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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