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|
|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.
Improve motor control of stability and movement patterns.
Caregiver will be able to follow the home exercise program independently.
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
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