PT Initial Evaluation: Spinal Cord Injury

Pamantasan ng Lungsod ng maynila

(University of the City of Manila)

Gen. Luna, Intramuros, Manila

Physical Therapy Initial Evaluation

General Information:

Pt. Name: A.D.

Age: 23

Sex: Male

Address: JP Burgos St., Antipolo, Quezon City

Civil Status: Single

Handedness: Right

Occupation: Call center agent

Religion: Catholic

Referring Unit: Phil. Orthopedic Center

Referring Doctor: Dr. Torres

Date of Referral: June 25, 2007

Rehab Unit: Phil. Orthopedic Center PMRD

Rehab Doctor: Dr. Basibas

Date of IE: July 3, 2007

Informant/Reliability: Patient/Good

Dx: Incomplete Traumatic SCI at T11-T12 c SL T10-T11 level 2º knife stab

HPI:

Present condition started 5 wks PTIE when pt was hold-upped and stabbed at his mid back on his way home in Frisco. He shouted for help but he suddenly experienced inability to move his body then lost consciousness. He was rushed by concerned bystanders to POC, was admitted and was given immediate first aid. He underwent an X-ray (see ancillary procedures) which revealed a partial cut at his spinal cord. He was told that he lost consciousness for the next 18 hrs and upon regaining consciousness, he felt paralysis at his lower portion of trunk and ® LE, absence of sensation at his lower trunk, abdominal area and (L) LE, slight weakness at his (L) LE and slight decrease of sensation at his ® LE. Pt was confined at the IPD spinal ward of POC for the next 1 week before he was transferred at the hospital’s IPD rehab ward where he stayed for the next 3 weeks. He received bed side PT which included PREs of his (B) UE, PREs of his (L) LE, PROMEs of his ® LE, ES of his ® LE, stretching of ® LE, proper bed positioning, sitting → standing B/T training and gait training c BAC. He was able to stand c +1 assist at trunk and still requires use of PKS at ® LE and knight taylor brace during ambulation c BAC a he was discharged from the hospital but was referred for PT Rehab on an OPD set-up. At home, pt continued c exercises taught to him at the hospital.

At present, pt will start PT Rehabilitation at POC-OPD. Delay on start of OPD PT tx was 2º delayed arrival of fabricated KAFO.

Drug Hx:

Meds	Dosage	Frequency	Year	Indication
Vit-B		od	2007-present	Supplement
Iron		od	2007-persent	Supplement
Ca supplements		od	2007-present	Supplement

Note: All meds were taken orally and some details were unrecalled by the pt

Ancillary Procedures:

Procedure	Date	Results
X-ray of the whole body (post, lat and ant views)	June 2, 2007	No pertinent results at bony structures
CBC	June 2, 2007	Unrecalled results

PMHx:

(-) Trauma at head, back and (B) LE

(-) Htn

(-) Heart Disease

(-) Pulmonary Disease

(-) Allergies / sensitivities

FMHx:

Father Mother

Htn ü ü

Heart Disease ü cause of death – May, 2004

Cataract ü ü

DM û û

TB û û

CVA û û

Brothers are allergic to fur

PSEHx:

◦ Type B personality

◦ Youngest of 3 siblings

◦ Smoker (Smokes 5-8 sticks of cigarette per day)

◦ Alcoholic beverage drinker (at least 5 liters of beer/week)

◦ Hobbies: Playing and listening on his PSP, enjoys party gimmicks and surfing the internet.

◦ Financial status: Good. Pt is still paid by the company he works at and will still be paid for this month a he could completely return to work and family members also aid on his expenses p the incident.

◦ Primary Care Giver: can take care of himself as but is assisted by his brother or mother during LE dressing and transfers.

◦ Pt is mobile inside the house and as well as in nearby areas in their house c use of BAC

◦ Has only 1 family car and usually commutes for work taking several jeepney rides, MRT rides and bus rides to his office in Makati from QC and back.

◦ Lives c his family in a bungalow type of house and has 2 stair steps at the entrance door

◦ Room distances: bed room – bath room = ~ 2 m, bed room – living room = ~8 m, bed room – kitchen & dining area = ~ 10 m

◦ Pt’s bed ht = ~ 1.5 ft and has a firm mattress on it.

S:

C/c: “nahihirapan ako makatayo at makalakad ng mag-isa e, wala kasing lakas itong kanang paa ko e, pero sabi naman ni doc pwede pa naman e”

PT Translation: pt c/o difficulty to stand and ambulate independently

Pt. Goal: To be able to stand and walk independently c or s AD.

O:

VS:

	A	during	P
BP	120/90	120/90	110/90
PR	69bpm	80bpm	72bpm
RR	15cpm	17cpm	16cpm
T	36.5 °C	37°C	37°C

OI:

Mobile c BAC while wearing PKS at ® LE and knight taylor brace

Mesomorph

Alert, coherent, cooperative

(+) PKS at ® LE and knight taylor brace

(+) Postural deviation

(+) Gait deviation

(+) minimal atrophy at his ® LE

(+) stab scar at his back

(-) erythema on all exposed body parts

(-) deformities on (B) UE and LE

(-) pressure sores on exposed body parts

(-) swelling on all exposed body parts

Palpation:

Normothermic on all exposed body parts

(+) grade 1 pitting edema at ® LE

(-) tenderness

(-) subluxation

Neurologic Evaluation:

ASIA Classification: Monoplegia 2° to SCI incomplete ASIA B c motor level T1 ® and sensory level for pin prick and light touch at T9 at (L) c skeletal level at T9-T10 2° knife stab

Motor

	R	L
C5	5	5
C6	5	5
C7	5	5
C8	5	5
T1	5	5
L2	0	5
L3	0	5
L4	0	4
L5	0	4
S1	0	5
Total :	25	44

Motor Score: 69/100

Sensory

Light Pin

touch prick

	R	L	R	L
C2	2	2	2	2
C3	2	2	2	2
C4	2	2	2	2
C5	2	2	2	2
C6	2	2	2	2
C7	2	2	2	2
C8	2	2	2	2
T1	2	2	2	2
T2	2	2	2	2
T3	2	2	2	2
T4	2	2	2	2
T5	2	2	2	2
T6	2	2	2	2
T7	2	2	2	2
T8	2	2	2	2
T9	2	2	2	2
T10	1	1	2	1
T11	1	0	2	0
T12	1	0	2	0
L1	1	0	1	0
L2	1	1	1	1
L3	2	1	1	1
L4	2	1	2	1
L5	2	1	2	1
S1	2	1	2	1
S2	2	1	2	1
S3	2	1	2	1
S4-S5	2	2	2	2
	51	42	53	42

Sensory Score:

Pin prick: 95/112

Light touch: 93/112

Tone assessment:

Score	Modified Ashworth Scale
0	No increase in muscle tone
1	Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension.
1+	Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the reminder (less than half) of the ROM (range of movement).
2	More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved.
3	Considerable increase in muscle tone passive, movement difficult.
4	Affected part(s) rigid in flexion or extension.

Normotonic on (B) UE and (L) LE and grade 1+ spasticity on ® LE towards hip abduction, knee flexion & extension and ankle dorsiflexion.

Superficial Sensation

STD Used: Pinch for pain and light finger stroke for light touch taken via dermatomal distribution

Findings: Intact sensation at C2-T9 dermatomal distribution for (B) sides and L3-S5 at ® LE.

Decreased sensation for (L) T10-S3 dermatomes and ® T10-L1 for light touch and L1-L3 for pain.

Significance: Precaution for thermal agents.

Deep Sensation:

Proprioception

Findings: Impaired position sense at the level of ® knee

Kinesthesia

Findings: Impaired movement sense at the level of ® knee

Significance: Precaution on tx specially for gait training

Cortical sensations:

Tactile Localization

Findings: Impaired sensation. Pt was unable to accurately localize the points where therapist’s finger was placed on (B) LE but > inability to localize at (L) LE

MSR:

(R) (L)

Legend:

0 - areflexia

+ - hyporeflexia

++ - normoreflexia

+++ - hypereflexia

++++ - clonus

Findings: Normoreflexive for (B) UE and (L) LE, hyperreflexive on ® patellar reflex and (+) clonus for ® achilles reflex.

Significance: UMN affectation.

Pathologic Reflexes:

Babinski

Findings: (+) on (B) LE

Ankle Clonus

Findings: (+) on (R) LE

ROM:

Major joints of (B) UE and LE were grossly assessed and are WNL actively and passively done pain-free and has N end-feel except for the following joints which were noted with decreased ROM

Joint Motion	N Range	AROM	PROM	Difference A/P	End-feel
® hip extension	0-30º	0	0-30º	30º/0º	Firm
® hip flexion	0-120º	0	0-90º	120º/30º	Empty
® knee extension	135-0º	0	135-0º	135º/0º	Hard
® knee flexion	0-135º	0	0-135º	135º/0	Firm
® ankle dorsiflexion	0-20º	0	0-10º	10º/0º	Firm
® aknle plantar flexion	0-50º	0	0-50º	50º/0º	Firm
® foot eversion	0-15º	0	0-15º	15º/0º	Firm
® foot inversion	0-35º	0	0-35º	35º/0º	Firm

Findings:

◦ Absence in AROM 2º paralysis in ® LE.

◦ Limitation in passive ® hip flexion 2º precaution for low level SCI

◦ (+) tightness at ® plantarflexors

◦ (+) Grade 1+ spasticity during ® knee extension and ankle plantarflexion

Significance: Absence of AROM can limit gait training.

MMT:

All major myotomes of (B) UE and LE were assessed and graded 5/5 except for:

® L2 to S1 graded 0/5

® Trunk elevator, flexor and rotator are graded 2/5

® Hip flexors, abductors, adductors, knee flexors and toe flexors are also graded 0/5.

Significance: mm paralysis can affect gait training and endurance of pt during tx.

Anthropometric Measurements:

Muscle Bulk Measurements

LE landmark	®	(L)
4 in. above medial tibial plateau	46 cm	47.2 cm
2 in. above medial tibial plateau	41 cm	41.8 cm
4 in. below medial tibial plateau	29 cm	29.6 cm
2 in. below medial tibial plateau	34 cm	35 cm

Findings: Minimal mm bulk difference between LE.

Limb Girth Measurement

Landmark	(R) LE	(L) LE
Metatarsal heads	25.8 cm	24 cm
2 in. above metatarsal heads	28 cm	25.6 cm

Findings: ~ 2 cm difference between 2 feet shows significant edema at ® foot

Special test:

(+) Hamstring Tightness Test

Finding: Pt has tight hamstrings on (B) LE

(+) Beevor’s Sign

Finding: Umbilicus moved upward during test

(-) Thomas Test

Finding: Pt has no tight iliopsoas on (B) LE

Functional Assessment:

Balance/Tolerance Testing:

Legend for Balance:

N - can assume, maintain, wt shift and can be challenged

G - can assume, maintain and wt shift

F - can assume and maintain

P - can assume

NIL - can’t do any

Legend for Tolerance:

N - 46 mins.–1 hr

G – 31-45 mins.

F – 16-30 mins.

P – 1-15 mins.

0 - none

Findings: Sitting B/T: N/N

Standing B/T: Fair/Poor

Note: Pt was using PKS at ® LE and knight taylor splint between parallel bars.

Significance: For goal management and tx plan.

Postural Analysis:

All parameters of posture are level and present except:

Anterior/posterior View

◦ (B) shoulders are elevated c (L) shoulder higher

◦ trunk slightly listed to (L)

◦ (L) pelvis higher than ®

◦ ® hip ER

◦ ® foot supination

Note: Postural analysis was taken between parallel bars while wearing PKS at ® LE and knight taylor splint

Findings: Pt has postural deviations 2° ® abdominal and LE weakness.

Significance: Goal setting and tx plan.

Gait Analysis:

Pt was assessed while walking c use of BAC using a 3 pt-gait.

Note: Pt was using PKS at ® LE and knight taylor splint during gait analysis

ADL Analysis:

Pt is independent on ADLs requiring use of (B) LE such as bed mobility, feeding, self care, grooming and UE dressing but experiences:

◦ moderate difficulty c standing and ambulation

◦ moderate difficulty c transfers such as bed – chair, chair – bed, floor – toilet bowl, toilet bowl – floor, floor – bed and bed – floor.

◦ minimal difficulty c LE dressing

Significance: Tx plan and goal setting

A:

Dx: Incomplete Traumatic SCI at T11-T12 c SL T9-T10 level 2º knife stab

PT Impression: Brown Sequard syndrome c ASIA Classification of Monoplegia 2° to SCI incomplete ASIA B c motor level T1 ® and sensory level for pin prick and light touch at T9 at (L) c skeletal level at T9-T10 2° knife stab

Rehab potential: Good. Pt has a low SCI level and no complications on affected extremities, had an early start of PT rehabilitation and is very much enthusiastic about his therapy.

Goal: Get the pt to stand and walk independently c use of KAFO at ® and lofstrand cructch.

Problem List:

1. ADL difficulties:

◦ moderate difficulty c standing and ambulation

◦ moderate difficulty c transfers such as bed – chair, chair – bed, floor – toilet bowl, toilet bowl – floor, floor – bed and bed – floor.

◦ minimal difficulty c LE dressing

2. Paralysis on ® LE, lower abdominal area and low back.
3. Standing B/T: Fair/Poor
4. Minimal atrophy of ® LE mm
5. Decreased AROM 2° mm paralysis
6. Impaired sensation on (B) LE and abdominal area
7. ® ankle plantarflexor tightness
8. Postural deviations
9. Gait deviations
10. Gr 1 pitting edema at ® foot
11. Grade 1+ spasticity at ® LE towards hip abduction, knee flexion & extension and ankle dorsiflexion.

LTG: In 1 month tx session pt will:

1. Be able to ambulate properly c use of KAFO at ® LE and lofstrand crutch.

STG: In 2 weeks tx session pt will:

1. (?) Have an improvement on pt’s mm grade on ® LE mm groups of at most 1 MMT grade increments.

2. (?) Have an increased AROM on ® LE motions of at least 10º on motions of all jts of ® LE.

3. Have an elimination of Gr 1 pitting edema at ® LE

4. Have elimination of (R) ankle plantarflexor tightness.

P: Pt will be treated thrice a week as an out-pt.

Modalities:

1. US on (R) heelcord, bighead, 1MHz, continuous, c intensity of 2w/cm² x 15 mins prior to exercise.
2. ES on (R) quadriceps, hamstrings, gastrocsoleus, tibialis anterior, toe flexors and extensors x 90 contractions on each mm or mm groups.

Exercises: Pls remove knight taylor splint and PKS or KAFO when available

1. GPS of (R) hamstrings and heel cords x30 secs hold x 5 reps x 1 set simultaneous c PREs of (B) UE c 4 lb dumbbell, 10 reps x 1 set, all motions.

2. PROMEs on ® LE, 10 reps x 1 set, all motions.

3. PREs of (L) LE using 3 lbs ankle weights x 10 reps x 1 set, all motions.

4. Strengthen ® quadratus lumborum through hip elevation exercises (mm settings) x 7 secs hold x 10 reps x 1 set → in standing, hip elevation c ankle wts 7 secs hold x 5 reps.

5. Train pt proper diaphragmatic breathing.

6. Standing B/T training and gait training c KAFO.

Pre-requisite: Teach pt proper donning and doffing of KAFO.

KAFO Training: s knight taylor splint

1. Standing B/T between parallel bars while wearing KAFO at ® LE c single hand support → 2 finger support → hands free or SBA x 15 mins for 3 tx sessions then transfer outside parallel bars to also progress c tolerance and decreased guarding from CGA → SBA → fully independent.
2. Train pt c proper ambulation using BAC c 3 pt gait (c knight taylor splint) then eventually removing knight taylor splint then shifting to lofstrand crutch.

Home Instructions:

1. Advice pt to continue exercises taught at clinic at home.
2. Advice pt to elevate ® LE to eliminate the edema or passively do ankle pumping at ® LE
3. Advice pt to maintain proper diaphragmatic breathing

Britanico, Maria Socorro C.

Adolfo, Dominic

PT Intern 2008