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DO Department of Physical Medicine and Rehabilitation Nassau University Medical Center East Meadow. New York Professor of Clinical Physical Medicine and Rehabilitation Stony Brook University School of Medicine Stony Brook. New York Maryam Rafael Aghalar. Weiss. DO Department of Physical Medicine and Rehabilitation Nassau University Medical Center East Meadow. NY . MD.Neuromuscular Quick Pocket Reference Editors Rawa Jaro Araim. New York Lyn D. MD Chairman and Director of Residency Training Department of Physical Medicine and Rehabilitation Nassau University Medical Center East Meadow.
p. Araim. Weiss. 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. Includes bibliographical references and index. in particular our understanding of proper treatment and drug therapy.demosmedpub. 2. 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. Trauma. Library of Congress Cataloging-in-Publication Data Neuromuscular quick pocket reference / editors. express or implied. Nervous System–diagnosis–Handbooks. Maryam Rafael. [DNLM: 1. Maryam Rafael Aghalar. without the prior written permission of the publisher. .Visit our website at www. II. Lyn D. III. with respect to the contents of the publication. Medicine is an ever-changing science. mechanical. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. editors. Neurological Handbooks. NY 10036 Phone: 800-532-8663 or 212-683-0072 Fax: 212-941-7842 E-mail: rsantana@demosmedpub. Lyn D. Trauma Severity Indices–Handbooks. please contact: Special Sales Department Demos Medical Publishing 11 West 42nd Street. Musculoskeletal System–injuries–Handbooks. the authors. WE 39] 616. cm. professional associations. All rights reserved. For details. health care organizations. Nevertheless. editors. Neuromuscular Diseases–diagnosis–Handbooks. recording. Aghalar. Diagnostic Techniques. 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. or otherwise. electronic. paper) – ISBN 978-1-61705-092-3 (e-book) I. stored in a retrieval system. Weiss. Rawa Jaro Araim. No part of it may be reproduced. The authors. 5.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. ISBN 978-1-936287-50-5 (alk. and other qualifying groups. This book is protected by copyright. 4. 15th Floor New York.744–dc23 2011039621 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations. or transmitted in any form or by any means. LLC. photocopying. Research and clinical experience are continually expanding our knowledge. 3. Rawa Jaro. pharmaceutical companies.com Printed in the United States of America 11 12 13 14 / 5 4 3 2 1 .
Finally. MD for all of your guidance and support. Special thanks to Dr Weiss. Thank you to the entire NUMC staff of residents and attendings who make work fun. Helene. Lyn D. Stefan and Richard who give me perspective on what is truly important. Rawa Jaro Araim This book is dedicated to my Dad Parviz who encouraged me to go to medical school. and role model. MD. Without her. Without all of you.This book is dedicated to my dear father M. MD and Thomas Pobre. Weiss v . my husband Jahan and in-laws for their support. my Mom Flora who helped me get through it. Jaro who supported me in every endeavor and always believed in me more than I believed in myself. I would not be where I am today. and my kids Liora and Jacob who give me purpose. Ricardo Cruz. this book would not be possible. thank you to my mentors Lyn Weiss. Special thanks to my dear husband Nabeel Araim MD and my children Roua and Marwan for their unconditional love and support. chairman. my program director. Maryam Rafael Aghalar With love and thanks to my husband Jay and my children Ari.
Aphasia 25. Brunnstrom Stages of Recovery 24. Pressure Ulcers 16. Musculoskeletal Physical Exam 1. Upper Motor Neuron vs Lower Motor Neuron Lesion 14. Upper Motor Neuron Signs 15. 4. 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. Neuropsychology 53 56 60 61 65 71 72 73 74 75 76 78 79 80 81 83 vii . Rehabilitation Approach to Neurological Deficits 12. Standard Neurological Classification of Spinal Cord Injury 26. 2. Muscle Strength Grading Scale 17. 9.Contents Contributors Preface Acknowledgments ix xi xiii I. 3. Stroke Outcome 13. 7. 6. Ranchos Los Amigos Scale 22. Neurological Tests and Scales 11. Traumatic Brain Injury (TBI) Severity Indices 21. 8. Deep Tendon Reflex Grading Scale 18. 5. Glasgow Coma Scale 19. 10. Modified Ashworth Scale for Spasticity 23. Glasgow Outcome Scale (GOS) 20.
Mini Mental State Examination (MMSE) 30. Dermatomal Distribution of Nerve Roots 85 87 90 91 94 96 99 100 102 Index 105 . Radiculopathy 31. Peripheral Nerve Distribution 35.Contents viii 27. NIH Stroke Scale 29. Return to Play Guidelines After Concussion 28. Lumbosacral Plexus 33. Range of Motion: Upper Extremity 32. Brachial Plexus 34.
DO Edward Barawid. RN Vikram Agnish. MD Daniel Tsukanov. DO Sasha Iversen. MD Farah Siddiqui. Lilibeth Acero.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 Yuliya Maystrovskaya. DO Derek Higgins. DO Harry Lenaburg. DO Deborah Freidman. PhD Weibin Shi. DO Alfred Castillo. MD Lynn Schaefer. MD Anu Mutyala. MD ix . DO Ricardo Miranda. DO Shilo Kramer. MD Luke Garcia. DO Samaira Khan. DO Katie Kwaschyn. DO Teena Varghese. MD Chioma Ezeadichie. DO Ricardo Cruz.
practice. residents. It should be considered a first step. It should be noted that this book does not represent the complete spectrum of neuromusculoskeletal examination and does not give information on treatment. who felt that physical medicine and rehabilitation residents needed an efficient way to learn about the various musculoskeletal and neurological tests. They needed to know what the test was called. 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. students. xi . how to perform it. and we hope that it will provide a foundation for knowledge that can be advanced by further reading. and what the results meant. and research. this book is applicable for most health care practitioners (including allied health professionals. and attendings) who deal with the neuromusculoskeletal system. Although originally intended for PM&R residents. This book is meant to be used as a quick reference for a specific topic.Contents Preface This book was conceived by Dr Araim.
• D r Thomas Pobre for his assistance and review of the musculo-skeletal section of the book. xiii . • 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. • Dr Harry Lenaburg for his aid in editing the text.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. • S heila Slezak for ably assisting in the preparation of the manuscript. • Dr Dennis Dowling for his wonderful illustrations. who make the work of a residency enjoyable. Thank you also to the PM&R residents.
Neuromuscular Quick Pocket Reference .
Musculoskeletal Physical Exam .I.
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). Techniques: Examiner palpates patient’s radial pulse. Sensitivity: 84% Specificity: 90% Sources: 2. 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). Positive test: The loss or decrease of radial pulse or reproduction of symptoms (in neurogenic TOS). 3.1. The patient is asked to retract and then depress the shoulders. 4 Costoclavicular Test (Military Position) Purpose: TOS (entrapment of the subclavian artery by the clavicle and first rib). 4 3 . Sensitivity: No Data (ND) Specificity: ND Sources: 1. Techniques: Examiner palpates patient’s radial pulse while keeping patient’s shoulder at 90o abduction and in full external rotation.
electrophysiology. PA: WB Saunders Co. 2. Demirel A.56(4):155–160. PA: Elsevier. extension. 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. ultrasonography. Diagnosing thoracic outlet syndrome: contribution of provocative tests. Gillard J. 2010. 6 Sources 1. Calis M. Techniques: Examiner palpates patient’s radial pulse. Pérez-Cousin M. et al. 2001.1. and helical computed tomography in 48 pts. et al. and external rotation. Diagnostic values of clinical diagnostic tests in thoracic outlet syndrome. Malanga GA. 2006:48–55. In: Malanga GA. 3. Nadler SF. DJ. Magee. Hachulla E. 4. Physical examination of the cervical spine.68(5):416–424J. 2nd edition. The patient’s arm is held in slight abduction. Joint Bone Spine. Philadelphia. Philadelphia. eds. Positive test: The loss or decrease of radial pulse or the reproduction of symptoms (in neurogenic TOS). 1992:320–321. Sensitivity: 94–100% Specificity: 18–87% Sources: 4. Orthopedic Physical Assessment. 5. Scalenus anticus syndrome—usually affecting C8/T1/ulnar nerve). Musculoskeletal Physical Examination: An Evidence-based Approach. Nadler SF. Türkiye Fiziksel Tıp ve Rehabilitasyon Dergisi. while the patient is instructed to extend and rotate neck to affected side while taking a deep breath. Landes P. 4 . Altuncuog˘lu M.
Phys Ther.1. Neurovascular entrapment in the regions of the shoulder girdle and posterior triangle of the neck. J Hand Surg.24A(1):185–192. Bombardier C. What we know about the reliability and validity of physical examination tests used to examine the upper extremity. Marx RG. Pratt NE. 5 . 1986. Thoracic Outlet Syndrome (TOS) 5.66:1894–1900. 1999. 6. Wright JG.
which indicates muscle spasm or whiplash-associated disorder. it is called reverse Spurling’s. Sensitivity: 40%–44% Specificity: 90%–100% Sources: 4. the head can be extended. If still no pain. Cervical Spine Spurling’s Test (Foraminal Compression Test) Purpose: Cervical radiculopathy. 6 6 . Technique: The test can be done in 3 stages that increase the provocation of the symptoms. 4. 2. muscle strain. Technique: Patient can be seated or supine. 3. First. Sensitivity: 28%–60% Specificity: 92%–100% Sources: 1. If pain is felt on the opposite side. or dural irritability.2. 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. Positive test: Pain radiating into the ipsilateral arm. If the patient does not have radiating pain. Positive test: Decreased pain implies nerve root etiology. the patient’s head is compressed at neutral. the head can be extended and bended laterally to the affected side. Increased pain may be the result of ligament sprain. 5 Neck Distraction Test (Axial Manual Traction Test) Purpose: Cervical radiculopathy.
Furukawa T. et al. 1989. 5. 7 . Philadelphia.34(16):1658–1662. Viikari-Juntura E. The influence of cervical traction. 3.2. Compression of brachial plexus as a diagnostic test of cervical cord lesion.27:131–136. 1997. Jull G. 2nd edition.19:2170–2173. The diagnosis and treatment of cervical radiculopathy. 1994. 6. In: Orthopedic Physical Assessment. Spine. Tsukagoshi H. 2009. Nisell R. 1995. 1992:163. Spine. DJ Chapter 3. Takasaki H.29(7)(Suppl. Spine.14:253–257.):S236–S245. Scand J Rehab Med. Cervical spine: tests for neurological symptoms. Med Sci Sports Exerc. and Spurling test on cervical intervertebral foramen size. Sandmark H. Malanga GA. Laasonen EM. compression. PA: WB Saunders Co. Hall T. Uchihara T. 2. 4. Magee. Validity of clinical tests in the diagnosis of root compression in cervical disease. Cervical Spine Sources 1. Porras M. Validity of five common manual neck pain provoking tests.
5% Specificity: Subacromial bursitis: 44. then passively internally rotates and forward flexes the patients shoulder more than 90°.3% Rotator Cuff Pathology: 42. Sensitivity: Subacromial bursitis: 91.8% Sources: 8 Hawkin’s-Kennedy Test Purpose: Rotator Cuff (RTC) impingement/subacromial bursitis. Sensitivity: Subacromial bursitis: 75% Rotator Cuff Pathology: 83. Shoulder Neer’s Test Purpose: Rotator cuff (RTC) impingement/subacromial bursitis. Technique: Examiner flexes the patients shoulder to 90° and forcibly internally rotates the shoulder. Positive test: Reproducible shoulder pain.3.5% Rotator Cuff Pathology: 50. Positive test: Reproducible shoulder pain.6% Sources: 8 8 . Technique: Examiner stabilizes the scapula.3% Specificity: Subacromial bursitis: 47.7% Rotator Cuff Pathology: 87.
Positive test: The patient is unable to keep the arm up against resistance secondary to weakness or pain. 10 Full Can Test Purpose: Supraspinatus weakness/RTC impingement. Technique: The patient’s arm is held at 90° of abduction and 30° of horizontal adduction with full internal rotation (thumbs down). The patient resists downward resistance from the examiner. Shoulder Empty Can Test (Supraspinatus test) Purpose: Supraspinatus Pathology.3. Sensitivity: Supraspinatus pathology: 89% Specificity: Supraspinatus pathology: 50% Sources: 9. Positive test: The patient is unable to keep the arm up against resistance secondary to pain or weakness. Sensitivity: 86% Specificity: 57% Sources: 10 9 . The patient maintains this position against downward resistance. Technique: The patient’s shoulder is held at 90° of abduction and externally rotated (thumbs up).
Sensitivity: 56% Specificity: 98% Sources: 2 10 .5% Full-thickness rotator cuff tear: 87. Severe pain implies partial thickness tear. Technique: The patient is seated with the back to the examiner. The examiner externally rotates the shoulder while supporting the elbow and then releases the wrist. 12 External Rotation Lag Sign Purpose: Full thickness tears of supraspinatus and infraspinatus. Positive test: The patient is unable to return the arm to the side slowly.5% Positive predictive value: 100% Sources: 11. shoulder is abducted 20°. Shoulder Drop-Arm Test (Codman’s Test) Purpose: RTC (Rotator Cuff) tear. The elbow is flexed to 90°. Technique: The examiner abducts the patient’s shoulder to more than 90° and then asks the patient to slowly lower it to the side.3. Sensitivity: Partial-thickness rotator cuff tear: 14. Positive test: Patient cannot maintain shoulder in external rotation.9% Specificity: Partial-thickness rotator cuff tear: 77.3% Full-thickness rotator cuff tear: 34.
Technique: The patient is asked to lift the arm off of the back without and with resistance. and the patient is asked to rotate the arm externally against resistance.3. Modification: Internal rotation lag sign: The examiner lifts the patient’s arm off of back and asks the patient to maintain this position. Sensitivity: 100% Specificity: 93% Sources: 3 Lift Off Test Purpose: Subscapularis tendon tear. Positive Test: the patient is unable to maintain arm off of back. 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. Technique: The patient’s elbow is flexed to 90°. 17 11 . Positive test: The patient is unable to lift hand away from his/ her back. Shoulder Hornblower’s Sign (Patte’s Test) Purpose: Infraspinatus and teres minor integrity. Positive test: Pain or inability to maintain the externally rotated position and the arm drops back to neutral position.
7% Sources: 1 Belly-press Test Purpose: Subscapularis muscle tendon tear. 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. which takes over for the weak internal rotators. The examiner tries to lift the patient’s hand off the shoulder. Positive test: The patient is unable to keep the hand on the shoulder. Sensitivity: 60% Specificity: 91. externally rotating the shoulder. Positive test: The elbow drops backward. Technique: The patient attempts to maximally internally rotate his/her shoulder by pressing the hands on the abdomen with elbows coming forward (anteriorly). 14 12 . Shoulder Bear Hug Purpose: Subscapularis tear.3.
The patient’s shoulder is held in 90° abduction and passively moved into maximal external rotation. a posterior force is applied to the proximal humerus. Technique: The patient is supine. “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.3. while the other hand stabilizes the scapula. If the patient displays apprehension/ pain. (Grade I: 0–25% minimal movement). A posterior to anterior force is applied to the posterior aspect of the humeral head. Positive Test: A decrease in pain/apprehension with a posterior force implies anterior instability. The examiner applies a compressive force. Technique: The examiner grasps the proximal humerus with one hand. Sensitivity: 68% Specificity: 100% Sources: 15. moderate (Grade II: 25–50% movement—feeling the humeral head ride upon the glenoid rim). 16 Load and Shift Test Purpose: Anterior/posterior shoulder laxity/instability. (continued ) 13 . or severe (Grade III: more than 50% movement—feeling the humeral head ride up and over the glenoid rim). Shoulder Apprehension-Relocation Test (Jobe Relocation test) Purpose: Anterior shoulder instability. Positive test: The degree of glide is graded mild.
Positive test: Dimpling of the skin below the acromion suggesting widening of the subacromial space between the acromion and the humeral head.3. Shoulder Load and Shift Test (continued) Sensitivity: 50% Specificity: 100% Sources: 18 Sulcus Sign Purpose: Labral tear/inferior shoulder laxity/instability. Sensitivity: Combination of tests: 90% Specificity: 85% Sources: 18. 7 14 . Technique: The patient is seated or standing with the arm relaxed by the side. The patient’s arm is grasped by the examiner and pulled inferiorly.
With the arm in the same position. the examiner applies a downward force with the patient trying to resist. 20 15 . the arm is then externally rotated with the palm fully supinated. Pain at the AC joint or on top of the shoulder is diagnostic for AC joint pathology. The examiner applies a downward force with the patient trying to resist. 19.3. Pain or painful clicking inside the glenohumeral joint points to labrum injury. 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. Technique: The patient forward flexes the arm 90° with the elbow in full extension and adducts the arm 10°–15° medially.5% Ac joint: 90%–95% Sources: 6. and again. Sensitivity: Labrum: 100% AC joint: 16%–41% Specificity: Labrum: 98. The arm is internally rotated with thumbs pointing down.
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.
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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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subacromial impingement syndrome. J Bone Joint Surg Am.
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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. Elbow Joint Varus Stress Test (Adduction Stress Test) Purpose: Lateral collateral ligament instability. 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. A laterally directed force is applied to the distal forearm. A medially directed force is applied to the distal forearm. Positive test: Medial elbow pain and/or joint laxity. Sensitivity: No Data (ND) Specificity: No Data Sources: 2 19 . Technique: The patient is seated with forearm fully supinated and elbow flexed to 20º–30º. Technique: The patient’s arm is supinated and flexed to 25°. The examiner places one palm on the lateral aspect of the patient’s elbow. Positive test: Lateral elbow pain and/or joint laxity.
while the patient is asked to flex and pronate the wrist against resistance applied by the examiner. Positive test: Pain elicited along the origin of the flexor carpi radialis tendon at the medial elbow. Modification: Test may be performed with the elbow in full extension or with resisted third finger extension. Sensitivity: No Data (ND) Specificity: No Data Sources: 2 20 . Technique: The patient’s elbow is stabilized at 60°–90° of flexion with the forearm in prone position. Positive test: Pain over the lateral epicondyle. Sensitivity: No Data (ND) Specificity: No Data Sources: 2. The examiner places his/her thumb along the origin of the extensor tendons at the lateral epicondyle. The patient is asked to radially deviate and extend the wrist against resistance provided by the examiner’s other hand. 3 Resisted Wrist Flexion Purpose: Medial epicondylitis.4. Elbow Joint Cozen’s Test (Resisted Wrist Extension/Resisted Third Finger Extension) Purpose: Lateral epicondylitis. Technique: Patient’s forearm is supinated. and the elbow is flexed to 90°.
PA: Elselvier. Elbow Joint Sources 1. wrist. Nicoletta RJ. Musculoskeletal Physical Examination: An EvidenceBased Approach. Sports Medicine. eds. Physical examination tests for the shoulder and elbow. Agesen T. Physical examination of the elbow. and hand. Davis BA. 3. In: Schepsis AA. Wrightson J. Philadelphia. The 3-Minute Musculoseletal & Peripheral Nerve Exam. Heckert KD. 2009:31. Nadler SF. New York.4. et al. 21 . NY: Demos Medical Publishing. 2. 2006: 198–199. PA: Lippincott Williams & Wilkins. Busconi BD. Nadler S. 2006:155–165. Miller A. eds. Philadelphia. In: Malanga GA.
6 22 . Sensitivity: 43% Specificity: 74% Sources: 1. median nerve entrapment. Technique: The patient is asked to flex wrists for approximately 1 minute. Positive test: Reproduction of paresthesias/numbness in digits 1–4. 2. median nerve entrapment neuropathy at wrist.5. 5 Reverse Phalen’s Test (Wrist Extension) Purpose: CTS. 2. Technique: The patient is asked to extend wrists for approximately 1 minute. 3. 4. Positive test: Reproduction of paresthesias/numbness in digits 1–4. Wrist and Hand Phalen’s Test (Wrist Flexion) Purpose: Carpal Tunnel Syndrome (CTS). Sensitivity: 71%–80% Specificity: 20%–80% Sources: 1.
Technique: The examiner extends and taps the wrist over the median nerve in the area of the distal wrist crease. Wrist and Hand Tinel’s Sign at the Wrist Purpose: CTS. common peroneal. (continued ) 23 .5. fibular head. Sensitivity: 25%–44% Specificity: 94%–98% Sources: 1. 2. Sensitivity: 87% Specificity: 90% Sources: 1. Positive test: Reproduction of paresthesias/numbness in digits 1-4 (can also be performed at the cubital tunnel. Positive test: Reproduction of paresthesia in the digits 1–4. 7 Finklestein’s Test Purpose: Tenosynovitis of the extensor pollicis brevis and abductor pollicis longus tendons (de Quervain’s). and tibial nerve compression. 4 Carpal Compression Purpose: CTS. 2. firm pressure to the median nerve with thumbs while placing the rest of the fingers over the dorsum of the hand and wrist. respectively). 3. Technique: The examiner applies gentle. median nerve entrapment neuropathy at wrist. median nerve entrapment neuropathy at wrist. and medial malleolus for ulnar.
2006:48–55. Musculoskeletal Physical Examination. 2 Sources 1. Agesen T. PA: Elsevier. and hand. Philadelphia. Physical examination of the elbow. Nadler SF. 2 Valgus Testing of Ulnar Collateral Ligament Purpose: Ulnar collateral ligament tear/rupture/ Gamekeeper’s thumb. and the ulnar deviates the wrist. Sensitivity: No Data (ND) Specificity: No Data Sources: 1. et al. wrist. The thumb can be positioned in extension to assess the accessory ligament. An EvidenceBased Approach. Wrist and Hand Finklestein’s Test (continued ) Technique: The thumb is flexed into the palm with the hand in a fist. 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. Nadler SF. In: Malanga GA. The examiner grasps the fist.5. Technique: Valgus stress applied over the metacarpal phalangeal joint (MCP) in 30° of flexion by grasping the thumb proximal to the joint. eds. 24 . Wrightson J. Positive test: Reproduction of pain at the radial side of the wrist to the thumb.
Gelberman RH. Ghavanini MRA. 25 . J Bone Joint Surg Am. Miller A. 7. Letz R. Carpal tunnel syndrome: an evaluation of the provocative diagnostic tests. Tan AM. 1972.5. et al. J Hand Surg Br.68:735–737. Durkan JA. Phalen GS. A new diagnostic test for carpal tunnel syndrome. DiCuccio. Electromyogr Clin Nerophysiol. Gerr F.83:29–40. Haghighat M. 4. Gellman H. J Bone Joint Surg. 6. 2009. AM 1991. The sensitivity and specificity of tests for carpal tunnel syndrome vary with the comparison of subjects.38:437–441. Heckert K. New York. Carpal tunnel syndrome: reappraisal of five clinical tests.73:535–538. Wrist and Hand 2.23(2):151–155. Clin Orthop Rel Res. 1986. The 3-Minute Musculoskeletal & Peripheral Nerve Exam. 1998. The carpal tunnel syndrome: clinical evaluation of 598 hands. 3. 1998. Davis B. NY: Demos Medical Publishing. 5.
the examiner drops the leg to a point where pain is resolved and dorsiflexes the ankle. radiating from the buttocks down the posterior thigh to below the knee (sciatic nerve distribution). 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). Lumbar Spine Straight Leg Raise Test (SLRT) (Lasegue’s Sign/ Lazarevic’s Sign) Braggard’s Sign Purpose: Spinal cord root compression/lumbosacral (LS) radiculopathy. Positive test: Pain at 30° to 70° of hip flexion. The examiner lifts one leg off the table with the knee fully extended. Braggard’s sign—When the patient reports pain after lifting the leg.6. Technique: Perform the SLRT on the nonsymptomatic side. Positive test: Pain is elicited down the leg that was not lifted. Positive test is radiating pain. Technique: The patient is supine. Sensitivity: 91% Specificity: 26% Sources: 1 Crossed Straight Leg Raise Test Purpose: Spinal cord root compression/LS radiculopathy. Sensitivity: 29% Specificity: 88% Sources: 1 26 .
Positive test: Pain radiating down that leg to below the knee. The examiner flexes the knee to more than 90° and then extends the hip. 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. Crossed Femoral Test) Purpose: Femoral nerve root irritation (L2-L4)/high lumbar radiculopathy.6. Modifications: Crossed femoral stretch test can also be performed (refer to crossed SLRT). while the other hand brings the patient’s foot into dorsiflexion and flexes the hip with the knee extended. Technique: The patient is prone on the table. 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. Sensitivity: 44% Specificity: 58% Sources: 2 Femoral Nerve Stretch Test (Ely’s Test.
Distraction: A positive exam finding disappears when the patient is distracted. rotates. Technique: The patient is sitting or standing. Overreaction: During physical examination. 1. sweating. Tenderness: Superficial or nonanatomical tenderness. or disproportionately verbalizes. the patient overreacts by tensing up his muscles. Lumbar Spine Facet Grind Test (Extension and Load Test. Radiating pain implies disk herniation. The examiner extends. Sensitivity: No Data (ND) Specificity: No Data Sources: 4 Waddell Signs Purpose: Non-organic/psychological causes of low back pain. Sensitivity: No Data (ND) Specificity: No Data Sources: 5 28 . 4. Example: Nondermatomal sensory loss or entire limb weakness. Example: Axial loading of head or rotation of pelvis and shoulder causes Low Back Pain (LBP). 2. 3. Example: SLR positive in supine but negative when sitting. Positive test: Nonradiating low back pain implies facet pathology. Simulation tests: Pain provoked by a simulated/sham maneuver that does not actually test that area. Regional disturbances: If physical exam diverges from accepted neuroanatomy. and laterally flexes the lumbar spine while compressing the ipsilateral shoulder. tremors.6. Kemp’s Test) Purpose: Facet pathology vs disk prolapse/protrusion. 5.
3. McCulloch JA. Venner RM. Stankovic R. 29 . The test of Laseque: systematic review of the accuracy in diagnosing herniated discs.5:117–125. Dzaferagic A. Davis B. Miller A. Use of lumbar extension. Wadell G. Bouter LM.25:1140–1147. 5. NY: Demos Medical Publishing. 1919. Spine. 2. 2009:52. Willner S. Dtsch Z Nervenbeilk. New York. physical and neurological examination in evaluation of patients with suspected herniated nucleus pulposus: a prospective clinical study. Spine. Heckert K.6. slump test. Wassermann S. The 3-Minute Musculoskeletal & Peripheral Nerve Exam. Johnell O. Man Ther. Maly P. Bezemer PD. Ueber ein neues Schenkelnersymptom nebstr Bemerkungen zur Diagnostik der Schenkerlnerverkrankungen. 1980. 4. 1999. Lumbar Spine Sources 1. van der Windt DA. 2000. Kummel E. Nonorganic physical signs in low back pain. Deville WL.4(1):25–32.19(43):140–143.
and then released to allow the leg to drop. Technique: The patient lies on the unaffected side. Positive test: Pelvic drop on the unsupported side suggests weak gluteus medius muscle on the supported side. 4. 7 30 . 3.9% Sources: 2. 6. Positive test: The leg remains passively abducted. the leg is held in extension). extended. Test is repeated on the other side. Sensitivity: 72.7% Specificity: 76. 9 Ober Test (Modified Ober Test) Purpose: Tensor fascia lata/ iliotibial band tightness.7. The examiner grasps the ankle lightly with one hand and steadies the patient’s hip with the other. 5. Sensitivity: No Data (ND) Specificity: No Data Sources: 1. 3. The affected side is flexed at the knee to 90° (for Modified Ober Test. The leg is abducted. Technique: The patient is observed from the rear standing on one leg. Hip Trendelenburg Test/Sign Purpose: Gluteus medius weakness.
The examiner flexes. Adduction. Extension (FABERE) Purpose: Hip joint pathology. Sensitivity: No Data (ND) Specificity: No Data Sources: 3. abducts. Pressure is applied to the knee to further externally rotate the hip. 5 Piriformis/Flexion.7. Positive test: Pain over the piriformis. Positive test: Reproducible groin or hip pain. Internal Rotation (FAIR) Purpose: Piriformis muscle spasm/tightness. The examiner stabilizes the pelvis by applying pressure to the contralateral ilium. The examiner flexes the hip to 60° with knee flexed while applying a downward pressure on the knee. Technique: The patient lies supine. and externally rotates the hip with the ankle resting on the contralateral knee. Sensitivity: No Data (ND) Specificity: No Data Sources: 5. External Rotation. Hip Patrick’s/Flexion. 8 31 . Abduction. Technique: The patient lies on the unaffected side.
3. Oakley SP. 2. 32 . New York. Cuccurullo SJ. Bird PA. Freeman ED. Nade SM. 1985. 3. ed. Hip flexion contractures: a comparison of measurement methods.66:620–625. Wolf LS. 1985. Shnier R. et al. The significance of the Trendelenburg test. Physical Medicine and Rehabilitation—Board Review. Hardcastle PH. 4. J Bone Joint Surg. Brown DP. Technique: The patient lies supine while the examiner checks for excessive lordosis. Musculoskeletal medicine. Bartlett MD. 5 Sources 1. 2010:215–217. The other hip should remain straight on the table. Arch Phys Med Rehabil. 2001. The examiner flexes one of the patient’s hips. bringing the knee to the chest to flatten out the lumbar spine. In: Cuccurullo SJ. Positive test: The hip remaining straight on the table flexes implying a contracture of the iliopsoas.67(5):741–746. and the patient holds the flexed hip against the chest.44:2138–2145. Arthritis Rheum. Hip Thomas Test Purpose: Hip flexion contractures. NY: Demos Medical Publishing. et al.7. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Sensitivity: No Data (ND) Specificity: No Data Sources: 1. Shurtleff DB.
6.355:3–7.7. 7.18:105–110.52:73–75. Krabak BJ. Bandy WD. Clin Orthop. Trendelenburg F. Prather H. 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. Hip 5. 1981. Acta Orthop Scand. In: Malanga GA. Trendelenburg’s test 1895. J Orthop Sports Phys Ther. The piriformis muscle syndrome: sciatic nerve entrapment treated with section of the piriformis muscle. 2006:253–254. Physical Examination of the hip. Solheim LF. 33(6):326–330. Philadelphia. Nadler SF. PA: Elsevier. The role of iliotibial band and fascia lata as a factor in the causation of low back disabilities and sciatica. Reese NB. 33 . Ober FB. 9. Siewers P. J Bone Joint Surg. 264. 8. Musculoskeletal Physical Examination: An Evidence-Based Approach. Jarmain SJ. 1936. Paus B. eds. 2003.
The unaffected side is flexed at the knee and hip. 7 Gaenslen’s Test Purpose: SI joint pathology. 2. Modification: The patient can also lie on the side. 9. Sensitivity: 68% Specificity: 35% Sources: 2. 3. Technique: The patient lies on the side with the painful side up. The examiner applies a downward force over the iliac crest. 10. 12 34 . 4. Positive test: Pain over the SI joint on the side that is off the table. compressing the SI joint. 5. Modification: This test can be performed with the patient supine while applying a compressive force into the midline of the hip. and the top leg can be tested by drawing it backward toward the examiner. 11. Sacroiliac Joint Compression Test (Midline Sacral Thrust) Purpose: Sacroiliac (SI) joint pathology. 8. The examiner stabilizes the unaffected hip. Positive test: Pain over the gluteal region near the SI joint. The lower extremity on the affected side is dropped off the table. 6. Sensitivity: 0%–19% Specificity: 90%–100% Sources: 1. Technique: The patient lies supine with the affected side closer to the edge of the table.8. Positive test: Pain over the SI joint region. extending the hip joint.
1927. Prather H. Man Ther. Sensitivity: No Data (ND) Specificity: No Data Source: 13 Sources 1. Van der Wurff P. eds. Blower PW. 2006:227–249. Arthritis Rheum. Rantanen P. Newton DRL. Hagmeijer RH. 1989. Clinical examination of the sacroiliac joints: a prospective study. Griffin AJ. Nadler SF. Physical examination of the sacroiliac joint. Clinical tests of the sacroiliac joint. Meyne W. Nadler SF. 6. 5. and the other hand extends the opposite hip joint.4:62–64. Technique: The patient lies prone. Proc R Soc Med.5(2):89–96. LeClerq S. JAMA.5(1):30–36. Gaenslen FJ. Van der Wurff P.8. Clinical sacroiliac tests in ankylosing spondylitis and other causes of low back pain: two studies. Clinical tests of the SI joint—a systemic methodological review. J Man Med. 35 . In: Malanga GA. 1: Reliability. 1957. Philadelphia. 2. Russel AS. Man Ther. Aireksinen O. 4. Sacro-iliac arthrodesis. Poor agreement between so– called sacroiliac joint tests in ankylosing spondylitis patients. Hagmeijer RH.43(2):192–195. 1981. Sacroiliac Joint Yeoman’s Test Purpose: SI joint. Positive test: Pain over the SI joint.24:1575–1577. Ann Rheum Dis. 2000. PA: Elsevier Mosby.89: 2031–2035. Solomon J.50:850–853. 7. Meyne W. and the examiner puts one hand on the sacrum. Discussion on the clinical and radiological aspect of Sacro-iliac disease. Maksymowych W. 8. Musculoskel etal Examination: An Evidence-Based Approach. 1984. 3. 2000.
Rosen E. Pauza K. with an analysis of 100 cases. MA: Blackwell Science. et al. Positive sacroiliac screening tests in asymptomatic adults. Spine. 1928. Gross J. 1119–1122. W. Spine. Musculoskeletal Examination. 12. Griffin J. Lancet. Dreyfuss P. 1996. 11. Dreyfuss P. 10. Michaelsen M. Dreyer S.19:1138–1143. The sacroiliac joint as an underappreciated pain generator.8. Daum WJ. et al. Cambridge. 36 . Am J Orthop. 1994. 1996. Fetto J. 1995. 13. The relation of arthritis of the sacro-iliac joint to sciatica.24:475–478. Yeoman. Sacroiliac Joint 9.21:2594–2602. The value of medical history and physical examination in diagnosing sacroiliac joint pain.
For the lateral meniscus. Technique: The patient is prone with the knees flexed at 90˚. 6. 5. and the leg is steadily extended. the patient’s knee is positioned in full flexion and the tibia in external rotation. Modifications: A valgus or varus stress is added to the rotation component in order to further challenge the integrity of the menisci. Positive test: Pain or “clunk” is noted. Distracting the tibia (and inducing pain) indicates ligamentous injury.9. 11. Technique: To assess the medial meniscus. 12 Apley Grind Test Purpose: Meniscal injury. Knee McMurray’s Test Purpose: Meniscal injury. 4. 10. (continued ) 37 . Positive test: A painful response over the lateral or medial joint line indicates meniscal pathology. Sensitivity: 16%–58% Specificity: 77%–98% Sources: 2. 8. The examiner grasps one foot and both externally and internally rotates as far as possible while applying a downward pressure on the foot. the test can be repeated with the tibia held in internal rotation.
Sensitivity: 64% Specificity: 90% Sources: 12 38 . Positive test: The patient is unable to do this maneuver (without pain). 8. Duck Walk) Purpose: Meniscal injury. 90% Lateral Sources: 3 Childress’s Test (Squat. 10. Rotation into internal and external rotation is repeated several times. Duck Waddle. 11.9. Technique: Standing on the affected leg. 5. Technique: The patient squats and attempts to take a few steps in this position. Knee Apley Grind Test (continued ) Sensitivity: 13%–16% Specificity: 80%–90% Sources: 2. 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. 92% Lateral Specificity: 97% Medial. Sensitivity: 89% Medial. 4. Positive test: Pain over joint line or sensation of locking or catching. 6. 12 Thessaly/Disco Test Purpose: Meniscal injury.
Positive test: Pain and/or apprehension. the patient externally rotates the legs and slowly squats. and the patella is pushed laterally in a slow and controlled manner. Sensitivity: 32% Specificity: 86% Sources: 7. Positive Test: Pain or click felt at the joint line. To test the lateral meniscus. Technique: The patient lies supine with the knees flexed to 30° over the clinician’s thigh. To test the medial meniscus.9. Technique: The patient stands with feet 30-40 cm from each other and knees in full extension. the patient internally rotates the legs and squats. Sensitivity: 67% Medial 64% Lateral Specificity: 81% Medial 90% Lateral Sources: 1 Patella Apprehension Test (Fairbanks) Purpose: Patellar subluxation. Knee Ege’s Test Purpose: Meniscal injury. 9 39 . Both thumbs are placed over the medial patella border.
The examiner applies a downward and inferior pressure over the superior border of the patella and asks the patient to contract the quadriceps. 16. Knee Patellofemoral Grinding Test (Clark’s test) Purpose: Patellofemoral dysfunction and/or chondromalacia patella.9. Sensitivity: 22.24% Specificity: more than 97% Sources: 13. The examiner sits on the subject’s foot.2%–95. Positive test: Pain/crepitus over the patella. and then pulls it anteriorly with both hands. 9 Anterior Drawer Test Purpose: Anterior cruciate ligament (ACL) injury/laxity. Technique: The patient lies supine with the knees extended. grasps the tibia. 15. 17. making sure the patient is completely relaxed. Positive test: Increased forward tibial displacement compared with the non-affected side. 14. 18 40 . Technique: The patient is supine with the hip flexed to 45° and knee flexed to 90°. Sensitivity: 49% Specificity: 75% Sources: 7.
19. Technique: The patient’s knee is flexed to 30° while applying a valgus force to the knee and internally rotating the tibia. 16. 15. 17. Technique: The patient is supine. Knee Lachman Test Purpose: ACL injury/laxity. causing the lateral tibial plateau to sublux. 24 41 .67%–99% (under anesthesia) 80%–98.9.8% (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. Positive Test: A palpable/audible click will be heard implying tibial relocation.4% (under anesthesia) Not reported without anesthesia Specificity: >98% (under anesthesia) Not reported without anesthesia Sources: 14. Sensitivity: 84. 18 Pivot Shift Test Purpose: ACL injury/laxity. 17. Sensitivity: 35%–98. Positive test: Increased forward tibial displacement compared with the other side. The examiner then slowly extends the knee.
knee flexed to 90°. Knee Reversed Lachman Test Purpose: Posterior cruciate ligament (PCL) injury/laxity. Posterior force is applied to the proximal tibia. The examiner holds the knee in 20°–30° of flexion and pulls the tibia posteriorly. Positive test: Increased posterior tibial displacement compared with the non-affected side. Technique: The patient lies supine with the involved hip flexed to 45°. 21. 23. Positive test: Increased posterior tibial displacement compared with the other side. 20. Technique: The patient is supine. and foot in neutral position. 24.9. 25 42 . Sensitivity: 51%–100% Specificity: 99% Sources: 13. 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.
9. 27 Varus Stress Test Purpose: Lateral collateral ligament injury/laxity. 26. The examiner applies valgus (medial) force across the joint line. Positive test: Increased laxity/widening or pain of the medial joint line compared to the non-affected side. Knee Valgus Stress Test Purpose: Medial collateral ligament injury/laxity. Sensitivity: 86%–96% Specificity: No Data (ND) Sources: 13. Technique: The patient is supine and the knee flexed to 30°. Sensitivity: 25% Specificity: No Data (ND) Sources: 13 43 . Technique: The patient is supine and the knee flexed to 30°. The examiner applies varus (lateral) force across the joint line. Positive test: Increased laxity/widening or pain of the lateral joint line compared to the other side.
Fowler PJ. Sally PI. 2006. et al. 7. Hattam P. 2003. Haddad FS. Boya H. 8. Special Tests in Musculoskeletal Examination: An Evidence-Based Guide for Clinicians. Acute dislocation of the patella: a correlative pathoanatomic study.84:592–603. Nijs J. The accuracy of physical diagnostic tests for assessing meniscal lesions of the knee—a meta-analysis. Akseki D. Van der Auwera C. Ozcan O.17:806–811.5(3):184–186. et al. Arthroscopy. 9. et al. Konan S. 2007. 2010. 2005. Yoshiya S.9.24(1):52–60. Zibis AH. Rayan F. Clin Orthop Relat Res. Physical examination of the knee: a review of the original test description and scientific utility of common orthopedic tests. 2001. Scholten RJ. 4. Andrus SA. Siparsky PN. J Fam Pract. 5. 1996. Kurosaka M.50(11):938–944. Philadelphia.455:123–133. The diagnosis of meniscus tears: the role of MRI and clinical examination. 12. 2009. Opstelten W. 11. Arch Phys Med Rehabil. Efficacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear.23:271–274. A new weight-bearing meniscal test and a comparison with McMurray’s test and joint line tenderness. T. Speer KP. Knee Sources 1. PA: Elsevier Mosby. 3. Karachalios.87(5):955–962. London: Churchill Livingstone Elsevier. Lubliner JA. et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. 2. Smetham A. Yagi M. 6. Poggi J. 1st ed. Diagnostic value of five clinical tests in patellofemoral pain syndrome. Nadler SF. Am J Sports Med. Deville WL. The predictive value of five clinical signs in the evaluation of meniscal pathology. Musculoskeletal Physical Examination: An Evidence-Based Approach. 10. Hantes M. 1st ed. Malanga GA. Nadler SF. Ryzewicz M. Peterson B. 2004. Van Geel C. Arthroscopy. 1989. et al. Do physical diagnostic tests accurately detect meniscal tears? Knee Surg Sports Traumatol Arthrosc.20(9):951–958. Man Ther. Int Orthop. et al. 44 . 1999. et al. 2005.11:69–77. J Bone Joint Surg. Malanga GA.
Rubinstein RA Jr. Knee 13. Clinical diagnosis of ruptures of the anterior drawer ligament: a comparative study of the Lachman test and the anterior drawer sign. Rettig AC. 22:550–557. Warren RF. 1981. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med.13:5–10. Am J Sports Med.317:237–242.9.12:189–191. Larson RL. Evaluation of knee instability in acute ligamentous injuries. Peterson L. The diagnostic accuracy of ruptures of the anterior cruciate ligament comparing the Lachman test. Loos WC. Reliability of the anterior drawer test. Messner DG. and the Lachman test. Kim HK. 19. 1988. Initial versus examination under anesthesia. 24. 1980. Friedman MJ. 17. 23. 1985. Acute posterior cruciate ligament injuries. Donaldson WF III. Moore HA. 1982. Orthopedics. 1987. 14. Heckman JD. Mitsou A. Del Pizzo W. Am J Sports Med. Ann Chir Gynaecol. Injury. 18. Katz JW. 1986. Interstitial tears of the posterior cruciate ligament of the knee. The acute pivot shift: clinical correlation. Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. Harilainen A. Kim SJ. 45 . DeLee JC.9:86–92.19:427–428. and the pivot shift test in acute and chronic knee injuries. McCarroll JR. Jonsson T.8:68–78. 15. Am J Sports Med. 1994. Renstrom P.3:764–772. Stone ML. 1984. Shelbourne KD. Lucie RS. Clinical diagnosis of ruptures of the anterior cruciate ligament: a comparison between the Lachman test and the anterior drawer sign. the pivot shift test. the anterior drawer sign. Results of early surgical repair. Blazina ME. A comparison of acute anterior cruciate ligament examinations. Am J Sports Med. Posterior cruciate ligament injuries.14:88–91. Clin Orthop. 16. Fox JM.10:100–102. 21. Wickiewicz T. Daniel DM. 20. 1980.70:386–391. J Bone Joint Surg Am. VanMeter CD. 22. Am J Sports Med. Barnett P. Vallianatos P. Clendenin MB.76:269–273. Wiedel JD. Althoff B. 1995. Fingeroth RJ. Am J Sports Med. 1988. Sachs R.
Cross MJ. Riddle DL. 26. Munk PL. The lateral compartment. Rothstein JM. Vellet AD. Hughston JC. Garvin GJ. Knee 25. McClure PW.9. Moschi A. Part II. Classification of knee ligament instabilities. 27. 1976.58:173–179. 1989. Can Assoc Radiol J. J Bone Joint Surg Am.69:268–275. Intertester reliability of clinical judgments of medial knee ligament integrity. Phys Ther. 46 . Tears of the medial collateral ligament: magnetic resonance imaging findings and associated injuries.44:199–204. Andrews JR. 1993.
The calf is squeezed to produce plantar flexion via the Achilles tendon. Positive test: No plantar flexion with squeezing of the calf.10. If the patient is unable to lie on the exam table. Sensitivity: 78% Specificity: 75% Sources: 2 47 . knees flexed to 90°. the patient can sit with the legs off the table and knee flexed to 90°. Technique: The patient sits with legs off the table. Sensitivity: 96% Specificity: 93% Source: 1 Anterior Drawer Test Purpose: Anterior talofibular ligament (ATFL) laxity. Technique: The patient lies prone on the examination table. Positive test: Difference in laxity between the two sides. in an attempt to draw the talus anteriorly from beneath the tibia. Ankle Thompson test (Simmond’s Test) Purpose: Achilles tendon injury/ rupture. The examiner stabilizes the distal part of the leg with one hand and applies anterior force to the heel with the other hand.
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:
II. Neurological Tests and Scales .
Proprioceptive Neuromuscular Facilitation Description: Combination of passive stretching and isometric contractions (7). 5). Resistance is used during spiral and diagonal movement patterns with the goal of facilitating impulses to other parts of the body (3. and facilitate selective automatic. 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. 6). Brunnstrom Approach/Movement Therapy Description: Uses primitive synergistic patterns in an attempt to improve motor control through central facilitation (4). The key element is limb positioning out of synergy focusing on the proximal to distal. using sensory information (tactile cue through manual contacts. oal is to normalize tone. 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). verbal directions) to reinforce weak movement patterns and to discourage overactive ones (3. voluntary reactions (4). Facilitation to promote motor learning. inhibit primitive patterns of G movement. Primitive reflex synergies are considered normal processes of recovery (4).11. 4. (continued ) 53 .
The key element is to uses resistance. and primitive postural reaction to facilitate gross synergistic movements and the return of muscle tone and focus on general progressing to isolated movements (1. Rehabilitation Approach to Neurological Deficits Brunnstrom Approach/Movement Therapy (continued) Enhances specific synergies through use of cutaneous proprioceptive stimuli and central facilitation (4). vibration. icing. 54 . slow stroking. and joint compression (2. 3). 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. 4). tendon tapping.11. 3. Can be used with hypotonia or hypertonia (3). The affected limb is then used intensively for either 3 or 6 hours a day for at least 2 weeks (4). Inhibitory or facilitative input through the use of quick stretch. Constraint-induced Movement Therapy Description: Forces the patient to use the affected limb by restraining the unaffected limb. fast brushing. associated reaction.
Peckham PH. Mortimer JT. 1997.11. Physical Medicine and Rehabilitation Board Review. Cuccurullo SJ. Eyssette M. Brissot R. Davis Company. 4th ed. McAtee RE. 2007:60. Restoration of gait by functional electrical stimulation for spinal cord injured patients. Facilitated Stretching PNF and Strengthening Made Easy. Zorowitz RD. 2. Gait restoration and gait aids. J Bone Joint Surg AM. Sisto SA. Gallian P. Keith MW. eds. PA: Lippincott Williams and Wilkins. 2005:1393–1396. Follow up of five patients. In: DeLisa JA et al. 5. 55 . Bogey RA.. Schmitz TJ. Philadelphia.35:905–916. Philadelphia. An implanted upper extremity neuroprosthesis. 1995. 2007:17–18. 720. Focusing on facilitated stretching. 7. Champaign. In: McAtee RE. eds. ed. Pa: F. In: Cuccurullo SJ. 1988. 2nd ed. et al. et al.A.33:660–664. NY: Demos Medical Publishing. 512. New York. Charland J. Kilgore KL. Charland J. 6. Physical Medicine and Rehabilitation: Principles and Practice. Stroke. Physical Rehabilitation. Baerga E. 3. O’Sullivan SB. 2010:27–28. Rehabilitation Approach to Neurological Deficits Sources 1. IL: Human Kinetic. 4. Paraplegia. 3rd ed. A spiral nerve cuff electrode for peripheral nerve stimulation. IEEE Trans Biomed Engi. et al. Scheiner A. Naples GG.79:533–541. 5th ed.
continence of bowels and bladder (3. 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. A global score is calculated out of 56 possible points (5. The items are scored from 0 to 4. 4). and by direct observation of some activities (3). 6). 6). The BI measures what the patient actually does rather than what they can do. 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. dressing. 6). walking on level surface. Measures the patient’s ability to maintain balance both statically and while performing various functional movements— for a specified duration of time (5. The items include feeding. going up and down stairs. bathing. 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. 4). grooming. 56 . Information is obtained via verbal reports from patients.12. caregivers and staff. Stroke Outcome Barthel Index (BI) Description: Ten items that measure a person’s daily functioning (activities of daily living and mobility). with a score of 0 representing an inability to complete the task and a score of 4 representing independent item completion. transferring to and from a toilet.
8). 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. 57 . balance. and to plan and assess treatment. The scale is composed of five domains (each with multiple items) (1. 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. describe motor recovery. and joint functioning in hemiplegic poststroke patients. sensation.100 (normal motor performance) • Sensation: (0–24) • Balance: (0–14) • Joint ROM: (0–44) points. • Joint pain: (0 to 44) points. It is used to determine disease severity. 3 seated and 4 standing) • Joint range of motion (8 joints) • Joint Pain Scoring: Domains (2): • Motor score: 0 (hemiplegia). Fugl-Meyer Assessment (FMA) Description: Designed to assess motor functioning.12.
Requires constant nursing care. Olsson S. Jaasko L. • 5 —Severe disability. Assistance with bodily needs. Sources 1. bedridden. Md State Med J. • 4 —moderately severe disability.7(Suppl):85–93. Scand J Rehabil Med. Able to look after own affairs without assistance. 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). Able to carry out all activities. Scand J Rehabil Med. 10). A method for evaluation of physical performance. Steglind S. The post-stroke hemiplegic patient. Mahoney Fl. Barthel DW. 3. Fugl-Meyer AR. Scoring: • 0—no symptoms. • 3 —moderate disability. Fugl-Meyer AR. Assistance with ambulation. despite some symptoms. The scale ranges from 0-6. but unable to carry out all previous activities. • 1 —no significant disability.7:13–31. Functional evaluation: the Barthel Index. • 2 —slight disability.14:2:61–65. 1975. 1980. • 6—Dead (9. 10). Leyman I. 1. 2. Post-stroke hemiplegia assessment of physical properties. Requires some help. 58 . but able to walk unassisted.12. incontinent. indicating perfect health without symptoms to death (9. 1965.
Stroke Outcome 4. comparison of the responsiveness of the Barthel Index and Functional Independence Measure. Visser M. Berg K. Measuring balance in the elderly: Validation of an instrument. Van Swieten J.15:49–56. Gayton D. Berg K.19(5):604–607. 1999. 6. Cass SP. II. 1989. NeuroRehabilitation. Williams JI. Stroke. 5. Physiotherapy Canada.66(4):480–484. Williams JI. Whitney SL. Cerebral vascular accidents in patients over the age of 60. Rochelle A. 7. 1992. Rankin J. 8. Hobart JC. Wood-Dauphinee S. Choksi A. et al. Prognosis. Neurol Neurosurg Psychiatry. Van der Putten JJMF. Can J Pub Health. A review of balance instruments for older adults. Zwick D. Measuring balance in the elderly: preliminary development of an instrument. 9. Koudstaal P. Evaluation and treatment of balance in the elderly: a review of the efficacy of the Berg Balance Test and Tai Chi Quan. Am J Occup Ther. Domowicz J. Scott Med J. 1957.41:304–311.2:S7–S11. Maki B. 1998. 1988. Measuring the change in disability after inpatient rehabilitation. Freeman JA. Wood-Dauphinee S. 2000.52:666–671.12. J. Interobserver agreement for the assessment of handicap in stroke patients. Thompson AJ.2(5):200–215. 59 . 10. Poole JL.
Buschbacher RM. 3rd ed. Ragnarsson KT. Physical Medicine and Rehabilitation. 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. eds. PA: Saunders Elsevier. Adam BS. Chan L et al. 2007:1288–1291. Bryce TN. Philadelphia. Spinal cord injury. 60 .13. In: Braddom RL.
3.14. 11. 13 Oppenheim Reflex Technique: Apply a firm downward stroke along the anterior border of the tibia. 9. 10. 3. Specificity: 96% Sensitivity: 31% Sources: 3. Stroke the leg from shin to foot while the patient holds the leg in flexion. Specificity: 90% Sensitivity: 80% Sources: 1. Positive Test: Dorsiflexion of the hallux of the opposite leg. Positive Test: Dorsiflexion of the hallux and other toes fan out. 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. 12 61 . Specificity: No Data (ND) Sensitivity: No Data Sources: 1. 14 Crossed Upgoing Toe Sign Technique: With the patient supine. 2. 12. passively flex the limb at the hip. Positive Test: Dorsiflexion of the hallux. 8.
2 Hoffman Sign Technique: Tap the volar or dorsal surface of the third or fourth finger. 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. 16. Specificity: No Data (ND) Sensitivity: No Data Sources: 1.14. 5. 15. Positive Test: Involuntary flexing of the end of the thumb and index finger. 7 Palmomental Reflex Technique: Stroke the thenar or hypothenar eminence in a proximal to distal direction up to five times. 17 62 . 6. Specificity: 58%–98% Sensitivity: 24%–95% Sources: 3. Positive Test: Contraction of thigh adductors and inward rotation of leg. Upper Motor Neuron Signs Cross Adductor Reflex Technique: Tap the sole of the patient’s foot. Specificity: 74% Sensitivity: 94% Sources: 1.
Pradhan S. Saunders Company. Early diagnosis of cervical spondylotic myelopathy. 1981:168–179. Bailey K. 5. 12. 2004.16(12):1353–1355. Reliability of clinical tests in the assessment of patient with neck/shoulder problems-impact of history. Fannin M. Berger JR. Extensor toe sign: by various methods in spastic children with cerebral palsy. Wang J.21:49–52. 2002.14.252:106–107. 1st ed. Morrow D. England: Blackwell Scientific Publications. Correlation between a positive Hoffman’s reflex and cervical pathology in asymptomatic individuals. South Med J. B. Hindfelt B. Correlation between magnetic resonance imaging and radiographic measurement of cervical spine in cervical myelopathic patients. 8. Mayo Clinic and Mayo Foundation. Hanko J. Upper Saddle River.12:239–242. 63 . Wong WC. Leung HB. Spine. J Orthop Surg. Strender LE. 11. 1998. Glaser J. 1972. 9. Spine. 2005.13:2222–2231. PA: W. Spillane J. Cervical spinal cord compression and the Hoffman sign. 4. J Neurol. Cure J. 1991. Iowa Orthop J. J Child Neurol. 7. NJ: Pearson Prentice Hall. Bickerstaff E. 5th ed. 2001. 10. Bertilson B. Denno JJ. Acta Orthop Scand. Orthopedic Physical Examination Tests: An Evidence-Based Approach. 2. Absence of the Babinski sign in brain death. Philadelphia.95(10):1178–1179. Meadows GR. Clinical Exam in Neurology. The significance of a crossed extensor hallucis response in neurological disorders: a comparison with the Babinski sign. A useful clinical sign. 2001. Ghosh D. De Freitas G. 1989:185–194.43:234–238. Grunnesjo M. Upper Motor Neuron Signs Sources 1. 3. Hegedus E.13(5):216–220. Spine. Cook C. The “bedsheet” Babinski. 2008:12–22. Neurologic Exam in Clinical Practice. 5th ed. Sung R. 6. Rosen I. Wong TM. 26:67–70. 2003. Andre C. Oxford.
Kumar SP. 2000. Upper Motor Neuron Signs 13.64(9). 17. 14. Miller FB. Neurology India. August B.65:1165–1168. Eur Neurol.14. 16. The diagnostic value of three common primitive reflexes. Biran I. Miller T.48:314–318. J Am Med Assoc. Costeff H. 64 . 1984.48(2):120–121. Sazbon L. Johnston SC. Neurology. Abramski O. 2005. 15. Haggiag S.1656. Clinical value of the palmomental reflex. Gotkine M. Should the Babinski sign be part of the routine neurological examination? Neurology. Isakov E.23(1):17–21. Lack of hemispheric localizing value of the palmomental reflex. Ramasubramanian D. 2005. 1952. The Babinski sign—a reappraisal.
7). Pressure Ulcers A pressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure. 7). Apply hydrocolloid dressing change every 5 days (6. Eliminate direct pressure (heel boots. Stage II Clinical Features: Partial thickness skin loss of dermis presenting as a 65 . Darkly pigmented skin may not have visible blanching. provide pressure redistribution mattress. 2. 3). 5. and/or a combination of these (1). Check prealbumin level and address deviation (5. friction. and prop tubing away from the body) (6. 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. wedge. 3. shear. 2. Optimize nutrition. Stage I Clinical Features: Intact skin with nonblanchable redness of localized area usually over a bony prominence. Apply protective ointment twice daily and as needed with each perineal care (6. chair cushion. 7). its color may differ from the surrounding area (1. 10). 4. Treatment: 1. 7).15.
2.15. Optimize nutrition as with stage I (5. Eliminate direct pressure as with stage I (6. 3. 7). add wound gel (for dry wound bed). fill dead space with calcium alginate as primary. For the intact blister. tendon. but bone. then cover with gauze daily. apply protective ointment after wound cleanser. Stage III Clinical Features: Full thickness tissue loss. 3. 10). If infected. Subcutaneous fat may be visible. may use topical antiseptic along with debriding agent and/or antibiotic (8). Slough may be present but does not obscure the depth of tissue loss. 3). May also present as an intact or open/ruptured serum-filled blister (1. (B) Necrotic tissue present—apply enzymatic debriding agent. or muscles are not exposed. then cover with secondary gauze dressing daily (8). (A) No necrotic tissue with zero to minimal exudates— apply moist wound dressing with wound gel cover with gauze and change twice daily (4. 66 . Cleanse with wound cleanser. 4. 2. 3). apply dry dressing and eliminate direct pressure (6. 2. Cover with gauze twice daily or cover with hydrocolloid change every 5 days (6. 7). 6. Pressure Ulcers shallow open ulcer with a red-pink wound bed without slough. For open blister/epidermal loss. If moderate to severe exudates: apply enzymatic debriding agent. 2. May include undermining and tunnelling (1. Treatment: 1. 7). Treatment: 1. 7).
15. No necrotic tissue with zero to minimal exudate— wound gel dressing and cover with gauze daily (4. 7). 10). 5. 3). fill dead space with calcium alginate (for moderate to severe exudates) or gauze (for minimal to no exudates) twice daily (8). Eliminate direct pressure as with stage I (6. Slough or eschar may be present on some parts of the wound bed. If infected. 2. 7). Treatment: 1. 6. 10). Pressure Ulcers 4. 5. antibiotic. Optimize nutrition as with stage I (5. Necrotic tissue is present—enzymatic debriding agent. or chemical agent (Dakin’s solution) for a limited period of time (6). tendon. Optimize nutrition as with stage I (5. A. Cleanse with wound cleanser (6. or muscle. Stage IV Clinical Features: Full thickness tissue loss with exposed bone. 7). Eliminate direct pressure as with stage I (6. 3. 4. 7). 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 . Often include undermining and tunnelling (1. B. may use topical antiseptic. 2.
wedge. 3). 2. brown. chair cushion. Pressure Ulcers tissue from pressure and/or shear. If infected. boggy. mushy. 7). Optimize nutrition. antibiotic. 7). 7). 10). firm. Treatment: 1. Eliminate direct pressure (use heel boots. 2. 5. 2. 3. The area may be (preceded) by tissue that is painful. Clean the wound with wound cleanser (6. gray. Apply calcium alginate (for moderate to severe exudates) or gauze (for minimal to no exudates) twice daily (6. 68 . a black leathery necrotic tissue (1. 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. 3). prop tubing away from the body) (6.15. or chemical agent (Dakin’s solution) for a limited period of time (6. Treatment: 1. 7). tan. 2. or black) or covered with eschar. or cooler compared to adjacent tissue (1. 4. green. may use topical antiseptic. Stage: Unstageable Clinical Features: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow. warmer. provide pressure redistribution mattress. Check prealbumin level and address deviation (5. Eliminate direct pressure as with stage I.
Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. or pressure exerted by a medical device (6). Sussman C. monitor for changes (6. et al. 7). Bennett RG. Treatment: 1. Optimize nutrition as with stage I (5. change daily. Eliminate pressure. 7). 2. Henderson CT. The National Pressure Ulcer Advisory Panel. Ankrom AM. May use negative pressure wound therapy after debride ment if wound has a depth that needs to granulate efficiently (9). and IV or unstageable treatment management as indicated) (6.10(5):16–9. Optimize nutrition as with stage I (5. 2005. 8. Moving toward consensus on deep tissue injury and pressure ulcer staging. Ayello EA. Adv Wound Care. Sprigle S. Pressure Ulcers 6.15. 10). Adv Skin Wound Care. pressures on mucous membranes. Sources 1. Dry necrotic eschar on feet with no signs or symptoms of infection: no debridement. cover with dry gauze. manage according to tissue loss and characteristics (refer to stages II. Draft definition of stage I pressure ulcers: inclusion of persons with darkly pigmented skin.18(8): 415–420. 7. Black JM. 69 . Adv Skin Wound Care. 1997. 3.18(1):35–42. 2. 2005. III. 10). et al. 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.
” Pressure Ulcer Treatment”. PA Lippincott. Philadelphia. Quick Reference Guide. 3rd ed. Nutritional assessment & treatment. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. 3rd ed. In: Sussman C. In: Sussman C. 10. Jensen BB. PA Lippincott. Williams & Wilkins. Pressure Ulcers 4. 70 . Management of the wound environment with dressings and topical agents. Quick Reference Guide. 1994. Wound Care: A Collaborative Practice Manual for Health Professionals. Philadelphia. Debridement choices for chronic wounds. Sussman G. PA: Lippincott. 2007:211–214. Philadelphia. 2007:250–266. Assessing the hydroaffinity of Hydrogel dressings. Wound Care: A Collaborative Practice Manual for Health Professionals. Ayello EA. Valenzuela A. eds. eds. 8. 2009:16–30. Cuddigan JE.Inc. et al. Philadelphia.15. 2009:7–9. Florida. Wound Care: A Collaborative Practice Manual for Health Professionals. 6. ed. Gabriel A. 7. J Wound Care.Wound Care TIMEsaver Manual. Prevention of pressure ulcers. 3rd ed. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. Jensen BB. Williams & Wilkins. In: Sussman C. “Management of wound environment with negative pressure wound therapy”. 5. 2007:63–70. Posthauer ME. eds. 2009:16–30. 3rd ed. Wound Care: A Collaborative Practice Manual for Health Professionals. Hay.(3):89–91.St. Jensen BB. Image Sources Smith & Nephew.”Pressure Ulcer Staging System”. Thomas S. PA: Lippincott. Williams & Wilkins.Petersburg. In: Sussman C. Smith & Nephew. 2008 (1):18–37. Jensen BB. 9. National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. Quick Reference Guide. Hiltabidel E. Williams & Wilkins. Pressure ulcer treatment. 2007:283–294.
71 . Physical Medicine and Rehabilitation. paralysis 100 Source 1. Chan L et al.16. 2007:22–33. eds. Philadelphia. Buschbucher RM. fasciculations observed in the muscle 76–99 0/5 No muscle contraction visible or palpable. Panagos A. In: Braddom RL. et al. 3rd ed. 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. O’Dell MW. Lin CD. The physiatric history and physical examination. PA: Saunders Elsevier Company.
The physiatric history and physical examination. O’Dell MW. 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. Philadelphia. et al. Panagos A. 2007:18. 72 . Chan L et al.17. In: Braddom RL. Physical Medicine and Rehabilitation. PA: Saunders Elsevier Company. Deep Tendon Reflex Grading Scale Deep Tendon Reflex Clinical Findings Grade: 4+ or ++++ Hyperactive with clonus (more than 5 involuntary. 3rd ed. Buschbucher RM. Lin CD. eds.
Glasgow Coma Scale Score Motor Verbal Eyes 6 Obeys commands 5 Localizes painful stimuli Oriented. 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.18. 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.
74 . Glasgow Outcome Scale (GOS) Stage Description 1 Dead 2 Vegetative state: no interaction with environment (unresponsive). 1981. Sources 1. Jennett B. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. 2010:59. 1974. Bond MR. NY: Demos Medical Publishing. 3. Teasdale. 2. Galang G. Snoek J.44:285–293.2:81–84. In: Cuccurullo SJ. Elovic E. Lancet. Traumatic brain injury. Baerga E. G.19. 3 Severe disability: follows commands but dependent upon others for daily support. 4 Moderate disability: independent in activity of daily living but cannot work or return to school. J Neurol Neurosurg Psychiatry. 2nd ed. 5 Good recovery: able to return to work or school. ed. et al. New York. Physical Medicine and Rehabilitation Board Review. et al. Assessment of coma and impaired consciousness.
20. L. Parameters determining late recovery of consciousness. Sazbon. 75 . Outcome in 134 patients with prolonged posttraumatic unawareness. 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. 1990.72:75–78. J Neurosurg.
may recognize close contacts. Ranchos Los Amigos Scale 76 Level Response Clinical Features I No response to pain Patient does not respond to auditory.21. follow simple commands (localize and removal of noxious stimulus) IV Confused-agitated Disoriented. may require restraints for safety. non-agitated Somewhat alert. gross movements to noxious stimuli (grimace) III Localized response to pain Limited. visual. or tactile stimuli. withdrawing from pain. able to follow . but purposeful. may do simple routine activities with assistance (confusion) V Confused-inappropriate. appears in a deep sleep (coma) II Generalized response to pain Limited. inconsistent responses. potentially aggressive. visual. which may include turning toward sound. etc. responds to commands. or tactile stimuli. more specific responses to auditory. visual. may recognize close contacts. but not fully oriented. inconsistent response to auditory. or tactile stimuli.
improved memory of recent events. In: Braddom RL. or act inappropriately or be sexually suggestive (frontal lobe syndrome-like symptoms) VI Confusedappropriate Alert and oriented. impairments in executive functioning. speak. functions with assistance VII Automaticappropriate May perform routine care independently. 77 . may have cognitive defects (spontaneous) Sources 1. 3rd ed. PA: Saunders Elsevier Company. 2. Kreutzer JS. poor memory and may confabulate. Physical Medicine and Rehabilitation. Taylor L. Ranchos Los Amigos Hospital. Philadelphia. Buschbacher RM. Rehabilitation after traumatic brain injury. 1979. Ranchos Los Amigos Scale Level Response V (continued) Clinical Features tasks for brief periods. eds. Chan L et al.21. may be inflexible and rigid (affect—flat) VIII Purposefulappropriate Able to function independently. 2007:1146. Cifu DX. Slater DN. may perseverate. Rehabilitation of the head-injured adult: comprehensive physical management. Professional Staff Association.
Baerga E. NY: Demos Medical Publishing. passive movement difficult. Interrater reliability on a modified Ashworth Scale of muscle spasticity. 4 Affected part(s) rigid in flexion or extension. New York. Modified Ashworth Scale for Spasticity Score Clinical Findings 0 No increase in muscle tone. Bohannon RW. 2010:809–822. 1+ Slight increase in muscle tone.67:206–207.22. 1987. Elovic E. 3 Considerable increase in muscle tone. Phys Ther. ed. 1 Slight increase in muscle tone. Sources 1. followed by minimal resistance throughout limited Range of motion. 2nd ed. Associated topics in physical medicine and rehabilitation/spasticity. 2 More marked increase in muscle tone through most of the Range of motion. 78 . but affected part(s) easily moved. Physical Medicine and Rehabilitation Board Review. 2. catch. White BF. In: Cuccurullo SJ. catch and release or minimal resistance at the end of the Range of motion.
Zorowitz RD. 79 . Philadelphia. 4 Movements are outside of flexor and extensor synergy (peak of synergy). 7 Normal function restored. Brunnstrom Stages of Recovery Stage Clinical Findings 1 Paralysis. and Cuccurullo SJ. eds. In: Cuccurullo SJ. 6 Spasticity resolved. New York. 2. decrease in spasticity. Sources 1. most muscle activation is selective and independent from synergy (further decrease in spasticity). NY: Demos Medical Publishing. basic flexor and extensor synergy patterns. 2010:26.23. 2005:1667. spasticity appears. improved movement (start of fine movement) and coordination. Walsh NE et al. flaccidity 2 Minimal voluntary movements. 3 Voluntary movement within the synergy patterns. Gans BM. Physical Medicine and Rehabilitation Principles and Practice. increase in spasticity (prominent). Physical Medicine and Rehabilitation Board Review. 4th ed. Stroke. Baerga E. ed. 2nd ed. Stroke rehabilitation. Brandstater ME. 5 Complex movement combinations. In: DeLisa JA. PA: Lippincott Williams & Wilkins.
eds. Physical Medicine and Rehabilitation Principles and Practice. 80 . Buschbacher RM. Roth EJ. In: Braddom RL. Walsh NE et al. 3rd ed. Brandstater ME. eds. Stroke rehabilitation.24. Rehabilitation in stroke syndromes. 4th ed. PA: Saunders Elsevier. Aphasia Aphasia Fluency Comprehension Repetition Global (−) (−) (−) Broca (−) (+) (−) Transcortical Motor (−) (+) (+) Wernicke (+) (−) (−) Transcortical Sensory (+) (−) (+) Conduction (+) (+) (−) Anomia* (+) (+) (+) Mixed Transcortical (−) (−) (+) *Anomia: Cannot Name Objects: Impaired: (−) Intact: (+) Sources 1. PA: Lippincott Williams & Wilkins. Gans BM. Harvey RL. 2. In: DeLisa JA. Philadelphia. Yu D. Physical Medicine and Rehabilitation. Philadelphia. 2005:1666. Chan L et al. 2007:1179.
25. Standard Neurological Classification of Spinal Cord Injury 81 .
American Spinal Cord Injury Association: International Standard for Neurological Central Cord Brown-Sequard Anterior Cord Conus Medullaris Cauda Equina STEPS IN CLASSIFICATION 1. 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 . Otherwise injury is incomplete. against gravity and provides normal resistance 4 active movement. 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. revised 2002. Source: ASIA standard neurological classification of spinal cord injury. Determine motor levels for right and left sides. not testable. ► CLINICAL SYNDROMES (OPTIONAL) E = Normal: Motor and sensory func tion are normal. If voluntary anal contraction = No AND all S4-S5 sensory scores 0 AND any anal sensation = No. ASIA IMPAIRMENT SCALE ► NT. gravity eliminated 1 palpable or visible contraction 0 total paralysis MUSCLE GRADING 25.82 5. C = Incomplete: Motor function is preserved below the neurological level. 3. AIS=A Record ZPP NO ( For ZPP record lowest dermatome or myotome on each side with some (non-zero score) preservation) 4. full range of motion. B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. sufficient resistance to be considered normal if identifiable inhibiting factors were not present 5 active movement. NO Are at least half of the key muscles below the (single) neurological level graded 3 or better? ► Classification of Spinal Cord Injury.) ► YES AIS=C AIS=D If sensation and motor function is normal in all segments. Determine ASIA Impairment Scale (AIS) Grade: Is injury Complete? If YES. Patient unable to reliably exert effort or muscle unavailable for test ing due to factors such as immobilization. A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5. against gravity 2 active movement. Note: in regions where there is no myotome to test. 2. then injury is COMPLETE. Determine the single neurological level. in examiner’s judgment. the individual is neurologically intact. D = Incomplete: Motor function is pre served below the neurological level and at least half of key mus cle grade of 3 or more. Is injury incomplete? If NO. full range of motion. AIS=E Note: AIS E is used in follow up testing when an individual with a documented SCI has recovered normal function. full range of motion. The following order is recommended in determining the classification of individuals with SCI. against gravity and provides some resistance 3 active movement. the ASIA Impairment Scale does not apply. the motor level is presumed to be the same as the sensory level. If at initial testing no deficits are found. full range of motion. Determine whether the injury is Complete or Incomplete (sacral sparing). Determine sensory levels or right and left sides. IL. pain on effort or contracture. 5* muscle able to exert. Chicago.
26. 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. impaired sequencing. decreased initiation. 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. distractibility. Neuropsychology Effect of Traumatic Brain Injury (TBI) Domain Examples of Tests Intelligence Wechsler Adult Intelligence Scale (WAIS) Reduced performance IQ. decreased organization. impaired judgment/ impulse control. 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. poor free recall. may need cueing for retrieval 83 . trouble with abstract reasoning. difficulty set-shifting and multitasking.
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. Washington. Lucas. JA. DC. Addeo. 84 . Clinical Neuropsychology: A Pocket Handbook. 2006:351–380. Traumatic brain injury and postconcussion syndrome. eds. 2nd ed. Nussbaum PD. American Psychological Association.26. Robins DL. anxious. In Snyder PJ. R. decreased motivation Source 1.
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
NIH Stroke Scale Category Description Score Motor leg (right and left. National Institutes of Health. each side should be calculated separately) No drift Drift Cannot resist No effort against gravity No movement Amputation. trunk. heel to shin) Absent Present in one limb Present in two limbs 0 1 2 Sensory (pin prick to face. Source: National Institute of Neurological Disorders and Stroke. 88 . joint fusion 0 1 2 3 4 9 Limb ataxia (finger to nose. compare side to side) Normal Partial loss Severe loss 0 1 2 Language (name item. 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. leg. arm. describe a picture.28.
P atient received heparin within 48 hours prior with elevated partial thromboplastin time. In: Cuccurullo SJ. P rothrombin time greater than 15 seconds or International Normalized Ratio greater than 1. 2nd ed. Arterio-venous malformation. ed. Baerga E.28. 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. Physical Medicine and Rehabilitation Board Review. 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. Cuccurullo SJ. 89 . Zorowitz RD. Stroke. heparin) 1. NY: Demos Medical Publishing. New York. 3.7 2. 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.
place. Inc.” [Repeat up to 5 times..] Reading: “Please read this and do what it says.] CLOSE YOUR EYES Mini Mental state allows clinician to grade the cognitive state of a patient. A Score of 24–26 is considered normal. Reproduced by special permission of the Publisher. Mini Mental State Examination (MMSE) Consists of a series of questions including orientation to date. TABLE [pause]. Psychological Assessment Resources. obeying commands. APPLE [pause]. Published 2001 by Psychological Assessment Resources. A Score of 23 or below indicates cognitive impairment. PENNY [pause]. copying a design Orientation to Time: “What is the date?” Registration: “Listen carefully. by Marshal Folstein and Susan Folstein. Now repeat those words back to me. naming objects. Inc. 1998. I am going to say three words. writing. but score only the first trial. 2001 by Mini Mental LLC.” [Show examinee the words on the stimulus form. Lutz. 16204 North Florida Avenue. from the Mini Mental State Examination. recall. You say them back after I stop. repetition. Inc. Scoring ranges From: 0–30. reading. Florida 33549.] Naming: “What is this?” [Point to a pencil or pen. Copyright 1975. 90 . time.29.
Abductor pollicis longus (r). Infraspinatus (sc). Deltoid (a) Rhomboids (ds). Extensor digitorum (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). Flexor carpi radialis (m) Third digit Medial palm and 5th digit Biceps (mc). Radiculopathy† 91 . Supinator (r). Flexor pollicis longus (m). Elbow flexion Decreased Strength (continued ) Flexor pollicis brevis (m). Wrist flexion. Extensor indicis (r) Triceps (r). Flexor digitorum profundus (m). Finger extension Elbow flexion. ECRL and B (r). Flexor carpi ulnaris (u). Wrist extension Shoulder abduction. Biceps (mc). Brachioradialis (r).Disc C4–C5 C5–C6 C6–C7 C7–T1 Root C5 C6 ¤C7 C8 None Triceps Brachioradialis Biceps Diminished Reflex Finger flexion Elbow extension. Supraspinatus (sc). First dorsal interosseous (u).
Radiculopathy† .92 Disc T1–T2 L4–L5* L5–S1* Root T1 L4 L5 None Patellar None Diminished Reflex Ankle dorsiflexion. Vastus medialis (f). Great toe extension Knee extension Finger abduction and adduction Decreased Strength Lateral leg and dorsum of foot Medial leg Medial elbow Semitendinosus (s). Peroneus longus (sp). Extensor hallucis longus (dp). Extensor digitorum longus (dp). First dorsal interosseous (u) Muscles with Positive Diminished EMG Findings (nerve/ Sensation innervation) 30. Tensor fascia latae (sg) Vastus lateralis (f). Tibialis posterior (t). Tibialis anterior (dp). Semimembranosus (s). Tibialis anterior (dp) Flexor pollicis brevis (m). Gluteus medius (sg).
*Disc herniation in lumbar spine may produce a more complex picture than in the cervical spine. In lumbosacral spine. Herniated discs can affect the same level (as listed in chart) or. (sc)=suprascapular. (dp)=deep peroneal. ECRL and B=extensor carpi radialis longus and brevis. because of the cauda equina. (r)=radial. ¤ In cervical spine. (+H Reflex) Notes: PSW=Positive sharp waves. Biceps femoris (s). (u)=ulnar. Radiculopathy† 93 . L5 is the most common radiculopathy. The “traversing nerve” is the nerve that is passing the disc without exiting. (ig)=inferior gluteal. Peroneus longus (sp). (sp)=superficial peroneal. (s)=sciatic.* Achilles Ankle plantarflexion Lateral foot Gastrocnemius (t). The most likely traversing nerve to be affected is the level below (that nerve is the most taut as it will soon be exiting). (ds)=dorsal scapular. Gluteus maximus (ig). (m)=median. any level below. (sg)=superior gluteal. S1 30. fibs=fibrillation potentials. For example. (t)=tibial nerve. the L5–S1 disc often affects the S1 nerve root. Nerves: (a)=axillary. (f)=femoral. (mc)=musculocutaneous. C7 radiculopathy is most common. Peroneus brevis (sp). † 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.
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.
Philadelphia. Joint range of motion and muscle length testing. Reese NB. Yates C. 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. Bandy WD.31. 2010:31–47. PA: WB Saunders. Athletes will have sport-specific adaptations resulting in increased and decreased range of motion at certain joints. Expect the majority of these values for range of motion to decrease with increasing age. Source 1. 95 .
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.32. A Adductor brevis. intermedius). lower border of gluteus maximus ___________ . Quadriceps (Rectus Femoris. Saphenous— medial leg and foot L2–L4 Obturator dductor longus. scrotum/labia. Tensor fascia lata Posterior thigh. Obturator internus Medial thigh S2–S3 Postfemoral cut L4–S1 Superior gluteal ___________ luteus minimus. proximal calf. G Gluteus medius. P Iliacus. Sartorius nteromedial A thigh. lateralis. Vastus medialis. Adductor magnus (also sciatic nerve). Gracilis.
Extensor digitorum brevis Lateral sural— lateral leg and foot.32. Extensor digitorum longus. Peroneus tertius. Adductor magnus (also obturator nerve) Peroneal division: Biceps femoris (short head) ___________ L4–S2 Common peroneal (Leg) Superficial peroneal: Peroneus longus. Deep peroneal— first web space of foot 97 . Semimembranosus. First dorsal interosseus. Superficial peroneal— dorsum of foot. Lumbosacral Plexus Root Nerve Motor Sensory L5–S2 Inferior gluteal Gluteus maximus ___________ L4–S3 Sciatic (Thigh) Tibial division: Biceps femoris (long head). Peroneus brevis Deep peroneal: Tibialis anterior. Extensor hallucis longus. Semitendinosus.
lumbrical 3. interossei. Popliteus. Tibialis posterior. Lumbosacral Plexus 98 Root Nerve Motor Sensory L4–S2 Tibial (leg) Plantaris. Quadratus plantae Medial and Lateral branch to plantar aspect of foot . flexor hallucis brevis. Flexor digitorum longus edial sural M to posterior leg. adductor hallucis. first lumbrical Lateral plantar nerve: Abductur digiti minimi.32. Soleus. flexor digitorum brevis. Flexor hallucis longus. flexor digiti minimi. Calcaneal nerve to calcaneus L4–S2 Tibial (Foot) Medial plantar nerve: Abductor hallucis. Grastrocnemius medial and lateral. 4.
Brachial Plexus 99 .33.
34. Peripheral Nerve Distribution 100 .
Peripheral Nerve Distribution 101 .34.
35. Dermatomal Distribution of Nerve Roots 102 .
Dermatomal Distribution of Nerve Roots 103 .35.
56 Bear hug. 80 Codman’s test. 60 105 . 84 Beck depression inventory. 13 ASIA Impairment Scale. 83 B Babinski Sign/Koch Sign. 54 Continuous performance test (CPT). 12 Beck anxiety inventory. 27 Crossed straight leg raise test. 81–82 Atrophy. 61 Barthel index (BI). 23 Anterior talofibular ligament (ATFL). 19 California Verbal Learning Test. 47 Clark’s test. 72 Brunnstrom Stages of Recovery. 79 Deep tendon reflexes. 16 Crossed femoral test. 83 Constraint-induced movement therapy. 83 Controlled Word Association Test (COWAT). 84 Belly-press test. 10 Apley grind test. 60. 6 Clock Drawing. 19 Cervical spine. 60 Axial manual traction test. 38 Anterior drawer test. 83 Active compression test. 53 Brachial plexus. 67–68 Brunnstrom approach. duck walk). duck waddle. 15 Category test. return to play guidelines after. 53–54 Deep Tendon Reflex Grading Scale. 40 Aphasia. 99 D Braggard’s sign. 34 Apley scarf test. 56–57 Costoclavicular test. 16 Concussion. 37–38 Compression test. 26 Crossed upgoing toe sign.Index A C Abduction stress test/Jobe’s test. 3 Cozen’s test. 47 Carpal compression. 4 Childress’s test (squat. 40. 61 Bobath approach. 83 Adduction stress test. 85 Apprehension-relocation test. 20 Crossed-arm adduction test/ac joint test. 26 Dakin’s solution. 12 Berg Balance Scale (BBS). 6 Adson’s test.
74 Minnesota multiphasic personality inventory (MMPI). 28 K External rotation lag sign. 83 H Dermatomal distribution of nerve roots. internal rotation (FAIR)/Piriformis. 9 Extension and load test. 11 E Hyperabduction test. 10 Hand and wrist. 34 Military position. 10 Kemp’s test. 62 Hornblower’s sign. 75 Mini Mental State Examination (MMSE). 28 Fasciculations. 13 Empty can test. 23–24 Lift off test. 37–46 F Facet grind test. 19–21 J Ely’s test. 6 Lumbosacral plexus. 90 Glasgow Outcome Scale (GOS). adduction. 8 Drop-arm test. 84 .Index Delis-Kaplan Executive Function System (DKEFS). 3 Glasgow Coma Scale (GCS). 31 Load and shift test. 26 Finklestein’s test. 27 L Lachman test. 39 Elbow joint. 41 Lasegue’s sign/Lazarevic’s sign. 96–98 Lumbar spine. 11 Flexion. 27 Jobe relocation test. 57 Full can test. 30–33 Hoffman sign. 37 106 G Midline sacral thrust. 26–29 Fugl-Meyer assessment (FMA). 102–103 Hawkin’s-Kennedy test. 75 Foraminal compression test. 3 Ege’s test. 22–25 Hip. 28 Knee. 73. 13–14 Loss of consciousness (LOC). 60 Femoral nerve stretch test. 34 Gaenslen’s test. 9 M McMurray’s test.
39 Rotator cuff (RTC) impingement. 71 Posttraumatic amnesia duration (PTA). 30 O’Brien test. 6 Neer’s test. 30 Peripheral nerve distribution. 58 Phalen’s test. external rotation. 82 Posterior drawer test. extension (FABERE). 31 S Sacroiliac (SI) joint pain. 54 Patella apprehension test (Fairbanks). 34–36 Scalene test. 53 Neck distraction test. 78 Patte’s test. 53–55 Resisted wrist extension/resisted third finger extension. 22 Movement therapy. 83 Rey Osterrieth Complex Figure.Index Modified Ashworth Scale for Spasticity. 83 Rey Auditory Verbal Learning Test (RAVLT). 53–54 Pivot shift test. 76–77 Range of motion: upper extremity. 40 Patrick’s/flexion. 22 P Paced auditory serial addition test. 11 Modified Ober test. 83–84 NIH Stroke Scale. 87–89 O Ober test. 65–70 N Proprioceptive neuromuscular facilitation. 15 Oppenheim reflex. 60 Pressure ulcers. 8 Nerve entrapment test. 8 Patellofemoral grinding test. 27 Neurodevelopmental technique. 53 Neuropsychology. 94–95 Rehabilitation approach to neurological deficits. 75 Muscle tone. 83 Palmomental reflex. 20 Resisted wrist flexion. 42 Reverse Phalen’s test. 62 Rood approach. 61 R Radiculopathy. 41 Muscle grading. 91–93 Ranchos Los Amigos Scale. 20 Reversed Lachman test. abduction. 4 107 . 42 Muscle Strength Grading Scale. 100–101 Modified Rankin Scale.
16 Spinal cord injury. 16 . 24 Simmond’s test.Index Scalenus anticus syndrome. 6 Valgus stress test. 30 108 Wechsler Adult Intelligence Scale (WAIS). 35 Yergason’s test. 83 Varus stress test. 81–82 V Spurling’s test. 24 Stroke outcome. 75 Traumatic brain injury (TBI). 48 flexion. 8–18 Ulnar collateral ligament valgus testing of. 19. 3 Wrist Tinel’s sign at the wrist. 3–5 Wechsler Memory Scale (WMS). 48 Thessaly/Disco test. standard neurological clasification of. 27 Upper motor neuron vs lower motor neuron lesion. 32 Thompson test. severity of. 83 Sulcus sign. 56–59 Stroop Color-Word Interference Test. 83 and hand. 4 U Sensorimotor approach. 60 Speed’s test. 22 Trail making tests. 47 Upper motor neuron signs. 83 Y Yeoman’s test. 54 Shoulder. 61–64 Slump test. 9 W Waddell signs. 83 Wisconsin card sort test. 38 Thomas test. 23 extension. 26 Valgus testing of ulnar collateral ligament. 43 Straight leg raise test (SLRT). 73 Trendelenburg test/sign. 22–25 Traumatic brain injury (TBI) severity indices. 14 Supraspinatus weakness. 83 Wright’s test. 28 T Talar shift test. 43 Visual cancellation tests. 22 Tinel’s test. 19. 47 Thoracic outlet syndrome (TOS).
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