Initial Evaluation for

Spinal Cord Injury

In partial fulfillment of the requirements

for Clin Ed 1: Case Conference
 Submitted by:

BSPT – 4
BORELA, Rhue Andrea Paula A.
CASTINO, Ma. Nichole A.
CINCO, Axel Justine S.
GUYOT, Andre F.
MANTARING, Arjane M.
MONARES, Johanna Lynn M.
REYES, Charlton John C.
TOREVILLAS, Lex Martine J.
Group 4

Submitted to:
Mr. Jan Andy Gatillo, PTRP
Ms. Eva Alexis Cebellos, PTRP
Ms. Sharah Charisse Wang, PTRP
  Initial Evaluation

Name: C.V.P Date of IE: 09/ 23/19

Age: 16 y/o Date of Admission: O.P

Sex: ♀ Room #: O.P

Address: Balagtas, Panganiban, Cebu City Referring M.D: Dr. Arbatin (exact name unrecalled)

DOB: 01/29/2003 Date of Referral: 06/07/19

Nationality: Filipino Physiatrist: unrecalled

Civil Status: Single Date of consultation: unrecalled

Occupation: N/A; student Dx: T/C (to consider) Traumatic SCI (Non-traumatic SCI 2°
Pott’s disease)

Religion: Roman Catholic Meds: Myrin od ac (dosage unrecalled)

Handedness: R
/S/: (All pertinent information was taken from the pt.)

C/O: Pt. c/o difficulty walking d/t (due to) weakness of both (B) legs. (PT should have asked if there is
still pain, rate of pain, type & location)

HPI: Pt’s current condition started when pt. felt pain (PT should have asked for the pain rating & type
of pain) on her back somewhere in March 2019 (exact date unrecalled) which caused her to have a
consultation c a private physician (exact name unrecalled) & was diagnosed c UTI, prescribed c
cefuroxime (dose unrecalled) which was taken for 7 days but back pain was still not addressed. (PT
should have asked for the name of the hospital) Pt. still continued to join dance practices in school
which caused her back pain to worsen. Pt. just ignored it because she thought that the pain would just
go away until she woke up one morning on May 10, 2019 experiencing a severe stabbing pain in her
lower back rated as 9.5/10 ( 0 = no pain; 10 = worst pain possible) c numbness on B LEs. Pt. was
unable to get up from bed, stand & walk. Pt. was then brought to Chong Hua Medical Hospital in
Fuente (PT should have asked method of arrival to hospital such as: stretcher-bound, w/c bound/arm
borne) where the pt. had an x-ray which showed a “break on the spine” & MRI showing severe
pathological compression fx on T6 vertebral body c gibbus deformity, paravertebral mass which
caused compression on thecal sac and SC findings may be 2° to Pott’s disease. She was then admitted
on the same day (May 10, 2019) under the care of Dr. Arbatin (exact name unrecalled). Pt. underwent
surgical removal of the mass on May 16, 2019 & wherein a metal implant was also inserted on the
spine; received one PTRx as an IPT (Initial PT treatment) & was discharged (D/C) on May 18, 2019.
She started having PTRx in San Nicholas Rehabilitation Center last June 05, 2019 c a schedule MWF
Prior level of function: Pt. can do ADLs s any difficulty & limitation (Pt. is indep in all ADLs); & was
active in school activities.
Social Hx: Pt. lives c family including mother, 2 siblings, grandmother, aunt & 2 cousins. Her siblings
go to school which can assist her during night time & her grandmother & aunt assist her when
mother is not around. Pt. has no (cultural &religious) belief which can interfere c PTR.
Employment Status: Pt. is an incoming grade 11 student but stopped at present d/t (due to)
condition. Prior to summer vacation, she goes to school Monday to Friday (8:00 am(a.m)- 5
pm(p.m.)); joins school activities; active member of dance team, attending practice p class for
approx.. ~3 hrs. every dance practice session.
Living Environment: Pt. lives in a 2-storey house c cemented flooring c stairs having ~8 steps c
railings on both sides; ~10 steps main door <-> bed, ~11 steps bed <-> kitchen; ~7 steps bedroom
<-> CR; (-) ramp since ground floor is level from outside <-> inside of the house.
General Health Status: Pt. rates general health status as fair because she can now walk s any assist.;
no more back pain & sees that her condition is improving.
Social Health Habits: Pt. is an active member of dance team in school; spends most of her time in
dance practice & likes to binge-watch K-dramas during freetime; denies smoking & drinking.
Family Health Hx:

Disease Maternal Paternal Patient

Htn/ CVA (Htn) (+) N/A (-)

CVA (-) N/A (-)

DM (-) N/A (-)

OA (-) N/A (-)

CA (-) N/A (-)

Arthtitis (-) N/A (-)

Significance: Pt. is (-) for any heredito-familial dse paternally & maternally. (Pt is at risk of htn
2° maternal genetic predisposition; Paternal hx was not asked since pt. grew up s father.)
Medical/ Surg Hx:

Procedure Date Hospital

1.Surgical Removal of Paravertebral May 16, 2019 Chong Hua Medical Hospital
Mass

2.Spinal Metal Implant May 16, 2019 Chong Hua Medical Hospital

Other Clinical Test:

Test Date Hospital Result

1.X- ray May 10, 2019 Chong Hua Medical Hospital “break” on the spine
2.MRI May 10, 2019 Chong Hua Medical Hospital Severe pathological
compression fx on T6
vertebral body c gibbus
deformity
Functional Status: Pt. can do ADLs indep. (Pt. can do ADLs indep. c difficulty)

Medications:

Dosage Frequency Indication

Myrin unrecalled od ac TB
B- complex unrecalled od supplements
sangobion unrecalled od Iron supplements c
vitamins & minerals

Pt. goals: Pt. states that she wants to achieve complete relief of pain on B LE & be able to
ambulate s any difficulty to resume active lifestyle & be able to dance again.
/O/:

OI: Pt. came to Rehab indep c supervision (-) assistive device; ectomorphic as to body built; (+) gait
deviations; (-) postural deviations; (-) assistive device; (-) edema, (-) wounds

SYSTEMS REVIEW:
Cardiopulmonary System: unimpaired; (-) edema
a Rx p Rx LOCATION, METHOD, POSITION

BP (mmHg) 120/70 mmHg 110/70 mmHg L Brachial artery, Auscultatory, Sitting

PR (bpm) 80bpm 81 bpm L Radial Artery, Palpation, Sitting

RR (cpm) 17 cpm 17 cpm Chest, Observation,Sitting

Integumentary System: unimpaired
Skin color: unimpaired
Skin texture: unimpaired
Pliability & turgor: unimpaired
Musculoskeletal System: impaired (on B LE)
Gross ROM: impaired (on B LE)
Gross Strength: impaired on B LE
Gross Symmetry: unimpaired (impaired on B LE)

Height:

Weight:
Neuromuscular System: (impaired)
Balance: impaired, difficulty in prolonged standing & walking d/t (due to) weakness in B LE
Gait: impaired, d/t (due to) weakness in B LE
Locomotion: impaired
Motor Function: impaired (unimpaired)
Communication: Age appropriate & unimpaired

Affect: Pt’s emotional & behavioral responses are unimpaired

Cognition: unimpaired; alert & oriented x3 as to PPT (person, place, time)

Learning Barriers: Pt. has no learning barriers

Learning Style: Pt. learns best through verbal instructions c demonstration

Educational Needs: HEP, postural education & body mechanics, safety &
energy conservation technique, emphasis on compensatory movements during
exercise, disease process
Test & Measures:

ASIA Impairment Scale:

ASIA Impairment Scale

☐ A = Complete: No motor or sensory function is preserved in the sacral segments S4 to S5.

☐ B = Incomplete: Sensory but motor function is preserved below the neurological level and
includes the sacral segments S4 to S5.

☐ C = Incomplete: Motor function is preserved below the neurological level, and at least half of
key muscles below the neurological level have a muscle grade less than 3.

☐ D = Incomplete: Motor function is preserved below the neurological level, and at least half of
key muscles below the neurological level have a muscle grade of 3 or more.

☐ E = Normal: Motor and sensory function is normal.

Clinical Syndromes
☐ Central cord
☐ Brown-Sequard
☐ Anterior cord
☐ Conus medullaris
☐ Cauda equina

Significance: Pt. has normal sensation in all dermatomal level; except T3-L1 not assessed
bec of pt’s choice of privacy & is already functional in performing ADLs c slight difficulty in
amb & transfers.
DTR:

Legend:
0 - Arreflexia
+ - Hyporeflexia
++ - Normal
+++ - Hyperreflexia
++++ - Clonus

Sig: Pt. has normal reflexes (normoreflexive) (indicating intact reflex arc.)

ROM: All major jts. In the body were grossly assessed (actively & passively in sitting
position) & found to be WNL (c normal end-feels), except the ff:
 Motion Normal AROM Difference PROM Difference End Feel
(Normal - (Normal -
AROM) PROM)
R hip flexion 0-120° 0-80° 40° 0-95° 25° Firm
L hip flexion 0-120° 0-50° 70° 0-70° 50° Firm
R hip 0-40° 0-20° 20° 0-25° 15° Firm
abduction
L hip 0-40° 0-20° 20° 0-25° 15° Firm
abduction
R hip 0-20° 0-10° 30° 0-20° 0° Firm
adduction
L hip 0-20° 0-10° 10° 0-15° 5° Firm
adduction
R knee 0-135° 0-110° 25° 0-120° 15° Firm
Sig: LOM was present on B LE d/t weakness 2° to traumatic SCI.
flexion
L knee flexion 0-135° 0-125° 10° 0-130° 5° Firm
Significance: Pt. has ↓ ROM on B active & passive hip flexion, abduction, adduction & B active & passive knee
flexion due to muscle weakness 2° to Non-traumatic SCI. (PT should have assessed ROM in hip correctly c
proper positioning)
MMT: All major muscle groups of the body were grossly assessed & graded 5/5 except:

Muscle group R L

Hip Flexors 3-/5 3-/5

Hip Abductors 3-/5 3-/5

Hip Adductors 3-/5 3-/5

Knee Flexors 4-/5 4-/5

Knee Extensors 4+/5 4/5

Sig: Pt. presents c weakness on B LE due to 2° to traumatic SCI.

Significance: Pt. presents c ↓ muscle strength due to weakness on B hip flexors,

abductors, adductors & B knee flexors & extensors 2° non-traumatic SCI.
Legend:

0 Zero No palpable or observable contraction of muscle

1 Trace Palpable contraction but no visible movement; no resistance

1+ Trace Plus Min. observable motion (<50% ROM), gravity minimized, no resistance

2- Poor Minus At least 50%, gravity minimized, no resistance

2 Poor Able to move through full ROM gravity eliminated

2+ Poor Plus Full available ROM, gravity minimized, slight manual resistance

3- Fair Minus At least 50% ROM, against gravity, no resistance

3 Fair Full available ROM, against gravity, slight manual resistance

3+ Fair Plus Full available ROM, against gravity, slight manual resistance

4- Good Minus Full available ROM, against gravity, nearly mod. manual resistance

4 Good Full available ROM, against gravity, mod. manual resistance

4+ Good Plus Full available ROM, against gravity, nearly strong manual resistance

5 Normal Full available ROM, against gravity, strong/max manual resistance

Balance & Tolerance:

Position Balance Tolerance

Sitting Good Fair

Standing Good Fair

Walking Good Poor

Legend:

Balance:

Normal Static: pt. able to maintain steady balance s handheld

support
Dynamic: pt. accepts max. challenge & can shift weight
easily within full(?) range in all directions
Good Static: pt. able to maintain balance s handheld support,
limited postural sway
Dynamic: pt. accepts mod. challenge, able to maintain
balance while picking up object from the floor
Fair Static: pt. able to maintain balance c handheld support;
may require occasional (?) min. assistance
Dynamic: pt. accepts min. challenge; able to maintain
balance while turning head/ trunk
Poor Static: pt. requires handheld support & mod-max assist.
to maintain position
Absent Pt. unable to maintain balance
Tolerance:

Good >60mins

Fair + 45 - 60 mins

Fair 30 - 45 mins

Poor + 15 - 30 mins

Poor <15mins

Sig: Pt. presents c impaired balance & tolerance d/t (due to) weakness of B LE which limits pt’s
ability to accept perturbations 2° non-traumatic SCI. (PT should have used another assessment
tool for balance & tolerance like Berg Balance Scale to determine pt.’s risk of fall; PT should
have separated findings on static or dynamic Balance)
Pathological Reflexes:

Procedure (+) sign Remarks

Babinski Stroking on lat. edge of
foot to big toe by stroking
inverted J
Chaddocks Stroking lat. aspect of foot
beneath lat. mal.
Gordons Forcefully stroking or
squeezing calf muscle
Oppenheim Stroking med. side. of tibial
crest in upward motion
Ext. of big toe, fanning of
toes
Ext. of big toe, fanning of
toes
Ext. of big toe, fanning of
toes
Ext. of big toe, fanning of
toes
(-) fanning of toes & ext of
big toe
(-) fanning of toes & ext of
big toe
(-) fanning of toes & ext of
big toe
(-) fanning of toes & ext of
big toe

Sig: Pt. is (-) in all pathological reflexes indicating integration of reflexes

Significance: Pt. presents (-) pathological reflexes indicating (-) UMNL.
Coordination:

Test Grade

Heel on shin 4

Alternate tapping of feet 4

Legend:
4 Normal Performance

3 Minimal Impairment Able to accomplish activity, slightly less than normal control, speed & steadiness

2 Moderate Impairment Able to accomplish activity, movements are slow, awkward & unsteady

1 Severe Impairment Able only to initiate activity s competition, movements are slow, c significant unsteadiness, oscillations and/or
extraneous movements

0 Activity Impossible

Sig: Pt. has no coordination problem

Significance: Pt. presents c unimpaired coordination indicating (-) UMNL.
Gait Assessment:

STANCE PHASE R L

Initial Contact No deviations were noted. No deviations were noted.

Loading Response Trunk leans laterally toward the ipsilateral side. Trunk leans laterally toward the ipsilateral side.

Mid Stance Pelvis drops toward the ipsilateral side. Knee Pelvis drops toward the ipsilateral side. Knee
wobbles. wobbles.

Terminal Stance No deviations were noted. No deviations were noted.

Pre - Swing No deviations were noted. No deviations were noted.

SWING PHASE R L

Initial Swing No deviations were noted. No deviations were noted.

Mid Swing No deviations were noted. No deviations were noted.

Terminal Swing No deviations were noted. No deviations were noted.

Significance: Pt. presents c (+) knee wobbling in B LE & (+) pelvic drop c trunk leaning on the ipsilateral side due to
muscle weakness 2° non-traumatic SCI. (PT should have assessed & documented for the gait properly)
Postural Assessment: (Pt. position: standing)

Anterior Posterior Lateral

Head Midline Midline Aligned to shoulder

Shoulders B sh level horizontally B sh level horizontally (-) protraction of SH
Trunk/Spine Normally aligned Normally aligned Slight kyphosis on cervical region
Pelvis B pelvis level c ASIS B pelvis level c PSIS (-) Ant & post. Tilting
Knee B patella neutral; (-) (-) genu (-) genu recurvatum
genu varum/valgum varum/valgum
Ankle (-) deviations (-) in toeing/out- Neutral
toeing

Significance: Pt. has slight kyphotic deformity d/t (due to) (+) gibbus deformity
Significance: Pt. presents c (-) postural deviation. (PT should have correctly assessed the
posture.)
Functional Independence Measure:
Self-care

a. Eating 7
b. Grooming 7
c. Bathing 5
d. Dressing - upper 7
e. Dressing - lower 5
f. Toileting 5
Sphincter Control

g. Bladder 7
h. Bowel 7
Transfers

i. Bed, chair, w/c 5

 j. Toilet 5

k. Tub, shower 5
Locomotion

l. Walk/ wheelchair 5
m. Stairs 5
Communication

n. Comprehension 7
o. Expression 7
Social Cognition

p. Social Interaction 7
q. Problem Solving 7
r. Memory 7
Total: 110/126
Legend:

Independent No helper
7- complete indep (timely, safely)
6- modified indep (device)

Modified Dependence Helper

5- supervision (subject-100%)
4- minimal assist (subject-75%)
3- moderate assist (subject-50%)

Complete Dependence
2- Max. assist (subject-25%)
1- Total assist (subject- less than 25%)

Significance: Pt. has a total score of 110/126 showing complete independence in most
ADLs except bathing, dressing LE, toileting, locomotion & transfers d/t (due to) weakness
of B LE (2° Non-traumatic SCI)
/A/

Problem List:

1. Difficulty performing functional ambulation

2. ↓ muscle strength & LOM on B LE
3. Impaired balance & tolerance in walking & prolonged standing
4. (+) postural deformity
5. Impaired stability
1. Difficulty performing functional activities like bathing, dressing in LE, transfers & locomotion
2. ↓ AROM & PROM in B hip flexors, abductors, adductors & B knee flexion
3. ↓ muscle strength on B hip flexors, abductors, adductors & B knee flexors & extensors
4. Impaired balance & tolerance sitting, standing & walking

PT Impression: Pt. presents c ↓ muscle strength & LOM on B LE showing difficulty in prolonged walking
& standing d/t impaired stability & tolerance. Pt. will benefit from sit to stand/standing exercises to
improve balance & tolerance, wobble board to ↑ stability, AROMEs to prevent loss of motion & ES & FES
on B LE for muscle re-education.
PT Diagnosis: Pt. presents c ↓ AROM & PROM in B hip flexors, abductors,
adductors & B knee flexors due to muscle weakness 2° non-traumatic SCI
which limits her ability to perform functional activities like bathing, dressing in
LE, transfers & locomotion. Pt. will benefit from AROME & stretching to ↑ ROM
in B hip & knee motions; will also benefit from PREs on B hip & knee
musculature to ↑ muscle strength.

PT Diagnosis(Practice pattern should have been used instead of PT Diagnosis):

Neuromuscular Pattern H: Impaired motor function, peripheral nerve integrity
& sensory integrity associated c non-progressive disorders of the spinal cord
Prognosis: Pt. has good Rehab potential d/t (due to) young age, good
compliance to Rehab, willingness to improve & progression of the condition.
(PT should have added the support system of the pt. who is always available
to assist in ADL’s)
/P/
LTG:
1. Pt will be able to demonstrate normal balance & tolerance in standing & walking p 2 mos of
PTR to be able to ambulate s any limitation
2. Pt. will demonstrate functional MMT muscle strength on B LE c a muscle grade of 4+/5 p 12
PT Rehab sessions.
3. Pt. will demonstrate normal postural alignment on L view p 12 PT Rehab sessions.
4. Pt. will demonstrate complete independence in functional amb specifically in transfers p 12
mos of PT Rehab sessions
5. Pt. will demonstrate good stability p 2 mos of PTR sessions.
Expected Outcome:
6. Pt. will be able to achieve an increment of ~20° of ROM actively & passively in B hip & knee
motions p 4 mos. of PTR sessions to be able to do activities s difficulty.
7. Pt. will be able to achieve a MMT grade from 3-/5→4/5 on B hip flexors, abductors & adductors,
from 4-/5→5/5 on B knee flexors & from 4+/5→5/5 on B knee extensors p 4 mos. of PTR sessions
to be able to perform functional activities.
8. Pt. will be able to achieve an ↑ in tolerance in sitting & standing from Fair→Good, et. in walking
from Poor→Fair+ p 3 mos. of PTR sessions to be able to amb. safely et. indep. anywhere s
supervision.
STG:
1. Pt. will be able to demonstrate good balance & tolerance in prolonged standing & walking p 6 PT Rehab sessions
(2 weeks)
2. Pt. will demonstrate ↑ muscle strength on B LE p 6 PT Rehab sessions (2 weeks)
3. Pt. will demonstrate improved postural alignment to address gibbus deformity p 6 PT Rehab sessions (2 weeks)
4. Pt. will demonstrate modified independence in functional amb activities in transfers p 6 PT Rehab sessions (2
weeks)
5. Pt. will demonstrate improved stability p 6 PT Rehab sessions (2 weeks)
Anticipated Goal:
6. Pt. will be able to achieve an increment of ~5° of ROM actively & passively in B hip & knee motions p 2 mos. of PTR 
sessions  to be able to do activities c ease.
7. Pt. will be able to achieve a MMT grade from 3-/5→3+/5 on B hip flexors, abductors & adductors,, from 4-/5→4+/5 
on B knee flexors & from 4+/5→5/5 on B knee extensors p 2 mos. of PTR sessions to be able to perform functional 
activities.
8. Pt. will be able to achieve an ↑ in balance in sitting, standing & walking from Good→Normal p 2 mos. of PTR sessions 
to be able to transfer safely. 
9. Pt. will be able to achieve an ↑ in tolerance in sitting & standing from Fair→Fair+, et. in walking from Poor→Fair p 1 
mos. of PTR sessions to be able to amb. safely et. indep. 
IP: Pt. will be seen & treated in the Rehab as an OP, 3x/week (MWF) at 11am-12nn c the ff. management given:
1. ES & FES x5 min. on B LE for muscle re-education
2. // bar exercises to ↑ LE strength & improve tolerance & stability
a. Sit-to-stand x10 reps x3 sets
b. Standing c perturbations x3 min in all planes x10 reps x3 sets
c. Weight shifting exercises while standing on foam x10 reps x3 sets
d. Heel raises x10 reps x3 sets
e. Marching in place c 2kg Ankle weights x10 reps x3 sets

3. PREs on B LE using green thera band & ankle weights (5lbs) on all hip, knee & ankle motions x8 reps x2 sets to ↑ muscle strength
4. Gait training c cones c 2kg Ankle weights for 3 meters x 3 sets
5. Partial Squats x10 reps x3 sets to strengthen quadriceps
6. Partial Lunges x10 reps x3 sets to strengthen quadriceps

Suggestion:
1.Bicycle Ergometer for 5 mins to ↑ cardiovascular endurance
HEP:
2.Stepping up & down the stairs (1st 3 steps) x 10 reps x 1 set
3.Weight shifting x 10 reps x 1 set
4.AROMEs on B LE to maintain jt. & soft tissue integrity
Precautions:
5.Easy fatigability
6.Risk for falls