Professional Documents
Culture Documents
Precautions none
Prior Functional Level 100% powerlifting, full participation in field and PT events
Forearm + + + + Community
Household
Elbow + - + -/ Follows Commands
Assist
Up. Arm + + + + Easily Distracted Device CR
Shoulder + - + /- Home Environment Non-Ambulatory
+ Align Neck + + Single Safety Awareness
Married (w/kids)
= Align Lats + + + + Poor
1 boy 5yrs – plays baseball
Lower Extremities -2 7- 2-- + 1 girl 3 yrs – tea parties, dress up, dogs
Fair
+ + Single Parent Good
- Align Lumbar Divorced Needs Verbal/Tactile Cues
Committed Relationship
= Align Hip + + + + Sensation
Thigh + + /- + No apparent nerve damage Pain Status
Groin + + + + Says pain is minimal but while performing
functional tests it is clearly visible that
Knee - + - + pain is present. Occasionally
L.Leg - + -/ + overcompensates with R Leg.
Ankle + /- + + Trunk Strength/ROM Psychosocial
Foot + + + + Poor Work on creating safe environment where
open dialog about pain and recovery are
Tone Fair
encouraged. Mentally tough but needs to
Outstanding physical fitness Good return to full participation when he is
Continue with core exercises to maintain physically healed .
Undercompensating L physique and mobilization
Coordination Barriers in Learning Endurance
Hand/Eye + Military training Extremely high pain tolerance compared to
past clients with torn ACLs. Will be able to
High pain tolerance
push patient during treatment plan but he
has been trained to not show emotion.
Comments PATIENT IDENTIFICATION
Lack Major Biomechanical issues
Adjustments made on Neck & Lumbar
Intensive Rehab of the L Knee Bradley Austin Quinter, PFC
Rehabilitation Therapy
Physical Therapy Evaluation
NT = Not Tested CGA = Contact Guard Assist WBAT = Weight Bear as tolerated Equipment HW = Hemiwalker
NA = Not Applicable Min. A = Minimal Assist PWB = Partial Weight Bearing CR = Crutches SW = Standard Walker
Codes
I = Independent Mod. A = Moderate Assist TTWB = Toe Touch Wt. Bearing SPC = Single Point Cane FWW = Front Wheel Walker
S = Supervised Max. A = Maximum Assist NWB = Non-Weight Bearing NBQC = Narrow Base Quad Cane 4WW = Four Wheel Walker
SBA = Stand By Assist U = Unable WBQC= Wide Base Quad Cane WC = Wheelchair
Functional Status
Mobility Assist Mobility Assist Mobility Assist Transfers Assist
Cut Right Max. A Lunge R Leg Mod. A Hop L Leg U Lateral WBAT
Cut Left Max. A Lunge L Leg U Hop R Leg I Forward Max. A
Stationary Squat PWB Jump TTWB Kneel-Stand CGA Backward Max. A
Balance Sitting Standing Gait
Static + Equipment n/a Distance (Feet) 3.0
Dynamic + Assist CGA Weight Bearing R/L
Gait Analysis
Slightly longer length of stay in swing phase
Assessment
Problems Plan of Treatment
Decline in Mobility Most mobility ex. need assist Mobility Training
Decline in Transfers All transfers need assist Transfer Training
Decline in Gait Favoring R leg Progressive Gait/Stairs Training
Safety Awareness Deficits Instructions on Safety
Balance Deficits Left leg Balance Training
ROM/Strength Deficits Overall loss of strength/ROM after Therapeutic Exercises (specify) Weekly plans to follow
surgery
Other (specify)
Other (specify)
Frequency/Duration of Treatment:2/wk for first 5 weeks || 1-2/wk for months 2-6 depending on improvement
Comments: Surgery performed well, no infection, outstanding PATIENT IDENTIFICATION
physical fitness should enable for a more rapid recovery