NEUROLOGY 1 STANDARDISED ASSESSMENT CHECKLISTS Kim Miller 2002 Please refer to Appendix One: Initial Assessment of Neurologically Impaired

Patients in your theory manual for further information regarding the assessments described below When performing any assessment with a patient it is important to adequately explain the test in terms the patient will understand. Assessment of Cranial Nerves III, IV and VI Patient should be comfortably and securely seated so that they are able to concentrate on the task. This test is often performed preceding the visual fields assessment. Instructions to Patient: Asked to follow finger or pencil with their eyes in various directions Test process: Slowly moves finger/pencil through 4 cardinal planes and then diagonally in both directions Tests convergence by bringing finger/object toward patients nose Observes carefully determine if eyes do not move in parallel (dysconjugate gaze) Observes carefully for evidence of nystagmus Repeats test one eye at a time if dysconjugate gaze or nystagmus identified to confirm findings Provides appropriate feedback to patient regarding test results Test results: A positive result indicates lesions of cranial nerves III, IV or VI based upon movement impairment. Nystagmus may be indicative of disorders of the cerebellum, labyrinthine or retinal disease, or involvement of a substantial portion of the brain stem. Visual Fields Assessment Patient should be comfortably and securely seated so that they are able to concentrate on the task. It is advisable to have some confidence in the communication abilities of your patient prior to testing. If communication is inadequate, test results will be invalid Instructions to Patient: Asked if usually wears glasses Asked to indicate when they can first see the therapists finger/pencil.. Asked to fixate on an object (eg. Therapists nose, item on the wall) Asked to cover or close one eye Reminded to continue to fixate on object as required during assessment

Test process:

Each eye assessed individually (one eye covered) Checks to ensure that the finger/pencil cannot be seen initially (limits of visual field quadrant) Slowly brings finger/pencil from periphery to center of visual field quadrant Tests all four quadrants (top, bottom, medially and laterally) Tests bilaterally Provides appropriate feedback to patient regarding test results Test result: A positive result indicates gross defects along visual pathway from retina to cortex (parietal and occipital lobes) Visual Extinction Assessment Patient should be comfortably and securely seated so that they are able to concentrate on the task. This test is often performed immediately following the visual fields assessment and should on be performed in the intact portion of the visuals fields. Instructions to Patient: Asked to indicate when the finger in his/her visual field is wiggled Informed that one or both fingers could be moved/wiggled Asked to fixate with both eyes on an object (eg. Therapists nose, item on the wall) Reminded to continue to fixate on object as required during assessment Test process: Places fingers near the lateral limits of the visual fields of the (L) and (R) eye Checks to ensure that the fingers can be seen (hence the need for the preceding visual fields assessment) Wiggles either the (L), (R) or both fingers in random order Reconfirms fingers are placed within visual fields if a positive result is obtained Repeats testing to confirm visual neglect a minimum of three times Provides appropriate feedback to patient regarding test results Test result: A positive result indicates visual neglect/inattention (perceptual difficulty). Sensation Assessment Patient should be comfortably and securely positioned so that they are able to concentrate on the task. It is advisable to have some confidence in the communication and cognition abilities of your patient prior to testing. If communication and/or cognition is inadequate, test results will be invalid. Light touch: Instructions to patient: 1. Ability to detect stimulus: Asked to indicate when arm/hand/leg. is touched (this can be done verbally, by nodding head, using gestures etc) 2. Inquired as to whether the stimulus is of comparable strength to the other side, or to other body parts or within the same limb

3. Ability to localise stimulus: Asked to indicate where arm/hand/leg is touched (this is done preferably by pointing to the location, but may be done verbally) 4. Tactile extinction: Asked to indicate whether their right side, left side or both sides are touched simultaneously (this can be done verbally or using gestures) Procedures. 1. Ability to detect stimulus: Cotton balls or tissues used to touch patient Adjusts clothing appropriately to permit testing Demonstrates first on the intact side with eyes open to confirm understanding of task Asks patient to close eyes/occludes vision Areas tested reflect likely pathology eg. sensory homunculus vs. nerve roots vs. peripheral nerves Stimulus is presented unpredictably and appropriately eg light touch must be kept very light and brief No cueing is provided regarding stimulus presentation either through the sound of the tissue touching the patient or through cueing by the therapist eg. "can you feel this?" Provides appropriate feedback to patient regarding test results 2. Ability to localise stimulus (typically done after ability to detect stimulus is confirmed) Demonstrates first on the intact side with eyes open to confirm understanding of task Asks patient to close eyes/occludes vision Areas tested reflect likely pathology eg. sensory homunculus vs. nerve roots vs. peripheral nerves Stimulus is presented unpredictably No cueing is provided regarding stimulus presentation either through the sound of the tissue touching the patient or through cueing by the therapist eg. "can you feel this?" Provides appropriate feedback to patient regarding test results Test results: A positive result indicates sensory impairment anywhere along the sensory pathway. The pattern of sensory loss can provide some clues as to the location of the lesion. Refer to Framework for Assessment for a brief discussion of conditions that can impact sensory assessment findings. 3. Tactile extinction: (ONLY performed if sensation is confirmed intact through assessments 1 and 2) Demonstrates with eyes open and confirms understanding of the test Asks patient to close eyes/occludes vision Touches intact side, affected side or both sides simultaneously in a random order Repeats testing to confirm tactile extinction if suspected Provides appropriate feedback to patient regarding test results

Test results:

A positive result may indicate failure to acknowledge simultaneously presented stimuli associated with sensory neglect/inattention. Sharp/dull Typically assessed less often than light touch in neurological patients. Pain sensibility is particularly important to evaluate in individuals with spinal cord involvement as the spinal pathways that mediate pain (lateral spinothalamic) differ from those that mediate discriminative touch (posterior columns). Instructions to patients Asked to indicate whether the stimulus presented is sharp or dull Procedures Appropriate items used to evaluate sharp/dull eg. paperclip, pin Adjusts clothing appropriately to permit testing Demonstrates first on the intact area/side with eyes open to confirm understanding of task Asks patient to close eyes/occludes vision Areas tested reflect likely pathology eg. sensory homunculus vs. nerve roots vs. peripheral nerves Due care taken to avoid injury Stimulus is presented unpredictably Provides appropriate feedback to patient regarding test results Test results A positive result indicates loss of pain sensibility. The pattern and nature of sensory loss can provide some clues as to the location of the lesion. Refer to Framework for Assessment for a brief discussion of conditions that can impact sensory assessment findings. Proprioception Traditionally proprioception assessment has been divided into assessment of position sense (awareness of the position of the joint at rest) and movement sense or kinesthesia (awareness of movement). Choose those areas that relate to the identified problem (eg. assess LL rather than UL proprioception if balance is a problem). The patient should be comfortably and securely positioned so that they are able to concentrate on the task. It is advisable to have some confidence in the communication abilities of your patient prior to testing Position sense: Instructions to patient: Asked to indicate the static position of the joint verbally, with gestures or by duplicating the position with the opposite limb (depending upon the abilities of the patient) Procedure: Demonstrates on unaffected joint first with eyes open to confirm understanding of task Range of motion being assessed is identified (e.g. This is up and this is down) Asks patient to close eyes/occludes vision Minimizes tactile cues (ie. handles the lateral aspects of the joint)

Small increments of range are used Patient asked to indicate position of joint while held in a static position by the therapist Testing for each joint repeated 5 times and the number of correct responses recorded (e.g. 2/5 correct) Provides appropriate feedback to patient regarding test results

Movement sense (Kinesthesia): Instructions to patient: Asked to indicate the direction of movement while the joint is in motion verbally, with gestures or by mirroring the movement with the opposite limb (depending upon the abilities of the patient often impractical for proximal LL joints) Procedure: Demonstrates on unaffected joint first with eyes open to confirm understanding of task Range of motion being assessed is identified (e.g. This is up and this is down) Asks patient to close eyes/occludes vision Minimizes tactile cues (ie. handles the lateral aspects of the joint) Small increments of range are used Patient asked to indicate position of joint while the extremity is in motion Testing for each joint repeated 5 times and the number of correct responses recorded (e.g. 2/5 correct) Provides appropriate feedback to patient regarding test results Note that Dr. Barry Stillman has shown duplication of position with the same limb to be the most accurate method of testing proprioception. Unfortunately this method is not often used in the clinic at present.

Test results: A positive result may indicate loss of/poor proprioception in the joint. Results are typically recorded as the number of correct trials/ 5 trials for each joint. Movement Control Assessment There is no standard way to assess movement control used by physiotherapists across Victoria. Please refer to the Movement Control section in Appendix 1 of your manual and information from your 3rd year practical sessions in 513 302 to assist you in this assessment. The Motor Assessment Scale (MAS) is used at some sites as a standardised measure of movement control. Muscle Tone Assessment During assessment, muscle tone is the resistance felt as a muscle is lengthened or stretched during passive movement. Muscle spasticity is revealed when the resistance that is felt by the examiner is velocity dependent (.i.e. the resistance becomes more apparent when the muscle is lengthened more quickly). The resistance that the examiner feels in an individual with an upper motorneuron lesion results from physical inertia of the extremity (which generally remains unchanged), mechanical/elastic characteristics of muscle & connective tissue and neural contributions at a segmental level and as result changes in descending central pathways. By undertaking a Tardieu Muscle Tone Assessment the examiner can differentiate between

mechanical and neural contributions to muscle tone. The procedures for undertaking the Tardieu are included in the 3rd year theory manual and in the Manual for Clinical Outcome Measurement in Adult Neurological Physiotherapy 3rd ed. (Hill et al, 2005). The following instructions relate to assessment of muscle tone using the Modified Ashworth Scale. These procedures will not differentiate between resistance offered by neural and mechanical factors, but they are often used to initially screen for changes in muscle tone. If you are recording muscle tone using the Modified Ashworth Scale the position of the patient during testing should be specified. Typically the tone is assessed with the patient fully supported in a supine position so that the patient can relax their muscle/muscle group being tested. Muscle tone is always assessed with a relaxed muscle. Instructions to patient: Examiner inquires regarding the presence of pain in the limb to be tested Asked to relax and allow the therapist to move the limb passively eg. " Let me move you". Procedure: If proximal UL musculature is being assessed; briefly determines whether subluxation is present at the shoulder and takes appropriate precautions to prevent further shoulder injury Available passive range of motion (muscle length) is initially assessed by slowly moving the limb through range; endfeel is noted Once muscle length is determined, the limb is moved through midrange more quickly to feel the resistance to the movement related to the velocity of the movement (test for the presence of spasticity). Care is taken not to overstretch or traumatize a very spastic muscle by moving too quickly. Comparison is made to the opposite side (possibly the unaffected side in a unilateral stroke patient) Provides appropriate feedback to patient regarding test results Test results: Muscle tone rated using a 0 4 rating of magnitude and quality of resistance felt (as described and graded by the Modified Ashworth Scale). Co-ordination Assessment (as a symptom of cerebellar dysfunction) Co-ordination (as defined for our clinical purposes) may be impaired as result of cerebellar pathology or severe sensory impairment. The procedures described below relate to assessment for co-ordination deficits associated with suspected cerebellar dysfunction. Depending upon the pathology of your patient it may be advisable to rule out ataxia related to sensory impairment. The examples provided here are not exhaustive; there are many ways that people choose to assess coordination. During testing the patient should be comfortably and securely positioned so that they are able to concentrate on the requested task. Instructions to patient: Asked to perform the tasks as quickly and accurately as possible

Asked to move through full range of movement

Procedure: Determines that patient has adequate motor control to perform isolated movements prior to commencing coordination testing. Available active range of motion is initially assessed; the influence of gravity is considered Inquiries made with regard to pain; particularly when assessing the upper limb Provides appropriate feedback to patient regarding test results Upper Limb: Finger to nose test Examiner standardises position by placing their finger at the patient's arm's length away Consideration is given to positioning of the patient (eg. securely seated; available range of shoulder flexion and active movement) Scores accuracy of reaching the target /10 Records time to complete 10 alternating finger-nose movements Alternating forearm supination-pronation Examiner establishes expected range of forearm supination/pronation Scores incidences of dysdiadochokinesia /10 Records time to complete 10 alternating movements Lower Limb: Heel to shin test Patient is positioned in supine or long sitting Examiner clearly establishes expected targets based upon available active range of motion Scores accuracy of reaching the target /10 Records time to complete 10 alternating heel to shin movements Foot tapping or alternating knees If choosing foot tapping, the examiner establishes active range of motion at the ankle Scores incidences of dysdiadochokinesia /10 Records time to complete 10 alternating movements