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Principles of the Physical
Examination
Robert Freeman
Why do a Physical Exam?
• Allows interpretation of gait data
• Check outputs from gait data
• Place the data in context
Pelvic Obliquity
25
-25
Up
Down
deg
Hip Ab/Adduction
20
-20
Add
Abd
deg
Pelvic Rotation
40
-40
Int
Ext
deg
Hip Rotation
60
-60
Int
Ext
deg
What do we Measure?
• Joint Ranges
– Muscle lengths
– Capsular tightness
• Bone version / deformity
• Strength
• Selective Control
• Evidence of Neurology (spasticity, dystonia…)
• Essential core data set and tailored tests
Who does the Exam?
• Appropriately trained clinician
• Assistant
Training
• CMAS standards
3 The laboratory must keep a log for each staff member containing,
a) The identity of any professional registration body, along with the
registration number
b) Evidence of gait laboratory induction training for new staff…
c) Annual update of repeatability measures (where applicable).
4 Repeatability testing is required:-
a) For each test carried out by the clinical movement analysis service
where clinical judgment is required
RJAH Repeatability
• Reduced set of
– Clinical examination (JB, WB, KE, NE, RF, SJ, AR)
• Hip Ab/Add, Pop ang, In/eversion, Anteversion, Staheli,
BMS
Hip Abduction Hip Adduction Anteversion Staheli
SJ 30.0 20.0 15.0 -10.0
NE 25.0 20.0 5.0 -5.0
JB 25.0 20.0 5.0 0.0
WB 35.0 20.0 10.0 -10.0
KE 25.0 20.0 5.0 0.0
APR 25.0 30.0 10.0 -10.0
RF 30.0 20.0 5.0 0.0
Mean 27.9 21.4 7.9 -5.0
Popliteal Angle Leg Length BMA Inversion Eversion
SJ 35.0 80.6 35.0 10.0 0.0
NE 30.0 82.0 30.0 10.0 0.0
JB 25.0 81.0 35.0 25.0 0.0
WB 40.0 80.0 30.0 20.0 -5.0
KE 20.0 82.5 30.0 10.0 0.0
APR 25.0 82.0 30.0 30.0 0.0
RF 25.0 83.0 25.0 15.0 10.0
Mean 28.6 81.6 30.7 17.1 0.7
Goniometry
Muscle length
• Muscles that cross single joint
– How much force
• Biarticular muscles
– Stabilise one joint measure other
– To determine if capsular tightness or muscle,
stabilised joint should allow max ROM.
Muscle Strength
• 0 none
• 1 flicker
• 2 gravity eliminated
• 3 against gravity
• 4- some resistance
• 4 moderate resistance
• 4+ Submaximal movement against resist
• 5 full strength
length
force
0° 135°
Strength
Tone / Spasticity
• Modified Ashworth
– What speed
– 0, 1, 1+, 2, 3, 4
• Modified Tardieu Test
– Record an angle
– Slow movement length
– Fast movement spasticity
Selectivity
• Selective Control Assessment
– 0 Unable
– 1 Impaired
– 2 Normal
Standing / Walking
Supine
Hip
Hip
• Extension
Hip Adductors
Knee
• Popliteal angle
• Patella alta
• Lag
Ankle
• Silfverskiöld test
• Clonus, catch
Subtalar inversion / eversion
Subtalar Complex
• Inv + N - 0 - N + Eve
• Inv + N - 0 - N + Eve
• Inv + N - 0 - N + Eve
• Inv + N - 0 - N + Eve
Prone
Duncan Ely
Hip Version
Tibial Version
• Bimalleolar axis
Hind Foot Forefoot
Sitting
Confusion Test

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Principles of physical examination

  • 1. Principles of the Physical Examination Robert Freeman
  • 2. Why do a Physical Exam? • Allows interpretation of gait data • Check outputs from gait data • Place the data in context Pelvic Obliquity 25 -25 Up Down deg Hip Ab/Adduction 20 -20 Add Abd deg Pelvic Rotation 40 -40 Int Ext deg Hip Rotation 60 -60 Int Ext deg
  • 3. What do we Measure? • Joint Ranges – Muscle lengths – Capsular tightness • Bone version / deformity • Strength • Selective Control • Evidence of Neurology (spasticity, dystonia…) • Essential core data set and tailored tests
  • 4. Who does the Exam? • Appropriately trained clinician • Assistant
  • 5. Training • CMAS standards 3 The laboratory must keep a log for each staff member containing, a) The identity of any professional registration body, along with the registration number b) Evidence of gait laboratory induction training for new staff… c) Annual update of repeatability measures (where applicable). 4 Repeatability testing is required:- a) For each test carried out by the clinical movement analysis service where clinical judgment is required
  • 6. RJAH Repeatability • Reduced set of – Clinical examination (JB, WB, KE, NE, RF, SJ, AR) • Hip Ab/Add, Pop ang, In/eversion, Anteversion, Staheli, BMS
  • 7. Hip Abduction Hip Adduction Anteversion Staheli SJ 30.0 20.0 15.0 -10.0 NE 25.0 20.0 5.0 -5.0 JB 25.0 20.0 5.0 0.0 WB 35.0 20.0 10.0 -10.0 KE 25.0 20.0 5.0 0.0 APR 25.0 30.0 10.0 -10.0 RF 30.0 20.0 5.0 0.0 Mean 27.9 21.4 7.9 -5.0
  • 8. Popliteal Angle Leg Length BMA Inversion Eversion SJ 35.0 80.6 35.0 10.0 0.0 NE 30.0 82.0 30.0 10.0 0.0 JB 25.0 81.0 35.0 25.0 0.0 WB 40.0 80.0 30.0 20.0 -5.0 KE 20.0 82.5 30.0 10.0 0.0 APR 25.0 82.0 30.0 30.0 0.0 RF 25.0 83.0 25.0 15.0 10.0 Mean 28.6 81.6 30.7 17.1 0.7
  • 10.
  • 11. Muscle length • Muscles that cross single joint – How much force • Biarticular muscles – Stabilise one joint measure other – To determine if capsular tightness or muscle, stabilised joint should allow max ROM.
  • 12.
  • 13.
  • 14. Muscle Strength • 0 none • 1 flicker • 2 gravity eliminated • 3 against gravity • 4- some resistance • 4 moderate resistance • 4+ Submaximal movement against resist • 5 full strength
  • 16. Tone / Spasticity • Modified Ashworth – What speed – 0, 1, 1+, 2, 3, 4 • Modified Tardieu Test – Record an angle – Slow movement length – Fast movement spasticity
  • 17. Selectivity • Selective Control Assessment – 0 Unable – 1 Impaired – 2 Normal
  • 18.
  • 21. Hip
  • 24. Knee • Popliteal angle • Patella alta • Lag
  • 26.
  • 27.
  • 29. Subtalar Complex • Inv + N - 0 - N + Eve • Inv + N - 0 - N + Eve • Inv + N - 0 - N + Eve • Inv + N - 0 - N + Eve
  • 30. Prone