Patient Response Assessment — Assess patient responses to tests and measures, including physiological and mechanical reactions. - National Physical Therapy Examination NPTE

SECTION 1

Historical Context & Motivation

The systematic assessment of patient responses during physical therapy examination has evolved considerably over the past century, transforming from subjective observation into an evidence-based science. Early physical therapists, particularly those who served in the rehabilitation of soldiers following World War I, relied heavily on clinical intuition and gross observation to determine whether interventions were effective. The profession recognized early on that the ability to accurately interpret a patient's physiological reactions — such as changes in heart rate, blood pressure, and pain behavior — alongside mechanical reactions — such as alterations in range of motion, joint play, and tissue extensibility — was fundamental to safe and effective practice. As the profession matured through the mid-twentieth century, standardized outcome measures and objective assessment tools began to replace purely subjective approaches, creating the foundation of the examination process tested on the NPTE today.

1917 • Reconstruction Aides

During World War I, 'reconstruction aides' began using observational assessment to evaluate wounded soldiers' responses to therapeutic exercise, marking an early form of patient response assessment in physical rehabilitation.

1960s • Manual Muscle Testing Standardized

Daniels and Worthingham's manual muscle testing grading scale became widely adopted, creating a standardized framework for assessing mechanical responses to resistance and movement testing.

1978 • Guide to PT Practice Foundations

The APTA began formalizing the patient/client management model, including systematic approaches to tests and measures that require the clinician to assess and interpret patient responses in real time.

2001 • ICF Framework

The WHO's International Classification of Functioning, Disability and Health (ICF) provided a biopsychosocial lens for interpreting patient responses, linking body function impairments, activity limitations, and participation restrictions.

2014–Present • Evidence-Based Outcome Measures

Modern physical therapy integrates validated outcome tools — such as the Numeric Pain Rating Scale, dynamometry, and goniometry — requiring clinicians to interpret physiological and mechanical responses with precision for both clinical practice and licensure examinations.

This historical progression underscores a critical question that every aspiring physical therapist must answer: How do we systematically interpret and act upon the complex physiological and mechanical responses a patient exhibits during examination? The NPTE tests your ability to not merely perform tests and measures, but to accurately read and respond to what the patient's body is communicating — in real time, with clinical reasoning guiding each decision.

SECTION 2

Core Principles of Patient Response Assessment

Patient response assessment sits at the heart of the physical therapy examination process, functioning as the clinician's primary feedback mechanism during every test and measure performed. Whether you are measuring a patient's blood pressure response to positional change, evaluating end-feel quality during passive range of motion, or observing gait deviations under loaded conditions, you are continuously interpreting responses that fall into two broad categories: physiological responses that reflect the body's homeostatic and neurological systems, and mechanical responses that reflect the structural and biomechanical properties of musculoskeletal tissues. These two categories frequently overlap — for instance, a patient's cardiovascular response (physiological) during a six-minute walk test is inherently linked to the mechanical efficiency of their gait pattern.

Physiological Response Monitoring

Encompasses vital sign changes (heart rate, blood pressure, respiratory rate, SpO₂), pain responses, autonomic nervous system reactions (sweating, pallor, dizziness), and neurological signs (reflex changes, sensory alterations) that occur during or after tests and measures.

Mechanical Response Interpretation

Involves evaluating tissue behavior under applied forces — joint end-feel quality, muscle tone and length-tension relationships, tissue extensibility, joint accessory motion (arthrokinematics), and the mechanical integrity of ligaments and tendons during stress testing.

Normal vs. Abnormal Response Recognition

Clinicians must distinguish expected responses from pathological ones. A normal capsular end-feel at the shoulder differs markedly from a springy block suggesting a loose body. Expected exercise heart rate elevation differs from exertional hypotension requiring test termination.

Clinical Decision-Making Integration

Response assessment is not passive observation — it drives real-time decisions about test modification, exercise progression or regression, referral necessity, and safety. Each response informs the hypothesis-oriented algorithm for clinical reasoning.

Documentation and Communication

Patient responses must be objectively documented using standardized scales and measurement tools (e.g., NPRS, MMT grades, goniometric values, RPE). Accurate documentation ensures continuity of care and supports evidence-based practice.

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KEY TAKEAWAY

Think of patient response assessment like reading a car's dashboard while test-driving it. The check engine light (physiological alarm signs like abnormal vital signs) tells you about internal system function, while the way the steering feels and the suspension responds to bumps (mechanical responses like end-feel and joint mobility) tells you about structural integrity. A skilled driver — like a skilled clinician — monitors both simultaneously and makes decisions in real time about whether to continue, slow down, or pull over.

SECTION 3

Visual Framework: Physiological & Mechanical Response Pathways

This diagram illustrates the dual-pathway framework of patient response assessment. When a test or measure is applied, the clinician simultaneously monitors physiological responses (cardiovascular, neurological, autonomic, respiratory) and mechanical responses (joint, soft tissue, ligamentous, functional). Both pathways converge at the clinical decision point, where the therapist determines whether to continue, modify, terminate, or refer.

The diagram above presents the fundamental architecture of patient response assessment as a dual-pathway system. Notice that the physiological and mechanical pathways are not independent silos; they converge at the clinical decision node, reflecting the reality that a single test — such as a six-minute walk test — generates both cardiovascular data (heart rate, blood pressure, oxygen saturation) and mechanical data (gait pattern, joint alignment, compensatory strategies). The NPTE expects candidates to integrate information from both pathways simultaneously, recognizing that an abnormal finding in one domain may be explained by, or may exacerbate, findings in the other. For example, excessive pain (a physiological response) during passive knee extension may cause a protective muscle guarding response that alters the perceived end-feel (a mechanical response), which the clinician must differentiate from a true structural limitation.

SECTION 4

Physiological Response Mechanisms in Detail

Cardiovascular Responses

Cardiovascular monitoring during physical therapy examination is essential for patient safety and for determining exercise tolerance. The clinician assesses heart rate (HR), blood pressure (BP), rate pressure product (RPP), oxygen saturation (SpO₂), and the Rating of Perceived Exertion (RPE). Normal physiological responses to graded exercise include a linear increase in heart rate, a progressive rise in systolic blood pressure (SBP), and a relatively stable or slightly decreasing diastolic blood pressure (DBP). Abnormal responses that may warrant test termination include a drop in SBP of greater than 10 mmHg with increasing workload, an exaggerated hypertensive response (SBP > 250 mmHg or DBP > 115 mmHg), or a decrease in SpO₂ below 90%.

AGE-PREDICTED MAXIMUM HEART RATE

HR_max = 220 − Age (years)

This commonly used formula estimates the theoretical maximum heart rate. Target heart rate zones for exercise testing are typically calculated as a percentage of HR_max (e.g., 60–85% for moderate intensity). While the 220 − Age formula is a rough estimate, it remains a clinically practical tool.

RATE PRESSURE PRODUCT (MYOCARDIAL OXYGEN DEMAND)

RPP = HR × SBP

The rate pressure product estimates myocardial oxygen demand. An RPP exceeding approximately 30,000 may indicate excessive cardiac workload. This value is particularly important when monitoring patients with known coronary artery disease, as angina often occurs at a reproducible RPP threshold.

Pain Response Assessment

Pain is both a physiological and a perceptual phenomenon, and its assessment during examination is multidimensional. The clinician observes not only the patient's verbal report (using tools like the Numeric Pain Rating Scale (NPRS) or the Visual Analog Scale (VAS)) but also behavioral and autonomic indicators of pain such as guarding, facial grimacing, withdrawal reflexes, diaphoresis, and changes in respiratory rate. During provocation testing, the clinician systematically loads tissues and notes the onset, nature, intensity, and behavior of the pain response — whether it is concordant with the patient's chief complaint, whether it centralizes or peripheralizes (as in the McKenzie approach), and whether it resolves upon removal of the stimulus or persists.

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CRITICAL SAFETY NOTE

The NPTE frequently tests scenarios requiring test termination. Key absolute indications to stop an exercise test include: chest pain suggestive of ischemia, drop in SBP > 10 mmHg despite increasing workload, SpO₂ < 90%, signs of poor perfusion (cyanosis, pallor), patient request to stop, and neurological symptoms such as ataxia or visual disturbance. Knowing these termination criteria is essential for patient safety and for the examination.

Neurological Response Assessment

Neurological responses encompass a broad range of findings elicited during the physical therapy examination. Deep tendon reflexes (DTRs) are graded on a 0–4+ scale, where 2+ is considered normal, 0 is absent (areflexia), and 4+ indicates clonus. The pattern of reflex changes helps localize neurological lesions — for example, hyporeflexia at a specific spinal level suggests a lower motor neuron lesion, while hyperreflexia suggests an upper motor neuron lesion. Sensory testing evaluates dermatomal distribution of light touch and sharp/dull discrimination, proprioception, and vibration sense. Motor responses are assessed through myotomal testing and manual muscle testing, graded on the 0–5 scale. Balance and coordination responses during tests such as the Romberg, tandem stance, or rapid alternating movements provide additional insight into cerebellar and vestibular function.

SECTION 5

Mechanical Response Classification

Mechanical responses reflect the structural and biomechanical behavior of musculoskeletal tissues under applied forces. These responses are central to the orthopedic and musculoskeletal components of the NPTE and include assessment of end-feel, range of motion, joint accessory motion, muscle performance, and tissue integrity under stress.

The end-feel classification chart contrasts three normal (physiological) end-feels — hard, firm, and soft — against four abnormal (pathological) end-feels — muscle spasm, springy block, empty, and boggy. Recognizing the correct end-feel is critical for differential diagnosis and is a commonly tested concept on the NPTE.

Mechanical Test	Normal Response	Abnormal Response	Clinical Significance
PROM (Passive ROM)	Full range with appropriate end-feel for the joint	Decreased ROM with pain, abnormal end-feel, or hypermobility	Differentiates contractile vs. non-contractile tissue involvement
Joint Accessory Motion	Grade 3 (normal accessory glide)	Hypomobile (grades 0–2) or hypermobile (grades 4–6)	Guides joint mobilization grade selection and direction
MMT (Manual Muscle Test)	Grade 5/5 — full ROM against gravity with max resistance	Grades 0–4/5 indicating varying degrees of weakness	Localizes myotomal level; guides strengthening prescription
Ligament Stress Test	Firm endpoint, no excessive laxity or pain	Excessive laxity (Grade I–III), soft or absent endpoint	Indicates ligament integrity; Grade III = complete rupture
Special Test (e.g., Lachman)	Negative — firm endpoint, minimal anterior translation	Positive — excessive translation, soft or absent endpoint	Confirms or rules out specific pathology (ACL integrity)

Common Mechanical Tests and Their Normal vs. Abnormal Responses

SECTION 6

Worked Example: Integrating Physiological and Mechanical Responses

Consider the following clinical scenario: A 58-year-old male with a history of coronary artery disease and right knee osteoarthritis is referred to physical therapy for functional mobility assessment. The therapist performs a six-minute walk test (6MWT) while monitoring vital signs and observing gait mechanics. Below is a step-by-step analysis of the patient response assessment process.

Integrating Responses During a Six-Minute Walk Test

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Step 1 — Establish Baseline Vitals

Before beginning the 6MWT, the therapist records resting vital signs: HR = 72 bpm, BP = 138/82 mmHg, SpO₂ = 97%, RR = 14 breaths/min. The resting RPP is calculated as HR × SBP = 72 × 138.

Resting RPP = 9,936 (within normal limits, below 12,000 at rest)
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Step 2 — Calculate Target Heart Rate Range

Using the age-predicted maximum heart rate formula: HR_max = 220 − 58 = 162 bpm. The target heart rate range for moderate-intensity exercise (60–85% of HR_max) is 0.60 × 162 = 97 bpm to 0.85 × 162 = 138 bpm.

Target HR range: 97–138 bpm
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Step 3 — Monitor Physiological Responses During Test

At minute 3, the patient's HR is 118 bpm (within target range), BP is 162/80 mmHg (appropriate SBP rise, stable DBP), SpO₂ is 95% (acceptable), and RPE is 13/20 ("Somewhat hard" on the Borg scale). RPP at minute 3 = 118 × 162 = 19,116. The patient reports no chest pain, dizziness, or dyspnea beyond expected exertional breathlessness. These physiological responses are normal and do not indicate a need to terminate the test.

All physiological parameters within acceptable limits — continue test
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Step 4 — Assess Mechanical Responses During Gait

Simultaneously, the therapist observes gait mechanics. The patient demonstrates a right-sided antalgic gait pattern with decreased stance phase on the right, compensatory trunk lean to the right during right mid-stance, decreased right knee flexion during swing phase, and decreased step length bilaterally. These mechanical responses are consistent with pain-related avoidance behavior associated with right knee osteoarthritis and reduced quadriceps strength. The gait deviations worsen slightly after minute 4, suggesting fatigue-related decompensation.

Mechanical responses consistent with right knee OA; fatigue-related gait deterioration noted after minute 4
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Step 5 — Integrate Findings and Make Clinical Decision

At minute 6, the patient completes the test. Post-test vitals: HR = 126 bpm, BP = 170/78 mmHg, SpO₂ = 94%, RPE = 15/20. The total distance walked is 380 meters (normative values for a healthy 58-year-old male are approximately 550–620 meters). The therapist integrates the physiological data (appropriate cardiovascular response, no alarming vital sign changes) with the mechanical data (antalgic gait, fatigue-related worsening) to conclude that the patient has reduced functional exercise capacity, likely attributable to both deconditioning and right knee pain limiting gait efficiency. Post-test recovery vitals at 3 minutes: HR = 88 bpm, BP = 142/80 mmHg — appropriate recovery.

6MWT distance = 380 m (below normative); integrated assessment reveals both cardiovascular deconditioning and musculoskeletal limitation contributing to functional impairment

SECTION 7

Normal vs. Abnormal Responses: Key Differentiators

A hallmark of clinical competence — and a frequent testing domain on the NPTE — is the ability to distinguish normal from abnormal patient responses with confidence and accuracy. The following table outlines key physiological and mechanical parameters alongside their expected normal and concerning abnormal ranges. Understanding these distinctions is not merely academic; in clinical practice, a missed abnormal response can lead to patient harm, while misinterpreting a normal response as pathological can lead to unnecessary restriction of activity or inappropriate referral.

Parameter	Normal Response	Abnormal Response
Heart Rate (exercise)	Linear increase with workload; appropriate recovery within 3–5 min	Flat or blunted HR response (chronotropic incompetence); excessive tachycardia; failure to recover
Systolic BP (exercise)	Progressive rise proportional to workload (up to ~200 mmHg at peak)	Drop > 10 mmHg with increasing workload; SBP > 250 mmHg
Diastolic BP (exercise)	Stays relatively stable or decreases slightly	Rise > 15 mmHg; DBP > 115 mmHg
SpO₂	≥ 95% at rest; ≥ 90% with exertion	< 90% (desaturation indicates need to terminate test)
End-Feel	Hard, firm, or soft — matching expected tissue limiting motion	Spasm, springy block, empty, boggy — suggesting pathology
DTRs	2+ (normal, symmetrical bilaterally)	0 (areflexia), 1+ (hyporeflexia), 3+ (brisk), 4+ (clonus)
Capsular Pattern	Not present — all motions proportionally limited or full	Proportional ROM limitation in a characteristic pattern specific to each joint (e.g., shoulder: ER > ABD > IR)

Key Normal vs. Abnormal Physiological and Mechanical Responses

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KEY TAKEAWAY

Distinguishing normal from abnormal responses is analogous to how an engineer interprets structural load testing data. When a bridge beam deflects under load, some deflection is expected (normal response) — it demonstrates the material's elasticity. But if the beam deflects beyond the expected range, shows asymmetric bending, or fails to return to its original position (abnormal response), it signals structural compromise. Similarly, the physical therapist must know the expected response to every test and be prepared to interpret deviations as meaningful clinical data, not merely as noise.

SECTION 8

Connecting Patient Response Assessment to Advanced Clinical Reasoning

Patient response assessment at the entry-level provides the clinician with the raw data necessary for safe, effective examination. However, as clinical reasoning matures, these responses feed into more sophisticated analytical frameworks. The Hypothesis-Oriented Algorithm for Clinicians (HOAC) and the ICF model both rely on accurate patient response data to generate and test clinical hypotheses. Advanced practitioners use pattern recognition — built on thousands of assessed responses — to perform efficient, targeted examinations and to predict outcomes with greater accuracy.

Entry-Level Skill	Advanced Application
Monitoring HR and BP during exercise	Using exercise response data to prescribe precise training intensities based on ventilatory threshold and anaerobic threshold testing
Identifying end-feel type (hard, firm, soft)	Integrating end-feel with capsular pattern recognition, provocation sequencing, and treatment-based classification systems
Recording NPRS pain ratings	Applying pain neuroscience frameworks to differentiate nociceptive, neuropathic, and central sensitization patterns
Grading DTRs on a 0–4+ scale	Using reflex patterns with Babinski sign, clonus, and motor level testing to localize spinal cord pathology and predict neurological outcomes
Observing gait deviations	Performing instrumented gait analysis integrating kinematic, kinetic, and EMG data for complex orthopedic and neurological diagnoses

Entry-Level vs. Advanced Applications of Patient Response Assessment

For the NPTE, the expectation is firmly at the entry-level competency, but understanding the trajectory toward advanced practice provides valuable context. Each patient response you assess during examination is a data point that, when synthesized with clinical knowledge, patient history, and research evidence, forms the basis of the physical therapy diagnosis and the prognosis. The Guide to Physical Therapist Practice explicitly structures the patient/client management model around this iterative process: examine → evaluate responses → establish diagnosis → determine prognosis → implement interventions → re-examine. Patient response assessment is the engine that drives this entire cycle.

SECTION 9

Practice Problems

Question 1: CONCEPTUAL

A physical therapist is performing passive range of motion assessment of a patient's knee into extension and notes the motion stops abruptly with a rebound sensation. Which type of abnormal end-feel is this, and what pathology does it most likely suggest?

Show answer

This describes a springy block end-feel, which is an abnormal finding characterized by a rebound or bounce at the end range of passive motion. The most common pathological cause is a mechanical block within the joint, such as a meniscal tear or loose body (free-floating cartilage or bone fragment). This end-feel is distinguished from a normal hard end-feel (which is abrupt but without rebound) and from muscle spasm (which involves involuntary contraction rather than a bouncing sensation). Identifying a springy block should prompt the therapist to consider imaging referral and to avoid forceful mobilization at the restricted range.

Question 2: BASIC CALCULATION

A 65-year-old female patient is performing a submaximal exercise test. Her resting HR is 78 bpm and her resting SBP is 142 mmHg. Calculate (a) her age-predicted maximum heart rate, (b) her target heart rate range at 60–80% intensity, and (c) her resting rate pressure product.

Show answer

(a) HR_max = 220 − 65 = 155 bpm. (b) Target HR range: lower bound = 0.60 × 155 = 93 bpm; upper bound = 0.80 × 155 = 124 bpm. Therefore, the target HR range is 93–124 bpm. (c) Resting RPP = HR × SBP = 78 × 142 = 11,076. This resting RPP is within normal limits (typically below 12,000 at rest). If the patient has known coronary artery disease, the therapist should monitor for the RPP value at which anginal symptoms historically occur (the anginal threshold RPP), as symptoms tend to be reproducible at a consistent RPP value.

Question 3: INTERMEDIATE

During a six-minute walk test, a patient's vitals at minute 4 show: HR = 142 bpm, BP = 118/90 mmHg (baseline was 134/82 mmHg), SpO₂ = 91%, RPE = 17/20. The patient reports mild dizziness but denies chest pain. Identify all abnormal responses and determine whether the test should be continued, modified, or terminated. Justify your reasoning.

Show answer

Several abnormal responses are present. First, the systolic blood pressure has dropped from 134 mmHg to 118 mmHg despite increasing workload — a decrease of 16 mmHg, which exceeds the > 10 mmHg threshold for an exertional hypotensive response. Second, the diastolic blood pressure has risen from 82 to 90 mmHg, an 8 mmHg increase that, while not yet at the critical > 115 mmHg level, represents an abnormal upward trend. Third, while SpO₂ at 91% is above the absolute termination threshold of 90%, it represents significant desaturation. Fourth, the patient reports dizziness, which is a neurological symptom that may indicate cerebral hypoperfusion. The combination of exertional hypotension (SBP drop > 10 mmHg) and dizziness constitutes absolute indications for test termination. The test should be stopped immediately, the patient should be seated or placed supine, and vitals should be monitored until they return to baseline.

Question 4: APPLIED

A 42-year-old male presents with a 3-week history of right shoulder pain. During examination, passive ROM findings are: external rotation limited to 30° (normal 90°), abduction limited to 100° (normal 180°), and internal rotation limited to 50° (normal 70°). Active ROM mirrors passive ROM. The end-feel for all limited motions is firm/capsular. Resisted isometric testing of all shoulder muscles is strong and painless. (a) Identify the pattern of limitation. (b) What does this pattern suggest? (c) Why is the finding that resisted isometrics are strong and painless clinically significant?

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(a) The pattern of limitation is the capsular pattern of the glenohumeral joint, which is characterized by greatest limitation in external rotation, followed by abduction, followed by internal rotation (ER > ABD > IR). (b) A capsular pattern with firm end-feels bilaterally suggests a condition affecting the entire joint capsule, most commonly adhesive capsulitis (frozen shoulder) at this age and presentation. Other capsular conditions include inflammatory arthritis or post-immobilization capsular fibrosis. The 3-week history places this patient potentially in the 'freezing' phase of adhesive capsulitis. (c) The finding that resisted isometric testing is strong and painless is clinically significant because it indicates that the contractile tissues (muscles and tendons) are not the source of the problem. In Cyriax's approach, strong and painless resisted testing combined with limited passive ROM in a capsular pattern localizes the pathology to non-contractile (inert) structures — specifically the joint capsule. This differentiation guides treatment toward capsular-directed interventions such as joint mobilization and stretching, rather than tendon-focused interventions.

Question 5: CRITICAL THINKING

A patient with a T10 complete spinal cord injury is being assessed for upright tolerance using a tilt table. As the table is raised from supine to 60°, the patient develops the following responses: facial flushing and pounding headache above the level of injury, profuse sweating above T10, blood pressure rises from 110/70 mmHg to 195/120 mmHg, and heart rate drops from 82 bpm to 54 bpm. Below the level of injury, the skin is pale and piloerection (goosebumps) is observed. (a) What condition does this presentation represent? (b) Explain the physiological mechanism. (c) What is the appropriate immediate clinical action? (d) Why is understanding both the physiological and mechanical context important here?

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(a) This presentation represents autonomic dysreflexia (AD), a medical emergency that occurs in patients with spinal cord injuries at T6 or above (though it can occur at T10 in some patients, particularly if the injury produces incomplete sympathetic disruption above that level). (b) The mechanism involves a noxious stimulus below the level of injury (in this case, likely a full bladder triggered by the positional change or abdominal compression from the tilt table straps) that triggers a massive, unmodulated sympathetic response below the lesion — causing vasoconstriction (pallor, piloerection below T10) and severe hypertension. The intact parasympathetic system above the lesion attempts to compensate via the vagus nerve, causing bradycardia, facial flushing, and sweating above the lesion. However, the descending parasympathetic vasodilatory signals cannot pass below the lesion, so the hypertension persists. (c) Immediate clinical action: return the patient to a sitting or upright position (to use gravity to lower BP), loosen all restrictive clothing and straps, check for and address the noxious stimulus (catheter kinks, full bladder, skin pressure areas, fecal impaction), and monitor BP continuously. If BP remains dangerously elevated, emergency medical intervention is required. (d) Understanding both physiological and mechanical context is crucial because the trigger (mechanical — positional change, strap pressure) and the consequence (physiological — autonomic cascade) are inextricably linked. The therapist must simultaneously manage the mechanical environment (table position, straps, catheter) while monitoring the physiological response. This scenario exemplifies why patient response assessment is never purely one domain or the other — the clinician must integrate both to ensure patient safety.

SUMMARY

Patient Response Assessment: Summary Review

Summary

Patient response assessment is the process of interpreting physiological responses (including cardiovascular, neurological, autonomic, and respiratory parameters) and mechanical responses (including end-feel, range of motion, joint accessory motion, muscle performance, and ligament integrity) that patients exhibit during physical therapy tests and measures. The clinician must distinguish normal responses from abnormal responses to make real-time clinical decisions about whether to continue, modify, terminate, or refer.

Key formulas include the age-predicted HR_max (220 − Age) and the rate pressure product (HR × SBP) for cardiovascular monitoring. Critical test termination criteria include SBP drop > 10 mmHg with increasing workload, SpO₂ < 90%, SBP > 250 mmHg, DBP > 115 mmHg, and neurological symptoms. Mechanical assessment requires mastery of end-feel classification (three normal types: hard, firm, soft; and four abnormal types: spasm, springy block, empty, boggy), capsular patterns, and neurological grading systems (DTRs 0–4+, MMT 0–5). The integration of both physiological and mechanical findings drives the entire patient/client management model and is a core competency tested on the NPTE.