中興醫院 Date:

□ IP □ OP
Chung Shing Hospital WARD No.:
Physical Therapy Neurological Initial Y.O.B:
Evaluation Form
Social and Vocational:

Name: Hosp No.:

Date of Admission: Age/Sex: Handedness:

Diagnosis/Reason for admission:

Brief History:

Precautions:

Review of Systems:
WNL ABN WNL ABN
✔️ ✔️

✔️ ✔️

✔️ ✔️

✔️ ✔️
Medications:

General Observation:

Mental Status/Communication:
1. Consciousness clear : JOMA intact, C impaired
Communication : intact
Cooperation/Motivation:
Cooperation(Patient/caregiver) : Good/Good
Motivation(Patient/caregiver) : Good/Good
Facial/Vision:
Facial and vision :
Skin and Soft Tissue:

Sensation: S/E/W H / K /A
Light touch
Pinprick
Temperature
Joint position sense
Joint motion sense
Two point discrimination:
Pain:

Coordination:
Items (times/quality) Right Left
Finger-nose-finger

Heel on shin

Reflexes:
Right Left
Reflexes Response Reflexes Response
Biceps Biceps
Triceps Triceps
Brachioradialis Brachioradialis
Patellar Patellar
Achilles Achilles
Babinski sign Babinski sign

Balance Reactions/Righting reactions:

Skeletal and Joint condition(ROM, Deformities, Subluxation, Leg length discrepancies):

ROM :

Deformities :
Subluxation :
Posture:
 Ant. view Lat. view
Sitting 1. 1.

Standing 1.

Motor Control (Active movement, Tone, Strength, Synergy):

Head/Neck/Trunk:
MMT: 4
Upper Extremities:
Brunnstrom stage(P/D): V / V Gr.4
MAS:
Joint Muscle R L
S Flexor 0 0
Extensor 0 1
E Flexor 0 1
Extensor 0 0
W Flexor 0 0
Extensor 0 0
MMT: (R’t side MMT: 4)
L’t Flex Ext Add Abd IR ER Pronation Supination
S 2 3 3 2 3 3
E 3 3 3 3
W 4 4
Lower Extremities:
Brunnstrom stage: V Gr.4
MAS:
Joint Muscle R L
H Flexor 0 0
Extensor 0 0
K Flexor 0 0
Extensor 0 0
A Flexor 0 0
 Extensor 0 0
MMT: (R’t side MMT: 4)
L’t Flex Ext Add Abd IR ER Dorsi Plantar Inver Ever
H 4 4 4 4 4 4
K 4 4
A 4 2 4 4
Upright Control:
KEY:
Flex Ext
W=Weak
R L R L
M=Moderate
Hip S M S M
S=Strong
Knee S M S M
E=Excessive
Ankle S W S W

Functional Level(Amount of assistance, quality of movement):

Key: I= Independent Min. A= Minimal Assistance
MI= Modified Independence Mod. A=Moderate
Assistance
S= Supervision Max. A= Maximal Assistance
CG= Contact Guard D= Dependent
Bed Mobility: Rating Indications of Type of Transfer +/ or Equipment
Rolling to Right Sidelying I
Rolling to Left Sidelying I
Rolling Supine to Prone S
Rolling Prone to Supine S
Supine to Sitting S
Sitting to Supine S
Bridging I

Transfers:
Sit to Stand CG
Stand to Sit CG
Bed to Chair CG
Chair to Bed CG
W/C to Car CG
Car to W/C CG

Ambulation:
Level CG
Carpet NA
Ramps: Angle NA
Curbs: Height NA
Stairs: stairs, flights NA

Gait pattern:
Trunk Hip Knee Ankle
Stance phase 1. Forward 1. Insufficient 1. Normal 1. Foot flat
2. Round hip extension 2. Push-off
 shoulder 2. Trendelenburg weakness
Swing phase 1. Forward 1. Normal 1. Normal 1. Insufficient
2. Round dorsiflexion
shoulde
r
Berg Balance Scale
1. Sit to stand :4
2. Standing unsupported : 3
3. Sitting unsupported : 4
4. Standing to sitting : 4
5. Transfers : 4
6. Standing with eyes closed : 2
7. Standing with feet together : 2
8. Reaching forward with outstretched arm : 1
9. Retrieving object from floor : 2
10. Turning to look behind : 3
11. Turning 360 degrees : 2
12. Placing alternate foot on stool : 0
13. Standing with one foot in front : 2
14. Standing on one foot : 0
Total : 33 (score < 36 means risk of fall approach 0%)

Management of W/C parts Rating Indications of Type of Transfer +/ or Equipment

Brakes NA
Armrests NA
Legrests NA
Foot Plates NA
Ramp Retarders NA

NA
Wheelchair Mobility: □Man □Elec

Level Propulsion NA
Rough Terrain NA
Ramps: Angle NA
Curbs: Height NA

Velocity: □W/C Walking

Preferred speed: 186 M/min
Fast speed: 120 M/min

Endurance: 6min. walking test □ 6min. arm ergometer test

HR SBP DBP RR RPE Distance (m)

Pre-e’x 102 139 74 21
Post-e’x 109 168 74 28 6 228
Equipment/Arch Barriers:
NA
Assessment:
Impression: R’t MCA infraction/c L’t hemiplegia.
Problem list:
1. Poor standing balance due to poor even weight bearing
2. Poor sit ⇋ stand mobility due to poor even weight bearing and balance reaction
3. Pain due to knee OA and restrict of ROM
4. ROM limitation
1) Shoulder flexion ROM limitation due to muscle tone and pain
2) Pronation and supination ROM limitation due to Brunnstrom stage 4
5.Abnormal gait pattern
1）Foot flat due to poor dorsiflexor strengthening
2）Trunk lean backward due to core muscle
weakness 3）Trendelenburg due to hip abductor
weakness
4）Ankle poor push-off due to poor plantarflexor strengthening

Goals: Plan:
STG (2 weeks)
Increase WB to L’t side ⚫ 1.1 Stand on tilting table with R’t foot
F→G step up and down or step by step.
⚫ 1.2 Use step to practice step by step or
step on step with L’t foot keep on the
step.
⚫ 1.3 Put sand bags infront of patient L’t
side, use R’t hand to take and throw it.
⚫ 1.4 Touch mirror in front of patient when
she stand up (Practice functional reach)
Improve dynamic standing balance reaction ⚫ 2.1 Forward reach practice
F→G ⚫ 2.2 Same as 1.1, 1.2, 1.3, 1.4
⚫ 2.3 Pick up sand bags from outside
of BOS to move patient’s COG
Pain ⚫ 3.1 Electrotherapy
Reduce to nature ⚫ 3.2 PROM
Increase shoulder flexion ROM ⚫ 4.1 Roll ball on the wall up and down
ROM 100 degree to full range ⚫ 4.2 Finger ladder
Improve pronation and supination ⚫ 5.1 Throw up sand bags and grasp it from
MMT : 4→5 R’t or L’t side
⚫ 5.2 Throw up sand bags and grasp it by
doing pronation
Improve dorsiflexor strength ⚫ 6.1 Use thera-band cross on ball of foot
MMT : 2→3 and R’t foot do dorsiflexion and change
another foot
⚫ 6.2 Stand infront of wall. When patient
swing trunk forward, then patient do
plantarflexion; when patient swing trunk
backward, then patient do dorsiflexion
Improve core muscle strength ⚫ 7.1 Bridge
Trunk backward lean → trunk natural ⚫ 7.2 Stand on tilting plate
Improve hip abductor ⚫ 8.1 Kick ball by sideway
strength MMT : 3→4 ⚫ 8.2 Step by step by sideway
⚫ 8.3 Use towel do AAROM
⚫ 8.4 Use thera-band do resisted ROM
Improve plantarflexor strength ⚫ 9.1 Same as 6.2
MMT : 2→3 ⚫ 9.2 Do tiptoe
LTG (2 months)
1. Walk at home independently and safely
2. Transfer, ambulation of ADL independently and safely
Home program
1. Standing with both hand grasp on chair and do plantarflexion *20 times / round
2. Do one leg stand with both hand grasp on chair (both leg)*20 times / round
PTs: