Step 4: Assessing the Physical Therapy Patient

Before developing a treatment program for a patient, the physical therapist will determine the patient’s fitness level. The patient’s fitness level, or their body’s ability to withstand a physical workload and to recover in a timely manner, can be measured in any of the following ways:

• Cardiomuscular strength
• Electromyography
• Flexibility or range of motion
• Gait
• Muscle strength
• Posture

Cardiomuscular Strength

Cardiomuscular strength indicates how hard the heart muscle can work. There are many ways to test the heart muscle, including the cardiac stress test, an EKG diagnostic, through physical examination and with radiography.

Online Learning

Build on what you are learning by reading the article Heart Disease and Stress Tests.

Medical specialists may have specialized training to set-up and perform electrocardiogram testing. An electrocardiogram (EKG/ECG) is a graphic record of cardiac action currents obtained with the electrocardiograph.

What’s the difference between an ECG and an EKG? Nothing; they are exactly the same thing. So why the two acronyms? When the word electrocardiogram is translated into the German language, it’s spelled as elektro-kardiographie, which developed into EKG. Although both are acceptable, EKG is a more universal acronym for this procedure as ECG sounds too similar to EEG, which is an electroencephalogram.

The machine used to record the EKG is called an electrocardiograph, or an EKG machine. This machine will amplify and measure small differences in the electrical charge or voltage. It reads and records the electrical activity from lead wires and provides a recording of the electrical activity of the heart in the form of a graph, showing the heart’s electrical activity as line tracings on paper. The machine needs to warm up prior to the procedure, so you’ll turn it on so it can warm up during the preparation steps.

With lead wires, also known as EKG cables, one end is attached to the EKG machine and the other is attached to an electrode. You may have to plug the lead wires into the EKG machine before starting the test. Signals are transmitted from the electrodes, through the lead wire, to the EKG machine. The end that attaches to electrodes may have clips or snaps.

Electrodes are disposable discs containing conductive media (gel) that are attached to the lead wires by clips or snaps. If alligator clips are used, you’ll attach those to the EKG leads when preparing the equipment. You can apply the electrodes to the patient before attaching them to the lead wires or after. The electrodes contain a gel that conducts the skin surface voltage changes through color-coded lead wires connected to the EKG machine.

Note, that terminology is important. The term lead is not used to indicate the lead wire or an electrode. Lead describes the measurement of electrical activity of the heart. Each lead picks up electrical activity from a different position on the heart muscle, allowing the interpreter to “see” the heart from many different angles.

An EKG records the electrical signal between electrodes. The printed record of the electrical activity of the heart is called a rhythm strip or an EKG tracing. EKG paper is graph paper made up of small and larger heavily lined squares. The horizontal axis of the graph paper represents time while the vertical axis is the voltage. The smallest squares on the paper are one millimeter wide and one millimeter high. There are five small squares between the heavier lines. This paper is standardized to allow for consistency in analyzing rhythm strips. Be sure to check if the amount of EKG paper is adequate prior to the procedure.

Both time and amplitude are measured on the graph paper. Time is measured on the horizontal line; amplitude or voltage is measured on the vertical line. The squares on the EKG paper represent the measurement of the length of time required for the electrical impulse to span a specific part of the heart. Proper interpretation of EKG tracing is dependent, in part, on the understanding of the time increments as represented on EKG paper.

Measuring Time and Amplitude

Width of each small box = 0.04 seconds

Width of each large box = 0.20 seconds

Skin Preparation

As you know, the electrodes contain a gel that conducts the skin surface voltage changes through color-coded lead wires connected to the EKG machine. For optimal electrode contact, you need to place the electrodes on the patient’s skin at least five minutes before the start of calibration. Be sure to assess the patient prior to placing the electrodes, ensuring the skin is dry, hairless and oil-free, as this can affect electrode contact.

When applying the electrodes, avoid sites with bony prominence or fatty areas. Do not place electrodes on skin over incisions, irritated skin or body parts where there is lots of possible muscle movement. Avoid implanted pacemakers or defibrillators when placing the electrodes.

Skin impedance is the skin’s resistance to electrical signals that flow through it. This resistance can delay or prevent the transmission of the electrical signal to the electrode. Clipping the patient’s hair and abrading the patient’s skin are two methods of preparing the skin to avoid skin impedance.

Because hair is a non-conductive material that can compromise the adhesion of the electrode, it should be removed. Hair at the electrode sites should be removed by clipping rather than shaving. Clipping is the use of an electronic device with fine teeth to cut hair close to the patient’s skin. Shaving, on the other hand, is a method using a sharp blade that is drawn over the patient’s skin to cut hair close to the skin surface. Shaving can cause skin irritation and should be avoided.

Once the site has been identified and the hair removed, you will gently prepare the skin for electrode application. Clean the electrode sites with mild soap and water. If the skin is oily, rub the area with an alcohol wipe or gauze pad. Dry the skin after cleaning.

Skin abrasion is the process of removing dead skin, which enhances the ability to pick up electrical signals. The EKG technician should gently abrade the skin prior to applying the electrodes. This can be done using an abrasive pad, or skin abrader tape.

Electrode Placement

This section will give you a basic undertaking of how to place the electrodes to get a proper lead reading. The 12-lead EKG is used for routine analysis of the heart and is the most common type of EKG test. However, the 3-lead EKG and 5-lead EKG may also be used. Here, you’ll learn about the electrode placement for each type of lead. Placement of the electrodes affects the accuracy of the EKG reading.

The electrodes are labeled with an inscription and color. Note that the colors are not universal, as two standards exist for the EKG. The American Heart Association (AHA) provides the standard for the United States. For this course, you will refer to the AHA standard.

Before you look at the specific placement of electrodes for each type of EKG, let’s look at the options for the limb leads. Keep in mind that the inscription and color used as reference when discussing the electrode placement are from the AHA. Review the placement for each electrode, keeping in mind it’s the patient’s right and left, not your own!

Color	Inscription	Location
White	RA	Anywhere between the right shoulder and right elbow; below the right clavicle
Black	LA	Anywhere between the left shoulder and left elbow; below the left clavicle
Red	LL	Anywhere above the left ankle and below the torso; left upper quadrant
Green	RL	Anywhere above the right ankle and below the torso; right upper quadrant

Although the electrodes for the limb leads are usually placed on the trunk or torso of the patient, they can also be placed on the upper arms and thighs. However, they must be uniform. This means if you put one on the left wrist, you shouldn’t put the other on the left upper arm. Note that for stress testing, the limb leads are placed on the torso to allow the limbs free movement.

Optional limb lead placement

Note, when performing an EKG on a patient who has one or more limbs amputated, place the leg electrodes on the thighs or abdomen; place the arm electrodes on the shoulders or upper chest.

3-lead EKG

The 3-lead EKG is typically used for continuous monitoring of the heart rhythm. It’s not used for routine or screenings. The 3-lead was the original EKG using just bipolar leads, or the limb leads, for the recording. A 3-lead EKG uses three limb lead electrodes, one on each arm and one on the left leg.

3-lead EKG

5-lead EKG

The 5-lead EKG can also be used for continuous monitoring of the heart rhythm but may also be used for telemetry or ambulatory monitoring. In addition to the three electrodes placed in the 3-lead EKG, you’ll add the electrodes at the right leg and sternum for the 5-lead EKG. The electrode for V1 is placed right of the sternum at the fourth intercostal space.

5-lead EKG

12-lead EKG

The 12-lead EKG is often known as the resting 12-lead EKG. This type of testing is used for the stress test as well. In addition to the electrodes placed in the 5-lead EKG, you’ll add the rest of the chest leads for the 12-lead EKG.

Color	Inscription	Location
Red	V1	4th intercostal space to the right of the sternum
Yellow	V2	4th intercostal space to the left of the sternum
Green	V3	Directly between V2 and V4
Blue	V4	5th intercostal space at midclavicular line
Orange	V5	Level with V4 at left anterior axillary line
Purple	V6	Level with V5 at midaxillary line

12-lead EKG

One of the most common questions regarding a 12-lead EKG asks why there are only 10 electrodes. Some leads share the same electrodes. Recall, the limb leads provide six recordings of voltages, and each of the six chest leads provide a reading. This results in 12 readings from the 10 electrodes.

Ambulatory Monitoring

Ambulatory monitoring records the heart’s rhythm for a longer period of time—even as long as a month. Often, the information is stored in the device until it’s downloaded by the provider; however, the reading can be transmitted by telephone to a computer for an immediate reading as soon as symptoms occur, if necessary. This device is used when the provider is looking for signs and symptoms of acute or chronic heart disease. With all ambulatory monitoring, ensuring the electrodes are secure is very important because of the length of monitoring.

A Holter monitor is a type of ambulatory monitor that is usually placed on a patient in the provider’s office and removed after 24-48 hours. Prior to the appointment, the patient should take a shower or bath, unless the provider instructs otherwise. Most monitors can’t be removed and must be kept dry once monitoring begins. A Holter monitor is a small, wearable device with 5-lead EKG that provides data during the patient’s daily activities. It’s important to note that the placement of electrodes is slightly different than during a standard EKG. Usually, a 5-lead placement is used, but a 7-lead might be used as well.

Holter Monitor Lead Placement
White	Right manubrium
Blue	Centered on manubrium
Black	Left manubrium
Brown	2 cm right of xiphoid process
Orange	5th rib, left of midclavicular line
Red	5th rib, left anterior axillary line
Green (ground)