Final Review: Important Scales

NPTE Final Frontier has put together a list of important scales (neuromuscular,
musculoskeletal, cardiopulmonary, pediatrics, and other systems) for a final review.

CARDIOPULMONARY

New Blood Pressure classification

• Normal: Less than 120/80 mm Hg

• Elevated: Systolic between 120-129 and diastolic less than 80
• Stage 1: Systolic between 130-139 or diastolic between 80-89
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg
• Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients
needing prompt changes in medication if there are no other indications of problems,
or immediate hospitalization if there are signs of organ damage

Ankle brachial index (Ankle SBP/ Arm SBP)

ABI Range Possible Indication

>1.2 Falsely elevated, arterial disease, diabetes
1.19-0.95 Normal
0.94-0.75 Mild arterial disease and intermittent
claudication

0.74-0.50 Moderate arterial disease and rest pain

<0.50 Severe arterial disease

Grading scale for pulse strength

0 Absent, not palpable
1+ Pulse diminished, barely palpable
2+ Easily palpable, normal
3+ Full pulse, increased strength
4+ Bounding, too strong to obliterate
Respiratory/ metabolic acidosis and alkalosis
Acid Normal Alkaline
pH <7.35 7.35-7.45 >7.45
PCO2 >45 35-45 mmHg <35
HCO3- <22 22-26 mEq/L >26

COPD GOLD classification

Stage Characteristics
Stage 1: Mild . FEV1/FVC < 70%
•FEV1 ≥ 80% predicted
•With or without symptoms of cough and sputum
production

Stage 2: . FEV1/FVC < 70%

Moderate •50% ≤ FEV1 < 80% predicted
•Shortness of breath with exertion
•With or without symptoms of cough and sputum
production

Stage3: . FEV1/FVC < 70%

Severe •30% ≤ FEV1 < 50% predicted
•Greater shortness of breath with exercise,
decreased exercise capacity, fatigue and repeated
exacerbations of their disease

Stage 4: Very . FEV1/FVC < 70%

severe •FEV1 < 30% predicted or FEV1 < 50% predicted
plus chronic respiratory failure

Angina scale
0 No angina
1 Mild, barely noticeable
2 Moderate, bothersome
3 Moderately severe, very uncomfortable
4 Most severe or intense pain ever experienced
Edema/Pitting scale
1+ Indentation is barely detectable
2+ Slight indentation visible when skin is
depressed, returns to normal in 15 seconds.
3+ Deeper indentation occurs when pressed and
returns to normal within 30 seconds.
4+ Indentation lasts for more than 30 seconds.

Intermittent claudication Scale

Grade I Definite discomfort or pain, but only at initial or modest levels
Grade II Moderate discomfort or pain from which the patient’s attention can
be diverted (e.g., by conversation)
Grade III Intense pain from which the patient’s attention cannot be diverted
Grade IV Excruciating and unbearable pain

Classification of heart failure

NEW YORK HEART ASSOCIATION STAGES
Class I: mild HF No limitation in physical activity (up to 6.5
METs); comfortable at rest, ordinary
activity does not cause undue fatigue,
palpation, dyspnea, or anginal pain
Class II: slight HF Slight limitation in physical activity (up to
4.5 METs); comfortable at rest, ordinary
physical activity results in fatigue,
palpation, dyspnea, or anginal pain
Class III: moderate HF Marked limitation of physical activity (up
to 3.0 METs); comfortable at rest, less than
ordinary activity causes fatigue, palpation,
dyspnea, or anginal pain
Class IV: severe HF Unable to carry out any physical activity
(1.5METs) without discomfort; symptoms
of ischemia, dyspnea, anginal pain present
at rest; increasing with exercise
AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION (ACCF)/ AMERICAN HEART
ASSOCIATION (AHA) STAGES
Stage A At high risk for HF but without structural
heart disease or symptoms of heart failure
Stage B Structural heart disease but without sign or
symptoms of HF
Stage C Structural heart disease with prior or
current symptoms of HF
Stage D Refractory HF requiring specialized
interventions
Normal values for infants and adults
Parameter Infant Adult
Heart rate 120 bpm 60-100 bpm
Blood pressure 75/50 mmHg < 120/80 mmHg
Respiratory 40 br/ min 12-20 br/min
rate
PaO2 75-80 mmHg 80-100 mmHg
PaCO2 34-54 mmHg 35-45 mmHg
pH 7.26-7.41 7.35-7.45
Tidal volume 20ml 500ml

Considerations prior to the use of Postural Drainage

Precautions to the use of Trendelenburg position (head of bed tipped down 15° to18°)
Circulatory system Pulmonary edema, congestive heart failure, hypertension
Abdominal problems Obesity, ascites, pregnancy, hiatal hernia, nausea and vomiting,
recent food consumption
Neurologic system Recent neurosurgery, increased intracranial pressure,
aneurysm precautions
Pulmonary system Shortness of breath

PRECAUTIONS TO THE USE OF SIDELING POSITION

Circulatory system Axillo-femoral bypass graft
Musculoskeletal system Humeral fractures, need for hip abduction brace, other
situations that make sideling uncomfortable, e.g., arthritis,
shoulder bursitis.

Considerations prior to using vibration and shaking

General guidelines Pain made worse by the technique
Circulatory system Aneurysm precautions, hemoptysis
Coagulation disorders Increased partial thromboplastin time (PTT), increased
prothrombin time (PT), decreased platelet count (below
50,000), or medications that interfere with coagulation
Musculoskeletal Fractured rib, flail chest, degenerative bone disease, bone
conditions metastases.
RPE SCALE
 NEUROMUSCULAR

Modified Ashworth Scale for Grading Spasticity

0 No increase in muscle tone
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.

ASIA impairment scale (American spinal injury association)

A =Complete No sensory or motor function is preserved in sacral segments S4-S5
B=Sensory Sensory but not motor function is preserved below the neurologic
incomplete level and includes the sacral segments S4-S5
C=Motor Motor function is preserved below the neurological level, and more
incomplete than half of key muscles below the neurological level have a muscle
grade less than 3.
D=Motor Motor function is preserved below the neurological level, and at least
incomplete half of key muscles below the neurological level have a muscle grade
of 3 or more.
E=Normal Sensory and motor functions are normal

PNF
Initial Mobility Stability Controlled Skill ROM
mobility Feeding
Contract- relax Rhythmic Slow reversal Agonistic Gait
stabilization reversals Trunk
Hold-relax Alternating Slow reversal Normal timing
isometrics hold
Hold- relax Slow reversal Agonistic Resisted
active movement reversals progression
Joint distraction Slow reversal Slow reversal
hold
Repeated Slow reversal
contraction hold
Rhythmic Timing for
initiation emphasis
Rhythmical
rotation
Rhythmic
stabilization
Balance and locomotion
Berg balance • Assess risk of falling
test • 14 tasks scored 0-4
• Everyday living tasks, static, dynamic and transitional
movements in sitting and standing positions
• Max score 56, less than 45 indicates increased risk of falling
Fugl-Meyer • Assess balance specifically for patients with hemiplegia
Assessment of • Each of the 7 items are scored from 0-2
Physical • The cumulative test score for all components is 226 with
Performance availability of specific subtest scores (e.g., UE maximum score
(FMA) is 66, LE score 34; balance score 14).
Functional reach • Asses standing balance and risk of falling
test • Maximum distance one can reach forward beyond arm’s length
while maintaining a fixed BOS in the standing position.
• Age related standard measurements for functional reach:
AGE MEN WOMEN
20-40 16.7 (± 1.9) 14.6 (± 2.2)
41-69 14.9 (± 2.2) 13.8 (± 2.2)
70-87 13.2 (± 1.6) 10.5 (± 3.5)

» If patient struggles to reach their appropriate distance,

increase risk of fall is present.

Romberg test • Assessment tool of balance and ataxia that initially positions
the patient in unsupported standing, feet together, upper
extremities folded, looking at a fixed point straight ahead with
eyes open. With eyes open, three systems (visual, vestibular,
somatosensory) provide input to the cerebellum to maintain
standing stability
• If there is a mild lesion in the vestibular or somatosensory
system, the patient will typically compensate through visual
sense. Next the patient maintains the same standing posture,
but closes the eyes. A patient receives a grade of “normal” if
they are able to maintain the position for 30 seconds
• An abnormal response occurs with inability to maintain
balance when standing erect with the feet together and eyes
closed. Patients may exhibit sway or begin to fall.
• When the visual input is removed, instability will be present if
there is a larger somatosensory or vestibular deficit producing
the instability. If a patient demonstrates ataxia and has a
positive Romberg test, this indicates sensory ataxia and not
cerebellar ataxia.
Timed up and go • Asses mobility and balance
test • Person initially sits on a supported chair with firm surface,
transfers to a standing position, and walks approx. 10 feet.
 The patient must then turn around without external help,
walk back towards the chair, and return to sitting position
• The patient is scored on amount of sway, excessive
movements, reaching for support, sidestepping, or other
signs of loss of balance.
• Healthy adults are able to complete the test in less than 10
seconds.
• Scores of 11 to 20 seconds are considered within typical for
frail elderly or individuals with a disability; scores over 30
seconds are indicative of impaired functional mobility and
high fall risk.
Tinetti » Tool to asses for increased risk of falling.
performance » Assesses balance through sit to stand and stand to sit
oriented from an armless chair, immediate standing balance with
mobility eyes open and closed tolerating a slight push in the
assessment standing position, and turning 360 degrees.
» The original POMA I scale has a total possible score of 28.
It was developed for use with the frail elderly, especially
nursing home residents with a propensity to fall. Patients
who score less than 19 are considered at high risk for falls
and those who score between 19 and 24 are at moderate
risk for falls. A revised form, the POMA Ia, includes five
additional items and was designed for use as a predictor
of falls among community-dwelling elderly (with a total
possible score of 40).
» >24:Low risk
» 19-24:Moderate risk
» 19<High Risk

Walkie-talkie Dual tasking

test

Functional Independence Measure

The amount of assistance required to complete a task is commonly documented using
definitions from the Functional Independence Measure (FIM).The amount of assistance is
scored on an 8-point ordinal scale where:
1 = total assistance (patient performs less than 25% of the effort)
2 = maximal assistance (patient performs 25% to 49% of the effort)
3 = moderate assistance (patient performs 50% to 74% of the effort)
4 = minimal assistance (patient performs greater than 75% of the effort)
5 = supervision (patient requires verbal cues, setup, or stand by)
6 = modified independent (patient requires assistive or adaptive device)
7 = independent
PEDIATRICS

Myelodysplasia orthotics and functional prognosis

Level Orthosis Functional prognosis
Thoracic THKAFO Wheelchair for all functional mobility, standing and
L2 Parapodium walking for physiologic benefits.
L1-L3 Reciprocating gait Wheelchair for most functional mobility, short
orthosis (RGO) household ambulation possible.
HKAFO
L3-L4 KAFO Wheelchair for community mobility. Household
ambulation possible.
L4-S1 AFO Household or community ambulation (although may be
Ground-reaction limited)
AFO
S1 Foot orthosis (FO) Community ambulation
Supramalleolar
orthosis (SMO)

APGAR scale

Gross motor classification for cerebral palsy

Level I Walk without restrictions; limitations in more advanced gross motor skills
Level II Walk without assistive devices; limitations walking outdoors and in the
community
Level III Walk with assistive mobility devices; limitations walking outdoors and in the
community
Level IV Self-mobility with limitations; children are transported or use power mobility
outdoors and in the community
Level V Self-mobility is severely limited, even with the use of assistive technology.
MUSCULOSKELETAL

Manual grading of accessory joint motion

Assessed grade Classification of joint
movement
0 Ankylosed
1 Considerable hypomobility
2 Slight hypomobility
3 Normal
4 Slight hypermobility
5 Considerable hypermobility
6 Unstable

Muscle grading
Zero 0 0 No visible or palpable contraction
Trace 1 T No observable motion, palpable muscle contraction
Poor- 2- P- At least 50% but not full ROM, gravity minimized, no resistance
Poor 2 P Full ROM, gravity eliminated
Poor+ 2+ P+ Full available ROM, gravity minimized, slight manual resistance
Fair- 3- F- At least 50% but not full ROM, against gravity, no resistance
Fair 3 F Full ROM against gravity
Fair+ 3+ F+ Full ROM against gravity, slight resistance
Good- 4- G- Full ROM against gravity, nearly moderate resistance
Good 4 G Full ROM against gravity, moderate resistance
Good+ 4+ G+ Full ROM against gravity, nearly strong resistance
Normal 5 N Full available ROM, against gravity, strong manual resistance

Salter- Harris Fracture classification

Type Anatomical deformity
I Entire epiphysis
II Entire epiphysis and portion of the metaphysis
III Portion of the epiphysis
IV Portion of the epiphysis portion of the metaphysis
V Nothing “broken off”; compression injury of the epiphyseal plate.
Referred pain

Joint mobilizations
Grade 1 Small amplitude rhythmic oscillations performed at the beginning
of the range

Grade 2 Large amplitude rhythmic oscillations performed within the range,

but not reaching the limit

Grade 3 Large-amplitude rhythmic oscillations are performed up to the limit

of the available motion and are stressed into the tissue resistance

Grade 4 Small-amplitude rhythmic oscillations are performed at the limit of

the available motion and stressed into the tissue resistance

Grade 5 Small amplitude. High velocity thrust technique performed to snap

adhesions at the limit of range
Tissue appearance in imaging
Radiograph (X- CT T1 MRI T2 MRI
ray)
Air Black Black Black Black
Fat Poorly visualized Black White Gray
Bone cortex White White Black Black
Bone marrow White Gray White Gray

Nerve tension tests

ULTT1 ULTT2 ULTT3 ULTT4
Median Nerve, Median Nerve, Radial Nerve Ulnar Nerve, C8
Anterior Musculocutaneous & T1 nerve root
Interosseous Nerve, Axillary N
Nerve
Shoulder Depression, Depression, Depression, Depression,
Abduction 110 Abduction 10 Abduction 10 Abduction 10 –
Degrees Degrees Degrees 90 Degrees
Elbow Extension Extension Extension Flexion

Forearm Supination Supination Pronation Supination

Wrist Extension Extension Flexion & Ulnar Extension &

Deviation Radial Deviation
Fingers Extension Extension Flexion Extension

Shoulder Lateral rotation Medial rotation Lateral rotation

Cervical Contralateral Contralateral side Contralateral Contralateral

Spine side flexion flexion side flexion side flexion
OTHER SYSTEMS

BMI
Underweight <18.5
Normal 18.5-24.9
Overweight 25-29.9
Obese 30-40
Extreme obese >40

Wagner grading system for diabetic ulcers

Grade 1 Superficial ulcer without subcutaneous tissue involvement

Grade 2 Penetration through the subcutaneous tissue; may expose bone, tendon,
ligament, or joint capsule
Grade 3 Osteitis, abscess, or osteomyelitis
Grade 4 Gangrene of digit
Grade 5 Gangrene of foot requiring disarticulation

Dressings
Mild Transparent films, hydrocolloid dressing,
gauze
Mild to moderate Hydrogel dressing (cannot be used in
infected wounds)
*** amorphous form of hydrogel can be
used for infected wounds
Moderate to severe Foams
Severe Alginates (max capacity)

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