A COMPILATION OF DOCUMENTS

CAMP LAPU- LAPU STATION HOSITAL

MAY 2019

SUBMITTED BY:

Rene Sandlee Orate

CDU PT Intern 2019

SUBMITTED TO:

Ms. Rea Gizelle Villacarlos , PTRP

 SCHEDULE OF MONTHLY ACTIVITIES
SUN MON TUES WED THURS FRI SAT
1 2 3 4
Holiday Orientation

5 6 7 8 9 10 11
 Reporting: Reporting: PNI
PNI UE LE
Weekly
exam:
cervical
pain
12 13 14 15 16 17 18
Reporting: Reporting: LBP
cervical
pain
Weekly
exam: Fx

19 20 21 22 23 24 25
Weekly:
Exam LBP
26 27 28 29 30 31
Weekly PM: General
Exam: TBI Endorsements Cleaning

PATIENTS’ TREATMENT SCHEDULE

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

8:00 – Palmones/Ignaci Palmones/Figer Palmones/Ignacio Palmones/Figer Palmones/I

9:20 o gnacio
9:20 – Aguinaldo /Aguinaldo Aguinaldo Aguinaldo /Aguinaldo
10:40
Hayag/Medalle Hayag/Medalle Hayag/Medalle Hayag/Medalle Hayag/Med
10:40 – alle
12:00
12:00 – LUNCH BREAK
12:30
12:30 – Quinanola Quinanola Quinanola Quinanola Quinanola
2:00
1:50 – Quinanola Quinaola Quinanola Quinanola Quinanola
4:00

GENDER OF PATIENTS HANDLED

 GENDER

MALE FEMALE
 CASE HANDLED
Ms spasm shoulder strain lbp CVA Bicipital tendonitis Gunshot wound OA TBI
 Case handled

Valencia Aguinaldo Parallag Quinanola Palmones Medalle

Hayag Rinka Figer Omandam
 AGE GROUPS

30-40 40-50 50-60 60-70

LOW BACK PAIN

Definition

- it is any localized pain or referred pain in the low back area experienced at the lumbar and sacroiliac region
- It is like a common cough and cold in biomechanical origin (it comes and goes)
- Usually described also as discomfort in the lumbosacral region that may or may not radiate to the buttocks, hips and legs
- It is not a condition or a specific disease. But rather, it is a symptom due to a lot of conditions.
- *Mostly, it is a common musculoskeletal symptom that may be either acute or chronic

Etiology
 A. Degenerative
1. Osteoarthritis – MC in the lumbar spine
2. Degenerative Disk Disease
3. Spondylosis
B. Inflammatory
1. Rheumatoid Arthritis
2. Ankylosing Spondylitis
3. Osteomyelitis
C. Infections
1. Spondylitis
2. Infection of the Disk itself
D. Metabolic
1. Osteoporosis
E. Neoplastic
1. Bone tumors @ the vertebral column
F. Traumatic
1. Accidents
2. Fracture (Pars interarticularis)
3. Dislocations
G. Skeletal/Structural
1. Structural Scoliosis
2. Congenital skeletal irregularities (i.e., congenital narrowing, spina bifida)
3. Pelvic obliquity
4. True LLD
H. Mechanical/Biomechanical
1. Abnormal posture
2. Faulty body mechanics (mechanical strain)
3. Ruptured, bulging, herniated disks  cauda equine syndrome (nerve root)
I. Viscerogenic – mimic mechanical back pain
1. Urinary Tract Infection
2. Kidney problems

J. Vascular
1. Abdominal Aortic Aneurysm
K. Psychogenic
L. Others
1. Paget’s Disease
2. Fibromyalgia

Epidemiology

- 2nd most common neurological ailment in the United States –next to headache
- Males = Females; most often between ages 30-50, due in part to the aging process but also as a result
of sedentary lifestyle
-Females at late stage have this kind of problem
-Affects 80% of the general US population at some point in their lives with sufficient severity to cause
absence from work; it surpasses AIDS, stroke, CA as a cause of disability

Pathophysiology

**LUMBOSACRAL ANGLE = 30O

- Any alteration of the lumbosacral angle will subject the tissues to changes

 ANY OF THE ANATOMIC STRUCTURES OF THE SPINE, INCLUDING LIGAMENTS, MUSCLES,

SKIN, FACET JOINTS, VERTEBRAES AND NERVE ROOTS MAY PRODUCE LBP.
 THE NUCLEUS PULPOSUS WOULD DECREASE IN PROTEOGLYCANS AS ONE AGES. THE
COLLAGEN CONTENT OF THE NUCLEUS PULPOSUS WOULD INCREASE IN THE EXPENSE OF
THE PROTEOGLYCANS.
 WITH AGING, NUCLEUS PULPOSUS BECOMES MORE FIBROUS AND WOULD LOSE SOME OF
THIS HYDRODYNAMIC PROPERTIES
 INTEVERTEBRAL DISC WOULD DECREASE IN HEIGHT THEREBY NARROWING THE
INTERVERTEBRAL FORAMEN. COMBINED WITH LOCALIZED STRESS, IT COULD LEAD TO
 IMPINGEMENT OF PAIN SENSITIVE STRUCTURES, DISC HERNIATIONS, THAT COULD LEAD TO
THE PRODUCTION OF LBP
Psychogenic
-emotional factors slow blood
circulation then leads to muscle spasm
-Autonomic Nervous System
-Existing local areas of
vasoconstriction
-MC affected: Multifidus muscle is
Affected (decreased blood supply in
the muscle)

Clinical Manifestations

CLINICAL MANIFESTATION
PAIN
-mild, moderate, severe
-periodic, constant
increased pain with activity; tenderness to palpation (possible back strain)
increased pain with extension; decreased with flexion (most likely from spinal stenosis)
constant pain; nocturnal pain; localized tenderness; weight loss (possible malignancy)
radicular pain (+) SLR test -> (possible disc herniation)
aching pain associated with decreased ROM; (+) Schober’s Test (Ankylosing Spondylitis)
radiating pain (possible nerve root impingement)
Pain that is worse in the morning and gets better with movement (muscle injury)
Pain that is worse at night and not relieved by exercise (referred pain)
Pain that goes all the way down (sciatica/slipped sic)

ACUTE LOW BACK PAIN

-onset is sudden, or gradual but pain is severe
-pain felt could be localized or diffused
-In the presence of disc herniation, pain and tingling sensation may radiate to the periphery

*aggravated by movement and relieved in rest specifically in recumbency

**The position that loads the spine the most is during:
1. SITTING - by the force received from the ischial tuberosities (pelvis); the reaction force when sitting is directed to the
lumbar spine
2. Standing – 2nd only since the reaction force at the ankle and foot
3. Recumbency (as the least) – either supine or prone
**manifest pain & is (+) with SLR when LE is eleveated uo to 60o

CHRONIC LOW BACK PAIN

- 80O SLR –exhibits pain
- Cause of back pain is not addressed
- Long-term
- Majority are due to facet joints or biomechanic causes
- Usually always has a history of LBP

*LBP or chronic pain @ lumbosacral region – over L4-L5, L5-S1

*usually with tenderness or poor muscle tone over lumbosacrals which are exaggerated by movement and activity

Diff. Diagnosis

VASCULAR vs. NEUROGENIC CLAUDICATION

NEUROGENIC CLAUDICATION
(PSEUDOCLAUDICATION)
LOW BACK PAIN
EFFECT OF STANDIN
DIRECTION OF RADIATION
OF PAIN IN LE
VASCULAR CLAUDICATION
(INTERMITTENT CLAUDICATION)
frequently present absent
provokes symptoms does not provoke symptoms
downward upward
SENSORY SYMPTOMS present in 66% absent
MUSCLE WEAKNESS present in >40% absent
REFLEX CHANGES present in about 50% absent
ARTERIAL PULSES normal decrease or absent
ARTERIAL BRUITS absent frequently present
EFFECT OF REST WHILE STANDING no relief relief of symptoms
WALKING UPHILL symptoms produced later Sx produced earlier
WALKING DOWNHILL Sx produced earlier Sx produced later
BICYCLING does not provoke Sx provokes symptoms

COMPLICATION
Low back pain can make any movement of the spine painful, compromising ADLs. Compromised normal activities if continued for
prolonged period of time can lead to musculoskeletal dysfunction.
Examples are:
- Joints that are not moved can become stiff & weak.
- Prolonged bed rest can lead to bone weakness (may be very long period of reduced activity)
- Postural deformities if tight structures are not stretched
- Deconditioning muscles that are not used regularly become weak

Med/Surg. Management

Medications commonly used for the treatment of acute low back pain include aspirin and other nonsteroidal anti-inflammatory drugs
(NSAIDs), acetaminophen and, possibly, muscle relaxants. Patients taking opioid analgesic drugs, often used in the first few days after
the development of acute low back pain, do not return to full activity sooner than patients taking NSAIDs or acetaminophen. 16Muscle
relaxants are more effective than placebo but no better than NSAIDs in relieving acute low back pain. Oral corticosteroids and
antidepressants do not appear to be effective in patients with acute low back pain, and their use is not recommended. 1

Spinal manipulation has been shown in several randomized trials to be beneficial. 17 Shoe insoles—over-the-counter foam or rubber
inserts and custom-made orthotics—may also be beneficial in some patients. Spinal traction, transcutaneous electrical nerve
stimulation, biofeedback, trigger-point injections, facet joint injections and acupuncture are usually not helpful in the manaagement of
acute low back pain.1 Surgery may be indicated in selected patients who are not helped by conservative treatment and who have
debilitating symptoms after one month of therapy. Patients with red flags noted at the initial evaluation may be candidates for
immediate surgery.

PT assessment

RANGE OF MOTION
The examiner should record the patient's forward flexion, extension, lateral flexion and lateral rotation of the upper torso. Pain with
forward flexion is the most common response and usually reflects mechanical causes. If pain is induced by back extension, spinal
stenosis should be considered. Unfortunately, the evaluation of spinal range of motion has limited diagnostic use,10 although it may be
helpful in planning and monitoring treatment.

MUSCLE STRENGTH

PALPATION OR PERCUSSION OF THE SPINE

Point tenderness over the spine with palpation or percussion may indicate fracture or an infection involving the spine. Palpating the
paraspinous region may help delineate tender areas or muscle spasm.

HEEL-TOE WALK AND SQUAT AND RISE

A patient unable to walk heel to toe, and squat and rise may have severe cauda equina syndrome or neurologic compromise.
STRAIGHT LEG RAISING TEST
With the patient in the supine position, each leg is raised separately until pain occurs. The angle between the bed and the leg should be
recorded. Pain occurring when the angle is between 30 and 60 degrees is a provocative sign of nerve root irritation (Figure 1, top).
Bending the knee while maintaining hip flexion should relieve the pain, and pressure in the popliteal region should worsen it (popliteal
compression test).11 If placing the knee back in full extension during straight leg raising and dorsiflexing the ankle also increase the
pain (Lasègue's sign), nerve root and sciatic nerve irritation is likely.

The result of straight leg raising is positive in 95 percent of patients with a proven herniated disc at surgery, but it is also positive in 80
to 90 percent of patients without any form of disc protrusion at surgery. 12 In contrast, crossed straight leg raising is less sensitive but
much more specific for disc herniation. In the crossed straight leg raising test, the contralateral, uninvolved leg is raised (Figure 1,
bottom). The test result is positive when pain is produced.

REFLEXES AND MOTOR AND SENSORY TESTING

Testing knee and ankle reflexes in patients with radicular symptoms often helps determine the level of spinal cord compromise. An
altered knee or ankle reflex alone does not suggest the need for invasive management because this finding is generally transient and
fully reversible.8

Weakness with dorsiflexion of the great toes and ankle may indicate L5 and some L4 root dysfunction. Sensory testing of the medial
(L4), dorsal (L5) and lateral (S1) aspects of the foot may also detect nerve root dysfunction. 1

PT management

-electrotherapy (ES, US, TENS, etc)

-passive positioning of the lumbar spine (*Kisner, page 421, box 15.6)

- Strengthening exercises

- Stretching exercises

- hot and cold pack application

- Spinal Traction

- shoe Modifications - Orthotics

-pt. education

Comparing AquaStretch with supervised land based stretching for

Chronic Lower Back Pain
lynda G.KeanePGc, MSc, BSc (Hons), ATRIC, AEA, mSMA (2017)

POPULATION:
 29 actually took part in this research with no subjects dropping from the study once it commenced.
  aged between 18-70, self-reported CLBP for 3 months or more
 no surgical intervention to the lower back, no specific injury to the lower back, and not pregnant.
 Exclusion criteria were: acute back pain lasting 1 to 6 weeks, osteoporosis, stenosis, fractured vertebrae, history
of back surgery, spondylosis and spondylitis.

INTERVENTION:

 The control group comprised 9 subjects (1 male and 8 females) continue their normal levels of physical activity
throughout the study period without changes. They were specifically instructed to avoid any new form of
treatment for CLBP.
 Land-based stretching comprised 10 subjects (2 male 8 female) lasting 30 minutes twice a week.
 The AquaStretch group comprised 10 subjects (2 male and 8 female). Subjects were asked to attend two 30
minute AquaStretch sessions a week at a pool temperature of 30°C.

COMPARISON

 Self-reported level of pain (intensity) improved within both AquaStretch and LBS groups
 However it is evident that at week 6 the comparison between LBS and AquaStretch indicates that LBS group
perceived less pain than the AquaStretch group.
 it is evident from the data of this current study that between week’s 6 and 12 the reduction in pain starts to
plateau for the LBS group but continues to improve in the AquaStretch group
 This plateauing in the LBS subjects may in part reflect their inability to dynamically stretch into positions and
directions on land because they were restricted by the force of gravity and solid surfaces including floors and
walls, whereas the AquaStretch subjects were free to move in any and all directions.
 research into water exercise has found benefits to include a reduction in heart rate and blood pressure lactate,
reduce systolic and diastolic blood pressure, improvements in walk time, depression anxiety & physical activity.

OUTCOME

 The findings of this study have revealed AquaStretch to be a beneficial additional technique to help in the
reduction of pain, disability and kinesiophobia in subjects with CLBP.
 it is evident that a combination of both AquaStretch and land based stretching would provide a more cost
effective treatment programme for sufferers of CLBP.
INITIAL EVALUATION

PERSONAL DATA Date of IE: 03-May-2019

Name: LTC Parallag, Rhoderick, O-011912 - PA Handedness: R

Age/Sex: 47/♂ Date of Consultation: Unrecalled

Address: Fort Boniacio, Taguig Date of Admission: OP

Tel#/Cell#: 09178836106 Bed#/Rm#: OP

Nationality: Filipino Date of Referral: Unrecalled

Civil Status: Married Referring MD: Col Getulio J Santos Jr, MC (Ret)

Occupation: Philippine Military Officer Physiatrist: Direct

Religion: Roman Catholic Dx: L shoulder ms. strain

S:

Informant: (Pt.100% reliability)

C/C: Pt. c/o constant deep aching pain on the L middle deltoid area graded 3/10 on NPRS & (0= no pain, 5=mod pain,10
=severe pain) is aggravated during carrying heavy loads at shoulder level towards all motions graded 8/10 on NPRS (0=
no pain, 5=mod pain,10=severe pain) especially during abd.

HPI: Pt.’s current condition started earlier this year, which he kept on tolerating. Stated since then, his R shoulder constantly
ache which limits him to do push ups & play recreational activities such as golfing at his full potential; had kinesiotaping on
L shoulder which resulted a bruising on his L deltoid tuberosity & on his armpit due to the inhibition made by the tape. Stated
was able to undergo PT Rx session at Fort Bonifacio for 6 PT Rx last April 2019 (specific date unrecalled); was referred by
Col Getulio Santos Jr MC (Ret) to undergo PT Rx session which started on 02-May-2019 in Camp Lapu-lapu station hospital.

Med/Surg Hx:

Date Reason
exact date diagnosed unrecalled HTN (controlled)
FMHx:

Maternal Paternal Pt
HTN (+) (+) (+)
DM (-) (-) (-)
Pulmonary problems (-) (-) (-)
CA (-) (-) (-)
CVA (-) (-) (-)
Cardiac problems (-) (-) (-)
OA/RA (-) (-) (-)
Personal Hx:

 Social Hx: Pt. has no cultural & religious belief that may hinder quality care, lives alone & is indep throughout his
ADLs.
 Employment/Work Status:Pt is a full-time military officer in the army, works ~ 0800-1700H qd inside the office; is
seated most of the time.
 General Health Status: Pt.’s rating of his health as good & has not experienced any major life changes during the
past yr.
 Social Health Habits: : Pt. denies smoking cigarettes but admits to drinking ~1-2 bottles of alcoholic beverages
occasionally; wakes up at 0500H qd for a 30 min to 1 hr jog., does push-ups, sit-ups & planking for another 30 min.
as ex.
Living Environment:

 Pt. lives in a 1-story cement house with tiled flooring.

 Cabinet & light switch heights are of standard ht.

Ancillary Procedures:

Procedure, Area Date, Hospital Result

CT Scan, brain Unrecalled, Normal findings
X-Ray, chest Unrecalled, Normal lung findings
Medications

Source Name Dosage/Frequency Indications Compliance

Pt. losartan 50 mg, OD Anti-HTN Pt. is compliant
Prior Level of Function: Pt. was indep towards all aspects of ADLs such as dressing upper & lower garments as well as
all aspects of transfers.

Current Level of Function: Pt. is indep towards all aspects of ADLs such as dressing upper and lower garments as well
all aspects of transfers & amb but shows difficulty performing work related task using his R UE such as carrying heavy
objects & reaching heavy objects above cabinets.

Goals & Attitude toward Therapy:

 Pt. wants a total pain relief on R middle deltoid area to be able to return to his functional & recreational activities s,̄
hindrance
OI:

 Amb s̄ assist. device  (+) wound scar on ant. deltoid & armpit area
 Mesomorph  (-) Gait deviation
 (-) Postural deviaton
SYSTEMS REVIEW:

Cardiopulmonary System: Unimpaired.

V.S. a Rx p Rx Location, method, position

BP (mmHg) 110/80 110/70 L brachial artery, auscultory, sitting
PR (bpm) 87 86 L index finger, pulse ox, sitting
SpO2 (%) 97 99 L index finger,pulse ox, sitting
Integumentary System: Unimpaired

Musculoskeletal System:

 Gross symmetry: Unimpaired in standing, sitting & activities

 Gross ROM: impaired , R UE
 Gross Strength: impaired , R UE
Neuromuscular System:

 Gait: Unimpaired
 Locomotion: Unimpaired
 Balance: Unimpaired
 Motor function: unimpaired
Communication: Age appropriate, unimpaired.

Affect: Emotional & behavioural response unimpaired

Cognition: Pt.is cooperative, alert & oriented x3 as to PPT

Learning Barriers: Pt. can understand Visayan language but can understand best using Tagalong upon conversation.

Learning Style: Pt. learns best when exercises are demonstrated c̄ tactile reinforcement.

Education Needs: Pt. needs to learn about the dse process, respecting the pain & proper body mechanics upon sitting.

TEST & MEASURES:

Sensory Assessment: Sensory testing device used: small nylon brush or cotton for light touch, sharp & dull ends of a
neurohammer for superficial pain and deep pressure respectively.
Superficial Sensory
Light touch Pain Pressure Light touch Pain Pressure
Region
L L L R R R
2 2 2 C4 2 2 2
2 2 2 C5 2 2 2
2 2 2 C7 2 2 2
2 2 2 T1 2 2 2
Legend: 2-Normal, 1-Impaired, 0-Abesent

Significance: Pt. shows an intact superficial sensory integrity.

Palpation:

 (-) tenderness on R UE
 (-) swelling on R UE
 (-) atrophy on R UE

Legend for Tenderness: grade I – Pt. complaints of pain, II – Pt. complaints of pain & winces, III – Pt. winces & withdraws, IV – Pt. will not allow palpation
of jt

ROM: All major jts. in the body were grossly assessed, actively & passively, & found to be WNL c̄ normal end-feel except:

Joint N° AROM° DIFF° PROM° DIFF° END-FEEL

L shoulder flex 0-180° 0-80° 100° 0-180° 0° Firm
L shoulder abd 0-180° 0-70° 110° 0-180° 0° Firm
L shoulder int. rot. 0-70° 0-65° 5° 0-68° 2° Firm
L shoulder ext. rot 0-90° 0-83° 7° 0-88° 2° Firm
Legend:

Normal End-Feels Abnormal End-Feels

End-Feel Structure
End-Feel Structure Soft Feels boggy, with fluid shift
Soft Soft tissue approximation Firm Occurs sooner or later than normal
Firm Muscular stretch Hard Grating or bony block is felt
Capsular stretch No real end because pain prevents reaching end of
Ligamentous stretch Empty ROM. No resistance is felt except. for pt.’s protective
Hard Bone contracting bone ms. splinting/spasm
Significance: Pt. shows LOM on R shoulder flex, abd, int. rot & ext, rot. due to muscle imbalance 2° chronic pain from R
shoulder muscle strain.

MMT: All major ms. groups in the body were grossly assessed & graded 5/5 except:

L UE Musculatures R UE
3+/5 on all musculatures Shoulder 5/5 on all musculatures
5/5 Biceps 5/5
5/5 Triceps 5/5
5/5 on all musculatures Wrist & Hand 5/5 on all musculatures
Manual Muscle Testing Grades
Grades Grade Abbrev. 0-5 Scale Criteria
Normal N 5 Full available ROM, against gravity, strong manual resistance
Good Plus G+ 4+ Full available ROM, against gravity, nearly strong manual resistance
Good G 4 Full available ROM, against gravity, moderate strong manual resistance
Good Minus G- 4- Full available ROM, against gravity, nearly moderate strong manual resistance
Fair Plus F+ 3+ Full available ROM, against gravity, slight manual resistance
Fair F 3 Full available ROM, against gravity, no resistance
Fair Minus F- 3- At least 50% of ROM, against gravity, no resistance
Poor Plus P+ 2+ Full available ROM, gravity minimized, slight manual resistance
Poor P 2 Full available ROM, gravity minimized, no resistance
Poor Minus P- 2- At least 50% of ROM, gravity, no resistance
Trace Plus T+ 1+ Minimal observable motion (less than 50% ROM), gravity min, no resistance
Trace T 1 No observable motion, palpable muscle contraction, no resistance
Zero 0 0 No observable or palpable muscle contraction

Physical Rehabilitation 6th Edition by O’Sullivan & Schmitz

Significance: Pt. shows ms. weakness on all L shoulder musculature due to disuse from pain 2°L muscle strain.

Special Test:

Positive
Test Performed Procedure Indication Result
Response
Neer impingement Pt.’s arm fully elevated & med rot. (+) discomfort (+) overuse injury of (+) pain & discomfort was
test By examiner (+) pain supraspinatus felt by pt.
(+)apprehension
Empty can test Pt.’s arm abd at 90° & med rot. & (+)weakness Supraspinatus tear on (+) pain was felt by pt
resisted while examiner looks for (+) pain muscle or tendon. upon resist. on the med
weakness rot arm.
Active O Brien’s Pt.’s arm is med rot. & is applied (+)painful clicking (+) SLAP lesion (-) painful clicking upon
compression test eccentric force then is lat rot. the (+) pain assessment.
is applied again
Significance:Pt. shows possible impingement syndrome of L supraspinatus showing symptoms of L muscle strain.

ADL Analysis:

 Quick-DASH (Disability of the Arm, Shoulder, & Hand):

1. Open a tight or new jar
2. Do heavy household chores (e.g., wash walls, floors) 1
3. Carry a shopping bag or briefcase 2
4. Wash your back 2
5. Use a knife to cut food 1
6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, 4
tennis, etc)
7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities 1
with family, friends, neighbors or groups?
8. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or 3
hand problem?
9. Arm, shoulder or hand pain 3
10. Tingling (pins & needles) in your arm, shoulder or hand 1
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? 1
Legend: Severity & Functional Scale: 1=No difficulty/Not limited; 2=Mild difficulty/Slightly limited; 3=Moderate difficulty/Moderately limited; 4=Severe
difficulty/Very limited; 5=Extremely/Unable

Significance: Pt. shows severe difficulty upon doing recreational activities & limits him to do his regular activities as well as
carrying heavy objects on his L UE due to Lshoulder pain 2° L muscle strain.

Posture: Pt. was tested in standing position.

Landmark Ant Post Lat

 Head Eyes & ears symmetrical, nose is in line
c̄ sternum; no lat bending noted.
Neck No tracheal deviatons noted ;trachea
aligned c̄ sternum
Shoulder R & L shoulders are Level.
Trunk/spine Chest & rib flares evenly
Occiput is aligned c̄ C7spinous
process; no lat bending noted.
Occiput is aligned c̄ C7spinous
process
R & L shoulders are Level.
Aligned thoracic/lumbar vertebrae
Earlobe is align c̄ acromion process.
N cervical lordosis; no sig noted.
Acromion is align c̄ earlobe; no
protraction/retraction noted.
N kyphotic thoracic & lumbar lordosis

Pelvis/hip R & L ASIS levelled R & L PSIS levelled N ant. pelvic tilt.
Knees Patella are symmetrical;no displacement R & L Popliteal crest is symmetrical B ant to lat malleoli.
noted
Ankle B lat & med malleolus are level. B lat & med malleolus are level. Lat malleoli align c̄ lat tibal condyle.
Significance: Pt. shows (-) postural deviation indicating a good posture.

A:

PT Dx: Subacute stage of chronic inflammation on L shoulder ms. Strain due to repetitive microtrauma resulting to LOM &
↓ muscle strength 2 ° disuse.

Prioritized Problem List:

1. Difficulty carrying heavy objects, doing his recreational activities such as golfing & fitness exercises like push ups.
2. LOM on L shoulder flex, ext, int. rot & ext. rot
3. Ms. weakness on all L shoulder musculature.
4. Constant , deep aching pain on R shoulder graded 3/10 on NPRS
Evaluation: Pt’s pain on L shoulder limits his full potential upon performing ADLs such as carrying heavy loads &
recreational activities such as playing golf, & doing push ups; can benefit from modalities such as TENs + HMP & US to ↓
pain; gentle passive stretching to ↑ mobility; scapular mobilization to ↑ stabilisation to prevent re-injury & Mobilization c̄
movement to ↑ scapulohumeral rhythm & joint tracking.

Dx:

 Practice Pattern: Musculoskeletal Pattern D: Impaired joint mobility function, muscle performance, range of motion
associated with connective tissue dysfunction.
Prognosis: Pt. has a good rehab potential. Although pt’s case is recurrent, it is not progressive; is cooperative & is willing
to undergo PT session.

Focus of Rehab: To totally eliminate pain on R shoulder in order for pt. to resume in carrying heavy loads, ↑ functional
performance & to relieve discomfort.

P:

Expected Outcomes:

1. Pt. Will be able to carry mod. to heavy loads on L UE s̄ difficulty & be able to return to his prior level of performance
on ADLs such as getting objects overhead ,transferring mod to heavy objects on table top ↔ overhead cabinets &
do recreational activities such as golfing ,doing push ups & planking p̄ 15 mos of PT Rx.
Anticipated Goals:

1. Pt. will be able to verbalize a ↓ of constant pain from 5/10→3/10 & pain upon moving L shoulder c̄ resist/load from
8/10 → 5/10 p̄ 5PTRx to gradually return to prior level of performance in ADLs, recreational activities & for the
progression of pt. Mx exercises given.
2. Pt. will be able to demonstrate an ↑ in ROM on L shoulder flex, abd, int. rot. & ext. rot c̄ increments of ~ 10 increments
p̄ 6 PTRx to be able to do functional activity such reaching & lifting objects above cabinets s̄ less difficulty.
3. Pt. will demonstrate a ↑ MMT grade from 3+/5→4/5 p̄ 6 PT Rx on L shoulder to be able to carry mod load objects
above cabinets & gradually return to prior level of performance in recreational activities such as push up.
PT Intervention Plan:

1. HMP + TENs on L shoulder x15 min to ↓ pain & promote healing.

2. US on L mid & ant. Deltoid area x 5 mins
1. Gentle passive stretching of L shoulder flex, ext, int. & ext. rot. 5 sec hold x 10 reps to ↑ mob & ↓ muscle imbalance.
Suggested PT Mx:

1. Scapular mobilization → all planes x 10 reps x 2 sets to ↑ glenohumeral rhythm.

2. AROMEs c̄ 3 sec hold at terminal range → all planes x10 reps to ↑ ROM.
3. Mobilization c̄ movement → ext. rot. x 12 reps x 1 set to ↑ joint tracking.
4. Manual RROM → all planes x 10 reps x 1 set to ↑ ms. str.
Pt.&Family Education:

1. Respect pain
 2. Disease process
Recommendations:

1. Self- stretching on B Hamstrings & gastrocnemius x 20 reps x 3 sets to ↑ ms. strength.

Precautions:

3. cardio/pulmo
4. falls/fx

RENE SANDLEE ORATE

CDU PT INTERN ‘19

RE-EVALUATION

PERSONAL DATA: Occupation: Ret

Name: Col. Jefferson Omandam (Ret) Religion: Roman Catholic

Age/Sex: 60/♂ Date of RE: 13-May-2019

Address: Block 8, Woodland Subd., Brgy.Binaliw II, Cebu Handedness: L

City
Date of Consultation: Unrecalled
Nationality: Filipino
Date of Admission: OP
Civil Status: Married
Bed#/Rm#: OP
Date of Referral: 04-May-2018 Physiatrist: Direct

Referring MD: Dr. Maj Gian Carlo L. Cabanag, MC Dx: S/P R Knee Arthoplasty

S:

Informant: (Pt. & pt.’s wife c̄ 100% reliability)

Initial C/C: Pt. c/o gnawing pain R knee graded 3/10 on NPRS (0= no pain, 5= moderate pain, 10= severe pain) aggravated
by strenuous activities such as tennis sport & relieved by rest.

Current Condition: Pt. c/o of intermittent deep gnawing pain on R Knee graded 2-3/10 on NPRS (0= no pain, 5= moderate
pain, 10= severe pain) aggravated during prolonged walking & strenuous activities like tennis & is relief upon rest as well
as seldom c/o intermittent discomfort on L knee upon playing tennis for prolonged period of time.

Current Med/Surg:

Date Reason
2016 (specific date unrecalled) R Knee Osteoarthritis
Current Ancillary Procedures:

Procedure Date, Hospital Result

MRI, B Knee 2016 ( exact date unrecalled) R Knee Osteoarthritis
X-Ray, B Knee 2016 (Exact date unrecalled) (+) joint space narrowing
Goals & Attitude toward Therapy:

 Pt. wants a total pain relief on his R Knee to be able to do ADLs such as walking especially for a prolonged period
of time & IADLs such as cleaning his car as well as doing recreational activities like playing tennis s̄ guarding &
difficulty.
 Pt. wants to strengthen core & B LE ms. strength to do ↑ functional performance in walking & recreational activites
such as tennis.
OI:

 Amb s̄ assist. device  (-) atrophy on R LE

 Mesomorph  (-) orthosis
 (-) postural deviation
SYSTEMS REVIEW:

Cardiopulmonary System: Impaired or Unimpaired.

V.S. a Rx p̄ Rx Location, method, position

BP (mmHg) 120/70 110/80 L brachial artery, auscultory, sitting
PR (bpm) 87 90 L index finger, pulse ox sitting
SpO2 (%) 94 99 L index finger, pulse ox, sitting
Integumentary System: Unimpaired

Musculoskeletal System:

 Gross symmetry: Unimpaired

 Gross ROM: Unimpaired
 Gross Strength: unimpaired
Neuromuscular System:

 Gait: Unimpaired
 Locomotion: Unimpaired
 Balance: Unimpaired
 Motor function: Unimpaired
Communication: Age-appropriate, unimpaired

Affect: Emotional & behavioural responses are unimpaired

Cognition: Pt. is cooperative, alert & oriented x3 as to PPT

Learning Barriers: Pt. has no learning barriers that can affect Rx session.

Learning Style: Pt. learns best when demonstrated & c̄ verbal cues.

Education Needs: HEP, respect pain, & disease process.

TEST & MEASURES:

Previous ROM: All major jts.in the body were grossly assessed, actively & passively, & found to be WNL c̄ normal end-feel
except:

Motion Normal L LE ROM R LE ROM

Active Diff Passive Diff End-feel Active Diff Passive Diff End-feel
Knee flex 0-135° 0-130° 5° 0-135° 0° Soft 0-132° 3° 0-135° 0° Soft
Knee ext 135-0° 135-0° 0° 135-0° 0° Hard 135-0° 0° 135-0° 0° Hard
Current ROM: All major jts.in the body were grossly assessed, actively & passively, & found to be WNL c̄ normal end-feel
except:
Motion Normal L LE ROM R LE ROM
Active Diff Passive Diff End-feel Active Diff Passive Diff End-feel
Knee flex 0-135° 0-130° 5° 0-133° 2° Soft 0-132° 3° 0-135° 0° Soft
Knee ext 135-0° 130-0° 5° 133-0° 2° Hard 132-0° 3° 135-0° 0° Hard

Significance: Pt. shows a N ROM on B knee → all planes & that the limitation of 2-5° in flex & ext is due to ms. bulk & tissue
approximation.
Legend:
Normal End-Feels
Abnormal End-Feels
End-Feel Structure
Soft Feels boggy, with fluid shift
End-Feel Structure Firm Occurs sooner or later than normal
Soft Soft tissue approximation Hard Grating or bony block is felt
Firm Muscular stretch No real end because pain prevents reaching end of
Capsular stretch Empty ROM. No resistance is felt except. for pt.’s protective
Ligamentous stretch ms. splinting/spasm
Hard Bone contracting bone

Physical Rehabilitation 6th Edition by O’Sullivan & Schmit

MMT: . All major ms. groups in the body were grossly assessed & graded 5/5 except:

L LE Musculatures R LE
5/5 on all musculatures Hip 5/5 on all musculatures
5/5 Quadriceps 4+/5
5/5 Hamstrings 5/5
5/5 on all musculatures Ankle & foot 5/5 on all musculatures
Manual Muscle Testing Grades
Grades Grade Abbrev. 0-5 Scale Criteria
Normal N 5 Full available ROM, against gravity, strong manual resistance
Good Plus G+ 4+ Full available ROM, against gravity, nearly strong manual resistance
Good G 4 Full available ROM, against gravity, moderate strong manual resistance
Good Minus G- 4- Full available ROM, against gravity, nearly moderate strong manual resistance
Fair Plus F+ 3+ Full available ROM, against gravity, slight manual resistance
Fair F 3 Full available ROM, against gravity, no resistance
Fair Minus F- 3- At least 50% of ROM, against gravity, no resistance
Poor Plus P+ 2+ Full available ROM, gravity minimized, slight manual resistance
Poor P 2 Full available ROM, gravity minimized, no resistance
Poor Minus P- 2- At least 50% of ROM, gravity, no resistance
Trace Plus T+ 1+ Minimal observable motion (less than 50% ROM), gravity min, no resistance
Trace T 1 No observable motion, palpable muscle contraction, no resistance
Zero 0 0 No observable or palpable muscle contraction

Physical Rehabilitation 6th Edition by O’Sullivan & Schmitz

Significance: Pt. demonstrates a normal ms. strength on B LE musculatures except a grade of 4+/5 on R quad ms due to
avoidance of activity & possible disuse 2° intermittent deep gnawing pain on R Knee
Posture: Pt. was tested in standing position.

Landmark Ant Post Lat

Head Eyes & ears symmetrical, nose is in line c̄ Occiput is aligned c̄ C7spinous process Earlobe is
sternum; no lat bending noted. align c̄
acromion
process
Neck No tracheal deviations noted ;trachea aligned Occiput is aligned c̄ C7spinous process N cervical
c̄ sternum lordosis
Shoulder R & L shoulders are Level R & L shoulders are Level. Slightly
protracted

Trunk/spine Chest & rib flares evenly Aligned thoracic/lumbar vertebrae N

kyphotic
thoracic&
lumbar
lordosis
Pelvis/hip R & L ASIS levelled R & L PSIS levelled N ant.
pelvic tilt.
Knees Patella are symmetrical; no displacement R & L Popliteal crest is symmetrical B ant to
noted lat
malleoli.
Ankle B lat & med malleolus are level B lat & med malleolus are level. Lat
malleoli
align c̄ lat
tibal
condyle.
Significance: Pt. shows (-) postural deviation indicating a good posture.

Previous LGM:

Landmark: Lateral epicondyle of femur.

L R Difference
2’ above 38cm 39.6 1.4cm
4’ above 39.1cm 40.3cm 1.2cm
6’ above 39.2cm 41.8cm 2.6cm
2’ below 34.4cm 35.4cm 1cm
4’ below 34.0cm 34.4cm 0.4cm
6’ below 34.3cm 34.9cm 0.6cm
Current LGM:

Landmark: Lateral epicondyle of femur.

L R Difference
2’ above 39cm 39cm 0 cm
4’ above 40cm 40cm 0 cm
6’ above 40.5cm 40.3cm 0.2cm
2’ below 34.5cm 34.4cm 0.1cm
4’ below 34.0cm 34.4cm 0.4cm
6’ below 34.3cm 34.9cm 0.6cm
Significance: Pt show (-) significance of LGM indicating a (-) swelling/edema on pt,’s B knee.
A:

PT Dx: Chronic stage of OA on R knee & possible osteopenia on L knee which leads to his limitation on
prolonged amb & performance on recreational activities such as tennis.

Prioritized Problem List:

1. Intermittent gnawing pain on R knee graded 2-3/10 on NPRS (0 – no pain,10 – severe pain)
aggravated by strenuous activities such as playing tennis, long distance walk & is relieved by rest.
Evaluation: (Includes problem list in narrative type & how they affect pt.’s functions; treatable problem first
& PT interventions to restore function lost.)

Dx:

 Practice Pattern: Musculoskeletal Pattern H: Impaired Jt mobility, motor function, ms performance,

& rom associated c̄ jt arthroplasty.
Prognosis: Pt has a good rehab potential since pt. shows no other symptoms and complications aside
from intermittent pain on his R knee & has a good attitude towards having a active & healthy lifestyle.

Focus of Rehab:

1. To eliminate the pain felt on R knee to be able to improve performance & experience s̄ difficulty on
ADLs such as amb long distance & recreational activities such as tennis
P:

Previous Expected Outcomes:

1. Pt. will demonstrate playing tennis for longer periods s̄ p̄12 PT Rx to be able to compete on
tournament.
Current Expected Outcomes

2. Pt. will be able to play tennis for longer periods & be able to tolerate walking for prolonged period
of time p̄ 12 PT Rx to be able to compete on tournaments & be able to continue his active lifestyle
respectively.
Previous Anticipated Goals:

1. Pt. will verbalize a ↓ of pain on R knee from 3/10→1/10 p̄ 5 PT Rx to be able to perform sport
activities c̄ less difficulty.
2. Pt. will demonstrate a normal ROM on R Knee flex p̄ 5 PT Rx to improve flexibility.
Current Anticipated Goals:

1. Pt. will verbalize a ↓ of pain on R knee from 2/10→1/10 p 6 PT Rx to be able to perform on ADLs
such as amb in long distances & recreational sport such as tennis s̄ difficulty.
PT Intervention Plan:

1. HMP + TENS on R knee x 20 min. for pain relief.

2. US at low supersonic setting on B Knee x6 min. each to ↑ soft tissue extensibility.
3. Paraffin wax bath on R hand x 5 min for pain relief.
4. Tendon gliding on R hand to facilitate movement.
Suggested PT Mx:

1. Stationary bike x 20 mins c̄ 4lb ankle weights on B LE to ↑ cardiopulmonary endurance & LE ms.
endurance.
2. Resist. exercise on quadrupe position c̄ 4lb angle weights on B LE to ↑ LE ms. strength & core ms.
3. Resist exercise using functional trainer → B LE extension in sitting c̄ 10 lbs, 20lbs, 25lbs x 12 reps
x 3 sets to ↑ quad ms. strength.
Pt.&Family Education:

1. Respect pain
Recommendations:

2. Self- stretching on L triceps x 20 reps x 3 sets to ↑ ms. strength.

Precautions:

5. v.s. monitoring ā, during, & p̄ Rx

6. cardio/pulmo
7. falls/fx

Rene Sandlee M Orate

CDU PT INTERN ‘19

 Reflection paper

Being assigned in Camp Lapu-lapu was my 6th rotation since I started internship. It was fun yet
challenging. I got a chance to know new people with chronic cases of CVA & able to share my
knowledge about what their cases & get to learn to be more optimistic and rely on manual
therapy to address the problems each patient has. Some of them taught me wisdom about life
and even guidance towards adulthood. I become more motivated to become a Physical
therapist after seeing these patients and shared some good memory with them. I hope I will
improve much more and be able to treat each of my future patients & clients in the best way I
can.
Ms. Rea ,Sir leo & the other staffs guided me how to do the given exercises to the patient in a
way that it maximizes what can be use or to optimize what is available to be able to address the
same result. It was fun getting to know and building a bond with my fellow interns especially
after lunch where almost everyone are done with their errands in the rehab. The staffs at camp
my fellow interns boosted my confidence in socializing which is one of my weakness, especially
meeting new faces and having to speak while many are listening.
Thank you for your guidance Ms. Rea and the things you taught me from reva to the skill set in
being a good intern which I can bring to my next rotation & future Physical Therapist.
 CURRICULUM VITAE

Personal Background

Name : Rene Sandlee M. Orate

Address : Ph2 Blk9 Lot 20-21 Camella

Homes Lawaan Talisay City Cebu

Contact No. : 09568765563

Email Address : andeeorate@gmail.com

Educational Background

2005 - 2010
Elementary Level Grade 1-6
St. Thomas Aquinas School Montessori
Natalio B. Bacalso S National Hwy, Lawaan 1, Talisay City,

2010 - 2013
High School
Don Bosco Thechnology Center
Pleasant Homes Subd., Buhisan Rd, Punta Princesa labangon Cebu

2013 - 2019
Tertiary Level
Bachelor of Science in Physical Therapy
Cebu Doctors’ University
Mandaue City