Documente Academic
Documente Profesional
Documente Cultură
AddisAbaba,Ethiopia
JUNE2012
BY
MONIKAMANN,PT
Inaffiliationwith
HEALTHVOLUNTEERSOVERSEAS
monikamann@sbcglobal.net
2
GOALS
v Understandtheimportanceofclinicalreasoninginreferencetophysicaltherapyevaluation
andtreatment.
v Abilitytodelineateandidentifytheprosandconsoffourbasicclinicalreasoningstrategies.
v BeabletoutilizethebasicconceptsoftheDisablementModelwhenformulatinggoalsfor
patients.
v ExplainwhatSINSareandthereimportancetotreatmentplanning.
v Filloutabodychartcorrectlyonasamplepatient.
v Giveexamplesofhowtoaskfollowupquestionstopatientsinordertoobtainspecificand
quantitativesubjectiveinformation.
v Enumerateatleast5questionsonemaywanttoaskaboutpain.
v UnderstandComparablesignsandtheirimportance.
v Performasystemsreviewwithanorthopedicpatient.
v PrioritizeandperformappropriateTestsandMeasuresonanorthopedicpatientbasedon
informationgleanedfromtheSubjectiveEvaluation,includingdiscussionofclinical
indicatorsanddatagenerated.
v Formulateasuitableassessmentforanorthopedicassessmentincludingfunctional
limitationsanddisabilities,measureablegoals,andatreatmentplan.
v Discussandunderstandwhenandhowoftenapatientshouldbeassessed.
v Understandcriteriaforterminationofphysicaltherapyservices.
3
INTRODUCTION
Clinicalreasoningreferstothethinkinganddecision-makingprocesses
thatareusedinclinicalpractice.(1)Itallowsusasphysicaltherapiststo
determinewhattotreatfirst,prioritizewhichtechniquestoselect,how
vigorouslytoapplythem,andhowtoevaluatethepatientsresponseto
treatment.(2)
Thiscoursewillemphasizehowwecanofferthemostefficientand
effectivecaretopatientsbyanalyzingandresolvingtheproblemsthey
presentwith,usingasystematicclinicalreasoningapproach.
HiggsandJones(3)havedefinedclinicalreasoningasthethinkingand/or
decision-makingprocessesusedinclinicalpractice.
Morespecificallyitistheprocessbywhichthetherapist,interactingwith
thepatientandothers(suchasfamilymembersorothersprovidingcare),
helpspatientsstructuremeaninggoals,andhealthmanagement
strategiesbasedonclinicaldata,patientchoices,andprofessional
judgmentandknowledge.
WHYISTHISIMPORTANT?
Helpsassureadesirableoutcomeoftherehabilitationprocess.
RaisesPhysicalTherapistsfrombeingmerelytechnicianstobeing
professionals.
AccordingtoNitaMuir(4)inordertocompetentinassessingand
evaluatingpatients,andestablishinganappropriatetreatmentprogam,
oneneeds
Asoundbaseofknowledgeandexperienceinformedby
Clinicalstandardsandresearchevidence,
Anabilitytoexercisesoundcriticalthinkingand
Diagnosticreasoningskillsinadditionto
Theabilitytodevelopatherapeuticrelationshipwiththepatient.
4
Clinical Reasoning Strategies
RecognitionorInductiveReasoning
o Thisisbasedonpastknowledgeandexperience:
recognizingsimilarpatternsofsignsandsymptomsand
thengroupingthemtogethertomakeahypothesisonthe
diagnosisandtreatmentthatwouldbeaffective.
o Pros:Fast,Conclusionscanbereachedwithimprecise
data(5)
o Cons:lackscertainty.Needexperiencetorecognize
pattern(5)
Hypothetico-DeductiveReasoning
o Makingdeterminationsaboutthepatientsproblemand
comingupwithahypothesisaboutitbasedonthedata
presentedintheevaluation.
o Pros:organized,ateachableskill(5)
o Cons:slow,canbedependentontoomuchdata(5)
Knowledge-ReasoningIntegration
o ThisisacombinationofHypothetico-DeductiveReasoningand
PatternRecognition/InductiveReasoning
o Needastrongknowledgebaseforthistobemostsuccessful.
IntegratedPatient-CenteredReasoning
o Incorporatesmutualdecision-makingwiththepatient
and
o Takesintoaccountthecontextofthesituation.
o Usescognitionandknowledge.
Cognitionallowsyoutoprioritizeandrealizewhat
informationisrelevant.Itallowsyoutointerpret
theinformationpresentedandformahypothesis.
Thisisdifferentthanknowledge.
5
Byusingacombinationofallofthesestrategiesoneachievesan
improvementintheaccuracyofdiagnosis.(6)
Whenutilizingclinicaldecision-making,thetreatmentofpatientscanbe
representedwiththisdiagram:
Xray(-)
Painisconstantandvariable.Gettingbetter.
Inlastweekworstpainis7/10whenliftingapieceoffurniture.
Best2/10.Average4/10.
7
AggravatingFactors:Liftingmorethan10pounds.Turninghead
tolookoverleftshoulder.Sleepingonleftsidewakesseveral
timesanightandhasdifficultygettingbacktosleep.Deep
breathing.Beinguprightmorethanonehour.
EasingFactors:Lyingonback.Massage.Rest.Vicodin.
Other:Marriedwithtwochildrenunder3.Difficulttopickthem
up.UsuallyplayssocceronSundaysandnowhecant.Offwork
now.Patientisconcernedaboutnotbeingabletoworkandbring
inincome.
WhatotherinformationwouldyouliketoknowaboutGosh?Why?
Howcanyouapplythefollowingstrategiestotheevaluation:
RecognitionorInductiveReasoning:
Hypothetico-DeductiveReasoning:
Knowledge-ReasoningIntegration:
IntegratedPatient-CenteredReasoning:
8
DISABLEMENT MODEL & CLASSIFICATION
(From CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST
PRACTICE Part 3 Segment 1 and 2)
FUNDAMENTALCONCEPTS
GOALSOFAPPLYINGDISABLEMENTMODEL
Positionthebodyofknowledgeinphysicaltherapywithinatheoreticalframework
relevanttoclinicalpractice
Delineatethemajorpathways--fromdiseaseorinjurythroughtovariousfunctional
consequences
MODELSOFABILITY/DISABLIITY
Modeltodelineateconsequencesofdisease&injuryastheyimpactatthelevelofa
person&society
BasedonworkofNagiandadoptedbythe
WorldHealthOrganization(WHO)NationalCenterforMedicalRehabilitation
ResearchInstituteofMedicine
(8)
9
PATHOLOGY(cellularlevel)
Interruptionofnormalcellularprocesses
Biochemical,physiologic&anatomicabnormalitiesofthehumanorganism
IMPAIRMENT(bodysystems)
Lossorabnormalityofphysiological,psychological,oranatomicalstructureorfunction
Classificationofabnormalitiesdiagnosisofimpairment
Examples:Aerobiccapacity/endurance;gait,locomotion&balance;integumentary
integrity;jointintegrity&mobility;motorfunction;muscleperformance;ROM;pain;
posture;ventilation&respiration/gasexchange
FUNCTIONALLIMITATION(wholeperson)
Restrictionoftheabilitytoperformanaction,task,oractivityinanefficient,typically
expected,orcompetentmanner
Classificationofrestrictionsdiagnosisoffunctionallimitations
Examples:Rolling,crawling,sitting,standing,walking,climbing,carrying,pulling,lifting,
bending,turning,twisting,doingbuttons,tyingshoelaces,bathing,dressing,grooming,
shopping,shoveling,vacuuming
DISABILITY(personsrelationtosociety)
Inabilitytoengageinage-specific,sex-specific,orgender-specificrolesinaparticular
socialcontextorphysicalenvironment
Classificationofinabilities-diagnosisofdisability
Examples:Work(job,school,play),community,leisureintegrationorreintegration
WherewouldthesefitintotheDisablementModel?
Inabilitytoshopforfamily
myocardialinfarction
abilitytoambulate
aerobiccapacityorendurance
Management Models
MEDICAL PATIENT MANAGEMENT MODEL
FOCUS ON DISEASE / INJURY
History / Physical Exam
10
Invasive Tests & Measures
Diagnosis: Cellular / System Level
Intervention: Pharmacology or Surgery
Outcome: Cure / Repair of Tissue or System
REHABILITATION PATIENT MANAGEMENT MODEL
FOCUS ON DYSFUNCTION
History / Physical Exam
Noninvasive Tests & Measures
Diagnosis: System / Person Level
Intervention: Improve Movement Performance
Outcome: Remediate impairments/optimize function
DISABLEMENT CRITERIA
Based on established expected norms for age, sex, anthropometrics, social
contexts, work standards
Norms used to:
Hypothesize regarding effects of disease or injury on systems, function & roles
Measure impact of risk factors & interventions on outcomes
IMPACT ON DISABLEMENT
RISK FACTORS
Predisposing Characteristics: Biological Congenital Demographic
Psychological Behavioral Lifestyle Social Environmental
INTRA-INDIVIDUAL FACTORS
Habits, Lifestyle & Behaviors Psychosocial Attributes / Coping Activity
Accommodations & Adaptations
EXTRA-INDIVIDUAL FACTORS
Medical care & rehabilitation Medications & other therapy Physical & social
environment External supports
APPLICATIONS OF DISABLEMENT MODEL
Standardize clinical practice in classification group
Open collegial discussion for peer review & quality improvement
Generate questions for clinical research
11
RELATIONSHIP OF Health-Related Quality of Life (HRQOL) TO DISABLEMENT CONCEPTS
PATHOLOGY
IMPAIRMENT
Adapted from Jette, 1994
The effect on the health-related quality of life takes place when there are functional
limitations and disabilities.
DISABLEMENT IMPACT
Health-related QOL: Total well-being
Self-perceived health
Physical status
Intellectual functioning
Performance of social roles
Social interactions
Economic status
Satisfaction
EMPHASIS & GOALS OF PHYSICAL THERAPY
Physical therapy is a health profession that emphasizes the sciences of
pathokinesiology & the application of therapeutic exercise for the prevention,
evaluation & treatment of disorders of human motion.
(Hislop, 1976)
FUNCTIONAL LIMITATION
DISABILITY
12
EXAMPLE: A patient presents to you with her L leg in a cast stating she was in a
car accident and fractured her femur and pelvis. She was NWB for 6 wks and
now is in a cast and using crutches. She states that her prior level of function
incudes caring for her family and home including, shopping and preparing food.
Pathology _______________________________________
Impairments - ______________________________________
Functional Limitations - _____________________________
Disabilities - _______________________________________
PLAN
Is this enough information to elaborate an effective plan of care?
What else do we need to consider?
General Demographics Social History Employment/Work Growth &
Development Living Environment General Health Status Social/Health
Habits Family History
Medical/Surgical History
Current Condition)(s))/Chief Complaint(s)
Functional Status and Activity Level
Medications Other Clinical Tests
Functional
problem/disability
Measurable
Goal
Treatment Plan
1
2
3
4
13
USE OF CLINICAL DECISION-MAKING
IN AN EVALUATION
Whyareevaluationsimportant?
o Clarifytheseverityandnatureoftheproblem
o Findwhatfunctionaldeficitsapatienthas
o Touncovertheprincipalproblemscontributingtofunctional
deficits(pain,weakness,lackofROM,etc)
o Totakeobjectivemeasurementsthatcanbereferredbacktolaterin
ordertoassessprogress.
Whydoweneedtheaboveinformation?
o Inordertodesignthemosteffectiveandefficienttreatment
planforeachpatientsothattheycanreachtheirrehabilitation
goalsasrapidlyaspossible.Wellgointothisinmoredetail
later,butisitappropriateforallpatientswiththesame
diagnosistoreceivethesametreatment?
Whataresomefactorsthatmightinfluenceyourchoiceof
treatment?
14
WhyisitnecessarytoevaluateapatientifanMDhasalready
examinedthem?
o Theprimarygoalofamedicalexamistoformulatea
differentialdiagnosisofthepatientsproblem.
o TheprimarygoalofaPTevaluationistogathersubjectiveand
objectiveinformationthatwillguidetheclinicaldecision
makingregardingwhatPTtreatmentswillbemosteffectivein
reachingtherehabilitationgoalsforthept.
Documentationisanessentialelementofevaluationandtreatment.
AccordingtothePhysicalTherapyGuidetoClinicalPractice:
Asyouallknow,aphysicaltherapyevaluationconsistsof4parts:
Subjective
Objective
Assessment
Plan
Documentsshouldincludeappropriateevaluations&
interventions,expectedoutcomes,&recommended
frequency,intensity&durationofphysicaltherapy
services.Thespecificconditionsforwhichcareis
describedcanbebasedondiagnoses,oronotherbases,
suchasfunctionallimitationsordisabilities.
15
Subjective Evaluation
LISTEN!
OnsetofcurrentEpisode
16
(7)
AreaofSymptoms(bodychart)
o Descriptors,typeofpain,relationshipofpainareas,
numbness/tingling.
17
BehaviorofSymptoms
o ConstantorIntermittent
o Aggravatingandeasingfactors
o 24HourBehavior
18
(7)
o Askfollowupquestionstotrytoelicitanswersthatareas
specificandmeasurableaspossible.
o Thinkaboutwhatthisistellingyouaboutwhich
structuresmaybeinvolved.
o Marksignificantfindingswithanasterisk
19
Painscale
o Current
o Past
o Worst
o Best
Functionallimitationsanddisabilities
SINSseverity,irritability,nature,stage
Severity
o referstotheintensityofthepainprovokingactivity.
Cautionisnecessaryduringtheexaminationand
treatment.
Irritability
o ameasureofhoweasilythepatientssymptomsare
aggravatedandhowquicklytheysubside.:Ifapatients
symptomscomeoneasilyanddontsubsidewithinafew
minutesofstoppingtheaggravatingactivity,thenthe
conditionisconsideredirritable.
Nature
o referstothetypeofissuethatiscausingthesymptoms
(i.e.:mechanical,inflammatory,etc.)
Stageoftheinjury
o acute-
o subacute-
o chronic
20
LifestyleFactors
o Work
o Recreationalactivities
o Family/supportsystem
o Environment
Medicalhistory
o othermedicalproblemswhichmayhaveaninfluence.
o Previoustreatmentsforthecurrentconditionand
outcomes.
o Priorleveloffunction.
PatientsGoals
o Itsveryimportanttoinquireastowhatthepatients
goalsare.
Attempttogatherfunctional/realisticgoalsfromthe
patient.
Duringsubjectivequestioning,wewanttoassurethattheinformationwe
arereceivingisasspecificandquantitativeaspossible.
Whydowewanttonotespecificandquantitativeinformation
fromthepatient?
21
AFTERSUBJECTIVEEVAL:formhypothesis
PRIORITIZEWHICHOBJECTIVETESTSYOUWILLPERFORM
Arespecialtestsindicated?(neurologicalorcardiopulmonarytest,etc)
Influenceofseverityandpathologyontheexaminationandtreatment
HerearesomethingsapatientmighttellyouandIwantyoutoletme
knowifyouthinktheywouldbegoodindicatorstomeasureprogress
inthefuture.Ifyoudontthinktheywouldbegoodtousefor
measurementsofprogress,letmeknowhowthestatementscanbe
improved:
Ihavepaininmyhip.
IhavepaininmyhipwhenIwalk.(whatotherinformationdowe
want?)
Icanonlysitforonehour.
Myleftarmisweak.
Icantpickupmydaughterwithmyleftarm.(whatotherinformation
dowewant?)
Ihavealotofnumbnessinmyhand.
22
o Isthepain...
Severe
Latent
o Isthedisorderirritable?
o Doesthenatureofthedisorderindicatecaution?
o Aretherecontraindications?
ThekindofExam
o Doyouthinkyouwillneedtobegentleormoderatelyfirmwithyour
examination?
o DoyouexpectaCOMPARABLESIGNtobeeasyorhardtofind?
o Whatmovementsdoyouthinkwillbecomparable?
o Whatassociatedfactorsneedtobeexamined?
o Aretherefactorsthatcouldcausetheproblemtoreoccur?(posture,
muscleimbalance,instability,weakness,obesity,etc)
o Doyouthinkyouwillneedtofocusmostonweakness,stiffness,pain,
orinstability?
23
Objective Evaluation
ConsistsofSpecifictestsandmeasurementstodetermineinan
objectiveandquantitatemannertheseverityandtypeofproblemthat
thepatientpresentswith.Also,themeasurementstakenintheobjective
evaluationarenecessaryinordertodeterminetheextentofprogressin
thefuture.
24
Oneofthegoalsoftheorthopedicobjectiveevaluationistofind
comparablesigns.Thesearenecessaryinordertohelpusinthe
diagnosisofwhichtissuesareinvolved,andalsoinre-assessingprogress
aftertreatment.
Systems Review
Assesstheinformationgatheredinthesubjectiveandobjective
evaluationinordertolisttheproblemsthatyouaregoingtoaddressand
setupmeasureableandfunctionalgoalsinordertodecrease
functionallimitationsanddisabilityasmuchaspossible.
Here is an example of some findings from two similar patients. Fill in the charts
below for each of them.
SUBJECTIVE: Ayana is a 53 year old woman who complains of pain in her right
arm when she puts on a sweater, lies on her right side, lifts a pot of tea, or
reaches up to put dishes away in a high shelf. She states that these problems
have come on slowly over the past couple of years. She says that the shoulder
doesnt hurt when she isnt moving it but when she reaches up high or reaches
back to put on her sweater the pain can reach a level 8 on a 1 10 scale. Pain
gets worse through the day.
38
OBJECTIVE:
PROM: Fl limited at 140 by pain and stiffness
ABD limited at 95 degrees by stiffness
ER limited at 20 degrees by pain and stiffness
IR limited at 55 degrees by stiffness
Isometric Tests to the Shoulder: All negative
AROM: FL limited at 120 by pain and stiffness (substitutes by elevating
scapula)
ABD limited at 90 by stiffness
ER limited at 10 degrees by pain.
IR limited at 60 by stiffness (substitutes with anterior rotation of
the scapula.
Accessory Movements of the GH and AC joints generally limited.
Posture: Forward rounded shoulders with abducted scapulae.
Work: Sits at a desk through the day.
What else do you want to know?
SINS
Severity___________________________________________________
Irritability___________________________________________________
Nature____________________________________________________
Stage_____________________________________________________
39
Functional
Problproblem/disability
Measurable Goal Treatment Plan
1
2
3
4
SUBJECTIVE: Hakim is a 25 year old male. He works in construction and has
been having pain in his right shoulder for the past three weeks after lifting a 100
pound crate overhead. He complains of pain (6/10) when taking a shirt off
overhead, turning the steering wheel of the car, lying on his right side, and lifting
anything over five pounds. The pain wakes him 1 2 times a night and it can be
difficult to get back to sleep.
OBJECTIVE:
PROM: Fl limited at 140 by pain and stiffness
ABD limited at 95 degrees by pain
ER limited at 20 degrees by pain and stiffness
IR limited at 55 degrees by pain
Isometric Tests to the Shoulder: + to ABD and ER with ABD eliciting more pain
than ER. After isometric tests, pt continues to have increased pain in shoulder
throughout the rest of the evaluation.
AROM: FL limited at 120 by pain and stiffness (substitutes by elevating
scapula)
ABD limited at 90 by pain
ER limited at 10 degrees by pain.
IR limited at 60 by pain (substitutes with anterior rotation of
the scapula.)
40
Posture: UEs in IR with tight pecs and over-developed upper trap.
What else do you want to know?
SINS
Severity___________________________________________________
Irritability___________________________________________________
Nature____________________________________________________
Stage_____________________________________________________
Functional
problem/disability
Measurable Goal Treatment Plan
1
2
3
4
41
TREATMENT
(See CLINICAL DECISION MAKING: UTILIZING THE GUIDE TO PHYSICAL THERAPIST
PRACTICE Part 6)
PLAN OF CARE
Integrates data from evaluation
Specifies:
Goals & outcomes
Direct interventions
Frequency of visits
Duration of episode of care
Discharge plan
42
RE-ASSESSMENT OF PLAN
Evaluate progress
Modify or redirect intervention
Respond to new clinical findings
Address failure to respond to current interventions
CRITERIA FOR TERMINATION OF PT SERVICES
Discharge
Goals and outcomes achieved
Discontinuation
Continued intervention declined
Unable to progress due to medical, psychosocial, or financial
limitations
Lack of benefit from further intervention determined
Key subjective findings and objective comparable signs should be re-
assessed at every visit.
Specific comparable signs should also be checked and re-checked
before and after a specific treatment.
43
APPENDIX A
Step Test for Aerobic Capacity
Equipment
1. a 12 inch high bench (or a similar sized stair or sturdy box), watch for
timing minutes.
Procedure
Step on and off the box for three minutes. Step up with one foot and then the
other. Step down with one foot followed by the other foot. Try to maintain a
steady four beat cycle. It's easy to maintain if you say "up, up, down, down".
Go at a steady and consistent pace. This is a basic step test procedure - see
also other step tests.
Measurement
At the end of 3 minutes, immediately check the patients HR while they are still
standing.
Results
This step test is based loosely on the Canadian Home Fitness Test and the
results below are also based from data collected from performing this test.
44
3 Minute Step Test (Men) - Heart Rate
Age 18-25 26-35 36-45 46-55 56-65 65+
Excellent <79 <81 <83 <87 <86 <88
Good 79-89 81-89 83-96 87-97 86-97 88-96
Above
Average
90-99 90-99 97-103 98-105 98-103 97-103
Average 100-105 100-
107
104-
112
106-
116
104-
112
104-
113
Below Average 106-116 108-
117
113-
119
117-
122
113-
120
114-
120
Poor 117-128 118-
128
120-
130
123-
132
121-
129
121-
130
Very Poor >128 >128 >130 >132 >129 >130
3 Minute Step Test (Women) - Heart Rate
Age 18-25 26-35 36-45 46-55 56-65 65+
Excellent <85 <88 <90 <94 <95 <90
Good 85-98 88-99 90-102 94-104 95-104 90-102
Above Average 99-108 100-111 103-110 105-115 105-112 103-115
Average 109-117 112-119 111-118 116-120 113-118 116-122
Below Average 118-126 120-126 119-128 121-129 119-128 123-128
Poor 127-140 127-138 129-140 130-135 129-139 129-134
Very Poor >140 >138 >140 >135 >139 >134
Source: Canadian Public Health Association Project (see Canadian Home Fitness
Test)
Also can use 6 minute walk test: Average healthy adult can ambulate 400
600 meters in 6 minutes.
45
Appendix B
Geriatric Assessment !""#$%&' MU PT 8390
Tinetti Performance Oriented Mobility Assessment
(POMA)`
Description:
The Tinetti assessment tool is an easily administered task-oriented test that measures an older adult`s
gait and balance abilities.
Equipment needed: Hard armless chair
Stopwatch or wristwatch
15 It walkway
Completion:
Time: 10-15 minutes
Scoring: A three-point ordinal scale, ranging Irom 0-2. '0 indicates the
highest level oI impairment and '2 the individuals independence.
Total Balance Score 16
Total Gait Score 12
Total Test Score 28
Interpretation: 25-28 low Iall risk
19-24 medium Iall risk
19 high Iall risk
* Tinetti ME. PerIormance-oriented assessment oI mobility problems in elderly patients. !"#$ 1986;
34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993)
46
Tinetti Performance Oriented Mobility Assessment (POMA)
- Balance Tests -
Initial instructions: Subject is seated in hard, armless chair. The following maneuvers are tested.
1. Sitting Balance Leans or slides in chair =0
Steady, safe =1 _____
2. Arises Unable without help =0
Able, uses arms to help =1
Able without using arms =2 _____
3. Attempts to Arise Unable without help =0
Able, requires > 1 attempt =1
Able to rise, 1 attempt =2 _____
4. Immediate Standing Balance (first 5 seconds)
Unsteady (swaggers, moves feet, trunk sway) =0
Steady but uses walker or other support =1
Steady without walker or other support =2 _____
5. Standing Balance
Unsteady =0
Steady but wide stance( medial heals > 4 inches
apart) and uses cane or other support =1
Narrow stance without support =2 _____
6. Nudged (subject at maximum position with feet as close
together as possible, examiner pushes lightly on subjects
sternum with palm of hand 3 times)
Begins to fall =0
Staggers, grabs, catches self =1
Steady 2 _____
7. Eyes Closed (at maximum position of item 6)
Unsteady =0
Steady =1 _____
8. Turing 360 Degrees Discontinuous steps =0
Continuous steps =1 _____
Unsteady (grabs, staggers) =0
Steady =1 _____
9. Sitting Down
Unsafe (misjudged distance, falls into chair) =0
Uses arms or not a smooth motion =1
Safe, smooth motion =2 _____
BALANCE SCORE: _____/16
47
Tinetti Performance Oriented Mobility Assessment (POMA)
- Gait Tests -
Initial Instructions: Subject stands with examiner, walks down hallway or across room, first at usual pace, then back
at rapid, but safe pace (using usual walking aids)
10. Initiation of Gait (immediately after told to go
Any hesitancy or multiple attempts to start =0
No hesitancy =1 _____
11. Step Length and Height
Right swing foot
Does not pass left stance foot with step =0
Passes left stance foot =1 _____
Right foot does not clear floor completely
With step =0
Right foot completely clears floor =1 _____
Left swing foot
Does not pass right stance foot with step =0
Passes right stance foot =1 _____
Left foot does not clear floor completely
With step =0
Left foot completely clears floor =1 _____
12. Step Symmetry
Right and left step length not equal (estimate) =0
Right and left step length appear equal =1 _____
13. Step Continuity
Stopping or discontinuity between steps =0
Steps appear continuous =1 _____
14. Path (estimated in relation to floor tiles, 12-inch diameter;
observe excursion of 1 foot over about 10 ft. of the course)
Marked deviation =0
Mild/moderate deviation or uses walking aid =1
Straight without walking aid =2 _____
15. Trunk
Marked sway or uses walking aid =0
No sway but flexion of knees or back or
Spreads arms out while walking =1
No sway, no flexion, no use of arms, and no
Use of walking aid =2 _____
16. Walking Stance
Heels apart =0
Heels almost touching while walking =1 _____
GAIT SCORE = _____/12
BALANCE SCORE = _____/16
TOTAL SCORE (Gait + Balance ) = _____/28
48
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