B. Physical Performance skills and client factors Reflexes (superficial and deep tendon reflexes), Muscle tone Range of Motion Muscles strength Voluntary control Co-ordination Sensation (cutaneous and cortical) Cognitive - Perceptual functions Hand functions Functional Ability Hand functions Cognition and Perception Cranial Nerves Cerebellar functions Recommended book(s) for Reference: 1. Pedretti’s Practice skills for physical dysfunction edited by Heidi McHugh Pendleton ,Winifred Schultz Krohn 2. Occupational Therapy for Physical Dysfunction by Mary Vining Radomski, Catherine A Trombly 3. Occupational Therapy and Physical Dysfunction, Principles, Skills and Practice by Ann Turner, Margaret Foster, Sybil E Johnson 4. Introduction to Occupational Therapy by Hussey Subonis ,Chafea O Brien 5. Occupational Therapy and Mental Health edited by Jennifer Creek, Lesley Lougher 6. Mental Health Concepts and Techniques for the Occupational Therapy Assistant by Mary Beth Early 7. Frames of Reference in Psychosocial Occupational Therapy by Mary Ann Bruce, Barbara Borg 8. Willard & Spackman’s Occupational Therapy 9. Occupational Therapy for children by Jane Case Smith 10. Frames of Reference for Pediatric Occupational Therapy by Paula Kramer , Jim Hinojosa
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occupational therapy physical assessment reflexes muscle tone ROM strength coordination sensation
Here is a detailed explanation of each physical assessment area in Occupational Therapy (OT):
Physical Performance Skills and Client Factors - OT Assessment Guide
1. Reflexes (Superficial and Deep Tendon Reflexes)
Reflexes are involuntary, stereotyped responses to specific stimuli. In OT assessment, they help identify the integrity of the nervous system and the level of central nervous system (CNS) involvement.
Deep Tendon Reflexes (DTRs)
These are monosynaptic stretch reflexes mediated by the spinal cord:
| Reflex | Nerve Root | How Elicited |
|---|---|---|
| Biceps | C5, C6 | Tap biceps tendon at elbow |
| Brachioradialis | C5, C6 | Tap radius above wrist |
| Triceps | C7 | Tap triceps tendon at elbow |
| Knee (patellar) | L3, L4 | Tap patellar tendon |
| Ankle (Achilles) | S1, S2 | Tap Achilles tendon |
Grading (0-4+):
- 0 = Absent (suggests lower motor neuron [LMN] lesion or neuropathy)
- 1+ = Diminished
- 2+ = Normal
- 3+ = Increased (suggests upper motor neuron [UMN] lesion)
- 4+ = Clonus (strongly suggests UMN lesion)
Superficial Reflexes
These require an intact reflex arc and descending cortical pathways:
| Reflex | Stimulus | Normal Response |
|---|---|---|
| Plantar (Babinski) | Stroke lateral sole | Flexion of toes (Babinski sign = extension = UMN lesion) |
| Abdominal | Stroke abdominal quadrant | Umbilicus moves toward stimulus |
| Cremasteric | Stroke inner thigh | Testicular elevation |
| Corneal | Touch cornea | Bilateral eye blink (CN V and VII) |
Primitive/Developmental Reflexes
Important in pediatric OT:
- ATNR (Asymmetrical Tonic Neck Reflex) - arm/leg extension on the face side; integrates by 6 months
- STNR (Symmetrical Tonic Neck Reflex) - neck flexion = arm flexion + leg extension; integrates by 9-11 months
- TLR (Tonic Labyrinthine Reflex) - supine = extension tone; prone = flexion tone
- Moro Reflex - startle response; integrates by 4-6 months
- Palmar Grasp - integrates by 3-4 months
Persistence of primitive reflexes beyond expected integration age interferes with voluntary motor development and functional performance.
2. Muscle Tone
Muscle tone is the resting tension in a muscle - its resistance to passive stretch.
Normal Tone
A mild, continuous state of partial contraction allowing immediate response to movement demands.
Abnormal Tone Categories
| Type | Description | Underlying Condition |
|---|---|---|
| Hypertonia | Increased resistance to passive movement | UMN lesion (stroke, CP, TBI, SCI) |
| Spasticity | Velocity-dependent hypertonia; "clasp-knife" response | UMN lesion |
| Rigidity | Non-velocity-dependent resistance; "lead-pipe" or "cogwheel" | Basal ganglia disorders (Parkinson's) |
| Hypotonia | Decreased or absent resistance; "floppy" | LMN lesion, cerebellar disorders, Down syndrome |
| Flaccidity | Complete absence of tone | Acute spinal shock, LMN lesion |
Assessment Tools
- Modified Ashworth Scale (MAS) - 6-level scale (0-4) for spasticity
- Tardieu Scale - measures spasticity at fast and slow velocities
- Passive ROM observation - therapist moves limb to gauge resistance
OT Relevance
Abnormal tone affects positioning, splinting, ADL performance, and ability to use assistive devices. Normalizing tone (e.g., through weight-bearing, inhibitory handling) is a key treatment goal.
3. Range of Motion (ROM)
ROM is the arc through which a joint moves, measured in degrees using a goniometer.
Types
- Active ROM (AROM) - the patient moves the joint independently; reflects muscle strength + joint integrity
- Passive ROM (PROM) - the therapist moves the joint; reflects joint integrity and tissue extensibility only
Measurement Tool
A goniometer (protractor-like device) is used. The axis is placed at the joint center, the stationary arm along the proximal segment, and the moving arm along the distal segment.
Normal Values (Selected Joints)
| Joint | Motion | Normal ROM |
|---|---|---|
| Shoulder | Flexion | 0-180° |
| Shoulder | Abduction | 0-180° |
| Elbow | Flexion | 0-145° |
| Wrist | Flexion/Extension | 0-80° / 0-70° |
| Hip | Flexion | 0-120° |
| Knee | Flexion | 0-135° |
End Feel
Therapists assess the quality of resistance at the end of ROM:
- Hard end feel - bone on bone (normal at elbow extension)
- Soft end feel - soft tissue approximation (normal at knee/elbow flexion)
- Firm/capsular - ligamentous or capsular stretch (normal at most joints)
- Pathological end feel - empty, spasm, or boggy = indicates pathology
OT Relevance
ROM limitations affect reach, grasp, self-care, and work tasks. OT uses stretching, splinting, and purposeful activity to improve or maintain ROM.
4. Muscle Strength
Muscle strength is the maximal force a muscle can generate against resistance.
Manual Muscle Testing (MMT)
Standardized method to grade muscle strength using Kendall or MRC grading system:
| Grade | Description |
|---|---|
| 0 | No contraction |
| 1 | Visible/palpable contraction, no movement |
| 2 | Full ROM with gravity eliminated |
| 3 | Full ROM against gravity, no added resistance |
| 4 | Full ROM against gravity with some resistance |
| 5 | Full ROM against gravity with full resistance (Normal) |
Dynamometry
- Grip strength: Measured using a Jamar dynamometer in 5 handle positions
- Pinch strength: Lateral pinch, tip pinch, three-jaw chuck pinch measured with a pinch gauge
- Age- and sex-specific norms are used for comparison.
OT Relevance
Weakness affects all functional tasks. Strengthening activities (purposeful and preparatory) are graded to progressively increase resistance. Compensatory strategies and adaptive equipment are used when strength cannot be restored.
5. Voluntary Control
Voluntary control refers to the patient's ability to intentionally initiate, sustain, and cease purposeful movement.
Assessment Includes
- Ability to move on command
- Quality of movement - smooth vs. effortful
- Presence of involuntary movements (tremor, chorea, dystonia)
- Isolated vs. synergistic movement patterns
Motor Control Levels (After UMN Lesion - Brunnstrom Stages)
Used especially post-stroke:
| Stage | Description |
|---|---|
| 1 | Flaccidity, no voluntary movement |
| 2 | Spasticity developing, synergy patterns begin |
| 3 | Spasticity peaks, voluntary synergy patterns |
| 4 | Spasticity decreasing, movements out of synergy |
| 5 | More isolated joint movements |
| 6 | Near-normal coordination, spasticity absent |
| 7 | Normal function restored |
OT Relevance
Tasks are graded based on the level of voluntary control available. Neurodevelopmental treatment (NDT/Bobath), movement re-education, and task-oriented training target recovery of voluntary control.
6. Coordination
Coordination is the ability to produce smooth, accurate, controlled movements requiring the integrated function of the cerebellum, basal ganglia, sensory systems, and motor pathways.
Types of Coordination
- Gross motor coordination - large-limb movements (reaching, walking)
- Fine motor coordination - small, precise movements (writing, buttoning)
- Bilateral coordination - using both hands together in a controlled manner
- Eye-hand coordination - visual guidance of hand movements
Assessment Tests
| Test | What It Assesses |
|---|---|
| Finger-nose-finger test | Upper limb dysmetria |
| Heel-knee-shin test | Lower limb coordination |
| Rapid alternating movements (dysdiadochokinesia) | Cerebellar function |
| Romberg test | Proprioceptive vs. cerebellar balance |
| Nine Hole Peg Test | Fine motor coordination and speed |
| Purdue Pegboard Test | Unimanual and bimanual dexterity |
| Box and Block Test | Gross manual dexterity |
OT Relevance
Incoordination (ataxia) impairs handwriting, feeding, dressing, and vocational tasks. Weighted utensils, sensory feedback, and coordination training are common OT interventions.
7. Sensation (Cutaneous and Cortical)
Cutaneous (Primary/Peripheral) Sensation
Tests the integrity of peripheral nerves and spinothalamic/dorsal column tracts:
| Modality | Test Method | Pathway |
|---|---|---|
| Light touch | Cotton wool or monofilament | Dorsal column (fine) / Spinothalamic (crude) |
| Pain | Sharp object (pin) | Lateral spinothalamic tract |
| Temperature | Warm/cold test tubes | Lateral spinothalamic tract |
| Vibration | Tuning fork (128 Hz) on bony prominence | Dorsal column - medial lemniscus |
| Proprioception (joint position sense) | Move digit, patient identifies direction | Dorsal column |
| Deep pressure | Press on tissues | Mixed pathways |
Cortical (Higher-Order) Sensation
Requires intact primary sensation plus parietal cortex processing:
| Test | What It Detects |
|---|---|
| Stereognosis | Identify objects by touch without vision |
| Graphesthesia | Identify numbers/letters traced on skin |
| Two-point discrimination | Smallest distance perceived as two points (normal palm ~8 mm, fingertip ~3-5 mm) |
| Tactile localization | Point to where touched |
| Tactile extinction | When touched bilaterally simultaneously, neglect of one side |
Assessment Tools
- Semmes-Weinstein Monofilament Test - quantifies light touch threshold
- Nottingham Sensory Assessment
OT Relevance
Sensory loss affects safety (burns, wounds), motor control, and dexterity. OT uses sensory re-education, protective techniques, and environmental modifications.
8. Cognitive-Perceptual Functions
Cognitive Functions
These are higher brain functions essential for occupational performance:
| Domain | What It Involves | Common Assessment |
|---|---|---|
| Attention | Sustained, selective, divided attention | Trail Making Test, LOTCA |
| Memory | Short-term, long-term, working memory | MMSE, Rivermead Behavioral Memory Test |
| Executive function | Planning, problem-solving, initiation, inhibition | Executive Function Performance Test (EFPT), Cognitive Assessment of Minnesota |
| Orientation | Awareness of person, place, time | MMSE |
| Insight/Awareness | Self-awareness of deficits | Patient Self-Assessment |
Perceptual Functions
Perception is the brain's interpretation of sensory input:
| Perception Type | Deficit | Implication |
|---|---|---|
| Visual-spatial | Spatial disorientation | Difficulty with navigation, dressing |
| Figure-ground | Can't distinguish object from background | Misplacing items |
| Depth perception | Misjudging distances | Pouring, reaching inaccuracies |
| Body scheme | Distorted body image | Dressing apraxia |
| Unilateral neglect | Ignoring one side of space | Safety hazard; missing food on plate |
| Apraxia | Inability to perform learned movements despite intact motor/sensory function | Cannot sequence tasks like brushing teeth |
| Agnosia | Inability to recognize familiar objects/people/sounds | Cannot identify a comb by sight |
| Constructional ability | Drawing/assembling 2D-3D objects | Difficulty with ADLs requiring spatial arrangement |
Common OT Perceptual Assessments
- Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)
- Motor Free Visual Perception Test (MVPT)
- Rivermead Perceptual Assessment Battery (RPAB)
9. Hand Functions
Hand function assessment evaluates the full range of the hand's capacities needed for daily life:
Components Assessed
| Area | Details |
|---|---|
| Grip strength | Cylindrical, spherical, hook, lateral, pinch grips |
| Pinch strength | Tip, lateral (key), tripod/three-jaw chuck |
| Dexterity | Speed and precision of fine motor tasks |
| Sensation | Two-point discrimination, monofilament test |
| ROM | Individual finger/thumb joint motion |
| Edema | Measured by volumetry or circumference |
| Coordination | Fine motor accuracy |
| Functional use | Ability to perform ADL tasks with the hand |
Prehension Patterns
| Pattern | Description | Example Activity |
|---|---|---|
| Power grip | Force-dominant; palm and fingers wrap around object | Holding a hammer |
| Precision grip | Control-dominant; fingertip manipulation | Picking up a coin |
| Lateral pinch | Thumb pad against index finger lateral side | Turning a key |
| Tip pinch | Thumb tip to index finger tip | Threading a needle |
Assessment Tools
- Jebsen-Taylor Hand Function Test - 7 subtests simulating ADL tasks
- Minnesota Manual Dexterity Test
- Nine Hole Peg Test
- Box and Block Test
- DASH Questionnaire (Disabilities of Arm, Shoulder, Hand)
10. Functional Ability
Functional ability is the capacity to perform real-world occupational roles and daily activities.
Areas Assessed
- Activities of Daily Living (ADL) - bathing, dressing, feeding, grooming, toileting, transfers
- Instrumental ADL (IADL) - cooking, driving, managing finances, shopping, medication management
- Mobility - transfers, ambulation, wheelchair use
- Work/vocational tasks - task simulation, work hardening assessments
- Leisure activities - ability to engage in meaningful activities
Key OT Functional Assessment Tools
| Tool | Purpose |
|---|---|
| Functional Independence Measure (FIM) | 18-item scale covering motor and cognitive domains |
| Barthel Index | ADL independence in neurological/rehab settings |
| COPM (Canadian Occupational Performance Measure) | Client-centered self-rating of performance and satisfaction |
| WeeFIM | Pediatric version of FIM |
| AMPS (Assessment of Motor and Process Skills) | Observational assessment during actual ADL tasks |
11. Cognition and Perception
(See section 8 above for full detail)
This is assessed together as an integrated domain because perceptual deficits frequently have cognitive underpinnings and both affect occupational performance in the same tasks (e.g., meal preparation, driving, dressing).
Key integrated assessment: LOTCA and COGNISTAT assess both domains simultaneously.
12. Cranial Nerves
Cranial nerve assessment is done to identify brainstem pathology, localize lesions, and understand how deficits affect function (e.g., vision for reading/driving, swallowing for feeding, facial expression for communication).
| CN | Name | Function | OT-Relevant Test |
|---|---|---|---|
| I | Olfactory | Smell | Identify familiar scents |
| II | Optic | Vision | Snellen chart, visual fields |
| III, IV, VI | Oculomotor, Trochlear, Abducens | Eye movements, pupil | Extraocular movement tracking, pupillary reflex |
| V | Trigeminal | Face sensation + mastication | Corneal reflex, facial sensation, jaw strength |
| VII | Facial | Facial expression, taste (ant. 2/3 tongue) | Smile, frown, eye closure, taste test |
| VIII | Vestibulocochlear | Hearing and balance | Rinne/Weber tests, vestibular assessment |
| IX | Glossopharyngeal | Taste (post. 1/3 tongue), swallow | Gag reflex |
| X | Vagus | Swallowing, voice, autonomic | Phonation, gag reflex, swallowing assessment |
| XI | Accessory | SCM and trapezius | Shoulder shrug, head rotation |
| XII | Hypoglossal | Tongue movement | Tongue protrusion and lateral movement |
OT Relevance
- CN II, III, IV, VI deficits affect visual scanning, reading, ADL safety
- CN VII palsy affects feeding, oral motor control, social participation
- CN IX, X deficits affect swallowing - OT conducts dysphagia screening and oral-motor interventions
13. Cerebellar Functions
The cerebellum coordinates and fine-tunes movement, maintaining balance and motor learning.
Key Cerebellar Functions Assessed
| Function | Deficit Sign | Clinical Test |
|---|---|---|
| Coordination | Ataxia | Finger-nose-finger, heel-shin test |
| Smooth movement | Dysdiadochokinesia | Rapid alternating movements |
| Accuracy | Dysmetria (over/undershooting) | Finger-nose test |
| Balance | Truncal/gait ataxia | Romberg test, tandem walking |
| Speech | Dysarthria (slurred, scanning speech) | Conversation, reading aloud |
| Eye movements | Nystagmus | Smooth pursuit tracking |
| Posture | Titubation (tremor at rest of head/trunk) | Observation |
Localization
- Midline (vermis) lesion - truncal ataxia, gait ataxia, trunk instability while sitting
- Lateral (hemisphere) lesion - ipsilateral limb ataxia, dysmetria, intention tremor
OT Relevance
Cerebellar ataxia affects writing, feeding, dressing, and all precision tasks. OT interventions include:
- Proximal stabilization before distal function
- Weighted utensils/tools to dampen tremor
- Environmental adaptations
- Task simplification and compensatory strategies
- Coordination training with feedback
Summary: OT Clinical Reasoning Framework
When conducting a physical assessment, OT therapists integrate all findings to answer three key questions:
- What is the underlying impairment? (neurological, musculoskeletal, or combined)
- How does it affect occupational performance? (ADL, IADL, work, leisure)
- What can be improved, compensated, or adapted? (treatment planning)
The assessment is client-centered and always links physical findings back to meaningful occupational roles and goals, as guided by frameworks like the OTPF (Occupational Therapy Practice Framework) and models like MOHO, Biomechanical Model, and Rehabilitative/Compensatory Model.
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