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



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

Pain Descriptions and Related Structures Type o f Pain Cramping, dull, aching Sharp, shooting Sharp, bright, lightning-like Burning, pressure-like, stinging, aching Deep, nagging, dull Sharp, severe, intolerable Throbbing, diffuse Structure Muscle Nerve root Nerve Sympathetic nerve Bone Fracture Vasculature

Helps to focus and individualize physical examination SENSORIUM Alert Lethargic Obtunded Stupor Coma awake and attentive to normal stimulation drowsy, may fall asleep if not stimulated difficult to arouse, frequently confused when awake responds only to strong, noxious stimuli: returns to unconscious state cannot be aroused



Awareness of Time, Person, and Place (oriented x 3) AMBULATORY STATUS Note patient’s mode of locomotion (wheelchair, ambulatory with or without assistive device, bedridden, bed bound etc.) SKIN (color, texture, presence of lesions, scars) PRESSURE SORES Stage 1 Stage 2 dermis) Stage 3 Stage 4 non-blanchable erythema of intact skin abrasion, blister, or shallow crater (epidermis & deep crater, necrosis/damage of necrotic tissue extensive destruction, tissue necrosis extending up to muscle and bone

BODY BUILD Ectomorphic thin, prominence of structures from ectoderm Mesomorphic muscular, prominence of structures from mesoderm Endomorphic heavy, fat body built, prominence of structures from endoderm

PALPATION GUIDELINES Note differences in tissue tension, muscle tone & texture Note differences in tissue thickness Identify palpable anomalies Define areas of tenderness Temperature variations Pulses, tremors, fasciculations Dryness, excessive moisture Abnormal sensation Remember!! Palpate uninvolved part first and painful areas last TENDERNESS (Pain upon palpation)


Tenderness Scale/Grading

1 2 3 4

complains of pain complains of pain & winces winces & withdraws limb patient won’t allow palpation

EDEMA Grading of Edema depression depression Severe 3+ ½” to 1” depth of depression Mild 1+ Moderate 2+ < ¼” ¼” to ½” depth depth of of

BLOOD PRESSURE Adult Blood Pressure Normal Pre-HTN Stage 1 Stage 2 < 2 y.o. 3-5 y.o. <120 mmHg / <80 mmHg 120-139 mmHg/80-89 mmHg 140-159 mmHg/90-99 mmHg ≥ 160 mmHg/100 mmHg 106-110 mmHg/59-63 mmHg 113-116 mmHg/67-74 mmHg

Infant Blood Pressure

Factors that may alter the Blood Pressure Elevate BP Pain Auscultatory gap Sleeplessness gap Recent smoking Distended bowel/bladder Recent exercise Chilling Lowers BP Recent meal Dehydration Auscultatory


PULSE RATE Adult Pulse Rate Normal 60-100 bpm (avg. 70 bpm) Tachycardia >100 bpm Bradycardia < 60 bpm Normal 4+ 3+ 2+ 1+ 0 70-170 bpm (avg. 120 bpm)

Infant Pulse rate Pulse Grading

Bounding Increased Brisk, expected Diminished, weaker than expected Absent, unable to palpate

RESPIRATORY RATE Adult RR Normal 12-20 cpm Tachypnea > 20 cpm Hyperpnea increase depth and rate Normal 30-60 cpm scale +1 mild, noticeable +2 mild, noticeable to observer +3 continue +4 continue TEMPERATURE Normal Conversion 98.6˚F or 37˚C ˚F= [˚C x 9/5] + 32 ˚C= [˚F-32] x 5/9 Intermittent normal and alternate b/n pyrexia & subnormal within 24 hr period severe, can’t moderate, can

Infant RR

Dyspnea (shortness of breath) to px

Types of Fever


Relapsing/Recurrent normal Sustained/Constant

alternate b/n pyrexia & lapse for > 24 hr consistently elevated temperature

Sensory impairments interfere with acquisition of new motor skills since motor learning is dependent on sensory information and feedback SENSORY ASSESSMENT PRINCIPLES Sensory assessment is completed prior to any testing that involves active motor function Initial screening for mental status (arousal, attention, orientation, cognition & memory), vision & memory should be done prior to performing sensory tests. Patient should be instructed not to guess if uncertain about the response Demonstrate the test to orient the patient on what to expect and what response is needed Test order: Superficial—Deep—Cortical & Distal to Proximal Apply the stimuli in a random order to avoid giving patient “clues” to the correct response It is good to use a chart or picture to represent the areas with sensory problem so as to easily identify if a certain pattern exists EXAMINATION PROTOCOL Superficial sensation Pain avoid Use sharp end of a pin, applying stimuli close to each other


Let finger slide over the pin Light touch brush Pressure Temperature Response Use thumb enough to indent skin Use test tubes with warm (41-50˚F) and cold (104113˚F) When patient feels stimuli, respond with yes, now or unable to tell Move the extremity Use cotton or camel hair

Deep sensation

Kinesthesia passively range Response

in initial, mid or terminal with very minimal grip to reduce tactile stimulation Describe direction as up or down, in or out while the extremity is in motion. Also patient can imitate the movement in opposite extremity. The extremity is held in a static position in initial, mid or terminal range with very minimal grip to reduce tactile stimulation Describe direction as up or down, in or out while the extremity is in static position. Also patient can imitate the movement in opposite extremity. Place the base of a vibrating tuning fork on a bony prominence. Random application of vibrating and non vibrating stimuli should be done. Patient should also be given earphones





Response Cortical sensation familiar Stereognosis

to remove the auditory clues. Verbally identify the vibrating stimuli The patient is given a object to be held and manipulated The patient is asked to identify the object verbally


Tactile localization Therapist touches different areas in patient skin surface Response Patient points out the area that the therapist touches Two-point Discrimination Applies simultaneous stimuli on the patient’s skin Response Identify if the perception of one or two stimuli Graphesthesia Trace letters, numbers or designs on skin Response Identify what is the traced figure



PATIENT HISTORY & INTERVIEW Symptom Onset Location Quality Behavior sudden, gradual, insidious, traumatic localized, diffuse, deep, superficial, changes, spreads severity, characteristic aggravating factors, relieving factors

Illustrations: Numerical Pain Rating Scales Circle the number which best represents the intensity of your pain 0 1 No Pain Imaginable 2 3 4 5 Pain 6 7 8 9 10 Worst

Previous Care/Medical History

Previous occurrence of the condition, treatments received and its effects Other significant conditions Medications taken, type, frequency, dose Patient’s hopes for outcome

Past medical history Medications Treatment goals


Occupational, recreational, social history patient’s work and activities, architectural barriers, environmental accessibility
Illustrations: Rate Patient’s Function What percentage of your work activities are you able to perform? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Illustrations: Rate Patient’s Function What percentage of your home activities are you able to perform? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Illustrations: Rate Patient’s Function What percentage of your recreational activities are you able to perform? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

RANGE OF MOTION Things to remember Normal side is tested first, unless bilateral movements are needed AROM-PROM-Isometric movements Painful movements are done last Apply over pressure at end of range with care Over pressure maybe applied to point of pain but not beyond


Resisted isometrics are done with the joint in resting position Active ROM Often estimated except if more accurate measurement is needed, goniometer should be used If can be performed by patient easily without pain or other symptoms, then passive testing is usually not necessary

Attention!! Limitations in AROM may indicate affection of either contractile or none contractile tissue or both. The examiner must perform further testing to isolate the cause.

Passive ROM

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

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

Effect on Symptom

Pain aggravated or persistent in passive usually indicates noncontractile structures (bones, joint, ligaments, cartilage etc.)


End Feel End Feel

Abnormal End Feels Examples
Soft tissue edema Synovitis

Soft Occurs sooner or later in the ROM than is usual, or in a joint that normally has a firm or hard end-feel. Feels boggy Firm Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or hard end-feel. Hard Occurs sooner or later in the ROM than is usual, or in a joint that normally has a soft or firm end-feel. A bony grating or bony block is felt. Empty No real end-feel because pain prevents reaching end of ROM. No resistance is felt except for patient’s protective muscle splinting or muscle spasm

Increased muscular tonus Capsular, muscular, ligamentous shortening

Chondromalacia Osteoarthritis Loose bodies in joint Myositis ossificans Fracture

Acute joint inflammation Bursitis Abscess Fracture Psychogenic Disorder


Pattern of Limitation

Capsular Patterns Can be due to 2 situations a. Joint effusion or synovial inflammation (acute stage) b. Relative capsular fibrosis (chronic stage)

Attention!!! Determine what causes the capsular pattern, if it is inflammation treatment is same for acute stage. If the cause is fibrosis, treatment is same for chronic stage. Non-Capsular Patterns Usually involve one or two motions of a joint. Cause can be d/t structures other than the joint capsule. (internal joint derangement, adhesions of part of joint capsule, ligament shortening, muscle strain and shortening) Capsular Patterns


Shoulder Elbow Forearm Wrist CMC 1 2-5 UE digit Hip Knee Ankle Subtalar Midtarsal Metatarsalphalangeal joint 1 Metatarsalphalangeal joint 2-5

ER>ABD>IR F>E Pronation=Supination F=E ABD & EXT Equal restriction direction F>E IR, F, ABD F>E PF>DF Varus restricted Restricted DF, medial rotation E>F Tend toward Flexion Tend toward extension PF, ABD, in all

IP joint

ROM Values





Flexion Extension Abduction Medial rotation

0-180 0-60 0-180 0-70


Motion Flexion


Extension Abduction Adduction

0-120 0-30 0-45 0-30


Elbow Forearm Wrist

Lateral Flexion Pronation Supination Extension Flexion Radial Ulnar deviation Abduction Flexion Extension Opposition

0-90 0-150 0-80 0-80 0-70 0-80 0-20 0-30

Knee Ankle

Subtalar Great toe

ER/IR Flexion PF DF Inversion Eversion Inv/Evr

0-45 0-135 0-50 0-20 0-35 0-15 0-5

Thumb CMC

0-70 MTP 0-15 0-20 PI Tip of thumb to or tip of fifth digit Lesser toe MTP 0-50 0-80

flexion extension flexion

0-45 0-70 0-90

flexion extension flexion flexion

0-40 0-40 0-35 0-30

MCP Flexion IP Flexion Digits Second Fifth Flexion MCP Hyperextensio Abduction PIP DIP Flexion Flexion Hyperextensio n


0-90 0-45 0-100 0-90 0-10

ACESSORY JOINT MOTIONS Tested if PROM is limited or painful; Tested for amount of motion, effect on symptoms, and end feel. Accessory joint motion grades 1 hypomobility 2 3 4 5 hypermobility 6 Grades 0 & 6 indicated Grades 1 & 2 Grades 4 & 5 surgery considered, unstable joint mobilization not slight hypomobility normal slight hypermobility considerable 0 ankylosed considerable

joint mobilization to increase joint extensibility increasing joint extensibility not indicated; taping, bracing, strengthening indicated


RESISTED ISOMETRIC TESTING Joint should be placed in a position midway through the range, to produce minimal tension in inert structures. RESULTS OF RESISTED ISOMETRIC TESTING

Findings Strong and painless

Possible Pathologies There is no lesion or neurological deficit involving the tested muscle and tendon. There is a minor lesion of the tested muscle or tendon. There is a disorder of the nervous system, neuromuscular junction, or a complete rupture of the tested muscle or tendon, or disuse atrophy. There is a serious, painful pathology such as a fracture or neoplasm. Other possibilities include an acute inflammatory process that inhibits muscle contraction, or a partial rupture of the tested muscle or tendon.

Strong and painful Weak and painless

Weak and painful

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


MANUAL MUSCLE TESTING Manual Muscle Testing Grades
Grades Normal N 5 10 Criteria Full available ROM, against gravity, strong manual resistance Full available ROM, against gravity, nearly strong manual resistance Full available ROM, against gravity, moderate manual resistance Full available ROM, against gravity, nearly moderate manual resistance Full available ROM, against gravity, slight manual resistance Full available ROM, against gravity, no resistance At least 50% of ROM, against gravity, no resistance Full available ROM, gravity minimized, slight manual resistance Full available ROM, gravity minimized, no resistance At least 50% of ROM, gravity minimized, no resistance Minimal observable motion (less than 50% ROM), gravity minimized, no resistance

Good Plus








Good Minus




Fair Plus








Fair Minus




Poor Plus




Poor Poor Minus

P P–

2 2–

2 1

Trace Plus







T No observable motion, palpable muscle contraction, no resistance





No observable or palpable muscle contraction

CLOSE-OPEN PACKED POSITION Resting (Loose/open Packed) Position of Joints
Joint Facet (spine) Temporomandibular Glenohumeral Acromioclavicuiar Sternoclavicular Ulnohumeral (elbow) Radiohumeral Proximal radioulnar Distal radioulnar Radiocarpal (wrist) Carpometacarpal Position Midway between flexion and extension Mouth slightly open (freeway space) 55° abduction, 30° horizontal adduction Arm resting by side in normal physiological position Arm resting by side in normal physiological position 70° flexion, 10° supination Full extension, full supination 70° flexion, 35° supination 10° supination Neutral with slight ulnar deviation Midway between abduction-adduction and flexionextension Metacarpophalangeal Slight flexion Interphalangeal Hip Knee Talocrural (ankle) Slight flexion 30° flexion, 30° abduction, slight lateral rotation 25° flexion 10° plantar flexion, midway between maximum inversion and eversion Subtalar Midway between extremes of range of movement Midtarsal Midway between extremes of range of movement Tarsometatarsal Midway between extremes of range of movement Metatarsophalangeal Neutral

Close Packed Position of Joints
Joint Facet (spine) Temporomandibular Glenohumeral Acromioclavicular Sternoclavicular Ulnohumeral (elbow) Radiohumeral Proximal radioulnar Distal radioulnar Radiocarpal (wrist) Metacarpophalangeal Position Extension Clenched teeth Abduction and lateral rotation Arm abducted to 90° Maximum shoulder elevation Extension Elbow flexed 90°, forearm supinated 5° 5° supination 5° supination Extension with radial deviation Full flexion (fingers)


Metacarpophalangeal Interphalangeal Hip Knee Talocrural (ankle) Subtalar Midtarsal Tarsometatarsal Metatarsophalangeal

Full opposition (thumb) Full extension Full extension, medial rotation* Full extension, lateral rotation of tibia Maximum dorsiflexion Supination Supination Supination Full extension

TONE Modified Ashworth Scale Grade Description
0 1 No increase in muscle tone. Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension. Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM. More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved. Considerable increase in muscle tone, passive movement difficult. Affected part(s) rigid in flexion or extension.


2 3 4

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


Grade Evaluation
0 Absent contraction 1+ Hyporeflexia

Response Characteristics
No visible or palpable muscle with reinforcement. Slight or sluggish muscle contraction with little or no joint movement. Reinforcement may be required to elicit a reflex response. Slight muscle contraction with slight movement. Clearly visible, brisk muscle with moderate joint movement. Strong muscle contraction with one to three beats of clonus. Reflex spread to contralateral side may be noted. Strong muscle contraction with sustained clonus. Reflex spread contralateral side maybe noted to


Normal joint Hyperreflexia contraction Abnormal





Normal Patient is able to maintain steady balance without support (static). Accepts maximal challenge and can shift weight in all directions (dynamic). Patient is able to maintain balance without support (static). Accepts moderate challenge; able to maintain balance while picking object off floor (dynamic). Patient is able to maintain balance with handhold (static). Accepts minimal challenge; able to maintain balance while turning head/trunk (dynamic). Patient requires handhold and assistance (static).




CTSIB (Clinical Test for Sensory Interaction in Balance








1. Eyes open, fixed support 2. Eyes closed, fixed support 3. Visual conflict, fixed support 4. Eyes open, moving surface 5. Eyes closed, moving support 6. Visual conflict moving support


Result-Interpretation 2,3,5,6 Visual loss 5, 6 Vestibular loss 4, 5, 6 Surface, somatosensory input 3, 4, 5, 6 Sensory selection

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


1. Finger to nose

The shoulder is abducted to 90 degrees with the elbow extended. The patient is asked to bring the tip of the index finger to the tip of the nose. Alterations may be made in the initial starting position to assess performance from different planes of motion. The patient and therapist sit opposite each other. The therapist's index finger is held in front of the patient. The patient is asked to touch the tip of the index finger to the therapist's index finger. The position of the therapist's finger may be altered during testing to assess ability to change distance, direction, and force of movement.

2. Finger to therapist's finger

3. Finger to finger

Both shoulders are abducted to 90 degrees with the elbows extended. The patient is asked to bring both hands toward the midline and approximate the index fingers from opposing hands. The patient alternately touches the tip of the nose and the tip of the therapist's finger with the index finger. The position of the therapist's finger may be altered during testing to assess ability to change distance, direction, and force of movement.

4. Alternate nose to finger

5. Finger opposition

6. Mass grasp

The patient touches the tip of the thumb to the tip of each finger in sequence. Speed may be gradually increased. An alternation is made between opening and closing fist (from finger flexion to full extension). Speed may be gradually increased. With elbows flexed to 90 degrees and held close to body, the patient alternately turns the palms up and down. This test also may be performed with shoulders flexed to 90 degrees and elbows extended. Speed may be gradually increased. The ability to reverse movements between opposing muscle groups can be assessed at many joints. Examples include active alternation between flexion and extension of the knee, ankle, elbow, fingers, and so forth.

7. Pronation/supination

8. Rebound test


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

9. Tapping (hand)



1.Standing in a normal, comfortable posture. 2.Standing, feet together (narrow base of support). 3.Standing, with one foot directly in front of the other in tandem position (toe of one foot touching heel of opposite foot). 4.Standing on one foot. 5.Arm position may be altered in each of the above postures (i.e., arms at side, over head, hands on waist, and so forth). 6.Displace balance unexpectedly (while carefully guarding patient). 7.Standing, alternate between forward trunk flexion and return to neutral. 8.Standing, laterally flex trunk to each side. 9.Standing: eyes open (EO) to eyes closed (EC) ability to maintain an upright posture without visual input is referred to as a positive Romberg sign. 10.Standing in tandem position eyes open (EO) to eyes closed (EC) (Sharpened Romberg). 11.Walking, placing the heel of one foot directly in front of the toe of the opposite foot (tandem walking). 12.Walking along a straight line drawn or taped to the floor, or place feet on floor markers while walking. 13.Walk sideways, backward, or cross-stepping. 14.March in place. 15.Alter speed of ambulatory activities; observe patient walking at normal speed, as fast as possible, and as slow as possible. 16.Stop and start abruptly while walking. 17.Walk and pivot (turn 90, 180, or 360 degrees). 18.Walk in a circle, alternate directions. 19.Walk on heels or toes. 20.Walk with horizontal and vertical head turns. 21.Step over or around obstacles. 22.Stair climbing with and without using handrail; one step at-a-time versus step-over-step. 23.Agility activities (coordinated movement with upright balance); jumping jacks, alternate flexing and extending


the knees while sitting on a Swiss ball.

Impairment Dysdiadochokinesia

Sample Test Fi n g e r t o n o s e Alternate nose to finger Pronation/supination Knee f l ex i o n / ex t e n s i o n Walking, alter speed or direction Pointing and past

Dysmetria pointing eight

Drawing a circle or figure Heel on shin. Placing feet on floor markers while walking

Movement decomposition Finger to nose (dyssynergia) Finger to therapist's finger Alternate heel to knee Toe to examiner's finger Hypotonia movement reflexes Tremor (intention) Observation during functional activities (tremor will typically increase as target is approached or movement speed increased) Alternate nose to finger Finger to finger Finger to therapist's finger Toe to examiner's finger Tremor (resting) Observation of patient at rest Observation during functional activities (tremor will diminish significantly or disappear with movement) Observation of steadiness of Fixation or position holding (upper Application of manual resistance to assess muscle strength Passive Deep tendon

Tremor (postural) normal standing posture Asthenia and lower extremity)


Rigidity activities

Passiv e moveme nt Observation during functional Observation of resting posture(s)

Bradykinesia swing and trunk motions





Walking, alter speed and direction Request that a movement or gait activity be stopped abruptly Observation of functional activities: timed tests Disturbances of posture Fixation or position holding (upper and lower extremity) Displace balance unexpectedly in sitting or standing Standing, alter base of support (e.g., one foot directly in front of the other; standing on one foot) Disturbances of gait straight line Walk along a

Walk sideways, backward March in place Alter speed and direction of ambulatory activities Walk in a circle
















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


Functional Independence Measure (FIM)






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