CLINICAL CORRELATION 1

GENERAL INFORMATION:

Patient’s Name: J.C.D. Age: 27

Sex: Male
Address: Laging Handa, Diliman, Quezon City
Civil Status: Single
Handedness: Right-handed Occupation: Security Guard
Height: 182 cm
Weight: 57 kg
BMI: 19.3 kg/m2
Referring Unit: SJM Referring MD: Dr. D.G. Rehab MD: Dr.A.V.
Date of Admission: April 15, 2020
Date of Referral: June 8, 2020
Date of IE: June 21, 2020
Diagnosis: SCI - T7 Motor Incomplete ASIA D 2° GSW

SUBJECTIVE INFORMATION

C/C:
“Nahihirapan ako tumayo mag-isa at kailangan sinusuportahan pa ako ng tatay ko. Nahihirapan din ako sa pagsuot ng
pantalon sa kaliwang binti ko dahil ‘di ko sya maigalaw at tuwing kinakalong ko, naninigas sya. Nung isang araw naman,
natapunan ako ng nanay ko ng mainit na kape sa binti, wala akong naramdaman na paso at sakit sa magkabilang binti
ko pero nararamdaman ko naman kapag naglalambing yung pusa namin at dumidikit sya sa kanang paa ko.”

PT Translation:
Pt. c/o difficulty on standing up independently and LE dressing d/t muscle stiffness and monoparesis of (L) LE. Pt. also
c/o loss of pain and temperature sensation on (R) LE but a total loss of all sensation on his (L) LE.

Pt.’s Goal:
To be able to perform ADLs without difficulty and to stand up and perform safe ambulation independently.

HPI:
This is a case of J.C.D, 27 y/o, male, single, known for having a history of DM Type 2 controlled since 2019 and a
history of physical trauma last 2019, admitted for the first time in SJM Hospital with a c/c of muscle stiffness and
monoparesis of (L) LE.
~ 2 months PTIE, pt. was at work when a group of suspicious men entered and started robbing the bank. The pt.,
being a security officer tried to stop their heinous act but unfortunately resulted in being shot on his back by one of the
gunmen. The pt. remained conscious and bystanders who have witnessed the incident called for help. ~10 mins after,
the rescue personnel arrived and rushed the pt. to the hospital. While in the ambulance, the pt.’s spine was immobilized
with a spine board, was given first aid, and was ensured of an adequate airway, breathing, and circulation.
~ 2 months PTIE, after ~30 minutes from the arrival of the ambulance, the pt. arrived at SJM Hospital. Pt.
appeared to be able to respond to basic commands but seemed drowsy and has significant paresthesia and loss of
movement on (L) LE. Other significant findings include BP = 100/70 mmHg, HR = 60 bpm, and temperature = 34°C. Pt.
was given 25 mg of Midodrine and 50 mg of Atropine to normalize HR and BP. Pt. was confined the same day and
undergone laboratory procedures such as CT scan that revealed (+) burst fracture in T7 vertebrae and MRI that revealed
(+) (L) hemisection on T7 spinal cord. Pt. was then diagnosed using the ISNCSCI with SCI - T7; ASIA D Motor
Incomplete with a suspected Brown Sequard Syndrome to determine the neurologic status and undergone surgery.
~1 month PTIE, after ~ 1 month of spinal stabilization, pt. was allowed to do bed mobility to prevent further
complications such as pressure sores and muscle atrophy. However, pt. also reported of an infrequent mobilization of his
(R) LE and c/o its weakness. Pt. also reported stiffness on his (L) LE.

~ 2 weeks PTIE, pt. was able to roam around the hospital using a wheelchair and support from his parents. Pt. was then
discharged after being admitted at SJM for more than 1 month and was referred to PT for further evaluation and
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treatment. However, pt. was unable to immediately attend PT services d/t financial problems and only stayed at home.

~ 1 week PTIE, pt. reported that he has difficulty trying to stand up from his wc without assistance from his father d/t
weakness of his (R) LE. Pt. also c/o of increased muscle stiffness on his (L) LE.

~ 1 day PTIE, after ~ 2 weeks since the doctor’s referral for PT, the pt. decided to attend PT services for further
evaluation and treatment.
PMHx:
(+) DM Type 2 (Controlled since 2019)
(+) Physical Trauma (2019)
(-) Hx of Fall
(-) HTN
(-) Pneumonia
(-) Pulmonary Embolism
(-) DVT
(-) CAD
(-) Osteoporosis
(-) Heterotrophic Ossification

FMHx:

Maternal Paternal

DM (Type 2) (+) (+)

HTN (-) (-)

DVT (-) (-)

CVD (-) (-)

Pneumonia (-) (-)

Osteoporosis (-) (-)

P/SHx:
Personality: Type B Personality
Lifestyle: Pt has an active lifestyle; Pt. is hardworking and has a regular fitness exercise routine (jogging and
workout).
(+) Smoking Hx: 18/20 x 10 years = 9 packs per year
(+) Alcohol Beverage Drinker: ~ 2-3 times a week

Home/Work Situation Home Situation:

• Pt. is living in a bungalow house.
• Pt. is the only child and lives with his parents at home.
• Type of flooring: Cement
• Lighting: Ambient
• Door width: ~30 in.
• Type of doorknob: Classic/typical round doorknob
• Type of faucet handle: Classic/typical round handle
• Height of shelves: ~55 in.
• Height of dining table: ~30 in.
• Height of chair: ~18 in. Distances:
• Bedroom ↔ Bathroom: ~ 12 steps
• Bedroom ↔ Kitchen: ~ 16 steps
• Bedroom ↔ Living room: ~ 8 steps
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 • Bedroom ↔ Main door: ~ 7 steps
• Main door ↔ Living room: ~ 5 steps
Work Situation:
• Pt. works the morning and afternoon shift, from 8am - 4pm every Mondays to Fridays.
• Pt. rides his bicycle from home to his workplace and vice versa (15 min. ride).
• Pt. usually guards the entrance in his work establishment.
• Pt. undergone training before starting his job.
• Pt. works as a security guard for almost six years prior to the accident.
Ancillary Procedure:

Date Test/Procedure Result

April 15, 2020 CT Scan (+) Burst fracture on C5 Vertebra

April 15, 2020 MRI (+) Hemisection on C5 Spinal

Cord
(-) Hemorrhage
(-) Herniated Disc

Present Medication:

Medication Dosage Frequency Indication

Metformin 100 mg b.i.d Lowers blood

sugar level

Baclofen 20 mg b.i.d. Muscle

Relaxant

OBJECTIVE FINDINGS:
A. Vital Signs
Before During After

Temperature 36.5 ° (Afebrile) 37 ° 36.5 °

(Afebrile) (Afebrile)

RR 19 cpm 20cpm 18 cpm

HR 80 bpm 92 bpm 85 bpm

BP 120/80 mmHg 125/80 mmHg 120/80 mmHg

Findings: Pt’s BP increase beyond normal limits during and after rehabilitation.
Significance: For baseline purposes, treatment safety measures.

B. Ocular Inspection
• Pt. is wheelchair-bound
• Pt. is A/C/C x3
• Pt. is Mesomorph
• (+) Surgical wound (T7 level at back)
• (+) Atrophy on (L) LE
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 • (+) WoundSscar on (L) heel and (L) Buttock
• (-) Pressure Sore
• (-) Orthoses (TLSO)
• (-) Attachments (IV line / Catheter)
• (-) Ventilator
• (-) Trophic Skin Change
• (-) Postural Deviation
• (-) Dislocation
• (-) Swelling
• (-) Deformity
• (-) Asymmetry
• (-) Splints
C. Palpation
• Px is normothermic on all exposed body parts
• Pt is normotonic on (B) UE and (R) LE; Pt. is hypertonic and grade 2 spasticity on MAS for (L) hip and knee flexors,
and plantar flexors.
• (-) Muscle spasm
• (-) Edema
• (-) Subluxation
• (-) Tenderness
• (-) Guarding / Splinting

D. Neurological Evaluation
• International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

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E. Reflex Testing
• Deep Tendon Reflex
L R
LEGEND:
- Areflexia: 0
- Hyporeflexia: +
- Normoreflexia: ++
- Hyperreflexia: +++
- Clonus: ++++

Findings: Pt. is norrnoreflexive on (B) UE and (R) LE while hyperreflexive on (L) LE Significance: To check intact reflex
arc, (+) UMNL
• Pathological Reflex

Reflex Procedure/ Stimulus Response

(+) Babinski (L) LE Stroke the lateral sole of foot up Big toe extends and fanning of
to the ball of foot four small toes

(+) Chaddock on (L) LE Stroke lateral aspect of foot Big toe extends and fanning of
four small toes

(-) Oppenheim’s (B) LE Anteromedial tibial surface No response

(-) Gordon (B) LE Squeezing of calf muscles No response

(-) Plotrowski’s (B) LE Percussion of tibialis ant. mm No response

(-) Rossolimos (B) LE Tapping plantar surface oftoes No response

(-) Schaeffer (B) LE Pinching the achilles tendon in No response

the middle third

(-) Hoffman;s (B) UE Flicking of terminal phalanx of No response

index, middle, or ring finger

Findings:(+) Babinski and Chaddock Reflex on (L) LE Significance: To rule out any active UMNL.

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F. Motor Control
• Tonicity – Modified Ashworth Scale

Findings: Pt. has grade 2 spasticity on (L) hip and knee flexors and plantarflexors.
Significance: Determine the ability of mm resistance to passive manipulation
• Balance

Activities Grades
Sitting in normal comfortable 3
position

Sit to Stand 2
Standing in normal comfortable 2
position

Walking, placing foot on markers 1

Findings: Pt. has a fair grade on balance

Significance: For pt. safety during intervention process

• Coordination

LEFT Coordination Test RIGHT COMMENTS

4 Finger to nose 4 Normal performace on (B) UE

0 Tapping (Foot) 4 LOM on (L) UE d/t paralysis

0 Drawing a circle 4 LOM on (L) UE d/t paralysis

Findings: Pt. has normal performance on (B) UE and (R) LE; Unable to accomplish task on (L) LE 2° to paralysis.
Significance: Pt. cannot elicit bilateral actions of the LE d/t (L) LE paralysis

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G. Cranial Nerve Testing
• All cranial nerves were tested and intact

H. Range of Motion
All joints of (B) UE/LE are WNL, pain free, actively & passively done, except for:

Active Motion Passive Difference End Feel

(Normal Values) (A/P)

0-0° (L) Hip Flexion (0-120°) 0-90° (120°/30°) Pathologic firm

0-0° (L) Hip Extension (0-20°) 0-10° (20°10/°) Pathologic firm
0-0° (L) Hip Abduction (0-45°) 0-40° (45°/5°) Pathologic firm
0-0° (L) Hip Adduction (0-30°) 0-25° (30°/5°) Pathologic firm
0-0° (L) Hip IR (0-45°) 0-40° (45°/5°) Pathologic firm
0-0° (L) Hip ER (0-45°) 0-40° (45°/5°) Pathologic firm
0-0° (L) Knee Flexion (0-135°) 0-105° (135°/30°) Pathologic firm
0-0° (L) Knee Extension (0-10°) 0-5° (10°/5°) Pathologic firm
0-0° (L) Ankle DF (0-20°) 0-10° (20°/10°) Pathologic firm
0-0° (L) Ankle PF (0-50°) 0-30° (50°/20°) Pathologic firm
0-0° (L) Ankle Inversion (0-35°) 0-25° (35°/10°) Pathologic firm
0-0° (L) Ankle Eversion (0-15°) 0-5° (15°/10°) Pathologic firm
Findings: Pt. has LOM on all active movements of (L) LE 2° to paralysis; Pt. also has decreased ROM on all passive
movements of (L) LE 2° to spasticity.
Significance: Pt. may have difficulty performing ADLs and safe ambulation.

I. Functional Muscle Testing

• Upright Motor Control
All movements of (L) LE are not tested d/t paralysis and movements of (R) LE are WNL, except for:
Movement Score

(R) Hip flexion M

(R) Knee flexion M

(R) Plantarflexion M

Findings: Pt. has moderate score for (R) Hip and knee flexion, and (R) plantarflexion.
Significance: To ascertain flexion control of single weight bearing extremity.

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 J. Functional Mobility
Bed Mobility
• Rolls to the side: no assist / ind
• Bridging: min. assist Transitional Movement
• Rolls to (R): no assist / ind
• Rolls to (L): no assist / ind
• Scoots up in bed: no assist / ind
• Supine-to-sit: no assist / ind
• Sit-to-supine: no assist / ind
• Sit to Stand: min. assist
• Transfers bed-to-chair: min. assist Standing: Cannot tolerate longer time
Ascending and Descending stairs: ma. assist on (L) side Eating: no assist / ind
Bathing: supervision
Dressing: no assist / ind UE; min assist LE
ance: Functional mobility is essential for a person to complete everyday task.

K. Anthropometric Measurement
• Muscle Bulk Measurement
Reference Point (R) (L) Difference

- 8 inches from greater 36 cm 34 cm 2 cm

trochanter to the bulkiest portion of
thigh mm
- 4 inches from tibial tuberosity to
the bulkiest portion of leg 24 cm 22 cm 2 cm
mm

Findings: Pt. has minimal mm atrophy on (L) thigh and leg.

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L. Spinal Cord Independence Measure (SCIM)

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Findings: The pt. has a score of 15/20 for self-care; 40/40 for respiration & sphincter management; 16/40 for mobility
(room and toilet) with the total of 71/100.
Significance: The 1st examination serves as based line data from which it will be compared for possible improvement for
the succeeding 5 more examination.

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 ASSESSMENT:

A. PT Diagnosis
• Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with
Spinal Disorders.
• Impaired Motor Function, Peripheral Nerve Integrity, and Sensory Integrity Associated with Nonprogressive Disorders of
the Central Nervous System.

B. PT Impression: Pt. is a 27-year-old male with a medical diagnosis of Motor Incomplete ASIA D - SCI at C7 level 2° GSW
with a suspected hemisection of the SC that manifests a Brown Sequard Syndrome. It was further defined by LOM of the
(L) LE d/t spastic monoparesis, a total loss of all sensation of the (L) LE, loss of pain and temperature sensation on (R)
LE, atrophy of the (L) LE, Grade 2 spasticity on (L) hip and knee flexors, and plantarflexors, muscle spasm on (L) LE,
hyperreflexive (L) LE, (+) Babinski and Chaddock reflex on (L) LE, inability to accomplish coordination task on (L) LE, Fair
grade for balance, decreased PROM on all movements of (L) LE such as Hip, flexion, extension, abduction, adduction,
internal and external rotation, Knee flexion and extension, Ankle dorsiflexion, plantarflexion, eversion, and eversion,
moderate upright motor control for (R) hip and knee flexion, and (R) plantarflexion, minimal to no assistance on
functional mobility,

C. Prognosis / Rehabilitation Potential

• Pt. has a good prognosis considering that the pt. has a low neurological level of lesion, a motor incomplete injury, a
positive or type B personality, and an active lifestyle.

D. Problem List
1. Difficulty in LE dressing 2° spasticity on (L) hip and knee flexors, and plantarflexors.
2. Loss of pain and temperature sensation on (R) LE and total loss of all sensation on (L) LE.
3. Balance, weight-bearing standing, and functional mobility mild impaired
4. Moderate upright motor control
5. Muscle atrophy on (L) LE

E. Long Term Goals Rehabilitative:

Pt. will be able to do ADLs and IADLs independently and without difficulty as manifested by the ability to perform LE
dressing and bathing, and be able to ambulate independently from household to community setting within 4 months.

Participative:
Pt. will be able to return to jogging and working out for his regular physical fitness routines within 3 months.
Pt. will be able to go out with friends and workmates to do leisure and recreational activities within 2 months.

Preventive:
Pt. will be educated of the existing condition to prevent secondary comorbidities and complications such as osteoporosis,
pulmonary embolism, DVT, and a further increase in muscle tone.

F. Short Term Goals

1. Pt. will exhibit decrease mm tone on (L) hip and knee flexors, and plantarflexors from grade 2 to grade 1 as manifested
by the ability to perform transfer movements and LE dressing easily and independently within 3-5 tx sessions.
2. Pt. will be able to recognize and completely accept the loss of the sensation of pain and temperature on his (R) LE and
the total loss of all sensation on his
(L) LE as manifested by the pt.’s ability to easily adapt to these changes within 6-8 tx sessions.
3. Pt. will able to improve balance, weight bearing during standing, and functional mobility as manifested by the ability to
rise from sitting without difficulty, clear obstacles when doing household ambulation, and safe and easy mobility transfers
within 7-9 tx sessions.

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4. Pt. will able to achieve a 110° of (R) Hip flexion, 125° of (R) knee flexion, and 40° (R) plantarflexion as manifested by
the pt.’s ability to ascend on stairs within 7-10 tx sessions.
5. Pt. will have a decreased atrophy on the (L) LE from a difference of 2cm to 1cm as manifested by an improved passive
movement of the (L) LE within 8- 10 tx session.

PLAN

A. Prescribed PT Management
1. GPS of (L) hip & knee flexors, and plantarflexors x 15sh x 10reps x 2-3 sets.
2. D1 PNF pattern on (L) LE x 10reps x 2-3 sets.
3. Pt. education for the adaptation on the changes and loss of sensation.
4. Sit to stand exercise on parallel bars x 10reps x 2-3 sets.
5. Weight shift exercise with AD on parallel bars x 10 reps x 2-3 sets.
6. 3-point gait training with AD – Axillary crutch.
7. Mechanical strengthening exercise using dumbbell and ankle weights on (B) UE &
(R) LE x 10reps x 2-3 sets.
8. PROME towards (L) hip and knee flexion – extension, (L) hip abduction – adduction, (L) ankle
plantarflexion – dorsiflexion x 10reps x 2-3 sets.

B. Suggested PT Management
1. FES x 20mins on (L) LE flexors & extensors
2. HKAFO

C. Home Instructions
1. Educate the pt.’s family about the condition and assist pt. in home exercises.
2. Family member should not hesitate to consult a doctor whenever some problems occur.

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