procedure and description about coordination assessment

1. PROJECT ON ASSESSMENT OF COORDINATION
By
IRAM ANWAR
Summer Project –I
Submitted to the
Amity Institute of Physiotherapy
Amity University Uttar Pradesh
In partial fulfilment
of the requirements for the degree of
Bachelor of Physiotherapy
Under the guidance of
Dr. Jasmine Chawla (PT)
Assistant Professor
Amity Institute of Physiotherapy
Amity University Uttar Pradesh
Noida
2018

2. TABLE OF CONTENTS
1. DECLARATION
2. FACULTY GUIDE APPROVAL
3. ACKNOWLEDGEMENT
4. INTRODUCTION
5. DISCRIPTION
6. PURPOSE
7. CAUSES
1. FLACCIDITY
2. SPASTICITY
3. CEREBELLAR ATAXIA
4. TABES DORSALIS
5. SYRINGOMYELIA
8. FEATURES OF COORDINATION TESTS
9. BALANCE TESTING INSTRUMENTS
10. ADMINISTERING THE COORDINATION EXAMINATIONS
a. PREPRATION
b. PATIENT PREPRATION
c. PRELIMINARY OBSERVATION
d. EXAMINATION
e. CASE STUDY
11. PREPRATION
12. AFTER CARE
13. RISKS
14. RECORDING TESTS RESULTS

3. 1.ASSESSMENT OF COORDINATION
Balance is the ability to maintain the center of gravity over the base of support, usually while
in an upright position. Coordination is the capacity to move through a complex set of
movements that requires rhythm, muscle tension, posture, and equilibrium. Balance and
coordination depend on the interaction of multiple body organs and systems including the
eyes, ears, brain and nervous system cardiovascular system and muscles. Tests or
examination of any or all of these organs or systems may be necessary to determine the
causes of loss of balance, dizziness, or the inability to coordinate movement or activities. 1
It is a smooth, rhythmical and accurate harmonial activity performed in correct sequence of
action of the group of muscles called as coordination. Lack of coordination is said to be
incoordination or asynergia.
Incoordination is the jerky, inaccurate nonpurposeful movement done by the group of
Fig:- 1
muscles.
Motor control is “the ability of the central nervous system to control or direct the neuromotor
system in purposeful movement and postural adjustment by selective allocation of muscle
tension across appropriate joint segments.” Motor control also has been defined “as the
ability to regulate or direct the mechanisms essential to movement.” Component of motor
control include normal muscle tone and postural response mechanisms, selective movements
and coordination.
Coordinate movement involves multiple joints and muscles that are activated at the
appropriate time and with the correct amount of force so that smooth, efficient and accurate
movement occurs. Thus, essence of coordination is the sequencing, timing and grading of the
activation of multiple muscles groups.”
The ability to produce these responses is dependent on somatosensory, visual and vestibular
input, as well as a fully intact neuromascular system from the motor cortex to the spinal cord.

4. Coordinated movements are characterized by appropriate speed, distance, direction, timing,
muscular tension .in addition, they involve appropriate synergistic influences (muscle
recruitment), easy reversal between apposing muscle groups (appropriate sequencing of
contraction and relaxation), and proximal fixation to allow distal motion or maintenance of a
posture.
Two terms often associated with coordination are dexterity and agility. Dexterity refers to
skilful use of the fingers during fine motor tasks. Agility to refers to the ability to rapidly and
smoothly initiate, postural control.
There are several general types of coordination.
Intralimb coordination refers to movements occurring within a single limb (e.g alternately
flexing or extending the elbow; use of one upper extremity to brush the hair; or motor
performances of a two single lower extremity during a gait cycle).
Interlimb coordination refers to the integrated performances of two or more limbs working
together (e.g alternately flexing one elbow while extending the other; bilateral upper
extremity tasks as required during sliding transfers or dressing activities or between limb
movements of the lower extremities and/or upper extremities during walking).
Visual motor coordination refers to ability to integrate both visual and motor abilities with the
environmental context to accomplish a goal (e.g tracing over a zigzag line, writing a letter,
riding a bicycle, or driving an automobile). A subcategory of visual motor coordination with
important implications for activities of daily living (ADL) is eye-hand coordination such as
required for using eating utensils, personal hygiene; or reaching for visual target (e.g a book
from shelf).
Eye hand coordination is perhaps more aptly termed eye-hand-head coordination because
movements of the head is typically required for the eyes to fixate on target or object.
Physical therapists are frequently involved in management of patients with coordination
impairments. These impairments are often associated with activity limitation that are related
to, and indicative of, the type, extent, and location of central nervous system (CNS)
pathology. Some CNS lesions present very classic and stereotypical impairments, but others
are much less predictable. Examples of medical diagnosis that typically demonstrate
coordination impairments include traumatic brain injury, Parkinson’s disease, multiple
sclerosis, Huntington’s disease, cerebral palsy, Sydenham’s chorea, cerebellar tumors,
vestibular pathology, and some learning disabilities.

5. 2.DESCRIPTION
Assessment of balance and coordination can include discussion of the patient's medical
history and a complete physical examination including evaluation of the heart, head, eyes,
and ears. A slow pulse or heart rate, or very low blood pressure may indicate a circulatory
system problem, which can cause dizziness or fainting. During the examination, the patient
may be asked to rotate the head from side to side while sitting up or while lying down with
the head and neck extended over the edge of the examination table. If these tests produce
dizziness or a rapid twitching of the eyeballs (nystagmus), the patient may have a disorder of
the inner ear, which is responsible for maintainin
Fig:-2

6. An examination of the eyes and ears may also provide clues to episodes of dizziness or
incoordination. The patient may be asked to focus on a light or on a distant point or object,
and to look up, down, left, and right moving only the eyes while the eyes are examined.
Problems with vision may, in themselves, contribute to balance and coordination
disturbances, or may indicate more serious problems of the nervous system or brain function
hearing loss, fluid in the inner ear, or ear infection might indicate the cause of balance and
coordination problems.
Various physical tests may also be used. A patient may be asked to walk a straight line, stand
on one foot, or touch a finger to the nose to help assess balance. The patient may be asked to
squeeze or push against the doctor's hands, to squat down, to bend over, or stand on tiptoes or
heels. Important aspects of these tests include holding positions for a certain number of
seconds, successfully repeating movements a certain number of times, and repeating the test
accurately with eyes closed. The patient's reflexes may also be tested. For example, the
doctor may tap on the knees, ankles, and elbows with a small rubber mallet to test nervous
system functioning. These tests may reveal muscle weakness or nervous system problems
that could contribute to incoordination
As ergonomics becomes a major emerging practice area in occupational therapy, balance and
coordination is increasingly analyzed in workplace evaluations. Good balance and
coordination, such as finger dexterity, may be needed for a worker to properly complete a
specific task in his or her job. Assessments used to determine coordination include the
Crawford Small Parts Dexterity Test, Bennettt Hand-Tool Dexterity Test, Purdue Pegboard,
and the Minnesota Rate of Manipulation Test
Standardized test that evaluate gross motor coordination include the Bruinlinks-Oseretsky
Test of Motor Proficiency, which evaluates gross and fine motor coordination, muscle
strength, balance, and visual motor control; the Devereux Test of Extremity Coordination,
which assesses static balance, motor attention span, and sequential motor activity; the
Lincoln-Oseretsky Motor Development Scale, which assesses motor tasks such as walking
backwards and one-foot standing; and the Miller Assessment for Preschoolers, which
assesses gross motor function in young children.

7. 3.PURPOSE
Tests of balance and coordination, and the examination of the organs and systems that
influence balance and coordination, can help to identify causes of dizziness, fainting, falling,
or incoordination.
The purposes of performing a coordination examination of motor function are to determine
the following:
1. Muscle activity characteristics during voluntary movement.
2.Ability of muscles or groups of muscles to work together to perform a task or functional
activity.
3.Level of skill and efficacy of movement
4.Ability to initiate, control, and terminate movement
5.Timing, sequencing, and accuracy of movement patterns
6.Effect of therapeutic and pharmacological intervention on motor function over time.
Fig:-3

8. Data from the coordination examination assist the therapist with establishing the diagnosis of
underlying impairments, activity limitation and of underlying impairments, activity
limitations, and participation restrictions (disability): assist with establishing anticipated goals
to remediate impairments and formulating expected outcomes encompass remediation of
activity limitation and participation restrictions; and support dicision making in establishing a
prognosis and determining specific, direct interventions.
Fig:-4

9. 4.CAUSES
4.1.Flaccidity
Any of the lower motor lesion results in the flaccidity. In this case the nerve impulses cut off
before reaching the muscles said to be paralysed and are otherwise called as atonic muscles .
there is loss of muscle action, due to less venous drainage, lack of blood supply and loss of
muscle bulk. As the result of weakness the patient cannot perform the movement in
coordinate manner. There will be a lack of fluency in performing an activity , so that these
movements are said to be coordinate movements.
4.2.Spasticity
Upper motor neuron lesion results in spasticity. Tone of the muscles is more and muscles are
tight and contracted. Spasticity never occurs in one group of muscles. It is always parts of a
total flexor or total extensor synergy. Due to the spasticity in nature of muscle it produces the
abnormal movements. The movements may not be rhythmical and coordinate manner.
4.3.Cerebellar Ataxia
Cerebellar lesion results in coordinated movements. Normally, the muscles are hypotonic.
There will be “ataxic” type of gait. A-without , taxic-order without the higher center order the
body parts shows swaying, ill-timed, dyssynergic movement. Teamwork of the muscles being
lost. Dysarthria-difficulty in speech, scanning speech is the commonest feature in it.
Intentional tremor , difficulty in achieving the accurate distance of movement (dysmetria),
loss of the alternating the movements (Dysdiadokokinesia) .for example, supination and
pronation , oscillation of eye ball (Nystagmus)are the clinical features of this comdition.
4.4.Tabes Dorsalis
It is also called as posterior column disease. Posterior column of the spinal cord involved in
this case, so that sensory loss is the major clinical feature of this condition. pain over the
girdle and lightning type of pain presents.
4.5.Syringomyelia
It is a chronic progressive disorder in which the cavitations develop in the spinal cord .it may
be extend up to cervical region sometime upto brainstem is called as syringiobulbia. Loss of
sensation and motor loss presents through out the upper and lower extremity. Small muscles
of the hand involvemore and the lower limb with the spastic parapresis.

10. 5.FEATURES OF COORDINATION TESTS
Coordination tests generally can be divided into two main categories: gross motor
movements and fine motor movements.
Gross motor test include body posture, balance, and exrtremity movements involving large
muscle groups. Examples of gross motor activities include crawling, kneeling, standing,
walking and running.
Fine motor tests address movements concerned with utilization of small muscle groups that
involves skillfull controlled manipulation of objects. Examples of fine motor activities
include finger dexterity tasks such as as buttoning a shirt, typing, or handwriting.
Two subdivisions of coordination tests (unequilibrium and equilibrium) have traditionally
been used for providing structure and organization to administration of the tests.
Nonequilibrium tests address components of limb movements. Equilibrium or balance tests
consider the ability to maintain the body in equilibrium with gravity both statically and
dynamically.
Coordination test also address patient capabilities in four basic areas of functional task
requirments: transitional mobility, stability, dynamic postural control and skill.
Fig:-5

11. Coordination tests
Test Description
Alternate heel to knee
and heel to toe
While lying down, the patient is asked to touch his or her
knee and big toe alternately with the heel of the opposite
extremity.
Alternate nose to
finger
The patient alternately touches the tip of his or her nose and
the tip of the therapist's finger with the index finger. The
therapist may move his or her finger during testing to assess
ability to change distance, direction, and force of movement.
Drawing a circle While sitting, standing, or lying down, the patient alternately
draws an imaginary circle in the air, or on a table or floor,
with either upper or lower extremity. Instead of a circle, a
figure-eight pattern may be used.
Finger to finger With both shoulders abducted to 90° and the elbows
extended, the patient is asked to bring both hands toward the
midline and approximate the index fingers from opposing
hands.
Finger to nose With the shoulder abducted to 90° and the elbow extended,
the patient is asked to bring the tip of the index finger to the
tip of the nose. The initial starting position may be changed
to assess performance from different planes of motion.

12. Coordination tests
Test Description
Finger opposition The patient touches the tip of the thumb to the tip of each
finger in sequence. Speed may be gradually increased.
Finger to therapist's
finger
The patient and therapist sit opposite each other. The
therapist holds his or her index finger in front of the patient,
and the patient is asked to touch the tip of the index finger to
the therapist's index finger. The position of the therapist's
finger may be altered during testing to assess ability to
change distance, direction, and force of movement.
Fixation or position
holding
Upper extremity: The patient holds arms horizontally in
front.
Lower extremity: The patient holds the knee in an extended
position.
Mass grasp The patient alternately opens and closes the fist (finger
flexion to full extension). Speed may be gradually increased.
Pronation/supination With elbows flexed to 90° and held close to body, the patient
alternately turns his or her palms up and down. This test also
may be performed with shoulders flexed to 90° and elbows
extended. Speed may be gradually increased.

13. Coordination tests
Test Description
The ability to reverse movements between opposing muscle
groups can be assessed at many joints, including the knee,
ankle, elbow, fingers, etc.
Rebound test The patient is positioned with the elbow flexed. The therapist
applies sufficient manual resistance to produce contraction of
biceps. Normally when resistance is suddenly released, the
opposing muscle group (triceps) will contract and "check"
movement of the limb. Many other muscle groups can be
tested for this phenomenon, such as the shoulder abductors or
flexors, and elbow extensors.
Tapping Foot: The patient is asked to "tap" the ball of one foot on the
floor without raising the knee; heel maintains contact with
floor.
Hand: With the elbow flexed and the forearm pronated, the
patient is asked to "tap" his or her hand on the knee.

14. 6.BALANCE TESTING INSTRUMENTS
The Berg Balance Scale. This widely-used instrument identifies balance impairment.
Functional activities such as reaching, bending, transferring, and standing are used as items
on the test to measure balance. The test items are graded on a five-point scale to determine
extent of impairment.
Clinical Test of Sensory Interaction and Balance (CTSIB). This test, also known as the
Sensory Organization Test, assesses static balance under six combinations of sensory
conditions. For example, visual conditions vary by testing while the eyes are closed, open,
and also when peripheral vision is restricted. The test also includes having the subject balance
while standing on a hard floor and while standing on foam. The effect on posture and balance
is graded and scored.
Functional Reach Test. This test measures a person's stability while leaning forward and
reaching as far as possible with arm outstretched and parallel to the floor in front of the body.
A normal reach is at least six inches, measured from the distance the fist has traveled during
the reach.
The Tinetti Balance Test of the Performance-Oriented Assessment of Mobility Problems.
This test measures balance and gait while performing typical daily activities. The activities
are graded as normal, adaptive, or abnormal to determine the severity of balance impairment.
The Timed Up and Go Test. This test measures the time it takes a person to rise from a
standard armchair and stand, walk three meters, turn around, and walk back to the chair and
sit down.
The Physical Performance Test. This test evaluates a person's physical functional
capabilities. The person performs nine separate activities, such as feeding and writing, and is
scored on each of the activities based on speed from 0-4.

15. Fig:-6
Fig:-7

16. Fig:-8
Fig:-9

17. 7.ADMINITERING THE COORDINATION EXAMINATION
Before initiating the coordination examination, the testing environment should be identified
and prepared, needed equipment gathered, and consideration given to patient prepration (i.e.,
what information and instruction will be provided).
a. PREPRATION
The coordination examination should be administered in quiet, well lighted treatment area
sufficiently large to accommodate walking activities included in the equilibrium portion of
the tests. Ideally, the room should be equipped with two standard chairs and a mat or
treatment table. A watch or clock with second hand should be available for timed components
of examination, as well as a method of occluding vision (an expensive blindfold used for
sleeping works well).
b. PATIENT PREPRATION
The coordination examination should be administered when the patient is well rested.NA full
explanation of the purpose of the testing should be provided. Each coordination test is
described and demonstrated individually by therapist before actual testing. such
demonstration should be attended to carefully, as lack of clarity will negatively affect motor
responses. Because testing procedures require mental concentration and some physical
activity, fatigue, apprehension, or fear may adversely influence test results.
c. PRELIMINARY OBSERVATION
Observation is an essential skill in clinical decision making. Accurate and careful patient
observation provides a rich source of preliminary information before performing a
coordination examination. Treatment intervention will be directed, at least in part, toward
improving functional performance and activity. levels, initial observations should logically
focus here. Depending on the practice setting environment, the patient might be observed
performing any number of functional activities such as bed mobility, selfcare routines (e.g.,
dressing, combing hair, changing position from lying or sitting to standing, maintaining a
standing position, and walking. Use of appropriate patient, general information can be
obtained that will assist in localizing specific areas of impairment. this information will
include the following:
 General level of skill in each activity and amount of assistance or assistive devices
required
The occurrence of extraneouslimbmovements, oscillation;specificextremities’ involved
 Postural sway or unstreadiness
 Distribution: proximal and/or distal musculature, unilateral or bilateral
 Situations or occurrences that alter impairment
 Amount of time required to perform an activity
 Level of safety fall risk

18. d. EXAMINATION
Guided by information from the preliminary observation of functional activities, tests should
be selected to address the required movement capabilities of interest for the individual
patient.
Generally, nonequilibrium test are completed first, followed by the equilibrium tests.
Attention should be directed to carefully guarding the patient during testing, the following
question can be used to help direct the therapist observations.
PART-1: Nonequilibrium Coordination Tests
Key of grading
4 Normal performance
3 Minimal impairment: able to accomplish activity; slightly less than normal control, speed
and steadiness
2 Moderate impairment: able to accomplish activity; movements are slow, awkward and
unsteady
1Severimpairment: able only to initiate activity without completion; movements are slow
with significant unsteadiness, oscillation, and/or extraneous movements
0Activity impossible
PART-2: Postural control and Balance Tests
Key to grading
4 Normal: able to maintain steady balance without handhold support (static)
Accepts maximal challenge and can shift weight easily within full range in all directions
(dynamic)
3 Good: able to maintain balance without handhold support, limited postural sway(static)
Accepts moderate challenge able to maintain balance while picking object off floor
(dynamic)

19. 2 Fair: able to maintain balance with handhold support; may require occasional minimal
assistance (static) Accepts minimal challenge able to maintain balance while turning
head/trunk (Dynamic)
1 Poor: requires handhold support and moderate to maximal assistance to maintain
position(static)
Unable to accept challenge or move without loss of balance(dynamic)
0 Absent: Unable to maintain balance
Fig:-10

20. 8.PREPARATION
No special preparation is required prior to administration of balance and coordination tests.
The patient may be asked to disrobe and put on an examination gown to make it easier for the
doctor to observe muscles and reflex responses.
9.AFTERCARE
No special aftercare is generally required. However, some of the tests may cause episodes of
dizziness or incoordination. Patients may need to use caution in returning to normal activities
if they are experiencing any symptoms of dizziness, lightheadedness, or weakness.
10.RISKS
These simple tests of balance and coordination are generally harmless.
11.RECORDING TEST RESULTS
A generally accepted formate for recording results from coordination tests has not been
established and approaches to documentation vary considerably among institutions and
individual therapists.
Several option are available for recording results from a comprehensive examination of
coordination. A coordination examination form is useful to provide a composite picture of the
areas of impairment noted. They may be general or they may be specific to a given group of
patients, such as those with brain injuries. In general, these forms lack reliability testing.
However, they do provide a systematic method of data collection and documentation. In
addition, use of the same form for periodic re-examination facilities ease of comparison of
changes over time. These forms frequently include some type of rating scale in which level of
performance is weighted using a scale with descriptors attached.
During testing, postural instability may be assigned to each components of the coordination
examination. An advantage of using rating scales is that they provide a mechanism for

21. quantifying patient performance based on subjective ratings. Inherent limitations of using
scales include the following:
1.the description may not be reflective of individual patient performance;
2.discriptors may not be defined adequately or detail appropriately;
3.without training individual interpretation decreases reliability of itraexaminer and
interexaminer testing.
Using a combination of a rating scale and narrative comments or summary will ensure that all
coordination impairment is adequately documented.
Measuring the length of time required to complete a motor or functional task provides an
important quantitative measure of movement capability. because accomplishing an activity in
a reasonable amount of time is a important criterion of performance, the length of time
required to accomplish certain activities is recorded by use of stop watch.
Periodic videotaping of patient performance can be use effectively to document coordination
impairment and monitor progress over time. For some patients, such recording can provide
the basics of suggestion about altering movement strategies to improve function and direct
attention to safety precautions. Viewed in sequence over time, the visual record can also
improve patient motivation to attain further gains. Videotapes have also been used to
determine the impact of medications on coordinated movement via preintervention and
postintervention administration (e.g., patients with Parkinson’s disease).

22. CASE STUDY-1
Name: Mr. Pradeep Midha
Age: 72 years
Gender: Male
Occupation: Chartered Accountant
Address: A-37, Lajpat Nagar-4
Date of Assessment: 28/05/2018
Chief complaint: Weakness in right upper limb, slight weakness in right lower limb, Unable
to perform ADL’s
History of present illness: Sudden onset of weakness in right upper limb as well as right
lower limb since the morning of 24/05/2018.
On Observation: - Mesomorphic built
Cannula on left wrist
Holter monitor on the day of assessment
On Examination: Patient is conscious, alert, oriented and following commands.
B.P. - 110/80 mm Hg
Pulse - 84/min
Temp. - 98.6 F
SpO2 - 96%
Muscle tone – Normal (Grade 2)
Muscle power -
Upper limb Left side Right side
Shoulder 5 4
Elbow 5 4
Wrist 5 3
Lower limb
Hip 5 4
Knee 5 4
Ankle 5 3

23. Balance - Sitting: Normal
Standing: Static - Normal
Dynamic - Good
Coordination Assessment:
Non-equilibrium Coordination Tests
Test Grade-Left Grade-Right
Finger to nose 4 4
Finger to Therapist’s finger 4 3
Finger to finger 3 3
Finger opposition 4 4
Mass grasp 4 3
Pronation/Supination 4 4
Tapping (Hand) 4 4
Tapping (Foot) 4 3
Toe to Examiner’s finger 3 3
Heel on shin 4 3
Drawing a circle (Hand) 4 4
Drawing a circle (Foot) 4 3
Equilibrium Coordination Tests
Test Grade
Sitting in normal comfortable position 4
Sitting, weight shifting in all directions 4
Sitting, multidirectional functional reach 4
Sitting, picking an object up off floor 4
Standing in a normal comfortable posture 4
Standing, feet together (narrow BOS) 3
Standing on one foot (right foot) 2
Standing, tandem position 3
Standing, eyes open to eyes closed
(Romberg Test)
3

24. Walk: sideways 4
Walk: backwards 3
Walk: on heels 3
Walk: on toes 3
March in place 3
Stairclimbing with handrail 4
Stairclimbing without handrail 3
Diagnosis: Acute Cerebrovascular Accident (BG Bleed left side)
Rehab protocol:
1. Active ROM exercises for both upper and lower limbs (Strengthening exercises)
2. Standing activities –
 Ball catch and throw
 Marching
 Forward stepping
 Side stepping
 Wobble board
 Ball kicking
 Standing with eyes closed
 Tandem walking
3. Sitting –
 Peg board activities
 Finger gripping activities

25. CASE STUDY-2
Name: Mrs. Ravinder Kaur Arora
Age: 70 years
Gender: Female
Occupation: Housewife
Address: HNo-611, 1st Floor, Gali No.6, Govind Puri
Date of Admission: 31/05/2018
Chief complaint: Sudden onset of weakness in left upper limb, difficulty in talking, left
facial muscles weakness
Past history: T2 Diabetes mellitus, Hypertension
History of present illness: Sudden onset of weakness in left upper limb, facial palsy
(faciobrachial palsy) at 12 noon on 29/05/2018
On observation: Mesomorphic built
Cannula on right wrist
On Examination: Patient is conscious, alert, oriented and following commands.
B.P. - 170/80 mm Hg
Pulse - 82/min
Temp. - 98.4 F
Muscle tone – Normal
Muscle power -
Upper limb Left side Right side
Shoulder 3 5
Elbow 2 5
Wrist 2 5
Lower limb
Hip 3 5
Knee 3 5
Ankle 3- 5

26. Balance - Sitting: Good
Standing: Static - Good,
Dynamic – Fair
Coordination Assessment:
Non-equilibrium Coordination Tests
Test Grade-Left Grade-Right
Finger to nose 2 4
Finger to Therapist’s finger 2 4
Finger to finger 2 4
Finger opposition 0 4
Mass grasp 1 4
Pronation/Supination 1 4
Tapping (Hand) 1 4
Tapping (Foot) 2 4
Toe to Examiner’s finger 3 4
Heel on shin 2 4
Drawing a circle (Hand) 2 4
Drawing a circle (Foot) 2 4
Equilibrium Coordination Tests
Test Grade
Sitting in normal comfortable position 4
Sitting, weight shifting in all directions 3
Standing in a normal comfortable posture 4
Standing, feet together (narrow BOS) 3
Standing on one foot (left foot) 1
Standing, tandem position 2
Standing, eyes open to eyes closed
(Romberg Test)
2
Sharpened Romberg test 1

27. Walk: sideways 3
Walk: backwards 3
March in place 3
Stairclimbing with handrail 3
Stairclimbing without handrail 1
Diagnosis: Acute infarct in right cortical region
Rehab protocol:
1. Active ROM exercises for left upper and lower limbs (Strengthening exercises)
2. Standing activities –
 Ball catch and throw
 Marching
 Forward stepping
 Side stepping
 Standing with eyes closed
 Tandem walking
3. Sitting –
 Peg board activities
 Hand held dynamometer
 Finger gripping activities
4. Facial exercises-
 Blowing out air from mouth
 Smiling
 Try to whistle

28. REFRENCES
1.wikipedia (Google)
2.sullivan
3.