cerebrum - how to assess Flashcards
part 4 of unit 2
what are the catgeories of neurological assessments
- mental status
- language/communication
- motor assessments
- sensory assessments
- special senses
mental status - informal assesssment of alertness and orientation
when is it performed?
how many levels of alertness?
4 components of orientation?
how is this documented?
when is it performed?
- done while obtaining historical info from pt when a neuroloigcal problem is suspected
how many levels of alertness?
- 5 alert, lethartic, obtunded, comatose, stupor, somnolent
4 components of orientation?
- person, place, time, situation
how is this documented?
- A & O x #
mental status - formal assessment
- retentive memory & immediate recall
- recent memory
- remote memory
- general knowledge
- higher functioning
common cognition otucome measures inlcude items assessing each of these different domains
Montreal Cognitive Assessment (MoCA)
constructs assessed?
- visuospatial/executive function
- naming
- memory
- attention
- language
- abstraction
- delyaed recall
- orientation
what is a normal score for the montreal cognitive assessment (MoCA)?
out of 30; normal ≥ 26
Mini Mental State Exam (MMSE)
constructs assessed?
- orientation
- registration
- attention and calculation
- recall
- language
- copying
what is the scoring for mini mental state exam (MMSE)
out of 30
- normal is 24-30
- mild cog impairment is 18-23
- severe cog impairment is 0-17
MoCA and MMSE
what might we, the PT, do if our pt scores outside of the normal range? how does this info impact our PT sessions?
communicate prior to the test and then follow up with honesty –> so this is what we are going to do about the problem we found.
- tailor the communication based on deficits/tailor treatment
- refer out
MoCA and MMSE
what does it mean if our patient scores within the normal range, but shows deficits in a single construct (like recall) on both MoCA and MMSE?
following the recall example:
- provide extra resources: videos, pictures
against its tailoring the session to what the patient needs
language/communication
informal assessment
- assess hearing ability very early in the examination and at adjust yuor communication appropriately, if hearing deficits
- done while taking the history by ntoing pt’s abiolilty to hear questions and respond
- at minimum PT’s should report pt’s comprehension and ability to express himself verbally or nonverbally
langugae/communication
informal assessment:
what questions are you asking/answering as you assess?
- can the client speak
- do they have word finding problems consistent with expressive aphasia or trouble enunciating consistent with dysarthria?
- note voice quality, is volume adequate
- does the individual understand language or show signs ofreceptive aphasia
What is dysarthria
difficulty in articulating words, caused by impairments of the control of muscles used in speech
what might we, the PT, do if our patient demonstrates impaired language or communication?
how does this info impact our PT sessions?
if its new and happens during session –> problematic, refer out
if known just depends on what their impairment is –> how have they been communicated with most effectively with others. bring in family memebers, whiteboad to write down thoughts, adjust your speaking langauge in order for them to understand you, usual visual aides if needed
motor system assessments:
what to do
- muscle strength/force production
- active vs. passive ROM
**- reflexes - muscle tone
- fractionation**
- **synergistic movement patterns **
- motor control and coordination
deep tendon reflexes
testing procedure?
- patient needs to be completely relaxed, usually seated edge of mat
- place muscle midway between shortest and longest lengths
- need potial resting tension of muscle being tested - stimulus must be brief but strong
- assess and compare bilat
what is the deep tendon reflex scoring
deep tendon reflexes
what score(s) would you expect with an uppper motor neuron lesion? why?
- possible light reflexes (babinski) hyperreflexia
this is because UMN do not directly synapse with skeletal muscles - they synapse with LMN. loss of descending inhibition to shut it off ends up with an excess movement
deep tendon reflexes
what score(s) would you expect with a lower motor neuron lesion? why?
-hyporeflexia
the lower motor neuron actually synapses with the muscle itself
clonus
- rhythmic oscillating stretch reflex tath is related to UMN lesions
- therefore conus is generally accompanied by hyperreflexia
clonus is common in muscle with?
long conduction delays, such as the long reflex tracts found in distal muscle groups
muscle tone
- the resistance of a muscle to stretch: the overall stiffness of the muscle
muscle tone
skeletal muscle have what kind of resistance? what is the result?
- intrinsic resistance to stretch resulting from the elastic properites of tendions, connective tissue, and the muscle tissue itself
muscle tone
when do you, the PT tetect the amoutn of tension/resistance ?
detect the amount of tension/resistance of a relaxed muscle during PASSIVE ROM
muscle tone
tone can fluctuate over the course of the day, why?
due to many factors:
- infections
- stress
- volitional effort
- medicatin
- temp
muscle tone testing procedure
- move slowly through the joints ROM
- move quicly through each motion
what is muscle tone general scoring?
muscle tone
what score(s) would you expect wiht an upper motor neuron lesion?
hypertonia - 3+,4+
what score(s) would you expect with a lower motor neuron lesion?
hypotonia 0,1+
muscle tone - categories of hypertonicity
rigidity
not velocity dependent or direction dependent
these are different presentations:
- cogwheel: tension that gives way in little jerks
- lead pipe: smooth rigidity that continues through entire range
bidirectional
you will feel it throughout regardless of how slow/fast or what direction its moved
muscle tone - categories of hypertonicity
spasticity
volcity-dependent and direction-dependent
- may be characterized by a “catch and release”
- thought to be casue by imbalance of descending inhibitory and faciitatory influences on muscle stretch reflexes; hyper excitability of afferent pathways and dysfunctional processing of afferent peripheral nerve inputs by the spinal cord
you may not feel it slow but you feel it fast. you may also only feel it going into extension not flexion - as an example
modified ashworth scale
clincial test for spasticity
0 is normal for this scale
clinical test for SPASTICITY -velocity and direction dependent
pendulum test
procedures:
equipemnt:
scoring:
clinical test of spasticity
procedures:
- the patient sits on an exam table and PT holds. the patients foot with knee fully extension
equipement:
- typical equipment used is either elctro-goniometes, uni-lanar video or I2 motion analysis systems
scoring:
- using computer data for number of oscillations and amplitude, values of the relaxation index (R1 and R2) are calculated and compared to norms
passive swinging assessment –> observe number of ossilactions
in the ACUTE period immediately after UMN damage there is often hypotonia and areflexia… why?
this is true of any UMN injury –>
why?
- loss of descending corticospinal input
- compromised of the SMA
this is just FYI
typical presentation of UMN is hyperreflexia and hypertonia in the chronic phase
movement fractionation
fractionated movement reflects that pt’s ability to actively move at one joint without moving at other joints
like being able to isolate each finger to type
movement fractionation
testing procedure:
- pt in a sitting position with back
- check the PROM for each extremity and joint involved
- ask the pt to perform isolated movements; instruction may be veral or visual
- identify each movement as fractionated or unfractionated
fully extending arm and asking to move just the shoulder joint into flexion is fractionation
fractionated movement
tips for assessing - support weight of limb only, do not guide this motion
UE:
LE:
UE:
- when testing flexion at any joint strt with all joints in extension
- when testing extension at any joint start with all joints in flexion
LE:
- when testing flexion at any joint start with all joints in extension/PF
- when testing extension at any joint, start with all joints in flexion/DF
movement fractionation - UE
1. shoulder flexion
fractionated: moves through shoulder ≥50% ROM without substitution
movement fractionation - UE
2. flex and extend the elbow with neutral supination/pronation
movement fractionation - UE
3. flex and extend the wrist against gravity
movement fractionation - UE
flex and extend the fingers agaisnt gravity
movement fractionation - UE
flex and extend the index finger with the other fingers fully flexed
movement fractionation - LE
flex hip in sagittal plane
movement fractionation - LE
extend knee in sagittal plane
movement fractionation - Le
dorsiflex ankle in sagittal plane
synergistic movmenet patterns (synergies)
- multi-joint movmeents that occur simultaneously whe ntrying to move an isolated joint (finger, wrist, elbow, shoulder flexion when bringing the hand to the mouth to stifle a yawn)
synergistic movement patterns is common to see in individuals that
have had an UMN lesion
common
UE:
flexion syngery components
- scapular retraction and elevation
- shoulda bduction, ext rot, elbow flexion, forearm supination
- wrist/finger flexion
LE:
flexion syngery components
- hip flexion
- abduction
- ER
- knee flexion
- ankle DF
- inverison
- toe DF
when do PT’s assess synergistic movement patterns
- clinican watches the client while they perform AROM as well as funtional movmeents (grasping, walking)
- the cinet can sachieve movment only through one rigid movement patterns, then they are said to be bound in synergy
syngery is noted, the clinician should ask the client to move out of these patterns and observe whether the client can move out of the syngerygy pattern
sensory system assessments include
- proprioception
- kinesthesia
- vibration testing
- light touch
- pain
- temp
talk through how a deep tendon stretch occurs
- tendon stretch
- muscle spindle Ia afferent fiber –> cell body in dorsal root ganglion –> inhibitory interneuron –> extensor and flexor motor neurons –> ventral root –> one path inhibited the non working muscle while the other activates the muscle that tendon was stimulated
