INITIAL EVALUATION

Name: ​R. D. J.
Age: ​43 y/o
Sex: ​Male
Address: ​Las Piñas City
Civil Status: ​Married
Religion: ​Roman Catholic
Occupation: ​Prosecutor Attorney
Nationality: ​Filipino
Handedness: ​Right
Date of incident: ​December 31, 2018
Date of Referral: ​January 14, 2019
Referring Doctor: ​Dr. M. P.
Date of IE: ​January 17, 2019
Rehab Doctor: ​Dr. J. B.
Type of Patient: ​Outpatient
Informant/Reliability: ​Patient/Reliable
Diagnosis: ​Incomplete SCI, ASIA C, Brown Sequard Syndrome on T10 (left hemisection)
affectation

Chief Complaint:
“Di ko na magalaw yung kaliwang paa ko at wala na akong maramdaman sa dalawa kong
paa. Nakakaramdam din ako ng sakit sa likod ko kung san ako nabaril.”

PT translation:
Pt complains of inability to move L LE and inability to feel on both LE. Pt. also complains of
pain on the gunshot wound site.

Pt Goal:
“Gusto kong makalakad ulit, makabalik sa pagtatrabaho at sa paglalaro ng golf.”

PT translation:
Pt wants to be able to walk, return back to work and play golf again.

S:

Premorbid status: ​Pt is a prosecutor attorney working in the Department of Justice. Pt only
works on the weekdays unless there are urgent situations that might force the Pt to work
even on the weekends. Pt job involves moving from one place to another like doing
research, field investigations, and presenting evidences in court. Pt is independent in all
aspects of ADLs & IADLs.
HPI:

​3 weeks prior to PT IE,

Around 7 pm, the pt was in an argument with someone in the parking lot of the
hospital and after the argument, the person he was arguing with walked away to go to his
car and the pt turned his back to walked away as well then the pt suddenly felt excruciating
pain on mid back (VRS:10/10) and fell forward into the ground and realized that he had been
shot in the back and he cannot stand up or move. The witnesses called inside the hospital
for help and the pt was immediately brought to the emergency room by placing him on a
spine board secured with straps and a cervical collar. In the ER, the pt’s gunshot wound was
cleaned and wrapped up with gauze dressing, stabilized the vital signs and immobilized
around the thoracolumbar area with a backboard. The pt is in spinal shock, was
administered with IV fluid with methylprednisolone ​(see medications) a ​ nd was attached to an
oxygen for respiration. The pt was in shock and disoriented and the pt’s family was
contacted to inform them of the pt’s condition. When the pt’s family arrived, they were asked
for the pt’s personal information.
The attending doctor requested for an X-ray, CT scan and MRI ​(see ancillary
procedures)​ of the anterior and posterior trunk and results revealed that the bullet lodged
into the paravertebral muscle and hit the T10 level of the spinal vertebra that caused
comminuted fracture and spinal shock. The pt also underwent CBC and results showed that
the pt didn’t acquire any infections from the bullet. The pt didn’t acquire any injuries of the
head as the pt fell forward when shot at the back, as reflected by the MRI results. The pt was
then subjected for surgery for the removal of the bullet and for the open reduction internal
fixation of the fracture on the T10 level, then the pt was given a thoracolumbar bandage for
immobilization and is then confined with IV fluids with methylprednisolone, IV fluids for
nutrition, and oxygen tank for respiration and a catheter attached for the presence of bowel
and bladder incontinence.The pt also takes acetaminophen ​(see medications)​ which
decreased the excruciating pain felt on the middle lower back due to the gunshot wound
from VRS 10/10 to 8/10. The pt is observed to watch out for signs and symptoms of AD. The
pt’s vital signs are stable and didn’t show any signs of AD. The pt was cleared for daily
inpatient PT and does ankle pumping of both LE, PROM’s of both upper extremities, and
proper bed positioning to avoid other complications such as pressure sores, wound care and
skin care are also being monitored. The pt is not cleared for upright positions yet and
PROM’s of both lower extremities. The pt was then assessed by the attending doctor with
the ASIA impairment scale ​(see attached form)​ and results showed a classification of C
incomplete spinal cord injury with motor and sensory loss on the L LE and sensory loss on R
LE. Wound care is taken cared by the attending nurse. Observations for complications which
the pt didn’t show any signs of and inpatient PT was continued for the rest of the week.

2 weeks prior to PTIE,

The pt still does daily inpatient PT and does passive ankle pumping, PROM’s of both
upper extremities, and proper bed positioning to avoid other complications such as pressure
sores. The pt is still not cleared for upright positions and PROM’s of both lower extremities.
The pt’s trunk has bandage for immobilization of the trunk. Wound care is taken cared by the
attending nurse. The pt still has IV fluids attached for nutrition but does not take
methylprednisolone anymore. Pt still has catheter for the bladder and bowel incontinence
and is attached to an oxygen tank for respiration. No symptoms of AD were noted.

1 week prior to PTIE,

The pt continues the inpatient PT doing passive ankle pumps, PROM’s of both upper
extremities, proper bed positioning and was already cleared for sitting upright training and
PROM’s of both lower extremities. AAROMS of R LE are done and is progressed to AROMS
as tolerated. The pt still has IV fluids attached for nutrition, an oxygen tank for respiration
and a catheter for the bowel and bladder incontinence and is being observed for signs and
symptoms of complications especially AD and no symptoms were noted

At Present,
The pt is now cleared for outpatient PT and can sit upright. The IV fluids and oxygen
tank are removed but the catheter is still attached. Pt is wheelchair bound (standard manual
wheelchair) and is now only wearing a thoracolumbosacral plastic body jacket for limiting
motion of the trunk. The pt has motor and sensory loss on the L LE and sensory loss on the
R LE.

ANCILLARY PROCEDURES

DATE PROCEDURE RESULTS

December 31, 2018 X-RAY on A/P Trunk Bullet penetrated to the

paravertebral mm.
(+) Comminuted Fracture on
T10
(-) Heterotopic Ossification

January 1, 2019 CT-Scan of the Spine Lodged into Paravertebral

muscle at T10-T11 vertebral
level

(-) damaged internal organs

January 1, 2019 MRI of the head (-) Brain swelling

(-) Internal Hemorrhage

January 1, 2019 CBC RBC - Normal (4.5

million/ml)
WBC - Normal (9.800/ml)
 (-) Infections

MEDICATIONS

Date Medications Dosage Significance Possible Effects

December 31 to Acetaminophen 75 mg bid Pain reliever ➔ Nausea

present ➔ Stomach pain
➔ Itching
➔ Rash
➔ Headache

2013 to present Amlodipine 5 mg od For control of ➔ Dizziness

HTN ➔ Lightheadedn
ess
➔ Swelling of
ankle/feet
➔ Stomach pain
➔ Tiredness

PMHx:
● (+) HTN (Controlled - Diagnosed since 2013)
● (-) Previous trauma to the spine
● (-) Past Hospitalizations and surgeries
● (-) Disease of the spine
● (-) DM
● (-) Pulmonary disease
● (-) Cardiovascular disease
● (-) Other neurological diseases
● (-) Cancer
● (-) Osteoporosis
● (-) Arthritides

FMHx:

MATERNAL PATERNAL

HTN (+) (-)

Pulmonary Conditions (-) (+)

Cardiovascular Conditions (-) (-)

CA (-) (-)
 Autoimmune Conditions (-) (-)

Arthritides (-) (-)

PSEHx:
● ​Pt is a smoker - 10 sticks per day for the past 20 years.
● Alcohol beverage drinker - drinks during special occasions, average of 2 bottles
(started drinking since 1995 at the age of 20 years old, beer)
● Pt has a relatively active lifestyle
○ Jog’s every evening for 1 and a half hr inside their subdivision
○ Plays golf with colleagues at least once a week, every saturday, for 2-3 hours
● Pt works as a prosecutor attorney in the Department of Justice located in Malate,
Manila
○ Pt travels for 1 hr to and from work
○ Pt drives himself to and from work via a private automatic car (AUV)
○ Pt’s work building has ramps and stairs
○ Pt’s office is on the 3rd floor and uses the elevator
○ Pt's office is 20 square meters
○ Pt's office door is 36 inches wide
○ Pt’s work desk is 15 steps from the main door
○ Pt’s office has own restroom 15 steps away
○ Pt does desk job in front of a laptop or computer and does paper work
○ Meet clients at near coffee shops approx. 4km to 10km away from office
● Pt lives with his wife (housewife) and 2 sons (16 and 18 years old)
● Pt has 1 maid that stays on weekdays (monday-friday) and does the household
chores. The maid goes home every weekend (saturday & sunday)
● The wife does the cooking everyday
● Pt lives in a bungalow (500 sqm)
○ Pt’s room is 10 steps away from bathroom
○ Pt’s bathroom is 10 sq ft
○ Pt's bathroom has no grab bars for support
○ Pt’s bedroom is 20 steps away from the living room, 15 steps from the kitchen
and dining area, 30 steps from the main door
○ No stairs and ramps at all
● Pt walks his dog around the neighborhood (approxi. 2 km) during his free time
(sunday)
● Pt plays golf with his friends every weekend
● Pt is financially stable and can pay for PT sessions.
O:

VITAL SIGNS:

VITAL SIGNS BEFORE DURING AFTER

BP 120/80 mmHg 130/90 mmHg 130/80 mmHg

HR 70 bpm 75 bpm 78 bpm

RR 13 cpm 15 cpm 14 cpm

TEMP. 36.1 °C 37 °C 36.5 °C

O2 SAT 98% 97% 98%

Findings: ​Pt's BP is increased during treatment

Significance​: Pt vital signs should always be monitored for baseline purposes.

OI:
● Alert, coherent, cooperative
● Pt is wheelchair bound (manual wheelchair)
● Normal BMI: Mesomorph (BMI: 22.9 wt: 155lbs, Ht: 5’9”)
● (+) AD (Wheelchair assisted by wife)
● (+) Thoracolumbosacral Plastic Brace
● (+) Foley catheter
● (+) Incision wound on back (see body diagram)
● (+) Gauze dressing on wound
● (+) Thoracic breather
● (-) Other attachments
● (-) Pressure Sores
● (-) Swelling on all extremities
● (-) Trophic skin changes on exposed areas
● (-) Redness and other skin conditions
● (-) Muscle atrophy on B LE

Palpation:
● Normothermic on all exposed areas
● N skin turgor, mobility, consistency
Deep Sensation:
Kinesthesia: ​Pt. is tested with eyes closed, raising the knee joint . Pt. will answer “going up
or going down” depending on the direction of movement of the extremity. Pt is tested 5
times.

Findings: ​Pt failed to answer correctly for 5 times on L LE. Pt answered correctly for 5 times
on R LE.
Significance: ​pt has an impaired Kinesthesia on L LE due to spinal cord lesion

Proprioception: ​Pt is tested with eyes closed, raising the knee joint. Pt will answer “up or
down” depending on the position of the extremity. Pt is tested 5 times.

Findings: ​Pt failed to answer correctly for 5 times on L LE. Pt answered correctly for 5 times
on R LE.
Significance: ​Pt has an impaired proprioception on L LE due to spinal cord lesion

Dermatomes:
STD’s used​:​ pin for pain, cotton balls for light touch, thumb for deep pressure, and 2 test
tubes with stopper with and warm and cold water for temperature.

Levels R L

Pain/Temp. Light Touch Pain/Temp. Light Touch

T9 Intact Intact Intact Intact

T10 Impaired Intact Intact Impaired

T11 Impaired Intact Intact Impaired

T12 Impaired Intact Intact Impaired

L1 Impaired Intact Intact Impaired

L2 Impaired Intact Intact Impaired

L3 Impaired Intact Intact Impaired

L4 Impaired Intact Intact Impaired

L5 Impaired Intact Intact Impaired

S1 Impaired Intact Intact Impaired

 S2 Impaired Intact Intact Impaired

S3 Impaired Intact Intact Impaired

S4 & S5 Intact Intact Intact Intact

Findings: ​Pt has 0% sensation on R LE as to pain and temperature but has intact sensation
as to light touch and deep pressure. Pt has 0% sensation on L LE as to light touch and deep
pressure but has intact sensation as to pain and temperature.
Significance: ​Pt has impaired sensation on B LE due to spinal cord lesion

Myotomes:

Myotomes Muscles Muscle gr on Left Muscle gr on Right

C5 Elbow flexors 5 5

C6 Wrist extensors 5 5

C7 Elbow extensors 5 5

C8 Finger flexors 5 5

T1 Finger abductor 5 5
(little finger)

L2 Hip flexors 0 3

L3 Knee extensors 0 3

L4 Ankle dorsiflexors 0 3

L5 Long toe extensors 0 3

S1 Ankle plantar flexors 0 3

Findings: ​Pt’s L2, L3, L4, L5, and S1 myotomes has a Grade of 0 and a muscle grade of 3
on all R LE muslces
Significance: ​Pt has an impaired myotome on L2, L3, L4, L5, and S1 due to spinal cord
lesion
DTR:

Findings: ​Pt. is hyperreflexive on L3-L4 and S1-S2

Significance: ​Due to spinal cord affectation

Pathological Reflexes:

Findings Reflex Procedure Response Significance

(+) Plantar reflex Stroke from the Fanning of the (+) Spinal
lateral side of the toes cord lesion
sole of the foot up
to the base of the
1st phalanx

(+) Chaddock Stroke around the Fanning of the (+) Spinal

lateral ankle and up toes cord lesion
the lateral dorsal
aspect of the foot

(+) Abdominal reflex Brisk, light strokes Absence of (+) spinal

over the skin of the contraction cord injury on
abdominal muscles towards the side T8-T12
(T10 for this
pt)

(+) Bulbocavernosus Squeezing the Contraction of the Intact

reflex Glans penis bulbocavernosus
muscle

(+) Cremasteric reflex Stroke inner part of Contraction of the Intact

 the thigh perianal area

Tone Assessment: ​(Note: Modified Ashworth Scale is used)

Procedure: Tested by doing passive range of motion on knee joint.

Muscle group Grade

L Lower Extremity 1+

R Lower Extremity 0

Findings: ​Pt has an MAS score of 1+ on L LE

Significance: ​Pt has slight increase in muscle tone due to brown sequard SCI

Legend:

BALANCE ASSESSMENT ​(Note: Pt. sitting on a chair with backrest)

Legend:

BALANCE TEST GRADE

Sitting in a normal comfortable position 2

Sitting, weight shifting in all directions 2

Sitting, multidirectional functional reach 2

 Sitting, picking an object up off floor 2

Findings: ​Pt is able to maintain sitting balance with handheld support that may require
occasional minimal assistance. Pt is also able to maintain balance while turning his head or
trunk.
Significance: ​Pt has fair static and dynamic sitting balance 2º Spinal cord Lesion

PULMONARY ASSESSMENT:

COUGH ASSESSMENT
Intensity: ​Sharp
Frequency: ​non-persistent
Depth: ​Deep

Chest Symmetry:

Location Findings

Upper Lobe Symmetrical

Middle Lobe Asymmetrical

Lower Lobe Asymmetrical

Findings: ​Pt has asymmetrical chest movement at Middle and Lower lobe
Significance: ​Pt has asymmetrical chest movement due to impaired abdominal and
intercostals due to SCI injury

Chest Mobility:

Landmarks Maximal Inspiration Maximal Expiration Difference

Angle of Louis 97 cm 99 cm 2 cm

Xiphoid Process 93 cm 95 cm 1 cm

Lower Costal 88 cm 90 cm 1 cm
Cartilages at the T10
Level

Findings: ​Pt. presents 1 cm difference across the landmarks of xiphoid process and lower
costal cartilages at T10 level
Significance: ​Pt. has a limited chest expansion
Pulmonary Auscultation:

Anterior
Landmarks Findings

Above the clavicle Vesicular

Below the clavicle Vesicular

Above the nipple Vesicular

Medial to the nipple Vesicular

Lateral to the nipple Vesicular

Below lateral to the nipple Vesicular

Findings: ​All landmarks are vesicular

Significance: ​Normal breath sounds

Posterior
Landmarks Findings

Medial Superior angle of scapula Vesicular

Medial Vertebral border Vesicular

Medial spine of scapula Vesicular

Medial Inferior angle of scapula Vesicular

Medial 10th rib Vesicular

Lateral inferior angle of scapula Vesicular

Lateral 10th rib Vesicular

Findings: ​Pt exhibits normal breath sounds

Significance: ​To assess possible pulmonary dysfunction.

CARDIOVASCULAR ASSESSMENT:

Auscultation:
 Landmarks Findings

Aortic Valve Area (-) abnormal heart sounds

Pulmonic Valve Area (-) abnormal heart sounds

Second Pulmonic Valve Area (-) abnormal heart sounds

Tricuspid Valve (-) abnormal heart sounds

Mitral Valve (-) abnormal heart sounds

Findings: ​Pt exhibits normal heart sounds

Significance: ​Will not hinder pt during physical therapy treatment.

Wound Assessment: ​(Note: Wound assessment was done during changing of wound
dressing)

● Location: ​Middle lower back (see body diagram).

● Size: ​20mmx80mm
● Edges: ​Well-defined
● Base:
○ Beefy red color
○ (-) Exudates
○ (-) Necrosis
○ (-) Eschar
○ (-) Slough
○ (-) Odor
● (-) Granulation Tissue
● Periwound:
○ (-) Edema
○ (-) Maceration
○ (-) Exposed structures
Findings: Pt’s wound has well defined edges and beefy red color with no significant
abnormalities on wound
Significance: ​Pt shows good healing process

ROM:
All major joints of both UE and R LE, neck are actively and passively done with precaution
and WNL and with normal end feel except for the following:

Note: ROM of trunk motions are to be tested if pt gets clearance from the doctor. AROM for
L LE is not tested d/t spasticity

Motion PROM NORMAL DIFFERENCE END

VALUES FEEL

L Hip Flexion 0-110° 0-120° 10° Soft

L Hip 0-15° 0-20° 5° Firm

Extension

L Hip 0-40° 0-45° 5° Firm

Abduction

L Hip 0-25° 0-30° 5° Firm

Adduction

L Hip 0-40° 0-45° 5° Firm

External
Rotation

L Hip Internal 0-35° 0-45° 10° Firm

Rotation

L Knee 0-130° 0-135° 5° Soft

Flexion

L Knee 130-0° 135-0° 5° Soft

Extension
 L Ankle 0-40° 0-50° 10° Firm
Plantarflexion

L Ankle 0-15° 0-20° 5° Firm

Dorsiflexion

L Ankle 0-25° 0-35° 10° Firm

Inversion

Ankle 0-10° 0-15° 5° Hard

Eversion

Findings: ​LOM on L hip flexion, hip extension, Hip Adduction, Hip External Rotation, Hip
Internal Rotation, Knee Flexion, Knee Extension, Ankle Plantarflexion, Ankle Dorsiflexion,
Ankle Inversion, Ankle Eversion 2​°​ to muscle tightness
Significance: ​Pt will have difficulty with ambulation

SPECIAL TEST

Findings Special test Procedure Response Indication

(-) Rubor of Pt. at supine, is Once lowered, If the color

dependency asked to the color of the takes more than
test elevate both skin of the limb 30 minutes to
legs to a 45° should return to return the test
angle and hold a pink color. would be
for two minutes. positive for
The examiner arterial
observes the insufficiency
color of the feet

(-) Venous filling Pt. at supine, Normal filling Greater than 15

time the examiner time is 15 seconds
will elevate the seconds indicates
extremity being arterial disease
tested, then whereas less
lowered into than 15
dependent indicates
position. The venous disease.
examiner will
record the time
it takes for the
veins on top of
the foot to refill.

(-) Homan’s sign Pt. at supine, is Deep calf pain

 test asked to extend and tenderness
the knee of may indicate
tested
extremity. The
examiner then
raises the pt’s
straight leg to
10°, then
passively and
abruptly
dorsiflexes the
foot and
squeezes the
calf with other
hand.

(-) BP cuff test for A blood Patient felt pain Chronic venous
venous pressure cuff at 40 mmHg insufficiency
insufficiency placed around
pt’s calf, it is
then inflated
until 40 mmHg

Physical Measures:

6 - Minute Arm Test

Pt was tested using an upper extremity ergometer.

During the final 30 seconds of the test

● Baseline Outcome Variables of Heart Rate: 103 bpm
● Borg Scale - Ratings of Perceived Exertion (RPE) (6-20 points): 16

Findings​: pt has a decreased cardiopulmonary endurance 2° to spinal cord lesion

Significance​: pt will be having difficulties in performing exercises and ADLs

Functional Outcome Measures:

(See Attached SCIM form)

Spinal Cord Independence Measure

Findings:
● Self Care Subscore = 15/20
● Respiration and Sphincter Management Score = 23/ 40
● Mobility Subscore = 12/40

Total SCIM Score = 50/ 100

 Significance:​ Pt is having difficulties in independently doing ADLs and IADLs such as
bowel and bladder management, using the toilet and transferring. Pt also is unable to
ambulate, ascend and descend stairs and transfer from the ground to the wheelchair.

A, P

PT Diagnosis: ​(Pattern H: Impaired Motor Function, Peripheral Nerve Integrity, and Sensory
Integrity Associated With Nonprogressive Disorders of the Spinal Cord)

Pt will have difficulty returning back to work as a prosecutor attorney and experience
difficulty in doing ADLs in the aspects of self-care, dressing, transfer and ambulation as
reflected by SCIM score of 50/100, paralysis of L LE, grade 3 muscle weakness of hip
flexors, knee extensors, ankle dorsiflexors, long toe extensors, and ankle plantar flexors of R
LE, Muscle tightness on all L LE muscle groups,fair static and dynamic sitting balance, (+)
abnormal reflexes, decreased cardiopulmonary endurance as reflected by the 6-MAT with
Borg RPE score from 16, asymmetrical chest movement on middle and lower lobe, limited
chest expansion, and impaired sensation of B LE due to Incomplete SCI ASIA C/ Brown
Sequard Syndrome, T10 (Left Hemisection) affectation.

Problem List

1. Decreased cardiopulmonary endurance as reflected by 6-MAT and presence

of other pulmonary complications
2. Difficulty in doing ADLs as reflected by SCIM score of 50/100
3. Fair static and dynamic sitting balance
4. Surgical wound on mid-lower back
5. Mm weakness all R LE muscles
6. LOM on L hip flexion, hip extension, hip adduction, hip external rotation, hip
internal rotation, knee flexion, knee extension, ankle plantarflexion, ankle
dorsiflexion, ankle inversion, ankle eversion
7. Loss of sensation on B LE

Prognosis:
Pt has favorable prognosis due to the following factors:

PROGNOSTICATING FACTORS

+ -

Incomplete SCI injury Smoker

 Age (+) HTN

Motivated

Financially stable

Supported by family

(-) Other neurological conditions

Anticipated Problems

● Depression
● Contractures
● Muscle Atrophy
● Osteoporosis due to immobilization
● Deep Vein Thrombosis
● Heterotopic Ossification
● Pressure Sores
● Post-traumatic Stress Disorder

LTG: ​ Pt will have an improved cardiopulmonary endurance as reflected in 6-MAT from Borg
RPE score of 16 to 11 using 10 minutes of standard UE ergometry. Pt will also exhibit a
normal chest expansion, chest mobility and sharp, deep coughing upon PT discharge in 6
months.

Problem list STG (Pt will be seen 4x a Plan of Care

week for 6 mos)

Decreased cardiopulmonary Improved cardiopulmonary Upper Ex ergometry using

endurance and other endurance as reflected by standard ergometer x 10
pulmonary complications the 6-MAT with Borg RPE min. x Borg RPE of 15
score from 16 to 13 in two
Upper Ex AROM using PNF
weeks PT session
diagonal patterns x 10 reps
x 3 sets

Deep diaphragmatic
breathing x 3 reps

Segmental breathing
directed towards the middle
and lower lobes x 3 reps x 1
set
 Chest mobility exercises on
upper and lateral chest x 3-4
reps x 1 set

Incentive spirometry not up

until the point of fatigue

Sharp deep double coughs

x 5 sets

Difficulty in doing ADLs as Pt will exhibit an improved For Self Care: donning of
reflected by SCIM score of SCIM score from 50/100 to doffing of lower ex garments
50/100 70/100 in 4 weeks of PT and wearing shoes:
session ● ADL simulation for
donning and doffing
lower ex garments
● Use of loose clothing
for lower ex or
reacher for donning

For Transfer training on

wheelchair to bed, ground,
chair etc.:
● Wheelchair should
have removable
armrest
● Floor to wheelchair
transfers
X 5 reps then
progress reps as
tolerated and
environment: higher
chair, higher bed.

Sit to Stand training:

Personal:
AAROMS on R LE muscles:
● Hip flexors
● Hip extensors
● Ankle dorsiflexors
Task:
● Emphasis on leaning
forward
● Emphasis on
scooting forward
● Emphasis on using
good leg to support
Environment:
● From high chair to
 low chair

Progress to:
Locomotor training:

● BWSTT with ES set

at 500-750 msec
train, 50-80 pulses
per second, 1.0 to
1.5 msec pulse
duration and 60 to
150V

Adjust treadmill
speed and BWS as
tolerated by patient

1. Upright standing
using locomotor
training principles
2. Locomotor training
on treadmill with
BWS and manual
assistance
3. Upright standing
while practicing
loading and
extension on the left
lower ex while the
right lower ex is
unloaded and flexed
on treadmill with
BWS using
locomotor training
principles
4. Community
ambulation training

Fair static and dynamic Pt will exhibit an improved Weight shifting exercises in
sitting balance static and dynamic sitting sitting position x 5 reps
balance from fair to good in progress reps as tolerated:
2 weeks of PT session - Forward
- Backward
- side to side

Progress to:
● Perturbation
exercise in sitting
position with
instructions
 Progress to:
Perturbation
exercises in sitting
without instructions
Progress to:
● Reaching meaningful
objects such as
paper, hammer,
objects with handle

Surgical wound on Pt will exhibit a good wound IRR using localizer on mid
mid-lower back healing with no signs of lower back x 20mins
infection in 2 weeks of PT
session ES on periwound area x 20
mins

Mm. weakness on R hip Pt will exhibit an increased Multiple Angle Isometric

flexors, knee extensors, mm strength from grade ⅗ to exercises on all mm groups
dorsiflexors, long toe ⅘ in 3 weeks of PT session of R LE per 30 degree
extensors and plantarflexors increments x 6SH x 3 sets

Progress to:
PRE on all R LE mm groups
using 5 lbs ankle weights x
8 reps x 2 to 3 sets

Progress reps to 10 to 15
reps and weights to 10lbs as
tolerated

LOM on L hip flexion, hip Pt will have an increased Gentle passive stretching
extension, hip adduction, hip ROM by 5-10 increments in towards all directions of LE
external rotation, hip internal 3 weeks of PT session x 15SH x 5 reps
rotation, knee flexion, knee
extension, ankle
plantarflexion, ankle
dorsiflexion, ankle inversion,
ankle eversion

Loss of sensation on B LE Pt will exhibit an improved Resensitization:

sensation on B LE in 3 Sensory Integration using:
weeks of PT session Lego Blocks x 20 Minutes
Macaroni Shells x 20
Minutes

Progression:
Mung beans x 20 Minutes
Salt x 20 Minutes

Referral to an Occupation
 Therapist

Patient-Client Related Instructions

A. Patient Education
● Skin care
○ Always inspect skin
○ Check for possible ulcerations
○ Check for dryness
○ Always use lotions
● Wound care
● Adhere to medications properly
● Teach Patient pressure relief maneuver every 15 minutes when in w/c.
● Caregiver education as to autonomic dysreflexia

B. Exercise to do at home
● Strengthening exercise on L UE using 4 lbs dumbbells x 10 reps x 1-2 sets
● Strengthening exercise on R UE using 4 lbs dumbbells x 10 reps x 1-2 sets
● Self-stretching on L UE x 15SH x 5 reps x 1 set
● Self-stretching on R UE x 15SH x 5 reps x 1 set
● PROME towards all motions on L LE x 10 reps
● AAROME towards all motions on L LE x 10 reps

C. Other instructions
● Comply on wearing brace
○ Always check the fit of the brace
○ Wear for 23 hrs a day; 1 hr for self care
● Avoid positions of contractures in the L Leg
● Change of bed and wheelchair position every 5-10 min. to avoid pressure sores
● Watch for signs and symptoms of AD

D. Precautions
● Avoid excessive trunk motions
● Avoid overexertion
● Avoid any trauma especially to the back
● Avoid falls
● Avoid prolonged positions on wheelchair and on bed to avoid pressure sores
● Close vital signs monitoring

E. Communication, Coordination, and Collaboration with other health care

professionals.
● Referral to Occupational Therapy for Adaptive devices for self care and grooming
● Referral to Orthotist for modification of wheelchair and brace