PHYSIOTHERAPY ASSESSMENT

J.EINSTEIN BABU.,BPT.,MPT(Neuro).,MIAP,MBA(HealthCare Management)

PHYSIOTHERAPIST,
ESIC MODEL HOSPITAL & MEDICAL COLLEGE
(Under Ministry of Labour & Employment, Govt of INDIA),
Rajaji Nagar, BANGALORE-560010
eins_mpt@rediffmail.com
Wbsite: http://physiotherapy-jobs.blogspot.com/

SUBJECTIVE DATA

QUESTION GUIDELINES

Describe the onset of the symptoms or mechanism of injury.

Determine whether symptoms are recent, recurrent, or insidious.

Determine whether perpetuating circumstances exist.

Describe how the symptoms are perceived.

Establish the location, type, and nature of the pain or symptoms.

Determine whether the pain and symptoms fit into a

Pattern:
Segmental reference zones
Nerve root patterns
Extra segmental reference patterns
(Dural reference, myofascial pain patterns,
peripheral nerve patterns, or circulatory pain)

Describe the behavior of the symptoms through a 24-hour

period while carrying out typical daily activities.
Identify which motions or positions cause or ease the symptoms.

Determine how severe or how functionally limiting the

problem is. (Functional limitations in terms of daily living,
work, family, social, and recreational activities)

Determine how irritable the problem is by how easily

the symptoms are evoked and how long they last.

Describe any previous history of the condition. Find out if

there has been previous treatment for the problem and the

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results of the treatment.

Describe related history, such as any medical or surgical intervention.

Briefly describe general health, medications, and x-ray or other pertinent

studies that have been performed. Identify any medical conditions that
may alert you to using special precautions or to contraindications to any
testing procedures.

PAIN

Pain Descriptions and Related Structures

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

INSPECTION

Helps to focus and individualize physical examination

SENSORIUM

Alert awake and attentive to normal stimulation

Lethargic drowsy, may fall asleep if not stimulated
Obtunded difficult to arouse, frequently confused when awake
Stupor responds only to strong, noxious stimuli: returns to
unconscious state
Coma cannot be aroused

ORIENTATION

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Awareness of Time, Person, and Place (oriented x 3)

AMBULATORY STATUS

Note patient’s mode of locomotion (wheelchair, ambulatory with or

without assistive device, bedridden, bed bound etc.)

SKIN (color, texture, presence of lesions, scars)

PRESSURE SORES

Stage 1 non-blanchable erythema of intact skin

Stage 2 abrasion, blister, or shallow crater (epidermis & dermis)
Stage 3 deep crater, necrosis/damage of necrotic tissue
Stage 4 extensive destruction, tissue necrosis extending up to muscle
and bone

BODY BUILD

Ectomorphic thin, prominence of structures from ectoderm

Mesomorphic muscular, prominence of structures from mesoderm
Endomorphic heavy, fat body built, prominence of structures from
endoderm

PALPATION

PALPATION GUIDELINES

Note differences in tissue tension, muscle tone & texture

Note differences in tissue thickness
Identify palpable anomalies
Define areas of tenderness
Temperature variations
Pulses, tremors, fasciculations
Dryness, excessive moisture
Abnormal sensation

Remember!! Palpate uninvolved part first and painful areas last

TENDERNESS (Pain upon palpation)

Tenderness Scale/Grading 1 complains of pain

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

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EDEMA

Grading of Edema Mild 1+ < ¼‖ depth of depression

Moderate 2+ ¼‖ to ½‖ depth of depression
Severe 3+ ½‖ to 1‖ depth of depression

VITAL SIGNS

BLOOD PRESSURE

Adult Blood Pressure Normal <120 mmHg / <80 mmHg

Pre-HTN 120-139 mmHg/80-89 mmHg
Stage 1 140-159 mmHg/90-99 mmHg
Stage 2 ≥ 160 mmHg/100 mmHg

Infant Blood Pressure < 2 y.o. 106-110 mmHg/59-63 mmHg

3-5 y.o. 113-116 mmHg/67-74 mmHg

Factors that may alter the Blood Pressure

Elevate BP Lowers BP

Pain Recent meal

Auscultatory gap Dehydration
Sleeplessness Auscultatory gap
Recent smoking
Distended bowel/bladder
Recent exercise
Chilling

PULSE RATE

Adult Pulse Rate Normal 60-100 bpm (avg. 70 bpm)

Tachycardia >100 bpm
Bradycardia < 60 bpm

Infant Pulse rate Normal 70-170 bpm (avg. 120 bpm)

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Pulse Grading 4+ Bounding
3+ Increased
2+ Brisk, expected
1+ Diminished, weaker than expected
0 Absent, unable to palpate

RESPIRATORY RATE

Adult RR Normal 12-20 cpm

Tachypnea > 20 cpm
Hyperpnea increase depth and rate

Infant RR Normal 30-60 cpm

Dyspnea (shortness of breath) scale +1 mild, noticeable to px

+2 mild, noticeable to observer
+3 moderate, can continue
+4 severe, can’t continue

TEMPERATURE

Normal 98.6˚F or 37˚C

Conversion ˚F= [˚C x 9/5] + 32
˚C= [˚F-32] x 5/9

Types of Fever Intermittent alternate b/n pyrexia & normal and

subnormal within 24 hr period

Relapsing/Recurrent alternate b/n pyrexia & normal

lapse for > 24 hr
Sustained/Constant consistently elevated
temperature

SENSORY ASSESSMENT
Sensory impairments interfere with acquisition of new motor skills since
motor learning is dependent on sensory information and feedback

SENSORY ASSESSMENT PRINCIPLES

Sensory assessment is completed prior to any testing that involves

active motor function

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 Initial screening for mental status (arousal, attention, orientation,
cognition & memory), vision & memory should be done prior to
performing sensory tests.

Patient should be instructed not to guess if uncertain about the

response

Demonstrate the test to orient the patient on what to expect and what
response is needed
Test order: Superficial—Deep—Cortical & Distal to Proximal
Apply the stimuli in a random order to avoid giving patient ―clues‖ to
the correct response

It is good to use a chart or picture to represent the areas with sensory

problem so as to easily identify if a certain pattern exists

EXAMINATION PROTOCOL

Superficial sensation Pain Use sharp end of a pin, avoid

applying stimuli close to each
other
Let finger slide over the pin
Light touch Use cotton or camel hair brush
Pressure Use thumb enough to indent
skin
Temperature Use test tubes with warm (41-
50˚F) and cold (104-113˚F)
Response When patient feels stimuli,
respond with yes, now or
unable to tell

Deep sensation Kinesthesia Move the extremity passively

in initial, mid or terminal range
with very minimal grip to
reduce tactile stimulation
Response Describe direction as up or
down, in or out while the
extremity is in motion. Also
patient can imitate the
movement in opposite
extremity.
Proprioception The extremity is held in a static
position in initial, mid or
terminal range with very

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 minimal grip to reduce tactile
stimulation
Response Describe direction as up or
down, in or out while the
extremity is in static position.
Also patient can imitate the
movement in opposite
extremity.
Vibration Place the base of a vibrating
tuning fork on a bony
prominence. Random
application of vibrating and
non vibrating stimuli should be
done. Patient should also be
given earphones to remove
the auditory clues.
Response Verbally identify the vibrating
stimuli

Cortical sensation Stereognosis The patient is given a familiar

object to be held and
manipulated
Response The patient is asked to identify
the object verbally

Tactile localization Therapist touches different

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

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 MUSCULOSKELETAL ASSESSMENT

PATIENT HISTORY & INTERVIEW

Symptom Onset sudden, gradual, insidious, traumatic

Location localized, diffuse, deep, superficial, changes,
spreads
Quality severity, characteristic

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 Behavior aggravating factors, relieving factors

Illustrations: Numerical Pain Rating Scales

Circle the number which best represents the intensity of your pain

0 1 2 3 4 5 6 7 8 9 10
No Pain Worst Pain
Imaginable
Previous Care/Medical History Previous occurrence of the
condition, treatments received and
its effects

Past medical history Other significant conditions

Medications Medications taken, type, frequency,

dose
Treatment goals Patient’s hopes for outcome

Occupational, recreational, social history patient’s work and activities,

architectural barriers,
environmental accessibility

Illustrations: Rate Patient’s Function

What percentage of your work activities are you able to perform?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Illustrations: Rate Patient’s Function

What percentage of your home activities are you able to perform?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Illustrations: Rate Patient’s Function

What percentage of your recreational activities are you able to perform?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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RANGE OF MOTION

Things to remember Normal side is tested first, unless bilateral

movements are needed

AROM-PROM-Isometric movements

Painful movements are done last

Apply over pressure at end of range with care

Over pressure maybe applied to point of pain but

not beyond

Resisted isometrics are done with the joint in

resting position

Active ROM Often estimated except if more accurate

measurement is needed, goniometer should be
used
If can be performed by patient easily without pain
or other symptoms, then passive testing is
usually not necessary

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

Passive ROM Slightly greater than AROM

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

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

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 Effect on Symptom Pain aggravated or persistent in passive
usually indicates non-contractile
structures (bones, joint, ligaments,
cartilage etc.)

End Feel Abnormal End Feels

End Feel Examples

Soft
Occurs sooner or later in the Soft tissue edema
ROM than is usual, or in a Synovitis
joint that normally has a firm
or hard end-feel. Feels
boggy

Firm
Occurs sooner or later in the
ROM than is usual, or in a
joint that normally has a soft
or hard end-feel.
Increased muscular tonus
Capsular, muscular, liga-
mentous shortening

Hard
Chondromalacia
Occurs sooner or later in the
Osteoarthritis
ROM than is usual, or in a
Loose bodies in joint
joint that normally has a soft
Myositis ossificans
or firm end-feel.
Fracture
A bony grating or bony block
is felt.

Empty
No real end-feel because Acute joint inflammation
pain prevents reaching end Bursitis
of ROM. No resistance is felt Abscess
except for patient’s Fracture

protective muscle splinting Psychogenic Disorder

or muscle spasm

Pattern of Limitation Capsular Patterns

Can be due to 2 situations

a. Joint effusion or synovial inflammation

(acute stage)

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 b. Relative capsular fibrosis (chronic
stage)

Attention!!!
Determine what causes the capsular pattern, if it is inflammation
treatment is same for acute stage. If the cause is fibrosis, treatment is
same for chronic stage.

Non-Capsular Patterns

Usually involve one or two motions of a

joint. Cause can be d/t structures other
than the joint capsule. (internal joint
derangement, adhesions of part of joint
capsule, ligament shortening, muscle
strain and shortening)

Capsular Patterns

Joint Pattern
Shoulder ER>ABD>IR

Elbow F>E

Forearm Pronation=Supination

Wrist F=E

CMC 1 ABD & EXT

2-5 Equal restriction in all
direction

UE digit F>E

Hip IR, F, ABD

Knee F>E

Ankle PF>DF

Subtalar Varus restricted

Midtarsal Restricted DF, PF, ABD,

medial rotation

Metatarsalphalangeal joint 1 E>F

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 Metatarsalphalangeal joint Tend toward Flexion
2-5

IP joint Tend toward extension

ROM Values
AVERAGE RANGES OF MOTION FOR THE UPPER EXTREMITIES
IN DEGREES FROM SELECTED SOURCES
A

Joint Motion values Motion values J

Shoulder Flexion 0-180 Hip Flexion 0-120 o
Extension 0-60 Extension 0-30 i
Abduction 0-180 Abduction 0-45 n
Medial rotation 0-70 Adduction 0-30 t
Lateral rotation 0-90 ER/IR 0-45
Elbow Flexion 0-150 Knee Flexion 0-135
Forearm Pronation 0-80 Ankle PF 0-50 m
e
r
i
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c
a
n
 Supination 0-80 DF 0-20
Wrist Extension 0-70 Inversion 0-35
Flexion 0-80 Eversion 0-15
Radial 0-20 Subtalar Inv/Evr 0-5
Ulnar deviation
deviation 0-30 Great toe
Thumb
CMC Abduction 0-70 MTP flexion 0-45
Flexion 0-15 extension 0-70
Extension 0-20 PIP flexion 0-90
Opposition Tip of thumb to
base
or tip of fifth digit Lesser toe
MTP flexion 0-40
MCP Flexion 0-50 extension 0-40
IP Flexion 0-80 PIP flexion 0-35
Digits DIP flexion 0-30
Second -
Fifth
MCP Flexion 0-90
Hyperextension 0-45
Abduction
PIP Flexion 0-100
DIP Flexion 0-90
Hyperextension 0-10

ACESSORY JOINT MOTIONS

Tested if PROM is limited or painful; Tested for amount of motion, effect on

symptoms, and end feel.

Accessory joint motion grades 0 ankylosed

1 considerable hypomobility
2 slight hypomobility
3 normal
4 slight hypermobility
5 considerable hypermobility
6 unstable

Grades 0 & 6 surgery considered, joint mobilization not indicated

Grades 1 & 2 joint mobilization to increase joint extensibility
Grades 4 & 5 increasing joint extensibility not indicated; taping,
bracing, strengthening indicated

RESISTED ISOMETRIC TESTING

Joint should be placed in a position midway through the range, to produce

minimal tension in inert structures.

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 RESULTS OF RESISTED
ISOMETRIC TESTING

Findings Possible Pathologies

Strong and painless There is no lesion or neurological deficit
involving the tested muscle and tendon.

Strong and painful There is a minor lesion of the tested muscle

or tendon.

Weak and painless There is a disorder of the nervous system,

neuromuscular junction, or a complete
rupture of the tested muscle or tendon, or
disuse atrophy.

Weak and painful There is a serious, painful pathology such as

a fracture or neoplasm. Other possibilities
include an acute inflammatory process that
inhibits muscle contraction, or a partial
rupture of the tested muscle or tendon.

Remember!!! Burasae can produce pain in isometric contraction if it’s

inflamed even though it’s non-contractile

MANUAL MUSCLE TESTING

Manual Muscle Testing Grades

Grades Criteria
Normal N 5 10
Full available ROM, against
gravity, strong manual
resistance

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 Good Plus G+ 5– 9
Full available ROM, against
gravity, nearly strong
manual resistance
Good G 4 8
Full available ROM, against
gravity, moderate manual
resistance
Good Minus G– 4– 7
Full available ROM, against
gravity, nearly moderate
manual resistance
Fair Plus F+ 3+ 6
Full available ROM, against
gravity, slight manual
resistance
Fair F 3 5 Full available ROM, against
gravity, no resistance
Fair Minus F– 3– 4
At least 50% of ROM, against
gravity, no resistance
Poor Plus P+ 2+ 3
Full available ROM, gravity
minimized, slight manual
resistance
Poor P 2 2
Full available ROM, gravity
minimized, no resistance
Poor Minus P– 2– 1
At least 50% of ROM, gravity
minimized, no resistance

Trace Plus T+ 1+ Minimal observable motion

(less than 50% ROM), gravity minimized,

no resistance
Trace T 1 T
No observable motion, palpable
muscle contraction, no resistance

Zero 0 0 0
No observable or palpable muscle
contraction

CLOSE-OPEN PACKED POSITION

Resting (Loose/open Packed) Position of Joints

Joint Position

Facet (spine) Midway between flexion and extension

Temporomandibular Mouth slightly open (freeway space)
Glenohumeral 55° abduction, 30° horizontal adduction
Acromioclavicuiar Arm resting by side in normal physiological position
Sternoclavicular Arm resting by side in normal physiological position

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Ulnohumeral (elbow) 70° flexion, 10° supination
Radiohumeral Full extension, full supination
Proximal radioulnar 70° flexion, 35° supination
Distal radioulnar 10° supination
Radiocarpal (wrist) Neutral with slight ulnar deviation
Carpometacarpal Midway between abduction-adduction and flexion-extension
Metacarpophalangeal Slight flexion
Interphalangeal Slight flexion
Hip 30° flexion, 30° abduction, slight lateral rotation
Knee 25° flexion
Talocrural (ankle) 10° plantar flexion, midway between maximum inversion and eversion
Subtalar Midway between extremes of range of movement
Midtarsal Midway between extremes of range of movement
Tarsometatarsal Midway between extremes of range of movement
Metatarsophalangeal Neutral

Close Packed Position of Joints

Joint Position
Facet (spine) Extension
Temporomandibular Clenched teeth
Glenohumeral Abduction and lateral rotation
Acromioclavicular Arm abducted to 90°
Sternoclavicular Maximum shoulder elevation
Ulnohumeral (elbow) Extension
Radiohumeral Elbow flexed 90°, forearm supinated 5°
Proximal radioulnar 5° supination
Distal radioulnar 5° supination
Radiocarpal (wrist) Extension with radial deviation
Metacarpophalangeal Full flexion (fingers)
Metacarpophalangeal Full opposition (thumb)
Interphalangeal Full extension
Hip Full extension, medial rotation*
Knee Full extension, lateral rotation of tibia
Talocrural (ankle) Maximum dorsiflexion
Subtalar Supination
Midtarsal Supination
Tarsometatarsal Supination
Metatarsophalangeal Full extension

MOTOR EVALUATION

TONE

Modified Ashworth Scale

Grade Description
0 No increase in muscle tone.

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 1 Slight increase in muscle tone, manifested by a catch and release or
by minimal resistance at the end of the ROM when the affected
part(s) is moved in flexion or extension.

1+ Slight increase in muscle tone, manifested by a catch, followed by minimal

resistance throughout the remainder (less than half) of the ROM.

2 More marked increase in muscle tone through most of the ROM, but affected
part(s) easily moved.

3 Considerable increase in muscle tone, passive movement difficult.

4 Affected part(s) rigid in flexion or extension.

DEEP TENDON REFLEXES

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

Grade Evaluation Response Characteristics

0 Absent No visible or palpable muscle contraction

with reinforcement.

1+ Hyporeflexia Slight or sluggish muscle contraction with

little or no joint movement. Reinforcement may be
required to elicit a reflex response.

2+ Normal Slight muscle contraction with slight joint

movement.

3+ Hyperreflexia Clearly visible, brisk muscle contraction

with moderate joint movement.

4+ Abnormal Strong muscle contraction with one to three

beats of clonus.
Reflex spread to contralateral side may be noted.

5+ Abnormal Strong muscle contraction with

sustained clonus. Reflex spread to
contralateral side maybe noted

BALANCE

FUNCTIONAL BALANCE GRADES

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Normal Patient is able to maintain steady balance without support (static).
Accepts maximal challenge and can shift weight in all directions
(dynamic).

Good Patient is able to maintain balance without support (static).

Accepts moderate challenge; able to maintain balance while picking
object off floor (dynamic).

Fair Patient is able to maintain balance with handhold (static). Accepts minimal
challenge; able to maintain balance while turning head/trunk (dynamic).

Poor Patient requires handhold and assistance (static).

CTSIB (Clinical Test for Sensory Interaction in Balance

1 2 3 4 5 6

1. Eyes open, fixed support 5. Eyes closed, moving

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

Result-Interpretation

2,3,5,6 Visual loss

5, 6 Vestibular loss
4, 5, 6 Surface, somatosensory input
3, 4, 5, 6 Sensory selection

COORDINATION ASSESSMENT

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NON-EQUILIBRIUM TESTS

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

TEST PROCEDURE
1. Finger to nose The shoulder is abducted to 90 degrees with
the elbow extended. The patient is asked
to bring the tip of the index finger to the
tip of the nose. Alterations may be made
in the initial starting position to assess
performance from different planes of
motion.

2. Finger to therapist's finger
The patient and therapist sit opposite each
other. The therapist's index finger is held in
front of the patient. The patient is asked to
touch the tip of the index finger to the
therapist's index finger. The position of the
therapist's finger may be altered during
testing to assess ability to change distance,
direction, and force of movement.

Both shoulders are abducted to 90 degrees

3. Finger to finger
with the elbows extended. The patient is
asked to bring both hands toward the
midline and approximate the index fingers
from opposing hands.

4. Alternate nose to finger The patient alternately touches the tip of the
nose and the tip of the therapist's finger
with the index finger. The position of the
therapist's finger may be altered during
testing to assess ability to change
distance, direction, and force of
movement.

5. Finger opposition The patient touches the tip of the thumb to the
tip of each finger in sequence. Speed may be
gradually increased.

6. Mass grasp An alternation is made between opening and

closing fist (from finger flexion to full exten-
sion). Speed may be gradually increased.

7. Pronation/supination With elbows flexed to 90 degrees and held close

to body, the patient alternately turns the
palms up and down. This test also may be
performed with shoulders flexed to 90
degrees and elbows extended. Speed may

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 be gradually increased. The ability to
reverse movements between opposing
muscle groups can be assessed at many
joints. Examples include active alternation
between flexion and extension of the knee,
ankle, elbow, fingers, and so forth.

8. Rebound test The patient is positioned with the elbow flexed.

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

With the elbow flexed and the forearm

9. Tapping (hand) pronated, the patient is asked to "tap" the
hand on the knee.

The patient is asked to "tap" the ball of one

10. Tapping (foot) foot on the floor without raising the knee;
heel maintains contact with floor.

11. Pointing and past pointing
The patient and therapist are opposite each
other, either sitting or standing. Both patient
and therapist bring shoulders to a horizontal
position of 90 degrees of flexion with elbows
extended. Index fingers are touching or the
patient's finger may rest lightly on the thera-
pist's. The patient is asked to fully flex the
shoulder (fingers will be pointing toward
ceiling) and then return to the horizontal
position such that index fingers will again
approximate. Both arms should be tested,
either separately or simultaneously. A normal
response consists of an accurate return to the
starting position. In an abnormal response,
there is typically a "past pointing," or
movement beyond the target. Several
variations to this test include movements in
other directions such as toward 90 degrees of
shoulder abduction or toward 0 degrees of
shoulder flexion finger will point toward
floor). Following each movement, the
patient is asked to return to the initial
. horizontal starting position.

12. Alternate heel to knee; heel to toe From a supine position, the patient is asked to
touch the knee and big toe alternately with
the heel of the opposite extremity.

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 From a supine position, the patient is
instructed to touch the great toe to the
examiner's finger. The position of finger
13. Toe to examiner's finger may be altered during testing to assess
ability to change distance, direction, and
force of movement.

From a supine position, the heel of one foot

is slid up and down the shin of the
opposite lower extremity.
14. Heel on shin

The patient draws an imaginary circle in the air

with either upper or lower extremity (a table or
the floor also may be used). This also may be
15. Drawing a circle done using a figure-eight pattern. This
test may be performed in the supine position
for lower extremity assessment.

Upper extremity: The patient holds arms

horizontally in front (sitting or standing). Lower
16. Fixation or position holding extremity: The patient is asked to hold the knee
in an extended position (sitting).

EQUILIBRIUM COORDINATION TESTS

1. Standing in a normal, comfortable posture.

2. Standing, feet together (narrow base of support).
3. Standing, with one foot directly in front of the other in tandem position (toe of one foot
touching heel of opposite foot).
4. Standing on one foot.
5. Arm position may be altered in each of the above postures (i.e., arms at side, over
head, hands on waist, and so forth).

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

Impairment Sample Test

Dysdiadochokinesia
Finger to nose
Alternate nose to finger
Pronation/supination
K n e e f le x io n / e x te n s io n
Walking, alter speed or direction

Dysmetria Pointing and past pointing

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

Movement decomposition Finger to nose

(dyssynergia) Finger to therapist's finger
Alternate heel to knee
Toe to examiner's finger

Hypotonia Passive movement

Deep tendon reflexes

Tremor (intention) Observation during functional activities (tremor will typically

increase as target is approached or movement speed increased)
Alternate nose to finger
Finger to finger
Finger to therapist's finger
Toe to examiner's finger

Tremor (resting) Observation of patient at rest

Observation during functional activities (tremor will diminish
significantly or disappear with movement)

Tremor (postural) Observation of steadiness of normal standing posture

Asthenia Fixation or position holding (upper and lower extremity)

Application of manual resistance to assess muscle strength

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 Rigidity Passive movement
Observation during functional activities
Observation of resting posture(s)

Bradykinesia Walking, observation of arm swing and trunk motions

Walking, alter speed and direction Request that a movement or gait
activity be stopped abruptly Observation of functional activities:
timed tests

Disturbances of posture Fixation or position holding (upper and lower extremity)

Displace balance unexpectedly in s i t t i n g o r s t a n d i n g
Standing, alter base of support (e.g., one foot directly in front
of the other; standing on one foot)

Disturbances of gait Walk along a straight line

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

GAIT ANALYSIS

24
GAIT TERMS

TRUNK DEVIATIONS: STANCE PHASE

25
HIP DEVIATIONS: STANCE PHASE

HIP DEVIATIONS: SWING PHASE

26
KNEE DEVIATIONS: STANCE PHASE

KNEE DEVIATIONS: SWING PHASE

ANKLE & FOOT DEVIATIONS: SWING PHASE

27
ANKLE & FOOT DEVIATIONS: STANCE PHASE

28
RATING FOR GAIT ANALYSIS

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 FUNCTIONAL ANALYSIS

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

30
Functional Independence Measure (FIM)

31
Katz Index of ADL

32
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