Professional Documents
Culture Documents
in Occupational·
Therapyand
Physical Therapy
Julia Van Deusen, PliO, OTR/L, FAOTA
Professor
Department of Occupational Therapy
College of Health Professions
Health Science Center
University of Florida
Gainesville, Florida
Assessment
in Occupational
Therapyand
Physical Therapy
W.B. SAUNDERS COMPANY
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ISBN 0-7216-4444-9
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permission in writing from the publisher.
J'Oontributors
ELLEN D. ADAMS, MA, CRC, CCM JERI BENSON, PhD
Executive Director, Physical Restora Professor of Educational Psychology
tion Center, Gainesville, Ronda Measurement Specialization, The Uni
Work Activities versity of Georgia, College of Educa
tion, Athens, Georgia
JAMES AGOSTINUCCI, SeD, OTR Measurement Theory: Application ,.0
Associate Professor of Physical Occupational and Physical Therapy
Therapy, Anatomy & Neuroscience,
Physical Therapy Program, University STEVEN R. BERNSTEIN, MS, PT
of Rhode Island, Kingston, Rhode Assistant Professor, Department of
Island Physical Therapy, Ronda Interna
Motor Control: Upper Motor Neuron tional University, Miami, Ronda
Syndrome Assessment of Elders and Caregivers
vii
vIII CONTRIBUTORS
REFERENCES
DeJong, G. (1987). Medical rehabilitation outcome measurement in a changing health care market. In M. J. Furher
(Ed.), Rehabilitation outcomes: Analysis and measurement (pp. 261-272). Baltimore: Paul H. Brookes.
Johnston, M. v., Keith, R. A., & Hinderer, S. R. (1992). Measurement standards of interdisciplinary medical
rehabilitation. Archilles of Physical Medicine and Rehabllitation, 73, 12-5.
Joint Commission on Accreditation of Healthcare Organizations (1994). A guide to establishing programs for
assessing outcomes in clinical settings. Oakbrook Terrace, IL: JCAHO.
Joint Commission on Accreditation of Healthcare Organizations (1993). The measurement mandate: On the
road to performance improvement in health care. Oakbrook Terrace, IL: JCAHO.
World Health Organization. (1980). International classification of impairment, disability. and handicap.
Geneva, Switzerland: World Health Organization.
KENNETH OrrENBACHER
ce
Our professions of occupational therapy and physical therapy are closely linked by our
mutual interest in rehabilitation. We interact through direct patient service activities, and
students in these fields frequently have courses together in the educational setting. Because
of their common core and the fact that joint coursework is cost effective, it is probable that
in the future more, rather than fewer, university courses wi)) be shared by occupational and
physical therapy students. One type of content that lends itself we)) to such joint study is that
of assessment. Assessment in Occupational Therapy and Physical Therapy is well suited
as a text for graduate students in these joint courses.
Although designed as a text for graduate students in occupational therapy, physical
therapy, and related fields, this book will also meet the needs of advanced clinicians.
Assessment in Occupational Therapy and Physical Therapy is intended as a major
resource. When appropriate, certain content may be found in more than one chapter. This
arrangement minimizes the need to search throughout the entire volume when a specialist
is seeking a limited content area. It is assumed that the therapiSts using this text will have a
basic knowledge of the use of clinical assessment tools. Our book provides the more
extensive coverage and research needed by health professionals who are, or expect to be,
administrators, teachers, and master practitioners. Assessment in Occupational Therapy
and Physical Therapy is not intended as a procedures manual for the laboratory work
required for the entry-level student who is learning assessment skills. Rather, this book
provides the conceptual basis essential for the advanced practice roles. It also provides a
comprehensive coverage of assessment in physical therapy and in occupational therapy.
After a general overview of measurement theory in Unit One, Unit Two covers component
assessments such as those for muscle strength or chronic pain. Unit Three thoroughly
addresses the assessment of motor and of sensory processing dysfunction. In Unit Four,
age-related assessment is covered. Finally, in Unit Five, activities of daily living are addressed.
The contributing authors for this book have been drawn from both educational and service
settings covering a wide geographic area. Although the majority of authors appropriately are
licensed occupational therapists or physical therapists, contributors from other health
professions have also shared their expertise. Such diversity of input has helped us reach our
goal of providing a truly comprehensive work on assessment for occupational therapists and
for physical therapists.
JuUA VAN DEUSEN
DENIS BRUNT
nowledgments
We wish to express our sincere thanks to all those who have helped contribute to the
success of this project, especially
UNIT1WO
CHAPTER 3
Joint Range of Motion ....................................................................49
CHAPTER 4
Hand Analysis ...............................................................................78
CHAPTERS
Clinical Assessment of Pain ............................................................ 123
CHAPTER 6
Cardiovascular and Pulmonary Function ...........................................134
CHAPTER 7
Psychosocial Function ................................................................... 147
Melba J. Arnold, MS, OTR/L, and Elizabeth B. Devereaux, MSW. ACSW/L, OTR/L, FAOTA
CHAPTER 8
Body Image ................................................................................ 159
xvii
xviii CONTENTS
CHAPTER 9
Electrodiagnosis of the Neuromuscular System ................................... 175
CHAPTER 10
UNIT THREE
Adult 247
CHAPTER 11
CHAPTER 12
Julia Van Deusen, PhD, OTR/L, FAOTA, with Joanne Jackson Foss, MS, OTR
Sharon A. Cermak, EdD, OTR/L, FAOTA, and Keh-Chung Un, SeD, OTR
COGNITION, 333
UNIT FOUR
CHAPTER 13
Joanne Jackson Foss, MS, OTR, and Bonnie R. Decker, MHS, OTR
CHAPTER 14
Bonnie R. Decker, MHS, OTR, and Joanne Jackson Foss, MS, OTR
CHAPTER 15
Gail Ann Hills, PhD, OTR, FAOTA, with Steven R. Bernstein, MS, PT
Assessment of Activities of Daily Living 419
CHAPTER 16
Self-Care....................................................................................421
CHAPTER 17
CHAPTER 18
Shirley J. Jackson, MS, OTR/L, and Felecia Moore Banks, MEd, OTR/L
CHAPTER 19
CHAPTER 20
Bruce A. Mueller, OTR/L, CHT, BIen D. Adams, MA, CRC, CCM, and Carol A. Isaac, PT, BS
Index..............................................................................................523
U NIT ONE
Overview of
Measurement
Theory
CHAPTER 1
Measurement Theory:
Application to
Occupational and
Physical Therapy
Jeri Benson, PhD
Barbara A. Schell, PhD, OTR, FAOTA
SUMMARY This chapter begins with a conceptual overview of the two primary is
sues in measurement theory, validity and reliability. Since many of the measure
ment tools described in this book are observationally based measurements, the re
mainder of the chapter focuses on several issues with which therapists need to be
familiar in making observational measurements. First, the unique types of errors in
troduced by the observer are addressed. In the second and third sections, meth
ods for determining the reliability and validity of the scores from observational
measurements are presented. Since many observational tools already exist, in the
fourth section we cover basic gUidelines to consider in evaluating an instrument for
a specific purpose. In the fifth section, we summarize the steps necessary for de
veloping an observational tool, and, finally, a discussion of norms and the need for
local norms is presented. The chapter concludes with a brief discussion of the
need to consider the social consequences of testing.
The use of measurement tools in both occupational and define the nature and scope of clinical problems, provide
physical therapy has increased dramatically since the early benchmarks against which to monitor progress, and serve
1900s. This is due primarily to interest in using scientific to summarize important changes that occur as a result of
approaches to improve practice and to justify each profes the therapy process (Law, 1987). Within departments or
sion's contributions to health care. Properly developed practice groups, aggregated data from various measures
measures can be useful at several levels. For clinicians, valid allow peers and managers to both critically evaluate the
measurement approaches provide important information effectiveness of current interventions and develop direc
to support effective clinical reasoning. Such measures help tions for ongoing quality improvement.
3
~~--" - .
4 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
Measurement is at the heart of many research endeavors and refine measures will be interested in the more recent
designed to test the efficacy of therapy approaches (Short procedures for stUdying reliability and validity.
DeGraff & Fisher, 1993; Sim & Arnell, 1993). In addition
to professional concerns with improving practice, meas
urement is taking on increased importance in aiding
decision-making about the allocation of health care re CONCEPTUAL BASIS OF VALIDITY AND
[2]
Reliability Theory
where 0'2 0 is the "observed score" variance, O'2 T is the
Clinicians and researchers are well aware of the impor "true score" variance, and O'2E is the "error score vari
tance of knowing and reporting the reliability of the scales ance." The variance is a group statistic that provides an
used in their practice. In understanding conceptually what index of how spread out the observed scores are around
is meant by reliability, we need to introduce the concept of the mean "on the average." Given that the assumptions
true score. A true score is the person's actual ability or of classical test theory hold, the error score drops out of
status in the area being measured. If we were interested in Equation 1-2, and the reliability coefficient (p"J is de
measuring the level of "functional independence" of an fined as
individual, no matter what scale is used, we assume that
each individual has a "true" functional independence pxx = 0' 2 TO'O
/ 2 [3]
score, which reflects what his or her functional abilities are,
if they could be perfectly measured. An individual's true Therefore, the proper interpretation of Equation 1-3 is
score could be obtained by testing the individual an infinite that a reliability coefficient is the proportion of observed
number of times using the same measure of functional score variance that is attributed to true score variance. For
independence and taking the average of all of his or her test example, if a reliability coefficient of 0.85 were reported for
scores. However, in reality it is not possible to test an our measure of functional independence, it would mean
individual an infinite number of times for obvious reasons. that 85% of the observed variance can be attributed to true
Instead, we estimate how well the observed score (often score variance, or 85% of the measurement is assessing the
from one observation) reflects the person's true score. This individual's true level of functional independence, and the
estimate is called a reliability coefficient. remaining 15% is attributed to measurement error.
While a true score for an individual is a theoretical The observed score variance is the actual variance
concept, it nonetheless is central to interpreting what is obtained from the sample data at hand. The true and error
meant by a reliability coefficient. A reliability coefficient is score variance cannot be calculated in classical test theory
an expression of how accurately a given measurement tool because they are theoretical concepts. As it is impossible to
has been able to assess an individual's true score. Notice test an individual an infinite number of times to compute his
that this definition adds one additional element to the more or her true score, all calculations of reliability are consid
commonly referred to definition of reliability, usually ered estimates. What is being estimated is a person's true
described as the accuracy or consistency of the measure score. The more accurate the measurement tool is, the
ment tool. By understanding the concept of true score, one closer the person's observed score is to his or her true
can better appreciate what is meant by the numeric value score. With only one measurement, we assume that 0 = T.
of a reliability coefficient. In the next few paragraphs, the How much confidence we can place in whether the as
mathematic logic behind a reliability coefficient is de sumption of 0 = T is correct is expressed by the reliability
scribed. coefficient. (For the interested reader, the derivation of the
In an actual assessment situation, if we needed to obtain reliability coefficient, given that the numerator of Equation
a measure of a person's functional independence, we likely 1-3 is theoretical, is provided in many psychometric theory
would take only one measurement. This one measurement texts, e.g., Crocker & Algina, 1986, pp. 117-122. Also,
6 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
Equation 1-3 is sometimes expressed in terms of the error lowed by a volumetric reading obtained by water displace
score as 1 - (a2E/a20)') ment and a clinical rating based on therapist observation.
In summary, the conceptual basis of reliability rests on Because an unimpaired person's hand naturally swells
the notion of how well a given measurement tool is able to slightly at different times or after some activities, we would
assess an individual's tme score on the behavior of interest. expect some differences if measurements were taken at
This interpretation holds whether one is estimating a different times of day. Because these inconsistencies are
stability, equivalency, or internal consistency reliability expected , they would not be attributed to measurement
coefficient. Finally, as discussed earlier with regard to error, as we expect all the ratings to increase or decrease
validity, reliability is not a property of the measurement tool together. However, inconsistencies among the items within
itself but of the score derived from the tool. Furthermore, the edema battery would suggest measurement error. For
as pointed out by Sim and Arnell (1993) the reliability of a example, what if the tape measure indicated an increase in
score should not be mistaken for evidence of the validity of swelling, and the volumeter showed a decrease? This would
the score . suggest some measurement error in the battery of items.
~ The internal consistency coefficient reflects the amount of
measurement error due to internal differences in scores
Measurement Error measuring the same constmct.
To claim that an instrument is a measure of a trait that is
The study of reliability is integrally related to the study of assumed to remain stable over time for noninjured indi
how measurement error operates in given clinical or viduals (excluding children), such as coordination , high
research situations. In fact, the choice of which reliability reliability in terms of consistency across time as well as
coefficient to compute depends on the type of measure within time points across items or observations is
ment error that is conceptually relevant in a given meas required. Potential inconsistency over measurement time is
urement situation, as shown in Table 1-1 . measured by the stability coefficient and reflects the degree
The three general forms of reliability shown in Table 1-1 of measurement error due to instability. Thu's, a high
can be referred to as classical reliabil,ity procedures because stability coefficient and a high internal consistency coeffi
they are derived from classical test theory, as shown by cient are required of tools that are attempting to measure
Equation 1-1 . Each form of reliability is sensitive to differ traits. It is important to know how stable and internally
ent forms of measurement error. For example, when con consistent a given measurement tool is before it is used to
sidering the measurement of edema it is easy to recognize measure the coordination of an injured person. If the
that edema has both trait (dispositional) and state (situ measurement is unstable and the behavior is also likely to
ational) aspects. For instance , let us say we developed an be changing due to the injury, then it will be difficult to know
edema battery, in which we used a tape measure to meas if changes in scores are due to real change or to measure
ure the circumference of someone's wrist and fingers , fol- ment error.
TABLE 1- 1
StabiHty (test-retest) Change in subject situation over time (e.g., Test, wait, retest with the same tool and
For tools monitoring change over memory, testing conditions, compliance) same subjects
time (e.g .. Functional Independence Any change treated as error, as trait ex Use PPM; results will range from -1 to 1,
Measure) pected to be stable with negatives treated as O. Time inter
vals should be reported. Should be > 0.60
for long intervals, higher for shorter in
tervals
Equivalency (parallel forms) Changes in test forms due to sampling of Prepare parallel forms, give forms to same
For multiple forms of same tool (e.g. , items. item quality subjects with no time interval
professional certification examinations) Any change treated as error, as items thought Use PPM; results will range from -1 to 1,
to be from same content domain with negatives treated as O. Should be
> 0.80
procedures. Finally, the procedures for developing local systematic observer biases can occur. First, an observer
norms to gUide decisions of therapists and health care may tend to be too lenient or too strict. This form of bias
managers in evaluating treatment programs are covered. has been referred to as either error of severity or error of
leniency , depending on the direction of the bias. Quite
often we find that human beings are more lenient than they
are strict in their observations of others. A second form of
ERRORS INTRODUCED BY OBSERVERS bias is the error of central tendency. Here the observer
tends to rate all individuals in the middle or average
Observer effects have an impact on the reliability and the category. This can occur if some of the behaviors on the
validity of observational data. Two distinct forms of ob observational form were not actually seen but the observer
server effects are found: 1) the observer may fail to rate the feels that he or she must put a mark down. A third type of
behavior objectively (observer bias) and 2) the presence of systematic bias is called the halo effect. The halo effect is
the observer can alter the behavior of the individual being when the observer forms an initial impression (either
rated (observer presence). These two general effects are positive or negative) of the individual to be observed and
summarized in Table 1-2 and are discussed in the following then lets this impression guide his or her subsequent
sections. ratings. In general , observer biases are more likely to occur
when observers are asked to rate high-inference or
evaluation-type variables (e.g., the confidence with which
Observer Bias the individual buttons his or her shirt) compared with very
specific behaviors (e.g., the person's ability to button his or
Observer bias occurs when characteristics of the ob her shirt).
server or the situation being observed influence the ratings To control for these forms of systematic observer bias,
made by the observer. These are referred to as systematic one must first be aware of them. Next, to remove their
errors, as opposed to random errors. SystematiC errors potential impact on the observational data , 'adequate
usually produce either a positive or negative bias in the training in using the observational tool must be provided.
observed score, whereas random errors fluctuate in a Often , during training some of these biases come up and
random manner around the observed score. Recall that the can be dealt with then. Another method is to have more
observed score is used to represent the ' 'true score," so any than one observer present so that differences in rating may
bias in the observed score has consequences for how reveal observer biases.
reliably we can measure the true score (see Equation 1-3).
Examples of rater characteristics that can influence obser
vations range from race, gender, age, or social class biases Observer Presence
to differences in theoretical training or preferences for
different procedures. While the "effect" of the presence of the observer has
In addition to the background characteristics of observ more implications for a research study than in clinical
ers that may bias their observations, several other forms of practice, it may be that in a clinical situation , doing
TABLE }· 2
Observer biases
Background of observer Bias due to own experiences (e.g ., race , gender, Increase observer awareness of the influence of his
class, theoretical orientation , practice preferences) or her background
Error of severity or leniency Tendency to rate too strictly or too leniently Provide initial and refresher observer training
Provide systematic feedback about individual rater
tendencies
Error of central tendency Tendency to rate everyone toward the middle Do coratings periodically to detect biases
Minimize use of high-inference items where possible
Halo effect Initial impression affects all subsequent ratings
Observer presence Changes in behavior as a result of being measured Spend time with individual before evaluating to de
sensitize him or her to observer
Discuss observation purpose after doing observation
Observer expectation Inflation or deflation of ratings due to observer's per Do routine quality monitoring to assure accuracy
sonal investment in measurement results (e.g., peer review, coobservations)
something out of the ordinary with the patient can alter his research in this area has indicated the inadequacy of
or her behavior. The simple act of using an observational reporting observer agreement alone, as it can be highly
form to check off behavior that has been routinely per misleading (McGaw et aI., 1972; Medley & Mitzel, 1963).
formed previously may cause a change in the behavior to The main reason for not using percentage of observer
be observed. agreement as an indicator of reliability is that it does not
To reduce the effects of the presence of the observer, address the central issue of reliability, which is how much of
data should not be gathered for the first few minutes when the measurement represents the individual's true score.
the observer enters the area or room where the observation The general lack of conceptual understanding of what the
is to take place. In some situations, it might take several reliability coefficient represents has led practitioners and
visits by the obseiver before the behavior of the individual researchers in many fields (not just occupational and
or group resumes to its "normal" level. If this precaution is physical therapy) to equate percentage of agreement
not taken, the behavior being recorded is likely to be methods with reliability. Thus, while these two concepts
atypical and not at all representative of normal behavior for are not the same, the percentage of observer agreement
the individual or group. can provide useful information in studying observer bias or
A more serious problem can occur if the individual being ambiguity in observed events, as suggested by Herbert and
rated knows that high ratings will allow him or her to be Attridge (1975). Frick and Semmel (1978) provide an
discharged from the clinic or hospital, or if in evaluating the overview of various observer agreement indices and when
effect of a treatment program, low ratings are initially given these indices should be used prior to conducting a reliability
and higher ratings are given at the end. This latter situation study.
describes the concept of observer expectation. However,
either of these situations can lead to a form of systematic
bias that results in contamination of the observational Variance Components Approach
data, which affects the validity of the scores. To as much an
extent as possible, it is advisable not to discuss the purpose To consider the accuracy of the true score being
of the observations until after they have been made. measured via observational methods, the single best pro
Alternatively,. one can do quality monitoring to assure cedure is the variance components approach (Ebel, 1951;
accuracy of ratings. Frick & Semmel, 1978; Hoyt, 1941). The variance
components approach is superior to the classical ap
proaches for conducting a reliability study for an observa
tion tool because the variance components approach
allows for the estimation of multiple sources of error in the
ASSESSING THE RELIABILITY OF measurement (e.g., same observer over time, different
OBSERVATIONAL MEASURES observers, context effects, training effects) to be partitioned
(controlled) and studied. However, as Rowley (1976) has
The topic of reliability was discussed earlier from a pOinted out, the variance components approach is not well
conceptual perspective. In Table 1-1, the various methods known in the diSciplines that use observational measure
for estimating what we have referred to as the classical ment the most (e.g., clinical practice and research). With so
forms of reliability of scores were presented. However, much of the assessment work in occupational and physical
procedures for estimating the reliability of observational therapy being based on observations, it seems highly
measures deserve special attention due to their unique appropriate to introduce the concepts of the variance
nature. As we noted in the previous section, observational components approach and to illustrate its use.
measures, compared with typical paper-and-pencil meas The variance component approach is based on an
ures of ability or personality, introduce additional sources analysis of variance (ANOVA) framework, where the
of error into the measurement from the observer. For variance components refer to the mean squares that are
example, if only one observer is used, he or she may be routinely computed in ANOVA. In an example adapted
inconsistent from one observation to the next, and there from Rowley (1976), let us assume we have n;;:: 1 obser
fore we would want some information on the intrarater vations on each of p patients, where hand dexterity is the
agreement. However, if more than one observer is used, behavior to be observed. We regard the observations as
then not only do we have intrarater issues but also we have equivalent to one another, and no distinction is intended
added inconsistencies over raters, or interrater agreement between observations (observation five on one patient is no
problems. Notice that we have been careful not to equate different than observation five on another patient). This
intrarater and interrater agreement with the concept of "design" sets up a typical one-way repeated-measures
reliability. Observer disagreement is important only in that ANOVA, with P as the independent factor and the n
it reduces the reliability of an observational measure, which observations as replications. From the ANOVA summary
in turn reduces its validity. table, we obtain MSp (mean squares for patient) and MSw
From a measurement perspective, percentage of ob (mean squares within patients, or the error term). The
server agreement is not a form of reliability (Crocker & reliability of a score from a single observation of p patients
Algina, 1986; Herbert & Attridge, 1975). Furthermore, would be estimated as:
10 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
Ji\BI l. 1<I
Assess current status Do items represent the domain? Content a) Internal consistency within each subarena
~_ _-=::::::::::i::::
12 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
'I,\BI [ 1 -·1
Descriptive Infonnation
Title , author, publisher, date X X X
Intended age groups X
Cost X
Time (train, score, use) X
Scale Development
Need for instrument X X X X
Theoretical support X X
Purpose X X X X
Table of specifications described?
Item development process X
Rationale for number of items
Rationale for item format X X X
Clear definition of behavio r X
Items cover domain X
Pilot' testing X X X
Item analysis X X X
Psychometric Properties
Observer agreement X X
Reliability
Stability
Equivalency NA
In ternal-consistency X X
Standard error of measurement
Generalizability approaches X X
Validity
Content
Criterion related
Construct X
Sample size and description X X X
Independent Reviews NA NA X
tool can be reliable and valid for many different purposes; dressed in the manual or other sources. In our example
therefore, each practitioner or researcher needs to be able assume the reason for using the FIM is to determin
to evaluate a given tool for the purpose for which he or she usefulness as an outcome measure of "program effec
intends to use it. ness of an inpatient rehabilitation program." Such
Numerous sources may need to be consulted to decide comes would be useful in monitoring quality, mee
if a given tool is appropriate for a specific use. Some of program evaluation gUidelines of accrediting bodies,
the information needed to evaluate a measurement tool helping to identify program strengths useful for marke
may be found in the test manual. It is important to services. In deciding whether the FIM is an appropriate
recognize that different kinds of test manuals, such as for our purposes, the following questions emerge:
administration and scoring guides and technical manuals, Does it measure functional status?
exist. In a technical manual, you should expect to find the Should single or multiple disciplines perform the rati
following points addressed by the author of the instrument How sensitive is the FIM in measuring change
(at a minimum): admission to discharge of inpatients?
Need for the instrument How.weLl does it capture the level of human assist
Purpose of the instrument required for individuals with disabilities in a varie
Intended groups or ages functional performance arenas?
Description of the instrument development proce Does it work equally well for patients with a rang
dures conditions, such as orthopedic problems, spinal
Field or pilot testing results injury, head injury, and stroke?
Administration and scoring procedures Most of these questions are aimed at the reliability
Initial reliability and validity results, given the in validity of the scores from the FIM. In short, we nee
tended purpose know how the FIM measures functional status and for w
Normative data (if relevant) groups, as well as how sensitive the measurement is.
Sometimes the administration and scoring procedures According to Law (1987, p. 134), the form of va
and the normative data are a separate document from the called for in our example is evaluative. Law desc
technical manual. Book chapters are another source of evaluative instruments as ones that use "criteria or item
information and are likely to report on the theoretical measure change in an individual over time." Under ev
underpinnings of the scale and more extensive reliability, ative instruments, Law suggests that the items shoul
validity, and normative results that might include larger responsive (sensitive), test-retest and observer reliab
samples or more diverse samples. The most recent infor should be established, and content and construct va
mation on a scale can be found in journal articles, which are should be demonstrated. Given our intended use of
likely to provide information on specific uses of the tool for FIM, we now need to see if evidence of these form
specific samples or situations. Journal articles and book reliability and validity exists for the FIM.
chapters written by persons who were not involved in the In terms of manuals, the only one available is the G
development of the instrument offer independent sources for the Use of the Uniform Data Set for Med
of information in terms of how useful the scale is to the Rehabilitation Including the Functional Independe
research community and to practicing therapists. Finally, Measure (FlM) Version 3.1, which includes the
depending on the popularity of a given scale, independent (Center for Functional Assessment Research, 19
evaluations by experts in the field may be located in test Stated in the Guide is that the FIM was found to
review compendiums such as Buros' Mental Measure "face validity and to be reliable" (p. 1), with no suppor
ment Yearbooks or Test Critiques found in the reference documentation of empiric evidence within the Gu
section of the library. Since the FIM was developed from research funding
As shown in Table 1-4, we consulted four general types needed to consult an additional source, the final re
of sources (test manual, grant reports, book chapters, and of the grant (Granger & Hamilton, 1988). In the
journal articles) to obtain the information necessary to report is a brief description of interrater reliability an
evaluate the FIM as a functional outcome measure. The validity. Interrater reliability was demonstrated thro
FIM, as part of the Uniform Data System, was originally intraclass correlations of 0.86 on admission and 0.8
designed to meet a variety of objectives (Granger & discharge, based on the observations of physicians,
Hamilton, 1988), including the ability to characterize cupational and physical therapists, and nurses. The
disability and change in disability over time, provide the terrater reliability study was conducted by Hamilton
basis for cost-benefit analyses of rehabilitation programs, colleagues (1987). In a later grant report, Heinemann
and be used for prediction of rehabilitation outcomes. To colleagues (1992) used the Rasch scaling techniqu
evaluate the usefulness of the FIM requires that the evaluate the dimensionality of the FIM. They found
therapist decide for what specific purpose the FIM will be the 18 items do not cluster into one total score but sh
used. A clear understanding of your intended use of a be reported separately as motor (13 items) and cogn
measurement tool is critical to determining what form(s) of (5 items) activities. Using this formulation, the aut
reliability and validity you would be looking to find ad reported internal consistency estimates of 0.92 for m
~ique also indicated where specific items are in need of evidence, questions have been raised about the appropri
~evision and that others could be eliminated due to ateness of using a total FIM score, as opposed to reporting
redundancy. The Rasch analysis indicated that the FIM the separate subscale scores.
"tems generally do not vary much across different patient As was already mentioned, more literature about the FIM
subgroups, with the exception of pain and burn patients exists than has been referenced here, and a thorough
on the motor activities and patients with right and bilateral review of all the relevant literature would be necessary to
m oke, brain dysfunction , and congenital impairments on fully assess the FIM. The intent here is to begin to
:he cognitive activities (Heinemann et aI., 1992). This demonstrate that effective evaluation of measurement
m plies that the FIM items do not fit well for these disability tools requires a sustained effort, using a variety of sources
groups and should be interpreted cautiously. The authors beyond the information provided by the test developer in
'ndicate that further study of the FIM in terms of item the test manual. However, even this cursory review sug
revision and item misfit across impairment groups was gests that observer agreement studies should be under
needed. In sum, the reliability data reported in the sources taken by the local facility to check the consistency among
we reviewed seem to indicate that the FIM does produce therapists responsible for rating patient performance (see
reliable interrater data, and that the FIM is composed of section on reliability of observation measures). This is but
:wo internally consistent subscales: motor and cognitive one example of the kinds of responsible actions a user of
activities. measurement tools might take to assure appropriate use of
The information provided in the grant under the heading measurement scores.
of validity related primarily to scale development and
refinement (e.g. , items were rated by clinicians as to ease of
e and apparent adequacy), to which the authors refer as
face validity. In the face validity study conducted by DEVELOPMENT OF OBSERVATIONAL
Hamilton and associates (1987), clinical rehabilitation MEASURES
therapists (with an average of 5.8 to 6.8 years of experi
ence) rated the FIM items on ease of use, redundancy, and Quite often an observational tool does not exist for the
other factors. However, the results from the face validity required assessment, or a locally developed "checklist" is
study do not address whether the scale possesses content used (e .g., prosthetiC checkouts or homemaking assess
validity. In fact, psychometricians such as Crocker and ments, predriving assessments) . In these situations, thera
Algina (1986), Nunnally (1978), and the authors of the pists need to be aware of the processes involved in
Standards for Educational and Psychological Testing developing observational tools that are reliable and valid.
(1 985) do not recognize face validity as a form of scale The general procedures to follow in instrument construc
validation. Therefore, if face "validity" is to be used , it tion have been discussed previously in the occupational
would. be more appropriately placed under instrument therapy literature by Benson and Clark (1982) , although
development procedures. (The procedures for determining their focus was on a self-report instrument. We shall adjust
the content validity of scores from an instrument were the procedures to consider the development of observa
described previously under the section on validity of tional instruments that baSically involve avoiding or mini
observational measures.) mizing the problems inherent in observational data. To
In terms of construct validity of the FIM for our in illustrate this process, we have selected the evaluation of
tended purpose, we wanted to see whether the FIM homemaking skills. The purpose of this assessment would
scores can discriminate those with low levels of functional be to predict the person 's ability to safely live alone .
independence from those with high levels of indepen There are two major problem areas to be aware of in
dence . It was necessary to consult journal articles for this using observational data: 1) attempting to study overly
information . Several researchers reported the ability of complex behavior and 2) the fact that the observer can
the FIM to discriminate levels of functional independence change the behavior being observed. The second point is
of rehabilitation patients (Dodds et aI., 1993, Granger et not directly related to the development of an observational
aI., 1990) . measure but relates more to the reliability of the measure.
From a partial review of the literature, we can say that the The first point is highly relevant to the development of an
FIM was able to detect change over time and across observational measure and is addressed next .
patients (Dodds et aI., 1993; Granger et aI., 1986). While Often when a therapist is interested in making an
the interrater agreement appears adequate from reports by observation of an individual's ability to perform a certain
the test authors , some researchers report that when ratings task, the set of behaviors involved in the task can be overly
are done by those from different disciplines or by untrained complex, which creates problems in being able to accu
raters , reliability decreases (Adamovich , 1992; Chau et aI. , rately observe the behavior. One way to avoid this problem
1994; Fricke et aI. , 1993). From a validity perspective, is to break down the behavior into its component parts.
recent literature strongly suggests that the FIM may be This is directly analogous to being able to define the
measuring several different dimensions of functional ability behavior, both conceptually and empirically. This relation
18 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
ship was iHustrated in Figures 1-1 and 1-2, in which a the stove. This lack of safety can be due to cogni
conceptual definition of the trait fu nctiona J independence problems (e.g. , lack of immediate recognition of prob
was given above the dashed line. It should be recognized and timely response), motor problems (e.g ., moves
that several conceptual definitions based on different slowly to respond to the emergency), or affective probl
theoretical positions regarding our understanding of what (e.g., does not care about safety).
functional independence means could exist. Each concep In thinking about the behavior units and dimension
tual definition of a trait could in turn lead to different ways the behavior to be observed, Borg and Gall (1983) h
to operationalize the trait at the empirical level (see the area suggested that to be able to observe the behavior relia
below the dashed line in Figure 1-2). First, let us consider one should use descriptive or low-inference variable
how conceptual and operational definitions are developed items. In general, "observer inference refers to the deg
for the behavior to be observed. A conceptual or theoretical of observer judgement intervening between the actual d
definition begins most often with unsystematic observa observed and the subsequent coding of that data on ob
tions or hunches about a particular behavior from working vational instruments." (Herbert & Attridge, 1975, p.
in the clinic. For instance, therapists may be aware that A descriptive or low-inference variable is one that can
meal p'lanning and preparation, cleaning, and washing clearly defined and easily observed (e.g., turns on
clothes are typical behaviors that people must do to live stove). While many behaviors in occupational or phys
alone. Therapists often have to make predictions about therapy are of the low-inference variety, on some o
how well a person would do at home, based on patient sions a therapist may be called on to observe high-infere
performances observed in the clinic. For instance, a behaviors. A high-inference variable is one that involv
therapist may feel that by observing a patient in the simple series of events, where the behaviors are more globa
act of making a cup of instant coffee, a prediction could be where the therapist must draw a conclusion about the
made about that person's safety in preparing meals at havior being observed. Examples of high-inference v
home. These thoughts are then abstracted up to a more ables might be items such as " how well will t)1e per
theoretical level where they are fit into a complex of respond to kitchen emergencies?" or more globally, "H
behavior patterns, and a theory regarding the behavior of well does the individual respond to household emerg
interest begins to be formed. Theories are used to explain cies?" Being able to respond to emergencies represen
behavior and in this case are only useful if they can be series of behaviors. How should the therapist rate the
empirically verified. Therefore, it is important to be able to havior if all behaviors related to emergency responses
test a theory, which is where the operational definition not successful, such as when the person can dial 911
comes in. To test a theory we must move from the cannot describe what to do next for a fire? Even m
conceptual level to the empirical 'level, at which the actual difficult to reliably observe are evaluative variables.
data are collected . To collect data regarding a particular evaluative variable requires an inference regarding the
theory of behaVior, we must operationally define the havior, plus the therapist must make a judgment about
behavior to be studied. An operational definition then behavior as welL For example, an evaluative item might
makes concrete what is implied in the conceptual defini " Rate how safe the person is likely to be living alone."
tion. For example, the concept of kitchen safety might be only does this type of item or variable require an inferen
operationalized as the person 's ability to verbalize kitchen but the therapist must make a qualitative judgment to
safety concerns; demonstrate safe use of the stove; and spond to the item.
safely obtain supplies, prepare food, and clean up after Borg and Gall (1983) have warned that high-infere
ward. and evaluative variables often lead to less-reliable obse
The conceptual definition of the behavior is important tions. To counter this reliability problem, Medley and M
because it attempts to define the boundary of the domain (1963, p . 252) have espoused a very strong posit
covered by the behavior. For instance, a narrow definition stating that the observer should use the least amoun
of kitchen safety might be operationalized as the ability to judgment possible, only a judgment "needed to perc
safely heat meals in a microwave. A broader definition whether the behavior has occurred or not." Herbert
would include obtaining groceries, preparing three meals a Attridge's (1975) position on the level of inference is m
day, and cleaning up after meal preparation. Also, the balanced , calling for the level of inference that is deman
domain may consist of one or more dimensions. For each by the complexity of the behavior studied. If it is essen
dimension, each act or task must be explicitly and sequen to the behavior being observed that high-inference
tially described. That is, within each dimension are poten evaluative variables are necessary, then to produce reli
tially several' 'behavior units" that comprise the behavior to observational data, a great deal of attention must be g
be observed, and each must be detailed. For instance, the to training observers to be able to " see" and then rate
concept of' 'kitchen safety" can include cognitive as well as high-inference and evaluative types of variables con
motor aspects. A person can verbalize safe procedures but tently. This point is addressed more in the section
act unsafely, or a person may not even be aware of safety training observers.
concerns. Further, the scope of safety issues can vary. For To organize the behavior units and dimensions of
instance, a person may be safe in routine situations but behavior as speCified in the conceptual and operatio
unable to respond to emergency situations, such as a fire on definitions, a table of specifications is often used. A tabl
specifications guides instrument construction to ensure TABLE I 5
that 1) all dimensions and behavior units are considered
and 2) a sufficient number of items is written to cover each EXAMPLE OF TABLE OF SPECIFICATIONS
dimension. Later, if content validation is required for the FOR KITCHEN SAFElY*
TYpe of test score interpretation, the table of specifications Verbalize Obtain Prepare Clean
again is used in classifying the instrument's items by a panel Safety Supplies Food Up
of experts.
An example of a table of specifications is shown in Table CognitiCJe 10%/2 10%/2 15%/3 5%/1
1-5 for measuring the behavior of kitchen safety. In the Sensorimotor 20%/4 20%/4 10%/2
ble, the column headings indicate important components
Ajject;CJe 10%/2
of the construct of kitchen safety. The rows reflect different
dimensions of each of these behavior units. At each Percentage indicates percent o f items allocated per cell, followed by actual
intersection of the rows and columns, we would make a number of items. A blank cell indicates that the component/dimension
represented by that cell is not re levant.
iudgment about the relative importance of this cell and the
number of items to be included. It is common to use experts
35 resources in identifying the degree of importance of each error variance than systematic variance. Therefore , we
art of the assessment. Assuming we wanted to keep the agree with Borg and Gall that using three to five observa
:001 brief, we might start by limiting ourselves to 20 items tion points per item should be sufficient to rate most
:otal, and then apportion them, based on our predeter behaviors and improves the reliability of the observations of
mined percentages. For example, the first row-by-column high-inference and evaluative items.
::ell , "verbalize safety and cognitive," we show as being Finally , when the observational form is developed, it is
somewhat less important (10%, or wo items) then the important to field test the instrument. Field testing (or pilot
second row-by-column cell, "obtain supplies and sen testing) allows one to be sure all aspects of the behavior
sorimotor" (20%, or four items). The number of items have been included , determine whether each behavior unit
de pends on many factors, such as the level of complexity of is suffiCiently described to be able to rate it, and assess how
:he behavior to be measured, the number of dimensions easy the form is to use. In addition, instructions on how to
and behavior units that were operationally defined, and the use the form should be developed and field tested. Any
amount of time available to observe the behavior. revisions to the form or instructions should be made and
field tested again to see how the revisions work. Once the
form has been suffiCiently field tested, we then turn to the
The Observational Form training of observers to use the form.
TABLE 1 (,
Requires Some
Cuing or
Completes Physical Unable to
Low-Inference Items Independently Assistance Perform
High-Inference Items
separate item scores are now additive. While it is possible scores expressed in terms of interval measurements.
to add up the rankings from ordinal measurements , it Typically, item difficulties are expressed as the proportion
should be pointed out that an assumption is being made of individuals passing an item, where a proportion is an
that the distance between each scale point is equal. ordinal measurement.
Typically, these distances are not equal but reflect different In addition to the interval properties of the Rasch scaling
distances for each observer. This distinction might be made technique, the items subjected to a Rasch analysis are no
clear by the following, more typical , situation. Consider longer sample dependent. That is, the level of difficulty for
your response to a self-report attitude measure with a 1 to an item , once scaled, is independent from the group used
5 likert-type response format. For item 1 you might select for the scaling. Recall that sample dependency was one of
a 5 (strongly agree) and then for item 2 select response the problems with the classically based procedures. For
4 (agree). The assumption of interval measurement we are example, using traditional items analysis, the difficulty of an
making when these two responses are summed is that we item is dependent on the group tested. If the same item is
move one unit's distance in intensity when going from a given to a more able group, the item appears easy; on the
response of 4 to 5. The validity of this assumption becomes otber hand, if the item is given to a less able group, the item
even more tenuous when we consider that the assumption appears difficult. Clearly it is not a very desirable property
is assumed to hold not just for an individual's responses but for an item's difficulty value to "bounce" around. Fischer
across individuals as well. The Rasch procedures, on the (1993) provides a nice illustration of this issue in her
other hand, convert the ordinal data into interval data development of a motor scale. Another deSirable property
through a logistic transformation based on the proportion of Rasch scaling is that the individual's scores obtained
of persons with a given item score (Andrich, 1988; Fischer, from the measurement are also independent in terms of the
1993). The result is item difficulty values and person ability set of items used. What is meant here is that a person's
ability score can be estimated from any set of items that determine how accurate the tool is in assessing true score.
have been Rasch scaled. Thus, not every individual has to In the initial process of training observers, it is very
take the same set of items or the same number of items. important that the theoretical and operational definition of
This really frees up the examiner to select the set of items the behavior to be observed is made clear. We do not want
[hat is most appropriate for the individual and not frustrate the observers rating the behavior they "think" should be
him or her with a set of items that is either too difficult or rated but the behaviors on which the observational form
too easy. Once the items have been Rasch scaled, the was developed. Usually, brief, concise definitions are
observer or examiner does not need to be concerned with provided and discussed for clarity. Borg and Gall (1983)
administering all the items to each examinee; a subset can have suggested that testing the observers at this point on
just as efficiently measure his or her "true" score as the full their understanding of the behavior may be helpful. We
set of items. In fact, it could be argued that administering a certainly agree with their suggestion, especially if the
subset of items targeted to the individual's ability is more observation is part of a research study. This should also be
', vhat assessment should be like, compared with the tradi considered more often with instruments used in practice.
tional format of everyone receiving the same set of items. It is highly desirable to have available videotapes of the
Thus , Rasch scaling permits sample-free and test-free behavior to be observed for the therapist to study and
measurement. replay. The training session then can run segments of the
The Rasch model is a model from a larger class of models videotape, have the therapist use the observational form,
:-eferred to as item response theory models. Item response then stop the tape for discussion of what behavior was
theory models form the basis of modern test theory, as noted and whether it matches with the criterion. In the
opposed to the classical procedures referred to earlier in training of observers, it is critical that a criterion be
this chapter. One feature that distinguishes modern test established. Usually, the criterion is the ratings made by the
[heory from classical test theory is that the assumptions of trainer, and the objective is for the therapists in training to
[he model are directly testable, whereas the assumptions produce the ratings that the trainer made. In this way, the
for classkal test theory are not. (The assumptions for reliability of the raters can be assessed. If therapists in
classical test theory involve the error term shown in training do not match the criterion, then the videotape can
equations 1-1 and 1-2. The assumptions consider that an be stopped, and the behavior that was missed or mis
individual is tested an infinite number of times on a given marked can be discussed and corrected. Being able to show
instrument and that: 1) the mean of their error score is zero the persons being trained exactly what behavior is repre
llle = 0], 2) the correlation between the error scores is zero sented by the item on the observational form improves
IPee = 0], and 3) the correlation between an individual's their understanding of the behavior and hence the reliability
[rue score and his or her error scores is zero [Pte = 0].) of their observations. Thus, the point of providing training
The assumptions made in using the Rasch procedures for observers is to ensure the reliability of the data.
are that the trait being measured is unidimensional, the Once the training using videotapes has reached a
items used have equal discrimination power, and the items satisfactory level, then the training should be moved to an
are locally independent. Local independence refers to the actual site in which the behavior can be observed. This
fact that responses to one item do not influence the enables a more realistic training arena in which to try out
responses to another item. If these assumptions can be the observational form and the accuracy of the observers.
verified, then a person's score on a scale is only a function The observers should not be practicing on patients for
of his or her ability and the difficulty level of the item. whom actual data are required. It may be possible for the
As pointed out earlier in the chapter, in observational criterion rater to make the rating that is required for the
data, other sources of variation are introduced into the patient and the observers being trained to likewise rate
measurement, such as observer effects. The many-faceted the behavior and then compare the results after the fact. If
Rasch model allows other sources of test score variation to possible, videotaping these actual settings benefit those
be accounted for, as did the variance component proce currently being trained and could be used in later training
dures described in the section on reliability of observational efforts as well.
measures. Fischer (1993) illustrates the use of the many When the observers are trained to an adequate level to
faceted Rasch model, in which rater severity and the use the instrument in the setting in which it was designed,
challenge of the task performed were considered in then the process of gathering reliability data should be
addition to item difficulty and person ability. started. One final point on the training of observers: If
rating takes place over time, such as when treatment is
needed over a long period or in a longitudinal research
Training Observers study, it is critical to reevaluate the reliability of the
observers periodically. This can be done by either having
The research on observer training has shown that the criterion rater jointly rate the individual along with the
serious attention to this step in the process helps to ensure rater(s) being studied or videotape the rater(s) being studied
reliable data (Spool, 1978). In fact, once the observers are so that the criterion rater can also rate the same behavior.
sufficiently trained, we can begin to collect reliability data to These types of checks on the reliability of the observers
22 UNIT ONE-OVERVIEW OF MEASUREMENT THEORY
for the development of tools such as the FIM and the Norms-Summarized scores from group tested during
Research, 1990).
Observer bias-When characteristics of the observer or
the situation being observed influence the ratings made by
the observer.
SUMMARY AND CONCLUSIONS Observer presence-When the presence of the ob
server alters the behavior of the individual being tested .
This chapter began with a conceptual overview of the Reliability coefficient-An expression of how accu
two primary issues in measurement theory, validity and rately a given measurement tool has been able to assess an
reliability. Since many of the measurement tools described
i this book are observationally based measurements, we
-_.
individual's true score.
-
S ample dependency-Has two forms: a) inferential,
focused much of the chapter around the issues therapists when the statistic of interest fluctuates from sample to
need to be familiar with in making observational measure sample and b) psychometriC, when the items constituting
ments. This overview should set the stage for a better an instrument are a "sample" from a universe of all
understanding of observational measurement encountered potential items.
i:1later chapters in this book. Finally, the chapter ends with Standardized-Measurement taken under a speCific set
the use of local norms to enable therapists and faCility of guidelines for administration and scoring.
plete without attention to the ethics involved in testing Validity-The rocess by- which scores frgm ~~r,?
human beings. We are reminded of the seminal work of ments take a c-ID.eaning.
Messick (1989), in which he asserts that one should not VaHdity coefficient-Correlation between a predictor
interpret the meaning of any score without consideration of and the criterion.
the social consequences of that test score.
Because it is common to use tools to assess individuals,
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Disease Control. Wilkerson, D. L. , Batavia, J.D., & DeJong , G. (19 92). The use of
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observation systems and manua ls. American Educational Research services. Archives of Physical MediCine, 74, 111-120.
Journal . 12, 1-20. World Health Organization (1980) . Int erna tional classification of
Hoyt, C (1941). Test reliability estimated by the analysis of variance. impairments, disabilities, and handicaps. Geneva: World Health
Psychometrika , 6, 153-160. Organization.
U NI T TW O
Compo ent
Assessments of
the A ult
.-..
--=-- - -..-..
2
SUMMARY One of the most frequent physical assessment tests used in rehabilita
tion is the testing of muscle strength. Strength measurements are used for diagnos
tic and prognostic purposes. Changes in strength are also used to assess changes
in a patient's condition and to determine the effectiveness of exercise programs.
Although strength is a frequently used term, it is not universally used for the
same measurement. Strength may be used when muscle torque, force, power;
or work would be a more appropriate term. A myriad of anatomic, physiologic,
biomechanical, psychological, pathologic and other factors contribute to muscle
performance. Knowledge of these factors is important if tests of muscle strength
are to be carried out and interpreted in a meaningful manner. Clinical assessment
of muscle strength involves measuring the force exerted against an external force
or resistance. This force may include the effect of gravity and that exerted by a
therapist or a muscle testing device. Manual muscle tests (MMTs) without
instrumentation have a long history of clinical use but have been subjected to little
scientific scrutiny. MMTs are limited by the strength of the examiner and are
of limited value because of their unproven reliability and lack of responsiveness.
Instrumented MMTs with hand-held dynamometry improve the reliability and
responsiveness of testing muscle strength but are also limited by the strength of the
examiner. Isokinetic and isoinertial devices are now frequently used to assess
muscle performance in static and dynamic modes. The devices are mechanically re
liable and are reasonably reliable in measuring the forces exerted by muscles, al
though this depends on the conditions of testing. Most reliability studies have been
conducted on normal, healthy individuals. The validity of muscle strength tests has
not been tested. They appear to have face validity for measuring the force exerted
by a muscle. The validity of muscle strength tests as diagnostic or prognostic tools
has not been established. Muscle strength tests are in frequent use despite the
paucity of information about the reliability of strength tests in populations for
whom the test is deSigned, rather than in healthy individuals. It is essential that the
relationship between the patient's problems with function and clinical tests of
muscle strength is established.
27
. - --- -~-~
28 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
..... __,_ _ __
(Lamb, 1985), although they have been subjected t
""~;r~~,,,,,,t~_~_;_IWM?*~ ~ _~ ~ ~~,~
OVERVIEW OF MUSCLE STRENGTH scientific scrutiny. The initial development and doc
tation of MMTs occurred about 80 years ago an
The measurement of muscle strength is a fundamental attributed to Lovett, an orthopedic surgeon (Danie
component of a physical assessment. Strength measure Worthingham, 1986; Kendall et aL, 1993). The prin
ments are used in clinical practice for diagnostic purposes, of MMT have changed little since that time, although
to examine the improvement or deterioration of a patient's modifications have been made, especially in regard
status over time, and as a predictive or prognostic tooL grading system used.
Strength tests are also used to determine the extent of The bases of MMTs are simple and essentially
strength loss by comparing the results of strength tests anatomic and· biomechanical principles. Thus, the
between opposite limbs or against normative data. measures of impairment rather than function, and
In addition, strength tests are used in clinical research as their use is most common for persons with disord
outcome measures. The results of strength tests can be the muscle or peripheral neural systems (Daniel
used to describe a population and examine the effects of Worthingham, 1986), these tests have been use
exercise programs or some other therapy. Measurements patients with central nervous system problems, inc
of static and dynamic muscle performance (torque output, those with brain injury (Riddle et aI., 1989).
fatigue, work, or power) can be related to the histochem Fundamental to MMT is the notion that muscles,
istry, biochemistry, and electromyographic activity of individually or as a group, have a specific action on a
muscle to better understand the physiologic bases of Based on this premise and utilizing the effects of gravi
muscle function and to determine the relationship between manual resistance provided by the therapist as ex
static and dynamic strength tests and functional activities. forces, a patient is positioned in such a way that one m
The major function of the muscular system is to stabilize or group of muscles is primarily responsible for mo
and support the body and allow movement to occur. Muscle joint through a specific range of motion. Grading of m
function is the product of a myriad of contributing sub strength is then based on the arc of movement produ
systems. The biologic subsystems include sensory, motor, the muscle and the amount of external resistance
and cognitive systems. In addition, muscle function is motion. The muscle or tendon is palpated by the the
influenced by the environment, the task, and the time and to ensure that the muscle of interest is contracting a
effort required to complete the task. substitution of muscle activity is responsible for the sp
Many different techniques purport to measure strength. movement tested.
Some are very simple, such as manual muscle tests (MMTs),
and others use complex equipment and computerized INSTRUMEMTED TESTS OF MUSCLE STRENGTH
technology and provide a plethora of information. Is one
method of testing better or more reliable than the other? Although the criteria for grading muscle streng
What do these tests tell us? Do either of these methods of quite specific, manual grading does not provide qu
testing have anything to do with function? Clinicians and tive data about the force or torque generated by the m
researchers test muscle strength regularly, but what do we Thus, instrumented strength testing (1ST) was deve
really know about the psychometric characteristics of the Instrumented strength testing allows one to quantify
level of validity. A measure has face validity if it simply units which can exert the most force, but which are
appears to measure what it is supposed to measure. Con to fatigue. In humans, muscles are composed o
struct validity is the degree to which the scores obtained different types of motor fibers; however, the fibers s
are in agreement with the theoretical construct of that by each motor neuron are homogenous. Some pat
which is measured. Criterion validity concerns the extent or injury conditions, e.g., low back problems, re
to which the measur;Is related to other measures that are selective atrophy of FF (Mattila et al., 1986; Rissane
regarded as a "gold standard" of measurement. Another 1995; Zhu et ai, 1989). However, this loss can be r
property that any clinical measurement tool needs is re with training at maximal or submaximal effort (Riss
sponsiveness or sensitivity to change. Responsiveness is aI., 1995).
the ability of a test to measure clinically important change. The endurance performance of a muscle is influe
Variability and error are factors in all measurements. A a number of factors. The morphologic characteristic
number of sources contribute to the variability of test muscle, muscle mass, capilliary density, and percen
measurements. Knowledge of the sources of variability is SF fibers are all related to efficiency of activity
necessary for appropriate interpretation of test results. 1995). The recruitment of a larger muscle mass a
The measurement device may be a source of variability. spread of power output over a large area, includ
The device may be reliable, in that under the same recruitment of different muscles, all potentially e
conditions it always provides a similar reading. However, endurance or limit fatigue.
the device may systematically over- or underestimate the Biomechanical factors are also important in
measurement. This is one reason why devices such as an function. These factors are linked to anatomic st
HHD are not necessarily interchangeable. and playa role in the muscles' ability to generate fo
The observer is another source of variability in a test cause movement. Cytoarchitectural factors that in
measurement. Generally, less variability occurs within than muscle performance include the arrangement of
between observers. The variability may be more systematic fibers and the angle of pull of the muscle.
within than between observers but may differ depending on At the macro muscle level, aponeuroses and tend
the test; therefore, it needs to be measured. both store energy and redirect force, thus improv
The subject can be a source of variability. Strength efficiency of muscle action. Passive tension of a
measurements may change within a testing session due to contributes to the total tension that a muscle gen
fatigue or discomfort. They may change between sessions Shorter muscles have relatively high levels of
depending on the stability of the condition, intervening tension earlier in the range than longer muscles. T
activities, and other stresses. contributes to the differences in length-tension r
Psychometric factors obViously influence the measure ships between muscles.
ment of muscle strength. In addition, a myriad of biologic Another factor that influences muscle perform
and motivational characteristics contribute to the muscle elastic energy. Elastic energy can be stored and
tension, muscle strength, and muscle performance that is formed into kinetic energy (Soderberg, 1992).
being measured. These factors are now discussed. tension and elastic energy are important becau
influence measurements of muscle strength. Applic
a stretch prior to a measurement can increase the a
Biologic Factors Influencing of force generated by the muscle.
Muscle Strength At the micro level, the generation of force is inf
by the arrangement of muscle fibers (Trotter et ai.,
At the most basic level, movement and force are If the fibers of the motor unit are in series rath
produced by the contraction of the sarcomeres (Ghez, parallel, then the capacity of the motor unit to d
1991). The amount of contractile force that a muscle can force is hindered. This is because the total force that
produce depends on its absolute size, i.e., its length and developed by a motor unit is related to the sum of
cross-sectional area, the cytoarchitecture, the phenotype, generated by fibers lying in parallel, not in series,
and the vascularity of the muscle. These factors influence other. Thus, forces would be smaller in a series-
not only the magnitude of force that the muscle can muscle, such as sartorious, compared with a musc
generate but also how quickly that force can be generated parallel fibers, such as soleus (Edgerton et ai., 198
and the duration for which it can be maintained. Based on the work of several researchers, Sod
The amount of force generated by a muscle is controlled (1992) has illustrated how muscles with the same
through the recruitment order and the firing rate of the angle of pull, and fiber type, but with different
motor neuron. Motor units are recruited in a fixed order sectional areas and length differ in the magnitude o
from weakest to strongest. The weakest input controls that they can generate and the velocity with which th
the SF (slow fatigable) fibers, which are resistant to fatigue generate this force. All other factors being equal, th
but generate the least force. The FFR (fast fatigue-resistant) the muscle's cross-sectional area, the larger is the m
units are recruited next and, finally, the FF (fast fatigable) force-generation capacity. Within this same muscl
greater the velocity with which the peak force can be 2. Tissue injury leads to the release of a cascade o
achieved (Soderberg, 1992). biochemical mediators that are both neurogenic an
The force-velocity relationships of a muscle are also nonneurogenic in origin
important considerations. Essentially, lower forces are 3. These biochemical mediators sensitize nociceptiv
associated with faster velocities. Conversely, higher forces nerve endings directly and indirectly (Coderre et a
are associated with slower velocities. However, this rela 1993)
tionship holds true only for concentric contractions. Ec
centric contractions are associated with higher forces at The presence of pain, the anticipation of pain, and th
higher velocities. The magnitude of force generated iso fear of injury can influence the performance of the perso
metrically is lower than that generated eccentrically but being tested. This influence can be at both a conscious an
higher than that generated concentrically (Komi, 1973). an unconscious level. Research is needed to examine th
It is clear that many factors influence the force that a effect of pain on measures of muscle strength, both durin
muscle can exert and the duration for which it can do so. test sessions and over time. Simplistic interpretations abou
The physical factors discussed above are doubtless related a patient's "real pain" or lack of effort during muscl
to function. Some of the functional implications, such as strength testing should be recognized as a reflection of th
the preponderance of SO (slow oxidative) muscle fibers in personal biases of the clinician. Although some worker
endurant muscles, are obvious. It also seems obvious that have suggested that strength testing can provide evidenc
the method of testing muscles should provide information of pain and malingering, this is not true. No empirica
about their functional ability. This is not always the case. evidence supports this biased opinion. Furthermore, th
For instance, is an isometric test of muscle strength the best notion is flawed from a theoretical perspective because
way to test a muscle whose primary function is one that assumes that pain mechanisms are stable and that a simpl
involves rapid motion? Also, isolated tests of individual relationship exists between pain and motion or pain an
muscles may not give much indication of their ability to muscle contraction. None of these assumptions are cor
function in a coordinated pattern of activity. rect.
rate of loss, both between individuals and between muscles ability to endure physical activities was the most pow
(Rogers and Evans, 1993). The decline in muscle can be predictor of isokinetic performance. Perhaps more i
attributed to loss of muscle mass or an altered capacity of tantly, these authors showed that a patient's fear of re
the muscle to generate force. Recent research has shown was also a pertinent factor in strength testing.
that dynamic strength declines earlier and more rapidly The patient's ability to focus on the strength test a
than isometric strength (Pentland, et al., 1995). Thus, the screen out distractions influences the measurement
method of testing influences the results between different can be facilitated through instructions by the tester
age groups. tractions have been shown to have a negative influen
Although a decline of muscle mass occurs in the elderly, test results. They influence the planning of the activ
this loss of strength is greater than that accounted for by well as the activity itself (Pratt and Abrams, 1994).
cross~sectional area alone (Vandervoort and McComas, strength testing conditions should be focused on the
1986). The loss of muscle mass is due to a decline in both a consistent manner so that the truest measure of m
the number and the size of muscle fibers and in the degree strength is obtained.
of vascularization (Rogers and Evans, 1993). Differential
loss of fiber type may account for the differential decline in
isokinetic, compared with isometric, strength (Pentland et
ai., 1995).
Summary
All of the previously discussed factors are influenced by
Figure 2-2 summarizes the preceding information
inactivity and by cardiovascular fitness, as well as by aging.
clear from this overview section that many factors co
Thus, it is difficult to tease out causes and consequences of
ute to what would appear to be a simple muscle co
aging, inactivity, and cardiovascular fitness on measures of
tion. Clinicians must be aware that a myriad of f
muscle strength. Furthermore, these changes can be
contribute to muscle strength and that assessme
reversed through training of sufficient intensity and dura
muscle strength is more than a mere test of the m
tion. Thus, although normative data must account for
Although it is necessary to know how to test m
gender and age, individual variability is paramount. Indi~
strength, it is also necessary to know what the results
vidual variability in muscle strength testing is even more
test mean. The interpretation of the test results mu
crucial when tests of muscle strength are conducted
made in the context of all relevant factors.
clinically. In a clinical population, the physiologic and
psychosocial impact of an injury or disease enhances this
individual variability.
muscle strength and endurance. Issues of validity, reliabil the angles of the hip or knee? What is the effect o
ity, and utility are addressed within this section. gravity?
6. Order of testing. Include the type of contraction
(isometric, concentric, or eccentric), the muscle
Strength Test Protocol groups, and the velocity of testing.
Documentation 7. Commands and vocal encouragement. Standard
ized commands should be used. Vocal encourage
No matter what the type or the purpose of the strength ment should be standardized as much as possible
test, the testing protocol must be well described. Strength 8. Test range of motion. At what point in the range
tests, as with any other measurement test, must be was the strength test conducted?
reproduced as exactly as possible so that measurement 9. Criterion measure. Are peak or average values o
errors and artifacts are minimized. Thus, test protocol torque or force used? Is work or power used? Wha
descriptions should include the following: was the number of repetitions, and were absolute o
relative values used? For example, with absolute
1. Warm-up procedure. The length of time or number values, are the torques expressed as angle speCific
of contractions prior to the test, as well as whether or the angles at peak torque? If relative values are
the warm-up contractions were maximal or sub used, relative to what?
maximal. 10. Instrument and settings. What instrument wa
2. Previous practice sessions. Motor skills are learned used, and how was it used? What were the settings
and improve with practice. Does the test measure a on the machine, e.g., damping, lever arm, pause, o
change in strength or an improvement in skill? minimum force?
3. The method of stabilization. Can the subject
stabilize himself or herself by holding on with hands?
Are stabilization straps used? If so, where are the
straps placed, and how many are there? The better Isome'tric Tests
the stabilization, the higher the torque.
MANUAL MUSCLE TESTS
4. Rest periods. What is the length of the rest period
between contractions and set of contractions? Probably the most common tests in general use are
5. Position of the subject. Include the relation of the MMTs. These tests have a long history of use, require no
muscle to gravity. Is the position easily reproduc equipment, and are generally regarded as basic clinica
ible? Does the subject have back support? What are skills. These facts no doubt contribute to the frequency with
~~-~
" - -
~:;~::--
:/ ~-~" ":E"
. :"--t~~~~"':-
34 UNIT TWO-COfvlPONENT ASSESSMENTS OF THE ADULT
which MMTs are used. Manua'i muscle tests are weH TABLl2 I
described by Kendall and colleagues (1993) and by Daniels
and Worthingham (1986). Both groups of authors stress GRADING SYSTEMS USED IN MANUAL
the importance of attention to detail when using MMTs. MUSCLE TESTING
Kendall and coworkers suggest that precision in MMT is Criteria for M
necessary to preserve the "science" of muscle testing Grading S ymbols Grading
(p. 4). In fact, MMT has been subjected to little scientific
scrutiny. That is not to suggest that the techniques are not Normal 10 5 5.0 100% Can move or hold
sound, but merely that they have not been systematically gravity and max
resistance
tested. Proponents of techniques have the responsibility to Good + 9 4+ 4.5 80% Can raise part aga
test the techniques that they describe so well. Good 8 4 4.0 gravity and an e
Nevertheless, some important points must be kept in Good 7 4 3.66 resistance
Fair + 6 3+ 3.33 50% Can raise part aga
mind regarding the use of MMT. Both Kendall and associ Fair 5 3 3.0 gravity
ates (1 993) and Daniels and Worthingham (1986) describe Fair 4 3 2.66
standardized positions that attempt to isolate muscle func Poor + 3 2+ 2.33 20% Produces moveme
Poor 2 2 2.0 gravity eliminate
tion . Resistance to the motion is applied throughout the Poor 1 2 1.5
range of motion (Daniels and Worthingham, 1986) or at a Trace T 1 1.0 5% A flicker or feeble
specific point in the range (Kendall et aL , 1993). In addition traction
Zero 0 0 0.0 0% No contraction
to ap plying resistance through the range of motion (the
"make test"), Daniels and Worthingham also use a "break
tes1" ' at the end of range. In the break test, the patient is
instructed to "hold " the limb as the therapist applies a healthy subjects. These calculated scores were the
gradual increasing resistance. Pain or discomfort should pared with the measured scores. Essentially, the
not occur, and if it does then the test should be discontinued revealed that the MMT and HHD scores were co
(Daniels and WortJ1ingham, 1986, p. 3). Make and break but significantly different. Bohannon also reported
tests are not equivalent and should not be used interchange MMT percentage scores overestimated the extent to
ably. Using dynamometry, Bohannon (1988, 1990) has the patient was "normal." However, Bohannon se
shown that significantly greater strength values occur with have trouble with the designation normal, since a
the break test compared with the make test in both healthy his normal subjects were designated as "normal m
subjects and in patients . Problems with this study are evident. One of th
Grading systems for MMT have included letter grades, pertinent concerns relates to the different starting p
numeric grades, percentage grades, and descriptive cri used in testing muscle strength with HHD compar
teri a . Pluses and minuses have also been utilized (Table MMT. All HHD testing was conducted in sitting po
2-1). The methods of Kendall and colleagues and of whereas MMT tests were conducted in Side-lying po
Daniels and Worthingham have obvious similarities and The author did not correct for effect of gravity even
some differences (e.g ., grading system). Neither method it would have had a significant impact. Finally, Bo
has a proven advantage. Neither method has been sub did not report reliability in this study.
jected to much critical scrutiny. Based on the weight of the Reliability differs depending on the strength
limited evidence available, the reliability of MMT is low muscle and its anatomic characteristics. It seems
(Beasley, 1961; Frese et aL, 1987; Wadsworth et aL, that it is easier to palpate a contraction in a large sup
1987). It is obvious that the reliability of the test would muscle like the quadriceps than in a small deep musc
depend on which muscle was being tested , the strength of as the piriformis. Thus, reliability would be higher
that muscle , and whether other confounding factors such MMT in the quadriceps. Conversely, it would be dif
as , but not limited to, the presence of spasticity, were determine whether the contraction of the quadrice
present. The confounding impact of spasticity on the good (80%) or normal (100%) in a large athletic in
results of muscle strength tests is not surprising. It is because the therapist would have difficulty challeng
surprising that the examiners' designation of "normal" is muscle with manual resistance.
somewhat idiosyncratic. This problem of relatively weak therapist streng
In a study by Bohannon (1986), one third of the normal reported by Deones and colleagues (1994). These
subjects were graded as "normal minus ." Bohannon gators measured quadriceps strength in a healthy
examined muscle strength of the knee extensors in a tion using the Kin-Com and HHD. They reporte
controlled trial. He compared knee extension " make " correlations in strength measured with each device
forces in 60 healthy ad ults and 50 patients with a variety of they attributed to the examiner not being able to re
neuromuscular diagnoses. The MMT grades were con force of the quadriceps.
tJ'asted with forces measured with an HHD . The author In a review of MMT, Lamb (1985) noted that in M
calculated dynamometer percentage scores for the pa patient responds to the amount of force applied
tients, based on the dynamometer scores measured on the examiner. Different examiners no doubt apply a d
different amount of force at different times. Force applica muscles in a functional manner, and the relationshi
tion by therapists has been reviewed and tested and is a between muscle impairment and functional deficit is ce
significant source of variability (Simmonds and Kumar, tainly not clear. The patient's motivation, determination
1993a; Simmonds et at, 1994). Although the application ability to problem-solve and substitute alternative moto
of the testing technique can be standardized in terms of patterns has far more to do with function than with th
patient position and the point at which the examiner isolated ability of a muscle to contract.
applies resistance to the muscle, the amount of applied Although the MMT has a long history and is entrenche
resistance is still variable. The examiner also has to in clinical education and practice, it is a technique tha
compare the muscle with "normal," but the concept of needs to be systematically and scientifically scrutinized. It
normal and the expectation of how a muscle should necessary to determine which specific MMT tests ar
perform is somewhat idiosyncratic. In addition to problems reliable, under what conditions, and in what patient group
with reliability, MMT grading scales are not responsive to It is also necessary to determine which MMTs are no
change (Griffen et aL, 1986). A large change in muscle useful, and they should be discarded. Finally, it is necessar
strength is necessary before such variation is reflected in a to determine the diagnostic and prognostic and discrim
change of grade on an MMT scale. For example, a muscle native validity of MMTs and to determine what can b
may be conferred a grade of "good" because it can move reasonably inferred from the results of specific MMTs.
a joint through a full range of movement against gravity and
an external force applied by the examiner. Although
INSTRUMENTED MUSCLE TESTING
repeated testing over time would reveal an increase in the
muscle's functional ability, this improvement could not be The problems of poor reliability and responsiveness ar
measured using the zero-normal grading system. The use alleviated somewhat with the use of instrumented MMT
of "pluses" and "minuses" to the grading system may have (Bohannon, 1986; Currier, 1972; Riddle et aI., 1989
been instituted in an effort to improve the responsiveness Stratford and Balsor, 1994; Trudelle-Jackson et aI., 1994
of the test but probably only leads to lower levels of However, instrumented hand-held MMTs are still limited b
reliability . the therapist's ability to adequately resist muscle strength
The lack of reliability and responsiveness of MMT is Instrumented muscle testing has increased the level o
problematic because the test is supposed to measure accuracy and the reliability of strength testing and ha
change in a patient's muscle strength. This may not be a contributed significantly to the body of knowledge abou
problem clinically if other more responsive tests are used to muscle performance. One of the first devices to be used
measure change in the patient's function. The other tests measuring muscle strength was the cable tensiometer. A
may provide more useful information in regard to how the the name implies, cable tensiometers measure tension in
muscle is functioning; they could also help to validate cable. To use this device to test muscle performance, on
MMTs. But one must ask, if MMTs are not useful, why use end of the cable is attached to a limb segment and the othe
them? to a fixed object. The tensiometer is then placed on th
The main value of the MMTs is in their apparent ability cable, and a gauge on the meter measures the amount o
(which needs to be tested) to isolate and to test the tension. Calibration is necessary to convert the gaug
contractability and "strength" of individual muscles and reading into a measure of force. This is usually done b
groups of muscles that are weak. The use of MMTs is less suspending known weights from the cable, reading an
useful in stronger muscles because it is limited by the ability recording the measurement from the gauge, and conver
and strength of the therapist to provide resistance to the ing these units into units of force. A key procedural facto
muscle while adequately stabilizing the patient. MMTs have for using the cable tensiometer is that the cable must b
limited usefulness in recording improvement or deteriora positioned along the line of muscle action. A secon
tion in a patient's condition because they have poor procedural point to consider (because it facilitates compu
reliability and lack responsiveness. It could be argued that, tation) is that the cable should make a 90-degree angle wit
if the reliability and responsiveness of MMTs is poor, then the point of attachment to the body.
validity is moot. However, different types of validity exisi. Cable tensiometers have been used in research (Beasley
The lowest level of validity is face validity. Face validity 1961; Currier, 1972), are fairly reliable, and provide th
asks, does the test appear to measure what it is supposed quantitative data needed for research and clinical applica
to measure? So, is an MMT supposed to measure the ability tions. However, they have never been widely used in th
of a muscle to contract, to move a limb through a range of clinic. The same is true for strain gauges. A strain gauge
motion, or to function normally? Manual muscle tests a device that has electroconductive material incorporate
measure the ability of a muscle to contract and to move a in it. The application of a load to this device results
limb through a range of motion. They do not measure the deformation of the electroconductive material, whic
ability of a muscle to function. Function is much more changes the electrical resistance and thus the electric
complex than an isolated muscle contraction. Although outputto a display device. Again, calibration is necessary t
one can infer that function will be impaired if a muscle or convert the electrical output into force. These devices ar
36 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
not discussed further here because they have not been Thus , the MS can be applied against bony surfaces w
utilized by clinicians in the past and are unlikely to be so in causing discomfort (the experience of pain or disc
the future. during a test would confound the results of the test
In contrast , HHD has been widely adopted in clinical The HHD is a hand-held device that incorporates
practice. A few reasons probably account for the adoption scales or strain gauges to measure applied force . The
of these instruments. measures the applied force in kilograms or pounds
no conversion of measurement units is required . The
1. The need to document the results of clinical tests in a
is used in the same way as the MMT and the MS. T
quantitative manner. Th~s is a prerequisite so that
is subject to some of the same limitations of
treatment efficacy can be established and optimal
especially that regarding the strength of the exa
treatment regimens can be defined.
Bohannon (1986) suggests that this limitation may
2. The technique of HHD is the same as that used during
as the examiner becomes more experienced. B
the MMT, and therapists are very familiar with MMT
(1956) showed that examiners were able to hold a
techniques .
higher forces with practice . A learning effect exists
3. The devices are inexpensive, simple to understand ,
examiner as well as for the patient. The learning
and simple to use.
results in a greater amount of force being recorded,
Two devices are described and discussed in this sec force difference is obviously not reflective of a cha
tion: the modified sphygmomanometer (Fig. 2-3) and the muscle strength.
HHD (Fig. 2-4). The HHD has been tested for intrarater, interrat
A mod ified sphygmomanometer (SM) can be used to interdevice reliability for different muscles and in di
quantify the resista nce offered during a manually resisted population groups (Bohannon , 1990; Riddle et aI.,
isometric contraction (Giles, 1984; Helewa et al. , 198 1; Trudelle-Jackson et aI., 1994) and for quantitative
Helewa et aI. , 1990). Sp hygmomanometers are usually parisons between make and break tests (Stratfor
available in the clinic and are easily modified to measure Balsor, 1994). This device has also been compare
muscle strength. Essentially, the MS is a regular sphygmo other, more technically sophisticated, devices such
manometer from which the bladder has been removed Kin-Com isokinetic testing unit (Deones et ai,
from the cuff. The bladder is folded into three sections and Stratford and Balsor, 1994; Trudelle-Jackson et ai,
placed in a cotton bag. Alternatively, the cuff may simply In a nonblinded trial, Bohannon (1988) used an H
be rolled up . A baseline pressure is set within the MS , and measure intratester and intra session reliability of me
the device is then placed between the body part and of force in the elbow flexors of 31 healthy subjec
the therapist's hand , as if an MMT was being carried reported good reliability (ICC = 0.995). Trudelle-Ja
out. The patient then performs a resisted contraction and colleagues (1994) tested interdevice reliability a
against the MS cuff, and the pressure is noted. Conversion not demonstrate such high levels of reliability.
from units of pressure to units of force necessitates authors also tested a healthy population. They co m
calibration. two different HHDs and mea.sured hamstring force
The MS has one advantage over the HHD, and thus is class correlatie n coefficients between the two devic
related to its softness and compressibility of the material. low (ICC = 0.58) . These results suggest that di
devices cannot be used interchangeably to mea
patient's progress . These authors also compared th
measured with the HHDs to that measured wi
Kin-Com (parallel forms of concurrent reliability). Th
calculated between the Kin-Com and each HHD
reasonable (ICCs = 0.83 and 0.85), but an analy
variance between the Kin-Com and the HHDs reve
significant difference between the Kin-Com and one
HHDs. The mean force measured with each HH
7.5 kg and 12.5 kg; the mean force measured w
Kin-Com was 13 kg. This suggests that the differe
values is clinically significant as well as statistically
cant. It also shows that calibration should be checke
odically, and that HHD devices are not interchang
Riddle and colleagues (1989) tested the stren
several muscle groups within and between session
sample of patients with brain damage . They measur
muscle forces on the paretic and nonparetic lim
FI GURE 2-3. Use of modified sphygmomanometer to measure grip their surprise , they obtained higher levels of reliabi
strength. the nonparetic limb compared with the pareti
FIGURE 2-4. A, Hand-heJd dynamo meter. B, Use
of hand-held dynamometer to measure quadriceps
force. (A and B, Courtesy of Lafaye tte Instrument.
Lafayette, IN.)
(ICC = 0.90-0.98 and 0.31-0.93, respectively). This was pinch meters (Fig. 2-6). Both of these devices measur
a repeated measures design with strength measures taken force , which is recorded in pounds or kilograms on a gauge
more than 2 days apart. The lower level of reliability Computerized versions of these devices are available bu
obtained on the non paretic side may be due to the are not always necessary or advantageous, depending o
difficulty associated with applying adequate resistance to the mathematic algorithms used in the software . Stan
strong muscles. dardized testing protocols are included with the device
The HHD dynamometer can be used to assess isometric Both intra- and interrater reliability of the gri p strengt
strength in many muscle groups relatively easily. Its reli dynamometer is good in normals (Neibuhr et ai, 1994
ability is lower when it is used to test relatively large and Stratford et ai , 1987: Stratford, 1989) and patien
relatively strong muscles. Although isometric measure (Stegnick Jansen, 1995).
ment of force has face validity, it is not clear how much The influence of the position of the elbow joint durin
force is necessary to perform specific functional tasks. testing of normal subjects is not clear. Math iowetz an
Also, HHD is not useful for testing trunk strength or hand associates (1985) showed that elbow joint position influ
strength. enced the magnitude of grip force, but the results were no
For hand strength testing, two devices are in common replicated by Balogun and colleagues (1991) . Stegnic
clinical use: grip strength dynamometers (Fig. 2-5) and Jansen (1995) contrasted grip force in a patient and contro
FIGURE 2-5. A, Grip dynamometer. (Sammo ns Preston, Burr Ridge. IL.) B, Use o f grip dynamometer to measure grip fo rce.
--
- _0
38 UNIT TWO-COI'vlPONENT ASSESSMENTS OF THE ADULT
FIGURE 2-6. A, Pinch meter. B, Use o f pinch meter to measure pinch force .
group with the elbow in flexed compared with extended muscular contractions against a mechanical system
position. Twenty-two subjects with lateral epicondylitis and provides a constant load , such as when lifting a free w
15 normal subjects participated. Excellent reliability coef In fact, the load of a ~ree weight is not constant be
ficients were reported (ICCs ::::: 0 .9 5). Noteworthy was the changes in the angulation of the limb lever influenc
fact that elbow position did not influence grip strength in effect of gravity on the load . A consequence of this
the normal group but did influence grip strength in the the muscle could be working at its greatest mech
patient group. In the patient group, grip strength was advantage when the resistance of the load has its
greater with the elbow flexed on both the involved and the effect (Hislop and Perrine, 1967), and the muscle
uninvolved sides. The magnitude of difference was much not be challenged throughout its range. Theoreti
greater on the involved side. This work highlights the isokinetic exercise challenges the muscle througho
problems inherent in testing normal subjects and general range.
izing those findings to patient populations. Patients and Isokinetic testing uses an electromechanical devic
non patients are different. prevents a moving body segment from exceeding a p
To summa rize , it can be stated that reliability of instru angular speed. The axis of the device is aligned wi
mented MMT is reasonable and appears to be primarily anatomic axis of the joint that will be moving. The leve
limited by the strength of the examiner, standardization of of the device is attached to the subject's limb, an
technique is important, and instruments are not inter subject is instructed to move as fast as possible . The d
changeable. The validity of instrumented MMT is subject to does not initiate motion, nor does it provide any resis
the same issues and questions posed for noninstrumented to motion until the preset speed is reached. Howev
MMT. The validity needs to be assessed. soon as the subject's limb moves as fast as the preset s
the device exerts an opposing force against the m
body. As the subject tries to accelerate, the machine r
Dynamic Tests the movement. The harder the subject pushes again
device , the greater is the resistance provided by the d
Isometric measureme nts provide some information This resistance is measured by the machine througho
about muscle strength that is important to clinicians. But range of motion and torque curves are plotted using
because muscles usually fundion in a dynamic manner, it of motion and torque (Fig. 2-8) . The earliest machine
makes sense to measure muscle performance in a dynamic a strip chart recorder, but most machines are now
manner (Fig. 2-7). Although dynamic testing appears to be puterized . Algorithms within the software compute
more functional , the relationship between function and sures such as average and peak values of torque, p
dynamic testing has not been established (Rothstein et a!. . and work in addition to the position within the ran
1987). One of the first papers to appear in the physical which peak torque was generated. The output is u
therapy literature about isokinetic exercise was by Hislop presented in tabular and graphic form (Fig. 2-8).
and Perrine (1967). These authors differentiated between Much of the research in isokinetic testing has
isotonic (constant load) and isokinetic (constant speed) conducted on the knees of normal subjects, but resear
exercise. They suggested that isotonic exercise involves have examined the machines, muscle groups other
ent attachments that allow an examiner to test different mance in a dynamic quantitative manner has contributed
muscle groups, including those of the trunk. Trunk testing the body of knowledge about muscle performance. Isome
machines are discussed separately. ric tests provide information about the ability of a muscle
INITIAL REPORT
PATIENT NAME: Edward REPORT DATE: Mon Jan 10 20: 56: 06
TEF TRUNK EXTENSION/FLEXION
CYBEX TEST DATE(S) 1nt1994
EXTENSION
PEAK TORQ (ftlbs) 209 67 27
PEAK TORQ % BW 116% 37% 15%
ANGLE OF PEAK TORQ 32 6 7
TORQ@ DEGREES
TORQ@ DEGREES
FLEXION
PEAK TORQ (ftlbs) 151 118 84
PEAK TORQ % BW 83% 65% 46%
ANGLE OF PEAK TORQ 52 45 47
TORQ@ DEGREES
TORQ@ DEGREES
FIGURE 2-8. Output from isokinetic device. (Courtesy of Isotechnologies, Inc., Hillsborough. NC.)
TRUNK EXTENSION/FLEXION Mon Jan 1020:56:131994
TORQUE VS. POSITION-INITIAL REPORT
test date-11711994 14:20
LEGEND:
- maximum points, test speed-60 deg/sec
- average points, test reps-3
- bestwork
FLEXION EXTENSION
440 440
I
400 400
T
0 360 360
R 320 320
Q
U 280 280
E 200 200
F 160 160
T 120 120
* _/
80 ."..
80
L
B 40 I 40
S 20 20
0 I
0
95° -15° 0° 40°
ANGLE (degrees) ANGLE
COMMENTS: ________________________________________________________________________
exert a force or torque against an external resistance. power, peak power, average power, instantaneous power
Dynamic tests also provide information about muscle and contractile power.
work, muscle power, the speed of muscle contraction, and Power is the rate or speed of doing work and is expressed
the ability of a muscle to maintain a force through a range in watts. Computation of power is relatively straightfor
of motion (Moffroid et al., 1969; Moffroid and Kusiak, ward in isokinetic testing because the speed is constan
1975; Rothstein etal, 1987). As noted earlier, although the (power = work/time). According to Moffroid and Kusiak
testing appears to be more functional than isometric (1975), other types of power are calculated by substituting
testing, the validity of isokinetic testing has not been some specific value into an equation. For example, peak
established. The construct of movement occurring .at power is defined as peak torque divided by the duration o
constant speed is artificial (Kannus, 1994), as are the the isokinetic contraction (peak power = peak torque
positions and movement constraints under which isoki contraction duration). Thus, in the peak power equation
netic testing is done. peak torque is substituted for work, and distance is dropped
Isokinetic tests measure the follOwing characteristics of from the equation. Operational definitions of terms are
muscle performance. Torque is the force that acts about an obviously necessary. But definition of a term does not make
axis of rotation. It is the product of this force and its point it a useful or meaningful term. Rothstein and coworker
of application from the axis of rotation. Work is force (1987) decry the erroneous use of measurement terms and
exerted through some distance. lsokinetic testing measures caution clinicians about uncritical acceptance of the jargon
force and the angular distance through which the limb associated with isokinetic testing. In support of thei
moves. Thus, the work of the muscle can be computed position, they describe how "power" has been erroneously
easily (work> = torque or force x distance). In the clinical used to describe the torque values measured during high
context, work is a term that may be reserved for that done velocity testing.
by the therapist. Power is a more frequently used term, but This consideration of terminology is not simply a pedan
it is also used inappropriately at times. Moffroid and Kusiak tic diSCUSSion of semantics. Words are powerful tools
(1975) define five separate measurements of power: Loosely used pseudoscientific terms have a tendency to
42 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
persist because they have an aura of credibility and techno of known value are applied to the load arm at a kno
logic sophistication that does not invite questioning distance from the point of rotation. Because the wei
critical or otherwise. This facilitates the adoption of errone values and arm length are known, the torque applied to
ous terms into accepted dogma. shaft is also known. This torque value is then compa
Appropriate terms or measures obtained with dynamic with that torque value recorded by the machine. This c
strength testing devices usually include such measurements bration procedure tests in the isometric mode. lsokin
as isometric torque or force and isokinetic force or torque calibration is not speCifically tested, which is problem
throughout the range of joint motion and at different when strength testing is conducted in the isokinetic mo
velocities. Power and work can be computed from torque The manufacturers claim that their device has long-te
and velocity data using the equations noted previously. Test stability and accuracy, but whether this has been tested w
factors that can influence these measures are as follows. the machine in clinical use is not clear. Cybex II calibrat
Velocity. The velocity at which the isokinetic test is protocol uses known weights applied at a single speed.
conducted makes a significant difference to the torque based on extensive testing of the device, Olds and asso
output and the position in range at which peak torque ates (1981) have suggested that the Cybex should be tes
output occurs (Chen et al., 1987; Gehlsen et aI., 1984; daily and at every test speed. Essentially, the calibrat
Hsieh et aI., 1987; Osternig et aI., 1977; Rothstein et aI., protocol needs to simulate the clinical testing situation
1983; Tredinnick and Duncan, 1988; Watkins et aI., much as possible. This includes testing the machine w
1984). It is well known that a force velocity relationship the settings that are used during clinical testing, eg,
exists in dynamic muscle contractions. This relationship is damp setting on the Cybex II.
essentially linear (Rothstein et aI., 1983). An increase in the Damp is a means of redUcing signal artifacts in electr
load on a dynamically contracting muscle causes the systems. An undamped eletric signal results in "oversho
velocity of the contracting muscle to decrease. Similarly, as or an erroneously high torque reading. Sapega and
the velocity of the muscle contraction increases, the torque leagues (1982) showed that the overshoot was due
generated by the muscle decreases, and peak torque occurs inertial forces rather than muscular torque. The Cybe
later in the range. These findings are robust between has five damp settings (0-4). Increasing the value of
different muscle groups and between normal subjects and damp setting results in a decrease in the peak torque an
patient groups. shift of the curve to the right, which implies that p
Experience and Repetitions. Isokinetic tests are not only torque occurred later in the range (Sinacore et aI., 198
a test of strength but also a test of motor skill. Learning is The important point is that all the machine settings mus
involved in this skill, which is reflected in torque increases, documented, and clinical evaluations must be retes
and of course influences the reliability of the test. Based on using the same settings.
their study of knee extensor torque in 40 healthy women, Another factor that affects torque output is gravity. T
Johnson and Seigel (1978) recommended that a mean of effect of gravity obviously varies with the position of
three repetitions provides the highest level of reliability limb. If gravity is not corrected for, then the torq
(0.93-0.99). Their protocol included a warm-up of three generated, and thus the power and work calculated, wo
submaximal and three maximal contractions, and strength be subject to error (Winter et a!., 1981). The error would
tests conducted at 180 degrees per second. In another systematic and therefore would not affect the reliability
study, Mawdsley and Knapik (1982) tested 16 subjects with the isokinetic tests, but the validity of the measureme
no warm-up, in three sessions across 6 weeks, at 30 would be compromised. Fillyaw and coworkers (19
degrees per second. They reported no Significant differ tested peak torques of the quadriceps and hamstrings in
ence in torque values across the 6-week time period. The soccer players. They computed the effect of gravity a
results from the within-session testing were interesting. In added this value to the quadriceps torque and subtracte
the first trial, the first test produced the highest torque, from the hamstring torque. Depending on the speed
whereas in the second and third sessions, the first trial testing, the effect of gravity correction on mean p
produced the lowest torque. It is difficult to explain why torques was approximately 6 ft-lb in the quadriceps a
torque values increased with each repetition within the first 8 ft-lb in the hamstrings.
test session but decreased with each repetition in the sec One other equipment consideration that affects iso
ond and third sessions. Based on the information reported, netic muscle testing relates to the center of rotation of
any interpretation would be entirely speculative. However, equipment and its alignment with the center of rotation
the fact that no significant difference was seen between the the joint axis. This is an especially important issue
averaged values across the 6-week period suggests that measuring muscle strength in multijoint areas, such as
under the conditions of testing used in the study, a reason trunk.
able level of reliability can be expected over a relatively long Testing Protocol. Potentially many factors within
time period (6 weeks). specific testing protocols could influence the measurem
Calibration and Equipment. The manufacturers of isoki of muscle strength. Factors such as length and type
netic devices usually supply the calibration protocol for use warm-up activity, the number and length of rest perio
with their machine. For the Lido isokinetic device, weights and the type and order of muscle contractions could
make it difficult to compare the results from different and very costly in financial and personal terms. They can
studies. But these factors have not been specifically tested, lead to a great deal of distress and demand on the health
so the extent of the influence is really not known and these care system. Many patients in rehabilitation are patients
factors should be tested. with low back problems. The trunk is a complex multiseg
The mechanical aspects of isokinetic machines appear mental system with multiple joints, multiple axes of motion
to be reliable. But how reliable is the device for measuring and multiple complex musculature. It is more difficult to
muscle strength? And is the level of reliability different in measure range of motion and muscle strength in the trunk
patient populations compared with normals and at differ than it is in peripheral joints because of the trunk's
ent testing speeds? A reasonable level of reliability appears complexity. The perceived need to quantitatively measure
to exist in testing muscle strength, as long as standard trunk function coupled with the availability of new technol
protocols are adhered to. Standardization is crucial be ogy has led to the development of trunk testing devices
cause so many factors can influence the test measurement. There is now a great deal of use, and unfortunately misuse
The validity of the tests and of the interpretation of the of trunk testing devices.
output has received less scrutiny. Functional strength tests of trunk musculature have been
The reliability of specific isokinetic devices in measuring used as a preemployment screening tool, as a measure o
muscle strength has been examined to a limited extent progress in rehabilitation, and as a "malingerer detector."
testing different muscle groups. In a recent review of Use of functional muscle testing as a screening device is
isokinetic testing of the ankle musculature, Cox (1995) based on some epidemiologic data that suggest that manua
concluded that isokinetic testing was generally reliable. materials handling leads to back injuries. However, the
However, he noted that reliability was higher for the supporting evidence for this notion is not strong. Mos
plantar- and dorsiflexors than for the inverters and everters. studies are retrospective; do not distinguish between back
It was apparent from the review that most studies were injuries, reports of back injuries, and time lost from work;
conducted on normals. Frisiello et al. (1994) examined the and do not account for confounding psychosocial variables
test-retest reliability of the Biodex isokinetic dynamometer (Pope, 1992).
(Biodex Medical Systems, Shirley, NY) on medial and This knowledge has not stemmed the tide of technology
lateral rotation of the shoulder. He tested eccentric peak or the inappropriate use of isodevices. Recent critica
torque of both shoulders in 18 healthy adults at 90 and 120 reviews on trunk strength testing with isodevices conclude
degrees per second. He reported ICC values between 0.75 that no evidence has been found to support the use of these
and 0.86, with medial rotation being slightly less reliable devices for preemployment screening, medicolegal evalu
than lateral rotation. ation, or even clinical evaluation (Andersson, 1992
It appears from the literature that isokinetic devices are Mooney et al., 1992; Newton and Waddell, 1993; Pope
mechanically reliable within themselves, but comparisons 1992). The strength of this criticism may be a reaction to
between devices have not been conducted. It also appears overclaims by manufacturers and overinterpretation o
that isokinetic devices measure muscle torque reliably. results by those with a vested interest in the device or in the
Many reliability studies have been conducted measuring results of the test. Inappropriate interpretation of results
peripheral muscle strength in normal subjects. The "nor may also be due to an incomplete understanding o
mal" subjects are frequently well educated, well motivated, biopsychosocial factors that contribute to a person's per
and free from pain and dysfunction. Typical patients may formance on an isodevice. Medicolegal issues and clini
also be well educated and well motivated, but they usually cians' suspicions have complicated the use of trunk testing
have some discomfort and dysfunction, which may influ machines to a shameful degree. However, on the positive
ence their performance and thus the reliability of the side, these machines do provide information that is no
strength measure. Therefore, the assumption of similar otherwise available. Systematic research is now necessary
levels of reliability in patients is not appropriate. Reliability to determine the validity of the information that these
needs to be established in the specific populations that are devices do provide about trunk function.
to be tested under the conditions of testing that are used in Trunk testing devices have contributed to the body o
that population. knowledge on trunk performance, including isometric and
dynamic trunk strength. Isomachines for trunk testing were
introduced about 10 years ago. They now include the
Trunk Testing Cybex back testing system, the Udo, the Kin-Com, and the
B-200. With the exception of the B-200 (Fig. 2-9), which
Finally, an area of testing that has evolved rapidly in the is an isoinertial (constant resistance) device, most trunk
last decade is the use of isokinetic and isoinertial devices to testing machines are isokinetic. All the isokinetic devices
measure isometric and dynamic muscle strength in the operate on similar principles to each other and to the
trunk. Spinal problems are complex problems that are isokinetic devices that measure peripheral muscle strength.
difficult to prevent, difficult to diagnose, and difficult to The main difference between the devices is in the tes
treat. The tendency for spinal problems to recur is a source positions (lying, sitting, semistanding, or standing) and 'the
44 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
degree of stabilization and constraints to motion. Some of 1982), and the iliac crest (Suzuki and Endo, 1983) h
the machines can measure strength in all directions of trunk been used as a designated axis of motion. It is no
motion simultaneously and with the person in the same whether any axis has more validity than another. Ho
device, eg, the B-200. Other devices have different ma regardless of which axis is intended for selection, a
chines for different motions. For example, the Cybex of plus or minus one spinal level exists betwe
system has one device that measures trunk flexion and segment that is intended for selection and that w
extension and another that measures axial rotation. actually selected (Simmonds and Kumar, 1993b
All of the factors that need to be considered in isokinetic important points for testing are that the specific axis
testing in peripheral muscles, such as warm-up protocol be documented and that the same axis should be u
and standardization of instructions, need to be considered repeated testing.
in trunk testing. There are, however, some factors that are In peripheral joints, isometric strength was show
unique to strength testing of the trunk because of its greater than dynamic strength. Moreover, as the velo
biomechanical complexity. testing increased, the magnitude of torque decreased
The amount of torque generated by a muscle is the occurred later in the range. The same phenome
product of force and the length of the lever arm from the present in trunk masculature, and this holds for al
axis of motion. Determining the axis of motion in a tions of movement (Kumar et a!., 1995a; Kumar
multiaxial system is obviously problematic. The hip joint 1995b).
(Hasue et aI., 1980), the LS-S 1 joint (Davies and Gould, The position of testing trunk performance influen
the musculature and because of the differential effects of isokinetic devices can be useful for measuring clinica
gravity on the trunk. Cartas and colleagues (1993) evalu change, Studies that have compared males and females
ated the effect of subject position on isometric and and patients and controls are consistent in their findings
isoinertial muscle performance. They tested 25 healthy Muscle strength is lower in a group of females compared
male subjects with the 8-200 isoinertial dynamometer on with a group of males . Furthermore, muscle strength i
two different occasions. The first test involved isometric lower in a group of patients compared with a group o
measurements in three directions and in three positions; healthy subjects. However, within all groups, a high level o
sitting (hip in 90 degrees fleXion) , semistanding (hip at 135 variability is seen between individual subjects This variabil
degrees fleXion) , and standing. The second session in ity compromises the ability of the isokinetic test results to
volved dynamic testing in three directions against 50 discriminate between indiuidual patients and indiuidua
percent resistance. Isometric flexion strength was highest controls, In attempting to classify subjects as patients o
in standing and lowest in semistanding, whereas isometric controls, Newton and colleagues (1993) found that isoki
extension strength was not influenced by position. Dy netic scores were not useful. Using two standard deviations
namic muscle performance was highest in standing for all as the cut-off criteria, 80 percent of patients were deSig
directions. These results give an indication of the impor nated "normal. " This figure was reduced to 56 percen
tance of posture to muscle strength and suggest that one using one standard deviation as the cutoff criterion. The
particular posture is not optimal for all muscle perfor data from this study did not provide much support for the
mance. Unfortunately, these tests were conducted in ability of isokinetic tests to discriminate between norma
normal, pain-free individuals. The results cannot be gen subjects and those with spinal problems. Mean torque
eralized to the patient population because patients have scores are not useful in discriminating between patients and
different pathophysiologic constraints on their posture and control subjects. Is it possible that evaluation of the ratio
on their muscle performance. between flexor to extensor strength is more useful? Al
Several investigators have used isomachines to compare though some authors have suggested that this is the case
muscle performance between patients and pain-free sub (Maye r et al., 1985; McNeill et aI. , 1980; Suzuki and Endo
jects (Cassisi et aI., 1993; Gomez, 1994; Newton et aI., 1983), no consensus as to the normative ratio has been
1993). Newton and colleagues (1993) tested 70 normal reached. This lack of consensus can be explained by recen
subjects and 120 patients using the Cybex II device. They work of Kumar and colleagues (1995a, 1995b). They
considered the reliability of the device and the learning showed that the ratio of flexion to extension strength varies
effect of the subjects. They evaluated whetherisokinetic as a function of trunk position and speed of testing,
measures could discriminate between patients and con Other difficulties in attempting to use isokinetic scores to
trols. They also examined the relationship between clinical discriminate between patients and controls are reported by
and isokinetic measures. Gomez (1994), Gomez tested 168 normal subjects and
Similar to other reports, the device was found to be 120 patients using the 8-200, speCifically to look a
reliable and a learning effect was noted. It was interesting
to find that the magnitude of the learning effect was greater
in the patients than in the controls. A couple of factors can Ti\BI.L 2 2
account for this.
SHOWS HOW USE Of PERCENTAGE
First, the magnitude of difference was calculated as a CHANGE SCORES TO DEMONSTRATE A
percentage change in mean torque. The torque output was LEARNING EffECT IS BIASED IN fAVOR
lower in the patient group compared with the control OF PATIENTS·
group; thus, patients are at a mathematical advantage. For
example , it can be seen from Table 2-2 that the magnitude Velocity
of change between the first and second test of trunk of Test
(degrees Test 1 Test 2 Magnitude Learning
extension at 120 degrees per second was 14. 6 ft-Ib in the per sec) (ft-Ib) (ft-Ib) of Cbange % I ncrease
normal group and 18.3 ft-lb in the patients , a negligible
difference between groups, However, when this difference Normal Group (n = 21)
is presented as a percentage learning increase, the appar 60 122,6 142,9 20 ,3 16
ent learning effect is much more significant in the patient 90 116,9 132.4 15,5 13
120 98,8 113.4 14,6 15
group (28%, compared with 15% in the normal group), All
data should be scrutinized, and this example shows why , Patient Group (n = 20)
Cooke and colleagues (1992) examined isokinetic per 60 93.5 122,0 28.5 30
90 88,3 100,9 12, 6 14
formance in 45 subjects with low back pain, They acknowl 120 63,4 81.7 18,3 28
edged a learning effect between the first and second tests
but found no Significant difference in strength measures : Based on data from Newton, [VI" Thow, M" Somerville, D" He nderson
between the second and third test. They conducted isoki I. , & Waddell , G, (1993) Trunk strength testing with iso-machines
Part 2 : Experime ntal eva luation of the Cybex II bac k testing system in
netic tests at 2 and 4 weeks following therapy and normal subjects and patients with chronic low back pain , Spin e, 18(7)
measured an improvement in muscle strength beyond that 812-824
46 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
asymmetry of trunk strength and range of motion. He factors that influence the test? They should a
found that asymmetric motion and strength was present in whether the measurement has any relationship w
the subjects with low back pain. However, the asymmetry patient's problem as the patient perceives it.
did not discriminate between patients and normal subjects. I would like to leave the reader with the follOWin
This was because ALL subjects were asymmetric and to ponder: We sometimes measure what we m
moved asymmetrically. because we can measure it, it is easy to measure,
The magnitude of variability of isokinetic test data both have been taught to measure it. We do not measu
within and between groups argues against the value of we should measure because it is more difficult an
using normative isokinetic data. Comparing the magnitude complex. We then use the easy measure to infe
of force exerted by a patient against a normative database about the difficult measure.
is probably less useful than using the patient as his or her Isolated and constrained tests of muscle strength
own control and measuring the change in performance. own do not provide an adequate indication of coor
The tremendous variability in the magnitude of muscle discomfort-free functional muscle activity.
strength is due to the myriad of factors that influence
strength and that influence the measurement of muscle
strength. It is difficult for normative databases to control for
the considerable number of relevant factors.
It is obvious from the previous discussion that many Concentric-A shortening muscle contraction.
issues regarding trunk testing with isomachines are unre
Eccentric-An eccentric muscle contraction is
solved. These issues will only be resolved through system
which the muscle lengthens as it continues to m
atic research. They will not be resolved through anecdotal
tension.
devices in terms of measuring trunk function has not been Fatigue-The inability to maintain torque over a p
established. time or a set number of contractions. What you lose
you maintain, ie, 30 percent loss of power equals
nance of 70 percent power.
of the muscle but on many other factors too. The reliability Isotonic-An isotonic contraction is when the
of muscle strength varies with the methodology of testing. force generated by a muscle results in movement o
Reliability and responsiveness have not been adequately Moment arm-The perpendicular distance from
demonstrated with MMTs. The reliability of instrumented of action of the force to the fulcrum.
lations for whom the test is intended Sped6dty-The ability of a test to identify only
2. Establishing whether and how isometric and dynamic with the condition of interest.
tests of muscle strength can be used for diagnostic Strength-I) Force or torque produced by a
and prognostic purposes during a maximal voluntary contraction; 2) measu
3. Demonstrating the relationship of isometric and of force output at the end of a lever; or 3) maximal
dynamic tests of muscle strength to function torque required to resist an isometric or isotonic
Finally, before using any measurement test, clinicians tion.
should ask themselves why they are using the test and what
they hope to learn from the results of that test. What are the 'The definitions given here are operational definitions.
architecture and interfiber matrix in sensorimotor partitioning. Behav
object about a specified fulcrum. ioral and Brain Science, 12,651,652.
Estlander, A.-M., Vanharanta, H., Moneta, G. B., Kaivanto, K (1994).
Anthropometric variables, self-efficacy beliefs, and pain and disability
ratings on the isokinetlc performance of low back pain patients. Spine,
REFERENCES 19, 941-947.
Fillyaw, M., Bevins, T, & Fernandez, L (1986). Importance of correcting
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CHAPTER 3
SUMMARY Early measurement of joint range of motion (ROM) was initiated by the
necessity to assess disability from postwar injuries. Measurements of joint ROM
provide information designed to describe status, document change, explain perfor
mance, and predict outcome. It is critical to establish reliability in goniometric mea
surements to substantiate consistency over time. Some level of validity should al
ways be demonstrated with measurements of ROM, correlating the measurements
taken with the actual angles involved. While it is difficult to compare reliability stud
ies, those methods with established standardized procedures demonstrate a higher
degree of repeatability. The universal goniometer has been established as one of
the most accurate and efficient instruments used in measuring joint ROM. Because
of the enormous financial burden related to low back pathology, methods of mea
suring lumbar ROM for purposes of function and disability have come under
scrutiny. To establish "normal" ROM measurements as a standard for reference,
population differences such as age, sex, race and ethnic background, as well as vo
cation, clearly need to be considered before standards can be enforced stringently.
Measurements related to functional ROM continue to be the key to providing
meaningful information about the patient's progress.
Within this chapter, each section covers a specific joint, examining reliability and
validity studies on ROM for that joint, describing the latest devices and methods for
measuring joint ROM, as well as providing tables with "norms" for joint ROM and
information regarding functional ROM.
The measurement of joint range of motion (ROM) has clinician, as well as to the patient, regarding progress or
been a part of clinical assessment since the early 1920s and lack thereof (Bohannon, 1989; Miller, 1985). Certainly the
continues to be one of the most commonly used techniques meaning of joint ROM and what it tells therapists, particu
for evaluation used by physical and occupational therapists larly with regard to patient function, has been perSistently
today (Cobe, 1928; Hewitt, 1928; Smith, 1982; Miller, challenged, especially in the area of lumbar ROM (Waddell,
1985). The necessity of taking joint ROM measurements 1992).
has been an accepted part of the evaluation procedure and Therapists have also witnessed that the term normal
is often performed clinically without the understanding of ROM assures neither normalcy nor that a patient will return
its purpose and usefulness in providing information for the to normal functional activity, particularly when related to
49
50 UNIT TWO-COMPONENT ASSESSMENTS OFTHE ADULT
return to work status (Waddell et aL, 1992). Despite the tremities. In addition, by the year 2000 it is estimated
difficulties with which therapists are confronted, it is clear 15 percent of the Gross National Product may be spe
that they will continue to use assessment of ROM as a part the low back problem (Cats-Baril & Frymoyer, 1
of the evaluative process. When assessing joint ROM, Therefore, a special section on ROM for the lumbar s
therapists want to link the act with a measurement, which offers an in-depth review of commonly used
converting their observations into quantitative information niques, has been included.
(Michels, 1982). This information in turn allows therapists
to make decisions regarding the necessity of specific
treatment for the patient, as well as approach and modifi
cation of treatment. It also gives some indication of HISTORICAL PERSPECTIVE
progress, as well as anticipated functional status or disabil
ity (American Medical Association, 1969; Miller, 1985). The early beginnings of ROM measurements date
Assessment of joint ROM is based on what are termed to the first decade of this century, when two Fr
objective measurements, as distinguished from subjective physiologists, Camus and Amar (Smith, 1982), des
measurements, e.g., visual estimation. Objective measure and began to use protractor goniometers to measur
ments are characterized by the relative independence of relationship between mensuration and disablemen
the examiner, providing reliability estimates that demon deed, much of the earlier literature appears to
strate the apparent subjective error (Bohannon, 1989; consequence of the postwar era and the necessi
Rothstein, 1989). Realizing that clinical measurements are relating ROM to disability (Smith, 1982).
probably never completely objective, relying always to The nomenclature and much of the standardized m
some extent on the examiner's judgment (Rothstein, ods for measuring range of motion have been establ
1989), it should be noted that objective measures can by the American Academy of Orthopedic Surgeons
provide evidence of improvement (increases in ROM) often basis for this system was established by research perfo
earlier than subjective measurements or measurements of by Cave and Roberts (1936) and has been widely acc
function (Bohannon, 1989). throughout the medical world (Smith, 1982). The pro
An ongoing goal should be to constantly make efforts sion of these standards to improve objectivity by lo
toward reducing the amount of error of variance in both at inter- and intraobserver reliability and va
measurement procedures and to provide an accurate (Hellebrandt et aL, 1949; Leighton, 1955) added co
representation of the changes displayed by the patient. erably to the progression toward increased objectiv
Bohannon (1989) lists four basic purposes for objective measurements. Although a variety of instruments
measures: 1) to describe status, 2) to document change, 3) methods have been used for measuring ROM, the univ
to explain performance, and 4) to predict outcome. A fifth goniometer has been recognized as an accurate
reason should be to encourage the patient's interest and convenient instrument for measurements (Defib
motivation in the treatment program (Palmer and Epler, 1964; Moore, 1949a; Salter, 1955).
1990). Even though the methods indicated by the Ame
In assessing ROM, the therapist can determine the Academy of Orthopedic Surgeons have been widely
patient's status by comparing measurements with those of both the reliability of these methods and the certain
the uninvolved joint or with "normal" values. The ability to what has been cited as "normal range" values are h
document change is made by the therapist's remeasure questionable given the paucity of research that w
ments made over time. By knowing a patient's measure confirm these methodologies. However, ongoing res
ments in relation to measurements necessary for functional has continued to substantiate the reliability and valid
ROM (e.g., climbing steps or combing hair), the therapist certain methods and instrumentation, as well as docu
can determine the patient's ability to perform a speCific normal ROM values (Boone & Azen, 1979; Elveru e
task. By measuring the ROM of various joints acting along 1988; GogiaetaL, 1987; Riddleetal., 1987; Rothst
a kinetic chain, functional activities can be predicted to aI., 1983). Although goniometry has long been use
some extent (Bohannon, 1982). assessment in physical therapy, it was not until the
The purpose of this chapter is to provide the clinician 1940s that formal studies were performed to d
with a quick reference to reliability and validity of ROM mine the reliability of these measurement techn
measurements for various upper and lower extremity (Hellebrandt et aI., 1949; Moore, 1949b). Moore
joints. Another goal is to introduce alternative methods that earlier researchers in recognizing the necessity of loc
depict novel and insightful procedures and instrumentation the "axis of motion," as well as appropriate place
designed to acquire information regarding changes in of the two arms of the goniometer along definitive
musculoskeletal joint position. The majority of the sections landmarks. (For a more in-depth historical accou
on specific joint ROM provide both a table of "normal" methodology and instrumentation, see Moore's two
joint ROM measurements and information regarding func work [1949a, 1949b], which was followed by th
tional ROM, with particular emphasis on the upper ex Hellebrandt et aI., 1949.) The determination tha
varied instrumentation was confirmed by these studies. goniometry (universal goniometer, fluid goniometer, an
electrogoniometer) for measuring elbow ROM showed
significant differences between the goniometers and sug
gested that interchangeable use of the different types i
RELIABILITY inadvisable. The varied results of these studies suggest tha
although a small amount of error may occur within th
Clinicians agree that measurement of ROM is an impor goniometer, the main source of variation is in the method
tant part of the assessment process; it thus becomes ology, and that by standardizing procedures, improve
paramount that these measurements are shown to be reliability can be realized.
reliable, i.e., they can be reproduced over time. It can be
said that objective measures are only as good as their
repeatability, i.e., their ability to be reproduced accurately
(Gajdosik & Bohannon, 1987; Low, 1976). Hellebrandt VALIDITY
and associates (1949) defined good reliability for ROM as
an agreement of measurements within 3 degrees of one It has been suggested that the goniometric error i
another. To substantiate what determines a reliable mea negligible and that the source of errors is from poo
surement procedure is difficult at best Because reliability of methodology (Salter, 1955). Although some small amoun
goniometric measurements have been demonstrated to of error may occur within the instrument used for mea
vary between different joints of the body (Boone et al., surement due to equipment fault, the accuracy of goniom
1978; Hellebrandt et al., 1949; Low, 1976; Rothstein et eters can be ascertained. To validate a measurement o
aI., 1983), measurement error may be attributed to factors unknown validity, researchers compare it with anothe
such as length and mass of a body segment and ability to measurement of known validity (criterion-based validity
identify bony landmarks. Other factors influencing varia (Rothstein & Echternach, 1993). An example of this would
tion are changes occuring over time (Atha & Wheatley, be to compare an instrument designed for measuring ROM
1976; Bohannon, 1984), differences due to the time of day with something that has a known angle (Crowell et al.
that measurements are taken (Russell et al., 1992), and 1994). Concurrent validity, a class of criterion-base
levels of goniometric skills among raters (Fish & Wingate, validity, can be established by comparing two instrument
1985). These variations certainly leave the therapist with of measurement, one of unknown validity and the othe
the sobering thought that any interpretation of the data on having demonstrated validity during measurement of
goniometric measurement must be performed with discre specific joint (Rheault et aI., 1988).
tion. When assessing the accuracy of goniometric measure
Comparing two different forms of a test on the same ments, realizing the limitation of the information received
subjects (parallel-forms reliability) indicates whether mea is paramount The goniometric measurements give th
surements obtained can be used interchangeably (Roth examiner quantity in degrees concerning a joint being
stein & Echternach, 1993). Youdas et al., (1993) demon assessed (Michels, 1982). However, this does not give u
strate an example of this when comparing goniometric information about a specific tissue or allow the examiner to
measurements with visual estimates of ankle joint ROM. A make qualitative judgments concerning worth, usefulness
comparison of two methods of goniometry (Grohmann, or value of the joint being assessed (Bohannon, 1987
1983) demonstrated no difference between using the Rothstein, 1989). For example, when assessing lumba
lateral and over-the-joint methods of goniometry for mea ROM, the therapist cannot interpret the results as infor
suring the elbow joint In examining methodology, Ek mation about the vertebrae, disks, or muscles; nor can th
strand and coworkers (1982) determined that a standard therapist determine the level of function of the patient from
ized method increased reliability in jOint motions of the the measurements alone. Until the results of the ROM
lower extremity. The use of different instruments to make measurements can be highly correlated with the status of
measurements of the same joint angle was demonstrated as specific tissue, functional movement, or activity, the thera
reliable by Hamilton and Lachenbruch (1969), who used pist is limited in the interpretation to a measurement o
three different devices to measure finger joint angle. In quantity in degrees only.
comparing three different-sized goniometers to measure While therapists have depended on their knowledge o
knee and elbow ROM, Rothstein and colleagues (1983) anatomy and appropriate placement of the goniometer to
demonstrated a high level of interdevice reliability. Greene ensure accurate measurements (content validity), difficult
and Wolf (1989) demonstrated a strong relationship be in finding bony landmarks or in identifying the axis o
tween the Ortho Ranger (electronic goniometer; rotation may jeopardize the results. Radiographic compari
Orthotronics, Inc., Daytona Beach, FL) and a universal sons have long been referred to as the "gold standard" i
goniometer for shoulder internal and external ROM but a terms of validity studies and have been used effectively i
poor relationship for elbow movements. A comparative studies of ROM (Enwemeka, 1986). Other methods such
52 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
as cinematography (Bohannon, 1982; Vander-Linden & 1965; Boone & Azen, 1979). In looking at normal
Wilhelm, 1991), electrogoniometry (Chiarello & Savidge, of digital ROM in young adults, Mallon and colle
1993), as well as other motion analysis systems (Day et al., (1991) found females had greater total active motion
1984; Pearcy et al., 1984; Petersen et al., 1994; Scholz, digits.
1989), offer new directions in strengthening content While the above studies demonstrate some ge
validity by demonstrating criterion-based validity (Gadjosik trends in regard to gender and age, fewer studie
& Bohannon, 1987). available with regard to ROM differences in race and e
backgrounds (Ahlberg, et al., 1988; Allender et al., 1
Roach & Miles, 1991). These studies clearly point
shortcomings of following a strict adherence to a giv
NORMALCY IN JOINT RANGE of "normal" measurements of ROM rather than all
OF MOTION specific patient characteristics to determine the op
measurements for a given situation. Finally, while
While it is imperative that reliability is demonstrated for these studies of normal measurements improve our k
an ROM measurement procedure and that some form of edge base, the therapist should not lose sight of the
validity is indicated to confirm a "true" measurement, it is important aspect, returning the patient to an ROM
also recommended that normative data be available to functional. Understanding the ROM that is necessa
which to compare the measures. A point of reference is functional movement patterns is paramount when m
helpful in giving information to the clinician about where ing joint ROM. Miller (1985) suggests three advanta
the patient is in terms of "normal range." Standards that using functional ROM over other methods: 1) go
clinicians use to judge the progress of their patient may treatment are based on individual characteristics, su
assist in determining the cause of functional deficits. Many gender, age, and activity level; 2) therapists are
medicolegal and disability evaluations use "norms" as a assisted in understanding the problem and devel
standard in determining the level of disability (American strategies for treatment; and 3) therapists are able to
Medical ASSOCiation, 1969). on relieving a problem rather than on achieving
Because many studies have demonstrated bilateral sym quantity that has been deemed "normal."
metry in ROM measurements (Boone & Azen, 1979;
Mallon et al., 1991; Roaas & Andersson, 1982), it has
been suggested that the uninvolved joint be used as a
reference point to assess progress made in the involved WRIST AND HAND
joint. However, this rationale has been challenged (Miller,
1985) from the standpoint that compensatory mecha Many complicating factors must be considered
nisms alter biomechanics, causing changes in movement measuring the joints of the wrist and hand, includin
patterns and ROM. This may be particularly true in chronic large number of joints and the intricacy in the variat
diseases or injury. joint surfaces, particularly within the wrist. The num
Although the message is clear that normal values of joint joints and multiple muscle attachments may lead
ROM are necessary as a standard to measure progress, the creased variations in measurements of the wrist
problem becomes specificity of standards. General stan compared with a more simple joint like the elbow
dards for ROM can not be applied across the board for all 1976). The presence of scars, edema, large hypertr
populations. An early study by Clark (1920) that listed and deformed joints, as in rheumatoid arthritis, ma
rough averages for various joint ROM measurements was make the wrist difficult to measure in terms of gonio
followed by studies in which measurements of a more placement. It is important to stabilize the numerous
specified population (Cobe, 1928; Hewitt, 1928) demon segments, allowing for accurate alignment of the go
strated that females had on the average greater wrist eter during ROM measurements of the hand and
motion than males. More recent studies (Boone & Azen, (Hamilton & Lachenbruch, 1969). Because a subst
1979) examined age differences in a group of male number of variables can add to measurement error
subjects, noting an overall reduction in joint ROM with measuring the joints of the hand and wrist, the necess
increased age, specifically indicating a progressive reduc providing a reliable method of measurement and i
tion in hip abduction and rotation during the first two mentation is foremost.
decades of life. Bell and Hoshizaki (1981) demonstrated in An early study assessing the finger joint angle (Ham
eight different joints a general decline in ROM with age (not & Lachenbruch, 1969) demonstrated no significan
clearly indicated in upper extremity joints) and that females ance when looking at three different goniomete
have greater ROM than males throughout life. When determining joint angle: a dorsum goniometer, a uni
measuring ROM in the hip, knee, and ankle of males 30 to goniometer, and a pendulum goniometer. When m
40 years of age, Roaas and Andersson (1982) found ing ROM for the wrist and hands in flexion and exten
Significant differences between measures found by previ the clinician is confronted with basically three techn
ous studies (American Academy of Orthopedic Surgeons, for measurement: 1) measurement utilizing vola
& Moran, 1981); 2) the use of the ulnar surface (Moore
1984; Norkin & White, 1985); and 3) the use of the radial
surface (Hamilton & Lachenbruch, 1969) (Fig. 3-1).
The use of these different methods in measuring wrist
ROM has led to varied approaches with conflicting results
(Horger, 1990; Solgaard et al., 1986). When comparing
the three methods in measuring passive wrist ROM in a
clinical setting, LaStayo and Wheeler (1994) found that the
dorsal/volar alignment method had a higher reliability than
either the radia'l or ulnar method.
Under controlled conditions, Hamilton and Lachen
bruch (1969) found the lateral (radial) method of measure-
FIGURE 3-5. The range of the first metacarpal in the long axis.
o f movement. B, End of movement.
ELBOW
FIGURE 3-6. The range of the first metacarpal in the short axis. A, Start like other musculoskeletal joints, the elbow has receive
of movement. B, End of movement. attention in the way of reliability studies. As a hingelik
TABLE J l
MEASUREMENTS WITIDN UMlTS OF " NORMAL" ROM IN DEGREES FOR THE HAND AND
WRIST. REPORTED BY SEVERAL AUTHORS AND RESEARCHERS·
Boone & Dorinson & Esch & Gerhardt & Solgaard Wiechec&
AAOS Azent Wagner Lepley Russe AMA et al.=!, Kruseo
doint (1965) (1979) (1 9 48) (1974) (1975) (1958) (1986) (1939)
Wrist
Flexion 80 76 80 90 60 70 77 60
Extension 70 75 55 70 50 60 73 55
Radial deviation 20 22 20 20 20 20 26 35
Ulnar deviation 30 36 40 30 30 30 40 75
• Studies not showing demographics in table did not include them in the original research.
t N = 109, 18- 54 y, male.
r N = 31,24--65 y, male and female.
AAOS = American Academy of Orthopedic Surgeons; AMA = American Medical Association.
56 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
Elbow
Flexion 150 143 145 150 150 150 149 135
Radioulnar
Pronation 80 76 80 90 80 80 S6 90
Supination 80 82 70 90 90 SO 93 90
supination and pronation has been cited (Macrae 1983), designed to determine relative contributions of the scapu
offering the examiner some assistance with regard to a lothoracic and glenohumeral movements to scapular plane
point of reference for alignment of the goniometer. abduction. Using a double goniometer, the authors cleverly
Another method for measuring forearm pronation and isolated the contributions of the scapula at 58.62 degrees
supination utilizes an axial rotation gravity goniometer and the glenohumeral at 112.52 degrees to give the total
(Fig. 3-7). This method demonstrated a high level of scapulohumeral " rhythm" (Fig. 3-8). The reliability of this
intertester reliability (r = 0.94) for measuring supination technique has been challenged in recent years in a study by
and pronation (n = 50) (Laupattarakasem et al., 1990). Youdas and associates (1994). The results of this study
When looking at normal values for elbow flexion and indicated that the margin of error for intratester measure
extension, Boone and Azen (1979) provided values of 0 to ments (variance of > 3 degrees 50 percent of the time and
145 degrees and 0 to 140.5 degrees when comparing a > 8 degrees 10 percent of the time between first and
population younger than 19 years with one older than 19 second measurements) was dinica:]]y unacceptable.
years, respectively. Additional normative values are listed A method utilized by DeVita and colleagues (1990) in
in Table 3-3. measuring scapular motion used the spine (third thoracic
Studies to determine functional ROM (Safaee-Rad et al., vertebrae) and the inferior angle of the acromion process of
1990) found that the required ranges for performance of
three feeding tasks (eating with a spoon, eating with a fork ,
and drinking from a handled cup) required 70 degrees to
130 degrees elbow flexion and from 40 degrees forearm
pronation to 60 degrees forearm supination.
SHOULDER
It is well recognized that the shoulder is one of the more
complex functional units within the body. Earlier studies
(Helle brandt et aI., 1949) indicated reliable repetitive
measurements involving shoulder joint movements, with
the exception of medial rotation and shoulder abduction.
Shoulder external rotation was examined by Boone and
Azen (1978), who demonstrated both intratester and
intertester reliability when measuring the shoulder at
r = 0.96 and 0.97, respectively. Because of the combined
FIGURE 3-8. A method for measuring both glenohumeral and
contributions of both the glenohumeral and the scapu scapulothoracic ROM using a double goniometer. Scapular angle is the
lothoracic movements, resulting in total shoulder ROM, angle o f the spine of the scapula to the vertical: glenohumeral angle is the
delineation of the two needs to be identified when per angle between the spine of the scapula a nd the humerus. Summation of
the two angles is the arm angle. (From Doody, S . G. , et al. [1970J.
forming ROM measurements of the shoulder (Friedman & Shoulder movements during abduction in the scapular plane . Archives of
Monroe, 1966). An early study (Doody et a!., 1970) was Physical Medicine and Rehabilitation , 51, 595-604.)
58 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 3-9. It is important to note the amount of shoulder abduction FIGURE 3-10. Measurement of shoulder abduction in the s
when measuring shoulder external and internal rotation . plane. This position is the most functional position for elevation.
the scapula as the "moveable" reference point Another all motions ranging from ICC = 0.87 to 0.99, wh
method (Kibler, 1991) used a linear measurement from the intertester reliability for measurements of flexion, a
nearest spinous process to the inferior angle of the scapula. tion , and lateral rotation ranged from ICC = 0.84 to
When investigating various techniques used in previous Intertester reliability for horizontal abduction and a
studies, Gibson and coworkers (1995) demonstrated a high tion , extension, and medial rotation was poor. The g
level of intra- and intertester reliability (intraclass correla metric measurements of shoulder PRO M appeared
tion coefficient [ICC] = 0.95, 0.92) for the method of unaffected with different-sized goniometers in this
DeVita and coworkers (1990); however, they found low however. reliability between testers appears to be sp
,i ntertester reliability for the Kibler (1991) method. It has to movements measured.
been suggested that these methods may provide results that " Normal" ROM within the shoulder appears to b
prove to be somewhat difficult to interpret by the clinician , specific, decreasing in aU ranges slightly with increase
particularly the Kibler (1991) method. (Boone & Azen, 1979). A list of normal ROM mea
When measuring shoulder ROM, the clinician needs to ments from several authors is provided in Table 3-4
be aware of the contributions not only of shoulder flexion Functional ROM for the shoulder during three fe
and abduction but also of accompanying motions, e .g., tasks (eating with a spoon, eating with a fork , and dri
external and internal rotation. Accompanying motion that from a handled cup) required 5 degrees to 45 de
occurs during active shoulder flexion was ingeniously
determined in a study by Blakely and Palmer (1 984). In this
study, a universal goniometer and a gravity-activated angle
finder were utilized to determine that medial rotation of the
humerus accompanied active and passive shoulder flexion
movements. During measurements of shoulder internal
and external rotation , the amount of shoulder abduction
needs to be noted, as this may limit ROM measurements
(Fig. 3-9). Also, the plane in which shoulder elevation is
made should be recorded, as this too may limit the available
ROM (Fig. 3-10). The plane of the scapula (30 degrees-45
degrees to the frontal plane) has been described as the most
functional position for elevation because the capsule is not
twisted on itself and the deltoid and supraspinatus are best
aligned for shoulder elevation (Zuckerman & Matsen,
1989) (Fig. 3-11).
Riddle and colleagues (1987) examined both intertester
and intratester reliability of shoulder passive range of
motion (PROM), utilizing two different-sized universal FIGURE 3-11. T he plane of the scapula measures approxima
goniometers. T hey demonstrated intratester reliability for degrees to 45 degrees to the frontal plane.
SEVERAL AU11IORS AND RESEARCHERS
Boone & Dorinson & Esch& Gerhardt & Wiechec &
AAOS Azen* Wagner Lepley Russe AMA Krusen
Joint (1965) (1979) (1948) (1974) (1975) (1958) (1939)
Shoulder
Flexion 180 167 180 170 170 150 180
Extension 60 62 45 60 50 40 45
Abduction 180 184 180 170 170 150 180
Internal rotation 70 69 90 80 80 40+ 90
External rotatio n 90 104 90 90 90 90+ 90
Horizontal abduction 45 30
Horizontal adduction 135 140 135
shoulder flexion , 5 degrees to 35 degrees shoulder abduc arms or placement of the axis may cause large variations
tion, and 5 degrees to 25 degrees shoulder internal rotation in angular measurements (Robson, 1966). Much literature
(Safaee-Rad et al. , 1990). It has been demonstrated that exists on various techniques that have been used over the
restrictions in elbow joint ROM significantly increase the years to try to determine more accurate and efficient ways
need for an increased arc of motion for both shoulder to measure cervical ROM (Defibaugh , 1964; Hand, 1938;
flexion and internal rotation during feeding tasks (Cooper Loebl, 1967; Moore, 1978; Schenker, 1956). The tape
et al. , 1993). measure is used to determine the distance between bony
landmarks (e.g ., chin to sternal notch , chin to acromion
tip) in many of the methods tried over the years (Storms,
1955; Moll & Wright, 1976), with varying degrees of
CERVICAL SPINE accuracy.
To avoid inaccuracies due to changing reference points,
While the spinal segment is one of the most frequently several early studies placed or attached a gravity-assisted
treated areas of the body, it continues to be one of the most device or an equivalent measurement device to the head
elusive areas in determining reliable measurements for and determined ROM by changes affected by gravity (Buck
ROM . Because of the difficulty in aligning the goniometer et al., 1959; Hand, 1938; Leighton, 1955; Schenker,
with a definitive axis of rotation, as well as the inability to 1956). This appears to have been one of the more accurate
locate standardized landmarks to act as points of reference techniques for measurement described in the literature
(Cole, 1982), the cervical spine remains one of the least (Defibaugh, 1964b; Kadir, 1981; Tucci et al., 1986). An
accurately yet most highly measured of all musculoskeletal increased level of accuracy through increased standardiza
joints. Having 23 points of contact at which motion occurs tion can be achieved by attaching a gravity goniometer to
from the occiput to the first thoracic vertebra, cervical the subject's head and taking measurements from changes
motion combines sliding and rotation with flexion (Kottke in head position . With the universal goniometer, a moder
& Mundale, 1959). Because flexion and extension occur at ate to good level of accuracy was demonstrated w.ith
each of the cervical vertebrae, the axis of rotation for intratester reliability. However, intertester reliability proved
flexion and extension movements is segmental in the to have only a marginal level of accuracy with extension
sagittal plane with multiple axis; consequently, a single and rotation, proving to offer a higher level of reliability
instantaneous axis of rotation (IAR) for the entire cervical than side-bending and cervical flexion (Tucci et al., 1986 ;
spine cannot be isolated. Measuring the total movement of Youdas et aI., 1991). Improving on this method in terms of
the head in anyone plane approximates the change in the efficiency, accuracy , and ease of use, the cervical ROM
degrees occurring in the cervical spine. Anatomically, instrument (CROM) has demonstrated a high level of
alignment of the goniometer's axis with the external intertester and intratester reliability (Capuano-Pucci et al.,
auditory meatus has been used for measuring flexion and 1991) (Fig . 3-12).
extension (Norkin and White, 1985). Due to the shift of the Cinefluorography and the electronic digital inclinometer
line of reference during flexion and extension, it becomes have contributed greatly to our knowledge of normal
virtually impossible to maintain congruency with the refer cervical ROM , demonstrating a high level of reliability
ence point (Kottke & Mundale, 1959; Nordin & Frankel; when compared with radiographic measurements (Field
1989). Slight variations in alignment of the goniometer's ing , 1957 ; Kottke & Mundale, 1959; Mayer et al. , 1993).
60 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
TABLE :~-~J
Flexion 60 67 59 50 49
Extension 75 77 80 70 67
Rotation
Right 80 73 85 70 87
Left 80 74 89 69 84
Lateral flexion
Right 45 51 43 44
Left 45 49 44 39
'I/\BLL 3- ()
-
--- ~
62 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
the use of such methods (Nelson et aI., 1979; Wolf et aI., 'IABLE :3-7
1979). Consequently, therapists should be hesitant in
reaching important conclusions about facts such as pro POTENTIAL ERRORS AFFECTING
gression based on these inadequate measures. Originally, REUABIUTV OF 1HE MODIFIED SCHOBE
ME11IOD EVALUATED IN ntiS STUDY
the addendum to this procedure as advocated by the
American Medical Association was the use of the goniom 1. Presence or absence of " dimples of Venus. "
eter (American Medica'i Association, 1971). The use of the 2. Anatomic location of dimples of Venus.
uniaxial goniometer to measure multiaxial spinal move 3. Anatomic variability of location of 10-cm line (correlation
among a skin mark 10 cm above the interdimple line. spinous
ment is obviously problematic (Mayer & Gatchel, 1988). process at that level , and the number of levels from T-12 to S
Fitzgerald and associates (1983) confirm these problems measured with the technique).
when they reported coefficients of variance (CVs) of up to 4. Problems introduced by skin distraction occurring in the absen
of movement of underlying bony structures (e.g., the sacrum).
53 percent using the goniometer. (The use of CVs in 5. Problems engendered by expression of results of an essentially
determining reliability of measures is of questionable value angular movement in linear terms (in ce ntimeters , not degrees
[Williams et aI. , 1993], although they were commonly used 6. Problems in developing a normative database created by popu
lation variation in human height superimposed on a fixed-leng
in earlier research.) test.
Another method once described as promising (Merritt et
a!., 1986) and still prevailing is the finger-to-floor method. From Miller, S . A., Mayer, T, Cox, R. , & Gatchel, R. J. (1992). Relia
Interesting to note is that it has been long known that problems asso ciated with the modi.fied Schober technique fo r true lu
fle xion m easurement . Spine, 17, 345-348.
patients with multilevel stabilization involVing more motion
segments than merely the lumbar spine are able to touch
their toes (Mayer et aI., 1984). Advocates of this method many or all of the problems associated with the Scho
are deceived not only by large amounts of accompanying technique .
hip movement but also by movements in the thoracic spine The 01 is generally attributed to Loebl (1967). Reliab
and , to a lesser degree , the amount of movement at the studies by Keeley and coworkers (1986) reported interr
knee , anIJe, and upper extremities. Merritt and colleagues reliability values of ICC = 0.92 for 9 subjects with chro
(1986), in comparing three simple noninvasive methods, low back and 0.90 for 11 subjects without low back p
found the finger-to-floor method to be least reproducible . Waddell and associates (1991), using the spinal inclin
Two methods that they found to be more promising and eter, showed an ICC of 0.91 for interobserver reprod
worthy of attention are the modified Schober technique ibility of lumbar flexion. The landmarks used for measu
and the double inclinometer method. Both methods have ment for both the Schober and the 01 methods
the advantage of isolating the lumbar spine ROM. In 1937, described in Table 3-8 and in the succeeding instructio
Schober used a simple tape measure to estimate lumbar on measurement of spinal ROM in the sagittal plane.
ROM. This technique has been modified (Macrae & Wright, Today, electrogoniometers using these prinCiples
1969) and remodified (Williams et aI., 1993), and distrac offered. A more recent study concluded both the 01
tion techniques can be used to measure movement in the the Cybex EOI (Cybex , Ronkonkoma, Ny) to be s
coronal plane as well. Fitzgerald and coworkers (1983), stantially more reliable than observation (Chiarello
using the Schober method, reported an interobserver Savidge, 1993). Mayer and colleagues (1984), in a v
reliability using the Pearson correlation coefficient of dation study, concluded that no significant differe
r = 1.0 for flexion and r = 0.88 for lumbar extension but existed between Dl measures and radiographic measu
had the disadvantage of using healthy, young subjects.
Beattie and associates (1987) used both healthy subjects
and subjects with low back pain and reported high reliability
TABLl~ 3 S
with the modified Schober attraction method for measur
ing extension. Macrae and Wright (1969) attempted to REFERENCE POINTS ADVOCATED BY
validate both the modified Schober and the Schober 'IFFERENT AunlORS WHEN MEASURING
techniques, comparing them with radiographic techniques. LUMBAR ROM
Pearson product-moment correlation coefficients of
r = 0.97 for the modified Schober and r = 0.90 for the Inferior Superior
Technique Landmark Landmark
Schober technique were reported compared with radiog
raphy . Portek and colleagues (1983), however, demon Schober Lumbosacral junction A point 10 cm
strated little collaboration between any of the commonly above lumbosac
used clinical methods , including the modified Schober junction
Modified Schober 5 cm below lumbosa- A point 10 cm
technique and radiographs. Miller and associates (1992) cral junction above lumbosac
have questioned the modified Schober technique on both junction
scientific merit due to the potential error (Table 3-7) and on Modified-modified Midline intersection A point 15 cm
Schober of posterosuperior above midline in
clinical grounds. Clinically, these authors offer the double iliac spine tersection
inclinometer (01) as a validated technique that eliminates
technique is controversial (Portek et aI. , 1983). More convinced of their reliability and validity (Grieve, 1987
recently, reliability studies have compared these two very Grimsby , 1990; Kaltenborn & Lindahlo, 1969; Maitland
'promising methods. Merritt and associates (1986) sug 1986 ; Paris, 1987). In fact, a whole profession is based on
gested that to increase objectivity of spinal ROM mea the ability to reliably palpate intervertebra.l motion. Inter
surements, the Schober test should be used in routine esting to note is the discovery of the palpatory illusion
clinical examinations. They showed that the modified (Lewit & Liebenson , 1993). Sobering is the scientific
Schober method demonstrated high reproducibility (in evidence that has proven these assessment techniques to
flexion , CV = 6.3 percent for interexaminer reproduc be unreliable (Maher & Adams, 1994). ObViously, the
ibility and 6.6 percent for intraexaminer reproducibUity), opinion of many of these manual therapists must be
whereas the inclinometer showed poorer reproducibility scrutinized in light of the reliability studies.
(in extension, CV = 65.4 percent for interexaminer re Finally, the measurement of lumbar spine ROM is a
producibility and 50.7 percent for intraexaminer repro clinical conundrum, especially when considering move
ducibility) . ment outside the sagittal plane. The measuring of norma
Gill et aI., (1988) compared the repeatability of the values is inherently difficult and affected by many factors
modified Schober, double inclinometer, finger-to-floor, and that are often overlooked. The usefulness of these mea
photographic methods. They concluded that the modified sures to the clinician is not really clear. By using skin
Schober method was the most repeatable (CV = 0.9 distraction , skin attraction, and double inclinometer meth
percent for modified Schober flexion and 2.8 percent for ods, a therapist can improve the objectivity of lumbar spine
modified Schober extension). An additional study (Williams ROM measurements in the sagittal plane . The low back
et aI., 1993) compared the modified-modified Schober problem threatens the health of the public, and it is only
with the DI method. The authors found that the modified through becoming more scientific and thus more objective
modified Schober method of measuring the lumbar ROM that cl inicians move toward a solution .
(ICC = flexion 0.72 and extension 0.76) was more reliable
than the DI technique (lumbar flexion 0.60 and lumbar
extension 0 .68). No validation was given for this new Sagittal Spinal Range of Motion
method in the study. Problems with the DI technique may Measurement
be attributed to palpation of bony landmarks, use of the flat To increase the reliability of lumbar flexion and exten
surface of the inclinometer over the curvature of the flexing sion, the double inclinometer method or versions of the
spine (i.e ., offering many tangents), and technical skills. Schober method are recommended. The following proce
Both techniques have both disadvantages and advan dure is suggested :
tages. Either method is offered as a more reliable method 1. Accurate location of anatomic landmarks is critical
than goniometric, eyeballing, or finger-to-floor measures. Helpful tips are that the dimples of Venus usually
However, a problem common to both methods that correspond to S-2, the iliac crests are approximately
should be considered is the starting position when stand at the L-4 ,5Ievel, counting up the spinous processe
ing (Keeley et aI., 1986; Sullivan et al., 1994). To a large will find T-12 and L-1, and the average length of the
degree, the initial lordosis (not apparent lordosis) deter male lumbar column is 18 em (Waddell et aI. , 1992
mines the amount of flexion or extension available. An Williams et aI. , 1989)
obese person with increased lordosis has potentially less 2. A standardized starting position needs to be selected
extension and a potential for an inflated flexion value. The e.g. , bare feet, heels together, knees straight, equa
American Academy of Orthopedic Surgeons (1965) ad weight-bearing. looking straight ahead, arms hang
vocates the use of tape measures when measuring lumbar ing at the side , relaxed (Waddell et aI., 1992) .
spine flexion. The American Medical Association has 3. A " neutral " lumbopelvic position is required, e.g.
revised its guidelines and now supports the use of the midway between flexion and extension to eliminate
spinal inclinometer (Engelberg, 1988). The American troubles of differing lordosis (others have modified the
Medical Association firmly states that an evaluation uti standing starting position to eliminate this problem
lizing the spinal inclinometer takes precedence over an (Sullivan et aI. , 1994) .
evaluation using an alternative measuring technique. Be 4. Warm-up is necessary for reliable measures , e.g., flex
fore 1988, the use of the goniometer was advocated by and extend twice , left and right rotation twice, left and
the American Medical Association , and it is questionable right lateral flexion twice, and one more flexion and
as to whether these measures, which have been shown extension (Keeley et aI., 1986; Waddell et al. , 1992)
to be notoriously unreliable, would have taken precedence 5. The inclinometers or tape measures should be placed
over the Schober techniques, which have been proven to on the selected points and held in place (Figs. 3-13
be more reliable. and 3-14).
An area that is very controversial and of great impor 6. Instruct the patient to bend forward as far as possible
tance to the manual therapist is the art of assessment of (Figs. 3-15 and 3-16).
64 UNIT TWO-COMPONE~JT ASSESSMENTS OF THE ADULT
FIGURE 3-13. Skin distraction and attraction techniques are based on FIGURE 3-15. Schober's method using the attraction techniq
the fact that the distance between two pOints marked on the skin over the trunk extension.
spine increases with flexion and decreases wi th exte nsion. Demonstrated
here is the modified Schober's method. Initial measurement in neutral
lumbar position .
THORACIC SPINE
As with the lumbar spine, similar difficulties exist in
measuring ROM through the thoracic spine. Difficulties in
isolating pure planar movements due to coupling motions,
as well as maintaining accurate contact with bony land
marks during measurement, are some of the problems
clinicians are faced with. Although reliability studies for
thoracic ROM have been elusive, recommendations from
the literature indicate similar methods for measuring the
thoracic spine as were incorporated with the lumbar spine,
e .g. , Loebl (01). Placement of the inclinometer for sagittal
fle xion and extension should be on T-12/ L-1, as well as on
C -7 IT -1 , with the difference in the two beginning and end
measurements giving the total thoracic ROM (American
Medical Association, 1991).
HIP
During measurement of hip ROM , controlling for the
movement of the pelvis is of paramount importance
(Ashton et aI. , 1978; Gajdosik et aI., 1993). The lumbar FIGURE 3-18. Spinal inclinometer method used to measure trun
curve is often used as a reference point to alert the therapist extension.
66 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
TABLE ~'J
VALUES FOR "NORMAL" ROM FOR 11IE HIP. USTED BY VARIOUS AUDIORS
Roac:h &
Boone & Dorinson & Esc:b & Gerbardt& Roa_& Miles Wiec:bec: &
AAOS Azen· Wagner Lepley Ru sse AMA Andersont (NHANES 1) Krusen
Joint (1965) (1979) (1948) (1974) (1975) (1958) (1982) (1991) (1939)
Hip
Flexion 120 122 125 130 125 100 120 121 120
Extension 30 10 50 45 15 30 9 19 45
Abduction 45 46 45 45 45 40 39 42 45
Adduction 30 27 20 15 15 20 30
Internal 45 47 30 33 45 40 33 32
rotation
External 45 47 50 36 45 50 34 32
rotation
mental group, the other measurements were inconsistent comparing three instruments (a standard plastic: goniom
and had poor reliability. Hip extension measurements in eter, a flexometer, and a tape measure) for measuring SL
particularly were low, even when the examiners made (Hsieh et aI., 1983) demonstrated a good level of interse
efforts to control for compensatory pelvic movement by sion reliability for both the goniometer and the flexomete
flexion of the opposing hip (Fig. 3-19). (r = 0.88) and for the tape measure (r = 0.74). In the sam
study, high intrasession reliability was found for all thre
(r = 0.94). To isolate the contribution of the lumbar spin
Straight-Leg Raise the pelvis was palpated during passive SLR to determin
the point at which pelvic rotation began (Hsieh et aI
Certainly one of the most measured ROMs has been for 1983).
the straight-leg raise (SLR) (Fig. 3-20). However, this A review of the methods that might improve reliabili
measurement has not been without its difficulties in ascer has presented varied hip positions, active versus passiv
taining a standardized method in which reliability can be and trial repetitions during SLR (Cameron et aI., 1994
assured (Bohannon, 1984; Cameron et aI., 1994; Gaj Cameron and coworkers determined that all of thes
dosik et aI., 1985; Tanigawa et aI., 1972). An early study factors made a difference in the amount of SLR exper
enced and recommended consistency of method during th
performance and interpretation of the SLR. Other meth
ods to determine SLR have included the knee extensio
method with the hips stabilized at 90 degrees of flexi o
Roach &
Boone Dorinson Ekstrand Esch& Gerhardt Roaas & Mile s Wiechec
AAOS & Azen· & Wagner et aI.t Lepley & RDBSe AMA Anderson:f: (NHANES 1)§ & Krusen
Joint (1965) (1979) (1948) (1982) (1974) (1975) (1958) ( 1982) (1991) (1939)
Knee
Flexion 135 143 140 144 135 130 120 144 132 135
Extension -2
method for determining the amount of translation has However, Forster and associates (1989) demonstrated
become important, particularly when the pathomechanics significant inter- and intraexaminer variations in measure
of an ACL deficient knee is under study. During the past 10 ments of both absolute displacement of knees and side-to
years, special measurement of A-P joint laxity during side differences in pairs of knees. A more recent study
postreconstruction of knees with deficient ACLs has been (Graham et aI., 1991) of the KT-1000 presented conflict
measured via an arthrometer (Daniel et a!., 1985) (Fig. ing views, demonstrating a poor level of reliability (less than
3-24). Earlier studies involving the KT-1000 (MEDmetrics 50 percent) in determining laxity in the knee with a
Corps., San Diego, CAl, an arthrometer designed to deficient ACL. Graham and colleagues (1991) indicated
measure tibial translation, indicated that it was a useful tool that the anterior drawer test and Lachmans test were found
for both confirming reduction and demonstrating a mean to be more accurate indicators of knees with deficient ACLs
difference in laxity in normal and injured knees (Daniel et when compared with the KT-1000 (see Fig. 3-24).
a!., 1985). Hanten and Pace (1987) demonstrated mea Another study (Holcomb et a!., 1993) of A-P translation
surements of ICC = 0.92 and 0.84, respectively, for inter using the KT-1 000 reported a high intratester reliability of
and intratester reliability when using the KT- I OOO to test ICC = 0.98-1.0, but a low intertester re)iability of
43 healthy male subjects for A-P translation. ICC = 0.53 was demonstrated. A more recent study (Rob
TA m I :~ II
VALUES FOR "NORMAL" ROM FOR THE ANKLE AND FOOT. AS USTED BY
SEVERAL AUTIfORS
Baggett Boone & Dorinson Esch& Gerhardt Milgrom Roaas & Wiechec
MOS & Young' Azent & Wagner Lepley & Russe et aI.:j: AMA Andersson§ & Krusen
Joint (1965) (1979) (1948) (1982) (1974) (1975) (1985) (1958) (1982) (1939)
Plantar flexion 50 56 45 65 45 40 40 55
DorSiflexion 20 81:2191 13 20 10 20 20 15 30
Subtalor joint
Inversion 35 37 50 30 40 32 30 27
Eversion 15 26 20 15 20 4# 20 27
1993) of three methods for measuring STJN position measurement of tibia vara, which is the angle formed by
(open kinetic chain, closed kinetic chain , and navicular distal third of the leg to a horizontal line to the suppor
drop test) demonstrated poor intra- and intertester reliabil stance surface (ground) . Lohmann and associates (19
ity when measuring (n = 30 ft) with a goniometer (for the demonstrated a mean absolute difference between m
first two methods) and when measw-ing the distance surements of tibia vara of 2 to 3 degrees (Fig. 3-28).
change from the floor to the navicular mark on a marked
index card (for the third method). However, a later study
measuring STI N (Sell et al ., 1994) using two measurement
techniques (calcaneal position wi th an inclinometer [Fig .
3-27] and navicular drop test) in a weight-bearing position Attraction meth ods-Measuring procedure usin
(n = 60) demonstrated moderate to high reliability. tape measure to record a decrease in distance between
Studies of normal ankle do rsiflexion demonstrated a points marked on the skin over the spine as it extend
reduction in mean values with increasing age (middle age to
old age), decreasing from 2 0 .0 degrees to 13.5 degrees in Coefficient of variation-Measure of variability in
males, whereas in females these values decreased from measurements relative to the mean value. Depicts
20.7 degrees to 10. 1 degrees (Vandervorrt et aI., 1992). variability of measurements within the subjects as wel
Normal ROM for inversion and eversion of the subtalar the variability of the actual measurement. A ratio of
standard deviation and the mean in terms of a percenta
joint using a method described by the American Academy
of Orthopedic Surgeons (1965) was 35 degrees and 15 Distraction methods-Measuring procedure usin
degrees, respectively. It has been suggested that 4 degrees tape measure to record an increase in distance betw
to 6 degrees of inversion and eversion, for a minimal tota,1 two points marked on the skin as the spine flexes.
range of 8 degrees to 12 degrees, is normal for locomotion Flexicurve techniques-Measuring procedures
(Root et aI. , 1977). Although norms have been cited for which a tester manually molds a flexible curve to the mid
subtalar inversion and eversion and STIN (3 degrees varus) contour of the subject's lumbar spine. The flexible curv
positions (Mjlgrom et al. . 1985), the baSis for "normal " then traced onto paper, and either a tangential o
STIN with regard to the stance phase of gait has been trigonometric method is used to ca'iculate ROM.
largely conjecture, without proven reliable or valid methods Intraclass correlation coefficient (ICC)-Asses
performed on any substantial-sized group during gait common variance. Examines two or more sets of score
activities (Root et aI. , 1977; McPoU & Cornwall , 1994; the same variable.
Wright et a1. , 1964). Table 3-11 lists norms for ankle and
foot ROM. Modified Schober technique-Skin distract
A measurement quite possibly offering the therapist attraction method using a midline point 5 CM below
lumbosacral junction and a point 10 CM above it.
increased information with regard to the biomechanical
alignment and forces acting on the ankle and foot is Pearson product-moment correlation coe
dent-Generalized measure of linear association. Use
determining association concerning a bivariate distr
tion.
Pelvic incUnometer-Designed with calipers wit
mounted gravity protractor. Able to measure the chang
position of two separate points by the placement of ei
ends of the calipers over an identifable area used a
landmark.
Pendulum goniometer-Goniometer usually mad
metal with two movement arms. One arm is allowed
move freely in accordance with. the line of gravity an
used as a vertical reference.
Spinal incUnometer-A circular fluid-filled disk wi
weighted needle indicator, which is maintained in
vertical, that is placed over the spine and used to meas
ROM in degrees as the spine moves.
Subtalar joint neutral-The position in which the
is neither pronated nor supinated. The position of in
sion or eversion that the calcaneus assumes when the t
is congruent in relation to the tibia.
FI GURE 3-28. Measw'ement of tibiil vara: an angle formed from a line 3·Space lsotrak-Electomagnetic device for the m
parallel to the lower leg bisecting the horizontal (ground) . surement of three-dimensional movements.
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Bohannon, R. W (1989). Objective measures, Physical Therapy, 69(7),
590-593.
Bohannon, R. W (1987), Simple clinical measures. Physical Therapy,
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CHAPTER 4
SUMMARY This chapter discusses the normal anatomy of the various structures of
the hand, with emphasis on the anatomic, physiologic, and functional importance
of each anatomic entity. Important factors about the functional and surgical
anatomy of the hand are outlined . A short discussion of clinical examples and a
comprehensive evaluation protocol follow .
The hand is involved in every aspect of our lives, from birth to death. It is hard to
imagine a life without hands. Like any other organ in the human body, the hand
has its own characteristics and functions and is uniquely equipped to perform its
functions, to service, and to connect human beings with the outside world. It is an
intricately structured and dynamic organ created with mathematic perfection and
harmony between all its various parts. The ideal hand performs its function
precisely and flawlessly. Disruption in anyone of its parts interferes, in a major
way, with its function . Problems of the hands rarely, if ever, affect the quantity of
life, but they do drastically affect the quality of life.
Nothing in this chapter is new or revolutionary. The facts discussed are based on
the experience of the author and the data obtained from other experts referenced.
The only thing that might be unique is the emphasis the author places on the ab
solute necessity and need for any health care profeSSional who will have the chance
or the obligation to treat hands to be absolutely sensitive and attuned to the nor
mal anatomy, the desired function, and the process of evaluation. There is no
room for guess work and no place for luck. Without solid knowledge of the
anatomy and function of this organ, very little will be able to be done. Medicine , at
least from the anatomic point of view, is a science based on facts. When knowl
edge is not adequate, the profeSSional must seek the help of colleagues and the lit-
o erature.
The upper extremity is present to allow the hand to perform its functions . The
length of the upper extremity and the position and the type of shoulder and elbow
joints are primarily designed to allow the hand to function. Consequently, the
shoulder, the arm , and the elbow, as much as they are not directly a part of the
hand, are directly related to the hand. Anatomically, the hand starts from the wrist
joint area. Functionally, however, the hand starts from the elbow.
78
ANATOMY
General Anatomy
SKIN
The skin is primarily the protective organ of the body,
and it is unique in the hand (Barron , 1970). On the palmar
or volar aspect, the skin is thicker, lighter in color, and more
stably tethered in position when compared with the darker,
thin, loose skin on the extensor aspect or the dorsal side.
On the volar aspect, the skin is marked with creases or lines
that are of utmost significance anatomically and function FIGURE 4-2. Palmar triangle boundaries .
ally . The skin on the dorsum is more lax, is not directly
attached to the bone structure underneath it, and also has
wrinkles that allow the skin to stretch when one makes a extensor aspect of the fingers (Milford, 1988). The dee
fist (Fig. 4-1). If the skin on the dorsum of the hand were layer covers the interossei between the metacarpals. At th
to be tight, then the wrinkles would disappear, and it would wrist level, the deep fascia is organized in the extenso
consequently become difficult to make a fist. retinaculum, which is divided into six compartments Wig
4-3). In the palmar aspect , the deep fascia is incorporate
with the palmar aponeurosis.
SUPERFICI AL FASCIA
Specialized parts of the deep fascia are the flexo
The superficial fascia on the dorsal aspect of the hand is retinaculum and the digital ligaments of Landsmeer and
very thin . The superficial fascia in the palmar aspect has the Clel1and (Milford, 1988). This palmar fascia is a speCialize
fibrofatty tissue, the amount and the density of which vary fascia that is present only in the palm and in the sole of th
from one location to the other. The palmar triangle in the foot, where its functional, aspect is to give thickness an
center of the palm consists of the distal palmar crease as its stability to the skin (Fig . 4-4) . The palmar fascia starts from
base and the junction of the thenar and hypothenar the heel of the hand and extends in various fiber arrange
eminence at the wrist as its tip (Fig. 4-2). It is the only area ments up to the distal interphalangeal joint crease of th
devoid of fat (Milford, 1988). In the areas where it is fingers and thumb. The attachments of the palmar fascia
located, the fat acts as a pressure cushion. The absence of the deep structures (including the bones), the skin along th
fat in the palmar triangle is Significant, as it keeps the skin various creases, and the skin of the palm restrict the skin o
well tethered and consequently allows the cup of the hand the hand from being freely mobile. The restriction of ski
to deepen when a fist is made . The fat extends to the web mobility is evident in the palmar triangle. The palmar fasci
spaces to protect the vascular bundles, especially the veins. in the terminal phalangeal areas is replaced by strands o
tough fibrous tissue called fibrous septae , which anchor th
skin to the terminal phalanx and give stability to the tip o
DEEP FASCIA
the digit (Fig. 4-5).
Within the dorsal aspect , the deep fascia is arranged in
two layers. The superficial layer covers the extensor
BONES
tendons and continues into the extensor hood on the
The skeleton of the hand consists of 29 bones that begin
with the distal end of the radius and the head of the ulna a
the wrist (Landsmeer, 1976; O'Brien and Eugene, 1988
(Figs. 4-6 and 4-7). The radius is the main forearm bon
at the wrist joint, and the ulna is the main forearm bone a
the elbow joint.
FIGURE 4-1. Note the difference be tween the thin loose skin on the
dorsum and the thick, less-mobile skin on the pa lma r aspect. fiGURE 4-3. Extensor retinaculum.
80 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
Nail plate f
Fibrous s
Insertion of the
terminal tendon , Ii If'll
Terminal
phalanx
Middle
phalanx
Proximal
phalanx
Pisiform
Tmp"oid ~ H,m'"
~
Trapezium Capitate
Scaphoid Triquetrum
~ ~ Lumate
Scaphoid
l --->"--+--Metacarpal
Trapezoid Hammate
Dorsal aspect
FIGURE 4-9. Cross-seclion o f the carpal tunnel. F.c.R. = tunnel ior the
flexor carpi rad ialis.
S =Scaphoid
L = Lunate
T = Triquetrum
P = Pisiform Each finger has three phalanges (see Fig . 4 -7), and the
H = Hammate thumb has two. Those of the thumb are the widest and the
C = Capitate
Td = Trapezoid shortest. Th ose of the middle finger are the longes . Each
Tm = Trapezium phalanx has a concave wide base and a condylar head .
R = Radius
They all have a gentle curve concave toward the palmar
U = Ulna
aspect to continue with the longitudin I arch of the hand.
The terminal phalanx is the end of the hand skeleton and
FIGURE 4-7. Bones of the hand , including parts o f metacarpa l.
does not reach the tip of the digit but ends at a leve l around
the junction of the proximal two thirds and the distal third
metacarpals have a longitudinal gentle curve that is con of the nail bed. The end of the terminal phalanxes has an
cave toward the palmar aspect, with the deepest part of the expanded round irregular shape known as the tuft, that
curve at the middle finger metacarpal. This is part of the plays a major role in for ming the hape of and contributing
longitudinal arch of the hand that extends from the wrist to the stability of the digit tip. The space between the skin
to the fingertips (Hollinshead, 1982 ; Milford, 1988) (see of the tip at the distal end of the nail bed and the end of the
Fig . 4-7) . Each metacarpal has a base , a shaft, and a head. terminal phalanx is occupied with fat and fi brous septae
The position of and the relationship between the meta (see Fig. 4-5). It would be very painful if the end of the bone
carpal heads of the index, middle, ring, and little fingers were to reach the skin because of the digit tip and the direct
make the base fo r the transverse metacarpal arch of the pressure of the bone on the skin. The termin al phalangeal
hand (Milford, 1988). The arch is concave toward the area is supported partly by the terminal phalanx and partly
palm, with the deepest point of the arch at the metacarpal by the nail plate, which compensate for the absence of the
head of the middle finger. The middle finger is atthe center terminal phalanx in the distal third of the terminal pha
most, deepest part of the longitudinal arch. (see Fig . 4-7) . langeal Clrea.
JO iNTS
Distal Radioulnar Joint. The distal radi uln ar joint is
located proximal to the radial carpal joint. The radial side
of the head of the ulna arti ulates with a notch on the radial
Lateral
Medial
column
column---
.........::-- - Longitudinal arch
Metacarpal ~
formed by the distal carpal row and the basis of the five - + - - - 1 st Meta
metacarpals. The basal joint, or the carpometacarpal joint, PIsiform ----~+
of the thumb between the trapezium and the first meta Hammate----+_
r Trap
carpal is the most mobile. The carpometacarpal joint of the :> ' ~ \ Sc
little finger between the base of the fifth metacarpal and the
hamate bone is the second most mobile. The ring and index
carpometacarpal joints have the least mobility. The middle
finger carpometacarpal joint has no mobility at all, as it is
the rigid, stable center of the longitudinal arch and is I/ Lunate
continuous with the central longitudinal rigid column of the Ulna Radius
carpal bones (see Fig. 4-11). FIGURE 4-1 2 . Ligaments of the wrist, volar aspect.
~r/-
patient cannot use the thumb at all with an unstable ulnar
collateral ligament. In the fingers, however, the radial col
j; ---Proximal
latera l ligam nt of the proximal interphalangeal joint is
~~Phalallx
more critical, as it takes the stress of the opposition be
tween the thumb and the finge rs. No deformities of the
Tight volar plate
joints can develop without disruption to the ligaments,
which renders joints unstable and sets the stage for defor
~--Metacarpal head mities to occur in response to the vario us stress factors to
:..---~,--~ J
Tight collateral which the joint is exposed.
Lax folded volar p l a t e - - - - - ~ T-ligament
Proximal MUSCLES
I phalanx
Muscles that playa direct role in hand function insert at
various locations in the hand and a re grouped into two
divisions based on their location of origin. The first is the
FIGURE 4-13. Metacarpophalangeal joint volar plate and co llateral
ligament in extension and in flexion. extrinsic group of muscles, which are located on the flexor
and extensor aspects of the forearm . They orig,inate in the
forearm and are inserted in specific locations in the hand .
flexed, the volar plates fold and beco me more lax and The second is the intrinsic group of small muscles, which
shorter. If they fibrose in this position, they shrink and are located exclusively in the hand (i.e., they originate and
become tight, which limits the extension of involved joints. insert inside the hand).
At the metacarpophalangeal joints , the collateral liga Extrinsic Muscles. Extrinsic muscles are located on the
ments become tight with the metacarpophalangeal joints in flexor a nd extensor aspects of the forearm. They are
90 degrees flexion and become loose when the metacar frequently referred to as the long fl exors and long exten
pophalangeal joints are in the extended position and can sors. There are two flexor and two extensor surface
allow abduction and adduction , as shown in Figure 4-14 . muscles, which originate or insert away from the hand but
At the interphalangeal joints, however, the collateral indirectly affect the function of the hand . O n the flexor
ligaments are tightest in the extended position and become surface. these two muscles a re the pronator teres and the
loosest in the flexed position. pronator quadratus. On the extensor aspect the two
These are important facts because in positioning the muscles are the supinator and the brachioradialis.
joints during treatment , the conditions of these ligaments Pronator Teres. This muscle has tv\lO origins: first, a
must be understood. humeral origin from the lower part of the medial supra
If the ligaments of the joints are disrupted, the joint condylar ridge and med ial epicondyle and second, an ulnar
becomes unstable. Consequently, the function of the hand origin from the coronoid process of the ulna. The pronator
is compromised. Some ligaments are much more vital than teres inserts into the middle of the lateral surface of the
others. A good example is the ulnar collateral ligament of radius. Nerve supply is median nerve C6-7. To test the
the metacarpophalangeal joint of the thumb, as compared action of this muscle, the arm is held next to the body with
the elbow in partial fleXion , and the patient is asked to
pronate the forearm (Fig. 4-15).
Tight collateral ligament
Pronator Quadratus. This muscle originates in the volar
~r/- aspect of the distal ulna deep to the flexor tendons and is
inserted in the volar aspect distal fourth of the radius. To
test the action of this muscle, the arm is held next to the
~----- body with the elbow fully flexed. and the patient is asked to
Stretched volar plate pronale the forearm. Nerve supply comes from median
nerve C7-Tl (Fig 4-1 6).
Srachloradialis. The brachioradiaUs originates from the
upper third of the lateral supracondylar ridge of the
--:>-7'-1"-- Loose collateral humerus and inserts in the radial side of the lower end of
Folded volar plate - - - ligament
the radius. Nerve supp ly is the radial C5-6. To test this
muscle. the arm is held next to the body, elbow partially
flexed , fo rearm in neutral position , and the patient is asked
to flex the e lbow (Fig . 4-17).
Supinator Muscle. This muscle originates in the lateral
FIGURE 4-14. Interphalangeal joint in extension and in flexion . epicondyle of the humerus and inserts in the proximal third
84 UNIT TWO-COMpmJE~JT ASSESSMENTS OF THE ADULT
A B
FIGURE 4-23. Isola ting the sublimis flexor to the ring finger (A ) and to
FIGURE 4-20. Palma ris longus. the little finger (B).
86 UNIT TWO-COMPONENT ASSESSrviEr~TS OF THE AOULT
A B
FIGURE 4-25. Isolating the action of the flexor digitorum to the ring FIGURE 4-27. Extensor carpi radialis longus and brevis. They ar
finger (A) and to the little fi nger (B). difficult to isolate clinically .
FIGURE 4-28. Extensor carpi ulnaris.
FIGURE 4-30. Extensor digiti minimi.
RGURE 4-39. Rexor digiti minimi. FIGURE 4-41. Opponens digiti minimi.
90 UNIT TWO-COMPONENT ASSE SSMENTS OF THE ADULT
of the base of the thumb metacarpal. The abductor pollicis finger bone. The same is true for extensor digiti mini
longus tendon acts as an abductor and stabilizer of the the little finger.
most dynamic part of the hand , which is the thumb Extensor Indicis Proprius. This tendon starts at the
metacarpal. Consequently, this makes it a very frequently third of the forearm and then passes through the f
used tendon , and because of its anatomic relationship as compartment, along with the four common extensors
it travels through the first extensor compartment and as the dorsum of the hand, it lies on the ulnar side o
it lies on the distal border of the radius , it is vulnerable extensor digitorum communis to the index finger a
to irrlitation and inflammation. Inflammation of this ten inserted into the base of the terminal phalanx and th
don , along with its companion extensor pollicis brevis tensor hood mechanism. This muscle tendon unit, be
(located in the first extensor compartment), is what is working along with the common extensors of the fin
known as tenosynovitis of the first extensor compartment produces the independent extension of the index fing
(de Quervain's disease) . Extensor Digiti Minimi. This tendon starts at the l
Extensor Pollicis Brevis. This tendon becomes superficial third of the forearm and travels distally through a sp
in the distal part of the forearm and travels along the fifth compartment in the extensor retinaculum. Eith
tendon of the abductor pollicis longus through the first side the compartment or just distal to it, it splits into
extensor compartment and continues distally as it inserts portions. This tendon, coupled with the extensordigit
partly in the dorsal aspect of the base of the proximal proprius to the little finger, is inserted in the extenso
phalanx and partly into the extensor expansion of the pansion on the dorsum of the proximal phalanx and p
thumb . It extends and abducts the carpometacarpal joint in the base of proximal phalanx. The muscle tendon u
and extends the metacarpophalangeal joint. It also plays a the extensor digiti minimi extends the little finger in
part in extension of the interphalangeal joint of the thumb , junction with the other extensors but also independ
through its insertion in the extensor expansion. extends the little finger.
Extensor Pollicis Longus. This tendon stays deep in the Lumbricals. From the muscle belly, the tendons t
distal third of the forearm and in the wrist joint area until it distally through the lumbrical canal on the radial si
gets out of its own third compartment, which is located on each digit and continue distally volar to the transverse
the ulnar side of the dorsal tubercle of the radius. At this of the metacarpophalangeal joint. The lumbrical ten
point, it changes its direction to all oblique radial direction , join the lateral edge of the extensor expansion o
crosses superficially to the tendons of the two radial extensor hood mechanism as they become the most
extensors of the wrist, and continues distally until it part of what is known as the conjoint tendon of the
becomes attached to the dorsal expansion of the extensor muscles of the hand . The other part of that con
mechanism of the thumb alld is inserted in a very wide flat tendon, which is proximal to the lumbrical, almost al
tendon, which almost covers the whole width of the dorsal belong to the interossei. As the lumbricals are volar t
aspect of the base of the terminal phalanx. This muscle axis of the metacarpophalangeal joints and are dors
tendon unit extends all the joints of the thumb . Because of the axis of the interphalangeal joints, they extend
its oblique course and the side-to-side mobility on the latter, and with the fingers extended at these joints,
dorsum of the first metacarpal, it can also abduct and flex the first joints. Their attachment of origin to the f
adduct the thumb. profundus and their attachment of insertion to th
Extensor Digitorum Proprius "Communis." The tendons of tensor system allow the lumbricals to play an impo
the extensor digitorum proprius to the index, middle , ring , role in the balance between the flexor and exte
and little fingers start proximal to the wrist and travel systems of the fingers.
through the fourth compartment of the extensor retinacu Interossei. Like the other small muscles of the hand
lum over the center of the wrist. On the dorsum of the hand , interossei tendons travel a very short distance dorsal t
the tendons are connected together by oblique bands, deep transverse ligament of the palm but anterio
which allow these tendons to work together when the hand the axis of flexion at the metacarpophalangeal joint.
needs to function with the fingers extended in one unit. At are inserted in the extensor expansion , forming
the level of the metacarpophalangeal joints, these long proximal part of the conjoint tendon of the small mu
extensors to the fingers divide into two parts. The deeper of the hand into the digits. The action of the inter
part of the tendon is inserted at the base of the proximal depends on whether they are palmar or dorsal. The d
phalanx on the extensor aspect. The superficial part joins muscles abduct the other fingers away from the middle
the extensor hood mechanism on the extensor aspect of Those that act on the middle finger abduct the finger t
the proximal phalangeal area of the fingers. This group of radial or the ulnar side. The first dorsal interosseus ro
muscle tendons primarily extends the metacarpopha the index finger radially at the metacarpophalangeal
langeal joints. However, through the extensor hood expan to allow for thumb-to-index pinching. The palma
sion mechanism, these tendons playa role in the extension terossei adduct the fingers toward the line of the long fi
of the interphalangeal joints. tn a hyperextended position Because of their line of pull and their relationship to th
of the metacarpophalangeal joints , these tendons have the of the metacarpophalangeal and interphalangeal jo
tendency to abduct the fingers from the line of the long the interossei, like the lumbricals, flex the metacarpo
of the middle phalangeal area, just before the two later
extensor bands become the terminal tendon, they ar
joined together with the triangular loose ligament, whic
maintains the lateral band's position dorsal to the proxim
interphalangeal joints and in touch with the central: slip
its insertion in the base of the middle phalanx. In the thumb
the extensor hood mechanism operates on the sam
principle as the other fingers but with some variation. Non
of the lumbricals or interossei in the hand contribute to th
FIGURE 4-46. Extensor hood mechanism. extensor mechanism of the thumb. There are the tw
extensor tendons that join the common extensor mecha
nism. On the radial side are the tendon of the abducto
langeal joint and, through their insertion into the extensor pollicis brevis and the flexor pollicis brevis. On the ulna
expansion, extend the interphalangeal joints. side is the tendon of the adductor pollicis.
The Extensor Hood Mechanism. The extensor hood
mechanism (Fig. 4-46), which starts at the level of the
~IERVE SUPPLY
metacarpal head and extends to the middle of the middle
phalanx, is a very complex area of tendon insertion and is Three nerves are involved in the hand: the median nerv
a classic example of the uniqueness of tendon arrangement (C-S, C-6, C-7, C-8, and T-l), the radial nerve (C-S, C-6
in the hand that allows it to perform its function in the most C-7, C-8, and T-l), and the ulnar nerve (C-8 and T-l). I
dynamic and harmonious way (Tubiana et aL, 1984). In the the forearm, the three nerves are mixed (motor an
fingers at the level of the metacarpophalangeal joint, the sensory). With the exception of the radial nerve, whic
long extensor tendon, joined by the independent extensor becomes purely sensory in the hand area, the ulnar an
to the index and little fingers, divides into a superficial and median nerves continue to the hand as mixed sensory an
deep portion. The deep portion, as it crosses over the motor. Knowledge of the course and the location of th
metacarpophalangeal joint, becomes adherent to the dor nerve, its branches, and the muscles it supplies is absolutel
sal capsule and is inserted at the base of the proximal crucial to properly evaluate and manage a neurolog
phalanx. The superficial portion passes into the extensor problem. The accuracy of locating the site of an injury t
hood mechanism. The sagittal bands, which are the the nerve becomes clear when conSidering as an examp
proximal part of the extensor hood mechanism, are joined injury to the ulnar nerve at the elbow versus an injury to th
and overlapped on each side toward the dorsal aspect by same nerve at the wrist. In the first instance, a clinic
the interosseous tendon that passes from the hand to the picture of loss of sensation to the ring and little fingers, bot
fingers dorsal to the transverse metacarpal ligament but in the volar and dorsal aspects, along with the ulnar half o
volar to the axis of the metacarpophalangeal joint. The the hand, is seen. Besides the sensory loss, paralysis of th
superficial part of the interosseous tendon joins the lateral flexor carpi ulnaris, the part of the flexor digitorum
aspect of the sagittal bands. The deep portion of the profundus to the ring and little fingers, and all the inte
interosseous tendon is attached to the base of the proximal ossei, the hypothenar muscles, the two ulnar lumbrical
phalanx on the side through which the tendon is passing. the adductor pollicis, and the deep head of the flexo
The lumbrical tendon, however, joins the extensor hood pollicis brevis occurs. In the case of injury to the ulnar nerv
mechanism distal to the point of attachment of the at the wrist, however, the flexor carpi ulnaris, the flexo
interosseous tendon. From the description just given, it digitorum profundus to the ring and little fingers, along wit
becomes quite obvious that overlying the extensor aspect the sensory function to the dorsum of the ring and litt
of the proximal phalanx is the extensor hood mechanism, fingers and the ulnar side of the dorsum of the hand, will b
which is primarily a conjunction of the superficial part of spared from loss. The clinical presentation, the line o
the long extensor of the fingers, the conjoint tendon of the management, and the prognosis of an injury at any of thes
lumbrical, and the superficial part of the interossei tendon. locations will be totally different.
At that particular location overlying the distal third of the The same principle does apply to all the nerves of th
proximal phalanx, the common extensor hood splits into extremity. The only situation in which an injury to the uln
two major groups: the central band and the lateral bands. nerve at the elbow will not result in intrinsic paralysis is th
The central band passes over the proximal interphalangeal case of Martin-Gruder anastomosis (Fig. 4-47).
joint capsule to be attached to the base of the middle Ulnar Nerve. In the forearm, the ulnar nerve (Fig. 4-48
phalanx. The lateral parts of the extensor hood mechanism comes through the cubital canal behind the medial ep
pass on the lateral aspect of the proximal interphalangeal condyle of the elbow, enters through the flexor arch, an
joint and then join together about halfway over the dorsal then gives its only motor branches in the forearm to th
aspect of the middle phalanx. Together, they make the flexor carpi ulnaris (note' 'ulnar nerve distribution") and th
terminal tendon, which is inserted at the base of the part of the muscle belly of the flexor digitorum profundu
94 urm TWO-C OMPONE~JT ASSE SSilJ1ErHS OF THE ADULT
FIGURE 4-47. Maltin-Gruder anastomosis . FIGURE 4-49. Median nelVe course, distribution, and bra nch
dorsal arteries to the thumb , the two dorsal arteries to the Anterior
index, and a branch to the dorsal aspect of the carpus. interosseous artery - - - - - - - - - Dorsal
The ulnar artery , the second terminal branch of the interosseous arter
brachial artery at the elbow, travels distally on the flexor AGURE 4-52. Arterial vessels of the hand .
.
, -
-
- . .
~.,.-=-
96 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
THE HAIR
Hair is distributed on the dorsal aspect of the hand and Surface Anatomy
the forearm, and the hair pores on the hand and forearm
slant toward the ulnar side. Hair on the volar aspect of the Knowledge of the surface anatomy and the land
forearm is usually sparse. The texture , pattern, and color of of the hand is absolutely critical, as it facilitates u
the hair is a Significant indicator of the condition of the skin. standing and the process of clinical evaluation (Ka
For example, the hair is dry, brittle, and shiny in some Functional and Surgical Anatomy of the Hand ,
pathologic conditions that affect the hand , as in the (Fig. 4-53) .
chronic, painful stiff hand syndrome. The proximal wrist crease is in line with the radio
joint. The distal wrist crease runs between the pis
and the scaphoid bones and in Bne with the pro
THE NAIL PLATE COMPLEX
border of the flexor retinaculum. The distal palmar c
The nail plate complex (see Fig . 4-5) is located in the begins on the ulnar border of the hand at the level
distal half of the terminal phalangeal area of the digits. It is metacarpal head of the little finger and then runs acro
made of the nail plate, the proximal nail fold , the lateral nail metacarpal heads transversely to the base of the
folds, the nail bed , and the root of the nail. The nail is firmly finger. The proximal palmar crease starts just proxim
attached to its nail bed, which is in turn attached to the the index metacarpal and then runs obliquely acro
terminal phalanx, where the proximal end of the root shaft of the third , fourth, and fifth metacarpals to the
reaches the insertion of the extensor tendons at the base of border of the hand . The thenar (the radial longit
the terminal phalanx . The nail 's main function is to support palmar crease) extends from the junction of the hea
the tip of the digit. The terminal phalangeal area is sup shaft of the index finger metacarpal. From the
ported on the dorsal aspect partly by the terminal phalanx extends to the ulnar side of the proximal part of the
and partly by the nail pJate . Absence of the nail plate de metacarpal and then continues proximally to the tr
prives the tip of the digit of any dorsal support and , conse oscaphoid joint. This joint is used as a landmar
quently, the tip of the digit rolls backward. This is Significant locating the point of attachment of the rubber bands
in cases of injuries to the digit tips. Loss of the integrity and flexor tendon repair (Fig. 4-54). The creases at the
the stability of the tip of the digit interferes with the preci of the digits are approximately at the junction o
sion movement of the hand. It is absolutely essential that all proximal one third and the distal two thirds o
health care professionals who are involved in hand surgery proximal phalanx. In the finger, two transverse creas
be very sensitive to the importance of the nail plate as an present. The proximal one is in front of the pro
integral anatomic part that is necessary to the support of interphalangeal joint, and the distal one is in front
the terminal phalangeal area and consequently to the func distal interphalangeal joint. The flexor retinaculum
tion of the digits. tends from the distal wrist crease to a line about 1
FIGURE 4-54. A, Trapeziosca phoid joint. B-F, All finger tips point to trapezioscaphoid jOint wh ile in flexion.
distally (Fig. 4-55). This line corresponds to another line the corresponding arteries bifurcate near the web space o
across the palm from the ulnar side of the hyperextended the fingers at the level of he bases of the proxima
thumb and runs transversely across the palm to the ulnar phalanges. The web spaces of the fingers are located in lin
side. The pisiform can be felt at the base of the hy with the crease at the base of the finger, which correspond
pothenar eminence, and the hook of the hamate is about to the junction between the p roximal a nd distal two third
2.5 cm distal and radial to it. The tubercle of the scaphoid
is the bony prominence felt at the base of the thenar
eminence with the crest of the tra pezium distal to it (Fig.
4-56). These bony landmarks are the point of attachment
of the flexor retinaculum to the carpal bones. A line,
extending proximally from the radial side of the ring finger
to the medial side of the biceps tendon at the elbow,
marks the course of the median nerve (Fig. 4-57). A line,
extending distally from the anterior aspect of the medial
epicondyle of the elbow to the radial side of the pisiform
at the wrist, marks the course of the ulnar artery and nerve
(see Fig. 4-57). [n the wrist area the median nerve lies
immediately on top of the lunate bone. The thenar
branch, or the recurrent branch of the median nerve ,
comes out from the main trunk about 1 .5 inches distal
to the distal wrist crease.
The division of the common palmar digital nerve occurs
just distal to the level of the superfiCial palmar arch , while
crease ~-""_ Proximal wri
crease
S = Scaphoid
L = Lunate
T = Triquetrum
P = Pisiform
H = Hamate
C = Capitate
Td =Trapezoid
Tm =Trapezium
R = Radius
U = Ulna
FIGURE 4-55. Flexor retinaculum. FIGURE 4-56. Sur face anatomy.
98 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 4-57. Surface anatomy of the course of the radial artery, the
median nerve, the 111nar nerve, and the ulnar artery ,
SKIN'
Skin lacerations must be treated early, if possible. If no
violation of any other structures has occurred, the wound is
treated conservatively or surgically. If sutures are required,
it is usually recommended not to remove the sutures before
3 weeks have passed. The skin of the hand is fairly thick and
takes longer to heal than the skin elsewhere on the body .
Also , the hand is a very dynamic organ , and the skin needs
to heal properly before the sutures are removed. The pa
tient is given the usual instructions on how to take care of FIGURE 4-63. Flexor tendon zones.
the wound, keep it clean, and protect the hand until it heals.
Zone four: Is the carpal tunnel area where the f
FI~IGERTIP INJURIES tendons to all the digits are located
Zone five: Extends from the musculotendinous jun
Fingertip injuries are a common problem. The level and to the carpal tunnel
the shape of the amputation or tissue loss dictate the type In the thumb, zone one extends from the middle o
of management needed . The goal is to achieve repair so proximal phalanx to the insertion of the flexor po
the tip of the finger can be functional. Usually if the skin lost longus at the base of the terminal phalanx. Zone
is less than 1 cm in diameter with no bone exposed , it will extends from the metacarpophalangeal joint to the m
heal by itself . If any bone is exposed or if the injury is more of the proximal phalanx . Zone two in the thumb is diff
than 1 cm in diameter, then surgical treatment is indicated from zone two in the fingers because only one tend
in the form of skin grafts or local or distant pedicle flaps. there . Zone three is located around the flexor po
Surgical management can be performed in one stage, as in longus in the thenar eminence area.
the case of skin grafts and local flaps, or in two stages, as Repair of the flexor tendons can be either pri
in the case of distant pedicle flaps. Postoperative care is in (within a few hours), delayed primary (within 3 wee
the form of wound management, along with therapy and the injury), or secondary (when it is done after 3 w
exercises. of the injury) . Zone five usually has the best prog
after tendon repair, followed by zones three , four,
one . Because of the unique condition of the pa
TENDONS
having two large tendons squeezed in a tunnel, in
Tendons perform their function through gliding. Be to the tendons in zone two are usually the most dif
cause of the unique conditions tendons of the hand must go with the poorest prognosis. In the past, zone two
through from their point of origin at the muscle belly to known as "no man's land, " but during the last 25 y
their point of insertion in the bone, the healing process of it has been renamed " some man's land. " Even in the
an injury can affect the gliding mechanism of the tendon of circumstances and with the best of care, repair o
and also affect the efficiency of its function. Through its two flexor tendons when lacerated in zone two ha
path, the tissue surrounding the tendon can vary from one potential for major problems because of scarring
location to the next. As a result, the condition and the type adherence that will interfere with the tendon gl
of tissues respond to trauma, inflammation, and healing mechanism. Flexor tendon repair should only be u
differently from one location to another. It is because of taken by specialists in hand surgery. After the tendon
these factors that the tendon's path has been divided into repaired , patients are then started on the proper the
zones. Each zone requires a unique form of management course, and some might require surgical tenolysis i
and has a unique prognosis ( Doyle & Blythe, 1975; future. Surgical tenolysis improves tendon gliding a
KJeinert , 1975; KJeinert & Stormo, 1973; Lister, 1984; commoilly needed in patients who had zone two te
Verdan, 1964; Verdan, 1972). repairs.
Flexor Tendons (Fig. ~3). The five zones of the flexor Extensor Tendons. Extensor tendons have been di
tendons are as follows : into eight zones (Fig. 4-64). They are easier to repai
Zone one: Has the flexor digitorum profundus only and have a much better prognosis than the flexor tend
extends from the insertion of the sublimis at the base Repair, splinting, and therapy are the steps followed
of the middle phalanx to the base of terminal phalanx injury. The zones are as follows:
Zone two : Contains the two flexor tendons and extends Zone one: Over the distal interphalangeal joint
from the distal palmar crease at the level of the Zone two: Over the middle phalanx
metacarpophalangeal joint to the insertion of the Zone three: Over the proximal interphalangeal joi
sublimis tendon Zone four: Over the proximal phalanx
Zone three: Is the middle of the palm where the Zone five: Over the metacarpophalangeal joint
lumbricals originate Zone six: Over the dorsum of the hand
Injuries to the nerves can be open or closed, transacte
or injured in continuity, simple or associated with othe
injuries. Contused or bruised nerves heal spontaneousl
without treatment. However, lacerated nerves requir
surgical treatment. After the surgical repair, nerves grow
back at the rate of 1 inch per month. After a nerve i
FIGURE 4-64. Extensor tendon zones. injured, the distal part of the nerve degenerates , while th
proximal part of the nerve regenerates and grows distally
Consequently, meticulous nerve repair with the prope
Zone seven: At the extensor compartments
alignment is essential so that the new nerve growth can b
Zone eight: At the distal forearm
directed toward its proper channel. At the beginning, newl
grown nerves are overly sensitive, sometimes resulting i
LI GAMENTS hyperparesthesia and dysthesia. Regenerated nerves re
qUire special therape utic techniques, such as stimulatio
Injuries to the ligaments can be closed or open , partial or
and desensitization.
complete, simple or associated with both bone and joint
injury. They are treated conservatively or surgically, de
pending on the type of ligament, its location, and the type
and size of the injury. Ligaments must be protected either Neurologic Problems
by casting or by splinting. The patient begins therapy later,
with the goal of maintaining the integrity of range of Any nontraumatic problems of the nerves can either b
motion with a stable joint. as a result of peripheral nerve compression, inflammator
peripheral neuropathies paralysis (as in leprosy or diabe
tes), or because of central neurologic problems, such as i
BONES cerebral palsy. Nerve compression syndromes, which ar
Injuries to the bones can be open or closed , displaced or common in the hand are:
undisplayed, stable or unstable, intra- or extraarticular, 1. Carpal tunnel syndrome
simple or associated with other injuries (Lister, 1984; 2. Entrapment of the median nerve and/or the anterio
O 'Brien and Eugene, 1988). The bones are treated either interosseous nerve at the pronator teres
conservatively or surgically, depending on the type of 3. Entrapment of the radial posterior interosseous nerv
fracture , its location, and its stability. With the various at the supinator tunnel
surgical modalities available, broken bones in the hand can 4. Entrapment of the ulnar nerve at the Guyon's cana
be treated surgically, and within a few days the patient can 5. Entrapment of the ulnar nerve at t he cubital cana
begin an active therapy program, with excellent results. behind the medial epicondyle Occasional entrap
ment of the superficial radial nerve by the brachiora
dialis in the lower third of the forearm also may occur
JOINTS Modalities of nerve compression treatment depend o
Injuries to the joints involve the articular cartilage, the the stage at which the patient seeks treatment. At an earl
ends of the bones, and the capsule. Injuries can be open or stage, management might only entail a change in th
closed, simple or associated with other injuries-especially patient's pattern of living along, with splinting and antiin
injuries to the bones and ligaments. The modality of flammatory medications. However, surgical managemen
treatment depends on the type of injury. Again , a therapy would be required in advanced cases.
course is almost always recommended and should begin Paralysis of the peripheral nerves can be high or low
with guarded active, then active and passive, and finally depending on its location, and is treated according to it
with full active and passive range of motion. type. Nerve repairs or tendon transfers can be performed
Cerebral palsy is a central neurologic condition , and initia
splinting when an affected child is young can be helpful
BLOOD VESSELS However, some patients might require surgical treatment
Injury to the blood vessels can be either open or closed,
simple or associated with other injuries, depending on the
type of injury. However, dominant arteries must be re Pressure Injection Injuries
paired surgically . If nondominant arteries are the only thing
injured and the vascularity of the digit is not compromised, Industrial toxic substances under pressure that vary from
then in most cases, surgical repair of the artery is not 500 to several thousand pounds per square inch can b
indicated, and the hand needs to be protected until the accidentally injected in the hand (most commonly th
wounds heal. digits). What is unique about these injuries is that the
102 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
initially appear minimal but are later followed by severe case, a remnant of the dermis is always left. Second-degr
pain and swelling as a result of the pathologic changes burns are characterized by intense pain and the presence
that occur in the tissues, and the consequences are blisters, which should be left intact, as they act as a biolo
devastating. Initially, only a pinpoint injury to the skin at natural dressing, and they will rupture spontaneously. T
the site of the accidental injection is seen. The amount patient should be seen daily and started on antibioti
of damage depends on the type of chemical and the whirlpool baths, elevation of the hand, changes of dre
pressure under which it was injected. The toxic substance ings, and exercise. The second-degree burn heals spon
can spread from the digits to the hand and even to the neously unless infection occurs, and then the remaini
forearm. Management almost always requires surgical layers of the dermis will be lost and, consequently, the bu
debridement, with the wounds left unclosed. The patient will be classified as a third-degree burn. Third-degree bu
is treated with therapy, whirlpool baths, elevation of the are characterized by almost complete loss of the skin. Wh
hand, exercise, and antibiotics. The wounds are left to skin is left appears white, tight, leathery, and is painless,
heal by secondary intention or delayed reconstruction. no sensation is present. A patient with a third-degree bu
The determining factor about the type of surgical modality should undergo surgical debridement and then reconstru
of delayed reconstruction depends on the amount and tion. Again, postoperative care requires elevation a
type of tissue loss. It is very important to remember that exercise until the wounds heaL
even in the best hands and with the best of care, pressure
injuries can leave a digit totally disabled to the extent that
CHEMICAL BURNS
its amputation becomes necessary to allow the hand to
function properly. Chemical burns can ile caused by an alkaline or an aci
agent. Initial treatment should be in the form of copio
rinsing with water. In the case of alkaline burns, woun
Cold Injuries should be washed with a diluted acidic solution. For aci
burns, the wounds should be rinsed with diluted sodiu
Exposure to cold can cause severe injury to the extrem bicarbonate. Phenol burns are neutralized by ethyl alcoh
ity. Early symptoms include burning, itching, and redness. Hydrofluoric acid burns are treated by copious irrigation
The exposed extremity becomes very cold and then numb. water, injection of calcium gluconate locally, and soaki
Cold injuries, as in burns, are claSSified according to the the dressing with benzalkonium chloride and calciu
depth of the burn. First-degree cold exposure injuries are gluconate.
superficial and usually recover spontaneously. Second
degree injuries include partial-thickness skin loss, which
ELECTRIC BURNS
can heal by secondary intention, as long as no infection
occurs, which might destroy the remaining layers of the Electric injury usually happens with exposure to curre
dermis. Third-degree injuries result in full-thickness skin over 500 volts, which travel through the body along t
loss and require surgical management. lines of the least reSistance, meaning the blood vessels a
Regardless of the depth of injury, the initial treatment of nerves. With electric current burns, the patient's conditi
the cold injury is in the form of rewarming with water 40°C is critical. Such burns cause extensive and severe dama
to 42°C. During the rewarming process, the patient will, along their path. The treatment is usually surgical w
most probably, experience burning pain, aching, and intense follow-up therapy; secondary surgery is of
paresthesia. The hand is treated either conservatively or required.
surgically, depending on the depth of the damage. Eleva
tion and exercise are necessary. Sympathetic ganglion
blocks or antithrombotic therapy may be considered. Infections
Infections of the hand can be superficial or deep a
Burns acute or chronic. They can be treated on an outpatient
inpatient basis conservatively or surgically, depending
Burns can be either thermal, chemical, or electric and the severity of the infection.
are classified according to their depth.
PARONYCHIA
THERMAL BURNS
Paronychia is an inflammation of the tissues around t
First-degree burns are superficial and cause redness and nail plate complex. The most common organism is Stap
pain. Initial treatment is usually to rinse in cold water and ylococcus aureus. At the early stages of cellulitis, anti
then apply some dressing. The hand should heal sponta otics, elevation, and soaking usually diminish the proble
neously with some exercise if it is kept elevated. Second However, in the presence of an abscess, surgical draina
degree burns can be either superficial or deep. In either by removal of the nail plate is necessary.
removed, the nail bed and the nail folds need to be Sometimes the problem resolves without leaving an
protected until the new nail plate grows. It is almost always residual effects, but sometimes it leaves significant stiffness
necessary to apply a piece of petroleum gauze or any other which might require future surgical management. Som
sterile sheet to cover the nail bed and to be underneath the suppurative tenosynovitis cases are so severe that eve
proximal and the lateral nail folds. This protects the nail bed with the best of care, the problem of management is s
from any injury and also prevents any future adhesion complex that the digit may be left stiff and deformed, so
between the nail folds and the nail bed, which might result eventually must be amputated.
in a future deformity of the nail plate.
DEEP SPACE INFECTIONS
FELONS
This usually happens in the thenar and the midpalma
A felon is an infection of the terminal phalangeal area spaces. The collar button abscess is another type of dee
and presents with swelling, redness, and intense pain. space infection that starts between the digits in the we
Because of the anatomic presence of the fibrous septae and in the palmar surface and spreads dorsally (Burkhalte
also of the attachment of the palmar fascia at the distal 1989). Pain is usually the most common presentin
interphalangeal joint crease, the terminal phalangeal area symptom, along with swelling, redness, and stiffness o
is considered a closed space. Unless the condition is the hand. Surgical incision and drainage, along wit
treated, the swelling and the redness progressively become proper administration of antibiotics, whirlpool, and ex
worse. Without treatment, the increased pressure and the ercise are necessary.
presence of infection in the closed compartment can
jeopardize the blood supply to the terminal phalangeal area
HUMAN BITE INFECTIONS
and result in osteomyelitis and necrosis of the bone.
Adequate treatment of infections in the terminal pha The vast majority of human bite infection cases happe
langeal area require surgical drainage. Postoperative care as a result of clenched-fist fights. A puncture wound injure
includes soaking, therapy, and active and passive exercise the skin, tendon, and joint structures, including cartilage o
until the wounds heal. bone. The most common organism found in human bit
infections is Eikenella corrodens, a gram-negative ro
facultative organism (Patzakis et aI., 1987).
HERPES INFECTIONS
Clinically, the patient presents with pain, redness, an
Herpes infection can affect the tips of the digits and is swelling at the site of injury. The pathologic condition coul
extremely painful. It is usually manifested in single or mul be cellulitis, arthritis, osteomyelitis or lymphangitis. Th
tiple variable-sized vesicles around the tip of the digit. condition is mostly treated surgically. The consequence o
Health care professionals who are exposed to infected pa the infections that result secondary to human bites ar
tient saliva are the most susceptible (Louis and Silva, sometimes so severe that even with the best of care and i
1979). It also may be seen in patients with acquired immu the best of hands, bone and soft tissue damage may lead t
nodeficiency syndrome or immunosuppression (Glickel, chronic irreparable stiffness, and amputation of the dig
1988). Treatment is usually symptomatic, along with anti becomes necessary.
biotics to protect against secondary infection. Diagnosis
primarily depends on the history and the fluorescent
ANIMAL BITES
antibody studies of the fluid from the vesicles. Some
ointments and oral medications are available for herpes Cats and dogs are the most common animals that bit
infections. humans. However, bites by rare exotic animals may also b
seen. Staphyloccus aureus is the most common organism
in dog bite cases, and Pasteurella multocida is the mo
SUPPURATIVE FLEXOR TE~IDON TENOSYNOVITIS
common organism in cat bites (Snyder, 1989). As in th
Infection of the flexor tendons in the flexor tendon case of human bites, treatment can be conservative o
sheath can be secondary to trauma or may spread through surgical, and the prognosis is very guarded.
the bloodstream. The diagnostic signs are known as the
Kanavel's signs: 1) longitudinal swelling of the flexor
SEPTIC ARTHRITIS
tendon sheath; 2) tenderness with possible redness of the
skin along the tendon sheath; 3) the digit or digits held in a Infection of the joints can either be secondary to traum
flexed position to minimize the pain; and most significantly or blood borne. If the infection is not treated properly
4) severe pain on the passive extension of the joints destruction of the joint may occur, which results in stif
(Neviaser, 1978). Suppurative tenosynovitis needs to be ness. The most common condition of septic arthritis
treated surgically. Besides incision and drainage, intraop secondary to human bites; the most common blood-born
erative and postoperative irrigation with antibiotic solu infection of the joint is due to gonorrhea. Septic arthrit
104 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
of the joint should be treated surgically, along with the aged or older. It sometimes occurs in younger people a
proper antibiotics, postoperative whirlpool, and exercise. is more common in men than in women. The disease h
Depending on the severity of infection and the adequacy three stages: 1) an early stage that is proliferative; 2)
of treatment, some joints eventually will be completely active stage that is fibrocellular; and 3) an advanced sta
distroyed and will require surgical reconstruction or even that is fibrotic. It usually begins with a painful nodule in t
amputation later on. palm of the hand, and the disease process progress
gradually over a long period until it eventually causes
flexion contracture of the metacarpophalangeal and int
Inflammatory Conditions phalangeal joints. In the early stages of the disease, patien
are advised to avoid any trauma to the hand. The
Aseptic inflammation of the tissues that affect the contractures can be localized in one part of the hand, mo
tendons and the synovial sheath can occur in several commonly on the ulnar side, but can be widespread. T
locations. As a result of the inflammatory process, the only proper treatment is surgical excision of the involv
tissues and involved areas become swollen, painful, and palmar fascia, with postoperative wound care, splintin
tender and interfere with the function of the part involved. and exercise.
GENERAL APPEARANCE
The general appearance of the hand must be assessed, FIGURE 4-66. Wright's test.
including its posture and position, patient attitude, ban
dages, and splints; these are only a few examples of the
small blood vessels. Interference with the blood supp
factors that the examiner has to observe as the process of
the hand can occur in any location along the vascula
evaluation continues. Painh~, stiff hands are usually held in
a very specific, guarded posture that seems to be a of the extremity. Patients complain of pain, cold in
ance, ischemic neuritis, and possible presence of a m
comfortable position for the patient. The affect of the
patient and his or her attitude can help the examiner the case of aneurysms. Evaluation may show change i
color, temperature, and texture, as well as the presen
understand the extent of the impact of the hand problem
ulcerations or gangrene, along with signs of neuriti
on him or her.
evaluate the blood supply to the extremity, certain tes
be done.
SKIN EXAMINATION Adson's Test. T his test exaggerates compression o
The presence or absence of wrinkles and scars is the first neurovascular bundle in the neck. T'h e patient is direc
observation that needs to be made. The color of the skin, brace the shoulder posteriorly, turn his or her head
its texture, sweat patterns, hair pattern, and hair texture affected extremity, raise the chin, inhale, and hold
are also important factors to evaluate. The temperature of her breath . A diminished radial pulse at the wrist o
the patient's skin, as felt by the examiner's extensor aspect involved extremity results in a positive Adson's sign te
of the fingers , should be examined in an ascending distal to compression of the neurovascular bundle in the tho
proximal manner, and the difference in temperature is outlet area (Fig. 4-66)
noted as the examiner moves his or her fingers on the Wright's Test. This is an extension of Adson 's test
extremity (Fig. 4-65). The temperature of the skin and the patient assumes the same posture as described in Ad
presence of any changes, ulcers , gangrene, or swelling test. Then the affected arm is abducted to at least 9
should be noted during the procedure. grees and externally rotated, and the radial pulse is ch
at the wrist. A diminished pulse is considered a positiv
for vascular compression (Fig. 4-67) .
EXAMINIATION OF THE ARTERIAL SUPPLY
The blood supply to the hand comes from the subclavian
artery that moves distally and ends up in the peripheral
FIGURE 4-65. Checking the skin temperature from distal to proximal. FIGURE 4-67. Adson's test.
FIGURE 4-68. AJlen 's test. A, Occlusion of the radial and ulnar a rteries, B, After the blood has been pumped o ut. ote the pale ness o f the ha nd
e, The ulna r artery is released, The radial artery is still occluded , Note the return of blood to the hand through the ulna r arte ry, 0 , The two arte ries a r
occluded again and the blood is pumped out once mo re , E, The pressure is released from the radial artery but maintained o n the ulna r a rtery, The bloo
flows back to the hand through the palma r radial artery ,
Allen's Test (Fig. 4-68). This test determines arterial examiner's thumbs is incomplete . If the hand stay
supply at the hand from the radial, ulnar, and possibly the blanched and pale , the examiner should release eithe
median artery. The median artery is a small , threadlike radial or ulnar artery pressure . The hand should regai
structure that runs along the median nerve in almost coloration with in 2 to 5 seconds . Repeat this process b
aU patients. Embryologically, the anterior interosseous releasing the pressure on the other artery this time. A
artery atrophies and becomes the median artery as the filling time greater than 7 seconds is indicative of sever
ulnar and radial arteries mature. However, in some pa problems (Koman, 1985) of the adequacy of arterial bloo
tients , a fairly decent-sized functioning median artery is flow to the hand.
present. The steps for Allen 's test are as follows: locate Special Tests to Evaluate the Adequacy of Blood Flow to th
the radial and ulnar arteries at a point 0.5 inch to 1 inch Hand. These tests are arteriograms a nd thermogra phy.
proximal to the volar wrist crease. The radial artery is
located just to the radial aspect of the flexor carpi radialis
VEI NS OF THE HAND
tendon, and the ulnar artery is located just to the radial
aspect of the flexor carpi ulnaris tendon. The patient The veins on the dorsum of a normal hand should be ver
makes a tight fist (an object such as an ace wrap can be easy to see or feel. mo re so in light-skinned individuals.
squeezed if a complete fist cannot be accomplished) The the veins are not easy to de ect. then they should b
examiner occludes the radial and ulnar arteries using a compared with the ve ins on the other normal extremity
downward and lateral pressure with the terminal pha Use of drugs for medical or nonmedical reasons can caus
langeal area of the thumbs. The patient pumps the blood thrombosis or thrombophlebiti , and the veins could b
out of the hand by opening and closing his or her fist seen or felt as painful or painless cordlike structures , or the
several times until the hand becomes pale. Next, the are simply occluded and not easy to see or feel. Th
patient leaves the hand open and relaxes the fingers, after presence of tenderness, pain, redness , or fir mness alon
which the hand should remain pale and blanched. The the course of the veins should be noted. The puffy hand i
hand will not blanch and be pale if the patient has a secondary to venous thrombosis, subcutaneous fibroSiS
functioning major median artery, as it is the only artery and lymphatic obstruction (Neviaser, 19 72) . Venogram
not occluded by the pressure applied by the examiner's may be necessa ry to further evaluate the venous drainag
digits, or if occlusion of the radial or ulnar arteries by the system of the extremity.
·." I.~""'~
108 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 4-14. Volar flexion o f the wrist. FIGURE 4-18. limited flexion of all the joints of the fingers .
.~- .
- ~ !~.~--
110 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADLJLT
AGURE 4-80. The hitchhiker position. FIGURE 4-82. Independen t full extension of index and little fi
FIGURE 4-83. Independent extens.ion o f the middle and ring fingers is
no t possible, as these two digits do not have independent extensors.
Neurologic Examination
The median , ulnar, and radial nerves innervate the hand
and possess a sensory and motor component. Variou
sensory tests are available and include evaluations o
tactile sensation, e.g ., Semmes-Weinstein Monofilaments
(Tubiana et al., 1984), deep sensation, temperature
pinwheel test , two-point discrimination, object ,identifica
FIGURE 4-84. Note obstruction o f flexion at the distal interphalangeal
joint of the middle finger. which will interfere with the ability to flex the
distal interphalangeal joints o f the ring and little fingers .
FIGURE 4-85. Extrinsic extensor tightness test. FIGURE 4-87. Intrinsic tightness test.
112 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
tion (stereognosis), texture identification, and Tinel 's sign. 60 seconds, and record if patient reports symptoms o
The principle behind performing the last test is to irritate tingling in median nerve-innervated sensory territory.
an already sensitive nerve. Assessment for Tinel's sign is
done by gently tapping a sensory nerve with a blunt object
that has the same circumference as the nerve. Unpleasant Special Tests
feelings (e.g ., paraesthesia , hyperparasthesias) may occur
in one of three locations or directions: at the site of FINKELSTEIN'S TEST
tapping , at a direction going distal from the tapped area, When performing this test, you are assessing for th
or in a direction proximal from the tapped area . !f the presence of tenosynovitis of the extensor pollicis longu
sensation travels proximally, it is not a positive Tinel's sign.
The test is only positive when the unpleasant feelings are at
the location of the tapping or in a direction distal to it.
Other useful tests are Phalen 's and reverse Phalen's
(Phalan, 1951). The principle behind performing these
tests is to put the median nerve under maximum pressure
by diminishing the size of the tunnel and by kinking or
stretching the nerve in either test , which eventually causes
irritation of the nerve. For Phalen 's test, place the wrist in
90 degree palmar flexion , with the fingers relaxed, the
elbow at 90 degrees of flexion , and the shoulder at 90
degrees abduction (Fig. 4- 89).
For the reverse Phalen 's test (Fig. 4-90), place the wrist
in 90 degrees of dorsiflexion with the fingers relaxed, the
elbow at 90 degrees of flexion, and the shoulder at 90
degrees abduction. Maintain the above positions for 0 to
and abductor pollicis brevis tendons located in the first of Finkelstein's test can lead to the patient developing d
dorsal compartment. The pathology of de Q uervain's Quervain's.
disease includes swelling (inflammation), thickening (ten
don sheath), tightness, and adhe ions. Any attempt at distal
gliding of the two tendons either passively or actively will be WARTENBERG'S TEST
limited and very painful. (Positive Finkelstein 's test results
In this test, the little finger remains abducted if the patien
usually indicate de Quervain's disease) . To perform the
has a weak palmar interossei and unbalanced action of th
Finkelstein's test , place the pa tient's wrist in radial devia
long extensor tendon , which indicates ulnar nerve weak
tion and midway between pronation and supination with all
ness.
the digits closed in a fist and the fingers covering the flexed
thumb in the palm (Fig. 4-91) . Ask the patient to relax . A
gentle jerking motion in the direction of ulnar deviation is
FROMEN T'S TEST
passively applied. A positive test result occurs when the
movement causes pain; however, if the wrist is je rked too This is a test of active thumb adduction, using a piece o
much , the patient may feel pain even ;f he or she does not paper between thumb and first finger (see Fig . 4-38). Th
have de Quervain's disease. The imprope r administration patient is asked to hold paper without flexing the interpha
114 UNIT TWO-COMPONENT ASSESSMENTS OFTHE ADULT
HAND EVALUATION
NAME: __________________________________ DATE: _ _ _ _ _ _~
~.NO:__________________________________ AGE:
------
ADDRESS: _______________________________________________
OCCUPATION: _ _ _ _ _ _ _ _ _ _ _ HAND DOMINANCE: _____
INVOLVED HAND: ATTENDING PHYSICIAN: _ _ _ _ _ _ _ __
Previous surgeries/treatments/medicationsltherapy:
115
116 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
Soft Tissue Integrity: (Edema, Surface Irregularities, Moisture/Dryness, Wrinkling/Shininess, Tapering, Nod
Scars-Location and Size) Diagram on last page
Joint Status: (Volar Plate, Collateral Ligaments, Grind Test, Stress Test)
RIGHT LEFT
+ - Middle Finger Extension + -
+ - Finkelstein's + -
+ - Adson's + -
+ - Froment's + -
+ - A of F + -
TINEL'S
RIGHT LEFT
+ - Radial Nerve + -
+ - Median Nerve + -
+ - Ulnar Nerve + -
-
ALLEN'S
RIGHT LEFT
+ - Radial Artery +
+ Ulnar Artery +
RIGHT LEFT
+ - Phalen's +
+ Reverse Phalen's +
Grip: (Level R Ibs. L Ibs.
Lateral Pinch: R Ibs. L Ibs.
3 Jaw Pinch: R Ibs. L Ibs.
Tip Pinch: R Ibs. L Ibs.
Forearm Circumference:
Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
RIGHT LEFT
Wrist Ext.
RADIAL Thumb Ext.
Finger Ext.
RIGHT LEFT
Wrist Flex.
MEDIAN Thumb Flex.
Thenars
RIGHT LEFT
Wrist Flex.
ULNAR Finger Flex.
Hypothenars
Intrinsics
Range of Motion:
RIGHT
COMMENTS: __________________________________________________________
LEFT
MP OPP F RD
IP WBSP E UD
PMP POPP PF PRD
PIP PWBSP PE PUD
S F F AB IP
P E E AD EP
PS PF PF PAB PIR
PP PE PE PAD PER
COMMENTS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
RIGHT LEFT
RADIAL SFC. ULNAR SFC. RADIAL SFC. ULNAR SFC.
Thumb
Index
Middle
Ring
Small
. - ~-=-
. . -~.~~ ~~~:~::
120 UN IT TWO-COMPONENT ASSESSMENTS OF THE ADULT
RIGHT LEFT
Plan: To forward a copy of this hand evaluation to the attending physician for use in determining the medical stat
of this patient.
Examiner Date
122 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
Barron, J. N. (1970). The structure and function of the skin of the han
Hand, 2, 93-96.
Abduct-To bring or move away from the center of the
Barton, N. J. (1973). Radial nerve lesions. Hand, 5, 200-208.
Brand, P. W, Beach, R B., & Thompson, D. E. (1981). Relative tensi
body.
and potential excursion of muscles in the forearm and hand. Journ
Adduct-To bring toward the center of the body.
of Hand Surgery, 6, 209-219.
Burkhalter, W E. (1989). Deep space infections. Hand Clinics,
Arthritis-Inflammation of the joint.
553-559.
Dobyns, J. H. (1984). Pain dysfunction syndrome \IS. reflex sympathe
Arthrodesis-To fuse bones of a joint together and then
dystrophy. American SOciety for Surgery of the Hand, 92.
cancel the joint.
Doyle, J. R, & Blythe, W F. (1975). The finger flexor tendon shea
and pulleys: Anatomy and reconstruction (pp. 81-87). AAO
Chondroma-Cartilagenous mass attached to the skel
Symposium on Tendon Surgery in the Hand. St. Louis: C. V. Mosb
etal system.
Glickel, S. Z. (1988). Hand infections in patients with acquired immun
deficiency syndrome. Journal of Hand Surgery, 13, 770-775.
Collateral Hgament-The ligaments on each side of
Kaplan's functional and surgical anatomy of the hand (2nd ed
the joint to hold bones together and provide stability.
(1984). Philadelphia: J. B. Lippincot.
Kleinert, H. K. (1975). Symposium on tendon surgery in the ha
Contract-To shrink in size.
(p. 91). American Academy of Orthopedic Surgeons. Philadelph
Contracture-A deformity across a joint.
C. V. Mosby.
Kleinert, H. K. & Stormo, A. (1973). Primary repair of flexor tendon
Cyst-A sac inside the tissue-it could happen inside bone
OrthopediC Clinics of North America, 4, 865.
or soft organs.
Koman, L. A. (1985). Diagnostic study of vascular lesions. Hand Clinic
1,217-230.
Distal-Part away from the body.
Lamb, D. W. (1970). Ulnar nerve compression lesions at the wrist a
hand. Hand, 2, 17, 18.
Dorsal flexion-To bend toward the dorsal aspect; to
Lamb, D. W, & Kuczynski, K. (1981). The practice of hand surge
extend.
(1st ed.). Oxford: Blackwell Scientific Publications.
Landsmeer, J. M. F. (1976). Atlas of anatomy of the hand. Edinburg
Extension-Movement away from volar flexion.
'Churchill Livingstone.
Extrinsic-Outside the hand.
Lister, G. D., Belsole, R B., & Kleinert, H. E. (1979). The radial tunn
syndrome. Journal of Hand Surgery, 4, 52-59.
Fascia-Anatomic layer of connective tissue.
Louis, D., & Silva, J. (1979). HerpetiC whitlow; Herpetic infections of t
digits. Journal of Hand Surgery, 4, 90-93.
Fibrous septae-Strands of fibrous tissue that anchor
McFarland G. B., Mayer, J. R, & Hugill, J. V. (1976). Further observati
the skin to bone and deeper structures.
on the anatomy of the ulnar nerve at the wrist. Hand, 8, 115-11
Milford, L. (1988). The hand (3rd ed.). St. Louis: C. V. Mosby.
Flexion-To bend.
Mitchell, S. W (1864). Gunshot wounds, and other injuries of nerve
Flexor-Volar side.
Philadelphia: J. B. Lippincott.
Moss, S. H., & Switzer, H. E. (1983). Radial tunnel syndrome: A spectru
Intrinsic-Inside the hand.
of clinical presentations. Journal of Hand Surgery, 8, 414-420.
Neviaser, R. J. (1978). Closed tendon sheath irrigation for pyogenic flex
Myositis-Inflammation of the muscles.
tenosynovitis. Journal of Hand Surgery, 3, 462-466.
Ossificans-Calcification in tissues other than bone.
Neviaser, R J. Butterfield, W, & Wieche, D. (1972). The puffy hand
drug addiction. Journal of Bone and Joint Surgery, 54A, 629-63
Osteoma-Bone mass attached to the main bone.
Nicolle, F. V., & Woolhouse F. M. (1976). Nerve compression syndrom
of the upper limb. Journal of Trauma, 5, 298-313.
Palmar-Toward the volar aspect; "palmar face of the
O'Brien, T., & Eugene, T. (1988). In D. P. Green (Ed.), Fractures of t
hand."
metacarpals and phalanges in operative hand surgery (2nd ed
New York: Churchill Livingstone.
Pronate-To turn toward the ground (Le., face down).
Patzakis, M., Wilkins, J., & Bassett, R (1987). Surgical findings
Proxima1-Part toward the body or nearer to the body.
clenched-fist injUries. Clinical Orthopaedics and Related Researc
220, 237-240.
Radial-Toward the radius and the thumb.
Phalen, G. S. (1951). Spontaneous compression of the median nerve
the wrist. Journal of the American Medical Association, 145, 112
Supinate-To turn away from the ground (Le., face up).
Snyder, C. (1989). Animal bite wounds. Hand Clinics, 5, 571-590.
Ulnar-Toward the ulna and the little finger.
Steinbrocker, O. (1968). The shoulder-hand syndrome: Present p
spective. Archives of Physical Medicine and Rehabilitation, 4
Volar-Pertaining to the palm; plantar.
388-395.
Sudeck, P. (1900). Veber die acute entztindliche knochenatrophie. Arch
Volar flexion-To bend toward the volar aspect.
Far Klinische Chirurgie, 62, 147-156.
Volar plate-Thick fibrous collagen structure that makes
Taleisnik, J. (1976). The ligaments of the wrist joint. Journal of Ha
Surgery, 1, 110.
up the ligament on the volar aspect of the small joints of the
Tubiana, R, Thomine, J. M., & Mackin, E. (1984). Examination of t
fingers.
hand and upper limb. Philadelphia: W. B. Saunders.
Verdan, C. E. (1964). Practical consideration for primary and seconda
repair in flexor tendon injuries. Surgical Clinics of North Americ
44(4),951-970.
REFERENCES
Anatomy of the hand. (1988). CIBA Clinical Symposium 40 (3 Lampe,
E. W.: Surgical): 1.
CHAPTER 5
•
Asse sment
al n
Robert G. Ross, MPT, CHT
Paul C. LaStayo, MPT, CHT
SUMMARY This chapter reviews the basic physiology of pain and the sensory and
affective dimensions of the patient's pain experience. The chapter then examines
a variety of scales that the physical therapist and occupational therapist can use
to assess pain intensity, pain affect, and pain location in a clinical setting . Many of
the measures are clinically reliable and valid, while others have not been thoroughly
tested. These pain assessment tools are simple and effective and should be used
clinically as part of a complete patient evaluation.
Pain is a common human experience. Typically, it is pain Without effective measurement of pain, a therapist would
that makes someone seek health care (Knapp & Koch, not be able to critically evaluate the treatment tech
1984). In fact, over 80 percent of all office visits to niques used to control it. Therefore, the clinical assess
physicians are by individuals whose primary symptom is ment of pain is not a trivial endeavor. Therapists must
pain (Koch, 1986). Many types of diseases , injuries, and understand the physiologic factors associated with the
medical and surgical procedures are associated with pain perception of pain and the multiple dimensions of an
(Bonica & Benedetti , 1980). Due to the ubiquitous nature individual's pain experience . Coupled with this, a thera
of pain, one would expect that this sensation would be well pist needs a full complement of pain assessment scales
understood. However, thoroughly comprehending its that are cost effective and easily integrated into the clinical
many characteristics remains elusive. It is commonplace setting.
for some patients to have the same type and degree of It is vital for the clinician to accumulate baseline infor
physical pathology yet have different pain experiences. In mation on the patient's pain to help in determining the
addition to physical pathology, many cultural, economic, underlying causes of the pain. Subsequent assessments are
social, demographic, and environmental factors influence also important to determine whether treatment is effective
an individual's perception of pain. An individual's psycho in reducing the patient's pain or whether treatment
logical state, personal history, and situational factors modifications are necessary. Finally, if clinicians use assess
contribute to the quality and quantity of his or her pain ment tools that are we'll founded in research , the scales can
(Turk & Melzack, 1992). be incorporated with other outcome measures, thus im
To understand and adequately treat pain (and its under pacting the quality and cost of rehabilitation (Cole et aI. ,
lying pathology), the clinician needs to measure pain . 1992).
123
- ~ .~ ' . -
124 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
+
THE PHYSIOLOGY OF PAIN ,; . +
SG l < ,h'-cell
It is thought that pain is the result of tissue trauma or
disease that initiates a complex set of chemical and electric
events in the body. When a noxious mechanical, chemical, Small M,e
or thermal stimulus of sufficient intensity occurs, the body
transforms this stimulus into electric activity in sensory
nerve endings . Myelinated A-IJ. and unmyelinated C fibers FIGURE 5-1. Diagram of the revised Melzack and Wall gate cont
are first-order neurons that transmit this electrically coded theory . A~-Large A-~ primary, first-order neuron; AB, C-small A-
nociceptive information from the periphery to the dorsal C primary, first-order neuron; SG-substantia gelatinosa; T-cell-secon
order neuron.
horn of the spinal cord (Fields, 1988). A-IJ. and C fibers
enter the dorsal horn where they synapse with second
order neurons. descending modulation syste m that includes such stru
The second-order, or relay, neurons ascend through the tures as the corticospinal tract in the cortex and medu
spinothalamic tract to the reticular formation of the brain (Wallace, 1992).
stem , periaqueductal gray hypothalamus, and thalamus. In
the thalamus, third-order neurons send axons to the
somatosensory cortex and the limbic system, where the
signal is interpreted as pain (Wallace , 1992). THE DIMENSIONS OF PAIN
During the transmission of nociceptive information from
the spinal cord to these higher centers, the individual 's Even with identifiable neuroanatomic pathways, it is s
perception of pain can be modified (Fields, 1988). The gate unclear why such great variability occurs in how peop
control theory (Melzack & Wall, 1965) explains the inter perceive pain . Clinically, we treat some patients wi
action of the peripheral afferents with a pain modulation severe injuries who experience little pain and others wi
system in the substantia gelatinosa within the gray matter minor trauma who are totally debilitated by pain. The
of the spinal cord . differences may be explained partially by the fact that pa
According to the gate control theory , pain modulation is is unique among all the senses. Pain involves two maj
the result of a balance of large-diameter A-~ neurons components: the sensory component and the affecti
transmitting nonnociceptive information , including touch , component.
proprioception, and pressure, and small A-IJ. and C sensory The sensory component of pain has been described
neurons transmitting nociceptive information. discomfort that can often be identified and located to
A-beta, A-delta, and C neurons ascend into the substan particular part of the body and graded with respect
tia gelatinosa of the spinal cord . There, they synapse with intensity (Fields, 1988). Clinically, we typically define pa
both internuncial neurons in the substantia gelatinosa and intensity by how much a patient hurts (Jensen & Karol
second-order neurons called tract cells (T-cells). These 1992).
T-cells are also termed wide-range dynamic neurons be The affective component of pain, however, is differen
cause they receive input from multiple sources, including This component involves a complex series of behavio
A-beta, A-delta, and C fibers . The substantia gelatinosa that an individual may employ to minimize, escape,
acts as a " gate" or modulator to either inhibit or facilitate terminate a noxious stimulus. It is this affective compone
the transmission of noxious impulses to the T-cells . of pain that may explain the uniquely different wa
The modulation of pain occurs when excessive large individuals perceive pain and the variability of their painf
diameter A-beta fiber activity stimulates the substantia experience. For example, why do some patients require (
gelatinosa. Excitation of the substantia gelatinosa "closes demand!) pain medication when their dentist fills a cavit
the gate" to nociceptive information transmitted by A-delta whereas others need none at all? Why do some wom
and C neurons to the T-cells and to higher centers . cope with the pain of childbirth by requesting medicati
Excessive A-delta and C fibe r activity can inhibit the whereas others use none?
substantia gelatinosa. When this occurs, the "gate opens," Clinically, the most important difference between t
and increased nociceptive information is transmitted to the sensory and affective aspects of pain is the distinctio
T-cells and higher centers , resulting in a more painful between pain detection and pain tolerance (Fields, 1988
experience (Fig. 5-1). Pain can also be influenced by a Pain detection threshold relates to the sensory aspect an
same person at different times . Pain tolerance, on the other scales of pain intensity, including the NRS, VRS, and VAS
hand , is extremely variable as it is related to the affective with 100 patients with a variety of rheumatic diseases
component of pain. Due to its multidimensional nature , no Correlation coefficients were high between pain score
two individuals tolerate pain in the same way (Turk & derived from the different pain scales (Downie et al., 1978)
Kerns, 1983). To effectively assess pain in the clinical In a second study, the effects of analgesics on pathologi
setting, therefore , the therapist must weigh and consider pain in a double-blind study were assessed by the VRS an
both the sensory and affective components of the pain VAS. The comparison of the VRS and the VAS pain ratin
experience. scales by a linear regression gave a highly significan
correlation (r = 0.81, P < 0 .001) (Ohnhaus & Adler
1975).
The clinician must be aware of several important factor
ASSESSING THE SENSORY when evaluating VRS scores. First, VRSs are usually score
COMPONENT/PAIN INTENSITY by assigning a number to each word , according to its ran
on the order of pain intensity. For example, on the 5-poin
Three methods commonly used to assess pain intensity scale in Table 5-1 , "none" would be given a score o
are the Verbal Rating Scale (VRS), the Visual Analogue 0; "mild, " a score of 1; "moderate, " a score of 2; "se
Scale (VAS), and the Numerical Rating Scale (NRS). vere, " a score of 3; and "very severe, " a score of 4. Th
number associated with the adjective is then used for th
patient's score of pain intensity. This information is ordina
Verbal Rating Scale data and must not be interpreted as interval data. That is
the difference between a score of 2 and 3 must not b
The VRS is a list of adjectives that describe different viewed as the same as the difference between 3 and 4. Fo
levels of pain intensity, ranging from no pain to extreme example , during an initial evaluation and subsequen
pain (Table 5-1). VRSs are effective tools for assessing pain treatment of a patient after total knee replacement, th
because they are both valid and reliable . The VRSs are valid patient is given four VRSs over a speCific period o
because they measure what they intend to measure-pain rehabilitation. The scores, using a 5-point VRS as de
intensity. The VRSs are also reliable in that the results of a scribed are "very severe " (4), "severe " (3), " moderate" (2)
VRS for pain intensity are consistent and free from error " mild" (1), and " none" (0). How should these scores b
(Downie et al., 1978; Jensen et al. , 1986; Jensen et al., interpreted? The clinician can say objectively that th
patient's pain intensity has decreased since the start o
treatment. However, these rank scores do not allow fo
interpretation of the magnitude of the differences relate
VERBAL RATING SCALES fOR PAIN by the patient.
INTENSI1Y Some limitations of VRSs are the inability of man
patients to link the proper adjectives to their level of pai
S-Point Scale" IS-Point Scalet intensity and the inability of illiterate (of foreign language
speaking) patients to comprehend the adjectives use
None Extremely weak (Jensen & Karoly, 1992).
Mild Very weak
Moderate Weak
Severe Very mild
Very severe Mild
Very moderate
Numerical Rating Scale
Slightly moderate
Moderate An NRS asks patients to rate their perceived level of pai
Barely strong intensity on a numerical scale from 0 to 10 (an ll-poin
Slightly intense
Strong scale) or 0 to 100 (a 101-point scale). The 0 represents " n
Intense pain" and the 10 or 100, " pain as bad as it could be .
Very strong Figure 5-2 outlines the NRS-l Oland the II -Point Bo
Very intense
Extremely intense Scale.
With this scale, the clinician can obtain valuable baselin
• Reprinted from Grace ly, R. H., McGrath , P., & Dubner, R. (1978). Ratio data and then use the scale at every subsequent treatmen
scales of sensory and affective verbal pain descriptors. Pain , 5, 5-18, or on a weekly basis to monitor whether progress
with kind permission from Elsevier Science B. V , Amsterdam , The
Netherlands. occurring.
t Reprinted from Gracely, R. H. , McGrath, P., & Dubner, R. (1978). Numerical Rating Scales are valid measures of pai
Validity and sensitivity of ratio scales of sensory and affective verbal pain intensity and have demonstrated sensitivity to treatment
descripto rs: Manipulation of affect by diazepam. Pain, 5, 19-29, with
kind permission from Elsevier Science B. V, Amsterdam, The Nether expected to ameliorate pain intensity (Jensen et al ., 1986
lands. Jensen et al. , 1989; Seymour, 1982). Furthermore , thes
126 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
WI-NUMERIC RATING SCALE For example, during an initial evaluation, you cho
the VAS as the scale to determine the patient's perceiv
pain intensity. After hearing a brief description of
Please indicate on the line below the number scale, the patient makes a pencil slash through the 10-
between 0 and 100 that best describes your pain. line at a measured distance of 6.3 cm. This becomes
A zero (0) would mean "no pain," and a one patient's baseline score of pain intensity. Subsequen
hundred (100) would mean "pain as bad as it you can administer and score a new VAS at regu
intervals during the rehabilitation to chart the patie
could be." Please write only one response.
progress.
Visual Analogue Scales provide a high number
response categories. As with the NRS-1 0 1 (with 1
responses), a VAS 's 10-cm line can be measured
increments of millimeters, from 0 to 100 mm, allow
for 101 possible responses. This potentially makes
VAS (and the NRS-101) more sensitive to pain inten
than other measures with more limited responses su
AN ll-POINT BOX SCALE as the VRS 5-point scale. Also, the VAS may be m
sensitive to changes in chronic pain rather than in ac
pain (Carlsson , 1983; McGuire, 1984).
Zero (0) means "no pain," and a ten (10) means
While the VAS is easy to administer, two poten
"the worst pain ever." On the 0 to I 0 scale be sources of error exist. First, some patients, particula
low, put an "X" through the number that best older ones, may have difficulty working with graphic rat
pinpoints your level of pain. than verbal scales of their pain (Jensen et aI., 19
Kremer et aI., 1981). Patients may find it difficult to r
their pain on the VAS because it is hard to understa
10 11 I 2 I 3 141 5 16 17 I 8 I 91101 Therefore, proper supervision by the clinician may
FIGURE 5-2. The 10l-point Numerical Rating Scale and an ll-point crease the chance of error (Jensen et aI., 1986). Inaccur
box scale. measurement of the patient's VAS is another source
error. If the clinician or researcher does choose the VA
thoughtful patient explanation and thorough attention
scales are extremely simple to administer and score, scoring are vital (Jensen & Karoly, 1992).
lending their application to a greater variety of patients
than other scales (Jensen et aI., 1986; Littman et aI. ,
1985). Descriptor Differential Scale
Another method to assess pain intensity is the D
Visual Analogue Scale scriptor Differential Scale (DDS) (Gracely & Kwilo
1988) (Table 5-2). Twelve descriptor items are presen
The VAS is another measure used to assess pain in this scale. Each descriptor is centered over 21 h
intensity and typically consists of a 10- to 15-cm line, with zontal dashes. At the extreme left dash is a minus si
each end anchored by one extreme of perceived pain and at the extreme right dash is a plus sign. Patients
intensity (Fig. 5-3) . The VAS has one end of its line labeled asked to rate the magnitude of their pain in terms of ea
"no pain " and the other, "pain as bad as it could be." The descriptor. If their pain is equal to that of a spec
patient is asked to mark along the line what best approxi descriptor, they place a check mark directly below
mates his or her level of perceived pain intensity. The word. If their pain is greater than the descriptor, th
distance measured from "no pain" to where the patient's place a check to the right, depending on how much m
marks the scale represents the score. intense they rate their pain. If the pain is less than
specific descriptor, they place their check to the left, a
so on. Each descriptor has a rating of intensity on a sc
The visual analogue scale (VAS) of 0 to 20. Thus, 21 responses are possible for e
descriptor.
No pain
I IPain as bad
as it could be
One advantage of the DDS is that it is a multiple-it
measure, as compared with single-item measures. T
may provide more reliable and valid assessments of p
No pain
I t( IPain as bad
as it could be
than single-item scales (Jensen & Karoly, 1992). Since
Score = 6.3 em DDS is of recent development, however, further resea
FIGURE 5-3. The Visual Analogue Scale (VAS) and an example of a is needed to test its reliability among varying pati
compl eted VAS with a score of 6.3. populations.
ing." Patients are asked to select a word that best describe
DESCRIPTOR DIFFERENTIAL SCAlE OF their affective pain (Table 5-3).
PAIN INTENSITY Verbal Rating Scales can be scored by a ranking method
Instructions: Each word represents an amount of sensation. Rate
Weak
Verbal Rating Scales for pain affect have two importan
I
drawbacks. The first is the question of validity. For
(- ) ------------------------------------------------------------------------------------- (+)
measure of pain affect to be valid, it must be distinct from
Strong
I
measures of pain intensity. Recent research with pos
(- ) ----------------------------------------------------------- -------------------------- (+) operative patients (Jensen et aI., 1989) indicates tha
Very mild VRSs designed to measure pain affect were not distinc
I
(- ) -------------------------------------------------------------------------------------- (+)
from measures of pain intensity. It is recommended tha
Extremely intense further research be conducted into the validity of VRS
I
among different patient populations. Second, the patien
(- ) ------------------------------------------------ ------------------------------------ (+)
Very weak
must choose a descriptor even if none of the availabl
I descriptors adequately describe his or her affective re
(-) - - ---------- ----------------------------------------------------------------------- (+) sponse. This may result in a false representation of th
Slightly intense
I pain.
(-) ------------------------------------------------------------------------------------ (+)
Very intense
I
(- ) ------------------------------------------------------------------------------------- (+)
Visual Analogue Scale
Mild
I
Visual Analogue Scales for pain affect are. similar t
(- ) --------------------------------------------------------------------------------------- (+)
Bearable
Clinically, measurement of pain intensity alone is not Distracting
sufficient to establish a complete picture of the patient's Unpleasant
pain experience. It is necessary to measure the affective Uncomfortable
Distressing
dimension as well, The following questions can be better Oppressive
understood by assessing the affective component of pain: Miserable
How unpleasant or upsetting is the patient's pain'? To what Awful
Frightful
extent does the patient's pain disrupt his or her behavior'? Dreadful
Can the patient cope with pain'? Why do such differences Horrible
exist among patients' abilities to cope with pain'? Agonizing
Unbearable
Intolerable
Excruciating
Verbal RatingScale
Reprinted from Gracely, R H. , McGrath, P., & Dubner, R. (1978) . Rat
scales of senso ry and affective verbal pa in descri ptors. Pain, 5, 11 , wi
Verbal Rating Scales for assessing pain affect consist of kind permission from Elsevier Science B. V, Amsterdam , The Nethe
adjectives describing increasing levels of unpleasantness, lands.
128 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
Slightly distressing
describes the pattern of pain being experienced by choos
I
ing words from three, three-word columns with words suc
(- ) ---------------------------------------------------------------------- ---------------- (+)
as " continuous," "intermittent," and "momentary." Wha
Very unpleasant
I activities the patient has found that relieve or exacerbat
(- ) ----------------------- ----------------------- -------------------------------------- (+) the pain are also written down. In part four, the patien
Distressing rates the pain he or she is experiencing on a scale of 0 to
I
(-) --------------------------- ------------------------------- ----- -------------------- (+) 5, with 0 corresponding to "no pain," 1 to "mild," 2 t
Very annoying " discomforting, " 3 to "distressing," 4 to "horrible," and
I
to " excruciating."
(- ) ------------------------------------------------------------------------------------ (+)
Slightly intolerable Three important scores are tabulated from the MPQ
I
1. The descriptors in the first 20 categories are divided
(- ) ---------------- ----------------------------------------------------------------------- (+)
into four groups: 1 through 10, sensory ; 11 throug
Very distressing
! 15, affective ; 16, evaluative; and 17 through 20, mis
(-) -------------------------------------------------------------------------------------- (+) cellaneous . Each descriptor is ranked according to it
Into lerable position in the category . For example, in column one
I
(- ) ------------------------------------------------------------------------------------- (+)
"flickering" would be given a rank of 1, and "quiv
Very into lerable ering," a rank of 2. The sum of the rank values i
I
assigned the Pain Rating Index (PRI).
(- ) --------------------------------------------------------------------------------------- (+)
.. -- "...~
130 UNIT "TWO-COMPONENT ASSESSMENTS OF THE ADULT
I (low) 5 (high)
9 10 II 12
Dull Tender 'fi ring Sickening
Sore Taut Exb:1u!\ling Suffocating
Thi s questionnaire has been designed to lell U~ more about your pain . Four major questi ons Hurting Rasping
w(! ask are: Aching Spliuing
I. Where is your pain? Heavy
2. What dOt!s it fed like?
3. How does it change with time? 13 14 15 16
4. How strong is it ? Fe.arful Puni ,. ; hing Wretched Ann oyi ng
Frightful Gmeling Blinding T rou bll!somc
Terrifying Cruel Mi serable
It is impol1::mt that you tell us how your pain feel s now . Please follow the instructions
Vicious Intense
at thl.! beginning of each pan Killing Unbearable
17 18 19 20
Spreading Tight Cool Nagging
~) R. Mel z:1c k, Oct. 1970 Radiati ng Numb Cold Nauseating
Penetrating Drawing Frc"Czing Agonizing
Piercing Squeezing Dreadful
Tearing Tortllring
3 4
Mild Di scomforting Distressing Horrible Excruciating
To answ~r ~ach que~t ion below, write the numbe r of the most appropriare word in the
space bC5idc the questi on
FIGURE 5-5. The McGill Pain Questionnaire . (Reprinted from Melzack, R. [1975J. The McGill Pain Questionnaire: Major properties and scori
methods Pain, 1, 280,281 , with kind permission from Elsevier Science B. v., Amsterdam, The Netherlands.)
Perhaps one of the most interesting features of the MPQ used to differentiate between trigeminal neuralgia an
is its potential for differentiating among pain syndromes. atypical facial pain. The results showed a correct predictio
One study (Leavitt & Garron, 1980) found different for 90 percent of the patients .
descriptor patterns between two major types of low back The MPQ is the most thorough clinical tool for assessin
pain. The authors found that patients with "organic" a patient's pain. However, the clinician must consid
causes used different patterns of words from patients whether the MPQ is too complex and time consuming fo
whose pain was "functional"-having no physical causes. the patient, since it involves answering 70 separate que
In a more recent study (Melzack et aJ. , 1986), the MPQ was tions each time it is administered (Machin et aI., 1988
PAIN LOCATION, BODY DIAGRAMS,
AND MAPPING
In additionto assessing pain intensity and pain affect, the
location of the patient's pain is an important third dimen
sion of the pain experience. Asking the patient, "Where is
your pain?" may not be sufficient to pinpoint its location.
The pain drawing is a reliable and valid instrument for
assessing the location of pain (Margolis et ai., 1988;
Schwartz & DeGood, 1984). The pain drawing may be an
appropriate assessment of pain location, particularly in the
chronic pain population (Margolis et aI., 1986; Ransford et
al., 1976).
Figure 5-6 is a representative example. Patients are
asked to color or shade areas on the line drawing of a
human body that correspond to areas on their bodies that
are painful. Additional symptoms such as "numbness" and
"pins and needles," as well as more detailed descriptors of
pain such as "deep," "superficial," "burning," "aching,"
and "throbbing," can be denoted by various symbols.
The pain drawing can be used to help establish treatment
programs as well as a measure of treatment outcome.
However, the clinician must consider how the pain drawing
is interpreted. Recently, a scoring method has been
CONCLUSIONS
This chapter has reviewed the physiology of pai
explored the dimensions of the pain experience, an
provided a variety of scales to assess pain intensity, pa
affect, and pain location in the clinical setting. Althoug
every patient's pain experience is unique and influenced b
numerous factors, a thorough pain evaluation shou
include an assessment of pain intensity, pain affect, an
pain location.
FIGURE 5-6. Example of a body diagram. Many of the measures presented are clinically reliab
132 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
and valid, whereas others have not yet been thoroughly Downie, W. w., Leatham, P. A., Rhind, V. M., Wright, v., Branco, J.
& Anderson, J. A. (1978). Studies with pain rating scales. Annals
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tional therapists in the clinical setting. Without question, Feller, I., & Jones, C. A. (1973). Nursing the burned patient. Ann Arb
MI: Braun-Bromfield.
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effectiveness of these assessment tools with a variety of Scale: Applying psychophysical principles to clinical pain assessme
patient populations. Even so, these pain assessment scales Pain, 35, 279-288.
Gracely, R. H., McGrath, P, & Dubner, R. (1978). Validity and sensitiv
are simple and effective tools that can and should be used of ratio scales of sensory and affective verbal pain deSCripto
clinically. Manipulation of affect by diazepam. Pain, 5, 19-29.
Graham, C., Bond, S. S., Gerkousch, M. M., & Cook, M. R. (1980). U
of the McGill Pain Questionnaire in the assessment of pain: Repli
bility and consistency. Pain, 8, 377-387.
Jensen, M. P., & Karoly, P. (1992). Selheport scales and pro
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Reading, A. E., Everitt, B. & Sledmere, C. M. (1982). The McGill Pain Turk, D. C., & Melzack, R. (1992). The measurement of pain and t
Questionnaire: A replication of its construction. British Journal of assessment of people experiencing pain. In D. C. Turk & R. Melza
Clinical Psychology, 21, 339-349. (Eds.), Handbook of pain assessment (pp. 3-12) (1st ed.). New Yo
Reading, A. E. (1989): Testing pain mechanisms in persons in pain. In Guilford Press.
P. D. Wall & R. Melzack (Eds.), The textbook of pain (2nd ed.) Vanderlet K., Andriaensen, H., Carton, H., & Vertommen, H. (198
(pp. 269-280). Edinburgh: Churchill Uvingstone. The McGill Pain QUestionnaire constructed for the Dutch langua
Schwartz, D. P., & DeGood, D. E. (1984). Global appropriateness of pain (MPQ-DV). Preliminary data concerning reliability and validity. Pa
drawings: Blind ratings predict patterns of psychological distress and 30,395-408.
litigation status. Pain, 19,383-388. Wallace, K. G. (1992). The pathophysiology of pain. Critical Ca
Seymour, R. A. (1982). The use of pain scales in assessing the efficacy of Nursing, 15(2), 1-13.
analgesics in post-operative dental pain. European Journal of Clinical Wilke, D. J., Savedras, M. C., Hozemer, W. L, Esler, M. D., & Paul,
Pharmacology, 23, 441-444. M. (1990). Use of the McGill Pain Questionnaire to measure pa
Stein, C., & Mendl, G. (1988). The German counterpart to the McGill A meta-analysis. NurSing Research, 39, 36-41.
Pain Questionnaire, Pain, 32, 251-255.
CHAPTER 6
Gardiovascula'r and
Pulmonary Function
Functional activities require that an individual be able to through disease, deconditioning, or both . In this ins
draw on the cardiovascular and pulmonary systems to a patient may become short of breath when transf
respond to a wide variety of demands. The reserves in these from the bed to a wheelchair. Physical and occupa
systems provide a range from resting to maximal ability. therapists need to assess a patient's endurance an
Physical and occupational therapists are interested in the these assessments to plan treatment programs.
patient's ability to respond to activities of daily living. Improved endurance is one of the most common c
Endurance from this perspective is often submaximal. Most goals for occupational and physical therapists; ho
persons would rarely need to draw on maximal capacities. there are no widely accepted standards for measurin
On the other hand, clinicians frequently encounter indi evaluating endurance in patient populations. This
viduals whose reserves have been severely restricted despite the fact that there are a number of good me
Cl.". "
136 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
or tests that can be used. These methods range from very 150
simple to more complex tests requiring considerable
instrumentation. In this chapter the focus is on measuring 140
cardiovascular, autonomic, and pulmonary responses to ~130
D.
activities; on the clinical applications of these tests; and on III
test interpretation. 2120
Cardiovascular responses include the ability of the heart ~
t
to pump an adequate amount of blood, the distribution of
I
m110
the blood through changing blood pressure, and the
delivery of the blood through the blood vessels. The 100
pulmonary system responds to exercise by increasing the
90' i i i i i i i i i i i i i i
rate and depth of ventilation to provide adequate gas 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 27
exchange. By matching ventilation with the blood perfused Oxygen consumption (mUkglmin)
in the lung, the blood will be adequately oxygenated and FIGURE 6-1. Heart rate compared with increasing oxygen con
carbon dioxide eliminated. Under normal circumstances, tion during exercise for fit and unfit individuals.
the cardiovascular and musculoskeletal systems or both
limit exercise capacity and endurance. The pulmonary
system's capacity is much greater and is not thought to heart rate is determined using a conversion table (Sin
normally limit exercise capacity. & Ehsani, 1985) (Table 6-1). Standardizing the proce
An additional consideration for the clinician is that as much as possible should increase the accuracy of
cardiovascular disease is the most common chronic disease rate assessments. Procedural considerations include n
in American adults (Hahn et aI., 1990). Many patients the position of the measure (e.g., either supine or sitti
referred for physical or occupational therapy have overt or resting heart rates), using a similar time period, avo
latent cardiovascular disease. A number of therapists are using the thumb, and using the same artery. Exc
also involved in cardiac and pulmonary rehabilitation pressure on the carotid artery can cause a reflex slow
programs. These programs require that the therapist the heart rate (White, 1977). Palpated radial and c
recognize the normal as well as the abnormal responses of heart rates are not Significantly different from heart
the systems. recorded with an electrocardiogram (ECG) during ex
Both cardiovascular and pulmonary measures are dis in healthy subjects (Sedlock et a!., 1983).
cussed in this chapter. Measures of heart rate, blood
pressure, and exercise capacity are presented, in addition
to measures of ventilation and oxygen saturation. TABl F. 6-1
The heart rate is probably the easiest means for the 220 82
clinician to monitor cardiovascular responses to activity. 21.0 86
20.0 90
The validity of the heart rate as a cardiovascular measure is 19.0 95
based on the linear relationship between heart rate, the 18.0 100
intensity of aerobic exercise, and the oxygen consumption 17.5 103
17.0 106
(Montoye et a!., 1996). (Fig. 6-1). Resting heart rate is 70 16.5 109
to 75 beats per minute and increases incrementally with 16.0 113
gradually increasing aerobic activity until maximal exercise 15.5 116
15.0 120
capacity is reached. Variability in heart rate responses 14.5 124
between persons is created by age, level of fitness, and 14.0 129
presence or absence of disease. A 65-year-old individual 13.5 133
130 138
who is not fit will have higher submaximal heart rates and 12.5 144
lower maximal heart rates than a fit 65-year-old. 12.0 150
Determining the heart rate by palpating either the radial 11.5 157
11.0 164
or the carotid pulse is the most common means used in 10.5 171
rehabilitation settings. Heart rates are palpated either for a 10.0 180
fixed period of time (i.e., 10, 15, or 60 seconds) and 9.5 189
9.0 200
extrapolated to establish the beats per minute or a given
number of beats are counted (i.e., 30 beats). The latter Time for 30 beats.
method is much easier to use during exercise activities. The tHeart rate per minute.
others are less accurate (Leger & Thivie rge , 1988; Trei
et a!., 1989). Gretebeck and colleagues (1991) report
that a portable heart rate monitor they tested missed f
beats but that its operation was influenced by proximity
a computer or microwave oven, traffic signals , and
driving, among other things. The chest sensor must
snugly attached to the subject and located on a rib or bo
prominence to decrease the possibility of muscle interf
ence. These devices have been found to be reliable duri
assisted ambulation with elderly nursing home reside
(Engelhard et a!., 1993); however, there is little informati
on the use of these devices in clinical settings with vario
patient populations. Clinicians should monitor the acc
racy of these devices for their own application and settin
A more detailed record of heart rate, rhythm, and t
analysis of the ECG can be obtained by using standard EC
monitoring. This is more frequently used in intensive ca
cardiac, or pulmonary rehabilitation. Lead placement
either a bipolar, single-lead system or 10 leads , which p
vides a standard 12-lead ECG (Gamble et a!., 1984) (F
6-3). A bipolar system is less sensitive in detecting ischem
FIGURE 6-2. Heart rate telemetry system (Polar Vantage XL) showing
heart rate wrist monitor and chest belt transmitter. (Courtesy of Polar CIC, ECG changes during exercise than a 12-lead syste
Inc., Port Washington , NY) (Froelicher, 1983; Hanson , 1988); however, a bipolar le
is recommended for exercise testing in pulmonary patie
unless ischemic heart disease is suspected (American As
Many clinical situations do not allow the therapist to ciation of Cardiovascular and Pulmonary Rehabilitatio
palpate the pulse rate during an activity. For example, 1993). Rate determination from the recording is possi
when doing gait training with a patient who requires because of the standard paper speed of the ECG. An EC
contact guarding, the pulse rate may need to be taken heart rate ruler or other methods using the interval betwe
immediately after the exercise stops. Generally, the pulse two R waves provides the rate (Schaman, 1988) (Fig. 6-
should be palpated within 15 seconds of exercise cessation ECG rate determination is accurate as long as interferen
because the pulse begins to decrease rapidly after the from motion artifact is minimized during exercise by prop
activity is stopped (Pollock et a!., 1972). The number of skin preparation and the use of adequate, gelled electrod
beats should be counted for 10 seconds and extrapolated to with secure placement.
the minute value. Although postexercise heart rates are ECG rhythm is the determination of the interval betwe
significantly lower, the difference is only about 4 percent
lower than the heart rate recorded during exercise (Cotton
& Dill, 1935: McCardle et a!., 1969; Sedlock et a!., 1983).
Accuracy is improved if the pulse is located rapidty and the
measure taken as quickly as possible. My colleagues and I
have found intertherapist reliability of palpated carotid
pulses in elderly postoperative patients performing assisted
ambulation to be poor (Protas et a!., 1988)
Portable heart rate telemetry systems can also be used to
record exercise heart rates. These devices are composed
of a chest band with a sensor and a telemetry receiver
that can be worn on the patient's wrist or on the thera
pist (Fig. 6-2). The heart rate can be displayed on the
receiver and stored so that heart rate trends over time can
be recorded. The rate is derived by averaging four beats A B
over a period of time. The higher the heart rate , the shorter FIGURE 6-3 . A, Bipolar lead CM5 has a positive electrode on the f
rib interspace (C5) and the other on the manubrium (M). B, The 10-l
the measurement time. Many devices can also be pro placements for a standard 12-lead electrocardiogram. (A from Froelic
grammed to record the rate at different intervals (e.g., every V. F , et at [19761. A comparison of two-bipola r e lectrocardiograp
15 seconds for 4 hours). Some devices have computer leads to lead V5. Chest, 70. 611-616. B from Gamble . P. , McManus,
Jensen. D., Froelicher. V. [1 9841. A comparison of the standa rd 12-l
interfaces so that a record of heart rates over several hours electrocardiogram to exercise electrode placements Chest, 85, 6
or days can be determined . Some of these devices corre- 622)
138 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
000
o Lf) 0 Lf) 0 The arm should be positioned at the level of the h
C') ~ ~ r-- <D
the cuff wrapped firmly around the arm about
above the antecubital fossa with the arrows on
aligned with the brachial artery. Three cuff si
available-child (13 to 20 cm), adult (17 to 26 c
large adult (32 to 42 cm)-and should be used for d
body sizes. The stethoscope should be placed abo
below the antecubital fossa over the brachial
FIGURE 6-4. Heart rate determination from an electrocardiogram can
be performed by using a rate scale for each heavy line on the tracing.
Palpating the artery before placing the stethosc
enhance accuracy. The cuff should be inflated qU
about 200 mm Hg , or 20 mm Hg above the expecte
each R wave. Normally, the rhythm should be regular with pressure. The air in the cuff should be released slo
equal intetvals between each R wave. Irregular intervals to 3 mm Hg per heartbeat. Systolic pressure is the p
between R waves are referred to as arrhythmias. Variations when the first Korotkoff's sound is heard. The Kor
in rhythm can occur sporadically or at a fairly predictable sounds are created by turbulence when the cuff p
interval, for example, every third or fourth beat. Although goes below the pressure in the brachial artery. D
some arrhythmias can be detected while palpating a pulse pressure can be read at two points as the pressur
as an uneven pulse rate, identification of the arrhythmia cuff is released. The first is the pressure when the
can only be done with an ECG. become muffled, called the fourth phase diastoli
The value of ECG monitoring during activity or exercise pressure, or when the sound disappears com
is one of safety. If a therapist is working with a patient known as the fifth phase diastolic blood pressure.
whose condition is unstable , who is at high risk for the fourth phase measure for accuracy. Because th
arrhythmias or coronary artery disease, or who has a recent be differences between the pressure readings for t
history of cardiovascular disease, detecting abnormal re and left arms, the pressure should consistently b
sponses may indicate the need for a different exercise from either right or left. At least two readings sh
intensity or pace to lessen the cardiovascular stress. averaged, especially if the reading differs by more
Evidence from supervised cardiac rehabilitation programs mm Hg (National Heart Lung and Blood Institute
indicates that the rate of myocardial infarction is 1 per Exercise blood pressures require additional c
300,000 patient-hours, with a mortality rate between 1 in ations. First, since the patient is probably moving
790 ,000 patient-hours of exercise (Van Camp & Peterson , exercise, the arm on which the blood pressure
1986) and 1 in 60,000 participant hours (Haskell, 1994). taken should be as relaxed as possible. A standing
There are no published accounts of myocardia!l infarctions sphygmomanometer is preferred during exercise to
or sudden death during physical or occupational therapy motion artifact. An aneroid manometer (the most c
exercise. This may suggest that medically supervised available clinically) must be regularly calibrated acco
exercise programs are relatively safe with or without ECG the manufacturer's instructions and is more difficul
monitoring even though the risk of a serious event cannot
be eliminated. Clinicians should be aware of a numbe r of
risk classification systems available for detecting individuals TABII : (, 2
at risk for a cardiac event during exercise (American
ClASSIFICATION OF BLOOD PRESSUR
College of Sports Medicine, 1995).
FOR ADULTS·
SystoUe DiastoUe
(nun Hg) (nun Hg) Category
BLOOD PRESSURE
<130 <85 Normal
130-139 85-90 High normal
Resting and exercise measurements of blood pressure, 140-159 90-99 Mild (stage 1) hyper
just as heart rate, are easily monitored by most clinicians. 160- 179 100-109 Moderate (stage 2)
The procedure is a bit more complicated but, if precise, is tension
180-209 110-119 Severe (stage 3) hyp
accurate. Resting blood pressure values are used to deter tension
mine hypertenSion. Table 6-2 provides a classification ?2 10 ?120 Very severe (stage 4
system for blood pressure. tension
fatigue. Cycle ergometers are useful for testing individuals Distances covered in the 6-minute walk test can di
who have gait or balance disturbances such as in Parkin tiate between healthy elderly persons and individua
son's disease or cerebral palsy, whereas arm-crank or New York Heart Association Class II and III heart d
wheelchair ergometers are used in testing individuals who My colleagues and I have found the 5-rhinute distanc
have limited use of the lower extremities, such as patients moderately correlated with peak oxygen consump
with spinal cord injuries (Pitetti et aI. , 1987). Maximal elderly women (Stanley & Protas, 1991) and that
oxygen consumption and maximal heart rate are 20 to 30 walking distances are reliable in elderly postop
percent lower during arm-cranking than treadmill or cycle patients (Protas et aI. , 1988). Nursing home p
ergometry (Pollock & Wilmore , 1990; Protas et al. , 1996). walked significantly farther in the late afternoon than
As a result, there is a poor correlation between maximal morning with a walk test (Englehard et al. , 1993).
values achieved during upper extremity and lower extrem observations suggest that distance walked during
ity testing (McCardle et al., 1991). This makes it difficult to walking tests in several patient populations are va
predict responses to upper extremity exercise from lower reliable if readministered during the same time of day
extremity tests (Protas et aI. , 1996). Exercise programs for 6--4 presents some of the distances and the po
enhancing cardiovascular endurance of the upper extremi clinical meaning of these values.
ties should be based on upper extremity exercise tests. A more useful approach to a walk test for clinicia
Arm-crank activities, however, are less familiar to most be looking at what a clinically significant improv
persons and are more difficult to perform . might be after an exercise intervention. Price and
The test-retest reliability of exercise tests is quite high. ates (1988) reported an increase from 1598 feet to
This is true for treadmills, bicycle ergometers, and arm feet (176 feet) during a 5-minute walk after a 3-
crank ergometers (Bobbert, 1960; Ellestad et al., 1979; exercise program consisting of flexibility and strengt
Fabian et aI., 1975; Pollock et al. , 1976; Protas et aI., exercises and walking to improve endurance in 5 p
1996). Several factors influence the outcomes of exercise with either osteoarthritis or rheumatoid arthritis. A
tests. In elderly persons, higher maximal oxygen consump absolute increase in walking distance of 161 fe
tions are reached with a repeated test; therefore, an elderly reporteci for 47 individuals with osteoarthritis af
person may require more than one exercise test session to 8-week exercise intervention compared with a
become familiar with the test (Thomas et al., 1987). The group not participating in the exercise program (Pe
work increments used in the test changes the maximal et aI., 1993). A change in 5-minute walk distanc
oxygen consumption reached. If the increment is too large elective total hip replacement was reported from
or too small, a lower maximal oxygen consumption occurs 894 feet at 3 months after surgery and 1115 feet
(Buchfuhrer et al., 1983). For example, the increment years of recovery (Laupacis et al. , 1993). Tes
between stage 3 (3.4 mph , 14 percent grade treadmill reliability of a 5-minute walk test with elderly person
elevation) and stage 4 (4.2 mph , 16 percent grade) of a a standard error of the measurement of 135 feet, su
Bruce protocol is the difference between fast walking up a ing that a clinical improvement should be at least 1
slight hill and running up a moderate hill. This may be an to be meaningful and greater than the variability of th
accurate increment for a healthy young person but too A continuous, progressive chair step test has
challenging for a frail elderly person. On the other hand, if developed for exercise-testing frail elderly indi
the increment is too small, it makes the test excessively long (Smith & Gilligan, 1983). Subjects sit comfortably in
(Lipkin et aI., 1986). It is recommended that exercise test and kick up to a target that is 6, 12, or 18 inches hig
increments be individualized so that the test length is 8 to kicking rate should be controlled at l / second, alter
12 minutes (Froelicher, 1994). right and left legs so that there are 30 kicks/second
target is used for a 3-minute period. For the fourth an
stage, the subject continues to kick to the 18-inch
while simultaneously raising the ipsilateral upper extr
CLINICAL TESTS AND OTHER Heart rate is observed for each stage of exercise. T
MEASURES OF EXERCISE INTENSITY
An increase in the physical and occupational therapy
"lABJ f ()- 4
care administered in the home or in sites such as nursing
homes and community health centers has enhanced the PERFORMANCE ON A 5-MINUTE WALK
need for measures of exercise tolerance that do not require TEST FOR MlDDLE-AGm OR OlDER
much equipment. Several tests that are based on walking or SUBdECfS
running for a specific time or distance have been developed
(Balke, 1963; Cooper, 1968; Guyatt et aI. , 1985; Kline et Classification Distance (fee
al., 1987). The timed tests measure the distance covered
when walking or running as fast as possible for 15, 12 , 9 , Average or above >1500
Fair (moderate impairment) 1000-1300
6 , or 5 minutes. Higher distances and faster walking are Poor (severe impairment) <1000
associated with a greater estimate of exercise capacity.
a wide age range (20 to 59) and fitness levels. Physi
RATINGS OF PERCEIVED EXERTION activity status (PA-R) is grossly classified according to
subject's usual activity pattern . The percent body fat mo
Original Scale Revised Scale
is slightly more accurate (r = .81, SEE = 5.35 ml/Kg/m
6 0 Nothing at all than the model based on body mass index (r = .7
7 Very, very light 0.5 Very , very weak SEE = 5.70 ml/kg/min). The equations are as follows
8 1 Very weak
9 Very light 2 Weak
10 3 Moderate Percent Body Fat Model :
11 Fairly light 4 Somewhat strong
12 5 Strong V0 2 peak = 50.513 + 1.589 (PA-R) - 0.289
13 Somewhat hard 6
14 7 Very strong (age) - 0.552 (% fat) + 5.863 (F = 0, M = 1)
15 Hard 8
16 9 Body Mass Index (BMI):
17 Very hard 10 Very, very strong
18 • Maximal
19 Very, very hard V0 2 peak = 56.363 + 1.921 (PA-R) - 0.381
20 (age) - 0.754 (BM!) + 10.987 (F = 0, M = 1)
From Noble , B. J ., Borg , G. A. v., Jacobs, I. , Ceci , R., & Kaiser, P. (1983).
A category ratio perceived exertion scale : Relationship to blood and These equations have not been validated with populatio
muscle lactates and heart rate . Medicine and S cience of Spo rts Exercise, with chronic disabilities seen by physical and occupatio
15, 523-528. therapists, nor with an aging population , but the simplic
may make this an option for estimates of exercise capac
by the therapist. The clinician should keep in mind t
lasts between 6 and 12 minutes. The endpoints are considerable error may occur with these estimates.
volitional fatigue (particularly hip muscle fatigue) , inability
to maintain the pace, knee pain , or 70 percent of
age-predicted heart rate is reached . I have found that many
frail nursing home residents can perform this test safely. RESPIRATORY RATE
Ratings of perceived exertion have been devised for use
in reflecting individual exercise intensity (Borg, 1982; Observing respiratory rate can be easily done by m
Noble et al., 1983). Table 6-5 shows the rating scales used, clinicians. The resting rate in adults is generally 12 to
either a 6 to 20 or a 0 to 10 point scale . An explanation of . breaths per minute . A fuJI breath occurs from the beginn
the scales must be given before the exercise . The patient is of inspiration to the end of expiration . The accuracy of
told that a 6 on the 6 to 20 scale is comparable to walking observation of resting ventilation is enhanced if the pati
at a comfortable pace without noticeable strain, whereas a is unaware that the therapist is noting breathing frequen
20 is the most difficult exercise the patient has experienced (Wetzel et al. , 1985). Breathing frequency increases up
comparable to exercise that cannot be continued without 36 to 46 breaths per minute during maximal exerc
stopping . The ratings can be differentially used to indicate (Astrand 1960; Wasserman & Whipp, 1975). Low
central exertion from the heart and lungs, local muscle maximal breathing rates occur in older individuals (Astra
fatigue , or a combination of both. The scale values are 1960). Exercise breathing frequencies that exceed
strongly correlated with exercise intensity, oxygen con breaths per minute are associated with ventilatory lim
sumption, heart rate, and , for the 0 to 10 scale, blood tion (Wasserman et al., 1994). Breathing frequenc
lactate levels and ventilation . An intensity necessary for a during exercise are most reliably measured with op
cardiorespiratory training effect and a threshold for blood circuit methods. Normal maximal ventilatory breath
lactate accumulation can be achieved at a rating of values during exercise are shown in Table 6-6.
" somewhat hard" or "hard" or between 13 and 16 on the
6 to 20 scale or 4 or 5 on the 0 to 1 0 scale (American
College of Sports Medicine , 1995). This may be an easier TARLE 6-6
method to use than to teach a patient to take his or her
pulse as a means of monitoring exercise intensity. Much of NORMAL MAXIMAL BREAnDNG VALUES
the application of ratings of perceived exertion have been DURING EXERCISE
with healthy normal subjects and individuals with cardio
Value Rate
vascular disease.
One method of nonexercise estimation of maximal Respiratory frequency < 50 breaths per minu
oxygen consumption has been suggested (Jackson et al., Tidal volume (VT) < Inspiratory capacity
1990). The estimate is based on regression equations that Minute ventila tion/ maximal volun 72% ± 15
tary ventilation (VE/MW)
use age, physical activity status, and percent body fat or Breathing reserve (MW - VE max) 38 ± 22 L/ min
body mass index to derive maximal oxygen consumption .
,.- L i4J4!b .. ..
.. . . .,-:. ~ ~ .
'
142 UNIT 1WO-COMPONENT ASSESSMENTS OFTHE ADULT
TABLE 6-7
TIDAL VOLUME AND MINUTE RATING OF DYSPNEA
VENTILATION
DYSPNEA INTENSITY"
Tidal volume is the volume of air breathed in one
I-Mild , noticeable to patient but not to observer
inhalation or exhalation. The resting tidal volume is 0.50 2-Some difficulty, noticeable to observer
ml ± 0.10 ml. Tidal volume can increase to an average of 3-Moderate difficulty, but can continue
1.9 to 2.0 L during maximal exercise (Astrand, 1960). The 4- Severe difficulty, patient cannot continue
absolute value of the maximal tidal volume is related to an DYSPNEA LEVELSt
individual's height , age , and gender. The highest values are O-Able to count to 15 easily (no additional breaths necessary
seen in tall , 20-year-old men . The maximal tidal volume is I-Able to count to 15 but must take one additional breath
between 50 and 55 percent of the vital capacity for men 2-Must take two additional breaths to count to 15
3-Must take three additional breaths to count to 15
and between 45 and 50 percent for women (Cotes, 1975; 4-Unable to count
Spiro et al. , 1974). The maximal tidal volume is generally The patient is asked to inhale normally and then to count out
70 percent of the inspiratory capacity (Wasserman & to 15 over a 7.5- to 8.0-second period . Any shortness of b
can be graded by levels.
Whipp , 1975). Exercise , even at a maximal value, does not
use all of the lung capacity but only uses up to 70 percent "From Hansen, P. (1 988). Clinical exercise testing . In S . N.
of the available capacity. This is another way of looking at Painter, R. R. Pate et al. (Eds.). Resource manual for gUidel
the fact that , under normal circumstances, exercise is exercise testing and prescription (p. 215). Philadelphia: Lea &
t From Physical therapy management of patients with pulmonary
limited by the cardiovascular and musculoskeletal systems , Downey, CA: Ranc hos Los Amigos Med ical Center, Physical T
not the lungs. In individuals with restrictive lung disease the Department.
maximal exercise tidal volume approaches 100 percent of
the inspiratory capacity, suggesting that lung capacity is
implicated in limited exercise when restrictive lung disease ability to respond to the demand and is distinct
is present. tachypnea (rapid breathing) or hyperpnea (increase
The minute ventilation is the product of the tidal volume tilation) (West, 1982). Several methods have bee
times the breathing frequency . Minute ventilation increases scribed for rating the intensity of the dyspnea.
linearly with increasing exercise until the ventilation thresh methods are based on ordinal scales and opera
old is reached, where ventilation increases faster than the definitions of dyspnea intensity (Table 6-7). These
oxygen consumption . During mild to moderate exercise , have not been well validated; however, the clinician
the minute ve ntilation is increased primarily by increasing keep in mind that it is difficult to measure a sub
the tidal volume (the depth of breathing.) With harder sensation.
exercise , increased minute ventilation is accomplished by
increased breathing frequency (Spiro et al. , 1974). The
maximal minute ventilation is between 50 and 80 percent
of the maximal voluntary ventilation (Hansen et al. , 1984). PULMONARY FUNCT:ION TiESTS
The maximal voluntary ventilation is the volume of air that
can be breathed in 12 to 15 seconds. The difference Pulmonary function tests provide information o
between the maximal voluntary ventilation and the maxi functional characteristics of the lung. These tests m
mal exercise minute ventilation reflects the breathing air flow and air flow resistance, lung volumes, an
reserve, or the functional difference between respiratory exchange. For a review of individual tests and me
capacity and what is used during exercise. The breathing ment issues related to pulmonary function tests the
reserve tends to be reduced in individuals with chronic is referred elsewhere (Protas, 1985) .
obstructive lung disease (Bye et al., 1983; Pierce et al. , Pulmonary function tests have limited applicati
1968) . many rehabilitation settings. For instance, rehabilitat
terventions for individuals with chronic lung disease
do not change pulmonary function values of diseased
even though the patient may demonstrate improved
tion. The relationship between pulmonary function
DYSPNEA SCALES sures, walking ability, and submaximal exercise p
mance has been shown to be poor in individual
Dyspnea is a primary symptom that limits exercise in chronic bronchitis (Mungall & Hainesworth, 1979)
individuals with pulmonary or cardiovascular disease . Dys wise , there is no correlation between regional lung
pnea is the subjective sensation of difficulty with breathing. tion clearance as measured by a radiolabeled techniq
The patient often reports being " short of breath " or not maximal expiratory flow during either a cough or a
being able to "catch" his or her breath. Dyspnea occurs expiratory technique (e.g. , " huffing "), viscoscity or e
when the demand for ventilation outstrips the patient's ity of the sputum, and the amount of sputum expect
that maximal expiratory flow during a cough or forced Exercise tests with the observation of pulmonary
expiratory technique and the sputum production provide exchange provide important information about the fu
no guide to the efficacy of secretion clearance in the lung . tional status of an individual patient that cannot be provi
On the other hand, pulmonary function values do improve by pulmonary function tests. In essence, what the clini
in individuals with cystic fibrosis who were hospitalized for wants to know is whether a patient 's ability to function
an acute exacerbation of the disease and who underwent to exercise is limited. Using a standard, incremen
either cycle ergometer exercise and one bronchial hy progressive exercise testing protocol offers the chanc
giene treatment or three bronchial hygiene treatments observe cardiopulmonary responses under controlled
alone each day during the hospital stay (Cerny, 1989). ercise conditions.
Likewise, pulmonary function tests have been used to Several pulmonary measures provide information on
assess treatment outcomes after either inspiratory resis ventilation, gas exchange, and metabolism. The resp
tive muscle training or abdominal weight training in a tory exchange ratio (RER) is the ratio between exha
group of individuals with cervical spinal cord lesions. A carbon dioxide and oxygen consumed (VC0 2/V02)'
7 -week period of training produced significant increases RER is normally 0.70 at rest (less carbon dioxide produ
in pulmonary function values for both treatment inter per unit of oxygen) and increases to greater than 1 : 1 w
ventions, but there were no differences between the two maximal exercise. As exercise increases, the metab
interventions (Derrickson et aI. , 1992). The value of demands increase and the pulmonary system begin
pulmonary function measures to the clinician may depend buffer the blood pH by eliminating more carbon diox
on the type of patients seen, as well as on the inter (Wasserman & Whipp, 1975). Observing the ventila
ventions used. The clinician may need to monitor the equivalents for carbon dioxide and oxygen (mi
pulmonary function of the individual with a high cervical ventilation/carbon dioxide exhaled, VE/VC0 2 , and min
spinal cord lesion more closely than the individual with ventilation/oxygen consumed, VE/V02) gives a nonin
stable, chronic obstructive pulmonary disease. sive, indirect measure of ventilation-perfusion (VA
matching or the physiologic dead space to tidal volu
ratio (VD/VT).
The ventilatory eqUivalents normally decrease until
EXERCISE TESTS ventilatory threshold for VE!VC02 or lactate threshold
VE!V02 (Fig. 6-5) . The VE!VC02 value is normally betw
Although exercise tests have been previously discussed 26 and 30, while the VE!V02 is between 22 and
in this chapter, several additional comments are appropri- (Wasserman et aI., 1994). Elevated ventilatory equival
Name: DOE, JOHN Temp: 23 Pbar: 746 DS: 115 Date: 8/16/
ID: 89-20795-4 Sex: MAge: 57 yr Ht: 157.0cm Wt: 73.5 'kg BSA: 1.74 m
VC02 RER PET02 VE
ml/min mmHg
o ¢
2000.
1800 1.40
VT V02 Max
1600
¢¢
Time Min 5:47 7:37
V02 672 995 ¢ ¢ ¢
RER 0.92 1.21 1400
HR 125 149 1.20
VE 20 44 1200
VEN02 30 44
Pet02 106 122
Watts I: 43 77 1000
800
indicate either hyperventilation or uneven \IA/Q (increased Exercise test mode-Type of equipment used fo
\IDNT). Individuals with obstructive lung disease often have Exercise test protocol-Standard combinati
\IA/Q mismatching and have increased ventilatory equiva intensities, stage progressions, and stage durations.
lent values.
Fifth phase diastolic blood pressure-Blood
sure when the Korotkoff's sounds disappear comp
Fourth phase diastolic blood pressure-B
OXYHEMOGLOBIN SATURATION pressure when the Korotkoff's sounds become m
Hypox.emia-Decreased partial pressure of a
The degree to which arterial blood is oxygenated (partial oxygen.
Because these devices are most useful during exercise, the Pulse oximeters-Noninvasive measure of oxy
clinician should carefully secure the probe to the finger and globin saturation.
should select activities that will reduce motion artifact (cycle Respiratoty ex.change ratio (RER)-Ratio o
ergometer vs. treadmill). The estimates of Sa02 when ume of exhaled carbon dioxide to volume of o
saturation is below 78 percent tend to be inaccurate and consumption.
disease.
Submaximal exercise test-A test which end
predetermined endpOint, such as a heart rate of 150
or with the appearance of significant symptoms.
Body mass index-Weight in kilograms per height in TIdal volume-Volume of air breathed in one inha
meters squared.
or exhalation.
ventilation.
Ventilation threshold-Ventilation increases
Chair step test-A progressive test with four levels or than oxygen consumption. Approximately the poin
stages conducted sitting by kicking to increaSingly higher increasing exercise intensity where more carbon d
targets. The last stage adds reciprocal arm movements with needs to be exhaled.
Pollock, M. L., Bohannon, R L., Cooper, K. H., Ayres, J. J., Ward, A., increasing work rate test for assessing the physiological strai
White, S. R, & Linnerud, A. C. (1976). A comparative analysis of four submaximal exercise. Clinical Science and Molecular Medicine,
protocols for maximal treadmill stress testing. American Heart Jour 191-206.
nal, 92, 39-45. Stanley, R K., & Protas, E. J. (1991). Validity of a walk test in eld
Pollock, M. L., Broida, J., & Kendrick, Z. (1972). Validity of palpation women. Physical Therapy, 71, S73.
technique of heart rate determination and its estimation of training Taylor, S. A., Buskirk, E., & Henschel, A. (1955). Maximal oxygen in
heart rate. Research Quarterly, 43, 77-81. as an objective measure of cardiorespiratory performance. Journa
Pollock, M. L., & Wilmore,J. H. (1990). Exercise in health and disease: Applied Physiology, 8, 73-80.
Evaluation and prescription for prevention and rehabilitation Ternes, W. C. (1994). Cardiac rehabilitation. In E. Hillegass, &
(2nd ed.). Philadelphia: W. B. Saunders. Sadowsky (Eds.), Essentials of cardiopulmonary physical ther
Price, L. G., Hewett, H. J., Kay, D. R, & Minor, M. M. (1988). (pp. 633-675). Philadelphia: W. B. Saunders.
Five-minute walking test of aerobic fitness for people with arthritis. Thomas, S., Cunningham, D. A., Rechnitzer, P. A., Donner, A. P
Arthritis Care and Research, 1, 33-37. Howard, J. H. (1987). Protocols and reliability of maximum oxy
Protas, E. J. (1985). Pulmonary function testing. In J. M. Rothstein (Ed.). uptake in the elderly. Canadian Journal of Sport Science,
Measurement in physical therapy (pp. 229-254). New York: 144-150.
Churchill-Livingstone. Treiber, F. A., Musante, L., Hartdagan, S., Davis, H., et al. (19
Protas, E. J., Cole, J., & Haney, K. (1988). Reliability of the three-minute Validation of a heart rate monitor with children in laboratory and
walk test in elderly post-operative patients. Journal of Cardiopulmo settings. Medicine and Science of Sports and Exercise, 21, 338-3
nary Rehabilitation, 3, 36. Van Camp, S. P., & Peterson, R A. (1986). Cardiovascular complicat
Protas, E. J., Stanley, R K., Jankovic, J., & MacNeill, B. (1996). of outpatient cardiac rehabilitation programs. Journal of Amer
Cardiovascular and metabolic responses to upper and lower extremity Medical Association, 256, 1160-1163.
exercise in men with idiopathic Parkinson's disease. Physica 1Therapy, Ward, A., Ebbeling, C. B., & Ahlquist, L. E. (1995). Indirect method
76,34-40. estimation of aerobic power. In Maud, P. J. & Foster, C. (E
Schaman, J. P. (1988). Basic electrocardiographic analysis. In S. N. Blair, Physiological assessment of human fitness (pp. 47-56) Champa
P. Painter, R R Pate, L. K. Smith, & c. B. Taylor (Eds.), Resource IL: Human Kinetics.
manual for gUidelines for exercise testing and prescription (p. 183). Wasserman, K, Hansen, J. E., Sue, D. S., Sue, D. Y., Whipp, B. J
Philadelphia: Lea & Febiger. Casaburi, R. (1994). Principles of exercise testing (pp. 123-1
Sedlock, D. A., Knowlton, R G., Fitzgerald, P. I., Tahamont, M. V., & Philadelphia: Lea & Febiger.
Schneider, D. A. (1983). Accuracy of subject-palpated carotid pulse Wasserman, K., & Whipp, B. J. (1975). Exercise physiology in health
after exercise. Physician and Sports Medicine, 11, 106-116. disease. American Review of Respiratory Diseases, 112, 219-2
Shephard, R. J. (1987). Physical activity and aging. (2nd ed., pp. West, J. B. (1982). Pulmonary pathophysiology (2nd ed., pp. 52-
81-86). Rockville, MD: Aspen Publishers. Baltimore: Williams & Wilkins.
Sinacore, D. R, & Ehsani, A. A. (1985). Measurements of cardiovascular Wetzel, J., Lunsford, B. R, Peterson, M. J., & Alvarez, S. E. (19
function. In J. Rothstein (Ed.), Measurement in physical therapy (pp. Respiratory rehabilitation of the patient with a spinal cord injury.
255-280). New York: Churchill-Livingstone. Irwin & J. S. Tecklin (Eds.), Cardiopulmonary physical therapy
Skinner, J. S. (1993). Importance of aging for exercise testing and 395-420). St. Louis: C. V. Mosby.
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Spiro, S. c., Juniper, E., Bowman, P., & Edwards, R H. T. (1974). An
CHAPTER 7
Psychosocial Function
SUMMARY Since the early 1800s, the assessment of psychosocial functional per
formance has existed as a philosophical foundation for occupational therapy in
support of "holistic" therapy. Occupational therapy promotes the concept of ho
lism in treatment, operating under the belief that full recovery from illness requires
both physical and psychological treatment. Implementation of the holistic approach
involves the use of a variety of occupational therapy theories and assessment
techniques. Assessment of psychosocial dysfunction may be performed indepen
dently or as a component of a major functional performance evaluation. Psychoso
cial assessment addresses the loss of functional performance in areas of work, play
or leisure, and interpersonal and emotional behavior. Psychosocial dysfunction
can be a result of physical illness or a psychological condition. Treatment approach
is determined by results from the psychosocial functional evaluation.
viduals in the production of various useful goods and 1993; Mosey, 1986; Perry & Bussey, 1984). How
services, which encouraged self~reliance. perform daily routine tasks and the manner in which
Guided by changes in thought by the APA on the etiology socially interact with others and exhibit psycholog
of mental illness, the occupational therapy approach behavior depend on emotional, as well as cogniti
progressed from moral treatment, promoted by Adolph abilities. Recovering from a mental illness or a psycholo
Meyer, psychiatrist and founder of the occupational cal condition is considered by some theorists to be a re
therapy profession, to that of "habit training." Habit of an analytic process that addresses ego functioning a
training was introduced by Eleanor Clarke Slagle, co unconscious actions leading to need fulfillment. A return
founder of the occupational therapy profession. Slagle's cognitive functioning is thought to be a result of the natu
concept of healthy habits included behavior that was healing process of the neurologiC structures of the br
"industrious, hard working, neat, clean, polite, self con combined with environmental adjustments. These neu
trolled, and emotionally restrained." Slagle's treatment logic structures are responsible for functions of the br
approach consisted of training in socially acceptable con referred to as occupational performance compone
duct (Hopkins & Smith, 1993). Because habit training and (American Occupational Therapy Association [AOT
moral treatment neglected the affective and interpersonal 1994). Occupational performance components incl
experiences of clients, both perspectives were eventually three main categories: sensory motor components, cog
abandoned (Mosey, 1986). tive integration components, and psychosocial or psyc
By the mid~ 1900s, the occupational therapy approach logical components (AOTA, 1994).
had progressed from a symptomatology perspective pro According to "Uniform terminology for occupatio
moted by William Rush Dunton, also a cofounder of the therapy" (AOTA, 1994), human function occurs in th
profession, to that of a psychoanalytic and SOciological performance areas: activities of daily living (ADL), wo
orientation. Major proponents of this new perspective and play or leisure activities. The lowest level of functio
were Gail S. Fidler and Jay W. Fidler, coauthors of independence in humans is the ability to perform ba
Introduction to psychiatric occupational therapy (1954) self-care needs. If the primary self-care skills of feedi
and Occupational therapy: A communication process in hygiene, grooming, toileting, and dressing are lost due
psychiatry (1963). The writings and clinical contributions illness or disease, a loss of independent functioning
made by the Fidlers provided a stable treatment foundation occur (AOTA, 1994). Additional performance skills t
in psychiatric occupational therapy that continues to exist can be affected by functional impairment are known
as a component of present-day approaches (Mosey, instrumental activities of daily living (IADL). These IA
1986). are tasks that are vital to total functional independence a
The remainder of this chapter presents three major involve greater complexity in skill and cognitive capabil
psychosocial theories and examples of assessments used in Examples of IADL include following a medication routi
occupational therapy: the analytic perspective of the shopping, preparing a meal, doing housework, usin
Fidlers, the cognitive disability perspective by Claudia telephone, managing money and time, and travel
Allen, and the model of human occupation by Gary (Hopkins & Smith, 1993).
Kielhofner. Finally, occupational therapy assessment of When effective psychosocial function is interrupted
interpersonal skills and emotional behavior is specifically psychiatric or physical illness or by an injury to the bra
addressed. some aspects of the occupational performance com
nents and occupational performance areas may beco
affected. Those areas affected can be revealed throu
psychosocial assessment processes as a part of the to
PSYCHOSOCIAL FUNCTION evaluation. Assessment of performance may be requi
DYSFUNCTION for one or several performance components or areas. T
type of psychosocial assessment performed should
Successful psychosocial functioning requires harmony supported by a frame of reference. The chosen frame
between one's psychological capability and the skills reference would support the underlying purpose of
required to perform routine daily tasks. It is the ability to be assessment process being utilized and would gUide
able to take care of one's daily needs in a responsible and overall treatment approach.
safe manner. An individual may experience the loss of this
harmony for various reasons. Specifically, the effects of a
psychiatric illness, a physical illness or accident, or a
neurologic impairment that affects the function of the brain ACTIVITIES THERAPY AND ANALYTIC
can result in a range of performance difficulties or psycho FRAMES OF REFERENCE
social dysfunction.
Literature from a variety of sources indicates that In occupational therapy, the use of activities a
successful psychosocial functioning involves both emo therapeutic process was first based on the psychoanal
tional and cognitive components (Allen, 1985; Levy, and psychodynamic theoretical perspectives of Sigm
Mahler, and others (Bootzin et aI., 1993; Gallatin, 1982; therapy intervention is based on the disease and med
Mears & Gratchel, 1979). The psychoanalytic theorists model focusing mainly on the pathology and nature of
postulate that abnormal behavior is a result of unconscious mental illness. The pioneers in occupational ther
intrapsychic motivational conflict of a sexual or aggressive treatment using the analytic frames of reference were
nature, a result of an inferiority complex, or problems with Fidlers. Although their work occurred during a time w
object relations involving strong emotional ties. These the medical model defined most health profeSSions, t
intrapsychic conflicts are believed to be established during theoretical approach included emphasis on rehabilita
childhood and are thought to be a result of interpersonal and the resumption of responsibilities within the envir
interactions that at some point involve one or both par ment (Fidler & Fidler, 1963).
ents. The intrapsychic conflicts are thought to be the The Fidlers' theoretical base and function-dysfunc
impetus for how one thinks, feels, or behaves (Bootzin et continuum were similar in focus to that of other psyc
aI., 1993). analytic theorists, e.g., unconscious conflict, interperso
According to the psychoanalytic theory, a return to relations, communication, object relations, and symb
normal function is accomplished by exploring the origin activity. Identification of specific behavior is not poss
and symbolism of the unconscious conflicts and bringing under this frame of reference, since dysfunction is defi
them into conscious awareness, thus developing greater as any unexplainable form of conduct (Bootzin et aI., 19
insight on the part of the individual about the nature of the Gallatin, 1982; Mosey, 1986). Three evaluation catego
behavior. The establishment of insight is thought to occur are offered: the patient's relationship to the therap
through an analytic process that also includes what Freud group, and activity. The clinician is required to interpret
termed "loose association," in which the patient is able to individual's behavior according to the theoretical base
freely express thoughts without judgment from the thera function-dysfunction continuum. Consistent with the
pist to allow repressed content to surface and to achieve sence of specific behavior identification, the process
need fulfillment. The patient's ability to return to the change is also unclear and relegated to examples of h
community at a productive level is thought to occur only occupational therapy as a modality could be included in
after successfully working through the intrapsychic conflict overall treatment process (Mosey, 1986).
(Fidler, 1982). Object relations analysis as a part of the analytic fra
From the psychoanalytic perspective, dysfunctional be of reference is a process based primarily on the contr
havior among patients varies Significantly and does not tions of theorists such as Freud, Jung, Azima, Masl
present in any particular order because dysfunction is Mahler, Fidler and Fidler, Mosey, Naumberg, and oth
considered to be any form of behavior that is unexplain For this reason, the object relations analysis is conside
able. Mosey (1986) identified categories that could serve to be an eclectic process involving the synthesis of sev
as individual function-dysfunction continuums: (1) intra theories. In the object relations analysis, the individu
psychic conflict that is developmental in nature accord relationship and interaction with objects for need gra
ing to Freud; (2) nondevelopmental types of intrapsychic cation and self-actualization are explored. Objects
conflict such as conflicts concerning love, hate, auton defined as people, things, and ideas (Bruce & Borg, 19
omy, trust, aggression, and others; and (3) intrapsychic Mosey, 1970, 1986). Because this framework is eclec
conflict areas involving maladaptive ideas about self or the theoretical base involves several concepts: "nee
others. drives and objects, affect, will, attending and the forma
In occupational therapy, Fidler and Fidler (1963), Fidler of complexes, cognition, and symbolism" (Mosey, 19
(1982), and Mosey (1970, 1973, 1986) have made pp.37-62).
significant therapeutic contributions using the analytic Mosey (1970, p. 232) defines a complex as "a gesta
frames of reference that reflect the treatment of intrapsy repressed affect, energy and intrapsychic content ass
chic conflict through the use of activities and objects. They ated with some type of conflict." Almost any experie
believe that effective treatment in the psychoanalytic can form the nucleus of a complex. The complexes c
process must go beyond logistical dialogue that reveals great Significance, as they serve as indices for the funct
the origin of intrapsychic conflict to include symbolic dysfunction continuum. Examples of the complexes
activities that provide further confirmation of conflict and clude feelings related to inferiority, trust, gratification
engage the patient in attempts to alter maladaptive be needs for safety, and love and self esteem.
havior. According to Mosey (1970, 1973, 1986), thera Assessment Instruments. Projective techniques h
peutic intervention based on the analytic frames of ref been the primary evaluation approach utilized in occu
erence is most effective with patients who possess a high tional therapy with the psychoanalytic treatment conc
degree of cognitive ability. Average intelligence is required (Fidler & Fidler, 1954, 1963; Fidler, 1982; Hemp
for the thinking, problem-solving, and psychological fi 1982; Mosey, 1986). The distinguishing feature of pro
nesse that is necessary for insight that leads to the tive techniques exists in the assignment of a relati
resolution of intrapsychic conflict and need gratifica unstructured task, Le., one that permits an almost un
tion. ited variety of possible responses. To encourage
150 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
the patient's performance for appropriateness of group The aforementioned studies primarily involved obser
placement. Before establishing validity, the interrater reli tion of performance. Findings by Ottenbacher revea
ability for group performances was determined where that cognitive assessment was mainly a result of subject
r = 0.69. The validity for group placement was r = 0.76 determination based on clinical observations and, as su
(Allen, 1985). Group placement categories were limited to it is difficult to verify treatment success (Abreu & Tog
cognitive levels three and four versus five and six. 1987).
A study of schizophrenic subjects from a work rehabili Backman (1994) concluded that because of its nove
tation unit of a psychiatric hospital investigated the rela the RTI has yet to undergo the intense standardizat
tionship between cognitive levels at the time of discharge process necessary to legitimize its claim as a valid a
and social adjustment in the community. While results reliable tool in assessing change in behavior. Backm
revealed a significant but low correlation between cognitive asserts that without standardization, the RTI's greatest
function and pay earnings at the time of discharge is to provide an explanation of a client's ability (or disabil
(r = 0.33, P < 0.05), no comparative information was to perform self-care tasks. Thus, although some stud
available following discharge. Additionally, a very low have provided data in support of the validity and reliabi
correlation between cognitive function and social adjust of the Allen tests, much work is still needed before they c
ment (r = 0.2 to r +0.3) was evident by the end of be accepted by rehabilitation professionals as valid a
3 months following discharge. Similar studies involving reliable assessment tools. Because of the precise descr
schizophrenic subjects, cognitive levels, and community tion inherent in the Allen tests and the favorable attitu
adjustment revealed no conclusive results (Allen, 1985). their author holds toward research, investigations of th
A criterion-related validity study of the ACL was done assessment instruments are continually in progress.
with patients diagnosed with major depression to investi
gate cognitive impairment and its relation to ability to
function. The results revealed Pearson r correlation be
tween all test scores for admission ranging from 0.01 to HUMAN OCCUPATION
0.42 when compared with the ACL (n = 32). The Pearson
r between all test scores and the ACL at discharge ranged Early formal work that identified occupational behav
from 0.05 to 0.24 (n = 32). Other results supported the as a core philosophy in occupational therapy was f
ACL as a sensitive measure of cognitive levels based on the presented by Mary Reilly in her 1961 Eleanor Clarke Sla
significant increase of the mean score from admission to lecture (Reilly, 1962). Other occupational therapy co
discharge; 75% rating at levels four to six and 91% rating tributors to the philosophy of occupational behavior
at levels five to six, respectively, with n = 32 (Allen, 1985). clude Matsutsuyu, Florey, Shannon, Burke, and Ba
Comparisons were made between the studies for both (AOTA, 1986). Over the years, Reilly's development of
schizophrenia and depression, which supported the con occupational behavior model has provided a foundation
struct validity of the ACL. Results revealed significant other perspectives in identifying the relationship betwe
differences, which indicated that the ACL was able to human occupational behavior and occupational thera
differentiate between the two patient populations, identi "A model of human occupation," originally published
fying the schizophrenic patients as being more severely Kielhofner and Burke in 1980, was based on Reilly's wo
impaired in cognitive ability. This earlier model was based on the postulate that hum
A study between disabled and nondisabled adult popu behavior is innate, spontaneous, and occurs because of
lations investigated their similarities and differences in ur.seJo_eW1ore and master the environment (AOT
performance on the ACL. Results also supported construct 1988; Kielhofner, 1985; Miller, 1993). In his most rec
validity, revealing the disabled adults to be functioning at a edition of A model of human occupation: Theory a
lower cognitive level than the nondisabled group. Another application, Kielhofner (1995) revised his theoreti
important finding that is difficult to interpret was that perspective of the human being, basing it on t~enera
demographic data such as social class, level of education, dynamical, and open systems theories. This revised mo
and others were greater indicators of cognitive ability than ~()ntinues to view the human as a system but as one tha
was the ACL (AOTA, 1988). complex and dynamic. The dynamiCal concept is based
Lastly, a study involving subjects with senile dementia the dynamical systems theory relative to the physi
was designed to investigate the relationship between sciences. AccJ)rding to Kielhofner, the complexity a
cognitive disability and the performance of ADL. Results of dynamical aspects of the human system are inherent in
the study revealed that cognitive impairment produces system's ability to readily adjust to varying situations. T
observable limitations in routine task behavior. Results human system's ability to readily adjust is accomplished
further supported validity, revealing a significant relation creating a form of new energy to establish new order
ship between the ACL scores and the scores on the one's life situation. Kielhofner (1995) refers to this proc
Physical Self-Maintenance Scale and the Instrumental as self-organization through behavior. The model cont
Activities of Daily Living Scale in patients with senile ues to incorporate the holistic approach to occupatio
dementia. dysfunction and involves synthesizing other theoreti
The revised model maintains the view of the human performance dysfunction (See Table 7-1). Additional
system consisting of three subsystems that interact with the observation of behavior during the assessment proce
environment. These three subsystems make it possible for provides necessary information about social interacti
the human system to choose based on motivation, to and self-management skills. Table 7-1 is based on Ki
organize, and to produce occupational behavior. Volition is hofner's (1985) assessment "instrument library," whi
the subsystem responsible for motivation, choices, and will. provides descriptive information on 64 instruments. In h
Habituation is the subsystem responsible for organizing instrument library, Kielhofner identifies the contents
behavior into patterns and routines. The mind-body-brain each assessment tool, standardization information, app
performance subsystem is responsible for the skills that cable patient populations, and reference sources. Ea
produce behavior for interacting with the environment assessment tool is matched to the components of t
(Kielhofner, 1985). These three subsystems interact in a model of human occupation to assist the examiner
collaborative manner to influence occupational behavior. effective application of each instrument to the model. In t
The revised model's view of dysfunction is based on revised edition (1995), Kielhofner provides more rece
the inabilily of an individual to organize, choose, or per and expanded assessment information for greater rei
form what David Nelson refers to as occupational forms forcement and support of the model.
(Kielhofner, 1995). Occupational forms are the inherent Assessment Tools and Research Data. The follOwing is
aspects of a task that guide how an individual should partial collection of data on assessment tools common
perform. Occupational forms are "rule-bound sequences used under this model.
of action which are at once coherent, oriented to a
purpose, sustained in collective knowledge, culturally 1. Bay Area Functional Performance Evaluatio
recognizable and named" (Kielhofner, 1995, p. 102). (BaFPE): A task performance and observation rati
Occupational dysfunction exists when an individual is scale used to evaluate dailiz livi~lIsjn~-D
unable to demonstrate behavior that would meet his or her cognitlo!l,. Clff,?cJ,~Cll.1dp~rfQr!l1anf~ (Task-Orient
own needs or the demands of the environment. A number Assessmen~+~cale and Social Interaction Ski
of factors may influence occupational dysfunction, which [SIS) Scale. The SISJs.~ rating scale used to asse
can result in a negative effect on the structures of the patients' socia ehavior based on observation
human system, i.e., the volition, habituation, and mind self-report.
body-brain subsystems. Clinicians attempting to under Interrater reliability was determined through fo
stand occupational dysfunction must determine the restric pairs of occupational therapiSts, each of who
tions placed on each subsystem and the environment as a studied an individual group of 25 patients. The fo
result of dysfunction and understand the collaborative patient groups were titled county inpatient men
effect on the human system. health center, longer term; Veteran's Hospital, acu
Change in occupational behavior is the result of the inpatient; private, for-profit acute psychiatric; a
interaction of the three subsystems with the environment. univerSity-affiliated psychiatric, acute inpatient.
Change is initiated through the volition subsystem based on Interrater reliability was determined for the TO
the client's motivation, sense of efficacy, interests, and and the SIS. Correlations for the TOA are in exce
values. Treatment is directed toward organizing occupa of 0.90, with 80 percent of the correlations equali
tional behavior so that adaptive functioning is restored, or exceeding 0.80 in three of four test groups.
resulting in a balance between the individual's inner needs Another reliability study investigated comparis
and the environmental requirements. Use of the model is of the correlations for items changed in the revis
not limited to a specific patient population (Kielhofner, TOA with those in the original version. Findin
1995). revealed improvement in 10 of the original 16 scal
Assessment Instruments. Assessment of occupational on the TOA Results also showed high correlatio
status involves an interactive analysis of the three sub for the items added to the revised TOA Final
systems as well as environmental constraints. The assess internal consistency among certain subscales with
ment process involves the use of a collection of instruments the TOA was studied. Findings revealed an avera
to gather information on the patient's current occupational correlation of 0.60, with a range of 0.29 to 0.8
status, including occupational performance history data. Interrater reliability correlations for the SIS a
Evaluation results are interpreted and synthesized to deter lower than those for the TOA, with a range of 0.7
mine the client's current occupational status. Because of to 0.79. To improve the validity of the SIS, fi
the constant interaction between the human system and observation situations were substituted for those
the environment, collection and syntheSis of assessment the Original version. With these substitutions, resu
data are ongoing (Kielhofner, 1995). revealed an increase in all correlations, includi
Numerous psychosocial assessment tools are applicable reliability (Asher, 1989; Kielhofner, 1985; William
to the model. Because of the assessment diversity, each & Bloomer, 1987).
PSYCHOSOCIAL ASSESSMENT INSTRUMENTS
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Performance Components a IQ I 02 •
Psychosocial S iriUs and Psychological I I
Components
1. PSYCHOLOGICAL
A. Values
B. Interests
X X
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X I X
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I X
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X X
X X
X X X
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C. Self-conce pt X X X X X X X X X X
2 . SOCIAL
X X X X X X X
c
A. Role performance
B. Social conduct X X X X X X
C. Interpersonal skills I I X I X X X X X X
D. Self-expression X X X X X X X
3. SELF-MANAGEMENT
X X X X X
I A. Coping skills
B. Time management X X X X X X X X
C. Self-control X X X X X
Performance Context
A. TEMPORAL ASPECTS
X X X X X X X X X X X X X X X X X X X X
I 1. Chronological
l 2. Developmental X X X
I 3. life cycle I X X
4. Disability status X
I
B. ENVIRONMENT
X X X
I 1. Physical •
r 2. Social X X X X X
r X X
3. Cultural X X X
Based o n info rmatio n from American Occupatio nal Therapy Association. (1 994). Unifo rm term inology for occupational th e rapy. Ame rican Journal of Occupatio nal Th e rapy, 48(11), 1047-1059;
In Kielhofner, G. (ed) . (1985) model o f human occupatio n. Baltimore, MD ; Williams & Wilkins.
(1989) and Mann and Klyczek (1991), use of the on categorical responses between the test and retes
BaFPE was effective in identifying deficits in the three Findings were based on 124 nondisabled adul
component areas of cognition, performance, and ranging from 18 to 79 years of age. Results wer
affect. In the 1989 study, the authors presented as follows (Asher, 1989; Kielhofner, 1985, 1995
normative data for the total TOA in the form of actual Oakley et aI., 1986):
scores and "z" scores on 144 psychiatric inpatients.
a. Individual roles for a given time category-kapp
A significant difference was identified between pa
estimates ranged from slight to near perfec
tients evaluated within the first 14 days of admission
agreement. Percent agreement was 73 to 97
and those evaluated after more than 14 days of
with an average of 88 percent.
hospitalization. A table of standard scores that re
b. Each role over three time categories-kapp
sulted from the study allows the clinician to compare
estimates ranged from moderate to substantia
information acquired on recently tested patients with
Percent agreement was 77 to 93, with an averag
the normative data provided by Mann and associates
of 87 percent.
(1989). Data comparison may reveal a need for or a
c. Each time category for the 10 roles assessed
lack of treatment in a certain component area.
kappa estimates were substantial for present tim
In the study by Mann and Klyczek (1991), results
and moderate for past and future. Percent agree
from the 1989 study were used to determine norma
ment averaged 87 across time categories.
tive data for 266 psychiatric inpatients. Study results
d. Age of subjects (two age groups) and time betwee
revealed standard scores for cognitive, performance,
test administration-kappa estimates were mod
and affective components for each task; each param
erate to substantial. Percent agreement was 7
eter of the cognitive, performance, and affective
to 95.
components; and each total task summary score.
e. Valuation of each role-kappa estimates wer
Standard scores were presented in table form for
moderate. Percent agreement was 79.
comparing and reporting results of testing patients.
f. Reportedly has content validity founded on litera
Data comparison may reveal a need for treatment in
ture review.
either a component area or in a specific parameter. In
summary, Mann and coworkers (1989) and Mann The Role Checklist is available through the Mod
and K1yczek (1991) concluded that the BaFPE is a of Human Occupation Clearinghouse.
valid tool to be used in identifying performance diffi 4. Self-Esteem Scale: A self-report scale that measure
culties of psychiatric inpatients. They further suggest feelings about oneself, abilities, and accomplish
that for best results, clinicians should establish local ments. Primarily used with adolescents but has als
norms and standard scores for comparison based on had a history of use with elderly clients. Reliabilit
test results from their own inpatient environment. based on Guttman scale, with correlations of 0.92 fo
The BaFPE is available through Maddak, Inc., reprodUcibility and 0.72 for scalability. Test-rete
Pequannock, NJ. reliability was 0.85 (Asher, 1989; Kielhofner, 1985
2. Occupational Case Analysis Interuiew and Rating The Self-Esteem Scale is available through Prince
&ale (OCAIRS): A semistructured interview and ton University Press, Princeton, NJ.
rating scale designed for data gathering, analysis, and 5. Occupational Functioning Tool (renamed Assess
reporting a client's occupational adaptation. Results ment of Occupational Functioning, 1995): A
of the interrater reliability study revealed 57 percent interview and observation screening tool for assess
of the components with correlation coefficients rang ing the three subsystems; volition, habituation, an
ing between 0.50 and 0.80; 36 percent had lower performance. Primary use is with institutionalize
than 0.50, and 7 percent had in excess of 0.80 clients. Standardization results were based on 4
(Kaplan & Kielhofner, 1989). institutionalized older adults. Reliability measure
Investigation of content validity revealed 81.8 revealed interrater correlation coefficients of 0.48 t
percent to 100 percent correct matches between the 0.65, with 0.78 as a total score. Test-retest coeff
interview questions and 9 of the 11 model compo cients ranged from 0.70 to 0.90 based on Pearso
nents (Kielhofner, 1985). product-moment correlations (Kielhofner, 1985
The OCAIRS is available through the Model of 1995).
Human Occupation Clearinghouse, Department Criterion-related validity moderately supported b
of Occupational Therapy, M/C 811, University of significant correlations of - 0.42 to - 0.84 when re
Illinois at Chicago. lated to similar screening tools (Kielhofner, 1985
3. Role Checklist: A self-report checklist for adult 1995).
psychiatric patients designed to assess productive The Assessment of Occupational Functioning
roles in life by indicating their perception of their available through the Model of Human Occupatio
past, present, and future roles. Reliability is based on Clearing H o u s e . . .
156 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
6. Assessment of Communication and Interaction social interaction: the Interpersonal Skill Survey and
Skills (ACIS): an observation assessment tool de Group Interaction Skill Survey. Both are used to co
signed to measure social performance in personal data while observing clients in an evaluation group set
communication and group interactions. Studies re The Interpersonal Skill Survey is a six-item forma
vealed (Kielhofner, 1995) modest interrater relia interaction and affective behaviors that are rated on a s
bility, indicating a need for further refinement of of 1 to 4. The rating results are followed by an .inter
the tool. Subsequent studies for construct validity, process involving a discussion between the client and
based on revision of the tool, revealed that the therapist to review and clarify any discrepancies betw
assessment items do form a single unidimensional the therapist's and the client's observations.
scale (Kielhofner). The Group Interaction Skill Survey is a for
The ACIS is available through the Model of Human arranged according to group types: parallel, pro
Occupation Clearinghouse. egocentric-cooperative, cooperative, and mature gro
7. Fisher's Assessment of Motor and Process Skills The survey is used as a guide to determine the client's
(AMPS): An observation assessment tool designed to of social interaction development. Scoring involves ch
evaluate quality and effectiveness (not impairment) of ing off behaviors exhibited by the client in the evalua
motor and process performance skills while the setting. The completion of the survey is followed by
individual performs IADL, e.g., meal preparation, interview process to highlight the client's successes an
driving (Kielhofner, 1995). discuss social interaction behaviors that may not have b
Studies support the reliability and validity of the mastered.
AMPS. Construct validity, test internal consistency, Mosey (1986) also provides the clinician with evalua
score stability over time, and interrater reliability have tools and guidelines to assess social interaction in life t
all been supported (Kielhofner, 1995). A major for work, school, family relations, and play or leisure. E
advantage of the AMPS is that test task choice is survey lists behaviors typical to the life task area and ca
available to the patients. utilized as a preassessment tool to record responses b
.
t.
Administration of the AMPS requires formal train on an interview with the client, family member, or c
Ii ing. Training is available through the AMPS Project, giver, or the survey may be used as a guide in sco
Occupational Therapy Building, Colorado State Uni observed behavior during evaluation or in simulated t
.' versity, Fort Collins, CO. ment situations.
Fidler addresses the evaluation of interpersonal skil
the context of a Life-style Performance Profile (AO
1988). The profile identifies and organizes performa
INTERPERSONAL SKII.LS AND skills and deficits according to the client's sociq<:::u
EMOTIONAL BEHAVIOR envirQI1JIlent. The profile can also provide firtormatio
potential resources for impr:ovil}g_sKins~can--iden
Interpersonal skills are defined as the ability to use factors that may interfere- ~ith skill development or
verbal and nonverbal communication to interact with gression. By creating a profile about the client'~J}i.st
others in casual and formally sustained relationships in performance including all components and lite task ar
individual and group settings (AOTA, 1994; Mosey, 1986). a-distinct pattern of behavior is revealed regarding so
Interpersonal skills involve both social interaction and interaction in work, school, play or leisure, and fa
emotional behavior. The ability to successfully interact in relationships.
society and process emotions is perhaps the greatest Emotional behavior as defined by the AOTA's "
challenge for humans. Social interaction and emotional form terminology for occupational therapy" (1994
control are psychosocial daily life tasks that are interwoven self-management and includes coping skills and
into major daily life tasks of work, school, leisure, and control. The ability to maintain emotional control w
family relations, as well as numerous other routine activities faced with stressful events depends on coping skills de
(AOTA, 1994). oped during childhood and carried forward into adulth
Interpersonal skill dysfunction results in an inability to Theorists on emotional development agree that c
effectively communicate and interact with others in various hood is the point of origin; however, they disagree on
settings. Mosey (1986) describes the communication and primary source of emotional behavior (Bee, 1985; Per
interaction as processes that involve skills and abilities in Bussey, 1984). Bee (1985) identified three theore
initiating and responding to sustained verbal exchanges, viewpoints on the development of emotional behavior
assertiveness, expression of ideas and feelings, awareness temperamen t theory operates on the belief that emoti
of others' needs and feelings, compromise and negotia behavior is of a biologic origin and that individuals are b
tion, and the ability to take part in cooperative and with certain characteristics that influence how they inte
competitive events. Assessment of interpersonal skill dys with the environment and how others may respond.
function should reflect the appropriate life task area(s) psychoanalytic theorists hypothesized that emoti
affected. Mosey (1986) identified two methods of assessing behavior is influenced by the three personality structu
influenced by social demands that occurred throughout life areas: 88 percent did not have difficulty understa
in stages of development. Lastly, social theorists postulate ing the FlM, 97 percent believed there were
that one's emotional behavior is learned through observa unnecessary items in the FlM, and 83 perc
tion of modeled behaviors. believed there was not a need for additional ite
The occupational therapy evaluation and treatment (Developed by The Center for Functional Assessm
process strongly supports the social theorist's position on Research, State University of New York at Buff
learned behavior. Occupational therapy assessment of from The Center for Functional Assessment
emotional behavior is typically performed as a component search, 1990.)
of an overall functional evaluation, Le., observation of
social interaction, frustration tolerance, problem solving,
judgment, and overall coping relative to the productive use
of defense mechanisms. The following are examples of SUMMARY
assessment tools commonly used in determining an indi
vidual's emotional capability: This chapter is by no means conclusive regarding
1. AAMD Adaptive Behavior Scale: Evaluation of the psychosocial assessment tools available in occupatio
subject's effectiveness in coping with environmental therapy. What has been provided is a manner in which
demands through behavioral adaptation. Twenty assessment process can be approached based on a cho
four areas of' social and personal behavior are theoretical frame of reference. Interpersonal skills
addressed. Reliability measures revealed interrater emotional behavior have been addressed to identify th
reliability correlations of 0.86 for part one (psycho manifestation in the psychosocial assessment process
social, sensory-motor, and daily living skills) and 0.57 occupational therapy and to provide examples of ins
for part two (maladaptive behaviors, behavior disor ments commonly used to determine the degree
ders, and medication). (Developed by the American dysfunction.
Association on Mental Deficiency, Washington DC;
from Asher, 1989; Moyer, 1981.)
2. Bay Area Functional Performance Evaluation
(BaFPE): Includes the SIS, which rates behavior in
seven parameters. Behavioral information can be Cooperative group-A homogeneous non-ta
acquired through an interview process with a care oriented group whose aim is to promote sharing
giver or by actual observation of performance. Al thoughts and feelings and acceptance among its membe
though the greatest emphasis is on social interaction,
Egocentric cooperative group-A task-orien
the seven-item scale also addresses related emotional
group whose aim is to promote self-esteem throu
aspects of behavior. Refer to the section on model
activities that emphasize cooperation, competition, le
of human occupation for research data related to
ership, and other group roles.
the SIS. (Developed by Bloomer & Williams; from
Maddak Inc., Pequannock, NJ.) HoHstic-Relates to the "whole" and assumes the wh
3. Emotions Profile Index: A brief, standardized per is greater than the sum of its parts. In occupational thera
sonality test for adolescents and adults. The profile treating the whole of the patient, both the phys
index provides information about various basic traits condition and the associated psychosocial situations.
and conflicts. Literature search did not reveal re Loose association-A type of thinking that is typica
search data on this index. (Developed by unknown schizophrenic patients in which they may ramble or fre
source; from Moyer, 1981.) express their thoughts during therapy.
4. Functional Independence Measure (FIM): A seven Medical JDOdel-Patient treatment that is based on
level scale assessment tool ranging from independent nature of the disease and considers the disease to b
to dependent behavior that is designed to measure separate entity from the patient. Treatment does
disability regardless of the actual diagnosis. The FlM consider the patient's functional capabilities.
measures self-care, sphincter control, mobility, loco
Parallel group-An activity group in which interact
motion, communication, and social cognition. Al
is not required.
The construct of body image is a complex one (Cash & Problems can result from neural lesions, which result
Pruzinsky, 1990; Tiemersma, 1989). It incorporates both bodily inattention, or in misperception of body sha
the neural body scheme, which is subject to disturbance size , or relationships. They can result from actual physi
from lesions, and its psychological representation formed bodily impairments such as loss of a limb, or fr
through cultural and environmental input, also subject to psychosocial influences affecting the mental represen
disturbance. This latter aspect of body image includes a tion of some aspect of the body. Body image is a holi
perceptual component involving estimation of the real construct and seldom is encountered without psycholo
body shape and size, as well as its attitudinal aspect cal and physical manifestations. Consequently, asse
pertaining to knowledge of and feelings about the body. Of ment of body image has been addressed by both n
particular importance to occupational therapy and to rology and psychology . Because of their relation to th
physical therapy is the notion that our body image disciplines, applied fields such as occupational thera
incorporates images of the function of the body and its have also been concerned with body image instrum
parts necessary for skilled performance, images dependent tation. Typically, several instruments addreSSing the ma
on both its psychological and physical components (Cash aspects of body image are needed for adequate asse
& Pruzinsky, 1990; Keeton et al. , 1990). A social aspect ment (Butters & Cash, 1987; Lacey & Birtchnell, 19
to the body image also exists and is researched by Thompson, 1990; Van Deusen, 1993).
addreSSing subjects' ideal body image (Fallon & Rozin,
1985; Keeton et al., 1990). It is assumed that the ideal
body image is based on cultural influences .
Since body image is complex and many faceted, it HISTORY
logically follows that disturbances are diverse. Body image
disturbance refers to problems in the integration of the According to Tiemersma (1989), body image is a v
neural body scheme and its psychosocial representation. old construct. The notion of body image extends back
1
- ~ --~
-- - -
160 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
ancient and medieval times, and actual medical records of assessment for body image disturbances associated
body image phenomena date from the 16th century. In neural lesions. The sociocultural model and the sch
clinical neurology during the first part of the 20th century, model in cognitive psychology can be useful guide
the notion was elaborated and popularized through the assessment procedures for body image disturbance re
works of Head and Schilder (cited in Tiemersma, 1989). to problems with mental representation.
Head defined the neural body scheme as a dynamic schema
resulting from past postures and movements. Schilder
emphasized the mental image from psychosocial and Neurophysiologic Theory
psychoanalytic perspectives.
Following the period of classical definition of body Tiemersma (1989) described a neurophysiologic e
scheme in clinical neurology, interest in this area declined nation for body scheme. The Finger Localization
until the introduction of assessment tools by psychologists (Benton et aL, 1994) and the Behavioural Inattention
in the 1950s. This was the time of development of body (Bin (Wilson et aL, 1987a) are sample assessments re
image projective tests and attitude scales and the refine to neurophysiologic theory. According to Tieme
ment of neurologic evaluation. (1989), the muscle spindles, tendon organs, joint,
Although body image concepts were compatible early in cutaneous receptors are the sensory receptors of parti
the century with those of Gestalt psychology, the midcen~ importance to the body scheme. Information from t
tury work of Fisher and Cleveland (cited in Tiemersma, receptors is transmitted by means of afferent tracts to
1989) was the first major body image research from the somatic sensory association area of the parietal corte
field of psychology. Their primary work, in which body primary site for body scheme function. The brain has m
boundary relationships were focal, was strongly influenced somatosensory maps, each specialized for a speCific
by the psychoanalytic theorists. Assessment was through dality, such as joint position. Somatosensory processi
projective technique (Fisher, 1990). However, Fisher re by means of a complex network within the central ner
cently advocated the multidimensional complexity of the system, which is considered very plastic since damag
body image construct, necessitating a diversity of measur the nervous system results in much cortical reorganiza
ing tools. His explanation of the vast amount of body image From this perspective, body scheme can be viewed a
research in psychology over the decades was that' 'Human function of patterns of excitation in the brain. The li
identity cannot be separated from its somatic headquarters system is associated with affective aspects of body im
in the world. How persons feel about their somatic base and the motor system with images of bodily performa
takes on mediating significance in most situations" (p. 18). Although he has described body scheme in term
DUring the 1970s, interest in body image research neuroscience, Tiemersma's position on body image
temporarily declined for a number of reasons, such as the no means limited to this domain.
nebulousness of its definition and incompatibility with The position of Lautenbacher and colleagues (199
popular theoretical positions. The widespread concern not inconsistent with that of Tiemersma (1989). T
about anorexia nervosa brought a resurgence of body authors believe there is strong agreement that the m
image research by the late 1970s and 1980s. This was a representative of the body is dependent on the integr
period in which body image test development flourished of sensory stimuli. The first stage of central nervous sy
(Thompson, 1990). processing (in sensory cortical areas) results in many
In the current era, deliberate attempts have been made schemes, schemes that can be affected by disturbanc
to integrate approaches from neurology and psychology sensory input. If the discrepancy among these m
(Lautenbacher et aI., 1993; Tiemersma, 1989). Body schemes is not too great, they become integrated (in
image authority, Thompson, writing in 1990, predicted temporal lobes) into one "body selL" Like Tiemer
" ... an expanding role into the 1990s for the researcher Lautenbacher and associates consider the body self pl
and clinician interested in the assessment ... of body image and integration subject to cognitive and affective
disturbance" (p. xiv). Appropriately, at the present time, ences. Final integration of the body self is dependent o
the creation of new tests has declined, but refinement of old activity of widespread cortical and subcortical areas.
tests has not.
Sociocultural Model
BODY IMAGE MODELS Many authors, including Cash and Pruzinsky (19
Lacey and Birtchnell (1986), and Van Deusen (1993),
Many theories concerning body image exist (Tiem recognized the influence of culture on body image. H
ersma, 1989; Thompson, 1990). Several theoretical ever, Thompson (1990) emphasized the importance o
positions are of particular relevance to assessment in sociocultural body image modeL Inherent in the soci
occupational therapy and physical therapy. The neuro tural model is the assumption that current societal
physiologic explanation of body scheme is fundamental to dards are the major factor relating to body image di
our society: KINDS OF BODY IMAGE
1. Physical attractiveness is highly valued DISTURBANCES
2. Thinness equals beauty, and obesity is negatively
valued Lacey and Birtchnell (1986) have categorized b
3. Beauty equals goodness so that thinness is also image disturbances into four groups: 1) those due
equated with goodness neurologic disorder, 2) those following acute dismemb
4. Society encourages women's preoccupation with the ment, 3) those associated with actual physical proble
pursuit of beauty and 4) those accompanying psychiatric diagnosis
5. Society reinforces the bodily alteration of women to without physical disability. Van Deusen (1993) used th
enhance society's notion of beauty groups to organize body image disturbances likely to
6. A build emphasizing upper extremity musculature is encountered in patients treated by rehabilitation spec
the ideal masculine body ists. Although assessment tools may be useful for m
7. Men show less body image disturbance than do than one type of disturbance, often instruments have d
women related to only one category.
Assessments relating to this sociocultural model include
those dealing with ideal size and shape relative to the
personally known or .felt body image. An example of this Neurologic Disorder
kind of instrument is the Body Image Assessment devel
oped by Williamson (1990). Lesions of the central nervous system leading to
paired neurologic function can disturb the body schem
Under these conditions, psychosocial factors may add
Model From Psychology the body image disturbance beyond that from the neu
logically impaired scheme. Cumming (1988) described
Another model of theoretical interest for assessment of various body scheme disturbances from neurologic di
body image disturbance is the schema organization in ders. Many problems have been observed, including 1)
cognitive psychology, especially when integrated with the nial of paralysis or paresis of the involved limbs, 2) inab
ecologic perspective. In general, it is agreed that schemata to identify body parts or relationships, 3) a special condit
are cognitive structures that organize prior, guide new, and of inability to identify parts, namely finger agnosia, 4)
retrieve stored information (Safran & Greenberg, 1986). ability to distinguish right from left on one's own body or
Paradoxically, with the advent of cognitive psychology in a confronting body, 5) disturbed use of body pa
the 1970s, body image research decreased (Tiemersma, particularly in writing, 6) perception of body parts
1989). Probable contributing factors were the close ties of abnormally large or small, 7) inability to identify the are
body image research with the gestalt and psychoanalytic body part touched, 8) inattention to the stimulated b
views of psychology. side contralateral to the brain lesion, 9) extinction of stim
However, the schema model in cognitive psychology to the involved side when Simultaneously administered
derives quite basically from the body image writings of the uninvolved side, and 10) inability to use body part
Sir Henry Head, which influenced the ideas about schema address the hemispace contralateral to the side of br
elaborated by Bartlett, by Piaget, and by Neisser (Safran & lesion.
Greenberg, 1986; Tiemersma, 1989). Furthermore, it has Patients treated in rehabilitation facilities who may h
at least a limited theoretical link with cognitive behavioral one or more of these neurologic body scheme disorders
therapy, a major current treatment approach for body those challenged by stroke, by traumatic head injury,
image disturbances (Butters & Cash, 1987; Freedman, substance abuse, by brain tumor, or by other patholo
1990; Van Deusen, 1993). conditions affecting the central nervous system. B
Safran and Greenberg (1986) believe that the work of psychologists and neurologists have developed many
Neisser in particular integrates the two positions in cogni struments for assessment of body image disturbances
tive psychology with value for therapy. According to their this category (Van Deusen, 1993).
perspective, Neisser combined the best of the information
processing position, the idea of schemata, with the eco
logic position, which emphasizes environmental interac ACIIte Dismemberment
tion. Neisser maintained that we both act on and are acted
on by the environment. Because of this action, internal This category of body scheme disorders includes th
schemata experience ongoing revision. The Feelings of patients who experience the phantom phenomena foll
Fatness Questionnaire (FOFQ) (Roth & Armstrong, 1993) ing amputation of a body part. The temporary phant
is a particularly good example of an assessment tool sensation of the missing part is almost universal after a
congruent with this theoretical perspective. limb loss. Phantom sensation is attributable to contin
162 UNIT 1WO-COMPONE~T ASSESSMENTS OF THE ADULT
existence of the neurologic scheme after loss of the actual Illustrative Cases
physical part. Because of interactions of central nervous
system mechanisms and loss of the sensory receptors of the Occupational therapists and physical therapists s
missing part, phantom pain may occur but, as yet, is not address intervention only for body image disturb
fully understood. A logical estimate is that more than 60% Rather, enhanced or improved body image is one
of adults experience phantom pain follOwing limb ampu complex of rehabilitation goals. The illustrative ca
tation. Although phantom sensation may actually aid ports presented here are hypothetical, particularly i
rehabilitation by providing the trainee with a complete they address only one facet of the total assessment pr
body perception, phantom pain must be considered a in the rehabilitation setting. An example is given
disturbance of body image that can greatly interfere with patient requiring body image assessment for neural sc
performance. Phantom pain can also occur after breast disturbance and for a patient requiring body image a
surgery or spinal cord injury but has not been as extensively ment for disturbance of psychological representatio
studied as for limbs. Phantom pain can be assessed in Neurologic Disorder: Neural Scheme Disturbance. M
rehabilitation settings by use of instruments designed to is a 52-year-old African-American homemanager m
evaluate chronic pain in relation to functional activity to an executive in Pasadena, California. She is a
(Van Deusen, 1993). hemisphere stroke survivor with mild hemiparesis
left upper and lower extremities. Mrs. B. is in the re
tation unit being assessed by the occupational therapi
physical therapist, and the language pathologist
Actual Physical Problem language pathologist has found no speech impair
While evaluating Mrs. B. 's status in activities of daily
Adults who are challenged by physical disabilities such (ADL), the therapists found her unable to respond to s
as bums or rheumatoid arthritis may be susceptible to presented to her left. The BIT (described in the Instr
body image disturbances. Persons in this category may tation section) was administered, and scores confirm
L.
I'"
be baSically well adjusted, but because of unfavorable presence of severe left side neglect. Major obje
societal input can suffer body image disturbances in the incorporated into Mrs. B.'s rehabilitation program
1.1
process of adjusting their image to their new physical were for enhanced left body side awareness an
reality. The body image disturbance in this category is improved function with objects to her left. Although M
secondary to the physical problem (Lacey & Birtchnell, anticipates being able to afford weekly assistance wi
1986). Attitudinal body image assessment is necessary for home chores when discharged, improved body sche
this category of disturbances since disturbances would be vital for her return to her full role as a homemanage
in the psychological representative aspect of the body conservative residential setting.
image. PhYSical Problem: Disturbance of Psychological R
sentation. J. T. is a 23-year-old white man severely b
in a camping accident. The involved areas include m
the shoulder and neck area and lower face. H
Psychiatric Diagnosis undergone two surgeries as well as rehabilitation
well-known institution. His girlfriend of 2 years be
Body image disturbances are a condition of many involved with another man a month after J. T.'s acc
psychiatric diagnoses and problems. Persons with distur His parents are divorced. He lives with his mother, w
bances in this category have no visible physical problem to a waitress at a local chain restaurant, and J. T
account for the body image disturbance. essentially no contact with his father. He was enrol
Disturbances vary widely from that of the person with a general education courses at the community college
normal nose inSisting on surgery to correct the deformity to time of his accident. Since his discharge from the re
the major body image distortions of the person challenged tation center, J. T. has been unwilling to resume c
by schizophrenia (Lacey & Birtchnell, 1986). Although work. He applied for two retail sales positions an
many disturbances in this category are seldom encountered rejected. He has recently been admitted to a work ha
by occupational and physical therapists, some, such as the ing program for assessment by occupational therap
attitudinal body image problem of the youth with bulimia physical therapy. The initial impression of the ther
nervosa, may be seen. Others may be encountered by was that J. T. has the physical capacity for many ki
occupational therapists in psychiatric settings where as employment. Several sarcastic comments by J. T. abo
sessment would involve projective techniques or psychiat appearance led to administration of an attitudinal
ric interviews, making it beyond the scope of this chapter. image self-report questionnaire. Results indicated s
Assessment for this category involves instrumentation body image disturbance. The therapists recommen
addressing the psychological representation of the body psychological consultation since J. T. 's body image
image. lem was apparently a major hindrance to employ
INSTRUMENTATION body image disturbances associated with disruption of
central nervous system scheme. Assessments are for
Because of its many facets, innumerable instruments for categories of neurologic disorder and acute dismemb
assessing body image are described in the literature. Many ment. I have also included a computerized tool t
of these tools are appropriate for use by rehabilitation deserves further research. These instruments are
personnel for assessing body image dysfunction. Others 1. Right-Left Orientation Test (Benton et al., 1994)
are better used as research instruments. Furthermore, the 2. Finger Localization Test (Benton et al., 1994)
various instruments can be categorized as to whether they 3. BIT (Wilson et aL, 1987a)
are primarily used to assess disturbances of the neural 4. Pain Disability Index (Pollard, 1984).
scheme or to assess disturbances in the psychological 5. Computerized Test of Visual Neglect and Extinct
representation component of the body image. I have (Anton et aI., 1988)
necessarily had to limit the number of instruments dis
cussed and have categorized those selected under their RIght-Left Orientation Test. Among the tests for neu
function relative to the neural scheme or psychological psychological assessment developed by Arthur Benton
representation. My selections were based on the desire to his colleagues is the Right-Left Orientation Test (Bento
1) provide examples of the different kinds of tools available al., 1994). There are four forms of this test, the orig
(e.g., self-report questionnaires, size estimation tech form (A), a "mirror image" version (B) for use as
niques), 2) include instruments suitable for clinical interven alternate form, and forms Rand L, designed for use w
tion and for research purposes, 3) include samples of patients unable to use their right or left hands. Form R
instruments for assessment of all four categories of body shown in Rgure 8-1. Performance on this 5-minute
image disturbance, and 4) provide information on those requires verbal comprehension and slight motor skill as w
tools that my literature review showed to be best re as the spatial-symbolic aspects of right-left discriminatio
searched. In addition, I have prOvided some examples of is designed to evaluate. Items included to assess
the more recent, innovative instruments that hold promise hierarchical skills in right-left orientation are orientat
for future development. toward one's own body (lowest on hierarchy), orientat
From a practical point of view, it must be understood that toward a confronting person, and orientation toward on
much overlap in assessment occurs. Clear-cut categoriza own body combined with a confronting person.
tion by function is not always possible. A tool or technique Normative data are available from 126 men and 1
may be designed to ascertain presence of a neural body women without brain disease and from 94 adults with br
scheme deficit but ultimately be more useful for assessment disease (Benton et al., 1994). Various problems in right-
of a psychological disturbance. An example is the size disorientation can thus be identified from the stand
estimation technique widely used for perceptual body administration of this test. Data are provided that defin
image research in anorexia nervosa studies. Directions generalized defect, a confronting person defect, and
requesting responses of how subjects feel about their own body defect. If systematic reversal occurs (all left w
bodies or comparison of actual image with their ideal have it should be right), it is assumed that right-left orientatio
differentiated subjects with eating disorders from those intact but the person is confused with verbal labels, as mi
without, although both groups have been found to overes be the case with patients challenged by aphasia.
timate their size (Keeton et al., 1990; Van Deusen, 1993). I found no reliability data on this specific measure
right-left orientation. However, Baum obtained an in
rater reliability coefficient of r = 0.94 for a similar ins
ment used with adults having had head injury (cited
Neural Scheme Disturbances Zoltan et al., 1986). Also, some evidence of constr
validity was found. An early version of Benton's Right-L
Disturbances of the neural body scheme were tradition Orientation Test (Sauguet et aI., 1971) as well as
ally evaluated by neurologists and psychiatrists by means of current test (Benton et aI., 1994) discriminated apha
interviews or clinical observations. This tradition was from nonaphasic persons in respect to orientation to on
incorporated into occupational therapy assessment proce own body. Benton and collaborators believe that right-
dures (Zoltan et aI., 1986) and is widely in use today, orientation has symbolic as well as spatial determinants
despite the availability of standardized instruments. Some case study of Gerstmann syndrome (Mazzoni et al., 19
clinicians prefer the flexibility of patient assessment al also supported the construct validity of this test. T
lowed by nonstandardized tools and appreciate such complex of dyscalculia, dysgraphia, right-left disorien
practical advantages as low cost. tion, and finger agnosia was shown to be present i
From those standardized or semistandardized instru patient with a very proscribed area of cerebral traum
ments discussed in the literature and appropriately used by Although the specific items of Benton's test for right-
occupational therapists and physical therapists, I have orientation were apparently not used, the instrum
~--- - -.;;;;;==-~-
~--
164 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
Examiner's Body
13. Point to my right eye. +-R
14. Point to my left leg. +-R
15. Point to my left ear. +-R
16. Point to my right hand. +-R
17. Put your left hand on my left ear. +-R
18. Put your left hand on my left eye. +-R
19. Put your left hand on my right shoulder. +-R
20. Put your left hand on my right eye. +-R
SUM ____________________
Performance Pattern
A. Normal Total Score _ _ _ _ _ _ _ _ _ _
B. Generalized Defect Reversal Score _ _ _ _ _ _ _ __
C. "Confronting Person" Defect Comments: _ _ _ _ _ _ _ _ _ _
D. Specific "Own Body" Defect
E. Systematic Reversal
FIGURE 8-1. Right-left orientation test, Fonn R for persons unable to use their right hand. (From Benton, A. L., deS. Hamsher, K., Varney, N. R
& Spreen, O. CONTRIBUTIONS TO NEUROPSYCHOLOGICAL ASSESSMENT. Copyright ©1983 by Oxford University Press, Inc.)
Benton's hierarchy and used similar items. Benton and other (Zoltan et al., 1986), It would be of interest
associates (1994) cited a study showing small but significant research the Finger Localization Test in this respect
relationships between right-left orientation scores and the to obtain other data to further verify its reliability
pertinent variables of brain atrophy, EEG slowing, and validity.
educational background. Finally, construct validity was Behavioural Inattention Test. The BIT (Wilson et
further supported by Fischer and colleagues (1990). These 1987a, 1987b) was designed in England as a measur
researchers showed that the "confronting" items on the unilateral visual neglect (UN). According to Heilman
Right-Left Orientation Test discriminated persons with collaborators (1985), the neglect syndrome includes b
dementia of the Alzheimer type at all stages not only from lack of intention to act in the space contralateral to the
control subjects but also from persons with multiinfarct of the brain lesion and inattention to sensory input to
dementia. Scores for visuospatial dysfunction and aphasia body side contralateral to the site of the lesion. The
did not differentiate these groups. An abbreviated version addresses the former aspect of the neglect syndrome
of the Right-Left Orientation Test was used because of the is concerned with the body function aspect of body im
age of the subjects. Further research is needed for docu rather than identification of the body parts. Tests such
mentation of the reliability and validity of Benton's test of that by MacDonald (1960) have long been used
right-left orientation. Particularly, the relationship between occupational therapists to identify patient problems w
right-left orientation and task performance must be deter body part recognition, including those resulting fr
mined to support the,use of the Right-Left Orientation Test inattention to sensory input to a body side.
in rehabilitation assessment. The BIT has changed through the usual developme
Finger Localization Test. A second test designed by process involved in test construction, and the curr
Benton and colleagues (Benton & Sivan, 1993; Benton et version (Wilson et al., 1987a) is distributed in the Un
aI., 1994) pertinent to an aspect of the body scheme is that States. The unique feature of the BIT is that it includes A
for the localization of fingers to assess finger agnosia. tasks. The intent of these ADL behavioral subtests i
Again, verbal comprehension and a slight amount of motor increase the tester's understanding of the specific d
skill are required to perform. This test is in three parts living problems of a patient with unilateral neglect tow
graded as to ease of localization. Tasks require localization more effective rehabilitation procedures. Content vali
of single fingers with vision and then without vision, was sought by having these behavioral tasks selected
followed by localization of pairs. Depending on the pa occupational therapists and psychologists who underst
tient's choice, responses can be made by verbal name or the daily living problems of patients challenged by unilat
finger number or by pointing to a finger on a drawing. neglect (Stone et al., 1987; Wilson et al., 1987a). Initia
Normative data were collected from 104 hospitalized the criterion-related validity of these ADL subtests
patients aged 16 to 65 years with no history of psychiatric measures of neglect was estimated by correlation w
or brain disease. Data also were obtained from 61 patients scores from six conventional tests of UN. Except for a
with brain disease (Benton et al., 1994). From the norma bisection test, coefficients ranged from r = 0.59 to 0.
tive data, several problems in finger localization were The current test manual (Wilson et al., 1987a) give
defined from those scores outside the total score limits, coefficient of r 0.67 for the relation between questi
outside single hand score limits, and outside the difference naire responses by patient therapists and the scores
score between hands. Borderline scores were also re patients on the ADL subtests. Estimates of reliability w
corded. also acceptable for these ADL subtests, with alternate fo
I could not locate any report of reliability studies with reported as r 0.83 and 100% agreement between
Benton's Finger Localization Test. However, evidence of raters (Wilson et al., 1987b). The current version of this
its construct validity suggests that it must measure in a (Wilson et aL, 1987a) has the following nine behavi
consistent manner. On an early version of this test, controls (ADL) subtests:
made no errors and response mode was only nonverbal. Picture scanning, in which subjects identify daily liv
This test discriminated between persons with and without items in three color photographs, and omissions
aphasia (Sauguet et al., 1971). scored
When vision was not used, Benton's Finger Localization Telephone dialing, in which the task is to dial a disc
Test discriminated between subjects with brain disease and nected telephone
control subjects (Benton et al., 1994). The case reported by Menu reading, in which a menu is opened and items
Mazzoni and coworkers (1990), which I discussed in read (or pOinted to) and omissions scored
relation to right-left orientation, also supported the con Article reading, in which a short newspaper article is r
struct validity of the Benton test of finger localization. aloud and errors scored; this subtest is not given
I found no study relating scores on Benton's Finger language-impaired persons
Localization Test with those from tests of ADL or occupa Telling and setting time, in which the time is read fro
tional performance, although occupational therapists have digital and an analogue clock, and the time is set on
suggested that finger agnosia is related to poor dexterity for analogue clock
-
----
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,
166 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
Coin sorting, in which 18 coins are prearranged and conventional BIT subtests for a I-month period. T
must be pointed out when named by the tester scores did not vary by more than one point over t
Address and sentence copying, in which an address and Considering the evidence for test stability of the BIT, it
a sentence are copied interest that Small and Ellis (1994) found inconsis
Map navigation, in which three sets of sequential scores from a long-term follow-up study of neglect patie
directions are traced with a finger on a maplike item These authors attributed this inconsistency to brief per
Card sorting, in which the person points to a selection of of remission in the unilateral neglect of their sample.
playing cards as named by the tester The BIT (Wilson et aI., 1987a) was standardized on
Test materials are presented opposite the subject's midline, rehabilitation patients averaging 2 months post str
and, although other errors may be noted for further The manual provides normative data from only 50 per
investigation, only errors of omission are scored. without cerebral lesion. Cermak and Hausser (1989) h
In addition to the ADL behavioral subtests, the BIT has justifiably criticized these normative data. On the pos
six simple pencil and paper conventional subtests of UN: side, the cutoff score from these data defined as ha
line crossing, letter cancellation, star cancellation, figure neglect the expected greater proportion of subjects
and shape copying, line bisection, and representational had right hemisphere, as opposed to left hemisph
drawing. According to the test authors (Wilson et al., strokes. Research should address improved normative
1987a), these subtests may be used to diagnose the for the BIT. Although there is little reason to expect
presence or absence of unilateral neglect. Small and Ellis from the United States to differ from the British dat
(1994) found these six subtests of the BIT discriminated study confirming this expectation would also be of inte
between their control subjects and a patient group with dual to the American therapist.
diagnoses of anosognosia and visuospatial neglect. A Stone and colleagues (1991) successfully shortened
principal components analysis clearly showed that these six BIT for use with short-term acute stroke patients.
conventional subtests were contributing to the same con shortened version was validated by comparing the
struct, defined as visual neglect. The star cancellation was scores with occupational therapists' assessments of un
the most sensitive measure of the six subtests (Halligan et eral neglect from ADL evaluations. Further research on
al., 1989). In a New Zealand study (Marsh & Kersel, 1993), shortened BIT is needed.
13 subjects were found to have visual neglect when Pain Disability Index. No instrument was found spe
assessed with the line crossing and star cancellation cally designed to assess the phantom pain associated
subtests and two other tests of neglect. The star cancella dismemberment. The Pain Disability Index (POI) develo
tion was the most sensitive of these four measures and the by Pollard (1984) is an easily administered scale asses
only one found to correlate Significantly with scores from a chronic pain in relation to activity and, conseque
measure of ADL, the Modified Barthel Index (r = 0.55). applicable to phantom limb pain. The POI, consistin
The test manual gives a correlation coefficient of r = 0.92 self-report ratings of the extent that chronic pain interf
between scores from the ADL behavioral subtests and with seven categories of life activity (family and h
those from the six conventional subtests for 80 rehabilita responsibilities, recreation, social activity, occupat
tion patients with unilateral cerebral lesions. sexual behavior, self-care, and life support activity),
The BIT is being used in research because of its well-researched tool (Gronblad et aI., 1993; Gronbla
functional relevance. One group (Robertson et al., 1990) al., 1994; Jerome & Gross, 1991; Taitet aI., 1987; T
considered it as their principal measure in a controlled al., 1990). Originally, ratings of the seven categories w
study of the effects of computerized treatment for UN summed, but factor analyses by the Tait research gr
patients after stroke. Although the BIT did not discriminate (1987, 1990) showed the instrument to have a two-fa
between groups, neither did five of their other six measures structure, discretionary (voluntary) versus obligatory ac
of UN. In another intervention study using single system ties, so that an overall score has little meaning. The
design, the researchers found that with two subjects, the results should be interpreted in terms of ratings of dis
BIT did discriminate between pretest and six-month per tionary activities (home, recreation, social, occupation,
formances (Cermak et al., 1991). The suggestion of sexual) and of ratings of the obligatory activities esse
Cermak and Hausser (1989) that the behavioral subtest for living (self-care, such as dressing, and life support,
items be validated against real-life ADL performance as eating). Reasonable internal consistency was obta
makes sense in view of the use of the BIT for its functional for each factor (alpha = 0.85, discretionary; 0.70, ob
properties. tory). The test-retest reliability coefficient was low for
The current test manual (Wilson et al., 1987a) shows Tait research group (1990), but a 2-month time span
excellent reliability data for the Behavioural Inattention explain the coefficient of r 0.44 (n = 46). The Gron
Test in its entirety. The IS-day interval test-retest coeffi group (1993) obtained I-week, test-retest intraclass co
cient for 10 subjects with brain damage was r 0.99; the lation coefficients of 0.91 (total POI), 9.87 (discretio
interrater coefficient was r 0.99; and the parallel form factor), and 0.73 (obligatory factor) for 20 subjects
coefficient was r = 0.91. Small and Ellis (1994) observed domly selected from their total of 94 patients with chr
two control subjects, testing them each week with the six back pain.
the construct validity of the POI. Initially, Pollard (1984) pain, but specific research in this area would be valuab
showed that this scale discriminated between nine persons The POI would be an instrument of choice for assessm
with lower back pain with a current work history from nine in longitudinal studies of rehabilitation in which chro
who had just received surgery. The Tait research group pain is a factor.
(1987, 1990) showed that the POI discretionary and Computerized Tests. In this information age, compu
obligatory factors discriminated outpatients with pain from aided testing is a given. However, because of time and c
inpatients with pain, the former, as expected, being less constraints, use of a well-developed paper and pencil t
disabled by their pain. In a major study, 197 POI high often may be of more practical value in the clinic than
scorers (greater disability) were compared with 204 low use of elaborate electronic measuring devices. Comput
scorers. The high scorers reported more psychological ized tests that are useful to the clinician are obviou
distress, pain, and disability, stopped activity more, were in desirable. Anton and colleagues (1988) reported such a t
bed more during the day, and spent more total time in bed designed to assess visual neglect and extinction. In this t
than did low scorers. Two other studies also supported the situation, the subject, with gaze fixed centrally, respond
construct validity of this instrument. Multiple regression to randomly appearing lights (Fig. 8-2). Lights appeared
procedure showed that time in bed, stopping of activity, the subject's right side, to the left, or simultaneously to ri
psychological distress, and work status predicted POI and left sides. Testing with 30 "normal" volunteers show
scores. Patients who were employed had lower POI scores that, although errors were made, no difference was ma
than did those unemployed. Finally, it was found that high in the number on the right and left sides. When used w
POI scorers had higher rates of pain behaviors such as patients after right cerebrovascular accident (CVA), grea
verbal complaints and grimaces than did low scorers. response to right than to left lights would indicate negle
Gronblad and collaborators (1993, 1994) provided still Response only to right with simultaneous lights would sh
further support for the construct validity of the POI, since extinction. Relative to clinical evaluation by a physician a
the POI total values correlated r = 0.83 with those from identification by occupational therapists from paper a
the extensively used and researched Oswestry Oisability pencil testing, the computerized test was found to be hig
Questionnaire. The coefficient for the discretionary factor sensitive, identifying visual neglect in 16 and extinction
was r = 0.84 but only r = 0.41 for the obligatory factor, 13 of 24 subjects with right CVA. In every instance, wh
showing less support for the validity of this part of the POI. neglect and extinction were identified by the physician
The POI was also related to a measure of pain intensity at occupational therapist, they were also identified by
r = 0.69. Further work showed the POI to discriminate computerized testing, but the computerized test identif
persons with chronic pain who were working from those five more cases of extinction than did the physician and
on sick leave. Since the POI is a self-report measure, more cases of neglect than did the occupational therap
Gronblad and associates (1994) studied its relation to
objective physical therapist observations of activities requir
ing back and leg muscle use. Subjects were 45 outpatients
with chronic back pain. Activities included a sit-up test
emphasizing abdominal muscles, an arch-up test for back
muscles, and a squatting test for lower extremity muscles.
Although correlation coefficients were low (0.30s and
0.40s), these researchers did find significant relationships
between POI results and observed activity scores, even after
adjustment for age and gender. Jerome and Gross (1991)
were concerned that the POI scores might not provide any
useful information beyond that of a pain intensity scale. For
74 subjects from a university pain clinic, they correlated
POI results to several variables used to assess functional
status in chronic pain. Although pain intensity was highly
related to POI, when intensity was partialled out, discre
tionary POI scores were still related to level of depression,
lack of employment, and use of pain medication. Thus, the
POI does provide information on disability beyond that
provided by a pain intensity scale.
In summary, an impressive body of research supports the
construct validity of the POI with chronic pain patients. I
concur with the researchers who consider the POI a feasible FIGURE 8-2. Computerized test for visual neglect and extinction. (F
Anton, H., Hershler, c., Lloyd, P., & Murray, D. [1988]. Visual neg
clinical instrument if used as part of a battery to assess the and extinction: A new test. Archives of Physical Medicine and Re
relation of chronic pain and activity level. The POI should bilitation, 69, 1013-1O16.)
168 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
Anton and coworkers (1988) reported limited informa These psychophysical methods are of two types: b
tion on reliability, merely stating that three each of control size estimation procedures and the whole-image disto
and experimental subjects were retested within 2 to methods. In the former, using lights, calipers, or o
3 weeks, with no change in test results. Construct validity instruments, subjects estimate the width of their var
was supported. The data from this computerized test body sites (such as hips or chest), and distortion score
supported the position of neurologists that neglect is a computed by comparing estimates to actual measu
severe manifestation of extinction since neglect never typically taking variables such as height and weight
occurred in the absence of extinction. consideration. The whole-image distortion procedures
Because this computerized test of Anton and colleagues photographic or video methods for subjects to estim
(1988) appears to be well worth the effort of those their bodies as a whole (Van Deusen, 1993). I select
researching this type of testing, I was surprised to locate body size procedure, the Body Image Detection De
only one later study. Beis and collaborators (1994) de (BIDD) (Ruff & Barrios, 1986) to illustrate this kind of b
scribed a modification of the Anton test, which was image assessment instrument.
designed to detect visual field deficits as well as visual The attitudinal measures have been subdivided
neglect. From 63 subjects with brain injury, 17 were various ways (Ben-Tovin & Walker, 1991; Thomp
identified as having visual field defects and 12 as having 1990; Van Deusen, 1993). I believe that three c
neglect. Identifications of visual field defects by the com goriesincorporate instruments of major use to occ
puter test did not differ significantly from those by ophthal tional therapists and physical therapists: 1) self-re
mologist tests. The array of 64 light emitting diodes (LEDs) tools requiring responses to figures or Silhouettes; 2)
for this study (in a somewhat tighter semicircular arrange report tools requiring responses to verbal statem
ment than that for the Anton test) allowed for well-defined about size, shape, or other aspects of body image;
control data. All errors by the 31 control subjects were 3) the semantic differential technique (Van Deu
limited to the final five lights to the right or left sides. Further 1993).
research is needed on this type of testing for unilateral The instruments I selected to illustrate the wide arra
neglect. measures of the psychological representation aspec
To summarize, one aspect of body image that needs body image include examples from each category:
assessment in rehabilitation is neural scheme disturbance.
1. Body Image Detection Device (BIDD) (Ruf
Persons with conditions such as phantom limb pain or
Barrios, 1986)-psychophysical measure
unilateral neglect are examples of patients needing such
2. Body Image Assessment (Williamson, 1990)-s
assessment. Five examples of instruments of research and
report, silhouette measure
clinical interest were discussed.
3. Multidimensional Body-Self Relations Questionn
(MBSRQ) (Cash & Pruzinsky, 1990)-self-rep
Disturbances of Psychological verbal statements measure
4. Body Shape Questionnaire (BSQ) (Cooper et
Representation 1987)-self-report, verbal statements measure
5. Body Image Assessments Using the Semantic D
Many instruments were reviewed that purport to assess
ential Technique (Isaac & Michael, 1981)-bip
body image disturbances associated strongly with psycho
adjective attitude scales
logical or social conditions. These tools have been used for
assessment of body image disturbances of persons with I also included two recently developed instruments
actual physical disabilities or with psychiatric diagnoses but minimal research work, the FOFQ (Roth & Armstr
with no known neural lesion to distort the neural scheme. 1993) and the Color-a-Person Body Dissatisfaction
Thompson (1990) was among those who recognized (CAPn (Wooley & Roll, 1991). These tests provide va
that, even with the neural body scheme disturbance scores as body image changes within situational con
excluded, body image disturbance remained a multidimen and both instruments deserve further research attent
sional construct. Thus, he discussed measures designed to Body Image Detection Device. Of those devices
assess the perceptual and the subjective components of techniques developed for research investigating body
disturbances. Keeton and associates (1990) also catego estimation accuracy, particularly for subjects challenge
rized assessment tools for the psychological representation anorexia or bulimia nervosa, one tool receiving rese
aspect of the body image into these same categories attention was the BIDD originated by Ruff and Ba
(perceptual and attitudinal). Measures of body size estima (1986). The BIDD projects light onto a wall for the sub
tion (width of body parts) and whole-image distortion to adjust to their estimated body site widths by manipula
procedures have been termed perceptual, but this term can the templates of the apparatus. The subjects' site
cause them to be confused with measures used to assess (face, chest, waist, hips, thighs), estimated one at a t
neural body scheme disturbances often classified as per are compared with their actual widths measured by
ceptual (Zoltan et al., 1986), so I prefer the term used by investigator, so that a ratio can be computed for ove
Meermann (1983), psychophysical methods. underestimation of size (estimated/actual discrepanc
sizes, a self/ideal discrepancy index can also be computed. used figures or silhouettes graded from very thin to v
Data from college students, 20 with bulimia and 20 with obese as stimuli for response by subjects in their b
out, in the Ruff and Barrios study (1986) showed internal image studies (Bell et al., 1986; Fallon & Rozin, 1985)
consistency coefficients (Cronbach's alpha) of 0.79 to computer program version has also been evalua
0.93. Interrater reliability coefficients were r = 0.98 or bet (Dickson-Parnell et al., 1987).
ter. A1I3-week test-retest reliability coefficients were in the One such silhouette assessment procedure for b
O. 70s and 0 .80s for bulimic and control subjects, except for image was designed and researched by Williamson a
the waist estimate of bulimic subjects (0.44). The authors' colleagues (Williamson, 1990; Williamson et al., 19
second study (Cited by Thompson, 1990) showed much Williamson et al., 1993). Nine silhouettes (Fig. 8-3) grad
lower coefficients among college women. Keeton and as from thin to obese are presented to subjects on car
sociates (1990) in their use of the BIDD found a coefficient Cards are presented in a fixed order since no difference w
(alpha = 0.93) indicating high interrater reliability of the found from the random display originally used. Stand
measurement of the actual body site sizes. instructions are used to request first accurate and th
Considerable evidence exists for the construct validity of preferred body size choices from the cards. Administrat
the data obtained from the BIDD. The estimated/actual time is less than 1 minute. Normative data of subje
index discriminated between three weight groups, 12 each height and weight were established by cluster analy
of normal, over-, and underweight nonclinical subjects (Williamson et al., 1989). These data may be used
(Cash & Green, 1986), between 20 each of bulimic determine if testees show body images outside of norm
subjects and controls (Ruff & Barrios, 1986), and between limits.
47 male and 78 female college students (Keeton et al., Data estimating the reliability and validity of the B
1990). The self-estimate scores and self/ideal discrepancy Image Assessment were obtained (Keeton et al., 19
index showed moderate correlations (0.42 to 0.67) with Williamson, 1990; Williamson et al., 1989; Williams
those from a silhouette tool. For women, the self/ideal et al., 1993). Test-retest reliability data were gathe
discrepancy index was also significantly related to scores on from I-week, 2-week, and 3- to 8-week intervals betw
a test for bulimia, but the coefficient was low at r 0.38. administrations. All reliability estimates were in the 0.7
Evidence indicated that BIDD results were independent 0.80s, or 0.90s.
from those of attitudinal measures (Keeton et al., 1990). Williamson and colleagues provided evidence for
A modification of the BIDD, the Adjustable Light Beam construct validity of the Body Image Assessment (Willi
Apparatus, allows the projected light to be Simultaneously son, 1990; Williamson et al., 1989; Williamson et
adjusted for the three body sites (waist, hips, and thighs) 1993). In two separate studies, as hypothesized, it discri
after practice with the face (Thompson & Spana, 1988). nated between persons with bulimia nervosa and con
The authors provided detailed directions for construction of subjects and between persons with anorexia nervosa a
this device. It has also received research attention showing control subjects. No score differences were found betw
acceptable reliability coefficients and evidence that size eating-disordered subjects. As hypothesized, relationsh
estimation data are independent from those of attitudinal were found between scores on tests of eating attitudes a
measures (Altabe & Thompson, 1992; Coovert et al., bulimia and those of the Body Image Assessment. Furth
1988; Thompson & Spana, 1988). more, another research team, Keeton and cowork
FIGURE 8-3. Silhouettes for the Body Image Assessment by Williamson. (From Williamson, D. A. [1990]. Assessment of eating disorders: Obe
anorexia, and bulimia nervosa. Needham Hights, MA: Allyn & Bacon.)
-
, '
. -~ -
- ""
. " ;:~~=
170 UNIT lWQ-COMPONENT ASSESSMENTS OF THE ADULT
(1990), also supported the construct validity of a modified From their survey data, Cash and collaborators (Bro
version of the Body Image Assessment in their study et aL, 1990) refined the BSRQ. The current instrume
examining a number of body image measurements. the Multidimensional Body-Self Relations Questionna
Body-Self Relations Questionnaire. Many self-report (MBSRQ), was reduced to 69 items from the original 1
scales of the Likert type using verbal statements have and to six subscales from the original nine. Because of
been used by body image researchers for investigation correlation of data, the cognitive and behavioral dim
of disturbances of persons challenged by anorexia ner sions were combined to one orientation dimension, w
vosa, mastectomy, severe burns, and other problems the affective (evaluation) dimension maintaining indep
(Van Deusen, 1993). The self-report questionnaire de dence. The revised BSRQ part of the MBSRQ
vised and researched by Winstead, Cash, and collabora 54 items, and the other items make up a body ar
tors (Cash & Pruzinsky, 1990) is an outstanding example satisfaction and a weight attitude scale. Sample items
of this type of assessment procedure. Their conceptual "Most people would consider me good-looking" and "I
framework was a multidimensional, psychosocial one in very well coordinated" (Cash & Pruzinsky, 1990).
which body image was originally assessed by the nine validate their conceptual frame of reference, Brown
subscales of the Body-Self Relations Questionnaire colleagues (1990) analyzed the factor structure of
(BSRQ), which addressed the cognitive, affective (evalu BSRQ with separate split-sample factor analyses for e
ative), and behavioral dimensions of three somatic gender. The survey data from 1064 women and 988 m
domains: physical appearance, fitness, and health. For were used. It was expected that the analyses would rev
the various subscales, internal consistency coefficients factors that could be defined by the six subscales: appe
were reported from alpha = 0.68 to 0.91 (Winstead & ance, fitness, and health evaluation; and appearan
Cash, cited in Cash & Pruzinsky, 1990), alpha = 0.91 fitness, and health orientation. The six predicted fact
(Noles et al., 1985),0.83 to 0.92 (Cash & Green, 1986), were generated by each of the four analyses plus a seven
and the 0.80s (Butters & Cash, 1987). Test-retest scores an illness orientation factor. Items loading on the illn
from the physical appearance domain over 1 month were orientation factor pertained to alertness to symptoms
0.85 to 0.91 (Cash & Green, 1986). illness, as distinguished from items about motivation
Evidence exists of the construct validity of the physical ward bodily wellness, which loaded on the health orien
appearance domain items from the BSRQ. Noles and asso tion factor. Further study showed marked stability of
ciates (1985) found the affective dimension to discriminate factor structure between and within genders. The constr
depressed from nondepressed subjects. Cash and Green validity of the MBSRQ as a measure of the psycholog
(1986) showed these items to discriminate among nonclini representation aspect of body image has continued to
cal subjects by weight group. Pasman and Thompson demonstrated through research results obtained with
(1988) found these items to differentiate between male and use of this instrument (Cash et al., 1991; Denniston et
female runners, the latter being less satisfied with their 1992). Unquestionably, the MBSRQ is a body image t
physical appearance. Keeton and collaborators (1990) with very acceptable reliability and validity data. Compu
found scores from the affective/appearance domain to be software is available to facilitate the use of this instrum
related to several other attitudinal body image measures, as (Cash & Pruzinsky, 1990).
well as to a measure of eating disorders. Thompson and Body Shape Questionnaire. British researchers Coop
Psaltis (1988) found BSRQ scores related to those from a Taylor, Cooper, and Fairburn (1987) perceived the lack
figure rating scale. Of particular importance was the evi a body image tool dealing specifically with body sh
dence provided by Butters and Cash (1987) that the BSRQ concerns. They developed a measure directing subject
(all domains) showed Significantly improved body image respond in terms of how they felt about their appeara
follOwing cognitive-behavioral treatment of experimental over the past four weeks. Sample items from their B
relative to control subjects. Although these experimental follow:
subjects had shown dissatisfaction with their body images, Have you felt so bad about your shape that you h
they were functioning college students, not patients. cried? (p. 491)
From a magazine survey (Cash, 1990; Cash et aL, Have you felt excessively large and rounded? (p. 4
1986), data were obtained on the BSRQ from 30,000 Have you felt ashamed of your body? (p. 492)
persons. Norms were established (N = 2000) from a Have you pinched areas of your body to see how m
random sample of these data stratified for age and gender. fat there is? (p. 493)
Since this sample contained 91% white, 84% college Items were obtained through interviews with wom
educated subjects and 37% never-married persons, it is not having eating disorders and with nonclinical univer
representative of the general population. These BSRQ women. From statistical analyses of data from nonclin
data clearly differentiated persons who did poorly from and clinical female samples, 51 items were reduced to
those who did not on a psychosocial adjustment scale A single score is obtained by adding items (Cooper et
included with the survey. The BSRQ also showed women 1987). That the BSQ has a unitary structure has b
as having less positive body images than men, although not supported by several factor analytic studies (Mumford et
to the extent anticipated. Adolescents showed less positive 1991; Mumford et al., 1992). Internal consistency relia
body images than did other age groups. ity was excellent (alpha = 0.93).
Impaired :_ Unimpaired
and attitude tests (Cooper et al., 1987). Concurrent validity
was substantiated by other researchers (Rosen et aI., 1990) Incomplete Complete
with a correlation of r = 0.78 between eating disorder Unsuccessful _ : _: _ : Successfu
scales and the BSQ in a sample of 106 female subjects.
Research with the BSQ showed it to discriminate Negative Positive
between patients with bulimia nervosa and comparable Bad Good
nonclinical women, between women rated as concerned
and not concerned about their shape, and between prob Painful Pleasurable
able bulimics and other women in a community sample Ugly Beautifu
(Cooper et al., 1987). In a discriminant analysis (Rosen et
al., 1990), eating disorder scales contributed nothing Boring Interesting
beyond the BSQ to group placement (control vs. eating Awkward Gracefu
disordered subjects).
Cross-cultural validity of the BSQ was shown in several Unimportant Importan
studies, including one on subjects from New Zealand and
Asia. According to these authors, evidence was strong
because of similar factor structures across cultures (Mum
ford et al., 1991, 1992). By modifying items slightly for
Hands image: RA ( . - - ) and controls ( e - - ).
male subjects, Kearney-Cooke and Steichen-Asch (1990)
used the BSQ to divide 112 male college students into
those at risk for eating disorders and those not at risk. FIGURE 8-4. Semantic differential technique for hand imag
persons with rheumatoid arthritis. (From Van Deusen, J. [19931. B
These authors then found the expected differences be Image and perceptual dysfunction In adults. Philadelphia: W
tween these groups on eating attitudes and body satis Saunders.)
faction; even greater differences were found with their
clinically diagnosed anorexiclbulimic subjects. To sum
marize, considerable evidence supports the construct va with rheumatoid arthritis (Van Deusen, 1993). It was u
lidity of the BSQ. simply as an attitude scale consisting of scales for s
Because the BSQ is measuring only one construct reports on trunk, arms, hands, and legs (see Fig. 8-
(Mumford et aI., 1991, 1992) and because of the current Harlowe, my coinvestigator, and I found this seman
need for efficient measures, Evans and Dolan (1993) differential to discriminate subjects with rheumatoid art
investigated short forms of the BSQ. Their analysis and tis from nonclinical control subjects. The scale for ha
replication showed internal consistency coefficients in also discriminated between subjects with arthritis who
the 0.90s for the short, 16-item alternate forms. These traditional programming from those subjects participat
authors supported construct validity of these short forms by in an experimental dance experience.
obtaining results consistent with their hypotheses in several The semantic differential also was found to be
instances. For example, moderately high correlations were effective method to assess body image of persons w
found with eating attitude scores, and the short form BSQ severe burns. Orr and colleagues (1989) used this too
could separate subjects reporting eating problems from show that perceived social support (especially by peers) w
those not reporting them. Certainly, more efficient meas the variable most highly associated with body im
urement tools are necessary in view of current health care adjustment of young adults with burns.
trends. A study reported from Germany (Steinhausen & V
The Semantic Differential Technique. Citing the work of rath, 1992) used the semantic differential approach
Osgood and collaborators, Isaac and Michael (1981) assess body image of adolescents with anorexia nervo
described the use of the semantic differential method for Bipolar adjectives used were beautiful-ugly, desirab
measuring the meaning of concepts. It consists of a five- to undesirable, dirty-clean, soft-hard, proportion
nine-step scale anchored by bipolar adjectives. On a form unproportional, light-heavy, powerful-weak, pleasa
with items randomly arranged, the subject marks the step unpleasant, fragile-massive, attractive-repulsive, lar
best describing his or her attitude toward the concept being small, inactive-active, firm-flabby, bad-good, a
conSidered (Fig. 8-4). The semantic differential has been a uncomfortable-comfortable. This scale differentiated
very useful tool, and literally thousands of references verify subjects with anorexia from 109 control subjects. T
its value. This technique is well suited to the assessment of analyses showed a similar factor structure (attractiven
body image. For this purpose, its use with clinical samples and body mass dimensions) for the subjects with
challenged by anorexia nervosa, burns, and rheumatoid without anorexia nervosa. This semantic differential a
arthritis is next described. showed sensitivity to the therapeutic body image chan
I chose the semantic differential technique for assess of anorexic subjects.
ment of body image in our studies with adults diagnosed To summarize, the semantic differential technique
172 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
tests (0.50s) were obtained. Haimovitz and collaborators Internal consistenqr re6abi6ty--Consistency
(1993) showed that the CAPT scores varied under dif performance on the items of a test.
of 144 undergraduate women. Furthermore, the CAPT Phantom sensation-The feeling that an amputa
appeared to measure body image when subjects were part is still present.
especially self-critical rather than body image in gen Psychophysical method-Procedures developed
eral. researchers of eating disorders that allow subjects
Unlike the CAPT, the FOFQ was designed specifically as estimate their body size by such means as adjusting lig
an affective measure of body image across contexts. The calipers, or video images.
authors of FOFQ (Roth & Armstrong, 1993) proposed to
measure the subjective experience of fatness across a
variety of situations. Content validity was established by
contributions of items from experienced mental health REFERENCES
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CHAPTER 9
Eleotrodiagnosis of the
Neuromuscular System
1
176 UNIT 2-GOMPONENT ASSESSMENTS OF THE ADULT
C fibers. Within a peripheral nerve, all nerve fibers are not ++-++++++++++++++++
of equal size but actually cover a wide range of diameters. B--+----------------~~
Another classification is frequently used to describe sensory
nerve fibers. In this classification, the fibers are also FIGURE 9-1. The action potential. An idealized diagram. In A, t
grouped according to diameter, but a Roman numeral potential arises underneath the electrode and propagates away from
The plus and minus signs represent ions situated outside and inside t
classification is used: Group I contains the largest afferent nerve. This is recorded as a biphasic negative-positive wave. T
fibers; Group II, the next largest; Group III, the third largest; waveform (as seen on an oscilloscope screen) of the potential recorded
and then Group N, which corresponds to the small the electrode is drawn above the electrode; negativity is drawn upwa
Another situation common in clinical practice is shown in B; the potent
unmyelinated C fibers. Within these main groups are (i.e., ion exchange) approaches the electrode and passes underneath it.
further subdivisions-labeled a, b, c. One often sees a nerve this case, a positive-negative-positive triphasic wave is recorded.
classified as Ia; this means that the nerve is of the largest
diameter and fastest conduction.
Classification of Peripheral Nerve Injuries. Peripheral characterized by the much more usable terms conductio
nerve injuries are often classified as neuropractic, axonot slOWing and disorders with conduction block. Disorde
metic, or neurotmetic. Neuropraxia is a reversible injury in with slowing of conduction can occur with demyelination
which some loss of distal function occurs, with no associ the axons; a conduction block occurs with a metabol
ated structural change of the nerve axon. Causes of alteration in the membrane, as with anesthetic block or
neuropraxia can include neural ischemia or local electrolyte structural alteration in the axon. Reduced or abse
imbalance or trauma (e.g., as in the transient alteration in responses are the result of nerve degeneration after axon
sensation sometimes associated with leg crossing or in a interruption.
nerve block caused by a local injection of an anesthetic). Electrophysiology of Peripheral Nerves. Current electr
Acute compression neuropathies such as Saturday night physiologic techniques and concepts are the result
palsy or crutch palsy of the ulnar nerve, as well as chronic continual refinements made over 300 years. The ner
entrapments such as carpal tunnel syndrome or tardy ulnar "impulse" or "discharge" is a wave of changing electr
palsy, are considered neuropraxic (although the latter two charge that passes down the axon from the neuron's c
can later be associated with focal demyelination). In body (Fig. 9-1).
neuropraxia, nerve action potentials can be generated A resting or unstimulated neuron has an active mech
above and below the injury site but are not recorded across nism that maintains the interior of the cell in a state
the site of injury; therefore, the lesion can be preCisely negative charge while the area immediately outside the c
delineated electrophysiologically. Axonotmesis is of more membrane is positively charged. When a neuron is stim
increased severity and is characterized by a loss ofaxons lated, the permeability of the membrane alters, which le
and myelin, with preservation of the surrounding connec in positively charged sodium ions. This momentarily r
tive tissue. A more severe type of peripheral nerve trauma verses the charge on both sides of the nerve membran
is neurotmesis. In this case, the axons and myelin are This area of reversed charge is the nerve impulse, which
destroyed, with additional disruption of the surrounding recorded by electrophysiologic recording equipment. T
connective tissue. An example of this would be a complete nerve impulse induces an identical change in the area
nerve transection. the axon adjacent to it, and the impulse then travels dow
Pathophysiology of Peripheral Nerves. Neuropraxia, ax the nerve axon. Once the nerve impulse has passe
onotmesis, and neurotmesis produce certain eiectrophysi sodium ions are pumped back out of the cell, and after
ologic alterations, which can be classified into disorders brief recovery period, the original charged {polarized} sta
axon (the synapse), it causes release of a chemical neu
rotransmitter, which travels across the narrow gap between Stimulus
one neuron and the next, triggering an impulse in the
second.
A-+----
TECHNIQUE AND WAVEFORM A
NOMENCLATURE
Nerve conduction studies (NCSs) assess peripheral sen
sory and motor function by recording the response evoked
B-+--
b
by stimulation of selected peripheral nerves. Sensory NCSs
are performed by electrically stimulating a peripheral nerve
and making a recording at a measured distance, either
Response
proximally or distally from the stimulation site. Motor NCSs
are performed by stimulating a peripheral nerve and
recording from a muscle innervated by that nerve (Figs.
9-2 through 9-5). These studies have been used clinically
since the 1950s to localize peripheral nerve disease and to FIGURE 9-3. General scheme for motor nerve conduction studies
general idea in conducting peripheral nerve conduction studies
differentiate it from disorders of the muscle or neuromus stimulate the peripheral nerve with a bipolar electrode and th
cular junction. Comprehensive reviews are found in refer calculate the so-called conduction velocity of the nerve. The electr
ences (Aminoff, 1992; Ball, 1993; Buchthal et al., 1975; applied to the skin over the nerve, which is stimulated. This produc
activation of the nerve fiber. The response to stimulation is recorded
Daube, 1985, 1986; Gilliatt, 1982; Johnson, 1988; the muscle. The muscle response is usually measured with su
Kimura, 1983, 1984; Oh, 1984). electrodes. The earliest muscle response is termed the M wave
Motor Nerve Conduction Studies. The clinical utility for interval between the time of stimulation and the onset of the M w
the latency of the response. To calculate a pure nerve conduction
motor NCSs was first described by Hodes and associates city, the nerve is stimulated at two separate points (A and B), an
(1948). The functional integrity of motor fibers in any latency measurements are then obtained (a and b). The distance be
peripheral nerve can be evaluated by motor conduction points A and B is measured in millimeters. The conduction veloc
meters per second is equal to
studies if this nerve can be adequately stimulated and the
response of one or more of the muscles that it innervates distance between A and B in mm
can be recorded. Typically, the more accessible nerves conduction time between A and B (in msec)
the median, ulnar, tibial and peroneal nerves-are more The conduction time between A and B is equal to the latency (
readily studied. The musculocutaneous, radial, facial, from point A minus the latency at point B.
femoral, phrenic, suprascapular, intercostal, and others
can also be studied. The electric response of the muscle is
called the compound muscle action potential (CMAP). This in the region of the recording electrode that are innerv
CMAP is the summated electric activity of the muscle fibers by the nerve that is stimulated.
The CMAP recorded after stimulation of a periph
nerve is called the M wave. With supramaximal stimula
all of the fibers in a muscle innervated by the stimu
nerve contribute to the potential. The earliest part of th
" I r - - - M wave wave is elicited by the fastest-conducting motor axons.
M wave is described by its latency, amplitude, and con
Stimulus ration. The latency is the time in milliseconds from
application of the stimulus to the initial recorded deflec
j from baseline, and this is the time required for the ac
potentials in the fastest-conducting fibers to reach
nerve terminals in the muscle and activate the muscle f
(see Fig. 9-2). As mentioned before, the latency v
directly with the distance of the stimulating electrode to
Peak to peak
muscle.
amplitude Typically, the peripheral nerve is studied at more
one site along its course to obtain two or more CMAPs.
latencies, amplitudes, and configuration of these ev
FIGURE 9-2. Idealized compolll1d muscle action potential, responses are then compared (see Figs. 9-3 through 9
178 UNIT 2-GOMPONENT ASSESSMENTS OF THE ADULT
~
Long Latency (Long Loop) Reflexes. As has always b
Record the case in clinical electrophysiology, whenever a poten
F-wave H-reflex
is termed a short latency response or a long late
Record response, inevitably an even shorter latency or lon
latency response is soon discovered; the H reflex an
FIGURE 9-6_ Anatomic pathways for the F wave and H reflex. For the waves are no exception. Although these are called l
F wave, the motor fiber is the afferent as well as the efferent pathway, and
for the H reflex, the Ia peripheral nerve fiber is the afferent pathway and latency responses, even longer latency responses
the motor fiber is the efferent pathway. There is a monosynaptic reflex arc known and have interesting properties.
in the H reflex pathway but no synapse involved for the F wave. The insert Long latency reflexes of human hand and fore
shows an axial view showing anatomic relationships of dorsal and ventral
nerve roots, spinal cord, and intervertebral foramen. muscles have been described in voluntarily contrac
muscles. These long latency reflexes can be elicited
various stimuli, including muscle stretch, electric stim
tion of pure muscle afferents, mixed nerves, or p
opportunity to measure conduction along the most proxi cutaneous afferent nerves. At least for the muscles actin
mal segment of motor axons, including the nerve root. the wrist and fingers, evidence exists that indicates th
Usually the F wave does not occur at a constant fixed responses are mediated pathways ascending the sp
latency from trial to trial but varies slightly; therefore, the cord up to the brain and then down from the brain thro
electromyographer generally records 10 or more F wave the spinal cord out through the motor neurons. A la
potentials and reports on the best (shortest) latency. The and somewhat difficult to read, literature concerns var
latency of this "late response" is between 20 and 50 reflexes in this category. In a review, Deuschl and Luck
meters per second, depending on the nerve stimulated and (1990) summarize the different terminologies for var
180 UNIT 2-COMPONENT ASSESSMENTS OF THE ADULT
components of these responses. Another readable and between root injury and other peripheral nerve probl
thorough review was presented by Marsden and colleagues that might cause similar symptomatology. Evaluatio
(1983). functional integrity of nerve roots can be important
Although no special equipment (other than normal NCS patient management with regard to further diagno
equipment) is required for analysis of these responses, they evaluation and surgical intervention.
are typically not studied in the neurology/physical medi Usually in radiculopathies the most common cli
cine clinic, partly because clinical correlations are not as presentation is with sensory symptoms. In nerve
well established for these potentials. These responses dysfunction, the locus of the injury is at or proximal to
obviously reflect integrated activity in ascending and de foraminal opening (see Fig. 9-6, insert). Normal studie
scending pathways involved in neuromuscular control, but sensory nerves in the distribution of the sensory compla
the functional significance of these responses is a matter of or abnormal clinical sensory examination would be con
much discussion. tent with a radiculopathy, while abnormalities of sen
conduction would indicate a more distal site of in
____ ~ __
, ~".o=o, _ _,_"" Similarly, slowing of motor conduction velocity w
argue for peripheral nerve dysfunction rather than n
CLINICAL UIILll'Y OF NERVE root dysfunction.
CONDUCTION STUDIES The H reflex can be effectively used to assess the
dorsal root, but somatosensory evoked potentials
Peripheral Neuropathies. Peripheral neuropathy can af cussed later) are needed to adequately study nerve roo
fect peripheral nerve axons, their myelin sheaths, or both. other levels. Abnormal H reflexes or F waves by themse
Various types of pathologic changes in peripheral neurop do not establish a diagnosis of a radiculopathy but
athy can result in different patterns of electro physiologic complement other electrophysiologic information. C
abnormality. Peripheral neuropathies are manifested by ventional nerve conduction studies are usually norma
sensory, motor, and autonomic signs and symptoms. NCSs cervical and lumbosacral radiculopathies (Eisen, 1987
are sensitive tests for evaluating polyneuropathies, and radiculopathy, most lesions can occur proximal to
such studies can define the presence of a polyneuropathy, dorsal root ganglion; therefore, the sensory nerve fibers
the location of the nerve injury, and usuaily the pathophysi intact, and, consequently, distal sensory nerve poten
ology (demyelination vs. focal axonal block). are normal, even if the patient has a sensory de
Common types of peripheral neuropathy are a mono However, in radiculopathy, damage to motor nerve fi
neuropathy of the median nerve at the wrist (carpal tunnel may occur, and, consequently, a slowing of motor con
syndrome), ulnar neuropathy at the elbow, and peroneal tion can often be detected.
nerve at the knee with localized slowing of conduction or Plexopathies. Diagnosis of nerve root damage local
conduction block in these regions. Jablecki and colleagues to nerve plexi often poses a clinical challenge. N
(1993, p. 1392) reviewed 165 articles on the use of NCSs techniques that can localize lesions to the plexi
in carpal tunnel syndrome and concluded that "NCSs are available. Such studies can also provide evidence aga
valid and reproducible clinical laboratory studies that peripheral nerve abnormalities, which could produce s
confirm a clinical diagnosis of CTS with a high degree of lar symptoms. Serial studies can follow the course of pl
sensitivity and specificity." In diabetes, a wide variety of injuries and aid in management and prognosis.
abnormalities can be seen in NCSs (Kimura, 1983). In the System Degenerations. Some system degeneration
Guillain-Barre syndrome, or inflammatory polyradiculopa the central nervous system involve either the dorsal
thy, a wide range of electrophysiologic abnormalities also ganglia or the anterior horn cells. Motor neuron dise
exists (Kimura, 1983). Often, electrophysiologic studies such as amyotrophic lateral scleroSiS, spinal muscular a
can provide longitudinal information concerning the phy, Charcot-Marie-Tooth disease, Kugelberg-Wela
course of a polyneuropathy and can usually be used for disease, and others are characterized by degeneratio
prognosis, as in the Guillain-Barre Syndrome. anterior horn cells and, therefore, loss of peripheral m
Axonal neuropathies can often be found in toxic and axons. This is reflected by a reduction in amplitude of
metabolic disorders. The major abnormality found by CMAP, which is proportional to the loss ofaxons inner
nerve conduction studies is a reduction in amplitude of ing the muscle. Sensory system degenerations are foun
the CMAP or SNAP, simply because fewer nerve fibers spinal cerebellar degeneration, vitamin B12 deficiency,
are present. Some axonal neuropathies, such as vitamin carcinomatous sensory neuropathy. The degenera
B12 deficiency, carcinomatous neuropathy, and Frie seen in sensory pathways in the spinal cord is due to de
dreich's ataxia, predominantly affect sensory fibers, while eration of the cells of origin in the dorsal root ganglia; t
others such as the lead neuropathies seem to affect motor cells are the source of the large sensory fibers in the per
nerve fibers more. eral nerves and therefore show abnormalities with sen
Radiculopathies. Electrophysiologic studies can identify nerve testing. A moderate number of sensory axons m
the specific level of root injury and also differentiate be involved before SNAP amplitudes become notice
result in an abnormally low amplitude CMAP.
Spinal cord
Disorders of the Neuromuscular Junction. The myasthenic
syndrome and botulus poisoning are likely to show changes
in nelVe conduction studies. Both of these conditions result
in a low rate of release of acetylcholine from nelVe
terminals and, therefore, a block of neuromuscular trans
mission to a large portion of the muscle fibers. The CMAPs
are usually of low amplitude.
Disorders of Involuntary Activity. Some disorders are
manifested as stiffness of muscles, myokymia, and cramp
ing. These are due to excessive discharges in peripheral
motor axons. Numerous clinical patterns and a wide varia Motor Muscle fibe
ELECTROMYOGRAPHY
Action potentials seen on
In 1938, Denny-Brown and Pennybacker pointed out oscilloscope screen recor
the clinical utility of analyzing the electric activity of muscle, from needle electrode
Atrophied muscl
Motor neuron
, Regenerating
Technique and Waveform
Q
,V axon
Nomenclature
(l
Reinnervated ~,f The clinical utility of EMG lies in its ability to de
muscle fiber abnormalities in muscle activity resultant to injury to
nerve innervating that muscle. The EMG examina
includes four phases: the evaluation of spontaneous (
ing) muscle activity, insertional activity, activity du
minimal muscle contraction, and activity during max
Action potentials seen on muscle contraction. During these four phases, the e
oscilloscope screen recorded
from needle electrode
tromyographer looks for abnormal electric activity of
I I I I I I I I I I I inserted into muscle muscle. The activity from the needle electrode is led
powerful amplifiers, and the activity is displayed on
oscilloscope screen. The electromyographer often l
FIGURE 9-8. Diagram of motor unit in motor neuron disease. The the output of the amplifier to a loudspeaker; var
motor neuron on the left is degenerating. Its muscle fibers have become
atrophic (symbolized by dotted lines), and units innervated by the abnormal patterns produce distinctive sounds, which
degenerated nerve no longer produce motor unit potentials. This is often facilitate recognition. These needle EMG changes
apparent on the oscillograph screen by decreased rate of action potentials discussed under "Abnormal EMG Activity."
(compared with Fig. 9-7), However, the neuron on the right has sprouted
additional axonal branches that reinnervate some of the denervated The waveforms of various types of normal EMG act
muscle fibers, These muscle fibers produce a larger than normal motor are shown in Figure 9-10.
unit potential (compared with Fig, 9-7), and they also fire spontaneously Spontaneous Activity. A very important point is
at rest (fascicuiations), (Adapted, with permission, from Kandel, E., &
Schwarz, J, H. [1981]. Principles of Neural Science. Stamford, CT: normal muscle fibers, with normal nerve supply, show
Appleton & Lange.) spontaneous (Le., at rest) electric activity.
SPONTANEOUS VOLUNTARY WAVEFORMS OF MUSCLE
ACTIVITY CONTRACTION UNIT POTENTIALS
A
Normal Fasciculation
Positive
sharp wave
~
B
Neurogenic
C
Myopathy
1IIIIIJlIIII
FIGURE 9-10. Some general features of the EMG in normal subjects (A), in patients with neurogenic diseases (B), and in myogenic diseases (C)
rising and falling pattern of action potentials (bottom trace) seen on the oscilloscope is referred to as "myotonic discharge." (Adapted, with permis
from Kandel, E., & Schwarz, J. H. [19811. Principles of Neural Science. Stamford, CT: Appleton & Lange.)
Voluntary Activity. The motor unit potential (MUP) is the of slight differences in intensity and quality which are h
sum of the potentials of muscle fibers innervated by a single to detect in the complex electrometer record." For rea
anterior horn cell. Motor unit potentials are characterized who might visit an EMG laboratory, these various "soun
by their firing pattern and their morphology. Recruitment are described.
is the initiation of firing of additional motor units as the Fibrillation Potentials. Fibrillation potentials are ac
active motor unit potentials increase their rate of discharge, potentials of single muscle fibers that are twitching sp
as when a patient is asked to contract a muscle. taneously in the absence of innervation. Fibrillation po
Abnormal EMG patterns are diagrammed in Figure tials can have two different forms: a brief spike or a pos
9-10B and C. wave. Spikes are considered to be muscle fiber ac
Neuromuscular diseases can show abnormal spontane potentials recorded extracellularly, and positive waves
ous discharges or abnormal voluntary MUPs. Abnormal muscle fiber action potentials recorded from an injured
spontaneous activity includes fibrillation potentials, fas of the muscle fiber. When run into a loudspeaker, fibrilla
ciculation potentials, myotonic discharges, neuromyo potentials sound like the "ticking of a clock," i.e.,
tonic discharges, complex repetitive discharges, myo occur at regular intervals. Any muscle fiber that is de
kymic discharges, and cramps. Only the first two are vated can produce fibrillation potentials, and becaus
encountered frequently in the EMG laboratory. this, a wide variety of both neurogenic and myopa
Motor unit potentials are characterized by their processes can show fibrillation potentials. Fibrillation
morphology-they can have abnormal duration, be tentials can therefore be seen in lower motor neu
polyphasic, or can vary in size. The recruitment pattern of diseases, neuromuscular junction diseases, and mu
MUPs can be altered; all of these are noted by the elec diseases. Fibrillation potentials do not appear immedia
tromyographer. Early on, Adrian and Bronk (1929, p. 10) after motor axon loss but have an onset 14 to 35 days a
noted that recognition of abnormal EMG patterns was injury. They persist until the injured muscle fiber either
made easier if the amplified electric activity was run into a reinnervated or degenerates due to lack of nerve su
loudspeaker, " ... for the ear can pick out each new series (generally about 1.5 to 2 years after denervation).
184 UNIT 2-COMPONENT ASSESSMENTS OF THE ADULT
Fasciculation Potentials. Fasciculation potentials are the years. The founder of modern EMG, Adrian, would
action potentials of a group of muscle fibers innervated by right at home in a modern EMG laboratory, as would
an anterior horn cell, Le., action potentials of an entire developers of sensory and motor NCSs. This is in mar
motor unit. When run into a speaker, fasciculation poten contrast to the almost yearly advances in imaging t
tials sound (to some) like "raindrops on a roof." As niques such as computed tomography (CT) and magn
opposed to fibrillation potentials, fasciculation potentials resonance imaging (MRI). However, several new E
require an intact motor unit; their appearance indicates techniques to study the fine points of motor unit ph
motor unit "irritation." Fasciculation potentials can occur ology have been developed over the last decade or
in normal subjects and in a wide variety of neuromuscular These are single fiber EMG, macro EMG, and scann
disorders. EMG. Despite the enthusiasm of "early adopters"
Myotonic Discharges. These discharges consist of high these techniques, they are, for the most part restricte
frequency trains of action potentials that are provoked by research laboratories or at least very large acade
electrode movement or percussion or contraction of the centers. These techniques are concerned with measu
muscle. The frequency and amplitude of these potentials activity in individual muscle fibers, or displaying the
wax and wane and, consequently, if the signal is run into a tiotemporal activity of an entire motor unit. The intere
speaker, it produces a sound like that of a "dive bomber." reader should consult the article by Stalberg and
The pathogenesis of the myotonic discharge is uncertain oszeghy (1991), which discusses normal and clinical
but it is thought to be related to a disorder of the muscle amples and has a good reference list. For purposes h
fiber membrane. discussion of these emerging techniques is relegated
NeurolDyotonic Discharges (Neurotonic Discharges). the glossary.
These are motor unit potentials associated with continuous
muscle fiber activity. The activity is rapid-1 00 to 300 per
second. Such activity can be seen in chronic spinal muscu CliI'lical Utility
lar atrophy, tetany, and anticholinesterase poisoning.
COlDplex Repetitive Discharges (Bizarre High-Frequency The reader is referred to some of the numerous c
Potentials). Complex repetitive discharges are the action prehensive references on clinical correlations of E
potentials of groups of muscle fibers discharging at high (Aminoff, 1992; Ball, 1993; Brown and Bolton, 19
rates (3 to 40 per second.). The sound of the signal run into Daube, 1985, 1986; Johnson, 1988; Kimura, 19
a speaker has been described as a "motorboat that misfires 1984; Oh, 1984; Shahani 1984; Willison, 1964). On
occasionally. " Complex repetitive discharges are seen in a brief summary is presented here.
variety of myopathic and neurogenic disorders, such as Myopathy. Disorders of muscle can be often defined
poliomyositis, amyotrophic lateral sclerosis, spinal muscu examining the characteristics of motor units. Such cha
lar atrophy, chronic radiculopathies, chronic neuropathies, teristics include the morphology of individual motor u
poliomyositis, and other myopathies. An experienced as well as recruitment and interference patterns.
electromyographer can distinguish complex repetitive dis physiologic abnormality in myopathies is lessened ten
charges from other trains of high-frequency discharges generated by muscle fibers. This is accompanied
such as neuromyotonic discharges, myokymic discharges, decreased size, increased duration, and increased comp
cramps, tremor, and others. ity of motor unit potentials. In many muscle disea
MyokylDic Discharges. Myokymic discharges are sponta electromyographic abnormalities of resting muscle du
neous muscle potentials associated with fine quivering of disruption of the normal connections between the n
muscles, usually in the face. Myokymic discharges rise in and muscle are present. By evaluating these change
the lower motor neuron or axon. They are differentiated myopathic process can be ruled in or ruled out. Elec
from fasciculation potentials by their distinct pattern (flut neurophysiologic studies are important for patient m
tering and bursts), and the discharges have been described agement, as they can establish the presence of a myopa
as the sound of "marching soldiers." Myokymic discharges and can also be helpful prior to muscle biopsies
have a distinct clinical Significance. They are seen in identifying exactly which muscles are clinically invol
patients with multiple scleroSiS, brain stem neoplasm, Serial studies can be used to follow the course o
polyradiculopathy, facial palsy, radiation plexopathy, and myopathy and monitor the effect of therapy.
chronic nerve compression. Nerve conduction should be normal in patients with p
CralDp Potentials. Cramp potentials resemble MUPs. myopathy. However, in many myopathies, including m
They fire at a rate of 30 to 60 per second. They fire when tonic dystrophy, hypothyroidism, sarcoidosis, polymy
a muscle is cramping, Le., when it is activated strongly in a tis, and carcinomatous neuromyopathy, peripheral n
shortened position. Cramps are a normal phenomenon ropathy is usually present. Regarding electromyogra
but can also be indicative of some disorders, including salt abnormalities, an increased amount of insertion act
depletion, chronic neurogenic atrophy, and uremia. (I.e., electric activity recorded immediately on insertio
A common "complaint" about conventional NCS and the needle electrode) may be found in myopathic disord
EMG testing is that very little has changed over the last 40 and abnormal spontaneous activity is often present.
unit potentials during a strong voluntary contraction. A full pain syndromes has explained many patients' compla
interference pattern is recorded, but the potentials are (Travell and Simons 1983,1992), and Headley (1993)
lower in amplitude and have altered wave forms. described a role for surface EMG in various phenome
Neuromuscular Junction Disorder. Electrophysiologic ex which could be attributable to trigger points. One is
aminations can accurately localize clinical disorders of neu concept of referred reflex muscle spasm caused by act
romuscular transmission to the neuromuscular junction. tion of a trigger point in another, sometimes dist
These disorders include myasthenia gravis, Lambert-Eaton muscle. Another phenomenon described by Headle
syndrome, botulism, and the congenital myasthenic syn reflex inhibition of muscle activity by a trigger point
dromes. Disturbances of the neuromuscular junction can distant muscle. This inhibition may be movement spec
also be seen in certain peripheral neuropathies, neuronop Le., a given muscle might work normally during
athies, myopathy, and myotonic disorders. These can be movement but not during another movement. Headley
distinguished from primary disturbance of the neuromuscu provided intriguing examples of how surface EMG can
lar junction by clinical examination and by peripheral used to study such phenomena, and she uses this techni
NCSs. Individual motor unit potentials show a marked as part of a treatment protocol.
variation in morphology because of blocking of impulse The relationship b€ltween paraspinal surface e
transmission to individual fibers within the motor unit. tromyography and low back pain is controversial. Pertin
Radlculopathy. Abnormalities in a myotomal distribution studies can be found in Deluca (1993), Roy and associ
can define a root injqry. Needle EMG in radiculopathies is (1989,1990), and Sihvonen and colleagues (1991).
abnormal only when the injury is of sufficient degree to A problem with selecting patients with low back pain
produce axonal transection or a conduction block. Scientific studies is picking patients with similar pathoph
ology. Aside from disk disease, a number of musculos
etal disorders need to be conSidered, including muo
tension, lumbosacral sprain, strain, and mechanical p
SURFACE ELECTROMYOGRAPHY Clearly, many more studies with large numbers of pati
are needed to clarify the role of surface EMG in elec
In traditional needle EMG, action potentials are recorded diagnosis.
intramuscularly through thin needles. In contrast, the It should be emphasized that surface EMG is curre
frequency and amplitude of single motor unit firing meas considered to be a technique that is not diagnostic
ured with surface EMG muscle activity is recorded from the useful, and its performance is generally not reimbursed
surface of the skin via a disk electrode. What is measured third-party payers. Traditional electromyographers ge
is a summation of muscle action potentials, providing a ally tend to totally discount surface EMG as being of v
general measure of muscle contraction. Thus, needle EMG limited usefulness. One reason is that the technique se
cannot provide general information concerning whole to be technically unsophisticated, but a more impor
muscle contraction, and surface EMG cannot give specific reason is that consistent deSCriptions of surface E
information regarding individual motor units. characteristiCS in back pain patients have not been
The use of surface EMG has been in two main areas: sented. Every possible result has been reported in
1) as biofeedback in pain management; and 2) to try to literature. For example, some studies have shown pati
quantify low back pain due to muscular dysfunction. to have an elevated EMG activity, some have shown th
The use of surface EMG as a biofeedback modality has to have a similar EMG pattern to normals, and some rep
been extensively reviewed by Headley (1993). Since the lowered EMG activity. In some studies, patients with
1960s, biofeedback has been used as a technique to back pain have been found to have asymmetries betw
promote muscle relaxation. The basic premise of the left and right paraspinal muscles. Asymmetries in E
relaxation model of pain management is that pain causes activity are thought to be the result of excessive and chro
stress, and this stress in turn increases anxiety of the bracing and guarding. For patients with elevated E
patient, thereby further increasing the pain. The use of activity, high muscle tension is proposed in a muscle sp
biofeedback for relaxation was based on the assumption model, and in patients with lowered amounts of E
that muscle activity is at a higher level because of anxiety or activity, low muscle tension is proposed by a mu
stress and that muscles are overreactive to stressful activity. deficiency model.
In 1985, Bush and colleagues demonstrated that many
patients with chronic low back pain do not have elevated
paraspinal EMG activity, and they raised the question of
whether relaxation training of chronic low back patients EVOKED POTENTIALS
was a desired protocol. Most research papers, at least early
ones, on surface EMG and low back pain are hampered by Evoked potentials are electric potentials that are ge
lack of control subjects and unclear relationship between ated in the central nervous system in response to sens
the experience of pain and surface EMG measurements. (auditory, visual, somatosensory) stimuli. The existenc
186 UNIT 2-GOMPONENT ASSESSMENTS OF THE ADULT
these potentials has been known for over 100 years, and a
century of literature of data obtained in experimental
animals and humans exists. Just in the period of 1966 to
1993, Index Medicus lists over 32,000 papers on evoked
potentials. Some adequate comprehensive reviews have
been performed; the reader should consult the books by
Aminoff (1992), Chiappa (1983), Halliday (1992), and
Spehlmann (1985), and chapters by Cole and Pease
(1993) and Eisen and Aminoff (1986).
Based on the pioneering studies on evoked potentials
by George Dawson in the 1940s and 1950s (1947,
1954), techniques and equipment were developed in the
1960s that allowed these potentials to be recorded from Thalamu
the scalp of human subjects. Initial studies were per
formed with custom-built computers at the Massachusetts
Institute of Technology in Boston and the Central Institute
for the Deaf in S1. Louis. Since the introduction of
Medial
"user-friendly" special-purpose computers into hospital lemniscus - - - - - - - - - - 1
settings in the 1970s, a vast amount of clinical data has
been obtained.
~--Medulla
Basically, potentials are recorded from the scalp using
conventional electroencephalogram electrodes, which are
fed into a so-called averaging computer. This specialized
computer enables potentials that are evoked by sensory Cuneate fasciculus
Gracile fasciculus - - - - I
stimuli to be extracted from the ongoing brain activity.
Techniques have been developed that enable us to record
from the scalp electric activity generated deep within the
.1 Spinal cord
brain stem. Auditory brain stem eIJoked potentials have la fibers
,tj' proven very useful in detecting structural lesions affecting peripheral nerve
the auditory pathway; therefore, they are useful in detect
ing acoustic neuromas or cerebellopontine angle tumors.
FIGURE 9-11. Anatomic pathways for SEPs. Moderate-int
Various studies report a 95 percent accuracy with this electric stimulation of the peripheral nerve excites the largest myel
technique. fibers. The axons terminate in the spinal cord and then travel upw
Visual eIJoked potentials (VEPs) are used to document the ipsilateral dorsal column pathways of the spinal cord. These tract
cross over to the other side of the brain at the lower brain stem.
structural abnormalities in the visual pathway and, as such, continue upward in the mediallemniscal system of the brain stem
have become routine in the workup of patients suspected thalamus. The fibers then project to the cerebral cortex: Nerves fro
of having multiple sclerOSiS. Even if such a patient had upper extremity project to the sensory cortex located in the parietal
and fibers mediating information from the lower extremities projec
transient visual symptoms a decade prior to testing, VEPs more midline area of sensory cortex.
still accurately register the now subclinical abnormality.
Over the last 20 years, many reports have documented 90
to 100 percent accuracy in detecting generalized demyeli
nating disease. In the last 10 years, techniques have been develope
Somatosensory eIJoked potentials (SEPs or SSEPs) are intraoperative monitoring of sensory pathways in
generated in response to an electric stimulus to a peripheral spinal cord and brain, as well as various cranial n
nerve. These potentials mostly are used to document pathways at risk during neurosurgical or orthopedic
lesions proximal to the spinal nerve root. See Figure 9-11 cedures.
for the anatomic pathways involved in SEP generation. Imaging studies (MRI and CT) give information, so
A segmental analysis can be readily performed by stimu times exquisite, about the anatomy of the central ner
lation of a variety of nerves that enter the spinal cord at system. In contrast, the clinical history, neurologic
different levels. Traditional nerve conduction tests and amination, and electrophysiologic studies give info
EMG often fail to detect lesions that are proximal to the tion concerning the physiology and functional integri
dorsal root ganglion, so this procedure, which is very well the nervous system. It is common to find anato
tolerated by patients, provides complementary and "very abnormalities that do not cause neurologic dysfun
often essential information documenting the source of (Boden et aI., 1990; Jensen et aI., 1994), and conver
sensory disturbance in, say, patients suspected ofhaving it is often not possible for imaging techniques to d
spinal stenosis. onstrate an anatomic basis for a disturbance of cere
imaging techniques are complementary diagnostic pro SOMATOSENSORY EVOKED
cedures rather than alternatives. The anatomic and physi POTENTIALS
ologic information obtained from these procedures needs
to be integrated with the clinical history and status of the Technique
individual patient. Evoked potential studies, like EMGs
and NCSs, should be regarded as an extension of the Stimulus Technique. Although somatosensory potent
clinical examination, with the added advantage of pro can be elicited by mechanical stimulation, most clinical
viding objective, reproducible, and quantitative data con research work utilizes electriC stimulation of periph
cerning these various pathways in the nervous system. nerves. The most commonly studied nerves in the up
Electrophysiologic procedures are somewhat more sen extremity are the median, ulnar, superficial radial, a
sitive in detecting lesions in the brain stem, where MRI sometimes, the musculocutaneous and digital nerves in
is not quite so sensitive. Evoked potential testing is fingers. In the lower extremities, the mostly commo
considerably less expensive than MRI and therefore can studied nerves are the posterior tibial, sural, superfi
often serve as a useful screening test, i.e., if a battery of peroneal, saphenous, and common peroneal. Less co
somatosensory, visual, and possibly auditory evoked po monly studied are the pudendal and lateral femoral c
tentials is normal in a patient with a diagnosis of "possible neous nerves. For mixed nerve stimulation, the intensit
multiple sclerosis," then a series of expensive imaging the electric stimulus is adjusted to obtain a twitch in eit
studies of the brain, -cervical, thoraciC, and lumbar spinal a thumb (for median nerve), little finger (for ulnar nerve)
cord might be deferred, depending on the clinical big toe (for posterior tibial nerve) stimulation. It has b
situation. shown that this intensity is adequate to stimulate the la
myelinated nerve fibers, and no further benefit is obtai
by recording in raising this intensity. Generally,
stimulus is well tolerated by patients, particularly patie
NEAR-FIELD AND FAR-FIELD who have already undergone a peripheral nerve cond
POTENl'lALS tion test, which utilizes a much stronger stimulus intens
In 15 years of performing this test, the author
So-called near-field recording methods are utilized to encountered only two patients who found the stimulus u
record evoked potentials in which the recording electrode for this test to be intolerable. For purely cutaneous ner
is relatively near the generator site, such as cortical evoked such as the sural nerve, the patient feels paresthe
potentials, in which the scalp electrode is placed above the radiating into the peripheral distribution of the nerve be
cortical area of interest-visual, auditory, or somatosen studied when adequate stimulus intensity (for record
sory. These cortical, near-field, evoked potentials have evoked potentials) is attained.
relatively high amplitude, restricted scalp distribution, and Recording Technique. For recording somatosensory
relatively long latencies. Typically, one scalp electrode is tentials, it is of paramount importance that the patien
placed close to the area under study (active electrode), and as relaxed as possible and endeavor to minimize scalp
the other (reference electrode) is placed at a relatively less neck muscle tension because these large muscles can,
active area. usually do, cause considerable myogenic contaminatio
Far-field recording methods are used for recording the recording of the evoked potential. Therefore, it is us
potentials that are thought to be generated a relatively long to have the patient either lying down or lying back i
distance from the recording electrode, i.e., in the brain reclining chair and as comfortable and as relaxed
stem or spinal cord. Far-field potentials were first described possible.
by Jewett and Williston in 1970 (1971) in studies of the The recording protocol suggested by Chiappa (19
auditory system. These investigators described a series of has proven to give clinically useful results. BaSica
potentials generated in the auditory centers of the brain Chiappa proposed for upper extremity stimulation reco
stem that could be recorded at the level of the scalp. This ing the peripheral volley over the brachial plexus from
finding was basically not accepted by the authorities at that location known as Erb's point and then from electro
time and was initially widely ridiculed as being impossible. placed over the posterior neck recording potentials gen
However, Jewett's pioneering studies were quickly cor ated in the spinal cord or lower brain stem, and t
roborated by others, and clinical uses were found. Soon recording from somatosensory cortex over the lateral sc
far-field potentials were also discovered for the somatosen area. The reference (inactive) electrode is placed over
sory system. Far-field potentials recorded at the scalp have frontal midline region (Fig. 9-12). Some purists h
an extremely low amplitude (1 microvolt or less, three objected to this technique, but this recording mont
orders of magnitude smaller than potentials recorded with provides good clinical data and has been used by
NCSs on EMG) and require sophisticated techniques and present author since 1980 with excellent clinical corr
high-quality eqUipment. tion. For lower extremity stimulation, analogous potent
=. ~"--
188 UNIT 2-COMPONENT ASSESSMENTS OF THE ADULT
CT myelograms had normal SEPs. Saal and colleagues secondary gain or a conversion reaction, and this is q
(1992) studied SEP results from 100 consecutive patients commonly commonly encountered in the neurology
referred for the evaluation of upper lumbar radiculopathy physical medicine clinic. Electrophysiologic measures
and offer some statistics with regard to the sensitivity, provide support for the clinical impression, but nor
specificity, and predictive value of SEP and EMG with ref electrophysiologic tests certainly do not rule out any neu
erence to anatomic imaging tests. For example, for L4 logic disorder.
radiculopathies, they found the SEP to be in 100 percent
agreement with the imaging study, whereas EMG was only
in agreement 64 percent of the time. For L2 and L3 radicu
lopathies, the SEP was in agreement 88 percent of the DERMATOMAL EVOKED POTENTIALS
time. In this study, EMG testing was negative in 23 of 26
cases in which SEP abnormalities corresponded to ana Theoretically, one should be able to stimulate over
tomic pathology. skin of specific dermatomes (as opposed to stimula
Although there are many other studies in the literature, directly over a nerve) and record cerebral responses (
these studies are representative. Although most investiga 9-14). A scalp recorded potential so recorded is referre
tors summarize their results as finding that the SEP is as a dermatomal (somatosensory) evoked potent
"useful," it is dear that studies with much larger numbers Theoretically, such a potential should be a reflection
of patients with proven pathology are needed to quantify input from just one sensory nerve root. This is a popular
the actual usefulness of this technique. Like other electro controversial technique at present. Dermatomal stim
physiologic studies, SEP testing is sometimes more an art
than a science; in both test administration and interpreta
tion and patient selection, a certain amount of subjective
ness is acceptable.
Plelopathy. SEPs can often provide accurate localization
of root avulsion in traumatic plexopathies. As mentioned,
needle EMG can only show abnormalities after nerve
degeneration has progressed distally. Thus, shortly after
trauma, SEP testing can give a fair amount of information,
sometimes prognostic, about the continuity between pe
C5
ripheral and central nervous systems, Le., ability to elicit
SEPs when evidence of plexopathy exists suggests a more
favorable prognosis than if the SEP cannot be recorded
at all.
..
Cervical Spondylotic Myelopathy. It has been the author's
experience that SEPs are quite helpful in the work-up of
patients with cervical spondylosis. Paradoxically, in pa T12/
/
used in guiding therapy and in basic knowledge of the diseases as multiple sclerosis and amyotrophic
pathophysiology of movement disorders. Since these sclerosis, as well as for critical use in surgical dec
techniques are not in widespread use, they are not making, e.g., for treatment of carpal tunnel syndro
presented here. The interested reader should consult the during intraoperative monitoring during spine or
survey by Hallett (1992). surgery.
The goal of the electrodiagnostic consultation
electrophysiologic evaluation of the peripheral n
nerve roots, central nervous system, neuromuscular
GUIDELINES FOR ELECTRODIAGNOSTIC tion, and muscles and correlation of these results wi
TESTING whole clinical picture to arrive at an accurate diagno
the patient. It is the position of the American Acade
The American Association for Electrodiagnostic Medi Eiectrodiagnostic Medicine that the electrodiagnosti
cine has published fairly speCific gUidelines (1992) as to sultant should be a physician who has had special tr
what is the appropriate testing for various neuromuscular in neurologic and neuromuscular diseases and also
disorders. These gUidelines should be consulted to see if a application of the techniques described in this chapte
particular test on a patient was adequate to make diagnostic electrodiagnostic consultation is an extension of the
inferences. Basically, the guidelines merely propose com rologic examination; unlike most laboratory tests
mon sense, i.e., studying several nerves before making a testing is not done in a standard fashion and must of
diagnosis of polyneuropathy, studying several muscles modified for an individual patient. Certain electrodia
within a myotome, and studying several muscles outside tic technicians who are certified in evoked potent
that myotome when assessing for radiculopathy. These peripheral nerve testing often conduct these tests b
guidelines, however, only make recommendations for not render the final interpretation. A controversial a
peripheral nerve testing and needle electromyography and the performance of needle electromyography . Techn
do not address evoked potentials, motor evoked potentials, are often employed to perform this test to cut cost
Single-fiber EMG or surface EMG. Guidelines for clinical many authorities believe that only physicians shoul
evoked potential studies have been published by the form any examination that requires needle insertion
American EEG Society (1994). is the position of the American Association of Elec
agnostic Medicine, the American Medical Associatio
.. t,.
i American Academy of Neurology, the American Aca
of PhYSical Medicine and Rehabilitation, the Am
."
=I.:. WHO SHOULD PERFORM Neurologic Association, and the Department of Ve
ELECTRODIAGNOSTIC TESTING? Affairs (Veterans Administration).
The following are numbers and addresses of organiza for that fiber-Le., conduction along motor fibers tow
tions involved in electrodiagnostic testing. In addition to the spinal cord and conduction along sensory fibers aw
these national organizations, there are many state and from the spinal cord.
regional suborganizations. Cathode-The negative terminal of a source of elec
AAEM (American Association of Eledrodiag current.
nostic Medicine). (Formerly the American Asso Cerebral evoked potential-Electric waveforms
ciation of Electromyography and Electrodiagnosis.) biologic origin recorded over the head and elicited
Blackenridge Skyway Plaza, 21 Second Street, S.W., sensory stimuli. See specific evoked potentials, e.g., som
#103, Rochester, Minnesota 55901. (507) 288-0100. tosensory evoked potential, visual evoked potent
MET (American Association of Electrodiagnos auditory evoked potential.
tic Techs). P.O. Box 79489, North Dartmouth, Cramp discharge-Repetitive firing of action potent
Massachusetts 02747. (508) 771-1220. with the configuration of motor unit potentials at a h
AAN (American Academy of Neurology). 2221 frequency in a large area of muscle, associated with
University Avenue, S.w., Suite 335, Minneapolis, Min involuntary, painful muscle contraction (cramp).
nesota 55414. (612) 623-8115. Depolarization-A decrease in the electric poten
AEEGS (American EEG Society). p.o. Box 30, difference across a membrane from any cause, to
Bloomfield, Connecticut 06002. (203) 243-3977; (203) degree, relative to the normal resting potential.
286-0787. polarization.
ASET (American Society of Electroneurodiag Electrode-A device capable of conduction of electric
nostic Technologists). 204 W. 7th Street, Carroll, Electrodes may be used to record an electric poten
Iowa 51401. (712) 792-2978. difference (recording electrodes) or to apply an elec
current (stimulating electrodes). In both cases, two e
trodes are always required.
Electromyography (EMG)-Recording of electric
tivity of muscles can be accomplished with needle
Action potential-The all-or-none, self-propagating, surface electrodes.
nondecrementing voltage change recorded from an excit End-plate activity-Spontaneous electric activity
able muscle or nerve. Commonly, the term refers to the corded with a needle electrode close to muscle end-pla
(nearly) synchronous summated action potentials of a
Evoked compound muscle action potential-T
group of cells, e.g., motor unit potential.
electric activity of a muscle produced by stimulation of
Amp6tude-With reference to an action potential or nerves supplying the muscle. See M wave, F wave,
evoked potential, the maximum voltage difference be H wave reflex.
tween two points, usually baseline to peak or peak to peak.
Evoked potential-Electric waveform elicited by
Anode-The positive terminal of a source of electric temporally related to a stimulus, most commonly
current.
electric, visual, or auditory stimulus delivered to a sens
Antidromic-Refers to an action potential or the stimu
receptor or nerve. See action potential, cerebral evo
lation causing the action potential that propagates in the
potential, somatosensory spinal evoked potential,
direction opposite to the normal (Le., orthodromic) one
sual evoked potential.
1
194 UNIT 2-GOMPONENT ASSESSMENTS OF THE ADULT
Brown, W. F., & Bolton, c. F. (Eds.). (1987). Clinical electromyography. Hallett, M. (1992). Electrophysiological evaluation of moveme
Boston: Butterworth. ders. In M. J. Aminoff (Ed.), Electrodiagnosis in clinical ne
Buchthal, F. (1961). The general concept of the motor unit. Neuromus (pp. 403-419). New York: Churchill Livingstone.
cular Disorders, 38, 3-30. Halliday, A. M. (Ed.). (1992). Evoked potentials in clinical test
Buchthal, F., & Rosenfalck, P. (1966). Spontaneous electrical activity of ed.) (p. 741). New York: Churchill Livingstone.
human muscle. Electroencephalography and Clinical Neurophysiol Headley, B. J. (1993). The use of biofeedback in pain mana
ogy, 20, 32l. Physical Therapy Practice, 2, 29-40.
Buchthal, F., Rosenfa1ck, A., & Belise, F. (1975). Sensory potentials of Hodes, R., Larrabee, M. G., & German, W. (1948). The
normal and diseased nerves. In P. J. Dyck, P. K Thomas, & E. I. I. electromyogram in response to nerve stimulation and t
Lambert (Eds.), Peripheral Neuropathy (pp. 442-464). Philadelphia: duction velocity of motor axons. Studies on normal
W. B. Saunders. injured peripheral nerves. Archiues of Neurologic Psychia
Burke, R. E. (1981). Motor units: Anatomy, physiology, and functional 340-365.
organization. InJ. M. Brookhart & V. B. Mountcastle (Eds.), Handbook Hume, A. L., Cant, B. R., & Shaw, N. A. (1979). Central somato
of physiology: Section 1, the nervous system. Vol. II: Motor control, conduction time in comatose patients. Annals of Neuro
part 1 (pp. 345-422). Baltimore: Williams & Wilkins. 379-384.
Burke, D., Skuse, N. F., & Lethlean, A. K (1981). Cutaneous and muscle Jablecki, C. K, Andary, M. T., So, Y. T., et al. (1993). Literatur
afferent components of the cerebral potential evoked by electrical of the usefulness of nerve conduction studies and electromyogr
stimulation of human peripheral nerve. Electroencephalography and the evaluation of patients with carpal tunnel syndrome. Mu
Clinical Neurophysiology, 51,579-588. Nerve, 16, 1392-1414.
Bush, C., Ditto, B., & Fruerstein, M. (1985). A controlled evaluation of Jensen, M. C., Brant-Zawadki, M. N., Obuchowski, N., et al.
paraspinal EMG biofeedback In the treatment of chronic low back pain. Magnetic resonance imaging of the lumbar spine in people
Health Psychology, 4, 307-32l. back pain. New England Journal of Medicine, 331, 69-73
Chlappa, K H. (1983). Euoked potentials in clinical medicine. New Jewett, D. L., & Williston, J. S. (1971). Auditory-evoked f
York: Raven Press. averaged from the scalp of humans. Brain, 94, 681-696.
Chokroverty, S. (Ed). (1990). Magnetic stimulation in clinical neuro Johnson, E. (Ed.). (1988). Practical electromyography. Ba
physiology. Boston: Butterworth. Williams & Wilkins.
Cole, J. L., & Pease, W. S. (1993). Central nervous system electrophysi Katifi, H. A., & Sedgwick, E. M. (1987). Evaluation of the der
ology. In J. A. Delisa (Ed.), Rehabilitation medicine: Principles and somatosensory evoked potential in the diagnosis of lumbosa
practice (pp. 308-335). Philadelphia: J. B. Lippincott. compression. Journal of Neurology, Neurosurgery and Psy
Cros, D., Chiappa, K H., Gominak, S., Fang, J., Santamaria, J., King, 50,1204.
P. J., & Shahani, B. T. (1990). Cervical magnetic stimulation. Kimura, J. (1983). Electrodiagnosis in diseases of nerue and
,. , Neurology, 40,1751-1756. Principles and practices. Philadelphia: F. A. Davis.
Daube, J. R. (1985). Electrophysiologic studies in the diagnosis and
Kimura, J. (1984). Principles and pitfalls of nerve conduction
prognosis of motor neuron disease. Neurologic Clinics, 3, 473-494.
Annals of Neurology, 16, 415-429.
-
J
•. :. ,I
.,'
Daube, J. R. (1991). Needle examination in clinical electromyography.
The application of scientific investigation to the ampu underlying cause of the observed signs and symptoms, the
tee 's gait began just after World War II with the return home the evaluation can be more thorough. The followin
of thousands of veteran amputees. It was at this time that sections outline what the literature has described as typic
the Committee on Prosthetics and Research Development gait variations or deviations associated with transtibial an
of the National Research Council established the Biome transfemoral amputees. The majority of these imbalance
chanic Laboratories to study prosthetics and amputee do not act independently of each other; in fact, many act
rehabilitation. The University of California (UC) at Berkley combination, depending on the cause of the asymmetry
and UC San Francisco were primarily concerned with Bearing in mind the similarities and associated pattern
lower limb study, and the UC Los Angeles' focus was the betl..veen the gait variations described will help the clinicia
upper limb (Sanders, 1986). Inman and colleagues (1981) to better visualize the amputee's gait pattern.
were charged with the investigation of the fundamentals of
human walking and the role of prosthetics with respect to
the amputee. Measurement techniques included the use of
motion picture cameras positioned along the walkway for
TRANSTIBIALAMPUTEE-VARIATIONS
sagittal and frontal views. Transverse plane data were FROM NORMAL GAIT
collected using the cameras placed below glass walkways
(Eberhart & Inman, 1951). Ground reaction forces were Engsberg and coworkers (1990) found that childre
measured using forceplates, and electromyography (EMG) with transtibial amputations tend to walk with
study provided information concerning muscle activity greater forward flexion of the trunk. This has also
(Gage & Hicks, 1985). The remarkable amount of research been observed in adult amputees. Altered posture,
and the number of publications produced by this distin relocation of the COM to a more anterior position
guished group of investigators helped establish the stan and loss of proprioception in the prosthetiC limb
dards in prosthetic fabrication, alignment, and amputee resulting in the need to view the floor are some of
assessment. The tl..vo noted publications authored by this the common explanations when loss of range of
exceptional gathering of scientists, Human Limbs and motion at the hip or trunk is not at fault.
Their Substitutes (Klopsteg et al., 1968) and Human In the frontal plane, the COM remains over the
Walking (Inman et al., 1981), continue to provide the nonprosthetic limb in children throughout the gait
time-tested foundation for prosthetiC researchers and cycle. Additionally, the trunk has a tendency to shi
clinicians today and have been described as the final toward the nonprosthetic limb during both non
statement on gait analysis of the precomputer era (Ca prosthetic and prosthetic support (Engsberg et al.,
vanagh & Henley, 1993). 1992). While this study focused on children, adults
Saunders and colleagues identified six major determi may also tend to maintain relatively greater body
nants of gait (Saunders et al. , 1953). What they were weight support over the sound limb throughout
essentially describing was the ability of humans to control stance, suggesting an adaptation to lack of function
the center of mass (COM) over base of support (BOS) or lack of confidence in the prosthetic limb.
during walking. Any deviation from the delicate rhythmic • Increased hip extensor activity in the prosthetic
movement of COM over BOS could have an effect on limb is present during early stance and mid-stance.
the individual's gait pattern and overall energy expendi This burst of muscular activity is believed to assist i
ture during walking. The more harmonious the displace propelling the body forward and compensating for
ment of the COM within the body, the less muscular effort the lack of energy generated during late stance due
is required to maintain upright posture and allow mo to the absence of the ankle (Czerniecki et al.,
mentum to carry the body from one foot to another in 1991; Gitter et al. , 1991; Winter & Sienko, 1988)
a balanced and efficient manner. The identification of • The time from initial contact on the ground to load
critical events that maintain normal displacement of COM ing response when the prosthetiC foot is flat on the
over BOS gives the observer insight into the events that ground is greater for the amputee because of the
assist humans in maintaining balance and minimizing rigid prosthetic ankle (Winter & Sienko, 1988).
CI The loss of plantar flexion at terminal stance repre
effort during walking. For the amputee, regardless of the
level of amputation, prosthetiC fitting and gait training sents a significant loss in the mechanical power
should be focused on the restoration of ambulation while generated during the normal gait cycle. As previ
minimizing any deviation from the natural plane of pro ously described , the increased hip extensor output
gression of the body's COM over its BOS. Compensatory is the major compensatory mechanism for this
mechanisms for an imbalance in the displacement of the loss (Czerniecki et al., 1991; Gitter et al., 1991 ;
COM over the BOS in amputees result in asymmetric gait Winter & Sienko, 1988).
patterns and the increased metabolic cost of walking
(Engsberg et al., 1990; Engsberg et al., 1992; Hannah To compensate for the loss of active plantar flexio
& Morrison, 1984). "energy storing" or " dynamic response" prosthetic fe
As with any assessment, if the evaluator understands the were designed to give the amputee some "spring" ju
TRANSTlBIAL AMPUTEE MEAN VELOCITY. CADENCE. AND STRIDE LENGDI
Author Cause Velocity (mlmin I±» Cadence (steps/min I±» Stride Length (m
prior to the swing phase of gait. The "stored energy" is studies report that forces acting across the sou
mechanical energy that is absorbed as the force of the limb joints of amputees are no different from
amputee's body weight is placed over the foot's deflector joint forces experienced by non-amputees, sug
plate during mid-stance and returned as the limb moves ing no predisposition for degenerative change
toward swing. Gitter and associates (1991) did report a (Hurley et aL, 1990; Lewallen et aL, 1986). In
difference in the mechanical efficiency, the ratio of energy study, Hungarford and Cockin (1975) found t
absorbed during mid-stance to the energy released during the knee on the amputated side had severe qu
terminal stance, between prosthetic feet. The solid ankle ceps atrophy , marked osteoarthritis, and mod
cushion heel (SACH) foot efficiency was 39%, Seattle Foot ate joint space narrowing. However, the ampu
71 %, and Flex Foot 89%, which was considerably less group had fewer complaints of pain than the
compared with the efficiency ratio generated (264%) by the control group with similar findings.
active contraction of the intact plantar flexors. Interest • Asymmetry of prosthetic gait results if optima
ingly, there is no significant difference in the pattern or alignment is not achieved. Prosthetic foot dors
magnitude of power output generated by the knee and hip ion is the most important prosthetic alignmen
between dynamic prosthetic feet and nondynamic pros change, and hip flexion-extension motions are
thetic feet (Gitter et aL, 1991; Winter & Sienko, 1988). most sensitive to alignment changes (Hannah
Therefore, there appears to be little or no compensation by Morrison, 1984).
the hip or knee moving the limb into swing to make up for Walking velocity and cadence have been consi
the loss of plantar flexion. tently demonstrated as less than those in nona
The prosthetic limb typically has a longer step putee ambulators (Pagliarulo et aL, 1979; Rob
length, and the time to complete the step is less & Smidt, 1981; Waters et aL , 1976; Winter &
than that of the nonprosthetic limb. As a result, Sienko, 1988) (Tables 10-1 and 10-2). Wate
greater acceleration is accomplished by the pros colleagues (1976, 1988) demonstrated that ca
thetic limb (BreakIy, 1976; Robinson et aL , 1977). of amputation has a direct relationship to walk
The faster the amputee walks, the greater the velocity and cadence, with vascular amputees
asymmetry in step length, with the prosthetic limb ing more slowly than traumatic amputees. Ho
taking longer and faster steps (Robinson et aI., ever, it appears that walking speed is not relat
1977). This could be attributed to the amputee at length of residual limb or the weight of the pro
tempting to increase walking speed by overcom thesis (Gailey et aI., 1994).
pensating with the limb that is at fault for slowing The metabolic cost of ambulation for the trans
him or her down. amputee is greater than that for nonamputee
Stance time is longer on the nonprosthetic limb lators (Huang et aL , 1979; Pagliarulo et al., 1
than the prosthetic limb (BreakIy, 1976; Robinson
et aL, 1977). Greater stance time on the nonpros TABLE 10--L
thetic limb may provide greater stability and an
opportunity to maintain balance. The reduction NONAMPUTEE MEAN VELOCI1Y.
in stance on the prosthetic limb is frequently attrib CADENCE. AND STRIDE LENGDI
uted to one or more of the following: poor balance,
weakness, pain, lack of confidence while on the Cade nce
Velocity (steps/min Stride L
prosthesis, or a combination of factors. Author (mlmin I±I) I±» (m I±
Alteration in normal walking patterns over many
years may result in degenerative changes to Drillis (1958) 87 113 1.53
weight-bearing joints on the sound limb (Burke et Finley (1970) 78 114 1.38
Waters et a\. 80 113 1.42
aL, 1978; Hungarford & Cockin, 1975; Klopsteg (1988)
et aL , 1968; Powers et aL, 1994). However, other
202 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
TABLE 10-3
OF AMBUJATION
Rate of Oxygen Uptake Net Oxygen Cost Heart Rate
Author Type (mVkg/min I±]) (ml/kg/m I±]) (beats/min I±])
Waters et al., 1976). In an attempt to reduce prosthetic limb is a common gait deviation (Jae
oxygen uptake and heart rate, amputees may adopt gers et al., 1995; James , 1973c; Klopsteg et al.,
a slower walking speed (Table 10-3). 1968). James (1973c) noted that with a decrease i
Other influencing factors such as age, self-selected walking the width of the walking base, there is decreased
speed, prosthetic weight (Gailey et a1., 1994), and the type lateral trunk bending. The assumption is that
of prosthetic foot , such as the "energy storing " prosthetic decreasing step width decreases the lateral displace
feet or dynamic feet versus the use of conventional ment in COM; consequently, less contractile effort
prosthetic feet such as the SACH foot , do not reduce the would be necessary to control trunk movement. An
metabolic cost of amputee walking (Lehmann et a1. , 1993; other reason for late ral trunk bending over the
Perry & Shanfield , 1993) . The length of the residual limb prosthetic side is that the amputee is attempting to
(Gailey et aI. , 1994; Gonzalez et aI., 1974) and the cause reduce weight-bearing directly over the prosthetic
of amputation (Waters et al., 1976) appear to have the limb because of pain, instability, poor balance, or
most Significant effect on the metabolic energy cost of lack of trust in the prosthesis.
walking for transtibial amputees. • The inability of the prosthetic knee to flex during
early stance results in an upward acceleration of
the trunk as the body progresses over the prostheti
limb toward mid-stance (Klopsteg et aI., 1968).
The most Significant consequence is the loss of
TRANSFEMORAL AMPUTEES smooth progression of the vertical displacement of
VARIATIONS FROM NORMAL GAIT COM and, as a result , an increase in the metabolic
cost of walking (Peizer et al., 1969).
Transfemoral amputees have been described Because of the loss of musculoskeletal tissue, there
as having an increase in stride width during ambula is a loss of muscle strength and a greater difficulty
tion, increasing the displacement of the COM lat in balanCing over the prosthesis . Balance problems
erally (James & Oberg, 1973; Murray et aI. , 1964; and loss of strength are directly related to the
Zuniga et aI., 1972). One suggested reason for length of the residual limb: amputees with shorter
the increase in walking width is prosthetic side hip limbs experience greater difficulties than those with
abductor weakness, which would require greater lat longer limbs (Jaegers et al., 1995; James, 1973a;
eral stability (Jaegers et al., 1995; James & Oberg, James, 1973c; Ryser et aI., 1988). Consequently,
1973). Another possible explanation expands on transfemoral amputees compensate for the
the lateral stability concept. As with transtibial am decreased ability to maintain Single-limb balance
putees, the COM of the transfemoral amputees over the prosthesis by taking a shorter stride length
may have a tendency to shift over the nonpros with the sound limb, a faster prosthetiC step , or a
thetic limb , providing greater stability; therefore , lateral lean of the trunk over the prosthetic limb
the sound limb adducts . If the prosthetic limb were in an attempt to reduce weight bearing and main
to follow the natural forward progression, the width tain balance.
of walking base would be more narrow, resulting • Lack of ankle plantar flexion in the prosthetic limb
in the prosthetic limb 's having to exert greater mus results in the amputee relying on the hip flexors to
cular stability as the COM moves laterally during flex the hip and prosthetic knee during terminal
prosthetic stance. If the prosthetic limb is slightly stance. To flex the knee, a contraction of the hip
more abducted, a strut effect occurs during stance, greater than normal is required, and in addition,
requiring less muscular effort and greater lateral sta flexion must be initiated conSiderably earlier than
bility. normal (Hale, 1991; Klopsteg et al., 1968). How
Increased lateral bending of the trunk over the ever, most transfemoral amputees tend to flex the
(Jaegers et aI., 1995). Additionally, medium- to over the prosthesis produces a shorter step le
short-limbed transfemoral amputees demonstrate with the nonprosthetic limb.
faster transition from hip extension to hip flexion to There is an increase in the double-support ph
assist in flexing the prosthetic knee (Jaegers et aI., indicating a need for additional stability (Jaege
1995). Restoration of rotation of the pelvis in the aI., 1995; James & Oberg , 1973; Murray et
transverse plane assists in passively flexing the knee 1981). To maintain balance, the amputee inc
(Inman et aI., 1981 ; Peizer et aI., 1969; Stokes et the period of double support before progressi
aI., 1989) and may eliminate the need to over to the next phase of Single-limb support.
compensate with the hip flexors. Unfortunately, A slight increase in knee flexion on the nonpr
many amputees lose pelvic rotation because they thetic limb during stance may be present to as
use their hip flexors to " kick" the prosthetic leg for in absorbing increased ground reaction forces
ward. (Jaegers et aI. , 1995 ; James & Oberg, 1973)
More time is spent on the anatomic heel-midfoot • As with transtibial amputees, in transfemoral
and mid foot-toe and less at mid foot than on the tees Hungarford and Cockin (1975) found on
prosthetic side (Zuniga et aI., 1972). The loss of graphs of the nonamputated limb hip greater
smooth transition and normal timing of weight dence of osteoporosis and joint space narrow
transfer over the sound stance limb may be attrib than in nonamputee controls and an absence
uted to altered pelvic and hip mechanics of the teophytes. Only 10 percent of 54 transfemor
prosthetic limb. Because the amputee typically at amputees had normal radiographs . Patellofem
tempts to generate sufficient momentum to flex the osteoarthritis in the sound limb was found to
prosthetic knee by "kicking" the prosthesis for considerably higher in the amputees than in n
ward, there is a tendency to keep the COM over amputees, with 63 percent of the transfemora
the heel of the stance limb. The posterior rotation putees, 41 percent of transtibial amputees, an
of the pelvis and the increased hip flexion on the only 22 percent of the control group demons
prosthetic side do not permit the smooth transition positive findings.
of the COM from the heel to toe on the stance Transfemoral amputees have decreased velOC
limb. Instead, the COM remains over the heel for a cadence as compared with transtibial ampute
longer period of time as the swing limb recovers nonamputee ambulators (Godfrey et aI., 1975
from the upward thrust initiated to propel the pros James, 1973b; Murray et aI. , 1981; Waters e
thetic limb forward. To make up for the increased 1976) (Table 10-4; see also Table 10-2). Inte
time spent on the heel , there is a need for a rapid estingly, it has been suggested that walking sp
transition over the midfoot to get to the toe in time not related to residual limb length (Jaegers et
as the prosthetic limb descends during terminal 1995).
swing and the sound limb prepares to leave the • The metabolic cost of ambulation for the
ground. transfemoral amputees is also greater than th
Transfemoral amputees typically take a longer step for the transtibial amputees and nonamputee
with the prosthetic limb and demonstrate an (Table 10-5). RedUCing the speed of ambulati
increased stance time on the sound limb (James & assists in lowering the energy cost and heart r
Oberg, 1973; Murray et aI., 1981; Skinner and (Huang et aI., 1979; Waters et aI., 1976). Mo
Effeney, 1985; Zuniga et aI., 1972). As previously over, each of the previously described variatio
discussed, the amputee has greater confidence from normal gait has some impact on the ove
during single-limb support over the sound limb and metabolic energy cost of walking . Therefore,
TA [~ [ r: 1(l-4
D = DysvascuJar; T = traumatic.
--
.
~
-
------ ~
-
-.:"
204 tJNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
TABLE 10 S
need for reducing the extent of the deviations bilitation outcome than age, level of amputation,
becomes paramount during the gait training and number of limbs involved (Brodzka et aI., 1990; Chan
prosthetic fitting process. Tan , 1990; Medhat et aI., 1990; Nissen & Newm
Comprehension of the principles of gait permits the 1992; Pinzur et aI. , 1992; Walker et aI., 1994).
clinician to have greater insight into the variance that exists The level of amputation can have a Significant impact
between normal and prosthetic gait, as well as the differ the amputee 's ability to adjust to learning to ambulate w
ences within the various levels of amputation. Moreover, the prosthesis. There are several individual factors t
once the cause of the deviation is identified, an appropriate must be considered when determining the expected gait
treatment plan may be designed to address the specific a particular level of amputation. The inability to adequat
needs of the individual. If the amputee lacks the physical master anyone of these contributing factors can prevent
strength , balance, or gait biomechanics to walk correctly, amputee from reaching an optimal level of gait. Yet,
then these issues may be addressed. Conversely, if the amputee with a high-level amputation who goes on
prosthesis is at fault and requires an alignment adjustment master each of the components of gait can achieve
or modification , then the necessary prosthetic action may higher-quality gait than an amputee with presuma
be taken. greater potential who does not learn to walk properly fo
multitude of reasons (Medhat et aI., 1990; Pinzur et
1992). The following is a summary of the influenc
elements associated with the level of amputation a
prosthetic componentry. A brief statement of each e
CRITICAL ELEMENTS OF GAIT WITH ment is followed by a sample question the clinician m
RESPECT 10 LEVEL OF AMPUTATION want to consider when assessing the amputee.
AND PROSTHESIS The degree of displacement of the COM over the
BOS in all three planes of movement. Maintainin
The causes for amputation in North America can be normal displacement of COM over BOS optimize
divided into four categories; however, estimate.s on the anatomic movement and metabolic cost of gait.
percentages do vary. Approximately 70 to 90 percent are Any alteration of COM displacement results in
the result of vascular disease, less than 20 percent are for compensatory movements and increased metabol
traumatic reasons, approximately 4 percent are because of cost (Engsberg et aI., 1992; Peizer et aI., 1969;
tumor, and 4 percent are congenital (Glattly, 1963; Glattly , Saunders et aI. , 1953).
1964; Kerstein, 1974; Sanders, 1986; Tooms, 1980). Can the amputee maintain the expected displa
During the period leading to amputation, there frequently ment of the COM over the BOS without compen
exist secondary complications that could affect gait or satory movements such as unequal stance time,
function. Amputees with vascular disease commonly have increased lateral trunk leaning, or decreased arm
problems associated with diabetes, heart disease, and other swing?
debilitating diagnoses. Traumatic amputees present with Asymmetry of motion secondary to an imbalance
fractures , soft tissue injuries, or neuromuscular impair the muscle groups between the lower extremities
ments associated with the accident. Congenital amputees (Breakly, 1976; Engsberg et aI., 1992). Frequent
may have more than one extremity involved or associated muscle groups become abnormally hyperactive
neuromuscular complications. during the gait cycle as a compensatory mechani
Age can influence the amputee's ability to ambulate with or to provide a sense of security to the amputee
a prosthesis , just as age influences the gait of nonamputee (Gitter et aI. , 1991 ; Winter & Sienko, 1988).
ambulators. This is not to say that age alone dictates the Can muscle of the residual limb be reeducated
amputee's capabilities. On the contrary, level of activity prevent unwarranted hyperactivity during certain
prior to amputation has a greater influence on the reha phases and to create a smooth progression of the
trunk, and arms? Will the amputee be able to maximize the u
Diminished coordinated movement between the re of the remaining muscles that may have been
maining anatomic joints secondary to the loss of altered in length , length-tension relationship ,
proprioceptive feedback and absence of muscu by surgical technique?
lature on the prosthetic side (Mensch & Ellis , 1986; • The potential increase in body temperature se
Skinner & Effeney, 1985; Waters et al., 1976). ary to loss of skin surface area disrupts the bo
Can the amputee move the prosthetic foot/ankle natural homeostasis. This leads to an overall
assembly, knee, and hip joint fluidly and effiCiently increase in metabolic cost during all activities
with the remaining musculature and without (Levy, 1983; Mensch & Ellis, 1986).
proprioceptive feedback from the absent jOints? Will the amputee reach a level of cardiopulm
• The loss of the normal biomechanics of the ana nary fitness to overcome the physiologic defic
tomic ankle and foot and the inability of the pros minimize the metabolic cost of ambulation?
thesis to simulate specific movements. This would The amputee's gait can vary significantly depend
include the loss of not only muscle and joints but the cause of amputation, associated diagnoses, a
also their roles in gait, such as propelling the level of amputation and the critical elements asso
body forward during late stance or functioning with each level of amputation. Because there are so
as shock absorbers (Fisher & GoUickson , 1978; variables regarding amputee gait, it is difficult to i
Radcliffe , 1962). one particular pattern that can be associated w
Will the amputee be able to compensate for this particular " type " of amputee. It is for this reaso
loss physically or with a prosthetiC device? normal gait may be used as the gold standard for al
• Anatomic limitations of the residual limb or physi of amputation , realizing that in the majority of amp
ologic requirements result in a compromise in predisposing factors beyond their control limit their
prosthetiC design or alignment. The effect of the to obtain a " normal" gait pattern.
prosthetiC design on the mechanics of gait may
cause the amputee to deviate from a normal gait
pattern (Murphy & Wilson, 1962; Radcliffe , 1955;
Radcliffe, 1957 ; Radcliffe, 1961 ; Radcliffe, 1962).
Will the compensations made in prosthetic de FUNCTIONAL GAIT ASSESSMENT
sign because of predisposing physical abnormalities OF THE AMPUTEE
significantly affect the overall gait pattern?
The kinetic energy normally stored as potentiall en Because amputee gait is complex and there are so
ergy in the anatomic limb during gait is absent critical elements , the idea of observing an amputee
(Ganguli et al., 1973; Gitter et ai., 1991; Yoshihiro and simply identifying one or two causes for a par
et a!., 1993). The prosthetic limb offers limited ki deviation may result in a misdiagnosis or inco
netic energy return. More dynamic prosthetiC assessment. Therefore, it may be worth the eval
components available today offer some mechanical time to perform a more in-depth assessment in an a
potential energy storage; however, this varies tre to gain greater insight into the ' ;big picture. "
mendously between components, amputees, and a Ambulation profiles are defined as clinical te
variety of other conditions. locomotion skill (Craik & Oatis , 1995; Reimers,
Does the amputee have the ability to produce or Wolf, 1979) or as quantitative methods of ass
receive maximum benefit from the kinetic energy ambulatory function (Craik & Oatis, 1995; Olney
return stored within the prosthetiC limb? 1979; Wolf, 1979). The information obtained from
• The loss of the skeletal lever arm . The proximal tests can provide a more global view of the patient's
muscle groups acting on the remaining bone must to maintain standing balance, negotiate turns, an
overcome a longer lever arm to control the entire from a chair, and , in some cases , of physiologic factor
lower extremity during the gait sequence (Ganguli et as decreased cardiorespiratory or muscular endu
al., 1973; James, 1973c; Mensch & Ellis, 1986). Used along with a standard gait evaluation, the ambu
Does the amputee have the ability to sufficiently profile tests can determine how a patient walks and
control the prostheSis with the remaining bone functi onal limitations may prevent him or her from
length? ing an optimal level of gait. The clinical adminis
• The loss of contractile tissue results in diminished requires only an assessment form, walkway , sta
potential strength (Ganguli et ai., 1973; James, rehabilitation equipment, and minimal time and
1973c; Mensch & Ellis, 1986; Winter & Sienko, Moreover, interrater reliability for ambulation profil
1988). The changes in insertions of the remaining generally is good. Currently, no one assessment too
musculature are altered , consequently changing to evaluate the amputee 's locomotive function. Ho
---
- --=--
206 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
A~! ~JlA I
ltl
Reference Limb:
LD RD i(
I I Major deviation Weight
Accept
Single-Limb
Support
Swing Limb
Advancement MAJOR
r- Minor deviation [C LR MSt TSt PSw ISw MSw TSw PROBLEMS:
Trunk Lean: B/F
Latera[ lean: RlL
Rotates: B/F
Pelvis Hikes Weight
1---+-- - - + - - - 1 - - --1-- - 1 - - -1----+----11 Acceptance
Ti[t: PIA
Lacks forward rotation
Lacks backward rotation
Excess forward rotation
Excess backward rotation
Ipsilateral drop
Contralateral drop
Hip F[exion: limited Single-Limb
1---r---I----r---I----r---r------+----~ISupport
excess
Inadequate extension
Past retract
Rotation: [RiER
Ad/Abduction: Ad/Ab
Knee F[exion: limited
excess
Inadequate extension
Wobbles
Hyperextends Swing Limb
1---1-------1------+------+------+------+------+------11 Advancement
Extension thrust
Varus/valgus: VrN[
Excess contralateral flex
Ankle Forefoot contact
Foot-f[at contact
Foot slap
Excess plantar flexion
Excess dorsiflexion
Inversion/eversion : Iv/Ev
I I I Excessive UE
Weight Bearing D
Heel off
No heel off
!Drag
~--~----~-----+----~r-----t----II----_t----~IName
Contralateral' vaulting
Toes Up
Inadequate extension
Clawed D ! Diagnosis
© 1991 LARE[, Rancho Los Amigos Medical Center, Downey, CA 90242
FIGURE 10-1. Form for ful[-body gait analysis. (Courtesy of Rancho Los Amigos Medica[ Center, Physical Therapy Department.)
Sagittal Weight Single-Limb
View Acceptance Support Swing
eliminated depends on whether the assessment was correct ation (Fig . 10-1) is an excellent tool to assist the ev
and the treatment appropriate and on the patient's ability in systematically identifying the minor and major
to respond to the treatment. Consequently, there is a need tions that occur during each phase of gait. The ev
for a confirmation of the original diagnosis, reassessment must then determine the cause of the deviation{s
of the current treatment plan, and an appraisal for future general categories-{I) impaired motor control, (2)
treatment plans . The process of reassessment must be mal joint range of motion, (3) impaired sensation (in
performed whether an elaborate motion analysis, EMG, balance), and (4) pain (Observational Gait A
and ground force gait evaluation are performed or if the 1993)-are potential amputee causes, while on
therapist used OGA to evaluate and prepare the rehabili tional category-(5) prosthetic causes-must be in
tation treatment. for amputee assessment. It should be emphasize
there are four major categories for potential cause
deviations that are amputee related and one that i
thetic related. This is an important note because t
PROSTHETIC OBSERVATIONAL quently the prosthesis is distinguished as being
GAIT ASSESSMENT for the amputee 's gait deviations. When attempts to
the prosthesis are performed and the deviation p
Assessment of the amputee 's gait does not differ from becomes worse, or is replaced by another deviation
the evaluation of any other patient diagnosis. A form such cians may want to further explore the potential am
as Rancho Los Amigos Medical Center's Full Body Evalu causes rather than persisting in modifying the pros
210 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
The Prosthetic Observational Gait Assessment Form mon deviations observed with all levels of lower extremi
(POGA) (Fig. 10-2) and the corresponding Prosthetic Gait amputees, and the corresponding Gait Assessment Char
Deviation Identification Charts (Tables 10-7 and 10-8) are suggest the possible causes for the observed gait devi
designed to simplify the process of identifying a gait tions.
deviation and determining the cause of the deviation To use the assessment system, the evaluator systemat
(Gailey, 1996). The assessment form lists the most com- cally observes the various body segments from the groun
TABLE 10- 7
2. Inadequate suspension
Uneven arm swing 1. Poorly fitted socket causing pain or insta 1. Poor balance
3. Habit
From Gailey, RS. (1996). One step ahead: An integrated approach to lower ex tremity prosthetics and amputee rehabilitation . Miami, FL: A
Rehabilitation Therapy.
up as the amputee walks. Each of the three general phases ing the evaluation . Without the necessary informatio
of gait-weight acceptance, single-limb support, and both planes, deviations may be missed or misinter
SWing-should be partitioned in the observer's mind to Interestingly, Krebs and coworkers (1985) found
assist in isolating the deviation. Finally, the evaluator must reliability with sagittal view assessment, whereas E
consider both the sagittal and frontal views when perform- and colleagues (1991) found that frontal plane asse
212 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
TAI3LE lOS
External rotation of the prosthesis 1. Anterior or medial brim pressure 1. Extension force too great
2. Too-stiff heel cushion or plantar flexion 2. Poor residual limb muscle control
bumper 3 . Improperly donned prosthesis
3. Too long a heel lever
4. Too much built-in toe-out
Knee flexion or instability 1. Knee axis too far ahead of TKA line 1. Weak hip extensors
2. Insufficient socket flexion 2. Severe hip flexion contracture
3. Too-long heel lever arm 3. Altered height of shoes
4. Too-stiff heel cushion or plantar flexion
bumper
5. Too much dorsiflexion
Foot slap 1. Too-soft heel cushion or plantar flexion 1. Too-forceful driving of prosthesis to the
bumper ground ensuring knee stability
2. Too short a heel lever
Single-Limb Support (Mid-Stance to Terminal Stance)
Increased knee flexion (excessive 1. Insufficient knee friction 1. Too-strong hip flexion
heel rise)
Increased knee extension (terminal 1. Insufficient knee friction 1. TOO-Vigorous hip flexion followed by
impact) strong hip extension
2. Security to ensure knee extension
Medial whip 1. Excessive external rotation l. Improper donning of prosthesis
2. Too-tight socket 2. Excessive adipose tissue with poor muscl
3. Excessive valgus of prosthetic knee control
4. Scilesian belt too tight laterally
TRANSFEMORALAMPUI'EE PROS11lETIC GAIT DEVIATION IDENTIFICATION CHART Conti
Gait Deviation Prosthetic Cause Amputee Cause
2. Vaulting
Sound Limb and Arm Swing
3. Habit
Unequal step length 1. Improperly fitted socket causing pain 1. Fear and insecurity
From Gailey, R. S. (1996) . One step ahead: an integrated approach to lower extremity prosthetics and amputee rehabilitation. Miami, FL: A
Rehabilitation Therapy.
was more reliable when performing OGA Clinically, commonly observed for transtibial and transfemo
however, the evaluator should observe from both planes putees are listed in the Prosthetic Gait Assessment
and in many cases must be aware of the amputee's Other excellent resources offer a more complete li
endurance level to ensure that an accurate picture of the potential deviations, many of which are rarel
walking pattern can be observed before fatigue becomes a (Bowker & Michael, 1992; Lower-Limb Pros
factor. 1980; Mensch & Ellis, 1986; Sanders, 1986).
Once the gait deviation(s) have been identified by using To confirm the assessment, the evaluator may w
the POGA form, the cause for the gait deviation should be attempt to correct the deviation by instructing the am
confirmed by using the Prosthetic Gait Deviation Identifi on how to physically overcome the impairment o
cation Chart. The evaluator must determine if the deviation the appropriate prosthetic adjustment. Unfortu
is related to physical or prosthetic causes. The potential when it comes to physical limitation, it is not
amputee and prosthetic causes for gait deviations most possible to correct the deviation immediately. In
214 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
cases, because of physical deconditioning , diagnosis, or Temporospatial- The relationship of time and spac
other impairment, the amputee might have to adopt a less Transfemoral amputee-A person with an ampu
than satisfactory gait pattern. However, it is important to tion site through the femur bone (above-knee ampute
note that prosthetic componentry and gait training meth
Transtibial amputee-A person with an amputati
ods introduced over the last decade have offered many fit
site through the tibial/fibula bone. The site must be abo
and motivated amputees the ability to learn how to walk
the malleoli but not past the knee joint (below-kn
with barely a detectable gait deviation .
amputee).
Weight acceptance f - The initial period in the g
cycle when body weight is dropped onto the limb. T
CONCLUSIONS phases of initial contact and loading response are involve
- --
~
. -
- - ~ - -
216 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
problems in elderly patients. Journal of the American Geriatrics pathological gait and for rehabilitation protocols. Physiotherap
Society , 34(2}, 119-126. Callada , 37(4}, 245-252.
Tooms, R. E. (1980). Incidence of amputation. In A. Edmonson & Winter, D. A. (1984). Kinematic and kinetic patterns in human gait
A . H . Greenshaw (Eds.), Campbell's Operative Orthopedics (6th ed.). Variability and compensating effects. Human Movement Science, 3
Vol. 1. St. Louis. MO : C. V. Mosby. 51-76.
Volpicelli, L. J., Chambers, R. B , Wagner, F. w., et al. (1983). Am Winter, D. A., & Sienko, S. E. (1988) . Biomechanics of below-kne
bulation levels of bilateral lower-extremity amputees. J Bone Joint amputee gait. Journal of Biomechanics, 21(5), 361-367.
Surg 65A(5}, 599-605. Wolf, S. L. (1979). A method for quantifying ambulatory activities
Walker, C. R C. , Ingram. M. G., Hullen, M. G, et al. (1994). Lower limb PhYSical Therapy, 59, 767-768.
amputation following injury: A survey of long-term functional outcome. Yoshihiro E., Masatoshi, B., Nomura, S., Kunimi, Y, & Takahashi, S
Injury, 25, 387- 392. (1993). Energy storing property of so-called energy-storing prostheti
Waters, R L. , Lunsford, B. R, Perry, J., et al. (1988). Energy-speed feet. Archives of Physical Medicine and Rehabilitation, 74,68-72
relation of walking: Standard tables. Journal of Orthopedic Research, Zatsiorsky, V. M., Werner, S. L. , & Kaimin, M. A. (1994). Basi
6,215-222. kinematics of walking: Step length and step frequency. A review
Waters, R L. , Perry, J., Antonelli, D., et al. (1976). Energy cost of Journal of Sports Medicin e and Physical Fitness, 34(2), 109-134
amputees: The influence of level of amputation. Journal of Bone and Zuniga, E. N., Leavitt, L. A., Calvert, J. c., et al. (1972). Gait patterns i
Joint Surgery, 58A(1}, 42-46. above-knee amputees. Archives of Physical Medicine and Rehabili
Winter, D. A. (1985). Concerning th e scientific basis for the diagnosis of tation, 53, 373-382.
A myriad of assessment tools are available to aid in the Academy of Orthopedic Surgeons (1975) . These form
determination of a prescription for an upper extremity provide a means to diagrammatically record a biomechani
orthosis or prosthesis. This has led to the development of cal analysis of the upper extremity and to translate thi
a wide range of descriptive forms used to record informa analysis into an orthotic or prosthetic prescription. The
tion and organize the results of these many assessments. assessments recorded in this form include patient vari
Authors well noted for their expertise in the fields of ables, status of the upper limb, range of motion (ROM)
orthotics, prosthetics, occupational and physical therapy, volitional motor strength, sensibility, and an orthotic
and medicine have published many of the evaluations in recommendation .
use today . Fess and Philips (1987) present a series of uppe
A series of technical analysis forms for orthotic and extremity evaluations including prescription forms and
prosthetic prescription was published in 1975 by the checkout forms for both orthotics and prosthetics. The
Committee on Prosthetics and Orthotics of the American forms presented were created for use in independen
include those components noted above with the addition of nyms describing the anatomic parts it crosses and u
functional assessments of one's ability to perform activities description of the mechanical action on that body
of daily living (ADL) . Therefore, the orthosis mentioned earlier is describe
These forms record and organize information but do not dynamic WHO with MCP extensor assist digits 2-5
assist in the analysis of that information or in the decision Terminology in the prosthetics community has rem
making process that culminates in an optimally prescribed stable, with little deviation noted from utilizing the
orthosis or prosthesis . This chapter presents a decision tree nyms of BE for a below-elbow prosthesis, AE f
that organizes the flow of information toward a final above-elbow prosthesis, and SD for a shoulder disar
functional outcome-the custom-fabricated and -fit ortho tion prosthesis. Consistent acceptance of this termin
sis or prosthesis. The decision tree utilizes the data from the makes for clear communication between team mem
necessary evaluation tools described in depth throughout with less room for misinterpretation.
this text. The branches of the tree guide the clinician
through the process of assessment, analysis, and decision
making to choose the most appropriate path utilizing
objective data and empiric evidence as necessary. DECISIONTREE (Fig. 10-3)
Evaluation is by its nature a hierarchic proc
investigation. Information gleaned from one asses
TERMINOLOGY often leads to the choice of another evaluation too
tool may further define the original data, or it may l
In an attempt to create a common terminology with an altogether different path of investigation. The
which to describe orthoses, the American Academy of chosen for the evaluation are dependent on avail
Orthopedic Surgery suggests the use of acronyms (1975). familiarity, and the skill and knowledge level o
These acronyms are based on the joints an orthosis investigator.
crosses. A hand orthosis becomes an HO, a forearm-based An assessment tool is instructive only to the exte
orthosis that crosses the wrist and hand becomes a WHO. the analysis of the information it provides is relevant
Further information is added by describing the components question being asked. The decision tree is suggeste
added to the base orthosis . A WHO with MCP (metacar means to assist in the formulation of appropriat
pophalangeal) extension assist 2-5 is a forearm base with necessary questions. With the ever-increasing ar
an outrigger providing a dynamic force to assist the second assessment tools and the ever-decreasing time avail
through fifth digits into MP joint extension. The intent of use those tools, it is imperative that the questions ask
this terminology was to facilitate communication among answered lead to appropriate clinical decisions .
team members to ensure understanding and compliance
with the ultimate prescription . The terminology has found
its greatest acceptance in the description of lower extremity
orthoses. The upper extremity terminology and the tech DIAGNOSIS
nical analysis forms , however, have not yet found universal
acceptance in the medical or therapy communities . It is the ultimate responsibility of the treating clini
The American Society of Hand Therapists has published understand the implications of a given diagnosis. Ad
a Splint Classification System (SCS, 1992) that describes ments in medical technology have furthered the refin
upper extremity splints in functional rather than in design of the diagnostic process . The results from ma
terms. The SCS describes three overriding purposes of resonance imaging and arthroscopic surgical explo
splints: restrictive , immobilizing, and mobilizing. Splints provide the clinician with in-depth knowledge o
may fulfill more than one function or purpose, depending structures involved in a diagnosis. They do not, ho
on the method of fabrication and the problems being lead to improved orthotic treatment for that dia
addressed. This results in rather extensive descriptive unless further assessment is performed to identi
terminology that has not as yet been incorporated into the biomechanical effects of the given disease or traum
majority of clinical recording forms. The treating clinicians, whether specialists or ge
Upper extremity orthotics terminology is further hin ists , must take it on themselves to clarify any question
dered by the common usage of two different terms, have when presented with a diagnosis and a prescr
orthosis and splint, to describe the same device. In the for an upper extremity orthosis or prosthesis. The d
presentation of any measurement tool , uniform terminol sis is very simply only a first clue in the investi
ogy must be used if there is to be agreement on what is process. The diagnosis should guide the clinician to a
being measured and on how the measurement is to be questions and perform the biomechanical assessmen
described. The term orthosis is used throughout this prove or disprove the efficacy of the prescription. Per
218 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
Upper
Upper
Extremity
Extremity
Orthotics
Orthotics
Single surface
ROM
Circumferential
Sensibility
Dynamic
Upper Strength
Serial static
Extremity Volume
Static progressive Plaster
Orthotics Pain
Semiflexible Leather
Rest or protect Function
Resilient Rubber and
Restore motion Age Circulation
components silicone
Restore function Sex Tissue
Outriggers Low-temperatur
Prevention Cognition Proximal stability
Hinges plastic
Primary Socioeconomic
External power Foam
Upper Work history Upper
Fabric
Extremity Avocation Extremity
Upper High-temperatur
Prosthetics Expectations Prosthetics
Extremity plastic
Replace grasp ROM
Prosthetics Laminates
Extend control Sensibility
Body powered Metal
Body image Muscle control
Myoelectric
ADL independence Wound
Cosmetic
Immediate
Terminal device
postoperative
Wrist unit
fitting
Socket
Edema control
Hinges
Strength
Elbow unit
FIGURE 10-3. The decision tree is presented to assist the clinician through the process of determining and providing the optimal orthosis or prosthes
Use of the decision tree is a hierarchic process whereby information at one branch leads the clinician to the next higher level of decision making .
questions must consider the status of skeletal involvement, cal burns; vascular disease, including arteriosclerosis o
soft tissue structures, and neurologic involvement. vasospastic disease; tumors; infections; or neurotroph
A necessary question to be asked is "How long has it disease, such as diabetes. In the case of congenit
been since the onset of disease or trauma?" Soft tissue, problems, terminal deficiency is the type seen mor
including muscle, tendon, and skin, undergoes structural frequently; however, patients also present with termin
changes with the onset of trauma , edema, or long-term deformity and with permanent nerve loss, such as brachi
immobilization . With long-term flexion contractures, the plexus injury with flail arm.
shortening of the musculotendinous junctures, along with
reabsorption of volar skin, may make reduction of a
contracture with intermittent orthotic application unfea
sible. l ong-term posturing of the neurologically impaired PURPOSE-ORTHOTIICS
hand may have led to functional contractures, which, if
reduced, would lead to loss of fW1ction rather than func It is wise to consider at this point in the decision proce
tional gains. what an orthosis cannot do, as well as what it can do. A
In the case of the upper extremity prosthetiC prescrip orthosis can provide mobility or stability to a joint b
tion , the diagnosis of partial hand, wrist disarticulation, generally not both. An orthosis cannot proVide dexterity
long below-elbow, short below-elbow, elbow dislocation, and it can generally supply only one type of prehension.
long above-elbow, short above-elbow, or shoulder disar can provide gross strength but with little or no control ov
ticulation amputation is only the description of the level of the amount of force applied. Although an orthosis ca
amputation . The diagnosis must also be considered in substitute for the natural protective padding of the hand
terms of the cause of the absence, be it traumatic or a degree, cushions or pads add bulk and may imped
congenital. Upper extremity amputations can result from a mobility. An orthosis can do virtually nothing to a
variety of trauma , including avulsion or crush-type injury; sensibility and in fact often hinders it by covering sensa
thermal injury, including frostbite, electric burns, or chemi surfaces. Finally, an orthosis can rarely substitute for th
and functional hand, but during the treatment process ,
these desirable features may be compromised.
The stated purpose of an orthosis must have a measur
able outcome if one is to determine the effectiveness of the
intervention. In determining purpose, assessments are
suggested to clarify the pathology we seek to treat or
alleviate. Many authors have described other categories for
upper extremity orthotics (Brand, 1993; Fess & Philips,
1987; Redford, 1986; Rose, 1986). Although one could
probably argue for the addition of several categories, four
are identified here.
Restore Joint Motion or addition, this static force is not likely to facili
Correct Deformity involuntary contraction. A serial static orthosis su
cylindrical cast is an example of an orthotic app
Several orthotic designs are available when restoration often indicated to correct a long-standing contractur
of joint ROM is desired. Dynamic orthoses can be fabri patient cooperation in an orthotics program is not f
cated to restore motion through the use of resilient
components, or a static progressive design may be indi
cated. Dynamic orthoses utilize a variety of mechanisms Restore or Augment Function
with which to provide traction , including springs, rubber
bands, and woven or knitted elastic threads or straps Orthoses fabricated to substitute for lost or im
(Fig. 10-4). Static progressive designs use nonresilient function span the spectrum from simple hinged o
straps or buckle designs to apply traction (Fig . 10-5). Serial that align or control motion to complex externally p
static designs rely on remolding by the clinician to reposi orthoses. Function may be supplied by one o
tion a joint at end range to facilitate tissue expansion . designs . First, the dynamic functional design uses e
Orthoses with resilient or dynamic components are con power or dynamic components to assist insuffic
traindicated in the presence of involuntary muscle contrac replace absent muscle innervation. The externally p
tions. For such patients, static progressive components orthosis is an example of this design. Second, an
may be useful, as they are designed to apply an adjustable functional orthosis can be designed to mechanically
static force against which the patient cannot move. In fer power from one joint to another. A radial nerv
WHO with static MP assist 2-5 is an example of th
10-6). Finally, a passive functional orthosis au
function through the stabilization of unstable joints,
positioning the hand to accomplish functional task
Prevent Deformity or
Cumulative Trauma
Muscle contractures that occur due to the para
paresis of the antagonist may be prevented by posi
FIGURE 10-4. This dynamic orthosis consists of a static base, outrigger, the muscle at its resting length to prevent shorteni
and traction supplied by steel springs. reduction of muscle fibers. One example of a fun
220 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
orthotic or prosthetic use. The cognitively impaired indi ses or at least different terminal devices to meet his or h
vidual requires the assistance of a competent and motivated job demands.
caregiver to ensure carryover with a prescribed wearing
program . If a dedicated caregiver is not available , the
choice of no orthosis or prosthesis, as opposed to one Avocational History
improperly applied or unused, may be in the best interest
of the patient. The upper extremity prosthesis should provide th
amputee with the ability not only to return successfully
employment but also , wherever possible, to return to his
Socioeconomic Status her avocational life. This may require consideration
special terminal devices or other components to allow f
The economics involved in the fabrication of an initial task performance (Figure 10-10).
orthosis or prosthesis and the cost of maintenance must be
considered. The clinician may eschew more expensive,
"high-tech" components when these are not economically Patient Expectations
feasible. In an environment of ever-rising restraints on
reimbursement, the economics of necessary rehabilitation The traumatic amputee who has had no previo
technology may be borne more and more by the recipient. exposure to another amputee or to a prosthetic device
Clinicians must be sensitive to the financial resources of likely to have unrealistic expectations. He or she may hav
their patients. read about or seen a "bionic arm" and may expect
This again points to the situation of the child amputee receive a "replacement arm." He or she may be fearf
who may do quite well with an externally powered pros about the course of life without an arm or part of an arm
thesis. Insurance may only pay for the initial fitting. The The sooner questions can be answered and correct info
child will need adjustments on a yearly basis or perhaps
even more frequently; therefore, unless the family can pay
for the equipment or find another source to help, the child
will not be kept in well-fitting devices.
Another consideration is the amputee who lives in a
remote area or whose home does not have electriCity. The
battery-powered prosthesis requires access to electricity to
charge the battery and to more regular maintenance to
keep it in good working order. Where access to these
services is questionable , body power is more reliable.
Work History
The motivation of a person wishing to return to gainful
employment plays a major role in his or her acceptance or
rejection of an orthosis or prosthesis. The clinician must
not discount the possible societal or finan cial rewards for
not returning to employment. The person motivated by the
desire or the necessity of returning to work is likely to assist
in the determination of which orthosis or prosthesis to
fabricate. It is necessary to fully understand the demands of
a person's job to choose the appropriate components that
will ensure adequate force and maximal longevity for a
given device. The component requirements for the carpen
ter are different than those for the office administrator.
The work history of the upper extremity amputee is
important in making decisions related to prosthetic com
ponents , harnessing , and suspension and is a strong
determinant in the choice of a body- versus electrically
powered prosthesis. Special terminal devices are available
for specific occupations, especially in the Dorrance series
FIGURE 16-10. This patient with a below-elbow amputation is usi
(Dorrance Company, Campbell, California). The individual a p rehensile hand terminal device for his woodworking project. He us
whose job has several facets may require different prosthe a split hook for most activities.
Definitive orthoses, in contrast to prostheses, are gen initial visit. The clinician may simply establish a base'lin
erally fit farther along in the rehabilitation process. The the jOints included in the orthosis by recording the po
patient may have already been fit with a temporary orthosis of the joints within the orthosis. One certain ma
for the purpose of training as well as for determining the progress is the recovery of motion that allows for impr
optimal functional position in which to fabricate the fina l orthotic positioning , even as pain persists.
orthosis. Generally, if an orthosis provides meaningful Pain caused by inflammation secondary 10 overu
function-that is, meaningful to the recipient-it will be more easily assessed, and only the arc of motion in w
accepted . If the orthosis acts as a hindrance for those tasks the patient experiences the pain need be restricted
the patient deems important, it will likely be rejected. advent of semi flexible orthoses that allow for midr
motion but increase their restriction as range incr
requires that the clinician record two sets of measurem
available active ROM and pain-free active ROM.
ASSESSMENTS Sensibility. In the presence of acute trauma, assess
of pain may be solely via subjective report from the pa
It is at this branch of the tree that the decision variables It is likely that in the most acute stages, the patie
for orthotics and prosthetics diverge. It is the difference clinician is unable to distinguish between subjective
inherent in providing areplacement for a missing limb or in and objective sensibility. If pain is secondary to a diag
providing a support or assist for an existing part that of nerve entrapment or localized inflammation, the
necessitates this divergence . Although the ultimate objec cian needs to establish some baseline measure of sen
tive may be the same-to restore function-the assess ity. It is suggested that a brief evaluation of light to
ments necessary to achieve this objective vary. For clarity deep pressure responses be performed using mon
and ease of following the decision process, the branches of ments. This assessment is suggested for the purpo
the orthotics decision tree are presented first , followed by comparison rather than as a basis for treatment plan
the branches of the prosthetic decision tree. The final Strength Testing. When a resting orthosis is prescrib
branch converges to present materials common to both reduce pain related to a chronic diagnosis , an abbrev
orthotics and prosthetics. assessment of functional strength patterns may b
dicated.
Volume. Volumetric assessment may be indicat
either acute or subacute trauma, as well as in the pres
ORTHOTICS of chronic inflammatory disease . It is essential to r
vo~ume prior to the application of an orthOSiS, as any
Once it has been determined that an orthosis is appro of immobilization may exacerbate edema due to
priate, that the patient is accepting of the need for an decrease in active muscle function when the hand or
orthosis, and what it is that the clinician wishes to is put at rest. Of particular interest to the treating clin
accomplish, the true work of gathering data begins. Each should be the effect of volume on pain. A volum
clinician must have a basic set of evaluation tools and a reduction that is not accompanied by an expressed r
thorough knowtedge base to use those tools properly . This tion in pain and increase in ROM may indicate
text concerns itself with specific evaluation techniques, and extensive tissue or skeletal involvement.
the reader is referred to the appropriate chapters for Subjective Pain Assessment. Pain is a subjective s
greater detail and depth in technique . What is presented tion and should be recorded in a consistent manner
here is the rationale behind the use of a particular use of scales on which the patient indicates a level of
evaluation. The appropriate evaluation techniques and may be used and reassessed over time (Merskey, 197
tools are discussed for each of the four defined orthotic pain scale developed for clinical use by this author
purposes. measures how restrictive pain is in the performance of
activities is suggested as one means of demonstr
progress to the patient (see Appendix A at the end o
Rest or Protection for Pain Reduction chapter). The use of body charts may aid the clinici
distinguishing the site of injury from areas of referred
Range of Motion. Orthoses fabricated for the purpose of and help to define the appropriate intervention.
rest or protection, by their very definition, restrict motion. assessment of pain should be independent of the pre
It is therefore necessary to determine precisely the degree one. The patient should be given a clean recording
and arc or motion one seeks to restrict. In the presence of each time and not encouraged to compare levels from
acute trauma, it may not be possible to determine the origin assessment to the next. This limits the ~ikelihood
of the pain or precisely which structures are involved. symptom exacerbation will influence the choice of
Careful recording of available ROM prior to providing vention.
224 UNIT TWO-COMPONENT ASSESSMENTS OF THE ADULT
Functional ·Task Performance. By its very definition, a presupposes normal function of the sympathetic nerv
protective orthosis is meant to rest a part to relieve pain. In that supply vasomotor function (skin color and temper
the case of an acute trauma, the patient's performance of ture), sudomotor function (sweat), pilomotor functio
tasks with the involved extremity is contraindicated. As (goose flesh response) , and trophic function (skin textur
sessment of functional skills is done only to assess the soft-tissue atrophy , nail and hair changes, and rate
patient's ability to perform one-handed tasks. It is desirable healing) (Callahan, 1 984) . The reduction in or loss of an
that the dinician be schooled in the use of adaptive of these sympathetic nerve functions affects the plastic an
equipment and techniques needed to ensure that a patient viscoelastic properties of skin. Normal skin provides
will not be unduly burdened by an orthosis. unparalleled cushion to protect the underlying skeleto
If this is a subacute injury or chronic disease for which a maintains the flexibility needed to allow for motion, an
semiflexible orthosis will be used during activity, the responds to the stresses placed on it by creating callus
clinician needs to perform a simple task analysis to ensure distribute pressure. Sympathetic dysfunction impairs t
that the patient can perform necessary tasks while wearing plasticity and elasticity of the skin, contributing to ischem
the orthosis without exacerbating symptoms. The danger and eventual breakdown.
in not ascertaining and limiting those activities that exac If the presenting diagnosis or the patient's subjecti
erbate pain is that the chosen intervention will fail. report indicates possible sensory involvement, a thoroug
cutaneous sensibility evaluation is necessary before dete
mining an orthotic prescription. The available battery
Restore Motion or Correct Deformity cutaneous sensibility assessments does not include anyon
conclusive assessment from which to determine the stat
Range of Motion. Perhaps no orthotic application re of a patient's sensation.
quires as careful and thorough a patient assessment as does From the available tests, an evaluation of light touc
the fitting of an orthosis designed to restore motion or deep pressure response is suggested using the Semme
correct deformity. This type of orthosis is meant to increase Weinstein aesthesiometer monofilaments available fro
motion in one, or possibly several, planes. Therefore, it is North Coast Medical, San Jose , California (Bell-Krotoski
necessary to have a precise recording not only of the al., 1990; Brand, 1993; Gelberman et al., 1983; vo
degree of available ROM but also of the amount of torque Prince & Butler, 1967). This assessment is chosen for
required to achieve this motion. repeatability and standardization of the pressure applied
The techniques of torque ROM are well described in each filament (Figure 10-11) . The information gather
hand therapy literature (Bell-Krotoski et al. . 1990: Brand, aids the clinician in determining the areas of the hand
1993; F,Jowers & Pheasant, 1988). Torque ROM is useful extremity most likely to tolerate traction, determine a
in distinguishing tendon restriction from joint capsule appropriate wearing schedule, and facilitate necessa
restriction and in differentiating viscous restriction from precautions when it is not possible to avoid positioni
elastic restraint. The torque angle curve (TAC) is a graphic traction over areas of skin that demonstrate impair
representation of a series of torque angle measurements. cutaneous or sympathetic function.
The development of a TAC provides the information In the absence of a conclusive cutaneous sensory exam
necessary to determine at what angle to apply traction , nation, the clinician should be careful not to discount t
how much force to apply, and for how long. The TAC of a patient's subjective report. The patient may descri
joint most likely to respond to orthotic application is a symptoms elicited only with evocative activity or positio
gradual or soft curve, demonstrating a slow progressive
resistance to force. The indication of a soft end-feel or
"give" as the TAC is developed bodes well for the success
of orthotic treatment. The joint that produces an abrupt,
sharp curve is likely to reqLlire a longer period of treatment,
and the ultimate response may be less than optimal.
The type and amount of leverage utilized , the wearing
schedule, and the need for frequent readjustments and
realignment are in great part determined by the informa
tion gained from the TAC. The "giving" joint can be
expected to respond more rapidly and require more
frequent angle adjustments. The firmer, contracted joint
may require longer wearing times and is likely to tolerate
less force application due to the opposing reaction of firmly
restricted structures.
Sensibility. The skin's normal expected tolerance to FIGURE 10-11. Tests oj response to light touch-deep pressure usi
monofilaments produce objective and repeatable data to be employed
force is given at a pressure of 50 g/cm 2 and may be as high the decision process. (Courtesy of North Coast Medical, San Jo
as 100 Kg/cm 2 (Brand , 1993; Yamada, 19 70). This California.)
Circulation. The vascular supply of the hand should be
assessed prior to the application of any orthosis, particu
larly when the goal of the orthosis is to restore motion Restore or Augment Function
through the application of traction . The primary blood
supply to the hand , through the radial and ulnar arteries, Range of Motion. A primary consideration when
can be compromised through the fitting of an orthosis, mining the feasibility of fitting an orthosis design
especially in the presence of edema. restore function is whether passive RO M is suffic
A visual check of color and palpation of the radial and achieve the desired outcome. If it is not , it will be nec
ulnar pulses at the wrist may be all that is required. to first fit an orthosis to restore motion . It is not desir
However, if any sign of cyanosis is noted or pulses are felt all cases to achieve full passive or active ROM.
to be diminished, the Allen's test for arterial patency may limitation may be {unctional , as in the fitting of a
be performed (Ashbell et al., 1967). The test involves driven tenodesis orthosis limitation in interphalange
having the patient exsanguinate the hand through fisting joint extension and metacarpophalangeal (MCP)
while the clinician occludes the ulnar and radial arteries flexion is desirable to achieve a stable pinch.
with pressure at the wrist. The patient then opens the hand Recording of total active motion (TAM) and total p
while the examiner releases either the ulnar or radial artery motion (TPM) is recommended to assist in the deter
and watches for revascularization. The procedure is re tion of proper positioning. Total active motion and
peated , and the opposite artery is evaluated. This test is proVide a picture of functional, not necessarily full ,
dependent on the patient's ability to perform fisting , which Care should be taken when recording digital TAM and
is often not viable in the absence of full motion. A positive to note and be consistent in place ment of the wri
result, particularly if th.ere is involvement in both arteries, forea rm when recording digital ROM .
may preclude orthotic fitting. If an orthotic fitting is done, Sensibility. The greatest limitation of upper ext
close and frequent inspection must be performed to orthotics is that they can impede hand function
monitor vascularity. presence of sensory impairment. An orthosis often h
strength. Assessment of strength may be indicated to disadvantage of covering sensate areas of the ha
determine the force available to counteract the reaction of extremity, thereby restricting fLUlctional use of thes
the orthosis. If the patient can move against a resilient force faces. The cutaneoLls sensibility battery should lead
to relieve pressure, an orthosis is likely to be tolerated for development of a map of the hand that clearly defines
longer wearing periods. The performance of a targeted and degrees of sensory impairmenL To that e nd
manual muscle test may indicate available sources of suggested that an evaluation of light touch-cleep pr
muscle power to be harnessed to augment the orthosis. If response be performed Llsing the Semmes-Weinstei
involuntary hypertonicity is present, this force may be thesiometer monofilaments, as described previously
sufficient to overcome static traction and result in areas of Tests that seek to define a level of functional sen
ischemia and skin breakdown. Although it is not possible to include the Moberg pickup test, static and moving
perform a manual muscle test in the presence of spasticity, point discrimination, and using a sliding aesthesiom
an assessment and grading of the force required to the Disk-Criminator' 1 (Figs. 10-12 and 10-13) (D
overcome the spasticity should be noted. 1981; Moberg, 1958). Functional testing reveals a
Tissue Extensibility. Much of the information on the tive patterns of function developed by the pati
extensibility of the involved tissues is gleaned from the compensate for sensory deficits . An orthotic desig
performance of torque ROM. It is crucial to determine and prohibits these compensatory patterns is likely
grade the end-feel of the tissues around a chosen joint. To rejected as too cLlmbersome or dysfunctional.
reiterate, tissues with a soft or spongy end-feel respond Strength. Frequently, the indication for an ortho
more rapidly to orthotic treatment and require more augment motion is insufficient strength or stabi
frequent realignment Those joints with a firm or hard perform fW1ctionai tasks. No published studies have
end-feel respond more slowly and require longer wearing presented that define the functional grip or pinch st
periods in the orthosis. necessary for the performance of self-care activities
Functional Task Performance. Orthoses with resilient source cites 20 lb as minimum grip strength and 5
components fit for the purpose of restoring motion or cor as minimum pinch strength necessary to perform
recting deformity are generally used intermittently. Of im daily activities (Nalebuff & Philips , 1984). In the abse
port is the patient's ability to independently and properly speCific data, the clinician is left to correlate meas
don and doff the orthosis. Daily activities may be per grip and pinch strength with observed performan
formed with the orthosis removed so that the orthosis does functional tasks.
not become a functional impediment. Serial static orthoses Computer instrumentation for grasp and pinch st
such as cylindriC casts are designed lor full-time wear and assessment is now availabJe and accessible to the cli
are not removed , even for hygiene . The patient or care- One example is the Greenleaf SOLO system that in
..'- .....
_-;.- -..,-. :
226 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 10-15. A, The early-fit prosthesis is fabricat ed with layers of elastic plaster covered by regular pl aster. B, Components such as the wrist un
shown here are added to the plaster socket.
(Fig . 10-15). The rigid plaster dressing provides compres The rigid or semirigid dressing itself serves as the mean
sion to assist with ede ma con.trol. The compression of external compression. The dressing must be changed t
provided by the dressing also helps with control of phan accommodate decreases in edema . As mentioned prev
tom pain. Although the mechanism through which phan ously, edema measure ments help to determine the pa
tom pain is reduced or relieved is not adequately under tie n.t's readiness for definitive prosthetic fitting. Edem
stood , it is possible to provide anecdotal evidence of its measurements must be taken regularly and documente
reduction (Jacobs & Brady, 1975).
The patient who is fitted immediately after surgery does
not have the opportunity to develop unilateral patterns of
activity performance that the patient who has to wait
several weeks or even months for a prosthesis to be fit
is certain to develop. In addition, the patient has the op
portunity to experiment with various terminal devices to
familiarize himself or herself with what is available and to
help in definitive terminal device selection.
Edema Control
Edema control is important in all postoperative manage
ment, but especially so in the amputee, as it affects the
timing for the patient's definitive prosthetic fitting . Edema
control may be addressed by elevation, regardless of the
type of postoperative dressing chosen.
Where a soft dressing is chosen, the patient may also
be instructed in the use of an elastic wrap or Compresso
grip stockinette (Para Medical Distributors, Kansas City,
Missouri) to provide assistance with edema control and with
shaping of the residual limb. The elastic wrap is applied in
a graded figure-of-eight fashion from distal to proximal
(Fig. 10-16). If the limb is short, especially if it has been
amputated at a short above-elbow level , it is very difficult to
keep the wrap in place . Using a chest wrap with a
figure-of-eigM over the shoulder can help to maintain
the position of the wrap. The Compressogrip, while it
decreases control of pressure application, is less likely to
FIGURE 10-16. The elastic wrap assists with edema control as well
slip and may be very useful for the patient or family member wi th shaping of the residual limb. The wrap is applied from distal
who is having difficulty applying the elastic wrap correctly. proxima l in a graded figure-oi-e ight fa shion.
creased or absent residual sensibility, as identified th
sensibility evaluation as described earlier, must be
special attention in terms of socket fit. Frequent insp
to prevent the development of skin breakdown and w
healing problems is recommended. These prob
should they be allowed to develop, could result
amputee's needing to go without the prosthesis
healing is accomplished.
Just as diminished sensibility can present problem
the amputee, hypersensitivity or pain caused by a
roma can present its own complications. A hypersen
wound area or neuroma can prevent the amputee
tolerating the pressure of the prosthesis and severel
FIGURE 10-11. Circumferential edema measurements are taken wearing tolerance. Appropriate intervention is ind
frequently, as they help to determ ine the patient 's readi ness for his or her in these cases.
definitive prosthesis.
Range of Motion
Active and passive ROM are assessed goniometrically on
Strength
a regular basis. These measurements are taken without and
The patient must have adequate strength in his
later with a definitive prosthesis. This is one method that is
residual musculature to support prosthetiC compo
used to determine if the definitive prosthesis has achieved
and to power them successfully. Manual muscle tes
a good fit.
indicated to assess muscle strength. For example,
GenHe active and passive ROM exercises are sta rted as
case of the short below-elbow amputation, where a st
soon as possible following amputation surgery. Motion is
hinge is needed to increase the effective range th
much easier to maintain than ,it is to regain once it is lost.
which the patient is able to drive the prosthetic for
Pronation and supination are especia'lly difficult to regain.
use of this hinge requires greater strength on the part
Patients have a habit of posturing their residual limb in
amputee to achieve the motion. Additional compon
pronation and allowing the interosseous membrane to con
in the form of amplifiers may be needed to overcom
tract into a shortened position. As the level of amputation
problem
becomes higher, residual pronation and supination lessens.
Effective elbow motion may also lessen at higher bdow
elbow levels. As a general rule, everything that can move
should move, to ensure maximum functional ability follow
ing prosthetic fitting. Good shoulder and scapular motions DESIGN AND COMPONENTS
are essential for operation of the body-powered prosthesis. ORTHOTICS
Rest or Protection to Reduce Pain
Sensibility
There are two design options for orthoses directed
Most upper extremity sockets are fit as total-contact and protection. One is the fabrication or fitting
sockets; i.e., there is equal pressure distribution over Single-surface orthosis-one that covers only the pal
- ---
•
. L
230 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 10-22. The low-profi le o utrigger acts as a pivot point for the
static component of the traction line . Once the pivot pOint is established
at 90 degrees 1.0 the part being acted on. the angle of pull o f the resilient
component may be directed as needed.
- -
234 UNIT 1WO-COMPONENT ASSESSMENTS OF THE ADULT
Wrist Units
The wrist unit provides a point of attachment for th
terminal device, allows for prepositioning of the termin
device in either pronation or supination, and aillows for th
exchange of terminal devices. Wrist units are available
either friction or locking type. Quick-disconnect compo
nents are available for rapid switching of terminal device
A wrist flexion component is available for the amputee wh
has a bilateral injury or is unable to operate close to th
body with the opposite arm; e.g., an individual with a wri
fusion on the opposite side (Fig. 10-31).
Prosthetic Socket
The prosthetic socket encases the residual limb. A
extension is used to fill the space between the end of th
socket and the wrist unit or between the end of the limb an
the elbow unit in above-elbow patients. Socket design
FIGURE 10-26. This patient is wearing a conventional below-elbow
system with mechanical hand.
dependent on the level of amputation, residual functio
and prosthetic choice.
Special socket designs such as the split socket o
is not feasible (Fig. 10-28). A wide variety of cosmetic Muenster socket may be necessary for individuals with ve
prostheses are available, from prefabricated gloves to short below-elbow amputations. The Muenster socket ha
those that are custom fit and custom colored. The very high trim lines and encases the olecranon an
price range is as varied as the options, and it often falls condyles to provide additional stability. The disadvantag
to the therapist to justify the cosmetic prosthesis to
third-party payers. Patients are generally encouraged
to look toward a functional prosthesis, either conven
tional or myoelectric, before the notion of a cosmetic
prosthesis is introduced, since restoring function is Ollr
primary goal. In addition to the choices listed above,
hybrids that combine aspects of several system types
are also available.
Terminal Device
Every upper extremity prosthesis includes a terminal
device. The terminal device may be either a hook or a hand
that is either voluntary opening or voluntary closing. As the
names imply. force is required either to open the terminal
device to achieve prehension or to close the terminal device
to maintain prehension. The terminal device may be man FIGURE 10-27 . The below-elbow myoelectric system used by th
ual (Fig. 10-29) or electric in operation (Fig. 10-30), de patient has an electric hand.
FIGURE 10-28. A. The patient's residual limb prior to fitting with a cosmetic prosthesis. B, The same hand following prosthetic fitti
of this socket is that elbow flexion is limited, usually to about socket, where residual elbow flexion is also limited
70 degrees, because of these trim lines. step up the range of flexion through which the stump
The split socket includes a socket that encases the to drive the prosthetic forearm by either a 2: 1 or 3: 2
residual limb and a separate forearm shell that includes the i.e., for every 1 degree of active elbow flexion, the fo
wrist unit and terminal device. This design may be used with will move 2 degrees. As mentioned earlier, the dis
step-up hinges discussed in the following section or with tage of using this device is that the strength requ
other modifications, such as an elbow lock. achieve the same amount of flexion nearly doubles
Harness Systems
The most frequently used harnessing system
figure -of-eight (Fig. 10-33). The below-elbow h
functions to suspend the prosthesis and to allow the
to utilize body motions to operate the terminal devic
harness works to hold the socket firmly against the r
limb . The power of body motions is transmitted
terminal device via the cable system. Other harn
systems that are frequently used are the figure-of-ni
the chest strap with shoulder saddle. The less-cumbe
figure-of-nine harness is most appropriate for
below-elbow amputations, as it provides a greater
of freedom. In above-elbow harneSSing, the sys
meant to provide power to flex the elbow and to lo
unlock it.
FIGURE 10-29. One example of a conventional terminal device is the The chest strap and shoulder saddle harnessing ar
Dorrance 5X. (Courtesy of Dorrance Company, Campbell, California) ment may be used for individuals who do frequent
236 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
FIGURE 10-30. The e lectric hand (A) and the Griffer (B) are the most frequently used myoelectric terminal devices. (B , Courtesy of Otto Bo
Minneapolis, Minnesota.)
lifting or fo r those who are unable to tolerate an axilla loop, system-the operation of the terminal device. In th
perhaps due to nerve or skin irritation. system, the cable slides through a single length of housin
to achieve this function . In the above-elbow prosthesis, th
cable system is required to perform two fun ction
Control Systems
The below-elbow cable system is the Bowden system.
The cable produces only one function in the below-elbow
FIGURE 10-31. A combination fl exion wrist unit is often used with FIGURE 10-32. The above-elbow elbow lock mechanism runs fr
bilateral am putees to improve their ability to perform tasks close to the harness to the elbow unit. It locks the e lbow in the desired degrees
midlin e. elbow fl exion.
to make appropriate choices for a given prescriptio
It is ever more important in an era of cost contai
that clinicians choose those materials that will serv
for short- or long-term use of an orthosis. Orthoses
cated to augment function for the spinal cord-injur
tient are considered permanent and must be fabr
from long-lasting materials . Orthoses expected to b
intermittently or for a short time frame may be app
ately fabricated from lower-cost materials that h
known limited shelf life .
To facilitate the assessment process along the de
tree , at this point we present an explanation of ma
and their properties and then offer suggestions for
FIGURE 10-33. The most frequently used below-elbow harnessing is
the figure-ol-eight (A) , which includes an axilla loop on the uninvolved
rials for each orthotic or prosthetic application.
side , a Sllspensor stra p , and contro l strClP that qttaches to the control cable
on the involved side.
Plaster-of-Paris
terminal device operation and elbow flexion . The above
elbow cable system is known as the fair lead or dual-cable The ready availability, low cost, and ease of
system. It uses two lengths of cable housing to accomplish plaster-of-Paris continues to make it an appropriate
the two functions of elbow flexion and terminal device rial for many orthotic and prosthetic applications. P
operation (Fig. 10-34). of-Paris is manufactured from calcium sulfate , more
monly known as gypsum. Plaster-of-Paris band
commercially available in loose dry plaster bandag
hard-coated bandages, and in elastic fabric impreg
MATERIALS with plaster (Prosthetic Orthotic Center).
Setting time can be manipulated by increasing
The materials used in orthotic and prosthetic fabrication creasing the water temperature. Water temperature
span a broad spectrum from low-cost, readily available not be set above 150°F (65.5°C), as excessive tempe
plaster-of-Paris bandage to expensive Kevlar ', Kingsley actually prevents rather than hastens setting time.
Manufacturing Company, Costa Mesa , California, and working with plaster bandage , the clinician should be
that setting time and drying time are not equivalent. S
is a relatively short process, while drying takes signif
longer and is not complete until the excess wate
evaporated from the plaster. Drying may take any
from 8 hours to several days, depending on the siz
thickness of the apphed bandage.
Plaster-of-Paris is highly moldable, has excellent ri
can be used circumferentially or for Single-surface ap
tions , and is comparatively low in cost. This conve
and low cost continue to make plaste r-of-Paris band
frequent choice for postsurgical positioning. Plaster
as the initial model of the residual limb and as the ba
fabrication of the check socket in prosthetics. It is al
rigid component of the early-fit prosthesiS.
Leather
Animal skins and hides are composed mainly of m
intricately interlaced protein fibers. Tanned leath
FIGURE 10-34. The above-e lbow la ir lead cable sys tem has two tensile properties unmatched by any other material o
le ngths 01 cable housing. As the cable slides through the first , the elbow weight. It can retain a molded shape permanently
is brough t into position. Once the e lbow is locked , the cable is Iree to
operate the terminaJ device. The termina l device cannot be operated maintaining flexibility and strength. Leather is highly
without first locking the elbow. ture resistant yet maintains excellent porosity for v
238 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
tion. Leather can be cut, perforated, sewn, molded with Low-Temperature Thermoplastics
water, laminated, and riveted.
Most of the leathers used in orthotic and prosthetic Low-temperature thermoplastics include synthetic r
applications are vegetable tanned for a smooth texture and ber sheets, such as Orthoplasf" (Johnson and Johnso
to prevent skin irritation. CaHskin and cleer skin are used in Piscataway, New Jersey), and polyester polycaprolacto
upper extremity orthotic applications due to their light to sheets , such as NCM Clinic'" (North Coast Medical, In
medium weight. Weight is expressed in the number of San Jose , California) and Polyform~ (Smith & Neph
ounces per square foot with light weight being 2 to 3 oz per Rolyan, Germantown , Wisconsin). By definition , the
square foot, and medium weight being 3 .5 to 4 oz per thermoplastics require no more than 180°F (80°C)
square foot (Redford, 1986). or wet heat to become moldable, and they may be shap
When wet, leather can be readily stretched and molded directly on the body part. Their principle use is in upp
over a plaster or wood mold. Once dry , leather holds its extremity orthotics, where rapid fabrication and frequ
molded shape permanently and continues to contour and remo'lding for positioning are essential.
mold to a body part over time. In upper extremity The array of available low-temperature thermop'lastic
prosthetics, leather is frequently used in the fabrication of ever expanding. The clinician is referred to the therm
shoulder saddles and as portions of the harnessing system . plastic charts available from distributors for specific ch
For these applications, heavier horsehide and stretchable acteristics of each material. Basic characteristics of lo
cowhide are used for their durability and strength . temperature thermoplastics are given in Appendix B at
end of the chapter to assist the clinician in choosing
thermoplastic most appropriate for a given applicati
Rubber and Silicone Elastomers Low-temperature plastics are susceptible to oxidat
and crystallization that cause breakdown of the polym
Natural and synthetic rubber is available in a variety of structure over time. The level of resistance to crystallizat
forms , all of which have the common characteristic of varies among low-temperature plastics , and therefore
elasticity. Rubber and rubberlike compounds are highly shelf life of plastics varies. Those thermoplastics t
resilient to pressure deformation and so have excellent contain isoprene are known to be more susceptible
shock-absorbing qualities. Silicone elastomers are now oxidation and experience yellowing and structural deg
available for use in both orthotic and prosthetic fabrication dation more quickly.
(Haberman, 1995). Their use is suggested relative to the
use of rubber due to their ease of application and ready
availability.
Natural rubber is a highly elastic material with good tear Polyethylene Foams and
and abrasion resistance. The disadvantage of the use of Cellular Rubbers
natural rubber in orthotic and prosthetic applications is its
Ilow resistance and tendency to degrade with exposure to The two basic classes of foams and cellular rubbers
sunlight, water, skin oils, and most solvents. Of the open-cell and closed-cell structures. In open-cell foams a
commonly used synthetic rubbers, Butyl rubber has greater rubbers, fluids can flow through the holes. The holes i
resistance to heat, sunlight, and water but is not as resilient closed-cell structure are separately sealed , preventing fl
or elastic as natural rubber. Neoprene is one of the transfer. Foam denSity is dependent on the size of individ
synthetic rubbers commonly used for orthotics today. cells, the ratio of cell space to volume, and the continuity
Neoprene combines excellent resistance to water, aging , discontinuity of the cells (Redford, 1986).
and heat with good resistance to oil and solvents. Neoprene Open-cell foams are softer and spongelike and allow
lacks the extreme resistance of rubber to deformation and varying degrees of ventilation. Their use in orthotics
requires the addition of plastic or metal stays to provide any primarily as lining materials to assist in the distribution
Significant degree of joint restriction (Redford, 1986). shear stress and to act as a moisture wick. Closed-cell foa
Silicone elastomers are available in a variety of forms are firmer and nonabsorbent and can often be heat-mold
for the fabrication of flexible orthoses. Open-weave fab to create a semiflexible orthosis. Plastizote (Kewell Co
rics or bandages can be incorporated into the mold for verters Limited , Surrey, England) is a commonly us
greater strength and longevity. Silicone elastomers retain closed-cell polyethylene foam that is moldable when hea
their flexibility and elastic qualities when molded and are at 230°F to 285°F (110°C to 140°C). Plastizote can
often recommended when an orthosis is required during used as a liner or incorporated with thermoplastic
sporting events. Unlike rubber, silicone is stable in heat leather to form a semiflexible orthosis.
and in oxidizing environments and does not yellow with Polyethylene foams have the disadvantage of ra
time. The elasticity and elongation of silicone are not loss of their density and absorption capacity under pr
equivalent to those of rubber, but silicone is a highly accept sure. This limits their usefulness to non-weight-bear
able substitute. orthoses. Their lack of fluid absorption may also be seen
frequent changes of cotton lining, and heat may be of components significantly, but it does so at an incre
somewhat dissipated by perforating the foam. cost. The choice of laminates is dependent in good p
the stress tolerances needed, on funding availability, a
the experience of the prosthetist or orthotist.
Woven and Knit Materials
Cotton duck, polyester and cotton woven with elastic Metals
threads, and a variety of vinyl-impregnated materials are in
common use for upper extremity orthotics. Woven or knit The metals most commonly used in orthotics are
materials are readily available, cost effective, and easily less steel and aluminum. Metal alloys such as those
modified for custom fitting . The use of such materials for titanium or magnesium offer some distinct advantag
orthotic application is generally limited to short-term use terms of decreased weight and density and incr
due to the limited durability of these materials. tensile .strength. Their disadvantage is high cost,
limits their use to small component parts.
The metals are chosen for their properties of stre
High-Temperature Thermoplastic weight; resistance to deformation, fatigue, and corro
ease of fabrication; and cost. Aluminum is commonly
The deSignation of high temperature when applied to in upper extremity orthotics due to its high streng
thermoplastics denotes materials that become moldable at weight ratio and its corrosion resistance. Alumin
350°F to 450°F (176°C-232°C) and can only be molded approximately one third the weight of steel, and its str
over a model. High-temperature thermoplastics are highly can be enhanced by heat treatment, the addition of
resistant to stress and heat and are ideal for long-term use amounts of alloy metals, or by cold working to increa
and for weight-bearing applications. Corrective forces can tensile strength. Pure aluminum is a relatively soft
be incorporated into the model prior to vacuum forming that can be hammered and thinned to accomm
the materials over the model for an exact fit. complex shapes without loss of strength or increa
Of the high-temperature plastics used in orthotics, brittleness (Redford, 1986) .
polyethylene has the most application in upper extremity Although resistant to corrosion, aluminum can be
orthotics. Polyethylene is available in low-, medium-, or aged by alkalis and acids. To counteract this , aluminu
high-density formulas, each having a specific gravity and be coated by anodizing or by exposing it to electr
tensile strength. Low-density polyethylene is most com action. This has the added advantage of giving alum
monly used in upper extremity orthotics and prosthetics parts a more attractive finish and allows the metal
due to its toughness and flexibility. Low-density polyeth colored for a cosmetically pleasing appearance.
ylene can be heated in a convection oven and then
vacuum formed or hand formed on a plaster model. With
care , polyethylene may be molded over a foam base Materials Application
directly on the patient. Polyethylene is used also in upper
extremity prosthetics to make molded shoulder saddles Although many materials may be useful for one
and triceps cuffs. cation, and one material may be useful for many ap
The high-temperature thermoplastics are susceptible to tions, there are choices to be made to choose the
both oxidation and crystallization that, over time , lead to appropriate material for a given application. Appendi
structural failure. These plastics, however, have a signifi the end of the chapter gives suggestions for material
cantly greater life span than the low-temperature plastics for the described orthotic and prosthetic applica
and are likely to last for up to 10 years. Durability, cost, availability, and fabrication experien
factor into the decision.
Laminating Resins
Prosthetic Checkout
A variety of polyester, acrylic, and epoxy resins are
available for creating thin shell laminates for use in upper Prosthetic checkout is performed to ensure tha
extremity orthotics and particularly for prosthetics. These completed device is fitting and operating well and t
shells are formed over plaster models , and some materials adheres to clinic prescription. A few of the items eval
can then be heated , sanded, and reshaped as needed. at checkout include length, efficiency in various plan
Color can be added to certain resins to simulate skin tones. motion, control system efficiency, ROM with and w
The addition of nylon or carbon graphite into the resins the prosthesis, and suspension.
---
.'
The length of the completed prosthesis should be close degrees of full available ROM. The prosthesis should n
to that of the uninvolved arm. This becomes a problem in slip distally by more than 1 inch when a heavy axial loa
fitting a myoelectric prosthesis in the wrist disarticulation 50 lb , is applied at the terminal device.
patient where limited space is available for componentry.
The patient should be able to move through space to
complete a task without the terminal device opening and Orthotic Checkout
closing involuntarily. The patient should be able to achieve
maximum opening or closing of the terminal device with All custom-fit and custom-fabricated orthoses shou
the forearm in 90 degrees of flexion at waist and at mouth be checked for fit and function. The wearer shou
levels. be instructed in recommended wearing schedules and
For the conventional prosthesis, efficiency is evaluated the performance of regular skin checks. Orthoses fa
with the elbow in 90 degrees of flexion . A small spring scale ricated from both high- and low-temperature therm
that registers up to 50 lb in l-lb increments is required with plastics should be checked regularly for signs of we
adaptors to attach the scale to a hand, hook, or hanger. The particularly for any signs of potential fracture sites.
control cable is disconnected from the terminal device , and If an orthosis is fit to restore or augment motion, ongoi
the scale with appropriate adaptor is attached. A 0.5-inch documentation should be performed to ensure that th
thick wood block is placed in the terminal device. The purpose is in fact being met. Once the wearer has ceas
amount of force required to open the terminal device is to make gains, it must be determined whether an adju
recorded. The cable is reattached. Next, the scale with ment or realignment is necessary or if no further progre
adaptor is attached at the hanger, the proximal end of the is possible . At that point, the orthosis should be disconti
cable assembly through which the cable assembly attaches ued, a retaining orthosis fabricated to consolidate the gai
to the harness. Again, the evaluator pulls on the scale, and made, or an alternative intervention considered.
the amount of force required to open the terminal device is Any wearer of a long-term orthosis should arrange f
recorded. Efficiency is determined by multiplying force at follow-up with a therapist or orthotist for regular maint
the terminal device by 100 and dividing it by the force at the nance and reassessment of the continuing necessity of t
hanger. The prosthesis should be at least 80 percent orthosis. Patients will and do accommodate to the use of
efficient. orthosis that has long since ceased to bring them a
The patient should be able to achieve at least 50 percent benefit beyond that of a placebo. It is the health profe
of full available pronation and supination with the prosthe sional's responsibility to educate patients in the prop
sis in place. In a standard below-elbow socket, active elbow usage, including expected outcomes from use, of eve
flexion with the prosthesis in place should be within 10 orthosis he or she fits.
APPENDIX A
Patients are given a clean , unmarked form to indicated their subjective pain level each time it is assessed in the
Indicate the statement that most accurately reflects how the pain you are experiencing affects you on a daily bas
_ _ _ I require rest breaks at least every hour and regular medication to accomplish my daily activities.
_ _ _ I can perform activities for 2 to 3 hours before pain interferes and I must rest or take medication.
_ _ _ I can usually accomplish all my activities but I am aware of the pain several times a day and take medica
least once a day.
___ I
am aware of the pain occasionally but it does not stop my performance of daily activities. I do not requir
medication.
bow- Temperature
Thermoplastic
Characteristics
The low-temperature thermoplastics currently available grees of memory, from 100 percent to very slight memo
are frequently described by their handling characteristics or ability to regain size and thickness if stretched.
their handling when warm-and their finished charac Self·Sealing Edges. This refers to the tendency of the c
teristics-their qualities when cold . Given here is a brief edges of material to round and seal together when cut whi
explanation of the terms used to describe these character warm. Scissors crimp warm material as they cut. Gene
istics, followed by a description of categories of available ally , materials that have little or no memory seal togeth
materials. and stay sealed even when reheated. Materials with hig
degrees of memory do not seal as firmly when cut an
unseal if reheated.
CHARACTERISTICS OF WARM
OR MOLDABLE MATERIAL
CHARACTERISTICS OF COLD
Resistance to Stretch. This refers to the tendency of a OR MOLDED MATERIAL
material to stretch and thin with only the force of gravity
pulling on it. Materials with low resistance to stretch tend to Rigidity Versus Flexibility. These terms describe th
conform easily with only minimal effort on the clinician's degree to which a molded material will resist deformatio
part. Those materials that resist stretch even with manual when force is applied . Materials with a high degree
force require and tolerate more aggressive handling to resistance to deformation are considered to be rigid. Mat
achieve conformability. rials that give or deform with force are flexible . Low
Conformability or Drape. Conformability has a direct temperature thermoplastics range from very flexibl
correlation with resistance to stretch. If a material has low highly perforated 1/16 inch (1.6 mm) thick materials, to ve
resistance to stretch, it will have a high degree of conform rigid 1/s inch (3.2 mm) or 1/ 16 inch (4.2 mm) materials.
ability. When laid on the body part, the material will Self·Adherence or Bonding. This describes the strength
conform intimately around the angles and configurations of the bond between two pieces of material pressed togeth
that part. Materials with high resistance to stretch have a when warm and cooled . The majority of materials ava
low degree of conformability and require handling on the able today are coated to resist accidental bonding an
clinician's part to achieve good conformability and fit , require a solvent to remove the coating to allow bondin
especially around small parts and bony prominences. The strength of the bond varies between materials an
Memory. Memory is the ability or tendency for molded is in part dependent on how hot the materials are whe
material to return to its original cut shape and thickness pressed together and whether a wet or dry heat band w
when reheated. Materials are available with varying de used.
242
---
---~
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8 XION3ddV
~ .'
~-----'
Low 16gb
Silicone! Temperature Temperature
Plaster leather Rubber Plastic: Foam Fabric Plastic LamiDat_ Metal
Ortllotic.
REST AND Short-term, Long-term Cushioning Short-term use, Uners for For short-term Long-term
PROTECTION posttrauma, use only Good for small good prefabricated or intermittent use only
postsurgical protective adjustability or molded use
orthoses orthosis
RESTORE Serial static Uners to assist Excellent due to Relieve or Outriggers
MOTION, designs with scar easy remolding distribute
CORRECT management Attachments pressure
DEFORMIlY easy to add
RESTORE OR Excellent for Protection over Use for less than Une cuffs for Polyethylene, For hand and Aluminum,
AUGMENT heavy use atrophied 1 y, use when pressure long-term use forearm shells composits
MOTION for cuffs parts functional distribution outriggers
return and comfort
expected
PREVENTION Postoperative Good durability Short-term For safety and Functional Long-term For dynamic
use for long- use, trial comfort, activities positioning, componen
term use positioning prevent self- Semiflexible polyethylene,
injury orthoses polypropylene
Pro.tllet'c.
!POF [POF sockets For harness Protect May use for Cushion and Dacron or nylon Cable system
incision, scar molding socket help achieve for harness
management contact
HARNESS Elk. horsehide. Sleeve liners
russet
SOCKET Check sockets Uner sleeve for Shoulder saddles, Acrylic. epoxy
suspension triceps cuffs polyester
resins
246 UNIT lWO-COMPONENT ASSESSMENTS OF THE ADULT
BIBLIOGRAPHY
REFERENCES Burkhalter, W E., Mayfield , G, & Carmona , L. S. (1976) The up
extremity amputee: Early and immediate post-surgical prosth
American Academy of Orthopaedic Surgeons. (1975) . Atlas of orthot fitting. Journal of Bone and Joint Surgery, 58A (1) .
ics . St. Louis, MO C. V Mosby Company. Childress, D . S. (1981). External power in upper limb prosthetics
American Society of Hand Therapists. (1992) . Splint classification American Academy of Orthopaedic Surgeons, Atlas of limb prost
system . Chicago: American Society of Hand Therapists. ics, surgical and prosthetic principles. St. Louis, MO: C. V Mo
Ashbell , T. , Kutz, J. , & Kleinert, H. (1967). The digital Allen test. Plastic Company.
and Reconstructive Surgery, 39, 31l. Day, H . J . (1981) . The assessment and description of amputee acti
Bell-Krotoski , J. A, Breger, D . E., & Beach , R. B. (1990) . Application of Prosthetics and Orthotics Inte rnational, 5(1), 23-28.
biomechanics for evaluation of the hand. In Rehabilitation of the Fryer, C. M . (1981) . Upper limb prosthetic components. In Amer
hand: Surgery and therapy (3rd ed.) . St. Louis, MO : C. V Mosby Academy of Orthopaedic Surgeons, Atlas of limb prosthetics, su
Company . cal and prosthetic principles. St. Louis, MO : C. V Mosby Compa
Bell-Krotoski , J. A (1990). Light touch-deep pressure testing using Jacobsen , S c., & Knutt, D . (1973) . A preliminary report on the U
Semmes-Weinstein monofilament. In Rehabilitation of the hand: arm . Salt Lake City, UT: University of Utah.
Surgery and therapy (3rd ed.). St. Louis, MO C. V Mosby Company. Lamb , D. W (1993) . State of the art in upper-limb prosthetics. Jour
Brand, P. W. (1993). Clinical mechanics of the hand (2nd ed) St. Louis , of Hand Therapy 6(1), 1- 8 .
MO: C. V Mosby Company. Maiorano, L. M. , & Byron , P. M . (1990) . Fabrication of an ear
Callahan, A D. (1984). Sensibility testing: Clinical methods. In Rehabili prosthesis In J. M. Hunter, L. H. Schneider, E. J. Mackin , & A
tation oj the hand (2nd ed.). St. Louis , MO: C. V Mosby Company. Callahan (Eds .), Rehabilitation oj the hand. Philadelphia : C. V Mo
Dellon, A L. (1981). Evaluation of sensibility and reeducation of Company.
sensation in the hand. Baltimore: Williams & Wilkins. New York University, Post Graduate Medical School. (1982). Prosthe
Fess, E. E., & Philips, C. A (1987). Appendixes In Hand splinting
and orthotics, upper limb prosthetics. New York: New York Uni
principles and methods. St. Louis, MO: C. V Mosby Company .
sity.
Fess, E. E., & Philips, C. A (1987). Hand splinting principles and
Olivett , B. L. (1990). Adult amputee management and conventi
methods. St. Louis, MO: C. V Mosby Company. prosthetic training. In J. M. Hunter, L. H. Schneider, E. J. Mackin
Flowers, K R., & Pheasant, S. D. (1988). The use of torque angle curves A D. Callahan (Eds.), Rehabilitation of the hand. Philadelp
in the assessment of digital joint stiffness. Journal of Hand Therapy, C. V Mosby Company.
1(2),69. Sanderson, E. R., & Scott, R. N. (1985). UNB Test oj Prosth
Gelberman, R. H., et al. (1983). Sensibility testing in peripheral nerve Function: A test Jor unilateral upper extremity amputees. N
compression syndromes: An experimental study in humans. Journal of Brunswick, NJ: Bio-engineering Institute, University of New B
Bone and Joint Surgery, 65A, 632. swick.
UNIT THREE
Assessment of
Central Nervous
System Function
of the Adult
C HAP T E R 1 1
SUMMARY Stroke survivors cope with a variety of motor, sensory, cognitive, per
ceptual, psychological, social, and functional disabilities. This chapter focuses on
the motor impairments associated with cerebrovascular accident and examines
standardized assessments that evaluate motor performance after stroke. Problems
of motor performance in individuals with stroke are complex and varied. Reha
bilitation specialists have not yet reached consensus about the sequence of recovery
or the preferred intervention strategies for improving motor performance in this
population. Therefore, many therapists still use nonstandardized, qualitative evalua
tion tools that reflect their unique clinical philosophies.
This chapter reviews the major therapeutic approaches to treating motor dys
function in individuals with hemiplegia due to stroke and describes the major as
sessment tools that reflect each of these approaches. Research data to support the
reliability and validity of these tools are provided.
...:::..=-:,:..~-- ==-~ ,.
:.- .. - ~
250 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
series of recovery stages. All patients began with total, Hook grasp
flaccid paralysis of limb muscles. This was followed by the Lateral prehension
Palmar prehension
muscles, and the influence of tonic neck reflexes on active Spheric grasp
movement and muscle tone in the arm and leg . Release of grasp
Patients whose recovery was not arrested at one of these Manipulative tasks
~
- --- -- ----=--
:. - ~&.--
. ~
254 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
tested while the patient lies supine with his or her shoulder
placed in external rotation at 90 degrees flexion . In this DESCRIPTIONS OF STANDARDIZED
position, gravity exerts a compressive force upon the arm, ASSESSMENT TOOLS
thus minimizing the muscular activity needed to maintain
the posture. Early movements from this starting position
include protraction of the scapula while the therapist Most therapists administer qualitative evaluations of th
provides distal arm support, flexion and extension of the areas of dysfunction just described. Assessment, which i
often divided between the occupational therapist and
elbow, eccentric control of the deltoid for slowly lowering
the arm, and internal and external rotation of the shoulder physical therapist , is considered to be an integrated part o
while maintaining an extended elbow. Variations in for intervention. Initial and ongoing findings are used as
guide for planning speCific treatment strategies. Qualitativ
ward, upward, and sideward reach are tested in the sitting
and standing positions. Performance breakdown is in assessments, however, do not provide objective or meas
ferred when the patient demonstrates evidence of involun urable scores. Therefore, standardized tools are necessary
for quantifying patient progress and for use as outcom
tary scapula retraction, shoulder internal rotation, or elbow
flexion. Lower extremity movements are generally as measures in clinical research studies.
sessed within the context of gross mobility tasks , standing,
and ambulation.
Functional hand s kiDs are assessed as soon as a The Fugl-Meyer Assessment
patient demonstrates active movement in the wrist and
fingers , regardless of proximal motor return. First, active Fugl-Meyer and colleagues (1975) used Brunnstrom'
movement and stability of the wrist are assessed. This is sequence of recovery as a framework in developing an
accompanied by an evaluation of the person 's ability to ordinal scale for assessing motor performance in individu
use the tenodesis relationship between wrist and fingers , als after stroke. The Fugl-Meyer Assessment (FMA) evalu
as well as the ' ability to flex and extend the wrist and ates five component areas:
fingers independently of one another. Brunnstrom's pos Joint motion and pain
tulated sequence of recovery (see Table 11-2) provides Sensation
a useful guide for ordering further assessment items. The Balance
patient is asked to perform a variety of grasp patterns, Upper extremity motor function
using functional objects whose sizes and shapes are likely Lower extremity motor function (Fugl-Meyer, 1980
to elicit specific types of grasp. In addition, it is useful to Fugl-Meyer et aI. , 1975).
observe the individual's ability to combine functional grasp Individual items within each component area are graded
with the shoulder, elbow, and forearm in a variety of on a three-point ordinal scale. A score of 0 is assigned if th
positions. Performance of functional tasks requiring bi item cannot be performed; 1 if the item is performed
manual integration and finger dexterity is also assessed partially; and 2 if it is fully performed. Specific instruction
(Eggers, 1984). for scoring each test item are provided in early report
Ambulation is assessed through visual observation of about the tool. Duncan and Badke (1987) have enhanced
the patient's body segments throughout the phases of the the ease in applying these criteria by deSigning a clea
gait cycle. Observed patterns of motion are compared with scoring form . Cumulative scores are calculated and re
the normal kinematics of gait, and the therapist hypoth ported for each test component, as well as for the tota
esizes which underlying impairments contribute to the gait evaluation.
deviations observed. Some common gait impairments in Joint motion and pain are assessed at a total of 22
individuals with hemiplegia include motions of the arm and leg. Scores for joint motion reflec
Abnormal foot inversion during stance normal passive range of motion (PROM) (2), decreased
Tendency to hyperextend or buckle the knee during PROM (1), or "only a few degrees of motion" (0). Pain
stance scoring for each movement ranges from 0, marked pain, to
Inability to eccentrically contract the ankle dorsiflexors to 2, no pain. Maximum cumulative scores for both join
prevent foot slap during early stance motion and pain are 44, for a maximum of 88 points on
Lack of hip extension during stance this component of the assessment.
Presence of the Trendelenberg sign at the pelvis (down Sensation assessment includes evaluation of ligh
ward pelvic tilt on the intact side) due to insufficient touch sensation on the upper arm, palm of hand, thigh
activity of the hip abductors during stance and sole of foot and proprioception at all major joints of th
Lack of pelvic rotation toward the forward leg during late arm and leg. Scores on each of these 12 items range from
swing and early stance o for no sensation to 2 for normal responses. Maximum
Lack of hip and knee flexion for smooth progression of score on the sensation component is 24 points.
the leg during swing (Carr & Shepherd, 1987b; Balance is evaluated for the seven functions listed in
Sawner & LaVigne, 1992) Table 11-3. Protective extension is assessed by observing
that assess unsupported sitting and standing are scored
according to the length of time the patient is able to
1. Wrist stability in 15 degrees extension (shoulder neutral. elbow
Assessment of upper and lower extremity 2. Active flexion / extension of wrist (same positions of shoulder, el
motor function is organized according to the following bow. and forearm as in item 1)
3. Wrist stability with shoulder at 30 degrees (elbow and forearm
1. Presence of reflex activity (hyperactive stretch and 4 . Active fle Xion/extension of wrist (same proximal position as in
5. Circumduction
2. Volitional movement within the flexor and extensor
synergies From Fllgl-Meyer, A. R , Jaasko. L. , Leyma n, I. , Olsson, S , & Steglin
3. Volitional movement that deviates from the basic S . (1975) . The post-stroke hemiplegic patient: A method o f evaluation
physical performance. Scandinavian Jou rnal of Rehabilitation Me
synergies cine, 7, 13-3l.
4. Volitional movement that is relatively independent of
the synergy patterns
5. Normal reflex activity (normal muscle tone)
All joints of the lower extremity are assessed together in recommend that patient scores can be interpreted
items that evaluate for hyperactive reflexes , components of percentage of recovery. For example, a score of 80 wou
the flexor and extensor synergies, movements combining be considered to indicate 80% motor recovery in lim
synergies, movement out of synergies, and normal re function (Fugl-Meyer, 1980).
flexes. Coordination and speed are tested by instructing the Gowland (1990) has designed an alternative evaluati
supine patient to move the heel to the opposite knee five tool that closely mirrors the structure of the FMA. Gowla
times in rapid succession. Performance is assessed for presents detailed descriptions of motor behaviors of t
tremor, dysmetria , and speed. The maximum cumulative arm, hand , leg, foot, and postural control that represe
score for tests of the lower extremity is 34 points. each of Brunnstrom's recovery stages. Ailthough this sca
The FMA gives considerably more attention to upper, as does not provide a quantitative score, it does enab
compared with lower, extremity movement. The shoulder, therapists to record progression through the recove
elbow, and forearm are assessed together in the same stages for the five areas assessed.
sequence as described for the lower limb, yielding a
maximum cumulative score of 36 points . Five wrist func
tions are assessed (Table 11-4). Seven tests of hand Standardized Assessments Based
function are listed in Table 11-5. Coordination and speed on the Neurodevelopmental
are tested by asking the blindfolded patient to touch the tip Treatment Philosophy
of his or her index finger to the nose five times in rapid
succession . As in the coordination and speed test for the Therapists who advocate Bobath's principles oft
lower limb, performance is assessed for tremor, dysmetria, reject Brunnstrom's emphasis on synergy patterns a
and speed. The total maximum score for tests of the upper stages of recovery and therefore may question the co
extremity is 66 points. struct validity of the FMA. In the following section , thr
Since the maximum cumulative scores for upper and standardized tools based on the NOT perspective a
lower extremity motor function equal 100, the authors discussed.
From Fugl-Meyer, A. R , J aasko, L., Leyman , I., Olsson, S., & Steglind, From Fllgl-Meyer, A. R, Jaasko , L., Leyman, I. , Olsson, S , & Stegli
S. (1975). The post-stroke hemiplegic patient A method of evaluation of S . (1975). The post-stroke hemiplegic patient: A method of evalua tion
physical performa nce. Scandi navian Journal of Rehabilitation Medi physical performance. Scandinavian Journal of Rehabilitation Me
cine, 7, 13-3l. cin e, 7, 13-31. .
-
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,
,
I
- .
.
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256 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
THE RIVERMEAD MOTOR ASSESSMENT tion , leg and trunk, and arm. This tool uses Guttman
scaling and orders test activities hierarchically, according
The Rivermead Motor Assessment (Lincoln and to their difficulty. Guttman's technique is designed to
Leadbitter, 1979) requires patients to complete a series ensure that a given score on each subscale indicates
of functional movements in three categories: gross func- specifically what tasks the person can and cannot perform
General Instructions
Go through items in order of difficulty. Score 1 if patient can perform activity, 0 if he cannot.
Three tries are allowed; after three consecutive failures, stop that section and proceed to the
next.
Total
FIGURE 11-1. Rivermead Motor Assessment Protocol. (From lincoln, N., & Leadbitter, D. 11979J. Assessment of motor function in stroke patients.
Physiotherapy, 65, 48-51.)
Leg and Trunk
1. Roll to affected side. (Starting position should be lying, not crook
lying. May not use hands.)
2. Roll to unaffected side. (Same conditions as 1.)
3. Half bridging. (Starting position-half crook lying. Patient must put
some weight through affected leg to lift hip on affected side. Phys
iotherapist may position leg, but patient must maintain position
even after movement is completed.)
4. Sitting to standing. (May not use arms. Feet must be flat on floor.
Must put weight through both feet.)
5. Half crook lying: Lift affected leg over side of bed and return it to
same position . (Affected leg in half crook position . Lift leg off bed
onto support, e.g., box, stool, floor so that hip is in neutral and
knee at 90 0 while resting on support. Must keep affected knee
flexed throughout movement. Do not allow external rotation at hip.
This tests control of knee and hip.)
6. Standing, step unaffected leg on and off block. (Without retraction
of pelvis or hyperextension of knee. This tests knee and hip control
while weight bearing through the affected leg.)
7. Standing, tap ground lightly five times with unaffected foot. (Without
retraction of pelvis or hyperextension of knee. Weight must stay on
affected leg. This again tests knee and hip control while weight
bearing through the affected leg, but is more difficult than 6.)
8. Lying, dorsiflex affected ankle with leg flexed. (Physiotherapist may
hold affected leg in position, knee at 90 0 • Do not allow any inver
sion. Must have half range of movement of unaffected foot.)
9. Lying, dorsiflex affected ankle with leg extended. (Same conditions
as 8 with leg extended. Do not allow any inversion or knee flexion.
Foot must reach plantigrade [90 0 ].)
10. Stand with affected leg in neutral position, flex affected knee.
(Physiotherapist may not position leg. This is extremely difficult for
most hemiplegic patients, but is included to assess minimal dys
function.)
Total
(Portney & Watkins , 1993; Guttman, 1944). This is an that assess balance, gross mobility, ambulation , and ste
advantage over cumulative scoring, as used in the FMA, climbing. Items progress to assess higher levels of function
because two individuals who receive the same cumulative as compared with the FMA. For example, to achieve highe
score are not necessarily performing at the same level of scores, patients are required to walk without an aid , walk u
function in all areas. As patients improve , they can and down four steps without a rail, and perform
successfully perform progressively more items in the functional task including walking, turning , and objec
hierarchy. A score of 1 is given if the person can perform retrieval. This greater level of difficulty, which is als
the task; 0 if he or she cannot. Testing continues until reflected in the test's other two subscales, allows th
the person fails three consecutive test activities. This Rivermead Assessment greater sensitivity in testing pa
feature provides shorter testing time for individuals with tients who have achieved higher levels of motor recovery
less motor recovery. (See Figure 11-1 for the test pro Scores are less likely to demonstrate a "ceiling effect.
tocol .) Subsequently, the tool may encourage therapists to estab
The gross function subscale includes a series of items lish and achieve higher goals for patient performance
258 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
Arm
1. Lying, protract shoulder girdle with arm in elevation. (Arm may be
supported.)
2. Lying, hold extended arm in elevation-some external rotation-for
at least 2 seconds. (Physiotherapist should place arm in position
and patient must maintain position with some external rotation.
Do not allow pronation. Elbow must be held within 30° of full ex
tension.)
3. Flexion and extension of elbow with arm as in 2. (Elbow must ex
tend to at least 20° full extension. Palm should not face outwards
during any part of movement.)
4. Sitting, elbow into side, pronation and supination. (3f4 range is ac
ceptable, with elbow unsupported and at right angles.)
5. Reach forward, pick up large ball with both hands and put down
again. (Ball should be on table so far in front of patient that he has
to extend arms fully to reach it. Shoulders must be protracted, el
bows extended, wrists neutral or extended and fingers extended
throughout movement. Palms should be kept in contact with ball.)
6. Stretch arm forward, pick up a tennis ball from table, release on
mid-thigh on affected side, return to table, then release again on
table. Repeat five times. (Shoulder must be protracted, elbow ex
tended and wrist neutral or extended during each phase.)
7. Same exercise as 6 with pencil. (Patient must use thumb and fin
gers to grip.)
8. Pick up a piece of paper from table in front and release five times.
(Patient must use thumb and fingers to pick up paper, not pull it to
edge of table. Arm position as in 6.)
9. Cut putty with a knife and fork on plate with non-slip mat and put
pieces into a container at side of plate. (Bite size pieces.)
10. (Stand on spot, maintain upright position, pat a large ball on floor
with palm of hand for five continuous bounces.)
Total
Balance is indirectly assessed through active task perfor supine position and asked to perform shoulder girdl
mance; no manual displacements are provided . protraction followed by external rotation of the shoulde
The leg and trunk subscale reflects NOT's emphasis and controlled elbow flexion and extension while maintain
on the importance of dynamic weight bearing through the ing the arm in an elevated position. Items progress t
lower limbs. The half-bridging task requires weight bearing increasingly more difficult arm activities while sitting an
through both feet to elevate the pelvis when the person is then while standing . Patients are required to demonstrat
lying supine . Two items require the person to maintain the forward reach pattern (shoulder protraction, elbow
upright standing on the affected leg while releasing body extension, wrist and finger extension) advocated by Bobat
weight from the other leg . In the scale's most difficult item, as being integral to upper limb recovery . Use of the uppe
the individual is asked to control movement at the knee in limb for dynamic weight bearing is assessed by requiring th
a closed kinematic chain by flexing the affected knee while person to stand with his or her affected arm abducted to 9
standing. degress and the palm flat against a wall. While maintainin
Tasks on the arm subscale clearly reflect an NOT this position, the patient rotates his or her body in a close
perspective. In early items, the patient is tested in the chain on the weight-bearing hand. The final item on thi
Arm, cont.
11. Continuous opposition of thumb and each finger more than 14
times in 10 seconds. (Must do movements in consistent sequence.
Do not allow thumb to slide from one finger to the other.)
12. Supination and pronation onto palm of unaffected hand 10 times in
10 seconds. (Arm must be away from body, palm and dorsum of
hand must touch palm of good hand. Each tap counts as one. This
is similar to 4, but introduces speed.)
13. Standing, with affected arm abducted to 90 0 , with palm flat against
wall. Maintain arm in position. Turn body towards wall and as far as
possible towards arm; i.e., rotate body beyond 90 0 • (Do not allow
flexion at elbow, and wrist must be extended with palm of hand
fully in contact with wall.)
114. Place string around head, tie bow at back. (Do not allow neck to
flex. Affected hand must be used for more than just supporting
string. This tests function of hand without help of sight.)
15. Pat-a-cake 7 times in 15 seconds. (Mark cross on wall at shoulder
level. Clap both hands together-both hands touch crosses
clap-one hand touches opposite cross-clap-other hand touches
opposite cross. Must be in correct order. Palms must touch. Each
sequence counts as one, give patient three tries. This is a complex I
pattern which involves coordination, speed and memory as well as
good arm function.)
Total of 1 to 10
Total
For information contact Dr. Nadina Lincoln, Department of Psychology, University of Nottingham, Nottingham NG7 ZRD, UK.
FIGURE 11-1. Continu ed
Pain
BASED ON THE BOBATH APPROACH:
TAHIJ II (,
Procedures
Support is given at the elbow and wrist by examiner. and the following passive movements are performed
1. With the shoulder in external rotation and the elbow in extension, flex shoulder to a range from 0 to full flexion
2. With shoulder flexed at 90 0 , flex and extend elbow, bringing palm of hand to opposite shoulder and to the top of the head
3. With elbow flexed and palm of hand on opposite shoulder, flex and extend the shoulder
4 . With elbow extended and shoulder flexed to 90°, protract the shoulder
5. With arm next to trunk, forearm and hand supported , and with the elbow flexed to 90°, pronate and supinate forearm
0
6. With elbow extended and shoulder at 90 (with forearm in neutral position and arm supported at elbow and wrist), flex and extend the wrist
7. With elbow extended, shoulder flexed at 90 0 with wrist and forearm in neutral position (arm supported at elbow and wrist) flex and extend
fingers
Ratings
Procedures
Support is given at the knee and toes by examiner, and the following passive movements are performed
1. With the knee flexed to 90° and ankle held in neutral pOSition, flex and extend the hip
2. With ankle held in neutral, flex and extend the knee
3. With the knee flexed to 90° and the ankle held in neutral, abduct and adduct the hip
4. With the affected knee crossed over the unaffected knee , protract the pelvis on the affected side
5. With the knee flexed to 70 0 with the foot resting on the floor, dorsiflex and plantar flex the ankle; with the knee extended and the lower ex
tremity supported, dorsiflex and plantar flex the toes
6. With the knee flexed to 70° and the foot resting on the floor, flex and extend the toes; with the knee extended and the lower extremity sup
ported , flex and extend the toes
Ratings
Procedures
TRUNK
Patient is sitting with fingers crossed, elbows extended , and shoulder flexed to 90 0 . Patient's arms cradled in therapist's forearms: passive rota
tion of upper trunk on lower trunk is performed
NECK
Patient is transferred in supine position later in the evaluation ; patient's head cradled in therapist's hands: passive anterior flexion , lateral flexio
and rotation of the neck is performed
Ratings
o = Flaccidity
3 = Normal
From Corriveau, H. , Guarna , F. , Dutil, E. , Riley , E., Arsenault, A. B., & Drouin, G. (1988). An evaluation ofthe hemiplegiC subject based on the Bob
approach. Part II: The evaluation protocol. Scandinavian Jo urnal of Rehabilitation Medi cine, 20, 5-11.
Muscle tone and voluntary movement are evalu the patient is asked to reach laterally for an object with th
ated through a series of patterned movements that re nonaffected hand. This reflects an understanding that th
semble the reflex inhibiting patterns (or postures) espoused more subtle postural adjustments may be best elicite
by Bobath in early writings (Bobath, 1978). In the muscle through active, rather than passive, shifts of body weigh
tone assessment (Table 11-6), the therapist passively The Montreal Evaluation does not assess higher-lev
moves the patient into these positions and notes excessive motor functions of dynamic weight bearing, ambulation, o
resistance to the passive muscle lengthening . In the step climbing . Evaluation of hand function is limited to on
assessment of voluntary movement (Table 11-7), the item, which requires the patient to oppose his or her thum
patient is required to actively reproduce these patterns. to the fingers.
Postural reactions are assessed in the sitting posi
tion. The therapist provides lateral displacement at the
ASHBURN'S PHYSICAL ASSESSMENT FOR
pelvis three times on each side and observes for the
STROKE PATIENTS
following reactions:
Head righting Ashburn's (1982) PhYSical Assessment for Stroke Pa
Elongation of trunk and weight shift tients provides an ordinal scale , divided into three majo
Abduction-extension reactions of the extremities sections: lower limb activities, upper limb activ
Protective extension of the affected upper extremity ties, and balance and movement activities. Item
are scored on a three-point continuum, as in the FMA.
Three lower limb activities are assessed: hip an
TABII II 7
knee flexion while standing; isolated knee flexion from
'DIE MONTREAL EVALUATION-ACTIVE
prone position; and ankle dorsiflexion tested while the hi
MOVEMENT
and knee are extended and when the hip and knee ar
flexed.
A: Active Movement: Upper Extremity The ten upper limb activities include should
shrugging, arm thrusting, arm raiSing, forearm supination
Procedures wrist dorsiflexion , finger extension , and pinch grip. Cle
1. All the same movements in the section on muscle tone but done illustrations on the test form facilitate correct testing of a
actively limb items.
2. Opposition of fingers with arm by the side. elbow flexed , and
Eighteen balance and movement activities asses
wrist in neutral
Patient RLAH # _ __
2 A Associated reaction
C. Shoulder abduction
3 D. Hold a pouch
E. Stabilize a pillow
F. Stabilize a jar
4 G. Stabilize a package
H. Wringing a rag
K. Fold a sheet
6 M. Box on shelf
O. Cat's cradle
7 P. Light bulb
DATE
EXAMINER
FIGURE 11-2. Functional test for the hemiparetic upper extremity. (Reprinted by permission of the Occupational Therapy Department, Rehabilitatio
Engineering Center. Rancho Los Amigos Hospital, Downey. CA. Note ; 40-page protocol booklet is available from Rancho Los Amigos Occupation
Therapy Department, Rehabilitation Engineering Center, 7413 Golondrinas Street, Downey, CA 90242 .)
function through the performance of 17 standardized tasks minus for failing at the task. After the assessment , th
(Fig. 11-2). Like the Rivermead Motor Assessment, items person is scored as functioning at the highest level in whic
are ordered hierarchically, according to their difficulty. he or she successfully completed all tasks. This categoriz
Grading is on a pass-fail basis, and most activities are timed . tion of performance by functional levels assists therapists
Patients who do not successfully complete a task within the establishing treatment goals, and it allows for objectiv
3-minute prescribed period fail that item. documentation of patient progress.
Items are grouped according to seven levels of upper The seven levels of upper extremity function refle
extremity function, ranging from (1) absence of voluntary influence by both Brunnstrom and NOT approaches. Item
movement to (7) selective and coordinated movement. The at early levels elicit associated reactions and gross synerg
patient earns a plus for successfully completing a task or a patterns. Subsequent levels require use of the hemiparet
finger dexterity, combined with proximal control. babies, adults who are recovering from stroke do not nee
There are strengths and weaknesses to the use of to follow a developmental sequence to achieve improve
naturalistic tasks on an assessment of upper extremity motor function.
function. One important asset is that the test score actually Assessment of balanced sitting pays close atten
provides a direct indication of functional performance. In tion to postural alignment during quiet sitting and func
addition, the task-oriented instructions are easier for tional movement. The person's ability to adjust to displace
patients with cognitive and perceptual deficits to follow ment of his or her center of gravity is tested through activ
than test items that require performance of abstract movement, rather than the application of external force
movements. The walking assessment requires high-level func
The authors caution therapists about a drawback to the tion to achieve moderate and maximum scores. As in th
tool's clinical use. Since each task requires the integration Rivermead Assessment, patients are asked to walk wit
of multiple skills (e.g., sensory awareness , shoulder control, no aid and to perform a complex sequence includin
grasp , coordination) a patient's score does not identify walking, turning , and retrieving an item from the floor
specific deficit areas. The examiner is responsible for An individual receives the highest score if he or she is abl
qualitatively assessing which impairments have contributed to quickly ascend and descend steps without holding ont
to an individual's failure on a test item. This qualitative the rail.
assessment, rather than the numeric score , guides thera Evaluation of upper ann function and hand move
peutic intervention. An additional weakness is that pro ments is similar to that in the Rivermead Assessment. Th
gression from one task to the next often requires significant major difference is that on the Rivermead, patients are no
improvements in function . The test may not be sensitive asked to demonstrate wrist or hand function unless the
enough to reflect incremental achievements in upper can accomplish earlier test items requiring shoulder, elbow
extremity performance. and forearm control. The MAS recognizes that som
individuals may regain hand function before achievin
recovery in proximal muscles.
Carr and Shepherd's Motor The advanced hand activities item allows fo
Assessment Scale for assessment of higher-level grasp and manipulative skills
Stroke ,Patients Unfortunately, no theoretical rationale is provided for th
hierarchical scoring of patient performance. Loewen an
Carr and Shepherd and colleagues (1985) developed this Anderson (1988, 1990) developed the Modified Moto
tool to reflect contemporary views about motor recovery Assessment Scale (MMAS) by adapting the scoring criteri
after stroke. They offered the Motor Assessment Scale for advanced hand activities and eliminating the genera
(MAS) as an alternative to other standardized assessments tonus item.
that are based on the assumptions that recovery is charac
terized by stereotyped movements in synergies and recov
ery proceeds in a proximal to distal sequence.
The MAS includes eight items representing the follOWing PSYCHOMETRIC 'RESEARCH ON THE
areas of motor behavior: STANDARDIZED ASSESSMENT TOOLS
Supine to side lying onto intact side
Supine to sitting over side of bed The Fugl-Meyer Assessment
Balanced sitting
Sitting to standing Of all the available standardized tests of motor recover
Walking after stroke , the FMA has been most rigorously analyze
Upper arm function for reliability and validity. Consequently, it ·is the mos
Hand movements frequently chosen measure for clinical studies in whic
Advanced hand activities poststroke motor function is a dependent variable.
Each item is scored on a seven-point scale from 0 to 6, For the initial pilot study (Fugl-Meyer et aI., 1975), 80
according to the criteria listed in Table 11-8. The original patients were evaluated with the FMA within 1 week o
version of the scale also included one item related to muscle hospital admission for acute cerebrovascular accident
tone on the affected side. The general tonus score is These individuals were examined at monthly intervals for
based on the examiner's continuous observation and months and tested again at 1 year. The number of subject
handling throughout the assessment and is graded differ remaining to completion of the study decreased to 15
ently than other items. Reasons for withdrawal included no finding of motor defiC
Tests of gross mobility on the MAS deliberately omit on initial evaluation , new episodes of stroke or other illness
assessment of rolling because Carr and Shepherd and their failure to cooperate with retesting , and death .
coworkers believe that rolling over is given excessive Longitudinal findings supported the postulated sequenc
264 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
TAI3Ll 1 [ -I->
1. Pulls self into side lying. (Starting position must be supine lying, legs extended. Patient pulls self into side lying with intact arm, moves af
fected leg with intact leg.)
2. Moves leg across actively. and the lower half of the body follows. Starting position as above. Arm is left behind.
3. Arm is lifted across body with other arm. Leg is moved actively, and body follows in a block. (Starting position as above.)
4. Moves arm across body actively. and the rest of the body follows in a block. (Starting position as above.)
5. Moves arm and leg and rolls to side but overbalances. (Starting position as above. Shoulder protracts and arm flexes forward.)
6. Rolls to side in 3 seconds. (Starting position as above. Must not use hands.)
2. Supine to Sitting Over S ide of Bed
1. Side lying, lifts head sideways but cannot sit up. (Patient assisted to side lying.)
2. Side lying to sitting over side of bed. (Therapist assists patient with movement. Patient controls head position throughout.)
3. Side lying to sitting over side of bed. (Therapist gives stand-by help [see General Rules item 5[ by aSSisting legs over side of bed.)
4. Side lying to Sitting over side of bed. (With no stand-by help.)
5. Supine to sitting over side of bed . (With no stand-by help.)
6. Supine to sitting over side of bed within 10 seconds. (With no stand-by help.)
3. Balanced Sitting
1. Sits only with support . (Therapist should assist patient into sitting.)
2. Sits unsupported for 10 seconds. (Without holding on, knees and leet together, feet can be supported on floor.)
3. Sits unsupported with weight well forward and evenly distributed. (Weight should be well forward with hips flexed, head and thoracic spine
extended , weight evenly distributed on both sides.)
4. Sits unsupported, turns head and trunk to look behind. (Feet supported and together on floor. Do not allow legs to abduct or feet to move.
Have hands resting on thighs , do not allow hands to move onto plinth. Turn to each side.)
5. Sits unsupported, reaches forvvard to touch floor, and returns to starting position . Feet supported on floor. Do not allow patient to hold on.
Do not allow legs and feet to move. support affected arm if necessary. Hand must touch floor at least 10 cm (4 in) in front of feet. Reach
with each arm.
6. Sits on stool unsupported , reaches sideways to touch floor, and returns to starting position. (Feet supported on floor. Do not allow patient to
hold on. Do not allow legs and feet to move , support affected arm if necessary. Patient must reach sideways not forward. Reach to both
sides.)
4. Sitting to S tanding
1. Stands on affected leg and steps forward with other leg. (Weight-bearing hip must be extended. Therapist may give stand-by help.)
2. Walks with stand-by help from one person.
3. Walks 3 m (10 It) alone or uses any aid but not stand-by help.
4. Walks 5 m (16 It) with no aid in 15 seconds.
5. Walks 10 m (33 It) with no aid, picks up a small sandbag from floor, turns around, and walks back in 25 seconds. (May use either hand.)
6. Walks up and down four steps with or without an aid but without holding on to the rail three times in 35 seconds.
6. Upper Arm Function
1. Supine, protract shoulder girdle with arm in 90 degrees of shoulder flexion. (Therapist places arm in position and supports elbow in ex
tension.)
2. Supine, hold arm in 90 degrees of shoulder flexion for 2 seconds. (Therapist places arm in position and patient must maintain position with
some [45 degrees] external rotation. Elbow must be held within at least 20 degrees of full extension.)
3. Supine, hold arm in 90 degrees of shoulder fleXion, flex and extend elbow to take palm to forehead. (Therapist may assist supination of
forearm.)
4. Sitting, hold extended arm in forward flexion at 90 degrees to body for 2 seconds. (Therapist should place arm in pOSition, and patient main
tains position. Patient must hold arm in midrotation [thumb pointing up]. Do not allow excess shoulder elevation.)
5. Sitting. patient lifts arm to above position, holds it there for 10 seconds, and then lowers it. (Patient must maintain position with some exter
nal rotation. Do not allow pronation.)
6. Standing, hand against wall. Maintain hand position while turning body toward wall. (Arm is abducted to 90 degrees with palm flat against
the waiL)
MOTOR ASSESSMENT SCALE SCORING CRITERIA Continued
7. Hand Movements
1. Sitting, extension of wrist. (Patient sits at a table with forearm resting on the table . Therapist places cylindric object in palm of patient's
hand. Patient is asked to lift object off the table by extending the wrist. Do not allow elbow nexion .)
2. Sitting , radial deviation of wrist. (fherapist places forearm in mid-pronation~supination, i.e., resting on ulnar side, thumb in line with forearm
and wrist in extension, fingers around a cylindric object. Patient is asked to lift hand off table. Do not allow elbow nexion or pronation.)
3. Sitting, elbow into side, pronation and supination. (Elbow unsupported and at a right angle. Three-quarter range is acceptable.)
4. Sitting, reach forward , pick up large ball of 14 em (5 in) diameter with both hands, and put it down. (Ball should be placed on table at a dis
tance that requires elbow extension. Palms should be kept in contact vAth the ball.)
5. Sitting, pick up a polystyrene cup from table and put it on table across other side of body. (Do not allow alteration in shape of cup.)
6. Sitting, continuous opposition of thumb and each finger more than 14 times in 10 seconds. (Each finger in turn taps the thumb , starting with
index finger. Do not allow thumb to slide from one finger to the other. or to go backward.)
8. Advanced Hand Activities
1. Pick up the top of a pen and put it down again. (Patient reaches forward to arm's length , picks up pen top. releases it on table close to
body.)
2. Pick up one jellybean from a cup and place it in another cup. (Teacup contains eight jellybeans. Both cups must be at arms ' length. Left
hand takes jellybean from cup on right and releases it in cup on left.)
3. Draw horizontal lines to stop at a vertical line 10 times in 20 seconds. (At least five lines must touch and stop at the vertical line. lines
4. Hold a pen, make rapid consecutive dots on a sheet of paper. (Patient must do at least two dots a second for 5 seconds. Patient picks pen up
and pOSitions it without assistance. Pen must be held as for writing. Dots not dashes.)
5. Take a dessert spoon of liquid to the mouth. (Do not allow head to lower toward spoon. liquid must not spilL)
6. Hold a comb and comb hair at back of head. (Shoulder must be externally rotated, abducted at least 90 0 Head erect.)
Carr, J. H., Shepherd, R. B., Nordholm, L., & Lynne, D. (1985). Investigation of a new motor assessment scale for stroke patients. PhYSical Therap
65, 175-180.
of recovery assessed in the FMA. In all cases where the Intratester and intertester reliability were estab~ished in
development of motor behavior could be followed, stage 2 study of 19 adult patients who had sustained cerebrova
behaviors preceded stage 3 behaviors, which preceded cular accidents at least 1 year before testing (Duncan et aI
stage 4 behaviors, and so on. This proVides strong support 1983). All participants had previously been discharge
for the construct validity of the tool. Data indicated that from occupational and physical therapy because of pl
balance did not necessarily follow the restoration of motor teaued motor recovery. Four physical therapists wit
function of the limbs. However, full recovery of balance experience administering the FMA served as examiner
only occurred in patients who achieved maximum scores For analysis of intratester reliability, one therapist ad
on the lower extremity subtest. Sensation scores did not ministered the complete FMA three times to each patien
correlate with either maximum motor behavior achieved at at 3-week intervals. Two sets of correlation coefficien
final test or slope of the recovery curve. This finding indi were determined: between tests 1 and 2 and between tes
cates that somatosensory function may not serve as a prog 2 and 3. Correlation coefficients for the total test wer
nostic indicator of success in achieving motor recovery. 0.984 and 0.988, indicating extremely high intrarate
Motor recovery of the shoulder-arm system was compared reliability. Intratester correlation coefficients for subtes
with recovery of lower extremity use through paired differ ranged from 0.865 Uoint range of motion and pain) t
ences regression analysis. This yielded a mean correlation 0.996 (upper extremity motor function). Highest correla
coeffiCient of 0.88, indicating a fairly strong relationship tions were found on the upper extremity and low
between amount of recovery in the arm and leg. extremity motor subscores, and lowest correlations wer
In subsequent piloting with 21 patients (Fugl-Meyer, found for the balance and joint range of motion/pai
1980), patients were grouped for statistical analysis ac subscores. All correlation coefficients were statistical
cording to their cumulative scores for upper and lower significant at the 0.001 level. Analysis of variance of a
extremity function. Scores between 50 and 84 were total scores and subscores yielded no significant difference
categorized as indicating severe impairment, scores be among the score distributions for first, second, and thir
tween 85 and 95 as moderate impairment, and scores testings.
from 96 to 99 as minimal impairment. Contractures, For analysis of interrater reliability, participants pe
which developed most frequently in the shoulder and ankle, formed only one section (upper or lower extremity moto
were significantly more pronounced in patients with severe performance) of the FMA on two additional occasions wit
impairments than in those with moderate or minimal two different examiners. Therefore, interrater reliability fo
impairments, Motor function was significantly associated the joint motion and pain, sensation, and balance subtes
with balance, joint motion, and , inversely, with joint pain . was not established. Scores from these two test session
--~
- - - ~-
- .'
, ~
. ..'
266 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
were correlated with one another, as well as with the Standardized Assessments Based
corresponding scores received on the third testing of the
intrarater reliability tests with the first examiner. Therefore,
on the Neurodevelopmental
two sets of correlation coefficients were determined for Treatment Philosophy
total upper extremity function (r = 0.984 and 0.995), total
THE RIVERMEAD MOTOR ASSESSMENT
lower extremity function (r = 0.922 and 0.953), and each
of the subscores for upper and lower extremity function. PsychometriC issues were a focus in the development of
Correlation coefficients for the subscores ranged from this tool. The order and instructions for test items in the
0.833 (lower extremity coordination) to 0.997 (hand final version were developed in response to pilot testing,
function). Analysis of variance revealed statistically signif which assessed interrater reliability and criteria for consid
icant differences in intertester scores for upper extremity eration as a Guttman scale. Initial piloting included 51
coordination and reflex assessment. However, the authors patients on a stroke rehabilitation unit. Seven physical
attribute this to one examiner 's misinterpretation of scor therapists participated in reliability testing, which was
ing instructions. No other statistically significant differences based on videotapes of seven assessments.
were found between intertester scores. The extent to which the data fit the Guttman scale model
In summary, intratester reliability was established for the was evaluated by calculating coefficients of reproducibility
entire FMA, and intertester reliability was established for and coefficients of scalability for each of the three sections
the upper and lower extremity components. Cumulative (gross function, leg and trunk, and arm). Coefficients of
scores for upper and lower extremity motor function reproducibility ranged from 0.90 (leg and trunk) to 0.98
ranged from 50% to 98% of maximum performance, with (gross function). Coefficients of scalability ranged from
a mean of 74% . 0.79 (leg and trunk) to 0.96 (gross function). Findings for
Concurrent validity of the FMA has been established all three sections met the criteria to be considered valid
through a series of studies that established strong relation Guttman scales. The same statistical analyses were con
ships between scores on this test and on tests of other ducted with data from retesting 40 of the participants after
variables associated with motor recovery. It should be a 4-week interval. Similar results were achieved. Test-retest
noted that the subtests of upper and lower extremity reliability of the Rivermead's final version was established
function are most commonly used in these studies. There in a study of 10 hemiparetic individuals who were no longer
fore, no statements can be made about the validity of participating in rehabilitation due to plateaus in motor
subscales of balance, sensation, or joint motion and pain. recovery. Patients were assessed and then reassessed by
Fugl-Meyer and associates found significant relation the same examiner 4 weeks later. Correlation coefficients
ships when comparing the total motor score with indepen were 0.66 (P < 0.05) for gross function , 0 .93 (P < 0.001)
dence in activities of daily living (Fugl-Meyer et al., 1975; for leg and trunk, and 0.88 (P < 0.001) for arm . The
Sjogren & Fugl-Meyer, 1982), participation in leisure test developers point out that the lower correlation be
activities and sexual intercourse (Sjogren & Fugl-Meyer, tween test and retest scores on the gross function scale
1982), and scores on another test of arm control (Berglund was due to lack of variation of scores within the 10
& Fugl-Meyer, 1986). Kusoffsky and coworkers (1982) patients.
determined that somatosensory evoked potentials are Subsequent testing of the Rivermead's scalability indi
predictive of Fugl-Meyer scores. Badke and Dunkan (1983) cated that the gross function and arm sections met
reported a statistically significant relationship between Guttman scale criteria , with a sample of individuals pre
abnormalities in postural adjustments in standing with FMA senting with acute strokes (Adams, 1993a). Recovery in
scores on the lower extremity subscale. these areas followed a hierarchic pattern on repeated
The FMA has been used in a number of clinical studies testing, whereas recovery of leg and trunk function dem
about stroke rehabilitation. It was chosen as the tool for onstrated a more uneven pattern, which did not corre
measuring outcome in a longitudinal study of motor recov spond to the hierarchic listing of the items on the assess
ery in a cohort of patients with an acute lesion in the carotid ment. This finding, which is consistent with findings using
distribution (Duncan et al., 1992). FMA scores reflected the the FMA, indicates that improvements of motor function in
dependent variable in an experimental study comparing the arm follow a more predictable sequence during acute
the effectiveness of EMG biofeedback, positional feedback recovery than does improvement of trunk or leg function.
with electrical stimulation , and proprioceptive neuromus In a study of nonacute stroke patients aged 65 or older
cular facilitation in improving arm and hand function in (Adams, 1993b), only the gross function section retained
stroke patients of more than 6 months duration (Kraft et aI. , the properties of a Guttman scale. This indicates that after
1992). In a study of functional recovery after discharge the acute stage, patterns of further recovery are less likely
from inpatient stroke rehabilitation (Ferrucci et aI., 1993), to follow predictable sequences.
the FMA was used as a measure of neural impairment. Further piloting of the Rivermead Assessment is needed.
Interestingly, the two latter studies found that FMA scores Firstly, establishment of interrater reliability would enable
continued to improve when individuals were studied more multiple examiners to compare their scores. Secondly, ad
than 1 year after their cerebrovascular accidents. ditional assessment of test-retest reliability, using a sample
scores on this subtest. Finally, the scale's criterion-related function. An interrater study yielded intraclass correlation
validity needs to be determined . The Rivermead Motor coefficients of 0.79 and 0.77 for upper and lower limb
Assessment has been used as an outcome measure in stud function, respectively.
ies of rehabilitation for balance (deWeerdt et aI., 1989) and
functional abilities (Juby et aI., 1994).
ASHBURN'S PHYSICAL ASSESSMENT
FOR STROKE PATIENTS
THE MONTREAL ASSESSMENT
Although this test has standardized instructions and
Validity of subtests related to the upper extremity was yields a numeric score, no statistical analysis of scores ha
established in a study of 62 individuals who participated in been reported. The test has been used clinically in a numbe
a 2-month inpatient stroke rehabilitation program (Ar of rehabilitation programs in England. A qualitative assess
senault et aI., 1988). Participants were evaluated three ment of interrater reliability revealed few disagreements in
times. They received a pretest on admission , an intertest scores when individuals were evaluated independently by
after 1 month of NOT, and a posttest just before leaving the 15 paired observers (Ashburn, 1982).
center after 2 months of NOT. Each evaluation included the
following tests:
The nonstandardized Brunnstrom Evaluation (Brunn Tests of Upper Extremity Function
strom, 1970)
The Upper Extremity Functional Test (Carroll , 1965) Since the Action Research Arm Test, like the Rivermead
The upper extremity section of the FMA, excluding tests Motor Assessment, is a Guttman scale, coefficients o
of the wrist and hand scalability and reproducibility are used as measures o
The Montreal Assessment validity. These coefficients range from 0.94 to 0.99 for th
Friedman two-way ANOVA for ordinal data was used to four subtests (Lyle, 1981). Interrater and test-retest reli
determine differences in scores on all four tests across the abilities were established through pilot testing to be 0.99
three measurements taken during each patient's rehabili and 0.98, respectively (Lyle, 1981). The tool's construc
tation stay. All four evaluation protocols indicated statisti validity is supported by results from a study in which 53
cally significant progress over time. Interestingly, this individuals were assessed with this evaluation and the FMA
finding indicates that the FMA of the upper arm is a valid at 2 weeks and at 8 weeks after the onset of strok
tool for measuring progress, even when patients receive (deWeerdt & Harrison, 1985). Spearman rank correlation
Bobath-oriented intervention . coefficients between scores on the two evaluations wer
Spearman-rho correlations were determined between extremely high (r = 0.91 at 2 weeks after stroke; r = 0 .94
scores on each of the four assessments given at each at 8 weeks after stroke).
testing. For this calculation, the authors correlated scores Although descriptive measures have been reported from
on a partial version of the Montreal Assessment, which piloting of The Arm Function Test (DeSouza et al., 1980)
excluded subtests of sensorium and pain. Pretest, intertest, no formal reliability or validity data are available.
and posttest scores on the partial Montreal Evaluation
correlated significantly (P < 0.001) with corresponding
FUNCTIONAL TEST FOR THE HEMIPARETIC
scores on the other three assessments. Correlation coeffi
UPPER EXTREMITY
cients with the FMA were 0.73 for the pretest, 0.62 for the
intertest, and 0.85 for the posttest. The current version of The Functional Test was devel
Content validity of the Montreal Evaluation was estab oped after several years of clinical use of an initial version
lished through principal component analysis of scores for which was first developed in 1964 (Wilson et aI., 1984)
38 hemiplegic subjects who were tested on admission, after Notable revisions included removal of redundant items and
1 month of treatment, and just before discharge (Corriveau changes in the order of tasks.
et aI., 1992). Principal component analysis revealed three To establish interrater reliability, two occupational thera
factors that correspond to the subsections of this tool: pists tested 10 patients within 2 days. Each individual'
Factor one: mobility-postural reactions and active scores between the two raters were within one item of each
movements other, and the Spearman's rank correlation between th
Factor two: muscle tone testers was 0 .976.
Factor three : sensorium and pain A pilot study, including 82 individuals who participated
The statistical link between scores of postural reactions in a stroke rehabilitation program, established concurren
and active movements provides support for the NOT validity of The Functional Test. In addition, analysis o
concept that limb movements can be improved through the scores provided support for the hierarchy of test items
development of enhanced postural reactions. Using multiple regression analysis, an objective test battery
A reliability study of this tool (Corriveau et al., 1992) of subskills associated with upper extremity function wer
268 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
found to predict performance on The Functional Test. The same examiner twice within a 2-week period (Carr et aI.,
objective test battery included evaluations of 1985). High interrater reliability was determined in two
1. Active, selective extension of the elbow, wrist, and separate studies. In the first study (Carr et aI., 1985), one
index finger metacarpophalangeal joint expert examiner assessed five individuals who were a
2. Active shoulder flexion and abduction various stages of motor recovery after stroke. Her assigned
3. Isometric wrist extension torque scores became the criterion ratings, and the assessmen
4. Two-pOint discrimination on the palmar distal pha sessions were videotaped . After instruction and 3 weeks of
lanx of the index finger practice implementing the MAS, 20 physical therapists
5 . Proprioception of the index finger, wrist, and elbow and physical therapy students viewed the tapes and scored
6. Assessment of spasticity in the finger, wrist , and each patient's performance. (General tonus , item 9, was
elbow flexors not included since this cannot be assessed by observation
This multiple regression data demonstrated that the alone.) Spearman correlation coefficients between the
composite scores from the test battery accounted for 86% rater's scores and the criterion ratings for each of the
of the variance of The Functional Test scores (P < 0.001) patients were calculated and averaged to yield a reliability
(Wilson et aI. , 1984). Stepwise regression analysis demon coefficient of 0.95.
strated that all tests on the objective battery contributed to In a subsequent study (Poole & Whitney, 1988) two
variation in Functional Test scores, except for active examiners observed actual assessments of 24 individuals
extension of the elbow and index finger, two-point discrimi after stroke and scored each subject independently. This
nation , and spasticity. yielded an interrater reliability coefficient for the total score
Indirect support for the validity 01 using functional hand of 0.99 . All coefficients for individual items were high and
tasks to assess upper extremity motor recovery after stroke statistically Significant at the 0.001 level except general
is provided in an unrelated study of the hemiplegic arm tone (r = 0.29).
(Wade et aI., 1983). This highly referenced research used Poole and Whitney (1988) also assessed concurrent
a series of seven tasks to assess arm function, but no reports validity by testing 30 subjects on both the MAS and the
exist in the literature of the test's reliability or validity. FMA and comparing scores. Spearman correlation coef
Future longitudinal studies of recovery in arm function ficients could not be calculated for the supine to sidelying
would have stronger psychometric foundations if they used and supine to sitting activities since no comparable items
The Functional Test, rather than Wade and colleagues' are on the FMA. General tone was not included in
assessment. calculating a total MAS score because this item, unlike all
Further support for The Functional Test's concurrent others, is not scaled ordinally. The correlation for the total
validity was provided in a study of motor function and scores on the MAS and the FMAwas 0.88 (P < 0.001). Al
activities of daily Jiving (Filiatrault et aI., 1991). Scores on correlations for individual items were strong and significan
The Functional Test correlated highly with upper extremity at the 0 .001 level, except for sitting balance (r = 0 .28).
scores on the FMA (r = 0.96). In addition , scores on The The poor correlation between the balanced sitting item
Functional Test increased between time of admission to a with scores on sitting balance in the FMA is not a negative
rehabilitation unit, 1 month later, and at time of discharge. finding for the MAS. The FMA's evaluation of balance is
Sensitivity to change, however, was greater for the FMA based on outdated pr,inciples and assesses static responses
than for The Functional Test. Since this is probably due to to sudden, external disturbances, The MAS assesses
the Functional Test's small global score (0-7), a French balance in the context of dynamic adjustments during
version has been adapted with a numeric scale (i.e., 0,1,2) active task performance. Furthermore , the sitting balance
for each task and a global score of 34 points (Dutil et aI., component on the FMA is psychometrically weak, with no
1990). evidence of either reliability or concurrent validity with
In summary, The Functional Test has well-established other assessments of sitting balance.
reliability and validity. Since individuals are scored on a Although correlation between scores on MAS's two
pass-fail basis for each item, total scores range only from 0 items of hand function with the FMA's combined wrist and
to 7, and may not be sensitive to small improvements. If hand motor scores was high (r = 0 .92) , questions were
reliability can be established for the newer French version, raised about the validity of the scoring hierarchy for the
the test may be even more useful as an outcome measure MAS's advanced hand activities item (Poole & Whitney,
in clinical studies of upper extremity recovery after stroke. 1988).
Loewen and Anderson's (1988 , 1990) MMAS adapted
the original MAS in response to concerns raised in earlie
Carr and Shepherd's Motor pilot testing. Specifically, they removed the general tonus
item and reordered the scoring hierarchy for advanced
Assessment Scale for hand activities. Interrater reliability of the MMAS was
Stroke Patients determined to be 0.96 through a Spearman rank-order
correlation analysis of scores assigned by 14 trained
Test-retest reliability was established as 0 .98 in a pilot physical therapists who watched videotaped assessments
study of 15 individuals after stroke who were tested by the of seven individuals with hemiplegia due to stroke.
after watching the videotapes 1 month later. Spearman items are passed.
rank-order correlation coefficients ranged from 0.81 to Closed kinematic chain-A system in which motio
1.00, with a median of 0.98. Analysis of individual items at one joint produces motion at all other joints in
showed correlations of 1.00 for all examiners on the hand predictable manner; occurs during human movemen
movements and advanced hand activity items. Lowest when the distal end of an extremity is fixed on a supportin
intrarater correlations were found for the supine to side surface.
lying item . This is probably due to the fact that scoring on
Guttman scaling-Cumulative scales that present a se
the hand assessments is based on the person's ability to
of items that reflect increasing intensities of the character
succeed at a hierarchy of specific tasks. Scoring for the
istic being measured.
supine to side lying item is based on a qualitative assess
ment of the person's performance of one activity. Motor control-The mechanisms by which individua
In summary, both the MAS and MMAS are highly regulate and coordinate actions to perform tasks.
reliable. Concurrent validity for the MAS, using the FMA as Motor learning-The process by which individua
criterion, is also high. The scoring hierarchy for advanced develop skilled control in performing motor tasks.
hand activities on the MMAS seems to be an improvement Muscle tone-A muscle 's readiness to reflexively re
to the original. However, its validity still needs to be spond to stretch.
established. The original MAS was used successfully as a
Open kinematic chain-A system in which bod
measure of the dependent variable in a study of reha
segments are free to move without causing motion a
bilitation outcome following stroke (Dean & Mackey,
another joint; occurs during human movement when th
1992). Construct validity for the sit to stand item (Ada
distal end of an extremity moves freely in space.
& Westwood, 1992) and the walking item (Nugent &
Schurr, 1994) has been supported in clinical studies. Postural adjustments-Automatic, anticipator
mechanisms that enable an individual to maintain balanc
against gravity, optimal alignment between body parts, an
optimal orientation of the head, trunk, and limbs wit
SUMMARY relation to the environment.
Postural control-Ability to maintain optimal postura
Occupational and physical therapists often provide alignment and balance in a variety of dynamic activities i
intervention to enhance motor function in individuals who changing environments.
are recovering from stroke. No doubt exists that stroke is a Postural responses (reactions)-An older term
difficult disease to study because its clinical manifestations used to describe postural adjustments; overlooks the auto
and extent of recovery vary widely between individuals matic, anticipatory qualities of these mechanisms.
(Lyden & Lau, 1991). However, it is hoped that the
Primitive reflexes-Involuntary, often abnorma
standardized tools described in this chapter can be used as
changes in muscle tone in response to quick stretch o
outcome measures of motor function in well-designed
muscles or changes in the position or orientation of th
research studies that examine the efficacy of selected
head.
approaches to stroke rehabilitation.
Reflex-inhibiting patterns-Combinations of move
ments designed to decrease tone in spastic muscles an
facilitate active movement; advocated by NDT in th
1970s.
Associated reactions-Abnormal reflex movements Spasticity-Hyperactive response to stretch in selecte
that occur simultaneously with voluntary movement of muscle groups.
another body segment and are accentuated by excessive
effort or anxiety.
Balance-Ability to maintain an upright posture by
maintaining one's center of gravity within the current base
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SUMMARY This subchapter briefly describes the available methods for assessing
the symptoms related to upper motor neuron syndrome (UMNS). The procedures
described are predominantly limited to more practical assessment techniques that
physical and occupational therapists may use in evaluating UMNS clinically. More
sophisticated, albeit not necessarily practical, evaluations are included if they are
noninvasive and appear valid and reliable. In addition, semiquantitative evaluations,
such as timed motor tasks, are not included because research does not support
their use as a valid and reliable measure of UMNS.
The clinical importance for measuring symptoms is extremely important, espe
cially as the health care system evolves. It would be inappropriate to focus
treatment on a particular symptom (spasticity) if one could not accurately document
change. This subchapter reviews many techniques used to evaluate the symptoms
related to UMNS and spasticity. No one assessment stands out as being superior to
. ----, =. -=
272 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
others; some are more appropriate clinically, whereas others are more suited for
research study. Furthermore, some evaluations are better at documenting change,
whereas others are superior at quantifying intensity of symptoms. Therefore, cli
nicians need to choose the appropriate assessments that fit their needs. Knowledge
of the assessment's advantages and disadvantages will help in this decision.
Upper motor neuron refers to central nervous system Performance deficits (positive symptoms), on the othe
(CNS) cells whose axons form descending motor pathways hand , are symptoms more likely seen in patients with
that either directly or indirectly exert influences on lower cerebral vascular accident (CVA) or traumatic brain injury
motoneurons (Noback et aI., 1991). The term upper (TBI). In this group, patients usually exhibit muscle weak
motor neuron is often used interchangeably with cortico ness , fatigability, and loss of dexterity. Several physiologi
spinal and pyramidal neuron. The pyramidal or the factors may contribute to these performance deficits. For a
corticospinal system refers to those fibers that originate in complete review, refer to Katz and colleagues (1992)
the cerebral cortex and descend to the spinal cord Landau (1980), Giuliani (1991), Dohrmann and Nowack
through the medullary pyramids. Corticospinal fibers de (1974) , and Dimitrijevic and Nathan (1967). Performance
cussate in the lower medulla and enter the spinal cord as the deficits produce the functional disability seen in uppe
lateral corticospinal and anterior corticospinal tracts. The motor neuron syndromes, although more visually dramatic
corticospinal tracts are the only tracts that directly connect symptoms are identified with abnormal behaviors (Bishop
the cerebral cortex to the spinal cord . There are other 1977; Hagbarth, 1993; Young & Wiegner, 1987).
descending cortical systems that travel to the spinal cord; The goal for all therapists is to have their patients achieve
however, they synapse in the brain stem before going to functional independence . The physical impairment tha
spinal levels . These other "extrapyramidal" tracts also are results from upper motor neuron disease usually jeopar
included in the term upper motor neuron (Carpenter, dizes a person's ability to perform many daily living tasks
1991 ; Kandel et aI. , 1991; Kuypers, 1981). Initially, the therapist must assess the patient's level o
Lower motor neuron refers to motor neurons (alpha functioning and then develop a treatment plan that wil
cells) that innervate and control voluntary skeletal muscle . improve or eliminate the factors that are hindering perfor
Destruction of lower motor neurons results in a loss of mance. As the course of rehabilitation proceeds, intermit
voluntary and reflex responses of the denervated muscle. tent systematic assessments are conducted to objectively
Afterward, the muscle rapidly atrophies, and flaccid pa determine patient progress.
ralysis ensues (Carpenter, 1991; Kandel et aI., 1991; In today's changing world of health care distribution, the
Kuypers , 1981). role of objective assessment is becoming as important a
In this subchapter, the term upper motor neuron the therapy itself. With the rising cost of health care
syndrome denotes the spasticity resulting mainly from insurance companies are demanding more objective as
corticospinal lesions. It must be realized that most lesions of sessment regularly. PreViously, clinical assessment wa
the CNS damage structures other than corticospinal path based on observation. The therapist would use a checklis
ways. They also involve various other " extrapyramidal " indicating whether a functional item could be accom
CNS structures. The functional loss following an upper
motor neuron lesion, therefore, varies, depending on the
structures involved.
'Ii\BI r: 11 -')
Symptoms from upper motor neuron syndromes may be UPPER MOTOR NEURON SYNDROME
subdivided into two categories, abnormal behaviors (posi
tive symptoms) and performance deficits (negative symp Abnormal behaviors (positive symptoms)
toms) (Table 11-9) (Katz & Rymer, 1989). Abnormal Reflex release phenomena (pathologic reflexes)
Hyperactive proprioceptive reflexes
behaviors are defined as exaggerated movements that Increased resistance to stretch
result from the release of descending inhibitory control. Relaxed cutaneous reflexes
The symptoms that fall into this category are the Babinski Loss of precise autonomic control
Performance deficits (negative symptoms)
reflex, loss of autonomic control, exaggerated flexor re Decreased dexteri ty
flexes, increased proprioceptive reflexes, hypertonia, clo Paresis/weakness
nus, spasticity, and other synkinesias. These deficits are Fatigability
more likely observed in individuals with spinal cord injury,
From Katz R. T. , & Rymer, W. Z. (1989). Spastic hyperto nia : Mechanism
as these patients have lost the connections to higher and measurement. Archives of Physical Medi cin e and Rehabilitation
control centers (Katz & Rymer, 1989). 70; 144-155.
effective objective measurement techniques has been re
strictive for physical and occupational therapists, since
TENDON REFLEXES
quantification is necessary to evaluate various modes of
treatment. Efforts to develop quantifiable assessments have Tendon reflexes (T-reflexes) are based on a two-neuro
been limited. or monosynaptic reflex arc. Slight stretching of a muscl
This subchapter discusses the assessment tools advo activates the neuromuscular spindle, and the resultan
cated to quantitatively evaluate the symptoms of upper excitation travels to the spinal cord via the large Ia musc
motor neuron syndrome. Quantification of these symp spindle afferents. Ia axons synapse on and excite alph
toms has been a difficult and challenging problem. motor neurons , causing the stretched muscle to contrac
(Fig. 11-3). This reflex is considered a postural reflex, sinc
muscle spindles monitor changes in muscle length. Th
stretch reflex is the basis of the T-reflex that is used i
POSITIVE SYMPTOMS- SPASTICITY neurologic examinations. A hammer delivers a sharp blo
(ABNORMAL BEHAVIORS) (tap) to the muscle tendon, stretching the muscle and i
spindles, resulting in reflex contraction of the homologou
Spasticity is defined as " a motor disorder characterized muscle. The level of spasticity is evaluated by subjectivel
by a velocity-dependent increase in tonic stretch reflexes assessing the degree of reflex muscle contraction. Th
(muscle tone) with exaggerated tendon jerks, resulting from results are recorded on an ordinal scale where 0 equals n
hyperexcitability of the stretch reflex, as one component of response and +2 and +4 are normal and hyperactiv
upper motor neuron syndrome" (Lance & Burke, 1974). responses, respectively. Between values represent varia
Clinicians perceive spasticity as a major impairment for tions in muscle tone activity (Greenberg et a!., 1993).
individuals with upper motor neuron lesions. Many thera Electromyography (EMG) is utilized when more objectiv
pists believe spasticity is the cause of the abnormal and precise assessments are needed . T-reflex amplitude
movements and poor dexterity observed following upper are measured and compared with normative values ob
motor neuron lesions. Although debatable, research has tained from a population of healthy people. Mean value
shown that spasticity rarely causes movement abnormali equal to or greater than 2 standard deviations abov
ties (Young & Wiegner, 1987). Indeed, spasticity has been normative values are considered abnormal and indicativ
useful in helping some patients stand , dress, and transfer. of spasticity (Ottenbacher, 1986).
The controversy over the dehabilitating effect of spas Another assessment procedure uses the ratio of supra
ticity is partially due to the heterogeneity of its clinical maximal T-reflexes to the supramaximal direct moto
status . The heterogeneity arises from the numerous differ response" (TmaxIMmax). Since it is presumed that th
ent sites in the CNS that may be damaged, the time from maximal direct motor (M) response represents the tota
the injury, and the nature of the reaction of the CNS to the motor neuron pool activated by a maximal stimulus, th
injury (Dimitrijevic et a!., 1989). This is probably one of the ratio of T max to Mmax represents the percentage of th
reasons spasticity is so hard to quantify . The need to motor neuron pool participating in the T-reflex. Th
quantify functional disability is important since therapists method assumes that presynaptic inhibition by descendin
need to correlate rehabilitative procedures with functional tracts is held constant. Patients with severe hyperreflexi
progress. This section provides the reader with a critical have T maxlMmax ratios around 1 , whereas the ratios o
review of the more common assessment techniques con subjects with normal tone are much lower (Dimitrijevic &
cerning spasticity. Nathan, 1967). Treatment effects are assessed by the rati
of posttreatment to pretreatment measurements (T
reflexafter;T-reflexbefore). DecreaSing ratios represent pos
Neurophysiologic Assessments tive treatment outcomes.
The use of T-reflexes in quantifying spasticity has man
Increased motor neuron excitability (MNE) is found in disadvantages. Objective quantification of T-reflexes re
patients with upper motor neuron lesions and hyperre quires a constant testing environment (Bishop, 1977
flexia (Magladery et a!., 1953). Clinically, monosynaptic Patient positioning and limb stabilization must be con
reflexes provide a means for testing phasic stretch reflexes , trolled to prevent these parameters from altering th
a cardinal feature in spasticity. Physicians have routinely response under study . A constant force striking the tendo
assessed the strength of patient's stretch reflexes as part of
the neurologic examination. Increased strength and speed 'The direct motor respo nse o r M-wave is a nonre nexive musc
of the stretch reflex are hallmark responses in clinically contractio n afte r stimulating a mixed nelVe. Electrical stimulation initiat
diagnosing muscle spasticity (Greenberg et a!., 1993; a nelVe impulse in mo tor fibers that travels directly to the muscle witho
involving spinal cord neurons. The muscle contraction elicited occu
Pryse-Phillips & Murray, 1985). sooner than a reflex contractio n because the nelVe impulse travels
This section describes the electrophysiologic procedures shorter distance and has no synaptic delay.
274 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
la fiber
is essential since reflex amplitude is directly proportional to reflex, however, the H-reflex stimulus bypasses the muscle
the force applied . Lastly, sensitive recording equipment is spindle, thus providing a measure of central reflex ex
needed so that modest changes in reflex parameters can be citability.
detected and reproduced reliably (Desmedt, 1973). The H-reflex is usually elicited by delivering a submaxi
Other difficulties relate to the interpretation of the mal stimulus to the tibial nerve in the popliteal fossa and
objective measures. For example, T-reflex amplitudes vary recording over the soleus muscle.t H-reflexes are evoked
between individuals. In fact, some healthy subjects have by a 1-ms rectangular pulse at frequencies no greater than
reflex amplitudes in the range considered hyperactive. To 0.2 Hz. The compound nerve action potential propagates
account for this variability, tendon reflexes are tested to the spinal cord, monosynaptically facilities spinal motor
bilaterally whenever possible. The presence of reflex neurons, and then proceeds down the efferent motor
asymmetry is clinically significant in interpreting the data.' axons, causing homonomous muscle contraction . A mini
T-reflex measures do not correlate well with other clinical mum of 10 consecutive reflexes is collected, and the
assessments of spasticity. Fellows and colleagues (1993, peak-to-peak reflex amplitudes are measured and aver
pp 536-537) studied the T-reflex as a clinical marker in aged. As with T-reflexes, the HmaxlMmax ratio is used to
human spasticity. They could not demonstrate any corre determine the percentage of the motor neuron pool
lation between the T-reflex and other clinical assessments participating in the H-reflex (Gassel, 1969; Taborikova &
of spasticity. They concluded "that the tendon jerk reflex Sax, 1968).
provides an incomplete picture of the pathological changes Angel and Hofmann (1963) and Matthews (1966) were
in the reflex responses in spasticity . Investigations restrict the first to suggest the use of HmaxlMmax ratios as a
ing themselves to this test will fail to reveal, or run the risk measurement of spasticity. They observed that maximum
of misinterpreting, the complex changes occurring in more H-reflex amplitudes, when compared with the maximum
physiological reflex responses that cause the patient far M-wave amplitudes, were higher in patients with spasticity
more problems." than in healthy individuals. These findings suggest tha
excitability in the monosynaptic stretch reflex arc is in
creased in spasticity (Burke et aI., 1976).
H-REFLEX
Evaluation of concurrent changes before and after
The H-reflex is an electrically evoked equivalent to the treatment sessions give some perspicacity into patien
monosynaptic stretch reflex. Unlike the muscle stretch progress. However, quantifying functional progress to
treatment over long periods, data reproducibility becomes
an important issue. There are few studies that test the
<This procedure assumes the unaffected side in hemiparesis is not
impaired . Thilmann demonstrated, however, the nonparetic limb has
abnormal characteristics and thus should not be used as a comparison tUpper limb H-reflex investigations use a similar protocol, except the
against normal values (Thilmann et a!., 1990). Reflex comparisons median nerve is stimulated in the cubital fossa and the recording electrode
between the two sides could lead to erroneous clinical impressions. are placed over the flexor carpi radialis muscle (Jabre, 1981).
sistency and the clinical correlates of HIM ratios in 10 Magladery et al. , 1953; Yap, 1967 ; Zander Olsen &
patients with spastic hemiparesis and seven subjects with Diamantopoulos, 1967); it is heightened in Parkinson
out neurological impairment. They found a high degree of disease and in diseases of the basal ganglion (Gasse
intersession consistency (r = 0.94) in the measurements 1973). This same phase is abolished during spinal shoc
from hemiparetic subjects tested on three separate occa but increases slowly with muscle tone return (Zander Olse
sions . However, intercorrelations between clinical assess & Diamantopoulos , 1967). Gassel (1973) has also sug
ments and HmaxlMmax ratios were not significant. None gested its use in investigating the CNS 's response t
theless , they concluded that Hmax/ Mmax ratio is a reliable pharmacologic agents.
indicator of spasticity and can be used to assess the effects Koelman and coworkers (1993) studied the relationshi
of treatment interventions repeated over days or weeks . between H-reflex recovery curves and the various clinica
Katz and colleagues, in two similar investigations, also signs of upper motor neuron syndrome in 80 patients
looked at the reliability of HmaxlMmax ratio in quantitatively Their findings showed that the H-reflex recovery curve lat
assessing spastic hypertonia in subjects after cerebral facilitation phase increased with enhancement of tendo
vascular accidents (Katz et al., 1992; Katz & Rymer, 1989). reflex activity and clonus. The facilitation period did no
Their results showed large intrasubject variations in the show any significant correlation with muscle tone or muscl
Hma"IM max ratios and poor statistical correlation with strength.
clinical assessments. They concluded, as did others (Sax & Garcia-Mullin and Mayer (1972) investigated the rela
Johnson , 1980) that Hmax/Mmax ratios are not a good tionship of the H-reflex recovery cycle to spasticity i
measurement tool to quantitatively assess changes in patients with hemiplegia . Their results agreed with those o
spasticity . other studies (Koelman et al. , 1993; Tardieu et aI., 1977
Therefore , HmaxlMmax ratios must be interpreted cau No correlations could be demonstrated between th
tiously and should not be used as a clinical measurement of H-reflex recovery cycle and the severity of the hemiplegia
spasticity. However, if the clinician realizes its limitations the degree of spasticity, and the subsequent recovery o
and elicits the reflex according to standardized protocol , functional return. These studies suggest that H-refle
statistical comparisons can be made between a patient's recovery curves are not useful in quantifying spasticity o
progress and his or her recorded baseline . predicting motor recovery.
1 ----------1\ 7:.
syndrome . As can be observed, the graphs consist of
several phases. The first phase that occurs with interstimu 60
Ius intervals from 3 to 10 msec elicits a test reflex that varies
~ 40----:;;:;./:/
in size with the intensity of nerve stimulation (Magladery et
aI., 1953). This facilitation is similar in normal individuals
and patients with upper motor neuron syndrome. A phase
- -:::/ '
of inhibition follows the initial phase, and its duration has 20 - - - - . /- - - - - - -/~ - - - - - - - - - - - - - - - - - - - - - - - - - - -
/ .-"
been shown to decrease in upper motor neuron lesions.
The next phase is a facilitatory phase occurring at 50 to
400 msec that peaks at 200-300 msec. The facilitation
a .--
·1
I
50
• .......
75
,
:.- -_.-.""!III ~
276 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
l\
.~. ~/.
interneurons. Aside from the la afferents, higher centers
also project to and terminate on la inhibitory interneurons 100r-- =-=
(Fig. 11-5). Suprasegmental lesions reduce presynaptic
inhibition by decreasing the excitatory signals onto these la
inhibitory interneurons . Reducing presynaptic inhibition in
80
\\•
~~.
/
60 \ .,.I
\... .....J.
this way allows more input through to the motor neurons /
from the periphery than normally. Conceivably, this may - Hemiplegic
40
account for the increase in stretch reflex output after a
normal muscle stretch in spasticity. 20
. - . Control
\--
Vibration
.
o' 10 20 '50 100 200' 500 ,~I ; 23
INTERVAL msec sec
Stretch
"The F-wave is not a true reflex and must be differentiated from the
H-reflex, which looks similar. F-waves are differentiated from the H-reflex 250 MS
by specific characteristics, including 1) appearance at a higher stimulus
threshold than that required for the H-reflex and the direct muscle
response, 2) an amplitude of less than 5% of the Mma , response, 3) FIGURE 11-7. Typical MI-M4 reflex pattern evoked in health
impe rsistence of the F response, 4) oscillations in latency and amplitude subjects. The trace represents the rectified average obtained from
under constant conditions,S) failure of supramaximal stimulation to block displacements during which the subject maintained a plantar flexin
the F-wave , and 6) appearance of the F-wave in many muscles (hands and torque. (From Hallett, M. [1985J. Spasticity: Assessment and pathophys
feet) in which the H-reflex is not present. NormaHy, the H-reflex is only ology. [n P. J. Delwaide & R. R. Young [Eds.], Clinical neurophysiology
seen in large postural muscles in healthy adults (Fisher, 1978, 1992; spasticity [pp. 83-93J. With kind permission from Elsevier Science-N
Kimura e t aJ., 1984; Schiller & Stalberg, 1978; Kimura et aJ., 1984). Sara Burgerhartstraat 25 , 1055 KV Amsterdam, The Netherlands.)
278 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
and M3; 45-65 ms) after the onset of stretch. Finally, a voluntarily. On cessation of the vibration, the postvibratory
prolonged response, the appearance of which is depen contraction of the muscle subsides slowly in a stepwis
dent on voluntary intent, is seen after 90 to 100 ms (M4) fashion in about 30 seconds (Eklund & Hagbarth, 1966)
(Fellows et aI., 1993). The most widely adopted nomen After CNS injury, the TVR becomes variable and weak
clature for these observed responses is that of Lee and (lower muscle tension). The muscle tension that develop
Tatton (1975). Under this scheme, the three LLR re augments and subsides quickly in contrast to the slow toni
sponses are called M1 , M2, and M3, respectively, with the recruitment of motor units (MU) in healthy individuals. In
M4 response representing volitional contraction (see Fig. spasticity the TVR is not isolated to the muscles vibrated bu
11-7). It is thought that LLR (M2 and M3 deflections) may usually irradiates to neighboring muscles on the same and
function in postural adjustments in response to environ contralateral sides. The TVR also cannot be voluntarily
mental perturbations during voluntary movements (Mars inhibited (Bishop, 1977; Burke et aI., 1972; Hagbarth &
den et aI., 1983). Eklund, 1968) .
Typically, subjects are pos.jtioned in an apparatus with Unfortunately, to my knowledge, no validity or reliability
the limb connected , via linkages, to a torque motor. The studies have been conducted on the TVR, nor have any
torque motor is capable of moving the limb through various correlations been made with clinical measures. Therefore
velocities, amplitudes, displacements, and torques. The the TVR remains elusive in the measurement of spasticity
procedure usually requires the subject to isometrically
contract against a lever while the limb is randomly stretched
FLEXOR REFLEXES
by the torque motor. Muscle stretch evokes the reflex
responses. Surface electromyography is used to record the It is well known that noxious cutaneous stimulation
muscle myoelectric signals. Reflex amplitude and duration evokes withdrawal reflexes in the ipsilateral limb
are measured and compared with a standard. Sherrington (1903) first noticed this phenomenon . H
In spasticity, LLRs are unpredictable . Some patients concluded that stimuli to any dermatome of the ipsilatera
exhibit increases in LLR, whereas the LLRs of others leg caused facilitation of flexor motor neurons with simul
remain normal or diminished (Hallett, 1985). taneous inhibition of extensor motor neurons; this wa
termed the "flexor withdrawal reflex."
Many studies have been conducted on this reflex sinc
TONIC VIBRATION REFLEX
Sherrington's early studies, and its physiology is now wel
Mechanical vibration, at approximately 100 times per known. The flexor reflex is a polysynaptic defense re
second (100 Hz), applied to a muscle or tendon induces an sponse to noxious stimulation of the skin. The pattern o
involuntary tonic reflex contraction of the same muscle. the muscles activated in the reflex is according to its biologi
This reflex is called the "tonic vibration reflex (TVR)" since function; i.e., withdrawal of the stimulated limb away from
it is elicited by a mechanical vibration (Hagbarth & Eklund, a dangerous stimulus. The normal flexor reflex in healthy
1968). TVRs can be evoked in flexor and extensor muscles humans is produced by stroking the sole of the foot with
in both the upper and lower limbs. sharp instrument. The clinical examination can be mor
The TVR is thought to depend upon the excitation easily quantified if the mechanical stimulation is replaced b
mainly of the primary endings of muscle spindles, which electrical stimulation through a pair of electrodes placed on
are highly sensitive to vibration. It is a polysynaptic stretch the plantar surface or over the cutaneous nerves innervat
reflex that also depends on supraspinal pathways (Eklund & ing this surface. The application of a train of stimuli 20 to
Hagbarth, 1966; Matthews, 1966). Clinically, vibration 30 msec in duration at a frequency of 30 to 50 Hz produce
has been used to enhance muscle contraction and to a tingling or touch sensation, and 500 to 2000 H
increase limb awareness (Trombly, 1989). produces a pricking or sharp pain sensation. Afferent fiber
The TVR is elicited, preferably by a 80- to 120-Hz that influence flexor motor neurons and cause limb with
vibration, to a muscle tendon at a vibratory amplitude of 1 drawal are termed flexor reflex afferents (Dimitrijevic
to 2 mm (Curry & Clelland, 1991; Dimitrijevic et aI., 1989; 1973; Hagbarth & Finner, 1963).
Eklund & Hagbarth , 1966). Application of the vibrator to The flexor reflex is a two-component exteroceptiv
the tendon is more effective than application to the muscle reflex (Fig. 11-8). The first component consists of
belly; however, either place is acceptable (Eklund & synchronized burst at a latency of approximately 70 ms. I
Hagbarth, 1966). A constant testing environment is re is followed by a desynchronized second burst (latenc
quired since the strength of the TVR is enhanced by muscle 150-250 ms) that is longer in duration and lower in
lengthening, muscle contraction, frequency and amplitude amplitude. The reason for the two-component refle
of the vibration, posture, and the individual's state of patterns is the stimulation of different afferents tha
relaxation . conduct impulses at different velocities . Both component
When the TVR is elicited in healthy individuals, the are modulated by suprasegmental structures, and it i
tension within the muscle increases slowly (rise time the second component that is associated with the lim
-20-30 sec) before reaching maximum. Reflex contraction withdrawal from a noxious stimulus (Dimitrijevic , 1973
lasts only while vibration is applied and can be inhibited Shahani & Young, 1973).
electrophysiologic criteria .
Milanov (1992) reinvestigated the flexor reflex as an
assessment tool for the quantification of spasticity . Hi
results confirmed earlier studies that the flexor reflex can b
used to assess interneuron excitability. He further con
cluded that the flexor reflex can be a useful assessment o
L
50 ms
treatment influences on interneurone activity. Correlation
between the reflex parameters and the degree of spasticity
however, were insignificant. Therefore, the flexor reflex
may be useful in revealing possible pathophysiologi
mechanisms of spasticity but is of limited value in clinica
assessment.
--. .
280 UNIT THREE-ASSESSMENT OF CENTRAL NERVOU S SYSTEM FUNCTION OF THE ADULT
maximum
fA[jL[ 11 1:2
Angle of flexion
EXAMPlE OF FUGL-MEYEIl ASSESSMENT reversal
FOR THE UPPER UMB
FIGURE 11-9. The pendu[um-like movements (swinging back an
ClassiBeation and Progress RecoM forth) of the ,leg after it has been dropped from the extended position
tI600~~
Ill. Wrist circumduction (stabilize forearm)
Digits
Stage
I. Flaccidity, no voluntary movement
II. Little or no active finger flexion d
III. Mass grasp or hook grasp Time
IV. Lateral prehension; release by thumb movement 1-----1
a. Semivoluntary mass extension- small range of motion 5 sec
V. Palmar prehension
a. Voluntary mass extension-variable range of motion
b. Spherical grasp (awkward) FIGURE 11-10. Goniometric traCings from a pendulum test of patient
c. Cylindrical grasp (awkward) with intracranial lesions. Figure represents a normal pendulum test
VI. All types of grasp with improved skill (a = Angle of maximum possible knee fle xion; b = angle of the knee with
a. Voluntary finger extension- full range of motion the leg hanging freely; c = knee fully extended; d = angle of flexion a
b. Individual finger movements (do dexterity tests) which the knee first reverses direction after the leg is dropped
d- a = relative angle of reversal.) (Adapted from Bohannon, R. W, &
Trom bly, C. (1989). Motor control therapy. [n C. Trombly (ed .), Smith, M. B. [19871. [nterrater reliability of a modified Ashworth Scale o
Occupational therapy for physical dysfuncti on , 3rd ed. Baltimore: Muscle Spasticity. PhYSical Therapl', 67(2), 206-207, with the permis
Williams & Wilkins. sion of the APTA.)
282 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
140.0
~ ,Ao \A,
~ 120.0
OJ
Q)
~
Q)
g> 100.0
« -;11-1.,..,---.J,U,I
, -~7!--ic)f(~\~~~~~~
x / 'c::::::o<>
j
80.00
60.00
160.0
Moderately spastic subject
150.0
140.0
Ul
Q)
l5, 130.0
Q)
~
Q)
120.0
'5l
c
« FIGURE 11-11. The pendulum movements of the lower limb
110.0 after it is released from the extended position. Diagram also dem
onstrates a method to assess spastic hypertonia of the quadriceps
100.0 and hamstTing muscle groups. Ao represents the amplitudes of the
damped sinusoidal curve as the limb falls from the extended posi
tion to the final resting angle. Al represents the amplitude of the
90.00 plotted waveform from full extension to its first absolute minimum.
I Top, A normal subject. Bottom, A moderately spastic subject.
Note the marked damping of the altered sinusoidal curve in the
0.000 1.00 2.00 3.00 4.00 5.00 6.00
spastic subject. (Refer to text for full explanation of assessment.)
Time (sec) (From Katz , R. T. , et a1.119921. Objective quantification of spastic
hypertonia: Correlation with clinical findings. Archives of PhYSi
co/ Medicine and Rehabilitation, 70, 339--347.)
extended position to the final resting angle was measured These results strongly endorse the pendulum test as a
(Ao) and compared with the amplitude of limb motion from measure of spasticity. The pendulum test is an accurate and
full extension to its first absolute minimum angle (AI) ' They reliable means of quantifying spasticity; however, one
called this ratio the relaxation index (RI = AI/Ao). Since in shortcoming is that it can only be performed manually on
neurologically healthy individuals, the RI is generally more the lower extremity quadriceps muscle group. Another
than 1.6, a correction factor was introduced to the RI weakness in the manually performed pendulum test is that
equation (CRI), where CRI = AI/1 .6Ao. A CRI value the undamped acceleration of the leg when dropped may
greater than 1 signifies a nonspastic limb, and a CRI less exceed a limb acceleration of greater than 300 degrees per
than 1 Signifies various degrees of spasticity (Katz et aI., second . Since spasticity is velocity dependent and accel
1992). Katz and colleagues used this calculation method of erations of this magnitude are not physiologic, the test
the pendulum test in the quantification of spasticity. They becomes Less sensitive and unimportant.
demonstrated that the pendulum test accurately identified Biomechanical equipment can be used to simulate the
a spastic limb in all of their subjects who had clinical pendulum test (Bohannon & Larkin, 1985). One such
evidence of spasticity. Furthermore, intra subject and inter system is the Cybex II isokinetic dynamometer. The Cybex
subject variability was stable, and the test correlated II system allows the examiner to precisely measure the
significantly with their clinical scale. refleXive induced muscle resistance while the muscle is
Bohannon (1987) studied the between-trial variability in the agonist and antagonist muscle groups. The degree
and reliability of the pendulum test performed with the spastic hypertonia is measured by assessing the magnitu
Cybex II isokinetic dynamometer. Using the relative angle of torque evoked in response to the stretch. The thresho
of reversal method (RAR) of calculation, he demonstrated angle is determined by a change in the slope of the torq
no significant difference in the RAR among four leg drops recording and the onset of EMG activity due to activati
in 30 patients with spasticity. Bohannon concluded that the of the stretch reflex.
test performed on the Cybex II isokinetic dynamometer Figure 11-13 is an example from a subject with hem
was reliable (r = 0.96). The variability in the testing proce paresis. The responses are from the unaffected side (N) a
dure over long times (days to weeks), however, was not the side of hemiparesis (S). The subject was asked to rel
examined and remained questionable. while a series of elbow extension movements were admi
istered to the limb. Each trial consisted of extending t
limb through an arc of 1 radian (57.3 degrees) at a consta
TORQUE/ELECTROMYOGRAM
angular velocity of 0.5 radians per second (Powers et a
CURVES-RAMP AND HOLD
1988).
The ramp and hold technique measures the amount of Initial torque deflections observed in Figure 11-13 a
torque produced during a specified passive joint move relatively constant between the two limbs. This is becau
ment. Threshold angle, the angle at which a significant the initial ramp phase is due to the limb's inertia and shou
increase occurs in torque or EMG activity, is also measured be the same between the left and right limbs. The torqu
(Katz & Rymer, 1989; Katz et al., 1992; Myklebust et al., therefore, remains relatively low and constant during t
1989; Powers et al., 1988; Powers et al., 1989). initial portion of the lengthening movement. Torque an
The subject usually is connected to a device that is EMG activity begin to increase, compared with those of t
coupled to a servo-controlled torque motor (Fig. 11 unaffected limb, once the onset of reflex-mediated EM
12).The torque motor applies a force to the device that activity develops. This increase occurs approximately o
passively moves the limb though a specified horizontal third of the way through the ramp phase.
displacement at different velocities (i.e., 0 .25, 0.5, l.0 Powers and colleagues (1988) used the ramp and ho
radians per second). Angular position and velocity are technique to investigate the relative contributions of t
measured by a potentiometer and tachometer attached to stretch reflex threshold to stretch evoked torque in subjec
Oscilloscope
EMG signals
r-:-:aii + - - Torque
- 7 + - - - Torque motor
~ -- :'=;,. - _.
with spasticity. Comparisons of ramp and hold measures maintained constant rate of stretch). On the other hand,
were correlated with clinical measures of hypertonia . The when velocity is held constant over an angular range, the
clinical measure was based on a 1 to 5 ordinal scale, stimulus again varies due to the differences in the mechani
where 1 and 2 corresponded to mild spasticity, and 4 and cal advantage of muscles at different joint angles.
5 related to severe spasticity. The authors demonstrated
that subjects with clinical ratings less than 3 tended to
have low values of stretch-evoked torque (0.9 to 4.7 Nm) SPASTICITY MEASUREMENT SYSTEM-SINUSOIDAL
and high threshold values (0.26 to 1.00 Nm). Subjects OSCILLATION
with high clinical ratings had higher torque values (3 .3 to
4.7 Nm) and low thresholds (0.05 to 0.34 Nm). Inter To avoid the difficulties of the ramp and hold method just
mediate ratings were more variable. On the basis of these mentioned, an alternative method to quantify spasticity can
findings , Powers and associates concluded that there was be used. This method uses sinusoidally oscillating motions
a definite correlation, although broad, between the ramp imposed on a joint as the stimulus to evoke muscle
and hold technique and the clinical assessment of spas responses . Sinusoidal oscillations are claimed to produce
ticity. more repeatable and controllable stimulus parameters than
Two other studies that investigated the use of the ramp the ramp method (Lehmann et al. , 1989).
and hold technique to quantify spasticity showed similar Subjects are positioned prone on a padded plinth, with
results. Significant correlations were noted between ramp the knee straight, the foot secured to a footplate, and the
and hold torque measurements and threshold angles and ankle aligned with the footplate shaft. A motor randomly
the Ashworth and Fugl-Meyer scales of hypertonicity. imposes sinusoidal oscillating motions on the joint at
Intrasubject and intersubject variability were nonsignificant frequencies ranging from 3 to 12 Hz. The torque is
even when the clinical perception of spasticity changed. measured in response to the oscillating movement through
The authors concluded that the ramp and hold test is a 5-degree arc . Figure 11-14 demonstrates schematically
consistently related to clinical measures of spastic hyper the device used to move and record data from the lower
tonia and is more accurate than other clinical measures limb.
presently used (Katz et al., 1992; Katz & Rymer, 1989). Fourier analysis techniques are used to measure the
The disadvantage of the ramp and hold technique is with amplitude and phase shift of the torque waveform , relative
the stretch stimulus that evokes the reflex. The stretch to the displacement waveform, to characterize spasticity
stimulus consistency varies with stretch velocity, enhancing (Agarwal & Gottlieb, 1977; Lehmann et al., 1989; Price et
as velocity increases and diminishing when velocity de al. , 1991; Rack et al., 1984). This system was termed the
creases (a reason for using isokinetic devices that allow a spasticity measurement system (SMS) and is shown sche-
(i) 1.0
Q) c:
-0 ) .<0
c:'O
« <0
fSo.o
Q) 5
=>~
crE
~z
~~
0
s
~
_0
10
'OQ)
'O-.!!?
I- E
'O~
0
'0
<0
21
matically in Figure 11-15. It was designed to characterize (Lehmann et a!., 1989; Price et a!., 1991; Rack et a!
the response of the ankle to a passive, controlled stretch on 1984).
the triceps surae muscle group (Lehmann et a!., 1989; The viscous component is comparable to a damper tha
Price et a!., 1991). is 90 degrees out of phase with the disp'lacement. It wi
The ankle's response to sinusoidal displacements is produce a resisting force in proportion to the velocit
expressed in terms of net stiffness after limb inertia and applied and the viscosity of the damper. Therefore, th
equip ment drag have been eliminated. The term stiffness total stiffness can be observed in graphic form by plottin
represents the ratio of the net torque to displacement (T/0) the vector sum of the elastic and viscous stiffness compo
and is composed of 1:IA10 quantities, elastic and viscous nents. The arc tangent of the ratio of the viscous to th
stiffness. Elastic stiffness is similar to a torsional spring that elastic stiffness is the phase angle (see Fig . 11-15C) that
represents the elasticity of the gastroc-soleus-Achilles expressed as a function of frequency in a Nyquist diagram
tendon complex. It is in phase with the displacement of the To express the responses over the frequency spectrum o
ankle , and the force produced is proportional to the 3 to 12 Hz with a single value, a "pathlength" calculatio
angular displacement and the stiffness of the spring is performed. Phase angles and vector amplitudes ar
'"'"
(])
-"M- Spring
-ir'Damper L{}:J- Spring &
damper
~
V'""""7
."" '"'" '"'"
V •• _----_ ••
1
g'" Eo (]) (])
.~"" ~
."" t
QJ'" '" '"~
Increasing
'Q"
::.
Q
frequency
<..> <..>
Vo --
S S Vo -----------.
I
Eo
I
Frequency Frequency
Elastic stiffness
A B C
FIGURE 11-15. Stiffness response of idealized mechanical elements to sinusoidal displacements over spectrum of frequencies. A, Spring elemen
B. Damper element. C, Spring element in parallel with damper element. (From Price, R., et al.119911 . Quantitative measurement of spasticity in childre
with cerebral palsy. Developmental Medicine and Child Neurology, 33, 585-595 .)
286 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
Torque
I 25 Mn
Angle
I 30 degrees
i IT= T max + T 2 + T3 + T 4
~ Time (sec)
2 3 4
FIGURE 11-17. A typical torque-angular displacement curve displaying the 5-s midtest period. T m " , and the four consecutive IT also are shown . (From
Firoozbokhsh, K K , et al. [1 9 93] . Isokinetic dynametric technique for spasticity assessment. America n Journal of Physical Medic ine and
Rehabilitation, 72, 379-38 5 .)
more, the initial torque value is also affected by the rate of Fetters (1991) and Kluzik and colleagues (1990) adv
acceleration and deceleration of the limb . Serial summa cate assessing purposeful movement rather than the ma
tion of consecutive resisting torques, avoid this shortcom nitude of the disorder's symptoms. These authors stre
ing by measuring damped oscillations whose values depend that this approach is needed because therapeutic interve
on the passive viscoelastic properties of the paretic muscles tions on abnormal behaviors have not been too successf
(Firoozbakhsh et at. , 1993). in the treatment of patients. Their approach uses kinemat
The disadvantages of this technique are twofold. First, an and videotape recordings to analyze reaching movemen
expensive isokinetic dynamometer is required to perform in three-dimensional space. This method has the adva
the examination. Second and more importantly, because tage of looking at complex human movement as it occurs
of the assessment novelty, it has not undergone stringent life situations by assessing both the quantitative and qualit
validity and reliability testing. Further studies are needed tive components involved in a purposeful movement.
before its use in the quantification of spasticity can be Reaching movements are recorded using a motio
sanctioned. analysis and recording system. Two infrared light-emittin
diodes are attached : one on the skin over the ulna 's stylo
process and the other on the target. Two cameras reco
the infrared light emitted by the diodes as the arm mov
through space. Kinematic data are collected and the
NEGATIVE SYMPTOMS averaged. The data are further simplified by combining th
(PEJRFORMANCE DEFICITS) three-dimensional movement components into a sing
displacement coordinate for each movement fram
As stated previously, the symptoms of weakness, fatiga The distance that the infrared diodes traveled during th
bility, and poor dexterity are more serious functional reaching movement is calculated by determining th
deficits affecting patients' movements than is spasticity. distance that the diode moves between consecutive frame
Evidence shows that reducing spasticity does not improve Acceleration and deceleration are also calculated (Kluzik
function; however, it continues to be identified by clinicians al., 1990).
as an important factor associated with movement dysfunc Statistical analysis for individuals uses the two standa
tion (Gordon, 1989; Landa u & Hunt, 1990; Young & deviation band method described earlier. Briefly , tw
Wiegner, 1987). Since functional improvement is usually horizontal lines are drawn above and below the mea
the therapeutic goal, emphasis should be placed on baseline data . Statistical significance is shown if tw
enhancing movement performance rather than decreasing successive data points occur outside the two standa
spasticity . deviation band (Ottenbacher, 1986).
Few studies have looked at the effect of occupational and Qualitative data are recorded using videotape that has
physical therapy on enhancing movement performance. A frame-by-frame analysis capability. Quantitative criteria a
reason for the paucity of movement analysis may be due to established for each of the qualitative components so th
the few evaluation techniques that are available to reliably the data can be analyzed and compared . For exampl
assess movement performance. A reliable measure would Fetters (1991) looked at associated reactions (AR) b
need to detect both qualitative and quantitative changes of calculating the amount of time the nonreaching han
a particular movement (Fetters, 1991; Kluzik et at. , 1990). remained on the table (tnr) and dividing it by the sum
Quantitative components are fundamental to all move movement time (smt) and reaction time (rt) (AR = tn
ments and are therefore more obvious of scrutiny during [smt + rtll. Evaluation results were shown to be reliabl
evaluation. Characteristically these include movement am valid , and sensitive for describing change in both quantit
plitude, duration, and trajectory. The qualitative compo tive and qualitative movement parameters (Kluzik et a
nents are less obvious but just as important. For example , 1990).*
movement qualities such as biomechanical alignment, A disadvantage of this assessment technique is th
proper synergistic patterns, proximal stability, and head expense of the digital motion analysis system equipme
control all assist in movement refinement. Deterioration in and video cameras required to complete the assessmen
any of these associative reactions will decrease motor Additionally, depending on the level of equipment, motio
performance. Rarely are these qualities considered in the analysis can be time consuming. Another obstacle, whi
treatment or evaluation of motor disorders. It is paradoxical is similar to the drawbacks with electrophysiologic asses
that so much attention is place on the positive symptoms of ments , is the plethora of kinematic variables that may b
upper motor neuron syndrome rather than the more
debilitating symptoms. This section describes the few
techniques that are known to evaluate the negative symp 'The WATSMART motion analysis system used in these experimen
was shown to be valid and reliable (ICCs > 0.99), Validity and reliabil
toms (movement performance) resulting from upper motor may be compromised if adherence to accura te experiment setup is n
neuron syndrome. performed (Sch olz, 1989),
288 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
used to assess motor performance. Many variables are activity in response to each maneuver and produces a
considered appropriate to analyze movement perfor motor control profile (MCP) of EMG activity. Figure 11-18
mance , and the ones best suited are controversial in the is a schematic representation of the upper motor neuron
research literature. Therefore , the usefulness of these EMG protocol. The MCP can be graphically illustrated , as
assessments will always foster debate (Palmer et aI. , 1988; shown in Figure 11-19. The authors claim that this method
Parette et aI. , 1984). characterizes the subject's functional motor status and can
follow changes in their status after therapeutic intervention
(Dimitrijevic et aI. , 1989; Sherwood , 1993; Sherwood et
Integrative Electromyography al. , 1994).
Assessment One disadvantage with the assessment is the expensive
equipment needed with adherence to strict recording
Sherwood and associates (1994) proposed a quantitative parameters. Thus, the BMCA requires trained technolo
measurement of spasticity and upper motor neuron symp gists to perform and score (integrative EMG analysis) the
toms that measure the amount of EMG activity generated maneuvers. Another disadvantage is that the assessment
during various active and passive maneuvers. The protocol does not correlate well with the Ashworth and other clinical
is designed to test purposeful volitional motor control of scales (r = 0.05-0.2), although certain individual BMCA
paretic or paralyzed muscles with segmental reflexes and maneuvers (passive movement index) correlated higher.
responses to volitional activation of non paralyzed muscles Therefore, the assessment is more relevant for classifying
away from the recorded muscles. The Brain Motor Control patients and documenting change than for quantifying
Assessment (BMCA), as it is termed, characterizes the total clinical symptoms.
Isokinetic
dynamametry
- - - 10' - - - i - - - - - - - -
10 minute
relaxation
- - - - 1 2' - - - -
Reinf.
maneuvers
- - 7'-
Cut.
- v;;::;
5 Passive
movement
. "// ~
/~ / /
- 7' Tap I
-2'- --
Clonus
-4'-
Vibratory
reflex
-5'--
Plantar
reflex
- 4' - - -
Cort.
stim.
-5'
Surface EMG recording during maneuvers
t
o
t
10
t
22 +--+
29 32
t
38
+-H
45 47 51
t p
57 61 65
Minutes
FIGURE 11-18. The upper motor neuron EMG protocol. Along the bottom axis is the time for each event. The schema on the left and right illustrate
the fact that, although the signals recorded are surface EMG signals, the information derived relates to the activity of the population of motor neurons
in the spinal cord . (Cort . = cortical; Cut. = cutaneous; Reinf. = reinforcement; stirn . = stimulation .) (From Dimitrijevic, M. M., et al. [19891 . Clinical
neurophysiological techniques in the assessment of spasticity. PhYS ical M edicin e and Re habilitat io n : State of t he Art R e views, 3(2) , 64-83 .)
>
2
c:;
~
<D
:2
1000
LEFT
,f
~
IJ..I
C1> 100
«>
10
I~
<D
Jfv\r
1000 +----------------;;"".,...,...,...----'------'-----+
• LEFT
:2
UJ.
RM Voluntary Passive Clonus Vibration Plantar RM Voluntary Passive Clonus Vibration Plantar
reflex reflex
FIGURE 11-19. Four motor control profiles from subjects with varying degrees of residual descending control. Each point represents the combin
integrative EMGs recorded from 12 channels for each maneuver within a category. The RM category , for example, contains five points representi
six reinforcement maneuvers, deep breathing, jaw clench , eyes closed, neck flexion against resistance, and the Jendrassik's maneuver. (Refer to origin
source for complete explanation of method.) A, Neurologically healthy; B, has preserved but altered voluntary control; C, severely impaired volunta
motor function with hyperexcitable segmental reflexes; D, no suprasegmental influence. Maneuvers are labeled in groups: RM = Reinforceme
maneuvers; Vol = voluntary movement attempts; Pass = passive limb movements: CI = clonus elicitation; VR = vibratory reflex; WR = withdraw
reflex/reflex suppression. (From Sherwood, A. M. [19931. Characterization of upper motor neuron dysfunction: Motor control profile. Proceedings
the 15th International Conference of the IEEEE EMBS, 15, 1227.)
See Table 11-13 for a summary of the various tech Interneuron-A neuron that is neither motor nor se
niques available to evaluate upper motor neuron syn sory but connects neurons together.
~~
- - - --
- . . .
290 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
T/\13I.r I I 1:\
Positive Symptoms
NEUROPHYSIOLOGIC ASSESSMENTS
1. Tendon reflexes Easily administered and analyzed Needs a constant testing environment
Limb stabilization must be controlled for
Tendon striking force must be constant
Sensitive recording equipment is required
Intersubject variability is high
Poor correlation with clinical assessments
2 . H-reflexes Easily administered and analyzed Needs a constant testing environment
Stimulus stability controlled for Limb stabilization must be controlled for
Sensitive recording equipment is required
Intra- and intersubject variability is high
Poor correlation with clinical assessments
Can only be elicited from antigravity extensor
muscles
3. H-reflex recovery curves Same as H-reflex technique above Same as H-reflex technique above
4. Presynaptic inhibition Same as H-reflex technique above Same as H-reflex technique above
Weak correlation with clinical assessments
5 . F-waves Easily administered and analyzed Supramaximal stimulus is required to elicit response
Can be elicited from many muscles including Sensitive recording equipment is needed
the hand Response occurrent is intermittent
Reflex reflects only motor neuron activation Poor correlation with clinical assessments
May assist in differentiating pathologic from normal
states of MNE
6. Long latency stretch reflexes May reflect suprasegmental structures Sophisticated equipment is required for eliciting re
sponse and recording
Reflexes are unpredictable
Poor understanding of the reflexes
Poor correlation with clinical assessments
7 . Tonic vibration reflex Easily administered and analyzed No literature on the validity or reliability of the
reflex
8. Flexor reflexes Easily administered Response elicited with noxious stimulus (painful)
Provides a means of assessing spinal cord inter Sophisticated recording equipment is required
neurons Poor correlation with clinical assessments
CLINICAL ASSESSMENTS
1. Modified Ashworth scale Very easily performed Subjective
Inexpensive Validity decreases upon repeated usage
Examiner can account for confounding influencing Limited sensitivity
factors
High interrater reliability
2 . Fugl-Meyer scale Very easily performed Same as above but to a lesser degree
Inexpensive
Examiner can account for confounding influencing
factors
High interrater reliability
More objective than modified Ashworth scale
Can be statistically analyzed
Demonstrated to be valid and reliable
Correlates well with other clinical measures
3. Pendulum test Easily performed When performed manually, only tests the quadri
Intra- and intersubject variability is stable ceps muscles
Good correlation with other clinical tests Sensitivity of test may be a problem due to accelera
Shown to be accurate and reliable tions of limb above physiologic values
To increase sensitivity expensive biomechanical
equipment is needed (i.e. , Cybex II dynamometer)
4. Ramp and hold Correlates with clinical measures, although broadly Sophisticated and expensive equipment needed
More objective and accurate than other clinical Stretch stimulus varies, depending on limb position
measures Not sensitive to changes in passive elastic
Intra- and intersubject variability varies nonsignifi properties
cantly
SUMMARY OF TECHNIQUES TO EVALUATE UPPER MOTOR NEURON SYNDROME Continued
Technique Advantages Disadvantages
5. Sinusoidal oscillation Stimulus parameters are considered more repeat Sophisticated and expensive equipment needed
able and controlled than ramp methods Analysis and calculation more sophisticated and
Pathlength is independent of increases in passive harder to understand
elastic properties of muscle; therefore , more ac
curate than ramp method
6. Iso kinetic dynamometry Simpler than ramp and hold and sinusoidal methods Expensive isokinetic dynamome ter is required
of testing Has not undergone stringent validity and reliability
Shown to be reliable testing
Negative Symptoms
1. Kinematic analysis Evaluates purposeful movements rather than magni Expensive digital motion analysis system needed
tude of symptoms Analysis can be time consuming
Looks at complex movement phYSiologically, not Plethora of kinematic variables that are used in
under laboratory conditions analysis
Results are reliable, valid, and sensitive for both
quantitative and qualitative movements pa
rameters
2 . Integrative EMG assessment Tests purposeful volitional movements Sophisticated EMG eqUipment needed
Characterizes total activity of movements Recording parameters are very strict
Results can be graphically illustrated for comparison Required trained technologists to perform and score
purposes the maneuvers
Characterizes the subject's functional motor status Does not correlate with other clinical scales
Reflex-Involuntary movement elicited by a stimulus Va6dity-A valid assessment is one that measures wh
applied to the periphery, transmitted to the CNS, and it is purported to measure.
directed back out to the periphery.
Re6ability-A reliable assessment is one that measures
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-. ,........ _.
C HAP T E R 1 2
Sensory Processing
Introduction to Sensory Processing
SUMMARY Because the neural processing of sensory input is very complex, the
assessment for functioning (or dysfunctioning) in this area is necessarily complex.
Sensory processing involves many modalities including somatosensory, visual, audi
tory, gustatory, and olfactory. Assessment includes not only the many kinds of
sensation but also the many skill levels manifested in this processing. We have di
vided this discussion of assessment of sensory processing into three major areas
typically addressed by occupational and physical therapists: evaluation of the sen
sory receptive component (sensory deficits), assessment of the integrative
component (perceptual dysfunction), and assessment of the more complex integra
tive component (conceptual dysfunction). Because of their relevance to physical
and occupational therapists' activities, the modalities emphasized are the
somatosensory (Le., touch, temperature, pain, and proprioception) and the visual.
The language pathologist or audiologist is typically responsible for in-depth auditory
assessment, and olfactory and gustatory sensation is less vital for the performance
of most daily activities .
Many models exist elaborating complex sensory pro storage of sensory input from internal and exte
cessing. Luria's model has been shown to be useful in sources. Unit II consists of three zones, one for project
rehabilitation (Abreu & Toglia , 1987; Purisch, 1993). As a second for projection-association , and the third
described by Purisch (1993), this model proposes three association. Dysfunction from damage to these a
units involved in brain-behavior relationships. Unit I func involves progressively more complex sensory proces
tions for the modulation of arousal and selective attention skills. Unit III (anterior cerebral cortex) involves the m
so that damage results in dysfunction in these areas. complex aspects of sensory processing, including in
Biologic and environmental sources of arousal are pro tion, regulation , evaluation, and modification of behav
cessed by the Ascending Reticular Activating System; therefore, damage can affect motor skills, speech,
intentional arousal is initiated by cortical structures. Unit II tudes, and cognition. According to Purisch (1993), t
involves the cortical functions of reception, coding, and principles apply to brain-behavior relationships: 1) hie
296 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
chic organization within the brain, 2) diminishing specific retrieval of visual images (visual memory), as precedin
ity of the sensory modality, and 3) progressive lateraliza highest forms of visual processing (visuocognition foll
tion. The Luria-Nebraska Neuropsychological Battery is by adaptation). One of the emphases of occupat
the test battery based on the Luria model. Although this therapy based on this model is that the foundational v
battery is not appropriately used by occupational or skills such as visual acuity and visual attention ar
physical therapists, these professionals do use the Luria primary importance and must be treated before hi
model to guide their own assessments of sensory process level functions can be addressed. Thus, it is cruci
ing dysfunction. initially assess these foundational skills.
A second model showing the complexity of sensory Such specialists as the neuropsychologist, the neu
processing is the Reitan-Wolfson Model of Neuropsycho gist, and the optometrist have special expertise in
logical Functioning (Reitan & Wolfson, 1988). This model evaluation of sensation. If current reports are availab
serves as the framework for assessment with the Halstead the patient's sensory processing status, the occupat
Reitan Neuropsychological Test Battery, again a battery and physical therapist typically use these reports an
not appropriate for use by occupational or physical thera their own as a part of their other therapeutic assessm
pists. However, this model can conceptualize the sequenc such as in the activities of daily living evaluation. In set
ing for the assessments that are a part of the occupational where sensory reports are not available, it may be n
and physical therapy process. According to the Reitan sary to assess sensory processing status directly.
Wolfson Model, processing occurs at five levels: 1) input;
2) attention, concentration, and memory; 3) language and
visuospatial skills; 4) concept formation, reasoning, and
REFERE~ICES
logical analysis; and 5) output. A third model, that of Moore
(Warren, 1993), which is directed specifically to the visual Abreu, B. C, & Toglia, J. p, (1987), Cognitive rehabilitatio
system, involves the same kind of hierarchic processing, occupational therapy model. American Journal of Occupa
Therapy, 41, 439-448,
with minor differences. The foundational level is responsi Purisch, A. D, (1993, December), Brain-behavior relationships,
ble for quick, accurate, and complete receipt of informa presented at the Introduction to the Luria-Nebraska Neurops
tion by the central nervous system (oculomotor control, logical Battery Workshop of the Neuropsychological Associa
California, Orlando, FL.
visual fields, visual acuity). The next skill level is visual Reitan, R. M., & Wolfson, D, (1988), The Halstead-Reitan Neu
attention, influenced strongly by global attention, a reticu chological Test Battery and REHABIT. Cognitive Rehabilit
lar system function. Next is scanning, with a systematic, 6,10-17
Warren, M, (1993), A hierarchical model for evaluation and treatm
sequential information-seeking function. After pattern visual perceptual dysfunction in adult acquired brain injury, P
identification, this hierarchy includes the storage and American Journal of Occupational Therapy, 47, 42-54,
Sensory Deficits
Julia Van Deusen, PhD, OTR/L, FAOTA
with
Joanne Jackson Foss, MS, OTR
Evaluation of visual field deficits such as homonymous Thus, assessment of somatosensory deficits is perti
hemianopsia in the CVA patient often is accomplished by to some kinds of hand function, such as the picking u
the use of confrontational testing (Bouska et al., 1990). As small objects; however, a recent study of stroke pat
the patient fixates on a targeted area, such as the examin (Robertson & Jones, 1994) showed no relation betw
er's nose or forehead, a stimulus target is moved in an arc sensation and a hand test involving simulated eating, o
from the periphery. The patient then indicates the point at manipulation, and other functional hand activities,
which the stimulus comes into view. Poor depth percep Jerosch (1993) showed that results of sensibility as
tion, another common visual deficit observed in stroke ment did not predict activities of daily living results in t
patients, also can be evaluated through the use of confron with peripheral nerve injury. He suggested compensa
tational testing. The patient identifies the closest of two functioning as the explanation because all subjects w
targets. These tests can be performed with or without an evaluated at least 2 years after surgical repair. Clinical
eye patch (Zoltan et al., 1986). The CVA patient may time is a major problem, somatosensory testing c
exhibit visual neglect with or without the presence of a consist only of a functional measure such as the Mo
visual field cut; therefore, it is important to test for both (Trombly & Scott, 1989) involving the picking up of s
deficits. objects. There are many reasons why therapists rec
Because the assessment of visual neglect has been mend more extensive somatosensory assessment.
addressed elsewhere in this book, we do not discuss it here. Primary somatosensory deficits include those of
Besides visual acuity, discussed in the previous paragraphs, prioception, pain, temperature, and the tactile mode (
Warren (1993b) also is concerned with assessing the touch, pressure, vibration, two-point discrimination
foundational visual deficits of visual field and oculomotor wide variety of problems require somatosensory as
function. She cites evidence supporting the idea that the ment. As previously stated, to evaluate other leve
finger confrontation visual field test is sensitive only to gross sensory processing in persons with central nervous sy
deficits. Warren recommends that occupational therapists lesions, it is necessary first to assess sensibility deficits. E
measure visual field deficits by means of computerized the patient emerging from coma is assessed for respo
automated perimetry to identify potential patient problems to tactile stimulation. In the instrument developed
with activities such as driving. Unfortunately, a perimeter is Crosby and Parsons (1989), responses to tactile stimul
costly and serves a limited patient population. Warren also rated as part of their neurologic assessment of perso
suggests the following observations of activities of daily coma to aid in detecting changes in the comatose s
living indicative of field deficits if visual inattention or The hand therapist is intimately concerned with
neglect is known to not be present: missing or misreading matosensory assessment. Cooke (1991) proVided e
the beginnings or ends of words, consistently bumping reasons why occupational and physical therapists c
objects to one side, and obviously moving the head to view plete a systematic sensibility evaluation following per
objects in a certain plane. eral nerve injury of their patient. Many of these reason
Warren (1993b) believes that occupational therapists similar to those we have had for our sensibility assessm
often are the first professionals to observe patient oculo of patients with central nervous system lesions. An ast
motor dysfunction. She suggests the use of simple screen has been put before those reasons typically applicab
ing tests such as that described by Bouska and coworkers both types of problems.
(1990). The purposes of the occupational therapy screen *Assess extent of sensory loss
ing in this complex visual area are to describe the functional Evaluate its recovery after nerve repair
effect of the defiCit and to refer the patient appropriately for Aid in diagnosis of peripheral nerve injury
evaluation by a vision specialist. The interested therapist *Determine functional impairment
can obtain considerable information about oculomotor Compare effectiveness of different surgical proced
function from Warren's articles (1993a, 1993b). Contribute data for legal purposes
*Provide data pertinent to patient precautions
*Determine the best time for sensory reeducation
evaluate its effectiveness
SOMATOSENSORY DEFICITS We have described tests often used clinically by therap
supplemented by samples of tests appropriate for resea
In peripheral nerves, motor and sensory fibers can be Usually, at least part of the testing necessitates occl
clearly distinguished. Motor and sensory junction is not as vision. Although vision can be blocked with a shee
clearly differentiated. As Marsh and Smith (1986, p. 82) cardboard, the preferred method is use of a cut-out
have so aptly stated, "The motor system is actively used in similar to that included with the Benton tactile percep
gathering sensory information and the afferent system is tests (Benton et al., 1994, p. 96). When assessing el
used in control of motor performance." Limited evidence interpretation of the results of sensibility testing should
from research and case histories does indicate the relation into consideration the data showing they have hi
between impaired fine motor control and impaired sensa somatosensory thresholds than younger persons (Eva
tion (Bell-Krotoski et at., 1993; Marsh & Smith, 1986). al., 1992; Horch et al., 1992).
Trombly and Scott (1989) described clinical testing for ate amount of therapist time or expense, especially sin
proprioception or position sense. Holding the involved thermal assessment has not been found to be clinica
part laterally, the therapist passively positions the joint to useful for quantifying hand function or predicting
be tested. This positioning is done slowly, 10 degrees per recovery (Dellon, 1993). Cooke (1991) suggested a set
second, and the patient is asked to reproduce it with the assessment tools that excluded pain and temperature
opposite uninvolved part or to describe the position. Joints use by the therapist treating peripheral nerve injuri
may be tested singly or in combination, but large joints are however, some early-stage patients may need pain a
tested separately from the small ones. Each joint is scored temperature evaluations so that return of protective se
independently. sation can be monitored. The idea that results from testi
Dannenbaum and Jones (1993) addressed evaluation of only one modality (e.g., temperature) in stroke patie
the proprioceptive system specifically by the flexion or could provide information on the other primitive sens
extension of the patient's proximal or distal interpha was not supported (Harlowe & Van Deusen, 198
langeal joint of each finger. Typically, 10 trials are allowed therefore, if persons with central nervous system lesio
per finger. The patient responds to the flexed or extended show need for such testing, all modalities need to
joint by indicating "up" or "down." Normative data are included.
available for this test. We recommend for research purposes the Automat
Carey and colleagues (1993) described a method for Tactile Tester (ATT), a computer-controlled device used
assessment of proprioception appropriate for research. measure temperature and pain as well as touch a
Only the wrist position was used in their project. This vibration (Horch et aI., 1992). This instrument is describ
proprioceptive discrimination test used a pointer on top of later in this section of Chapter 12. PhYSical therapists a
a protractor scale as the response mechanism for the might use in research the Quantitative Somatosenso
subject. The subject's hand was passively moved to 20 Thermotest (QST) described by Verdugo and Och
different wrist pOSitions in random sequence. The test (1992). This test allows rigorous assessment of warm a
score was the mean absolute error between the actual cold sensation and heat and cold pain. Normal cont
measured wrist pOSition and the subject's estimate with the values for thermal-specific and thermal pain thresholds
pointer. Carey and associates showed by use of quasiex hand and foot are provided for the QST, as is informati
perimental single-subject design with four subjects that this on various kinds of sensory pathology.
test was sensitive to improvement following a discrimina
tion training program. Other tests for proprioception have
also been shown to be useful for experimental work Touch and Pressure
(Dannenbaum & Jones, 1993).
The Semmes-Weinstein Monofilament Aesthesiome
Test (Bell-Krotoski et aL, 1993), the weighted touc
Pain and Temperature pressure aesthesiometer (Sieg & Williams, 1986), t
Disk-CriminatorTM (Robertson & Jones, 1994), and t
Assessment of the primitive or protective sensibilities of Automated Tactile Tester (Horch et al., 1992) are
pain and temperature is accomplished by evaluating sharp possible instruments for assessing touch and pressu
versus dull and warm versus cold responses. Among those sensitivity. We have not reviewed the tests for textu
describing clinical methods for pain and temperature discrimination and object recognition (stereognosis), oft
assessment are Cooke (1991), Harlowe and Van Deusen discussed with tests of sensibility, since we agree with t
(1985), and Trombly and Scott (1989). Traditionally, pain position (Cooke, 1991; Dannenbaum & Jones, 1993) th
is assessed by randomly applying to the patient's skin the these functions require a high degree of perceptu
blunt and sharp ends of a pin for appropriate identification. cognitive ability as well as sensitivity and we believe tests
Temperature is assessed by test tubes of hot and cold water, texture and object recognition are therefore more appr
first applied to the therapist's own skin for the determina priately addressed in discussions of higher-level senso
tion of approximate temperature and then applied ran processing assessment. Although reliable assessment
domly to the patient's skin. Therapists assess pain and responses to high- and low-frequency vibration has be
temperature sensibility less frequently than they evaluate demonstrated with the ATT (Horch et aL, 1992; Jimen
touch and proprioception for several reasons: (1) the et at., 1993), some therapists do not consider vibrati
traditional methods of assessment are not very satisfactory, testing to be of vital importance clinically in either perip
especially for temperature (Cooke, 1991; Harlowe and eral nerve (Bell-Krotoski et aI., 1993) or CNS inju
Van Deusen, 1985); (2) pain and temperature sensibility (Dannenbaum & Jones, 1993). Vibration testing might
recover first, so that satisfactory performance on other eliminated in the clinic when intervention time is at
tests of sensibility implies no need to test pain and premium. It should be incorporated in research involvi
temperature (Cooke, 1991; Marsh & Smith, 1986); and sensibility assessment.
300 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
SelRlRes-Weinstein MonofilalRents. The Semmes and available from Sammons Preston, 1-800-323-55
Weinstein monofilament aesthesiometer (available from an octagonally shaped disk for measuring static and mo
Sammons Preston, 1-800-323-5547), as discussed by two-point discrimination of fingers and toes. Holdin
Bell-Krotoski and coworkers (1993), by Cooke (1991), and Disk-Criminator, the examiner places the points on th
by Trombly (1989), is used to evaluate light touch and deep of the patient. The distance between the points is a
pressure. It consists of nylon monofilaments in rods, each able, and the subject indicates whether he or she feel
of which can be held perpendicular to the skin so that the or two points (Robertson & Jones, 1994). Major con
filament touches the skin (see figures, Chapter 10). The have been raised about the reliability and validity of
filaments are graded as to length and thickness and bend from hand-held tools used for assessing two-point disc
when a peak-force threshold has been achieved in contact nation (Bell-Krotoski et al., 1993).
with the skin. The filaments maintain a constant force with AutolRated Tactile Tester. The ATT (Horch et al., 1
only minor amounts of variation. According to Bell Jimenez et al., 1993) is an automated device for as
Krotoski and associates (1993), the mini-kit of five fila ing touch-pressure, high- and low-frequency vibra
ments is time-saving and appropriate for most clinical warmth, sharpness, and two-point discrimination.
testing. For upper extremity sensory abnormality screen Stimulus delivery is precisely controlled by computer.
ing, only one filament is necessary (pressure rating, 2.83). ATT uses the "staircase" method to establish thresh
To track sensory function, the use of at least five filaments calculation of which is also done by computer. A stim
is required. The lightest filament is applied first, with threshold is defined as the minimal stimulus level req
subsequent application of the more forceful filaments in to produce an awareness of sensation. In the "stairc
order. Although this application differs from the original method, once the stimulus has been detected by
method for the test, it has been found to be time saving and subject, its intenSity is reduced until it is no longer det
reliable by clinical users. Formal reliability for this test was when it is raised until again detected. This procedu
established in a rigorous study in which the complete set of continued until at least five reversals from detectio
filaments (20, all new) was used. Care in application and nondetection have occurred, and the results are
II"
t;;:: regular calibration of the filaments are necessary for averaged. Horch and collaborators (1992) and Jim
;;'li objectivity. Although there are limited normative data for and others (1993) reported a study of 62 "normal" sub
!(
:S;. this test, it is typically used with patients who have (aged 9 to 83 y), which they considered to establis
peripheral nerve injuries in only one extremity, so the other validity, intertester reliability, and test-retest reliabilit
:1I. limb can be used for control data. Normative data are the ATT. "Age-related norms were established that
•it
essential if used in assessing sensibility of persons diag be used for future patient studies" (Jimenez et al., 1
.,{. nosed with only unilateral brain injury since both hands p.125).
are often affected (Dannenbaum & Jones, 1993). This Three studies showed that the ATT can be succes
Semmes-Weinstein monofilament tool is being widely and used to assess sensation of patients with burns and c
successfully used clinically and apparently is considered the tunnel syndrome (Jimenez et al., 1993). The au
best available tool for assessing tactile sensibility. reported that light touch and low-frequency vibration
Weighted Touch-Pressure Tool. A less delicate device was the most important modalities for tracking recovery
used in research by Sieg and Williams (1986) to assess intervention. Although much more research is nee
touch-pressure sensibility. These researchers found the use including replication with large. numbers of "nor
of a metal capsule into which graded weights could be subjects as well as continued patient research, the AT
inserted to be effective. Weights of 0.5, 1, and 2 oz were shown excellent promise as a research tooL Perhap
used. The blunt point of the capsule was applied to the skin, ATT is not yet practical for use in many clinics, but it
and its handle allowed for control of stimulus weight for any well be a widely used clinical tool in the future
desired duration. somatosensory assessment.
Disk-CrilRinator™. A common clinical method of the
assessment of tactile sensibility is through reports of
two-point discrimination. The underlying neuromecha
nism for two-point discrimination is responsible for sensory Aestheslometer-An instrument for measuring t
experiences (tactile-spatial) that are more complex than for sensibility.
SUMMARY This section of Chapter 12 addresses the assessment of the integrative com
ponent of sensory processing. Various approaches and assessment tools are discussed in
relation to neuropathology. Additional factors related to asessment of visual perception
are discussed. Finally, suggestions on how to choose an assessment are given.
Brain damage, depending on its severity and location, Rather, the patient should be carefully assessed for
can be responsible for various deficits in perceptual func ceptual deficits. Over the past years, a number o
tion. Perceptual deficits are present in many individuals sessment procedures have been developed for evalu
with differing neurologic conditions. Perceptual problems of specific types of these deficits. These procedures
are most characteristic of individuals with right cerebrovas heavily on neuropsychological tests (Benton et aI., 19
cular accident lesions (Gouvier & Cubic, 1991; Hier et aI., that is, the elicitation of specific behavioral respons
1983) but are also found in individuals with left cerebrovas specific stimuli under controlled conditions (Ben
cular accident lesions (Okkema, 1993; Zoltan et aI., 1986). 1994). The purpose of this discussion is to review t
Perceptual deficits have also been reported in individuals developments, particularly with reference to their i
with Alzheimer's disease (Eslinger & Benton, 1983; Hend cations for clinical application and theoretical accoun
erson et aI., 1989; Mendez et aI., 1990; Nebes, 1992; Ska these deficits.
et aI., 1990; Swihart & Pirozzolo, 1988; Zec, 1993), mul The assessment of perceptual dysfunction is prob
tiple sclerosis (Fennell & Smith, 1990), and Parkinson's one of the most difficult areas of investigation for
disease (Brown & Marsden, 1986, 1988; Cummings & practicing rehabilitation clinician. Unlike aphasic disor
Huber, 1992; Grossman et aI., 1993). Although the defi perceptual deficits often go unnoticed by the patient
cits after head injury are most often reported in the cogni care providers and come to light only when dir
tive domain in the areas of memory, problem solVing, and evaluated. More often than not, individuals with aph
judgment (Lezak, 1995), individuals may also show percep present with relatively clear dissociations in a numb
tual deficits (Gianutsos & Matheson, 1987; Neistadt, psycholinguistic processes (Goodglass & Kaplan, 19
1988, 1992). In addition to perceptual impairment in indi thereby allowing the development of reliable taxonomi
viduals with known neurologic disorders, there has been a aphasias. In contrast, selective disruption of spatioper
reported decline in visuospatial and constructional abilities tual components after brain damage has been more dif
in the normal aging population (Howieson et aI., 1993; to isolate and measure (Delis et aI., 1988a). The pri
Ogden, 1990; Schaie, 1994; Spreen & Strauss, 1991). reason is probably that spatioperceptual structure doe
Deficits in perceptual abilities can greatly impact the life contain temporally discrete entities such as phonemes
of a patient with brain damage, and their presence is one words but must be inferred from perceptual judgments
of the major disruptive factors impeding rehabilitation visuospatial constructions (Delis et aI., 1988b). To fu
success (Barer, 1990; Bernspang et aI., 1987, 1989; complicate the issue, it is difficult to give a clear and co
Campbell et aI., 1991; Chen Sea et aI., 1993; Denes et aI., account for the organization of perceptual functions i
1982; Friedman, 1990a, 1990b, 1991; Hartman-Maeir, brain (Beaumont & Davidoff, 1992). Although we
1995; Kinsella et aI., 1993; Maeshima et aI., 1990; getting increasingly detailed anatomic and physio
Nogak, 1992; Shiel, 1989; Stone et aI., 1993; Sunderland maps, especially of the visual pathways in the brain,
etal., 1987; Sundetetal., 1988; Taylor etal., 1994; Towle increasingly sophisticated accounts of perceptual de
& Lincoln, 1991a; Wiart et aI., 1994). after circumscribed brain lesions, there is still a long w
Perceptual dysfunction is a particularly likely explanation go in putting it all together into a coherent th
in cases in which the patient fails to fully participate in (Corballis, 1994).
self-care activities and in retraining for reasons other . Despite this difficulty, numerous assessment techni
than deficits in sensation, comprehension, or lack of mo have been developed in the past two or three decad
tor ability (Arnadottir, 1990). The patient should not allow clinically and theoretically relevant description
be dismissed as uncooperative or cognitively impaired. the problems. In the following, we attempt to summ
use. Although perceptual deficits can be found in a variety ers assess the components of performance, including
of sensory domains (e.g., vision , hearing, touch , smell, pects of visual perception . Still others are primarily in
taste and kinesthesis), our discussion is centered on per ested in examining a patient's potential for learning so th
ceptual deficits in the visual domain. Perceptual dysfunc can identify the type of rehabilitation strategies that will
tions in the auditory domain are not addressed because most effective. These three approaches to assessment
they are conventionally within the expertise area of functional assessment, assessment of performance co
speech and language pathologists. Specific deficits to be ponents, and dynamic assessment (Table 12-1).
dealt with here include visuoperceptual disorders, con
structional disorders, and unilateral neglect because they
are most commonly noted by occupational therapists Functional Task Assessment
(Grieve, 1993).
Acquired visuoperceptual disorders involve changes in The approach used by many occupational therapists i
visual and perceptual functioning after cerebral insult. The assess functional activities and identify the tasks with wh
disabilities may be reflected behaviorally in a variety of an individual has difficulty (Neistadt, 1988, 1994a, 199
performance deficits: in failure to discriminate between Okkema, 1993). For example, the therapist may perfo
objects; in defective discrimination of complex stimulus an assessment of activities of daily living (ADL) (e
configuration (e .g., combinations of figures or forms); dressing oneselD and rate the accuracy, the amount
and in faulty localization of objects in space and defec verbal cueing needed , and the speed needed to compl
tive topographic orientation (Benton & Tranel, 1993). the activity or the therapist may rate the patient's ability
Constructional disorders , according to Benton (1967), complete each of the specific steps of the activity (e.g.,
refer to "an impairment in combinatorial or organizing sleeve in coat). In aJl cases, the specific perceptual sk
activity, in which details must be clearly perceived and in underlying performance are not specified, although
which the relationships among the component parts of therapist may make assumptions or hypotheses ab
the entity must be apprehended if the desired synthesis perceptual abilities or deficits. Examples of assessment
of them is to be achieved." Unilateral neglect is clinically this type include the Functional Independence Meas
characterized by the inability to perceive or respond to (FIM) (Dodds et aI., 1993; Granger et aI., 1993; Keith et
stimuli presented to the contralesional space, despite the 1987), the Barthel Index (Mahoney & Barthel, 19
absence of significant sensory or motor deficits (Heilman Wade & Collin, 1988), the Klein-Bell (Klein & Bell, 198
et aI. , 1993). the Ribideau Kitchen evaluation (Neistadt, 1994b, 1994
and other functional assessments described in Unit Five
this text. A limitation of many of these assessments is t
they do not differentiate between physical and cognit
APPROACHES TO PERCEPTUAL components of an activity for the adult with brain inj
ASSESSMENT (Toglia , 1989). the majority of functional assessme
used in physical disabilities emphasize motor skills and
Occupational therapists use a variety of approaches to not evaluate the perceptual or cognitive components of
assess perception in the adult with brain injury. Whereas tasks. This is problematic because there is a growing use
TABLE 12- 1
Functional Assessment of specific functional Knowledge of patient performance Does not provide insight regardin
tasks and ADL on relevant tasks the underlying problems caus
"Readily understandable to patient ing the functional performance
and family deficit
Performance components Assessment of the perceptual and Identification of clients strengths Multiple deficits are frequently
constructional abilities believed to and weaknesses to design treat found
contribute to adequate functional ment strategies Training of deficit components m
performance not result in improved function
performance
Dynamic assessment Assessment that analyzes the pa Provides information about client's Experienced clinician needed
tient's response to cues, task learning ability and therefore Scores not standard
modifications, and characteristics provides guidance in selecting
of the task appropriate intervention strat
egies
From Su, C. Y , et al. (1 995). Performance of older adults with and without cerebrovascular accide nt on the test of visuaJ-perceptual skills. Ameri
Jo urnal of Occupatio nal Therapy, 49(6), 495. Copyright 1995 by the American Occupational Therapy ASSOCiation, Inc. Reprinted with permiss
"-;":':. , :~- . ,
304 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
Evaluationof Performance
Components
An alternative approach to assessment is to eval
FIGURE 12-1. Spatial relation difficulties manifested in underestima specific perceptual abilities to identify the aspects that
tion of distances when reaching for a cup. (From Arnadottir, G. [19901.
The brain and behavior. Assessing cortical dysfunction through activities believed to interfere with functional activity. An advan
of daily living . SI. Louis, MO: C. V Mosby.) to assessment of specific perceptual abilities is to enable
to better design appropriate intervention techniques and detection/correction (self-generated or externally gen
strategies that may include remediation of the deficits and ated). Toglia (1992) emphasizes that dysfunction is not t
capitalizing on the client's strengths. specific but is related to the characteristics of the task
Evaluation of individual cognitive skills and components the environment. This approach is detailed in sev
such as orientation , attention, organization, and problem articles (Abreu, 1995 ; Toglia, 1989; 1991a, 199
solving and reasoning are discussed in the next section of 1992). Kaplan (1990) also supports the use of dyna
this text. Here we discuss the evaluation of visual percep assessment, which she refers to as the process appro
tual and visual motor disorders under the categories of and argues that in addition to knowing whether a pat
visuoperceptual disorders, constructional disorders, and passes or fails a task, it is critical to know how a pat
unilateral neglect. approaches a task. The advantage of the dynamic
Assessment of basic visual skills is critical but is not process approach is that it provides more information t
discussed in this section. Warren (1993a, 1993b, 1994) is relevant for treatment than traditional assessment. T
presents a hierarchical model of visual perception and approach, however, places greater demand on the the
examines skills that she believes are the foundation of and pist's clinical experience and ingenuity.
prerequisites for higher level perceptual abilities. These
foundation skills include visual acuity, visual fields, oculo
motor control, and visual attention and scanning (see
Section 2 of this chapter, Sensory Deficits , for a description
of the assessment of these foundation abilities) .
NEUROPATHOLOGY AND RESEARCHON
Assessment of specific perceptual abilities is intended to THE ASSESSMENT TOOLS
enable the therapist to better understand the nature of the
deficit , to identify the patient's strengths, and to identify In the follOWing section, we discuss the neuropathol
those deficits that are believed to interfere with function of three major categories of perceptual disorde
visuoperceptual disorders, constructional disorders,
and then to use that information to develop treatment
unilateral neglect-and review relevant research on th
strategies. For example, in a study on driving, visuoper
ceptual test scores explained 64 percent of the variance in assessment.
the driving assessment (Galski et aI. , 1992, 1993). The
research group noted that use of the perceptual tests
identified performance deficits that could be amenable to Visuoperceptual Disorders
remediation or compensation for driving skill. However, it
is important to recognize that improving the component A basic division of visuoperceptual disorders pertain
abilities may not automatically result in improved perfor the difference between defects in the identification of
mance in functional tasks (see Neistadt, 1995). In addition , formal characteristics of objects and defects in the lo
in patients with brain damage, multiple impairments are ization of these objects in space (Benton & Tranal, 199
common and it is often difficult to precisely differentiate Identification of the neuroanatomic correlates has led to
factors that interfere with function (Toglia, 1989). Simi identification of two cortical visual systems: a ven
larly , some patients who may show impairment on speCific system (inferior occipitotemporal pathway) subserving
tests may perform adequately on functional tasks because ject recognition (the "what" system) and a dorsal sys
they are able to perform the task using other abilities. Thus , (OCCipitoparietal pathway) subserving the appreciation
it is important to incorporate both functional assessment spatial relationships (the "where" system) (see Levine
and assessment of components. al., 1985; Mishkin et aI., 1983; Post & Liebowitz, 19
Trevarthen , 1968) (Fig. 12-3).
The occipitotemporal system, also known as focal
Dynamic Assessment attentive vision , involves attending to the salient feature
an object to discriminate the details. This enables
Toglia (1989, 1991a, 1991b, 1992) advocates a dy individual to identify objects and differentiate them fr
namic investigative approach to supplement conventional other objects. It enables the reader to distinguish betw
measures of performance components as a means of a "b" and a "d." The OCCipitoparietal system invo
analyzing the patient's processing strategies and determin peripheral or ambient vision and is concerned with de
ing his or her potential for learning. This approach includes tion of events in the environment and their location
analyzing the patient's response to cues and task modifi space and relation to the individual. Visual input must
cations to be able to assess his or her potential for learning. integrated with other sensory information, including
The characteristics of the task include the modality of tile , auditory, kinesthetic, vestibular, and propriocept
stimulus presentation, the number of stimuli , the number of perceptions, to provide this information (Warren, 199
task steps, and the familiarity of the task. Additional factors 1993b). Both systems working in concert contribute
may include the rate and duration of stimulus presentation, efficient perceptual processing and to visual mem
the type of feedback (before activity, during an activity, on (Mishkin et at., 1983). In fact, it has been pOinted out t
.,,"-.~'" ..~
306 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
Sequence of synaptic and axonal flow in the cerebral cortex: input into 1° and 2 ° visual cortex, then via several parallel-distributed
pathways and circuits:
1. Superior circuit - - Superior parietal lobe and prefrontal lobe + FEF.] - *1
2. Inferior circuit - - Post temporal lobe and prefrontal lobe + FEF.
3. To limbic cortex especially temporal lobe components *2 & cingulate gyrus.
4. To the kinetic system to obtain a visual-manual and/or visual-motor program.
5. To the synergic system to obtain a coordinated-sequencial programs for desired (goal oriented) movements involved in activities
including visual movements.
*1. Prefrontal lobes: anticipatory executive, including judgement, of the CNS including (FEF) frontal eye fields for controlling visual
movements in all skilled activities.
To parahippocampal }
gyrus & hippocampus *2
Temporal lobe cortex to uncus and
amygoaloid nucleus
D -= The major association pathways that relay Note : Brain stem circuitry that is critical for normal vision is
visual information from the visual cortices into not illustrated:
adjacent lobes and to the prefrontal lobes Kinetic - Basal ganglia
A. Superior occipitofrontal fasciculus. Synergic - Cerebellum and associated nuclei
B. Parietotemporal & parieto-occip. fascic.
C. Inferior occipitofrontal fasciculus.
Area CD noted above is in the posterior part of the superior parietal lobule: MAJOR FUNCTIONS include visuospatial orientation, senso
appreciation of the external environment including an internal memory map of the environment and body-image map plus movement
detection.
Area ® noted above is in the posterior temporal lobe: MAJOR FUNCTIONS include visuo-object and color recognition, orientation of
objects and detailed serial processing of environment stimuli.
FIGURE 12-3. Two visual systems: parallel-distributed processing. (Courtesy of Josephine Moore, Vermillion, SD .)
damage to either system can result in spatial disorientation , large. Table 12-2 describes many of the commonly
although this occurs for different reasons (Lezak, 1995). tests of visual perception.
Perceptual processes include the structuring and orga
nization of information : recognition, identification and
VISUAL ANALYSIS AND SYNTHESIS
claSSification; discrimination; and the extraction of mean
ing (Giles & Clark-Wilson, 1993). Under this rubric con Visuoperceptual skills considered to involve ana1lysis
gregates a heterogeneous collection of disorders because synthesis include making visual discriminations, differ
the spectrum of performances that can be distorted as a ating foreground from background (figure ground), re
consequence of defective visuoperceptual function is very nizing objects on the basis of incomplete informa
TESTS OF VISUAL PERCEPTION
Hooper Visual Organization Test Hooper, 1958; revised 1983 The test consists of 30 line draw Western Psychological Services,
ings of simple objects that have 12031 Wilshire Boulevard, L
been cut into pieces and rear Angeles, CA 90025-1251; se
ranged. The subject must ver Lezak, 1995, pp. 409-411.
bally identify what the object
would be if the pieces were put
back together.
Visual Form Discrimination Benton , 1983 Book of 16 line drawings in which Psychological Assessmen t Re
a stimulus and an array of sources (PAR), P.O. Box 998,
choices are presented simulta Odessa, FL 33556; see Bento
neously. The subject must dis et aI. , 1994, pp. 65-72.
criminate among the four re
sponse choices.
Visual Object and Space Warrington & James, 1991 To assess speCific impairments of Western Psychological Services,
Perception (VOSP) cognitive function after brain 12031 Wilshire Boulevard, L
damage. The VOSP is designed Angeles, CA 90025-1251; se
to reflect specificity of right Lezak, 1995, pp. 408-409.
hemisphere lesions.
Nine tests are included: 1 test
(shape detection screening test)
screens out patients for whom
the VOSP is inappropriate; 4
tests assess object perception
(incomplete letters, silhouettes ,
object decision, progressive
silhouettes); 4 tests assess space
perception (dot counting, posi
tion discrimination, number lo
cation, cube analysis).
Motor-Free Visual Perception Colarusso & Hammill, 1996 ; Visual perception test with 36 Academic Therapy Publications
Test-Revised Bouska & Kwatny, 1983 items in which the subject is 20 Commercial Blvd, Novato
shown a line drawing and is CA 94947-6191 ; see Bouska
asked to match the stimulus Kwatny, 1983.
from a multiple-choice set of
other drawings; originally stan
dardized for children by
Calorusso and Hammill; norma
tive data and scoring system for
use with adults is presented by
Bouska and Kwatny.
Test of Visual Perceptual Skills Gardner. 1982 A non motor test of visual percep Psychological and Educational
tion that assesses seven visual Publications, 147 Rollins Rd.,
areas: discrimination, memory, Burlingame , CA 94010; see S
spatial relationships , form con et aI. , 1995.
stancy, sequential memory. fig
ure ground, and closure; origi
nally designed and standardized
for children; normative data re
cently available for adults.
Judgement of Line Orientation Benton, 1983 Subject is required to match one Psychological Assessment Re
or two lines with those showing sources (PAR), PO . Box 998,
the same inclination on an array Odessa. FL 33556; see Bento
of lines presented on the same et aI. , 1994, pp. 53-64.
card.
Picture Completion Weschsler, 1981 Identification of details within a Psychological Corporation, 555
picture to identify the missing Academic Ct. , San Antonio, T
feature. 78204-2498.
Raven 's Progressive Matrices Raven A series of three nonverbal tests of Psychological Corporation, 555
varying ability level that assess Academic Ct. . San Antonio, T
mental ability by requiring the 78204-2498 .
subject to solve problems pre
sented in abstract visual figures
and designs .
-
-~
308 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
TABU 12 2
Embedded Figures Test Spreen & Benton , 1969 Test consists of 16 line drawings Neuropsychology Laboratory,
used as stimulus figures and pre versity of Victoria, Victoria,
sented in left half of test book ish Columbia , VSW 3P5
let. The right half of each sheet Canada ; see Spreen & Strau
is a complex figure drawing in 1991 , pp. 291-296.
which the stimulus figure is em
bedded. Subjects must search
for and trace the stimulus figure
in the embedded design using a
pencil. Healthy adults make few
errors on this test.
Visual Figure Ground Ayres, 1966 A test of the Southern California Western Psychological Services
Sensory Integration Tests; origi 12031 Wilshire Boulevard, L
nally developed for children; Angeles, CA 90025-1251.
normative data is available for
adults in the American Journal
of Occupational Therapy.
Test of Facial Recognition Benton et aI. , 1983 Examines ability to recognize faces Psychological Assessment Re
without a memory component; sources (PAR), P.O . Box 998
subject matches identical front Odessa, FL 33556; see Ben
views, front views with side et aI. , 1994, pp. 35-52.
views, and front views taken un
der different lighting conditions.
Minnesota Paper Form Board Likert & Quasha, 1970 Spatial task involving high level Psychological Corporation, 55
Test, Revised 1969 perceptual ability and analytical Academic Ct. , San Antonio,
processing; involves ability to 78204-2498 ; see Lezak, 19
perceive fragments as wholes. pp. 362-363
Corsi Block Tapping Test Milner, 1971 (research tool) Memory for sequence of spatial lo
cations. Nine black 1 V2-inch
cubes are fastened in a random
order to a blackboard. Examiner
taps blocks in a prearranged or
der and the subject copies the
tapping pattern .
(visual closure) , and synthesizing disparate elements into a Hammill, 1972 ; Bouska & Kwatny , 1983), and the Te
meaningful whole (Efferson, 1995). Some tests of percep Visual Perceptual Skills (TVPS) (Gardner, 1982) asse
tual abilities include only one element. Examples of these variety of different perceptual skills . Whereas the V
tests include the Visual Organization Test, which assesses includes several subtests , each of which assesses a dis
visual organization (Hooper, 1983) (Fig. 12-4), or the aspect of visual perception, the MVPT assesses a co
Visual Form Discrimination Test (Benton et aI., 1983), nation of visuoperceptual abilities.
which assesses the ability to analyze the critical features of The Visual Object and Space Perception Test (
forms and decides which of the response stimuli are the rington & James, 1991) was designed to reflect specif
same as the target stimuli (Fig . 12-5). The Visual Form of right hemisphere lesions and includes a set of
Discrimination Test is a multiple choice test of visual different tests that were originally designed for rese
recognition. There are 16 items, each consisting of a target with adults with brain damage (Table 12-3, Fig . 12-6).
set of stimuli and four stimulus sets below the target. The first test, a shape detection screening test, is used to sc
distractors contain small variations of displacement, rota out patients for whom the VOSP is inappropriate.
tion, or distortion. Approximately two thirds of the control tests assess aspects of object perception (incom
subjects received at or near ceiling scores . Lezak (1995) letters, silhouettes, object decision, progressive sil
noted that patients with left anterior lesions, right parietal ettes), and four tests assess aspects of space perception
lesions, and bilateral diffuse lesions were associated with counting , position discrimination, number location,
the highest percentages of impaired performance on this analysis). Normative data and cut scores are prOVide
test. each test indiVidually so that the tests can be used e
In contrast to tests that assess a single aspect of visual indiVidually or as a battery.
perception, other tests such as the Visual Object and Space The Motor-Free Visual Perception Test (MVPT)
Perception Test (VOSP) (Warrington & James, 1991), the larusso & Hammill, 1972) and The Test of Visual Per
Motor-Free Visual Perception Test (MVPT) (Colarusso & tual Skills (Gardner, 1982) were originally designed
includes items in the areas of spatial relationships, visual
discrimination, figure-ground, visual closure, and visual
memory. The test was originally standardized for children
aged 4 through 8 years. The test has just been revised (The
Motor-Free Visual Perception Test-Revised [MVPT-R])
(Colarusso & Hammill, 1996) (Fig. 12-7) and includes 4
®CD D
008 <X> CD
MVPT-R are presented for children aged 4 to 11 . The
authors state that because "Maturation of the human visual
perceptual system is considered to be completed (i .e.,
"adult") by 10-11 years of age" (p. 13), the MVPT-R can D
be used with adults as well as children (Colarusso & Ham
mill, 1996). The MVPT will also be available in a format 3 4
with stimuli arranged vertically rather than horizontally as
<X> CD a 00 CD
with the MVPT and the MVPT-R. This new format will
present the stimuli at visual field midline to allow assess
ment of visual perception in both children and adults with
out the confounding effects of visual field deficits. Bouska
.F IGURE 12-5. item 9 of the Visual Form Discrimination
and Kwatny (1983) have used the MVPT (1972 version) 1 = rotation of major figure; 2 = correct response ; 3 = rotation of pe
with adults and provide normative data for adults aged 18 eral figure ; 4 = distortion of other major figure. (From Contributio
to 80 years old. Several measures can be computed from Neuropsychological Assessment: A Clinical Manual , 2/ e by Arth
Benton , Abigail B . Sivan , Kerry de S. Hamsher, Nils R. Varney
the test administration with adults: raw score, average time Otfried Spreen. Copyright © 1994 by Oxford University Press
per item, response behavior for left-sided figures , response Reprinted by permission.)
behavior for right-sided figures, performance behavior for
left-sided figures, and performance behavior for right-sided
figures. This scoring system was developed with particular that has been normed for adults is the Test of V
application for use with stroke patients in an effort to sepa Perceptual Skills (TVPS) (Non-Motor) (Gardner, 19
rate problems in visual perception from unilateral neglect. The TVPS contains 112 items that involve the us
Another test that was originally designed for children but two-dimensional configurations. It is divided into s
subtests of visual perception: Visual Discrimination, V
Memory, Visual Spatial Relationships, Visual Form C
stancy, Visual Sequential Memory, Visual Figure Gro
and Visual Closure (note: although each test is designe
assess a specific aspect of visual perception, ther
overlap among the subtests). Each subtest has a prac
test plate that is followed by 16 items arranged in ord
increasing difficulty. Subjects respond by indicating on
four or five options on each item that matches the
sample (Fig . 12-8). Hung and colleagues (1987) used
test to examine visuoperceptual skills in young adults
learning disabilities and found the test to discrimi
between individuals with and without learning disabil
Normative data have been published for 155 no
adults, aged 45 to 84 (Table 12-4) (Su et al., 1995).
researchers found that performance decreased with
creasing age; education was also a Significant facto
addition, the authors found that the test discrimin
between individuals with and without stroke, with indiv
als with stroke performing more poorly than no
FIGURE 12-4. Stimulus (cup) from the Hooper Visual Organization
Test. The individual must synthesize visual information to picture the controls. The scores on two subtests, Visual Form C
object after viewing its parts. (Stimulus from the Hooper Visual Organi stancy and Visual-Spatial Relationships, contributed
zation Test copyright © 1983 by Western Psychological Services, nificantly to the discriminant function between the con
original edition copyright © 1958 H. Elston Hooper. Reprinted with
permission of the publisher, Western Psychological Services, 12031 and stroke groups. There was no difference in pe
Wilshire Boulevard, Los Angeles, CA 90025. All rights reserved.) mance of individuals with left compared with right c
.
- .
. t
.,
310 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OFTHE ADULT
lABI .E 12 -:~
Screening Shape Detection Screening Consists of 20 cards; half the cards dis Screens out subjects who are not appro
play an overall pattern with an embed priate for this test
ded degraded X that the subject must
identify.
Object Perception Incomplete Letters Subject must identify a letter that has Measu res ability to identify degraded let
been degraded. ter stimuli and is sensitive to right po
terior lesions
Silhouettes Consists of the rotated and blackened Measures degree of impairment in obje
shape of 15 objects and 15 animals; recognition
the subject names or describes each
object.
Object Decision Subject sees a set of 20 cards, each with Distinguishes word-finding problems fro
four black silhouette shapes that have perceptual processing deficits
been rotated. Of these, one is a real
object and three are distractors. The
subject must identify the shape that is
a silhouette of a real object.
Progressive Silhouettes Objects presented in silhouette, initially Assesses recognition threshold by pre
distorted (elongated) and rotated , with senting silhouettes of the same objec
increasingly closer approximations to from various angles
the object. The number of silhouettes
needed to correctly identify the object
is recorded.
Space Perception Dot Counting Subject sees an array of 5 to 9 black dots Measures spatial scanning and ability to
randomly distributed on a white card. localize a single pOint
Subject must identify the number of
dots in each of 10 arrays.
Position Discrimination Subject sees a set of 20 cards, each with Assesses ability to discriminate between
two squares next to each other. One different positions in space
square has a black dot exactly
centered; the other is slightly off cen
ter. The subject must identify the pic
ture with the dot in the center.
Number Location Two squares, one above the other, are A more complex test of spatial discrimi
presented on each of 10 cards. The nation
top square has randomly placed num
bers 1 to 9. The bottom square has a
single dot in a different position. The
subject must identify the number that
corresponds to the position of the dot.
Cube Analysis This is a 10-item block counting task. Measures perception of complex spatia
The subject sees an outline represent relationships
ing a three-dimensional arrangement
of blocks and must identify the number
of blocks in the picture.
brovascular accident lesions, although the sample size was among the salient visuoperceptual disorders after br
quite small (11 subjects in each group). disease , particularly disease of the right hemisphere (B
ton et aI., 1994). A frequently used test to evaluate
ability, the Judgment of Line Orientation Test, was
SPATIAL PERCEPTION
signed by Benton and colleagues (1978). In this test ,
Spatial orientation, one component of visual perception, subject is required to match one or two lines with th
refers to " the ability to relate to the position, direction, or shOwing the same inclination on an array of lines presen
movement of objects or points in space" (Lezak, 1995, p. on the same card (Fig. 12-9).
344). Disorders of spatial orientation may occur for The Judgment of Line Orientation Test has been
different reasons. As illustrative examples, disorders of line scribed in detail and includes normative data for individ
orientation perception and topographic orientation are aged 16 to 74 (Benton eta!., 1994). Data are also inclu
depicted because of their theoretical interest and functional for individuals with brain damage. Forty percent of r
significance. brain-damaged patients showed impaired performance
Disorder of Line Orientation Perception. Disturbances of this test, as compared with only 6 percent of patients w
appreciation of the directional orientation of lines are left brain damage , none of whom showed a remarka
hemisphere lesions performed more poorly on the task Disorder of Topographic Orientation. Topographic dis
than patients with left hemisphere lesions. Further evi entation is a disturbance of the ability to find the w
dence in support of the association between judgment of around an environment (Henderson, 1992-1993a; Pa
line orientation and right hemispheric function came from son & Zangwill, 1945). The lesion responsible for to
a positron emission tomographic scan study (Gur et al., graphic disorientation is frequently bilateral when
1987). An increase in cerebral blood flow in the right disorder is not secondary to unilateral neglect (McFie et
hemisphere was found during performance on this task. 1950). Descriptions of the disorder include the inability
By electrical stimulation mapping in awake patients describe the spatial layout of objects in a room or
undergoing neurosurgery, Fried and associates (1982) buildings and landmarks in large-scale spaces . To
identified the loci of the right hemisphere where stimula graphic disorientation is often manifested by the pati
tion disrupted line orientation perception. These loci are who gets lost in the hospital and cannot find the way b
located in the parieto-occipital junction and in a small to his or her room . The central disability is primaril
region of the posterior frontal cortex, the homologue of disorder of the relationship of two or more objects in spa
Broca's area. Although the perception of directional resulting in the loss of the sense of direction and of
orientation is mediated primarily by the right hemisphere in ability to establish a spatial scheme or map to loca
right-handed subjects, evidence has also been provided objects and describe routes (Henderson, 1992-1993
suggestive of a left hemisphere contribution to judgments Most assessments of topographic orientation are ob
A
B
C
FIGURE 12-6. Items from selected subtests of the Visual Object and Space Perception Test. A , Two items (camel and frog) from the Silhouettes sub
B, Multiple-choice item from the Object Decision subtest. C, An item from the Cube AnalysiS subtest. (Copyright E. Warrington & M . James, Tha
Valley Test Co., Suffolk, England .)
''I'(MIIIIIIIL ..
312 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
A B c D
FIGURE 12-7. An item from the Motor-free Visual Perception Test-Revised. (Courtesy of Academic Therapy Publications, Novato, CA
vational and are not standardized. Frequently the patient is When assessing topographic orientation, it is critica
assessed by observing his or her movement within an assess the patient in familiar as well as unfamiliar envi
environment in response to directional cues (e.g., go to the ments. Familiar environments should include the pati
Occupational Therapy Department; tell me how you would home; and if it is expected that the patient will be ab
go to the Occupational Therapy Department; draw a map move independently within the community (i.e., driv
to show how you would go to the Occupational Therapy work, take the bus, walk to the corner store, or go to
Department; or draw a map of the layout of your home). bank), this ability should be assessed as well.
~~~~ ~
2 3 4 5
Total-T
M 1750.01 1196.44 1331.74 1746.68 2095.52 1916.82
SD 563.64 289.82 35572 571.32 546.68 629.75
Total-A
M 76.10 85.64 79 .00 73.07 65.33 59.91
SD 15.98 13.89 13.32 14.31 16.54 14.54
VD
M 11.94 13.11 12 .87 1U5 10.33 10.27
SD 2.83 1.92 2.17 3.12 3.15 2.81
VM
M 9 .79 10.97 10.33 9.40 8.21 7.86
SD 2.82 2.40 2.74 2.65 2.87 2.77
VSR
M 12.07 13.53 12.00 12.03 10.64 9 .14
SO 2.81 2.31 2.58 2.58 3.18 2.78
VFC
M 10.37 11.39 10.48 10.33 9 .15 7.14
SO 2.81 3 .27 2.68 2.44 2.49 264
VSM
M 10.35 12.33 10.76 9.85 8 .21 8 .09
SD 2.71 2.37 202 2.33 2.67 3 .12
VFG
M 10.58 12.36 10.93 10.00 8.85 8 .36
SD 2.75 2.45 2.652 2.25 2.72 2.90
VC
M 11.01 11.94 11.63 10.33 9.94 9.05
SD 2.83 2.44 270 2.89 2.87 318
Total-A = Total accuracy score of 1VPS. Total-T = Total time score of lVPS. TVPS = Test of Visual-Perceptual Skills. VC = Visual closure VD =
discrimination. VFC = Visual form constancy. VFG = Visual figure-g round. VM = Visual memory. VSM = Visual sequential memory. VSR = V
spatial relationships.
From Su, C. Y., et aJ. (1995). Performance of older adults with and without cerebrovascular accident on the test of visual-perceptual skills. Am e
Journal of Occupational Therapy, 49(6) , 491-499 . Copyright 1995 by the American Occupational Therapy Association, Inc . Reprinted
permission.
Constructional Disorders
The term constructional praxis is a broad concept
has been applied to different types of activities w
common characteristic involves requiring the individu
assemble , join , or draw parts to form a single un
structure (Benton et al., 1994). According to Le
" constructional performance combines perceptual ac
6 with motor response and always has a spatial compon
5 7
(1995 , p . 559). Constructional tasks encompass
4 8 classes of activities: (1) drawing (graphomotor), an
building or assembling . These can be further subdiv
into two-dimensional and three-dimensional tasks.
Although there is no consensus as to whether cons
tional disorders are more specifically associated with
cerebral hemisphere than the other, the right hemisp
_ _ _ _ _ _ _ 11 has more often been implicated (Binder, 1982; Bla
FIGURE 12-9. An item from The Judgme nt of Line Orientation Test. Bernard, 1984; Mack & Levine, 1981; Piercy & Sm
The individual must visually match the two stimulus lines oriented at 1962). A recent meta-analysis (Le., quantitative liter
different angles to the stimulus array. (From Contributions to Neuropsy review) of 20 relevant studies (Lin & Tickle-Degnen, 1
chological Assessme nt: A Clinical ManLwl , l i e by Arthur L. Benton,
Kerry de S. Hamsher, Nils R. Varney , and Otfried Spreen. Copyright © revealed that, on the average, patients with r,ight h
1983 by Oxford University Press, Inc . Reprinted by permission.) spheric lesions performed more poorly on construct
TABLE 12-5
TESTS OF DRAWING
Clock Drawing Not standardized Subject is asked to draw a clock. See Freedman et al., 1994
Benton Revised Visual Retention Sivan, 1991 The test evaluates visual percep Psychological Assessment Re
Test, 5th ed. tion, visual memory, and visuo sources (PAR), P.O. Box 998,
constructive abilities. The test Odessa, FL 33556
consists of three alternate but
equivalent forms that may be
administered under the condi
tions of copying or reproducing
the designs from memory after
varying delays (no delay,
5-second delay, 15-second de
lay). Each copy/ reproduction is
scored according to the number
of correct designs and the num
ber of errors.
Rey Osterrieth Complex Figure Meyer & Meyer, 1995 The test consists of a complex fig Psychological Assessment Re
ure that the subject is asked to sources, Odessa, FL
copy. Scoring for immediate
and delayed recall versions is
available.
Bender Visual Motor Gestalt Test Bender, 1938 Drawing test that consists of hav Psychological Corporation, 555
ing the subject copy nine geo Academic Ct., San Antonio, T
metric designs that are pre 78204-2498
sented sequentially. The
drawings are reproduced
on a single sheet of paper.
Visual Motor Integration (VMI) Berry, 1989 Norms are not available for adults, Psychological Assessment Re
but the authors suggest that for sources (PAR), P.O. Box 998
practical purposes the norms Odessa, FL 33556
for the oldest age can be used
for older age groups.
Trail Making Test Reitan In this test of complex visua.1scan Forms may be ordered from
ning and conceptual tracking, Ronald Lewis, Ph .D. , 41730
the subject is timed while con Brandywine, Clinton Townshi
necting circles on a page. Two MI 48038 ; see Lezak, pp.
forms each contain 25 circles. 381-384
In part A the circles are num
bered 1-25. In part B, 13 of
the circles are numbered 1-13;
the remaining circles are labeled
A through L; the subject must
alternate between numbers and
letters. The score is the time to
complete the task.
tasks than patients with left hemispheric lesions. The figures such as a flower, a person, or a clock or comp
magnitude of the laterality effect was the same for grapho designs such as the Rey Osterrieth Complex Figure (Lez
motor tasks and assembly tasks . A Significantly larger effect 1995). Memory mayor may not be required, depending
was found in tasks that gave the patient a model to work the task. Table 12-5 lists some of the frequently u
from than in tasks that did not provide the patient with a drawing tests.
model. Analysis of the type of errors on drawing tasks
The variety of tests that have been used to assess afforded insights into the brain-behavior relationsh
constructional disorders is great (see Lezak, 1995). Se Research examining the performance of individuals w
lected tests are presented under the two main categories of right versus left brain damage has indicated that altho
tasks: drawing and assembly. both groups show impaired performance on many c
structional tasks, the two groups show different types
errors. Patients with right hemisphere damage tend
DRAWING TASKS
perform in a piecemeal fragmented manner, often los
Drawing tests usually involve either copying or drawing the overall gestalt or configuration of the structure. T
on verbal request, often referred to as free drawing. often show an increase in the number of details , w
Drawing tasks may include relatively simple and everyday missing the overall concept. If patients also mani
may maintain the overall structure or configuration but tend ing system with scoring examples, recent data on reliabi
to lose details and have simplified performances (Table and interrater agreement in scoring, and analysis
12-6 and Figures 12-10 through 12-13). cognitive factors underlying performance on the test (F
A frequently used drawing in assessing constructional 12-15).
abilities is a clock. Differences in clock drawings as a The Rey Osterrieth Complex Figure is also an exam
function of task demand and locus of lesion have been of a complex drawing task that can be administered und
demonstrated by Kaplan (1990). When asked to draw a conditions of copying and recall with or without a del
clock with its time set at 10 after 11, patients with a right This complex figure was originally devised by Rey in 19
temporal lesion may manifest left neglect on drawings to to investigate both perceptual organization and vis
command but remain relatively intact on drawings to copy. memory in subjects with brain damage (Lezak, 1995).
Patients with a right parietal lesion tend to show the 1944, Osterrieth standardized Rey's procedure and
opposite pattern of dissociation (Fig. 12-14). The broad tained normative data for children and adults. The test
variety of abnormal clocks drawn by patients with focal volves reproduction of the complex figure (Fig. 12-1
brain lesions can be found in the text of Freedman and Both the process (the subject's approach to the task
colleagues (1994). strategy) and the product (the actual drawing) are evaluat
The extent of memory required in drawing tasks varies After completion of the drawing, the subject may be ask
widely from test to test. Copying tasks do not depend on to redraw the design from memory. When the copy dra
memory. Free drawing tasks involve memory of the object ing is poor, the examiner must determine whether the di
and its properties, but because these tests usually involve culty in drawing is based on problems in visuospatial a
drawing familiar objects, such as a house, memory is visuomotor integration difficulties. In this case, recall is u
minimized, particularly for specifics. Some tests such as the ally not administered because it will reflect the visuospa
Benton Visual Retention Test (Sivan, 1992) and the Rey or visuomotor difficulties rather than memory (Lez
Osterrieth Complex Figure (Lezak, 1995) include formats 1995).
that include both copying and memory (recall with or The Rey Osterrieth Complex Figure has been us
without a delay). The Benton Visual Retention Test extensively in neuropsychological assessment. It has be
(BVRT), fifth edition (Sivan, 1992), is a clinical and reported that 75 percent of patients with frontal lo
research instrument used to assess visual perception, visual lesions perform significantly differently from the cont
memory, and visuoconstructive abilities. The BVRT pro subjects. The most common errors tend to be "repetiti
vides three alternate forms as well as four alternative of an element that had already been copied, an er
methods of administration. Each version of the test con resulting from the patient's losing track of what he or s
tains 10 designs, with each design containing one or more had drawn because of a disorganized approach" (Lez
figures. The test can be administered in about 5 minutes. 1995, p. 577). Laterality effects were also noted. Patie
TABLE 12-6
Frequency Greater
Severity More severe
Hemianopia 50 percent 50 percent
Associated problems Aphasia Unilateral neglect
ERROR PATTERNS IN CONSTRUCTIONAL TASKS
Configuration Maintains overall configuration/gestalt; simplified Loses overall configuration/gestalt; piecemeal
approach
Individual features Misses individual features, simplified, loses internal Internal features are present but disorganized
detail
Complexity (number of lines) Omissions, reduced number of pieces Additions
Spatial aspects Spatial relationships are preserved Rotations, reversals, poor spatial relationships
between parts
Orientation Difficulty with perspective; tends to orient di
agonally
Facilitation strategies Performance improves with a model or cues (e.g., Not aided by cues or model
landmarks)
Spontaneous vs. copied drawings Right hemisphere damage is worse, but difference between hemispheres is greater on copied drawings
because copying helps drawings of left hemisphere lesion but has little effect on drawings of right
lesion.
316 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
Copies Spontaneous
-----\
A --------\
j'
n l.
~~
D
;;L
~
U~\fJt ~ n 6 71!\j
--<==J
/~
~
Ul
C
o
'(ij
~
bL:LJ lB
U
r=::::J~0- ......, 1/
~
b
7fi
~I / \ : ~~d'" ~r
I\~~ ~0
15 I. (
--l
{1
l;GJ
-\ ) iJ ]
"LJ f
I
~ ~( 0f~
~ I~ fil ' ,'~
~
~~l)L !((~ r~
/ Il V
Il _
/
\J~ J )-
lJaJ ffi r1ffij /r~
cL- "cj ~
,e
,
~
>-1 i=-------n
Copies Spontaneous
o 1/\
r~
6 ~u
/~IILla1
In dO I
~
\ ?7
~v
1.-"')
Ul
C
\ ,,/
_/ \J
o
'(ij
~
107
L rl tl
V> ~
D ul ~
E
f-/
L~' ___ ~n(
OJ
a:
'--' if
r;~
I~" ~_~.
V:, 'LJ
i(
~ r
~ (~1
~~Io~
FIGURE 12-10. Drawings by individuals with right and left hemisphere damage. (From Percy, M., et al. [19601. Constructional apraxia asso
with unilateral cerebral lesions-left and right sided compared. Brain, 83, 225-242. By permission of Oxford University Press.)
A B
FIGURE 12-1 L Drawings of a house by individuals after a right cerebrovascular accident. A, Severe neglect and mild to moderate proble
constructional abilities are shown. B, Severe neglect and severe problems in constructional abilities are shown.
EE EE
FIGURE 12-12. Drawing of a person by an individual with tight
cerebrovascular accident. Severe neglect with intact constructional abili FIGURE 12-13. Copy of a house by a man who had sustained a
ties is shown. cerebrovascular accident that resulted in neglect.
12 I
"
3
A
ASSEMBLY TASKS
Assembly or building tasks may be divided into tw
dimensional constructional tasks such as block desi
JO
y<,z-i I,
\
/ c.. 1
2.
(Wechsler, 1981), parquetry blocks (Niestadt, 1989), st
pattern constructions (Goodglass & Kaplan, 1983),
three-dimensional constructions such as building fr
photographs or models (Benton & Fogel, 1962; Benton
'\~3
,
aI., 1994; Critchley, 1953). Table 12-7 identifies many
9 : 'V 4 the commonly used tests of constructional abilities t
g involve assembling or building.
7 c;, 6
E
'!, '7
'" F
One of the most commonly used and researched tests
three-dimensional block construction is that described
FIGURE 12-14. Clocks drawn by individuals with a (A) lesion in the Benton and associates (1994) (Fig. 12-18). This standa
posterior region of the right hemisphere, illustrating spatial disorganiza
tion of numbers and omission of hands on copy task; (B) lesion in posterior ized, objectively scored test requires the subject to rep
right hemisphere showing spatial disorganization of numbers and left duce three block models of increasing complexity, using
hemi-inattention ; (C) and (D) lesion in right parietall'obe showing spatial 8 , and 15 blocks from an assortment of 29 blocks on a tr
disorganization (I.e ., left neglect) on the copy version (C) but not on
command (D); (E) and (F) right temporal lobe lesion illustrating more A comparable but more difficult form using photograph
spatial disorganization (i.e. , omission of outer configuration and inatten the same block constructions is proVided. The time tak
tion to spatial layout of number) on the command condition (F) than on the for the construction of each model is recorded in secon
copy condition (E). (From Clock Drawing: A Neuropsychological Analysis
by Morris Freedman , Larry Leach, Edith Kaplan , Gordon Winocur, although accuracy rather than speed is emphasiz
Kenneth I. Shulman, and Dean C. Delis. Copyright © 1994 by Oxford (Spreen & Strauss, 1991). Scoring is the total number
University Press, Inc. Reprinted by permission.) blocks correctly assembled with a time correction fac
Recording of the types of errors is also included . A m
(Fig. 12-17). The reader is referred to Lezak (1995, pp. complete description of the test and accompanying n
569-578) for a review of scoring systems and to D'Elia and mative data is described in several sources (Benton et
associates (1995) and Spreen and Strauss (1991) for 1994; Lezak, 1995; Spreen & Strauss, 1991).
comprehensive norms on this test. In a study by Benton and associates (1979) using
three-dimensional block construction task, 54 percent
patients with right hemisphere lesions scored lower th
95 percent of the controls whereas 23 percent of indivi
als with left hemisphere lesions scored at that level.
another study, among patients with left hemisphere
sions, constructional deficits were most commonly seen
6.
individuals with receptive aphasia (Benton et aI., 199
Recently, Neistadt (1989) developed the Parque
FIGURE 12-15. An item from the Benton Visual Retention Test. (From Block Test. This test of constructional ability invol
Benton Visual Retention Test: 5th Edition. Copyright © 1991 by The
Psychological Corporation. Reproduced by permission. All rights re constructing four block designs of 32 blocks each fr
served.) model design cards. The materials for this test include a
available are shown in order of easiest to hardest in Figure 1989 ; 1991 ; 1994b), has been shown to be reli
12-19 (Neistadt, 1989), which also includes the average (test-retest coefficient of r = 0.92) and shows a high
times that healthy college students, aged 18 to 35 years, significant correlation with the WAlS-R Block Design
took to accurately complete the designs. In addition to time (r = 0.84), a frequently used measure of constructi
to complete the design, error ratio scores are calculated ability. Neistadt has used this test extensively with indiv
that consist of the number of incorrectly and unplaced als with head injury and has suggested guidelines for
blocks in the design(s) completed divided by the total of intervention (functional or remedial) based on the cli
performance on the test and his or her respons
training.
Another test that can be used to assess constructi
abilities and that involves assembly is the Tinker Toy
(Lezak, 1982 , 1995). Although this test is used primari
assess executive abilities (the ability to formulate a goal
to plan, initiate, and carry out the activity to achieve
goal), the test evaluates an interplay of constructi
abilities and executive abilities. The Tinkertoy Test incl
50 pieces from the standard Tinkertoy set. The patie
told to make whatever he or she wants. This test requ
the ability to manipulate pieces with both hands. Scori
based on complexity, including whether the patient m
(a) Female, age 62 a structure, the total number of pieces used in
right middle cerebral artery
construction, whether the patient appropriately named
structure, whether there were moving parts , whether it
three dimensions , and whether it was free standing, Po
are subtracted for specific types of errors. This te
described more fully in Lezak (1995, pp . 659-665).
CONSTRucnONAL ABILITIES:
A UNITARY DISORDER?
Research has indicated that often an individual with b
damage fails on some constructional tasks but no
others. In a classic study addressing this issue, Benton
Fogel (1962) analyzed the interrelations among the
formances of 100 brain-damaged patients on four
(b) Female, age 61 structional tasks (copying designs , stick-construc
right middle cerebral artery three-dimensional block construcNon , and block design
was found that the intertest correlations were never
high, though statistically significant due to the large sam
size. The finding indicated that both common and diffe
abilities were involved in various constructive tasks.
subsequent study using the aforementioned four ta
Benton (1967) noted that the degree of commun
between failure in copying designs and the other three
was consistently lower than the degree of communali
failure among the other three tests. It is conceivable tha
graphomotor element in copying designs may have
dowed the test with a specific character that is not sh
by the other three tests requiring assembling abili
Beyond this, because the degree of concurrence among
(c) Male, age 71 other three tests was far from close, it was evident
right parietal-temporal infarct intra individual variation in performance level on these
FIGURE 12-17. Copy of the Rey Osterrieth Complex Figure by three exists. The immediate implication of this finding is tha
individuals with right cerebrovascular accident and neglect. A, Female ,
age 62, right middle cerebral artery lesion. B, Fema le, age 61, right middle unsatisfactory to use failure on anyone test as the
cerebral artery lesion . C, Male, age 71 , right parietal-temporal infarct. operational definition of constructional impairment
320 U~IITTHREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
cause such a practice runs the risk of committing a dimensions are required , degree of executive func
false-negative error in diagnosis. As Critchley (1953) has required, and how much overall motor skill is necess
found, assessment on a three-dimensional constructional Therefore, the various tests used to measure constructio
task appeared to be necessary because some patients with abilities may yield different results even though each
parietal lesions who had no difficulty on the commonly purports to be measuring the same skill (Benton & Fo
employed two-dimensional tests displayed gross abnor 1962). To provide a plausible typology of constructio
malities of construction when the test moved into the third performances, future research may attempt factor anal
dimension. to determine the underlying dimensions (or characterist
Benton and Fogel (1962) emphasize that each construc being measured by various constructional tests .
tional test used to measure constructional praxis skills may The question remains as to whether constructio
not be measuring the same skill. Tests may vary in regard impairment as disclosed by failure on these tasks is in
to degree of difficulty, whether two or three spatial a unitary deficit. According to some authors (Benson
TABl.E 12-7
Three-Dimensional Block Benton There are two equivalent forms of the Psychological Assessment Resour
Construction test in which the subject is pre (PAR), P.O. Box 998, Odessa.
sented with three block models (6 33556; see Benton, et at. 1994
blocks. 8 blocks, and 15 blocks), pp. 115-136.
one at a time , and required to con
struct an exact replica by selecting
the appropriate blocks from a set of
29 blocks on a tray. A version in
which the subject must replicate the
constructions based on photo
graphs of the model is also present.
Parquetry Blocks Test Neistadt. 1989' Subject is required to construct four Parquetry blocks available from
block designs of 32 blocks each. Learning Resources; see Neista
Time and accuracy are recorded, 1989,1994.
and error ratio scores are calcu
lated.
Tinke r Toy Lezak, 1983. 1995' Subject is given 50 pieces of a stan See Lezak, 1995, pp. 659-665 .
dard Tinkertoy set and told to make
whatever he or she wants; scored
for complexity of construction ac
cording to specified criteria: as
sesses executive and planning abili
ties as well as construction.
Block Design Wechsler, 1981 Subtest of the WAIS-R in which the Psychological Corporation, 555
subject is given four or nine red and Academic Ct. , San Antonio, TX
white blocks and must reproduce 78204-2498.
block designs made by the exam
iner and from a card in which the
designs are printed in smaller scale
than the blocks.
Object Assembly Wechsler, 1981 Subtest of the WAIS-R that contains Psyc hological Corporation, 555
four cut-up figures of familiar Academic Ct., San Antonio, TX
objects: manikin , profile, hand , and 78204-2498.
elephant. Responses are scored for
time and accuracy.
Stick Construction Goodglass and Kaplan , 1983< Subject is asked to construct match See Goodglass and Kaplan , 1983
stick geometriC figures from
memory. Each of 14 designs is first
assembled before the subject. Each
design is exposed for 10 seconds
and then removed, and the subject
is asked to reproduce it.
Constructional Praxis Test Ayres, 1989 A subtest of the Sensory Integration
and Praxis Tests. Subject constructs
two different models of varying com
plexity. Test is standardized for chil
dren but has been used with adults
~ith cerebrovascular accident.
Barton, 1970; McFie & Zangwill, 1960), two separate 1983) to 90 percent (Schenkenberg et aI., 1980). T
pathogenetic mechanisms underlie constructional disor variation in incidence may reflect the sensitivity of the t
ders: a manifestation of a disturbance at the executive or used for diagnosis (Ogden, 1987) and the selection crit
planning level in the constructional act in left hemisphere for the subject cohorts (Sunderland et aI. , 1987). Altho
lesioned patients and a secondary consequence of a the majority of lesions causing neglect occur in
disturbance of visuoperception following right hemisphere temporoparietal lobe (Cappa et al., 1991), lesions of
damage. frontal lobe (Mesulam , 1985), inferior parietal lobe, lat
frontal lobe, cingulate gyrus, thalamus, and striatum m
also result in the disorder (Heilman et aI. , 1993).
Unilateral Neglect Although unilateral neglect may occur for visual, a
tory , olfactory, or tactile modalities, the majority of neg
Unilateral neglect is a common neurobehavioral disorder assessments tap the visuospatial aspect of the syndro
that occurs after brain damage and has important func Some of the most commonly used tests (for either clin
tional implications. This disorder is more common after a or research purposes) include line bisection tests, copy
right hemisphere lesion (Heilman et al., 1985), although or drawing tests, cancellation tests , and reading t
some recent studies (e.g., Ogden , 1987; Stone et al., (Cermak & Lin, 1994). Table 12-8 summarizes many
1993) have indicated that neglect may occur more com the tests used to evaluate neglect. Besides their clin
monly in left hemisphere stroke than previously reported . usefulness, these tests have been used for research
The incidence of unilateral neglect after right hemisphere neglect mechanisms and therapy. A brief review of relev
stroke varies greatly, ranging from 12 percent (Smith et al. , research is provided below.
T/\~ I.I I LK
Line Bisection Test Schenkenberg, et al., 1980" Line bisection of 20 lines of three Schenkenberg et al., 1980.
graph out loud in which the left See Lezak, 1995. pp. 393-39
margin is variably indented.
Behavioral Inattention Test Wilson et al. , 1987 Test consists of six conventional pa
per and pencil tests of neglect in
cluding cancellation tests, a line
bisection test, and drawing tests.
There are also nine behavioral
tests designed to simulate ADL:
picture scanning, telephone dial
ing, menu reading , article read
ing, telling and setting time, coin
sorting, address and sentence
copying, map navigation, and
card sorting.
neglect tends to be erratic regardless of the stimulus array phasized the distinction between peripersonal space
(Mesulam, 1985). extrapersonal space.
It has been suggested that because paper and pencil tasks
are usually limited in space, the therapist should also
READING TESTS
examine the patient's scanning strategies in a larger space
(Warren, 1993a, 1993b, 1994). In a typology of spatial Because reading is a functional skill and is easy
abilities, Henderson (1992-1993a, 1992-1993b) also em- measure, a variety of studies have used reading to ass
T* .. ~~6*O-o-·00--o-,**0~-"*O
OOvO.-<>**-*OO,*o**-<>.O~O
. * * . 0 * .... 000VVO*0-*6'*O*.
o v * * 0 0 ~ * 0 * 0 .... * - • 0 * -<> * * 6 0
~ 0 0 '* ~ * 0 - 6 * 0 • * v 0 0 • 0 . 0 0 '*
* 0 * * -<> 0 0 .. ti * v * * .... * 0 - 0 ~ * ~ 0
- * .. 0*ti*0-<>OO·6V**.~.**6
0****·_-<>0.**-tiV6**0 .. *0
*D.***"*Oti~ .. OO·**O~,*O*
A~VO*0"06*0.,*0*.ti • • *-0~
0* TO" ~ 00 If • T
.. •
_ lfO 0* l:J. * 0 v 0
0* * .... V 0 0
v 0 *. .... 00 * (From Weintraub, S., & Mesu
M. M. 11985]. Mental state as
ment of young and elderly adu
~ 0 . 0 0 - Vlf-<>V· -<> If 6 behavioral neurology. In M.
*0 * .
0.... 0 0 .. -<> '\7 0 • 0 0 .l:J.. 0 • * 0 • ** Mesulam [Ed.], Principles of be
ioral neurology Ipp. 71-1
B If -<> * _ * 0 0 ~ * .... V* If Philadelphia, F. A Davis.)
FIGURE 12-22. Scan path renects
the order in which the subject, a 71
year-old man with a right cerebrovas
cular accident lesion, cancelled target
stimuli.
neglect and to examine the outcome of various stimulus comprehensive information for developing rehabilita
manipulations and intervention procedures (Butter & programs (Halligan et aL , 1991 ; Wilson et aL, 198
Kirsch, 1992; Gordon et aI., 1985; Lin, 1994b; Piz 1987b). This standardized test battery consists of
zamiglio et aL, 1992; Robertson et aL , 1988; Robertson et conventional subtests that have traditionally been use
aL, 1990; Robertson & North, 1994; Weinberg et aL, assess unilateral neglect. These subtests include three vi
1977, 1979; Young et aL, 1983). Clinical observation has search (cancellation) tasks , a figure copying task, a
indicated that neglect patients tend to ignore one side of the bisection task, and a drawing task (Table 12-9). The
page or word when reading. Battersby and coworkers a'lso includes nine behavioral subtests that are designe
(1956) developed a reading test that consisted of 10 enable identification of the types of functional problems
large-printed phrases on cards. Kinsbourne and War patient may experience ,in everyday life. The subt
rington (1962) reported that patients with neglect commit simulate ADL and include tasks such as scanning pict
two basic varieties of reading errors: (1) they may omit or and naming the objects in the pictures (e .g., a bathro
misread the first letters of a particular word ; (2) because of and a hospital room), dialing a telephone, reading a me
difficulty refixating from the end of the line to the beginning reading a short article, and telling and setting time o
of the next, they may fail to read the first word{s) on a given clock (Table 12-10).
line. Riddoch (1990) has presented a detailed analysis of The BIT was standardized on 80 patients with str
the errors in reading observed in patients with neglect. (Halligan et aI., 1991 ; Wilson et aL , 1987a, 1987b).
Caplan (1987) developed the Indented Paragraph Test in scores of 50 British controls between the ages of 19 and
which the left margins of the paragraph are variably were used to establish the limits of normal performance
indented (Fig. 12-23). The author suggests that this test the conventional and behavioral subtests . The interr
identifies more subtle levels of left-sided neglect than text reliability of the instrument was established by having
with a predictable format , although this was not supported independent raters score 13 subjects after str
by Towle and Lincoln (1991b), who examined perfor (r = 0 .99) . Parallel form reliability for the behavioral
mance on a reading task containing the same material but tests was determined by giving two alternate versions of
with different layouts. test to 10 patients (r = 0 .91). Test-retest reliability
calculated by testing 10 patients on two separate o
sions, about 15 days apart (r = 0.99). This instrum
THE BEHAVIORAL INATTENTION TEST
therefore, appears to be reliable. This is especially true
The Behavioral Inattention Test (BIT) is designed to test-retest reliability because patients with brain dam
include both conventional tests of neglect as well as a are characterized by spontaneous fluctuations in per
sampling of performance of everyday skills to provide more mance on such tests.
326 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
Trees brighten the countryside and soften the harsh lines of city
things. Trees are the best-known plant and man's experience. They are
feet or more. Shrubs are also woody, but they are usually
learn to identify them at a distance. One group o f trees has simple leaves
only the leaves but also the flowers, fruit , seeds, bark,
buds , and wood are worth studying. When you look at a tree, see it as a
being in a com munity of plants and animals. The oldest trees live
wood products, turpentine and resins are the great value. They also are
enjoy. Trees can be studied at every season, and they should be. Each
FIGURE 12-23. The Indented Paragraph Test. (From Caplan , B. [19871 . Assessment of unilateral neglect: A new reading test. Journal of C
and Experimental Neuropsychology, 9, 359-364 )
TABU 12-()
Line Crossing Present page containing 40 one-inch lines in a variety 18 left, 18 right , 4 center lines that are not scored;
of orientations on the page. Subject is instructed to maximal score = 36.
make an " X" through each line.
Letter Cancellation Present page containing five rows of capital letters. 20 left , 20 right " R"s and " E"s; maximal score = 4
Subject is instructed to make an " X " through each
''R ' and '·E."
Star Cancellation Present page containing randomly arranged small stars, 27 left, 27 right small stars; maximal score = 54.
large stars, letters, and words. Subject is instnlcted to
make an "X" through each small star.
Figure and Shape Copying Two parts: (A) Present page containing line drawings of (A) One point is given for each complete drawing.
star, cube , and daisy arranged vertically on left side ure is lack of any major component of drawing:
of page. Subject is instructed to copy each on the maximal score = 3. (B) One point is given only if
corresponding right side of page. (B) Present page shapes are complete; maximal score = 1.
containing a group of simple geometric shapes. Sub
ject is instructed to copy the three drawings on one
separate sheet of paper.
Line Bisection Present page containing 3 horizontal 8-inch lines. Sub 3 points for each line bisected within one-half inch
ject is instructed to mark the center of each line . right or left of center; 2 points for within three
fourths inch; 1 point for within 1 inch. Maximal
score = 9.
Representational DraWing Present blank sheet of paper. Subject is instructed to 1 point is given for each complete drawing; maxim
make three drawings on it. A clock face. a man or a score = 3.
woman, and a butterfly.
'Points are given for correct performance; thus , higher scores reflect better performance . Overall maximal score = 146; scores below 129 in
neglect. (Data from Wilson , B., et al. [1987a]. Behavioral inattention test. Hants, England : Thames Valley Test Company.)
BEHAVIORAL SVBTESTS FOR 'DIE
involved the correlation of the behavioral scores with
BEHAVIORAL 1NA1TEN110N TEST
responses to a short ADL questionnaire completed b
Subtest Description occupational therapist when the assessment was adm
tered (r = 0.67) . The reader is referred to Chapter 8, w
Picture Scanning Present picture of meal on plate, also includes a discussion of unilateral neglect.
then wash basin, then view of
room, one at a time. While
viewing each photo, subject is
instructed to point out and
name all objects in the picture.
Telephone Dialing Present disconnected telephone ADDITIONAL ASPECTS TO CONSIDER
and cards with phone numbers
to be dialed. Phone numbers in
IN ASSESSING VISUAL PERCEPTION
crease in length from five to
seven digits. Awareness of Disabillity
Menu Reading Present menu. Subject is in
structed to read it aloud .
Article Reading Present page containing news ar Awareness of ability and disability is a key to acc
ticle printed in three columns on perceptual processing. Normally, we know when a ta
the page. Subject is instructed difficult and we pay more attention to the informa
to read it aloud.
Telling and Setting the Time (A) Present three photographs of a enabling us to extract the important details. Crosson
digital clock, one at a time. Sub coworkers (1989) identified three types of awareness
ject is instructed to read each 1. Intellectual awareness : The patients have kn
time aloud ; (B) Present large
cardboard analogue clock with edge of a defiCit but do not know how to use
movable hands. Examiner sets knowledge in their functioning and are not awa
three times, and subject is in the consequences of the deficit to their daily
structed to read each time
aloud; (C) On same cardboard tioning. An example is the patient who can tell
clock, subject is instructed to set that he has a problem "doing things on the left s
three specific times. but who then proceeds to eat only the food on
Coin Sorting Present coins arranged on board.
Subject is instructed to point out right side of his tray or shave the right side of his
all coins of a specific type when 2. Emergent awareness: The patients have a g
each is named by examiner. recognition that something is wrong. When
perform a task and make an error, they realize
Scoring: Each subtest has a maximum score of nine. Points are subtracted
from the maximum score for errors/omissions by a formula specified for something is wrong and can, at times, self cor
each subtest. For example, if a patient with neglect reads an ar
he may realize it does not make sense and will
search for words on the left.
The validity of the BIT has also been examined and
3 . Anticipatory awareness: The patients with this
supported in several recent studies. Halligan and col
leagues (1989) examined the performance of 80 patients of awareness can specifically anticipate a pro
with a diagnosis of unilateral stroke on the six conventional before it occurs and can plan strategies b
subtests of the BIT to analyze the relationship among these making an error.
subtests. It was found that the six subtests all intercorrelated If a patient is not aware that he or she has perce
problems , then he or she cannot anticipate when task
highly. A subsequent principal component analysis showed
that all tests loaded significantly on one underlying com be difficult. Therefore, the patient does not use incre
attention to task. Thus , assessing awareness of pe
ponent (eigen value = 4 .36, percentage of variance ex
plained = 72.6). The results provided preliminary evidence mance is critical to evaluation of perceptual abilities.
of factorial validity of the conventional subtests.
The authors of the instrument evaluated the concurrent,
criterion-related validity of the behavioral subtests in two The Importance of Context
ways. First, the relationship between total scores on the
behavioral subtest and total scores on the conventional Different aspects of perception have been viewe
subtests was studied for 80 patients with initial diagnoses of separate subskills. Some researchers have suggested
unilateral stroke, yielding a correlation of 0.92 (Wilson et these subskills forma hierarchical continuum (e .g., Wa
al., 1987a). The authors believe that the strong correlation 1993a, 1993b, 1994), whereas others have sugges
between the conventional subtests and the behavioral conceptualization that analyzes the interaction amon
subtests helps establish the validity of the latter subtests task characteristics, environment, and individual to
because the conventional subtests were selected from understand perceptual function and dysfunction
previously published studies and are considered valid Toglia, 1992). Toglia (1991a, 1992) emphasizes
328 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
dysfunction is not task specific but is related to the motor abilities. These tests include Digit Speed and H
characteristics of the task and the environment. Research Steadiness, Visuomotor Pursuit, Ballistic Visuom
has clearly indicated that visual perception is influenced by Movement, Visuomotor Sequences, Fine Motor Coord
context, including the characteristics of the task and the tion, Visuomotor Scanning, and Visuomotor Learning
environment (Abreu, 1995; Gibson, 1988; Neistadt, with the Boston Cancellation Test, a drawing tablet
1994a; Trombly, 1995). cordless pen is required.
There are many issues to consider in deciding wheth
use a computer-based assessment. Advantages are
Moving Versus Stable Environments variables may be manipulated systematically, exam
scoring time is reduced, scoring can be more detai
Most often, visual perception is tested in a stable envi scoring errors can be reduced, and the assessment ma
ronment with the patient stable (seated in a chair) and the more motivating for the subject. Disadvantages are o
environment stable (paper on the table). However, in cost. In addition, if the subject is not familiar with usi
everyday life, it is often the case where the individual is computer, this may present a new learning situation and
moving (e.g., walking down the aisle in a grocery store) or or her performance may not be valid.
the environment is moving (e.g., cars in the road) or both
the individual and the environment are moving (crossing a
busy street). In these instances, the individual must make
ongoing perceptual judgments, many that involve antici SELECTING AN ASSESSMENT
pation. It is critical to examine a patient's performance in
these situations. Often patients who can develop strategies There are literally hundreds of measures of percep
to compensate and perform adequately on paper and and perceptuomotor abilities. Some emphasize percep
pencil tasks have difficulty in the real world because of these discrimination; others emphasize constructional abili
issues. Some tests have been well standardized, providing dat
normative performance as well as reliability and vali
others have minimal psychometric data.
Computer-Based Assessment Research has indicated that performance in man
these tests does not correlate highly, indicating
There have been an increasing number of assessments of perception is multifaceted. This means that it may
perceptual abilities that have been computerized. Many of necessary for a therapist to select more than one ass
these are highly similar to the paper and pencil version. An ment. Given the large numbers of assessments of per
example of this is the computerized version of Mesulam's tual and constructional abilities, the therapist need
cancellation tests. The Boston (Mesulam) Cancellation Test know how to select a particular assessment(s).
(BCT), distributed by Food for Thought, is available for the The approach to assessment and the selection of spe
IBM (or equivalent) computer and requires a drawing tablet assessments should reflect the purpose of the assessm
with cordless pen. An advantage to this test is that scoring (Schenkman, 1994). If the therapist is primarily intere
can be done more quickly and information about subject in the assessment of clinically relevant naturalistic behav
performance can be more detailed (e.g., the reaction time then a functional approach may be the most appropr
of responses on the left vs. the right side of the page can be model. If, on the other hand, a therapist is intereste
provided and a scan path can be drawn). identifying why a patient may be having difficulty
Examples of tests that are not available in a paper and particular tasks, then examination of the performa
pencil version is the Software for the Assessment of Visual components may be useful. Finally, if the therapis
Analysis and Synthesis (SRT) and the Software for the primarily interested in identifying factors that facil
Assessment of Motor Functioning (MAB). Both tests are performance, then use of a dynamic model may be
distributed by Food for Thought and are available for the most relevant.
IBM (or equivalent) computer. The SRT assesses visual and A model suggested by Trombly (1993) involves
spatial functioning. It assesses right brain or frontal defi integration of these approaches in a top-down fash
ciencies and includes two- and three-dimensional figure Trombly believes that the "occupational therapy ass
testing, intensive error analysis, and spatial operations ment procedure should reflect our conceptualizatio
analysis. The test has three parts. First, subjects compare a occupational therapy and that there should be congrue
complex graphic model to alternative shapes with system among goals, assessments, and treatment" (p. 2
atic variations. Second, subjects reconstruct the model Because occupational therapists are experts in occu
using object pieces and active reconstruction including tional functioning, Trombly suggests starting the ass
object movement, rotation, and mirroring. Third, subjects ment process with inquiry into role competency
compare stationary and moving three-dimensional objects meaningfulness. The advantages of this approach are
in a more sophisticated test version. it "helps the client to connect abilities (component
The MAB includes seven tests that require perceptuo function) with occupational performance" (p. 253).
zation (WHO) International Classification of Impairments, Ideational apraxia-A disruption in the sequen
Disabilities and Handicaps (ICIDH). Schenkman (1994) organization of the gestures required to carry ou
emphasizes the need to identify whether the assessment complex performance, owing to the disintegration
evaluates impairment, performance, disability, or some inadequacy of the plan of action.
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332 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
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Cognition
Barbara Haase, MHS, OTR/L
Cognition allows each of us to take in information and the patient's diagnosis, and the facility . In many setting
use the information to plan meaningful interactions with cognitive assessment is performed by the occupation
others and with the environment. It is the ability to therapist and/or speech-language pathologists. More
understand and to be aware of the environment (Zoltan, depth assessments may be completed by psychologists a
1990). The assessment of cognitive functioning needs to neuropsychologists, when available , Health care prac
be taken into account and is necessary for the development tioners, whether phYSiCians, nurses, or therapists, need
and implementation of intervention plans, regardless of the understanding of cognitive processes and the impact th
patient's diagnosis . impairment of these processes has on the general we
being and independent functioning of the patient. T
patient's cognitive level influences his or her ability to follo
through with medical care and can determine whether
CONTEXT FOR ASSESSMENT or she is able to maintain his or her lifestyle and to l
independently (Cohen & Mapau, 1988). Many diagnos
The depth and breadth of the cognitive assessment have accompanying cognitive deficits. These include ce
performed is generally based on the therapist's discipline , brovascular accidents (CVAs), traumatic brain injury (TB
334 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
multiple sclerosis, and dementia. Patients with diagnoses in administered only by psychologists. These assessme
other areas may also have cognitive problems. These diag require the specialized training only a psychologist has
noses include orthopedic disorders, cardiac disorders, and interpretation. Other assessments are available to al
cognitive changes after surgery. The cognitive deficits may health practitioners for use. This section of Chapter
be the result of secondary diagnoses, such as dementia, or attempts to review some of the standardized assessme
other problems such as a reaction to anesthesia or intensive available to assess cognition, as well as to provide ideas
care unit psychosis (Lindenmuth et aI., 1980). Some cogni nonstandardized assessments. Not all practitioners feel
tive problems may be long term and progressive; others occupational therapists should perform standardized
may be short term, lasting a few hours to a few days. sessment. Morse (1986) believes that occupational th
Cognition is generally assessed either formally or infor pists should perform only screenings and neuropsych
mally during an occupational therapy (OT) assessment. ogists should do the standardized testing beca
Physical therapy (PT) assessments should also assess psychologists are more knowledgeable in the pro
cognition to meet the needs of their intervention program. administration of the tests and more knowledgeable in
Physical therapists need to recognize cognitive deficits and modification of the assessment, if needed.
when to refer patients to practitioners skilled in cognitive Standardized assessment has benefits to the practitio
assessment. Cognition is taken into account in the as it not only provides insight in how the patien
treatment-planning stage. Strub and Black (1977) state functioning, based on a normal population, but also of
that more comprehensive assessment of mental status is a baseline in measurable terms to chart progress. Qua
needed in health care whenever problems in cognition are tative data from recognized standardized tests is essentia
noted. Many patients are often discharged to home with document progress, to appropriately plan treatment,
recognition of cognitive problems but without the problems to promote the efficacy of intervention for insura
having been fully investigated to determine their impact on intermediaries. Standard assessment, whether formali
function. A thorough cognitive assessment is needed to standardized tests or assessments standard to a facility, a
establish a baseline on which to measure progress, gain prOvides a comparison of one patient with anoth
understanding of the patient's strengths and weaknesses, Whether a specialty is utilizing standardized assessmen
and determine the patient's learning style (Cohen & is obtaining the information from other diSciplines, ev
Mapau, 1988; Morse, 1986). Understanding the location person on the team should be familiar with the assessm
of the lesion may assist in selection and interpretation of the type of information the assessment provides, and h
the assessment. This information may not be applicable for the information may be used to benefit the patien
more diffuse leSions, such as with traumatic brain injury and treatment planning.
cortical atrophy. Prior to a more formalized assessment of There are no formal standards for how cognition sho
cognitive deficits, assessment for sensory deficits (e.g., be assessed. This may depend on the type of setting
tactile, auditory, visual) and perceptual deficits needs to be which the therapy program is based. Frequently, in m
completed (Morse, 1986; Zoltan, 1990). These assess acute settings when time is a limitation, a short, qu
ments are described in Sections 2 and 3 of this chapter. screen of general cognitive function or a short assessm
Knowledge of these deficits may assist in the appropriate of the area of deficit to quantify information for repor
selection of assessment instruments and certainly is a factor may be appropriate. In more in-depth settings, such a
in the interpretation of assessments. The patient's level of rehabilitation, generally the occupational therapist st
functioning in speech and language may also affect his or tures a more comprehensive assessment. Some progra
her responses. offer more in-depth assessment than others. Some as
with more standardized measures. The depth in wh
cognition is assessed may be dependent on the type
facility. In short-term acute settings and nursing hom
TEAM APPROACH cognition may be assessed through observation of
patient's performance in activities of daily living (ADL
The role of each team member is significant in deciding through other routine assessments. Often the practitio
a discipline's role in cognitive assessment. The team mem is limited in assessment time Owing to facility guideli
ber's role will influence the type and amount of assessment reimbursement, or discharge plans. Longer-term p
a particular diScipline performs. For example, when neu grams, such as home health, outpatient settings, and m
ropsychologists are readily available in a post-acute brain comprehensive nursing homes, may allow for more t
injury setting, the occupational therapist may perform spent in the assessment of cognition. The programs
fewer standardized tests and may rely more on discussions generally have the flexibility to spend the greatest t
with team members. In other brain injury or rehabilitation assessing cognition are inpatient rehabilitation and p
settings, the information from testing in OT and speech acute rehabilitation programs. Other, shorter-term p
therapy, as well as observations from the entire team, may grams, as mentioned, may assess cognition on a m
trigger the need for further neuropsychological assess intensive scale; however, this appears to be less freque
ment. Many standardized assessments are permitted to be seen.
The neuropsychology literature offers three basic ap
proaches to cognitive assessment (Golden, 1981). These
approaches were designed primarily for the neuropsy ASSESSMENT ENVIRONMENT
chologist for the identification and diagnosis of cognitive
problems. However, they provide insight into how thera The environment in which a patient is assessed also
pists may structure their assessments within their own influences the patient's response on a cognitive assessmen
settings. One approach is the "standard battery ap (Zoltan, 1990). There may be differences in performance
proach." All patients are administered the same test from morning to afternoon and differences influenced by
battery to assess all major skill areas. This approach has the type of environment, quiet or busy. It is important when
merits, as it may identify an area of cognitive impairment assessing to be consistent with the environment in retesting
not thought to be a problem for the patient. This approach situations. Most assessments recommend a quiet, nondis
also allows a comparison among patients. A limitation to tracting environment in which the patient is not drawn off
this approach is that the time required for assessment is task by other noises or movements in the room. At times
usually lengthy. A second approach is the "flexible ap it may be important to assess a patient in a busy environ
proach." With this approach, the testing is tailored to the ment. Intentionally conducting an assessment in a noisy
individual, based on the clinician's impression of the patient environment can be beneficial with the patient who needs
and where deficits are expected to be found. Although to return to work in a noisy and busy work environment or
beneficial due to being individualized, its limitation is that because information about the patient and his or her ability
some areas of cognitive functioning may be overlooked. to handle these distractions is prOvided. When assessing, i
The third approach is a "combination approach." It is important to document the type of environment in which
involves a core of testing that all patients would receive, the assessment was conducted.
coupled with other tests deemed important by the clinician.
Some authors in the neuropsychology literature feel that
the test scores are less important in the assessment than the
process that the patient undertakes to complete the FACTORS INFLUENCING ASSESSMENT
assessment (Feher et aI., 1989). This has also been
supported by the idea that some cognitive skills such as Prior to implementing any cognitive assessment it is
insight and planning are not able to be quantitatively important to assess other areas of function that may have
assessed. Strub and Black (1977) suggest that mental status an impact on the patient's responses, including an assess
assessments should be structured hierarchically so that ment of visual and motor skills (Morse, 1986). Othe
deficits of performance of base functions (attention and factors that may affect performance on cognitive assess
language) can be noted early in the assessment process. ments include motivation, fatigue, fear of testing, and
Finding underlying deficits is useful because higher-level medications (Golden, 1981). Age should be accounted for
tests may not be administered, or the results of the base in the interpretation of assessments of cognition. As they
deficits may need to be taken into account when interpret grow older, people tend to do less well on these types o
ing higher-level functions. assessments. In some populations, such as those with TBI
Many OT programs utilize a combination approach. and eVA, motor function may be a factor to consider in tes
eVA patients, for example, may all undergo the same basic interpretation. Nonmotor assessments or comments re
screen, but specific assessment in areas of deficit are lated to motor functioning on cognitive assessments for
addressed, as noted. One advantage that the occupational persons with ataxia and other types of incoordination
therapist may have over the neuropsychologist, who may persons using the nondominant extremity, and patients
only administer tests, is that the occupational therapist has with no upper extremity motor function should be available
the benefit of observing the patient in functional occupa and need to be documented with the findings.
tions. This may guide the therapist in test selection. Also,
the occupational therapist is usually looking for quantitative
data to support the suspected deficit areas that he or she
observed and to establish a baseline for measuring change. COMPONENTS OF ASSESSMENT
Assessment of patients with dementia is necessary in
many situations. Most assessments have been developed Attention
for the patient with mild to moderate dementia. Assess
ments and studies for the patient with severe dementia are The ability to attend and concentrate forms the basis for
not as Widely available (Saxton & Swihart, 1989). In many, if not all, cognitive functions. The many differen
addition, there is little correlation between results on attentional processes work together to process informa
neuropsychological tests and the ability to carry out tion (Toglia, 1993a). These processes include alertness o
336 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
arousal, the ability to select stimuli, the ability to span Set shifting is the ability to cease direct attention to
attention, the ability to shift attention, and information task and give attention to another. Many complex
processing (Gloag, 1985). The reticular formation and cesses occur during this function: the ability to initiate
brain stem, which make up Luria's first brain block, are the shift, the ability to disengage from one task or resp
basic neuroanatomic structures of attentional processes. inhibition, and the ability to engage in another focu
The ability to attend is necessary for all levels of information attention. One example of set shifting abilities is wh
analysis and recall. Attention is often thought of as an secretary is typing at the computer, the telephone ri
ongoing process rather than a function performed in and the secretary shifts immediately from the comp
isolation (Adamovich et aI., 1985). Attention involves occupation to that of answering the telephone. Once
intense concentration, the ability to inhibit distracters, and phone call is completed, the secretary is able to retur
the ability to shift locus of attention according to internal the typing occupation again, immediately picking up w
and external demands. Arousal, or alertness, is defined as he or she left off.
the general readiness of the nervous system to receive and The speed of information processing is usually incl
act on information. It is seen as an involuntary act of the with attentional subskills. It is defined as the need to ch
nervous system and is dependent on incoming sensory or group information into smaller bits to be handled by
information. Arousal tends to alter the overall level of nervous system. It may also be described as the nerv
responsiveness of the entire nervous system (Abreu and system's way of making use of relevant cues and igno
Toglia, 1987). The normal level of arousal or alertness others so it can concentrate on critical features. It is
changes throughout the day. These changes generally individuals attach to novel stimuli, apply meaning to in
affect the speed at which an individual is aware of and and organize a response for performance. Informa
responds to stimuli and not the processing itself. For processing usually occurs very quickly. When tasks bec
example, it is often easier to attend to a lecture early in the too difficult or when they are too easy, attention decrea
morning when a conference is beginning than in the middle An example of delayed processing time may be when
of the day after lunch. Structures that are most involved patient with a eVA sits dressing himself or herself but t
with arousal or alertness are the reticular formation and the an excessive amount of time to orient himself or herse
thalamic nuclei. the clothing. It takes him or her longer to remember
Selecting which stimulus to attend to is influenced by the to dress because he or she must adapt to a new one-han
reticular activating system, as it filters sensory input and dressing technique.
affects our state of arousal. We have only a limited capacity
for attention; therefore we need to screen out what not to
PROBLEMS
attend to. Inputs are processed both consciously and
unconsciously (DeGangi & Porges, 1991). Selective atten Basically, any lesion in the brain affects attent
tion may be directed externally to the individual or inter Problems with attention affect our ability to tune
nally, such as with memory representations of past events. important elements in the environment, to process in
When a stimulus is registered, the nervous system works to mation for learning, and to engage in occupations
match the stimulus with past memories. When the stimulus Gangi & Porges, 1991). Deficits of attention may be
is novel, more attention is focused on the stimulus. If the with cerebral contusions, ischemic vascular lesions
stimulus is not new and is recognized then attention can be mors, TBI, and hypoxia (Adamovich et al., 1985). A
shifted away from the stimulus, and there is a greater tion problems are also seen with degenerative disor
capacity to bring other information into the conscious such as multiple sclerosis, Alzheimer's disease, schizop
realm. For example, in many indoor lecture rooms, the nia, and affective disorders (Toglia, 1993a).
sounds of the heating system and people speaking softly Attention deficits include:
are screened out to allow individuals to attend to the • Distractibility
presenter. The occasional door opening or book falling to • Perseveration (inability to set shift)
the floor distracts the student's attention momentarily as a • Decreased concentration
novel stimulus; however, his or her attention usually returns • Slowness in information processing
to the speaker quickly. • Increased confusion
leagues' (1964) patients with brain damage tended to remember a phone number out of the phone book
underestimate the duration of 1 minute, and 67 percent of long enough to dial the number. Once the number has
Coheen's subjects with organic brain damage also made dialed, the importance of remembering the numb
obvious errors in time estimation, as compared with only 6 negated, and it is not easily remembered.
percent of normals making errors. The Test of Orientation Long-term memory (LTM) is the ability to remembe
of Rehabilitation Patients is standardized and uses infor longer periods. Most authors do not agree on how
mation pertinent to rehabilitation settings. Many standard LTM is. There is not a limited capacity in LTM (To
ized assessments have orientation as components of their 1993a). Long-term memory involves the ability to
assessment. These include material as it is transferred from short- to long-term sto
• Bay Area Functional Performance Evaluation and the ability to search, locate, and retrieve these ch
• Cognitive Assessment of Minnesota of information so they may be worked with. O
• Cognitive Behavior Rating Scales described as remote memory, LTM includes events
• Loewenstein Occupational Therapy Cognitive As facts learned in the past, such as family vacations as a
sessment or school friends.
• Short Portable Mental Status Questionnaire Other types of memory are discussed in the litera
• Mini-Mental State Exam (Toglia, 1993b):
• Middlesex Elderly Assessment of Mental State • Episodic memory: memory for events
• Neurobehavioral Cognitive Status Examination • Semantic memory: memory encompassing rules
• Severe Impairment Battery meanings, and concepts
• Procedural memory: memory for sequence
• Prospective memory: ability to remember to do
Mamory something in the future
• Declarative memory: memory of facts and even
Memory is the ability to take in, store, and retrieve involves semantic and episodic memory
information (Morse, 1986). Memory has also been defined
as the ability to learn new information and to retrieve
PROBLEMS
previously learned information (Auerbach, 1986). Loring
and others (1989) describe memory as the stored percep Amnesia is often used to describe memory def
tual experiences that can be brought to consciousness to Patients with amnesia may demonstrate anterograde
alter ·future thought and behavior. Memory can be divided nesia or retrograde amnesia, and many also confab
into memorizing, storing, and retrieving. During the when faced with questions they do not know how
memorizing stage, the person takes in information through respond to (Butters & Miliotis, 1985). Many patients
the appropriate sensory modality, where it is registered in amnesia have generally intact intellectual functions; h
short-term memory (Strub & Black, 1977). The informa ever, cognitive performance may not be intact. R
tion can then be stored in long-term memory when it is grade amnesia is difficulty remembering events that
worked with in some manner, such as through repetition or place before the onset of the amnesia. This is usual
associating the new information with previously stored relation to events that took place more recent to the o
information. The act of storing information is an active of amnesia. Longer-term, older memory is generally i
process. The ability to retrieve is also an active process and (Nissen, 1986). Anterograde amnesia is difficulty lear
depends on the efficiency of the first two steps. Disruption and remembering new information since the onse
at any step influences a person's ability to remember. amnesia. Anterograde amnesia may be global or mat
Memory is encompassed in the secondary and tertiary specific.
zones of the occipital, parietal, and temporal lobes of Brain lesions almost anywhere in the cerebrum ma
Luria's second brain block. The types of memory may fect memory (Loring et aI., 1989). Deficits in memory
include immediate, short term, long term, remote, antero be a result of the encoding stage or retrieval stag
grade, retrograde, visual, auditory, and kinesthetic. memory, and this is why so many neuroanatomic com
Short-term memory (STM) is also referred to as working nents may be implicated. Memory deficits are a prim
memory. Short-term memory is a capacity-limited system problem in TBI survivors (Brooks, 1983; Gloag, 19
in which there is a small amount of information that can be Patients with TBI also have an increased complain
taken in to work with. Capacity for STM is approximately memory deficits as the duration of posttraumatic amn
seven items of information (Loring et aI., 1989). More increases. In traumatic amnesia, memory disorders
information can be recalled in STM if it is put into chunks, often associated with temporal lobe damage (Hecae
or the information is grouped. Short-term memory may Albert, 1978). Other types of disorders in which amne
include recalling a phone number to dial. People have a a symptom include Alzheimer's disease, CVA, Korsak
limited capacity to remember a great quantity of informa syndrome in alcoholics, and progressive degenerative
tion, and the ability to remember the information decreases mentia (Butters & Miliotis, 1985). Patients with Korsak
over time after it is no longer as useful. For example, you syndrome tend to lose the ability to learn new informa
Onset of memory deficits in the patient with dementia is ASSESSMENT OF MEMORY
often insidious (Strub & Black, 1977), with primary
Test Component Assessed
caregivers having a difficult time establishing a date as to
when the memory problems started . Depressed patients Autobiographical Memory Inter- Personal , retrograde memor
often appear to have a memory disorder; however, when view
tested they are able to provide appropriate responses to Contextual Memory Test Recall and metamemory
Continuous Visual Memory Test Visual memory
memory questions . Squire and Cohen (1984) note several Doors and People Recall and recognition, visua
theories to describe the deficit of amnesia. Breakdown in and auditory
the system could occur at various times in the memory Rey Complex Figure Test Visual memory
Rivermead Behaviora l Memory Recall and recognition , visua
process. Amnesia could be a disorder of encoding, with the Test and auditory, functional ta
problem being the type of strategy utilized to encode
information. It could be a storage disorder in how the
learned information is retained and the length of time
Table 12-11. (All assessments are described in the ch
between training and testing. Lastly, amnesia has been
ter.) Other cognitive assessments with memory com
discussed as a disorder of retrieval. Squire and Cohen cite
nents include the Bay Area Functional Performance Ev
several examples from their research and that of others that
ation, Dementia Rating Scale, Loewenstein Occupatio
show that patients with memory loss can learn and retain
Therapy Cognitive Assessment, Short Portable Me
skills. Some amnesic patients, even though they are not
Status Questionnaire, Mini-Mental State Examinat
able to verbalize memory retention, are able to demon
Middlesex Elderly Assessment of Mental State , Neuro
strate procedural memory. Studies have shown that pa
havior Cognitive Status Examination, Cognitive Beha
tients with global amnesia learned mirror tracing, solved
Rating Scale , Cognitive Assessment of Minnesota,
puzzles, and performed tactile mazes with knowledge of
Severe Impairment Battery.
rules and with increased speed over trials. This may be
despite patients' insistence they had not learned the task
preViously. Patients with dementia often have difficulty Executive Functions
with immediate memory owing to decreased attention and
general cortical atrophy (Strub & Black, 1977). Alzhei Executive functions include the ability to organize
mer's patients often demonstrate deficits with new learn carry out speCific occupations-more speCifically,
ing. Patients with head injury demonstrate an acute loss of ability to make decisions, organize, sequence, prob'l
memory. Problems are more evident in patients with solve, generalize, and demonstrate judgment. Luria's t
temporal lobe injury. brain block, composed of the prefrontal lobes, is prima
responsible for these executive functions, although
damage may be in other, lower levels of the brain (Mo
ASSESSMENT
1986).
Instruments designed for assessment of memory should Organization is the ability to sequence and plan the s
assess as many types of memory as possible. This infor to an occupation. More specifically, organization is
mation is helpful in documenting the specific nature of the ability to break down an occupation into its compon
deficit and assisting in the intervention process. Knowledge parts or steps and structure or complete them in the pro
of the individual's weaknesses, as well as strengths, allows sequence. Problem solving involves many steps: the ab
the practitioner to capitalize on the most effective type of to recognize an error, the ability to generate solutions,
memory the patient may have available. Spreen and ability to select the proper solution, the ability to implem
Strauss (1991) also note that the assessment of memory a solution, and the ability to assess the effectiveness
should be comprehensive. They state that assessment solution. This process may be repeated as needed. G
should test immediate and short-term memory, how effec eralization is taking information learned in one situa
tivelya patient retrieves stored information, and the ability and applying it to another situation that is similar
to remember new information. They suggest that memory different in some manner.
needs to be assessed in both the verbal and nonverbal Judgment is the ability to anticipate consequences (F
modes, along with looking at recall versus recognition. et aI., 1989). Judgment has also been assumed to inc
Many nonstandardized ways of assessing memory have the ability to plan , problem-solve, and reason. What en
been described by Strub and Black (1977). These include good judgment differs, depending on a person's a
orientation, digit repetition , remote memory of events in culture, education, and personal characteristics. Ins
the patient's life, recall of unrelated words , recall of a story, into deficits may also be included in this area. Others
visual memory (visual design reproduction), and paired judgment is no different than insight. Insight has b
associate learning. There are also many standardized defined as one's conscious and unconscious knowledg
assessments available for assessment of memory. Refer to one's behavior and whether a patient is able to recog
. "'- --.'1"""'.
340 UNIT THREE-ASSESSMENT OF CENcTRAL NERVOUS SYSTIEM FUNCTION OF THE ADULT
his or her own symptoms (Feher et al., 1989). If a patient when errors are made or be able to generate approp
is not aware that he or she is having a problem, then it is solutions to implement. Attention to safety, in relatio
difficult, if not impossible, to have the patient work on judgment, may be impaired. Patients with brain dam
remediating the problem. Bruce (1994) states that insight often demonstrate decreased insight into their def
is dependent on a person 's knowledge of his or her own resulting in their involving themselves in situations that
cognition, which is known as metacognition . Metacogni are not able to handle cognitively, including basic skil
tion influences all of a person's cognitive and perceptual independent living, vocational pursuits, and driving.
processes. In patients with dementia, problem-solving abilities
Metacognition is the means whereby we are able to often the most vulnerable (Zemke, 1994). Later in dem
predict our performance on a given task. Bruce (1994) tia, the ability to perform familiar tasks decreases . Co
feels that the best assessment of metacognition is through tive problems in the area of executive function are see
self-report and interview. Toglia (1993a) has described patients with psychiatric problems. Poor decision ma
methods to work on these metacognitive processes to and goal setting is seen in patients with affective disord
facilitate better understanding of a person's cognitive especially in the manic phase. Self-monitoring is al
functioning. problem . The patient with depression may not m
decisions readily and may demonstrate decreased org
zation. Patients with schizophrenia may demonstrate p
PROBLEMS
lems becoming engaged in a task and with self-monito
Patients with brain damage with a variety of etiologies An example of a patient with executive function p
often appear confused or unmotivated. This has been lems is a 45-year-old woman with a parietal occipital
described as more of a problem with executive function CVA. The patient, prior to her CVA, was manager
than confusion (Zemke, 1994). Lezak (1985) has noted large department store. She scored within normal limit
that disorders of executive functioning disrupt perfor basic cognitive and perceptual assessments presente
mance in planning, volition, quality control of perfor OT. When presented with the Rey Complex Figure
mance , and self-regulation during performance. Self (original version), her drawing reproduction looked q
regulation includes initiation, shifting to and from different accurate and actually scored 32 of 34 points, placing h
activities, and problem solving. Patients with brain damage the 40th percentile. Further investigation of how
may not demonstrate the ability to organize occupations completed the drawing, following a procedure docume
sufficiently to initiate them or sequence them properly to in the test section of this chapter, demonstrated defici
completion. Impersistence or the inability to work at a task executive functioning . Her approach to the reproduc
until completion may be seen . Patients may not recognize of the figure was piecemeal and fragmented (Fig. 12-
3
3
(;
D
~__~6______------~D
Lezak (1985) notes that few assessments have been Therapy Cognitive
developed to assess executive functioning , The Wisconsin A ssessment
according to specified piles. The examiner tells the patient tus Examination
whether he or she is correct. The patient must determine Raven 's Progressive Matrices Ability to formulate constructs
shape, or number. Toglia (1993b) has designed an assess Short Category Test Problem solVing and abstract
ships, organize, and solve problems. Other informal as cognitive strategies
AREA OF ASSESSMENT
Executive Mental
Attention Functioning Status Memory Orientation
-: .~ .
requires the ability to learn new information. The assess ACL-PS was found to significantly distingUish between
ments developed by Allen include The Allen Cognitive two groups.
Level Test (leather lacing tool), both original and enlarged A large version of the ACL (LACL) has been introdu
version; Routine Task Inventory; Cognitive Performance and is commercially available. The LACL uses a shoel
Test; and, most recently, the Allen Diagnostic Module. for the running stitch and a wider lace painted white on o
Allen Cognitive Level Test. The Allen Cognitive Level Test side for the whip and cordovan stitches. The leather pi
(ACL) was developed for use in 1973 (Allen et aI., 1992b). is also enlarged with larger holes. These changes w
Validity and reliability studies have been conducted on made to compensate for decreased vision, especially in
several versions including the Allen Cognitive Level geriatric population. Initial studies demonstrate Signific
Original (ACL-O), Allen Cognitive Level-Expanded correlations among the LACL and the Mini-Mental St
(ACL-E), and the Allen Cognitive Level-Problem Solving Exam and the Routine Task Inventory. The assessme
(ACL-PS). are able to be modified to compensate for other proble
The ACL-0 is a quick assessment of a patient's ability to such as one-handed performance and tremors. Work
learn. It has been found to provide an estimate of a patient's also being completed on a verbal assessment for patie
ability to perform visuomotor tasks. The patient is asked to who have no use of their hands.
perform several different types of stitches on a leather Although not an assessment developed by Allen,
lacing sample, including a running stitch, whip stitch, and Kitchen Task Assessment is Similar. It is felt to go beyo
single cordovan stitch. The test utilizes a five-pOint scale the ACL, as it also incorporates the performance with
and measures patients' abilities in levels 2 through 6. Allen highest amount of cues needed (Baum & Edwards, 199
(1985) demonstrated high interrater reliability with the The Kitchen Task Assessment looks at the cognitive sk
ACL-O. She considered the assessment valid (r 0.76) for of initiation, organization, sequencing, task performan
placing patients in groups with patients with similar judgment and safety, and task completion. For m
cognitive levels. Concurrent validity is r = 0.53 on admis information, contact S & S Worldwide, P.O. Box 5
sion when related to the Brief Psychiatric Rating Scale and Colchester, CT 06415-0513.
r = 0.46 with the Block Design of the Wechsler Adult Cognitive Performance Test. The Cognitive Performa
Intelligence Scale (WAIS). The ACL-O was replaced by Test (CPT) was developed to assess the functional leve
other versions Owing to lack of sensitivity and other patients with Alzheimer's disease and is in a standardi
problems (Allen et aI., 1992a). The ACL-E was developed ADL format (Allen et at., 1992b). The CPT utilizes All
with a lengthened score sheet, and a twist in the leather cognitive levels, with the focus of the assessment being
lacing was included in the assessment, where previously it the information processing deficits the patient dem
had been left to chance. Improved normative information strates in common functional occupations. The ta
resulted from these changes. Significant correlations were themselves, though described as having face validity,
found between the ACL and the revised WAIS (WAIS-R) not as important as the way the patient deals with
Block Design, Object Assembly, Picture Arrangement, increasing complexity of the demands of the occupati
Digit Symbols and Digit Span, Performance Scale, Verbal The CPT has been utilized to document change over t
Scale, and Full Scale IQ. The ACL was again updated in in patients with Alzheimer's disease and to predic
1990, and the latest version, the ACL-90, is commercially patient's ability to function in various contexts. The test w
available. Changes included three versus two stitches developed to measure actual patient performance, ver
completed by the patient to make certain that the patient the use of caregiver rating scales and the Mini-Mental St
actually learns the stitch versus completing it by chance. Exam.
Another change to the ACL-90 allows the examiner to The assessment utilizes the ADL tasks of dreSS
prompt the patient as he or she completes the test. shopping, making toast, using the telephone, washing,
The ACL-PS was developed in 1991 to assess more traveling. Everyday tasks were chosen, as anxiety tend
specifically the skills of deduction, planning, and problem increase with unfamiliar tasks in persons with demen
solving (Josman & Katz, 1991). The ACL-PS alters the The equipment and administration of the test are standa
sequence of directions for the ACL. The examiner asks ized. There is a system of providing and eliminating sens
the patient to replicate the lacing stitches by first looking at cues, depending on the patient's performance. An
the completed stitches. If the patient is unable to do the ample of a test item is "The patient is asked to choose w
stitches by looking at them, then verbal instructions are he or she would wear if he or she were to go outside o
given, and then demonstration may be prOVided. Initial cold, rainy day." The patient must choose from an arra
research on a small sample of adolescents with psychiat men's and women's clothing, including raincoats, a rob
ric disorders found Significant correlations between the sheer scarf, a straw hat, and a rain scarf.
ACL-PS and the Loewenstein Occupational Therapy Cog It is felt that the patient should score Similarly on all
nitive Assessment (LOTCA) (Katz & Heimann, 1990). Nor tasks; however, the overall cumulative score is utilized
mal adolescents were also given both tests. All of the nor interpretation of performance. The assessment has b
mal adolescents and 47 percent of the adolescents with found not valid for identifying higher-level ADL per
psychiatric diagnoses completed the ACL at level 6. The mance deficits in patients at level 6. Results from the t
(IADL), and need for supervision. A patient with a score of patient recall facts from his or her past, such as teache
30 at level 5 may perform basic ADL, may have difficulty names or place of wedding. The autobiographic incide
with planning IADL and therefore may make errors, and schedule asks the patient to recall three incidents fro
may be able to live alone with occasional checks and some childhood, adulthood, and his or her current life. Scores a
assistance for IADL. A patient at level 3 with a total score given for full and partial recall. Memories are validated
of 18 would demonstrate very few IADL abilities, could talking with friends or relatives.
perform ADL with set-up and direction, and would need The AMI was found to discriminate between controls a
24-hour supervision. Initial studies demonstrated a steady patients with amnesia (due to TBI, CVA, or dementia) in
decline in CPT scores over a 4-year period with Alzhei small sample. Further research is needed. For mo
mer's patients. information, contact National Rehabilitation Servic
Routine Task Inventory. The Routine Task Inventory (RTI) Northern Speech Services, Inc., 117 North Elm Stre
is a standardized way of documenting and judging behavior P.O. Box 1247, Gaylord, MI 49735.
using the Allen cognitive levels format (Allen et aI., 1992b).
The RTI describes behavior of the patient with eight
BAY AREA FUNCTIONAL PERFORMANCE
activities under five general areas:
EVALUATION
• Self-awareness disability-includes problems with
basic self-care: tasks an individual performs to ap The Bay Area Functional Performance Evaluati
pear clean, attractive, and healthy (BaFPE) was developed in 1977 and 1978 as an asse
• Situational awareness disability-centered around ment of daily functional performance of patients w
problems with daily living at home and in the com psychiatric diagnoses (Houston et aI., 1989). It was revis
munity, such as obtaining food and housekeeping in 1987. The assessment grew out of a desire to asse
• Occupational role disability-includes problems with psychiatric patients' functioning by quantifying behavior
the ability to organize and perform primary role oc how they relate to objects and to other people in th
cupations, such as work and pacing self environment. The authors feel that behavior is a product
• Social role disability-involves problems meeting a patient's psychological processes. The BaFPE compris
social expectations, including communicating and two subtests: the Task Oriented Assessment (TOA) and t
follOwing instructions Social Interaction Scale (SIS). The TOA is made up of f
The assessment provides sample questions that may be tasks: sorting by different categories, money and mark
asked of the patient or caregiver when direct observation is ing, drawing a house plan, block design, and drawing
not possible. Heimann and others (1989) describe the RTI person. There are 10 skills assessed through the five task
as one way to examine the impact that neurologic and These include the cognitive skills of memory for instru
psychiatric disorders have on everyday ADL functions. The tions, organization of time and materials, attention spa
authors believe the use of functional performance assists in and ability to abstract. Performance components inclu
defining OT's role in some settings and identifies a patient's the patients' ability to complete the task, their efficienc
problem areas to provide guidelines for his or her level of and errors. The affective component includes motivatio
care. A correlation between the RTI and the Mini-Mental frustration tolerance, a behavioral impression, and se
State Exam was found that confirms a decline in functional confidence. Patients are rated on a scale from 1 to 4 poin
performance as mental impairment increases. 1 being marked dysfunctional, and 4, functional or appr
priate. On the SIS, the clinician rates the behavior of t
patient in five specified social situations, ranging from o
AUTOBIOGRAPHICAL MEMORY INTERVIEW
on one to an unstructured group. The components of soc
The Autobiographical Memory Interview (AMI) is an as behavior assessed include response to authority, verb
sessment of a patient's remote personal memory, which communication, psychomotor behavior, ability to wo
may be affected with retrograde amnesia (Kopelman et aI., with others in a group, social behavior, group participatio
1990). The patient is engaged in a semistructured interview and independence. The patients are rated on a five-po
to assess his or her recall of facts and speCific incidences in rating scale.
his or her past. Autobiographic memory is not generally More research has been conducted on the origin
assessed in other standardized tests. The assessment looks BaFPE than on the revised version, which was complet
at the three time bands of childhood, early adulthood, and several years later and contains significant changes. Re
recent memory. The developers of the test believe that ability improved with the revised version. Validity stud
assessment of autobiographic memory is important for the have been primarily conducted on the original BaFPE a
global understanding of a patient's memory impairment, to have been inconclusive. In one study by Klyczek & Ma
assist with counseling, and to aid in intervention. The test (1990), the BaFPE showed low correlations between t
was developed for patients 18 years to old age. It can be TOA and the Mental Deficiency Adaptive Behavior Sc
used with disorders in which memory is a problem, such as (ABS). Some Significant correlations were found betwe
346 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
parts of the BaFPE and the ABS. The authors believed that tion), memory disorder, and dementia. Scores are obtai
the BaFPE was helpful in learning about the patients and from observation by a reliable person, in some instance
how they approached tasks. Houston and colleagues family member. The patient is rated on a five-pOint sc
(1989) found that therapists working in psychiatry liked the from 1 ("not at all like this person" or "this person's abi
BaFPE but found it too long. A training course has been is very low") to 5 ("very much like this person" or "t
available to teach clinicians how to administer and score the person's ability is very high"). The CBRS can be comple
BaFPE, which the authors found beneficial. The BaFPE is in 15 to 20 minutes. Raw scores are transformed i
available from Consulting Psychologists Press, 3830 E. T-scores and percentiles. A profile of the patient's fu
Bayshore Road, Palo Alto, CA 94303, (415) 969-8901. tioning in all areas is graphed so that strengths a
weaknesses may be identified.
Williams (1987) states that the CBRS are best utili
COGNITIVE ASSESSMENT OF MINNESOTA
with patients with dementia. The test was developed
The Cognitive Assessment of Minnesota (CAM) was de creating items from interviews with families and from
veloped by occupational therapists to assess a broad range literature that is pertinent to patients with dementia a
of cognitive abilities in persons with brain damage (Rustad depression. The original number of items was scaled do
et aI., 1993). The CAM was developed as a screening tool by a group of 10 neuropsychologists. Some of the in
from a rehabilitation framework rather than as a diagnostic research of the CBRS suggests that the tool may discri
tool for patients with psychiatric diagnoses. Its authors de nate between patients with dementia and patients w
signed the test to quantify the presence of cognitive deficits depression. Family members were found to be relia
for intervention. The test consists of the manual, score raters. Norms are based on a sample of 688 peop
sheet, and some common objects, such as paper, a pencil, Research has been proposed on patients with TBI a
blocks, and a toothbrush. It takes approximately 40 min CVA. For more information, contact Psychological Asse
utes to administer. Subtests of the CAM include attention, ment Resources, Inc., P.O. Box 998, Odessa, FL 335
memory, visual neglect, following directions, orientation,
temporal awareness, matching, object identification, visual
CONTEXTUAL MEMORY TEST
and auditory memory and sequencing, recall and recogni
tion, money skills, math skills, foresight and planning, The Contextual Memory Test (CMT) was developed
safety and judgment, concrete problem solving, and ab an occupational therapist to assess awareness of mem
stract reasoning. The authors considered the test appropri deficits (Toglia, 1993b). It was designed to be used wit
ate for patients at Rancho Level IV and higher and for range of diagnoses, including CVA, TBI, dementia, depr
patients who have had a CVA. The CAM is not appropriate sion, schizophrenia, and other neurologic disorders. T
for patients with severe perceptual deficits, visual acuity CMT assesses a patient's metamemory, or awareness
defiCits, and aphasia. Scoring varies based on the subtest. his or her memory capabilities, as well as a patie
Scores for each area are plotted on a graph with a break memory capacity, recall, and strategy use. The CMT
down of no impairment to severe impairment rankings. intended as an adjunct to other, more conventio
Norms were developed on administration of the CAM to memory tests. The test consists of the manual, two la
200 normal subjects, aged 18 to 70. There were no effects presentation cards, 40 recognition cards, and a scor
from age or level of education. Interrater reliability was booklet. Two versions of the test, the restaurant vers
demonstrated. Test-retest reliability was demonstrated with and the morning version, allow for reassessment. In
retesting in 1 week. Validity was established with 200 first part of the test, the patient is presented with a card
normal patients and 39 patients with brain injury and right which are 20 line drawings (Fig. 12-26). The patient is
CVA. The CAM correctly identified over 95 percent of the told that the items on the card relate to a theme or conte
patients with cognitive impairment. Significant correla The patient is asked to study the card and try to remem
tions have been demonstrated for the CAM with the as many items as possible. In the second part of the t
Porteus Maze Test and the Mini-Mental State Exam. For the patient is provided with the context in which
more information, contact Therapy Skill Builders, 3830 pictures are related. This is done to determine if provid
East Bellevue, P.O. Box 42050-4SW, Tucson, AZ 85733. contextual cues improves the patient's performance a
his or her awareness of his or her performance. T
patient is asked to recall items from each part of the t
COGNITIVE BEHAVIOR RATING SCALES
If on part two the patient continues to be unable to rec
The Cognitive Behavior Rating Scales (CBRS) were then the recognition cards may be used. Delayed re
developed to formalize observation of cognitive abilities in may also be assessed after approximately 20 minu
patients who are not testable by other test batteries Prior to' the presentation of the stimulus card and a
(Williams, 1987). The CBRS comprise 116 items in the the recall, the patient is asked a series of questions ab
areas of language deficit, apraxia, disorientation, agitation, his or her perception of his or her memory and awaren
need for routine, depression, higher cognitive deficits of strategies utilized to remember.
(memory, abstract reasoning, language, and motor execu Several scores are obtained: recall, recognition, awa
For more information on the CMT, contact Therapy Sk
Builders, 3830 East Bellevue, P.O. Box 42050-4SW
Tucson, AZ 85733.
~ d" -:
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. ~~,,::.;;:cc ,0'
~ ~~~-
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348 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
do not need to complete them. Total possible score is 144. subtests in four areas: orientation, perception, visuomo
A score of 123 or less has often been reported as a cutoff organization, and thinking operations (Itzkovich et
score. This is based on studies by Montgomery and Costa 1990). It was developed in 1974 since use of neurop
in 1983 in which 62 percent of patients with dementia, 36 chological assessments in OT were considered inadequ
percent of patients with focal brain damage, and no for planning rehabilitation intervention. The LOTCA
depressed patients were correctly classified. The scores can designed to identify the patient's assets and limitation
be interpreted as T-scores and converted to a percentile. the areas listed on various levels of complexity, enable g
There is a section on the score sheet to score the percentile setting, and serve as a screening tool for further ass
for the entire test, as well as for the individual subscales. ment. The LOTCA was based on the principles of L
Norms are based on healthy persons aged 65 to 81. and of Piaget.
Schmitt and coworkers (1989) note qualitative inequality The LOTCA can be administered in about 45 min
between the subscales, with some subscales, such as and may be completed during two or three sessions
construction, adding only six points to the total score and addition to the standard procedure, it contains a proced
others contributing as many as 39 points to the total score. for assessment of patients with aphasia.
Fortunately, the tendency has been to interpret the data on The LOTCA was normed on 55 adult subjects aged
different subtests instead of using the scale in its totality to 70 and on 240 children aged 6 to 12. In standardiz
(Christensen, 1989). For more information, contact Psy procedures, Significant differences were found in the sco
chological Assessment Resources, Inc., P.O. Box 998, in relation to years of education. The LOTCA was foun
Odessa, FL 33556. be a valid test of perceptual and cognitive function
differentiate between normals and patients with CVA
TBI. The results were more valid on initial assessment t
DOORS AND PEOPLE TEST
on reassessment 2 months later. Criterion-related vali
The Doors and People Test (DPT) was designed to assess was fair when the visuomotor organization and the Bl
memory. The authors, Baddeley and associates (1994) Design subtest of the Weschsler Adult Intelligence S
believe that the assessment goes beyond functional tests were correlated. No other subcomponents of the ass
such as the RBMT to also assess the nature of the ment have been validated. For more information, con
underlying deficit. The test was designed to assess visual Western Psychological Services, 12031 Wilshire Bo
and verbal memory through both recognition and recall. It vard, Los Angeles, CA 90025-1251.
was also designed to be a short, simple test that is not
stressful and to eliminate deficits due to perceptual prob
MINI-MENTAL STATE EXAM
lems. Furthermore, the authors wanted the assessment to
include learning and forgetting measures. The DPT con The Mini-Mental State Exam (MMSE) is another ass
sists of 4 people photographs, 12 door photographs, and ment of the cognitive aspects of mental functions and
4 simple drawings. The patient is asked to recall the names devised in 1975 (Folstein et al., 1975). It was develope
of the four people, both immediately and at delayed recall. be used with psychiatric, neurologic, and general med
The doors are presented for a visual recognition test. The patients (Naugle & Kawczak, 1989). The MMSE invo
shapes are presented for a visual recall, both immediately the ability to read, verbalize, draw, and write. The ass
and delayed. The test is scored, and an overall score is ment can be modified by utilizing larger print if the sub
calculated. The score can be broken down to assess the is visually impaired. The assessment is not timed.
patient's visual versus verbal memory and recall versus MMSE assesses orientation, the ability to follow verbal
recognition. The authors note that the subscale scores written directions, attention, recall, language, read
should lead the examiner to further assessment, as the writing, and copying. It has two sections, one assess
subtest size is limited. Raw scores can be translated to verbal responses and the other assessing the ability
scaled scores and percentiles. follow written and verba1commands (Folstein et al., 197
Studies during the development of the test suggest In the second section, the subject is asked to copy a des
validity for patients with Alzheimer's disease, CVA, and write a sentence, and follow written directions. So
schizophrenia. The authors believe that different patterns criticize the directions for the MMSE, which allow the t
of memory deficit are demonstrated by the various diag between recall of objects to vary based on the patie
noses; however, more research is needed. For more ability to answer the previous question in a timely man
information, contact National Rehabilitation Services, (Schmitt et ai, 1989).
Northern Speech Services, Inc., 117 North Elm Street, The MMSE was successful in distinguishing patients w
P.O. Box 1247, Gaylord, MI49735. cognitive impairment from those without. Using a cuto
20 of 30 points, the test successfully distinguished pati
with dementia and depression with cognitive impairm
LOEWENSTEIN OCCUPATIONAL THERAPY
from normals and persons with depression only. Score
COGNITIVE ASSESSMENT
less than 20 indicate the need for further investigation
The Loewenstein Occupational Therapy Cognitive As the patient's cognitive status. The MMSE correlated hig
sessment (LOTCA) is an assessment battery comprising 20 with the WAIS in initial studies. Test-retest reliability is h
initially validated on two groups of patients, 69 with brain the Short Portable Mental Status Questionnaire, and
disease and 63 normals. The MMSE was found to be Mattis Dementia Rating Scale. It is also different from th
sensitive to the presence of cognitive deficits in the sample, scales in that it allows for a profile demonstrating streng
particularly dementia (Folstein et al., 1975). Concurrent and weaknesses of the patient, versus a global cogni
validity was confirmed with the MMSE and the WAIS. The interpretation. The NCSE was designed to focus on deg
MMSE correlated highly with both the verbal and perfor of disability and is not designed to discriminate betw
mance aspects of the WAlS. Naugle and Kawczak (1989) average and superior performance. The test takes 5 to
report on studies in which the MMSE correctly identified 87 minutes to administer.
percent of patients with cognitive impairment when a There are two sections to the assessment (Veltman et
cutoff of 23 to 24 points was used. They found that the 1993). The first part is the status profile, which consist
MMSE was 63.3 percent less sensitive when the patient areas of level of consciousness, orientation, attenti
had 8 years or less of education and 65.2 percent less language, visual construction, verbal memory, calculat
sensitive when the patient was 60 years or older. They also and verbal reasoning. There is also a process section
noted a higher incidence of false negatives in neurologic which information related to clinical observations is co
patients with right brain damage and concluded that the piled, including affect, response time, the ability to c
test was not sensitive to right hemisphere lesions. Persons centrate, emotional status, and copying. Most section
with higher lQs have also been found to score higher. the test begin with a more demanding screen of the a
(Resource: no commercial source.) being assessed. If the patient passes this item, the ski
considered intact. If the patient fails this item, the me
portion of the test is administered. Patients may still
MIDDLESEX ELDERLY ASSESSMENT
considered normal in their functioning on the me
OF MENTAL STATE
portion even if they fail the screen. Scores are plotted o
The Middlesex Elderly Assessment of Mental State graph for an overview of areas of strength and areas
(MEAMS) was developed to screen for global impairment limitation. Both the status profile and the process feat
of cognitive skills in the elderly. It is intended to show are standardized. Scores should be analyzed together.
whether any areas of the brain are not functioning as Normative data were completed using 60 normals, a
effectively as possible and whether these problems need 20 to 66, and geriatric persons with a mean age of 7
further investigation (Golding, 1989). It is not a test of years. In the geriatric population, the scores on the subt
intelligence. There are two versions composed of 12 for construction, memory, and similarities were lower t
subtests, including orientation, memory, naming, compre for the younger populations. In one study (Schwamm et
hension, verbal fluency, arithmetic, perceptual functions, 1987), the NCSE correctly identified 28 of 30 patients w
and motor perseveration. The test takes approximately 10 central nervous system lesions, as compared with 16 of
minutes to administer and score. There are two parallel 30 identified with the MMSE. The developers of the
versions of the test. The maximum score possible is 12. note the difference between the NCSE and tests such as
Scores of 8 or 9 suggest borderline performance, and MMSE in how the results are described. Because the NC
scores of 7 or below indicate that a more detailed does not have a global score, areas of strength do not h
assessment is needed, including a neuropsychological the potential to improve the total score and mask subn
evaluation. The test was validated on patients aged 65 to mal performance in subareas. Furthermore, it is also
93 attending a day hospital in England. The patients that there is a gradation of skills inherent in the NCSE
diagnosed with multUnfarct dementia and Alzheimer's found in other assessments such as the MMSE. The NC
disease scored Significantly lower on the MEAMS than did was utilized with subjects with mild brain injury in a study
other patients. For more information, contact National Veltman and others (1993). Thirty-nine percent of patie
Rehabilitation Services, Northern Speech Services, Inc., with mild brain injury were identified with the NCSE, an
117 North Elm Street, P.O. Box 1247, Gaylord, Ml percent had marginal scores. The patients with posi
49735. cognitive deficits were assessed on more comprehens
neuropsychological tests, and 97 percent were found
have cognitive deficits. Most of these patients did comp
NEUROBEHAVIORAL COGNITIVE
of problems. For more information, contact NCNG, I
STATUS EXAMINATION
P.O. Box 460, Fairfax, CA 94978.
The Neurobehavioral Cognitive Status Examination
(NCSE) is a quick screening test of cognitive ability in the
RAVEN'S PROGRESSIVE MATRICES
areas of language, constructions, memory, calculations,
and reasoning. The NCSE also separately assesses con The Raven Progressive Matrices (RPM) is a set of th
sciousness, orientation, and attention (Kiernan et al., tests used to measure the ability to form constructs. T
1987). The NCSE was designed to assess behaviorally three tests are the Standard Progressive Matrices (SP
involved patients in an acute diagnostic hospital unit. The the Colored Progressive Matrices (CPM), and the
350 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
vanced Progressive Matrices (APM). The SPM consists of Services, 12031 Wilshire Boulevard, Los Angeles,
60 stimuli, divided into five sets that progressively assess 90025-1251.
the patient's ability to discern relationships among the
stimuli. The CPM consists of 36 items and adds color to the
REY COMPLEX FIGURE TEST
test stimuli to assist children in determining the relation
ANO RECOGNITION TRIAL
ships among the stimuli. The authors believe the CPM to be
beneficial with the geriatric population. The APM is similar The Rey Complex Figure Test (RCFT) was first devi
to the SPM but is timed. The APM has 48 problems and is by Rey in 1941 to investigate perceptual organizati
more complex than the SPM. The fact that the APM is visual spatial constructional ability, and visual memory. T
timed makes it an assessment of intellectual efficiency. This test also assesses several other cognitive processes (Spr
may be beneficial when assessing patients for work when & Strauss, 1991), including organization and prob
quick judgments often are needed. The SPM was designed solving. Osterrieth standardized the test on children a
to assess a wide range of mental abilities, without influence adults. Taylor made an alternate form for retesting p
of educational, cultural, and physical abilities (Raven et aI., poses. A published standardized version is now availa
1988). The assessment may be used in association with the (Meyer & Meyer, 1995).
Mill Hill Vocabulary Scale (MHV), which is an assessment of The standardized version (Meyer & Meyer, 1995)
a person's ability to recall acquired information. Together expanded on the previously unpublished versions of
the SPM and the MHV can be used for a general test of test's copy and recall sections. It also includes a recognit
intelligence. The SPM was originally developed in the test section. The test consists of a 16-page test bookle
1930s and was revised in the late 1930s. Further norms cover the copy, immediate recall, delayed recall, a
have been obtained through the 1980s. Norms are avail recognition subtests. The test contains a laminated stimu
able from young children to geriatric populations with the card and manual. The patient is first asked to copy
RPM. stimulus onto the test manual. The patient is then asked
Good correlations have been noted between the SPM recall the figure in the noncued recall section, first afte
and nonverbal and intelligence performance tests (Raven et 3-minute delay and later after a 30-minute delay. Follow
al., 1988). Generally, the RPM and vocabulary tests have the 30-minute recall, the patient is presented with figu
examined two factors: educative and reproductive ability real and distracters, from which he or she must iden
(Raven et al., 1991). The authors define educative as the aspects recognized from the complex figure. The amo
ability to discern meaning from confusion or the ability to of time needed to complete each of the drawings may
form constructs, nonverbally, and make sense of the noted. The test situation calls for the above materials, a
constructs presented. Educative ability is not to be confused pencil, and a stopwatch (Fig. 12-27).
with the ability to problem-solve. Educative ability is, Previous studies of the use of the RCFT have varied in
instead, the manner in which constructs are developed for presentation of the stimulus figure and in the length of t
the way problems in everyday life are handled. The RPM for the noncued recall aspect of the test. Based on resea
has the patient analyze the relationships among four to by Meyer and Meyer (1995), the patient is to draw
nine stimuli. The manner in which each piece is related to design from a portrait, rather than a landscape, orien
the whole is decreed. Warren (1993) describes a process of tion. Their studies found that patients have a tendency
visuospatial cognition, which may be a way of interpreting elongate the figure when given the landscape presentati
the usefulness of the RPM. Reproductive ability entails
familiarity with a cluster of verbal information. Some
validity studies demonstrate that the SPM also assesses
spatial abilities along with intellectual functioning. Some
studies relate findings on the RPM to the monitoring of
dysfunction for decline or improvement. There is also some
research on the SPM and MHV with schizophrenic pa
tients. This author has utilized the RPM with patients with
a CVA and TBI, especially to document higher-level
cognitive deficits and to provide an objective means of
demonstrating improvement.
All of the RPM require the use of a test booklet, answer
sheet, and pencil. The APM also requires a stopwatch. The
assessments have a standard set of instructions and are set
up to be self-directed in learning, with the sets progressing
from simple to complex. The SPM can take 30 to 45
minutes to administer. Norms, based on the total correct,
are age based and may be converted to percentile scores. FIGURE 12-27. The Rey Complex Figure. Subjects must copy
For more information, contact Western Psychological figure, which is set out horizontally. (Approximation of test item.)
suggested the use of colored pencils for the patient to use noncued recall part of the assessment, patients with
to complete the figure. Each time the subject completes a brain damage generally remember the overall structure
section of the drawing, the examiners give him or her a have difficulty recalling the details (Morse, 1986). Th
different colored pencil to complete the next section. with right brain damage tend to be less accurate and h
Meyer and Meyer (1995) feel this procedure distracts pieces missing. They demonstrate difficulty with the ove
patients, especially those with moderate to severe brain structure of the design but tend to be good with the deta
damage, makes the test more challenging in terms of fine The patient with right brain damage tends to work righ
motor and depth perception aspects, and is difficult to left. Patients with frontal lobe damage tend to demonst
validate in terms of specific instructions. They recommend the greatest differences from the model, as they tend to
that the examiner draw the stimulus figure along with the track of where they are in the reproduction and o
patient in the space provided in the test booklet, noting the transform elements in the model. There appears to be a
sequence of completion. percent learning effect noted on the noncued recall sec
Scoring is done by assigning point values of 0, 0.5, 1, of the test when patients are retested after 1 month (Spr
and 2 points on 18 aspects of the drawing for a possible & Strauss, 1991). In a study by Bigler (1989), the RC
total of 36. The subject's score can be converted to a was given to two groups of patients, one with head in
t-score and norm, which is age related from ages 18 to 89. and the other with dementia of the Alzheimer's type.
Meyer and Meyer (1995) have tightened the scoring over patients were presented the RCFT and the memory asp
previous works (Spreen & Strauss, 1991). Criteria and ex after a 3-minute delay. The results demonstrated
amples are included in the test manual for each of the 18 patients with head injury generally demonstrated in
units. The scores are entered on a graph for each subsec copying and impaired memory, while the patients w
tion of the test. Meyer and Meyer (1995) have identified Alzheimer's demonstrated impairment of both aspe
several profiles for memory loss based on how a patient's The patients with head injury showed learning o
scores plot on a graph. From the pattern, the more specific multiple trials, where the Alzheimer's patients did not
problem resulting in memory difficulties, such as with atten this study, the authors believe the Alzheimer's patie
tion, storage, and retrieval, can be determined. Some items poor performance was due to sensory overload for p
on the recall and recognition test have been identified as cessing strategies and the complexity of the task.
items that may indicate questionable motivation in a pa In practice, the most valuable information derived f
tient, especially when the items are recalled and not recog the RCFT is often in the subjective interpretations of
nized. It should be noted that much of the clinical interpre manner in which patients completed the model, and t
tation is suggested to be performed by professions with organization and spatial orientation. In many instances,
psychological testing and neuropsychological background. score may not change from initial assessment to discha
Norms have been developed for children, with adult-type assessment even though the overall quality of the de
reproduction noted at age 13 years. has significantly improved. This seems to be a prob
On a more subjective basis, the drawing can be assessed when reporting speCific scores. Therefore, it is impera
by how it was completed by the subject. Seven procedural to also include the manner in which the design
types have been noted, with 90 percent of normal subjects reproduced in any documentation related to the pati
completing the figure in one of two ways. With the Rey The test has been found to be sensitive to TBI, temp
drawing, normal subjects either complete the large rec lobe damage, Alzheimer's disease, and Parkinson's dise
tangle first or an outside figure first, such as the cross upper as a test of visuospatial constructional ability and a meas
left, and then add the detail. Rey has noted that brain of visuospatial memory in relation to lateralization
injured subjects have difficulty with the test, possibly lesion, frontal lobe damage, TBI, and Parkinson's dise
because the large rectangle does not exist for them. Their It has also been noted to be helpful in differentia
drawings are often fragmented, that is, completed in a between various forms of memory problems. Val
piecemeal approach. The drawings of these patients may studies have factored with the WAIS-R, especially
closely resemble the original, and their score may be near performance subtests. Criterion validity has been fo
normal; however, the process by which the subjects with the Benton Visual Retention Test, Hooper Vi
organized the drawing may give clues to their organiza Organization Test, and the Trail Making Test (Meye
tional skills or their decreased ability to process as much Meyer, 1995). For more information, contact Psychol
information as normal subjects. Patients with frontal lobe cal Assessment Resources, Inc., P.O. Box 998, Odessa
injury often exaggerate, perseverate, and confabulate their 33556.
reproductions (Morse, 1986). Patients with frontal lobe
damage may also have difficulty planning the reproduction.
RIVERMEAD BEHAVIORAL MEMORY TEST
Problems with the spatial organization may be noted in
patients with posterior lesions (Spreen & Strauss, 1991). The Rivermead Behavioral Memory Test (RBMT)
Right/left differences can be seen in the drawings of developed to assess problems with everyday memory
352 UNITTHREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OFTHE ADULT
to provide a monitor for changes in memory with inter SEVERE IMPAIRMENT BAITERY
vention (Wilson et al., 1991; Wilson et al., no date). The
assessment was designed to be utilized by allied health The Severe Impairment Battery (SIB) was developed
practitioners working with patients with memory prob assess cognitive skills in patients who are unable
lems. The assessment attempts to provide situations that complete standard neuropsychological tests. The ta
persons may encounter on a regular basis that require provided in the SIB were taken from a wide variety
memory. The developers of the assessment believed that it low-level tasks that address the behavioral and cognit
would fill the need for a memory assessment that was deficits frequently associated with persons with sev
quantifiable but not as structured as earlier laboratory tests dementia (Saxton et al., 1993). The test is designed to
of memory and more descriptive than general observations beyond standard mental status examinations that ass
of patients' functioning. The subtests in the RBMT were overall cognitive functioning. The SIB examines spec
chosen because they represented the areas that patients cognitive areas in greater depth. There are 57 questio
with TBI reported as difficult. Subtests include recall of with a total score of 0 to 133 points. The assessm
name and appointment, recognition of faces and objects takes approximately 20 minutes to complete. The SIB
recently seen, remembering a route, remembering a story, made up of one-step commands that are presented v
and orientation. There are four parallel versions of the test. bally along with gestures. Commands may be repea
There is a screening test and a standardized profile. The as necessary. Scoring allows for nonverbal and parti
assessment was validated on patients with TBI and normals correct responses. Only one answer is timed. The SIB
aged 16 to 70 years, with no age effects noted. Subsequent structured to be more of a natural interview than a form
studies in 1989 (Cockburn & Smith) provide norms for assessment, which is how most severely demented
patients 70 years and older. The RBMT does correlate with tients respond best (Saxton & Swihart, 1989). The s
other accepted measures of memory. Studies demon tests of the SIB include attention, orientation, langua
strated that the patients with TBI had more memory deficits memory, social skills, visuoperceptual ability, and c
than those with CVA. structional ability. In addition, there are subtests to
The test kit provides all that is needed to administer the termine if the patient responds to his or her name,
RBMT. It includes four versions of the assessment for assess praxis, and to assess social interaction skills. T
retesting, manuals, an audiotape for learning to administer assessment of social interaction skills is derived from
the test, and a timer. The patient is presented with various Communicative Activities of Daily Uving Scale. Sco
situations, verbally or visually, and is asked to recall or range from 0 to 100. Scores are given for corre
recognize the stimuli in question. Some items are asked for partially correct, and incorrect responses. Since the
immediately, some after a short delay, and others after a is utilized only with severely impaired patients, there is
somewhat lengthier delay. The patient is given a score of cutoff score. Analysis on individual subscales is enco
two, one, or zero, based on his or her responses. For both aged to obtain information about the patient's abilit
the screening and profile scores, the total score is com The test is designed for subjects with a test score low
puted, and the patient falls either above the cutoff for than 9 on the MMSE and lower than 90 on the Ma
normal memory or below for various levels of impairment. Dementia Rating Scale Test (Saxton & Swihart, 198
The score is designed to provide an indication of overall Administrators are encouraged to spend time establish
memory function and should not be broken down into rapport with the patient outside of the test environme
analysis of function on the various subtests. The score can It is essential that the clinician administering the asse
be adjusted for aphasic patients with the verbal sections ment be familiar with the test to conduct it in a rela
deleted from the total score. The score may also be yet structured manner.
modified for patients with perceptual problems by deleting Although other assessments measure decline in funct
the immediate and delayed route, orientation, date, and of cognition, such as the DRS, the SIB is more sensitive
faces. Suggestions for administering the RBMT to the lower and more severe cognitive deficits. Other asse
elderly are also included. ments, such as the DRS, are more sensitive to mild
One problem this author and other occupational thera moderate deficits (Saxton & Swihart, 1989). Validat
pists have encountered is with one of the orientation studies were completed on the second version of the t
questions: "Who is the Prime Minister of England?" Many which had 133 possible points but has now been redu
Americans do not readily know the correct answer. North to 100. Significant correlations were found between
ern Speech Services, who distributes the assessment in the SIB and both the MMSE and the DRS. High interra
United States, feel that substituting other similar, more reliability was demonstrated (Saxton et al., 1993). I
familiar questions such as "Who is the Vice President" or study by Panisset and colleagues (1994), the SIB was fou
"Who is the governor of (your state)" would not adversely to correlate with the MMSE. High test-retest reliabili
affect the outcome of the test. For more information, were noted. The primary deficit areas in performance w
contact National Rehabilitation Services, Northern Speech in the areas of praxis, memory, and orientation. Seven
Services, Inc., 11 7 North Elm Street, P.O. Box 1247, six percent of the severely demented patients did better
Gaylord, MI 49735. praxis tests with the actual object than with photos for
Purchasers of the test also need to purchase some decline in Alzheimer-type dementia.
household items to use as distracters in part of the test.
For more information, contact National Rehabilitation
STROOP COLOR A~ID WORD TEST
Services, Northern Speech Services Inc., 117 North Elm
Street, P.O. Box 1247, Gaylord, MI 49735. The Stroop Color and Word Test (SCWT) was develop
from observations of psychologists that people are slow
at naming colors by hue than at reading the names of col
SHORT CATEGORY TEST
(Golden, 1978). Over the years, this phenomenon w
The Short Category Test (SCT) was developed to further researched, including work with patients w
decrease the length and the complexity of the Category organic brain disorders. Being able to recite the color o
Test (CT) on which it is modeled (Wetzel & Boll, 1987). printed word appears to relate to verbal processing. In t
The original CT, administered by neuropsychologists, is manner, the automatic verbal processing, that of read
208 questions long, taking over 2 hours to administers and the word, interferes with the process of relating the colo
has not been very portable since it uses a slide projector. the word, which is the conscious task at hand. Some ha
The SCT comprises 100 test items, divided into five test found the Stroop test to be helpful in identification
booklets. It takes 15 to 30 minutes to administer. The SCT attention defiCits, as the patient must inhibit one stimu
may be administered by paraprofessionals, with interpre and concentrate on another via continued suppression
tation being made from observations on this and other may thus be considered an assessment of the ability to
assessments by professionals with advanced training and shift.
experience. The SCWT is made up of three stimuli sheets. It ta
Both the SCT and the CT were designed to be sensitive only a few minutes to administer and score. The patie
to brain damage. The tests assess the person's ability to are asked to read five columns of 20 items. The first t
solve problems, handle abstract concept formation, and sheet has the patient read black names of colors. This is
deal with situations in everyday life. The SCT was found to make certain that the patient is able to read. The seco
discriminate 83 percent of a group of people with brain test sheet has the patient state the color of four "Xs"
damage from those without brain damage. For more make certain that he or she is able to identify all the col
information, contact Western Psychological Services, utilized in the test. The third stimulus page has columns
12031 Wilshire Boulevard, Los Angeles, CA 90025 words printed in different colors. The color the word
1251. typed in never matches the word printed. On the th
page, the patient is asked to identify the color of the w
and to ignore the word that is printed. Three scores
SHORT PORTABLE MENTAL
obtained; the color score, the word score, and the col
STATUS QUESTIONNAIRE
word score. Scoring consists of the number of words re
The Short Portable Mental Status Questionnaire in 45 seconds. Errors are not counted, although th
(SPMSQ) was developed in 1975 to provide a short, easily decrease the overall score. Normal scores for patie
scored assessment of intellectual functioning (Pfeiffer, between ages 16 and 44 are provided. Adjustments
1974). The assessment consists of 10 items, including printed for patients 45 to 80 years of age and for childr
orientation, current events, and serial mathematic calcula Raw scores are converted to T-scores.
tions. As with other mental status examinations, it does The SCWT has been utilized as a test to aid in
not assess visuospatial skills, constructional skills, and identification of brain dysfunction. Problems with
abstraction. It is not timed. The assessment was standard SCWT with color naming have been found to be related
ized on 997 elderly adults aged 65 and older. Scores right hemisphere lesions (Golden, 1978). In a previo
indicate intact, mildly impaired, moderately impaired, or study described by Golden (1978), almost 89 percent
severely impaired performance. There is an adjustment for control subjects were correctly classified, along with o
African-American subjects and for subjects based on their 84 percent of patients with brain injury. Psychia
educational status. Further validation studies were per patients were correctly classified 83 percent of the tim
formed (Pfeiffer, 1974), with an SPMSQ score of moderate The test is available from Stoelting Company, 6
to severe impairment agreeing with the diagnosis of Wheat Lane, Wood Dale, IL60191, and Western Psyc
organic brain syndrome at 92 percent. Test-retest coeffi logical Services, 12031 Wilshire Boulevard, Los Angel
cients of 0.82 and 0.83 were found when the question CA 90025-1251.
naires were given 4 weeks apart. Although mental status
assessments, such as the SPMSQ, have been utilized by
SYMBOL DIGIT MODALITIES TEST
health care practitioners as a predictor of an individual's
capacity to care for himself or herself, this relationship was The Symbol Digit Modalities Test (SDMT) is used
not verified by research (Winograd, 1984). In a study by screen for cerebral dysfunction in adults and child
354 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
(Smith, 1982). The test involves meaningless geometric ended questions may be answered. If the patient h
designs that are converted, either in writing or orally, into difficulty answering the questions, then he or she is ask
their associated number response. The written version is to respond to questions through auditory recognition. T
suggested for those patients with language deficits. Patients assessment takes about 15 minutes to administer. Ther
should be retested on the oral version if their written version a training module in the test manual for rehabilitat
score is greater than one standard deviation below the profeSSionals to learn administration and scoring.·
mean. The score is derived from the number of correct Deitz and coworkers (1990) demonstrated interrela
conversions that the patient made during a 90-second time reliability utilizing this training method with two occu
interval. Scores over one standard deviation below the tional therapists. Construct validity was demonstra
mean when brain injury is known suggest cerebral dysfunc (Deitz et a!., 1993) with scores of rehabilitation patie
tion. A cutoff of 1.5 standard deviations below the mean with brain injuries scoring significantly lower than rehab
correctly identified 86 percent of patients with chronic tation patients without brain injury. For more informati
brain lesions (Smith, 1982). contact Therapy Skill Builders, 3830 East Bellevue, P
Pfeiffer and others in 1981 (cited in Smith, 1982) found Box 42050-4SW, Tucson, AZ 85733.
that the SDMT was the best instrument in their study to
discriminate normal and depressed elderly from patients
with senile dementia. The patients were also given the WISCONSIN CARD SORTING TEST
Raven's CPM and the MMSE. Studies also have been The Wisconsin Card Sorting Test (WCST) was develop
conducted for evaluation of aphasics, as it is believed to assess executive functioning in terms of abstract reaso
aphasia is an impairment of verbal symbolic processing. ing and the ability to shift cognitive strategies and
Significant correlationS were found with aphasics in terms problem-solve as conditions or the environment chang
of the severity of their speech and language dysfunctions (Heaton et al., 1981). The test is made up of four stimu
and nonverbal cognitive dysfunctions, as assessed by the cards, two identical decks of response cards, and a reco
SDMT. booklet. The patient is asked to sort the cards into one
The authors report the SDMT to measure some func four piles. The examiner tells the patient only if he or s
tions of both the left and right hemispheres. The left is correct or not. The patient is not told how to sort
hemisphere has a role in the interpretation of language cards but must conclude this based on the examine
symbols and numbers. The right hemisphere plays a role in responses. The patient first sorts by color, then form, th
visual perceptual processing. number, with the sequence being repeated. The exami
The SDMT was originally standardized on over 1300 changes the conditions (e.g., from sorting based on colo
normal adults aged 18 to 78. Test-retest reliability is good. that based on form) after the patient has given 10 corr
Scores are generally higher with the oral version. Retesting responses and without informing the patient that
on the oral version following the written showed fewer conditions are changing. The test concludes after all
differences as age increased. Children's interpretation for conditions have been met successfully or both sets of ca
ages 8 to 17 is also included in the manual. For more have been exhausted. The test is not timed. It takes m
information, contact Western Psychological Services, patients 20 to 30 minutes to complete. The score deta
12031 Wilshire Boulevard, Los Angeles, CA 90025 the number of correct responses with the number of tri
1251. administered. The number of errors, perseverative
sponses, perseverative errors, and nonperseverative err
THE TEST OF ORIENTATION OF REHABILITATION can be converted to standard scores, T-scores, and p
PATIENTS centile scores. A learning to learn score is also calculat
which looks at the number of trials and the number of err
The Test of Orientation of Rehabilitation Patients with each category. For more information, contact P
(TORP) is an orientation test that was developed by chological Assessment Resources, Inc., P.O. Box 99
occupational therapists to assess patients with brain injury Odessa, FL 33556.
in inpatient rehabilitation settings (Deitz et al., 1990). The
TORP was developed to be used with patients with
neurologic disorders such as CVA and TBI. The authors
developed the test to fill the void of an objective measure of
orientation more specific to the inpatient setting. It was also
AlertnesslArousal-General readiness of the nervo
developed to assess only orientation, whereas other scales
system to receive and act on information
include orientation along with other cognitive abilities
(Deitz et aI., 1993). The test has 46 questions under five Amnesia-Memory deficit
domains: person and personal situation, time, place, Attention-Area of cognition that encompasses ale
schedule, and temporal or time awareness. The evaluation ness and arousal, the ability to select stimuli, the ability
yields a total score and can be looked at via the separate span attention, the ability to shift attention, and inform
domain scores. The assessment is given so that open- tion processing
Allen, C., Kehrberg, K, & Burns, T. (1992b). Evaluation instruments
environment
C. Allen, C. Earhart, & T. Blue (Eds.), Occupational therapy treatm
goals for the physically and cognitively disabled. Rockville, M
Dementia-Acquired loss of intellectual functioning
American Occupational Therapy Association.
Distractibility-Difficulty sustaining attention
Allen, C., & Reyner, A (No date). How to start using the cognitive lev
Colchester, CT: S & S Worldwide.
Executive functioning-Higher-level cognitive skill
Auerbach, S. (1986). Neuroanatomical correlates of attention
group that includes goal setting, organization, self
memory disorders in traumatic brain injury: An application of neuro
havioral subtypes. Journal of Head Trauma Rehabilitation, 1, 1-
monitoring, problem solving, decision making, and regu
Baddeley, A., Emslie, H., & Nimmo-Smith, I. (1994). Doors and Peop
lating performance
Suffolk, England: Thames Valley Test Company,
Baum, C., & Edwards, D. (1993). Cognitive performance in se
Impersistence-Difficulty sustaining action when atten
dementia of the Alzheimer's type: The Kitchen Task Assessme
tion is needed, such as keeping one's eyes shut on
American Journal of Occupational Therapy, 47, 431-436.
command; decreased ability to stay with a task until
Benton, A, Hamsler, K, Varney, N., & Spreen, O. (1983). Contri
tions to neuropsychological assessment: A clinical manual. N
completed
York: Oxford University Press.
Information processing-The rate at which informa
Benton, A, Van AUen, M., & Fogel, M, (1964). Temporal orientatio
cerebral disease. Journal of Nervous and Mental Disease, 1
tion is dealt with by the nervous system, including the ability
110-119.
to chunk information together into smaller bits so it may be
Bigler, E. (1989). Rey Auditory Verbal Learning and Rey-Osterr
handled by the nervous system
Complex Figure Design performance in Alzheimer's disease and clo
head injury. Journal of Clinical Psychology, 45, 277-280.
Judgment-The ability to anticipate consequences
Brooks, N, (1983). Disorders of memory. In M. Rosenthal, E. Griffith,
Bond, & J. Miller, (Eds.), Rehabilitation of the head injured ad
MeDlOry-The ability to take in, store, and retrieve
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Bruce, M. (1994). Cognitive rehabilitation: Intelligence, insight,
knowledge. In C. B. Royeen (Ed.), American Occupational Thera
Metacognition-A person's awareness of his or her
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Metamemory-A person's awareness or knowledge of
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his or her own memory
versity Press.
Christensen, K (1989). Anew approach to the measurement of cogni
Organization-The ability to sequence and plan occu
deficits in dementia. Clinics in Geriatric Medicine, 5, 519-530.
pations by deducing the relationship between objects
Cockburn, J., & Smith, P. (1989). The Rivermead Behavioural Mem
Test. Supplement 3: Elderly People. Titchfield, Hants, Engla
Orientation-A person's knowledge of person, place,
Thames Valley Test Company.
time, and situation
Coheen, J. (1950). Disturbances in time discrimination in organic b
disease. Journal of Nervous and Mental Disease, 112, 121-1
Perseveration-Difficulty set shifting, therefore con
Cohen, R., & Mapau, R (1988). Neuropsychological assessment
tinuing to perform with one response pattern
treatment planning: A hypothesis testing approach. Journal of H
Injury Rehabilitation, 3, 12-20,
Problem solving-Includes the abilities to recognize
DeGangi, G., & Porges, S. (1991). Attention? Alertness/Arousal. InC
errors, generate solutions, select and implement a solution,
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and judge the effectiveness of the solution implemented
Rockville, MD: American Occupational Therapy Association.
Deitz, J., Beeman, c., & Thorn, D, (1993). Test of Orientation
Set shifting-The ability to cease direct attention to one
Rehabilitation Patients. Tucson, AZ: Therapy Skill Builders.
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Deitz, J., Tovar, V., Thorn, D., & Beeman, C. (1990). The Tes
Orientation of Rehabilitation Patients: Interrater reliability. Americ
Standardized assessment-Test for which the pro
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cedure of administration is documented and conducted in
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Manual, Volume 1. Gaithersburg, MD: Aspen Publishers, Inc.
the same manner each time
Diller, L (1993). Introduction to cognitive rehabilitation. In C. B. Roy
Vigilance-Ability to sustain attention over extended
(Ed.), American Occupational Therapy Association Self Stu
Series: Cognitive Rehabilitation, Baltimore: American Occupatio
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Feher, E., Doody, R, Pirozzolo, F., & Appel, S. (1989). Mental sta
assessment of insight and judgment. Clinics in Geriatric Medicine
477-498.
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Allen, C., Earhart, c., & Blue, T. (Eels.). (1992a). Occupational therapy Year Book.
._
~~ - ~~~~
~...::::--=-,;,.-
~ ~~ #~
_ 4~-~-=~~
~ ~~ -~~~~;:;:
, ""'--~-:;::..
356 UNIT THREE-ASSESSMENT OF CENTRAL NERVOUS SYSTEM FUNCTION OF THE ADULT
Heaton, R., Chelune, G., Talley, J., Kay, G., & Curtiss, G. (1981). Pfeiffer, E. (1974). A Short Portable Mental Status Questionnaire fo
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& Grossman, R. (1979). The Galveston Toglia, J. (1993b). Contextual Memory Test. Tucson, AZ: Therapy
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American Journal of NurSing, 80, 1456-1458. Wetzel, L., & Boll, T. (1987). Short Category Test, booklet for
Loring, D., Lee, G., & Meador, K (1989). Issues of assessment of the manual. Los Angeles: Western Psychological Services.
elderly. Clinics in Geriatric Medicine, 5, 565-581. Williams, J. M. (1987). Cognitive Behavior Rating Scales man
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Meyer, J., & Meyer, K (1995). Rey Complex Figure Test and Recog Rivermead Behavioural Memory Test. Supplement 2: Valida
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Dementia Rating Scale. Behavioural Memory Test. Edmunds, England: Thames Valley
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assessment. In Brain injury: Cognitive and prevocational approaches Winograd, C. H. (1984). Mental status tests and the capacity for self
to rehabilitation (pp. 51-88). New York: The Tiresias Press. Journal of the American Geriatrics Society, 32, 49-55.
Naugle, R., & Kawczak, K (1989). Limitations of the Mini-Mental State Zemke, R. (1994). Task skills, problem solving, and social interactio
Examination. Cleveland Clinic Journal of Medicine, 56, 277-284. C. B. Royeen (Ed.), American Occupational Therapy Associa
Newcombe, F. (1985). Rehabilitation in clinical neurology. In JAM. self-study series: Cognitive rehabilitation. Rockville, MD: Ame
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609-642). Amsterdam and New York: Elsevier Science Publishers. Zoltan, B. (1990). Evaluation and treatment of cognitive dysfunctio
Nissen (1986). Neuropsychology of attention and memory. Journal of L. Pedretti & B. Zoltan (Eds.), Occupational therapy practice skill
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Panisset, M., Roudier, M., Saxton, J., & Boller, F. (1994). Severe Company.
Impairment Battery: A neuropsychological test for severely demented
patients. Archives of Neurology, 51, 41-45.
UNIT FOUR
Age-Related
Assessment
- - - - --
,
. .
~
C HAP T ER 1 3
Pediatrics:
Developmental and
Neonatal Assessment
Joanne Jackson Foss, MS, OTR
Bonnie R. Decker, MHS, OTR
... ...
~
360 UNIT FOUR-AGE-RELATED ASSESSMENT
th~ potential for higber-Ievels of performance, and the tion planning. Continuing education coursework or a
·t1illcr~ currenfstrengths and capabilities (Carrasco, 1993). certification process is necessary for some evaluations,
Reviewing these assessment data allows the therapist to while for others it is the therapist's responsibility to gain
decide if OT or PT intelVention will help the child to knowledge of the parameters of the device (American
resolve, adapt to, or cope with the identified problem or Occupational Therapy Association, 1995).
problems~ Also, this review provides information to allow The data collection part of the assessment process often
the therapist to begin to understand if coping or adapting begins with a historical review of the child's records, and
to the problem will impede the child's continued develop intelViews with caregivers, teachers, family members, or
mental process (Pratt, 1989). others able to give significant information. These inter
views may be structured by the use of checklists allOwing for
ease in recording and standardizing the data. The therapist
Issues may also choose to perform a naturalistic or clinical
obselVation at this time to arrive at decisions concerning
Assessment of an individual child is important for the appropriate evaluation methods. A screening instrument
effective planning and implementation of intelVention. might also be used to further provide the necessary
Basic to the information therapists must take into con introductory information.
sideration as they begin the assessment process are the
decisions that will be affected by the process and the
interpretation of the results~ Ethical issues of concern are Clinical Observations
the use of assessment results when making a diagnosis
that classifies or labels a child (King-Thomas, 1987). Clinical obselVations can be performed along with a
Labels that denote specific criteria are often required to screening or in conjunction with other types of evaluation
determine a child's eligibility for OT and PT selVices. For instruments. Qill.i~tiefl.s are based on sound
instance, therapists·who practice in school system-based clinical judgments made by the therapist (Pratt et al., 1989).
setting§.iii(CoffiRCf~qwreato -pert6l'ttCcompreiIensroe ~entsare based on the therapist's training and
standardized developmeritalassessments to qualifychil practical experJeDCe and on a thorough knowledge of
dren for special selVices (Crowe, 1989). However, labels developmental skills and theory. Information generated
have a way of following a child through time along with from clinical observations allows the therapist to report
the assumptions made about the child's abilities based on successful, as well as deficient, performance along with a
that label; therefore, the-accuracy of assessment data on description and analysis of "how and what" affected the
which the label is based is critical. MiSjudgments about the outcome. This is information that is not always available
child's abilities when making prognostic or placement from a standardized or more formal evaluation (Cook,
decisions can be costly, especially in terms of the thera 1991; Dunn, 1993), The following are components of a
pist's relationship with the family and the child. Assess typical clinical observation (Fisher & Bundy, 1991; Pratt et
ment results and the decisions they will trigger have a aI., 1989),
direct impact on the emotional well-being of the child and A Parent/child interaction: The therapist may observe
the family (Cook, 1991). interactions between the parent and the child during
The professional responsibility for the ethical application activity or play. Information concerning the parent's
of assessments and their results lies with the therapist spontaneous handling of the child and the nature of
(American Occupational Therapy Association, 1994b). Of the child's response to this handling provides excel
highest importance is the confidentiality of assessment lent information concerning the everyday experi
information. The information should be used only as it was ences of the parent and the child. Conversing during
originally intended. Care must be taken that the child's and this initial contact gives the parents an opportunity to
the family's rights are protected, and caution should be provide information from a historical perspective (a
exercised to prevent discrimination when issues of access developmental history), Parents and caregivers often
to the information are considered (American Occupational have an accurate perception of the child's problems
Therapy ASSOCiation, 1994a). when expressed in a functiQpal manner'"-~
Included in the therapist's responsibility is the commit B. Spontaneous movements~nd environmental inter
ment to be well trained in the procedures and the intended action; It is important to obselVe the spontaneous
uses of specific evaluation tools (American Occupational movements of the child while he or she is engaged in
Therapy Association, 1994a). Many of the evaluation interactions with toys and the environment. Areas of
devices used by therapists today require that the examiner concern would include:
be well educated in the domains that the test is evaluating • What is the level of exploration and response to
and knowledgeable about the normal developmental proc toys?
ess. Knowledge of normative occupational functioning is • Does the child show normal and abnormal pos
essential for effective interpretation of results and intelVen tural patterns in movements to reach toys? How
compensatory in nature? formalized and comprehensive evaluation.
• If present, how do these specific abnormal pos The selection process of an appropriate screening
tural movement patterns interfere with play? instrument may be even more crucial than that of the
• What is the child's choice or primary position? selection of an actual evaluation tool. Important decisions
Where or in what position does the child func such as whether to continue the evaluation process or
tion most normally and successfully? make a referral to other modalities can be based on
• What is the interplay between sensory informa screening results, making the accuracy of information
tion and movement patterns? Does the child gathered at this stage critical (Huber & King-Thomas,
rely on only one sense, such as vision, to gain 1987). The standardization, validity, and reliability of the
information about the toys? screening tool are issues to be weighed in the selection.
• What toys and activities are attractive to the
child? What toys are avoided? The child's
emotional reactions give us much information Choosing an Evaluation Instrument
about processing of sensory input.
• What is the child's hand use like? What patterns The 9Ssessment process continues by choosing an
of manipulation does the child use with toys? appropriate evaluationTnstru"inent for the child's situation.
C. Reactions to placement in positions; Observations The choices available include standardized qnd nonstand
here include postural components such as~ ardized, git~n- and norm-referenced devices.
trunk, and pelvic control; upper extremity use; and NumerOus evaluatioidnstruments have been designed to
giUss-mo15fcooidination and skills. Positions to be assess children suspected of having special needs. Choos
observed include prone and supine, rolling, sitting ing the appropriate device to answer the child's specific
(both supported and unsupported), quadruped, need then becomes the therapist's dilemma. Increasingly,
kneeling, and standing. therapists are being held accountable to agencies outside
O. Dynamic movements: As the child moves as inde their profeSSion to justify the receipt of their services.
pendently as possible, the therapist is able to make O,Q~f!1~ntption of the child's specific problems and the
several observations that provide clues as to where to results of the intervention proc~ss need to be clearly
begin the intervention. Also, the therapist can begin articulated. Establfshment--C;T'C\ measurable baseline of
to make a prediction of the long-term goals of the progress must be clearly shown to justify placement of a
intervention process. child in an OT or PT program and continuation of those
• How does the child achieve or assume a posi services over time.
tion? Can the child make postural adjustments How do we go about chOOSing an appropriate device?
to maintain or hold posture? First, we must identify what it is we need to know about the
• Can the child make the transition in and out of child. Will we need comprehensive information about the
prone and supine, rolling, sitting (both child's ~veran deveTopmerifa1·tevel or information abou
supported and unsupported), quadruped, kneel one specific area, such as play and social skills, motor-skills,
ing, and standing? perceptUafskTlls, or specific functional abilities? Based on
• In dynamic movement patterns, such as locomo the decision about what information is required, tests
tion, can we predict the child's ability for inde within that category should be reviewed for their psycho
pendent ambulation? With some adaptation metric properties. The test to be considered must be a
or technique on the therapist's part, can the reliable..and valid measure of the child's abilities. - .....
child achieve higher skills? -Infor~~a:Eour what-the assessment results will be
used for, who is going to use the results, and in what setting
may influence our choice of evaluation devices. To ensure
Screening that the data collected are appropriate and valid to the
decisions being made, devices used for measuring specific
The therapist may elect to use ~ninJtc:leyic~s in the functions should be used.
initial stages of evaluation for several reasons. The nature The basic physical requirements of the evaluation items
of the design of most devices allows for anct Qllic:;:Jsness . also affect the appropriateness of the device for a specific
of administration. Therefore, if the situation calls for child. The results of an assessment that does not allow the
gathering information about groups of children at risk for child to show his or her strengths and capabilities is useless
difficulties or if a therapist is evaluating a child with mild or to therapists and others and discriminates against the child.
diffuse problems, a screening tool mayb~ h~pful, as well as Otherpracticai -issues-J:Q consider are the skills of the
cosiandtimg. effic~ntA deVicesuch as the P~J.I~.1:JJWould prospective examiner and the environment of the testing
provide an overall look at the child's developmental site. The accuracy and usefulness of the data collected
362 UNIT FOUR-AGE-RELATED ASSESSMENT
about the child's performance may be influenced by being at risk for developmental delay. Several have been
constraints of time, space, equipment, and skill or prepa selected for review and discussion here, and others are
ration. included in Table 13-1.
Developmental Profile
spheres of influence on children's development (Meisils & aI., 1992) is a screening instrument that was originally
A variety of developmental instruments are available to Test (DDSn. Since that time it has undergone a major
therapists working with children suspected of having or revision and restandardization. It is now titled the Denver II,
TABLE 13-1
ASSESSMENTS FOR CIDIDREN SUSPECTED OF HAVING OR BEING AT RISK FOR DEVELOPMENTAL DElAY
Movement Assessment of 2-18 mo Identify movement patterns 10-15 Individually administered; Reliability: TR = 0 .87 to Chandler, 1986;
Infants Screening Test that interfere with normal minutes domains: muscle tone , 0.97; IR = 0.81 to 0.95 Chandler et aI.,
(MAI-ST) development primitive reflexes, voli No validity information 1988
tional movement
Denver II 0-6y Initial screen of well children 20-35 Individually administered, Original version (DDST) stan Frankenberg et aI. ,
suspected of having or be- minutes norm-referenced test; dardized on over 2000 1992; Frankenbe
ing at risk for developmen- domains: personal-social, normal children et aI. , 1990
tal delay fine-motor adaptive, lan Reliability: IR & TR = 0 .90
guage, and gross motor. to 0 .99. No correlation
Test form can be used sev studies available
eral times to document Validity: content validity
progress; child 's behavior shown through wide use
during testing recorded of DDST and expert
on form review
Miller Assessment for 2 yr, 9 ma- Assist in the identification of 30-40 Individually administered, Standardization sample: Miller, 1988; Miller
Preschoolers (MAP) 5 yr, 8 mo preschoolers with mild to minutes norm-referenced test; 1200 normal children Schouten , 1988;
severe developmental domains: sensory and mo Reliability: IR = 0.84 (coordi Miller & Sprong,
delays tor abilities, cognitive func nation index) to 0.99 on 1987
tioning, and combined individual index scores,
.
, Test (BDI-ST)
ASSESSMENTS FOR CIDLDREN SUSPECTED OF HAVING OR BEING AT RISK FOR DEVEWPMENTAL DElAY Continued J.
Gl
m
Developmental Target PSychODletriC ::b
m
r
Screens Population Purpose TIme Comments Properties References l>
-l
m
0
Criterion-related validity to l>
C/l
C/l
Vineland, Developmental m
C/l
Activities Screening Inven C/l
tory, and Stanford Binet s:
m
Early Intervention Devel 0-6 y Provide a general overview 1h Individually administered Reliability: IR = 0.89 , Brown et aI., 1981 ; Z
-l
opmental Profile (EIDP) of developmental mile norm-referenced test; TR = 0.90 Rogers &
stones based on specific domains: perceptual/fine Validity: Content correlates D'Eugenio,
age-related skills of chil motor, cognition, lan strongly with Bayley Motor 1981
dren with all types of dis guage , social/emotional. Scales, Siossen Intelligence
abilities self-care, and gross motor Test, and Vineland Social
skills, Provides a profile of Maturity Scale
the child 's current perfor
mance with basal and ceil
ing levels established; test
form can be used several
times to document
progress
Bayley Scales of Infant 1--42 mo Assess current developmental 30--60 min Individually administered Normative data: Nationally Bayley. 1993
Development" function, diagnose devel standardized test; sub stratified random sample
(BSID-II) opmental delay , plan inter scales: Motor Scale; Men of 1700 children
vention strategies tal Scale: Behavior Rating Reliability: IC = 0.88 for
Scale, Basal and ceiling Mental Scale, 0.84 for
levels are established , Motor Scale, 0.88 for Be
Scores are converted to a havior Rating Scale
Mental Development In SEM = 5.21 for Mental
dex , Psychomotor Devel Scale, 6.01 for Motor
opmentlndex, and Scale. TR = 0.87 for
percentiles; training is en Mental Scale, 0.78 for
couraged Motor Scale . IR = 0.96 for
Mental Scale, 0.75 for
Motor Scale
Validity: Content. construct
and criterion related de
scribed in manual
IC = Internal consistency reliability; JR = interrater reliabi lity; SEM = standard error of measurement; TK = test-retest reliability.
items have been eliminated or revised, and new language
items and a behavioral rating scale that records subjective
Preschoolers
behavioral observations have been added. The developers
were also concerned about training in test administration The Miller Assessment of Preschoolers (MAP) (Mille
and interpretation, so they have made available a video 1988; Miller & Schouten, 1988; Miller & Sprong, 1987
training program and a technical manual to aid in profi is a preschool screening test designed to assist in th
ciency. idirrtification of developmentally delayed preschoolers
The Denver II was developed for use with well children or Areas of preacademic skills are assessed. Preacademi
children that have no symptoms of overt problems. It is skills are those prerequisite skills and behaviors that appea
used as an initial sf~ ing or to 11l0nitor the developmental to predict successful performance in school. The test i
progresso c ildren suspected of h'iWmg or being at risk for designed to assess children who exhiOit mild to sever
developmental delays. As a screening test, it is designed not problems that affect one or more developmental areas an
for diagnosis but to assist in planning or identifying the are between the ages of 2 years 9 months and 5 years
neea for aiagnostic evaluation. As such, the test does not wontb The MAP assesses sensory and motor abilities
provide a composite score, nor is it a predictor of future cognitive functioning, and the corTibine-d abilities or skill
developmental progression; rather, it gives an overall that require the use of sensorimotor and cognitive abilitie
picture of a child's developmental progress over several together. The 27 test items and st;:;:;Ctured observations ar
developmental domains. arranged in five mdexes: foundations, coordination, verba
The test can be used on more than one occasion to nonverbal, and complex tasks. Humphrey and King
screen children from birth to 6 years old. Consisting of 125 Thomas (1993) suggest that the best use of the MAP migh
task items, the test is arranged by area of development and be to assist in identifying the child's current strengths an
by the growth curves used to assess normal performance of intervention needs. They also suggest that the data ob
developmental skills. Areas screened are personal and tained from the administration of this test are particularl
social, fine motor and adaptive, language, and gross motor useful for planning treatment and documenting changes i
skills. Test behavior is recorded after completion of the performance.
items, providing a record of the behaviors and how they The test items, manual , and score sheets are notable fo
affected performance. Taking between 20 and 35 minutes their simplicity and ease in use. A score reflecting the tota
to administer, individual test items are scored based on the or composite performance on the battery can be calcu
average percentage of children that have achieved that skill lated. Also, individual scores on each index compare th
by the determined age range. Each developmental task has child 's performance to the norm and can be used t
been further delineated by when 25, 50 , 75 , and 90 determine specific areas that need more in-depth testing
percent of children in the standardization sample achieved The developers have found scores on this assessment to b
the specific task. The child's performance receives a score predictive of school-rated behaviors. However, poor per
based on these designations: a "caution" when between formance on the MAP should not be used as a means t
75 and 90 percent of children hav; achieved the task, or a diagnose intellectual or medical problems, but the infor
"delay" when 90 percent have achieved it. The overall mation obtained through the use of the test should b
number of items on which a child receives a " caution" or combined with more detailed diagnostic assessment. Per
"delayed" score determines the need for further testing or centile scores are interpreted as indicating that the child a
observation. is at risk and ,in need of a referral for further testing, b) ha
When the Denver II was assessed for two types of some areas of concern and is in need of a follow-u
reliability, examiner-observer and test-retest stability, the assessment, or c) exhibited norma'! performance. Th
average scores were higher than the original version and MAP can be administered to document developmenta
were in the 90 to 99 percent range. Correlational studies progress and intervention efficacy after a suitable tim
have not been done. lapse of 6 months to 1 year.
The individual test items of the original version (DDST) The assessment takes approximately(30 to 40 , inute
were standardized on more than 2000 children in 1988. to administer by a trained evaluator. Altnougn the test
The age at which children passed each item and the designed for use by profeSSionals with varied background
determination of the percentage designations were deter and training, the evaluator should have experience i
mined from this sample. psychological and developmental assessment, experienc
Content validity relies on the wide acceptance of the with preschool-aged populations, and familiarity wit
utility of the original DDST, as well as the fact that the items standardized testing procedures. Along with practice ad
were written and selected by profeSSionals in the field of ministering the assessment, a prospective evaluator shoul
pediatric development and screening (Frankenburg et aL, obtain a learning videotape or attend a continuing educa
1990). Other types of validity studies have not been tion workshop to ensure that he or she is administering th
conducted. test and observationa'l items in a standardized manner. Th
-=; • • l; ~. ~
manual contains clear and specific instructions for the cognitive , with subdomains of perceptual discrimination,
administration of each test item, scoring instructions, and memory, reasoning and academic skills, and conceptual
interpretation. development. Each domain may be administered individu
Reliability. The use of the MAP has been found to be a ally, or the entire battery can be administered. Information
reliable and consistent method of screening preschool can be obtained through structured administration of items,
sensorimotor performance. The interrater reliability, con observation, and interviews.
ducted by two examiners and 40 normal children on the Basal and ceiling levels are established in administered
MAP, ranged from 0.84 to 0.99 on individual test indexes subdomains . Scores range from 0 (incorrect response) to 1
and was 0 .978 for the total test. The performance index of (attempt that does not meet the full criteria), to 2 (response
coordinafion.....(~) was the only score that was below meets the full criteria). Ten age levels have been estab
0.97. Test-retest reliability was conducted by three exam lished . Raw scores are converted to percentile ranks,
iners on 80 normal children. The reliability was calculated standard scores, and age equivalency. The scores allow the
on the stability of the child's total score. The scores examiner to compare (a) the total score with each domain,
expressed as percentages in the MAP manual ranged from (b) domains with one another, (c) subdomains with the
a low of 72 percent (coordination index) to a high of 94 domains, and (d) subdomains with one another.
percent (nonverbal index) agreement after retest. Internal The BDI was designed for use by teachers and others
reliability for the MAP was calculated to be near 0.80 for interested in measuring a child's functional abilities. The
both item raw scores and the average item-to-test correla developers recommend that the examiner familiarize him
tions. self or herself with the items and practice administering the
Validity. The MAP has been found to be a valid measure test. The BDI is for children from birth to 8 years of age who
of sensorimotQt:..pertormance in preschool. Content valid have a single disability or any combination of disabilities.
ity was established by review by content experts and a Some test items include specific adaptations for children
review of the literature. Content validity of test items was with specific impairments.
also determined by a pilot field test of a "try-out" or Normative Sample. Stratified random sampling of the
research edition of the MAP. four major geographic regions from the U.S. census was
Standardization. The MAP was standardized on 1200 used for the norming sample. Forty-two test administrators
normal children using a random, stratified sampling pro at 28 test sites in 24 states partiCipated. A total of 800
cedure. Variables considered were age, geographic region , children were tested , with equal numbers across 10 age
race, sex, community size, and socioeconomic status. ranges. The sampling method is outlined in the manual.
Although the MAP is one of the better instruments Reliability and validity information were recalculated in
available for use by pediatric occupational and physical the 1988 version. The standard error of measurement for
therapists, it does have a number of problems (Schouten & the total BDI was 20.02, with a range of 2 .12 to 9 .05,
Kirkpatrick, 1993). Considerable dialogue about this tool depending on the age range. Test-retest reliability was 0.99
has taken place in the OT research literature (Short for the total test and ranged from 0.90 to 0.99 for the age
Degraff, 1993). ranges. No interrater reliability is reported in the 1988
revision.
Validity. Content validity was established by having con
. The Battelle Developmental tent experts review the BDI. Construct validity was demon
,Inventory strated through the correlation of the subdomains to each
other and to the domains in a logical way. The correlations
The Battelle ' Developmental Inventory (BDI) (Newborg were generally above 0.80, with a BDI total correlation of
et aI., 1988) is nationally standardized and administered 0.97 . The lowest area was muscle control (0 .56). The au
individually over a 1- to 2-hour period . The pr.imary thors suggested that this was low due to the ceiling effect of
purpose of the BDI is identification of developmental the test. A factoral analysis indicated that each subdomain
strengths and weaknesses of children both with and without was located in the correct domain. In comparing BDI
disabilities. Two versions have been published , the first in scores for children with a variety of disabling conditions
1984 and the revised edition in 1988. The BDI also with those for nondisabled children, the BDI accurately
assists with deveLoping and implementing individual edu identified children with developmental problems across the
cation plans (IEPs). The full BDI battery includes five five domains. Criterion-related validity was established by
domains: (a) personal and social, with subdomains of adult comparing the BDI with the Vineland Social Maturity Scale
interaction, expression of feelings and affect, self-concept, (Vineland), Developmental Activities Screening Inventory
peer interaction, coping , and social roles; (b) adaptive, with (DASI), Stanford-Binet Intelligence Scale , Wechsler Intelli
subdomains of attention, eating, dreSSing, personal re gence Scale for Child-Revised, and Peabody Picture Vo
sponsibility, and toileting; (c) motor, with subdomains of cabulary Test scores . Overall, the BDI total score correlated
muscle control, body coordination, locomotion, fine best with the Vineland (0.94), and DASI (0.91) .
muscle control, and perceptual motor; (d) communication, The BDI is a widely used inventory (Goodman & Pollak,
with subdomains of receptive and expressive; and (e) 1993). A problem that has been identified with this test is
can be obtained, depending on how the child's birthdate is assessment of feeding and pulmonary ability and biome
compared with the age category (Boyd, 1989). One chanical problems , such as limitations in range of motio
problem found with the literature is that the authors do not and splinting needs.
indicate which version of the BDI was used , making
comparisons difficult.
The Neurological'Assessment of the
Preterm and Full-Term Infant
NEON'ATAL ASSESSMENT The NAPFI (Dubowitz & Dubowitz, 1981) was designe
to proVide a developmental profile of full-term and preterm
Low-birth weight infants and those with high-risk factors
infants. This test can be administered shortly after birth an
are surviving in increasing numbers because of advances in
is designed for sequential uses. It has been developed t
neonatology. Therapists providing services in the neonatal
provide information concerning the current functiona
intensive care unit (NICU) must be aware of medical as well
state of the infant's nervous system .
as developmental issues in the neonate. The therapist must
The test items were selected from other recognized tes
be sensitive to a variety of physiologic state, motor,
of preterm and full-term infant behavior (Braze'lton, 1984
attention , and interactive behaviors. These behaviors are
Prechtl, 1977; Saint-Anne Dargassies, 1977). The testin
constantly interacting and changing, which alters the ways
items include those that assess aspects of higher-order neu
in which the neQnate responds to the sensory input from
rologic function , as well as more traditional neurologic tes
the environment. Most neonatal assessments address the
ing items. The areas of infant behavior assessed are habitu
infant's neurobehavioral organization . The neurobehav
ation, movement and tone, reflexes, and neurobehaviora
ioral assessment allows the therapist to assess the stability
responses (orientation, alertness and excitability, irritabili
of the physiologic state, self-regulation behaViors, and
and consolability, defensive reactions, and crying) .
attention and interaction systems during handling . Other
The NAPFI can be administered quite qUickly and is ver
components of development that may be included in
easy to score . Organized through the use of illustration
neonatal assessment would be reflexive development,
the test requires no specific training to administer; how
muscle tone , motor activity, and postural development.
ever, it is recommended that users should have practic
The assessment process provides the therapist with
administering the test to healthy infants before using it fo
baseline information and allows the therapist to document
clinical purposes. The test manual contains detailed in
progress (Miller & Quinn-Hurst, 1994). During the assess
structions for administration of test items and procedure
ment, the therapist's focus is on the neonate 's reactions to
The testing form is easy to use and is arranged in
speCific types of stimuli. Careful attention is given to the
recommended sequential order; however, this order can b
amount of environmental support necessary to achieve the
varied according to the infant's state and needs. A
neonates ' responses (Als et aI., 1982). A variety of
experienced examiner can administer this test in approx
instruments are available to therapists working with neo
mately 15 to 20 minutes.
nates suspected of having or being at risk for developmen
Reliability. The NAPFI is reported to have good inte
tal delay. Several have been selected for review and
rater reliability, but no other measures of statistical sound
discussion here , and others are included in Table 13-2 .
ness have been reported .
Some of the neonatal neurobehavioral assessments
require certification for the examiner, and others do not.
The Neonatal Neurobehavioral Evaluation (NNE) (Morgan
et aI., 1988), the Neurological Assessment of the Preterm The Assessment of Preterm Infant
and Full-Term Infant (NAPFI) (Dubowitz & Dubowitz, Behavior
1981), and the NeurologiC Evaluation of the Newborn and
the Infant (Amiel-Tison & Grenier, 1983) do not require The APIB (AIs et aI., 1982) is one of the most compre
certification. The Neonatal Behavioral Assessment Scale hensive standardized evaluations available for the asses
(NBAS) (Brazelton, 1973, 1984), the Assessment of ment of the neurobehavioral functioning in preterm in
Premature Infant Behavior (APIB) (AIs et aI. , 1982), and fants . The AIPB is based on the NBAS (Brazelton , 1973
the Naturalistic Observation of Newborn Behavior (NONB) 1984), extending the types and amounts of data collecte
(Als, 1984) all require certification . The trainee should have and refining the use of the test for premature infants . Th
a strong background in normal and abnormal infant scoring and interpretation of this assessment is qui
development. Training occurs via workshops or video complex, requiring a certification process that require
tapes. The trainee then practices the assessment prior to approximately 1 year to complete. Therapists who seek t
concluding reliability training. Specific centers that provide become certified in the use of this instrument should hav
certification are listed in the back of each individual manual. excellent evaluation skills and experience, extensive expe
- ~ ..
; . -~ ....--...
co
ASSESSMENTS FOR INFANTS wmt LOW BIR'IH WElGIIT AND DIOSE
INFANTS AT WGH RISK FOR DEVELOPMENTAL DIFFICULTIES c
z
=i
Target Psychometric -n
0
Neonatal Population Purpose Tune Conunents Properties Reference C
;J:J
Assessment of Premature Premature Provide a comprehensive 45-60 min Standardized assessment of Reliability: IR = examiners AIs et aI., 1982; Als
:l
G)
Infant Behavior (APIB) infants neurobehavioral subsystem stability before, must be trained in adminis et aL 1988a, 'T'
;J:J
rience working with newborns, and good memory and ton Neonatal Assessment Center in Boston, Massachu
judgment (Vergara, 1991). The APIB provides information setts.
concerning the infant's response to stress, interactive
abilities, and the physiologic "cost" of stress and interac
tion, among other data. The data are collected in six areas The Bayley Scales of Infant
or "packages," which are arranged sequentially, placing Development-Second Edition
increasing demands on the response abilities of the infant.
The examiner identifies which tasks or handling proce The Bayley Scales of Infant Development-Second Edi
dures to which the infant responds well without interven tion (BSID-II) (Bayley, 1993) are based on the original
tion, the tasks the infant needs environmental support to Bayley Scales of Infant Development (BSID) (Bayley,
handle well, and the tasks the infant is not capable of 1969). Much of the original content has been retained, and
handling with or without support (Als et aI., 1988). new materials created. The purpose of the BSID-II is to
The infant must have the physiologic stability to tolerate assess the current developmental function of infants and
a number of handling procedures. The APIB takes between children. The BSID diagnoses developmental delay and
45 and 60 minutes to administer. As it also takes about the assists in planning intervention strategies. The BSm-II is a
same amount of time to score and interpret, it can be quite nationaJlly standardized, individually administered assess
costly and time consuming. However, this can be balanced ment. Three scales are included: 1) the Mental Scale, which
by the comprehensive nature of the data collected on includes memory, habituation, problem solving, early
completion. number concepts, generalization, classification, vocaliza
As the APIB requires very comprehensive training and tions, language, and social sk,j]Js; (2) the Motor Scale, which
certification, the interrater reliability can be perceived as includes control of gross and fine muscle groups; and (3) the
high. Each certified examiner must administer and score Behavior Rating Scale (BRS) (formerly the Infant Behavior
the test at r = 0.90 or higher before using the instrument. Record), which encompasses qualitative aspects of behav
The validity of the APIB is based on its original version, ior, including attention and arousal, orientation and en
the NBAS. The construct validity has been determined as gagement, emotional regulabion, and motor quality. The
adequate in discriminating between at-risk, high-risk, and BRS proVides supplemental information for the Mental
normal children. and Motor Scales.
The child receives credit or no credit on administered
items. Basall and ceiling levels are established in the Mental
The Neonatal Behavioral Assessment and Motor Scales. Raw scores, based on the number of
Scale items receiving credit, are calculated for all three scales.
The BRS raw scores are converted to percentiles. The raw
The NBAS (Brazelton, 1973, 1984) was developed to scores are converted into Mental Development Index (MOl)
measure the neurobehavioral responses of infants between and Psychomotor Development Index (POI) scores, with a
36 weeks and 44 weeks gestation. The test addresses 90 or 95 percent confidence interval based on one of the
neurobehavioral organization in the context of the infant's 17 age levels. Based on the MOl, POI, and percentiles, the
interactive abilities. Originally intended for use with full child's performance can be classified as within normal
term infants as a parental training tool, it is often used with limits or mildly, moderately, or significantly delayed.
premature infants as well. However, as performance on the Examiners using the BSID-II should have extensive
test items requires greater physiologic stability than some experience in administration and interpretation of assess
of other instruments assessing infant behavior (e.g., the ments of young children. The instructions should be
NONB, which does not require the handling of the infant), followed exaotly. When testing a child with a physical or
it is recommended that the NBAS be used as the pre perceptual deficit, the examiner may choose to adapt the
term infant approaches full-term gestational age (Miller & test items. However, the authors state that if the instruc
Quinn-Hurst, 1994). tions are changed, the results cannot be compared with
The NBAS has 28 behavioral items and 18 elicited those of the normative sample. Interpretation should be
responses (reflexes). The test items are grouped into completed as suggested by the Standards for Educational
clusters of behaviors, providing a description of the infant's and Psychological Testing (American Psychological Asso
overall behavior. The clusters include habituation, orienta ciation, 1992). All test materials and forms are provided in
tion, motor behaviors (including tone, response to sensory the BSID-II kit. The BSID-II is intended for children
information, and reflexes), range and regulation of state between the ages of 1 and 42 months.
behaviors, and autonomic stability. The Kansas Supple Standardization. Several pilot studies were conducted.
mentary items are for the evaluation of high-risk infants Based on the pilot studies, changes were made to test
(Brazelton, 1984). materials, scoring, or the manual. Try-out testing was then
Certification and training in the administration of this done with a stratified sample of 643 children. Stratification
assessment are needed. Information concerning the re was on the basis of race or ethnicity, parent education level,
quirements for this process are available from The Brazel gender, and age. Examiners used selected items from the
the BSID-II. After try-out testing, the BSIO-II was evaluated Factor one was emotional regulation, factor 2 was orie
for racial and gender bias. In addition, an expert panel tation or engagement, and factor 3 was motor quality.
reviewed the test items for bias. The norms for the BSIO-II The BSIO-II scores were compared with scores on t
came from a national, stratified (age, gender, race or original BSIO for 200 children. Moderate correlations we
ethnicity, geographic region , and parent education) ran found between the MOl (r = 0.62) and POI (r = 0.63). Th
dom sample that was representative of the U.S. population was expected due to the changes in the BSIO-II. The me
for children from 1 to 42 months of age. A total of 1700 score on the BSIO-II was lower for both the MOl and t
children participated, with 100 children in each of the 17 POI. The BSIO-II was also corre1lated with other tes
age groups. Details are in the manual. Thompson and colleagu
Reliability. The reliability for each scale at each of the age (1994) and Wasserman and coworkers (1993) examin
levels was calculated using coefficient alpha. The average the validity of the BSIO-II. Both studies confirmed that t
coefficient for the Mental Scale is 0.88 , for the Motor Scale BSIO-II had adequate construct validity.
is 0.84 , and for the total behavior rating scale is 0.88.
Standard error of measurements averaged 5 .21 for the
Mental Scale and 6 .01 for the Motor Scale.
Test-retest reliability was computed for four age levels (1, CONCLUSIONS
12, 24, and 36 months). The interval between testing
ranged from 1 to 16 days , with an average of 4 days. The The areas included and the type of instrument select
Mental and Motor Scale coefficients for 1 and 12 months for developmental and neonatal assessment depend p
were 0 .83 and 0.77, respectively. At 1 month, coefficients marily on the purpose of the evaluation. Some referr
ranged from 0.48 to 0.70 for the behavior rating scale; at clearly specify the reasons for referral and the areas
12 months, they ranged from 0 .57 to 0.90. At 24 and 36 components of function that should be assessed, but in t
months , Mental and Motor Scale coefficients were 0.91 for majority of cases, these decisions are left to the therapi
the Mental Scale, 0 .79 for the Motor Scale, and 0.60 to Assessment in the areas of developmental and neona
0.71 for the behavior rating scale. The total coefficients for assessment is most often a team process to provide the b
the combined ages were 0.87 for the Mental Scale and overall view of the child's strengths and problems.
0.78 for the Motor Scale . This chapter has presented an overview of just some
Interrater reliability was completed by having a second the variety of instruments available for evaluation
rater discretely observe the administration of the BSIO-II. children with developmental issues. Therapists should
Each rater independently scored the child. The MOl and cautious about interpreting the results of those evaluatio
POI scores were compared. Coefficients were 0.96 for the in which they do not have the appropriate training
Mental Scale and 0.75 for the Motor Scale. The authors expertise.
believe that the Motor Scale requires physical manipulation
of the child, which may have contributed to the lower
coefficients. Coefficients were also calculated for the BRS
for the youngest (0.70) and oldest (0.88) age groups.
Validity. Content validity for the three scales was estab
lished by having experts review both domains to be tested ConsolabiUty-The ability of a child to be consoled
and the individual items . Construct validity for the Mental comforted after a disruption of state.
and Motor Scales was established by correlating each item Developmental milestones-A progressive co
with the total score for each age for which the item was tinuum of recognized developmental skills and abilities.
included. Items were placed in the scale where they had the Full term-An infant born between 37 and 41 wee
highest correlation. Correlations between the MOl and POI after conception.
Three factors were identified for the 6- to 12-month age Individual educational plan (IEP)-A process fe
group, which accounted for 46 percent of the variance. erally mandated by the Education for Handicapped Ch
Factor one was orientation or engagement, factor two was dren Act (Public Law 94-142) and Handicapped A
motor quality, and factor three was emotional regulation . Amendments of 1986 (Public Law 99-457) for childr
Three factors were identified for the 13- to 42-month age preschool through secondary educational level who are t
372 UNIT FOUR-AGE-RELATED ASSESSMENT
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Brown, S. L., D'Eugenio, D. B., Drews, J. E., Haskin, B. S., Lynch, E. w. ,
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high-risk infants in the neonatal intensive care unit. American Journal and premature neonate. New York: Exce rpta Medica.
of Occupational Therapy, 48, 506-513. Schouten, P. w., & Kirkpatrick, L. A. (1993). Questions and concern
Morgan , A. E. , Koch, V., Lee , V, & Aldag , J . (1988) . Neonatal about the Miller Assessment for preschoolers. The Occupation
Neurobehavioral Examination: A new instrument for quantitative Therapy Journal of Research, 13(1), 7-28.
analysis of neonatal neurological status. Physical Therapy, 68, 1352 Short-Degraff , M. (Ed.) (1993). The Occupational Therapy Journal o
1356. Research, 13(1) .
Newborg, J., Stock, J. R, Wnek, L., Guidubaldi, J., & Svinicki, J. (1988). Thompson, B., Wasserman , J. D. , Gyurke, J. S., Matula , K, Mitchell,
Battelle Developmental Inventory: Examiner's manual. Chicago: H. , & Carr, B. (1994). The validity of mental and motor scores fro
Riverside. the new Bayley Scales of Infant Development lI: A second ord
Pratt, P. N. (1989). Occupational therapy in pediatrics. In P. N. Pratt & A. factor analysis. San AntoniO, TX: Southwest Educational Researc
S. Allen (Eds.) , Occupational therapy for children (2nd ed.). St. Louis , Association. (ERIC Document Reproduction Service No . ED 366623
MO: C. V Mosby Co. Vergara, E. R (1991). Overview of neonatal intervention (Unit 1
Pratt, P. N., Coley, I. L. , Allen, A. S ., & Schanzenbacher, K E. (1989). Tallahassee , FL: Department of Education.
Methods of assessments and screening . In P. N. Pratt & P. N. Allen Wasserman, J. D., Thompson , B. , & Matula , K (1993). The facto
(Eds.), Occupational therapy for children (2nd ed.). St. Louis, MO: structure of the Behavior Rating Scale of the Bayley Scales of Infa
C. V Mosby Co. Development II: Cross-sample, cross-sectional, and cross-metho
Prechtl, H. F. (1977) The neurological examination of the full-term investigations of construct validity. New Orleans: Mid-South Educ
newborn infant. Philadelphia: J. B. Lippincott. tional Research Association. (ERIC Document Reproduction Servic
Rogers, R J., & D'Eugenio , D. B. (1977). Assessment and application. No. ED 363 639).
In D. B. D'Eugenio & M. Moersch (Eds.), Developmental program
~
---- - I
'.' - ~''";.S; .. '
: ' I·
C HAP T E R 1 4
Pediatriics,: Assessment
of Specific Functions
Bonnie R. Decker, MHS, OTR
Joanne Jackson Foss, MS, OTR
This chapter focuses on the assessment instruments ing problems to evaluate specific components or areas of
available to evaluate specific areas of function and dysfunc function and to determine the effect these specific compo
tion in the pediatric population . Assessment in specified nents have on the child's overall functioning. Assessing the
areas of performance can be accomplished through the use specific functions might include taking a more in-depth
of standardized and nonstandardized assessments, as well Ilook at s1lch prerequisite capacities as visual-perceptual,
as skilled activity analysis and observation. As the therapist sensorimotor, play, and functional performance .
begins the analysis of the skills and functions that are It is important in this part of the assessment process to
creating difficulties for the child, the concern is not only maintain a view of the child's total functioning and not
what the child can or cannot do but also why the child's to become reductionistic. The tendency might be to begin
performance has been affected in such a manner. Subse to view the child as having, for example, a "fine motor/
quently, it is often necessary in Jjght of the child's present handwriting problem" or a "mobility problem" without
375
376 UNIT FOUR-AGE-RELATED ASSESSMENT
maintaining the larger view of the child's ability to function Each scale has skill categories. The gross motor scale
within the context of his or her environment (Pratt et aI., includes reflexes, balance, nonlocomotor, locomotor, and
1989). Developmental skills and capacities are interrelated receipt and propulsion of objects. The fine motor scale
and therefore cannot be considered in an isolated manner includes grasping, hand use, eye-hand coordination, and
without losing sight of the child's overall occupational manual dexterity.
performance in the home, at play, or in school. The PDMS has been widely used by pediatric therapists.
As discussed in the previous chapter, the therapist However, several criticisms have been made; scoring
continues to be profeSSionally obligated to gain sufficient criteria for the score of 1 are indistinct, making it difficult to
knowledge about the use of assessment instruments and to judge whether a performance is a 0 or a 1. Another
apply the information gained through their proper use in concern has been that the Gross Motor Scale is nondis
an ethical manner. The selection , administration , and criminatory for children with and without delays from 48 to
interpretation of evaluation instruments is an important 59 months of age. This is an issue because the PDMS is
professional responsibility. The impact of this process can widely used for this age range. In addition , the total test is
have far-reaching effects on the lives of children and their noIidiscriminatory for children with and without delays
families (King-Thomas, 1987). from5irtb to 5 months. It is also of concern that relatively
few test items are available in the test kit. The remaining
equipment is not speCifically described, making it difficult to
adhere to the standardization process (Hinderer et al.,
SENSORIMOTORASSESSMENT 1989).
The complete test takes abou~45 to 60 minutes to
Sensorimotor capacities in children include a wide range administer, which aHows about 20 minutes per scale. A test
of varied skills and abilities . The process of sensorimotor kit includes some materials, but others will have to be
development is a series of increasingly complex skills supplied by the examiner. Examiners should familiarize
culminating in the child's ability to form adaptive motor themselves with the manual instructions prior to adminis
responses based on sensory motor input. Sensory infor- tering the test. During administration of the test items, a
mation from the visual , tactile, vestibular, proprioceptive, basal and a ceiling level are established within each skill
and auditory syst';ms provides the basis for the develop- 'categury. The scoring criteria are consistent for the entire
ment ·of posture and· equilibrium and gross and fine motor test; a score of 0 indicates failure, a score of 1 notes a clear
skills. Learning toiIlt~grate and interpret sensory input and resemblance to the criterion, and a score of 2 indicates that
to refine motor responses allows the child to develop the the child performs the behavior exadly. The raw scores are
skills that are prerequisite for academic performance. totaled for each skill category and each scale. These scores
Young children that manifest sensorimotor deficits ex- are converted to percentiles, standard scores, age equiva
perience delays in the acquisition of gross and fine motor lency, mean motor age equivalency, and scaled scores.
milestones; they frequently have not integrated early The normative sample was stratified by geographic
reflexive behaviors and display poor balance and coordi- I region, race , and sex. A total of 617 children were
nation . Sensorimotor delays can be observed later with included . The-home was the primary test site.
delays in auditory-language
-
and visual-spatial
- skills ,
and The standard error of measurement ranged from 1.10 to
become more obvious in the school years with difficulties in 5.39 for the 17 age levels. This indicates good stability of
cOQs;:eptual abilities, reading, writing , and mathematics. scores. Interrater reliability was established by having a
A variety of assessments of sensorimotor functions are second rater observe the test. The coefficients were 0.99
available; a selected group are discussed both in the text for the total test. Coefficients on individual items were
and in Table 14-1. Selection of the most appropriate 0.965 for the Gross Motor Scale and 0.940 for the Fine
instrument is made on the basis of the age of the child, the Motor Scale. Test-retest reliability was determined after a
type of the information needed, and how the information time interval of no more than 1 week for 38 children.
will be used. Coefficients were 0.99 for both scales when including the
basal items. When looking only at the items administered,
the coefficients were 0.946 for Gross Motor Scale and
The Peabody Developmental 0.801 for Fine Motor Scale.
Motor Scales Content validity was established as the authors re
searched other valid normal motor development assess
The Peabody Developmental Motor Scales (PDMS) ments, and the content was verified by examining Harrow's
(Folio & Fewell, 1983) assess the gross and fine motor skills Taxonomy. Construct validity was demonstrated through
of children from -birth to 83 months of age in relation to review of motor development theory. Consistent with
their adaptive capacities~ The PDMS identifies the areas of this theory , scores on the PDMS increase with age . The
strengths and weaknesses, and the areas identiAed are then PDMS can also identify children with problems, as com
used to facilitate programming. The test is administered pared with the normative sample. Criterion-related validity
individually. The PDMS is standardized and has two scales. was determined by comparing scores on the PDMS with
TABLE 14-1
PEDIATRIC ASSESSMENTS
Sensorimotor
Gross and Fine Target
Motor Tests Population Purpose TIme Comments Psychometric: Properties Refereoc:e
Alberta Infant 0-18 mo Measures gross motor 20-30 min Norm-referenced tool. Con Normative sample: 2202 Cana Piper & Da
Motor Scale maturation, monitors tains 58 items. Observes dian infants stratified by sex 1994
(AIMS) motor behaviors es child in four positions: and age
sential to evaluation prone, supine, sitting, and Reliability: IR for single occasion
of development of at standing. Score sheet has and across occasions = 0.955
risk infants over time drawings with key descrip to 0.996; TR = 0.858
tions of postures or move to 0.948
ment components that Validity: Content established by
must be present to receive experts; concurrent-scores
credit. Positional and total were correlated with PDMS
scores obtained . Scores are gross motor scores
graphed and percentiles es (0.90-0.99) and BSID motor
tablished. scale (0.84-0.97)
Bruininks-Oseretsky 4 .5-14.5 y Test of developmental 45 min Norm-referenced test. Normative sample: 765 American Bruininks, 1
Motor Develop- gross and fine motor Domains: Four fine motor children
ment Scale skills subtests and five gross mo Psychometric results are mixed;
(BOTMP) tor subtests. Requires large reader is referred to the review
room for some test items. for overview
Erhardt Develop- Birth to 15 mo; Measures qualitative Varies with age Criterion-based test; com Appropriate psychometric data Erhardt, 19
mental Prehen- 1-6 y change in the devel- of child pares quality and level of not available for the use of test
sion Assessment opment of hand func performance to develop as a standardized instrument
(EDPA) tion in children with mental progression of hand
developmental delays function.
J,
.~ I Gross Motor Func-
tion Measure
(GMFM)
Children with
cerebral palsy
Measures changes in
gross motor function
over time
Criterion-based observation in
five dimensions: lying and
rolling; sitting; crawling and
Normative sample: Described in
manual
Reliability-IR = 0.87-0.99 for
Russell et aI
1990
Infant Neurological 1-15 mo Assesses neurologic 10-15 min Standardized , individually ad Normative sample : 308 infants Ellison et al.. t
G>
International Bat integri~ from ministered 20-item test bat tested, with some tested more 1985; 'Y'
:JJ
tery (INFANIB) neonatal intensive tery. Items come from the than once , yielding 365 tests Ellison, m
care unit through Milani-Comparetti, French Reliability studies are in progress 1986 ~
m
follow-up angles, primitive reflexes, Content validity-Review of Cl
and hand and head posi literature; criterion validity- l>
en
tion. Test sheet used draw Factor analysis revealed interre en
m
ings and descriptions of latedness of test items en
en
scores. Scoring is on a con s:
m
tinuum of 1 to 5. Cutoff Z
-;
scores are given for three
age levels. Cutoff scores in
dicate normal, transient,
abnormal results. Complete
instructions are available
·from the first author.
Movement Assess 0-12 mo Systematic assessment 30--{'0 min to Standardized, criterion Normative sample: Norms have Chandler et aI. ,
ment of Infants of motor behaviors; give test; referenced assessment. not been established yet; how 1980
(MAl) identifies motor dys 30 min to Four sections: muscle tone, ever, there is a profile for
function and monitors score primitive reflexes , auto 4-month-old infant behavior
the effects of inter matic reactions, and voli Value of high-risk scores estab
vention tional movement. Each sec lished on 35 infants tested at
tion has its own scoring 4 months and at 1 year
scale. Scoring is based on Reliability and validity are not in
risk points. A high score the manual
indicates a poor perfor
mance.
Peabody Develop 0-83 mo Assesses a child's gross 45--{'0 min; Administered individually; Normative sample: Sample was Folio & Fewell,
mental Motor and fine motor skills each scale is standardized test. Has two stratified by geographic region, 1983
Scales (PDMS) in relation to adaptive about 20 min scales. Each scale has skill race , and sex; 617 children
capacities; identifies categories. The gross mo were included-The home was
areas of strengths and tor scale includes reflexes, the primary test site
weaknesses that facili balance. nonlocomotor. lo Reliability: SEM = 1.10 to 5 .39 for
tate programming comotor, and receipt and the 17 age levels; IR = 0 .998 for
propulsion of objects. The Gross Motor Scale and 0 .996
fine motor scale includes for Fine Motor Scale ;
grasping, hand use, eye TR = 0 .946 for Gross Motor
hand coordination , and Scale and 0.801
manual dexterity. Basal and for Fine Motor Scale (both are for
ceiling established. Raw items administered)
scores are converted to Content, construct, and criterion
percentiles, standard referenced validity described in
scores, age equivalency, manual
mean motor age equiva
lency, and scaled scores.
Test kit includes some ma
terials.
Posture and Fine Developmental Identifies quality of mo 30-45 min The child's postural control Normative sample: Not available. Case-Smith,
Motor Skills As age of tor function and ma and proximal stability are Reliability: IR = 0.988 for the 1988, 19
sessment of In 2-6mo jor motor problems observed in prone and su posture section , 0.989 for the 1992, 19
fant (PFMAI) typically not identified pine. Then, fine motor and fine motor section, and 0 .989
until the child is older distal control are observed. for the total test; TR was estab
Basic testing equipment is lished after 2-5 d; coefficients
required. Instructions for were 0.853 for the posture sec
administering and scoring tion, 0.913 for the fine motor
items are in manual. section, and 0.936 for the total
test.
Validity: Construct validity estab
lished by correlating PFMAI
scores with age; coefficients
were 0.941 for the total test
0 .924 for fine motor section ,
and 0 .892 for the posture
section; concurrent validity es
tablished with 32 normal in
fants correlating PFMAI with
the PDMS; coeffiCient for pos
ture section was 0.83, and for
fine motor section was 0 .67.
Quality of Upper 18 mo-8 y A qualitative assessment 30-45 min Criterion-referenced test. 34 Reliability: IR total score = 0.95, DeMatteo et
Extremity Skills of developmental pat items in four domains: dis with range of 0.51-0.96; TR 1993
Test (QUEST) terns that form the sociated movements, grasp, total score = 0 .95, with range
base for functional weight bearing , protective of 0.75- 0.95
upper extremity use extension. Each upper ex Validity: Content from review of
tremity scored separately. literature; construct correlated
No scoring criteria in therapist's judgment of hand
cluded. function to chronologic age
Correlations were 0.58-0.72 for
hand function and 0.33 with
chronologic age; concurrent
established by comparing the
QUEST to PDMS: correlations
were 0.58 for total test and
0 .48-0.84 on individual do
mains
·il
Table continued on following
, ~
PEDIATRIC ASSESSMENTS Continued c:
Z
-i
."
SensorilDOtor o
c:
Gross and Fine Target ::rJ
BSID = Bayley Scales of Infant Development; IR = interrater reliability; SEM = standard error of the mean; TR = test-retest reliability.
correlation coefficient for the BSID Mental Scale with the test-retest reliability, internal consistency, and validity of
PDMS total Fine Motor Scale was 0.78, with skill catego this test. An interrater reliability study was conducted using
ries ranging from 0.26 to 0.80 . The coefficient for the an earlier version, but is not reflective of the current EDPA
BSID Motor Scale with the PDMS total Gross Motor Scale (Erhardt, Beatty, & Hertsgaard, 1981). In a study of
was 0.37 , with skill categories ranging from O.OS to 0.64. intrarater and interrater objective reliability in trained and
Correlation to the West Haverstraw was similar. This range untrained examiners, examiners rated children's perfor
of coefficients was what the authors expected. mance by use of videotape (Scheer et al., 1994). The study
demonstrated high levels of intrarater objectivity among
trained examiners (with median correlaHon coefficients of
The Erhardt Developmental 0.91 and 0 .88) and interrater reliability in the moderate to
Prehension Assessment high range (with a median correlation of 0.77). In their
analysis, the authors showed that the interrater reliability
The Erhardt Developmental Prehension Assessment was improved by training. In two recent studies of interrater
(EDPA) (Erhardt, 1982) is designed to assess the develop reliability, altered versions of the test have been used
ment of hand function in children. This test measures (Pollock et aI., 1991; Tomacelli & Palisano , 1990). Both of
qualitative change in hand function and was designed to aid these studies have shown promising results, but the
in the treatment planning process. The EDPA is widely alterations of the items and the scoring procedures make it
used by pediatric therapists (Henderson, 1991). This difficult to apply the results to the assessment available and
criterion-referenced test assesses the development of pre to clinical use.
hension patterns from gross upper extremity movements
to fine fingertip prehension . Based on the .sequenti 1
progressions and age levels of the development of rehen The ,Bruininks-Oseretsky ,Motor
siol) from the work of Gesell and Halverson, the test is Development Scale
designed to be used with children who have developmental
delays by comparing performance with the normal devel The Bruininks-Oseretsky Motor Development Scale
opmental progression of hand function. .0 I ' (BOTMP) (Bruininks, 1978) is a standardized t'est of
The instrument is divided into three sections. The first developmental gross and fine motor skills. It is administered
two sections evaluate involuntary positional and reflexive to individual children from 4.S to 14.S years old who
patterns and voluntary cognitively directed patterns from appear to have motor pro ems -nor related to obvious
birth to IS months of age. The third section addresses neurolo ic d sfunction. Forty-six test items are divided into
pencil grasp and prewriting skills from 1 to 6 years of age. eight subtests. e fine motor subtests are upper limb
The first two sections of the test are useful for evaluating the coor . ation, speedaria exterltY, respons_e speed, and
postural prerequisites of prehension for children who have vistral~b or c ntrol. The gross motor subtes s are: run
not yet developed independent hand function. Erhardt ning speed and agility, balance, bilateral coordination, and
(1982) states that the IS-month-old skills as described in strength. The test takes approximately 4S minutes t6
this scale represent mature prehension and present an administer and requires a large room to accommodate the
approximate norm for assessing the prehension skills of balan.c.e bejl..m, running , ana
otner gross motor items. This
older children. standardized assessment appears to be Widely used by
Each developmental pattern is depicted in a draWing , pediatric therapists. The BOTMP is easy to learn to use and
and the child is scored on the age-appropriate skill, as well has a clearly detailed manual with administration and
as on the sequential prerequisite components needed for scoring instructions.
each pattern. The assessment is scored using a four-level On each item the child is scored on how long it takes to
hierarchic rating of a plus (+) or minus (-) scale. From complete the task, the number of repetitions performed,
highest to lowest, each pattern is scored as well integrated the number of errors made, or by passing or failing
and normal (+), not present (-) , emerging or not well according to set criteria. The child's raw score on each item
integrated (±), or transitional (+t). is converted to,2.floint sco re.,- the point scores are totaled,
The EDPA, originally published and distributed nation and each subtest is comguted to a gro -motor, fine motQJ,.
ally in 1979, has undergone two revisions by Erhardt. The and totru5atteQ,l_composite-score. Subtest scores can be
current version now in use was revised in 1982. In its converted- t~ standard scores, percentile ranks, or age
current form , this instrument continues to lack the psycho equivalent scores. epara e norms for boys and girls are
metric requirements necessary as a standardized, objective provide for the total battery score. Directions-and scoring
measure. The administrative and scoring instructions are instructions are included for a ; hort screening f;rm of the
not clearly presented, and the testing environment is not battery, which takes approxiii'1atel)l -15 020 ~inutes to
specified (Pollock et al., 1991). In a critique of this test, administer and score . - _.J
Dunn (1983) has stated that research studies are needed to Reviews of the psychometric properties of this testing
-----
,
382 UNIT FOUR-AGE-RELATED ASSESSMENT
instrument are mixed, and although i~ is recommended as point scores on these subtests will be the best indicators o
a good evaluative to,.Qt.jQe } herapist needs to be aware of the child's strengths and deficits in motor function. The low
its limitations. A ~test-retest ,study on nondisabled children test-retest reliability on the Response Speed and Balanc
fou'ld fair to gocxflest;retest reliability for second and sixth subtests is problematic as well, with the Response Spee
grad~ondisabled children (DeGangi, 1987). The reliabil subtest having the least value (see Table 14-1).
ity coefficients for the total battery and for the short form
version of the test were abo\f~ .80 f.~) both grades. The
coefficients for grade two were fJ'"':'I7 for the gross motor
composite~ .88 fu r the fine motor composite, an~§5 SENSORY INTEGRATION
an~t.. 0.68, \ r espectively, for the sixth grade children.
Coefficients for individual subtests ranged from 0.58 to Sensory integration addresses the integration and orga
0.89 for second grade and from 0 .29 to 0.89 for sixth nization of the information from the different sensor
grade. They were abov~0.80 for all subtests except for modalities. This input is received from the environment an
Balance and Response Speed. Interrater reliabilty has only from ones's body and is used in dealing effectively with th
be enevaluated for one of the eight subtests. The interrater environment (Ayres, 1991). Sensory integrative theor
reliability was determined for the Visual-Motor subtest only and practice is based on the work of A. Jean Ayres. Th
and was reported by Bruininks (1978) to be 0 .77 to 0 .97 theory of sensory integration continues to be modified an
on individual test items in the subtest. revised through the research that continues in neurobio
To measure eonstruct validity, Bruininks (1978) cited logic processing and treatment efficacy studies bein
"
three studies in the-manual contrasting the performance of conducted by therapists. The goal of Ayres' research was t
children with and without mental and learning disabilities; describe the relationships between behaviors, such a
only the Response Speed subtest did not discriminate sensorimotor and academic learning , and neural function
among the groups of children . In studying the relationship ing. Ayres felt that in studying these relationships, it wa
of subtest scores to chronologic age, correlations ranged important to look not only at the'yisual system but also a
from 0 .57 to 0.86, indicating a strong relationship. In the vestibular, proprioceptive, and tactile systems (Walker
measuring illternaLconsistency, correlating iodilJidtial test 1993).
items with subtest scores and the total test scores, Bruininks Children with sensory integrative problems exhibit prob
(1978) reported moderate to high correlations, indicating lems integrating and processing sensory and motor behav
that the functions in each subtest were related and that the ior. They display deficits in cognition, language, percep
subtests are measuring overall fine and gross motor tion, and motor skills, and they often have difficulties wit
development. .emoJional stability (Ayres, 1972; DeGangi et aI., 1993)
The standard error of measurement (SEM) for this Often, the problems of children with these difficulties g
instrument iSrather large , complicating the scoring process unrecognized until they enter school and begin the proces
for examiners. As reported by Bruininks in the test manual of learning reading, writing, and mathematics . Most ofte
(1978), the SEM for subtests, which have a mean of 15 and these children are identified as being learning disabled
a standard deviation of 2, is 2 or 3 standard score points. however, it has become increasingly recognized that simila
For the composite scores, which have a mean of 50 and a problems are apparent in children with deve:[opmenta
standard deviation of 10, an SEM of 4 or 5 standard points delays .
is applied . Several instruments measuring sensory integrative func
Wilson and co'l1eagues (1995) make severa~ suggestions tioning are presented here and in Table 14-2. Ihe tool
in light of their analysis of the BOTMP. Because of the lack were selected as a representative sample of those availabl
of interrater reliability studies, they caution that the test, to test areas of sensory processing and function.
when used to show improvement, should be administered
by the same examiner. They also make other suggestions
as a result of their examination of the use of the BOTMP in The DeGangi-Ber,k Test of Sensory
reevaluation and as documentation of the efficacy of Integration
treatment. The authors note that the normative standard
and composite scores that were based on a population of The DeGangi-Berk Test of Sensory Integration (TSf
nondisabled children may not show change if the progress (Berk & DeGangi, 1987) is a standardized, criterion
is slower than normal developmental maturation. As a referenced assessment that measures sensory integrativ
result, they suggest that therapists use the subtest 120int abilities. The purpose of the test is to detect sensor
scores rather than the composite and standard scores for integrative dysfunction in the early years. The test result
comparison. From their analysis , they also report that the can be used for screening or diagnosis, depending on th
subtes~s Running Speed and Agility, Balance, Visual Motor needs of the child. The TSI is intended for children from
Control, Upper Limb Speed and Dexterity appear to ages 3 to 5 with suspected sensory integration problem
provide the greatest degree of discrimination between and should not be used alone to determine the diagnosis
children with and without motor problems. Therefore, the The TSI includes 36 items that are divided into thre
TABLE 14-2
PEDIATRIC ASSESSMENTS
Sensory Target
Integration Population Purpose TIme Comments Psychometric Properties Reference
A Guide to Testing 5--6 y Clinical observation of 30-45 min Nineteen subtests, with focus on No psychometric information; Dunn, 1981
Clinical Observations children's perfor postural mechanisms and reflex does provide standard z
in Kindergarten mance on variety of integration, including eye domi scores for some items
tasks; provides a nance and eye movements. Ad
foundation for fur ministration and scoring de
ther study scribed in manual. No overall
interpretation. Evaluators should
be familiar with sensory integra
tion theory.
DeGangi-Berk Test of 3-5 y Detects sensory inte 30 min Thirty-six items on three subtests: Normative sample: 101 normal Berk & DeGangi,
Sensory Integration grative dysfunction postural control, bilateral motor children and 30 delayed chil 1983, 1987
(TSI) integration, and reflex integra dren in the Washington DC
tion. Scores are interpreted as area and 8 delayed children
normal, at-risk, or deficient. in Indiana
Some equipment comes in the Reliability: IR = 0.67-0.79 for
kit. Evaluators should be familiar postural control; 0.74-0.76
with sensory integration theory. for bilateral motor
integration; 0.14-0.49 for
reflex integration, and
0.73-0.79 for the total test
Decision
reliability = 0.79-0.93;
TR = 0.85-0.96
, Validity: Content-panel of ex
perts reviewed; construct
items demonstrated a signifi
f cant discrimination index;
classification accuracy for
test = 81 %; least effective
subtest was reflex integration;
intercorrelation matrix showed
moderately low subtest coef
ficients (0.39-0.65)
; i~
i integration theory
~
(I Table continued on follOWin
•
c
z
=i
o"
c
::xl
~
m
:b
m
r
~
m
o
»
en
TABLE 14~2 en
m
en
en
PEDIATRIC ASSESSMENTS Continued s:
m
Z
-i
Sensory Target
Integration Population Purpose Time Comments Psychometric Properti_ Reference
Touch Inventory for 6~12 y Screening test for tac 10 min Language competency of 6 years Normative data: 415 children Royeen, 1985, 1990
Elementary-School tile defensiveness old; IQ of 80; no physical dis included
Aged Children mE) abilities. Items can be repeated Reliability: IC = 0.79 (Royeen.
until the child understands. 1986); TR = 0.59 (Royeen.
Equipment easy to make. Some 1987a); IR = 1.00
training required. TIE included Validity: Content through panel
in appendix. of experts (Royeen, 1985);
discriminates between nor
mal and children with tactile
defensiveness (85% accuracy)
(Royeen, 1986)
Touch Inventory for Teachers of Screening test for tac 60 min Teachers of the children were Normative data: Not Royeen, 1987b
Preschoolers (TIP) children tile defensiveness interviewed about a child 's be available--patterns
2.5-4.5 y haviors of scores presented
Reliability: IC = 0.90
Validity: Content through re
view by experts
......... ----- - ~
z
=i
-n
0
C
~
:l
Gl
'T'
~
m
r
~
m
Cl
»
en
TABLE 14-2 en
m
en
en
PEDIATRIC ASSESSMENTS Continued s:
m
Z
-j
SensoI'V Target
Integration Population Purpose TIme Comments Psychometric Properties Reference
Touch Inventory for 6-12 y Screening test for tac 10 min Language competency of 6 years Normative data: 415 children Royeen , 1985. 1990
Elementary-School tile defensiveness old; IQ of 80; no physical dis included
Aged Children (TIE) abilities. Items can be repeated Reliability: IC = 0 .79 (Royeen.
until the child understands. 1986); TR = 0.59 (Royeen ,
Equipment easy to make . Some 1987a); IR= 1.00
training required. TIE included Validity: Content through panel
in appendix. of experts (Royeen, 1985);
discriminates between nor
mal and children with tactile
defensiveness (85% accuracy)
(Royeen, 1986)
Touch Inventory for Teachers of Screening test for tac 60 min Teachers of the children were Normative data: Not Royeen, 1987b
Preschoolers (TIP) children tile defensiveness interviewed about a child's be available-patterns
2.5-4.5 y haviors of scores presented
Reliability: IC = 0.90
Validity: Content through re
view by experts
more extensive information needed to use this test battery riences and functions within the family, at school , and with
in the clinic competently. peers. The willingness of the teenager to cooperate
appears critical to the establishment of a rapport early in
the interview process. The interview takes approximately
1 hour. The questions are divided into six sections repre
PSYCHOSOCIAL ASSESSMENT senting the developmental stages of the occupational
choice process . Rating criteria are predetermined for each
Psychosocial assessment in pediatrics addresses a variety individual question; as the criteria are based on evidence of
of behaviors, ranging from the normal stresses and transi normative behaviors rather than on the behavior itself, the
tions of childhood to the persistent maladaptive problems author feels subjective value judgments can be eliminated
that result in a label of psychopathology . Most children from influencing the scoring of the items. Using a plus and
being treated by therapists are at risk for difficulties in minus system of scoring, the appropriate behaviors (+),
psychosocial and emotional development no matter what marginal or borderline behaviors (0) , and inappropriate
their primary diagnosis. Often in looking for th~e sensorimo: behaviors (-) are identified .
tor deficits underlying behaviors, therapists often overlooK The content of this assessment was developed by a
these-domains and their effect on self-care, play, commu review of the literature on child and adolescent role
nication , and school performance (Cronin, 1996). behaviors. A test-retest study was conducted on a sample of
In choosing an appropriate evaluation tool, it is impor 12 adolescents diagnosed with psychiatric dysfunctions
tant to remember that a child 's performance on assess and 28 normal subjects. The median coefficient was 0.91,
ments of psychosocial functions can be influenced by the indicating high reliablity in this small sample (Black, 1982).
stimulation level of the test environment and the effects of
the medications often prescribed to influence behavior.
Therefore, information and data collected should be con The Preschool Play Scale
firmed through skilled observations of the child in the
natural settings and environments in which the child is The purpose of the Preschool Play Scale (PPS) (Knox
expected to perform, such as the classroom, community, 1974) is to provide a descriptive measure of free play. The
and home. It is also valuable to obtain information through PPS is designed to measure play behaviors in children from
direct interviews with the child, teachers, and caregivers. birth to 6 years of age. Play behaviors are described in
Several of the instruments available for the assessment of yearly increments across four dimensions : space manage
pediatric psychosocial function and dysfunction are dis ment, material management, imitation, and participation.
cussed both in the text and in Table 14-3. Tests of The dimensions include 16 categories of play behavior.
cognition and intelligence are not covered here, as the Through observation , the child 's level of play is recorded
assessment of these domains of psychological functioning for each dimension. Descriptions of the play behaviors are
are most often conducted by other professionals. The tools on the score sheet. The examiner records the presence or
selected for discussion here are meant to be a representa absence of each of the 16 behaviors. The examiner then
tive sample of the types instruments available to assess the looks at each dimension 's behaviors and decides on an age
areas of psychosocial performance as both a primary and level that most of the descriptors are in. The play age is
secondary diagnosis. determined by averaging the dimensional scores. A play
quotient can be calculated by dividing the play age by the
child's chronologic age and multiplying by 100. The play
The Adolescent Role Assessment observer needs a general understanding of the four dimen
sions of the scale and adequate knowledge of early
The Adolescent Role Assessment (Black, 1976) is an childhood development. The observation period may las
instrument designed to identify adolescents at risk for from 15 to 30 minutes. Longer periods may increase
making poor occupational choices. Occupational choices reliability (Harrison & Kielhofner, 1986).
are those decisions that culminate in the selection of an Interrater reliability was examined with 90 subjects
occupational role . This assessment is based on the premise between the ages of 4 months and 6 years. Correlation
that occupational choice is a developmental decision coefficients were 0.996 for the overall play age, with
making process (Ginzberg, 1972). The Adolescent Role ranges of 0.98 to 0.99 for the four dimensions. Test-retes
Assessment explores the teenager's past and present reliability was completed after a I-week interval, with
performance through the use of a semistructured inter coefficients of 0.96 for the play age and 0.86 to 0.96 for
view. Intervention decisions can then be based on the the four dimensions (Bledsoe & Shepherd, 1982).
hypothesis that the skills needed to make occupational Content validity was established because the items were
choice decisions have not been developed as part of the based on play theory literature (Knox, 1974). Concurren
childhood developmental process (Black, 1982). validity was established by comparing play ages with
Through the use of a gUided dialogue, the examiner asks chronologic ages, with a correlation of 0.89 to 0.95 for the
questions related to the adolescent's childhood play expe four dimensions and 0.96 for the total score. Scores on the
TAB LE 14- 3
PEDIATRIC ASSESSMENTS
Target
Visual Perception Population Purpose Time COlDIDents Psychometric Properties Reference
Developmental Test of 4-10 y Identifies presence and 30-60 min Eight subtests: Four require eye-hand
Normative sample: 1972 children in Hammill et aI.,
Visual Perception degree of visual per coordination (eye-hand coordina
12 states representing four major
II (D1VP-2) ception deficits to refer tion, copying, spatial relations,
U.S. Census districts; sites selected
those children for ser visual-motor speed), and four are from PRO-EO's customer files; 14
vices, to evaluate effec motor reduced (position in space, data collectors represented 16
tiveness of interven figure--ground, visual closure, form schools and tested all children in
tion. and to serve as constancy). Kit includes all materials the school (demographic informa
research tool tion in manual)
subtests
criterion-related-established by
~
m
TABLE 14-3 0
:l>
en
en
PEDIATRIC ASSESSMENTS Continued m
en
en
:;;
m
Target Z
--
Visual Perception Population Purpose Time Conunents Psychometric Properties Reference
Test of Visual 4-12 y Determine child 's 7-15 min Test includes seven subtests: visual Normative sample: 962 children Gardner, 1982
Perceptual Skills strengths and weak diSCrimination , visual memory, from the San Francisco Bay area
(TVPS) nesses in visual percep visual-spatial relationships, visual with an age range of 4 y-12 y, 11
tion based on nonmo form constancy, visual sequential moo testing was conducted at 12
tor testing memory, visual figure-ground. and schools
visual closure. Child points to or in Reliability: IC = 0.83-0.92 for the
dicates correct answer. All subtests total test, with a median of 0.90;
are administered. Ceiling is estab these are generally higher at lower
lished on all subtests. Raw scores age levels; SEM = total test: 3.0-4.12
are converted into standard scores, across age groups. with a median
percentiles, and perceptual ages of 3.2; subtests range from 1. 34-1. 75
from one of nine age levels. Validity: Content- weak; item validity
Spearman rank order correlation
between item order and item
difficulty = 0.90-0.99; concurrent
subtests intercorrelations range
from 0.18-0.40; children with
learning disabilities scored Signifi
cantly lower; criterion-related
established by comparing two tests
skill that develops as the central ervous system does, The Developmental Test of Visual Perception-Second
perceptual skills and abilities vary acro;; different age Edition (D1VP-2) (Hammill et aI., 1993), is based on
ranges in pediatrics. This makes the assessment of these Frostig's (1964) original Developmental Test of Visual
PEDIATRIC ASSESSMENTS
Psychosocial Target c
z
Assessments Population Purpose TIme Comments Psychometric Properties Reference =i
-n
0
C
Adolescent Role 13-17y Identifies deficiencies in 1h Data collected through guided Sample: 12 adolescents with vari Black, 1976, 1982 ::0
'I
"',; .,
.llt
,"
t- ~ ~i
i!
394 UNIT FOUR-AGE-RELATED ASSESSMENT
Perception. The purpose of the DTVP-2 is fourfold: (a) to and 0.95 for the total test. Interrater reliability wa
identify the presence and degree of visual perceptual or established by having two people independently score 88
visual-motor difficulties in a child , (b) to identify children protocols. The coefficients ranged from 0.87 to 0.98 fo
who should be referred for services, (c) to evaluate the the subtests and 0.98 for the total test.
effectiveness of intervention programs , and (d) to fun~ti.Q,n. Content validity was established through the rational
as a research tool. The DTVP-2 is a battery of~e for the content of the sub tests and demonstrated by th
subtests,l each measuring a different part of visual per- results of the item analysis procedures that were use
ception and visual-motor abilities. All eight subtests are during the test construction. Concurrent validity wa
interrelated. Four of the subtests are motor enhanced, established by comparing the DTVP-2 with the MVPT
meaning that they require eye-hand coordination: (a)eY..e (Colarusso & Hammill, 1972) and the Developmental Tes
hand coordination, (b) copying, (c) spatial relations, and of Visual-Motor Integration (VMl) (Beery, 1989). The coef
(d) l1sual-motor speed. TFie@he;: four subtests are motor ficients comparing the DTVP-2 with the MVPT range from
reduced , meaning that the child may point to a correct 0 .27 to 0.82 for the subtests and 0.78 for the total test. Th
answer: (a) position in space, (b) figure-ground , (c) visual coefficients for the DTVP-2 and the VMI range from 0.41
closure, and (d) form constancy, - ) to 0 .95 for the subtests and 0.87 for the total test. Thes
-rQ~ DTVP-2 is appropriate for children betwee~nd " indicate that the DTVP-2 has concurrent validity. Con
~O years oj age. The directions can be adapted for chilOren struct validity was supported through age differentiatio
who are non-English speaking or hearing impaired. The because children's performance increases with age. Th
test can also be used for children with motor impairments. DTVP-2 scores were intercorrelated. The coefficients wer
In these instances, the examiner should determine the all Significant (P < 0.01). The median coefficient was 0.36
appropriateness of administering the motor-enhanced This indicates that a low degree of relationship exist
subtests . between the subtests. The DTVP-2 was compared with th
The equipment includes the examiner's manual, a National Teacher Assessment and Referral Scales (NTARS
picture book, a response booklet, and a profile/examiner (Hammill & Hresko, 1993). The coefficients indicated tha
form. Standardized instructions and scoring criteria are perceptual skills were diHerent from cognitive skills. Facto
included in the manual. Some subtests have ceilings; others analytic studies of the DTVP-2 yielded one factor. Thi
do not. Raw scores are obtained for each subtest. These are supported its validity as an assessment of visual perception
converted to age equivalencies, percentile rankings, and Because this is a new test no other research studies ar
standard scores according to the child's chronologic age. available.
Composite quotients, percentiles , and age equivalencies
are also obtained for the overall test, the motor-reduced
subtests, and the motor-enhanced subtests. Standard
scores can be placed on a graph. Space is also available to FUNCTIONAL ASSESSMENTS
record administration conditions.
The battery can be administered by anyone interesteq in Comprehensive pediatric assessment should always in
looking at visual perceptual skills inc hildren. The authors clude the evaluation of age-appropriate functional abilities
recommend that examiners receive formal training in Developing independence in the daily functional skills o
assessment. The test takes approximately 30 to 60 minutes self-care and environmental competence, such as feeding
to administer. It can be administered in as many sessions as mqbility, dressing, and grooming, are critical co'ffiponent
needed. of the developmental processes. Assessment of the child'
Normative information was collected on 1972 children. performance in these areas provides information concern
Data collection sites were selected from PRO-EO's (Austin, ing the child's ability to apply the discrete developmenta
TX) customer files . Fourteen data collectors representing milestones to mastery and independence in his or he
16 schools participated. The data collectors represented environment. Treatment goals in pediatric interventio
the four major U.S. census districts . All collectors tested all include enhancing the quality of life of children wit
appropriate children in the school (unless the parent had disabilities by aiding in the inclusion of such children in th
not given permission). Complete demographic informa home, school , and community at large; to do so means tha
tion on the children is in the manual. therapists and caregivers must include daily functional skill
Internal consistency reliability coefficients for the in treatment and assessment activities. This section of th
DTVP-2 were 0 .96 or above for the total test and 0.93 or chapter and Table 14-5 provide an overview of a sampl
above in the motor-enhanced and motor-reduced subtests. of the assessment tools available for the evaluation o
Individual sub tests are 0.80 or higher. The average SEM functional skills and abilities in children. The value o
values for each sub test were 1, 2 for the motor-reduced including the assessment of functional skills is that
subtests, 2.5 for the motor-enhanced subtests, and 2 for provides valuable information concerning the applicatio
the total test. Test-retest reliability, with a 2-week interval of discrete developmental milestones to the child's home
between tests, ranged from 0.80 to 0 .92 for the subtests community, and educational intervention goals.
TABLE 14-5
Functional Target
Assessments Population Purpose TIme Comments Psychometric Properties Reference
Behavioral Assess Children with Provides an objective and 15-30 min Assesses feeding functions: jaw c10 Reliability: Internal consistency of the Stratton , 1981
ment Scale of feeding graded method of docu sure, lip closure. tongue control, scale ranged from 0,67- 0.78; IR
Oral Functions in problems menting the major as swallowing, cheWing, and drinking. was computed using intra class corre
Feeding pects of oral function in Criterion-based scoring, descrip lation coefficients of agreement ranged
relation to feeding diffi tions of scoring are on the test from 0.72-0,84; TR intraclass cor
culties form. Scores range from 0 (non relation coefficients was 0,67-0.79;
functional) to 5 (normal). Results both IR and TR are marginally ac
are documented as percentage of ceptable (Ottenbacher et aI., 1985)
occurrence of scores,
Evaluation of Oral Neonates Provides a description of 10-15 min Descriptive information about No psychometric information available Glass & Wolf, 1994
Structures oral-motor behaviors tongue, jaw. lips, checks, and pal
that are based on un ate function during feeding , with
derstanding the infant's emphasis on the infant's resting
medical problems and position and components of move
maturity level ment needed for feeding, Includes
multisensory observation prior to
and during feeding. Information
presented is specific to the neo
nate.
Pediatric Evaluation 6 mo-7.5 y Measures the child's daily Varies Assesses self-care mobility, and social Normative sample: 412 children Haley et al.. 1992
of Disability In functional capabilities functioning through three scales; Reliability: Internal consistency-
ventory (PED!) and skills performance; Functional Skills, Caregiver Assis ICC = 0 .95-D.99, IR was ICC =
identifies skills child tance, and Modification Scales , 0.96 0.99 on Assistance Scale and
performs indepen Data collected through observation .91 and 1.00 on Modification Scale
dently and with assis or interview. (social function = 0 ,79)
tance Validity: Construct-score changes in
'I normative sample consistent with
progression of normal developmen
i j tal change concurrent; PEl and
BDIST were 0.73 and 0.71
i ,
"
,I
Pre-Feeding Scale Children with Provides an objective as 30-60 min Descriptive information No psychometric information available Morris & Klein, 198
f "
feeding
problems
sessment of oral motor
abilities and other is
only-readers referred to text
chapter on normal acquisition of
sues related to feeding feeding skills. Includes parent ques
tionnaire to obtain feeding history.
Information includes family issues
and concerns; the learning, com
municative, physical, and sensory
environment; normal oral-motor
skills: limiting oral motor skills;
treatment explorations; and a feed
ing plan,
1
G
m
:h
~
m
o
l>
C/
C/
m
C
PEDIATRIC ASSESSMENI'S Continued C
s:
m
Z
-
Functional Target
Assessments Population Purpose TIme Comments Psychometric Properties Reference
Neonatal Oral 34 w gesta " Differentiate tongue and 10- 15 min Evalutes components of rate; rhyth No psychometric information available Braun & Palmer, 1985
Motor Assess tional age jaw movements during micity; consistency of degree of
ment Scale and up both non nutritive and jaw excursion ; and direction, range,
(NOMAS) nutritive sucking : iden and timing of tongue movement
tify normal and deviant during nutritive and non nutritive
oral-motor patterns; sucking. Scores are criterion refer
and quantify oral-motor enced and descriptions are on the
skills" (p . 14) score sheet. All scores are totaled.
Scores are classified as normal ,
disorganized, or dysfunctional.
Vineland Adaptive Birth-IS y, Evaluates daily living scales Varies Measures four domains: communica Reliability and validity conducted on Sparrow et aI. , 1984
Behavior Scales 11 mo necessary to indepen tion, daily living skills, socialization, each individual scale
dently perform person- and motor skills. Three scales: in Information available in the manual
ally and SOcially terview survey, comprehensive in of each version of the Scales
terview. and classroom edition.
Test manuals are clear, but scoring
and administration are quite com
plex, requiring familiarity .
correlation coefficients ranged from 0.84 to 1.00, indicat state that the PEDI provides promise as a comprehensiv
ing a high level of agreement between the two scales. A and unique instrument for the evaluation of a wide range o
study of a sample of children with disabilities was conducted clinically significant functional behaviors and also as
to address the question of reliability among respondents on research tool. However, they continue with criticisms o
functional status. When comparing the responses of the some of the scoring and administration procedures. The
child 's parents and the child 's rehabilitation team mem also address the issue of how to reflect the quality of th
bers , almost all scales had a high level of reliability. child's performance. Other issues that Reid and coworker
However, the Social Function component of the Modifica discuss include the lack of information from this tool to
tions Scale proved to be problematic again (ICC = 0.30), address cognitive function, and those behaviors that can
leading to some changes in the methods for scoring these influence performance, such as attention and motivation
items. The authors indicate in the manual that studies are
being conducted into the interrater reliability and test-retest
reliability among rehabilitation team members.
Validity studies of the PEDI have studied construct, CONCLUSIONS
concurrent, discriminative, and evaluative validity. The
authors (Haley et al., 1992) studied construct validity by This chapter has focused on a samrling of the assess
comparing the scores of children in the normative sample ment instruments available to evaluate specific areas o
at three different age levels (infant, preschool , and school function and dysfunction in the pediatriC population . When
age) . The curves or changes in scores among the age levels assessing a child, it is often necessary to evaluate discret
were consistent with the authors' expectations of the skills and areas of performance. These specific areas migh
changes during the normal developmental process. Feld include prerequisite capacities such as Visual-perceptual
man and associates (1990) further addressed construct and sensorimotor, sensory integrative, psychosocial, and func
discriminative validity when comparing the scores of tional performance.
children with and without disabilities on the PEDI and the Assessing specific areas of function often helps th
Battelle Developmental Inventory Screening Test (BDIST) . therapist to understand the effects these specific compo
In this study, the disabled sample scored significantly lower nents have on the child's overall functioning. Assessmen
on the PEDI than did the nondisabled sample. The of more specific areas of performance can be accom
Modifications and the Functional Skill Scales of the PEDI plished through the use of standardized instruments, as wel
were found to be the best discriminators between groups, as through activity analysis and clinical observation. It i
correctly identifying over 70% of the children. important for the assessment process, however, that th
The PED! manual cites the previously mentioned study therapist maintain an overview of the child 's total function
and others addressing concurrent validity. Scores on the ing within his or her environment and not reduce the child'
PEDI Functional Skills and Caregiver Assistance Scales difficulties to these areas of discrete function.
summary scores have been compared with scores on the
BDIST and the children's version of the Functional Inde
pendence Measure (Wee-FIN). Correlations between the
scores on the BDIST and PEDI for the total sample of Adaptive behaviors-The ability to alter behaviora
disabled and nondisabled children were moderately high responses to changes in input from the environment.
(r = 0.73 and 0.71). The Social Function Scales again
Caregiver(s)-The person or people who provide vari
proved problematic; however, this study was conducted
ous types of care needed by the child .
with the developmental version of the test before the scor
ing procedures for this scale were changed. The concurrent Integration-The organization of information from sev
validity studies with the Wee-FIN also provided high corre eral sources into a unifying whole.
-~ .
lations (r = 0.80-0 .97) . Occupational choice-The developmental decision
Another area of validity would be the ability of this process by which adult independence of occupation i
instrument to identify change in functional status over time achieved; recognition of personal strengths and liabilities
or evaluative validity. Two clinical studies were conducted Praxis-The ability to plan and execute a coordinated
with children with minor to moderate injuries and with movement.
severe disabilities. According to the authors, the results of
Visual-motor skills-Abilities related to the coordina
these studies indicate that the PEDI is responsive selectively
tion of visual sensory information with motor responses
to specific clinical populations (Haley et al. , 1992). Further
research is currently being conducted to assess the respon
siveness of the instrument to changes in child's functional REFERENCES
Morris, S. E. & Klein, M. D. (1987). Pre-feeding skills. Tucson , AZ: Royeen, C. B. (1987b). TIP-Touch Inventory for Preschoolers: A pil
Therapy Skills Builders. study. Physical and Occupational Therapy in Pediatrics, 7(1
Ottenbacher, K., Dauck, B. S., Grahn, v., Gevelinger, M .. & Hassett. c. 29-40.
(1985). Reliability of the Behavioral Assessment Scale of Oral Func Royeen, C. B. (1990). Touch inventory for elementary-school-ag
tions in Feeding. The American Journal of Occuaptional Therapy, children. American Journal of Occupational Therapy, 44, 155-15
39, 436-440. Russell, D. J., Rosenbaum, P. L., Gowland, c., Hardy, S. , Lane, M
Piper, M. c., & Darrah, J. (1994). Motor Assessment of the Developing Plews, N., McGavin, H., Cadman, D. T, & Jarvis, S. (1990). Manu
Infant. Philadelphia: W. B. Saunders Company. for the Gross Motor Function Measure: A measure of gross mot
Pollock, N. , Law, M., & Jones, L. (1991). The reliability & validity of function in cerebral palsy. Hamilton, Ontario, Canada: McMast
a revised version of the Erhardt Developmental Prehension Assess University.
ment. The Canadian Journal of Occupational Therapy, 58(2), Scheer, c., Morris, S., Williams, J., & McPherson, J. J. (1994). 'I ntrarat
77-84. & interrater objectivity of the Erhardt Developmental Prehensio
Pratt, P. N., Coley, J. L., Allen, A. S., & Schanzenbacher, K. E. (1989). Assessment among the trained & untrained examiners. The Occup
Basic methods of assessment and screening. In P. N. Pratt & A. S. Allen tional Therapy Journal of Research, 14, 53-66.
(Eds.), Occupational therapy for children (2nd ed.). St. Louis, MO: C. Schopler, E., Reichler, R. J., & Renner, R. (1988). Childhood Autis
V. Mosby Company. Rating Scale (CARS). Los Angeles, CA: Western Psychologic
Provost, B., & Oetter, P. (1993). The Sensory Rating Scale for Infants and Services.
Young Children: Development and reliability. Physical and Occupa Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vinelan
tional Therapy in Pediatrics, 13(4), 15-35. Adaptive Behavior Scales. Circle Pines, MN: American Guidan
Reid, D. T, Boschen, K., & Wright, V. (1993). Critique of the Pediatric Services, Inc.
Evaluation of Disability 'Inventory (PEDI). Physical and Occupational Stratton, M. (1981). Behavioral Assessment of Oral Functions in Feedin
Therapy in Pediatrics, 13(4),57-87. The American Journal of Occupational Therapy, 35, 719-721.
Richardson, P. K., Atwater, S. w., Crowe, T K., & Deitiz, J. C. (1992). Takata, N. (1974). Playas a prescription. In M. Reilly (Ed.), Playa
Performance of preschoolers on the Pediatric Clinical Test of Sensory exploratory learning (pp. 209-246). Beverly Hills, CA: Sage.
Interaction for Balance. The American Journal of Occupational Takata. N. (1969). The play history. The American Journal of Occup
Therapy, 46, 793-800. tional Therapy, 23, 314-318.
Richter, E. w., & Montgomery, P. C. (1989). The Sensorimotor Tomacelli, D. l., & Palisang, R. J. (1990). Concurrent & construct valid
Performance Analysis. Hugo, MN: PDP Press. of the Erhardt Developmental Prehension Assessment & the Peabo
Royeen, C. B. (1986). The development of a touch scale for measuring Developmental Fine Motor Skill. Pediatric Physical Therapy, 2(1
tactile defensiveness in chil'dren. Ameri'can Journal of Occupational 15-19.
Therapy, 40,414-419. Walker, K. F (1993) A. Jean Ayres In R. J. Miller & K. F Walker (Eds
Royeen, C. B. (1985). Domain specifications of the construct tactile Perspectives on theory for the practice of occupational therap
defensiveness. American Journal of Occupational The,"Opy, 39, Gaithersburg, MD: Aspen Publishing, Inc.
596-599. Westcott, S. L. , Crowe. T K., Dietz, J. c., & Richardson, P. (1994
Royeen, C. B. (1988). Review of the DeGangi-Berk Test of Sensory Test-retest reliability of the Pediatric Test of Sensory Interaction f
Integration. Physical and Occupational Therapy in Pediatrics, 8(2/ Balance. Physical and Occupational Therapy in Pediatrics, 14(1
3), 71-75. 1-22.
Royeen, C. B. (1987a). Test-retest reliability of a touch scale for tactile Wilson, B. N., Polatajro, H. J., Kalan, B. J. & Faris. P. (995). Use
defensiveness. Physical and Occupational Therapy in Pediatrics, Bruininks-Oseretsky Test of Motor Profiency in Occupational Therap
7(3), 45-52. The American Journal of Occupational Therapy 49, 8-17.
C HAP T E R 1 5
ssessment of Ede s
and Caregivers
Gail Ann Hills, * PhD, OTR, FAOTA
with
Steven R. Bernstein, MS, PT
Assessment of the elderly is a multifaceted and compli and Kane, 1981 , p. 1). These issues are what make
cated process. Any assessment of the elderly for a specific working with the elderly interesting but complicated.
dysfunction must take into consideration the impairment of Since many of the disability-specific assessments tha
functional ability as it is superimposed on normal aging may be used with the elderly are covered in other chapters
changes. The effects of this combination of pathology in this book, this chapter addresses only issues that are
associated with aging changes may be very different in an specific to assessment of the elderly .
elderly person than in a younger person with the same The philosophies and goals of occupational therapy (OT
disability . The issues in assessment of the elderly that Kane and physical therapy (PT) in general are embedded in the
and Kane summarized as early as 1981 are still relevant rehabilitation concept of restoring the individual to the
today. "Conventional wisdom now holds that: 1) the fullest level of usefulness (Hasselkus, 1989). Hasselkus
elderly are subject to multiple diagnoses; 2) the physical, states that OT rests on the theories of human developmen
mental, and social well-being of an elderly individual are through occupation (Kielhofner, 1982), and that PT is
very closely interrelated , so that multidimensional assess based on the clinical science of pathokinesiology (Hislop
ments of health status are necessary; and 3) measures of 1975). In the rehabilitation paradigm, OT and PT are
functional status that examine the ability to function primarily concerned with the restoration of motor skills to
independently despite disease , physical and mental disabil regain maximal abilities in activities of daily living (ADL)
ity, and social deprivation are the most useful overall Assessment is directly related to the treatment areas
indicators to assist those who care for the elderly " (Kane Physical therapy areas include therapeutic movement
posture, general body mechanics, functional activities, and
modalities (Rusk, 1977; Shestack, 1977). Occupationa
'Formerly, Gail Hills Maguire. therapy areas include using purposive activities to restore
401
402 UNIT FOUR-AGE-RELATED ASSESSMENT
physical function, perceptual-motor training, prosthetic Physical therapy assessment has been organized around
and orthotic training, prevocational exploration, home the "SOAP" framework (Subjective, Objective, Assess
making, and supportive therapy. ment, Plan) for assessment of performance. Both occupa
Since these early beginnings, both OT and PT assess tional therapy and physical therapy assess the environmen
ment and treatment have evolved with societal changes to from their unique perspective.
include the independent living movement, with the empha
sis on utilizing the strengths of the individual and peer
support groups. In 1989, Hasselkus suggested that the
evolving attitudes toward health care in general and care of FUNCTIONAL ASSESSMENT
the elderly in particular have resulted in assessment and
treatment along a continuum from the traditional rehabili Relationship Between Function
tation to independent living. In actuality, assessment and and Disease
treatment of the elderly is unique because of an element
that is often overlooked in health care literature regarding In addition to the frequent functional presentations o
the elderly; i.e., the perceptions of the elderly regarding disease in old age that may be characterized by the absence
functional assessment and intervention may be affected by of classic or typical clinical findings, another phenomenon
their valuing of such activities in relation to the effects on common with the elderly is the poor correlation between
their total life at this stage of their lives. This may be why type and severity of functional disability and the number o
many elderly individuals are resistive to turning their home diagnoses. Since illness and functional loss both increase
into a hospital-type environment. Their primary goal may with age, it is often assumed that the frequency of diseases
be to keep their environment as normal, aesthetically or conditions of older persons correlates with the kind and
pleasing, and as comforting as possible, even if this means intensity of functional disability. However, this is not the
compromising some functional independence. However, case. A long list of problems or illnesses accumulated by an
the health professionals' primary goals are to advocate any old person does not necessarily result in serious loss o
modifications to behavior or the physical environment that function. Many elderly persons with very long lists o
will increase the autonomy or independence of the elderly serious problems still maintain independence. Anothe
person. To be effective, assessment and treatment must be common error is to assume that the specific functiona
shaped by the particular elderly population and the setting impairment is related to the organ or system with the
of the intervention. disease. For example, mobility problems would be attrib
For purposes of this discussion, OT assessment is orga uted to musculoskeletal or neurologic disorders and incon
nized under the two categories of functional ability and the tinence to the bladder. This causality principle does no
environment. Both functional ability and the environment necessarily apply with the elderly. Certain vulnerable
are organized around the theory of human occupation. The tissues and organ systems may be likely to decompensate
assessment of functional ability is grouped around the three as a result of systemiC disease anywhere in the body, which
categories of 1) the patient's perception of competence may compromise the functional integrity of an elderly
and interests in chOOSing daily living activities (volition), individual (Besdine, 1988). The systems that are mos
2) the patient's recurrent patterns of behavior in daily living vulnerable to impairment vary with each individual; there
(habituation), and 3) the patient's organization and capac fore, the areas of functional ability that may be compro
ity for occupational performance in daily life (per mised in each individual will also vary. Two importan
formance); the fourth category includes factors that facili implications for these non correlations between functiona
tate or hinder occupational performance (environment). ability and diagnoses are pivotal for good care of the
Assessment of functional ability in this context is mul elderly. First, functional impairment should be assessed
tiphasic and includes the person's volitional areas, such as independent of the medical diagnoses. Secondly, although
interests, values, and ability to be autonomous, plus his or specific pathology may exist in a particular organ system
her habits and roles, as well as the more traditionally it does not mean that the primary pathology exists in tha
emphasized skill components and the ability to perform specific organ system or that any functional loss due to
various activities. The environment includes both phYSical disease is attributed to that particular system. Health
and social components, including physical resources and professionals can manage this phenomenon specific to the
social supports, particularly the caretaker. The physical and elderly by enumerating functional impairments paralle
social environments are intermeshed to compose occupa with the clinical findings of impairment when developing
tional behavior settings that constitute a meaningful con therapeutic goals to increase independence (Besdine
text for performance (Kielhofner, 1995a). Looking at the 1988).
occupation of elderly individuals from this perspective A study by Baron and others (1987) of hand function o
accommodates the unique needs of individuals shaped by the elderly in relation to osteoarthritis (OA) supported this
their personal profiles, including their personal percep notion of noncorrelations. Osteoarthritic patients assessed
tions, roles, habits, and performance abilities within their with The Smith Hand Function Test (Smith, 1973) showed
environmental context. correlations to age, coordination, and hand strength bu
ment Questionnaire (HAQ) (Fries et aI., 1982) correlated 1980), four variables were associated with a greater
with radiographic OA manifestations and joint tenderness, likelihood of the elderly dying within 15 months. Two of
as well as sex and hand strength. The authors concluded these were related to functional ability: 1) if the person is no
that OA does not seem to contribute significantly to the longer self-sufficient in personal care (ADL), and 2) if the
objective decline in hand function but may contribute to a person is no longer able to do heavy work around the house
subjective sense of functional limitation. without help (IADL).
As the elderly person becomes more frail, small changes
in the individual's ability to perform daily activities or the
ability of a caregiver to provide support can have a major Central Indicator for Treatment
impact on the person's style and quality of life. Chances are Planning
much greater that such small changes will have more of an
impact on the lifestyles of elderly individuals than on those Functional assessment is important for all· persons with
of younger persons. loss of independence, but it is especially important for the
elderly for whom independent abilities are more easily
affected by the broad array of illnesses and problems
Functional Decrease as a Sign common in old age (Besdine, 1988). As people age, the
of Illness possibility that they will have difficulty with functional
activities increases, particularly past the age of 85 years.
In addition to impact on lifestyle, a decrease of functional The report of the Health and Public Policy Committee of
ability in the elderly can be the first sign of new illness or the American College of Physicians recognized that de
exacerbation of a chronic disease. Unlike younger persons, creased functional ability of the elderly is an increasingly
the elderly often do not exhibit a single, specific complaint major issue as the population ages. "Although most elderly
that helps to determine a differential diagnosis, but rather non institutionalized adults are functionally competent, the
they exhibit one or more nonspecific problems indicated by percentage who need help doing everyday activities
functional impairment. Functional presentation of illness doubles with each successive decade up to age 84, and
might include any of the following: cessation of eating or triples between ages 85 and 94" (Almy, 1988, p. 70).
drinking, falling, urinary incontinence, dizziness, acute Kane and Kane (1981) supported the concept that func
confusion, new onset or worsening of previously mild tional ability, rather than the absence or presence of
dementia, loss of weight, and generalized failure to thrive disease, is the central issue with the elderly. "Measures of
(Besdine, 1988). If we accept that the onset of problems is functional status that examine the ability to function
not easily recognized by many health professionals, family independently despite disease, physical and mental disabil
members, and the elderly themselves, then this apparent ity, and social deprivation are the most useful overall
age difference in manifestation of illness is very important indicators to assist those who care for the elderly" (p. 1).
to the case management of the elderly. It is important that Even though there is general agreement that indepen
elderly individuals and the people who compose their dence is the key issue of health care for the elderly and
formal and informal support systems be aware that disrup assessment of functional ability is of prime importance,
tion of homeostasis by any pathology is likely to be ex trends in reimbursement for maintenance of function are
pressed in the most vulnerable or delicately balance directly counter to this need. Home health care is limited to
systems. Therefore the weakest links are likely to fail, and only about 12 to 15 percent of those who actually need
the results may be ADL or instrumental activities of daily such services. Branch and others (1988) found that require
living (IADL) problems rather than the usual classic symp ments for assistance in ADL and functional dependency are
toms seen in the younger population (Besdine, 1988). The factors placing the elderly at high risk for needing home
implication for the elderly and everyone involved with their care. ASSistance required with ADL or IADL is not covered
care is that deterioration of functional independence in by Medicare, so the elderly must often seek assistance from
previously unimpaired active elders may be an early, subtle family or friends. This lack of funding for personal care
sign of an unidentified illness. Rapid and thorough clinical grew out of the movement away from the medical model
evaluation of the presenting functional impairments may and the belief that intervention when the elderly person is
be the only way that independence and the quality of life medically stable could lead to perpetuation of the sick role
can be maintained (Besdine, 1988). Leaders in the field and unnecessary dependency. "Management of medically
have recommended that health care providers routinely stabilized disability is primarily a personal matter and only
carry out a functional assessment that is complementary to secondarily a medical matter" (Dejong, 1979, p. 440).
the traditional diagnostic work-ups that precede treatment However, this lack of support for maintenance of the frail
recommendations. This combined process has been called elderly when needed may increase the strain on family
Comprehensive Functional Assessment (CFA) (Champlin, caregivers until they can no longer cope and thus actually
1985). hasten institutionalization of the elderly.
404 UNIT FOUR-AGE-RELATED ASSESSMENT
friends come to stay with you for a period of time. Imagine are quite varied among elderly individuals. Role change fo
that your mother is trying to assist you in preparing the the elderly is not always negative, and the strength an
evening meal. Ordinarily you might do much of the prepa quality of the remaining and new roles may be satisfactor
ration alone without much thought, particularly if the meal to many elderly individuals (Blau, 1973; Rogers & Snow
is very familiar and you prepare it without any recipes. 1985).
During the meal preparation, you might even go over your The greatest impact of role change for the elderly ma
work day in your mind or make plans for the next day. occur at or during retirement from paid employment. Th
However, your mother is not familiar with your kitchen and expectation that older adults would eventually retire from
also wants to defer to your preferences, so she asks you work and find something useful to do was probably one o
several questions about where to locate dishes and how big the clearest expectations of society in the United State
you want the vegetables chopped. Suddenly you find you (Atchley, 1972). However, even this expectation ha
cannot prepare the meal routinely. Having someone differ changed. At least two trends are going on simultaneousl
ent working with you requires attention and conscious in the United States. One is the abolishment of mandator
thought. The movement of more occupations from the retirement at age 65 and the increase in alternative wor
habituation to the conscious level is the reason people often patterns, such as part-time or contract work after retire
feel very tired after having house guests for several days, ment, which has resulted in many people working in som
even if the guests do not require extra tasks or actually manner past retirement age. The rise in the age o
perform some of your normal chores. Elderly individuals elegibility for full social security benefits that is presentl
have had a much longer time to develop routine patterns, being phased in ensures a later retirement age for many
and physical or social circumstances forcing them to In addition to the trend for later retirement for many
change these habits may cause a strain at the very time there is also the second trend toward early retiremen
when their general endurance is decreasing; therefore, (Rogers & Snow, 1985; Sheppard, 1976). Elderly in thi
they may need to rely more on routine behavior to conserve group usually have positive attitudes toward increase
their expenditure of energy. In the OT assessment, it is leisure time and an acceptable level of financial resources t
important to determine why elderly persons seem to cling support their desired retirement lifestyle. However, wit
to habits that are no longer very effective. The reason may the increased life expectancy and the high rate of inflatio
be limitations in cognitive or motor abilities or an attempt to in the past decade, many elderly who retired on adequat
conserve energy rather than what may appear to be an incomes have seen their retirement income outpaced b
attitude of rigidity. Umitations in obtaining and processing inflation and their standard of living reduced to an unac
information may make the elderly less inclined to mod ceptable level. This unexpected reduction in resources ma
ify their routine behavior, even when their coping mech be most evident just as the elderly enter the older years
anisms prove to be ineffective (Rogers & Snow, 1985; beyond 85, when their medical and social support costs ca
Botwinick, 1973). There may be another explanation for be expected to increase.
elderly individuals' seeming resistance to changing old hab American society has few expectations for the elderl
its and using new methods or equipment-when sensory beyond maintaining financial and personal independenc
input or memory may be impaired, particularly with the as much as possible and continuing to exhibit socia
frail older population over 85 years of age, input and reten responsibility. That is why the elderly have sometimes bee
tion of information for new learning may be more difficult labeled as having a roleless role (Rogers & Snow, 1985)
and may be why tasks are performed in the way that was Attitudes toward retirement are very complex and ar
learned prior to the sensory or memory impairment. influenced by individuals' life experiences in addition t
At the same time that changes in habits may be their attitudes about work and retirement. The effects of th
occurring, the elderly person is often subjected to more changes in roles due to retirement vary among elderl
negative than positive changes in circumstances, such as individuals. For some, retirement is a very positive goal wit
widowhood, retirement from work, and loss of lifelong a chance for more time free from work to pursue new rol
friends through relocation or death. These role changes options and associated interests. For others, cessation o
may require additional demands for new learning and work is seen as negative because available new roles are no
changes in habits, regardless of the elderly person's personally valued as highly as the worker role. Losses o
preferences. status, financial resources, and social networks may also b
Roles. Roles change throughout the life cycle, and loss of associated with the loss of workplace roles.
roles can occur at any age. However, the elderly population If a person experiences a loss of roles due to some physi
has an increased probability that the role losses will be cal dysfunction, often he or she can resume at least part o
involuntary and more negative, and it is less likely that a role the role if a restructuring of the environment to support rol
loss will be replaced by a new role. This may impinge on the performance takes place. Dysfunction in the performanc
individual's sense of personal control, as discussed under area may have an impact on habits as well as roles.
Personal Causation. Role loss may also reduce social Measures of Habituation. Occupational therapy assess
engagement, which can have a further negative impact. ment in the habitual area may include a role checklist an
Just as with other aspects of aging, the effects of role loss schedules of daily activities associated with various roles
The mind-brain-body performance subsystem refers to on functional activities (Brody & Vijayashanker, 1977
the organization of both mental and physical components, HasseIkus, 1974; Rogers & Snow, 1985). Because th
which in concert make up the capacity for occupational majority of therapists do not directly treat sensory loss, it i
performance. Performance emerges out of the flow of often an area that is neglected in assessment and treat
information between the constituents and the exchange of ment. This is a serious oversight because the indirect effect
action and information with the environment (Fisher & of sensory loss can be profound for elderly individuals
Kielhofner, 1995a). Therefore, screening and recording of the deficit level ca
Performance skills are elements of action that can be make treatment planning more realistic.
obsetved during occupational performance. Three types of Vestibular Functioning. Reduction in the ability to re
performance skills are motor, process, and communication spond to vestibular information can result in a reduction i
and interaction skills. Motor domains and skills include the older person's ability to recover balance with a shift i
posture, mobility, coordination, strength and effort, and body position, which increases the danger of falling (Birren
energy. Process domains and skills include energy, knowl 1964; Corso, 1971; Rogers & Snow, 1985). As wit
edge, temporal organization, organizing space and ob everything else associated with aging changes, accident
jects, and adaptation. Communication and interaction and falls involve more processes than just the speed o
domains and skills include physicality (physical expression neural transmission. However, there is evidence to sugges
or interaction with others), language, relations, and infor that if therapists assess elderly persons' ability to react t
mation exchange. Social interaction domains and skills emergency situations and then have them practice th
include acknowledging, sending, timing, and coordinating correct behavior through role playing, their responses ma
(Fisher & Kielhofner, 1995b). Assessment of functional become more automatic and their total reaction tim
status in the performance area refers to an individual's quicker and more efficient, which could assist them in a
ability to actually perform certain tasks or activities. actual emergency.
Traditionally, the performance subsystem, particularly Dally Living Activities. Occupational therapy assessmen
skills, is where most of occupational therapists' assessment on the performance level would include functional activitie
time and effort have been focused, particularly in treating and any deficiencies in skill components. As alread
physically disabled patients. This tendency to focus on the mentioned, two of the main outcome activities essential t
performance area is partly due to the time needed to assess the functioning of the elderly are ADL and IADL. Sinc
the component skills necessary to perform one or more both ADL and IADL are a series of complex activities, thi
functional activities as well as to assess the ability to often means that when a dysfunction in one or more of th
perform the functional activities in as safe, coordinated, activities is present, the physical and mental component
and normal a way as possible. essential to performance of these daily activities must b
Age-related changes occur in all systems of the body, but assessed before or in addition to assessment of the actua
the results of these changes on the performance skills of the performance of the activities.
elderly are quite variable, both within a specific individual Physical and Mental Capacity. Orem (1985) define
and among elderly persons. This means that although self-care deficits as the difference between the actio
similarities exist among the changes seen with aging, the capabilities of individuals for self-care and the action tha
profiles of a group of elderly individuals would be more individuals should take. Kim and associates (1984) empha
varied than those of a group of children also experiencing sized that it is important for health profesSionals t
age-related changes. This makes comprehensive assess differentiate between patients who are not performin
ment of the elderly very important. All the normal changes self-care because of motivation or some physical problem
of aging plus the changes associated with a specific from those who lack the capacity to perform owing t
pathology must be considered by the therapist. Because no cognitive deficits. In reviewing the etiologies of self-car
general consensus has been reached in the literature deficit, Tracey (1989) also concluded that even if a
concerning where normal aging changes end and pathol individual might be physically capable of performin
ogy begins, such distinctions are not made for purposes of self-care, cognitive impairment and depression can be th
this discussion. The therapist must deal with problems cause of a self-care deficit. The following six factors hav
originating from both sources. been associated with self-care deficits: intolerance t
Sensory Changes. Probably the aging changes that have activity, decreased strength and endurance, pain or dis
the greatest universal effect on individuals are sensory comfort, perceptual or cognitive impairment, musculo
changes. All five senses change, but just as with other aging skeletal impairment, and depression or severe anxiet
changes, the sensory receptors decline at different rates (North American Nursing Diagnosis Association, 1990)
within and among individuals (Maguire, 1995b). Neuro Capacities and limitations of self-care may be deter
logic transmission of sensory information is affected on all mined during assessment of the physical and mental statu
levels, including transmission from sensory organs to the of an individual. The mental status assessment shoul
brain, within the brain, and from the brain to the motor include tests for concentration, attention span, short- an
408 UNIT FOUR-AGE-RELATED ASSESSMENT
long-term memory, orientation, expressive and receptive and distance that the toilet is from the individual (environ
speech, apraxias, and higher cognitive functions (Skrastins ment). Variables like this and many others need consider
et al., 1982). A study of 40 institutionalized elderly women ation before one functional assessment form can eventually
was undertaken to determine if changes occurred in mental be adopted. However, the goal of equivalent and well
status and functional abilities over the course of 1 year. documented data for research and functional instrument
Findings indicated a decline in mental status and an will continually be supported (Besdine, 1988; Kutner et al.
increase in functional dependency (Hamilton & Creason, 1992; Mellette, 1993). Because no one perfect evaluation
1992). However, the authors suggest that cognitive impair exists for every type of clinical situation, therapists must b
ment did not always result in a self-care deficit. trained to develop their own descriptive assessments or to
Many of the assessment instruments commonly used utilize several existing standardized formats (O'Sullivan &
with the elderly combine one or more performance Schmitz, 1994). A combination of using both is a good
components or functional activities. In addition to having to idea. Some of the more standardized formats are the Tuft
be concerned about assessing the components and actual Assessment of Motor Performance (TAMP) (Gans et at.
functional activities, the health care professional must be 1988), the Katz Index of Activities of Daily Living (Katz e
concerned about the validity and reliability of the actual al., 1963), the Functional Independence Measure (FIM
instruments. In a longitudinal study of the functional status (Uniform Data System for Medical Rehabilitation, 1990)
among community elders, Branch and others (1984) found the Barthel Index (Mahoney & Barthel, 1965), and th
that the choice of operational ADL measures is important Functional Status Index (Cech & Martin, 1995). The
in trying to interpret assessment data. There was a great following section reviews some of the more importan
difference in the rate of loss of independence recorded, aspects of developing your own age-related assessmen
depending on the measure. For example, adding two items tools.
to a four-item ADL scale greatly increased the scale's
sensitivity to changes in functional status.
Because most of the assessments of skill in occupational The Assessment
performance are covered in other areas of this text, just a
few types of assessments that may be useful for the elderly A good assessment relates to all types of patients. It mus
population are mentioned. be adaptable to different situations. It must address th
Measures of Performance. Measures of performance hospitalized geriatric nonambulatory patient as well as the
might include a history of falls and screening for mental elderly patient who has an active lifestyle but developed a
status, depression, ADL and IADL, sensory deficits, func shoulder problem during a golf game. Because of the varied
tional range of motion, and functional muscle strength. If possibilities that are present in this age group, physica
serious deficits are noted, more detailed testing can be therapists must prepare themselves with a different assess
administered. See the Appendix at the end of this chapter ment philosophy. This philosophy might best be explained
for a listing of specific tests. as having an awareness of the age-related conditions tha
need consideration when performing the evaluation
These considerations will be addressed from the traditiona
SOAP note format which describes the Problem first, and
PHYSICAL THERAPY ASSESSMENT then the Subjective, Objective, Assessment, and Plan
(Kettenbach, 1995). In planning the assessment, the physi
The PT assessment is challenging owing to the unique cal therapist must not forget normal developmenta
ness and variety of the physical and mental attributes of the changes as well as the presenting pathology. The age
geriatric patient, which have been previously discussed. related data are needed to formulate a logical conceptua
This section relates these unique issues specifically to PT framework applicable to the individual assessment (Haley
assessment of the elderly. etal., 1994).
Recent literature suggests that a move is occurring
toward computerized rehabilitation assessment to improve
PROBLEM LIST
the efficiency of documentation and communication (Koch
et al., 1994). A standardized geriatric functional assess Problem lists of the elderly are different when compared
ment is not a new idea and has been supported by many with those of younger patients. Persons over age 65
(Besdine, 1988). However, one standardized geriatric demonstrate increased functional impairment. In fact
assessment form has not been universally accepted in the 75 percent have at least one chronic illness. More than
clinical or academic community (O'Sullivan & Schmitz, third can not perform their major activity independently
1994). This is partly due to the uniqueness of the geriatric and 5 percent are confined to home. In the over-75 ag
patient. Haley and colleagues (1994) gave the example that group, 15 percent are confined to home, and even mor
persons with the same level of physical impairment mayor debilitation exists in the over-80 age group, of which
may not have the same physical problems using a toilet. 25 percent cannot go outdoors. When ill, the elderly and
One obvious difference might include the physical location younger patients differ; the younger patients usually hav
The multiple problems of the elderly also affect many
mobility functions and ADL. The good news is that the
OBJECTIVE DATA
problems are usually successfully treated if detected by
assessment (Besdine, 1988). The assessment also depends on collecting key poin
objective data. The ultimate assessment includes a muscu
loskeletal, neurologic, cardiorespiratory, vascular, derma
SUBJECTIVE INFORMATION
tology, and endocrine system evaluation. All of these
Subjective information can be the most important part of assessments are lengthy and important but not always
the assessment. When first meeting the patient, physical practical with the elderly. As previously mentioned, the
therapists immediately begin gathering subjective informa patient's condition is the restricting factor. Difficult deci
tion from comments, observations, as well as from others sions must be made immediately as to what the assessmen
associated with the elderly, particularly their caregivers. will include. Minimally, it should be based on your knowl
(See Assessment Methods.) At this point, the therapist edge of normal and pathologic disease of elders. One
must immediately decide how much assessment time is physical therapist suggests assessing only the three areas o
practical for the initial session. The patient's medical status dressing, feeding, and walking (Bottomley, 1989). Al
may only allow 15 minutes or less. This time-limiting factor though this tri-area classification seems overly simplified, i
is obviously more important in evaluating the elderly than does impress one with the reality of basic functional needs
when assessing younger patients. Subjective information When planning objective data collection, normal aging
involves patients' orientation, cognitive level, pain, short changes that are musculoskeletal in nature must be con
ness of breath, communication abilities, and family rela sidered, including decreased strength, flexibility, endur
tionships. While gathering this subjective information, the ance, and coordination. As a result of these changes, the
physical therapist will be assessing many sensory functions. elderly have decreased postural stability, impaired balance
It is well known that normal developmental aging results in when walking, a slower gait, increased episodes of falling
decreasing sensory functions. One noted change is de and less ability to carry out their ADL.
creased visual function, resulting in decreased depth per Kutner and others (1992) emphasize this further and
ception and contrast recognition. The contrast deficits are report that these musculoskeletal areas are the major key
commonly associated with lack of light. Other diminished points in preventing injury and redUcing loss of function
sensory changes are hearing loss, diminished touch, and The physical therapist must also be cognizant of declining
less acute taste and smell abilities (Maguire, 1995b). It is cardiovascular efficiency and endocrine functions, thus
interesting to note in animal studies that pain thresholds alerting the evaluator to precautions involving patients
may increase. This phenomenon may possibly explain cardiac status, shortness of breath, and osteoporosis
why the elderly report difficulty localiZing pain (Hall & (Kutner et al., 1992; Lewis, 1995). Strength assessment i
Perlmutter, 1985). During assessment it should be kept in a very important aspect of the elderly assessment. It i
mind that the elderly need more time for information generally agreed that atrophy is associated with aging
processing and also for learning new motor tasks. Reaction Strength is maximal during the 20s and 30s. Decreases are
times are longer, and memory skills diminish (Haywood, noted thereafter but are not functionally significant unti
1993). The therapist must keep in mind the variability around 75 years of age. The most commonly affected
among elderly individuals. Disease may result in more muscle groups are the antigravity muscles. These muscle
serious physical and mental declines in function. During the groups are needed for many ADL, such as getting up ou
subjective assessment, the therapist will easily identify the of a chair, sitting down, climbing stairs, and standing. In
more serious pathologic problems such as advanced Alz people 75 to 84 years of age, Kutner and others (1992
heimer's disease, speech deficits, and severe depression found that 15 percent were unable to climb stairs and 24
(Cherney, 1995). percent were unable to lift a 10-lb weight. The causes are
This subjective assessment can be influenced by attitudes sometimes due to sedentary living, but there are norma
of the therapist as well as of the patient. Your assessment physiologic explanations related to changes in muscle fibe
should not be biased by ageism or discriminatory influ types and neuronal motor unit degeneration (Haywood
ences. Studies have shown that therapists sometimes think 1993). However, studies now show that the elderly can
older patients are less worthy of rehabilitation. If patients Significantly decrease the loss of strength from disuse or a
detect this "internal ageism," the therapist may interpret sedentary life through exercise (Cech & Martin, 1995
patient reactions to this ageism as poor motivation (Bonder Lewis, 1995).
& Wagner, 1994). Range of motion and joint mobility or flexibility also
It is at this point that the physical therapist must decrease with age as a result of both normal developmen
determine the most important objective data to collect. The and pathologic conditions. Age-associated losses of flex
therapist must be practical and consider the available time ibility may be the result of increased collagen formation and
and the mental and physical status of the patient. The sedentary lifestyle. Common postural changes include a
410 UNIT FOUR-AGE-RELATED ASSESSMENT
forward head, kyphotic spine, and knee and hip flexion standing balance on thick foam. The most challenging
contractures. Common pathologic causes are from arthri situation is standing on the foam with vision occluded by the
tis, scleroderma, sclerosis, Parkinson's disease, and os lantern (Crutchfield & Barnes, 1993). Lastly, one mus
teoporosis (Kisner & Colby, 1990; Lewis, 1995). Assess assess the environmental factors of fall prevention that are
ment determines range of joint motion limitations and the in the home, such as dangerous steps, lack of bathroom
reasons for the restricted movements. handrails, inadequate lighting, and throw rugs.
A major part of PT is gait and balance assessment, which
of course is highly dependent on endurance and coordina
ASSESSMENT AND PLAN
tion. Balance problems in the elderly are a serious concern,
a frequent cause of falling, and a leading cause of accidental The SOAP note concludes with the assessment and plan
death (Haywood, 1993). In the study by Kutner and These aspects of the evaluation conclude the PT findings
coworkers (1992) of individuals between 75 and 84 years and develop the treatment plan for intervention. Reassess
of age, it was found that 7 percent of the subjects were ment is continuous, and treatment regimens must be
unable to walk across a small room, and 24 percent were designed to maintain the highest-quality lifestyle by achiev
unable to walk a half mile. Most important are the issues of ing the least restrictive and cognitively acceptable environ
patient safety-specifically, fall prevention. Falls are the ment. The Mobility Opportunities Via Education (MOVE
most prevalent cause of injury among the elderly, and 30 program philosophy emphasizes this concept best with
percent of elderly community dwelIers fall each year. questions. With this method, therapists continually ask
Fall prevention assessment involves a multisystems ap themselves during treatment if the intervention is really
proach of assessing both external and internal factors. The going to make a functional improvement in the person'
internal factors requiring PT assessment are strength, lifestyle and, if not, whether the choice of treatmen
muscle tone, endurance, coordination, proprioception, method should be reassessed and changes recommended
balance, vestibular system integration, sensory loss, and (Bidabe & Lollar, 1988).
cognitive abilities. All of these functions tend to decrease
during the normal aging process. During normal gait, the
patient must be able to balance on one leg during swing
through. A common balance assessment is single-limb ENVIRONMENTAL ASSESSMENT
balance, or standing on one leg. Balance assessment
studies have shown that single-limb balance in people 70 to The previous discussion covered the first three areas o
79 years of age can be maintained for only 14 seconds, assessment of the elderly, which dealt with assessment o
while for people 20 to 29, it was 30 seconds. When this test occupational behavior on the volitional and habituation
was performed with eyes closed, the elderly group main levels in OT and on the performance level for PT and OT
tained balance for onlt,T 4 seconds, while the younger The fourth and last area of assessment for OT and PT, the
people were able to maintain balance for 28 seconds environment, is discussed here. For purposes of this
(Daleiden & LewiS, 1990). discussion, the environment is defined as occupationa
Addressing balance problems and fall prevention realIy behavior settings. "The occupational behavior setting is a
emphasize the practical reasons for performing a proper composite of spaces, objects, occupational forms, and/o
proprioception and sensory assessment. For example, social groups that cohere and constitute a meaningfu
elderly patients with difficulty walking or bearing weight on context for performance" (Kielhofner, 1995a, p. 104)
a foot that is inverted in such a way that an ankle sprain or This conceptualization incorporates natural and fabricated
fall may result may need to be properly assessed for motor physical elements as well as how the nature of objects in
planning, foot placement, and abnormal muscle tone. Gait space affords or presses for occupational behavior. The
training is very difficult with abnormal muscle tone. The social environment includes social groups that provide fo
patient must be assessed for each of the functions that are and assign occupational roles to the elderly within the
related to proper foot and leg placement: sensory and group as well as creating the context for acting out these
proprioception deficits and abnormal muscle tone. An roles and occupational forms. Occupational forms are
other influence on gait and balance is diminished vestibular "rule-bound sequences of action which are at once coher
system function. The popular "foam and dome test" ent, oriented to a purpose, sustained in collective knowl
described in many texts is simple to administer and requires edge, culturally recognizable, and named" (Kielhofner
only a piece of foam or a cushion, a paper lantern, and a 1995a, p. 102).
blindfold. The foam and dome test measures different
sensory conditions. The testing conditions alter sensory
input to detect standing balance deficits. Vision is altered by Social Environment
blindfolding and also by covering open eyes with a paper
lantern. A large Japanese paper lantern with a pattern is The assessment of the social situation of the elderly
placed over one's head to disrupt visual flow. Ankle and individual who is no longer completely independent is very
lower extremity proprioception is examined by observing important. A distinction is made here between the terms
support is the actual assistance, such as financial and tance of supporting caregivers when she said "Small g
emotional, that the social network can provide. It is may mean the difference between an intermediate c
important to make the distinction between these two placement and personal care that can be provided at ho
constraints because persons in the social network mayor or in less restrictive settings" (p. 6). The necessity
may not offer social support. For example, a family consider elderly individuals in the context of their fam
member may not offer much social support, while a has led to a family-oriented approach to case managem
neighbor or friend may offer more support than anyone, (Hasselkus, 1989). In reporting on a family living transi
including the elderly person, realizes. Recognition of the program, Sasano and colleagues (1977) said that "
important role of social supports is reflected in many of tients' interests can best be served by considering the fam
the multidimensional tests, such as the Multidimensional and that, accordingly, families should be involved as m
functional assessment (Duke University, 1978), which as possible in preparation for rehabilitation" (p. 1
assesses elderly persons' abilities and their available social However, the role of the family is just as important for
supports. It is the match of these two factors that often elderly requiring only functional maintenance rather t
determines whether an elderly individual can remain in rehabilitation.
the community or will need some type of institutional Just as therapists have mixed feelings concerning
care. Even if the level of dependence is conSiderable, role of the family in rehabilitation, in general (Wat
elderly individuals may be able to remain in their own 1987) they also have ambivalent attitudes toward
homes if the combination of formal and informal supports family role in rehabilitation and maintenance of the
is adequate. Rzetelny and Mellor (1981) has suggested derly. If asked, most health profeSSionals would agree
that the support system of the elderly may be considered family participation in the therapeutic process is im
to have three components: 1) the informal system, which tant (Payton et al., 1990; PeloqUin, 1990). Howe
is usually selected by the elderly persons themselves and rehabilitation staff may theoretically believe in the v
is often based on longstanding relationships, 2) the of family participation in rehabilitation while actu
semisupport system, which is provided by neighborhood utilizing a directive model in which the family is expec
organizations such as churches or senior citizen centers, to defer to the wishes of the profeSSional. This sa
and, finally, 3) the formal networks, which are the struc attitude seems to exist for care of the elderly; w
tures that comprise services and organizations such as receiving care, the elderly person is often expected
social security and Medicaid. defer to the wishes of younger family caregivers as
If there is a caregiver in the informal support system, this as professionals.
person is the most significant, and sometimes sole, source Taking a family approach in assessment of the eld
of support for the elderly person. Because they are so requires an assessment of the caregiver as well as of
important, caregivers of the elderly are discussed sepa elderly. The more dependent or involved the elderly per
rately, even though they are part of the social environment is with caregivers, the more important this becom
of the elderly. Evaluating caregiver burden as part of the geriatric ass
ment may be equally as important as assessment of
elderly person (Brown, Potter, & Foster, 1990).
Caregivers The literature shows that the majority of caregivers
the elderly are women who are either spouses or a
Results of a national survey of home care for the elderly children. A large proportion are over 65 years of
done in the 1960s revealed that 80 percent of the care is themselves, and only a small minority use formal serv
provided by the family (Home care for persons 55 and over, (Stone, Cafferata, & Sangl, 1987). This is supported
U.S., 1972). This continues to be the case. As the nation Corbin & Strauss (1988), who reported that only ab
continues to age, the stress on caregivers will increase 10 percent of informal caregivers utilize formal servi
rather than decrease, particularly for the "sandwich" Approximately 35 percent of caregivers are spou
generation of caregivers who may be providing some Sixty-four percent of these spousal caregivers are wom
measure of care for their children and grandchildren as well (Huston, 1990). The major detrimental effects of care
as for aging parents. In fact, we now have many families ing for this spousal group are resulting health problems
with more than one generation of elderly still living. This social isolation because of the demands of caregiving
issue is very relevant to the wider community if we concerns about leaving their spouses unattended. T
understand that the availability and capabilities of family social isolation may also be due to their loss of the rol
members to care for their frail elderly is the major husband or wife and subsequently being thrust into the
determining factor as to whether a person will be able to of caregiver. The loss of spousal roles coupled with so
avoid or at least delay institutionalization and remain in the isolation may lead to the loss or diminution of other r
community. At the very least, small gains in capacities such such as worker or friend, which will exacerbate the c
as strength or endurance or in performance of functional and possibly lead to further role losses and subsequ
412 UNIT FOUR-AGE-RELATED ASSESSMENT
social losses. If unchecked, these negative cycles can lead the provision of assistance to family members caring for the
to feelings of loss of autonomy or control over their patients. Intervention should be tailored to meet individua
situations, particularly if their elderly spouses' conditions needs, but the three areas that were pinpointed by the
do not improve. "Most spousal caregivers admit to a caregivers as being essential were information and skills
significantly higher degree of depression than is found in relative to physical care, emotional support, and respite
age-matched control subjects" (Huston, 1990, p. 673). when possible. Since only 15 percent of the subjects
This seems to indicate that the more depressed a caregiver were utilizing community resources, a referral system to
is, the more burdensome the caregiver perceives the care. community agencies seemed clearly indicated (Perry &
Therefore, Drinka and coworkers (1987) believe that all de Meneses, 1989). Many of the problems identified in this
caregivers should be screened for depression because it study are very similar for caregivers taking care of frail
could often be relieved with medications or psychosocial elderly individuals.
therapy. If caregivers do not receive some relief through Culler (1993) has emphasized the importance of educa
treatment, the feelings of burden may eventually seem too tion as part of the occupational therapy plan, but assess
great, so that the caregivers will feel unwilling or unable to ment of educational needs is important for all areas of the
continue to care for their elderly family members. If the health care team. The OT assessment would include
depression can be resolved, then the caregivers' percep identifying what new strategies and techniques for the
tions of their competence will be more realistic (Rogers, caregiver, as well as for the elderly individual, need to be
1987), and practical planning to relieve their feelings of incorporated into the treatment plan. This assessment wil
burden can also be more realistic and effective. directly relate to the habituation level, which involves the
In a study of 53 elderly persons living in the community, patient's and family's habits and lifestyles. Determining the
Schirm (1989) concluded that it is essential that services for needs and goals of occupation for the caregiver, as well as
the elderly include the care of their caregivers as well. A for the patient, is best done as part of the assessmen
study of the elderly who received caregiving from formal process. These goals may affect the motivation for treat
and informal caregivers found that in some instances, the ment: " ... the effectiveness of treatment often depends
caregivers were suffering from the same or Similar chronic on the patient's ability and motivation as well as the
conditions as the persons for whom they were caring. The cooperation of family members or the available socia
importance of measuring functional independence is well support system" (Maguire, 1990, p. 277). In PT, the needs
established, but function is not the basis on which eligibility and goals of the caregiver in relation to ambulation and
for Medicare reimbursement is made. Therefore, assis safety are crucial.
tance primarily in ADL and IADL activities must be Measures of Social Environment. Information is needed
included in future health care policies as much as care on social supports, including family and friends, and
involving technical health services (Schirm, 1989). measures of caregiving such as reaction, burden, and
In a study of caregivers, Hasselkus (1989) has identified strain. A list of specific instruments has been included in the
three primary goals of caregivers: 1) getting things done, Appendix at the end of this chapter.
2) ensuring health and well-being for the care receiver,
and 3) preserving health and well-being for the caregiver.
All the caregivers in this study were concerned with Physical Environment
reaching these goals but differed in regard to how they
prioritized and reached them. Hasselkus suggested that Occupational therapy and PT are both concerned with
these discrepancies between the views of caregivers and the physical environment. Traditionally, assessments of
health professionals may lead to less effective treatment architectural barriers in the home and community and
for the care recipient. However, this process is where training in adaptive techniques and equipment have been
health professionals are most apt to differ with caregivers. important roles for both OT and PT. PhYSical therapy has
Clinicians are trained to be concerned with elderly per had primary responsibility for ambulation activities and
sons being as independent as possible, but caregivers and equipment, while OT's major emphasis has been on ADL
even elderly persons themselves may see this goal as and IADL. Both professions have been concerned with
secondary in their total life context. Hasselkus (1991) factors related to falls and the elderly.
points out that "Whereas health professionals are likely Measures of the Physical Environment. Measures of
to have an explicit professional code of ethics to gUide the impact of the physical environment are often in
their practice, informal family caregivers draw on implicit cluded in evaluations designed or modified by individua
ethical convictions for their practice" (p. 209). These therapy departments. Evaluations or parts of evaluations
implicit convictions may not always be immediately ap that might focus on aspects of the physical environmen
parent to the caregiver or the professional, but it is include evaluations of architectural barriers in various
important in the assessment process to determine the settings, home layouts, homemaking checklists, and en
views of the elderly and their caregivers. vironmental influences in histories of falls. Assessmen
Initial results of a pilot study of caregiving for cancer in these areas is elaborated in other chapters of this
patients suggested that the intervention most needed was book.
scope of this single chapter, but a sample list of instru
The previous discussions of assessment have included ments with their references has been included to facilitate
the theoretic and conceptual aspects of assessment of the review of the actual instruments by the readers (see
elderly for OT and PT and have included a discussion of Appendix). This list should be seen simply as a sampling
the areas of concern. Assessment of the elderly is a for further study and not necessarily an inclusive o
multifaceted process, and at this time, no universal as representative selection of the "best" assessments for the
sessment instrument is used in either diScipline. There- elderly.
ments Useful
with the Elderly
Activities of Daily Living (From OARS) (George & Fillen Instrumental Activities of Daily Living (From OARS
baum, 1985) (George & Fillenbaum, 1985)
Assessment of Communication & Interaction Skills Interpersonal Support Evaluation List (Cohen et al., 1985
(MOHO Clearing House, 1995) Klein-Bell Activities of Daily Living Scale (Klein & Bell
Assessment of Living Skills and Resources (Williams et al., 1982)
1991) Kohlman Evaluation of Living Skills (Kohlman-Thompson
Assessment of Motor and Process Skills (AMPS Project, 1992)
1995) London Psychogeriatric Rating Scale (Hersch et al., 1978
Assessment of Occupational Functioning (Watts et ai, Mini-Mental Status Examination (Anthony et al., 1982
1989) Modified Interest Checklist (Occupational Therapy Depart
BaFPE Social Interaction Scale (Williams & Bloomer, ment, 1995)
1987) Multidimensional Functional Assessment Questionnair
BaFPE Task Oriented Assessment (Williams & Bloomer, (From OARS) (George & Fillenbaum, 1985)
1987) Multidimensional Observation Scale for Elderly Subject
Barth Time Configuration (Barth, 1985) (Helmes, 1988)
Caregiver Reaction Assessment (Given et al., 1992) NIH Activity Record (Furst, 1995)
Caregiver Strain Index (Robinson, 1983) Occupational Case Analysis Interview and Rating Scal
(Slack Book Order Dept, 1995)
Cognitive Capacity Screening Examination (Jacobs et aL,
1977) Occupational Performance History Interview (America
Occupational Therapy ASSOCiation, 1995)
Comprehensive Assessment and Referral Evaluation
(Gurland et aL, 1977-1978) Occupational Questionnaire (MOHO Clearing House
1995)
Environment Assessment Scale (Kannegieter, 1986)
Older Americans Resources and Services (George &
Environmental Questionnaire (Dunning, 1972)
Fillenbaum, 1985)
Family Burden Interview (Zarit et al., 1980)
Role Checklist (Oakley, 1995)
Family Environment Scale (Moos, 1976) Scorable Self Care Evaluation (Clark & Peters, 1992)
Functional Activities Questionnaire (Pfeiffer et aL, 1982) Screen for Caregiver Burden (Vitaliano et al., 1991)
Functional Assessment Inventory (Pfeiffer et al., 1981) Self Assessment of Occupational Functioning (MOHO
Functional Independence Measure (FlMS) (Uniform Data Clearing House, 1995)
System for Medical Rehabilitation, 1990) Self-Efficacy Scale (Scherer & Maddux, 1982)
Health Assessment Questionnaire (Fries et al., 1982) Services Assessment Questionnaire (From OARS) (Georg
Home Hazard Checklists (Tideiksaar, 1986) & Fillenbaum, 1985)
414
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tioning, and personality characteristics in old age. Gerontologist, 12, New York: Van Nostrand Reinhold.
168-173. Shestack, R. (1977). Handbook of physical therapy. New York:
Lewis, C. B. (1995). Musculoskeletal changes with age: Clinical implica Springer.
tions.ln C. 8. Lewis (Ed.), Aging: The health care challenge (3rd ed.). Skrastins, R., Merry, G. M., Rosenberg, G. M., & Schuman, J. E. (1982)
Philadelphia: F. A Davis Company. Clinical assessment of the elderly patient. Canadian Medical Associa
Maguire, G. H. (1995a). Activities of daily living. In C. B. Lewis (Ed.), tion Journal, 127(3), 203-206.
Aging: The health care challenge (3rd ed.). Philadelphia: F. A Davis Slack Book Order Department, 6900 Grove Road, Thorofare, NJ
Company. 08086-9447, Phone: 1-800-257-8290, Fax: (609) 853-5991, Order
Maguire, G. H. (1990). Occupational therapy. In W. Abrams & R. Berkow # 30543.
(Eds.), The Merck manual ofgeriatrics. New Jersey: Merck&Co., Inc. Smith, H. B. (1973). Smith hand function evaluation. American Journal
Maguire, G. H. (1995b). Sensory changes in the elderly. In C. B. Lewis of Occupational Therapy, 27, 244-251.
(Ed.), Aging: The health care challenge (3rd ed.). Philadelphia: Stone, R., Cafferata, G., & SangJ, J. (1987). Caregivers of the frail elderly:
F. A Davis Company. A national profile. The Gerontologist, 27(5), 616-626.
Mahoney, E L., & Barthel, D. W. (1965). Functional evaluation: Barthel Tideiksaar, R. (1986). Preventing falls: Home hazard checklists to help
index. Maryland State Medical Journal, 14,61-65. older patients protect themselves. Geriatrics, 41, 26-29.
Philadelphia: J. B. Lippincott Company. dwelling veterans. The Gerontologist, 31(1), 84-91.
Uniform Data System for Medical Rehabilitation. (1990). Guide to the Williams, S., & Bloomer, J. (1987). &y area functional performance
Uniform Data Set. New York: State University of New York at Buffalo. evaluation (2nd ed.). PaJo Alto, CA: Consulting Psychologist Press.
Vitaliano, P., Russo, J., Young, H., Becker, J., & Maiuro, R. (1991). The Zarit, S. H., Orr, N. K., & Zarit, J. M. (1985). The hidden victims of
screen for caregiver burden. The Gerontologist, 31(1), 76-83. Alzheimer's disease: Families under stress. New York: New York
Watson, P. G. (1987). Family participation in the rehabilitation process: University Press.
The rehabilitators' perspective. Rehabilitation NurSing, 13, 70-73. Zarit, S. H., Reever, K., & Bach-Peterson, J. (1980). Relatives of the
Watts, J. H., Brollier, C., Bauer, D., & Schmidt, W. (1989). The impaired elderly: Correlates of feelings of burden. The Gerontologist,
assessment of occupational functioning: The second revision. Occupa 20(6), 649-655.
tional Therapy in Mental Health, 8(4), 61-67.
UNIT FIVE
Assessment of
Activities of Daily
Living
C HAP T E R 1 6
SUMMARY The information in this chapter is intended to help the reader under
stand the theoretic basis of self-care assessments and gain knowledge about some
of the measurement issues in self-care assessment. This chapter also provides infor
mation about current important self-care assessments for use in rehabilitation.
The historical background of self-care assessments is outlined. It is pOinted out
that most self-care assessments do not have an explicit theoretic basis but have
been developed using checklists of self-care activities. The influence of c1ient
centered practice on self-care assessment has led to more recent assessments that
take into account the environment in which clients perform self-care activities.
Information about the source, clinical utility, and psychometric properties of im
portant self-care assessments is presented.
Many self-care assessments are discussed in the litera The type of scaling used in most self-care assessments is
ture. In fact, Feinstein and colleagues (1986) identified at ordinal scaling. With ordinal scales, one cannot be assured
least 43 different measures of self-care. Most of these that distances between scores are equal. For example, if a
measures have not been developed using a theoretic model self-care assessment is scored with a scale from 1 to 4, the
about the conceptual basis of functional self-care perfor difference in self-care abilities between scores of 1 and 2
mance. The majority of measures have been developed versus scores of 3 and 4 cannot be assumed to be equal.
using a checklist of self-care skills required for individuals Several authors have criticized, the use of ordinal scaling in
with specific diagnostic impairments. For example, Jette self-care measures because it limits the comparability of
(1980) has developed a self-care measure specifically for scores across individuals and programs (Fisher, 1994;
individuals with arthritis. Keith, 1984; Merbitz et al., 1989), It has been suggested
Several more recent self-care measures have been that multifaceted Rasch techniques, which are statistical
developed using a specific theoretic model for the item procedures to develop interval scaling from ordinal data, be
selection and development (Hebert et al., 1988; Jette, used for all self-care measures. The development of
1987; Laver & Powell, 1995). It has a)so been increas measures using Rasch techniques is increasing and has
ingly recognized that the ability to perform self-care been used with measures such as the FIM (Granger et al.,
activities is a very complex issue and is dependent on the 1986), the Patient Evaluation and Conference System
environment in which the person is performing the (PECS) (Harvey & Jellinek, 1981), and the Assessment of
activity. A person's ability to perform self-care activities Motor and Process Skills (AMPS) (Fisher, 1994). Using
is dependent on the transactional relationship between Rasch analysis, scoring adjustments can be made for
the individual's skills, the activities that he or she is difficulty of items and for different observers. While the use
required to perform, and the environments in which of Rasch analysis is becoming more popular, others
performance occurs (Law, 1993). (Streiner & Norman, 1989) have argued that many scales
Measures such as the Functional Independence Mea constructed using ordinal scaling are quite robust and meet
sure (FIM) (Granger et al., 1986) and the Barthel Index the assumptions for interval data, Rasch techniques are
(Mahoney & Barthel, 1965) are measures developed on only one of several scaling techniques that can be employed
a disability rather than a diagnostic basis. In those as to ensure the appropriateness of scaling for a self-care
sessments, the focus of the assessment is on the ability assessment.
to measure any difficulties in performing an activity Rehabilitation service providers assess self-care activities
because of an impairment. These measures can there to determine which activities clients are having difficulty
fore be applied to people with many different diagnostic performing. The other aspect of self-care assessment that
labels. is very important is determining the reasons for the diffi
The focus of rehabilitation has been changing recently culties in performance. The majority of self-care assess
to a client-centered perspective in which rehabilitation ments do not provide specific information about problems
priorities are based on the individualized needs of clients in individual skills or deficits within the environment that
(Canadian Association of Occupational TherapiSts, contribute to decreased performance. Two measures, the
1991). Few self-care measures reflect the client-centered AMPS (Fisher, 1994) and the Structured Observational
model of practice (see Law et al., 1994a for an example). Test of Function (SOTOL) (Laver & Powell, 1995) have
In fact, most self-care assessments apply the same items been developed to provide a simultaneous assessment of
to the assessment of all individuals. Self-care assessments IADL and the underlying skills required to perform those
generally reflect a North American value of independence activities. Although the AMPS is an assessment of IADL,
and respect for individual rights. If a self-care measure the methodology used for the development of this measure
uses a standardized list of items, that measure is unable is exciting, and the ability of the measure to both identify
to reflect differences in individuals' culture, values, and performance deficits as well as the reasons for these deficits
needs (Law, 1993). Feinstein and coworkers (1986) have is very useful to rehabilitation service providers.
suggested that clients should be involved in the construc Many self-care assessments are performed with clients in
tion of self-care assessments and that client preferences a rehabilitation or institutional setting. Performing an
should be considered in any self-care assessment. They assessment in this setting, which is unfamiliar to the client,
have also indicated concerns that most self-care assess has significant implications regarding the contextual valid
ments rate only quantity of performance but do not fo ity of the assessment process. A few studies have evaluated
cus on the client effort required to achieve that perfor the effects of performing and assessment in different
mance. environments. Research with the AMPS has indicated that
assessment is carried out (Nygard et aI., 1993; Park et dresSing, eating, and washing. In a study by Shiner and
al., 1993). It has been recommended that assessment of others (1987) using a modified Barthel Index, correlations
self-care activities be performed in the environment in between scores based on observation and those based on
which the client would ordinarily carry out those activities. a telephone interview were greater than r > 0.97 for the
Another approach to ensuring the contextual validity of total score and r > 0.85 for individual items. These results
a self-care assessment is to use an individualized assess indicate a high level of concordance between a self-report
ment. For example, the Canadian Occupational Perfor and observational scores. Results from this study also
mance Measure (COPM) (Law et al., 1991; Law et aL, indicate that agreement between self-report measures and
1994a) is an individualized assessment of a client's per observation is enhanced when the self-report measures are
ception of his or her performance and satisfaction with administered by a well-trained interviewer.
performance in self-care as well as other daily activities. It is important for rehabilitation clinicians to ensure that
Because it is individualized, the client is able to identify they receive training in the administration of any self-care
those self-care activities that are important for him or her assessment. Also, clinicians within a rehabilitation setting
to perform and is able to rate performance in those should evaluate their consistency or reliability in adminis
activities considering the environment in which they are tering the measure. High-reliability statistics found in
routinely completed. validation research for a self-care measure do not ensure
It is importaht to know if a self-care assessment is that the measure will be used reliably in a specific clinical
measuring an individual's capacity to do self-care activities situation. The reliability of a measure needs to be re
or actual performance. Both aspects of assessment may be checked when a self-care assessment is to be used in a
important, particularly at different stages in the rehabilita clinical rehabilitation program.
tion process. For example, early in rehabilitation, it may be
very important to assess the individual's capacity to per
form necessary self-care activities. Once a client has
returned to his or her former living situation, assessment of SELF-CARE MEASURES
self-care activities should focus on what the client is actually
able to perform on a day-te-day basis. In assessing actual Because of the number of self-care assessments in the
performance, some self-care assessments penalize indi literature, not all can be described here. The assessments
viduals for the use of technical aids or assistive devices. included in this section of the chapter reflect self-care
Other measures, such as the Klein-Bell Scale (Klein & Bell, assessments that are widely used, are suitable for a range of
1982), are based on an underlying philosophy that the use diagnostic categories, and have undergone psychometric
of technical devices is appropriate, and clients are not validation. More recent assessments using innovative
penalized in their score on that measure for the use of such methodologies have also been included.
of devices.
Increasingly, self-care assessments are based on the
self-report of the client. The use of self-report measures is Barthel Index
supported within a client-centered model of practice
because it can allow the client to identify the self-care The Barthel Index is one of the oldest self-care measures.
activities that are important for him or her to perform It was initially developed to measure changes in functional
within the environment in which he or she lives. The use of status for clients undergoing inpatient rehabilitation. The
a self-report measure to determine client perceptions is Barthel Index is available from Mahoney & Barthel (1965).
quite valid. However, the use of self-report measures as a
substitute for direct observation when determining difficul
CLINICAL UTILITY
ties in performance and the reasons for these difficulties is
controversial. Although it is useful to know if differences The Barthel Index is completed by a rater who is a
exist between observed performance and client self-report, rehabilitation professional. Rating is completed using in
therapists may not be clear on how to deal with these formation from records or follOwing direct observation of a
differences. Klein-Paris and associates (1986) found that client's functional performance.
self-report assessments are more likely to agree with The Barthel includes 10 activities that are rated using
observational assessments when clients are not cognitively either a two-point or a three-pOint ordinal scale. Scores for
impaired and when the self-care items being assessed are activities have been weighted so that final item scores range
less complex. Several studies have indicated that Significant from 0 for dependent performance to 15 for independent
differences often occur in self-care assessments between performance. Total score on the assessment ranges from
client self-report and direct observation by rehabilitation o to 100 in increments of 5. The completion time of the
personnel (Edwards, 1990; Kivela, 1984; Rubenstein et scoring, including observation, should take approximately
al., 1984). Kivela (1984) found that percentage agreement 1 hour.
424 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
STANDARDIZATION AND RELIABILITY occupational therapy to identify self-care issues that are
causing problems and to evaluate their perception of
Although the Barthel has been the subject of many
change in performance and satisfaction after intervention.
studies, no published manual is available. Insofar as reli
The COPM is available from the Canadian Association of
ability studies are available, no internal consistency has
Occupational Therapists, Carleton Technology and Train
been reported. Interrater data range from adequate to
ing Centre, Suite 3400, Carleton University, 1125 Colo
excellent. Kappa statistics for items range from 0.54 to
nel By Drive, Ottawa ON K1S 5R1. The cost for a manual
0.88. Interrater reliability was found to be 0.95 (Granger et
and 100 measures is $25.95 plus shipping. A training
aI., 1979). Test-retest reliability coefficients using Kappa
video is also available.
statistics range from 0.47 to 1.00 for items, and overall
test-retest reliability reported was 0.87. Scoring by physi
cians based on a client interview has been found not to be CLINICAL UTILITY
reliable (Ranhoff & Laake, 1993). However, use of a
The COPM is administered by the occupational therapist
telephone interview by trained interviewers is reliable
using a semistructured interview. Clients are asked to
(Shiner et aI., 1987).
identify areas of self-care with which they are having
difficulty in performance or satisfaction with their perfor
VALIDITY mance. Once a client has identified self-care issues, he or
she is asked to rate his or her performance in the self-care
The items on the Barthel appear to cover the domain of activity and his or her satisfaction with that performance
basic self-care, although no specific method to ensure the using a scale of 1 to 10. The same scale is used for
content validity was used. It has been tested against many reassessment. The average completion time is 20 minutes,
other ADL or self-care evaluations. For example, correla with a median time of 30 minutes.
tions with the physical, upper extremity, lower extremity,
sensory component, excretory function, mental and emo
tional status (PULSES) profile range from -0.74 to -0.90 STANDARDIZATION AND RELIABILITY
(Granger et al., 1979). Correlations of the Barthel with a The COPM is a standardized instrument in that it has
number of stroke scales range from 0.66 to 0.83 (DeHaan specific instructions and methods for administering and
et al., 1993). The Barthel has been found to correlate scoring the test. However, the administration of the test is
significantly with age (Fortinsky et al., 1981; Nakayama et individualized to enable clients to identify self-care issues
al., 1994). Studies by Granger and colleagues (1979) have that are important to them. COPM is not norm referenced.
indicated that individuals receiving scores of below 60 on A manual including administration instructions, reliability,
the Barthel are dependent in self-care. Initial scores on the and validity information and clinical examples is available.
Barthel Index have been shown to predict length of stay Internal consistency reliability is not applicable. No reports
and rehabilitation outcome (Shah & Cooper, 1991; Wylie, of interrater reliability studies are included. For test-retest
1967). reliability, interclass correlation coefficients were 0.63 for
performance and 0.84 for satisfaction in a study of 27 se
niors attending an outpatient day program and 0.76 and
OVERALL UTILITY
0.79 for parents of children with disabilities.
The Barthel, although it is an older index, remains one of
the most widely used self-care measures. One of the most
VALIDITY
Significant criticisms about the Barthel is its use of an
ordinal scale that has not been validated or shown to Content validity is excellent for this assessment because
produce interval level measurements. Nevertheless, signif the COPM is an individualized measure, and the content is
icant evidence exists that the Barthel is a reliable measure determined individually by each client. At this time, no
that can describe self-care status and has some predictive criterion validity has been reported.
validity. The responsiveness of the Barthel to evaluate Studies of the responsiveness of the COPM (Law et aI.,
change over time has yet to be established. 1994b) indicated that performance and satisfaction scores
changed significantly over time in 139 clients of mixed
diagnosis. A study of 30 clients of an outpatient day
program indicated that client and family independent
Canadian Occllpational Performance ratings of change correlated from 0.53 to 0.62 with
Measure change on the COPM. In a study of the use of verbal
self-guidance with 10 children 7 to 12 years of age with
The COPM (Lawet al., 1994a), applicable to all clients, developmental coordination disorder, scores on the COPM
is an individualized measure of a client's perception of changed significantly and agreed with changes on video
performance and satisfaction in areas of self-care, produc tape records using the Behavioural Observation Scale
tivity, and leisure. It is designed to enable clients of (BOS) (Wilcox, 1994).
0.89 for ADL (Hebert et al., 1988).
The COPM provides a useful and clinically meaningful
method to enable clients to identify self-care problems
before rehabilitation intervention. It is a new measure, and OVERALL UTILITY
initial research indicates that its test-retest reliability is good
The MSMAF represents a unique approach to assess
to excellent and its construct validity in terms of respon
ment in that it attempts to link disability and handicap.
siveness has been demonstrated. Further research of other
Although it has been cited as a measure of handicap, the
aspects of reliability and validity are required.
items on the MSMAF measure disability, and these infer
ences have not been tested. Further work is required to
examine the test-retest reliability of the MSMAF as well as
Functional Autonomy Measuring its criterion and construct validity.
System
The Functional Autonomy Measuring System (MSMAF)
Functional Independence Measure
was developed to provide a descriptive measure of the
The AM is an assessment used to describe the degree of
disability status and an inferred measure of handicap status
disability experienced by an adult rehabilitation client and
for elderly clients. It is available from System de Measure de
to evaluate change in groups of clients over time. It is
I'Automie Foncetionnelle, Hopital d'Youville, 1536 Belve
available from the Department of Rehabilitation Medicine,
dere Sud, Sherbrooke, Quebec, Canada J1H 4C4.
State University of New York at Buffalo, Buffalo General
Hospital, 100 Hye Street, Buffalo, NY 14203.
CLINICAL UTILITY
The MSMAF is completed by health professionals using CLINICAL UTILITY
ratings based on their knowledge of client performance or The AM is completed by a member of the rehabilitation
their observations of client performance. The MSMAF team based on information derived from observation of
assesses 29 items in six domains: ADL, mobility, commu client performance. It uses a 7-point scale to evaluate 18
nication, mental functions, and IADL. Self-care items items in areas of self-care, sphincter control, mobility,
included are eating, bathing, dressing, grooming, urinary locomotion, comm~nication, a~d sOcial cognitiori~ TI1~
continence, fecal continence, and using the bathroom. average completion time for the AM is approximately~30
Client performance is rated on a 4-point scale ranging from minutes and 10 to 20 minutes to score the measure.
o for complete autonomy to -3 for total dependence.
Based on the disability ratings, inferences are made about
whether this disability leads to a handicap. In making these STANDARDIZATION AND RELIABILITY
inferences, the resources that the client has to overcome A detailed administration manual for the AM is available.
this disability are considered. The completion time ex The scoring system for the FIM uses ordinal scaling. Rasch
pected for this assessment is an average of 40 minutes. analysis has been used to transform the AM ordinal ratings
into an interval scale. Normative standards for the AM have
STANDARDIZATION AND RELIABILITY been developed using data from 230 clients with brain
injuries (Long et aI., 1994). Internal consistency reliability
The MSMAF is a relatively new measure. Assessment has not been reported. In a sample of 799 clients, interclass
forms along with instructions are available. Few standard correlation coefficients for interrater reliability for total AM
ization studies have been done of the MSMAF to date. scores and scores for AM categories ranged from 0.88 to
Internal consistency has not been reported. Weighted 0.96. Kappa scores for AM items ranged from 0.48 to
Kappa coefficients examining interrater reliability for ac 0.63. Test-retest reliability has not been reported.
tivity groups and total score range from 0.52 for commu
nication to 0.75 for IADL. For self-care activities, the
weighted Kappa was 0.66 (Hebert et al., 1988). Test-retest VALIDITY
reliability has not been reported. Content items of the FIM were developed using the im
pairment disability and handicap framework from the
World Health Organization and information from the lit
VALIDITY
erature and rehabilitation experts. The AM has been
The MSMAF was developed using the World Health shown to predict burden of care better than other measures
Organization classification of impairments, disability, and (Granger et al., 1990), and admission FIM scores have
handicaps. No criterion validity has been reported. Corre been found to be the best predictor of disability in stroke
lation between the amount of nursing care time and the survivors (Oczkowski & Barreca, 1993). Many studies
426 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
evaluating the construct validity of the FIM have been com Reliability for the pain and difficulty indices are also in the
pleted. These include studies of patterns of difficulty with acceptable range.
the motor and cognitive FIM items (Granger et aI., 1993),
prediction of burden of care (Granger et aI., 1990), ability
VALIDITY
of the FIM to measure changes in motor and cognitive
function during rehabilitation (Heinemann et aL, 1993), The FSI was developed using extensive information from
patterns of results of items on the FIM when subjected to previous self-care measures and from the literature fol
Rasch analysis (Heinemann et aI., 1993), and prediction of lowed by factor analysis to reduce the number of items from
rehabilitation outcome after stroke (Oczkowski & Barreca, 45 to 18. Correlations of the FSI with health professional
1993). assessments, including Arthritis and Rheumatism Associa
tion (ARA) functional classification, ARA stage of disease,
and professional global assessment of function and disease
OVERALL UTI LlTY
activity, ranged from 0.25 to 0.49 (Jette, 1987). Rates of
The FIM is a clear and concise s~essment_ agreement between the FSI and observation of perfor
whose primary purpose is to evaluate change over time in mance in self-care and IADL tasks ranged from 0.77 to
rehabilitation programs. Its observer reliability and validity 0.95.
for program evaluation use have been well established.
Therapists should be cautioned not to use the FIM for
OVERALL UTILITY
evaluation of change in individual clients, as it is less
responsive in this situation. The FSI is a well-developed assessment that covers a
number of domains applicable to clients with arthritis. Its
reliability and validity have been well tested.
Functiollal Status Index
The Functional Status Index (FSI) was developed as part Goal Attainment Scaling
of a Pilot Geriatric Arthritis Program and is designed for use
in a program evaluation for clients with arthritis. It is Goal attainment scaling (GAS) is a method of evaluating
available from Allen M. Jette, PT, MGH Institute of the effectiveness of the therapy intervention. Through this
Health Professions, 15 River Street, Boston, MA 02108 process, goals are set in collaboration with clients, and
3402. changes over time are documented and scored. It is
applicable to all clients. GAS is a methodology that is
available at no cost from Stolee and associates (1992), Cot
CLINICAL UTILITY
& Finch (1991), or Ottenbacher & Cusick (1990).
The FSI is a self-report tool in which clients are asked to
rate their performance as well as the degree of pain and
CLINICAL UTILITY
difficulty in accomplishing tasks. The FSI includes 18 items
in the areas of gross mobility, hand activities, personal care, Goal attainment scaling assesses change in performance
home chores, and social activities. It has four personal care on specific goals in self-care. The goals are set by rehabili
items. Clients are asked to rate degree of assistance for tation professionals, usually in collaboration with clients.
each activity on a scale of 0 to 4, with 0 indicating There is a standard procedure for GAS. A specific
independent and 4, unable or unsafe to do the activity. problem area in self-care is identified. The expected level of
Clients are then asked to rate the degree of pain and the performance is then set. Levels of performance attainment
degree of difficulty on a scale of 1 to 4 with 1 meaning no that are less than expected and better than expected are
pain or no difficulty and 3, severe pain or severe difficulty. then set. The expected level of performance is rated 0, and
Completion time is approximately 20 to 30 minutes. other levels are rated from +2 to -2. After intervention, the
achieved level of performance is scored according to the
five attainment levels that had been preset. Change scores
STANDARDIZATION AND RELIABILITY
for single or multiple goals can be calculated using a
The FSI is a standardized instrument, and a manual is standard score expressed as a T score. T scores have a
available. Using coefficient alpha, the internal consistency mean equal to 50 and a standard deviation of 10.
of the FSI categories ranged from 0.23 for hand activities Completion time ranges from 15 to 45 minutes for each
to 0.81 for social and role activities. Internal consistency of client.
personal care was 0.67. Using interclass correlation coef
ficients, interrater reliability ranges from 0.64 for hand
STANDARDIZATION AND RELIABILITY
activities to 0.89 for social and role activities (Jette, 1987).
Test-retest reliability ranges from 0.40 for social and role Standard procedures have been established and outlined
activities to 0.87 for home chores. Personal care is 0.82. in the literature for using GAS. The mathematic calcula
tency has not been reported. Interclass correlation scores reported.
of 0.87 to 0.88 were obtained between physician and
primary care nurses with 15 seniors in a geriatric program
VALIDITY
(Stolee et aI., 1992). Substantial training of rehabilitation
personnel is required to ensure consistency in goal setting In developing the Katz Index of ADL, the authors used
across individuals. Test-retest reliability has not been re items from the literature. Guttman scaling was used to
ported. confirm the hierarchic nature of the index. The Katz has
been compared to the Barthel Index and the Kenny
Self-Care Evaluation (Gresham, Phillips & Labi, 1980) and
VALIDITY
was found to be less responsive than either measure. In a
Content validity is ensured because GAS is an individu study of 194 nursing home residents, correlation between
alized measure and the content is determined individually the Katz and the Sickness Impact profile was found to be
by each client. In the study by Stolee and colleagues (1992), 0.39 (Mulrowet aI., 1994).
the correlation of GAS scores with global outcome rating
was 0.82. The authors also found that the correlation of
OVERALL UTILITY
change in GAS score to change in Barthel was 0.86. The
average change in GAS score was a gain of 23.9 points The Katz Index of ADL is a quick, simple, basic self-care
(standard deviation was 7.4), compared with a gain on assessment. Its most clinically useful purpose is as a
the Barthel index of 18.3 points (standard deviation descriptive or predictive assessment to gather information
was 19.8). effiCiently about self-care.
OVERALL UTILITY
Kenny Self-Care Evaluation
Goal attainment scaling represents a useful method to
measure change in individualized goals in clients. It is useful The Kenny Self-Care Evaluation (Iverson et al., 1973)
in multidisciplinary settings and can apply to all clients. It is describes self-care abilities and evaluates changes in self
more suitable as a clinical rather than a research tool. The care over time in adults involved in rehabilitation. It is
training to ensure consistency of GAS application has been available from the Kenny Rehabilitation Institute, 1800
found to be extensive. Also, mathematic calculation of the Chicago Avenue, Minneapolis MN 55404. Cost is limited
GAS is complex and controversial. to the cost of printing the measure.
in self-care assessment is greater than the Barthel or the -0.86 was found between Klein-Bell score discharge and
Katz (Donaldson et al., 1973). Studies of its construct amount of personal care assistance required, indicating
validity have not been reported. that assistance increases as Klein-Bell score decreases
(Klein & Bell, 1982). Scores on the Klein-Bell Scale were
able to indicate children who had self-care problems due to
OVERALL UTILITY
disability (Law & Usher, 1987). Law & Usher also found
The Kenny Self-Care Evaluation provides a clear and that the Klein-Bell Scale was responsive to changes over
concise reading form to assess physical self-care tasks. It time, as indicated by therapist and parent judgmental
appears to adequately cover the domain of self-care change. Unruh and others (1993) found that parent reports
activities. A limited number of reliability and validity studies of children's function on the Klein-Bell Scale agreed with
are available for this measure. therapist ratings more that 85% of the time.
PULSES profile, and the Physical Self-Maintenance Scale and seniors. Items were defined and reviewed using a
(Settle & Holm, 1993) found that the PULSES profile did consensus procedure. Criterion and construct validity are
not provide enough information to plan rehabilitation currently being tested.
intelVention. Scores On the PULSES profile were higher
for those who returned to an independent living situation
OVERALL UTILITY
after rehabilitation (Granger et al., 1979).
The SAFER is a clinically useful assessment to evaluate
safety. Reliability and validity testing is currently being
OVERALL UTILITY
completed.
The PULSES profile provides a comprehensive over
view of self-care function but is not likely to be responsive
to change because it is limited to a few items. Structured Assessment of
Independent Living Skills
The Structured Assessment of Independent Living Skills
The Safety Assessment of FUllCtion (SAILS) was developed to assess everyday activities in
and the Environment for clients with dementia to document or describe problems
Rehabilitation and potentially evaluate change over time. It is available
from the article by Mahurin and colleagues (1991).
The Safety Assessment of Function and the Environ
ment for Rehabilitation (SAFER) tool is designed to evalu
CLINICAL UTILITY
ate seniors' abilities to function safely within their living
environment (Oliver eta!., 1993). Its primary purpose is to The SAILS is a criterion-based measure in which a
describe safety problems present within a living situation. number of test items are administered to a client and scored
Safety and self-care tasks are included in the measure. It is based on his or her performance at that time. It includes
available from Community Occupational Therapy Associ items in the areas of fine motor skills, gross motor skills,
ates (COTA), 3101 Bathurst Street, Suite 200, Toronto, dressing skills, eating skills, cognitive tasks, receptive
Ontario M6A 2A6, Canada. Guidelines for administration language, expressive language, time and orientation,
and scoring, along with the SAFER measure, cost $75.00. money-related skills, instrumental activities, and social
interaction. Most items are scored on a four-point scale,
with 0 indicating no performance and 3, correct response
CLINICAL UTILITY
to all items. Some items are also timed. Completion time
The SAFER is completed by the occupational therapist ranges from 1 to 1.5 hours.
after obselVation of client performance in his or her living
environment. The SAFER tool includes 97 items, which
STANDARDIZATION AND RELIABILITY
are scored on a dichotomous (problem/not a problem)
scale. Items are scored after performance of self-care and The SAILS is a relatively new measure. A short manual
other ADL and IADL tasks are obselVed in the living with instructions is available from the authors. Standard
environment. Scores are calculated as the percentage of ization to date has involved preliminary studies using
applicable items that are considered to be a safety problem. 36 individuals. An internal consistency study found an
Completion time takes 20 minutes to 2 hours, depending alpha coefficient of 0.90 for the SAILS. Interrater reliability
on the nature of the living environment. between two raters was r = 0.99. In a study using 10 cli
ents, test-retest reliability was 0.81 for total score and
0.97 for motor time (Mahurin et al., 1991).
STANDARDIZATION AND RELIABILITY
The SAFER is a standardized measure, and guidelines for
VALIDITY
the administration and scoring of the tool are available. In
a study with 56 community-dwelling seniors, the Kuder Items for the SAILS were selected after a review of
Richardson-20 internal consistency coefficient was 0.83. current assessment techniques. Inclusion of items was
ObselVer and test-retest reliability are currently being based on three criteria: theoretic relevance, practicality,
tested. and gradation of task difficulty (Mahurin et al., 1991).
Correlations of the SAILS were as follows: with the
Geriatric Depression Scale, 0.39; with the Mini-Mental
VALIDITY
State Exam, 0.60; with the Weschler Adult Intelligence
Content validity of the SAFER tool was established Scale, 0.73 to 0.79; and with the Global Deterioration
initially by searching for items within the literature and was Scale, 0.69. Scores on the SAILS for a group of clients with
followed by a review by a panel of occupational therapists Alzheimer's disease were significantly lower than those of
a control group of elderly clients who were the same age 0.67 for the four self-care tasks, and 0.54 for the
and had similar years of education. neuropsychological checklist. Test-retest reliability using
Kappa statistics were 0.92 for the screening assessment,
0.5 to 0.77 for the four self-care tasks, and 0.55 for the
OVERALL UTILITY
neuropsychological assessment.
The SAILS is a new measure and has received limited
psychometric testing. It appears to provide clinically useful
VALIDITY
information in a number of self-care areas. Initial testing for
reliability and validity demonstrated acceptable reliability The SOTOF was developed using a framework from the
and construct validity. National Council of Medical Rehabilitation Research,
which outlines an assessment model ranging from patho
physiology to impairment to functional limitation to dis
The Structured Observational Test ability. The four tasks that are evaluated cover important
of Function self-care tasks and can be used to identify major neuropsy
chological problems leading to difficulties in self-care.
The Structured Observation Test of Function (SOTOF) Correlations above 0.05 level of statistical significance
is designed as a simultaneous descriptive assessment of were found between the SOTOF and other measures such
self-care abilities of older adults and underlying neuropsy as the River-Mead Perceptual Reception Battery, National
chological function .contributing to these abilities. It is Adult Reading Test, Chesington OT Neurological Assess
available from NFER-Nelson Publishing Company, Darville ment Battery, and River-Mead ADL Assessment for Stroke
House, 2 Oxford Road East, Windsor Brookshire, England Patients. Deficits of ADL performance and a neuropsy
SL4 1DF. The cost for a complete set, including the chological on the SOTOF were found to be very similar to
manual, five instruction cards, 50 record forms, and those deficits identified on other measures used in the
25 ADL neuropsychological record forms is $59.95. criteria Validity study.
external standard (e.g., another assessment of the same Iversen, LA, Silberberg, N. E., Stever, R. c., & Schoening, H.A (1973).
The revised Kenny Self-Care Evaluation: A numerical measure of
attribute). independence in activities of daily living. Minneapolis, MN: Sister
ReHability-The consistency of an assessment score Kenny Institute.
Jellinek, H. M., Torkelson, R. M., & Harvey, R. E (1982). Functional
under different administration conditions, such as at differ abilities and distress levels in brain injured patients at long-term
ent times (test-retest reliability) or with different therapists follow-up. Archives of Physical Medicine and Rehabilitation, 63,
(observer reliability). 160-162.
Jette, A M. (1980). Functional Status Index: Reliability of the chronic
Responsiveness-The ability of an assessment to mea disease evaluation instrument. Archives of Physical Medicine and
sure change in performance over time in situations where Rehabili tation, 61, 395-401.
Jette, A M. (1987). The Functional Status Index: Reliability and validity
change truly occurs. Responsiveness is a type of construct of the self-report functional disability measure. Journal of Rheuma
validity for assessments used to measure change over time. tology, 14, 15-19.
Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in
the development of ADL. The Gerontologist, 10,20-30.
Keith, R A (1984). Functional assessment measures in medical rehabili
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1 7
4
436 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
LEFT RIGHT
HS-FF FF-HO HO-TO HS-FF FF-HO HO-TO
GAIT DEVIATIONS Early Mid Late Early Mid Late COMMENTS
Knee flexion
Knee extension
Hip flexion
Hip extension
Genu varum
Genu valgum
Hip adduction
Hip abduction
Pes varus
Pes valgus
in motion at the knee at initial ground contact, mid-stance, reported in this study. The authors, however, made tw
heel-rise, and toe-off as well as genu valgum. The raters interesting observations. First, although the reliability
also monitored temporal and distance factors. The evalu gait observation was moderate at best in this study
ation form is shown in Figure 17-2. However, to improve probably is higher than the normal clinical assessment
the reliability of gait observation they used slow and which therapists do not use videotape analysis. Second,
stop-action techniques, a strategy recommended by Krebs raters were able to view a videotape of normal gait, the
and colleagues (1985) after their study. Raters recorded this would clearly facilitate observation techniques giv
knee flexion as being either inadequate, normal, or exces the descriptive variables used to define joint motion in th
sive and temporospatial factors (see Fig. 17-2) as de study.
creased, normal, or increased. There was only slight to The previously mentioned studies only considered re
moderate agreement between raters. For knee motion the ability (Le., how reproduceable were the results obtained
assessment of genu valgum received the highest agreement Hughes and Bell (1994) measured both the reliability an
followed by knee flexion at mid-stance. For temporal and validity of visual gait analysis of patients with hemiplegi
distance factors the raters showed moderate agreement on Validity measures how well the clinician's assessmen
stride length. Genu valgurn (ICC == 0.69) and stride length agreed with those obtained from an objective measureme
(ICC == 0.49) showed the highest ICC (2,1). The raters not system. Patients were filmed and a split-screen techniq
being knowledgeable of the normal values of the variables was used to simultaneously show lateral and anteropost
being observed could explain the low-to-moderate values rior views of gait. The raters were experienced physic
438 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
E = excessive
Kinematic Factors
Subphase of Stance: Initial Contact Mid-stance Heel-off Toe-off
Knee Flexion
Genu Valgum _ _ _ __
Temporospatlal Factors
Please rate the reference leg relative to the contralateral leg for the step length and stance
time assessment.
Key: D decreased
N normal
increased
Stride Length
Step Length
therapists who were allowed to use slow motion and freeze istics of gait between observation one and observation two,
frame techniques to analyze gait during Swing and stance then little Significance was given to the relation between
phase as well as describing general characteristics of gait changes in walkway measures and the raters' scores.
such as posture and step length. A three-point scale was
used that denoted the patients' gait as being normal, a
barely noticeable abnormality or a definite abnormality. An
electrical contact system (these systems are described later)
provided objective measures of time and distance factors TEMPORAL AND DISTANCE
that were used to determine the validity of visual observa PARAMETERS OF GAIT
tion of gait. The reliability coefficients reported by Hughes
and Bell (1994) are greater than those reported by Eastlack There are a number of measurements that can be made
and associates (1991), This may well be due to the use of of the walking pattern, In general these may be divided into
three therapiSts who were specialized in the rehabilitation kinetics, which measures the forces that cause the move
of stroke patients as opposed to a larger number of ments, and kinematics, which are measures of the move
therapists who were less specialized and experienced. For ments themselves without reference to the forces that
the three raters their recordings were more consistent the cause them. For a complete analysis one would need both
second time they observed the patients walk where the types. Over the past decade or so there has been a major
average within-rater agreement for the general character move to develop systems to objectively measure the
istics of gait and swing and stance phases were 0.81, 0.86, plethora of gait parameters. These vary from simple foot
and 0.84, respectively. The between-rater agreement was switches, to electromyography, to force platforms to
high for the three components of gait (0.71 to 0.90), with sophisticated optoelectronic systems (Harris & Wertsch,
rater agreement being more consistent for swing-phase 1994). For the most part the technical complexity and
motion. Because there were few changes in the character- expense of such systems put them beyond the reach of
system, none has been widely accepted, perhaps because ing of the ground contact events are clearly going
of expense, sophistication of equipment, and time con change, an issue that is addressed later.
straints. A more tangible explanation for the lack of such
systems in the United States may be the difficulty in getting
reimbursement for gait analysis. Treatment, however, can
be more readily billed to the insurance companies and,
consequently, it is in this endeavor that the therapist is likely
ANALYSIS OF TEMPORAL AND
to concentrate. DISTANCE PARAMETERS USING
By its very nature the subjective assessment currently ELECTRICAL CONTACT
used by the vast majority of therapists looks at kinematic SYSTEMs-HEMIPARETIC GAIT
parameters including timing and placement of foot/floor
contact and walking speed. If reliably assessed, these events The temporal and distance gait parameters are outco
provide useful data with which to document a patient's gait measures that are often indicative of problems result
characteristics and changes after treatment. Wall and from underlying causes. As such, they might be though
coworkers (1987) clearly demonstrate how time and as the vital signs of locomotion in much the same way
distance parameters can be used to describe abnormal temperature, pulse, and blood pressure are used to ref
walking patterns. They divide the gait cycle into stance the general status of health. They are not altered in ev
(support) and swing phases, as shown in Figure 17-3, gait abnormality, nor are they necessarily diagnostic. T
where Al represents initial ground contact or heel contact have, however, been shown to be very useful measures
in normal gait, B 1 is toe-off of the stance limb, A2 is second many gait disorders, of which hemiparetic gait provide
heel contact of the same foot, and B2 is second toe-off. Al useful example. It was previously implied that the use
to Bland A2 to B2 represent stance phase whereas B 1 to highly sophisticated gait analysis equipment is beyond
A2 represents swing phase. If we could capture these data reach of the majority of clinicians. Such systems emp
for both feet, then we would have multiple events with the integrated use of high-speed filming of joint kinemat
which to document a patient's performance or change in electromyography, and the analysis of ground react
performance. These events are now shown in Figure 17-4 forces. There are clearly other less sophisticated a
where C2, D2, and C3 are the equivalent to AI, B1, and expensive, but still objective, means by which we
A2 but for the contralateral limb. These data now pro capture temporal and distance events. There have bee
vide the timing of double-stance times where both feet are great number of techniques, devices, and systems design
Simultaneously in contact with the ground. For example, speCifically to measure some or all of the temporal a
Al (right heel contact) to D1 (toe-off of the left foot) is a distance parameters of gait that could be used by
double-stance period where the right limb is providing a clinician. These vary from markings made by a felt-tip p
braking force (braking double support) and the left limb an attached to a shoe (Cerny, 1983), to stopwatch and g
acceleration force before toe-off termed a thrusting (Robinson & Smidt, 1981), to foot switches (Bajd & Kr
double support (Wall et al., 1987). Al to A2 represents 1980), to transduced walkways (Cheung et al., 19
stride time whereas A1 to C2 is left step time and C2 to A2 Crouse et al., 1987; Gifford & Hughes, 1983) and ot
is right step time. If we are able to capture the timing and specialized devices (Klenerman et aI., 1988; Pinzur et
position of these events, we would be able to derive not just 1986). In this section such data are reviewed to descr
stride and step lengths and times, stance and double-stance how temporal and distance parameters of gait have be
times, and swing-phase time but also other important used to describe hemiparetic gait. All the studies review
used an electrical contact system, some of which w
STRIDE
. .
)I : directly interfaced to a computer.
Wall and Ashburn (1979) used a walkway in which el
: Support : Swing • trical circuits were shorted out by means of aluminum c
:~~-----------.. : ••------~)I :
ducting tape attached to the patient's shoes. There w
separate circuits for each foot. Temporal and distance f
tors analyzed were stance time, stride time, swing tim
stride length, step length, velocity, cadence, and doub
support time. These data were recorded against time.
example of the data output for a patient with left hemip
TIME gia who was evaluated on two separate occasions is sho
FIGURE 17-3. The temporal phases of one foot during the normal gait in Figure 17-5. Both time and distance factors are p
cycle. (From Wall, J. C., Charteris, J., & Turnbull, G.!. [19871. Two steps sented on the data output and are derived from the f
equals one stride equals what?: The applicability of normal gait nomen
clature to abnormal walking patterns. Clinical Biomechanics, 2, 119 contact data illustrated in the figure. The use of a c
125.) during left stance is also shown. Stance time is shown b
440 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
D1 C2 D2 C3
sequence of dots. The beginning of the sequence repre stance time ratios, and, as can be seen in Table 17-1,
sents initial ground contact and the end of the sequence stance time on the hemiplegic side was always less than on
toe-off. From this information, stance, swing, stride, and the uninvolved side. Perhaps the most important of these
double-support times can be calculated. It is clear that the measures is walking speed because most other gait param
hemiparetic limb has a shorter stance time than the unin eters change with velocity (Grieve & Gear, 1966; Rosenrot
volved limb and also has an increased swing time. The right et aI., 1980). A major feature of many gait disorders is a
braking double-support time is longer than the left braking reduced walking speed; and for a given condition, such as
double-support time. Distance factors are shown by single Parkinson's disease, clinical improvement would lead to an
dots that represent the position of initial ground contact for increased walking speed and a clinical decline to a reduced
each limb. The follow-up data illustrate a more symmetric speed (Stern et aI., 1983). In addition, Brandstater and
gait with longer stride lengths, greater velocity, and ca associates (1983) showed walking speed may also be a
dence. predictor of changes in other time and distance factors in
Others have used electrical contact systems, both walk patients with hemiplegia. Strong correlations (0.84 to
way and footswitch systems, to study hemiplegic gait 0.96) between walking speed and stance period, stride
(Brandstater et aI., 1983; Mizrahi et aI., 1982a, 1982b; period, cadence, and stride length were noted.
Hill et aI., 1994; Wall & Turnbull, 1986). In addition to the Wall and Turnbull (1986) also advocated the use of sym
time and distance factors described by Wall and Ashburn metry ratios. They used similar equipment as described
(1979), Mizrahi and coworkers (1982a, 1982b) also earlier (Wall & Ashburn, 1979), but they normalized walk
employed specific symmetry equations that simply ex ing speed to body height because this measure of speed has
pressed the relative times (distances) of ground contact of been shown to be more closely related to other time and
the uninvolved limb to two consecutive ground contacts of distance factors of gait. Their output data are shown in
the paretic limb (i.e., step time) (length). For normal gait this Figure 17-6 where symmetry ratios can be calculated for all
ratio should be 0.5. Mizrahi and coworkers (1982a, components of stance. In normal gait these ratios should
1982b), therefore, expressed asymmetry as deviation from equal 1. An advantage of the calculation of these ratios is
this baseline figure. As opposed to having a walkway by that they allow identification of asymmetry within a specific
which patients would interrupt an electrical circuit by component of stance. For example; the authors reported
pressure during stance, Brandstater and colleagues (1983) that their mean asymmetry ratios were 1.37 for double
used a foot switch system. With such a system, normally braking support, 1.51 for Single-limb support, and 1.19 for
open switches are usually constructed within an insole that total support. The ability to isolate asymmetry specific to a
may be placed within the shoe or taped to the bottom of the component of stance phase allows the clinician to develop
shoe. These switches can be strategically placed, for more appropriate treatment strategies.
example, at the heel, first and fifth metatarsal, and great toe If a facility were to invest in equipment that could provide
areas. Pressure during gait closes these switches, and the objective measures of time and distance parameters of gait,
digital data would then be processed by computer. Those then an electrical contact system, similar to those refer
time and distance parameters just described were calcu enced earlier, would be a recommended choice. Such a
lated along with symmetry data that provided a direct ratio system whether designed by contract or commercially
of the uninvolved to the paretic limb. Of further interest was purchased are far less expensive than the more sophisti
the comparison of time and distance factors to stages of cated motion analysis systems and more economical with
motor recovery, as determined by the Brunnstrom method regard to complexity and evaluation time. A report by Hill
with Fugl-Meyer scoring. Their data are shown in Table and associates (1994) also provides support as to the
17-1 (Brandstater et aI., 1983). reliability of such measuring devices. They used a foot
Although Table 17-1 shows general improvement of all switch system to measure distance and time characteristics
gait variables with motor recovery there was only a of hemiplegic gait. There was strong reliability in the
statistical relationship with walking speed (r = 0.88) and comparison of two walking trials for all parameters mea
swing symmetry (r = 0.69). Swing symmetry reflects sured (ICC [2, 1] 0.82 to 0.98). Measures of symmetry
ratio of noninvolved single limb support to that of involved place or if the change was due to, for example, measur
single limb support). However, Hill and associates (1994) ment error. This puts the clinician at risk for documentin
reported relatively large confidence intervals (95%) for patient improvement as real rather than chance variatio
most of the above measures. The confidence interval For example, using the data from Hill and associat
SCALE,S
o 2 3 4
SUPPORT
TIME (s)
SWING
TIME (s)
STRIDE TIME
STRIDE LENGTH
·• 1.83 s
0.87m
LEFT FOOT 1.03 0.80 VELOCITY • 0.47 m/s
RIGHT FOOT 1.26 0.58 CADENCE • 65.6 steps/m
AID 0.79 1.09 DOUBLE SUPPORT TIME, LTO-RHS • 0.21 s
RTO-LHS • 0.28$
TABU : 17 1
Walking speed (m/s) 0.16 ± 0 .07 0 .17 ± 0.08 0.40 ± 0.15 0 .65 ±0.11 0.31 ± 0.21 1.14 ± 0.10
Stride period (sec) 2.8± 0.7 28 ±0.7 2.0 ± 0.4 1.4±0.1 2.3 ± 0.8 1.2 ± 0.1
Cadence (steps/min) 45±9 45±9 63± 11 85±9 57 ± 18 104±9
Stride length (m) 0.41 ± 0 .12 0.44 ±0.16 0.73 ± 0.20 0.91 ± 0.09 0.60 ±0.25 1.32 ± 0.12
Stance period (sec)
Affected side 1.9 ± 0.7 1.9 ± 0.8 1.2 ± 0.3 0.89 ± 0 .11 1.6 ± 0.7 0.68 ± 0.07
Unaffected side 2.5 ± 0.7 2.3 ±0.8 1.5 ± 0.3 0 .95 ± 0 .13 1.9 ± 0.8 0.68 ± 0.08
Swing period (sec)
Affected side 0.89 ± 0 .21 0.88 ± 0 .33 0.74±0.12 0.53 ± 0.07 0.78 ± 0.25 0.48 ± 0.03
Unaffected side 0.34 ± 0.11 0.44 ± 0.11 0.52 ± 0.12 0.47 ± 0.06 0.44 ± 0.12 0.48 ± 0.03
Stance/swing ratio
Affected side 2.4± 1.3 2.6 ± 1.7 1.7 ± 0.5 1.7 ± 0.3 2.1±1.2 1.4 ± 0.1
Unaffected side 8.1 ± 3.2 6.0 ± 3.1 2.9 ± 0.7 2.1 ± 0.4 5.0 ± 3.2 1.4±0.1
Double support 54 ± 14 50 ± 15 34± 9 29 ± 5 43 ± 15 17 ± 2
(percent of stride)
Stance symmetry 0.77 ± 0.11 0.82 ± 0.14 083 ± 0.09 0.94±0.17 0.83 ± 0.12 1.00 ± 0.03
(affected/unaffected)
Swing symmetry 0.41 ± 0.16 0.55 ± 0.21 0.70±0.13 0.91±0.19 0.62 ± 0.23 0.99 ± 0.02
(unaffected/affected)
Stance/swing ratio 0.33 ± 0.18 0.47 ± 0.22 0.59 ± 0.19 0.88 ± 0.30 0.53 ± 0.27 1.01 ± 0.06
symmetry (affected/
unaffected)
From Brandstater, M. E., deBruin, H., Gowland, C., & Clark, B. (1983). Analysis of temporal variables. Archives of Physical Medicine and
Rehabilitation, 64, 583-587.
(1994), gait velocity would have to either decrease by at between individual trials. The authors discuss potential
least 4.54 m/min or increase by at least 9 .30 m/min for strategies for reducing measurement error. If reduction of
the clinician to say with confidence that a real change due error can be achieved then clearly, such electrical contact
to therapeutic intervention actually took place. Respective systems could provide the clinician with an appropriate
limits for cadence were 14.89 and 18.29 steps/ min and measuring device that is simple to use, that is relatively
for stride length , 0.05 and 0.14 m. According to Hill and inexpensive when compared with motion analysis systems,
associates (1994), these broad confidence intervals are due and that provides objective data on time and distance
to between-patient variability, whereas the strong correla parameters of gait that can be used to detect change in
tion coefficients are the result of within-patient consistency patient performance.
A B c D E
Nonaffected
1
Affected
1 2 3 4 5
FIGURE·17-6. Temporal phases
of gait cycle. A complete stride
includes support and swing phases
and is commonly regarded as start
ing with initial contact of one foot
Nonaffected Affected with ground and terminating with
same foot again making contact
(from A-E). Swing phase is equiva
Initial contact A C
lent to single support on contralat
Final contact D B
eral side. (From Wall , J . c., &
Double braking support 1 3 Turnbull, G. I. 119861. Gait asym
Double thrust support 3 1 metries in residual hemiplegia . Ar·
Single support 2 4 chives of Physical Medicine and
Total support (1+2+3) (3+4+5) Rehabilitation, 67, 550-553.)
90 80 70
c 6'0
o So
'w
(/) "'0
~ <f:,
Ol
o '8
C. o
"0
a
til
~ Foot angle
o
l1.. .c
0, D
c ...........
.c • ~
. ~
c.
Step width
A-B= heel to heel
0,' (j) C-D= toe to toe
.t= c E.t=
Q)
-.J
~ 0lQ)
i:I:-.J ....~ ....... .
Q)
"0
.;::
Ci5
FIGURE 17-7. Left panel, Mea
surement of stride and step length
c
1 : :~: : : : : : : :J
from the ink imprints on the paper
strip. Right panel, Computation of
foot angle and step width from the
imprints on the paper strip. (From
Boenig, D. D. [19771 . Evaluation of
a clinical method of gait analysis. h. Toe
Physical Therapy, 57, 795-798,
with the permission of the APTA.)
o Heel
__ : .,. '·~_'O-; ~ ~
444 UNlIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
'IA[jLL 17 L
1 2
Physical Physical 4
Assistance Assist a n ce 3 Independent 5
Temporal.Distance Level" Level I SupertJision on Level Independent
Measure (n = 10) (n = 15) (n = 6) (n = 8) (n = 22)
1.4
c
U 1.2 E 120 _ Healthy
Q)
en
:[1.0 a;-100 D MS
:§.
.£
<..>
0.8 Q) 80 D Hemiparetic
<..>
o c
Qi 0.6 ~ 60
> C\l
IX 0.4 u 40
IX
0.2 20
a b c d
L a b c d
(i) (ii)
I 20
.
~20~
-S.
2.0
:5 1.6 -l
1.6
Ol
c
ITln n'
W
1.2
J:: •
..9i 1.2 -l
a.. _ I""""l -l
t:i I .._"-0
~
IX
IX 0.4
0.4 L
e f a b abc d
(iii) (i I)
FIGURE 17-8. Mean values and 95 percent confidence intervals for five temporal-distance measures in neurologically impaired subjects (MS, n = 24;
hemiparetic, n = 37). a, Functionally independent MS subjects (n = 12); b, all MS subjects; c, functionally independent hemiparetic subjects (n = 10); d,
all hemiparetic subjects; e, hemiparetic involved lower extremity; and f, hemiparetic uninvolved lower extremity. Healthy values are weighted averages
compiled from published values. Asterisk indicates significant difference from MS group (P < 0.03). (From Holden, M. K, et al. [1986]. Gait assessment
for neurologically impaired patients. PhYSical Therapy, 66, 1530-1539, with the permission of the APTA.)
RElATiONSHJP- OF AMBlJIAll0N AID USED AND FUNCTIONAL AMBlJIATiON CATEGORY
TO TEMPOJlAL.DISTANCE MEASURES
Ambulation Aid Category Functional Ambulation Category
shown in Figure 17-8. The data for healthy subjects were poral and distance gait parameters from video. Gaudet a
extrapolated from the literature. The differences between coworkers (1990) showed how step widths and s
gait of healthy individuals and the sample of hemiparetic lengths could be accurately and reliably measured fro
and multiple sclerosis patients is apparent. For hemiparetic video . They suggested that the technique could be i
patients, strong correlations were not noted between the proved if a camcorder had an automatic focus, a featu
temporal distance parameters of gait (see Fig. 17-8) and common to most camcorders currently available. W
the clinical characteristics of age, duration of disability, (1991) showed how the ability to advance a video throu
number of clinical symptoms, and number of gait devia one field at a time and identify each field could be used
tions (r = 0.40 to 0.28). Similar data were reported for the determine the temporal phases of the gait cycle. T
multiple sclerosis patients (r = -0 .35 to r = -0.19). For validity and reliability of this technique has been repor
both groups of patients more impressive correlations, on by Wall and Crosbie (1996a) . Footswitches were plac
however, were noted between time and distance param on the heel and great toe of each foot and were connect
eters of gait and functional ambulation category and type of to light-emiting diodes . The subjects were filmed by a vid
ambulation aid used. These correlations are shown in Table camera as they walked across a force plate ("gold st
17-3. Functional ambulation was categorized as the pa dard"). The camera also filmed the image. of the Iig
tient being able to ambulate independently on all surfaces, emiting diodes. A signal from a time code generator w
independently on level surfaces only, dependent for super added to the videotape. The timing data from the fo
vision, dependent for physical assistance (light touch), or plate and footswitches allowed the determination of ri
dependent for physical assistance (support body weight). and left total support time, right step time , and ri
Type of ambulation aid was categorized as one cane or braking double support. For barefoot walking these valu
crutch, two canes or crutches, or a walker. As can be seen for data from the force plate were 0.76 , 0.74, 0 .59, a
from Table 17-3, the stronger correlations were noted for 0.15 second, respectively . Corresponding data from
the patients with multiple sclerosis. The relationship be footswitches were 0.75, 0.73, 0 .59, and 0.16 secon
tween velocity and cadence and the categories of ambula Similar differences were noted for heel contact and toe-
tion aid and functional ambulation appear to be the most where the switches tended to close after heel strike on
impressive for both groups of patients. force plate and open before toe-off from the force pla
The data from the force plate and footswitches are inde
remarkably similar. However, the authors determined t
their modified video-based system was more accurate
RECENT ADVANCES determining the times of heel contact and toe-off than
use of footswitches. Interrater reliability (ICC [2, 1])
Video technology has vastly improved in recent years, observation from the video of both right and left to
and features are available on modern videocassette record support time was 0.94, for right step time , 0 .95, and
ers and camcorders produced for the home market that right braking double-support, 0.46. The superb slo
were only available to industrial users previously. Some of motion capability afforded by videocassette recorders w
these features have allowed for the development of a four heads is the basis for a number of techniques
number of techniques for objectively measuring the tem measure the durations of the temporal phases of the g
446 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
cycle. Timing can even be achieved with a multimemory Boenig, D. D. (1977). Evaluation of a clinical method of gait analysis.
Physical Therapy, 57, 795-798.
stopwatch (Wall & Scarborough, 1996) or a personal Brandstater. M. E., de Bruin , H., Gowland , c., & Clark, B. (1983).
computer (Wall & Crosbie, 1996b). Given the advantages Hemiplegic gait: Analysis of temporal variables. Archives of Physical
of using video to enhance subjective assessment, the ability Medicine and Rehabilitation, 64, 583-587.
Cerny, K. (1983). A clinical method of quantitative gait analysis. Physical
to obtain objective measurements from the recording Therapy, 63, 1125-1126.
should make these techniques very applicable to use in the Cheung, c., Wall, J. C. & Zelin, S. (1983). A microcomputer based
clinical environment. system for measuring the temporal phases of amputee gait. Prosthetics
and Orthotics International, 7, 131-140.
Clarkson, B. H. (1983). Absorbent paper method for recording foot
placement during gait. Physical Therapy, 63, 345-346
Crouse, J. G., Wall, J . c. , & Marble, A. L. (1987). Measurement of the
temporal and spatial parameters of gaH using a microcomputer based
CONCLUSION system. Journal of Biomedical Engineering, 9, 64-68.
Eastlack, M. E. , Arvidson, J., Snyder-Mackler, L., Danoff, J . v., &
McGarvey, C. L. (1991). Interrater reliability of videotaped observa
Gait assessment is an everyday responsibility for the tional gait-analysis assessments . Physical Therapy, 71, 465--472 .
practicing therapist. Visual assessment, which is almost Gaudet, G., Goodman, R., Landry, M., Russell, G, & Wall, J. C. (1990).
universally used for this purpose, has been shown to be Measurement of step length and step width: A comparison of videotape
and direct measurement. Physiotherapy Canada, 42, 12-15.
unreliable at best. Measurement of the temporal and Gifford, G., & Hughes, J. (1983). A gait analysis system in clinical
distance factors of gait have been found to be clinically practice. Journal of Biomedical Engineering, 5, 297-30l.
useful. It has been suggested that the use of video might be Goodkin , R., & Diller, L. (1973). Reliability among physical therapists in
diagnosis and treatment of gait deviations in hemiplegics. Perceptual
a helpful adjunct to visual assessment. Techniques that now and Motor Skills, 37, 727-734 .
allow for these measurements to be made objectively from Grieve , D. w., & Gear, R. (1966). The relationship between length of
a video recording have been developed and should prove stride, step frequency, time of Swing and speed of walking for children
and adults. Ergonomics, 5, 379-399.
useful for clinical use. Harris, G. F , & Wertsch, J . J . (1994). Procedures for gait analysis.
Archives of Physical Medicine and Rehabilitation, 75, 216-225.
Hill, K. D, Goldie, P. A , Baker, P. A, & Greenwood, K. M. (1994) . Retest
reliability of the temporal and distance characteristics of hemiplegic gait
using a footswitch system. Archives of Physical Medicine and
Rehabilitation, 75, 577-583.
Cadence-Steps per minute.
Holden, M. K., Gill, K. M., & Magliozzi , M. R. (1986). Gait assessment for
Double support-Period of time during gait when both
neurologically impaired patients. Physical Therapy, 66, 1530-1539.
Holden, M. K., Gill, K. M. , Magliozzi, M. R., Nathan, J., & Piehl-Baker,
feet are in contact with the ground.
L. (1984) Clinical gait assessment in the neurologically impaired.
Electromyography-Provides information as to what
Physical Therapy, 64, 35--40.
Hughes, K. A , & Bell, F (1994). Visual assessment of hemiplegic gait
muscles are active during gait.
following stroke: Pilot study. Archives of Physical Medicine and
Force platform-The output of the force platform is the
Rehabilitation, 75, 1100-1107.
Klenerman, L., Dobbs, R. J., Weller, c., Leeman, A L. , & Nicholson,
ground reaction force.
P. W. (1988). Bringing gait analysis out of the laboratory and into the
Ground reaction force-Forces at the ground that
clinic. Age and Aging, 17, 397--400.
Krebs, D. E., Edelstein, J. E, & Fishman, S. (1985). Reliability of
react to the forces generated while walking.
observational gait kinematic gait analysis. Physical Therapy, 65,
Heel contact-Contact on the ground by the heel, which
1027-1033.
Mizrahi, J ., Susak, Z., Heller, L., & Najenson , T (1982a). Objective
in normal gait signifies the beginning of stance.
expression of gait improvement of hemiplegics during rehabilitation by
Kinematics-Measures of movement without reference
time-distance parameters of the stride. Medical and Biological Engi
neering and Computing, 20, 628-634.
to the forces that cause the movement.
Mizrahi, J., Susak, Z., Heller, L. , & Najenson, T (1982b). Variation of
Stance phase-Period of time the foot is in contact with
time-distance parameters of the stride as related to clinical gait
improvement inhemiplegics. Scandinavian Journal of Rehabilitation
the ground during gait.
Medicine, 14, 133-140.
Step length-Heel contact of one foot to heel contact of
Nichols, P. J. R. (1979) . Rehabilitation of the stroke patient. Age and
Aging, 8, Suppl., 67-75.
the other foot, measured along the line of progression.
Patla, A. E, Proctor, J., & Morson, B. (1987). Observations on aspects
Stride-Heel contact of one foot to heel contact of the
of visual gait assessment: a questionnaire study. Physiotherapy
Canada, 39, 311-316.
same foot (two steps).
Pinzur, M. S., DiMonte-Levine, P. , Trimble, J., Haag, K. , & Sherman , R.
Time code generator-Equipment that adds informa
(1986). Temporal gait monitoring: A new device. Archives of Physical
Medicine and Rehabilitation, 67, 344-345.
tion on time to a video tape, allowing field identification.
Robinson, J. L., &Smidt , G. L. (1981). Quantitative gait evaluation in the
Toe off-Foot leaving contact with the ground , which
clinic. Physical Therapy, 61, 351-353.
Rosenrot , P. , Wall, J. c., & Charteris, J. (1980). The relationship between
signifies the end of stance and the beginning of swing.
velocity, stride time, support time and swing time during normal
walking. Journal of Human Movement Studies, 6, 325-335.
Shores, M. (1980) . Footprint analysis in gait documentation. Physical
Therapy, 60, 1163-1167
REFERENCES Stern, G. M., Franklyn, S. E. , Imms, F J., & Prestidge, S. P. (1983).
Quantitative assessments of gait and mobility in Parkinson 's disease.
Bajd, T, & Kralj, A. (1980). Simple kinematic gait measurements. Journal of Neural Transmission, Suppl. 19,201-214.
Journal of Biomedical Engineering, 2, 129-132. Turnbull, G. I., & Wall, J. C. (1985). The development of a system for the
videotape using a field counting technique. International Journal of motion video and a personal computer: accuracy and reliab
Rehabilitation Research , 14, 344-347. Physiotherapy.
Wall, J. c., & Ashburn , A. (1979). Assessment of gait disability in Wall, J. C., & Scarbrough, J. (1996). The use of a multime
hemiplegics. Scandinavian Journal of Rehabilitation Medicine, 11, stopwatch to measure the temporal gait parameters. Journa
95--103. Orthopedic and Sports Physical Therapy.
Wall, J. c., Charteris, J. , & Turnbull, G. 1. (1987). Two steps equals one Wall, J. c., & Turnbull, G. 1. (1986). Gait asymmetries in res
stride equals what?: The applicability of normal gait nomenclature to hemiplegia . Archives of Physical Medicine and Rehabilitation,
abnormal walking patterns. Clinical Biomechanics, 2,119-125. 550-553.
C HAP T E R 1 8
ome Management
rights of people with disabilities but also offered persons ADL HIERARCHY
with special needs greater consumer control, creating new Management
assessment tools and markets of technology. COMPLEX ADLs
Current trends in health care and advancements in Care of others
technology have influenced the development of standard Money management
ized clinical assessments and realistic clinical simulations of Household maintenance
home and community, where therapists can directly evalu Shopping
ate the performance of home management skills. For Cleaning
example, Easy Street (HSM Group, 1992), recently re Meal preparation and clean-up
named Independence Square, an advanced technologic Clothing care
simulation, creates a realistic community and home envi Safety precautions
ronment in the clinic setting . This allows the patient and
SIMPLEX ADLs
therapist to discuss structural differences that may ad
Self-care
versely affect in-home performance .
Feeding
Assessment tools of home management skills have
Hygiene
expanded in various directions over the past 50 years.
Bathing
While some rehabilitation programs continue to allow
Basic communication
therapists to complete at-home evaluations with their
patients, most have adopted more cost-effective measures . MobiUty
Such measures include component skills assessment using Ambulation
the Assessment of Motor and Process Skills (AMPS) , the Wheelchair propulsion
Bay Area Functional Performance Evaluation (BaFPE), the Transfers
Milwaukee Evaluation of Daily Living Skills (MEDLS), or a Bed mobility
simulated home environment, which allows direct obser FIGURE 18-1. ADL hierarchy. (Adapted from Functional Perfor
mance in Older Adults. Bonder, B., & Wagner, M. B.119941. Functional
vation of performance (see Table 18-2). performance in older adults. Philadelphia: F.A. Davis Company.)
Currently, the particular challenge continues to be the
creation of assessments that provide functional outcome
measures that are norm referenced and reliable and that probably one of the most important roles he or she will
have good predictive validity but are useful to a clinician experience during a lifetime (Culler, 1993). Oakley (1981)
when time constraints are of utmost importance. Since defined a home maintainer as a person who has respon
many new markets have emerged, including home econo sibility at least one day a week for the upkeep of the home,
mists , biomechanical engineers, and architects, together e.g. , for tasks such as house cleaning or yard work. Home
with occupational and physical therapists, more statistically management not only includes cleaning and yard work but
sound and efficient home assessment tools are anticipated . also consists of clothing care, meal preparation and clean
Additionally, with third-party payors demanding functional up, shopping, money management, household mainte
outcomes and rehabilitation's continued emphasis on nance, and safety procedures. According to Rogers and
discharge to home, greater efforts will yield better instru Holm (1994), there are three categories of daily living
mentation. tasks, which are generally perceived to be hierarchically
arranged from simple to complex and include mobility,
self-care, and complex activities of daily living (ADL).
Home management tasks are among the most complex
THEORETIC APPROACHES ADLs and are identified at the highest end of the hierarchy.
Mobility is placed at the lowest end of the hierarchy, and
Theoretic approaches that undergird home manage self-care is identified at midpoint (Fig. 18-1).
ment are highly dependent on and embedded in notions Conceptually, home assessments are multidimensional.
about physical functioning and task performance. These At least two hierarchy systems are used to classify home
notions are advanced in postulates such as developmental management skills: the ADL hierarchy and the dysfunc
hierarchies, dysfunctional-functional continuums, and the tional hierarchy.
process of task analysis . Home management can easily be
addressed under several theoretic treatment approaches
because of its multidimensional nature. However, the Activities of Daily Living Hierarchy
occupational performance model is considered one uni
fied , task-oriented , conceptual framework that addresses The ADL hierarchy basically separates foundational self
the functional elements of performance of the homemaker care skills and mobility from home management tasks. The
role. This framework embodies treatment approaches hierarchy is ordered by increased levels of performance
consistent with rehabilitation and the model of human difficulty and recognizes the increased demand for cogni
occupation. tive abilities required to accomplish the higher-order tasks.
A person's ability to maintain a home environment is The term Instrumental Activities of Daily Living (IADL),
it ta
to complete the task. The time frame yields a reality ch
For examp'le, if a patient takes 20 minutes to make a
Dysfunctional Hierarchy of coffee and serve it, one might determine that this i
unrealistic task for this patient to perform. The t
The concept of a dysfunctional hierarchy in rehabilita oriented approach provides valuable data about the
tion is an outgrowth of the traditional medical model's vidual's potential level of performance. Consistent ob
influence on terminology related to disrupted perfor vation and analysis are concepts unique to this appro
mance. For years, the words chosen to reflect the impact of and are essential for use of any good home evalua
disease on daily life were interchangeable, with no distinc instrument. Task-oriented approaches can be viewe
tion between how the terms "impairment," "disability," or theoretical models of practice such as the occupati
"handicap" were used (Christiansen, 1991). In 1980, the performance model.
World Health Organization (World Health Organization,
1980; Wood, 1980) classified these terms in a level of
dysfunctional hierarchy (Fig. 18-2), according to the Occupational Performance Model
International Classification of Diseases (lCD), which was
later incorporated into a document called the Interna The occupational performance approach (Amer
tional Classification of Impairment, Disability, and Occupational Therapy Association , 1974) focuses on
Handicap (ICIDH) (Wood, 1980). "doing process " of an activity or occupational task to
This dysfunctional hierarchy, according to Christiansen accomplished. In this occupational performance
(1991), was among the first used as a means of classifying onomy, the role of the task performer is clearly defi
assessment tools in rehabilitation. Explanations are pro and the activities and tasks required for successful
vided from a systems approach. The hierarchy assigns performance are closely examined. For example,
meaning to the impact of a condition on daily living. For primary role of a patient is that of a mother, wife, and ho
example, "impairment" is viewed as permanent or tem maintainer, the tasks that she might be required to perf
porary loss or abnormality affecting psychological, physi (based on distinct social expectations) would be tasks s
ologic, or anatomic structures or function. The term as preparing a meal, cleaning the house, and shopping
disability is defined as the result of an impairment that Appendix 0 ). The performance skills needed to perf
restricts one's ability to perform one's life activities or to such tasks would involve decision making, problem solv
fulfill one's life role. The term handicap was described as a and the ability to handle objects. The process of asses
disadvantage resulting from an impairment or disability home management should provide the best possible
that limits or prevents normal role fulfillment, as viewed by ture of an individual's level of functional performanc
the patient. Attention is given to age, sex, social, cultural, the role that he or she is expected to resume. For
environmental, and economic consequences of the indi reason, this task-oriented performance-based model
vidual. Degrees of restriction by severity or disability groups propriately assesses the characteristic behaviors or per
are not provided with this hierarchy, making it difficult to mance demonstrated by the person in a natural contex
use effectively for assessment purposes. Kielhofner (1985) proposed a continuum of occu
tional function -and dysfunction that would incorpo
concepts of competence, efficacy, and helplessness.
Task Approach optimum level of occupational functioning would inc
achievement, competence, and exploration based
The traditional task-oriented approach continues to be McClelland 's (1961) progress in the continuum of nor
the most popular approach among therapists . This ap development from exploration to achievement. Occu
proach requires direct observation of the patient perform tional function (exploration to achievement), depic
ing a task and the therapist's analyzing the skill perfor progressive development of skills and habits into satis
mance and level of performance. This type of assessment tory role performance. Models of practice that incorpo
function-dysfunction hierarchies are shown in Table 18
Although the use of hierarchies is valuable, more resea
HANDICAP
is needed before their full potential for use can
actualized.
DISABILITY
ASSESSMENT FACTORS
IMPAIRMENT
Many factors must be considered when assessing ho
FIGURE 18-2. World Health Organization dysfunctional hierarchy. management skills. The cultural values of the patients
452 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
TABU: 18- 1
World Health
Occupational Performance
Functional
Organuation
Dysfunction-Function Hierarchy
Assessment
Hierarchy
Handicap: A disadvantage for Occupational role (American Occupational Therapy Association , 1974): Role performance:
a given individual Task-oriented approach to performance Self-report questionnaire
resulting from an impair Function: Dysfunction: Interview
ment or disability that Able to fulfill role as a home Unable to perform duties or Direct observation of role
limits or prevents the maker skills as a homemaker performance
fulfillment of a role
(Wood, 1980)
Disability: Restriction or inabil Occupational performance task: Task performance:
ity to perform a task or ac Function: Dysfunction: Self-repoli
tivity within a normal range Able to judge distance of cup Unable to judge distance of Interview
or function without assis and pour hot coffee into cup while pouring hot Direct observation and
tance the cup coffee analysis
Impairment: Loss or abnormal Occupational performance components:
Performance component
ity of psychological, physi Function: Dysfunction :
enablers:
ologic, or anatomic struc Normal muscle tone; normal Abnormal muscle tone ; deficits
Specific tests in the area of
tures or function visual processing in spatial relations range of motion, tone,
sensation, strength , cogni
tion, and perception
Pathology: Disruption of Pathology: Pathology: Pathology:
blood flow to the brain RCVA RCVA RCVA
their families, the living situation, finances and other modifications, and adaptations. For example, a patient
resources, and the patient's medical status, as well as task who lives in a private home will have different equipment
demands, must be considered . needs than a person who lives in a rental apartment. Also,
the " home" for a patient could be a homeless shelter that
sleeps six people in a room .
Cultural Values
A patient's family and cultural values are critical to suc Finances and Other Resources
cessful management in the home. Client-provider collabo
ration on treatment goals can result in shorter hospital stays A patient's financial situation and available resources can
(Shendell-Falik, 1990) and better goal attainment (Czar, significantly affect decisions that are made when assessing
1987). Patients and families often lack consistent, compre the home and management skills. Although cost-effective
hensive information to enable them to effectively adjust recommendations are routinely the goal of most therapists,
and cope with family members returning to the home. a person who does not have the financial resources to make
Studies indicate that a family's ability to cope with chronic the suggested modifications in the home might have to
illnesses can make a significant impact on adaptation and consider modifications that are even less costly. Informa
rehabilitation. Thus, it is important to determine whether tion gathered by the therapist about insurance coverage,
the patient's and family 's cultural values and beliefs support community and family foundations, and other local sup
the need for independence in home management. For ex port, can help therapists and their clients make tough
ample, a patient's husband found it difficult to allow her to deCisions that might make the difference between whether
perform a task independently because the task appeared a patient can return home or must be placed in a nursing
to be difficult. Other family members may find it necessary facility.
to perform home management duties for their loved one
because it is traditional and customary to do so.
Medical Status and Performance
Components
Living Situation
Because home management tasks require a significant
Living situation influences recommendations for further amount of physical and cognitive skills, it is important that
assessment in the area of home management, home a therapist consider the patient's most recent medical
factors (see Appendix C) . If a patient has underlying factors problem-solving process involved in home manageme
that prevent him or her from performing basic self-care assessment is illustrated with a specific case study
skills and requires significant assistance from others, a Appendices A and B.
home management assessment might not be appropriate.
As a patient's functional status improves, a home manage
ment assessment would be recommended. Nonetheless ,
an assessment of the home environment can be initiated if SELECTING AHOME ASSESSMENT
discharge is imminent. Today, early discharge from acute TOOL
care settings requires therapists to assess the home for
architectural barriers and to provide home programs for One of the most critical responsibilities a therapist h
the patient, family, or caregiver, when the patient is acutely is the selection of an appropriate assessment instrume
ill. These patients often return home with follow-up home The therapist must understand the statistical concepts a
therapy and other home supports. Home management philosophic and theoretic bases behind the developm
assessments are completed by the home therapist when of the instrument. Knowing these essentials makes
appropriate. easier to analyze available instruments to determine th
value and utility for a given situation or for a particu
client.
Task Demands In reviewing the statistical characteristics of an asse
ment, the therapist should, at a minimum, select
It also is important to understand what is required to instrument with validity and reliability data.
perform a particular task that is to be considered. A home The validity of an instrument is of utmost concern to t
management task could involve primarily physical charac researcher and the therapiSt. Validity is the statisti
teristics, such as the use of weight-bearing joints with lifting descriptor that indicates how accurately the instrum
and shifting of weight from one point to another (e .g ., measures what it claims to measure. Among home ma
moving a hot coffee pot off the stove to the table). It is also agement instruments, validity is fairly easy to achieve sin
important to consider the cognitive and emotional skills it measures certain concrete physical properties and co
required for performing a given task. This is why it is mon attributes well agreed on by most therapists.
important to complete a task analysis as part of the The primary types of validity critical to the selection
assessment process. This analysis will give a clearer picture home assessment scales are content validity, constru
of the task demands. Shopping requires a person to be able validity, and predictive validity (see Chapter 1 for
to problem-solve to get the items purchased from the store in-depth description of validity and reliability.)
to home. Carrying a grocery bag is a task demand that Content validity refers to the items selected to
should be considered when shopping. Therapists and included in a test as representative of the universe
patients should also be familiar with the options available possible items. Without making an assessment too long
when considering the task demands of shopping . For too short, one must determine if the assessment is inclus
example, a person could use a shopping cart or have enough to adequately represent the many homemaki
groceries delivered to the home. However, until physical, tasks and situations a patient may commonly encount
cognitive or perceptual, and psychosocial demands of this Second, one must consider whether the measure is refl
task have been considered closely, proposing solutions, tive of the way each task is commonly accomplished in t
such as delivering groceries to the home, is not very useful. patient's home.
Task demands also are perceived by each patient differ Construct validity unites psychometric notions w
ently. A therapist's perception of task demands and a theoretic notions. What does performance on this measu
patient's perceptions could differ considerably. This is a really mean? Other factors that may influence the perf
likely reason why many standardized home management mance outcome (e.g., whether the patient is too tired or t
assessments are not available and why it is important to find weak and whether it is the optimum time of day) must
out from the patient or family how tasks are usually teased out to determine if the instrument validly measu
performed . A therapist's skill and judgment in conSidering the construct it claims to measure, i.e., the construct
all factors, including the demands of the task, can often home management ability.
have a greater impact on the assessment of complex ADL Predictive validity (Kerlinger, 1973) compares the t
than on basic self-care assessments (Hopkins & Smith, measure with the actual measure of performance of
1993). Since few standardized instruments on complex attribute in the home situation. In other words, a clien
ADL exist, profeSSional skill and judgment are required for performance on a clinical assessment of homemaki
performing home management assessments. tasks should adequately predict performance of the clien
In summary, the role of the therapist in assessing home the real home situation. Predictive validity is the m
management skills is a challenging one. High-level ADL important type of validity to consider when dealing w
assessment requires considerable complex problem solving practical problems and outcomes. Therefore , all ho
454 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
assessment scales must have acceptable predictive validity Surgical procedures such as total hip replacement in
to make them useful assessment tools. volve the placement of a prosthesis and, like many surgical
To be interpretable, a test must be reliable. Unless one procedures, require a period of immobilization or restric
can depend on the results of the measurement instrument, tions that might prevent a patient from performing certain
one cannot make accurate predictions. Reliability is types of activities. For a total hip replacement, a patient is
essential to dependability in measurement. Furthermore , not allowed to flex the hip beyond 90 degrees. Therefore,
reliability is reflected in an instrument as stability or activities that involve reaching, placing , and bending need
consistency of a measure across time. For example, when to be carefully assessed . Because surgical procedures are
an infinite number of therapists uses a measuring tape to often temporary by nature, a patient might decide to have
determine the height of a countertop or the width of a door someone perform home management tasks until the re
sill, they should each record the same tape measurement. covery period has ended. The need for equipment also is
The tape measure calibrations are consistent no matter assessed for temporary use . With an expected level of re
what shape, distance, or object it measures. covery, approaches that focus on restoring performance
Many of the ADL assessments report test-retest reli components such as range of motion, muscle strength, and
ability. This type of reliability indicates whether the test endurance (biomechanical approaches) might be paired
measures the construct in the same way each time the with performance-oriented approaches that examine tasks
assessment measure is used. SpeCifically, test-retest refers related to role performance.
to the client being retested using the same instrument,
usually by the same therapist. If the test is reliable, the score
will be essentially the same unless a change occurs in the
patient.
The Older Adult
The majority of the standardized home assessments
For the older adult, factors such as changes in neuro
report interrater reliability, which may be determined by
muscular status, impaired vision , and cognitive changes
having two therapists simultaneously observe the same
need to be considered. Because some of these changes
client perform a given assessment task. Each rater assigns
result in problems such as loss of balance, falls, and
a score based on preestablished criteria. The two thera
memory impairment, a variety of assessment areas should
pists' ratings on each performance item are compared for
be closely considered.
interrater agreement.
A common problem in assessing older adults emerges
Whether the author has reported reliability and validity
because of fluctuation in capability and performance. Most
is noted for assessments recorded in this section (Table
established assessment instruments assume that stability is
18-2). Since for almost all assessments listed in the table,
present; however, performance stability is less likely in
the coefficient was at least 0.80, an acceptable coefficient,
elders than in younger persons . For example, older
only an "X" is recorded , indicating that these data were
persons may choose not to or may be unable to clean the
reported .
front yard on a very hot day or a cold and snowy day.
Regardless of rating criteria used, frequency in perfor
mance can vary. It is also important to take a complete
history of the older adult; some older adults have never
HOME MANAGEMENT ASSESSMENT learned to perform home management duties that are not
FOR SPECIAL NEEDS gender specific (Rogers and Holm, 1994). For example, an
older male might not be accustomed to cooking and would
To assess a patient's ability to perform tasks in the not have a problem relying on a family member to cook,
home, the previous assessment factors should be con whereas, an older woman may not have learned to make
sidered . In addition, a therapist must know the patient's repairs to the house or mow the lawn. With the older adult,
age, diagnosis, and pertinent precautions that might have expectations need to be considered closely. With home
an impact on function. management tasks being optional in nature, the older adult
might choose to have assistance rather than learn a new
task or perform an old task that might require a lot of time
and energy. Also, cost is often a concern with the older
The Postsurgical Patient adult who lives on a fixed income.
To assess a patient with surgical diagnoses, therapists
should anticipate that the patient will need to adhere to
certain precautions. For this reason , therapists often The Person with Brain Damage
intervene early during the assessment process by providing
the patient and family the restrictions and precautions and Following a brain injury, a patient might be unable to
guiding the use of adaptive equipment and methods of focus on relevant internal or external stimuli. As a result, he
compensation . or she might not be able to exert the cognitive influences
TABLE lS -2
Assessment of Motor and Rsher (1994) General Assesses IADL (e.g., meal Observation XIX
Process Skills (AMPS) preparation, home manage
ment) as the client would
normally perform them. Per
son chooses to perform two
or three familiar tasks from
among 50 possibilities. Per
son 's performance is rated
in two skill areas: IADL mo
tor and IADL process.
Bay Area Functional Per Asher & Williams Psychiatric clients Assesses flmctional perfor Task observation XIX
formance Evaluation (1989) mance of ADL, motor skills, and interview
(BaFPE) sensation endurance, cogni
tion , sensory motor func
tioning, and appearance.
Two subtest: Task Oriented
Assessment (fOA) and S0
cial Interaction Scale (SIS).
Comprehensive Evaluation Casanova & Gerber Chronic adult psy Rates client's performance in Observation
of Basic Living Skills (1976) chiatric inpatients personal care and hygiene
across seven basic living
skills; meal planning, use of
telephone. transportation.
shopping and meal prepara
tion, service, and clean-up.
Functional Activities McDowell & Newell Normal and older Screening tool for assessing Paper/pencil com Predictive
Questionnaire (FAO) (1987) adults and those activities necessary for pleted by spouse
with senile de higher-level independent or significant
mentia skills including personal fi others
1.1
nances, managing forms,
(I e.g., taxes and Social Secu
jl rity Insurance, shopping,
making coffee, playing a
game, tracking current
events, and mobility.
Maguire 's Tri-Level Maguire (1985) Geriatric clients Assesses ADL across six cate Observation None
ADL Assessment gories: communications,
food needs, dressing, hy
giene, organization, and mo
bility across three environ
mental levels: personal home ,
or sheltered environment.
'X indicates that reliability or validity is present. XIX indicates both are present.
Table continued on following
TABLE 18 2
c;:
z
HOME MANAGEMENT ASSESSMENTS Continued ::::j
-n
<:
m
Spedal Assessment Re6abi6ty/ I
Name of Test Authors Population Descriptive SUmmal'Y Method Va6dity* »
en
en
m
en
Milwaukee Evaluation of Leonardelli (1988) Long-terrn psychi- Behavioral assessment of basic Observation Interrater reliability/ en
s:
Daily Living Skills atric clients ADL skills in money han criterion m
Z
(MEDLS) (chronic schizo dling , safety awareness, use -l
0
phrenics) of public transportation and -"
telephone, medication man »
0
-f
agement, clothing care, use
of community resources, ~
ability to read and write, m
en
meal planning and prepara 0
-"
tion and other household CJ
care are not included. ,~
Older Americans Resources Kane & Kane (1981) Geriatric clients Assesses ability to use tele Interview clients or None ,-<
and Services Instruments phone and higher level ADL. significant others :;s
(OARS) e.g., financial management, z
G)
shopping, housekeeping,
and meal preparation.
Philadelphia Geriatric Cen- Lawton (1980) Geriatric clients Assesses higher-level ADL, in Interview client or None
ter (PGC) Scale c1uding shopping, food prep responsible other
aration, housekeeping, laun
dry, use of public transporta
tion, financial and medica
tion management.
The Rabideau Kitchen Neistadt (1992) Adults with trau Assessment of skill perfor Observation Test-retest/
Evaluation-Revised : matic brain injury mance in simple meal prep none
An Assessment of (TBI) or subtle aration of a sandwich and
Meal Preparation Skill cognitive percep hot beverage. Scored from
(RKE-R) tual deficits dependent (1) to indepen
dent (7).
Independent Living Skills Johnson et al. (1980) Chronically emo- Rated functional levels using None
Evaluation (ILSE) tionally disturbed behavioral descriptors across
clients living in 10 categories, including
apartments money management (bank
ing and budgeting), meal
preparation and storage ,
clothing care, and use of
transportation
Index of ADL Katz (1983) Assesses functional indepen XIX
dence in self-care activities
using a ranking score
Barthel Index Mahoney & Barthel Neuromuscular and Adapted version scores the Observation of task Test/retest 0 .89/
(The Maryland Disability (1965) musculoskeletal functional level of the client performance predictive
Index) disorders across 10 self-care tasks and validity
mobility, using weighted
ranges from 0 to 100 (inde
pendent in all tasks).
persons with men basic2 elf-care and higher
tal and physical level ADL across five cate
dysfunctions gOries (170 items), including
self-care, safety and money
management, transportation
and telephone, work, and
leisure.
Kohlman Evaluation of Kohlman-Thompson Multiple populations Assesses minimum standards Interview and obser Interrater reliabi
Living Skills (KELS) (1979) for independent living across vation of task predictive vali
18 daily living skills areas:
self-care, safety and health,
money management, trans
portation, telephone, work,
and leisure. Provisions also
to assess cognition, memory,
attention span, comprehen
sion. reality-testing, and
sound judgment.
The Role Checklist: Oakley (1981); Bar Adolescents, adults, A written inventory along a Paper/pencil self Interrater/ conte
Parts I and II ris et at. (1987) and elderly with temporal continuum, where report inventory
physical and psy Part I is designed to assess
chological dys one's major life role(s) based
function on occupational compo
nents, and Part II measures
the degree to which the indi
vidual values each life role.
Satisfaction with Yerxa et at. (1982) Normal and physi Using a five-point frequency Interview (self XIX
Performance Scaled cally challenged scale score across two sub report)
Questionnaire (SPSQ) persons scales: home management
(24 items) and social com
munity problem solving (22
items). Score indicates per
centage of time (25%-100%)
client is satisfied with his or
her performance in these in
.~ dependent living areas.
-!
Scorable Self-Care Clark & Peters Adults with psycho Assess areas of personal self Observation XIX
I.
i' j Evaluation (1984) social disabilities care housekeeping tasks,
money management, work,
and leisure.
.,
~
458 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
measurable factors that might interfere with functioning in Culler, K. (1993). Home and family management. In H. Hopkins &
H. Smith (Eds.), Willard and Spackman's occupational therapy (8th
the home.
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Home management-Higher-Ievel ADL that individu
Czar, M. (1987). Two methods of goal setting in middle-age adults facing
critical life changes. Clinical Nurse Specialist, 1, 171-177.
als perform in the home environment. Such activities
Dean, E. (1994). Cardiopulmonary development in functional perfor
include organization of the home, housekeeping routines,
mance in older adults. Philadelphia: F. A. Davis Company.
shopping, budgeting, and money management.
Devaney, J. (1994). Tracking the American dream: Fifty years of housing
history from the Census Bureau: 1940to 1990. U.S. Census Housing
Independence-Having adequate resources to accom
Reports. Washington DC: U.S. Department of Commerce Economics
plish everyday tasks.
and Statistics Administration; U.S. Government Printing Office.
Fillenbaum, G. (Ed.). (1987). Development of a brief, internationally
Instrumental activities of dally living (lADL) usable screening instrument. In G. Maddox & E. Buse (Eds.), Aging:
Higher-order activities that support independence, includ The universal human experience. New York: Springer.
Fisher, A. (1994). Assessment of motor and process skills (AMPS)
ing housekeeping duties, shopping, budgeting, and money [Unpublished manual]. Dept. of Occupational Therapy, University of
management. Illinois at Chicago.
Frey, N. (1989). Functional Outcome: Assessment and Evaluation. In
Mobility tasks-Those tasks that involve moving the Delisa, J. A. (ed): Rehabilitation Medicine. Philadelphia: J. B. lippin
body from one position or place to another. cott.
Hemphill, B. (1988). Mental health assessment in occupational
Occupational performance-Task accomplishment therapy. Thorofare, NJ: Slack.
in everyday living within a desirable role. Hopkins, H., & Smith, H. (Eds.). (1993). Willard and Spackman's
occupational therapy (8th ed.). Philadelphia: J. B. Lippincott Com
Occupational performance component-Any sub pany.
system that contributes to the performance of tasks in HSM Group, Ud. (1992). Easy street. Scottsdale, AZ: HSM Group, Ud.
every day living; underlying factors such as motivation, Hunt, L (1994). Functional performance in older adults (pp. 284
294). Philadelphia: F. A. Davis Company.
range of motion, cognition. Johnson, J., JohnsonNinnicombe, B., & Merril, G. (1980). The inde
Performance-Routine task behavior, in contrast to pendent living skills evaluation. Occupational Therapy in Mental
Health, 2, 5-18.
capacity, which is the ability to perform a task. Kane, R. E., & Kane, R. L (1981). Older Americans Resources and
Personal seH-c::are tasks-Those tasks that involve Services Instrument (OARS). In Assessing the elderly. Lexington, MA:
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taking care of body-oriented, fundamental, personal needs Katz, S. (1983). Assessing self-maintenance: Actfvities of daily living,
like feeding and toileting. mobility, and instrumental activities of daily living. Journal of Ameri·
can Geriatric Society, 31.
Roles-Set of expectations governing the behavior of Kerlinger, F. (1973). Foundations of behavioral research (2nd ed.). New
persons holding a particular position in society. York: Holt, Rinehart, & Winston, Inc.
Kielhofner, G. (1985). A model of human occupation: Theory and
Tasks-Work assigned to, selected by, or required of a application. Baltimore: Williams & Wilkins.
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accomplishment of a goal. Part N. Assessment and intervention. American Journal of Occupa
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Klein, R. M., & Bell, B. (1982). Self-care skills: Behavioral management
with Klein-Bell ADL scale. Archives of Physical Medicine & Rehabili
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ENDIX A
Study
Sherry is a 41-year-old woman who lives with her family and cooking again. Although Sherry is able to
husband and 7-year-old son. She loves to jog and explore perform her simple ADLs with supetvision, the therapist
new and innovative cooking ideas. Many of Sherry's friends has concerns about her ability to perform more complex
consider her to be an expert in ethnic cooking. Two weeks ADLs (IADLs) such as cooking, house cleaning, and
ago, Sherry was found conscious on the bathroom floor, shopping.
unable to move the left side of her body. She was rushed to Sherry ambulates with a cane on the unit; however, in a
the emergency department, where a complete work-up busy clinic, she often misjudges the distance of some items
revealed an occlusion to the right middle cerebral artery. from others and has difficulty lifting weighted items in her
Sherry was diagnosed with a right cerebrovascular acci room. Today, Sherry's therapist will have her prepare a
dent, with residual left-sided weakness and was hospitalized meal. Before Sherry completes such a task, the therapist
for continued follow-up care and rehabilitation. At present, asks her questions based on her distinct role as a home
Sherry has shown significant improvement since her maintainer that provide a clear picture of the task demands
admission to the hospital. She has increased muscle tone in in the area of cooking. This enables simulation of this
the left upper extremity and is able to perform volitional activity, as much as possible, in a natural context. For
movement patterns and use her arm to assist with simple example, Sherry's therapist wants to know how often she
ADLs, such as eating or hygiene, with supervision. Sherry cooks meals, what type of meals she prepares, and what
is very anxious to return home, and discharge is planned for kinds of kitchen equipment are commonly used.
within the next 2 days. She looks forward to seeing her
462
ENDIX B
sidualleft-sided weakness
EXAMPLE: Prominent deficits in complex ADL
EXAMPLE: Recommend instruction; instruct patient not 7. Are these adaptations and/or home supports tempo
to pour hot items; heat water in microwaveable cup; rary or long-term?
use one-handed technique EXAMPLE: Long-term supervision is anticipated with
4. What type of adaptation or home support would be less use of adaptive methods
needed?
8. Is the potential for continued improvement anticipated
EXAMPLE: Microwave; supervision with cooking
to a level at which future adaptations or home support
will not be needed?
5. Are the recommended adaptations or home support
EXAMPLE: Improvement is anticipated; however,
reasonable and cost effective?
Sherry may require some long-term supervision for
EXAMPLE: Yes, has microwave at home; husband is safety
supportive
9. What mechanism is in place to reassess continued
6. What kind of resources are available to assist with improvement?
needed adaptations or home supports? EXAMPLE: Sherry will be followed three times per week
EXAMPLE: Husband will assist with preparation of meals for outpatient occupational therapy services; reas
and supervision of patient in kitchen sessment will be completed on an out-patient basis
ENDIX C
mon Functional
Problems and Limitations
Identified in the Area of
Home Management*
• Carrying hot coffee
UPPER EXTREMITY RANGE OF • Opening doors
MOTION DIFFICULTY • Handling faucets
• Opening and closing containers
• Reaching above or below cabinets, oven, or other ob • Operating small appliances
jects
• Placing items on the stove
• Grasping cups, plates, utensils
• Making up the bed MUSCLE WEAKNESS
• Folding clothes
• Sweeping with a broom
• Lifting grocery bags
• Vacuuming the floor • Lifting canned goods
• Mopping the floor • Lifting laundry basket
• Dusting a table • Lifting iron and other appliances
• Folding clothes • Opening doors
• Cleaning the bathtub and other surfaces
• Moving furniture
• Hanging up clothes
• Writing a menu
ENDURANCE LIMITATIONS • Following appropriate emergency procedures
• Finding items in a cluttered kitchen or shopping mall
Difficulty in completing any home activity that requires • Keeping track of schedules, such as which day to
sustained effort or movement over a specified period of put out the trash
time, such as the following: • Finding his/her way to the store
• Preparing large meals for family • Juggling more than one task at a time such as answer
• Unpacking clothes ing the telephone and washing
• Performing yard work
e Management
Terminology
1. Home management: Obtaining and maintaining method of payment, and completing money trans
personal and household possessions and environment actions
a. Clothing care: Obtaining and using supplies, e. Money management: Budgeting, paying bills
sorting, laundering (hand, machine, and dry clean), and using bank systems
folding, ironing, storing, and mending f. Household maintenance: Maintaining home
b. Cleaning: Obtaining and using supplies, picking yard, garden, and appliances
up and puting away, vacuuming or sweeping and g. Safety procedures: Knowing and performin
mopping floors, dusting, polishing, scrubbing, wash preventive and emergency procedures to maintain
ing windows, cleaning mirrors, making beds, and safe environment and to prevent injuries
removing trash and recyclables
2. Care of others: Providing for children, spouse
c. Meal preparation and clean-up: Planning
parents, pets, or others, such as giving physical care
nutritious meals, preparing and serving food, open
nurturing, communicating, and using age-appropriat
ing and closing containers and cabinets and drawers,
activities
using kitchen utensils and appliances, cleaning up,
and storing food safely
From the American Occupational Therapy Association. (1994). Un
d. Shopping: Preparing shopping lists (grocery and form terminology, third edition. American Journal of Occupationa
other), selecting and purchasing items, selecting Therapy, 4(11), 1074.
467
ENDIX E
pational Therapy
Home Evaluation
Patient's Name: Diagnosis: __________________
Home Address:
Home Telephone:
doorway? ____________________________ c. If no, give doorway width and any other reaso
b. Is the door automatic?
YES NO d. What kind of bed does patient use? _ _ _
c. Are there steps between entrance and main areas? e. Is there any adaptive equipment present?
YES NO YES NO
6. ELEVATOR 9. BA1HRooM
a. Is there a passenger elevator? a. Where is the bathroom located? _ _ _ _ _
YES NO b. Is it accessible?
doors, or across the floor? _________ h. If yes, put a check beside the appropriate fixtu
d. Are stairs, halls, and exits free from clutter? rail mounted next to commode _________
YES NO rail mounted on tub wall _________
e. Are throw rugs eliminated or fastened down? onefaucet ______________
YES NO two faucets _ _ _ _ _ _ _ _ _ _ _ _
f. Are strong banisters or railings placed along each L Is there a shower?
stairway? YES NO
YES NO j. Is there any adaptive equipment present?
g. Is furniture arranged to allow free movement in YES NO
heavy traffic areas? k. If yes, please list: _ _ _ _ _ _ _ _ _ _
YES NO I. If yes, is it being used?
RECOMMENDATIONS
Evaluator
Data from Shirley J. Jackson and Felecia M. Banks. Howard University Occupational Therapy Department, 1995.
1 9
mmunity Activities
Carolyn Schmidt Hanson, PhD, OTR
SUMMARY Integrating the individual with an illness or injury into the community is
important for therapists to consider. Within the community, public areas need to
be accessible for individuals with disabilities. Legislation such as the Americans with
Disabilities Act of 1990 has facilitated barrier removal and modification of struc
tures in the public sector. Informal and formal community integration assessments
used by clinicians are discussed in this chapter. In addition, a special section on
driving is presented.
After being hospitalized owing to trauma or illness, an The combination of these factors has led to mo
individual typically engages in basic activities of daily living emphasis being placed on making the environment acce
while recovering in an institution. As therapists, we need to sible to all . Although physical and , particularly, attitudin
consider methods of integrating the individual back into the barriers remain, people with disabilities are finding it eas
community, whether the person is in an acute care facility to participate in community activities than in the pa
or a rehabilitation program. Once discharged home, this (Reynolds, 1993).
individual may begin to perform more activities indepen
dently and eventually venture into the community. How
ever, tasks may be more difficult and take longer to perform
after hospitalization . Whereas driving to the bank and
LEGISLATION
withdrawing money used to take 10 minutes, it may now
The intention of the ADA has been likened to t
require more than twice that time and require a family
philosophy of occupational therapy : engaging in purpos
member to drive the newly recuperating individual to the
ful activity is essential to humans (Bachelder & Hilto
bank. A 10-minute task for one has just become a
1994). Owing to its legal ramifications, the ADA is havi
30-minute task for two people. This chapter focuses on
an impact on our society. The ADA is not new legislati
assessments used to integrate individuals with physical
but a direct outgrowth of Section 504 of the Rehabilitati
disabilities back into the community.
Act of 1973, otherwise known as the Handicapped Bill
According to Law and colleagues (1995), three major
Rights. Although it extends the scope of Section 504
factors help explain why physical and occupational therapy
encompass all public facilities and is not just limited
goals are currently more community based :
federal agencies, the intent of the ADA is no different th
1. The independent living movement
this passage from the Rehabilitation Act of 1973:
2. The increased number of elderly living in our society
3. Legislation such as the Americans with Disabilities No otherwise qualified handicapped individual in
Act (ADA) of 1990 the United States shall, solely by reason of his
47
472 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
handicap, be excluded from participation in, be de Miami is on the coast, the beach is a familiar place to visit;
nied the benefits of or be subjected to discrimina therefore, a hospital in south Florida might request a beach
tion under any program or activity receiving federal module. The modules known as "enhanced care environ
fi nancial assistance. ments" are motivating and fun for people. Dix (1992)
(FEDERAL REGISTER, P. 163) stated that individuals involved in Independence Square™
activities viewed their therapy as being more beneficial
The ADA mandates accessibility of public accommoda when they were rehearsing skills in a more realistic
tions (Title III) and federal and state government entities environment. Not always is it possible to observe indi
(Title II). Title I applies to employment opportunities for viduals in their own communities. With Independence
individuals with a disability, and Title IV pertains to SquareTM, the community can be brought to the individuaL
telecommunications. Title V is a miscellaneous category. In this manner, skills can be assessed in a structured and
As can be seen by the five titles, individuals with all types of controlled environment.
disabilities are covered by this legislation. No longer will Gradually extending rehabilitation efforts into the com
stairs to a courthouse or restrooms with small, heavy doors munity allows the practicing of necessary functional skills in
prevent an individual using a wheelchair from entering more meaningful and unpredictable situations. Observing
these areas. Structured modifications will be needed to individuals during a planned community outing is one
provide access to all people. Compliance with the ADA is method of determining physical and psychological compe
expected, but it is not being monitored per se. If a violation tence. For example, a comprehensive program focusing
is reported, the case will be reviewed by the court and on reintegrating the postgrafted burned individual into the
action taken. community (Goggins et aI. , 1990) consisted of the follow
Public accommodation gUidelines meeting ADA speci ing phases: preparation (finanCial considerations of
fications are available through regional Disability and institutional reimbursement for the community activity;
Business Technical Assistance Centers (see Appendix at roles of the team members, individual, and family ; individu
the end of this chapter). To evaluate the accessibility of a alized goal setting), performance (preparing the person
particular building, therapists can use The ADA Checklist mentally, physically, and emotionally for the activity;
for Readily Achievable Barrier Removal (Adaptive Envi coaching and prompting the individual during the activity;
ronments Center, 1992). This checklist reviews entrance considering the particular situation-noting the individual's
ways, parking, accessibility of goods and services, usability interactions with the environment), and evaluation (the
of restrooms, and miscellaneous items, such as telephone individual with burns plays an active role in discussing how
and drinking fountain heights . The checklist enables a goals were met and how the outing was viewed, along with
therapist or any other interested person to evaluate feedback from team members). Individuals benefit from
whether a building is accessible or not and additionally these structured outings, but cost effectiveness needs to be
provides possible solutions for inaccessible areas. The documented.
checklist was designed for buildings already in existence. EI-Ghatit and coworkers (1980) mentioned that standard
evaluation of individuals with spinal cord injuries entailed
residing in an apartment 7 miles away from the hospital
before discharge was planned. The apartment complex
COMMUNITY REliNTEGRATION was located near stores, churches, and public transporta
tion to facilitate the transition of the individual into
Informal Assessments community activities. The hospital was just far enough
away from the apartment complex to encourage indepen
An ideal time to work on community activities is when dent functioning.
the individual is first hospitalized. Individuals in some An outpatient intensive group-oriented program has
facilities may have the opportunity to eat in a public dining been found to assist individuals with mild to moderate brain
room, attend a religious service, and even get a haircut injury to find employment and be more active in the
while being treated by health professionals (Goggins et aI. , community (Smigielski et aI., 1992). To be considered for
1990). In addition to these common activities, individuals this program , an individual must undergo a 2-day interdis
may be able to visit the post office and bank and to pick up ciplinary assessment conducted by a physiatrist , clinical
a few items from the grocery store-all under one roof. A neuropsychologist, physical therapist , occupational thera
wide variety of facilities across the country have used pist, speech pathologist, medical social worker, and nurse.
Independence Square™ (developed by the creator of A team conference is held after the assessment to deter
"Easy Street") to bridge the gap from hospital to home mine if the individual with a brain injury is capable of full
(Henderson , 1994). Independence Square™ consists of participation . The patient and interested family members
realistic modules , each being a replica of places of business then meet with the interdisciplinary team to discuss treat
and leisure, such as a bank, grocery store , restaurant, and ment. This assessment has proved to be a valuable resource
beach . Numerous modules are available, but custom order owing to its comprehensive nature. Whether the individual
ing is possible for a specific location. For example, since is accepted into the outpatient program or not, recommen
ment, and vocational planning , as appropriate. week apart (Whiteneck et aI., 1992). For interrater relia
ity, the ratings of the individual with SCI were compa
with those of a spouse or close relative (Table 19-
Formal Assessments Content validity was found to be adequate when rehab
tation profeSSionals rated individuals with various levels
The Community Integration Questionnaire (CIQ), origi SCI. In a pilot sample, a high correlation was found on
nally designed for persons with traumatic brain injury (TBI), subscale of productive activity for the CIQ and occupat
consists of 15 questions in three domains: home integra on the CHART but not for the social integration subsca
tion, social integration, and productive activities (Willer et (Willer et aI., 1994). Across all five dimensions , the m
aI., 1994). This questionnaire is to be completed by the severe the impairment, the more significant the handic
individual with the brain injury or the person most familiar However, considerable variability in handicap was evid
with the individual. Alternate forms of the CIQ include in those with similar impairments (see Table 19-1).
telephone and computerized versions. The CIQ takes The Reintegration to Normal Living (RNL) Index w
approximately 15 minutes to answer questions relating to developed to evaluate how successfully individuals w
the use of transportation , social, employment, and school integrated into their communities after sustaining an inj
related activities, in addition to household responsibilities. or managing a chronic condition. According to R
Willer and others (1994) have reported high test-retest authors Wood-Dauphinee and colleagues (1988), rein
reliability (greater than 0.90) and good validity of the CIQ . gration was defined by the following domains: indo
Formalized interrater reliability studies have not been community, distant mobility, self-care, daily activity, rec
conducted, but comparisons have been made between ational activity, social activity, general coping skills, fam
responses made by family members and the individuals roles, personal relationships, and presentation of self
themselves. Significant differences on all sections of the others. "I spend most of my days occupied in a w
CIQ and the total CIQ score were found between able activity that is necessary or important to me" is an exam
bodied individuals (control group) and individuals with TBI. of one of the statements used in the RNL questionnai
Also, significant differences were found between those with The aforementioned items are rated according to a scale
TBI who lived independently as opposed to in a supported 1 to 10, ranging from "this statement does not describe
living situation (Willer et aI., 1994). In a sample of 352 situation" (1) to "this statement fully describes my sit
individuals with TBI and 237 nondisabled people, Willer tion" (10) . A second version of the questionnaire w
and colleagues (1993) discovered that individuals with TBI developed for people who require adaptive devices, mo
were significantly less integrated on every subscale of the aids , or human assistance. The RNL is available in b
CIQ than the nondisabled, except for one area: Females French and English.
with TBI were integrated into home activities to the same Preliminary studies have shown high internal con
extent as nondisabled females. Further research is needed tency of the RNL (0 .90 and higher). In determin
to evaluate reliability over time and for different methods of intenater reliability, Wood-Dauphinee and associa
administering the CIQ. Other areas for exploration include (1988) found higher correlations when the responses
comparison of the CIQ with related assessments and using cancer patients were compared with those of their sig
this instrument with different populations. icant others (0 .63) as opposed to those of the hea
The Craig Handicap Assessment and Reporting Tech profeSSionals caring for them (O .40). With this in mind ,
nique (CHART) was developed to determine rehabilitation researchers excluded the ratings of health profession
outcomes in relation to activities that society views as being from future studies . Authors of the RNL Index reco
productive (Whiteneck et aI., 1992). Handicap in this mended that populations other than cancer patients
assessment is defined in the same fashion as the World studied and monitored for longer periods of time (Wo
Health Organization (WHO) definition: An impairment or
disability that interferes with the fulfillment of roles consid
TABLE 19-1
ered appropriate for an individual's age, gender, and
culture. While constructing the items in this inventory, REUABIUIY OF DIE CRAIG HANDICAP
Whiteneck and associates (1992) paid attention to the ASSESSMENT AND REPOIl11NG
variety of ways in which social roles were fulfilled. Designed TECHNIQUE
for the spinal cord population, CHART is a survey
consisting of the following components: physical indepen Test-Retest Interrat
dence, mobility, occupation, social integration, and eco
Physical independence 0.92 0.80
nomic self-suffiCiency. A maximum score of 500 points is Mobility 0.95 0.84
possible, with 100 points allotted for each of the five Occupation 0.89 0.81
components. CHART was calibrated on the able-bodied Economic self-sufficiency 0.80 0.69
Social integratio n 0.81 0.57
population. Good test-retest reliability has been docu Overall 0.93 0.83
mented on 135 individuals with spinal cord injury (SCI) who
474 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
Dauphinee et al., 1988). Regarding construct validity, a In 1990, Galski and associates reported that a typical
moderately strong correlation was found between the RNL driver evaluation consisting of predriver components (per
and the Quality of Life (QL) Index. The QL was designed for ceptual and cognitive tasks) and on-the-road components
physicians to use with individuals with cancer and other had no predictive validity or criterion validity with individu
chronic diseases. Requiring only several minutes to admin als who had had a stroke or TBI. The evaluator's decision to
ister, the domains measured include activity, daily living, pass or fail an individual with a neurologic impairment was
health, support, and outlook on life. High internal consis based not on any of the subtests but more on subjective
tency and interrater reliability of the QL have been reported information . Components of the predriver evaluation did
(Spitzer et al. , 1981). not correlate with on-the-road tests. Galski and others
(1990) emphaSized the necessity of clearly identifying skills
necessary for driving . Galski and colleagues (1992) pro
posed a particular model of driving (the cybernetic model),
DRIVING which they tested on 35 individuals with TBI. Individuals
were given a predriver evaluation (various neuropsycholog
Driving is an important activity to a great number of ical tests), simulator evaluation (two-dimensional driving
people , as it represents independence. When unable to exercise), and behind-the-wheel evaluation (on a protected
drive, one has to rely on others to engage in activities course , as well as in usual traffic). Results indicated that
outside of the home . No particular driving assessment is 93% of the variability of the driving outcome was explained
considered standard, as individuals with disabilities vary, as cumulatively by the predriver and simulator evaluations in
do driving evaluators. Currently, profeSSionals invo1lved in addition to behavioral measures (e.g., inattention, distract
disabled driving have the opportunity to become recog ibility). In fact, the seven neuropsychological tests alone
nized as driver rehabilitation specialists by taking a certifi primarily accounted for driving outcome. Following up on
cation examination . their past recommendations, Galski and coworkers (1993)
Driving assessments mentioned in the literature include evaluated 58 individuals with TBI and 48 with cerebrovas
computerized and standardized psychometric tests , visual cular accident (CVA) on behind-the-wheel driving perfor
tests , and on-the-road driver evaluations (Brooke et al. , mance. They again found that the predriver evaluation,
1992; Engrumetal., 1989; Korner-Bitensky etal. , 1994). along with the simulator evaluation and behavioral mea
Many of the same perceptual tests were found in these sures, was the best method of determining driving ability
different assessments, such as the Trail Making test of the because of its high sensitivity and the safety it provides the
Halstead-Reitan Neuropsychological Battery and portions patient and driving evaluator.
of the Wechsler Adult Intelligence Scale (WAIS-R) (Lezak, Sprigle and colleagues (1995) surveyed driving evalua
1983). The Cognitive Behavioral Driver's Index (CBDI) is tors across the country regarding their driving assessments
one such instrument that combines the aforementioned and satisfaction with their evaluations and equipment. The
tests and the Driver Performance Test. The CBDI was 21-question survey was returned by 138 evaluators from
designed for the neurologically involved individual and has 44 states and consisted of occupational therapists (62% of
shown high internal consistency and reliability and good the evaluators), with the main location of driver training
valldity (Engrum et aI., 1989). being a medical facility (80%) for all evaluators. The most
Gouvier and others (1988) mentioned five components commonly measured phYSical characteristics were range of
that were essential in determining driving ability: gross motion, manual muscle testing, sensation, grip and pinch
sensory and motor function; cognitive and perceptual strength, fine motor dexterity, and eye-hand coordination .
ability; knowledge of rules of the road and judgment Driving characteristics most commonly measured included
regarding driving situations (as measured by the Driver gas, brake, and steering force and brake and steering
Performance Test fDPT]); computerized driving simulator reaction time. Sprigle and others (1995) commented on
and small vehicle (e.g., golf cart) maneuvering competence the lack of standardized methods for identifying driving
on a closed course; and full-size vehicle maneuvering ability and the reliance on subjective functional tests.
competence on a closed course and public highways. If at Despite this , they noted that 66% of the survey respon
any point during the evaluation process a person does not dents were satisfied with their evaluations and equipment
adequately master one of the components, the test is (e.g ., simulators) . Further research to be conducted should
ended . Training may then be implemented tb correct the identify assistive driving equipment and essential driving
specific deficit. This assessment was designed for the characteristics that predict driving ability.
population with TBI and for other severely disabled indi After passing the various components of a driver assess
viduals. Further validation of the five components is ment, individuals may require adaptations to their vehicles.
needed. However, the OPT used in component three has Sabo and Shipp (1989) have identified equipment and
been standardized on 8000 automobile and light truck strategies for a variety of disabilities. Since each person
drivers and has good predictive validity (Weaver, 1982); with a disability presents a unique challenge, generaliza
i.e. , significantly higher automobile accident rates occur in tions concerning any diagnosis and its relation to driving
people who score below the average classification rating on are difficult to make. For more information regarding
the OPT. driving and the disabled, refer to the Appendix that follows.
AP PENDIX
,esources
ASSOCIATION OF DRIVER EDUCATORS FOR THE ties have the same opportunities as the nondisabled in f
DISABLED (ADED): An international organization pro ing employment and accessing public accommodati
viding service in the field of driver education for the and public transportation.
disabled. Responsible for the development of the Cer Cognitive Behavioral Driver's Invento
tified Driver Rehabilitation Specialist (CDRS) exami (CBDI)-Test battery that measures cognitive and beh
nation. A list of driver training evaluators in each ioral skills applicable to driving ; is available in softw
state is available on request. For more information, call form . The CBDI was developed and researched in a clin
Ric Cerna at (608) 884-8833. rehabilitation setting of brain-injured individua'ls.
LOUISIANA TECH UNIVERSITY CENTER FOR REHA Community integration-Refers to getting peo
BILITATION SCIENCE AND BIOMEDICAL ENGI with an injury or disease back into regular activities wi
NEERING: Several booklets written by experienced the community, such as working , socializing, engagin
driving evaluators are available regarding motor vehicle leisure skills, performing activities of daily living,
selection , adaptive driving devices, and vehicle modi driving.
fications. Workshops on driver assessment and train
Community Integration Questionnaire (CIQ
ing of staff are conducted by the professionals at the
Assesses the degree of community integration of indiv
Center. For more information , contact Mike Shipp at
als with a disability. Originally designed for the popula
(318) 257-4562 or 711 S. Vienna, P.O. Box 3185,
with TBI.
Ruston , Louisiana 71272 .
Craig Handicap Assessment and Report
GUYNES DESIGN INC. (GO!): Creator of Independence
Technique (CHART)-Community assessment
Square™ Rehabilitation Centers enhanced care en
signed originally for individuals with an SCI.
vironments (creator of the original "Easy Street").
For more information, contact Patricia Moore at Driver Performance Test (DPT)-Tests knowle
(602) 254-6690. of rules of the road and judgment regarding driv
situations.
ADA CHECKLIST FOR READILY ACHIEVABLE BAR
RIER REMOVAL: To obtain a copy, ask for the Disability Handicap-An impairment or disability that interf
and Business Technical Assistance Center in your geo with the fulfillment of roles considered appropriate fo
graphic region by calling 1-800-949-4ADA. individual's age, gender, and culture.
Independence Square™-Realistic modules of b
nesses and leisure areas in which people with disabil
can bridge the gap from hospital to home by practic
various activities.
Quality of Life Index (QL)-Designed for phYSi
AccessibiHty-Pertaining to the physical arrangement use , this concise questionnaire measures how well indiv
of a building, outside facility , or other structure and the ease als with chronic problems are performing at home.
with which people with disabilities can enter the structure Reintegration to Normal Uving Index (RN
and benefit from its services and products. Designed originally for chronic populations, this quest
Americans with DisabiHties Act (ADA)-Legis naire assesses how well an individual is faring within
lation enacted in 1990 mandating that people with disabili community and home.
~ -.- ~- .
476 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
·Activities
Bruce A. Mueller, OTR/L, CHT
Ellen D. Adams, MA, CRC, CCM
Carol A. Isaac, PT, BS
treatment-not the goal of treatment. "Despite recent modality, not the goal. Barton (Cited in Hanson & Walker,
technological advances, physical disability work programs 1992) indicates that therapeutic work was preliminary to
of the 1990s are distinctly similar to those of the early and dovetailed with real vocational education, which was
1900s" (Hanson & Walker, 1992, p. 56). Hanson and beyond the scope of occupational therapy.
Walker have cited numerous references that document that As Harvey-Krefting (1985) points out, "therapists began
moral treatment stemmed from the use of recreation, to feel uncomfortable with the simple operating principle
employment, and self-care as a mode of treatment for that it was good for disabled people to keep busy. This
mental illness. The mentally ill were no longer treated as discomfort eventually led to the borrowing and adopting of
subhuman. Work was prescribed to increase self-esteem knowledge from other disciplines and hence, the develop
and to meet unconscious needs. ment of the 'inner-mechanism paradigm'" (p. 304). In the
In the early years, the pioneers of occupational therapy inner-mechanisms paradigm, therapists began to establish
used the environment around them as a mode of treatment, work evaluation programs and to develop work samples
a situation not unlike today when a work hardening facility that reflected specific jobs. This new scientific approach
has a group lunch prepared by a primary school food that therapists should not be just observers; they should
service worker. In the 30s "some considered the entire take a more scientific, objective, and professional ap
hospital to be an occupational therapy department" (Mar proach, was emphasized. Harvey-Krefting (1985) further
shall, 1985, p. 297). As Edwina Marshall points out, the notes that "holistic principles accepted during the occupa
occupational therapist had "clearly defined" responsibili tional paradigm were sacrificed to narrow, more precise
ties and "industrial therapy or employment therapy was concepts such as defense mechanisms and sensory inte
born." She further notes that "the occupational therapists gration" (p. 304). During this new way of looking at the
initiated and supervised the program using activities nec therapeutic use of work, new definitions of work assess
essary for the normal function of patients and employees as ment and work therapy were developed. Work as an end in
in treatment modalities. Work assignments were matched gainful employment became the crux of the program.
with experience, aptitude, and interests of the patient" Harvey-Krefting (1985) notes that "evaluation in the
(Marshall, 1985, p. 297). One would have to search the occupational paradigm was mainly prevocational in nature
literature to its depths to find a description of the goals of and used crafts or daily living skills to assess readiness for
work assessment and work hardening that is better written, work therapy" (p. 303).
more on target, and more simply stated yet complex. In the 1950s, structured prevocational programs be
In the 1930s and 1940s, workshops were beginning to came popular. The TOWER (Testing Orientation Work
become respected modes of treatment. However, occupa Evaluation and Rehabilitation) System drew therapists
tional therapy's role and work evaluation changed in the from around the country. As Ogden-Niemeyer and Jacobs
1950s due to the burgeoning field of vocational rehabili (1989) indicate in their book Work Hardening, State of
tation and through occupational therapy volitional distanc the Art, prevocational evaluation and vocational evalua
ing from this field. During an occupational therapy confer tion were originally part of the same service that provided
ence in the late 1950s, only 2 of 34 curriculum directors both primary and secondary vocational assessment, which
defended work evaluation as a necessary component of all then became specialized. Primary vocational assessment
occupational therapy treatment for all age and disability deals with the general trainability, or potential for further
groups. Opponents placed work evaluation in a back room intensive testing or training for employment. Secondary
with vocational counselors and would not consider it vocational assessment deals with potential for specific
occupational therapy (Marshall, 1985, p. 298). Some training areas, Le., work evaluation, in what was then (in
occupational therapists did not follow this consensus. In the the late 1950s and early 1960s) part of the already
early 1950s "the paradigm of occupation was attacked by mentioned growing field of vocational evaluation. "Results
both members of the medical profeSSion and occupational from the evaluations yielded production features of neat
therapy" (Harvey-Krefting, 1985, p. 304). A paradigm, by ness, safety, work habits, intellectual and attitudinal fac
definition, is an example serving as a pattern. As Kuhn tors" (Hanson & Walker, 1992, p. 60). Hanson and Walker
(1970) suggests, a paradigm explains what the profession further note that other programs included prevocational
does and how it is done. As Harvey-Krefting (1985) notes, assessment geared for the person who did not have a work
the occupational therapy paradigm indicated "the health history or who had not worked for many years. Although
restoring effect of occupation in the extensive use of crafts the TOWER System was preeminent during this time, it
as work projects" (p. 303). She notes that Kielhoffer and was not without drawbacks. While being comprehensive (it
Burke (cited in Harvey-Krefting, 1985) describe the occu was used for 2 weeks to 6 months minimum, 5 to 6 hours
pational paradigm period as one when therapists treated per day graduated to 8 hours per day), it needed a large city
problems stemming from interruptions in work or lack of population base and was expensive.
occupation. Idleness, poor work habit formation, and lack Other tests produced in the 1950s were done in
of social skills were seen as demoralizing and as fostering a association with The Dictionary of Occupational Titles
sick or invalid role. Work was introduced to break this cycle (Field & Field, 1988; described later in this chapter), as
(Harvey-Krefting, 1985). Again, work was the treatment indicated by Wegg (1960). Wegg further indicates that
available for each testing kit. These early work samples led done within the scope of physical dysfunction.
the way for the Jewish Evaluation Vocational System Low back pain is the most commonly assessed diso
(JEVS) and Valpar Work Samples. The McCarron-Dyal for return-to-work functional capacity evaluations (FC
Work Evaluation System was also established primarily for Mayer and Gatchel (1988) indicate "low back pain is
the mentally retarded and the chronically mentally ill. most expensive, benign condition in industrialized co
Singer was an evaluation system for unspecified target tries. It is also the number one cause of disabilitie
groups and had 20 work samples for skilled trades. In persons under the age of 45" (p. 93). They further n
Velozo's (1993) article, he states "vocational evaluations that more than 1 percent of the working-age populatio
(work evaluations developed by vocational evaluators) totally and permanently disabled by the problem. Our o
generally provide testing in one or more of the following research indicates the follOWing statistics regarding
areas: A) vocational interests; B) aptitudes and achieve centages of FCEs by diagnosis:
ments; C) motor skills; D) work samples" (p. 204). Since • Low back problems (strains and sprains, herniate
vocational evaluations emerged from the Carl Perkins discs, and fusions), 39 percent
Vocational Act, most of these have been designed to assess • Upper extremities or hand injuries, 36 percent
the potential worker, e.g., the disabled student. These • Cervical injuries, 14 percent
types of tests do not readily transfer to the injured worker • Other (lower extremities and multiple injuries), 1
attempting to return to work. The vocational evaluation percent
would be the evaluation of choice (as long as the physical The physical demand levels of the injured workers'
abilities and limitations are known) for the injured worker who presented for FCEs were broken down as follows
who has a desire to return to work but is unable to return • Sedentary work (lifting less than 10 Ib, infrequen
to his or her usual and customary job and has no standing and walking), 8 percent
transferrable skills. As Velozo (1993) further points out, • Light work (lifting 10 to 20 lb occasionally,
"unlike traditional vocational assessments, no single diSCi frequent standing and walking), 43 percent
pline can lay claim to developing evaluations for the injured • Medium work (occasional lifting 20 to 50 Ib,
worker" (p. 204). We agree since it is our intent to frequent lifting 10 to 20 Ib), 46 percent
recommend that evaluation of the injured worker not be • Heavy work (lifting 100 Ib maximum with freque
done by a single discipline. Evaluation of the injured worker lifting or carrying of objects up to 50 lb) or very
is best done within the scope of an interdisciplinary heavy work (lifting objects in excess of 100 Ib
program. Issues addressed include prior and current work with lifting or carrying of objects 50 Ib or more),
history, the individual's current psychosocial and voca 3 percent
tional milieu, abnormal illness behaviors, medical history, These categories of work are further clarified in
diagnosis and biomechanical issues, physical abilities and section on The Dictionary ofOccupational Titles (Fie
limitations, current litigation, and funding sources. No one Field, 1988).
therapist can adequately address all of these areas, even
when the issues to be assessed are clear. We recommend a
continuum of care from a focused 1- to 2-hour evaluation
for the simple release to work parameters to a full-blown INTRODUCTION TO FUNCTIONAL
interdisciplinary functional capacity evaluation utilizing a CAPACITY EVALUATION
physical or occupational therapist (depending on diagnosis)
and a vocational rehabilitation counselor. The FCE is an interdisciplinary evaluation that is use
In summary, work assessment has evolved over a assess the physical, functional, vocational, and psycho
number of years and has its roots in the pioneers of cial status of an injured worker. The importance of the F
occupational therapy. No one discipline of occupational or has been made clear by the comments of a physician
physical therapy or vocational evaluation can claim to be an attorney who usually represent the insurance comp
the full developer of work assessment. It is our contention in workers' compensation litigation (see Appendix C at
that work assessment is best done in an interdisciplinary end of this chapter). Musculoskeletal testing, computer
program that is specifically geared to deal with the workers' and standardized testing, vocational and psychoso
compensation system and that deals specifically with the history (see Appendix D at the end of this chapter),
injured worker population's needs. abnormal illness behavior are addressed. These areas
described in detail in the following sections.
and professional staff. The referral for the FeE most often work and locating restrooms, rest areas, and fire plan and
comes from the treating physician. Other referral sources exits. Release forms (Figs. 20-1 and 20-2) to request
include the insurance adjustor (also known as the carrier), additional medical, vocational, or psychological reports
rehabilitation providers, plaintiff or defense attorneys, and and to release the results of the FeE to the appropriate
employers. In some instances, the referring physician is not persons are signed by the client and witnessed by the staff.
actually treating the injured worker but is seeing the Additional medical history is assessed, and a general health
individual for an independent medical evaluation. Some screen is administered. The client's blood pressure and
states require a prescription from a doctor to perform a pulse are taken to make sure they are within safe, testable
FeE. This is a good practice whether or not it is required by limits.
law, as it allows the injured worker and the evaluators to The client is asked to sign an FeE Participation Agree
have the confidence that the physician supports this type of ment (Fig. 20-3), which is explained to the injured worker
testing and agrees that the client is able to participate in the by the therapist who will be performing the FeE. This form
testing. tells the client what is expected in terms of exertion. The
At the time of the referral, the referral source is asked for client is instructed to stop an activity if abnormal discomfort
certain identifying data on the client, including the client's (Le., discomfort other than what he or she usually feels) is
name, address, age, phone number, date of injury, diag experienced. The client is told verbally and in writing that
nosis, surgeries, employer, insurance carrier, rehabilitation consistency of effort and maximum voluntary effort is being
provider, and attorney and physician information. This assessed throughout the testing. The client and the thera
information becomes part of the permanent record. At this pist both sign this form.
time it is also important to request medical records for the The client's past medical history is secured by means of
evaluators to review prior to the injured worker's arrival for a questionnaire that is filled out by the client and reviewed
their evaluation. for pertinent information that may affect or limit aspects of
Once the referral is received, verbal authorization to the evaluation. The client is asked to report on any surgery
perform the FeE is obtained from the insurance adjustor, ever had, medications currently being taken, and all doctors
and the price for the FeE is established. It is a good idea at currently treating him or her for any condition. The client
that point to follow up the conversation with a letter is asked to report to the therapist the diagnosis as he or she
confirming the date and time of the appointment and the understands it, and it is compared with the diagnosis given
charge that was agreed on. Some states regulate the fees to the therapist by the physician. At times the client may
and the professionals required to perform the evaluations. have more current information on his or her condition
After authorization for the service is obtained, the injured than was relayed at referral. The client is also asked to
worker should be notified by phone and in writing of his or describe his or her symptoms verbally, to answer ques
her appointment time. The injured worker should be tions on several pain assessment questionnaires, and to
encouraged to call with any questions he or she may have complete a pain drawing and rating diagram. Facilities
to help alleviate any fears regarding the purpose and nature and FeE systems vary widely on pain and behavioral
of the testing. Making phone contact with the person to be questionnaires administered and the degree of health
evaluated increases compliance in attending the scheduled screening.
appointment. The letter sent to the client should include the As part of the evaluation, a psychosocial and vocational
date and time of testing, who requested and authorized the history questionnaire (see AppendiX D at the end of this
FeE, what to wear, directions to the facility, and encour chapter) is mailed to the client to fill out prior to coming
agement for the client to inform the therapist in advance of to the evaluation, or it is given to the client on arrival
medical problems that are not related to the injury but could to the facility. The purpose of this questionnaire is to
interfere with testing. The letter should direct the client to obtain information regarding the injured worker's per
call to confirm the appointment and to clarify any questions ception of his or her social, vocational, educational,
he or she may have. Other persons involved in the care of financial, family, and recreational activities prior to and
the injured worker, Le., the rehabilitation provider, medical since the injury. It is recommended that a certified re
doctor, and adjustor, should always be kept informed of habilitation counselor further explore this information
appointment dates, times, and changes if they occur to with the injured worker to assess the impact of the injury
promote ongoing and open communication and to prevent on the client's life. This information is also used to assist
the injured worker from "falling through the cracks," or the client in developing realistic vocational goals as he or
getting lost in the system, thereby increasing the overall she begins the return-ta-work process and to identify
cost by delaying the return to work. Additionally, keeping other potential, non-injury-related barriers to successfully
everyone informed eases the process of coordinating returning to work. It is important to note that no current
return medical appointments. assessment tool can establish motivation or lack thereof.
When the injured worker arrives for his or her appoint The professionals involved in the FeE process have a
ment, he or she is initially oriented to the facUity, which responsibility to report objective data and professional
includes introduction of the staff with whom he or she will observations.
PHYSICAL RESTORATION CENTERS
of Florida
INFORMATION RELEASE/REOUEST
INFORMATION RECIPIENT (specify individual, title, program, agency, address. any or all as appropriate)
INSURANCE CARRIER:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
REHABllJTATION:________________________________________
CLIENT ATIORNEY:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
OTHER:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PURPOSE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
To the recipient of this information: This information is being disclosed to you from records whose
confidentiality is protected by Federal Law. Federal regulations prohibit you from making any further
disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise
permitted by such regulations (42 CRF Part 2). A general authorization for the release of medical or
other information is NOT sufficient for this purpose.
of Florida
Client/Patient Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I hereby grant permission for any and all information regarding my medical, psychological,
emotional or social condition and/or treatment be released from:
Client/Patient Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Relationship: ---'Sel!<!!lf~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Wituess: __________________________________________________
3601 S.w. 2ND AVENUE. SUITE S GAINESVILLE. FLORIDA 32607-2802 • PHONE (904) 336-6830 FAX (904) 336-6910
FIGURE 20-2. Permission form to request records from sources who have treated or evaluated the client.
motion is with a tape measure: The examiner measures the devices such as the Cybex EDI 320 do the work of two
difference in length between the 12th thoracic (T12) inclinometers electronically, making range of motion mea
spinous process and first sacral (S 1) spinous process after surement much easier. Other trunk and cervical range of
the patient bends forward. A more accurate solution is the motion measurements that can be done with inclinometers
use of two inclinometers: One is placed at the T12 spinous are described very specifically in the American Medical
process, and the other, over the sacrum. Then the client is Association's (AMA's) Guide to the Evaluation of Perma
asked to flex or extend. After the numbers are recorded, nent Impairment (1988).
one is subtracted from the other, thus revealing true lumbar Muscle testing is often very arbitrary at best, especially
range of motion. This method of separating the lumbar when the examiner is trying to distinguish between" good"
spine segments from the hip component has been shown (4 of 5) and "normal" (5 of 5). However, some hand-held
to be reliable and reproducible (Keeley et aI., 1986). Other dynamometers accurately measure force in pounds or
Nicholas Manual Muscle Tester, which can give the exam done; this is discussed under the section on abnorm
iner numeric data that can be useful in determining illness behavior in this chapter.
abnormal illness behavior. Blankenship and Ergometrics PhYSical therapy clinics throughout the nation perfo
are two manufacturers who offer integrated muscle testing evaluations on work-injured populations at the end of
as part of a computerized FCE system. course of acute therapy. Typically, the assessment is
Other tests can be added to the musculoskeletal exami evaluate physical abilities and functional activities. T
nation at the therapists' discretion. The preceding was not results are then sent to the injured worker's physician, a
meant to be an exhaustive list; however, these items should a release to work level is established. The assessment of
be covered if a musculoskeletal examination is included in includes musculoskeletal examination and strength test
I acknowledge that certain jobs require manual lifting of loads sufficient to warrant
consideration of testing my strength. mobility. and endurance. The results of the tests are
to be included in the report. Consistency of effort will also be evaluated. Tests are
included that will evaluate if you are performing with your best effort.
Risk of injuring myself during the evaluation has been minimized. The effort given should
be what I believe I'm capable of exerting if given a heavy object to handle on my job. HI
feel any abnormal discomfort during the evaluation, or I feel I can't safely perform as
requested, I am allowed and requested to stop my exertion at that level.
Participation in the evaluation is strictly voluntary. I fully understand the above and wish
to participate in the evaluation.
Date Date
3601 S.W. 2ND AVENV'E, SUITE S GAINESVILLE, FLORIDA 32607-2802 • PHONE (904) 336-6830 FAX (904) 336-6910
FIGURE 26-3. Form the client is asked to sign prior to participating in the evaluation.
484 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
and is appropriate for the person who reports that he or able. The Jamar Dynamometer, utilizing CVs, also became
she is able to return to the same job and does not have overt widely used. Ogden-Niemeyer and Jacobs (1989, p. 101)
behavioral or psychosocial problems. point out that
This type of evaluation generally takes an hour or less to
the rationale for maximum voluntary effort is based
perform by one therapist, it does not have a validity
on a number of assumptions. The first assumption
component, and it does not address specific job duties. This
is that, given an inherently reliable procedure where
evaluation should not be used for the person who has not
body posture, individual joint angles, and muscles
progressed appropriately in physical therapy, for the
are carefully controlled, individuals giving maxi
person who reports that he or she is unable to return to
mum effort during an assessment of strength will
work, for the person who has no job to return to, or for the
show a high level of reliability and low variance dur
person with overt pain behaviors. Appendix E at the end of
ing closely spaced serial trials. The second assump
this chapter is an example of a format for a physical abilities
tion is that the individual who is magnifying dys
assessment.
function consciously or unconsciously will not give
maximum effort during physical testing. The third
is that the lack of maximum effort is associated
Maximum Voluntary Effort with inconsistency or unreliability of performance.
What is the state of the art, state of the science, state of Multiple literature sources traditionally list 15 percent as
the "guess" when evaluating maximum voluntary effort? the cutoff point for MVE. That is, if enough CVs are greater
As clinicians who work in the field of FCEs and return-to than 15 percent, submaximal effort is suspected. Recent
work programs, we are deluged with physicians, insurance research is challenging this concept (Robinson et al.,
adjustors, and attorneys who want to know "Is this person 1993). Robinson and colleagues showed that classification
for real?" "Is he or she exaggerating the symptoms?" rates had unacceptably large errors, with 69 percent of
"Does he or she have real problems?" Knowing if the submaximal efforts being classified as maximal with the
injured worker produces a maximum voluntary effort traditional 15 percent cutoff. They also reported that the
(MVE) is imperative to the outcome validity of the FCE. The currently practiced method of using a low number of
therapist needs to know the evaluee's effort, since ethically repetitions to calculate CVs may result in very unstable
and professionally we are required to offer suggestions and measures. Currently many facilities and evaluation systems
make decisions that directly affect people's lives. We are (e.g., Blankenship, Key, Ergos, Maximum Voluntary Effort
called on by employers to assist them in the reemployment Protocol) rely at least partially, if not heavily, on using CVs
process, by attorneys for expert testimony, by insurance to determine MVE. Further confirmatory research in this
companies who want cost-effective treatment and positive area seems to be warranted; however, it should be noted
outcomes, and by physicians who are ultimately responsi that most of the research supports CVs as a method of
ble for the decision to release the injured worker to work determining submaximal effort. The literature reveals other
and with what restrictions. methods for determining MVE. Bell-shaped curves were
The topic of MVE is identified in the literature as far back first described by Stokes in 1983. He proposed that using
as 1954 (Bectol, 1954). Research on this topic is ongoing, a five-position dynamometer, a modified bell-shaped curve
and this area of practice needs further study. Significant represents a maximal effort. Additionally, flattened curves
research and clinical focus have been directed toward were demonstrated in conjunction with electromyography
identifying the injured worker who is magnifying his or her (EMG) in the 1993 literature by Hoffmaster and associates.
symptoms through tests of MVE. In 1972, Donald B. Coefficients of variation with the dynamometer on multiple
Chaffin and his colleagues, from their attempts to reduce trials are also frequently used as another indicator of MVE.
high injury rates among workers in strenuous jobs requiring Incidentally, Bectol (1954) described the beginnings of
frequent lifting, pushing, and pulling, advised a method of using CVs. This method was formally described in 1988 in
isometric strength testing for preemployment screening an excellent article by Leonard Matheson entitled, "How
(cited in Ogden-Niemeyer & Jacobs, 1989). These tests do you know he tried his best? The reliability crisis in
were found to be reliable, with a coefficient of variation industrial rehabilitation." This concept was developed into
(CV) for repetitive trials between 10 percent and 13 a specific set of protocols, as described by Barren and
percent (Ogden-Niemeyer & Jacobs, 1989). A coefficient coworkers (1992). They suggested that a baseline of 14
of variation is a standard deviation of the test and retest sets of 20 would fall below the CV standardized cutoff point
scores divided by the mean, multiplied by 100. Static to determine the trial as a maximum effort on the Baltimore
strength testing combined with coefficients of variation was Therapeutic Equipment (BTE). The BTE is an upper
the hallmark of the more objective methods of determining extremity work simulator that can measure static strength
effort. Equipment such as the Isometric Strength Testing of the upper extremities.
Unit (ISTU) produced by Ergometrics and the Force Gauge In 1988, King and Berryhill described a method for
Platform devised by Keith Blankenship, PT, became avail comparing the BTE with the dynamometer. They stated
voluntary effort should be made solely on the position of illness behavior in this chapter.
the hand on the dynamometer test" (Le., bell-shaped Force curves with dynamic testing are also available
curves) (p. 207). In this study, King and Berryhill showed a validity criteria. Torque curves and range of motion
positive correlation between the BTE Work Simulator and available for consistency, and thorough training is availa
the Jamar Dynamometer. through the manufacturers (e.g., Cybex, Biodex, a
The Rapid Exchange of Grip (REG) test was described by Medex). This equipment is more fully described in
Hildreth and colleagues (1989) for assessing MVE. Utiliz computerized test section of this chapter.
ing a hand grip dynamometer on position two is recom The central theme of the MVE testing is that no one t
mended. The evaluee then switches hands rapidly while should be used to determine MVE- not pain drawin
exerting maximum effort. If the REG decreases, the effort elevated CVs, stocking anesthesia of the lower extrem
is considered valid; if it increases, lack of MVE is suspected. or even inconsistent SLR with distraction. Although al
From this author's experience, increase of 100 percent or these tests are signs of suspected lack of effort, a com
more in grip strength has been demonstrated with rapid nation of tests is ideal. But what is the critical number
exchange of grip. The theory is that when REG is done tests failed before the therapist can identify the effort
quickly, the evaluee has less cortical control, and a truer submaximal? Everyone would probably agree that mor
assessment of strength is measured. better. In the changing field of health care, multiple-
Distraction tests are also used in assessing MVE. As evaluations may be a thing of the past. In our experien
Blankenship (1989 ,p. 506) indicates, the ability to do 2-day FCEs representing 8 to 12 hours
testing and being reimbursed appropriately is gone. The
these are tests which are performed while the pa
fore, it becomes imperative to assess the situation in 1 t
tient is aware that the test is being performed, and
hours to see if the evaluee is giving full effort. The luxury
performed again when the patient is not aware that
observing consistency over days, making careful detai
the test is being performed. A passed distraction
analysis of behavior and function and how they relate to
test results when the response to both tests is the
diagnOSis, is gone. Now the therapist must perfo
same. A failed distraction test results when one re
provocative tests that require the proper response from
sult is recorded when the patient is aware that the
injured worker to assess the level of effort.
test is being performed and a different result is
Assessing validity must start with informed consent. T
recorded when the patient is not aware it is being
evaluee must know that his or her effort and phys
performed.
function will be assessed. As stated previously, the clien
An example of this is when the evaluee is told that he or she told verbally and in writing that consistency of effort a
is going on a "walking test," and the evaluee stops MVE will be assessed throughout the evaluation. Be w
approximately 20 feet after going out the front door, of the individual who makes a production of how much p
claiming that low back pain prevents further walking. If he or she is in but reports that he or she is here to "do
later during the FCE, the evaluee walks twice the original best." Such individuals may further state that "I h
distance during the carrying test, then this would be a failed always tried hard at everything I do," as evidenced by his
distraction test. The idea is that during the carrying test, the her prior line of work, number of working years, numbe
evaluee and his or her accompanying symptoms are hours per day, and other supporting evidence. As Bl
focused on the 5-lb weight. Logically, the individual would kenship (1994, p.430) suggests, be wary of the eval
not be able to carry the 5-lb weight farther than he or she who reports high pain yet continues testing:
is able to walk unencumbered. Blankenship (1989) cites
From a logical position, a person expressing high
another important example, the straight leg test. Since
pain for which there is an organic basis would no
most chronic patients are aware that the straight leg raises
agree to go through with an FCE which would cau
should be limited and produce pain when performed in the
further pain and possible re-injury. Therefore a
supine test position, that result usually occurs. But they are
person reporting a high pain level but who agrees
not aware that the same results should occur while
be subjected to an FCE must not be feeling much
performing a manual muscle test of the quadriceps in the
pain, or they would refuse to partiCipate.
seated position while the hips are at approximately 80
degrees of flexion and the knee fully extended. In this Excellent continuing education courses are availa
position, with the client holding onto the front edge of the from multiple sources (e.g., Matheson ASSOciates; Ke
table so that he or she cannot lean backward, the leg is Blankenship and Duwane Saunders; and Karen Schu
being raised to what would be comparable to a 60- to Johnson provide valuable information and may be reach
80-degree straight leg raise. Significant differences in the at (714) 836-1224, (800) 248-8846, and (800) 6
results indicate that the patient is trying to control the 8357, respectively). It is also recommended that for
results of the test. It should be noted that Blankenship uninitiated therapist in this field, follOwing set procedure
(1989) describes in great detail additional validity criteria. perhaps best. Using set procedures with respected
486 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
search behind their methods is advantageous in providing cess is based on the bibliography of over 150 pub
a high level of care, and it can be defended during a lished articles which increases the credibility of
deposition for a litigated case. Using established proce legal testimony by the user. There are over 150 va
dures also minimizes the clinician 's liability exposure. lidity criteria in the evaluation process to help de
Therapists performing FCEs are commonly required to termine if the patient is responding to answers ac
give depositions supporting the validity and reliability of the curately and exerting good effort. The evaluation
testing measures, as well as information regarding the can be performed with a non -computerized system
client's performance during the testing. or computerized system. The computerized system
If the evaluee is giving full effort, then the rest of the FCE includes report writing software which totally auto
is used to develop a level of restrictions and identify specific mates the entire process. This evaluation takes
activities the client may be restricted from or may need to three to four hours.
avoid . If, however, the test results are invalid and the initial
portion of the FCE represents submaximal effort, a deci
sion must be made. The therapist may choose to complete Key Method
the evaluation to give a minimum amount of activity that
the client can tolerate or may choose to terminate the test The Key Method was developed in 1980 by physical
entirely and report the results to the physician or carrier. In therapist Glenda Key in an attempt to objectively measure
some cases, it is advisable to discuss the findings of the capability of injured workers and their abilities to per
less-than-full effort with the evaluee. This should be done form work. The Key Method of whole-body assessment is a
on a case-by-case basis, assessing the client's psychological standardized, computerized, objective evaluation tool used
strength and ability to handle this type of information. It is for return-to-work decisions and assessment. It can be used
possible that with certain individuals, a change of behavior with any injury, such as "musculoskeletal , neurological ,
will occur, especially when the issue is discussed in a repetitive trauma, and others" (Miller, 1994, personal
nonthreatening way. If a decision has been made to discuss communication). Over 27 functional tests typically can be
the less-than-full effort findings with the injured worker, the used in the 4-hour assessment. These procedures measure
therapist may go about it using language such as "perhaps weight lifting, pushing and pulling, carrying, work day tol
you were distracted and the results indicate less than full erance, sitting, standing, upper extremity function , and
effort. Would you like to attempt some of the tests again 7" walking tolerance, as well as posture consistency and in
It is necessary that the therapist develop rapport with the consistency and four levels of participation. The Key
individual to be tested. It has been reported that decreased Method names four levels of validity: 1) valid (safe); 2) con
fear helps the evaluee to give more consistent responses on ditionally valid (underworking); 3) conditionally invalid
objective testing. (overworking); and 4) invalid (manipulator). The manufac
In summary, the therapist observes, evaluates, docu turer reports that over 600 providers used the Key Method
ments, analyzes , and gives objective findings . If the results in the United States, the United Kingdom, Australia, and
are inconsistent with maximum effort, therapists may Canada and that their computerized system was built on the
instruct and give gUidance to the client in an effort to attain principles of whole-body functioning, return-to-work capa
full effort. bilities, standardized protocols, and functionally based out
The state of the art of MVE is gaining the cooperation comes. A picture of the system is included (Fig. 20-4).
and appropriate responses from the client. The state of the
science is collecting and analyzing the data with the current
research in mind. The state of the " guess" is what the
future research holds for determining MVE.
tABLE 20- 1
.'" "." . ..
488 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
7. Cross-sectional age differences in lift capacity were bolts from the left upright and mount them on the right.
found. If these represent actual age changes and lift The time begins when the examinee picks up the first
capacity, the results of this research suggest that such wrench and ends when the last bolt has been tightened.
changes may be the result of the combined effects of Norms have been established for industrial and educa
distribution of the musculoskeletal and cardiovascular tional groups, male job applicants in a southern plant, male
systems with age. This can be studied through the adults at a vocational gUidance center, airline engine
ELC lift capacity test in a longitudinal or cross mechanics, apprentice welders in a steel company, electric
sequential design. maintenance workers, employees and applicants in a
8. The ELC can be used to evaluate adequacy for job manufacturing company, boys in a vocational high school ,
demands as depicted by the U.S. Department Physi and high school drop-outs in a metropolitan center. Both
cal Demand Characteristics Support System. The the reliability and the validity of the Hand Tool Dexterity
ELC is an inexpensive procedure that does not Test have been established .
require commercial equipment; however, several
companies have been licensed to use the patented
protocol. An example of the EPIC test device is seen Purdue Pegboard
in Figure 20-6.
The Purdue Pegboard measures dexterity for two types
of activity, one involving gross movements of the hands,
Hand Tool Dexterity Test fingers, and arms and the other, primarily fingertip dexter
ity. It was initially designed to help select employees for
The Hand Tool Dexterity Test was constructed to assembly packing and other industrial and assembly jobs.
provide a measure of efficiency using regular mechanics The Purdue Pegboard is used increasingly by rehabilitation
tools , as this type of skill is important in a wide variety of agenoies as an assessment tool and is used frequently in the
jobs. This test attempts to measure manipulative skill FCE and work hardening settings due to the low cost and
independent of intellectual factors. "The essence of the ease of administration and scoring. The Purdue Pegboard
examination procedure is to measure the ability of the was standardized after testing thousands of employ~es in a
examinee to perform manual tasks required" (Bennett, wide variety of industrial jobs. However, it is recommended
1981 , p. 3). This test is ideal as part of a functional that the Purdue Pegboard test be validated locally, as jobs
evaluation due to the ease of administration in scoring, and that have the same titles often differ significantly from
no reading ability is required of the examinee . The score is employer to employer. Test, retest reliabilities for single
the total amount of time it takes to remove 12 nuts and trial scores ranged from 0.60 to 0.76, and according to the
Spearman Brown formula, the three trial scores estimated
range was 0.82 to 0.91 (Tiffin , 1987l.
lates light work and assesses a client's ability to out, strength testing " measures a person 's abilities to exert
balance, stoop, kneel, crouch, reach, handle , finger, forces in functional situations : static (isometric), dynamic
feel, and see. It also assesses whole body range of and psychophysical tests. " Examples of dynamic testing
motion, agility, and stamina through gross body equipment include tools manufactured by Lido, Cybex, and
movements. Biodex, as well as the BTE. Psychophysical tests, as
VCWS-14, Integrated Peer Performance, provides described by Snook and associates (1970) and others,
information relevant to the assessment of a variety provide information about a speCific task, such as lifting.
of capacities, including sitting tolerance, the use This type of testing provides information based on the fact
of arms , ability to pinch , and sensation. Secondary that lifting is a function of more than pure strength. In fact,
characteristics typically revealed by this work this type of testing demonstrates that a person's lifting
sample include various work-related social skills, the ability (or any other ability) is determined by a combination
ability to follow instruction, concentration, motiva of judgment and motivational, perceptual, and physical
tion , communication skills, the ability to cooper abilities. An example of this type of test is the ELC, as
ate with others, and self-confidence. described previously under " Standardized Testing."
• VCWS-19, Dynamic Physical Capacity, is a work
sample designed to simulate the work tasks of a
shipping clerk. The client must read invoices, locate
a shipping carton, remove the carton from a shelf,
Isometric Testing
pack the carton correctly, weigh it, and place it in a
Isometric testing is one form of streng.th testing generally
simulated shipping and receiving area. The work
regarded as safe to administer and reliable. It should not be
sample allows the evaluator to observe the client's
the only method of strength testing during an FCE. The
ability to follow instructions, physical stamina,
therapist would not be able to predict how a hand can use
concentration, motivation, communication skills,
a pair of pliers by just dynamometer testing, as he or she
decision making, frustration control, and self
would not be able to predict how well a plumber could
confidence. The VCWS-201 is a physical capacity
install a commode using an isometric lifting device. In
and mobility screening evaluation, and the sample
general terms, static assessments are very useful. The
is designed speCifically to be a nonmedical screen
National Institute of Occupational Safety and Health
ing of the 17 physical demand factors of The
(NIOSH) recommended in 1981 that strength testing be
Department of Labor (climbing, balanCing, stoop
employed on a preemployment basis. Much research on
ing, kneeling , crouching, crawling, walking, stand
static testing has been done as a component of preemploy
ing , talking , lifting, reaching, handling, fingering,
ment and postoffer screening processes. Static test equip
feeling, pushing, pulling, and seeing) .
ment is typically less expensive than isokinetic or isody
The VALPAR Corporation has a publication entitled
namic equipment.
VALPAR Component Work Samples, uses in allied
As described by Chaffin and others (1972), isometric
health (Christopherson & Hayes, 1992), which thor
strength testing involves exertion of a force in a given
oughly explains each of the work samples. This can be
posture against a fixed resistance. The exertion is mea
obtained by contacting VALPAR International Corpora
sured hydraulically (dynamometer), mechanically (spring
tion, P.O. Box 5767, Tucson, AZ, 85703.
gauge) , or electrically (load cell) and is compared with the
strength requirements of a job. The height of the measuring
device when measuring lifting can be adjusted to simulate
a certain job. The width of the dynamometer can also be
COMPUTERIZED TESTING (ISOMETRIC, adjusted to simulate the width of a tool for gripping to
measure pOSition-specific strength. Recently, these devices
ISOINERTIONAL, AND ISOKINETIC) have been combined with computers to be able to make the
measurements more accurate. An advantage of most of
Static Strength Testing these systems is that a CV is usually computed for the
therapist as well. Consequently, measures of MVE are
Evaluation of strength is usually an extremely important
available, which are very accurate, simultaneous with the
part of the FCE. Assessment OF strength can be very
needed information of static strength . Most static lifting
specific. One can measure a specific muscle or muscle
devices are also easily adjusted to a height to measure the
group (e.g., pinch strength after carpal tunnel release) or
injured worker's pushing and pulling ability.
more general function (e.g., in functional assessment ,
Static strength testing is not without drawbacks. As
lifting from waist to shoulder height). Lifting involves many
Isernhagen (1988, p . 99) points out,
muscle groups and , if functionally related to the job, is
important to evaluate. isometric lijts traditionally test only in one geomet
Assessment of strength can be done utilizing three ric plane oj movement whereas normal human
frameworks of assessment. As Isernhagen (1988) points junction normally cuts across three planes. Second,
changes in posture, joint loading, and muscle 3. Other influences on performance (e.g. , noise
length/tension ratios that accompany functional ac spectators) are to be minimized
tivity ... 4. The worker should be informed of any risk inher
in the testing procedure
On the other hand, Chaffin and coworkers (1972) note that
5 . The worker should be informed of how the data
if the worker is able to isometrically exert a force that is
be used
double the maximum force required on a person's job, then
6. The worker should be advised of his or her gene
he or she is in a lower risk category for developing a back
performance in positive terms but not be giv
injury ("understressed"). If the worker produces a force
specific values to compare with other participa
between the actual force on the job and twice the force on
7 . Workers should not be coerced to perform tests; i
the job, he or she is rated " considerably stressed. " If the
the person tested should be allowed to discontin
worker cannot isometrically exert the amount that the job
participation at any time without malice
requires , he or she is considered " overly stressed. " Work
Strength testing is particularly germane to FCEs. Ma
ers in the overly and considerably stressed category showed
and Gatchel (1988) note that patients with back injur
back injury and severity rates two to three times those in the
who received a comprehensive treatment program in
understressed groups (Chaffin et aI. , 1972). The ISTU (Fig.
interdisciplinary setting (physical or occupational thera
20-9) is a good example of static strength testing equip
psychological counseling , medical treatment, and rehab
ment. This unit is adjustable, and strength can be assessed
tation counseling) achieved an 85 percent success
in the arm, leg or squat, and torso lifting positions . Static
return-to-work rates, whereas the nontreatment gro
pushing and pulling can also be assessed with the ISTU.
achieved a 45 percent successful return-to-work ra
The strength tests are all performed as a sustained
Similar numbers were obtained in a 2-year follow-up stu
voluntary isometric exertion for 5 seconds. The average
Strength training and job-oriented postures were an in
exertion by the worker during the final 3 seconds is
gral part of this program. In their program, Mayer a
registered, as well as the peak value during the 5-second
colleagues (1985) used both isokinetic strength tru
time interval. At least three successive Hfts are performed
with a reasonable rest period (30 seconds) between trial~
testing and isometric lifting capacity evaluations. They n
that following treatment, their patients developed capa
generally being used. Coefficients of variation can then be
ties that surpassed those in the general non- back-inju
utilized to assess MVE on this type of testing. If a specific
population. This statement perhaps points out the bigg
lifting height is known to correlate with the worker's job
advantage of isometric testing ; it ,is well researched , giv
duties, so much the better. To minimize variations due to
excellent validity and reliability data . A picture of the IST
motivational factors of the client, these instructions are
which is available from Ergometrics, is in Figure 20-9. T
recommended by Chaffin and colleagues (1972):
equipment is currently available linked to a compu
1. Instructions to the evaluee are to be objective with no
giving MVE information as well as documenting fo
emotional appeal
curves. Force curves are the amount of force plotted ver
time. Analyzing these force curves is an additional way
assessing MVE.
world. They are used in many types of rehabilitation, values to measure strength. Most of the reasearch has bee
including industrial, orthopedic, cardiac and pulmonary, done with isokinetics, which is discussed here.
and upper extremity. The Work Simulator's uses in the The use of the isokinetic machine for trunk testin
evaluation procedures are also well documented. Studies became very popular in the 1980s as new technolog
have been published describing the Simulator's uses in increased. Many studies have been done, and the equi
consistency of effort testing , standardized upper extremity ment has been shown to be reliable (Friedlander et a
strength testing, and FeEs. The following research has 1991). Normally, specific trunk testing equipment is n
been completed on the BTE: Several studies have tested used in the FeE; however, some valuable information cou
the reliability and validity collected from the system. be gained if it is available. Many argue about whether trun
Reliability coefficients have been recorded from 0.913 to testing equipment realistically measures patient functio
0.998, showing high reliability. Studies by King and (i.e., ability to return to work), which is needed in the Fe
Berryhill (1988) and Matheson (1989) have focused on the report. Mayer and associates (1989) found that isolate
use of the BTE in the assessment of MVE. Studies by trunk extension strength paralleled lifting capacity. On th
Williams (1991) , Schultz-Johnson (1987) , and others have other hand , many practitioners believe that actual dynam
discussed the Work Simulator's application to FeE and lifting is a better assessment for lifting capacity (Blanke
work hardening. Studies by Anderson (1990) and Berlin ship, 1989). Few, if any, practioners use trunk testin
and Vermette (1985) have focused on the development of equipment as a sole testing device to determine functio
normative data for standardized tests performed on the In the sagittal plane, trunk extension musculature co
Work Simulator. In our opinion , this equipment is state of sists primarily of the erector spinae, gluteus maximus, an
the art in regard to upper extremity evaluation and is very hamstrings. Often, the lumbar paraspinals get injured b
useful for validity testing (Fig. 20-10). cause the primary movers (the glutei) get fatigued or th
client was in an awkward position and the secondary mo
ers (the lumbar paraspinals) had to be used instead. Trun
Trunk Testing flexor musculature consists of the rectus abdominis, obliq
externus abdominis, and iliopsoas (Smith et aI., 1985), an
There are several ways of testing strength . Some manu rotation in the axial plane is primarily performed by th
facturers use isometric, isoinertial, and isokinetic torque contralateral abdominal oblique (Mayer et aI., 1985).
Several studies give some general principles that can b
useful in assessing a patient's torque curves. Mayer an
colleagues (1989) found that postoperative patients ha
profound deficits in true lumbar mobility and isolated trun
extension. Lumbar motion was 50 percent to 60 perce
of normals, and trunk strength values were between 5
percent and 60 percent of gender-specific normativ
values (Mayer et aI., 1989). In other studies, patients wi
chronic low back pain had decreased values and showe
greater variability than normals. Patients also showed
more rapid decline in torque values as the velocity i
-= ill
-
-
creased (Mayer et aI. , 1985; Smidt et aI., 1983). Studi
have also revealed that female patients and normals sho
66 to 75 percent of the total trunk strength of male patien
and normals (Mayer, et aI., 1985 ; Smith et al. , 1985
Another study showed that for peak abdominal and bac
extensor strength, the range of superiority of men ov
women was 39 to 57 percent, and the range of superiori
of normals over patients with chronic low back pain was 4
to 82 percent (Smidt et al., 1983). Studies also indicate th
while men have greater trunk strength , women demo
strate endurance equal to or greater than that of me
(Langrana & Lee, 1984; Smidt et aL, 1983). Also, great
discrepancies were found between patients and contro
for women than for men (Mayer et ai., 1985). It was al
found that age and gender tend to change peak torqu
values (Langrana & Lee, 1984; Smith et aJ., 1985).
FIGURE 20-10. BTE, computerized treatment and evaluation device comparing trunk flexors and extensors, some studi
for use in a variety of rehabilitation clinics . Note the excellent adjustabilily. demonstrated that the abdominals were more susceptib
testing device that can measure isometric and isoton
torque , velocity, and range of motion. The unique param
eter of this machine is that it collects this information in
three cardinal planes simultaneously, which gives t
therapist the opportunity to look at muscular substitution
tendencies of the measured plane. For example, if dynam
flexion and extension torque were being measured, on
the data had been entered and stored , a therapist may ent
the other two planes and observe any activity occurring
well (Geril , 1994, personal communication). Extensi
research by many different researchers also has been do
using this machine , and it has been the subject of ma
reliability and validity studies. These studies have show
good values for reproducibility for normal subjects f
isometric torque and dynamic performance paramete
(Gomez et al., 1991); however, the B200 showed po
FIGURE 20-11. 8200 is a lumbar testing device that can measure reproductivity for range of motion measurements (Dilla
isometric and isotonic , torque, velocity, and range of motion . et al. , 1991), which the company recognizes as well.
MedX (Fig . 20-12) manufactures another machine th
can measure trunk extension. This was invented by Arth
to fatigue than back extensors in patients and normals Jones , who developed the Nautilus fitness equipmen
(Langrana & Lee, 1984; Smidt et aI., 1983) and that in Much research has been done using this machine in sever
patients with low back pain, the most substantial strength areas of the United States, and dramatic increases
deficit was in trunk extensors (Mayer et al., 1985). lumbar paras pinal strength have been recorded aft
Patient positioning is one of many lactors that can cause rehabilitation (Jones, 1993). The MedX machine isolat
discrepancies in trunk torque (strength). One study found the lumbar paraspinals by anchoring the pelvis ve
that the iliopsoas doubled flexor strength when the patient carefully. This decreases the effect of the glutei. Testing o
was tested in standing (langrana & Lee, 1984). Also, if the the MedX is that of maximal isometric effort through
pelvis is not stabilized adequately, lumbar paraspinal series of seven points throughout the lumbar range
strength cannot be differentiated from the glutei, which are motion , which researchers say is approximately 72 d
functionally much stronger muscles. grees . A free booklet can be obtained from the Med
Variability in force output can be secondary to submaxi Corporation (Jones , 1993), which gives ample inform
mal effort, which is also a factor in the substantial strength tion regarding rehabilitation and testing procedures .
deficits found (Mayer et aI., 1985). This lowered effort can The Lido Back (Fig . 20-13) attachment is a goo
have two main causes: 1) fear of injury intensified by example of what several manufacturers are doing to ma
psychological factors and 2) conscious effort to mislead back testing available to clinics who already own
(Mayer et aI., 1985). One of the uses of a trunk testing isokinetic device for extremity testing. This makes an eas
machine during an FCE is visual observation of torque affordable answer for the clinic; however, pelvic stabiliz
curves. Many manufacturers support that inconsi6tency of tion might be difficult compared with that using a machi
the shape and quality of curves with several trials can show that measures only low back musculature.
an uncooperative subject (Jones et al., 1988). However,
Hazard and associates (1988) demonstrated that intercurve
variability can distinguish maximal from submaximal isoki
netic effort only 70 to 90 percent of the time in normal
subjects. This artide stated that visual technique is subjec
tive and that inexperienced subjects could produce consis
tent curves inadvertently while exerting submaximal effort.
Although some argue about the accuracy of these data,
they still can be useful when used in combination with other
results of MVE testing.
Many trunk testing machines are on the market. In this
section, only three are reviewed , but manufacturers are
FIGURE 20-12. MedX, Primarily inte nded for clinical research . T
more than happy to give a prospective buyer ample version of the lumbar extension machine provides both testing a
information as well as research articles. Most of the exercises when rotated into the lateral position.
' ':'' . .
494 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
...-= -- ~ • .
498 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
'II\BLE 20 2
Lifting: Raising or lowering an object from one level to another (in Floor to waist (Fig . 20-14) Lift from bottle handles, deep squat to
cluded upward pulling) standing
12 in to waist: (Fig. 20-15) This lift places stress primarily on the low
back muscles; lift from 12 in handles to standing
Waist to shoulder: (Fig. 20-16) Patient lifts from 12 in handles at
waist height and laterally moves so that hands go to a level at
shoulder height
Shoulder to overhead: (Fig. 20-17) Hands grasp box in a pronated
position at shoulder level and patient lifts box 8 to 10 in overhead
while side-stepping
Carrying: Transporting an object, usually holding it in the hands or At waist height, carrying should be performed with a 14 in box for
arms or on the shoulder (Fig . 20-18) any distance (15 ft); weights are added until the test is terminated
Pusbing: Exerting force on an object so that the object moves away Pushing any type of "sled" for a distance (e.g., 25 ft) with the handle
from the force (including jerking) (Fig. 20-19) approximately 36 in from the floor (this will make comparison with
Snook's data easier), which should be measured with a dynamom
eter; the torso should be straight or in slight kyphosis; add apprOXi
mately 25 Ib of weight with each repetition, which increases push
ing force approximately 10 Ib (Blankenship, 1989)
PulDng: Exerting force on an object so that the object moves to Pull with any type of sled for 7 to 10ft using a dynamometer to mea
ward the force (including jerking) (Rg. 20-20) sure force; for longer distance, workers tend to push instead of pull
Climbing: Ascending or descending ladders, stairs, scaffolding, Normally, this is tested using stairs or ladder, depending on the job
ramps, poles, and the like, using the feet and legs or hands and description of the worker; evaluator can use stairs, a single step,
arms (not pictured) stairmaster, ladder, or versiclimber
Five flights of stairs up and down at a steady pace gives an "occa
sional" Dictionary of Occupational Titles rating (Blankenship,
1989)
Bending or stooping: Bending the body downward and forward Evaluator may want to choose either static or repetitive bending, de
by bending the spine at the waist pending on the patient's job
Kneeling: Bending the legs at the knees to come to rest on the Patient places one or both knees on the floor for approximately
knee or knees 2 min
Crouching or squatting: Bending the body downward and for Patient may squat wth both feet flat or on metatarsal head, or he or
ward by bending the legs and spine she may sit on one heel with the other foot flat ; occasional fre
quency is documented when the patient can hold this position for
2 min; patient can perform functional activities while in this posi
tion if evaluator desires
Crawling: Moving about on the hands and knees or hands and feet Patient crawls nonstop for a distance or may stay confined to a small
area and perform dexterity or assembling tasks
Reaching: Extending the hands and arms in any direction Can be divided into overhead and forward reaching and also static
and repetition; the patient can work statistically for 5 minutes or
perform 25 repetitive reaches; the patient can be performing a
functional activity or any kind of activity
Handling: Seizing, holding, grasping, turning, or otherwise Handling can be assessed best by using standardized testing such as
working with the fingers primarily (rather than with the whole the Minnesota Rate of Manipulation, VALPAR Simulated Assem
hand or arms, as in handling) bly, or others
Feeling: Perceiving such attributes of objects and materials as size, Rngering can be assessed by using standardized tests such as the
shape, temperature, or texture by means of receptors in the skin , Craford Small Parts Test, Purdue Pegboard Test, Jebsen Taylor
particularly those of the fingertips Hand Function Test, or others (in part from Blankenshp, 1989)
Talking: Expressing or exchanging ideas by means of the spoken Talking, hearing, or seeing, although necessary components for most
word jobs, are usually not formally addressed during an FCE; the loss of
Hearing: Perceiving the nature of sounds by the ear these functions may be described in functional terms and noted in
Seeing: Obtaining impressions through the eyes of the shape, size, their impact on ability; however, formal assessment of talking, see
distance, motion, color, or other characteristics of objects; the ma ing, and hearing is best assessed by other professionals
jor visual functions are 1) aCUity-far and near, 2) depth percep
tion, 3) field of vision, 4) accommodation, and 5) color vision; the
functions are defined as follows:
1. Acuity, far-clarity of vision at 20 ft or more
FIGURE 20-15. Lifting from 12 inches off the floor to waist height;
note the neutral pelvis. FIGURE 20-17. Lifting to overhead.
SOD UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
SUMMARY
This chapter has provided an in-depth review of work
assessment related to the industrially injured population.
This population can be difficult to eva1luate and treat for
numerous psychological, social, vocational, and physical
reasons. The therapist responsible for treatment and
assessment of the injured worker must be aware of all of
these factors to provide appropriate intervention.
The new graduate and the experienced therapist alike
should have special training in performing FeEs because
of the legal implications with this type of assessment. The
therapist who takes on this responsibility must be pre
pared to give depositions and to provide expert testimony
in court.
Study of Mr. C.
supervisor as well as a reported feeling that he could not go The client had an 11th grade education and reportedly
back to work for that company. Mr. C. was currently was working on his General Education Degree. His past job
married to his second wife, who had also previously been experience included working for a landscaping firm as both
injured on her job, with subsequent litigation. The client a laborer and a maintenance superintendent and also route
reported that his father and brother-in-law had also sus driving for another wholesale company. The client re
tained totally disabling work injuries. Mr. C. had five ported that someone else had been hired to take his place
children, three with his present wife and two from the at his job, and that light-duty jobs were not available. He felt
previous marriage, who did not live with him. Mr. C. did pay as though he had been terminated from his position and he
child support for the two children who did not live with him. wanted to consider retraining if he could be trained for a job
He reported having lost two cars owing to financial with a good salary. The client also reported that he could
difficulties since the injury. He stated that a typical day for not imagine who would hire someone with a back injury
him included watching television and sometimes babysit such as his.
ting. He stated that around the house he occasionally did After intervention of work hardening, Mr. C. successfully
dishes and laundry and that since his accident, he was returned to work with his same employer doing the same
unable to participate in the hobbies of danCing, horseback job. This is a clear-cut case of the physician, injured worker,
riding, and sports. He did state that he was able to coach a insurance adjustor, and work hardening teams all interact
children's football team; however, he did that with his ing to ensure a successful outcome.
physician's permission.
ENDIX B
~ A) Sit
B) Stand
(1) 2 3
1 (2) 3
4
4
5
5
6
6
7
7
8 (hrs)
8 (hrs)
-~~ C) Walk
D) Drive, per client report
TOTAL DURING ENTIRE 8 HOUR DAY
A) Sit
B) Stand
1 2
1 2
1 (2) 3
(1) 2 3
3
3
4
4
5
5
4 (5) 6
456
6
6
7
7
8 (hrs)
8 (hrs)
7 8 (hrs)
7 (8l (hrs)
.- \0
:I:I~
waist level lift: 50 lbs_
O~
B) 11-20 lbs. (Light) [ I [ I [ I [ I
C) 21-50 lbs. (Medium) [ I lXl30 lb. [Xl [ I
~~
...
ill
D) 51-100 lbs.
E) 101+ lbs.
(Heavy) [ I
(Very Heavy) [ I
[ I
[ I
[ I
[ ]
[
(
I
~r...
E) 101+ Ibs. (Very Heavy) [ I [ I [ I [I
.... ill '"
(I.)
ill
IX =
....
4. Client can use hands for repetitive action such as:
-.........
13 ~
~ A) Right
B) Left
SIMPLE GRASPING PUSHING & PULLING OF ARM CONTROLS
[X] Yes [ I No
[X J Yes [ I No
~ ] Yes
f< I Yes
[] No
[I No
FINE MA"ffi>lJl.ATION
[X] Yes [ ] No
[X] Yes [ I No
(I.) :1:1
~O 5. Client is able to: Continuously Frequently Occasionally Never
[ ] [X] [ I [ ]
Q..*
... A) Stoop/Bend
B) Squat [ ] [X] [I [ I
~
2
.-
C) Crawl
D) Climb
[ J
[I
[ I
[xl
[XI
[ I
[ I
[ ]
E) Reach [ I [xl [ ] [ ]
...
..c: F) Push [ I [I [yJ [ I
~ G) Pull [ ] [ I [xl ( ]
~
B) Being around moving machinery [x] [ ] [ J [ ] [ ]
C) Exposure to dust, fumes, gases [ ] [ ] [ ] [ I [X]
D) Changes in temperature, humidity [ ] [ I [ I [ ] [X]
7. Comments:
Physician's Recommendation
9. Client can work now:
10. Physician's Signature
Yes _No Part Time (Hrs/Days) _ _ _ Full Time _ _ RTW
The following is a summary of the objective findings of the Interdisciplinary Functional Capacity Evaluation. Th
evaluators were Bruce A. Mueller, OTR/L, C.H.T., and Ellen Adams, M.A., c.R.C., C.C.M.
Validity: The client demonstrated consistent and maximal effort throughout the functional capacity evaluation, a
evidenced by passing 88% of the validity criteria assessed (36 of 41).
Interdisciplinary Team Recommendations: The following recommendations have been made by the team:
1. Release this client to full duty with guidelines as listed on the enclosed Work Capacity Checklist.
Referral Questions
No specific questions were posed by the referral source. Questions identified by the Interdisciplinary Team include
1. Can the cUent return to his same job? Yes. The client demonstrates the appropriate physical abilities to compl
with the physical demands of his previous job functions with Moo-Cow Farms as a delivery route driver.
2. At what physical demand level can the cUeat be released? Medium. Medium work is defined by the u.s
Department of Labor Guidelines as lifting 50 pounds maximum with frequent lifting andlor carrying of objects weighin
up to 25 pounds. His occasional carry is 40 pounds with two hands and 35 pounds with either hand. He can lift 5
pounds occasionally from the floor to waist height. He can frequently lift 30 pounds from floor to waist level.
3. Is the cUent Hkely to benefit from further services? No.
Vocational/Psychosocial Summary
Mr. R. reports that he is employed by Moo-Cow Farms and has been since August 10, 1992. He was involved in
work-related motor vehicle accident on February 14, 1994. The client reports he continues to work for Moo-Cow Farms
and at this time he is working as a trainer for milk delivery people. At the time he was injured, he was a milk delivery person
The client reports that he works from 3:30 am to 5:00 or 6:00 pm approximately 60 to 70 hours per week 5 days a week
He reports that prior to his injury he worked on commission, but now he receives an hourly rate. The client reports tha
prior to his injury, he grossed approximately $600 per week; now he is grossing $400 per week. The client does not hav
an attorney, and he does not have a rehabilitation counselor or nurse working with him.
Mr. R. states that to perform his job, he must drive a truck and deliver milk and butter to schools, hospitals, nursin
3601 S.w. 2ND AVENUE, SUITE S GAINESVILLE, FLORIDA 32607-2802 • PHONE (904) 336-6830 FAX (904) 336-6910
506 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
homes, and restaurants. He reports using a milk hook, a hand truck, a computer, and a work truck. He reports lifting and
carrying 40 pounds in one hand and 80 pounds in both hands and pushing and pulling over 240 pounds. He also reports
having to stoop, bend, squat, kneel, crawl, climb ladders, climb stairs, twist, walk on uneven ground, reach above shoulder
height, reach at shoulder height, and reach below shoulder height to perform his job duties. The client reported that the
most difficult part of his job was dealing with mad customers. He states that he did get along well with his coworkers and
his bosses, and he continues to do so.
The client is 23 years old, he has a 12th grade education, and he has special training as a certified machinist and has
a class A commercial driver's license. He has a past work history that includes being a dock supetVisor for a transportation
company, where he drove a fork lift, supetVised three other employees, and dispatched drivers for the trucking company.
He also has a past history working in construction making custom cabinets. Mr. R. is married. He reports that his wife is
a full-time student in a respiratory therapy program. He reports that at this time his living situation is such that he and his
wife are able to meet their expenses. He reports that for the last year, since his marriage, he has lived on some property
that belongs to his grandfather. He reports having to maintain the property and having to pay utility bills to live there. The
client reports that he does have a current driver's license and dependable transportation. He reports he was ticketed for
the accident and that he went to driving school to have the points removed from his license.
The client was asked what he does for fun, and he reported that he does not have much time to do fun activities because
he works so much. He stated that his hobbies and interests were old cars and boating. He reports spending his days off
working or fixing things that break down. He reports that around the house he does most everything including cooking,
cleaning, and vacuuming; however, he reports some diminished activity.
The client reports that he is being told by his employer that as soon as he is physically able to return to driving the truck,
he will be allowed to do that. The client, however, stated he is fearful of returning to driving a truck for fear he will have
a muscle spasm that could cause him to have another accident. He reports that his position as a trainer is secure at this
time, and that there is no pressure for him to return to driving.
Medical History: A thorough review of records provided from the treating physicians was performed by the
interdisciplinary team.
Client's Diagnosis: Thoracic/lumbar strain.
Surgeries: None.
Pain Behaviors: The client does not appear to present with inappropriate illness behaviors. This is reinforced with his
low scores on Waddell Signs of +2/5, a low score on appropriate pain inventories. He also does not improve his range
of motion or performance via distraction throughout the evaluation.
Pain drawing and pain rating were performed both pre- and posttesting. Prior to the testing, the client rated his
pain as a 3.5 on a 0 to 10 scale. After the testing, the client rated his pain as a 4.5. His area of discomfort did not change,
nor did indicated pain levels increase in intensity. These areas are the low thoracic and upper lumbar spine.
Musculoskeletal Evaluation
Trunk ROM: Forward bending 85°
Extension 12°
Right side bend 27°
Left side bend 30°
Motor, Sensory, and DTRs: Intact, brisk, and symmetric.
Flexibility: He is within normal limits in hamstring length; however, his hip flexors are mildly restricted, eliciting some back
pain. His right piriformis complex is restricted at approximately 30° IR at the hip. The left is within normal limits.
SLR: He exhibits a 90° SLR in sitting bilaterally. He demonstrates a 45° SLR left and a 67° SLR right in the supine position.
Special Tests: He has a decreased left pelvic shear with some pain elicited. He also presents with an apparent posterior
rotation of the right ilium causing him some discomfort with flexion of the right hip.
Tests Administered
1. Grip Strength: Grip strength was tested using a Jamar dynamometer and measured in pounds. Rve level grips were
taken to observe for a bell-shaped curve, suggestive of full effort. Coefficients of variation were calculated on these
measurements. A CV less than 15% is indicative of full effort. Mathiowetz norms for this client's age and gender were
recorded.
Coefficient of variation results were below 15% on 9 of 10 calculated.
2. Computerized Testing, Isometric Strength Test Unit: The ISTU is designed to quantify a person's ability to lift, pus
or pull in various postures. This procedure has been recommended by NIOSH. The client was asked to repeat ea
position for three or more attempts to produce data for calculation of CV.The CV is less than 10% in a valid tes
Arm lift: Average of 48.1 pounds
Coefficient of variation 10.0%
High/near Uft: Average of 75.2 pounds
Coefficient of variation 14.2%
High/far lift: Average of 64.7 pounds
Coefficient of variation 3.24%
Pull task: Average of 90.8 pounds
Coefficient of variation 6.31%
Leg lift: Average of 97.7 pounds
Coefficient of variation 13.5%
Comments: His values for dynamic lifting as extrapolated from static strength testing are as follows:
Shoulder lift: Expected 40 pounds, 30 pounds for validity .
Front carry: Expected 42.3 pounds, 31.7 pounds for validity
Leg lift: Expected 54.0 pounds, 32.4 pounds for validity
Pull task: Expected 68.0 pounds, 51.5 pounds for validity
Overhead lift: Expected 46.3 pounds, 43.7 pounds for validity
3. Computerized Testing, Baltimore Therapeutic EqUipment: The BTE Work Simulator is designed to simulate upp
extremity motions required during performance of job tasks. Tool attachments were selected to simulate motio
appropriate to the client's functional use. A coefficient of variation less than 15% is indicative of full effort.
The right is 0.8% of the left on tool #162. Coefficient of variation, right, 3.1%; left, 4.8%.
The client was evaluated using the BTE to assess isometric strength. The following BTE attachments were used
test supination and pronation and pushing and pulling ability: 302,504. Coefficient of variation results were belo
15% on eight of eight calculated.
4. Purdue Pegboard Test: This test measures the dexterity needed for potential employees to perform jobs such
assembly work, packing, or machine operation. Tip pinch dexterity and the ability to reach when seated at a tab
height were assessed. The client completed three 1-minute trials following the Purdue Pegboard Assembly protoco
He completed an average of 36 assemblies. This places him in the high-speed trainable or good category for fi
motor and assembly tasks using the hands.
5. Repetitive Squats: The client completed 20 full nonsupported squats.
6. Dynamic One-Repetition Activities: This test indicates the maximum weight an individual can handle one to fo
times in 8 hours. Results;
Roor to waist level lift: 50 pound occasional maximum accepted with a 30 pound frequent lift demonstrate
exertion factor -3
Waist level to shoulder lift: 30 pound occasional maximum accepted
Waist level to overhead level lift: 25 pound occasional maximum accepted with a 20 pound frequent l
demonstrated; exertion factor -1
Comments: His exertion factors of -3 and -1 are indicative of good correlation in his perception of effort as compar
with increase of his heart rate measured on the Borg rating of perceived exertion scale.
7. Push/pull: The client was asked to push and pull a nonwheeled sled over carpet 150 feet each direction. H
demonstrated the ability to push with 47.5 pounds force and pull with 50.0 pounds force. This translates into
moderate task for pushing and pulling.
8. Prolonged Sitting: 30 to 45 minutes per client report.
9. Prolonged Standing: 2 hours observed.
10. One-Handed Carry: The client was asked to carry the maximum amount of weight tolerable in the right hand for
distance of 150 feet. The client Was then asked to repeat this test with the left hand. Right hand: 35 pounds. Left han
35 pounds.
508 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
11. Two-Handed Carry: The client was asked to carry the maximum tolerable weight in both hands for a total distance
of 150 feet. Forty pounds were tolerated.
12. Repetitive Reach: This reach was performed at a waist level with unweighted upper extremities. The client was
requested to continue with this bilateral repetitive reaching activity for 8 minutes. Overhead reaching was completed
for 8 minutes with 192 repetitions.
13. Sustained Reach: This reach was performed at a waist level, shoulder level, or overhead level with unweighted upper
extremities. The client was asked to complete an 8-minute test time. Overhead level reaching for 8 minutes was
completed.
14. Crawling: The client was asked to complete a I-minute trial of crawling on the mat. He was able to do this, and this
places him in the occasional category for crawling.
15. Kneeling: The client was asked to kneel and then stand upright on carpet for one repetition. The client was able to
do this.
16. Stair Climbing; The client was asked to complete five flights of 11 steps, both ascending and descending. He
completed the task in 1 minute and 18 seconds, with a pretest heart rate of 82, posttest of 123, and a recovery rate
of 96. He completed a total of 110 steps, placing him in the frequent category for stair or ladder negotiation.
17. Balance: The client was asked to walk the 5.5-inch balance beam over a I-minute trial. He used an ankle with an
occasional hip strategy throughout the test. This would give him some minimal to moderate restrictions for working
in unprotected heights.
Tests Deferred by the Evaluator: None.
Thank you for allowing us to assist in the care of this client. Ellen Adams, M.A., C.R.c., C.C.M., completed the
Vocational PsychOSOCial Summary and coauthored the referral questions and recommendations. If we can be of any further
assistance, please feel free to call us at (904) 336-6830. Any further written reports can be forwarded on request.
Sincerely,
Capacity Evaluation
Included are two comments on the usefulness of FeE, opinion based in this manner provided no real functiona
one by a physician and the other from an attorney who value to the claimant, except to meet statutory and
usually represents the insurance company in workers' administrative requirements. With the evolution of physica
compensation litigation. or functional capacity testing of injured workers, the
Work assessment, as indicated earlier, is best done in an problems oflack of objectivity in determining "restrictions"
interdisciplinary team approach. Many professionals utilize at a first glance would have appeared to have been
functional capacity evaluations within the scope of their resolved. Unfortunately, new problems with use and
participation not only of treating but also of evaluating the misuse of information obtained in this manner became
patient. evident. To understand this new problem, let us look back
at the concept of "restriction." A restriction on the activity
of the patient was supposed to be set by the physician based
on the medical findings, diagnosis, and prognosis. As
PHYSICIAN STATEMENT discussed previously, this determination has been histori
cally inconsistent, unSCientific, arbitrary, and not truly
The confusion in medical, legal, employer, and admin objective. In most cases, restrictions were set only because
istrative circles regarding the difference between disability of administrative requirements to establish that a "disabil
and impairment is well known to those who work in the ity" existed so that a claim of injury could be adjudicated
occupational medicine community. Now, add to this the With the advent of functional capacity testing, in mos
additional confusion created by the use of information instances we can generate objective, SCientific data and
gained by functional capacity testing of claimants. truly measure the really important question of "what can
Historically, physicians have been required by adminis the patient do, what can the patient not do" after being
trative bodies to provide an opinion based on the medical permanently injured. But was the information obtained by
findings and diagnosis of what the patient was "restricted" functional capacity testing really providing the physician
from dOing, primarily for the occupational setting but also with a tool to set "restrictions'" based on the effects of the
for general physical activities. This opinion has traditionally occupational injury? The answer to this question is at the
been prOvided at the judgment of the physician based on heart of the problem. The functional capacity test evaluates
the training and experience of the physician. Such a system the physical capacity of the whole person. The physica
has been fraught with a lack of objectivity. capacity of the whole person is affected by many variables
An opinion regarding restriction of physical activity only one of which is the occupational injury in question. In
obtained in this manner from a physician (scientist) was in addition, the general health, congenital conditions, prio
most cases, however, not really based on any scientific injuries, physical build, motivation, and, probably, age and
prinCiples, not obtained in an objective manner, and not sex all contribute to some extent to the performance of the
supported by any valid medical evidence. In reality, an patient on functional capacity testing.
509
510 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
Functional testing in reality determines the ability of the more difficult in establishing restrictions on a claimant's
claimant to perform on standardized tests and equipment, activities. Again, the phYSician must rely on judgment and
then extrapolates this information to provide a summary or experience in setting appropriate restrictions for the
estimate of the patient's general physical capacity. If valid, diagnosis, which is in this case not only physical but also
testing determines the limits of the claimant's physical crosses into the realm of psychological.
performance, at least on the day of the testing. It thus can -OREGON K. HUNTER, MD, BoARD CERTIFIED PHYSIATRIST
provide us [physicians] with the limits of the abilities or
performance of the claimant. However, the concept of
limits or limitations of ability determined by functional
capacity testing is not the same as the concept of restric ATTORNEY STATEMENT
tions on activities that are set by physicians. If the role of the
occupational physician is to set restrictions based solely on From the workers' compensation defense prospective,
an industrial injury or condition, use of functional capacity FCEs and work hardening programs are, in my opinion,
testing to set such restriction is truly not appropriate. The separate. The FCE is critical to the determination of
FCE is providing us with information that is not exactly whether a claimant is able to return to some type of
congruent with the concept of restrictions. If functional physical activity that might be combined with a job
capacity testing is providing us with the physical ability or description to indicate to the judge of compensation claims
limitations of a claimant's abilities, then why are these data that the claimant is not completely disabled and retains
used to determine what restrictions should be placed on a some wage earning capacity. It is also very important in the
claimant? Practically, this method, despite its limits, is FCE that accurate notes be kept to determine at a later
probably giving us the closest objective approximation that date, in either deposition testimony or trial testimony,
we can get at this stage of the evolution of functional testing whether it appeared that the client was putting forth a full
because there is currently no other reliable method for effort during the functional evaluation. I have seen many
determining restrictions on function objectively. cases in which there will be notations that the claimant
The compensation system demands of the medical appear to have inconsistent results or even incomprehen
provider a statement or opinion of the effect of an injury sible results from a FCE. These types of notations are very
on function. The provider [physician] has a duty to set helpful to the judge in determining whether the claimant is
restrictions that fit the diagnosis but must use the best or is not able to return to work.
means available for making this determination. Currently, The work hardening program is very important in a
the FCE is the only objective method available to deter different way. Once it appears from a FCE that there may
mine function of the claimant. This type of testing is not be a position in the work environment that the claimant
cheap, however, and cost-containment strategies may may successfully complete, the work hardening program
prohibit the use of FCEs to only the more complex and seems to help him or her get back into the flow of activity.
difficult cases. Many of these claimants have been sitting around for a
When an FCE is performed, validity criteria need to be significant period of time, and just the physical and mental
considered to assess the patient's motivation to provide deconditioning make it difficult for them to return to more
best performance during the testing process. If validity than a full schedule. Work hardening helps the claimant get
criteria are not met yet there is evidence of injury and over this hump and return to the work place. Again,
organic disease, the physician must then rely on judgment notations in the file concerning efforts are very important
and experience in establishing appropriate restrictions for to help the judge determine whether the claimant was in
the nature of the injury and physical condition of the fact seeking to participate willingly or not.
patient. If a concomitant somatization disorder 105M III -JAMES H. McCARTY, JR., ESQUIRE, DEFENSE ATTORNEY
diagnosis] has an effect on function, the use of FCE is even [ATTORNEY FOR THE INSURED]
ENDIX 0
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WELCOME
In order to get to know more about you, we would like you to answer these questions. This information will be very helpfu
to us through all phases of your treatment/evaluation. Thank you for your cooperation.
Date
NAME: ________________________________________________________________
WHAT DOCTOR(S) ARE CURRENTLY TREATING YOU FOR YOUR INJURY? _____________________
DATEOFACCIDENT~NJURY: _________________________________________________
LAST DATE YOU WORKED ANYWHERE: _________________________________________
WHATIS~ASYOURJOBTITLE:---------------------------------------------
WHO IS~AS YOUR WORK SUPERVISOR: _________________________________________
WHAT ARE~ERE YOUR WORK HOURS: _________________________________________
HOW MANY HOURS PER WEEK DOIDID YOU WORK: _________________________________
ANNUAL/HOURLY SALARY WHILE WORKING: _____________________________________
PRESENT SALARY FROM WORKERS' COMP: ________________________________________
601 S.w. 2ND AVENUE, SUITE S GAINESVILLE, FLORIDA 32607-2802 • PHONE (904) 336-6830 FAX (904) 336-6910
NAME: _____________________________________________________________
WHEN DID YOU RETAIN THIS ATTORNEY? _________________________
NAME: ___________________________________________________________
PLEASE DESCRIBE YOUR JOB AS IF YOU WERE TElliNG SOMEONE WHO KNEW NOTHING ABOUT TH
WORK YOU DO:
PLEASE UST THE TYPE OF MACHINES, TOOLS, AND EQUIPMENT YOU USEIUSED:
WHILE WORKING, HOW MUCH WEIGHT DO YOU THINK YOU HAD TO UFT/CARRY?
DOIDID YOUR COWORKERS AND BOSS GET ALONG WITH YOU? (EXPLAIN)
WHAT DO YOU THINK NEEDS TO HAPPEN FOR YOU TO BE ABLE TO RETURN TO WORK?
PLEASE LIST ANY OTHER JOBS YOU HAVE HELD IN THE PAST:
YEAR _ _ __ JOBTITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
YEAR: _ _ __ JOBTITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
YEAR _ _ __ JOBTITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
YEAR _ _ __ JOBTITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
HAVE YOU SERVED IN THE MILITARY? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
BRANCH: RANK AT DISCHARGE: _ _ _ __
ARE YOU CURRENTLY MARRIED: Yes _ _ No; DIVORCED: _ _ Yes _ _ No;
SINGLE: _ _Yes _ _ No; WIDOWED: _ _ Yes _ _ No; LIVE-IN RELATIONSHIP: Yes _ _ No
AGES: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
TIME? _ _ Yes _ _ No
Aerobic: Endurance: A lO-minute treadmill walk to patient tolerance beginning at 1.0 mph and increasing every
30 seconds up to 3.5 mph. No grade change. Record time (minutes) and mph.
Dynamic: Ac:tlvlties: Check appropriate category-occasionally means @ 2-5 hrs./day, no restrictions means
RepetitIve Bendlng: 2 min; PP 1 min; PP 1-2 min; UMP <1 min; UMP
(slight knee bend, 10" from chair;
return to start position)
Static: Kneeing: 2mln; PP 1 min; PP 1-2 min; UMP <1 min; UMP
(choice of kneeling position)
Dynamic: Squatting: 2min; PP 1 min; PP 1-2 min; UMP <1 min; UMP
(5 sec. squat, 10 sec. stand)
Carrying: 50 ft.; 50# max. 50 ft.; 30# 50ft.; 20# 25 ft.; 10#
(13# box plus weights)
Overhead Reaching: L & Rfull FL 1/2 full FL shld, level <shldr. level
(2# wt., elbow extension,
alternate UE)
Climbing: 3 min; 15 flts. 2 min; 10 flts. 1 min; 5 flts. <1 min; <5 flts.
PP = proper posture UMP = unable to maintain proper posture
(WEST)
(MIDTOWN)
620 NW 16th AVE, GAINESVILLE, FL 32601, PH (904) 375-6559
516
Observations:
Body Mechanics: Good Fair Poor
(provide instructions during PM)
Recommend Work Category: Dictionary of Occupational Titles, Vol II, U.S. Department of Labor,
pp. 654--655, 1965.
Sedentary Work: 10 lbs. or less maximum and occasional lifting of objects 5 lbs. or less; minimal
walking required.
UghtWork: 20 lbs. maximum, with frequent lifting of 10 lbs. or less; some sitting and
standing, pushing and pulling.
Heavy Work: Lifting 100 lbs. max. with frequent lifting of objects to 50 lbs.
Very Heavy Work: Lifting objects more than 100 lbs., frequent lifting of objects 50 lbs. or more.
Physidan Signature: _ _ _ _ _ _ _ __
Date: _ _ __
standard deviation and the mean in terms of a percentage; Ergonomics-The branch of science and technolo
it has no units of measurement. A high percentage would that includes what is known and theorized about hum
indicate considerable variability. behavioral and biologic characteristics that can be vali
DisabiHty--An alteration, expressed in nonmedical applied to the specification, design, evaluation, operatio
terms, of an individual's capability to meet personal, social, and maintenance of products and systems to enhance sa
or occupational demands or to meet statutory or regulatory effective, and satisfying use by individuals, groups, a
requirements. The gap between what the individual is organizations.
required to do and what he or she is able to do. Functional capacity evaluation (FCE)-The obj
Electromyography-The recording and study of the tive determination of the claimant's ability to participate
intrinsic electric properties of skeletal muscle by means of activities within the work setting that require bendin
518 UNIT FIVE-ASSESSMENT OF ACTIVITIES OF DAILY LIVING
held constant.
oriented, and individualized program that provides transi
tion between acute care and return to work, while address
Isokinetic-The velocity is constant, while the force
ing the issues of productivity, safety, physical tolerance,
exerted is allowed to vary.
and work behavior. Services should be delivered in specific
Isometric-The velocity is zero. Exercises consisting of
areas of expertise by registered, certified, licensed, or
voluntary muscle contractions, with no joint motion being
degreed personnel or should be performed substantially in
elicited.
their presence and should be provided on a regular
Kyphosis-A convex backward curvature of the spine.
continuing basis. Work hardening programs use real or
simulated work activities in a relevant work environment.
Lordosis-Hollow back; anteroposterior curvature of the
spine.
Work sample evaluation-Sample of actual job tasks
or a mock-up of actual tasks to determine the client's job
Prevocational evaluation-Evaluation of activities of
activity or evaluation.
REFERE~ICES
Psychophysical tests-A psychophysical test is a test
Smith, S. S., Mayer, T. G., Gatchel, R. J., & Becker, T. J. (1985). Velozo, C. A. (1993). Work evaluations: Critique of the state of the art of
Quantification of lumbar function. Part 1: Isometric and multispeed functional assessment of work. American Journal of Occupational
isokinetic trunk strength measures in sagittal and axial planes in normal Therapy, 47(3), 203-209.
subjects. Spine, 10,912. Waddell, G., Main, C., Morris, E., DiPaola, M., & Gray, L. (1984).
Snook, S. H., Irvine, C. H., & Bass, S. F. (1970) Maximum weights and Chronic low back pain, psychologic distress, and illness behavior.
workloads acceptable to male industrial workers. American Industrial Spine, 9(2), 209-213.
Hygiene ASSOCiation Journal, 31, 579-586. Waddell, G., McCulloch, J. A., Kummel, E., & Venner, R. M. (1980).
Stokes, H. M. (1983). The seriously uninjured hand: Weakness of grip. Nonorganic physical signs in low-back pain. Spine, 5(2), 117-125.
Journal of Occupational Medicine, 25, 638-684. Waddell, G., Pilowsky, I., & Bond, M., (1989). Clinical assessment of and
Tiffin, J. (1987). Purdue pegboard examiners manual. Serence R~ interpretation of abnormal illness behavior in low back pain. Pain, 39,
search Associates: USA. 41-53.
Uden, A., Astrom M., & Bergenuddtt, H. (1988). Pain drawings in Wegg, L. S. (1960). The essentials of work evaluation. American Journal
chronic back pain. Spine, 13(4), 389-392. of Occupational Therapy, 14, 65-69.
U.S. Department of Labor. (1972). Handbook for Analyzing Jobs. Williarns, K. (1991). Functional capacity evaluation of the upper extrem
Superintendent of Documents, US Government Printing Office, Wash ity. Work, 1(3),48-64.
ington, D.C. 20402.
essment Summary
In the health care arena of the late 1990s and early 21st 12. Furthermore, since initial assessment time may
century, rehabilitation has a major role since the emphasis limited, therapists are increasingly needing to mesh
of health care is increasingly on functional improvement, component assessments Simultaneously with the treatm
the ultimate goal of rehabilitation. Appropriate assessment process. The thorough understanding of component
is a major key to efficient and effective rehabilitation for the sessment provided in Unit Two of Assessment in Oc
wide variety of patients or clients with whom occupational pational Therapy and Physical Therapy provides
therapists and physical therapists are concerned. Since therapist of the future with the in-depth information ab
efficient and cost-effective but quality rehabilitation is component assessment necessary for integrated per
mandated for the future, it is imperative that occupational mance.
therapists and physical therapists are able to demonstrate Because of continuing medical advances, people
through accurate assessment the progress and increasing living longer, and infant survival rate is higher. Thu
function of their clients. Assessment in Occupational greater proportion of the therapist's assessment invo
Therapy and Physical Therapy has provided in one instruments geared specifically to the geriatric popula
volume information from the experts on all aspects of this and a larger proportion of assessment also invo
assessment process. Although contributors have primarily children. Although there is obvious overlap with
been drawn from the professions of the title, the expertise assessment of adults, assessment of children and eld
of other health professionals who are also concerned with requires the special considerations that have been el
increase in function has been included to illustrate the need dated in the age-related assessment portion of this bo
for interdisciplinary cooperation throughout the client In conclusion, Assessment in Occupational Ther
assessment process. and Physical Therapy has dealt in a comprehensive
Because of the increasing time constraints in many rigorous fashion with all aspects of the assessment proc
health service settings, time for assessment is declining. vital to the roles these professions currently hold and wi
Assessment of activities of daily living (self care, gait, home assuming in the future changing health scene. Altho
management, community activities, and work skills) may be much of the information has been directed toward
the only feasible formal assessment allowed. However, vanced clinical assessment, the book has also inclu
knowledgeable rehabilitation professionals must be able to materials of value to the researcher in the rehabilita
integrate the component assessments with the more fields. Thus, Dr. Brunt and I anticipate that this book wil
obviously functional ones to obtain the information base of considerable use both for direct patient intervention
necessary for effective intervention. Such dual-function for research purposes.
instruments have been discussed in parts of Chapters 8 and JUIJA VANDEU
x
Note: Page numbers in italics refer to illustrations; page numbers followed by t refer to tables.
A Age (Continued)
Ankle, ROM measurement in, 70-72, 70-72
261
343-345
Apraxia, constructional, 313-322. See also
193
in transtibial amputee, 201-202, 202t ment for, 258-259, 258-259
419-521
205
140
elderly, 407
207t
Arthrodesis, definition of, 122
Work. Prosthetic Gait Deviation Identification Ashburn's Physical Assessment for Stroke
Activities of daily living (ADL) tasks, in func Charts in, 210, 210t-213t Patients, description of, 261
tional assessment of perception, Prosthetic Observational Gait psychometric research on, 267
182,183
208,209 sessment, 318-319, 320t, 321
183
objective measures in, 206
Assessment of Communication and Interac
Aesthesiometer(s), 299
Identification Chart for, 210t-211t
155
assessment and, 357-417. See also Analytic frames for reference, in occupational
Attention, definition of, 354
523
524 INDEX
of,186
171-172
function of, assessment of, 247-356
Axonotmesis, 176
neurophysiologic theory of, 160
Cerebral evoked potential, definition of, 193
366-367
Brain damage, home management assess
Clavicle, stimulation of, somatosensory
155
Brunnstrom approach, to motor recovery af
sessment, 314t, 315, 318
emotional, 156-157
Cognition, assessment of, 333-355
behavior, abnormal.
c
C fibers, pain and, 124
elderly, 404
in transtibial amputee, 201, 20lt
Evaluation in, 345-346
315,318
definition of, 144
Contextual Memory Test in, 346,
Evaluations, 486
Caregivers, in assessment of elderly, 411-412
Lowenstein Occupational Therapy
in, 165-166
Carrying, physical demands of, 498t
350-351
168-169
definition of, 193
351-352
in psychological representation
202, 203
Stroop Color and Word Test in, 353
disturbances, 168-172
in transtibial amputee, 200
Symbol Digit Modalities Test in,
221-222
somatosensory, definition of, 132
Dysfunctional hierarchy, 451, 451
172
Corticospinal neuron, 272. See also Upper
E
Early Intervention Developmental Profile,
Cold injuries, of hand, 102
Creep, definition of, 246
362, 364t
Component assessments, 25
Cycle ergometers, for exercise testing, 140
Edema, control of, in assessment of upper
Computerized tests, in body image assess D Elastic energy, muscle performance and, 30
ment, 167-168
Dallas Pain Questionnaire, in abnormal ill Elbow, prosthetic units for, 235, 236
104-105
Depolarization, 195
disease in, 402-403
431
190-191
temporal/distance parameters of gait,
in home assessment tool selection. 453
Descriptor Differential Scale, for pain affect,
439-442,441-442,442t
Questionnaire, 170
for pain intensity, 126, 127t
Electrocardiogram (ECG), in heart rate as
316-319
Disk-Criminator, in tactile sensibility assess Electrodiagnosis, of movement disorders,
Contextual body image tools, in body image Doors and People Test, 348
syndrome, 288-289, 288-289, 290
assessment. 172
Dorsal flexion, definition of, 122
291t
Dupuytren's, 104
tion, 305
Emergent awareness, definition of, 329
526 INDEX
Emotions Profile Index, in emotional behav of, 255, 255t Force platform, definition of, 446
and, 30
Extrinsic finger tightness test, 111
290t
410-412
254-255
488
in proximal segment studies, 178-179, 179
Fugl-Meyer scale, of functional return after
EqUipment, in isokinetic tests, 42
Fabric, in orthotic/prosthetic fabrication, 239
hemiplegia, in spasticity assessment,
Ergometers, for exercise testing, 140
applications of, 245t
280-281, 281t, 290t
ErgonomiCS, definition of, 517
Face validity, definition of, 30
Full term, definition of, 371
of leniency, 8
Far-field potentials, in electrodiagnosis, 187
Functional capacity evaluation (FCE),
of severity, 8
FaScia, definition of, 122
479-494
in electrodiagnosis, 185-191
Fibrillation, definition of, 194
Hand Tool Dexterity Test in, 488
motor, 191,191
Fibrillation potentials, EMG waveforms of,
interdisciplinary, summary of, 505-508
somatosensory, 187-190
183
isometric testing in, 490-491, 491
of elderly, 404
Finger Localization Test, 165
Participation Agreement for, 480, 483
340-341, 342t
in lumber spine, 62, 63
release forms for, 480, 481-482
100-101, 101
Flexor pollicis longus, 85-86, 86, 91
Patients, 261
tion of, 103
observational, 436-438, 437-438
lower, prosthesis for, 199-214. See also trauma to, 100, 100
assessment of, in amputee, functional,
temporospatial, 206
survivor, 254
performance components in, 452-453
objective measures in, 206
hair of, 96
resources in, 452
20It
intrinsic, 88-90, 88-90
Homonymous hemianopsia, evaluation of,
438-445
of, 108, 110-111, 110-111
Hooper Visual Organization Test, 307t, 308
analysis of, simple clinical assessments
nail plate complex of, 96
309
439-442,441-442,442t
neurologic problems of, 101
Hyperpolarization, 195
sures and, 10
trauma to, 99-101, 100-101
Hypoxemia, definition of, 144
in cervical spine, 59
Hand-held dynamometer, in muscle testing,
in elbow, 56,56-57
36-37,37
in hand, 52
Handling, physical demands of, 498t
in hip, 65-66, 66
Harness systems, for upper extremity' pros
I
in knee, 68
theses, 235-236, 237
Ideational apraxia, definition of, 329
in lumbar spine, 62
Healing, wound, in assessment of upper ex Illness, functional decrease in elderly as sign
in shoulder, 57-58, 57-58
tremity prosthetics, 227
of,403
in wrist, 52-53, 53
Hearing, physical demands of, 498t
Illness behavior, abnormal, assessment of,
441-442,442t
Millon Behavioral Health Inventory in
Hemiplegia, due to stroke, motor dysfunction
496
H
H reflexes, in proximal segment studies, 179,
179
281t,290t
numeric pain rating scale in, 495
elderly, 405-406
Hierarchical model, of motor behavior, 251
regional disturbances in, 494
Hair, of hand, 96
Hip, ROM measurement in, 65-66, 66
simulation tests in, 494
Halo effect, 8
Holistic, definition of, 157
tenderness in, 494
functional, 99, 99
definition of, 459-460
Inclinometer, definition of, 518
528 INDEX
Inclinometer (Continued)
Leg (Continued)
pelvic, definition of, 72
J subscale of Rivermead Motor Assessment
456t metacarpophalangeal, 82
Ugament(s), collateral, definition of, 122
371-372
219
Line orientation perception, disorder of,
378t
230-232,230-232 Long latency reflexes, in nerve conduction
therapy, 478
radial carpal, 82
Assessment, 348
Intercarpal joint, 82
Lumbrical muscle group, 90, 90
170
upper motor neuron syndrome, Maguire's Tri-Level ADL Assessment, 455t
Interphalangeal joint, 82
Klein-Bell Activities of Daily Uving Scale,
Maximum voluntary effort, in functional ca
Interrater agreement, 9
428,457t
pacity evaluation, 484-486
of, 72
69t 144
Intrarater agreement, 9
Knit materials, in orthotic/prosthetic fabrica
in abnormal illness behavior assessment,
equipment in, 42
experience in, 42
L
Laminating resins, in orthotic/prosthetic fab
power in, 41
rication, 239
195
repetitions in, 42
Late responses, in proximal segment studies,
in cognitive assessment, 338-339, 339t
torque in, 41
178--179
Mental capacity, in occupational therapy as
velocity in, 42
Latency, definition of, 194
sessment of elderly, 407-408
work in, 41
in motor nerve conduction studies, 177,
Mental status, in cognitive assessment, 342
29,46
Leather, in orthotic/prosthetic fabrication,
in transtibial amputee, 201-202, 202t
490-491,491
Leg, prostheSis for, 199-214. See also
Metacarpals, 80--81, 81
State, 349
control of, in assessment of upper
456t
extensor digiti minimi, 87, 87
stimulation of, somatosensory evoked
495
extensor pollicis brevis, 87, 87
Neglect, unilateral, assessment of, 322-327.
Minnesota Paper Form Board Test, 308t
extensor pollicis longus, 87, 87
See also Unilateral neglect, assess
Minnesota Rate of Manipulation, in
flexor carpi radialis, 84, 85
ment 0/.
functional capacity evaluation, 488-489
flexor carpi ulnaris, 84-85, 85
Neonatal Behavioral Assessment Scale, 368t,
Minute ventilation, 142
flexor digiti minimi brevis, 89
370
194
and prosthesis and, 204-205
Edition in, 370-371
26lt
morphologic characteristics of,
in, 368t, 370
271-291. See also Upper motor stiffness of, definition of, 289
surface anatomy of, 97, 98, 98
recovery of, after stroke, 249-269. See biologic factors influencing, 30-32
peripheral, 176-177. see also Peripheral
177-178
manual, 33-35
ulnar, 93-94, 94
neuron syndrome.
tests of, historical perspective of, 28-29
clinical utility of, 180-181
182
manual,28
in neuromuscular junction disorder
308-309,312
capacity evaluation, 481-484
in voluntary activity disorder diagnosis, 181
Movement(s), active, in extremities, in
Myelopathy, cervical spondylotic, somatosen
motor, 177-178, 177-178
261
Myoelectric prostheses, upper extremity, Neural scheme disturbance{s), 162
191-192
Myokymic discharges, EMG waveforms of,
Neurobehavioral Cognitive Status Examina
530 INDEX
o
Object Assembly Test, 320t
of newborn, 369t
Observational measures, advantages of, 7
Oxyhemoglobin saturation, 144
112
Rasch scaling procedures in, 19-21
181
generalizability theory and, 10
assessment of, 127-130
185
reliability of, assessing, 9-10, llt
assessment of, subjective, in upper
175-195
Observed score, 5
clinical assessment of, 123-132
evoked potentials in, 187-191. see also Observer bias, definition of, 23
joint, Fugl-Meyer Assessment of, 254
194
assessment tools and research data on,
orthotic reduction of, in upper extremity,
neuron syndrome.
ment of occupational status, 155
scales for, 241
neuron syndrome.
management assessment, 451, 452t
Pain detection threshold, 124-125
313-322
struments, 456t
Palmar, definition of, 122
311-313, 313t
Ordinal scaling, for self-care assessments,
Palmaris brevis, 89-90
273-280,29Ot
line, perception of, disorder of, 310-311,
occupational,478
turbances, 160
topographic, disorder of, 311-312
Paronychia, 102-103
Neuropraxia, 176
Orientation of Rehabilitation Patients, Test
Parquetry Block Test, 318-319, 32Ot, 321
Neurotmesis, 176
of, 338, 354
Partial pressure of arterial oxygen, defini
Neurotonic discharges, EMG waveforms of,
Orthodromic, definition of, 194
tion of, 144
184
Orthodromic conduction, definition of, 289
Patient Evaluations Conference System,
and, 11-12
See also Upper extremity, orthotics
Peabody Developmental Motor Scales, 376,
definition of, 23
for.
378t, 381
developing, 22-23
sessment, 494-495
363t, 366-367
495
Oximeters, pulse, definition of, 144
Denver II in, 362, 363t, 365
365-367
408-410
of body image, disturbances of assessment
361-362
37-38
Psychophysical method, definition of, 172
387-388
cation, 237
PsychOSOCial function, activities therapy and,
363t, 365-366
evaluation of, 190
cognitive disability and, 150-152
281-282,281-283,290t
Postural reactions, tests of, in Montreal
tests of, 142-143
assessment, 141
Infant, 379t
PULSES Profile, 429-430
310-311,313
bizarre high-frequency, EMG waveforms
evaluation, 488
computer-based, 328
fibrillation, EMG waveforms of, 183
Q
Quality of Upper Extremity Skills Test, 379t
328
resting, 195
Quantitative Somatosensory Thermotest, 299
selection, 453-454
R
Rabideau Kitchen Evaluation-Revised: An
constructional, 313-322
299-300
Assessment of Meal Preparation Skill
unilateral neglect as, 322-327
Pressure injection injuries, of hand, 101-102
(RKE-R),456t
visuoperceptual, 305-312
Presynaptic inhibition, in spasticity assess Radial, definition of, 122
elderly, 407-408
Prevocational evaluation, definition of, 518
Radial carpal joint, 82
Phalanges, 81, 81
upper extremity, 216-246. See also Random Chinese Cancellation Test, 322t
Phalen's test, 112, 112
Upper extremity, prosthetics for. Range of motion (ROM), 49-73
456t
psychoanalytic theory, 149
for restoring or augmenting function, 225
derly,412
bances,161
71t
532 INDEX
in hip, 65-66, 66
of Safety Assessment of Function and the
Functional Status Index in, 426
64-65
Living Skills, 430
Katz Index of Activities of Daily living
in pelvis, 67-68,67-68
of Structured Observational Test of
in, 427
normalcy in, 52
Resins, laminating, in orthotic/prosthetic fab
in, 428--429
349-350
Respiratory frequency, definition of, 144
430
Reading tests, in unilateral neglect assess Responsiveness, definition of, 30, 46, 432
Living Skills in, 43Q.-431
278-279, 290t
351-352
Self-perception, muscle strength and, 32
179-180
psychometric research on, 266-267
Semantic differential technique, in body im
252-253
in occupational therapy assessment of
Semmes-Weinstein Monofilament Aesthesi
274,29Ot
Rubber, in orthotic/prosthetic fabrication,
definition of, 172
278,290t
applications of, 245t
in assessment of upper extremity
System, 425
195
Assessment in, 377t, 381
427
Scorable Self-Care Evaluation, 457t
Sensorimotor Performance Analysis, 380t
of Kenny Self-Care Evaluation, 427
Secondary gain, definition of, 518
Sensory changes, in occupational therapist's
Scale, 428
in pain transmission, 124
Sensory cortex, stimulation of, somatosen
of observational measures, assessment of, Canadian Occupational Performance evoked potentials in evaluation of,
Cognition.
pendulum test in, 281-282,281-283, Static strength testing, in functional capacity
somatosensory, 298-300
290t
evaluation, 490
visual,297-298
presynaptic inhibition in, 275-277,
Stick Construction Test, 320t
tials (SEPs).
spasticity measurement system in,
Stimulus, definition of, 195
221
assessment, 284-286, 285-286
motion/correcting deformity, 225
353
313
strength of.
Shoulder, ROM measurement in, 57-58,
Specifications, table of, definition of, 23
Strength testing, in upper extremity orthosis
57-59,59t
Specificity, definition of, 46
assessment, 223
fabrication, 238
testing, 36, 36
Stretch reflex(es), definition of, 291
assessment, 494
Spine, cervical, ROM measurement in,
Stride length, definition of, 214
195
lumbar, ROM measurement in, 60-65,
in transtibial amputee, 20lt
410-411
static, definition of, 246
in individuals with, 252-254
ment,157 190
254-269
Sociocultural model, of body image distur Spontaneous activity, definition of, 195
based on neurodevelopmental
187-190
of Functional Independence Measure, 425
psychometriC research on,
clinical utility of, 189-190
of Functional Status Index, 426
266-267
Spasticity, 273-287
Scale, 428
neurodevelopmental treatment and,
280t, 290t
of Patient Evaluations Conference System,
therapeutic approaches enhancing,
281t,290t
of Structured Assessment of Independent
Structured Observational Test of Function, 431
534 INDEX
mity,225
checkout of, 240
ment, 451
311-312
static, progressive, 231, 231, 232,232
Task performance, in orthotic assessment, Torque, definition of, 29, 47, 246, 291,
serial, 230, 230
227
assessment, 283-284, 283-284
checkout of, 239-240
137 '
478
cosmetic, 233-234, 235
development, 156
Transcranial electrical stimulation, 191
design and components of, 233-237,
sessment, 494
Chart for, 21Ot-211t
myoelectric, 233, 234
92
Trauma, to hand, 99-101, 100-101
socket for, 234-235
interossei, 92-93
Trunk testing, 43--46
performance deficits in, 287-289
lumbrical, 92
in functional capacity evaluation,
spasticity in, 273-287. See also Spasticity.
ofhand,90-93,91,93
492-494,493-494
symptoms of, 272, 272t
110-111
Twitcheil's findings, on motor recovery after
positive, 273-287. See also Spasticity.
palmaris longus, 91
Measure, 424
290t
U
Ulnar, definition of, 122
System, 425
high-temperature, in orthotic/prosthetic
Behavioral Inattention Test in, 322t,
of Klein-Bell Activities of Daily Uving
fabrication, 239
325, 326t, 327, 327t
Scale,428
" .~
overall, of Barthel Index, 424
of Structured Assessment of Independent
313t
Measure, 425
of Structured Observational Test of
visual analysis and synthesis and, 306,
System, 425
Validi,ty coefficient, attenuated/disattenuated,
Vocational evaluation, definition of, 518
426
definition of, 23
Volar flexion, definition of, 122
Living, 427
of elderly, 404-405
Volume, in upper extremity orthosis assess
of Kenny Self-Care Evaluation, 428
Variance component approach, to assessing
ment, 223
Scale, 428
9-10
Voluntary action, definition of, 195
System, 429
examination of, 107
183
Function, 431
Ventilation-perfusion matching, definition of,
Waveform, definition of, 195
144
Weight acceptance, definition of, 214
content, 13
in exercise tests, 143-144
132
criterion-related, 14-15
Verbal Rating Scale (VRS), definition of, 132
in pain perception, 124
Questionnaire, 170
definition of, 301
case study on, 501-502
366-367
Visual closure, definition of, 329
516-517
Measure, 424
Visual field defiCits, definition of, 301
Work Evaluation System Technologies II
System, 425
Visual Figure Ground Test, 308t
pacity evaluation, 487, 487
425-426
Visual Form Discrimination Test, 307t, 308,
518
427
Test, 307t, 308, 310t, 311
Workers' Compensation Act, definition of,
Scale, 428
309,312, 313t extremity prosthetics, 227
11-15
computer-based,328
applications of, 245t
429
moving versus stable environments in,
Wrist, prosthetiC units for, 234,236
ISBN 0-7216-4444-9
90071
9 780721 644448
I~