Neurological Objective Assessment Overview

ICF Framework & Neurological Objective Assessment

Relevance of ICF Framework

  • The ICF framework is relevant to neurological objective assessment, focusing on:
    • Body Structure and Function: Assessing impairments relating to anatomical structures and their functions.
      • Examples: Range of motion, strength, tone, sensation, coordination, and vision.
    • Activities: Functional assessments of:
      • Examples: Bed mobility, transfers, sitting and standing balance, gait and mobility, and stair climbing.
    • Participation: Assessing the ability to:
      • Examples: Access the community, engage in shopping, sports, hobbies, work, and caring for others.

Source vs. Problem Based Assessment

Source Based Assessment:
  • Impairment-focused, traditional neurological assessment.
  • Systematically tests for all impairments.
  • Concludes with an assessment of activity or functional tasks.
  • Commonly used by medical doctors and neurologists.
Problem Based Assessment:
  • Activity-based assessment.
  • Involves observing specific activities or tasks.
  • Compares patient performance to normal standards.
  • Hypothesizes contributing impairments based on observed movement abnormalities.
  • Tests only these hypothesized impairments to confirm or refute them.
Key Considerations
  • Both approaches aim to identify a problem list or contributing impairments.
  • The choice between source-based and problem-based depends on:
    • Setting, priorities, patient condition (severity of illness/injury), time constraints, and the experience of the patient.
  • Acute inpatients may require impairment testing before activity observation for safety.
  • Private practice may prioritize specific activities based on patient goals.
  • Learning: Problem-based assessment relies on observation skills and understanding of movement patterns.
  • Flexibility: Assessment isn't linear, and plans may need adaptation based on the situation.
  • Initial Observation: Objective assessment begins upon initial contact with the patient, observing spontaneous movement to form hypotheses.

Differences Reiterated:

  • Problem-Based:
    • Activity observation first.
    • Specific impairment testing based on hypotheses.
  • Source-Based:
    • Impairment review first.
    • Activity observation follows.
  • Goal: Both approaches aim to understand impairments contributing to activity limitations.
  • This course focuses on a source-based process to ensure comprehensive impairment testing and understanding.
  • Sensation: Sensation deficits are not always observable; thus, a source-based approach is emphasized.

Core Components of Neurological Physiotherapy Assessment

  1. Observation
  2. Active Range of Motion
  3. Strength
  4. Passive Range of Motion
  5. Tone
  6. Sensation
  7. Coordination
  8. Vision
  9. Functional Assessment
  10. Outcome Measures
  11. Specific Activity/Task/Participation Elements (depending on the situation)

Other Assessment Components (Situational)

  • Considerations: Condition, severity, symptoms, and service setting.
  • Assessment starts with the patient's current position and environment.
Initial Patient Position
  • Hospital: Bed or chair/wheelchair.
  • Outpatient: Wheelchair or ambulating.
  • Home: Chair, bed, or ambulating.
  • Assessment order may change depending on the patient's initial position.
  • Safety: Assess active range of movement, strength, and sitting balance before transfers.
Sitting Assessment:
  • Volitional movement, strength of limbs and trunk, and sitting balance.
  • Vision assessment.
  • Manual handling for both patient and therapist safety.
  • Variability: Consider the patient's best and worst performance times.
  • Recommendations: Account for skill set differences and the 24-hour picture.
  • Demonstration: Request patient demonstrations without assistance first.
  • Instructions: Be mindful of impulsive patients or those with cognitive/communication challenges.

Observation: A Key Skill

  • Degree and extent of observation depend on the setting.
  • Hospital: Focus on medical stability, wellness, attachments, and equipment.
  • Community: Focus on home access (slopes, steps, stairs, grass), home environment (space, doorways, corridors, clutter), and floor surfaces.
Attachments to Note:
  • IV lines, gelcos, IDCs, CVDs, drains, oxygen lines, PEG tubes, NCTs, CVCs, PICC lines, and stoma bags.
  • Medical Observations: Note current observations (taken or documented).
  • Severity Indicators: Bedridden vs. sitting out of bed, wheelchair vs. walking, and gait aids. Determine level of mobility, severity and or cognition.
  • Wheelchair Type: Motorized vs. manual, and ability to propel.
  • Additional Observations:
    • Alertness
    • Positioning, posture, and alignment
    • Spontaneous movements
    • Cognition, behavior, insight, and communication
    • Skin for wounds or abnormalities
    • Breathing, sputum management, and swallowing
    • Documentation

Active Range of Motion & Strength

  • Core component of neurological physiotherapy assessment.
  • Source based assessment systematically assesses all limbs.
  • Problem based assessment only assesses joints and muscle groups hypothesized in contributing to movement issues.
  • Purpose: Determine if impairments impact activity/functional performance and participation, guiding treatment and further assessment.
  • Distinction from Musculoskeletal Physiotherapy: Focus on systematic assessment of the whole body, not diagnosis of specific body structure pathologies.
  • Active range of motion is affected by strength, yet they are distinct and require separate assessment and documentation.
  • Other factors besides strength can affect active range of motion.
  • This course covers upper and lower motor neuron lesions.
  • Source-based assessment focuses on a systematic flow for completing a full-body assessment.

Passive Range of Motion

  • Core component of neurological physiotherapy objective assessment.
  • Focus on full body systematic assessment in a timely manner.
  • Purpose: Identify limitations impacting activity and participation, and consider reasons for restrictions noted.
  • Patient Safety: Patients with neurological deficits may lack voluntary control, increasing injury risk.
  • Handling: Extreme care is needed when moving a patient's limb.
  • Sensory/Pain Awareness: Patients may have sensory deficits or be unable to communicate pain effectively.

Tone Assessment

  • Core component of neurological physiotherapy objective assessment.
  • Changes in tone can include high or low tone, involuntary muscle spasms, dystonia, dyskinesia, spasticity and rigidity.
  • Tone and passive range of motion are related, but they are not the same thing and need to be assessed differently and documented separately.

Somatosensory Assessment

  • Focus on systematic approach for neurological physiotherapy objective assessment.
  • Implications for treatment and management.
  • Light touch, vibration, temperature, and sensory discrimination.
  • Proprioception is also included.
  • Altered sensations such as paresthesia and pain.

Coordination

  • Display of motor control and deficits (ataxia).
  • Ataxia may relate to cerebellar dysfunction or sensory dysfunction.
  • Tests include finger-to-nose, heel-to-chin, and hand/foot tapping.

Vision Assessment

  • Determines if the patient can see their environment.
  • Implications for assessment and therapy positioning.
  • Potential need for scanning practice.
  • Safety and therapy specifics for mobility.
Components:
  • Visual fields, eye movements, visual inattention/neglect, and double vision (diplopia).

Functional Assessment (Activities Section of ICF)

  • Bed Mobility:
    • Mostly for patients in hospital.
    • Rolling, moving up and down the bed, side to side and bridging.
  • Transfers:
    • Lie to sit, sit to lie, and transfers between surfaces.
    • Practice required for neurological deficits.
  • Sitting and Standing Balance:
    • Observation of posture.
    • Static and dynamic balance assessment.
    • Support/assistance requirements.
    • Sitting balance assessed before transfers.
  • Mobility/Gait:
    • Pre-gait assessment (standing, weight shift, knee control, stepping potential).
    • Stepping/mobilizing ability and quality.
    • Assistance, equipment, and verbal cues.
    • Endurance and gait speed.
    • Direction changes (backwards, sideways).
    • Steps, stairs, slopes, and obstacles.
    • High-level mobility.
    • Dual tasking.

Outcome Measures

  • Useful for informing prognosis, care planning, assessing change, and effectiveness of treatment.
  • Standardized measures for objective data at baseline, monitoring, and discharge.
  • Measures should be meaningful to the patient and reflect therapy aims/goals.
  • Specific services have requirements for data collection and funding.
  • A variety of measures may be needed to address different areas of the ICF framework.
  • Websites with links to common assessments.

Further Assessment (Specific Situations)

  • Specific function/task-specific activities.
  • Arm function tasks.
  • Car transfers.
  • Floor transfers.
  • Hobbies (golf, lawn bowls, woodwork).
  • Outdoor mobility and higher-level activities and negotiation.

Respiratory Function

  • Considerations: Indicators in subjective assessment, condition, orofacial muscle effects, time in ICU/surgery, acute/chronic status, and patient medical history.
  • Observations: Saturation levels, temperature, oxygen use, appearance, respiratory rate, cough, and swallowing issues.

Reflexes, Cranial Nerves and Motor Planning

Reflexes
  • Often completed by neurologists for diagnosis.
  • Not used to determine diagnosis in neurological physiotherapy, rather it helps to distinguish between upper and lower motor neuron issues.
  • The presence or absence of these obviously can help distinguish between upper and lower motor neuron issues and where hyperactive reflexes are present this may be indicative of abnormal tone and upper motor neuron lesions.
  • The Babinski reflex and clonus will be covered.
Cranial Nerves
  • Assessment completed by neurologists or medical specialists.
  • Information collected by reviewing medical records.
  • Vision and vestibular assessments are relevant aspects.
Motor planning
  • Motor planning may include initiation of movement, apraxia, bradykinesia, akinesia, and freezing of gait.
  • Vestibular Assessment may be required.

Documentation of Objective Assessment

  • Dependent on setting and electronic medical record use.
  • Document all key components or justify omissions.
  • Distinguish assessment from recommendations/plan.
  • Independence requires no cues; document all assistance levels and equipment used.
  • In ink errors should be crossed out and an initialed and a new note written. They should never be white out used.
General Guidelines:
  • Identifiers, legible, concise (black/blue pen), approved abbreviations, date/time, signature, consent documented.
  • Facts: Factual and objective language.
  • Storage: Secure storage for at least seven years with confidentiality.
  • Electronic and paper templates available.
Key Headings:
  • Observations
  • Active Range of Motion & Strength
  • Passive Range of Motion
  • Spasticity
  • Sensation
  • Coordination
  • Vision
  • Function: Bed mobility, transfers, balance, gait, mobility and outcome measures.