SUBJECTIVE

Patient Profile

Name:

Age:

Gender:

Settings:

D.O.A:

D.O.AX:

DR Diagnose:

DR Mx:

Chief Complaint:

History

Present History:

Past History:

Personal History:

Medical History:

On Medication:

OBJECTIVE

Observation

General

Race:

Gender:

Posture:

General built:

Gait:

Local

Swelling:

Scars:

Muscle wasting:

External Appliances:

Deformity:

On Palpation

Temperature:

Tenderness:

Oedema:

Vital signs:

On Examination

Higher functions

Memory:

Intelligence:

Level of consciousness:

Behaviour:

Orientation:

Speech:

Cranial Nerves Examination

Name Test Abnormal SignsOlfactory Identify a familiar odour, e.g coffe, orange with one

nostril at a time Partial or total loss of smellAltered or increased sense of smell

Optic Read with one eye covered, detects objects or movement

Visual fields defects, loss of visual acuity, colour blind

Oculomotor Follow the examiner’s finger, which moves up and down and side to side, keeping the head in mid position

Squint, ptosis, diplopia, pupil dilation

Trochlear As for oculomotor Diplopia, squintTrigeminal Test facial sensation, clench teeth (the examiner

palpates the masseter and temporalis muscles)Trigeminal neuralgia, loss mastication and sensation in eye, face, sinuses and teeth

Abducens As for oculomotor Gaze palsyFacial Test ability to move the face, e.g close eyes tightly,

wrinkle brow, whistle, smile, show teethBell’s palsy, loss of taste and ability to close eyes

Vestibulocochlear Examiner rubs index finger and thumb together noisily beside one ear and silently beside the other. Patients identifies the noisy side.

Tinnitus, deafness, vertigo, ataxia, nystagmus

Glossopharyngeal Swallow, evoke the gag reflex by touching the back of the throat with a tongue depressor

Loss of tongue sensation and taste, reduced salivation, dysphagia

Vagus As for glossopharyngeal Vocal cord paralysis, dysphagia, loss of sensation from internal organs

Accessory Rotate neck to one side and resist flexion, ie contract sternocleidomastoid. Shrug shoulders against resistance

Paralysis of innervated muscles

Hypoglossal Stick out tounge. Push tounge into left and right side of the cheek

Dysphagia, dysarthria, difficulty masticating

Sensory Examination

Superficial senses

Pain:

Fine touch:

Crude touch:

Temperature:

Deep senses

Pressure:

Vibration:

Joint position sense:

Cortical senses

Tactile localization:

Two point discrimination:

Steriognosis:

Reflex Examination

Superficial

Corneal:

Pupillary:

Cremastric:

Gag:

Abdominal:

Plantar/Babinski:

Deep

Biceps jerk:

Triceps jerk:

Brachioradialis jerk:

Quadriceps/knee jerk:

TA/ankle jerk:

Motor Examination

Range Of Motion

Joints Movements Right (active)

Right (passive)

Left(active)

Left(passive)

diffrence

Shoulder

Flexion

ExtensionAbductionAdductionM.rotationL.rotation

Elbow FlexionExtensionSupinationPronation

Wrist FlexionExtensionRad deviationUl deviation

Hip FlexionExtensionAbductionAdduction

Knee FlexionExtension

Ankle DorsiflexionPlantar flexion

Muscle Tone

Muscle under stretch R L R LShoulder flexor Hip flexorShoulder extensor Hip extensor Shoulder abductor Hip adductorShoulder adductor Hip abductorElbow flexor Knee extensorElbow extensor Knee flexorWrist flexor Ankle plantarflexorWrist extensor Ankle dorsiflexorFinger flexor Ankle inversionFinger extensor Ankle eversion

0- No increase in muscle tone1- Slight increase in muscle tone, manisfested by a catch and release or by minimal resistance at the end of the

range of motion when the affected parts is moved in flexion or extension.2- Slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout the

remainder (less than half) at the ROM.3- More marked increase in muscle tone through most of the ROM, but affected parts easily moved.4- Considerable increase in muscle tone, passive movement difficult.5- Affected parts rigid in flexion or extension.

ADL Assessment

Barthel Index

1. Bowels: 2. Bladder:3. Grooming:4. Toilet use:5. Feeding:6. Transfer:7. Mobility:8. Dressing:9. Stairs:10. Bathing:

Total Score =

Berg Balance Scale

1. Sitting to standing2. Standing unsupported

3. Sitting with back unsupported4. Standing to sitting5. Transfers6. Standing unsupported with eye closed7. Standing unsupported with feet together 8. Reaching forward with outstretched arm while standing9. Pick up object from floor from a standing position 10. Turning to look behind over left and right shoulders while standing 11. Turn 360 degrees 12. Placing alternate foot on step or stool while unsupported 13. Standing unsupported one foot in front14. Standing on one leg

Total Score :

Motor Assessment Scale (MAS)

1. Supine to side lying on intact side2. Supine to sitting over the side of bed3. Balanced sitting4. Sitting to standing5. Walking6. Upper arm function7. Hand movements8. Advanced hand activities

Total Score:

Functional Independence Measure (FIM)

Self-Care1. Eating2. Grooming3. Bathing4. Dressing - Upper Body5. Dressing - Lower Body6. Toileting

Sphincter Control7. Bladder Management8. Bowel Management

Transfers9. Bed, Chair, Wheelchair10. Toilet11. Tub, Shower

Locomotion 12. Walk/Wheelchair

13. Stairs

Communication14. Comprehension15. Expression16. Social Cognition17. Social Interaction18. Problem Solving19. Memory

Total Score:

Gait Assessment

Dynamic Gait Index

1. Gait level surface2. Change in gait speed3. Gait with horizontal head turns4. Gait with vertical heads turns5. Gait and pivot turn6. Step over obstacles7. Step around obstacles8. Steps

Total Score:

Coordination Test

Finger to Finger:

Finger to nose:

Heel to shin:

Balance Test

Sitting

-Static:

-Dynamic:

Standing

-Static:

-Dynamic:

Physiotherapy Impression

Short Term Goal

Long Term Goal

Plan of Treatment

Home Exercise Program

Re-assessment

Review

Barthel Index of Activities of Daily Living

.

The Barthel Index

Bo w e l s 0 = incontinent (or needs to be given enemata) 1 = occasional accident (once/week)2 = continentPatient's Score:

Bladd e r 0 = incontinent, or catheterized and unable to manage 1 = occasional accident (max. once per 24 hours)2 = continent (for over 7 days)Patient's Score:

Grooming0 = needs help with personal care1 = independent face/hair/teeth/shaving (implements provided)Patient's Score:

Toilet use 0 = dependent1 = needs some help, but can do something alone 2 = independent (on and off, dressing, wiping)Patient's Score:

Feeding0 = unable1 = needs help cutting, spreading butter, etc. 2 = independent (food provided within reach)Patient's Score:

(Collin et al., 1988)

Scoring:

Sum the patient's scores for each item. Total possible scores range from 0 – 20, with lower scores indicating increased disability. If used to measure improvement after rehabilitation, changes of more than two points in the total score reflect a probable genuine change, and change on one item from fully dependent to independent is also likely to be reliable.

Transf e r 0 = unable – no sitting balance1 = major help (one or two people, physical), can sit 2 = minor help (verbal or physical)3 = independentPatient's Score:

Mobility0 = immobile1 = wheelchair independent, including corners, etc.2 = walks with help of one person (verbal or physical) 3 = independent (but may use any aid, e.g., stick)Patient's Score:

Dre s sing 0 = dependent1 = needs help, but can do about half unaided2 = independent (including buttons, zips, laces, etc.)Patient's Score:

Stairs0 = unable1 = needs help (verbal, physical, carrying aid) 2 = independent up and downPatient's Score:

Bathing0 = dependent1 = independent (or in shower)Patient's Score:

Total Score:

Berg Balance Scale1. SITTING TO STANDINGINSTRUCTIONS: Please stand up. Try not to use your hand for support.( ) 4 able to stand without using hands and stabilize independently( ) 3 able to stand independently using hands( ) 2 able to stand using hands after several tries( ) 1 needs minimal aid to stand or stabilize( ) 0 needs moderate or maximal assist to stand

2. STANDING UNSUPPORTEDINSTRUCTIONS: Please stand for two minutes without holding on.( ) 4 able to stand safely for 2 minutes( ) 3 able to stand 2 minutes with supervision( ) 2 able to stand 30 seconds unsupported( ) 1 needs several tries to stand 30 seconds unsupported( ) 0 unable to stand 30 seconds unsupported

If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4.

3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOLINSTRUCTIONS: Please sit with arms folded for 2 minutes.( ) 4 able to sit safely and securely for 2 minutes( ) 3 able to sit 2 minutes under supervision( ) 2 able to able to sit 30 seconds( ) 1 able to sit 10 seconds( ) 0 unable to sit without support 10 seconds

4. STANDING TO SITTINGINSTRUCTIONS: Please sit down.( ) 4 sits safely with minimal use of hands( ) 3 controls descent by using hands( ) 2 uses back of legs against chair to control descent( ) 1 sits independently but has uncontrolled descent( ) 0 needs assist to sit

5. TRANSFERSINSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair.( ) 4 able to transfer safely with minor use of hands( ) 3 able to transfer safely definite need of hands( ) 2 able to transfer with verbal cuing and/or supervision( ) 1 needs one person to assist( ) 0 needs two people to assist or supervise to be safe

6. STANDING UNSUPPORTED WITH EYES CLOSEDINSTRUCTIONS: Please close your eyes and stand still for 10 seconds.( ) 4 able to stand 10 seconds safely( ) 3 able to stand 10 seconds with supervision ( ) 2 able to stand 3 seconds( ) 1 unable to keep eyes closed 3 seconds but stays safely( ) 0 needs help to keep from falling

7. STANDING UNSUPPORTED WITH FEET TOGETHERINSTRUCTIONS: Place your feet together and stand without holding on.( ) 4 able to place feet together independently and stand 1 minute safely( ) 3 able to place feet together independently and stand 1 minute with supervision

( ) 2 able to place feet together independently but unable to hold for 30 seconds( ) 1 needs help to attain position but able to stand 15 seconds feet together( ) 0 needs help to attain position and unable to hold for 15 seconds

8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDINGINSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both arms when reaching to avoid rotation of the trunk.)( ) 4 can reach forward confidently 25 cm (10 inches)( ) 3 can reach forward 12 cm (5 inches)( ) 2 can reach forward 5 cm (2 inches)( ) 1 reaches forward but needs supervision( ) 0 loses balance while trying/requires external support

9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITIONINSTRUCTIONS: Pick up the shoe/slipper, which is place in front of your feet.( ) 4 able to pick up slipper safely and easily( ) 3 able to pick up slipper but needs supervision ( ) 2 unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently( ) 1 unable to pick up and needs supervision while trying( ) 0 unable to try/needs assist to keep from losing balance or falling

10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDINGINSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. Examiner may pick an object to look at directly behind the subject to encourage a better twist turn.( ) 4 looks behind from both sides and weight shifts well( ) 3 looks behind one side only other side shows less weight shift( ) 2 turns sideways only but maintains balance( ) 1 needs supervision when turning( ) 0 needs assist to keep from losing balance or falling

11. TURN 360 DEGREESINSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.( ) 4 able to turn 360 degrees safely in 4 seconds or less( ) 3 able to turn 360 degrees safely one side only 4 seconds or less( ) 2 able to turn 360 degrees safely but slowly( ) 1 needs close supervision or verbal cuing( ) 0 needs assistance while turning

12. PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTEDINSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touch the step/stool four times.( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds( ) 3 able to stand independently and complete 8 steps in > 20 seconds( ) 2 able to complete 4 steps without aid with supervision( ) 1 able to complete > 2 steps needs minimal assist( ) 0 needs assistance to keep from falling/unable to try

13. STANDING UNSUPPORTED ONE FOOT IN FRONTINSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the subject’s normal stride width.) ( ) 4 able to place foot tandem independently and hold 30 seconds( ) 3 able to place foot ahead independently and hold 30 seconds( ) 2 able to take small step independently and hold 30 seconds( ) 1 needs help to step but can hold 15 seconds( ) 0 loses balance while stepping or standing

14. STANDING ON ONE LEGINSTRUCTIONS: Stand on one leg as long as you can without holding on.( ) 4 able to lift leg independently and hold > 10 seconds( ) 3 able to lift leg independently and hold 5-10 seconds( ) 2 able to lift leg independently and hold ≥ 3 seconds( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently.( ) 0 unable to try of needs assist to prevent fall

( ) TOTAL SCORE (Maximum = 56)

MOTOR ASSESSMENT SCALE

Supine to Side-lying onto intact side (starting position: supine with knees straight)1. Uses intact arm to pull body toward intact side. Uses intact leg to hook impaired leg to pull it over. 2. Actively moves impaired leg across body to roll but leaves impaired arm behind.3. Impaired arm is lifted across body with other arm. Impaired leg moves actively & body follows as a block. 4. Actively moves impaired arm across body. The rest of the body moves as a block.5. Actively moves impaired arm and leg rolling to intact side but overbalances. 6. Rolls to intact side in 3 seconds without use of hands.

Supine to Sitting over side of bed1. Pt assisted to the side-lying position: Patient lifts head sideways but can’t sit up.2. Pt may be assisted to side-lying & is assisted to sitting but has head control throughout.3. Pt may be assisted to side-lying & is assisted with lowering LEs off bed to assume sitting. 4. Pt may be assisted to side-lying but is able to sit up without help.5. Pt able to move from supine to sitting without help.6. Pt able to move from supine to sitting without help in 10 seconds.

Balance Sitting1. Pt is assisted to sitting and needs support to remain sitting.2. Pt sits unsupported for 10 seconds with arms folded, knees and feet together & feet on the floor.3. Pt sits unsupported with weight shifted forward and evenly distributed over both hips / legs. Head and thoracic spine extended.4. Sits unsupported with feet together on the floor. Hands resting on thighs. Without moving the legs the patient turns the head and trunk to look behind the right and left shoulders.5. Sits unsupported with feet together on the floor. Without allowing the legs or feet to move & without holding on the patient must reach forward to touch the floor (10 cm or 4 inches in front of them) The affected arm may be supported if necessary.6. Sits on stool unsupported with feet on the floor. Pt reaches sid e w a ys without moving the legs or holding on and returns to sitting position. Support affected arm if needed.

Sitting to Standing1. Pt assisted to standing – any method.2. Pt assisted to standing. The patient’s weight is unevenly distributed & may use hands for support.3. Pt stands up. The patient’s weight is evenly distributed but hips and knees are flexed – No use of hands for support.4. Pt stands up. Remains standing for 5 seconds with hips and knees extended with weight evenly distributed. 5. Pt stands up and sits down again. When standing hips & knees are extended with weight evenly distributed 6. Pt stands up and sits down again 3 x in 10 seconds with hips & knees extended & weight evenly distributed

Walking1. With assistance the patient stands on affected leg with the affected weight bearing hip extended and steps forward with the intact leg.2. Walks with the assistance of one person.3. Walks 10 feet or 3 meters without assistance but with an assistive device. 4. Walks 16 feet or 5 meters without a device or assistance in 15 seconds.5. Walks 33 feet or 10 meters without assistance or a device. Is able to pick up a small object from the floor with either hand and walk back in 25 seconds.6. Walks up and down 4 steps with or without a device but without holding on to a rail 3 x in 35 seconds

Functional Independence Measure (FIM) Instrument

ADMISSION DISCHARGE FOLLOW-UP

Self-Care

A. Eating

B. Grooming

C. Bathing

D. Dressing - Upper Body

E. Dressing - Lower Body

F. Toileting

Sphincter Control

G. Bladder Management

H. Bowel Management

Transfers

I. Bed, Chair, Wheelchair

J. Toilet

K. Tub, Shower

Locomotion

L. Walk/Wheelchair

M. Stairs

Motor Subtotal Score

Communication

N. Comprehension

O. Expression

Social Cognition

P. Social Interaction

Q. Problem Solving

R. Memory

Cognitive Subtotal Score

TOTAL FIM Score

L E V E L S

Independent7 Complete Independence (Timely, Safely) 6 Modified Independence (Device)

Modified Dependence5 Supervision (Subject = 100%+) 4 Minimal Assist (Subject = 75%+)3 Moderate Assist (Subject = 50%+)

Complete Dependence2 Maximal Assist (Subject = 25%+)1 Total Assist (Subject = less than 25%)

Note: Leave no blanks. Enter 1 if patient is not testable due to risk

NO HELPER

HELPER

_

DYNAMIC GAIT INDEX DATE:

Grading: record the lowest category that applies.

1. Gait level surface: Instructions: Walk at your normal speed from here to the next mark (20’).(3) Normal: walks 20’, no assistive devices, good speed, no evidence for imbalance, normal gait

pattern.(2) Mild impairment: walks 20’, uses assistive devices, slower speed, mild gait deviations.(1) Moderate impairment: walks 20’, slow speed, abnormal gait patters, evidence for imbalance. (0) Severe impairment: cannot walk 20’ without assistance, severe gait deviations or imbalance.

2. Change in gait speed. Instructio n s : Begin walking at your normal pace (for 5’), when I tell you “go”, walk as fast as you can (for 5’). When I tell you “slow”, walk as slowly as you can (for 5’). (3) Normal: Able to smoothly change walking speed without loss of balance or gait deviation.

Shows significant difference in walking speeds between normal, fast and slow paces.(2) Mild impairment: Is able to change speed but demonstrates mild gait deviations, or no gait

deviations but unable to achieve a significant change in velocity, or uses as assistive device.(1) Moderate impairment: Makes only minor adjustments to walking speed, or accomplishes a

change in speed with significant gait deviations, or changes speed but loses balance but is able to recover and continue walking.

(0) Severe impairment: Cannot change speeds, or loss balance and has to reach for a wall or be caught.

3. Gait with horizontal head turns. Instructio n s : Begin walking at your normal pace. When I tell you to “look right”, keep walking straight, but turn your head to the right. Keep looking to the right until I tell you “look left”, then keep walking straight and turn your head to the left. Keep your head to the left until I tell you, “look straight”, then keep walking straight, but return your head to the centre.(3) Normal: Performs head turns smoothly with no change in gait.(2) Mild impairment: Performs head turns smoothly with slight change in gait velocity, i.e. minor

disruption to smooth gait path or uses walking aid.(1) Moderate impairment: Performs head turns with moderate change in gait velocity, slows down,

staggers, but recovers, can continue to walk.(0) Severe impairment: Performs task with severe disruption of gait, i.e. staggers outside 15” path,

loses balance, stops, reaches for wall.

4. Gait with vertical head turns. Instructions: Begin walking at your normal pace. When I tell you to “look up”, keep walking straight, but tip your head and look up. Keep looking up until I tell you, “look down”. Then keep walking straight and turn your head down. Keep looking down until I tell you, “ look straight”, then keep walking straight, but return your head to the centre.(3) Normal: Performs head turns smoothly with no change in gait.(2) Mild impairment: Performs head turns smoothly with slight change in gait velocity, i.e. minor

disruption to smooth gait path or uses walking aid.(1) Moderate impairment: Performs head turns with moderate change in gait velocity, slows down,

staggers, but recovers, can continue to walk.(0) Severe impairment: Performs task with severe disruption of gait, i.e. staggers outside 15” path,

loses balance, stops, reaches for wall.

F:\Intranet\BIRU website\physiotherapy section\Dynamic Gait Index v.doc

5. Gait and pivot turn. Instruction s : Begin walking at your normal pace. When I tell you, “turn and stop”, turn as quickly as you can to face the opposite direction and stop.(3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance. (2) Mild impairment: pivot turns safely in >3 seconds and stops with no loss of balance.(1) Moderate impairment: Turns slowly, requires verbal cueing, requires several small steps to

catch balance following turn and stop.(0) Severe impairment: Cannot turn safely, requires assistance to turn and stop.

6. Step over obstacle. Instructions: Begin walking at your normal speed. When you come to the shoebox, step over it, not around it, and keep walking.(3) Normal: Is able to step over box without changing gait speed; no evidence for imbalance.(2) Mild impairment: Is able to step over shoe box, but must slow down and adjust steps to clear

box safely.(1) Moderate impairment: Is able to step over box but must stop, then step over. May require

verbal cueing.(0) Severe impairment: Cannot perform without assistance.

7. Step around obstacles. Instructio n s : Begin walking at normal speed. When you come to the first cone (about 6’ away), walk around the right side of it. When you some to the second cone (6’ past first cone), walk around it to the left.(3) Normal: Is able to walk safely around cones safely without changing gait speed; no evidence of

imbalance.(2) Mild impairment: Is able to step around both cones, but must slow down and adjust steps to

clear cones.(1) Moderate impairment: Is able to clear cones but must significantly slow speed to accomplish

task, or requires verbal cueing.(0) Severe impairment: Unable to clear cones, walks into one or both cones, or requires physical

assistance.

8. Steps. Instructions: Walk up these stairs as you would at home.(i.e. using a rail if necessary. At the top, turn around and walk down.(3) Normal: Alternating feet, no rail.(2) Mild impairment: Alternating feet, must use rail.(1) Moderate impairment: Two feet to a stair, must use rail. (0) Severe impairment: Cannot do safely.

TOTAL SCORE