physical therapy assessment

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SUBJECTIVE DATA QUESTION GUIDELINES Describe the onset of the symptoms or mechanism of injury. Determine whether symptoms are recent, recurrent, or insidious. Determine whether perpetuating circumstances exist. Describe how the symptoms are perceived. Establish the location, type, and nature of the pain or symptoms. Determine whether the pain and symptoms fit into a Pattern: Segmental reference zones Nerve root patterns Extra segmental reference patterns (Dural reference, myofascial pain patterns, peripheral nerve patterns, or circulatory pain) Describe the behavior of the symptoms through a 24-hour period while carrying out typical daily activities. Identify which motions or positions cause or ease the symptoms. Determine how severe or how functionally limiting the problem is. (Functional limitations in terms of daily living, work, family, social, and recreational activities) Determine how irritable the problem is by how easily the symptoms are evoked and how long they last. 1

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Page 1: Physical Therapy Assessment

SUBJECTIVE DATA

QUESTION GUIDELINES

Describe the onset of the symptoms or mechanism of injury.Determine whether symptoms are recent, recurrent, or insidious.

Determine whether perpetuating circumstances exist.

Describe how the symptoms are perceived.Establish the location, type, and nature of the pain or symptoms.

Determine whether the pain and symptoms fit into a Pattern:

Segmental reference zonesNerve root patterns Extra segmental reference patterns(Dural reference, myofascial pain patterns, peripheral nerve patterns, or circulatory pain)

Describe the behavior of the symptoms through a 24-hour period while carrying out typical daily activities.

Identify which motions or positions cause or ease the symptoms.

Determine how severe or how functionally limiting the problem is. (Functional limitations in terms of daily living, work, family, social, and recreational activities)

Determine how irritable the problem is by how easily the symptoms are evoked and how long they last.

Describe any previous history of the condition. Find out if there has been previous treatment for the problem and the results of the treatment.

Describe related history, such as any medical or surgical intervention.

Briefly describe general health, medications, and x-ray or other pertinent studies that have been performed. Identify any medical conditions that may alert you to using special precautions or to contraindications to any testing procedures.

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PAIN

Pain Descriptions and Related Structures

Type o f Pain Structure

Cramping, dull, aching Muscle

Sharp, shooting Nerve root

Sharp, bright, lightning-like Nerve

Burning, pressure-like, stinging, aching Sympathetic nerve

Deep, nagging, dull Bone

Sharp, severe, intolerable Fracture

Throbbing, diffuse Vasculature

INSPECTION

Helps to focus and individualize physical examination

SENSORIUM

Alert awake and attentive to normal stimulationLethargic drowsy, may fall asleep if not stimulatedObtunded difficult to arouse, frequently confused when awakeStupor responds only to strong, noxious stimuli: returns to

unconscious stateComa cannot be aroused

ORIENTATION

Awareness of Time, Person, and Place (oriented x 3)

AMBULATORY STATUS

Note patient’s mode of locomotion (wheelchair, ambulatory with or without assistive device, bedridden, bed bound etc.)

SKIN (color, texture, presence of lesions, scars)

PRESSURE SORES

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Stage 1 non-blanchable erythema of intact skinStage 2 abrasion, blister, or shallow crater (epidermis & dermis)Stage 3 deep crater, necrosis/damage of necrotic tissueStage 4 extensive destruction, tissue necrosis extending up to

muscle and bone

BODY BUILD

Ectomorphic thin, prominence of structures from ectodermMesomorphic muscular, prominence of structures from mesoderm Endomorphic heavy, fat body built, prominence of structures from

endoderm

PALPATION

PALPATION GUIDELINES

Note differences in tissue tension, muscle tone & textureNote differences in tissue thicknessIdentify palpable anomaliesDefine areas of tendernessTemperature variationsPulses, tremors, fasciculationsDryness, excessive moistureAbnormal sensation

Remember!! Palpate uninvolved part first and painful areas last

TENDERNESS (Pain upon palpation)

Tenderness Scale/Grading 1 complains of pain2 complains of pain & winces3 winces & withdraws limb4 patient won’t allow palpation

EDEMA

Grading of Edema Mild 1+ < ¼” depth of depressionModerate 2+ ¼” to ½” depth of

depressionSevere 3+ ½” to 1” depth of depression

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VITAL SIGNS

BLOOD PRESSURE

Adult Blood Pressure Normal <120 mmHg / <80 mmHg Pre-HTN 120-139 mmHg/80-89 mmHg

Stage 1 140-159 mmHg/90-99 mmHgStage 2 ≥ 160 mmHg/100 mmHg

Infant Blood Pressure < 2 y.o. 106-110 mmHg/59-63 mmHg3-5 y.o. 113-116 mmHg/67-74 mmHg

Factors that may alter the Blood Pressure

Elevate BP Lowers BP

Pain Recent mealAuscultatory gap DehydrationSleeplessness Auscultatory gapRecent smokingDistended bowel/bladderRecent exerciseChilling

PULSE RATE

Adult Pulse Rate Normal 60-100 bpm (avg. 70 bpm)Tachycardia >100 bpmBradycardia < 60 bpm

Infant Pulse rate Normal 70-170 bpm (avg. 120 bpm)

Pulse Grading 4+ Bounding3+ Increased2+ Brisk, expected1+ Diminished, weaker than expected0 Absent, unable to palpate

RESPIRATORY RATE

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Adult RR Normal 12-20 cpmTachypnea > 20 cpmHyperpnea increase depth and rate

Infant RR Normal 30-60 cpm

Dyspnea (shortness of breath) scale +1 mild, noticeable to px

+2 mild, noticeable to observer

+3 moderate, can continue+4 severe, can’t continue

TEMPERATURE

Normal 98.6˚F or 37˚CConversion ˚F= [˚C x 9/5] + 32

˚C= [˚F-32] x 5/9

Types of Fever Intermittent alternate b/n pyrexia & normal and

subnormal within 24 hr period

Relapsing/Recurrent alternate b/n pyrexia & normal

lapse for > 24 hrSustained/Constant consistently elevated

temperature

SENSORY ASSESSMENT

Sensory impairments interfere with acquisition of new motor skills since

motor learning is dependent on sensory information and feedback

SENSORY ASSESSMENT PRINCIPLES

Sensory assessment is completed prior to any testing that involves active motor function

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Initial screening for mental status (arousal, attention, orientation, cognition & memory), vision & memory should be done prior to performing sensory tests.

Patient should be instructed not to guess if uncertain about the response

Demonstrate the test to orient the patient on what to expect and what response is needed

Test order: Superficial—Deep—Cortical & Distal to Proximal Apply the stimuli in a random order to avoid giving patient “clues” to the correct response

It is good to use a chart or picture to represent the areas with sensory problem so as to easily identify if a certain pattern exists

EXAMINATION PROTOCOL

Superficial sensation Pain Use sharp end of a pin, avoid applying stimuli close to each otherLet finger slide over the pin

Light touch Use cotton or camel hair brush

Pressure Use thumb enough to indent skin

Temperature Use test tubes with warm (41-50˚F) and cold (104-113˚F)

Response When patient feels stimuli, respond with yes, now or unable to tell

Deep sensation Kinesthesia Move the extremity passively in initial, mid or terminal

range with very minimal grip to reduce tactile stimulation

Response Describe direction as up or down, in or out while the extremity is in motion. Also patient can imitate the movement in opposite extremity.

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Proprioception The extremity is held in a static position in initial, mid or terminal range with very minimal grip to reduce tactile stimulation

Response Describe direction as up or down, in or out while the extremity is in static position. Also patient can imitate the movement in opposite extremity.

Vibration Place the base of a vibrating tuning fork on a bony prominence. Random application of vibrating and non vibrating stimuli should be done. Patient should also be given earphones to remove the auditory clues.

Response Verbally identify the vibrating stimuli

Cortical sensation Stereognosis The patient is given a familiar

object to be held and manipulated

Response The patient is asked to identify the object verbally

Tactile localization Therapist touches different areas in patient skin

surfaceResponse Patient points out the area

that the therapist touchesTwo-point Discrimination Applies simultaneous stimuli

on the patient’s skinResponse Identify if the perception of

one or two stimuliGraphesthesia Trace letters, numbers or

designs on skinResponse Identify what is the traced

figure

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MUSCULOSKELETAL ASSESSMENT

PATIENT HISTORY & INTERVIEW

Symptom Onset sudden, gradual, insidious, traumaticLocation localized, diffuse, deep, superficial, changes,

spreadsQuality severity, characteristicBehavior aggravating factors, relieving factors

Illustrations: Numerical Pain Rating Scales

Circle the number which best represents the intensity of your pain

0 1 2 3 4 5 6 7 8 9 10No Pain Worst Pain

ImaginablePrevious Care/Medical History Previous occurrence of the

condition, treatments received and its effects

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Past medical history Other significant conditions

Medications Medications taken, type, frequency, dose

Treatment goals Patient’s hopes for outcome

Occupational, recreational, social history patient’s work and activities, architectural barriers, environmental accessibility

Illustrations: Rate Patient’s Function

What percentage of your work activities are you able to perform?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Illustrations: Rate Patient’s Function

What percentage of your home activities are you able to perform?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Illustrations: Rate Patient’s Function

What percentage of your recreational activities are you able to perform?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

RANGE OF MOTION

Things to remember Normal side is tested first, unless bilateral movements are needed

AROM-PROM-Isometric movements

Painful movements are done last

Apply over pressure at end of range with care

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Over pressure maybe applied to point of pain but not beyond

Resisted isometrics are done with the joint in resting position

Active ROM Often estimated except if more accurate measurement is needed, goniometer should be usedIf can be performed by patient easily without pain or other symptoms, then passive testing is usually not necessary

Attention!!Limitations in AROM may indicate affection of either contractile or

none contractile tissue or both. The examiner must perform further testing

to isolate the cause.

Passive ROM Slightly greater than AROMTested for amount of motion (goniometric value), effect on symptom, end feel, and pattern of limitation

Attention!!!Limitations in passive ROM maybe d/t bone or joint abnormalities or tightness of these structures. Pain during this test is usually related to pinching, stretching, or moving of non-contractile tissue.

Effect on Symptom Pain aggravated or persistent in passive usually indicates non-contractile structures (bones, joint, ligaments, cartilage etc.)

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End Feel Abnormal End Feels

End Feel Examples

Soft Occurs sooner or later in the ROM than is usual, or in a joint that normally has a firm or hard end-feel. Feels boggy

FirmOccurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or hard end-feel.

HardOccurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or firm end-feel.A bony grating or bony block is felt.

EmptyNo real end-feel because pain prevents reaching end of ROM. No resistance is felt except for patient’s

protective muscle splinting or muscle spasm

Soft tissue edema Synovitis

Increased muscular tonusCapsular, muscular, liga-mentous shortening

Chondromalacia OsteoarthritisLoose bodies in joint Myositis ossificansFracture

Acute joint inflammation BursitisAbscessFracture

Psychogenic Disorder

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Pattern of Limitation Capsular Patterns

Can be due to 2 situations

a. Joint effusion or synovial inflammation (acute stage)

b. Relative capsular fibrosis (chronic stage)

Attention!!!Determine what causes the capsular pattern, if it is inflammation treatment is same for acute stage. If the cause is fibrosis, treatment is same for chronic stage.

Non-Capsular Patterns

Usually involve one or two motions of a joint. Cause can be d/t structures other than the joint capsule. (internal joint derangement, adhesions of part of joint capsule, ligament shortening, muscle strain and shortening)

Capsular Patterns

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ROM ValuesAVERAGE RANGES OF MOTION FOR THE UPPER EXTREMITIES

IN DEGREES FROM SELECTED SOURCES

Joint Motion values

A

of Orthopaedic,Kendall Motion values

Shoulder Flexion 0-180 Hip Flexion 0-120Extension 0-60 Extension 0-30Abduction 0-180 Abduction 0-45Medial rotation 0-70 Adduction 0-30Lateral 0-90 ER/IR 0-45

Elbow Flexion 0-150 Knee Flexion 0-135

Joint Pattern

Shoulder

Elbow

Forearm

Wrist

CMC 1 2-5

UE digit

Hip

Knee

Ankle

Subtalar

Midtarsal

Metatarsalphalangeal joint 1

Metatarsalphalangeal joint 2-5

IP joint

ER>ABD>IR

F>E

Pronation=Supination

F=E

ABD & EXTEqual restriction in all direction

F>E

IR, F, ABD

F>E

PF>DF

Varus restricted

Restricted DF, PF, ABD, medial rotation

E>F

Tend toward Flexion

Tend toward extension

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Forearm Pronation 0-80 Ankle PF 0-50Supination 0-80 DF 0-20

Wrist Extension 0-70 Inversion 0-35Flexion 0-80 Eversion 0-15Radial 0-20 Subtalar Inv/Evr 0-5Ulnar deviation 0-30 Great toe

ThumbCMC Abduction 0-70 MTP flexion 0-45

Flexion 0-15 extension 0-70Extension 0-20 PI flexion 0-90Opposition Tip of thumb to

or tip of fifth digit Lesser toe

MTP flexion 0-40

MCP Flexion 0-50 extension 0-40IP Flexion 0-80 PIP flexion 0-35

Digits DIP flexion 0-30Second -FifthMCP Flexion 0-90

Hyperextensio 0-45Abduction

PIP Flexion 0-100DIP Flexion 0-90

Hyperextension

0-10

ACESSORY JOINT MOTIONS

Tested if PROM is limited or painful; Tested for amount of motion, effect on symptoms, and end feel.

Accessory joint motion grades 0 ankylosed1 considerable hypomobility2 slight hypomobility3 normal4 slight hypermobility5 considerable hypermobility6 unstable

Grades 0 & 6 surgery considered, joint mobilization not indicatedGrades 1 & 2 joint mobilization to increase joint extensibilityGrades 4 & 5 increasing joint extensibility not indicated; taping,

bracing, strengthening indicated

RESISTED ISOMETRIC TESTING

Joint should be placed in a position midway through the range, to produce

minimal tension in inert structures.

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RESULTS OF RESISTEDISOMETRIC TESTING

Findings Possible Pathologies

Strong and painless There is no lesion or neurological deficit involving the tested muscle and tendon.

Strong and painful There is a minor lesion of the tested mus-cle or tendon.

Weak and painless There is a disorder of the nervous system, neuromuscular junction, or a complete rupture of the tested muscle or tendon, or disuse atrophy.

Weak and painful There is a serious, painful pathology such as a fracture or neoplasm. Other pos-sibilities include an acute inflammatory process that inhibits muscle contraction, or a partial rupture of the tested muscle or tendon.

Remember!!! Burasae can produce pain in isometric contraction if it’s inflamed even though it’s non-contractile

MANUAL MUSCLE TESTING

Manual Muscle Testing Grades

Grades Criteria

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Normal N 5 10Full available ROM, against

gravity, strong manualresistance

Good Plus G+ 5– 9Full available ROM, against

gravity, nearly strongmanual resistance

Good G 4 8Full available ROM, against

gravity, moderate manualresistance

Good Minus G– 4– 7Full available ROM, against

gravity, nearly moderatemanual resistance

Fair Plus F+ 3+ 6Full available ROM, against

gravity, slight manualresistance

Fair F 3 5 Full available ROM, againstgravity, no resistance

Fair Minus F– 3– 4 At least 50% of ROM, againstgravity, no resistance

Poor Plus P+ 2+ 3Full available ROM, gravity

minimized, slight manualresistance

Poor P 2 2 Full available ROM, gravityminimized, no resistance

Poor Minus P– 2– 1At least 50% of ROM, gravity

minimized, no resistance

Trace Plus T+ 1+ Minimal observable motion

(less than 50% ROM), gravity minimized, no resistance

Trace T 1 TNo observable motion, palpable

muscle contraction, no resistance

Zero 0 0 0No observable or palpable muscle contraction

CLOSE-OPEN PACKED POSITION

Resting (Loose/open Packed) Position of Joints

Joint Position

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Facet (spine) Midway between flexion and extensionTemporomandibular Mouth slightly open (freeway space)

Glenohumeral 55° abduction, 30° horizontal adductionAcromioclavicuiar Arm resting by side in normal physiological positionSternoclavicular Arm resting by side in normal physiological positionUlnohumeral (elbow) 70° flexion, 10° supinationRadiohumeral Full extension, full supinationProximal radioulnar 70° flexion, 35° supinationDistal radioulnar 10° supinationRadiocarpal (wrist) Neutral with slight ulnar deviationCarpometacarpal Midway between abduction-adduction and flexion-extensionMetacarpophalangeal Slight flexion

Interphalangeal Slight flexionHip 30° flexion, 30° abduction, slight lateral rotationKnee 25° flexionTalocrural (ankle) 10° plantar flexion, midway between maximum inversion and eversionSubtalar Midway between extremes of range of movementMidtarsal Midway between extremes of range of movementTarsometatarsal Midway between extremes of range of movementMetatarsophalangeal Neutral

Close Packed Position of Joints Joint Position

Facet (spine) ExtensionTemporomandibular Clenched teethGlenohumeral Abduction and lateral rotationAcromioclavicular Arm abducted to 90°Sternoclavicular Maximum shoulder elevationUlnohumeral (elbow) ExtensionRadiohumeral Elbow flexed 90°, forearm supinated 5°Proximal radioulnar 5° supinationDistal radioulnar 5° supinationRadiocarpal (wrist) Extension with radial deviationMetacarpophalangeal Full flexion (fingers)Metacarpophalangeal Full opposition (thumb)Interphalangeal Full extensionHip Full extension, medial rotation*Knee Full extension, lateral rotation of tibiaTalocrural (ankle) Maximum dorsiflexion

Subtalar SupinationMidtarsal SupinationTarsometatarsal SupinationMetatarsophalangeal Full extension

MOTOR EVALUATION

TONE

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Modified Ashworth Scale

Grade Description

0 No increase in muscle tone.

1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension.

1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM.

2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved.

3 Considerable increase in muscle tone, passive movement difficult.

4 Affected part(s) rigid in flexion or extension.

DEEP TENDON REFLEXES

Jaw (trigeminal)Biceps (C5, C6)Triceps (C7, C8)Hamstrings (L5, S1, S2)Patellar (L2, L3, L4)Ankle (S1, S2)

Grade Evaluation Response Characteristics

0 Absent No visible or palpable muscle contraction with reinforcement.

1+ Hyporeflexia Slight or sluggish muscle contraction withlittle or no joint movement. Reinforcement may be required to elicit a reflex response.

2+ Normal Slight muscle contraction with slight joint movement.

3+ Hyperreflexia Clearly visible, brisk muscle contraction with moderate joint movement.

4+ Abnormal Strong muscle contraction with one to three beats of clonus.

Reflex spread to contralateral side may be noted.

5+ Abnormal Strong muscle contraction with sustained clonus. Reflex spread to contralateral side maybe noted

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BALANCE

FUNCTIONAL BALANCE GRADES

Normal Patient is able to maintain steady balance without support (static).Accepts maximal challenge and can shift weight in all directions (dynamic).

Good Patient is able to maintain balance without support (static).Accepts moderate challenge; able to maintain balance while picking object off floor (dynamic).

Fair Patient is able to maintain balance with handhold (static). Accepts minimal challenge; able to maintain balance while turning head/trunk (dynamic).

Poor Patient requires handhold and assistance (static).

CTSIB (Clinical Test for Sensory Interaction in Balance

1 2 3 4 5 6

1. Eyes open, fixed support

2. Eyes closed, fixed support

3. Visual conflict, fixed support

4. Eyes open, moving surface

5. Eyes closed, moving support

6. Visual conflict moving support

Result-Interpretation

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2,3,5,6 Visual loss5, 6 Vestibular loss4, 5, 6 Surface, somatosensory input3, 4, 5, 6Sensory selection

COORDINATION ASSESSMENT

NON-EQUILIBRIUM TESTS

Tests should be performed first with eyes open and then with eyes closed. Abnormal responses include a gradual deviation from the "holding' position and/or a diminished quality of response with vision occluded. Unless otherwise indicated, tests are performed with the patient in a sitting position.

TEST PROCEDURE1. Finger to nose

2. Finger to therapist's finger

3. Finger to finger

4. Alternate nose to finger

5. Finger opposition

The shoulder is abducted to 90 degrees with the elbow extended. The patient is asked to bring the tip of the index finger to the tip of the nose. Alterations may be made in the initial starting position to assess performance from different planes of motion.

The patient and therapist sit opposite each other. The therapist's index finger is held in front of the patient. The patient is asked to touch the tip of the index finger to the therapist's index finger. The position of the therapist's finger may be altered during testing to assess ability to change distance, direction, and force of movement.

Both shoulders are abducted to 90 degrees with the elbows extended. The patient is asked to bring both hands toward the midline and approximate the index fingers from opposing hands.

The patient alternately touches the tip of the nose and the tip of the therapist's finger with the index finger. The position of the therapist's finger may be altered during testing to assess ability to change distance, direction, and force of movement.

The patient touches the tip of the thumb to

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6. Mass grasp

7. Pronation/supination

8. Rebound test

9. Tapping (hand)

10.Tapping (foot)

11.Pointing and past pointing

the tip of each finger in sequence. Speed may be gradually increased.

An alternation is made between opening and closing fist (from finger flexion to full extension). Speed may be gradually increased.

With elbows flexed to 90 degrees and held close to body, the patient alternately turns the palms up and down. This test also may be performed with shoulders flexed to 90 degrees and elbows extended. Speed may be gradually increased. The ability to reverse movements between opposing muscle groups can be assessed at many joints. Examples include active alternation between flexion and extension of the knee, ankle, elbow, fingers, and so forth.

The patient is positioned with the elbow flexed. The therapist applies sufficient manual resistance to produce an isometric contraction of biceps. Resistance is suddenly released. Normally, the opposing muscle group (triceps) will contract and "check" movement of the limb. Many other muscle groups can be tested for this phenomenon, such as the shoulder abductors or flexors, elbow extensors, and so forth.

With the elbow flexed and the forearm pronated, the patient is asked to "tap" the hand on the knee.

The patient is asked to "tap" the ball of one foot on the floor without raising the knee; heel maintains contact with floor.

The patient and therapist are opposite each other, either sitting or standing. Both patient and therapist bring shoulders to a horizontal position of 90 degrees of flexion with elbows extended. Index fingers are touching or the patient's finger may rest lightly on the therapist's. The patient is asked to fully flex the shoulder (fingers will be pointing toward ceiling) and then return to the horizontal position such that index fingers will again approximate. Both arms should be tested, either separately or simultaneously. A normal response consists of an accurate return to the starting

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12.Alternate heel to knee; heel to toe

13.Toe to examiner's finger

14.Heel on shin

15.Drawing a circle

16.Fixation or position holding

position. In an abnormal response, there is typically a "past pointing," or movement beyond the target. Several variations to this test include movements in other directions such as toward 90 degrees of shoulder abduction or toward 0 degrees of shoulder flexion finger will point toward floor). Following each movement, the patient is asked to return to the initial .horizontal starting position.

From a supine position, the patient is asked to touch the knee and big toe alternately with the heel of the opposite extremity.

From a supine position, the patient is instructed to touch the great toe to the examiner's finger. The position of finger may be altered during testing to assess ability to change distance, direction, and force of movement.

From a supine position, the heel of one foot is slid up and down the shin of the opposite lower extremity.

The patient draws an imaginary circle in the air with either upper or lower extremity (a table or the floor also may be used). This also may be done using a figure-eight pattern. Thistest may be performed in the supine position for lower extremity assessment.

Upper extremity: The patient holds arms horizontally in front (sitting or standing). Lower extremity: The patient is asked to hold the knee in an extended position (sitting).

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EQUILIBRIUM COORDINATION TESTS

1. Standing in a normal, comfortable posture.

2. Standing, feet together (narrow base of support).3. Standing, with one foot directly in front of the other in

tandem position (toe of one foot touching heel of opposite foot).

4. Standing on one foot.5. Arm position may be altered in each of the above

postures (i.e., arms at side, over head, hands on waist, and so forth).

6. Displace balance unexpectedly (while carefully guarding patient).

7. Standing, alternate between forward trunk flexion and return to neutral.

8. Standing, laterally flex trunk to each side.9. Standing: eyes open (EO) to eyes closed (EC) ability to

maintain an upright posture without visual input is referred to as a positive Romberg sign.

10. Standing in tandem position eyes open (EO) to eyes closed (EC) (Sharpened Romberg).

11. Walking, placing the heel of one foot directly in front of the toe of the opposite foot (tandem walking).

12. Walking along a straight line drawn or taped to the floor, or place feet on floor markers while walking.

13. Walk sideways, backward, or cross-stepping.14. March in place.15. Alter speed of ambulatory activities; observe patient

walking at normal speed, as fast as possible, and as slow as possible.

16. Stop and start abruptly while walking.17. Walk and pivot (turn 90, 180, or 360 degrees).18. Walk in a circle, alternate directions.19. Walk on heels or toes.20. Walk with horizontal and vertical head turns.21. Step over or around obstacles.22. Stair climbing with and without using handrail; one

step at-a-time versus step-over-step.23. Agility activities (coordinated movement with upright

balance); jumping jacks, alternate flexing and extending the knees while sitting on a Swiss ball.

Impairment Sample Test

Dysdiadochokinesia F i n g e r t o n o s e Alternate nose to finger Pronation/supination Knee f lexion/extension Walking, alter speed or direction

Dysmetria Pointing and past pointing Drawing a circle or figure eight Heel on shin.

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Placing feet on floor markers while walking

Movement decomposition Finger to nose (dyssynergia) Finger to therapist's finger

Alternate heel to knee Toe to examiner's finger

Hypotonia Passive movement Deep tendon reflexes

Tremor (intention) Observation during functional ac-tivities (tremor will typically

increase as target is approached or movement speed increased)

Alternate nose to fingerFinger to finger

Finger to therapist's finger Toe to examiner's finger

Tremor (resting) Observation of patient at rest Observation during functional ac-tivities (tremor will diminish significantly or disappear with movement)

Tremor (postural) Observation of steadiness of normal standing posture

Asthenia Fixation or position holding (upper and lower extremity)

Application of manual resistance to assess muscle strength

Rigidity P a s s i v e m o v e m e n t Observation during functional ac-

tivities Observation of resting posture(s)

Bradykinesia Walking, observation of arm swing and trunk motions

Walking, alter speed and direction Request that a movement or gait activity be stopped abruptly Observation of functional activities: timed tests

Disturbances of posture Fixation or position holding (upper and lower extremity)

Displace balance unexpectedly in s i t t i ng o r s tand ing Standing, alter base of support (e.g.,

one foot directly in frontof the other; standing on one

foot)

Disturbances of gait Walk along a straight line

Walk sideways, backward March in place

Alter speed and direction of ambu-latory activities

Walk in a circle

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GAIT ANALYSIS

GAIT TERMS

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TRUNK DEVIATIONS: STANCE PHASE

HIP DEVIATIONS: STANCE PHASE

HIP DEVIATIONS: SWING PHASE

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KNEE DEVIATIONS: STANCE PHASE

KNEE DEVIATIONS: SWING PHASE

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ANKLE & FOOT DEVIATIONS: SWING PHASE

ANKLE & FOOT DEVIATIONS: STANCE PHASE

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RATING FOR GAIT ANALYSIS

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FUNCTIONAL ANALYSIS

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Barthel's index of activities of daily living (BAI)

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Functional Independence Measure (FIM)

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Katz Index of ADL

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