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in Occupational·
Physical Therapy

Julia Van Deusen, PliO, OTR/L, FAOTA
Department of Occupational Therapy
College of Health Professions
Health Science Center
University of Florida
Gainesville, Florida

Denis Brunt, PT, EdD
Associate Professor
Department of Physical Therapy
College of Health Professions
Health Science Center
University of Florida
Gainesville, Florida

in Occupational
Physical Therapy
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Library of Congress Cataloging-In-Publication Data

Assessment in occupational therapy and physical therapy I [edited by]
Julia Van Deusen and Denis Brunt.

p. cm.

ISBN 0-7216-4444-9

1. Occupational therapy. 2. Physical therapy. I. Van Deusen,
Julia. II. Brunt, Denis.
[DNLM: 1. Physical Examination-methods. 2. Physical Therapy­
methods. 3. Occupational Therapy-methods. we 205 A847 1997]

RM735.65.A86 1997 616.0T54-<lc20

DNLM/DLC 96-6052

Assessment in Occupational Therapy and Physical Therapy 0-7216-4444-9

Copyright © 1997 by WB. Saunders Company

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without
permission in writing from the publisher.

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To those graduate students everywhere

who are furthering their careers

in the rehabilitation professions

Executive Director, Physical Restora­ Professor of Educational Psychology­
tion Center, Gainesville, Ronda Measurement Specialization, The Uni­
Work Activities versity of Georgia, College of Educa­
tion, Athens, Georgia
JAMES AGOSTINUCCI, SeD, OTR Measurement Theory: Application ,.0
Associate Professor of Physical Occupational and Physical Therapy
Therapy, Anatomy & Neuroscience,
Physical Therapy Program, University STEVEN R. BERNSTEIN, MS, PT
of Rhode Island, Kingston, Rhode Assistant Professor, Department of
Island Physical Therapy, Ronda Interna­
Motor Control: Upper Motor Neuron tional University, Miami, Ronda
Syndrome Assessment of Elders and Caregivers

Lecturer, Department of Occupational Associate Professor, Department of
Therapy, Uriiversityof Ronda, College Physical Therapy, College of Health
of Health Professions, Gainesville, Professions, Health Science Center,
Ronda University of Ronda, Gainesville,
Psychosocial Function Ronda
Editor; Gait Analysis
Assistant Professor, Howard Univer­ PATRICIA M. BYRON, MA
sity, Washington, DC Director of Hand Therapy, Philadel­
Home Management phia Hand Center, P.C., Philadelphia,
IAN KAHLER BARSTOW, PT Prosthetic and Orthotic Assess­
Department of Physical Therapy, Uni­ ments: Upper Extremity Orthotics
versity of Ronda, GaineSville, Ronda and Prosthetics
Joint Range of Motion
Director of Marketing and Product De­ Professor, Boston University, Sargent
velopment, North Coast Medical, Inc., College, Boston, Massachusetts
San Jose, California Sensory Processing: Assessment of
Prosthetic and Orthotic Assess­ Perceptual Dysfunction in the Adult
ments: Upper Extremity Orthotics
and Prosthetics



Assistant Professor of Occupational Rehabilitation Medicine Associates
Therapy, University of Central Arkan­ P.A., Gainesville, florida
sas, Conway, Arkansas; Adjunct Fac­ Electrodiagnosis of the Neuromuscu­
ulty, Department of PediatriCS, Univer­ lar System
sity of Arkansas for Medical Sciences,
Pediatrics: Developmental and Neo­ PhD,OTR
natal Assessment; Pediatrics: Assess­ Assistant Professor, Department of
ment of Specific Functions Occupational Therapy, College of
Health ProfeSSions, University of flor­
EUZABETH B. DEVEREAUX, MSW, ida, GaineSville, florida
ACSWIL, OTRIL, FAOTA Community Activities
Former Associate Professor, Director
of the Division of Occupational GAIL ANN HILLS, PhD, OTR, FAOTA
Therapy (Retired), Department of Psy­ Professor, Occupational Therapy De­
chiatry, Marshall University School of partment, College of Health, flor­
Medicine; Health Care and Academic ida International University, Miami,
Consultant, Huntington, West Virginia florida
Psychosocial Function Assessment of Elders and Caregivers

Instructor of Occupational Therapy, Director of Rehabilitation Services,
University of florida, GaineSville, Columbia North florida Regional
florida Medical Center, Gainesville, florida
Sensory Processing: Sensory Defi­ Work Activities
cits; Pediatrics: Developmental and
Neonatal Assessment; Pediatrics: SHIRLEY J. JACKSON, MS, OTRIL
Assessment of Specific Functions Associate Professor, Howard Univer­
sity, Washington, DC
ROBERT S. GAILEY, MSEd, PT Home Management
Instructor, Department of Ortho­
paedics, Division of PhYSical Therapy, PAUL C. LaSTAYO, MPT, CHT
University of Miami School of Medi­ Clinical Faculty, Northern Arizona
cine, Coral Gables, florida University; Certified Hand Therapist,
Prosthetic and Orthotic Assess­ DeRosa Physical Therapy P.c., flag­
ments: Lower Extremity Prosthetics staff, Arizona
Clinical Assessment of Pain
Department of Physical Therapy, Uni­ MARY LAW, PhD, OT(C)
versity of florida, Gainesville, florida Associate Professor, School of Reha­
Joint Range of Motion bilitation Science; Director, Neurode­
velopmental Clinical Research Unit,
BARBARA HAASE, MHS, OTRIL McMaster University, Hamilton, On­
Adjunct Assistant Professor, Occupa­ tario, Canada
tional Therapy Program, Medical Col­ Self-Care
lege of Ohio, Toledo; Neuro Clinical
Specialist, Occupational Therapy, St. KEH-CHUNG UN, ScD, OTR
Francis Health Care Centre, Green National Taiwan University, Taipei,
Springs, Ohio Taiwan
Sensory Processing: Cognition Sensory Processing: Assessment of
Perceptual Dysfunction in the Adult

Clinical Coordinator, Physical Restora­ FAOTA
tion Center, Gainesville, Rorida Associate Professor and Chair, Occu­
Work Activities pational Therapy Department, Brenau
University, Gainesville, Georgia
KENNETH J. OTTENBACHER, PhD Measurement Theory: Application to
Vice Dean, School of Allied Health Occupational and PhYSical Therapy
Sciences, University of Texas Medical
Branch at Galveston, Galveston, Texas MAUREEN J. SIMMONDS, MCSP,
Foreword PT,PhD
Assistant Professor, Texas Woman's
ELIZABETH T. PROTAS, PT, PhD, University, Houston, Texas
FACSM Muscle Strength
Assistant Dean and Professor, School
of Physical Therapy, Texas Woman's JUUA VAN DEUSEN, PhD, OTR/L,
University; Clinical Assistant Profes­ FAOTA
sor, Department of Physical Medicine Professor, Department of Occupa­
and Rehabilitation, Baylor College of tionalTherapy, College of Health Pro­
Medicine, Houston, Texas fessions, Health Science Center, Uni­
Cardiovascular and Pulmonary versity of Rorida, Gainesville, Rorida
Function Editor; Body Image; Sensory Pro­
cessing: Introduction to Sensory Pro­
A. MONEIM RAMADAN, MD, FRCS cessing; Sensory Processing: Sensory
Senior Hand Surgeon, Ramadan Hand Defects; An Assessment Summary
Institute, Alachua, Rorida
Hand Analysis JAMES C. WALL, PhD
Professor, Physical Therapy Depart­
ROBERT G. ROSS, MPT, CHT ment; Adjunct Professor, Behavioral
Adjunct Faculty of PhYSical Therapy Studies and Educational Technology,
and Occupational Therapy, Quin­ University of South Alabama, Mobile,
nipiac College, Hamden, Connecticut; Alabama
Clinical Director, Certified Hand Gait Analysis
Therapist, The Physical Therapy Cen­
ter, Torrington, Connecticut
Clinical Assessment of Pain

Associate Professor, Occupational Ther­
apy Department, New York, New York
Motor Control: Motor Recovery Af­
ter Stroke


The complexity of defining and assessing rehabilitation outcome is frequently identified as one of the reasons for the slow progress in developing instruments and conducting outcome research in occupational and physical therapy. 1987). This book begins by stating that "One of the greatest challenges confronting health care organizations in the 1990's is learning to apply the concepts and methods of performance measurement. the impact of routinely delivered care on patients' lives. Assessment in Occupational Therapy and PhYSical Therapy. One consequence of this organizational structure is a focus on assessment xl . Johnston." This text. The text begins with a compre­ hensive chapter on measurement theory that provides an excellent foundation for understanding the complexities of asseSSing impairment. 25): "Among the most important reasons for establishing an outcome assessment initiative in a health care setting are: • to deSCribe. and effectiveness that are certain to increase in the future. the JCAHO published a related text titled A guide to establishing programs and assessing outcomes in clinical settings (JCAHO. p. cardiology and neurology.word In describing the importance of interdisciplinary assessment in rehabilitation. and • to evaluate the effectiveness of care and identify opportunities for improvement. or a pathology. In discussing the importance of assessment in health care. In fact. Dejong has argued that traditional medical research and practice is organized around these pathologies and organ systems. for example. the unit of analysis in many medical specialties is an organ. In 1993 the JCAHO published The measurement mandate: On the road to performance improvement in health care. in quantitative terms. we can move rehabilitation to a position of leadership in health care. Keith. disability. accountability. In contrast. The unit of analysis in rehabilitation is the individual and the individual's relationship with his or her environment. If we move rapidly and continue our efforts. 1994). the authors present the following consensus statement (p. Without assessment expertise. • to establish a more accurate and reliable basis for clinical decision making by clini­ cians and patients. An indication of the importance of developing assessment expertise is reflected in recent publications by the Joint Commission on Accreditation of Health Care Organizations (JCAHO)." The ability to develop new assessment instruments to keep pace with the rapidly changing health care environ­ ment will be absolutely critical to the future expansion of occupational therapy and physical therapy. 1980). a body system. is designed to help rehabilitation practitioners achieve these objectives." The following year. 5-5) note that "We must improve our measures to keep pace with the development in general health care. Part of the difficulty in developing assessment procedures and outcome measures relevant to the practice of rehabilitation is directly related to the unit of analysis in research investigations (Dejong. and Hinderer (1992. and handicap as defined by the World Health Organization (WHO. rehabilitation practitioners will be unable to meet the demands for efficiency.

S. 1994. Furher (Ed. Assessment in Occupational Therapy and Physical Therapy will help ensure that the consumers of rehabilitation services receive the best possible treatment planning and evaluation. R. (1980). Joint Commission on Accreditation of Healthcare Organizations (1993). Switzerland: World Health Organization. Baltimore: Paul H. to evaluate the effectiveness of care and identify opportunities for improvement (JCAHO. R. M. v. Geneva. p. Each chapter provides detailed information concerning evaluation and measurement protocols along with research implications and their clinical applications. World Health Organization. International classification of impairment. In today's rapidly changing health care environment. 12-5. Informa­ tion in this text will help therapists meet this professional responsibility. In the current bottom-line health care environment.. Assessment in Occupational Therapy and Physical Therapy will help rehabilitation practitioners to achieve the three objectives of outcome assessment identified by the JCAHO. Julia Van Deusen and Denis Brunt have done an admirable job of compiling current information on areas relevant to interdisciplinary assessment conducted by occupational and physical therapists. Johnston. The chapters cover a wide range of assessment topics from the examination of muscle strength (Chapter 2) to the evaluation of work activities (Chapter 20). 73. In M. In contrast to these narrowly focused medical specialties. (1987). disability. Measurement standards of interdisciplinary medical rehabilitation. In particular. Joint Commission on Accreditation of Healthcare Organizations (1994). Oakbrook Terrace. J. IL: JCAHO. Brookes. that is. are still the direct responsibility of occupational and physical therapists. 25). (1992). REFERENCES DeJong. however. and handicap. The measurement mandate: On the road to performance improvement in health care.). the goal of rehabilitation is to improve an individual's ability to function as independently as possible in his or her natural environment. A. A guide to establishing programs for assessing outcomes in clinical settings. Keith. there are many variables related to service delivery and cost containment that rehabilitation therapists cannot control.. Medical rehabilitation outcome measurement in a changing health care market. IL: JCAHO. & Hinderer. Achieving this goal requires measurement instruments and assessment skills that cover a wide spectrum of activities and environments. Archilles of Physical Medicine and Rehabllitation. KENNETH OrrENBACHER . G. Oakbrook Terrace.xii FOREWORD procedures and outcome measures that emphasize an absence of pathology or the performance of a specific organ or body system. The interpretation of assessment procedures and the development of treatment programs. 261-272). the use of an electrocardio­ gram to evaluate the function of the heart. Rehabilitation outcomes: Analysis and measurement (pp. the comprehensive coverage of assessment and measurement procedures will allow occupational and physical therapists to achieve the final JCAHO outcome assessment objective. for instance.

In Unit Four. Assessment in Occupational Therapy and Physical Therapy is not intended as a procedures manual for the laboratory work required for the entry-level student who is learning assessment skills. administrators. age-related assessment is covered. rather than fewer. Assessment in Occupational Therapy and Physical Therapy is well suited as a text for graduate students in these joint courses. university courses wi)) be shared by occupational and physical therapy students. Because of their common core and the fact that joint coursework is cost effective. or expect to be. this book provides the conceptual basis essential for the advanced practice roles. and master practitioners. Our book provides the more extensive coverage and research needed by health professionals who are. certain content may be found in more than one chapter. and related fields. Such diversity of input has helped us reach our goal of providing a truly comprehensive work on assessment for occupational therapists and for physical therapists. Although designed as a text for graduate students in occupational therapy. it is probable that in the future more. The contributing authors for this book have been drawn from both educational and service settings covering a wide geographic area. Rather. this book will also meet the needs of advanced clinicians. When appropriate. This arrangement minimizes the need to search throughout the entire volume when a specialist is seeking a limited content area. Finally. Unit Three thoroughly addresses the assessment of motor and of sensory processing dysfunction. One type of content that lends itself we)) to such joint study is that of assessment. contributors from other health professions have also shared their expertise. teachers. It is assumed that the therapiSts using this text will have a basic knowledge of the use of clinical assessment tools. It also provides a comprehensive coverage of assessment in physical therapy and in occupational therapy. Although the majority of authors appropriately are licensed occupational therapists or physical therapists. and students in these fields frequently have courses together in the educational setting. After a general overview of measurement theory in Unit One. Assessment in Occupational Therapy and Physical Therapy is intended as a major resource. ce Our professions of occupational therapy and physical therapy are closely linked by our mutual interest in rehabilitation. activities of daily living are addressed. in Unit Five. physical therapy. We interact through direct patient service activities. Unit Two covers component assessments such as those for muscle strength or chronic pain. JuUA VAN DEUSEN DENIS BRUNT .


nowledgments We wish to express our sincere thanks to all those who have helped contribute to the success of this project. JULIA VAN DEUSEN DENIS BRUNT . Saunders Company who have been so consistently helpful. OTR And the many. and Orit Shechtman. especially Kristin Froelich. many others. University of Florida. who viewed it through the eyes of an occupational therapy graduate student. PhD. particularly Helaine Barron and Blair Davis-Doerre The special reviewers for the chapter on hand assessment. JoAnne Wright. B. for their cooperation The professionals at W. especially The many contributors who have shared their expertise The staff in the Departments of Occupational Therapy and Physical Therapy.


.............................. CHT....... MSW................................... Schell...... Devereaux................................................ and Elizabeth B.................. and Paul C...... PhD..................................................... Ross.... PT CHAPTER 4 Hand Analysis ..... 123 Robert G..... MPT..................................... MPT....................... PT... 159 Julia Van Deusen....... OTR/L........... CHT CHAPTER 6 Cardiovascular and Pulmonary Function ........ FAOTA UNIT1WO Component Assessments of the Adult 25 CHAPTER 2 Muscle Strength ........... ACSW/L........ 27 Maureen J.. and Barbara A........ Simmonds......................3 Jeri Benson................ PhD............................................... and Ian Kahler Barstow.. OTR/L. FAOTA xvii ... MCSP. ents UNIT ONE Overview of Measurement Theory 1 CHAPTER 1 Measurement Theory: Application to Occupational and Physical Therapy .. MD.... FACSM CHAPTER 7 Psychosocial Function .. PhD..... Arnold..... PT............. OCS........ FAOTA CHAPTER 8 Body Image ............ PhD.. OTR/L... OTR......................78 A...49 Jeffery Gilliam... MS...... FRCS CHAPTERS Clinical Assessment of Pain .......... PhD CHAPTER 3 Joint Range of Motion .. MHS. LaStayo........... Protas............... 147 Melba J...........134 Elizabeth T.......... Moneim Ramadan........................ PT..

......... Decker...... OTR/L.. PhD.... and Keh-Chung Un.......... 199 LOWER EXTREMITY PROSTHETICS........ ..... CO......... OTR....... OTR/L.... MS.. OTR.... Decker............... 296 Julia Van Deusen... with Joanne Jackson Foss... PhD................ 295 Julia Van Deusen.401 Gail Ann Hills. PhD. OTR CHAPTER 12 Sensory Processing ......................... FAOTA SENSORY DEACITS......... Bernstein... SeD.... MA UNIT THREE Assessment of Central NelVous System Function of the Adult 247 CHAPTER 11 Motor ControL ........ and Patricia M. Hammond...... OTR/L.. 271 James Agostinucci.....295 INTRODUCTION TO SENSORY PROCESSING.. with Steven R......... MHS.. 302 Sharon A............ and Joanne Jackson Foss... MHS.. FAOTA.... OTR CHAPTER 15 Assessment of Elders and Caregivers ...... Cermak.. FAOTA... OTR ASSESSMENT OF PERCEPTUAL DYSFUNCTION IN THE ADULT.. OTR UPPER MOTOR NEURON SYNDROME.... and Bonnie R... FAOTA..........359 Joanne Jackson Foss............... PT UPPER EXTREMITY ORTHOTICS AND PROSTHETICS...... Gailey... 249 Joyce Shapero Sabari.......... MS........... PT ... OTR COGNITION...... 333 Barbara Haase....375 Bonnie R. PhD CHAPTER 10 Prosthetic and Orthotic Assessments . 175 Edward J.xviii CONTENTS CHAPTER 9 Electrodiagnosis of the Neuromuscular System .. PhD......... 199 Robert S.. MS.. MHS........ MSEd.. BS UNIT FOUR Age-Related Assessment 357 CHAPTER 13 Pediatrics: Developmental and Neonatal Assessment............. 216 Julie Belkin.... OTR/L.................... OTR. MS..... OTR CHAPTER 14 Pediatrics: Assessment of Specific Functions ...... Byron. MHS. OTR............. EdD.....249 MOTOR RECOVERY AFrER STROKE.......... SeD.

..... PT. OTR/L....421 Mary Law....... BS An Assessment Summary ..................................................................... and Carol A... CCM............... EdD CHAPTER 18 Home Management ............ Mueller.... Jackson................ OTR CHAPTER 20 Work Activities ...... PhD..523 ........ OTR/L..........Assessment of Activities of Daily Living 419 CHAPTER 16 Self-Care.... BIen D.......... Adams...... Wall.449 Shirley J..........435 James C........ OTR/L CHAPTER 19 Community Activities .................521 Index.................................................. MA......4 77 Bruce A. and Felecia Moore Banks...................................... MEd..471 Carolyn Schmidt Hanson.... MS.. PhD........................................................ PT............ OT(C) CHAPTER 17 Clinical Gait Analysis: Temporal and Distance Parameters ................. CRC.......................... PhD......................... and Denis Brunt........... CHT.................................. Isaac....


U NIT ONE Overview of Measurement Theory .


the re­ mainder of the chapter focuses on several issues with which therapists need to be familiar in making observational measurements. First. Within departments or sion's contributions to health care. in the fourth section we cover basic gUidelines to consider in evaluating an instrument for a specific purpose. For clinicians. . finally. . Since many of the measure­ ment tools described in this book are observationally based measurements. and. In the fifth section. OTR. This is due primarily to interest in using scientific to summarize important changes that occur as a result of approaches to improve practice and to justify each profes­ the therapy process (Law. Such measures help tions for ongoing quality improvement. The chapter concludes with a brief discussion of the need to consider the social consequences of testing. CHAPTER 1 Measurement Theory: Application to Occupational and Physical Therapy Jeri Benson. and serve 1900s. FAOTA SUMMARY This chapter begins with a conceptual overview of the two primary is­ sues in measurement theory. Properly developed practice groups. The use of measurement tools in both occupational and define the nature and scope of clinical problems. PhD. valid allow peers and managers to both critically evaluate the measurement approaches provide important information effectiveness of current interventions and develop direc­ to support effective clinical reasoning. a discussion of norms and the need for local norms is presented. meth­ ods for determining the reliability and validity of the scores from observational measurements are presented. Schell. the unique types of errors in­ troduced by the observer are addressed. 3 ~~--" . Since many observational tools already exist. 1987). validity and reliability. provide physical therapy has increased dramatically since the early benchmarks against which to monitor progress. In the second and third sections. PhD Barbara A. aggregated data from various measures measures can be useful at several levels. we summarize the steps necessary for de­ veloping an observational tool.

For example. 1980). Such understanding should promote What this means is that one study does not validate or fail valid interpretation of findings. expectations are likely to vary as a function of sometimes overlooked. is how well one can predict performance in different repeated measures of grip strength could be used by one contexts. as well as justifying the need for Psychometric theory is concerned with quantifying ob­ ongoing service provision (Wilkerson et aI. That is. meas­ urement is taking on increased importance in aiding decision-making about the allocation of health care re­ CONCEPTUAL BASIS OF VALIDITY AND sources. validity is an attribute of evaluating and developing observational measurement a measurement and not an attribute of an instrument (Sim tools (or any other type of tool). we must understand two essential determine the functional outcomes patients and clients elements of psychometric theory: reliability and validity. Impairments mayor may Validity is the single most important psychometric not result in disabilities. as each purpose has a different reliability. such as recent thinking in assessing the reliabil­ situations takes on a different meaning depending on the ity and validity of observational measures. Therefore. ters of this book can be thought of as being directed at quantifying either impairments or disabilities (World Health Organization. Of servations of behavior. For example. and. a better understanding of the conceptual basis Most of the measures discussed in the remaining chap­ for these two terms seems a relevant place to start. 1993). The follOWing It is obvious then that two separate validity studies are topics are addressed: the conceptual baSis of validity and required for each purpose. Numerous studies are needed. injury. whereas in the latter situation. whether a therapist is assessing an impair­ measure of grip strength to describe the current level of ment or the degree of disability. as it is the process by which scores from implies problems in adequately performing usual func­ measurements take on meaning.g. or developmental delays. 1993)." What is validated is the males and females of different ages for use in evaluating the score obtained from the measurement and not the tool results of grip strength testing. and life validate a scale or measuring tool.4 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY Measurement is at the heart of many research endeavors and refine measures will be interested in the more recent designed to test the efficacy of therapy approaches (Short­ procedures for stUdying reliability and validity. Finally. guidelines for supporting validity evidence. Therefore. Different psychometric concerns are likely to interpretation about the scores derived from the scale surface when considering the measurement of impair­ (Cronbach. a major itself. In addition to professional concerns with improving practice. 1978). how well does being able to walk in . therapist to assess a patient's consistency of effort to test the gym or prepare a light meal in the clinic predict his or her apparent willingness to demonstrate full physical performance in the home? Therefore. Sim & Arnell. 1993. Another therapist might want to use the same testing. the too) would retical and practical information with which to better under­ need to show content validity for the score interpretation. For instance. the need & Arnell. researchers who develop fails to support the validity of the score interpretation. finally. culture. This distinction makes sense if one considers that a concern in using functional assessments to assess disability given tool can be used for different purposes. measurement tools are RELIABILITY being investigated for their usefulness in classifying differ­ ent kinds of patient groups. This subtle yet impor­ ments versus functional abilities. one must first consider the purpose for work. disability concept. nervous system. appropriate uses. for local norms. . 1992). when rating tant distinction in terms of what is being validated is impairments. Impairments are problems that occur at the organ system level (e. different samples. Educators will different approaches. one does not tional tasks consistent with one's age.. normative data are needed for given measurement tool is "valid. issues involved in making observational meas­ objective. before evaluating a capacity and to suggest his or her motivation to return to given tool's validity. DeGraff & Fisher. Impairments typically result from illness. To quantify the behaviors we are particular concern in the United States is the need to interested in studying. the grip strength measurement tool would The objective of this chapter is to provide occupational need to show predictive validity for maximum effort and physical therapy professionals with sufficient theo­ exertion. experience as a result of therapy efforts. the purpose for testing strength and endurance for a hand-injured individual. Nunnally. At the health policy level. For example. what is validated is an situation. Thus. Thus. In contrast to impairment. Alternatively. Clinicians should be able to use this infor­ A second aspect of validity is that test score validation is mation to assess the quality of a measurement tool and its a matter of degree and not an all-or-nothing property. the score in each of the two above urements. as we often hear one say that a age or gender. former situation. 1971. musculo­ Validity skeletal system). using sions that are both effective and ethical. In the should be clear. allowing for practice deci­ to validate a scale.. and different find this chapter useful in orienting students to important populations to build a body of evidence that supports or measurement issues. stand the measurements used in each field.

simple relationship forms the basis of what is referred to as validity studies are continually needed. The relationship between in the context of the development and evaluation of observed. the derivation of the In an actual assessment situation. In the next few paragraphs.85 were reported for scores. we estimate how well the observed score (often score variance. 1989) are discussed as a reminder of Since the concept of reliability is a statistic that is based on the need to reevaluate the validity of measures used in the notion of individual differences that produce variability occupational and physical therapy as times change and the in observed scores. Later in this chapter. Crocker & Algina. Also. A reliability coefficient is score variance cannot be calculated in classical test theory an expression of how accurately a given measurement tool because they are theoretical concepts. and the reliability coefficient (p"J is de­ measuring the level of "functional independence" of an fined as individual. the How much confidence we can place in whether the as­ mathematic logic behind a reliability coefficient is de­ sumption of 0 = T is correct is expressed by the reliability scribed. we need to rewrite Equation 1-1 to nature of the professions change. true. 1978). and O'2E is the "error score vari­ tance of knowing and reporting the reliability of the scales ance. As it is impossible to has been able to assess an individual's true score. By understanding the concept of true score. The 1989. Nunnally. one closer the person's observed score is to his or her true can better appreciate what is meant by the numeric value score. if they could be perfectly measured. What is being estimated is a person's true described as the accuracy or consistency of the measure­ score. as social or cultural "classical test theory" and is shown by Equation 1-1: conditions change over time and cause our interpretation of the trait or behavior to change. the Wechsler Intelligence Scales).g." Given that the assumptions true score.Thus. if a reliability coefficient of 0." The variance is a group statistic that provides an used in their practice. and the estimate is called a reliability coefficient. given that the numerator of Equation a measure of a person's functional independence. if we needed to obtain reliability coefficient. and error scores for a group is given by observational measurement tools. all calculations of reliability are consid­ commonly referred to definition of reliability. 1986. or 85% of the measurement is assessing the from one observation) reflects the person's true score.. remaining 15% is attributed to measurement error. validation is viewed as an continual process (Messick. This individual's true level of functional independence. Even when a large body of discrepancy between an individual's true score and his or evidence seems to exist in support of the validity of a her observed score is referred to as the error score. While a true score for an individual is a theoretical The observed score variance is the actual variance concept. For independence and taking the average of all of his or her test example. With only one measurement. we likely 1-3 is theoretical. the proper interpretation of Equation 1-3 is score could be obtained by testing the individual an infinite that a reliability coefficient is the proportion of observed number of times using the same measure of functional score variance that is attributed to true score variance. is referred to as an individual's observed score. This one measurement texts. its validity must be reestablished [1] periodically. we assume that each individual has a "true" functional independence pxx = 0' 2 TO'O / 2 [3] score. 117-122. In understanding conceptually what index of how spread out the observed scores are around is meant by reliability. that 85% of the observed variance can be attributed to true Instead. in reality it is not possible to test an our measure of functional independence. which reflects what his or her functional abilities are. An individual's true Therefore. usually ered estimates.g. . The more accurate the measurement tool is. Equation 1-2: [2] Reliability Theory where 0'2 0 is the "observed score" variance. the social consequences of testing (MeSSick. we assume that 0 = T. (For the interested reader.. we need to introduce the concept of the mean "on the average. e. If we were interested in Equation 1-2. The true and error meant by a reliability coefficient. no matter what scale is used. Thus. is provided in many psychometric theory would take only one measurement. This particular scale (e. A true score is the person's actual ability or of classical test theory hold. for a scale to observed score (0) = true score ( T ) + error score (E) remain valid over time. Much more is said about represent a group of individuals who have been measured the methods used to validate test scores later in the chapter for functional independence. However. O'2 T is the Clinicians and researchers are well aware of the impor­ "true score" variance. it nonetheless is central to interpreting what is obtained from the sample data at hand. it would mean individual an infinite number of times for obvious reasons. coefficient. pp. the error score drops out of status in the area being measured. the ment tool. Notice test an individual an infinite number of times to compute his that this definition adds one additional element to the more or her true score. of a reliability coefficient.


Equation 1-3 is sometimes expressed in terms of the error lowed by a volumetric reading obtained by water displace­
score as 1 - (a2E/a20)') ment and a clinical rating based on therapist observation.
In summary, the conceptual basis of reliability rests on Because an unimpaired person's hand naturally swells
the notion of how well a given measurement tool is able to slightly at different times or after some activities, we would
assess an individual's tme score on the behavior of interest. expect some differences if measurements were taken at
This interpretation holds whether one is estimating a different times of day. Because these inconsistencies are
stability, equivalency, or internal consistency reliability expected , they would not be attributed to measurement
coefficient. Finally, as discussed earlier with regard to error, as we expect all the ratings to increase or decrease
validity, reliability is not a property of the measurement tool together. However, inconsistencies among the items within
itself but of the score derived from the tool. Furthermore, the edema battery would suggest measurement error. For
as pointed out by Sim and Arnell (1993) the reliability of a example, what if the tape measure indicated an increase in
score should not be mistaken for evidence of the validity of swelling, and the volumeter showed a decrease? This would
the score . suggest some measurement error in the battery of items.
~ The internal consistency coefficient reflects the amount of
measurement error due to internal differences in scores
Measurement Error measuring the same constmct.
To claim that an instrument is a measure of a trait that is
The study of reliability is integrally related to the study of assumed to remain stable over time for noninjured indi­
how measurement error operates in given clinical or viduals (excluding children), such as coordination , high
research situations. In fact, the choice of which reliability reliability in terms of consistency across time as well as
coefficient to compute depends on the type of measure­ within time points across items or observations is
ment error that is conceptually relevant in a given meas­ required. Potential inconsistency over measurement time is
urement situation, as shown in Table 1-1 . measured by the stability coefficient and reflects the degree
The three general forms of reliability shown in Table 1-1 of measurement error due to instability. Thu's, a high
can be referred to as classical reliabil,ity procedures because stability coefficient and a high internal consistency coeffi­
they are derived from classical test theory, as shown by cient are required of tools that are attempting to measure
Equation 1-1 . Each form of reliability is sensitive to differ­ traits. It is important to know how stable and internally
ent forms of measurement error. For example, when con­ consistent a given measurement tool is before it is used to
sidering the measurement of edema it is easy to recognize measure the coordination of an injured person. If the
that edema has both trait (dispositional) and state (situ­ measurement is unstable and the behavior is also likely to
ational) aspects. For instance , let us say we developed an be changing due to the injury, then it will be difficult to know
edema battery, in which we used a tape measure to meas­ if changes in scores are due to real change or to measure­
ure the circumference of someone's wrist and fingers , fol- ment error.

TABLE 1- 1


ReUabiHty Type Sources of Error Procedure

StabiHty (test-retest) Change in subject situation over time (e.g., Test, wait, retest with the same tool and
For tools monitoring change over memory, testing conditions, compliance) same subjects
time (e.g .. Functional Independence Any change treated as error, as trait ex­ Use PPM; results will range from -1 to 1,
Measure) pected to be stable with negatives treated as O. Time inter­
vals should be reported. Should be > 0.60
for long intervals, higher for shorter in­

Equivalency (parallel forms) Changes in test forms due to sampling of Prepare parallel forms, give forms to same
For multiple forms of same tool (e.g. , items. item quality subjects with no time interval
professional certification examinations) Any change treated as error, as items thought Use PPM; results will range from -1 to 1,
to be from same content domain with negatives treated as O. Should be
> 0.80

Internal consistency (how will items
Changes due to item sampling or item A. SpUt half: Test, split test in half.
in tool measure the same construct)
quality Use PPM, correct with Spearman­
For tools identifying traits (e.g., Sensory
Any change treated as error, because items Brown Should be > 0.80
Integration and Praxis Test) thought to be from same content B. Covariance procedures: Average
domain of all split halves. KR20, KR 21 (di­
chotomous scoring: right/wrong , mul­
tiple choice), Alpha (rating scale). Should
be > 0.80

Issue of Sample Dependency coefficient would be expected. However, if mobility were
more broadly defined, such as an individual's ability to
The classical approaches to assess scale reliability shown move freely throughout the home and community, then a
in Table 1-1 are sample-dependent procedures. The term reliability coeffiCient of 0.70 may be promising. To increase
sample dependent has two different meanings in meas­ the 0.70 reliability, we might increase the number of items
urement, and these different meanings should be consid­ used to measure mobility in the home and community.
ered when interpreting reliability and validity data. Sample Psychometric sample dependency has obvious implica­
dependency usually refers to the fact that the estimate of tions for validity. The more narrowly defined the domain of
reliability will likely change (increase or decrease) when the behaviors, the more limited is the validity generalization.
same scale is administered to a different sample from the Using the illustration just described, being able to walk a
same population. This change in the reliability estimate is 10-foot corridor tells us very little about how well the
primarily due to changes in the amount of variability from individual will be able to function at home or in the
one sample to another. For example, the reliability coeffi­ community. Later in the chapter, we introduce procedures
cient is likely to change when subjects of different ages are for determining the reliability and validity of a score that are
measured with the same scale. This type of sample not sample dependent.
dependency may be classified within the realm of "statis­ Numerous texts on measurement (Crocker & Algina,
tical inference," in which the instrument is the same but the 1986; Nunnally, 1978) or research methods (Borg & Gall,
sample of individuals differs either within the same popu­ 1983; Kerlinger, 1986) and measurement-oriented re­
lation or between populations. Thus, reliability evidence search articles (Benson & Clark, 1982; Fischer, 1993;
should be routinely reported as an integral part of each Law, 1987) have been written; these sources provide an
study. extensive discussion of validity and the three classical
In terms of interpreting validity data, sample dependency reliability procedures shown in Table 1-1.
plays a role in criterion-related and construct validity Given that the objective of this chapter is to provide
studies. In these two methods, correlational-based data are applications of measurement theory to the practice of
frequently reported, and correlational data are highly occupational and physical therapy, and that most of the
influenced by the amount or degree of variability in the measurement in the clinic or in research situations involves
sample data. Thus, a description of the sample used in the therapists' observations of individual performance or be­
validity study is necessary. When looking across validity havior, we focus the remaining sections of the chapter on
studies for a given instrument, we would like to see the the use of observational measurement. Observational
results converging for the different samples from the same measurements have a decided advantage over self-report
population. Furthermore, when the results converge for measurements. While self-report measurements are more
the same instrument over different populations, even efficient and less costly than observational measurements,
stronger validity claims can be made, with one caution: self-report measures are prone to faking on the part of the
Validity and reliability studies may produce results that fail individual making the self-report. Even when faking may
to converge due to differences in samples. Thus, in not be an issue, some types of behaviors or injuries cannot
interpreting correctly a test score for patients who have had be accurately reported by the individual. Observational
cerebrovascular accidents (CVAs), the validity evidence measures are favored by occupational and physical thera­
must be based on CVA patients of a similar age. Promising pists because they permit a direct measurement of the
validity evidence based on young patients with traumatic behavior of the individual or nature and extent of his or her
brain injury will not necessarily generalize. injury. However, observational measurements are not
The other type of sample dependency concerns "psy­ without their own sources of error. Thus, it becomes
chometric inference" (Mulaik, 1972), where the items important for occupational and physical therapiSts to be
constituting an instrument are a "sample" from a domain aware of the unique effects introduced into the measure­
or universe of all potential items. This implies that the ment process when observers are used to collect data.
reliability estimates are specific to the subdomain consti­ In the sections that follow, we present six issues that
tuting the test. This type of sample dependency has focus on observational measurement. First, the unique
important consequences for interpreting the specific value types of errors introduced by the observer are addressed. In
of the reliability coefficient. For example, a reliability the second and third sections, methods for determining the
coeffiCient of 0.97 may not be very useful if the measure­ reliability and validity of the scores from observational
ment domain is narrowly defined. This situation can occur measurements are presented. Since many observational
when the scale (or subscale) consists of only two or three tools already exist, in the fourth section we cover basic
items that are slight variations of the same item. In this case, guidelines one needs to consider in evaluating an instru­
the reliability coefficient is inflated since the items differ ment for a specific purpose. However, sometimes it may be
only in a trivial sense. For example, if we wanted to assess necessary to develop an observational tool for a specific
mobility and used as our measure the ability of an individual situation or facility. Therefore, in the fifth section, we
to ambulate in a 10-foot corridor, the mobility task would summarize the steps necessary for developing an observa­
be quite narrowly defined. In this case, a very high reliability tional tool along with the need for utilizing standardized


procedures. Finally, the procedures for developing local systematic observer biases can occur. First, an observer
norms to gUide decisions of therapists and health care may tend to be too lenient or too strict. This form of bias
managers in evaluating treatment programs are covered. has been referred to as either error of severity or error of
leniency , depending on the direction of the bias. Quite
often we find that human beings are more lenient than they
are strict in their observations of others. A second form of
ERRORS INTRODUCED BY OBSERVERS bias is the error of central tendency. Here the observer
tends to rate all individuals in the middle or average
Observer effects have an impact on the reliability and the category. This can occur if some of the behaviors on the
validity of observational data. Two distinct forms of ob­ observational form were not actually seen but the observer
server effects are found: 1) the observer may fail to rate the feels that he or she must put a mark down. A third type of
behavior objectively (observer bias) and 2) the presence of systematic bias is called the halo effect. The halo effect is
the observer can alter the behavior of the individual being when the observer forms an initial impression (either
rated (observer presence). These two general effects are positive or negative) of the individual to be observed and
summarized in Table 1-2 and are discussed in the following then lets this impression guide his or her subsequent
sections. ratings. In general , observer biases are more likely to occur
when observers are asked to rate high-inference or
evaluation-type variables (e.g., the confidence with which
Observer Bias the individual buttons his or her shirt) compared with very
specific behaviors (e.g., the person's ability to button his or
Observer bias occurs when characteristics of the ob­ her shirt).
server or the situation being observed influence the ratings To control for these forms of systematic observer bias,
made by the observer. These are referred to as systematic one must first be aware of them. Next, to remove their
errors, as opposed to random errors. SystematiC errors potential impact on the observational data , 'adequate
usually produce either a positive or negative bias in the training in using the observational tool must be provided.
observed score, whereas random errors fluctuate in a Often , during training some of these biases come up and
random manner around the observed score. Recall that the can be dealt with then. Another method is to have more
observed score is used to represent the ' 'true score," so any than one observer present so that differences in rating may
bias in the observed score has consequences for how reveal observer biases.
reliably we can measure the true score (see Equation 1-3).
Examples of rater characteristics that can influence obser­
vations range from race, gender, age, or social class biases Observer Presence
to differences in theoretical training or preferences for
different procedures. While the "effect" of the presence of the observer has
In addition to the background characteristics of observ­ more implications for a research study than in clinical
ers that may bias their observations, several other forms of practice, it may be that in a clinical situation , doing

TABLE }· 2


JofIueuces Definition Strategies to Control

Observer biases
Background of observer Bias due to own experiences (e.g ., race , gender, Increase observer awareness of the influence of his
class, theoretical orientation , practice preferences) or her background

Error of severity or leniency Tendency to rate too strictly or too leniently Provide initial and refresher observer training
Provide systematic feedback about individual rater

Error of central tendency Tendency to rate everyone toward the middle Do coratings periodically to detect biases
Minimize use of high-inference items where possible
Halo effect Initial impression affects all subsequent ratings

Observer presence Changes in behavior as a result of being measured Spend time with individual before evaluating to de­
sensitize him or her to observer
Discuss observation purpose after doing observation

Observer expectation Inflation or deflation of ratings due to observer's per­ Do routine quality monitoring to assure accuracy
sonal investment in measurement results (e.g., peer review, coobservations)

something out of the ordinary with the patient can alter his research in this area has indicated the inadequacy of
or her behavior. The simple act of using an observational reporting observer agreement alone, as it can be highly
form to check off behavior that has been routinely per­ misleading (McGaw et aI., 1972; Medley & Mitzel, 1963).
formed previously may cause a change in the behavior to The main reason for not using percentage of observer
be observed. agreement as an indicator of reliability is that it does not
To reduce the effects of the presence of the observer, address the central issue of reliability, which is how much of
data should not be gathered for the first few minutes when the measurement represents the individual's true score.
the observer enters the area or room where the observation The general lack of conceptual understanding of what the
is to take place. In some situations, it might take several reliability coefficient represents has led practitioners and
visits by the obseiver before the behavior of the individual researchers in many fields (not just occupational and
or group resumes to its "normal" level. If this precaution is physical therapy) to equate percentage of agreement
not taken, the behavior being recorded is likely to be methods with reliability. Thus, while these two concepts
atypical and not at all representative of normal behavior for are not the same, the percentage of observer agreement
the individual or group. can provide useful information in studying observer bias or
A more serious problem can occur if the individual being ambiguity in observed events, as suggested by Herbert and
rated knows that high ratings will allow him or her to be Attridge (1975). Frick and Semmel (1978) provide an
discharged from the clinic or hospital, or if in evaluating the overview of various observer agreement indices and when
effect of a treatment program, low ratings are initially given these indices should be used prior to conducting a reliability
and higher ratings are given at the end. This latter situation study.
describes the concept of observer expectation. However,
either of these situations can lead to a form of systematic
bias that results in contamination of the observational Variance Components Approach
data, which affects the validity of the scores. To as much an
extent as possible, it is advisable not to discuss the purpose To consider the accuracy of the true score being
of the observations until after they have been made. measured via observational methods, the single best pro­
Alternatively,. one can do quality monitoring to assure cedure is the variance components approach (Ebel, 1951;
accuracy of ratings. Frick & Semmel, 1978; Hoyt, 1941). The variance
components approach is superior to the classical ap­
proaches for conducting a reliability study for an observa­
tion tool because the variance components approach
allows for the estimation of multiple sources of error in the
ASSESSING THE RELIABILITY OF measurement (e.g., same observer over time, different
OBSERVATIONAL MEASURES observers, context effects, training effects) to be partitioned
(controlled) and studied. However, as Rowley (1976) has
The topic of reliability was discussed earlier from a pOinted out, the variance components approach is not well
conceptual perspective. In Table 1-1, the various methods known in the diSciplines that use observational measure­
for estimating what we have referred to as the classical ment the most (e.g., clinical practice and research). With so
forms of reliability of scores were presented. However, much of the assessment work in occupational and physical
procedures for estimating the reliability of observational therapy being based on observations, it seems highly
measures deserve special attention due to their unique appropriate to introduce the concepts of the variance
nature. As we noted in the previous section, observational components approach and to illustrate its use.
measures, compared with typical paper-and-pencil meas­ The variance component approach is based on an
ures of ability or personality, introduce additional sources analysis of variance (ANOVA) framework, where the
of error into the measurement from the observer. For variance components refer to the mean squares that are
example, if only one observer is used, he or she may be routinely computed in ANOVA. In an example adapted
inconsistent from one observation to the next, and there­ from Rowley (1976), let us assume we have n;;:: 1 obser­
fore we would want some information on the intrarater vations on each of p patients, where hand dexterity is the
agreement. However, if more than one observer is used, behavior to be observed. We regard the observations as
then not only do we have intrarater issues but also we have equivalent to one another, and no distinction is intended
added inconsistencies over raters, or interrater agreement between observations (observation five on one patient is no
problems. Notice that we have been careful not to equate different than observation five on another patient). This
intrarater and interrater agreement with the concept of "design" sets up a typical one-way repeated-measures
reliability. Observer disagreement is important only in that ANOVA, with P as the independent factor and the n
it reduces the reliability of an observational measure, which observations as replications. From the ANOVA summary
in turn reduces its validity. table, we obtain MSp (mean squares for patient) and MSw
From a measurement perspective, percentage of ob­ (mean squares within patients, or the error term). The
server agreement is not a form of reliability (Crocker & reliability of a score from a single observation of p patients
Algina, 1986; Herbert & Attridge, 1975). Furthermore, would be estimated as:


MSp MSw sources of measurement error) is a more suitable method
[4) for assessing reliability of measurement tools used in
ric = MSp + (n - I)MSw
clinical practice. For example, we might be interested in
how the reliability of clinical observations is influenced if the
Equation 1-4 is the intraclass correlation (Haggard, number of therapists making the observations were in­
1958). However, what we are most interested in is the creased or if more observations were taken by a single
mean score observed for the p patients over the n> 1 therapist. In these situations, the statistical procedures
observations, which is estimated by the following expres­ associated with generalizability theory help the clinical
sion for reliability: researcher to obtain reliable ratings or observations of
behavior that can be generalized beyond the specific
-MSw situation or therapist.
rxx = [5) A final point regarding the reliability of observational
data is that classic reliability procedures are group-based
statistics, where the between-patient variance is being
studied. These methods are less useful to the practicing
Generalizability Theory therapist than the variance components procedures of
generalizability theory, which account for variance within
Equations 1-4 and 1-5 are specific illustrations of a individual patients being treated over time. Roebroeck and
more generalized procedure that permits the "generaliz­ coworkers (1993) illustrate the use of generalizability
ability" of observational scores to a universe of observa­ theory in assessing reliably the change in patient progress
tions (Cronbach et al., 1972). The concept of the universe over time. They show that in treating a patient over time,
of observational scores for an individual is not unlike that of what a practicing therapist needs to know is the "smallest
true score for an individual introduced earlier. Here you can detectible difference" to determine that a real change has
see the link that is central to reliability theory, which is how occurred rather than a change that is influenced by
accurate is the tool in measuring true score, or, in the case measurement error. The reliability of change or difference
of observational data, in producing a score that has high scores is not discussed here, but the reliability of difference
generalizability over infinite observations. To improve the scores is known to be quite low when the pre- and
estimation of the "true observational score," we need to postmeasure scores are highly correlated (Crocker &
isolate as many sources of error as may be operating in a AJgina, 1986; Thorndike & Hagen, 1977). Thus, gener­
given situation to obtain as true a measurement as is alizability theory procedures account for multiple sources
possible. of measurement error in determining what change in
The variance components for a single observer making scores over time is reliable. For researchers wanting to use
multiple observations over time would be similar to the generalizability theory procedures to assess the reliability of
illustration above and expressed by equations 1-4 and 1-5, observational data (or measurement data in which multiple
where we corrected for the observer's inconsistency from sources of error are possible), many standard "designs"
each time point (the mean squares within variance com­ can be analyzed using existing statistical software (e.g.,
ponent). If we introduce two or more observers, then we SPSS or SAS). Standard designs are one-way or factorial
can study several different sources of error to correct for ANOVA designs that are crossed, and the sample size is
differences in background, training, and experience (in equal in all cells. Other nonstandard designs (unbalanced in
addition to inconsistencies within an observer) that might terms of sample size, or not all levels are crossed) would
adversely influence the observation. All these sources of required specialized programs. Crick and Brennan (1982)
variation plus their interactions now can be fit into an have developed the program GENOVA, and a version for
ANOVA framework as separate variance components to IBM-compatible computers is available (free of charge),
adjust the mean observed score and produce a reliability which will facilitate the analysis of standard and nonstan­
estimate that takes into account the background, level of dard ANOVA-based designs.
training, and years of experience of the observer. It is not possible within a chapter devoted to "psycho­
Roebroeck and colleagues (1993) provide an introduc­ metric methods in general" to be able to provide the details
tion to using generalizability theory to estimate the reliabil­ needed to implement a generalizability study. Our objective
ity of assessments made in physical therapy. They point was to acquaint researchers and practitioners in occupa­
out that classical test theory estimates of reliability (see tional and physical therapy with more recent thinking on
Table 1-1) are limited in that they cannot account for determining the reliability of observers or raters that
different sourceS of measurement error. In addition, the maintains the conceptual notion of reliability, i.e., the
classical reliability methods are sample dependent, as measurement of true score. The following sources can be
mentioned earlier, and as such cannot be generalized to consulted to acquire the details for implementing variance
other therapists, situations, or patient samples. Thus, components procedures (Brennan, 1983; Crocker &
Roebroeck and associates (1993) suggest that generaliz­ Algina, 1986; Evans, Cayten & Green, 1981; Shavelson &
ability theory (which is designed to account for multiple Webb, 1991).

the clinic should possess content validity, as she includes it
ASSESSING THE VALIDITY OF in each reason for testing.
OBSERVATIONAL MEASURES Given that validity is the most important aspect of a test
score, we shall discuss the procedures to establish each
Validi tells us what the test score measures. However, form of validity noted in Table 1-3 for any measurement
5ina; anyone test can be use or qUlfeaifre-r~nt'purposes, tool. However, we focus our illustrations on observational
we need to know not just "is the test score valid" but also measures. In addition, we point out the issues inherent in
is the test score valid for the purpose for which I wish to each form of validation so that the practitioner and
J5e it?" Each form of validity calls for a different procedure researcher can evaluate whether sufficient evidence has
llat permits one type of inference to be drawn. Therefore, been established to ensure a correct interpretation of the
the purpose for testing an individual should be clear, since test's scores.
being able to make predictions or discuss a construct leads
to very different measurement research designs.
Several different procedures for validating scores are Construct Validation
derived from an instrument, and each depends on the
purpose for which the test scores will be used. An overview Construct validation is reguired when the interpretation
of these procedures is presented in Table 1-3. As shown in to be made of the scores implies an explanation of the
the table, each validation procedure is associated with a benailior or trait. A construct is a theoretical conceptual­
given purpose for testing (column 1). For each purpose, an ization ottnebe havior developed from observation. For
illustrative question regarding the interpretation of the example, functional independence is a construct that is
score is provided under column 2. Column 3 shows the operationalized by the Functional Independence Measure
fo rm of validity that is called for by the question, and (FIM). However, or a cons truCt'io be useful;--Lord and
::olumn 4, the relevant form(s) of reliability given the Novick (1968) advise that the construct must be defined on
purpose of testing. two levels: operationally and in terms of how the construct
Law (1987) has organized the forms of validation around of interest relates to other constructs. This latter point is the
three general reasons for testing in occupational therapy: heart of what Cronbach and Meehl (1955) meant when
descriptive, predictive, and evaluative. She indicates that they introduced the term nomological network in their
an individual in the clinic might need to be tested for several classical article that defined construct validity. A nomologi­
different reasons. If the patient has had a stroke, then the cal network for a given construct, functional independence,
therapist might want "to compa!'e [him or her] to other stipulates how functional independence is influenced by
stroke patients (descriptive), determine the probability of other constructs, such as motivation, and in turn influences
full recovery (prediction) or assess the effect of treatment such constructs as self-esteem. To specify the nomological
(evaluative)" (p. 134). For a tool used descriptively, Law network for functional independence or any construct, a
suggests that evidence of both content and construct strong theory regarding the construct must be available.
validation of the scores should exist. For prediction, she The stronger the substantive theory regarding a construct,
advises that content and criterion-related data be available. the easier it is to design a validation study that has the
Finally, for evaluative, she recommends that content and potential for providing strong empirical evidence. The
construct evidence be reported. Thus, no matter what the weaker or more tenuous the substantive theory, the greater
purpose of testing is, Law feels that all instruments used in the likelihood that equally weak empirical evidence will be

Ji\BI l. 1<I

Purpose of the Test Validity Question Kind of Validity ReliabiUty Procedures

Assess current status Do items represent the domain? Content a) Internal consistency within each subarena

b) Equivalency (for multiple forms)

c) Variance components for observers

Predict behavior or How accurate is the prediction? Criterion-related: concurrent a) Stability

performance or predictive b) Equivalency (for multiple forms)

c) Variance components for observers

Infer degree of trait How do we know a specific Construct a) Internal consistency

or behavior behavior is being measured? b) Equivalency (for multiple forms)

c) Stability (if measuring over time)

d) Variance components for observers

~_ _-=::::::::::i::::­


gathered, and very little advancement is made in under­
standing the construct. Constructs
Benson and Hagtvet (1996) recently wrote a chapter on
the theory of construct validation in which they describe the
process of construct validation as involving three steps, as
suggested earlier by Nunnally (1978): 1) specify the domain
of observables for the construct, 2) determine to what ex­
tent the observables are correlated with each other, and 3)
determine whether the measures of a given construct cor­
relate in expected ways with measures of other constructs. Empirical:
The first step essentially defines both theoretically and op­
erationally the trait of interest. The second step can be
thought of as internal domain studies, which would include FIGURE 1-1. Relationship between a theoretical construct
such statistical procedures as item analysis, traditional fac­ empirical measurement.
tor analysis, confirmatory factor analysis (Jreskog, 1969),
variance component procedures (such as those described theoretical, abstract level to the empirical level, as sho
under reliability of observational measures), and multitrait­ Figure 1-1 below the dashed line, where the sp
multimethod procedures (Campbe'll & Fiske, 1959). A rela­ aspects of function are shown . Each construct is ass
tively new procedure to the occupational and physical to have its own empirical domain. The empirical d
therapy literature, Rasch modeling techniques (Fischer, contains all the possible item types and ways to me
1993) could also be used to analyze the internal domain of the construct (e.g. , nominal or rating items, self-r
a scale. More is said about Rasch procedures later in this observation, performance assessment). Finally, s
chapter. The third step in construct validation can be within the empirical domain in Figure 1- 1 is. our s
viewed as external domain studies and includes such statis­ measure of functional independence, the FIM . Th
tical procedures as multiple correlations of the trait of inter­ operationalizes the concept of functional independe
est with other traits, differentiation between groups that do terms of an individual's need for assistance in the ar
and do not possess the trait, and structural equation model­ self-care, sphincter management, mobility, locom
ing (Joreskog , 1973). Many researchers rely on factor anal­ communication, and social cognition (Center for
ysis procedures almost exclusively to confirm the presence tional Assessment Research, 1990). A number of
of a construct. However, as Benson and Hagtvet (1996) possible aspects of function are not included in th
pOinted out, factor analysis focuses primarily on the inter­ (such as homemaking, ability to supervise attendan
nal structure of the scale only by demonstrating the conver­ driving) because of the desire to keep the assessme
gence of items or similar traits. In contrast, the essence of as short as possible and still effectively reflect the deg
construct validity is to be able to discriminate among differ­ functional disability demonstrated by individuals.
ent traits as well as demonstrate the convergence of similar Figure 1-2 illustrates how others have operation
traits. The framework proVided by Benson and Hagtvet for the theoretical construct of functional independen
conducting construct validity studies indicates the true rehabilitation patients, such as the Level of Rehabil
meaning of validity being a process. That is, no one study Scale (LORS) (Carey & Posavac, 1978) and the B
can confirm or disconfirm the presence of a construct, but a (Mahoney & Barthel, 1965). It is expected that the
series of studies that clearly articulates the domain of the and Barthel would correlate with the FIM becaus
construct, how the items for a scale that purports to meas­ operationalize the same construct and their items
ure the construct fit together, and how the construct can be subset of the aspects of function domain (see large s
separated from other constructs begins to form the basis of circle in Figure 1-2). However, the correlations wou
the evidence needed for construct validation. be perfect because they do not operationalize the con
To illustrate how this three-step process would work , we of functional independence in exactly the same way
briefly sketch out how a construct validity study would be they include some different aspects of functional ind
designed for a measure of functional independence, the dence).
FIM. First, we need to ask, "How should the theoretical and In our hypothetical construct validity study, we now
empirical domains of functional independence be concep­ selected a specific measurement tool, so we can mo
tualized?" To answer this question, we would start by to step 2. In the second step, the internal domain of th
drawing on the research literature and our own informal is evaluated. An internal domain study is one in whi
observations. This information is then summarized to form items on the scale are evaluated . Here we might use
a "theory" of what the term functional independence analysis to determine how well the items on th
means, which becomes the basis of the construct, as shown measure a single construct or whether the two dime
in Figure 1-1 above the dashed line. recently suggested by Linacre and colleagues (1994)
A construct is an abstraction that is inferred from empirically verified. Since the developers of the
behavior. To assess functional independence, the construct (Granger et al., 1986) suggest that the items be summ
must be operationalized. This is done by moving from the total score, which implies one dimenSion, we can te

Theoretical trait: assess the behavioral domain of interest. For example,
Theoretical consider Figure 1-1 in thinking about how the FIM would
be evaluated for content validity. The behavioral domain is
the construct of functional independence, which needs to
be defined in its broadest sense, taking into account the
various perspectives found in the research literature. Then
functional independence is operationally defined as that set
of behaviors assessed by the FIM items (e.g., cognitive and
motor activities necessary for independent living). Once
::mpirical these definitions are decided on, an independent panel of
experts in functional independence would rate whether the
5 cognitive items and the 13 motor items of the FIM
R GURE 1-2. Several empirical measures of the same theoretical adequately assess the domain of functional independence.
:'.)OStruct. Having available a table of specifications (see section on
developing an observational form and Table 1-5) for the
co mpeting conceptualizations of what the FIM items seem experts to classify the items into the cells of the table
'0 measure. facilitates the process. The panel of experts should be: 1)
For the third step in the process of providing construct independent of the scale being evaluated (in this case, they
',<alidity evidence for the RM scores, we might select other were not involved in the development of the FIM) and 2)
variables that are assumed to influence one's level of undisputed experts in the subject area. Finally, the panel of
fu nctional independence (e.g. , motivation, degree of family experts should consist of more than one person.
sup port) and variables that functional independence is Crocker and Algina (1986) provide a nice framework for
thought to influence (e .g., self-esteem, employability). In conducting a content validity study along with practical
this third step, we are gathering data that will confirm or fail considerations and issues to consider. For example, an
to confirm our hypotheses about how functional indepen­ important issue in assessing the content validity of items is
dence as a construct operates in the presence of other what exactly the expert rates. Does the expert evaluate
constructs. To analyze our data, we could use multiple only the content of the items matching the domain, the
regression (Pedhazur, 1982) to study the relation of difficulty of the task for the intended examinee that is
motivation and degree of family support to functional implied in the item plus the content, the content of the item
independence . A second regression analysis might explore and the response options, or the degree of inference the
whether functional independence is related to self-esteem observer has to make to rate the behavior? These questions
and employability in expected ways. More advanced point out that the "task" given to the experts must be
statistical procedures combine the above two regression explicitly defined in terms of exactly what they are to
analyses in one analysis. One such procedure is structural evaluate so that "other item characteristics" do not influ­
equation modeling (Joreskog, 1973). Benson and Hagtvet ence the rating made by the experts. A second issue
(1996) provide an illustration of using structural equation pertains to how the results should be reported. Crocker and
modeling to assess construct validation in a study similar to Algina (1986) point out that different procedures can lead
what was just described. The point of the third step is that to different conclusions regarding the match between the
we expect to obtain results that confirm our hypotheses of items and the content domain.
how functional independence as a construct operates. If we The technical manual for an assessment tool is important
do happen to confirm our hypotheses regarding the for evaluating whether the tool has adequate content
behavior of functional independence, this then becomes validity. In the technical manual, the authors need to
one more piece of evidence for the validity of the FIM provide answers to the following questions: " Who were the
scores. However, the generalization of the construct be­ panel of experts?" "How were they sampled?" "What was
yond the sample data at hand would not be warranted (see their task?" Finally. the authors should indicate the degree
earlier section on sample dependency). Thus, for appro­ to which the items on the test matched the definition of the
priate use of the FIM scores with individuals other than domain. The results are often reported in terms of per­
those used in the hypothetical study described here, a centage of agreement among the experts regarding the
separate study would need to be conducted. classification of the items to the domain definition. Content
validation is particularly important for test scores used to
evaluate the effects of a treatment program. For example,
Content Validation a therapist or facility manager might be interested in
determining how effective the self-care retraining program
To determine the content validity of the scores from a is for the patients in the spinal cord injury unit. To draw the
scale, o~wo.!. !lcLneed to sp~cify an explicit definition of the· conclusion that the self-care treatment program was effec­
behavioral domain and how that domain is to be opera­ tive in working with rehabilitation patients with spinal cord
tionally defined. This step is critical, since the task in injuries, the FIM scores must be content valid for measuring
content validation is to ensure that the items adequately changes in self-care skills.


Criterion-Related Validity of the prediction is 36% when the validity coefficient
0.60 and 18% when the validity coefficient is 0.42 . Th
There are two forms of criterion-related validation: accuracy of the prediction tells us how much variance th
concurrent and predictive. Each form is assessed in the predictor is able to explain of the criterion out of 100%
same manner. The only difference between these two Given the results just presented, it is obvious that the choic
forms is when the criterion is obtained. Concurrent of the predictor and criterion should be made very carefully
validation refers to the fact that the criterion is obtained at Furthermore, multiple predictors often improve the accu
approximately the same time as the predictor data, racy of the prediction. To estimate the validity coefficien
whereas predictive validation implies that the criterion was with multiple predictors requires knowledge of multipl
obtained some time after the predictor data. An example of regression, which we do not go into in this chapter. A
concurrent validation would be if the predictor is the score readable reference is Pedhazur (1982).
on the FIM taken in the clinic and the criterion is the Since criterion-related validation is based on using
observation made by the therapist on visiting the patient at correlation coefficient (usually the pearson produc
home the next day, then the correlation between these two moment correlation coefficient if the predictor and crite
"scores" (for a group of patients) would be referred to as rion are both continuous variables), then the issues t
the concurrent validity coefficient. However, if the criterion consider with this form of validity are those that impact th
observation made in the home is obtained 1 or 2 months correlation coefficient. For example, the range of individua
later, the correlation between these scores (for a group of scores on the predictor or criterion can be limited, th
patients) is referred to as the predictive validity coefficient. relationship between the predictor and criterion may not b
Thus, the only difference between concurrent and predic­ linear, or the sample size may be too small. These thre
tive validation is the time interval between when the factors singly or in combination lower the validity coeff
predictor and criterion scores are obtained. cient. The magnitude of the validity coefficient also
The most important consideration in evaluating reduced, influenced by the degree of measureme,nt error i
criterion-related validity results is "what ,is the criterion?" In the predictor and criterion. This situation is referred to a
a criterion-related validity study, what we are actually the validity coefficient being attenuated. If a researche
validating is the predictor score (the FIM in the two wants to see how high the validity coefficient would be if th
illustrations just given) based on the criterion score. Thus, predictor and criterion were perfectly measured, th
a good criterion must have several characteristics. First, the follOwing equation can be used :
criterion must be "unquestioned" in terms of its validity,
i.e., the criterion must be considered the "accepted ryx' = rx/VCrxx ) . Cryy) [7
standard" for the behavior that is being measured. In the
illustrations just given, we might then question the validity where rxy' is the corrected or disattenuated validit
of the therapist's observation made at the patient's home. coefficient, and the other terms have been previousl
In addition to the criterion being valid, it must also be defined . The importance of considering the disattenuate
reliable. In fact, the upper bound of the validity coefficient validity coefficient is that it tells us whether it is worth it t
can be estimated using the following equation: try and improve the reliability of the predictor or criterion
If the disattenuated validity coefficient is only 0.50, then
might be a better strategy to select another predictor o
ry/ = VCrxx) . Cryy) [6] criterion.
One final issue to consider in evaluating criterion-relate
where ryX' is the upper bound of the validity coefficient, rxx validity coefficients is that since they are correlations, the
is the reliability of the predictor, and ryy is the reliability of can be influenced by other variables. Therefore, correlate
the criterion. If the reliability of the predictor is 0.75 and the of the predictor should be considered to determine if som
reliability of the criterion is 0.85, then the maximum other variable is influencing the relationship of interest. Fo
validity coefficient is estimated to be 0.80, but if the instance, let us assume that motivation was correlated wit
reliability of the predictor is 0.60 and criterion is 0 .70, then the FIM. 1f we chose to use the FIM to predict employability
maximum validity coefficient is estimated to be 0.42. Being the magnitude of the relationship between the FIM an
able to estimate the maximum value of the validity coeffi­ employability would be influenced by motivation. We ca
cient prior to conducting the validity study is critical. If the control the influence of motivation on the relationshi
estimated value is too low, then the reliability of the between the FIM and employability by using partial corre
predictor or criterion should be improved prior to initiating lations. This allows us to evaluate the magnitude of th
the validity study, or another predictor or criterion measure actual relationship free of the influence of motivation
can be used. Crocker and Algina (1986) provide a discussion of the nee
The value of the validity coefficient is extremely impor­ to consider partial correlations in evaluating the results o
tant. It is what is used to evaluate the accuracy of the a criterion-related validity study.
prediction, which is obtained by squaring the validity Now that the procedures for assessing reliability an
coefficient (r x / ) ' In the illustration just given, the accuracy validity have been presented, it would be useful to appl

them by seeing how a therapist would go about evaluating the guidelines into five sections (descriptive information,
a measurement tool. scale development, psychometric properties , norms and
scoring, and reviews by professionals in the field). To
respond to the points raised in the guidelines, multiple
sources of information often need to be consulted.
EVALUATION OF OBSERVATIONAL To illustrate the use of the gUidelines, we again use the
MEASURES FIM as a case example because of the current emphasis on
outcome measures. Due to the FIM being relatively new,
Numerous observational tools can be used in occupa­ we need to consult multiple sources of information to
tional and physical therapy. To assist the therapist in evaluate its psychometric adequacy. We would like to point
selecting which observational tool best meets his or her out that a thorough evaluation of the FIM is beyond the
needs, a set of gUidelines is proVided in Table 1-4. These scope of this chapter and , as such, we do not comment on
gUidelines are designed to be helpful in evaluating any either the strengths or the weaknesses of the tool. Rather,
instrument, not just observational tools. We have organized we wanted to sensitize the therapist to the fact that a given

'I,\BI [ 1 -·1


Manual Grant Reports Book Chapter Articles

Descriptive Infonnation
Title , author, publisher, date X X X
Intended age groups X
Cost X
Time (train, score, use) X

Scale Development
Need for instrument X X X X
Theoretical support X X
Purpose X X X X
Table of specifications described?
Item development process X
Rationale for number of items
Rationale for item format X X X
Clear definition of behavio r X
Items cover domain X
Pilot' testing X X X
Item analysis X X X

Psychometric Properties
Observer agreement X X
Equivalency NA
In ternal-consistency X X
Standard error of measurement
Generalizability approaches X X
Criterion related
Construct X
Sample size and description X X X

Nonns and Scoring
Description of norm group NA
Description of scoring X
Recording of procedures X
Rules for borde rline X
Computer scoring available
Standard scores available

Independent Reviews NA NA X

NA = nonapplicable; X = info rmatio n needed was found in this source.


tool can be reliable and valid for many different purposes; dressed in the manual or other sources. In our example
therefore, each practitioner or researcher needs to be able assume the reason for using the FIM is to determin
to evaluate a given tool for the purpose for which he or she usefulness as an outcome measure of "program effec
intends to use it. ness of an inpatient rehabilitation program." Such
Numerous sources may need to be consulted to decide comes would be useful in monitoring quality, mee
if a given tool is appropriate for a specific use. Some of program evaluation gUidelines of accrediting bodies,
the information needed to evaluate a measurement tool helping to identify program strengths useful for marke
may be found in the test manual. It is important to services. In deciding whether the FIM is an appropriate
recognize that different kinds of test manuals, such as for our purposes, the following questions emerge:
administration and scoring guides and technical manuals, Does it measure functional status?
exist. In a technical manual, you should expect to find the Should single or multiple disciplines perform the rati
following points addressed by the author of the instrument How sensitive is the FIM in measuring change
(at a minimum): admission to discharge of inpatients?
Need for the instrument How.weLl does it capture the level of human assist
Purpose of the instrument required for individuals with disabilities in a varie
Intended groups or ages functional performance arenas?
Description of the instrument development proce­ Does it work equally well for patients with a rang
dures conditions, such as orthopedic problems, spinal
Field or pilot testing results injury, head injury, and stroke?
Administration and scoring procedures Most of these questions are aimed at the reliability
Initial reliability and validity results, given the in­ validity of the scores from the FIM. In short, we nee
tended purpose know how the FIM measures functional status and for w
Normative data (if relevant) groups, as well as how sensitive the measurement is.
Sometimes the administration and scoring procedures According to Law (1987, p. 134), the form of va
and the normative data are a separate document from the called for in our example is evaluative. Law desc
technical manual. Book chapters are another source of evaluative instruments as ones that use "criteria or item
information and are likely to report on the theoretical measure change in an individual over time." Under ev
underpinnings of the scale and more extensive reliability, ative instruments, Law suggests that the items shoul
validity, and normative results that might include larger responsive (sensitive), test-retest and observer reliab
samples or more diverse samples. The most recent infor­ should be established, and content and construct va
mation on a scale can be found in journal articles, which are should be demonstrated. Given our intended use of
likely to provide information on specific uses of the tool for FIM, we now need to see if evidence of these form
specific samples or situations. Journal articles and book reliability and validity exists for the FIM.
chapters written by persons who were not involved in the In terms of manuals, the only one available is the G
development of the instrument offer independent sources for the Use of the Uniform Data Set for Med
of information in terms of how useful the scale is to the Rehabilitation Including the Functional Independe
research community and to practicing therapists. Finally, Measure (FlM) Version 3.1, which includes the
depending on the popularity of a given scale, independent (Center for Functional Assessment Research, 19
evaluations by experts in the field may be located in test Stated in the Guide is that the FIM was found to
review compendiums such as Buros' Mental Measure­ "face validity and to be reliable" (p. 1), with no suppor
ment Yearbooks or Test Critiques found in the reference documentation of empiric evidence within the Gu
section of the library. Since the FIM was developed from research funding
As shown in Table 1-4, we consulted four general types needed to consult an additional source, the final re
of sources (test manual, grant reports, book chapters, and of the grant (Granger & Hamilton, 1988). In the
journal articles) to obtain the information necessary to report is a brief description of interrater reliability an
evaluate the FIM as a functional outcome measure. The validity. Interrater reliability was demonstrated thro
FIM, as part of the Uniform Data System, was originally intraclass correlations of 0.86 on admission and 0.8
designed to meet a variety of objectives (Granger & discharge, based on the observations of physicians,
Hamilton, 1988), including the ability to characterize cupational and physical therapists, and nurses. The
disability and change in disability over time, provide the terrater reliability study was conducted by Hamilton
basis for cost-benefit analyses of rehabilitation programs, colleagues (1987). In a later grant report, Heinemann
and be used for prediction of rehabilitation outcomes. To colleagues (1992) used the Rasch scaling techniqu
evaluate the usefulness of the FIM requires that the evaluate the dimensionality of the FIM. They found
therapist decide for what specific purpose the FIM will be the 18 items do not cluster into one total score but sh
used. A clear understanding of your intended use of a be reported separately as motor (13 items) and cogn
measurement tool is critical to determining what form(s) of (5 items) activities. Using this formulation, the aut
reliability and validity you would be looking to find ad­ reported internal consistency estimates of 0.92 for m

reliability decreases (Adamovich . independence from those with high levels of indepen­ There are two major problem areas to be aware of in dence . some researchers report that when ratings task. . 1993. Chau et aI. (The procedures for determining their focus was on a self-report instrument. predriving assessments) . we can say that the The first point is highly relevant to the development of an FIM was able to detect change over time and across observational measure and is addressed next . using a variety of sources groups and should be interpreted cautiously. and congenital impairments on fully assess the FIM. clinical rehabilitation MEASURES therapists (with an average of 5.8 to 6. and Quite often an observational tool does not exist for the other factors. measure but relates more to the reliability of the measure. of validity related primarily to scale development and refinement (e. "tems generally do not vary much across different patient As was already mentioned. the set of behaviors involved in the task can be overly are done by those from different disciplines or by untrained complex. In these situations. is to break down the behavior into its component parts. as opposed to reporting redundancy. and a thorough on the motor activities and patients with right and bilateral review of all the relevant literature would be necessary to m oke. rately observe the behavior. This demonstrate that effective evaluation of measurement m plies that the FIM items do not fit well for these disability tools requires a sustained effort. the results from the face validity required assessment. which creates problems in being able to accu­ raters . the reliability data reported in the sources taken by the local facility to check the consistency among we reviewed seem to indicate that the FIM does produce therapists responsible for rating patient performance (see reliable interrater data. we have selected the evaluation of tended purpose.) mizing the problems inherent in observational data. and the authors of the pists need to be aware of the processes involved in Standards for Educational and Psychological Testing developing observational tools that are reliable and valid. (1 985) do not recognize face validity as a form of scale The general procedures to follow in instrument construc­ validation. 1993). 1986). . In fact. with the exception of pain and burn patients exists than has been referenced here. From a partial review of the literature. more literature about the FIM subgroups.. even this cursory review sug­ revision and item misfit across impairment groups was gests that observer agreement studies should be under­ needed. One way to avoid this problem 1994. Nunnally (1978). be more appropriately placed under instrument therapy literature by Benson and Clark (1982) . psychometricians such as Crocker and ments. if face "validity" is to be used . patients (Dodds et aI. or a locally developed "checklist" is study do not address whether the scale possesses content used (e . Granger et aI. The purpose of this assessment would scores can discriminate those with low levels of functional be to predict the person 's ability to safely live alone . measurement tools might take to assure appropriate use of The information provided in the grant under the heading measurement scores. From a validity perspective.. we wanted to see whether the FIM homemaking skills. 1992. However. While Often when a therapist is interested in making an the interrater agreement appears adequate from reports by observation of an individual's ability to perform a certain the test authors . This is but :wo internally consistent subscales: motor and cognitive one example of the kinds of responsible actions a user of activities.g.8 years of experi­ ence) rated the FIM items on ease of use.. In sum. Granger et not directly related to the development of an observational aI. 1990) . The second point is of rehabilitation patients (Dodds et aI.. and that the FIM is composed of section on reliability of observation measures). The intent here is to begin to :he cognitive activities (Heinemann et aI. Fricke et aI.~ique also indicated where specific items are in need of evidence. Several researchers reported the ability of complex behavior and 2) the fact that the observer can the FIM to discriminate levels of functional independence change the behavior being observed. We shall adjust the content validity of scores from an instrument were the procedures to consider the development of observa­ described previously under the section on validity of tional instruments that baSically involve avoiding or mini­ observational measures. brain dysfunction . In the face validity study conducted by DEVELOPMENT OF OBSERVATIONAL Hamilton and associates (1987). However. To In terms of construct validity of the FIM for our in­ illustrate this process. both conceptually and empirically. redundancy. It was necessary to consult journal articles for this using observational data: 1) attempting to study overly information . recent literature strongly suggests that the FIM may be This is directly analogous to being able to define the measuring several different dimensions of functional ability behavior.g. Therefore. prosthetiC checkouts or homemaking assess­ validity. . to which the authors refer as face validity.. items were rated by clinicians as to ease of e and apparent adequacy).. This relation­ . thera­ Algina (1986). although development procedures. The authors beyond the information provided by the test developer in 'ndicate that further study of the FIM in terms of item the test manual. The Rasch analysis indicated that the FIM the separate subscale scores. 1992). it tion have been discussed previously in the occupational would. questions have been raised about the appropri­ ~evision and that others could be eliminated due to ateness of using a total FIM score. 1993.

in the clinic. let us consider one should use descriptive or low-inference variable how conceptual and operational definitions are developed items.g. For instance. turns on clothes are typical behaviors that people must do to live stove). motor problems (e. a table of specifications is often used. and each must be detailed. Examples of high-inference v home. on some o how well a person would do at home. 1975.. Borg and Gall (1983) h to operationalize the trait at the empirical level (see the area suggested that to be able to observe the behavior relia below the dashed line in Figure 1-2). demonstrate safe use of the stove. Theories are used to explain cies?" Being able to respond to emergencies represen behavior and in this case are only useful if they can be series of behaviors. For each by the complexity of the behavior studied. p . a person may be safe in routine situations but behavior as speCified in the conceptual and operatio unable to respond to emergency situations..g. This point is addressed more in the section act unsafely. Each concep­ In thinking about the behavior units and dimension tual definition of a trait could in turn lead to different ways the behavior to be observed. and clean up after­ Borg and Gall (1983) have warned that high-infere ward. a behaviors. A tabl . or affective probl theoretical positions regarding our understanding of what (e. preparing three meals a Attridge's (1975) position on the level of inference is m day. These thoughts are then abstracted up to a more ables might be items such as " how well will t)1e per theoretical level where they are fit into a complex of respond to kitchen emergencies?" or more globally. then to produce reli tially several' 'behavior units" that comprise the behavior to observational data. safely obtain supplies. A broader definition whether the behavior has occurred or not. it is important to be able to havior if all behaviors related to emergency responses test a theory." tion. concerns. It should be recognized and timely response). To collect data regarding a particular evaluative variable requires an inference regarding the theory of behaVior.g. each act or task must be explicitly and sequen­ to the behavior being observed that high-inference tially described. How should the therapist rate the empirically verified. where the behaviors are more globa act of making a cup of instant coffee. the scope of safety issues can vary. lack of immediate recognition of prob was given above the dashed line. a great deal of attention must be g be observed. That is. or a person may not even be aware of safety training observers. A high-inference variable is one that involv therapist may feel that by observing a patient in the simple series of events. For instance. A person can verbalize safe procedures but tently. the balanced . based on patient sions a therapist may be called on to observe high-infere performances observed in the clinic. and washing clearly defined and easily observed (e. 252) have espoused a very strong posit covered by the behavior. an evaluative item might makes concrete what is implied in the conceptual defini­ " Rate how safe the person is likely to be living alone. such as when the person can dial 911 comes in. Therefore. moves that several conceptual definitions based on different slowly to respond to the emergency). cleaning.g . such as a fire on definitions. p. Further. therapists may be aware that A descriptive or low-inference variable is one that can meal p'lanning and preparation. at which the actual difficult to reliably observe are evaluative variables. If it is essen dimension. and a theory regarding the behavior of well does the individual respond to household emerg interest begins to be formed. First. plus the therapist must make a judgment about behavior to be studied.18 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY ship was iHustrated in Figures 1-1 and 1-2.. the concept of kitchen safety might be only does this type of item or variable require an inferen operationalized as the person 's ability to verbalize kitchen but the therapist must make a qualitative judgment to safety concerns. An operational definition then behavior as welL For example. and evaluative variables often lead to less-reliable obse The conceptual definition of the behavior is important tions. For instance. Medley and M because it attempts to define the boundary of the domain (1963. a narrow definition stating that the observer should use the least amoun of kitchen safety might be operationalized as the ability to judgment possible. in which a the stove. functional independence means could exist. the to training observers to be able to " see" and then rate concept of' 'kitchen safety" can include cognitive as well as high-inference and evaluative types of variables con motor aspects. calling for the level of inference that is deman domain may consist of one or more dimensions. a prediction could be where the therapist must draw a conclusion about the made about that person's safety in preparing meals at havior being observed." (Herbert & Attridge. we must operationally define the havior. and cleaning up after meal preparation. which is where the operational definition not successful. within each dimension are poten­ evaluative variables are necessary. data are collected . In general. "observer inference refers to the deg for the behavior to be observed. "H behavior patterns. only a judgment "needed to perc safely heat meals in a microwave. For example. . This lack of safety can be due to cogni conceptual definition of the trait fu nctiona J independence problems (e. Therapists often have to make predictions about therapy are of the low-inference variety. For To organize the behavior units and dimensions of instance. Also." Herbert would include obtaining groceries. A conceptual or theoretical of observer judgement intervening between the actual d definition begins most often with unsystematic observa­ observed and the subsequent coding of that data on ob tions or hunches about a particular behavior from working vational instruments. and spond to the item. To test a theory we must move from the cannot describe what to do next for a fire? Even m conceptual level to the empirical 'level. does not care about safety). While many behaviors in occupational or phys alone. For instance. prepare food. To counter this reliability problem.

g. defined and involves low-inference behaviors . instructions on how to and behavior units that were operationally defined. validate this hierarchy. The Rasch measurement models It may be important to have several high-inference or (Fischer. the amount of response that the observer marks on the FIM (7 = com­ variance increases. as shown in Table 1-6. the FIM motor and cognitive items could be suggest that most human observations cannot be reliably hierarchically ordered such that an individual can be placed rated on a continuum with more than five points. The observational form is used to Often the items on the observational form are arranged record or score the behavior. That is.. the first row-by-column high-inference and evaluative items. such as the level of complexity of is suffiCiently described to be able to rate it. In addition. "verbalize safety and cognitive. The number of items have been included . Once the form has been suffiCiently field tested. the increase in variance and .· inference and evaluative items. 1993) are procedures that are currently being evaluation items.CJe 10%/2 of the construct of kitchen safety. the number of dimensions easy the form is to use. determine whether each behavior unit de pends on many factors. the table of specifications Verbalize Obtain Prepare Clean again is used in classifying the instrument's items by a panel Safety Supplies Food Up of experts. Once the behavior to be observed has been fully defined b oth theoretically and operationally) and the number of Rasch Scaling Procedures irems has been decided on. a ordering of items in turn allows the ordering of individuals three-point scale is easier to use and produces more reliable in terms of their ability on the trait being measured . when the observational form is developed. For . Any amount of time available to observe the behavior. followed by actual intersection of the rows and columns. Rasch measurement models are . If each behavior is well and off a chair is easier than gettting in and out of a bathtub . to measure objectively. Assuming we wanted to keep the agree with Borg and Gall that using three to five observa­ :001 brief. then it is just a matter easier than others. It is common to use experts 35 resources in identifying the degree of importance of each error variance than systematic variance. and assess how :he behavior to be measured. This have fewer categories to record the behavior. many therapists would suggest that getting on items. e.specifications guides instrument construction to ensure TABLE I 5 that 1) all dimensions and behavior units are considered and 2) a sufficient number of items is written to cover each EXAMPLE OF TABLE OF SPECIFICATIONS dimension. An example of a table of specifications is shown in Table CognitiCJe 10%/2 10%/2 15%/3 5%/1 1-5 for measuring the behavior of kitchen safety. or four items). we would make a number of items. Therefore . scale of measurement. For example. we might start by limiting ourselves to 20 items tion points per item should be sufficient to rate most :otal. Rasch scaling converts the ordinal pOints (aU other factors held constant). or wo items) then the important to field test the instrument. one can opt to rank order the items on a scale from easiest to hardest. it is important to be able to ' e quite easy to use. and the use the form should be developed and field tested. the column headings indicate important components Ajject. and then apportion them. the . scaling procedures that permit a test developer to the high." we show as being Finally . That is. Later. based on our predeter­ behaviors and improves the reliability of the observations of mined percentages. revisions to the form or instructions should be made and field tested again to see how the revisions work. To increase the level of reliability for in part. ::ell . which then become the instance. Field testing (or pilot second row-by-column cell. More importantly. The rows reflect different dimensions of each of these behavior units. Interval measurements have more reliability may be spuriously inflated and represent more desirable properties than ordinal measurements .)f transferring those descriptions. In the Sensorimotor 20%/4 20%/4 10%/2 ble. For ratings than a seven-point scale. At each Percentage indicates percent o f items allocated per cell. Borg and Gall (1983) example. it is somewhat less important (10%. we then turn to the The Observational Form training of observers to use the form. to the observational form. or some behaviors precede others. if content validation is required for the FOR KITCHEN SAFElY* TYpe of test score interpretation. While it on a continuum from less independent to more indepen­ is a well-known fact that if you increase the observation dent. However. "obtain supplies and sen­ testing) allows one to be sure all aspects of the behavior sorimotor" (20%. the next step is to produce the observational form. It should be obvious that these items require a tional therapy that have the potential to validate hierarchi­ higher level of observation skill and are much more difficult cally based assessments. the form can From a theoretical perspective. such as those shown in the lower part of used in the development of assessment tools in occupa­ Table 1-6. If each behavior unit under hierarchically. hence. iudgment about the relative importance of this cell and the number of items to be included. which in turn increases the reliability of plete independence to 1 = total assistance) to an interval a scale. A blank cell indicates that the component/dimension represented by that cell is not re levant. we art of the assessment. some behaviors are presumed to be each dimension has been described .

using traditional items analysis. The Rasch procedures. This distinction might be made technique. While it is possible scores expressed in terms of interval measurements. the item even more tenuous when we consider that the assumption appears difficult. once scaled. convert the ordinal data into interval data development of a motor scale. 1988. The result is item difficulty values and person ability set of items used. Consider longer sample dependent. Recall that sample dependency was one of a 5 (strongly agree) and then for item 2 select response the problems with the classically based procedures. is independent from the group used 5 likert-type response format. Another deSirable property through a logistic transformation based on the proportion of Rasch scaling is that the individual's scores obtained of persons with a given item score (Andrich. Fischer across individuals as well. on the (1993) provides a nice illustration of this issue in her other hand. from the measurement are also independent in terms of the 1993). more typical . Fischer. to add up the rankings from ordinal measurements . The validity of this assumption becomes otber hand. if the item is given to a less able group. For 4 (agree). it Typically. the level of difficulty for your response to a self-report attitude measure with a 1 to an item . ordinal measurement. EXAMPLE OF LOW· AND mGH·INFERENCE ITEMS FROM KITCHEN SAFElY ASSESSMENT Requires Some Cuing or Completes Physical Unable to Low-Inference Items Independently Assistance Perform Patient writes out a menu for the day Patient obtains supplies for sandwich Patient puts meat on bread High-Inference Items Patient plans nutritious meals Patient routinely uses safe practices Patient can locate supplies for meals High-Inference and Evaluation Items Patient plans nutritious meals of high quality Patient has adequate endurance to perform daily cooking tasks Patient is well motivated to use safety practices separate item scores are now additive. The assumption of interval measurement we are example. situation. That is. If the same item is move one unit's distance in intensity when going from a given to a more able group. Clearly it is not a very desirable property is assumed to hold not just for an individual's responses but for an item's difficulty value to "bounce" around. For item 1 you might select for the scaling. item difficulties are expressed as the proportion should be pointed out that an assumption is being made of individuals passing an item. these distances are not equal but reflect different In addition to the interval properties of the Rasch scaling distances for each observer. the item appears easy. Typically. on the response of 4 to 5. where a proportion is an that the distance between each scale point is equal. the difficulty of an making when these two responses are summed is that we item is dependent on the group tested. the items subjected to a Rasch analysis are no clear by the following.20 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY TABLE 1 (. What is meant here is that a person's .

replay. such as observer effects. as noted and whether it matches with the criterion.ability score can be estimated from any set of items that determine how accurate the tool is in assessing true score. This can be done by either having The research on observer training has shown that the criterion rater jointly rate the individual along with the serious attention to this step in the process helps to ensure rater(s) being studied or videotape the rater(s) being studied reliable data (Spool. In the opposed to the classical procedures referred to earlier in training of observers. Fischer (1993) illustrates the use of the many­ When the observers are trained to an adequate level to faceted Rasch model. in observational criterion rater to make the rating that is required for the data. We do not want [hat is most appropriate for the individual and not frustrate the observers rating the behavior they "think" should be him or her with a set of items that is either too difficult or rated but the behaviors on which the observational form too easy. In fact. started. compared with the tradi­ considered more often with instruments used in practice. The assumptions consider that an be stopped. The training session then can run segments of the The Rasch model is a model from a larger class of models videotape. then the training should be moved to an are locally independent. challenge of the task performed were considered in then the process of gathering reliability data should be addition to item difficulty and person ability. verified. brief. We set of items. tional format of everyone receiving the same set of items. as did the variance component proce­ currently being trained and could be used in later training dures described in the section on reliability of observational efforts as well. are that the trait being measured is unidimensional. it is very take the same set of items or the same number of items. One feature that distinguishes modern test established. important that the theoretical and operational definition of This really frees up the examiner to select the set of items the behavior to be observed is made clear. 1978). vhat assessment should be like. then a person's score on a scale is only a function The observers should not be practicing on patients for of his or her ability and the difficulty level of the item. it is critical to reevaluate the reliability of the observers periodically. once the observers are so that the criterion rater can also rate the same behavior. we can begin to collect reliability data to These types of checks on the reliability of the observers . such as when treatment is needed over a long period or in a longitudinal research Training Observers study. not every individual has to In the initial process of training observers. If these assumptions can be the observational form and the accuracy of the observers. whom actual data are required. and the objective is for the therapists in training to [he model are directly testable. other sources of variation are introduced into the patient and the observers being trained to likewise rate measurement. It is highly desirable to have available videotapes of the Thus . then the videotape can equations 1-1 and 1-2. and the items satisfactory level. :-eferred to as item response theory models. Being able to show instrument and that: 1) the mean of their error score is zero the persons being trained exactly what behavior is repre­ llle = 0]. the for classkal test theory are not. In this way. it could be argued that administering a certainly agree with their suggestion. It may be possible for the As pointed out earlier in the chapter. whereas the assumptions produce the ratings that the trainer made. and 3) the correlation between an individual's their understanding of the behavior and hence the reliability [rue score and his or her error scores is zero [Pte = 0]. If Rasch model allows other sources of test score variation to possible. This should also be '. the Once the training using videotapes has reached a items used have equal discrimination power. The many-faceted the behavior and then compare the results after the fact. especially if the subset of items targeted to the individual's ability is more observation is part of a research study. If therapists in classical test theory involve the error term shown in training do not match the criterion. Once the items have been Rasch scaled. have been Rasch scaled. videotaping these actual settings benefit those be accounted for. Rasch scaling permits sample-free and test-free behavior to be observed for the therapist to study and measurement. Borg and Gall (1983) administering all the items to each examinee. Usually. Usually. the was developed. in which rater severity and the use the instrument in the setting in which it was designed. Local independence refers to the actual site in which the behavior can be observed. In fact. the point of providing training The assumptions made in using the Rasch procedures for observers is to ensure the reliability of the data. sufficiently trained. One final point on the training of observers: If rating takes place over time. This fact that responses to one item do not influence the enables a more realistic training arena in which to try out responses to another item. concise definitions are observer or examiner does not need to be concerned with provided and discussed for clarity. it is critical that a criterion be this chapter.) of their observations. Item response then stop the tape for discussion of what behavior was theory models form the basis of modern test theory. and the behavior that was missed or mis­ individual is tested an infinite number of times on a given marked can be discussed and corrected. Thus. 2) the correlation between the error scores is zero sented by the item on the observational form improves IPee = 0]. a subset can have suggested that testing the observers at this point on just as efficiently measure his or her "true" score as the full their understanding of the behavior may be helpful. (The assumptions for reliability of the raters can be assessed. have the therapist use the observational form. Thus. measures. the criterion is the ratings made by the [heory from classical test theory is that the assumptions of trainer.

like the FIM comprising three Content dimensions (and therefore three scores) and not one. a manager at the treat­ and various forms of standard scores. percentiles. all therapists are trained in using the tool. Before addressing the need for local norms and how to To develop local normative data. admin­ the individuals who were tested during standardization of istering it in the same time frame. For Develop table of specifications example. attention should be paid to OBSERVATIONAL MEAS how relevant. While percentiles are useful in that most combined and summarized . the youngest age represented Devel op observation form is 16 . and scoring it in the same the scale. a differences in outcomes associated with different lengths of . For example. a person's raw score When data are collected in a systematic standardized can be converted to a percentile and to a T-score for fashion . parison of the type of individuals seen at the facility to the commercial norms. they are not appropriate for rized by reporting means. For help to prevent " rater drift" (Borg & Gall. T-scores.22 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY TAB LL 1 7 thorough description of the individuals in the norm group is essential for score interpretation. Train observers to use form were appropriate percentages of ages . collection of local norms would enable a com­ tional measure is given in Table 1-7. many tools used in practice do not OBSERVATIONALMEASURES have normative data. statistical analyses. standard deviations. standard deviations. if a commercially developed tool is used fre­ ensure the reliability of the observationaj data . then Variance components proced ures Rasch-based procedures recency of norms is not an issue. individual's score. then Criterion referenced Construct normative data on the FIM would have to be recollected to Assess any ethical issues ensure adequate interpretation of the three new scores. However. and recent the norm group Develop conceptual definition of behavior to be observed is. the norms will not be relevant..g. some form of standard score could be Rather. By compiling data on the tool over time . For many commercially available measurement manner. The summarized data ment facility might want to see what the "average " intake then are reported as norms in the manual accompanying score is on the patients who have a diagnosis of head injury the test. therefore. From the descriptive statistics. and their "average" exit scores. a treatment facility might want to develop local norms . therefore . standard deviation is 10). where the mean is set at 50 and the specific set of gUidelines for administration and scoring. norms are just the summarized data for the sample used. Norms should not be confused with standards. means. OVERVIEW OF STEPS IN DEVELOPING In describing the norm group. the data collected on the tools. Relevant refers to whether the norm group has similar Develop operational definitions of behaviors to be obselved characteristics to those of individuals to be evaluated. Under these conditions.. such as the change. In this way . averaged . if our under­ Assess validity appropriate to purpose standing of the trait changes. If the normative data Assess reliability appropriate to purpose are a few years old and no changes have occurred in our Classical procedures understanding of the trait or behavior being tested . In some' cases. Percentiles should not be which are predetermined levels used to make decisions . if your practice involves mostly children and you Percentage weights of relative behaviors within domain Number of items see that in the norm group. and ethnic Assess rater agreement groups included? Finally. the scores for all the individuals tested can be comparison. it might be useful to consider the topic of the measurement tool is used in a standardized manner. Additionally. Standardized can be computed to use in comparing individual scores means that the measurement has been taken under a (e. Representative refers Pilot to whether the population was sampled in a way that Define and repilot as needed Finalize form adequately reflects your patients or clients . the norms can could look at cost-to-benefit relationships. compiling local norms would help in clinical decision-making. one must be sure that gather them . An overview quently by the facility for which normative data are already of the steps we have presented in developing an observa­ available . Norms refer to the scores obtained from that is. normative data have already been collected and tool at the facility can be combined and basic descriptive summarized in the test manual for use in evaluating an statistics computed (e . These types of tools are more commonly percentiles) .g. norms in general. genders. Unintended effects of measurement Normative data are very useful for therapists to compare Social consequences an individual 's level of functioning with the typical expec­ tations for an unimpaired person . Given that norms are sample dependent. 1983) and instance. recency of norms refers to when Intrarater Interrater the normative data were gathered. standard scores referred to as standardized measurements. The data are typically summa­ people can understand them. One might find differences in the characteristics of individuals served by your own facility and the sample that was used to develop the norms in the test DEVELOPING LOCAL NORMS FOR manual. the manager tested. representative. For example. If a different sample is tested.

The Interplay Between Design and ments necessarily result in disability. Sage University Paper Series on Quantitative Applications in the Social Sciences. Educational research: An introduction it becomes important to raise and openly discuss these (4th ed. New York: Wiley. Pitfalls in functional assessment: A That is. This chapter began with a conceptual overview of the Reliability coefficient-An expression of how accu­ two primary issues in measurement theory. -­ .State University of New York . careful test Andrich. We are reminded of the seminal work of ments take a c-ID. Local norms-Normative data collected at a specific facility or site. Inter-rater Attenuated-Measurement error has influenced the agreement of two functional independence scales: The Functional result. e. Since no "statistically Data Analysis in the Measurement of Coping.. Buffalo.). 2(4) ..?­ human beings. managers to make comparisons of individuals or groups of individuals at their facility. individual's true score. A guide for instrument development and quences of testing . 1990). Finally. (1959). score interpretation is called for. Research. concerns in a variety of forums. (1983). R.eaning. the social consequences of that test score. 42-51. 'Center for Functio nal A ssessment Research. Messick (1989). M . Ender based approaches " exist to evaluate the value implications (Eds. we -_. responsible Brennan . we must be careful that the label of the tool does not take REFERENCES on more meaning than the validity evidence can support. Psychological Bulletin . (1982). J" & H agtvet. & Fiske . R. & Gall . & Posavac. E. (1992). Disability and Re habilitation. stantly be aware of the potential and actual social conse­ Benson. (1983). 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SUMMARY AND CONCLUSIONS Observer presence-When the presence of the ob­ server alters the behavior of the individual being tested . the Nomological network-A representation of how dif­ need for such information has been an important motivator ferent constructs are interrelated. Borg.. K. N" Daler. Thus. In fact . F. not two . -= . (1978). stay. Guide for the use of the uniform data set for medical rehabilitation including the functional independence measure (FIM) version 3. 63-71. American Journal of Occupa­ tional Therapy . testing requires that the measurement community under­ Campbell . Elements of generalizability theory. focused much of the chapter around the issues therapists when the statistic of interest fluctuates from sample to need to be familiar with in making observational measure­ sample and b) psychometriC. New York: Longman. by the multitrait-multimethod matrix. functional independence have value implications that may Neurore habilitation. 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U NI T TW O Compo ent Assessments of the A ult . .. -. --=-.-.. .-..


27 . Strength measurements are used for diagnos­ tic and prognostic purposes. It is essential that the relationship between the patient's problems with function and clinical tests of muscle strength is established. Manual muscle tests (MMTs) without instrumentation have a long history of clinical use but have been subjected to little scientific scrutiny. rather than in healthy individuals. physiologic. al­ though this depends on the conditions of testing. PT. it is not universally used for the same measurement. 2 Maureen J'. Strength may be used when muscle torque. A myriad of anatomic. Changes in strength are also used to assess changes in a patient's condition and to determine the effectiveness of exercise programs. The devices are mechanically re­ liable and are reasonably reliable in measuring the forces exerted by muscles. . Most reliability studies have been conducted on normal. Although strength is a frequently used term. The validity of muscle strength tests as diagnostic or prognostic tools has not been established. Clinical assessment of muscle strength involves measuring the force exerted against an external force or resistance. or work would be a more appropriate term. Isokinetic and isoinertial devices are now frequently used to assess muscle performance in static and dynamic modes. --. power. -~-~ . Instrumented MMTs with hand-held dynamometry improve the reliability and responsiveness of testing muscle strength but are also limited by the strength of the examiner. psychological. force. MMTs are limited by the strength of the examiner and are of limited value because of their unproven reliability and lack of responsiveness. biomechanical. Knowledge of these factors is important if tests of muscle strength are to be carried out and interpreted in a meaningful manner. MCSP. pathologic and other factors contribute to muscle performance. Muscle strength tests are in frequent use despite the paucity of information about the reliability of strength tests in populations for whom the test is deSigned. Simmonds. They appear to have face validity for measuring the force exerted by a muscle. This force may include the effect of gravity and that exerted by a therapist or a muscle testing device. healthy individuals. PhD SUMMARY One of the most frequent physical assessment tests used in rehabilita­ tion is the testing of muscle strength. The validity of muscle strength tests has not been tested.

work. it is necessary to discuss strength testing in a precisely the force generated by a muscle or a gro muscles. measures of impairment rather than function. Kin-Com (Chattecx Corp. those with brain injury (Riddle et aI. muscle function is motion.. Measurements patients with central nervous system problems. and electromyographic activity of individually or as a group.. forces. the task.. categorized as isokinetic. Thus. 28 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT . have a specific action on a muscle to better understand the physiologic bases of Based on this premise and utilizing the effects of gravi muscle function and to determine the relationship between manual resistance provided by the therapist as ex static and dynamic strength tests and functional activities. Hillsborough.. but what do we Thus.e.. The biologic subsystems include sensory. motor. biochemistry. Grading of m function is the product of a myriad of contributing sub­ strength is then based on the arc of movement produ systems. These devices provide quantitative manual resistance by the therapist.t~_~_.. The (Isotechnologies. Strength tests are also used to determine the extent of The bases of MMTs are simple and essentially strength loss by comparing the results of strength tests anatomic and· biomechanical principles. inc of static and dynamic muscle performance (torque output... especially in regard status over time. Early 1ST devices consisted of cable tensiom strain gauges.. these tests have been use exercise programs or some other therapy.. Muscle joint through a specific range of motion. sensitive. fatigue. Han dynamometers (HHDs) are in regular clinical use a comprehensive manner. what is known about the factors that influence the test? To address these and other questions. 1993). The muscle or tendon is palpated by the the influenced by the environment. 1985). i. or power) can be related to the histochem­ Fundamental to MMT is the notion that muscles. such as manual muscle tests (MMTs). the purpose of this chapter discussed later in this chapter. substitution of muscle activity is responsible for the sp Many different techniques purport to measure strength. valid. constant resistance. They can provide inf are._ _ __ (Lamb. NC) back t MANUAL MUSCLE TESTS device is an example of an isoinertial device that me Early clinical tests of muscle strength involved the use of trunk strength.. 1986. The prin ments are used in clinical practice for diagnostic purposes. Such devices c testing. Is one method of testing better or more reliable than the other? Although the criteria for grading muscle streng What do these tests tell us? Do either of these methods of quite specific.~ OVERVIEW OF MUSCLE STRENGTH scientific scrutiny. and still mation about muscle function.. Kendall et aL. istry. and In addition. Strength measure­ Worthingham. an orthopedic surgeon (Danie component of a physical assessment.. and others use complex equipment and computerized INSTRUMEMTED TESTS OF MUSCLE STRENGTH technology and provide a plethora of information. The results of strength tests can be the muscle or peripheral neural systems (Daniel used to describe a population and examine the effects of Worthingham. considered useful diagnostic and prognostic tests tion about muscle strength.. Chattan Historical Perspective of TN). power. although to examine the improvement or deterioration of a patient's modifications have been made. In addition. endurance.r~~. and Udo (Loredan Biomedical Inc. and as a predictive or prognostic tooL grading system used. or ertial. The Cybex II (Lume Bay Shore._IWM?*~ ~ _~ ~ ~~. manual grading does not provide qu testing have anything to do with function? Clinicians and tive data about the force or torque generated by the m researchers test muscle strength regularly. the muscle and the amount of external resistance and cognitive systems. 1986). Inc. or hand-held load cells that measure metric strength at some point in the range. i. movement tested. and specific? Have the tests been tested? If so. is to critically review the theoretical and practical bases of The second generation of 1ST devices were thos muscle strength and the clinical methods of muscle strength measured dynamic muscle strength. Thus.e. although they have been subjected t ""~. C examples of isokinetic devices that can be used to m Strength Tests muscle strength in the limbs or the trunk. Some are very simple. strength tests are used in clinical research as their use is most common for persons with disord outcome measures. and . 1989). The initial development and doc tation of MMTs occurred about 80 years ago an The measurement of muscle strength is a fundamental attributed to Lovett. DaviS. NY).. the between opposite limbs or against normative data. of MMT have changed little since that time. constant velocity. and the time and to ensure that the muscle of interest is contracting a effort required to complete the task. The tests were. instrumented strength testing (1ST) was deve really know about the psychometric characteristics of the Instrumented strength testing allows one to quantify I tests in common clinical use? Are the tests reliable. __. a patient is positioned in such a way that one m The major function of the muscular system is to stabilize or group of muscles is primarily responsible for mo and support the body and allow movement to occur. under what conditions? Finally.

the strength of one state of affairs. Conversely. Another measurement term is power. For example. . of the technology. indicative of the imprecise use of the word. but strength may also be expressed measure (Johnston et aI. An isotonic contraction is c Scores are reliable but not valid when the internal force generated by a muscle results in d Scores are valid but not reliable movement of a joint. Face validity is the lowe unit time. a fact that is presented. It is th Quantified strength values may be reported in absolute degree to which the measurement corresponds to the tru terms or in relative values. it commonly used term in lay usage. Reliability of measures is importan an isometric or isotonic contraction. It is the degree to which a force tends to rotate measure is not useful if it does not measure what it an object about a specified fulcrum. The types of validity in most frequent use include fac . It occurs when the internal force produced b the muscle exceeds the external force of resistance. The agonist-to-antagonist ratio is evidence that supports logical inferences made from th most frequently used. Thes strength is defined as muscular force or power. These terms apply to all types of muscle qs. The temporal factor indicates that the muscle is working over a period of time. to successful marketing. but clearly the muscle does change shape a Scores are both reliable and valid and the protein filaments within the muscle certainly b Scores are neither reliable nor valid shorten (Gordon et aI. Validity is the accuracy of the measurement. Some fundamental prinCiples are now brief many different ways of determining strength. It is the most important consideration whe muscle group may be expressed as a ratio with the torque selecting a test. 1992). and criterion validity. Torque is a more but it is not the only criterion to be considered. A concentric contraction is a shortenin contraction. Thus. or between-tester reliability). in part. but no movement of a joint occurs. A dictionary Reliability is the degree to which repeated measur definition of strength highlights the problem. it is a less ambiguous term than strength. An isometric contraction is when the muscle generates an internal force or tenSion. Fatigue is described as either the amount of power that is lost or that which is maintained. They base their argument on Measurement principles are discussed in depth elsewhe the fact that reported tests of muscle strength have utilized in this book. Endur­ bb b ance is the ability to maintain torque over a period of time b b or a set number of contractions. yet this is clearly not the case. If the measure misses the target. Muscular ments of a stable phenomenon fall closely together. A reliab precise term. Again. fatigue is the inability to maintain torque over a period of time or a set number of contractions. the time may be the total duration of b b a purposefully fatigue-inducing endurance activity. The notion of reliability is illu measure of the maximal force or torque required to resist trated in Figure 2-1.. This time period may be b b long or short. Devices that measure th Strength is defined as the force or torque produced by a same phenomenon may also be compared (concurren muscle during a maximal voluntary contraction.. A measure is validated by accumulatin of another muscle group.has advanced and moved ahead of the scientific evaluation the motion. It means Graphic representation of the concepts of reliability and validity constant length. Yet these measurements can be taken by the same person (intra test are different terms with different meanings. One example of such a period is the time b taken by the muscle to move a limb through a range of b motion. Alternatively. Isotonic contractions are further described as concentr and eccentric. in terms of body weight. due. It is therefore or within-tester reliability) or by different testers (intertest imperative that operational definitions are used. nonscientific term that needs to be operationally urement as well as the principles of muscle activity defined if it is to be of value. Cogent discussion of the measurement of muscle pe Mayhew and Rothstein (1985) have noted that strength formance requires consideration of the principles of mea is a vague. a 30% loss of power is eqUivalent to the maintenance cc c cc c of 70% of power. The term isometric is a misnomer. Graphic representation of reliability and validity. 1966). A Terms and Issues Related to Strength eccentric contraction is one in which the muscle lengthen Testing and Measurement while it continues to maintain tension. It is a parallel-forms reliability). Power is work per construct. the term isotonic is a FIGURE 2-1.c contractions. which may explain why not a true or valid measure. Torque is not a supposed to measure.

. parallel. forces would be smaller in a series- not only the magnitude of force that the muscle can muscle. not in series. 1995). Based on the work of several researchers. Passive tension of a measurements may change within a testing session due to contributes to the total tension that a muscle gen fatigue or discomfort. finally. and fiber type. the larger is the m units are recruited next and. within than between observers but may differ depending on At the macro muscle level. ment of muscle strength. such as soleus (Edgerton et ai. Elastic energy can be stored and tension. both store energy and redirect force. However. the phenotype. In addition. 1992).e.30 UNIT TWQ-COMPONENT ASSESSMENTS OF THE ADULT level of validity. 1995).. aponeuroses and tend the test. less variability occurs within than muscle performance include the arrangement of between observers. 1989). Thus. and muscle performance that is formed into kinetic energy (Soderberg. intervening tension earlier in the range than longer muscles. Another 1995. Zhu et ai. then the capacity of the motor unit to d 1991).. but which are appears to measure what it is supposed to measure. Criterion validity concerns the extent or injury conditions. 198 and the duration for which it can be maintained. this loss can be r property that any clinical measurement tool needs is re­ with training at maximal or submaximal effort (Riss sponsiveness or sensitivity to change. The endurance performance of a muscle is influe Variability and error are factors in all measurements. and percen measurements.g. thus improv The subject can be a source of variability. being measured. 1986. T activities. spread of power output over a large area. th but generate the least force. A a number of factors. The FFR (fast fatigue-resistant) the muscle's cross-sectional area. a myriad of biologic Another factor that influences muscle perform and motivational characteristics contribute to the muscle elastic energy. and playa role in the muscles' ability to generate fo The observer is another source of variability in a test cause movement.or underestimate the Biomechanical factors are also important in measurement. These factors are now discussed. includ The device may be reliable. however.. Responsiveness is aI. This is one reason why devices such as an function. The amount of contractile force that a muscle can force is hindered. The morphologic characteristic number of sources contribute to the variability of test muscle. Muscle Strength At the micro level. i. The variability may be more systematic fibers and the angle of pull of the muscle. endurance or limit fatigue. At the most basic level. the fibers s are in agreement with the theoretical construct of that by each motor neuron are homogenous. and other stresses. Rissane regarded as a "gold standard" of measurement. the generation of force is inf by the arrangement of muscle fibers (Trotter et ai. All other factors being equal. These factors are linked to anatomic st HHD are not necessarily interchangeable. The recruitment of a larger muscle mass a The measurement device may be a source of variability. the ability of a test to measure clinically important change. They may change between sessions Shorter muscles have relatively high levels of depending on the stability of the condition. re to which the measur. its length and developed by a motor unit is related to the sum of cross-sectional area. contributes to the differences in length-tension r Psychometric factors obViously influence the measure­ ships between muscles. Con­ to fatigue. but with different motor neuron. Sod The amount of force generated by a muscle is controlled (1992) has illustrated how muscles with the same through the recruitment order and the firing rate of the angle of pull. capilliary density..Is related to other measures that are selective atrophy of FF (Mattila et al. Cytoarchitectural factors that in measurement. These factors influence other. low back problems. Strength efficiency of muscle action. therefore. movement and force are If the fibers of the motor unit are in series rath produced by the contraction of the sarcomeres (Ghez.. such as sartorious. Generally. Within this same muscl . in that under the same recruitment of different muscles. Some pat which is measured. compared with a musc generate but also how quickly that force can be generated parallel fibers. muscle strength. The weakest input controls that they can generate and the velocity with which th the SF (slow fatigable) fibers. generated by fibers lying in parallel. Applic a stretch prior to a measurement can increase the a Biologic Factors Influencing of force generated by the muscle. This is because the total force that produce depends on its absolute size. all potentially e conditions it always provides a similar reading. it needs to be measured. Motor units are recruited in a fixed order sectional areas and length differ in the magnitude o from weakest to strongest. the device may systematically over. and the vascularity of the muscle. Knowledge of the sources of variability is SF fibers are all related to efficiency of activity necessary for appropriate interpretation of test results. the cytoarchitecture. tension and elastic energy are important becau influence measurements of muscle strength. the FF (fast fatigable) force-generation capacity. which are resistant to fatigue generate this force. However. A measure has face validity if it simply units which can exert the most force. e. muscles are composed o struct validity is the degree to which the scores obtained different types of motor fibers. In humans. muscle mass.

in measures of muscle strength. The magnitude of force generated iso­ fear of injury can influence the performance of the perso metrically is lower than that generated eccentrically but being tested. 1995. test sessions and over time. This notion is reasonable and true for grou as one of true strength. problematiC. this is not true. 1995a. a review of pain mecha­ than physiologic factors (Harris and Rollman. this rela­ 1993) tionship holds true only for concentric contractions. measures of pai nents. PAIN AND MUSCLE PERFORMANCE DEMOGRAPHIC FACTORS INFLUENCING MUSCLE STRENGTH Perhaps one of the most important but least studied factors that influences muscle performance is the presence Conventional wisdom suggests that females are weake of pain. However. then. characterized by even greater variability. Furthermore. is an isometric test of muscle strength the best notion is flawed from a theoretical perspective because way to test a muscle whose primary function is one that assumes that pain mechanisms are stable and that a simpl involves rapid motion? Also. Some of the functional implications. in Endurance is associated with the ability to tolerate discom measuring the muscle strength of patients that have had. No empirica about their functional ability. Endurance measures ar In truth. 1986). Newto Pain has been oversimplified. Kumar et aI. pain and injury are not always well correlated. 1995b. A few erroneous ods of testing. th For instance. Essentially. higher forces nerve endings directly and indirectly (Coderre et a are associated with slower velocities. tissue reported that differences in measures of muscle strengt injury and pain are related. None of these assumptions are cor function in a coordinated pattern of activity. Backman and collegues (1995 beliefs about pain exist: 1) in the acute pain state. Although some worker endurant muscles. lower forces are 3. In Several authors have reported that the strength of female such cases. but pain is multidimensional and has cognitive tribute to the high variability in endurance performance and affective dimensions as well as physiologic compo­ which is a test of tolerance. Certainly. is that the pain literature is that a large range of individual variability exist is psychological or at least exaggerated. isolated tests of individual relationship exists between pain and motion or pain an muscles may not give much indication of their ability to muscle contraction. Pain and the fear of pain and injury influence the than males and older individuals are weaker than younge measure of muscle strength. an unconscious level. which is why it has et ai. Unfortunately. evidence supports this biased opinion. The assumption. It also seems obvious that have suggested that strength testing can provide evidenc the method of testing muscles should provide information of pain and malingering. clinicians and researchers should be aware Significant losses in maximal force production occur wit that: aging. But testing of muscle strength is weight. 1993a). It is possible tha Nociceptive activity contributes to the physiologic dimen­ psychosocial factors. 1973). One fact that is evident from th the pain to persist.. This influence can be at both a conscious an higher than that generated concentrically (Komi.greater the velocity with which the peak force can be 2. although substantial variability can be seen in th . and th higher velocities. biochemical mediators that are both neurogenic an The force-velocity relationships of a muscle are also nonneurogenic in origin important considerations. 1983) nisms is beyond the scope of this chapter. Even the physiologic component of pain has been tolerance are strongly influenced by psychOSOcial rathe oversimplified. are obvious. health status. However. Ec­ centric contractions are associated with higher forces at The presence of pain. Kumar et aI. Simplistic interpretations abou The physical factors discussed above are doubtless related a patient's "real pain" or lack of effort during muscl to function. However. the influence of pain on the measure of muscle is about 60 to 70 percent that of males (Backman et aI strength has to recognized. or fort and pain. both durin muscle can exert and the duration for which it can do so. This is not always the case. 1992). Tissue injury leads to the release of a cascade o achieved (Soderberg. rect. This appears to be true across differen remained enigmatic. and usual activity level are controlled done and needs to be done in patients with chronic pain. Research is needed to examine th It is clear that many factors influence the force that a effect of pain on measures of muscle strength. con sion of pain. Conversely.. do have pain. The presence of pain during comparisons of young versus old or male versus female bu an MMT is cause to discontinue the test (Daniels and only as long as confounding variables such as heigh Worthingham. the anticipation of pain. between genders almost disappeared when the subjects the tissue has healed and no physiologic reason exists for weight was considered. These biochemical mediators sensitize nociceptiv associated with faster velocities. and 2) in the chronic pain state. including motivational factors. This invalidates the measure individuals. and a frequent cause of muscle groups and for both isometric and dynamic meth frustration for patient and clinician alike. such as strength testing should be recognized as a reflection of th the preponderance of SO (slow oxidative) muscle fibers in personal biases of the clinician.

1993). strength testing conditions should be focused on the 1986). clinically. Estlander are subject to misinterpretation. cross~sectional area alone (Vandervoort and McComas. these changes can be contribute to muscle strength and that assessme reversed through training of sufficient intensity and dura­ muscle strength is more than a mere test of the m tion. the physiologic and psychosocial impact of an injury or disease enhances this individual variability. the in muscle strength and an increase in muscle torque due to should provide objective. clear from this overview section that many factors co Thus. The contributory role of therapists involved in physical rehabilitation is to learning must be considered when strength tests are patients in attaining their optimum level of physica administered and interpreted. these authors showed that a patient's fear of re the muscle to generate force. most frequently used tests in physical rehabilitation (C 1983). et al. This results in a series of strength along the neuromuscular pathway. Thus. that if muscles are to be assessed. In a clinical population. Tests of muscle strength ar action is rooted in cognitive activity (Bandura and Cervone. Indi~ strength. The modus opera skills for the tester and the testee. test results. individual variability is paramount.. Differential loss of fiber type may account for the differential decline in isokinetic. The loss of muscle mass is due to a decline in both a consistent manner so that the truest measure of m the number and the size of muscle fibers and in the degree strength is obtained. as well as an increase in muscle depending on their usual function. 1994).. CLINICAL STRENGTH TESTING Cognitive Factors Influencing Muscle Strength Muscle strength tests are indicated in the major patients who have pathology or injury that resu The capability for intentional and purposeful human movement impairment. This increase in force is the also clear that muscles contract and work in different result of a learning effect. compared with isometric. population for which the tests are designed. although normative data must account for Although it is necessary to know how to test m gender and age. tractions have been shown to have a negative influen Although a decline of muscle mass occurs in the elderly. This is not surprising. as well as by aging. If the test function. Muscles playa fundamental r time is necessary to learn a complex motor skill. strength (Pentland et ai. It seems ob strength capability. it is also necessary to know what the results vidual variability in muscle strength testing is even more test mean. that dynamic strength declines earlier and more rapidly The patient's ability to focus on the strength test a than isometric strength (Pentland. 1995).. Perhaps more i attributed to loss of muscle mass or an altered capacity of tantly. Secondly. as well as cognitiv tests that show an increase in the magnitude of measured motivational factors. They influence the planning of the activ this loss of strength is greater than that accounted for by well as the activity itself (Pratt and Abrams. The following se and colleagues (1994} found that the patients' belief in their discusses specific tests and the instruments used to a . A distinction must be made assessed using tests that provide useful information re between an increase in muscle torque due to a true change ing the muscle's ability to function.32 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT rate of loss. inactivity. Self-efficacy is one's belief in otherwise the tests will not be used. Recent research has shown was also a pertinent factor in strength testing. it is difficult to tease out causes and consequences of ute to what would appear to be a simple muscle co aging. Summary All of the previously discussed factors are influenced by Figure 2-2 summarizes the preceding information inactivity and by cardiovascular fitness. they sho discussion on learning}. 1994). the personal capabilities to perform a specific action. (See section on trunk testing for more therefore. The interpretation of the test results mu crucial when tests of muscle strength are conducted made in the context of all relevant factors. the screen out distractions influences the measurement method of testing influences the results between different can be facilitated through instructions by the tester age groups. or if they are. and cardiovascular fitness on measures of tion. 1995). Tests of muscle strength are learned psychomotor ai. 1993). or skill. both between individuals and between muscles ability to endure physical activities was the most pow (Rogers and Evans. reliable information in the c learning the motor skill of the test. Thirdl Motivation and self-perception of abilities influence the tests should be simple to use and simple to inte measurement of strength. More practice over a longer occupational function. The decline in muscle can be predictor of isokinetic performance. and loss of function is the primary reason movement for strength testing is an unfamiliar movement patients are referred to therapy. influence muscle performance force over a period of time. of vascularization (Rogers and Evans. Clinicians must be aware that a myriad of f muscle strength. Thus. Furthermore. then optimal performance cannot occur before the It is clear from the previous section that many f movement is learned.

Does the test measure a on the machine.C f . Thus. Documentation 7. and how was it used? What were the settings and improve with practice. reliabil­ the angles of the hip or knee? What is the effect o ity. These tests have a long history of use. relative to what? maximal.~::-. Criterion measure. as with any other measurement test. Is the position easily reproduc­ equipment. Instrument and settings. Innervation ratio Responsiveness Tester strength muscle strength and endurance. MANUAL MUSCLE TESTS 4. These facts no doubt contribute to the frequency with ~~-~ " . and were absolute o relative values used? For example. as well as whether or the angles at peak torque? If relative values are the warm-up contractions were maximal or sub­ used. the muscle Strength Test Protocol groups. must be was the strength test conducted? reproduced as exactly as possible so that measurement 9. -­ ~:. dynamic Concentric vs. The length of time or number values.. Position of the subject. eccentric Velocity of testing lsokinetic Isoinertial Muscle factors Fiber type 1 Measurement factors Criterion values Average Fast fatigable Peak Fast fatigue resistant Operational definition Absolute or relative values Slow fatigable Reliability Position in range Cytoarchitecture Intratester Force/torque Angle of pull Intertester Work Length of lever Test-retest Power Parallel vs. Rest periods. and are generally regarded as basic clinica ible? Does the subject have back support? What are skills. Healthy Motivation Manual Patients Learning Instrumented Injury Level of skill Individual vs.g... The method of stabilization. Previous practice sessions. are the torques expressed as angle speCific of contractions prior to the test. :"--t~~~~"':- . Include the type of contraction (isometric.- Static vs. Test range of motion. where are the straps placed. Issues of validity. Standard ized commands should be used. gravity? 6. the higher the torque. Are peak or average values o errors and artifacts are minimized. Warm-up procedure. with absolute 1. What is the length of the rest period between contractions and set of contractions? Probably the most common tests in general use are 5. series fibers Validity Device Size of muscle Face Device settings Length Construct Gravity correction FIGURE 2-2.. Motor skills are learned used. the testing protocol must be well described.. damping. Can the subject stabilize himself or herself by holding on with hands? Are stabilization straps used? If so. Commands and vocal encouragement. 10. and how many are there? The better Isome'tric Tests the stabilization. Order of testing. concentric. and utility are addressed within this section. o change in strength or an improvement in skill? minimum force? 3.­ :/ ~-~" ":E" .. lever arm. test protocol torque or force used? Is work or power used? Wha descriptions should include the following: was the number of repetitions. Vocal encourage No matter what the type or the purpose of the strength ment should be standardized as much as possible test. Summary of factors Cross-sectional area Discriminative Tester skill influencing the measure of muscle Vascularity Predictive Tester expectation strength. group muscles Pathology Self-efficacy Position of subject Comorbidity Fear of injury Joint position 01 test Pain Distress Stabilization Gender Depression Warm-up Age Perceived effort Prestretch Height Expectation Previous practice Weight Rest periods Usual activity level Encouragement Active Order of testing Sedentary General health status J STRENGTH . Strength 8. What instrument wa 2. e. Include the relation of the MMTs. At what point in the range tests.. pause. or eccentric). and the velocity of testing. require no muscle to gravity.


which MMTs are used. Manua'i muscle tests are weH TABLl2 I
described by Kendall and colleagues (1993) and by Daniels
and Worthingham (1986). Both groups of authors stress GRADING SYSTEMS USED IN MANUAL
the importance of attention to detail when using MMTs. MUSCLE TESTING
Kendall and coworkers suggest that precision in MMT is Criteria for M
necessary to preserve the "science" of muscle testing Grading S ymbols Grading
(p. 4). In fact, MMT has been subjected to little scientific
scrutiny. That is not to suggest that the techniques are not Normal 10 5 5.0 100% Can move or hold
sound, but merely that they have not been systematically gravity and max
tested. Proponents of techniques have the responsibility to Good + 9 4+ 4.5 80% Can raise part aga
test the techniques that they describe so well. Good 8 4 4.0 gravity and an e
Nevertheless, some important points must be kept in Good ­ 7 4­ 3.66 resistance
Fair + 6 3+ 3.33 50% Can raise part aga
mind regarding the use of MMT. Both Kendall and associ­ Fair 5 3 3.0 gravity
ates (1 993) and Daniels and Worthingham (1986) describe Fair ­ 4 3­ 2.66
standardized positions that attempt to isolate muscle func­ Poor + 3 2+ 2.33 20% Produces moveme
Poor 2 2 2.0 gravity eliminate
tion . Resistance to the motion is applied throughout the Poor­ 1 2­ 1.5
range of motion (Daniels and Worthingham, 1986) or at a Trace T 1 1.0 5% A flicker or feeble
specific point in the range (Kendall et aL , 1993). In addition traction
Zero 0 0 0.0 0% No contraction
to ap plying resistance through the range of motion (the
"make test"), Daniels and Worthingham also use a "break
tes1" ' at the end of range. In the break test, the patient is
instructed to "hold " the limb as the therapist applies a healthy subjects. These calculated scores were the
gradual increasing resistance. Pain or discomfort should pared with the measured scores. Essentially, the
not occur, and if it does then the test should be discontinued revealed that the MMT and HHD scores were co
(Daniels and WortJ1ingham, 1986, p. 3). Make and break but significantly different. Bohannon also reported
tests are not equivalent and should not be used interchange­ MMT percentage scores overestimated the extent to
ably. Using dynamometry, Bohannon (1988, 1990) has the patient was "normal." However, Bohannon se
shown that significantly greater strength values occur with have trouble with the designation normal, since a
the break test compared with the make test in both healthy his normal subjects were designated as "normal m
subjects and in patients . Problems with this study are evident. One of th
Grading systems for MMT have included letter grades, pertinent concerns relates to the different starting p
numeric grades, percentage grades, and descriptive cri­ used in testing muscle strength with HHD compar
teri a . Pluses and minuses have also been utilized (Table MMT. All HHD testing was conducted in sitting po
2-1). The methods of Kendall and colleagues and of whereas MMT tests were conducted in Side-lying po
Daniels and Worthingham have obvious similarities and The author did not correct for effect of gravity even
some differences (e.g ., grading system). Neither method it would have had a significant impact. Finally, Bo
has a proven advantage. Neither method has been sub­ did not report reliability in this study.
jected to much critical scrutiny. Based on the weight of the Reliability differs depending on the strength
limited evidence available, the reliability of MMT is low muscle and its anatomic characteristics. It seems
(Beasley, 1961; Frese et aL, 1987; Wadsworth et aL, that it is easier to palpate a contraction in a large sup
1987). It is obvious that the reliability of the test would muscle like the quadriceps than in a small deep musc
depend on which muscle was being tested , the strength of as the piriformis. Thus, reliability would be higher
that muscle , and whether other confounding factors such MMT in the quadriceps. Conversely, it would be dif
as , but not limited to, the presence of spasticity, were determine whether the contraction of the quadrice
present. The confounding impact of spasticity on the good (80%) or normal (100%) in a large athletic in
results of muscle strength tests is not surprising. It is because the therapist would have difficulty challeng
surprising that the examiners' designation of "normal" is muscle with manual resistance.
somewhat idiosyncratic. This problem of relatively weak therapist streng
In a study by Bohannon (1986), one third of the normal reported by Deones and colleagues (1994). These
subjects were graded as "normal minus ." Bohannon gators measured quadriceps strength in a healthy
examined muscle strength of the knee extensors in a tion using the Kin-Com and HHD. They reporte
controlled trial. He compared knee extension " make " correlations in strength measured with each device
forces in 60 healthy ad ults and 50 patients with a variety of they attributed to the examiner not being able to re
neuromuscular diagnoses. The MMT grades were con­ force of the quadriceps.
tJ'asted with forces measured with an HHD . The author In a review of MMT, Lamb (1985) noted that in M
calculated dynamometer percentage scores for the pa­ patient responds to the amount of force applied
tients, based on the dynamometer scores measured on the examiner. Different examiners no doubt apply a d

different amount of force at different times. Force applica­ muscles in a functional manner, and the relationshi
tion by therapists has been reviewed and tested and is a between muscle impairment and functional deficit is ce
significant source of variability (Simmonds and Kumar, tainly not clear. The patient's motivation, determination
1993a; Simmonds et at, 1994). Although the application ability to problem-solve and substitute alternative moto
of the testing technique can be standardized in terms of patterns has far more to do with function than with th
patient position and the point at which the examiner isolated ability of a muscle to contract.
applies resistance to the muscle, the amount of applied Although the MMT has a long history and is entrenche
resistance is still variable. The examiner also has to in clinical education and practice, it is a technique tha
compare the muscle with "normal," but the concept of needs to be systematically and scientifically scrutinized. It
normal and the expectation of how a muscle should necessary to determine which specific MMT tests ar
perform is somewhat idiosyncratic. In addition to problems reliable, under what conditions, and in what patient group
with reliability, MMT grading scales are not responsive to It is also necessary to determine which MMTs are no
change (Griffen et aL, 1986). A large change in muscle useful, and they should be discarded. Finally, it is necessar
strength is necessary before such variation is reflected in a to determine the diagnostic and prognostic and discrim
change of grade on an MMT scale. For example, a muscle native validity of MMTs and to determine what can b
may be conferred a grade of "good" because it can move reasonably inferred from the results of specific MMTs.
a joint through a full range of movement against gravity and
an external force applied by the examiner. Although
repeated testing over time would reveal an increase in the
muscle's functional ability, this improvement could not be The problems of poor reliability and responsiveness ar
measured using the zero-normal grading system. The use alleviated somewhat with the use of instrumented MMT
of "pluses" and "minuses" to the grading system may have (Bohannon, 1986; Currier, 1972; Riddle et aI., 1989
been instituted in an effort to improve the responsiveness Stratford and Balsor, 1994; Trudelle-Jackson et aI., 1994
of the test but probably only leads to lower levels of However, instrumented hand-held MMTs are still limited b
reliability . the therapist's ability to adequately resist muscle strength
The lack of reliability and responsiveness of MMT is Instrumented muscle testing has increased the level o
problematic because the test is supposed to measure accuracy and the reliability of strength testing and ha
change in a patient's muscle strength. This may not be a contributed significantly to the body of knowledge abou
problem clinically if other more responsive tests are used to muscle performance. One of the first devices to be used
measure change in the patient's function. The other tests measuring muscle strength was the cable tensiometer. A
may provide more useful information in regard to how the the name implies, cable tensiometers measure tension in
muscle is functioning; they could also help to validate cable. To use this device to test muscle performance, on
MMTs. But one must ask, if MMTs are not useful, why use end of the cable is attached to a limb segment and the othe
them? to a fixed object. The tensiometer is then placed on th
The main value of the MMTs is in their apparent ability cable, and a gauge on the meter measures the amount o
(which needs to be tested) to isolate and to test the tension. Calibration is necessary to convert the gaug
contractability and "strength" of individual muscles and reading into a measure of force. This is usually done b
groups of muscles that are weak. The use of MMTs is less suspending known weights from the cable, reading an
useful in stronger muscles because it is limited by the ability recording the measurement from the gauge, and conver
and strength of the therapist to provide resistance to the ing these units into units of force. A key procedural facto
muscle while adequately stabilizing the patient. MMTs have for using the cable tensiometer is that the cable must b
limited usefulness in recording improvement or deteriora­ positioned along the line of muscle action. A secon
tion in a patient's condition because they have poor procedural point to consider (because it facilitates compu
reliability and lack responsiveness. It could be argued that, tation) is that the cable should make a 90-degree angle wit
if the reliability and responsiveness of MMTs is poor, then the point of attachment to the body.
validity is moot. However, different types of validity exisi. Cable tensiometers have been used in research (Beasley
The lowest level of validity is face validity. Face validity 1961; Currier, 1972), are fairly reliable, and provide th
asks, does the test appear to measure what it is supposed quantitative data needed for research and clinical applica
to measure? So, is an MMT supposed to measure the ability tions. However, they have never been widely used in th
of a muscle to contract, to move a limb through a range of clinic. The same is true for strain gauges. A strain gauge
motion, or to function normally? Manual muscle tests a device that has electroconductive material incorporate
measure the ability of a muscle to contract and to move a in it. The application of a load to this device results
limb through a range of motion. They do not measure the deformation of the electroconductive material, whic
ability of a muscle to function. Function is much more changes the electrical resistance and thus the electric
complex than an isolated muscle contraction. Although outputto a display device. Again, calibration is necessary t
one can infer that function will be impaired if a muscle or convert the electrical output into force. These devices ar


not discussed further here because they have not been Thus , the MS can be applied against bony surfaces w
utilized by clinicians in the past and are unlikely to be so in causing discomfort (the experience of pain or disc
the future. during a test would confound the results of the test
In contrast , HHD has been widely adopted in clinical The HHD is a hand-held device that incorporates
practice. A few reasons probably account for the adoption scales or strain gauges to measure applied force . The
of these instruments. measures the applied force in kilograms or pounds
no conversion of measurement units is required . The
1. The need to document the results of clinical tests in a
is used in the same way as the MMT and the MS. T
quantitative manner. Th~s is a prerequisite so that
is subject to some of the same limitations of
treatment efficacy can be established and optimal
especially that regarding the strength of the exa
treatment regimens can be defined.
Bohannon (1986) suggests that this limitation may
2. The technique of HHD is the same as that used during
as the examiner becomes more experienced. B
the MMT, and therapists are very familiar with MMT
(1956) showed that examiners were able to hold a
techniques .
higher forces with practice . A learning effect exists
3. The devices are inexpensive, simple to understand ,
examiner as well as for the patient. The learning
and simple to use.
results in a greater amount of force being recorded,
Two devices are described and discussed in this sec­ force difference is obviously not reflective of a cha
tion: the modified sphygmomanometer (Fig. 2-3) and the muscle strength.
HHD (Fig. 2-4). The HHD has been tested for intrarater, interrat
A mod ified sphygmomanometer (SM) can be used to interdevice reliability for different muscles and in di
quantify the resista nce offered during a manually resisted population groups (Bohannon , 1990; Riddle et aI.,
isometric contraction (Giles, 1984; Helewa et al. , 198 1; Trudelle-Jackson et aI., 1994) and for quantitative
Helewa et aI. , 1990). Sp hygmomanometers are usually parisons between make and break tests (Stratfor
available in the clinic and are easily modified to measure Balsor, 1994). This device has also been compare
muscle strength. Essentially, the MS is a regular sphygmo­ other, more technically sophisticated, devices such
manometer from which the bladder has been removed Kin-Com isokinetic testing unit (Deones et ai,
from the cuff. The bladder is folded into three sections and Stratford and Balsor, 1994; Trudelle-Jackson et ai,
placed in a cotton bag. Alternatively, the cuff may simply In a nonblinded trial, Bohannon (1988) used an H
be rolled up . A baseline pressure is set within the MS , and measure intratester and intra session reliability of me
the device is then placed between the body part and of force in the elbow flexors of 31 healthy subjec
the therapist's hand , as if an MMT was being carried reported good reliability (ICC = 0.995). Trudelle-Ja
out. The patient then performs a resisted contraction and colleagues (1994) tested interdevice reliability a
against the MS cuff, and the pressure is noted. Conversion not demonstrate such high levels of reliability.
from units of pressure to units of force necessitates authors also tested a healthy population. They co m
calibration. two different HHDs and mea.sured hamstring force
The MS has one advantage over the HHD, and thus is class correlatie n coefficients between the two devic
related to its softness and compressibility of the material. low (ICC = 0.58) . These results suggest that di
devices cannot be used interchangeably to mea
patient's progress . These authors also compared th
measured with the HHDs to that measured wi
Kin-Com (parallel forms of concurrent reliability). Th
calculated between the Kin-Com and each HHD
reasonable (ICCs = 0.83 and 0.85), but an analy
variance between the Kin-Com and the HHDs reve
significant difference between the Kin-Com and one
HHDs. The mean force measured with each HH
7.5 kg and 12.5 kg; the mean force measured w
Kin-Com was 13 kg. This suggests that the differe
values is clinically significant as well as statistically
cant. It also shows that calibration should be checke
odically, and that HHD devices are not interchang
Riddle and colleagues (1989) tested the stren
several muscle groups within and between session
sample of patients with brain damage . They measur
muscle forces on the paretic and nonparetic lim
FI GURE 2-3. Use of modified sphygmomanometer to measure grip their surprise , they obtained higher levels of reliabi
strength. the nonparetic limb compared with the pareti

FIGURE 2-4. A, Hand-heJd dynamo meter. B, Use
of hand-held dynamometer to measure quadriceps
force. (A and B, Courtesy of Lafaye tte Instrument.
Lafayette, IN.)

(ICC = 0.90-0.98 and 0.31-0.93, respectively). This was pinch meters (Fig. 2-6). Both of these devices measur
a repeated measures design with strength measures taken force , which is recorded in pounds or kilograms on a gauge
more than 2 days apart. The lower level of reliability Computerized versions of these devices are available bu
obtained on the non paretic side may be due to the are not always necessary or advantageous, depending o
difficulty associated with applying adequate resistance to the mathematic algorithms used in the software . Stan
strong muscles. dardized testing protocols are included with the device
The HHD dynamometer can be used to assess isometric Both intra- and interrater reliability of the gri p strengt
strength in many muscle groups relatively easily. Its reli­ dynamometer is good in normals (Neibuhr et ai, 1994
ability is lower when it is used to test relatively large and Stratford et ai , 1987: Stratford, 1989) and patien
relatively strong muscles. Although isometric measure­ (Stegnick Jansen, 1995).
ment of force has face validity, it is not clear how much The influence of the position of the elbow joint durin
force is necessary to perform specific functional tasks. testing of normal subjects is not clear. Math iowetz an
Also, HHD is not useful for testing trunk strength or hand associates (1985) showed that elbow joint position influ
strength. enced the magnitude of grip force, but the results were no
For hand strength testing, two devices are in common replicated by Balogun and colleagues (1991) . Stegnic
clinical use: grip strength dynamometers (Fig. 2-5) and Jansen (1995) contrasted grip force in a patient and contro

FIGURE 2-5. A, Grip dynamometer. (Sammo ns Preston, Burr Ridge. IL.) B, Use o f grip dynamometer to measure grip fo rce.

- _0 ­


FIGURE 2-6. A, Pinch meter. B, Use o f pinch meter to measure pinch force .

group with the elbow in flexed compared with extended muscular contractions against a mechanical system
position. Twenty-two subjects with lateral epicondylitis and provides a constant load , such as when lifting a free w
15 normal subjects participated. Excellent reliability coef­ In fact, the load of a ~ree weight is not constant be
ficients were reported (ICCs ::::: 0 .9 5). Noteworthy was the changes in the angulation of the limb lever influenc
fact that elbow position did not influence grip strength in effect of gravity on the load . A consequence of this
the normal group but did influence grip strength in the the muscle could be working at its greatest mech
patient group. In the patient group, grip strength was advantage when the resistance of the load has its
greater with the elbow flexed on both the involved and the effect (Hislop and Perrine, 1967), and the muscle
uninvolved sides. The magnitude of difference was much not be challenged throughout its range. Theoreti
greater on the involved side. This work highlights the isokinetic exercise challenges the muscle througho
problems inherent in testing normal subjects and general­ range.
izing those findings to patient populations. Patients and Isokinetic testing uses an electromechanical devic
non patients are different. prevents a moving body segment from exceeding a p
To summa rize , it can be stated that reliability of instru­ angular speed. The axis of the device is aligned wi
mented MMT is reasonable and appears to be primarily anatomic axis of the joint that will be moving. The leve
limited by the strength of the examiner, standardization of of the device is attached to the subject's limb, an
technique is important, and instruments are not inter­ subject is instructed to move as fast as possible . The d
changeable. The validity of instrumented MMT is subject to does not initiate motion, nor does it provide any resis
the same issues and questions posed for noninstrumented to motion until the preset speed is reached. Howev
MMT. The validity needs to be assessed. soon as the subject's limb moves as fast as the preset s
the device exerts an opposing force against the m
body. As the subject tries to accelerate, the machine r
Dynamic Tests the movement. The harder the subject pushes again
device , the greater is the resistance provided by the d
Isometric measureme nts provide some information This resistance is measured by the machine througho
about muscle strength that is important to clinicians. But range of motion and torque curves are plotted using
because muscles usually fundion in a dynamic manner, it of motion and torque (Fig. 2-8) . The earliest machine
makes sense to measure muscle performance in a dynamic a strip chart recorder, but most machines are now
manner (Fig. 2-7). Although dynamic testing appears to be puterized . Algorithms within the software compute
more functional , the relationship between function and sures such as average and peak values of torque, p
dynamic testing has not been established (Rothstein et a!. . and work in addition to the position within the ran
1987). One of the first papers to appear in the physical which peak torque was generated. The output is u
therapy literature about isokinetic exercise was by Hislop presented in tabular and graphic form (Fig. 2-8).
and Perrine (1967). These authors differentiated between Much of the research in isokinetic testing has
isotonic (constant load) and isokinetic (constant speed) conducted on the knees of normal subjects, but resear
exercise. They suggested that isotonic exercise involves have examined the machines, muscle groups other

ent attachments that allow an examiner to test different mance in a dynamic quantitative manner has contributed
muscle groups, including those of the trunk. Trunk testing the body of knowledge about muscle performance. Isome
machines are discussed separately. ric tests provide information about the ability of a muscle

FIGURE 2-7. A , lido isokinetic device . B, Calibration of
the lido isokinetic device using weights. C, Subject in
position for the measurement of ankle dorsi- and plantarflex­
ion . (A-C, Courtesy of Loredan Biomedical , Inc., Davis, CA.)


PATIENT NAME: Edward REPORT DATE: Mon Jan 10 20: 56: 06

SPEED (deglsee) R 60 120 150
BODY WEIGHT (Ibs) (180)

PEAK TORQ (ftlbs) 209 67 27
PEAK TORQ % BW 116% 37% 15%

ACCEL. TIME (sees) .06 .13 .21
TOTAL WORK (BWR, ftlbs) 195 47 17
TOTAL WORK (BWR) %BW 108% 26% 9%
AVG. POWER (BWR, 226 110 52
AVG. POWER (BWR) %BW 125% 61% 28%
TAE (ftlbs) 27.6 26.2 17.6
TOTAL WORK SET 1 (ftlbs)
1st SAMPLE 1 (TW)
2nd SAMPLE 1 (TW)
TOTAL WORK SET 2 (ftlbs)
1st SAM PLE 2 (TW)
2nd SAMPLE 2 (TW)

PEAK TORQ (ftlbs) 151 118 84
PEAK TORQ % BW 83% 65% 46%

ACEL. TIME (sees) .07 .09 .21
TOTAL WORK (BWR. ftlbs) 144 93 56
TOTAL WORK (BWR) %BW 80% 51% 31%
AVG. POWER (BWR. 169 216 162
AVG. POWER (BWR) %BW 93% 120% 90%
TAE (ftlbs) 26.1 49.5 52.2
TOTAL WORK SET 1 (ftlbs)
1st SAMPLE 1 (TW)
2nd SAMPLE 1 (TW)
TOTAL WORK SET 2 (ftlbs)
1st SAMPLE 2 (TW)
2nd SAMPLE 2 (TW)

PEAK TORQ 72% 176% 311%
TOTAL WORK (SWR) 73% 197% 329%
AVERAGE POWER (BWR) 74% 196% 311%
MAX ROM (72)
(e) COPYRIGHT LUMEX 1987.1988.1989.1990

FIGURE 2-8. Output from isokinetic device. (Courtesy of Isotechnologies, Inc., Hillsborough. NC.)

TRUNK EXTENSION/FLEXION Mon Jan 1020:56:131994
test date-11711994 14:20
- maximum points, test speed-60 deg/sec
- average points, test reps-3
- bestwork

440 440
400 400
0 360 360
R 320 320
U 280 280
E 200 200

F 160 160
T 120 120
* _/
80 ."..
B 40 I 40
S 20 20
0 I
95° -15° 0° 40°
ANGLE (degrees) ANGLE

COMMENTS: ________________________________________________________________________

FIGURE 2-8 Continued

exert a force or torque against an external resistance. power, peak power, average power, instantaneous power
Dynamic tests also provide information about muscle and contractile power.
work, muscle power, the speed of muscle contraction, and Power is the rate or speed of doing work and is expressed
the ability of a muscle to maintain a force through a range in watts. Computation of power is relatively straightfor
of motion (Moffroid et al., 1969; Moffroid and Kusiak, ward in isokinetic testing because the speed is constan
1975; Rothstein etal, 1987). As noted earlier, although the (power = work/time). According to Moffroid and Kusiak
testing appears to be more functional than isometric (1975), other types of power are calculated by substituting
testing, the validity of isokinetic testing has not been some specific value into an equation. For example, peak
established. The construct of movement occurring .at power is defined as peak torque divided by the duration o
constant speed is artificial (Kannus, 1994), as are the the isokinetic contraction (peak power = peak torque
positions and movement constraints under which isoki­ contraction duration). Thus, in the peak power equation
netic testing is done. peak torque is substituted for work, and distance is dropped
Isokinetic tests measure the follOwing characteristics of from the equation. Operational definitions of terms are
muscle performance. Torque is the force that acts about an obviously necessary. But definition of a term does not make
axis of rotation. It is the product of this force and its point it a useful or meaningful term. Rothstein and coworker
of application from the axis of rotation. Work is force (1987) decry the erroneous use of measurement terms and
exerted through some distance. lsokinetic testing measures caution clinicians about uncritical acceptance of the jargon
force and the angular distance through which the limb associated with isokinetic testing. In support of thei
moves. Thus, the work of the muscle can be computed position, they describe how "power" has been erroneously
easily (work> = torque or force x distance). In the clinical used to describe the torque values measured during high
context, work is a term that may be reserved for that done velocity testing.
by the therapist. Power is a more frequently used term, but This consideration of terminology is not simply a pedan
it is also used inappropriately at times. Moffroid and Kusiak tic diSCUSSion of semantics. Words are powerful tools
(1975) define five separate measurements of power: Loosely used pseudoscientific terms have a tendency to


persist because they have an aura of credibility and techno­ of known value are applied to the load arm at a kno
logic sophistication that does not invite questioning­ distance from the point of rotation. Because the wei
critical or otherwise. This facilitates the adoption of errone­ values and arm length are known, the torque applied to
ous terms into accepted dogma. shaft is also known. This torque value is then compa
Appropriate terms or measures obtained with dynamic with that torque value recorded by the machine. This c
strength testing devices usually include such measurements bration procedure tests in the isometric mode. lsokin
as isometric torque or force and isokinetic force or torque calibration is not speCifically tested, which is problem
throughout the range of joint motion and at different when strength testing is conducted in the isokinetic mo
velocities. Power and work can be computed from torque The manufacturers claim that their device has long-te
and velocity data using the equations noted previously. Test stability and accuracy, but whether this has been tested w
factors that can influence these measures are as follows. the machine in clinical use is not clear. Cybex II calibrat
Velocity. The velocity at which the isokinetic test is protocol uses known weights applied at a single speed.
conducted makes a significant difference to the torque based on extensive testing of the device, Olds and asso
output and the position in range at which peak torque ates (1981) have suggested that the Cybex should be tes
output occurs (Chen et al., 1987; Gehlsen et aI., 1984; daily and at every test speed. Essentially, the calibrat
Hsieh et aI., 1987; Osternig et aI., 1977; Rothstein et aI., protocol needs to simulate the clinical testing situation
1983; Tredinnick and Duncan, 1988; Watkins et aI., much as possible. This includes testing the machine w
1984). It is well known that a force velocity relationship the settings that are used during clinical testing, eg,
exists in dynamic muscle contractions. This relationship is damp setting on the Cybex II.
essentially linear (Rothstein et aI., 1983). An increase in the Damp is a means of redUcing signal artifacts in electr
load on a dynamically contracting muscle causes the systems. An undamped eletric signal results in "oversho
velocity of the contracting muscle to decrease. Similarly, as or an erroneously high torque reading. Sapega and
the velocity of the muscle contraction increases, the torque leagues (1982) showed that the overshoot was due
generated by the muscle decreases, and peak torque occurs inertial forces rather than muscular torque. The Cybe
later in the range. These findings are robust between has five damp settings (0-4). Increasing the value of
different muscle groups and between normal subjects and damp setting results in a decrease in the peak torque an
patient groups. shift of the curve to the right, which implies that p
Experience and Repetitions. Isokinetic tests are not only torque occurred later in the range (Sinacore et aI., 198
a test of strength but also a test of motor skill. Learning is The important point is that all the machine settings mus
involved in this skill, which is reflected in torque increases, documented, and clinical evaluations must be retes
and of course influences the reliability of the test. Based on using the same settings.
their study of knee extensor torque in 40 healthy women, Another factor that affects torque output is gravity. T
Johnson and Seigel (1978) recommended that a mean of effect of gravity obviously varies with the position of
three repetitions provides the highest level of reliability limb. If gravity is not corrected for, then the torq
(0.93-0.99). Their protocol included a warm-up of three generated, and thus the power and work calculated, wo
submaximal and three maximal contractions, and strength be subject to error (Winter et a!., 1981). The error would
tests conducted at 180 degrees per second. In another systematic and therefore would not affect the reliability
study, Mawdsley and Knapik (1982) tested 16 subjects with the isokinetic tests, but the validity of the measureme
no warm-up, in three sessions across 6 weeks, at 30 would be compromised. Fillyaw and coworkers (19
degrees per second. They reported no Significant differ­ tested peak torques of the quadriceps and hamstrings in
ence in torque values across the 6-week time period. The soccer players. They computed the effect of gravity a
results from the within-session testing were interesting. In added this value to the quadriceps torque and subtracte
the first trial, the first test produced the highest torque, from the hamstring torque. Depending on the speed
whereas in the second and third sessions, the first trial testing, the effect of gravity correction on mean p
produced the lowest torque. It is difficult to explain why torques was approximately 6 ft-lb in the quadriceps a
torque values increased with each repetition within the first 8 ft-lb in the hamstrings.
test session but decreased with each repetition in the sec­ One other equipment consideration that affects iso
ond and third sessions. Based on the information reported, netic muscle testing relates to the center of rotation of
any interpretation would be entirely speculative. However, equipment and its alignment with the center of rotation
the fact that no significant difference was seen between the the joint axis. This is an especially important issue
averaged values across the 6-week period suggests that measuring muscle strength in multijoint areas, such as
under the conditions of testing used in the study, a reason­ trunk.
able level of reliability can be expected over a relatively long Testing Protocol. Potentially many factors within
time period (6 weeks). specific testing protocols could influence the measurem
Calibration and Equipment. The manufacturers of isoki­ of muscle strength. Factors such as length and type
netic devices usually supply the calibration protocol for use warm-up activity, the number and length of rest perio
with their machine. For the Lido isokinetic device, weights and the type and order of muscle contractions could

make it difficult to compare the results from different and very costly in financial and personal terms. They can
studies. But these factors have not been specifically tested, lead to a great deal of distress and demand on the health
so the extent of the influence is really not known and these care system. Many patients in rehabilitation are patients
factors should be tested. with low back problems. The trunk is a complex multiseg
The mechanical aspects of isokinetic machines appear mental system with multiple joints, multiple axes of motion
to be reliable. But how reliable is the device for measuring and multiple complex musculature. It is more difficult to
muscle strength? And is the level of reliability different in measure range of motion and muscle strength in the trunk
patient populations compared with normals and at differ­ than it is in peripheral joints because of the trunk's
ent testing speeds? A reasonable level of reliability appears complexity. The perceived need to quantitatively measure
to exist in testing muscle strength, as long as standard trunk function coupled with the availability of new technol­
protocols are adhered to. Standardization is crucial be­ ogy has led to the development of trunk testing devices
cause so many factors can influence the test measurement. There is now a great deal of use, and unfortunately misuse
The validity of the tests and of the interpretation of the of trunk testing devices.
output has received less scrutiny. Functional strength tests of trunk musculature have been
The reliability of specific isokinetic devices in measuring used as a preemployment screening tool, as a measure o
muscle strength has been examined to a limited extent progress in rehabilitation, and as a "malingerer detector."
testing different muscle groups. In a recent review of Use of functional muscle testing as a screening device is
isokinetic testing of the ankle musculature, Cox (1995) based on some epidemiologic data that suggest that manua
concluded that isokinetic testing was generally reliable. materials handling leads to back injuries. However, the
However, he noted that reliability was higher for the supporting evidence for this notion is not strong. Mos
plantar- and dorsiflexors than for the inverters and everters. studies are retrospective; do not distinguish between back
It was apparent from the review that most studies were injuries, reports of back injuries, and time lost from work;
conducted on normals. Frisiello et al. (1994) examined the and do not account for confounding psychosocial variables
test-retest reliability of the Biodex isokinetic dynamometer (Pope, 1992).
(Biodex Medical Systems, Shirley, NY) on medial and This knowledge has not stemmed the tide of technology
lateral rotation of the shoulder. He tested eccentric peak or the inappropriate use of isodevices. Recent critica
torque of both shoulders in 18 healthy adults at 90 and 120 reviews on trunk strength testing with isodevices conclude
degrees per second. He reported ICC values between 0.75 that no evidence has been found to support the use of these
and 0.86, with medial rotation being slightly less reliable devices for preemployment screening, medicolegal evalu
than lateral rotation. ation, or even clinical evaluation (Andersson, 1992
It appears from the literature that isokinetic devices are Mooney et al., 1992; Newton and Waddell, 1993; Pope
mechanically reliable within themselves, but comparisons 1992). The strength of this criticism may be a reaction to
between devices have not been conducted. It also appears overclaims by manufacturers and overinterpretation o
that isokinetic devices measure muscle torque reliably. results by those with a vested interest in the device or in the
Many reliability studies have been conducted measuring results of the test. Inappropriate interpretation of results
peripheral muscle strength in normal subjects. The "nor­ may also be due to an incomplete understanding o
mal" subjects are frequently well educated, well motivated, biopsychosocial factors that contribute to a person's per
and free from pain and dysfunction. Typical patients may formance on an isodevice. Medicolegal issues and clini
also be well educated and well motivated, but they usually cians' suspicions have complicated the use of trunk testing
have some discomfort and dysfunction, which may influ­ machines to a shameful degree. However, on the positive
ence their performance and thus the reliability of the side, these machines do provide information that is no
strength measure. Therefore, the assumption of similar otherwise available. Systematic research is now necessary
levels of reliability in patients is not appropriate. Reliability to determine the validity of the information that these
needs to be established in the specific populations that are devices do provide about trunk function.
to be tested under the conditions of testing that are used in Trunk testing devices have contributed to the body o
that population. knowledge on trunk performance, including isometric and
dynamic trunk strength. Isomachines for trunk testing were
introduced about 10 years ago. They now include the
Trunk Testing Cybex back testing system, the Udo, the Kin-Com, and the
B-200. With the exception of the B-200 (Fig. 2-9), which
Finally, an area of testing that has evolved rapidly in the is an isoinertial (constant resistance) device, most trunk
last decade is the use of isokinetic and isoinertial devices to testing machines are isokinetic. All the isokinetic devices
measure isometric and dynamic muscle strength in the operate on similar principles to each other and to the
trunk. Spinal problems are complex problems that are isokinetic devices that measure peripheral muscle strength.
difficult to prevent, difficult to diagnose, and difficult to The main difference between the devices is in the tes
treat. The tendency for spinal problems to recur is a source positions (lying, sitting, semistanding, or standing) and 'the


FIGURE 2-9. A, 8-200 isoinertial back testing unit. B
subject in the 8-200 isoinertial back testing device. (A
Courtesy of Isotechnologies, Inc., Hillsborough, NC.)

degree of stabilization and constraints to motion. Some of 1982), and the iliac crest (Suzuki and Endo, 1983) h
the machines can measure strength in all directions of trunk been used as a designated axis of motion. It is no
motion simultaneously and with the person in the same whether any axis has more validity than another. Ho
device, eg, the B-200. Other devices have different ma­ regardless of which axis is intended for selection, a
chines for different motions. For example, the Cybex of plus or minus one spinal level exists betwe
system has one device that measures trunk flexion and segment that is intended for selection and that w
extension and another that measures axial rotation. actually selected (Simmonds and Kumar, 1993b
All of the factors that need to be considered in isokinetic important points for testing are that the specific axis
testing in peripheral muscles, such as warm-up protocol be documented and that the same axis should be u
and standardization of instructions, need to be considered repeated testing.
in trunk testing. There are, however, some factors that are In peripheral joints, isometric strength was show
unique to strength testing of the trunk because of its greater than dynamic strength. Moreover, as the velo
biomechanical complexity. testing increased, the magnitude of torque decreased
The amount of torque generated by a muscle is the occurred later in the range. The same phenome
product of force and the length of the lever arm from the present in trunk masculature, and this holds for al
axis of motion. Determining the axis of motion in a tions of movement (Kumar et a!., 1995a; Kumar
multiaxial system is obviously problematic. The hip joint 1995b).
(Hasue et aI., 1980), the LS-S 1 joint (Davies and Gould, The position of testing trunk performance influen

McNeill et aI. A couple of factors can Ti\BI. Newton and colleagues (1993) tested 70 normal reached. SHOWS HOW USE Of PERCENTAGE First. and this example shows why .3 100. 6 14 formance in 45 subjects with low back pain. thus. Studies that have compared males and females ated the effect of subject position on isometric and and patients and controls are consistent in their findings isoinertial muscle performance.3 28 edged a learning effect between the first and second tests but found no Significant difference in strength measures : Based on data from Newton. They also examined the relationship between clinical discriminate between patients and controls are reported by and isokinetic measures.3 16 ent learning effect is much more significant in the patient 90 116. Gomez tested 168 normal subjects and Similar to other reports. It was interesting to find that the magnitude of the learning effect was greater in the patients than in the controls. Unfortunately. The torque output was LEARNING EffECT IS BIASED IN fAVOR lower in the patient group compared with the control OF PATIENTS· group. 1980. between flexor to extensor strength is more useful? Al Several investigators have used isomachines to compare though some authors have suggested that this is the case muscle performance between patients and pain-free sub­ (Maye r et al. " This figure was reduced to 56 percen tance of posture to muscle strength and suggest that one using one standard deviation as the cutoff criterion.8 113. it can be seen from Table 2-2 that the magnitude Velocity of change between the first and second test of trunk of Test (degrees Test 1 Test 2 Magnitude Learning extension at 120 degrees per second was 14. Furthermore. The first test involved isometric lower in a group of patients compared with a group o measurements in three directions and in three positions. The particular posture is not optimal for all muscle perfor­ data from this study did not provide much support for the mance.the musculature and because of the differential effects of isokinetic devices can be useful for measuring clinica gravity on the trunk. G. They work of Kumar and colleagues (1995a. Using two standard deviations namic muscle performance was highest in standing for all as the cut-off criteria. 1995b). 18(7) measured an improvement in muscle strength beyond that 812-824 . Gomez (1994).5 13 120 98.6 142. Newton et aI. For example . measures could discriminate between patients and con­ Other difficulties in attempting to use isokinetic scores to trols. All data should be scrutinized.6 15 group (28%. They evaluated whetherisokinetic as a function of trunk position and speed of testing. They conducted isoki­ I.. Patient Group (n = 20) Cooke and colleagues (1992) examined isokinetic per­ 60 93. a high level o sitting (hip in 90 degrees fleXion) . They tested 25 healthy Muscle strength is lower in a group of females compared male subjects with the 8-200 isoinertial dynamometer on with a group of males . (1993) Trunk strength testing with iso-machines Part 2 : Experime ntal eva luation of the Cybex II bac k testing system in netic tests at 2 and 4 weeks following therapy and normal subjects and patients with chronic low back pain . Is it possible that evaluation of the ratio on their muscle performance. Cartas and colleagues (1993) evalu­ change.4 81. compared with 15% in the normal group). muscle strength i two different occasions. However. Mean torque eralized to the patient population because patients have scores are not useful in discriminating between patients and different pathophysiologic constraints on their posture and control subjects. these tests were conducted in ability of isokinetic tests to discriminate between norma normal. Gomez. speCifically to look a reliable and a learning effect was noted. However.. In attempting to classify subjects as patients o in standing and lowest in semistanding.3 ft-lb in the patients . These results give an indication of the impor­ nated "normal.9 132. within all groups. .4 14. the appar­ 60 122.5 30 90 88. . 1993. the device was found to be 120 patients using the 8-200. This lack of consensus can be explained by recen subjects and 120 patients using the Cybex II device. The second session in­ ity compromises the ability of the isokinetic test results to volved dynamic testing in three directions against 50 discriminate between indiuidual patients and indiuidua percent resistance. Suzuki and Endo jects (Cassisi et aI. & Waddell . The results cannot be gen­ subjects and those with spinal problems. Isometric flexion strength was highest controls. D" He nderson between the second and third test.. and standing. healthy subjects. pain-free individuals. Dy­ netic scores were not useful.L 2 2 account for this. [VI" Thow. no consensus as to the normative ratio has been 1993). Newton and colleagues (1993) found that isoki extension strength was not influenced by position. They acknowl­ 120 63. when this difference Normal Group (n = 21) is presented as a percentage learning increase.0 28. the magnitude of difference was calculated as a CHANGE SCORES TO DEMONSTRATE A percentage change in mean torque. They considered the reliability of the device and the learning showed that the ratio of flexion to extension strength varies effect of the subjects. Spin e. 6 ft-Ib in the per sec) (ft-Ib) (ft-Ib) of Cbange % I ncrease normal group and 18. 80 percent of patients were deSig directions.9 20 . 1985.4 15. whereas isometric controls.7 18.5 122. a negligible difference between groups. patients are at a mathematical advantage. 1994. 1983).9 12. semistanding (hip at 135 variability is seen between individual subjects This variabil degrees fleXion) . M" Somerville.

The magnitude of variability of isokinetic test data both have been taught to measure it. but Power-Work per unit time. Establishing whether and how isometric and dynamic with the condition of interest. 2-2). This chapter shows how complex the measurement of muscle strength is. He factors that influence the test? They should a found that asymmetric motion and strength was present in whether the measurement has any relationship w the subjects with low back pain. before using any measurement test. ie. devices are not interchangeable. did not discriminate between patients and normal subjects. because we can measure it.46 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT asymmetry of trunk strength and range of motion. of the muscle but on many other factors too. muscle testing is reasonable. at least in normal subjects. own do not provide an adequate indication of coor The tremendous variability in the magnitude of muscle discomfort-free functional muscle activity. time or a set number of contractions. evidence or patient or clinician testimonials. What you lose you maintain. should ask themselves why they are using the test and what they hope to learn from the results of that test. tests of muscle strength can be used for diagnostic Strength-I) Force or torque produced by a and prognostic purposes during a maximal voluntary contraction. is probably less useful than using the patient as his or her Isolated and constrained tests of muscle strength own control and measuring the change in performance. It is obvious from the previous discussion that many Concentric-A shortening muscle contraction. issues regarding trunk testing with isomachines are unre­ Eccentric-An eccentric muscle contraction is solved. They will not be resolved through anecdotal tension. These issues will only be resolved through system­ which the muscle lengthens as it continues to m atic research. include Sensitivity-The ability of a test to correctly ide 1. or 3) maximal dynamic tests of muscle strength to function torque required to resist an isometric or isotonic Finally. devices in terms of measuring trunk function has not been Fatigue-The inability to maintain torque over a p established. However. The strength of a muscle is dependent Isometric-An isometric contraction is when the on a variety of factors in different domains (see Fig. Establishing the reliability of strength tests in popu­ subjects with the condition of interest. Priorities of research cal change. lations for whom the test is intended Sped6dty-The ability of a test to identify only 2. force generated by a muscle results in movement o Reliability and responsiveness have not been adequately Moment arm-The perpendicular distance from demonstrated with MMTs. Demonstrating the relationship of isometric and of force output at the end of a lever. lsoinertial-Constant resistance to a movemen CONCLUSIONS Isokinetic-Constant velocity of the joint. 2) measu 3. it is easy to measure. Responsiveness-The ability of a test to measu Systematic research is necessary. We then use the easy measure to infe of force exerted by a patient against a normative database about the difficult measure. Comparing the magnitude complex. strength is due to the myriad of factors that influence strength and that influence the measurement of muscle strength. clinicians tion. The reliability of instrumented of action of the force to the fulcrum. The validity of the of time or a set number of contractions. generates an internal force or tension but no move Measures of muscle strength are dependent on the strength a joint occurs. It is difficult for normative databases to control for the considerable number of relevant factors. What are the 'The definitions given here are operational definitions. The reliability Isotonic-An isotonic contraction is when the of muscle strength varies with the methodology of testing. The greatest shortcoming in tests of muscle strength lies in their lack of proven ReHabiHty-The degree to which repeated m diagnostic and prognostic validity when they are used for ments of a stable phenomenon fall closely togethe this purpose. 30 percent loss of power equals nance of 70 percent power. We do not measu within and between groups argues against the value of we should measure because it is more difficult an using normative isokinetic data. I would like to leave the reader with the follOWin This was because ALL subjects were asymmetric and to ponder: We sometimes measure what we m moved asymmetrically. not a c shortening or lengthening of the muscle. . It can be stated that these machines are mechanically reliable and appear Endurance-The ability to maintain torque over to measure muscular torque reliably. the asymmetry patient's problem as the patient perceives it.

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Because of the enormous financial burden related to low back pathology. PT. To establish "normal" ROM measurements as a standard for reference. Certainly the continues to be one of the most commonly used techniques meaning of joint ROM and what it tells therapists. MHS. 1928. clearly need to be considered before standards can be enforced stringently. challenged. describing the latest devices and methods for measuring joint ROM. 1985). regarding progress or been a part of clinical assessment since the early 1920s and lack thereof (Bohannon. While it is difficult to compare reliability stud­ ies. 1985). Miller. sex. Hewitt. and predict outcome. PT SUMMARY Early measurement of joint range of motion (ROM) was initiated by the necessity to assess disability from postwar injuries. explain perfor­ mance. 1989. Measurements of joint ROM provide information designed to describe status. race and ethnic background. The universal goniometer has been established as one of the most accurate and efficient instruments used in measuring joint ROM. population differences such as age. CHAPTER 3 Joint Range of Moron Jeffery Gilliam. correlating the measurements taken with the actual angles involved. those methods with established standardized procedures demonstrate a higher degree of repeatability. as well as vo­ cation. has been perSistently today (Cobe. Measurements related to functional ROM continue to be the key to providing meaningful information about the patient's progress. as well as to the patient. Miller. examining reliability and validity studies on ROM for that joint. has been an accepted part of the evaluation procedure and Therapists have also witnessed that the term normal is often performed clinically without the understanding of ROM assures neither normalcy nor that a patient will return its purpose and usefulness in providing information for the to normal functional activity. It is critical to establish reliability in goniometric mea­ surements to substantiate consistency over time. Within this chapter. Some level of validity should al­ ways be demonstrated with measurements of ROM. 1982. 1928. methods of mea­ suring lumbar ROM for purposes of function and disability have come under scrutiny. especially in the area of lumbar ROM (Waddell. The measurement of joint range of motion (ROM) has clinician. each section covers a specific joint. particularly when related to 49 . particu­ for evaluation used by physical and occupational therapists larly with regard to patient function. as well as providing tables with "norms" for joint ROM and information regarding functional ROM. Smith. The necessity of taking joint ROM measurements 1992). oes Ian Kahler Barstow. document change.

1969.. (For a more in-depth historical accou on specific joint ROM provide both a table of "normal" methodology and instrumentation. 1 of the evaluative process.. 1983). assessment in physical therapy. functional activities can be predicted to aI. throughout the medical world (Smith. providing reliability estimates that demon­ deed. with particular emphasis on the upper ex­ Hellebrandt et aI. 1955) added co representation of the changes displayed by the patient. ods for measuring range of motion have been establ 1989). Moore joints. (Michels. see Moore's two joint ROM measurements and information regarding func­ work [1949a. 1955). 1982). Even though the methods indicated by the Ame In assessing ROM. This information in turn allows therapists to make decisions regarding the necessity of specific treatment for the patient. as distinguished from subjective physiologists. Rothst a kinetic chain. 1992). visual estimation. Objective measure­ and began to use protractor goniometers to measur ments are characterized by the relative independence of relationship between mensuration and disablemen the examiner. 1982). 2) to document change. Another goal is to introduce alternative methods that earlier researchers in recognizing the necessity of loc depict novel and insightful procedures and instrumentation the "axis of motion. erably to the progression toward increased objectiv Bohannon (1989) lists four basic purposes for objective measurements. and 4) to predict outcome. 1990). climbing steps or combing hair). 1949. Therefore. When assessing joint ROM.) The determination tha . 1982). In addition. as well as approach and modifi­ cation of treatment. By measuring the ROM of various joints acting along 1988. as well as docu can determine the patient's ability to perform a speCific normal ROM values (Boone & Azen. Realizing that clinical measurements are relating ROM to disability (Smith.50 UNIT TWO-COMPONENT ASSESSMENTS OFTHE ADULT return to work status (Waddell et aL. However.. Miller. has been included. 1989. Camus and Amar (Smith. 1979. which offers an in-depth review of commonly used converting their observations into quantitative information niques. ongoing res ments in relation to measurements necessary for functional has continued to substantiate the reliability and valid ROM (e.and intraobserver reliability and va measurement procedures and to provide an accurate (Hellebrandt et aL. des measurements.g." as well as appropriate place designed to acquire information regarding changes in of the two arms of the goniometer along definitive musculoskeletal joint position. Salter. 1989). Although a variety of instruments measures: 1) to describe status. A fifth goniometer has been recognized as an accurate reason should be to encourage the patient's interest and convenient instrument for measurements (Defib motivation in the treatment program (Palmer and Epler. 1949b). 1982). 3) methods have been used for measuring ROM. GogiaetaL. 1949b].g. Leighton. e. which was followed by th tional ROM. Moore. the therapist certain methods and instrumentation. the therapist can determine the Academy of Orthopedic Surgeons have been widely patient's status by comparing measurements with those of both the reliability of these methods and the certain the uninvolved joint or with "normal" values. 1987.. Elveru e task. 1964. 1982). 1985). 1949a. It also gives some indication of HISTORICAL PERSPECTIVE progress. The early beginnings of ROM measurements date Assessment of joint ROM is based on what are termed to the first decade of this century. Moore. it was not until the The purpose of this chapter is to provide the clinician 1940s that formal studies were performed to d with a quick reference to reliability and validity of ROM mine the reliability of these measurement techn measurements for various upper and lower extremity (Hellebrandt et aI. as well as anticipated functional status or disabil­ ity (American Medical Association. 1987. Although goniometry has long been use some extent (Bohannon. The ability to what has been cited as "normal range" values are h document change is made by the therapist's remeasure­ questionable given the paucity of research that w ments made over time. it should be noted that objective measures can by the American Academy of Orthopedic Surgeons provide evidence of improvement (increases in ROM) often basis for this system was established by research perfo earlier than subjective measurements or measurements of by Cave and Roberts (1936) and has been widely acc function (Bohannon.. 1949. By knowing a patient's measure­ confirm these methodologies. it is clear 15 percent of the Gross National Product may be spe that they will continue to use assessment of ROM as a part the low back problem (Cats-Baril & Frymoyer. 1989). by the year 2000 it is estimated difficulties with which therapists are confronted. much of the earlier literature appears to strate the apparent subjective error (Bohannon. Riddleetal. a special section on ROM for the lumbar s therapists want to link the act with a measurement. when two Fr objective measurements. Despite the tremities. The pro An ongoing goal should be to constantly make efforts sion of these standards to improve objectivity by lo toward reducing the amount of error of variance in both at inter. relying always to The nomenclature and much of the standardized m some extent on the examiner's judgment (Rothstein. the univ to explain performance. consequence of the postwar era and the necessi Rothstein. The majority of the sections landmarks. probably never completely objective. 1949..

Bohannon. difficult and Wolf (1989) demonstrated a strong relationship be­ in finding bony landmarks or in identifying the axis o tween the Ortho Ranger (electronic goniometer. 1976. validity. when assessing lumba lateral and over-the-joint methods of goniometry for mea­ ROM. surement due to equipment fault. the accuracy of goniom 1978. the thera reliable by Hamilton and Lachenbruch (1969). i. it thus becomes ology. be to compare an instrument designed for measuring ROM 1976. Low. they can be reproduced over time. 1984). Low. Ek­ mation about the vertebrae. Rothstein and colleagues (1983) anatomy and appropriate placement of the goniometer to demonstrated a high level of interdevice reliability. The use of different instruments to make measurements can be highly correlated with the status of measurements of the same joint angle was demonstrated as specific tissue.e. 1976).. Rothstein et eters can be ascertained. and 1994). an electrogoniometer) for measuring elbow ROM showed significant differences between the goniometers and sug gested that interchangeable use of the different types i RELIABILITY inadvisable. 1992).. fluid goniometer. A make qualitative judgments concerning worth. researchers compare it with anothe such as length and mass of a body segment and ability to measurement of known validity (criterion-based validity identify bony landmarks. realizing the limitation of the information received subjects (parallel-forms reliability) indicates whether mea­ is paramount The goniometric measurements give th surements obtained can be used interchangeably (Roth­ examiner quantity in degrees concerning a joint being stein & Echternach.. who used pist is limited in the interpretation to a measurement o three different devices to measure finger joint angle. tion. Until the results of the ROM lower extremity. (1993) demon­ assessed (Michels. can be established by comparing two instrument 1985). These variations certainly leave the therapist with of measurement. Concurrent validity. one of unknown validity and the othe the sobering thought that any interpretation of the data on having demonstrated validity during measurement of goniometric measurement must be performed with discre­ specific joint (Rheault et aI. 1986). It can be said that objective measures are only as good as their repeatability. differences due to the time of day with something that has a known angle (Crowell et al. 1988). The varied results of these studies suggest tha although a small amount of error may occur within th Clinicians agree that measurement of ROM is an impor­ goniometer. Hellebrandt VALIDITY and associates (1949) defined good reliability for ROM as an agreement of measurements within 3 degrees of one It has been suggested that the goniometric error i another.. 1987 1983) demonstrated no difference between using the Rothstein. reliable. Hellebrandt et al. 1993).. In quantity in degrees only. or value of the joint being assessed (Bohannon. 1987. Other methods such . Although some small amoun goniometric measurements have been demonstrated to of error may occur within the instrument used for mea vary between different joints of the body (Boone et al. 1989). 1982). comparing three different-sized goniometers to measure While therapists have depended on their knowledge o knee and elbow ROM.e.. Youdas et al. FL) and a universal sons have long been referred to as the "gold standard" i goniometer for shoulder internal and external ROM but a terms of validity studies and have been used effectively i poor relationship for elbow movements. 1955). or activity. disks. Other factors influencing varia­ (Rothstein & Echternach. Daytona Beach. To validate a measurement o aI.. measurement error may be attributed to factors unknown validity. and that by standardizing procedures. or muscles.varied instrumentation was confirmed by these studies. Radiographic compari Orthotronics. the main source of variation is in the method tant part of the assessment process. A comparative studies of ROM (Enwemeka. 1993). Inc. their ability to be reproduced accurately (Gajdosik & Bohannon. functional movement. For example.. that measurements are taken (Russell et al. Greene ensure accurate measurements (content validity). When assessing the accuracy of goniometric measure Comparing two different forms of a test on the same ments. nor can th strand and coworkers (1982) determined that a standard­ therapist determine the level of function of the patient from ized method increased reliability in jOint motions of the the measurements alone. goniometry (universal goniometer. rotation may jeopardize the results. To substantiate what determines a reliable mea­ negligible and that the source of errors is from poo surement procedure is difficult at best Because reliability of methodology (Salter. improve paramount that these measurements are shown to be reliability can be realized. However. usefulness comparison of two methods of goniometry (Grohmann. a class of criterion-base levels of goniometric skills among raters (Fish & Wingate. An example of this would tion are changes occuring over time (Atha & Wheatley. 1949. i. the therapist cannot interpret the results as infor suring the elbow joint In examining methodology. this does not give u strate an example of this when comparing goniometric information about a specific tissue or allow the examiner to measurements with visual estimates of ankle joint ROM.. 1983).

When m 40 years of age.. These studies clearly point shortcomings of following a strict adherence to a giv NORMALCY IN JOINT RANGE of "normal" measurements of ROM rather than all OF MOTION specific patient characteristics to determine the op measurements for a given situation. 1928) demon­ segments. The presence of scars.. 1982. a uni measuring ROM in the hip. noting an overall reduction in joint ROM with measuring the joints of the hand and wrist. 1984. joint surfaces. A point of reference is functional movement patterns is paramount when m helpful in giving information to the clinician about where ing joint ROM. decades of life. 1969). When determining joint angle: a dorsum goniometer. particularly within the wrist. offer new directions in strengthening content While the above studies demonstrate some ge validity by demonstrating criterion-based validity (Gadjosik trends in regard to gender and age. 1988. Vander-Linden & 1965. (1991) found females had greater total active motion 1984. 1979. and a pendulum goniometer. Because a subst 1979) examined age differences in a group of male number of variables can add to measurement error subjects. Hewitt. available with regard to ROM differences in race and e backgrounds (Ahlberg.52 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT as cinematography (Bohannon. et al.. ma rough averages for various joint ROM measurements was make the wrist difficult to measure in terms of gonio followed by studies in which measurements of a more placement. 1987). Allender et al. 1989). knee. 1969) demonstrated no significan clearly indicated in upper extremity joints) and that females ance when looking at three different goniomete have greater ROM than males throughout life. as well as other motion analysis systems (Day et al. However.. the creased variations in measurements of the wrist problem becomes specificity of standards. Roaas & Andersson. and activity level. 1991). digits. and 3) therapists are able to Medical ASSOCiation. (Hamilton & Lachenbruch. allowing for accurate alignment of the go strated that females had on the average greater wrist eter during ROM measurements of the hand and motion than males. Mallon and colle 1993). edema. Mallon et al. Many gender. of digital ROM in young adults. large hypertr populations. Miller (1985) suggests three advanta the patient is in terms of "normal range. specifically indicating a progressive reduc­ providing a reliable method of measurement and i tion in hip abduction and rotation during the first two mentation is foremost. fewer studie & Bohannon." Standards that using functional ROM over other methods: 1) go clinicians use to judge the progress of their patient may treatment are based on individual characteristics. electrogoniometry (Chiarello & Savidge. 1994. Pearcy et al. It is important to stabilize the numerous specified population (Cobe. and ankle of males 30 to goniometer. it is important aspect. includin patterns and ROM. Bell and Hoshizaki (1981) demonstrated in An early study assessing the finger joint angle (Ham eight different joints a general decline in ROM with age (not & Lachenbruch. Petersen et al. as in rheumatoid arthritis. 2) therapists are medicolegal and disability evaluations use "norms" as a assisted in understanding the problem and devel standard in determining the level of disability (American strategies for treatment. Scholz. 1982). Roaas and Andersson (1982) found ing ROM for the wrist and hands in flexion and exten Significant differences between measures found by previ­ the clinician is confronted with basically three techn ous studies (American Academy of Orthopedic Surgeons. su assist in determining the cause of functional deficits. Finally." metry in ROM measurements (Boone & Azen. returning the patient to an ROM also recommended that normative data be available to functional. 1991. This may be particularly true in chronic large number of joints and the intricacy in the variat diseases or injury. An early study by Clark (1920) that listed and deformed joints. More recent studies (Boone & Azen. Boone & Azen. The num Although the message is clear that normal values of joint joints and multiple muscle attachments may lead ROM are necessary as a standard to measure progress.. 1979). 1 Roach & Miles. 1991). Understanding the ROM that is necessa which to compare the measures. this rationale has been challenged (Miller. 1969). for measurement: 1) measurement utilizing vola . General stan­ compared with a more simple joint like the elbow dards for ROM can not be applied across the board for all 1976). 1928. age. while While it is imperative that reliability is demonstrated for these studies of normal measurements improve our k an ROM measurement procedure and that some form of edge base. In looking at normal Wilhelm. it has been suggested that the uninvolved joint be used as a reference point to assess progress made in the involved WRIST AND HAND joint. causing changes in movement measuring the joints of the wrist and hand.. on relieving a problem rather than on achieving Because many studies have demonstrated bilateral sym­ quantity that has been deemed "normal. the therapist should not lose sight of the validity is indicated to confirm a "true" measurement. the necess increased age. 1985) from the standpoint that compensatory mecha­ Many complicating factors must be considered nisms alter biomechanics.

the use of a standard error of measurement (SEM) in the wrist of ±4 to 6 degrees appears to be an acceptable figure for intratester reliability while generally a slightly higher SEM. edema. Measurement of wrist flexion and extension can be taken by using (A) the radial side of wrist and hand.g. structure and biaxial movement of the carpometacarpa . Low.& Moran.and interobserver variability (Fig. The American Medica Association (1988) quantifies the loss of the thumb as a 40 FIGURE 3-1. 1989. ±6 to 8 degrees . 1985). percent loss of the total hand . 3-2) to determine functional flexion of the digits (American Medi­ cal Association.. Hamilton & Lachen­ bruch. although this has not always been found to be the case. Hamilton and Lachen­ bruch (1969) found the lateral (radial) method of measure- FIGURE 3-2. LaStayo and Wheeler (1994) found that the dorsal/volar alignment method had a higher reliability than either the radia'l or ulnar method. In estimating changes in ROM. 1988) have been used follOWing tendon repair (Jansen & Watson . as LaStayo and Wheeler (1994) found a lower SEM and slightly higher intertester reliability during passive wrist measurement. demonstrating small intra. although with less substantial data confirming their reliabil­ ity. 1969. Boone & Azen . and 3) the use of the radial surface (Hamilton & Lachenbruch. 1979. The use of these different methods in measuring wrist ROM has led to varied approaches with conflicting results (Horger. 1990. Methods using a ruler to measure the distance between the finger and the palm of the hand (often a speCific point e. 2) the use of the ulnar surface (Moore 1984. When comparing the three methods in measuring passive wrist ROM in a clinical setting. Measurement of finger flexion uses a method o measuring the distance between the pulp of the finger and the dista palmar crease. Because of the unique or (C) the suggested volar or dorsal side of hand. 1986). 3-1). 3-3). Solgaard et al. (8) the ulnar side of hand . 1976).. pulp of finger to distal palmar crease) (Fig. Norkin & White. The importance of the thumb and the functional loss in its absence is difficult to quantify. 1993). other methods have been presented in the literature that raise some interest. Dijkstra and associates (1994) present a method for measuring thumb appositon (distance between the thumb and wrist). and enlarged jOints make i apparent that appropriate selection of methods should be determined by the adaptability of the method to the speCific clinical situation . is characteristic of intertester reliability (Bear-Lehman & Abreu. 1981). 1969) (Fig. ment was as reliable as the dorsal method when measuring finger ROM. Under controlled conditions. Problems with good joint alignment second­ ary to joint deviation. While the above studies present proven methods for measuring ROM in the wrist and hand .

A joint and the thumb's ability to move through a 360-degree are. the ability to measure circumduction is of value to the therapist. particularly in a clinical setting Teague. 64. While returning a patient to what would be consid FIGURE 3. Browne and coworkers (1979) present a method for measuring circumduction of the thumb by taking measurements of the axes of the ovoid-shaped design of circumduction (Fig. as weH as assessin effects of adjacent joints in the finger and how the affect ROM. Gruenwald. However.. 1958). general concensus that the metacarpophalangea (Mep) has 90 degrees of flexion and the proxima phalangeal joint (PIP) has 100 degrees . B. Me thod for measurement of circumduction of the thumb to evaluate results of oppo nensplasty.. demonstrating a n . indicating an increase in circumduction motion. o f movement. Plastic 1985 study by Palmer and coworkers. 3-6) give the therapist a quantifiable amount . Circumduction motion of the metacarpal head about a normal ROM is deemed important. 1965. 3-4). An increased distance in mea­ surements of the long axis (X-Z) (Fig. a paucity of research on the measurement of digital ROM and effects of contiguous joints on ROM exists (Mallon et aI. 1991). As previously mentioned. However. M. Tables 3-1 and 3-2 give reported provided by several researchers for "normal" ROM wrist and hand and for the digits of the hand. while the interphalangeal joint (DIP) has 70 to 90 degrees (Am x Association Orthopedic Surgeons. Digital ROM has often been left to a FIGURE 3-5. American cal Association . is functional ROM.I.54 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT FIGURE 3-3. A. 3-5) and short axis (Y-Y') (Fig. A method for measuring thumb apposition measures the distance between th e pulp of the thumb and the \. E. 204-207) performed 52 standardized tests .Tist.. C [19791. a more critical m long axis (X-Zl. the intricacies of the joints of the hand and the complexity of the movement patterns most assuredly match the complexity of its function. The range of the first metacarpal in the long axis. Z. 10 normal s and Reconstructive Surger}l. End of movement.4 . and a short axis (Y-Y') (Adapted from Browne. little has been done way of differentiating the values among the digi quantifying these differences .

AMA = American Medical Association. 10 degrees for radial deviation. who looked at func tional ROM in regard to three feeding tasks (eating with spoon. 1990). AAOS = American Academy of Orthopedic Surgeons. Only a small percentage of th active ROM (AROM) of the joints was actually required fo functional tasks. Start like other musculoskeletal joints. functional flexion average 61 degrees at the Mep joints . degrees extension. eating with a fork . These estimates are more in line with earlie studies by Palmer and colleagues (1985). A. . t N = 109. In this study. End of movement. In looking at ROM for joints o the hand (Hume et aI. Ryu an colleagues (1991) demonstrated that a battery of activitie of daily living couId be performed with 70 percent of th maximal range of wrist motion. when our goal is to return patient to extracurricular activities. This is somewhat more than tha estimated previously by Palmer and associates (1985) Safaee-Rad and coworkers (1990) . The range of the first metacarpal in the short axis. male. Wrist rotation was found to b negligible.54 y. found that 40 degrees forearm pronation to 6 degrees forearm supination . 11 activities of daily livin were evaluated for functional ROM of the Mep an interphalangeal (IP) joints. These measure ments indicate ranges that are required to perform basi functional activities. The thumb demonstrate functional flexion averaging 21 degrees at the Mep join and 18 degrees at the IP joint. ELBOW FIGURE 3-6. which was 40 degrees fo wrist flexion and extension and 40 degrees of combine radial and ulnar deviation. and drinking from a handle cup). attention in the way of reliability studies. and 1 degrees for ulnar deviation. . Kruseo doint (1965) (1979) (1 9 48) (1974) (1975) (1958) (1986) (1939) Wrist Flexion 80 76 80 90 60 70 77 60 Extension 70 75 55 70 50 60 73 55 Radial deviation 20 22 20 20 20 20 26 35 Ulnar deviation 30 36 40 30 30 30 40 75 • Studies not showing demographics in table did not include them in the original research. r N = 31. B. As a hingelik TABLE J l MEASUREMENTS WITIDN UMlTS OF " NORMAL" ROM IN DEGREES FOR THE HAND AND WRIST. REPORTED BY SEVERAL AUTHORS AND RESEARCHERS· Boone & Dorinson & Esch & Gerhardt & Solgaard Wiechec& AAOS Azent Wagner Lepley Russe AMA et al. we clearly must asses the ROM necessary to realize a predetermined moto pattern. male and female.24--65 y. with 10 degrees wrist flexio to 25 degrees wrist extension and from 20 degrees wri ulnar deviation to 5 degrees wrist radial deviation wa required to perform tasks. 60 degrees at the PIP joints and 39 degrees at the DIP joints. however.=!. This amount was 32 percen of the amount of flexion that was available. 18. the elbow has receive of movement.

Arrow indicates the position of upper arm again st (Laupattarakasem.. indicating a wide range of errors for both the goniometer and visual estimation (Baldwin & Cunningham..g. ~n a comparison of two methods using a half-circled goniometer for goniometric measurements of the elbow. Earlier studies of the elbow have questioned the reliability of the universal goniometer when comparing it with visual estimation.. Cl Beach. & Nunley. Digital ranges of motion: Normal values in young adults. has been an area of research to determine reliability. A comparison of two measure­ FIGURE 3-7. 1 MP Extension -16 --26 determined a high level of both intertester and intra t Flexion 85 86 PIP Extension -5 -8 reliability (ICC = 0. Orthotronics. Another study performed during that same period indi­ cated a moderately high level of reliability. joint. the Ortho Ranger pronation. Brown. W. e. while measuring fore Flexion 105 105 DIP Extension -5 -12 Flexion 71 71 Ring MP Extension -15 -30 Flexion 99 98 PIP Extension -4 -8 Flexion 107 109 DIP Extension -4 . A new method for measuring forearm supinatio ment devices (Greene & Wolf. W . male and female. 271-274. 18-35 y. A. MP = Metacarpophalangeal.89 and 0 . with intraob­ selver error less than 3 degrees and interobserver error less than 5 degrees (low. respectively) when u Flexion 103 101 three different-sized universal goniometers for measu DIP Extension -4 -11 the elbow position. One of the better comparative stu Index with regard to methodology (Rothstein et al. Daytona simple design of instrument and a controlled reliability study. a more recent study comparing a univ RECORDED BY MAllON AND goniometer with a fluid-based goniometer indicated COLLEAGUES· intertester reliability for standard goniometers (r = 0 Joint Motion Male Female compared with the fluid-filled goniometer (r = 0 .. J.) .96. and studies to substantiate reliability Flexion 90 91 been elusive. 16A. Negative numbers indicate hyperextension. Flexion 71 73 Long The ability to measure pronation and supination MP Extension -13 . as well as the use of various measurement devices.92) (P erick et al. The recommendation that the patient PIP Extension -4 -9 a short stick. 1976).23 been less exact.56 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT TABl [:~-2 elbow ROM demonstrated good within-session relia but a poor relationship between the two device "NORMAL" DIGITAL ROM IN DEGREES. Data from Mallon. 119901 . Grohmann (1983) noted no difference between the lateral and the over-the-joint methods of goniometric measure­ ment of the elbow joint. et al. 1976).. 1989). lnc. Axial rotation gravity goniome (electronic goniometer.I. H . in measuring Orthopaedics and Related Research. The study of different methods of measurement. a pencil. FL) and the universal goniometer.12 Flexion 65 61 Small MP Extension -15 -22 Flexion 103 106 PIP Extension -7 -11 Flexion 106 106 DIP Extension -3 -12 Flexion 63 66 • N = 120. 1976). 1988). 882-887. 251. R . The Journal of Hand Surgery . its axis of rotation is at approximately the center of the trochlea (Morrey & Chao . (1991). addition.

Using a double goniometer. male and female. measuring scapular motion used the spine (third thoracic Studies to determine functional ROM (Safaee-Rad et al. angle o f the spine of the scapula to the vertical: glenohumeral angle is the delineation of the two needs to be identified when per­ angle between the spine of the scapula a nd the humerus.96 and 0. A method for measuring both glenohumeral and contributions of both the glenohumeral and the scapu­ scapulothoracic ROM using a double goniometer. designed to determine relative contributions of the scapu­ offering the examiner some assistance with regard to a lothoracic and glenohumeral movements to scapular plane point of reference for alignment of the goniometer. This method demonstrated a high level of scapulohumeral " rhythm" (Fig. et al.. '\' N = 31 . 595-604. AMA = American Medical Association. The reliability of this intertester reliability (r = 0. who demonstrated both intratester and intertester reliability when measuring the shoulder at r = 0.:f: Krusen Joint (1965) ( 1979) ( 1948) (197 4) (1975) (1 958) ( 1988) (1986) ( 1939) Elbow Flexion 150 143 145 150 150 150 149 135 Radioulnar Pronation 80 76 80 90 80 80 S6 90 Supination 80 82 70 90 90 SO 93 90 • N = 109.) . IS­ 54 y. eating with a fork . Boone and Azen (1979) provided values of 0 to ments (variance of > 3 degrees 50 percent of the time and 145 degrees and 0 to 140. Shoulder external rotation was examined by Boone and Azen (1978). . t N = 30 .t et a1. REPORTED BY SEVERAL AUTHORS Boone & Dorinson & Escb & Gerhardt & Petherick Solgaard Wiecbec & MOS Azen.94) for measuring supination technique has been challenged in recent years in a study by and pronation (n = 50) (Laupattarakasem et al.. The results of this study When looking at normal values for elbow flexion and indicated that the margin of error for intratester measure­ extension. Earlier studies (Helle brandt et aI. 1970) was Physical Medicine and Rehabilitation . x = 24 y. Summation of the two angles is the arm angle. "NORMAL" ROM MEASUREMENTS IN DEGREES FOR THE ElBOW. AAOS = American Academy of Ortho pedic Surgeons . Youdas and associates (1994). Because of the combined FIGURE 3-8. Archives of Monroe. (From Doody. male. vertebrae) and the inferior angle of the acromion process of 1990) found that the required ranges for performance of three feeding tasks (eating with a spoon.5 degrees when comparing a > 8 degrees 10 percent of the time between first and population younger than 19 years with one older than 19 second measurements) was dinica:]]y unacceptable. years.. 1990). male and female. [1970J.97.62 degrees supination utilizes an axial rotation gravity goniometer and the glenohumeral at 112. respectively. and drinking from a handled cup) required 70 degrees to 130 degrees elbow flexion and from 40 degrees forearm pronation to 60 degrees forearm supination. with the exception of medial rotation and shoulder abduction. 1966). the authors cleverly Another method for measuring forearm pronation and isolated the contributions of the scapula at 58. An early study (Doody et a!. Wagner Lepley Russe AMA et al. forming ROM measurements of the shoulder (Friedman & Shoulder movements during abduction in the scapular plane . abduction. Scapular angle is the lothoracic movements. supination and pronation has been cited (Macrae 1983). 24-65 y. 3-7).52 degrees to give the total (Fig. SHOULDER It is well recognized that the shoulder is one of the more complex functional units within the body. resulting in total shoulder ROM. respectively. 3-8). S . 1949) indicated reliable repetitive measurements involving shoulder joint movements. G. Additional normative values are listed A method utilized by DeVita and colleagues (1990) in in Table 3-3. 51..

58 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT FIGURE 3-9. Gibson and coworkers (1995) demonstrated a high tion . and dri external and internal rotation. 1991) used a linear measurement from the intertester reliability for measurements of flexion. the amount of shoulder abduction needs to be noted. This position is the most functional position for elevation. During measurements of shoulder internal and external rotation .. and medial rotation was poor. tion . 3-11). as this too may limit the available ROM (Fig. In this study. . decreasing in aU ranges slightly with increase particularly the Kibler (1991) method. the scapula as the "moveable" reference point Another all motions ranging from ICC = 0. tasks (eating with a spoon. a universal goniometer and a gravity-activated angle finder were utilized to determine that medial rotation of the humerus accompanied active and passive shoulder flexion movements. however. It is important to note the amount of shoulder abduction FIGURE 3-10. plane. It has to movements measured.g. The plane of the scapula (30 degrees-45 degrees to the frontal plane) has been described as the most functional position for elevation because the capsule is not twisted on itself and the deltoid and supraspinatus are best aligned for shoulder elevation (Zuckerman & Matsen. specific. 1989) (Fig. Accompanying motion that from a handled cup) required 5 degrees to 45 de occurs during active shoulder flexion was ingeniously determined in a study by Blakely and Palmer (1 984). the clinician needs to ments from several authors is provided in Table 3-4 be aware of the contributions not only of shoulder flexion Functional ROM for the shoulder during three fe and abduction but also of accompanying motions. wh method (Kibler.95. utilizing two different-sized universal FIGURE 3-11. eating with a fork . as this may limit ROM measurements (Fig. (Boone & Azen.87 to 0. A list of normal ROM mea When measuring shoulder ROM.92) for the method of unaffected with different-sized goniometers in this DeVita and coworkers (1990). extension. 1979). 3-9). been suggested that these methods may provide results that " Normal" ROM within the shoulder appears to b prove to be somewhat difficult to interpret by the clinician . and lateral rotation ranged from ICC = 0.84 to When investigating various techniques used in previous Intertester reliability for horizontal abduction and a studies. the plane in which shoulder elevation is made should be recorded. Also. T hey demonstrated intratester reliability for degrees to 45 degrees to the frontal plane. e . they found low however. T he plane of the scapula measures approxima goniometers. 0. 3-10).99.i ntertester reliability for the Kibler (1991) method. Measurement of shoulder abduction in the s when measuring shoulder external and internal rotation . a nearest spinous process to the inferior angle of the scapula.and intertester reliability (intraclass correla­ metric measurements of shoulder PRO M appeared tion coefficient [ICC] = 0. reliability between testers appears to be sp . Riddle and colleagues (1987) examined both intertester and intratester reliability of shoulder passive range of motion (PROM). The g level of intra.

a moder­ & Mundale. 1955. Schenker. and 5 degrees to 25 degrees shoulder internal rotation in angular measurements (Robson. the cervical ROM degrees occurring in the cervical spine. demonstrating a high level of reliability ence point (Kottke & Mundale.. 1966). Leighton. Kadir. . with a definitive axis of rotation. SEVERAL AU11IORS AND RESEARCHERS Boone & Dorinson & Esch& Gerhardt & Wiechec & AAOS Azen* Wagner Lepley Russe AMA Krusen Joint (1965) (1979) (1948) (1974) (1975) (1958) (1939) Shoulder Flexion 180 167 180 170 170 150 180 Extension 60 62 45 60 50 40 45 Abduction 180 184 180 170 170 150 180 Internal rotation 70 69 90 80 80 40+ 90 External rotatio n 90 104 90 90 90 90+ 90 Horizontal abduction 45 30 Horizontal adduction 135 140 135 • N = 109. 1964. it becomes have contributed greatly to our knowledge of normal virtually impossible to maintain congruency with the refer­ cervical ROM . 1957 . Nordin & Frankel. . Much literature (Safaee-Rad et al. Slight variations in alignment of the goniometer's ing . It has been demonstrated that exists on various techniques that have been used over the restrictions in elbow joint ROM significantly increase the years to try to determine more accurate and efficient ways need for an increased arc of motion for both shoulder to measure cervical ROM (Defibaugh . Schenker. 1959. 5 degrees to 35 degrees shoulder abduc­ arms or placement of the axis may cause large variations tion.. the cervical spine remains one of the least (Defibaugh. the axis of rotation for intratester reliability. 1986). Improving on this method in terms of the head in anyone plane approximates the change in the efficiency. with varying degrees of CERVICAL SPINE accuracy. 1993). To avoid inaccuracies due to changing reference points. The tape et al. 3-12). 1982).. Hand. 1938. spine cannot be isolated. as well as the inability to 1956). Having 23 points of contact at which motion occurs tion can be achieved by attaching a gravity goniometer to from the occiput to the first thoracic vertebra. 1955. 1959). flexion and internal rotation during feeding tasks (Cooper Loebl. Measuring the total movement of Youdas et aI. chin to acromion tip) in many of the methods tried over the years (Storms. Mayer et al. shoulder flexion . 1981. chin to sternal notch . accuracy . male. cervical the subject's head and taking measurements from changes motion combines sliding and rotation with flexion (Kottke in head position . 1990). when compared with radiographic measurements (Field­ 1989). instrument (CROM) has demonstrated a high level of alignment of the goniometer's axis with the external intertester and intratester reliability (Capuano-Pucci et al. Kottke & Mundale. However. 1993). extension (Norkin and White. measure is used to determine the distance between bony landmarks (e. 1967.ith each of the cervical vertebrae. 1978. With the universal goniometer. MOS = American Academy of Orthopedic Surgeons. auditory meatus has been used for measuring flexion and 1991) (Fig . Anatomically. 1959. 1959. and ease of use. Because of the difficulty in aligning the goniometer et al. Moore.. Tucci et al. 1985). . 1938.. Because flexion and extension occur at ate to good level of accuracy was demonstrated w. Hand. 1976). Due to the shift of the Cinefluorography and the electronic digital inclinometer line of reference during flexion and extension. 1964b. consequently. Moll & Wright. While the spinal segment is one of the most frequently several early studies placed or attached a gravity-assisted treated areas of the body. a single and rotation. 1956). . 18-54 y. This appears to have been one of the more accurate locate standardized landmarks to act as points of reference techniques for measurement described in the literature (Cole. proving to offer a higher level of reliability instantaneous axis of rotation (IAR) for the entire cervical than side-bending and cervical flexion (Tucci et al. An accurately yet most highly measured of all musculoskeletal increased level of accuracy through increased standardiza­ joints.g . 1986 .. AMA = American Medical Association. 1991). it continues to be one of the most device or an equivalent measurement device to the head elusive areas in determining reliable measurements for and determined ROM by changes affected by gravity (Buck ROM . intertester reliability proved flexion and extension movements is segmental in the to have only a marginal level of accuracy with extension sagittal plane with multiple axis.

are based on lost ROM versus a mean value .e. American M cal Association . 17-62 y . Sullivan et al. data (Gilbert. are inadequate (Sullivan et aI. Interestin many orthopedic surgeons (Davis. occupation (Russell et al. it is of cr importance that thorough. 1979. In the appendicular skeleton. 1988). § N = 58. Unfortunately. spinal ROM measurements are influenced to diffe degrees by many factors . as well as hypomobility. 1990). disability ratings are la based on the lumbar spine ROM measurements. i. 1987). wal. 1989). Frym et aL.. Howes & Isdale. Burto LUMBAR SPINE Tillotson. 18-23 y. 1993)..e. maJe and female. 1984). warming up (Keel Cats-Baril . 1986. male and female . The use of the CRaM instrument in measuring cervi­ cal ROM . a Table 3-5 lists normal ROM measurements provided by paucity of good.§ AMA Buck' Defibaugbt et al. 1994) consider much ROM. Thus. sagittal p ROM is determined solely by comparison with norma FIGURE 3-1 2. previous histor peopre younger than 45 years of age and costs society an low back pain (Burton et ill. For example. and valid data exists . 1986). normal ROM can determined by comparing ROM measurements both normative data and with the uninvolved limb (Amer Academy of Orthopedic Surgeons. accurate documentatio mobillity is undertaken to determine hypermobility (Bu et al. 1991. 1 Tanz. male . t N = 30. 1965. i.. and the techni the management of this industrialized epidemic is becom­ with which normative data are collected (Pearcy & T ing increasingly important (Helms. r N = 20. as the mean value recommended by the American Me Association. through a ch plane of motion.. x = 23. 1987). No various contributors. 1992). 20-40 y. Objective mea. 1994).. 1971). sitting-to-stan estimated 25 to 100 billion dollars a year (Frymoyer & height ratios (Batti' e et aI. TABLE :~-~J SEVERAL REPORTED VALUES FOR "NORMAL" ROM OF DIE CERVICAL SPINE Capuano-Pucci Mayer et al. Moll & Wright. 1968. ... 1993).5 y.60 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT surement of spinal ROM is thought to be of cr scientific importance in determining disability (Amer Medical Association. normative data. reliable. In the axial skeleton. obesity (Batti' e et aI. gender (Batti'e et aL. male and female .. McKenzie. 1991). 1989). 1994).. time of day (Ru et al. 1971). 19 and monitoring the patient's progress (Mayer Gatchel. ] 953). 1987. hypermobility leading to "instabil to be pathologic (Froning & Frohman. selecting appropriate th peutic intervention (Maitland.. 1991). 1971. These variables are thoug include age (Moll & Wright. . le Simple backache is the most disabling condition of activities (Burton & Tillotson. 1990). The demand for scientific evidence in aI.~ (CROM) (Electronic IncUnomet Motion (1 988) (1959) (1964) (199 1) (1993) Flexion 60 67 59 50 49 Extension 75 77 80 70 67 Rotation Right 80 73 85 70 87 Left 80 74 89 69 84 Lateral flexion Right 45 51 43 44 Left 45 49 44 39 •N= 100.

. With respect to height. L. From Bogduk. observed males to have greater ROM Tibrewal. & Twomey. "Thes (1993). using the mexlified importance of three-dimensional movement (Pearcy Schober technique. colleagues (1989) could not find any clear correlation The objective measurement of 15 joints encased in 1 between sagittal mobility and trunk height.. and sitting-to­ consideration since the gold standard is of limited use is th standing height ratio . 1984. ~ . Burton and objectivity of the methods to gain normal information. Pearcy et aI. For example.. flexible curves (Burton. flexicurve. a large normative base using bias and error (Deyo et aI. With regard to Newer knowledge on lumbar spine motion reveals th gender. Moll and Wright (1971) . normal values is the visual estimation (Nelson et aI. Finally. distraction Youdas et associates (1992) have demonstrated circadian variations coupled fashion . 1988). In research. and motion analysis Wright. the inclinometer (Loebl. 1984). are subject to observ concerns regarding exposure. 1994. Lateral Flexion Axial Rotation Flexion and Level Left Right Left Right Flexion Extension Extension U-2 S 6 1 1 8±S S±2 13 ± S L2-3 S 6 1 1 10 ± 2 3±2 13 ± 2 L3-4 S 6 1 2 12 ± 1 1±1 13 ± 2 L4-S 3 S 1 2 13 ± 4 2±1 16 ± 4 LS-Sl 0 2 1 0 9±6 S±4 14 ± S • Mean range (measured in degrees. as demonstrated by Keeley and cowork­ the goniometer (American Medical Association. Although it is generally be valuable not only in measuring the extremes of spin accepted that a history of low back pain affects subsequent motion but also. Russell and colleagues interpretations of three-dimensional information. Batti'e and coworkers (1987) found Normal data are influenced by many variables besides ag ROM with distraction methods not only to be influenced by and gender. sobering of movement. 1985).. 1983). taking vector stereography. inaccessib'le to the naked eye and moving . 1993. 1967. inclinometry.. 1995). 1985). Table 3-6 describes discrepancy of up to 30 percent that has been noted wi 'I/\BLL 3. 1991). as has been illustrated.... 1971 ers (1986). both the reliability and validity of the Fitzgerald et aI. very importantly. declines with age (Moll & Wright.. in measuring the patter mobility (Burton et aI. Not surprising is th this gold standard is not available .() RANGES OF SEGMENTAL MOnON IN MALES AGED 25 TO 36 YEARS. 1989. Wolfet at.. as normalcy (Hayes et aI. expensive equipment such as biplanar radiograph did not control for time of day. an techniques) must be scrutinized. 1979 need for warm-up..g. N. 1993).. An exciting developme exposure to adult sports has been shown to produce a is the 3-Space Isotrak. 1984 commonly believed. Russell et aI." (Pearcy. using the 3-Space Isotrak (Polhemus Navigation two-dimensional measurements may be erroneous due SCiences. 1994). UK). Clinical anatomy of the lumbar spine (2nd ed. Schober. Williams et aI. A very importa age and gender but also by obesity. and photographic methods hav measurements at different times throughout the day can been used (Mayer & Gatchel. 1937. 1985... 1986 methods used to gain normative values (e . Of further lenge of making objective measurements has been met b consideration in obtaining reliable. concurred that lateral bending was gener­ movements in the third dimension. insight considering age and gender (Bogduk.. is a difficult task. It has been shown used (Burton & Tillotson. but females were observed to have Normal-plane radiographs are limited to two-dimension greater frontal plane motion. 1971 . 1984 in the sagittal plane. New York: Churchilllivingstone. It is of particular importance to note th is the work by Waddell and associates (1992). Radiographic perseveres probably because it is time efficient and simpl measures are thought to be the gold standard for validating It must be realized that all clinical examinations. Tanz. skin distraction methods (Macrae methods. Mayer et aI. 1979. 1969. using a spinal large variations occur in normal ROM that have le inclinometer. 1953). 1989. 1993). even thos methods and gaining normal ROM values. I. The most accurate spinal measurements rely on radio­ The practice of estimating ROM by visual observatio graphic measures (Pearcy et aI. and measurements ally greater in females. Pearcy et aI.. and an increased to large errors. Russell et al. 1993).. with standard deviation). which gives three-dimension reduction in spinal mobility when flexicurve techniques are motion analysis (Russell et aI. (1991) . sophist and have further complicated the reliabilities of studies that cated.. Russell and cm of spine.). the cha cause discrepancies of greater than 5 degrees. Due to ethical thought to be irrefutably objective. Leisure activities have been pro­ movements out of the planes of the radiographs are liab posed to influence lumbar mobility. they have shown that lumbar flexion in researchers to question the usefulness of ascertainin chronic low back pain patients was not restricted. Sullivan et aI. Penning et aI. 1992). - --.. Clinically. height.

Cox. Waddell and associates (1991). Problems introduced by skin distraction occurring in the absen of movement of underlying bony structures (e. (The use of CVs in 5. R. Originally. Clinically..88 for lumbar extension but existed between Dl measures and radiographic measu had the disadvantage of using healthy. concluded that no significant differe r = 1.. process at that level . In 1937. however. Anatomic variability of location of 10-cm line (correlation among a skin mark 10 cm above the interdimple line. A more recent study concluded both the 01 tion techniques can be used to measure movement in the the Cybex EOI (Cybex .90 for the Inferior Superior Technique Landmark Landmark Schober technique were reported compared with radiog­ raphy . 53 percent using the goniometer. including the modified Schober junction Modified Schober 5 cm below lumbosa.g. although they were commonly used 6. and upper extremities. 1988). using the spinal inclin Two methods that they found to be more promising and eter. The landmarks used for measu and the double inclinometer method. & Gatchel. Problems in developing a normative database created by popu lation variation in human height superimposed on a fixed-leng in earlier research. A.92 for 9 subjects with chro (1986). 1979. A point 10 cm technique and radiographs.0 for flexion and r = 0. J. 1986) and still prevailing is the finger-to-floor method. described in Table 3-8 and in the succeeding instructio Schober used a simple tape measure to estimate lumbar on measurement of spinal ROM in the sagittal plane. hip movement but also by movements in the thoracic spine The 01 is generally attributed to Loebl (1967). Portek and colleagues (1983). Both methods have ment for both the Schober and the 01 methods the advantage of isolating the lumbar spine ROM. young subjects. From Miller. anIJe. and distrac­ offered. LUMBAR ROM Pearson product-moment correlation coefficients of r = 0. 1993). (1992). Problems engendered by expression of results of an essentially determining reliability of measures is of questionable value angular movement in linear terms (in ce ntimeters . demon­ Schober Lumbosacral junction A point 10 cm strated little collaboration between any of the commonly above lumbosac used clinical methods . the amount of movement at the studies by Keeley and coworkers (1986) reported interr knee . patients with multilevel stabilization involVing more motion segments than merely the lumbar spine are able to touch their toes (Mayer et aI..fied Schober technique fo r true lu fle xion m easurement . not degrees [Williams et aI. in a v reliability using the Pearson correlation coefficient of dation study. Wolf et aI. 17. Ronkonkoma. low back and 0. REUABIUTV OF 1HE MODIFIED SCHOBE ME11IOD EVALUATED IN ntiS STUDY the addendum to this procedure as advocated by the American Medical Association was the use of the goniom­ 1. 1984). Today.. " eter (American Medica'i Association. Macrae and Wright (1969) attempted to REFERENCE POINTS ADVOCATED BY validate both the modified Schober and the Schober 'IFFERENT AunlORS WHEN MEASURING techniques. and the number of levels from T-12 to S Fitzgerald and associates (1983) confirm these problems measured with the technique). R. Beattie and associates (1987) used both healthy subjects and subjects with low back pain and reported high reliability TABLl~ 3 S with the modified Schober attraction method for measur­ ing extension. Mayer.. Mayer and colleagues (1984).90 for 11 subjects without low back p found the finger-to-floor method to be least reproducible . Reliab and . in comparing three simple noninvasive methods. 1971). Merritt and colleagues reliability values of ICC = 0. . 345-348. comparing them with radiographic techniques. ROM. therapists should be hesitant in reaching important conclusions about facts such as pro­ POTENTIAL ERRORS AFFECTING gression based on these inadequate measures. Miller and associates (1992) cral junction above lumbosac have questioned the modified Schober technique on both junction scientific merit due to the potential error (Table 3-7) and on Modified-modified Midline intersection A point 15 cm Schober of posterosuperior above midline in clinical grounds. reported an interobserver Savidge. stantially more reliable than observation (Chiarello using the Schober method. these authors offer the double iliac spine tersection inclinometer (01) as a validated technique that eliminates . Presence or absence of " dimples of Venus. electrogoniometers using these prinCiples 1969) and remodified (Williams et aI. Advocates of this method many or all of the problems associated with the Scho are deceived not only by large amounts of accompanying technique . 1993). the sacrum).) test. This technique has been modified (Macrae & Wright. T.91 for interobserver reprod worthy of attention are the modified Schober technique ibility of lumbar flexion. to a lesser degree . Another method once described as promising (Merritt et a!.. S . The use of the 2..97 for the modified Schober and r = 0. Spine. when they reported coefficients of variance (CVs) of up to 4. Fitzgerald and coworkers (1983). 'IABLE :3-7 1979). 1993]. Ny) to be s coronal plane as well. spinous ment is obviously problematic (Mayer & Gatchel.62 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT the use of such methods (Nelson et aI. showed an ICC of 0. . uniaxial goniometer to measure multiaxial spinal move­ 3. Consequently. Relia Interesting to note is that it has been long known that problems asso ciated with the modi. Anatomic location of dimples of Venus.

and the average length of the degree. 1990. They concluded that the modified sures to the clinician is not really clear. . a therapist can improve the objectivity of lumbar spine modified Schober extension). An additional study (Williams ROM measurements in the sagittal plane . 1969. and 3-14). .76) was more reliable than the DI technique (lumbar flexion 0. double inclinometer.. The inclinometers or tape measures should be placed over the Schober techniques.72 and extension 0. looking straight ahead.7 percent for intraexaminer repro­ clinical conundrum.8 percent for ods. In fact.g. e. 1994) . The American troubles of differing lordosis (others have modified the Medical Association firmly states that an evaluation uti­ standing starting position to eliminate this problem lizing the spinal inclinometer takes precedence over an (Sullivan et aI.. and double inclinometer meth percent for modified Schober flexion and 2. and that are often overlooked. 1987 recently. CV = 6.60 and lumbar extension 0 . ment outside the sagittal plane. Problems with the DI technique may Measurement be attributed to palpation of bony landmarks.. opinion of many of these manual therapists must be whereas the inclinometer showed poorer reproducibility scrutinized in light of the reliability studies. An area that is very controversial and of great impor­ 6. The following proce Both techniques have both disadvantages and advan­ dure is suggested : tages. 1986. The e.. The American Medical Association has 3. 1989) obese person with increased lordosis has potentially less 2. By using skin Schober method was the most repeatable (CV = 0. 1983). equa American Academy of Orthopedic Surgeons (1965) ad­ weight-bearing. The low back et aI. Paris. would have taken precedence 5. and it is only with the DI method. A standardized starting position needs to be selected extension and a potential for an inflated flexion value.g.4 percent for interexaminer re­ Finally.. The authors found that the modified­ through becoming more scientific and thus more objective modified Schober method of measuring the lumbar ROM that cl inicians move toward a solution . offering many tangents). the double inclinometer method or versions of the spine (i. 1994). (ICC = flexion 0. 1992) .. CV = 65. flex fore 1988. use of the flat To increase the reliability of lumbar flexion and exten surface of the inclinometer over the curvature of the flexing sion. No validation was given for this new Sagittal Spinal Range of Motion method in the study. and it is questionable right lateral flexion twice. 1992 mines the amount of flexion or extension available. 1987). spine flexion. the use of the goniometer was advocated by and extend twice . 1988). 1994). 1993). e. the initial lordosis (not apparent lordosis) deter­ male lumbar column is 18 em (Waddell et aI. counting up the spinous processe ing (Keeley et aI. a problem common to both methods that correspond to S-2. Merritt and associates (1986) sug­ 1986 . Waddell et al. Helpful tips are that the dimples of Venus usually However. . heels together.6 percent for intraexaminer reproducibUity). relaxed (Waddell et aI.9 distraction . 1993) compared the modified-modified Schober problem threatens the health of the public. which have been proven to on the selected points and held in place (Figs.5Ievel. A " neutral " lumbopelvic position is required. 3-13 be more reliable. Accurate location of anatomic landmarks is critical than goniometric. Warm-up is necessary for reliable measures .. revised its guidelines and now supports the use of the midway between flexion and extension to eliminate spinal inclinometer (Engelberg. (in extension. left and right rotation twice. Schober method are recommended. . eyeballing. especially when considering move ducibility) . finger-to-floor. and one more flexion and as to whether these measures. (1988) compared the repeatability of the values is inherently difficult and affected by many factors modified Schober. skin attraction.l motion. Either method is offered as a more reliable method 1. To a large will find T-12 and L-1. which have been shown extension (Keeley et aI. The usefulness of these mea photographic methods. .e . ObViously. Instruct the patient to bend forward as far as possible tance to the manual therapist is the art of assessment of (Figs. Inter surements.3 percent for interexaminer reproduc­ be unreliable (Maher & Adams. the iliac crests are approximately should be considered is the starting position when stand­ at the L-4 . the measurement of lumbar spine ROM is a producibility and 50. . The measuring of norma Gill et aI. reliability studies have compared these two very Grimsby . Maitland 'promising methods. An Williams et aI. Be­ 4. arms hang vocates the use of tape measures when measuring lumbar ing at the side . 1986. Sobering is the scientific Schober method demonstrated high reproducibility (in evidence that has proven these assessment techniques to flexion .g. or finger-to-floor measures. 3-15 and 3-16).. a whole profession is based on gested that to increase objectivity of spinal ROM mea­ the ability to reliably palpate intervertebra. 1992) to be notoriously unreliable. They showed that the modified (Lewit & Liebenson . . left and the American Medical Association . knees straight. and technical skills. the Schober test should be used in routine esting to note is the discovery of the palpatory illusion clinical examinations. bare feet. More convinced of their reliability and validity (Grieve. Sullivan et al. the ibility and 6. Kaltenborn & Lindahlo. evaluation using an alternative measuring technique. technique is controversial (Portek et aI.68).

measure the length of the tape measure to the nearest millimeter. 8. 9. Initial measurement in neutral lumbar position . Demonstrated here is the modified Schober's method. spine increases with flexion and decreases wi th exte nsion. If the modified Schober technique is being used . Skin distraction and attraction techniques are based on FIGURE 3-15. Schober's method using the attraction techniq the fact that the distance between two pOints marked on the skin over the trunk extension. Ask the patient to bend backward as far as possible. Spinal inclinometer methods require placemen instruments over fixed points and ta king tangential measuremen superior inclinometer is fixed over T12-Ll. pelvic trunk flexion. and the inferior inclin is placed over the sacrum. Lumba r flexion and extension a re derive FIGURE 3-1 4.64 UNIT TWO-COMPONE~JT ASSESSMENTS OF THE ADULT FIGURE 3-13. Instruct the patient to return to neutral. (PF) = S/-SI' lumbar flexion = TF-PF. FIGURE 3-16. . If the inclinometer method is being used. 7 . measuretQ the nearest degree . Schober's method using the distraction technique with these simple measurements: total flexion (TF) = Lj'-L j .

1984 ). particularly in the presence of a hi flexi on contracture (Gajdosik et at. are some of the problems clinicians are faced with.g. whereas hip flexion and extensio were determined by a gravity inclinometer attached to th patient's thigh.4. . With th 3-18)..percent. Spinal inclinometer method used to measure trunk r = 0. e . Gajdosik et aI.74 for hip abduction.5 percent fo hip extension . . 55. Spinal inclinometer method used to measure trun curve is often used as a reference point to alert the therapist extension. 1978. as it is ve ry difficult for the tester t delineate the obliteration of the normal lumbar curv during measurement. et aI. Loebl (01). which improve (r = 0 . Ekstrand an colleagues (1 982) utilized a rigid standardized p rocedur for measurement with identification and marking of th anatomic landmarks. 2 percent. The results showed coefficie nts o variation of 1. . To determin the amount of hip flexion deformity present. reliability of r = 0. 1993). If the inclinometer method is therapists. controlling for the movement of the pelvis is of paramount importance (Ashton et aI. Table 3-9 lists norms for hip ROM according to individual researchers. with mild to moderate spastic cerebral palsy. 1991). . HIP During measurement of hip ROM . respectively In this study. and hip abduction . hip flexion . with the difference in the two beginning and end measurements giving the total thoracic ROM (American Medical Association. Placement of the inclinometer for sagittal fle xion and extension should be on T-12/ L-1. measure to the nearest degree (Fig. Ashton and associates (1978) deter mined an ove rall relatively low level of reliability whe giving specific procedural instructions (described by th If the modified Schober technique is being used . 1993). 3-17). hip abduction was made with a double protractor goniometer.82) with specific instructions to the exper THORACIC SPINE As with the lumbar spine.. similar difficulties exist in measuring ROM through the thoracic spine. Using the universal goniometer. as well as maintaining accurate contact with bony land­ marks during measurement. Although reliability studies for thoracic ROM have been elusive. while measuring passive hip ROM in childre being used. 1965) to a measure the length of the tape measure to the nearest experimental group of therapists versus a control group o millimeter (Fig. Boone and coworker (1 9 78) demonstrated a higher intratester reliability o FIGURE 3-17. The determination of degrees of true hi extension and flexion is probably one of the more comple measurements . exception of hip external rotation. American Academy of Orthopedic Surgeons.79 and 0. and 2 . l. Difficulties in isolating pure planar movements due to coupling motions. as op posed to an interteste flexion . recommendations from the literature indicate similar methods for measuring the thoracic spine as were incorporated with the lumbar spine. as well as on C -7 IT -1 . The lumbar FIGURE 3-18.

mental group. In the sam study.66 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT TABLE ~'J VALUES FOR "NORMAL" ROM FOR 11IE HIP..88) and for the tape measure (r = 0. USTED BY VARIOUS AUDIORS Roac:h & Boone & Dorinson & Esc:b & Gerbardt& Roa_& Miles Wiec:bec: & AAOS Azen· Wagner Lepley Ru sse AMA Andersont (NHANES 1) Krusen Joint (1965) (1979) (1948) (1974) (1975) (1958) (1982) (1991) (1939) Hip Flexion 120 122 125 130 125 100 120 121 120 Extension 30 10 50 45 15 30 9 19 45 Abduction 45 46 45 45 45 40 39 42 45 Adduction 30 27 20 15 15 20 30 Internal 45 47 30 33 45 40 33 32 rotation External 45 47 50 36 45 50 34 32 rotation • N = 109. a flexometer. used to measure force placed against the posterior leg during SLR. ma le and female. AAOS = American Academy of Orthopedic Surgeons. male. 30--40 y. 1972). Cameron et aI. Hip extension measurements in eter. Other meth ods to determine SLR have included the knee extensio method with the hips stabilized at 90 degrees of flexi o FIGURE 3-19. male.4 .. r N = 1683. To isolate the contribution of the lumbar spin Straight-Leg Raise the pelvis was palpated during passive SLR to determin the point at which pelvic rotation began (Hsieh et aI Certainly one of the most measured ROMs has been for 1983). An early study factors made a difference in the amount of SLR exper enced and recommended consistency of method during th performance and interpretation of the SLR. Note that the lumbar spine is to stay in FIGURE 3-20. t N = 108. 1994 assured (Bohannon. (r = 0.74). high intrasession reliability was found for all thre (r = 0. x = 22. A method used to decrease the contribution of the lumbar spine to hip extension. and a tape measure) for measuring SL particularly were low. 3-19). 1984.. 3-20).94)... 1985. active versus passiv taining a standardized method in which reliability can be and trial repetitions during SLR (Cameron et aI. 1994. this A review of the methods that might improve reliabili measurement has not been without its difficulties in ascer­ has presented varied hip positions. even when the examiners made (Hsieh et aI. 25-74 y. the other measurements were inconsistent comparing three instruments (a standard plastic: goniom and had poor reliability. Tanigawa et aI. 1983) demonstrated a good level of interse efforts to control for compensatory pelvic movement by sion reliability for both the goniometer and the flexomete flexion of the opposing hip (Fig. . AMA = American Medical Association. However. Gaj­ Cameron and coworkers determined that all of thes dosik et aI. The use of a blood pressure cuff as a feedback devi contact with the table during measurement. the straight-leg raise (SLR) (Fig.

when measur­ FIGURE 3-21. 1985). McHugh et a!. 1994). which indicates to the user changes in the position of the lumbar spine during SLR.. 0. .. 1976. This particu'lar study This method . Cameron et a!. res pectively. 1994.. The use of a passive versus an the inclinometer used by Gilliam and coworkers (1994) and active method of measuring SLR does appear to influence Walker and colleagues (1 987) provided two finger braces. which the opposite thigh is stabilized with straps versus the 1994). achieving an overall intertester reliability of ICC = 0. .. a method that might better control for force during SLR would be measuring force with a dynamometer (Bohannon & Lieber. A modification to thigh stabilized with straps. position (Gajdosik et a!.95 . Bohannon. 3-20).96 . Perhaps a method that would better control for the contribution of the lumbar spine through pelvic rotation during SLR would be to use a stabilization device placed at the low back position .. A later technique intro­ (Gajdosik & Lusin . 1985). 1994: Gajdosik et aI. 1984) measured both anterior and posterior pe:lvic tilt utilizing a computerized system with external markers over bony landmarks. measured from an angle made by a line from the ASlS to the 3-21)... 1988. 199 1). the necessity for control­ . 1984. A method (Alviso et a!. 1993) (Fig . 3-22). respectively).and opposite thigh. with greater increases apparent with allOWing for palpation of the anterior-superior iliac spine passive ROM (Cameron et a!. uses trigonometric functions to measure pelvic ROM. demonstrating both good demonstrated that the clinician should take into consider­ ation the contribution of pelvic rotation to the angle of SLR when interpreting results. which has been addressed using a method in spine (Fig. ing posterior and anterior pelviC inclination .90. 1983). which would indicate when FIGURE 3-22. demonstrated poor validity com­ indicated increased ROM with low back flat position versus pared with radiogra phic measurements.. 1986) or equivalent instrumentation (Helewa et aI. 1992). An early study (Day et a!. 1994).. 1993).Hng for the amount of force applied has often been overlooked (Bandy & Irion . In retation to measuring ROM of passive Sl R. straight-leg ROM. Comparing the position of the duced by Walker and colleagues (1987) utilized an incli­ ankle dorsiflexion versus plantar flexion during active and nometer placed on the anterior superior iliac spine and the passive SLR (Gajdosik et a!. slightly flexed to allow for low back flat intraobserver reliability (ICC = 0. 1994). PSIS as it bisects the horizontal. Measuring the pelvic indination allows therapists to monitor quantifiable changes in the position of the pelvis made during therapeutic intervention (Gilliam et a!. Gajdosik et a!.. The apparently critical aspect fo rmed with the horizontal from a line drawn between the of SLR has been controlling pelvic rotation (Bohannon et anterior-superior illiac spine and the posterior-superior Wac a l. This method was later used (Gilliam et al . however. demonstrating a high level of both inter. A pressurized biofeedback device. and posterior-superior iliac spine while measurements are 1993). 1994). 1993) (see Fig. . 1985) showed significantly posterior superior iliac spine to determine the angle less ROM with dorsiflexion.. inclination . originally suggested by Sanders and Stavrakas (198 1). It has also been demonstrated that the accommodation to "stretch tolerance" leve'! is a factor in measuring ROM during passive SLR (Halbertsma et al. .. PELVIC RANGE OF MOTION Physical therapists are often involved with treatments that are designed to affect the position of the lumbopelvic region (Sal & Sal.87 and ICC = 0. An early study analyzing passive straight-leg raise read (Crowell et aI. Conceivably. The inclinometer is used to measure changes in pelvic the lumbar curve began to flex (Jull et a!. It should also be recognized that small increases in sequential multiple measurements of joint range may in fact be a normal occurrence of compliance of the viscoelastic tissues with repeated mea­ surements (Atha & Wheatley. .

As surgical procedures have progres et aI. stairs.99) were high when compared with roe genograms (Gogia et al. comparing goniome measurements with radiographic bone angle measu FIGURE 3-23. which was flexes and extends in the sagittal plane but also allows statistically shown to be related to the patient's test A-P translation in the sagittal plane. this is unsupportecl unt validity study can substantiate this claim . the interes utilize his or her own technique in measuring the knee. 1991).93). The use of various-sized goniometers did not in the transverse plane (Nordin and Frankel.98-0. The evaluating the results of these techniques following ope results showed high intertester and intra tester ICC values of tions has led to instruments specifically designed to m 0. Investigations were Measurement of anterior-posterior (A-P) translation ( later made into the reliability of various goniometers within ity) has been commonplace in knees suspected of be a clinical setting in examining PROM at the knee (Rothstein ACL deficient.. . R.68 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT appear to affect the reliability of measurements.50 when measuring the knee. Journal of Orthopedic and another study of goniometric measurements of the kn Sports Physical Therapy. 19 used the universal goniometer to measure six positions the knee..70). Normative measurement American Academy of Orthopedic Surgeons (1965) for the knee are presented in Table 3-10 . normal ROM measurements for the knee ability r = 0. decreasing with age. Many times. interrater reliability (ICC = 0. Universal a fluid-based goniometers have demonstrated good in tester reliability r = 0. It has b process have added to the increased interest in the ROM of traditionally suggested that a knee ROM of 290 degree this joint. clinical situations lend themselves to vis (Fig . (From Crowell . J.95) and validity (r = 0. [19941. The movements of the knee joint are not demonstrated good intertester and intratester reliabi those of a simple hinge joint but involve spinning. 1983). 198 Goniometric measurements purport to give us an ac rate account of the actual angle at the knee made by universal goniometer. Understanding that the knee not o intertester ICC for knee extension (0. respectively. 1989) .99) and vali (ICC = 0..97 .. other sources h KNEE suggested that goniometry has proven to be more relia than visual estimates of joint ROM (Moore. as in cated in this study (Rothstein et a!.. & the bone angle measurements. which were significantly different. L. 1973). with the exception of Tillman.82. All goniometric measurements were comparabl allowing for direct palpation of the ASIS and PSIS during inclinometer placement. measures of innominate bone inclination. e. 3-23). rolling. but showed moderately low sure the A-P motion. Studies tester reliability of r = 0. This device should prove beneficial for mea­ estimations of ROM measurements at the knee. Cummings. . 0 degrees to 90 degrees. necessary to negotiate elevated terrain. suggested that visual estimation is more accurate th goniometric measurement when bony landmarks are easily palpated (American Academy of Orthopedic S geons.. However. each individual was allowed to with ever-newer reconstructive techniques. Certainly in the medical age when clinical study taken with a larger sample size (43) de total knee replacements and anterior cruciate ligament mined that PROM measurements were better determin (ACL) repairs are common occurrences . as well as tibial rotat position. In this study. statistical test differences between instruments in this study suggest that the two instrume should not be used interchangeably (Rheault et a!. G. An early study (Boone et aI. 1983).83. An early study using a small subject size ( than the knee. J.g. D. This younger populations have shown that knee extension of study used standardized measurements described by the measures less than 0 degrees. often simultaneously (Nordin and Frankel.99 and 0. The use of an inclinometer utilizing finger braces. however. when using visual estimates to determine ROM of kn and gliding.87 while shoWing a significantly lower inter­ o to 135 or 140 degrees . associated gonio­ goniometrically over visual estimation to minimize metric readings of knee ROM during the rehabilitation error of measurement (Watkins et a!. Rowe. Walker. Sal Few joints are exposed to measurements of ROM more 1955). 88-97) both intertester reliability (ICC = 0.87 and r = 0. Smidt. goniometer demonstrated a high level of intra tester reli­ Generally. 1949a.. knee AROM on 12 healthy volunteers. 1965.. R. 1964). 20[2]. However. A radiograp study to verify the knee goniometry (Enwemeka. Intratester and intertester reliability and validity of first 15 degrees. It has b suring pelvic inclination in the sagittal plane. 1978) using the universal clines. ments. 1978) 1989. S. affected by rheumatoid arthritis (Marks et a!. 1987).. whereas the flu based goniometer showed a concurrent validity r = 0.

1991) of the KT-1000 presented conflict­ measured via an arthrometer (Daniel et a!.and intraexaminer variations in measure­ of an ACL deficient knee is under study. particularly when the pathomechanics significant inter. respectively. San Diego. ACCORDING TO VARIOUS AUTHORS AND RESEARCHERS Roach & Boone Dorinson Ekstrand Esch& Gerhardt Roaas & Mile s Wiechec AAOS & Azen· & Wagner et aI. an arthrometer designed to deficient ACL. patellar sensor pad. D. force-sensing handle. C. method for determining the amount of translation has However. 3-24). 22-30 y..84. Instrumented measurement of anterior laxity of the knee. 1993) of A-P translation surements of ICC = 0. Earlier studies involving the KT-1000 (MEDmetrics 50 percent) in determining laxity in the knee with a Corps.. foot support.. displacement dial indicator (the data are sent via cable to an X-V plotter as applied force versus joint displacement). 18-54 y.98-1.92 and 0. male and female. D. Velcro strap. 67AI51. 1985). special measurement of A-P joint laxity during side differences in pairs of knees. Hanten and Pace (1987) demonstrated mea­ Another study (Holcomb et a!. CAl. but a low intertester re)iability of 43 healthy male subjects for A-P translation. A.53 was demonstrated.I OOO to test ICC = 0. tibial tubercle sensor pad. 1. arthrometer case. E.0. for inter­ using the KT-1 000 reported a high intratester reliability of and intratester reliability when using the KT. t N = 108.. thigh support. Ante­ rior force is applied. male. 2. t N = 25. 1985) (Fig. demonstrating a poor level of reliability (less than 3-24). et al. M. 25-74 y. G. indicated that it was a useful tool that the anterior drawer test and Lachmans test were found for both confirming reduction and demonstrating a mean to be more accurate indicators of knees with deficient ACLs difference in laxity in normal and injured knees (Daniel et when compared with the KT-1000 (see Fig. and H. a!. Forster and associates (1989) demonstrated become important. The use of an arthromometer for measurement of joint excursion (anterior or poste­ rior translation) in the sagittal plane. male. 30-40 y. § N = 1683.. A more recent study postreconstruction of knees with deficient ACLs has been (Graham et aI. male. A more recent study (Rob­ FIGURE 3-24. ICC = 0. 3.t Lepley & RDBSe AMA Anderson:f: (NHANES 1)§ & Krusen Joint (1965) (1979) (1948) (1982) (1974) (1975) (1958) ( 1982) (1991) (1939) Knee Flexion 135 143 140 144 135 130 120 144 132 135 Extension -2 • N = 109. (From Dale. F. AAOS = American Academy of Orthopedic Surgeons.. B. 720-725) . Graham and colleagues (1991) indicated measure tibial translation. A constant pressure of 20 to 30 Newtons is applied to the patellar sensor pad to keep it in contact with the patella. During the past 10 ments of both absolute displacement of knees and side-to­ years. ing views. Journal of Bone and Joint Surgery. VALUES FOR "NORMAL" ROM FOR TIlE KNEE. 11985). AMA = American Medical Association. Posterior force is applied.

with mean ankle dorsiflexion of 22 .75 for three different levels of force used with the KT-1 000 and found that a change of > 5 mm must take place to indicate a true change in anterior tibial displacement. (1982) determined the coefficient of variation of Intrarater reliability has been shown to be more subst ±1. Boha ranges.. 1993.25 and 0. Other authors have stated plantar flexion.. Ekstrand (ICC = 0. whereas an ankle pivotal point. It has been a long-held notion that plantar flexion. The device allows the foot to rotate that only 5 degrees of dorsiflexion is necessary. as a difference of 3 mm in anterior tibial position between two knees of the same patient has been cited as diagnostic for ACL deficiency (Stcaubli & Jakob . while being substantially 1993). The weight-bearing technique for measuring ank dorsiflexion . it has also been shown that wit Norkin and White . The effect on measurements of ankle dorsi­ siflexion (ICC = 0. the clinician 's evaluation of ankle dorsiflexion method for determining ankle ROM when compared continues to be performed while the patient is in a the goniometer (Youdas et aI . A study of ankle joint dorsiflex­ universal goniometer. Elveru et aI. Muwanga and associates (1985) 10 degrees of ankle dorsiflex ion is necessary for normal duced a new method for measuring ankle dorsiflexio locomotion (Root et aI.70 UNIT TWO~COfv1PONENT ASSESSMENTS OF THE ADULT nett et aL .. FIGURE 3-25.72) for plantar flexion (Elveru et aI.9 degrees with knees flexed . The joints of the ankle and foot .89-0. Although the measurements. 1988) and moderate reli make a difference. During gait. deserve more in the way of critical assessment in ROM. This may prove to be ineffective in demon­ strating a possible ACL defiCiency. 1988) (ICC = 0. 1 et aI. s planes of movement (Root et al. These measurements desc the lower leg is sufficient for normal gait (Downey.28) (Youdas e bearing method as 8. 1977) found within the cantly different measurements between methods ankle-foot complex.50. the reliability as well as the vatidity of this device in providing accurate measurements should be questioned .96 Diamond e .9. 1985). maximum amount of dorsiflexion occurs during the stance Visual estimation continues to prove to be a phase of gait.3 percent) had a high correlation. Investigating three d substantiated reliabilit'y of methods or established normal ent methods in measuring ankle dorsifleXion. yet little research has sured in weight-bearing position. intertester reliability for active ion by Baggett and Young (1993) measured the average joint measurement is poor for ankle dorsiflexion amount of dorsiflexion available using the non-weight­ plantar flexion (ICC = 0.. 1993). 19 9 1).87. Because normal ambulation requires found. because of their position and their necessity in locomotion. Using a gravity inclinometer. Studies on PROM have found outcomes va higher at 20. 19 89). 1977). 1960). the maximum amount of dorsi­ Both intra tester and intertester reliability proved to h flexion occurs just before heel lift while the knee is in an difference of less than 3 degrees in 86 percent o extended position (Downey & Banks. Alignment of one arm of the goniometer should be ANKLE AND FOOT plane of the suppoliing surface . 3-25). This may be due in part to the significant complex­ and coworkers (1989) demonstrated that the ma ity within each joint as well as to the multiple axes and (83. 2 5 degrees. Elveru et aL. however. 1995) demonstrated an inlertester reliability of ICC = 0.67-0. . mea. patient population. Diamond et aI .90 degrees with the weight-bearing technique from good to poor in interrater reliability for ankle (Fig. assuring that the foot is held s still others suggest that motion past a 90-degree angle to in a strapped position. 1987 .5 degrees with in measuring ankle dorsiflexion for PROM (ICC = knees straight and 24. f urthe rmore . II! light of the conflicting results of these various studies. 1993). non-weight-bearing position (Baggett and Young. 1 flexion with the knees flexed versus extended appears to (ICC = 0. However. validity studies have suggested the KT.74-0. and the other arm is aligned to the aspect of the fibula . these two motions have been the main focus of Although the universal goniometer appears to be the research on ROM of the ankle.. demonstrating that the use of different landm primary movements of ankle dorsiflexion and plantar can provide a reliable indication of ankle dorsifle flexion. followed by calcaneal mode used for measurement of ankle dorsiflexion inversion and eversion.l 000 may underestimate A-P translation when compared with roentgen stereophotogrammetry in both operated and uno perated knees with deficient ACLs (Jonsson et aI. AROM measurements performed ·on normal volun Tanz.

male and female . study of 31 diabetics. However. Lattanza and reliability.. r N = 272. 18-20 y. (1988).86) (Elveru et aI. . . measurement of hindfoot eversion and inversion 1964). x = 22. AMA = American Medical Association. AAOS = American Academy of Orthopedic Surgeons. (From Sell. as well as PROM for ankle plantar flexion protractor. 1988).. Of course et aI.75. In the study by Elveru and colleagues was used during gait on only a few subjects (Wright et aI. 91 Weight-bearing. AS USTED BY SEVERAL AUTIfORS Baggett Boone & Dorinson Esch& Gerhardt Milgrom Roaas & Wiechec MOS & Young' Azent & Wagner Lepley & Russe et aI. FIGURE 3-27.. Reliability differences in these studies appear to be associated with lengthy training periods incorporated to have moderate intratester reliability (ICC = 0. Intrarater reliability for Orthopedic and Sports Physical Therapy.82) and plantar flexion (ICC = 0. 18-66 y. § N = 96. this supposition was based on since weight-bearing is the functional position of the ankle research performed with an orthotic device deSigned as a and foot. . Journal of (ICC = 0.86) (Youdas et al. et al. 19(3). 30-40 y. However. males. Two measurement techniques for assessing subtalar joint position : A reliability study.74.:j: AMA Andersson§ & Krusen Joint (1965) (1979) (1948) (1982) (1974) (1975) (1985) (1958) (1982) (1939) Plantar flexion 50 56 45 65 45 40 40 55 DorSiflexion 20 81:2191 13 20 10 20 20 15 30 Subtalor joint Inversion 35 37 50 30 40 32 30 27 Eversion 15 26 20 15 20 4# 20 27 • N = 30. it should provide the necessary information as to mechanical analog of a subtalar and ankle joint system and position during gait. 1993). 0.77 .4. 3-26). AROM has been shown to be good for ankle dorsiflexion (ICC = 0 . 1977). male. [1994). TA m I :~ II VALUES FOR "NORMAL" ROM FOR THE ANKLE AND FOOT.25) (Fig. E. Measurement of hind foot inversion and eversion performed with patient in prone-lying position. K. respectively) and poor intertester reliability methodology for measurements taken (Diamond et aI. males . # Hindfoot. A reliability study (Picciano et aI. II Non-weight-bearing.. Diamond and associates (1989) Just as measurements of ankle dorSiflexion and plantar measured ankle eversion and inversion and STIN position flexion have demonstrated variations in weight-bearing demonstrating moderate to good interrater and intra rater versus non-weight-bearing measurements.17. t N = 109.FIGURE 3-26. Techniques for assessing subtalar joint position and subtalar joint neutral (STIN) position has been shown have been conflicting.. prior to the experiment most probably improving the and 0. It has been purported that the subtalar joint coworkers (1988) determined that an increase in subtalar motion is an important baseline indicator of the potential eversion position was greater in the weight-bearing posi­ for excessive pronation versus supination during gait (Root tion when examining subtalar neutral position. in a 1989). and 0. (ICC = 0. l 62-167 . The measurement o f ca lcaneal position using a gravity 1989).32.0.

respectively. surement of three-dimensional movements. Examines two or more sets of score activities (Root et aI.. Depicts 20. .1 two points marked on the skin as the spine flexes. 3-27] and navicular drop test) in a weight-bearing position Attraction meth ods-Measuring procedure usin (n = 60) demonstrated moderate to high reliability. A ratio of standard deviation and the mean in terms of a percenta joint using a method described by the American Academy of Orthopedic Surgeons (1965) was 35 degrees and 15 Distraction methods-Measuring procedure usin degrees. 1977). Lohmann and associates (19 ity when measuring (n = 30 ft) with a goniometer (for the demonstrated a mean absolute difference between m first two methods) and when measw-ing the distance surements of tibia vara of 2 to 3 degrees (Fig. Pelvic incUnometer-Designed with calipers wit mounted gravity protractor. One arm is allowed move freely in accordance with. range of 8 degrees to 12 degrees. The position of in sion or eversion that the calcaneus assumes when the t is congruent in relation to the tibia. Table 3-11 lists norms for ankle and foot ROM. Subtalar joint neutral-The position in which the is neither pronated nor supinated.72 UNIT TWO-COMPO NENT ASSESSMENTS OF THE ADULT 1993) of three methods for measuring STJN position measurement of tibia vara. and navicular distal third of the leg to a horizontal line to the suppor drop test) demonstrated poor intra. 3-28). FI GURE 3-28.5 degrees in Coefficient of variation-Measure of variability in males. Use determining association concerning a bivariate distr tion. a later study measuring STI N (Sell et al . that is placed over the spine and used to meas ROM in degrees as the spine moves. The flexible curv positions (Mjlgrom et al. . 1 degrees (Vandervorrt et aI. Wright et a1. which is the angle formed by (open kinetic chain. and either a tangential o STIN with regard to the stance phase of gait has been trigonometric method is used to ca'iculate ROM. increased information with regard to the biomechanical alignment and forces acting on the ankle and foot is Pearson product-moment correlation coe dent-Generalized measure of linear association. largely conjecture. the baSis for "normal " then traced onto paper. Spinal incUnometer-A circular fluid-filled disk wi weighted needle indicator. 1977. Pendulum goniometer-Goniometer usually mad metal with two movement arms.7 degrees to 10. tape measure to record a decrease in distance between Studies of normal ankle do rsiflexion demonstrated a points marked on the skin over the spine as it extend reduction in mean values with increasing age (middle age to old age). whereas in females these values decreased from measurements relative to the mean value. Measw'ement of tibiil vara: an angle formed from a line 3·Space lsotrak-Electomagnetic device for the m parallel to the lower leg bisecting the horizontal (ground) . . the same variable. 1994. change from the floor to the navicular mark on a marked index card (for the third method). 1985). Modified Schober technique-Skin distract A measurement quite possibly offering the therapist attraction method using a midline point 5 CM below lumbosacral junction and a point 10 CM above it. closed kinetic chain . for a minimal tota.. the line of gravity an used as a vertical reference. 1964). . Able to measure the chang position of two separate points by the placement of ei ends of the calipers over an identifable area used a landmark.0 degrees to 13. is normal for locomotion Flexicurve techniques-Measuring procedures (Root et aI. 1992).and intertester reliabil­ stance surface (ground) . It has been suggested that 4 degrees tape measure to record an increase in distance betw to 6 degrees of inversion and eversion. . McPoU & Cornwall . variability of measurements within the subjects as wel Normal ROM for inversion and eversion of the subtalar the variability of the actual measurement. which is maintained in vertical. However. without proven reliable or valid methods Intraclass correlation coefficient (ICC)-Asses performed on any substantial-sized group during gait common variance. 1994) using two measurement techniques (calcaneal position wi th an inclinometer [Fig . decreasing from 2 0 . Although norms have been cited for which a tester manually molds a flexible curve to the mid subtalar inversion and eversion and STIN (3 degrees varus) contour of the subject's lumbar spine.

R. & Al-Nahdi. R.. W. The economics of spinal Association. Cybex II isokinetic dynamometer Allender. & Tillotson. A method for measuring and 74-76. c. R. Burton. & Savidge. 1347-135l. The range of active motion at the wrist of white range of motion of seventeen joint actions in humans. Normal range of motion of joints measuring pelvic tilt in standing. J. Pickles. L (1984). (1988). Bartko. & Palmer M. Variation in ciation.). L Comparison of the reliability of the 307-317. Relationships of age and sex with Cobe. 68.. Chicago: American Academy of Boone. Method for measure­ disability. N" & Twoomey. Day. Chiarello. K.. G. lumbar sagittal mobility with low back trouble. D. P. Clark. 163(5). 584-589).. Physical Therapy. & measurement on hip flexion.. A system of joint measurement. S. M. Journal of Bone and Joint Surgery. Intertester reliability for Boone. Journal of the Buck. 10. Dong. M.. O. M" & Gruenwald. International Journal of Epidemiology. (1994). (1991). K M. K. 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and the elbow. and functional importance of each anatomic entity. Like any other organ in the human body. if ever. It is hard to imagine a life without hands. and to connect human beings with the outside world. with its function . but they do drastically affect the quality of life. Disruption in anyone of its parts interferes. Nothing in this chapter is new or revolutionary. When knowl­ edge is not adequate. the desired function. FRCS SUMMARY This chapter discusses the normal anatomy of the various structures of the hand. CHAPTER 4 A. the hand starts from the wrist joint area. affect the quantity of life. It is an intricately structured and dynamic organ created with mathematic perfection and harmony between all its various parts. the profeSSional must seek the help of colleagues and the lit- o erature. Problems of the hands rarely. Moneim Ramadan MO. The ideal hand performs its function precisely and flawlessly. the hand starts from the elbow. the hand has its own characteristics and functions and is uniquely equipped to perform its functions. is a science based on facts. are directly related to the hand. Medicine . in a major way. The length of the upper extremity and the position and the type of shoulder and elbow joints are primarily designed to allow the hand to function. A short discussion of clinical examples and a comprehensive evaluation protocol follow . with emphasis on the anatomic. to service. Important factors about the functional and surgical anatomy of the hand are outlined . Consequently. from birth to death. at least from the anatomic point of view. The upper extremity is present to allow the hand to perform its functions . Without solid knowledge of the anatomy and function of this organ. and the process of evaluation. as much as they are not directly a part of the hand. The only thing that might be unique is the emphasis the author places on the ab­ solute necessity and need for any health care profeSSional who will have the chance or the obligation to treat hands to be absolutely sensitive and attuned to the nor­ mal anatomy. The hand is involved in every aspect of our lives. Functionally. Anatomically. There is no room for guess work and no place for luck. 78 . physiologic. the arm . very little will be able to be done. The facts discussed are based on the experience of the author and the data obtained from other experts referenced. the shoulder. however.

in the terminal phalangeal areas is replaced by strands o tough fibrous tissue called fibrous septae . 4-1). as it keeps the skin various creases. The dee fist (Fig. SUPERFICI AL FASCIA Specialized parts of the deep fascia are the flexo The superficial fascia on the dorsal aspect of the hand is retinaculum and the digital ligaments of Landsmeer and very thin . This palmar fascia is a speCialize fibrofatty tissue. 1988 (Figs. and it would wrist level. ally . fiGURE 4-3. The palmar triangle in the foot. 1988). The absence of the deep structures (including the bones). and the ulna is the main forearm bone a the elbow joint. which is divided into six compartments Wig 4-3). the skin is thicker. In the palmar aspect . the deep fascia is incorporate with the palmar aponeurosis. is not directly attached to the bone structure underneath it. 1976. 4-2). and it is unique in the hand (Barron . Palmar triangle boundaries . then the wrinkles would disappear. 1970). It is the only area ments up to the distal interphalangeal joint crease of th devoid of fat (Milford. Extensor retinaculum. 4-5). At th to be tight. The superficial fascia in the palmar aspect has the Clel1and (Milford. and the skin of the palm restrict the skin o well tethered and consequently allows the cup of the hand the hand from being freely mobile. If the skin on the dorsum of the hand were layer covers the interossei between the metacarpals. where its functional. aspect is to give thickness an center of the palm consists of the distal palmar crease as its stability to the skin (Fig . 1988). In the areas where it is fingers and thumb. the skin along th fat in the palmar triangle is Significant. especially the veins. lighter in color. The radius is the main forearm bon at the wrist joint.ANATOMY General Anatomy SKIN The skin is primarily the protective organ of the body. The superficial layer covers the extensor BONES tendons and continues into the extensor hood on the The skeleton of the hand consists of 29 bones that begin with the distal end of the radius and the head of the ulna a the wrist (Landsmeer. The attachments of the palmar fascia located. and more stably tethered in position when compared with the darker. The restriction of ski to deepen when a fist is made . 1988). O'Brien and Eugene. The palmar fascia starts from base and the junction of the thenar and hypothenar the heel of the hand and extends in various fiber arrange eminence at the wrist as its tip (Fig. FIGURE 4-1. thin. 4-6 and 4-7). the skin is marked with creases or lines that are of utmost significance anatomically and function­ FIGURE 4-2. Within the dorsal aspect . loose skin on the extensor aspect or the dorsal side. On the volar aspect. the fat acts as a pressure cushion. which anchor th skin to the terminal phalanx and give stability to the tip o DEEP FASCIA the digit (Fig. retinaculum. less-mobile skin on the pa lma r aspect. The palmar fasci spaces to protect the vascular bundles. and also has wrinkles that allow the skin to stretch when one makes a extensor aspect of the fingers (Milford. The skin on the dorsum is more lax. The fat extends to the web mobility is evident in the palmar triangle. 4-4) . the amount and the density of which vary fascia that is present only in the palm and in the sole of th from one location to the other. the deep fascia is arranged in two layers. On the palmar or volar aspect. Note the difference be tween the thin loose skin on the dorsum and the thick. the deep fascia is organized in the extenso consequently become difficult to make a fist. .

4--9). .vo lateral columns. 4-10 and 4-11). A. This arch is conc toward the volar aspect and is the bony boundary of FIGURE 4-4. trapezoid.80 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT Nail plate f Fibrous s Proximal nail fold " Insertion of the terminal tendon . Anatomy of the terminal phalangeal area. The palmaris longus inserts in the palmar fascia B. carpal tunnel (Fig. By itself. At its center. The ca rpus has eight carpal bones a rra nged transversely thumb metacarpal only articulates with the trapezium . 4-8). and p isiform are in the The hand has five metacarpals.m'" ~ Trapezium Capitate Scaphoid Triquetrum ~ ~ Lumate FIGURE 4-6 Bones of the h Ulna Radius Radius Ulna posterior aspect. Terminal phalanx Middle phalanx Proximal phalanx Pisiform Tmp"oid ~ H. The thumb is the shor proximal row. triquetrum . and the lateral columns are made by the remaining carpal bone each side of the central column (Fig. The distal carpal articulates with the bases of the metacarpals. The trapezium. hamate are in the distal row. the deepest par n. Ii If'll FIGURE 4-5. The carpal bones are arranged in such a way they form the transverse carpal arch . The distal row carpal bones. The central longitud column consists of the lunate and the capitate.e palmar fascia holds the skin of the volar aspeci at the creases and in the transverse carpal arch forms the beginning of turn is attached to the bones and the deep inter muscular septae of the center of the 'longitudinal arch and runs with the mid hand. finger ray (Figs. scaphoid. and and the widest . lunate. Each carpal b has a unique shape and size. which allows it to fit in location . and the middle finger is the longest. into the proximal and carpal rows and arranged longitudi­ remaining four metacarpals articulate with the other th nally into the central and the h. capitate.

JO iNTS Distal Radioulnar Joint.. Transverse carpa l arch Scaphoid l --->"--+--Metacarpal Trapezoid Hammate Dorsal aspect FIGURE 4-9. Cross-seclion o f the carpal tunnel..R. The arch is concave toward the area is supported partly by the terminal phalanx and partly palm. Each metacarpal has a base . with the deepest part of the expanded round irregular shape known as the tuft. and the H = Hammate thumb has two. (see Fig . FIGURE 4-10. 4-7) . that curve at the middle finger metacarpal.. which compensate for the absence of the head of the middle finger. It would be very painful if the end of the bone carpal heads of the index. 1988). including parts o f metacarpa l. deepest part of the longitudinal arch. Those of the thumb are the widest and the C = Capitate Td = Trapezoid shortest. including transverse carpa l arch.::--­ . does not reach the tip of the digit but ends at a leve l around the junction of the proximal two thirds and the distal third metacarpals have a longitudinal gentle curve that is con­ of the nail bed. middle... The space between the skin to the fingertips (Hollinshead. Carpal bone columns. . Longitudinal arch Ulna Radius Transverse carpal arch Thu mb FIGURE 4-8. = tunnel ior the flexor carpi rad ialis. The distal radi uln ar joint is located proximal to the radial carpal joint. langeal Clrea. with the deepest point of the arch at the metacarpal by the nail plate. a shaft. and a head. 1988) (see of the tip at the distal end of the nail bed and the end of the Fig . ring. This is part of the plays a major role in for ming the hape of and contributing longitudinal arch of the hand that extends from the wrist to the stability of the digit tip..c. Arches of the hand. 4-5). Milford. terminal phalanx is occupied with fat and fi brous septae The position of and the relationship between the meta­ (see Fig. The end of the terminal phalanxes has an cave toward the palmar aspect. S =Scaphoid L = Lunate T = Triquetrum P = Pisiform Each finger has three phalanges (see Fig . F. The terminal phalanx is the end of the hand skeleton and FIGURE 4-7. The termin al phalangeal hand (Milford. The radial side of the head of the ulna arti ulates with a notch on the radial Lateral Medial column column--- .. Bones of the hand . 1982 .. 4-7) . R = Radius They all have a gentle curve concave toward the palmar U = Ulna aspect to continue with the longitudin I arch of the hand. and little fingers were to reach the skin because of the digit tip and the direct make the base fo r the transverse metacarpal arch of the pressure of the bone on the skin. Th ose of the middle finger are the longes . 4 -7). The middle finger is atthe center­ terminal phalanx in the distal third of the terminal pha­ most. Each Tm = Trapezium phalanx has a concave wide base and a condylar head .

1976. The middle finger carpometacarpal joint has no mobility at all. 1. which are all prim of the ball and socket variety. Arches of the hand. dorsal. FIGURE 4-1 2 . th they have two convex condyles at the head with a gro depreSSion. stable center of the longitudinal arch and is I/ Lunate continuous with the central longitudinal rigid column of the Ulna Radius carpal bones (see Fig. In the digits . The carpometacarpal joints are 5th Metacarpal ~ formed by the distal carpal row and the basis of the five . 1976) Ligament side of the distal end of the radius and with the proximal specialized connective tissue structures. At the wrist joint. Ligaments of the wrist. the ligaments are in the joint at the wrist. Carpometacarpal Joints. since tures of the base of the metacarpal of the middle finge to be treated quite differently from fractures of the ba the metacarpal of the thumb or the little finger. They allow flexion. and their pri surface of the triangular fibrocartilage . however. 1984. The distal radiulnar joint allows supination and pro­ ments are located in the volar. but it is the mobility of some of these bones that gives the Capitate intercarpal jOints their uniqueness. and adduction range of motion. Taleisnik. as shown in F Radial Carpal Joint. Metacarpophalangeal Joints. 4-11). The ring and index carpometacarpal joints have the least mobility. but the latter is only part of the joint in certain volar plates. but on the lateral aspect of the joints. Located between the various carpal tional and Surgical Anatomy of the Hand. and valley in between and allow flexion extension range of motion.1 st Meta metacarpals. . It is attached responsibility is to maintain stability while allowing mo between the ulnar side of the end of the radius and the base of the joints. tegrity of the ligaments around the jOints ( Hollins 1982. as it is the rigid. or the carpometacarpal joint.. exten abduction . the shape of the articular surfaces. numerous intricatel of the styloid process of the ulna. 4-13) (Kaplan's F Intercarpal Joints. and ulnar nation of movement to take place. It only involves the scaphoid and part of and the lateral aspect. The basal joint. volar aspect. When the joint to perform its function. radial. The itself. but more so on th FIGURE 4-11. Landsmeer. The interphalangeal joint tween the phalanges are of the bicondylar variety. L bones. the ranges of motion of the VJTist. The radial carpal joint is the main 4-12. These joints allow some of the carpal bones to be mobile in the very l''?stricted space given. -kJ ~ f Transverse carpal arch . No communication ranged ligaments not only hold the carpal bones tog occurs between the distal radial ulnar joint and the radial but also hold the carpal bones to the metacarpals di carpal joint or the various components of the wrist joint and the long bones of the forearm proximally.. called the collateral ligaments (Fig. The d ence in treatment is a result of the fact that the mo varies from one digit to the other. ligaments are called fibrocartilage. The laxity or tightness of the ligament that make the wrist area very unique and very well adapted pends on the position of the joints. 1976). The metacarpophalan joints are located between the heads of the metacarpal the base of the proximal phalanges. Interphalangeal Joints. and surrounding muscles and tendons.- ~ *= LIGAMENTS The stability of the joints depends on the bony stru of the joint. On the volar aspect. PIsiform ----~+ of the thumb between the trapezium and the first meta­ Hammate----+_ r Trap carpal is the most mobile. between all the bony components. the intercarpal joints are a very complex set of joints meer.+ .82 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT Longitudinal arch All these are important facts to remember. The dorsal aspect of the joints h the lunate to articulate with the radius and the triangular ligaments. The carpometacarpal joint of the :> ' ~ \ Sc little finger between the base of the fifth metacarpal and the hamate bone is the second most mobile.

The brachioradiaUs originates from the upper third of the lateral supracondylar ridge of the --:>-7'-1"-. humeral origin from the lower part of the medial supra­ If the ligaments of the joints are disrupted. They orig. O n the flexor ligaments are tightest in the extended position and become surface. the collateral liga­ Extrinsic Muscles. however. a must be understood. At the metacarpophalangeal joints .. On the extensor aspect the two These are important facts because in positioning the muscles are the supinator and the brachioradialis. which limits the extension of involved joints. 4-17). Srachloradialis. and the patient is asked to flex the e lbow (Fig .. A good example is the ulnar collateral ligament of radius.---~. which are located on the flexor and extensor aspects of the forearm .e.. elbow partially flexed . flexed. muscles. which renders joints unstable and sets the stage for defor­ ~--Metacarpal head mities to occur in response to the vario us stress factors to :. Tight collateral ligament Pronator Quadratus. ---Proximal latera l ligam nt of the proximal interphalangeal joint is ~~Phalallx more critical. Nerve supp ly is the radial C5-6. ~ T-ligament Proximal MUSCLES I phalanx Muscles that playa direct role in hand function insert at various locations in the hand and a re grouped into two divisions based on their location of origin. they originate and become tight. Nerve supply is median nerve C6-7.­ ligament the radius. extrinsic group of muscles. Nerve supply comes from median nerve C7-Tl (Fig 4-1 6).Loose collateral humerus and inserts in the radial side of the lower end of Folded volar plate . The pronator is compromised. If they fibrose in this position. the arm is held next to the body. This muscle originates in the lateral FIGURE 4-14. the joint condylar ridge and med ial epicondyle and second.. which shorter. however. 4-15). the collateral indirectly affect the function of the hand . they shrink and are located exclusively in the hand (i. Interphalangeal joint in extension and in flexion . To test this muscle.. This muscle originates in the volar ~r/.. To test the action of this muscle. To test the the metacarpophalangeal joint of the thumb. these two muscles a re the pronator teres and the loosest in the flexed position. Extrinsic muscles are located on the ments become tight with the metacarpophalangeal joints in flexor a nd extensor aspects of the forearm. and the patient is asked to Stretched volar plate pronale the forearm. which originate or insert away from the hand but At the interphalangeal joints. as it takes the stress of the opposition be­ tween the thumb and the finge rs. They are 90 degrees flexion and become loose when the metacar­ frequently referred to as the long fl exors and long exten­ pophalangeal joints are in the extended position and can sors. as shown in Figure 4-14 . and the patient is asked to pronate the forearm (Fig. The first is the FIGURE 4-13.inate in the forearm and are inserted in specific locations in the hand . pronator quadratus. This muscle has tv\lO origins: first. as compared action of this muscle. the volar plates fold and beco me more lax and The second is the intrinsic group of small muscles. epicondyle of the humerus and inserts in the proximal third . the function of the hand origin from the coronoid process of the ulna. Metacarpophalangeal joint volar plate and co llateral ligament in extension and in flexion. Some ligaments are much more vital than teres inserts into the middle of the lateral surface of the others. Supinator Muscle. the conditions of these ligaments Pronator Teres. Lax folded volar p l a t e . insert inside the hand). There are two flexor and two extensor surface allow abduction and adduction . fo rearm in neutral position . aspect of the distal ulna deep to the flexor tendons and is inserted in the volar aspect distal fourth of the radius. No deformities of the Tight volar plate joints can develop without disruption to the ligaments. the arm is held next to the body with the elbow in partial fleXion . Consequently.. ~r/- patient cannot use the thumb at all with an unstable ulnar collateral ligament. the arm is held next to the ~----.--~ J Tight collateral which the joint is exposed.. an ulnar becomes unstable. joints during treatment . In the fingers. the radial col­ j. body with the elbow fully flexed.

forear m is held in supination. the medial border of the olecranon . Pronator quadratus. The Palmaris Longus.84 UNIT TWO-COMpmJE~JT ASSESSMENTS OF THE ADULT FIGURE 4-17. Its action is tested by h a. view . Flexors of the wrist supply is median nerve C7-8. B. a b. and it inserts at the volar surface base of the second metacarpal. To test the supinator. . an d the elbow is p of the lateral surface of the radius nerve supply. It is i 3. dorsal view. This muscle originates in the muscle supinates the forearm (Fig. 1. If present. Palmaris longus . Flexor carpi radialis the thumb and the little finge r tip to tip and then fiex b. with the elbow fiexed fully. Long fiexors of the fingers Flexor Carpi Ulnaris. This muscle originates in the a. Nelve supply is the median nerve C7-8. Brachioradialis. Nerve supply is the ulnar Flexor Carpi Rad/alls. Flexor pollicis longus (the long fiexor to the thumb) in the pisiform bone . Pronator teres. Supin(ltor. 2. A . Flexor digitomm superficialis "sublimis" epicondyle. Brachioradia FIGURE 4-15. Flexor carpi ulnaris wrist. epicondyle and inserts into the fiexor retinaculum a The long fiexors that originate in the forearm and are palmar aponeurosis a t the wrist and palm of the han inserted in the hand are the following: muscle is absent in 10 percent of the population. Flexor digitorum profundus upper part of the posterior border of the ulna. FIGURE 4-18. 4-18). its tendon becomes the most pro c. This muscle's origin is in the com­ mon fiexor origin in the medial epicondyle. Nerve fiexed while this muscle fiexes and radially deviates th supply is radjal nerve C5-6. the FIGURE 4-16. 4-19). the (Fig. if present under the skin at the wrist area (Fig. To test this muscle . forearm is held in neutral. 4-20).

I f The origin of on occasion. ring. which supplies the profundus to the ring and little fingers . The origin of this muscle is in the upper two thirds of the anterior and medial surfaces of A B the ulna and from the adjoining half of the interosseous FIGURE 4-22. . To test for any of the sublimis units. Flexor carp i radialis. C8-T1. 4-22 and 4-23 ). which gives the profundus to the index and middle fingers. 4-24 and 4-25). This muscle originates in the forearm from the radius and interosseous membrane and . with the exception of the finger whose muscle unit is being tested. Nerve supply is the median nerve C 7-Tl. partly from the coronoid process of the ulna. Nerve supply to the muscle belly. Flexor carpi ulnaris. if present. The action of any unit of this muscle is tested by holding the hand in FIGURE 4-19. and from the ulnar collateral ligament. is from the median nerve through its anterior interosseous branch C7-Tl. Flexor Pol/lcls Longus. Isolating the sub limis flexor to the index fing er (AJ and membrane. except the distal interphalangeal joint to be tested (Figs. the little finger (B). Flexor Oigiforum Profundus. it flexes and ulnarly deviates the wrist (Fig 4-21). is through the ulnar nerve C8-T l. the hand has to be held flat on the table with the forearm supinated and all the fingers blocked from movement. It inserts at the base of the terminal phalanx of to the middle finger (B) the index. middle. The superficialis tendons insert at the volar surface base of the middle phalanx. the medial border of the coronoid process of the upper two thirds of the anterior border of the radius . Nerve supply to the A B FIGURE 4-23. The patient is then asked to actively flex the proximal interphalangeal joint (Figs. and little fingers. it i usually of a much smaller size than the superficialis tendon of the other fingers. muscle belly. FIGURE 4-21. The superfi­ cialis to the little finger is absent in about 20 percent of hands and. Flexor Dlglforum Superficialis "SublimIs. Isola ting the sublimis flexor to the ring finger (A ) and to FIGURE 4-20. Palma ris longus. supination with the wrist and all the finger joints blocked from movement. this muscle is in the medial epicondyle of the humerus. With the forearm supinated.

Isolating the action of the profundus tendon to the index from the distal third of the lateral supracondylar ridge. To test muscle . This mu 6. It 2. the forearm is held in pronation. finger (A) and to the middle finger (B). Extensor carpi ulnaris lateral epicondyle of the common extensor tendon. and inserts at the ex muscles are present: sor aspect of the base of the third metacarpal. It is inserted into the base of the terminal phalanx of the muscle is tested by holding the forearm in full prona thumb. Long com mon extensor proprius to the fingers ulnar deviation (Fig. Extensor pollicis longus of the ulna. Extensors to the wrist and action are the same as for the extensor carpi rad a. 4-28). and the carpi radialis brevis (Fig. . the interphalangeal joints are fully flexed . the wrist and the metacar­ is almost impossible to isolate this muscle from the exte pophalangeal joint of the thumb are stabili zed. A Extensor Carpi Radialis Longus. 4-27). and A B FIGURE 4-25. Nerve supp~y is the radial nerve C 3. Extensor carpi radialis longus and brevis. To test for its action. Nerve supply is the median nerve through its while the fingers are closed in a fist. which is called On the extensor side of the fo rea rm. Extensor carpi radialis brevis Extensor Carpi Ulnaris. difficult to isolate clinically . The four tendons of muscle insert partly in the base of the proximal pha of the fingers and partly in the extensor hood me nism. Extensor pollicis brevis the extensor aspect. The patient is anterior interosseus branch C7-Tl. (extensor digitorum communis) Extensor Dig/forum Communis to the Fingers. Nerve supply is the radial C6. the wri stabilized. Long independent extensor dig iti m inimi to the little originates in the anterior surface of the lateral hum finger epicondyle from the fascia covering the muscle from the intermuscular septum. Extensors to the thumb has a partial origin in the middle part of the posterior bo a. the lateral epicondyle of the humerus . b. Nerve supply is the radial nerve C7-8. Abductor pollicis longus Its action is tested as other wrist extensors are tested 4. Nerve su 1.7. Isolating the action of the flexor digitorum to the ring FIGURE 4-27. 4-26 ). Extensor carpi radialis longus longus (see Fig. Flexor pollicis longus. It inserts at the base of the fifth metacarpa b. 4-27). This muscle 's orig FIGURE 4-24. In testin the hand is held in supination . This muscle originat thumb (Fig. it inserts at the base of the second metacarpal on extensor aspect. the following common extensor tendon origin. asked to extend the wrist with radial deviation. patient is asked to flex the interphalangeal joint of the Extensor Carpi Radialis Brell/s.86 UNIT TWO-COMPONENT ASSESSrviEr~TS OF THE AOULT FIGURE 4-26. This muscle originates in c. They ar finger (A) and to the little fi nger (B). Extensor indicis proprius with the knowledge that this muscle extends the wrist 5.

This muscle originates in the epicondyle and also from its own muscle fascia. or neutral. FIGURE 4-30. 4-30). the wrist is stabilized. the wrist is stabilized in extension. Extensor Pol/lcis Brevi's. Nerve supply is the radial nerve C7-S . This muscle originates deep in the forearm from the lower part of the ulna and the adjoining interosseous membrane. Extensor Pollicis Longus. all fingers are flexed. It inserts into the extensor hood mechanism of the thumb and through that into the base of the terminal phalanx of the thumb. in the base of the proximal phalanx and partly in the extensor hood mechanism. Extensor indicis proprius. po llicis longus. Extensor Indlcls Proprius. Note the hyperextension at the interphalangeal jo int of the thumb. Extensor carpi ulnaris. Nerve supply is the radial nerve C6-7. and the patient is asked to extend the little finger only (Fig. " extensor pollicis longus. The muscle is tested in the same manner as the extensor digitiminimi. Extensor digiti minimi. Extensor Digiti Minimi. This originates in the dorsal surface of the ulna and interosseous membrane. anatomic "snuff box. FIGURE 4-33. The muscle is tested with the wrist and the metacarpophalangeal joint of the thumb stabilized in neutral and the forearm in pronation. Its tendon inserts partly FIGURE 4-31. speCifically. to hyperextend the FIGURE 4-32. 4-32). Extensor pollicis longus. 4-29). . To test this muscle. This originates in the radius and the interosseous membrane and inserts in the dorsal aspect of the base of the proximal phalanx and partly into the extensor mechanism of the thumb. The patient is asked to extend the thumb and. Nerve supply is the radial nerve C7-S . supination. A ll of the extensors of the digits in action: extensor digiti FIGURE 4-29. interphalangeal joint (Fig. 4-33). extensor fingers. The tendon inserts partly into the base of the terminal phalanx and partly into the extensor hood mechanism. and the patient is asked to extend the thumb independent of the position of the forearm (Fig. patient is asked to extend the metacarpophalangeal joints (Fig. common extenso r " digitum extensor. " extensor indicis pro prius o f metacarpophalangeal joints of the index. To test this muscle . 4-31). middle . the forearm is held in pronation. FIGURE 4-28. ring . the only exception being that the patient is asked to extend the index finger (Fig. and little o n the ulnar side of the common extensor part to the index. Extensor digitorum communis with isolated extension minimi. Nerve supply is the radial C7-S.

is the basis for Froment's sign. are located on the radial side proximal phalanx. and originates fro m the flexor radialis . Flexor pollicis brevis. by the median n (Fig. Its action is tested by stabilizing the wrist. Some p multiple slips into the lateral side of the base of the first might reach the palmar aspect of the metacarpophalan metacarpal. The 3) lumbrical muscles. carpi radialis. With the exception of the adductor pollicis and of the metacarpophalangeal joint and into the exten the deep head of the flexor pollicis brevis. origin of the oblique head of the adductor pollicis. The muscles are divided into capitate and the trapezoid. With the joint and the sesamoid bone (Fig. The deep head is supplied by by the median nerve and act together as a group. regard of ·the position of the forearm . The superficial head arises from is very difficult to isolate the function of this muscle from the flexor retinaculum . bones: trapeZOid . third. trapezium. and the sheath of the fl interference of the other extensors of the thumb. The adductor pollicis arises by most superficial of the group .88 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT AGURE 4-36. That muscle is inserted into the base of the base of the proximal phalanx into the ulnar sesam radial side of the proximal phalanx in the lateral tubercle bone of the metacarpophalangeal joint and also into and occasionally into the lateral sesanlOid of the metacar­ extensor expansion of the thumb. It head and a deep head. the trapezium. they are supplied expansion of the thumb. The opponens pollicis lies deeper t AbductorPol/lcis Longus. Opponens Pollicis. also called the the lateral tubercle on the radial side of the base of short muscles of the thum b. and sometimes from the deep aspec Intrinsic Muscles. They also insert into the radial sesam of the hand . is located on the radial side of heads: the oblique head from the sheath of the flexor c the thenar eminence area. 4-36). and 4) interossei. adduct the thumb toward the index finger (Fig . forearm in neutral and the wrist stabilized. with a slip fro m the tendon of the abductor head arises from the shaft of the third metacarpal. 2) hypothenar muscles. ulna . and by asking the patien nism of the thumb (which will be discussed later). FIGURE 4-37 . difficult to isolate the independent function of each muscle. the patient is Flexor Pol/icis Brevis. The abductor pollicis brevis is the Adductor Pollicis. heads of the flexor pollicis brevis unite and are inserted Thenar Muscle Group. and fourth metaca reticulum at the wrist. It is inserted sometimes through radial half of the shaft of the first metacarpal. along with the extensor mechanism of the fingers (Fig. Nerve supply is the radial nerve C6-7. The transv more frequent ly. It is very ulnar nerve. 4--35). The deep head arises from and insert inside the hand. 4-37). Abductor Po/licis Brevis. This muscle has both a superf asked to abduct the carpometacarpal joint of the thumb. A bductor pollicis brevis. and the capitate bones. base of the second . and the interosseous retinaculum and the trapezium bone. It is inserted into membrane between them. and the superficial head. AGURE 4-34. These are the muscles that originate the palmar aponeurosis. Opponens pollicis. Adductor pollicis . and. the scaphoid. which occurs when patient is asked to hold a paper firmly between the thu fiGURE 4-3 5. where it continues with four groups: 1) thenar muscles. This muscle originates from the the abductor pollicis brevis and arises from the fl dorsal aspect of the radius. T he thenar muscles. It is supplied by the u pophalangealjOint and also partly into the extensor mecha­ nerve. 4-34). pollicis lo ngus and occaSionally with a slip from the tendon adductor pollicis is inserted in the tubercle 011 the ulnar of the palmaris longus.

This group of muscles is is inserted in the dist I two thirds of the medial half of the located on the ulnar side of the hand. to use the nexor poliicis longus to nex the interphalangeal jOints of the thumb to give power to thumb adduction . Fromenl s test. . the hook of the hamate . Flexor Digiti Minimi Brevis. tendon . This is a very small subcutaneous muscle that arises from the medial border of the p lmar aponeuro sis and is inserted into the skin of the medial border of the RGURE 4-39. Abductor digiti minimi.. The hamate is the roof of the Guyon's canal. It is pophalangeal joint. minimi abducts the little finger away from the ring finger. The muscle will be felt in the ulnar borde neutral and the forearm supinated. the little finger is twisted actively as If to than are the thenar muscles. the little finger is abducted actively. interphalangeal joint to hold the paper through the action Opponens Digiti Minimi. I Hypothenar Muscle a plied by the ulnar nerve and are easier to test independently neutral position. the little finger is actively flexed a t the metacar hamate. With the wrist in neutral position and resting on a flat surface with the palm up to cancel the action of the digi and the index finger. With the wrist . or in some cases it might jus and extends the interphalangeal joints of the little finger. FIGURE 4-41. They are all sup­ palmar aspect of the fifth metacarpal . the abductor digiti of the hand (Fig. The opponens digiti minimi arises of the flexor pollicis longus (Fig. With the wrist stabilized in meet the thumb . 4-38). in case of paralysis of this muscle. extensors. With the wrist in neutra or spreading over from the pisiform to the hook of the position. from the hook of the hamate a nd the flexor re tinaculum. Rexor digiti minimi. be joined as part of its neighboring small muscles in the The opponens digiti minimi brings the little finger toward hypothenar area . It originate fro m the flexor retinaculum the thumb (Fig. Opponens digiti minimi. It i from the tendon of the flexor carpi ulnaris at the wrist from inserted into the medial side of the base of the proxima the pisiform bone and also from the fibrous arch spanning phalanx of the little finger. 4-41). 4-40). e . phalanx of the little finger and partly into the extensor Palmaris Brevis. The abductor digiti minimi arises the muscle to the origin of the abductor digiti minimi. and the rigid the patient will not be able to hold the paper between the contracted muscle will be felt a t the ulnar border o f the hand thumb and the index finger unless the thumb is flexed at the (Fig. 4-39) . This muscle is absent in abou The flexor digiti minimi flexes the metacarpophalangeal 20 to 30 percent of people.FIGURE 4-38. in full extension). with the interphalangeal joints held in inserted into the medial side of the base of the proximal neutral (i.with paralysis of the first do rsal interosseous and the adductor poliicis " ulnar nerve injury. and the fibrous arch which unite Abductor Digiti Minimi." the patient has FIGURE 4-40.

There are seven interossei muscles. The two lumbricals that adjoining dorsal surfaces of the second. The first one arises from the ulnar side and adjoins the palmar aspect of Muscles are the contractile structure but tendons the second metacarpal. its main function is to protect the ulnar nerve and the ulnar vessels. The medial two arise by two heads from the much bigger than the palmar ones and arise from adjacent sides of the profundus tendon to the long . pronated and the wrist stabilized . All tendons are primarily designed to perform a function plays a major role in the harmony of the dynamics of hand (Doy. Klei and 5tormo. the dorsal ones abduct metacarpophalangeal joints of all the fingers . 1973. The first dorsal interossei arise f and little fingers. They also digits . In their journey from the end of the muscle to FIGURE 4-43. They are inse fingers are supplied by the median nerve. Kleineli. E tendon unit has to follow a certain path and is attache the bone in a unique way that ultimately maximizes actions of the muscle unit. hand.le and Blythe. Finger abducti on-palmar interossei. third. is inserted in the bas the terminal phalanx just distal to that particular joint. Each muscle unit ends in single multiple tendon units. and fourth and fifth . some . wh of the profundus tendon to the index and long fingers. The three remaining dorsal interossei arise from extensor expansion to the fingers. we will discuss each tendon separately. form a kind of tunnel that transmits the radial artery into These small muscles are inserted into the lateral edge of the palm . 1975. The lateral two arise from the lateral side the first and second metacarpal shafts by two heads. Almost all the extri muscles have long tendons . Verdan . Interossei Muscle Group. When present. With the forearm pronated. and the short muscles in hand have short tendons. Tendons are always inse distal to the joint on which they exert their funct consequently. insertion in the bone.angeal and interphalang langeal joints are extended (Fig. 1975. There are four lumbrical fourth and fifth metacarpals. 4-43 and 4-44). All the interossei are supplied by the u fingers are supplied by the ulnar nelve. third originate from the profundus of the index and middle fourth . With the forearm nerve . The two lumbri­ into the base of the proximal phal anx and the exten cals that originate from the profundus of the ring and little expansion. some tendons curve. ring. adjacent metacarpals. The four dorsal interossei muscles. the wrist stabilized . Finger adduction-dorsal interossei. the flexor profundus . which attach to the bone. respective'ly. all the lumbricals extend the hand resting flat on a table to cancel the long tendo the interphalangeal joints and Simultaneously flex the the volar interossei adducts. The interossei also help the lumbricals with t extend the interphalangeal joints when the metacarpopha­ action on the metacarpophal. joints (Figs. 4-42) .90 UNIT TWO-COMPONENT ASSE SSMENTS OF THE ADULT FIGURE 4-42. Due to the uniqueness of tenc:\ons. 1964). Lumbrical Muscle Group. Lumbrical-interossei position '·action. which flexes the d interphalangeal joint of the finger. The two remaining interossei arise specialized connective tissue that is designed to trans from the radial side and adjoin the palmar surface of the contractions of the muscle into joint action through process of gliding . The three palmar interossei arise from the TENDONS metacarpals of the fingers on which they act. " FIGURE 4-44.

and at the distal palmar FIGURE 4-45. The majority of the remaining population. It is the length and size of this tendon into the flexor fibrous sheath. the base of the distal phalanx. Each tunnels are specialized compartments located at strategic segment or slip continues distally to be inserted almost locations in the hand . which extends proxi­ out of the first extensor compartment. proximal phalanx. more tendons might go through a specialized compart­ The vinculum breve is a small triangular band in the interval ment. and becomes Around the level of the metacarpophalangeal joint. The tendons have their own blood supply and are extending from the tendon to the proximal part of the covered with a specialized tissue called the tenosynovium . consequently. Its synovial sheath. no then goes through the decussation of the sublimis opposite specific functions are lost in its absence. where the segments partially join again. When the palmaris longus muscle is deeply under the superficialis tendons . Each tendon of the present. In addition. The profundus. they middle phalanx. or slips. As it enters the fibrous that make it adequate to be used as a tendon graft to recon­ sheath . proximal phalanx. wrist area that it becomes vulnerable to an inflammatory and the most ulnar part forms the tendon to the little finger. The tendon of this muscle starts in cialis tendon to the little finger is absent in about 20 percent the lower third of the forearm and travels in a separate deep of the population and is very small and less developed in the compartment that is on the radial side of the wrist. partly through with the tendon of the profundus . The tendon of this muscle is fairly distal interphalangeal joint and is also supplied by the long and runs through the carpal tunnel deep to the flexor aforementioned long vincula. the superfi­ Flexor Carpi Radialis. thenar muscles. It is inserted into the palmar aspect of crosses the tendons of the two radial extensors of the wrist. while obvious. still in the fibrous flexor sheath. Each segment passes around and then posteriorly to the joining tendon of the straight. lent donor tendon. The tendons of the superficialis have the maximize the pulling forces of the muscle unit. The extensor pollicis longus tendon is a good example crease. One or vincula breve and longus. It travels on the the fibrous flexor sheath or tunnel at the base of the radial side with the tendon of the extensor pollicis brevis. making it an excel­ the proximal phalanx . It profundus. which carries the blood supply The two tendons cross over the radial artery after they exit to the tendon . and others go through tunnels (FigA-4S). each tendon enters the fibrous flexor sheath along of a tendo n that partly goes straight. The four tendons go through the carpal tunnel and lie Palmaris Longus. each superficialis tendon splits into two segments. This tendon starts at the muscle origin and is outside the carpal tunnel. longus is flexion of the interphalangeal joint of the thumb and some flexion of the metacarpophalangeal joint. The abductor mally into the forearm. This position is maintained through the carpal tunnel but the tendons diverge (one to each finger) in the palmar triangle. travels is inserted in a Widespread manner into the palmar apo­ distally through the palmar triangle of the hand and then neurosis of the hand. and. The tendon of this muscle metacarpophalangeal joint of the thumb and then enters becomes superficial in the distal forearm. The tendons for the long and ring fingers are almost always superficial to those for the index and litde fingers. The function of these tunnels is to separately into the margins of the palmar surface of the safeguard against bowstringing. and partly without a pulley on the more carpal. it runs behind the sublimis tendon to each digit and struct another missing tendon in the hand. is inserted in the volar aspect of the base of the terminal it turns around superficial to it and then travels deep to the phalanx. after its exit from the carpal tunnel area . and then it in the thumb around the flexor poliicis longus can extend becomes attached to its point of insertion in the lateral side . which is attached to the capsule on the volar aspect of the Flexor Pollicis Longus. The vinculum longus is a slender band to move . as in bowstringing." Usually four tendons (one for each finger) arise from the muscle belly around the middle of the forearm . then around a curve. Each tendon has a vinculum breve. flexor carpi radialis tunnel is hidden behind the thenar Flexor Digitorum Profundus. Flexor Digltorum Superficialis "Sublimis. a pulley o n the dorsum of the wrist. As previously mentioned. The tendon has a very well and then travels through the first extensor compartment. developed vinculum breve. which carry the blood vessels . it has a very long tendon and short muscle belly. The tendon of the profundus carpi radialis tunnel and then just distal to the carpal tunnel. The most radial part of the muscle active tendon and is squeezed in its tunnel so deep in the belly of the profundus forms the tendon to the index finger. condition known as flexor carpi radialis tendinitis. and if they have to cross in front of the joint. It is such an middle of the forearm. is significant because any infection pollicis longus splits into multiple tendon slips. tha t is why the tendon pops out. The compartments are located proximal or distal to between the terminal part of the tendon and the front of the joints. then proximal interphalangeal joint and the distal part of the structural changes in the pulley take place to allow the joint proximal phalanx . It runs between the two sesamoids at the Abductor Pollicis Longus.

From the muscle belly. The action of the inter part of the tendon is inserted at the base of the proximal depends on whether they are palmar or dorsal. which is located on each digit and continue distally volar to the transverse the ulnar side of the dorsal tubercle of the radius. and because of its anatomic relationship as compartment. Consequently. flex the metacarpo . This tendon starts at the l Extensor Pollicis Brevis. it can also abduct and flex the first joints. The first dorsal interosseus ro muscle tendons primarily extends the metacarpopha­ the index finger radially at the metacarpophalangeal langeal joints. Inflammation of this ten­ inserted into the base of the terminal phalanx and th don . this makes it a very frequently third of the forearm and then passes through the f used tendon . This tendon. coupled with the extensordigit partly in the dorsal aspect of the base of the proximal proprius to the little finger. through the fourth compartment of the extensor retinacu­ Interossei. middle . they extend its oblique course and the side-to-side mobility on the latter. ring . This tendon becomes superficial third of the forearm and travels distally through a sp in the distal part of the forearm and travels along the fifth compartment in the extensor retinaculum. dorsum of the first metacarpal. This muscle axis of the metacarpophalangeal joints and are dors tendon unit extends all the joints of the thumb . This group of radial or the ulnar side. This tendon stays deep in the Lumbricals. it changes its direction to all oblique radial direction . be (located in the first extensor compartment). At this of the metacarpophalangeal joint. The superficial part joins muscles abduct the other fingers away from the middle the extensor hood mechanism on the extensor aspect of Those that act on the middle finger abduct the finger t the proximal phalangeal area of the fingers. The abductor pollicis finger bone. profundus and their attachment of insertion to th Extensor Digitorum Proprius "Communis. This tendon starts at the metacarpal. join the lateral edge of the extensor expansion o crosses superficially to the tendons of the two radial extensor hood mechanism as they become the most extensors of the wrist. along with its companion extensor pollicis brevis tensor hood mechanism. Because of the axis of the interphalangeal joints. Extensor Digiti Minimi. through the extensor hood expan­ to allow for thumb-to-index pinching. these long proximal part of the conjoint tendon of the small mu extensors to the fingers divide into two parts. interossei tendons travel a very short distance dorsal t the tendons are connected together by oblique bands. these tendons playa role in the extension terossei adduct the fingers toward the line of the long fi of the interphalangeal joints. The other part of that con mechanism of the thumb alld is inserted in a very wide flat tendon. Like the other small muscles of the hand lum over the center of the wrist.92 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT of the base of the thumb metacarpal. As the lumbricals are volar t aspect of the base of the terminal phalanx. At are inserted in the extensor expansion . However. The palma sion mechanism. these tendons have the of the metacarpophalangeal and interphalangeal jo tendency to abduct the fingers from the line of the long the interossei. This muscle tendon unit. junction with the other extensors but also independ through its insertion in the extensor expansion. Extensor Pollicis Longus. it is vulnerable extensor digitorum communis to the index finger a to irrlitation and inflammation. it splits into extensor compartment and continues distally as it inserts portions. The d phalanx on the extensor aspect. which is the thumb Extensor Indicis Proprius." The tendons of tensor system allow the lumbricals to play an impo the extensor digitorum proprius to the index. it lies on the ulnar side o it lies on the distal border of the radius . It extends and abducts the carpometacarpal joint in the base of proximal phalanx. extends the little finger. needs to function with the fingers extended in one unit. and with the fingers extended at these joints. the tendons t distal third of the forearm and in the wrist joint area until it distally through the lumbrical canal on the radial si gets out of its own third compartment. is what is working along with the common extensors of the fin known as tenosynovitis of the first extensor compartment produces the independent extension of the index fing (de Quervain's disease) . forming the level of the metacarpophalangeal joints. which almost covers the whole width of the dorsal belong to the interossei. The lumbrical ten point. and continues distally until it part of what is known as the conjoint tendon of the becomes attached to the dorsal expansion of the extensor muscles of the hand . most dynamic part of the hand . like the lumbricals. role in the balance between the flexor and exte and little fingers start proximal to the wrist and travel systems of the fingers. deep transverse ligament of the palm but anterio which allow these tendons to work together when the hand the axis of flexion at the metacarpophalangeal joint. The muscle tendon u and extends the metacarpophalangeal joint. It also plays a the extensor digiti minimi extends the little finger in part in extension of the interphalangeal joint of the thumb . tn a hyperextended position Because of their line of pull and their relationship to th of the metacarpophalangeal joints . is inserted in the extenso phalanx and partly into the extensor expansion of the pansion on the dorsum of the proximal phalanx and p thumb . Their attachment of origin to the f adduct the thumb. along with the four common extensors it travels through the first extensor compartment and as the dorsum of the hand. Eith tendon of the abductor pollicis longus through the first side the compartment or just distal to it. The same is true for extensor digiti mini longus tendon acts as an abductor and stabilizer of the the little finger. which is proximal to the lumbrical. On the dorsum of the hand . almost al tendon. The deeper of the hand into the digits.

are joined injury to the ulnar nerve at the elbow versus an injury to th and overlapped on each side toward the dorsal aspect by same nerve at the wrist. a clinic the interosseous tendon that passes from the hand to the picture of loss of sensation to the ring and little fingers. Besides the sensory loss. the line o the long extensor of the fingers. becomes adherent to the dor­ nerve. At that particular location overlying the distal third of the The same principle does apply to all the nerves of th proximal phalanx. 4-47). and all the inte interosseous tendon is attached to the base of the proximal ossei. From the description just given. paralysis of th superficial part of the interosseous tendon joins the lateral flexor carpi ulnaris. whic long extensor tendon. the two ulnar lumbrical phalanx on the side through which the tendon is passing. the flexo interosseous tendon. is seen. and the deep head of the flexo The lumbrical tendon. divides into a superficial and median nerves continue to the hand as mixed sensory an deep portion. joined by the independent extensor becomes purely sensory in the hand area. the flexor carpi ulnaris. C-8. There are the tw extensor tendons that join the common extensor mecha nism. which is inserted at the base of the part of the muscle belly of the flexor digitorum profundu . With the exception of the radial nerve. side is the tendon of the adductor pollicis. locations will be totally different. they make the flexor carpi ulnaris (note' 'ulnar nerve distribution") and th terminal tendon. they ar joined together with the triangular loose ligament. 1984). the part of the flexor digitorum aspect of the sagittal bands. I dynamic and harmonious way (Tubiana et aL. and the ulnar nerve (C-8 and T-l). Together. C-7. and T-l). its branches. just before the two later extensor bands become the terminal tendon. Knowledge of the course and the location of th metacarpophalangeal joint. C-8. the radial nerve (C-S. fingers and the ulnar side of the dorsum of the hand. In the first instance. however. On the radial side are the tendon of the abducto langeal joint and. The lateral parts of the extensor hood mechanism comes through the cubital canal behind the medial ep pass on the lateral aspect of the proximal interphalangeal condyle of the elbow. along wit becomes quite obvious that overlying the extensor aspect the sensory function to the dorsum of the ring and litt of the proximal phalanx is the extensor hood mechanism. In the the forearm. C-6 in the hand that allows it to perform its function in the most C-7. as it crosses over the motor. bot fingers dorsal to the transverse metacarpal ligament but in the volar and dorsal aspects. enters through the flexor arch. and the muscles it supplies is absolutel sal capsule and is inserted at the base of the proximal crucial to properly evaluate and manage a neurolog phalanx. along with the ulnar half o volar to the axis of the metacarpophalangeal joint. whic maintains the lateral band's position dorsal to the proxim interphalangeal joints and in touch with the central: slip its insertion in the base of the middle phalanx. Non of the lumbricals or interossei in the hand contribute to th FIGURE 4-46. joint capsule to be attached to the base of the middle Ulnar Nerve. the hypothenar muscles. it digitorum profundus to the ring and little fingers. The accuracy of locating the site of an injury t hood mechanism. which are the the nerve becomes clear when conSidering as an examp proximal part of the extensor hood mechanism. the ulnar nerve (Fig. The Extensor Hood Mechanism. The extensor hood mechanism (Fig. 4-48 phalanx. the conjoint tendon of the management. The deep portion. C-6. In the forearm. 4-46). of the middle phalangeal area. The the hand. and T-l). The deep portion of the profundus to the ring and little fingers. is a very complex area of tendon insertion and is Three nerves are involved in the hand: the median nerv a classic example of the uniqueness of tendon arrangement (C-S. joins the extensor hood pollicis brevis occurs. On the ulna expansion. the sensory). nerve at the elbow will not result in intrinsic paralysis is th The central band passes over the proximal interphalangeal case of Martin-Gruder anastomosis (Fig. In the thumb the extensor hood mechanism operates on the sam principle as the other fingers but with some variation. the common extensor hood splits into extremity. The only situation in which an injury to the uln two major groups: the central band and the lateral bands. an joint and then join together about halfway over the dorsal then gives its only motor branches in the forearm to th aspect of the middle phalanx. the ulnar an to the index and little fingers. In the case of injury to the ulnar nerv mechanism distal to the point of attachment of the at the wrist. through their insertion into the extensor pollicis brevis and the flexor pollicis brevis. The superficial portion passes into the extensor problem. the three nerves are mixed (motor an fingers at the level of the metacarpophalangeal joint. which starts at the level of the ~IERVE SUPPLY metacarpal head and extends to the middle of the middle phalanx. Extensor hood mechanism. The sagittal bands. and the prognosis of an injury at any of thes lumbrical. however. the adductor pollicis. The clinical presentation. extensor mechanism of the thumb. and the superficial part of the interossei tendon. will b which is primarily a conjunction of the superficial part of spared from loss. extend the interphalangeal joints.

which is the motor to the th area. Maltin-Gruder anastomosis . the median nerve div finger and the ulnar side of the ring finge r. Distal to the carpal tunnel . distal to which it gives face of the flexor retinaculum. with the exception of the abductor into individual digital nerves that supply the adjoining s pollicis brevis . which is primarily motor and goes through the buried inside the thenar muscle's bulk. It is because of the superficial location of this n the forearm. It then crosses over the wrist to the dorsum of that any surgical incisions on the radial side of the wris the hand to supply sensory fWl ction to the ulnar dorsum to be avoided. At this point. and the pronator quadratus. The two r lumbricals are supplied by branches from the com digital nerves. head of the flexor pollicis brevis.94 urm TWO-C OMPONE~JT ASSE SSilJ1ErHS OF THE ADULT FIGURE 4-47. the superficial of the thumb . It is the sensory nerve of the palmar aspect of the thumb . 4-45) . 1951). and bra nch which inserts in the ring and little fingers (Lamb. in FIGURE 4-48. ficialis . an injury to ulnar nerve proximal to the Martin-Gruber anastom results in prevention of the paralysis of the ulnar innerv intrinsic muscles (see Fig. 195 1. the median n is the sensory nerve to the radial haH of the palm . " is a very important nerve . Through the anterio the forearm. it g a palma r sensory branch for the hypothenar e minence its smallest branch . 19 70 . 1981 . and sensory. to enter the carpal tunnel . and the two lwnbricals that In the forearm . Ulnar course and distribution. the median nerve give crease. the pronator teres. which is " the recurrent branch. a branch from the ante nerve itself continues distally between the two heads of the interosseus connects with the ulnar nerve in the fore pronator teres and then under the flexor digitorum super- (Martin-Gruber anastomosis).) The nerve continues distally in the forearm the forearm . index. including branches . and ring fingers. it gives rise to the anterior interosseus (wh ich terosseous branch. 4-49) enters the flexor digitorum sublimis. where it lies superficial to al The ulnar nerve contin ues to the wrist level and enters flexor tendons and is intimately attached to the under the hand through the Guyon's canal. It then divides Into two branches: the deep ulnar muscles that travel a very short distance before ge nerve . distribution. The median nerve continues its jou the extensor side of the ring and little finge rs. Abo the ulnar artery until about 2 inches proximal to the wrist inches proximal to the wrist. it supplies the ulnar half of the fl is purely motor) that passes under the deep head of the digitorum that inserts in the index and middle fingers. and the superficial ulnar nerve. the palmaris longus. pronator teres and continues moving toward the wrist flexor pollicis longus. if the latter is present. Phalen . Median Nerve. the me nerve supplies the thenar muscles through its m branch . The latter remains superficial and then splits into of its function severely compromises the workings of the palmar digital nerves to supply both sides of the little hand . FIGURE 4-49. Besides the motor supply . middle. with the exception of the deep head of the fl pollicis brevis and the adductor pollicis. In this case. The median 15 percent of the population. and middle fingers and to the radial side of the ring fin . the median nerve supplies the fl join the index and middle fingers. where it becomes superficial under the sk on the radial side of the flexor carpi ulnaris as it is joined by under the palmaris longus. the opponens poUicis breviS. In a Lamb and Kuczynski . carpi radialis . The deep ulnar into an inde pendent digital nerve to the radial side of branch becomes purely motor and supplies ali the small thumb and three common digital ne rves . The motor bra hypothenar arch . the dorsal sensory nerve branches out palmar cutaneous branch that travels distally under the and turns around to the ulnar side of the distal third of the on the ulnar side of the flexor carpi radialis and crosses ulna underneath the flexor carpi ulnaris musculotendinous the base of the thenar eminence to end in the pa junction to a ppear on the dorsal aspect of the lower end of triangle . to whi ch it remains attached until the lower thir Phalen . Each later div muscles of the hand. As it exits the tunnel. After the median nerve (Fig . Injury to this nerve results in a very pa overlying the fourth and fifth metacarpals and continues to disabling neuroma. Median nelVe course. In the hand .

where . the second terminal branch of the interosseous arter brachial artery at the elbow. common palmar digital arteries that divide into the proper passing on the radial side of the forearm to the anatomic digital arteries for the adjacent sides of the four fingers and "snuff box" area. it divides into multiple branch to the ulnar side of the little finger. . 1983). At this point. turning around the radial aspect vessels d the distal end of the radius across the anatomic snuff box. 4-50) palmar branch travels deep into the palm to join the gives its first motor branches to the brachioradialis and the deep palmar branch of the radial artery that makes the two radial extensors of the wrist. ~. At the elbow.. the supinator tunnel and supplies all the remaining muscles The two vascular palmar arches (superficial and deep) of the extensor aspect of the forearm as it moves distally are located in the palm.t . the radial nerve (Fig. is perficial arch.. It travels distally on the radial side of the forearm. index . Its superficial branch makes the su­ ficial and a deep branch . deep to the abductor pollicis longus.. The deep palmar branches that move distally to supply the extensor aspect of arch is dominantly supplied by the radial artery and lies the radial half of the hand and the extensor aspect of the deeply under the flexor tendons. The superficial palmar arch is toward the wrist joint. It then divides into a super­ deep palmar arch.. Then it continues on .--. 1973. . . surface of the forear m underneath the flexor carpi ulnaris. and a branch to the dorsal aspect of the carpus.+ . Its branches are the three lower third of the forearm.. The deep Radial Nerve. Finally. interosseous artery .Dorsal The ulnar artery . BLOOD SUPPLY TO THE HAND The blood supply to the hand (Fig. 4-51 and 4-52) is primarily through the dominant radial artery the less Digital vessels dominant ulnar artery and partly through the anterior and posterior interosseous arteries (Kaplan 's Functional and Surgical Anatomy of the Hand.Superficial palmar arch the two heads of the first dorsal interossei muscle. Moss et al. travels distally on the flexor AGURE 4-52. and then at the heel of the hand it enters Guyon 's canal. This nerve goes through branch of the radial artery joins.. The radial artery is a terminal branch of the brachial artery at the elbow. and middle fingers (Barton. it divides into the deep palmar and the superficial palmar branches. Its branches include the two . The deep branch . - - ­ . Diagramma tic representation of the arterial supply to the hand. FIGURE 4-50.. the extensor pollicis brevis. the two dorsal arteries to the Anterior index. it supplies a branch to the superficial palmar -~f--Metacarpal arch. and the extensor po!licis longus to enter in between "--::-=-=-. palmar arch two heads of the adductor pollicis. ­ .. and that is what the superficial palmar the posterior interosseous nerve. where it becomes superficial. at the wrist level.. ­ . where it is joined by the ulnar nerve on its ulnar side . to the palm between the --t---Deep Radial artery ----'. and branches .Ulnar artery dorsal arteries to the thumb . The superficial branch that is purely dominantly supplied by the ulnar artery and is located at the sensory moves distally under the brachioradialis to the level of the mid palmar crease.-=. As it comes out of Guyon's canal .. 1979 . It gives two branches to thumb. Lister et the thumb and a branch to the radial side of the index finger al. purely motor. FIGURE 4-51.. 1984). through the first intermetacarpal space . Radial nerve course.. Arterial vessels of the hand . . distribution.. it ends up by anastomosing with the deep branch of the ulnar artery to form the deep palmar arch.

volar and dorsal. standing and the process of clinical evaluation (Ka For example. the proximal nail fold . which travels along the veins. The nail 's main function is to support palmar crease) extends from the junction of the hea the tip of the digit. pathologic conditions that affect the hand . as in the (Fig. Surface lan of creases. and shiny in some Functional and Surgical Anatomy of the Hand . and the distal one is in front the terminal phalangeal area and consequently to the func­ distal interphalangeal joint. conse­ oscaphoid joint. and fifth metacarpals to the reaches the insertion of the extensor tendons at the base of border of the hand . and the hair pores on the hand and forearm slant toward the ulnar side. Absence of the nail plate de­ metacarpal and then continues proximally to the tr prives the tip of the digit of any dorsal support and . the blood wiIl stagnate and the hand will swell. In the finger. The texture . This joint is used as a landmar quently. 4-5) is located in the begins on the ulnar border of the hand at the level distal half of the terminal phalangeal area of the digits. A . The proximal one is in front of the pro integral anatomic part that is necessary to the support of interphalangeal joint. painful stiff hand syndrome. 4-54).96 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT and to the three palmar metacarpal arteries_ These arteries pass to join the common palmar digital arteries distal to the middle palmar crease_ The vascular carpal arches. the ulnar. The blood is returned from the hand through gravity if the hand is elevated and through the peripheral muscular pump when the hand is in action. The hand also has a lymphatic draining system. The flexor retinaculum tion of the digits. B. brittle. the lateral nail metacarpal heads transversely to the base of the folds. and the posterior inter­ osseous arteries. This is Significant locating the point of attachment of the rubber bands in cases of injuries to the digit tips. tends from the distal wrist crease to a line about 1 . Venous drainage from the hand is accomplished through a multitude of small veins . It is metacarpal head of the little finger and then runs acro made of the nail plate. The terminal phalangeal area is sup­ shaft of the index finger metacarpal. Loss of the integrity and flexor tendon repair (Fig. the anterior. It is absolutely essential that all proximal one third and the distal two thirds o health care professionals who are involved in hand surgery proximal phalanx. pattern. and the root of the nail. chronic. as it facilitates u the hair is a Significant indicator of the condition of the skin. and color of of the hand is absolutely critical. then it must be elevated to allow for venous drainage. the hair is dry. The proximal palmar crease starts just proxim attached to its nail bed. The creases at the the stability of the tip of the digit interferes with the preci­ of the digits are approximately at the junction o sion movement of the hand. The distal palmar c The nail plate complex (see Fig . fourth. Scaphoid (S) and pisiform {Pl . The nail is firmly finger. The thenar (the radial longit the terminal phalanx . The proximal wrist crease is in line with the radio joint. two transverse creas be very sensitive to the importance of the nail plate as an present. if not. Various small-sized blood vessels branch out from the vascular tree in the forearm and hand to enter the bones through minute foramina or travel along and supply the various nelVes with blood and also reach the tendons along the vincula . This makes it very clear that if the hand is not working . From the ported on the dorsal aspect partly by the terminal phalanx extends to the ulnar side of the proximal part of the and partly by the nail pJate . where the proximal end of the root shaft of the third . which eventually join and form the network of larger veins that are located on the dorsal side of the hand. which is in turn attached to the the index metacarpal and then runs obliquely acro terminal phalanx. THE HAIR Hair is distributed on the dorsal aspect of the hand and Surface Anatomy the forearm. Hair on the volar aspect of the Knowledge of the surface anatomy and the land forearm is usually sparse. the nail bed . The distal wrist crease runs between the pis and the scaphoid bones and in Bne with the pro THE NAIL PLATE COMPLEX border of the flexor retinaculum. 4-53) . are located in the wrist area and are supplied by branches from the radial . FIGURE 4-53. the tip of the digit rolls backward.

A. which correspond pothenar eminence. FIGURE 4-56.5 inches distal to the distal wrist crease. [n the wrist area the median nerve lies immediately on top of the lunate bone. .5 cm distal and radial to it. These bony landmarks are the point of attachment of the flexor retinaculum to the carpal bones. Flexor retinaculum. marks the course of the ulnar artery and nerve (see Fig. 4-57). The tubercle of the scaphoid is the bony prominence felt at the base of the thenar eminence with the crest of the tra pezium distal to it (Fig. The division of the common palmar digital nerve occurs just distal to the level of the superfiCial palmar arch . or the recurrent branch of the median nerve . B-F. extending proximally from the radial side of the ring finger to the medial side of the biceps tendon at the elbow. A line. 4-55). The thenar branch. comes out from the main trunk about 1 . All finger tips point to trapezioscaphoid jOint wh ile in flexion. while crease ~-""_ Proximal wri crease S = Scaphoid L = Lunate T = Triquetrum P = Pisiform H = Hamate C = Capitate Td =Trapezoid Tm =Trapezium R = Radius U = Ulna FIGURE 4-55. This line corresponds to another line the corresponding arteries bifurcate near the web space o across the palm from the ulnar side of the hyperextended the fingers at the level of he bases of the proxima thumb and runs transversely across the palm to the ulnar phalanges. 4-57). The pisiform can be felt at the base of the hy­ with the crease at the base of the finger. FIGURE 4-54. extending distally from the anterior aspect of the medial epicondyle of the elbow to the radial side of the pisiform at the wrist. The web spaces of the fingers are located in lin side. and the hook of the hamate is about to the junction between the p roximal a nd distal two third 2. distally (Fig. 4-56). marks the course of the median nerve (Fig. Trapeziosca phoid joint. A line. Sur face anatomy.

On the palmar FIGURE 4-59. the muscles and nerves are of the pathology of ulnar drift .5 cm proximal to the location of the partment on its ulnar side. The proximal interphalangeal joints are about 0. 2) median nerve. At the distal tion of the long extensor tendons is an integral compon forearm and the mist area. 5) flexor digitorum between the proximal nail fold and the middle creases at profundus.98 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT FIGURE 4-57. the median nerve. weakness. if present. when present. and the nerve . is the most pro and the midpoint between the base of the long finger and nent bony landmark on the dorsum of the hand. 3) two sublimis The root of the nail touches the end of the exten tendons to the middle and ring fingers. the metacarpophalangea'l joint is about 2 cm the anatomic snuff box below the tendon . The palmar cutaneous disruption of the harmony of the digit movement. which happens in rheum arranged as follows . longus. T superficial palmar arch runs obliquely between the pisiform head of the ulna . the latter being the closest to the midline of the digit. The palmaris longus on top of the knuckles and held in place by the sa tendon. which is the deepest. nerve superficial to it. these joints. The flexor carpi knuckles. (see Fig. from superficial to deep: 1) palmaris toid arthritis. and the ulnar artery .5 cm.25 cm from the knuckles of and the abductor pollicis longus. and ring fingers (Fig. the flexor carpi radialis metacarpophalangeal joints are about 1 cm distal to is the most radial tendon (Fig . along with other structu . the 111nar nerve. The extensor pollicis is the most prominent tendon aspect. digit and held in place by the sagittal bands. followed by the long ext hand can the arterial pulsations be felt as well. of the proximal phalanges. 4-58). and the dorsal ulnar sens superficial arch. artery. Extensor digitorum communis independent tend FIGURE 4-58. Dislo palmariS longus and the flexor carpi radialis. proximal to the edge of the web spaces of the fingers. Surface anatomy of the course of the radial artery. The snuff box is located between the extensor FIGURE 4-60. 4-59). On the dorsum of the hand. This would lead of the base of the thenar eminence. middle . 4-5) longus. 4) two sublimis tendon insertion in the terminal phalanx at a point halfw tendons to the index and little fingers. just proximal to the wrist. The neurovascular bundles in the digits lie against the flexor sheath palmar to the line joining the ends of the palmar digital creases from dorsal to palmar being the vein. The long extensor tendons are centrally loca ulnaris is the most ulnar tendon. the extensor pollicis lon The radial artery pulsations can be felt in the distal end of is the most prominent tendon and makes the ulnar bou the forearm. The radial artery and multiple branches of the superficial radial nerve are in the anatomic snuff box. and future deformities. Any disruption in the balance of the sagi point at the junction of the ulnar third and radial two thirds bands leads to dislocation of the tendon. 4-60). on the radial side of the wrist. Surface anatomy of the tendons on the volar aspect of well centralized over the center of the metacarpophalangeal joint of the wrist-flexor carpi radialis. Nowhere else in the ary of the anatomic snuff box. and 6) flexor pollicis distal interphalangeal joint. The deep palmar arch on the fifth extensor compartment on its radial side. with the distal palmar wrist crease. and pollicis longus and tendons of the extensor pollicis bre the distal joints are about 0. On the dorsum of the hand. On the volar aspect of the wrist. which lies deep to the flexor carpi radialis tendon. wh branch of the median nerve runs distally between the results in pain . the sixth co other hand is about 1. palmaris. and flexor carpi ulnaris. with its styloid process. is seen as the most prominent tendon tal bands of the extensor hood mechanism on each s running obliquely from the middle of the forearm toward a (Fig . The sors to the index.

they can perform their functions of various grips. Trauma can be closed or open. as the functions of hands are unique langeal joint. These factors metacarpophalangeal joint and to extend at the interpha­ should be considered. Trauma can be as simple as to involve only the skin or as complex as to involve the skin and other anatomic parts such as the tendons. the wrist joint is about 10 to 15 degrees in dorsal extension. and independent movements of the wrist or the digits. the thumb is adducted with the tip at the level of the radial FIGURE 4-6 2. If the joint is in extension or partially flexed. his or her age. The hand 's elements move around the transverse and the long. the lumbricals and possibly the interossei must be non­ Besides the basic needs for normal daily activity.itudinal axes. or pad-to-side actions. the hammer squeeze. This is perhaps the only reason why the lumbricals puncture wound or as severe as a mutilation or amputation originate from the flexor tendons and insert into the injury. the The long flexors are primarily responsible for the closing required hand functions of a musician are totally different motion of the digits. pinches. side of the distal interphalangeal joint of the index finger (Fig. the hand functional. If a normal hand is the ultimate goal of lumbricals is required. . For the digits to open . Resting position. Power grips of the hand have been reconstruction and cannot be attained. and the fingers are in a gentle curve flexion at their joints. The metacarpo­ lumbricals become paralyzed . and the metacarpophalangeal extensor and the flexor mechanisms of the digits. The long extensors extend the metacarpophalangeal joints. this allows them to ade­ 15 to 25 degrees dorsiflexion (Fig. The hand is involved in a wide range of functions. and the spheric grip. the hook grip. The thumb is quately perform the job of "messenger" between the fully abducted in opposition. as possible. and the type of work he or she does are only a few of the factors that can have an impact on the result of treatment. injuries that can occur. they must extend at the metacarpophalangeal and the interphalangeal joints. and be constantly moving jointly or independently or in pad-to-pad. but they cannot extend the CLINICAL CONDITIONS interphalangeal joints unless the lumbricals and interossei contract to help with the extension of the interphalangeal Trauma joints and to counteract any attempt by the long flexors to contract and consequently bend the interphalangeal Traumatic injuries to the hand can be as minor as a joints. When the hand is in a relaxed position. depending on whether the integrity of the skin has been violated. a combination of different positions. others may require much more complex management protocols. The type of injury and the status of the tissue determine not only the type but also the outcome of the treatment. In this position. For instance. either some or all grips include the precision rotation and the precision of the digits must either be in a closed or open position translation. must perform other specific functions. the screwdriver squeeze. While some injuries may require only minor conservative or surgical management. Precision For the hand to function properly. When the hand is in a functional position. the posture of clawing. For the digits to bend at the from those of a banker or manual laborer. the long degrees flexion . and bones . his or her medical condition. The precision movement can include tip-to-tip. 4-61). then the recon­ divided into the squeeze grip (which includes the simple struction should aim toward making the hands as functional squeeze). with flexion being minimal in the index finger and maximal in the little finger. 1988). then when the Ilong ex­ phalangeal joints of the fingers are in at least 65 to 75 tensors extend the metacarpophalangeal joints. and all the interphalangeal joints of the flexors will also be in motion and the hand will take on fingers are extended (Milford. 4-62). therefore. nerves . What follows is a discussion of some of the FIGURE 4-61. the type of patient. The experience and knowledge of the health care provider. the wrist is in extensor hood mechanism . Functional position. only the function of the interossei and the to each patient. the disc grip. For a clawing motion to occur.

They are easier to repai Zone one: Has the flexor digitorum profundus only and have a much better prognosis than the flexor tend extends from the insertion of the sublimis at the base Repair. the case of skin grafts and local flaps. in Tendons perform their function through gliding. then surgical treatment is indicated from zone two in the fingers because only one tend in the form of skin grafts or local or distant pedicle flaps.100 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT SKIN' Skin lacerations must be treated early. Postoperative care is in (within a few hours). Also . there . as Repair of the flexor tendons can be either pri in the case of distant pedicle flaps. or in two stages. and therapy are the steps followed of the middle phalanx to the base of terminal phalanx injury. the wound is treated conservatively or surgically. The skin of the hand is fairly thick and takes longer to heal than the skin elsewhere on the body . zone two through from their point of origin at the muscle belly to known as "no man's land. " but during the last 25 y their point of insertion in the bone. along with therapy and the injury). Through its two flexor tendons when lacerated in zone two ha path. Extensor tendons have been di tendons are as follows : into eight zones (Fig. 1972). and healing mechanism. It is because of taken by specialists in hand surgery. it will extends from the metacarpophalangeal joint to the m heal by itself . as in longus in the thenar eminence area. The goal is to achieve repair so proximal phalanx to the insertion of the flexor po the tip of the finger can be functional. The pa­ tient is given the usual instructions on how to take care of FIGURE 4-63. repairs. four. Zone is less than 1 cm in diameter with no bone exposed . If sutures are required. 1984. of the injury) . the healing process of it has been renamed " some man's land. splinting. 1975. if possible. 1964. patients are then started on the proper the zones. As a result. Lister. Flexor Tendons (Fig. or secondary (when it is done after 3 w exercises. The level and to the carpal tunnel the shape of the amputation or tissue loss dictate the type In the thumb. the hand is a very dynamic organ . 4-64). the wound. Because of the unique condition of the pa TENDONS having two large tendons squeezed in a tunnel. Zone four: Is the carpal tunnel area where the f FI~IGERTIP INJURIES tendons to all the digits are located Zone five: Extends from the musculotendinous jun Fingertip injuries are a common problem. If any bone is exposed or if the injury is more of the proximal phalanx . If no violation of any other structures has occurred. commoilly needed in patients who had zone two te Verdan. and some might require surgical tenolysis i and has a unique prognosis ( Doyle & Blythe. 1973. KJeinert & Stormo. In the past. repair o and also affect the efficiency of its function. Flexor tendon repair should only be u differently from one location to another. The five zones of the flexor Extensor Tendons. The zones are as follows: Zone two : Contains the two flexor tendons and extends Zone one: Over the distal interphalangeal joint from the distal palmar crease at the level of the Zone two: Over the middle phalanx metacarpophalangeal joint to the insertion of the Zone three: Over the proximal interphalangeal joi sublimis tendon Zone four: Over the proximal phalanx Zone three: Is the middle of the palm where the Zone five: Over the metacarpophalangeal joint lumbricals originate Zone six: Over the dorsum of the hand . and the skin needs to heal properly before the sutures are removed. one . Zone five usually has the best prog after tendon repair. the tissue surrounding the tendon can vary from one potential for major problems because of scarring location to the next. Usually if the skin lost longus at the base of the terminal phalanx. inflammation. Zone two in the thumb is diff than 1 cm in diameter. Each zone requires a unique form of management course. and protect the hand until it heals. Be­ to the tendons in zone two are usually the most dif cause of the unique conditions tendons of the hand must go with the poorest prognosis. ~3). keep it clean. delayed primary (within 3 wee the form of wound management. After the tendon these factors that the tendon's path has been divided into repaired . Flexor tendon zones. 1975. zone one extends from the middle o of management needed . it is usually recommended not to remove the sutures before 3 weeks have passed. Verdan. followed by zones three . " Even in the an injury can affect the gliding mechanism of the tendon of circumstances and with the best of care. the condition and the type adherence that will interfere with the tendon gl of tissues respond to trauma. Surgical tenolysis improves tendon gliding a KJeinert . Zone three is located around the flexor po Surgical management can be performed in one stage. future.

Entrapment of the ulnar nerve at t he cubital cana begin an active therapy program. with the goal of maintaining the integrity of range of Any nontraumatic problems of the nerves can either b motion with a stable joint. The patient begins therapy later. stable or unstable. or because of central neurologic problems. some patients might require surgical treatment Injury to the blood vessels can be either open or closed. Carpal tunnel syndrome simple or associated with other injuries (Lister. Nerve compression syndromes. and the capsule. After the surgical repair. Ligaments must be protected either Neurologic Problems by casting or by splinting. After a nerve i FIGURE 4-64. 2. with excellent results. 1984. dominant arteries must be re­ Pressure Injection Injuries paired surgically . and its stability. They are treated conservatively or surgically. Injuries can be open or stage. Again . Extensor tendon zones. Injuries to the nerves can be open or closed. lacerated nerves requir surgical treatment. and finally depending on its location. partial or and desensitization. and the type and size of the injury. At the beginning. intra. Entrapment of the ulnar nerve at the Guyon's cana be treated surgically. Entrapment of the radial posterior interosseous nerv fracture . What is unique about these injuries is that the . injured. depending on the type of 3. sometimes resulting i LI GAMENTS hyperparesthesia and dysthesia. However. and within a few days the patient can 5. the the stage at which the patient seeks treatment. behind the medial epicondyle Occasional entrap ment of the superficial radial nerve by the brachiora dialis in the lower third of the forearm also may occur JOINTS Modalities of nerve compression treatment depend o Injuries to the joints involve the articular cartilage. while th proximal part of the nerve regenerates and grows distally Consequently. and initia splinting when an affected child is young can be helpful BLOOD VESSELS However. simple or associated with othe injuries. transacte or injured in continuity. complete. However. then active and passive. such as i BONES cerebral palsy. However. its location. 1988). Regenerated nerves re qUire special therape utic techniques. simple or associated with other injuries-especially patient's pattern of living along. With the various at the supinator tunnel surgical modalities available. The modality of flammatory medications. nerves grow back at the rate of 1 inch per month. broken bones in the hand can 4. surgical managemen treatment depends on the type of injury. the distal part of the nerve degenerates . Entrapment of the median nerve and/or the anterio O 'Brien and Eugene. de­ pending on the type of ligament.or extraarticular. simple or associated with both bone and joint injury. Contused or bruised nerves heal spontaneousl without treatment. displaced or common in the hand are: undisplayed. depending on the type of injury. digits). surgical repair of the artery is not 500 to several thousand pounds per square inch can b indicated. newl grown nerves are overly sensitive. At an earl ends of the bones. and is treated according to it with full active and passive range of motion. its location. as a result of peripheral nerve compression. and the hand needs to be protected until the accidentally injected in the hand (most commonly th wounds heal. simple or associated with other injuries. type. which ar Injuries to the bones can be open or closed . course is almost always recommended and should begin Paralysis of the peripheral nerves can be high or low with guarded active. 1. meticulous nerve repair with the prope Zone seven: At the extensor compartments alignment is essential so that the new nerve growth can b Zone eight: At the distal forearm directed toward its proper channel. The bones are treated either interosseous nerve at the pronator teres conservatively or surgically. Nerve repairs or tendon transfers can be performed Cerebral palsy is a central neurologic condition . such as stimulatio Injuries to the ligaments can be closed or open . management might only entail a change in th closed. Industrial toxic substances under pressure that vary from then in most cases. with splinting and antiin injuries to the bones and ligaments. inflammator peripheral neuropathies paralysis (as in leprosy or diabe tes). If nondominant arteries are the only thing injured and the vascularity of the digit is not compromised. a therapy would be required in advanced cases.

which might destroy the remaining layers of the Electric injury usually happens with exposure to curre dermis. In either by removal of the nail plate is necessary. and is painless. no sensation is present. are classified according to their depth. with the wounds left unclosed. and exercise. experience burning pain. pressure injuries can leave a digit totally disabled to the extent that CHEMICAL BURNS its amputation becomes necessary to allow the hand to function properly. The hand is treated either conservatively or required. and soaking usually diminish the proble neously with some exercise if it is kept elevated. Phenol burns are neutralized by ethyl alcoh ity. Third-degree bu is treated with therapy. only a pinpoint injury to the skin at natural dressing. . Initially. In the case of alkaline burns. Second­ degree injuries include partial-thickness skin loss. A patient with a third-degree bu The determining factor about the type of surgical modality should undergo surgical debridement and then reconstru of delayed reconstruction depends on the amount and tion. They can be treated on an outpatient inpatient basis conservatively or surgically. itching. The treatment is usually surgical w most probably. which travel through the body along t loss and require surgical management. The toxic substance ings. superficial and usually recover spontaneously. lines of the least reSistance. whirlpool baths. the patient's conditi the cold injury is in the form of rewarming with water 40°C is critical. Wh hand. and antibiotics. and intense follow-up therapy. water. The patient will be classified as a third-degree burn. At the early stages of cellulitis. as long as no infection occurs. Second­ However. Chemical burns can ile caused by an alkaline or an aci agent. depending Burns can be either thermal. The wounds are left to skin is left appears white. The most common organism is Stap pain. First-degree cold exposure injuries are gluconate. surgical draina degree burns can be either superficial or deep. During the rewarming process. heal by secondary intention or delayed reconstruction. and the consequences are blisters. which should be left intact. PARONYCHIA THERMAL BURNS Paronychia is an inflammation of the tissues around t First-degree burns are superficial and cause redness and nail plate complex. as they act as a biolo devastating. The hand should heal sponta­ otics. meaning the blood vessels a Regardless of the depth of injury. Hydrofluoric acid burns are treated by copious irrigation The exposed extremity becomes very cold and then numb. chemical. Initial treatment is usually to rinse in cold water and ylococcus aureus. elevation. Infections Infections of the hand can be superficial or deep a Burns acute or chronic. elevation of the hand. Third-degree injuries result in full-thickness skin over 500 volts. changes of dre pressure under which it was injected. postoperative care requires elevation a type of tissue loss. secondary surgery is of paresthesia. along their path. leathery. and soaki Cold injuries. anti then apply some dressing. Eleva­ tion and exercise are necessary. injection of calcium gluconate locally. the wounds should be rinsed with diluted sodiu Exposure to cold can cause severe injury to the extrem­ bicarbonate. are claSSified according to the the dressing with benzalkonium chloride and calciu depth of the burn. exercise. and redness. consequently.102 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT initially appear minimal but are later followed by severe case. surgically. With electric current burns. woun Cold Injuries should be washed with a diluted acidic solution. tight. Initial treatment should be in the form of copio rinsing with water. a remnant of the dermis is always left. Such burns cause extensive and severe dama to 42°C. and they will rupture spontaneously. Again. which ELECTRIC BURNS can heal by secondary intention. and then the remaini forearm. elevation of the are characterized by almost complete loss of the skin. For aci burns. in the presence of an abscess. the bu debridement. The second-degree burn heals spon can spread from the digits to the hand and even to the neously unless infection occurs. T the site of the accidental injection is seen. the initial treatment of nerves. Second-degr pain and swelling as a result of the pathologic changes burns are characterized by intense pain and the presence that occur in the tissues. The amount patient should be seen daily and started on antibioti of damage depends on the type of chemical and the whirlpool baths. Sympathetic ganglion blocks or antithrombotic therapy may be considered. as in burns. or electric and the severity of the infection. the patient will. depending on the depth of the damage. Early symptoms include burning. Management almost always requires surgical layers of the dermis will be lost and. aching. It is very important to remember that exercise until the wounds heaL even in the best hands and with the best of care.

1989). and amputation of the dig 1988). Suppurative tenosynovitis needs to be ness. DEEP SPACE INFECTIONS FELONS This usually happens in the thenar and the midpalma A felon is an infection of the terminal phalangeal area spaces. treatment can be conservative o sheath can be secondary to trauma or may spread through surgical. arthritis. which results in stif (Neviaser. It is almost always residual effects. condition is mostly treated surgically. If the infection is not treated properly 4) severe pain on the passive extension of the joints destruction of the joint may occur. chronic irreparable stiffness. The diagnostic signs are known as the Kanavel's signs: 1) longitudinal swelling of the flexor SEPTIC ARTHRITIS tendon sheath. the bloodstream. Th tiple variable-sized vesicles around the tip of the digit. in a future deformity of the nail plate. an Herpes infection can affect the tips of the digits and is swelling at the site of injury. Besides incision and drainage. intraop­ secondary to human bites. bone. along with swelling. and stiffness o is considered a closed space. It also may be seen in patients with acquired immu­ the best of hands. the patient presents with pain. As in th Infection of the flexor tendons in the flexor tendon case of human bites. and Pasteurella multocida is the mo SUPPURATIVE FLEXOR TE~IDON TENOSYNOVITIS common organism in cat bites (Snyder. Postoperative care as a result of clenched-fist fights. so between the nail folds and the nail bed. bone and soft tissue damage may lead t nodeficiency syndrome or immunosuppression (Glickel. but sometimes it leaves significant stiffness necessary to apply a piece of petroleum gauze or any other which might require future surgical management. Pain is usually the most common presentin interphalangeal joint crease. and active and passive exercise the skin. Surgical incision and drainage. Staphyloccus aureus is the most common organism in dog bite cases. sometimes so severe that even with the best of care and i 1979). Without treatment. 1987). the swelling and the redness progressively become proper administration of antibiotics. the terminal phalangeal area symptom. It is usually manifested in single or mul­ be cellulitis. The most common condition of septic arthritis treated surgically. presence of infection in the closed compartment can jeopardize the blood supply to the terminal phalangeal area HUMAN BITE INFECTIONS and result in osteomyelitis and necrosis of the bone. The pathologic condition coul extremely painful. the nail bed and the nail folds need to be Sometimes the problem resolves without leaving an protected until the new nail plate grows. However. biotics to protect against secondary infection. along with anti­ becomes necessary. the increased pressure and the ercise are necessary. The most common organism found in human bit infections is Eikenella corrodens. The consequence o Health care professionals who are exposed to infected pa­ the infections that result secondary to human bites ar tient saliva are the most susceptible (Louis and Silva. and ex worse. therapy.removed. 1978). The collar button abscess is another type of dee and presents with swelling. A puncture wound injure includes soaking. 3) the digit or digits held in a Infection of the joints can either be secondary to traum flexed position to minimize the pain. and most significantly or blood borne. Unless the condition is the hand. Some ointments and oral medications are available for herpes Cats and dogs are the most common animals that bit infections. redness. HERPES INFECTIONS Clinically. Treatment is usually symptomatic. the problem of management is s from any injury and also prevents any future adhesion complex that the digit may be left stiff and deformed. and joint structures. humans. redness. This protects the nail bed with the best of care. 2) tenderness with possible redness of the skin along the tendon sheath.. osteomyelitis or lymphangitis. and the prognosis is very guarded. space infection that starts between the digits in the we Because of the anatomic presence of the fibrous septae and in the palmar surface and spreads dorsally (Burkhalte also of the attachment of the palmar fascia at the distal 1989). redness. Diagnosis primarily depends on the history and the fluorescent ANIMAL BITES antibody studies of the fluid from the vesicles. including cartilage o until the wounds heal. whirlpool. a gram-negative ro facultative organism (Patzakis et aI. tendon. Adequate treatment of infections in the terminal pha­ The vast majority of human bite infection cases happe langeal area require surgical drainage. and intense pain. bites by rare exotic animals may also b seen. Septic arthrit . the most common blood-born erative and postoperative irrigation with antibiotic solu­ infection of the joint is due to gonorrhea. which might result eventually must be amputated. Som sterile sheet to cover the nail bed and to be underneath the suppurative tenosynovitis cases are so severe that eve proximal and the lateral nail folds. along wit treated.

Various theories have attempted very common in whites. It usually begins with a painful nodule in t amputation later on. ligaments. If the condition persists. arthrodesis. Clinically. and exercise. stiffness. Som drugs. along with the patient's inability side of the wrist and an inability to use the hand. palm of the hand. and Sudeck's atrop DUPUYTREN'S FASCIITIS AND CONTRACTURE (Sudeck. The Aseptic inflammation of the tissues that affect the contractures can be localized in one part of the hand. splintin tender and interfere with the function of the part involved. Symptoms of de Quervain's tenosynovitis gery. Abnormal prolo include severe pain. DE QUERVAIN'S TENOSYNOVITIS THE PAINFUL HAND SYNDROME This condition is an inflammation of the abductor pollicis longus and the extensor pollicis brevis in the first extensor Transient pain and dystrophic response to injury. and exercise.104 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT of the joint should be treated surgically. Some cases can bene is almost always described as coming from the last joint of from conservative treatment. reflex sympathetic dystrophy (Mitchell. The latter various pathologic entit over a span of 6 to 8 weeks. Nonoperative management is in the form of oral antiinflammatory medication and a cortisone-xylocaine Connective Tissue Diseases local injection around the flexor tendon in the A-pulley area. When the inflamed tendon is at the level of the the aging process or following trauma and inflammato metacarpophalangeal joint as the tendon enters the A-I conditions or secondary to systematic disease processes. when the tenderness is actually at the level of the surgical management in the form of arthroplasties metacarpophalangeal joint where the A-I pulley is located. is more common in men than in women. pulley. Joint deformities can occur as a result of norm locking of the finger in flexion. pain dy function syndrome (Dobyns.. and tenderness on the radial gation of this response.g. along with the aged or older. Treatment can conservative. as cortisone can cause attenu­ body in general can also affect the hand (e. tion can be treated conservatively with antiinflammatory the hallmark of the chronic painful hand syndrome. but others may requ the digit. the condition is known as trigger digit. disseminat ation and eventual rupture of the tendon. swelling. painful. and the disease process progress gradually over a long period until it eventually causes flexion contracture of the metacarpophalangeal and int Inflammatory Conditions phalangeal joints. If the examples of names given to describe painful hands a condition persists. 1984). 1968). The pain is required in certain occupations. The condi­ control the pain and the associated dystrophic changes. The articular cartilage is destroyed. Usually it is scleroSis. mo tendons and the synovial sheath can occur in several commonly on the ulnar side. postoperative whirlpool. Treatment of the condition can be either conservative or surgical. most common preferred to give no more than two injections of cortisone rheumatoid arthritis). the only proper treatment is surgical excision of the involv tissues and involved areas become swollen. T locations. patien are advised to avoid any trauma to the hand. the joints and various deformities. s compartment. and possible injection of cortisone. then affect soft tissues. splinting. or disease to the hand is normal. It is very important not to repeat the cortisone Any connective tissue disease process that affects t injections indiscriminantly. with postoperative wound care. some joints eventually will be completely active stage that is fibrocellular. various trophic changes a of the palmar fascia is very rare in African-Americans and functional deficits. surgical. 1900). and. the entity is characterized Aseptic chronic inflammation with fibrosis and scarring chronic pain. and the joints themselves become ve and inside the flexor tunnel. and palmar fascia. In the early stages of the disease. and 3) an advanced sta distroyed and will require surgical reconstruction or even that is fibrotic. The disease h Depending on the severity of infection and the adequacy three stages: 1) an early stage that is proliferative. and the capsu surgical management in the form of release of the A-I around the joints. It sometimes occurs in younger people a proper antibiotics. As a result of the inflammatory process. tendons. They eventually result in destruction pulley and tenosynovectomy is indicated. 1864). or a combination of the two. the joint spac tendon becomes difficult as it goes through the A-I pulley become narrow. TRIGGER DIGIT OSTEOARTHRITIS Tenosynovitis of the flexor tendons causes the tendon to Osteoarthritic changes can affect the joints as a part swell. then surgical management is indicated. but can be widespread. Gliding of the in gout. Patients complain of pain and painful. the shoulder-ha syndrome (Steinbrocker. and the finger snaps as the daily living activities or repetitive intermittent loading th patient attempts to move it passively or actively. 2) of treatment. lupus erythematosus. especially in those who are middle describe the pathophysiology and the proposed mech .

and other suc The hand evaluation should not be done unless the factors on the hand. . nosis of the case. and prog the volar aspect of the wrist. which is most com­ History of previous problems has a direct or an indirec monly on the dorsal wrist aspect or. and the proper systematic evaluation that will lead to specific current problem. Benign bone tumors of the hand can be chondromas. It is necessary to obtain a detailed description of th radiography. and gout. treatment. AND HAND DOMINANCE approach that will help the examiner avoid the pitfalls of These are also factors that need to be addressed durin missing any items in the evaluation process. life. or bone cysts. including patient habits and recreational likes an dislikes. are another type of slow-growing epilepsy. It is characterized by pain. swellings that can be wrongly diagnosed as tumors. Prognosis for the chronic painful hand syndrome is very guarded. a Tumors are classified as either benign or malignant. The socia factors. have been described. the proper manage­ impairment or disability that will directly affect the patient' ment. such as the peripheral nerve entrapmen History syndrome. on impact on the diagnosis. Previous fractures. as well as on their manage ondary tumors result from primary tumors in the lung. osteomas. carpometa­ PAST INJURIES AND PREEXISTING CONDITIONS carpal bossa. Also. but also in deciding futur the proper diagnosis and. but some othe oughly. the Appendix. Ex­ amples are posttraumatic myositis ossificans. type Tumors in the hand are typically benign. and each element must be addressed thor­ genital anomalies that affect the hand. Some conditions produce importance. function. which some times will completely resolve itself when the pregnanc Various elements make up the history part of patient terminates. and infections. it is the the process of examination. The list shoul and severe tenderness. Most large soft and mechanism of injury in traumatic cases are of critica tissue tumors are lipomas. SEX. obesity. others begin gradually. Inclusion cysts. SOCIAL HISTORY. both conservative the patient's statements. and endurance patient's complaint and to ask questions to clarify some o testing. cold intolerance. Patient age is particularly important in con evaluation. drinking. AND OCCUPATION 90 percent of them are enchondromas. motion disorder syndromes. Primary tumors are mainly sarcomas. Various treatment modalities. and sec­ light on the current problems. Hand dominance is significan knowledge of anatomy. The most problems. previous medica ganglions originate in the flexor tendon sheath. ONSET OF SYMPTOMS AND DATE OF INJURY Some ailments that affect the hand start abruptly. The most common soft tissue benign tumor is the ganglion. Malignant tumors in the hand are very rare and can be primary or sec­ These are issues that have to be explored to help she ondary. problems are also unique to certain age groups. as i ruMORS OF THE HAND the case of traumatic problems. The evaluation should be done consistently and in a very systematic way that is repeated with each patient. it becomes very clear tha occupation does cause and directly affect some of th pathologic conditions that can affect the hand. No specific scientific data exist regarding th effects of smoking. thermography. both invasive and noninvasive. which occur when also include other general medical problems that ca an injury drives a fragment of skin epithelium into the directly or indirectly affect the hand. A sample hand evaluation form appears in the pathologic status of the hand. It is this organization and consistent systematic AGE. Also. and surgical. such as diabetes subcutaneous tissues. ment and prognosis. various pathologic enti­ not only in relation to the diagnosis and the prognosis of th ties. some problems are uniqu to females. In about 10 percent of hands. which occurs during pregnancy. and previous operations are only a few ex painful and the smallest of all benign tumors is the glomus amples of items about which the examiner needs to ask tumor. bone scan. can also influence the decisions regarding th EVALUATION OF THE HAND patient. and painless benign tumor. line of management. less commonly. hopefully. Some ailments that affect the hand are more commo in females than in males. The date. With the explosion of the repetitiv breast. which in 50 percent of the cases is located under This list also includes previous surgeries and medica the nail plate. in the case of peripheral nerve entrapment. but enough clinical knowledge an examiner has certain forms or note pads on which to data exist to make us believe that these habits can influenc record findings. but FAMILY. or kidney.

and hair texture affected extremity. sweat patterns. . Patients complain of pain. along with signs of neuriti on him or her. GENERAL APPEARANCE The general appearance of the hand must be assessed. A diminished pulse is considered a positiv for vascular compression (Fig. These two aspects are very important from a diagnostic and management point of view. ischemic neuritis.106 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT Examination of the Hand The hand is examined from the anatomic and functional aspects. The color of the skin. A diminished radial pulse at the wrist o the patient's skin. The temperature of the skin and the patient assumes the same posture as described in Ad presence of any changes. as well as the presen understand the extent of the impact of the hand problem ulcerations or gangrene. Painh~. Interference with the blood supp factors that the examiner has to observe as the process of the hand can occur in any location along the vascula evaluation continues. ulcers . and the difference in temperature is outlet area (Fig. The examiner must take certain steps to address the anatomic condition and perform tests to evaluate functional aspects. stiff hands are usually held in a very specific. T his test exaggerates compression o The presence or absence of wrinkles and scars is the first neurovascular bundle in the neck. Checking the skin temperature from distal to proximal. including its posture and position. 4-67) . Evaluation may show change i color. SKIN EXAMINATION Adson's Test. The affect of the patient and his or her attitude can help the examiner the case of aneurysms. should be examined in an ascending distal to compression of the neurovascular bundle in the tho proximal manner. Some steps can evaluate both aspects of the hand . and hold are also important factors to evaluate. patient attitude. brace the shoulder posteriorly. or swelling test. turn his or her head its texture. T'h e patient is direc observation that needs to be made. In addition . as felt by the examiner's extensor aspect involved extremity results in a positive Adson's sign te of the fingers . hair pattern. raise the chin. the hand components should be examined not only as independent units but also in association with other units of the hand . evaluate the blood supply to the extremity. Wright's test. ban­ dages. temperature. and possible presence of a m comfortable position for the patient. Then the affected arm is abducted to at least 9 should be noted during the procedure. The temperature of her breath . gangrene. FIGURE 4-66. 4-66) noted as the examiner moves his or her fingers on the Wright's Test. these are only a few examples of the small blood vessels. Adson's test. inhale. This is an extension of Adson 's test extremity (Fig. and the radial pulse is ch at the wrist. certain tes be done. 4-65). and splints. guarded posture that seems to be a of the extremity. and texture. FIGURE 4-67. grees and externally rotated. EXAMINIATION OF THE ARTERIAL SUPPLY The blood supply to the hand comes from the subclavian artery that moves distally and ends up in the peripheral FIGURE 4-65. cold in ance.

These tests are arteriograms a nd thermogra phy. mo re so in light-skinned individuals. The the course of the veins should be noted. The patient pumps the blood thrombosis or thrombophlebiti . or the several times until the hand becomes pale. The radial artery is still occluded . ote the pale ness o f the ha nd e. However.~""'~ . 0 . The pressure is released from the radial artery but maintained o n the ulna r a rtery. AJlen 's test. after presence of tenderness. The puffy hand i hand will not blanch and be pale if the patient has a secondary to venous thrombosis. as it is the only artery and lymphatic obstruction (Neviaser. and the ulnar artery is located just to the radial aspect of the flexor carpi ulnaris tendon. B. then they should b examiner occludes the radial and ulnar arteries using a compared with the ve ins on the other normal extremity downward and lateral pressure with the terminal pha­ Use of drugs for medical or nonmedical reasons can caus langeal area of the thumbs. This test determines arterial examiner's thumbs is incomplete . 19 72) . Repeat this process b aU patients. If the hand stay supply at the hand from the radial. ulnar.FIGURE 4-68. the examiner should release eithe median artery. The two arte ries a r occluded again and the blood is pumped out once mo re . After the blood has been pumped o ut. The steps for Allen 's test are as follows: locate Special Tests to Evaluate the Adequacy of Blood Flow to th the radial and ulnar arteries at a point 0. proximal to the volar wrist crease. Th patient leaves the hand open and relaxes the fingers. The patient The veins on the dorsum of a normal hand should be ver makes a tight fist (an object such as an ace wrap can be easy to see or feel. redness . pain. the are simply occluded and not easy to see or feel. The ulna r artery is released. A artery atrophies and becomes the median artery as the filling time greater than 7 seconds is indicative of sever ulnar and radial arteries mature." I. present. The radial artery is located just to the radial aspect of the flexor carpi radialis VEI NS OF THE HAND tendon. squeezed if a complete fist cannot be accomplished) The the veins are not easy to de ect. or fir mness alon which the hand should remain pale and blanched. Embryologically. A. Note the return of blood to the hand through the ulna r arte ry. Occlusion of the radial and ulnar a rteries. E. The median artery is a small . in some pa­ problems (Koman. 1985) of the adequacy of arterial bloo tients . and possibly the blanched and pale . The hand should regai structure that runs along the median nerve in almost coloration with in 2 to 5 seconds . and the veins could b out of the hand by opening and closing his or her fist seen or felt as painful or painless cordlike structures . ·. 4-68). a fairly decent-sized functioning median artery is flow to the hand. Allen's Test (Fig. Next. The bloo flows back to the hand through the palma r radial artery . or if occlusion of the radial or ulnar arteries by the system of the extremity. subcutaneous fibroSiS functioning major median artery. the anterior interosseous releasing the pressure on the other artery this time. threadlike radial or ulnar artery pressure . Venogram not occluded by the pressure applied by the examiner's may be necessa ry to further evaluate the venous drainag digits.5 inch to 1 inch Hand.

108 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT BONES.The interphalangeal joint must be held in a neut that gives details about masses . or instability of an individual joint or multiple joints ates not only the bone and the joint structure of the ha should be noted. and hypertrophy proper systematic muscle evaluation can enable the exa iner identify any problems. index fin ger. the overall mode of function of the ha The collateral ligaments. and type of bone structure are only a few of the elements to evaluate in the radiographs. 4-70) . the joint has to be in 90 degrees flexion to check the stability of the collateral ligaments (Fig. Limitation of the passive range follows the intravenous injection of a radioactive material. radiographs in the three basic standard positions of anteroposterior. redness. The range of motion should be examined. Limitation of or difficult to see fractures . provide lateral must be addressed. computed axial tomographic (CAT) scan uses much finer slices and can be more detailed and informative. atrophy.. and the terminal phalangeal area of the thumb. This last related to it. tumors. Checking the stability and the integrity of the collat ligament on the radial side of the proximal interphalangeal joint of the nique that takes pictures of the part being imaged in slices. look for general appearance of tone. and oblique are essential for the proper evaluation of the skeletal system of the hand. The range of motion. presence or absence of deformities. eva mity . The of motion. Normally. integrity of the joint spaces. The ran of dye inside joint spaces. It is very import joint to be examined in the desired position to evaluate the to remember that the different parts of the hand work n integrity of the various ligaments. and liga­ position while the integrity and the stability of the collate ments. will adopt a system of his or her own t will enable him or her to systematically evaLuate extremity. The passive range of mot evaluated. latera. The volar ligaments are only as individual units but also in conjunction with ea to prevent unlimited hyperextension of the particular joint. and given individual grade. it allows the integrity of the joint of motion of any paliicular joint should be evaluated b spaces. A bone scan is a radiologiC examination that joint to work properly. painful hand passive and active range of motion has different sign syndrome. The fing . When examining the muscles. the capsule. each u should be examined both individually and in conjunct with other units . Based on the clinical condition and the history. in making a fist. stability to the joint. on the other hand. MUSCULOTENDINOUS SYSTEM When examining the muscles and tendons. other. Instability of the joints is checked by but also all the other elements that contribute to the ran applying manual stress to any specific ligament. A ligament . Note the patient's fingertips should touch the distal palmar cre 90-degree flexion to stretch the collateral ligament. Polytomography is a special radiographic tech­ FIGURE 4-70. motion alone is different in its Significance from limitat It is very useful in cases of pain with unknown origin. n stability of any joint is evaluated by holding the bone only from an individual joint aspect but also in conjunct proximal to a joint and then by moving the bone distal to the with other joints (Figs. cance. through ti and experience . Note the neutral position o f the joint to stretch the collat it is useful for a detailed evaluation of a bone area. evaluated. defor­ recorded. FIGURE 4-69. The active range of motion evaluates not o special test is very helpful in cases of suspected instability or the integrity of the joint and all the structures related in cases where reproduction of symptoms at filming could it but also the integrity of all the elements that allow be done. active or passive. activated. Video fluoroscopy is a radiologic examination of evaluates the integrity of the joint and all the structu the area of the hand with a television monitor. 4-71 to 4-78). and the ligaments around it to be actively and passively. possible tumors. An arthrogram is done by injection of a special type ligaments are checked at that joint (Fig. The alignment of the bones. JOINTS. Have the patient open the fingers and make a fist to sh all the units togethe}·. It is very important that each muscle a tendon be isolated. Measurements of both should be observed a The presence of any signs of swelling. Each examiner. occult of the active range of motion alone. bones . special studies in addition to the basic radiographs might become necessary. AND LIGAMENTS Along with the clinical evaillation. In the case of the metacarpalpha­ langeal joint. Magnetic resonance imaging (MRI) is a special radiologic procedure 4-69). Checking the integrity of the collateral' ligament on the radial-side metacarpophalangeal joint of the left index fing er. and vascular lesions. therefore.

limited flexion of all the joints of the fingers .~. . Radial deviation of the wrist. FIGURE 4-13. Full flexion of metacarpal and proximal interphalangea joints but no flexion of the distal Interphalangeal joints. Ulnar deviation of the wrist. Full flexion of all the joints of the fingers. FIGURE 4-15. FIGURE 4-11. . FIGURE 4-18. Volar flexion o f the wrist. ~ !~. FIGURE 4-12. FIGURE 4-16.~-- . Full flexion of the interphalangeal joints with fu extension of the metacarpophaiangecli joints. Extension of the wrist. FIGURE 4-14. FIGURE 4-11. ~ .

east or west. 4-80) should be with the is possible (Fig. muscles . other hand will have full flexion adduction opposition a With the thumb fully adducted. Thumb pulp-to-pulp opposition and full flexion adduc­ tion . The little finger on joint (see Fig. the forearm pronated or supinated with the metacarpal phalangeal unit joints (see Fig. or up or down. depending on which ring fingers (Fig. abducted and extended at the basal and the metacarpo langeal joints with hyperextension at the interphalan should bend to cover the distal half of the middle phalangeal joint. 4-83).110 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADLJLT AGURE 4-81. ligaments. the patient reaches the tips of only distal to the thumb and little finger is done with the wrist in about ne distal palmar crease. Independen t full extension of index and little fi . FIGURE 4-82. 4-75). that All the flexors of the digits can flex their corresp the hitchhiker is going. Relationship of jOint flexion of the index finger a other fingers. when the patient Pulp-to-pulp opposition (see Fig. and the thumb will be fully fundus to the middle . It is important to remember tha tip of the thumb at the palm at a point at the base of flexion at the metacarpophalangeal joint of the little f the !little finger crease and the distal palmar crease at the with no adduction or opposition does not allow pul ulnar side of the palm (Fig. 4-81). Independent full extension of the index or the little f The hitchhiker position (Fig. then the problem is usually associated or in dorsiflexion. tendons. 4-79). The hitchhiker position. as they each have an indepen wrist in neutral between volar and dorsal flexion and extensor. and extension up to ne the problem is usually associated with the interphalangeal only of the interphalangeal joint. full flexi If the fingertips touch proximal to the distal palmar crease. If. The wrist will be in about 5 to 10 ing joints independently. full abduction at the basal joint of the thumb. bones. ring. patient's ability to bring the tip of the thumb to the desired Full flexion of the interphalangeal joint of the index fi point will be because of a limitation in thumb adduction is possible with full extension of the remaining t or full flexion at the metacarpophalangeal or the inter­ fingers . or joints. the metacarpophalangeal joint. 4-79) between makes a fist. but the same is not possible for the middle an forearm pronated or supinated fully. FIGURE 4-79. full flexion at the metacarpophalangeal joint and full extension at the i metacarpal and interphalangeal joint should place the phalangeal joints. north or south. areas of the index and middle fingers. joints of the remaining fingers (Fig. Any limitation in the pu1lp opposition to be possible. 4-77) . direction. which w together in one unit. and little fingers. The pathologic reason for the limitation there will have to be flexion at the metacarpophalan can be in the skin. 4-82). with the exception of the degrees ulnar deviation . An obstruction of flexion at the d interphalangeal joints of any of the three fingers bl AGURE 4-80. but with full flexion of all the index finger jo phalangeal joint.

flexion the profoundus action in the remaining two fingers FIGURE 4-86. The examiner place sublimis action without blocking the profundus of the the metacarpophalangeal in extension and flexes th remaining two fingers. Neurologic Examination The median . length and tension of tendon transfers or tendon grafts in Extrinsic Flexor Tightness Test: Simultaneous Wrist Exten­ reconstruction procedures. Independent extens. . object . ulnar. Semmes-Weinstein Monofilaments (Tubiana et al. as these two digits do not have independent extensors. the patient should be able to fully close the digits and extended. Extrinsic extensor tightness test. it is impossible to check the Intrinsic Tightness Test (Fig... two-point discrimination. FIGURE 4-87. and radial nerves innervate the hand and possess a sensory and motor component.g . length of the extensor mechanism. Under normal circum­ (i. if tightness interphalangeal jOints). 4-86). Thumb is ab with the wrist in full volar flexion (Brand et al. which will interfere with the ability to flex the distal interphalangeal joints o f the ring and little fingers . Note obstruction o f flexion at the distal interphalangeal joint of the middle finger. Under normal cir­ Extrinsic Finger Tightness Test.e. ducted and slightly flexed at the metacarpophalangeal and This position indicates no extensor tightness. 4-88).. This demonstrates gliding ful possible if any 'long flexor tightness is present. extend wrist-fingers flex . the patient should be able to fully extend the the wrist at least in neutral or preferably in full flexion to flex digits with the wrist fully extended. It should be possible with cumstances . This is a normal phenomen Extrinsic Extensor Tightness Test:Composite Wrist Flexion caused by the length-tension ratio of the extrinsic tendon Plus f inger Flexion (Fig. 4-85). In the same fingers. deep sensation. sion Plus Finger Extension (Fig.ion o f the middle and ring fingers is no t possible. (Fig. then the position mentioned would not be this ratio must be preserved. Variou sensory tests are available and include evaluations o tactile sensation. 1984). flex wrist-fingers extend and thumb is fully abducted stances.identifica FIGURE 4-84. . This posture is not all of the joints of the fingers.FIGURE 4-83. interphalangeal joints. FIGURE 4-85. For maximum function of the hand were present. temperature pinwheel test . This is an important fact that is utiHzed beneficially in surgical procedures and therapy when needed. 1981). e. 4-84) . Intrinsic tightness test. 4-87). Tenodesis (Fig. Extrinsic flexor tightness test. any Hmitations indi LENGTH-TENSION TESTS cate a positive intrinsic tightness test. as it is used in adjusting th possible . Passive and active flexion of th interphalangeal tests should be free.

4. you are assessing for th or in a direction proximal from the tapped area . The test is only positive when the unpleasant feelings are at the location of the tapping or in a direction distal to it. and Tinel 's sign. Assessment for Tinel's sign is done by gently tapping a sensory nerve with a blunt object that has the same circumference as the nerve. tion (stereognosis).112 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT FIGURE 4-88. 4-90). FIGURE 4-89. Tenodesis. Unpleasant Special Tests feelings (e. and record if patient reports symptoms o The principle behind performing the last test is to irritate tingling in median nerve-innervated sensory territory. Phalen's test. !f the presence of tenosynovitis of the extensor pollicis longu sensation travels proximally. . with the fingers relaxed.89). Reverse Phalen's test. 1951). paraesthesia . and the shoulder at 90 degrees abduction. place the wrist in 90 degrees of dorsiflexion with the fingers relaxed. the elbow at 90 degrees of flexion . texture identification. an already sensitive nerve. Finkelstein's test. and the shoulder at 90 degrees abduction (Fig. FIGURE 4-91.. hyperparasthesias) may occur in one of three locations or directions: at the site of FINKELSTEIN'S TEST tapping . at a direction going distal from the tapped area. it is not a positive Tinel's sign. the elbow at 90 degrees of flexion. Other useful tests are Phalen 's and reverse Phalen's (Phalan. The principle behind performing these tests is to put the median nerve under maximum pressure by diminishing the size of the tunnel and by kinking or stretching the nerve in either test . which eventually causes irritation of the nerve. Maintain the above positions for 0 to FIGURE 4-90. When performing this test. For Phalen 's test. A and B.g . For the reverse Phalen 's test (Fig. place the wrist in 90 degree palmar flexion . 60 seconds.

Large object circular grip . place the pa tient's wrist in radial devia­ long extensor tendon . which indicates ulnar nerve weak tion and midway between pronation and supination with all ness. however.AGURE 4-92. C. if the wrist is je rked too This is a test of active thumb adduction. A gentle jerking motion in the direction of ulnar deviation is FROMEN T'S TEST passively applied. the digits closed in a fist and the fingers covering the flexed thumb in the palm (Fig. and abductor pollicis brevis tendons located in the first of Finkelstein's test can lead to the patient developing d dorsal compartment. Hook grip. B. Special grip. thickening (ten­ don sheath). and adhe ions. Any attempt at distal gliding of the two tendons either passively or actively will be WARTENBERG'S TEST limited and very painful. Three-digit pinch. Tip-to-tip grip. A positive test result occurs when the movement causes pain. tightness. The imprope r administration patient is asked to hold paper without flexing the interpha . disease includes swelling (inflammation). Th have de Quervain's disease. (Positive Finkelstein 's test results In this test. Power grip (hammer grip) H. The pathology of de Q uervain's Quervain's. 4-91) . Key grip. Ask the patient to relax . F. Tip-to-side grip. the patient may feel pain even . 0. A. G. To perform the has a weak palmar interossei and unbalanced action of th Finkelstein's test . the little finger remains abducted if the patien usually indicate de Quervain's disease) . E. using a piece o much . 4-38).f he or she does not paper between thumb and first finger (see Fig .

such as the elbow crease (Fig. Normal grip strength and appropriate patient participation produce a bell-shaped curve. The when the hand is immersed. 4-93). Rapid alternat­ ing grip pattern at all levels or comfortable grip at level two FIGURE 4-93. discussed in other chapters of this text. An inability to hold without flexing indicates a positive test result and motor ulnar nerve palsy. the other extremity.114 UNIT TWO-COMPONENT ASSESSMENTS OFTHE ADULT langeal size and for edema can al CIRCUMFERENCE MEASUREMENTS taken. Many other compared with the measurement at a similar point in the are designed to asses hand function. The amount of water s circumference of the forearm is then measured at the out from one hand is compared with the amount spill chosen point. and three-jaw grip. uninvolved hand. which is accomplished with the index. many of thes other extremity and with future measurements. . which is accomplished with all digits. EVALUATION OF GRIP (FIG. power grip is evaluated at all five levels. VOLUMETRIC MEASUREMENTS Measures for changes . The circumference of the extremity at a ch Measures are made at specific levels of the forearm and point is compared with measurements at a simi'lar po arm for bU'lk to compare with those of future evaluations. and the power grip. Using a dynamometer. and middle fingers. tip-to-side (lateral) grip. Circumference measurement. 4-92) The two types of grips are the precision grip. thumb. and hook grip. Swelling in one hand is measur A point is chosen at a fixed distance from an anatomic the amount of water spilled out from a marked cont landmark. spheric grip. Examples of a power grip include grasp grip. or three assess "normal gripping" ability of the patient. The measurement in one extremity is immersing the other. Examples ol precision grip include tip-to-tip grip.

FL 32054 Gainesville. FL 32055 (904) 496-2323 (904) 373-3130 (904) 755-8688 HAND EVALUATION NAME: __________________________________ DATE: _ _ _ _ _ _~ ~. PPENDIX Ramadan Hand Institute 850 E. Hernando Street Lake Butler.NO:__________________________________ AGE: ------­ ADDRESS: _______________________________________________ OCCUPATION: _ _ _ _ _ _ _ _ _ _ _ HAND DOMINANCE: _____ INVOLVED HAND: ATTENDING PHYSICIAN: _ _ _ _ _ _ _ __ Present problem(s) to include functional limitations: Past problems/injuries to the upper extremity: Previous surgeries/treatments/medicationsltherapy: Observations (posture of hand): Illustration continued on following page 115 . Main Street 6241 NW 23rd Street 407 N. FL 32602 Lake City.

Radial Artery + ­ + Ulnar Artery + RIGHT LEFT + . Finkelstein's + - + . Tapering. Collateral Ligaments. Glide. Adson's + - + . Excursion) RIGHT LEFT + . Surface Irregularities. Ulnar Nerve + - - ALLEN'S RIGHT LEFT + . Middle Finger Extension + - + . Median Nerve + - + . Wrinkling/Shininess.116 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT Soft Tissue Integrity: (Edema. A of F + - TINEL'S RIGHT LEFT + . Nod Scars-Location and Size) Diagram on last page Joint Status: (Volar Plate. Phalen's + ­ + Reverse Phalen's + . Stress Test) Tendon Integrity: (Length. Radial Nerve + - + . Grind Test. Moisture/Dryness. Froment's + - + .

5 cm. L Ibs. RADIAL Thumb Ext. Hypothenars Intrinsics Illustration continued on following pag . RIGHT LEFT Wrist Flex. L Ibs. ULNAR Finger Flex. Atrophy) RIGHT LEFT Wrist Ext. Tip Pinch: R Ibs. L Ibs.Grip: (Level R Ibs. MEDIAN Thumb Flex. 7 cm below volar elbow crease R _ _ _ _ __ 3 cm L _ _ _ _ __ R _ _ _ _ __ 5cm L _ _ _ _ __ R _ _ _ _ __ 7cm L _ _ _ _ __ Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ Motor Nerve Innervation: (Strength. Finger Ext. Jamar Dynamometer-5 levels in Ibs. L Ibs. R1 _ _ _ __ 2 _ _ _ __ 3 _ _ _ __ 4 _ _ _ _ __ 5 _ _ _ __ L 1 _ _ _ __ 2 _ _ _ _ __ 3 _ _ _ _ __ 4 _ _ _ _ __ 5 _ _ _ _ __ Forearm Circumference: 3 cm. Thenars RIGHT LEFT Wrist Flex. Lateral Pinch: R Ibs. 3 Jaw Pinch: R Ibs.


~~ ~~~:~:: . ULNAR SFC.~-=- . LEFT PASSIVE MOBILITY ACTIVE MOBILITY MP PIP DIP MP PIP DIP I I M M R R L L THUMB MOBILITY WRIST MOBILITY MP OPP F RD IP WBSP E UD PMP POPP PF PRD PIP PWBSP PE PUD FOREARM ELBOW SHOULDER MOBILITY S F F AB IP P E E AD EP PS PF PF PAB PIR PP PE PE PAD PER COMMENTS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Sensory Integrity: 2 Point Discrimination RIGHT LEFT RADIAL SFC. RADIAL SFC. Thumb Index Middle Ring Small Illustration continued on following page - . ULNAR SFC. . -~. .

VONFREy) Sensory Testing: Semmes Weinstein RIGHT LEFT Volume of the Hands: Time of Day Administered: _ _ _ _ _ __ RIGHT LEFT _ _ _ _ _ _ __ Summary of FindingsITherapist's Impression _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .120 UN IT TWO-COMPONENT ASSESSMENTS OF THE ADULT Other: (VIBRATION AT 30. 256 CPS.

Photo on file: _ _ Yes _ _ No Plan: To forward a copy of this hand evaluation to the attending physician for use in determining the medical stat of this patient. Examiner Date .

R J. (1989). D. Surgical Clinics of North Americ 44(4). (1973). J. (1972). V. of Hand Surgery. 3. of clinical presentations. D. Far Klinische Chirurgie. Journal of Hand Surgery. 5. (1976). 81-87). Fibrous septae-Strands of fibrous tissue that anchor McFarland G. (1984). 13. Hand. (1970). Hand Clinics. 388-395. W. A. Herpetic infections of t digits. Journal of Bone and Joint Surgery. Journal of Trauma. (1975). Journal of Hand Surgery. & Kuczynski. Philadelphia: J. Moss. & Switzer. Mosb etal system. Hand Clinic 1. J. H. The puffy hand drug addiction. Koman.217-230. & Woolhouse F. Arthritis-Inflammation of the joint. 'Churchill Livingstone. Animal bite wounds. Fascia-Anatomic layer of connective tissue. 1. CIBA Clinical Symposium 40 (3 Lampe.. T.. W. Collateral Hgament-The ligaments on each side of Kaplan's functional and surgical anatomy of the hand (2nd ed the joint to hold bones together and provide stability. Gunshot wounds. L. L. (1951). 4. Dorsal flexion-To bend toward the dorsal aspect. Arch Volar flexion-To bend toward the volar aspect. 462-466. Ulnar-Toward the ulna and the little finger. (1984). Pain dysfunction syndrome \IS. 770-775. St. N. Sudeck. Closed tendon sheath irrigation for pyogenic flex Myositis-Inflammation of the muscles. E. Journal of Hand Surgery." metacarpals and phalanges in operative hand surgery (2nd ed New York: Churchill Livingstone. 8. reflex sympathe Arthrodesis-To fuse bones of a joint together and then dystrophy. P. Mitchell. J. Ulnar nerve compression lesions at the wrist a hand. Phalen. Neviaser. V.. 414-420. H. American SOciety for Surgery of the Hand. 8. D. Symposium on tendon surgery in the ha Contract-To shrink in size. & Mackin. Journal of Hand Surgery. Beach. E. Ossificans-Calcification in tissues other than bone. Journal of Hand Surgery. Pronate-To turn toward the ground (Le. Philadelphia: J. face down). B. (1984). cancel the joint. Brand. Hand Clinics. Butterfield. Glickel. Louis: C. Philadelphia: W. Neviaser. (1976). M. 553-559. 571-590. Louis: C. HerpetiC whitlow. Thomine. (1981). (1988). (1989). D. (1981). The practice of hand surge extend. on the anatomy of the ulnar nerve at the wrist. J. Burkhalter. Hand. (p. Verdan. & Wieche. P. & Silva. C. M. P. Spontaneous compression of the median nerve the wrist. 18. D. Flexion-To bend. Surgical findings Proxima1-Part toward the body or nearer to the body. (1979). E. S. Fractures of t hand. O. W. 54A. J. 90-93. Louis. S. The shoulder-hand syndrome: Present p spective. (1988). & Eugene. B. (1973). clenched-fist injUries. V. E. F.. 298-313. W (1864). Relative tensi body... Radial nerve lesions. 5. Radial-Toward the radius and the thumb. hand and upper limb. H. Volar plate-Thick fibrous collagen structure that makes Taleisnik. The hand (3rd ed. Green (Ed. R (1987). 17.. Practical consideration for primary and seconda repair in flexor tendon injuries. W F. Distal-Part away from the body. and potential excursion of muscles in the forearm and hand. 52-59. Journ Adduct-To bring toward the center of the body. S. G. face up).951-970. Lippincot. R. Lippincott. "palmar face of the O'Brien. (1968). & Hugill.). 2. Archives of Physical Medicine and Rehabilitation. plantar.. 4. J. (1975). tenosynovitis.. .. 115-11 Milford. (1985). (1976). J.).: Surgical): 1. Extrinsic-Outside the hand. Mayer. Lamb. V. R B. J. 112 Supinate-To turn away from the ground (Le. J. R. Journal of Ha Surgery. 629-63 Osteoma-Bone mass attached to the main bone. 147-156. 62.. Atlas of anatomy of the hand. K. Mosby. Mosby. Nerve compression syndrom of the upper limb. St. 209-219. 91). & Blythe. N. Palmar-Toward the volar aspect. Doyle. & Thompson. J. REFERENCES Anatomy of the hand. B. W. Examination of t fingers. E. Abduct-To bring or move away from the center of the Barton. (1983). 5. A. Hand infections in patients with acquired immun deficiency syndrome.. (1979). The radial tunn syndrome. and other injuries of nerve Flexor-Volar side. G. or soft organs. V. Edinburg Extension-Movement away from volar flexion. 2. Philadelph Contracture-A deformity across a joint. 92.. W. M. The structure and function of the skin of the han Hand.122 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT Barron. C. H. H. 145. C. (1988). F. Saunders. In D. J. K. The finger flexor tendon shea and pulleys: Anatomy and reconstruction (pp. (1964). Dobyns. & Stormo. Wilkins. Z. & Bassett. (1970). 865. Snyder. 93-96. (1978). S. Diagnostic study of vascular lesions. 6. AAO Chondroma-Cartilagenous mass attached to the skel­ Symposium on Tendon Surgery in the Hand. 237-240. B. K. Oxford: Blackwell Scientific Publications. Clinical Orthopaedics and Related Researc 220. 4. & Kleinert. Hand. 110. Radial tunnel syndrome: A spectru Intrinsic-Inside the hand. (1988). R. Belsole. 200-208. W E. J. up the ligament on the volar aspect of the small joints of the Tubiana. Kleinert. T. Journal of the American Medical Association. R B. Deep space infections. (1st ed. to Lamb. M. Landsmeer. American Academy of Orthopedic Surgeons. Nicolle. Kleinert. R.). Veber die acute entztindliche knochenatrophie. 4 Volar-Pertaining to the palm. D. H. The ligaments of the wrist joint. (1900). Further observati the skin to bone and deeper structures. Patzakis. Lister. Steinbrocker. E. Primary repair of flexor tendon Cyst-A sac inside the tissue-it could happen inside bone OrthopediC Clinics of North America. (1976).

the scales can (Turk & Melzack. MPT. and situational factors modifications are necessary. 1986). Due to the ubiquitous nature individual's pain experience . pain affect. the clinician needs to measure pain . Coupled with this. one would expect that this sensation would be well pist needs a full complement of pain assessment scales understood. Many types of diseases . not be able to critically evaluate the treatment tech­ 1984). In fact. personal history. In mation on the patient's pain to help in determining the addition to physical pathology. Ross. LaStayo. be incorporated with other outcome measures. Pain is a common human experience. lying pathology). Therapists must pain (Koch. Subsequent assessments are social. many cultural. and understand the physiologic factors associated with the medical and surgical procedures are associated with pain perception of pain and the multiple dimensions of an (Bonica & Benedetti . Therefore. a therapist would that makes someone seek health care (Knapp & Koch. thoroughly comprehending its that are cost effective and easily integrated into the clinical many characteristics remains elusive. it is pain Without effective measurement of pain. 1992).~ ' . These pain assessment tools are simple and effective and should be used clinically as part of a complete patient evaluation. Typically. ~ . . and environmental factors influence also important to determine whether treatment is effective an individual's perception of pain. CHT SUMMARY This chapter reviews the basic physiology of pain and the sensory and affective dimensions of the patient's pain experience. the clinical assess­ physicians are by individuals whose primary symptom is ment of pain is not a trivial endeavor. and pain location in a clinical setting . The chapter then examines a variety of scales that the physical therapist and occupational therapist can use to assess pain intensity. However. over 80 percent of all office visits to niques used to control it. CHAPTER 5 • Asse sment al n Robert G. MPT. 1992). economic. if clinicians use assess­ contribute to the quality and quantity of his or her pain ment tools that are we'll founded in research . while others have not been thoroughly tested. Many of the measures are clinically reliable and valid. Finally. underlying causes of the pain. It is commonplace setting. thus im­ To understand and adequately treat pain (and its under­ pacting the quality and cost of rehabilitation (Cole et aI. -­ . demographic. 123 . a thera­ of pain. injuries. CHT Paul C. for some patients to have the same type and degree of It is vital for the clinician to accumulate baseline infor­ physical pathology yet have different pain experiences. An individual's psycho­ in reducing the patient's pain or whether treatment logical state. 1980).

Myelinated A-IJ. pain modulation is is unique among all the senses. acts as a " gate" or modulator to either inhibit or facilitate terminate a noxious stimulus. There. descending modulation syste m that includes such stru The second-order. C-small A- nociceptive information from the periphery to the dorsal C primary. The gate unclear why such great variability occurs in how peop control theory (Melzack & Wall. the "gate opens. and small A-IJ. When this occurs. The of the spinal cord . horn of the spinal cord (Fields. Pain involves two maj the result of a balance of large-diameter A-~ neurons components: the sensory component and the affecti transmitting nonnociceptive information ." Clinically. and C neurons ascend into the substan­ particular part of the body and graded with respect tia gelatinosa of the spinal cord . A-IJ.h'-cell It is thought that pain is the result of tissue trauma or disease that initiates a complex set of chemical and electric events in the body. is differen cause they receive input from multiple sources. Small M. neurons ascend through the tures as the corticospinal tract in the cortex and medu spinothalamic tract to the reticular formation of the brain (Wallace. and C fibers enter the dorsal horn where they synapse with second­ order neurons. where the signal is interpreted as pain (Wallace . When a noxious mechanical.124 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT The goals of this chapter are to 1) review basic physiol­ Descending ogy of pain. third-order neurons send axons to the somatosensory cortex and the limbic system. 1988). first-order neuron. they synapse with intensity (Fields. Excitation of the substantia gelatinosa "closes demand!) pain medication when their dentist fills a cavit the gate" to nociceptive information transmitted by A-delta whereas others need none at all? Why do some wom and C neurons to the T-cells and to higher centers . 5-1). AB. or relay. and pressure. the body transforms this stimulus into electric activity in sensory nerve endings . we treat some patients wi action of the peripheral afferents with a pain modulation severe injuries who experience little pain and others wi system in the substantia gelatinosa within the gray matter minor trauma who are totally debilitated by pain. It is this affective compone the transmission of noxious impulses to the T-cells . first-order neuron. and 3) offer modulation control a full range of pain assessment scales available to the clinician for easy integration into the clinical setting. 1992). including touch . escape. periaqueductal gray hypothalamus. ­+ SG l < . chemical.. 1988). SG-substantia gelatinosa. discomfort that can often be identified and located to A-beta. THE DIMENSIONS OF PAIN During the transmission of nociceptive information from the spinal cord to these higher centers. A~-Large A-~ primary. we typically define pa both internuncial neurons in the substantia gelatinosa and intensity by how much a patient hurts (Jensen & Karol second-order neurons called tract cells (T-cells). it is s perception of pain can be modified (Fields. why do some patients require ( gelatinosa. including This component involves a complex series of behavio A-beta. In the thalamus. proprioception. Diagram of the revised Melzack and Wall gate cont are first-order neurons that transmit this electrically coded theory . . and C sensory The sensory component of pain has been described neurons transmitting nociceptive information. and unmyelinated C fibers FIGURE 5-1. For example. however. 1992). component. the most important difference between t and increased nociceptive information is transmitted to the sensory and affective aspects of pain is the distinctio T-cells and higher centers . Large A~ + THE PHYSIOLOGY OF PAIN . Clinically. differences may be explained partially by the fact that pa According to the gate control theory . resulting in a more painful between pain detection and pain tolerance (Fields. 1988). 2) identify the dimensions of pain. Pain can also be influenced by a Pain detection threshold relates to the sensory aspect an . Clinically. A-delta.e or thermal stimulus of sufficient intensity occurs. A-delta. the individual 's Even with identifiable neuroanatomic pathways. 1988 experience (Fig. stem . and thalamus. and C fibers . 1965) explains the inter­ perceive pain . The substantia gelatinosa that an individual may employ to minimize. T-cell-secon order neuron. cope with the pain of childbirth by requesting medicati Excessive A-delta and C fibe r activity can inhibit the whereas others use none? substantia gelatinosa. of pain that may explain the uniquely different wa The modulation of pain occurs when excessive large­ individuals perceive pain and the variability of their painf diameter A-beta fiber activity stimulates the substantia experience. T-cells are also termed wide-range dynamic neurons be­ The affective component of pain. These 1992).

occurring. & Dubner. To effectively assess pain in the clinical In a second study. For example. " a score of 3. H. The comparison of the VRS and the VAS pain ratin experience. Due to its multidimensional nature . 5. and "very severe. 1978. VRS.. With this scale. ranging from no pain to extreme example . V . using a 5-point VRS as de intensity. thes . during an initial evaluation and subsequen pain (Table 5-1). Jensen et al. 19-29. First. VRSs are usually score COMPONENT/PAIN INTENSITY by assigning a number to each word . Pain . vere.same person at different times . How should these scores b (Downie et al. The scores. P < 0 . The 0 represents " n Intense pain" and the 10 or 100.001) (Ohnhaus & Adler 1975).. . INTENSI1Y Some limitations of VRSs are the inability of man patients to link the proper adjectives to their level of pai S-Point Scale" IS-Point Scalet intensity and the inability of illiterate (of foreign language speaking) patients to comprehend the adjectives use None Extremely weak (Jensen & Karoly. Jensen et al.81. R.. The Nether­ expected to ameliorate pain intensity (Jensen et al . 1986. " a score of 1.. H. scales by a linear regression gave a highly significan correlation (r = 0. the therapist must weigh and consider pain in a double-blind study were assessed by the VRS an both the sensory and affective components of the pain VAS. on the other scales of pain intensity. (1978). "moderate. McGrath . Ratio data and then use the scale at every subsequent treatmen scales of sensory and affective verbal pain descriptors. or on a weekly basis to monitor whether progress with kind permission from Elsevier Science B. The Netherlands. therefore . Very strong Figure 5-2 outlines the NRS-l Oland the II -Point Bo Very intense Extremely intense Scale. 1989. R. 1986 lands. these rank scores do not allow fo interpretation of the magnitude of the differences relate VERBAL RATING SCALES fOR PAIN by the patient. Th number associated with the adjective is then used for th patient's score of pain intensity. Pain tolerance. R. "se Scale (VAS). interpreted? The clinician can say objectively that th patient's pain intensity has decreased since the start o treatment. 1983). . Fo levels of pain intensity. th because they are both valid and reliable . . Seymour. "severe " (3). " a score of 4. " pain as bad as it could be . 5. R. Mild Very weak Moderate Weak Severe Very mild Very severe Mild Very moderate Numerical Rating Scale Slightly moderate Moderate An NRS asks patients to rate their perceived level of pai Barely strong intensity on a numerical scale from 0 to 10 (an ll-poin Slightly intense Strong scale) or 0 to 100 (a 101-point scale). Amsterdam . with kind permission from Elsevier Science B. The VRSs are also reliable in that the results of a scribed are "very severe " (4). and the Numerical Rating Scale (NRS). P. " a score of 2. Furthermore . This information is ordina Verbal Rating Scale data and must not be interpreted as interval data. including the NRS. according to its ran on the order of pain intensity. 1982). is extremely variable as it is related to the affective with 100 patients with a variety of rheumatic diseases component of pain. Pain. no Correlation coefficients were high between pain score two individuals tolerate pain in the same way (Turk & derived from the different pain scales (Downie et al. " moderate" (2) VRS for pain intensity are consistent and free from error " mild" (1).. 1978) Kerns. The VRSs are valid patient is given four VRSs over a speCific period o because they measure what they intend to measure-pain rehabilitation.. P. the Visual Analogue 0. McGrath. Amsterdam. Jensen et al. and " none" (0). The clinician must be aware of several important factor ASSESSING THE SENSORY when evaluating VRS scores. and VAS hand . VRSs are effective tools for assessing pain treatment of a patient after total knee replacement. & Dubner. on the 5-poin Three methods commonly used to assess pain intensity scale in Table 5-1 .. the clinician can obtain valuable baselin • Reprinted from Grace ly. 5-18. (1978). the effects of analgesics on pathologi setting. t Reprinted from Gracely. "none" would be given a score o are the Verbal Rating Scale (VRS). Numerical Rating Scales are valid measures of pai Validity and sensitivity of ratio scales of sensory and affective verbal pain intensity and have demonstrated sensitivity to treatment descripto rs: Manipulation of affect by diazepam. V. That is the difference between a score of 2 and 3 must not b The VRS is a list of adjectives that describe different viewed as the same as the difference between 3 and 4. "mild. 1992). However.

two poten "the worst pain ever." and a ten (10) means While the VAS is easy to administer. a so on." and a one patient's baseline score of pain intensity. however. further resea FIGURE 5-3. allow for 101 possible responses. 1984). you cho the VAS as the scale to determine the patient's perceiv pain intensity. proper supervision by the clinician may FIGURE 5-2. 5-3) . Patients intensity (Fig. 1985). The Visual Analogue Scale (VAS) and an example of a is needed to test its reliability among varying pati compl eted VAS with a score of 6. from 0 to 100 mm. put an "X" through the number that best older ones. intense they rate their pain. the patient makes a pencil slash through the 10- between 0 and 100 that best describes your pain. a VAS 's 10-cm line can be measured increments of millimeters. than verbal scales of their pain (Jensen et aI. First. The word. 1983. may have difficulty working with graphic rat pinpoints your level of pain. The VAS has one end of its line labeled asked to rate the magnitude of their pain in terms of ea "no pain " and the other. they place a check mark directly below mates his or her level of perceived pain intensity.3 cm. with zontal dashes. populations. If their pain is equal to that of a spec patient is asked to mark along the line what best approxi­ descriptor. The 10l-point Numerical Rating Scale and an ll-point crease the chance of error (Jensen et aI. Also. Twelve descriptor items are presen The VAS is another measure used to assess pain in this scale. the VAS may be m sensitive to changes in chronic pain rather than in ac pain (Carlsson . 1992). McGuire." Please write only one response. 19 Kremer et aI. ..3 em DDS is of recent development. After hearing a brief description of Please indicate on the line below the number scale. th distance measured from "no pain" to where the patient's place a check to the right. Littman et aI.. This potentially makes VAS (and the NRS-101) more sensitive to pain inten than other measures with more limited responses su AN ll-POINT BOX SCALE as the VRS 5-point scale. 1986." The descriptor. "pain as bad as it could be. This becomes A zero (0) would mean "no pain.. progress. Each descriptor is centered over 21 h intensity and typically consists of a 15-cm line. Patients may find it difficult to r their pain on the VAS because it is hard to understa 10 11 I 2 I 3 141 5 16 17 I 8 I 91101 Therefore. 21 responses are possible for e descriptor. Subsequen hundred (100) would mean "pain as bad as it you can administer and score a new VAS at regu intervals during the rehabilitation to chart the patie could be. particula low. If the clinician or researcher does choose the VA thoughtful patient explanation and thorough attention scales are extremely simple to administer and score. 1986). Visual Analogue Scales provide a high number response categories. T may provide more reliable and valid assessments of p No pain I t( IPain as bad as it could be than single-item scales (Jensen & Karoly. Descriptor Differential Scale Another method to assess pain intensity is the D Visual Analogue Scale scriptor Differential Scale (DDS) (Gracely & Kwilo 1988) (Table 5-2). 1981). 1992). scoring are vital (Jensen & Karoly. line at a measured distance of 6. . Thus. during an initial evaluation.126 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT WI-NUMERIC RATING SCALE For example. measurement of the patient's VAS is another source error. as compared with single-item measures. Since Score = 6. Zero (0) means "no pain. No pain I IPain as bad as it could be One advantage of the DDS is that it is a multiple-it measure. As with the NRS-1 0 1 (with 1 responses). If their pain is greater than the descriptor." On the 0 to I 0 scale be­ sources of error exist. depending on how much m marks the scale represents the score. some patients. Each descriptor has a rating of intensity on a sc The visual analogue scale (VAS) of 0 to 20.. lending their application to a greater variety of patients than other scales (Jensen et aI. At the extreme left dash is a minus si each end anchored by one extreme of perceived pain and at the extreme right dash is a plus sign.3. Inaccur box scale. If the pain is less than specific descriptor. they place their check to the left.

----------------------------------------------------------------------." an Faint so on until each word has a rank score associated with I (Jensen et aI..(+) from measures of pain intensity.) --------------------------------------------------------------------------------------. Amsterdam . & Kwilosz . R H. This may result in a false representation of th Slightly intense I pain. 1989). It is recommended tha Extremely intense further research be conducted into the validity of VRS I among different patient populations. . in Table 5-3. McGrath. Pain.) ------------------------------------------------------------------------------------. 1989) indicates tha Very mild VRSs designed to measure pain affect were not distinc I (.) -------------------------------------------------------------------------------------. The Nethe adjectives describing increasing levels of unpleasantness. & Dubner. it must be distinct from Strong I measures of pain intensity.---------------------.(+) Very weak must choose a descriptor even if none of the availabl I descriptors adequately describe his or her affective re (-) . Pain. (-) -----------------------------------------------------------------------------------. measurement of pain intensity alone is not Distracting sufficient to establish a complete picture of the patient's Unpleasant pain experience.(+) an" 8. For example.(+) those for pain intensity.) -------------------------------------------------------------------------------------. pain is given a score of " 0. wi Verbal Rating Scales for assessing pain affect consist of kind permission from Elsevier Science B. except that the end points ar Reprinted from Gracely. Recent research with pos (. 5. the word representing the lowest level o your sensation in relation to each word with a check mark. Rat scales of senso ry and affective verbal pa in descri ptors. The affective VAS scale (Fig. as this method assumes equa I (-) --.) . V. . V . R. PAIN INTENSITY Verbal Rating Scales can be scored by a ranking method Instructions: Each word represents an amount of sensation. R. (. (1978) . H . It is necessary to measure the affective Uncomfortable Distressing dimension as well..----------------------------------------------------------.) ----------------------------------------------------------.(+) sponse. (1988). D. with kind permission from Elsevier Science B.------------------------------------------------------------------------------------. 11 . " As stated earlier. M.. TABl [." his or her score would b (.(+) score of the word chosen.-~ VERBAL RATING SCAlE OF PAIN AFFECT ASSESSING THE AFFECTIVE COMPONENT OF PAIN 15-Point Scale Bearable Clinically. lands. The following questions can be better Oppressive understood by assessing the affective component of pain: Miserable How unpleasant or upsetting is the patient's pain'? To what Awful Frightful extent does the patient's pain disrupt his or her behavior'? Dreadful Can the patient cope with pain'? Why do such differences Horrible exist among patients' abilities to cope with pain'? Agonizing Unbearable Intolerable Excruciating Verbal RatingScale Reprinted from Gracely." the next a score of " 1.(+) Weak Verbal Rating Scales for pain affect have two importan I drawbacks.) ------------------------------------------------------------------------------------.(+) Visual Analogue Scale Mild I Visual Analogue Scales for pain affect are. 5-4) typically use differential scale: Applying psychophysical principles to clinical pain a 10.(+) measure of pain affect to be valid. if th Moderate I patient selects the work " awful. 35.(+) Very intense I (.---------.) ------------------------------------------------------------------------------------. The first is the question of validity.-----------------------------------.(+) operative patients (Jensen et aI.) -----------------------------------------------." Patients are asked to select a word that best describe DESCRIPTOR DIFFERENTIAL SCAlE OF their affective pain (Table 5-3). Second. 280. Rate With this method .to 15-cm line that is anchored at one end by " not ba assessment. P. The Netherlands. caution should be exercised whe Barely strong interpreting the VRS. ing.. For (. The descripto r different..(+) intervals between each descriptor This ranking metho Inte nse may not produce scores that are accurate numerica I representations of pain.-------------------------. The patient' s score equals the ran (. . Amsterdam. the patien (. similar t (.

A minus sign is lo possible for me" (Price et al. not distressed. annoyance. one-tailed test) and the 1-month/4-month DIE PAIN DISCOMFORT SCAlE follow-up correlation was 0. the PDS is unique 5. 1 am scared about the pain I feel. with kind permissio item 9. When I feel pain I am hurting. UK . 1987). mak­ affective nature of the pain is equal to a specific descr ing them valid measurements (Price et aI. Jou Psychosomatic Research.. . My pain is a minor annoyance to me. therapists can easily If the pain is greater than the descriptor. P. Several of its items are different person . 0 . Kidlingto on life. Langford Lane. and so on.58 (P < 0. Also. o 1 2 4.001. patients using the is less than the specific descriptor." 1GB. one tailed­ test). 1975). The MPQ chronic pain patients. the DDS at all feeling possible for me has a separate scale for assessing pain affect (Grac FIGURE 5-4. With the PDS. a check is placed affective VAS may have difficulty with graphic represen­ left. My pain does not stop me from enjoying the affective subscale of the MPQ (in which respondents life. helpless­ 7. and distress in response to pain. 4 = This is very true for me. as assessed by Beck whether each of the statements below is more true or false f you . Kwilosz. o 1 23 8 ." or Reprinted from Jensen. When I am in pain. o 1 2 response (10) than the VRS (choice of one descriptor) or 3. 1 = This is somewhat untrue for me. and the McGill Pain per question. Pain Discomfort Scale (PDS) (Jensen et al. 0. (0 through 4) according to the following scale: The correlation coefficients were Beck Depression Inven­ 0= This is very untrue for me. two-tailed test) (Jensen et al. as with VASs for pain intensity. the DDS has recently developed. 1987). P. 1991).. Therefore. Table 5-5 outlines the DDS for pain a The patient has a choice of 12 descriptor items. TAI3I . to me). & Harris . "I never let the pain in my body affect my outlook Elsevier Science Ltd. o 1 2 choose from five categories). As previously explained. However. The Boulevard. I never let the pain in my body affect my developed and validated for chronic pain patients whose outlook on life. P.76 (P < 0. subjects were administered the scale at discharge and at 1 month and at 4 months following discharge. (1991) . two-tailed test). depending on how much less he or she rates the tations of their pain. The pain 1experience is unbearable.E S--4 The discharge/I-month follow-up correlation was 0. but 1 am ness. o 1 2 among affective measures since it is the only measure that 6. o 1 2 inappropriate for acute and postoperative pain. . The Visual Analogue Scale (VAS) of pain affect. and Affective 2 = This is neither true nor untrue for me (or it does not a Subscale. 35 (2/3). "My pain does not stop me from enjoying life.. changes in an individual's affective pain perception. o 1 23 10. 199 1) (Table 5-4). Answer by circling the appropriate number Questionnaire (MPQ) Affective Subscale (Melzack. 3 = This is somewhat true for me. the patient is asked to indicate the level of agreement (from 0 = "This is very untrue for me" to McGill Pain Questionnaire 4 = "This is very true for me") for each of 10 items on the scale. o 1 2 be quickly administered and it provides a broader range of 2.001. such as item 4. having a rating of "unpleasantness.. 151 ." Each descrip at all" and at the other end by "the most unpleasant feeling centered over 21 horizontal dashes. I become almost a pain averaged 9 years' duration. responses. Each descriptor has 21 po not used. I have learned to tolerate the pain I feel. Karoly .001. to the extreme left. tory .01. o 1 2 The one drawback of the PDS is that the scale was 9. The advantages of this measurement tool are that it can 1. The pain I feel is torturing me. o 1 2 directs patients to indicate their feetings of fear. The most widely used and most thoroughly resea The PDS is a valid and reliable measure of pain affect for assessment tool for pain is the MPQ. and further research must be conducte Pain Discomfort Scale varying patient populations. 1967). depression. To assess test-retest stability of the developed from a two-part study (Melzack & Torge PDS. If the ever.. M. its advantage its potential ability to assess the sensory and aff A relatively new method of assessing pain affect is via the components of pain.64 (P < 0. a check is p measure the scale inaccurately if meticulous technique is to the right. Please answer every question and circle only one numb Depression Inventory (Beck.128 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT Visual analogue scale (VAS) of pain affect Descriptor Differential Scale Not bad I I The most unpleasant In addition to the scale for pain intensity. How­ he or she places a check directly below the word. and a plus at the extreme right Visual Analogue Scales for pain affect are sensitive to patient rates the unpleasantness of each descriptor. 1988). I feel helpless about my pain . The construct validity of the PDS was examined Instructions: Please indicate by circling the appropriate numbe against two indices.38 (P < 0.

fear.----------------------------------------------------------------------. Stein & scale for pain intensity (part 4) (Fig . chronic. in 5 minutes . 1980 The MPQ consists of a top sheet to record necessary Reading 1989.) -----------------------------------------------------------------------------------.) ----------------------. The patient marks an "E" for external pain. 5. or an " EI" for both internal an (. an each subclass." 1 to "mild.. that category is left blank. 1985.----. The Netherlands. 35. The clinician ca administer the questionnaire before and after a series o 1971)." 4 to "horrible.------------------------------------------------------------. onto which the patient indicates the location of hi (-) ------------. (+) the pain are also written down. Initially. space . the patient chooses one word from each of 20 I (. evaluative. R.. 16. (1988) . Pain. The Present Pain Index (PPI) is tabulated from th differential scale: Applying psycho physical principles to clinical pain patient's response to part 4.(+) or her pain . Melzack & Katz. . the patient should be able to complete the MPQ your sensation in relation to each word with a check mark. and surgery. words that studies of acute. (+) categories that best describes his or her pain at tha Annoying moment.(+) cellaneous . classified into three major classes and 16 subclasses. words that has been modified and translated into several language describe the pattern of pain (part 3). Reading et a!." Wha Very unpleasant I activities the patient has found that relieve or exacerbat (. 1982. respectively..-----------------------------------------------------------------------." 2 t Very annoying " discomforting. assessment.) ----------------------. and laboratory-induced pain. Graham et a!. " 3 to "distressing.) ------------------------------------------------------------------------------------. three-word columns with words suc (. 1987. You decide to administer th qualities in terms of tension. (+) Slightly intolerable Three important scores are tabulated from the MPQ I 1. mis (-) -------------------------------------------------------------------------------------. in column one I (. reliable. Initial scores on the PRI and the PPI are 52 an related properties.. . 283.) ---------------. describe temporal properties of pain (part 2). H . 1988). Amsterdam . 2) words that describe the affectiue 4 (" horrible"). intenSity at the time of administration. --­ ". determines the pain intensities implied by words within The MPQ has been proven to be valid. with kind permissio n from Elsevier Science Each MPQ score represents an index of pain quality an B. (+) as " continuous.-------------------------------------. and 17 through 20. (+) into four groups: 1 through 10. Reprinted from Gracely. Wilke et a!. Slightly unpleasant The line drawings of the body are anterior and posterio I views. with experience administerin Instructions: Each word represents an amount of sensation. V. with 0 corresponding to "no pain. Unpleasant In part 2. the patien Distressing rates the pain he or she is experiencing on a scale of 0 to I (-) --------------------------. These words were percentage change from the initial value. and autonomic proper­ MPQ biweekly for 1 month.. M. 1990) patient medical information. of the MPQ. this represents an objective change in th total pain experience .(+) "flickering" would be given a rank of 1. and "quiv Very into lerable ering." and I to " excruciating.----------------------.) --------------------------. Each descriptor is ranked according to it Into lerable position in the category .(+) external pain. D. 11 throug Very distressing ! 15." "intermittent. For example." and "momentary. (+) Slightly distressing describes the pattern of pain being experienced by choos I ing words from three. and a five-pOint rating (Vanderlet et a!. (+) 5. The second part of the study patient's pain experience. the patien (-) ------------------------------------------------------------------------------------...---------------. The descriptors in the first 20 categories are divided (. sensory . a Slightly annoying I "I" for internal pain. useful (Chapman et a!.~ . this test may take 15 t PAIN AFfECT 20 minutes to administer. pressure. The number of words chosen is determined.5). and 3) eualuatiue after the last MPQ are 21 and 2 ("discomforting") words that describe the subjective overall intensity of the respectively. (.) ---------------------------------------------------------------------. The sum of the rank values i I assigned the Pain Rating Index (PRI). These For example." (. Mendl.------------------------------.(+) 2.-------------------. Rate the MPQ. rather than simply handing the MPQ to th DESCRIPTOR DIFFERENTIAL SCAlE OF patient along with a pencil. In part four. you might administer the MPQ to a patien classes were 1) words that describe the sensory qualities of who has just begun rehabilitation follOWing spinal fusion the experience in terms of time. The descriptor 3. heat.) --------------------------------------------------------------------------------------..------------------------------------------------------. If no single word is appropriate from an I category. line drawings of the body for This assessment tool has also been used in over 100 the patient to indicate the pain location (part 1). The difference can be expressed as different aspects of the pain experience. affective . 1992. The scores of the PRI and PP ties that are part of the pain experience. The first part categorized 102 words that describe treatment sessions." a rank of 2. & Kwilosz . In part 3 .

Where is your Pain ? Please mark.ack PAIN QUESTIONNAIRE Some of the words below describe your pn: ~nt pain. the MPQ was tions each time it is administered (Machin et aI. Four major questi ons Hurting Rasping w(! ask are: Aching Spliuing I. Lca\'c out any category that is nOI suitable. atypical facial pain.\ent pain of increas ing intenSit y. What Does Your Pain Feel Like? McGill-MeI7. 1970 Radiati ng Numb Cold Nauseating Penetrating Drawing Frc"Czing Agonizing Piercing Squeezing Dreadful Tearing Tortllring Part I. [1975J..hing Boring Cuuing Pulsing Shooting Drilling Lacerating Diagn osis: _ _ _ _ _ __ Throbbing Stabbing Bcating . Which word or words would you use to describe the pattern of your pain? Continuou5. Which word describes your pain right now? 2. Rhythmic Brief Steady Periodic Momentary Constant Intelminent Tramicnt 2. Put E if external.. The McGill Pain Questionnaire: Major properties and scori methods Pain.t rhe followin g 5 \\. Which word dcscribt!s the worst toothache you ever had ? 5. The authors found that patients with "organic" a patient's pain. hing Wretched Ann oyi ng Frightful Gmeling Blinding T rou bll!somc Terrifying Cruel Mi serable It is impol1::mt that you tell us how your pain feel s now . They arc: 3 4 Mild Di scomforting Distressing Horrible Excruciating To answ~r ~ach que~t ion below. neurological. How Docs Your Pain Change With Time? 1. Patient's name Age _ _ __ File No. The results showed a correct predictio One study (Leavitt & Garron. Put E1 if bOlh external and internal. Dosagc _ _ _ _ _ _ _ _ _ __ Gnawing WrenChing Scalding Smartmg.281 . the patient. Oct. on the drawings below.t _ _ _ _ _ _ __ Cramping Scaring Stinging Pa1ient's intelli gence : circle number that represents best cSlimal~ Cru~hing I (low) 5 (high) 9 10 II 12 Dull Tender 'fi ring Sickening Sore Taut Exb:1u!\ling Suffocating Thi s questionnaire has been designed to lell U~ more about your pain .cribcs the worst headache you ever had? 6 . with kind permission from Elsevier Science B. What k. Where is your pain? Heavy 2.) Perhaps one of the most interesting features of the MPQ used to differentiate between trigeminal neuralgia an is its potential for differentiating among pain syndromes. or I if internal. Typc _ _ _ _ _ _ _ _ __ Pressing Pulling Burning Itchy 2.l.OU mark. . v. write the numbe r of the most appropriare word in the space bC5idc the questi on I.! beginning of each pan Killing Unbearable 17 18 19 20 Spreading Tight Cool Nagging ~) R. (Reprinted from Melzack.'ords rcprc. Which word dc. What kind of things increase your pain? Part 4. How strong is it ? Fe. 1986).130 UNIT "TWO-COMPONENT ASSESSMENTS OF THE ADULT Part 2. the clinician must consid causes used different patterns of words from patients whether the MPQ is too complex and time consuming fo whose pain was "functional"-having no physical causes. Time given in rcl<. Mel z:1c k.. Amsterdam.g . ncar the areas which ). The Netherlands.ind of Ihing ~ relicve your pain ? 3. Part 3.llion 10 thi $ tes. The McGill Pain Questionnaire . etc. How does it change with time? 13 14 15 16 4. Lancinating POlmding Analgei. since it involves answering 70 separate que In a more recent study (Melzack et aJ. 3. However. 280.): Quivering A a. 1980) found different for 90 percent of the patients .cribes the wor!"t stomach-ache you ever had? FIGURE 5-5. Cirele ONLY those words that best describe it.oTy-lhe one that applies best. Which word dt:s.ic (if already administered): Pinching Tugging Hot Tingling I. How Strong Is Your Pain '? Pcople agree tha. Date _ _ _ _ __ I 2 4 Flickering Jumping Prickin g Sharp Clinical cah:~g01y (e. Usc only a single word in each appropriate catc:. descriptor patterns between two major types of low back The MPQ is the most thorough clinical tool for assessin pain. Please follow the instructions Vicious Intense at thl. 1988 .• cardiac. .arful Puni . the areas where )'ou feci p<tin.... What dOt!s it fed like? 3.. Which word de!tcribc!' il Jl its worst? 3. R. 1. Which word dc!"cribcs it whcn it is lea!-I 4.

.. 60. The pain drawing can be used to help establish treatment programs as well as a measure of treatment outcome. Ransford et al." "burning." and "throbbing. J. 24. Recently." as well as more detailed descriptors of pain such as "deep. Pain. Asking the patient.. 1986. 1986) (Fig.. Example of a body diagram. 1973). "Where is your pain?" may not be sufficient to pinpoint its location. However.PAIN LOCATION. a thorough pain evaluation shou include an assessment of pain intensity. the location of the patient's pain is an important third dimen­ sion of the pain experience. C. Additional symptoms such as "numbness" and "pins and needles.) developed." "aching. weights were assigned to body areas equal to th percentage of body surface they covered.. particularly in the chronic pain population (Margolis et aI. CONCLUSIONS This chapter has reviewed the physiology of pai explored the dimensions of the pain experience." can be denoted by various symbols. 1984). The pain drawing is a reliable and valid instrument for assessing the location of pain (Margolis et ai. BODY DIAGRAMS. 5-7 For each of the 45 areas. The pain drawing may be an appropriate assessment of pain location. an provided a variety of scales to assess pain intensity. based on the presence or absence of pain each of 45 body areas (Margolis et aI. Tait. R.. This scorin system is similar to the system used for assessing bu victims (Feller & Jones. a scoring method has been FIGURE 5-7. and pain location in the clinical setting. Schwartz & DeGood. Patients are asked to color or shade areas on the line drawing of a human body that correspond to areas on their bodies that are painful. V. AND MAPPING In additionto assessing pain intensity and pain affect. Pain drawing scoring template. with kind permission from Elsev Science B. S. 1988. the clinician must consider how the pain drawing is interpreted. FIGURE 5-6. Figure 5-6 is a representative example. Amsterdam. [1986l.. The Netherlands. Many of the measures presented are clinically reliab . & Krause. B. pain affect." "superficial. To score th drawings. A rating system for use w patient pain drawings. 1976). Althoug every patient's pain experience is unique and influenced b numerous factors. an pain location. (Reprinted from Margol R. a score of 1 was assigned if patient's shadings indicated that pain was present and score of 0 if pain shadings were absent. pa affect.

. w. U of the McGill Pain Questionnaire in the assessment of pain: Repli bility and consistency. G.. P. R. S. D. Harkins. Springfield. R (1986). Journal of Clinical Psychology.. Jensen. E. Finch. R. Melzack. Pain Jensen M. (1968). MD: National Center for Health Statistics. J.. these pain assessment scales Pain. C. experimental and theoret. P. the visual analogue scale. B. Terrance. usually 10 to 15 Margolis. P. Chibnall. Pain. R. McGrath. & Krause. . 3. Melzack. Ohnhaus. 186-189.­ for discrimination and diagnosis. relationships among different types of clinical and experimental pa 22. 277-299. R. Jensen. 49-51­ Margolis. (1978). & Benedetti. The management of new pain in off gelatinosa of the spinal cord that can either facilitate or ambulatory care. Pain. J. V.. Pain. (1985). Rhind. The measurement of clin tolerance is a principal aspect of the affective dimension. 8. Dubner. & Wall. & Cook.. of his or her pain. (1986). Post-operative pain. Research. The subjective experience of acute pain: An assessment of Internuncial neuroas-Cells located in the substantia utility of 10 indices... Cole. P.. R.. endeavors rather than by physical therapists and occupa­ Relds. Decosse (Eds. & Amsel.J. these scales have been used in research the Rheumatic Diseases. & Tait. (1983).. Kens Wide-range-dynamic neuroas-Cells located in the (Ed. 379-384. & Karoly. Price. Sensory-affect & Reading A. W. In R. New Yo Affective dimeasion of pain-The complex series of Guilford Press.. The Clinical Journal of Pain. (1988).1-31. R. Bond. Part I. whereas others have not yet been thoroughly Downie.132 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT and valid. (1992). Jensen. R. Pain. 423-439). from the periphery to the dorsal horn of the spinal cord. II: Charles spinal cord that respond to a broad spectrum of noxious Thomas. & Braver. M. D. and nonnoxious stimuli. Gerkousch. R. & Anderson. & N. P. C. 150. A. Tait. & Koch. Validity of a back pain classificat for detecting psychological disturbances as measured by the MM important in the localization of pain. 28.. E.). & Garron. R. pain intensity: A comparison of six methods. 149-154. The skin senses (pp. PHS 84-1250). M. K. P. Gracely. choose a word from the list that best describes the intensity Machin. (1992). (1973). The management of new pain in office ambulatory ca National ambulatory medical care survey. National ambulatory medical care survey. T. 117-126. J. Walker. 34. H.. Even so. Aspects of the McGuire. B. (1980). No 123 (DHHS Publication No. M. J. A. C. Pain mechanisms: A new theo management. 152-156. P. 8. Manipulation of affect by diazepam. H. P.. C. Fromm.. calal aspects.. J. L. & Casey. & Baker C (1987). & Schneider. Verbal rating scale-A list of adjectives to describe Littman. (1984). J. Pain measurement: An overview. tional therapists in the clinical setting. T.). 1. H (1984). M. 1. (1967). M. R. (1978). The McGill Pain Questionnaire: Appra and status. 33(3). 1980 and 19 Advance data from vital and health statistics. v. The Canadian Physical Therapy Association. (1971). D. In B.. motivational and cen control determinants of pain: A new conceptual modeL In D. 279-288. Foley. (1986). 378-381. 297-307. Nurs reliability and validity of the visual analogue scale. P. Wright. R.. w. A. Pain. A. M. E. Cole.. Gowland. PHS 86-1250). Without question. C (1980). Carlsson.. M. 24. (1980). (1975). Gowland.. Melzack (Ed Handbook of pain assessment (pp.. S. Assessing the affect First-order neurons-Myelinated and unmyelinated component of chronic pain: Development of the pain discomfort sca nerve fibers that transmit electronically coded information Journal of Psychosomatic Research. Chapman. Graham. 153-15 Knapp. New York: Hoeber. E. behaviors a person uses to escape a painful stimulus. (1989). M. & Adler. New York: Guilford Press. P. Assessment of chronic pain. (1985). S.. Gracely. Feller. & Jones. REFERENCES Melzack. 36.. F. J. K L.. & Wylson. Koch. & Igneli. 971-979. R. C Turk & R. Pain measurem or unpleasantness. F. S. L (1988). Test-retest reliabi centimeters long with each end achored by extremes of of the pain drawing instrument. Melzack. & Katz. Kremer. Anesthesiology. Pain. D. C. Studies with pain rating scales. A. Pain. by intensity. ville.). (1992). S. I. (1981).. in randomized clinical trials. Pain (2nd ed. Pain. Pain..... Selheport scales and pro dures for assessing pain in adults. 27. Reassessm of verbal and visual analog ratings in analgesic studies. Clini either pain intensity or pain effect. 5(2). Nursing the burned patient. 152-168) (1st ed. 35. Karoly P. Leatham. (1986). Karoly. 37. Pain. The Descriptor Differen effectiveness of these assessment tools with a variety of Scale: Applying psychophysical principles to clinical pain assessme patient populations. J. C. Science. D. A patient is asked to use with patient pain drawings.. The Clinical Journal of Pain. F. Annals tested. respectively. New York: McGraw-Hill. The McGill Pain Questionnaire: Major propert and scoring methods. 97 (DHHS Publ Second-order neurons-Cells that transmit informa­ tion No. R.). & Harris.). Casey. 57-65. more clinical research is needed to further detail the Gracely. M.. G. tion from the spinal cord to the higher centers in the brain. 135-151) (1st ed. R.. MD: Natio Sensory dimension of pain-Pain that can be iden­ Center for Health Statistics. G. E. The measurement of clinical pain. & Dubner. Branco. Visual analogue scale-A line. Validity and sensitiv are simple and effective tools that can and should be used of ratio scales of sensory and affective verbal pain deSCripto clinically. H. Advance data from vital and hea tified and located to a specific part of the body and graded statistics. & Mayo. 27. Methodological problems in C. 35(2/3). Melzack (Eds. A. B. C. R. (1965).. (1988). (1988). E. 8. (1975). P. Depression: Clinical. R... Atkinson. section of the central sulcus (in the parietal lobe) that is Leavitt. Handbook of p assessment (pp. Ann Arb MI: Braun-Bromfield. On the language of pa Bonica.. Pain. H.. The patient is asked to Pharmacology Therapy. 5.. 16. 50-59. R. Melzack. Mayo (Eds. & Torgerson. 377-387. D. Hyattsville. E. O'Riordan.. H. Sensory.87-101.). D. H... E. J. R. In D. Lewith. T. S. S. Fmch. 8. S.. Hya inhibit the transmission of noxious stimuli. M.. Somatoseasory cortex-A region in the posterior 241-248. 1(3). No. C Turk & R. Condon & J.. Pain. E.): Physical rehabilitation outcome measurement of pain: A comparison between verbal rating scale a measures (1st ed. J. K. place a mark on the line that best describes his or her pain. Bland. R. 19-29. W. A physiological approach to clinical Melzack. 161-168. (1991). N. Trigemi neuralgia and atypical facial pain: Use of the McGill Pain Questionna Beck.. 297-302. Measurement of pa Patient preference does not confound measurement. & Burns. Karoly. & Kwilosz. R. D. Philadelphia: Lea & Febiger. R. Ironically. In D. 16-23. C. A rating system either pain intensity or pain effect.

E. analgesics in post-operative dental pain.. & Vertommen. G. Pharmacology. D.. 57-68. The German counterpart to the McGill A meta-analysis. P. European Journal of Clinical Wilke. R. The textbook of pain (2nd ed. H.) Vanderlet K. (1992).383-388. Pain Questionnaire. 21. H. Andriaensen. R. (1982). Melzack (Eds. Savedras. Preliminary data concerning reliability and validity. (1990). P. Global appropriateness of pain (MPQ-DV). M. Carton. M. The McGill Pain Turk. 1. Pain. . Edinburgh: Churchill Uvingstone. (1989): Testing pain mechanisms in persons in pain. British Journal of assessment of people experiencing pain. (1984). H. New Yo Reading. In D. 127-134. A. C. litigation status. The McGill Pain QUestionnaire constructed for the Dutch langua Schwartz... D.). Handbook of pain assessment (pp. (1988). (1982). D. & Melzack. The pathophysiology of pain. Everitt. & Paul.. (1992). Wallace. Pain. 36-41. Use of the McGill Pain Questionnaire to measure pa Stein.395-408. Turk & R. In Guilford Press. 251-255. C. 15(2).). & DeGood. 39.. 269-280). B. (198 (pp. D. A. Melza Clinical Psychology. D. 23. NurSing Research.). Pa drawings: Blind ratings predict patterns of psychological distress and 30. J. G. W. C. The measurement of pain and t Questionnaire: A replication of its construction. L. A. C.. E. (Eds. Wall & R.. M. E. 339-349. 19. 441-444. 32. 1-13. & Mendl. C. Hozemer. Reading. Esler. Critical Ca Seymour.. D. The use of pain scales in assessing the efficacy of Nursing. 3-12) (1st ed.. & Sledmere. K. M.


but there are instruments available for recording pulmonary re­ sponses to activities. clinical measures of exercise capacity. planning an exercise program. patient's ability to respond to activities of daily living. ho persons would rarely need to draw on maximal capacities. Functional activities require that an individual be able to through disease. and establishing the outcomes of an intervention. This viduals whose reserves have been severely restricted despite the fact that there are a number of good me Cl. Physical and occupa systems provide a range from resting to maximal ability. In this ins draw on the cardiovascular and pulmonary systems to a patient may become short of breath when transf respond to a wide variety of demands. In this chapter the discussion is focused on the evaluation of exercise capacity and endurance using standard exercise test­ ing protocols. Current methods available to the cli­ nician are discussed. Another means for measuring the difficulty of a task is to monitor heart rate responses.". The clinician needs to be familiar with a number of standard tests for assessing these functions. CHAPTER 6 Gardiovascula'r and Pulmonary Function Elizabeth T. there are no widely accepted standards for measurin On the other hand. clinicians frequently encounter indi­ evaluating endurance in patient populations. Observa­ tion of breathing patterns may be the simplest way for the clinician to detect the stress of an activity. especially in an individual who has pulmonary disease. Protas. therapists need to assess a patient's endurance an Physical and occupational therapists are interested in the these assessments to plan treatment programs. Improved endurance is one of the most common c Endurance from this perspective is often submaximal. PhD. deconditioning. Finally. The clinician must be able to accurately record the heart rate and interpret the results. " . Most goals for occupational and physical therapists. Another aspect of the ability to perform functional activity or to exercise is the ability of the lungs to deliver oxygen to the working muscles and to eliminate carbon dioxide. Blood pressure is an easily accessible measure of cardiovascu­ lar and autonomic responses. PT. and other measures of exertion. The reserves in these from the bed to a wheelchair. or both . Standardizing the methods of measuring blood pressure will greatly increase the reliability of these values. FACSM SUMMARY The measurement of cardiovascular and pulmonary function is crucial to assessing the patient's status. monitoring blood oxygenation is important.

Variability in heart rate responses 14. These methods range from very 150 simple to more complex tests requiring considerable instrumentation.. 21.5 116 15. 1983).e. A number of therapists are using the thumb. 1985) (Table 6-1). or 60 seconds) and 9.. 15.g. the cardiovascular and musculoskeletal systems or both limit exercise capacity and endurance. and 14. cussed in this chapter. 1990). the distribution of I m110 the blood through changing blood pressure. and pulmonary responses to ~130 D.5 171 rehabilitation settings. 6-1). In this chapter the focus is on measuring 140 cardiovascular.. The pulmonary system's capacity is much greater and is not thought to heart rate is determined using a conversion table (Sin normally limit exercise capacity. 1977). Procedural considerations include n in American adults (Hahn et aI. and exercise capacity are presented. Measures of heart rate.­ activities.5 189 9. Palpated radial and c recognize the normal as well as the abnormal responses of heart rates are not Significantly different from heart the systems. The tHeart rate per minute.0 90 The validity of the heart rate as a cardiovascular measure is 19. autonomic. A 65-year-old individual 13.5 144 lower maximal heart rates than a fit 65-year-old. The latter Time for 30 beats.. 30 beats). and the delivery of the blood through the blood vessels. avo latent cardiovascular disease.0 150 Determining the heart rate by palpating either the radial 11. 6-1 HEART RATE CONVERSION D ETERMINE BY TIMING 30 CARDIAC CYCLES HEART RATE nme· Ratet The heart rate is probably the easiest means for the 220 82 clinician to monitor cardiovascular responses to activity. By matching ventilation with the blood perfused Oxygen consumption (mUkglmin) in the lung. the blood will be adequately oxygenated and FIGURE 6-1. Under normal circumstances.5 157 11.0 164 or the carotid pulse is the most common means used in 10. and on III test interpretation. the 18.5 124 between persons is created by age. 1996). Many patients the position of the measure (e. and the oxygen consumption 17.e.0 200 extrapolated to establish the beats per minute or a given number of beats are counted (i. The 100 pulmonary system responds to exercise by increasing the 90' i i i i i i i i i i i i i i rate and depth of ventilation to provide adequate gas 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 27 exchange.136 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT or tests that can be used.0 95 based on the linear relationship between heart rate.5 103 17.0 106 (Montoye et a!..0 113 gradually increasing aerobic activity until maximal exercise 15.. Exc also involved in cardiac and pulmonary rehabilitation pressure on the carotid artery can cause a reflex slow programs. . in addition to measures of ventilation and oxygen saturation. using a similar time period. Resting heart rate is 70 16. 2120 Cardiovascular responses include the ability of the heart ~ t to pump an adequate amount of blood. These programs require that the therapist the heart rate (White.0 180 fixed period of time (i. recorded with an electrocardiogram (ECG) during ex Both cardiovascular and pulmonary measures are dis­ in healthy subjects (Sedlock et a!. level of fitness. blood pressure. & Ehsani.5 109 to 75 beats per minute and increases incrementally with 16.0 120 capacity is reached.5 133 130 138 who is not fit will have higher submaximal heart rates and 12.0 100 intensity of aerobic exercise. 10. Heart rate compared with increasing oxygen con carbon dioxide eliminated. tion during exercise for fit and unfit individuals. (Fig. on the clinical applications of these tests.0 86 20. Heart rates are palpated either for a 10. 12. TABl F.0 129 presence or absence of disease. and using the same artery. Standardizing the proce An additional consideration for the clinician is that as much as possible should increase the accuracy of cardiovascular disease is the most common chronic disease rate assessments. either supine or sitti referred for physical or occupational therapy have overt or resting heart rates). method is much easier to use during exercise activities.

For example. The higher the heart rate . Port Washington . a bipolar le is recommended for exercise testing in pulmonary patie unless ischemic heart disease is suspected (American As Many clinical situations do not allow the therapist to ciation of Cardiovascular and Pulmonary Rehabilitatio palpate the pulse rate during an activity... single-lead system or 10 leads . 1984) (F 6-3). Gretebeck and colleagues (1991) report that a portable heart rate monitor they tested missed f beats but that its operation was influenced by proximity a computer or microwave oven. . there is little informati on the use of these devices in clinical settings with vario patient populations. (Courtesy of Polar CIC. the pulse rate may need to be taken heart rate ruler or other methods using the interval betwe immediately after the exercise stops. [1 9841. This is more frequently used in intensive ca cardiac. Heart rate telemetry system (Polar Vantage XL) showing heart rate wrist monitor and chest belt transmitter. Accuracy is improved if the pulse is located rapidty and the measure taken as quickly as possible. McManus. 1988). or pulmonary rehabilitation. 1983. A comparison of two-bipola r e lectrocardiograp 15 seconds for 4 hours). Some devices have computer leads to lead V5. These devices are composed of a chest band with a sensor and a telemetry receiver that can be worn on the patient's wrist or on the thera­ pist (Fig. Many devices can also be pro­ placements for a standard 12-lead electrocardiogram. Hanson . Trei et a!.g. 6-2)... ECG changes during exercise than a 12-lead syste Inc. 1988) (Fig. F . however. the difference is only about 4 percent lower than the heart rate recorded during exercise (Cotton & Dill. 1935: McCardle et a!. Sedlock et a!. 6- should be palpated within 15 seconds of exercise cessation ECG rate determination is accurate as long as interferen because the pulse begins to decrease rapidly after the from motion artifact is minimized during exercise by prop activity is stopped (Pollock et a!. Chest. 1988) Portable heart rate telemetry systems can also be used to record exercise heart rates. Generally. 1983). A bipolar system is less sensitive in detecting ischem FIGURE 6-2. 622) . 85. P. et at [19761. (A from Froelic grammed to record the rate at different intervals (e. however. the pulse two R waves provides the rate (Schaman. 6 or days can be determined . Lead placement either a bipolar. others are less accurate (Leger & Thivie rge . D. 1989). 1993). V. rhythm. 1988. Froelicher. 1993). Clinicians should monitor the acc racy of these devices for their own application and settin A more detailed record of heart rate. The heart rate can be displayed on the receiver and stored so that heart rate trends over time can be recorded.. Some of these devices corre. The 10-l the measurement time. 70. among other things. B. The rate is derived by averaging four beats A B over a period of time. Jensen. A. and driving. Although postexercise heart rates are ECG rhythm is the determination of the interval betwe significantly lower. 611-616. 1972). 1969.. NY) (Froelicher. Bipolar lead CM5 has a positive electrode on the f rib interspace (C5) and the other on the manubrium (M). A comparison of the standa rd 12-l interfaces so that a record of heart rates over several hours electrocardiogram to exercise electrode placements Chest. gelled electrod beats should be counted for 10 seconds and extrapolated to with secure placement. the shorter FIGURE 6-3 . the minute value. every V. Rate determination from the recording is possi when doing gait training with a patient who requires because of the standard paper speed of the ECG. My colleagues and I have found intertherapist reliability of palpated carotid pulses in elderly postoperative patients performing assisted ambulation to be poor (Protas et a!. which p vides a standard 12-lead ECG (Gamble et a!. B from Gamble . The number of skin preparation and the use of adequate.. An EC contact guarding. and t analysis of the ECG can be obtained by using standard EC monitoring. traffic signals .... The chest sensor must snugly attached to the subject and located on a rib or bo prominence to decrease the possibility of muscle interf ence. These devices have been found to be reliable duri assisted ambulation with elderly nursing home reside (Engelhard et a!.

Reprinted with permission from National Heart. Lung. exercise. 160. Table 6-2 provides a classification ?2 10 ?120 Very severe (stage 4 system for blood pressure. <D the cuff wrapped firmly around the arm about above the antecubital fossa with the arrows on aligned with the brachial artery. called the fourth phase diastoli The value of ECG monitoring during activity or exercise pressure. Although goes below the pressure in the brachial artery. become muffled. and Treatment of High Blood Pressure. identification of the arrhythmia cuff is released. American Heart Association. with a mortality rate between 1 in ations. every third or fourth beat.179 100-109 Moderate (stage 2) The procedure is a bit more complicated but. (1993).. The fifth report of the Joint Committee on D The arm should be bare. If a therapist is working with a patient known as the fifth phase diastolic blood pressure. and supported by a table or the clinician 's hand . Systolic pressure is the p between R waves are referred to as arrhythmias. 2 at risk for a cardiac event during exercise (American ClASSIFICATION OF BLOOD PRESSUR College of Sports Medicine. D some arrhythmias can be detected while palpating a pulse pressure can be read at two points as the pressur as an uneven pulse rate. 1994). 153. The cuff should be inflated qU about 200 mm Hg . who is at high risk for the fourth phase measure for accuracy. Heart rate determination from an electrocardiogram can be performed by using a rate scale for each heavy line on the tracing. tension The methods for taking resting blood pressure are "Not laking antihypertensive medication and not acutely ill. should be selected. Three cuff si available-child (13 to 20 cm). . for example. or 20 mm Hg above the expecte each R wave. Resting blood pressure values are used to deter­ tension mine hypertenSion. Archives o supinated .138 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT 000 o Lf) 0 Lf) 0 The arm should be positioned at the level of the h C') ~ ~ r-. the arm on which the blood pressure 1986) and 1 in 60. This may suggest that medically supervised available clinically) must be regularly calibrated acco exercise programs are relatively safe with or without ECG the manufacturer's instructions and is more difficul monitoring even though the risk of a serious event cannot be eliminated. especially if the reading differs by more Evidence from supervised cardiac rehabilitation programs mm Hg (National Heart Lung and Blood Institute indicates that the rate of myocardial infarction is 1 per Exercise blood pressures require additional c 300. 1995). First. The air in the cuff should be released slo equal intetvals between each R wave. The Kor in rhythm can occur sporadically or at a fairly predictable sounds are created by turbulence when the cuff p interval. Because th arrhythmias or coronary artery disease. 1995. is tension 180-209 110-119 Severe (stage 3) hyp accurate. adult (17 to 26 c large adult (32 to 42 cm)-and should be used for d body sizes. American College of and diastolic pressures fall into different categories.000 patient-hours. the rhythm should be regular with pressure. the pressure should consistently b sponses may indicate the need for a different exercise from either right or left. slightly flexed with the forearm Evaluation . An aneroid manometer (the most c exercise. Wh straightforward (Altug et al. a Institute. 1993. Clinicians should be aware of a numbe r of risk classification systems available for detecting individuals TABII : (. whose condition is unstable . Irregular intervals to 3 mm Hg per heartbeat. detecting abnormal re­ and left arms. since the patient is probably moving 790 . Palpating the artery before placing the stethosc enhance accuracy. FOR ADULTS· SystoUe DiastoUe (nun Hg) (nun Hg) Category BLOOD PRESSURE <130 <85 Normal 130-139 85-90 High normal Resting and exercise measurements of blood pressure. taken should be as relaxed as possible. The patient should be seated for at least 5 minutes.000 participant hours (Haskell. or when the sound disappears com is one of safety. or who has a recent be differences between the pressure readings for t history of cardiovascular disease. The first is the pressure when the can only be done with an ECG. if precise. At least two readings sh intensity or pace to lessen the cardiovascular stress. 154-183. A standing There are no published accounts of myocardia!l infarctions sphygmomanometer is preferred during exercise to or sudden death during physical or occupational therapy motion artifact. The stethoscope should be placed abo below the antecubital fossa over the brachial FIGURE 6-4. Variations when the first Korotkoff's sound is heard. Normally. are easily monitored by most clinicians. 140-159 90-99 Mild (stage 1) hyper just as heart rate. 1987). the highe Sports Medicine.000 patient-hours of exercise (Van Camp & Peterson . averaged. Med ici ne.

. and wheelchair ergometers are the m Reviews of the most common protocols are available common equipment used for exercise tests. Sinacore & Ehsani. Astrand & Rhymin mately eye level of the clinician. 1987. 1995). For example. The mode refers to the method or ty of exercise tests in relation to the detection .ities. the availability sumption when tested on treadmills . Submaximal te seems to be decreasing with increasing exercise (Dubach et are of more value to most physical and occupat. 1993).. A mercury manometer should be at approxi­ College of Sports Medicine. These applications Exercise tests can also be distinguished by the mode a are conSiderably different from the more usual application protocol of the test. Also in some popu Many standardized exercise or stress testing protocols tions . and bei maximal versus submaximal.2 and 6 percent (Shepha Reprinted with permission from American College of Sports Medicine. 1978). signs of myocardial ischemia occur. Naughton et aI. (3) treatment evalu­ 1993). be used to establish a treatment plan. The clinician shou blood pressure responses in some clinical populations . American College of Sports advantages and disadvantages for all of these devic Medicine. For be aware that submaximal tests when used to pred example. Treadmills. estimated by between 5 to 25 percent for anyo individual (Ward eta1. Taylor et aI. y can see that an extrapolation from several of the measu of submaximal heart rate and oxygen consumption for a EXERCISE TESTS versus an unfit individual can result in Significantly differ predictions of the maximal values.. or sympto cause the test to be terminated (Altug. ar prognosis of coronary artery disease (Bruce et aI. These criteria a Rate of inflation or deflation of cuff pressure Experience of clinician often difficult to obtain with elderly persons and individu Reaction time of clinician with various disabilities (Shephard .g. POTEN11AL SOURCES OF ERROR IN change ratio (RER = volume of carbon dioxide exhale BLOOD PRESSURE ASSESSMENT volume of oxygen consumed) over 1.) Baltimore: Williams & Wilkins. damaged brachial artery) cients of variation for maximal oxygen consumption ha been reported of between 2. 1994). the high of special equipment. ended when a predetermined heart rate or workload reached. Prediction of maximal valu most common applications of exercise tests in physical based on submaximall responses assumes a linear relatio and occupational therapy are (1) exercise prescription. and a plateau in the oxyg Improper cuff size consumption (an increase of less than 150 ml/min w Auditory acuity of clinician increasing exercise) (Froelicher. additional advantages of having normative values based The most common method of distinguishing exercise thousands of tests. and of equipment used. Table 6-3 summarizes potential sources of error therapists because these tests can determine the patien in blood pressure aI. 1989). disabiJ. The consumption may not exist. and (4) to ensure patient safety. There a elsewhere (Altug et al. having many potential workloads . Treadmills have t home care than in a hospital setting . crank ergometers.. 1993). . Submaximal tests can (1995).. (2) to screen pressure that falls with increasing exercise. 1993. The systolic pressure 1954. ation . Bruce et aI. a the measurements are made does not impact exercise assess the outcomes of the treatment. Abnormal responses include a systolic pressure that response and oxygen consumption during exercise does not increase with increasing exercise or a systolic predict maximal oxygen consumption . Tests can be classified as or running. the test environment. 1985). Blood pressure safety during an activity. and the characteristics of the pa­ estimates of exercise capacity are determined with trea tient. there appear to be no significant differences maximal capacity introduce considerable inaccuracy in beween morning and afternoon blood pressure during the estimate . a linear relation between heart rate and oxyg 1973. such as the elderly and individuals with chro have been developed (Balke & Ware. different tests may be needed for mills (McKiran & Froelicher. Americ with motion . 1959. The test selected may depend on the Individuals can achieve the highest maximal oxygen co purpose of the test . 1993. Wright & Sidney. Coe Certain physiologic abnormalities (e. Maximal oxygen consumption can be und walking in frail elderly persons (Engelhard et aI.. reaching ag Inaccurate sphygmomanometer predicted maximal heart rate. The time of day in which current status. diagnosis .. Repeated m Improper stethoscope placement or pressure sures derived from maximal exercise tests tend to Background noise Arm not relaxed reliable regardless of the population being tested . A number of criteria are used the least limited of the testing devices by local mus . and (3) to estimate cardiovascu should be taken again immediately if the systolic pressure endurance during functional activities. 1955).15 . ACSM's Guidelines for Exercise Tes ting and Prescription (5th ed. 1987). requiring the familiar activity of walk tests is by the endpoint of the test. cycle ergometers. ship between heart rate and oxygen consumption (Skinn (2) assessment of exercise endurance . 1995).. 1973). 1964. Submaximal tests a should increase with increasing intensity of exercise activ­ used (1) to determine the relationship beween heart r ity. If you look at Figure 6-1. 1995. therefore.

Cooper. Several factors influence the outcomes of exercise with either osteoarthritis or rheumatoid arthritis. . or 5 minutes. exercise program consisting of flexibility and strengt Fabian et aI. bicycle ergometers. The group not participating in the exercise program (Pe work increments used in the test changes the maximal et aI. 1979. a lower maximal oxygen consumption occurs 894 feet at 3 months after surgery and 1115 feet (Buchfuhrer et al. 1975. 16 percent grade) of a a standard error of the measurement of 135 feet. A more useful approach to a walk test for clinicia Arm-crank activities. . Pollock et al. progressive chair step test has challenging for a frail elderly person. .140 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT fatigue. A change in 5-minute walk distanc oxygen consumption reached. the increment years of recovery (Laupacis et al. 1976. For the fourth an stage. This may be an to be meaningful and greater than the variability of th accurate increment for a healthy young person but too A continuous. . 1968. Guyatt et aI. and arm­ feet (176 feet) during a 5-minute walk after a 3- crank ergometers (Bobbert. Tes between stage 3 (3. 1991). . might be after an exercise intervention. If the increment is too large elective total hip replacement was reported from or too small. 1985. higher maximal oxygen consump­ absolute increase in walking distance of 161 fe tions are reached with a repeated test. the subject continues to kick to the 18-inch while simultaneously raising the ipsilateral upper extr CLINICAL TESTS AND OTHER Heart rate is observed for each stage of exercise. On the other hand. The timed tests measure the distance covered when walking or running as fast as possible for 15. 1990. Nursing home p ergometry (Pollock & Wilmore . 1991) and that oxygen consumption and maximal heart rate are 20 to 30 walking distances are reliable in elderly postop percent lower during arm-cranking than treadmill or cycle patients (Protas et aI. ties should be based on upper extremity exercise tests. 14 percent grade treadmill reliability of a 5-minute walk test with elderly person elevation) and stage 4 (4. Kline et Classification Distance (fee al. It is recommended that exercise test and kick up to a target that is 6.. su Bruce protocol is the difference between fast walking up a ing that a clinical improvement should be at least 1 slight hill and running up a moderate hill. 1993). 12. 1963. there is a poor correlation between maximal morning with a walk test (Englehard et al. .. or 18 inches hig increments be individualized so that the test length is 8 to kicking rate should be controlled at l / second. 1960. are less familiar to most be looking at what a clinically significant improv persons and are more difficult to perform . Exercise programs for 6--4 presents some of the distances and the po enhancing cardiovascular endurance of the upper extremi­ clinical meaning of these values. right and left legs so that there are 30 kicks/second target is used for a 3-minute period. Maximal elderly women (Stanley & Protas. 9 . Average or above >1500 Fair (moderate impairment) 1000-1300 6 . For example. 1988)..4 mph . A tests.2 mph ... This makes it difficult to walking tests in several patient populations are va predict responses to upper extremity exercise from lower reliable if readministered during the same time of day extremity tests (Protas et aI. exercises and walking to improve endurance in 5 p 1996). . if developed for exercise-testing frail elderly indi the increment is too small. Higher distances and faster walking are Poor (severe impairment) <1000 associated with a greater estimate of exercise capacity. therefore. 1986).. In elderly persons. Ellestad et al. 1994).. Subjects sit comfortably in (Lipkin et aI. 1987). 1983). values achieved during upper extremity and lower extrem­ observations suggest that distance walked during ity testing (McCardle et al. . alter 12 minutes (Froelicher. 12 . 1993). ates (1988) reported an increase from 1598 feet to This is true for treadmills. 1987). however. Protas et al. 1996). walked significantly farther in the late afternoon than As a result. Several tests that are based on walking or SUBdECfS running for a specific time or distance have been developed (Balke. it makes the test excessively long (Smith & Gilligan.4 care administered in the home or in sites such as nursing homes and community health centers has enhanced the PERFORMANCE ON A 5-MINUTE WALK need for measures of exercise tolerance that do not require TEST FOR MlDDLE-AGm OR OlDER much equipment. whereas arm-crank or New York Heart Association Class II and III heart d wheelchair ergometers are used in testing individuals who My colleagues and I have found the 5-rhinute distanc have limited use of the lower extremities. 1996). 1993). 1987). Protas et aI. Price and The test-retest reliability of exercise tests is quite high. . such as patients moderately correlated with peak oxygen consump with spinal cord injuries (Pitetti et aI.. an elderly reporteci for 47 individuals with osteoarthritis af person may require more than one exercise test session to 8-week exercise intervention compared with a become familiar with the test (Thomas et al. Cycle ergometers are useful for testing individuals Distances covered in the 6-minute walk test can di who have gait or balance disturbances such as in Parkin­ tiate between healthy elderly persons and individua son's disease or cerebral palsy.. T MEASURES OF EXERCISE INTENSITY An increase in the physical and occupational therapy "lABJ f (). 1983).

M = 1) From Noble . very strong 18 • Maximal 19 Very.-:. with chronic disabilities seen by physical and occupatio 15. Exercise breathing frequencies that exceed strongly correlated with exercise intensity.VE max) 38 ± 22 L/ min body mass index to derive maximal oxygen consumption . heart rate. SEE = 5. G. local muscle maximal breathing rates occur in older individuals (Astra fatigue . 1994).5 Very . Ceci . ' . The resting rate in adults is generally 12 to either a 6 to 20 or a 0 to 10 point scale .. The accuracy of told that a 6 on the 6 to 20 scale is comparable to walking observation of resting ventilation is enhanced if the pati at a comfortable pace without noticeable strain. . One method of nonexercise estimation of maximal Respiratory frequency < 50 breaths per minu oxygen consumption has been suggested (Jackson et al. nor with an aging population . ~ ~ . very hard V0 2 peak = 56.. 1982.381 20 (age) . The patient is of inspiration to the end of expiration . I.81.. but the simplic may make this an option for estimates of exercise capac by the therapist. The ratings can be differentially used to indicate (Astrand 1960. The estimate is based on regression equations that Minute ventila tion/ maximal volun­ 72% ± 15 tary ventilation (VE/MW) use age.. Breathing frequenc lactate levels and ventilation .. and . or a combination of both. . A category ratio perceived exertion scale : Relationship to blood and These equations have not been validated with populatio muscle lactates and heart rate . 1985). clinicians. The equations are as follows 8 1 Very weak 9 Very light 2 Weak 10 3 Moderate Percent Body Fat Model : 11 Fairly light 4 Somewhat strong 12 5 Strong V0 2 peak = 50. J . inability to maintain the pace. M = 1) 15 Hard 8 16 9 Body Mass Index (BMI): 17 Very hard 10 Very.. . . Wasserman & Whipp.. Table 6-5 shows the rating scales used. and percent body fat or Breathing reserve (MW . knee pain . The scale values are 1960).552 (% fat) + 5. The clinician should keep in mind t lasts between 6 and 12 minutes. oxygen con­ breaths per minute are associated with ventilatory lim sumption. Observing respiratory rate can be easily done by m Noble et al. (1983). 523-528..70 ml/kg/min).363 + 1. v. R. B. Jacobs. whereas a is unaware that the therapist is noting breathing frequen 20 is the most difficult exercise the patient has experienced (Wetzel et al. very weak SEE = 5. a wide age range (20 to 59) and fitness levels. . .7 7 Very. . Physi RATINGS OF PERCEIVED EXERTION activity status (PA-R) is grossly classified according to subject's usual activity pattern .289 13 Somewhat hard 6 14 7 Very strong (age) . Medicine and S cience of Spo rts Exercise.589 (PA-R) .0.863 (F = 0. therapists.987 (F = 0. A fuJI breath occurs from the beginn the scales must be given before the exercise . volitional fatigue (particularly hip muscle fatigue) . The endpoints are considerable error may occur with these estimates.. Borg . . Tidal volume (VT) < Inspiratory capacity 1990).0. Low central exertion from the heart and lungs.0. An intensity necessary for a during exercise are most reliably measured with op cardiorespiratory training effect and a threshold for blood circuit methods.35 ml/Kg/m 6 0 Nothing at all than the model based on body mass index (r = . L i4J4!b . RESPIRATORY RATE Ratings of perceived exertion have been devised for use in reflecting individual exercise intensity (Borg. Breathing frequency increases up comparable to exercise that cannot be continued without 36 to 46 breaths per minute during maximal exerc stopping ..0.. blood tion (Wasserman et al. breaths per minute . 1983). This may be an easier TARLE 6-6 method to use than to teach a patient to take his or her pulse as a means of monitoring exercise intensity. " somewhat hard" or "hard" or between 13 and 16 on the 6 to 20 scale or 4 or 5 on the 0 to 1 0 scale (American College of Sports Medicine . A. P. very light 0. physical activity status. & Kaiser. for the 0 to 10 scale. Much of NORMAL MAXIMAL BREAnDNG VALUES the application of ratings of perceived exertion have been DURING EXERCISE with healthy normal subjects and individuals with cardio­ Value Rate vascular disease.513 + 1. Normal maximal ventilatory breath lactate accumulation can be achieved at a rating of values during exercise are shown in Table 6-6.921 (PA-R) . 1995). I have found that many frail nursing home residents can perform this test safely.754 (BM!) + 10. 1975).. An explanation of . The percent body fat mo Original Scale Revised Scale is slightly more accurate (r = . or 70 percent of age-predicted heart rate is reached .

Pierce et al. an reserve. however.. The maximal tidal volume is I-Able to count to 15 but must take one additional breath between 50 and 55 percent of the vital capacity for men 2-Must take two additional breaths to count to 15 3-Must take three additional breaths to count to 15 and between 45 and 50 percent for women (Cotes. The maximal minute ventilation is between 50 and 80 percent of the maximal voluntary ventilation (Hansen et al. " huffing ").to 8. viscoscity or e when the demand for ventilation outstrips the patient's ity of the sputum. . does not use all of the lung capacity but only uses up to 70 percent "From Hansen. and submaximal exercise p mance has been shown to be poor in individual Dyspnea is a primary symptom that limits exercise in chronic bronchitis (Mungall & Hainesworth.9 to 2. where ventilation increases faster than the definitions of dyspnea intensity (Table 6-7).0 L during maximal exercise (Astrand. noticeable to patient but not to observer inhalation or exhalation. The difference Pulmonary function tests provide information o between the maximal voluntary ventilation and the maxi­ functional characteristics of the lung. 1974).Severe difficulty. and the amount of sputum expect . maximal exercise tidal volume approaches 100 percent of the inspiratory capacity. The highest values are O-Able to count to 15 easily (no additional breaths necessary seen in tall . and gender. For instance. 1982). 1975. noticeable to observer ml ± 0. lung volumes.) With harder sensation. tachypnea (rapid breathing) or hyperpnea (increase The minute ventilation is the product of the tidal volume tilation) (West. 1960). linearly with increasing exercise until the ventilation thresh­ methods are based on ordinal scales and opera old is reached.0-second period . In S . many rehabilitation settings. 20-year-old men . there is no correlation between regional lung pnea is the subjective sensation of difficulty with breathing. age . increased minute ventilation is accomplished by increased breathing frequency (Spiro et al. walking ability. In individuals with restrictive lung disease the Department. The maximal tidal volume is generally The patient is asked to inhale normally and then to count out 70 percent of the inspiratory capacity (Wasserman & to 15 over a 7. During mild to moderate exercise .). Downey. 215). exercise is exercise testing and prescription (p. 1979) individuals with pulmonary or cardiovascular disease . patient cannot continue absolute value of the maximal tidal volume is related to an DYSPNEA LEVELSt individual's height . N. For a review of individual tests and me capacity and what is used during exercise. or the functional difference between respiratory exchange. exercise . but can continue 1. 1985) . under normal circumstances. . The relationship between pulmonary function DYSPNEA SCALES sures.5. PULMONARY FUNCT:ION TiESTS The maximal voluntary ventilation is the volume of air that can be breathed in 12 to 15 seconds. P. the clinician the minute ve ntilation is increased primarily by increasing keep in mind that it is difficult to measure a sub the tidal volume (the depth of breathing. Pate et al. Resource manual for gUidel the fact that . 1984). Minute ventilation increases scribed for rating the intensity of the dyspnea. Physical T not the lungs. Any shortness of b can be graded by levels. These tests m mal exercise minute ventilation reflects the breathing air flow and air flow resistance. 1974). Dys­ wise .50 2-Some difficulty. R. 1983. Whipp . Exercise . The resting tidal volume is 0. obstructive lung disease (Bye et al.10 ml. These oxygen consumption . This is another way of looking at Painter. Pulmonary function tests have limited applicati 1968) . rehabilitat terventions for individuals with chronic lung disease do not change pulmonary function values of diseased even though the patient may demonstrate improved tion. suggesting that lung capacity is implicated in limited exercise when restrictive lung disease ability to respond to the demand and is distinct is present. (1 988). Clinical exercise testing . Philadelphia: Lea & t From Physical therapy management of patients with pulmonary limited by the cardiovascular and musculoskeletal systems . of the available capacity. Dyspnea occurs expiratory technique (e. 4-Unable to count Spiro et al. (Eds. CA: Ranc hos Los Amigos Med ical Center. even at a maximal value. The breathing ment issues related to pulmonary function tests the reserve tends to be reduced in individuals with chronic is referred elsewhere (Protas. R. The 4. .142 UNIT 1WO-COMPONENT ASSESSMENTS OFTHE ADULT TABLE 6-7 TIDAL VOLUME AND MINUTE RATING OF DYSPNEA VENTILATION DYSPNEA INTENSITY" Tidal volume is the volume of air breathed in one I-Mild . . have not been well validated. . Tidal volume can increase to an average of 3-Moderate difficulty. 1975). tion clearance as measured by a radiolabeled techniq The patient often reports being " short of breath " or not maximal expiratory flow during either a cough or a being able to "catch" his or her breath.g. Several methods have bee times the breathing frequency .

1989). As exercise increases. Likewise. tional status of an individual patient that cannot be provi On the other hand. VE/V02) gives a nonin stable. In essence. the metab interventions (Derrickson et aI. The resp tive muscle training or abdominal weight training in a tory exchange ratio (RER) is the ratio between exha group of individuals with cervical spinal cord lesions. . VE/VC0 2 . incremen either cycle ergometer exercise and one bronchial hy­ progressive exercise testing protocol offers the chanc giene treatment or three bronchial hygiene treatments observe cardiopulmonary responses under controlled alone each day during the hospital stay (Cerny. ercise conditions. sive. and metabolism.20 VE 20 44 1200 VEN02 30 44 Pet02 106 122 Watts I: 43 77 1000 800 FIGURE 6-5.74 m VC02 RER PET02 VE ml/min mmHg o ¢ 2000.. The VE!VC02 value is normally betw Although exercise tests have been previously discussed 26 and 30. Using a standard. 5t.) V02 ml/min . Paul. The value of demands increase and the pulmonary system begin pulmonary function measures to the clinician may depend buffer the blood pH by eliminating more carbon diox on the type of patients seen. 1975). gas exchange.70 at rest (less carbon dioxide produ in pulmonary function values for both treatment inter­ per unit of oxygen) and increases to greater than 1 : 1 w ventions. 1800 1.40 VT V02 Max 1600 ¢¢ Time Min 5:47 7:37 V02 672 995 ¢ ¢ ¢ RER 0. A comparison of the ventilatory equivalent for carbon di­ 600 oxide ryE!VC02) and the ventilatory equivalent for oxygen ryE!VO z) dur­ 400 ing increasing exercise. The ventila­ tion threshold is the point at which 200 'I/E!VC02 begins to increase.5 'kg BSA: 1. what the clini in individuals with cystic fibrosis who were hospitalized for wants to know is whether a patient 's ability to function an acute exacerbation of the disease and who underwent to exercise is limited. A carbon dioxide and oxygen consumed (VC0 2/V02)' 7 -week period of training produced significant increases RER is normally 0. pulmonary function tests have been used to Several pulmonary measures provide information on assess treatment outcomes after either inspiratory resis­ ventilation. indirect measure of ventilation-perfusion (VA matching or the physiologic dead space to tidal volu ratio (VD/VT). The clinician may need to monitor the equivalents for carbon dioxide and oxygen (mi pulmonary function of the individual with a high cervical ventilation/carbon dioxide exhaled.. as well as on the inter­ (Wasserman & Whipp. several additional comments are appropri. (Cour­ tesy of Medical Graphics Corp. Elevated ventilatory equival Name: DOE.92 1. chronic obstructive pulmonary disease. 1994). MN.that maximal expiratory flow during a cough or forced Exercise tests with the observation of pulmonary expiratory technique and the sputum production provide exchange provide important information about the fu no guide to the efficacy of secretion clearance in the lung . Observing the ventila ventions used. The ventilatory eqUivalents normally decrease until EXERCISE TESTS ventilatory threshold for VE!VC02 or lactate threshold VE!V02 (Fig. and min spinal cord lesion more closely than the individual with ventilation/oxygen consumed. 6-5) . pulmonary function values do improve by pulmonary function tests.0cm Wt: 73. but there were no differences between the two maximal exercise. 1992). while the VE!V02 is between 22 and in this chapter. JOHN Temp: 23 Pbar: 746 DS: 115 Date: 8/16/ ID: 89-20795-4 Sex: MAge: 57 yr Ht: 157. (Wasserman et aI.21 1400 HR 125 149 1.

Thus. can be breathed in 12 to 15 seconds.emia-Decreased partial pressure of a The degree to which arterial blood is oxygenated (partial oxygen. Fifth phase diastolic blood pressure-Blood sure when the Korotkoff's sounds disappear comp Fourth phase diastolic blood pressure-B OXYHEMOGLOBIN SATURATION pressure when the Korotkoff's sounds become m Hypox. and stage durations. such as a heart rate of 150 or with the appearance of significant symptoms. versions that use finger-probe sensors may be more accurate than devices that use earlobe sensors (Men­ Percent body fat-Measured by skin calipers or i gelkoch et al. condition that can be harmful to a patient. The estimates of Sa02 when ume of exhaled carbon dioxide to volume of o saturation is below 78 percent tend to be inaccurate and consumption. Hypoxemia is decreased Pa02 and is a indicating maximum exercise. Body mass index-Weight in kilograms per height in TIdal volume-Volume of air breathed in one inha meters squared. The last stage adds reciprocal arm movements with needs to be exhaled. Dyspnea scales-Numeric ratings of dyspnea intensity. even within the same model. Submaximal exercise test-A test which end predetermined endpOint. Individuals with obstructive lung disease often have Exercise test protocol-Standard combinati \IA/Q mismatching and have increased ventilatory equiva­ intensities. that is attributed to fat. 100 mm Hg for a 20-year-old to 80 mm Hg for an 80-year­ Maximal exercise test-Maximal ability to pe old (Marini. the Pa02 values may to continue the exercise and reaches several other c increase slightly. or 12 m interval between each R wave on the ECG. however. kicking. outside the intensive care minute. however. Ventilation threshold-Ventilation increases Chair step test-A progressive test with four levels or than oxygen consumption.. dioxide consumed. which determine the percent of body w greater than or equal to 85 percent in nonsmokers. Pulse oximeters are a noninvasive method of ration of hemoglobin in arterial blood. Ventilatoty equivalent for oxygen or ca Dyspnea-The subjective sensation of breathing diffi­ dioxide-Ratio of minute ventilation to oxygen or c culty. the value of these Respiratoty frequency-Number of breath devices is limited in individuals with severe pulmonary minute. In one value is generally 95% of higher.144 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT indicate either hyperventilation or uneven \IA/Q (increased Exercise test mode-Type of equipment used fo \IDNT). Walk test-An indirect means to measure cardiova endurance in the clinical setting by noting the di Electrocardiogram rhythm-Determination of the walked in a fixed period of time such as 5. Pa02) is reflected by the Korotkoff's sounds-Created by turbulence wh oxyhemoglobin saturation of arterial blood (Sa02)' Arterial blood pressure cuff goes below the blood pressure oxygenation at rest decreases with age from approximately brachial artery. 1987). with the patient walking as far and as fast as possib . should select activities that will reduce motion artifact (cycle Respiratoty ex. treadmill). The individual is no without cardiopulmonary disease. Accuracy is improved when Sa02 is ance devices. The Sa02 values at rest are 95% or higher and do not normally decrease Maximum voluntatyventilation-Volume of a with exercise (Wasserman. review it was suggested that the accuracy of pulse oxime­ Partial pressure of arterial oxygen (Pa ters is variable. Approximately the poin stages conducted sitting by kicking to increaSingly higher increasing exercise intensity where more carbon d targets. the Pulse oximeters-Noninvasive measure of oxy clinician should carefully secure the probe to the finger and globin saturation. Measured in liters per minute. Breathing reserve-Difference between maximum vol­ Ventilation perfusion matching (VAlQ)-Ra untary ventilation and the maximum exercise minute alveolar ventilation to pulmonary circulation. ventilation. stage progressions. 1994). Because these devices are most useful during exercise. lent values. unit the use of catheters in most clinical situations is Oxyhemoglobin saturation (Sao2 )-Oxygen impractical. disease. pressure of arterial oxygen. Degree of arterial blood oxygenation. 1994). can miss undetected hypoxemia. or exhalation. During heavy exercise in individuals exercise with large muscle groups.change ratio (RER)-Ratio o ergometer vs.6. The Sa02 can be monitored using an indwelling catheter Minute ventilation-Volume of air breathed to draw blood samples. The resting n monitoring Sa02 under a variety of circumstances.

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the first of whom was Philippe people with physical disabilities. OTR/L Elizabeth B. The emphasis of moral treatment was humanitari­ treatment period. who organized what is now known as ill were thought to be demonic and a danger to society and. were totally isolated from their environment of The "arts and crafts" movement followed the mo origin. Psychoso­ cial assessment addresses the loss of functional performance in areas of work. Treatment approach is determined by results from the psychosocial functional evaluation. and the vocatio Numerous people were major promoters of the mo­ approach became the basis for occupational therapy ral treatment movement. The diversional could control his environment and improve his life on proach became synonymous with the therapeutic pract earth" (Hopkins & Smith. Promoters of the arts a Pinel. The moral movement occurred during a time of educational and therapeutic with a vocational and political change and was based on the belief that "man diversional approach . Occupational therapy promotes the concept of ho­ lism in treatment. MS. American Psychiatric Association (APA). a physician considered to be Moral treatment evolved in the early 1800s in response to father of American psychiatry and the first to use mo unbearable and inhumane conditions that existed for treatment in the United States. Psychosocial dysfunction can be a result of physical illness or a psychological condition. the movement was viewed as b anism. A strong influence in England was the Tu HISTORIC PERSPECTIVE family. Assessment of psychosocial dysfunction may be performed indepen­ dently or as a component of a major functional performance evaluation. and Dr. included Benjamin Rush. Later. who promoted reform throughout Europe and crafts movement engaged mentally and physically ill in 1 . play or leisure. p. MSW. ACSW/L. 1993. CHAPTER 7 Psychosocial Function Melba J. as such. of occupational therapy in psychiatry. who prOVided mentally ill individuals with cloth educated them in self-control . OTR/L. and interpersonal and emotional behavior. Implementation of the holistic approach involves the use of a variety of occupational therapy theories and assessment techniques. Devereaux. Those identified as mentally Kirkbride. operating under the belief that full recovery from illness requires both physical and psychological treatment. respectively. FAOTA SUMMARY Since the early 1800s. America. 27). the assessment of psychosocial functional per­ formance has existed as a philosophical foundation for occupational therapy in support of "holistic" therapy. Thomas people who were mentally ill. and engaged them Ocupational therapy for psychosocial dysfunction dates employment situations for self-reliance. Arnold. Other support back to the era in which "moral treatment" was advocated.

Assessment of performance may be requi DYSFUNCTION for one or several performance components or areas. doing housework. and travel Allen. managing money and time. 1994). instrumental activities of daily living (IADL). The writings and clinical contributions illness or disease. 1994). wo orientation. and the model of human occupation by Gary (Hopkins & Smith. Fidler. also a cofounder of the therapy" (AOTA. polite. preparing a meal. It is the ability to be assessment process being utilized and would gUide able to take care of one's daily needs in a responsible and overall treatment approach. the occupational therapy approach behavior depend on emotional. occupational therapy assessment of When effective psychosocial function is interrupted interpersonal skills and emotional behavior is specifically psychiatric or physical illness or by an injury to the bra addressed. toileting. the effects of a psychiatric illness. a physical illness or accident." Slagle's treatment logic structures are responsible for functions of the br approach consisted of training in socially acceptable con­ referred to as occupational performance compone duct (Hopkins & Smith. cog abandoned (Mosey. both perspectives were eventually three main categories: sensory motor components. tive integration components. If the primary self-care skills of feedi and Occupational therapy: A communication process in hygiene. 1985. or a neurologic impairment that affects the function of the brain ACTIVITIES THERAPY AND ANALYTIC can result in a range of performance difficulties or psycho­ FRAMES OF REFERENCE social dysfunction. self con­ combined with environmental adjustments. Those areas affected can be revealed throu psychosocial assessment processes as a part of the to PSYCHOSOCIAL FUNCTION­ evaluation. Recovering from a mental illness or a psycholo Meyer. These neu trolled. and dressing are lost due psychiatry (1963). clean. Major proponents of this new perspective and play or leisure activities. to that of "habit training. Additional performance skills t in psychiatric occupational therapy that continues to exist can be affected by functional impairment are known as a component of present-day approaches (Mosey. and psychodynamic theoretical perspectives of Sigm . had progressed from a symptomatology perspective pro­ According to "Uniform terminology for occupatio moted by William Rush Dunton. 1984). co­ unconscious actions leading to need fulfillment. Because habit training and (American Occupational Therapy Association [AOT moral treatment neglected the affective and interpersonal 1994). and emotionally restrained. The lowest level of functio were Gail S. neat. are tasks that are vital to total functional independence a The remainder of this chapter presents three major involve greater complexity in skill and cognitive capabil psychosocial theories and examples of assessments used in Examples of IADL include following a medication routi occupational therapy: the analytic perspective of the shopping. 1986. Occupational performance components incl experiences of clients. A return founder of the occupational therapy profession. These IA 1986). Levy. the use of activities a successful psychosocial functioning involves both emo­ therapeutic process was first based on the psychoanal tional and cognitive components (Allen. Finally. a loss of independent functioning made by the Fidlers provided a stable treatment foundation occur (AOTA. An individual may experience the loss of this harmony for various reasons. safe manner. Slagle's cognitive functioning is thought to be a result of the natu concept of healthy habits included behavior that was healing process of the neurologiC structures of the br "industrious. Fidler and Jay W. 1993). 1993). which encouraged self~reliance." Habit of an analytic process that addresses ego functioning a training was introduced by Eleanor Clarke Slagle. the cognitive disability perspective by Claudia telephone. How services. to that of a psychoanalytic and SOciological performance areas: activities of daily living (ADL). perform daily routine tasks and the manner in which Guided by changes in thought by the APA on the etiology socially interact with others and exhibit psycholog of mental illness. Literature from a variety of sources indicates that In occupational therapy. human function occurs in th profession. Specifically. the occupational therapy approach logical components (AOTA. usin Fidlers. Mosey. The chosen frame between one's psychological capability and the skills reference would support the underlying purpose of required to perform routine daily tasks. 1994). coauthors of independence in humans is the ability to perform ba Introduction to psychiatric occupational therapy (1954) self-care needs. psychiatrist and founder of the occupational cal condition is considered by some theorists to be a re therapy profession. T type of psychosocial assessment performed should Successful psychosocial functioning requires harmony supported by a frame of reference. grooming. and psychosocial or psyc By the mid~ 1900s. hard working. Perry & Bussey. 1986). promoted by Adolph abilities. as well as cogniti progressed from moral treatment.148 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT viduals in the production of various useful goods and 1993. some aspects of the occupational performance com nents and occupational performance areas may beco affected. Kielhofner.

1986). object relations..37-62). e. To encourage . ited variety of possible responses. Mosey (1986) identified categories that could serve to be an eclectic process involving the synthesis of sev as individual function-dysfunction continuums: (1) intra­ theories. The patient's ability to return to the change is also unclear and relegated to examples of h community at a productive level is thought to occur only occupational therapy as a modality could be included in after successfully working through the intrapsychic conflict overall treatment process (Mosey. and symbolism" (Mosey. 1986). Azima. 1970. one that permits an almost un tion. the object relations analysis is conside able. The complexes c process must go beyond logistical dialogue that reveals great Significance. cognition. since dysfunction is defi them into conscious awareness. Because this framework is eclec conflict areas involving maladaptive ideas about self or the theoretical base involves several concepts: "nee others. or behaves (Bootzin et continuum were similar in focus to that of other psyc aI. aggression.. therapy intervention is based on the disease and med Mears & Gratchel. ents. (Fidler. 1993).. will." Almost any experie believe that effective treatment in the psychoanalytic can form the nucleus of a complex. things. 1963). Mosey. Object relations analysis as a part of the analytic fra From the psychoanalytic perspective. 1954. These the medical model defined most health profeSSions. 19 omy. Jung. as they serve as indices for the funct the origin of intrapsychic conflict to include symbolic dysfunction continuum. Fidler and Fidler (1963). In the object relations analysis. According to Mosey (1970. Consistent with the pist to allow repressed content to surface and to achieve sence of specific behavior identification. They ated with some type of conflict. and ideas (Bruce & Borg. 1986). 19 (1982). Three evaluation catego behavior. havior. 1982. 1982). a return to relations. 1986) have made pp. (2) nondevelopmental types of intrapsychic cation and self-actualization are explored. and Mosey (1970. drives and objects. trust. The distinguishing feature of pro nesse that is necessary for insight that leads to the tive techniques exists in the assignment of a relati resolution of intrapsychic conflict and need gratifica­ unstructured task. significant therapeutic contributions using the analytic Mosey (1970. or problems with Fidlers. the process need fulfillment. communication. unconscious conflict. thera­ Assessment Instruments. a result of an inferiority complex. The clinician is required to interpret termed "loose association.g. 1982. analytic theorists. dysfunctional be­ of reference is a process based primarily on the contr havior among patients varies Significantly and does not tions of theorists such as Freud. Fidler of complexes." in which the patient is able to individual's behavior according to the theoretical base freely express thoughts without judgment from the thera­ function-dysfunction continuum. and love and self esteem.Mahler. Masl present in any particular order because dysfunction is Mahler. Le. The establishment of insight is thought to occur are offered: the patient's relationship to the therap through an analytic process that also includes what Freud group. 1973. and symb normal function is accomplished by exploring the origin activity. Average intelligence is required (Fidler & Fidler. Hemp for the thinking. feels. affect. and oth considered to be any form of behavior that is unexplain­ For this reason. t intrapsychic conflicts are believed to be established during theoretical approach included emphasis on rehabilita childhood and are thought to be a result of interpersonal and the resumption of responsibilities within the envir interactions that at some point involve one or both par­ ment (Fidler & Fidler. Objects conflict such as conflicts concerning love. 1986). 1982. 19 insight on the part of the individual about the nature of the Gallatin. and psychological fi­ 1982. Gallatin. thus developing greater as any unexplainable form of conduct (Bootzin et aI. 232) defines a complex as "a gesta frames of reference that reflect the treatment of intrapsy­ repressed affect. Mosey.. Although their work occurred during a time w object relations involving strong emotional ties. hate. problem-solving. The intrapsychic conflicts are thought to be the The Fidlers' theoretical base and function-dysfunc impetus for how one thinks. attending and the forma In occupational therapy. and others (Bootzin et aI. and activity. 1963. gratification engage the patient in attempts to alter maladaptive be­ needs for safety. p. 1986). Fidler and Fidler. Examples of the complexes activities that provide further confirmation of conflict and clude feelings related to inferiority. and others. Naumberg. 1973. 1979). energy and intrapsychic content ass chic conflict through the use of activities and objects. The pioneers in occupational ther intrapsychic motivational conflict of a sexual or aggressive treatment using the analytic frames of reference were nature. interperso According to the psychoanalytic theory. auton­ defined as people. Identification of specific behavior is not poss and symbolism of the unconscious conflicts and bringing under this frame of reference.. 1993. Mosey. and (3) intrapsychic Mosey. the individu psychic conflict that is developmental in nature accord­ relationship and interaction with objects for need gra ing to Freud. The psychoanalytic theorists model focusing mainly on the pathology and nature of postulate that abnormal behavior is a result of unconscious mental illness. Fidler. trust. Projective techniques h peutic intervention based on the analytic frames of ref­ been the primary evaluation approach utilized in occu erence is most effective with patients who possess a high tional therapy with the psychoanalytic treatment conc degree of cognitive ability.

" Cogn projective testing. Magazine Picture Collage: Pictures are cut out of injury to the brain. Allen ruled out theories 3. Draw-A-Person: Projective drawings of people. the procedures are disguised in that the function involves the following occupational performa individual is usually unaware of the type of psychological components: arousal. In situat in which this integrative effect is absent. from Western Psychological provide measurable results of cognitive performance Services. or Mosey (1986. 1993. traumatic brain injury. these a 1982.) on the belief that cognitive disabilities are due to illnes 6. disability impairment. and a person. H. B. 1981). a tree. the occupational performance areas. 1982. cognitive dysf 1. process followed by interpretation of the examinee's integrative effects of the cognitive components result in performance by the examiner.) Based on her research and on accounts published 2. and functi structure. (Developed by Buck. capability. from Hopkins & Smith. dexterity. cognitive ability that influences normal per tion about attitudes. and Soviet psychologists. memory. Los Angeles. finger­ learned that the manifestations of psychiatric illne painting. and creativity. suggestibility. of a house. AOTA.) (Allen. and clay mod­ substance abuse. 45) defines cognitive function a structures the situation. other theorists. These abil The following are examples of psychoanalytic projective result in the capacity to exhibit independent functionin techniques used in occupational therapy (Hemphill. 1982. Object History: The examinee is asked to remember effect on the brain. general instructions are provided to the examinee. (From syndrome. To this end. 1993. 1982. A I: battery using pencil drawing. 464). acute and chr Hopkins & Smith. will reflect fundamental aspects of cortical process that involves the use of information for psychological functioning" (Anastasi. According to Allen (AOTA.) Use of the CDM requires an understanding of nor 9. and developmental disabilities. attention. indepen­ nently affected. results in a variety of effects on cognitive ability. and clay modeling. 1988).) organic brain syndromes. from Hemphill. concen interpretation that will be made of the responses (Anastasi). had physical disability origins. 1994. (Developed by Hemphill. attention span. personality disorders. Claudia Allen was initially designed as an evaluation The examinee is required to discuss each task pro­ treatment format for clients with psychiatric illnes duction. finger painting.) severe functional disability. With e eling with an interview-discussion to gain informa­ condition. 150 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT unlimited variety of possible responses. mood. cognitive and social mance of human activities may be temporarily or per skills. Goodman Battery: Consists of tasks of decreasing human function. 1972 and by Ross. The CDM places emphasis on the f dence. from tional consequences of cognitive impairments. In purpose of thinking and problem solving. Moyer. problem solv Projective testing involves an interview and discussion and learning (AOTA.) clients with psychiatric illnesses led to the developm 5. Projective COGNITIVE DISABILITY testing is based on the hypothesis that "the way in which the individual perceives and interprets the test material. p. Purpose is to assess cognitive and affective independence. resulting in limitations in functi available magazines and glued on a sheet of paper. presumption that with cognitive impairment. The examiner makes interpretations of the Further refinement of the model led to its use in examinee's performance and discussions. p. plaster sculpture. 1970. 1971. recognition. only brief. Although the nature of the illness or in (Unstructured reporting format by Buck and Lerner. The cognitive levels mea . Diagnostic categories may inc something that was important or valued at earlier cerebrovascular accidents. (Developed by Chemin. enabling the Hopkins & Smith. (Developed cognitive levels that are graded from normal functionin by Evaskus. The Fidler Diagnostic Battery: Projective testing tion exists. eating disord tile. prim 8. that consists of presenting the examinee with three The cognitive disability model (CDM) developed sequential tasks. Shoemyen. figure drawing. drawing. Allen presents the CDM in the form o ego assets and deficits affecting function. vidual to carry out his or her daily living skills. acquired immunodefici periods of life and also to explain why. intellect. 1993.) diagnostic category may be any condition that can hav 7. Abreu & Toglia. Azima Occupational Therapy Battery: Projective Piaget. Los Angeles. finger painting.) ties would be permanently impaired. 1977. Battery: Projective test with finger-painting involved learning and normal memory based on and tile. schizophrenic disorders. 1985. 1987). 4. CA. pursuit of evaluation and treatment methods that w (Developed by Urban. from Western Psychological Ser­ dation of the CDM is a neuroscience approach that is b vices. the theoretic f revised manual. tion. ability to problem-solve and make decisions. and clay. Shoemyen Battery: Contains four tasks: mosaic affective disorders. orientation. 1988). (Developed by Azima revealed strong similarities to those of medical illne and Azimaj from Hemphill. (Devel­ treatment of a variety of clients whose cognitive disab oped by Fidler and Fidler. from Hemphill. House-Tree-Person: Freehand drawing by examinee of the CDM. CA.

feeding. Evaluation and performance to the descriptions under each task. The following is a summary description quick assessment of a person's ability to function. so objects in periph­ function. familiarity and the absence of biases. with Cognitive Disability Model Assessment Process. By performing task analysis. Patient lacks awareness patients who are diagnosed as having senile dementia. so three function (Allen. and walk­ In a study of hospitalized patients diagnosed w ing. that is administered to either the patient or the caregiver or Research. The A of function-dysfunction for each level ( information is processed during task performance. With own behavior. 1987. The instrumental scale has eight tasks: housekeeping. Level five: Patient demonstrates more flexibility in Allen Diagnostic Module (ADM). The leather acti is graded according to complexity. and the Through task analysis. structed to imitate hand-clapping actions. process. training is usually impossible. and words to gUide Task analysis is also a viable part of the COM. but food and water though each stitch involves repetitive manual activity. toileting. when the patient is gUided. complexity of task procedures step by step. 1985. dreSSing. Validity of the ACL was determined by ra . as he or she is unable clinician with the opportunity to observe general functio to preplan or anticipate the consequences of his or performance as well as the ways in which the indivi her actions. which is a set of attending to elements of the physical environment. 1985). schizophrenia. Patient is compliant. Level three: Actions are directed toward physical patients functioning at levels one. To reflect each of the cognitive levels. Level one: Patient does not respond to the environ­ running stitch (levels two and three) to a whip stitch (l ment. the physical scale and the cognitive deficits. patient's cognitive level of functioning. Research done on the COM involve instrumental scale. 1992. Use of the AOM provides exploration and trial and error. The physical scale contains six tasks: study of four patient populations. 1985). Lack of pat 4. one or two inaud completion. The patient is have a destructive nature. toileting. By matching the patient's reported or obser natural healing or the use of medication. (Allen. ranging from a sim 1. It includes 14 support of the effectiveness of the COM in determin routine tasks in two subscales. Arousal level is running stitch is thought to be more universal in term very low. repetitive. The COM describes six levels of cog­ The ACL test is a screening tool designed to provid nitive dysfunction. thus. and three. Level two: Patient often exhibits unusual postures. Allen and Reyner. A la gestures. Change is gradual. Each of the correlation. The behavioral desc use the COM. and telephoning. The LCL test was designed to assess the performanc 3. Gross motor activity version of the ACL is also available for individuals w for proprioceptive experiences may be exhibited visual impairments (Allen. eliminate procedures that patients cannot do while per The rou tine task in ven tory (RTf) is an interview process ting them to use remaining abilities. task analysis is a systematic process of identifying based on ability to associate with symbolic cues. spending money. Allen (1985) cited several research finding by observation of the patient's performance. Earhart and coworkers (1993) developed 5. traveling. Motor behavior is spontaneous and COM. Level six: Patient is able to calculate a plan of action used follOwing the ACL but prior to the RTI. three consecutive audible responses reveal l eral field cause confusion. Attention is concrete. the clinician must acknowledge that im­ tions may also serve as potential observations of per provements in cognitive levels of performance are due to mance. the ACL was found to have an interr preparing food. may process new information. He or she learns by to their cognitive complexity. the therapist determining functional level of performance: the routine guide the patient in accomplishing routine daily ta task inventory. usually an exact match of a sample responses or other imitated movements reveal level provided.99 with the Pearson product-mom laundry. shopping. bathing. images. as well as make discharge recommendati possess. Cognitive Levels. routines can be followed and situational training can To assist the clinician with the assessment and treatm occur. of the connection between his or her actions and goal LCL uses the imitation of motor action to assess achievement. standardized craft activities that have been rated accord but the deficit is still present. e objects in the environment. intake remains a primary concern. grooming. and may patient's cognitive level of function. two. The administra 2. Level four: Patient exhibits actual attempt at task response reveals level one function. involves the use of a leather lacing activity to identif Allen et aL. The AOM is intended to 6. the Allen Cognitive Level (ACL). or repetitive motions. treatment are directed toward making necessary adjust­ therapist is able to determine the patient's level of cogni ments to the remaining cognitive abilities a client may functioning. Actions are guided. 1985). including primary aspects such as eating and four) to a more complicated single cordovan stitch. doing reliability of r 0. taking medication. The emphasis on those steps that the patient is unable COM involves three phases of assessment that are used in perform. and to use symbolic cues. 1985). and scoring of the ACL have been standardized. any activity can be adapted lower cognitive level (LCL) test (Allen. 1991).

Before establishing validity. This revised mo and others were greater indicators of cognitive ability than ~()ntinues to view the human as a system but as one tha was the ACL (AOTA. Backm revealed a significant but low correlation between cognitive asserts that without standardization." originally published fying the schizophrenic patients as being more severely Kielhofner and Burke in 1980. 1988). Because of the precise descr schizophrenic subjects. 1986). although some stud available following discharge. Kielhofner (1995) refers to this proc Physical Self-Maintenance Scale and the Instrumental as self-organization through behavior. the interrater reli­ tion of performance. dysfunction and involves synthesizing other theoreti . clude Matsutsuyu. respectively. with n = 32 (Allen.05). 1987). The results revealed Pearson r correlation be­ tween all test scores for admission ranging from 0. and occurs because of lations investigated their similarities and differences in ur. the RTI's greatest function and pay earnings at the time of discharge is to provide an explanation of a client's ability (or disabil (r = 0. identi­ "A model of human occupation. level of education. which indicated that the ACL was able to human occupational behavior and occupational thera differentiate between the two patient populations. The dynamiCal concept is based Lastly. with patients diagnosed with major depression to investi­ gate cognitive impairment and its relation to ability to function.24 (n = 32). 1985). 1985. Additionally. Group placement categories were limited to it is difficult to verify treatment success (Abreu & Tog cognitive levels three and four versus five and six. cognitive levels. The Pearson r between all test scores and the ACL at discharge ranged Early formal work that identified occupational behav from 0. spontaneous. no comparative information was to perform self-care tasks. dynamical. Similar studies involving reliable assessment tools.152 UNIT mO-COMPONENT ASSESSMENTS OF THE ADULT the patient's performance for appropriateness of group The aforementioned studies primarily involved obser placement.42 when compared with the ACL (n = 32).2 to r +0. Thus. Burke.33. Results human system's ability to readily adjust is accomplished further supported validity.01 to HUMAN OCCUPATION 0. Other results supported the as a core philosophy in occupational therapy was f ACL as a sensitive measure of cognitive levels based on the presented by Mary Reilly in her 1961 Eleanor Clarke Sla significant increase of the mean score from admission to lecture (Reilly. investigations of th A criterion-related validity study of the ACL was done assessment instruments are continually in progress. and community tion inherent in the Allen tests and the favorable attitu adjustment revealed no conclusive results (Allen. Another application. and Ba Comparisons were made between the studies for both (AOTA. basing it on t~enera demographic data such as social class.seJo_eW1ore and master the environment (AOT performance on the ACL. 75% rating at levels four to six and 91% rating tributors to the philosophy of occupational behavior at levels five to six.05 to 0. Results revealed significant other perspectives in identifying the relationship betwe differences. much work is still needed before they c ment (r = 0. Kielhofner. Over the years. was based on Reilly's wo impaired in cognitive ability. This earlier model was based on the postulate that hum A study between disabled and nondisabled adult popu­ behavior is innate. Miller. revealing the disabled adults to be functioning at a edition of A model of human occupation: Theory a lower cognitive level than the nondisabled group. T observable limitations in routine task behavior. complex and dynamic. AccJ)rding to Kielhofner. A study of schizophrenic subjects from a work rehabili­ Backman (1994) concluded that because of its nove tation unit of a psychiatric hospital investigated the rela­ the RTI has yet to undergo the intense standardizat tionship between cognitive levels at the time of discharge process necessary to legitimize its claim as a valid a and social adjustment in the community. which supported the con­ occupational behavior model has provided a foundation struct validity of the ACL. revealing a significant relation­ creating a form of new energy to establish new order ship between the ACL scores and the scores on the one's life situation. 1985). The validity for group placement was r = 0. Florey. In his most rec validity. Results also supported construct 1988. 1993). 1985). Shannon. 1962). Reilly's development of schizophrenia and depression.76 determination based on clinical observations and. Results of dynamical aspects of the human system are inherent in the study revealed that cognitive impairment produces system's ability to readily adjust to varying situations. Findings by Ottenbacher revea ability for group performances was determined where that cognitive assessment was mainly a result of subject r = 0. P < 0. the complexity a cognitive disability and the performance of ADL. Other occupational therapy co discharge. Kielhofner (1995) revised his theoreti important finding that is difficult to interpret was that perspective of the human being. their author holds toward research. The model cont Activities of Daily Living Scale in patients with senile ues to incorporate the holistic approach to occupatio dementia.3) was evident by the end of be accepted by rehabilitation professionals as valid a 3 months following discharge.69. as su (Allen. a very low have provided data in support of the validity and reliabi correlation between cognitive function and social adjust­ of the Allen tests. and open systems theories. While results reliable tool in assessing change in behavior. a study involving subjects with senile dementia the dynamical systems theory relative to the physi was designed to investigate the relationship between sciences.

acute inpatient. These three subsystems make it possible for provides necessary information about social interacti the human system to choose based on motivation. with a range of 0. Treatment is directed toward organizing occupa­ of 0." whi the subsystem responsible for motivation.. Findings revealed an avera to gather information on the patient's current occupational correlation of 0. (BaFPE): A task performance and observation rati Occupational dysfunction exists when an individual is scale used to evaluate dailiz livi~lIsjn~-D unable to demonstrate behavior that would meet his or her cognitlo!l. culturally 1. With these substitutions. acu Change in occupational behavior is the result of the inpatient. The revised model maintains the view of the human performance dysfunction (See Table 7-1). oriented to a purpose.. with 80 percent of the correlations equali tional behavior so that adaptive functioning is restored. i. fi the constant interaction between the human system and observation situations were substituted for those the environment. The follOwing is aspects of a task that guide how an individual should partial collection of data on assessment tools common perform. The mind-body-brain each assessment tool. TOA with those in the original version. Correlations for the TOA are in exce values. and and the SIS. 1995. 1985). revealed improvement in 10 of the original 16 scal Assessment Instruments. and to produce occupational behavior. for-profit acute psychiatric. Change is initiated through the volition subsystem based on Interrater reliability was determined for the TO the client's motivation. Occupational forms are the inherent Assessment Tools and Research Data. effective application of each instrument to the model. Veteran's Hospital. habituation. health center. p. 102). Because of the assessment diversity. or per­ and expanded assessment information for greater rei form what David Nelson refers to as occupational forms forcement and support of the model. The assess­ internal consistency among certain subscales with ment process involves the use of a collection of instruments the TOA was studied. These three subsystems interact in a model of human occupation to assist the examiner collaborative manner to influence occupational behavior.60. In h Habituation is the subsystem responsible for organizing instrument library. revealed an increase in all correlations. Clff. univerSity-affiliated psychiatric.~Cll. Occupational forms are "rule-bound sequences used under this model. longer term. 1987). Volition is hofner's (1985) assessment "instrument library. each & Bloomer. with a range of 0.29 to 0. app performance subsystem is responsible for the skills that cable patient populations. Use of the model is of the correlations for items changed in the revis not limited to a specific patient population (Kielhofner.90.79. and will. sustained in collective knowledge. or exceeding 0. Interrater reliability correlations for the SIS a Evaluation results are interpreted and synthesized to deter­ lower than those for the TOA.~ rating scale used to asse can result in a negative effect on the structures of the patients' socia ehavior based on observation human system. private. resu data are ongoing (Kielhofner. interests. Because of to 0. 1995).8 status. body-brain subsystems. a interaction of the three subsystems with the environment. of action which are at once coherent. Kielhofner. including occupational performance history data. In t The revised model's view of dysfunction is based on revised edition (1995). To improve the validity of the SIS. 1989. to and self-management skills. includi Numerous psychosocial assessment tools are applicable reliability (Asher. provides descriptive information on 64 instruments.80 in three of four test groups. choose. resulting in a balance between the individual's inner needs Another reliability study investigated comparis and the environmental requirements. Ea produce behavior for interacting with the environment assessment tool is matched to the components of t (Kielhofner. 1995). Clinicians attempting to under­ Interrater reliability was determined through fo stand occupational dysfunction must determine the restric­ pairs of occupational therapiSts.1dp~rfQr!l1anf~ (Task-Orient own needs or the demands of the environment. and mind­ self-report. The fo result of dysfunction and understand the collaborative patient groups were titled county inpatient men effect on the human system. which [SIS) Scale. Findin 1995).7 mine the client's current occupational status. . The SISJs. choices. the volition.?cJ. 1985. William to the model. Additional system consisting of three subsystems that interact with the observation of behavior during the assessment proce environment. and reference sources. Bay Area Functional Performance Evaluatio recognizable and named" (Kielhofner. collection and syntheSis of assessment the Original version.e. sense of efficacy. each of who tions placed on each subsystem and the environment as a studied an individual group of 25 patients. Kielhofner provides more rece the inabilily of an individual to organize. standardization information. Assessment of occupational on the TOA Results also showed high correlatio status involves an interactive analysis of the three sub­ for the items added to the revised TOA Final systems as well as environmental constraints. A number Assessmen~+~cale and Social Interaction Ski of factors may influence occupational dysfunction. Table 7-1 is based on Ki organize. Kielhofner identifies the contents behavior into patterns and routines. (Kielhofner.

"Cl _Ill ~ !i I ti . ~ .~ .. fa- If[. SOCIAL X X X X X X X c A. Physical • r 2. I~ 1. Disability status X I B. ~ ~ I.i. Coping skills B. &. i' f ~ e: ! I ~. Interpersonal skills I I X I X X X X X X D. ENVIRONMENT X X X I 1. TEMPORAL ASPECTS X X X X X X X X X X X X X X X X X X X X I 1. a III 1:1 a­ g -= i' ~ ~ ~ 0 il 1:1 .. .' =: ~ ~ III o 1:1 ~ III 1:1 a ~ (') ~ a ~ i I Ea­ rct. ~ III III 0 III £) 1:1 III 1:1 a ~. 48(11). (1 994).. Self-conce pt X X X X X X X X X X 2 ..1:1 1:1 III If ~ So a a I ~ 0 1:1 . i­ i' go III 0 1:1 IQ i' III 0 1:1 ~ Performance Components a IQ I 02 • Psychosocial S iriUs and Psychological I I Components 1. .1:I I ~ f ~ III ~ I 1:1C III ~ ~ I!. Values B. Chronological l 2. Self-expression X X X X X X X 3. Unifo rm term inology for occupational th e rapy. (') III.f ~ i it ~e.. Ame rican Journal of Occupatio nal Th e rapy. ~f ~ f ~ ~ ~i 0 -10 l i~ rs: s: ~ ~ S' ~f ~= ~t > e.. Role performance B. Social conduct X X X X X X C. life cycle I X X 4.. G. aI as..a 1:1~ . Baltimore. PSYCHOSOCIAL ASSESSMENT INSTRUMENTS r . e. Cultural X X X Based o n info rmatio n from American Occupatio nal Therapy Association.r. In Kielhofner. III !to 0 c~ III i ~a I!. SELF-MANAGEMENT X X X X X I A.a ~ :2­ ~ ('r. Cl. III .':"s:! ~ "a Q." ~ ( 02.. 0 0 tr 0 1:1 9: a So lg ~ " a. Time management X X X X X X X X C. (1985) model o f human occupatio n.. - ~ ~ 1:1 1:1 1:1 1:1" ~ e. Interests X X X X I X X I X X X X X X X X X X X X X X C.. Developmental X X X I 3..e.c ![ or. MD . Self-control X X X X X Performance Context A. 1047-1059.'i .... f .. = la I i· 0 1:1 g 02 1::1 e. Social X X X X X r X X 3. Williams & Wilkins. 0== i' - 0 f "Cl ~ s. ~ ~ " i ~ o2-2" ~ 1 {I':" a-0 ia-0 ~ ~ 2 ~. (ed) . PSYCHOLOGICAL A..

36 percent had lower performance. use of the on categorical responses between the test and retes BaFPE was effective in identifying deficits in the three Findings were based on 124 nondisabled adul component areas of cognition. Age of subjects (two age groups) and time betwee revealed standard scores for cognitive. reliability was 0. based on Guttman scale. components. psychiatric patients designed to assess productive The Assessment of Occupational Functioning roles in life by indicating their perception of their available through the Model of Human Occupatio past. 1985 2. and accomplish that for best results. clinicians should establish local ments. Test-rete Pequannock. tive data for 266 psychiatric inpatients. Self-Esteem Scale: A self-report scale that measure culties of psychiatric inpatients. and 7 percent had in excess of 0. 1989. habituation. Occupational Case Analysis Interuiew and Rating The Self-Esteem Scale is available through Prince &ale (OCAIRS): A semistructured interview and ton University Press. with an averag the normative data provided by Mann and associates of 87 percent. Department Criterion-related validity moderately supported b of Occupational Therapy.78 as a total score. valid tool to be used in identifying performance diffi­ 4. with correlations of 0. 1989. Percent agreement was 73 to 97 and those evaluated after more than 14 days of with an average of 88 percent. the authors presented as follows (Asher.0. A table of standard scores that re­ b. 1995): A of the interrater reliability study revealed 57 percent interview and observation screening tool for assess of the components with correlation coefficients rang­ ing the three subsystems. institutionalized older adults. test administration-kappa estimates were mod and affective components for each task. and ranging from 18 to 79 years of age. 1995 normative data for the total TOA in the form of actual Oakley et aI. volition. In the 1989 study. 1986): scores and "z" scores on 144 psychiatric inpatients. (1989) and Mann and Klyczek (1991).8 revealed interrater correlation coefficients of 0. 1985 The OCAIRS is available through the Model of 1995).92 fo The BaFPE is available through Maddak. Standardization results were based on 4 (Kaplan & Kielhofner. results and moderate for past and future. present. e. Valuation of each role-kappa estimates wer Standard scores were presented in table form for moderate. Each time category for the 10 roles assessed lack of treatment in a certain component area. 1985). Mann and coworkers (1989) and Mann The Role Checklist is available through the Mod and K1yczek (1991) concluded that the BaFPE is a of Human Occupation Clearinghouse. NJ. reprodUcibility and 0. ..84 when re Illinois at Chicago. performance.50. Primarily used with adolescents but has als norms and standard scores for comparison based on had a history of use with elderly clients. . kappa estimates were substantial for present tim In the study by Mann and Klyczek (1991).80. Reliabilit test results from their own inpatient environment. with 0. abilities. . product-moment correlations (Kielhofner. Study results d. and each total task summary score. rating scale designed for data gathering.65. They further suggest feelings about oneself. Percent agree from the 1989 study were used to determine norma­ ment averaged 87 across time categories. Results wer affect. Percent agreement was 7 eter of the cognitive. Role Checklist: A self-report checklist for adult 1995). Primary use is with institutionalize than 0. (1989). University of significant correlations of . and affective to 95. Individual roles for a given time category-kapp A significant difference was identified between pa­ estimates ranged from slight to near perfec tients evaluated within the first 14 days of admission agreement..85 (Asher. Human Occupation Clearinghouse. a. Reliability measure Investigation of content validity revealed 81. Data comparison may reveal a need for or a c. M/C 811.70 to 0. and 5. Occupational Functioning Tool (renamed Assess reporting a client's occupational adaptation. performance. 1985. hospitalization.42 to .72 for scalability. Percent agreement was 79. 1989). In summary. Results ment of Occupational Functioning. NJ. either a component area or in a specific parameter. performance. Reportedly has content validity founded on litera Data comparison may reveal a need for treatment in ture review. 1985 3. each param­ erate to substantial. Princeton. Each role over three time categories-kapp sulted from the study allows the clinician to compare estimates ranged from moderate to substantia information acquired on recently tested patients with Percent agreement was 77 to 93.48 t percent to 100 percent correct matches between the 0.90 based on Pearso nents (Kielhofner. Kielhofner. lated to similar screening tools (Kielhofner. an ing between 0. Reliability is based on Clearing H o u s e .50 and 0. Test-retest coeff interview questions and 9 of the 11 model compo­ cients ranged from 0.0.80 clients. Inc. analysis. comparing and reporting results of testing patients. and future roles. f. Kielhofner.

The ability to successfully interact in relationships. 1984). The profile identifies and organizes performa INTERPERSONAL SKII.inter the tool. leisure. ment situations. Assessment of interpersonal skill dys­ with the environment and how others may respond. play or leisure. Mosey. utilized as a preassessment tool to record responses b . however. Assessment of Communication and Interaction social interaction: the Interpersonal Skill Survey and Skills (ACIS): an observation assessment tool de­ Group Interaction Skill Survey. meal preparation. Scoring involves ch evaluate quality and effectiveness (not impairment) of ing off behaviors exhibited by the client in the evalua motor and process performance skills while the setting. e.' versity. discuss social interaction behaviors that may not have b Studies support the reliability and validity of the mastered. Mosey (1986) describes the communication and primary source of emotional behavior (Bee. The ability to maintain emotional control w family relations. society and process emotions is perhaps the greatest Emotional behavior as defined by the AOTA's " challenge for humans. and fa emotional behavior. school. AMPS. a-distinct pattern of behavior is revealed regarding so Interpersonal skills involve both social interaction and interaction in work. egocentric-cooperative. viewpoints on the development of emotional behavior assertiveness.~ith skill development or verbal and nonverbal communication to interact with gression. Per interaction as processes that involve skills and abilities in Bussey. 1995). test internal consistency. scale (Kielhofner). Bee (1985) identified three theore initiating and responding to sustained verbal exchanges. interview process to highlight the client's successes an driving (Kielhofner. E advantage of the AMPS is that test task choice is survey lists behaviors typical to the life task area and ca available to the patients. and the ability to take part in cooperative and with certain characteristics that influence how they inte competitive events. 1994). indicating a need for further refinement of of 1 to 4. Both are used to co signed to measure social performance in personal data while observing clients in an evaluation group set communication and group interactions. school. Fidler addresses the evaluation of interpersonal skil the context of a Life-style Performance Profile (AO 1988). By creating a profile about the client'~J} others in casual and formally sustained relationships in performance including all components and lite task ar individual and group settings (AOTA. Subsequent studies for construct validity. Mosey (1986) also provides the clinician with evalua score stability over time. as well as numerous other routine activities faced with stressful events depends on coping skills de (AOTA. family relations.g. Training is available through the AMPS Project. The completion of the survey is followed by individual performs IADL. family member. 1986). cooperative. The profile can also provide firtormatio potential resources for impr:ovil}g_sKins~can--iden Interpersonal skills are defined as the ability to use factors that may interfere. Colorado State Uni­ observed behavior during evaluation or in simulated t . t. A major for work. they disagree on settings. Administration of the AMPS requires formal train­ on an interview with the client. or c Ii ing. Studies re­ The Interpersonal Skill Survey is a six-item forma vealed (Kielhofner. 156 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT 6. compromise and negotia­ behavior is of a biologic origin and that individuals are b tion. oped during childhood and carried forward into adulth Interpersonal skill dysfunction results in an inability to Theorists on emotional development agree that c effectively communicate and interact with others in various hood is the point of origin. The rating results are followed by an . giver. pro Occupation Clearinghouse. 1994. process involving a discussion between the client and based on revision of the tool. The Group Interaction Skill Survey is a for The ACIS is available through the Model of Human arranged according to group types: parallel. and play or leisure. awareness temperamen t theory operates on the belief that emoti of others' needs and feelings. revealed that the therapist to review and clarify any discrepancies betw assessment items do form a single unidimensional the therapist's and the client's observations. school. Social interaction and emotional form terminology for occupational therapy" (1994 control are psychosocial daily life tasks that are interwoven self-management and includes coping skills and into major daily life tasks of work. CO. 1995). and mature gro 7. and interrater reliability have tools and guidelines to assess social interaction in life t all been supported (Kielhofner. and control. Fort Collins.. 1995) modest interrater relia­ interaction and affective behaviors that are rated on a s bility. or the survey may be used as a guide in sco Occupational Therapy Building. 1985. expression of ideas and feelings. function should reflect the appropriate life task area(s) psychoanalytic theorists hypothesized that emoti affected. Construct validity. Mosey (1986) identified two methods of assessing behavior is influenced by the three personality structu . Fisher's Assessment of Motor and Process Skills The survey is used as a guide to determine the client's (AMPS): An observation assessment tool designed to of social interaction development.LS AND skills and deficits according to the client's sociq<:::u EMOTIONAL BEHAVIOR envirQI1JIlent.

Emphasi rehabilitation services and 0. competition.) express their thoughts during therapy. Pequannock. The FlM consider the patient's functional capabilities. from Moyer. What has been provided is a manner in which demands through behavioral adaptation. Twenty­ assessment process can be approached based on a cho four areas of' social and personal behavior are theoretical frame of reference. sensory-motor. the psychosocial aspects re­ Projective tedmique--A method of studying pers lated to patient treatment are also addressed by ality in which the individual is given an unstructured ! assessing social interaction skills relative to patient that allows for a range_gfchgrg~1eristic~s. and social cognition. Treatment does disability regardless of the actual diagnosis. and 83 perc tion of modeled behaviors. . examin the use of the FlM by clinicians. Al­ thoughts and feelings and acceptance among its membe though the greatest emphasis is on social interaction. Measures revealed an Task analysis-A systematic-pr~. T progress. and conflicts. Le.57 occupational therapy and to provide examples of ins for part two (maladaptive behaviors. the SIS. mobility.) 2. Egocentric cooperative group-A task-orien the seven-item scale also addresses related emotional group whose aim is to promote self-esteem throu aspects of behavior. NJ. Association on Mental Deficiency..influenced by social demands that occurred throughout life areas: 88 percent did not have difficulty understa in stages of development. communication. and daily living skills) and 0.) HoHstic-Relates to the "whole" and assumes the wh 3. 1981. Lastly. and overall coping relative to the productive use of defense mechanisms. Emotions Profile Index: A brief. le of human occupation for research data related to ership. (Developed by Bloomer & Williams. observation of social interaction. 4. believed there was not a need for additional ite The occupational therapy evaluation and treatment (Developed by The Center for Functional Assessm process strongly supports the social theorist's position on Research. Functional Independence Measure (FIM): A seven­ Medical JDOdel-Patient treatment that is based on level scale assessment tool ranging from independent nature of the disease and considers the disease to b to dependent behavior that is designed to measure separate entity from the patient. Occupational therapy assessment of from The Center for Functional Assessment emotional behavior is typically performed as a component search. 1989. and medication).86 for part one (psycho­ manifestation in the psychosocial assessment process social. social theorists postulate ing the FlM. standardized per­ is greater than the sum of its parts. (Developed by unknown schizophrenic patients in which they may ramble or fre source. though the FlM is primarily deSigned to measure physical dysfunction. (Developed by the American dysfunction. AAMD Adaptive Behavior Scale: Evaluation of the psychosocial assessment tools available in occupatio subject's effectiveness in coping with environmental therapy. measures self-care. Standardization measures were based on responses are interpreted or analyzed byJh~. sphincter control. Bay Area Functional Performance Evaluation (BaFPE): Includes the SIS.88 for those discharged placed on steps that the patient is unable to perform. loco­ Parallel group-An activity group in which interact motion. Literature search did not reveal re­ Loose association-A type of thinking that is typica search data on this index. 97 percent believed there were that one's emotional behavior is learned through observa­ unnecessary items in the FlM. problem solving. behavior disor­ ments commonly used to determine the degree ders. which rates behavior in seven parameters. Behavioral information can be Cooperative group-A homogeneous non-ta acquired through an interview process with a care­ oriented group whose aim is to promote sharing giver or by actual observation of performance. Interpersonal skills addressed. Washington DC. from Maddak Inc. In occupational thera sonality test for adolescents and adults. Refer to the section on model activities that emphasize cooperation. Al­ is not required.86 on patients admitted to complexity of task procedures step by step. 1981. and other group roles. The following are examples of SUMMARY assessment tools commonly used in determining an indi­ vidual's emotional capability: This chapter is by no means conclusive regarding 1. 1990..) of an overall functional evaluation. judgment.of identifying ANOVA correlation of 0. Moyer. The profile treating the whole of the patient. Reliability measures revealed interrater emotional behavior have been addressed to identify th reliability correlations of 0. from Asher. State University of New York at Buff learned behavior. frustration tolerance.. both the phys index provides information about various basic traits condition and the associated psychosocial situations.

C. M. C. New York. A (1971). (pp. J. & Rdler. Barris. C. Baltimo MA: Uttle. Standard scores for the Bay A gies. American Journal of Occupational Therapy. tional therapy. J. (1993). New York. A model o/human occupation. Gaithersburg. L. psychology. Pequannock. p Allen. E. Bruce. Asher. tren Abreu. G. C. (1991). MD: American Occupational pational Therapy in Mental Health. S. The Eleanor Clarke Slagle lecture. G. C. Inc. B. & Reichler.. (1970). 276-279. Mears. (1993). 9(3).). (1980). 11(1). Abnormal psychology: Moyer. 1047-1059. C 26(1). C. K (1984). A model of human occupation.. Smith. NJ: Maddak. Willard and Spackman's occu Eleanor Clarke Slagle lecture. 156-16l. Klyczek. Earhart. Oc evaluation in mental health. Thorofare. 185-190. G. (1982). (1977). Bee... (1982). 48(5).). Center for Functional Assessment Research. (pp. Prentice-Hall. NY: Raven Press. Occupational therqpy orientation and eval Earhart. 563-575. Magazine picture collages as an pational Therapy Journal of Research. CT: S & S Worldwide. & Reyner. Concepts. (1970). K. The evaluation process in psychiatric occupa­ kins & H_ Smith (Eds.). Willard and Spackman's occupational thera can Occupational Therapy Association. E.. & Allen. (1973). tion: A study of procedure and media. R. Walker (Ed evaluation tools. tional Therapy. (1962). G. NJ: Slack. CT: S & S Worldwide. & Bloomer. Buffalo. K (1987).) (pp. The magazine picture collage: Devel Allen. Occupational therapy: A communicat REFERENCES process in psychiatry. R. American Journal of Occu levels. Assessment and evaluation: Overview. A. R. American Journal of Occupational Therapy in Mental Health. try. c. K. C. R. New York: Macmillan. (1981). & Bussey. J. H.). Fundamentals of abnorm AnastaSi. (1994). SCOPE. 439-448. (1995).). C. Bethesda. Cognitive disabilities: Measuring the Kielhofner. & Ross. K. Boston. Smith (Eds. (1993). 572-58l. J.. Uniform terminol­ Performance Evaluation (BaFPE): Standard scores. J. C. interview and rating scale. 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Christiansen Mosey. Colchester. In H. Bay Area Functional Per therapy. & Provancher. 169-191). Uppincott. H In B. Philadelphia. Journal of Clinical Psychia­ Baltimore. NJ: Slack. 51-75). Bethesda. Shoemyen. Three frames of reference for mental hea Row. Philadelphia. (Ed. T. (1994).) (pp. 34(9). NY: State University of American Journal of Occupational Therapy 16.). M. G. Englewood. & Blue. New York: Macmillan. & Alloy. J. PA: J. P. G. In R. Kaplan. NJ: Slack. In C. Cognitive disability frame of reference. PA: J. New York: McGraw-Hill. W. (1985). 1-7. R (1987).. Occupational case analy Allen. 67-71). Rdler. Occupatio ogy for occupational therapy. (1993). Thorofare. Assessment of self-care skills. occupational therapy. Conceptual framework and content. G. E. Allen. J. B. Cognitive rehabilitation: A model for New York: Macmillan. Hemphill (Ed. Willard & Spackman's occupational thera tional therapy. R. The evaluative process in psychiatric occu 41(7). (1989). & Kielhofner. Birmingham. 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addreSSing subjects' ideal body image (Fallon & Rozin. 1990). 1990). Three models related to assessments are described. other kinds of physical impairment. 1990. old construct. It incorporates both bodily inattention. images dependent tation. .. or in misperception of body sha the neural body scheme. Keeton et al. Two illustrative case reports are given. CHAPTER 8 Julia Van Deusen. 19 to the body image also exists and is researched by Thompson. 1989). They can result from actual physi from lesions. This latter aspect of body image includes a tion of some aspect of the body. A social aspect ment (Butters & Cash. It is assumed that the ideal body image is based on cultural influences . Tiemersma. . Body image assessment is pertinent to intervention for patients with neurologic disorders. Consequently. Lacey & Birtchnell. The construct of body image is a complex one (Cash & Problems can result from neural lesions. The validity and reliability of the various instruments are documented. and its psychological representation formed bodily impairments such as loss of a limb. Typically. several instruments addreSSing the ma on both its psychological and physical components (Cash aspects of body image are needed for adequate asse & Pruzinsky. which is subject to disturbance size . Van Deusen. 1985. or relationships. acute dismemberment. Since body image is complex and many faceted. ~ --~ -. 1987. I discuss the instrumentation for body image disturbances in which neural scheme disturbance is primary and for body image disturbances in which the psychological representation is the dominant dis­ turbance. body image is a v neural body scheme and its psychosocial representation. OTR/L. Body image is a holi perceptual component involving estimation of the real construct and seldom is encountered without psycholo body shape and size. PIlD. Because of their relation to th physical therapy is the notion that our body image disciplines. 1990. I discuss assessment of body image disturbance of adult patients likely to be evaluated by occupational or physical therapists in a rehabili­ tation setting. which result Pruzinsky. applied fields such as occupational thera incorporates images of the function of the body and its have also been concerned with body image instrum parts necessary for skilled performance. or fr through cultural and environmental input. and some psychiatric diag­ noses. it HISTORY logically follows that disturbances are diverse. 1990. 1993). FAOTA SUMMARY In this chapter. as well as its attitudinal aspect cal and physical manifestations. Keeton et al. also subject to psychosocial influences affecting the mental represen disturbance. - . Of ment of body image has been addressed by both n particular importance to occupational therapy and to rology and psychology . asse pertaining to knowledge of and feelings about the body. Body image disturbance refers to problems in the integration of the According to Tiemersma (1989). The notion of body image extends back 1 - .

the midcen~ importance to the body scheme. (1989). necessitating a diversity of measur­ the nervous system results in much cortical reorganiza ing tools. but refinement of old activity of widespread cortical and subcortical areas. body scheme can be viewed a research in psychology over the decades was that' 'Human function of patterns of excitation in the brain. Tiemersma's position on body image temporarily declined for a number of reasons. Many theories concerning body image exist (Tiem­ recognized the influence of culture on body image. Body schemes is not too great. If the discrepancy among these m (Lautenbacher et aI. Following the period of classical definition of body Tiemersma (1989) described a neurophysiologic e scheme in clinical neurology. This was a representative of the body is dependent on the integr period in which body image test development flourished of sensory stimuli. nebulousness of its definition and incompatibility with The position of Lautenbacher and colleagues (199 popular theoretical positions. 1989).. of body image and integration subject to cognitive and affective disturbance" (p. such as the no means limited to this domain. joint. Although body image concepts were compatible early in cutaneous receptors are the sensory receptors of parti the century with those of Gestalt psychology.160 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT ancient and medieval times. H ersma. Although he has described body scheme in term DUring the 1970s. interest in this area declined nation for body scheme. Thompson. Information from t tury work of Fisher and Cleveland (cited in Tiemersma. 1987a) are sample assessments re image projective tests and attitude scales and the refine­ to neurophysiologic theory. The neuro­ tural model is the assumption that current societal physiologic explanation of body scheme is fundamental to dards are the major factor relating to body image di . the muscle spindles. Their primary work. writing in 1990. tests has not.. The Finger Localization until the introduction of assessment tools by psychologists (Benton et aL. This was the time of development of body (Bin (Wilson et aL.. The widespread concern not inconsistent with that of Tiemersma (1989). tendon organs. The li identity cannot be separated from its somatic headquarters system is associated with affective aspects of body im in the world. The brain has m boundary relationships were focal. Fisher re­ by means of a complex network within the central ner cently advocated the multidimensional complexity of the system. 1989). deliberate attempts have been made schemes. In neural lesions. Assessment was through dality. interest in body image research neuroscience. schemes that can be affected by disturbanc to integrate approaches from neurology and psychology sensory input. 18). in which body primary site for body scheme function. 1989. processing (in sensory cortical areas) results in many In the current era. Schilder emphasized the mental image from psychosocial and Neurophysiologic Theory psychoanalytic perspectives. to problems with mental representation. 1993. each specialized for a speCific by the psychoanalytic theorists. The first stage of central nervous sy (Thompson. ences.. Appropriately. How persons feel about their somatic base and the motor system with images of bodily performa takes on mediating significance in most situations" (p.. xiv). including Cash and Pruzinsky (19 Lacey and Birtchnell (1986). 1994) and the Behavioural Inattention in the 1950s. Thompson (1990) emphasized the importance o positions are of particular relevance to assessment in sociocultural body image modeL Inherent in the soci occupational therapy and physical therapy. such as joint position. predicted temporal lobes) into one "body selL" Like Tiemer " . Tiemersma. However. Thompson. Head defined the neural body scheme as a dynamic schema resulting from past postures and movements. T about anorexia nervosa brought a resurgence of body authors believe there is strong agreement that the m image research by the late 1970s and 1980s. model in cognitive psychology can be useful guide the notion was elaborated and popularized through the assessment procedures for body image disturbance re works of Head and Schilder (cited in Tiemersma. and actual medical records of assessment for body image disturbances associated body image phenomena date from the 16th century. 1990). Several theoretical ever. Sociocultural Model BODY IMAGE MODELS Many authors. receptors is transmitted by means of afferent tracts to 1989) was the first major body image research from the somatic sensory association area of the parietal corte field of psychology. Somatosensory processi projective technique (Fisher. According to Tieme ment of neurologic evaluation. and Van Deusen (1993). Final integration of the body self is dependent o the creation of new tests has declined. they become integrated (in image authority. The sociocultural model and the sch clinical neurology during the first part of the 20th century. was strongly influenced somatosensory maps. an expanding role into the 1990s for the researcher Lautenbacher and associates consider the body self pl and clinician interested in the assessment . at the present time. which is considered very plastic since damag body image construct. 1990). 1990). His explanation of the vast amount of body image From this perspective.

Because of this action. a major current treatment approach for body those challenged by stroke. 5) disturbed use of body pa the 1970s. it is agreed that schemata to identify body parts or relationships. or by other patholo 1990. Physical attractiveness is highly valued DISTURBANCES 2. 1993). 3) a special condit are cognitive structures that organize prior. Greenberg. including 1) cognitive psychology. Lesions of the central nervous system leading to paired neurologic function can disturb the body schem Under these conditions. The temporary phant is a particularly good example of an assessment tool sensation of the missing part is almost universal after a congruent with this theoretical perspective. 7) inability to identify the are body image research with the gestalt and psychoanalytic body part touched. and obesity is negatively valued Lacey and Birtchnell (1986) have categorized b 3. Freedman. and 10) inability to use body part Sir Henry Head. Society encourages women's preoccupation with the ment. 3) those associated with actual physical proble pursuit of beauty and 4) those accompanying psychiatric diagnosis 5. perspective. Beauty equals goodness so that thinness is also image disturbances into four groups: 1) those due equated with goodness neurologic disorder. 4) retrieve stored information (Safran & Greenberg. Men show less body image disturbance than do than one type of disturbance. Probable contributing factors were the close ties of abnormally large or small. the schema model in cognitive psychology to the involved side when Simultaneously administered derives quite basically from the body image writings of the uninvolved side. An example of this Neurologic Disorder kind of instrument is the Body Image Assessment devel­ oped by Williamson (1990). Furthermore. A build emphasizing upper extremity musculature is encountered in patients treated by rehabilitation spec the ideal masculine body ists. Society reinforces the bodily alteration of women to without physical disability. which influenced the ideas about schema address the hemispace contralateral to the side of br elaborated by Bartlett. it has Patients treated i