PPC tut 9a

Pre-Assessment Considerations for Early Mobilization

• Importance of Initial Checks: It is mandatory to check for physical impairments before assisting a patient out of bed for the first time if there is any doubt regarding their physical capability.
• Exceptions via Clinical History: If a patient (e.g., a stroke patient) has a documented history of recent mobility (e.g., a nurse reports they walked to the toilet earlier that morning), a formal strength assessment or movement check may not be necessary before getting them up again.
• Determining Resource Readiness: For patients with an unknown status (e.g., a new presentation or a "zero" status), a quick assessment of impairments is necessary to determine the number of staff required to safely mobilize the patient.

Assessment of Muscle Strength (MMT)

• Primary Assessment Methodology: Manual Muscle Testing (MMT) is identified as the most appropriate tool for general strength assessment in this clinical context.
• Assessment Sequencing and Comparison:     - Always assess the "good side" (unaffected) before the "bad side" (affected).     - This allows the patient to understand the specific movement the therapist is trying to achieve.
• Efficiency in Clinical Practice:     - Positional Grouping: Formal MMT usually requires moving patients into various anti-gravity positions. In an acute setting, it is more efficient to test all possible muscle groups in a single position (e.g., supine) before transitioning the patient to another position.     - Rational for Grouping: This strategy saves time, reduces staffing requirements, and minimizes the physical burden on the patient by avoiding constant rolling (e.g., "rolling around, rolling back, rolling around").
• Simplified Strength Categorization for Time-Limited Sessions:     - If a session is limited (e.g., only $30$ minutes left after the subjective history and initial transfers), therapists can group MMT scores to prioritize intervention:         - MMT Score $0$: Paralyzed.         - MMT Score $1-2$: Very weak.         - MMT Score $3-4$: "Kinda" weak.         - MMT Score $5$: Strong.     - Specific MMT for every individual muscle group can then be deferred to the next session.
• Distinguishing Lower Grades: When a patient exhibits a score of $0$ or $1$, therapists should use palpation to determine if there is any muscle activation occurring that is not visible through limb movement.

Coordination and Cognitive Interferences

• Relationship between Strength and Coordination: While separate impairments, coordination and strength are interlinked. A patient requires a baseline level of strength to perform coordination tests (e.g., finger-to-nose testing requires elbow flexion and finger extension).
• Impact of Cognitive Impairments: Receptive processing issues or communication disorders (e.g., aphasia) can interfere with assessment results. A patient might fail to perform a movement not because of weakness ($MMT$) but because they do not understand the instructions.
• Selection of Coordination Tests: Coordination assessments should be targeted based on the functional goals of the session:     - Walking/Gait Focus: Prioritize lower limb coordination (e.g., heel-to-shin test).     - Upper Limb Focus: Prioritize upper limb coordination (e.g., finger-to-nose or reaching manipulation).
• Common Tests: Reference is made to the ASPB (likely a clinical assessment battery) involving coordination tests that therapists should be confident in performing.

Sensation and Proprioception Assessment

• General Sensory Testing Protocols:     - Testing is typically performed with the patient's eyes closed.     - Tools used include sharp/blunt objects (pinprick), light touch, and hot/cold stimuli.
• Nottingham Sensory Assessment (NSA):     - This is a formal measurement scale rather than just a subjective assessment.     - It yields a formal outcome score.     - Factors measured include pinprick, light touch, temperature, and other specific sensory measures.
• Proprioception Testing Techniques:     - Mirroring/Matching: The patient attempts to match the position of an affected limb with the unaffected limb.     - Directional Pointing: If the patient is too weak to mirror, the therapist moves a joint (e.g., the thumb) into a position, and the patient identifies which way it has moved.

Spasticity versus Contracture

• Contracture Defined: A reduction in joint range of motion ($ROM$) or an increased resistance at a joint that limits mobility. In bed-bound patients, this often presents as "standard postures," such as:     - Flexed positions (elbow, wrist, hips, knees).     - Hip adduction (legs positioned together).     - Plantarflexion of the feet.
• Agonist-Antagonist Imbalance: Contractures often occur when an agonist (e.g., wrist flexor) is significantly stronger than the antagonist (e.g., wrist extensor), pulling the joint into a fixed position while at rest.
• Spasticity Defined: A velocity-dependent increase in muscle tone. It is differentiated from contracture by how the muscle reacts to different speeds of movement.

The Tardieu Scale

• Speed Definitions:     - $V_1$: Slow speed (essentially passive range of motion).     - $V_2$: Speed of the limb falling under gravity (not commonly communicated/used in this specific clinical context).     - $V_3$: Fast speed (as fast as possible).
• Rating Parameters:     - Quality of Muscle Reaction: Rated on a scale of $0$ to $5$.     - Angle ($Y$): The specific joint angle where the muscle reaction occurs.
• Identifying Clonus:     - Fatiguable: Short-lived beats of muscle contraction.     - Unfatiguable: Repeated beats lasting more than $10$ seconds.

Case Study Analysis: Ankle and Elbow

• Ankle Assessment Case Study:     - Slow Speed ($V_1$): Muscle reaction was $0$. Joint angle achieved was approximately $5$ to $10^{\circ}$ of dorsiflexion.     - Fast Speed ($V_3$): The patient exhibited unfatiguable clonus (lasting >10 seconds). Because the clonus prevented reaching the end of range, this confirms a positive result for spasticity.
• Elbow Assessment Case Study:     - Slow Speed ($V_1$): Reached a point approximately $-5^{\circ}$ (five degrees off) full elbow extension. This indicates a loss of joint range (potential contracture).     - Fast Speed ($V_3$): A clear "catch and release" was noted at an angle of approximately $135^{\circ}$ (elbow flexion).     - Conclusion: This patient possesses both a contracture (loss of range at slow speed) and spasticity (velocity-dependent catch at fast speed).
• Clinical Recording Tip: If a patient is close to full range at slow speed, use "minus degrees" (e.g., $-5^{\circ}$ from extension). For midrange catches at fast speed, record the absolute angle (e.g., $135^{\circ}$ flexion).

Questions & Discussion

• Student Question: Do you do all strength in one position and then all coordination in that same position?
• Response: Yes, that is an efficient way to plan the session to balance efficiency, patient comfort, safety, and effectiveness.
• Student Question: How do you differentiate if spasticity is present?
• Response: You must see a change between the results at $V_1$ (slow) and $V_3$ (fast). If you get a muscle reaction at slow speed, you are likely not moving the limb slowly enough. Spasticity is velocity-dependent.
• Student Interaction: Students discussed finding a video of the Nottingham Sensory Assessment and the use of "vibration" in sensory testing (noting it is not on the Nottingham scale but used elsewhere).
• Instructional Note on Mastery Arms: Students were encouraged to practice assessments using "mastery arms" and were reminded to flick through the different modes on the equipment to properly simulate $V_1$ and $V_3$ speeds.