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Saint Mungo's Hospital - IRD Department

Physical Therapy Daily Note

Inpatient Rehabilitation (Setting 2)

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NAME: James Krum 

MRN: H07311980

AGE: 64 year old               DOB: 12/25/1960

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SUBJECTIVE:

Patient states, “I want to walk again today.” Patient reports low back pain 2/10, denies need for pain medication. Specifically denies pain to left foot/ankle or lower extremity after use of electrical stimulation yesterday. He’s agreeable to physical therapy and reassessments and is alert/oriented x 4. 

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Precautions: fall risk 

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OBJECTIVE:

Reassessments

  • Strength

    • Right lower extremity 

      • Hip flexion: 5/5

      • Hip abduction: 4+/5

      • Knee extension: 5/5

      • Knee flexion: 5/5 (tested in sitting)

      • Ankle dorsiflexion: 5/5

      • Ankle inversion: 5/5

      • Ankle eversion: 5/5

    • Left lower extremity 

      • Hip flexion: 2-/5

      • Hip abduction: 2-/5

      • Knee extension: 2+/5

      • Knee flexion: 1/5 (tested in sitting)

      • Ankle dorsiflexion: 1/5

      • Ankle inversion: 1/5

      • Ankle eversion: 1/5

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  • Spasticity

    • Right lower extremity: within normal limits

    • Left lower extremity

      • Hip adductors: MAS 1+

      • Knee extensors: MAS 2

      • Ankle plantarflexors: MAS 2

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  • Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Scores:

  • Bed mobility

    • Roll left and right: 3 (helper does less than half the effort)

      • Comments: requires minimum assistance to roll to right, standby assistance for locating bed rail and verbal cuing to roll to left 

    • Supine to sit: 3 (helper does less than half the effort)

      • Comments: utilizes right lower extremity to assist left lower extremity in bed, minimum assistance at trunk

    • Sit to supine: 3 (helper does less than half the effort)

      • Comments: utilizes right lower extremity to assist left lower extremity in bed, minimum assistance at trunk

  • Transfers

    • Sit to stand: 3 (helper does less than half of the effort)

      • Comments: minimum assistance of 1 for forward weight shift and to block left knee when pulling to stand at grab bar or railing, when pushing to stand from wheelchair arm rest requires moderate assist of 1

    • Chair/Bed-to-chair transfer: 2 (helper does more than half the effort)

      • Comments: squat pivot transfer wheelchair to bed (level surface) with right upper extremity reaching for bed railing and armrest removed with moderate assist of 1

    • Car transfer: safety concerns/unable to attempt

  • Ambulation

    • Walk 10 feet: 1 (helper does all of the effort or the assistance of 2 or more people is required)

      • Comments: ambulates along railing with right upper extremity support, left upper extremity placed in Givmohr sling, left posterior leaf spring ankle foot orthosis donned with tubigrip over forefoot of shoe. Requires maximum assistance for left lower extremity advancement, maximum assistance for left knee block during stance to prevent buckling, and moderate assistance at trunk throughout gait cycle. Rehab aide positioned posteriorly providing wheelchair follow and contact guard assistance, occasionally facilitating with lateral weight shift bilaterally. Maximum tolerance x 12 feet. 

    • Walk 50 feet with 2 turns: safety concerns/unable to attempt

    • Walk 150 feet: safety concerns/unable to attempt

    • Walk 10 feet on uneven surfaces: safety concerns/unable to attempt

  • Stairs

    • 1 step (curb): safety concerns/unable to attempt

    • 4 steps: safety concerns/unable to attempt

    • 12 steps: safety concerns/unable to attempt

  • Wheelchair Mobility

    • Wheels 50 feet: 4 (helper provides verbal cues and/or steadying assistance)

      • Comments: requires cuing to locking/unlocking left wheelchair brake 50% of the time, verbal cues for attending to left side as patient has tendency to deviate toward his left in hallway, patient utilizing right upper and lower extremity for propulsion.

    • Wheels 150 feet: 4 (helper provides verbal cues and/or steadying assistance)

      • Comments: requires cuing to locking/unlocking left wheelchair brake 50% of the time, verbal cues for attending to left side as patient has tendency to deviate toward his left in hallway, patient utilizing right upper and lower extremity for propulsion.

  • Other

    • Picking up object: safety concerns/unable to attempt

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  • Outcome Measures

    • Postural Assessment Scale for Stroke: 15/36

    • Berg Balance Test: 5/56

    • Timed wheelchair propulsion: requires 1 min 5 seconds to wheel 50 feet without turns, for speed of 0.23 m/sec

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Treatment

  • Gait training: gait training along railing with right upper extremity support, left upper extremity placed in Givmohr sling, left posterior leaf spring ankle foot orthosis donned with tubigrip over forefoot of shoe. Requires maximum assistance for left lower extremity advancement, maximum assistance for left knee block during stance to prevent buckling, and moderate assistance at trunk throughout gait cycle. Rehab aide positioned posteriorly providing wheelchair follow and contact guard assistance, occasionally facilitating with lateral weight shift bilaterally. Maximum tolerance x 12 feet, x 7 feet, x 12 feet increments with seated rest breaks in between. 

  • Neuromuscular re-education: functional electrical stimulation to left quadriceps (current 29 mA, pulse width 350 us, frequency 40 hz), hamstrings (current 19 mA, pulse width 350 us, frequency 40 hz), anterior tib (current 63 mA, pulse width 250 us, frequency 40 hz), and gastrocnemius (current 46 mA, pulse width 250 us, frequency 40 hz) completing sit to stands at hemi-bar with mirror providing visual cues for postural alignment, 3 sets of 8 reps with seated rest breaks in between. Patient able to verbalize sensation of stimulation at all electrode sites during application. Mild erythema following removal of electrodes

 

Electronic signature: Susan Lockhart, DPT 10/20/2024

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