Incorporating & Interpretation of Functional Testing & Training Across Patient
Types
Date: Friday, September 30, 2016
Session ID & Location: 3C: Ballroom H
Time: 1:00 PM - 3:00 PM
CEU Eligibility: 0.20
Presented by: Scott Lowe, PT, DPT, ATC, CEAS, CFE
Session Description: This presentation will be lecture–based with demonstrations of various
functional tests and training techniques. The first half will consist of methods and rationale for the
use of different tests and measures as well as interpretation of findings. Afterwards concepts for
addressing deficits found will be discussed with several real–life patient vignettes from initial
evaluation to post–assessment measures.
This presentation will be primarily focused for the outpatient setting, but information will be
applicable across many practice realms. Use of tests and training methods across different patient
populations will be addressed, including athletes, injured workers and general orthopedics.
Learners will be able to identify which functional test elements are appropriate for different
patient types including athletes, injured workers and those in the general orthopedic population.
Participants will also learn how to complete intervention elements appropriate for improving tests
found to be impaired. Evidence–based documentation will be discussed including how to
incorporate functional test findings in examinations and assessments with ideas for utilization with
different payor types.
Presenter Bio(s): Dr. Scott W. Lowe is a Physical Therapist and Clinic Director in Holly Springs,
GA. His professional interests include Manual Interventions, Clinical Education, as well as
Professional Issues and Advocacy. He has completed residency training in Orthopedics and is
certified in Ergonomics Assessment, Functional Capacity Evaluation, Functional Movement
Assessment and Athletic Training.
Pre­ and Post­Test for Functional Testing and Training Course 9/30/2016, PTAG and TPTA Fall Meeting, Scott W. Lowe 1: For what purpose if the MCTSIB administered? A: Assessment of bimanual dexterity, measuring both speed and accuracy B: Determining global balance as well as integration of individual components C: Dynamic gait assessment D: Measurement of work function to extrapolate abilities throughout an entire work day 2: Which of the following assessments has been shown to predict future injury risk among athletes with no injury history? A: Functional Movement Screen B: Isokinetic Quadriceps testing C: Berg Balance Test D: Presidential Physical Fitness Test 3: You are treating a patient status post ACL reconstruction who is nearing return to sport. What percentage of distance achieved on the Triple­Hop test as compared to the uninvolved extremity would suggest readiness for return? 4: Occasional performance of a work task is defined as what range of percentages of a work day? A: 10­30 B: 0­33 C: 0­25 D: 25­50 5: True or False, a concussion sustained in adolescents (less than 18 years of age) should be managed more conservatively than one sustained in adulthood (18 years of age or greater) 6: You are treating a workers compensation patient in the outpatient setting and want to gather information related to prognosis for return to work. Which of the following measures has the best predictive value? A: Manual Muscle Testing B: TUG C: Repeated lifting testing D: VO2 Max 7/25/2016
INCORPORATION AND
INTERPRETATION OF FUNCTIONAL
TESTING AND TRAINING ACROSS
PATIENT TYPES
Scott W. Lowe, PT, DPT, ACE, CEAS, CFE
What is Functional Testing?
-Any test or measure that replicates a
real-life activity that may be impaired
by the condition for which they are
seeking therapy services.
-In the International Classification of
Functioning paradigm, Functional
Movement Testing assesses Activity
and Participation elements.1
-No specialized training is required, but
many different continuing education
courses are offered on the topic
Types of Functional Testing
-Functional Mobility: TUG, 30 Second Sit to Stand Test
-Hand Function: Gripping, dexterity, coordination
-Balance: Romberg, Y-Balance, Single Leg Stance
-Work Tasks: Lifting, Carrying, Kneeling/Crouching
-Global Movements: FMS, FCEs, Ergonomic
Assessments
-Athletic Tests: Triple-Hop, Cone Drill
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30 Second Sit to Stand Test
-Measure of strength, control and balance with
good normative data available for general
geriatric population as well as those with OA.2
-Measure full repetitions of sitting and standing
completed in 30 seconds without assist from
arms.
-Standardized set-up is 17” chair
2
-Commonly used for many upper
extremity injuries
-Good predictive use for future morbidity
and mortality in the geriatric population 3
-Can be used to determine reliability of
effort
-With testing of grip positions 1-5 on
standard unit, highest strength will usually
be on positions 2 or 3 with bell-curve
distribution4
-3 repetitions of each position will also aid
with assessing reliability of effort.5,6
https://encryptedtbn1.gstatic.com/images?q=tbn:ANd9GcQblTX_WSk_
BO_RFoqOg7Gj3U44M8IZcGu3by8oKUKQYaU9nMbuA
Grip Strength Testing
-Nine Hole Pegboard test is one of the
most common tests and is easy to
administer.
-Participant is timed on placing all 9 pegs
in holes and then removing. Compare
involved and uninvolved sides.
-Good normative data and clinically
important change scores are available for
patients post-stroke and with Multiple
Sclerosis, but comparison to healthy
norms can be used for general population
and to set goals.7,8,9
Peg Turning Tests
https://www.handlungsplan.net/wpcontent/uploads//2010/06/Nine-Hole-Peg-Test-NHPTTestanordnung-f%C3%BCr-die-rechte-Hand.jpg
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-For the basic Romberg Test, close
stance with eyes open and eyes
closed. Arms crossed is generally
considered standard position but no
literature has specifically set it as
such.
-Normal is 30 seconds with no more
than minimal sway10,11
-In addition to use with patients with
adult neurologic conditions, data
can be valuable for ankle stability
and post-concussion assessment
Romberg Test/MCTSIB
Romberg Test/MCTSIB
-The Modified Clinical Test of
Sensory Interaction in Balance
builds on the Romberg by
adding unstable surface
condition for both eyes open
and eyes closed.11,12
-30 seconds per condition is the
goal
-Most studied in Geriatric
population as well as for those
with neurologic and vestibular
conditions, but may also give
good proprioceptive information
for patients with lower extremity
conditions.
-Available at: http://www.apdm.com/wpcontent/uploads/2014/05/mCTSIB-1024x507.png
Work Task Specific Tests
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Floor to Waist Lifting
-Strong predictor of return to work in
workers comp cases
-Easy to explain to patients how this
task relates to daily tasks.
-Most valuable information may be
from performing “Occasional Lifting”
which is tested at 2 lifts in 10 seconds,
followed by 10 seconds rest before
beginning next round at higher weight
based on clinical judgement (5-10# in
general)13,14
-Frequent Lifting is often extrapolated
as 50-60% of occasional amounts13
Crouching/Kneeling
-Used as a measure
of patient’s
willingness to assume crouch or
kneeling position as well as speed of
transitional movements with arm.
• -Standard procedure is timed measure
of 6 repetitions from top of box to floor
with hammer
-Three measures taken, generally only
with use of dominant hand.14
Available at: fcesoftware.com
Y-Balance Test
http://charlieweingroff.com/wp-content/uploads/y-balance-test-3.27.png
http
-Used to compare contralateral lower quarter
control away from the center of mass.
-Measured while standing on 1” block with leg
movement into all 3 directions for each leg
-Most commonly used with athletes, but can be
used with any patient who is able to complete
the test safely.
-Good reliability of rating and has shown
predictive value for injury risk among athletic
population16,17
-Online training available from
http://www.functionalmovement.com/certificatio
n/YBTLevel1
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Functional Movement Screening
-Exercises to address deficits found on
screen readily available online
-Has been shown to have predictive
value for future injury risk among
athletes and military populations17,18
-Each test item gives information about
multiple body parts and their
interactions
-Can easily document score and
compare with future reassessments
• -Offered via in-person or online
courses at
http://www.functionalmovement.com
/
Available at: http://www.physiopedia.com/images/6/60/FMS.jpeg
3 Cone Drill
-While not a traditional PT test/tool,
it has been shown useful for
assessment of athletic
performance
-Cones placed 15’ apart at 90
degree angles, from first cone run
to middle, touch and return, then
run around middle to last one,
around it and back.
-For reference, mean for NFL
draftees is 7.3+/- 0.45 seconds19
http://www.topendsports.com/testing/images/
3-cone-shuttle.gif
Triple- Hop Test
-Most researched for use after ACL reconstruction,
but can be used for any lower quarter condition,
provided that strength and balance are appropriate
and that there are no contraindications.
-Goal for Return to Activity is 85-90% of uninvolved
side20,21
Diagrammatic representation of the series of 4 hop tests: single hop for
distance, 6-m timed hop, triple hop for distance, and crossover hop for
distance. Adapted and reprinted by permission of Sage Publications Inc
from: Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry
determined by function hop tests after anterior cruciate ligament rupture.
Am J Sports Med. 1991;19: 513–518. Copyright 1991 by Sage Publications
Inc
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Documentation of Findings
-Worker’s Comp cases want to see functional measures, especially if related to job
demands.
-Job Demands questionnaires should be given to all WC evaluations if not
provided by employer or physician
-Most commonly implemented measures for this population include lifting,
crouching, grip strength and climbing.
-Medicare reviewers want to see functional measures related to functional
mobility and/or ADLs.
-Good examples; TUG, 30 second sit<>stand test, peg-turning test and 6 minute
walk test.
Concussion Function Assessment
• -In data published within the last year,
a survey of 1,272 Physical Therapists in
who practice in outpatient settings
found that while profession-wide
gains have been made in concussion
management guideline awareness
“gaps still exist” in both knowledge
and comfort levels for this
population.22
• -With growth of concussion
awareness, youth sports participation
rates and direct access, concussions
present both clinical and policyrelated issues for Physical Therapists
http://www.trbimg.com/img-55e862d9/turbine/la-etmn-concussion-movie-nfl-20150903
Concussion Assessment Continued
• -As in any PT evaluation, Red Flags must be
ruled out.23
• Focal neurologic deficits
• Widened Pulse Pressure
• Cervical Spine Examination
• -Balance measures of appropriate difficulty
should be implemented, e.g. MCTSIB23,24
• -Many neurocognitive measures are readily
available and easily administered, e.g. SAC and
ImPact
• -A starting point for improving comfort level
with these patients is
http://www.apta.org/StateIssues/Concussions/
Marsh AM, Fraser D, Marsh JP. Management
of concussion in the pediatric patient. J Pediatr
Health Care. 2013;27(6):499-504.
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Return to Activity
Questions?
Functional Training
-Now that we have assessed and found
deficits in function, how to we focus
our interventions accordingly?
-Many activities used as tests can be
beneficial for functional training as
well.
-Regardless of the patient, functional
training must be specific to THEIR
functions
-Patient wants to be able to tell that
activities within therapy are directed
towards their goals
http://www.eoi.es/blogs/imsd/files/2015/05/common_sense_not_so_common
_onesie.jpg
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Further Study
• Functional Movement Screen and
Y-Balance Test-functional
movement.com
• Ergonomic Assessment: The Back
School- thebackschool.net
• Functional Capacity Evaluation
•
-Arcon- fcesoftware.com
•
-Ergoscienceergoscience.com
Conclusion
-Select a few tests such as the ones
discussed today which may be
most pertinent to the population
you treat
-You must have a firm foundational
understanding of the “Why” to
gain full use of these tests and
treatments.
References
1Available at:
https://www.cdc.gov/nchs/data/icd/icfoverview_finalforwho10sept.pd
f
• 2Rikli, R. E. and Jones, C. J. (2013). "Development and validation of
criterion-referenced clinically relevant fitness standards for
maintaining physical independence in later years." The Gerontologist
53(2): 255-267.
3Bohannon RW. Hand-grip dynamometry predicts future outcomes in
aging adults. J Geriatr Phys Ther. 2008;31(1):3-10.
4Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity
of grip and pinch strength evaluations. The Journal of Hand Surgery
1984;9A(2):222-26.
5Goldman S, Cahalan TD, An KN. The injured upper extremity and the
JAMAR five-handle position grip test. Am J Phys Med Rehabil.
1991;70:306-308.
6Matheson, L., Bohr, P., & Hart, D. (1998). Use of maximum voluntary
effort grip strength testing to identify symptom magnification
syndrome in persons with low back pain. Journal of Back and
Musculoskeletal Rehabilitation, 10, 125–135.
Scott’s email:
[email protected]
• 7Mathiowetz, V., Kashman, N., et al. (1985). "Adult norms for the Nine Hole
Peg Test Of Finger Dexterity." OTJR: Occupation, Participation and Health,
5(1): 24-38.
8Oxford Grice, K., Vogel, K. A., et al. (2003). "Adult norms for a commercially
available Nine Hole Peg Test for finger dexterity." American Journal of
Occupational Therapy 57(5): 570-573
9Chen, H. M., Chen, C. C., et al. (2009). "Test-retest reproducibility and
smallest real difference of 5 hand function tests in patients with stroke."
Neurorehabil Neural Repair 23(5): 435-440.
10Cohen, J. A., Fischer, J. S., et al. (2000). "Intrarater and interrater reliability
of the MS functional composite outcome measure." Neurology 54(4): 802806.
11Hain CH, Micco AG. Cranial nerve VIII: Vestibulocochlear system. In: Goetz
CG, ed. Textbook of Clinical Neurology. 2nd ed. Philadelphia, PA: Elsevier
Science, 2003:195-210.
12Soochan Kim, Mijoo Kim, Nambom Kim, Sungmin Kim, Gyucheol
Han.Quantification and Validity of Modified Romberg Tests Using ThreeAxis Accelerometers.Green and Smart Technology with Sensor
Applications. Communications in Computer and Information Science
Volume 338, 2012, pp 254-261.
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References continued
•
•
•
•
•
•
•
13Saunders RL, Beissner
KL, Mcmanis BG. Estimates of weight that
subjects can lift frequently in functional capacity evaluations. Phys Ther.
1997;77(12):1717-28.
14Kuijer W, Brouwer S, Reneman MF, et al. Matching FCE activities and
work demands: an explorative study. J Occup Rehabil. 2006;16(3):46983.
15Matheson LN, Isernhagen SJ, Hart DL. Relationships among lifting
ability, grip force, and return to work. Phys Ther. 2002;82(3):249-56.
16Sefton JM, Hicks-Little CA, Hubbard TJ, et al. Sensorimotor function as
a predictor of chronic ankle instability. Clin Biomech (Bristol,
Avon)2009;24(5):451–458.
17Lehr ME, Plisky PJ, Butler RJ, Fink ML, Kiesel KB, Underwood FB. Fieldexpedient screening and injury risk algorithm categories as predictors of
noncontact lower extremity injury. Scand J Med Sci Sports.
2013;23(4):e225-32.
18Teyhen DS, Shaffer SW, Lorenson CL, et al. The Functional Movement
Screen: a reliability study. J Orthop Sports Phys Ther. 2012;42(6):530-40.
19Hoffman J. Norms for Fitness, Performance, and Health. Human
Kinetics; 2006.
•
20Reinke EK,
Spindler KP, Lorring D, et al. Hop tests correlate with
IKDC and KOOS at minimum of 2 years after primary ACL
reconstruction. Knee Surg Sports Traumatol Arthrosc.
2011;19(11):1806-16.
21 Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop
testing provides a reliable and valid outcome measure during
rehabilitation after anterior cruciate ligament reconstruction. Phys
Ther. 2007;87(3):337-49.
• 22Yorke AM, Littleton S, Alsalaheen BA. Concussion Attitudes and
Beliefs, Knowledge, and Clinical Practice: Survey of Physical
Therapists. Phys Ther. 2015;
• 23Stewart GW, Mcqueen-borden E, Bell RA, Barr T, Juengling J.
Comprehensive assessment and management of athletes with sport
concussion. Int J Sports Phys Ther. 2012;7(4):433-47.
• 24Mccrory P, Meeuwisse W, Johnston K, et al. Consensus statement
on concussion in sport - The 3rd international conference on
concussion in sport held in Zurich, November 2008. PM R.
2009;1(5):406-20.
•
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Pre­ and Post­Test for Functional Testing and Training Course 9/30/2016, PTAG and TPTA Fall Meeting, Scott W. Lowe 1: For what purpose if the MCTSIB administered? A: Assessment of bimanual dexterity, measuring both speed and accuracy B: Determining global balance as well as integration of individual components C: Dynamic gait assessment D: Measurement of work function to extrapolate abilities throughout an entire work day 2: Which of the following assessments has been shown to predict future injury risk among athletes with no injury history? A: Functional Movement Screen B: Isokinetic Quadriceps testing C: Berg Balance Test D: Presidential Physical Fitness Test 3: You are treating a patient status post ACL reconstruction who is nearing return to sport. What percentage of distance achieved on the Triple­Hop test as compared to the uninvolved extremity would suggest readiness for return? 4: Occasional performance of a work task is defined as what range of percentages of a work day? A: 10­30 B: 0­33 C: 0­25 D: 25­50 5: True or False, a concussion sustained in adolescents (less than 18 years of age) should be managed more conservatively than one sustained in adulthood (18 years of age or greater) 6: You are treating a workers compensation patient in the outpatient setting and want to gather information related to prognosis for return to work. Which of the following measures has the best predictive value? A: Manual Muscle Testing B: TUG C: Repeated lifting testing D: VO2 Max