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Download Treating Doctors Manual TD-5.2 Functional Capacity Evaluation
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Allegheny Health & Physical Medicine * Cervical Functional Capacity Patients Name:______________________________________ Date:_____________________ Head/ Neck Flex Coord Test: (check only one) SCM Strength Test: (check only one) [ ] [ ] The patient passed this test. The chin did not jut forward during movement The patient failed this test, the chin jutted forward during movement. This indicates the presence of flexor muscle weakness or incoordination [ ] [ ] The patient passed this test. They were able to do all of the actions required Grade II. The patient failed this test and falls into Grade II category, which indicates that the head was able to be lifted, but without full rotation Grade III. The patient failed this test and falls into Grade III category, which indicates that the head cannot be lifted or that it is lifted but rotation cannot be maintained [ ] Respiration Coord. Test: (check only one) Shoulder Abduct Coord. Test: (check only one) Trunk Lowering From Push-up: (check only one) ROM: C/S [ ] [ ] The patient passed this test. There was no indication of paradoxic breathing The patient failed this test. The results noted that the chest was raising more than the abdomen, and is an indicator of paradoxic breathing [ ] [ ] The patient passed this test The patient failed this test. It was noted that there was scapular elevation in the first 30-60 degrees of movement [ [ [ [ [ [ [ The patient passed this test. The patient failed this test. Weakness of the Serratus anterior was noted. The patient failed this test. Overactive rhomboid muscles were noted. The patient failed this test. Overactive upper trapezieus muscles were noted The patient failed this test. Overactive levator scapular muscles were noted. The patient failed this test. Overactive pectoralis muscles were noted. The patient failed this test. Weakness of the rhomboid muscle was noted by scapular winging ] ] ] ] ] ] ] Pain Sever Sever Sever Sever Sever Sever D/S Pain ______ ______ ______ ______ ______ ______ Mod Mod Mod Mod Mod Mod Shoulder Flexion ______ Extension ______ Right Lat Flexion ______ Left Lat Flexion ______ Right Rotation ______ Left Rotation ______ Mod Mod Mod Mod Mod Mod Sever Sever Sever Sever Sever Sever Manual Muscle Testing: Muscle C/S Flexors C/S Lateral Flexion Anterior Deltoid Posterior Deltoid Biceps Triceps Wrist Flexors Wrist Extensors Right __________ __________ __________ __________ __________ __________ __________ __________ Left __________ __________ __________ __________ __________ __________ __________ __________ Grip Strength: __________ __________ ______ ______ ______ ______ ______ ______ Mod Mod Mod Mod Mod Mod Wrist Sever Sever Sever Sever Sever Sever ______ ______ ______ ______ ______ ______ M M M M M M S S S S S S Additional Comments: Signed:________________________________________________________ [ ] A. Trasoline, D.C. [ ] J. Foltz, D.C. [ ] E. Bengel, D.C. Treating Doctors Manual TD-5.2 Functional Capacity Evaluation “Cervical Region”
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