Physiotherapy Impression Analysis Problem List 1. Pain on Lt. sh. d/t muscle tightness 2. Limited ROM on Lt.

side d/t pain and LMNL 3. Reduce in muscle strength on Lt. side d/t muscle disuse 4. Reduce in muscle tone d/t LMNL 5. Impaired of sensory function d/t nerve deficit 6. Fair in balance d/t poor of stability 7. Difficulty to perform bed mobility independently d/t trunk muscle weakness 8. Reduce functional ADL d/t decrease motor control 9. Poor postural control d/t STG 1. To reduce pain on Lt. sh within 1/52 2. To improve ROM within 2/52 3. To improve in muscle strength within 3/52 4. To improve muscle tone of the affected extremities within 3/52 5. To regain sensation within 2/52 6. To train balance within 3/52 7. To retrain walking and restore bed mobility within 2/52 8. To educate functional activities within 3/52 9. To improve good posture within 3/52

LTG 1. To get optimal functional activity independently of ADL such as walking, standing and going back to work within 3/12 2. To prevent secondary complication of present condition within 1/12 3. To train pt in normal gait within 2/12 Plan of Treatment - strengthening exs - deep breathing exs - mat activity - bridging - transfer - supine - gait training -balance training - postural training - knee control - double arm elevated - scapula mobilization - reaching activities side ly. sitting

Intervention 1. Bridging exs - pt in sup ly. position -flex the both knee - ask pt to lift up the hip and hold for 10sec - rep for 10 times 2. Passive movement - pt in sup ly position - Therapist passively move Lt. UL and LL in all direction - repeat for 8 times per session 3. Balance training Static balance Dynamic balance : pt has to maintain balance while therapist give force : pt accepts challenge and try to shift weight in all direction while do the jt. approximation on affected hand 4. Sit to stand exs - pt sit on chair - ask pt to hold chair support - ask pt to stand independently with supervision by therapist - repeat sit to stand for 7 times. 5. Train bed mobility - from supine ly position, ask pt to flex knee and use Lt arm to pull herself go into Rt. side ly, then bring down leg and used Rt. elb and Lt. hand to push against bed. - always observe if pt paleness. Ask if pt experienced dizziness and fatigue. Ask her to breath

6. Strengthening exs -SQE (staic quadriceps exs) : long sitt x ankle dorsiflex x push knee toward bed x hold 10 sec x 10 time rep. -SGE (static Gluteal exs) : sup lying x push the buttock toward the bed x hold 10 sec x 10 time repetition

Evaluation 1. Pt feel week but able to do the exs given 2. Pain on Lt sh. 3. Pt c/o dizziness during initial sup ly to sitting (ask pt to breath and rest for 5 min). During standing, pt c/o shaking of the knee. 4. Pt continue therapy on 8/3/2011

Reassessment 1. To continue exs for the next visit 2. To train pt to talk for the next visit

Progression note: 8/3/2011 2nd assessment S- Pt current complaint -pt claimed feel much better and able to lift up her Lt. hand -general body weakness on Lt. side -Numbness at proximal hand -easily get tired OGeneral: -alert and oriented -understand and co-operative -this time pt comes to Physio department (come using wheelchair companied by her son) Local: -muscle power same as initial assessment -able to sitt at the edge of bed by herself with minimal assistance -during standing pt start sway and sudden loss of knee control -no pressure sores are noted Vital sign Temp. : 37o BP HR RR : 125/80 mmHg :85 bpm : 19 bpm

Balance Position Sitting Standing Good Good Static Fair fair Dynamic

Int

: no improvement in balance same as initial assessment

Range Of Motion movement Lt. UL Lt. LL Active Limited ROM within inner range Limited ROM within inner range Pasive PFROM-ERP (on Lt.sh flex) PFROM

Int

: Reduce in ROM on Lt UL &LL d/t pain and muscle weakness

Functional Analysis Score Independent with no aid Modified independent with the use of aids Require supervision Requires minimal assistance Requires moderate assistance Requires maximum assistance Total independent

7 6 5 4 3 2 1

Transfer bed Transfer w/c Shifting ability Supine Side ly. Sitting Stting Standing

chair toilet

3 3 3

side ly. sitt standing

4 4 3 3 2

Int

: slightly improve in functional analysis pt able to perform from sup. To side ly and side ly to sitt with minimal assistance.

Motor Assessments Scale (MAS)

1) Supine lying to side lying on intact side 1) Pulls himself into side lying 2) Moves leg across actively and the lower half of the body follows in block 3) Arm is lifted across body using other arm. Leg is moved actively and body follows in block 4) Moves arm across actively and the rest of the body follows in a block

08/03/11

5) Moves arm and leg and roles to side but overbalances 6) roles to the side within 3 sec

2) Supine to sitting over side of bed 1) Side lying. Lift head sideways but cannot sit up 2) Side lying to sitting over side of bed ( Therapist assist patient) 3) Side lying to sitting side of bed ( with standby help) 4) Side lying to sitting side of bed 5) Supine to sitting side of bed 6) Supine to sitting side of bed ( within 10 sec)

08/03/11

3) Balanced sitting 1) Sits only with support 2) Sits unsupported for 10 sec 3) Sits unsupported with weight well forward and evenly distributed 4) Sits unsupported, turns head and trunk to look behind 5) Sits unsupported, reaches forward to touch floor and returns to starting position 6) Sits on stool unsupported reaches sideways to touch floor and return to starting position

08/03/11

08/03/11 4) Sitting to standing 1) Gets to standing with help from the therapist 2) Gets standing with standby help ( with standby help) 3) Gets to standing 4) Gets to standing and stands for 5 sec with hips and knees extended 5) Sitting to standing to sitting with no standby help 6) Sitting to standing to sitting with no standby help,5 times in 10 sec

5) Walking 1) Stands on affected leg and steps forward with other leg. 2) Walk with standby help from one person. 3) Walk 3m alone or uses any aids but no standby help. 4) Walks 5m without aids in 15 secs 5) Walks 10m without aid, turns around, picks up a small sandbag from floor, and walks back in 25 secs 6) Walks up and down 4 steps with or without an aid but without holding on to the rail 3 times in 35 secs

08/03/11

6) Upper Arm Function 1) Lying protract shoulder girdle with arm elevation 2) lying hold extended arm in elevation for 2 sec 3) flexion and extension of elbow to take palm to forehead with arm as 2 4) Sitting, hold extended arm in forward flexion at 90 to body for 2 secs. 5) Sitting, pt. lift arm to above position, hold it for 10 secs and lower it 6) Standing, arm abducted to 90 with palm flat against wall. Maintain arm position while turning body towards wall.

08/03/11

7) Hand movement 1) Sitting, extension of wrist 2) Sitting, radial deviation of wrist

08/03/11

3) Sitting, elbow into side pronation and supination

4) Reach forward, pick up ball of 14 cm diameter with both hands and put it down

5) Pick up a polystyrene cup from table and put it down table across other side of body 6) Continuous opposition of thumb and each finger more than 14 times in 10 sec

8) Advanced hand activities 1) picking up the top of the pen and putting it down again 2) picking 1 jelly bean from a cup and placing it in another cup 3) Drawing horizontal line to stop at a vertical line 10 times in 20 sec 4) Holding a pencil, making rapid consecutive dots on a sheet of paper 5) Taking a dessert spoon of liquid to the mouth 6) Holding a comb and combing hair at back of head

08/03/11

Total : 27 Int : pt having moderate functioning on the affected side

A-Problem list 1. Limited ROM on Lt. side d/t LMNL 2. Reduce in muscle strength on Lt. side d/t muscle disuse 3. Reduce in muscle tone d/t LMNL 4. Impaired of sensory function d/t nerve deficit 5. Fair in balance d/t poor of stability 6. Difficulty to perform bed mobility independently d/t trunk muscle weakness STG 1. To improve ROM within 2/52 2. To improve muscle strength within 3/52 3. To improve muscle tone within 3/52 4. To regain sensation within 2/52 5. To train balance within 3/52 6. To retrain walking and restore bed mobility within 2/52 P-strengthening exs -passive exs -active assisted exs -active inner range exs -gait training -balance training -sit to stand exs -Pt education

I1. Continue with previous Tx 2. Balance exs -single leg stand: ask pt to stand on Rt. leg, maintain position for 10 sec - frequency 5 times, rest 5 min, 2 sets 3. Gait training -pt stand on parallel bar -walk for 10 times -Rest in between -therapist correct the gait pattern while pt walking through parallel bar 4. Mobilising exs (Stick exs) - pt in sitting position -ask pt to hold the stick -initiate the movement, bring slowly the affected sh. Upward - rep for 8 time 5. Ambulation using parallel bar -pt standing st parallel bar -ask pt to walk along the parallel bar -duration for 10 min x rest in between 6. Pedal exs -pt in sitting position -put the ankle on padel -ask pt to cycling -duration for 20 min 7. Pt education -advice PAP to remind pt & assist to do exs that had been taught. -advice pt to wear sling to prevent sh. subluxation

E-

- pt able to perform all exs given -during padel cycling, pt able to control knee movement -pt able todo sit to stand with minimal assistance -pt able to control knee movt, shift weight but with close supervision by therapist hand hold parallel bar

R-

-Pt continue therapy on 9/3/2011 -to continue exs for the next visit

Progression note: 9/3/2011 3rd Assessment S-pt c/o there is slightly improve in motor function -pt still feels numbness of proximal hand -difficulty to lift up her hand OGeneral: -obey command - come to department using wheelchair companied by her son -slightly kyphotic posture Local : -skin in normal condition -no swelling on Lt.sh Vital Sign Temp. : 37o BP HR RR : 130/85 mmHg : 90 bpm : 19 bpm

Balance Position Sitting Standing Good Good Static Good Good Dynamic

Int

: pt having improvement in balance

Range Of Motion movement Lt. UL Lt. LL Active Limited ROM within mid range Limited ROM within inner range PFROM PFROM Passive

Int

: reduce in ROM with mid range

Functional Analysis Score 7 6 5 4 3 2 1 Independent with no aid Modified independent with the use of aids Require supervision Requires minimal assistance Requires moderate assistance Requires maximum assistance Total independent

Transfer bed Transfer w/c Shifting ability Supine Side ly. Sitting Stting Standing

chair toilet

3 3 4

side ly. sitt standing

4 4 3 3 3

Int

: slightly improve in functional analysis pt able to perform with minimal assistance.

Motor Assessments Scale (MAS)

1) Supine lying to side lying on intact side 1) Pulls himself into side lying 2) Moves leg across actively and the lower half of the body follows in block 3) Arm is lifted across body using other arm. Leg is moved actively and body follows in block 4) Moves arm across actively and the rest of the body follows in a block

08/03/11

5) Moves arm and leg and roles to side but overbalances 6) roles to the side within 3 sec

2) Supine to sitting over side of bed 1) Side lying. Lift head sideways but cannot sit up 2) Side lying to sitting over side of bed ( Therapist assist patient) 3) Side lying to sitting side of bed ( with standby help) 4) Side lying to sitting side of bed 5) Supine to sitting side of bed 6) Supine to sitting side of bed ( within 10 sec)

08/03/11

3) Balanced sitting 1) Sits only with support 2) Sits unsupported for 10 sec 3) Sits unsupported with weight well forward and evenly distributed 4) Sits unsupported, turns head and trunk to look behind 5) Sits unsupported, reaches forward to touch floor and returns to starting position 6) Sits on stool unsupported reaches sideways to touch floor and return to starting position

08/03/11

08/03/11 4) Sitting to standing 1) Gets to standing with help from the therapist 2) Gets standing with standby help ( with standby help) 3) Gets to standing 4) Gets to standing and stands for 5 sec with hips and knees extended 5) Sitting to standing to sitting with no standby help 6) Sitting to standing to sitting with no standby help,5 times in 10 sec

5) Walking 1) Stands on affected leg and steps forward with other leg. 2) Walk with standby help from one person. 3) Walk 3m alone or uses any aids but no standby help. 4) Walks 5m without aids in 15 secs 5) Walks 10m without aid, turns around, picks up a small sandbag from floor, and walks back in 25 secs 6) Walks up and down 4 steps with or without an aid but without holding on to the rail 3 times in 35 secs

08/03/11

6) Upper Arm Function 1) Lying protract shoulder girdle with arm elevation 2) lying hold extended arm in elevation for 2 sec 3) flexion and extension of elbow to take palm to forehead with arm as 2 4) Sitting, hold extended arm in forward flexion at 90 to body for 2 secs. 5) Sitting, pt. lift arm to above position, hold it for 10 secs and lower it 6) Standing, arm abducted to 90 with palm flat against wall. Maintain arm position while turning body towards wall.

08/03/11

7) Hand movement 1) Sitting, extension of wrist 2) Sitting, radial deviation of wrist

08/03/11

3) Sitting, elbow into side pronation and supination

4) Reach forward, pick up ball of 14 cm diameter with both hands and put it down

5) Pick up a polystyrene cup from table and put it down table across other side of body 6) Continuous opposition of thumb and each finger more than 14 times in 10 sec

8) Advanced hand activities 1) picking up the top of the pen and putting it down again 2) picking 1 jelly bean from a cup and placing it in another cup 3) Drawing horizontal line to stop at a vertical line 10 times in 20 sec 4) Holding a pencil, making rapid consecutive dots on a sheet of paper 5) Taking a dessert spoon of liquid to the mouth 6) Holding a comb and combing hair at back of head

08/03/11

Total : 29 Int : pt having moderate functioning on the affected side

A-Problem list 1.Limited ROM on Lt. side d/t LMNL 2. Reduce in muscle strength on Lt. side d/t muscle disuse 3. Reduce in muscle tone d/t LMNL 4.Impaired of sensory function d/t nerve deficit STG 1. To improve ROM within 2/52 2. To improve muscle strength within 3/52 3. To improve muscle tone within 3/52 4. To regain sensation within 2/52

P-

-strengthening exs -passive exs -active assisted exs -active inner range exs -gait training -balance training -sit to stand exs -Pt education

I1. Continue with previous Tx 2. Strengthening exs (sand beg) - pt in sup ly position -apply sand beg at pt ankle -ask pt to lift up her leg -hold for 5 sec, rep for 3 times 3. Gait training -pt stand on parallel bar -walk for 10 times -Rest in between -therapist correct the gait pattern while pt walking through parallel bar 4. Mobilising exs (Stick exs) - pt in sitting position -ask pt to hold the stick -initiate the movement, bring slowly the affected sh. Upward - rep for 8 time 5. Ambulation using parallel bar -pt standing st parallel bar -ask pt to walk along the parallel bar -duration for 10 min x rest in between 6. Pedal exs -pt in sitting position -put the ankle on padel -ask pt to cycling -duration for 20 min

7. Hand exs (fine object) -pt in sitt position -ask pt gently touch the fine object and differentiate the object -duration for 15 min 8. Pt education -advice PAP to remind pt & assist to do exs that had been taught. -advice pt to wear sling to prevent sh. subluxation

E-

- pt able to perform all exs given -during padel cycling, pt able to control knee movement -pt able to do sit to stand with minimal assistance -pt able to lift up the Lt. sh. with less pain

R-

-to continue exs for the next visit