Assessing Motor Function Part 2 PDF

Assessing Abilities and Capacities: Motor Function Part 2 OT 211 Dr. Qussai Obiedat  ASSESSMENT OF GAIT Walking, a critical component of daily task engagement, is a reasonable expectation for many individuals with CNS dysfunction. OTs work with pa...

Assessing Abilities and Capacities: Motor Function Part 2 OT 211 Dr. Qussai Obiedat  ASSESSMENT OF GAIT Walking, a critical component of daily task engagement, is a reasonable expectation for many individuals with CNS dysfunction. OTs work with patients who wish to improve their performance in several contexts. Such as kitchen, bathroom, leisure, or work In each of these contexts, the OT must help patients reach their optimal walking potential. PTs determine initial walking goals based on observation and comparison of each patient’s performance against the critical kinematic features of walking. 2  THE GAIT CYCLE The gait cycle for each leg is divided into a stance phase and a swing phase. Stance Phase: Weight-load acceptance: from heel contact to foot flat on ground Midstance: from foot flat on ground to heel off of ground Push-off: weight moving forward onto toes and foot preparing to leave ground Swing Phase: Liftoff (early swing): leg swings forward with foot clearing the ground Reach (late swing): leg decelerates and prepares for heel contact Basic knowledge about the motor requirements during each phase of the gait cycle guides therapists in their interventions for patients with CNS dysfunction. 3  REACH AND MANIPULATION The arm and hand function as a single unit in reach and manipulation, with the hand beginning to open for grasp at the start of a reaching action. In many activities, the upper body, or even the entire body, is an integral component of this single coordinated unit. Clearly, reach and grasp are not exclusively upper limb activities. All reaching actions from sitting or standing are preceded and accompanied by postural adjustments. When objects are beyond the arm’s reach, shifts in total body alignment contribute to functional performance. 4  REACH AND MANIPULATION Clinical assessment of reach and manipulation is achieved through detailed observation of each patient’s attempts to perform selected functional tasks. Therapists use their knowledge about the kinetics and kinematics of upper limb function to develop hypotheses as to which deficits may be serving as control parameters in limiting the versatility or efficiency of motor strategies. Most motor dysfunction can be attributed to specific: Muscle weakness Muscle stiffness and length changes Adaptive strategies developed to compensate for these impairments Shoulder pain may also be a significant control parameter to efficient reach. Therapists test their hypotheses through direct assessment of muscle strength and length and through patients’ responses to interventions designed to modify adaptive strategies. 5  DEXTERITY MEASUREMENT Dexterity requires hand ROM, hand strength, and sensation in order to manipulate objects. Individuals who lack full hand motion and function often complain about their inability to manipulate objects for writing, fastening clothing, or turning a key in a car or door. No one evaluation covers all features of hand function. Standard terminology regarding hand function is lacking, and there is limited evidence that the assessment of hand function indicates the patient’s actual performance in ADL. Thus, hand function tests should not substitute for assessments of ADL or other areas of occupation. Hand function tests (dexterity tests), can be helpful measures of improvement of performance skills. 6  BOX AND BLOCK TEST The Box and Block Test measures gross manual dexterity. It was developed to test people with severe problems affecting coordination. The subject transfers 1-inch blocks from one side of the box to the other. The score is the number of blocks transferred in 1 minute for each hand. 7  PURDUE PEGBOARD TEST The Purdue Pegboard Test of finger dexterity assesses picking up, manipulating, and placing little pegs into holes with speed and accuracy. It tests finger or fine motor dexterity. Four subtests that are performed with the subject seated. Preferred, Nonpreferred, Both hands, and Assembly The subtests for preferred, nonpreferred, and both hands require the patient to place the pins in the holes as quickly as possible, with the score being the number of pins placed in 30 seconds. The subtest for assembly requires the patient to insert a pin and then put a washer, collar, and another washer on the pin, with the score being the number of pieces assembled in 1 minute. The Purdue Pegboard Test manual provides normative data using percentile tables for adults and different categories of jobs and for children 5–15 years of age by age and sex. 8  NINE-HOLE PEG TEST The Nine-Hole Peg Test measures finger dexterity among patients of all ages. Test administration is brief, involving the time it takes to place nine pegs in holes in a 5-inch square board and then remove them. The Purdue Pegboard Test is preferred to the Nine-Hole Peg Test in the measurement of finger dexterity for the following reasons: The Purdue Pegboard Test has good test–retest reliability It is time limited It is for both unilateral and bilateral assessment Its normative data reflect a broader age range 9  TEMPA TEMPA is an acronym from the French for Upper Extremity Performance Test for the Elderly. It consists of nine tasks, five bilateral and four unilateral, reflecting daily activity. Each task is measured by the three subscores of speed, functional rating, and task analysis. The test takes about 15–20 minutes for an unimpaired elderly subject and about 30–40 minutes for an impaired elderly subject. Advantages of the TEMPA are clinical use, especially with hand patients older than 60 years of age; provision of both quantitative and qualitative data; simulation of ADL; test applicability; test availability; and acceptability to patients (Rallon & Chen, 2008). 10  TEMPA The nine tasks are to: 1. Pick up and move a jar 2. Open a jar and take a spoonful of coffee 3. Pour water from a pitcher into a glass 4. Unlock a lock and open a pill container 5. Write on an envelope and affix a postage stamp 6. Put a scarf around one’s neck 7. Shuffle and deal cards 8. Use coins 9. Pick up and move small objects 11  ASSESSMENT OF PRAXIS Apraxia: the inability to implement purposeful movement that cannot be explained by deficits in sensation, movement, or coordination. Types of apraxia: Limb apraxia. OT Constructional apraxia. OT Dressing types of apraxia. OT Verbal apraxia. SLP Buccofacial apraxia. SLP 12  LIMB APRAXIA Limb apraxia is usually associated with left rain damage in right-handed patients and right brain damage in left-handed patients Types of limb apraxia: Ideomotor Ideational Dissociation Conduction Conceptual 13 TYPES OF LIMB APRAXIA 14  ASSESSMENTS OF LIMB APRAXIA Florida Apraxia Screening Test-Revised (FAST-R): Thirty items Gesture to verbal command test: 20 transitive, 10 intransitive pantomime Scored on multiple error types Normal cutoff score is 15 out of 30 correct Assessment of Apraxia: Two subtests: Demonstration of object use (three sets of objects presented under three different conditions) Imitation of gestures (six gestures to be imitated). Each is scored from 0 (movement not recognizable) to 3 (performance is correct and appropriate). Maximum subscore for object use is 54, for imitation of gestures is 36 with a total score of 90. Total score below 86 is considered to identify apraxia. 15  ASSESSMENTS OF LIMB APRAXIA Screening for Apraxia: Five gestures (three transitive, two intransitive) Five dimensions for each task Scored on a 3-point scale Assessment of Disabilities in Stroke Patients with Apraxia: Set of standard activities of daily living (ADL) observations for assessment of disabilities caused by apraxia: personal hygiene, dressing, preparing food, and another of the therapist’s choice. Scoring: Four measures (independence, initiation, execution and control) scored from 0 (no observable problems) to 3 (therapist has to take over). Then they can be added together to get a total score. 16  CONSTRUCTIONAL APRAXIA Constructional apraxia is a specific deficit in spatial-organizational performance Patients with constructional apraxia have difficulty with copying, drawing, and constructing designs in two and three dimensions. Constructional apraxia was found to correlate with deficits of ADL. It can be seen functionally as difficulty with such activities as setting a table, making a sandwich, and making a dress and with any mechanical activity in which parts are to be combined into a whole. 17  CONSTRUCTIONAL APRAXIA Two types of constructional activities used in assessment: Graphic tasks (e.g., copying line drawings and drawing to command) Assembly tasks (e.g., block and stick designs) Both types are included in an evaluation of constructional apraxia. The most common example of a graphic task is copying geometric shapes (from simple to complex) and drawing without a model (e.g., house, clock, or flower). The Lowenstein Occupational Therapy Cognitive Assessment (LOTCA) battery was standardized on brain- injured adults and contains a section on visuomotor organization containing block design, copying, drawing, and pegboard design. The test has another updated version called the Dynamic Lowenstein Occupational Therapy Cognitive Assessment (DLOTCA). 18  DRESSING APRAXIA Dressing apraxia refers to an inability to dress oneself. Usually due to RBD and secondary visuospatial disorganization. Evaluated functionally by watching clients dress themselves. The underlying problem needs to be determined (e.g., visual deficits, unilateral neglect, apraxia, or constructional apraxia) rather than evaluating dressing apraxia per se. 19  MOTOR NEGLECT Motor neglect presents as impaired initiation or execution of movement into contralateral hemispace by either limb. Types of motor neglect: Limb akinesia: Failure to move limb. Hypokinesia: Limb moves but only after a long delay and much encouragement. Hypometria: Movements are of decreased amplitude. Impersistence: Inability to maintain a movement or posture. Motor perseveration: Inability to disengage from a motor activity. Motor extinction: Delay or failure to move the contralesional limb when also required to move the ipsilateral limb. 20  MOTOR NEGLECT It is often difficult to differentiate between sensory and motor neglect because tests of motor neglect entail some form of sensory input. Clients fail to respond to a stimulus on the involved side because they do not see it or because they cannot initiate movement toward it. If motor neglect is suspected, one way to distinguish between the two entails contrasting a task that requires a hand response with one that has minimal motor response (e.g., naming letters on the involved side as opposed to pointing to the same letters). In other words, the stimulus (letters on the involved side) stays the same, and the motor response is varied. There are no standardized tests of motor neglect Observations of clients and how they use the affected extremity can provide insight into the presence of motor neglect. 21 Thank You! 22