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Slide 1
CHAPTER 5: EXAMINATION
PROCEDURES
PT: 151
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Slide 2 Introduction p. 117
• Effective PT is based on a sound examination and evaluation.
• Also important to identify potential life threatening or emergency conditions and/or the need to refer out.
• Examination is defined as (by the Guide) as a “comprehensive screening and specific testing process leading to diagnostic classification or, as appropriate, to a referral to another practitioner”
• Evaluation is defined as “dynamic process in which the PT makes clinical judgments based on data gathered during the examination”
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Slide 3 Introduction
• Three types of “formal” examinations and
evaluations used when a patient receives PT:
– An initial examination and evaluation
– Interim examination and evaluation
– A discharge examination and evaluation
• This chapter will focus on initial examination and
evaluation process and include discussion of the role
of the PTA in the interim and discharge
examinations.
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Slide 4 Patient History p. 118
• Investigation of patient’s history
• Can be obtained by:
– Patient’s medical chart
– Intake form
– Other supporting medical documentation
– Patient
– Family member
• Specific patient goals will be obtained. Can also see how realistic the patient is about outcomes. (PT and PTA may foresee that ambulation with an AD on hard surface is realistic goal, while the patient is planning on returning to golf)
• Must be conducted in private area- confidentiality.
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Slide 5 HISTORY
80% of the time, the diagnosis is
made in the first 60 seconds of
contact. (Sackett, et al)
Examination will then support or
disprove this hypothesis, leading to a
final hypothesis during the evaluation.
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Slide 6 Systems Review p 119
• “Clears” several systems that are potentially
involved or implicated in patient’s performance
or progress.
• Identify potential system abnormalities that
require referral back to MD. (GI, urinary,
cardiopulmonary)
• This is a system’s review; PT’s do not diagnose
a medical disease or pathology.
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Slide 7 Systems Review
• The PT communicates with the MD regarding
signs and symptoms that cause concern, not
suggesting the presence of a specific disease.
• Purpose: to determine if the pt. needs a
medical referral
• PT and PTA’s must be able to recognize
medical emergencies.
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Slide 8 Systems Review
Integumentary
Cardiopulmonary
Neurological
Musculoskeletal
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Slide 9 Skin Cancer
A – asymmetry
B – border irregularity
C – color variation within the lesion
D – diameter > 6 mm (pencil eraser)
E - evolution over time
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Slide 10 Skin Cancer
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Slide 11 DVT
Calf pain, edema, redness, warm to the touch
Recent surgery or immobilization
Calf pain that increases with standing/walking and
decreases with rest/elevation
Positive cuff sign – pain with 160-180 mm HG (BP
cuff around calf)
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Slide 12 Myocardial Infarction
Chest pain
Palor, sweating, nausea/vomiting
Left arm pain > Right arm pain
Jaw pain
Male over the age of 40
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Slide 13 Myocardial Infarction
Female over the age of 50.
History of high cholesterol
Symptoms lasting longer than 30 mins.
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Slide 14 Cancer
5% weight gain or loss over a 4-6 week
period
> 50 yrs old
History of CA
Colon CA: change in stool shape or diameter,
bloody stool
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Slide 15 Tests and Measures p 119
• Selection of appropriate tests and
measures is performed by PT
• PTA ROLE: To assist PT, the PTA may
repeat selected tests/measures at interim
and discharge.
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Slide 16
• Communication between PT and PTA is vital.
– The PTA may identify additional clinical signs
and symptoms when performing delegated
tests and measures, this requires
communication to PT so that the PT can
determine additional tests to be performed
and who should perform them.
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Slide 17 Vital Signs p 120
• Very important aspect in examination, provides
baseline cardiopulmonary function and screens any
potential emergencies that may occur during session.
• BP, pulse, and respirations must be assessed and
documented especially for the older patients or
patients with multiple medical issues.
• Vitals are taken frequently before, during and
after a session.
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Slide 18 Vital signs
Adult norms: HR 60-90, BP 120/80, RR
<20 bpm
Infant: HR higher, BP lower, RR higher
Approaches adult values around age of
6 years old
Geriatric: BP, HR, and RR all higher
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Slide 19 Observation p 121
Visual inspection
PT performs on exam
PTA must be able to communicate relevant
observations during treatment.
Observation of movement patterns, areas of
swelling/edema, atrophy, skin integrity,
contractures, and other skeletal or joint
abnormalities.
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Slide 20 Arousal, Attention, Cognition p 122
Provides information of how well the
patient will be able to voluntarily
participate in therapy as well as follow
directions, memory.
Arousal: Responsiveness to situation.
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Slide 21 Common descriptors:
Alert (awake and attentive)
Lethargic (drowsy, falls asleep)
Obtunded (hard to arouse from sleep, confused
when awake)
Stuporous (responsive only to strong, noxious
stimuli)
Comatose (nonresponsive to any type of
stimulation)
Persistent vegetative state (state of
unconsciousness with regular sleep/wake cycles).
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Slide 22 Arousal, Attention, Cognition p 122
Ability to follow directions: 1 step or multi-step
directions.
Short term/long term memory assessment:
Short term: provide list of 7 numbers or 5-7
words and ask the patient to repeat
immediately and then 5 minutes later.
Long term: assess ability to recall historical
facts or dates of marriage, birth, etc.
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Slide 23 Arousal, Attention, Cognition p 122
Attention: awareness to environment and
ability to focus on specific stimulus without
distraction.
Orientation: assessed according to orientation
to person, place, time and situation.
Documented according to how many domains
the person can correctly name “Oriented x
4/4;3/3” , Oriented x 2/4 (person, place)
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Slide 24 Sensation p 123-124
• Assessment of patient’s sensory integrity allows
therapist to identify the extent of impairment
of the sensory system.
• PT can identify areas that may have been
damaged. (dermatomes)
• Exteroceptive = superficial sensation
• Cortical Sensations = discriminative touch
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Slide 25 Sensation p 123-124
– Exteroceptive (superficial) and
proprioceptive (deep) senses: Light touch,
superficial pain, temperature, pressure,
vibration, joint position (proprioception), and
joint movement sense (kinesthesia)
– Combine sensations (cortical sensations):
Examples include 2 point discrimination,
bilateral simultaneous touch, texture
recognition, sterognosis, graphesthesia, and
barognosis.
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Slide 26 Dermatomes p. 125
C2 - posterior head
C3 - posteriolateral neck
C4 - sternoclavicular joint
C5 – lateral upper arm
C6 – lateral forearm, thumb
C7 – middle finger, palmer surface
C8 – little finger/ulnar part of hand
T1 – medial forearm
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Slide 27 Dermatomes
L1 – upper ant. thigh
L2 – mid. ant thigh
L3 – medial knee
L4 – medial malleolus
L5 – dorsum of 3rd
MTP
S1 – lat foot/heel
S2 – popliteal fossa
S3 – ischial tuberosity
S4 – perianal area
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Slide 28 Sensation
1st, ask patient what they are sensing.
2nd, perform a quick scan of sensation to find
out if any abnormalities are present
3rd , perform a demo of the test on the
opposite side? WHY???
Then specific sensation tests are performed as
detailed next slide.
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Slide 29 Sensation- Extroceptive and Proprioceptive
pp. 124 - 126
Light touch: Using a cotton ball particle, touch
the skin, “tell me when you feel me touching you
by saying now”
Location of touch: Using your thumb or
fingertip, apply pressure firm enough to indent
the skin. “tell me when you feel the stimulus by
saying now”.
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Slide 30 Sensation- Extroceptive and
Proprioceptive pg. 127
Fast pain: Using a large paperclip Apply
uniform pressure. “Tell me whether this feels
sharp or dull.”
Temperature: Fill one test tube with hot water,
the other with cold water. “Tell me whether this
feels warm, cold, or you are unable to tell me”
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Slide 31 Sensation- Combine (cortical)
sensations pg. 126
2 point discrimination: Use an instrument (like
caliper) with 2 ends apart. Then in successive
applications, the therapist then places the tips
closer together and asks the patient to say
when the points are perceived as one.
Texture recognition: The therapist gives the
patient cutouts of fabrics with different
textures and the patient is directed to identify
the texture perceived (soft, rough, thick, thin)
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Slide 32 Sensation- Combine (cortical)
sensations pg. 127
Stereognosis: Common items (ie. paperclips,
keys, dice, coins) are placed in patient’s hand
and they are asked to identify the object by
touching and feeling it.
Barognosis: The therapist gives the patient
objects of different weights and asks the
patient to identify which item is heaviest.
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Slide 33 CONSCIOUS PROPRIOCEPTION-p.127
Proprioception: Use fingertip grip over the
boney prominence of the lateral joint surfaces.
Tell the patient words to identify ROM positions
(initial, mid-, or terminal range). Move the joint
through a ROM then hold in static position. Ask
them to duplicate the motion on other
extremity.
Tests: knowing where limbs are in space
STATICALLY; has functional implications.
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Slide 34 Sensation- Extroceptive and
Proprioceptive pg. 127
Kinesthesia: Use fingertip grip, over boney
prominences of the lateral joint surfaces. Move
the joint passively in small increments up into
flexion (bending) or back to start which is
extension (straightening) , and ask the patient
to indicate the direction of movement.
Tests: knowing when the joint is moving,
perception of the joint AS IT MOVES has
implications with movement activities.
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Slide 35 Grading Sensation and
Proprioception
Normal – equal to other side or
100% accuracy
Impaired - 50%-100% accuracy
Absent – less than 50% accuracy
Use an odd number of trials to
determine outcome ( 3/3 = normal;
2/3 = impaired; 0-1/3=absent)
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Slide 36 Motor Examination p 128
Assessment of Muscular Tone:
Muscle tone is defined as: ability or
readiness of muscle to contract, which is
dependent upon the excitation of the motor
pool in the spinal cord.
There should be an appropriate amount of
tone present to allow the individual to
perform a movement that is synergistic,
appropriate in strength and in intensity.
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Slide 37 Motor Examination pg. 129
Assessment of Muscular Tone:
A range of tone can be found with
neurologically involved patients.
Flaccidity: absence of tone
Hypotonicity: Decreased tone
Hypertonicity: Increased tone
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Slide 38 Motor Examination pg. 129
Rigidity: state of severe hypertonicity that
results in an inability to move the extremity,
passively or actively, and with limitation in all
directions.
Spasticity: abnormal velocity-depedent
muscle tone: faster the limb is moved: more
resistance.
Assessed with the Modified Ashworth Scale
(page 139, table 5-3)
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Slide 39 Modified Ashworth Scale p. 130
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Slide 40 Motor Examination: Assessment of Strength
Manual Muscle Testing: Performed to
identify possible decreases in strength.
Weakness in muscle due to
musculoskeletal and peripheral nerve
injury means a problem along the nerve,
at the muscle/nerve junction or within the
muscle tissue itself = LMN lesion
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Slide 41
Weakness due to CNS damage is caused by a
problem with the spinal cord or brain and
comes from inside the spinal or cranial skeletal
system. = UMN lesion
Weakness may also be due to disuse, which is
not a pathology but an impairment caused by
inactivity.
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Slide 42 Motor Examination: Assessment of Synergy
pg 132
Stereotypical movements with neurological
insults.
Important for PTA’s to identify these abnormal
patterns and understand their implications in
terms of facilitating normal movement.
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Slide 43 Motor Examination p132, Table5-4
FLEXION SYNERGY
Upper Limbs
Scapular retraction, elevation or
hyperextension.
Shoulder abduction, external rotation.
Elbow flexion *** (strongest)
Forearm supination
Wrist and finger flexion.
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Slide 44 Flexion Synergy cont.
Lower Limbs
Hip flexion****, abduction, external
rotation
Knee flexion
Ankle dorsiflexion, inversion
Toe Dorsiflexion
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Slide 45 LE Flexion Synergy
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Slide 46 UE Flexion Synergy
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Slide 47 Motor Examination
EXTENSION SYNERGY
Upper Limbs
Scapular protaction
Shoulder adduction***, internal rotation
Elbow Extension
Forearm pronation***
Wrist and finger flexion
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Slide 48 Extension Synergy cont.
Lower Limbs
Hip extension, adduction***, internal
rotation
Knee extension***, ankle
plantarflexion***, inversion
Toe plantarflexion
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Slide 49 LE Extension Synergy
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Slide 50 UE Extension Synergy
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Slide 51
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Slide 52 Developmental Reflexes p133-4
The reemergence of one or more of these
reflexes or the absence of the higher level
reactions in older children or adults can have a
significant impact on muscle tone, the ability to
isolate movements, balance, and functional
skills such as feeding and ambulation.
Review Table 5-5, page 135-136
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Slide 53 Coordination p 134
The ability to perform smooth, accurate, controlled
motor responses that are characterized by
appropriate speed, distance, direction, timing, and
muscle tension. Gives the clinician information about
the ability of synergisitc muscle groups to produce a
smooth, coordinated, purposeful movement.
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Slide 54 Coordination pg 134
Non-weight bearing Coordination Tests:
Nose-finger-nose: Ask pt. to touch his nose with index finger, then touch your finger, then touch pt. nose. Inability to perform this test with smooth coordination is termed dysmetria (past pointing)
Rapid alternating movement: pt hold elbows flexed to 90 degrees and close to body, and then perform alternate pronation and supination of forearm. Inability to perform this is termed dysdiadochokinesia.
Heel to Shin: Pt in supine, asked to lift one leg up, use the heel of that leg to touch the kneecap of contralateral leg and then slide heel down shin (ataxia).
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Slide 55 Coordination
Weight bearing Coordination Tests:
1. Have pt stand with narrow BOS (feet together)
2. Have patient stand one foot in front of another (tandem).
3. Have patient in standing and have him or her take steps
follwing footprints placed on floor by therapist.
4. Have patient walk along straight line drawn or taped on
floor.
5. Have pt walk sideways, backward, or using cross steps.
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Slide 56 Coordination
Grading Scale:
Normal: smooth accurate, and controlled
Impaired: movement is slow or jerky
Absent: pt unable to perform
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Slide 57 Cranial Nerves p 137
Mnemonics: Odor Of Orangutan Terrified Tarzan
After Forty Voracious Gorillas Viciously Attacked
Him.
On Old Olympus’
Towering Top, A Finn and
German Drank(Viewed) Some
Hops.
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Slide 58
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Slide 59 Cranial Nerve Assessment p 137
These nerves originate in brainstem and innervate the head,
neck, and face.
Cranial Nerve I: Olfactory Nerve
Pt closes eyes, and then sniffs a cotton swab with non-noxious
odor (coffee, lemon, vanilla) and is asked to identify odor.
Cranial Nerve II: Optic Nerve
Test visual acuity: pt cover 1 eye and hold magazine 2-4
feet away and ask patient to read specific line.
Test visual field: sit in front of pt, ask patient to cover 1 eye
and look straight ahead with other. Examiner places a finger
out of the field and gradually brings it into view and asks pt
when they first see object.
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Slide 60 Cranial Nerve Assessment p 137
Cranial Nerves III, IV, VI: Oculomotor, Trochlear, and
Abducens Nerves
Hold up pen approximately 12 in. from pt. face
and asks pt to keep his or her eyes on pen.
Examiner moves pen up and down (CN III), down
and in (CN IV) and toward the nose to see if the
two eyes converge (CN III), and to laterally to both
sides (CN VI). The ability of eyes to track equally
and appropriately is also observed during this test.
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Slide 61 Cranial Nerve Assessment
Cranial Nerve V: Trigeminal Nerve
Test light touch and sharp/dull sensation of face or
tests strength of muscles of mastication
Cranial Nerve VII: Facial Nerve
Perform a manual muscle test of muscles of facial
expression (see Clarkson)
Cranial Nerve VIII: Vestibulocochlear Nerve/Auditory:
Test hearing, rub fingers close to pt ears and check
if pt can hear it
Test vestibular component: ask pt to stand on foam
with eyes close and observe sway.
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Slide 62 Cranial Nerve Assessment
Cranial Nerve IX: Glossopharyngeal Nerve
Assess gag reflex by moving tongue
depressor around in back of mouth
Cranial Nerve XII: Hypoglossal Nerve
Ask client to protrude tongue to check for
fasciculations, which are odd, nonvolitional
movements on the surface of the tongue.
Ask pt to protrude tongue and then observe
if she or he can move it rapidly from side to
side.
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Slide 63 Balance pg. 138
Important component of neuromuscular
examination.
Balance is essential for an individual to
maintain postural stability or equilibrium in
which the center of mass (COM) is maintained
within the boundaries of the BOS.
The limits of stability (LOS) is defined as “the
maximum angle from vertical that can be
tolerated without loss of balance”
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Slide 64 Balance p 138
When the COM moves beyond the LOS:
When perturbations come from rear, the
extensor muscles of hip, trunk, and neck to
prevent pt from falling forward.
When perturbations come from front, the hip
flexors, quads, abdominal muscles, and neck
flexors activate to prevent pt from falling
backwards.
When perturbations come from side: lateral
flexors of trunk and neck will activate.
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Slide 65 Balance
3 strategies a patient will utilize when LOS is
reached.
BOS is fixed while COM is disturbed
Ankle Strategy: COM shifts forward or backward
over ankle joints and used when balance
disturbances are small
Hip Strategy: COM is larger and faster and the
COM shifts forward, backward, or laterally over
hip joints
Brings about a realignment of BOS under the COM
Stepping Strategy: large, fast balance
disturbances.
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Slide 66 Balance: Assess Static and Dynamic Balance
Static/Quite: ability to maintain upright in
steady, nonmoving state
Dynamic/Active: pt’s ability to maintain
upright posture while performing activities
that move the COG within or outside of the
BOS
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Slide 67 Grading Balance pg. 143
Normal: pt is able to maintain steady balance without support
and able to maintain steady position after being challenged.
Dynamic- could be in form of perturbations or performing
activities that will make COG fall outside of BOS
Good: pt is able to maintain balance without support (static)
and is able to maintain position after being moderately
challenged (dynamic)
Fair: pt is able to maintain position with handhold (static) and
is able to accept minimal challenge (dynamic)
Poor: pt requires assistance of hand hold and clinical support
to maintain position (static) and is unable to accept any
challenge (dynamic)
Unable: pt needs maximal assistance to maintain position
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Slide 68 Balance
Romberg Test: Ask patient to stand feet together with eyes
open, then eyes closed.
Positive if pt able to maintain position with eyes open, but has
excessive sway or loses balance with eyes closed.
Sharpened Romberg
Same test but feet are placed in tandem
These tests are used to determine increased sway which may be
due to problems with somatosensory, visual, or vestibular systems.
The Clinical Test for Sensory Interaction on Balance (CTSIB)
Assesses integrity of various systems responsible for balance.
Uses thick foam pad and japanese lantern.
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Slide 69 Functional Ability pg. 142
Assess the following:
Rolling side to side
Supine to/from sitting
Maintaining sitting position
Transfers
Sitting to/from stand
Maintaining standing position
Locomotion in from or walking or propelling w/c
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Slide 70 Functional Ability
Assessment: Qualitative:
Describe the motion as normal or
abnormal (include description)
Describe how much, if any,
assistance is necessary
List amount of time it takes patient
to complete task.
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Slide 71 Assistance levels pg. 144
*based on how much effort is put forth by patient, not by PTA*
Independent: Patient consistently performs the skill
safely with no one present and in a timely manner. If
assistive device is needed, include name of device
Supervision or Setup: Patient performs 100% of
task, but requires verbal cueing, someone standing by,
or someone must set up items.
Contact Guarding: Patient performs 100% of task,
but person assisting gives full attention to pt and has
hands on pt for possible assistance or possible loss of
balance.
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Slide 72 Assistance levels pg. 144
Minimal Assistance: Patient expends 75% or
more of effort for the task.
Moderate Assistance: Pt expends 50-75% of
effort for task
Maximum Assistance: Pt expends 25-50% of
effort for task
Dependent: Patient expends less than 25% of
effort for task.
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Slide 73 Standardized Impairment and
Functional Tests pg. 144
Berg Balance Scale: assessment of balance via
performance of several everyday tasks.
Developed for elderly. Involves 14 balance
items and based on their ability to perform
these tasks and given score of 0,1,2,3,4. Takes
15-20 minutes to complete.
Normative Values:
<36= 100% at fall risk
<45 requires assistive device
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Slide 74 Standardized Impairment and
Functional Tests
Functional Reach Test: Use with elderly and involves
measurement of pt’s ability to reach forward while
standing, without falling. Takes 5 minutes to
complete
Normative Values:
20-40 year olds: Males: 16.7 inches, Females: 14.6
inches
41-69: Males: 14.9 inches, females: 13.8 inches
70-87: Males: 13.2 inches, females: 10.5 inches.
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Slide 75 Standardized Impairments and
Functional Tests
Tinetti Assessment Tool: Used with elderly population and has balance and gait components. 16 items, some scored as 0 or 1 or 0, 1, or 2. Takes 10-15 minutes to complete.
Timed Up and Go (TUG): measure time it takes for an individual to stand up from firm chair and walk 3 meters, turn around and sit down. Takes 5 minutes or less.
Normative Values: <10 seconds: normal, >30 seconds: dependent on most activities of daily living and mobility skills
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Slide 76 Standardized Impairments and
Functional Tests
Fugl-Meyer Assessment of Physical Performance:
developed for adults who have suffered a stroke
and looks at motor recovery, balance, sensation,
and motion. Takes 30-40 minutes to complete and
items given a score of 0, 1, or 2.
Motor Assessment Scale: used with adult patients
who have suffered stroke, includes 9 items including
15-30 minutes. Looks at functional movements and
tone.
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Slide 77 Standardized Impairment and
Functional Tests
The Barthel Index: Measures amount of
assistance required by an individual on 10
items of mobility and self-care ADL’s. Used
with adults with any diagnosis. Tool takes 5-20
minutes.
Functional Independence Measure: (FIM):
designed to assess the degree of assistance
required by pt at the beginning and end of
rehabilitation.
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