The Physiatric History and Physical Examination

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Chapter 1 The Physiatric History and Physical Examination

Michael W. O’Dell, C. David Lin, André Panagos

The physiatric history and physical examination (H&P) serves several purposes. It is the data platform from which a treatment plan is developed. It also serves as a written record that communicates to other rehabilitation and nonrehabilitation health care professionals. Finally, the H&P provides the basis for physician billing ¹⁶ and serves as a medicolegal document. Physician documentation has become the critical component in inpatient rehabilitation reimbursement under prospective payment, as well as proof for continued coverage by private insurers. The scope of the physiatric H&P varies enormously depending on the setting, from the focused assessment of an isolated knee injury in an outpatient setting, to the comprehensive evaluation of a patient with traumatic brain or spinal cord injury admitted for inpatient rehabilitation. An initial evaluation is almost always more detailed and comprehensive than subsequent or follow-up evaluations. An exception would be when a patient is seen for a follow-up visit with substantial new signs or symptoms. Physicians in training tend to overassess, but with time the experienced physiatrist develops an intuition for how much detail is needed for each patient given a particular presentation and setting.

The physiatric H&P resembles the traditional format taught in medical school but with an additional emphasis on history, signs, and symptoms that affect function (performance). The physiatric H&P also identifies those systems not affected that might be used for compensation.²² Familiarity with the 1980 and 1997 World Health Organization classifications is invaluable in understanding the philosophic framework for viewing the evaluation of persons with physical and cognitive disabilities (Table 1-1).^76,⁷⁷ Identifying and treating the primary impairments to maximize performance becomes the primary thrust of physiatric evaluation and treatment.

Table 1-1 World Health Organization Definitions

Term	Definition
1980
Impairment	Any loss or abnormality of psychologic, physiologic, or anatomic structure or function
Disability	Any restriction or lack resulting from an impairment of the ability to perform an activity in the manner or within the range considered normal for a human being
Handicap	A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal for that individual
1997
Impairment	Any loss or abnormality of body structure or of a physiologic or psychologic function (essentially unchanged from the 1980 definition)
Activity	The nature and extent of functioning at the level of the person
Participation	The nature and extent of a person’s involvement in life situations in relationship to impairments, activities, health conditions, and contextual factors

From World Health Organization 1980⁷⁶ and 1997,⁷⁷ with permission of the World Health Organization.

Because patients cared for in rehabilitation medicine can be extremely complicated, the H&P is many times a work in progress. Confirmation of historical and functional items by other team members, health care professionals, and family members can take several days. Many of the functional items discussed in this chapter will actually be assessed and explored more fully by other interdisciplinary team members during the course of inpatient or outpatient treatment. It is imperative that the physiatrist stays abreast of additional information and findings as they become available, and that lines of verbal or written communication be directed through the medical leadership of the team.

The exact structure of the physiatric assessment is determined in part by personal preference, training background, and institutional requirements (physician billing compliance expectations, forms committees, and regulatory oversight). The use of templates can be invaluable in maximizing the thoroughness of data collection and minimizing documentation time. Pertinent radiologic and laboratory findings should be clearly documented. The essential elements of the physiatric H&P are summarized in Table 1-2. Assessment of some or all of these elements is required for a complete understanding of the patient’s state of health and the illness for which he or she is being seen. These elements also form the basis for a treatment plan.

Table 1-2 Essential Elements of the Physiatric History and Physical Examination

Component	Examples
Chief complaint
History of present illness	Exploring location, onset, quality, context, severity, duration, modifying factors, and associated signs and symptoms
Functional history	Mobility: Bed mobility, transfers, wheelchair mobility, ambulation, driving, and devices required Activities of daily living: Bathing, toileting, dressing, eating, hygiene and grooming, etc. Instrumental activities of daily living: Meal preparation, laundry, telephone use, home maintenance, pet care, etc. Cognition Communication
Past medical and surgical history	Specific conditions: Cardiopulmonary, musculoskeletal, neurologic, and rheumatologic Medications
Social history	Home environment and living circumstances, family and friends support system, substance abuse, sexual history, vocational activities, finances, recreational activities, psychosocial history (mood disorders), spirituality, and litigation
Family history
Review of systems
General Medical Physical Examination
	Cardiac Pulmonary Abdominal Other
Neurologic Physical Examination
	Level of consciousness Attention Orientation Memory General fund of knowledge Abstract thinking Insight and judgment Mood and affect
Communication
Cranial nerve examination
Sensation
Motor control	Strength Coordination Apraxia Involuntary movements Tone
Reflexes	Superficial Deep Primitive
Musculoskeletal Physical Examination
Inspection	Behavior Physical symmetry, joint deformity, etc.
Palpation	Joint stability Range of motion (active and passive) Strength testing (see above) Painful joints and muscles
Joint-specific provocative maneuvers

An emergence in the use of electronic medical records (EMR) has significantly altered the landscape for documentation of the physiatric H&P in both the inpatient and outpatients settings.²³ Among the advantages of the EMR are increased legibility, time efficiency afforded by the use of templates and “smart phrases” that can be tailored to individual practitioners, and automated warnings regarding medication interactions or errors, as well as faster and more accurate billing. Disadvantages include overuse of the “copy and paste” function, leading to the appearance of redundancy among consecutive notes and the perpetuation of potentially inaccurate information, automated importation of data not necessarily reviewed by the practitioner at the time of service, and “alarm fatigue.” As regulation of hospital and physician practice and billing increases, the EMR will become more important in ensuring the proper, and sometimes convoluted, documentation required for safety initiatives⁴⁰ and physician payment.¹⁵

The Physiatric History

History-taking skills are part of the art of medicine and are required to fully assess a patient’s presentation. One of the unique aspects of physiatry is the recognition of functional deficits caused by illness or injury. Identification of these deficits allows for the design of a treatment program to restore performance. In a person with stroke, for example, the most important questions for the physiatrist are not just the etiology or location of the lesion but also “What functional deficits are present as a result of the stroke?” The answer could include deficits in swallowing, communication, mobility, cognition, activities of daily living (ADL), or a combination of these.

The time spent in taking a history also allows the patient to become familiar with the physician, establishing rapport and trust. This initial rapport is critical for a constructive and productive doctor–patient–family relationship and can also help the physician learn about such sensitive areas as the sexual history and substance abuse. It can also have an impact on outcome, as a trusting patient tends to be a more compliant patient.⁶² Assessing the tone of the patient and/or family (such as anger, frustration, resolve, and determination), understanding of the illness, insight into disability, and coping skills are also gleaned during history taking. In most cases, the patient leads the physician to a diagnosis and conclusion. In other cases, such as when the patient is rambling and disorganized, frequent redirection and refocus are required.

Patients are generally the primary source of information. However, patients with cognitive or mood deficits (denial or decreased insight) or with communication problems, as well as small children, might not be able to fully express themselves. In these cases, the history taker might rely on other sources such as family members; friends; other physicians, nurses, and medical professionals; or previous medical records. This can also have an impact on physician billing. Caution must be exercised in using previous medical records because inaccuracies are sometimes repeated from provider to provider, sometimes referred to as “chart lore.”

Chief Complaint

The chief complaint is the symptom or concern that caused the patient to seek medical treatment. The most common chief complaints seen in an outpatient physiatric practice are pain, weakness, or gait disturbance of various musculoskeletal or neurologic origins. On a physiatric consultation on an inpatient rehabilitation service, the predominant chief complaints are related to mobility, ADL, communication, or cognitive deficits and candidacy for inpatient rehabilitation. Unlike the relatively objective physical examination, the chief complaint is purely subjective and, when possible, the physician should use the patient’s own words. A patient can present with several related or unrelated complaints, in which case it is helpful to have the patient rank problems from “most bothersome” to “least bothersome.”

The specific circumstance of a patient offering a chief complaint can also allude to a degree of disability or handicap. For example, knowing that an obese mail carrier presents with the chief complaint of difficulty in walking because of knee pain could suggest not only the impairment but also an impact on his vocation and role as a provider for his family (participation, handicap).

History of the Present Illness

The history of the present illness (HPI) details the chief complaint(s) for which the patient is seeking medical attention, as well as any related or unrelated functional deficits. It should also explore other information relating to the chief complaint such as recent and past medical or surgical procedures, complications of treatment, and potential restrictions or precautions. The HPI should include some or all of eight components related to the chief complaint: location, time of onset, quality, context, severity, duration, modifying factors, and associated signs and symptoms (see Table 1-2).

In this case example, the patient is a 70-year-old man referred by his neurologist for physical therapy because the patient cannot walk properly (chief complaint). Over the past few months (duration), he has noted slowly progressive weakness of his left leg (location). Subsequent workup by his neurologist suggested amyotrophic lateral sclerosis (context). The patient was active in his life and working up until a few months previously, ambulating without an assistive device (context). Now he uses a straight cane for fear of falling (modifying factor). Besides difficulty with walking, the patient also has some trouble swallowing foods (associated signs and symptoms).

Functional Status

Detailing the patient’s current and prior functional status is an essential aspect of the physiatric HPI. This generally entails better understanding the issues surrounding mobility, ADL, instrumental activities of daily living (I-ADL), communication, cognition, work, and recreation, among others. The data should be as accurate and detailed as possible to guide the physical examination and develop a treatment plan with reasonable short- and long-term goals.

Assessing the potential for functional gain or deterioration requires an understanding of the natural history, cause, and time of onset of the functional problems. For example, most spontaneous motor recovery after stroke occurs within 3 months of the event.⁶⁸ For a recent stroke patient with considerable motor impairments, there is a greater expectation for significant functional gain than in a patient with minor deficits related to a stroke that occurred 2 years ago.

It is sometimes helpful to assess functional status using a standardized scale. No single scale is appropriate for all patients, but the Functional Independence Measure (FIM) is the most commonly used in the inpatient rehabilitation setting (Table 1-3; see Chapter 8).³ Measuring only activity limitation (disability) or performance, each of 18 different activities is scored on a scale of 1 to 7, with a score of 7 indicating complete independence. Intermediate scores indicate varying levels of assistance from very little (from an assistive device, to supervision, to hands-on assistance) to a score of 1 indicating complete dependence on caregiver assistance. FIM scores also serve as a kind of rehabilitation shorthand among team members to quickly and accurately describe functional deficits.

Table 1-3 Levels of Function on the Functional Independence Measure

Level of Function	Score	Definition
Independent	7 6

Another person is not required for the activity (no helper).

Complete independence: all the tasks described as making up the activity are performed safely, without modification, assistive devices, or aids, and within a reasonable amount of time.

Modified independence—one or more of the following can be true:

• The activity requires an assistive device.

• The activity takes more than a reasonable time.

• There are safety considerations.

Dependent The patient requires another person for either supervision or physical assistance for the activity to be performed (requires helper).

Supervision or set-up: the patient requires no more help than stand-up or cueing without physical contact, or the helper sets up needed items.

Minimal contact assistance: the patient requires no more help than touching and expends 75% or more of the effort.

Moderate assistance: the patient requires more help than touching and expends 50%-75% of the effort.

Maximal assistance: the patient expends 25%-50% of the effort.

Total assistance: the patient expends less than 25% of the effort.

From Anonymous³ 1997, with permission of the State University of New York at Buffalo.

Mobility

Mobility is the ability to move about in one’s environment and is taken for granted by most healthy people. Because it plays such a vital role in society, any impairment related to mobility can have major consequences for a patient’s quality of life. A clear understanding of the patient’s functional mobility is needed to determine independence and safety, including the use of, or need for, mobility assistive devices. There is a range of mobility assistive devices that patients can use, such as crutches, canes, walkers, orthoses, and manual and electric wheelchairs (Table 1-4; see Chapters 15 and 17).

Table 1-4 Commonly Used Mobility Assistive Devices

Category	Example
Crutches	Axillary crutches Forearm crutches Platform crutches

Canes

Straight cane

Wide- or narrow-based quad cane

Hemiwalker or pyramid cane

Walkers

Standard or pick-up walker

Rolling walker

Platform walker

Wheelchairs Types

Manual

Powered

Lightweight

Common modifications or specifications

Folding or solid frame

Elevated or removable leg rests

Removable armrests

Reclining

Off-the-Shelf Ankle-Foot Orthoses Common custom orthoses

Plastic ankle-foot orthosis

Metal ankle-foot orthosis

Knee orthosis

Knee-ankle-foot orthosis

Bed mobility includes turning from side to side, going from the prone to supine positions, sitting up, and lying down. A lack of bed mobility places the patient at greater risk for skin ulcers, deep vein thrombosis, and pneumonia. In severe cases, bed mobility can be so poor as to require a caregiver. In other cases, bed rails might be appropriate to facilitate movement. Transfer mobility includes getting in and out of bed, standing from the sitting position (whether from a chair or toilet), and moving between a wheelchair and another seat (car seat or shower seat). Once again, the history taker should assess the level of independence, safety, and any changes in functional ability.

Wheelchair mobility can be assessed by asking if patients can propel the wheelchair independently, how far or how long they can go without resting, and whether they need assistance with managing the wheelchair parts. It is also important to assess the extent to which they can move about at home, in the community, and up and down ramps. Whether the home is potentially wheelchair-accessible is particularly important in cases of new onset of severe disability.

Ambulation can be assessed by how far or for how long patients can walk, whether they require assistive devices, and their need for rest breaks. It is also important to know whether any symptoms are associated with ambulation, such as chest pain, shortness of breath, pain, or dizziness. Patients should be asked about any history of falling or instability while walking, and their ability to navigate uneven surfaces. Stair mobility, along with the number of stairs the patient must routinely climb and descend at home or in the community, and the presence or absence of handrails should also be determined.

Driving is a crucial activity for many people, not only as a means of transportation but also as an indicator and facilitator of independence. For example, elders who stop driving have an increase in depressive symptoms.⁵⁰ It is important to identify factors that might prevent driving, such as decreased cognitive function and safety awareness, and decreased vision or reaction time. Other factors affecting driving can include lower limb weakness, contracture, tone, or dyscoordination. Some of these conditions might require use of adaptive hand controls for driving. Cognitive impairment sufficient to affect the ability to drive can be due to medications or organic disease (dementia, brain injury, stroke, or severe mood disturbance). Ultimately, the risks of driving are weighed against the consequences of not being able to drive. If the patient is no longer able to drive, alternatives to driving should be explored, such as the use of public or assisted transportation. Laws differ widely from state to state on the return to driving after a neurologic impairment develops.

Activities of Daily Living and Instrumental Activities of Daily Living

ADL encompass activities required for personal care including feeding, dressing, grooming, bathing, and toileting. I-ADL encompass more complex tasks required for independent living in the immediate environment such as care of others in the household, telephone use, meal preparation, house cleaning, laundry, and in some cases use of public transportation. In the Occupational Therapy Practice Framework, there are 11 activities for both ADL and I-ADL (Box 1-1).⁴

BOX 1-1 Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (I-ADL)

Modified from [Anonymous]: Occupational Therapy Practice Framework: domain and process. Am J Occup Ther 56:609-639, 2002 (Erratum in: Am J Occup Ther 2003; 57:115) with permission.

The clinician should identify and document ADL the patient can and cannot perform, and determine the causes of limitation. For example, a woman with a stroke might state that she cannot put on her pants. This could be due to a combination of factors such as a visual field cut, balance problems, weakness, pain, contracture, hypertonia, or deficits in motor planning. Some of these factors can be confirmed later in the physical examination. A more detailed follow-up to a positive response to the question is frequently needed. For example, a patient might say “yes” to the question “Can you eat by yourself?” On further questioning, it might be learned that she cannot prepare the food by herself or cut the food independently. The most accurate assessment of ADL and mobility deficits often comes from the hands-on assessment by therapists and nurses on the rehabilitation team.

Cognition

Cognition is the mental process of knowing (see Chapters 3 and 4). Although objective assessment of cognition comes under physical examination (memory, orientation, and the ability to assimilate and manipulate information), impairments in cognition can also become apparent during the course of the history taking. Because persons with cognitive deficits often cannot recognize their own impairments (anagnosia), it is important to gather information from family members and others familiar with the patient. Cognitive deficits and limited awareness of these deficits are likely to interfere with the patient’s rehabilitation program unless specifically addressed. These deficits can pose a safety risk as well. For example, a man with a previous stroke who falls, sustaining a hip fracture requiring replacement, might not be able to follow hip precautions, resulting in possible refracture or hip dislocation. Executive functioning is another aspect of cognition, which includes the mental functions required for planning, problem solving, and self-awareness. Executive functioning correlates with functional outcome because it is required in many real-world situations.⁴⁵

Communication

Communication skills are used to convey information including thoughts, needs, and emotions. Verbal expression deficits can be very subtle and might not be noticed in a first encounter. If there is a reason to think that speech or communication has been affected by a recent event, it is advisable to ask family members if they have noticed recent changes. Patients who cannot communicate through speech might or might not be able to communicate through other means, known as augmentative communication, depending on the type of communication dysfunction and other physical and cognitive limitations. This can include writing and physicality (such as sign language, gestures, and body language). They can also use a variety of augmentative communication aids ranging from simple picture, letter, and word boards to electronic devices.

Past Medical and Surgical History

The physiatrist should understand the patient’s past medical and surgical history. This knowledge allows the physiatrist to understand how preexisting illnesses affect current status, and how to tailor the rehabilitation program for precautions and limitations. The patient’s past medical history can also have a major impact on rehabilitation outcome.

Social History

Home Environment and Living Situation

Understanding the patient’s home environment and living situation includes asking if the patient lives in a house or an apartment, if there is elevator access, whether it is wheelchair accessible, if there are stairs, whether the bathroom is accessible from the bedroom, and whether the bathroom has grab bars or handrails (and on which side). A home visit might be required to gain the best assessment. If there is no caregiver at home, the patient could require a home health aide. These factors help determine many aspects of the discharge plan.

Family and Friends Support

Patients who have lost function might require supervision, emotional support, or actual physical assistance. Family, friends, and neighbors who can provide such assistance should be identified. The clinician should discuss the level of assistance they are willing and able to provide. The assistance provided by caregivers can be limited if they are elderly, have some type of impairment, work, or are not willing to assist with bowel or bladder hygiene.

Substance Abuse

Patients should be asked about their history of smoking, alcohol use or abuse, and drug abuse. Because patients often deny substance abuse, this topic should be discussed in a nonjudgmental manner. Patients frequently feel embarrassment or guilt in admitting substance abuse, and also fear the legal consequences of such an admission. Substance abuse can be a direct and an indirect cause of disability, and is often a contributing factor in traumatic brain injury.¹⁹ It can also have an impact on community reintegration, because patients with pain and/or depression are at risk for further abuse. Patients who are at risk should be referred to social work to explore options for further assistance, either during the acute rehabilitation or later in the community.

Sexual History

Patients and health care practitioners alike are often uncomfortable discussing the topic of sexuality, so developing a good rapport during history taking can be helpful. Discussion of this topic is made easier if the health care practitioner has a basic knowledge of how sexual function can be changed by illness or injury (see Chapter 31). Sexuality is particularly important to patients in their reproductive years (such as with many spinal cord– and brain-injured persons), but the physician should enquire about sexuality in adolescents and adults, as well as in the elderly. Sexual orientation and safer sex practices should be addressed when appropriate.

Vocational Activities

Vocation is not only a source of financial security; it also significantly relates to self-confidence and even identity. The history should include the patient’s educational level, recent work history, and the ability to fulfill job requirements subsequent to the injury or illness. If an individual cannot fully regain the previous function level, the vocational options available should be explored. It is possible that the work environment can be modified to compensate for a functional loss or minimize musculoskeletal pain complaints. An example of this would be the installation of a wheelchair ramp for an accountant with paraplegia.

Finances and Income Maintenance

Patients can have financial concerns that are due to or exacerbated by their illness or injury. These concerns can also be addressed by the rehabilitation team social worker. Whether a patient has the financial resources or insurance to pay for adaptive devices such as a ramp or mobility equipment can significantly affect discharge planning. If patients cannot safely be discharged home, skilled nursing facility placement might need to be explored, at least on a temporary basis.

Recreation

The ability to engage in hobbies and recreational activities is important to most people, and any loss or limitation of the ability to perform these activities can be stressful. Recreation is a primary outcome in sports medicine. The recreational activity affected can involve physical exercise, such as a sporting activity, or can be more sedentary, such as playing cards. The team recreational therapist can be helpful in helping to restore the patient’s favorite recreations and offer new ones.

Psychosocial History

The history taker must recognize the psychosocial impact of impairment. Beyond the loss of function, the patient can also feel a loss of overall health, body image, mobility, or independence. The loss of function, and possibly of income as well, can place great stress on the family unit and caregivers. The treatment plan should recognize the patient’s psychosocial context and provide assistance in developing coping strategies, especially for depression and anxiety. This can help accelerate the patient’s process of adjusting to a new disability.

Spirituality and Belief

Spirituality is an important part of the lives of many patients, and some preliminary studies indicate that it can have positive effects on rehabilitation, life satisfaction, and quality of life.¹³ Health care providers should be sensitive to the patient’s spiritual needs, and appropriate referral or counseling should be provided.17

Pending Litigation

Patients should be asked in a nonjudgmental fashion whether they are involved in litigation related to their illness, injuries, or functional impairment. The answer should not change the treatment plan, but litigation can be a source of anxiety, depression, or guilt. In some cases the patient’s legal representative can play an important role in obtaining needed services and equipment.

Family History

Patients should be asked about the health, or cause and age of death, of parents and siblings. It is always important to know whether any family members have a similar condition. They should also be asked about any family history of heart disease, diabetes, cancer, stroke, arthritis, hypertension, or neurologic illness. This will help to identify genetic disorders within the family. Knowledge of the general health of family members can also provide insight into their ability to provide functional assistance to the patient.

Review of Systems

A detailed review of organ systems should be done discover any problems or diseases not previously identified during the course of the history taking. Table 1-5 lists some questions that can be asked about each system.²⁴ Note that this list is not comprehensive, and more detailed questioning might be necessary.

Table 1-5 Sample Questions for the Review of Systems

System	Questions
Systemic	Any general symptoms such as fever, weight loss, fatigue, nausea, and poor appetite?
Skin	Any skin problems? Sores? Rashes? Growths? Itching? Changes in the hair or nails? Dryness?
Eyes	Any changes in vision? Pain? Redness? Double vision? Watery eyes? Dizziness?
Ears	How are the ears and hearing? Running ears? Poor hearing? Ringing ears? Discharge?
Nose	How are your nose and sinuses? Stuffy nose? Discharge? Bleeding? Unusual odors?
Mouth	Any problems with your mouth? Sores? Bad taste? Sore tongue? Gum trouble?
Throat and neck	Any problems with your throat and neck? Sore throat? Hoarseness? Swelling? Swallowing?
Breasts	Any problems with your breasts? Lumps? Nipple discharge? Bleeding? Swelling? Tenderness?
Pulmonary	Any problems with your lungs or breathing? Cough? Sputum? Bloody sputum? Pain in the chest on taking a deep breath? Shortness of breath?
Cardiovascular	Do you have any problems with your heart? Chest pain? Shortness of breath? Palpitations? Cough? Swelling of your ankles? Trouble lying flat in bed at night? Fatigue?
Gastrointestinal	How is your digestion? Any changes in your appetite? Nausea? Vomiting? Diarrhea? Constipation? Changes in your bowel habits? Bleeding from the rectum? Hemorrhoids?
Genitourinary	Male: Any problems with your kidneys or urination? Painful urination? Frequency? Urgency? Nocturia?
	Bloody or cloudy urine? Trouble starting or stopping?
	Female: Number of pregnancies? Abortions? Miscarriages? Any menstrual problems? Last menstrual period? Vaginal bleeding? Vaginal discharge? Cessation of periods? Hot flashes? Vaginal itching? Sexual dysfunction?
Endocrine	Any problems with your endocrine glands? Feeling hot or cold? Fatigue? Changes in the skin or hair? Frequent urination? Fatigue?
Musculoskeletal	Do you have any problems with your bones or joints? Joint or muscle pain? Stiffness? Limitation of motion?
Nervous system	Numbness? Weakness? Pins and needles sensation?

From Enelow AJ, Forde DL, Brummel-Smith K: Interviewing and patient care, ed 4, New York, 1996, Oxford University Press,²⁴ with permission of Oxford University Press.

The Physiatric Physical Examination

Neurologic Examination

Neurologic problems are common in the setting of inpatient and outpatient rehabilitation, including functional deficits in persons with such conditions as stroke, multiple sclerosis, peripheral neuropathy, spinal cord injury, brain injury, and neurologic cancers. The neurologic examination should be conducted in an organized fashion to confirm or reconfirm the neurologic disorder, and subsequently to identify which components of the nervous system are the most and the least affected. The precise location of the lesion should be identified, if possible, and the impact of the neurologic deficits on the overall function and mobility of the patient should be noted. If a cause of the patient’s condition has not been identified at presentation to the rehabilitation service, a differential diagnosis list should be developed, the neurologic examination tailored appropriately, and consultations garnered, if indicated. An accurate and efficient neurologic examination requires that the examiner have a thorough knowledge of both central and peripheral neuroanatomy before the examination.

Weakness is a primary sign in neurologic disorders and is seen in both upper (UMN) and lower motor neuron (LMN) disorders. UMN lesions involving the central nervous system (CNS) are typically characterized by hypertonia, weakness, and hyperreflexia without significant muscle atrophy, fasciculation, or fibrillation (on electromyography). They tend to occur in a hemiparetic, paraparetic, and tetraparetic pattern. UMN etiologies include stroke, multiple sclerosis, traumatic and nontraumatic brain and spinal cord injuries, and neurologic cancers, among others. LMN defects are characterized by hypotonia, weakness, hyporeflexia, significant muscle atrophy, fasciculations, and electromyographic changes. They occur in the distribution of the affected nerve root, peripheral nerve, or muscle. UMN and LMN lesions often coexist; however, the LMN system is the final common pathway of the nervous system. An example of this is an upper trunk brachial plexus injury on the same side as spastic hemiparesis in a person with traumatic brain injury.⁵¹

Mental Status Examination

The mental status examination (MSE) should be performed in a comfortable setting where the patient is not likely to be disturbed by external stimuli such as televisions, telephones, pagers, conversation, or medical alarms. The bedside MSE is often limited secondary to distractions from within the room. Having a familiar person such as a spouse or relative in the room can often help reassure the patient. The bedside MSE might need to be supplemented by far more detailed and standardized evaluations performed by neuropsychologists, especially in cases of vocational and educational reintegration (see Chapters 4 and 35). Language is the gateway to assessing cognition and is therefore limited in persons with significant aphasia.

Level of Consciousness

Consciousness is the state of awareness of one’s surroundings. A functioning pontine reticular activating system is necessary for normal conscious functioning. The conscious patient is awake and responds directly and appropriately to varying stimuli. Decreased consciousness can significantly limit the MSE and the general physical examination.

The examiner should understand the various levels of consciousness. Lethargy is the general slowing of motor processes (such as speech and movement) in which the patient can easily fall asleep if not stimulated, but is easily aroused. Obtundation is a dulled or blunted sensitivity in which the patient is difficult to arouse, and once aroused is still confused. Stupor is a state of semiconsciousness characterized by arousal only by intense stimuli such as sharp pressure over a bony prominence (e.g., sternal rub), and the patient has few or even no voluntary motor responses.⁵⁶ The Aspen Neurobehavioral Conference proposed, and several leading medical organizations have endorsed, three terms to describe severe alterations in consciousness.²⁹ In coma, the eyes are closed with absence of sleep-wake cycles and no evidence of a contingent relationship between the patient’s behavior and the environment.²⁹ Vegetative state is characterized by the presence of sleep-wake cycles but still no contingent relationship. Minimally conscious state indicates a patient who remains severely disabled but demonstrates sleep-wake cycles and even inconsistent, nonreflexive, contingent behaviors in response to a specific environmental stimulation. In the acute settings, the Glasgow Coma Scale is the most often used objective measure to document level of consciousness, assessing eye opening, motor response, and verbal response (Table 1-6).³⁹

Table 1-6 Glasgow Coma Scale

Function	Rating
Eye opening	E
Spontaneous	4
To speech	3
To pain	2
Nil	1
Best motor response	M
Obeys	6
Localizes	5
Withdraws	4
Abnormal flexion	3
Extensor response	2
Nil	1
Verbal response	V
Oriented	5
Confused conversation	4
Inappropriate words	3
Incomprehensible sounds	2
Nil	1
Coma score (E + M + V)	3-15

From Jennett B, Teasdale G: Assessment of impaired consciousness, Contemp Neurosurg 20:78, 1981 with permission.

Attention

Attention is the ability to address a specific stimulus for a short period without being distracted by internal or external stimuli.⁶⁵ Vigilance is the ability to hold attention over longer periods. For example, with inadequate vigilance a patient can begin a complex task but be unable to sustain performance to completion. Attention is tested by digit recall, where the examiner reads a list of random numbers and the patient is asked to repeat those numbers. The patient should repeat digits both forward and backward. A normal performance is repeating seven numbers in the forward direction, with fewer than five indicating significant attention deficits.^52,⁶⁵

Orientation

Orientation is necessary for basic cognition. Orientation is composed of four parts: person, place, time, and situation. After asking the patient’s name, place can be determined by asking the location the patient is currently in or her or his home address. Time is assessed by asking the patient the time of day, the date, the day of the week, or the year. Situation refers to why the patient is in the hospital or clinic. Time sense is usually the first component lost, and person is typically the last to be lost. Temporary stress can account for a minor loss of orientation; however, major disorientation usually suggests an organic brain syndrome.⁶⁹

Memory

The components of memory include learning, retention, and recall. During the bedside examination, the patient is typically asked to remember three or four objects or words. The patient is then asked to repeat the items immediately to assess immediate acquisition (encoding) of the information. Retention is assessed by recall after a delayed interval, usually 5 to 10 minutes. If the patient is unable to recall the words or objects, the examiner can provide a prompt (e.g., “It is a type of flower” for the word “tulip”). If the patient still cannot recall the words or objects, the examiner can provide a list from which the patient can choose (e.g., “Was it a rose, a tulip, or a daisy?”). Although abnormal scores must be interpreted within the context of the remaining neurologic examination, normal individuals younger than 60 years should recall three of four items.⁶⁵

Recent memory can also be tested by asking questions about the past 24 hours, such as “How did you travel here?” or “What did you eat for breakfast this morning?” Assuming the information can be confirmed, remote memory is tested by asking where the patient was born or the school or college attended.⁴⁶ Visual memory can be tested by having the patient identify (after a few minutes) four or five objects hidden in clear view.

General Fundamentals of Knowledge

Intelligence is a global function derived from the general tone and content of the examination and encompasses both basic intellect and remote memory. The examiner should note the patient’s educational level and highest grade completed during the history. Examples of questions that can be asked include names of important elected officials, such as the current president of the United States or recent past presidents. It can be very difficult to identify when a patient with a very high intelligence premorbidly drops to a more average level after injury or illness. The history of memory or intellectual decline from a family member or close friend should prompt further evaluation of the patient.

Abstract Thinking

Abstraction is a higher cortical function and can be tested by the interpretation of common proverbs such as “a stitch in time saves nine” or “when the cat’s away the mice will play,” or by asking similarities, such as “How are an apple and an orange alike?” A concrete explanation for the first proverb would be “You should sew a rip before it becomes bigger,” whereas an abstract explanation would be “Quick attention to a given problem would prevent bigger troubles later.” An abstract response to the similarity would be “They are both kinds of fruit,” and a concrete response would be “They are both round” or “You can eat them both.” Most normal individuals should be able to provide abstract responses. A patient also demonstrates abstraction when he or she understands a humorous phrase or situation. Concrete responses are given by persons with dementia, mental retardation, or limited education. Abstract thinking should always be considered in the context of intelligence and cultural differences.⁶⁹

Insight and Judgment

Insight has been conceptualized into three components: awareness of impairment, need for treatment, and attribution of symptoms. Insight can be ascertained by asking what brought the patient into the hospital or clinic.¹⁰ Recognizing that one has an impairment is the initial step for recovery. A lack of insight can severely hamper a patient’s progress in rehabilitation and is a major consideration in developing a safe discharge plan. Insight can be difficult to distinguish from psychological denial.

Judgment is an estimate of a person’s ability to solve real-life problems. The best indicator is usually simply observing the patient’s behavior. Judgment can also be assessed by noting the patient’s responses to hypothetical situations in relation to family, employment, or personal life. Hypothetical examples of judgment that reflect societal norms include “What should you do if you find a stamped, addressed envelope?” or “How are you going to get around the house if you have trouble walking?” Judgment is a complex function that is part of the maturational process and is consequently unreliable in children and variable in the adolescent years.⁶⁹ Assessment of judgment is important to assess the patient’s capacity for independent functioning.

Mood and Affect

Mood can be assessed by asking the “Yale question”: “Do you often feel sad or depressed?”⁷² Establishing accurate information pertaining to the length of a particular mood is important. The examiner should document if the mood has been reactive (e.g., sadness in response to a recent disabling event or loss of independence), and whether the mood has been stable or unstable. Mood can be described in terms of being, including happy, sad, euphoric, blue, depressed, angry, or anxious.

Affect describes how a patient feels at a given moment, which can be described by terms such as blunted, flat, inappropriate, labile, optimistic, or pessimistic. It can be difficult to accurately assess mood in the setting of moderate to severe acquired brain injury. A patient’s affect is determined by the observations made by the examiner during the interview.¹¹

General Mental Status Assessment

The Folstein Mini-Mental Status Examination is a brief and convenient tool to test general cognitive function. It is useful for screening patients for dementia and brain injuries. Of a maximum 30 points, a score 24 or above is considered within the normal range.²⁵ Also available is the easily administered Montreal Cognitive Assessment.⁵⁴ The clock-drawing test is another quick test sensitive to cognitive impairment. The patient is instructed to “Without looking at your watch, draw the face of a clock, and mark the hands to show 10 minutes to 11 o’clock.” This task uses memory, visual spatial skills, and executive functioning. The drawing is scored on the basis of whether the clock numbers are generally intact or not intact out of a maximum score of 10.⁶⁶ The use of the three-word recall test in addition to the clock-drawing test, which is known collectively as the Mini-Cog Test, has recently gained popularity in screening for dementia. The Mini-Cog can usually be completed within 2 to 3 minutes.⁶⁰ The reader is referred to other excellent descriptions of the MSE for further reading.⁶⁵

Communication

Aphasia

Aphasia involves the loss of production or comprehension of language. The cortical center for language resides in the dominant hemisphere. Naming, repetition, comprehension, and fluency are the key components of the physician’s bedside language assessment. The examiner should listen to the content and fluency of speech. Testing of comprehension of spoken language should begin with single words, progress to sentences that require only yes–no responses, and then progress to complex commands. The examiner should also assess visual naming, repetition of single words and sentences, word-finding abilities, and reading and writing from dictation and then spontaneously. Circumlocutions are phrases or sentences substituted for a word the person cannot express, such as responding “What you tell time with on your wrist” when asked to name a watch. Alexia without agraphia is seen in dominant occipital lobe injury. Here the patient is able to write letters and words from a spoken command but is unable to read the information after dictation.¹² Some commonly used standardized aphasia measures include the Boston Diagnostic Aphasia Examination and the Western Aphasia Battery (see Chapter 3).⁶⁷

Dysarthria

Dysarthria refers to defective articulation, but with the content of speech unaffected. The examiner should listen to spontaneous speech and then ask the patient to read aloud. Key sounds that can be tested include “ta ta ta,” which is made by the tongue (lingual consonants); “mm mm mm,” which is made by the lips (labial consonants); and “ga ga ga,” which is made by the larynx, pharynx, and palate.⁴⁶ There are several subtypes of dysarthria including spastic, ataxic, hypokinetic, hyperkinetic, and flaccid.⁵²

Dysphonia

Dysphonia is a deficit in sound production and can be secondary to respiratory disease, fatigue, or vocal cord paralysis. The best method to examine the vocal cords is by indirect laryngoscopy. Asking the patient to say “ah” while viewing the vocal cords is used to assess vocal cord abduction. When the patient says “e,” the vocal cords will adduct. Patients with weakness of both vocal cords will speak in whispers with the presence of inspiratory stridors.⁴⁶

Verbal Apraxia

Apraxia of speech involves a deficit in motor planning (i.e., awkward and imprecise articulation in the absence of impaired strength or coordination of the motor system). It is characterized by inconsistent errors when speaking. A difficult word might be spoken correctly, but trouble is experienced when repeating it. People with verbal apraxia of speech often appear to be “groping” for the right sound or word, and might try to speak a word several times before saying it correctly. Apraxia is tested by asking the patient to repeat words with an increasing number of syllables. Oromotor apraxia is seen in patients with difficulty organizing nonspeech, oral motor activity. This can adversely impact swallowing. Tests for oromotor apraxia include asking patients to stick out their tongue, show their teeth, blow out their cheeks, or pretend to blow out a match.¹

Cognitive Linguistic Deficits

Cognitive linguistic deficits involve the pragmatics and context of communication. Examples can include confabulation after a ruptured aneurysm of the anterior communicating artery, or disinhibited or sexually inappropriate comments from a patient with frontal lobe damage after a traumatic brain injury. Cognitive linguistic deficits are distinguished from fluent aphasias (Wernickeʼs) by the presence of relatively normal syntax and grammar.

Cranial Nerve Examination

Cranial Nerve I: Olfactory Nerve

The examiner should test both perception and identification of smell using aromatic nonirritating materials that avoid stimulation of the trigeminal nerve fibers in the nasal mucosa. Irritant substances such as ammonia should be avoided. The patient is asked to close the eyes while the opposite nostril is compressed separately. The patient should identify the smell in a test tube containing a common substance with a characteristic odor, such as coffee, peppermint, or soap. The olfactory nerve is the most commonly injured cranial nerve (CN) in head trauma, resulting from shearing injuries that can be associated with fractures of the cribiform plate.⁵

Cranial Nerve II: Optic Nerve

The optic nerve is assessed by testing for visual acuity and visual fields and by performing an ophthalmologic examination. Visual acuity refers to central vision, while visual field testing assesses the integrity of the optic pathway as it travels from the retina to the primary visual cortex. Testing visual fields by confrontation is most commonly performed. The patient faces the examiner while covering one eye so the other eye fixates on the opposite eye of the examiner directly in front. The examiner wiggles a finger at the outer boundaries of the four quadrants of vision while the patient points to the quadrant where he or she senses movement. More accurately, a red 5-mm pin can be used to map out the visual field.⁵ For patients with visual field and extraocular movement deficits (see following discussion), further assessment by a neurooptometrist or visually trained occupational therapists can be helpful.

Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens Nerves

These three cranial nerves are best tested together because they are all involved in ocular motility. The oculomotor nerve (III) provides innervation to all the extraocular muscles except the superior oblique and lateral rectus, which are innervated by the trochlear (IV) and abducens nerves (VI), respectively. The oculomotor nerve also innervates the levator palpebrae muscle, which elevates the eyelid, the pupilloconstrictor muscle that constricts the pupil, and the ciliary muscle that controls the thickness of the lens in visual accommodation.

The primary action of the medial rectus is adduction (looking in) and that of the lateral rectus is abduction (looking out). The superior rectus and inferior oblique primarily elevate the eye, whereas the inferior rectus and superior oblique depress the eye. The superior oblique muscle controls gaze looking down, especially in adduction.⁴⁶

Examination of the extraocular muscles involves assessing the alignment of the patient’s eyes while at rest and when following an object or finger held at an arm’s length. The examiner should observe the full range of horizontal and vertical eye movements in the six cardinal directions.⁵ The optic (afferent) and oculomotor (efferent) nerves are involved with the pupillary light reflex. A normal pupillary light reflex (CNs II and III) should result in constriction of both pupils when a light stimulus is present to either eye separately. A characteristic head tilt when looking down is sometimes seen in CN IV lesions.⁷⁵

Cranial Nerve V: Trigeminal Nerve

The trigeminal nerve provides sensation to the face and mucous membranes of the nose, mouth, and tongue. There are three sensory divisions of the trigeminal nerve: the ophthalmic, maxillary, and mandibular branches. These branches can be tested by pinprick sensation, light touch, or temperature along the forehead, cheeks, and jaw on each side of the face. The motor branch of the trigeminal nerve also innervates the muscles of mastication, which include the masseters, the pterygoids, and the temporalis. The patient is asked to clamp the jaws together, and then the examiner will try to open the patient’s jaw by pulling down on the lower mandible. Observe and palpate for contraction of both the temporalis and the masseter muscles. The pterygoids are tested by asking the patient to open the mouth. If one side is weak, the intact pterygoid muscles will push the weak muscles, resulting in a deviation toward the weak side. The corneal reflex tests the ophthalmic division of the trigeminal nerve (afferent) and the facial nerve (efferent).

Cranial Nerve VII: Facial Nerve

The facial nerve provides motor innervation to all muscles of facial expression; provides sensation to the anterior two thirds of the tongue and the external acoustic meatus; innervates the stapedius muscle, which helps dampen loud sounds by decreasing excessive movements of the ossicles in the inner ear; and provides secretomotor fibers to the lacrimal and salivary glands.

The facial nerve is first examined by watching the patient as she or he talks and smiles, watching specifically for eye closure, flattening of the nasolabial fold, and asymmetric elevation of one corner of the mouth. The patient is then asked to wrinkle the forehead (frontalis), close the eyes while the examiner attempts to open them (orbicularis oculi), puff out both cheeks while the examiner presses on the cheeks (buccinator), and show the teeth (orbicularis oris). A peripheral injury to the facial nerve, such as Bell’s palsy, affects both the upper and the lower face, whereas a central lesion typically affects mainly the lower face.

Cranial Nerve VIII: Vestibulocochlear Nerve

The vestibulocochlear nerve, also known as the auditory nerve, comprises two divisions. The cochlear nerve is the part of the auditory nerve responsible for hearing, while the vestibular nerve is related to balance. The cochlear division can be tested by checking gross hearing. A rapid screen can be done if the examiner rubs the thumb and index fingers near each ear of the patient. Patients with normal hearing usually have no difficulty hearing this.

The vestibular division is seldom included in the routine neurologic examination. Patients with dizziness or vertigo associated with changes in head position or suspected of having benign paroxysmal positional vertigo should be assessed with the Dix-Hallpike maneuver (Figure 1-1). The absence of nystagmus indicates normal vestibular nerve function. With peripheral vestibular nerve dysfunction, however, the patient complains of vertigo, and rotary nystagmus appears after an approximately 2- to 5-second latency, toward the direction in which the eyes are deviated. With repetition of maneuvers, the nystagmus and sensation of vertigo fatigue and ultimately disappear. In central vestibular disease, such as from a stroke, the nystagmus has latency and is nonfatigable.²⁶ Rehabilitation therapists with training in vestibular rehabilitation can also provide invaluable data for developing a differential diagnosis of balance deficits.

FIGURE 1-1 The Dix-Hallpike maneuver is performed with the patient initially seated upright. The patient is asked to fall backward so that the head is below the plane of his or her trunk. The examiner then turns the patient’s head to one side and asks the patient to look in the direction to which the head is turned.

Cranial Nerves IX and X: Glossopharyngeal Nerve and Vagus Nerve

The glossopharyngeal nerve supplies taste to the posterior one third of the tongue, along with sensation to the pharynx and the middle ear. The glossopharyngeal nerve and vagus nerve are usually examined together. The patient’s voice quality should be noted, as hoarseness is usually associated with a lesion of the recurrent laryngeal nerve, a branch of the vagus nerve. The patient is asked to open the mouth and say “ah.” The examiner should inspect the soft palate, which should elevate symmetrically with the uvula in midline. In an LMN vagus nerve lesion, the uvula will deviate to the side that is contralateral to the lesion. A UMN lesion presents with the uvula deviating toward the side of the lesion.³¹

The gag reflex can be tested by depressing the patient’s tongue with a tongue depressor and touching the pharyngeal wall with a cotton tip applicator until the patient gags. The examiner should compare the sensitivity of each side (afferent: glossopharyngeal nerve) and observe the symmetry of the palatal contraction (efferent: vagus nerve). The absence of a gag reflex indicates loss of sensation and/or loss of motor contraction. The presence of a gag reflex does not imply the ability to swallow without risk of aspiration (see Chapter 27).⁵⁷

Cranial Nerve XI: Accessory Nerve

The accessory nerve innervates the trapezius and sternocleidomastoid muscles. While standing behind the patient, the examiner should look for atrophy or spasm in the trapezius and compare the symmetry of both sides. To test the strength of the trapezius, the patient is asked to shrug the shoulders and hold them in this position against resistance. To test the strength of the sternocleidomastoid muscle, ask the patient to rotate the head against resistance. The ipsilateral sternocleidomastoid muscle turns the head to the contralateral side. The ipsilateral muscle brings the ear to the shoulder.

Cranial Nerve XII: Hypoglossal Nerve

The hypoglossal nerve is a pure motor nerve innervating the muscles of the tongue. It is tested by asking the patient to protrude the tongue, noting evidence of atrophy, fasciculation, or deviation. Fibrillations in the tongue are common in patients with amyotrophic lateral sclerosis.³⁰ The tongue typically points to the side of the lesion in peripheral hypoglossal nerve lesions, but toward the opposite side of the lesion in UMN lesions such as stroke.

Sensory Examination

The examiner should be familiar with the normal dermatomal and peripheral nerve sensory distribution (Figure 1-2). Evaluation of the sensory system requires testing of both superficial sensation (light touch, pain, and temperature) and deep sensation (involves the perception of position and vibration from deep structures such as muscle, ligaments, and bone).

FIGURE 1-2 Distribution of peripheral nerves and dermatomes.

(Redrawn from Haymaker W, Woodhall B: Peripheral nerve injuries, Philadelphia, 1953, Saunders, with permission.)

Light touch can be assessed with a fine wisp of cotton or a cotton tip applicator. The examiner should touch the skin lightly, avoiding excessive pressure. The patient is asked to respond when a touch is felt, and to say whether there is a difference between the two sides. Pain and temperature both travel via the spinothalamic tracts and are assessed using a safety pin or other sharp sanitary object, while occasionally interspersing the examination with a blunt object. Patients with peripheral neuropathy might have a delayed pain appreciation and often change their minds a few seconds after the initial stimuli. Some examiners use the single or double pinprick of brief duration to test for pain, while others use a continuous sustained pinprick to better test for delayed pain.⁵⁰ Temperature testing is not often used and rarely provides additional information, but it is sometimes easier for patients to delineate insensate areas. Thermal sensation can be checked by using two different test tubes, one filled with hot water (not hot enough to burn) and one filled with cold water and ice chips.

Joint position sense or proprioception travel via the dorsal columns along with vibration sense. Proprioception is tested by vertical passive movement of the toes or fingers. The examiner holds the sides of the patient’s fingers or toes and asks the patient if the digits are in the upward or downward direction. It is important to grasp the sides of the digits rather than the nailbed, because the patient might be able to perceive pressure in these areas, reducing the accuracy of the examination. Most normal persons make no errors on these maneuvers.

Vibration is tested in the limbs with a 128-Hz tuning fork. The tuning fork is placed on a bony prominence such as the dorsal aspect of the terminal phalange of the great toe or finger, the malleoli, or the olecranon. The patient is asked to indicate when the vibration ceases. The vibration stimulus can be controlled by changing the force used to set the tuning fork in motion, or by noting the amount of time that a vibration is felt as the stimulus dissipates. Assuming the examiner is normal, both patient and examiner should feel the vibration cease at approximately the same time.

Two-point discrimination is most commonly tested using calipers with blunt ends. The patient is asked to close the eyes and indicate if one or two stimulation points are felt. The normal distance of separation that can be felt as two distinct points depends on the area of body being tested. For example, the lips are sensitive to a point separation of 2 to 3 mm, normally identified as two points. Commonly tested normal two-point discrimination areas include the fingertips (3 to 5 mm), the dorsum of the hand (20 to 30 mm), and the palms (8 to 15 mm).⁴⁶

Graphesthesia is the ability to recognize numbers, letters, or symbols traced onto the palm. It is performed by writing recognizable numbers on the patient’s palm with his or her eyes closed. Stereognosis is the ability to recognize common objects placed in the hand, such as keys or coins. This requires normal peripheral sensation as well as cortical interpretation.

Motor Control

Strength

Manual muscle testing provides an important method of quantifying strength and is outlined in the musculoskeletal examination section below.

Coordination

The cerebellum controls movement by comparing the intended activity with actual activity that is achieved. The cerebellum smoothes motor movements and is intimately involved with coordination. Ataxia or motor coordination can be secondary to deficits of sensory, motor, or cerebellar connections. Ataxic patients who have intact function of the sensory and motor pathways usually have cerebellar compromise.

The cerebellum is divided into three areas: the midline, the anterior lobe, and the lateral hemisphere. Lesions affecting the midline usually produce truncal ataxia in which the patient cannot sit or stand unsupported. This can be tested by asking the patient to sit at the edge of the bed with the arms folded so they cannot be used for support. Lesions that affect the anterior lobe usually result in gait ataxia. In this case, the patient is able to sit or stand unsupported but has noticeable balance deficits on walking. Lateral hemisphere lesions produce loss of ability to coordinate movement, which can be described as limb ataxia. The affected limb usually has diminished ability to correct and change direction rapidly. Tests that are typically used to test for limb coordination include the finger-to-nose test and the heel-to-shin test.⁵¹

Rapid alternating movements can be tested by observing the amplitude, rhythm, and precision of movement. The patient is asked to place the hands on the thighs and then rapidly turn the hands over and lift them off the thighs for 10 seconds. Normal individuals can do this without difficulty. Dysdiadochokinesis is the clinical term for an inability to perform rapidly alternating movements.

The Romberg test can be used to differentiate a cerebellar deficit from a proprioceptive one. The patient is asked to stand with the heels together. The examiner notes any excessive postural swaying or loss of balance. If loss of balance is present when the eyes are open and closed, the examination is consistent with cerebellar ataxia. If the loss of balance occurs only when the eyes are closed, this is classically known as a positive Romberg sign indicating a proprioceptive (sensory) deficit.⁴⁶

Apraxia

Apraxia is the loss of the ability to carry out programmed or planned movements despite adequate understanding of the tasks. This deficit is present even though the patient has no weakness or sensory loss. To accomplish a complex act, there first must be an idea or a formulation of a plan. The formulation of the plan then must be transferred into the motor system where it is executed. The examiner should watch the patient for motor-planning problems during the physical examination. For example, a patient might be unable to perform transfers and other mobility tasks but has adequate strength on formal manual muscle testing.

Ideomotor apraxia associated with a lesion of the dominant parietal lobe occurs when a patient cannot carry out motor commands but can perform the required movements under different circumstances. These patients usually can perform many complex acts automatically but cannot carry out the same acts on command. Ideational apraxia refers to the inability to carry out sequences of acts, although each component can be performed separately. Other forms of apraxia are constructional, dressing, oculomotor, oromotor, verbal, and gait apraxia. Dressing and constructional apraxia are often related to impairments of the nondominant parietal lobe, which typically are the result of neglect rather than actual deficit in motor planning.⁴⁶

Involuntary Movements

Documenting involuntary movements is important in the overall neurologic examination. A careful survey of the patient usually shows the presence or absence of voluntary motor control. Tremor is the most common type of involuntary movement and is a rhythmic movement of a body part. Lesions in the basal ganglia produce characteristic movement disorders. Chorea describes movements that consist of brief, random, nonrepetitive movements in a fidgety patient unable to sit still. Athetosis consists of twisting and writhing movements and is commonly seen in cerebral palsy. Dystonia is a sustained posturing that can affect small or large muscle groups. An example is torticollis, in which dystonic neck muscles pull the head to one side. Hemiballismus occurs when there are repetitive violent flailing movements that are usually caused by deficits in the subthalamic nucleus.⁵²

Tone

Tone is the resistance of muscle to stretch or passive elongation (see Chapter 30). Spasticity is a velocity-dependent increase in the stretch reflex, whereas rigidity is the resistance of the limb to passive movement in the relaxed state (non–velocity dependent). Variability in tone is common, as patients with spasticity can vary in their presentation throughout the day and with positional changes or mood. Some patients will demonstrate little tone at rest (static tone) but experience a surge of tone when they attempt to move the muscle during a functional activity (dynamic tone). Accurate assessment of tone might require repeated examinations.⁵⁶

Initial observation of the patient usually shows abnormal posturing of the limbs or trunk. Palpation of the muscle also provides clues, because hypotonic muscles feel soft and flaccid on palpation, whereas hypertonic muscles feel firm and tight. Passive range of motion (ROM) provides information about the muscle in response to stretch. The examiner provides firm and constant contact while moving the limbs in all directions. The limb should move easily and without resistance when altering the direction and speed of movement. Hypertonic limbs feel stiff and resist movement, while flaccid limbs are unresponsive. The patient should be told to relax because these responses should be examined without any voluntary control. Clonus is a cyclic alternation of muscular contraction in response to a sustained stretch, and is assessed using a quick stretch stimulus that is then maintained. Myoclonus refers to sudden, involuntary jerking of a muscle or group of muscles. Myoclonic jerks can be normal because they occasionally happen in normal individuals and are typically part of the normal sleep cycle. Myoclonus can result from hypoxia, drug toxicity, and metabolic disturbances. Other causes include degenerative disorders affecting the basal ganglia and certain dementias.⁶¹

Tone can be quantified by the Modified Ashworth Scale, a six-point ordinal scale. A pendulum test can also be used to quantify spasticity. While in the supine position, the patient is asked to fully extend the knee and then allow the leg to drop and swing like a pendulum. A normal limb swings freely for several cycles, whereas a hypertonic limb quickly returns to the initial dependent starting position.⁶⁷

The Tardieu Scale has been suggested to be a more appropriate clinical measure of spasticity than the Modified Ashworth Scale. It involves assessment of resistance to passive movement at both slow and fast speeds. Measurements are usually taken at 3 velocities (V1, V2, and V3). V1 is taken as slow as possible, slower than the natural drop of the limb segment under gravity. V2 is taken at the speed of the limb falling under gravity. V3 is taken with the limb moving as fast as possible, faster than the natural drop of the limb under gravity. Responses are recorded at each velocity and the degrees of angle at which the muscle reaction occurs.³⁴

Reflexes

Superficial Reflexes

The plantar reflex is the most common superficial reflex examined. A stimulus (usually by the handle end of a reflex hammer) is applied on the sole of the foot from the lateral border up and across the ball of the foot. A normal reaction consists of flexion of the great toe or no response. An abnormal response consists of dorsiflexion of the great toe with an associated fanning of the other toes. This response is the Babinski sign and indicates dysfunction of the corticospinal tract but no further localization. Stroking from the lateral ankle to the lateral dorsal foot can also produce dorsiflexion of the great toe (Chaddock sign). Flipping the little toe outward can produce the upgoing great toe also, and is called the Stransky sign. Other superficial reflexes include the abdominal, cremasteric, bulbocavernous, and superficial anal reflexes (Table 1-7).⁵²

Table 1-7 Important Normal Superficial Reflexes

Muscle Stretch Reflexes

Muscle stretch reflexes (which in the past were called deep tendon reflexes) are assessed by tapping over the muscle tendon with a reflex hammer (Table 1-8). In order to elicit a response, the patient is positioned into the midrange of the arc of joint motion and instructed to relax. Tapping of the tendon results in visible movement of the joint. The response is assessed as 0, no response; 1+, diminished but present and might require facilitation; 2+, usual response; 3+, more brisk than usual; and 4+, hyperactive with clonus. If muscle stretch reflexes are difficult to elicit, the response can be enhanced by reinforcement maneuvers such as hooking together the fingers of both hands while attempting to pull them apart (Jendrassik maneuver). While pressure is still maintained, the lower limb reflexes can be tested. Squeezing the knees together and clenching the teeth can reinforce responses to the upper limbs.⁴⁶

Table 1-8 Muscle Stretch Reflexes

Muscle	Peripheral nerve	Root level
Biceps	Musculocutaneous nerve	C5, C6
Brachioradialis	Radial nerve	C5, C6
Triceps	Radial nerve	C7, C8
Pronator teres	Median nerve	C6, C7
Patella (quadriceps)	Femoral nerve	L2–L4
Medial hamstrings	Sciatic (tibial portion) nerve	L5–S1
Achilles	Tibial nerve	S1, S2

Primitive Reflexes

Primitive reflexes are abnormal adult reflexes that represent a regression to a more infantile level of reflex activity. Redevelopment of an infantile reflex in an adult suggests significant neurologic abnormalities. Examples of primitive reflexes include the sucking reflex, in which the patient sucks the area around which the mouth is stimulated. The rooting reflex is elicited by stroking the cheek, resulting in the patient turning toward that side and making sucking motions with the mouth. The grasp reflex occurs when the examiner places a finger on the patient’s open palm. Attempting to remove the finger causes the grip to tighten. The snout reflex occurs when a lip-pursing movement occurs when there is a tap just above or below the mouth. The palmomental response is elicited by quickly scratching the palm of the hand. A positive reflex is indicated by sudden contraction of the mentalis (chin) muscle. It arises from unilateral damage of the prefrontal area of the brain.⁵³

Gait

Gait evaluation is an important and often neglected part of the neurologic evaluation. Gait is described as a series of rhythmic, alternating movements of the limbs and trunks that result in the forward progression of the center of gravity.⁹ Gait is dependent on input from several systems including the visual, vestibular, cerebellar, motor, and sensory systems. The cause of dysfunction can be determined by understanding the aspects of gait involved. One example is difficulty getting up, which is consistent with Parkinson’s disease, or a lack of balance and wide-based gait, which is suggestive of cerebellar dysfunction.

The examination starts by asking the patient to walk across the room in a straight line. This can also be assessed by observing the patient walking from the waiting area into the examination room. The patient is then asked to stand from a chair, walk across the room, and come back toward the examiner. The examiner should pay particular attention to the following:

1. Ease of arising from a seated position. Can the patient easily arise from a sitting position? Difficulty with a sit-to-stand task may indicate proximal muscle weakness, movement disorders with difficulty initiating movements, or a balance problem.

2. Balance. Does the patient lean or veer off to one side, which is an indication of cerebellar dysfunction? Patients with medullary lesions and cerebellar lesions tend to push to the side of the lesion. Diffuse disease affecting both cerebellar hemispheres can cause a generalized loss of balance. Patients with cerebellar disorders usually have balance issues with or without their eyes open. Patients with proprioceptive dysfunction can use their visual input to compensate for their sensory deficit.

3. Walking speed. Does the patient start off slow and then accelerate uncontrollably? Patients with Parkinson’s disease will have problems initiating movements, but then lose their balance once they are in motion. Patients with pain such as knee or hip arthritis often have limitations of ROM affecting gait speed. It has been shown that a self-selected gait speed of less than 0.8 m/s is a risk factor for falls in the stroke population.⁵⁹ The speed of walking remains stable until about age 70 when there is a 15% decline per decade. Gait speed is lower because elderly people take shorter steps. ⁷

4. Stride and step length. Does the patient take a small step or shuffle while walking? Patients with normal pressure hydrocephalus and Parkinson’s disease usually take small steps or shuffle (decreasing their step and stride length). Stride length is the linear distance between successive corresponding points of heel contact of the same foot, whereas step length is the distance between corresponding successive contact points of opposite feet.⁹ An average step length is approximately 2 feet for women and 2.5 feet for men.⁷³

5. Attitude of arms and legs. How does the patient hold his or her arms and legs? Loss of movement as in a spastic or contracted patient should be assessed. Patients with knee extension weakness might swing their knees into terminal extension, thereby locking their knee (genu recurvatum). The patient is then asked to also walk heel to toe in a straight line. Ask the patient to walk in a straight line by putting one heel of one foot directly in front of the toe of the other. This is also called tandem gait and is a test of higher balance. Tandem gait can be difficult for older patients, and in some other medical conditions (even without neurologic disease). Other tests to assess gait function include observing patients walk on their toes and heels. Balance can also be assessed by asking patients to hop in place and to do a shallow knee bend. Gait disorders have stereotypical patterns that reflect injury to various aspects of the neurologic system (Table 1-9).

Table 1-9 Common Gait Disturbances

Gait Type	Disease or Anatomic Location	Gait Characteristics
Hemiplegic	Unilateral upper motor neuron lesions with spastic hemiplegia	The affected lower limb is difficult to move, and knee is held in extension. With ambulation, the leg swings away from the center of the body, and the hip hikes upward to prevent the toes and foot from striking the floor. This is known as “circumduction.” If the upper limb is involved, there may be decreased arm swing with ambulation.³⁰ The upper limb has a flexor synergy pattern resulting in shoulder adduction, elbow and wrist flexion, and a clinched fist.
Scissoring	Bilateral corticospinal tract lesions often seen in patients with cerebral palsy, incomplete spinal cord injury, and multiple sclerosis	Hypertonia in the legs and hips results in flexion and the appearance of a crouched stance. The hip adductors are overactive causing the knees and thighs to touch or cross in a “scissor-like” movement. In cerebral palsy, there can be associated ankle plantar flexion forcing the patient to tiptoe walk. The step length is shortened by the severe adduction or scissoring of the hip muscles.³⁰
Ataxic	Cerebellar dysfunction or severe sensory loss (such as tabes dorsalis)	Ataxic gait is characterized by a broad-based stance and irregular step and stride length. In ataxic gait from proprioceptive dysfunction (tabes dorsalis), gait will markedly worsen with the eyes closed. There is a tendency to sway, while watching the floor usually helps guide the uncertain steps. Ataxic gait from cerebellar dysfunction will not worsen with eyes closed. Movement of the advancing limb starts slowly, and then there is an erratic movement forward or laterally. The patient will try to correct the error but usually overcompensates. Tandem gait exacerbates cerebellar ataxia.⁷⁴
Myopathic	Myopathies cause weakness of the proximal leg muscles.	Myopathies result in a broad-based gait and a “waddling-type” appearance as the patient tries to compensate for pelvic instability. Patients will have problems with climbing stairs or rising from a chair without using their arms. When going floor to standing, the patient will use their arms and hands to climb up their legs—known as Gower’s sign.¹³
Trendelenberg	Caused by weakness of the abductor muscles (gluteus medius and gluteal minimus) as in superior gluteal nerve injury, poliomyelitis, or myopathy	During the stance phase, the abductor muscle allows the pelvis to tilt down on the opposite side. In order to compensate, the trunk lurches to the weakened side to maintain the pelvis level during the gait cycle. This results in a waddling-type gait with an exaggerated compensatory sway of the trunk toward the weight-bearing side. It is important to understand that the pelvis sags on the opposite side of the weakened abductor muscle.¹³
Parkinsonian	Seen in Parkinson’s disease and other disorders of the basal ganglia	Patients have a stooped posture, narrow base of support, and a shuffling gait with small steps. As the patient starts to walk, the movements of the legs are usually slow with the appearance of the feet sticking to the floor. They might lean forward while walking so the steps become hurried, resulting in shuffling of the feet (festination). Starting, stopping, or changing directions quickly is difficult, and there is a tendency for retropulsion (falling backwards when standing). The whole body moves rigidly requiring many short steps and there is loss of normal arm swing. There can be a “pill-rolling” tremor while the patient walks.⁷⁴
Steppage	Diseases of the peripheral nervous system including L5 radiculopathy, lumbar plexopathies, and peroneal nerve palsy	The patient with foot drop has difficulty dorsiflexing the ankle. The patient compensates for the foot drop by lifting the affected extremity higher than normal to avoid dragging the foot. Weak dorsiflexion leads to poor heel strike with the foot slapping on the floor.³⁰ An ankle-foot orthosis can be helpful.
Apraxic	Gait impairment when there is no evidence of sensory loss, weakness, vestibular dysfunction, or cerebellar deficit; seen in frontal lobe injuries such as a stroke and traumatic brain injury	Despite difficulty with ambulation, patients can perform complex coordinated activities with the lower limbs.⁷⁰

Musculoskeletal Examination

Caveats

The musculoskeletal examination (MSK examination) confirms the diagnostic impression and lays the foundation for the physiatric treatment plan. It incorporates inspection, palpation, passive and active ROM, assessment of joint stability, manual muscle testing and joint-specific provocative maneuvers, or special tests (Table 1-10).^28,^35,⁴⁸ The functional unit of the musculoskeletal system is the joint. The comprehensive examination of a joint includes related structures such as muscles, ligaments, and the synovial membrane and capsule.⁶³ The physiatric MSK examination also indirectly tests coordination, sensation, and endurance.^28,⁴⁴ There is overlap between the examination (and clinical presentation) of the neurologic and musculoskeletal systems. The primary impairment in many cases in neurologic disease is the secondary musculoskeletal complications of immobility and suboptimal movement (in which the concept of the kinetic chain is important for evaluation). The MSK examination should be performed in a routine sequence for efficiency and consistency, and must be approached with a solid knowledge of the anatomy. The reader is referred to several excellent references that provide in-depth reviews of the MSK examination.^∗

Table 1-10 Musculoskeletal Provocative Maneuvers

Test	Description	Reliability (%)
Cervical Spine Tests
Spurling’s/neck compression test	A positive test is reproduction of radicular symptoms distant from the neck with passive lateral flexion and compression of the head.	Sensitivity: 40-60 Specificity: 92-100

Shoulder abduction (relief) sign A positive test is relief or reduction of ipsilateral cervical radicular symptoms with active abduction of the ipsilateral arm with the hand on the head.

Sensitivity: 43-50

Specificity: 80-100

Neck distraction test A positive test is relief or reduction of cervical radicular symptoms with an axial traction force applied by the examiner under the occiput and the chin while the patient is supine.

Sensitivity: 40-43

Specificity: 100%

Lhermitte’s sign A positive test is the presence of electric-like sensations down the extremities with passive cervical forward flexion.

Sensitivity: <28

Specificity: high

Hoffmann’s sign A positive test is flexion-adduction of ipsilateral thumb and index finger with passive snapping flexion of the distal phalanx of the middle finger.

Sensitivity: 58

Specificity: 78

Thoracic Outlet Tests Adson’s test A positive test is a decrease or obliteration of the ipsilateral radial pulse with inspiration, chin elevation, and head rotation to the ipsilateral side.

Specificity: 18-87

Sensitivity: 94

Wright’s hyperabduction test A positive test is obliteration of the palpated radial pulse at the wrist when the ipsilateral arm is elevated to 90 degrees. Unavailable Roos test A positive test reproduces the patient’s usual upper limb symptoms within 3 minutes of moderate opening and closing of the fist with the arms and elbows flexed to 90 degrees. Unavailable Costoclavicular test A positive test is indicated by a reduction in the radial pulse with shoulder retraction and depression as well as chest protrusion for 1 minute. Unavailable Rotator Cuff/Supraspinatus Tests Empty can/supraspinatus test A positive test is pain or weakness in the ipsilateral shoulder with resisted abduction of the shoulder, which is in internal rotation, with the thumb pointing toward the floor, and a forward angulation of 30 degrees.

Sensitivity: 79

Specificity: 38-50

Drop arm test A positive test is noted if the patient is unable to return the arm to the side slowly or has severe pain after the examiner abducts the patient’s shoulder to 90 degrees and then asks the patient to slowly lower the arm to the side. Unavailable Rotator Cuff/Infraspinatus and Teres Minor Tests Patte’s test A positive test is pain or inability to support the arm or rotate the arm laterally with the elbow at 90 degrees and the arm at 90 degrees of forward elevation in the plane of the scapula. This indicates tears of the infraspinatus and/or teres minor muscles.

Sensitivity: 36-71

Specificity: 71-91

Lift-off test A positive test is the inability to lift the dorsum of his hand off the back with the arm internally rotated behind the back as starting position. This indicates subscapularis pathology.

Sensitivity: 50

Specificity: 84-95

Scapular Tests Lateral scapular slide test This test allows for identification of scapulothoracic motion deficiencies using the contralateral side as an internal control The reference point used is the nearest spinous process. A scapulothoracic motion abnormality is noted if there is at least a 1-cm difference. The first position of the test is with the arm relaxed at the side. The second is with the hands on the hips with the fingers anterior and the thumb posterior with about 10 degrees of shoulder extension. The third position is with the arms at or below 90 degrees of arm elevation with maximal internal rotation at the glenohumeral joint. These positions offer a graded challenge to the functioning of the shoulder muscles to stabilize the scapula.

Sensitivity: 28-50

Specificity: 48-58

Isometric pinch test Used to evaluate scapular muscle strength. The patient is asked to retract the scapula into an “isometric pinch.” Scapular muscle weakness can be noted as a burning pain in less than 15 seconds. Normally, the scapula can be held in this position for 15 to 20 seconds with no discomfort. Unavailable Scapular assistance test A positive test is when symptoms of impingement, clicking, or rotator cuff weakness are improved when assisting the lower trapezius by manually stabilizing the upper medial border (of the scapula) and rotating the inferomedial border as the arm is abducted or adducted. Unavailable Scapular retraction test The test involves manually positioning and stabilizing the entire medial border of the scapula, which indicates trapezius and rhomboid weakness. The test is positive when there is increased muscle strength or decreased pain or signs of impingement with the scapula in the stabilized position. Unavailable Biceps Tendon Tests Yergason’s test The test is done with the elbow flexed to 90 degrees, with the forearm in pronation. The examiner holds the patient’s wrist to resist supination and then directs active supination be made against his or her resistance. Pain that localizes in the bicipital groove indicates pathology of the long head of the biceps. It can also be positive in fractures of the lesser tuberosity of the humerus.

Sensitivity: 37

Specificity: 86

Speed’s test A positive test is pain in the bicipital groove with resisted anterior flexion of the shoulder with extension of the elbow and forearm supination.

Sensitivity: 68-69

Specificity: 14-55

Shoulder Impingement Tests Neer’s sign test The test is positive if pain is reproduced with forward flexion of the arm in internal rotation or in the anatomic position of external rotation. The pain is thought to be caused by impingement of the rotator cuff by the undersurface of the anterior margin of the acromion or coracoacromial ligament.

Sensitivity: 75-88

Specificity: 31-51

Hawkin’s test This test is positive if there is pain with forward flexion of the humerus to 90 degrees with forcible internal rotation of the shoulder. This drives the greater tuberosity under the coracoacromial ligament resulting in rotator cuff impingement.

Sensitivity: 83-92

Specificity: 38-56

Yocum’s test This test is positive if there is pain with raising the elbow while the ipsilateral hand is on the contralateral shoulder. Unavailable Shoulder Stability Tests Apprehension test The test is positive if there is pain or apprehension while the shoulder is moved passively into maximal external rotation while in abduction followed by forward pressure applied to the posterior aspect of the humeral head. This test can be done either in the standing or supine position.

Sensitivity: 69

Specificity: 50

Fowler’s sign The examiner performs the apprehension test and at the point where the patient feels pain or apprehension the examiner applies a posteriorly directed force to the humeral head. If the pain persists despite the posteriorly applied force, it is primary impingement. If there is full pain-free external range, it is a result of instability.

Sensitivity: 30-68

Specificity: 44-100

Load and shift test The scapula is stabilized by securing the coracoid and the spine of the scapula with one hand with the patient in a sitting or supine position. The humeral head is then grasped with the other hand to glide it anteriorly and posteriorly. The degree of glide is graded mild, moderate, or severe.

Sensitivity: 91

Specificity: 93

Labral Pathology Tests Active compression test (O’Brien) The patient is asked to forward flex the affected arm 90 degrees with the elbow in full extension. The patient then adducts the arm 10 to 15 degrees medial to the sagittal plane of the body with the arm internally rotated so the thumb is pointed downward. The examiner then applies downward force to the arm. With the arm in the same position, the palm is then supinated and the maneuver is repeated. The test is considered positive if pain is elicited with the first maneuver and is reduced or eliminated with the second maneuver.

Sensitivity: 32-100

Specificity: 13-98.5

Crank test With the patient in an upright position, the arm is elevated to 160 degrees in the scapular plane. Joint load is applied along the axis of the humerus with one hand while the other performs humeral rotation. A positive test is when there is pain during the maneuver during external rotation with or without a click, or reproduction of the symptoms. The test should be repeated in the supine position when the muscles are more relaxed.

Sensitivity: 46-91

Specificity: 56-100

Compression-rotation test With the patient supine, the shoulder is abducted to 90 degrees, and the elbow flexed at 90 degrees. A compression force is applied to the humerus, which is then rotated, in an attempt to trap the torn labrum with reproduction of a snap or catch.

Sensitivity: 80

Specificity: 19-49

Acromioclavicular Joint Tests Apley scarf test A positive test is pain at the acromioclavicular joint with passive adduction of the arm across the sagittal midline attempting to approximate the elbow to the contralateral shoulder. Unavailable Lateral and Medial Epicondylitis Tests Resisted wrist extension For lateral elbow pain, the test is positive if pain is worsened with extension of the wrist against resistance. Unavailable Resisted wrist flexion and pronation This test is positive if medial epicondylar pain is reproduced with forced wrist extension as the patient maintains the elbow in 90 degrees of flexion, with the forearm supinated with the wrist flexed. A positive test indicates involvement of the flexor carpi radialis tendon. Medial elbow pain is most exacerbated with the elbow flexed. Unavailable Elbow Stability Tests Posterolateral rotatory instability This test is used to uncover a dislocated radiohumeral joint, which manifests as an obvious dimpling of the skin, generally at a maximum of 40 degrees of elbow flexion. The test is accomplished starting with the patient’s forearm in full supination with the elbow in full extension, the examiner slowly flexes the elbow while applying valgus and supination moments and an axial compression force, producing a rotary subluxation of the ulnohumeral joint. Unavailable Varus stress This test is positive if there is excessive gapping on the lateral aspect of the elbow joint. The arm is placed in 20 degrees of flexion with slight supination beyond neutral. The examiner gently stresses the lateral side of the elbow joint. Unavailable Jobe’s test (valgus stress) This test is positive if there is excessive gapping on the medial aspect of the elbow joint. The elbow is placed in 25 degrees of flexion to unlock the olecranon from its fossa. The examiner gently stresses the medial side of the elbow joint. Unavailable Carpal Ligament and Joint Tests Reagan’s test (lunotriquetral ballottement test) The lunate is fixed with the thumb and index finger of one hand while the other hand displaces the triquetrum and pisiform first dorsally then palmarly.

Sensitivity: 64

Specificity: 44

Watson’s test (scaphoid shift test) With the forearm slightly pronated, the examiner grasps the wrist from the radial side, placing his thumb on the palmar prominence of the scaphoid and wrapping his fingers around the distal radius. The examiners other hand grasps at the metacarpal level, controlling wrist position. Starting in ulnar deviation and slight extension, the wrist is moved radially and slightly flexed, with constant pressure on the scaphoid.

Sensitivity: 69

Specificity: 64

Shear test to assess the lunate triquetral ligament The examiner’s contralateral fingers are placed over the dorsum of the lunate. With the lunate supported, the examiner’s ipsilateral thumb loads the pisotriquetral joint from the palmar aspect, creating a shear force at the lunate-triquetral joint. Unavailable Ulnocarpal stress Pronation and supination of the forearm with ulnar deviation of hand generally evokes the wrist symptoms. Unavailable Finkelstein test This test is positive if there is pain at the styloid process of the radius as the patient places the thumb within the hand, which is held tightly by the fingers, followed by ulnar deviation of the hand. Unavailable Thumb basilar joint grind test The basal joint grind test is performed by stabilizing the triquetrum with the thumb and index finger and then dorsally subluxing the thumb metacarpal on the trapezium while providing compressive force with the other hand. Unavailable Median Nerve Tests at the Wrist Carpal compression test This test consists of gentle, sustained, firm pressure to the median nerve of each hand simultaneously. Within a short time (15 seconds to 2 minutes) the patient will complain of reproduction of pain, paresthesia, and/or numbness in the symptomatic wrist(s).

Sensitivity: 87

Specificity: 90

Phalen’s test (wrist flexion) This test is positive if there is numbness and paresthesia in the fingers. The patient is asked to hold the forearms vertically and to allow both hands to drop into flexion at the wrist for approximately 1 minute.

Sensitivity: 71-80

Specificity: 20-80

Wrist extension test (reverse Phalen’s test) The patient is asked to keep both wrists in complete dorsal extension for 1 minute. If numbness and tingling were produced or exaggerated in the median nerve distribution of the hand within 60 seconds, the test is judged to be positive.

Sensitivity: 43

Specificity: 74

Tinel’s sign at the wrist This test is positive if there is numbness and paresthesia in the fingers. It is done by extending the wrist and tapping in a proximal to distal direction over the median nerve as it passes through the carpal tunnel, from the area of the distal wrist crease, 2 to 3 cm toward the area between the thenar and hypothenar eminences.

Sensitivity: 25-44

Specificity: 94-98

Lumbar Spine Motion Tests Schober test The first sacral spinous process is marked, and a mark is made about 10 cm above this mark. The patient then flexes forward, and the increased distance is measured. Unavailable Modified Schober test A point is drawn with a skin marker at the spinal intersection of a line joining the dimples of Venus (S1). Additional marks are made 10 cm above and 5 cm below S1. Subjects are asked to bend forward, and the distance between the marks 10 cm above and 5 cm below S1 is measured.

Specificity: 95

Sensitivity: 25

Lumbar Disk Herniation Tests Straight-leg raise The supine patient’s leg is raised with the knee extended until the patient begins to feel pain, and the type and distribution of the pain as well as the angle of elevation are recorded. The test is positive when the angle is between 30 and 70 degrees and pain is reproduced down the posterior thigh below the knee.

Sensitivity:72-97

Specificity: 11-66

Crossed straight-leg raise The supine patient’s contralateral leg is raised with the knee extended until the patient begins to feel pain in the ipsilateral leg, and the type and distribution of the pain as well as the angle of elevation are recorded. The test is positive when the angle is between 30 and 70 degrees and pain is reproduced down the ipsilateral posterior thigh below the knee.

Sensitivity: 23-29

Specificity: 88-100

Bowstring sign After a positive straight-leg raise, the knee is slightly flexed while pressure is applied to the tibial nerve in the popliteal fossa. Compression of the sciatic nerve reproduces leg pain. Sensitivity: 71 Slump test The patient is seated with legs together and knees against the examining table. The patient slumps forward as far as possible, and the examiner applies firm pressure to bow the subject’s back while keeping sacrum vertical. The patient is then asked to flex the head, and pressure is added to the neck flexion. Last, the examiner asks the subject to extend the knee, and dorsiflexion at the ankle is added. Unavailable Ankle dorsiflexion test (Braggard’s sign) After a positive straight-leg raise, the leg is dropped to a nonpainful range, and the ipsilateral ankle is dorsiflexed, reproducing the leg pain. Sensitivity: 78-94 Femoral nerve stretch test With the patient prone, the knee is dorsiflexed. Pain is produced in the anterior aspect of the thigh and/or back. Sensitivity: 84-95 Sacroiliac Joint Pathology Tests Standing flexion test This test is performed with the patient standing, facing away from the examiner with his feet approximately 12 inches apart so that the patient’s feet are parallel and approximately acetabular distance apart. The examiner then places his thumbs on the inferior aspect of each posterior superior iliac spine (PSIS). The patient is asked to bend forward with both knees extended. The extent of the cephalad movement of each PSIS is monitored. Normally, the PSIS should move equally. If one PSIS moves superiorly and anteriorly compared with the other, this is the side of restriction. Unavailable Seated flexion test This test is performed with the patient seated with both feet on the floor. The examiner stands or sits behind the patient with the eyes at the level of the iliac crests and places his thumbs on each PSIS; the patient is instructed to flex forward. The test is positive if one PSIS moves unequally cephalad with respect to the other PSIS. The side with the greatest cephalad excursion implies articular restriction and hypomobility. While the patient is seated, the innominates are fixed in place, thus isolating out iliac motion. Unavailable Gillet test (One-leg Stork test) This test is performed with the patient standing, facing away from the examiner, with the feet approximately 12 inches apart. The examiner places thumbs on each PSIS. The patient is then asked to stand on one leg while flexing the contralateral hip and knee to the chest. Unavailable Compression test The examiner places both hands on the patient’s anterior superior iliac spine (ASIS) and exerts a medial force bilaterally to implement the test. The compression test is more frequently performed with the patient in a side-lying position. The examiner stands behind the patient and exerts a downward force at the upper part of the iliac crest. Unavailable Gapping test (Distraction) This test is performed with the patient in a supine position. The examiner places the heel of both hands at the same time on each ASIS, pressing downward and laterally. Unavailable Patrick (FABERE) test With the patient supine on a level surface, the thigh is flexed and the ankle is placed above the patella of the opposite extended leg. As the knee is depressed, with the ankle maintaining its position above the opposite knee, the opposite ASIS is pressed, and the patient will complain of pain before the knee reaches the level obtained in normal persons. Unavailable Gaenslen’s test The patient lies supine, flexes the ipsilateral knee and hip against the chest with the aid of both hands clasped about the flexed knee. This brings the lumbar spine firmly in contact with the table and fixes both the pelvis and lumbar spine. The patient is then brought well to the side of the table, and the opposite thigh is slowly hyperextended with gradually increasing force by pressure of the examiner’s hand on the top of the knee. With the opposite hand, the examiner assists the patient in fixing the lumbar spine and pelvis by pressure over the patient’s clasped hands. The hyperextension of the hip exerts a rotating force on the corresponding half of the pelvis in the sagittal plane through the transverse axis of the sacroiliac joint. The rotating force causes abnormal mobility accompanied by pain, either local or referred on the side of the lesion. Unavailable Shear test This test consists of the patient lying in the prone position, and the examiner applies a pressure to the sacrum near the coccygeal end, directly cranially. The ilium is held immobile through the hip joint as the examiner applies counter pressure against legs in the form of traction force directed caudad. The test is considered positive if the maneuver aggravates the patient’s typical pain. Unavailable Fortin finger test The subject is asked to point to the region of pain with one finger. It is positive if the patient can localize the pain with one finger to an area inferomedial to the PSIS within 1 cm, and the patient consistently pointed to the same area over at least two trials. Unavailable Hip Tests Thomas test The patient lies supine while the examiner checks for excessive lordosis. The examiner flexes one of the patient’s hips, bringing the knee to the chest, flattening out the lumbar spine while the patient holds the flexed hip against the chest. If there is no flexion contracture, the hip being tested (the straight leg) remains on the examining table. If a contracture is present, the patient’s leg rises off the table. The angle of the contracture can be measured. Unavailable Ely test The patient lies prone while the examiner passively flexes the patient’s knee. Upon flexion of the knee, the patient’s hip on the same side spontaneously flexes, indicating that the rectus femoris muscle is tight on that side and that the test is positive. The two sides should be tested and compared. Unavailable Ober test The patient lies on his side with the thigh next to the table flexed to obliterate any lumbar lordosis. The upper leg is flexed at a right angle at the knee. The examiner grasps the ankle lightly with one hand and steadies the patient’s hip with the other. The upper leg is abducted widely and extended so that the thigh is in line with the body. If there is an abduction contracture, the leg will remain more or less passively abducted. Unavailable Piriformis test The patient is placed in the side-lying position with the non–test leg against the table. The patient flexes the test hip to 60 degrees with the knee flexed, while the examiner applies a downward pressure to the knee. Pain is elicited in the muscle if the piriformis is tight. Unavailable Trendelenburg test The patient is observed standing on one limb. The test is felt to be positive if the pelvis on the opposite side drops. A positive Trendelenburg test is suggestive of a weak gluteus muscle or an unstable hip on the affected side.

Sensitivity: 72.7

Specificity: 76.9

Patrick (FABERE) test See above. Unavailable Stinchfield test With the patient supine and the knee extended, the examiner resists the patient’s hip flexion at 20 to 30 degrees. Reproduction of groin pain is considered a positive test indicating intraarticular hip dysfunction. Unavailable Anterior Cruciate Ligament Tests Anterior drawer test The subject is supine, hip flexed to 45 degrees with the knee flexed to 90 degrees. The examiner sits on the subject’s foot, with hands behind the proximal tibia and thumbs on the tibial plateau. Anterior force is applied to the proximal tibia. Hamstring tendons are palpated with index fingers to ensure relaxation. Increased tibial displacement compared with the opposite side is indicative of an anterior cruciate ligament tear.

Sensitivity: 22-70

Specificity: 97

Lachman test The patient lies supine. The knee is held between full extension and 15 degrees of flexion. The femur is stabilized with one hand while firm pressure is applied to the posterior aspect of the proximal tibia in an attempt to translate it anteriorly. Sensitivity: 80-99 Pivot shift test The leg is picked up at the ankle. The knee is flexed by placing the heel of the hand behind the fibula. As the knee is extended, the tibia is supported on the lateral side with a slight valgus strain. A strong valgus force is placed on the knee by the upper hand. At approximately 30 degrees of flexion, the displaced tibia will suddenly reduce, indicating a positive pivot shift test.

Sensitivity: 35-95

Specificity: 98-100

Posterior Cruciate Ligament Tests Posterior sag sign The patient lies supine with the hip flexed to 45 degrees and the knee flexed to 90 degrees. In this position, the tibia “rocks back,” or sags back, on the femur if the posterior cruciate ligament is torn. Normally, the medial tibial plateau extends 1 cm anteriorly beyond the femoral condyle when the knee is flexed 90 degrees.

Sensitivity: 79

Specificity: 100

Posterior drawer test Subject is supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and foot in neutral position. The examiner sits on the subject’s foot with both hands behind the subject’s proximal tibia and thumbs on the tibial plateau. A posterior force is applied to the proximal tibia. Increased posterior tibial displacement as compared with the uninvolved side is indicative of a partial or complete tear of the posterior cruciate ligament.

Sensitivity: 90

Specificity: 99

Patellofemoral Tests Patellar grind test (compression test) The subject is supine with the knees extended. The examiner stands next to the involved side and places the web space of the thumb on the superior border of the patella. The subject is asked to contract the quadriceps muscle while the examiner applies downward and inferior pressure on the patella. Pain with movement of the patella or an inability to complete the test is indicative of patellofemoral dysfunction. Unavailable Knee Meniscal Injury Tests Joint line tenderness The medial joint line is easier to palpate with internal rotation of the tibia, allowing for easier palpation. Alternatively, external rotation allows improved palpation of the lateral meniscus.

Sensitivity: 55-85

Specificity: 29-77

McMurray test With patient lying flat, the knee is first fully flexed; the foot is held by grasping the heel. The leg is rotated on the thigh with the knee still in full flexion. By altering the position of flexion, the whole of the posterior segment of the cartilages can be examined from the middle to their posterior attachment. Bring the leg from its position of acute flexion to a right angle while the foot is retained first in full internal rotation and then in full external rotation. When the click occurs (in association with a torn meniscus), the patient is able to state that the sensation is the same as experienced when the knee gave way previously.

Sensitivity: 16-58

Specificity: 58-98

Apley grind test With the patient prone, the examiner grasps one foot in each hand and externally rotates as far as possible, then flexes both knees together to their limit. The feet are then rotated inward and knees extended. The examiner then applies his left knee to the back of the patient’s thigh. The foot is grasped in both hands, the knee is bent to a right angle, and powerful external rotation is applied Next, the patient’s leg is strongly pulled up, with the femur being prevented from rising off the couch. In this position of distraction, external rotation is repeated. The examiner leans over the patient and compresses the tibia downward. Again the examiner rotates powerfully and if addition of compression had produced an increase of pain, this grinding test is positive and meniscal damage is diagnosed.

Sensitivity: 13-16

Specificity: 80-90

Ankle Stability Tests Anterior drawer test With the patient relaxed, the knee is flexed and the ankle at right angles, the ankle is grasped on the tibial side by one hand, whose index finger is placed on the posteromedial part of the talus and whose middle finger lies on the posterior tibial malleolus. The heel of this hand braces the anterior distal leg. On pulling the heel forward with the other hand, relative anteroposterior motion between the two fingers (and thus between talus and tibia) is easily palpated and is also visible to both the patient and examiner.

Sensitivity: 80-95

Specificity: 74-84

Talar tilt The talar tilt angle is the angle formed by the opposing articular surfaces of the tibia and talus when these surfaces are separated laterally by a supination force applied to the hind part of the foot. Unavailable Syndesmosis Tests Syndesmosis squeeze test The squeeze test is performed by manually compressing the fibula to the tibia above the midpoint of the calf. A positive test produces pain over the area of the syndesmotic ligaments. Unavailable Achilles Tendon Rupture Tests Thompson’s test The patient lies in a prone position with the foot extending over the end of the table. The calf muscles are squeezed in the middle one third below the place of the widest girth. Passive plantar movement of the foot is seen in a normal reaction. A positive reaction is seen when there is no plantar movement of the foot and indicates rupture of the Achilles tendon.

Sensitivity: 96

Specificity: 93

Palpation test The examiner gently palpates the course of the tendon. A gap indicates an Achilles tendon rupture.

Sensitivity: 73

Specificity: 89

Modified from Malanga GA, Nadler SF, editors: Musculoskeletal physical examination: an evidence-based approach, Philadelphia, 2006, Mosby.

Inspection and Palpation

Inspection of the musculoskeletal system begins during the history. Attention to subtle cues and behaviors can guide the approach to the examination. Inspection includes observing mood, signs of pain or discomfort, functional impairments, or evidence of malingering. The spine should be specifically inspected for scoliosis, kyphosis, and lordosis. Limbs should be examined for symmetry, circumference, and contour. In persons with amputation, the level, length, and shape of the residual limb should be noted. Depending on the clinical situation, it can be important to assess for muscle atrophy, masses, edema, scars, and fasciculations.⁶³ Joints should be inspected for abnormal positions, swelling, fullness, and redness.

These isolated findings can coalesce to influence global movement patterns that affect the kinetic chain. The term kinetic chain refers to the fact that the joints of the human body are not isolated but instead are linked in a series. Joint motion is always accompanied by motion at adjacent as well as distant joints, resulting in asymmetric patterns causing pathology of seemingly unrelated sites. This is especially true with a fixed distal limb. For example, very tight hamstring muscles decrease the lumbar lordosis, resulting in an increased risk of lower back pain. It is important to include this concept in any musculoskeletal assessment.

Palpation is used to confirm initial impressions from inspection, helping to determine the structural origins of soft tissue or bony pain and localize trigger points, muscle guarding, or spasm and referred pain.⁶³ Joints and muscles should be assessed for swelling, warmth, masses, tight muscle bands, tone, and crepitus.³⁶ Tone is typically determined while assessing the ROM. It is important to palpate the limbs and cranium for evidence of fracture in patients with a change in mental status after a fall or trauma.⁵²

Assessment of Joint Stability

The assessment of joint stability judges the capacity of structural elements to resist forces in nonanatomic directions.^52,⁶³ Stability is determined by several factors including bony congruity, capsular and cartilaginous integrity, and the strength of ligaments and muscles.⁵² Assessing the “normal” side establishes a patient’s unique biomechanics. The examiner first identifies pain and resistance in the affected joint, followed by an evaluation of joint play to assess “end feel,” capsular patterns, and hypomobility or hypermobility. Radiographic imaging can be helpful in cases of suspected instability—for example, flexion-extension spine films to assess vertebral column instability or magnetic resonance imaging to visualize the degree of anterior cruciate ligament rupture.

Joint play or capsular patterns assess the integrity of the capsule in an open-packed position. Open-packed refers to positions in which there is minimal bony contact with maximum capsular laxity.⁵⁸ Voluntary movement of a joint (active ROM) does not generally exploit the fullest range of that joint. Extreme end ranges of joint movements not under voluntary control must be assessed by passive ROM. There are several types of end feels (Table 1-11). Soft tissue compression is normal in extreme elbow flexion, yet if felt sooner than expected can indicate inflammation or edema. Tissue stretch is usually firm yet slightly forgiving, such as in hip flexion. Firmness that occurs before the end point of range, however, can be a sign of increased tone and/or capsular tightening. A hard end feel is normally seen with elbow extension, but in an arthritic joint it can occur before full range is achieved. An “empty” feel suggests an absence of mechanical restriction due to muscle contraction caused by pain. With muscle involuntary guarding or spasm, one notes an abrupt stop associated with pain.

Table 1-11 Types of “End Feels” in Range-of-Motion Testing

It is important to differentiate between hypomobile and hypermobile joints. The former increase the risk for muscle strains, tendonitis, and nerve entrapments, while the latter increase the risk for joint sprains and degenerative joint disease.⁵⁸ An inflammatory synovitis, for example, can increase joint mobility and weaken the capsule. In the setting of decreased muscle strength, the risk of trauma and joint instability is increased.⁵² If joint instability is suspected, confirmatory diagnostic testing can be done (e.g., radiography).^21,^37,^41,⁴⁷ The temporal relationship between pain and resistance on examination actually changes from acute to chronic injury. An acute joint demonstrates pain before resistance to passive ROM. In a subacute joint, there is pain at the same time as resistance to passive ROM. In a chronic joint, pain occurs after resistance to ROM is noted.⁵⁸

Assessment of Range of Motion

General Principles

ROM testing is used to document the integrity of a joint, to assess the efficacy of treatment regimens, and to determine the mechanical cause of an impairment.⁴⁰ Limitations not only affect ambulation and mobility, but also ADL. Normal ROM varies based on age, gender, conditioning, obesity, and genetics.⁵² Males have a more limited range when compared with females, depending on age and specific joint action.⁸ Vocational and avocational patterns of activity also potentially alter ROM. For example, gymnasts generally have increased ROM at the hips and lower trunk.⁵⁸ Passive ROM should be performed through all planes of motion by the examiner in a relaxed patient to thoroughly assess end feel.⁵⁸ Active ROM performed by the patient through all planes of motion without assistance from the examiner simultaneously evaluates muscle strength, coordination of movement, and functional ability.

Contractures are often obvious simply from visual inspection. Contractures affect the true, full ROM of a joint via either soft tissue or bony changes. A soft tissue or muscle contracture decreases with a prolonged stretch, whereas a bony contracture does not. It can be difficult or impossible to differentiate a contracture from severe hypertonia in CNS diseases. A diagnostic peripheral nerve block can eliminate the hypertonia for a few hours to determine the etiology of the contracture and guide the correct treatment for impaired mobility or ADL.

Assessment Techniques

ROM should be performed before strength testing. ROM is a function of joint morphology, capsule and ligament integrity, and muscle and tendon strength.^58,⁶³ Range is measured with a universal goniometer, a device that has a pivoting arm attached to a stationary arm divided into 1-degree intervals (Figure 1-3). Regardless of the type of goniometer used, reliability is increased by knowing and using consistent surface landmarks and test positions.²⁸ Joints are measured in their plane of movement with the stationary arm parallel to the long axis of the proximal body segment or bony landmark.⁵⁸ The moving arm of the goniometer should also be aligned with a bony landmark or parallel to the moving body segment. The impaired joint should always be compared with the contralateral unimpaired joint, if possible.

FIGURE 1-3 Universal goniometer.

(Redrawn from Kottke and Lehman⁴⁴ 1990, with permission.)

Sagittal, frontal, and coronal planes divide the body into three cardinal planes of motion (Figure 1-4). The sagittal plane divides the body into left and right halves, the frontal (coronal) plane, into anterior and posterior halves; and the transverse plane, into superior and inferior parts.²⁸ For sagittal plane measurements, the goniometer is placed on the lateral side of the joint, except for a few joint motions such as forearm supination and pronation. Frontal planes are measured anteriorly or posteriorly, with the axis coinciding with the axis of the joint.

FIGURE 1-4 Cardinal planes of motion.

The 360-degree system was first proposed by Knapp and West ^42,⁴³ and denotes 0 degrees directly overhead and 180 degrees at the feet. In the 360-degree system, shoulder forward flexion and extension ranges from 0 to 240 degrees (Figure 1-5, A). The American Academy of Orthopedic Surgeons uses a 180-degree system.⁵⁵ The standard anatomic position¹⁴ is described as an upright position with the feet facing forward, the arms at the side with the palms facing anterior.²⁸ A joint at 0 degrees is in the anatomic position, with movement occurring up to 180 degrees away from 0 degrees in either direction.²⁸ With the use of shoulder forward flexion as an example, the normal range for flexion in the 180-degree system is 0 to 180 degrees, and for extension is 0 to 60 degrees (Figure 1-5, B). These standardized techniques have been well described.^∗

FIGURE 1-5 Comparison of two range-of-motion systems.

Figures 1-6 through 1-21 outline the correct patient positioning and plane of motion for the joint and goniometer placement. To increase accuracy, many practitioners recommend taking several measurements and recording a mean value.⁵⁸ Measurement inaccuracy can be as high as 10% to 30% in the limbs and can be without value in the spine if based on visual assessment alone.^2,⁷¹ In joint deformity, the starting position is the actual starting position of joint motion. Spinal ROM is more difficult to measure, and its reliability has been debated.^28,³⁶ The most accurate method of measuring spinal motion is with radiographs. Because this is not practical in most clinical scenarios, the next most accurate system is based on inclinometers. These are fluid-filled instruments with a 180- or 360-degree scale. One or two devices are required.^2,³⁶ The American Medical Association Guides to the Evaluation of Permanent Impairment² outlines the specific inclinometer techniques for measuring spinal ROM.

FIGURE 1-6 Shoulder flexion and extension. Patient position: supine or sitting, arm at side, elbow extended. Plane of motion: sagittal. Normal range of motion: flexion, 0-180 degrees; extension, 0-60 degrees. Movements the patient should avoid: arching back, trunk rotation. Goniometer placement: axis is centered on the lateral shoulder, stationary arm remains at 0 degrees, movement arm remains parallel to humerus.

FIGURE 1-7 Shoulder abduction. Patient position: supine or sitting, arm at side, elbow extended. Plane of motion: frontal. Normal range of motion: 0-180 degrees. Movements the patient should avoid: trunk rotation or lateral movement. Goniometer placement: axis is centered on posterior or anterior shoulder, stationary arm remains at 0 degrees, movement arm remains parallel to humerus.

FIGURE 1-8 Shoulder internal and external rotation. Patient position: supine, shoulder at 90 degrees of abduction, elbow at 90 degrees of flexion, radioulnar joint pronated. Plane of motion: transverse. Normal range of motion: internal rotation, 0-90 degrees; external rotation, 0-90 degrees. Movements the patient should avoid: arching back, trunk rotation, elbow movement. Goniometer placement: axis on elbow joint through longitudinal axis of humerus, stationary arm remains at 0 degrees, movement arm remains parallel to forearm.

FIGURE 1-9 Elbow flexion. Patient position: supine or sitting, radioulnar joint supinated. Plane of motion: sagittal. Normal range of motion: 0-150 degrees. Goniometer placement: axis is centered on lateral elbow, stationary arm remains at 0 degrees, movement arm remains parallel to forearm.

FIGURE 1-10 Radioulnar pronation and supination. Patient position: sitting or standing, elbow at 90 degrees, wrist in neutral, pencil held in palm of hand. Plane of motion: transverse. Normal range of motion: pronation, 0-90 degrees; supination, 0-90 degrees. Movements the patient should avoid: arm, elbow, and wrist movements. Goniometer placement: axis through longitudinal axis of forearm, stationary arm remains at 0 degrees, movement arm remains parallel to pencil held in patient’s hand.

FIGURE 1-11 Wrist flexion and extension. Patient position: elbow flexed, radioulnar pronated. Plane of motion: sagittal. Normal range of motion: flexion, 0-80 degrees; extension, 0-70 degrees. Goniometer placement: axis is centered on lateral wrist over ulnar styloid, stationary arm remains at 0 degrees, movement arm remains parallel to fifth metacarpal.

FIGURE 1-12 Wrist radial and ulnar deviation. Patient position: elbow flexed, radioulnar joint pronated, wrist in neutral flexion and extension. Plane of motion: frontal. Normal range of motion: radial, 0-20 degrees; ulnar, 0-30 degrees. Goniometer placement: axis is centered over dorsal wrist midway between distal radius and ulna, stationary arm remains at 0 degrees, movement arm remains parallel to third metacarpal.

FIGURE 1-13 Second to fifth metacarpophalangeal flexion. Patient position: elbow flexed, radioulnar joint pronated, wrist in neutral, fingers extended. Plane of motion: sagittal. Normal range of motion: 0-90 degrees. Goniometer placement: axis on dorsum of each metacarpophalangeal joint, stationary arm remains at 0 degrees, movement arm remains on dorsum of each proximal phalanx.

FIGURE 1-14 Second to fifth proximal interphalangeal flexion. Patient position: elbow flexed, radioulnar pronated, wrist in neutral, metacarpophalangeal joints in slight flexion. Plane of motion: sagittal. Normal range of motion: 0-100 degrees. Goniometer placement: axis on dorsum of each interphalangeal joint, stationary arm remains at 0 degrees, movement arm remains on dorsum of each middle phalanx.

FIGURE 1-15 Hip flexion, knee extension. Patient position: supine or lying on side, knee extended. Plane of motion: sagittal. Normal range of motion: 0-90 degrees. Movements the patient should avoid: arching back. Goniometer placement: axis is centered on lateral leg over greater trochanter, stationary arm remains at 0 degrees. (This is found by drawing a line from the anterior superior iliac spine to the posterior superior iliac spine, and then drawing another line, perpendicular to the first, that goes through the greater trochanter. The last line is 0 degrees.) Movement arm remains parallel to lateral femur.

FIGURE 1-16 Hip flexion, knee flexion. Patient position: supine or lying on side, knee flexed. Plane of motion: sagittal. Normal range of motion: 0-120 degrees. Movements the patient should avoid: arching back. Goniometer placement: axis centered over greater trochanter, stationary arm is parallel to and below a line on patient drawn through both anterior superior iliac spines (this is perpendicular to 0 degrees), movement arm remains parallel to anterior femur.

FIGURE 1-17 Hip abduction. Patient position: supine or lying on side, knee extended. Plane of motion: frontal. Normal range of motion: 0-45 degrees. Movements the patient should avoid: trunk rotation. Goniometer placement: axis centered over greater trochanter, stationary arm is parallel to and below a line on patient drawn through both anterior superior iliac spines (this is perpendicular to 0 degrees), movement arm remains parallel to anterior femur.

FIGURE 1-18 Hip adduction. Patient position: supine, knee extended. Plane of motion: frontal. Normal range of motion: 0-30 degrees. Movements the patient should avoid: trunk rotation. Goniometer placement: axis over knee joint through longitudinal axis of femur, stationary arm remains at 0 degrees, movement arm remains parallel to anterior tibia.

FIGURE 1-19 Knee flexion. Patient position: prone or sitting, hip in neutral. Plane of motion: sagittal. Normal range of motion: 0-135 degrees. Goniometer placement: axis on lateral knee joint, stationary arm remains at 0 degrees, movement arm remains parallel to fibula laterally.

FIGURE 1-20 Hip internal and external rotation. Patient position: supine or sitting, hip at 90 degrees flexion, knee at 90 degrees flexion. Plane of motion: transverse. Normal range of motion: internal, 0-35 degrees; external, 0-45 degrees. Movements the patient should avoid: hip flexion movement, knee movement. Goniometer placement: axis over knee joint through longitudinal axis of femur, stationary arm remains at 0 degrees, movement arm remains parallel to anterior tibia.

FIGURE 1-21 Ankle dorsiflexion and plantar flexion. Patient position: sitting or supine with knee flexed to 90 degrees. Plane of motion: sagittal. Normal range of motion: dorsiflexion, 0-20 degrees; plantar flexion, 0-50 degrees. Goniometer placement: axis is on sole of foot below lateral malleolus, stationary arm remains along shaft of fibula (this is perpendicular to 0 degrees), movement arm remains parallel to fifth metatarsal.

Assessment of Muscle Strength

General Principles

Manual muscle testing is used to establish baseline strength, to determine the functional abilities of or need for adaptive equipment, to confirm a diagnosis, and to suggest a prognosis.⁵⁸ Strength is a rather generic term and can refer to a wide variety of assessments and testing situations.⁶ Manual muscle testing specifically measures the ability to voluntarily contract a muscle or muscle group at a specific joint. It is quantified using a system first described by Robert Lovett, M.D., an orthopedic surgeon, in the early twentieth century.²⁰ Isolated muscles can be difficult to assess. For example, elbow flexion strength depends not only on the biceps muscle but also on the brachialis and brachioradialis muscles. Strength is affected by many factors including the number of motor units firing, functional excursion, cross-sectional area of the muscle, line of pull of the muscle fibers, number of joints crossed, sensory receptors, attachments to bone, age, sex, pain, fatigue, fear, motivational level, and misunderstanding.^6,^52,⁵⁸ Pain can result in breakaway weakness caused by pain inhibition of function and should be documented as such. It is important to recognize the presence of substitution when muscles are weak or movement is uncoordinated. Females typically increase strength up to age 20 years, plateau through their 20s, and gradually decline in strength after age 30. Males increase strength up to age 20 and then plateau until somewhat older than 30 years before declining.⁵⁸ Muscles that are predominantly type 1 or slow-twitch fibers (e.g., soleus muscle) tend to be fatigue resistant and can require extended stress on testing (such as several standing toe raises) to uncover weakness.⁵⁸ Type 2 or fast-twitch fibers (e.g., sternocleidomastoid) fatigue quickly, and weakness can be more straightforward to uncover abnormalities. Patients who cannot actively control muscle tension (e.g., those with spasticity from CNS disease) are not appropriate for standard manual muscle testing methods.⁵⁸

Assessment Techniques

Manual muscle testing takes into account the weight of the limb without gravity, with gravity, and with gravity plus additional manual resistance.⁵⁸ Most examiners use the Medical Research Council scale, where grades of 0 to 2 indicate gravity-minimized positions, and grades 3 to 5 indicate increasing degrees of resistance applied as an isometric hold at the end of the test range (Table 1-12).⁵⁸ A muscle grade of 3 is functionally important because antigravity strength implies that a limb can be used for activity, whereas a grade of less than 3 implies that the limb will require external support and is prone to contracture.⁶³ A 1- or 2-grade intertester difference is acceptable,⁵⁸ but poor intertester reliability can be a problem with grades below 3.⁶ Other pitfalls encountered in testing strength are outlined in Table 1-13. To reduce measurement errors, one hand should be placed above and one below the joint being tested. As detailed in extended Tables 1-14 and 1-15, the examiner’s hands should not cross two joints, if possible. Placing a muscle at a mechanical disadvantage, such as flexing the elbow beyond 90 degrees to assess triceps strength, can help demonstrate mild weakness.³⁶ Extended Tables 1-14 and 1-15 summarize the joint movement, innervation, and manual strength testing techniques for all major upper and lower extremity muscle groups, respectively. The use of a dynamometer can add a degree of objectivity to measurements for pinch and grip.

Table 1-12 Manual Muscle Testing

Grade	Term	Description
5	Normal	Full available ROM is achieved against gravity and is able to demonstrate maximal resistance.
4	Good	Full available ROM is achieved against gravity and is able to demonstrate moderate resistance.
3	Fair	Full available ROM is achieved against gravity but is not able to demonstrate resistance.
2	Poor	Full available ROM is achieved only with gravity eliminated.
1	Trace	A visible or palpable contraction is noted, with no joint movement.
0	Zero	No contraction is identified.

ROM, Range of motion.

Modified from Cutter NC, Kevorkian CG: Handbook of manual muscle testing, New York, 1999, McGraw-Hill with permission of McGraw-Hill.

Table 1-13 Caveats in Manual Muscle Resting

Caveat	Rationale
Isolation	It is important to isolate individual muscles with similar functions instead of testing the entire muscle group.
Substitution patterns	It is important to be aware of basic substitution patterns (e.g., elbow flexion).
Suboptimal testing conditions	These occur when determining patients’ muscle strength when they are under the influence of, for example, sedation, significant pain, positioning, language or cultural barriers, spasticity, and hypertonicity.
Overgrading	This occurs when the practitioner applies increased force when the patient is unable to achieve the full available ROM yet is able to demonstrate a muscle grade of 3 or more in a lengthened position.
Undergrading	This occurs when the examiner is not aware of the effects of muscle contracture on ROM, and the muscle appears to lack full ROM when it has achieved its full available ROM.

ROM, Range of motion.

Modified from Cutter NC, Kevorkian CG: Handbook of manual muscle testing, New York, 1999, McGraw-Hill with permission of McGraw-Hill.

Table 1-14 Upper Limb Muscle Testing

Table 1-15 Lower Limb Muscle Testing

Dynamic screening tests of strength can also be done. A quick screen for upper extremity strength is to have the patient grasp two of the examiner’s fingers while the examiner attempts to free the fingers by pulling in all directions. For a proximal lower limb screen, the patient can demonstrate a deep knee bend (squat and rise), and for the distal lower extremity can walk on heels and toes. To make gait abnormalities more evident, patients can be asked to increase the speed of their cadence, and walk sideways and backward. Abdominal strength can be screened by observing the patient’s ability to go from supine to sitting with the hips and knees bent. If the hips and knees are extended, the iliopsoas is tested as well.³⁶

Assessment, Summary, and Plan

Only after completing a thorough H&P is the physiatrist able to develop a comprehensive treatment plan. The organization of the initial treatment plan and goals can vary from setting to setting but should clearly state impairments, performance deficits (activity limitation, disability), community or role dysfunction (participation, handicap), medical conditions that can affect achieving the functional goals, and goals for the interdisciplinary rehabilitation team (if other disciplines are involved in the patient’s care). Follow-up treatment plans and notes are likely be shorter and less detailed, but they must address important interval changes since the last documentation and any significant changes in treatment or goals. This documentation is often used to justify continued payment for third-party payers. Noting whether problems are new, stable, improving, or worsening can be critical for accurate physician billing compliance documentation. Accurate identification and documentation of the cause of the impairment and disability can be required for initial and continuing hospital payment.

A summary statement of no more than a few sentences is helpful to medical consultants and other team members. Although development of a separate medical and functional problems list is acceptable and often recommended, the physiatrist should make very clear how those medical issues alter the approach to treatment (i.e., how brittle diabetes, activity-induced angina, or pain issues might affect mobilization).

With a medical and functional problem list in hand, the management plan can be developed. Considering six broad interventional categories as originally outlined by Stolov et al.⁶⁴ is very helpful, particularly with complex patients in an inpatient rehabilitation setting. These six categories include prevention or correction of additional disability, enhancement of affected systems, enhancement of unaffected systems, use of adaptive equipment, use of environmental modification, and use of psychologic techniques to enhance patient performance and education. The physician should clearly delineate the therapeutic precautions for the other team members. Both short- and longer-term goals should be outlined, as well as estimated time frames for achieving those goals. Boxes 1-2 and 1-3 show examples of rehabilitation plans for an inpatient after subarachnoid hemorrhage and an outpatient with back pain, respectively.

Box 1-2 Inpatient Rehabilitation Plan