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NY . New York Maryam Rafael Aghalar. DO Department of Physical Medicine and Rehabilitation Nassau University Medical Center East Meadow. New York Lyn D. Weiss.Neuromuscular Quick Pocket Reference Editors Rawa Jaro Araim. New York Professor of Clinical Physical Medicine and Rehabilitation Stony Brook University School of Medicine Stony Brook. MD Chairman and Director of Residency Training Department of Physical Medicine and Rehabilitation Nassau University Medical Center East Meadow. MD. DO Department of Physical Medicine and Rehabilitation Nassau University Medical Center East Meadow.
For details. pharmaceutical companies.com ISBN: 978-1-9362-8750-5 ebook ISBN: 978-1-6170-5092-3 Acquisitions Editor: Beth Barry Compositor: Manila Typesetting Company Printer: Bang Printing © 2012 Demos Medical Publishing.demosmedpub. p. electronic. Maryam Rafael Aghalar.Visit our website at www. II. Neurological Handbooks. All rights reserved. Nevertheless. Diagnostic Techniques. No part of it may be reproduced. with respect to the contents of the publication.com Printed in the United States of America 11 12 13 14 / 5 4 3 2 1 . 15th Floor New York. Neuromuscular Diseases–diagnosis–Handbooks. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Araim. Weiss. health care organizations. mechanical. recording. Aghalar. 3. . [DNLM: 1. the authors. and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty. and other qualifying groups. or transmitted in any form or by any means.744–dc23 2011039621 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations. or otherwise. 5. Rawa Jaro Araim. without the prior written permission of the publisher. and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. LLC. professional associations. Library of Congress Cataloging-in-Publication Data Neuromuscular quick pocket reference / editors. ISBN 978-1-936287-50-5 (alk. WE 39] 616. please contact: Special Sales Department Demos Medical Publishing 11 West 42nd Street. Musculoskeletal System–injuries–Handbooks. 4. Nervous System–diagnosis–Handbooks. paper) – ISBN 978-1-61705-092-3 (e-book) I. Trauma. NY 10036 Phone: 800-532-8663 or 212-683-0072 Fax: 212-941-7842 E-mail: rsantana@demosmedpub. Lyn D. Maryam Rafael. photocopying. This book is protected by copyright. Lyn D. Medicine is an ever-changing science. Trauma Severity Indices–Handbooks. III. 2. editors. editors. Includes bibliographical references and index. The authors. Weiss. Research and clinical experience are continually expanding our knowledge. cm. express or implied. in particular our understanding of proper treatment and drug therapy. stored in a retrieval system. Rawa Jaro.
Helene. I would not be where I am today. and my kids Liora and Jacob who give me purpose. this book would not be possible.This book is dedicated to my dear father M. Stefan and Richard who give me perspective on what is truly important. Special thanks to my dear husband Nabeel Araim MD and my children Roua and Marwan for their unconditional love and support. Without her. my husband Jahan and in-laws for their support. my program director. Lyn D. MD for all of your guidance and support. Special thanks to Dr Weiss. MD and Thomas Pobre. Maryam Rafael Aghalar With love and thanks to my husband Jay and my children Ari. Thank you to the entire NUMC staff of residents and attendings who make work fun. thank you to my mentors Lyn Weiss. Jaro who supported me in every endeavor and always believed in me more than I believed in myself. my Mom Flora who helped me get through it. Rawa Jaro Araim This book is dedicated to my Dad Parviz who encouraged me to go to medical school. MD. Finally. and role model. chairman. Weiss v . Ricardo Cruz. Without all of you.
Muscle Strength Grading Scale 17. Pressure Ulcers 16. 10. Glasgow Coma Scale 19. Deep Tendon Reflex Grading Scale 18. 7. Rehabilitation Approach to Neurological Deficits 12. Upper Motor Neuron Signs 15. 4. Traumatic Brain Injury (TBI) Severity Indices 21. Aphasia 25. 8. Upper Motor Neuron vs Lower Motor Neuron Lesion 14. Stroke Outcome 13. Glasgow Outcome Scale (GOS) 20. Neuropsychology 53 56 60 61 65 71 72 73 74 75 76 78 79 80 81 83 vii . 3. Brunnstrom Stages of Recovery 24. Musculoskeletal Physical Exam 1. 5. Thoracic Outlet Syndrome (TOS) Cervical Spine Shoulder Elbow Joint Wrist and Hand Lumbar Spine Hip Sacroiliac Joint Knee Ankle 3 6 8 19 22 26 30 34 37 47 II. Neurological Tests and Scales 11. 6.Contents Contributors Preface Acknowledgments ix xi xiii I. 9. Modified Ashworth Scale for Spasticity 23. Ranchos Los Amigos Scale 22. Standard Neurological Classification of Spinal Cord Injury 26. 2.
NIH Stroke Scale 29. Peripheral Nerve Distribution 35.Contents viii 27. Brachial Plexus 34. Return to Play Guidelines After Concussion 28. Lumbosacral Plexus 33. Radiculopathy 31. Mini Mental State Examination (MMSE) 30. Dermatomal Distribution of Nerve Roots 85 87 90 91 94 96 99 100 102 Index 105 . Range of Motion: Upper Extremity 32.
DO Ricardo Miranda. DO Alfred Castillo. DO Teena Varghese. DO Edward Barawid. DO Samaira Khan. MD Lynn Schaefer. Lilibeth Acero. MD Anu Mutyala. DO Shilo Kramer. MD ix . MD Daniel Tsukanov. DO Katie Kwaschyn. PhD Weibin Shi. DO Harry Lenaburg. MD Luke Garcia. RN Vikram Agnish. DO Ricardo Cruz. DO Derek Higgins. DO Deborah Freidman.Contributors The authors would like to thank the following staff in the Department of Physical Medicine and Rehabilitation at Nassau University Medical Center for their contributions to this book. MD Chioma Ezeadichie. MD Yuliya Maystrovskaya. MD Farah Siddiqui. DO Sasha Iversen.
residents. It is our hope that this book will be useful to future generations of health care providers and help them deliver better care to their patients. this book is applicable for most health care practitioners (including allied health professionals. and research. This book is meant to be used as a quick reference for a specific topic. They needed to know what the test was called. who felt that physical medicine and rehabilitation residents needed an efficient way to learn about the various musculoskeletal and neurological tests. Although originally intended for PM&R residents. It should be noted that this book does not represent the complete spectrum of neuromusculoskeletal examination and does not give information on treatment. xi . and we hope that it will provide a foundation for knowledge that can be advanced by further reading. practice. and attendings) who deal with the neuromusculoskeletal system. how to perform it. students. It should be considered a first step. and what the results meant.Contents Preface This book was conceived by Dr Araim.
• Dr Harry Lenaburg for his aid in editing the text. xiii . Thank you also to the PM&R residents. • Dr Dennis Dowling for his wonderful illustrations.Acknowledgments Contents The authors would like to acknowledge the following individuals for their contributions to this project: • D r Sasha Iversen for her help as a model in the photographs. who make the work of a residency enjoyable. • D r Thomas Pobre for his assistance and review of the musculo-skeletal section of the book. • S heila Slezak for ably assisting in the preparation of the manuscript. • D r Ricardo (Eric) Cruz for his assistance and review of the neurological section of the book. • D rs Charles Ruotolo and Stanislav Avshalumov for their assistance and review of the orthopedic section of the book.
Neuromuscular Quick Pocket Reference .
Musculoskeletal Physical Exam .I.
4 Costoclavicular Test (Military Position) Purpose: TOS (entrapment of the subclavian artery by the clavicle and first rib). 4 3 . The patient is asked to retract and then depress the shoulders. Thoracic Outlet Syndrome (TOS) Wright’s Test (Hyperabduction Test) Purpose: Thoracic outlet syndrome (TOS) (entrapment of the subclavian artery by the pectoralis minor tendon and the coracoid process).1. 3. Positive test: The loss or decrease of radial pulse or reproduction of symptoms (in neurogenic TOS). Techniques: Examiner palpates patient’s radial pulse. Sensitivity: 84% Specificity: 90% Sources: 2. Techniques: Examiner palpates patient’s radial pulse while keeping patient’s shoulder at 90o abduction and in full external rotation. Sensitivity: No Data (ND) Specificity: ND Sources: 1. followed by protrusion of the chest and requested to hold the position for 1 minute. Positive test: The loss or decrease of radial pulse or reproduction of symptoms (in neurogenic TOS).
electrophysiology.56(4):155–160. Altuncuog˘lu M. 2nd edition. Türkiye Fiziksel Tıp ve Rehabilitasyon Dergisi. Malanga GA. Magee. Positive test: The loss or decrease of radial pulse or the reproduction of symptoms (in neurogenic TOS). et al. PA: WB Saunders Co. In: Malanga GA. 2006:48–55. 5. Sensitivity: 94–100% Specificity: 18–87% Sources: 4. The patient’s arm is held in slight abduction. Orthopedic Physical Assessment. eds. 2001. Nadler SF. PA: Elsevier. Musculoskeletal Physical Examination: An Evidence-based Approach. Joint Bone Spine. Demirel A. Hachulla E. Thoracic Outlet Syndrome (TOS) Adson’s Test (Scalene Test) Purpose: TOS (entrapment of the subclavian artery between the anterior and middle scalene or between anterior scalene and a cervical rib. Calis M. Scalenus anticus syndrome—usually affecting C8/T1/ulnar nerve). Philadelphia. Diagnosing thoracic outlet syndrome: contribution of provocative tests. 2. Physical examination of the cervical spine. Techniques: Examiner palpates patient’s radial pulse.1. ultrasonography. 6 Sources 1. Diagnostic values of clinical diagnostic tests in thoracic outlet syndrome. 4. 1992:320–321. et al. Pérez-Cousin M. Gillard J.68(5):416–424J. Philadelphia. Nadler SF. 4 . 3. 2010. and external rotation. while the patient is instructed to extend and rotate neck to affected side while taking a deep breath. Landes P. DJ. extension. and helical computed tomography in 48 pts.
Bombardier C. Neurovascular entrapment in the regions of the shoulder girdle and posterior triangle of the neck.1. Thoracic Outlet Syndrome (TOS) 5.66:1894–1900. Marx RG.24A(1):185–192. J Hand Surg. Wright JG. 1999. Phys Ther. 6. 1986. What we know about the reliability and validity of physical examination tests used to examine the upper extremity. 5 . Pratt NE.
First. the head can be extended and bended laterally to the affected side. 5 Neck Distraction Test (Axial Manual Traction Test) Purpose: Cervical radiculopathy. which indicates muscle spasm or whiplash-associated disorder. Increased pain may be the result of ligament sprain. 6 6 . 3. The examiner places one hand under the chin and the other at the base of the occiput and applies distractive force of up to 33 pounds. the patient’s head is compressed at neutral. it is called reverse Spurling’s. 2. Sensitivity: 28%–60% Specificity: 92%–100% Sources: 1. Positive test: Pain radiating into the ipsilateral arm. Positive test: Decreased pain implies nerve root etiology. Cervical Spine Spurling’s Test (Foraminal Compression Test) Purpose: Cervical radiculopathy. Sensitivity: 40%–44% Specificity: 90%–100% Sources: 4. Technique: The test can be done in 3 stages that increase the provocation of the symptoms. 4. If still no pain. the head can be extended.2. muscle strain. Technique: Patient can be seated or supine. If pain is felt on the opposite side. or dural irritability. If the patient does not have radiating pain.
1989. Porras M. In: Orthopedic Physical Assessment. DJ Chapter 3. 1995. Spine. 4.29(7)(Suppl. Med Sci Sports Exerc. 1994. Sandmark H. 7 . 3.14:253–257. 6. Compression of brachial plexus as a diagnostic test of cervical cord lesion. Jull G. 2009. Cervical Spine Sources 1. Philadelphia. 2. The diagnosis and treatment of cervical radiculopathy. Uchihara T. Hall T. et al.):S236–S245. PA: WB Saunders Co. Validity of clinical tests in the diagnosis of root compression in cervical disease. Malanga GA. Spine. compression. 5. 2nd edition. Magee. Spine. Tsukagoshi H. The influence of cervical traction. Validity of five common manual neck pain provoking tests. Takasaki H. Cervical spine: tests for neurological symptoms.34(16):1658–1662. Laasonen EM.19:2170–2173. Furukawa T. and Spurling test on cervical intervertebral foramen size. Viikari-Juntura E. 1997.27:131–136. Scand J Rehab Med.2. 1992:163. Nisell R.
Technique: Examiner stabilizes the scapula. Sensitivity: Subacromial bursitis: 75% Rotator Cuff Pathology: 83.5% Rotator Cuff Pathology: 50.8% Sources: 8 Hawkin’s-Kennedy Test Purpose: Rotator Cuff (RTC) impingement/subacromial bursitis.3% Rotator Cuff Pathology: 42. Positive test: Reproducible shoulder pain. Positive test: Reproducible shoulder pain. then passively internally rotates and forward flexes the patients shoulder more than 90°.3% Specificity: Subacromial bursitis: 47. Sensitivity: Subacromial bursitis: 91.7% Rotator Cuff Pathology: 87.3.6% Sources: 8 8 . Technique: Examiner flexes the patients shoulder to 90° and forcibly internally rotates the shoulder. Shoulder Neer’s Test Purpose: Rotator cuff (RTC) impingement/subacromial bursitis.5% Specificity: Subacromial bursitis: 44.
Shoulder Empty Can Test (Supraspinatus test) Purpose: Supraspinatus Pathology. Technique: The patient’s arm is held at 90° of abduction and 30° of horizontal adduction with full internal rotation (thumbs down). Positive test: The patient is unable to keep the arm up against resistance secondary to pain or weakness. Technique: The patient’s shoulder is held at 90° of abduction and externally rotated (thumbs up). Positive test: The patient is unable to keep the arm up against resistance secondary to weakness or pain.3. Sensitivity: 86% Specificity: 57% Sources: 10 9 . The patient resists downward resistance from the examiner. 10 Full Can Test Purpose: Supraspinatus weakness/RTC impingement. The patient maintains this position against downward resistance. Sensitivity: Supraspinatus pathology: 89% Specificity: Supraspinatus pathology: 50% Sources: 9.
shoulder is abducted 20°. 12 External Rotation Lag Sign Purpose: Full thickness tears of supraspinatus and infraspinatus. Positive test: Patient cannot maintain shoulder in external rotation.3% Full-thickness rotator cuff tear: 34. Shoulder Drop-Arm Test (Codman’s Test) Purpose: RTC (Rotator Cuff) tear.5% Full-thickness rotator cuff tear: 87.9% Specificity: Partial-thickness rotator cuff tear: 77. Positive test: The patient is unable to return the arm to the side slowly.3. Technique: The examiner abducts the patient’s shoulder to more than 90° and then asks the patient to slowly lower it to the side.5% Positive predictive value: 100% Sources: 11. Technique: The patient is seated with the back to the examiner. Severe pain implies partial thickness tear. Sensitivity: Partial-thickness rotator cuff tear: 14. Sensitivity: 56% Specificity: 98% Sources: 2 10 . The examiner externally rotates the shoulder while supporting the elbow and then releases the wrist. The elbow is flexed to 90°.
17 11 . Technique: The patient is asked to lift the arm off of the back without and with resistance. Technique: The patient’s elbow is flexed to 90°. and the patient is asked to rotate the arm externally against resistance. Sensitivity: 100% Specificity: 93% Sources: 3 Lift Off Test Purpose: Subscapularis tendon tear. Modification: Internal rotation lag sign: The examiner lifts the patient’s arm off of back and asks the patient to maintain this position. Sensitivity: Partial-thickness subscapularis tendon tears: 22% Full-thickness subscapularis tendon tears: 94% Modification: 97% Specificity: Partial-thickness subscapularis tendon tears: 99% Full-thickness subscapularis tendon tears: 99% Modification: 96% Sources: 13. Positive test: Pain or inability to maintain the externally rotated position and the arm drops back to neutral position. Shoulder Hornblower’s Sign (Patte’s Test) Purpose: Infraspinatus and teres minor integrity. Positive Test: the patient is unable to maintain arm off of back.3. Positive test: The patient is unable to lift hand away from his/ her back.
7% Sources: 1 Belly-press Test Purpose: Subscapularis muscle tendon tear.3. Technique: The patient attempts to maximally internally rotate his/her shoulder by pressing the hands on the abdomen with elbows coming forward (anteriorly). Positive test: The elbow drops backward. externally rotating the shoulder. Sensitivity: 60% Specificity: 91. which takes over for the weak internal rotators. The examiner tries to lift the patient’s hand off the shoulder. 14 12 . Shoulder Bear Hug Purpose: Subscapularis tear. Positive test: The patient is unable to keep the hand on the shoulder. Sensitivity: Partial-thickness subscapularis tendon tears: 29% Full-thickness subscapularis tendon tears: 88% Specificity: Partial-thickness subscapularis tendon tears: 98% Full-thickness subscapularis tendon tears: 97% Sources: 13. Technique: The examiner places the patient’s affected arm across the opposite shoulder at a 90° angle.
Technique: The patient is supine. a posterior force is applied to the proximal humerus. (Grade I: 0–25% minimal movement). moderate (Grade II: 25–50% movement—feeling the humeral head ride upon the glenoid rim). or severe (Grade III: more than 50% movement—feeling the humeral head ride up and over the glenoid rim). 16 Load and Shift Test Purpose: Anterior/posterior shoulder laxity/instability.3. If the patient displays apprehension/ pain. Shoulder Apprehension-Relocation Test (Jobe Relocation test) Purpose: Anterior shoulder instability. The patient’s shoulder is held in 90° abduction and passively moved into maximal external rotation. The examiner applies a compressive force. Positive Test: A decrease in pain/apprehension with a posterior force implies anterior instability. while the other hand stabilizes the scapula. Positive test: The degree of glide is graded mild. A posterior to anterior force is applied to the posterior aspect of the humeral head. (continued ) 13 . “loading” the humerus into the glenoid fossa and then glides/“shifts” in an anterior to posterior direction noting the amount of translation in relation to the glenoid. Sensitivity: 68% Specificity: 100% Sources: 15. Technique: The examiner grasps the proximal humerus with one hand.
The patient’s arm is grasped by the examiner and pulled inferiorly. Technique: The patient is seated or standing with the arm relaxed by the side.3. Sensitivity: Combination of tests: 90% Specificity: 85% Sources: 18. Shoulder Load and Shift Test (continued) Sensitivity: 50% Specificity: 100% Sources: 18 Sulcus Sign Purpose: Labral tear/inferior shoulder laxity/instability. Positive test: Dimpling of the skin below the acromion suggesting widening of the subacromial space between the acromion and the humeral head. 7 14 .
The examiner applies a downward force with the patient trying to resist. 20 15 . Pain at the AC joint or on top of the shoulder is diagnostic for AC joint pathology. and again. 19. the examiner applies a downward force with the patient trying to resist. Pain or painful clicking inside the glenohumeral joint points to labrum injury. Technique: The patient forward flexes the arm 90° with the elbow in full extension and adducts the arm 10°–15° medially. Sensitivity: Labrum: 100% AC joint: 16%–41% Specificity: Labrum: 98.3. With the arm in the same position. The arm is internally rotated with thumbs pointing down. the arm is then externally rotated with the palm fully supinated. Positive test: If pain is elicited with the first maneuver and is reduced with the second maneuver. Shoulder O’Brien Test (Active Compression Test) Purpose: SLAP (superior labrum from anterior to posterior)/ Acromioclavicular (AC) joint pathology.5% Ac joint: 90%–95% Sources: 6.
Apley Scarf Test (CrossedArm Adduction Test/AC
Purpose: AC joint pathology.
Technique: The patient’s arm
is held 90° of shoulder flexion
and is passively adducted
across the body horizontally bringing the elbow toward the
Positive test: Pain elicited at AC joint.
Purpose: Bicipital tendinopathy.
Technique: The patient’s elbow
is extended and the forearm
supinated. The patient flexes the
shoulder anteriorly against resistance.
Positive test: Pain localized to the bicipital groove.
Purpose: Bicipital tendinopathy.
Technique: The patient’s elbow
is flexed to 90° and the forearm
pronated. The patient tries to
supinate against resistance.
Positive test: Pain localized to the bicipital groove.
1. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new
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revisited: accuracy for diagnosis of full thickness supraspinatus tear. J Shoulder Elbow Surg. 2009;18(4):529–534.
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6. O’Brien SJ, Pagnani MJ, Fealy S, et al. The active compression test: a new and effective test for diagnosing labral tears
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9. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of
subacromial impingement syndrome. J Bone Joint Surg Am.
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can test” or the “empty can test,” in detecting the torn
supraspinatus tendon? Am J Sports Med. 1999;27:65–68.
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Positive test: Lateral elbow pain and/or joint laxity. while the other hand is along the ulnar aspect of the patient’s wrist. Sensitivity: No Data (ND) Specificity: No Data Sources: 1 Valgus Stress Test (Abduction Stress Test/ Jobe’s Test) Purpose: Medial collateral ligament instability. Sensitivity: No Data (ND) Specificity: No Data Sources: 2 19 . The examiner places one palm on the lateral aspect of the patient’s elbow. Technique: The patient is seated with forearm fully supinated and elbow flexed to 20º–30º. Positive test: Medial elbow pain and/or joint laxity. A medially directed force is applied to the distal forearm. A laterally directed force is applied to the distal forearm. Technique: The patient’s arm is supinated and flexed to 25°. The examiner places one hand along the medial aspect of the patient’s elbow and the other hand along the radial aspect of the distal forearm at the wrist.4. Elbow Joint Varus Stress Test (Adduction Stress Test) Purpose: Lateral collateral ligament instability.
4. Positive test: Pain elicited along the origin of the flexor carpi radialis tendon at the medial elbow. The patient is asked to radially deviate and extend the wrist against resistance provided by the examiner’s other hand. Sensitivity: No Data (ND) Specificity: No Data Sources: 2 20 . The examiner places his/her thumb along the origin of the extensor tendons at the lateral epicondyle. Technique: The patient’s elbow is stabilized at 60°–90° of flexion with the forearm in prone position. Elbow Joint Cozen’s Test (Resisted Wrist Extension/Resisted Third Finger Extension) Purpose: Lateral epicondylitis. and the elbow is flexed to 90°. 3 Resisted Wrist Flexion Purpose: Medial epicondylitis. while the patient is asked to flex and pronate the wrist against resistance applied by the examiner. Sensitivity: No Data (ND) Specificity: No Data Sources: 2. Technique: Patient’s forearm is supinated. Positive test: Pain over the lateral epicondyle. Modification: Test may be performed with the elbow in full extension or with resisted third finger extension.
eds. Davis BA. wrist. Miller A.4. et al. Musculoskeletal Physical Examination: An EvidenceBased Approach. 21 . PA: Elselvier. Agesen T. Physical examination tests for the shoulder and elbow. 2009:31. Philadelphia. 2006: 198–199. Elbow Joint Sources 1. Nadler SF. Nadler S. Heckert KD. Physical examination of the elbow. Philadelphia. and hand. 2. In: Malanga GA. PA: Lippincott Williams & Wilkins. eds. The 3-Minute Musculoseletal & Peripheral Nerve Exam. Nicoletta RJ. Sports Medicine. 3. Busconi BD. New York. In: Schepsis AA. NY: Demos Medical Publishing. 2006:155–165. Wrightson J.
Wrist and Hand Phalen’s Test (Wrist Flexion) Purpose: Carpal Tunnel Syndrome (CTS). 2. median nerve entrapment. Positive test: Reproduction of paresthesias/numbness in digits 1–4. 4. Sensitivity: 71%–80% Specificity: 20%–80% Sources: 1. 5 Reverse Phalen’s Test (Wrist Extension) Purpose: CTS. 2. median nerve entrapment neuropathy at wrist. Technique: The patient is asked to flex wrists for approximately 1 minute. 3.5. 6 22 . Technique: The patient is asked to extend wrists for approximately 1 minute. Sensitivity: 43% Specificity: 74% Sources: 1. Positive test: Reproduction of paresthesias/numbness in digits 1–4.
Sensitivity: 87% Specificity: 90% Sources: 1. median nerve entrapment neuropathy at wrist. (continued ) 23 . Positive test: Reproduction of paresthesias/numbness in digits 1-4 (can also be performed at the cubital tunnel. Technique: The examiner extends and taps the wrist over the median nerve in the area of the distal wrist crease. 4 Carpal Compression Purpose: CTS. and medial malleolus for ulnar. 2. median nerve entrapment neuropathy at wrist. respectively).5. Sensitivity: 25%–44% Specificity: 94%–98% Sources: 1. and tibial nerve compression. fibular head. Positive test: Reproduction of paresthesia in the digits 1–4. firm pressure to the median nerve with thumbs while placing the rest of the fingers over the dorsum of the hand and wrist. common peroneal. 3. Wrist and Hand Tinel’s Sign at the Wrist Purpose: CTS. 7 Finklestein’s Test Purpose: Tenosynovitis of the extensor pollicis brevis and abductor pollicis longus tendons (de Quervain’s). Technique: The examiner applies gentle. 2.
An EvidenceBased Approach. Wrightson J. Nadler SF. Philadelphia. The thumb can be positioned in extension to assess the accessory ligament. and the ulnar deviates the wrist. Sensitivity: No Data (ND) Specificity: No Data Sources: 1. Positive test: If there is more than 30° of laxity (or 15° more than the other side) rupture of the ligament is likely. Wrist and Hand Finklestein’s Test (continued ) Technique: The thumb is flexed into the palm with the hand in a fist. 24 . Positive test: Reproduction of pain at the radial side of the wrist to the thumb. and hand. Technique: Valgus stress applied over the metacarpal phalangeal joint (MCP) in 30° of flexion by grasping the thumb proximal to the joint. wrist.5. Nadler SF. 2 Valgus Testing of Ulnar Collateral Ligament Purpose: Ulnar collateral ligament tear/rupture/ Gamekeeper’s thumb. Sensitivity: No Data (ND) Specificity: No Data Sources: 1. et al. Agesen T. PA: Elsevier. The examiner grasps the fist. 2 Sources 1. Physical examination of the elbow. Musculoskeletal Physical Examination. eds. 2006:48–55. In: Malanga GA.
1986.5. 25 . Electromyogr Clin Nerophysiol.73:535–538. A new diagnostic test for carpal tunnel syndrome. Heckert K. 2009. Letz R. J Bone Joint Surg Am.38:437–441. Gelberman RH. 1998. Tan AM. 5. The carpal tunnel syndrome: clinical evaluation of 598 hands. DiCuccio. Gellman H. The sensitivity and specificity of tests for carpal tunnel syndrome vary with the comparison of subjects. Miller A. 6. Carpal tunnel syndrome: an evaluation of the provocative diagnostic tests. Durkan JA. AM 1991. Davis B. Ghavanini MRA. 4. Haghighat M. Phalen GS.83:29–40. 1998. 7. Wrist and Hand 2. et al. 3. Clin Orthop Rel Res. Gerr F. The 3-Minute Musculoskeletal & Peripheral Nerve Exam. NY: Demos Medical Publishing. J Bone Joint Surg. Carpal tunnel syndrome: reappraisal of five clinical tests. 1972.23(2):151–155. New York.68:735–737. J Hand Surg Br.
Lumbar Spine Straight Leg Raise Test (SLRT) (Lasegue’s Sign/ Lazarevic’s Sign) Braggard’s Sign Purpose: Spinal cord root compression/lumbosacral (LS) radiculopathy. Technique: The patient is supine. Sensitivity: 29% Specificity: 88% Sources: 1 26 . Positive test: Pain at 30° to 70° of hip flexion. Modifications: Can also be tested in the seated position and the knee brought into full extension (the hip is already flexed because the patient is seated). radiating from the buttocks down the posterior thigh to below the knee (sciatic nerve distribution). the examiner drops the leg to a point where pain is resolved and dorsiflexes the ankle. Positive test: Pain is elicited down the leg that was not lifted. Braggard’s sign—When the patient reports pain after lifting the leg. The examiner lifts one leg off the table with the knee fully extended. Sensitivity: 91% Specificity: 26% Sources: 1 Crossed Straight Leg Raise Test Purpose: Spinal cord root compression/LS radiculopathy. Technique: Perform the SLRT on the nonsymptomatic side. Positive test is radiating pain.6.
Crossed Femoral Test) Purpose: Femoral nerve root irritation (L2-L4)/high lumbar radiculopathy. Technique: The patient is prone on the table.6. The examiner flexes the knee to more than 90° and then extends the hip. while the other hand brings the patient’s foot into dorsiflexion and flexes the hip with the knee extended. Sensitivity: No Data (ND) Specificity: No Data Sources: 3 27 . Positive test: Pain over the anterior/medial thigh and/or back on the symptomatic leg. Lumbar Spine Slump Test (Nerve Entrapment Test) Purpose: Lumbar radiculopathy/ sciatica. Technique: The patient is seated and the examiner uses one hand to forward flex the cervical and thoracic spine. Positive test: Pain radiating down that leg to below the knee. Modifications: Crossed femoral stretch test can also be performed (refer to crossed SLRT). Sensitivity: 44% Specificity: 58% Sources: 2 Femoral Nerve Stretch Test (Ely’s Test.
The examiner extends. tremors. Positive test: Nonradiating low back pain implies facet pathology. Sensitivity: No Data (ND) Specificity: No Data Sources: 5 28 . Kemp’s Test) Purpose: Facet pathology vs disk prolapse/protrusion. 1. and laterally flexes the lumbar spine while compressing the ipsilateral shoulder. or disproportionately verbalizes. Regional disturbances: If physical exam diverges from accepted neuroanatomy. the patient overreacts by tensing up his muscles. Lumbar Spine Facet Grind Test (Extension and Load Test. Overreaction: During physical examination.6. 2. Radiating pain implies disk herniation. Sensitivity: No Data (ND) Specificity: No Data Sources: 4 Waddell Signs Purpose: Non-organic/psychological causes of low back pain. 3. sweating. Tenderness: Superficial or nonanatomical tenderness. 4. Example: Nondermatomal sensory loss or entire limb weakness. Distraction: A positive exam finding disappears when the patient is distracted. rotates. Example: Axial loading of head or rotation of pelvis and shoulder causes Low Back Pain (LBP). Simulation tests: Pain provoked by a simulated/sham maneuver that does not actually test that area. Technique: The patient is sitting or standing. 5. Example: SLR positive in supine but negative when sitting.
Stankovic R. Dtsch Z Nervenbeilk. 5. Use of lumbar extension. 29 . Lumbar Spine Sources 1. Spine. 1999. 1919. Ueber ein neues Schenkelnersymptom nebstr Bemerkungen zur Diagnostik der Schenkerlnerverkrankungen. van der Windt DA. Nonorganic physical signs in low back pain. The 3-Minute Musculoskeletal & Peripheral Nerve Exam.25:1140–1147.6. slump test. 2000. Willner S. Miller A. The test of Laseque: systematic review of the accuracy in diagnosing herniated discs. Bezemer PD. Kummel E. Wadell G. Deville WL. 2009:52. physical and neurological examination in evaluation of patients with suspected herniated nucleus pulposus: a prospective clinical study. NY: Demos Medical Publishing.19(43):140–143. Venner RM. Dzaferagic A. Wassermann S. Man Ther. New York. Spine. 4. 2. McCulloch JA. Johnell O.5:117–125. Bouter LM.4(1):25–32. Heckert K. Maly P. 1980. Davis B. 3.
and then released to allow the leg to drop. Sensitivity: No Data (ND) Specificity: No Data Sources: 1. the leg is held in extension). extended. Positive test: The leg remains passively abducted.9% Sources: 2. Technique: The patient lies on the unaffected side. 4. The affected side is flexed at the knee to 90° (for Modified Ober Test. 5. 3. Technique: The patient is observed from the rear standing on one leg. The examiner grasps the ankle lightly with one hand and steadies the patient’s hip with the other.7% Specificity: 76. Test is repeated on the other side. Positive test: Pelvic drop on the unsupported side suggests weak gluteus medius muscle on the supported side. Sensitivity: 72. The leg is abducted. 3. 6. 7 30 . Hip Trendelenburg Test/Sign Purpose: Gluteus medius weakness. 9 Ober Test (Modified Ober Test) Purpose: Tensor fascia lata/ iliotibial band tightness.7.
Technique: The patient lies supine. Hip Patrick’s/Flexion. Sensitivity: No Data (ND) Specificity: No Data Sources: 3. Positive test: Pain over the piriformis. and externally rotates the hip with the ankle resting on the contralateral knee. abducts. Positive test: Reproducible groin or hip pain. The examiner flexes. Technique: The patient lies on the unaffected side.7. Sensitivity: No Data (ND) Specificity: No Data Sources: 5. The examiner flexes the hip to 60° with knee flexed while applying a downward pressure on the knee. The examiner stabilizes the pelvis by applying pressure to the contralateral ilium. Abduction. External Rotation. 5 Piriformis/Flexion. Extension (FABERE) Purpose: Hip joint pathology. 8 31 . Internal Rotation (FAIR) Purpose: Piriformis muscle spasm/tightness. Adduction. Pressure is applied to the knee to further externally rotate the hip.
bringing the knee to the chest to flatten out the lumbar spine.66:620–625. Shnier R.7. The significance of the Trendelenburg test. 1985. NY: Demos Medical Publishing.44:2138–2145. Wolf LS. ed. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. The examiner flexes one of the patient’s hips. 3. Musculoskeletal medicine. 32 . In: Cuccurullo SJ. Shurtleff DB. 4. Sensitivity: No Data (ND) Specificity: No Data Sources: 1. 3. 5 Sources 1. et al. Arthritis Rheum. 2001. Physical Medicine and Rehabilitation—Board Review. et al. New York. 2. 1985. Arch Phys Med Rehabil. Brown DP. J Bone Joint Surg. 2010:215–217. Oakley SP. Bird PA. Cuccurullo SJ.67(5):741–746. Freeman ED. Hip Thomas Test Purpose: Hip flexion contractures. Bartlett MD. Hip flexion contractures: a comparison of measurement methods. and the patient holds the flexed hip against the chest. The other hip should remain straight on the table. Positive test: The hip remaining straight on the table flexes implying a contracture of the iliopsoas. Hardcastle PH. Nade SM. Technique: The patient lies supine while the examiner checks for excessive lordosis.
9. 7. Acta Orthop Scand. Jarmain SJ. In: Malanga GA. 1981. Reese NB. eds. Musculoskeletal Physical Examination: An Evidence-Based Approach. Paus B. Philadelphia. 1936. Nadler SF. 2006:253–254. Siewers P. 33 . Ober FB. The piriformis muscle syndrome: sciatic nerve entrapment treated with section of the piriformis muscle.355:3–7. J Bone Joint Surg.7. Trendelenburg F. PA: Elsevier. Use of an inclinometer to measure flexibility of the iliotibial band using the Ober test and the modified Ober test: differences in magnitude and reliability of measurements. 1998.52:73–75. Krabak BJ. Prather H. Bandy WD.18:105–110. 8. 6. 264. 33(6):326–330. Physical Examination of the hip. Hip 5. Trendelenburg’s test 1895. J Orthop Sports Phys Ther. Clin Orthop. The role of iliotibial band and fascia lata as a factor in the causation of low back disabilities and sciatica. Solheim LF. 2003.
7 Gaenslen’s Test Purpose: SI joint pathology. extending the hip joint. compressing the SI joint. and the top leg can be tested by drawing it backward toward the examiner. Positive test: Pain over the SI joint region. 5. Positive test: Pain over the SI joint on the side that is off the table. 10. Technique: The patient lies supine with the affected side closer to the edge of the table. Modification: The patient can also lie on the side. 9. 3. 4. Technique: The patient lies on the side with the painful side up. Sacroiliac Joint Compression Test (Midline Sacral Thrust) Purpose: Sacroiliac (SI) joint pathology. The lower extremity on the affected side is dropped off the table. 12 34 . 11. 6. 8.8. Positive test: Pain over the gluteal region near the SI joint. The examiner stabilizes the unaffected hip. 2. The examiner applies a downward force over the iliac crest. Sensitivity: 68% Specificity: 35% Sources: 2. Modification: This test can be performed with the patient supine while applying a compressive force into the midline of the hip. The unaffected side is flexed at the knee and hip. Sensitivity: 0%–19% Specificity: 90%–100% Sources: 1.
and the other hand extends the opposite hip joint. Man Ther. Musculoskel etal Examination: An Evidence-Based Approach. Man Ther. JAMA. Solomon J. Hagmeijer RH.5(2):89–96. In: Malanga GA. 6. Philadelphia. Griffin AJ. Newton DRL. Ann Rheum Dis.24:1575–1577. Clinical tests of the sacroiliac joint.50:850–853. Hagmeijer RH. Russel AS.43(2):192–195. Clinical examination of the sacroiliac joints: a prospective study. Maksymowych W. 1: Reliability. 2000. Proc R Soc Med. Rantanen P. Van der Wurff P. Sensitivity: No Data (ND) Specificity: No Data Source: 13 Sources 1. PA: Elsevier Mosby. Blower PW. eds. 2. and the examiner puts one hand on the sacrum. J Man Med. 2000. Nadler SF. Sacroiliac Joint Yeoman’s Test Purpose: SI joint. Meyne W. Technique: The patient lies prone.8. Discussion on the clinical and radiological aspect of Sacro-iliac disease.5(1):30–36. Van der Wurff P. Physical examination of the sacroiliac joint. 8. Positive test: Pain over the SI joint. 5. 35 . 1957. 1981. Arthritis Rheum. 1989. Aireksinen O.4:62–64. Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain: two studies.89: 2031–2035. 1984. 1927. LeClerq S. Gaenslen FJ. Meyne W. Clinical tests of the SI joint—a systemic methodological review. Prather H. Nadler SF. 3. Poor agreement between so– called sacroiliac joint tests in ankylosing spondylitis patients. 4. 2006:227–249. 7. Sacro-iliac arthrodesis.
Musculoskeletal Examination. Gross J. 1996. Positive sacroiliac screening tests in asymptomatic adults. Am J Orthop. The relation of arthritis of the sacro-iliac joint to sciatica. 1994. Sacroiliac Joint 9. Dreyfuss P. et al. Dreyfuss P. with an analysis of 100 cases.8. Griffin J. Cambridge. The sacroiliac joint as an underappreciated pain generator.24:475–478. 11. 1996. MA: Blackwell Science. 1119–1122. W. 10. Daum WJ.19:1138–1143. Pauza K. Spine. 12. 1995. Yeoman. et al. Spine. 1928. 13. Dreyer S. 36 . Rosen E. Lancet. The value of medical history and physical examination in diagnosing sacroiliac joint pain.21:2594–2602. Fetto J. Michaelsen M.
4. 8. 6. Distracting the tibia (and inducing pain) indicates ligamentous injury. 5. Technique: To assess the medial meniscus. and the leg is steadily extended. Positive test: Pain or “clunk” is noted.9. (continued ) 37 . 12 Apley Grind Test Purpose: Meniscal injury. Sensitivity: 16%–58% Specificity: 77%–98% Sources: 2. 11. 10. Modifications: A valgus or varus stress is added to the rotation component in order to further challenge the integrity of the menisci. For the lateral meniscus. The examiner grasps one foot and both externally and internally rotates as far as possible while applying a downward pressure on the foot. Technique: The patient is prone with the knees flexed at 90˚. Positive test: A painful response over the lateral or medial joint line indicates meniscal pathology. the patient’s knee is positioned in full flexion and the tibia in external rotation. Knee McMurray’s Test Purpose: Meniscal injury. the test can be repeated with the tibia held in internal rotation.
9. 11. Duck Waddle. Knee Apley Grind Test (continued ) Sensitivity: 13%–16% Specificity: 80%–90% Sources: 2. Technique: Standing on the affected leg. 4. the patient flexes the weight-bearing knee to approximately 20° and then rotates the femur with the body’s weight over the fixed foot and tibia. Sensitivity: 64% Specificity: 90% Sources: 12 38 . Sensitivity: 89% Medial. Positive test: The patient is unable to do this maneuver (without pain). 10. Technique: The patient squats and attempts to take a few steps in this position. 5. 8. 12 Thessaly/Disco Test Purpose: Meniscal injury. Duck Walk) Purpose: Meniscal injury. Rotation into internal and external rotation is repeated several times. 90% Lateral Sources: 3 Childress’s Test (Squat. 6. 92% Lateral Specificity: 97% Medial. Positive test: Pain over joint line or sensation of locking or catching.
and the patella is pushed laterally in a slow and controlled manner. the patient externally rotates the legs and slowly squats. To test the medial meniscus. To test the lateral meniscus. the patient internally rotates the legs and squats. Sensitivity: 32% Specificity: 86% Sources: 7.9. Both thumbs are placed over the medial patella border. Technique: The patient lies supine with the knees flexed to 30° over the clinician’s thigh. Sensitivity: 67% Medial 64% Lateral Specificity: 81% Medial 90% Lateral Sources: 1 Patella Apprehension Test (Fairbanks) Purpose: Patellar subluxation. Positive Test: Pain or click felt at the joint line. 9 39 . Technique: The patient stands with feet 30-40 cm from each other and knees in full extension. Knee Ege’s Test Purpose: Meniscal injury. Positive test: Pain and/or apprehension.
and then pulls it anteriorly with both hands.2%–95. Sensitivity: 22.9. Knee Patellofemoral Grinding Test (Clark’s test) Purpose: Patellofemoral dysfunction and/or chondromalacia patella. 16. making sure the patient is completely relaxed. Technique: The patient is supine with the hip flexed to 45° and knee flexed to 90°. The examiner applies a downward and inferior pressure over the superior border of the patella and asks the patient to contract the quadriceps. 9 Anterior Drawer Test Purpose: Anterior cruciate ligament (ACL) injury/laxity.24% Specificity: more than 97% Sources: 13. 15. Positive test: Increased forward tibial displacement compared with the non-affected side. 14. 17. 18 40 . Technique: The patient lies supine with the knees extended. Sensitivity: 49% Specificity: 75% Sources: 7. Positive test: Pain/crepitus over the patella. The examiner sits on the subject’s foot. grasps the tibia.
24 41 .67%–99% (under anesthesia) 80%–98. Sensitivity: 84. 19. Positive Test: A palpable/audible click will be heard implying tibial relocation. Technique: The patient’s knee is flexed to 30° while applying a valgus force to the knee and internally rotating the tibia. Positive test: Increased forward tibial displacement compared with the other side.9.8% (without anesthesia) Specificity: 95% (under anesthesia) Not reported without anesthesia Sources: 14. The examiner holds the knee in 20°–30° of flexion and pulls the tibia anteriorly. Knee Lachman Test Purpose: ACL injury/laxity. Sensitivity: 35%–98. causing the lateral tibial plateau to sublux. 15. 16.4% (under anesthesia) Not reported without anesthesia Specificity: >98% (under anesthesia) Not reported without anesthesia Sources: 14. 17. The examiner then slowly extends the knee. 17. 18 Pivot Shift Test Purpose: ACL injury/laxity. Technique: The patient is supine.
23. Sensitivity: 62% (without anesthesia) Not reported under anesthesia Specificity: 89% (without anesthesia) Not reported under anesthesia Sources: 21 Posterior Drawer Test Purpose: PCL injury/laxity. Knee Reversed Lachman Test Purpose: Posterior cruciate ligament (PCL) injury/laxity.9. knee flexed to 90°. Positive test: Increased posterior tibial displacement compared with the other side. Technique: The patient is supine. 21. Positive test: Increased posterior tibial displacement compared with the non-affected side. 24. and foot in neutral position. The examiner holds the knee in 20°–30° of flexion and pulls the tibia posteriorly. Posterior force is applied to the proximal tibia. 25 42 . 20. Sensitivity: 51%–100% Specificity: 99% Sources: 13. Technique: The patient lies supine with the involved hip flexed to 45°.
The examiner applies valgus (medial) force across the joint line. 26. The examiner applies varus (lateral) force across the joint line. Sensitivity: 25% Specificity: No Data (ND) Sources: 13 43 . Technique: The patient is supine and the knee flexed to 30°. Technique: The patient is supine and the knee flexed to 30°. Positive test: Increased laxity/widening or pain of the lateral joint line compared to the other side. Knee Valgus Stress Test Purpose: Medial collateral ligament injury/laxity. Sensitivity: 86%–96% Specificity: No Data (ND) Sources: 13. 27 Varus Stress Test Purpose: Lateral collateral ligament injury/laxity.9. Positive test: Increased laxity/widening or pain of the medial joint line compared to the non-affected side.
84:592–603. Do physical diagnostic tests accurately detect meniscal tears? Knee Surg Sports Traumatol Arthrosc. Am J Sports Med. PA: Elsevier Mosby. Arch Phys Med Rehabil. Nijs J. 44 . Malanga GA. 4. Van Geel C. et al. The predictive value of five clinical signs in the evaluation of meniscal pathology. Ryzewicz M. Int Orthop. et al. 3. J Bone Joint Surg. Sally PI. 6. Kurosaka M. et al. 2005. Karachalios. et al.5(3):184–186. 11. Konan S.24(1):52–60. Scholten RJ. T. Physical examination of the knee: a review of the original test description and scientific utility of common orthopedic tests. 1st ed.50(11):938–944.455:123–133. 2009. Zibis AH. 1989. J Fam Pract. Hattam P. Fowler PJ. Nadler SF. Special Tests in Musculoskeletal Examination: An Evidence-Based Guide for Clinicians. Hantes M. et al. Clin Orthop Relat Res. Andrus SA. A new weight-bearing meniscal test and a comparison with McMurray’s test and joint line tenderness. 2007. Yoshiya S. 10.9. Van der Auwera C.17:806–811. Rayan F. Speer KP. Arthroscopy. Siparsky PN.87(5):955–962. Opstelten W. 5. Peterson B. Nadler SF. Acute dislocation of the patella: a correlative pathoanatomic study. Ozcan O. 12. 9.23:271–274. 2004.20(9):951–958.11:69–77. Efficacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear. 8. 2006. 2001. 2. The diagnosis of meniscus tears: the role of MRI and clinical examination. Deville WL. Diagnostic value of five clinical tests in patellofemoral pain syndrome. Boya H. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. 7. 2003. Arthroscopy. Haddad FS. Akseki D. 1999. et al. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee—a meta-analysis. 1996. Yagi M. Knee Sources 1. Philadelphia. 2010. London: Churchill Livingstone Elsevier. Poggi J. Smetham A. Man Ther. 1st ed. et al. Musculoskeletal Physical Examination: An Evidence-Based Approach. Lubliner JA. Malanga GA. 2005.
18. Del Pizzo W. Renstrom P. Friedman MJ. Stone ML. 20. Heckman JD. Kim HK. Larson RL. 1980.9:86–92. 1988. 1995. 19. 21. Reliability of the anterior drawer test.70:386–391. DeLee JC.13:5–10.12:189–191. Barnett P. Posterior cruciate ligament injuries. Warren RF. Kim SJ. Rettig AC. Loos WC. 1982. The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test. Katz JW. Vallianatos P. Mitsou A. Fox JM. Knee 13. 14. 22.10:100–102. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. 1987. J Bone Joint Surg Am. Am J Sports Med.19:427–428. Am J Sports Med. Orthopedics. Daniel DM. 16. Am J Sports Med. 1988. 1994.14:88–91. 1980. Am J Sports Med. Initial versus examination under anesthesia. 1981. Peterson L. Donaldson WF III. 1985. Ann Chir Gynaecol. Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. 17. Clinical diagnosis of ruptures of the anterior drawer ligament: a comparative study of the Lachman test and the anterior drawer sign. Wiedel JD.8:68–78.76:269–273. Harilainen A. Am J Sports Med. Acute posterior cruciate ligament injuries. Lucie RS. Shelbourne KD. Results of early surgical repair. VanMeter CD. A comparison of acute anterior cruciate ligament examinations. Rubinstein RA Jr. Evaluation of knee instability in acute ligamentous injuries. Jonsson T. McCarroll JR. 24.9. 45 .317:237–242. Am J Sports Med. 1984. 23. Wickiewicz T. Messner DG. the anterior drawer sign. Fingeroth RJ. Blazina ME.3:764–772. Clin Orthop. 22:550–557. the pivot shift test. Clinical diagnosis of ruptures of the anterior cruciate ligament: a comparison between the Lachman test and the anterior drawer sign. and the Lachman test. Injury. Althoff B. 15. Am J Sports Med. The acute pivot shift: clinical correlation. 1986. Interstitial tears of the posterior cruciate ligament of the knee. and the pivot shift test in acute and chronic knee injuries. Sachs R. Clendenin MB. Moore HA.
Rothstein JM. Vellet AD. Knee 25.9. 1989. The lateral compartment.69:268–275. J Bone Joint Surg Am.44:199–204. 27. Andrews JR. 26. Intertester reliability of clinical judgments of medial knee ligament integrity. McClure PW. Riddle DL. Phys Ther. Hughston JC. Garvin GJ. Munk PL. Cross MJ. Part II. 1976. Can Assoc Radiol J. 1993. Classification of knee ligament instabilities. 46 . Tears of the medial collateral ligament: magnetic resonance imaging findings and associated injuries.58:173–179. Moschi A.
If the patient is unable to lie on the exam table. in an attempt to draw the talus anteriorly from beneath the tibia. the patient can sit with the legs off the table and knee flexed to 90°. Technique: The patient sits with legs off the table. The examiner stabilizes the distal part of the leg with one hand and applies anterior force to the heel with the other hand. knees flexed to 90°. Technique: The patient lies prone on the examination table. The calf is squeezed to produce plantar flexion via the Achilles tendon. Sensitivity: 96% Specificity: 93% Source: 1 Anterior Drawer Test Purpose: Anterior talofibular ligament (ATFL) laxity. Ankle Thompson test (Simmond’s Test) Purpose: Achilles tendon injury/ rupture.10. Sensitivity: 78% Specificity: 75% Sources: 2 47 . Positive test: No plantar flexion with squeezing of the calf. Positive test: Difference in laxity between the two sides.
Talar Shift Test
(Talar Tilt Test)
Purpose: Integrity of both the
ATFL and calcaneofibular. Both
ligaments must be torn for a
positive talar tilt test.
Technique: The distal tibia and
fibula are stabilized with one hand and an inversion stress
applied to the hind foot in an attempt to displace the ankle
mortise laterally. The lateral aspect of the talus is palpated during inversion of hind foot to determine if tilting is occurring at
Positive test: More than 10° tilt compared to the other side.
More than 20° tilt is positive regardless of the opposite ankle.
Normal tilt is less than 5°. Test can be performed under X-Ray.
Sensitivity: No Data (ND)
Specificity: No Data
Purpose: Tarsal tunnel syndrome (entrapment/compression
neuropathy of the posterior tibial nerve).
Technique: The examiner taps behind the medial malleolus.
Positive test: Pain/tingling/numbness felt over the plantar
aspect of the foot.
Sensitivity: No Data (ND)
Specificity: No Data
1. Maffulli N. The clinical diagnosis of subcutaneous tear of the
Achilles tendon: a prospective study in 174 patients. Am J
Sports Med. 1998;26:266–270.
2. Hertel J, Denegar CR, Monroe MM, Stokes WL. Talocrural
and subtalar joint instability after lateral ankle sprain. Med
Sci Sports Exerc. 1999;31(11);1501–1508.
3. Brinker RM, Miller DM. Fundamentals of Orthopaedics.
Pennsylvania, PA: Saunders; 1999:328–329.
4. Magee DJ, Zachazewski JE, Quillen WS. Pathology and Intervention in Musculoskeletal Rehabilitation. Saint Louis, MO:
Neurological Tests and Scales .II.
Resistance is used during spiral and diagonal movement patterns with the goal of facilitating impulses to other parts of the body (3. Facilitation to promote motor learning. Proprioceptive Neuromuscular Facilitation Description: Combination of passive stretching and isometric contractions (7). inhibit primitive patterns of G movement. voluntary reactions (4). 6). (continued ) 53 . verbal directions) to reinforce weak movement patterns and to discourage overactive ones (3. Primitive reflex synergies are considered normal processes of recovery (4). using sensory information (tactile cue through manual contacts.11. oal is to normalize tone. Rehabilitation Approach to Neurological Deficits Bobath Approach/Neurodevelopmental Technique Description: Based on the idea that a normal automatic postural reflex mechanism is the basis for normal motion patterns. Brunnstrom Approach/Movement Therapy Description: Uses primitive synergistic patterns in an attempt to improve motor control through central facilitation (4). Uses spiral and diagonal components of movement with the goal of facilitating movement patterns that will have more functional relevance than the traditional technique of strengthening individual group muscles (4). The key element is limb positioning out of synergy focusing on the proximal to distal. and facilitate selective automatic. 5). 4.
The affected limb is then used intensively for either 3 or 6 hours a day for at least 2 weeks (4). associated reaction. Inhibitory or facilitative input through the use of quick stretch. The key element is to uses resistance. and joint compression (2. slow stroking. 3. Rehabilitation Approach to Neurological Deficits Brunnstrom Approach/Movement Therapy (continued) Enhances specific synergies through use of cutaneous proprioceptive stimuli and central facilitation (4). Rood Approach/Sensorimotor Approach Description: Uses sensorimotor stimulation to modify muscle tone and voluntary motor activity (4). Focuses on facilitating specific muscle groups based on recovery stage and facilitating gross motor movements progressing to skilled movement to promote functional activity. 3). fast brushing.11. 4). Constraint-induced Movement Therapy Description: Forces the patient to use the affected limb by restraining the unaffected limb. vibration. and primitive postural reaction to facilitate gross synergistic movements and the return of muscle tone and focus on general progressing to isolated movements (1. Can be used with hypotonia or hypertonia (3). 54 . icing. tendon tapping.
Philadelphia. Schmitz TJ. PA: Lippincott Williams and Wilkins.A. Gait restoration and gait aids. et al. 2005:1393–1396. 55 . 4th ed. Bogey RA. 7. et al. 2nd ed. Eyssette M. McAtee RE. New York. Focusing on facilitated stretching. Stroke. IL: Human Kinetic. Baerga E. 1988. Kilgore KL. 5. 6. 2. A spiral nerve cuff electrode for peripheral nerve stimulation. et al. 512. 1995.79:533–541.11. 3. Paraplegia. An implanted upper extremity neuroprosthesis. Gallian P. Pa: F. NY: Demos Medical Publishing. IEEE Trans Biomed Engi. In: Cuccurullo SJ. Physical Rehabilitation. Zorowitz RD. 3rd ed. Keith MW. Brissot R. 2007:17–18. Facilitated Stretching PNF and Strengthening Made Easy. Charland J. O’Sullivan SB. 2010:27–28. Davis Company. In: McAtee RE. eds.. Follow up of five patients. Restoration of gait by functional electrical stimulation for spinal cord injured patients. 2007:60.35:905–916. Rehabilitation Approach to Neurological Deficits Sources 1. 1997. Mortimer JT. Sisto SA. eds. ed. 720. Charland J. Physical Medicine and Rehabilitation Board Review. Peckham PH. Philadelphia. Naples GG. In: DeLisa JA et al. 5th ed. Champaign. Scheiner A.33:660–664. Physical Medicine and Rehabilitation: Principles and Practice. 4. Cuccurullo SJ. J Bone Joint Surg AM.
dressing. walking on level surface. Scoring: Scoring on the BI can be interpreted as follows (3): 80–100—independent 60–79—needs minimal help with Activities of daily living 40–59—partially dependent 20–39—very dependent less than 20—totally dependent. transferring to and from a toilet. 6). 4). Information is obtained via verbal reports from patients. Measures the patient’s ability to maintain balance both statically and while performing various functional movements— for a specified duration of time (5. caregivers and staff. The items include feeding. grooming. and by direct observation of some activities (3). A global score is calculated out of 56 possible points (5. with a score of 0 representing an inability to complete the task and a score of 4 representing independent item completion. 56 . The assessment can be used to determine a baseline level of functioning and can be used to monitor improvement in activities of daily living over time (3. The items are scored from 0 to 4. 6). going up and down stairs. The BI measures what the patient actually does rather than what they can do. Berg Balance Scale (BBS) Description: Fourteen-item scale that quantitatively assesses balance and risk for falls in older community-dwelling adults through direct observation of their performance (5. bathing.12. 6). Stroke Outcome Barthel Index (BI) Description: Ten items that measure a person’s daily functioning (activities of daily living and mobility). continence of bowels and bladder (3. 4).
balance. Fugl-Meyer Assessment (FMA) Description: Designed to assess motor functioning. It is used to determine disease severity. The scale is composed of five domains (each with multiple items) (1. sensation. and to plan and assess treatment.100 (normal motor performance) • Sensation: (0–24) • Balance: (0–14) • Joint ROM: (0–44) points. describe motor recovery. Stroke Outcome Scoring: Total score (0–56): • 0–20=balance impairment (wheelchair bound) • 21–40=acceptable balance (walking with assistance) • 41–56=good balance (independent) (7. 2): • Motor functioning (in the upper and lower extremities) • S ensory functioning (evaluates light touch on two surfaces of the arm and leg and position sense for 8 joints) • Balance (contains 7 tests. 8). • Joint pain: (0 to 44) points.12. 57 . and joint functioning in hemiplegic poststroke patients. 3 seated and 4 standing) • Joint range of motion (8 joints) • Joint Pain Scoring: Domains (2): • Motor score: 0 (hemiplegia).
Requires some help. Fugl-Meyer AR. 2. • 2 —slight disability. 10). • 5 —Severe disability. • 3 —moderate disability. • 6—Dead (9. Fugl-Meyer AR. Stroke Outcome Modified Rankin Scale Description: Commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke (9).12. Able to look after own affairs without assistance. 10). but unable to carry out all previous activities. Leyman I. • 1 —no significant disability. • 4 —moderately severe disability. incontinent. The post-stroke hemiplegic patient. indicating perfect health without symptoms to death (9. Assistance with bodily needs. Scand J Rehabil Med. Scoring: • 0—no symptoms. The scale ranges from 0-6. Functional evaluation: the Barthel Index. Requires constant nursing care. but able to walk unassisted.7(Suppl):85–93. Olsson S. Scand J Rehabil Med. bedridden. Post-stroke hemiplegia assessment of physical properties. 1975. Able to carry out all activities. Md State Med J. Sources 1. Steglind S. A method for evaluation of physical performance. 1965. 1980. despite some symptoms.14:2:61–65. Mahoney Fl. Barthel DW. 1. Jaasko L. 58 .7:13–31. Assistance with ambulation. 3.
15:49–56. Prognosis. Cerebral vascular accidents in patients over the age of 60.41:304–311. Williams JI.52:666–671. Physiotherapy Canada. 8. Berg K. Domowicz J. Van Swieten J.19(5):604–607. Stroke Outcome 4. Zwick D. 9. Van der Putten JJMF. II. Freeman JA. 59 . Thompson AJ. Williams JI. 1988. Gayton D. Wood-Dauphinee S.66(4):480–484. Rochelle A. 1999. Choksi A. Rankin J. comparison of the responsiveness of the Barthel Index and Functional Independence Measure. Whitney SL.2(5):200–215. 10. Hobart JC. 2000. Visser M. 1957. Koudstaal P. 7. Cass SP. NeuroRehabilitation. Measuring the change in disability after inpatient rehabilitation. Can J Pub Health. Measuring balance in the elderly: Validation of an instrument.12. Measuring balance in the elderly: preliminary development of an instrument. Berg K. A review of balance instruments for older adults. et al. Wood-Dauphinee S. 1992.2:S7–S11. J. 6. Evaluation and treatment of balance in the elderly: a review of the efficacy of the Berg Balance Test and Tai Chi Quan. 1989. Neurol Neurosurg Psychiatry. 1998. Scott Med J. 5. Stroke. Poole JL. Am J Occup Ther. Maki B. Interobserver agreement for the assessment of handicap in stroke patients.
60 . Upper Motor Neuron vs Lower Motor Neuron Lesion Upper Motor Neuron Lesion Lower Motor Neuron Lesion Deep Tendon Reflexes Hyperreflexia Hyporeflexia Muscle Tone Increased Decreased Fasciculations Absent Present Atrophy Absent Present Babinski Sign/ Koch Sign Present Absent Test Source 1. PA: Saunders Elsevier. 2007:1288–1291. Physical Medicine and Rehabilitation.13. Chan L et al. eds. In: Braddom RL. Bryce TN. Philadelphia. 3rd ed. Adam BS. Buschbacher RM. Ragnarsson KT. Spinal cord injury.
Specificity: No Data (ND) Sensitivity: No Data Sources: 1. 14 Crossed Upgoing Toe Sign Technique: With the patient supine. Positive Test: Dorsiflexion of the hallux. passively flex the limb at the hip. Upper Motor Neuron Signs Babinski Sign/Koch Sign Technique: Stroke the lateral side of the sole of the foot from the heel to along the metatarsal pads. 10. 9. Specificity: 90% Sensitivity: 80% Sources: 1. 13 Oppenheim Reflex Technique: Apply a firm downward stroke along the anterior border of the tibia. 3. Stroke the leg from shin to foot while the patient holds the leg in flexion. 11. Positive Test: Dorsiflexion of the hallux of the opposite leg. Positive Test: Dorsiflexion of the hallux and other toes fan out. 2. 8. Specificity: 96% Sensitivity: 31% Sources: 3.14. 12 61 . 12. 3.
14. 15. Upper Motor Neuron Signs Cross Adductor Reflex Technique: Tap the sole of the patient’s foot. Positive Test: Involuntary flexing of the end of the thumb and index finger. 6. 2 Hoffman Sign Technique: Tap the volar or dorsal surface of the third or fourth finger. 5. 17 62 . Specificity: No Data (ND) Sensitivity: No Data Sources: 1. Positive Test: Continued contraction of the mentalis and orbicularis oris muscles via wrinkling of the skin of the chin and slight retraction of the mouth. 4. Positive Test: Contraction of thigh adductors and inward rotation of leg. 7 Palmomental Reflex Technique: Stroke the thenar or hypothenar eminence in a proximal to distal direction up to five times. Specificity: 74% Sensitivity: 94% Sources: 1. 16. Specificity: 58%–98% Sensitivity: 24%–95% Sources: 3.
63 . Hanko J. J Child Neurol. Wong TM. 2008:12–22. Berger JR. Upper Saddle River. Iowa Orthop J.14. Leung HB.95(10):1178–1179. Hindfelt B. Meadows GR. 11. A useful clinical sign.252:106–107. De Freitas G. Cure J. Cook C. Correlation between magnetic resonance imaging and radiographic measurement of cervical spine in cervical myelopathic patients. Sung R. Spine. 12. B.43:234–238. Hegedus E. 2005. Mayo Clinic and Mayo Foundation. England: Blackwell Scientific Publications. Reliability of clinical tests in the assessment of patient with neck/shoulder problems-impact of history. Fannin M. 26:67–70. Neurologic Exam in Clinical Practice. 2001. Pradhan S. J Orthop Surg. 5. 4. Spine. Bickerstaff E. 2. Philadelphia. Ghosh D. NJ: Pearson Prentice Hall. Wong WC. 1989:185–194. J Neurol. Wang J. Morrow D. The “bedsheet” Babinski. Extensor toe sign: by various methods in spastic children with cerebral palsy. Spine. 6. 2003. 2004. Upper Motor Neuron Signs Sources 1. Strender LE. 1998. 5th ed. 7. South Med J. 9.13(5):216–220. 1981:168–179. The significance of a crossed extensor hallucis response in neurological disorders: a comparison with the Babinski sign. Early diagnosis of cervical spondylotic myelopathy. Oxford. Spillane J.12:239–242. 3. 10. Absence of the Babinski sign in brain death. Grunnesjo M. 8. 1st ed.13:2222–2231. 1972. Orthopedic Physical Examination Tests: An Evidence-Based Approach. Cervical spinal cord compression and the Hoffman sign. 2001. Denno JJ. Rosen I. 2002. Bertilson B. Bailey K. Acta Orthop Scand.16(12):1353–1355. PA: W. Glaser J. Andre C. 1991. Correlation between a positive Hoffman’s reflex and cervical pathology in asymptomatic individuals.21:49–52. Saunders Company. 5th ed. Clinical Exam in Neurology.
Should the Babinski sign be part of the routine neurological examination? Neurology.48(2):120–121. Biran I. The Babinski sign—a reappraisal. Kumar SP. Sazbon L.64(9). Costeff H. 2000. 14. August B. 1952. Johnston SC. Abramski O. Haggiag S. The diagnostic value of three common primitive reflexes.1656. Ramasubramanian D.23(1):17–21. Lack of hemispheric localizing value of the palmomental reflex. 2005. 2005.48:314–318. Clinical value of the palmomental reflex. 64 . 15. Neurology India.14. J Am Med Assoc. Eur Neurol. 17. Miller FB.65:1165–1168. 16. Upper Motor Neuron Signs 13. Neurology. Isakov E. Gotkine M. Miller T. 1984.
Preventative measures: repositioning when lying (every 1 to 2 hours) on 30° lateral position when on the side or shifting position while sitting (every 30–60 minutes) (6. Check prealbumin level and address deviation (5. 7). 7). shear. and/or a combination of these (1). Optimize nutrition.15. Pressure Ulcers A pressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure. wedge. Stage II Clinical Features: Partial thickness skin loss of dermis presenting as a 65 . 2. its color may differ from the surrounding area (1. provide pressure redistribution mattress. Darkly pigmented skin may not have visible blanching. Eliminate direct pressure (heel boots. 2. chair cushion. Stage I Clinical Features: Intact skin with nonblanchable redness of localized area usually over a bony prominence. Apply hydrocolloid dressing change every 5 days (6. 5. Apply protective ointment twice daily and as needed with each perineal care (6. Treatment: 1. 3. friction. 4. 10). 7). and prop tubing away from the body) (6. 7). 3).
6. Treatment: 1. fill dead space with calcium alginate as primary. 4. Stage III Clinical Features: Full thickness tissue loss. For open blister/epidermal loss. 3). add wound gel (for dry wound bed). 7). tendon. 7). or muscles are not exposed. apply protective ointment after wound cleanser. (A) No necrotic tissue with zero to minimal exudates— apply moist wound dressing with wound gel cover with gauze and change twice daily (4. 3. 66 . Eliminate direct pressure as with stage I (6. 3. 10). 2. 2. may use topical antiseptic along with debriding agent and/or antibiotic (8). For the intact blister. 2. then cover with secondary gauze dressing daily (8). Optimize nutrition as with stage I (5. then cover with gauze daily. 2. Treatment: 1. Cover with gauze twice daily or cover with hydrocolloid change every 5 days (6.15. May also present as an intact or open/ruptured serum-filled blister (1. Slough may be present but does not obscure the depth of tissue loss. Subcutaneous fat may be visible. Cleanse with wound cleanser. apply dry dressing and eliminate direct pressure (6. Pressure Ulcers shallow open ulcer with a red-pink wound bed without slough. 3). If moderate to severe exudates: apply enzymatic debriding agent. May include undermining and tunnelling (1. 7). If infected. (B) Necrotic tissue present—apply enzymatic debriding agent. 7). but bone.
Eliminate direct pressure as with stage I (6.15. or chemical agent (Dakin’s solution) for a limited period of time (6). Optimize nutrition as with stage I (5. No necrotic tissue with zero to minimal exudate— wound gel dressing and cover with gauze daily (4. If infected. Cleanse with wound cleanser (6. fill dead space with calcium alginate (for moderate to severe exudates) or gauze (for minimal to no exudates) twice daily (8). 2. 10). Slough or eschar may be present on some parts of the wound bed. Stage IV Clinical Features: Full thickness tissue loss with exposed bone. or muscle. 4. 7). 5. antibiotic. Necrotic tissue is present—enzymatic debriding agent. 7). Pressure Ulcers 4. Optimize nutrition as with stage I (5. B. Stage: Deep Tissue Injury Clinical Features: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft 67 . 7). may use topical antiseptic. Eliminate direct pressure as with stage I (6. Often include undermining and tunnelling (1. 5. 6. tendon. 3). 10). 2. Treatment: 1. 3. 7). A.
7). or cooler compared to adjacent tissue (1. may use topical antiseptic. 2. Treatment: 1. 10). The area may be (preceded) by tissue that is painful. a black leathery necrotic tissue (1. 3). 2. Surgical evaluation for sharp debridement of necrotic tissue (unstable eschar with signs/symptoms of infection) followed by enzymatic debriding agent (8) or apply enzymatic debriding agent to slough that does not warrant sharp debridement. 7). Treatment: 1. boggy. 2. 4. mushy. Check prealbumin level and address deviation (5.15. brown. 68 . 7). firm. Pressure Ulcers tissue from pressure and/or shear. Eliminate direct pressure (use heel boots. Optimize nutrition. wedge. gray. Apply calcium alginate (for moderate to severe exudates) or gauze (for minimal to no exudates) twice daily (6. 3. tan. or chemical agent (Dakin’s solution) for a limited period of time (6. Stage: Unstageable Clinical Features: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow. Eliminate direct pressure as with stage I. antibiotic. 7). If infected. provide pressure redistribution mattress. Clean the wound with wound cleanser (6. 5. green. 2. 3). prop tubing away from the body) (6. or black) or covered with eschar. warmer. chair cushion.
Treatment: 1. The National Pressure Ulcer Advisory Panel. 2. May use negative pressure wound therapy after debride ment if wound has a depth that needs to granulate efficiently (9). 69 . Adv Skin Wound Care. and IV or unstageable treatment management as indicated) (6. Black JM. or pressure exerted by a medical device (6). manage according to tissue loss and characteristics (refer to stages II. Bennett RG. Adv Skin Wound Care. Optimize nutrition as with stage I (5. Ayello EA. 8. 7). Eliminate pressure.10(5):16–9. et al. III. 10). 10). Moving toward consensus on deep tissue injury and pressure ulcer staging.18(1):35–42. Adv Wound Care. Pressure Ulcers 6. Stage: Indeterminable Clinical Features: Not a pressure ulcer stage but a category to be used in limited situations: pressure under nonremovable dressing or device that cannot be visualized at the time of the inspection. Sprigle S. change daily. monitor for changes (6. Draft definition of stage I pressure ulcers: inclusion of persons with darkly pigmented skin. 7. 2005. Optimize nutrition as with stage I (5. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. et al. cover with dry gauze. 2005. Dry necrotic eschar on feet with no signs or symptoms of infection: no debridement. 3.18(8): 415–420. Sussman C. 7). pressures on mucous membranes. Sources 1. Ankrom AM.15. 2. 1997. Henderson CT.
Philadelphia. 10. Williams & Wilkins. PA Lippincott. Florida. Hiltabidel E. In: Sussman C.(3):89–91. 70 . Nutritional assessment & treatment. ed.Inc. Gabriel A. In: Sussman C. Pressure ulcer treatment. Cuddigan JE. “Management of wound environment with negative pressure wound therapy”. J Wound Care. Management of the wound environment with dressings and topical agents. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel.St. Thomas S. Quick Reference Guide. Jensen BB. 2009:16–30. 2007:283–294. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. 6. Valenzuela A. Sussman G. eds. Williams & Wilkins. Jensen BB. Jensen BB. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. Jensen BB. Posthauer ME. PA: Lippincott.Petersburg. 3rd ed. 2009:7–9. Philadelphia.Wound Care TIMEsaver Manual. Prevention of pressure ulcers. Williams & Wilkins. Wound Care: A Collaborative Practice Manual for Health Professionals. 2007:211–214. eds. Philadelphia. Wound Care: A Collaborative Practice Manual for Health Professionals.” Pressure Ulcer Treatment”. Ayello EA. 3rd ed. Debridement choices for chronic wounds. Philadelphia. eds. Quick Reference Guide.15. PA Lippincott. 1994. Smith & Nephew. Williams & Wilkins. Quick Reference Guide. In: Sussman C. 2009:16–30. Pressure Ulcers 4. Hay. 7. 9. Wound Care: A Collaborative Practice Manual for Health Professionals. Assessing the hydroaffinity of Hydrogel dressings. 2007:63–70. 8. 2007:250–266. Image Sources Smith & Nephew. In: Sussman C. 5. 3rd ed. 2008 (1):18–37.”Pressure Ulcer Staging System”. Wound Care: A Collaborative Practice Manual for Health Professionals. et al. PA: Lippincott. 3rd ed.
Physical Medicine and Rehabilitation. 3rd ed. fasciculations observed in the muscle 76–99 0/5 No muscle contraction visible or palpable. Philadelphia. Muscle Strength Grading Scale Muscle Grade Clinical Findings Motor Deficit (%) 5/5 Patient able to contract muscle against gravity while examiner applies full resistance 0 4/5 Patient able to contract muscle against gravity while examiner applies moderate resistance 1–25 3/5 Patient able to contract muscle against gravity with no resistance 26–50 2/5 Patient able to contract muscle with gravity eliminated 51–75 1/5 Trace movement seen or felt in the muscle. Chan L et al. eds. The physiatric history and physical examination.16. Buschbucher RM. 2007:22–33. PA: Saunders Elsevier Company. et al. 71 . Panagos A. paralysis 100 Source 1. Lin CD. In: Braddom RL. O’Dell MW.
PA: Saunders Elsevier Company. eds. Lin CD. et al. rapidly alternating muscular contractions and relaxations) Grade: 3+ or +++ Hyperactive without clonus Grade: 2+ or ++ Normal Grade: 1+ or + Hypoactive Grade: 0 Absent Source 1. Deep Tendon Reflex Grading Scale Deep Tendon Reflex Clinical Findings Grade: 4+ or ++++ Hyperactive with clonus (more than 5 involuntary. 2007:18. In: Braddom RL. Philadelphia. 72 . Physical Medicine and Rehabilitation. 3rd ed. Panagos A. Buschbucher RM. O’Dell MW. The physiatric history and physical examination.17. Chan L et al.
Glasgow Coma Scale Score Motor Verbal Eyes 6 Obeys commands 5 Localizes painful stimuli Oriented. disoriented Opens eyes spontaneously 3 Abnormal flexion to painful stimuli (decorticate response) Utters inappropriate words Opens eyes in response to voice 2 Extension to painful stimuli (decerebrate response) Incomprehensible sounds Opens eyes in response to painful stimuli Severity of Traumatic Brain Injury (TBI) Scoring: best motor+verbal+eye score.18. Total possible score: 3−15 Severe TBI: ≤8 Moderate TBI: 9–12 Mild TBI: ≥13 73 . converses normally 4 Flexion/withdrawal to painful stimuli Confused.
Glasgow Outcome Scale (GOS) Stage Description 1 Dead 2 Vegetative state: no interaction with environment (unresponsive). 3 Severe disability: follows commands but dependent upon others for daily support. et al. Galang G. 2nd ed. 2010:59. 1974. Traumatic brain injury. 4 Moderate disability: independent in activity of daily living but cannot work or return to school.44:285–293. J Neurol Neurosurg Psychiatry. Assessment of coma and impaired consciousness. 2. Physical Medicine and Rehabilitation Board Review. NY: Demos Medical Publishing. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. Sources 1. In: Cuccurullo SJ. Teasdale. Snoek J. 5 Good recovery: able to return to work or school.19. New York. G. ed. et al. Elovic E. 74 . Lancet.2:81–84. Jennett B. 3. Bond MR. 1981. Baerga E.
20. Parameters determining late recovery of consciousness. L. 1990. Sazbon.72:75–78. J Neurosurg. Traumatic Brain Injury (TBI) Severity Indices Mild TBI Moderate Severe TBI TBI Glasgow coma scale (GCS) 13–15 9–12 8 or less Loss of consciousness (LOC) <30 minutes 24 hours or less >24 hours Posttraumatic amnesia duration (PTA) 0–24 hours 1–7 days >7 days Indices Source 1. 75 . Outcome in 134 patients with prolonged posttraumatic unawareness.
gross movements to noxious stimuli (grimace) III Localized response to pain Limited. Ranchos Los Amigos Scale 76 Level Response Clinical Features I No response to pain Patient does not respond to auditory. or tactile stimuli. inconsistent responses. may do simple routine activities with assistance (confusion) V Confused-inappropriate.21. potentially aggressive. appears in a deep sleep (coma) II Generalized response to pain Limited. able to follow . may recognize close contacts. may recognize close contacts. may require restraints for safety. more specific responses to auditory. but purposeful. visual. withdrawing from pain. etc. visual. follow simple commands (localize and removal of noxious stimulus) IV Confused-agitated Disoriented. responds to commands. non-agitated Somewhat alert. but not fully oriented. which may include turning toward sound. or tactile stimuli. or tactile stimuli. visual. inconsistent response to auditory.
functions with assistance VII Automaticappropriate May perform routine care independently. In: Braddom RL. 2. Rehabilitation after traumatic brain injury. or act inappropriately or be sexually suggestive (frontal lobe syndrome-like symptoms) VI Confusedappropriate Alert and oriented. Ranchos Los Amigos Hospital. Physical Medicine and Rehabilitation. speak. 2007:1146. may perseverate. Kreutzer JS. Rehabilitation of the head-injured adult: comprehensive physical management. improved memory of recent events. Professional Staff Association. 77 . Cifu DX. may have cognitive defects (spontaneous) Sources 1. Ranchos Los Amigos Scale Level Response V (continued) Clinical Features tasks for brief periods. PA: Saunders Elsevier Company. Taylor L. Philadelphia.21. Slater DN. Chan L et al. 1979. eds. may be inflexible and rigid (affect—flat) VIII Purposefulappropriate Able to function independently. poor memory and may confabulate. impairments in executive functioning. Buschbacher RM. 3rd ed.
White BF. Modified Ashworth Scale for Spasticity Score Clinical Findings 0 No increase in muscle tone. Interrater reliability on a modified Ashworth Scale of muscle spasticity. New York. 2 More marked increase in muscle tone through most of the Range of motion. 78 . catch and release or minimal resistance at the end of the Range of motion. Physical Medicine and Rehabilitation Board Review. but affected part(s) easily moved. followed by minimal resistance throughout limited Range of motion.22. 1987. Elovic E. Baerga E. 1+ Slight increase in muscle tone. 2. ed. NY: Demos Medical Publishing. 2010:809–822. In: Cuccurullo SJ. Bohannon RW. Sources 1. 1 Slight increase in muscle tone. 2nd ed. Phys Ther. 4 Affected part(s) rigid in flexion or extension.67:206–207. 3 Considerable increase in muscle tone. catch. passive movement difficult. Associated topics in physical medicine and rehabilitation/spasticity.
Physical Medicine and Rehabilitation Principles and Practice. Walsh NE et al.23. In: Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. In: DeLisa JA. Brandstater ME. 7 Normal function restored. and Cuccurullo SJ. flaccidity 2 Minimal voluntary movements. basic flexor and extensor synergy patterns. 6 Spasticity resolved. Zorowitz RD. most muscle activation is selective and independent from synergy (further decrease in spasticity). 79 . eds. 2010:26. 4 Movements are outside of flexor and extensor synergy (peak of synergy). Brunnstrom Stages of Recovery Stage Clinical Findings 1 Paralysis. NY: Demos Medical Publishing. spasticity appears. Sources 1. Stroke rehabilitation. Baerga E. New York. decrease in spasticity. 2005:1667. 2nd ed. PA: Lippincott Williams & Wilkins. 4th ed. ed. Stroke. increase in spasticity (prominent). 5 Complex movement combinations. 3 Voluntary movement within the synergy patterns. 2. improved movement (start of fine movement) and coordination. Philadelphia. Gans BM.
4th ed. Philadelphia. PA: Lippincott Williams & Wilkins. Physical Medicine and Rehabilitation Principles and Practice. Roth EJ. Rehabilitation in stroke syndromes. Stroke rehabilitation. Physical Medicine and Rehabilitation. 2007:1179. 80 . 2005:1666.24. Harvey RL. In: Braddom RL. In: DeLisa JA. Philadelphia. Aphasia Aphasia Fluency Comprehension Repetition Global (−) (−) (−) Broca (−) (+) (−) Transcortical Motor (−) (+) (+) Wernicke (+) (−) (−) Transcortical Sensory (+) (−) (+) Conduction (+) (+) (−) Anomia* (+) (+) (+) Mixed Transcortical (−) (−) (+) *Anomia: Cannot Name Objects: Impaired: (−) Intact: (+) Sources 1. 2. Yu D. Buschbacher RM. Chan L et al. Brandstater ME. eds. eds. Walsh NE et al. PA: Saunders Elsevier. Gans BM. 3rd ed.
Standard Neurological Classification of Spinal Cord Injury 81 .25.
against gravity and provides some resistance 3 active movement. gravity eliminated 1 palpable or visible contraction 0 total paralysis MUSCLE GRADING 25.) ► YES AIS=C AIS=D If sensation and motor function is normal in all segments. 2. ► CLINICAL SYNDROMES (OPTIONAL) E = Normal: Motor and sensory func tion are normal. sufficient resistance to be considered normal if identifiable inhibiting factors were not present 5 active movement.82 5. pain on effort or contracture. A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5. full range of motion. Determine the single neurological level. 5* muscle able to exert. Patient unable to reliably exert effort or muscle unavailable for test ing due to factors such as immobilization. American Spinal Cord Injury Association: International Standard for Neurological Central Cord Brown-Sequard Anterior Cord Conus Medullaris Cauda Equina STEPS IN CLASSIFICATION 1. If at initial testing no deficits are found. D = Incomplete: Motor function is pre served below the neurological level and at least half of key mus cle grade of 3 or more. This is the lowest segment where motor and sensory function is normal on both sides and is the most cephalad of the sensory and motor levels determined in steps 1 and 2. Standard Neurological Classification of Spinal Cord Injury . AIS=E Note: AIS E is used in follow up testing when an individual with a documented SCI has recovered normal function. 3. C = Incomplete: Motor function is preserved below the neurological level. Otherwise injury is incomplete. IL. full range of motion. AIS=B YES Y ES (Yes=voluntary anal contraction OR motor function more than three levels below the motor level on a given side. and more than half of key muscles below the neurological level have a muscle grade less than 3. full range of motion. Determine motor levels for right and left sides. ASIA IMPAIRMENT SCALE ► NT. the individual is neurologically intact. then injury is COMPLETE. full range of motion. AIS=A Record ZPP NO ( For ZPP record lowest dermatome or myotome on each side with some (non-zero score) preservation) 4. Source: ASIA standard neurological classification of spinal cord injury. in examiner’s judgment. If voluntary anal contraction = No AND all S4-S5 sensory scores 0 AND any anal sensation = No. Determine whether the injury is Complete or Incomplete (sacral sparing). NO Are at least half of the key muscles below the (single) neurological level graded 3 or better? ► Classification of Spinal Cord Injury. Chicago. B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. Determine ASIA Impairment Scale (AIS) Grade: Is injury Complete? If YES. against gravity and provides normal resistance 4 active movement. The following order is recommended in determining the classification of individuals with SCI. the motor level is presumed to be the same as the sensory level. Determine sensory levels or right and left sides. against gravity 2 active movement. the ASIA Impairment Scale does not apply. Note: in regions where there is no myotome to test. Is injury incomplete? If NO. not testable. revised 2002.
distractibility. difficulty set-shifting and multitasking. slowed cognitive processing speed and reaction time Executive Functioning Trail Making Tests Wisconsin Card Sort Test Category Test Delis-Kaplan Executive Function System (DKEFS) Clock Drawing Controlled Word Association Test (COWAT) Stroop Color-Word Interference Test poor planning. trouble with abstract reasoning. or working memory & processing speed scales Attention Trail Making Tests Visual Cancellation Tests Continuous Performance Test (CPT) Paced Auditory Serial Addition Test (PASAT) reduced capacity. decreased initiation. Neuropsychology Effect of Traumatic Brain Injury (TBI) Domain Examples of Tests Intelligence Wechsler Adult Intelligence Scale (WAIS) Reduced performance IQ. impaired judgment/ impulse control. impaired sequencing. poor free recall.26. may need cueing for retrieval 83 . poor self-monitoring. wordfinding deficits Learning Wechsler Memory Scale and Memory (WMS) California Verbal Learning Test (CULT) Rey Auditory Verbal Learning Test (RAVLT) Rey Osterrieth Complex Figure impaired verbal and nonverbal learning. decreased organization.
26. 2nd ed. Addeo. Washington. anxious. decreased motivation Source 1. Traumatic brain injury and postconcussion syndrome. American Psychological Association. 2006:351–380. Clinical Neuropsychology: A Pocket Handbook. Neuropsychology Domain Examples of Tests Mood and Personality Beck Depression Inventory Beck Anxiety Inventory Minnesota Multiphasic Personality Inventory (MMPI) Effect of Traumatic Brain Injury (TBI) depressed. Robins DL. Nussbaum PD. 84 . eds. DC. JA. Lucas. R. In Snyder PJ.
27. Return to Play Guidelines After Concussion
No Loss of
(LOC), Posttraumatic Amnesia
(PTA) Less Than
No Symptoms for 1
for 1 week:
to play in 2
season if no
No Loss of
or LOC Less
Than 5 Minutes,
No symptoms for 1
1 month out
of play, may
play then if
for 1 week.
of season depending on
season if no
Loss of Consciousness
Greater Than 5
Minutes, Posttraumatic Amnesia Greater
Than 24 Hours
out of play,
to play then
if no symptoms for 1
to play next
season if no
27. Return to Play Guidelines After Concussion
1. Bergschneider M, Hovda DA, Shalmon E. Cerebral hyperglycolysis following severe human traumatic brain injury:
a positron emission tomography study. J Neurosurg.
2. Johnston KM, Pitto A, Chankowsky I, et al. New frontiers in
diagnostic imaging in concussive head injuries. Clin J Sport
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28. NIH Stroke Scale
Level of consciousness
Loss of consciousness
questions (month, age)
Answer both correctly
Answer one correctly
Loss of consciousness
eyes, close eyes, make
fist, let go)
Obeys both correctly
Obeys one correctly
Gaze (eyes open,
follows finger or face)
Partial gaze palsy
visual stimulus to
patient’s visual field
No visual loss
Facial palsy (show
teeth, raise eyebrows,
Motor arm (right and
left; each side should
be calculated separately)
No effort against gravity
Amputation, joint fusion
describe a picture. trunk. Source: National Institute of Neurological Disorders and Stroke. NIH Stroke Scale Category Description Score Motor leg (right and left. leg.28. National Institutes of Health. each side should be calculated separately) No drift Drift Cannot resist No effort against gravity No movement Amputation. joint fusion 0 1 2 3 4 9 Limb ataxia (finger to nose. arm. read sentences) No aphasia Mild to moderate aphasia Severe aphasia Mute 0 1 2 3 Dysarthria (evaluate clarity by repeating words) Normal articulation Mild to moderate dysarthria Near to unintelligible Intubated or other barrier 0 1 2 9 Extinction and inattention No neglect Partial Complete neglect 0 1 2 Total possible score: 52 TPA (tissue plasminogen activator) may be given with score of 9–22. heel to shin) Absent Present in one limb Present in two limbs 0 1 2 Sensory (pin prick to face. 88 . compare side to side) Normal Partial loss Severe loss 0 1 2 Language (name item.
P rothrombin time greater than 15 seconds or International Normalized Ratio greater than 1. Baerga E. Zorowitz RD. or aneurysm • H istory of gastrointestinal or genitourinary bleeding within the past 21 days • Pregnancy or lactation within the past 30 days • Major surgery within the past 14 days • Seizure at onset of stroke • Acute myocardial infarction • M inor stroke symptoms/transient ischemic attack (symptoms rapidly improving) • Head CAT SCAN positive for blood • BP greater than 185/100 despite medical treatment • Coagulopathy of patient on anticoagulants (warfarin. ed.28. In: Cuccurullo SJ.7 2. 89 . 3. heparin) 1. Physical Medicine and Rehabilitation Board Review. 2nd ed. P atient received heparin within 48 hours prior with elevated partial thromboplastin time. Patient taking warfarin Source 1. 2010:22–23.000 • Blood sugar < 50 or > 400 • History of stroke or severe head injury in the past 3 months • H istory of Intra-crainial hemorrhage. Arterio-venous malformation. New York. NY: Demos Medical Publishing. Stroke. NIH Stroke Scale Indications for Tissue plasminogen activator: • Age 18 years or older • Time of symptom onset well established (within 3 hours) • Patients with measurable neurological deficits • Head CAT SCAN negative for blood • Informed consent of the patient • NIH stroke scale of 9 to 22 Relative Contraindications of TPA: • Platelet count < 100. Cuccurullo SJ.
copying a design Orientation to Time: “What is the date?” Registration: “Listen carefully. Reproduced by special permission of the Publisher. Mini Mental State Examination (MMSE) Consists of a series of questions including orientation to date.] Reading: “Please read this and do what it says. 90 . You say them back after I stop. Psychological Assessment Resources. Published 2001 by Psychological Assessment Resources. naming objects. by Marshal Folstein and Susan Folstein. Scoring ranges From: 0–30. PENNY [pause]. 1998. from the Mini Mental State Examination..” [Repeat up to 5 times. A Score of 24–26 is considered normal. Florida 33549. Inc. but score only the first trial. APPLE [pause].] CLOSE YOUR EYES Mini Mental state allows clinician to grade the cognitive state of a patient. A Score of 23 or below indicates cognitive impairment. Now repeat those words back to me. Copyright 1975. Lutz.] Naming: “What is this?” [Point to a pencil or pen. Inc.29. repetition. recall. 16204 North Florida Avenue. 2001 by Mini Mental LLC. TABLE [pause]. time. I am going to say three words. obeying commands. reading.” [Show examinee the words on the stimulus form. place. Inc. writing.
Infraspinatus (sc). Extensor digitorum (r). Finger extension Elbow flexion. Extensor indicis (r) Triceps (r). Flexor digitorum profundus (m). First dorsal interosseous (u). Wrist flexion. Biceps (mc). Deltoid (a) Rhomboids (ds). Flexor carpi radialis (m) Third digit Medial palm and 5th digit Biceps (mc). Supraspinatus (sc). Elbow flexion Decreased Strength (continued ) Flexor pollicis brevis (m). ECRL and B (r). Deltoid (a) Lateral forearm and thumb Lateral upper arm and lateral elbow Muscles with Positive Diminished EMG Findings (nerve/ Sensation innervation) 30. Extensor carpi ulnaris (r). Radiculopathy† 91 . Flexor pollicis longus (m).Disc C4–C5 C5–C6 C6–C7 C7–T1 Root C5 C6 ¤C7 C8 None Triceps Brachioradialis Biceps Diminished Reflex Finger flexion Elbow extension. Flexor carpi ulnaris (u). Abductor pollicis longus (r). Brachioradialis (r). Supinator (r). Wrist extension Shoulder abduction.
Semimembranosus (s). Radiculopathy† . Vastus medialis (f).92 Disc T1–T2 L4–L5* L5–S1* Root T1 L4 L5 None Patellar None Diminished Reflex Ankle dorsiflexion. Gluteus medius (sg). Tibialis anterior (dp). Extensor digitorum longus (dp). Great toe extension Knee extension Finger abduction and adduction Decreased Strength Lateral leg and dorsum of foot Medial leg Medial elbow Semitendinosus (s). Tibialis posterior (t). First dorsal interosseous (u) Muscles with Positive Diminished EMG Findings (nerve/ Sensation innervation) 30. Tibialis anterior (dp) Flexor pollicis brevis (m). Extensor hallucis longus (dp). Tensor fascia latae (sg) Vastus lateralis (f). Peroneus longus (sp).
the L5–S1 disc often affects the S1 nerve root. *Disc herniation in lumbar spine may produce a more complex picture than in the cervical spine. (ds)=dorsal scapular. (mc)=musculocutaneous. (r)=radial. (sc)=suprascapular. ¤ In cervical spine.* Achilles Ankle plantarflexion Lateral foot Gastrocnemius (t). (m)=median. Gluteus maximus (ig). For example. because of the cauda equina. (dp)=deep peroneal. ECRL and B=extensor carpi radialis longus and brevis. Nerves: (a)=axillary. Peroneus longus (sp). (f)=femoral. (s)=sciatic. † In order to definitively diagnose a radiculopathy on Electromyography/NCS (Nerve Conduction Study) you must have positive findings (PSWs and fibs) in the paraspinal muscles of that spinal level along with positive findings in two muscles (each from a different peripheral nerve) from the same spinal level. Biceps femoris (s). C7 radiculopathy is most common. The most likely traversing nerve to be affected is the level below (that nerve is the most taut as it will soon be exiting). L5 is the most common radiculopathy. (t)=tibial nerve. any level below. Herniated discs can affect the same level (as listed in chart) or. (sp)=superficial peroneal. fibs=fibrillation potentials. Peroneus brevis (sp). S1 30. The “traversing nerve” is the nerve that is passing the disc without exiting. (u)=ulnar. (+H Reflex) Notes: PSW=Positive sharp waves. In lumbosacral spine. (sg)=superior gluteal. (ig)=inferior gluteal. Radiculopathy† 93 .
Range of Motion: Upper Extremity Joint Motion Degrees Shoulder Flexion Extension Abduction External rotation Internal rotation 165 50 175 90 65 Elbow Flexion Extension 140 0 Forearm Pronation Supination 75 75 Wrist Flexion Extension Abduction Adduction 70 70 20 30 Cervical Flexion Extension Side bending Rotation 45 55 35 55 Hip Flexion Extension Abduction Adduction Internal/external Rotation 120 20 40 25 30 Knee Flexion Extension 135 0 Ankle Dorsiflexion Plantarflexion Inversion Eversion 15 55 35 20 (continued) 94 .31.
Joint range of motion and muscle length testing. Philadelphia. Source 1. Athletes will have sport-specific adaptations resulting in increased and decreased range of motion at certain joints. Yates C. 2010:31–47. Bandy WD. 95 . Reese NB. Expect the majority of these values for range of motion to decrease with increasing age. PA: WB Saunders.31. Range of Motion: Upper Extremity Joint Motion Thoracolumbar Flexion Extension Side bending Rotation Degrees 75 25 30 30 Notes: All values have been rounded to the nearest 5 for simplification and are the average degrees of motion in patients age 25 to 84 years old.
Saphenous— medial leg and foot L2–L4 Obturator dductor longus. Sartorius nteromedial A thigh.32. A Adductor brevis. lower border of gluteus maximus ___________ . intermedius). lateralis. G Gluteus medius. Tensor fascia lata Posterior thigh. Obturator internus Medial thigh S2–S3 Postfemoral cut L4–S1 Superior gluteal ___________ luteus minimus. Quadriceps (Rectus Femoris. scrotum/labia. proximal calf. Gracilis. Lumbosacral Plexus Root Nerve 96 Motor Sensory L1–L2 Iliohypogastric ___________ Superior gluteal L1–L2 Genitofemoral ___________ Scrotal skin/ adjacent thigh and labia L2–L3 Lateral femoral cut ___________ Anterolateral thigh L2–L4 Femoral ectineus. Vastus medialis. P Iliacus. Adductor magnus (also sciatic nerve).
Extensor hallucis longus. First dorsal interosseus. Superficial peroneal— dorsum of foot. Extensor digitorum brevis Lateral sural— lateral leg and foot. Semimembranosus. Lumbosacral Plexus Root Nerve Motor Sensory L5–S2 Inferior gluteal Gluteus maximus ___________ L4–S3 Sciatic (Thigh) Tibial division: Biceps femoris (long head). Adductor magnus (also obturator nerve) Peroneal division: Biceps femoris (short head) ___________ L4–S2 Common peroneal (Leg) Superficial peroneal: Peroneus longus. Peroneus brevis Deep peroneal: Tibialis anterior. Peroneus tertius. Deep peroneal— first web space of foot 97 . Semitendinosus.32. Extensor digitorum longus.
first lumbrical Lateral plantar nerve: Abductur digiti minimi. Calcaneal nerve to calcaneus L4–S2 Tibial (Foot) Medial plantar nerve: Abductor hallucis. flexor digiti minimi.32. Soleus. Flexor digitorum longus edial sural M to posterior leg. 4. Flexor hallucis longus. flexor digitorum brevis. adductor hallucis. lumbrical 3. Lumbosacral Plexus 98 Root Nerve Motor Sensory L4–S2 Tibial (leg) Plantaris. Quadratus plantae Medial and Lateral branch to plantar aspect of foot . Popliteus. flexor hallucis brevis. Grastrocnemius medial and lateral. Tibialis posterior. interossei.
Brachial Plexus 99 .33.
Peripheral Nerve Distribution 100 .34.
Peripheral Nerve Distribution 101 .34.
Dermatomal Distribution of Nerve Roots 102 .35.
35. Dermatomal Distribution of Nerve Roots 103 .
54 Continuous performance test (CPT). 23 Anterior talofibular ligament (ATFL). 38 Anterior drawer test. 83 Active compression test. 83 Constraint-induced movement therapy. 84 Belly-press test. 83 Controlled Word Association Test (COWAT). 53 Brachial plexus. 47 Clark’s test. 83 B Babinski Sign/Koch Sign. 10 Apley grind test. 26 Crossed upgoing toe sign. 16 Crossed femoral test. 99 D Braggard’s sign. duck walk). 15 Category test. 60 Axial manual traction test. 84 Beck depression inventory. 61 Barthel index (BI). 3 Cozen’s test. 60. 19 California Verbal Learning Test. 47 Carpal compression. 56 Bear hug. 4 Childress’s test (squat. 61 Bobath approach. return to play guidelines after. 40. 83 Adduction stress test. 12 Berg Balance Scale (BBS). 20 Crossed-arm adduction test/ac joint test. 12 Beck anxiety inventory. 72 Brunnstrom Stages of Recovery. 81–82 Atrophy. 37–38 Compression test. 6 Adson’s test. 53–54 Deep Tendon Reflex Grading Scale. 40 Aphasia. 60 105 . 26 Dakin’s solution. 27 Crossed straight leg raise test. 34 Apley scarf test.Index A C Abduction stress test/Jobe’s test. 13 ASIA Impairment Scale. 80 Codman’s test. 56–57 Costoclavicular test. 79 Deep tendon reflexes. 85 Apprehension-relocation test. 19 Cervical spine. duck waddle. 6 Clock Drawing. 16 Concussion. 67–68 Brunnstrom approach.
75 Foraminal compression test. 83 H Dermatomal distribution of nerve roots. 19–21 J Ely’s test. 39 Elbow joint. 28 K External rotation lag sign. 74 Minnesota multiphasic personality inventory (MMPI). 13 Empty can test. 90 Glasgow Outcome Scale (GOS). 10 Kemp’s test. 9 M McMurray’s test. 73. 8 Drop-arm test. 96–98 Lumbar spine. 13–14 Loss of consciousness (LOC). 3 Ege’s test. 10 Hand and wrist. 3 Glasgow Coma Scale (GCS). 30–33 Hoffman sign.Index Delis-Kaplan Executive Function System (DKEFS). 9 Extension and load test. 27 L Lachman test. 28 Fasciculations. 31 Load and shift test. 62 Hornblower’s sign. 26 Finklestein’s test. 27 Jobe relocation test. 75 Mini Mental State Examination (MMSE). 26–29 Fugl-Meyer assessment (FMA). 60 Femoral nerve stretch test. 23–24 Lift off test. 84 . 41 Lasegue’s sign/Lazarevic’s sign. 102–103 Hawkin’s-Kennedy test. 34 Gaenslen’s test. internal rotation (FAIR)/Piriformis. 37 106 G Midline sacral thrust. 11 Flexion. 11 E Hyperabduction test. 22–25 Hip. 37–46 F Facet grind test. 28 Knee. adduction. 6 Lumbosacral plexus. 57 Full can test. 34 Military position.
6 Neer’s test. 83 Rey Osterrieth Complex Figure. 60 Pressure ulcers. 40 Patrick’s/flexion. 27 Neurodevelopmental technique. 20 Reversed Lachman test. 53 Neuropsychology. 82 Posterior drawer test. 75 Muscle tone. 65–70 N Proprioceptive neuromuscular facilitation. external rotation.Index Modified Ashworth Scale for Spasticity. 83–84 NIH Stroke Scale. 22 Movement therapy. 41 Muscle grading. 53 Neck distraction test. 30 O’Brien test. 8 Patellofemoral grinding test. 83 Palmomental reflex. 42 Reverse Phalen’s test. 42 Muscle Strength Grading Scale. 76–77 Range of motion: upper extremity. 22 P Paced auditory serial addition test. 61 R Radiculopathy. 53–54 Pivot shift test. 58 Phalen’s test. 11 Modified Ober test. 94–95 Rehabilitation approach to neurological deficits. 20 Resisted wrist flexion. 71 Posttraumatic amnesia duration (PTA). 53–55 Resisted wrist extension/resisted third finger extension. 62 Rood approach. 54 Patella apprehension test (Fairbanks). 83 Rey Auditory Verbal Learning Test (RAVLT). 78 Patte’s test. 8 Nerve entrapment test. 39 Rotator cuff (RTC) impingement. 87–89 O Ober test. abduction. 34–36 Scalene test. 15 Oppenheim reflex. extension (FABERE). 4 107 . 30 Peripheral nerve distribution. 91–93 Ranchos Los Amigos Scale. 100–101 Modified Rankin Scale. 31 S Sacroiliac (SI) joint pain.
54 Shoulder. 83 Wisconsin card sort test. 83 and hand. 16 Spinal cord injury. 48 flexion. 3–5 Wechsler Memory Scale (WMS). 22 Tinel’s test. 6 Valgus stress test. 56–59 Stroop Color-Word Interference Test. 26 Valgus testing of ulnar collateral ligament. 75 Traumatic brain injury (TBI). 43 Visual cancellation tests. 27 Upper motor neuron vs lower motor neuron lesion. 24 Simmond’s test.Index Scalenus anticus syndrome. severity of. 23 extension. 16 . 4 U Sensorimotor approach. 83 Y Yeoman’s test. 73 Trendelenburg test/sign. 83 Varus stress test. 61–64 Slump test. 28 T Talar shift test. 22 Trail making tests. 47 Upper motor neuron signs. 32 Thompson test. 24 Stroke outcome. 8–18 Ulnar collateral ligament valgus testing of. 19. 30 108 Wechsler Adult Intelligence Scale (WAIS). 3 Wrist Tinel’s sign at the wrist. 14 Supraspinatus weakness. 22–25 Traumatic brain injury (TBI) severity indices. 38 Thomas test. 35 Yergason’s test. 83 Sulcus sign. 19. 9 W Waddell signs. 60 Speed’s test. 43 Straight leg raise test (SLRT). 48 Thessaly/Disco test. 81–82 V Spurling’s test. 83 Wright’s test. 47 Thoracic outlet syndrome (TOS). standard neurological clasification of.
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