Lecture 2: Adult Neuromuscular Examination/Evaluation

what is select?

Select patient/client history components based on patient/client needs

what is identify ?

Identify the components of a systems review based on patient/client
needs and complexity

what is Select?

Select individual tests and measures designated in the Guide to
Physical Therapist Practice

what is integrate?

Integrate data from the examination in order to formulate a clinical
judgment that leads to a diagnosis, prognosis, and plan of care

what is establish?

Establish functional outcomes that specify expected time duration

• Multidimensional process
  • Process of gathering information
  • Reach decisions
  • Determine actions
  • Basis of patient/client management
  • Clinician and patient
  Hypothesis: testable explanation

Clinical Reasoning

• Results from the clinical reasoning process
• Evidence
Clinical reasoning: is why you choose something
Clinical decision making is what you chose

Clinical Decision Making

what are 5 Elements of Patient/Client Management

• examination

• evaluation

• diagnosis

• prognosis and plan of care

• intervention

what is under examination?

• history

• systems review

• tests and measures

• Gathering of data to determine why the patient needs therapy
• Chart Review
• Interview
• Other sources

• Doctors’ Orders
Diagnosis
Precautions
Medications
• Doctors’ Notes
Admission reports
Progress notes
Diagnostic Tests
Surgical Summaries
• Nurses’ notes
Progress notes
• Other (PT, OT, Speech, Social work, etc.)

history

• professionalism

• undivided attention

• addressing the patient

• privacy

• sit ~ 3 feet away

• open ended questions

• control the conversation

• respect cultural differences

history interview

• living environment

• stairs

• floor plan

• where is bedroom located

• where is bathroom located

• kitchen accessibility

• laundry location

• hallways

• number of people in the household

history environment

what is under living environment ?

• House vs apartment
• How many levels in home

what is under stairs?

• Number of steps into house
• Any railings and can both be reached at the same time
• Stairs to multiple floors

what is under floor plan?

• Layout of living area; What is and is not accessible
• Where is most time spent; Favorite place to sit
• Type of flooring

where is bedroom located ?

• Type of bed (regular vs hospital)
• Bedrails

where is bathroom located?

• Layout of bathroom
• Toilet seat height
• Grab bars
• Tub/shower

what is under hallways?

• Width and type of flooring
• Accessible with assistive device

number of people in the household

• Who does household chores
• Pets in the home

• Adaptive Equipment
  • Assistive devices
  • Wheelchair
  • Raised toilet seat
  • Grab bars
  • Hospital bed
  • Braces, orthotics
  • Adaptive feeding, dressing, bathing equipment

History: Adaptive Equipment

• Problems an individual may experience in involvement in life situations
• PIP: Patient identified problems
• NPIP: Non-patient-identified problems
• Inability to return to work
• not being able to participate in recreational activities like sports or dancing
• difficulty with self-care tasks like bathing or dressing (IADL’s)
• limited ability to engage in social events
• challenges with household chores like cooking or cleaning

Participation Restrictions

what is PIP

Patient identified problems

what is NPIP

Non-patient-identified problems

what are activity limitations?

• difficulty walking
• climbing stairs
• reaching overhead
• bending down to pick something up
• standing for long periods
• lifting objects

what is Systems Review: Precautions

• DNR
• Cardiac
• Sternal
• Seizures
• ROM limitations
• Weight bearing status
• Orthostatic hypotension

what is Systems Review: Cognition

• Consciousness
• Orientation
• Memory
• Safety awareness
• Ability to make needs known
• Expected emotional/behavioral responses
• Learning preferences (educational needs, learning barriers)

• A x O × 3 (person, place and time)
• Level of Consciousness
Alert: Normal
Lethargy: Drowsy
Obtunded: Difficult to arouse
Stupor: Responsive only to pain/touch
Coma: Arousal impossible

what is Mini-Mental State Examination (MMSE) scores?

24-30: normal
21-23: mild impairment
16-20: moderate impairment
15 or less: severe impairment

what is Montreal Cognitive Assessment (MOCA) scores?

26 or higher: Normal cognitive health
18–25: Mild cognitive impairment (MCI)
10–17: Moderate cognitive impairment
Less than 10: Severe cognitive impairment

what is Glasgow Coma Scale?

• Level of consciousness in acute brain injury

• Examines eye opening, motor response & verbal response

  • Score ranges from 3-15

  • Below 8 = severe injury

  • 9-12 = moderate injury

  • 13-15 = mild injury

what is Rancho Los Amigos Level Of Cognitive Functioning (RLA LOCF)?

Descriptive scale to examine cognitive and behavioral recovery in TBI

• Immediate – recall 3 items presented after 3-5 minutes
• Short term – “what did you have for breakfast”
• Long term – “ past events – “where were you born”

• Vision
• Hearing
• Speech

Memory

Heart Rate: 60 – 100 BPM
Blood pressure: 120/80
Oxygen Saturation: 96-100%
Respiratory Rate: 12 to 20 breaths per minute

Systems Review: Cardiovascular and Pulmonary

• Assessment of skin color
• Temperature
• Integrity
• pliability (texture)
• presence of scar formation

Systems Review: Integumentary System

Assessment (through interview or observation) of joint pain
swelling or stiffness,
weakness;
screening tests and measures of gross range of motion (ROM)
gross strength
posture and symmetry
joint temperature and alignment
Five Times Sit to Stand Test.

Systems Review: Musculoskeletal System

• Assessment (through interview or observation) of fatigue
• recent weight loss or gain
• usual level of blood sugar when checked (diabetes);
• screening tests and measures of the Functional
Assessment of Chronic Illness
• Therapy-Fatigue scale,
• 2- or 6MWT

Systems Review: Endocrine System

why systems review?

• confirm the need for further or more detailed examination
• rule out or differentiate specific system involvement
• determine if referral to another health-care professional is warranted
• focus the search of the origin of symptoms to a specific location or body part.

• From the History and Systems Review a hypothesis is generated about the patient’s condition

• Tests and Measures are then used to further investigate the condition

• The Tests and Measures are used to establish a diagnosis, prognosis, plan of care and to select appropriate interventions

Tests and Measures

What test are used to examine sensation?

• superficial

• deep

• combined

• Complete sensation examination on partner.
• Test for light touch and sharp/dull
• Dermatomes C5-T2

Tests and Measures: Sensation

• Temperature Awareness

• Cold: 41 – 50 f

• Hot: 104 – 113 f

• Pressure perception

  • The therapist's fingertip or a double-tipped cotton swab applies firm pressure on the skin surface

Sensory testing

• Kinesthesia

• proprioception

Sensory Testing -Deep Sensations

what is kinesthesia?

• awareness of movement
• extremity or joint(s) is moved passively through a relatively small range of motion (ROM)
• describe verbally the direction (up, down, in, out, etc.)
• respond by simultaneously duplicating the movement with the contralateral extremity

what is proprioception?

• joint position sense and the awareness of joints at rest
• extremity or joint(s) is moved through a ROM and held in a static position
• initial, mid-, or terminal range
• Vibration Perception
• tuning fork

what is Combined Cortical Sensations

• stereognosis

• tactile

• two point discrimination

• graphesthesia (traced figure identification)

• barognosis (recognition of weight)

what is stereognosis

Ability to recognize the form of objects by touch (stereognosis)

what is tactile?

ability to localize touch sensation on the skin (topognosis)

What tests are used to examine coordination

Grading
5. Normal performance
4. Minimal impairment: able to accomplish activity but with less than normal speed and skill
5. Moderate impairment: able to accomplish activity; movements are slow, awkward and unsteady
6. Severe impairment: able only to initiate activity
without completion
1. Activity impossible

What tests are used to examine muscle tone?

• Initial observation of resting posture

• Passive motion testing
  • Quick stretch
  • Clasp-knife reflex
  • Cogwheel rigidity
  • Lead pipe rigidity
  • Clonus

• Active motion testing

• Grade 0: No increase in muscle tone

• Grade 1: Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of ROM

• Grade 1+: Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM

• Grade 2: More marked increase in muscle tone through most of the ROM, but the affected part is easily moved.

• Grade 3: Considerable increase in muscle tone, passive movement is difficult.

• Grade 4: Affected part is rigid

Tests and measures: modified ashworth scale

• PROM and AROM

• upper and lower extremities

• manual muscle testing

• note any contractures, limitations or abnormal synergy patterns

Tests and Measures: ROM and Strength

• Lesions of corticospinal tract (i.e. CVA) can produce abnormal obligatory synergies

• Voluntary movements that are limited in the ability to adapt to demands placed upon them

• Selective movement control is severely disordered.

• As CNS recovery progresses, synergies become more variable

Tests and Measures: Abnormal Synergy Patterns

UE flexion testing

scapular retraction & elevation; shoulder abduction & ER, elbow flexion, forearm supination, wrist and finger flexion

UE extension testing

scapular protraction, shoulder adduction & IR, elbow extension, forearm pronation, wrist and finger flexion

LE flexion testing

hip flexion, abduction & ER, knee flexion, ankle dorisflexion & inversion, toe flexion)

LE extension testing

hip extension, adduction & IR, knee extension, ankle plantarflexion & inversion, toe extension

What scale is used to examine DTR’s?

• 0 – no response
• 1+ - present but depressed, low normal
• 2+ - average normal
• 3+ - increased, quicker than average, not necessarily abnormal
• 4+ - very brisk, hyperactive, with clonus
• Biceps, Brachioradialis, Patella, Achilles
• Test biceps DTR on partner

• athetosis

• choreiform movements

• resting tremors

• intention tremors

• fasciculations

Tests and Measures: Involuntary Movements

• Sitting and Standing posture
  • Head
  • Shoulders
  • Scapula
  • Upper extremities
  • Ribs
  • Trunk
  • Pelvis
  • Lower extremities

Tests and Measures: Posture

• Describe assistance needed, verbal cues
  • Bed mobility
  • Transfers
  • Wheelchair mobility
  • Gait
  • Stairs and elevations

Tests and Measures: Functional Mobility

Levels of Assistance

A standardized assessment instrument of functional status that is part of the
Uniform Data Set for Medical Rehabilitation; it tests 23 items in seven areas
of function and uses a seven-point scale for each item

7: Complete Independence
6: Modified Independence
5: Supervision or Setup
4: Minimal Assistance (75% or more)
3: Moderate Assistance (50-75%)
2: Maximal Assistance (25-50%)
1: Total Assistance (less than 25%

Functional Independence Measure (FIM)

• Static vs dynamic balance

• Grading Balance Scale

  • Poor, Fair, Good, Normal

• Tolerance to perturbations

Examining Sitting and Standing Balance

• Postural Assessment for Stroke Patient
• Activity-specific Balance Confidence Scale
• Falls Efficacy Scale
• CTSIB
• Tinetti POMA
• Berg Balance Scale
• Functional Reach Test
• Timed Up and Go (TUG)
• One legged stance
• Romberg stance
• Tandem stance
• Stops Walking When Talking

Balance