Quiz 1 Flashcards
Examination
History
Systems review
Tests and measures
- From history and systems review - determine needs and generate diagnostic hypotheses
- Use to establish diagnosis, prognosis, plan of care and select interventions
- Selection of specific tests and measures and depth of evaluation varies according to multiple factors
Age, severity of problem, stage of recovery, phase of rehab, home/community/work, and other factors - need to consider
Evaluation
Clinical judgement
Establish diagnosis, prognosis, plan of care
Diagnosis - organize ada into defined clusters, syndromes, categories
Prognosis - level of optimal improvement and time involved
Plan of care along w/ anticipated goals and expected outcomes, specific interventions, and proposed duration and frequency of interactions (in collab w/ clients and families)
Re-Examination
To modify or redirect interventions prompted by new clinical findings or failure to respond to PT interventions (referral back to physician)
Outcomes = impact on patient
- Disablement categories
- Risk reduction/prevention
- Wellness & fitness
- Societal resources
- Satisfaction
Why Examination?
Baseline info
Progression w/ disease or interventions
Placement decisions (rehab vs. long-term care)
Safety
Evidence of treatment effectiveness
Clinical Utility (Why Clinicians Choose Certain Tools)
Time to administer (concise vs testing everything; gross measures/screening)
Costs
Patient/client factors (diagnosis, tolerance - can they handle how long the test it?)
Sensitive to change - ability to measure change
Responsiveness -ability to measure meaningful clinical change (floor vs. ceiling effect - everyone is either at the top or bottom of test scale)
How to Select Examination Tools - Reliability
Consistency
Test-retest (stability of measure - admits once and retest them - should stay the same)
Intrarater - same therapist different times
Interrater - multiple therapists
How to Select Examination Tools - Validity
Accuracy
Face validity - does it look like what it’s going to measure (goniometry measures joint position)
Content validity - does it actually measure what it’s going to measure (VAS measures pain at rest or in motion, but does not assess factors that aggravate pain)
Construct validity - look at how’s tool built (not really concerned with this)
Concurrent ability - what’s been used in clinic compared to gold standard
Predictive validity
Predicative Validity
Predicts likelihood of return to function
Sensitivity - correct referrals/total abnormal x 100 = percentage of abnormal cases identified (how many people have condition)
Specificity - correct referrals/total normal x 100 = percentage at normal cases classified normal (how many people are normal and don’t have condition)
False Negative
Under referral
Tested negative, but have disease
False Positive
Over referral
Test positive, but don’t have disease
True Negative
Tested negative and don’t have disease
True Positive
Tested positive and have disease
Ability to Detect True Change
MDC (minimal detectable change) - statistical calculation - smallest amt of chance needed to exceed measurement variability
MCID (minimally clinical important difference)
- Clinically/patient meaningful change
- Usually compared to therapist or patient opinion of meaningful change or compared to gold/established standard measure
- Can depend on initial scores
Types of Instruments - Performance
Patient asked to perform tasks
Current level or ID max level
Do not measure real patient’s environment
Types of Instruments - Self-Assessment
Can be administered by therapist
Habitual performance (have you done it before and do it all the time) or perceived capacity (think you can do it)
May have time frame (how many times did you do this in last 24 hours)
May not have accurate reporting (lying, can’t read)
Degrees of Measurement - Nominal
Opposites - able to do vs. not able
Indep. vs. not indep.
Con - doesn’t provide enough info
Ex: can you stand up or no?
Degrees of Measurement - Ordinal
Degree to which person can perform
Rank order scale
- No difficulty/some difficulty/unable to do
- Min/mod/max assist
Con - not equal separation b/w categories
Summary Additive Con
Two patients w/ same score may be very different
Why Assess Function (Activity and Participation)
Patient’s key concern (as opposed to impairment level changes)
Collect consistent data
Provide baseline data
Determine other examinations (impairments such as ROM and strength)
Evaluate efficacy of rehab interventions
Capability vs. Performance
Can you vs. do you
Capability - 20% higher than performance
Depends on external environment and internal characteristics of individual
- Time constraints - may take them long time to do it and whip out their energy
- Energy demands - ADs to be used to save energy for other activities
Range of Motion
Measures - goniometry, tape measure
Functional tasks - getting up from floor, picking up a coin from floor, put on a coat, STS from low chair, place object overhead
Strength
Measures - MMT, one rep max, hand-held dynamometry, isokinetic dynamometry
Functional Tasks - picking up coin from floor, getting up from floor, lift weighted object, up/down 1-4 flights of stairs, chair rises
Balance
Measures - Tinetti, Berg, functional reach, Romberg/sharpened Romberg (EO/EC)
Functional tasks - obstacle course, picking coin up from floor, standing activities, turning 360, gait (change speed and direction)
Any time hands are in guard position - balance issue
Quick turns are when people fall
Cardiovascular Function
Measures - HR, BP, perceived exertion
Functional tasks - seated step test, 6 minute walk test, up/down 1-4 flights over stars, chair rises (x5 - timed chair rises, x10 timed stand rises)
Interrelationship between impairment and activity/function
Impairments doesn’t predict functions
Fugl-Meyer
Majority is impairment based
Performance based test
Approx. 30 minutes (can pick components)
Patients post stroke
Score: summary, UE, LE - 3 levels of grading (0,1,2)
Areas of assessment - UE/LE - joint range, joint pain, sensation (light touch, proprioception), DTRs, mvts in/out of synergy, grasp, coordination (tremor, dysmetria), sitting/standing balance
Dysmetria
Body can’t figure out distance needed to touch another part
Inaccurate aim
Berg Balance Scale
Balance - looks at risk of falling
Performance based
Approx. 15-20 minutes
5 levels of measurement
Higher score = better performance
Cutoff score < 45 - predictive of recurrent or future falls
Areas of assessment - STS, pivot transfers, changing BOS (feet together, tandem, one foot, place alternate foot on stool), reaching, bending, changing head position (looking behind you), eyes closed, turn 360
Resting Tremor vs. Intention Tremor
Resting tremor - tremors appear while resting, but disappear when moving
Intention tremor - start to move, tremor moves
Tinetti-POMA
Balance - performance-based - looks at risk of falling
Areas of assessment:
- Balance: sitting/standing balance, STS x3, turn 360, one foot stance, tandem stance, reaching, and bending
- Gait: initiation, path, balance, turning, timed walk, obstacle clearance
<19 - high risk for falls
19-24 - moderate risk
Functional Reach
Balance - performance based test
5 mins
> 15.2 but <25.4 cm - 2x as likely to fall
<15.2 cm - 4x more likely to fall
As you age, discrepancies b/w males and females increase
Looks at risk of falls
Multidirectional Reach Test
Balance - performance based test
Adds sideways and backward reaches
Fear of falling contributes to ability to reach backwards
Sit and Reach
Balance - performance based test
Patients w/ acute stroke - able to sit
1 min, raise intact arm to 90 degrees
TUG (Timed Up and Go)
Performance based - look at dependence
Stand up, walk 3 meters, cross a line, turn around, walk back, sit down
As quickly and as safe as possible
<20 seconds - independent in ADLs, community ambulation speed
> 30 seconds - increased dependence, need Ads, none could go out alone
Reliable for patients w/ PD
Time is dep. on pt’s ability
Use TUG to estimate Berg
Modifications to TUG
Cognitive - subtraction task (counting backwards by 3s)
Manual - holding almost full glass of water
Decrease in time to TUG alone
- Looks at ability to do two things at once
- Normal to have some decrements in both tasks
Huge time differences - higher risk of falls
Walk and talk test - have to stop and talk - higher risk for falls
BEST (Balance Evaluation Systems Test) Test
Full test - 27 items
Mini-BEST - 14 items (eliminated less reliable items)
Brief-BEST - 8 items (1 to 2 items in category)
Categories - biomechanical constraints, stability limits (functional reach), transitions (anticipatory postural adjustment - stand on one leg), reactive postural control (compensatory stepping), sensory orientation (modified foam and dome), dynamic gait/stability in gait = TUG
Short Physical Performance Battery
Screening test - performance based
Several components - chair rises 5x scored according to time, standing balance 3 foot positions (semi-tandem, side by side, tandem), walk 8 feet scored according to gait speed
Perfect score = 12
Low scores (4-6) - 4x more likely to have disability 4 years later
Mid-range scores (7-9) - 2x more likely
Physical Performance Test
ADLs, balance, gait speed
Task performance - performance-based
Approx. 10 minutes
9 or 7 items dependent on ability to use stairs
Time performance - scored according time to perform task except turning 360 degrees and no of flights of stairs
Quicker time = higher scores = better performance
Areas of assessment - writing, stimulated eating, putting book on shelf, putting jacket on, picking object from floor, 360 degrees turn, 50 m walk, stairs
Very reliable
Timed Movement Battery
Performance-based - screening test
Approx. 15-20 minutes
Two speeds - self-selected and as fast as possible
Quicker time = better score/performance
11 movement skills - supine to sit, STS, ambulation (6m towards, 3m backwards, walking and stepping over low (2 in) and high (6 in), obstacle, figure 8 walk, stairs, rising from floor
Can modify for pts
Rising from the floor - depicts fear of falling if they can’t get up
FIM (WeeFim for Children)
ADLs
Task performance tool - performance-based
7 levels of measurement w/ grades for device use (6) and supervision (5)
Higher scores = increased independence
Areas of assessment - feeding, dressing, bathroom skills, grooming, transfers, locomotion (ambulation/WC), stairs, communication, cognition
Heavily used in rehab
Score at admissions - predict where they wind up
Devices - different scores
WeeFim - children
Barthel Index
ADLs
Self report (5 mins) or observational tool (20 mins)
3 measurement levels (dependent = 0/assistance = 5/independent = 10)
Higher score = increased independence (100 = independent, 20-45 severe disability)
Areas of assessment - feeding, dressing, grooming, bathroom skills, transfers, ambulation, stairs
Katz Index of ADL
Observation/self-report
3 levels of measurement - indep w/o supervision, assist w/ more difficult components, assist or dep
Grading by letters (B = indeed in all but one area, C = indep except for bathing and one other area)
Areas of assessment - bathing, dressing, toileting, transfers (bed, chair), continence, feeding
NO AMBULATION ITEMS (bed mobility, transfers)
Rivermead ADL Scale
ADLs and IADLs
Task performance - performance based
30-60 minutes
3 levels of measurement (1 = indepen, 0v = requires verbal assistance, 0 = dep)
Higher score = increased independence
Areas of assessment
- Self care - grooming, bathroom skills, eating, dressing, mobility, transfers
- Household - money skills, meal prep, housecleaning, shopping, use of public transportation
Can be assisted
Wheelchair Skills Test
Performance based
Mean time to administer - 29 minutes
2 areas scored for each item - skills/safety and pass/fail or not tested (if easier skill was failed)
Forms for manual and power w/c (users and caregiver versions)
Skills such as driving, turning, transfers and curbs
SIP 68 (Sickness Impact Profile)
ADLs and IADLs
Measure of perceived function
Report or interview view
5-10 minutes
Add up number of checked items for each sub scale and for total scale (higher# = higher # of problems)
Areas of assessment
- Somatic autonomy (walking, dressing, stairs, bathroom use)
- Mobility control (stairs, inclines, distance walking, handiwork)
- Psychic autonomy and communication (concentration, thinking, decisions, speech)
- Social behavior
- Emotional stability
- Mobility range (into town, shopping, housework, business affairs)
SF-36
Self assessment or interview
About 10 minutes
Yes/no or 3 levels of measurement
Complex scoring (computer)
Lower scores represent poorer health
More for healthy community dwelling patients
Areas of assessment - physical functioning, physical role, social function, emotional role, mental health, energy/fatigue, bodily pain, general health perceptions
OASIS (Outcome and Assessment Info Set)
Mostly ADLs
Self assessment (takes longer, but get more info)
3 to 6 levels of measurement dependent on functional task
Higher scores for increasing dependence
Asks for prior and current level of functioning (what you could do before and what you do now)
- Big gap - can’t get back to PFS
- Small gap - can get back to PFS
Areas of assessment - bathroom skills, dressing, transfers, locomotion, feeding, housekeeping, transportation, telephone use
Recommended
FSQ
ADLs, IADLs
Self report - about 15 mins (scored by computer - produces warning zone)
Areas of assessment - physical function (BADL and intermediate ADLs - housework, errands, driving, sports), psychological function, work performance, social activity, quality of interaction, health satisfaction
Has work skills - capability to do work
FES (Falls Efficacy Scale)/Modified FES
Self report or interview
10 point scale (0 not at all confident to 10 completely confident)
Areas of assessment - 10 ADL skill in original version (cleaning, dressing, simple meals, bathing, simple shopping, in/out of chairs, walking in neighborhood, reaching into cabinets, hurrying to answer phone)
Modified version added using public transportation, crossing roads, light gardening/hanging laundry, using outside house steps
Ask men how afraid they are - won’t tell you anything
-How confident is better question to ask
SAFE (Survey of Activities and Fear of Falling in Elderly)
Self report or interview
11 activities ADLs and IADLs
4 levels - not worried to very worried
Asks if it is not due to fear or falling, why do you avoid activity
Have you reduced level of activity in past years
Areas of assessment - going out when slippery, visiting friends/relatives, go into places w/ crowds, walk several blocks, bend down to get something
Men won’t admit they’re worried
ABC (Activities-Specific Balance Confidence Scale)
Self report (5-10 mins)
Rated 0-100% confidence
Higher numbers increased confidence (less likely to need assistance to go out, more community activities)
Areas of assessment - reaching (eye level, over head, on tiptoes, standing on chair), picking up objects, ambulation (inside, outside, ramps, escalator, crowded mall, on ice), transfers (car)/stairs
Suitable for elderly who do activity outside home
Wider used to tool
How confident are you doing things
Ordered from easiest thing to do to hardest (confidence should go down)
Fear of Falling Avoidance Behavior Questionnaire
Self report - less than 3 mins to complete
5 levels of measurement (0-5)
Higher scores = increased activity avoidance
Areas of assessment - walking on level and uneven surfaces, carrying objects, stairs, transfers, leaving home, bathing, some IADLs, work, leisure
What are you avoiding and how much you are avoiding it
Combo of Self Report and Performance Based Measures
Patients w/ PD
Self report - ABC, FES
Performance - BERG, FRT, TUG, DGI
Two tests vs. three - best sensitivity/specificity w/ 3 tests w/ one being self report measure
Components of a Neurological Exam
Neurological history
Cognition
Communication
Cranial nerves
Muscle tone
Reflexes
Mental status (orientation/know where they are at)
Sensation
Perception
Strength
Mvt patterns
Balance
Coordination
Gait/locomotion
Functional abilities
Include concussions
Neurological History
Disturbance of consciousness
Nausea, vomiting (projectile - immediate ER - brain pressure)
Paresthesias - disturbances in sensation
Seizures (daydream all day and no sign when waving hand in front of them)
Headaches
Altered Vision (double vision - impending stroke)
Tinnitus (ringing in ears)
Vertigo, dizziness
Weakness, stiffness
Disturbances in B&B
Speech disorders
Incoordination
Cognition
Memory, judgement, attention span
Communication
Articulation deficits
Receptive language disorders - can’t understand
Expressive language disorders - can’t express what’s wrong/hurts
Mental Status
Orientation (to familiar or current environment)
Attention and state of consciousness
MiniMental State Exam (MMSE)
- <24 - cognitive impairment
- <20 - dementia/affective disorder
Mini-Cog (repeast 3 items, clock drawing, recall 3 items)
MoCA - Montreal Cognitive Assessment
10 minutes - screening test for mild cognitive impairment (MCI)
Max score - 30 - add 1 point for individual who has < 12 yrs of formal ed
26 and above considered normal
7 components - attention/concentration, executive function, language visuo-constructional skills, conceptual thinking, calculations, orientation
Sensory Testing
Provide baseline
Determine need to instruct patient in compensatory techniques
Assures pt safety and prevention of secondary complications - loss of sensation in pts w/ diabetes
Directed by recommended interventions - some modalities contraindicated w/ sensory loss
Assessment of Sensation - Protective
Pain via sharp/dull
Light touch
Deep pressure
Temp
Monofilaments
Loss of this group - injure body
Assessment of Sensation - Deep (Discriminative Sensation)
Vibration
Kinesthesia (jt is moving)
Proprioception (jt is static)
First sensations that are lost
Assessment of Sensation - Cortical (Discriminative Sensation)
Tactile Localization
Stereognosis
2 pt discrimination
Double simultaneous touch
Barognosis
Graphesthesia
Texture - perceive how it looks and then determine how hard/soft to drip something
Assessment of Sensation - Tinel’s Sign
Test for regrowth of peripheral nerve
New nerve - unmyelinated - painful
Assessment of Sensation - Functional Test
Modified Moberg’s Pick Up Test
Pick something up and move
Sensation loss - time increases for person
May need to pinch harder
Types of Neurological Lesions - Peripheral Nerve
Usually unilateral
Loss of all type of sensation in distribution of affected nerve
Sensory goes first, then motor
Types of Neurological Lesions - Nerve Root
Loss of all types of sensation in dermatome of affected nerve root (anything in pathway)
Usually unilateral
Types of Neurological Lesions - Spinal Cord
Loss of sensation is dependent on extent and area of spinal cord damage
Everything below damaged disc is gone
Types of Neurological Lesions - Diabetic Peripheral Neuropathy
Bilateral loss
Early in process, loss of vibration/temp
Prolonged disease, loss of protective sensation
Types of Neurological Lesions - Anterior Cord Syndrome
Anterior aspect is affected
Motor paralysis
Loss of pain/temp
Types of Neurological Lesions - Posterior Cord Syndrome
Loss of proprioception and light touch
Motor still in tact
Types of Neurological Lesions - Brain Stem
Sensory loss in contralateral side of body, except cranial nerve deficits, which occur on ipsilateral side
Types of Neurological Lesions - Cerebral Cortex
Sensory loss in contralateral side of body
Including ability to localize stimulation site (atopognosia)
Parietal lobe: loss of discriminative sensation (stereo, graph, sensory attention)
Loss of higher level sensation
Sensory attention - don’t really have sense for other side of body
Denervation
Loss of sensibility
Overlapping areas w/ decreased sensation
Recovery
- 1-2 mm per day
- Pain w/ pinch
- Tenderness to pressure and pinprick
- Light touch and discrimination
- Poorly localized (know someone is touching body part, but don’t know where)»_space; accurate localization (as receptors grow in, becomes accurate localization)
- Hypersensitivity - uncomfortable, but normal (need to tell pt it’s okay)
Compression
Sensory fibers are more susceptible than motor
Diminished vibratory perception precedes intermittent numbness and paresthesia
In more advances cases, symptoms are more constant and include sensibility test findings
In chronic cases, motor abnormalities occur
Small areas go first
Continous compression - starts to affect motor
Recovery from Compression
Dependent on severity
Mild - spontaneous recovery if compression is removed
Moderate-severe - surgical intervention
- Immediate, full recovery
- Gradual, full recovery
- Partial recovery
General Principles of Testing
Pt positioned comfortably w/ all areas to be tested exposed and accessible (if pt will have problems w/ balance when eyes closed, place pt is fully supported position - i.e. supine)
Procedure should be explained to pt BEFORE beginning exam
Establish area of normal sensation to use for comparison
Vision obscured during testing
Exam proceeds distal to proximal along sensory distribution
Variables in Sensory Testing
Testing environment - conditions around
Pt anxiety, distractibility, cognition, fatigue, etc
Callused vs. non-callused skin
Instrumented related variables (temp of tubes, filaments)
Method related variables (different equip b/w sessions)
Documentation
Status of sensation - intact, impaired, absent
Type of sensation
Location of testing
Sensory mapping
Not okay to say only “sensation is impaired”
Evaluation
Exam results are analyzed for pattern
Pattern should be interpreted to determine one or more possibilities for location of lesion
Other symptoms of NS pathology must be considered
Clarification of location of lesion should occur (medical tests)
Clinical Test for Sensory Interaction for Balance (CTSIB) or Foam and Dome
Visual, somatosensory (proprioception and kinesthesia), vestibular system
Tests for redundancy - which part of balance system is off
6 conditions under different sensory inputs:
- 1: eyes open, stable surface (normal)
- 2: eyes closed, stable surface (vision is absent)
- 3: visual conflict w/ moving surround/dome, stable surface (eyes are inaccurate)
- 4: eyes open, moving surface/foam (vestibular in tact)
- 5: eyes closed, moving surface/foam (vestibular in tact)
- 6: visual conflict w/ moving surround/dome, moving surface/foam (inaccurate vision and somatosensory, only rely on vestibular system)
First 3 on the floor, so somatosensory is available
Last 3 on foam, so somatosensory info is inaccurate
How are they using sensations to balance body
Perception
Gather sensory info and make decisions
Body scheme/image - how they feel about the body
Spatial relations - where am I in relation to other people and objects
Agnosias
Apraxias - ideomotor and ideational
Agnosias
Inability to recognize objects
Apraxias
Without mvt
No capability to induce mvt, even though you want to
Can see contraction of muscles, pt can’t get it to happen - DTRs in tact
Ideomotor
Can’t connect idea to motor output
Ex: tell patient to lick lips - can’t listen to command; however, once something is on lips, they’ll lick it
Ideational
Do something wacky w/ object
Idea w/ what to do w/ that object is wrong
Tonal Examination - Observation
At rest and during mvt
Flexor or extensor synergies
Flexor or Extensor Synergies
For LE, flex synergy is hip flex/abd/ER, knee flex, ankle DF (frog legs)
Extension is opposite
All muscles are bound (ex: hip flex to 90 degrees in sagittal plan is unable to occur - need to abduct out)
Flexion synergy - can’t walk
Tonal Examination - Appearance
Atrophy - lower muscle bulk, feels squished
Pseudohypertrophy - false hypertrophy; look big, but may not be able to do mvt b/c strength isn’t there
Fasciculations - fluttering of muscle fibers (portion of muscle fibers, not whole muscle)
Tonal Examination
Observation, appearance, palpation (consistency)
Muscle Tone - Tests
Passive mvt - changing speed and performing reversals
Pendulum test - used to assess spasticity (quads - extend knee and drop to see how quads would react)
Drop arm test - best to test integrity of automatic proprioceptive rxns (hold arms and then let go)
DTRs
DTR Nerves
Jaw - trigeminal
Biceps - C5
Brachioradialis - C6
Triceps - C7/8
Patellar - L2-4
Ankle - S1/2
Muscle Tone - Definition
Resistance of muscle to passive stretch
May be due to - physical inertia, intrinsic mechanical-elastic stiffness of muscle and CT, reflex muscle contraction
Categorized as - hypertonia, hypotonia, dystonia
Too many cross-bridges - high/low tone
Hypertonia
Too much tone
Spasticity - increases at increased speed
Clasp-knife reflex - keep pulling; at certain pt, it just drops b/c low tone
Clonus - keeps reflexing
Rigidity
Similar amount at all speeds
Cogwheel - slowly notching out (same whether you go fast or slow)
Leadpipe - lots of resistance when bending, but then it gets easier closer to midline
Decerebrate - ext of all extremities (taking off cerebrum and left w/ lower brain centers)
Decorticate - UE flexed, LE extended (remove cortex)
Hypotonia
Decreased muscle tone
Decreased DTRs, may appear weak
Flaccidity - no tone (denervated muscle)
Peripheral nerve injury - those muscles have no tone and don’t work)
Dystonia
Dystonic posturing - sustained muscle contractions that result in twisted mvts and abnormal posture
Segmental/focal - one specific part
Hemidystonia - half body
Generalized - whole body
Action induced - need to do action
Posture induced - induced by posture (ex: laying down vs. standing up)
Tonal Grading
General clinical scale
0 = no response (flaccid)
1 = decreased response (hypotonia)
2 = normal response
3 = exaggerated response (mild to moderate hypertonia)
4 = sustained response (severe hypertonia)
Scale for Spasticity - Modified Ashworth Scale for Spasticity
0 = no increase in tone
1 = slight increase (catch and release)
1+ = slight increase (initial catch followed by min resistance thru partial range)
2 = increased in tone thru/out most of range
3 = increased tone, passive mvt difficult
4 = rigid in ext and flexion
Scoring for DTRs
0 = no response
1+ = decreased response
2+ = normal response (slight muscle contraction w/ slight mvt)
3+ = exaggerated response (brisk muscle contraction w/ moderate jt mvt)
4+ = clonus (1-3 beats)
5+ = sustained clonus
Factors that Influence Tone
Position and interaction w/ tonic reflexes
Stress and anxiety
Volitional effort and mvt
Meds
State of CNS arousal
Environmental temp (shivering - higher level of tone; warm - mushy tone)
General health - fever, infection, metabolic/electrolyte imbalance
