Physical Therapy Progress Report
Children's First Rehab Service
First Steps Early Intervention System Physical Therapy Progress notes
| Child's Name: | Crystal Allbritton |
| Date of Birth: | July 18, 1999 |
| Today's Date: | January 14, 2002 |
| Service Coordinator: | Terry Rizen |
| Physical Therapist: | Conrad De Jesus |
| Treatment Diagnosis: | Spinal Muscular Atrophy |
| Hypotonia | |
| Delayed Gross Motor Development |
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 stability is poor-fair.
Note: hip internal rotation, flexion and adduction are contraindicated when combine due to hips subluxation.
Shoulder Joints stability is fair, no sign of subluxation.
Deep Tendon Reflexes: hyporeflexia to areflexia (slow reacting muscle response to no muscle response)
Developmental Reflex: slow anti gravity muscle response.
Posture: neck/trunk hyperextension when she loss her balance upon sitting and standing.
S-curve scoliosis upon standing due to muscle imbalance.
Both Wrist joints are ulnarly deviated
BALANCE: good-fair upon sitting, fair upon static standing standing with support
Gross Motor: she is able to make a few steps with support and with steppage gait. She able to tolerate quadruped and standing position with support. She able to sit independently.
ASSESSMENT: She able to tolerate all Physical Therapy exercises, stretching, Range of Motion with quick stretch technique to stimulate muscle contraction.
Desire outcome/Prognosis:
Improve motor control of stability and movement patterns.
Caregiver will be able to follow the home exercise program independently.
Goals:
Will be able to improve balance upon standing and tolerate standing activities well without knees hyperextension.
Will be able to response well upon muscle stimulation.
To correct posture and prevent/delay its progress.
To increase functional mobility.
PLAN: Continue skilled PT for neurodevelopmental techniques incorporate with play therapy, therapeutic exercise/activities, therapeutic massage, stretching, gait training and caregiver education for 45 minutes for twice a week.
Conrad De Jesus RPT, Early Intervention Specialist