Pathophysiology of OA:

1. BUILD-UP
The articular cartilage starts to show signs of weakening due to a lifetime of use
2. CARTILAGE SWELLING
Weight bearing activity causes the weakened cartilage to start swelling
(pain on activity, relieved by rest)
3. JOINT NARROWING
Swollen, weakened cartilage starts to wear causing the joint space to decrease
(stiffness pain)
4. BREAKDOWN
Continued wearing away of the articular cartilage leads to particles within the
joint and an irregular joint surface
(swelling joint clicking)
5. COMPENSATION
As the joint become more painful, we use it differently. This leads to new bone
growth on the joint margin (marginal osteophytes)
(limited range of motion)
LORMA COLLEGES

INITIAL EVALUATION
GROUP 4

Patients Name: F.B

Age:
50 y/o
Sex:
Male
Address:
San Fernando, La Union
Civil Status:
Married
Handedness:
(R)
Occupation:
Farmer
Religion:
Roman Catholic
Referring Dr.:
Dr. Galvez
Referring Unit:
OPD
Rehab Dr.:
Dr. Pimentel
Date of Referral:
2016
Date of Consultation: September 6, 2016
Date of Eval:
September 6, 2016
Diagnosis:
(R) hip OA
S:

c/c: F.B is a 50 y/o M, handed with (+) HTN (-) DM was referred for PT eval and
tx. Pt c/o radiating constant pain extended down from the front of his (R) thigh to
(R) knee graded 6/10 on pain scale. States that pain is felt during weight bearing
activities such as walking, climbing stairs, and sitting or rising from chair and
relieved only by non-weight bearing position like lying down on his back.
HPI: Present condition started 1 month ago prior to PTIE. Pain was felt while he
was in the field planting rice so he managed the pain by lying down on his back
and taking alaxan (1 tab qd).

PMHx: Unremarkable
PSHx: Pt is a farmer and work involves squatting, stooping down, and planting rice
on the field for ~7 hrs 5 times/wk. Pt lives with his wife and son (20 y/o) in a
bungalow house, bedroom to comfort room:7 steps, kitchen to living room:5 steps,
living room to main door:4 steps, and main door to rice field:50 steps. He is a social
smoker (6sticks/day) and an occasional alcoholic beverage drinker. Other than
planting rice, he also help his wife in making baskets which involves prolong
sitting. He had moderate difficulty in sitting down and can only last for ~1 hr.
Goal: "Gusto ko mawala na yung sakit para magawa ko ng maigi trabaho ko".
O:

VS: BP=during: 130/90mmHg; p= 140/90mmHg

PR=during: 80 bpm
RR=during: 18 cpm
To=during: 37oC
OI:

Manner of arrival: Ambulatory c assistive device

Mental status: Alert/ Coherent/ Cooperative
Body type: Ectomorph
Swelling: (+) on hip
Trophic skin changes: (+) erythema on hip
Tightness: (+) on hip jt
Atrophy: (+) hamstring muscles d/t inactivity
Attachment: (-)
Others: (+) Postural deviation (see Postural analysis)

PALPATION:
Thermal assessment: hyperthermic on groin area
Tone assessment: Normotonic on hip
Tenderness: (+) gr. II tenderness on groin area c dull, aching pain
when palpated
Muscle spasm: (+)
Edema (grade & type): (-)
ROM:
Findings: Motions of (B) UE/LE, neck and trunk were assessed actively, and
are WNL except for the ff:
Motions
AROM
PROM
(N)
Endfeels
o
o
o
hip extension
0 20
0 23
0 30
Empty
hip internal rotation
0 38o
0 40o
0 45o
Empty
hip abduction
0 30o
0 35o
0 45o
Capsular
hip adduction
0 18o
0 20o
0 30o
Capsular
o
Sig: LOM 2 to pain & formation of marginal osteophytes
MMT:
Findings: All major (m) of (B) UE/LE were grossly graded 5/5 except for:
Motion
Grade
hip extension
3/5
hip abduction
3+/5
hip adduction
4/5
hip internal rotation
4/5
Sig: (m) weakness 2o to inactivity
ST:
(+) Faber test
(+) Trendelenburgs sign

(+) Stinchfield Test

(-) Obers Test
(-) Nelatons Line
Sig: 2o to pain
NEUROLOGIC EVALUATION:
Sensory Testing
Devices Used: Pin for pain, brush for light touch and thumb for deep P
Findings: 100% Intact sensation
Sig: Intact sensory pathway
DTR:
(L)

(R)

++

Legend: 0
areflexia
+
hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus

++
++

++
++
++
++

++
++
++

Findings: Normoreflexive on (B) UE/LE

Sig: Intact reflex arc
ANTHROPOMETRIC MEASUREMENT:

Leg Length Measurement

Landmark
(L)
ASIS to medial
85 cm
malleolus
ALLM
T10 to medial
95cm
malleolus
Sig: TLL discrepancy 2o to marginal osteophytes
ALL discrepancy 2o to (m) immobility
TLLM

Muscle Bulk Measurement

(L)
35 cm
59 cm
30 cm
57 cm
25 cm
54 cm
20 cm
51 cm
15 cm
48 cm
10 cm
44 cm
5 cm
37 cm
Patella
34 cm
Sig: 2o to muscle atrophy

(R)
56 cm
53 cm
50 cm
48 cm
45 cm
41 cm
36 cm
34 cm

(R)
88cm

Diff
1cm

96cm

1cm

Difference
3 cm
4 cm
4 cm
3 cm
3 cm
3 cm
1 cm
0

PA:
Postural landmarks were assessed in standing position:
Anterior view: hip is slightly flex, adducted, & externally rotated
Posterior view: hip is slightly lowered, thoracic and lumbar scoliosis,
shoulder elevated
GA:
Stance Phase
IC
LR
MS

(L)
+
+
+

(R)
+
_
_

TS
Swing Phase
IS
MS
TS
Sig: Antalgic gait

(L)
+
+
+

(R)
_
_
_

FA:
Independent on all aspect of ADL except:
- Walking long distances
- Sitting to rising from chair
- Climbing stairs
- Dressing (putting on pants, socks & shoes)
A: Pt. was seen & treated today and was tolerated all PT Mx given s any adverse
effect
noted.
PT Impression: Pt is a 50 y/o male who works as a farmer has a difficulty in
performing weight bearing activities such as walking, climbing stairs, and
rising from chair d/t pain & stiffness on hip 2o hip OA
Procedural Intervention: Compensatory Intervention
Rehabilitation Potential: Excellent
Prognosis: Pt has a good prognosis that complies with PT Mx base on
rehabilitation potential and family support
Problem list
1. Constant dull aching
pain on his R hip
with PS 6/10

2. Pt. has maximum

3.

4.

difficulty in doing
weight bearing
activities such as
walking, climbing
stairs, and sitting
Limited ROM on
hip extension,
internal rotation,
abduction, &
adduction
(m) weakness on
hip extension,
internal rotation, &
abduction

5. (+) Postural
deviation

LTG (12 tx session)

Pt will demonstrate
proper body mechanics
& observe proper
posture to dec.
occurrence of pain p 3
wks
To prevent further
complication such as
contracture (4 wks)

STG (6 tx session)
Pt. will report a dec.
pain on hip from 6/104/10 p 3 days

Pt will achieve near to

(N) ROM on hip
extension, internal
rotation, abduction, &
adduction 4 wks
Pt wil achieve optimum
(m) strength on (R) hip
extension, internal
rotation, & abduction p
6 wks

Pt will increase ROM by

3o increments on hip
extension, internal
rotation, abduction, &
adduction p 4 days
Pt will increase (m)
strength by 5o
increments on (R) hip
extension, internal
rotation, & abduction p
1 wk
Pt will achieve (N)
posture p 2 wks

Pt will prevent further

complication such as
scoliosis 3 wks

Pt will report dec. in

difficulty on doing
weight bearing activities
from maximum to
moderate p 1 wk

P:

PT Mx:
Pt will be treated as an OPD pt for 12 tx sessions
1. Education on walking aids and complimentary techniques on pain
relief
2. Hydrotherapy x20 3x/wk for strengthening muscles on LE
3. AAROM exercises on hip extension, internal rotation, abduction, &
adduction x5 reps x2 sets ffd by gentle stretching hold for 20 sec. for
strengthening muscles on LE
4. US x 1.5 W/cm2 x 5 on hip to pain and promote healing
5. Jt mobilization on hip x grade II ant. & medial oscillation x7reps
x2sets to inc. jt mobilization
Precaution:
1. BP

INTRODUCTION
Rheumatoid arthritis is a connective tissue disease characterized by chronic
inflammatory changes in the synovial membranes and other structures, by migratory
swelling and stiffness of the joints and its early stage, and by a variable degree of
deformity, ankylosis, and invalidism in its late stage.
SIGNS AND SYMPTOMSPERIODS OF ACTIVE DISEASE

Pain and stiffness worsen after strenuous activity.

Onset is usually in the smaller joints of the hands and feet, most commonly in
the proximal interphalangeal joints. Usually symptoms are bilateral.
With progression, the joints become deformed and may ankylose or subluxate.
Pain is often felt in adjoining muscles; and eventually muscle atrophy and
weakness occur. Asymmetry in muscle strength and alterations in the line of
pull of muscles and tendons add to the deforming forces.
The person often experiences nonspecific symptoms such as low-grade fever,
loss of appetite and weight, malaise, and fatigue.
Most commonly involved initially are the small joints of the hands, wrists, and
feet.

CLASSIFICATION OF PROGRESSION OF RA

Stage I (Early)
Swelling and stiffness
Synovium involved, slight cartilage

Stage II (Midstage)
- Joint deformity
- Cartilage destruction, periarticular fibrosis, bony ankyloses

Stage III
-

Invalidism
Involves several joints

INCIDENCE
RA is estimated to afflict 3.6 million persons in the United States. It occurs throughout
the world, and its prevalence varies with little differences in climate. Women are
affected almost three times as often as men; 80% of the cases begin in persons
between 25 and 50 years of age; the highest incidence is found between 35 and 40
years of age.
ETIOLOGY

The cause of RA has not been determined. A slight familial tendency has been
demonstrated; the main histocompatibility complexes HLA-DW4 and PR4 are present
in increased frequency in population with seropositive RA. This probability reflects
some difference in immune response, perhaps making this group more susceptible to
the disorder. Hypothesis of the etiologic factor have included infection, abnormality of
the peripheral circulation, endocrine imbalance, metabolic disturbance, allergic
phenomenon, faulty adaptation the physical or psychic stress and many other
concepts. There is indirect evidence to suggest that infection and by slow viruses or
organisms of the mycoplasma group may play a role, but substantial proof is lacking.
Many investigation suggest that auto immunes mechanism are involved in the
pathologic process and that proteolytic enzymes release form disrupted lysosomes
within the joint play a part in the chronic synovial inflammation and the distraction in
the articular cartilage. Although all of these factors may be involved in the onset of
the disease or may aggravate or intensify its course, none has been proved to be its
cause. Despite the tremendous amount of data provided by the laboratory and
clinical investigation, no hypothesis is yet supported by enough evidence to be
accepted to be the true or major explanation of the disease.
Rheumatoid arthritis is currently regarded as belonging to a group to a connective
tissue disease that may exhibits somewhat similar clinical and pathologic changes.
Other members of the group include: SLE, polyarterithis nodosa, Dermatomyositis,
Progressive Systemic Sclerosis, and Rheumatic Fever. A fundamental relationship
between these diseases however has not been established.
EPIDEMIOLOGY
-

Women are affected 2-3 times more often than men

Increases in incidence with advancing age
Peak incidence in women is between the 4th and 6th decades

PATHOPHYSIOLOGY

RA
RF, IgM reacts with IgG
Synovial membrane inflammation
Vascular changes
Release of proteases
Pannus formation (makes collagenase)
Cartilage invasion beginning at the periphery

DEFORMITIES
1.
2.
3.
4.
5.
6.

Radial deviation of the wrist

Ulnar deviation of fingers
Hitchhikers thumb hyperextension of IP jt
Swan neck hyperextension of PIP and flexion of DIP
Boutonnieres flexion of PIP and hyperextension of DIP
Cut-up-toes due to shortening of MT heads

7. Rheumatoid nodules extensor surface of forearm

SOAP (R) Shoulder Rheumatoid Arthritis

GENERAL INFORMATION
Pts Name: M.R
*Significance: Initials are used for the privacy and confidentiality of the pts
identity.
Age: 43 yrs old
Sex/Gender: F
*Significance: RA affects women 2 to four times more than men. (OSullivan
6th ed.)
Address: Sto. Rosario, La union
Civil Status: Single
Handedness: (R)
Occupation: Teacher
*Significance: Occupational task such as repetitive shoulder movements
may contribute to pt.s present condition.
Referring Unit: Lorma Medical Center
Referring MD: Dr. Dominguez
Rehab MD: Dr. Q
Date of Referral: September 3, 2016
Date of IE: September 3, 2016
Diagnosis:
RA on (R) Shoulder
Height: 53ft (160cm)
Weight: 162lbs
SUBJECTIVE INFORMATION
C/C (chief complaint):
Verbatim:
Nakakaramdam po ako ng palagian na pananakit ng aking balikat ko madalas
tuwing umaga, sumasakit din ito kapag ginagalaw ko ang aking balikat,
madalas din akong nakakaramdam ng pangangalay.
Translated:
Pt. states that she feels, constant dull aching pain and stiffness in the (R)
Shoulder with a PS of 8/10 (using VAS) Pt. noted that pain is felt especially
during morning at 5:30 am. Pain is aggravated by movement such as flexion,
extensionand and it is usually relieved by rest and not moving the arm.
HPI:
States that the condition started 6 mos. Ago when pt. felt localized, dull
aching pain on (R) shoulder after constant use of UE at work, the pt.
experienced morning stiffness with a duration of 30 minutes and relieved
during movements. Pt reported pain aggravated with motion. 1 wk ago the
pain worsened and Pts work is affected, which prompted the pt. to seek
medical advice. He relieved the pain by taking Paracetamol 500mg 9x for the
pain and Mefenamic Acid 9x 500mg for the swelling, 3 days prior to going to
the hospital.
A week PTIE, pt. consulted Dr. D who requested a radiographic examination
(see Ancillary procedures). Pt. has been diagnosed of RA on (R) Shoulder. Dr. D
referred the patient to Dr. Q for further evaluation and management.
PMHx:

unremarkable
FMHx:

Maternal
HTN
DM
CVA
OA
Findings: Unremarkable

Paternal
-

Personal/Social Hx:
Pt. is a single 43 y/o female living sedentary lifestyle and is working 8 hours a
day as a teacher. Pt has no history of substance abuse, non-smoker and an
occasional alcohol beverage drinker.
Home Situation:
Pt. lives in a bungalow house with her 19 y/o niece.Comfort Room <->
Living Room -10 steps ;Bedroom <-> Kitchen 10 Steps; Kitchen <->
Living Room 10 steps; Living Room <-> Bedroom 10 steps
Work Situation:
- Pt. works as an elementary teacher which requires prolonged period of
standing, walking and and doing household chores like( ironing clothes,
cooking, writing) using the UE. Pt. works 8 hours a day.

Ancillary Procedure:
Date/Procedure
x-ray: 9/03/16, RA on
(R)shoulder:
Laboratory Tests

CBC

Results
(+) juxtaarticular
osteoporosis
(+) soft tissue swelling
increase in Erythrocyte
Sedimentation Rate (ESRCRP)
(+) Rheumatoid Factor
Increase in WBC count

*Significance: to Rule in RA and r/o adhesive capsulitis

*Significance: (+) Soft tissue swelling
Pts Goal:
Gusto ko nang matanggal ang sakit sa balikat ko at maiggalaw ito para
makapagtrabaho ako nang maigi
Translation:
The pt. states that she want achieve normal mobility & function s pain
& discomfort and to perform work s pain and limitation of movement.
OBJECTIVE FINDINGS:
Vital Signs:

T: 37.2 C
BP: 110/80 mmHg
PR: 78 bpm
RR: 18 cpm
*Significance: for Baseline purposes
Ocular Inspection:
Alert/Coherent/Cooperative
Pt. is Ambulatory s AD
Ectomorph in body built
(+) Gait deviation
(+) Postural deviation (see PA)
(+) Swelling on (R) shoulder
(+) Redness on (R) shoulder
(+) Asymmetry (B) shoulders
(-) Atrophy
(-) Attachments
Palpation:
Normothermic on all exposed body parts
(+) Tenderness (Grade 3) on (R) shoulder
(+) Normotonic on shldr.
(+) Muscle Spasm on (R) Shoulder
(+) Swelling R Shldr
(-) Edema
Range of Motion:
All joints are WNL, pain free, actively and passively done except for:
Motion

AROM

PROM

NORMAL

END FEEL

(R) shldr. Flexion

N/A

N/A

0-180

Empty

(L) shldr. Flexion

0-150

0-160

0-180

Empty

(R) shldr. Extension

N/A

N/A

0-60

Empty

(L) shldr. Extension

0-30

0-50

0-60

Empty

(R) shldr. Abduction

N/A

N/A

0-180

Empty

(L) shldr. Abduction

0-130

0-140

0-180

Empty

N/A

N/A

0-90

Empty

0-70

0-70

0-90

Empty

N/A

N/A

0-70

Empty

0-50

0-50

0-70

Empty

(R) shldr. Internal

Rotation
(L) shldr. Internal
Rotation
(R) shldr. External
Rotation
(L) shldr. External
Rotation

*Significance: LOM may be secondary to pain, inhibition or tightness . L ROM

affectation possibly d/t RA

MMT:

All major muscle of (B) UE/LE are grossly graded 4-5/5 except for:

++

Shldr. flexors
Shdlr. extensors
Shldr. abductors
Shldr. internal
rotators
Shldr. external
rotators

(R)
N/A
N/A
N/A
N/A

(L)
5/5
5/5
5/5
5/5

N/A

5/5

*Significance: Muscle weakness secondary to weak tendons and ligaments,

possibly atrophy d/t prolonged immobilization
ST:
(-) Apleys test
Sig. r/o adhesive capsulitis
Neurological Evaluation:
Sensory Testing
Devices Used: Pin for pain, brush for light touch and thumb for deep P
Findings: 100% Intact sensation
Sig: Intact sensory pathway
DTR:
(L)
(R)
Legend: 0 areflexia
++ + hyporeflexia
++
++
normoreflexia
+++ hyperreflexia
++
++
++++ clonus

++
++

++

++
++

Others:
Findings: Normoreflexive on (B) UE/LE
Sig: Intact reflex arc

Postural Analysis:
PA:
Findings:
Normal posture is noted except:
shldr. Higher than (L) shldr.
Limb Girth Measurement
For atrophy of limbs

LANDMARKS
ACROMION
PROCESS
1
2''
3''

RIGHT
15.5

LEFT
13

DIFF.
2.5

14.5
13
12.5

12.5
11.5
11.5

2
1.5
1

Sig. Swelling
Gait Analysis:
Findings:
Stance Phase
IC
LR
MS
TS
Swing Phase
IS
MS
TS
LR

Left
+
+
+
+

Right
+
+
+
+

+
+
+
+

Activities of Daily Living:

Independent on all aspects of ADLs except:
- Eating
- Grooming
- Doffing
- Donning Clothes
- Movements that involve the use of UE

ASSESSMENT:
PT Diagnosis: Impaired Joint Mobility, Motor Function, Muscle Performance, and
Range of Motion Associated With Rheumatoid Arthritis
PT Impression:
PT Impression: A 43 y/o female has a difficulty in AROM o e Shldr. d/t pain
8/10 felt upon mobilization. She has difficulty performing ADLs involving the use of
the UE such as (eating, grooming, doffing and donning clothes) and performing her
work as a teacher (writing on the board, holding out flash cards) but is ambulatory s
AD.
Prognosis & Rehab. Potentials:
Pt. has good prognosis for recovery due to early diagnosis. PT intervention and
management would help the patient address his complaints and difficulties. Pt.
Readily adheres to all tasks given and Pt. has a supportive family.

Problem List:
Problem List

LTG ( 4weeks

Tx sessions)

STG( 2weeks Tx
sessions)
Pt. will be relieved of pain
to a PS of 4/10 even upon
movement and weight
bearing w/n 2 wks. Of tx.

1. Pain and tenderness on the

shldr. With a PS of 8/10.

Pt. will feel pain upon movement

and weight bearing w/n 4 wks. Of
tx.

2. Swelling on the shldr. 2to

RA

Pt. Will have no swelling on the

shldr. by 4 wks. Of tx.

Pt. will have reduced

swelling on the shldr. by
50 % w/n 2 wks. Of tx.

3.Muscle weakness shldr. flex,

ext, abd, add. And ER and IR d/t
atrophy caused by
immobilization.

Pt. will achieve a grade 5 (m)

strength on shldr. flex, ext,
abd, add. And ER and IR w/in 6
wks. Of tx

Pt.will achieve a grade 3on

shldr. flex, ext, abd, add.
And ER and IR w/in 2 wks.
Of tx.

4. Limited ROM on shldr.

flexion,extension,abduction,addu
ction,internal rot.and ext. rot.as
well as slight LOM on (L) shldr.
flex,ext,abd,add,add,ER,and IR.

Pt. will achieved full ROM on

shldr. w/n 4 weeks of tx.

5. Pt. has difficulty in doing ADLs

such as (combing hair using R
Shldr.) (bathing, doffing and
donning clothes) at work.

To easily perform
ADLs(bathing,eating,doffing and
donning) and work s assistance
with no difficulty w/n 4 wks of tx.

Pt. will achieve (N)ROM on

shldr.flexion,extension,abd
uction,adduction,internal
rot.and ext. rot.as well as
slight LOM on (L) shldr.
flex,ext,abd,add,add,ER,an
d IR.w/in 2 wks. Of tx.
Pt will perform ADLs
(bathing,eating,doffing and
donning) and work s
assistance with min-mod
difficulty w/n 2 wks of tx.

PLAN
Prescribed PT Mx:
1.) HMP with TENS x 15mins on the (R) Shoulder for the pain
2.) stretching ex. 60 seconds hold x 10 reps x 2 to 3 sets for the jt. Pain and
stiffness
3.) Continuous US x 1.5 w/cm2 x 5 mins. to alleviate swelling
4.) Stretching (15 sec hold x 10 reps x 1 set)
5.) Isometric exercises on (R) Shoulder (15seconds hold x 10 reps x 1 set) for
(m) strengthening
6.) AAROME exercises (5reps x 1set) for (m) strengthening
Home Ward Instructions:
1.) Teach proper posture and body mechanics and jt. Conservation techniques
to reduce on jts.
2.) educate pt. on home exercise programs
3.) instruct proper body mechanics in performing task and ADL

MYOFASCIAL PAIN SYNDROME ON THE UPPER BACK

Pathophysiology:

Acute muscle strainTissue damage in a very localized area of

muscletears in sarcoplasmic reticulumfree calcium ionssustained
contractionincreased strain on vulnerable areas of musclefree
calcium ions.
Trigger Points:
These points are usually in the midportion or belly of the
affected muscle. Often the trigger point is located within a taut band in a
muscle with a decreased motion. Some researchers believe that they arise
from localized areas of muscle trauma, but biopsy studies show mostly normal
muscle. Others believe that they are suggestive of localized ischemia. These
findings are 2 to a local energy crisis in the muscle. Such an energy crisis
is postulated to cause release of substances that sensitize nociceptors to
respond to innocuous pressure. When controlled for level of conditioning,
however, patient and controls have the same subtle muscle changes.
Taut Band:
The taut band is a shortened group of muscle fibers and can be

best palpated by sliding the skin and subcutaneous tissues perpendicularly

across the fibers of the muscle. These bands are electrically silent and
therefore not due to muscle spasm
Local Twitch Response:
When one snaps the taut band containing a trigger point, a
transient contraction of the bands muscle fibers occurs. This sign is

diagnostically important, as noted below, but its pathophysiological significance

is unclear. EMG studies document electrical activity during the twitch that is not
blocked by total motor and sensory anesthesia. Needling of a trigger point also
produces a twitch response. The technique of snapping palpation requires
significant skill, and its validity as a diagnostic sign has not been established.

COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

GROUP 2
INITIAL EVALUATION
Patients Name
N.T.
Age
30 y.o.
Sex
Male
Address
San Juan, La Union
Civil Status
Married
Handedness
R
Occupation
Construction Worker
Religion
R.C.
Referring Dr.
Dr. M.C.
Referring Unit:
OPD
Rehab Dr.:
Dr. C.M.
Date of Referral:
08-27-2016
Date of Consutation
08-27-2016
Date of Eval:
08-27-2016
Diagnosis
R Myofascial Pain Syndrome on Upper Back.
S:
C/C: Masakit yung likod ko mula sa batok hanggang sa balikat ko, pati mata,
panga at gilid ng ulo ko masakit. Pt. c/o intermittent dull, aching pain on his
upper back radiating to his R eye, R side of jaw & R temple c PS 8/10. HPI: N.T.
felt pain 2 weeks ago p lifting multiple bags of cement weighing ~50 kgs. Pt.
took Alaxan FR 500 mg to relieve pain, the pt. usually sleeps with a pillow
under the affected area to relieve pain. Lifting heavy objects on his R sh.
pain. Pt. has moderate difficultly in performing ADLs such as grooming,
bathing and donning and doffing of shirts. Pt. has maximum difficulty in
performing fxnal skills such as lifting objects on his sh. PMHx: Pt didnt have
any injury before or any previous history of hospitalization, (-) HTN, (-) DM, (-)
Surgical Procedures. FMHx: Pt.s mother and father has (-) HTN and (-) DM.
PSHx: Pt. started working for a construction firm 1 mo. ago for~10 hrs. a day.
Work involves lifting heavy objects for a prolonged period of time, multiple
times. Pt. lives with his wife in a bungalow type house. Pt. consumes alcohol
occasionally. Pt. smokes 5 sticks/day.Goal: Sana wala na akong
maramdamang sakit.
O:

VS:
BP:
PR:
RR:
T:
OI:

a exer
110/70 mmHg
90 bpm
20 cycles
36.8 C

p exer
110/70 mmHg
100 bpm
20 cycles
37.5 C

Manner of Arrival: Pt. is amb s assist. device

Mental status: Alert/Coherent/Cooperative
Physique: Mesomorph
Swelling: (+) Swelling on R side of the neck R sh.
Trophic Skin Changes: (+) Erythema on neck R sh.
Attachment: (-)
Postural Deviation: (+) R sh slightly raised (see postural assessment)
Palpation:
Thermal Assessment: Normothermic on B UE/LE and trunk except for a
hyperthermic R sh.
Tone Assessment: Normotonic on B UE/LE and trunk except for a
hypertonic R sh.
Tenderness: (+) Grade 4 tenderness on R side of the neck R sh.
Muscle Spasm: (+) on Cervical Muscles R middle trapezius
Edema: (-) on B UE/LE
Tightness: R side of neck R sh
POSTURAL ASSESSMENT:
Findings:
Anterior View:
(+) R sh. is higher than the left
Lateral View:
(+) Thoracic kyphosis
(+) Forward head
(+) Chest, abdominal and back muscles have increased tone
Posterior View:
(+) R sh. is higher than the left
(+) R PSIS is higher
ROM:

Motion
Cervical
Flexion
Cervical
Extension
Cervical
Lateral
Flexion
Cervical
Rotation

MMT:

Findings: All major joints o (B) UE&LE are WNL actively and passively
done c normal end-feel except for

AROM

PROM

NORMAL

Differenc
e (AROM)

Differenc
e
(PROM)

END FEEL

0-30

0-35

0-50

20

15

Empty

0-43

0-48

0-60

17

15

Empty

0-25

0-28

0-45

20

17

Empty

0-40

0-42

0-80

40

38

Empty

Sig: LOM on R cervical flexion, extension, lateral flexion, rotation 2 to

pain.
Findings: All major (m) o (B) UE&LE are measured using the break
test and are grossly graded 5/5 except for
Muscle Group
Cervical Flexor
Cervical Extensor
Cervical Lateral Flexor
Cervical Rotator

(L)
5/5
5/5
5/5
5/5

(R)
3-/5
3-/5
3-/5
3-/5

Sig: Pt. exhibited 3-/5 grade on break test c some but not complete
ROM against gravity leading to (m) weakness on R cervical flexor,
extensor, lateral flexor, rotator 2 to disuse.
ST:
Findings:
(+) Snapping Palpation
(-) Spurlings Test
(-) Jacksons Test
Sig: Pt. has (+) taut band on R cervical (m) R middle trapezius
Neurologic Examination:
Sensory Testing:
Device Used: Pin for pain, brush for light touch, thumb for P, two test
tubes with hot and cold water for temperature.
Findings: 100% sensory intact on B UE/ LE, neck and trunk.
Significance: Intact sensory pathway
DTR:
(L)

(R)
Legend: 0 areflexia
+ hyporeflexia
++
normoreflexia
+++
hyperreflexia
++
++++
clonus
++

++

++
++
++
++
++

++
++

Findings: Normoreflexive on (B) UE/LE

Sig: Intact reflex arc

A:

Functional Analysis: Pt. has moderate difficultly in performing ADLs such as

grooming, bathing and donning and doffing of shirts. Pt.
has maximum difficulty in performing fxnal skills such as
lifting objects on his R sh.
PT Impression: Pt. has difficulty in doing ADL such as grooming, bathing, and
donning and doffing of shirts 2 difficulty in R cervical
flexion, extension, lateral flexion, rotation and is unable to
lift heavy objects on his R shoulder d/t pain felt during
flexion, extension and rotation of R shoulder.
Procedural Intervention: PT proposes a restorative intervention c 3 Tx
session/wk for ~5 wks.
Rehabilitation Prognosis: Pt. has excellent prognosis as to rehab.
Prognosis: Pt. complies to PT Mx readily and adheres to HEP given. Pt. has
also supportive wife.
Problem List
STG
LTG
Pt.
will
report
a

in
Pain
Pt.
will
demonstrate
Proper
1. Pain and tenderness on
on
R
side
of
neck

R
body
mechanics
and
R side of neck R
middle trapezius from 8/10 observe proper posture
middle trapezius

to 6/10 p every PT session

2. Pt. has (m) weakness

on R cervical flexor,
extensor, lateral
flexors, rotation 2 to
disuse.
3. Pt. has LOM on R
cervical flexion,
extension, lateral
flexion, rotation.
4. Pt. has maximum
difficulty in performing
fxnal skills such as
lifting objects on his R
sh.
5. Pt. has moderate
difficultly in performing
ADLs such as grooming,
bathing and donning
and doffing of shirts.

Pt. will report an in (m)

strength in R cervical (m)
from 3-/5 3/5 on MMT
grading in 6 wks.
Pt. will report an in ROM
on R cervical flexion,
extension, lateral flexion
and rotation to at least
75% of N range p 6 wks.
Pt. will exhibit diff. in
performing fxnal skills p 3
wks, however pt. will only
be able to perform light
intensity work
Pt. will display diff. in
performing basic ADLs
from mod. min. diff. p 3
wks

and conversation
technique to the
occurrence of pain p 3
wks.
Pt. will demonstrate an
in (m) strength by lifting
light objects ~10 kgs. on
his R sh. in 2 mos.
Pt. will demonstrate an
in ROM to near N range in
2 mos.
Pt. becomes efficient in
performing fxnal skills
from mod. diff. min. diff.
p 6 wks and Pt. may be
able to perform mod.
intensity work
Pt. become efficient in
performing basic ADLs s
any diff. p 6 wks

P: Pt will be treated as an OPD pt. for ~ 2mos

PT Mx:
1. HMP on cervical area 15 to relieve pain.
2. US 1.5 W/cm2 5 to relieve pain, decrease swelling and loosen
adhesions.
3. Deep tissue massage on R cervical area 15 to loosen tightness
of tight muscles on the area.
4. Cervical Traction c 7 sec hold, 7 sec rest 10 reps 2 sets 15 to
increase range of motion to flexion, extension, lateral flexion and
rotation.
Suggested
1.
2.
3.

Mx:
Education on suggested Mx to help pt. perform exercises at home.
Hot compress 15 on to R side of the neck relieve pain.
Pt. performs active, low-intensity stretching on R side of the neck to
flexion, extension, lateral flexion and rotation with his wifes
supervision to prevent loss of the gained ROM.

PATHOPYSIOLOGY OF CTS

Pts name
: C.S.
Age
: 28 y/o
Sex
:M

Address
: West Avenue, Manila City
Civil Status
: Single
Occupation
: Construction Worker
Handedness
: (R)
Religion
: Roman Catholic
Referring unit : OPD
Referring M.D : Dr. G
Rehab Dr.
: Dr. A
Date of consultation : Sept. 4, 2016
Date of admission : N/A
Date of referral
: Sept. 4, 2016
Date of IE
: Sept. 4, 2016
Dx
: Carpal tunnel syndrome
S:
C/C:masakit yung kamay ko parang may tumutusok sa tuwing gagamit ako ng
martilyot barena at sa tuwing akoy magbubuhat
PT Translate: Pt. c/o intermittent dull aching pain on (B) hands c pin and needle
sensation on (B) wrists and hands c the p/s of 7/10 aggravated after work and
relieved by shaking hands
HPI:
Pts present condition started 1 month PTIE, when pt. felt dull aching pain c pin
and needle sensation on (B) hands and wrists c the p/s of 7/10.The symptoms started
to show up p prolonged use of drill. The pain is aggravated by prolonged use of drill
and hammer and carrying loads exceeding 3 kg using one hand and 5 kg on (B)
hands. It is relieved by shaking hands. Pt. took Ibuprofen 200mg. to relieve pain. The
pt. went to LMC to have his hand checked by Dr. G prescribed Celebrex 200mg and is
advised to only take the medicine whenever he feels pain.
PMHx: Pt has no previous hx pertinent to the condition, significant injuries or dse.
FMHx:
Htn
DM
Heart dse.

FATHER
(+)
(-)
(-)

MOTHER
(-)
(-)
(-)

PSHx:
Pt. works as a construction worker, works for 12hrs/day and involves sitting and
standing, prolonged use of construction equipments and carrying loads, pt. lives in a
bungalow house, states that bedroom to bathroom is ~8 steps and bedroom to dining
area is ~15 steps, pt. has an active lifestyle, pt. has no history of cigarette smoking
and alcohol beverage drinking.
Pt.s goal:
gusto ko nang makabalik sa trabaho ng walang inaalalang sakit sa aking
kamay
O:
VS:
BP:
PR:
RR:
Temp:
OI:

Before ex.
120/80 mmHg
83 bpm
17 cpm
36.7 C

p ex.
130/80mmHg
90 bpm
20 cpm
37 C

Manner of arrival: amb c bandange on (B) wrists and hands

Mental status: Alert/Coherent/Cooperative
Physique: Mesomorph
(+) m abnormality: atrophy on thenar m
(+) Swelling on (B) wrists and hands
(-) Attachment
(-) Others
Palpation:
Thermal assessment: Normothermic on B wrists and hands
Tone assessment: Normotonic on (B) UE/LE
(+) Gr. 2 tenderness on (B) wrists and hands
(-) m spasm
(-) edema
Sensory Testing:
Device used: pin for pain, brush for light touch,
Findings: 100% intact sensation
Sig: intact sensory pathway
DTR:

Legend:
0 areflexia
+ hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus

Findings: Normoreflexive on (B) UE/LE

Sig: Intact reflex arc
ROM:
Findings: all jts of (B) UE/LE are grossly assessed B in AROM and PROM c N end feels
except,
MOTION
AROM
PROM
NORMAL
END FEELS
wrist flexion
0-66
0-70
0-80
Empty
(L) wrist flexion
0-69
0-74
0-80
Empty
wrist extension
0-57
0-60
0-70
Empty
(L) wrist extension
0-59
0-63
0-70
Empty
radial deviation
0-10
0-12
0-20
Empty
(L) radial deviation
0-13
0-15
0-20
Empty
ulnar deviation
0-18
0-21
0-30
Empty
(L) ulnar deviation
0-20
0-23
0-30
Empty
finger flex (MCP)1st
0-73
0-77
0-90
Empty
digit
(L) finger flex (MCP)
0-76
0-80
0-90
Empty
1st digit
finger flex (MCP)
0-75
0-79
0-90
Empty
2nd digit
(L) finger flex (MCP)
0-77
0-81
0-90
Empty
2nd digit
finger ext (MCP) 1st
0-33
0-36
0-45
Empty
digit
(L) finger ext (MCP)
0-36
0-40
0-45
Empty
1st digit
finger ext (MCP)2nd
0-35
0-39
0-45
Empty

digit
(L) finger ext (MCP)
2nd digit
thumb abd (CMC)
(L) thumb abd (CMC)
Sig: LOM

0-37

0-40

0-45

Empty

0-57
0-59

0-60
0-62

0-70
0-70

Empty
Empty

MMT:

Findings: All major m on (B) UE/LE are measured using the breaktest and are
grossly graded 5/5 except for,
ACTION
L
R
Wrist flexors
3-/5
2+/5
Wrist extensors
3/5
3-/5
Finger MP flexors
3-/5
3-/5
Finger PIP flexors
3-/5
3-/5
Finger DIP flexors
3-/5
3-/5
Thumb MP and IP flex
3/5
3/5
Thumb IP flex
3/5
3/5
Sig: in m strength 2 to ischemia
Grip Test Assessment
Grip Strength: Using a BP app at100mmHg as its baseline
Device Used: BP App
Initial
Trial 1
Trial 2
Trial 3
Average
Hand
100
110
120
120
116.67
(L) Hand
100
120
120
130
123.33
Sig: (+) difference in grip strength between (L) and hand
PA:
Findings: Postural landmarks where assessed in sitting and standing in A/P/L
view and are found to be within N alignment
Sig: for baseline data
Special Test:
(+) Phalens test
(+) Reverse Phalens test
(+) Tinels Sign
(+) Hand Elevation Test
(+) Pinch Grip Test
(+) ULTT1
(+) ULTT3
(-) ULTT2
(-) ULTT4
Sig: (+) Impingement of median nerve
GA:
Findings: Normal
Sig: for baseline data
Antrhropometric Measurement
Limb Girth Measurement:
A:
Rehabilitation Potential: Pt has excellent prognosis as to rehab
Prognosis: Pt. will achieve the anticipated goals and expected outcomes.
PT Impression: A 28 y/o M has difficulty on ADL such as combing hair, dressing,
bathing donning and doffing of shirts using (B) wrists and hands 2-- difficulty in
flexion, extension, ulnar and radial deviation and is unable to carry heavy loads using
B hands and wrist d/t pain.

PROBLEM LIST
1. Pain and tenderness
(gr.2) on B hand and wrist
c a PS of 7/10

LTG (24 Tx sessions)

Pt. will demonstrate AROM
s pain on B hand and wrist
within 6wks.

2. Limited ROM on B wrist

Flexion, Extension, Ulnar
and Radial deviation.
3.Weak grip strength on
(B) hand c a value of
116.67 mmhg on R and
123.33 mmhg on L
4. Difficulty on performing
ADL such as combing hair,
dressing and bathing using
either one or (B) of his
wrists and hands

Pt. will demonstrate N

ROM on B wrist within
6wks.
Pt. will demonstrate N grip
strength on B hand that is
proportional to his gender
and age within 5wks.
Pt. will report that he can
normally do ADL with ease
within 6wks.

5. Difficulty on performing
work activities such as
using hammer and drill

Pt. will report that he can

normally do work activities
activities such as using
hammer and drill

STG (12 Tx sessions)

Pt. will report pain and
tenderness on B hand and
wrist from 7/10 4/10
within 3wks
Pt. will report ROM on B
wrist by 2 increments
every Tx session
Pt. will report an
improvement on his grip
strength for about 2-3
mmhg every Tx session.
Pt. will report an
improvement when doing
his ADL such as combing
hair, dressing and bathing
using either one or (B) of
his wrists and hands every
Tx session
Pt. will report an
improvement when doing
work activities such as
using hammer and drill

P:
PT Mx:
1. TENS x 20 on thenar m to m strength
2. PWB on (B) hand x 8 dips c 12 sec intervals x 15 to intermittent dull aching
pain
3. US x 1.25w/cm2 x 5 on (B) wrists and hands to relieve pain, swelling, and
promote healing
4. Joint mobilization ex. on (B) wrists CMC jt. and (B) hands MCP, DIP, PIP jt. x Gr.
3 oscillation x inferior glide to ROM
Suggestions:
1. Volar wrist splints at night to relieve intermittent dull aching pain
2. Squeeze stress ball on alternating hands for at least 3 hrs/day to grip
strength
3. Use of other joints in performing task such as hammering a nail to avoid
further more injury

COMPONENTS OF ELECTRICAL CURRENT

Ions
Either positive of negatively charged particles
They possess electrical energy thus their ability to move about from a
higher concentration to a low concentration
Electrical Potential
- when an electrical force produces the movement of ions
from high to lo
concentration
Electrical Current
- is the net movement of negatively charged electrons
- always from a higher concentration to a lower concentration
Ampere (amp)
- the rate at which electrical current flow

- 1 amp is the movement of 1 coulomb

Coulomb
- the number of electrons
Volt
- The electromotive force that causes the movement of electrons
- the difference in electron population between two points
Voltage
- force resulting from an accumulation of electrons from one point. If two points
are connected by a good conductor then the electron flows from a higher
concentration to a low concentration
Conductance
- the ease of flow of electrons in a material/ medium
Insulators
- materials that resist the flow of electrons, contains few free electrons, thus
offering greater resistance to electron flow
Resistance
- a.k.a electrical impedance
- opposition in electron flow in a conducting material
- measured in OHMs
OHMS LAW
- current flow = voltage/ resistance
Electrical Power/ Energy
- product of the voltage or EMF and amount of energy flowing
Watt = Voltage x Amperes
*Watt indicates the rate at which electrical power is being used

ELECTROTHERAPEUTIC CURRENTS
Direct Current
- Also referred as Galvanic Current
- Uninterrupted, unidirectional flow of electrons towards the positive pole
Alternating Current
- continuous flow of electrons changing directions or reverses its polarity
- electrons always move from the negative to the positive pole
Pulsatile
- contains 3 or more pulses grouped together, interrupted for short period of
time and repeat at regular intervals
- used in Interferential and Russian Currents
GENERATORS OF ELECTROTHERAPEUTIC CURRENTS
TRANSCUTANEOUS ELECTRICAL STIMULATORS
- all therapeutic electrical generators regardless they deliver AC, DC or
PULSATILE Currents through electrodes attached to the skin
Transcutaneous Electrical Nerve Stimulators (TENS)
- stimulating peripheral nerves
Neuromuscular Electrical Nerve Stimulators (NMES)
- or Electrical muscle stimulator (EMS), for stimulating muscles directly
Microcurrent Electrical Nerve Stimulators (MENS)
- current intensities are too small to excite peripheral nerves
Devices that are plugged into the wall outlets use Alternating Current

These commercially produced AC changes its direction of flow 120 times/second,

thus 60 cycles/second
FREQUENCY
is the number of cycles occurring in one second
- Hertz (Hz), pulses per second (PPS), cycles per second (CPS)
115 220V the voltage of electromotive force producing the alternating
directional flow of electrons

Commercial Alternating Currents is produced at 60 Hz with a corresponding

voltage of 115 to 220V
Battery operated devices produce direct current ranging from 1.5 to 9V although
these in turn may produce modified types of current
Converting a current coming from an AC power source to a DC current
delivered to the patient is accomplished by a series of electrical components:
a. Transformer
- steps down, or reduce the amount of voltage from the power supply
b. Rectifier
- converts AC to pulsating DC
c. Filter
- changed the pulsating DC to a smooth DC
d. Regulator
- produces a controlled voltage output
e. Output Amplifier
- Magnify or increase the amplitude of the voltage output and control at
specific level
f. Oscillator
- Produces a specific waveform
WAVEFORMS
A graphic representation as to shape, direction, amplitude, duration, and pulse
frequency generated by electrotherapeutic devices displayed on an oscilloscope
WAVEFORM: Shape
Electrical current may take the shape of a sinusoidal, rectangular, square or
spiked waveform depending on the capability of the generator. AC, DC and Pulsed
currents may take any waveform.
WAVEFORM: Pulse vs. Phase
Pulse
- an individual waveform
Phase
- a portion of a wave that rises above or below the baseline for some period of
time
WAVEFORM: Current
Direct Current
Monophasic Current
single phase in each pulse, unidirectional either positive or negative
Alternating Current
Biphasic Current
2 separate phases, changing direction and polarity
symmetric vs. asymmetric

Pulsed Current
Polyphasic
- represents electric current conducted in a series of pulses of shirt duration
followed by interpulse interval
may flow in one direction (DC) or bidirectional (AC)
Interpulse Interval (msec)
- a period when current is not flowing
Intrapulse Interval
- interruption between single pulses

WAVEFORM: Current

WAVEFORM: Biphasic

WAVEFORM: Monophasic

Waveforms: Sine Waves

Waveforms: Rectangular Waves

Waveforms: Triangular or Spiked

Waveforms: Parts
Pulse Amplitude
reflects the intensity of the current, synonymous to Voltage and current
intensity
*Maximum Amplitude
- the highest point on each phase
Average Current
- the amount of current flow per unit time
- measured by the highest peak and the lowest peak amplitude
- can be increased by increasing pulse duration or pulse frequency or both
Pulse Charge

- the amount of electricity given on the patient on each pulse

- Monophasic vs. Biphasic
- Symmetric vs. Asymmetric
Rise Time
- the rate of rise to the amplitude
Decay Time
- from the peak to zero