PHYSICAL
THERAPY
PROGRESS
NOTES:
MAY
20,
2002
with
Conrad
de
Jesus
SUBJECTIVE: Parents main concern is Crystal's functional mobility.
OBJECTIVE:
Range
of
Motion:
within
normal
range
on
both
legs
and
arms.
(active-assistive)
Muscle
strength:
both
arms
and
legs
can
move
against
gravity
less
than
50%
of
the
available
range.
(2+/5)
Hips:
Hips
are
poor-fair.
Note:
hip
internal
rotation,
flexion
and
adduction
are
contraindicated
when
combine
due
to
hips
subluxation.
(Barlow's
test-is
positive
due
to
dislocatable
hips.)
Shoulder
Joints
stability
is
fair,
no
sign
of
subluxation.
Deep
Tendon
Reflex:
hyporeflexia
to
areflexia
(slow
reacting
muscle
response.)
Developmental
Reflex:
slow
anti
gravity
muscle
response.
Posture:
increase
on
lordotic
curve
both
on
cervical
and
lumbar
area.
S-curve
scoliosis
upon
standing
due
to
muscle
imbalance.
Cubitus
valgus
is
also
present
on
her
elbow.
Both
Wrist
joints
are
ulnarly
deviated.
Forearm
pronated
with
mild
contracture
of
the
supinator
muscles.
Balance:
good-fair
upon
sitting.
fair
upon
static
standing,
standing
with
support
Gross
Motor:
She
is
able
to
walk
with
two
hand
trunk
support.
She
is
able
to
tolerate
standing
holding
thru
furniture,
she
able
to
sit
independently.
However,
she
is
unable
to
sit
from
supine.
She
an
walk
independently,
pull
up
and
raise
her
head
and
upper
trunk,
pedal
her
legs
well,
during
pool
therapy
with
water
on
her
midthorax
level.
ASSESSMENT: She able to tolerate all Physical Therapy exercises, stretching, Range of Motion with quick stretch technique to stimulate muscle contraction.
Desire
outcome/Prognosis:
1.
Improve
motor
control
of
stability
and
movements
patterns.
2.
Caregiver
will
be
able
to
follow
the
home
exercise
program
independently.
GOALS:
1.
Will
be
able
to
improve
balance
upon
standing
and
tolerate
standing
activities
well
without
knees
hyperextension.
2.
Will
be
able
to
respond
well
upon
muscle
stimulation.
3.
To
correct
posture
and
prevent/delay
its
progress.
4.
To
increase
functional
mobility.
5.
Will
walk
independently
on
a
pool
without
loosing
her
balance.
6.
Will
be
able
to
control
her
self
well
upon
floating.
PLAN: Continue skilled P.T. for neurodevelopmental techniques incorporate with play therapy, therapeutic exercise/activities, therapeutic massage, stretching, gait training, pool therapy and caregiver education for 60 minutes for twice a week.
CONRAD
DE
JESUS
Early
Intervention
Specialist
