中興醫院 Date: 2022/11/28

 IP □ OP WARD
Chung Shing Hospital
No.: 011-2
Physical Therapy Neurological
Y.O.B: 1977/5/22
Initial Evaluation Form
Social and Vocational:

Name: 蘇 O 三 Hosp No.: 8330062

Date of Admission: 11/21 Age/Sex: male Handedness: R’t
Diagnosis/Reason for admission: L’t putaminal Hemorrhagic stroke

Brief History:
On 2022/9/27, he had R’t limb weakness while massaging. He was taken Yuanlin Christian
Hospital ER and his GCS was E4M6Va then. Brain CT showed L’t putaminal hemorrhage with
mild focal hematomas mass effect and perifocal brain edema. With the impression of
hemorrhagic stroke, he was referred to Changhua Christian Hospital and he was admitted to
SICU, conservation management was performed and his general condition became stable. On
9/29, he was transferred to ordinary ward. He ever tried hyperbaric oxygen therapy for once on
10/6. On 10/6, he was transferred to PM&R ward. He had better BP control under Exforge
5/50mg. On 10/25, he was transferred to Rehabilitation Clinic of Chung Shan Medical
University Hospital Daqing Campus. He complained about R’t shoulder pained with limited
ROM. Physical examination showed no swelling, tenderness, heat sensation, allodynia nor
muscle spasticity. Over-exercising during PT program was suspected and the symptoms
relieved after taking Cataflam for three days. Bedsides stretching and prevent over exercise
were educated for persisted R’t hand clumsiness and tightness. During hospitalized, he had
stable BP control.
After training, he could sit up independently with bedrails and had good sitting balance.
Minimal assistance was required for standing up with fair standing balance. He also started to
have ambulation training with a quadricane and under moderate assistance for short distance.
Because of persisted R’t limb weakness, he was admitted to our ward to further rehabilitation on
2022/11/28.
Precautions:
Nil
Review of Systems:
WNL ABN WNL ABN
✔️ Cardiac: ✔️ Musculoskeletal

✔️ Vascular: HTN ✔️ Bowel/Bladder:

✔️ Metabolic: ✔️ GI/GU: hypokalemia

✔️ Respiratory: ✔️ Other:
Medications:
Dosage Effect Side effect
Syntrend 25mg antihypertension  Headache, vision changes, dry
eyes (decreased tearing),
diarrhea, nausea or vomiting,
joint or
muscle pain, tiredness, or weakness
Norvasc 5mg/tab antihypertension  The drug was well tolerated.
Headache, edema, fatigue, nausea,
flushing and dizziness

Diovan 160mg/tab antihypertension  Headache, dizziness, viral

infection, upper respiratory
tract infection, cough (2.5%),
diarrhea, fatigue, rhinitis,
sinusitis, back pain, abdominal
pain, nausea, pharyngitis, joint
pain.
Silence 1mg/tab antispasticity  Drowsiness, dizziness,
weakness and emotional
instability.

General Observation:
He could walk into therapy room with quadricane but he need supervision by caregiver.
Mental Status/Communication:
1. Consciousness clear : JOMAC intact, M impaired (recent)
2. Communication : intact
Cooperation/Motivation:
Cooperation(Patient/caregiver) : Good/Good
Motivation(Patient/caregiver) : Good/Good
Facial/Vision:
Facial and vision : Nil
Skin and Soft Tissue:
Nil
Sensation: 踩地板的感覺 S/E/W H / K /A
Light touch NT */ intact / absent absent / absent / absent
Pinprick NT*/ absent / absent absent / absent / absent
Temperature intact intact
Joint position sense intact / intact /absent absent / impaired / intact
Joint motion sense intact / impaired / intact intact / intact / intact
Two point discrimination: NT*/ absent / absent absent / absent / absent
*: Because the sleeves are tight, it failed to direct contact his skin for those sensation tests.
Pain:
NA
Coordination:
Items (times/quality) Right Left
Finger-nose-finger 0 7 (smoothly)

Heel on shin 3 (overshooting) 7 (smoothly)

Reflexes: 只有鄭根富沒有 3+
Right Left
Reflexes Response Reflexes Response
Biceps +++ Biceps ++
Triceps +++ Triceps ++
Brachioradiali +++ Brachioradiali ++
s s
Patellar +++ Patellar ++
Achilles +++ Achilles ++
Babinski sign +++ Babinski sign -
Balance Reactions/Righting reactions: Sitting Head Trunk
Balance Static Dynamic Push to R Intact Intact
Sitting S/D Normal Normal Push to L Intact Intact
Standing Normal Good
S/D

Skeletal and Joint condition (ROM, Deformities, Subluxation, Leg length discrepancies):
ROM : ROM limitation on R’t shoulder IR, hip flexion, hip IR and ankle dorsiflexion (both of
knee flexion and extension)
R’t ROM End feel
Shoulder IR 0°-45° Firm
Hip flexion 0°-100° Firm
Hip IR 0°-35° Firm
Ankle dorsiflexion (KF) -15°-0° Firm
Ankle dorsiflexion (KE) -15°-5° Firm

Leg length: 90cm (L) / 90cm (R)

Deformities : Nil
Subluxation : Nil
Posture:

Ant. view Lat. view

Sitting 1. Neck forward (chin out)
 R’t hip was slight excessive ER 2. Slight rounded shoulder
3. flatten back
Standing Nil 1. Slight rounded shoulder
2. Knee hyperextension

Motor Control (Active movement, Tone, Strength, Synergy):

Head/Neck/Trunk:
MMT: 5
Upper Extremities:
Brunnstrom stage(P/D): stage V Gr.4 / stage V
MAS:
Joint Muscle R L
S Flexor 0 0
Extensor 0 0
E Flexor 2 0
Extensor 0 0
W Flexor 1 0
Extensor 2 0
MMT: L’t side MMT: 5
R’t Flex Ext Abd IR ER Pronation Supination
S 3- 5 2+ 2 2
E 4 4 5 5
W 5 5
Lower Extremities:
Brunnstrom stage: V Gr.4
MAS:
Joint Muscle R L
H Flexor 0 0
Extensor 0 0
Adductor 0 0
K Flexor 0 0
Extensor 2 0
A Flexor 2 0
 Extensor 0 0
MMT: L’t side MMT: 5
R’t Flex Ext Add Abd IR ER Dorsi Plantar Inver Ever
H 4 3 NT 2- 3 3
K 3- 5
A 1 1 1 1
Upright Control:
Flex Ext KEY:
R L R L W=Weak
Hip S S S S M=Moderat
Knee S S M S e S=Strong
Ankl W S W S
E=Excessiv
e
e

Functional Level(Amount of assistance, quality of movement):

Key: I= Independent Min. A= Minimal
Assistance MI= Modified Independence Mod. A=Moderate
Assistance
S= Supervision Max. A= Maximal Assistance
CG= Contact Guard D= Dependent
Bed Mobility: Rating Indications of Type of Transfer +/ or
Equipment
Rolling to Right Sidelying I Leg press the mat
Rolling to Left Sidelying I
Rolling Supine to Prone I
Rolling Prone to Supine I
Supine to Sitting I
Sitting to Supine I
Bridging I (Full range)

Transfers:
Sit to Stand I
Stand to Sit I
 Bed to Chair I
Chair to Bed I
W/C to Car I
Car to W/C I

Ambulation:
Level Min. A Use quadricane
(only 4 step without quadricane )
Carpet NA
Ramps: Angle NA
Curbs: Height NA
Stairs: stairs, flights Min. A up the stairs: step over step
(hold the down the stairs: step by step (R’t LE first)
armrest) 36 Stairs
4 Flights
2 Floors

Gait pattern: with quadricane

R’t Trunk Hip Knee Ankle
Stance phase Normal Steady Hyperextends Entire sole
down
Swing phase Normal 1. Circumduction 1. Moderate Foot inverts
2. Pelvic hiking knee stiffness
3. Pelvic retraction 2. Lack of
to R’t side terminal
selective
knee
extension

Management of W/C Rating Indications of Type of Transfer +/ or Equipment

parts
Brakes NA
Armrests NA
Legrests NA
Foot Plates NA
 Ramp Retarders NA

Wheelchair Mobility: NA
□Man □Elec
Level Propulsion NA
Rough Terrain NA
Ramps: Angle NA
Curbs: Height NA

Velocity: □ W/C  Walking

Preferred speed: 15 M/min
Fast speed: 16 M/min

Remark: Due to the poor control and coordination, he would use wrong walking pattern and even
fall down in fast speed. Therefore, regarding the safety I didn’t let him continue to increase
speed.

Endurance:  6min. walking test □ 6min. arm ergometer test

HR SBP D RR RPE Distance (m)

B
P
Pre-e’x 81 131 9 24
4
Post-e’x 79 118 8 23 9 54m
1
Remark: Because this test is done after mat exercise, there will be higher on Pre-e’x

Equipment/Arch Barriers:
Quadricane
Assessment:
Impression: CVA /c R’t hemiplegia
Problem list:
1 Abnormal gait pattern
1) Standing phase
 R’t Knee hyperextension due to
 impaired joint position sense of knee
  Entire sole down due to
 impaired joint position sense of knee
 insufficient strength of ankle dorsiflexor
 ROM limitation of ankle dorsiflexion
2) Swing phase
 Hip Circumduction, pelvic hiking and pelvic retraction to R’t side due to
 insufficient strength of knee flexor and ankle dorsiflexor
 ROM limitation of ankle dorsiflexion
 impaired joint position sense of hip and knee
 Moderate knee stiffness due to
 insufficient strength of knee flexor
 impaired joint position sense of hip and knee
 hypertonia of knee extensor
 Lack of terminal selective knee extension due to impaired joint position sense of
knee
 Foot inversion due to extensor synergy pattern
2 Min A. on up and down stairs
 hold the armrest
 down the stairs in step by step (R’t LE first)
3 Poor dynamic standing balance: good
4 ROM limitation on R’t limb (affected side)
1) Shoulder IR: 0°-45°
2) Hip flexion: 0°-100°
3) Hip IR: 0°-35°
4) ankle dorsiflexion (both of knee flexion and extension): -15°-0° (KF) / -15°-5° (KE)
5 Insufficient muscle strength of R’t limb (affected side)
1) UE (proximal)
 Shoulder flexion: 3- (MMT)
 Shoulder abduction: 2+ (MMT)
 Shoulder IR and ER: 2 (MMT)
 Elbow flexion and extension: 4 (MMT)
2) LE
 Hip flexion: 4 (MMT)
 Hip extension: 3 (MMT)
 Hip abduction: 2- (MMT)
 Hip IR and ER: 3 (MMT)
  Knee flexion: 3- (MMT)
 Ankle dorsiflexion, plantar flexion, inversion and eversion: 1 (MMT)
6 Abnormal muscle tone of R’t limb (affected side)
1) Elbow flexor: 2
2) Wrist flexor: 1
3) Wrist extensor: 2
4) Knee extensor: 1
Ankle dorsiflexor: 2
7 Poor sensation on R’t limb (affected side)
1) Light touch on wrist, hip, knee and ankle
2) Pinprick on elbow, wrist, hip, knee and ankle
3) Joint position sense on wrist, hip and knee
4) Joint motion sense on elbow
5) Two point discrimination on elbow, wrist, hip, knee and ankle
Goals: Plan:
STG (2 weeks)
1. Correct gait pattern
1) Standing phase
 Let R’t Knee maintain in neutral
position
 Produce R’t heel contact
2) Swing phase
 Decrease hip Circumduction,
pelvic hiking and pelvic
retraction to R’t side
 Decrease moderate knee stiffness
to near normal
 Produce terminal selective knee
extension
 Decrease foot inversion
1.1 R‘t foot step on football. Maintain
dorsiflexion and swing the leg to roll the
ball forward by the sole of foot.
 Dosage: 20 times/set, 2~3 sets
 Cue: hip flexion first and knee
full extension then.
1.2 Leg rest on the swiss ball in supine and bend
the leg to the chest with 5kg sand bag on bil.
ankle 去感受 hip flexion 的動作
 Dosage: 20 times/set, 2~3 sets
1.3
Tandem stance
balance
with the
involved foot behind or in front the other
foot
 Dosage: maintain 7 sec, 2 sets
1.4 Stand on one leg. Raising the opposite leg 3-5
inches off the floor
 Dosage: maintain 3 sec, 2 sets
 Progression: Raising the leg to
the front, back and side
1.5 L’t leg stand on the floor and the R’t leg
stand on tilting board or balance pad
 Dosage: maintain 20 sec, 2 sets
 Progression: Both legs on it
1.6 Lying on his back, next to a wall. Push the
foot into a swiss ball with the ball up
against the wall
 Dosage: maintain 30 sec, 2 sets
 Progression: increasing amounts
of pressure towards the wall
1.7 Maintain knee slight knee flexion in lunge
(R’t leg forward) 20sec, 2 sets
• Cue: knee shouldn’t over the toe.
Erect the trunk and avoid trunk
rotation.
1.8 Same as home program 1
1.9 Same as home program 2
1.10 Same as home program 3
1.11 Selective hip abduction in half kneeling
(L’t LE support)
 Dosage: 20 times/set, 2 sets
 Knee towards the 2rd and 3rd
toes
 Contact the gluteus and lateral
knee to give cue.
1.12 Proprioception training in standing with
holding para-bar for swing phase
 With mirror for visual feedback
 Progression: closed eyes. If there
is a mistake, he can open the eyes
and adjust.
 Hip flexion 30° and knee relax
naturally first. Then knee
extension to full range.
 Dosage: 15 times/set, 2 sets
2 Decrease assistance while stepping up and
down the stairs
 From Min A. to independent
3 Increase dynamic standing balance
 From good to normal
4 Increase ROM of R’t limb
 Shoulder IR: from 45° to 60°
 Hip flexion: 100° to 110°
 Hip IR: 35° to WNL
 ankle dorsiflexion (KF): from 0° to 5°
 ankle dorsiflexion (KE): from 5° to 10°
5 Increase muscle strength of R’t limb (affected
side)
1) UE (proximal)
 Shoulder flexion: from 3- to 3
 Shoulder abduction: from 2+ to
3-
 Shoulder IR and ER: from 2 to
2+
 Elbow flexion and extension:
from 4 to 5
2) LE
 Hip flexion: from 4 to 5
 Hip extension: from 3 to 3+
 Hip abduction: from 2- to 2
 Hip IR and ER: from 3 to 3+
 Knee flexion: from 3- to 3
 Ankle dorsiflexion, plantar
1
2.1 Same as home program 1
22 Same as home program 6
23 Same as home program 7
24 Same as home program 8
3.1 Same as 1.4
3.2 Same as 1.5
3.3 Forward reach training in lunge (R’t leg
foward) to different direction
 Dosage: 5 times/set in diverse
direction , respective 2 sets
4.1 Same as home program 1
4.2 Same as home program 2
4.3 Same as home program 3
4.4 Same as home program 4
4.5 Same as home program 5
UE
5.1 Same as home program 9
5.2 Same as home program 10
5.3 Same as home program 11
5.4 Same as home program 12
5.5 Same as home program 13
5.6 Pulley exercise with bandage: 2 blocks
LE
5.6 Affected LE hanged out of bed in supine
and lift it up to step the bed for selective
hip flexion with 1.5kg sand bag on ankle
 Dosage: 20 times/set, 2 sets
5.7 Strengthening exercise for hip extension
in prone with 1.5kg sand bag on ankle
 Both knee in flexion and
extension position
 Dosage: 20 times/set, 2 sets
5.8 Same as home program 14
 flexion, inversion and eversion:
from 1 to 2-
6 Normalize muscle tone of R’t limb (affected
side)
7 Increase sensation on R’t limb (affected side)
 Light touch on wrist, hip, knee and
ankle: absent to impaired
 Pinprick on elbow, wrist, hip, knee and
ankle: absent to impaired
 Joint position sense on wrist, hip and
knee: impaired to normal and absent to
impaired
 Two point discrimination on elbow,
wrist, hip, knee and ankle: absent to
5.9 Lift L’t leg and R’t hand in all-four
position
 Dosage: 20 times/set, 2 sets
5.10 L’t foot stepping in half kneeling
 Dosage: 20 times/set, 2 sets
5.11 Knee sitting to kneeling
 Dosage: 20 times/set, 2 sets
5.12 Strengthening exercise for hip IR and
ER in prone with 1.5kg sand bag on ankle
 Dosage: 20 times/set, 2 sets
5.13 Same as 1.1
5.14 PNF D1 and D2
 Dosage: 20 times/set, 2 sets
5.15 ES on TA and quadriceps for
facilitation
 Dosage: 20 min
5.16 Stepper
 Dosage: 20 min
6.1 RIP position
 Dosage: holding 10~15sec, 3 min
6.2 Stretching of wrist extensor and knee
extensor 膝蓋軟趴趴
 Dosage: holding 10~15sec, 7
times/set, 1 sets
6.3 Same as home program 1
6.3 Same as 1.7
7.1 Same as home program 16
7.2 Same as home program 17
7.3 Same as 1.12
7.4 Same as 1.13
7.5 Same as 1.14
7.6 Same as 1.15
7.7 Same as 1.16
 impaired
LTG (2 months)
1. Down the stairs from step by step (R’t LE first) to step over step
2. Ambulation
 Level: 10 steps without quadricane
3. Increase walking speed
 Preferred speed: 15 M/min to 17 M/min
 Fast speed: 16 M/min to 20 M/min
4 Increase ROM of R’t limb
 Shoulder IR: from 45° to 60°
 Hip flexion: 100° to 110°
 Hip IR: 35° to WNL
 ankle dorsiflexion (KF): from 0° to 5°
4. ankle dorsiflexion (KE): from 5° to 10°
Home program
1. Stretching exercise in Lunge for dorsiflexion
 Dosage: holding 10~15sec, 10 times/set, 3 sets/day
2. Stretching exercise in standing on slant board or step for dorsiflexion
 Dosage: holding 10~15sec, 10 times/set, 3 sets/day

3. Stretching exercise in quadruped.

 Slowly sit back, shifting weight over buttocks
(AAROM)
 Dosage: holding 10~15sec, 10 times/set, 1 set/day
4. Self-stretching by sound side in side lying for IR
 Dosage: holding 10~15sec, 10 times/set, 1 set/day

5. Stretching for hip flexion (knee to chest) by caregiver

 Dosage: holding 10~15sec, 10 times/set, 1 set/day
6. One leg on first stair and the other leg step to 2nd stair (both LE alternately)
 Dosage: 10 times/set, 2 set/day
7. Standing on the 2nd stair in front of the lower stairs.
L’t leg step down to first stair and R’t leg on 2nd stair to weight bearing
 Dosage: 5 times/set, 1 set/day
8. Standing on the 2nd stair in front of the higher stairs.
R’t leg stand on 2nd stair to weight bearing and the L’t leg alternatively step over first and
3nd stair. caregiver
 Dosage: 10 times/set, 1 set/day
9. AROM in sitting for Shoulder flexion
 Dosage: 10 times/set, 2 set/day
10. AROM in sitting for Shoulder abduction 需要考慮代償 supine 動作正確
 Dosage: 10 times/set, 2 sets/day
11. AROM in sitting for Shoulder IR and ER (forearm supported on table)
 Dosage: 10 times/set, 1 set/day
12. Strengthening exercise for elbow flexion in sitting with 5kg loading
 Dosage: 10 times/set, 1 set/day
13. Strengthening exercise for elbow extension in prone with 5kg loading
 Dosage: 10 times/set, 1 set/day
14. AROM in supine for hip abduction 踩下去不會翻得很嚴重 或很軟 短期 不一定要穿
 Dosage: 10 times/set, 1 set/day
15. AROM in prone for knee flexion
 Dosage: 10 times/set, 1 set/day
16. Use multiple types of textures or contact for sensory stimulation, such as cotton, rough
material, sandpaper of various grades, and Velcro.
 The textures can be wrapped around dowel rods for finger manipulation or to stroke
along the skin for 1-3 minutes.
 Dosage: 5 min
17. Place contact particles, such as cotton balls, beans, macaroni, sand, or other material, with
various degrees of roughness in tubs or cans, so the patient can run the involved hand or
foot through the material.
 Have the patient begin by manipulating or placing the extremity in the least irritating
texture for 1-3 minutes.
 Progression to the next texture of slightly more irritating but tolerable stimulus.
Maximum progress occurs when the most irritating texture is tolerated.
 Dosage: 1~3 min
PTs:
Hip core cause
coordination