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  • Physiotherapy Report Sample

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    Debesh Pradhan
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    The physiotherapy report summarizes the assessment of a patient with a T11 burst fracture and L3 complete neurology. Range of movement is full except for restricted trunk rotation, flexion, and extension due to fusion. Sensation is fully recovered. Power is normal except for weaker abdominals, back extensors, and lower limb muscles, ranging from 0/5 to 4/5. Coordination is intact for finger-nose tests but poor for heel-shin due to lack of hip control. Mobility in sitting is limited by metalwork and poor trunk side flexion, requiring trunk rotation and arm support.

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    The physiotherapy report summarizes the assessment of a patient with a T11 burst fracture and L3 complete neurology. Range of movement is full except for restricted trunk rotation, flexion, and extension due to fusion. Sensation is fully recovered. Power is normal except for weaker abdominals, back extensors, and lower limb muscles, ranging from 0/5 to 4/5. Coordination is intact for finger-nose tests but poor for heel-shin due to lack of hip control. Mobility in sitting is limited by metalwork and poor trunk side flexion, requiring trunk rotation and arm support.

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    4K tayangan2 halaman

    Physiotherapy Report Sample

    Diunggah oleh

    Debesh Pradhan
    The physiotherapy report summarizes the assessment of a patient with a T11 burst fracture and L3 complete neurology. Range of movement is full except for restricted trunk rotation, flexion, and extension due to fusion. Sensation is fully recovered. Power is normal except for weaker abdominals, back extensors, and lower limb muscles, ranging from 0/5 to 4/5. Coordination is intact for finger-nose tests but poor for heel-shin due to lack of hip control. Mobility in sitting is limited by metalwork and poor trunk side flexion, requiring trunk rotation and arm support.

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    dari 2

    SAMPLE PHYSIOTHERAPIST REPORT

    Date: 01/03/2010

    Physiotherapy Report following Assessment of XXX D.O.B 23/04/87

    Diagnosis: 14/05/99 T11 burst fracture with L3 complete neurology. Consequent anterior
    discectomy and fusion with bone graft T/8/9/10/11 and T12

    Sensation: Fully recovered.

    Range of Movement: Head/neck full range

    Upper limbs full range.

    Trunk Restricted rotation, flexion, side flexion and extension due

    To fusion with bone graft T9/10/11 and T12

    Lower limbs Full range of movement

    Tone: Normal throughout apart from slightly flaccid in right foot uses orthotic to manage

    right foot drop and assist dorsiflexion and toe clearance in gait.

    Power: (Using Oxford Scale of Power Rating where:

    0/5 = no muscle action, 1/5 =flicker or twitch of muscle action, 2/5 = able to

    Perform joint action with gravity eliminated, 3/5 = able to perform joint action

    Against gravity, 4/5 = joint action against gravity with some resistance and

    5/5 = joint action against gravity with maximal resistance)

    Neck and Upper limbs Grade 5/5

    Abdominals Grade 4/5 (weaker lower abdominals)

    Back extensors Grade 2/5

    Hip Abductors left 2/5 right 1/5

    Hip Adductors left 3/5 right 1/5

    Hip Flexors left 4/5 right 3/5

    Hip Extensors left 1/5 right 1/5


    Hip Internal Rotators left 0/5 right 0/5

    Hip External Rotators left 0/5 right 0/5

    Knee Flexors left 3/5 right 3/5

    Knee Extensors left 3/5 right 3/5

    Ankle Dorsiflexors left 3/5 right 0/5

    Ankle plantarflexors left 3/5 right 0/5

    Coordination: Finger nose test intact bilaterally

    Heel shin test poor control due to lack of control around hips to stabilise lower

    limb movement

    Mobility in chair: Metalwork restricts full trunk rotation and extension

    In sitting XXX demonstrates poor ability to side flex trunk and therefore rotates

    trunk to compensate. He relies heavily on strap holding him into chair to perform

    side flexion and uses arms to restore posture to vertical. XXX consequently has

    limited stability to reach laterally.

    XXX is unable to abduct hips to push thighs outwards into side of chair to assist

    trunk stability.

    XXX

    Physiotherapist MCSP SRP

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