PHYSICAL THERAPY INITIAL EVALUATION Pts initial: A.

J Age: 58 y/o Sex: F Religion: Roman Catholic Occupation: PE teacher Address: Las Pinas city Civil status: Married Referring MD: Dr. Santiago Referring unit: UPHSD Medical Hospital Date of referral: March 11, 2012 Date of PTIE: March 12,2012 Handedness: Right Diagnosis: OA of big toes MCP jt., RA of wrist Precautions: Avoid positions that aggravates pain Avoid lifting heavy objects S: Informant/ reliability: Pt/good C/C: Dull and nagging aching pain with 8/10(VAS) in the big toe when standing for more than 20 min, walking for more than 15 min and writing for more than 10 min. Pt stated that pain is aggravated upon weight bearing on her right foot, toe extension and during wrist extension on both wrist joints. Patient also complains of stiffness in early morning that lasts for 20 minutes. She also complains limitation on doing the household chores such as cooking and sweeping. Patient also complains that the limitation in writing restricts her from performing her role as a teacher. Pt goal and attitude towards the tx: Pt wants to manage pain secondary to OA and RA. She is willing to cooperate to get well quickly and live actively HPI:

5 days prior, Patient is demonstrating on how to jump high to catch the ball to her students, suddenly as she flexed her knees with both feet on the ground she got out balanced and fell backwards and placed both her hands towards the floor as she falls. After that she dismissed the class and she went to the school clinic to have her checked and was given cold pack on the affected parts. The attending physician gave her a pain killer called Advil (200mg) and told her to undergo an x-ray procedure as soon as possible. 4 days prior to PTIE, Pt didnt go to school. Still she didnt go to the hospital to consult a doctor and undergo in some procedures because she thought that it was just pain from the muscles. Pt experienced pain on her R foot especially her big toe whenever she stands or walk for prolonged period of time. She also experienced pain whenever she writes for a long period of time. She experience limitation on doing household chores. She also has difficulty climbing up and down their stairs. 3 days prior to PTIE, she tried to take an Advil again to relieve the pain. The medication relieved the pain for that whole day. 2 days prior to PTIE, she then again started experiencing recurring pain on her R foot and wrist whenever she does activities and even if she took the medications that day, it didnt relieve the pain.

1 day prior to PTIE, patient decided to rest for the whole day hoping that the pain would go away but also decided that if the pain doesnt disappear the next day then she would consult a doctor. On March 12, 2012, pt and her husband went to consult with Dr. Santiago at UPHSD Medical Hospital. Pt underwent radiography and roentgenogram and the result was grade 2-definite osteophytes and absent narrowing of the joint space and swelling of the tissues on the wrist joint, also positivity in subluxation of both wrist joints(See ancillary procedure). Pt was then referred to PTIE and treatment. Then the patient underwent physical therapy the next day. PMHX:

No history of trauma/fracture to any body parts No history of surgery to any body parts No pertinent medical conditions FMHX: CONDITIONS OA RA OTHER PERTINENT CONDITIONS PSEHX:

FATHER + -

MOTHER -

Pt lives in a two storey house with 3 bedrooms in the second floor with 2 flights of stairs composed of 10 steps each with a height of 6.5 inches per steps with railings There are two bathrooms. One bathroom is at the first floor and the other is on the second floor which both requires 8 steps to get there from every bedroom Pt is a high school PE teacher in a private school Pt lived with her husband aged 62 years old and is already retired from work Pt has one daughter, who is now 29 yrs. of age and currently works as a manager in a company Pt travels/ commutes for 20 minutes to get in school where she used to teach. She has to walk approximately 200m to get to the nearest terminal Pts hobbies includes reading, cooking, shopping Pt goes shopping with her daughter every Saturday and takes them 15 minutes to reach the mall Walks ~10 minutes to pray to the church every Sunday She does not have any vices Pt earns 15,000 a month Ancillary procedures: PROCEDURE Radiography Roentgenogram

DATE March 12,2012, March 12,2012

X-ray on both wrist joints and both March 12, 2012 foot

FINDINGS definite osteophytes and absent narrowing of the joint space Swelling of the tissues on the wrist joint. Subluxation of both the wrist joints and right big toe MTP joint

Present Medications: MEDS Acetaminophen phenylbutazone

DOSAGE 500 mg, Prn 500 mg, Prn

USAGE Pain relief Relieve of symptoms

SIDE EFFECTS None none

O: VS: Before BP (mmHg) 120/90 PR (bpm) 85 RR (cpm) 10 Temperature Afebrile to touch Sig: All VS are WNL. Pt may proceed to the treatment. OI: Pt is a endomorph Pt is cooperative (+) gait deviation (see gait analysis) (+) edema (+) skin redness on affected parts (-) wound on all exposed body part After 130/100 89 12 Afebrile to touch

Palpation: (+) swelling on both wrist joints and on right toe -MTP jt. (+) tenderness on affected parts (+) muscle spasm on wrist extensor muscles (-) muscle tone (+) afebrile to touch on all exposed body parts Postural Assessment Right shoulder lower than the left Lateral shifting to the left Sig: All landmarks on Anterior, Posterior, and Lateral views are WNL except on the shoulder which is due to the patients handedness. Lateral shifting due to the patients slight lifting of right LE secondary to threatened weight bearing. Pulmonary Assessment: Breathing Ax: Apical with deep irregular rhythm and symmetrical breathing pattern. Sig: Irregular rhythm and symmetrical breathing pattern is just due to old age and may still proceed to treatment proper.

Gait Analysis: Patient shows excessive right hip extension, excessive dorsiflexion of right foot during all gait phases except on midstance and terminal stance. Decreased plantar flexion of right foot during toe off and midswing. Sig: gait deviations that result to excessive movement may be due to pain. Decreased plantar flexion and excessive hip extension may be due to the patients threatened weight-bearing stability. Balance Assessment: Using the Dynamic Gait Index patient had a score of 18/24. The patient had a score of 2 during changing gait speed and step around obstacle. Then patient had a score of 1 in performing gait & pivot turn and step over obstacle. Sig: Balance deviations may be due to unfocused patient and low coordination secondary to old age. Anthropometric Measurement: Limb girth: Starting from the Medial Epicondyle Right Left Difference Medial epicondyle 27cm 27cm 0cm 4cm 26cm 26cm 0cm 8cm 25cm 25cm 0cm 12cm 25cm 25cm 0cm 16cm 24cm 24cm 0cm 20cm 24cm 24cm 0cm 24cm 23cm 23cm 0cm 28cm 23cm 23cm 0cm 32cm 25.5cm 25cm 0.5cm 36cm 25.5cm 25cm 0.5cm th Sig: All Landmarks are WNL except those structures on the 28 cm onwards that showed a larger measurement compared to other parts due to the swelling on both wrist joints. Limb girth: Starting from base of first metatarsal bone Right Left Difference st Base of 1 Metatarsal 20cm 20cm 0cm bone 2cm 20cm 20cm 0cm 4cm 19cm 19cm 0cm 6cm 19 cm 19cm 0cm 8cm 10.5 cm 8cm 2.5cm 10cm (base of big toe) 11cm 9cm 2cm 12cm 11cm 9cm 2cm Sig: All Landmarks are WNL except those structures on the right 8th cm onwards that showed larger measurement compared to the left toe that may be due to swelling on the right big toe MTP joint.

ROM: Joint Motion AROM PROM Normal Diff Active Diff Passive End Feel Wrist flexion 0-70 0-70 0-90 20 20 Empty Wrist 0-40 0-40 0-70 30 30 Empty extension Wrist 0-15 0-15 0-25 10 10 Empty abduction Wrist 0-50 0-50 0-65 15 15 Empty Adduction Ulnar 0-15 0-15 0-25 10 10 Empty Deviation Radial 0-45 0-45 0-65 20 20 Empty Deviation IP toe 0-40 0-40 0-50 10 10 Empty flexion IP toe 50- 10 50-10 50-0 10 10 Empty extension Sig: LOM of the said joints may be due to pain and joint stiffness secondary to Osteoarthritis and Rheumatoid Arthritis. MMT: All major muscle groups of both UE and LE are grossly assessed and graded 5/5. Other muscles that are graded and not in full ROM are: Wrist Flexors - 3/5 at 0-60 range Wrist Extensors 3/5 at 0-40 range Wrist Abductors 3/5 at 0-15 range Wrist Adductors 3/5 at 0-50 range Ulnar Deviators 3/5 at 0-15 range Radial Deviators 3/5 at 0-45 range IP toe Flexors 3/5 at 0-40 range IP toe Extensors 3/5 at 50-10 range Sig: The muscles have grades of 3/5 due to decreased use of the patient secondary to pain. Special Test: (-) Mortons Test (-) Homans sign (-) Tinels sign (+) Turf toe Sig: patient showed a negative sign on these special tests to rule out any possibility of having nerve impingement, embolism and anatomical problem with 2nd metatarsal.

ADL Assessment: Pt experiences pain and difficulty in performing the ff: Standing Patient feels a dull and nagging aching pain on her big toe when standing. Patient can only tolerate 20 minutes of standing. Patient prefers to do it using only the left lower extremity Walking Patient feels a dull and nagging aching pain on her big toe. Patient can only tolerate walking for less than 15 minutes. Walking downstairs Patient feels the dull and nagging pain upon climbing downstairs and can only tolerate 10 minutes of it. Patient shows that she is having a hard time on balancing her body upon stepping on her right foot. She also feels tired easily. Walking Upstairs Patient feels the dull and nagging pain upon climbing upstairs and can only tolerate 10 minutes of it. Patient shows that she is having a hard time on balancing her body upon stepping on her right foot. She also feels tired easily. Writing Patient also feels a dull and nagging pain during writing and can only tolerate 10 minutes of doing it. Whenever the patient does a wrist extension the pain is aggravated. She also feels tired easily. Sig: Patient is having a hard time standing, walking, walking downstairs and walking upstairs due to patient is threatened to weight bearing secondary to pain. Patient can only tolerate 10 minutes of writing and is easily fatigue due to pain and joint stiffness secondary to Rheumatoid Arthritis A: Refined List: Dull and nagging pain on both Pts wrist and left foot Swelling on both wrist joints and on right toe -MTP jt. LOM on wrist flexion, wrist extension, wrist adduction, wrist abduction, Ulnar deviation, Radial deviation, IP toe flexion and IP toe extension Muscle weakness of Wrist Flexors - 3/5 at 0-60 range, Wrist Extensors 3/5 at 0-40 range, Wrist Abductors 3/5 at 0-15 range, Wrist Adductors 3/5 at 0-50 range, Ulnar Deviators 3/5 at 0-15 range, Radial Deviators 3/5 at 0-45 range, IP toe Flexors 3/5 at 0-40 range, IP toe Extensors 3/5 at 50-10 range Postural deviations Gait deviations Difficulty in standing for more than 20 minutes Difficulty in walking for more than 15 minutes Difficulty in walking downstairs for more than 10 minutes Difficulty in walking upstairs for more than 10 minutes

Difficulty in writing for more than 10 minutes Pt wasnt able to perform her role as a teacher Pt wasnt able to do household chores like cooking and sweeping

Anticipated Problems: Muscle atrophy Poor tolerance to exercises Deconditioned body Compromised Immune system Increase for more than 20 mmHg during diastole in BP during exercise

PT Impression: Patient is unable to perform her role as a PE high school teacher, do household chores like cooking and sweeping due to difficulty in standing, walking, walking upstairs, walking downstairs and writing. Patient has a postural deviation on the shoulder which is due to the patients handedness and lateral shifting due to the patients slight lifting of right LE secondary to threatened weight bearing. Also the patient had a score of 18/24 in the Dynamic Gait Index which may be due to patients lack of focus and coordination secondary to old age. Also there is muscle weakness of Wrist Flexors - 3/5 at 0-60 range, Wrist Extensors 3/5 at 0-40 range, Wrist Abductors 3/5 at 0-15 range, Wrist Adductors 3/5 at 0-50 range, Ulnar Deviators 3/5 at 0-15 range, Radial Deviators 3/5 at 0-45 range, IP toe Flexors 3/5 at 0-40 range, IP toe Extensors 3/5 at 50-10 range may be due to decreased use of the patient secondary to a dull and nagging pain. The said impairments are due to Osteoarthritis on the right toe MTP joint and Rheumatoid Arthritis on both wrist joints. Prognosis: Patient will be able to go back doing household chores within 4 months of Physical Therapy due to: Cooperative patient Family Support Financial Stability Prognosis may be hindered due to: Prolonged bed rest Continuous faulty posture LTG:

Pt will stand while cooking for 30 minutes without rest periods and still feels no pain. Pt will walk upstairs and downstairs for 2o minutes without rest and feels no dull and nagging pain. Pt will write on varying heights of a blackboard without rest period for 25 minutes and feels no pain.

STG:

Pt will walk upstairs and downstairs for 15 minutes with relief from pain in 7 sessions Pt will write on a blackboard for 18 minutes with relief from pain in 7 sessions Pt will reach full ROM of all the affected muscles with relief from pain in 8 sessions Pt will have an increased MMT grade of 3+/5 on all affected muscles in 1 month

P: Pt will be seen as an op for 3 sessions per week for 3 months Warm up Period: Electrical Stimulation and TENS Rationale: TENS for decrease in pain. ES for maintaining and Increasing ROM TENS and ES on right Gastrocnemius muscle. Patient is lying prone with both lower extremity extended. The Bipolar technique is used wherein the Active electrode is placed on the proximal part of gastrocnemius and the Dispersive electrode is placed on the distal part. Then a frequency of 3Hz is set and an intensity that the patient can tolerate. This is done in every session for 20 minutes without rest period. AROM Exercises Rationale: Increase ROM AROM exercise on wrist flexors, wrist extensors, radial deviators, ulnar deviators, wrist abductors, wrist adductors, IP toe flexors and extensors. This is done for 10 reps and 2 sets. This is done in every session. Peripheral Joint Mobilization Grade II Distraction on wrist joints and right big toe MTP jt., 6sh, 5 reps with 3 sec. intervals between reps, 1 set, 3x/week Grade II Glide on both wrist joints and big toe MTP jt., in all planes of motion. 6sh, 3reps, 3x/week Grade II oscillation on wrist joints and big toe MTP joint, smooth regular oscillations, 2-3cycles/sec, 2min, 1 set, 3x/week Rationale: increase joint mobilization and ROM Strengthening Exercises Strengthening Exercises on wrist flexors, wrist extensors, radial deviators, ulnar deviators, wrist abductors, wrist adductors, IP toe flexors and extensors for 10 reps and 1 set. This is done in every session. Gait Training Rationale: To prevent falls that may be due to lack of alertness and coordination Gait training for 20 minutes. This is done in every session. Cool Down Period:

Cold packs on both wrist joints and big toe MTP joint and then elevate. This is done for 20 minutes in every session. Home Instructions: Patient should do the ROM exercises, strengthening exercises, and cold modality at home with a competent guardian to assist her. This is done once everyday. Patient should not hesitate to consult a doctor whenever some problems or other symptoms occur. Wear shoes that are not too flexible Avoid positions that aggravate the pain Patient should stop any activity that aggravates the pain.