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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)_____________________________                                      DATE__________________

                                    ELBOW  PHYSICAL  THERAPY  PRESCRIPTION  

___    Range  of  mo<on  (Ac<ve,  Ac<ve  Assisted,  Passive),  
         Flex/  Ex/  Pro/  Supina<on  
  
___  Passive  stretching  Wrist  Extensors  and  Flexors
         Begin  with  Elbow  flexed
         Progress  to  stretching  with  Elbow  in  extension

___  Strengthening:  Begin  if  range  of  mo<on  is  near  full:    Biceps,  Triceps,  Wrist  Flexors,  Wrist  Extensors,  
         Resisted  prona<on  and  supina<on.    Can  begin  with  Isometric  exercises,  then  progress  to  
         concentric  and  eccentric  exercise  as  
         tolerated.                                                                                                   
                                                                          
___  Ice  before  and  aUer  rehab  exercises

___  Modali<es  (s<m.  Ionto,  US)
Treatment:  ________  Dmes  per  week                DuraDon:  ________  weeks                ___  Home  Program
**  Please  send  progress  notes.

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

				
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