Patient Observation techniques

• Observations made depending on the position of the patient on a bed, sitting, standing, or during ambulation.
• ROM/MMT is used to test the functional joint range of motion and functional muscle strength.
• MAS (Modified Ashworth Scale) measures tone of the muscles and their resistance to stretch.
• Grip/Pinch Testing, Deep Tendon Reflex Testing, Assessment of Primitive Reflexes, and Screening for Balance are other forms of observation.

Observations

• Bed/Supine position may cause ataxia, tremor, or hyperactivity; Body is supported.
• Sitting may cause deep reflex of the patellar tendon, tremor, inability to coordinate opposition, and finger dysmetria.
• Dysdiadokinesia is the inability to perform rapid movements.
• Nystagmus is rapid eye movement.
• Standing may cause instability, ataxia, and uncontrolled trunk (needs support); Patients get more unstable when standing due to a decrease in points of contact.
• Ambulation can cause ataxic gait pattern with a scissoring gait, balance deficit, and hypertonicity.

Modified Ashworth Scale (MAS)

• Put patient in supine position.
• If testing a muscle that primarily flexes a joint, place the joint into a maximally flexed position, then move to a position of maximal extension over one second.
• If testing a muscle that primarily extends a joint, place the joint in a maximally extended position, and move it into a position of maximal flexion over one second.
• The patient should relax and try not to resist the movement.

MAS Scoring

• 0: No resistance, no increase in muscle tone - "smooth movement".
• 1: Slight increase in tone, manifested by a catch and release or by slight resistance towards the end of the ROM when moved into flexion or extension - "jerking motion".
• 2: Slight increase in tone, due to a catch or slight resistance throughout less than ½ the ROM - tone was tight throughout the first or second half of motion.
• 3: Increased muscle tone throughout the majority of the ROM, but limbs are still easily moved – tight or stiff for more than ½ of the motion.
• 4: Decent increase in tone, PROM – extreme stiffness.
• 5: Limbs are rigid in either flexion or extension with no movement.

Primitive Reflexes

• "Primitive Reflex" is a reflex a person is born with that develops with integration in early childhood.
• Spinal Level Reflexes deals with basic mobility and integrates at 2 months.
• Brainstem Reflexes are a static reflex affecting postural tone due to a change in head position/body positioning; integrated in the first 6 months.
• Mid-brain Reactions facilitate development of the maturation milestones and develops in childhood through the lifespan.
• Basal Ganglia Reflexes also known as “Equilibrium Reactions” enable a person to adapt to changes in the body’s center of gravity (vestibular, visual, and tactile integration), begins at 6 months and persists (Fall Prevention)
• Be sure to guard the patient when testing these reflexes

Spinal Level Reflexes

• Placing Reaction of Upper Limb: Pulling hand back and or flexion of arm when Sitting or in supine (Take the dorsum of the pt hand and lightly brush = putting on shirt, washing hands, social interactions
• Moro Reflex or "startle reflex" is when a Baby: drop neck or Adult: Loud noise. Drop or smack an object nearby (Individuals will jump and limbs will extend out). No response during flight or fight, being in school when a bell rings, driving when someone beeps their horn.
• Grasp: apply pressure to the ulnar surface of the hand; the person will grab your hand - writing, dressing, eating, or cooking
• Flexor Withdrawal: Knee will go to chest immediately when applying pressure to, or brush bottom of foot in a supine position or sitting - dressing, walking and stairs.
• Crossed Extension: Bringing one leg up in supine positions while on leg is extended with the other leg flexed and the other leg should not move if so - sleeping positions, stairs, and walking

Brainstem Reflexes

• Asymmetrical Tonic Neck Reflex "football pose:" patient is in supine only one arm extends to one side (extension of UE when looking left or right - when looking to right, right arm will extend; this can cause no neck flexion, school-based activities, and issues with sports.
• Symmetrical Tonic Neck Reflex: Patient is in sitting position with flexion UE, extending LE (As UE flexes the LE will extend an vice versa – downward dog and seated cobra yoga position causing with, eating, dressing and excising
• Tonic Labyrinthine: Patient is in supine position moving head forward and back (When head falls backwards back will arch extending both arms and legs straight out & when head comes forward back will curve bringing both arms and legs in fetal position) - sleeping, exercise, dressing
• Supporting Reactions: patient is in supine position or sitting & make firm contact with the ball of the foot (the foot should extend and begin to bear weight) - walking, standing being up stairs
• Associated Reactions: patient stays in sitting position while testing 1 arm (Other arm will help compensate for the tested arm) - brushing teeth, writing, brushing hair

Mid-brain Reactions

• Righting Reactions: Baby - move baby side to side to test balance. Adult - passively move head side to side to test balance. The body will follow the direction the head is turning - bathing, driving, and balance.

Basal Ganglia Reflexes

• Protective Extension when “putting on gait belt” standing with one hand on shoulder one of affected side, arms and extend as protective measures with patients when pushing on to shoulder. - bathing, sports, and dressing

Cerebellar Disorders

• Ataxia: Incoordination of voluntary movement.
• Dysarthria: Difficulty with speech articulation.
• Nystagmus: Rapid, repetitive, involuntary movement of the eyes.
• Hypotonia: Looseness and floppiness of trunk and extremities – “floppy baby.”
• Dysmetria: Disturbance in the ability to grade muscle tension to move specific distances accurately – movements will either over or undershoot the intended target.
• Dysdiadochokinesia: Incoordination of muscular contractions during rapid alternating and repetitive movements.
• Intention Tremor: Tremors that occur during the execution of a voluntary movement – tremor only occurs when moving.
• Titubation: Rapid rhythmic tremor in the trunk, or head when sitting or standing.

Functional Screening Procedures

• Gait-tandem walking: standing, have one hand in front, other hand in back due to poor trunk control - pt may fall forward or backwards; look for coordination of movement or trouble with balance walking heel & toe, which appears as wobbly/shaky movement with wide stepping
• Finger to Nose: Patient stands and brings stands finger to your finger (stand in front of pt) look for shaky/jerkish movement to nose.
• Heel to shin: Have patient to sit and bing heel to their shin with their other leg; look for uncoordinated movement when bringing heel to shin (shaky/jerkish movements) - pt tend to compensate when they stumble
• Alternating quickly arm motions: Have patient sit down and alternate at increasing speed; cerebral disease can cause patient with slow movement in arm.
• Thigh slapping: Patient sits down alternately palms up and slaps, gradually increasing speed - Look for the ability to complete the tasks.
• Toe tapping: patient sit, have pt tap toes on a floor, continue and then alternate a faster time- look for ability to complete tasks
• Finger to nose touching finger: Patient sat and bring finger their nose- look for their shoot of targeted finger
• Lateral & Vertical gaze: Patient sits and look at end range & shake in eyes as move to left and right Hypotonia: Patient sits position looking to hold themselves

Rating Scale

• 0: Patient is unable to accomplish task or assessment.
• 1: Severe difficulty is noted, movements are arrhythmic; unstable and uncoordinated.
• 2: Moderate level of difficulty is noted, movements are arrhythmic and rushed.
• 3: Movement is accomplished with only slight difficulty.
• 4: Movement is completed normally without difficulty or any atypical movements.

Muscle Stretch Reflex (MSR)

• Biceps Reflex: Place thumb over the biceps tendon, then strike the thumb with a quick sharp blow using the reflex hammer – only slight movement will occur due to position of arm and gravity.
• Triceps Reflex: Place pt arm in abduction, flexed making a 90° angle, palpate for tendon above olecranon and hit tendon with reflex hammer.
• Brachioradialis Reflex: Patient arm at their side resting on their lap or supported by therapist, find radial syloid and hit directly above it with reflex hammer.

MSR Grading

• 0 = no response
• 1+ = limited or small response
• 2+ = normal response
• 3+ = exaggerated response
• 4+ = sustained response – “clonus” abnormal, involuntary muscle contraction

Basal Ganglia Functional Screening

• Tremors includes involuntary movements in an extremity at rest (Functional Screening observe, make a sandwich, pour a glass water, then fold it place in envelop)
• Rigidity is for hypertonicity – increased resistance to passive movement of a joint In all four plains.
• Akinesia is the inability to initiate voluntary movement, in which no movements occurs.
• Bradykinesia is the slowed decreased of movement (poverty to movement to all the tasks); ask can they abrupt change moments even when walking straight up 1st as the change comes in change (functional series of facial expressions & demonstrate pt going through comb their hair).

Functional Assessments

• Chorea is a sudden rapid involving face and extremerizes = “dancing disability” dance like move all over, shoulder shrugs, hip movements /leg action and facial etc.
• Athetosis includes slow flailing, twisting wormlike moment, spasticity/hypotonicity and damage from caudate.
• Dystonia includes movement disorder of muscle tone with the neck posture/ proximities with sustained movement or contractions- ex, “kiccking necks to sides”
• TICs repetitive, brief movement involving eyes, head and shoulder.
• Dyskinesia includes poor movement