the morning, etc) 14