Use of movement system diagnoses in the management of patients with neuromuscular conditions: a multiple-patient case report.

Every, clinicians are faced the task of selecting the most effective interventions for each patient. In medicine, ideally the task of selecting the most effective interventions is preceded by the task of diagnosing the patient's condition. Specifically, the physician first investigates the cause or nature of a condition, then decides on the appropriate diagnostic label, and finally selects the most suitable intervention. In physical therapy, we have acknowledged that making a diagnosis is part of our patient management model. (1) We also have acknowledged that medical diagnoses are not sufficient to direct physical therapy intervention. (2-4) However, few clinically useful systems of diagnoses have been proposed, and none have been implemented on a wide-scale basis. The consequences of not having a diagnostic system are substantial. First, there is great variability in physical therapist practice, which we believe reduces the likelihood that all patients will receive the most suitable interventions. Second, there is little basis for creating the truly homogenous groupings of patients required to conduct meaningful, effective clinical research.

Previously, we described a set of human movement system diagnoses for patients with neuromuscular conditions. (5) Our system is based largely on having performed systematic clinical observations for many years. The systematic observations enabled us to identify clusters of impairments that seemed to be key to the patients' problems. Recently, we revised the system to clarify ideas and simplify terminology. The system now consists of 9 diagnoses, each of which is a collection of impairment level signs that characterize and are labels for the patient's primary movement system problem (Supplemental Appendix 1, available online only at www.ptjoumal.org).

In our system, the diagnosis is based on the results of diagnostic tests that are administered during a standardized clinical examination. The standardized examination includes tests for specific impairments and observational analysis of the manner in which critical tasks are performed. The tests for impairments are designed to identify deficits in motor control, muscle tone (level of hyper-excitability), muscle strength (force-generating capacity), nonequilibrium coordination, sensation, postural control, motion sensitivity, mental status, and joint range of motion. The critical tasks that are tested include: quiet sitting, quiet standing with feet hip's width apart and with feet together, step-up (placing one foot on a step and returning it to the floor), walking, walking while turning the head, stepping over obstacles, and walking forward and backward. All of the tests were selected because they measure movement variables that, in our clinical experience, enable us to differentiate among movement system problems.

When using our system, the physical therapist makes a diagnosis by first performing the standardized examination and then comparing the results for the patient to the criteria for the 9 categories. The online Supplemental Appendix 1 contains a definition of each diagnosis. In Supplemental Appendix 1, we have listed only the results of key tests and signs associated with each diagnosis, instead of specifying the results of every test in the examination. In some cases, the key tests are tests of impairments, and, in other cases, the key tests are results of task analysis. Although the diagnoses are not mutually exclusive, in most cases a patient will have only one diagnosis.

There are some cases in which more than one diagnosis may be appropriate. One example is a case in which a patient may have a pre-existing movement system problem and then acquire a new movement system problem. Another example is a case in which 2 equally dominant movement system faults are thought to be limiting the patient's function. In other cases, the examination findings may match the description and key tests of a single diagnosis, but an additional patient characteristic is present that may alter the expected outcome. In these cases, a descriptor may be appended to the diagnosis (eg, movement pattern coordination deficit with impaired memory) (online Supplemental Appendix 1). The diagnosis (movement pattern coordination deficit) states the nature of the movement problem, and the descriptor (impaired memory) implies that the patient's ability to learn new strategies may be limited, thereby altering the expected outcome. Once the movement system diagnosis is determined, the therapist then considers the prognosis for recovery of the movement system fault and selects interventions appropriate to the patient's diagnosis and prognosis.

The purposes of this case report are: (1) to illustrate application of the diagnostic system on 3 patients with hemiplegia due to stroke and (2) to describe recent modifications of the system. Our focus will be on lower-extremity (LE) functions and balance. In addition to the examination findings used to make a diagnosis and an outline of the patients' procedural interventions, we will include the results of standardized tests used to quantify the patient's status. All patients consented in writing to participate as subjects of a case report. All of the patient examinations and interventions were completed by one of the authors (PLS).

Patient 1: Force Production Deficit

Patient Examination

History and systems review. The patient was a 56-year-old man who began physical therapy intervention in the outpatient setting 8 days after a left cerebrovascular accident. He complained of stumbling, difficulty producing speech, weakness in the right LE, and moderate difficulty with activities of daily living involving the right hand. Exploration of his past medical history revealed the following: a hereditary hearing loss, newly diagnosed hypertension for which he was receiving medication, and type II diabetes mellitus. He was preparing to retire from his job as a forklift driver, and he was a grain farmer. He was married, and his wife worked full-time. Aside from his insulin, he did not know the names of the medications that he was taking, but he reported that he took them as prescribed. His goals were to return to farming, to engage in work around his house, and to be able to play with his grandchildren.

Tests and measurements. The results of the examination for this patient are shown in Table 1. (6-9) Unless otherwise indicated, the results are for the patient's right side, and the left side was normal.

The movement tests--fractionated movement (FM) and motoneuron response assessment (MRA)--are tests that were developed in our clinic and are described in detail in the online Supplemental Appendix 2. Fractionated movement is a measure that reflects the patient's ability to move at one joint without moving at other joints. The test was designed to identify important information about the movement system quickly and easily. In previous work, (10) we demonstrated high interrater reliability coefficients (intraclass correlation coefficients [ICCs]) among 4 examiners (ICC= 1.00 for upper-extremity [UE] FM, ICC = .98 for LE FM) and significant correlations with the Motricity Index (11) for the UEs (r=.71) and the LEs (r=.87).

The MRA is designed to reflect the level of hyperexcitability of a patient with central nervous system dysfunction, particularly after stroke. Previous work (12) has demonstrated acceptable interrater reliability coefficients among 4 examiners (ICC=.93 for UE MRA, ICC=.74 for LE MRA) and some evidence of a correlation with the Ashworth Scale (13) for the UEs (r=.57) and the LEs (r=.58). In contrast to the Ashworth Scale, (13) the MRA provides information about reflex behavior both during and after cessation of voluntary effort rather than just during passive testing conditions.

Evaluation and Diagnosis

Summary of tests of impairments. The patient had a mild increase in muscle tone in the right UE and LE, but his movement in both limbs was fractionated when moving against gravity. His muscle strength was less than normal on the right side.

Summary of analysis of critical tasks. The patient demonstrated signs of fatigue and difficulty initiating a sit-to-stand movement. The initiation phase of a sit-to-stand movement is the phase in which the LE force demands are the greatest. (14-17) The patient demonstrated hyperextension of the involved knee and a drop of the pelvis on the opposite side when he tried to bear weight on the involved side, such as during the step-up test (placing one foot up on a step and returning it to the floor), during gait, and when stepping over obstacles. Because there was no muscle shortness, the knee hyperextension and hip drop appeared to be due to an inability to support the joints during conditions of loading. The knee hyperextension and hip drop persisted during repeated trials despite provision of both verbal instruction and manual support.

Considering all of the examination results together, the primary movement fault affecting this patient's mobility and balance was inadequate muscle force production. Therefore, the movement system diagnosis was force production deficit.

Prognosis for Motor Recovery

When estimating the prognosis for motor recovery, the physical therapist should consider not only the medical diagnosis but also the available literature on motor recovery, natural history of the condition, and effect of medical treatments on motor recovery. The therapist should consider whether there is good or poor potential for recovery of the movement-related impairments before selecting specific interventions. Patients with good potential for recovery are likely to benefit from interventions designed to remediate the impairment. Patients with poor potential for recovery are expected to benefit most from being taught compensatory movement strategies or accommodations.

Patient 1 had weakness due to a stroke. He demonstrated rapid motor recovery, as evidenced by his ability to move against gravity and fractionate movement within the first few days after his stroke. Based on a review of the literature related to motor recovery after stroke, (18-23) the patient's prognosis for further motor recovery was good.

Prognosis for Functional Recovery

After stroke, early and significant motor recovery, as seen in this patient, is related to maximal functional recovery. (24-28) However, ongoing movement deficits persist even after mild stroke. (29,30) Considering the data about motor and functional recovery after stroke and our own clinical experience, there was little doubt that this patient would walk independently without an assistive device in the home and in the community. Furthermore, we considered it likely that the patient would be able to walk for extended periods in the community with minimal gait deficits when brief rests could be incorporated into the activity. By contrast, we considered it likely that the patient would fatigue and demonstrate marked gait deficits when walking for extended periods (2 hours or more) without brief rests and with more vigorous activity such as climbing and running.

Intervention

Rationale. The rationale for selecting appropriate interventions for a patient with a movement system diagnosis of force production deficit is not based on direct evidence, because no intervention study has incorporated a group of patients with this specific movement system diagnosis. Based on logic, we determined that interventions for a patient with force production deficit and a good prognosis for recovery should be aimed at remediation of the primary movement fault of weakness through strength training.

There is a growing body of knowledge regarding the effectiveness of strength training in people who have had a stroke, (31-36) but it is difficult to determine how many study subjects were actually similar to patient 1. Based on the studies reviewed, it appears that strength training is safe (32) in individuals who had a stroke at least 3 months prior to training and is related to improved performance in functional activities. (31,33-36) However, evidence specific to people with acute stroke is limited. There is support from the National Clinical Guidelines for Stroke (37) developed by the Royal College of Physicians in London for using strength training in individuals who have had a stroke; however, the guidelines do not state for which patients with stroke or in what phase of recovery a therapist should administer resisted exercise.

In addition, the American Heart Association/American Stroke Association-endorsed practice guidelines recommend "that strengthening should be included in the acute rehabilitation of patients with muscle weakness after stroke." (38(p e126)) More specifically, Cart and Shepherd (39) suggested that, in order to link improvement in muscle strength to improvement in functional performance, strength training should be oriented toward characteristics of tasks to be learned. After our analysis of the literature and based on our clinical experience, we believe that people with the diagnosis of force production deficit with a good potential for recovery after a central nervous system lesion may benefit from task-oriented training that is delivered in a resistance training paradigm (eg, performing 2-3 sets of 8-12 repetitions of the task at 60%-80% of the maximal resistance level, at a frequency of 2-3 times per week (40-43)).

Specific interventions and response to treatment. The specific interventions for this patient are described in the online Supplemental Appendix 3, with additional comments below. Consistent with a strengthening paradigm, (40-43) the intervention described was completed over 7 weeks at a frequency of 3 times per week. Sessions were generally 30 to 45 minutes long.

The patient was given in-shoe heel lifts to protect the posterior capsule of the knee from potential irritation and to improve the use of the quadriceps femoris muscle in controlling the knee during walking. The heel lifts placed the patient in relative plantar flexion at the instant of heel contact and during the stance phase of walking. Taping of the posterior aspect of the knee in an "X" with Leukosport tape * also provided a biomechanical block to knee hyperextension. When both the heel lift and tape were used, the patient did not hyperextend his knee during walking.

The therapist identified sitting down and rising to a standing position, stepping up and down on a step, and stair climbing as tasks that had high demands for force production and could be used for functional resistance training (Figs. 1, 2, and 3). In each of these tasks, the patient was cued to use the involved LE as much as possible. The tasks were made more difficult by modifying the height or incline of the surface and restricting use of the patient's uninvolved limb.

[FIGURES 1-3 OMITTED]

The patient progressed slowly with exercise performed on resistance training equipment, and he reported significant fatigue after these exercises, The patient reported minimal to no muscle soreness in the 24 to 48 hours after each session.

Outcome

Results of the clinical examination at the end of the patient's course of physical therapy intervention are provided in Table 1. Only those factors that changed are included in the table. The patient improved in the following: (1) ability to stand from low surfaces, (2) gait speed, (3) sustaining hip and knee extension during weight-bearing tasks, and (4) maneuvering over or around obstacles while walking without hesitating. He was able to chase his grandson across a room and run for short distances in the yard.

Patient 2: Fractionated Movement Deficit

Patient Examination

History and systems review. The patient was a 55-year-old man who started physical therapy intervention in the outpatient setting 3 months after a right cerebrovascular accident. The patient reported that he was in an acute care hospital immediately after his stroke for less than 1 week and in the rehabilitation hospital for 1 1/2 weeks. After his hospital discharge, he received physical therapy intervention at home until he began receiving care at the outpatient clinic.

The patient lived with his wife and had several children who lived at home intermittently. His wife assisted him with all activities of daily living. He had a wheelchair at home but did not use it. Instead, he reported walking in his home with a hemi-walker (side-stepper). He had not fallen since he had returned home from the hospital. In addition to reporting significant difficulty in performing activities with his left hand, he complained of left shoulder pain. Prior to his stroke, he was employed at a tree nursery. At the time of his first outpatient visit, he was pursuing status as a disabled worker. Previous medical conditions included a small myocardial infarction 2 years prior to the stroke leading to the current episode of care and a previous stroke with no residual deficits 7 years prior. He had hypertension for which he was taking medication. He did not know the names of the medications he was taking, but he reported that he was taking them as prescribed. His goals were to wall in the community alone and to drive his truck.

Tests and measurements. The results of the initial examination are provided in Table 2. Unless otherwise indicated, all deficits were on the left side.

Evaluation and Diagnosis

Summary of tests of impairments. The patient was unable to fractionate movement of the left UE and LE, and the movement time of his left LE was increased as compared with both his right LE and with movement times of people without impairments.

Summary of analysis of critical tasks. The patient's nonfractionated movement was evident in his performance of each task. He was unable to modify the movement pattern in response to either cueing or instruction. He lacked the postural stability necessary to accommodate for his slow movements, and his instability was particularly apparent when he attempted to stabilize on the right LE while advancing the left LE during a task. He became more unstable when he attempted to perform a lower-limb task at faster speeds.

Considering the tests of impairments and performance on critical tasks, the patient's diagnosis was fractionated movement deficit. Although some patients with stroke may demonstrate fractionated movement deficit in only the upper limb or the lower limb, patient 2 demonstrated this movement fault in both limbs.

Prognosis for Motor Recovery

The patient was not able to fractionate movement at one segment without movement at other segments. He also demonstrated a high level of motoneuron hyperexcitabllity, as evidenced by his MRA category. These findings along with the duration of his stroke (3 months) indicated that the quality of his movement was not likely to change, and the prognosis for motor recovery was poor. (18-23,44-47)

Prognosis for Functional Recovery

An understanding of the patient's clinical signs within the first 2 weeks after the stroke would assist in determining the patient's prognosis for functional recovery. (25-28) The patient reported that he was able to sit on the side of the bed without support in the first few days after his stroke. He also reported that he had always been continent in bowel and bladder. Retention of these abilities is associated with good functional recovery; their loss is associated with poor functional recovery. (25-27) The patient's severe motor deficit and prior stroke are associated with poor functional recovery. (26,27)

Given the patient's clinical picture, the literature on functional recovery after stroke, and our clinical experience with patients with FM deficit, we considered it likely that this patient would wall slowly but independently in the home without an assistive device and in limited outdoor settings using an assistive device. We considered it unlikely that he would be independent with more ambitious activities such as repeated, rapid squatting and stooping or lifting and carrying moderately heavy objects using both limbs. Likewise, we considered it unlikely that he would be independent with bimanual activities of daily living or tasks involving the left hand only.

Intervention

Rationale. As with the diagnosis for the first patient, the rationale for selecting interventions is not based on direct evidence from the literature, because no intervention study has included a group of patients with this specific movement system diagnosis (ie, FM deficit). In this case, the literature related to prognosis for motor recovery guided our intervention strategy. Because of the patient's poor potential for motor recovery, correcting the patient's movement patterns was not a part of the treatment plan. Rather, the overall treatment objective was to improve the patient's postural stability when performing the compensatory movement strategies he needed to use because he was not able to fractionate movement. In order to provide sufficient opportunity for practice of sufficiently complex postural stability tasks, the therapist recommended daily sessions for 2 to 3 weeks; however, the patient was unable to arrange transportation for this treatment frequency. As a result, the patient was treated 2 to 3 times per week for 8 weeks; each session lasted 45 to 60 minutes. The procedural interventions for this patient are detailed in the online Supplemental Appendix 4 and are highlighted below.

Specific interventions and response to treatment. During the first week of treatment, the patient practiced walking on level surfaces while using a straight cane. The patient's greatest challenges during walking were: (1) balancing on his right LE (uninvolved limb) during left LE (involved limb) swing, (2) regulating his right LE step length relative to his degree of stability on the left LE, and (3) consistently placing his left foot appropriately (Fig. 4). He used compensatory movement strategies, that is, lateral trunk flexion and hip hiking (elevation of the pelvis), to swing his left LE. Practice was aimed at improving the consistency of this movement strategy to ensure more consistent foot placement and stability. He was encouraged to practice walking at home with the straight cane when someone was nearby; but, because of fear of falling, he did not follow through with consistent practice at home until his third week of therapy.

[FIGURE 4 OMITTED]

The patient began stepping over obstacles in the first 2 weeks. He practiced stepping over obstacles, leading with both the left and right feet. His foot placement was more consistent when leading with the right foot, and this was the strategy that he was instructed to use.

During the third and fourth weeks of his therapy, the patient began to practice retrieving objects from the floor from a standing position. During his initial attempt at retrieving an object from a 30.48-cm-high (12-in-high) surface, he moved very slowly and started to fall backward when he began his return to an upright position. However, within a few trials, he was able to retrieve an object from the floor very slowly and to return to the standing position without loss of balance. Within 2 sessions, he was successful in retrieving objects from the floor on his initial attempt, but he still moved slowly.

The patient first attempted walking without an assistive device during the fifth week of therapy. He was able to walk only 3 to 4.6 m (10-15 ft) before he needed physical assistance with balance. With the increased postural demands of walking without a device, he again had difficulty with consistency of left foot placement. Within one session, he learned to decrease the length of steps he attempted to take, and he was able to walk up to 3 m (10 ft) without either using an assistive device or losing his balance.

The patient began practicing standing up from and sitting down on a 50.8-cm (20-in) sitting surface during the first week of therapy. He was most successful if he used his right foot to help him flex his left knee so that his foot was positioned underneath him for standing.

The patient initially attempted to climb stairs while using a railing during the first week of therapy. However, the task was too difficult for him for a number of reasons: he required complete support for balance, his left LE crossed midline with each attempt, and he was unable to correct these problems with practice. As a result, this task was considered to be too difficult to be therapeutic at that time. Stair climbing was evaluated each week but not practiced until the patient's stability with compensatory strategies was improved, and he was able to complete the task with only moderate assistance instead of maximal assistance.

The patient also practiced opening and closing doors while walking, carrying objects in his right hand while walking, and transferring to and from the floor. On his first attempts of these more complex tasks, he often had difficulty developing a successful movement strategy. However, once instructed in a possible strategy, he was generally successful by the second or third trial.

The therapist used the LiteGait partial body-weight support system ([dagger]) (Fig. 5) to improve walking endurance and speed. Initially, 30% to 40% of the patient's body weight was supported. (48-50) At first, he was too fatigued to walk longer than 10 minutes. For a while, the patient practiced walking both with and without an ankle-foot orthosis (AFO), but because his left foot placement was more consistent with the AFO, subsequent practice was done with the AFO.

[FIGURE 5 OMITTED]

During the last 2 weeks of therapy, the patient continued to practice all of the outlined tasks with an increasing emphasis on consistency of performance, flexibility of performance under varying environmental constraints, and efficiency. (51) This practice included walking outdoors and transferring in and out of the patient's truck.

Outcome

Results of the examination at the end of treatment are in Table 2. Only those factors that changed are included in the table. The patient showed improvement in his balance, independence with gait and stair climbing, ability to stand up from and sit down on a variety of surfaces (Fig. 6), ability to perform complex gait activities, and slight improvement in gait speed. He was slow but able to retrieve a pen or pencil from the floor, carry a bag of groceries short distances, open and close doors while walking with or without a cane, sit down and stand up from the floor without a chair or other support, step over a low object with a cane, step up and down a curb with a cane, walk outdoors with a cane, and ascend and descend a flight of stairs using a reciprocal pattern with the aid of a railing.

[FIGURE 6 OMITTED]

Patient 3: Perceptual Deficit

Patient Examination

History and systems review. The patient was a 76-year-old man who was admitted to the hospital from the emergency department with complaints of left-sided weakness 1 day prior to the initial physical therapist examination. He was found to have a right middle cerebral artery infarct and atrial fibrillation. After 1 week, his condition deteriorated somewhat, and he was found to have a new hemorrhage in the right basal ganglia. His medical history included hypertension, hyperlipidemia, [B.sub.12] deficiency, and a urinary tract infection.

Prior to having a stroke, the patient was retired but was quite active around his home and in the community. He required no assistance with activities of daily living, he was able to drive a car, and he particularly enjoyed yard work. He lived with his wife, who was in good health. His medications were adjusted during his stay in the hospital and, at discharge, included medications for all of the conditions in his history. The patient was unable to articulate specific goals but wanted to "get better."

Tests and measurements. The initial physical therapist examination was completed on the first day following the stroke. When the therapist entered the room in the intensive care unit, the patient was found lying in the bed with his head turned completely to the right. He was receiving 2 L of oxygen, and his vital signs, heart rhythm, and oxygen saturation were being monitored electronically. The results of his initial examination are shown in Table 3. In addition to these results, the therapist noted that the patient was awake, lethargic, and oriented. He was able to follow commands to perform 1- and 2-step movements, made jokes, and was somewhat restless. During the examination, he had difficulty maintaining his level of alertness.

Evaluation and Diagnosis

Summary of tests of impairment and analysis of critical tasks. Although the patient had a number of substantial impairments, including weakness of the left side, a left visual field loss, and disregard for the left side, the primary movement problem that affected this patient's mobility was his resistance to correction of vertical orientation. This statement is justified by the following line of reasoning. When the patient attempted to sit up straight, he fell to the left side. When the therapist attempted to correct the patient's postural alignment, the patient resisted correction to the midline position. The patient's weakness may have explained why he fell to the left side, but weakness did not explain why he shifted his weight toward that side and resisted correction to the midline position. In our experience, patients who are weak and have an accurate internal reference for postural orientation shift their weight toward the uninvolved side.

Similarly, the patient's left visual field loss may have explained why he shifted his weight toward the left side but would not explain why he resisted correction to the midline position. In our experience, patients with a visual field loss may shift their weight toward the side of the visual field loss, but they are able to orient to a midline position with minimal cues and guidance. The fact that the patient resisted correction to the midline position suggested that he had a faulty internal reference for postural orientation. (39) In our experience, all patients who resist correction to vertical orientation have disregard for the involved side, but not all patients with disregard for the involved side resist correction to vertical orientation.

Based on the results of the tests and the observations of our clinical examination, this patient's movement system diagnosis was perceptual deficit. The patient had a distorted sense of the vertical, and he resisted correction of midline position. To be more specific, we could add a descriptor "with visual field loss" if so desired.

Prognosis for Functional Recovery

Disregard for the involved side and poor postural control after stroke are associated with a poorer prognosis for functional independence and with a slower rehabilitation course than is expected when there is no disregard and good postural control. (52-56) Although this patient's sitting balance was very impaired initially, he was able to modify the strategy he used when sitting up from a right side-lying position. His lethargy significantly affected the therapist's ability to identify how readily he was able to modify his motor performance with practice. Given his very acute status, his ability to follow instructions (even though lethargic), and his other findings, we considered it likely that within 4 weeks the patient would be able to sit unsupported. We also considered it likely that he would require minimal assistance with transfers and be unlikely to use ambulation as a means of locomotion. (27,28,57,58)

Intervention

Rationale. In contrast to the situation for the first 2 cases, a rationale for intervention selection related to the perceptual deficit diagnosis can be based on direct evidence from the literature. In general, we agree with the principles previously described by Karnath and colleagues (59-61) for patients with contraversive pushing. Consequently, the procedural interventions were focused on increasing the patient's awareness of his postural control deficits, teaching him movements necessary to find a balanced position, and increasing his ability to maintain a balanced position while completing other movements. In addition, the therapist developed a plan for increasing the patient's tolerance to the upright position. The patient was treated in the acute care hospital for 2 weeks prior to being transferred to a rehabilitation hospital in another town. He tolerated 20 to 30 minutes of physical therapy intervention daily during the first 10 days after his stroke and 30 to 40 minutes per day during the last 4 days of his hospital stay. The procedural interventions for this patient are outlined in Supplemental Appendix 5 (available online only at www.ptjournal.org) and are described below.

Specific interventions and response to treatment. In all up-fight tasks, including sitting in a "cardiac" chair, the patient was encouraged to align himself with door jams, window frames, and other vertical objects within his visual field. The patient's ability to concentrate and focus on these instructions was limited to seconds at a time.

Because the patient had significant difficulty shifting weight from the left side to the right side, he was moved into a sitting position from a right side-lying position. Using this method, weight was already on his right hip before he attempted to move to a sitting position. His "pushing" behavior was consistently controlled when leaning on the right forearm with the elbow flexed in a sitting position. This position was used as a resting position whenever the patient lost his balance and demonstrated "pushing" behavior (Fig. 7). He practiced assuming an upright sitting position by moving from the resting position to a sitting position by lifting the arm from the bed and straightening his trunk to sit (Fig. 8).

[FIGURES 7-8 OMITTED]

The patient practiced coming to a standing position from a sitting position. He was prevented from using his right UE to assist with standing because doing so increased the pushing behavior. A bedside table was placed on the patient's right side, and he was cued to either reach his hand in the air or slide his hand toward the right front corner of the table while shifting his right hip toward the table (Fig. 9). He was able to achieve some active weight shift to the right side on his initial attempts with this activity.

[FIGURE 9 OMITTED]

The patient practiced maintaining his balance while moving his head from side to side and by moving either the right UE or LE while in the following positions: sitting and leaning on the right forearm, sitting in a chair without armrests, and standing. He consistently fell to the left side with each effort.

An initial part of the plan for the patient involved teaching the nursing staff to work with him on improving vertical tolerance. The therapist identified an appropriate chair-and-transfer strategy so that the patient could be out of bed at regular intervals. The nursing staff performed a passive transfer from the bed to a "cardiac" chair; using the cardiac chair was advantageous because it flattened like a bed for the transfer and then easily converted back to a chair. The patient sat in the chair 30 to 45 minutes, 3 times per day.

Outcome

The results of the examination just prior to discharge from the acute care hospital to the rehabilitation hospital are shown in Table 3. Only the factors that changed are included in the table.

Discussion

We have demonstrated that 3 patients with the same medical diagnosis had 3 different movement system diagnoses, each of which required a different set of interventions. We believe that, by focusing on the movement system rather than the medical diagnosis, we can categorize patients in ways that are distinctly meaningful for physical therapists. More specifically, by using a distinct set of movement system diagnoses, coupled with an understanding of the prognosis for recovery, we can most appropriately guide selection of interventions and facilitate research designed to test the effect of interventions. The set of movement system diagnoses for neuromuscular conditions that we have developed is at least a beginning for how to organize our thinking about diagnosis.

Benefits of System

Using a diagnostic system for the movement system as a basis for physical therapist practice improves the care of patients in 4 important ways: (1) therapists can follow a pattern of care for patients with similar movement system problems leading to less variability among providers, (2) therapists can target treatment toward a specific movement problem from the beginning of an episode of care with less reliance on trial and error, (3) therapists can communicate clearly with one another and with third-party payers, and (4) researchers can focus their studies on testing the effectiveness of movement interventions on patients with different types of movement problems rather than different types of diseases. We will now discuss each of these features of clinical practice in more detail.

Organizing practice around a focus on the movement system and a set of movement system diagnoses decreases variability in practice in at least 3 ways. First, before making a diagnosis, physical therapists should perform a standardized clinical examination; doing so ensures that all patients are. examined in the same way. Second, use of the standardized examination in concert with the definitions for the diagnoses ensures that all therapists arrive at the same diagnosis for a particular patient. Third, use of a system in which movement-related interventions are linked to specific movement system diagnoses ensures consistent treatment selection among therapists. Decreased variability in medical practice has been shown to improve the process and outcome of clinical care. (62,63) We expect that decreased variability in physical therapist practice will yield similar benefits for patients.

In standard physical therapist practice, there is no framework for selecting from among the vast array of strategies available to the therapist. As a result, standard physical therapy care for patients with neuromuscular conditions is often a process of trial and error, with related inefficiencies. When applying our system, therapists are directed toward strategies that we believe will either remediate impairments or assist in developing alternative compensatory movements, (26,64,65) depending on the patient's movement system diagnosis. With less trial and error in practice, the patient is able to maximize the available practice time by focusing only on those interventions that are most likely to be successful.

A system of diagnosis for physical therapy is useful in communicating with colleagues. A known, agreed-on set of labels for conditions that physical therapists manage will help colleagues develop an immediate mental picture of the patient as well as formulate ideas about intervention. A system of diagnoses also is useful in communicating with third-party payers, who--in our experience--have been responsive to requests for additional services for some patients because they see that we use fewer resources for other patients.

Finally, using a set of movement system diagnoses as the basis for grouping patients in clinical research studies may increase the likelihood that results will demonstrate the effectiveness of interventions and be more readily applicable in the clinical environment. Historically, subjects in intervention studies have been grouped based on their medical diagnosis; in some cases, subjects have been further categorized based on the severity of their condition. For example, some authors (66-68) have suggested that constraint-induced movement therapy (CIMT) is effective for improving UE function in patients who have had a stroke. Other authors (69) have suggested that CIMT may be effective for other conditions such as focal hand dystonia. In both conditions, the movement deficits of the patients are relatively mild. The unanswered question is whether CIMT is an intervention that appears to be effective for people who have specific medical diagnoses or an intervention that is effective for people with relatively mild movement system problems. In order for results to be more readily applicable to the clinical setting, the movement system interventions that we use might best be studied for their effectiveness on a given state of the movement system as opposed to a given disease. We believe that a set of movement system diagnoses such as ours may be at least a starting place for categorizing patients and that, if it is used by researchers, the results will be very beneficial for patients.

Limitations

Our movement system diagnoses for patients with neuromuscular conditions are focused on the diagnosis and prognosis aspects of patient management. They do not attempt to account for the context of the patient's care as defined by the patient's roles, support system, goals, or other variables. When using our system, the diagnosis is the movement system problem, and the prognosis is the potential for improvement. The context of the patient's case focuses the therapist on activities that are important and meaningful to the patient while holding fast to treatment principles that are consistent with the diagnosis and prognosis.

Our movement system diagnoses for patients with neuromuscular conditions have not been validated by research. Although our ideas have some face validity through repeated clinical use and implementation in various clinical settings, we have not tested our ideas through controlled studies. These studies are needed.

We do not have any evidence regarding the relationship between our movement system diagnoses and performance on standardized measures. For example, we can postulate that patients with movement pattern coordination deficit, force production deficit with a good prognosis for recovery, and sensory selection and weighting deficit will perform better on the Berg Balance Scale (6-8) than patients with sensory detection deficit or hypermetria (Supplemental Appendix 1, available online only at www.ptjournal.org). However, we do not know whether patients with sensory detection deficit and hypermetria will perform differently from each other on the Berg Balance Scale. (6-8) We do not believe that performance on standardized measures will prove to be diagnostic for movement system problems, but the relationship could be studied.

Conclusion

We have described a set of impairment-level movement system diagnoses for patients with neuromuscular conditions and have demonstrated use of the diagnoses with 3 patients. The set of diagnoses may have multiple benefits for clinical practice and research because it provides a framework for identification and management of specific human movement system problems.

All authors provided concept/idea/project design and writing. Dr Scheets provided data collection and analysis, patients, and facilities/equipment.

All requirements of Provena St Mary's Hospital for the protection of personal health information were met.

This article was received November 2, 2005, and was accepted January 8, 2007.

DOI: 10.2522/ptj.20050349

References

(1) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001:81:9-746.

(2) Sahrmann SA. Diagnosis by the physical therapist: a prerequisite for treatment. Phys Ther. 1988;68:1703-1706.

(3) Jette AM. Diagnosis and classification by physical therapists: a special communication. Phys Ther. 1989;69:967-969.

(4) Guccione AA. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 1991;71: 499-503.

(5) Scheets PL, Sahrmann SA, Norton BJ. Diagnosis for physical therapy for patients with neuromuscular conditions. Neurol Rep. 1999;23:158-169.

(6) Berg KO, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can. 1989;41: 304-311.

(7) Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Pub Health. 1992;83(S2):S7-S11.

(8) Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil. 1992;73:1073-1080.

(9) Granger CV, Hamilton BB, Sherwin FS. Guide for the Use of the Uniform Data Set for Medical Rehabilitation. Buffalo, NY: Uniform Data System for Medical Rehabilitation Project Office, Buffalo General Hospital; 1986.

(10) Scheets P, Morton S, Sahrmann SA, Norton BJ. Reliability, correlation, and relationship to function of measures of active motion in patients with hemiparesis [abstract]. Phys Ther. 1999;79:S100.

(11) Demeurisse G, Demol O, Robaye E. Motor evaluation in vascular hemiplegia. Eur Neurol. 1980;19:382-389.

(12) Sahrmann SA, Scheets P, Morton S, Norton BJ. Reliability, correlation, and relationship to function of measures of "tone" in patients with hemiparesis [abstract]. Phys Ther. 1999;79:S100.

(13) Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner. 1964; 192:540-542.

(14) Pai Y-C, Rogers MW. Speed variation and resultant joint torques during sit-to-stand. Arch Phys Med Rehabil. 1991;72: 881- 885.

(15) Schultz AB, Alexander NB, Ashton-Miller JA. Biomechanical analyses of rising from a chair. J Biomech. 1992;25:1383-1391.

(16) Wrentenberg P, Lindberg F, Arborelius UP. Effect of armrests and different ways of using them on hip and knee load during rising. Clin Biomech. 1993;8:95-101.

(17) Doorenbosch CAM, Harlaar J, Roebroeck ME, Lankhorst GJ. Two strategies of transferring from sit-to-stand; the activation of monoarticular and biarticular muscles. J Biomech. 1994;27:1299-1307.

(18) Gowland C. Recovery of motor function following stroke: profile and predictors. Physiother Can. 1982;34:77-84.

(19) Skilbeck CE, Wade DT, Hewer RL. Recovery after stroke. J Neurol Neurosurg Psychiatry. 1983;46:5-8.

(20) Gowland C. Predicting sensorimotor recovery following stroke rehabilitation. Physiother Can. 1984;36:313-320.

(21) Olsen TS. Arm and leg paresis as outcome predictors in stroke rehabilitation. Stroke. 1990;21:247-251.

(22) Duncan PW, Goldstein LB, Matchar D, et al. Measurement of motor recovery after stroke: outcome assessment and sample size requirements. Stroke. 1992; 23:1084-1089.

(23) Duncan PW, Goldstein LB, Homer RD, et al. Similar motor recovery of upper and lower extremities after stroke. Stroke. 1994;25:1181-1188.

(24) Wade DT, Wood VA, Heller A, et al. Walking after stroke: measurement and recovery over the first 3 months. Scand J Rehabil Med. 1987;19:25-30.

(25) Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry. 1987;50:177-182.

(26) Duncan PW. Stroke disability. Phys Ther. 1994;74:399-407.

(27) Kwakkel G, Wagenaar RC, Kollen BJ, Lankhorst GJ. Predicting disability in stroke: a critical review of the literature. Age Ageing. 1996;25:479-489.

(28) Patel AT, Duncan PW, Lai S, Studensld S. The relation between impairments and functional outcomes poststroke. Arch Phys Med Rehabil. 2000;81:1357-1363.

(29) Brown DA, Kautz SA. Speed-dependent reductions of force output in people with poststroke hemipareis. Phys Ther. 1999;79:919-930.

(30) Lai S-M, Studenski S, Duncan PW, Perera S. Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke. 2002;33:1840-1844.

(31) Duncan PW, Richards L, Wallace D, et al. A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Stroke. 1998;29:2055-2060.

(32) Brown DA, Kautz SA. Increased workload enhances force output during pedaling exercise in persons with poststroke hemiplegia. Stroke. 1998;29:598-606.

(33) Teixeira-Salmela LF, Oiney SJ, et al. Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Arch Phys Med Rehabil. 1999;80:1211-1218.

(34) Dean CM, Richards, CL, Malouin F. Taskoriented circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000;81: 409- 417.

(35) Teixeira-Salmela LF, Nadeau S, Mcbride I, Olney SJ. Effects of muscle strengthening and physical conditioning training on temporal, kinematic and kinetic variables during gait in chronic stroke survivors. J Rehabil Med. 2001;33:53-60.

(36) Ouellette MM, LeBrasseur NK, Bean JF, et al. High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors. Stroke. 2004;35:1404-1409.

(37) Internet Stroke Center. Guidelines and Consensus Statements. Royal College of Physicians, National Clinical Guidelines for Stroke, 2nd ed, Section 4.4.5, Strength and Aerobic Training. Available at: http://www. strokecenter.org. Accessed February 25, 2007.

(38) Duncan PW, Zorowitz R, Bates B, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100-e143.

(39) Carr J, Shepherd R. Stroke Rehabilitation: Guidelines for Exercise and Training to Optimize Motor Skill. London, United Kingdom: Butterworth-Heinemann; 2003: 230-231, 242-243.

(40) Deschenes MR, Kraemer WJ. Performance and physiologic adaptations to resistance training. Am J Phys Med Rehabil. 2002; 81(11 suppl):S3-S16.

(41) Kilmer DD. Response to resistive strengthening exercise training in humans with neuromuscular disease. Am J Phys Med Rehabil. 2002;81(11 suppl):S121-S126.

(42) Edgerton VR, Roy RR, Allen DL, Monti RJ. Adaptations in skeletal muscle disuse or decreased-use atrophy. Am J Phys Med Rehabil. 2002;81(11 suppl):S127-S147.

(43) Fitts RH. Effects of regular exercise training on skeletal muscle contractile function. Am J Phys Med Rehabil. 2003;82: 320-331.

(44) Sahrmann SA, Norton BJ. The relationship of voluntary movement to spasticity in the upper motor neuron syndrome. Ann Neurol. 1977;2:460-465.

(45) Snyder R, Tripp N, Sahrmatm SA, Norton BJ. The relationship between a tone assessment and fractionated movement with the hemiparetic upper extremity. Phys Ther. 1992;72(6 suppl):S89.

(46) Snyder MR, Kohne P, Sahrmann SA, Norton BJ. The relationship between the motorneuron response assessment and fractionated movement of the upper extremity in subjects with hemiplegia. Phys Ther. 1994;74 (5 suppl):S45.

(47) Sahrmann SA, Kohne P, Norton BJ. Postonset distribution of tone in patients with hemiparesis. Phys Ther. 1994;74(5 suppl): S41.

(48) Hesse S, Bertelt C, Schaffrin A, et al. Restoration of gait in nonambuiatory hemiparetic patients by treadmill training with partial body-weight support. Arch Phys Med Rehabil. 1994;75:1087-1093.

(49) Hesse S, Konrad M, Uhlenbrock D. Treadmill walking with partial body weight support versus floor walking in hemipartic subjects. Arch Phys Med Rehabil. 1999; 80:421- 427.

(50) Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Arch Phys Med Rehabil. 2003;84: 1458-1465.

(51) Quiun L, Gordon J. Functional Outcomes Documentation for Rehabilitation. St Louis, Mo: WB Saunders Co; 2003:63-73.

(52) Pedersen PM, Wandel A, Jorgensen HS, et al. Ipsilateral pushing in stroke: incidence, relation to neuropsychological symptoms, and impact on rehabilitation. The Copenhagen Stroke Study. Arch Phys Med Rehabil. 1996;77:25-28.

(53) Taylor D, Ashburn A, Ward CD. Asymmetrical trunk posture, unilateral neglect and motor performance following stroke. Clin Rehabil. 1994;8:48-53.

(54) Gottlieb D, Levine DN. Unilateral neglect influences the postural adjustments after stroke. J Neurol Rehabil. 1992;6:35- 41.

(55) Morgan P. The relationship between sitting balance and mobility outcome in stroke. Aust J Physiother. 1994;40:91-96.

(56) Franchignoni FP, Tesio L, Ricupero C, Martino MT. Trunk control test as an early predictor of stroke rehabilitation outcome. Stroke. 1997;28:1382-1385.

(57) Prescott RJ, Garraway WM, Akhtar AJ. Predicting functional outcome following acute stroke using a standard clinical examination. Stroke. 1982;13:641-647.

(58) Wade DT, Skilbeck CE, Hewer RL. Predicting Barthel ADL score at 6 months after an acute stroke. Arch Phys Med Rehabil. 1983;64:24-28.

(59) Karnath H-O, Broetz D. Understanding and treating "pusher syndrome." Phys Ther. 2003:83:1119-1125.

(60) Broetz D, Johannsen L, Karnath H-O. Time course of "pusher syndrome" under visual feedback treatment. Physiother Res Int. 2004;9:138-143.

(61) Broetz D, Karnath H-O. New aspects for the physiotherapy of pushing behavior. NeuroRehab. 2005;20:133-138.

(62) Deutsch SC, Denton M, Borenstein J. Clinical practice guidelines: a tool to help provide quality care. Geriatrics. 1998;53: 57-74.

(63) Carnett WG. Clinical practice guidelines: a tool to improve care. Qual Manag Health Care. 1999;8:13-21.

(64) Gowland CA. Staging motor impairment after stroke. Stroke. 1990;21(9 suppl):II-19-II-21.

(65) Nakayama H, Jorgensen HS, Raaschou HO, Olsen TS. Compensation in recovery of upper extremity function after stroke: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994;75:852-857.

(66) van der Lee JH, Wagenaar RC, Lankhorst GJ, et al. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke. 1999;30:2369-2375.

(67) Dromerick AW, Edward DF, Hahn M. Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke. 2000;31:2984-2988.

(68) Bonifer N, Anderson KM. Application of constraint-induced movement therapy for an individual with severe chronic upper-extremity hemiplegia. Phys Ther. 2003; 83:384-398.

(69) Taub E, Uswatte G, Pidikiti R. Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation--a clinical review. J Rehabil Res Dev. 1999;36:237-251.

PL Scheets, PT, DPT, NCS, is Manager, Therapy Services, Department of Rehabilitation, Carle Foundation Hospital, 611 W Park St, Urbana, IL 61801 (USA). Address all correspondence to Dr Scheets at: patricia.scheets@carle. com.

SA Sahrmann, PT, PhD, FAPTA, is Professor of Physical Therapy/ Neurology/Cell Biology & Physiology, Program in Physical Therapy, Washington University School of Medicine, St Louis, Mo.

BJ Norton, PT, PhD, is Associate Professor of Physical Therapy and Neurology and Associate Director of Postprofessional Studies, Program in Physical Therapy, Washington University School of Medicine.

[Scheets PL, Sahrmann SA, Norton BJ. Use of movement system diagnoses in the management of patients with neuromuscular conditions: a multiple-patient case report. Phys Ther. 2007;87:654-669.]

Table 1.
Results of Force Production Deficit Initial and Posttreatment
Examinations (a)

Initial Tests of Impairments

Fractionated movement         UE: present at shoulder, elbow, wrist,
                                hand, and first finger
                              LE: present at hip, knee, and ankle

Strength                      Shoulder flexion 3/5
                              Shoulder abduction 3-/5
                              Elbow flexion 4-/5
                              Elbow extension 3+/5
                              Wrist extension 3/5
                              Wrist flexion 3/5
                              Hand flexion 3/5
                              Hand extension 3/5
                              Hip flexion 4-/5
                              Hip extension 3/5
                              Hip abduction 4-/5
                              Knee extension 4+/5
                              Dorsiflexion 4+/5
                              Plantar flexion 2/5

MRA                           UE: moderate; LE: mild

Sensation                     No deficits in sensation of pain,
                                temperature, or joint position sense

Posttreatment Tests of Impairments

Fractionated movement         No change

Strength                      Hip flexion 4/5
                              Hip extension 4-/5
                              Hip abduction 4/5
                              Plantar flexion 2/5

MRA                           No change

Sensation                     No change

Initial Analysis of Critical Tasks

Quiet sitting                 Essential movement
                                components present

Sit-to-stand                  Able to stand from 45.7-cnt (18-
                                in) surface, left knee flexed
                                more than right knee, with
                                left foot placed farther back;
                                apparent decreased weight
                                bearing on right side;
                                fatigued with 10 repetitions,
                                as evidenced by increased
                                use of momentum to initiate
                                task and lack of full hip
                                extension at termination of
                                task

Quiet standing (feet hip      Able to stand unsupported
  width apart)                  without difficult); no change
                                with eyes closed compared
                                with eyes open

Quiet standing (feet          Able to assume position in first
  together)                     attempt with increased sway
                                at hips; able to maintain
                                position: center of mass
                                shifted toward left side: no
                                change with eyes closed
                                compared with eyes open

Step-up (placed one foot      Able to complete task,
  on top of 20.3-cm             alternating legs, 8 times; left
  [8-in] step and               lateral trunk flexion during
  returned it to floor)         right swing; left pelvic drop
                                during right stance; right
                                knee hyperextension during
                                right stance; decreased left
                                lateral trunk flexion with
                                practice, but no other
                                changes

Gait                          Ambulated without assistive
                                device or physical assistance
                                on smooth, level surface; line
                                of progression deviated to
                                right side; decreased right
                                dorsiflexion at heel contact;
                                hyperextension of right knee
                                during right stance; left pelvic
                                drop during right stance; line
                                of progression improved with
                                cues to focus on a visual
                                target and with practice;
                                speed=0.7 m/s (2.2 ft/s)

Complex gait                  Able to walk with head turning
                                side to side without deviation
                                in line of progression or
                                instability; stopped before
                                changing from forward
                                walking to backward walking;
                                stepped backward very slowly
                                and deliberately; able to step
                                over obstacle 10.2 cm (4 in)
                                in diameter; mild instability
                                when stance sustained on
                                right LE when stepping over
                                obstacle

Initial Standardized Measures

Berg Balance Seale (6-8)      52/56

Functional Independence       Mobility subscale score: 20/21
  Measure (9)                 Locomotion subscale score:
                                12/14

Posttreatment Analysis of Critical Tasks

Quiet sitting                 No change

Sit-to-stand                  Able to stand from 25.4-cm
                                (10-in) surface; weight bearing
                                appeared to be equal between
                                left and right Les

Quiet standing (feet          No change
  hip width apart)

Quiet standing (feet          Able to assume position on first
  together)                     attempt with no sway; weight
                                bearing appeared to be equal
                                between left and right LEs

Step-up (placed one foot      Able to complete task,
  cm top of 20.3-cm step        alternating legs, 8 times;
  and returned it to            sustained involved hip
  floor)                        extension during involved-
                                limb swing; involved knee
                                without hyperextension

Gait                          In-shoe heel lifts; line of
                                progression straight on all
                                surfaces; decreased right
                                dorsiflexion at heel contact
                                after 304.8 m (1,000 ft):
                                hyperextension of right knee
                                during right stance if tired:
                                speed = 1.2 m/s (4.0 ft/s)

Complex gait                  Able to change from forward to
                                backward walking without
                                hesitation; no difficulty
                                stepping backward; able to
                                step over obstacle 45.7 cm
                                (18 in) in diameter without
                                instability or hesitation

Posttreatment Standardized Measures

Berg Balance Scale (6-8)      54/56

Functional Independence       Mobility subscale score: 21/21
  Measure (9)                 Locomotion subscale score:
                                14/14

(a) Results pertain to the right side unless otherwise indicated.
UE=upper extremity, LE=lower extremity, MRA=motorneuron response
assessment.

Table 2.
Results of Fractionated Movement Deficit Initial and Posttreatment
Examinations (a)

Initial Tests of Impairments

Fractionated               Movement against gravity but
  movement                   nonfractionated in shoulder flexion, hip
                             flexion, and knee extension; no other
                             movement
Strength                   Unable to fractionate movement even in
                             gravity-neutralized positions
MRA                        UE: marked; LE: severe
Sensation                  Impaired joint position sense at ankle

Initial Analysis of Critical Tasks

Quiet sitting              Able to sit unsupported; center of mass
                             shifted to right side
Sit-to-stand               Unable to stand from 50.8-cm (20-in)
                             surface without UE support; able to
                             stand from 50.8-cm surface with right
                             UE support; decreased weight bearing on
                             involved side; slow to initiate; lack
                             of frill hip and knee extension on
                             termination; loss of balance posteriorly
                             at termination; able to recover balance
                             by stepping; some improvement with
                             anterior weight shift during execution
                             with practice and manual guidance to
                             assist dorsiflexion of tibia over foot
Quiet standing (feet       Able to stand unsupported for 30 s;
  hip width apart)           involved hip and knee flexed; increased
                             sway at ankle (uninvolved limb) with
                             eyes closed
Quiet standing (feet       Required assistance to assume feet-together
  together)                  position; able to stand 15 s; swayed at
                             hips; some improvement in amount of sway
                             with repetition; increased sway with eyes
                             closed
Step-up (placed one        Needed assistance to attempt task; very
  foot on top of             slow to flex involved lip and knee and
  20.3-cm [8-in]             unable to do so through sufficient
  step and returned          range of motion; unable to balance on
  it to floor)               uninvolved LE during attempts to swing
                             involved LE; unable to modify strategy
Gait                       Ambulated with moderate hand-hold
                             assistance; gait characterized by the
                             involved foot crossing midline, decreased
                             weight bearing on the involved side,
                             hyperextension of the involved knee
                             during stance, inadequate lip flexion
                             during swing of the involved side with
                             substitutions of hip lateral rotation
                             and adduction, and decreased step length
                             on the uninvolved side; independent
                             with hemi-walker (side-stepper) and
                             prefabricated AFO; standby assistance
                             with large-base quad cane due to
                             instability during swing on the involved
                             side; unable to modify movement strategy
                             for left swing; speed=0.1 m/s (0.2 ft/s)
Complex gait               Moderate assistance due to instability for
                             ambulation with head turning and stepping
                             backward; maxima assistance to step over
                             object

Initial Standardized Measures

Berg Balance Scale (6-8)   25/56
Functional                 Mobility subscale score: 10/21
  Independence             Locomotion subscale score: 7/14
  Measure (9)

Posttreatment Tests of Impairments

Fractionated movement      No change
Strength                   No change
MRA                        No change
Sensation                  No change

Posttreatment Analysis of Critical Tasks

Quiet sitting              No change
Sit-to-stand               Able to stand from 38.1-cm (15-in) surface
                             with UE support; decreased weight
                             bearing on involved side; slow
Quiet standing (feet hip   No change
  width apart)
Quiet standing (feet       No change
  together)
Step-up (placed one foot   Needed assistance to attempt task; very
  on top of 20.3-cm          slow to flex involved hip and knee and
  step and returned it       unable to do so through sufficient range
  to floor)                  of motion; unable to modify strategy
Gait                       Speed=0.2 m/s (1.71 ft/s) with straight
                             cane and left AFO; characterized by
                             decreased weight bearing on the involved
                             side, inadequate lip flexion during swing
                             of the involved side with substitutions
                             of hip lateral rotation and adduction,
                             and decreased step length on the
                             uninvolved side
Complex gait               Able to walk outdoors, step up and down
                             on a curb, and step over a low object
                             with a cane; able to carry fight objects
                             indoors with right hand

Posttreatment Standardized Measures

Berg Balance Scale (6-8)   43/56
Functional                 Mobility subscale score: 18/21
  Independence             Locomotion subscale score: 12/14
  Measure (9)

(a) Results pertain to the left side unless otherwise indicated.
UE=upper extremity, LE=lower extremity, AFO-ankle-foot orthosis.

Table 3.
Results of Perceptual Deficit Initial and Posttreatment
Examinations (a)

Initial Tests of Impairments

Fractionated movement             No movement in any muscle
                                    groups in LIE or LE
Strength                          No movement in any muscle
                                    groups in LIE or LE
MRA                               UE: mild; LE: moderate
Other                             Abnormal flexor withdrawal
                                    reflex in LE
Sensation/disregard               Absent touch and pain sensation
                                    in UE; left visual field loss;
                                    visual disregard for left side
                                    but able to track with eyes
                                    and move head just past
                                    midline to left side

Initial Analysis of Critical Tasks

Quiet sitting                     Unable to sit unsupported;
                                    center of mass shifted to left
                                    (involved) side by fixing distal
                                    right UE and extending arm;
                                    no weight bearing on left
                                    side; resisted correction of
                                    center-of-mass alignment;
                                    "pushing" behavior
Sit-to-stand                      Unable
Quiet standing (feet hip width    Unable
  apart)
Quiet standing (feet together)    Unable
Step-up (placed one foot on top   Unable
  of 20.3-cm [8-in] step and
  returned it to floor)
Gait                              Unable
Complex gait                      Unable

Initial Standardized Measures

Berg Balance Scale (6-8)          0/56
Functional Independence           Mobility subscale score: 3/21
  Measure (9)                     Locomotion subscale score: 2/14

Posttreatment Tests of Impairments

Fractionated movement             No change
Strength                          No change
MRA                               No change
Other                             No change
Sensation/disregard               No change

Posttreatment Analysis of Critical Tasks

Quiet sitting                     Able to sit once placed with feet
                                    supported, back unsupported
                                    up to 30 s; attempted to
                                    correct losses of balance by
                                    fixing distal right UE and
                                    extending arm, which
                                    resulted in "pushing"
                                    behavior; resisted correction
                                    of center-of-mass alignment
Sit-to-stand                      From 61-cm (24-in) surface;
                                    moderate assistance without
                                    11E support and controlling
                                    right foot placement;
                                    supported by a bedside table;
                                    demonstrated "pushing"
                                    behavior if distal right LIE
                                    fixed and right LE allowed to
                                    move laterally
Quiet standing (feet hip width    With support of bedside table;
  apart)                            cued to shift weight to right
                                    side; support needed for left
                                    knee; unable to bear weight
                                    on left side; able to maintain
                                    supported but balanced
                                    position for 10-15 s at a time
Quiet standing (feet together)    No change
Step-up (placed one foot on top   No change
  of 20.3-cm step and returned
  it to floor)
Gait                              No change
Complex gait                      No change

Posttreatment Standardized Measures

Berg Balance Scale (6-8)          No change
Functional Independence           Mobility subscale score: no
  Measure (9)                       change
                                  Locomotion subscale score: no
                                    change

(a) Results pertain to the left side unless otherwise indicated.
UE=upper extremity, LE=lower extremity, MRA=motorneuron response
assessment.