Differential diagnosis phase 2: examination and evaluation of functional movement activities, body functions and structures, and participation

Differential diagnosis phase 2: examination and evaluation of functional movement activities, body functions and structures, and participation


Since the beginning of the evolution of practice for movement specialists within the health care arena, clinicians have been expected to examine a client’s functional performance and draw conclusions from the examination. The synthesis of information gathered has led to the establishment of short- and long-term goals, a prognosis concerning the likelihood of the goals being achieved, and the time it will take to achieve those goals. Similarly, the selection of the most effective and appropriate intervention strategies will guide the therapist and patient toward the desired outcomes. Today, clients are referred for physical and occupational therapy with “evaluate and treat” orders as the common referral pattern used by physicians or other health care providers. With direct access to physical and occupational therapy becoming a reality in many states across the United States and other countries, many patients are walking into clinics because they have decided that therapy is the best alternative to assist with their functional problems. Whether through self-referral or referral from another medical or health care practitioner, once a client enters into a therapeutic environment, clinicians must first determine whether the individual is medically stable at a body system level (see Chapter 7) and an appropriate candidate for therapeutic intervention. Once medical screening has been completed and the therapist determines that there are no red flags to suggest that the client needs to be referred for additional disease or pathology examination or does not need therapeutic intervention, then the client enters into Phase 2 of the evaluation process (Figure 8-1). In this phase it is important to examine and identify the client’s strengths that will facilitate recovery of functional movement, as well as what the client is unable to do functionally.

Numerous tools are used to examine clients with physical complaints and problems with functional movement. Many of these tools directly measure specific strengths and weaknesses of body system structures and functions, helping the clinician to identify specific impairments of a client that are causes of functional loss. Each body system or impairment tool is intended for a specific purpose and is designed to supply the user with a given outcome measure in a predetermined set of values.

Other tools measure a client’s ability or limitation for performing functional activities. These tools are designed to examine the performance of a client during various functional skills and activities of daily living. Functional tools also provide the user with a predetermined set of values. These tools, however, do not directly supply information about the cause of the client’s functional movement problems. The user must extrapolate information from the results of each functional test and then choose the appropriate body system or impairment measurement tools to determine the combination of impairments that may be contributing to the limitations in the client’s ability to perform daily living activities or participate in normal life interactions.

A third category of assessment is the administration of participation outcome measures. These are designed to assess a client’s involvement or restriction in domestic, community, social, and civic life situations. These tools examine the client’s perspective on the effects of his or her health condition on the ability to function in major life areas, interpersonal interactions and relationships, and quality of life.

The process of examination and evaluation occurs throughout the entire episode of care. The therapist must be constantly assessing the patient’s health status during each encounter. Initially the therapist may miss something important that does not become identified until more complex activities are introduced. Once the subtle body system problems become obvious, the therapist may need to go back to identify more in-depth causes and fine-tune intervention strategies. The intervention strategy may proceed in various directions depending on whether the patient and therapist mutually agree that the goal should stress adaptation and compensation versus regaining function through motor learning.

To be able to provide information that is meaningful in determining the best possible intervention for a particular patient, the examination tools selected by the clinician must be objective, reliable, valid, and appropriately matched with patient expectations. These tools should also communicate necessary information in a language that is understandable to all health care professionals and the payer responsible for funding the services (see Chapter 10). With the limitations on visits within the clinical setting and the critically important variable of motivation and adherence of the patient, the setting of goals and the selection of intervention strategies need to be established through patient-centered participation.110

This chapter has been developed to help the reader work through the problem-solving and decision-making process for selecting appropriate tests. It is not within the scope of this chapter or text to explain each examination tool in detail. However, the reader is presented with an extensive list of tests for body function and structure, activity, and participation in Appendix 8-A.

Selection of appropriate tests and measures

After the patient history and interview and the review of systems, the next step in the patient/client management process is the selection of appropriate tests and measures that will identify the most important patient problems that require therapeutic intervention. In the clinical environment, the therapist often approaches this process by first identifying the functional activities that the patient is able and not able to do (activity limitation or functional limitation), hypothesizing the possible impairments causing this activity or functional limitation, and then testing the body systems and subsystems to identify the nature and extent of the impairments. Consistent with the International Classification of Functioning, Disability and Health (ICF) model, the client’s strengths are often emphasized as the foundation for this process. The approach is proactive and collaborative, truly capitalizing on the client’s potential and goals, and highlights the therapist-client partnership.

Tests of activity and functional performance

As mentioned previously, the therapist typically starts with the examination of functional activities. This step will allow the therapist to understand the specific functional tasks that the patient can do, as well as those activities or functions that the patient is unable to perform. It is important to observe the client during the performance of these tasks and to note the motor patterns used. Many functional assessment tools have been developed to provide a more objective assessment of everyday skills and tasks. Each tool is designed to measure and score a specific type of functional ability. Several tools test a range of skills from balance skills to walking ability during the performance of functional tasks. Some tests are quick and easy to set up and perform, such as the Functional Reach Test and Timed Up and Go (TUG) Test, whereas other tools may take longer to administer, such as the Berg Balance Scale or Fugl-Meyer Assessment. There are advantages and disadvantages to both of these types of tests. Those that are the quickest to administer tend to measure fewer functional skills and do not supply information on the total functioning of a client. However, if the clinician properly identifies the client’s problems and is able to focus on the most efficient way of measuring them, a quick functional test can be the most beneficial one to use. Tests that take a bit longer to administer typically assess multiple skills and supply the user with a more comprehensive picture of the client’s functional abilities including those in various domains such as gross mobility, self-care, cognitive ability, and communication ability, among others. Often the decision on the complexity of the assessment tool used is based on the client and family’s objectives and long-term goals.

Outcome scales for functional tests may be found in ordinal format (e.g., Functional Independence Measure [FIM], Barthel Index, Katz Index of Independence in Activities of Daily Living). Each has its own unique point value and range, varying from a two- to three-point scale (e.g., Tinetti Performance-Oriented Mobility Assessment [POMA]) to a seven-point scale (e.g., FIM). A few tools supply ratio scale data (e.g., the TUG, Functional Reach Test, and measures of gait velocity). Test data presented in ratio scale format will more clearly show incremental changes, thereby facilitating the comparison of pretherapy to posttherapy performance.

Tests of body functions and structures

After identifying problems with functional performance of activities, the clinician then focuses on the performance of appropriate tests for body functions and structures. Consistent with the ICF model, the intent is to identify which body systems or subsystems are intact and functioning normally and could be optimized as the patient works on regaining the ability to perform functional tasks or participate in life. In this step, it is also important to identify which body systems and subsystems are not normal. These body system impairments may be the cause of the functional loss.

Impairment (ICF; International Classification of Impairments, Disabilities, and Handicaps [ICIDH]; Nagi)11 is defined as the loss or abnormality of physiological, psychological, or anatomical structure or function at the organ system level.12 The clinician needs to make the distinction between primary impairments, which are a direct consequence of the client’s specific disease or pathological condition, and secondary impairments, which occur as sequelae to the disease or rehabilitation process or as the result of aging, disuse, repetitive strain, lifestyle, and so on. Moreover, the clinician must remember that, although functional limitations are usually caused by a combination of specific impairments, it is possible that impairments may not contribute to specific functional problems for a particular client. If this is the case, the clinician should make a determination regarding whether these impairments, if left uncorrected, will result in the development of activity limitations at a later time. Simultaneously, the patient needs to be a part of this discussion because the therapist may not have the time to address all impairments. The correction of particular impairments may have more meaning or value to the patient. To the consumer some impairments may lead to limitation of functions that are important to them, whereas other impairments may restrict an activity in which the patient would never want to participate.

The ultimate goal of any therapeutic intervention program is to attain the highest level of health and wellness possible. Measurement tools that the clinician chooses to use also need to reflect this end result. For example, “traditional” impairment measurements may indicate that a client demonstrates shoulder range of motion (ROM) that is decreased by 25 degrees. The more important question should be how this decrease in ROM affects the client’s ability to perform a functional task such as dressing or any other activity that the client perceives as important. The clinician is therefore encouraged to consider the functional implications of these measurements to obtain results that are more meaningful for the client.

The clinician is always faced with the challenge of identifying and administering examination tools that will not only reflect the client’s level of health and wellness but also reflect the client’s functional improvement as a result of the intervention provided. Functional measurement tools can be used as a baseline measure for those functional skills. However, these tools typically require a large improvement in a client’s functional performance for a clinically significant change to be seen. Results obtained from impairment tests can fill in the large gaps between numerical scores on functional scales, demonstrating objective measurements and trends in the direction toward improvement before any change is demonstrated on the functional examination.

Box 8-1 illustrates impairments that may be seen in patients/clients with movement disorders caused by neurological dysfunctions. These impairments are further classified as those that are within the central nervous system and those that are outside the central nervous system and result from interaction with the environment. These impairments are further discussed in detail in various sections of this book.

Range of motion testing is one example of a common neuromusculoskeletal system examination procedure. Clinicians depend heavily on ROM measurements as an essential component of their examination and consequent evaluation process. It is imperative that the data obtained from this procedure be reliable. It has been suggested that the main source of variation in the performance of this procedure is method and that reliability can be improved by standardizing the procedure.13

An impairment in ROM can be the result of other body system impairments. ROM measurements may be used to determine the effect of tone, balance, movement synergies, pain, and so forth on the neuromuscular system and ultimately on behavior. Most important, the clinician needs to remember that the ROM needed to perform a functional activity is more critical than “normal,” anatomical, biomechanical ROM values and must be considered when labeling and measuring impairments. For example, full ROM in the shoulder is seldom needed unless activities of daily living, work, or leisure activities require it, such as performing a tennis serve or reaching overhead to paint a ceiling. When needed for specific tasks, goniometric measurements of ROM are appropriate, but at other times a functional range measurement may be sufficient.

Muscle strength testing is another commonly used examination procedure. Clinicians use various methods of quantifying strength including “traditional” manual muscle testing (MMT) and the use of a dynamometer. As with ROM, strength should be correlated with the patient’s functional performance. Again, the clinician may find a client to have 3/5 strength in the shoulder flexor muscle groups or find grip strength to be 35 kg, but the more important question should be “What does this mean in terms of the client’s ability to perform activities of daily living, and/or can he use that power in a functional activity?” The clinician is also advised to make the distinction between muscle strength and muscular endurance as it relates to function. A client may have sufficient lower-extremity strength and power to get up from the seated position; however, this does not necessarily mean that the client has muscular endurance to perform the task repeatedly during the day as part of normal everyday activities.

The status of the cardiac, respiratory, and circulatory systems significantly affects a client’s functional performance (see Chapter 30). Blood pressure, heart rate, and respiration give the clinician signs of the patient’s medical stability and the ability to tolerate exercise. The clinician may also obtain the results of pulmonary function tests for ventilation, pulmonary mechanics, lung diffusion capacity, or blood gas analysis after determining that the client’s pulmonary system is a major factor affecting medical stability and functional progress. Various exercise tolerance tests also attempt to quantify functional work capacity and serve as a guide for the clinician performing cardiac and pulmonary rehabilitation.

A client who has difficulty performing activities of daily living and who has neurological impairments in the central motor, sensory, perceptual, or integrative systems needs to undergo examination procedures to establish the level of impairment of each involved system and to determine if and how that system is contributing to the deficit motor behaviors. Functional evaluation tools used may include the FIM, the Barthel Index, the Tinetti POMA, or the TUG test. The results of these tests will help to steer the clinician toward the most useful impairment tools to use to evaluate limitations in the various body systems. Impairment tools may include the Modified Ashworth Scale for spasticity, the Upright Motor Control Test for lower-extremity motor control, the Clinical Test of Sensory Interaction on Balance (CTSIB), or the Sensory Organization Test (SOT) for balance and sensory integrative problems, or computerized tests of limits of stability on the NeuroCom Balance Master, among others (see Appendices 8-A, 8-B, and 8-C).

The clinician is also advised to investigate the interaction of other organs and systems as they relate to the patient’s functional limitations. For example, electrolyte imbalance, hormonal disorders, or adverse drug reactions (see Chapter 36) may explain impairments and activity limitations noted in other interacting systems.

Tests for participation and self-efficacy

In ICF terminology, participation is defined as an individual’s involvement in a life situation. Domestic life, interpersonal interactions and relationships, and community, social, and civic life are some examples of aspects of participation that can be examined for each individual. Participation restriction is the term used to denote problems that individuals may experience in involvement in life situations. When considering participation it is important to obtain the individual’s perception of how the medical condition, impairments, and activity limitations affect his or her involvement in life and community. Therefore many of the tests for participation and self-efficacy are in self-report format. The Activities-specific Balance Confidence Scale (ABC), Short Form 36 (SF-36), and Dizziness Handicap Inventory (DHI) are examples of tests that can be used to gather information under this domain. These tests allow an individual to assess his or her health quality of life after an incident that affected activity and participation. Appendices 8-A, 8-B, and 8-D include tools that measure participation and quality of life.

Choosing the appropriate examination tool

The ability to choose the appropriate examination tool(s) for a particular client will depend on several factors:

The evaluator should select examination tools that will measure the client’s primary problems (activity limitations, impairments, and participation restrictions) and supply outcome values that are needed to set realistic treatment goals in accordance with those of the client and family and to plan efficient and effective intervention strategies. The clinician is advised to select functional tools that contain component skills that the particular client is having difficulty performing. Skills the client performs poorly will disclose the activity limitations. Skills the client performs well determine the client’s strengths and abilities. The evaluator must then focus on the client’s functional activity limitations as determined by the test(s) to determine the impairment tests that will be performed next. For example, if the client demonstrates difficulty in rising from a chair during a functional test and scores low on this skill on the outcome measure (the Tinetti POMA or Berg Balance Scale), the clinician must then closely examine the skill of coming to stand to determine the cause of the mobility limitation. The problem may be that the client cannot generate adequate muscle power to push up from the chair, does not have adequate ROM in the hip or the ankle joints to rise from the chair, or no longer sees a reason to get out of the chair, or that it hurts too much to even try. It may be a problem with dynamic balance during or after the transitional movement. Any impairment that is hypothesized by observing performance of the functional skill needs to be measured more specifically. It is up to the examiner to determine the next best steps to take to target the client’s problems as efficiently as possible, to measure and record the needed outcomes as objectively as possible, and then to set treatment goals in consultation with the client to design the best intervention to remediate or manage the problems.

Many of the examination tools that measure a client’s ability to perform functional activities have been accepted as valid, reliable, and useful for the justification of payment for services rendered. The number of activity limitations and the extent of the client’s participation limitation are often reasons why an individual either has accessed therapy services directly or was referred by a medical practitioner. For this reason, the third-party payer expects to receive reports concerning positive changes in the client’s functional status for therapeutic services to be justifiable (see Chapter 10). The initial list of functional or activity limitations or participation restrictions helps the therapist determine the extent of, expectations for, and direction of intervention, but it does not determine why those limitations exist. This is the question that is critical to answer as part of the evaluation process. Examination tests and procedures that identify specific system and subsystem impairments help the therapist determine causes for existing participation and activity limitations. These tools need to be objective, reliable, and sensitive enough to provide needed communication to third-party payers to explain the subsystem’s baseline progress during and after the intervention. These tools should also supply explanations for residual difficulties in the event that the functional problems themselves do not demonstrate significant objective change or show progress within the time frame estimated.

Using the evaluation process to link body system problems, activity limitations, and participation restrictions to intervention

After objective measures have been obtained for activity limitations, body system and subsystem impairments, and participation restrictions, clinicians must determine whether the impairments or the functional problems are changeable to a more independent, safe, and functional level. In certain situations a mobility limitation may be remediated and become more functional, although the contributing component impairments may remain unchanged. In other situations, impairment measures may significantly improve but the functional problem may remain unaltered. This is especially true when one impairment is significantly improved but functional progress is masked by the contribution of other impairments. The examiner must be able to come to a conclusion regarding the relationship between the client’s activity limitations and the existing body systems impairments. Without an understanding of this relationship, it is difficult to assess the effect of the treatment intervention(s) on an individual.

The interactions and interrelationships of the identified functional problems and impairments provide the clinician with an initial status or problem list specific to that individual. That list helps the clinician formulate a diagnosis for the movement dysfunction. Through consideration of the objective values obtained during the examination process, a target status to be reached at the conclusion of therapeutic intervention can be estimated. That target status is both impairment and function driven and traditionally would be considered a list of outcome goals. The interactions between impairments and their related activity and participation limitations make up the unique problem map of that individual and direct the clinician toward selecting optimal interventions.

The prognosis made by the clinician is based on the assessment of the likelihood that the patient will achieve the target outcome in a given time frame and estimated number of visits needed to reach the treatment goal. Once the clinician has measured and identified specific activity limitations and their respective impairments, he or she then has an excellent opportunity to conceptually understand how various impairments affect multiple functional problems and which impairments are activity specific.

The following case scenario synthesizes the clinical examination and evaluation process used by physical and occupational therapists.

Assume that a clinician has been called in to examine a client who has sustained an anoxic brain injury during heart surgery. The client’s cognitive ability is within normal limits, and he is highly motivated to get back to his normal activities. He is retired; he loves to walk in the park with his wife and to go on birdwatching experiences in the mountains with their group of friends. The clinician must select which functional tests to use to obtain an objective initial status and target the client’s problems. Currently the client requires assistance with all gross mobility skills and is demonstrating difficulty balancing in various postures and performing activities of daily living. Results of functional testing reveal that the client demonstrates significant limitations, requiring moderate assistance in the activities of coming to sit, sitting, coming to stand, standing, walking, dressing, and grooming. Assume that the client also displays impairment limitations in flexion ROM at the hip joints caused by both muscle and fascia tightness and hypertonicity within the extensor muscle groups. He has compensated to some degree and is able to perform bed mobility independently. Upper-extremity motor control is within normal limits, and thus the client is capable of performing many activities of daily living as long as his lower trunk and hips are placed in a supportive position and hip flexion beyond 90 degrees is not required. The client has general weakness from inactivity, and power production problems in his abdominals and hip flexor muscles owing to the dominance of extensor muscle tonicity. Once he is helped to stand, the extensor patterns of hip and knee extension, internal rotation, slight adduction, and plantarflexion are present. He can actively extend both legs after being placed in flexion, but he is limited in the production of specific fine and gross motor patterns. Thus a resulting balance impairment is present owing to the inability to adequately access appropriate balance strategies caused by the presence of tone, limb synergy production, and weakness in the antagonists to the trunk and hip extensors. Through the use of augmented intervention (see Chapter 9) the client is noted to possess intact postural and procedural balance programming; however, both functions are being masked by existing impairments. The decision is made to perform impairment measures, including assessments of ROM at the hip, knee, and ankle joints; the ability to produce strength in both the abdominal and hip flexor muscle groups; and volitional and nonvolitional synergic programming, balance, and posture, and volitional control over muscle tone. The demand on ROM, power production, and specific synergic programming will vary according to the requirements of the functional activities performed.

Using a clinical decision-making process, the clinician will conclude that the impairments that are being targeted to measure will vary from one functional activity to the next. For instance, if this client is demonstrating difficulty rising from a chair, the target impairment may be a ROM measurement. This same ROM impairment may also contribute to problems with moving about the base of support in functional sitting. The clinician makes the determination as to the extent to which the impairment interferes with each functional problem for that particular client.

These objective measurements help the clinician explain which outcomes would be expected to be achieved first and why. These measurements are recorded as part of intervention charting and help to objectively demonstrate that the client is improving toward functional independence. They also give an indication of what the client still needs to reach the desired outcome, the rate of learning that is taking place, and an estimation of recovery time that is still required. These objective measurements give to the clinician and the client a better avenue to discuss expectations with family members, other medical practitioners, and third-party payers. In this example, assume that, after intervention, functional ROM in the hip was achieved. However, this improvement did not result in an improvement in the activity problems because synergic programming prevented adequate hip flexion during one or more functional activities. Understanding and measuring the difference between lack of ROM as a result of muscle or fascia tightness versus lack of range from abnormal synergic patterning helps the clinician communicate why a client is successful in one activity and may still need assistance in another.

Scores obtained from tests of activity, participation, and impairments supply statistically important measurements that can then be used to discuss the limitations placed on the therapeutic environment by fiscal intermediaries. Therapists must be clear when documenting the initial status and the target status for clients so that the recommended intervention and length of stay may be justified (see Chapter 10).

When making a determination of the potential impact of an intervention on improving a client’s problems, clinicians must remember that a key factor in this process of examination and evaluation is the acceptance of the movement dysfunction or impairment by the client. A mobility problem or impairment may be clearly identified by a functional test or impairment test; however, the client may deny that the problem even exists. Acceptance of the problems by the client and a willingness to change are critical to the client’s adherence to the intervention strategy.

As mentioned earlier, the identification of potential impairments was done after functional testing to streamline the examination process. After performing the functional examination, the therapist postulated that the client might have impaired motor control, muscle weakness, sensory deficits, pain, and decreased endurance that may have been causing the functional limitations. MMT revealed lower-extremity strength of 1/5 in both ankle motions, 2/5 in both knees, and 3−/5 in both hips. Upper extremities tested as 1/5 finger flexors (incomplete grip), 2/5 wrist motions, and 3+/5 in both elbow motions. Shoulder and trunk strength were within functional limits for all motions. Sensory testing indicated absent touch and proprioceptive sensations from the foot to the knee of both lower extremities, with impaired sensation from the thighs to the hips. Both hands and wrists tested absent to touch and proprioception, with the elbows and shoulders testing intact. The client’s endurance was limited to short bouts of activity (3 to 5 minutes), with rapid muscular and cardiovascular fatigue. The presence of these impairments helped to explain the resultant functional limitations tested earlier.

In terms of standardized functional tests, the multidisciplinary FIM could give insight into this patient’s ability to function in multiple domains and categories. Baseline scores on the Tinetti POMA and the Berg Balance Scale could be collected because this client is expected to regain further function in balance and postural control as recovery from the condition occurs. As the client regains strength and peripheral sensory ability, he may be able to perform the TUG and the 10-Meter Walk Test. These functional assessments paint a better picture of what the client can and cannot do, as well as providing a way to measure functional progress in various activities throughout rehabilitation.

When determining an appropriate tool to examine a client’s functional status, the clinician must also consider the “ceiling and floor effect” of the functional tools. In this particular case, the patient is probably unable to perform the Functional Gait Assessment (FGA) but may be appropriate for beginning the balance portion of the Tinetti POMA. As the patient progresses, the predictive and discriminative properties of some of these tests could provide information regarding the patient’s likelihood of falling, or ability to safely perform selected functional tasks.

CASE STUDY 8-1   *

The patient is a 30-year-old man who was referred to outpatient physical therapy after a 1-week stay in an acute care facility following an exacerbation of relapsing-remitting multiple sclerosis (MS). His height was 2.05 m (6 feet 9 inches) and his weight was 133.81 kg (295 pounds). The patient was first diagnosed with MS 4 years ago. He developed optic neuritis during the exacerbation and was treated with corticosteroid pulse therapy. The patient’s past medical history included depression, gastroesophageal reflux disease (GERD), migraine headaches, and hyperlipidemia. After being diagnosed with MS, the patient had to stop working. Before the most recent hospitalization, the patient lived with his sister in a single-story home with five stairs to enter with a railing. At that time he was able to ambulate independently without an assistive device and to complete all activities of daily living without any assistance.

An outpatient physical therapy initial examination was conducted 1 week after the patient was discharged from the hospital. He reported that he was using a wheelchair to get to and from appointments, and inside his home. He was alert and oriented to person, place, and time, although responses were delayed and speech was slightly slurred. There were no complaints of pain, and the patient stated that fatigue and temperature had not affected him.

Several tests of functional movement activities were performed first. The patient was able to roll to the right and left with minimal assistance, with rolling to the right being less difficult for the patient. He needed supervision to move from supine to sitting.

The patient required moderate assistance to perform a sit-to-stand transfer. He was able to ambulate five steps with a front-wheeled walker (FWW) and moderate assistance of one person.

After examination of the patient’s functional movement activities, several tests of body function and structures were then administered. Passive ROM for all joints in both upper and lower extremities was within normal limits. The patient presented with 3/5 (fair) strength of the right upper and lower extremities and good (4/5) strength of the left upper and lower extremities during MMT. Light touch and superficial pain sensations tested intact from C4-S2 dermatomes bilaterally.

Sitting balance was scored as 3/4 (good), as the patient was able to accept moderate challenges. Standing static balance was 1+/4 (poor plus); the patient was able to maintain balance with handheld support and occasional minimal assistance.

Observational gait analysis was performed, and impairments in gait included the following: decreased step length bilaterally, wide base of support, decreased weight bearing through the right lower extremity, and lack of toe-off. It was also noted that ataxic type movements were present with ambulation.

The Gait Abnormality Rating Scale (GARS) was performed, and the patient scored a 32/48, indicating increased fall risk. The Tinetti POMA was also administered. The patient scored 8/28, indicating a high risk for falls. Several tests were performed using the NeuroCom Balance Master. The sit-to-stand test showed that the patient had difficulty maintaining balance immediately after rising and had more weight on his left lower extremity. The results were abnormal, based on the norms for the patient’s gender and age. Next, the weight-bearing squat test was done. During this test the patient was not able to maintain equal weight through bilateral lower extremities, with the patient bearing weight more on the left side. The patient then performed the limits of stability test, which revealed an inability to lean his center of gravity (COG) over his right lower extremity, or forward onto his toes. The patient then performed the rhythmic weight-shift test; he was not able to complete the forward-backward component of the rhythmic weight-shift test without falling, and he also had difficulty with directional control and velocity during lateral weight shifting.

Last, tests for participation and self-efficacy were administered. The Activities-specific Balance Confidence (ABC) Scale questionnaire was given to the patient to assess the patient’s balance self-efficacy. The patient had a score of 20%, indicating a low level of physical functioning. He scored 10% on being able to bend down, pick a slipper up off the floor, and reach for a can on a shelf at eye level with the use of a FWW.

The data collected at initial examination revealed limitations in functional performance resulting from impairments in balance, gait, strength, and motor control, giving the therapist the various movement diagnoses that reflected problems. The Guide to Physical Therapist Practice was used to classify the patient in the neuromuscular practice pattern E (impaired motor function and sensory integrity associated with progressive disorders of the central nervous system). The Guide indicates a range of 6 to 50 visits needed to reach anticipated outcomes for patients who are classified in this practice pattern. Intervention frequency and duration was set at three times per week for 8 weeks. The prognosis that the patient would be able to ambulate independently in the community with an assistive device in 8 weeks was good, given the patient’s willingness to participate in physical therapy, positive outlook, family support, and positive response to medical interventions. The plan of care that was developed focused on improving activity limitations such as transfers and gait and impairments such as weakness and imbalance. The long-term goals were set to be achieved in 8 weeks, and short-term goals were set to be achieved in 4 weeks.

*Case study modified from Larsen-Merrill J, Lazaro R: Use of the NeuroCom balance master training protocols to improve functional performance in a person with multiple sclerosis. J Stud Phys Ther Res 21:1–16, 2009.

APPENDIX 8-A image   Outcome Measures from the Neurology Section of the American Physical Therapy Association (APTA) Special Interest Groups (SIGs) from Neurologic Practice Essentials: A Measurement Toolbox,* Organized by Categories of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF)1417

ICF Category Outcome Measures
Balance and Falls SIG
Body Structure/Function None submitted
Activity Berg Balance ScaleFregly-Graybiel Ataxia Test Battery
Functional Reach Test
Gait Abnormality Rating Scale, Modified (mGARS)
Gait Speed—10 Meter Walk Test
Limits of Stability Test (LOS)
Physical Performance Battery
Sensory Organization Test (SOT)
Tinetti Performance-Oriented Mobility Assessment (POMA)
Walky-Talky Test
Participation Activities-specific Balance Confidence Scale (ABC)Tinetti Falls Efficacy Scale (FES)
Brain Injury SIG
Body Structure/Function Agitated Behavior ScaleAwareness Questionnaire
Coma/Near Coma Scale
Disorders of Consciousness Scale
Glasgow Coma Scale (GCS)
JFK Coma Recovery Scale, Revised
Modified Ashworth Scale
Patient Competency Rating Scale
Rancho Levels of Cognitive Functioning
Activity Berg Balance TestBrunel Balance Test
Functional Independence Measure (FIM)
Functional Independence Measure/Functional Assessment Measure (FIM/FAM)
High-level Mobility Assessment Test (HiMAT)
Participation Community Integration QuestionnaireCraig Handicap Assessment and Reporting Technique (CHART)
Disability Rating Scale
Mayo Portland Adaptability Inventory
Participation Objective, Participation Subjective
Degenerative Diseases SIG
Body Structure/Function ALS Functional Rating ScaleHoehn and Yahr Stage
Kurtzke Extended Disability Status Scale
Modified Ashworth Scale
Modified Mini-Mental State Examination (MMSE)
Unified Huntington’s Disease Rating Scale (UHDRS)
Unified Parkinson’s Disease Rating Scale (UPDRS)
Activity 2- or 6-Minute Walk Test360-Degree Turn Test
Berg Balance Scale
Dynamic Gait Index (DGI)
Functional Independence Measure (FIM)
Functional Reach Test
Gait Speed—Self-Paced and Fast
Modified Gait Abnormality Rating Scale
Schwab and England Scale
Timed Up and Go Test (TUG)
Tinetti Performance-Oriented Mobility Assessment (POMA)
Participation Fatigue Severity ScaleModified Falls Efficacy Scale
Modified Fatigue Impact Scale
Parkinson’s Disease Questionnaire–39 (PDQ-39)
Short Form 36 (SF-36) or Short Form 12 (SF-12)
Spinal Cord Injury SIG
Body Structure/Function American Spinal Injury Association (ASIA) Impairment Classification ScaleManual Muscle Testing (MMT)
Modified Ashworth Scale
Penn Spasm Frequency Scale
Activity Functional Evaluation in Wheelchair (FEW)Functional Independence Measure (FIM)
Quadriplegia Index of Function (QIF)
Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI)
Spinal Cord Injury Measure (SCIM)
Walking Index for Spinal Cord Injury–II (WISCI-II)
Wheelchair Assessment Tool (WAT)
Participation Craig Handicap Assessment and Reporting Technique (CHART)Impact on Participation and Autonomy (IPA)
Life Habits and Handicap (LIFE-H)
Stroke SIG
Body Structure/Function Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (FMA)Hand-Held Dynamometry
Mini-Mental State Examination (MMSE)
Modified Ashworth Scale
National Institutes of Health Stroke Scale (NIHSS)
Neurobehavioral Cognitive Status Examination
Postural Assessment Scale for Stroke (PASS)
Stroke Rehabilitation Assessment of Movement (STREAM)
Trunk Control Test
Trunk Impairment Scale
Activity 10-Meter Walk Test (10MWT)6-Minute Walk Test (6MWT)
Barthel Index
Berg Balance Scale
Chedoke-McMaster Stroke Assessment Scale
Frenchay Activities Index (FAI)
Functional Independence Measure (FIM)
Modified Rankin Handicap Scale
Motor Assessment Scale (MAS)
Rivermead Motor Assessment (RMA)
Timed Up and Go Test (TUG)
Participation Euro Quality of Life–5D (EuroQol-5D)Short Form 36 (SF-36)
Stroke Impact Scale (SIS)
Stroke Specific Quality of Life (SS-QOL)
Stroke-Adapted Sickness Impact Profile (SA-SIP30)
Vestibular SIG
Body Structure/Function Clinical Test of Sensory Interaction on Balance (CTSIB)Romberg Test and Sharpened Romberg Test
Sensory Organization Test (SOT)
Single-Leg Stance Test
Nystagmus Tests
Gaze-Evoked Nystagmus
Post–Head Shaking Nystagmus Test
Spontaneous Nystagmus
Vibration-Induced Nystagmus
Positional Testing
Dix-Hallpike Test
Motion Sensitivity Quotient (MSQ)
Tests of Voluntary Eye Movement
 Smooth Pursuit
 VOR Cancellation Test
Vestibular Ocular Reflex Tests (VOR)
Dynamic Visual Acuity Test (DVA)
Gaze Stabilization Test (GST)
Head Thrust Test (HTT)
Activity Dynamic Gait Index (DGI)Functional Gait Assessment (FGA)
Timed Up and Go Test (TUG)
Participation Dizziness Handicap Inventory (DHI)Physical Activities Scale for the Elderly
Short Form 36 (SF-36)
Vestibular Disorders Activities of Daily Living Scale (VADL)
Generic Measures
Body Structure/Function Mini-Mental State Examination (MMSE)
Activity 5- or 10-Meter Walk Test6-Minute Walk Test
Clinical Test of Sensory Interaction on Balance (CTSIB)
Four Square Step Test (FSST)
Functional Ambulation Categories
Functional Gait Assessment (FGA)
Trunk Impairment Scale
Participation Activities-specific Balance Confidence Scale (ABC)Short Form 36 (SF-36)
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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Differential diagnosis phase 2: examination and evaluation of functional movement activities, body functions and structures, and participation

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