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INFORMED CONSENT FORM FOR EXERCISE REHABILITATION

PATIENTNAME: Lauren Mesaros DATE: 6/16/16

As a patient of the Active Athletes and Sports Rehabilitation Center (AASRC) you have the right to be informed about your condition and interventions. The purpose of your therapeutic exercise program is to aid and accelerate the healing process. The undersigned hereby voluntarily consents to participate in a program of therapeutic exercise to aid in his/her recovery and healing process.

While being evaluated by your surgical physician, a personalized therapeutic exercise program will be set up for you. During your physical therapy sessions, it is vital that you provide feedback regarding any pain or discomfort that you may be having. If an exercise causes pain, you are to immediately stop that exercise and inform your physical therapist so that the exercise can be modified or discontinued in your rehabilitation process.

During your rehabilitation process it may be necessary to touch or expose the area of skin being treated. Removal of surgical dressings or stiches may also be necessary. Our staff’s main goal is your comfort and safety. If at any time you feel uncomfortable please communicate your concerns and necessary accommodations will be made.

Consent for Treatment

I give my consent for treatment by the staff of Active Athletes and Sports Rehabilitation Center to provide physical therapy and rehabilitation services as prescribed by my surgical physician. I have read this form and I understand the procedures that will be performed. I understand the contents of this form, and certify that it has been explained to me. I give consent to participate in this rehabilitation process.

PATIENTSIGNATURE: Lauren Mesaros DATE: 6/16/16

WITNESS SIGNATURE: Amanda Sivic, SPT DATE: 6/16/16

Active Athletes and Sports Rehabilitation Center1900 Euclid Ave Cleveland, OH 44114

(440) 829-5073

Active Athletes and Sports Rehabilitation Center PATIENT INTAKE QUESTIONNAIRE

PLEASE FILL OUT THIS FORM AS COMPLETE AS POSSIBLE. IT WILL ASSIST YOUR THERAPIST IN DEVELOPING A PLAN OF CARE FOR YOU. IF YOU HAVE ANY QUESTIONS, PLEASE FEEL FREE TO ASK FOR ASSISTANCE. THIS INFORMATION WILL REMAIN CONFIDENTIAL UNLESS AUTHORIZED FOR RELEASE BY THE PATIENT. NAME: Lauren Mesaros DATE OF BIRTH: 11/25/93 AGE: 22 OCCUPATION: College Student HOBBIES: Soccer, skiing, running, cooking, music DATE OF INJURY: 4/14/16 PLEASE CIRCLE: SUDDEN ONSET GRADUAL ONSET HAS THIS INJURY PREVENTED YOU FROM WORKING? YES NO IF YES, HOW LONG OFF WORK: N/A IS AN ATTORNEY INVOLVED WITH THE CASE? YES NO IF YES, ATTORNEY NAME: N/A

HAVE YOU SOUGHT PREVIOUS TREATMENT FOR THIS CONDITION?

No other treatment Massage Therapy Chiropractor Physical/Occupational Therapy Psychiatrist/Psychologist X Other: CSU Athletic Trainer

How did this injury occur? Playing in a soccer game; Went to pivot and turn and my knee gave out; Heard a popping noise

Have you had this injury before? Yes No

LIST ALL PRESCRIPTION MEDICATION YOU ARE TAKING (Including injection and skin patches): OXYCODONE 5-325

mg, PERCOCET 5-325 mg, Reclipsen (Desogestrel) 0.15 mg LIST ALL OVER-THE-COUNTER MEDICATIONS YOU ARE TAKING (Including vitamins and supplements): Biotin 5000 mcg, Daily Multi-Vitamin

PLEASE LIST ANY SURGERIES OR OTHER CONDITIONS FOR WHICH YOU HAVE BEEN HOSPITALIZED: DATE SURGERY/HOSPITALIZATION REASON 6/10/16 University Hospitals-Main Campus Right ACL Reconstruction Surgery

7/7/14 University Hospitals-Main Campus Left ACL Reconstruction Surgery, Left Meniscus clean-up

ARE YOU CURRENTLY HAVING OR HAVE EXPERIENCED ANY OF THESE SYMPTOMS IN THE PAST 3 MONTHS? Fever Chills Night Sweats Shortness of Breath Pins/Needles X Numbness Skin Rash Headaches Vision Problems Hearing Loss X Bowel/Bladder Problem

PLEASE CHECK ALL THE FOLLOWING CONDITIONS THAT APPLY TO YOU EITHER PRESENTLY OR IN THE PAST High Blood Pressure Epilepsy/Seizures Gout Varicose Veins Chest Pain/Heart Attack Kidney Disease Hepatitis Dizziness/Fainting Stroke Asthma Arthritis Depression Heart Disease Emphysema/Bronchitis Tuberculosis Lung Disease Cardiovascular Disease Hearing Loss Thyroid Problems Emotional/Psychological Problems Chemical Dependency (alcohol/drugs)

Allergies: Other: HAS ANYONE IN YOUR IMMEDIATE FAMILY (Parents, Brothers, Sisters) EVER BEEN TREATED FOR ANY OF THE FOLLOWING? Cancer Heart Disease Diabetes Tuberculosis X Mental Disorder

Arthritis High Blood Pressure Kidney Disease Stroke HAVE YOU RECENTLY EXPERIENCED ANY SIGNIFICANT CHANGES IN: X Mood X Energy level (restlessness, lethargy, or fatigue)

Interest or pleasure in daily activities Recurrent thoughts of death or harming yourself X Loss/Gain of appetite or weight loss/gain X Sleeping habits How many packs of cigarettes do you smoke per day? None

How many days per week do you drink alcohol? 1-3 days How much do you drink at an average sitting? 1-2 drinks

Are there any other substances that you regularly use? None

ARE YOU AWARE OF YOUR CURRENT DIAGNOSIS? YES NO

DO YOU HAVE QUESTIONS REGARDING YOUR DIAGNOSIS OR PROGNOSIS YES NO RATE YOUR AVERAGE DISCOMFORT ON THE SCALE BELOW 0 6 10 (no pain) (severe pain) PLEASE MAP YOUR AREAS OF DISCOMFORT OR ALTERED SENSATION ON THE BODY MAP: XXX = Pain 000 = Numb/Tingle *** = Weakness OTHER COMMENTS OR CONCERNS YOU MAY HAVE: Swelling/bruising down to right ankle after surgery; immobilizer

brace is a bit uncomfortable

Form reviewed by therapist: AS (PT initials) 6/16/16 Date

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PATIENT WORKSHEET

PROBLEM AREA (Please check one): ❒ Upper Extremity (A,D) ❒ Lower Extremity (B,F) ❒ Cervical/Thoracic (C,D) ❒ Lumbar (D,F) ❒ TMJ (C,E)

FUNCTIONAL INDEX

PART I: Answer all five sections in Part 1. Choose the one answer in each section that best describes your condition.

WALKING❒ Symptoms do not prevent me walking any distance.❒ Symptoms prevent me walking more than 1 mile.❒ Symptoms prevent me walking more than 1/2 mile.❒ Symptoms prevent me walking more than 1/4 mile.❒ I can only walk using a stick or crutches.❒ I am in bed most of the time and have to crawl to the toilet.

WORK(Applies to work in home and outside) ❒ I can do as much work as I want to.❒ I can only do my usual work, but no more.❒ I can do most of my usual work, but no more.❒ I cannot do my usual work.❒ I can hardly do any work at all (only light duty).❒ I cannot do any work at all.

PERSONAL CARE(Washing, Dressing, etc.)❒ I can manage all personal care without symptoms.❒ I can manage all personal care with some increased

symptoms.❒ Personal care requires slow, concise movements due to increased

symptoms.❒ I need help to manage some personal care.❒ I need help to manage all personal care.❒ I cannot manage any personal care.

SLEEPING❒ I have no trouble sleeping.❒ My sleep is mildly disturbed (less than 1 hr. sleepless).❒ My sleep is mildly disturbed (1-2 hrs. sleepless).❒ My sleep is moderately disturbed (2-3 hrs. sleepless).❒ My sleep is greatly disturbed (3-5 hrs. sleepless).❒ My sleep is completely disturbed (5-7 hrs. sleepless).

RECREATION/SPORTS(Indicate Sport if Appropriate: Soccer )❒ I am able to engage in all my recreational/sports activities without

increased symptoms.❒ I am able to engage in all my recreational/sports activities with some

increased symptoms.❒ I am able to engage in most, but not all of my usual recreational/sports

activities because of increased symptoms.❒ I am able to engage in a few of my usual recreational/sports activities

because of my increased symptoms.❒ I can hardly do any recreational/sports activities because of increased symptoms.❒ I cannot do any recreational/sports activities at all.

(Answer on initial visit.)

How many days ago did onset/injury occur? Right ACL reconstruction was 6 days ago.

PART II: Choose the one answer that best describes your condition in the sections designated by your therapist. A. UPPER EXTREMITYCARRYING

❒ I can carry heavy loads without increased symptoms.❒ I can carry heavy loads with some increased symptoms.❒ I cannot carry heavy loads overhead, but I can manage if they are

positioned close to my trunk.❒ I cannot carry heavy loads, but I can manage light to medium loads

if they are positioned close to my trunk.❒ I can carry very light weights with some increased symptoms.❒ I cannot lift or carry anything at all.

DRESSING❒ I can put on a shirt or blouse without symptoms.❒ I can put on a shirt or blouse with some increased symptoms.❒ It is painful to put on a shirt or blouse and I am slow and careful.❒ I need some help but I manage most of my shirt or blouse dressing.

❒ I need help in most aspects of putting on my shirt or blouse.❒ I cannot put on a shirt or blouse at all.

REACHING❒ I can reach to a high shelf to place an empty cup without increased

symptoms.❒ I can reach to a high shelf to place an empty cup with some

increased symptoms.❒ I can reach to a high shelf to place an empty cup with a moderate

increase in symptoms.❒ I cannot reach to a high shelf to place an empty cup, but I can reach

up to a lower shelf without increased symptoms.❒ I cannot reach up to a lower shelf without increased symptoms, but I

can reach counter height to place an empty cup.❒ I cannot reach my hand above waist level without increased

symptoms.

STAIRS❒ I can walk stairs comfortably without a rail.❒ I can walk stairs comfortably, but with a crutch, cane, or rail.❒ I can walk more than 1 flight of stairs, but with increased

symptoms.❒ I can walk less than 1 flight of stairs.❒ I can manage only a single step or curb.❒ I am unable to manage even a step or curb.

UNEVEN GROUND❒

❒

I can walk normally on uneven ground without loss of balance or using a cane or crutches. I can walk on uneven ground, but with loss of balance or with

❒

❒

❒

the use of a cane or crutches. I have to walk very carefully on uneven ground without using a cane or crutches. I have to walk very carefully on uneven ground even when using a cane or crutches. I have to walk very carefully on uneven ground and require physical assistance to manage it. I am unable to walk on uneven ground.

CONCENTRATION❒ I can concentrate fully when I want to with no difficulty❒ I can concentrate fully when I want to with slight difficulty.❒ I have a fair degree of difficulty in concentrating when I want to.❒ I have a lot of difficulty in concentrating when I want to.❒ I have a great deal of difficulty in concentrating when I want to.❒ I cannot concentrate at all.

HEADACHES❒ I have no headaches at all.❒ I have slight headaches which come less than 3 per week.❒ I have moderate headaches which come infrequently.❒ I have moderate headaches which come 4 or more per week.❒ I have severe headaches which come frequently.❒ I have headaches almost all of the time.

READING❒ I can read as much as I want without increased symptoms.❒ I can read as much as I want with slight symptoms.❒ I can read as much as I want with moderate symptoms.❒ I cannot read as much as I want because of moderate symptoms.❒ I can hardly read at all because of severe symptoms. ❒ I cannot read at all.

■ D. LUMBAR*/CERVICAL/UPPER EXTREMITY

DRIVING❒ I can drive my car or travel without any extra symptoms.❒ I can drive my car or travel as long as I want with slight symptoms.❒ I can drive my car or travel as long as I want with moderate symptoms.❒ I cannot drive my car or travel as long as I want because of moderate

symptoms.❒ I can hardly drive at all or travel because of severe symptoms.❒ I cannot drive my car or travel at all.

LIFTING❒ I can lift heavy weights without extra symptoms.❒ I can lift heavy weights but it gives extra symptoms.❒ My symptoms prevent me from lifting heavy weights but I manage if

they are conveniently positioned. (e.g. on a table)❒ My symptoms prevent me from lifting heavy weights but I manage

light to medium weights if they are conveniently positioned.

❒ I can lift only very light weights.❒ I cannot lift or carry anything at all.

TALKINGEATING

❒ I can eat whatever I want without symptoms.❒ I can eat whatever I want but it gives extra symptoms❒ Symptoms prevent me from eating regular food, but I can manage if

I avoid hard foods.❒ Symptoms prevent me from chewing anything other than soft

foods.❒ I can chew soft foods occasionally, but primarily adhere to a liquid

diet.❒ I cannot chew at all and maintain a liquid diet.

■ F. LUMBAR*/LOWER EXTREMITY

STANDING❒ I can stand as long as I want without increased symptoms.

SQUATTING❒ I can squat fully without the use of my arms for support.❒ I can squat fully, but with symptoms or using my arms for

support.❒ I can squat 3/4 of my normal depth, but less than fully.❒ I can squat 1/2 of my normal depth, but less than 3/4.❒ I can squat 1/4 of my normal depth, but less than 1/2.❒ I am unable to squat any distance due to symptoms .

SITTING❒ I can sit in any chair as long as I like.❒ I can only sit in my favorite chair as long as I like.❒ My symptoms prevent me sitting more than 1 hour.❒ My symptoms prevent me sitting more than 1/2 hour.❒ My symptoms prevent me sitting more than 10 minutes.❒ My symptoms prevent me from sitting at all..

❒ Can talk without any increased symptoms.❒ Can talk as long as I want with slight symptoms in my jaws.❒ Can talk as long as I want with moderate symptoms in my jaws.❒ Cannot talk as long as I want because of moderate symptoms in my

jaws.❒ Can hardly talk at all because of severe symptoms in my jaws.❒ Cannot talk at all.

❒ I can stand as long as I want, but it gives me extra symptoms.❒ Symptoms prevent me from standing for more than 1 hour.❒ Symptoms prevent me from standing for more than 30 minutes.

❒ Symptoms prevent me from standing for more than 10 minutes.❒ Symptoms prevent me from standing at all.

PLEASE DO NOT COMPLETE THE FOLLOWING SECTIONS ON FIRST VISIT

No Improvement Complete Recovery

■ WORK STATUS (check most appropriate)

NAME: Mesaros Lauren Elizabeth LAST FIRST MIDDLE ADDRESS: 8152 Bishops Court Olmsted Falls Ohio 44138 STREET CITY STATE ZIP PHONE: CELL (555) 555-5555 WORK (555) 444-4444 EMAIL: [email protected] PREFERRED WAY TO CONTACT YOU: WORK/ CELL

SEX: MALE / FEMALE DATE OF BIRTH: 11/25/93

MARITAL STATUS: MARRIED / SINGLE / OTHER

REFERRING PHYSICIAN: Dr. Goodfellow PRIMARY CARE PHYSICIAN: Dr. Stern

EMERGENCY CONTACT: Linda Mesaros- Mother PHONE: (555) 333-3333 NAME/RELATION

BILLING POLICY

Active Athletes and Sports Rehabilitation Center (AASRC) will submit claims to your insurance company. Please contact your insurance company to ask about your specific coverage for Physical Therapy. AASRC will provide an invoice for services rendered at the end of each billing month. Payment is expected within 30 days of invoice date, regardless of receipt of payment from your insurance company. Please be aware that your insurance provider may consider some, and perhaps all, of the services rendered not medically necessary. You will be responsible for these charges as well as any out of pocket expenses, deductibles, co-pays, and charges above reasonable and customary.

I, Lauren Mesaros, have read and agree with the above billing policy and authorize payment of medical benefits to AASRC. I understand I am financially responsible for payment of all services received from AASRC.

Signature of Patient or Responsible Party: Lauren Mesaros Date:6/16/16

If payment is not received within 30 days after receiving the invoice, I hereby give AASRC permission to charge my credit card. We accept Visa, MasterCard, and Discover- we will make a copy of your card to keep on file.

elb ImaginaPain WorstnPai No

woour pain has been in the last 24 hours on the scale belyorst wPlease indicate the X INDEPAIN

.woy treatment on the scale belparysical thehour pye made since the beginning of vaou hyement voPlease indicate the amount of imprX INDEIMPROVEMENT

Cardholder signature: Linda Mesaros Date: 6/16/16

Physical Therapy Setting: Outpatient

Initial Examination and Plan of Care

Patient Name: Lauren MesarosD.O.B: 11/25/93 Date of Service: 6/16/16Reason for Referral: Referred to PT after Right ACL Reconstruction SurgerySurgeon: Dr. Goodfellow

Reason for Referral

Current Condition: Pt. is a 22-year-old white female who underwent Right ACL reconstruction surgery on 6/10/16. Patellar tendon graft was used. Right ACL tear occurred suddenly on 4/14/16 while playing in a spring soccer game.

Past Medical History: Left ACL reconstruction surgery on 7/7/14.

Medications: Oxycodone 5-325 mg, Percocet 5-325 mg, Reclipsen (Desogestrel) 0.15 mg

Disability/Social History: Pt. lives in an apartment in downtown Cleveland with a roommate while attending Cleveland State University. Lives on the 2nd floor of the building and an elevator is available. Pt. reports not being able to run after the injury, and had major swelling in the R knee. Pt. is using crutches post-surgery and a full leg brace is worn. CPM and ice machine have been used continuously.

Prior Level of Function: Until time of injury, Pt. was able to do all physical activities normally and with no pain. Pt. is a member of the Cleveland State Women’s Soccer Team.

Patient’s Goal: To have reduced pain and to get full movement and stability back in her knee. Pt. hopes to get back to playing soccer at a high level. Pt. also does not want to have another knee injury in the future. She also hopes to be able to drive, walk without crutches or a brace, and be able to sleep without pain within the next few weeks.

Patient Self-Report: Pt. rates pain at worst 6/10, but unable to fully bend or straighten R knee because pain increases to 8/10 during these movements.

Systems Review

Cardiopulmonary System

HR: 60 bpmBP: 119/78Edema: swelling present around R knee and down to ankle/footRR: 14 breaths/min

Integumentary SystemNot impaired. Texture and integrity of the skin is normal. Some bruising color around R knee down to the ankle/foot

Musculoskeletal SystemHt.: 5’7 Wt.: 145 lbs., Gross Symmetry: Impaired, Gross ROM and strength: R knee ROM is impaired, R Quadriceps strength is impaired4

Neuromuscular SystemGait: ImpairedBalance: Impaired

Communication/CognitionUnimpaired

AffectEmotional/behavioral responses unimpaired

Learning BarriersUnimpaired

Learning style/Education needsVisual, prefers demonstrations and pictures when learning an exercise

Tests and Measures

Goniometry4

PROM R knee flexion: 15-85 degrees- Empty End FeelPROM R knee extension: 15-85 degrees- Empty End FeelPROM L knee flexion: 0-135 degrees- Soft End FeelPROM L knee extension: 0-135 degrees- Firm End Feel

Dermatomal TestingImpaired sensation of L3 to fine touch stimuli

Myotomal TestingImpaired at L3 knee extension

Reflex Integrity

Unimpaired

MMT4

R knee flexion: 3/5R knee extension: 2/5L knee flexion: 5/5L knee extension: 5/5

EvaluationPt. experiences sharp pain in R knee with knee flexion and extension. Pt.’s R knee flexion and extension ROM is impaired. Pt.’s R knee flexion and extension muscle strength is impaired as well. Impaired gait and balance are due to the underlying problems identified after R ACL reconstruction surgery. Gait/balance deficits are being addressed through the prescription of crutches and a full leg brace.

DiagnosisR knee ROM and strength are impaired4. Bruising within the leg is present-normal after ACL reconstruction surgery4.

PrognosisPt. displays good motivation to participate in physical therapy intervention. The pt. appears ready and eager to adhere to a home exercise program focusing on return to daily tasks with decreased pain and full mobility. Pt. will return to sport (soccer) in 6-9 months if they adhere to the intervention plan5.

Today’s Treatment 1 Intervention was performed under the supervision of the physical therapist

Physical Therapist examined the incision area to check for proper healing- 3 minutes at beginning of session

Full passive knee extension with PT assistance- 3 sets for 20 secs

Quad sets with electric stimulation- 3 sets of 10

Flexion Exercises-Wall and heel slides- 3 sets of 20

Improve balance- Shifting weight from one leg to the other while standing by table for support- 3 sets of 20 total

Ice on inflamed R knee area- 15 minutes at the end of session

Expected Outcomes 5 1. Pt. will be able to walk with no pain or limping by 2 weeks post op while wearing the full leg brace.

2. Pt. will increase PROM of R knee flexion and extension to normative values of 135 degrees and 0 degrees respectively by 6 weeks post op.

3. Pt. will increase muscle strength of R knee flexors (3/5) and R knee extensors (2/5), to 5/5 respectively by 6 months post op.

4. Pt. will have a leg symmetry index 90% for the single leg hop test for time, the single leg hop test for distance, and the single leg vertical jump test by 6 month post-op.

5. Pt. will be able to return to soccer drills and full contact play by 6 months post-op.

Anticipated Goals to be met by 6/20/16 1 1. Pt. will increase R knee flexion PROM to 95 degrees and R knee extension PROM to 5 degrees.

2. Pt. will be able to walk with no pain or limping for 1 mile at 3.0 mph while wearing the full leg brace.

3. Pt. will be able to participate in activities with her friends such as going to the mall and walking around for 1 hour with the full leg brace.

Intervention Plan 3 1. We will meet 2 times a week for 1 hour and 30 minutes each time at this facility for the first 3 months. For

the last 3 months we will meet 1 time per week for 1 hour and 30 minutes.

2. Pt. will also be given a home rehabilitation program and is expected to keep up with specific exercise that are given for the week.

3. We want to achieve full ROM of the R knee as soon as possible and regain strength within the quadriceps and hamstrings over time.

4. This week we will focus on balance, proprioception, shifting weight from one leg to other, increase one-legged activities, and discarding crutches5.

5. The pt. will then be progressed towards more aggressive activities as able2.

Home Exercise Program 4

The patient will be instructed of the following exercise and perform them for the PT to ensure proper technique:

Entire exercise program to be done 3 times per week at home

Full extension sets- push down on knee to extend- 5 sets for 30 seconds

Quad contraction sets- 5 sets for 10 seconds

Flexion exercises- wall and heel slides-3 sets of 20 reps

Weight shits by table for support if needed- 5 times for 30 seconds

Walk in front on mirror to normalize gait- 5 minutes total per day

Exercises will be added and adjusted accordingly as treatment progresses2

The patient is in agreement with this plan and responded very well to today’s treatment session. Patient was in a bit of pain and discouraged about having her 2nd ACL reconstruction surgery. She knows that it is a long, hard road to come back from, but is motivated to get back to her previous level of function in general and on the soccer field.

Amanda Sivic, SPT 6/16/16

Interim Note 1: Session 3- 6/20/16

Problem:Medical Diagnosis: Referred to PT after Right ACL Reconstruction Surgery

S (Subjective): Pt. is a 22-year-old white female who underwent Right ACL reconstruction surgery on 6/10/16. Patellar tendon graft was used. Pt. states that she has been adhering to home exercise program. Pain and swelling have decreased. Crutches are no longer needed, and pt. is using leg brace when walking.

Patient self-report: Pt. has increased R knee flexion and extension range of motion. Pt. has stated that pain level has decreased to a 0/10 on R knee when at rest, and a 2/10 on R knee during activity.

O (Objective):

Systems Review:

BP: 119/79

HR: 62 bpm RR:14 breaths/min Edema: area around R knee a bit swollen

Tests and Measures:

Goniometry:PROM R knee flexion: 3-95 degrees- Empty End FeelPROM R knee extension: 3-95 degrees- Empty End FeelPROM L knee flexion: 0-135 degrees- Soft End FeelPROM L knee extension: 0-135 degrees- Firm End Feel

MMT:R knee flexion: 3/5R knee extension: 3/5L knee flexion: 5/5L knee extension: 5/5

Today’s Treatment:

Stationary bike- 20 minutes, no resistance

Rowing machine- 1,000 meters

Range of motion exercises

o Wall/heel slides- 3 sets of 20

o Prone leg hangs off table- 3 sets for 60 secs

o Full extension set w/ PT assistance- 3 sets for 30 secs

Calf raises (by table)- 3 sets of 15

Straight leg raises w/5 lb. ankle weight- 3 sets of 15

Soft tissue message treatment to incision by PT- 3 min

Warm water stretching in therapy pool (Urban Disparities)- 15 minutes at the end of session to relax the muscles and loosen up the joints

A (Assessment):

Evaluation, Diagnosis, and Prognosis: As a result of the progression of the current intervention plan and the recent symptom relief, if the patient remains motivated the prognosis remains promising. Despite a bit of pain, and inability to confidently walk without the leg brace, the pt. seems to feel motivated when the ROM and muscle strength increase after performance of home exercises.

Discharge and/or Expected Goals/Outcomes: Pt.’s goals remain constant since initial note.

Short-term goals to be met by 6/24/16:1. Pt. will increase R knee extension PROM to 0 degrees, and R knee flexion PROM to 110 degrees. 2. Pt. will be able to walk normally for 1.5-mile with leg brace at 3.0 mph.3. Pt. will be able to participate in driving again.

P (Plan of Care):

Intervention Plan:

Pt. demonstrated home exercise program and the addition/progression of the following exercises were made:


Straight leg raises w/ 5 lb. ankle weight- 3 sets of 15

Prone leg hangs off table- 3 sets for 60 secs

Balancing on one leg- 3 sets for 30 secs each leg

Calf raises (by table)- 3 sets of 15

Patient responded very well to today’s treatment, and successfully demonstrated the home exercise program to the physical therapist. The plan for the next session (6/24) is to continue with the previously stated home exercise program and to build off today’s treatment exercises. Mini squats and stair walking will be introduced, as well as balancing exercises such as mini-trampoline standing.

Mini squats (0-40 degrees)- 3 sets of 10 Stair walking (up and down)- 5 sets total Mini-Trampoline standing

o 2 leg- 3 sets for 20 seco Single leg- 3 sets each leg for 10 sec

Emphasis on good quadriceps control and full knee extension will be crucial in the next session.

Physical Therapist: Amanda Sivic, SPT Date: 6/20/16

Interim Note 2: Session 8- 7/11/16

Problem:Medical Diagnosis: Referred to PT after Right ACL Reconstruction Surgery

S (Subjective): Pt. is a 22-year-old white female who underwent Right ACL reconstruction surgery on 6/10/16. Patellar tendon graft was used. Pt. states that she has been adhering to the home exercise program. Pain is no longer present during activity, and pt. is able to walk and weight bear without a leg brace.

Patient self-report: Pt. has increased R knee flexion and extension range of motion. Pt. has stated that pain level has decreased to 0/10 on R knee both at rest and during activity.

O (Objective):

Systems Review:

BP: 120/79 HR: 61 bpm RR:13 breaths/min Edema: No swelling present

Tests and Measures:

Goniometry:PROM R knee flexion: 0-125 degrees- Soft End FeelPROM R knee extension: 0-125 degrees- Firm End FeelPROM L knee flexion: 0-135 degrees- Soft End FeelPROM L knee extension: 0-135 degrees- Firm End Feel


Today’s Treatment:

Versa Climber- 10 minutes

Rowing Machine- 1,500 meters

Straight leg raises w/10 lb. ankle weight - 3 sets of 15

Side step downs (2 ft. box)- 3 sets of 8 each leg

Forward/Backwards step downs (2 ft. box)- 3 sets of 8 each leg

One-legged body weight squats- 3 sets of 8 each leg

Plank holds (Normal & R/L side)- 3 sets, 30 secs each position

A (Assessment):

Evaluation, Diagnosis, and Prognosis: Success of progression further motivates the patient and the prognosis remains promising. There was a notable increase in ROM of R knee flexion, and full R knee extension was achieved. The interventional progression will continue to challenge the pt. to gain further ROM and muscle strength. Future interventions will also begin to target the pt.’s core strength and endurance as well. Pt. continues to gain confidence in performing one legged (Right) exercises, and is optimistic about getting back to life without wearing the leg brace.

Expected/Discharge Outcomes: Remain constant since initial note.

Goals to be achieved by 7/22/16:1. Pt. will improve R knee flexion PROM to 130 degrees.2. Pt. will be able to walk for 2 miles at 4.0 mph on a 2.0 incline.3. Pt. will be able to participate and help out at soccer workouts by timing her teammates fitness tests, and

collecting balls after shooting drills.

P (Plan of Care):

Intervention Plan:

Pt. demonstrated home exercise program and the addition/progression of the following exercises were made:


One-legged body weight squats- 3 sets of 8 each leg

Two-legged deep squats- 3 sets of 10

Side step w/Thera band- 3 sets of 8 each leg


Walking for 30 minutes, 3 times per week

Patient responded very well to today’s treatment, and successfully demonstrated the home exercise program to the physical therapist. The plan for the next session (7/15) is to continue with the previously stated home exercise program and to build off today’s treatment exercises. We will start to focus on functional training and aerobic conditioning. The next session will be a special session in which we will try out some warm water stretching and aquatics therapy. We will first start out with:

Stationary bike with increased resistance (4.0) -20 minutes Warm Water Stretching (Urban Disparities)

o 15 min total body stretch Aquatics Therapy (NEXT)

o Pool walking/jogging- 5 minuteso Wall kicks (hold on to wall and kicks legs)- 3 sets of 30 seco Alternating one-legged hops- 3 sets of 10 each lego One-legged deep squats- 3 sets of 8 each lego Boogie board swimming- 5 minutes


Interim Note 3: Session 25

Patient Name: Lauren Mesaros Patient ID # 1234567Date of Admission: 6/16/16 Date of Birth: 11/25/93Today’s Date: 10/28/16 Time in: 6 am/pm* Time out: 7:30 am/pm*

Systems Review:System Not

ImpairedImpaired

Test Results/Comments

Cardiovascular/Pulmonary

X

Integumentary X

Musculoskeletal X

Neuromuscular X

Communication, Affect, Cognition

X

Subjective Information from Patient: Pt. is a 22-year-old white female who underwent Right ACL reconstruction surgery on 6/10/16. Patellar tendon graft was used. Pt. states that she has been adhering to home exercise program. Pt. has started jogging, and has improved strength/speed with forward and backward movements.

Pain (including location, intensity, quality, duration, and how addressed): Pt. rates pain 0/10 at rest and 0/10 with activity.

Procedural Interventions:Today’s Treatment: Therapeutic Exercise (includes balance):

1-mile jog warm up on treadmill- no incline, 7.0 mph

Rowing machine- 1,700 meters

Agilities w/stretch cord (jumping (for speed), skipping, lateral side shuffling (each side), jogging)- 3x each to the end of the room

Speed ladder drills- 3x eacho Forward running- high kneeo Lateral running- side to sideo In and out both feet

Box Jumps- 2 ft. box, 3 sets of 10

Slide board- 3 sets of 20 total

One legged hops for distance- measured by PT- 3x each leg

1-mile walk cool down on treadmill- no incline, 4.0 mph

Functional Training: N/ABed Mobility: N/ATransfers: N/A

Gait Training: N/AOther: N/A

Response to Interventions (may include vitals, objective measurements):

Vitals:BP: 116/78 HR: 59 bpm RR:13 breaths/min

Goniometry:PROM R knee flexion: 0-135 degrees- Soft End FeelPROM R knee extension: 0-135 degrees- Firm End FeelPROM L knee flexion: 0-135 degrees- Soft End FeelPROM L knee extension: 0-135 degrees- Firm End Feel


Coordination of Care, Communication & Documentation:Pt.’s progress notes have been sent to surgeon, Dr. Goodfellow.

Patient/Client Related Instruction:Education provided to: Patient

Contents & Methods: Demonstrated exercises for pt. and provided exercise diagrams and written instructions for home exercise program.

How learning demonstrated: X: verbalized understanding X: demonstrated understanding

Physical Therapy Assessment: Guide to Physical Therapist Practice Pattern: Joint Mobility, Motor Function, Muscle Performance, Range of Motion

Progress towards identified PT goals (or lack thereof with rationale): Pt. has achieved goals that were set in the previous interim note, and is on schedule to return to sport specific soccer drills with her team within the next month.

Goals to be met by discharge date of 11/11/16:1. Pt. will have no knee pain and full PROM for R knee flexion and extension (0-135 degrees). 2. Pt. will be able to jog for 2.0 miles at 7.0 mph.3. Pt. will be able to participate in sport specific soccer drills with her team such as foot-skills, passing,

shooting for an entire practice.

Justification for Discharge recommendation, skilled PT Services & medical necessity: Pt. will return in 2 weeks and be re-evaluated for discharge.

Physical Therapy Plan of Care: Frequency/duration: 1x/week for 2 more weeks

Interventions:


Cardiovascular exercises should be done 3-5 times per week (Jogging, swimming, biking)

Agilities (jumping, skipping, lateral side shuffling, jogging)- 3x 50 yards

Figure 8s w/soccer ball- 5x

Squats- 3 sets of 8- 125 lbs. (increase as needed)



Billing Notes: Progress notes and billing information have been submitted to the insurance company.

End of Episode of Care NoteSession: 27Date: 11/11/16

Problem: Referred to PT after Right ACL Reconstruction Surgery

S (Subjective):

Pt. is a 22-year-old white female who underwent Right ACL reconstruction surgery on 6/10/16. Patellar tendon graft was used. Pt. states that she has been adhering to home exercise program. Pt. rates overall pain as a 0/10 on the R knee both at rest and during activity. Pt. has participated in about 5 ½ months of physical therapy including various exercises. She is eager to return to soccer drills with her team, and to get back to full contact play. Pt. will continue to adhere to the home exercise program provided, which includes agility drills, strengthening, flexibility, and core exercises.

O (Objective):

Pt. has full R knee flexion and extension range of motion. Pt. has a leg symmetry index 90% for the single leg hop test for time, the single leg hop test for distance, and the single leg vertical jump test.

Goniometry:PROM R knee flexion: 0-135 degrees- Soft End Feel

PROM R knee extension: 0-135 degrees- Firm End FeelPROM L knee flexion: 0-135 degrees- Soft End FeelPROM L knee extension: 0-135 degrees- Firm End Feel


A(Assessment):

Diagnosis: Pt. came to physical therapy after surgery for R knee ACL reconstruction. Pt. has progressed well through physical therapy over the last 5 ½ months. No referral to other health professional is necessary at this time. Pt. will follow up with surgeon, Dr. Goodfellow at the 6 and 12-month post-op time.

Prognosis: No further therapy is necessary at this time. Pt. has achieved the anticipated goals and expected outcomes for her plan of care. The pt. has achieved full ROM for R knee flexion and extension (0-135) and full muscle strength of R knee flexors and extensors (5/5). The pt. is able to return to playing soccer and is experiencing no pain. The pt.’s goals/outcomes have been 100% met, and we have discussed plans to continue a home exercise program. Pt. will continue specific interventions to continue to strengthen and prevent future ACL injuries through a home exercise program.

P (Plan of Care):

Anticipated Goals/Expected Outcomes:All anticipated goals and expected outcomes were achieved.

Full ROM of R knee flexion/extension: 100% met Full muscle strength R knee flexors/extensors: 100% met No pain: 100% met Pt. has a leg symmetry index 90% for the single leg hop test for time, the single leg hop test for

distance, and the single leg vertical jump test: 100% met Return to soccer drills and contact play: 100% met

Home exercise program will include many of the previous HEP:

Cardiovascular exercises should be done 3-5 times per week (Jogging, swimming, biking)

Agility drills (jumping, skipping, lateral side shuffling, jogging)- 3x 50 yards (3x per week)

Figure 8s w/soccer ball- 5 sets (3x per week)

Back squats- 3 sets of 8- 125 lbs. (increase as needed) (2x per week)

Plank holds (Normal & R/L side)- 3 sets, 45 secs each position (3x per week)

o Continued progression of core stabilization exercises is encouraged

Flexibility exercises and proper postural form is also encouraged to be incorporated into daily life

No equipment was sold to the pt.

The pt. was seen for 5 ½ months. For the first 3 months the patient was seen 2x/week and for the remaining 2 ½ months the patient was seen 1x/week.

The pt. did not skip or cancel any treatment sessions (#=27), and adhered to the intervention plan. The pt. was discharged from PT once she achieved full pain free ROM, no pain, good knee stability, LSI 90%, and was cleared by her surgeon.

No follow-up appointments are necessary at this time.


Appeal for Additional Visits

Date: 9/30/16

To: BlueCross BlueShield Insurance

From: Amanda Sivic, SPT

RE: Ms. Lauren Mesaros

Dear BlueCross BlueShield Insurance Agent,

I have had the opportunity to work with your client, Ms. Lauren Mesaros. Her surgeon, Dr. Goodfellow, referred Ms. Mesaros to physical therapy services after having ACL reconstruction surgery on her right knee (6/10/16). We are currently taking the proper steps while referring to her plan of care, which will optimize the outcome of her therapy and ensure that she returns to soccer and other daily activities in proper condition. Ms. Mesaros has recently met her goals of achieving full range of motion within her right knee (0-135 degrees) and has achieved full muscle strength in both her right knee flexion and extension (5/5).

I believe that it would be in Ms. Mesaros’ best interest to continue with an additional 6 weeks of physical therapy (6 sessions). It has been shown that in months 4-5 after ACL reconstruction surgery, physical therapy focuses on proper landing techniques, jumping, and agility drills. Ms. Mesaros would evidently feel much more comfortable in the care of a licensed professional while doing these activities. Ms. Mesaros’ ultimate goal is to get back to the high level of NCAA Division I College Soccer, and additional sessions of physical therapy would most definitely help her do so. In order for Ms. Mesaros to have a leg symmetry index 90% for the single leg hop test for time, the single leg hop test for distance, and the single leg vertical jump test, additional sessions of physical therapy are extremely needed. The service of additional physical therapy sessions will help Ms. Mesaros to reach and maintain maximum functional capacity in performing her daily activities. This takes into account both the functional capacity of Ms. Mesaros, and the functional capacities that are appropriate for individuals of the same age.

I appreciate your time and consideration of Ms. Mesaros’ health and well-being. If you have any questions or concerns, please do not hesitate to contact me.

Respectfully,

Amanda Sivic, [email protected] Summary

Date: 11/11/16

To: Dr. Goodfellow, MD

From: Amanda Sivic, SPT

RE: Ms. Lauren Mesaros

Dr. Goodfellow,

Over the past several months (6/16/16-11/11/16), I have had the privilege of conducting physical therapy with your patient, Lauren Mesaros. You referred Ms. Mesaros to physical therapy after ACL reconstruction surgery on her right knee (6/10/16). Ms. Mesaros and I have developed mutual goals in terms of her recovery, and formed a unique treatment plan that we felt would effectively achieve these goals. Ms. Mesaros is very determined to return to playing full contact soccer at the NCAA Division I level.

Ms. Mesaros was treated with several strengthening, flexibility, agility, and core exercises, and became fully educated in proper posture form. Her symptoms have gradually improved throughout our treatment sessions to the point of complete relief. She has achieved full range of motion within her right knee (0-135 degrees) and has achieved full strength in her right knee flexion/extension as well (5/5). She also achieved a leg symmetry index 90% for the single leg hop test for time, the single leg hop test for distance, and the single leg vertical jump test. At this point in time, Ms. Mesaros has reached her personal goals with the help of extensive physical therapy.

If you have any questions or concerns, please do not hesitate to contact me.

Best Regards,

Amanda Sivic, [email protected]

References

1. Andriolo L, Filardo G, Kon E, et al. Revision anterior cruciate ligament reconstruction: Clinical outcome and evidence for return to sport. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2825-2845.

2. Gagnier JJ, Morgenstern H, Chess L. Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: A systematic review and meta-analysis. Am J Sports Med. 2013;41(8):1952-1962.

3. Papalia R, Franceschi F, Tecame A, D'Adamio S, Maffulli N, Denaro V. Anterior cruciate ligament reconstruction and return to sport activity: Postural control as the key to success. Int Orthop.

2015;39(3):527-534.

4. Petersen W, Taheri P, Forkel P, Zantop T. Return to play following ACL reconstruction: A systematic review about strength deficits. Arch Orthop Trauma Surg. 2014;134(10):1417-1428.

5. The guide to rehabilitation of anterior cruciate ligament (ACL) reconstruction http://www.kneeclinic.info/download/CKCGNHACLReconandRehabGuide040612.pdf

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