Fundamentals of the Physical Therapy Examination

Fundamentals of the Physical Therapy Examination • Discriminative Sensation • Spinal tract: posterior columns (plus portions of the cerebral cortex) • Background information: Tests of discriminative sensation require integration, analysis, and interpretation of touch, pressure, and position sense in the sensory cortex. • Four of these tests—stereognosis , graphesthesia, two-point discrimination, and point localization—are described below. • If there is severe impairment of touch sensation or of position sense, a patient’s performance on these tests will likely be poor. • If a patient’s touch sensation and position sense are good or only minimally impaired, an abnormal finding on any of the following tests may indicate a lesion in the somatosensory cortex. • Stereognosis • (defined as “object identification solely by touch”) • Equipment required: objects familiar to most people (paper clip, coin, cotton ball, key, rubber band) • Performing the test: • 1. Ask the patient to close his or her eyes and extend one hand (begin with the unaffected side; if both sides are affected, begin with the dominant hand). • 2. Place the object in the palm of the patient’s hand and ask the patient to identify the object. • 3. Perform several trials on both hands using different objects. • 4. Fine discrimination can be tested by asking the patient to identify the “heads” or “tails” side of a coin or to identify which coin is being held. • 5. The inability to identify common objects is called astereognosis. • Graphesthesia • (defined as “the ability to identify writing on the skin solely by touch”) • Equipment required: the blunt end of a pen or similar object. • Performing the test: • 1. Perform a demonstration with the patient’s eyes open so he or she is oriented to the top and bottom of the “paper” (the patient’s skin) you will write on. • 2. Ask the patient to close his or her eyes and extend one hand (begin with the unaffected side; if both sides are affected, begin with the dominant hand). • 3. Draw a large number in the patient’s palm . • 4. Perform several trials on both hands, using different numbers. • 5. The inability to identify numbers drawn on the skin is called agraphesthesia. • Two-Point Discrimination • Equipment required: two paper clips (unbent to allow for a pointed end) or a special two-point discriminator tool . • Performing the test: • 1. Ask the patient to close his or her eyes and extend one hand (begin with the unaffected side; if both sides are affected, begin with the dominant hand). • 2. On the pad of one finger, touch the patient with two points simultaneously and ask the patient if one or two points are felt. • 3. Alternate touching with one and two points in a random fashion in several places on the fingers and hand. • 4. Normally, individuals can discriminate two separate points that are 5 millimeters apart on the pads of the fingers. • 5. This may be performed on other areas of the body, but normal distances vary substantially from one region to the next. • Point Localization • Equipment required: none Performing the test: 1. Ask the patient to close his or her eyes. 2. Lightly touch an area on the patient’s skin. 3. Ask the patient to open his or her eyes and then point to the place that you touched. • 4. Repeat this on both sides and in various areas of the body. • 5. Persons with intact light touch sensation and an intact somatosensory cortex can usually perform this with good accuracy. • • • • Section 3: Deep Tendon Reflexes • PROCEDURE • Grip- ping the handle of the reflex hammer as you would a construction hammer and creating the tapping motion through movement of your forearm at the elbow will not allow for a quick enough tendon stretch. • The handle should be held somewhat loosely, and the motion should originate from your wrist in a quick “flicking” motion. The force of the tap should be moderate to strong. If the tendon is tapped too lightly, minimal stretch will occur and the muscle spindle may not respond. • The tendon to be tested should be on slight stretch. If you have difficulty locating the tendon, you may ask the patient to gently contract the muscle against your resistance, which should cause the tendon to become taut and more easily palpable. • Once you have located the tendon, the patient must be as relaxed as possible. For some patients this is quite difficult. • Distracting patients by having them volitionally contract muscles in another region of the body is a commonly used technique. Section 4: Coordination • The cerebellum, which means “little brain,” is located under the posterior cerebral hemispheres at the base of the skull . • Although it has been anatomically partitioned in a number of ways, the basic divisions include two lateral hemispheres that surround a narrow medial portion (the vermis). • The primary functions of the cerebellum include movement synergy (does not necessarily cause but greatly influences the quality of motor output through grouping and sequencing of muscle actions), maintenance of upright posture (in conjunction with the vestibular system), and maintenance of muscle tone throughout the body. • In the most simplistic sense, the cerebellar cortex receives a large majority of sensory input via tracts in the spinal cord, as well as other areas of the brain. • This information is then projected to the thalamus and brainstem for further processing. • While sensory input, analysis, and integration are the major functions of the cerebellum, it is considered part of the motor system because cerebellar damage is primarily manifested in motor (postural control, equilibrium, and coordination) dysfunction • A number of conditions can cause cerebellar damage, including cerebellar stroke, head trauma, alcoholism, primary and metastatic tumors, toxins (such as chemotherapy), multiple sclerosis, and some genetic cerebellar-related diseases (such as Friedreich’s ataxia). • The cerebellum is one of the highest consumers of oxygen in the nervous system and is highly sensitive to oxygen deprivation. • Therefore, conditions that temporarily halt circulation or respiration (e.g., ischemic stroke, respiratory or cardiac arrest, carbon monoxide poisoning) can quickly result in cerebellar damage. • The following list briefly describes several global signs of cerebellar dysfunction. • Ataxia : Defined as “without coordination”; demonstrated by volitional movements that lack a smooth trajectory and fine motor control. • Tremor : Typically intention tremor (tremor that begins and increases as the limb reaches a target during a volitional movement) and postural tremor (tremor induced by intentionally maintained head or trunk posture, or that of a limb suspended in front of the body). • Hypotonia : An overall decrease in normal resting muscle tone in the region of the body that corresponds to the lesion or dysfunction. • Dysarthria : Poor control of word formation due to the inability to coordinate the muscles and structures of speech. • Upper Extremity Tests • Rapid Alternating Movements (RAM) • This test typically uses the motions of pronation and supination in the forearm. The patient begins with the arms at the sides and the elbows flexed to 90°. He or she then moves both forearms repetitively from a fully pronated to a fully supinated position. • The motions are repeated for a period of approximately 10–15 seconds. Asking the patient to increase the speed of the alternating movements will increase the difficulty. • Other joints may be assessed using the RAM test, such as ankle dorsiflexion/plantar flexion, knee flexion/extension, elbow flexion/ extension, or finger flexion/extension. Individuals who have significant difficulty producing rapid alternating movements (typically slow, irregular, and clumsy) have an impairment called dysdiadochokinesia. • Finger Opposition • For this test, patients touch the tip of the thumb to the tip of each ipsilateral finger in sequence. • This test may be performed one arm at a time or simultaneously if the patient is able. Increasing the speed of movement increases the difficulty of the test. Reversing the direction of the sequence (index finger → little finger; little finger → index finger) also may increase the difficulty. Two trials should be sufficient to observe the patient’s performance. • Finger to Nose (or Chin) • The patient begins in a seated position with the arms abducted to 90°. With eyes open, the patient brings the tip of the index finger to the tip of his or her nose . • Several trials with each arm can be performed. If you feel the patient is at any risk for missing the nose but poking his or her eye, it is suggested that you instruct the patient to touch the chin instead. • Finger to Clinician Finger • For this test, you should sit directly in front of the patient. Hold your index finger in front of you (not close to your face). Ask the patient to first touch his or her nose with the tip of one finger, then touch the tip of your finger. • Continue this back and forth motion from the patient’s nose to your finger as you move your finger to different target areas. As with the Finger to Nose test above, use the patient’s chin if there is any risk of the patient’s poking himself or herself in the eye. • Patients with cerebellar dysfunction may demonstrate past pointing in which they will “overshoot” the target of your finger . This is also referred to as dysmetria. You may also notice increased hand tremor as the patient’s finger approaches the target of your finger (called intention tremor). • Lower Extremity Tests • Heel to Shin • From supine, ask the patient to place the heel of one foot onto the opposite knee and then run the heel down the shin to the ankle, then back up to the knee . • Toe to Clinician Finger • From supine, ask the patient to touch his or her great toe to your finger and then return the foot to the table. Alter your finger in space after each trial. • Toe Tapping • From seated, in which the patient’s feet are comfortably flat on the floor, ask the patient to repetitively tap the ball of one foot on the floor without raising the leg or lifting the heel from the floor • This can be assessed one foot at a time or with both feet simultaneously. • This test requires that the patient have adequate dorsiflexion active range of motion to lift the forefoot from the floor. If the patient has limited active dorsiflexion, this test can be performed in supine with the patient tapping the palm of your hand. • Tests of Standing or Walking • Tests that require the patient to stand or walk also require balance, range of motion, strength, and equilibrium. • Therefore, each of the following tests will assess much more than the patient’s coordination. • In addition, the patient’s safety must be a priority at all times; a gait belt and/or other appropriate safety equipment should be utilized. • Romberg and Tandem Romberg Tests These tests are also commonly used to assess balance. For the Romberg test, the patient is asked to stand unsupported with the feet together (touching) for up to 30 seconds. • The Sharpened (or Tandem) Romberg test requires the patient to stand unsupported with the heel of one foot touching the toe of the opposite foot. • If a patient is unable to maintain stance in the Romberg position, it is highly unlikely that he or she will be able to stand in tandem. • Gait Abnormalities found with gait tests may be due to a number of problems not related to coordination; these things should be considered prior to initiating a gait test for coordination. • The patient’s typical gait on a flat surface should be observed. • The patient may also be asked to demonstrate tandem gait (stepping with the heel of the swing leg landing just in front of and touching the toes of the stance leg). • For either of these observations, if the patient is at any risk of loss of balance or falls, the use of a gait belt and appropriate guarding must occur.