Neuro patient (stroke/Parkinson)

When you read the notes, check: Date of birth Diagnosis (if stroke: Tact, Pacs, Lacs, Pocs / MCA, ACA, basilar) (if Parkinson: often admitted to H for other conditions: Hypotension, chest infection...). Date of admission History of illness Dysphasia (in that case reduce the subjective and use more hands on and show examples of exercises so he can understand) Meds (optional) Past medical history (to know about other complications and so use precautions) Social history (living where, whom with, stairs, lifestyle, exercise program for that condition especially in Parkinson) Physio notes (useful to give you hints about the treatment and how the patient reacts) You refer all these details to the examiners and then tell them what is your plan with your assessment and treatment. You have to choose a function to assess and treat for the exam, so youll say you have chosen gait/lower limb/balance because the patient is supposed to be independent for discharge and social life and gait is the most important issue; or upper limb because its the most impaired and the arm is not functional while the patient can walk very well already and instead he cant dress himself for example. But usually gait and balance are the main, and even when the arm is not functioning is often due to fixation because of poor trunk balance. Subjective: You introduce yourself and say you are having an exam, then introduce your examiners and say they will just observe what you are doing. Tell the patient what you are going to do in that hour: Im supposed to give you some treatment for your condition, Ill ask you some questions first to know some information and then Ill see how I can help you with your difficulties. Optional questions (as you have them in the notes): what is the reason for your admission to H? How did it happen? Subjective for stroke: How do you feel you have recovered so far? What are your difficulties? Whats your main problem?Whats your goal for this rehab? Depending on the problems of the patient youll ask: Can you move easily in your bed? (Rolling) Can you sit on the edge of bed? (Supine to sitting of edge) Can you stand up? (Sit to stand)

Can you walk? (Gait) Do you use any walking aids/orthoses? Occasionally or all the time? How was you walking before the illness? Do you have any numbness in your arm or leg? Any pain in your shoulder? (Score from 0 to 10 if youre treating upper arm). Any pain anywhere else? Any vision problem? (hemianopya) Any dizziness? Do you live alone? Any stairs at home? Have you had any fall? When? Did you get injured? Any fall previously the illness? Can you get up from the floor? (balance and safety) Then you inform the patient you are going to have a look of his general movement to understand what he can do and how you can transfer him on bed. Of course you ask the patient how he usually transfers and you can find it in the notes in the file too. Subjective Parkinson: Same as stroke. You are not gonna ask for vision problems or numbness or pain in shoulder. But youll ask for any pain in general. You ask instead about the possible condition that has led him to H (hypotension, chest infection, whatever) so you make sure about the precautions you need to use. Also ask about drugs (most common for Parkinson: Sinemet, Madopar). You need to know how long usually the effect is with that patient and what time he got the last one, so you have an idea how the patient will respond to the treatment.

Objective stroke:
Still sitting on the wheelchair and according to the level of the patient: Can you make a fist? Can you open your hand? Can you grab this object? (look for wrist extension) Can you touch the other fingers with your thumb? (thumb opposition) Can you touch your chin? Can you touch you ear or behind your head? Can you reach my hand forward? (look for elbow extension) Can you lift your arm? Can you bring your hand behind back? Can you lift your toes? Can you straighten your knee? Can you lift your leg?

In case of Pocs the patient is likely to have ataxia, so you test also: Can you touch finger/nose? Can you do handspalms up and down quickly? Can you tap your toes/fingers? Can you slide your heel on the other shin up and down? Then you decide how to transfer the patient (angel transfer, sliding board, stand and turn, with assistance of examiners). Wheelchair close to bed on good side, bed slightly lower then wheelchair, get rid of arm support and foot support, transfer and get rid of wheelchair after having assured safety of patient in sitting or ask an examiner to move the wheelchair. Supine: Sensory test (only if patient or notes say there is numbness). Test only light touch, two points discrimination and proprioception. Close you eyes and tell me where Im touching (foot, lower leg, thigh start with good leg first and compare with bad one, score 0-10 if necessary). Im gonna move your big toe now (show on good one first), is it up or down? (do the same with ankle, knee and hip. Make sure you are holding limb on side, plus knee needs to be firm when assessing hip). Check ROM and tone of: Upper limb (skip it if youre not treating it): fingers, wrist, elbow, shoulder, in particular note pectoralis and biceps tone, wrist extension and shoulder extrarotation. Careful with pain. Lower limb: ankle, knee, hip, in particular calf/quad/add tone, dorsiflexion range and foot mobility. Bridging on both legs or single leg: note hip extension, gluts activation, knee control, equal weight bearing, wobbling. Sitting (feet on ground, 90hip/knee): Observe patient shirt off (if man): position in sitting, weight bearing, trunk flexion, overactivity trunk flexors, position of leg, foot flat on floor,etc. Assess balance (righting and equilibrium reactions with internal and external displacements): It looks to me your weight is not equal on both sides, so Im gonna slide my hands under your bottom and move you side to side to see how your weight is....(displace the patient on both side and feel possible resistance if resists on weightbearing on good side is because of pusher syndrome see how patient reacts and if he uses arm to hold himself).

Can you turn you head on left/right? Can you turn your trunk on L/R? Can you move your weight on your R/L hip? (note reaction of head and trunk). Can you reach out on your R/L side? Can you reach my hand here (down/up, both sides). Push gently the patient forward/backward/side to side. If patient is good with balance in sitting go to the next stage: sit to stand. Sit to stand: (use another person or equipment for safety) Observe: - feet placed appropriately (oedema ankle, high tome calf, poor mob foot?) - forward inclination trunk (extensor pattern?) - anterior pelvic tilt - dorsiflexion ankle - extension hip and knee (activation gluteus, high tone quadricep?) - watch also stand to sit Standing: balance time balance objective measure observe position balance test as in sitting (turn head/trunk, reach out...) bend down to pick object push gently the patient in several directions stand on one leg (if able) (also time as objective measure) turn 360 both directions

As objective measure you can use pieces of the Berg Balance Scale, as you wont have time to practise it all during the exam. Gait: note if walking aids and orthoses needed use as objective measures: 10m walk test, up and go test.

Gait patterns most seen: Hip circumdaction: hypertone quad, decreased ankle dorsiflexion, hypertone calf. Hip hitching: as above plus increased activity side trunk flexors. Hyperextension knee: hypertone quad, ant pelvic tilt, decreased hip extension, loss of ankle passive dorsiflexion. Catching toes: as hip circumdaction plus lack hamstring activation and decreased weight shift to unaffected leg. Flexed gait pattern: decreased hip, knee and trunk extension.

Objective Parkinson:
Supine: check if he lies flat on bed, ask to straighten arms and legs, bend knees, to see extensor movement pattern and functions in general. Check passive ROM (rigidity) and active rotation trunk and head. Prone: are you comfortable lying on your tummy? Can you roll on your tummy? In prone then ask to lift head, shoulders, arms and legs to see extensors strenght against gravity. Sitting: check balance and rotation. Can you turn you head right and left? Your trunk? And follow test balance as in stroke. Sit to stand as in stroke. Standing: test balance as in stroke. Gait: note if safe, walking aids, festinating gait, freezing periods, trunk rotation/arm swing, balance.

Treatment for Parkinson: (general for any patient affected) - Warm-up: in supine exercises to increase extension and rotation of the trunk. - Stretching: in supine, hamstrings, calves, pecs. - Balance work: in sitting/standing, reaching out activities, exercises using trunk rotation or extension. - Gait: use verbal clues, use pace (clapping or counting). Aim to decrease freezing periods and increase stride length.