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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
TOTAL MAXIMUM SCORE 30 POINTS19 PHT266
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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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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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A kl (S1 S2)
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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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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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