Subjective Assessment in Neurological Physiotherapy

ICF Framework and Neurological Physiotherapy Assessment

• The ICF framework is used for assessment, clinical reasoning, developing problem lists, goal setting, and measuring health, ability, and disability.
• Background knowledge about the health condition is important, including pathophysiology, anatomy, and prognosis.
• Underlying impairments such as body structures and functioning deficits (active range of movement, strength, sensation, coordination, vision, pain) are identified.
• Tasks and activities people participate in, current ability compared to usual performance, activity limitations, and participation restrictions are reviewed.
• Contextual factors relating to environmental or personal factors are gathered.
• Comprehensive assessment facilitates decision making, treatment planning, selection of treatment, determining the prognosis, and clarifying expectations.
• Assessment varies depending on the condition (e.g., stroke vs. functional neurological disorder), whether it is acute or chronic, and the setting.
• The therapist needs to consider whether improvement is likely, or function is to be maintained or deterioration prevented.

Components of Subjective Assessment

• Subjective assessment, objective assessment, clinical reasoning, treatment plan formulation, implementation, and reassessment of outcomes are important.
• Information gathering from various sources is essential:
  • Medical records.
  • Observation charts.
  • Referrals.
  • Interviews with patients, families, or carers.
  • Subjective outcome measures.
• Objective assessment involves observation, physical examination, and standardized measurement tools.
• The assessment process is iterative and continuous.
• Gather information before meeting the patient to avoid repeating questions.
  • Three identifiers: name, date of birth, and address or medical record number.
  • Presenting complaint and history.
  • Medical imaging or tests.
  • Vital signs or medical observations.
  • Medical precautions or limitations.
  • Past medical history, past surgical history, and medications.
  • Social situation and home environment.
  • Family history, handedness, and driving status.
  • Information from other professions regarding communication, swallowing, cognitive or behavioral aspects, and social circumstances.

Safety Considerations

• Always check case notes for updates and medical stability including nursing observations.
• Note any medical precautions, limitations, or contraindications.

Patient Interview

• Introduce yourself, your role, and gain consent for assessment.
• Check the three identifiers of the patient.
• Consider whether the patient is oriented to time, place, and person.
• Confirm information already gathered or collect it from the patient.
• Confirm past medical history, history of presenting complaint, symptoms, understanding of the condition, reason for referral/admission, and treatments so far.
• Confirm home environment, family history, handedness, and driving.
• Ask about patient's goals, expectations, perceptions, and beliefs.
• Inquire about pain, fatigue, vision, hearing, sensory problems, respiratory issues, mobility, function, falls, continence, vertigo, dizziness, or nausea.

Observation During Subjective Assessment

• Observe the patient’s insight, attitudes, belief, knowledge, and understanding.
• Note any communication or speech issues.
• Observe for cognitive issues, understanding of information and questions, and following commands.
• Note apparent mood, mental state, or behavior.
• Note signs of pain, discomfort, or fatigue.
• Look for spontaneous movements.
• Look for signs of breathing and respiratory status.
• Monitor medical stability and signs of deterioration.

Key Areas of Subjective Assessment

• Three Identifiers:
  • Name, date of birth, medical record number, address.
  • Ensuring correct patient, age, and location for discharge planning.
• Presenting Complaint:
  • Main complaint or problem and understanding of the reason for assessment.
• History of Presenting Complaint:
  • Underlying diagnosis and associated events, date of onset (acute vs. chronic), and any changes so far.
• Imaging Tests and Investigations:
  • Completed tests and results, precautions, instructions, contraindications, or limitations relating to safety.
• Medical Stability:
  • Blood pressure, heart rate, respiratory rate, temperature, ECGs, ABGs, hemoglobin, or blood glucose level.
  • Checking with nursing staff, medical team, or observation charts, or taking observations personally.
  • Monitoring for signs of clinical deterioration.
  • Consider swallowing and oral fluids, medication timing and impact.
• Past Medical History and Past Surgical History:
  • Flagging other comorbidities that might impact on assessment and management.
• Medications:
  • Flagging other medical issues with implications for timing of therapy.
• Social History:
  • Work, hobbies, comparing usual vs. current and recent ability.
• Home Environment:
  • Usual access and requirements, steps or stairs, and supports available.
• Family History:
  • Whether the condition applies to anyone else in the family or a related medical issue.
• Other Details:
  • Handedness, driving status and other professionals involved.

Additional Questions During Subjective Assessment

• Orientation to time, place, and person.
• Person's goals and their expectations.
• Previous physiotherapy or treatments.
• Pain and fatigue.
• Pre-existing deficits regarding vision or any known deficit now.
• Screening of respiratory function.
• Mobility and falls.
• Understanding of their continence.
• Occurrence of any dizziness.

Considerations for Patients with Communication and Cognitive Issues

• Simplify questions and use yes/no questions.
• Discuss communication strategies with a speech therapist.
• Give patients more time to process, think, plan, and respond.
• Use gestures, written word, pictures, or assistive devices.
• Change voice volume or speed of talking.
• Ascertain if an interpreter is required.
• Clarify information with family members or carers.
• Ensure accuracy and reliability of patient information.
• Consider religious or cultural considerations.
• Follow speech therapy recommendations.
• Assess patient's verbal responses.
• Use gestures for assessment or therapy.
• Use demonstration, imitation, writing, or pictures to communicate.
• Ensure patients have hearing aids or glasses.
• Address pain or discomfort first.
• Take into consideration impulsivity.

Managing Drowsy or Minimally Responsive Patients

• State the patient's name and announce who you are and what you are doing.
• Push their shoulder and rub their sternum to see if there is a response.
• Check with nursing staff and medical staff if unsure of their usual status.
• Alert a medical emergency response if it is not the patient's usual status.
• Monitor for signs of deterioration.

Outcome Measures

• Definition: Test or scale that measures accurately a particular attribute of health that is expected to be influenced by an intervention.
• Purposes:
  • Identify a specific problem.
  • Evaluate disease progression.
  • Evaluate the effective intervention.
  • Justify the need for physiotherapy.
  • Motivate patients.
  • Evaluate cost effectiveness.
• Considerations:
  • What construct it is that you want to change or evaluate.
  • The level of the patient's ability.
  • The level of the WHO ICF we're assessing or monitoring.
  • The reliability, validity and sensitivity of the tool.
  • The minimal clinical important difference.
  • The minimal detectable change considering things like floor and ceiling effects.
  • Also the practicalities of completing the outcome measure with this particular patient.
• Subjective Outcome Measures in Neurological Physiotherapy:
  • Stroke Impact Scale.
  • Activity Specific Balance Confidence Scale.
  • French A Activities Index.
  • SF 36 for quality of life.
  • River Mead Post Concussion Symptom Questionnaire.
  • Borg Rating of Perceived Exertion.

Goal Setting in Neuro Rehabilitation

• Definition: A desired future state to be achieved by a person with a disability as a result of rehabilitation activities.
• Rehabilitation goals:
  • Actively selected.
  • Intentionally created.
  • Have purpose.
  • Shared.
• Goal setting/planning: Establishment or negotiation of rehab goals.
• Goal setting depends on factors:
  • Organizational constraints.
  • Acute/chronic, mild/severe, progressive/improving disease.
  • Patient-centered wishes, expectations, priorities, and values (particularly at home).
• Importance of connection between patient goals and therapist/service oriented goals.
• SMART goals should be used, but also instill hope.
• Goal setting may improve patient outcomes:
  • Motivation.
  • Teamwork.
  • Patient-professional relationship.
  • Self-regulation.
  • Attachment to consequences of disability.
  • Specificity of training.
• Enhance patient self-determination.
• Degree of goal attainment is a useful measure of health outcomes.
• Goal setting can be a contractual/legislative requirement.
• Collaborative goal setting: Patient, family, significant others, and therapists.

Collaborative Goal Setting

• Involves the patient, family, significant others, and therapists.
• Identifies the client as an active co-planner in the rehabilitation process.
• Increases client level of satisfaction when they are involved.
• Formal goal setting processes can promote collaboration.
• Recommendations in the Australian Stroke Foundation guidelines:
  • Person with stroke/families should be involved.
  • Goals should be client-centered and documented.
  • Goals should be well-defined, specific, challenging, and reviewed/updated.
• Applies to all areas of neurological physiotherapy and all neurological conditions.
• Be aware of nuances with communication, cognition, insight, and the challenges.
• Importance of setting the bar high enough but also achievable and realistic.
• The goal needs to be difficult or challenging enough to get the optimal level of task performance.
• Importance of the goal to the person: How meaningful is this goal to them?
• Consider if the person is ready to make changes to their life and complete the tasks that are required.
• People need to have a level of belief or self efficacy.
• Self belief or self efficacy can be enhanced by preparing and training, active role modeling and persuasive conversation from others.

Documentation

• Documentation is usually completed under key headings.
• Practical Session: Consider the different components of a subjective assessment, what is asked and why, as well as having a go at practicing relating a subjective assessment using some case scenarios relevant to neurological physiotherapy.
• Upload a template of how you would structure your subjective assessment and discuss this between yourselves as a peer led learning opportunity.