Sample PT Prognosis and Goals
E.B
Spinal Cord Injury
Problem List
Impairment
Activity Limitation
Participation Restriction
PIPs
inability to walk inability to assume standing from sitting position inability to transfer independently
(bed wheelchair; wheelchair floor) inability to perform role as a teacher inability to do leisure activities with his spouse inability to perform role as family provider
NPIPs
weakness muscle atrophy impaired deep sensation grade 1 spasticity of B knee flexors decreased ms endurance impaired standing balance inability to maintain standing for more than 10 minutes inability to transfer independently (wheelchair floor) limitation in wheelchair ambulation (~200m with fatigue in B UE) inability to negotiate stairs
Priority Problems
Major
Minor weakness impaired proprioception and kinesthesia decreased ms endurance impaired standing balance inability to walk inability to assume standing from sitting position inability to transfer independently (bed wheelchair) inability to maintain standing for more than 10 minutes muscle atrophy grade 1 spasticity of B knee flexors
Diagnosis Px is unable to ambulate, transfer, assume and maintain standing independently due to impaired standing balance, weakness, and impaired deep sensation secondary to SCI. Inability to ambulate is further affected by decreased ms endurance.
Prognosis
E.B has good prognosis on stair ambulation with the use of BAC and KAFO in 3 months. The px has low level of neurological lesion and has motor incomplete ASIA score indicating that the px has high current functional status thus a possibility of higher future outcome compared to other SCI patients with high level of neurological lesion. It is good to note that px has undergone early spinal fracture stabilization preventing further complication of the injury and allowing early PT intervention. The px presents with grade 1 spasticity on (B) knee flexors and has impaired deep sensation such as
Spinal Cord Injury
Problem List
Impairment
Activity Limitation
Participation Restriction
PIPs
inability to walk inability to assume standing from sitting position inability to transfer independently
(bed wheelchair; wheelchair floor) inability to perform role as a teacher inability to do leisure activities with his spouse inability to perform role as family provider
NPIPs
weakness muscle atrophy impaired deep sensation grade 1 spasticity of B knee flexors decreased ms endurance impaired standing balance inability to maintain standing for more than 10 minutes inability to transfer independently (wheelchair floor) limitation in wheelchair ambulation (~200m with fatigue in B UE) inability to negotiate stairs
Priority Problems
Major
Minor weakness impaired proprioception and kinesthesia decreased ms endurance impaired standing balance inability to walk inability to assume standing from sitting position inability to transfer independently (bed wheelchair) inability to maintain standing for more than 10 minutes muscle atrophy grade 1 spasticity of B knee flexors
Diagnosis Px is unable to ambulate, transfer, assume and maintain standing independently due to impaired standing balance, weakness, and impaired deep sensation secondary to SCI. Inability to ambulate is further affected by decreased ms endurance.
Prognosis
E.B has good prognosis on stair ambulation with the use of BAC and KAFO in 3 months. The px has low level of neurological lesion and has motor incomplete ASIA score indicating that the px has high current functional status thus a possibility of higher future outcome compared to other SCI patients with high level of neurological lesion. It is good to note that px has undergone early spinal fracture stabilization preventing further complication of the injury and allowing early PT intervention. The px presents with grade 1 spasticity on (B) knee flexors and has impaired deep sensation such as