CVA

Assessment Procedure Intervention Procedure

DTR Biceps (C5-C6) Exercises for

Brachioradialis (C6) Flexibility
Triceps (C7) Patellar
(L4) Achilles (S1)

Stretching
Exercises

Peripheral joint
Mobilization
Cranial nerve CN 1 (olfactory)
integrity - Smell perfume or alcohol

CN 2 (optic)
- cover each eye separately and use an eye chart

CN 3, 4 & 6 (oculomotor, trochlea, abducens)

- move eyes in an H pattern

CN 5 (trigeminal)
-ask pt. To open their mouth and the therapist will try force to close it

CN 7 (facial)
-ask pt. To close their eyes and the therapist will force to open it

CN 8 (vestibulocochlear)
- cover ear and ~60 meter distance whisper words then have pt repeat it

CN 9 & 10 (Glossopharyngeal, Vagus)

- drink water; say “ah”

CN 11 (Spinal accessory)
-Ask pt. To shrug their shoulders and the therapist will force it down

CN 12 (Hypoglossal)
- ask pt to recite something like the alphabet or numbers.
- Ask patient to bring his/her tongue out and observe deviation
Tone Ax Modified ashworth scale (for spasticity) Rood’s
(kayla) Approach A. Facilitation Techniques
Facilitation
1. Place the patient in a supine position techniques 1. Fast brushing
(tactile) - With a soft camel hair paint brush
2. If testing a muscle that primarily flexes a joint, place the joint in a - Apply On each area to be
maximally flexed position and move to a position of maximal stimulated
extension over one second (count "one thousand one”) - Limit: 3-5 seconds

3. If testing a muscle that primarily extends a joint, place the joint in a 2. Tapping
maximally extended position and move to a position of maximal flexion - Tap 3-5 times over the ms belly
over one second (count "one thousand one”) before and during ms contraction

B. Proprioceptive stimuli

1. Quick-stretch
(proprioceptive) - Tap over the muscle or tendon
using fingertips to vigorously tap
the skin

2. Vibration
- Apply high-frequency vibration to
the muscle
 Superficial Procedure Indication
Sensory
Sensations
Integrity and
Integration Pain - Test pain using a -Analgesia
sharp object.
- apply light pressure -Hypoalgesia
to the skin
- test the shoulders, -Hyperalgesia
arms and legs,
comparing side to
side
and proximal to distal
areas

Temperature - Cold: apply the cool Thermanalgesia

tines of your tuning
fork to the skin Thermhypesthesia
- Hot: use a glass
tube or other Thermhyperesthesia
container filled with
warm
water.

Touch - Using your fingertips Anesthesia Hypoesthesia

or a wisp of cotton,
lightly stroke the skin Hyperesthesia
and determine if the
patient feels this
symmetrically in all
areas tested.
Deep Sensation Procedure Indication

Proprioception - Test toes and Polyneuropathy

(Joint Position fingers
Sense) - Move digit only a Myelopathy
few degree
- The patient should be
able to identify the
positional
change with eyes closed.

Kinesthesia - The extremity or

joint(s) is moved
passively through a
relatively small range
of motion (ROM).
- The therapist should
identify the range of
movement being
examined (e.g.,
initial, mid-, or
terminal range).

Vibration - Placing the base of a Pallanesthesia -

vibrating tuning fork absence of sensibility
on a bony prominence of vibration
(such as the sternum,
elbow, or ankle).
- Examiner’s thumb
and index finger
without making
contact with the
tines.
 Combined Cortical Procedure Indication

Stereognosis - ask pt to close eyes Astereognosis

- let pt identify object -Damaged post
at hand central gyrus
-Impairment in
parietal lobe

Tactile localization - ask pt to close eyes Atopognosia

- touch palm w/ felt Impaired
tip marker somatosensory cortex
- ask pt to locate exact in parietal lobe
point of marker

Barognosis - ask pt to close eyes Abarognosis

- pt identifies the Lesion in posterior
weight of object column-medial
lemniscus pathway

Graphesthesia - draw a Agraphesthesia

number/letter/shape Lesion in primary
using a blunt somatosensory
instrument. cortex
- have pt identify the
stimulus written

Spatial relations Ask the patient to place Unilateral neglect

the cutlery, plate, and
spoon in the proper
position when setting
the table.

Perceptual Apraxia
Functions ● Ideomotor Apraxia & Ideational apraxia - show me how to comb your
hair

● buccofacial apraxia - pretend to blow a candle or blow a kiss

ROM (passive -PROM PNF
& active) Stretching to
improve
mobility

-PNF
Postural Ax Posture plumb line Postural Exercises Bobath approach
(kayla) *observe pt from laterally, posteriorly & anteriorly *Put pillows under areas that need it
*take note for ears, shoulders, hips, knees and ankles in lateral view
A. Supine to Sidelying
 Postural
flexibilit
y
exercise

Postural assessment for stroke → To test for postural control

Total score: 36

1. Sitting without support

2. Standing with support
3. Standing without support
4. Standing on the paretic/non paretic leg
5. Supine to affected side latera;
6. Supine to non affected side lateral
7. Supine to sitting up on the edge of the table
8. Sitting on the edge of the table to supine
9. Sitting to standing
10. Standing to sitting
11. Standing , picking up a pencil from the floor
0 = cannot perform the activity
1 = can perform the activity with much help
2 = can perform the activity with little help
3 = can perform the activity without help
MMT Resistance
Exercises

Coordination UE -Coordination
● Finger to nose- ask pt. To bring tip of the index finger to tip of exercises
their nose.
● Finger to therapist’s finger
● Finger opposition- pt tip of thumb touch each finger in
sequence. Speed may gradually increase.
 ● Mass grasp- ask pt to open and close hand
● Pronation/supination- elbow flexed to 90, ask pt to take turns the
palms up and down
● Hand tapping- elbow flexed ask pt to tap the knee.

LE
● Foot tapping - tap foot w/out raising knee & heel remains sa
floor
● Alternate heel to knee; heel to toe- pt in supine pt is asked to
touch knee and big toe alternately w/ heel of opposite extremity -Transfer
● Heel-on-shin training
● Drawing a circle- pt in supine and ask to draw a circle sa toe
● Position holding- pt. Sitting ask to extend knee and hold -Wheelchair
mobility training
Balance & Romberg’s Test Exercises for
Tolerance 1. Stand with feet together impaired
2. Arms held next to body or crossed balance
3. Test first with eyes open
4. Test next with eyes closed
5. Scored by counting seconds the patient is able to stand w EC

Gait and Functional Gait Assessment (FGA) Bed mobility a. Treadmill

Locomotion =A 4-point ordinal scale, ranging from 0–3, is used to rate each task; training b. Parallel bar / walker if wala kay
=0 indicates lowest level of function. let the pt. Walk with PT’s
Total Score = 30 Gait training (w assistance
or w/o ambulatory
Tasks include: devices)
1. Walk at steady state
2. Walk and change speeds
3. Walk with horizontal head turns
4. Walk with vertical head turns
5. Walk and pivot turn
6. Walk and step over obstacles
7. Walk with a narrow base of support
8. Walk with eyes closed
9. Walk backward.
10. Climb stairs

LEG LENGTH DISCREPANCY

Observe pt in 2 landmarks with a tape measure:
**Measure ASIS to medial malleolus
 **compare both sides

Aerobic 6 minute walk test Mixed Aerobic

capacity & Using a 2 cones or chair as a point-to-point end have the pt walk for 6 mins Exercise
endurance
 SCI
Assessment Procedure Intervention Procedure

Light touch & Pin Prick

Sensory Transfers
C2 - occipital protuberance
C3 - supraclavicular C4 Breathing Deep-breathing Exercises
- acromioclavicular C5 - technique - The therapist can apply light pressure
lateral epicondyle C6 - during both inspiration and expiration.
thumb Manual contacts can be made just below the
C7 - middle finger sternum.
C8 - pinky
T1 - medial epicondyle
T2 - Apex of axillary Glossopharyngeal Breathing
T3 - 3rd ICS - The patient is instructed to take in small
T4 - nipple line amounts of air, using a “gulping” pattern,
T5 - 5th ICS thus utilizing available facial and pharyngeal
T6 - xiphoid/sternal muscles. The patient repeats this 6 to 10
T7 - 7th ICS times.
T8 - 8th ICS
T9 - 9th ICS Ambulation Treadmill
T10 - Umbilicus Exercises -The pt. walks on a treadmill within the pts.
T11 - 11th ICS tolerance
T12 - Inguinal ligament
L1 - Groin -have pt. walk with an obstacle and ask them
L2 - mid anterior thigh to step over the object
L3 - medial femoral condyle
L4 - medial malleolus
L5 - dorsum of the foot on the 3rd MTP
S1 - lateral malleolus/ lateral heel
S2 - Popliteal fossa S3
- Ischial tuberosity S4 -
S5 - anus
SCI MMT
C5 Elbow flexor Biceps brachii GRADE 3
Examiner Position: Support the wrist.
(ALL GRADE: Instructions to Patient: “Bend your elbow and try to reach your hand
sitting) to your nose.”
GRADE 4&5
Examiner Position: Place a stabilizing hand on the anterior shoulder. Grasp the
volar aspect of the wrist and exert a pulling force in the direction of elbow
extension.
Instructions to Patient: “Hold your arm. Don’t let me move it.”
GRADE 2
Examiner Position: Support the arm.
Instructions to Patient: “Bend your elbow and try to bring your hand
to your nose.”
GRADE 0&1
Examiner Position: One hand supports the forearm while the other hand palpates the
biceps tendon in the cubital fossa. The belly of the biceps brachii muscle may also be
palpated or observed for movement.
Instructions to Patient: “Bend your elbow and try to bring your hand to your nose.”

C6 Wrist extensor ECRL GRADE 3

(ALL GRADE: Examiner Position: One hand supports the distal forearm to allow the wrist to be
Sitting) pre-positioned in sufficient flexion for testing.
Instructions to Patient: “Bend your wrist upwards. Lift your fingers toward the
ceiling.”
GRADE 4&5
Examiner Position: Grasp the distal forearm to stabilize the wrist. Apply pressure
across the metacarpals in a downward direction toward flexion and ulnar deviation.
Instructions to Patient: “Hold your wrist up. Don’t let me push it down.” GRADE
0,1&2
Examiner Position: Support the forearm and ask the patient to bend the wrist
backwards into extension.
Instructions to Patient: “Bend your wrist backwards.”

C7 Elbow Triceps GRADE 3

extensor (ALL GRADE: Examiner Position: Support the upper arm.
Sitting) Instructions to Patient: “Straighten your arm.” GRADE
4&5
Examiner Position: Support the upper arm. Grasp the wrist and apply
 resistance to the distal forearm in the direction of elbow flexion. Instructions to
Patient: “Hold this position. Don’t let me bend your elbow.” GRADE 2
Examiner Position: Support the patient’s arm under the elbow and wrist.
Instructions to Patient: “Straighten your arm.” GRADE
0&1
Examiner Position: Support the arm. For trace function, palpate the distal triceps at
its insertion on the olecranon. The belly of the triceps muscle may also be palpated
and observed for movement.
Instructions to Patient: “Straighten your arm.”

C8 Middle finger FDP GRADE 3

(ALL GRADE: Examiner Position: Using two hands grasp the patient’s hand and stabilize the wrist
Sitting) in neutral. Secure the PIP and MCP joints in extension with both hands while isolating
the middle finger for testing. Stabilize the volar aspect of the 3rd middle phalanx with
the thumb of the opposite hand.
Instructions to Patient: “Bend the tip of your middle finger.” GRADE
4&5
Examiner Position: Stabilize the wrist, MCP and PIP joints as in Grade 3. Apply
pressure with the tip of the finger or thumb against the distal phalanx of the patient’s
middle finger.
Instructions to Patient: “Hold the tip of your finger in this bent position. Don’t let
me move it.”

GRADE 0,1&2
Examiner Position: Stabilize the wrist in neutral to avoid tenodesis, and the MCP and
PIP joints are in extension. For trace function, palpate the tendons of the long finger
flexors or observe the muscle belly for movement.
Instructions to Patient: “Bend the tip of your middle finger.”

T1 Pinky Abductor digiti GRADE 3

minimi Examiner Position: Support the patient’s hand, taking care to assure that the MCP
(ALL GRADE: joints are stabilized to prevent hyperextension.
Sitting) Instructions to Patient: “Move your little finger away from your ring finger, or
spread your fingers apart.”

GRADE 4&5
Examiner Position: Support the patient’s hand, taking care to assure that the MCP
joints are stabilized to prevent hyperextension. Use the index finger to apply pressure
against the side of the patient’s distal phalanx.
 Instructions to Patient: “Hold your little finger away from your ring finger. Don’t
let me push it in.”
GRADE 0,1&2
Examiner Position: Stabilize the dorsal wrist and hand by pressing down lightly on
the back of the hand. Be sure that the MCP joints are stabilized to prevent
hyperextension. Another method is to stabilize the wrist, but leave the hand flat on the
bed, further stabilizing the MCP joints. Palpate the abductor digiti minimi muscle and
observe the muscle belly for movement.
Instructions to Patient: “Move your little finger away from your ring finger or
spread your fingers apart.”

L2 Hip flexor Iliopsoas GRADE 3 (Standing)

Examiner Position: Support the dorsal aspect of the distal thigh and leg. Do not
allow flexion beyond 90° when examining acute thoraco-lumbar injuries due to the
kyphotic stress placed on the lumbar spine.
Instructions to Patient: “Lift your knee towards your chest as far as you can, trying
not to drag your foot on the exam table.”

GRADE 4&5 (Standing)

Examiner Position: Brace the anterior superior iliac spine
on the opposite side and place a hand on the distal anterior thigh, just above the knee.
Pressure is applied in the direction of hip extension
Instructions to patient: “Hold your knee in this position. Don’t let me push it down.”

GRADE 2 (Supine)
Examiner Position: Support the leg at the knee and ankle. Instructions to Patient:
“Try to bring your knee out to the side,”
or “Try to flex your hip toward the side of the body.”

GRADE 0&1 (Supine)

Examiner Position: Support the thigh to eliminate friction while palpating the
superficial hip flexors just distal to the anterior superior iliac spine.
Instructions to Patient: Ask the patient to “move your knee out to the side.”

L3 Ankle Tibialis anterior GRADE 3 (Sitting)

dorsiflexor Examiner Position: Place the arm under the tested knee and rest the hand on the
patient’s distal thigh. This causes the tested knee to flex to approximately 30°.
Instructions to Patient: “Straighten your knee.”
 GRADE 4&5 (Sitting)
Examiner Position: Place the arm under the tested knee and rest the hand on the
patient’s opposite thigh. Grasp the leg to be tested, just proximal to the ankle.
Instructions to Patient: “Hold this position. Don’t let me bend your knee.”

GRADE 2 (Sitting)
Examiner position: Support the distal thigh and ankle.
Instructions to Patient: “Straighten your knee.” GRADE
0&1 (Sitting)
Examiner Position: Support the distal thigh and leg. Palpate the patellar tendon or
the belly of the quadriceps muscle for trace function. The muscle belly may also be
observed for movement.
Instructions to Patient: “Straighten your knee.”

L4 Knee extensor Quadriceps GRADE 3 (Sitting)

Examiner Position: At the patient’s side. Support the leg under the knee and ankle.
Instructions to Patient: “Bend your ankle to pull your foot and toes up toward your
head."
GRADE 4&5 (Sitting)
Examiner Position: In the Grade 3 position, place
the hand on the dorsum of the foot and apply pressure downward in the direction of
plantarflexion.
Instructions to Patient: “Hold your ankle in this position. Don’t let me push it
down.”
GRADE 2 (Side-lying)
Examiner Position: Support the leg under the knee and ankle. Instruction to
Patient: “Lift the toes upward toward the head, bending the ankle upward.”
GRADE 0&1 (Side-lying)
Examiner Position: Palpate the proximal lower leg over the tibialis anterior
muscle belly or on the tendon of the tibialis anterior muscle as it crosses the
anterior ankle. Observe the muscle belly for movement.
Instructions to Patient: “Bring your toes upward toward your head, letting
your ankle bend.”

L5 Big toe Extensor Hallucis GRADE 3 (Sitting)

extensor Longus Examiner Position: At the patient’s side. Support the foot. Instructions to
Patient: “Lift your big toe upwards toward
 your knee.”

GRADE 4&5 (Sitting)

Examiner Position: At the patient’s side. Place the thumb on the distal phalanx of
the great toe and apply pressure downward in the direction of toe flexion.
Instructions to Patient: “Keep your toe lifted upward. Don’t let me push it down.”
GRADE 2 (Sitting)
Examiner Position: Support the leg under the knee and ankle. Instructions to
Patient: “Lift your big toe upwards toward
the knee.”
GRADE 0&1 (Sitting)
Examiner Position: Support the leg and palpate the extensor tendon of the long toe
for trace function.
Instructions to Patient: “Lift your big toe upwards toward your knee.”

S1 Ankle Gastrocnemius GRADE 3 (Sitting)

plantarflexor Examiner Position: Place one hand behind the knee to assist in stabilizing the leg.
The other hand is positioned under the sole of the patient’s foot, pushing the foot into
dorsiflexion. The patient’s heel remains resting on the exam table. Instructions to
Patient: “Push your foot down into my hand and lift your heel off the table.”

GRADE 4&5 (Sitting)

Examiner Position: Place one hand on the distal lower leg while the other hand
grasps the foot across the plantar surface of metatarsals. Apply pressure on the bottom
of the foot in the direction of dorsiflexion.
Instructions to patient: “Hold your foot pointed down. Don’t let me push it up.”

GRADE 2 (Sitting)
Examiner Position: Support the lower leg under the knee and ankle. For trace
function palpate either the gastrocnemius muscle belly or the achilles tendon, or
observe the muscle belly for movement.
Instructions to Patient: “Point your toes downward like a ballet dancer.” GRADE
0&1 (Sitting)
Examiner Position: Support the lower leg under the knee and ankle. For trace
function palpate either the gastrocnemius muscle belly or the achilles tendon, or
observe the muscle belly for movement.
Instructions to Patient: “Point your toes downward like a ballet dancer.”
Addtl. Notes:
(Kyra)

Dermatomes
C2 Occipital protuberance T8 8th ICS

C3 Supraclavicular T9 9th ICS

C4 Acromioclavicular T10 Umbilicus

C5 Lateral epicondyle T11 11th ICS

C6 Thumb T12 Inguinal ligament

C7 Middle finger L1 Groin

C8 Pinky L2 Mid-anterior thigh

T1 Medial epicondyle L3 Medial femoral condyle

T2 Apex of axilla L4 medial malleolus

T3 3rd ICS L5 Dorsum of the foot on the 3rd MTP

T4 Nipple line S1 Lateral malleolus/ lateral heel

T5 5th ICS S2 Popliteal fossa

T6 Xiphoid/Sternal S3 Ischial tuberosity

T7 7th ICS S4-S5 Anus

Myotomes
Spinal Level Myotomes muscles

C5 Elbow flexors Biceps Brachii, Brachialis

C6 Wrist extensors ECRL, ECRB

C7 Elbow extensors Triceps

C8 Finger flexors to the middle finger FDP

T1 Small finger abductors Abductor Digiti minimi

L2 Hip flexors Iliopsoas

L3 Knee extensors Quadriceps

L4 Ankle Dorsiflexors Tibialis Anterior

L5 Long toe extensors Extensor Hallucis Longus

S1 Ankle plantar flexors Gastrocnemius