INITIAL EVALUATION

General Information
Pt.’s Name: V.C.
Age: 19
Sex: M
Address: Tabok, San Juan, La Union
Civil Status: Single
Handedness: Right
Occupation: N/A
Religion: Roman Catholic
Referring Unit: IPD
Referring MD: Dr. O
Rehab MD: Dr. T
Date of Consultation: May 21, 2016
Date of Referral: May 31, 2016
Date of IE: March 2, 2017
Dx: Intraspinal, Intradural, Intramedullary tumor, incomplete traumatic SCI at C7-T1

S: (Informant/Reliability: Patient/Good)
C/C: Pt c/o inability to move B legs

HPI:
Present condition started last May 13, 2016 when pt. felt sudden decrease in sensation (80%)
and intermittent numbness from trunk at the level of the last rib to B legs as well as difficulty in moving B
legs. During this time, pt. can stand (~ 45’) and walk (~20’ on a leveled surface) but with difficulty and
needs some assistance from pt’s father, aunt and helper. Pt observed his condition while staying at home
for a week. And pt observed that the symptoms worsen within a week of observation. The pt’s sensation
continued to gradually decrease up to 50% and the duration on how long the patient can stand (~30’)
and walk (~10’) has decreased since the onset of symptoms and is assisted by his father and a house
helper.

May 21, 2016, the pt was brought to LMC by his father via a car for ~20’ of traveling time. Upon
arrival at the hospital, pt was given w/c and directly went to Dr. O in the OPD department. Dr. O
requested an MRI procedure for the patient (see Ancillary Procedure). After finding out that the pt has
tumor on the spine, Dr. O adviced the pt to undergo surgical procedure to remove the tumor p a week.

Within the week ā the surgery, the symptoms noted does not improve nor worsen as stated by
the by the pt.

May 28, 2016, Pt undergone surgical procedure by Dr. O to remove the tumor on his spine
(duration of procedure unrecalled). Pt woke up 4 hrs p surgery in a supine position. Pt noted that the
sensation he felt was the same as compared to the sensation felt ā the surgery. Pt cannot stand nor walk.
Although pt. can move within his bed but needs assistance. Pt was confined in a private room and was
given IV administration and a catheter (type of catheter unrecalled) within the week of stay.

May 31, 2016, while pt is still under observation as an in-pt, Dr. O assessed the pt’s reflexes,
sensation and m strength. Dr. O noted that pt’s reflexes are abnormal, pt has m weakness and decreased
sensation. Subsequently, pt was advised to undergo PT treatment as an in-pt.

Within the week inside the hospital, the pt had 2 tx session but there were no changes noted by
the pt.
 The PT POC are as follows:
ES on B LE x 20’
PROMES on B LE x 10 reps x 1 set  AAROME
AROMEs on B UE x 10 reps x 1set
PREs on B UE x 10 reps x 1 set

June 4, 2016, pt was discharged. Pt was advised to use manual w/c. Pt is completely indep and is
assisted by pt’s father and house helper.

June 5, 2016, pt started using manual w/c (type of w/c unrecalled) as prescribed by Dr. O. Pt can
self-propell his own w/c but needs some assistance when transferring.

June 6, 2016, PT tx sessions was resumed as an out-pt at LMC PT Rehab Center.

July 2016, pt noted that the m strength on B legs increased.

August 2016, pt stated that he can transfer from bed to chair indep.

November 2016, pt can assume quadruped position for ~10 mins

January 2017, pt can stand for inside the parallel bar for ~ 15’

At present, pt cannot still move his B legs and cannot walk on his own. Pt’s ADL has vastly
improved ever since, the pt is able to move around the house, self-care and transfer c mod difficulty.
However the pt is still not able to move his B feet as well as the sensation on B LE is still not recovered.

ANCILLARY PROCEDURE DATE/PLACE RESULT

(+) intraspinal, intradural,

MRI May 21, 2016/ LMC intramedullary tumor in C7-
T1 level

PMHx:
(+) Surgeries (see table below)
(+) Meningitis (2015)
(-) Htn
(-) Heart Dse
(-) Pulmonary Dse
(-) Allergies/ sensitivities

Surgeries:
Date/Place
2011 (exact date unrecalled)/LMC
2015 (exact date unrecalled)/LMC
2015 (exact date unrecalled)/LMC
May 2016(exact date unrecalled)/LMC
Procedure
Cyst resection on spine (exact name of procedure
unrecalled)
Cyst resection on spine, spinal shunt implantation
(exact name of procedures unrecalled)
Spinal shunt removal (exact name of procedure
unrecalled)
Cyst resection on spine (exact name of procedure
unrecalled)

FMHx:
 Mother Father
Breast CA (+) (-)
Ovarian CA (+) (-)
HTN (-) (-)
Heart Dse. (-) (-)

Note: Pt mother died d/t breast and ovarian CA

PSEHx:
Pt was a smoker 0.45 pack/year and social alcohol drinker when he was 14 y/o until the onset of
the symptoms of his present condition.

Pt. has an active lifestyle. Pt regularly perform exercises by himself to strengthen his upper body
such as sit-ups and self-stretching which varies in duration. Pt moves around their house on his own via
wheelchair. Pt has a type B personality and has a very hopeful perception in life who enjoys watching
television and surfing the internet. Pt lives in a bungalow type of house c his father, aunt and a helper.
Pt’ primary care giver is his father and a helper. Pt has good financial status and is supported by his
father. Pt sleeps on a firm mattress.

Home Dimensions
Main door  bedroom: ~15m
Bedroom  toilet: ~ 3 m
bedroom to dining area/ kitchen: ~11m
bedroom to toilet: ~5m
bed ht: ~1.5 ft

Goals: Pt’s goal is to stand and walk indep

O:

VS: Note: VS was taken p the tx session c 5’ rest

BP= 100/80 mmHg

PR= 78 bpm
RR= 17 cpm
T°= 36.6 ° C

OI: Manner of arrival: w/c bound

Mental status: Alert / Coherent / Cooperative
Physique: Mesomorph
(+) surgical scar on upper back area (see scar assessment)
(+) Bony deformities: (-) C7 spinous process
(+) Abdominal Binder
(+) Postural Deviation (see PA)
(-)Trophic skin changes
(-) Facial Asymmetry
(-) Swelling
(-) Atrophy
(-) Pressure Sore
(-) Braces
(-) Catheter
PALPATION:
Thermal assessment: normothermic on all exposed body parts
Tone assessment: normotonic on B UE/LE m except hypertonic bilat gastrocnemius m and bilat upper
trapezius
(+) m spasm on B upper trapezius
(-)Tenderness
(-) subluxation
(-) edema

RESPIRATORY ASSESSMENT:
Breathing Pattern
Findings: Diaphragmatic Breathing
Significance: Expansive and Efficient Breathing

Cough
Findings: Functional
Significance: intact phrenic n

Chest Expansion Measurement

Full Inspiration Full Expiration Difference

Level of Axilla 89.5 cm 88.9 cm 1.4 cm
Level of Xiphoid Process 67.4 cm 66.6 cm 1.2 cm

Findings: Normal Chest Expansion

Significance: To rule out accessory muscle breathing

Tone Assessment: Normotonic on (B) UE/LE c grade 2 m tone except for bilat gastrocnemius and bilat
upper trapezius m c grade 3 m tone
Significance: Hypertonic on gastrocnemius 2 to spasticity and hypertonic on upper trapezius 2 to m
spasm

Legends:
1- No Response
2- Decrease Response
3- Normal Response
4- Exaggerated Response
5- Sustained Response

SCAR ASSESSMENT
` Findings:
Shape: Irregular
Size: 20 cm
Depth: 1.5 cm
Sig: for baseline data
SPASTICITY ASSESSMENT
Modified Ashworth Scale
1- No increase in muscle tone
2- Slight increase in muscle tone manifested by catch and release or by minimal resistance at
the end range of ROM when the affected part is moved in flexion or extension
1+- Slight increase in muscle tone manifested by catch followed by minimal resistance
throughout the remainder (less than half) of ROM
3- More marked increase in muscle tone through most of the ROM but affected parts are easily
moved
4- Considerable increase in muscle tone, passive movement is difficult
5- Affected part is rigid in flexion or extension

Findings: Grade 3 spasticity on B gastrocnemius

Significance: 2 to UMNL

NEUROLOGICAL EVALUATION:
ASIA CLASSIFICATION:

MOTOR:

(R) (L)
C5 5 5
C6 5 5
C7 5 5
C8 5 5
T1 5 5
L2 1 1
L3 1 1
L4 1 1
L5 1 1
S1 1 1
TOTAL 30 30

MOTOR SCORE: 60/100

SENSORY:
LIGHT TOUCH PIN 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 1 1 1 1
T4 1 1 1 1
T5 1 1 1 1
T6 1 1 1 1
T7 1 1 1 1
T8 1 1 1 1
T9 1 1 1 1
T10 1 1 1 1
T11 1 1 1 1
T12 1 1 1 1
L1 1 1 1 1
L2 1 1 1 1
L3 1 1 1 1
L4 1 1 1 1
L5 1 1 1 1
S1 1 1 1 1
S2 1 1 1 1
S3 2 2 2 2
S4-5 2 2 2 2
TOTAL 38 38 38 38

PIN PRICK: 76/112

LIGHT TOUCH: 76/112

Findings: Paraplegia 2 to incomplete SCI, ASIA C c T1motor level and sensory level for pin prick and light
touch T2
Significance: 2 to incomplete traumatic SCI at C7-T1

SUPERFICIAL SENSATION:
STD Used: pin for pain, brush for light touch and thumb for deep P
Findings: intact sensation on bilat C2-T2 dermatomal distribution and 50% decreased sensation
for pain, light touch and deep pressure on T3-S2 dermatomal level on B sides
Significance: Sensory deficit 2 to spinothalamic tract affectation

DEEP SENSATION:
Findings: Intact proprioception and kinesthesia on B UE/LE
Significance: intact dorsal column lemniscal pathway

CORTICAL SENSATION:
Findings: Intact stereognosis, barognosis, graphesthesia, and 2-pt discrimination
Significance: intact dorsal column lemniscal pathway

DTR:
Findings: Normoreflexive on B UE, hypereflexive on B patellar reflex and B Achilles reflex
L R
+++ +++
Legend:
++ ++ 0 areflexia
+++ +++
+ hyporeflexia
++ ++ ++ normoreflexia
+++ hyperreflexia
Significance: 2 to UMNL
++++ clonus
PATHOLOGIC REFLEXES:
Findings:
(+) Babinski
(-) Chaddock
(-) Schaeffers
(-) Oppenhiem
(-) Gordons
(-) Gondas/Stransky
Significance: 2 to UMNL

ROM:
Findings:
All major joints of (B) UE are WNL actively and passively done, pain free c N end-feel
All major joints of (B) LE are WNL passively done, pain free c N end-feel

AROM PROM DIFFERENCE N ROM

MOTION END-FEEL
R L R L R L
Ankle 0-20
0 0 0-9 0-10 0-10 0-11 Firm
Dorsiflexors
Ankle 0-50
0 0 0-36 0-44 0-14 0-6 Firm
Plantarflexors

Note: Absent PROM on all major jts. of B LE and trunk

Sig: LOM 2 to spasticity on B heel cords

MMT:
Findings: All major m of B UE are assessed and grossly graded 5/5 except for the major m of B LE which
are grossly graded 1/5 and trunk which is graded 3/5
Significance: 2 to UMNL

Special Tests
Findings:

(-) Galleazi

(-) Silfverskiold

(-) Thomas test

(-) Popliteal angle test

(-) Ely’s test

 (-) Phelp’s gracilis test

(-) Staheli’s test

Sig: for baseline data

Sitting Standing Balance-Tolerance

Findings: Note: Pt was assessed in standing inside the parallel

Balance Tolerance Legend: Assume Maintain Weight- Challenge

(mins.)
Shif
Sitting G 27 ‘ 0 - - - -
Standing 0 15 ‘ P + - - -
F + + - -
G + + + -
N + + + +

Sig: 2 weak LE m

Postural Analysis
Findings: Postural landmarks are assessed in ant., post., and lat. views in standing position inside the //
bars and are found to be N except for:
Lateral View: increased lumbar lordosis
Sig: compensatory posture d/t LE m weakness

Gait Assessment:
Note: Pt is non- amb

Functional Assessment:

ADL GRADE
FIM LEVELS
Self- Care
Eating 7 No Helper
Grooming 7
7 - Complete Ind.
Bathing 7
Upper Garment Dressing 7 6 - Mod Ind.
Lower Garment Dressing 6
5 - Min Ind. (subject 100%)
Toileting 7
Sphincter Control 4 - Modified Dep, Min. Asst (75%)
Bladder Mx 7 3 - Modified Dep, Mod. Asst (50%)
Bowel Mx 7
Mobility 2 - Complete Dep, Max Asst (25%)
Bed Mobility 6 1 - Complete Dep, Total Asst (<25%)
Chair Mobility 6
Findings: Pt has mod indep on lower garment
Toilet 5
dressing, bed mob and chair mob. And is completely
Shower 2
dependent in shower mobility and locomotion.
Locomotion
Sig: 2 to LE m weakness
Walk 1
Stairs 1
A:
Communication PT Impression: Pt is completely dep on
Comprehension 7 locomotion and has modifiable indep on
Expression 7 lower garment dressing, bed mob and chair
Social Cognition
Social Interaction 7
Memory 7
 mob d/t Brown Sequard Syndrome c ASIA classification of Paraplegia 2 to Incomplete SCI, ASIA C c
motor level T1 and sensory level for pin prick and light touch T2 2 to intramedullary tumor on C6-T1 and
post-op complication. Pt has (+) spasticity, (+) pathologic reflex and is hypereflexive. Pt also has lordotic
posture and m spasm on B upper trapezius.

Rehab Potential &Prognosis: The pt.’s potential to achieve goals set is fair. Pt is young, cooperative and
motivated to reach the goals. There is no complication noted and pt started early on rehab. Although,
the level of lesion is high.

Procedural Intervention: The interventions that will be used on the rehabilitation of the pt are
compensatory and preventative measure. The pt’s condition cannot be completely resolved through PT
rehab. The management that will be done will serve as compensation to the problem caused by the
spinal cord injury. Preventative measures will also apply to the pt’s case to prevent any complications
since the patient is still young. The management will be performed 3x a week.

Problem List STG LTG

1. Pt. has m weakness on
B LE and trunk
2. Pt has cannot perform
AROM on all motion on
LE, LOM on Ankle DF
and PF
3. Pt has G sitting balance
and 27’ tolerance
4. Pt cannot assume
standing position and
tolerates 15’
5. Pt has mod indep on
lower garment dressing,
bed mob and chair mob.
And is completely
dependent in locomotion.
6. Pt has Grade 3
Spasticity on B
gastrocnemius m
7. Pt has a decreased
sensation on the level of
T2
8. Pt has m spasm on B
upper trapezius
9. Pt has lordotic posture
1. Pt will demonstrate an increase in
m strength on B LE from grade
1/5 to 2/5 and trunk from grade
3/5 to 3+/5 in MMT grading
within 6 months.
2. Pt will demonstrate AROM on LE
from 0 to 5 within 6 months
3. Pt will demonstrate an optimum
sitting tolerance p 6 months
4. Pt will demonstrate an increase in
grading of standing balance-
tolerance from 0 to P and an
increase in standing tolerance
from 15’ to 1 hr for 6 months
5. Pt will demonstrate an increase in
indep from complete
dependence, total assist to
complete dep, max assist in
locomotion within 6 months
6. Pt will demonstrate a decrease in
spasticity on B gastrocnemius
from Grade 3 to Grade 1 in the
modified ashwort scale exhibited
during PROME of ankle
dorsiflexion within 6 months
7. Pt will demonstrate an increase in
sensation p 6 months
8. Pt will demonstrate a decrease in
m spasm on B upper trapezius p 3
tx sessions
9. Pt will demonstrate an
improvement in posture p 6
months
1. Pt will demonstrate an optimum m
strength on LE by tolerating 5 min
standing in a parallel bar within 1
year
2. Pt will demonstrate an optimum
ROM within 1 yr
3. Pt will demonstrate an optimum
sitting balance p a year
4. Pt wil demonstrate an optimum
standing balance-tolerance p a year
5. Pt will demonstrate an optimum
inep in ADLs p a year
6. Pt will demonstrate eliminated or a
negative spasticity on B knee flexion
manifested during PROME of knee
flex within 1 year.
7. Pt will demonstrate optimum
sensation p 1 year
8. Pt will demonstrate absent m spasm
on B upper trapezius p a month
9. Pt will demonstrate optimum
posture p a year
P:

PT MX:

1. ES on the quadriceps m x 20’

2. Physiologic Standing as tolerated x5”
3. PRE x 20 reps on B UE, AP c grey thera tube
4. PROME x 10 reps on B LE
5. Sitting push-ups x 25 reps
6. GPS x 30 SH x 3 reps on B heel cords
7. US x 1.5 w/cm2 x 5’ on B heel cords, B upper trapezius
8. Quadruped x as tolerated x 5 reps c jt approximation
9. UE ergobike x 20’

Suggested PT Mx
1. Pt. & family education
2. Bed mob
3. Proper positioning and transfer
4. PBM
5. Home modifications
6. Rood’s Technique
7. PNF on B LE, AP x 10 reps x 2sets
8. TM on WBS

Precautions:
1. Autonomic Dysreflexia
2. Orthostatic Hypotension
3. Electrical Shock