College Portfolio

FAR EASTERN UNIVERSITY – NICANOR REYES MEDICAL FOUNDATION
SCHOOL OF PHYSICAL THERAPY
S.Y. 2020-2021
COMMUNITY BASED REHABILITATION
PARKINSON DISEASE
WRITTEN REPORT
SUBMITTED BY:
Austria, Ginger
Bada, Jeffrey Ian
Dela Cruz, Jacquiline
Garcia, Gabrielle Anne
Ramos, Jayna Mharee
SUBMITTED TO:
Jhonadea de Leon, PTRP

PHYSICAL THERAPY INITIAL EVALUATION
GENERAL INFORMATION
Pt.’s Name: J.B.
Age: 70 y/o
Sex: M
Address: Regalado Ave, Quezon City
Civil Status: Married
Handedness: R
Occupation: Retired Lawyer
Religion: Roman Catholic
Nationality: Filipino
Referring MD: Dr. G.G.
Referring Unit: FEU-NRMF
Rehabilitation MD: Dr. J.R.
Rehabilitation Unit: FEU-NRMF RU
Date of Referral: June 1, 2021
Date of IE: June 2, 2021
Medical Dx: Hoehn & Yahr Stage 2 Tremor Predominant Idiopathic Parkinson’s Disease
Informant: Pt. & pt.’s wife
S:
HPI:
Pt.’s present condition started ~8 mos. PTIE when the pt. was reading & suddenly felt his (R)
hand shaking. Pt. moved his hand by writing until the shaking disappeared & noticed his
handwriting became smaller. The next day, pt. claimed that hand shaking was gone. Pt. didn’t
seek medical help & thought it was only d/t tiredness from housework. ~6 mos. PTIE pt.
reported that he lost his sense of smell. Pt.’s wife also reported that pt. had a mask-like facial
expression c soft & monotonous voice. Pt. told her to disregard it. ~4 mos. PTIE pt. reported his
(R) fingers began to shake like rolling a pill. Pt. sat until it disappeared. Few weeks after, pt.
started to feel heaviness on his (B) upper & lower limbs resulting in difficulty in moving. Pt. drank
a glass of Ensure Gold milk for strength & energy. Pt. managed to do household chores c her
wife throughout the week c minimal difficulties. ~2 mos. PTIE pt. didn’t meet his family d/t
heaviness on (B) lower limbs. The next day, pt.’s wife noticed that pt. had poor posture c
difficulty & slowness or freezing in walking. Pt.’s wife advised him to go to the hospital, pt.
refused as it was only d/t aging. ~1 wk. PTIE while pt. & his wife were watching TV, pt. felt his
(B) hands shaking. Pt. stood up until it subsided. Pt.’s wife insisted & accompanied him to
FEU-NRMF Hospital on June 1, 2021 & was attended by Dr. G.G. who requested for ancillary
procedures (see ancillary procedures). Pt. was dx c Hoehn & Yahr Stage 2 Tremor Predominant
Idiopathic Parkinson’s Disease & was referred to FEU-NRMF RU as an O.P. on June 2, 2021
under Dr. J.R. for further assessment & PT management.

Ancillary Procedures:
Procedure Date Results Location
MRI of Brain June 1, 2021 (+) Depigmentation of
substantia nigra pars
compacta
FEU-NRMF Hospital
Apomorphine Test Responsive to
L-dopa & dopamine
agonists
FEU-NRMF Hospital
Present Medications:
Medicine Dosage Frequency Indication Side Effects
Levodopa/carbidopa
(Sinemet)
25 mg tid Reduce
bradykinesia,
rigidity & tremors
Nausea
Dyskinesia
Orthostatic
hypotension
Hallucinations
Confusions
PMHx:
[-] HTN
[-] DM
[-] Encephalitis
[-] TBI
FMHx:
History of: Paternal Maternal
HTN [-] [-]
DM [-] [-]
Parkinson’s Dse [-] [-]
Social Hx:
Pt. has a healthy & active lifestyle. Pt. usually spends time stationary cycling from 7:00am to
8:00am q Saturday. Pt. attends church & goes to the grocery q Sunday c his wife. On weekdays,
pt.’s wife often drives & goes to the mall c pt., mostly do household chores together, &
sometimes spend time c their son’s & daughter’s family when they visit them.
Social Habits:
Pt. is a non-smoker & non-drinker.

Home Situation:
Pt. lives c his wife in a well-lit & ventilated bungalow house in the same well-gated subdivision c
their son’s & daughter’s family. Pt.’s house has 2 bedrooms and 1 bathroom. Their house has
wooden flooring s raised platforms reported. The reference point is the pt. & his wife’s bedroom:
● Pt.’s bedroom ↔ living room is ~12 steps;
● Pt.’s bedroom ↔ bathroom is ~9 steps;
● Pt.’s bedroom ↔ dining area is ~15 steps;
● Pt.’s bedroom ↔ kitchen is ~19 steps,
● Pt.’s bedroom ↔ guest room is ~20 steps;
● Pt.’s bedroom ↔ main door is ~15 steps;
● Pt.’s bedroom ↔ garden is ~18 steps.
Pt. & pt.’s wife are unemployed; their son & daughter provide financial support. Pt. spends most
of his time at their room to read books.
Prior Level of Function:
Pt. was indep. in performing all ADLs & amb. such as eating, bathing, toileting, walking & other
recreational activities s any signs of difficulty.
C/C:
“Madalas ay biglang nanginginig ang mga kamay ko tuwing wala akong ginagawa, mawawala
rin ito kapag gumalaw ako. Nahihirapan at mabagal na din akong gumalaw at mag lakad dahil
sa pustura at paninigas ng mga braso at binti ko.”
PT Translation:
Pt. c/o resting tremor on (B) hands, difficulty & slowness in moving & walking d/t postural
instability & stiffness on (B) UE & LE.
Pt. Goals & Attitude:
“Gusto ko nang gumaling para matulungan ko ang asawa ko sa mga gawaing bahay dahil ayaw
kong maging pabigat sa kanya at sa mga anak namin. Gusto ko na ring makasama ang mga
anak ko at apo ko.”
PT Translation:
Pt. wants to regain indep. function. Pt. doesn’t want to be a burden to his family. Pt. wants to
help his wife do household chores & do recreational activities like spending time c his family.

O:
VS:
(N) Before IE During IE After IE
BP 120/80mmHg 118/70mmHg 120/80 mmHg 117/80mmHg
RR 12-20cpm 17cpm 19cpm 18cpm
PR 60-100bpm 80bpm 86bpm 82bpm
T° 36.5-37.5° 36.5° 36.9° 36.0°
OI:
● Amb. c min. assist s AD (+1)
● Ectomorph
● [+] Resting tremor on (B) hands
● [+] Bradykinesia
● [+] Gait deviation (see Gait Analysis)
● [+] Postural deviation (see Postural Analysis)
● [+] Hypomimia
● [-] Sialorrhea
● [-] Bruises on (B) HNT, UE, & LE
Palpation:
● Afebrile to all parts of the body touched
● [+] Tightness on (B) upper trapezius & pectorals
● [+] Rigidity on neck flexor, (B) UE flexors, & (B) LE flexors
● [+] Taut band on (B) upper trapezius
● [-] Tenderness of muscles on (B) UE & LE
Neurologic Evaluation:
Cognitive Assessment:
Mini-Mental State Examination (MMSE)
Findings: Pt. scored 25/30.
Tone Assessment: (Passive Motion Testing)
Findings: Pt. has grade +3 (mild to moderate hypertonia) for (B) UE & LE.
Sensory Assessment:
Findings: All sensory functions (superficial, deep & cortical) were tested in all areas & was
found WNL.
Deep Tendon Reflexes:
Findings: Pt. is graded 2+ on (B) UE & LE.

CN Testing:
Cranial Nerve Findings
CN I Pt. could not identify the identity of smell
CN VII Pt. had difficulties performing facial
expressions
ROM:
All major joints of HNT, (B) UE & LE were actively & passively assessed & was found to be
WNL, except:
MOTION
NORMAL
VALUE
AROM PROM
END FEEL
R L R L
Shoulder flexion 0-180° 0-150° 0-145° 0-160° 0-150° Firm
Elbow Extension 150-0° 150-10° 150-15° 150-5° 150-10° Firm
Hip Extension 0-20° 0-13° 0-10° 0-18° 0-15° Firm
Knee Extension 135-0° 135-20° 135-15° 135-10° 135-5° Firm
Ankle DF 0-20° 0-10° 0-15° 0-15° 0-18° Firm
Spinal ROM
Motion AROM PROM NROM End Feel
Cervical Extension 0-65° 0-70° 0-75° Firm
Cervical Rotation (left
and Right)
0-70° 0-75° 0-80° Firm
Thoraco-Lumbar
Flexion
7 cm 8 cm 10 cm (4 inches) Firm
Thoraco-Lumbar
Extension
3 cm 4 cm 5 cm (2 inches) Firm
Thoraco-Lumbar
Rotation (Left and
Right
R:35°
L: 35°
R:40°
L:40°
0-45° Firm

Special Tests:
Test Response
Glabellar tap Continuous blinking
Flesche Test/Occiput to wall Distance 5 cm
Postural Analysis:
Anterior View
Body Segment Findings
Shoulder (L) shoulder is slightly higher than ®
Wrist/ hand Slight flexed (B) hands
Hips (R) hip & ASIS slightly lower than (L) hip &
ASIS
Knees (R) knee slightly lower than (L) knee
Lateral View
Head Earlobe is anterior to the tip of the shoulder
Neck Neck in kyphosis
Shoulder Shoulders are rounded & posterior to
earlobes
Trunk Inc. kyphotic curve
Low back Inc. lumbar lordosis
Pelvic (+) Posterior pelvic tilt
Knee Knee flexion
Posterior View
Shoulders (L) shoulder slightly higher than (R)
Scapula Slightly protruded scapula
Hips (R) PSIS slightly lower than (L) PSIS
Knee (R) knee slightly lower than (L) knee

Gait Analysis:
Gait parameters Findings
Base of support 2 in.
Step length 20 in.
Stride length 35 in.
Cadence 140 steps per min.
Arm swing Reduced arm swing on (B) sides
Functional Assessment:
Functional Independence Measure (FIM)
Findings: Pt. scored 89/126; requires minimal assistance in transfers & locomotion; minimal
assist to supervision in self-care activities.
Outcome Measures:
Outcome Measures Findings
Functional Gait Assessment 16/30 (<18 = risk of fall)
Geriatric Depression Scale 12/15 ( >5 score = severe depression)
Timed Up & Go Test 15 seconds (>12 secs = risk of falling)
A:
PT Impression/Dx:
Pt. was medically dx c Hoehn & Yahr Stage 2 Tremor Predominant Idiopathic Parkinson’s
Disease presenting c resting tremor on (B) hands, bradykinesia, gait deviation, postural
deviation, mild to moderate hypertonia on (B) UE & LE, anosmia, hypomimia, hypophonia,
cogwheel rigidity, stooped posture & severe depression, that resulted to LOM on AROM and
PROM on (B) shoulder flexion, elbow extension, hip and knee extension, ankle dorsiflexion,
neck & trunk extension & flexion & AROM of neck & trunk rotation, difficulty in moving, difficulty
in ambulation c min. assist (+1), min. assist. in transfers, locomotion & ADLs, & increased risk of
falling which is further supported by tone assessment (3+), ROM, Postural Assessment, FGA
(16/30) , FIM (89/126), & TUG (15 secs).

PT Prognosis:
Pt. has a fair prognosis to return to ADLs such as self-care activities & IADLs such as
household chores. Prognosticating factors include pt.’s active lifestyle, family support & financial
stability will help the pt to slow down the progression of the disease. However, pt.’s age may
affect the outcome because the disease progresses with age & pt. is indicative of severe
depression.
Problem List:
1. Difficulty in performing ADLs such as Self-care activities d/t resting tremors on (B) hands
2. Postural Deviation: ↑ Kyphotic curve on neck & trunk and stooped posture
3. Gait deviation: FOG during amb resulting to Increased risk of fall (TUG: 15 secs and
FIM: 16/30)
4. LOM on AROM and PROM on (B) shoulder flexion, elbow extension, hip and knee
extension, ankle dorsiflexion, neck & trunk extension & flexion d/t rigidity (See ROM
table)
5. Hypomimia
LTG:
In 1 yr. pt. will be able to:
1. Improve amb; performing ADLs & IADLs s assist
2. Maintain proper posture in different body positions to reduce risk 2° complications &
better mobility
STG:
In 6 mos. pt. will be able to:
1. Perform indep fall recovery strategies to improve balance
2. ↑ mobility to improve amb
3. ↑ ROM by 10-20° increments
Intervention Scenario:
Pt’s problem list is based on pt’s IE and goals. The rehab team aims to bring pt. to his optimum
functional level in order to perform ADLs, IADLs, & participate in recreational activities indep s
assist. PT will be focused on addressing symptoms such as resting tremors, rigidity, gait &
postural deviation by giving stretching, balance & gait training.

ICF:
P:
PT Interventions:
Pt. will be treated as an O.P. 3x/wk (M, W, F) & will be given the following treatment:
1. AAROM exercises towards all motions for 10 reps x 3 sets
2. PNF for 10 reps x 3 sets to ↓ rigidity
● Bilateral UE Symmetrical D2 Flexion & Extension Patterns
● Unilateral LE D1 Extension Patterns
3. Balance exercises to improve pt.’s dynamic, anticipatory & reactive balance control (10
reps x 2 sets)
● Perturbation exercises (use of mirror) for 2 mins.
● Sit to stand
● Standing rotational movements
● Weight shifting c 5 secs hold
● Walk in different terrains
● Figure of eight walking
● Stair climbing
● Ball catching

4. Passive stretching of upper traps, pectorals, hamstrings, quadriceps & dorsiflexors for 30
secs hold x 2 sets to improve posture & ↑ flexibility.
5. Rood’s technique to relax the muscles
● Slow stroking
● Gentle rocking
● Neutral warm
6. Gait training: amb in // for 20m c floor markers for visual cuing of steps & verbal
feedback to improve motor control in amb
7. Fall recovery strategies:
● Quadruped creeping 5m x 2 sets
● Floor ↔ chair transfer x 10 reps x 2 sets
Home/Ward Instructions:
● Educate the family about pt’s condition
● Proper body mechanics
● Long and complex movement sequences should be avoided or broken down into
component parts
● ↑ number of repetitions to ↑ functional carryover of motor skills
● Visual & auditory cues should be included in all Rx & ADLs
● Promote indep relaxation exercises to help ease effects of rigidity on pt.
● Always remind pt. to “think big & move through the whole range”
● Encourage pt. to be active & avoid prolonged periods of inactivity to prevent 2°
complications & improve QOL
● Encourage family to join pt. in HEP to ↑ compliance, provide support, & provide
feedback.
● Avoid overdoing activities & allow adequate rest to avoid overfatigue
● Educate pt. in energy conservation in the household by making the locations of the pt.’s
distance to target area nearby, ensure good ventilation, seek help for heavy house
chores, etc.
HEP:
1. Postural Training
2. Stretching Exercises for 10 reps x 30 secs hold x 3 sets
● Trapezius stretch
● Forward arm reach
● Side bending
● Hip & calf stretch
3. Yoga for 5 secs hold per pose
● Cat pose
● Cow pose
● Cobra pose
● Low lunge
● Warrior II pose
● Chair cat pose

● Chair cow pose
● Chair gate pose
● Chair spinal twist
● Chair pigeon pose
● Modified low lunge
Referral:
1. Speech-Language Pathologist - for improvement of speech
2. Psychiatrist - to monitor & treat pt.’s depression
3. Occupational therapist for refining fine motor skills
EBP (RCT):
1. Title of the Study: Exercise for People in Early- or Mid-Stage Parkinson Disease: A
16-Month Randomized Controlled Trial
Objectives of the Study: The objective of this study is to compare short- and long-term
responses among 2 supervised exercise programs and a home-based control exercise
program.
Methodology:
● This study has 121 participants diagnosed with PD (Hoehn & Yahr stages 1–3)
and was conducted in an outpatient clinic. The 16-month randomized controlled
exercise intervention evaluates 3 exercise approaches such as
flexibility/balance/function exercise (FBF) that was supervised by a physical
therapist, aerobic exercise (AE) such as treadmill, bike, or elliptical trainer that
was supervised by an exercise trainer for, and home-based exercise
(controlgroup) using the National Parkinson Foundation Fitness Counts program,
with 1 supervised, clinic-based group session per month. The supervision of FBF
and AE group was provided 3 days per week for 4 months, and then monthly (16
months total).
● The evaluators were blinded when obtaining the outcomes. The primary
outcome measures were overall physical function (Continuous Scale—Physical
Functional Performance [CS-PFP]), balance (Functional Reach Test [FRT]), and
walking economy (oxygen uptake [mL/kg/min]). Secondary outcome measures
were symptom severity (Unified Parkinson's Disease Rating Scale [UPDRS]
activities of daily living [ADL] and motor subscales) and quality of life (39-item
Parkinson's Disease Quality of Life Scale [PDQ-39]).
Results: It is stated that CS-PFP scores were greater in the FBF group than in the
control group and the AE group during 4 months of intervention. Walking economy
improved in the AE group compared with the FBF group at 4 months , 10 months, and
16 months. On the other hand, balance was not different among groups at any time
point. In the secondary outcome measures, there was a significant difference in UPDRS
ADL subscale scores wherein FBF group performed better than the control group at 4
months and 16 months.
Conclusions: The FBF group demonstrated overall functional benefits at 4 months and
the AE group showed improvement in walking economy (up to 16 months).

Relevance to Practice in the PT Setting: The relevance of this study is it can serve as
a back up evidence in formulating and deciding what intervention is best for PD patients.
From the result of this study, it is evident that flexibility, balance and functional exercises
may be used to achieve better outcomes for PD patients.
Reference:
Schenkman, M., Hall, D. A., Barón, A. E., Schwartz, R. S., Mettler, P., & Kohrt, W.
M. (2012, November). Exercise for people in early- or mid-stage Parkinson disease: a
16-month randomized controlled trial. Physical therapy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488266/.
2. Title of the Study: Efficacy of neurofunctional versus resistance training in improving
gait and quality of life among patients with Parkinson’s disease: a randomized clinical
trial
Objectives of the Study: To compare the efficacy of neurofunctional training versus
resistance training in improving gait and quality of life among patients with PD
Methodology:
● This study is a randomized clinical trial that was conducted last February to August
2014 in Londrina, Brazil.40 patients were randomly divided between the
neurofunctional training group and resistance training group. The researchers were
blinded in allocating the respondents. The inclusion criteria are that patients should
be diagnosed with idio[athic PD, classified as Modified Hoehn & Yahr Scale stage 1.5
to 3, at least 50 years of age, able to walk independently, and not enrolled in any
other therapeutic program beyond taking medication.
● There was a pre and post evaluation that was conducted by the same researcher.
The tools and outcome measures that was used on the first day of evaluation was
Anthropometric data (Weight, Height and Body Mass Index), Modified Hoehn & Yahr
Scale (HY), Unified Parkinson's Disease Rating Scale (UPDRS), and Mini-Mental
State Examination (MMSE). On the second day of evaluation, Footprint test, Video
gait analysis, Parkinson’s Disease Quality of life (PDQL), Parkinson’s Disease
Questionnaire (PDQ-39) was collected.
● The resistance training group underwent stretching and strengthening exercises on
the main muscle groups of the lower limbs and trunk. The sessions of the exercises
were divided into 3 blocks (sessions 1 to 8, sessions 9 to 16, and sessions 17 to 24)
and the repetitions were gradually increased. This was performed with two sets of 10
repetitions. On the other hand, the neurofunctional training group underwent balance
training, sensory integration, agility, and motor coordination, stability limits,
anticipatory and reactive postural adjustments, functional independence, and gait
improvement. The sessions of the exercises were divided into 3 blocks (sessions 1 to
8, sessions 9 to 16, and sessions 17 to 24) and the complexity of exercise was
increased by changing the support base, therapeutic resources, exercise and
circuits.
Results: There was a significant improvement for both RT and NT groups when incomes to
stride length but it was greater in NT compared to the RT group. From the video gait
analysis, there was a significant improvement in the NT group in regards to the number of

steps, time of distance walked, gait speed and cadence. Overall, there was a significant
difference in the NT group and both groups showed significant improvement in QOL.
Conclusions: Both neurofunctional training and resistance training were proven
effective in improving the quality of life in PD patients. The gait of PD patients were
improved by specific training protocol, directed and enriched with sensorial resources in
NT compared to modest results in the RT group. The prescription of exercises in
rehabilitation programs has a significant role in improving the gait of PD patients.
Relevance to Practice in the PT Setting: Physical Therapists formulates the
prescription of exercises to PD patients during rehabilitation programs. This study
proved that neurofunctional and resistance training is effective to improve the quality of
life of the patients which is one of the main goals of PT in treating every patient. Physical
therapists improve the gait of the patients to promote independence during ambulation
and through this study it was stated that neurofunctional training is effective and safe to
use in training PD patients compared to resistance training.
Reference:
Smaili, S. M., Bueno, M. E. B., Barboza, N. M., Terra, M. B., Almeida, I. A. de, & Ferraz,
H. B. (2018, May 28). Efficacy of neurofunctional versus resistance training in improving
gait and quality of life among patients with Parkinson's disease: a randomized clinical
trial. Motriz: Revista de Educação Física.
https://www.scielo.br/j/motriz/a/Kz5qVp6dMG9LkCMD85Lx43B/?lang=en.
PT Initials & Signature:
AUSTRIA, GINGER ANNE D.
PT INTERN - BATCH 2022
BADA, JEFFREY IAN
DELA CRUZ, JACQUILINE ANDRE M.
GARCIA, GABRIELLE ANNE G.
RAMOS, JAYNA MHAREE

S.Y. 2020-2021
ADHESIVE CAPSULITIS
SOAP DOCUMENTATION
SUBMITTED BY:
Dela Cruz, Jacquiline Andre M.
SUBMITTED TO:
Ms. Jhonadea de Leon, PTRP
Ms. Ferry de Leon, PTRP
June 2021

Case: A 30 y/o (-) HTN (+) Type 2 DM (R) handed female was referred to PT eval and Mx due
to c/o localized, intermittent dull aching pain on the (L) shoulder region gr. 8/10 on SPS elicited
upon reaching forward and on the side and is aggravated by reaching overhead c pain gr. 9/10.
Pain is completely relieved by resting the shoulder on the side.
GENERAL INFORMATION
Pt.’s Name: K.C.
Age: 30 y/o
Sex: F
Handedness: R
Occupation: Housewife
Referring MD: Dr. J.T.
Referring Unit: FEU-NRMF
Rehabilitation MD: Dr. L.E.
Medical Dx: (L) Shoulder Adhesive Capsulitis 2° Type 2 DM
Informant: Pt.
S:
HPI:
Pt.’s present condition started ~3 mos. PTIE when the pt. was wiping glass walls & suddenly felt
a localized, intermittent, dull, aching pain on her (L) shoulder (PS: 8/10). Pt. claimed that the
pain was aggravated by raising her arm (PS: 8/10 → 9/10) & relieved by applying hot compress
while resting shoulder at the side (PS: 8/10 → 0/10). Pt. didn’t seek any medical help & thought
it was only d/t tiredness from housework. ~2 mos. PTIE while pt. was putting on her bra, pt. felt
dull, aching pain again c stiffness on her (L) shoulder (PS: 8/10); aggravated when she was
reaching her back for hooks (PS: 8/10 → 9/10). Pt. rested after, applied hot compress over the
(L) shoulder & took an Ibuprofen for pain relief (PS: 8/10 → 0/10). ~1 wk. PTIE pt. noticed her
posture changed. Pt. reported difficulty cleaning the house, returning tablewares & clothes to
cabinets, putting on a shirt & bra, combing her hair, & washing hair & back during bathing d/t
pain. At night, pt. c/o (L) shoulder pain while sleeping (PS: 3/10). Pt.’s husband advised her to
have it checked by a physician. ~1 day PTIE pt.’s husband accompanied her to FEU-NRMF
Hospital on June 10, 2021 & was attended by Dr. J.T. who requested for ancillary procedures
(see ancillary procedures) & prescribed medications (see present medications). Pt. was dx c (L)
Shoulder Adhesive Capsulitis 2° Type 2 DM & was referred to FEU-NRMF RU as an O.P. on
June 11, 2021 under Dr. L.E. for further evaluation & PT management.

(L) Shoulder
arthrography June 10, 2021
[+] Decreased capsular
volume
FEU-NRMF Hospital
(L) Shoulder T1 &
PD-fatsat MRI in
Coronal & Sagittal
Oblique View
[+] Thickened
coracohumeral ligament
& joint capsule
[+] Subcoracoid triangle
sign
FEU-NRMF Hospital
(L) Shoulder
ultrasound
[+] Synovial inflammation FEU-NRMF Hospital
Metformin
(2015-present)
500 mg BID Controls high
blood sugar
Vit. B12 deficiency
Myalgia
Cardiac d/o
GIT d/o
Respi tract infection
Headache
Rash
Flushing
Celecoxib 200 mg BID Reduces pain,
inflammation, &
stiffness
Fluid retention
Edema
HTN
Anemia
Angina pectoris
GIT d/o
Respi d/o
Arthralgia
Rash
PMHx:
[+] Type 2 DM (Controlled c Metformin since 2015)
[-] HTN
[-] Trauma
[-] Fx
[-] Hypo/hyperthyroidism
[-] Stroke
[-] Heart dse

FMHx:
DM [-] [+]
HTN [-] [-]
Stroke [-] [-]
Heart dse [-] [-]
Social Hx:
Pt. has a sedentary lifestyle. Pt. usually spends time watching tv after doing household chores.
Pt. does Zumba from 7:00am to 8:00am q Saturday c her friends & goes to the grocery c her
family in the afternoon. Pt. attends church c her family q Sunday morning & rests throughout the
day.
Social Habits:
Pt. has a healthy lifestyle. Pt. is a non-smoker & non-alcoholic; drinks enough water (~8-10
glasses) & eats healthy food. Pt. started to avoid unhealthy food in 2015 d/t her Type 2 DM;
takes her meds regularly. Pt. has a normal sleeping schedule & has enough sleep (~8-9 hrs) qd.
Home Situation:
Pt. lives c her husband & daughter in a well-lit & ventilated 2-storey house c 4 bedrooms & 2
bathrooms. Pt. does all household chores at home. Pt. cleans the living room c high ceiling &
glass walls (~144” in height) q wk using vacuum & long mop; washes the dishes & places
tablewares at the upper cabinet (~28” in height) qd; do laundry & places clothes at the cabinets
(~78” in height) q wk. Pt. usually spends her free time in the living room to watch tv.
Prior to onset of disease, pt. was sedentary d/t Type 2 DM but can perform household chores,
self-care, reaching overhead & back, & recreational activities s any pain or LOM on (L) shoulder.
C/C:
“Sumasakit at parang naninigas ang kaliwang balikat ko tuwing may inaabot ako, lalo na kapag
tinataas ko ‘to. Nahihirapan na akong mag punas ng matataas na salamin sa bahay, mag-abot
ng gamit sa kabinete, at mag-sampay ng damit; pati pag ligo, pag bihis, at pag suklay ng buhok.
Kamakailan lang sumasakit na rin ‘to tuwing gabi kaya hirap na akong matulog.”
PT Translation:
Pt. c/o localized, intermittent, dull, aching pain c stiffness on the (L) shoulder (PS: 8/10) upon
reaching forward & on the side; aggravated by reaching overhead & at the back (PS: 9/10)
which resulted in difficulty in wiping glass walls, reaching cabinets, hanging clothes, bathing,
dressing & combing hair; relieved by resting shoulder on the side. Pt. also c/o (L) shoulder pain
at night which resulted in sleep disturbance.

Pt. Goals & Attitudes:
“Gusto ko na ulit makagawa ng gawaing bahay, mapagsilbihan ang aking pamilya, makagalaw,
at makatulog nang walang sakit na nararamdaman. Gusto ko na ring bumalik sa pag Zumba
kasama ang mga kaibigan ko.”
PT Translation:
Pt. is willing to undergo PT treatment to be able to do previous activities s any pain.
O:
Vital Signs:
BP 120/80mmHg 120/80 mmHg 120/80 mmHg 110/70 mmHg
RR 12-20cpm 19 cpm 18 cpm 15 cpm
PR 60-100bpm 90 bpm 87 bpm 85 bpm
T° 36.5-37.5° 37° 37.1° 37.3°
OI:
● Indep. amb. s AD
● Mesomorph
● [+] Postural deviation (see postural assessment)
● [+] Gait deviation (see gait assessment)
● [+] Mm atrophy on (L) ant. deltoids
● [-] Swelling on (B) UE
● [-] Erythema on (B) UE
● [-] Bruises on (B) UE
● [-] Wounds on (B) UE
Palpation:
● Afebrile to touch on all assessed areas
● [+] Gr. 2 tenderness on (L) ant. shoulder
● [+] Mm guarding towards (L) sh. add. & IR
● [+] Mm spasm on (L) shoulder
● [+] Nodules on (L) shoulder
● [+] Taut bands on (L) shoulder
● [-] Crepitus on (B) UE
● [-] Edema on (B) UE
● [-] Contractures on (B) UE

ROM:
All joints of HNT, (B) UE & LE were actively & passively assessed & was found to be WNL,
pain-free c (N) end feel except for the ff:
Range of
Motion
(N) Patient Result Differences End Feel
Motion AROM PROM AROM PROM
(L) sh. flex. 0-180o
0-147o
0-153o
33o
27o
Hard capsular
(L) sh. abd. 0-180o
0-134o
0-138o
46o
42o
Hard capsular
(L) sh. ER 0-90o
0-65o
0-60o
25o
30o
Hard capsular
(L) sh. IR 0-70o
0-55o
0-60o
15o
10o
Hard capsular
MMT:
All major muscles on HNT, (B) UE & LE were assessed using break test & were grossly graded
⅘ except for the ff:
Muscle Group Grade
(L) sh. flexors 3/5 @ (0-147o
)
(L) sh. abductors 3-/5 @ (0-134o
)
(L) sh. external rotators 3-/5 @ (0-65o
)
(L) sh. internal rotators 3-/5 @ (0-55o
)
Special Tests:
Test Findings Significance
Shoulder Shrug Sign [+] Inability to do 90o
abd. s
elevating the scapula or shoulder
girdle during the maneuver
[+] Adhesive Capsulitis,
Rotator Cuff Tendinopathy,
or Shoulder OA
Apley’s Scratch Test [-] Pain [-] Rotator Cuff
Tendinopathy
Ellman’s Compression
Rotation Test
[-] Pain [-] Shoulder OA
Speed’s Test [-] Pain [-] Bicipital Tendinitis

Postural Assessment:
All body segments in ant., lat., & post. views assessed & found to be WNL except for the ff:
Anterior View Findings
Head Forward
(L) shoulder Rounded, adducted & IR
Posterolateral View Findings
Head Forward
(L) shoulder Rounded, adducted & IR
(L) scapulae Protracted & depressed
Thoracic kyphosis Excessive
Gait Assessment:
Gait was assessed & found to be WNL except for the ff:
Gait Parameters (N) Findings
Arm swing [+] R & L [+] R
[-] L
Upper Extremity Functional Index (UEFI)
Findings: Pt. scored 40 out of 80.
Outcome Measures:
A. Shoulder Pain Disability Index (SPADI) [MCID: 20 pts]
Findings: Pt. scored 88% in pain scale & 80% in disability scale c a total of 83% SPADI
score.
B. Disability of Arm and Shoulder (DASH) [MCID: 10.2 pts]
A:
PT Impression/Dx:
Based on PT examination, pt. has (L) Shoulder Adhesive Capsulitis 2° Type 2 DM as
manifested by localized, dull, aching pain (PS: 8/10) c stiffness; LOM on (L) sh. flex., abd., ER &
IR; mm weakness on (L) ant. & mid. deltoids, supraspinatus, infraspinatus, subscapularis &
teres minor which led to wiping glass walls, reaching cabinets, hanging clothes, bathing,
dressing, combing hair, going to grocery c family & Zumba c friends as supported by the
patient’s hx, results of ancillary procedures, objective examination, & the ff. outcome measures:
UEFI = 40/80, SPADI = 83%, & DASH = 82/100.

PT Prognosis:
Pt. has good prognosis d/t pt.’s motivation, healthy & active lifestyle, financial capability, support
system, & medications; but may be negatively affected by pt.’s sleeping schedule & associated
condition Type 2 DM which slows healing if not controlled.
Problem List:
1. Pt. has localized, intermittent, dull, aching pain c stiffness on (L) shoulder (PS: 8/10)
2. Pt. has difficulty performing reaching overhead & back activities
3. Pt. has difficulty performing household chores, self-care & recreational activities
4. Pt. has dec. AROM & PROM on (L) sh. flex., abd., ER & IR
5. Pt. has mm weakness on (L) sh. flexors, abductors, internal & external rotators
6. Pt. has poor posture
7. Pt. has gait deviation
8. Pt. has sleep disturbance
The problem list listed above were based on the pt.’s hx, results of subjective & objective
examination. The PT rehab aims to primarily restore shoulder function & maintain other body
functions by focusing on relieving pain, improving ROM & mm strength of the (L) shoulder
through modalities, ROME, strengthening, & functional exercises; secondarily adapt by
modifying lifestyle through home ergonomics.
ICF:

P:
LTG:
In 6 mos., pt will be able to:
Rehabilitative:
1. Perform household chores, self-care, reaching overhead, & recreational activities s any
pain & stiffness on (L) shoulder (PS: 3/10 → 0/10)
2. Have full ROM on all planes on (L) shoulder
3. Have normal mm strength on (L) shoulder (MMT: 4/5 → 5/5)
Preventive:
1. Eliminate pain & stiffness on (L) shoulder when performing any activity
2. Prevent contractures & mm atrophy by doing the HEP
STG:
In 2 mos., pt will be able to:
1. Perform household chores, self-care, reaching overhead, & recreational activities c
minimal pain & stiffness on (L) shoulder (PS: 8/10 → 3/10)
2. Have inc. AROM & PROM on (L) shoulder c ~20° increments
3. Have inc. mm strength on (L) shoulder (MMT: 3-/5 → 4/5)
PT Interventions:
Pt. will be treated as an O.P. 3x/wk (M, W, F) & will be given the following tx:
1. HMP on (L) ant. shoulder to alleviate pain & relax mm x20 mins
2. High-rate TENS on (L) ant. shoulder to reduce pain & assist in ROM x100-150 Hz
x50-80 microseconds x20 mins
3. Hold-relax progress → Contract-relax PNF stretching in all planes of (L) shoulder to inc.
ROM & flexibility x5 secs hold x10 secs rest x5 reps
4. (L) shoulder joint mobilization posterior & inferior glide c grade I oscillation to relieve pain
& inc. flexion & IR x10 secs distraction x5 secs rest
5. Scapular mobilization in all planes to inc. ROM x100 reps
6. PROME progress → AAROME progress → AROME on (L) shoulder flex [AAROME:
finger ladder], abd [AAROME: finger ladder], ER & IR to maintain joint mobility, inhibit
pain, & prevent contractures & mm atrophy x10 reps x2 sets
7. Strengthening ex. c yellow theraband progress → red theraband to strengthen mm &
prepare pt. for functional activities x10 reps x2 sets
a. Pendulum exercise s kettlebell progress → c kettlebell (~2-5 lbs) on (L) shoulder
to reduce pain, inc. ROM & flexibility x10 reps x2 sets
b. Towel stretch
c. Cross-body reach
d. Armpit stretch
e. Outward rotation
f. Inward rotation
8. Postural retraining to reduce kyphotic posture x10 reps x2 sets
a. Child’s pose
b. Cat cow

c. Standing cat cow
d. Chest opener
e. High plank
f. Downward-facing dog
g. Pigeon pose
h. Thoracic spine rotation
i. Glute squeeze
● Patient/family education regarding:
○ nature of pt.’s condition including the timeframes of each stage & pathology;
○ role of PT in rehabilitation;
○ home exercise program including its importance;
○ pain management techniques;
○ & energy conservation.
● Encourage the pt. to be active & the family to motivate the pt.
● Observe proper body mechanics.
HEP:

Referrals:
● Nutritionist & Dietician - for management of diabetes
● Orthopedist - for follow up check up care after PT treatment
Appendix

S.Y. 2020-2021
MODULE 5
CORONARY ARTERY DISEASE
SOAP DOCUMENTATION
SUBMITTED BY:
Yeung, Jerica L.
SUBMITTED TO:
June 2021

GENERAL INFORMATION
Pt.’s Name: E.D.
Age: 45 y/o
Sex: F
Handedness: R
Occupation: Housewife
Referring MD: Dr. L.G.
Referring Unit: FEU-NRMF CCU
Rehabilitation MD: Dr. M.E.
Medical Dx: Post-CABG 2° NSTEMI [Surgery: June 28, 2021]
Informant: Pt.
S:
HPI:
Pt.’s present condition started ~1 wk. PTIE while climbing 1 flight of stairs, pt. felt a mild
sudden, localized, intermittent, dull, squeezing pain (PS: 3/10) in the chest c SOB which lasted
for 15 mins; pt. rested to relieve pain (PS: 3/10 → 0/10). After 5 days, pt. reported to experience
sleep disturbance d/t moderate same type of chest pain (PS: 6/10) c breathlessness. Pt. took
prescribed Nitroglycerin & slept in a recumbent position for relief (PS: 6/10 → 0/10). ~2 days
PTIE while reaching the top of the cabinet, pt. suddenly felt a severe same type of chest pain
(PS: 9/10) radiating to back, neck, jaw & (L) shoulder c SOB & excessive sweating which lasted
for 30 mins; pt. rested & took Nitroglycerin but the pain didn’t subside. Pt.’s husband
immediately rushed her to FEU-NRMF E.R. on June 28, 2021 & was given immediate relief (PS:
9/10 → 7/10). Pt. was attended by Dr. L.G. who monitored her VS of BP: 140/80 mmHg, HR: 60
bpm, T°: 35.6°C, RR: 15 cpm, & O2sat: 94%; administered oxygen & IV fluids; requested for
ancillary procedures (see ancillary procedures). Pt. was medically dx c NSTEMI & was
recommended to do CABG by internal mammary arteries graft as the last resort. Surgery was
successful c no further complications noted. Pt. was immediately transferred to CCU to rest &
stabilize VS. Pt. then c/o post-op localized, intermittent, dull aching pain on chest (PS: 8/10) c
difficulty moving in bed, eating & toileting. ~1 day PTIE pt. was referred to FEU-NRMF RU as
an I.P. on June 28, 2021 under Dr. M.E. for further evaluation & cardiac rehabilitation.

Electrocardiography
June 28, 2021
[+] ST depression, T wave
inversion
FEU-NRMF Hospital
Blood Test [+] ↑ TnI, TnT & CkMB FEU-NRMF Hospital
Ibuprofen 200 mg QD Post-op pain Anaphylaxis, edema, HTN, liver
abnormalities, anemia, blurred
vision, tinnitus, respiratory d/o,
GIT d/o
Losartan 100 mg QD HTN Upper respiratory infections,
dizziness, stuffy nose, back pain,
diarrhea, fatigue, low blood sugar,
chest pain, high/low blood pressure
Metformin 500 mg BID DM Heartburn, stomach pain, nausea or
vomiting, bloating, gas, diarrhea,
constipation, weight loss,
headache, unpleasant metallic taste
in mouth
PMHx:
[+] HTN (dx & controlled c Losartan since 2015)
[+] Type 2 DM (dx & controlled c Metformin since 2017)
[+] CAD: Stable Angina
[-] Respi. dse.
FMHx:
HTN [+] [+]
DM [-] [+]
Heart dse. [-] [-]

Respi. dse. [-] [-]
Social Hx:
Pt. has a sedentary lifestyle; usually spends time taking care of her family & doing light
household chores. After housework, pt. spends her time watching TV, scrolling through social
media & sleeping. Pt. is a member of her children’s school parent council & attends the meeting
q Saturday. Pt. goes to church c her family q Sunday morning & rests throughout the day.
Social Habits:
Pt. has been religiously smoking ~4 sticks of cigarette per day for ~20 yrs (4 pack yrs) &
occasionally drinks alcoholic beverages c her friends (~3-4 bottles). Pt.’s diet is reported to be
poor, mostly containing junk foods & high in cholesterol. Pt. has a normal sleeping schedule &
has enough sleep (~8-9 hrs) qd.
Home Situation:
Pt. lives c her husband & 3 children in a well-lit & ventilated 2-storey house that has 4 bedrooms
& 2 bathrooms. Pt. does household chores at home c the help of her daughter. Pt. washes the
dishes & places tablewares at the upper cabinet (~25” in height) qd; sweeps the floor; do laundry
& places clothes at the cabinets (~75” in height) q wk. Pt. usually spends her free time in the
living room watching TV series or movies c her daughter. Pt. is unemployed; her husband &
daughter provide financial support; her other 2 children go to school.
Prior to onset of the disease, pt. can perform ADLs such as bathing, toileting, dressing, feeding
& self-care activities independently s any pain, weakness & fatigue.
C/C:
“Sumasakit yung bagong opera kong dibdib tuwing gumagalaw ako; mabilis din akong
mapagod. Hindi ko rin magawa pang makapunta maski sa banyo nang mag-isa kasi nanghihina
ako. Takot din ako na baka pag gumalaw ako ay bumuka ang tahi sa dibdib ko.”
PT Translation:
Pt. c/o post-op pain when moving & performing ADLs, easily fatigued, weakness & fear of
surgical incision reopening.
“Gusto ko na pong gumaling para makauwi na ko nang maasikaso ko na ang asawa’t anak ko,
makagawa na ulit ako ng mga gawaing bahay, makagalaw, at makatulog na walang sakit na
nararamdaman.”

PT Translation:
Pt. is willing to receive PT treatment to be able to take care of her family & do ADLs
independently s any pain, weakness & fatigue.
O:
Vital Signs:
Before IE During IE After IE
BP 120/80 mmHg 120/80 mmHg 110/70 mmHg
RR 19 cpm 18 cpm 15 cpm
PR 90 bpm 87 bpm 85 bpm
T° 37°C 37.1°C 37.3°C
O2 Sat 94% 95% 94%
OI:
● Bedbound
● Endomorph
● [+] Surgical dressing on anteromed. chest
● [+] Dextrose IV attachment on (L) wrist
● [+] Postural deviation (see postural assessment)
● [-] Gait deviation
● [-] Mm atrophy on (B) UE & LE
● [-] Deformity on (B) UE & LE
● [-] Nodule on (B) UE & LE
● [-] Alar flaring
● [-] Cyanosis
● [-] Pallor
● [-] Clubbing of nails
Palpation:
● Normothermic in all assessed body areas
● [+] Gr. 2 tenderness on anteromed. chest
● [+] Dry scaly skin
● [-] Mm tightness on (B) UE & LE
● [-] Mm guarding on (B) UE & LE
● [-] Edema on (B) UE & LE

Anthropometric Measurement:
Height Weight BMI
5’3” 163 lbs 29.2 (Overweight)
Auscultation:
Heart Sound Findings
S1 Altered
S2 Altered
S3 Normal
S4 Normal
Chest Expansion Measurement:
Landmark Max. Expiration Max. Inspiration Difference
Axilla 55” 58” 3”
Xiphoid 53” 55” 2”
Lower Ribs 59” 62” 3”
Exercise Capacity Measurement:
Resting Heart Rate Target Heart Rate Maximum Heart Rate
90 bpm 88-149 bpm 175 bpm
Special Tests:
Special Test Findings Significance
Capillary Refill Test [+] 2 secs [-] Arterial insufficiency
Venous Refill Time [+] 15 secs [-] Venous insufficiency
Kussmaul’s Sign [-] Inc. jugular venous
pressure on inspiration
[-] Right-sided heart failure
Hepatojugular Reflux Test [-] Inc. height of neck veins [-] Left-sided heart failure

ROM:
pain-free c (N) end feel except for the ff:
Range of
Motion
(N)
Patient Result Differences
End
Feel
Motion AROM PROM AROM PROM
L R L R L R L R
Sh. flex. 0-180o
0-70o
0-70o
0-80o
0-80o
110o
110o
100o
100o
Empty
Sh. ext. 0-60o
0-15o
0-15o
0-20o
0-20o
45o
45o
40o
40o
Empty
Sh. abd. 0-180o
0-15o
0-15o
0-20o
0-20o
165o
165o
160o
160o
Empty
MMT:
All major mm on HNT, (B) UE & LE were assessed using break test & were grossly graded ⅘
except for the ff:
Muscle Group Grade
(B) sh. flexors 3-/5
(B) sh. extensors 3-/5
(B) sh. abductors 3-/5
Postural Assessment:
All body segments in ant., lat., & post. views assessed & found to be WNL except for the ff:
Anterior View Findings
Head Forward head
Neck Lordotic
Shoulder Round sh.
Trunk ↑ Kyphosis
Outcome Measures:
A. Short Form-36
Findings: Physical Functioning 20%
Role Limitation d/t physical health 0%

Role limitation d/t emotional problems 100%
Energy/Fatigue 30%
Social Functioning 37.5%
Pain 20%
General Health 15%
Health Change 100%
B. Duke Activity Status Index
Findings: Pt. scored 0 out of 58.2 having the pt. Only capable of doing 2.74 METs
activities.
C. 5x Sit-to-Stand Test
Findings: Pt. was able to complete the test for 2 minute c rest intervals.
D. Fatigue Severity Scale
E. 2 Minute Walk Test
Findings: Pt. was able to amb. For 130m c +1 min. Assist. For 2 minutes c 1 period of
15s rest and reported a borg rating perceived exertion scale score of 6 (moderate activity)
for fatigue & 2 (slight) in modified borg dyspnea scale.
A:
PT Impression/Dx:
Based on PT examination, pt. has Post-CABG 2o
NSTEMI which was further defined by
difficulties in performing ADLs such as toileting, bathing, self-care, dressing, feeding, &
household chores, & going to social gatherings 2o
to post-op localized, intermittent, dull aching
pain on substernal surgical incision (PS: 8/10), LOM on specified motions; mm weakness on
specified mm groups; & postural deviation as supported by the pt.’s hx, ancillary procedures,
objective examination & the ff. outcome measures: SF-36, DASI = 0/58.2, 5xSTS, FSS = 52/63,
& 2MWT.
PT Prognosis:
Pt. has a fair prognosis to improve ability to perform indep. ADLs & amb. s pain & fatigue in 3
wks. based on positive prognosticating factors such as pt.’s motivation, attitude, financial
capability, support system & medications; c negative prognosticating factors such as sedentary
lifestyle, unhealthy diet & comorbidities such as HTN & Type 2 DM.
Problem List:
1. Pt. has localized, intermittent, dull aching post-op pain on substernal surgical incision
(PS: 8/10)
2. Pt. has difficulty performing ADLs & self-care activities
3. Pt. has dec. endurance
4. Pt. has dec. AROM & PROM on specified motions

5. Pt. has dec. mm strength on specified mm groups
6. Pt. has postural deviation
7. Pt. has fatigue
The PT rehab aims to primarily reduce pain, restore shoulder function & maintain other bodily
functions by patient education, ROM, aerobic, & strengthening exercises; secondarily increase
independence by bed mob. & functional exercises.
ICF:
P:
LTG:
Rehabilitative:
1. Pt will perform ADLs & self-care activities independently s any discomfort (PS: 4/10 →
0/10) after ~3 wks.
Preventive:
1. Pt. will adapt to lifestyle modifications & perform prescribed HEP to prevent mm atrophy
& contractures.

STG:
1. Pt. will perform ADLs & self-care activities independently s any discomfort for ⅗ trials
(PS: 8/10 → 4/10) after ~1 wk.
2. Pt. will present c inc. AROM & PROM by 10-20 increments on all planes on (B)
shoulder after ~1 wk.
3. Pt. will present c inc. mm strength on (B) shoulder (MMT: 3-/5 → 4/5) after ~1 wk.
4. Pt. will perform amb. from bed ↔ door for 2 rounds c min. fatigue & inc. endurance
(2MWT) after ~1 wk.
PT Interventions:
Pt. will be treated as an I.P. qd in 1 wk. & will be given the following tx for Phase 1:
1. PROME → AAROME in sitting position within pain-free range on (B) UE & LE on all
planes to maintain joint mob., inhibit pain, & prevent contractures & mm atrophy x10
reps x2 sets
2. Bed mobility exercises to maintain mobility during bed rest x5 reps x2 sets
a. Supine ↔ scooting up
b. Supine ↔ sidelying
c. Supine ↔ sit
d. Sit ↔ stand
3. Breathing & coughing exercises to minimize post-op pain during breathing & coughing
a. Diaphragmatic breathing x3-4 reps
b. Self-assisted coughing/with splinting
4. Aerobic exercise to improve cardiovascular health
a. Walking on the treadmill c min. assist. & normal speed x10 mins
b. UE ergometry x15 mins
5. Functional ROM exercises to increase indep. in ADLs
a. Reaching an eating utensil
b. Eating hand-to-mouth
c. Dressing (don/off hosp. gown)
d. Toileting (bathroom privileges)
○ Wound care management
○ How the surgery will affect the patient
○ Proper bed positioning & turning
○ Role of PT
○ Importance of HEP
○ Dietary & nutritional modifications
○ Lifestyle changes

○ Self-hemodynamic monitoring
● Sternal precautions
○ Avoid lifting for >/= 10 lbs
○ Avoid overhead reaching
○ Avoid reaching behind
○ Avoid driving
○ Avoid pushing or pulling activities
● Observe proper body mechanics.
● Encourage the pt. to be active & the family to motivate the pt.
HEP:
● AROME x10 reps x2 sets
○ Shoulder flexion
○ Shoulder extension
○ Shoulder abduction
○ Shoulder adduction
○ Shoulder internal rotation
○ Shoulder external rotation
○ Elbow flexion
○ Elbow extension
○ Hip flexion
○ Hip extension
○ Hip abduction
○ Hip adduction
○ Knee flexion
○ Knee extension
● Aerobic exercises x30-1 hr
○ Yoga
○ Zumba
○ Walking
○ Jogging
○ Stationary biking
● Strengthening exercises x10 reps x2 sets
○ Bicep curls
○ Tricep Extension
■ Bend slightly forward c back straight while holding 2-10lbs dumbbells &
arms parallel to the body. Lift the dumbbells and repeat.
○ Leg extension exercise

■ In a standing position while facing the wall c a pillow pressed on the chest
& yellow resistance band attached to a single leg, slowly pull the band
backward using the leg and repeat on the other side
○ Leg Abduction Exercise
■ In a standing position while facing the side c a pillow pressed on the chest
& yellow resistance band attached to a single leg, slowly pull the band
away from the free leg & repeat
○ Leg Flexion Exercise
■ In a standing position while facing the opposite of the wall c a
pillow pressed on the chest & yellow resistance band attached to a
single leg, slowly pull the band forward and repeat

Referrals:
● Nutritionist - for dietary evaluation, education & counseling
● Social Worker - for psychosocial counseling, patient & family education, discharge
planning & smoking cessation
● Rehabilitation Nurse - wound & skin care, pain management, safety education &
medication education
● Cardiologist - for follow up check up care after PT treatment
DELA CRUZ, JACQUILINE ANDRE M. YEUNG, JERICA L.
PT INTERN - BATCH 2022 PT INTERN - BATCH 2022
EBP:
A. Title of the Study: Effects of high-intensity interval versus continuous exercise training
on post-exercise heart rate recovery in coronary heart disease
B. Objectives of the Study: The main objective of this study is to compare the effects of a
moderate continuous training versus a high intensity interval training programme on
Vo2peak and HRR.
C. Methodology: Seventy three coronary patients were assigned to either HIIT or MCT
groups for 8 weeks. Incremental exercise tests in a cycloergometer were performed to
obtain VO2peak data and heart rate was monitored during and after the exercise test to
obtain heart rate recovery data.
D. Results: Both exercise programmes significantly increase VO2peak with a higher
increase in the HIIT group (HIIT: 4.5 ± 4.46 ml/kg/min vs MCT: 2.46 ± 3.57 ml/kg/min;
p = 0.039). High intensity interval training resulted in a significantly increase in HRR at
the first and second minute of the recovery phase (15,44 ± 7,04 vs 21,22 ± 6,62,
p < 0,0001 and 23,73 ± 9,64 vs 31,52 ± 8,02, p < 0,0001, respectively).
E. Conclusion: : The results of our research show that the application of HIIT to patients
with chronic ischemic heart disease of low risk resulted in an improvement in VO2peak,

and also improvements in post-exercise heart-rate recovery, compared with continuous
training.
F. Relevance to Practice in the PT: Heart rate recovery (HRR) has been considered a
prognostic and mortality indicator in both healthy and coronary patients.
G. Reference: Villelabeitia-Jaureguizar, K., Vicente-Campos, D., Senen, A. B., Jiménez, V.
H., Garrido-Lestache, M., & Chicharro, J. L. (2017). Effects of high-intensity interval
versus continuous exercise training on post-exercise heart rate recovery in coronary
heart-disease patients. International journal of cardiology, 244, 17–23.
https://doi.org/10.1016/j.ijcard.2017.06.067
H. PEDro Scale: This study scored 8 out of 11 in PEDro scale.
1. Eligibility criteria was specified.
2. Subjects were randomly allocated to groups.
3. Allocation was not concealed.
4. The groups were similar at baseline regarding the most important prognostic indicators.
5. There was no blinding of all subjects.
6. There was no blinding of all therapists who admitted the therapy.
7. There was blinding of all therapists who admitted the therapy.
8. Measures of at least one key outcome were obtained from more than85% of the subjects
initially allocated to groups.
9. All subjects for whom outcome measures were available received the treatment or control
condition as allocated or, where this was not the case, data for at least one key outcome
was analysed by “intention to treat”.

10. The results of between-group statistical comparisons are reported for at least one key
outcome.
11. The study provided both point measures and measures of variability for at least one key
outcome.

S.Y. 2020-2021
MODULE 1 - JULY ROTATION
TRAUMATIC SPINAL CORD INJURY
DISCUSSION BOARD
SUBMITTED BY:
SUBMITTED TO:
July 2021

I. Pathophysiology
According to Goodman, Traumatic Spinal Cord Injury can be classified as
concussion, contusion, or laceration. Concussion is caused by a blow or violent shaking
and results in temporary loss of function. Contusion is caused by a loss of central grey
and white matter which creates a cavity that is surrounded by a rim of intact white matter
at the periphery of the spinal cord. Laceration or maceration is caused by gunshot
wounds, knife wounds, and puncture injuries which disrupts the glia and tears the spinal
cord tissue; occasionally, this can result in complete transection of the cord.
Primary injury refers to structural damage which occurs immediately after trauma
resulting in primary destruction of neurons at the level of the injury by membrane
disruption, hemorrhage, and vascular damage. If an injured spine is not adequately
immobilized, more extensive primary injury may occur. Even after severe injuries, a small
peripheral rim of spared tissue and axons often remains. Spared descending systems
play an important role in recovery. On the other hand, secondary injury refers to a
pathophysiologic cascade initiated shortly after injury such as ischemia, hypoxia, edema,
etc. that tends to cause further neuronal damage beyond the mechanical damage
caused at the moment of impact. (Braddom, 2011)
Spinal cord contusion lesions are characterized by a primary area created by
hemorrhage of blood vessels which cause necrosis of cells; primary area eventually
spreads because of secondary injury associated with apoptosis, macrophages, and
microglia. The secondary damage may continue for days to weeks and move along the
segmental levels, which cause sensory and motor dysfunction. However, the spared rim
may allow normal processing and preservation of function. (Goodman, 2007)
Complete lesions are the result of spinal cord transection, severe compression or
contusion, or extensive vascular dysfunction; have complete loss of sensory and motor
function below the level of the lesion. Incomplete lesions occur when there is contusion
produced by bony fragments, soft tissue, or edema within the spinal canal; have partial
loss of sensory and motor function below the level of the injury. There are different types
of incomplete spinal cord injury:
1. Brown-Séquard Syndrome → damage to one side of the spinal cord most
commonly caused by stab and gunshot wounds; loss of the entire hemisection of
the spinal cord is rare; natural lesions are always irregular; weakness is
ipsilateral to the lesion; lateral column damage results in abnormal reflexes,
including a positive Babinski sign, and clonus; ipsilateral spasticity in the muscles
innervated below the lesion; dorsal column damage results in loss of
proprioception, kinesthesia, and vibratory sense; contralateral pain and
temperature loss starting a few levels below the lesion

2. Anterior Cord Syndrome → frequently caused by flexion injuries and is often the
result of loss of supply from the anterior spinal artery; damage to the anterior and
anterolateral aspect of the cord results in bilateral loss of motor function and pain
and temperature sensation because of interruption of the anterior and lateral
spinothalamic tracts and corticospinal tract
3. Central Cord Syndrome → damage to the central aspect of the spinal cord
caused by cervical hyperextension injuries; more severe neurologic involvement
in the upper extremities than in the lower extremities; peripherally located fibers
may not be as severely affected, and therefore function may be retained or
recovered in the thoracic, lumbar, and sacral regions, including the bowel,
bladder, and genitalia
4. Posterior Cord Syndrome → extremely rare, with preservation of motor function,
pain, and light touch sensation; loss of proprioception below the level of the
lesion, leading to a severe gait deviations
5. Conus Medullaris Syndrome and Cauda Equina Syndrome → damage at the
base of the spinal cord and generally result in flaccid lower limb paralysis, flaccid
bowel and bladder sphincters, resulting in difficulty with bowel accidents and
bladder leakage as well as lack of penile erection in males
The site of spinal cord damage determines the extent of the physical
impairments. Injury of the cord in the cervical region creates tetraplegia, or paralysis of
all four limbs. In addition to the limbs, the trunk and muscles of respiration are involved.
Damage in the thoracic or lumbar region will result in paraplegia or paraparesis involving
only the lower extremities and generally the lower trunk.
II. Early detection and rehabilitation
According to O’Sullivan, early detection begins at the location of the accident
wherein the rescue personnel questions and examines the patient for signs of SCI
before moving. The signs of SCI after trauma are paresthesia, lack of or impaired
movement or sensation in the extremities, spinal pain, and altered cognitive status or
level of alertness. Active and passive movements of the spine must be avoided if the
patient is suspected with SCI; movement of the spine is minimized by strapping the
patient to a spinal backboard or a full-body adjustable backboard, a supporting cervical
collar to immobilize the head, and multiple personnel to assist in moving the patient to
safety. These measures assist in maintaining the spine in a neutral position to prevent
further neurological damage. Cardiac, hemodynamic, and respiratory status are closely
monitored at the emergency room. Once the patient is stabilized, a complete
neurological examination is performed as well as imaging studies to assist in determining
the extent of damage and plans for medical management. Restoration of vertebral
alignment and early immobilization of the fracture site is the primary focus to prevent
further progression of neurological impairment. A urinary catheter is typically inserted
and secondary injuries are addressed. High doses of methylprednisolone may be given
early within 3-8 hours after the injury for 24-48 hours as it has an anti-inflammatory effect
by lessening secondary damage due to the inflammatory process and improvement in
motor and sensory function.

Early rehabilitation mainly focuses on fracture stabilization and spine
immobilization to prevent further damage to the cord. Reduction and immobilization of
spinal injuries can be achieved via conservative or operative methods. Indications for
surgical stabilization are unstable fracture site, gross malalignment, cord compression,
and deteriorating neurological status. Indication for closed reduction is cervical
subluxation or fracture dislocation injuries; it is achieved with the use of traction devices.
Patients with thoracic or lumbar injuries that are managed conservatively without surgery
require immobilization by positioning in a regular or rotating bed. After reduction of the
fracture site through conservative or surgical methods, the spine is immobilized with the
use of spinal orthoses and recumbent positioning. The following spinal orthoses are
used:
1. Cervical Orthoses
a. Halo → immobilize cervical fractures after both open and closed
reduction; consist of a halo ring with four steel screw attached directly to
the outer skull; attached to a body jacket or vest by four vertical steel
posts; limiting cervical motion in all planes; the most common
complication is loosening of the pin site causing instability or infection and
skin breakdown under the vest portion of the halo
b. Minerva → limits motion in all planes; provides excellent cervical stability
and allows early mobility and rehabilitation after SCI
c. Sterno-occipital-mandibular Immobilizer (SOMI) → less effective in
limiting cervical ROM; used with cervical collars such as Philadelphia
collar, Miami J collar, Aspen collar, and foam soft collar but they do not
effectively immobilize the spine
2. Thoracolumbosacral Orthoses → immobilize the spine with thoracic or lumbar
injuries; body jackets are bivalved and connected by hook-and-loop closures
which allows for removal during bathing and skin inspection
a. Jewett → prefabricated device made of a metal frame and pads; not as
effective for immobilizing the spine as a body jacket
III. Healthy lifestyle and diet
According to Field-Fote, regular physical activity is critical to living a healthy life
after SCI together with healthy nutrition, attention to safety issues, skin protection,
smoking cessation, regular medical and dental care, stress management, and
disability-specific screening for secondary conditions to ensure that the patient is able to
participate fully in their work, social, and personal lives.

IV. Physical therapy
According to O’Sullivan, the goals of physical therapy are to prevent secondary
complications, provide patient education, and begin early mobilization when medical
clearance is cleared. At its core, the rehabilitation is done to maximize the SCI patient’s
sensory and motor function recovery and help them reintegrate with society. Physical
therapists tailor the rehabilitative treatment based on the patient’s goals and injury level
and severity.
V. Outcomes
Functional Expectations for Patients with Spinal Cord Injury
Motor Level and
Key Muscles
Available
Movements
Functional Capabilities Equipment and Assistance
Required
C1-C4
Face and neck mm,
cranial nerve
innervation,
diaphragm
Talking,
mastication,
sipping, blowing,
scapular elevation
Activities of daily living
(ADL)
Dependence in basic ADL
(BADL)
Activation of computer,
light switches, page
turners, call buttons,
electrical appliances, and
speaker phones
Bowel and bladder
Dependent
Environmental control units
(ECU)
Brain-computer interface
(BCI)
Adaptive equipment such as
head or mouth stick
Full-time attendant required,
directs care provided by
attendants
Dependent, directs care
provided by attendants

Wheelchair mobility and
pressure relief in
wheelchair
Bed mobility
Transfers
Ambulation
Driving
Independent with power
wheelchair
Typical components include
adaptive controls such as
head, chin, tongue, or
sip-and-puff control
Electronically controlled
seating system (tilt and/or
recline)
Wheelchair cushion and
head/trunk support
Portable ventilator (depending
on innervation of diaphragm)
Dependent with positioning in
wheelchair
Dependent
Adjustable bed with pressure
reducing mattress
Directs care provided by
attendants
Dependent, attendants use
mechanical lift
attendants
Unable
Unable
C5
Biceps, brachialis,
brachioradialis,
deltoid,
infraspinatus,
rhomboid (major
and minor),
supinator
Elbow flexion and
supination,
shoulder external
rotation, shoulder
abduction and
flexion to ~90o
ADL
Feeding
Grooming, washing face,
and oral hygiene Bathing
and dressing (dependent)
Activation of computer,
light switches, page
turners, call buttons,
electrical appliances, and
speaker phones
Bowel and bladder
pressure relief in
wheelchair
Some assistance and/or setup
required depending on the
activity
Mobile arm supports, deltoid
aid
Adapted utensils and splinting
Adapted equipment (wash
mitt, adapted toothbrush, and
so forth)
Dependent
Adapted computer keyboard
Hand splints
Adapted typing sticks
ECU
Part-time attendant required,
directs care provided by
attendants
Dependent, directs care
provided by attendants
Independent to some assist
with manual wheelchair on
level surfaces
Requires plastic-coated hand
rims/extensions
Benefit from power-assist
wheelchair Independent with
power wheelchair using
handheld joystick

Bed mobility
Transfers
Ambulation
Driving
An electronically controlled
seating system (tilt and/or
recline)
Wheelchair cushion and trunk
support, dependent with
positioning in wheelchair
Assistance to dependent
Adjustable bed with pressure
reducing mattress
Bed rails and loops
attendants
Dependent, attendants use
mechanical lift
attendants
May be able to perform with
assistance and transfer board
Unable
Independent with van with
adaptive controls
C6
Extensor carpi
radialis,
infraspinatus,
latissimus dorsi,
pectoralis major
(clavicular portion),
pronator teres,
serratus anterior,
teres minor
Shoulder flexion,
extension, internal
rotation, and
adduction, scapular
abduction,
protraction, and
upward rotation,
forearm pronation,
wrist extension
(tenodesis grasp)
ADL
Feeding
and oral hygiene
Dressing
Bathing
Home management
Bowel and bladder care
pressure relief in
wheelchair
Bed mobility
Assistance to independent
with setup and/or equipment
Universal cuff, adaptive
utensils
Adaptive equipment, universal
cuff
Upper body: independent with
adaptive equipment
Lower body: assistance with
adaptive equipment
Assistance with adaptive
equipment
Assistance, may be
independent with certain
tasks with adaptive equipment
Part-time attendant required
May be able to be
independent with adaptive
equipment, likely to require
assistance/dependent
Independent with manual
wheelchair on level surfaces
May require power wheelchair
in community
Requires plastic coated hand
rims/ extensions
Benefit from power-assist
wheelchair
Independent with pressure
relief in wheelchair
Independent to some
assistance with adaptive

Transfers
Ambulation
Driving
equipment (e.g., bed rails,
loops, and so forth)
Independent to some
assistance with transfer board
Assistance with uneven
transfers
Unable
Independent with car/van with
adaptive controls
C7
Extensor pollicis
longus and brevis,
extrinsic finger
extensors, flexor
carpi radialis,
triceps
Elbow extension,
wrist flexion, finger
extension
ADL
Feeding
and oral hygiene
Dressing
Bathing
Home management
pressure relief in
wheelchair
Bed mobility
Transfers
Ambulation
Driving
Independent
Independent with most ADL
with adaptive equipment (e.g.
shower chair, hand rails,
button hook, adaptive
utensils) and wheelchair
accessible environment
Likely to require assistance
with heavy household tasks
Independent with adaptive
equipment
wheelchair in home and
community with plastic-coated
hand rims
May need some assist with
ramps, curbs, and uneven
terrain
May benefit from power assist
relief
Independent, may require
adaptive equipment (i.e., bed
rails, leg loops)
assistance between uneven
surfaces
Unable
Independent with car with
adaptive controls
C8
Extrinsic finger
flexors, flexor carpi
ulnaris, flexor
pollicis longus and
brevis, intrinsic
finger flexor
Finger flexion ADL
Feeding
and oral hygiene
Dressing
Bathing
Home management
Independent
Independent in all ADL, may
require adaptive equipment
(e.g., shower chair, hand rails,
reacher, adaptive utensils) for
some tasks and
wheelchair-accessible
environment
Better able to perform with

pressure relief in
wheelchair
Bed mobility
Transfers
Ambulation
Driving
less need for adaptive
equipment due to improved
hand function compared to
higher cervical level injuries
equipment
community
Better able to propel on
ramps, curbs, and uneven
terrain due to improved hand
function compared to higher
cervical level injuries
May benefit from power assist
relief
adaptive equipment (i.e., bed
rails, leg loops)
assistance between uneven
surfaces
May be able to transfer from
floor into wheelchair
Unable
adaptive controls
T1-T12
Intercostals, long
muscles of back
(sacrospinalis and
semispinalis),
abdominal
musculature (~T7
and below)
Improved trunk
control with more
caudal SCI,
increased
respiratory reserve,
pectoral girdle
stabilized for lifting
objects
ADL
pressure relief in
wheelchair
Bed mobility
Independent
Independent in all areas
Generally tasks become
easier and require less
adaptive equipment to
perform with improved trunk
control with more caudal SCI
equipment
community
Independent on ramps, curbs,
and uneven terrain
relief
Wheelchair mobility becomes
easier and more efficient with
improved trunk control with
more caudal SCI
Bed mobility skills become
easier and more efficient with
improved trunk control with
more caudal SCI

Transfers
Ambulation
Driving
Independent
Able to transfer from floor into
wheelchair
Transfers become easier and
more efficient with improved
trunk control with more caudal
SCI
Independent with
physiological standing and
ambulation for exercise over
short distance in the home
Assistive devices (e.g.,
forearm crutches)
Orthoses:
hip-knee-ankle-foot-orthosis
(HKAFO), knee-ankle-foot
orthosis (KAFO)
adaptive controls
L1-L3
Gracilis, iliopsoas,
quadratus
lumborum, rectus
femoris, sartorius
Hip flexion, hip
adduction, knee
extension
Ambulation Independent short distances
in home and possibly
community
Many choose to use
wheelchair in the community
due to high energy demands
of community ambulation
forearm crutches)
Orthoses: HKAFO, KAFO,
AFO (depending on which
muscles are innervated)
L4-L5, S1
Quadriceps (L4)
Anterior tibialis (L5)
Hamstrings
(L5–S1)
Gastrocnemius
(S1) Gluteus
medius and
maximus (L5–S1)
Extensor digitorum,
posterior tibialis,
peroneals, flexor
digitorum (L5, S1)
Strong hip flexion,
strong knee
extension, knee
flexion, ankle
dorsiflexion, ankle
plantarflexion,
ankle eversion, toe
extension
Ambulation Independent ambulation in
home and community
(L4-level injury may elect to
use wheelchair for long
distances)
forearm crutches, canes)
Orthoses: AFO Less
supportive assistive device
and orthoses the more caudal
the SCI
According to O’Sullivan, the functional expectations mentioned above for patients
with SCI are used to establish goals and outcomes. However, there are factors that may
affect functional recovery after SCI is dependent on many factors:
● Motor level
● Age
● Concomitant injury
● Preexisting health conditions

● Secondary complications
● Body type
● Psychosocial support
Based on the Guide to Physical Therapist Practice, below are the examples of
general goals and outcomes for patients with SCI:
● Airway clearance is improved.
● Aerobic capacity is increased.
● Integumentary integrity is improved.
● Muscle performance is increased.
● Risk of secondary impairments is reduced.
● Tolerates upright sitting posture.
● Independence in ADL.
● Independence transfers.
● Independence in wheelchair propulsion.
● Independence in self-directing care.
● Independence with pressure relief.
References:
Braddom, R. L., Chan, L., & Harrast, M. A. (2011). Physical medicine and rehabilitation.
Philadelphia, PA: Saunders/Elsevier.
Field-Fote, E. (2009). Spinal Cord Injury Rehabilitation. Philadelphia: F.A. Davis.
Goodman, C. C., & Snyder, T. E. K. (2007). Implications for the Physical Therapists. St. Louis,
Mo: Saunders/Elsevier.
O'Sullivan, S. B., & Schmitz, T. J. (1994). Physical rehabilitation: Assessment and treatment (3rd
ed.). Philadelphia: F.A. Davis.

S.Y. 2020-2021
TRAUMATIC SPINAL CORD INJURY
SOAP DOCUMENTATION
SUBMITTED BY:
SUBMITTED TO:
July 2021

GENERAL INFORMATION
Pt.’s Name: L.G.
Age: 30 y/o
Sex: M
Civil Status: Single
Handedness: R
Height: 5”7’
Weight: 158 lbs
BMI: 24.7 (Normal)
Occupation: Auto Mechanic
Referring MD: Dr. E.D.
Referring Unit: FEU-NRMF E.R.
Rehabilitation MD: Dr. J.Y.
Rehabilitation Unit: FEU-NRMF R.U.
Date of Referral: July 1, 2021
Medical Dx: (R) Incomplete Brown-Sequard Syndrome at T12 Level
Informant: Pt.
S:
HPI:
Pt.’s present condition started ~1 wk. PTIE when the pt. was robbed on the way home from
work, the robber stabbed him using a long sharp knife & ran away. Pt. fell on the ground & felt a
pins-and-needles sensation c sharp, severe, intolerable pain (PS: 10/10) on his (R) mid-back.
~10 mins, paramedics arrived, checked the pt. & found 1 stab wound c impaled knife. Pt. was
rushed to the nearest hospital. In the ambulance, direct pressure & bulky dressings were
applied around the impaled knife; checked his VS of BP: 100/60, HR: 60 bpm, T°: 35.6°C, RR:
15 cpm, & O2sat: 94%, & administered oxygen & IV fluids. ~8 mins, pt. arrived at FEU-NRMF
E.R. & was attended by Dr. E.D. Pt. was found to be under Phase 1 Spinal Shock. Pt. was
immediately brought to the O.R. to surgically remove the impaled knife which was found to be
penetrated into the spinal canal of T12 vertebra. Surgery was successful s any complications
noted. Pt. was transferred in a private room to rest & monitor his VS. Pt. was given IV Morphine
for post-op pain & IV Methylprednisolone for inflammation (PS: 7/10 → 0/10). ~2 days PTIE, pt.
c/o inability to move (R) leg c difficulty transferring, ambulating, toileting, bathing, & dressing. Pt.
was found to be under Phase 3 Spinal Shock. Pt. underwent neurological assessment &
ancillary procedures (see ancillary procedures) that led to mdx of (R) Incomplete
Brown-Sequard Syndrome at T12 Level. ~1 day PTIE, pt. was referred to FEU-NRMF R.U. as
an I.P. on July 2, 2021 under Dr. J.Y. for further evaluation & early rehabilitation.

X-Ray
July 1, 2021
[+] Penetrating injury on
T12 vertebra at AP view
FEU-NRMF Hospital
CT Scan [+] Fracture on T12
vertebra
FEU-NRMF Hospital
MRI [+] Hyperintensities on
T12 vertebra at T1
weighted sagittal & T2
weighted axial view
FEU-NRMF Hospital
IV Morphine 10 mg OD Moderate to
severe pain &
post-op pain
CNS depression,
orthostatic hypotension,
severe hypotension,
syncope constipation
IV
Methylprednisolone
40 mg OD Anti-inflammatory Adrenal suppression,
anaphylactoid reactions,
acute myopathy,
insomnia, HTN, mm
atrophy, mm weakness
IV Penicillin G 600 mg OD Post-surgery
wound infection
Jarisch-Herxheimer
reaction, hypersensitivity,
GI upset,
pseudomembranous
colitis
Oral Baclofen 5 mg TID Severe chronic
spasticity
Respiratory depression,
acute urinary retention,
CNS depression
PMHx:
[-] DM
[-] HTN
[-] Stroke
[-] Heart dse
[-] Tumor
[-] Infections

FMHx:
DM [-] [-]
HTN [+] [-]
SCI [-] [-]
Stroke [-] [-]
Heart dse [-] [-]
Social Hx:
Pt. has an active lifestyle. Pt. usually spends time working at auto repair shop c his co-workers.
Pt. goes to the gym q Saturday morning c his friends & attends church q Sunday morning c his
parents. Pt. also help his parents do household chores q.d.
Social Habits:
Pt. has an unhealthy lifestyle. Pt. smokes ~5 sticks of cigarette per day for ~5 yrs (1.25 pack
yrs) & drinks alcoholic beverages c his co-workers after work (~4 bottles); poor diet consists of
canned, junk, & high in cholesterol food (~2500 cal/day); gets enough sleep (~8 hrs) q.d.
Home Situation:
Pt. lives c his parents in a well-lit & ventilated bungalow house c ceramic tiles flooring & no
platforms reported. Pt.’s house has 2 bedrooms & 1 bathroom. Pt. does all heavy household
chores at home such as repairing, moving & cleaning furniture, & bathroom cleaning. Pt. spends
his free time at his room to play online games. Pt. is employed; his parents handle their sari-sari
store in front of the house. Pt.’s house is ~8 mins walking distance away from his workplace.
Work Situation:
Pt. works in an auto repair shop as an auto mechanic from 8:00AM-6:00PM (10 hrs) Mon-Sat.
Pt. walks from home ↔ work for ~8 mins. Pt. buys food from a carinderia beside his workplace
during his break time at 12:00nn & smokes a stick of cigarette right after c his co-workers. Pt.’s
work involves inspecting, diagnosing & repairing engines using his tools.
Hospital Situation:
Pt. is admitted & monitored in an air-conditioned private room at FEU-NRMF Hospital 3rd floor c
~28.12 sq m. Pt.’s bed ↔ door is ~10 steps & bed ↔ bathroom ~5 steps. Pt. has attached IV
fluids & medications administered & checked by the rotating nurse. Pt.’s food is delivered 3x/day
depending on the prescribed diet. Pt.’s mother stays c him to provide assistance.
Pt. was fully indep. in performing ADLs, recreational activities, & work duties s any discomfort on
(R) LE prior to injury.

C/C:
“Sumasakit yung bagong opera ko sa likod tuwing gumagalaw ako pero nawawala naman ‘pag
uminom ng gamot. Hindi ko maigalaw yung kanan kong hita, binti pati paa; wala rin akong
maramdaman tuwing hinahawakan iyon. Sa kaliwa naman, ‘di ko ramdam yung lamig gawa ng
aircon.”
PT Translation:
Pt. c/o post-op, sudden, localized, sharp stabbing pain at mid-back T12 level, inability to move
(R) LE c loss of touch sensation & (L) LE loss of temperature sensation.
“Gusto ko na mawala yung sakit ng bagong opera ko sa likod at maigalaw yung kanan kong
hita, binti at paa. Gusto ko na gumaling at makauwi para makabalik na ako sa trabaho at para
matulungan mga magulang ko.”
PT Translation:
Pt. is willing to receive PT treatment to be able to do ADLs & go back to work s pain, LOM, &
loss of sensation on (B) LE.
O:
Vital Signs:
BP 120/80mmHg 120/80 mmHg 120/80 mmHg 110/70 mmHg
RR 12-20cpm 19 cpm 18 cpm 16 cpm
PR 60-100bpm 90 bpm 87 bpm 85 bpm
T° 36.5-37.5° 37° 37° 37.2°
OI:
● Bedbound
● Ectomorph
● [+] Dressing on stab wound at the (R) mid-back T12 level
● [+] TLSO
● [+] IV attachment on the (R) wrist
● [-] Pallor
● [-] Pressure ulcer
● [-] Hematoma
● [-] Mm atrophy on (B) UE & LE
● [-] Swelling on (B) UE & LE
● [-] Bruises on (B) UE & LE
● [-] Deformity on (B) UE & LE

Palpation:
● Afebrile to touch on all assessed areas
● [+] Gr. 2 spasticity on (R) LE (see Tone Assessment)
● [+] Gr. 2 tenderness on stab wound at the (R) mid-back
● [-] Edema on (B) UE & LE
● [-] Contractures on (B) UE & LE
● [-] Mm guarding on (B) UE & LE
● [-] Taut bands on (B) UE & LE
Sensory Assessment:
All dermatomes of (B) UE were assessed & was found to be normal except for the ff:
A. Superficial Sensation
Test Procedure Findings
Light touch Pt. eyes closed while PT strokes on pt.’s (B)
LE skin using camel-hair of neuro hammer
& is asked to identify the sensation felt.
Pt. has altered light touch
sensation on (B) L1-L5
dermatome.
Pin prick Pt. eyes closed while PT applies stimulus
on pt.’s (B) LE skin using sharp-end of
neuro hammer & is asked to identify the
sensation felt.
Pt. has absent pin prick
sensation on (R) T12 &
altered on (R) L1-L5; (L)
L3-L5 dermatome.
Pressure Pt. eyes closed while PT applies pressure
on pt.’s (B) LE skin using blunt-end of neuro
hammer & is asked to identify the sensation
felt.
Pt. wasn’t able to perceive
pressure sensation on (R)
L1-L5 dermatome.
Temperature Pt. eyes closed while PT touches pt.’s (B)
LE skin using 2 test tubes c cold & hot
water; & is asked to identify whether
sensation is hot or cold.
Pt. wasn’t able to identify
both hot & cold sensation on
(L) L3-L5 dermatome.
B. Deep Sensation
Proprioception Pt. eyes closed while PT positions pt.’s (R)
LE & is asked to describe the position.
Pt. wasn’t able to describe
the position of (R) LE.
Kinesthesia Pt. eyes closed while PT moves (L) LE
passively into flex/ext. & is asked to mimic
movement on (R) LE.
Pt. wasn’t able to mimic
movement on (R) LE.
Vibration Pt. eyes closed while PT place the vibrating
tuning fork on bony prominences of (R) LE;
& is asked if pt. felt the vibration.
Pt. wasn’t able to feel
vibration sensation on (R) LE.

C. Combined Cortical Sensation
2-point
discrimination
Pt. eyes closed and is asked to identify if 1
or 2 pins were felt on the (R) LE.
Pt. wasn’t able to identify 2
points on (R) LE.
Tone Assessment: Modified Ashworth Scale
Findings: Pt. presents c Gr. 2 spasticity on (R) hip flexors, knee extensors, ankle DFs, PFs, &
toe extensors.
DTRs:
Findings: Pt.’s DTRs were graded 3+ or hyperreflexive on (R) patellar, hamstrings, tibialis
posterior & achilles reflexes; & 2+ or normal on (B) UE & (L) LE.
Pathological Reflexes:
Pathological Reflex Findings Significance
Babinski Reflex (+) Ext. of (R) big toe & fanning of
4 toes
(+) UMNL
Chaddock’s Reflex (+) Ext. of (R) big toe & fanning of
4 toes
(+) UMNL
ROM:
pain-free c (N) end feel except for the AROM of (R) LE, which was not assessed d/t spastic
paralysis.
MMT:
All major muscles on HNT, (B) UE & LE were assessed using break test & were grossly graded
⅘ except for the ff:
Muscle Group Grade (L) Grade (R)
Hip flexors 4/5 3-/5

Hip extensors 3/5 1/5
Hip adductors 4/5 3-/5
Hip abductors 3/5 1/5
Hip IRs 3/5 1/5
Hip ERs 4/5 3-/5
Knee flexion 3/5 1/5
Knee extensors 4/5 3-/5
Ankle dorsiflexors 3/5 1/5
Ankle plantar flexors 3/5 1/5
Ankle invertors 3/5 1/5
Ankle evertors 3/5 1/5
MTP big toe flexors 3/5 1/5
MTP big toe extensors 3/5 1/5
Spinal Cord Independence Measure (SCIM)
Findings: Pt. scored 15 out of 20 in self-care, 37 out of 40 in respiration & sphincter
management, & 9 out of 40 in mobility c a total of 61 out of 100 SCIM score.
Outcome Measures:
A. ASIA Impairment Scale (AIS)
Findings: Pt.’s has a grade of C which indicates incomplete SCI & Brown-Sequard as
the clinical syndrome.
B. ASIA International Standards for Neurological Classification of Spinal Cord Injury
(ISNCSCI)
Findings: Pt.’s (R) sensory level is T11 while (L) is T12; (R) motor level is T1 while (L) is
S1. Pt. has incomplete SCI at T12 neurological level.
C. Mini Mental State Examination (MMSE)
D. Numerical Pain Rating Scale (NPRS)
Findings: Pt.’s post-op pain is graded 7 out of 10.

A:
PT Impression/Dx: A
Pt. was medically dx c (R) Incomplete Brown-Sequard Syndrome at T12 Level which was further
defined by difficulty in performing ADLs & inability to work as auto mechanic 2° post-op, sudden,
localized, sharp stabbing pain at mid-back T12 level (NPRS: 7/10), spastic paraplegia on (R) LE
(MAS: 2/4), LOM on specified motions, mm weakness on specified mm groups, impaired
sensation on (B) LE as supported by ASIA Impairment Scale: C, SCIM: 61/100, ISNSCI:
Incomplete SCI at T12 neurological level, & MMSE: 30/30.
PT Prognosis:
Pt. has a good prognosis to improve ability to perform ADLs & amb. s AD in 6 mos. based on
positive prognosticating factors such as pt. has no comorbidities & FMHx was unremarkable;
pt.’s motivation, attitude, financial capability, support system, medications, & neurological level
of incomplete lesion which indicate greater likelihood of recovery.
Problem List:
1. Post-op, sudden, localized, sharp stabbing pain at mid-back T12 level (PS: 7/10)
2. Gr. 2 spasticity on specified mm groups
3. Difficulty in performing bed mob. & ADLs
4. Difficulty in amb.
5. Mm weakness on specified mm groups
6. Impaired fine & discriminative touch, proprioception, kinesthesia, & vibration on (R) LE
7. Impaired pain & temperature sensation on (L) LE
The rehab team will primarily focus on preventing secondary complications & reducing spasticity
by bed mob., positioning, PROM, & stretching exercises; secondarily, adapt by using ADs in
functional activities.

ICF:
P:
LTG:
Rehabilitative:
1. Pt. will perform community amb. indep. c AD (SCIM) after ~6 mos. of rehab.
Preventive:
1. Pt. will adapt the lifestyle modifications provided as well as prescribed HEP.
STG:
1. Pt. will report dec. post-op pain (NPRS: 7/10 → 0/10) on mid-back after ~8 wks.
2. Pt. will improve ADLs indep. c AD (SCIM) after ~8 wks.
3. Pt. will report dec. spasticity (MAS: 2/4 → 1/4) after ~8 wks.
4. Pt. will improve mm strength in specified mm groups (MMT: 1/5 → 3+/5) after ~8 wks.
5. Pt. will improve feeling of sensation in (B) LE afte ~8 wks.
PT Interventions:
Pt. will be treated as an I.P. 3x/wk (M, W, F) & will be given the following tx:
1. Bed mob. exercises to promote mobility & indep. while preventing pressure ulcers x5
reps x2 sets
a. Supine ↔ scooting up
b. Supine ↔ sidelying on affected side
c. Supine ↔ sidelying on unaffected side
d. Supine ↔ bed sitting

e. Bed sitting ↔ wheelchair sitting
f. Bed/wheelchair sitting ↔ standing
2. PROME → AAROME on (R) LE; AROME on (B) UE & (L) LE to maintain joint mobility &
inhibit pain while preventing contractures x10 reps x2 sets
3. Stretching exercises to increase flexibility x15 sh x3 sets
4. PNF PROM → AAROM → AROM Rhythmic Initiation of (R) LE to initiate movement &
improve coordination & kinesthesia
a. D1 flex/ext
b. D2 flex/ext
5. Bobath Technique to inhibit hypertonicity
a. Reflex-Inhibiting Movement Pattern
6. Rood’s Technique to reduce spasticity
a. Gentle Rocking
b. Tendinous Pressure
7. Wheelchair mobility exercises to increase indep. x5 reps x2 sets
a. Turning
b. Going up/down incline
c. Going around s obstacles
d. Going around c obstacles
8. Functional ROM exercises c ADs to increase indep.
a. Dressing c dressing sticks
b. Toileting c wheelchair transfer
9. Gait training to improve ability to stand & prepare for walk x10 reps x2 sets
a. Stepping
b. Sitting heel raises
c. Sitting toe raises
d. Single leg raise
e. Tandem stance
f. Single leg stance
g. Single leg abduction
○ nature of pt.’s condition;
○ secondary complications;
○ role of PT in rehabilitation;
○ home exercise program including its importance;
○ pain management techniques;
○ proper bed positioning & turning;
○ proper body mechanics.

HEP:
Referrals:
● Orthotist - for ADs
● Neurologist & Orthopedist - for follow up check up care after PT treatment

EBP:
A. Title of the Study: Effects of moderate- and high-intensity aerobic training in ambulatory
subjects with incomplete spinal cord injury - a randomized controlled trial
B. Objectives of the Study: The main objective of this study was to investigate the effects
of a 12-week moderate- or high-intensity gait exercise intervention on physical capacity
and physical activity level in ambulatory participants with SCI, soon after discharge from
inpatient rehabilitation.
C. Methodology: The study design was a randomized controlled trial with 30 participants
randomized into 3 groups: MIT group, HIIT group, or a control group. The MIT group was
instructed to exercise 3x a week at 70% of HRmax, while the HIIT group was instructed
to exercise twice a week at 85–95% of HRmax. The control group received treatment as
usual. The outcome measures used were peak VO2 for physical capacity, 6MWT for
walking ability, total daily energy expenditure and daily number of steps for physical
activity levels.
D. Results: The results of the study showed that there were no statistically significant
difference in changes from pre- to the post-test between the groups in either peak VO2
or 6MWT; no significant effect of group on the changes in the physical activity levels in
TDEE and daily amount of steps.
E. Conclusions: Performing HIIT did not exhibit a greater increase in physical capacity and
activity levels than performing MIT or “treatment as usual” in ambulatory participants with
SCI. However, performing HIIT would exhibit a greater increase in physical capacity and
activity levels, compared to moderate-intensity training.
F. Relevance to Practice in the PT: Physical deconditioning can further exacerbate the
impact of the spinal cord injury and lead to an increased risk for chronic secondary
health complications. Even though physical activity levels are found to increase during
inpatient rehabilitation, it seems to decline after discharge. Physical activity levels seem
to play an important role in the fitness and health of persons with a SCI.
G. PEDro Scale: This study scored 9 out of 11 in PEDro scale.

1. Eligibility criteria was specified.
2. Subjects were randomly allocated to groups.
3. Allocation was concealed.
4. The groups were similar at baseline regarding the most important prognosticating
indicators.
5. There was no blinding of all subjects.
6. There was no blinding of all therapists who administered the therapy.
7. There was blinding of all assessors who measured at least one key outcome.
8. Measures of at least one key outcome were obtained from more than 85% of the
subjects initially allocated to groups.
9. All subjects for whom outcome measures were available received the treatment or
control condition as allocated or, where this was not the case, data for at least one key
outcome was analysed by “intention to treat”.

10. The results of between-group statistical comparisons were reported for at least one key
outcome.
11. The study provided both point measures and measures of variability for at least one key
outcome.
H. Reference: Wouda, M.F., Lundgaard, E., Becker, F. et al. Effects of moderate- and
high-intensity aerobic training program in ambulatory subjects with incomplete spinal
cord injury–a randomized controlled trial. Spinal Cord 56, 955–963 (2018).
https://doi.org/10.1038/s41393-018-0140-9

Appendix

S.Y. 2020-2021
GERIATRIC PHYSICAL THERAPY
DISCUSSION BOARD
SUBMITTED BY:
SUBMITTED TO:
July 2021

I. Effects of Physical Therapy on Well-Being of Aging Population
According to Guccione, aging is an inevitable process and decline occurs in all
tissues and systems. Nonetheless, it is possible to prevent the severity of some diseases,
and delay or possibly avoid the condition of frailty by modifying lifestyle. As inactivity is
considered a contributor to impairments and loss of function, physical activity is the most
potent tool of physical therapists to optimize function throughout the entire life span as
they utilize the principles applied in the physical stress theory to help guide the geriatric
patients in modulation of exercise to the appropriate level to achieve positive gains in
tissue functioning and homeostasis; while avoiding, both the tissue damages of
excessively high stress and the physiological decline of inadequately low stress. Physical
therapy improves balance and reduces fall risk through balance training; increases
strength through strength training; remediates frailty and improves function in frail
geriatric patients through task-specific or general conditioning exercises.
II. Most Common Debilitating Condition of Geriatric Patient and How the Physical
Therapy will Help
According to Guccione, the image above is the six most common chronic health
conditions (arthritis/musculoskeletal, heart/circulatory, vision/hearing, fractures/joint

injury, diabetes, and mental illness) that result in activity limitations among the geriatric
patients. These patients' increasing age is associated with increasing prevalence of
activity limitations, with the exception of mental illness. Physical therapists help these
patients not only through critical interventions like exercise and physical activity, but also
to provide health promotion opportunities. Physical therapists instruct exercises and
physical activities to achieve primary prevention and risk reduction for the development
of those conditions aforementioned.
III. Education and Prevention for Aging Population
Physical therapists educate the aging population regarding the risk factor
modification and prevention of diseases. According to Guccione, every physical therapy
plan should address prevention, starting with the initial examination and evaluation
regardless of clinical setting to optimize health and decrease functional limitations and
impairments. There are three levels of prevention:
● Primary: focuses on instilling healthy behaviors and reducing risk factors by
intervening prior to the biological signs of a disease.
● Secondary: the pathology or disease is present, but intervention is focused on
behavior modification to manage the disease. The goal is to control
progression of the disease, improve strength, avoid loss of function, and
minimize or eliminate pain.
● Tertiary: the patient has a disease and is also afflicted with dysfunction
associated with that disease including a decrease in activity tolerance and
function. The focus of tertiary prevention is on functional mobility and
education of signs of symptoms of the disease and the prevention of further
deterioration.
References:
Braddom, R. L., Chan, L., & Harrast, M. A. (2011). Physical medicine and rehabilitation.
Guccione, A. A., Wong, R. A., & Avers, D. (2012). Geriatric Physical Therapy. 3rd ed.

S.Y. 2020-2021
GERIATRIC REHABILITATION: RHEUMATOID ARTHRITIS
SOAP DOCUMENTATION
SUBMITTED BY:
SUBMITTED TO:
July 2021

GENERAL INFORMATION
Pt.’s Name: L.G.
Age: 65 y/o
Sex: F
Handedness: R
Occupation: Vegetable vendor
Referring MD: Dr. E.D.
Referring Unit: FEU-NRMF O.P. Dept.
Rehabilitation MD: Dr. J.Y.
Rehabilitation Unit: FEU-NRMF R.U.
Date of Referral: July 10, 2021
Medical Dx: Early Stage Rheumatoid Arthritis
Informant: Pt.
S:
HPI:
Pt.’s condition started ~2 mos. PTIE when pt. suddenly felt morning stiffness on (R) fingers for
~1 hr, ignored it & went to work. The next week, when pt. was selling vegetables & felt a
localized, intermittent, dull, aching pain (PS: 6/10) on (R) fingers c red & warm swelling; pain
was aggravated when moving (PS: 6/10 → 7/10); alleviated by resting & applying cold compress
to relieve pain & swelling (PS: 6/10 → 0/10). Pt. thought those were only signs of aging. 2 days
after, pt. went back to work s any complaints. ~1 mon. PTIE, pt. reported fatigue while working
c the same type of pain (PS: 6/10) on (R) fingers & wrist. Pt. thought it was d/t overwork & went
home to rest; took an Ibuprofen for pain relief (PS: 6/10 → 0/10). The next week, pt. reported to
have a low-grade fever (38.3o
C), malaise & loss of appetite. Pt. took Paracetamol, rested & woke
up c morning stiffness on (B) fingers & wrist for ~1 hr. 2 days after, pt. went back to work. ~1
wk. PTIE, pt. c/o pain (PS: 7/10) on (B) fingers & wrists c swelling resulted in difficulty
gripping, eating, brushing, dressing, & carrying boxes of vegetables. Pt. then decided to have it
checked at FEU-NRMF Hospital. Pt. was attended by Dr. E.D. who prescribed medications (see
present medications) & requested for ancillary procedures (see ancillary procedures) that led to
mdx of Early Stage Rheumatoid Arthritis. ~2 days PTIE, pt. was referred to FEU-NRMF R.U.
under Dr. J.Y. as an O.P. for further evaluation & early rehabilitation.

(B) Wrists & Hands
X-Ray in Oblique &
Anterolateral View
July 12, 2021
No distinctive changes
[-] Osteoporosis
FEU-NRMF Hospital
Blood Test [+] ↑ RF = 15 IU/mL
[+] ↑ Anti-CCP = 21 u/mL
[+] ↑ ESR = 22 mm/hr
[+] ↑ CRP = 11 mg/L
[-] HLA-DR4
FEU-NRMF Hospital
(B) Wrists & Hands
T1-Weighted MRI in
Coronal View
[+] Synovitis on (B) MCP jts.
of 1st-5th finger, PIP jts. of
2nd-5th finger, & wrists jts.
FEU-NRMF Hospital
Losartan 50 mg qd HTN Upper respiratory
infections, dizziness,
stuffy nose, back pain,
diarrhea, fatigue, low
blood sugar, chest pain,
high/low blood pressure
Naproxen 500 mg qd Inflammation,
swelling, stiffness,
joint pain
GI bleeding, ulcers,
nausea, diarrhea,
indigestion, rash,
dizziness, drowsiness,
slowed blood clotting,
tinnitus, fluid retention
Methotrexate 7.5 mg qw Joint pain, fatigue,
redness, swelling
Decreased appetite,
abdominal discomfort,
nausea, diarrhea, skin
rash, itching, oral ulcers,
photosensitivity,
infection, unusual
bleeding/bruising
Etanercept 50 mg qw Joint pain, stiffness,
inflammation
Increased risk of serious
infection, lymphoma and
other malignancies

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