Functional Limitations G Codes Neurological Red Flags Other Neuro

Functional limitations G codes • Mobility: walking and moving around Pathology : Considerations for the • Changing and Maintaining body position Autonomous Practitioner • Carrying, Moving and Handling objects • Self care • Other PT/OT Primary Functional limitation Veronica Southard PT, DHSc, GCS • Other PT/OT Subsequent Functional limitation John Handrakis PT, DPT, EdD

Pathology of Neurodegenerative Neurological red flags diseases Movement disorders • More commonly seen neurodegenerative diagnosis: Weakness • Huntington’s disease Radicular pain • ALS Paresthesias • NPH HA (intense &/or with associated neuro signs) • PD Vertigo • Progressive Supranuclear Palsy Vision changes • MS • Autoimmune diseases • Guillian Barre • MG

Other Neuro pathologies we Huntington’s Disease encounter • CVA • Etiology: Autosomal dominant • Subdural hematoma – Ask for Family hx • TBI • Defect is on the 4 th chromosome • SC pathology at the nerve, nerve root, • Incidence: 2.71/100,000 intradiscal, vertebral body, cord • Onset generally 40’s. • Pathology caudate nucleus

• 6MWT ; 86.57 m • Etiology ; idiopathic degenerative disease of the CNS mn 10 m walk test; .34m/s • • Onset between 40-60 years. Incidence 2-7/100,000 1 • TUG; 2.98m/s • Pathology motor neurons of the motor cortex and BS • BBS; 5 points motor CN V,VII, IX, and XII. Gliosis of CST, degeneration of the ventral spinal roots, motor • Tinetti combined 4 points axons, peripheral nerves, and muscles. • Clinical Course is progressive and fulminating • Quinn L et al. Reliability and Minimal Detectable Change of Physical Performance Measures in • 1 McCrate ME, Kaspar BK. Physical activity and neuroprotection in Individuals with Pre-Manifest, and Manifest Huntington Disease. 2013; Phys Ther; 93 ;(7) 942- 956 amyotrophic lateral sclerosis. Neuromolecular Med. 2008;10:108 –117.

Suspect ALS NPH: Normal Pressure Hydrocephalus

• Upper and lower motor neuron signs • Recognized in 1965 • Pt has had a mental change, usually a subcortical – Progressive with asymmetric distribution dementia, that developed over several weeks and • Fasciculations may change from day to day • Sensory sparing • The gait is ataxic, wide based, slow and unsteady, spastic features may occur • Later development of urinary incontinence • Outcome tools difficult to find • Parkinson-like features • Primitive reflexes • Hyperreflexia

Suspect NPH NPH Video available online

• Wide based, stuck-to-the-floor gait • This website video demonstrates the gait of a patient • Relatively sudden cognitive problem with NPH and good concise exam footage • Youtube • Urinary incontinence http://www.youtube.com/watch?v=nh- mdafW8X8

• After shunt placement, no available evidence • Origin of PD may be long established before could be found. the movement syndrome starts • Recommend using older adult norms since – CN IX, X dysfunction the shunt is supposed to take care of the – Olfactory nuclei dysfunction pressure on the brain. • Loss of smell • Gait speed – Ascending brainstem meso/neocortex dysfunction • Chan DK, Cordato DJ, O'Rourke F. Geriatrics, 2008 • TUG

PD MDC for PD • Etiology/Pathology • Incidence 1% >50years of age • 6MWT; 82m. (Steffen T. Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified Parkinson disease • Course: starts as a unilateral resting tremor and rating scale in people with Parkinsonism. 2008, 88;(6):733-46.) spreads to the opposite side, lower extremities, • Gait speed; comfortable .18m/s fast, .25m/s. and the neck. (Steffen T. Seney M. ) • Bradykinesia, rigidity, loss of postural reflexes, • TUG; 3.5 sec Huang, S. L., Hsieh, C. L., et al. (2011). "Minimal detectable flexed posture, small steps, shuffling, and change of the timed "up & go" test and the dynamic gait index in people with festinating gait. Parkinson disease." Physical Therapy 91(1): 114-121. • Early symptoms: falls, generalized weakness, • FR; MDC for PD patients with a history of falls = deterioration of handwriting with small letters, 4.32cm. MDC for PD patients with no history of falls depression, generalized aches, stiffness, and loss of ( Smithson, F., Morris, M. E., et al. (1998). "Performance on olfactory sensation, OH (autonomic disorders), = 8.07cm. constipation. clinical tests of balance in Parkinson's disease." Phys Ther 78(6): 577-592.) •

Progressive Supranuclear Palsy (Steele-Richardson-Olszewski syndrome) MS • Idiopathic • Prevalence 60-100/100,000 • 1.1/100,000 (Bower et al, 1997; Schrag et al, 1999) • Etiology ? Genetics? Infection? Possible • Onset decades 6-7, males > females combination • Earliest sign: gait disturbance, axial rigidity • Autoimmune activation which makes the patient hyperextend the • Onset 10-50 years of age neck, progressive paralysis of gaze mechanisms • Early presentation is based on area of CNS white matter involved • Pseudo bulbar features such as marked dysarthria • Corticospinal tract involvement

• Multiple lesions of the white matter of the • The patient is young and has/had: CNS occurring in discrete episodes separated • Trigeminal neuralgia by an interval of several weeks or months. • Bilateral internuclear opthalmoplegia (diplopia) • Worsening of symptoms with increased body temperature (Uthoff’s phenomena) • Loss of proprioception in the hand leading to incoordination • L’hermittes sign • McArdles sign • Hyper DTRs

Early symptoms of MS Advanced signs MS

• Fleeting paresthesias • Bilateral spastic paraplegia • Emotional lability • Neurogenic bladder • Minor/ (or major) visual disturbances • Visual impairment Fatigability • • Dysarthria • Most common sign is weakness or sensory loss in extremities. One limb more involved • Intention tremor • S&S reflect typical spinal cord or brain syndrome • Ataxia problems not nerve root or n lesion • Nystagmus • Diplopia • Pseudobulbar syndrome with emotional lability

MS outcomes MDC Guillain Barre

• 6MWT; 24m ( Rampello A, Franceschini M, Pieopoli M et al. Effect of • Peripheral demyelinating disease aerobic training on walking capacity and maximal exercise tolerance in patients with Multiple Sclerosis: A randomized crossover controlled study. 2007, Phys ther • Autoimmune disease 87; 545-555.) • Not progressive (after disease runs its course)

• Disorder of the neuromuscular junction • Clinic test: have patient look up for 1 minute • Muscle fatigability, generalized or localized and observe for ptosis • Etiology: autoimmune • DTRs preserved. Normal sensory exam • Affects all ages, women at younger ages and twice as often • EMG usually the ulnar nerve is studied using the abd digiti minimi as the recording site, • Onset insidious, fluctuating weakness after exercise or at the end of the day there is a decrease in the amplitude of the • Course: bulbar m, diplopia, ptosis/ chewing problems, muscle AP by at least 12% by the 3-4 dysphagia ‰ proximal limb and neck muscle weakness contraction. Repetitive nerve stimulation • Respiratory m (URIs can be fatal: myasthenic crisis) results in decremental response.

Outcomes tools for functional Cerebrovascular disorders limitations measures for CVA • Underlying process often affecting the large (& – 6MWT : MDC 34m chronic stroke; Subacute smaller: lacunar) vessels can be 60.98m (Fulk GD, Echternach JL. Test-retest reliability and minimal detectable change of gait speed in individuals undergoing rehabilitation after stroke. J Neurol Phys – Ischemic Ther . 2008;32: 8-13.

• Atherosclerosis, emboli – BBS: MDC 6.9 points (Stevenson TJ. Detecting change in patients – Hemorrhagic withstroke using the Berg Balance Scale. Aust J Physiother . 2001;47:29–38. • HTN, aneurysm – chronic 4.66 (Hiengkaew V, Jitaree K, Chaiyawat P. Minimal detectable changes of the Berg Balance Scale, Fugl-Meyer Assessment Scale, Timed "Up & Go" Test, gait speeds, and 2-minute walk test in individuals with chronic stroke with different degrees • Deficits such as aphasia or hemiparesis, cortical of ankle plantarflexor tone. Arch Phys Med Rehabil . 2012; 93:1201–1208. deficits • Gait speed : Small meaningful change = 0.06m/s • Generally we know about these up front Substantial meaningful change = 0.14 m/s (Perera, S., Mody, S., et al. (2006). "Meaningful change and responsiveness in common physical performance measures in older adults." Journal of the American Geriatrics Society 54(5): 743-749)

Trauma: Subdural Other considerations subdural hematoma hematoma TBI blood in the dura, • Risk Factors include very young or very old age secondary to a tear in a vein crossing the • As we age the brain shrinks, subdural space subdural space enlarges and the veins that traverse the space must travel over a wider distance, making them Problem is increased more vulnerable to tears. intracranial pressure • Subdural hematoma is a common finding in shaken baby syndrome May take days to • In juveniles, an arachnoid cyst is a risk factor for a weeks to show up subdural hematoma. • Other risk factors (anticoagulants), ETOH, and Medical emergency dementia.

Intellectual property of original author with authorized use by MR- Institute of Continuing Education. Do not duplicate. Copyright 2013. 5 Signs and Symptoms Measuring limitations • A history of recent • Irritability head trauma • Gait speed: • Weakness or • Seizures Lethargy • Change in performance of > 0.05 m/s is • Headache (either attributed to "real variation in severe TBI • Loss of appetite constant or • Personality changes subjects (Watson, M. J. (2002). "Refining the ten-metre walking test fluctuating) for use with neurologically impaired people." Physiotherapy 88(7): 386- • Difficulty walking 397. • Blurred Vision • Dizziness • Deviated or • Disorientation abnormal movement of the eyes

Tumor/ SCI Limitations tools SCI

• Depends on the level of involvement • 10MWT: MDC: A change of 0.13 m/s was • Generally a progressive problem with mixed found to detect significant clinical change for sensory/strength impairments the 10MWT • Young or older people • Need to recognize neuroanatomy to ID • Lam, T., Noonan, V., et al. (2007). "A systematic review of functional ambulation outcome measures in spinal cord injury." Spinal Cord 46(4): 246-254.

References • Chan DK, Cordato DJ, O'Rourke F. Management for motor and non-motor complications in late Parkinson's disease. Geriatrics 2008;63(5):22-7. • Guberman A. An Introduction to Clinical Neurology, Essentials in Clinical Practice. Little, Brown, Boston, Mass.1994. The • Mosby’s Field Guide to Physical Therapy. Mosby, Elsevier. St. Louis, Missouri. 2009. 133-36: 150-53. • Miller DH, Leary SM. Primary-progressive multiple sclerosis. Lancet Neurol. 2007. 6; Neuroevaluation (10): 903-12. • Lui, A J. Byl, N N. A Systematic Review of the Effect of Moderate Intensity Exercise on Function and Disease Progression in Amyotrophic Lateral Sclerosis. J Neurol Phys Ther : 2009. 33 ;(2): 68-87. • Shorvon, SD. Neurological Emergencies. Butterworth Publisher, Current Medical John Handrakis PT, DPT, EdD Literature, London,UK 1989. • Scifers JR. Special Tests for Neurologic Examination. Slack Inc., New Jersey, 2008. Veronica Southard PT, DHSc, GCS • Goetz CG, ed. Textbook of Clinical Neurology . 3rd ed. Philadelphia, Pa: WB Saunders; 2007. • Goodman and Snyder. Differential Diagnosis in Physical Therapy. WB Saunders, Philiadelphia. 2 nd edition 1995.

Intellectual property of original author with authorized use by MR- Institute of Continuing Education. Do not duplicate. Copyright 2013. 6 Cerebral Cortex: lateral view A Neuroanatomically-directed Approach Image from W.H. Freeman and Sinauer Associates • Advantages – May be easier to organize tests according to structure Suppl – Lends itself in making a differential evaluation Motor Pre Sensory • Are the affected structures in the same general area or diffuse? Mental – Easier to link the presence of pathological signs with specific status neuro structure/s. • Are the structures implicated consistent with a dx? • Is the pathology spreading to adjoining structures? Memory • Disadvantages Balance – Dependent on examiner’s knowledge of coord neuroanatomy + BG CN tests CortSpin 37 Spinoth+DC 38 http://www.biologie.uni-hamburg.de/b-online/library/onlinebio/BioBookNERV.html

When neuro pathology is suspected Traditional Neuro Exam Pt Interview & history: • Determine predisposing factors & PMH • After pt history & vital signs – age, gender, BMI, lifestyle, tobacco, ETOH, DM, family hx of disease, etc. 1. Mental status • HPI & investigate the cc: – Neuro Symptoms: 2. Cranial Nerves • nature 3. Motor Exam • duration & intensity • anatomical area affected (distribution of S&S) 4. Reflexes • progressive 5. Coordination & Gait • initial onset – – sudden ≈ CVA, TBI 6. Sensory Exam – slow ≈ tumor, disease (infection, degenerative) • Ask re: c/o of weakness, incoordination, balance/falls, numbness, burning, or sensation changes. 39 Blumenfeld, H. 2002 40

• 1. Mental status (primarily prefrontal lobe) Mental Status (cont) – Affect • withdrawn, no eye contact, indifference – Languag e (left/dominant hemisphere: prefrontal, frontal, & (assessed during pt interview) parietal lobes) • assess spontaneous speech, repetition, – Cognition, orientation comprehension of spoken and written material, • a & o x 3 ability to write • comprehension of illness, appropriate judgment – Non-fluent (Broca’s aphasia) = (dominant post/inf frontal – Attention, memory, concentration , clarity of lesion) » associated with R hemiparesis/plegia thought (prefrontal & temporal lobes) • repetition of a sequence of numbers forwards & backwards – Fluent aphasic speech (Wernicke’s aphasia): word salad (concentration/memory) = (dominant posterior/sup temporal lesion) • subtract 7 from 100 (serial subtraction or if too hard, months » not necessarily associated with paresis/plegia as it’s forward & backward) (concentration/attention) located in auditory association area of L cerebral • Immediate and delayed recall of 3-5 words after 5 min hemisphere but may be associated with visual field (working memory) deficits 41 42

Motor System? Primary motor (along with corticospinal) – Assess strength, reflexes, coordination – Assess for presence of UMN signs… (weakness, spasticity, hyperreflexia, +Babinski) also Hoffman, Pronator drift • Reflexes – C5, 6, 7, L3, S1 – Jaw jerk, Corneal reflex (hyper if bilateral corticobulbar lesions) – Assess for presence of synergy • test high-level out of synergy isolated movements (primary motor & corticospinal above midbrain)

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Motor (subcortical) Motor (cortical) • Cerebellum • Nose to finger movement (full elbow extension) with + intention Premotor tremor, dysmetria, ataxia – ability to perform complex learned movements on • Dysdiadochokinesia command • Rebound phenomena • Inability to stand with narrow base of support with eyes open • mimic combing hair, brushing teeth, turning a doorknob, etc. • Basal ganglia Supplementary motor – Presence of S&S of – Follow 3-step command • PD: resting tremor, cogwheel rigidity, bradykinesia, hypokinesia, loss of N postural adjustments to balance perturbations, FF posture, akinesia/freezing, festinating gait, micrographia, mask-like face • Huntington’s disease: hyperkinesia, choreas, athetosis, hyper-erect posture

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Motor (PNS) 3. Test Cranial Nerves

• LMN Signs • Observe CN functions during patient – areflexia, atrophy, fasciculations, weakness • Differentiate distribution interview… – N root, peripheral n – symmetry of pupil size, eye movement, facial expression, – Distal, proximal hearing – Ask if there are any swallowing or balance problems or change in sense of smell

• Brief Cranial nerve exam: – II: Visual acuity – III: Size of pupils (symmetry) , reaction to light

– IV, VI: Ocular movements (LR 4,SO 6)3 Polling Question – V: jaw strength, facial sensation

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Intellectual property of original author with authorized use by MR- Institute of Continuing Education. Do not duplicate. Copyright 2013. 8 Cranial nerves (cont) 4. Intact Sensory System? • VIII: Auditory: acuity (symmetry of hearing) – Vestibular: • gaze stability while following finger & turning head in opposite direction (VOR) • One leg stand (OLS) • Fuduka’s marching

• VII, IX, X, XII: Movements of face, palate, tongue – VII: smile, say “puh-puh-puh”, whistle, close eyes tightly – IX, X: “kah-kah-kah” – XI: shoulder shrug, turn head – XII: “la-la-la” Polling Question

(Larsen P & Stensaas S 2009)49 50 http://bstr431.biostr.washington.edu/syl/lab3/fig3320.gif

4. Sensory Exam Sensory assessment • Primary Somatosensory: – lt touch, pinprick, vibration, proprioception • C. Occipital lobe (primary sensations) – visual acuity (retina & CN II) • Also tests integrity of Spinal Cord ascending tracts – LST: pin prick, temperature – recognition of objects – AST: crude light touch – visual field cut – Dorsal Column: vibration, proprioception, +Romberg (with eyes closed) • e.g., homonymous hemianopsia – If impaired, determine distribution of signs – depth perception • Cortical/hemi, SC/ para, distal > proximal, segmental/dermatomal, etc • Association Somatosensory: – stereognosis, graphesthesia, 2 pnt discrimination, Polling Question bilateral simultaneous touch 51 52

5. Assess Stance Assess Stance (cont) • Ability to sit to stand transfer • Assess postural stability • Repeated efforts, necessity of using UE support – increased sway, feet together, OLS, Romberg, • Postural abnormalities perturbation, stand on heels, toes – manually challenge standing balance with A-P pull. – Stooping (Parkinson’s) • Abnormal responses: – Hyper-extended – Multiple steps backwards, falls backwards, no – Lumbar lordosis use of UEs for protection • excessive = prox LE weakness (MD, myopathies) – Test balance – Kyphosis, forward head, scoliosis • Static: Romberg, tandem Romberg, OLS – Asymmetries • Dynamic: Tandem walk, FR, TUG, Tinetti, etc

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Intellectual property of original author with authorized use by MR- Institute of Continuing Education. Do not duplicate. Copyright 2013. 9 6. Gait Gait (cont) • Observe gait & tandem gait • Assess Assess for… – Presence of associated movements : • Abnormal movements • Alterations in N stance & swing phases • Symmetry of stride/stance (& arm swing) – Hip hiking/circumducted/toe drag, festinating, ataxic, spastic, etc. – Normal stride length » Cortical, subcortical, cerebellar, pyramidal lesions – Foot drag • Inability to walk on heels • Base of support – decreased dorsi, foot drop, steppage gait • Speed, steadiness » anterior tibialis weakness » UMN pyramidal tract lesion or » LMN, L5 radiculopathy, peroneal neuropathy • Inability to walk on toes Polling Question – Gastrocsoleus weakness – » LMN, S1-2 radiculopathy or posterior tibial neuropathy 55 56

REFERENCES Thank You • 1. Blumenfeld, H. Neuroanatomy through Clinical Cases. Sunderland, MA: Sinauer Associates, 2002. • 2. Campbell, W. DeJong's The Neurological Examination. Department of Physical Therapy Philadelphia: Lippincott Williams & Wilkins, 2005. • 3. Larsen, P., & Stensaas, S. NeuroLogic Exam: an Anatomical School of Health Professions Approach. New York Institute of Technology http://library.med.utah.edu/neurologicexam/html/home_exam.html , 2009. • 4. Ropper A and Brown R. Adams and Victors Principles of Neurology: McGraw Hill Medical Publishing Division, 2005. • 5. Shumway-Cook A, Woollacott M. Motor Control Theory and James J Peters, Bronx VA MC Applications, Williams and Wilkins Baltimore, 1995: 323-324 Center of Excellence for the Medical • 6. VanSwearingen JM, Paschal KA, Bonino P, and Yang JF. The modified Gait Abnormality Rating Scale for recognizing the risk Consequences of Spinal Cord Injury of recurrent falls in community-dwelling elderly adults. Phys Ther 76: 994-1002, 1996. • 7. Waxman, SG. Correlative Neuroanatomy. New York: Acknowledgements: Noam Y. Harel, MD, PhD LangeMedical Books/McGraw-Hill, 2000. Research Associate, James J Peters, Bx VA MC • 8. Young, PA, Young PH, and Tolbert DL. Basic Clinical Assistant Professor of Neurology and Rehabilitation Medicine, Neuroscience. Philadelphia: Lippincott Williams & Wilkins, 2008. 57 Mount Sinai School of Medicine 58

Questions to ask yourself

• Is there any more information needed to Case studies decide what is best for the patient? Webinar • What structures are involved? • Does the patient have an upper motor or lower motor neuron lesions? Both?

Veronica Southard PT DHSc GCS • Would you treat this patient today? John Handrakis PT EdD • Course of action?

• The patient is a 16 year old female who comes to your office with complaints of neck pain. She has been having discomfort since school started about 8 weeks ago . She plays soccer for the JV at her high school. She is Right handed and lives at home with her parents and 2 siblings. PMH: negative. Meds: Motrin for neck pain at bedtime • HPI: The patient reports that the pain has been present for about 3 months on and off . The PCP, recommended the Motrin for the neck pain and advised her to call back in a week if she was not better. The Motrin relieved the pain and stiffness to a degree so that the patient could return to previous activities. Four days ago her mom called the PCP because she was still taking the Motrin. The PCP then advised the parent to bring the patient to a PT. • The patient reported that she felt her left hand felt “funny” sometimes when she tried to use it. The patient points to the back of her neck when you ask her to localize the pain. Pt. states it is ~4/10 without Motrin, with meds 1-2/10. Also she notes urinary urgency. • C ROM is normal however some guarding is noted at all end ranges. Pt has mild forward head posture. There is slight tenderness to palpation at the nuchal line and cervical paravertebrals . • An upper quarter exam is completed and the following findings are present: • The patient has mild wasting and 3/5 of the intrinsic muscles of the Left C8- T1 nerve roots. There is also sensory loss over the entire C8-T1 dermatome distribution as follows: L UE numbness C8-T1 when tested for pain and temperature, loss of position sense L small finger . The biceps and triceps DTRs are 3+ on the left. Muscle strength of the triceps on the left is 1+/5 . Otherwise the R UE ROM/ MMT/ sensation WNL.

Patient #2 Patient #3 • The patient is a 42 year old female librarian, arriving at your clinic with LBP. PMH includes a diagnosis of anemia. Three years ago the patient had a The patient is a 37 year old homemaker, arrives at your outpatient clinic similar bout of back pain with leg weakness . The patient lives in a private • home with a full flight to get in. Pt. has two teenaged sons and is divorced. with a diagnosis of Bells Palsy on her referral. The referral indicates the Medications: Advil Gel caps for back pain and vitamins. PCP would like you to evaluate and treat the patient. • HPI: The LBP started ~ 1 month ago without a particular event . It is worse • The past medical history is significant for Hypertension and obesity. Meds with sitting and when she gets up in the morning. The low back pain has include Hydrochlorothiazide (mild diuretic). The patient is a 1ppd cigarette made the patient stop working for the last 7 days since she cannot get into and out of the car. VAS at rest is 5/10 and 7/10 with walking and smoker for the past 22 years. stairclimbing. Further questioning revealed the patient is having some • HPI: patient reports noticing difficulty closing her left eye for the past 2 difficulty voiding for the past 2 weeks and is sleeping on the living room weeks. Her husband noticed that her smile was uneven to one side. The couch to avoid climbing the stairs at night to go to the bathroom. The patient has not seen the MD . patient also states that she is drooling at night and is more tired than • Inspection: The patient walked in with a gait that appeared to have a usual. steppage component and wider than normal base of support . She touched • Examination: the patient is alert and oriented X3. Extremity ROM is WNL. the wall when she stopped walking. No device. When questioned she The muscles of the 7 th cranial nerve appear to be weak when compared reported that lately the pain has made her unsteady . Pt was unable to comply with most of your requests to assess trunk mobility and LE muscle to the opposite side. The patient is unable to close the left eye strongly. strength due to pain. Palpation: increased pain and muscle spasm noted Further clearing of the neuro system reveals that the patient has positive over the L SI joint and L5 paravertebrals. The patient was unable to walk on pronator drift. When tested the patients left arm moves approximately 3 her heels or toes because of instability. DTR’s biceps 3+, Achilles inches inferiorly and out to the side. Lastly, the patient’s frontalis muscle 3+bilaterally. A positive Babinski was elicited. A slight catch was noted with elbow ROM. is intact bilaterally.

Facial nucleus Patient #4

• http://library.med.utah.edu/kw/hyperbrain/anim/facial_muscles.html • A 69 year old male comes to your office for evaluation of R shoulder pain after a fall in the home. Pt is a retired teacher who lives alone in a senior garden apartment complex across the street. He is alert and oriented X3. PMHx: L TKR X 5 years, HTN, Afib. Meds include Metoprolol, Warfarin and Simvastin. Further investigation reveals that this patient has had 2 other falls within the past 6 months. The first was on the icy sidewalk; the second in the bathroom when turning from the toilet. Pt. has yet to see his MD. Denies LOC and dizziness. Inspection, a large ecchymotic area is noted over the R posterior shoulder. AROM (R) is reduced to ~130 degrees of flexion, 120 abd, 50 IR, 60ER, and -20 elbow extension. PROM is WNL, however the elbow demonstrates slight cogwheeling which is also apparent on the R. Babinski is +: DTRs 2+ UEs; and 3+ R LES . Sensory exam is unremarkable. Posture demonstrates a mild kyphosis and sl LE flexion at hips and knees in standing. There is decreased heel strike and reduced cadence during gait.