17447460 Physiotherapy Assessment in Neurology

8/14/2019 17447460 Physiotherapy Assessment in Neurology

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PHYSIOTHERAPY

ASSESSMENT INNEUROLOGYMohd Haidzir b Abd Manaf

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Introduction

The effectiveness of physiotherapytreatment depends on our ability toassess and analyze the main reasons

behind patients problems (Lennon &Hastings, 1996)

Principles of physiotherapy assessment

Outcome measures in relation to thephysiotherapy assessment

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Principles of PhysiotherapyAssessment

History Taking Details about the nature, severity,

frequency and pattern of the problem, as

well as past medical history Relieves symptoms, what previous

treatment or examinations has been

conducted and what other neurologicalsymptoms are experienced needs to becollected.

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Principles of PhysiotherapyAssessment

History Taking Difficulties patients may experience in

daily life as a consequences of their

movement problem. For example the impact upon social,

school, work life and impact upon social

relationship.There is a need to enquire about what

patients expect or hope thephysiotherapy can help with and what

outcomes they anticipate.

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Skull and spinal X-rays

Imaging of the brain and spinal cord

Computed tomography: CT

Magnetic resonance imaging: MRI

Electroencephalography (EEG)Electromyography and conduction studies

Peripheral nerve conduction

NEUROLOGICALINVESTIGATIONS

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Skull and spinal X-rays

These show:

fractures of the skull vault or base

skull lesions (e.g. metastases, osteomyelitis,

Paget's disease, abnormal skull foramina, fibrousdysplasia)

enlargement or destruction of the pituitary fossa- intrasellar tumour, raised intracranial pressure

intracranial calcification - tuberculoma,oligodendroglioma, wall of an aneurysm,cysticercosis.

Spinal X-rays show fractures, congenital bone

lesions (e.g. cysts), destructive lesions (infection,metastasis) or spondylosis (degenerative

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Imaging of the brain andspinal cord

Brain CT is now widely available world-wide and MRI is rapidly becoming a

standard test.

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Computed tomography: CT

CT scanning demonstrates: cerebral tumours

intracerebral haemorrhage and infarction

subdural and extradural haematoma free blood in the subarachnoid space

(subarachnoid haemorrhage, see )

lateral shift of midline structures anddisplacement/enlargement of the ventricularsystem

cerebral atrophy

spinal trauma (with CT myelography)

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Magnetic resonanceimaging: MRI The hydrogen nucleus is a proton whose

electrical charge creates a local electrical field.

These protons are aligned by sudden strongmagnetic impulses.

Protons are then imaged with radiofrequencywaves at right angles to their alignment.

The protons resonate and spin, then revert to

their normal alignment. As they do so, imagesare made at different phases of relaxation,known as T1, T2, T2 'STIR', diffusion-weightedimaging (DWI) and other sequences.

From these sequences, referred to as differentweightings, recorded images are compared.

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Magnetic resonanceimaging: MRI

Advantages of MRI distinguishes between brain white and

grey matter.

Spinal cord and nerve roots are imageddirectly.

Pituitary imaging.

MRI has greater resolution than CT(around 0.5 cm).

No radiation is involved.

Magnetic resonance angiography (MRA)

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Magnetic resonanceimaging: MRI

Tumours, infarction, haemorrhage, clot, MS plaques,posterior fossa, foramen magnum and spinal cordare demonstrated well on MRI.

Limitations of MRI are principally time and cost.

Imaging one region takes about 20 minutes.

Patients do need to cooperate.

Claustrophobia is an issue but 'open' machines are

available. A general anaesthetic may be necessary.

Patients with pacemakers or with metallic bodies inthe brain cannot be imaged. MR imaging for some

days after lumbar puncture frequently shows diffuse

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Electroencephalography(EEG)

The EEG is recorded from scalp electrodes on16 channels simultaneously.

Its main value is in diagnosing epilepsy and

diffuse brain diseases. Videotelemetry, which combines EEG with

video, is valuable in assessment of 'attacks'that are uncertain clinically.

Epilepsy

Spikes, or spike-and-wave abnormalities, arehallmarks of epilepsy, but it should be

emphasized that patients with epilepsy often

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Electroencephalography(EEG)

Diffuse brain disorders

Recognizable slow-wave EEG abnormalitiesappear in encephalitis, prion (Creutzfeldt-

Jakob) disease and metabolic states (e.g.hypoglycaemia and hepatic coma

Brainstem deathThe EEG is isoelectric (flat), but is no longer

necessary to confirm brain death

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Electromyography andconduction studies

Electromyography A concentric needle electrode is inserted

into voluntary muscle.

The amplified recording is viewed on anoscilloscope and heard through aspeaker.

Three main features are seen: normal interference pattern

denervation and reinnervation

myopathic, myotonic or myasthenic

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Peripheral nerveconduction

Four measurements are of principal value indiagnosis of neuropathies and nerve entrapment:

1. mean nerve (motor and sensory) conduction

velocity2. distal motor latency

3. sensory action potentials

4. muscle action potentials.

These measurements differentiate betweenaxonal and demyelinating damage and alsodetermine whether the process is focal or

diffuse.

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Neurological impairments can beassessed in terms of their presenceand severity.

Typical body functions that need to beassessed in the neurological patientare:

1. Joints

2. Muscles

3. Movements

4. sensations

Assessing Impairment16

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Cognitive function

Orientation in time and place, recall ofrecent and distant events (memory, level ofintellect, language and speech/cerebraldominance, other disorders of skilledfunction, e.g. apraxia)

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Mental state, attitude, insightOrientationScore one point for each correct answer:

What is the: time, date, day, month, year?Maximum: 5 points

What is the name of: this ward, hospital, district,town, country?

5 points

Registration

Name three objects only once. Score up to amaximum of 3 points for each correct repetition.Repeat the objects until the patient can repeatthem accurately (in order to test recall later).

3 points

Attention and calculation

Ask the patient to subtract 7 from 100 and then 7from the result four more times.Score 1 point for each correct subtraction

5 points

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Mental state, attitude, insightOrientationScore one point for each correct answer:

Language

Score 1 point for each of two simple objectsnamed (e.g. pen and a watch)

2 points

Score 1 point for an accurate repetition of thephrase: 'No ifs, ands or buts'

1 point

Give a 3-stage command, scoring 1 point for eachpart correctly carried out; e.g.

3 points

Write 'Close your eyes' on a blank piece of paperand ask the patient to follow the writtencommand. Score 1 point if the patient closes the

eyes.

1 point

Ask the patient to write a sentence. 1 point

Draw a pair of intersecting pentagons with eachside approximately 1 inch long.

1 point

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Joint function

Evaluation of the passive range ofmovement (shortening and contractures)

Reliable measurements using a

goniometer (Macdermid et al, 2000)

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Motor system

Upper limbs:Wasting and

fasciculation

Posture of arms: drift,rebound, tremor

Tone: spasticity orextrapyramidal rigidity

Power: 0-5 scale

Tendon reflexes: + or++ normal; +++increased: 0 absentwith reinforcement

Thorax and abdomen:Respiration

Thoracic and

abdominal musclesAbdominal reflexes

Cremasteric reflexes

Lower limbs:

Wasting andfasciculation

Tone, power andtendon reflexes

Plantar responses

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Muscle Function

Muscle strength

2. Scale of muscle strength (MRC UK, 1878)Grade

0 No muscular activity

1 Minimal contraction of muscle butinsufficient to move a joint

2 Contraction of muscle sufficient to movea joint but not to oppose gravity

3 Muscle contraction sufficient to move a

joint against gravity but not againstphysical resistance4 Muscle contraction sufficient to move ajoint against gravity but againstmild/moderate physical resistance

5 Normal power, that is muscular

contraction sufficient to resist firmresistance.

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Muscle Function

Muscle strength

2. Grip strength and pinch strength usinghand dynamometer (Bohannon &

Andrews, 1987)3. Equipment to measure muscle strength

(static or isometric) and power

(isokinetic)

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Muscle function

Muscle Size

2. Decrease or increase in muscle bulk( atrophy or hypertrophy).

3.Tape measure measuring limbcircumference

4. Ultrasound imaging reliable

measurement

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Muscle function

Muscle tone

Assessed by passively moving the limbsor trunk through the normal range of

movement whilst the patient remainsrelaxed

1. Normal2. Increased hypertonic due to spasticity or

rigidity

3. Decreased - hypotonic

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Muscle function

Muscle tone Depend on the velocity of the movementGrade Modified Ashworth Scale of muscle Spasticity

0 No increase in muscle tone

1 Slight increase in muscle tone , manifested by acatch and release or by minimal resistance at theend of the range of motion when the affected part ismoved in flexion or extension.

1+ Slight increase in muscle tone, manifested by acatch, followed by minimal resistance through the

remainder (less than half) of the range of movement

2 More marked increase in muscle tone through mostof the range of movement, but affected part easilymoved

3 Considerable increase in muscle toe, passivemovement difficult

4 Affected part rigid in flexion or extension

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Deep Tendon Reflexes

Involuntary contractions or tendonreflexes are increased in UMNL anddecreased in LMNL

6 reflexes can be tested using thisgrading system

Ankle, knee, biceps, supinator, triceps

and finger reflexes

Grade Grading of reflexes (Fuller, 1999)

0 absent

Present but only with reinforcement

1+ Present but depressed

2+ Normal

3+ Increased

4+ Clonus

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Biceps (C5, C6)

The patient's arm should be partiallyflexed at the elbow with the palm down.

Place your thumb or finger firmly on thebiceps tendon.

Strike your finger with the reflexhammer.

You should feel the response even if youcan't see it.

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T i (C6 C7)


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Triceps (C6, C7)

Support the upper arm and let thepatient's forearm hang free.

Strike the triceps tendon above theelbow with the broad side of thehammer.

If the patient is sitting or lying down, flexthe patient's arm at the elbow and hold itclose to the chest.

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B hi di li (C5 C6)


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Brachioradialis (C5, C6)

Have the patient rest the forearm on theabdomen or lap.

Strike the radius about 1-2 inches abovethe wrist.

Watch for flexion and supination of theforearm.

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K (L2 L3 L4)


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Knee (L2, L3, L4)

Have the patient sit or lie down with theknee flexed.

Strike the patellar tendon just below thepatella.

Note contraction of the quadraceps andextension of the knee.

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Ankle (S1, S2)

Dorsiflex the foot at the ankle.Strike the Achilles tendon.

Watch and feel for plantar flexion at theankle.

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Cl


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Clonus

If the reflexes seem hyperactive, test forankle clonus: ++

Support the knee in a partly flexed

position. With the patient relaxed, quickly

dorsiflex the foot.

Observe for rhythmic oscillations.

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(Babinski)

Stroke the lateral aspect of the sole ofeach foot with the end of a reflexhammer or key.

Note movement of the toes, normallyflexion (withdrawal).

Extension of the big toe with fanning of

the other toes is abnormal. This isreferred to as a positive Babinski.

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Balance

Traditionally good, fair , poor

Validated

measure BergBalance Scale

The Functional

Reach Test

Task

1 Sitting to standing

2 Standing unsupported

3 Sitting unsupported

4 Standing to sitting

5 Transfer

6 Standing with eyes closed

7 Standing with feet together

8 Reaching forward withoutstretched arm

9 Retrieving object from floor

10 Turning to look behind

11 Turning 360

12 Placing alternate foot on stool

13 Standing with one foot in front

14 Standing on one foot

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Co-ordination

Control of voluntary functions refers tothe patients ability to co-ordinatemovements.

Dysdiadochokinesia inability to tap andturn over the hand

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Co-ordination

Finger-nose testTremor and ataxiaTouch therapists

finger with theindex finger andthen touch hisnose

Make themovement faster

Moving thefinger(target)

Intention tremor when thepatients fingershows a tremoron approachingthe target finger.

Dysmetria

patient overshootthe target Action tremor

intention tremor

+ dysmetria

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Sensory Function

Proprioception

Joint position sense

Sensory function for detecting and

identifying the relative position of bodyparts whilst the patient has his eyesclosed

Distal joint are tested before proximaljoints.

The patient is asked in what directionthe joint is moved.

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proprioception

Rombergs Test Patient is asked to stand with the feet

together for a few seconds.

Make sure patients that they will becaught if they fall

If the patient falls with the eyes closed

then the test is positive

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Touch

The sensoryfunction of touchinvolves sensingsurfaces and theirtextures andqualities.

Pinprick test andlight touch test

Both test should be

demonstrated tothe patient first.

Both test begindistally and then

move proximally

Pinprick test Gently touches the

skin with the pin orback end and asks

the patientwhether it feelssharp or blunt

Light touch test Dabbing a piece of

cotton wool on anarea of skin

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Temperature

Two tubes cold and hot water

Patients eyes closed

Begin distally

Aiming to test each dermatome andeach main nerve

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Observation of gait

Assessment of gait

Global measures of activity limitations

Assessing Activities46

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Observation of gait

Symmetry

Duration of swing and stance phases

Muscle activation around ankle, knees,

hips and trunk, arm swing, trunkrotation, balance and speed.

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Parkinson's disease

There is muscularrigidity throughoutextensors and flexors.

Power is preservedbut walking slows.

The pace shortens toa shuffle; its base

remains narrow. Falls occur.

A stoop anddiminished arm

swinging become

Gait becomes festinant(hurried) in small rapidsteps.

There is particulardifficulty initiatingmovement and turningquickly.

Retropulsion describessmall backward steps,taken involuntarilywhen a patient is

halted.

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Cerebellar ataxia

In disease of thelateral cerebellarlobes stance becomes

broad-based, unstableand tremulous.

Ataxia describes thisimperfect control.

Walking tends to veertowards the moreaffected cerebellarlobe.

In disease confinedto cerebellarmidline structures

(the vermis) thetrunk becomesunsteady withoutlimb ataxia.

There is a tendencyto fall backwards orsideways - truncalataxia.

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Sensory ataxia

Peripheral sensorylesions (e.g.polyneuropathy,)cause ataxia becausethere is loss of thesense of joint position-proprioception.

Broad-based, high-stepping, stampinggait develops.

This ataxia is madeworse by removal ofadditional sensoryinput (e.g. vision) and

is worse in the dark. First described in

sensory ataxia oftabes dorsalis, this is

the basis of Romberg'stest.

Ask the patient toclose the eyes while

standing: observe

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Lower limb weakness

When weakness isdistal, each leg mustbe lifted overobstacles.

When ankledorsiflexors are weak,such as in a commonperoneal nerve palsy,

each foot, returns tothe ground with avisible and audibleslap.

Weakness of proximallower limb muscles(e.g. in polymyositis ormuscular dystrophy)

leads to difficulty inrising from sitting orsquatting.

Once upright, the

patient walks with awaddling gait, thepelvis being ill-supported by each

lower limb as it carries

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Gait apraxia

With frontal lobedisease (e.g. tumour,hydrocephalus,infarction), theacquired skill ofwalking becomesdisorganized.

Leg movement isnormal when sittingor lying but initiationand organization of

walking fail.

This is gait apraxia - afailure of the skilled actof walking.

Shuffling small steps(marche petits pas),difficulty initiatingwalking (gait ignitionfailure) or unduehesitancy maypredominate.

Urinary incontinence

and dementia are often

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Observation of gait

Hemiplegia

Foot drop

Lateral leg swing

High step

Hip hitch during swing phase (as)

Hyperextended knee, hip extension,

drop of the affected shoulder

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Observation of gait

Spastic paraparesis

Cerebral palsy,multiple sclerosis,

spinal cordcompression,

Scissoring gait

flexion andadduction of the hips

flexion of the knees

Dragging of the toes

Waddling gait

Marked rotation ofthe pelvis and

shoulders Proximal muscles

weakness

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Assessment Tools

Modified Rivermead Mobility Index

Barthel Index

Motor Assessment Scale

Functional Independence Measurement

Berg Balance Scale

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Documents

17447460 Physiotherapy Assessment in Neurology