Neurological Assessment 2024 PDF

PT-PNS 301- LH Neurological Assessment Dr. Sukumar Shanmugam Dr. Meruna Bose December 9, 2024 www.gmu.ac.ae COLLEGE OF ALLIED HEALTH SEIENCES Learning Objectives At the end of the Lectur...

PT-PNS 301- LH Neurological Assessment Dr. Sukumar Shanmugam Dr. Meruna Bose December 9, 2024 www.gmu.ac.ae COLLEGE OF ALLIED HEALTH SEIENCES Learning Objectives At the end of the Lecture and Non Lecture hours a student will be able to : Use comprehensive assessment of neurological disorders using standard and evidence-based assessment tools. Neurological Assessment Subjective Assessment Name : Age : Sex Occupation : Address : Date & Time of Evaluation : Chief Complaints Major Problems/Discomforts patient feels due to present illness Associated problems History Present medical history Past medical history Family history Socio economic status Personal history Psychological status General Observation – Head to Toe Drains ,tubes fixation External Aids and Appliances Swelling, edema Built Posture Attitude of Limbs in Static & Dynamic Postures Gait Involuntary movements, Assesory and trick movements Any Observable Deformities On observation Pressure Sore Clubbing Cyanosis Colour of Skin Nail Appearance Autonomic Changes in skin- hair loss, sweat, texture On Palpation Tone Tenderness Warmth Swelling & edema On Examination Vital Signs Temperature Pulse rate Heart Rate Respiratory rate Blood pressure On Neurological Examination Levels of Consciousness ( by Glasgow Coma Scale) Higher functions Mental status Orientation Memory Attention Special senses Speech Hearing Vision Touch Taste Cranial Nerve Assessment 1. Olfactory 2. Optic 3. Oculomotor 4. Trochlear 5. Trigeminal 6. Abducent 7. Facial 8. Vestibulocochlear 9. Glossopharyngeal 10. Vagus 11. Accessory 12. Hypoglossal Cranial Nerve I Cranial Nerve I - Olfactory Olfactory (sensory) Smell May be tested in patients after head injury or pituitary surgery Use coffee/lemon for testing Cranial Nerve II Cranial Nerve II- Optic Optic (sensory) Vision Visual acuity (Snellen Eye chart) Visual fields (Confrontation Test) Fundoscopic examination, papilledema, disk atrophy, retinal haemorrhages, corneal scarring, cataracts) Snellen Eye chart Cranial Nerves III,IV,VI Cranial Nerves III Oculomotor, IV Trochlear & VI Abducens Motor nerves that are tested together Eye movement Eyelid opening Pupil reaction  Target motion Cranial Nerve III, IV, VI Movement direction Prime mover Moves eyes up and Superior (elevates); Superior rectus toward nose medial (adducts) Moves eyes down Inferior (depresses); Inferior rectus The extra ocular movements through the six cardinal and toward nose; medial (adducts) fields of gaze. Moves eyes away Lateral (abducts) Lateral rectus from nose This examination allows assessment of each muscle in Moves eyes toward its primary field of action Medial (adducts) Medial rectus nose Moves eyes up and Superior (elevates); Inferior oblique away from nose lateral (abducts) Moves eyes down Inferior (depress); Superior oblique and away from nose lateral (abducts) Levator https://openstax.org/books/anatomy-and-p Opens eyes Superior (elevates) palpabrae hysiology-2e/pages/11-3-axial-muscles-of-t superioris he-head-neck-and-back#tbl-ch11_03 Compression along Closes eyelids Orbicularis oculi superior–inferior axis https://geekymedics.com/extraocular-muscles/#:~:text=The%20extraocular%20muscles%20(EOM) %20are,the%20movement%20of%20the%20iris. Cranial Nerve V Cranial Nerve V -Trigeminal nerve (mixed) Sensory component Test with light touch, pinprick, and temperature Corneal reflex Direct and consensual eye blink Motor component Muscles of mastication (Temporalis, Masseter) tested by having patient clench teeth Cranial Nerve VII Cranial Nerve VII -Facial (mixed) Sensory component Taste anterior 2/3 of tongue : Use salty , sweet, sour solutions to test the taste sensation Motor component Innervation of the face – Grade five standard expressions: 1. Eyebrow raise 2. Eye closure 3. Open mouth smile 4. Lip pucker 5. Snarl / show teeth Refer : Symmetry of Voluntary Movement-Sunnybrook Facial Grading Scale (FGS)  Cranial Nerve VIII - Vestibulocochlear (sensory) Cochlear component (hearing) Rubbing fingers or whisper into ear Weber Test & Rinne Test Vestibular component (balance) Nystagmus and vertigo Whisper Test Performing the Whisper Test -Check the patients response to your whispered voice one ear at a time Mask the hearing in the other ear by having the patient place a finger in the ear canal and gently move it rapidly up-and-down. Stand to the side of the patient at a consistent distance best for you, about 1 to 2 feet away from the ear being tested, and out of the patients line of vision Whisper a combination of three letters and numbers very softly and ask the patient to repeat the words heard Normal findings. The patient should hear softly whispered words in each ear at that distance of about 1 to 2 feet, responding correctly more than 50% of the time Weber and Rinne test Used to compare hearing by bone conduction with that of air conduction Hold the base of the tuning fork with one hand without touching the tines, and stroke or tap the tines gently. With your other hand, setting the tuning fork in vibration Performing Weber test Perform the Weber test by placing the base of the vibrating tuning fork on the midline vertex of the patients head Ask the patient if the sound is heard equally in both ears or is better in one ear Normal finding lateralization of sound. Is their lateralization of sound? To test the reliability of the patient’s response, repeat the procedure while occluding one ear, asking the patient in which hear the sound is best heard. It should be heard best in the occluded ear. Performing Rinne Test Step 1 The Rinne test is performed by placing the base of the vibrating tuning fork against the patient’s mastoid bone; begin counting or timing the interval with your watch. Ask the patient to tell you when the sound is no longer heard, noting the number of seconds Step 2 Quickly position the still vibrating tines 1cm to 2 cm from the auditory canal, and again ask the patient to tell you when the sound is no longer heard. Continue counting or timing the interval to determine the length of time, the sound is heard by air conduction Cranial Nerve IX & X ( Mixed) Cranial Nerve IX - Glossopharyngeal and X- Vagus The entire oral cavity is inspected CN IX and X are tested by Having the patient swallow Observing movement of the palate during phonation. Say “Ahh” A comment about quality of the patient's voice should be noted. Testing the gag reflex- CN IX and X, The sense of taste on the posterior third of the tongue, not tested usually - CN IX Bradycardia, tachycardia- CN X  Cranial Nerve XI Cranial Nerve XI Accessory Spinal accessory (motor) to Sternocleidomastoid & Trapezius Shoulder shrug Rotate head against resistance Cranial Nerve XII Hypoglossal Motor nerve Observe tongue at rest Tongue protrusion Lateral pressure to each cheek Sensory Assessment Superficial Pain Combined (Cortical) Light Touch Tactile Localization Pressure Two Point Discrimination Temperature Barognosis Stereognosis Deep Graphesthesia Movement Sense/ Kinesthetic Sense Position Sense Vibration etc Key to Grading for Sensory Assessment 0 = Absent, no response 1 = Decreased, delayed response 2 = Increased, exaggerated response 3 = Inconsistent response 4 = Intact, normal response NT = Unable to test Pain Type of Pain (Mc Gill Pain Questionnaire) Site of Pain Pain Grading (VAS, NRS) Pain Aggravating / reliving factors Time of Pain ( 24 hours pattern) Duration of pain Numerical rating scale(NRS) Visual analog scale(VAS)  Motor Assessment: Muscle tone (Hypo / Hyper) Modified Ashworth grading(if Hyper-Spastic) ; Check type of hypertonicity on slow passive movement in case of rigidity Voluntary Control Assessment (if spastic) Muscle power Assessment (if Hypo) Reflexes  Manual Muscle Testing if hypotonic- MRC Grading 0 – Absent or no any contractions 1 – Flicker of contraction 2 – Full range of Movement in Gravity Eliminated Position 3 – Full range of Movement in Against Gravity 4 – Full range of Movement in Against gravity with Minimal Resistance 5 – Full range of Movement in Against gravity with Maximal Resistance Spasticity Grading: Modified Ashworth Scale 0 - No Increase in the Muscle Tone 1- Slight Increase in the Muscle Tone manifested by Catch and Release at the start or at the end of ROM 1+ - Slight Increase in the Muscle Tone manifested by Catch and Resistance more than half of the ROM. 2 - Marked Increase in the Muscle Tone Through out the ROM 3 - Considerable Increase the Muscle Tone Passive Movement Difficult to perform. 4- Affected Part Rigid in either flexion or extension BRUNNSTROM’S STAGES OF RECOVERY https://www.homage.com.my/health/brunnstrom-stages-stroke-recovery/ Basic limb synergies Mass movement patterns in response to stimulus or voluntary effort or both – Gross flexor movement (flexor synergy) – Gross extensor movement (extensor synergy) – Combination of the strongest components of the synergies (mixed synergy) Appear during the early spastic period of recovery  Muscles are neurophysiologically linked and cannot act alone or perform all of their functions If one muscle in the synergy is activated, each muscle in the synergy responds partially or completely Patient cannot perform isolated movements when bound by these synergies  Abnormal Synergy Patterns a : Dominant component of synergy Flexor Synergy of Upper limb Voluntary Control Assessment: 0 No voluntary contraction 1 Initiation of contraction in synergy 2 Voluntary movement possible for half ROM in synergic pattern 3 Voluntary movement possible for full ROM in synergic pattern 4 Voluntary movement possible for half ROM in synergic pattern and half in out of synergy 5 Voluntary movement possible for full ROM in out of synergy, but with resistance movement shifts towards synergy pattern 6 Normal movements Myotomes  Reflex Assessment Superficial Reflex Abdominal reflex : Upper abdominal reflexes -T9-T11. Lower abdominal reflexes -T11-T12. Cremasteric reflex : Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal - L1-L2 Bulbocavernous / Anal : anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley - S2-S4 Plantar response : Babinski sign can indicate upper motor neuron lesion constituting damage to the corticospinal tract. Corneal reflex (blink reflex) : Involuntary blinking in response to corneal stimulation – Afferent V Cranial nerve; Efferent VII cranial nerve Myotatic (Deep tendon reflexes ) Jaw ( Trigeminal) Biceps C5 C6 Brachioradialis C5 C6 Triceps C7 C8 Hamstring L5 S1 S2 Patella L2 L3 L4 Ankle S1 S2 Deep Tendon Reflexes Grading 0 = no response 1+ = present but depressed, low normal 2+ = Average, normal 3+ = Increased, brisker than average; possibly but not necessarily normal 4+ = very brisk, hyperactive with clonus; abnormal Spinal/Primitive Reflex Flexor Withdrawal Crossed Extension Moro /Startle Reflex Grasp Reflex Plantar grasp Sucking Rooting Brain Stem Reflexes /Tonic Reflex STNR (symmetrical tonic neck reflex) ATNR (Asymmetrical tonic neck reflex) STLR (Symmetrical tonic labyrinthine reflex) Positive Supporting Associated Reaction Mid Brain & Cortical Reflex Neck Righting Reflex Body Righting Reflex (On Body) Labrynthine Righting Reflex Optical Righting reflex Body Righting Reflex (On Head) Protective Extension Equilibrium Reactions  Posture Assessment Using Plumb line or Posturography Assess for Trunk deformities- scoliosis, kyphosis,lordosis etc. Assess for deformities /abnormalities in limbs- flexion & extensor deformities of upper limb &lower limb using goniometer or inch tape. https://www.youtube.com/watch?v=SAPUEYMBD6o  STATIC SITTING BALANCE GRADING Grade Description NORMAL Able to maintain balance against maximal resistance GOOD Able to maintain balance against moderate resistance G-/ F+ Accepts minimal resistance FAIR Able to sit unsupported without balance loss and without UE support POOR+ Able to maintain with minimal assistance from individual or chair POOR Unable to maintain balance – requires mod/max support from individual or chair  STATIC STANDING BALANCE GRADING Grade Description NORMAL Able to maintain standing balance against maximal resistance GOOD Able to maintain standing balance against moderate resistance G-/ F+ Able to maintain standing balance against minimal resistance FAIR Able to stand unsupported without UE support and without LOB for 1- 2 min FAIR - Requires Min A or UE support in order to stand without LOB POOR+ Requires Mod A and UE support to maintain standing without balance loss POOR Requires Max A and UE support to maintain standing balance without  DYNAMIC SITTING BALANCE GRADING Grade Description NORMAL Able to sit unsupported & weight shift across midline maximally GOOD Able to sit unsupported & weight shift across midline moderately G-/ F+ Able to sit unsupported and weight shift across midline minimally FAIR Minimal weight shifting ipsilateral/front, difficulty crossing midline FAIR- Reach to ipsilateral side and unable to weight shift POOR+ Able to sit unsupported with min A and reach to ipsilateral side, unable to weight shift POOR Able to sit unsupported with Mod A and reach ipsilateral/front – can’t cross midline  DYNAMIC STANDING BALANCE GRADING Grade Description NORMAL Stand independently unsupported, able to weight shift and cross midline maximally GOOD Stand independently unsupported, able to weight shift and cross midline moderately G-/ F+ Stand independently unsupported, able to weight shift across midline minimally FAIR Stand independently unsupported, weight shift, and reach ipsilaterally, LOB when crossing midline FAIR- Reach to ipsilateral side and unable to weight shift Balance Assessment Examples of objective tools for balance assessment Using Berg Balance Scale Functional Reach Test (FRT) https://www.youtube.com/watch?v=NXZ0EmP7m9A Timed Get Up and Go (TUG) test https://www.youtube.com/watch?v=tNay64Mab78 Coordination tests Equilibrium tests E.g. : Romberg's test Non equilibrium tests. E.g. : Finger to finger Finger to nose Heel to shin  Gait Examination Qualitative test- Assess type of gait pattern- PATHOLOGICAL GAIT for various neurological conditions Observational Gait Analysis (OGA) Quantitative tests Step length Stride length (On average, a man's walking stride length is 2.5 feet, or 30 inches, according to Arizona State University Extension. A woman's average stride length is 2.2 feet, or 26.4 inches) Cadence (Average is 100 - 115 steps/min.) Base width (average is 0.17 m between heel centres) Bowel and Bladder Assessment Assess for UMN type- automatic- Spastic Neurogenic bladder due to complete transection of the spinal cord above the sacral segments, marked by complete loss of micturition reflexes and bladder sensation, violent involuntary voiding, and an abnormal amount of residual urine. LMN type – atonic An atonic bladder is one that doesn’t contract or empty properly, possibly due to nerve damage. The bladder fills until it overflows with excess urine that dribbles out.  BASIC ADLs Walking (ambulating) ability to get around the home or outside. Feeding, ability to get food from a plate into one’s mouth. Dressing and grooming, ability to select clothes, putting them on, and adequately managing one’s personal appearance. Toileting, ability to get to and from the toilet, using it appropriately, and cleaning oneself. Bathing, ability to wash one’s face and body in the bath or shower. Transferring, ability to move from one body position to another. This includes being able to move from a bed to a chair, or into a wheelchair. This can also include the ability to stand up from a bed or chair in order to grasp a walker or other assistive device.  INSTRUMENTAL ADLs Require more complex thinking skills, including organizational skills. Managing finances, such as paying bills and managing financial assets. Managing transportation, either via driving or by organizing other means of transport. Shopping and meal preparation. i.e. everything required to get a meal on the table. It also covers shopping for clothing and other items required for daily life. Housecleaning and home maintenance. Cleaning kitchens after eating, maintaining living areas reasonably clean and tidy, and keeping up with home maintenance.  FUNCTIONAL MEASURES 1. Katz Index of ADLs 2. Barthel ADL Index 3. Functional Independence Measure(FIM) 4. Lawton-Brody IADL Scale Environmental Assessment Interview the patient or caregivers regarding surroundings at home and workplace to check accessibility related issues after being diagnosed with any neurological condition. Reference Physical Rehabilitation, 6th edition by Susan B. O'Sullivan et al