EONS

Cognitive Screen: Orientation x 4- Left frontal lobe stroke. Test in supine.

 Why test cognition early in the examination process?

 

Cognition impacts the patient’s ability to participate in the evaluation and follow instructions. Identifying them early can help the clinician modify the exam appropriately and ensure that the patient is safe

Subjective Exam for a patient who plans to return home directly from the hospital: Ask any three relevantPatient History Questions-Test in sitting.

Why ask these types of questions so early in the exam?

These questions help guide the focus of the evaluation, identify safety risks, and determine discharge planning needs early in care

Systems Screen with an older adult who had a stroke: Ask 3 relevant screening questions related to systems beyond the neurologic system.

Why ask screening type questions related to other systems, in addition to the neurologic system, early in the exam? 

Do you have recent changes in bowel and bladder? Have you had a hard time breathing? Have you had chest pains?

 

Stroke patients often have comorbid conditions and identifying these early ensures safe exercise tolerance and prevents missing non-neuro red flags.

Demonstrate a test for Short Term Memory & a separate test for Attention. Left temporal lobe stroke. Test in sitting.

Describe under what circumstances either of these two tests would be administered.

STM – recall the 3 words after 5 minutes

 

Attention – spell the world backwards

 

Done if the patient demonstrates confusion or is easily distracted

 Test Cranial Nerves I & IX (Olfactory & Glossopharyngeal)-May test together with a simple question. Test in sitting.

Describe 2 reasons why it is good practice to do the Cranial Nerve Screen early in the exam process.

To identify later problems ( sensory or motor problems in other parts of the body, neglect)

Have you noticed any changes in your send of smell or taste?

Can detect additional CNS involvement

Cranial Nerve II (Optic)- Right occipital lobe stroke. Perform a test for acuity and a separate test for visual fields/ spatial neglect. Test in sitting.

Describe which visual field may be affected.

·     Visual field/spatial neglect - Hold fingers out to the side and ask which one is moving

·      Acuity – can you tell me the time on the clock or use a Snellen chart

·      The left visual field in both eyes would be affected in both eyes

Cranial Nerves III, IV, VI (Oculomotor, Trochlear, Abducens)- Left hemisphere stroke. Test in sitting.

Describe a normal response, and potentially 2 abnormal findings.

·      Draw a giant H with your finger and have them follow your finger with only their eyes

·      Normal response: they are able to track the finger with only their eyes, and they move synonymously

·      Abnormal response: They can’t track the finger without moving their head. Their eyes do not track the eye together (one does, and one doesn’t). they lose sight of the finger.

  Cranial Nerve V (Trigeminal)- Right parietal lobe stroke. Test in sitting.

If your patient who had a stroke has absent sensation on one side of the face, what may this be predictive of later in the examination process?

·      Light touch of all three branches

·      Difficulty with facial proprioception for motor planning

Cranial Nerve VII (Facial)- Left hemisphere stroke. Test in supine.

Describe how and why testing results would differ between a supranuclear lesion, like in this case, and a peripheral lesion (Bell’s Palsy).

·      Raise your eye brows and smile

·      Supranuclear lesion: contralateral lower face weakness

·      Peripheral lesion: entire side of face lesion

Cranial Nerve VIII (Vestibulocochlear)- Left brainstem stroke. Test in supine.

Describe how testing both ears simultaneously, as part of this test, can help identify or rule out auditory neglect.

·      Rub fingers near ears with eyes closed

·      Helps identify auditory neglect vs. peripheral hearing loss

Cranial Nerve X (Vagus)-Inquire about swallowing difficulties and listen for voice quality changes- hoarseness or breathy voice.

Describe the primary medical risk of offering food or drink to someone who is not able to effectively swallow.

·      They are at risk for aspiration

Cranial Nerve XI (Spinal Accessory)- Right frontal lobe stroke. Test in supine.

How would you quantify the results of this test if the patient is only able to move through partial range on the contralateral side?

·      Have then raise their shoulder, and then apply some relight resistance to confirm intact

·      Make sure you perform in gravity eliminated position and do both shoulders at the same time

·      2-/5

Cranial Nerve XII (Hypoglossal)- Right frontal lobe stroke. Test in sitting.

Based on the location of the lesion, to which side is the tongue likely to deviate? Explain why.

·      Can they stick their tongue out and move it side to side quickly

·      This would cause a contralateral tongue deviation because the lesion is in the cerebrum

·      Supranuclear: tongue will deviate away from the side of the lesion

·      Peripheral: tongue will deviate to the side of the lesion

Light touch Sensation- Suspected cerebral deficits. Test in sitting.

If your patient passes this test with “flying colors,” why is it not necessary in most cases to administer tests for deep pressure, proprioception, and pain?

·      Randomly and lightly touch various main area of the patient body, have them close their eyes and say yes if they can feel it

·      If the patient can feel the lightest sensation, then you can infer that they could also feel deeper sensations. You only test the deeper sensation if they cannot feel light touch

Light Touch Sensation- (Level will be given) spinal cord injury. Test key sensory points XX-XX (range of 3 levels). Test in supine. 

Why use a cotton ball and not your finger when testing light touch with suspected SCI?

·      The specific dermatome points, ASIA scale

·      It is a way to ensure a consistent and standardized test throughout with pressure and feeling. It avoids temperature from being felt from the fingers.

Light Touch Sensation- (Level will be given) spinal cord injury. Test key sensory points XX-XX (range of 3 levels). Test in supine.

Afterwards, describe in anatomical terms, the key sensory points you just tested.

o   C2 – Occiptal protuberance

o   C3 – Supraclavicular fossa

o   C4 – AC joint

o   C5 – Lateral Antecubital fossa

o   C6 – Dorsal aspect of the proximal phalanx of the thumb

o   C7 – Dorsal aspect of the proximal phalanx of the 3^rd digit

o   C8 – Dorsal aspect of the proximal phalanx of the 5^th digit

o   T1 – Medial Antecubital fossa

o   T2 – apex of the axilla

o   T4 – Nipple line

o   T10 – Belly button

o   L3 – Medial femoral condyle of the knee

o   L4 – Medial malleolus

o   L5 – dorsum of the foot at the 3^rd metatarsal phalangeal joint

o   S1 – lateral aspect of the calcaneus

o   S2 – Popliteal fossa

o   S3 – Ishial tuberosity

o   S4/5 - Perineal area.

Deep Pressure Sensation- Left middle cerebral artery stroke. Test in supine. 

Under what circumstances would testing for deep pressure be indicated?

·      Apply deeper pressure randomly to the R UE

·      You will test deep pressure if the patient fails light pressure

Pain Sensation- (Level will be given) spinal cord injury. Test key sensory points XX-XX (range of 3 levels). Test in supine.

Describe why pain sensation must be tested with spinal and brainstem lesions but may not need to be tested with suspected cerebral lesions.

·      ASIA scale, use a safety pin to test the areas. Test with the dull and sharp sides of the pin.

·      In order to know what levels of the ALS tract is affected and how severe (what part or the tract is affected), if a patient has a cerebral lesion, it could knock out the entire tract

·      In cerebral lesions, pain, light tough, deep pressure, etc, are all represented by the same area on the homunculus. There isn't a specific “lobe” that tests for pain like there is in the spinal cord. This is a more global type of sensory loss.

Pain Sensation- (Level will be given) spinal cord injury. Test key sensory points XX-XX (range of 3 levels). Test in supine.

Describe what score you would give to your patient who says “dull” when you press with the sharp side. Why?

·      ASIA, safety pin

·      Establish a normal value first in one of the unaffected       

limb to let the patient know what the dull and sharp ends actually feel like. Remind them that if they feel anything different from the normal feeling to let you know because you need to know if its hypo or hypersensitive areas

·      Descend from cephalic to caudal

·      Score: 0 because you that would be testing the DCML and not testing for pain at this point

Pain Sensation- (Level will be given) spinal cord injury. Test key sensory points XX-XX (range of 3 levels). Test in supine.

Describe the full neural pathway from start to finish.

·      ASIA, safety pin

·      ALS tract >

·      The first order neurons arise from the sensory receptors in the periphery. They enter the spinal cord, ascend 1-2 vertebral levels, and synapse at the tip of the dorsal horn – an area known as the substantia gelatinosa.

·       The second order neurons carry the sensory information from the substantia gelatinosa to the thalamus. After synapsing with the first order neurons, these fibers decussate at anterior white commissure, and then form two distinct tracts:

·      The third order neurons carry the sensory signals from the thalamus to the ipsilateral primary sensory cortex of the brain. They ascend from the ventral posterolateral nucleus of the thalamus, travel through the internal capsule and terminate at the sensory cortex.

Proprioception- Right middle cerebral artery stroke. Distal UE mainly affected. Test in sitting.

Performance on this test may be predictive of performance on which impairment level test that comes later in the examination process? Explain

·      Use index finger and curl and straighten it quickly, then ask if it is curled or straight with patients’ eyes closed, show them what is what before administering the test

·      The patient would have issue with non-equilibrium coordination tests for the UE as to complete these tasks they need to be able to sense where their UE is to be successful

Proprioception- Right middle cerebral artery stroke. Shoulder mainly affected. Test . in sitting.

Describe the neuropathway being tested, including where it originates, crosses, and terminates

·      Move the whole arm, have the patient whether you are moving the arm up/down with their eyes closed. Show them the positioning beforehand

·      DCML

·      The first order neurons carry sensory information regarding touch, proprioception or vibration from the peripheral nerves to the medulla oblongata. There are two different pathways which the first order neurons take:

·       Signals from the upper limb (T6 and above) – travel in the fasciculus cuneatus (the lateral part of the dorsal column). They then synapse in the nucleus cuneatus of the medulla oblongata.

·       Signals from the lower limb (below T6) – travel in the fasciculus gracilis (the medial part of the dorsal column). They then synapse in the nucleus gracilis of the medulla oblongata.

·      The second order neurons begin in the cuneate nucleus or gracilis. The fibers receive the information from the preceding neurons and delivers it to the third order neurons in the thalamus.

·       Within the medulla oblongata, these fibers decussate (cross to the other side of the CNS). They then travel in the contralateral medial lemniscus to reach the thalamus.

·      Lastly, the third order neurons transmit the sensory signals from the thalamus to the ipsilateral primary sensory cortex of the brain. They ascend from the ventral posterolateral nucleus of the thalamus, travel through the internal capsule and terminate at the sensory cortex.

Kinesthesia- Left anterior cerebral artery stroke. LE mainly affected. Test in supine. Describe the difference between kinesthesia and proprioception and which one would be harder for a patient to detect?

·      Use the big toe, up down and was you are moving it up and down ask the patient what is happening to their toe. Their eyes should be closed and show them what is what before completing the test

·      Kinesthesia will be given real time bout as the finger/toe is moving through a motion while proprioception is the finger/toe is in a specific position in space, not moving. A patient would have a more difficult time with detecting proprioception because it is a static concept.

Double Simultaneous Stimulation- Right hemisphere stroke. Test in supine.  Describe what finding(s) would trigger a need to administer this test and how abnormal findings could affect function. 

·      First demonstrate what you will do with the patients eyes open, patients’ eyes closed. Touch the patient in either one PLACE or two PLACES in different spots and have them tell you how many PLACES you touched them

o   Do not say times, you will lose points

·      DSS is testing for neglect of one side of the body. If a patient does not feel both touches either same or opposite side, they have neglect of one side of the body. It could affect daily tasks like dressing or eating or walking due to neglect on the one side of the body.

Stereognosis- Right middle cerebral artery stroke. UE mainly affected. Test in sitting.

Describe why a clinician may administer this test, especially when light touch and proprioception are already found to be intact.

·      Place various 3D objects in the patient's hands with their eyes closed and have then say what the object is. It needs to be an object that they will know what it is.

·      They would administer this test because it is combining sensory information with proprioceptive input which tests higher cortical functions. Integrates sensory information for meaning. Received, purpose, memory lobes

Graphesthesia-Left middle cerebral artery stroke. UE mainly affected. Test in sitting.

Describe why a clinician may choose to administer this test, rather than the test for stereognosis.

may have poor dexterity in R hand Stereognosis requires manual dexterity, graphesthesia does not

Hoffman Reflex- C4 spinal cord injury. Test in supine.

If this test is positive (pathologic) on both sides, what are you likely to find when testing deep tendon reflexes in the upper extremities?

·      Make a trough for their middle finger and stroke the nail of the middle finger.

·     It would be a positive UMN which would lead to you seeing hyperreflexia with the deep tendon reflexes, brisk or exaggerated reflexes, possibly clonus if seve

Babinski Reflex- T4 spinal cord injury. Test in supine.

Describe the specific neural pathway (where it originates, crosses, and terminates) being tested and what a positive test would look like.

·      Quickly “rub” the bottom on the patient’s lateral sole of their foot

·      Positive: big toe would extend (dorsiflex) and toes 2-5 toes would fan out or flex

·      Corticospinal Tract LE >:  primary motor cortex--> medulla cross--> anterior horn of SC

Biceps Deep Tendon Reflex-C5 SCI. Test in sitting.

Describe the reflex arc. Hit the tendon then to muscle spindle then to spinal cord to ascend to

·      Place thumb over patient’s bicep tendon and smack it, one and done

·      Patellar tendon is tapped, stretch receptor detects stretch, afferent neuron sends signal to spinal cord, direct synapse with efferent neuron, efferent neuron triggers contraction, lower leg kicks forward.

·      Muscle spindle in biceps is stretched due to the tap, which then sends signal through the dorsal root to the anterior horn, which then goes to the ventral root to cause a muscle contraction.

 

Brachioradialis Deep Tendon Reflex-Right frontal lobe stroke. Test in sitting.

If the patient exhibits a 2+ DTR on the right and a 3+ DTR on the left, which neural pathway (DCML, ALS, etc.) is likely damaged?

·      Corticospinal Tract, early or mild hyperreflexia

·      This would mean there is hyperreflexia of the corticospinal tract on the left due to loss of descending inhibition

Triceps Deep Tendon Reflex- C6 spinal cord injury. Test in supine. 

Describe why deep tendon reflexes usually become hyperreflexic in the presence of damage to the associated corticospinal pathway. 

·      The corticospinal pathway controls inhibitory control over spinal reflexes, when damage occurs to this pathway that inhibition is lost and the muscles will contract more, become more excitable and have an exaggerated motor response (hyperreflexia/spasticity)

Patellar Deep Tendon Reflex- Conus medullaris injury. Test in sitting.

How would you document your findings if no response is elicited on the left and only a palpable muscle contraction on the right?

·      L4

·      Left: 0

·      Right:1+, I think

Achilles Deep Tendon Reflex- Left frontal lobe brain tumor. Test in supine.

What score would you document if you elicit clonus?

·      4+

Resistance to Passive Motion Screen UEs- Right hemisphere stroke. Test in sitting.

Name the scale and describe the difference between a score of 1 and 1+. 

·      Tell them that you will move their arm slowly and then quickly through the ROM before administering it.

·      Quickly through partial range for UE

·      Spasticity- Modified Ashworth Scale

·      1: catch and release, minimal resistance at end ROM but can move through full ROM

·      1+: catch with minimal resistance throughout remainder or ROM (less than half)

Resistance to Passive Motion Screen UEs- Left hemisphere stroke. Test in supine.

Describe how you would document/score a considerable increase in muscle tone, with difficulty moving the UE into shoulder external rotation, though still able to go through the motion.

·      Quickly move through partial ROM

·      3, say the following or you will miss points

o   Modified Ashworth scale 3 out of 4 R shoulder IR’s

§  Documentation is in reference to the muscle that is spastic

Resistance to Passive Motion Screen LEs- Right hemisphere stroke. Test in sitting.

Describe the purpose of taking the patient through the slow phase first.

·      By going slow through the patients ROM, the clinician is testing and clearing the joint to make sure they have efficient PROM, while the quick motion is testing the muscle groups and allowing for spasticity

Resistance to Passive Motion Screen LEs- C7 Incomplete spinal cord injury. Test in supine. 

Describe how a score of 2 in bilateral hip adductors could affect walking.

·      The patient would present with a narrow BOS and could have a “scissor” gait pattern, limited weight shifting

·      Tell them you are going to move the legs slowly and them move them faster the second time. Work proximally to distally. Make sure you actually increase your speed to a “blazing fast” level the second time going through to pick up on the minor deficits of spasticity.

Strength/ROM Screen UEs in patient who had Left MCA stroke. The patient only partially raises the affected arm against gravity. Test in sitting.

After performing the full screen, what muscle grade would you score on the affected side for shoulder flexion? 

·      Review testing

·      2+ or 3-

Strength/ROM Screen LEs in patient with Parkinson’s Disease. Test in supine.

Why test sensation before testing muscle strength?

·      So that we know they can feel the pressure and know to resist, if not the clinician would score them incorrectly. Impaired sensation would show signs that there would be moor motor control which may interfere with the actual grading of muscle strength

·      Have them look at your hand on their arm and tell them to not let their leg move and they could have pretty good strength.

Hamstring Length Goniometric Measurement: T1 SCI. Must demonstrate and state the landmarks and how this patient’s measured length compares to the minimum desired hamstring length for someone with T1 complete SCI.  

• Why different from able-bodied?

  • For SCI patients who rely on long sitting and transfers, slightly shortened hamstrings are functionally beneficial.

  • Too much length → difficulty stabilizing pelvis in long sitting.

  • Too little length → difficulty with positioning, dressing, wheelchair function.

• Target Range:

  • ~110–120° of hip flexion with knee extended (measured via SLR).

  • This provides balance between functional mobility (transfers, long sitting) and prevention of contractures.

ASIA Impairment Scale (AIS) myotome strength testing: (Level will be given) spinal cord injury. Test key muscle at XX in supine in gravity-eliminated position.

Using the AIS muscle grades, what muscle grade would be given for partial range in this position?

·      1+ because they cannot move the body part through the full ROM in the gravity eliminated position

ASIA Impairment Scale (AIS) myotome strength testing: (Level will be given) spinal cord injury. Test key muscle at XX in supine to determine if strength is 4 or 5/5.

Why is all ASIA Impairment Scale (AIS) testing done in supine?

·      It is standardized, consistent and controlled, it is safe for the patient, and you have access to all dermatomes and myotomes

ASIA Impairment Scale (AIS) myotome strength testing: (Level will be given) spinal cord injury. Test key muscle at XX in supine against gravity and provide resistance.

What score would you give for a patient who moves fully against gravity but can only withstand very mild resistance? 

·      3

Pronation/Supination (diadochokinesia)- Left cerebellar stroke. Test in supine.

What is the purpose of eventually having the patient close eyes during coordination testing?

·      Demo how to do it and have then have them do it, faster, then close their eyes

·      Closing their eyes further tests coordination by taking out visual input and having their body use proprioception and unconscious and internal feedback pathways like the spinocerebellar pathway

·      You are testing proprioception!!!!!!!!!

Alternate Nose-to-Finger- C8 spinal cord injury. Test in supine.

Which specific aspect of non-equilibrium coordination is being tested?

·      Accuracy and coordination

Finger opposition- Left cerebellar stroke. Test in supine. Describe the spinocerebellar pathway.

o   ascending pathway that starts in the muscle spindles and then travels through the spinocerebellar tract to enter the cerebellum through the inferior cerebellar peduncle and remains ipsilateral.

·      Opposition tests fine motor

Foot Tapping- Stroke in the right thalamus. Test in sitting.

Describe which side would be likely affected.

·      The left side of the body, both sensory and motor functions because the thalamus is an important structure for both sensory and motor pathways

Check Reflex (Rebound test)-Right cerebellar infarct. Test in sitting.

What is the purpose of this test? 

·      To see if there is a cerebellar deficit, tests the ability to modulate muscle tone and stop movement appropriately. It is a test of involuntary postural control and coordinated muscle response

·      Normal response: involves the opposing muscle group rapidly checking the flexion movement with little motion occurring when the clinician releases manual resistance

·      Abnormal response: involves a large flexion motion or trunk control in response to the sudden change in resistance

Alternate Heel-to-Knee; Heel-to-Toe- Stroke in the left internal capsule. Test in sitting. What is the purpose of adding speed to this test?

·      Adding speed or having the patient increase their speed will check the accuracy and coordination of the patients cerebrocerebellar pathway because it controls direction, speed, and timing

Dynamic Sitting Balance- Multiple Sclerosis- Demonstrate how to test full reaching in all directions while ensuring patient safety.

How could you document your findings?

·      There are three different levels to this

o   Reach in multiple directions

o   Lift an arm up

o   Lift both arms up

·      Checking anticipatory control

·      Qualitative descriptions of response or lack of responses to loss of balance should also be noted (“Able to sit with….” Or “Unable to sit with….” Or “patient was able to perform…..”

Equilibrium Progressive Testing in standing in patient with T2 incomplete spinal cord injury. Progress 2 levels from the given starting position.

In addition to determining the maximum sustained position, what other qualitative assessments should be made?

·      MAKE SURE YOU HAVE THE PATIENT STEP OUT FROM THE SURFACE THEY WERE SITTING ON. This allows you to have room to guard behind the patient and on the other side.

·      Look for compensatory mechanisms and balance strategies (if they use their ankles and hips appropriately, do they use a stepping strategy).

·      Could be advancing feet position to decrease BOS or simply closing eyes

·      Steady/alignment, eyes open/closed, presence and proficiency of balance (absent, delayed, decreased magnitude), what did the patient rely on (visual, somatosensory, vestibular)? Amount of sway, postural alignment, motor strategies used to keep balance, time the position was held.

Timed Up and Go- 84-year-old female older adult who does not use an assistive device.

State how your patient performed compared to normative values.

·      Get up from chair and walk 10 feet around a cone and then turn around and sit back down. Always repeat the test at least twice

·      80–89-year-old female: 11 seconds +/- 3 seconds SD

Five Times Sit to Stand- 65-year-old with moderate diabetic neuropathy.

 What are the normative values for a 65-year-old, and how would your patient’s performance likely compare?

·      7.8 second +/-2.4 seconds SD is healthy ASK

·      I feel like it would be longer, greater than 15 seconds would indicate a functional impairment

Berg Balance Scale: Test Item X. Description of the item. Stroke with impaired sensation of the entire left side affecting stability. Score your patient for this item.

Under what conditions would you choose the Berg as your standardized assessment.

·      Demo and explain what you are going to do before you do it. Guard on the side with impaired sensation.

·      Balance in older individuals, to assess their balance and fall risk. This test does not test gait

·      It is important to anticipate that the patient will be independently ambulating and possibly living alone as well. Helps when determining whether to send the patient home or not and what assistance will be needed

Berg Balance Scale: Test Item X. Description of the item. Stroke with impaired sensation of the entire left side affecting stability. Score your patient for this item.

What is the cutoff score for low fall risk in older adults on the Berg? 

·      Low fall risk: 41-56

Tinetti (Performance Oriented Mobility Assessment-POMA)- Test item X. Description of the item. Stroke with right lower extremity muscle weakness.

Under what conditions would you choose the Tinetti over the Berg?  

·      Guard the patient on the right side and pull the gait belt all the way tight, move the patient away from the table, do not tell them you are going to nudge them, nudge 3 times that are unpredictable

·      The Tinetti is good for assessing gait and balance in the adult and elderly population and also looks at initiation of movements when completing gait. Berg checks balance only but Tinetti assesses both. The Tinetti would be good for patients with gait deficits, LE weakness, and dynamic transition problems.

Tinetti (Performance Oriented Mobility Assessment-POMA)- Test item X. Description of the item. Stroke with left side muscle weakness. What is the cutoff score for low fall risk on the Tinetti? 

·      Cutoff for a stroke is <20

·      Risk for falls: 24

Dynamic Gait Index: Test item X Description of the item. Stroke of the flocculonodular lobe of the cerebellum.

Score the item and describe why the DGI is an appropriate test for this patient.  

·      The flocculonodular lobe is associated with balance and eye movements, leading to vestibular issues; therefore, this test would be appropriate because it involves turning the head and acceleration during the gait which will challenge this system

Dynamic Gait Index: Test item X Description of the item. Stroke of the flocculonodular lobe of the cerebellum.

What is the primary difference between the DGI and the FGA (Functional Gait Assessment)?

·      The FGA took out the part of going around obstacles and added gait w/narrowed BOS, backwards gait, and gait w/eyes closed

10-Meter Walk Test (10MWT) in patient with Parkinson’s disease.

Report your time and describe the purpose of the first 2 meters and the last 2 meters.

·      The first 2 meters and last 2 meters consider the acceleration and deceleration of the patient, only the middle 6 meters should be assessed and timed

·      Good for home mobility

6-minute walk test in patient with RRMS who is in the remitting phase. Instruct the patient in how the test will be performed (where they need to walk to, etc.) and demonstrate about 10 feet into the test. How may performance on this test vary depending on the time of day AND what is one environmental factor that could be especially impactful on performance in someone with MS?

• Time of Day (Fatigue/Diurnal Variability):

  • Patients with MS often experience fatigue that accumulates throughout the day.

  • Performance is typically better in the morning and may decline in the afternoon/evening.

• Environmental Factor (Temperature Sensitivity):

  • Heat sensitivity is common in MS (Uhthoff’s phenomenon).

  • Warm room temperature or warm weather can exacerbate fatigue and motor symptoms, reducing walking distance.

MiniBESTest in patient with PD (Hoehn and Yahr Scale Stage 2). Administer and score item X. Why is the Mini-BESTest often more sensitive for detecting balance deficits in early Parkinson disease compared to the Berg Balance Scale?

• Berg Balance Scale (BBS) primarily assesses static balance and basic functional tasks.

• Limitations of BBS in early PD:

  • Ceiling effect: Patients in early PD often score near maximum despite subtle deficits.

  • Does not assess reactive balance or dynamic gait tasks in detail.

• Mini-BESTest advantages:

  • Evaluates dynamic and anticipatory postural control, which are often affected first in PD.

  • Includes reactive balance tasks, capturing early compensatory deficits.

  • Differentiates subtle impairments that may impact gait, turning, or obstacle negotiation.

Teach tenodesis Grasp Promotion/Protection to a patient with C6 ASIA A SCI (must teach how the tenodesis grasp works for grasping and releasing objects and how to promote/protect it).  Also, describe how the zone of partial preservation contributes to the decision whether to promote a contracture of the extrinsic finger flexors.

a.        Tenodesis grasp is used when patients have wrist extension but no active finger function. Wrist extension will cause passive finger flexion while wrist flexion causes passive finger extension.

b.        To hold an object, extend the wrist and you can grab an object between the fingers and the thumb.

c.        To release an object, you can flex the wrist which allows the fingers to open and release the object.

d.        To protect and promote tenodesis make sure when performing transfers that you minimize stress on the wrist and hands (use a slide board with a closed fist). With practice, you can learn to use the fingers by passively moving the wrist. Also make sure you do ROM activities for all wrist and finger joints, as well as strengthen the muscles. Adaptive equipment may be recommended (special sideboard).

e.        The zone of partial preservation is the area below the neurological level of injury where some function remains and is possible to gain back partially/fully. At C6/C7 you may have partial preservation of the finger flexors, which means that you should start out with the tenodesis grasp until you know for sure if you are going to get that function back or not. Once you get the function back, you can start using it more readily. On the opposite hand, if you know you are not going to get finger flexion back, you can promote a contracture of the extrinsic finger flexors to allow the individuals to grasp and release objects.

Response to a near syncopal episode due to orthostatic hypotension in a patient with C8 SCI who is in short sitting (must also describe two additional signs or symptoms that may indicate a drop in blood pressure in addition to a lower measured blood pressure)

a.        Orthostatic hypotension is when a patient is raised up too fast and the blood pressure drops suddenly. You need to immediately call for help and lay them back down, as well as lift their feet above their head.

b.        Other signs of hypotension include dizziness, lightheadedness, blurred vision, and confusion.

Response to autonomic dysreflexia in a patient with T4 SCI who is in supine (must also describe at least 3 additional actions that should be taken in trying to determine and eliminate the cause of the dysreflexia)

a.        Autonomic dysreflexia occurs in patients with a spinal cord injury above the T6 level when there is an abnormal and exaggerated response of the autonomic nervous system causing a sudden increase in blood pressure. You need to immediately sit the patient up.

b.        You should check their catheter for kinks and empty the bladder, see if there is something that they are sitting on (fork), look for open infected wounds, check for extremely tight clothing, check bowel movements, and look for any signs of fractures.

C6 ASIA A Supine to Side lying (teach the MOST appropriate technique for this level and state the important muscle at this level that allows the patient to maximize leverage in the arms for rolling. What are the spinal levels of innervation for this muscle?)

a.        Serratus anterior (major innervation at C5, with additional innervation at levels C6-C7). This muscle allows the patient to protract and reach the arms further forward to round the shoulder which will make it easier for the patient to roll side-to-side and gain more momentum in order to roll to side lying.

C6 ASIA A Side lying to Short Sitting (teach MOST appropriate technique for this level and describe the typical short sitting posture (spine and pelvis) for someone with a C6 level SCI)

a.        You will have the patient move their mat-side arm up further by their head and their sky-side arm pushing into the table. Then have them swing their head and protract their sky-side arm into the table to gain momentum, simultaneously instruct them to pull their mat-side arm underneath them to get them to prop onto their forearms. Then have the patient protracted and swing their head as they walk their upper body towards their legs. Swing arm back, leading with their thumb to scoop legs down and swing up to sit. Arms and shoulders protracting into legs to support upper body.

b.        The spine will be excessively rounded and more kyphotic due to a decrease in core and back musculature strength. The pelvis will be in an excessive posterior pelvic tilt. The shoulders will most likely be internally rotated and protracted forwards.

C7 ASIA A Supine to Side lying (Teach MOST appropriate technique for this level and describe at least one strategy to “set up the patient for success”)

a.        The patient will protract their shoulders and use momentum from arms and head to roll over to a side. At the end of their role, they need to reach out towards the side of the table. They can then use one of their arms (or the therapist can assist) to pull their leg into side lying.

b.        One strategy to set the patient up for success is to teach momentum strategies by using their arms or pressing into the bed with their elbow and triceps. You really want to make sure they are protracting their shoulder and reaching forward.

C7 ASIA A Side lying (start with hips and knees extended, as would be the position right after rolling to side lying) to Short Sitting requiring min assist. Teach MOST appropriate technique for this level, which is not the C6 crawling on elbows method-see the video example. Describe the skilled documentation you would use with your role in training the patient with this task).  

a.        At this level you should push up on your elbows to bring yourself to a taller position. Instead of hooking arms on the legs, you should fling your arm all the way back over you and then walk yourself up to long sitting. Then you will pull your legs over to the side of the bed to reach the short sitting position.

b.        Start by describing the activity performed (side lying to short sitting transfer in the hospital bed). Describe the level of assistance provided (minimal assistance x1). Justify the skilled intervention (assistance provided to prevent compensatory movements). Note the patient’s response (patient showed improved trunk control). State the functional relevance (this skill progresses toward functional independence in bed mobility). State the plan for future actions. Explain why you made your treatment decisions.

c.        A physical therapist’s role in this training task would be to guide the patient to ensure safety and an efficient transfer as well as providing proper guarding and assistance techniques to avoid harm to the patient.

C6 ASIA A Short sitting to Supine with min-mod assist (teach MOST appropriate technique for this level) (must also assign a GG code score, sometimes known as a QIM Quality Indicator Measure).

a.        GG score is most likely going to be 3 (partial/moderate assistance). This is when the helper does less than half of the effort required to complete the task.

C7 ASIA A Short sitting to Supine with max assist (teach the “all or none” method) (Instruct a tech in how to help with either the legs or trunk segment).

a.        Hook patients’ legs between their arms and then fling backwards onto the bed.

b.        To assist with the trunk, the tech could ensure that the trunk is even and straight on the bed before lying the patient down. This would involve adjusting the hip position by sliding them over. To assist with the leg segment, they could help hold the legs in the correct position to ensure that they do not fling out and become released. The tech should also be performing how to properly guard during this to make sure the patient does not fall off the side of the bed.

C6 ASIA B Bed to Wheelchair Slide Board Transfer Training with moderate assist from therapist and min assist from tech. (Must also describe the optimal location of the gait belt and what would be the adverse effect of having the tech (or therapist) assist via the gait belt if placed around the waste or higher).  

a.        Gait belt should be positioned as close to the hip as possible. This is to better allow the tech to assist with the transfer. If the belt was higher and the tech was trying to help, they may make the patient unstable and cause more falls. The belt may cause discomfort if it rides up, can lead to skin irritation/pressure sores, and cause respiratory issues if the belt is too high.

b.        Mod assist from the therapist means the patient performs the lift and guiding processes during the transfer as well as cues. They will help with trunk stability.

c.        The techs min assistance role would be to provide light tactile cues, help guard, and steady the patient to help them maintain balance. They will help adjust with weight shifts.

C6 Wheelchair to Bed Slide Board Transfer Training (Must describe the effect of not using a wheelchair cushion (or pillow) in the wheelchair during the transfer)

a.        The pillow allows for the slide board to be at equal heigh with the wheelchair with the arm rest removed. It causes a height discrepancy where the bed becomes higher than the wheelchair which makes the transfer difficult because they’re moving upward.  This also allows for correct trunk alignment during the transfer.

b.        If the pillow was removed there is an increased risk for shear forces, skin breakdown, and the patient being more unstable (falling off or not being able to complete transfer) because the seat is lower and firmer, which puts more pressure on the ischial tuberosities.

C7 Bed to Wheelchair Slide Board Transfer Training (Describe how slide board placement and removal is biomechanically achieved, such that the patient doesn’t fall over when trying to lift their thigh with their arms).  

a.        When placing and removing the slide board to/from the thigh, you will hook your arm underneath the leg that the slide board is moving under and then use the leverage from your elbow to prop the leg up. Once this leg is up, then you can use the opposite arm to slide the board out.

C7 Wheelchair to Bed Slide Board Transfer Training (Describe an additional important “lifting” muscle at the C7 level besides triceps, that is only weakly innervated at C6, but can significantly help with slide board transfers and scooting in long sitting)

a.        The pectoralis major and latissimus dorsi are innervated at the C7 level.

b.        This muscle will help with shoulder extension, adduction, and internal rotation. It helps lift the pelvis and stabilize the trunk when pushing down on a board or mat. It allows the patient to depress the shoulder girdle to help push up as well. It helps with the lift of the body.

T1 Bed to Wheelchair Slide Board Transfer with moderate assist. (The patient at this level would have full use of which body part, compared to higher neurologic levels of injury?)

a.        This patient would have full use of their upper extremities but would not have control over their trunk or lower extremity.

b.        This means that they can move themselves to the board with their arms as their main force. They also have full grip strength and capabilities. They have improved push off ability at this level.

T1 Wheelchair to Bed Slide Board Transfer Training in a young and otherwise healthy patient (What is the expected long-term outcome with this patient regarding bed mobility, transfers, wheelchair mobility, and ambulation?)

a.        They should be independent in bed mobility, transfers, and wheelchair mobility.

b.        For ambulation they will be wheelchair dependent but will be independent in these tasks.

T10 ASIA A SCI Bed to Wheelchair Sitting Pivot Transfer (pop-over) without sliding board with min assist. (Describe the key biomechanical feature that will allow a patient to move from one surface to the next without a slide board.)  

a.        They have full upper extremity strength and trunk stabilization through shoulder depression and increased scapular control. They are able to lift and move their pelvis laterally to perform the transfer. They also have full hand and wrist control which allows for a grasp of the bed and wheelchair to transfer. They also have some passive trunk stability due to the increased strength in the upper extremities.

b.        In sum, they are able to lift and move their pelvis through the strength of their upper extremity.

T6 ASIA D SCI partial stand pivot transfer with mod assist due to 3 to 4/5 muscle weakness. Explain to the patient what other functional activity you will also be working on that people with the ASIA Dclassification are often able to achieve with training.

a.        The additional functional activity that patients with this level of injury can do is to walk with assistive devices. At this level, you may be able to walk with assistive devices and braces to improve the stability of the legs.

b.        This training will consist of gait training, balance/postural control, strengthening of legs and core.

c.        They have the potential for ambulation if there is some muscle strength left in the hip flexors, quads, and ankle dorsiflexors.

T1 Bed to Wheelchair Slide Board Transfer Training with mod/max assist x 2. As part of this transfer training, demonstrate how to place a draw sheet/pad fully under the patient (not a pillowcase around the board) prior to placing the board to prevent skin-on-board friction and for the tech to use as a tool for graded assistance during the transfer.  

a.        The purpose of the draw sheet is to reduce friction and allow for more graded assistance during the transfer.

b.        One clinician will help roll the patient away from the transfer side, the other therapist will tuck the sheet in under the patient. The patient will then be rolled back over, and the sheet will be pulled through on the other side. You can do the same in sitting by shifting weight to one side. You can also already have the sheet placed on the slide board.

c.        The draw sheet allows the therapist to help with sliding the pelvis along the board and allows for easier repositioning of the patient if they begin to slip.

Prevention and response techniques to a patient with T3 ASIA A SCI sliding too far forward on the slide board mid transfer (demonstrate and describe what both the patient and therapist need to do to prevent and correct this dangerous position on the slide board)

a.        Make sure the patient it is sitting fully on the slide board and far enough back with well aligned hips before starting the transfer. Make sure the hands are firmly holding on. The patient should move slow and controlled to avoid losing control. They should also avoid leaning too far forward and too far backwards.

b.        The therapist should be positioned to the side and slightly in front of the patient. They should have a firm grip on the gait belt with one arm on the gait belt and the other on the patient’s shoulder. The therapists legs should be cradling the patients legs so that if they being falling they can push backwards into the chair with their legs as well.

c.        When falling, the patient should place hands firmly on the slide board or wheelchair and use their upper extremity and trunk to shift weight backwards. The therapist should hold tightly to the gait belt and provide a backward pull to adjust the patient’s position.

T10 SCI Floor to Wheelchair Transfer Training with min assist. (must demonstrate and describe at least 1 set up strategy to make the task more manageable in the early stages of training, as well as describe the biomechanical cue that allows paralyzed hips to move from the ground to the chair)

a.        In the early stages of training, there should be a mat below the patient to minimize the distance they have to travel from the floor to the wheelchair. You could also place a gait belt around the legs to keep them together.

b.        The cue that the patient should follow is to push their head forward and down to move their hips back and up into the chair(head-hips relationship). Once the hips are in the air, they should walk their hand backwards (on their fist to make the distance smaller).

C6 ASIA A SCI wheelchair pressure relief techniques (3 directions), including how to safely move in/out of these positions at the C6 level. (must also instruct in frequency and duration, educating the patient on the purpose for both the optimal frequency and duration)

a.        Pressure relief should be performed every 30 minutes for at least 90 seconds. This is to prevent pressure ulcers and relieve pressure on bony prominences.

b.        Forward lean – anterior pelvic tilt by leaning the body forward to shift the weight off of the ischial tuberosities. How they sit in short sitting, walk arms down to knees and lean forward.

c.        Lateral lean (both sides) – shift body to one side by pushing down on the opposite arm rest and leaning laterally to relieve pressure on one side of the body at a time. handle, loop their arm and retract their shoulder to relieve pressure off the contralateral ischial tuberosity, repeat on other side.

d.        Reclining backwards in a wheelchair to take pressure off of the LE.

e.        Not ideal/possible for C6 but you can also press up on the arm rests and hold yourself up.

T7 ASIA B anterior cord syndrome SCI wheelchair pressure relief techniques. May teach either Board exam method or Dr. Shaw’s method (describe the big advantage someone with ASIA B may have over someone with ASIA A classification regarding protecting pressure vulnerable areas)

a.        Board exam – lift up on armrests and elevate LE off of the seat cushion. Hold this position for 90 seconds every 30 minutes.

b.        Dr. Shaw – tilt to one side, tilt forward.

c.        A patient with ASIA B may have the ability to feel pressure or discomfort and let them know they are uncomfortable which gives them a warning that they need to perform pressure relief. Individuals with ASIA A do not have the ability to sense discomfort, specifically at the S4-5 level.

Demonstrate adjustment of wheelchair footrests in patient with T4 SCI for optimal pressure distribution of the surfaces in contact with the seat and foot rest (must describe the changes in location of pressure when footrests are too high and when too low). 

a.        The thighs should be evenly supported by the seat cushion, there should be a gap between the knees and the seat, and the feet should rest comfortably on the footplates without excessive knee movements. A roho seat cushion would be good to use. Hips should be at 90 90. Lumbar lordosis should be supported. Thoracic spine should reach the back of the seat.

b.        When the footrests are too high – increased pressure on ischial tuberosities. Patient may feel like they are sitting downward. Posterior pelvic tilt. Knees are elevated above hip level and thighs are not in contact with the seat. Could lead to pressures sores on the patients ischial tuberosities

c.        When the footrests are too low – increased pressure under the thighs and back of knee may be compressed (messes with circulation), anterior pelvic tilt, knee appear too low. Heels may be pressed too hard on the footrest. Could lead to pressures sores on the patients thighs.

Teach the gait pattern (standing/walking biomechanics) to a patient with T11 ASIA A SCI (for time-sake, instruct without donning braces, though must state the type of braces that would be used and describe the ROM requirements in the ankles and hips to stand and walk at this SCI level) 

a.        KAFO with loft strand or axillary crutches, ankles – 5-10 degrees, hips – 10-15 degrees.

b.        This patient will use a swing to or swing through gait where they place their crutches out in front of them and then swing forward either to the crutches or past the crutches. They may need to use hip hiking/circumduction to pull the legs through when not using crutches.

c.        When just standing, you want your pelvic to be anterior to the crutches to help maintain balance.

Gait training with a patient with L3 SCI with no neurologic preservation below L3 (for time-sake, train without bracing, though must state the type of braces that would be used).  

a.        At this level you would need AFOs with crutches or a walker.

b.        They would use 2 point or 4-point gait patterns. They will advance one leg at a time using their hip flexors to drive the leg forward. The knee extensors will also help pull the leg forward.

Optimal Wheelchair Propulsion over level ground in a patient with T3 SCI (must also teach the patient the long-term benefit of using this propulsion technique in open areas for long distances compared to relying solely on the short stroke method).

a.        The long stroke propulsion technique involves pushing from the back of the wheel all the way to the front of the wheel before letting go. This allows for a longer period of contact between the hands and the wheel, which maximizes the efficiency of each push. Emphasize the use of shoulder and scapular muscles to help push you.

b.        This allows for improved endurance, reduced fatigue, energy efficiency, reduced risk of overuse injuries, and better control over the wheelchair.

Initial Wheelie Training over level ground in patient with T10 SCI (must also teach the purpose for learning a wheelie)

a.        The purpose for learning a wheelie is to help aid in independence by allowing them to ambulate in a wheelchair throughout a community easier. This allows them to get up onto curves and higher surfaces. It will also help navigate uneven terrain and prevent the patient from catching onto obstacles.

C6 Short sitting Balance Progression, starting from the most stable position (The patient can only tolerate the activity for brief periods due to orthostatic hypotension. Demonstrate how you can still work on sitting balance despite this barrier.)

a.        Use gradual upright positioning when performing sitting balance such as a tilt table or a wheelchair, use short intervals with breaks for supine recover, and use adaptive equipment to help the patient. Monitor symptoms, cross the legs, bend at the waist.

b.        Use a reclining wheelchair, elevated head of the bed, reclined position in short sitting, have the patient off the side of the table in a slouched position.

C7 Short Sitting Balance Progression. The patient has a fractured right humerus and is non-weightbearing. Include in your balance progression training biomechanical education of what action the patient must concurrently learn to do when lifting an upper extremity from the support surface to avoid falling over.

a.        They must use a weight shift to the other side to assist in balance. They also need to keep the COM over the BOS which is where the lateral lean comes into place. They can also shift the pelvis to help them maintain balance. You could also continue to do balance with their affected arm supported with a pillow.

C6 Long Sitting Balance Progression, starting from the most stable position (Training must include teaching the patient how to protect the tenodesis grasp) Biomechanically, how is it possible that a person at this level can learn to walk their hands forward, from an initial position of being propped on extended arms?

a.        The tenodesis grasp is an extended wrist with flexed fingers. They must not extend their fingers in order to protect the tenodesis grasp.

b.        This patient can learn how to walk forward by using their tenodesis grasp and momentum from head swings to move themselves forward. They can internally rotate the shoulder to move themselves forward. Scapular protraction helps move the arms forward. The head hips relationship also plays a role in allowing them to move forward.

C7 Long Sitting Balance Progression. The patient’s hamstring length is currently 85 degrees bilaterally. Demonstrate a modified position to use during your balance progression training and describe how overstretching the thoracolumbar fascia (and associated low back soft tissue) would limit function in this patient.

a.        During long sitting balance, this patient could sit in a frogged leg position to shorten the hamstrings and still allow for balance to be tested. This accommodates to the shortened hamstrings.

Demonstrate optimal positioning in supine in a patient with a right MCA stroke and hemi motor/sensory deficits, including neglect, shoulder subluxation, as well as risk for edema in affected hand and ankle contracture.  

SIDELYING WITH LEG UP

• Head/neck: Neutral, slight turn toward involved side to reduce neglect.

• UE: Affected shoulder supported with pillow/towel roll under scapula; arm positioned in slight abduction/external rotation, elbow extended, wrist neutral, hand elevated on pillow to reduce edema.

• LE: Affected ankle supported in neutral (no plantarflexion) with foot splint or pillow under calf/ankle to prevent contracture.

• Trunk: Midline, avoid excessive trunk rotation away from affected side.

• This optimizes awareness of neglected side, protects the shoulder, and prevents edema/contractures.

Demonstrate positioning in bed for optimal pressure relief in a patient with a right MCA stroke and hemi motor/sensory deficits (Don’t forget to position the UE). Describe the bony prominences that are relieved in this position and others that are at greater risk, compared to the full supine position.

¾ sidling on the unaffected side

bony prominences relieved are occiput, scapula, sacrum and heels

bony prominence at greater risk are greater trochanter, lateral knee, and lateral malleolus

Teach a patient and caregiver how to perform active assisted exercise of the involved LE to prevent contracture and DVT. The patient had a right MCA CVA. The training must be hands-on with the caregiver. Describe to the patient and caregiver why the risk of DVT is higher in this patient who had a hemorrhagic stroke compared to someone who had an ischemic stroke.

• Hemorrhagic stroke → patients are immobilized longer because anticoagulation/antithrombotics are contraindicated early on (due to bleeding risk).

• Reduced prophylaxis + immobility = higher DVT risk than ischemic patients who may receive earlier anticoagulation.

Rolling toward the unaffected side after an MCA stroke. The patient has left neglect and 2-/5 strength in the UE and 2+/5 strength in the LE and requires max assistance. (must also assign a GG code score, sometimes known as a QIM Quality Indicator Measures).

GG code - 2 since there is max assist and helper does more than half effort

Supine to sit toward the hemiparetic side in a patient with a right frontal lobe glioblastoma with flaccid 0/5 UE strength and 3/5 LE strength. Describe why “throwing” the arms to roll is a good strategy for many people with SCI, but not so much for this patient who is flaccid in the UE.

you get better momentum by throwing the arms but since it is flaccid they cannot generate that momentum

this strategy relies on UE movement

CVA with hemorrhage into the subarachnoid space 2 days ago. Mild weakness on the left side, with generalized balance and cognitive deficits requiring mod assist x 2. Help the patient move from supine in bed to sitting in a chair. (Describe 3 benefits from this intervention and demonstrate why and how you mitigated the risk of excessive exertion during the first 7 days after stroke.)

3 benefits are better pulmonary function (pneumonia), reduces skin breakdown, stimulates postural control, better circulation

risk of excessive exertion - limit duration, use 2 person assist slowly, prove high back chair with arm supports

Sit to/from stand in a patient with right ACA stroke with 2/5 LE strength and poor awareness of foot positioning. The UE has 3/5 strength. (Demonstrate, then describe the long-term learning benefits of promoting greater reliance on internal feedback strategies, compared to external feedback.)

yes internal feed back because it promotes neuroplasticity and motor learning and longer retention

reliance of feedback comes from external