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PHYSIOTHERAPY ASSESSMENT IN NEUROLOGYMohd Haidzir b Abd ManafPHT 266
Introduction
The effectiveness of physiotherapy treatment depends on our ability to assess and analyze the main reasons behind patient’s problems (Lennon & Hastings, 1996)
Principles of physiotherapy assessment Outcome measures in relation to the
physiotherapy assessment
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Principles of Physiotherapy Assessment
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 neurological symptoms are experienced needs to be collected.
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Principles of Physiotherapy Assessment
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 the physiotherapy 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
NEUROLOGICAL INVESTIGATIONS
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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, fibrous dysplasia)
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 change).
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Imaging of the brain and spinal 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 and
displacement/enlargement of the ventricular system
cerebral atrophy spinal trauma (with CT myelography) skull and scalp lesions.
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Magnetic resonance imaging: MRI The hydrogen nucleus is a proton whose electrical
charge creates a local electrical field. These protons are aligned by sudden strong magnetic
impulses. Protons are then imaged with radiofrequency waves at
right angles to their alignment. The protons resonate and spin, then revert to their
normal alignment. As they do so, images are made at different phases of relaxation, known as T1, T2, T2 'STIR', diffusion-weighted imaging (DWI) and other sequences.
From these sequences, referred to as different weightings, recorded images are compared. Gadolinium is used as an intravenous contrast medium.
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Magnetic resonance imaging: MRIAdvantages of MRI distinguishes between brain white and grey
matter. Spinal cord and nerve roots are imaged directly. Pituitary imaging. MRI has greater resolution than CT (around 0.5
cm). No radiation is involved. Magnetic resonance angiography (MRA) images
blood vessels without contrast. It is useful in muscle disease, e.g. myositis.
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Magnetic resonance imaging: MRI
Tumours, infarction, haemorrhage, clot, MS plaques, posterior fossa, foramen magnum and spinal cord are 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 in
the brain cannot be imaged. MR imaging for some days after lumbar puncture frequently shows diffuse meningeal enhancement with gadolinium.
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Electroencephalography (EEG)
The EEG is recorded from scalp electrodes on 16 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, are
hallmarks of epilepsy, but it should be emphasized that patients with epilepsy often have a normal EEG between seizures
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Electroencephalography (EEG)
Diffuse brain disorders Recognizable slow-wave EEG abnormalities
appear in encephalitis, prion (Creutzfeldt-Jakob) disease and metabolic states (e.g. hypoglycaemia and hepatic coma
Brainstem death The EEG is isoelectric (flat), but is no longer
necessary to confirm brain death
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Electromyography and conduction studiesElectromyography A concentric needle electrode is inserted
into voluntary muscle. The amplified recording is viewed on an
oscilloscope and heard through a speaker. Three main features are seen: normal interference pattern denervation and reinnervation myopathic, myotonic or myasthenic
changes
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Peripheral nerve conduction
Four measurements are of principal value in diagnosis of neuropathies and nerve entrapment:
1. mean nerve (motor and sensory) conduction velocity
2. distal motor latency 3. sensory action potentials 4. muscle action potentials.
These measurements differentiate between axonal and demyelinating damage and also determine whether the process is focal or diffuse.
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Neurological impairments can be assessed in terms of their presence and severity.Typical body functions that need to be assessed in the neurological patient are:
1. Joints2. Muscles3. Movements4. sensations
Assessing Impairment16
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Cognitive function
Orientation in time and place, recall of recent and distant events (memory, level of intellect, language and speech/cerebral dominance, other disorders of skilled function, e.g. apraxia)
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Mental state, attitude, insight OrientationScore 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 a maximum of 3 points for each correct repetition.Repeat the objects until the patient can repeat them accurately (in order to test recall later).
3 points
Attention and calculation
Ask the patient to subtract 7 from 100 and then 7 from the result four more times.Score 1 point for each correct subtraction
5 points
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Mental state, attitude, insight OrientationScore one point for each correct answer:
Language
Score 1 point for each of two simple objects named (e.g. pen and a watch)
2 points
Score 1 point for an accurate repetition of the phrase: 'No ifs, ands or buts'
1 point
Give a 3-stage command, scoring 1 point for each part correctly carried out; e.g.
3 points
Write 'Close your eyes' on a blank piece of paper and ask the patient to follow the written command. 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 each side approximately 1 inch long.
1 point
TOTAL MAXIMUM SCORE 30 POINTS19 PHT266
Joint function
Evaluation of the passive range of movement (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 or
extrapyramidal rigidity Power: 0-5 scale Tendon reflexes: + or +
+ normal; +++ increased: 0 absent with reinforcement
Thorax and abdomen: Respiration Thoracic and
abdominal muscles Abdominal reflexes Cremasteric reflexes
Lower limbs: Wasting and
fasciculation Tone, power and
tendon reflexes Plantar responses
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Muscle Function
Muscle strength1. Scale of muscle strength (MRC UK, 1878)
Grade
0 No muscular activity
1 Minimal contraction of muscle but insufficient to move a joint
2 Contraction of muscle sufficient to move a joint but not to oppose gravity
3 Muscle contraction sufficient to move a joint against gravity but not against physical resistance
4 Muscle contraction sufficient to move a joint against gravity but against mild/moderate physical resistance
5 Normal power, that is muscular contraction sufficient to resist firm resistance.
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Muscle Function
Muscle strength1. Grip strength and pinch strength using
hand dynamometer (Bohannon & Andrews, 1987)
2. Equipment to measure muscle strength (static or isometric) and power (isokinetic)
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Muscle function
Muscle Size1. Decrease or increase in muscle bulk
( atrophy or hypertrophy).2. Tape measure – measuring limb
circumference3. Ultrasound imaging – reliable
measurement
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Muscle function
Muscle tone Assessed by passively moving the limbs
or trunk through the normal range of movement whilst the patient remains relaxed
1. Normal2. Increased – hypertonic due to spasticity or
rigidity3. 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 a catch and release or by minimal resistance at the end of the range of motion when the affected part is moved in flexion or extension.
1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance through the remainder (less than half) of the range of movement
2 More marked increase in muscle tone through most of the range of movement, but affected part easily moved
3 Considerable increase in muscle toe, passive movement difficult
4 Affected part rigid in flexion or extension
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Muscle function
Muscle tone – rigidity Increased in tone throughout the whole range of the
passive movement Lead pipe – agonist and antagonist muscles Cogwheel rigidity a regular intermittent break in tone is felt
throughout the whole range of movementGrade Unified Parkinson’s Disease Rating System Scale
(Lang & Fahn, 1989)
0 Rigidity absent
1 Rigidity slight or detectable only when activated by mirror or other movements
2 Mild to moderate rigidity
3 Marked rigidity but full range of motion easily achieved
4 Severe rigidity range of motion achieved with difficult
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Muscle functions
Co-ordination Integration of sensory feedback with
motor output of sufficient strength Involuntary contractions, involuntary
movement reactions, control of voluntary movement functions and involuntary movement functions.
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Deep Tendon Reflexes
Involuntary contractions or tendon reflexes are increased in UMNL and decreased in LMNL
6 reflexes can be tested using this grading 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 partially flexed at the elbow with the palm down.
Place your thumb or finger firmly on the biceps tendon.
Strike your finger with the reflex hammer.
You should feel the response even if you can't see it.
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Triceps (C6, C7)
Support the upper arm and let the patient's forearm hang free.
Strike the triceps tendon above the elbow with the broad side of the hammer.
If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest.
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Brachioradialis (C5, C6)
Have the patient rest the forearm on the abdomen or lap.
Strike the radius about 1-2 inches above the wrist.
Watch for flexion and supination of the forearm.
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Knee (L2, L3, L4)
Have the patient sit or lie down with the knee flexed.
Strike the patellar tendon just below the patella.
Note contraction of the quadraceps and extension 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 the
ankle.
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Clonus
If the reflexes seem hyperactive, test for ankle 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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Plantar Response (Babinski)
Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
Note movement of the toes, normally flexion (withdrawal).
Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.
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Balance
Traditionally – good, fair , poor
Validated measure – Berg Balance 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 with outstretched arm
9 Retrieving object from floor
10 Turning to look behind
11 Turning 360º
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 to the patient’s ability to co-ordinate movements.
Dysdiadochokinesia – inability to tap and turn over the hand
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Co-ordination
Finger-nose test Tremor and ataxia Touch therapist’s
finger with the index finger and then touch his nose
Make the movement faster
Moving the finger(target)
Intention tremor – when the patient’s finger shows a tremor on approaching the target finger.
Dysmetria – patient overshoot the target
Action tremor – intention tremor + dysmetria
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Co-ordination
Heel-shin test Line supine Move one heel from the knee down the
sharp anterior edge of the shin. Inability suggest ataxia
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Sensory Function
ProprioceptionJoint position sense Sensory function for detecting and
identifying the relative position of body parts whilst the patient has his eyes closed
Distal joint are tested before proximal joints.
The patient is asked in what direction the joint is moved.
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Sensory system
First, ask whether feeling in the limbs, face and trunk is entirely normal
Posterior columns: Vibration (using a 128 Hz tuning fork) Joint position Light touch 2-point discrimination (normal: 0.5 cm finger tips, 2
cm soles) Spinothalamic tracts:
Pain: use a split orange-stick or a sterile pin Temperature: hot or cold tubes
If sensation is abnormal, chart areas involved
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proprioception
Romberg’s Test Patient is asked to stand with the feet
together for a few seconds. Make sure patients that they will be
caught if they fall If the patient falls with the eyes closed
then the test is positive
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Touch
The sensory function of touch involves sensing surfaces and their textures and qualities.
Pinprick test and light touch test
Both test should be demonstrated to the patient first.
Both test begin distally and then move proximally
Pinprick test Gently touches the
skin with the pin or back end and asks the patient whether it feels sharp or blunt
Light touch test Dabbing a piece of
cotton wool on an area of skin
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Temperature
Two tubes – cold and hot water Patient’s eyes closed Begin distally Aiming to test each dermatome and
each main nerve
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Observation of gaitAssessment of gaitGlobal 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, trunk rotation, balance and speed.
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Parkinson's disease
There is muscular rigidity throughout extensors and flexors.
Power is preserved but walking slows.
The pace shortens to a shuffle; its base remains narrow.
Falls occur. A stoop and diminished
arm swinging become apparent.
Gait becomes festinant (hurried) in small rapid steps.
There is particular difficulty initiating movement and turning quickly.
Retropulsion describes small backward steps, taken involuntarily when a patient is halted.
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Cerebellar ataxia
In disease of the lateral cerebellar lobes stance becomes broad-based, unstable and tremulous.
Ataxia describes this imperfect control.
Walking tends to veer towards the more affected cerebellar lobe.
In disease confined to cerebellar midline structures (the vermis) the trunk becomes unsteady without limb ataxia.
There is a tendency to fall backwards or sideways - truncal ataxia.
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Sensory ataxia
Peripheral sensory lesions (e.g. polyneuropathy,) cause ataxia because there is loss of the sense of joint position - proprioception.
Broad-based, high-stepping, stamping gait develops.
This ataxia is made worse by removal of additional sensory input (e.g. vision) and is worse in the dark.
First described in sensory ataxia of tabes dorsalis, this is the basis of Romberg's test.
Ask the patient to close the eyes while standing: observe whether the patient becomes unstable (and prevent falling).
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Lower limb weakness
When weakness is distal, each leg must be lifted over obstacles.
When ankle dorsiflexors are weak, such as in a common peroneal nerve palsy, each foot, returns to the ground with a visible and audible slap.
Weakness of proximal lower limb muscles (e.g. in polymyositis or muscular dystrophy) leads to difficulty in rising from sitting or squatting.
Once upright, the patient walks with a waddling gait, the pelvis being ill-supported by each lower limb as it carries the full weight of the body.
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Gait apraxia
With frontal lobe disease (e.g. tumour, hydrocephalus, infarction), the acquired skill of walking becomes disorganized.
Leg movement is normal when sitting or lying but initiation and organization of walking fail.
This is gait apraxia - a failure of the skilled act of walking.
Shuffling small steps (marche à petits pas), difficulty initiating walking (gait ignition failure) or undue hesitancy may predominate.
Urinary incontinence and dementia are often present with frontal lobe disease.
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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 cord compression,
Scissoring gait ↑flexion and
adduction of the hips ↑flexion of the knees Dragging of the toes
Waddling gait Marked rotation of
the 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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