Neurological Examination-2 PDF

NEUROLOGICAL REHABILITATION ASSESSMENT METHODS Asst.Prof.Güzin Kaya Aytutuldu Biruni University  PYRAMIDAL SYSTEM SİSTEM  PİRAMİDAL SİSTEM  İstemli hareketlerin kararlaştırıldığı ve bunlarla ilgili ilk uyarıların oluşturulduğu beyin bölgesi, beyin kabuğunun (beyin korteksi) “Girus...

NEUROLOGICAL REHABILITATION ASSESSMENT METHODS Asst.Prof.Güzin Kaya Aytutuldu Biruni University  PYRAMIDAL SYSTEM SİSTEM  PİRAMİDAL SİSTEM  İstemli hareketlerin kararlaştırıldığı ve bunlarla ilgili ilk uyarıların oluşturulduğu beyin bölgesi, beyin kabuğunun (beyin korteksi) “Girus presentralis” denilen bölgesidir.  Girus presentralis, her iki beyin yarıküresinin frontal loplarının en arka bölümünü oluşturur. CEREBELLUM  Neurological rehabilitation program should be initiated as early as possible after the diagnosis of the disease or after the patient has overcome a life- threatening condition.  The characteristics of the assessment conducted by the physiotherapist to gather information about the patient's functional level may vary depending on the diagnosis, patient's age, and perception status, but they fundamentally resemble each other.  The aim of neurological rehabilitation program is to enable the individual to reach the most active state possible and assist them in achieving functional independence. Therefore, it is necessary to prevent, minimize, and if possible, eliminate the problems brought by the disease or those that may arise later. PHYSICAL THERAPY EVALUATION  1- Story  2- Observation: Skin, Edema, Speech, Perception, Pain, Loss of consciousness  3- Muscle Strength: Manual Muscle Testing (MMT), Dynamometer, Myometer  4- Muscle Tone: Flaccidity, Spasticity, Rigidity  5- Sensory Assessment: Deep and Superficial Sensation  In the evaluation of muscle strength, the classic manual muscle testing (0-5 scale) is commonly used worldwide.  In cases where more precise quantitative measurement is required, dynamometric and myometric measurements are also performed. DYNAMOMETER MYOMETER  6- Reflexes: Deep tendon reflexes, superficial reflexes, pathological reflexes  7- Joint Range of Motion: Goniometric measurements  8- Joint Stability: Tendons, muscles, and connective tissue  9- Muscle Lengths: Anti-gravity muscles  10- Anthropometric Measurements: Skinfold thickness, muscle mass, body fat percentage, height, and circumference measurements  11- Respiration: Number, shape, depth, respiratory function tests  12- Cardiovascular Structure: Systolic, diastolic blood pressure, heart rate  13- Posture: Assessment from anterior, posterior, and lateral angles  14- Deformities: Scoliosis, kyphosis, genu valgum, varum, pes cavus, planus, equinus, etc.  15- Special Assessment Techniques: Brunnstrom, Margaret Jonhstone, Bobath, etc.  16- Sphincter control: Urinary and fecal control  17- Ambulation: Normal, orthosis, wheelchair, cane, crutches, walker, etc.  18- Evaluation from the perspective of Work and Occupation Therapy  19- Evaluation from a Vocational Perspective  20- Evaluation of Activities of Daily Living (ADL)  21- There are specific "gold standard" evaluations for the disease. Neurolog Evaluation - Dominant hand: Identify which hand is being used - Alertness and General appearance - Speech disorder - Neck stiffness and Meningeal signs Necck Stiffness - Kernig- Brundzinski Cranial nerves -I.. Olfactory perception and discrimination -II. Visual acuity and visual field, examination of the fundus (retina and retinal vessels) -III, IV, VI: Eye movements, pupils, nystagmus -During the cranial nerve examination, the tongue muscles and SCM muscles are also evaluated. Motor system: Muscle strength Paresis tests Tonus Tonus increase is controlled. Spasticity Rigidity In some muscle diseases, there is a myotonic phenomenon: When the patient is asked to open and close their palm, they have difficulty opening their fists due to impaired muscle relaxation. SPASTICITY EVALUATION MODIFIED ASHWORTH SCALE 0 Normal tone. There is no increase in muscle tone. 1 Slight increase in tone. When the affected part is moved in flexion and extension, minimal resistance or a sensation of catching and releasing can be felt at the end of joint range of motion (ROM). 1+ Slight increase in muscle tone. Tugging sensation during movement, resistance felt in less than half of the ROM. 2 More pronounced increase in tone. Felt in most of the ROM, but the affected part can be easily moved. 3 Marked increase in tone. Passive movement is difficult throughout the ROM. 4 Severe increase in tone. The affected part is rigid and stiff in flexion and extension. REFLEX EXAMINATION 0 = Lost or not taken ± = Decreased + = Normal ++ = Active +++ = Increased ++++ = Polycythemic (Response with several movements in one stroke) Muscular atrophy: It is asked when it started and whether it progresses or not. Its localization, whether it is symmetric - asymmetric, proximal - distal, is determined. - Pseudohypertrophy Developmental asymmetry Examination of involuntary movements: -The examination includes the location, shape, duration, amplitude, and whether the movements displace the extremities. Tremor: Evaluate static, intention, and postural tremors. -Distinguish them from essential tremor. Investigate fasciculations (rapid twitching under the skin). OBJECTIVE SENSORY EXAMINATION: - Superficial (Exteroceptive) - Deep (Proprioceptive) - Cortical senses I Superficial Sensation: A- Touch sensation: Using cotton, determine the hypoesthetic area with the patient's eyes closed (If sensory impairment is on one side, perform symmetric evaluation.) B- Pain: Done with a needle. C- Temperature: With eyes closed, use two equal test tubes, one with hot water and one with cold water. II_Proprioceptive Sensation (Kinesthetic Sensation): Also known as conscious sensation. A- Position sensation: The patient's eyes are closed, and one of the limbs is placed in a specific position, while the patient is asked to match the opposite limb in a similar position. B- Passive movement sensation: Eyes are closed. One of the patient's fingers or toes is held from both sides and moved up and down. During this movement, the patient is asked to indicate the direction.. ROMBERG TEST: Romberg test is used to detect proprioceptive impairment. When the patient closes their eyes and stands with their feet together, their balance is disrupted, they start swaying in place, and may even fall to the ground. Romberg test is commonly observed in conditions such as Tabes Dorsalis, subacute combined degeneration of the Spinal Cord, and sensory neuropathies. D- Deep pain: Investigate whether there is pain by squeezing the Achilles tendon or applying strong pressure to the muscles. III. Cortical sensation: If the patient's superficial and deep sensation is good, A- Stereognosis: Identifying an object given to the hand with closed eyes. B- Two-point discrimination: The ability to perceive the ends of a blunt pair of points simultaneously as two separate points on the skin. Eyes should be closed. Normally, two points spaced 5 mm apart can be perceived on the fingertips, while on the back of the foot, this distance can increase to 5 cm. C- Graphesthesia: Recognizing a letter or number written on the skin with a blunt object with closed eyes (most commonly using the palms). D- Tactile localization: Investigating the ability to localize different points on the body by touching them with closed eyes. COORDINATION EXAMINATION: MEASURED MOVEMENT TESTS: Finger-nose test Knee-heel test 2. CONSECUTIVE MOVEMENT TEST: Perform rapid consecutive movements with the patient. A- Flex the patient's arms at the elbows, while the forearms are in a vertical position, and perform fast pronation- supination movements with both hands. B- Have the patient open one hand with the palm facing upwards. Use the back and palmar surface of the other hand to quickly perform pronation-supination movements against the open palm. C- Place the fingers of one hand side by side. Then, use the palmar surface of these fingers to rapidly and lightly strike the back of the other hand with consecutive small movements. 3. PAST POINTING: Both the patient and the clinician extend their arms forward. The patient brings their index fingers in front of the clinician's index fingers. Then, they lower their arms and return to their initial position, aligning with the clinician's fingers. The test can also be performed with the arms raised. It is done with the eyes closed and open. In cerebellar system disorders, the patient deviates outward towards the side of the arm lesion that is on the same side as the cerebellar hemisphere. In inner ear disorders, the deviation is towards the affected side. However, this movement is observed in both arms simultaneously. RESULT ASSESSMENT SCALES  At all stages of the rehabilitation process, especially in the evaluation phase, objective measurements should be made about the patient's condition and function using appropriate outcome measures. PURPOSES OF USE OF THESE SCALES:  1) In clinical applications, determining the treatment and monitoring the patient  2)Medical applications  3) Implementation of different treatment programs within and between communities  4) Determination of health policies  5) Resource allocation for health services WHAT QUALITY ARE THE SCALES?  In the field of neurological rehabilitation, various outcome evaluation scales are used for clinical monitoring and research purposes. These scales have a wide range in terms of quality.  1) Evaluating the person's functions in terms of ADLs  2) Evaluating some cognitive functions  3) Determining the patient's disability/disability level  4)Assessing quality of life  FUNCTIONAL ASSESSMENT  Functional assessment is a method of identifying a person's abilities and limitations. The main activities that fall within the scope of functional assessment are:  1)Self-care activities  2)Home related activities  3) Community activities  4)Detection  5)Communication  6) Professional activities PURPOSES OF USE OF FA SCALES  1)To make objective and cognitive measurement of the patient's functions.  2) To monitor functional development.  3)To guide the determination of therapeutic goals and prognosis  4)Determining treatment effectiveness A scale to be used for these purposes must have certain psychometric properties in order to provide accurate and objective measurement. These are: 1)Validity: a)Content validity b)Criteria validity c)Construct validity 2) Reliability 3) Sensitivity (responsiveness, sensitivity to charge) ASSESSMENT OF COGNITIVE DISORDERS Mini Mental State Examination (MMSE): It is a short, easily applicable scale that evaluates orientation, attention, calculation, memory and language, and is applied as a general cognitive screening test to different patient groups. FOR LANGUAGE AND SPEECH DISORDERS -Frenchay Aphasia Test -Sheffield Screening Test -Boston Aphasia Test (Boston Diagnostic Aphasia Examination) -Parch Index (Parch Index of Communicative Ability) ASSESSMENT OF MOTOR IMPAIRMENT  Fugl-Meyer Scale: It evaluates motor movement in detail in neurological disability. It is generally used in stroke patients. It evaluates lower extremity functions, balance, sensation, and joint range of motion separately. It is scored out of 226 points.  Rivermead Motor Assessment  Motricity index/Trunk Control Index  Motor Assessment Scale ADL ASSESSMENT IN NEUROREHABILITATION Barthel Index -It is considered as the gold index. -Evaluates physical dependency in ADLs. -It consists of 10 items (transfer, ambulation/TS use, going up and down stairs, nutrition, dressing, bathing, self-care and stool incontinence). -Scored between 0-100. -The weakness of the test is that it does not include cognitive evaluation. DİSABİLİTY ASSESSMENT Functional Independence Measurement (FIM) -It is a generic and global disability scale and shows how independent the person is in basic daily physical and cognitive activities. -FIM, which contains 18 items, basically measures in 2 areas. a)Physical/motor function (13 items) b)Cognitive function (5 items)  The items that make up FIM are grouped into 6 subgroups in terms of the activities they show:  -Self-care (6 items)  -Sphinter control (2 items)  -Mobility (3 items)  -Locomotion (2 items)  -Communication (2 items)  -Social cognition (3 items) The total FIM score varies between 18-126. Each item is scored at 7 levels (1-7). OTHER DISABILITY SCALES  1)Katz and Kenny Indexes  2) PULSES Profile (It is the first scale used in global disability assessment. It evaluates mental and psychosocial status as well as physical disability.)  Rivermead Mobility Index (only mobility activities are evaluated)  Frenchay Arm Test (evaluates the upper extremity only)  Nine Hol Peg Test (evaluates manual dexterity) DİSABİLİTY ASSESSMENT IN NEUROREHABILITATION  In 1980, the World Health Organization (WHO) emphasized that the handicap level should be determined in 6 areas as the basis for handicap evaluation. (orientation-physical dependence- mobility-occupation-social integration-economic sufficiency). 1)ESCROW PROFILE 2)CHART(Craig Handicap Assesment and Reporting Technique) -It was prepared based on WHO handicap areas. -A total of 27 questions and disability in 5 areas are tried to be determined. -Each field is calculated weighted out of 100. -Total score 500 (indicating no disability) -It has been used in patients with SCI. 3) EDINBURGH REHABILITATION STATUS SCALE (EDINBURGH REHABILITATION STATUS SCALE-ERSS) 4) ENVIRONMENT STATUS SCALE (ESS) INSTRUMENTAL ADL SCALES  1)NOTTINGHAM INSTRUMENTAL ADL INDEX (mobility-kitchen and housework- leisure)  2)FRENCHAY ACTIVITY EVALUATION (home-related activities-leisure time- social activity-business life)  3)LAWTON INSTRUMENTAL ADL SCALE (using the phone-shopping- housework-laundry-transportation-taking medications-dealing with financial affairs) QUALITY OF LIFE ASSESSMENT IN NEUROREHABILITATION 1)SF-36 (36-item short form survey)  -It consists of 8 subscales that evaluate physical and mental health (physical function, fulfilling roles related to physical limitation, pain, general health, vitality, social function, fulfilling roles related to emotional limitation, mental health).  -Used in stroke patients.  -Psychometric properties have been studied. 2)NOTTINGHAM HEALTH PROFILE (NHP)  -It aims to measure the person's perceived health status in terms of physical, emotional and social aspects.  -It consists of 2 parts. The scale is the first part and contains 38 items examining the quality of life in 6 areas (sleep, energy level, emotional state, social isolation, physical mobility and pain).  -The second part is paid work, household chores, social life, sexual life, hobbies and interests, holiday life.  -It was used in Parkinson's and stroke patient groups.  3)DISEASE ASSESSMENT PROFILE (SICKNESS IMPACT PROFILE-SIP)-136 items and 12 domains (ambulation- mobility-body care and movement- communication-attention-emotional state- social integration-sleep and rest-nutrition- home-related activity-work situation- hobby-leisure)-It has been used in patients with SCI.  The treatment program determined according to the evaluation results should be guided by the patient's age, psychosocial status, education and habits. For example, in pediatric cases, treatment should be combined with play.  Necessary arrangements should be made for the elderly, taking into account their habits, cardiovascular and physical conditions, and respiratory capacity. International Classification of Functioning, Disability and Health ICF AİMS OF ICF To establish a scientific basis for understanding and researching health and health-related conditions, their consequences and determinants; Creating a common language to increase communication about health and health-related situations among different users in society, including healthcare professionals, researchers, politicians and people with disabilities; To enable comparison of data across countries, health- related disciplines, services and time; To provide systematic coding schemes for health- related information systems. APPLİCATİON AREAS OF ICF  ICIDH has been used for many purposes since the publication of a trial edition in 1980, such as: As a statistical tool – in collecting and recording data (e.g. in population studies and research or in manipulating information systems);As a research tool – measuring quality of life or environmental factors and outcome variables; As a clinical tool – assessment, matching of treatment to specific conditions, vocational assessment, rehabilitation and outcome assessments;As a social policy tool – social security planning, compensation systems and policy designs and implementation; As an educational tool – in curriculum development and to build social action and raise awareness. ICF's Universe The ICF covers all areas of human health and some health- related components of well-being. He defines these health fields and health-related fields from 8 perspectives. This classification falls within the broad context of health and does not include conditions unrelated to health, such as conditions caused by socioeconomic factors. For example, people may be limited in performing tasks in their environment because of their race, gender, religion, or other socioeconomic characteristics, but these are not health-related participation restrictions classified in the ICF. There is a misconception that ICF is only relevant for people with disabilities; In fact, ICF is about all people. All health conditions and associated health and health-related conditions can be identified using the ICF. In other words, the use of the ICF is universal. Scope of ICF The ICF provides a description of conditions related to human functioning and limitations and provides a framework for organizing this information.creates a frame. It structures information in a meaningful, relevant and easily accessible way. The ICF organizes information into two sections: Part 1: Functions and Disability, (Activities and Participation) Part 2 is Contextual Factors (Environmental and Personal) In the health context:Body functions are physiological functions of body systems (including psychological functions). Body structure is the anatomical parts of the body such as organs, arms, legs and other parts. Function or structural disorders, such as a significant loss or abnormality in body functions or structure.are problems. Activity is an action or the performance of a task by a person. Participation means being in life. Activity limitations are the difficulties a person may encounter while performing activities. Participation restrictions are problems that a person may encounter in life situations. Environmental factors create the physical, social and intellectual environment in which people live and build their lives.