Tests & Measures in

Physical Therapy
Outcomes oriented model of patient
management Outcomes

Re-Examination
Intervention
Consultations

Prognosis and Plan of Care

Referral /

Diagnosis

Evaluation

Examination
INTERVIEW AND
SUBJECTIVE EXAM
SUBJECTIVE ASSESSMENT
 Interpretation of
the subjective
information
acquired by the
physical therapist
Subjective Information
 Information received from the patient that
is relevant to the patient’s present
condition
 Necessary to plan the objective
assessment of the patient & to justify or
explain certain goals that are set with the
patient
 Patient’s history
Gathering Subjective Information
 First step in the PT process
 First time to meet patient/client
 An interview process
Purposes
 Address the patient’s condition & problems
accurately
 Assist in monitoring progress, revising the
patient’s program, &/or discontinuing
therapy when necessary
Sources
 Patient/client, family, significant others, &
caregivers
 Consultation with other members of the
team (e.g., referring doctor, OT, SP)
 Review of patient/client record
Subjective Information
 Chief complaint/s
 History of present illness
 Past medical history
 Family history
 Functional history
 Personal history
 Social history
 Vocational history
Subjective Information
 Emotions, attitudes, & goals
 Anything the patient (or a designated
significant other) tells the PT that is
relevant to the patient’s case or present
condition
Chief Complaint/s
 Document the patient’s primary concern in
his or her own words
 Shoulder pain when reaching overhead
 I can no longer sit for a prolonged period of
time when working in front of the computer
History of Patient Illness (HPI)
 History of present problem
 Identifying the “problem” is not only
discovering the illness but also uncovering the
functional implications
 Should be described in a clear,
chronological narrative
History of Patient Illness (HPI)
Date of onset of
injury/condition/symptoms
 Is the injury recent? Recurrent?
Insiduous?
 Are there perpetuating circumstances that
exist?
Character & severity
 What is the type & nature of the
symptom/s?
 Do the symptom/s follow a pattern?
History of Patient Illness (HPI)
Location & extension
 What is the location of the symptom/s?
Time relationships
 Does the symptom/s decrease or get
worse as the day progresses?
 How irritable or easily evoked is/are the
symptoms?
History of Patient Illness (HPI)
Aggravating & alleviating factors
 What positions, motions, or form/s of
activity cause or ease pain?
 How severe or functionally limiting is/are
the symptom/s in terms of ADLs, work,
family, social, & recreational activities?
Associated complaints
 Are there associated symptoms?
 Are there related medical conditions?
History of Patient Illness (HPI)
Previous treatment & effects
 If this has been experienced before, what
treatment was done?
 What are the effects of treatment?
Progress, noting remissions &
exacerbations
Medications
 Complete list of the current medications
being taken
 Schedule of taking medications
 Effects of medications on the patient
Past Medical History
 A record of the patient’s significant illness,
trauma, & health maintenance during his
or her life
 Neurological, cardiopulmonary, &
musculoskeletal disorders
Family Medical History
 Identify hereditary disease/s within the
family
 Knowledge of the health & fitness of
family members
Functional History
 Prior level of function, pre-morbid status
 Characterize activity limitations &
participation restrictions that resulted
from the condition
 Identify remaining capabilities
Functional History
 Communication (listening, reading,
speaking, writing)
 Self-care activities (eating, bathing,
grooming, toileting, dressing)
 Mobility (bed mobility, transfers,
ambulation, & other forms of mobility)
Personal History
 Lifestyle – leisure/recreation
 Diet
 Alcohol, nicotine, and/or drugs
 Sexual history
Social History
 Family – marriage history & status,
family members & their roles, family
support
 Home – home design & architectural
barriers, ownership, location, distance
from important places
Vocational History
 Education & training – educational level
attained, acquisition of special licenses,
skills, & certifications
 Work – type, work descriptions,
architectural barriers at the workplace
 Finances – sources
Emotions, Attitudes, & Goals
 Insight on the patient’s level of motivation
and level of understanding about his or
her condition
 How do you feel about your condition?
 How do you feel about undergoing physical
therapy/rehabilitation?
 Collaborative goals
 Patient/client – centered therapy
PAIN ASSESSMENT
 Location
 Onset
 Duration & frequency
 Quality
 Intensity
 Provoking & relieving factors
 Associations with rest, activity, time of
day, & visceral function
Types of Pain
 Cramping, dull, aching – muscle
 Sharp, shooting – nerve root
 Sharp, bright, lightning-like – nerve
 Burning, pressure-like, stinging, aching –
sympathetic nerve
 Deep, nagging, dull – bone
 Sharp, severe, intolerable – fracture
 Throbbing – diffuse
Scales
 Verbal Rating Scale
 Visual Analog Scale
 McGill-Melzack Pain Questionnaire
Functional Levels of Pain
 Level 1: Pain after specific activity
 Level 2: Pain after specific activity resolving with
warm-up
 Level 3: Pain during & after specific activity which
does not affect performance
 Level 4: Pain during & after specific activity which
does affect performance
 Level 5: Pain with ADLs
 Level 6: Constant dull aching pain at rest which
does not disturb sleep
 Level 7: Dull aching pain which does disturb sleep
SYSTEMS REVIEW
Upper Quarter Screening
 Rapid assessment of mobility and
neurologic function of the cervical spine
and upper extremities
 Traditionally performed with the patient
sitting
Upper Quarter Screening -
Components
 Posture – sitting posture assessment
 ROM
 AROM cervical spine
 AROM of the upper extremities
 Passive overpressure of the cervical spine and
upper extremities, if the patient does not
exhibit signs and symptoms of pathology
 Resistive Testing (C1-T1)
 Dermatome Testing (C2-T1)
 Reflex Testing (C5-C7)
Lower Quarter Screening
 Rapid assessment of mobility and
neurologic function of the LS spine and
lower extremities
 Traditionally performed with the patient
standing or sitting
Lower Quarter Screening -
Components
 Postural Assessment
 ROM
 AROM lumbosacral spine
 AROM of lower extremities
 Passive overpressure of the lumbosacral spine
and lower extremities if patient does not
exhibit signs and symptoms of pathology
 Functional Testing (L4-S1)
 Resistive Testing (L1-S1)
 Reflex Testing (L4-S1)
 Dermatome Testing (L2-S5)
Lower Quarter Screening -
Components
 Functional Testing (L4-S1)
Functional Test Innervation Level
Heel walking L4-L5
Toe walking S1
Straight leg raise L4-S1
PALPATION
 Differences in tissue tension & texture
 Difference in tissue thickness
 Tenderness
 Temperature variation
 Pulses, tremors, & fasciculations
 Dryness or excessive moisture
 Abnormal sensation
Swelling
 Comes on soon after injury – blood
 Comes on after 8 to 24 hours – synovial
 Boggy, spongy feeling – synovial
 Harder, tense feeling with warmth – blood
 Tough, dry – callus
 Leathery thickening – chronic
 Soft, fluctuating – acute
 Hard – bone
 Thick, slow-moving – pitting edema
Tenderness
 Grade I: Patient complains of pain
 Grade II: Patient complains of pain &
winces
 Grade III: Patient winces & withdraws the
joint
 Grade IV: Patient will not allow palpation
of the joint
GONIOMETRY
 Measurement of
angles created at
human joints by
the bones of the
body
Knowledge
 Recommended testing positions
 Alternative positioning
 Stabilization required
 Joint structure & function
 Normal end-feels
 Anatomic bony landmarks
 Instrument alignment
Skill
 Position & stabilize correctly
 Move a part through the appropriate ROM
 Determine the end of ROM (end-feel)
 Palpate the appropriate bony landmarks
 Align the measuring instrument with
landmarks
 Read the measuring instrument
 Record the measurements correctly
The Tool: Universal Goniometer
 Body
 Arms
 Stationary arm
 Moving arm
Goniometric Alignment
 Fulcrum
 Placed over the approximate
location of the axis of motion
of the joint being measured
 Stationary arm
 Aligned parallel to the
longitudinal axis of the
proximal segment of the joint
 Moving arm
 Aligned parallel to the
longitudinal axis of the distal
segment of the joint
End-Feel
 The feeling which is experienced by the
examiner as a barrier to further motion at
the end of passive ROM
Normal End-Feels
 Soft
 Soft tissue approximation
 Firm
 Muscular, capsular, ligamentous stretch
 Hard
 Bone contacting bone
Abnormal End-Feels
 Soft
 Occurs sooner or later in the ROM than is
usual, or in a joint that normally has a firm or
hard end-feel
 Boggy
 Soft tissue edema, synovitis
 Firm
 Occurs sooner or later in the ROM than is
usual, or in a joint that normally has a soft or
hard end-feel
 Increased muscular tonus; capsular, muscular,
ligamentous shortening
Abnormal End-Feels
 Hard
 Occurs sooner or later in the ROM than is
usual, or in a joint that normally has a soft or
firm end-feel
 A bony grating or bony block is felt
 Chondromalacia, OA, loose bodies in joint, MO,
fracture
 Empty
 No real end feel because pain prevents
reaching end of ROM
 No resistance is felt except for patient’s
protective muscle splinting or muscle spasm
 Acute joint inflammation, bursitis, fracture,
psychogenic disorder
Modified Schober Technique
 One mark midway the
two PSISs
 A second mark on the
spinous process 10cm
above the first mark
 A third mark 5cm below
the first mark
MANUAL MUSCLE TESTING
 Wilhelmine Wright & Robert W. Lovett, MD
Knowledge & Skill
 Knowledge of muscles
 Location
 Anatomic features
 Direction & line of pull
 Function
 Familiarity with positioning & stabilization
 Ability to identify patterns of substitution
 Ability to detect contractile activity
 Sensitivity to differences in contour & bulk of
muscles
 Awareness of any deviation from normal values
for ROM
Knowledge & Skill
 Understanding that the muscle belly must not be
grasped at any time during a manual muscle test
 Ability to identify muscles with the same
innervation
 Knowledge of the relationship of the diagnosis to
the sequelae & extent of the test
 Ability to modify test procedures when necessary
 Knowledge of the effect of fatigue on the test
results
 Understanding the effect of sensory loss on
movement
Grading System
5 Normal (N)
4 Good (G)
3 Fair (F)
2 Poor (P)
1 Trace activity (T)
0 Zero (no activity) (0)
Grade 5 (Normal) Muscle
 When the examiner cannot break the
patient’s hold position
 Ability to complete a full ROM
 Maintain end-point range against maximum
resistance
Grade 4 (Good) Muscle
 Complete full ROM against gravity & can
tolerate strong resistance without
breaking the test position
 “gives” or “yields” to some extent at the
end of the range with maximum resistance
Grade 3 (Fair) Muscle
 Ability to move through the full range
against gravity but additional resistance,
however mild, causes the motion to break
Grade 2 (Poor) Muscle
 Can complete the full ROM in a gravity-
eliminated position
Grade 1 (Trace) Muscle
 Examiner can detect visually or by
palpation some contractile activity in one
or more muscles that participate in the
movement being tested
Grade 0 (Zero) Muscle
 Completely quiescent on both palpation or
visual inspection
Grade 3+ (Fair+) Muscle
 Can complete full ROM against gravity, &
the patient can hold the end position
against resistance
Grade 2+ (Poor+) Muscle
 Useful when grading the strength of the
PF
 Weight bearing: Patient can complete a partial
heel rise using the correct form
 Non-weight bearing: Patient takes maximum
resistance & completes full available range
Grade 2- (Poor-) Muscle
 Can complete partial ROM in the gravity-
minimized position
Break Test
 Manual resistance is applied to a limb or
other body part after it has completed its
range of movement or after it has been
placed at end range by the examiner
Active Resistance Test
 Application of manual resistance against
an actively contracting muscle or muscle
group
Application of Resistance
 One-joint muscles
 At end of range
 Two-joint muscles
 At or near midrange
SPECIAL TESTS
 Clinical accessory, provocative, or
structural tests
 Do not necessarily rule out a disease or
condition when they yield negative results
 The findings of the test depend PRIMARILY
on the skill & ability of the examiner
 Seldom taken in isolation to make a
diagnosis
Uses
 To confirm a tentative diagnosis
 To make a differential diagnosis
 To differentiate between structures
 To understand unusual signs
 To unravel difficult signs & symptoms
ANTHROPOMETRY
 Physical measurement of the human
body
 Provides the physical therapist with
building blocks for understanding the
complexities of human form & how it
interfaces with its environment
Anthropometry
 May provide a baseline to monitor
rehabilitation outcomes
 Provides the physical therapist a
basis of assessment whether the size
of a body part is changing over a
disease process, or as a result of
rehabilitation management
Anthropometry
 Assesses the following:
 Edema or effusion/swelling
 Muscular changes
 Gait & postural problems related to
asymmetry of body parts
Anthropometry
 Cornerstone of the design of all objects
& spaces used by humans
 Important in designing equipment &
materials for special populations such
as children, elderly, & persons with
disability
Types
 Static Anthropometry
 Refers to actual sizes of body
components
 Taken with the body fixed or in
standardized positions
Types
 Dynamic Anthropometry
 Refers to the ability of the body to
perform certain tasks with certain
distances, spaces or enclosures
 Taken with the body in various
working positions & is related to body
performances
Tools
 Tape measure
 Steel tape
Tools
 Anthropometer
 Caliper
Tools
 Volumeter
Muscle Bulk Measurement
 Indication
 Measure atrophy/ hypertrophy of a
limb
 Measuring tool
 Tape measure
Muscle Bulk Measurement
 Procedure
1. Identify a reference point (surface
landmark).
2. Identify area of the limb where muscle bulk
is greatest.
3. Measure the distance between (1) & (2).
Record this as the landmark.
4. Measure the circumference of the segment
around the landmark for both affected &
unaffected extremities.
Documentation of Findings
Muscle Bulk Measurement
Landmark Right Left Difference

Significance:
Limb Girth Measurement
 Indication
 Measure swelling/effusion or edema
 Measuring Tool
 Tape measure
Limb Girth Measurement
 Procedure
1. Select a reference point (surface
landmark).
2. From the selected reference point,
measure the circumference of the
limb every 1” proximally and
distally. Record these as your
landmarks.
Limb Girth Measurement
2. Measure the circumference from
each landmark depending on the
extent of edema or effusion/swelling.
3. Measure both unaffected & affected
extremities.
Documentation of Findings
Limb Girth Measurement
Landmark Right Left Difference

Significance:
Volumetric Measurement
 Indication
 Ideal for foot & hand edema or
effusion
 For irregularly shaped limbs
 Measuring tool
 Volumeter
Volumetric Measurement
 Procedure
 Fill volumeter with water & note initial
water level.
 Dip unaffected extremity & record the
difference in water level.
 Check water level again.
 Dip affected extremity & record
difference in water level.
Volumetric Measurement
 Normal difference between dominant &
non-dominant hand is 10mL
 Difference of 30-50mL is indicative of
swelling or edema
Volumetric Measurement
Volumetric Measurement
Leg Length Measurement
 Indication
 Measure leg length discrepancy
 True leg length discrepancy

 Functional leg length discrepancy

 Measuring Tool
 Tape measure
True Leg Length Discrepancy
 True shortening
 Caused by an anatomic or structural
change in the lower leg resulting from
congenital maldevelopment or trauma
 Coxa vara/valga, congenital hip
dysplasia, fracture
Functional Leg Length
Discrepancy
 Functional
shortening
 Result of
compensation for a
change that has
occurred because of
positioning rather
than structure
 Scoliosis, unilateral
foot pronation
True Leg Length
 Procedure
1. Properly position the patient
 Pelvis level
 Legs should be 4 – 8 inches apart &
parallel to each other
 Lower limbs must be placed in
comparable positions relative to the
pelvis
True Leg Length
2. Measure from the
ASIS to the lateral
or medial
malleolus
True Leg Length
3. Measure leg length of both extremities
4. If positive discrepancies are found,
perform segmental measurements of
both extremities
 Iliac crest to greater trochanter

 Greater trochanter to lateral knee joint

line
 Medial knee joint line to medial
malleolus
Functional Leg Length
 Measure distance from xiphisternum or
umbilicus to the medial malleolus
Documentation of Findings
True/Functional Leg Length
Measurement
Landmark Right Left Difference

Significance:
Leg Length Measurement
 Normal difference
 1 – 1.5 cm
 Orthoses would be prescribed for
patients with LLD
 Less than 1” – heel elevation
 More than 1” – shoe elevation
Heel Elevation
Shoe Elevation
 Stump Length Measurement
 Indication
 Good prosthetic fit
 Measuring Tool
 Tape measure
Stump Length Measurement
 Procedure
1. Select landmark depending on the type
of amputation
 Above-elbow – tip of acromion process
 Below-elbow – medial epicondyle
 Above-knee – medial inguinal line or
greater trochanter
 Below-knee – medial tibial plateau
Stump Length Measurement
2. Measure the residual limb from the
landmark to the distal end of the
stump
Documentation of Findings

Stump Length Measurement

Landmark Measurement

Significance:
Head Circumference Measurement
 Indication
 Assess head circumference in children
especially during the first 2 years of
life
 Identify presence of any
abnormalities in head size
 Measuring Tool
 Tape measure
 Landmark
 Inion to forehead just above the
supraorbital ridge
Head Circumference Measurement
 Ideal Head Circumference
 At birth – 13.8” (35cm)
 1 year – 33% increase
 6 years – 50% increase
 10 years – twice from birth
Head Circumference Measurement
 After birth, head circumference increase
is as follows:
 1st 4 months – 0.5” per month
 5th to 12th month – 0.25” per month
 2 years – 1” for the whole year or
0.25” per 3 months
 3-5 years – 0.5” per year
 6-20 years – 0.5” per 5 years
Documentation of Findings
Head Circumference Measurement

Measurement Normal Difference

Significance:
Static Measurements
 Standing posture
 Person stands erect & looks straight
ahead, with arms in a relaxed
position on the side
Static Measurements
 Seated posture
 Person sits erect and looks straight
ahead
 Thighs are parallel to the floor, &
knees are bent to a 90 degree angle
with feet flat on the floor
 Upper arm is relaxed & perpendicular
to the horizontal plane
 Forearm is at right angle to the upper
arm
Conventions
 Heights
 Vertical measurements
 Lengths
 Horizontal measurements in the sagittal
plane
 Breadths
 Horizontal measurements in the coronal
plane
Most Common Measurements
 Stature
 Eye height
 Shoulder height
 Elbow height
 Hip height
 Knuckle height
 Fingertip height
Most Common Measurements
 Sitting height
 Sitting eye height
 Sitting shoulder height
 Sitting elbow height
 Thigh thickness
 Buttock – knee length
 Buttock – popliteal length
 Knee height
 Popliteal height
Most Common Measurements
 Shoulder breadth
 Hip breadth
 Shoulder – elbow length
 Elbow – fingertip length
 Upper limb length
 Shoulder – grip length
 Standing vertical grip reach
 Sitting vertical grip reach
NEUROLOGICAL ASSESSMENT
 Sensation
 Reflexes
 Tone
 Cranial nerves
Sensory Testing
 Superficial
 Deep
 Combined cortical
Superficial Sensations
 Pain perception
 Temperature awareness
 Touch awareness
 Pressure perception
Deep Sensations
 Kinesthesia
 Proprioception
 Vibration
Combined Cortical Sensations
 Stereognosis
 Tactile localization
 Two-point discrimination
 Double simultaneous stimulation (DSS)
 Graphesthesia
 Recognition of texture
 Barognosis
Dermatomes
Dermatomes
Dermatomes
Dermatomes
Dermatomes
Dermatomes
Dermatomes
Upper Quarter Screening -
Components
 Resistive Testing (C1-T1)
Resistive Test Innervation Level
Cervical rotation C1
Shoulder elevation C2-C4
Shoulder abduction C5
Elbow flexion C5-C6
Wrist extension C6
Elbow extension C7
Wrist flexion C7
Thumb extension C8
Finger adduction T1
Myotomes
 C1-C2: neck flexion
 C3: neck side flexion
 C4: shoulder elevation
 C5: shoulder abduction
 C6: elbow flexion &/or wrist extension
 C7: elbow extension &/or wrist flexion
 C8: thumb extension &/or ulnar deviation
 T1: abduction &/or adduction of hand
intrinsics
Myotomes
 L1-L2: hip flexion
 L3: knee extension
 L4: ankle dorsiflexion
 L5: toe extension
 S1: ankle PF, ankle eversion, hip
extension
 S2: knee flexion
Common Deep Tendon Reflexes
 Jaw (CN V)
 Mandible, mouth closes
 Biceps (C5-C6)
 Biceps tendon, biceps contraction
 Brachioradialis (C6) **
 Triceps (C7-C8)
 Distal triceps tendon above the olecranon
process, elbow extension

**Giles, S. PT Exam: The Complete

Study Guide. 2008.
Common Deep Tendon Reflexes
 Patella (L3-L4)
 Patellar tendon, leg extension
 Medial hamstrings (L5, S1)
 Semimembranosus tendon, knee flexion
 Lateral hamstrings (S1-S2)
 Biceps femoris tendon, knee flexion
 Tibialis posterior (L4-L5)
 Tibialis posterior tendon behind medial
malleolus, PF with inversion
 Achilles (S1-S2)
 Achilles tendon, PF of the foot
Deep Tendon Reflex Grading
0 Absent
1 Diminished
2 Average (Normal)
3 Exaggerated
4 Clonus, very brisk
Superficial Reflexes
 Upper abdominal (T7-T9)
 Umbilicus moves up & toward the area being
stroked
 Lower abdominal (T11-T12)
 Umbilicus moves down & toward the area
being stroked
 Cremasteric (T12, L1)
 Scrotum elevates
Superficial Reflexes
 Plantar (S1-S2)
 Flexion of toes
 Gluteal (L4-L5, S1-S3)
 Skin tenses in gluteal area
 Anal (S2-S4)
 Contraction of anal sphincter muscles
Pathological Reflexes
 Babinski’s
 Stroking of the lateral aspect of side of foot
 Chaddock’s
 Stroking of lateral side of foot beneath lateral
malleolus
 Oppenheim’s
 Stroking of anteromedial tibial surface
 Gordon’s
 Squeezing of calf muscles firmly
Pathological Reflexes
 Hoffmann’s
 Flicking of terminal phalanx of index, middle,
or ring finger
 Rossolimo’s
 Tapping of the plantar surface of the toes
 Schaeffer’s
 Pinching of the Achilles tendon in middle third
Muscle Tone
 Palpation
 Passive motion testing
 Pendulum test
Grading of Tone
 0 No response (flaccidity)
 1+ Decreased response (hypotonia)
 2+ Normal response
 3+ Exaggerated response (mild-
moderate hypotonia)
 4+ Sustained response (severe
hypertonia)
Modified Ashworth Scale
Cranial Nerve Assessment
 Olfactory Nerve (I)
 Use aromatic non-irritant materials
 Optic Nerve (II)
 Visual acuity
 Severe deficit – Can patient see light or movement?
Can patient count fingers?
 Mild deficit – Wall or hand chart
 Visual Fields
 Pupils – size, shape, equality, reaction to light,
reaction to accommodation & convergence
Cranial Nerve Assessment
 Oculomotor Nerve (III), Trochlear Nerve
(IV), Abducens Nerve (VI)
 Pupillary response to light
 Presence of ptosis
 Ocular movement
 Conjugate movement
 Nystagmus
Cranial Nerve Assessment
 Trigeminal Nerve (V)
 Facial sensation over whole face
 Corneal reflex
 Temporalis & masseter muscles
 Jaw jerk
Cranial Nerve Assessment
 Facial Nerve (VII)
 Facial muscles
 Taste
 Vestibulocochlear Nerve (VIII)
 Conductive vs Sensorineural deafness
 Weber’s test, Rinne’s test
 Vestibulo-ocular reflex
Cranial Nerve Assessment
 Glossopharyngeal Nerve (IX), Vagus
Nerve (X)
 Voice
 Swallowing
 Gag reflex
 Accessory Nerve (XI)
 SCM & trapezius
 Hypoglossal Nerve (XII)
 Tongue
POSTURAL ASSESSMENT
 Standing
 Forward flexion
 Sitting
 Supine lying
 Prone lying
Anterior View
 Head in midline
 Jaw posture is normal
 Tip of the nose is in line with the
manubrium sternum, xiphisternum, &
umbilicus
 Trapezius neck line is equal on both sides
 Shoulders are level
 Clavicles & AC joints are equal & level
 Waist angles are equal
Anterior View
 Carrying angle at each elbow is equal
 Palms of both hands face the body in the
relaxed standing position
 High points of the iliac crest are the same
height on each side
 ASIS are level
 Pubic bones are level at the symphysis
pubis
 Patellae of the knees point straight ahead
Anterior View
 Knees are straight
 Heads of the fibula are level
 The medial & lateral malleoli of the ankles
are level
 Two arches are present in the feet & equal
on the 2 sides
 Feet angle out equally
 No bowing of bone
Lateral View
 Ear lobe is in line with the tip of the
shoulder & the high point of the iliac crest
 Each spinal segment has a normal curve
 Shoulders are in proper alignment
 Chest, abdominal, & back muscles have
proper tone
 No chest deformities
 Pelvic angle is normal
 Normal knee alignment
Posterior View
 Head in midline
 Shoulders level
 Spines & inferior angles of the spine are
level
 Spine is straight
 Ribs protrude or are symmetric on both
sides
 Waist angles are level
 Arms are equidistant from the body &
equally rotated
Posterior View
 PSIS are level
 Gluteal folds are level
 Knee joints are level
 Both of the Achilles tendons descend
straight to the calcanei
 Note for bowing of bone
Forward Flexion
 Asymmetry of the rib cage
 Asymmetry in the spinal musculature
 Presence of kyphosis
 If lumbar spine straightens or flexes as it
normally should
 Presence of any restriction to forward
bending
GAIT ASSESSMENT
Stance Phase Swing Phase
 Initial contact  Initial swing
 Load response  Midswing
 Midstance  Terminal swing
 Terminal stance
 Preswing
Normal Parameters of Gait
 Base width
 Distance between the 2 feet
 5 – 10 cm (2 – 4 inches)
 Step length
 Distance between 2 successive contact points
on opposite feet
 35 – 41 cm (14 – 16 inches)
 Stride length
 Distance between successive points of foot-to-
floor contact of the same foot
 70 – 82 cm (27.5 – 32.3 inches)
Normal Parameters of Gait
 Lateral pelvic shift
 Side-to-side movement of the pelvis during walking
 2.5 – 5 cm (1 – 2 inches)
 Vertical pelvic shift
 Keeps the COG from moving up & down more than 5 cm
(2 inches)
 Pelvic rotation
 Decreases the amplitude of displacement along the path
travelled by the COG & thereby decreases the COG dip
 8 degrees (4 degrees forward on the swing leg & 4
degrees posteriorly on the stance leg)
Normal Parameters of Gait
 Center of gravity
 5 cm (2 inches) anterior to S2
 Normal cadence
 90 – 120 steps/minute
FUNCTIONAL ASSESSMENT
 Measures how a person does certain
tasks or fulfills certain roles in the
various dimensions of living
 Method of describing abilities &
activities in order to measure an
individual’s use of the variety of skills
included in performing the tasks
necessary to daily living, vocational
pursuits, social interactions, leisure
activities, & other required behaviors
Functional Activity
 Encompasses all
those tasks,
activities, & roles
that identify the
person as an
independent adult
or as a child
progressing toward
adult independence
Purposes
 Baseline information for setting
function-oriented goals & outcomes of
intervention
 Indicators of a patient’s initial abilities &
progression toward more complex
functional levels
 Criteria for placement decisions
Purposes
 Manifestations of an individual’s level of
safety in performing a particular task &
the risk of injury for continued
performance
 Evidence of the effectiveness of a specific
intervention on function
Major Considerations in Selecting
a Functional Assessment Tool
1. Appropriateness to the target
population
2. Practical aspects of test administration
3. Psychometric properties
Multidimensional Functional
Assessment Tools
 Functional Independence Measure (FIM)
 Barthel Index
 Katz Index of ADL
 Sickness Impact Profile (SIP)
 Outcome and Assessment Information
Set (OASIS)
Functional Independence Measure
(FIM)
 18-item measure of physical, psychological, &
social function which is part of the Uniform
Data System for Medical Rehabilitation
(UDSMR)
 Usable by any trained health care
professional regardless of discipline & has
been judged acceptable by clinicians in the
medical rehabilitation field
Functional Independence Measure
(FIM)
 Documentation consists of recording what a
person actually does, not what that person
could do under certain circumstances
 A comprehensive instrument that captures
data on self-care, sphincter control, transfers,
locomotion, communication, & social
cognition
Functional Independence Measure
(FIM)
 7-point scale to measure gradations in
independent & dependent behaviors
 Includes a no helper category (6-7) & helper
category (1-5)
 Scores range from high of 126 to a low of 18
 Unweighted, ordinal scale
 Definitions for each level of
dependence/independence are given according to
functional label
Functional Independence Measure
(FIM)
 Target population: all rehabilitation clients
 Time required to complete an assessment
is approximately 20 minutes
 Minimal cost to administer
 Training needed
Functional Independence Measure
(FIM)
 Items displayed on one page, scores can
be recorded easily & observed at 3 or
more different points in time (admission,
discharge, follow-up)
Functional Independence Measure
(FIM)
 Established face validity, content validity
 High interrater reliability, high correlation
on individual items
 Established ability to capture change in
patient’s level of function
Barthel Index
 Widely used to monitor functional changes
in individuals receiving in-patient
rehabilitation, particularly in predicting the
functional outcomes associated with stroke
 Specifically measures the degree of
assistance required by an individual on 10
items of mobility & self-care ADL
 Has been used in rehabilitation research &
practice for more than 30 years
 At least 5 versions have been used
Barthel Index
 10 category, weighted index, perfect score of
100
 Each subscale, as well as the entire Barthel
index, gives a numerical score
 Data are aggregated
 A score of 60 represents the cutoff between
independence & more marked dependence
 A score of 40 or below indicates severe
dependence and 20 or below reflects total
dependence
Barthel Index
 Target population: adult population, all
diagnoses
 Time to complete assessment is
approximately 20 minutes if
performance observed; 5 minutes if
verbal information by client
 Minimal cost to administer
 Maybe completed by any health care
professional
Barthel Index
 Well-established validity
 Satisfactory reliability
 Lacks sensitivity
Katz Index of Activities
of Daily Living
 Originallydeveloped for use with
institutionalized patients but has
been adapted for use in community
based populations
 Katz Index of Activities
of Daily Living
 Focuses on patient performance & degree
of assistance required in 6 categories of
basic ADL – bathing, dressing, toileting,
transferring, continence, & feeding
 Uses both direct observation & patient
self-report over a 2-week period
Katz Index of Activities
of Daily Living
 The 6 major functional categories are
scored from A to G or Other, with A being
totally independent & G being totally
dependent in ADL
 Scoring based on the patient’s ability to
perform a task with or without assistance
from another person
Katz Index of Activities
of Daily Living
 The examiner scores 1 point for each
activity that is performed without human
help; a score of 0 is given if the activity is
performed with human assistance or is not
performed
Katz Index of Activities
of Daily Living
 Target population: all adults, children
 Time to complete assessment has not
been reported
 Minimal cost; common everyday objects
used
 Need for training has not been reported
Katz Index of Activities
of Daily Living
 Established predictive validity
 High test-retest reliability
 Instrumental Activities
of Daily Living Scale
 Designed to provide a simple, reliable,
comprehensive assessment of elderly
people in skills necessary for independent
living in the community
 Can be used to suggest interventions or
serve in the evaluation of progress
Instrumental Activities
of Daily Living Scale
 Includes 8 areas of assessment – ability to
use a telephone, shopping, food
preparation, housekeeping, laundry, mode
of transportation, responsibility for own
medications, & ability to handle finances
 Instrumental Activities
of Daily Living Scale
 Scores are based on observation of
behavior & need for assistance
 The 8 categories are rated according to 3-
5 levels of independence
 More suitable for women; when
administered to men, food preparation,
housekeeping, & laundry are eliminated
Instrumental Activities
of Daily Living Scale
 Lack of validity & reliability measures
Sickness Impact Profile (SIP)
 Developed to provide an appropriate &
sensitive measure of health status to
assess the outcome of health care
services
 Behaviorally-based instrument
 Can be used across types & severity of
illness, as well as across
demographically & culturally diverse
groups
Sickness Impact Profile (SIP)
 Contains 136 items in 12 categories of
activities
 sleep & rest
 eating
 work
 home management
 recreation & pastime
 ambulation
 mobility
Sickness Impact Profile (SIP)
 body care & movement
 social interaction
 alertness/intellectual functioning
 emotional behavior
 communication
Sickness Impact Profile (SIP)
 Either self-administered or administered
by an interview in 20-30 minutes
 SIP scores are percentage ratings based
on the ratio of the summed scale scores
to the summed values of all SIP items
 Higher scores indicate greater dysfunction
 Scoring takes 5-10 minutes with a
calculator
Sickness Impact Profile (SIP)
 Established test-retest reliability &
inter-rater reliability
 Established reliability of actual items
Outcome & Assessment
Information Set (OASIS)
 Designed to assure the collection of
pertinent data on the adult patient in the
home care setting that would allow home
health agencies to assess the quality of
care by measuring the outcomes of care
Outcome & Assessment
Information Set (OASIS)
 Contains 79 core items covering
sociodemographic characteristics,
environmental factors, social support,
health status, & functional status
Outcome & Assessment
Information Set (OASIS)
 Items are meant to be integrated into the
clinical record to highlight various aspects
of the patient’s status that identify
particular needs for care upon admission,
at follow-up every 60 days, and at
discharge
Outcome & Assessment
Information Set (OASIS)
 Can be administered by any health
professional
 Ease of administration increases with
familiarity with the instrument
 Response sets that accompany each item
are specifically matched to the item
Outcome & Assessment
Information Set (OASIS)
 Composed of 14 different items
including grooming, dressing the upper
body, dressing the lower body, bathing,
toileting, transfers,
ambulation/locomotion, feeding, meal
preparation, transportation, laundry,
housekeeping, shopping, & ability to
use the telephone
Outcome & Assessment
Information Set (OASIS)
 Reliability testing is still ongoing
MOBILITY ASSESSMENT
 Timed up and go test
 Timed chair rise
 Six-minute walk test
 Gait speed
Timed Up & Go Test (TUG)
 Quick & practical method of testing
basic mobility maneuvers
 Widely used performance-based
measure of functional mobility in
community dwelling adults
Timed Up & Go Test (TUG)
 The patient is seated comfortably in a
firm chair with arms & back resting
against chair; the patient is instructed
to rise, stand still momentarily, & then
walk 3 meters at normal walking speed,
turn 180 degrees, return to the chair,
turn & sit down
Timed Up & Go Test (TUG)
 Tape is used to mark the walking
distance and turning point
 Timing with a stopwatch begins when
the patient is instructed with “go” and
ends when the patient returns to the
start position in the chair
Timed Up & Go Test (TUG)
 The score is the time it takes (in
seconds) to complete the task
 Most adults can complete the test in 10
seconds
 scores of 11-20 seconds are considered
within normal limits for frail or elderly
individuals with a disability
 scores over 20 seconds are indicative of
impaired functional mobility
Timed Up & Go Test
 Very high interrater & intrarater
reliability
 Demonstrated concurrent validity
Timed Chair Rise
 Used to examine functional status,
lower extremity muscle force, & balance
in older adults
 Consists of timing an individual rising
from a standard chair without the use
of the arms for support on the chair
Timed Chair Rise
 The grade is able or unable
 If the grade is able, the seconds it took to
complete the test is recorded
 If the grade is unable, the individual is
tested with the use of the arms for support
on the chair
Timed Chair Rise
 Time to complete 5 chair stands has also
been used to reflect lower extremity
muscle force, balance & functional mobility
Timed Chair Rise
 Established test-retest & interrater
reliability
 Established concurrent & construct validity
Six-Minute Walk Test
 Measure of exercise tolerance &
endurance for community dwelling older
adults
 Easy to administer
 Consists of measuring the distance a
person can walk in 6 minutes
Six-Minute Walk Test
 Patient is instructed to walk at his/her
own pace and stop to rest if needed &
to cover as much distance as possible
 Study mean walk distance in older
adults - 2117 feet
 men - 1188 feet
 women - 1089 feet
Six-Minute Walk Test
 Mean distance covered by inactive older
individuals - 901 feet
 Mean distance covered by active older adults -
1629 feet
Six-Minute Walk Test
 Lack of standardization in administering
the test
 Demonstrated reliability & validity on a
representative sample of community
dwelling older adults
Gait Speed
 Used to describe & monitor mobility &
to screen for falls in older adults
 Easy to measure
 Consists of timing an individual while
he/she walks at a habitual pace over a
known distance
Gait Speed
 Distances used to calculate gait speed
have ranged from 6 to 20 meters
 Normal gait speed in healthy, young
adults – 1.2 to 1.5 m/s; older adults -
0.9 to 1.3 m/s
Gait Speed
 Established reliability & validity
COORDINATION ASSESSMENT
 Equilibrium tests
 Non-equilibrium tests
Non-Equilibrium
Coordination Tests
 Finger to nose
 Finger to therapist’s finger
 Finger to finger
 Alternate nose to finger
 Finger opposition
 Mass grasp
 Pronation/supination
Non-Equilibrium
Coordination Tests
 Tapping
 Pointing & past pointing
 Alternate heel to knee; heel to toe
 Toe to examiner’s finger
 Heel on shin
 Drawing a circle
 Fixation or position holding
Equilibrium Coordination Tests
 Standing in a normal, comfortable posture
 Standing, feet together
 Standing, tandem position
 Standing on one foot
 Arm position may be altered in each of the
above postures
Equilibrium Coordination Tests
 Displace balance unexpectedly
 Standing, alternate between forward trunk
flexion & return to neutral
 Standing, laterally flex trunk to each side
 Standing EO & EC
 Standing in tandem position EO & EC
Equilibrium Coordination Tests
 Tandem walking
 Walking along a straight line or on floor
markers
 Walking sideways, backward, or cross
stepping
 March in place
 Alter speed of ambulatory activites
Equilibrium Coordination Tests
 Stop & start abruptly while walking
 Walk & pivot
 Walk in a circle, alternate directions
 Walk on heels or toes
 Walk with horizontal & vertical head turns
 Step over or around obstacles
 Stair climbing
 Agility activities
Grading
 5 Normal performance
 4 Minimal impairment: able to accomplish,
slightly less than normal speed, requires
supervision/minimal contact guarding
 3 Moderate impairment: able to
accomplish activity; movements are
slow, awkward, & unsteady; requires
moderate contact guarding
 2 Severe impairment: able to initiate activity
without completion; requires maximal contact
guarding
 1 Activity impossible
BALANCE ASSESSMENT
 Functional Reach Test (FR)
 Maximal distance one can reach forward
beyond arm’s length while maintaining a fixed
BOS in the standing position
 Multidirectional Reach Test (MDFR)
 How far the individual can reach in the
forward, backward, & lateral directions
Berg Balance Scale
 Objective measure of static & dynamic
balance abilities
 14 functional tasks performed in everyday life
 Scores ranging from 0 – 4
 Maximum of 56 points possible
 Sensitive measure for low-functioning adults
 Scores of 45 or below is associated with a
high fall risk & each one-point drop in scores
ranging from 54 – 36 is associated with a
6 – 8% increase in fall risk
PULMONARY ASSESSMENT
 General appearance of the patient
 Analysis of chest shape & dimensions
 Posture & preferred positioning
 Breathing pattern
 Chest mobility
 Palpation
 Mediate percussion
 Auscultation
 Cough & cough production
General Appearance of the Patient
 Level of awareness
 Alert, responsive, or cooperative versus
lethargic, disoriented, or inattentive
 Body type
 Normal, obese, or cachectic
 Color
 Cyanosis peripherally or centrally
 Facial signs or expressions
 Nasal flaring, sweating, or distressed
appearance
General Appearance of the Patient
 Jugular vein engorgement
 Hypertrophy of or use at rest of accessory
muscles of ventilation
 Supraclavicular or intercostal retractions
occurring with inspiration
 Use of pursed-lip breathing
 Clubbing of digits
 Peripheral edema
Chest Shape & Dimensions
 AP & lateral dimensions are usually 1:2
 Common chest deformities
 Barrel chest
 Pectus excavatum
 Pectus carinatum
Posture or Preferred Positioning
 Sitting or standing
 Lean forward on their hands or forearms
 Elevation of shoulder girdle
 Resting or sleeping
 Head-up position
Breathing Pattern
 Normal respiratory rate – 12 to 20
breaths/minute
 Normal ratio of inspiration to expiration at
rest – 1:2
 Normal ratio of inspiration to expiration
with activity – 1:1
Abnormal Breathing Patterns
 Dyspnea
 Distressed, labored breathing
 Tachypnea
 Rapid, shallow breathing
 Decreased tidal volume but increased rate
 Bradypnea
 Slow rate with shallow or normal depth & regular rhythm
 Hyperventilation
 Deep, rapid respiration
 Increased tidal volume & increased rate of respiration
 Regular rhythm
Abnormal Breathing Patterns
 Orthopnea
 Difficulty breathing in the supine position
 Apnea
 Cessation of breathing in the expiratory phase
 Apneusis
 Cessation of breathing in the inspiratory phase
 Cheyne-Stokes
 Cycles of gradually increasing tidal volumes,
followed by a series of gradually decreasing
tidal volumes, & then a period of apnea
Chest Mobility: Symmetry
 Upper lobe expansion: tips of the thumbs
at the midsternal line at the sternal notch;
extend fingers above the clavicles
 Middle lobe expansion: tips of the thumbs
at the xiphoid process; extend fingers
laterally around the ribs
 Lower lobe expansion: tips of the thumbs
along the patient’s back at the spinous
process (lower thoracic level); extend
fingers around the ribs
Chest Mobility: Extent of Excursion
 Measure the girth of the chest with the
tape measure at 3 levels (axilla, xiphoid,
lower costal). Document change in girth
after a maximum inspiration & maximum
expiration.
 Place both hands on the patient’s chest or
back as previously described. Note the
distance between your thumbs after a
maximum inspiration.
Palpation
 Tactile fremitus
 Chest wall pain
 Mediastinal shift
Mediate Percussion
 To assess lung density in the lungs
 Dull & flat sound
 Greater than normal amount of solid matter in
the lungs in comparison with the amount of air
 Hyperresonant (tympanic) sound
 Greater than normal amount of air in the area
Auscultation of Breath Sounds
 T2, T6, T10
 Location, pitch & intensity, & the ratio of
sounds heard on inspiration versus
expiration
Normal Breath Sounds
 Vesicular
 Soft, low-pitched, breezy, but faint sounds
 Heard over most of the chest except near the
trachea & mainstem bronchi & between the
scapulae
 Audible considerably longer on inspiration than
expiration (3:1)
Normal Breath Sounds
 Bronchial
 Loud, hollow, or tubular, high-pitched sounds
 Heard over the mainstem bronchi & trachea
 Heard equally during inspiration & expiration
 A slight pause in the sound occurs between
inspiration & expiration
Normal Breath Sounds
 Bronchovesicular
 Softer than bronchial breath sounds
 Heard in the supraclavicular, suprascapular, &
parasternal regions anteriorly & between the
scapulae posteriorly
 Heard equally during inspiration & expiration
but without a pause in the sound between
cycles
Adventitious Breath Sounds
 Crackles
 Rales
 Fine, discontinuous sounds (bubbles popping
or hairs being rubbed between your fingers
next to your ear)
 Heard primarily during inspiration
 Wheezes
 Rhonchi
 Continuous high- or low-pitched sounds or
sometimes musical tones heard during
exhalation but occasionally audible during
inspiration
Cough & Cough Production
 Strength, depth, length, frequency
 Productivity & secretions
 Color (clear, yellow, green, blood-stained)
 Consistency (viscous, thin, frothy)
 Amount (minimal to copious)
 Odor (no odor to foul-smelling)
CARDIOVASCULAR ASSESSMENT
 Auscultation of heart sounds
 Evaluation of arterial sufficiency
 Evaluation of venous sufficiency
 Evaluation of lymphatic function
Auscultation: Normal Heart Sounds
 S1 (Lub)
 Occurs at the time of
mitral & tricuspid valve
closure & marks the
beginning of systole
 S2 (Dub)
 Occurs at the time of
aortic & pulmonic valve
closure & marks at the
beginning of systole
Auscultation: Normal Heart Sounds
 Systolic murmur
 Audible turbulence between S1 & S2
 Diastolic murmur
 Audible turbulence between S2 & S3
 S3 (ventricular gallop)
 After S1, clinically associated with left
ventricular failure
 S4 (atrial gallop)
 Before S1, associated with MI or chronic
hypertension
Evaluation of Arterial Sufficiency
 Palpation of pulses
 Skin temperature
 Skin integrity & pigmentation

 Test for rubor/reactive hyperemia

 Claudication time
Evaluation of Venous Sufficiency
 Girth measurements
 Percussion test
 Tests for DVT
 Homan’s sign
 Application of blood pressure cuff around the
calf
Evaluation of Lymphatic Function
 Skin integrity
 Girth measurements
Severity of Lymphedema
 Mild lymphedema
 1 to 2 cm increase in girth measurements
between the involved & non-involved limbs
 Moderate lymphedema
 2 to 5 cm increase in girth measurements
between the involved & non-involved limbs
 Severe lymphedema
 > 5 cm increase in girth measurements
between the involved & non-involved limbs
Types of Lymphedema
 Pitting edema
 Pressure on the edematous tissues with the
fingertips causes an indentation of the skin
that persists for several seconds after the
pressure is removed
 Reflects significant but short-duration edema
with little or no fibrotic changes in skin &
subcutatneous tissue
Types of Lymphedema
 Brawny edema
 Pressure on the edematous areas feels hard
with palpation
 Reflects a more severe form of interstitial
swelling with progressive, fibrotic changes in
subcutaneous tissues
 Weeping edema
 Most severe & long-duration form of
lymphedema
 Fluids leak from cuts & sores; wound healing is
significantly impaired
 Occurs almost exclusively in the lower
extremities
WOUND ASSESSMENT
 Wound location
 Wound size
 Tunneling or undermining
 Wound bed
 Wound edges
 Wound drainage
 Wound odor
Wound Characteristics
 If necessary, the wound is debrided
and/or rinsed prior to treatment
 Strive for consistency of measurements
 The patient should be positioned the same
manner each time
 The same clinician should remeasure the
patient each time
 A good light source that can be
manipulated to reduce shadows & glare
is beneficial
Wound Location
 Document using anatomically correct
terminology
 Document the side and body surface of
the lesion
 If multiple wounds exist, it may be
helpful to document wounds in relation
to anatomical landmarks
Wound Size
 Should NOT be estimated
 Should not be documented in
relationship to common objects
 “The wound is the size of a quarter”
 Can be determined by
 Direct measurement
 Tracings
 Photography
 Volumetric measurement
 Percent of total body surface area
Wound Size:
Direct Measurement
 Performed by
measuring the
longest length of the
wound and the
widest width
perpendicular to this
length
 Wound surface area
is computed by
multiplying length by
width
Wound Size:
Direct Measurement
 Wound Depth
 Measured by placing a probe in the deepest
part of the wound bed & noting the point at
which the probe is level with the
surrounding intact skin
 Depth measurements can be performed at
standard wound locations using the clock
method
Clock Method
 The 12-o’ clock position is assigned to the
part of the wound closest to the patient’s
head
 In addition to the deepest portion of the
wound, wound depth is also assessed at
varying points around the clock
 E.g., 3-o’ clock, 6-o’ clock, 9-o’ clock,
12-o’ clock
 The measured depth and the
corresponding reference position is
documented
Wound Size:
Direct Measurement
 Simple, fast, easy to learn, reliable, &
inexpensive
 May not adequately reflect wound size, or
changes in wound size, in irregularly
shaped or circular wounds
 It is not possible to accurately determine
the depth of the wound covered with
nonviable tissue
Wound Size: Wound Tracings
 A clean, conformable transparency & a
permanent, fine-tipped pen are required
 Commercially available wound tracing
sheets are used
 Two layers: a wound contact layer and an
adhesive permanent layer that can be
placed in the patient’s permanent record
Wound Size: Wound Tracings
 The wound contact layer is cleaned & rinsed to
prevent contaminating the wound
 The transparency is placed against the wound
while the clinician traces the wound
 The wound contact layer is discarded and the
outer permanent layer is affixed within the
patient’s medical record
 Wound surface area is estimated from the
tracing as previously described
 Wound depth is assessed using the direct
measurement technique
Wound Size: Wound Tracings
 A plastic wrap can also be used
 A clean plastic wrap is folded in half &
placed against the wound
 The wound is traced & the contact
portion of the plastic wrap is discarded
 The clinician photocopies or retraces the
uncontaminated, outer layer of plastic
wrap onto standard or grid paper to
keep as part of the patient’s permanent
record
Wound Size: Wound Tracings
 3 alternative methods of measuring
wound surface area
 Use of transparencies with premeasured
grid marks
 Planimetry
 Digitizing
Wound Size: Wound Tracings
 Simple, fast, easy to learn, reliable, &
inexpensive
 Advantages over direct measurement
 Provides a more accurate representation of
wound size
 Retained image is helpful for future
comparisons
 The main source of error appears to be
visualizing the wound perimeter through the
transparency & the tracing itself, rather than
calculating the area of the tracing
Wound Size:
Photographic Measurement
 Wound surface area can be determined
by tracing the photographic wound
image
 Advantages
 Avoids contact with the patient’s wound
 Provides additional information including
periwound & wound bed characteristics
 Equipment available today allows clinicians
with minimal photographic skill &
knowledge to obtain fairly consistent, high-
quality wound images
Wound Size:
Photographic Measurement
 Disadvantages
 Prone to errors in scale
 Both camera distance from the wound &
camera angle can influence the resulting
image size
 Inconsistent lighting conditions may also
make photographic wound assessment
problematic
 Costly & time-consuming
Wound Size:
Volumetric Measurement
 Measuring either the amount of molding or
saline required to fill the wound void
 Main advantage is that it provides a more
complete illustration of wound size by
portraying the wound in three dimensions
 Disadvantages
 Molding is time consuming & can be painful to the
patient
 It is unclear if the molding material may have
detrimental effects on wound healing
Wound Size:
Volumetric Measurement
 Calculating wound volume by measuring the
amount of saline to fill the wound void is time
consuming, inaccurate, & problematic
 Ensure adequate removal of any wound exudate or
saline prior to filling the wound void
 To avoid saline runoff, the wound must be either
positioned with its opening facing directly
perpendicular to the line of gravity or covered with
transparent film prior to filling with saline
 This cannot be used with wound that extend to body
cavities or fascial planes
Wound Size:
Total Body Surface Area (TBSA)
 Used for wounds covering large surface
areas
 Commonly used in patients with burn
injuries
 Quick, inexpensive, & reliable method
of estimating wound size
Tunneling/Undermining
 Tunneling
 Narrow passageway created by the
separation of, or destruction to fascial
planes
 Common in neuropathic ulcerations &
surgical wounds
 Measured by inserting a probe into the
passageway until resistance is felt
Tunneling
 Tunnel depth is the
distance from the
probe tip to the point
at which the probe is
level with the wound
edge
 Clinicians should use
clock terms to
identify the tunnel’s
position within the
wound bed
Tunneling/Undermining
 Undermining
 Occurs when the tissue under the wound
edges become eroded, resulting in a large
wound with a small opening
 More commonly found in patients with
pressure or neuropathic ulcers
 Generally encompasses a wider area
 Measured by inserting a probe under the
wound edge directed almost parallel to the
wound surface until resistance is felt
Undermining
 Amount of
undermining is the
distance from the
probe tip to the point
at which the probe is
level with the wound
edge
 Clock areas are also
used to identify the
area of undermining
Wound Bed
 May contain varying types & amounts of
granulation tissue, necrotic tissue, & other
structures
 Granulation tissue
 A temporary scaffolding of vascularized connective
tissue that fills the wound void
 Healthy granulation tissue has a beefy red
appearance
 Granulation tissue that is pale or dusky in color or
friable has poor blood supply or may be infected
 Document the characteristics of granulation tissue &
the percent of the wound bed it occupies
Wound Bed
 Necrotic tissue
 Should be described by color, consistency,
& percent of the wound bed that the tissue
occupies
 Slough is yellow or tan in color & has a
stringy or mucinous consistency
 Eschar is black necrotic tissue that may be
either soft or hard
Wound Bed
 Necrotic tissue
 Should also be described as adherent or
nonadherent to the wound bed
 Adherence refers to the ease with which the
necrotic tissue can be separated from the
wound
 The greater the depth of the destruction,
the more adherent necrotic tissue tends to
be
Wound Bed
 Other structures
 Exposed structures such a fascia, muscle,
tendon, joint capsule, or bone
 Document the type of structures & its
characteristics & the percent of the wound
bed that these structures occupy
 The presence of other items, such as
sutures, staples, foreign material, or
implants, should also be noted & described
Wound Edges
 Wound edge is the tissue at the
perimeter of the wound
 Note the following characteristics
 Distinctness
 Thickness
 Color
 Attachment to the base of the wound
Wound Edges
 Distinctness
 Some superficial wounds present with indistinct
wound edges when the wound gradually transitions
into intact skin
 Deeper wounds have more distinct & well-defined
wound margins
 Thickness
 Chronic wounds may present with thickened or rolled
wound edges
 Hyperkeratosis, or callus-like tissue is often seen at
the edges of wounds due to diabetes & peripheral
neuropathy
Wound Edges
 Attachment
 Wounds with attached edges are flush with
the surrounding tissue, whereas wounds
with unattached edges are deep & wound
side walls are evident
 Wounds with attached edges tend to
progress more quickly than wounds with
unattached edges
 Note evidence of epithelialization,
scarring, or pigment changes
Wound Drainage
 Assess & document the following
characteristics of wound drainage or
exudate
 Type
 Color
 Consistency
 Amount
Wound Drainage: Type
 Serous
 Protein-rich fluid with few WBC that is
generally seen in the inflammatory phase of
wound healing
 Clear to pale yellow
 Watery consistency
 Sanguinous
 Results from bleeding at the wound site
 Red (fresh) or dark brown (dehydrated)
 Consistency of blood or slightly thickened
water
Wound Drainage: Type
 Purulent
 Indicates wound infection
 White to pale yellow
 Certain infections have a characteristic drainage
color
 Blue-green indicates probable Pseudomonas
infection
 Viscous or creamy consistency
Wound Drainage: Amount
 None
 Desiccated wound bed
 Minimal
 Moderate
 Normal; however, wounds with drainage
that is disproportionate to the amount of
necrotic tissue may be infected
 Copious
 Possible infection, especially if out of
proportion to wound size
Wound Odor
 Highly subjective measure
 Should be assessed after the wound has
been debrided & cleansed
 Described as either present or absent
 Wounds with necrotic tissue are likely to
have at least a mild odor
Periwound & Associated Skin
Characteristics
 Structure & quality
 Color
 Epithelial appendages
 Edema
 Temperature
Structure & Quality
 Normal age-related skin changes
 Periwound hydration
 Anhydrous tissue: dry, scaly, or cracked
 Moist tissue: macerated
 Skin turgor
 Assessed by lifting up the tissue to be
tested between the thumb & index finger
 Note if there is a delay before the skin
returns to its normal position
Structure & Quality
 Presence & location of any calluses
 Scar formation
 Assess quality of scar tissue: thickness,
mobility, & color
 Presence of any deformities & describe
any deviations
 Varicosities, skin rashes
Color
 Describe color of the periwound &
associated skin in relation to both
neighboring skin & comparable skin on the
contralateral side
 Erythema
 An indicator of inflammation but if out of
proportion to the size & extent of the
wound, may indicate infection
 Blanchable or non-blanchable
 Amount should be quantified by measuring
how far the redness extends from the
wound edge
Color
 Skin that appears lighter or paler than
surrounding tissue may indicate
decreased blood supply or newly
formed scar tissue that has not yet
regained normal pigment
 Skin that is blue in color generally
represents areas of severe &/or
prolonged ischemia
 Hyperpigmentation of intact skin may
indicate long-standing venous
insufficiency
Epithelial Appendages
 Assess presence & quality of epithelial
appendages, including hair & nail
growth
 Areas of long-standing ischemia will be
unable to support hair growth;
particularly evident in the lower
extremity
 Prolonged ischemia also increases the
risk of nail fungal infections, making
them appear thick & yellow
Edema
 Assess for edema & induration
 Describe as pitting or non-pitting
 Quantify via circumferential
measurements or volumetric
displacements
Temperature
 Increase in temperature – inflammation
or infection
 Decrease in temperature – impaired
circulation
 Prior to testing, the patient should rest
supine with the area to be examined
uncovered for at least 5 minutes
 Assess skin surface temperature of
dorsum of the hand by lightly palpating
with the back of the hand
Temperature
 Temperature should be compared with
more proximal body segments & the
contralateral side
 Recorded as increased, normal, or
decreased
Questions
You are documenting the subjective
information you have gathered from
your patient. Which part of your
subjective assessment lists the patient’s
possible use of nicotine, alcohol or
drugs?
a. History of present illness
b. Past medical history
c. Personal history
d. Social history
You are documenting the subjective
information you have gathered from
your patient. Which part of your
subjective assessment lists the patient’s
possible use of nicotine, alcohol or
drugs?
a. History of present illness
b. Past medical history
c. Personal history
d. Social history
You are evaluating the gait of one of
your patients. The following are
considered normal parameters of gait,
EXCEPT
a. Base width of 8 cm
b. Step length of 35 cm
b. Cadence of 105 steps per minute
c. Stride length of 45 cm
You are evaluating the gait of one of
your patients. The following are
considered normal parameters of gait,
EXCEPT
a. Base width of 8 cm
b. Step length of 35 cm
b. Cadence of 105 steps per minute
c. Stride length of 45 cm
You are doing MMT of the facial muscles
of your patient. You noted that the
patient is unable to open her ® eye wide
when instructed to do so. Which of the
following nerve is most likely affected?
a. Facial nerve
b. Oculomotor nerve
c. Trigeminal nerve
d. Abducens nerve
You are doing MMT of the facial muscles
of your patient. You noted that the
patient is unable to open her ® eye wide
when instructed to do so. Which of the
following nerve is most likely affected?
a. Facial nerve
b. Oculomotor nerve
c. Trigeminal nerve
d. Abducens nerve
A patient was referred to your facility
because of OA of the cervical spine. In
testing the ROM of the patient’s cervical
extension, where should the fulcrum of
the goniometer be aligned?
a. Dorsal midline of the head, using the
occipital protuberance for reference
b. Over the external auditory meatus
c. Base of the nares
d. Over the spinous process of the C7
vertebra
A patient was referred to your facility
because of OA of the cervical spine. In
testing the ROM of the patient’s cervical
extension, where should the fulcrum of
the goniometer be aligned?
a. Dorsal midline of the head, using the
occipital protuberance for reference
b. Over the external auditory meatus
c. Base of the nares
d. Over the spinous process of the C7
vertebra
Mrs. Y walks in your clinic for PT
evaluation & treatment. She complains
of a deep, boring localized pain (VRS
8/10) on the distal third of her ®
forearm after protecting herself from a
fall. Which structure is most likely
affected?
a. Muscle
b. Bone
c. Nerve root
d. Vasculature
Mrs. Y walks in your clinic for PT
evaluation & treatment. She complains
of a deep, boring localized pain (VRS
8/10) on the distal third of her ®
forearm after protecting herself from a
fall. Which structure is most likely
affected?
a. Muscle
b. Bone
c. Nerve root
d. Vasculature
You are assessing a patient with an UMNL.
If you squeeze the patient’s calf firmly,
what pathological reflex are you assessing?
a. Oppenheim’s
b. Chaddock’s
b. Schaeffer’s
d. Gordon’s
You are assessing a patient with an UMNL.
If you squeeze the patient’s calf firmly,
what pathological reflex are you assessing?
a. Oppenheim’s
b. Chaddock’s
b. Schaeffer’s
d. Gordon’s
A patient was referred to you because of an
ulnar nerve injury. The following tests can
assist you in confirming this diagnosis,
EXCEPT
a. Egawa’s sign
b. Pinch grip test
c. Froment’s sign
d. Tinel’s sign at the elbow
A patient was referred to you because of an
ulnar nerve injury. The following tests can
assist you in confirming this diagnosis,
EXCEPT
a. Egawa’s sign
b. Pinch grip test
c. Froment’s sign
d. Tinel’s sign at the elbow
You are assessing the integrity of the
auditory component of your patient’s
vestibulocochlear nerve. During the
Weber’s test, the patient noted that the
sound he heard is louder in the normal ear.
What is this indicative of?
a. Normal hearing
b. Conductive deafness
c. Sensorineural deafness
d. None of the above
You are assessing the integrity of the
auditory component of your patient’s
vestibulocochlear nerve. During the
Weber’s test, the patient noted that the
sound he heard is louder in the normal ear.
What is this indicative of?
a. Normal hearing
b. Conductive deafness
c. Sensorineural deafness
d. None of the above
If a patient underwent ®
pneumonectomy, his trachea will shift to
the left side. If there is consolidation in
the lungs, mediate percussion will
produce a dull, flat sound.
a. Only the first statement is correct
b. Only the second statement is correct
c. Both statements are correct
d. Neither of the statements is correct
If a patient underwent ®
pneumonectomy, his trachea will shift to
the left side. If there is consolidation in
the lungs, mediate percussion will
produce a dull, flat sound.
a. Only the first statement is correct
b. Only the second statement is correct
c. Both statements are correct
d. Neither of the statements is correct
You are assessing a patient with true leg
length discrepancy. You highly suspect that
the patient has coxa vara. Which of the
following measurements will be most
indicative of such condition?
a. ASIS to medial or lateral malleolus
b. Iliac crest to the greater trochanter of the
femur
c. Greater trochanter of femur to the lateral
aspect of the knee joint line
d. Xiphisternum to medial malleolus
You are assessing a patient with true leg
length discrepancy. You highly suspect that
the patient has coxa vara. Which of the
following measurements will be most
indicative of such condition?
a. ASIS to medial or lateral malleolus
b. Iliac crest to the greater trochanter of
the femur
c. Greater trochanter of femur to the lateral
aspect of the knee joint line
d. Xiphisternum to medial malleolus