Physical therapy case study

1. Abigail Gaines
Physical Therapy Case Study
Initial Assessment: 1/4/2017
Patient is a 69-year-old female who underwent surgery for a rotator cuff repair.
The patient currently has difficulty with dressing, fixing hair, sleeping, cooking, driving,
and is unable to perform household duties. Her current impairment score is fifty-five
percent based on two factors. First, the patient reported a three on a zero to ten scale
indicating pain level. Zero would indicate that the patient reports having no pain, while a
ten would indicate that the pain is unbearable. The patient also filled out a disability of
the arm, shoulder, and hand (DASH) questionnaire and was found to have a score of
73.3. Patient’s right should passive range of motion (PROM) external rotation is ten
degrees and flexion is seventy-five degrees. Patient’s right shoulder strength was not
tested at this time. When palpated, there was generalized right shoulder tenderness as
reported by the patient.
Treatment Plan:
Suggested treatment would include two to three physical therapy sessions a week
for the next eight to twelve weeks. The patient will begin sessions with engaging in
exercises that target the right shoulder to increase the range of motion (ROM) and
strength and to decrease right shoulder pain with ROM. Some of these exercises include
pulleys, isometrics, therabands, and the UBE along with passive range of motion
stretching at the end of each session. Patient will also begin ultrasound and electrical
stimulation followed by ice.
Goals:
The goals of the physical therapy treatment include both short (5 weeks) and long
term (10 weeks) goals. The patient’s short term goals include becoming independent with
an initial home exercise program, to increase right should passive range of motion flexion
to 105 degrees in order to assist with self care, and to decrease right shoulder pain to two,
at worst, on a scale of zero to ten. The patient’s long term goals include decreasing her
DASH score by greater than or equal to ten points to demonstrate improved functional
abilities, increasing right shoulder manual muscle training (MMT) to 4+/5 to assist with
her household tasks which include lifting and carrying, increasing right shoulder ROM to
within normal limits (WNL) in order to assist with self-care including dressing and fixing
hair, and to complete greater than or equal to forty-five minutes of household duties with
increased sign and symptoms per report.

2. Second Assessment: 2/6/2017
The patient is showing gradual improvement and benefiting from physical therapy
sessions. Her current impairment level is now forty percent based on her pain level of
zero on a zero to ten scale and her DASH score of 54.3. Patient’s right shoulder PROM
external rotation is now thirty degrees and flexion is now ninety degrees. Patient reports
that when palpated, there is minimal right shoulder tenderness. Patient will continue to
progress with physical therapy and should continue for two to three times a week for six
to eight weeks.
Third Assessment: 3/2/2017
The patient is continuing to show gradual improvement with physical therapy.
Her current impairment level is now thirty-five percent based on her pain level of two on
a zero to ten scale and a DASH score of 28.4. Patient’s right shoulder PROM external
rotation is now fifty degrees and flexion is 125 degrees. Patient’s right shoulder MMT
external rotation is 4-/5 and flexion is 3+/5. She also reports minimal right shoulder
tenderness. Patient will continue to progress with physical therapy and should continue
for two to three times a week for six to eight weeks.
Fourth Assessment:3/27/2017
The patient continues to show gradual improvement with use of physical therapy.
Her current impairment level is now thirty percent based on her pain level of zero to two
on a zero to ten scale and a DASH score of 21.5 Patient’s right shoulder PROM external
rotation is now sixty-five degrees and flexion 145 degrees. Her right shoulder MMT
external rotation is 4-/5, flexion is 4-/5 and internal rotation is 4/5. Patient reports
minimal right shoulder tenderness when palpated. Patient will continue to progress with
physical therapy and should continue for two times a week for four to six weeks.

3. Table 1: Patient Progress
Date of
Treatment
Patient Pain
Level/Remarks
Range of
Motion
Strength Functional
Assessment
Exercises
1/4/2017 3 ER: 10
Flex: 75
Not tested CIL: 55%
DASH: 73.3
1/30/2017 1 – Shoulder
feels pretty
good today,
just mild pain
ER: 30
Flex: 85
Not tested Added pulleys for R.
shoulder ROM
2/9/2017 0 – Out of my
sling now, so
more pain in
the morning
Not
measured
Not tested Added finger ladder &
theraband for
strengthening/mobility
2/18/2017 3 – Slept
wrong last
night so
shoulder was
hurting
ER: 40
Flex: 125
Not tested Added shoulder shrugs &
isometric abduction for
shoulder strengthening
3/1/2017 2 – Shoulder is
not too bad,
still sore in my
bicep
ER: 50 Not tested Added supine ball &
scapular retraction for
shoulder strengthening
3/2/2017 2 – Still have
difficulties
getting my
hand behind
ER: 50
Flex: 125
MMT: ER:
4-/5
Flex: 3+/5
CIL: 35%
DASH: 28.4
Added depressions, PROM
flexion/abduction for
shoulder strengthening

4. my head &
difficulty
doing my hair
3/17/2017 3-4 – Shoulder
has been
hurting for a
few days
Not
measured
MMT:
ER: 4-/5
Flex 3+/5
Abd: 3+/5
IR: 4/5
No new exercises added
3/22/2017 1 – MD gave
me a shot,
feels shoulder
has a lot of
scar tissue
ER: 65
Flex: 145
Not
measured
Increased theraband ER to
20 reps
3/27/2017 0-2 – Only a
little pain
when I stretch
ER: 65
Flex: 145
MMT:
ER: 4-/5
Flex: 4-/5
IR: 4/5
CIL: 30%
DASH: 21.5
Added theraband flexion,
increased theraband IR/ER
to 30 reps
4/3/2017 1 – Did yard
work this
weekend,a
little sore
Not
measured
MMT: ER:
4-/5
Flex: 4-/5
No new exercises added
This is a table that shows the dates of treatment along with the patient’s pain level and remarks,
range of motion and strength measurements for the patient’s right shoulder, functional assessment
scores, and descriptions of changes in the patient’s exercise routine.
Results:
The patient underwent steady, gradual improvement throughout physical therapy
treatment. Although the patient is still coming regularly to physical therapy sessions, all
of her short-term goals have been met. These goals included becoming independent with
an initial home exercise program, increasing right shoulder PROM flexion to 105 degrees
to assist her with self-care activities, and decreasing right shoulder pain to a two on a zero
to ten scale at worst. The patient’s current impairment level for lifting and carrying is at
thirty percent and she is still progressing towards her initial goal of fifteen percent of
impairment. The patient shows a good prognosis and will continue physical therapy twice
a week for four to six weeks.