NEW-ANKLE-SPRAIN-PT

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					                                                              PHYSICAL  THERAPY  PRESCRIPTION

SETH  C.  GAMRADT,  MD
ORTHOPAEDIC  SURGERY  AND  SPORTS  MEDICINE
UCLA  DEPARTMENT  OF  ORTHOPAEDIC  SURGERY
1250 16th Street, Suite 3145
Santa Monica, CA 90404
310.319.1234 Appointments                                                                     PATIENT STICKER


CA  License:  A769260
www.gamradtortho.com


DIAGNOSIS  (  LEFT  /  RIGHT  )  ANKLE  SPRAIN    -­‐    GRADE        I            II            III          DATE__________


                                 ANKLE  PHYSICAL  THERAPY  PRESCRIPTION

___  Ice  Massage  /  Ice  Bath  /  Whirlpool
___  AnD-­‐Inflammatory  ModaliDes
___  Range  of  MoDon                AcDve  /  AcDve-­‐Assisted  /  Passive
___  Flexibility
___  Compression  –  Aircast  /  Jobst  IntermiPent  Compression
___  Isometrics  for  Inversion  /  Eversion  –  Progress  to  IsokineDcs  and  Isotonics
___  Isotonics  for  Plantar  /  Dorsiflexion
___  PropriocepDon  training,  BAPS
___  Advance  to  Lateral  step-­‐ups,  Sport-­‐cord,  Euroglide
Treatment:  __________  Hmes  per  week                                      ___  Home  Program
DuraHon:  __________  weeks


**Please  send  progress  notes.

Physician’s  Signature:_____________________________________________
Seth  C.  Gamradt,  MD,  APending  Orthopaedic  Surgeon,  UCLA

				
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