pk 1 astri 19 april final
TRANSCRIPT
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Case Presentation I
Tuesday, 19 April 2016
CASE PRESENTATION
PHYSICAL MEDICINE AND REHABILITATION MANAGEMENT OF PATIENT
WITH OSTEOSARCOMA OF RIGHT PROXIMAL TIBIA ENNEKING III POST
STANDARD TRANSFEMORAL AMPUTATION OF RIGHT LEG WITH
PULMONARY METASTASES
Presented by
dr! Set"# W#t" Astr" Ar"$"n
E%#&"ner
dr! I Ny'n M(rd)#n#* S+KFR,K
Presented "n T)e C'(rse '$ T#-"n. Res"den/y Tr#"n"n.
P)ys"/#0 Med"/"ne #nd Re)#b"0"t#t"'n Pr'.r#&
Med"/#0 F#/(0ty Un"1er"ty '$ Ind'nes"#
2#-#rt#
3456
Kepada Yth.
dr. I Nyoman urdhana, !pK"#$K
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CONTENT
CONTENT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"
CHAPTER 5 LITERATURE RE7IEW!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!5
5!5! OSTEOSARCOMA !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!5
5!3! ABO7E KNEE %TRANSFEMORAL8 AMPUTATION !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!9
5!:! REHABILITATION IN TRANSFEMORAL AMPUTATION !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!6
CHAPTER 3 CASE REPORT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!53
3!5! IDENTITY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!53
3!3! ANAMNESIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!53
3!:! PHYSICAL EXAMINATION!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!59
3!;! SUPPORTI7E EXAMINATION!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!3:
3!9! RESUME!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!36
3!6! DIAGNOSIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!3<
3!
3!=! REHABILITATION PROGRAM!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!3>
3!>! PROGNOSIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:5
CHAPTER : CASE ANALYSIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:3
REFERENCE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!::
APPENDICES !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:6
i
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CHAPTER 5
LITERATURE RE7IEW
5!5! OSTEOSARCOMA
5!5!5! De$"n"t"'n
The term osteosar&oma 'as (irst used in the early 1)00s *y Ale+is oyer, the
imperial (amily sur-eon (or Napoleon.%1 /steosar&oma is de(ined as a mali-nant
mesen&hymal tumor in 'hi&h the &an&erous &ells produ&e *one matri+.
/steosar&omas are &lassi(ied as primary and se&ondary. Primary are (urther su*$typed
as intramedullary&entral and sur(a&e osteosar&omas as per orld !health
/r-aniation &lassi(i&ation.%2
5!5!3! E+"de&"'0'.y
/steosar&oma is the most &ommon primary *one tumor.%3 The in&iden&e is
0.2$.0.3100.000year, hi-her in adoles&ents %0.)$1.1100.000year at a-e 14$19,
'here it a&&ounts (or 510 o( all solid &an&ers. Adults are less a((e&ted 'ith a se&ond
pea7 in&iden&e *et'een 40 and 80 years. This later in&iden&e is usually asso&iated
'ith se&ondary osteosar&oma that &ould arise in Pa-ets disease, *one in(ar&ts and(i*rous dysplasia. The male$(emale ratio is 1.:;1.%:
5!5!:! C0"n"/#0 M#n"$est#t"'n
The tumours usually arise in the metaphyseal re-ion o( the lon- *ones o( the
e+tremities, un&ommonly o&&ur in the diaphysis %9.%2,: The most &ommon
anatomi& sites o( osteosar&oma at initial presentation are the lon- *ones o( the lo'er
lim*s. "i(ty per&ent o( osteosar&omas are lo&ated around the 7nee, in the distal (emur, pro+imal ti*ia, or pro+imal (i*ula. Appro+imately 10 o( tumors o&&ur in the mid or
pro+imal (emur, and 9 o&&ur in the pro+imal humerus.%4,6
The most &ommon presentation is site spe&i(i& pain. This is -enerally
'orsened *y physi&al e+ertion. Appro+imately 20 &omplain o( ni-ht pain.%8 Ni-ht
pain -radually de
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throu-h the &orte+ and li(ts the periosteum resultin- in rea&ti
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sal
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The most important pro-nosti&ator is the presen&e o( metastasis at
presentation. The se&ond pro-nosti&ator is the response o( tumour to neo$ad=u
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easurements are ta7en (rom an easily identi(ied *ony landmar7 to the palpated end
o( the lon- *one, the in&ision line, or the end o( so(t tissue. In the trans(emoral lim*
the startin- pla&e (or measurement &an *e the is&hial tu*erosity or the -reater
tro&hanter.%22
Ta*le 2. @es&ripti
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itsel(. Phantom lim* sensation is the per&eption that the e+tremity is still present and
o&&asionally distorted in position. Phantom lim* sensation typi&ally (ades a'ay
'ithin the (irst year a(ter amputation. Phantom lim* pain is di((erentiated as a pain(ul
per&eption 'ithin the a*sent *ody part. Pain at the sur-i&al site, in&ludin- in&isional
dis&om(ort, is &ommon and should resol
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5!:!: P'st,'+er#t"1e P)#se
This phase *e-ins immediately post$operatiuipment pres&ription, and &ontinued
patient edu&ation and emotional support.
Time to (ittin- o( prosthesis is usually 6$) 'ee7s or lon-er, on&e stump has
matured. In the meantime, -ait trainin- is initiated 'ithout a prosthesis. "un&tional
mo*ility trainin- (or indi
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e((e&ti
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systems (or prostheti& -ait. e(ore startin- the prostheti& trainin-, there are seuate (or 'ei-ht *earin- and there are no a*rasionss7in
tears on 'ei-ht *earin- sur(a&es or lo&ation o( straps $ !tump shape is appropriate (or
prostheti& use, that is, the distal end should *e narro'er than the pro+imal end $
Patient is a*le to tolerate su((i&ient pressure on stump to *e-in 'ei-ht *earin- $ Pain
is reasona*ly under &ontrol
*. o*ility le
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>uadrilateral desi-n and the is&hial &ontainment desi-n.
2. !uspension;
There are
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CHAPTER 3
CASE REPORT
3!5! IDENTITY
Name ; N
A-e ; 36 years old
Address ; ?e*a7, #an-7as*itun-
/&&upation ; ouse'i(e
Bdu&ation ; 3rd &lass Blementary !&hool
arital status ; arried 'ith t'o &hildrens
edi&al re&ord ; :113239@ate o( e+amination ; April )th, 2016
3!3! ANAMNESIS
istory 'as ta7en on April ), 2016 (rom autoanamnesis, patients &ousin,
patients hus*and and (rom patients medi&al re&ord.
3!3!5! C)"e$ /'&+0#"ntPost trans(emoral amputation o( ri-ht le- 1 'ee7s a-o.
3!3!3! H"st'ry '$ t)e Present I00ness
Patient under'ent sur-i&al trans(emoral amputation o( the le(t lim* on ar&h
30, 2016 at #!C. !he 'as re(erred (rom /rthopedi& @epartment (or reha*ilitation
pro-ram a(ter amputation.
A*out 10 years a-o %2006, there 'as a small lump in the *a&7 side o( *ehind
her ri-ht 7nee. The lump had &lear *order 'ith (irm &onsisten&y, immo*ile, pain(ul
and tender on palpation and 'as -ettin- *i--er pro-ressi
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lon- time, the lump re&urred in the same lo&ation %*ehind the ri-ht 7nee. The
&hara&teristi& o( the lump 'as same 'ith pre
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Patient is not a*le to stand 'ith one le- 'ithout hand support (or more than 10
se&onds. o*iliation 'as helped *y usin- *ilateral &rut&shes (or near distan&e, *ut
(or (ar distan&e she usually use 'heel&hair helped *y her hus*and or her sister. !he
&an do most o( the a&ti
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&osmesis reason. Patient 'ants to return to her a&ti
13.00 J 18.00 Ta7e a nap, &hat 'ith her roommates and nei-h*or,learnin- usin- *ilateral &rut&hes and mo
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!B
Nutritional !tatus
Gait Pattern
alan&e
24
ody 'ei-ht ; 32 7-ody hei-ht ; 140 &mI ; 1:.2 %Dnder'ei-thIdeal *ody 'ei-ht O %*ody hei-ht$100 J
10%140$100 $10 O :4 7-A*ouate
Normal
alnutrition
!ittin- *alan&e;
normal
!tandin- *alan&e
impaired
General Physi&al "indin-s
Syste& P)ys"/#0 F"nd"n.s I&+ress"'n
Inte-ument
!7in; *ro'n$&olored, no rash, no dry s7in, no
hyperpi-mentation, normal temperature
Normal
air; no hair loss Normal Nail; no yello'ish, no si-n o( anemi&&yanoti& Normal
ead No masstumor, no haematoma, no edema, nolesiontrauma si-n
Normal
Ne&7
No de(ormity, no mass, tra&shea in the midline,
symmetri&al, no enlar-ement o( lymph nodes,
&arotid pulsation normal
Normal
Byes
Con=un&ti
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alon- the le(t mid&la
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CN II; /pti&us
Fisual a&uity test %-ross e+amination 'ith
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CN FIII; Festi*ulo&o&hlear
$ Auditory test; patient &ould shear ru**in- (in-ers pla&ed at distan&e (rom *oth ear.
Impression; normal
CN IQ, Q; Glossopharyn-eal, Fa-us
$ !ymmetri& ar&h o( pharyn+ and u
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$ ?ateral;"or'ard head, strai-ht &eruate
Palmar preshension;
Tripod -rip ; ade>uateade>uate
Pin&h -rip ; ade>uateade>uate
Plate -rip ; ade>uateade>uate
Cylindri&al -rasp ; ade>uateade>uate
!pheri&al -rasp ; ade>uateade>uate
Coordination test
Inde+ (in-er J inde+ (in-er ; -ood-ood
Inde+ (in-er J nose ; -ood-ood
20
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Inde+ (in-er J nose J inde+ (in-er ; -ood-ood
Pronation J supination ; -ood-ood
ROM MMT
o
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$ ip
#i-ht ; no de(ormity, no in(lammation si-n, normotrophy
?e(t ; no de(ormity, no in(lammation si-n, normotrophy
$ Thi-h
#i-ht ; a*o
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?e(t ; normotonus, no tenderness, no spasm
$ Pulse; A. (emoralis RR re-ular, -ood
A. poplitea NTR re-ular, -ood
A. dorsalis pedis NTR re-ular, -ood
o
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3! ;! SUPPORTI7E EXAMINATION
?A+r"0 55* 34568
M"n" Ment#0 St#te E%#&"n#t"'n 23 %Normal (or le
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CT S/#n T)'r#% ?M#r/) 3:* 34568
Kesimpulan;
Nodul paru multipel %se*a-ian *er7alsi(i7asi disertai lim(adenopati su*7arina, sesuai
lesi metastasis.
L#b'r#t'ry
59@4:@56 :4@4:@56 59@4:@56 :4@4:@56
* 12.1 54!3 !G/T ;= $t :6!4 30.9 !GPT 30 $Britro&yte :.30 :!9< Al*umin 3.99 $C )3.8 )6.6 Natrium 1:: 139
CF 2).1 2).6 Kalium :.42 3.)2CC 33.6 33.0 Chlorida 103.0 103.6Throm*o&yte 339 39) Calsium %Ca
@arah$ ).)
?eu7o&yte 54!>5 5>!65 Calsium %CaRRIon
$ 1.22
?B@ ;4 a-nesium $ 1.)4PT "os(at Inor-ani7
%P$ :.0
Patient Kreatinin darah 0.60 $
Control 10.9 10.) Dreum darah 22 $APTT 10.) 10.8 G@! 94 8:Patient eG"# 118.6 $Control :2.6 39.1
3!9! RESUME
A 36 years old (emale patient re(erred to edi&al #eha*ilitation Poly&lini&
(rom /rthopaedi& Poly&lini& to -et reha*ilitation pro-ram a(ter amputation 1 'ee7s
a(ter ha
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@epression !&ale s&ore is normal. Patient has already a&&epted her &ondition and
hopes she &ould still do her pre
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B'dy str(/t(res
s.840; stru&ture o( lo'er e+tremity
s.:30; stru&ture o( respiratory system
A/t"1"t"es #nd P#rt"/"+#t"'n
Gener#0 t#s-s #nd Dends
d230;&arryin- out daily routine
M'b"0"ty
d.:34;mouisition o( -oods and ser
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$ Improuate nutrition
$ ana-ement o( the stump
$ ana-ement o( phantom sensation and pain
$ Preuality o( li(e
Bdu&ation
$ A*out the &ondition and the treatment
o( the patient
$ Pro*lems that &an arise in a patient at
home li7e pain or (ati-ue, ho' to sol
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$ #insin- the stump 'ell and to'el
dryin-
$ Clean the s7in (olds 'ith an appli&ator
or &otton s'a*
$ Any 'ound*ruise ha
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se&onds, 10 repetitions, 3+day
$ amstrin- settin- e+er&ise %!B; hold 4
se&onds, 10 repetitions, 3+day4 Phantom pain and
sensation
No phantom pain
and no phantom
sensation
Bdu&ation ;
$ @o the desensitiation te&hni>ues;
massa-in- and tappin- o( residual lim*$ irror therapy
6 i-h ris7 o( (alls Pre
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9 ilateral para&er
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CHAPTER :
CASE ANALYSIS
32
ildly dependentA@?
i-h #is7 o( (all
Am*ulation 'ith *ilateral &rut&shes
prosthesis
?un-etastasis
Bner-ye+penditure
?imited a&ti
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REFERENCE
1. Peltier ?; /rthopedi&s; a history and i&ono-raphy, Chapter 11No
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&hildren and adoles&ents 'ith osteosar&oma. L Pediatr !ur-. 2006 LanE:1%1;19:$
9.
13. @in&*as "/, Ko&a !, andel N, et al; The role o( preoperati
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24. Bs>uenai A, @iGia&omo #. #eha*ilitation a(ter amputation. L Am Podiatr ed
Asso&. 2001 LanE91%1;13J22.
26 @eFita FT, ?a'ren&e T!, #osen*er- !A. @eFita, ellman, and #osen*er-s
Can&er; Prin&iples W Pra&ti&e o( /n&olo-y. ?ippin&ott illiams W il7insE 200).
18:) p.
34
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A++end"% 5! M"n" Ment#0 St#te E%#&"n#t"'n
D'"n Tested ?Test8 S/'re
/rientation
$ Year, month, day, date, time
$ Country, to'n, distri&t, hospital, 'ard
#e-istration
$ B+aminer names 3 o*=e&ts %e.-.; apple, ta*le, &oin
$ Patient as7ed to repeat 3 names J s&ore 1 (or ea&h &orre&t
ans'er
Attention and Cal&ulation
$ !u*tra&t 8 (rom 100, then repeat (rom result, et&. stop
a(ter 4
$ 100, 93, )6, 89, 82, 64
$ %Alternati
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1. @BP#B!!B@ //@ %!adness, hopeless, helpless, 'orthless0OA*sent5T)ese $ee0"n. st#tes "nd"/#ted 'n0y 'n (est"'n"n.
2OThese (eelin- states spontaneously reported
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2O?oss o( interest in a&tiuen&y.A
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1Oea
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T't#0 S/'re :
4 , < N'r
) $ 13 O ild @epression1:$1) O oderate @epression19 $ 22 O !e
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3 andiri ] ]
8 o*ilisasi*er=alan 0 Tida7 mampu1 isa *er=alan den-an 7ursi
roda
2 er=alan den-an *antuan 1oran-'al7er
3 andiri ] ]
) erpa7aian 0 Ter-antun- oran- lain1 !e*a-ian di*antu %misal;
men-an&in-7an *a=u2 andiri ] ]
9 Nai7 turun tan--a 0 Tida7 mampu
1 utuh pertolon-an ]2 andiri ]
10 andi 0 Ter-antun- oran- lain1 andiri ] ]
T/TA? NI?AI 20 1)
Keteran-an; !7or I %Nilai A@?; 20 ; andiri
535> Keter.#nt(n.#n r"n.#n
9J11 ; Keter-antun-an sedan- 4 J ) ; Keter-antun-an *erat
A++end"% ;! E#stern C''+er#t"1e On/'0'.y Gr'(+ ?E/'.8 S/'re @ (br'd S/'re
A++end"% 9! K#rn'$s-y Per$'rn/e St#t(s S/#0e De$"n"t"'ns R#t"n.
Ab0e t' /#rry 'n n'r #/t"1"ty #nd t' 100 Normal no &omplaintsE no e
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'r- n' s+e/"#0 /#re needed!
disease.
>4Ab0e t' /#rry 'n n'r #/t"1"ty
&"n'r s".ns 'r sy&+t'&s '$ d"se#se!
)0 Normal a&ti
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1. !ITTING T/ !TAN@INGIN!T#DCTI/N!; Please stand up. Try not to use your hand (or support.← % : a*le to stand 'ithout usin- hands and sta*ilie independently← % 3 a*le to stand independently usin- hands← % 2 a*le to stand usin- hands a(ter se % 2 a*le to trans(er 'ith
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3; % 2 a*le to stand 3 se&onds39 % 1 una*le to 7eep eyes &losed 3 se&onds *ut stays sa(ely36 ? 8 4 needs )e0+ t' -ee+ $r'& $#00"n.
←
8. !TAN@ING DN!DPP/#TB@ IT "BBT T/GBTB#
IN!T#DCTI/N!; Pla&e your (eet to-ether and stand 'ithout holdin- on.3< % : a*le to pla&e (eet to-ether independently and stand 1 minute sa(ely3= % 3 a*le to pla&e (eet to-ether independently and stand 1 minute 'ithsuper % 2 a*le to pla&e (eet to-ether independently *ut una*le to hold (or 30se&onds:4 % 1 needs help to attain position *ut a*le to stand 14 se&onds (eet to-ether :5 ? 8 4 needs )e0+ t' #tt#"n +'s"t"'n #nd (n#b0e t' )'0d $'r 59 se/'nd
←
). #BACING "/#A#@ IT /DT!T#BTCB@ A# I?B!TAN@ING
IN!T#DCTI/N!; ?i(t arm to 90 de-rees. !tret&h out your (in-ers and rea&h(or'ard as (ar as you &an. %B+aminer pla&es a ruler at the end o( (in-ertips'hen arm is at 90 de-rees. "in-ers should not tou&h the ruler 'hile rea&hin-(or'ard. The re&orded measure is the distan&e (or'ard that the (in-ers rea&h'hile the su*=e&t is in the most (or'ard lean position. hen possi*le, as7su*=e&t to use *oth arms 'hen rea&hin- to a
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IN!T#DCTI/N!; Turn &ompletely around in a (ull &ir&le. Pause. Then turn a(ull &ir&le in the other dire&tion.← % : a*le to turn 360 de-rees sa(ely in : se&onds or less← % 3 a*le to turn 360 de-rees sa(ely one side only : se&onds or less← % 2 a*le to turn 360 de-rees sa(ely *ut slo'ly← % 1 needs &lose super