Quiz 4 Flashcards
why do we do a neurologic screen?
to ID red flags
to obtain data for differential dx
guidance for tool selection
to ID need for referral
to obtain baseline for the pt
to ID changes over time
what is a screening?
brief
determines need for detailed exam
screens for red flags
determines need for referral
what is an examination?
focused search for origins
ID system-related impairments that could contribute to activity and participation limitations
what belongs in a screen?
observation
reflex testing
motor assessment
sensation
coordination
balance
CN screen
what is a part of observation?
posture and general symmetry
muscle appearance
involuntary movements (tremors, bradykinesia, hypokinesia)
what is included in a mental status screen?
alert and oriented
memory screen
general behavior
what pathways are testing in UMN testing?
DCML pathway
corticospinal tracts
corticobulbar tracts
where does the DCML cross?
at the medulla
what sensations is the DCML responsible for?
proprioception, kinesthesia, discriminitive touch, stereognosis, tactile pressure, graphesthesia, recognition of texture, 2 point discrimination, vibration
where do the corticospinal tracts go to and from?
cortex to SC just proximal to the ant horn cell
where do the corticobulbar tracts go to and from?
cortex to CNS
what is the UMN presentation?
muscles paresis
hypertonicity (spasticity or rigidity)
hyperreflexia
abnormal reflexes
weakness not focal
(+) special/pathologic tests
what are the UMN pathologies?
TBI
stroke
SCI
any disorder affecting the cerebrum, BS, or SC
what is dystonia?
prolonged involuntary movement, twisting, or writhing repetitive movements
UMN
what is hypertonia?
increased resisitance to PROM
UMN
what is hypotonia?
decreased resistance to PROM
LMN
what is spasticity?
velocity-dependent increase in muscle tone
UMN
what is rigidity?
velocity-independent increase in muscle tone
increased resistance to movement throughout ROM in both directions
BG
UMN
how do we test for spasticity in flexors?
have pt in a comfortable relaxed position
begin by moving the jt slowly into flex, then ext, increasing speed gradually with repetition
quickly pull into extension
how do we test for spasticity in extensors?
pt in a comfortable relaxed position
begin by moving the jt slowly into ext, then flex, increasing speed gradually with repetition
quickly pull into flexion
what is a grade 0 in the modified ashworth scale of UMN testing?
no increased in muscle tone
what is a grade 1 in the modified ashworth scale of UMN testing?
slight increase in muscle tone, manifested by a catch and release or by min resistance at the end of the ROM when the affected part(s) is moved into flex/ext
what is a grade 1+ in the modified ashworth scale of UMN testing?
slight increase in muscle tone, manifested by a catch, followed by min resistance throughout the remainder of the ROM (<1/2)
what is a grade 2 in the modified ashworth scale of UMN testing?
more marked increase in muscle tone through most of the ROM, but affect part(s) moves easily
what is a grade 3 in the modified ashworth scale of UMN testing?
considerable increase in muscle tone, passive movement is difficult
what is a grade 4 in the modified ashworth scale of UMN testing?
affected part(s) rigid in flex/ext
what are the special/pathological tests for UMNs?
pronator drift test
clonus testing
Babinski sign
Hoffman sign
what is the pronator drift test?
stadnw with both arms flexed to 90 deg
palms up/forearms supinated
eyes closed
maintain position for 20-30 seconds
(+) test: downward drift of one arm
what is clonus testing of the LE?
tested at the ankle
knee should be slightly flexed
being slowly moving from DF to PF several times
then quickly jerk into DF with hold
what is clonus?
rapid, reflexive, back and forth motion that continues for multiple cycles
what is clonus testing of the UE?
tested at wrist
slowly move the wrist into flex/ext
then quickly jerk into ext
what is the test for the Babinski sign?
pt positioned in supine w/skin below the ankle exposed
using the end of the reflex hammer, firmly and quickly stroke the object upward along the palmar side of the foot
move up toward the toes from the calcaneus and move medially across the metatarsal region
(+) test: toe ext and abd (fanning of toes)
what is the test for the Hoffman sign?
flick the distal phalynx of the middle finger into flexion
(+) test: flex of 1st/2nd DIPs
what is a (+) Hoffman sign suggestive of?
CNS lesion
cord compression
should the Hoffman sign be viewed in isolation?
no!
when should UMN testing be on the front burner?
when we need to add evidence for suspected CNS lesion
when should UMN testing be on the back burner?
if there’s no clinical evidence pointing to UMN
what is the purpose of deep tendon reflex testing?
testing for sensory-neuromotor integrity by stimulating a monosynaptic stretch reflex (response)
what is the procedure for DTR testing?
place extremity in a relaxed position
locate the tendon of the muscles being tested
loosely grip the reflex hammer
strike the tendon directly or protect the tendon with your thumb and strike the thumb
observe/record response
what are common DTR testing locations?
tendon of biceps, brachioradialis, triceps, quads, and Achilles tendon
what is a 0 in DTR reflex testing?
no reflex
what is a 1+ in DTR reflex testing?
min/depressed reflex
what is a 2+ in DTR reflex testing?
normal response
what is a 3+ in DTR reflex testing?
overly brisk response
what is a 4+ in DTR reflex testing?
extremely brisk response w/clonus
what is a 5+ in DTR reflex testing?
sustained clonus
t/f: DTR testing should be compared bilaterally
true
t/f: DTR grades of 1+ through 3+ are normal unless assymetric
true
what is the nerve root of the biceps?
C 5-6
how is the biceps DTR tested?
sitting, arm ext, palpate biceps tendon and tap with thumb over tendon
what is the response for biceps DTR testing?
elbow flex
what is the nerve root of the brachioradialis?
C6-7
how is the brachioradialis DTR tested?
sitting, arm at the side, palpate the brachioradialis, tap the muscles belly or tendon at the radial tub
what is the response of brachioradialis DTR testing?
elbow flex w/slight supination
what is the nerve root of the triceps?
C6-8
how is the triceps DTR tested?
sitting with arm supported in abduction, hit at the triceps tendon, proximal to the elbow
what is the response of triceps DTR testing?
elbow extension
what is the nerve root of the patellar tendon?
L3-4
how is the patellar tendon DTR tested?
sitting with leg bent over the edge of the chair, tap the patellar tendon
what is the response of patellar tendon DTR testing?
knee extension
what is the nerve root of the hamstrings?
L5, S1-2
how are the hamstrings DTRs tested?
prone with knee semiflexed and supported, tap on finger directly over tendon at knee
what is the response of hamstring DTR testing?
slight contraction of knee flexors
what is the nerve root of the Achilles tendon?
S1-2
how is the Achilles tendon DTR testing?
sitting with leg bent over edge of chair, ankle in DF, tap Achilles tendon
what is the response of Achilles tendon DTR testing?
ankle PF
when is DTR testing on the front burner?
when s/s suggest UMN/LMN involvement
if pt’s symptoms are worsening
when is DTR testing on the back burner?
with conditions unrelated to the NS
post op tendon/lig repair, ankle sprain, etc
if dx is already present and well established, DTR won’t give any new info
what is an example of documenting DTR testing?
patellar (L4) R 1+, L 2+; Achilles (S1) R 2+, L 2+
3+ B for patellar and Achilles tendons (2+ for all UE DTRs B)
what are the LMN pathologies?
peripheral nerve injury
radiculopathy
peripheral neuropathy
polio
GBS
ALS
what is the presentation of a pt with a LMN lesion?
paralysis
hypotonia
hyporeflexia
fasciculations
ipsi weakness
- segmental/focal pattern
- atrophy from denervation
what is the order of clinical return of sensory nerve fxn?
1) pain and temp
2) moving touch, 2-point discrimination
3) constant touch and static 2-point discrimination
4) 256 hz vibration
what are the sedden classifications of nerve injury and their corresponding Sunderland classification?
neuropraxia (1)
axonotmesis (2)
neurotmesis (5)
what is involved in Sunderland grade 1 nerve injury?
conduction block
myelin sheath damage
what is involved in Sunderland grade 2 nerve injury?
axonal discontinuity
myelin sheath and axon damage
what is involved in Sunderland grade 3 nerve injury?
myelin, axonal and endoneural disruption
what is involved in Sunderland grade 4 nerve injury?
perineural rupture and fascicle disruption
myelin, axon, endo, and peri damage
what is involved in Sunderland grade 5 nerve injury?
nerve trunk discontinuity
myelin, axon, endo, peri, and epi damage
when is the Wallerian degeneration in nerve injury?
axonotmesis and neurotmesis
2nd-5th degree
what are myotomes?
defined group of muscles supplied by a single nerve root
what is the muscle action of the C1 myotome?
capital flexion
what is the muscle action of the C2 myotome?
cervical flexion
what is the muscle action of the C3 myotome?
cervical lateral flexion
what is the muscle action of the C4 myotome?
scap elevation
what is the muscle action of the C5 myotome?
shoulder abd, elbow flex
what is the muscle action of the C6 myotome?
wrist ext
what is the muscle action of the C7 myotome?
elbow ext
what is the muscle action of the C8 myotome?
thumb ext, finger flex
what is the muscle action of the T1 myotome?
finger abd
what is the muscle action of the L2 myotome?
hip flex
what is the muscle action of the L3 myotome?
knee ext
what is the muscle action of the L4 myotome?
ankle DF
what is the muscle action of the L5 myotome?
great toe ext
what is the muscle action of the S1 myotome?
ankle PF
what is the muscle action of the S2 myotome?
knee flex
what muscle does the long thoracic nerve innervate?
serratus anterior
what muscle does the suprascapular nerves innervate?
supraspinatus and infraspinatus
what muscle does the axillary nerve innervate?
deltoids
what muscle does the musculocutaneous nerve innervate?
biceps
what muscle does the radial nerve innervate?
high: triceps
mid humerus: wrist extensors, MCP extensors, thumb retropulsion
distal: sensory only
what does the proximal median nerve innervate?
wrist flexors
ape hand
benedictine sign
what does the distal median nerve innervate?
thenar eminence
ape hand
what does the proximal ulnar nerve innervate?
claw hand
what are the peripheral nerve deformities?
ulnar claw deformity
benedictine sign
ape hand deformity
what does the obturator nerve innervate?
obturator externus
adductor compartment
what does the femoral nerve innervate?
illiacus
pectineus
sartorius
quads
what does the tibial nerve innervate?
muscles of posterior calf
what does the common fibular nerve innervate?
anterior leg muscles
lateral leg muscles
intrinsic muscles
what does the superior gluteal nerve innervate?
glut med
glut min
TFL
what does the inferior gluteal nerve innervate?
glut max
what does the sciatic nerve innervate?
posterior thigh muscles
when should motor assessment be on the front burner?
if suspected nerve root pathology is present
used to differentaite bw nerve root dysfxn and injury to peripheral nerve
determine involvement of SCI
can be done for quick screen
when should motor assessment be on the back burner?
in conditions unrelated to spinal nerve root pathology
not a priority in orthopedic cases where nerve root pathology is low/absent
what is an example of a motor exam documentation?
weakness (4-/5) in R ankle DF (L4) an great toes extension (L5); no pain upon resistance. R L2, L3, S1 myotomes all 5/5; L L2-S1 5/5
what is an example of a motor exam assessment in documentation?
pt’s s/s consistent w/R L4-5 nerve root dysfxn based on reported pain and paresthesia pattern and determined strength in L4-5
t/f: peripheral nerve injuries generally present w/impairments that parallel the distribution of the involved nerve
true
what is the pattern of sensory loss in DM?
early symptoms w/stocking-glove distribution in peripheral neuropathy
t/f: with CNS involvement, there is generally a more diffuse pattern of sensory involvement
true
the following indicates a lesion to what tract(s)? :
contra loss of pain and temp
lesion of the antero-lateral tracts
the following indicates a lesion to what tract(s)? :
loss of vibration or 2 point discrimination
lesion of DCML
t/f: sensory and motor loss is usually indicative of nerve root involvement
true
what structures are involved in sensory exam?
primary sensory cortex
secondary sensory cortex
homunculus
what is the sequencing of the sensory exam?
superficial senses examined first
then deep senses
then cortical senses
if there is no superficial sense of touch, usually don’t proceed to proprioceptive and kinesthetic assessments or cortical assessments
distal to proximal
what needs to be documented in a sensory exam?
modality of testing
quantity of involvement or body surfaces assessed
deg of severity (absent, impaired, delayed)
localization of sensory impairment
impact of sensory loss of fxn
what is the C3 dermatome?
lateral neck
what is the C4 dermatome?
over the clavicle
what is the C5 dermatome?
lateral upper arm
what is the C6 dermatome?
thumb
what is the C7 dermatome?
middle finger
what is the C8 dermatome?
medial border of the hand
what is the T1 dermatome?
medial forearm
what is the T2 dermatome?
medial upper arm close to the axilla
what is the L1 dermatome?
anterior groin
what is the L2 dermatome?
middle to upper anterior thigh
what is the L3 dermatome?
middle to lower medial thigh
what is the L4 dermatome?
medial aspect of the foot to great toe and proximal lateral thigh to medial tibia
what is the L5 dermatome?
central dorsum of foot and ankle
what is the S1 dermatome?
lateral aspect of the foot and ankle
what is the S2 dermatome?
middle posterior thigh
what are the superficial sensations testing?
pain
temp
touch awareness (light touch)
what are deep sensations testing?
kinesthesia
proprioception
vibration
what are combined cortical sensations testing?
stereognosis
tactile localization (performed w/touch awareness)
2 point discrimination
what is involved in the sensory exam of pain?
sharp vs dull discrimination (protective sensation)
toothpick and q tip or paperclip
apply randomly
apply light pressure, not a swiping motion
what is involved in the sensory exam of temp?
using test tubes of water (warm and cold)
use the side of the test tubes, not the tip
randomly apply and assess perception of sensation
pt will reply verbally “cold” or “hot” after each stim application
what is involved in the sensory exam of touch awareness?
light touch:
- cotton swab, camal hairbrush, tissue, fingers gently rub across an area
- ask pt if they recognize the stim saying “yes” or “now”
pressure perception:
- use fingertip or double tip cotton swab
- apply firm pressure on skin enough to indent the skin, but no enough to cause pain
- pt asked to ID when they feel the response
what is sensory extinction?
feeling only one side when both sides are stimulated (unilateral neglect in CVA)
touching 2 points and the pt only feels one
what is involved in the sensory exam of kinesthesia?
small amounts of passive motions are performed
larger jt motions will be more discernable than smaller
therapist should maintain loose grip
PT demonstrates movements to pt with eyes open
pt asked to ID the direction of the movement
pt can also duplicate the motion w/the opposite limb
why shouldn’t you grip the plantar and dorsal side of the foot in kinesthesia testing? how should you grip the foot?
bc the pt can still sense pressure on the foot and can possibly descern the movement from the pressure
instead, grip the sides of the hand, toes, fingers, wrist, or foot
what is involved in the sensory exam of proprioception?
the jt is moved through a portion of ROM and held static
pt asked to ID ROM previously described by the therapist (initial, mid, terminal)
therapist hold jt in static position
pt asked to describe the position
pt can also be asked to duplicate the position
‘
pt can also duplicate position with contra limb
what is kinesthesia?
awareness of movement
what is proprioception?
jt position sense and awareness of jts at rest
what is involved in the sensory exam of vibration?
place the tuning fork (128 hz) on a bony prominence
alternate bw vibration/non-vibration
pt should perceive the vibration by verbally telling the PT if there is vibration or not
best to use headphones if available bc the auditory cue of the tuning fork can cue the pt to the correct response
t/f: deep sensations and combined cortical sensations are not check at the dermatomal level, but at bony prominences
true
t/f; you need at least 2 of the following sensations to maintain static balance: vision, somatosensation, and vestibular systems
true
what is involved in the sensory exam of stereognosis?
small objects used that are easily obtainable, cultural, and familiar (keys, coins, combs, paper clips, pencils, etc)
place an object in the pt’s hand for manipulation and identification
allow the pt to handle several samples prior to starting the test
modification for speech impairment using blinding and pics
what is stereognosis?
ability to recognize the form of an object by touch
what is involved in the sensory exam of 2 point discrimination?
2 points are applied simultaneously w/ equal pressure and gradually moved closer together to determine the smallest distance they can differentiate
varies bw individuals and body parts
an aesthesiometer and circular 2 point discriminator can be used or 2 paper clips
apply gradually reducing distances bw 2 points
alternate w/occasional single point
have pt verbally respond “one” or “two”
what is 2 point discrimination?
ability to perceive 2 points applied simultaneously
measures the smallest distance b/w 2 stimuli
what is involved in quantitative sensory threshold testing?
using monofilaments
pressures vary from 0.026 g to 100g
apply filament perpendicular to skin until it bends
apply 3x at each side
apply gradually thicker filament until the pt can perceives pressure w/vision occluded
what is involved in the sensory exam of peripheral neuropathy?
sensory testing for tactile sensation and proprioception
apply stim for light touch, dull, temp, vibration, pressure
test pressure sensation in specific areas of the foot using force applied through monofilaments
determine pt awareness of pressure (protective sensation)
how many sensory sites are there on the dorsum of the foot?
3
how many sensory sites are there on the plantar side of the foot?
9
what is meant by “loss of protective sensation”?
inability to detect 10g of force applied through a 5.07 monofilament
when should sensory testing be on the front burner?
any pt w/NS involvement should include both sensory items from posterior columns and spinothalamic tracts
pt with DM or any other disease that could affect distal sensation
suspected nerve root involvement (LBP)
when should sensory testing be on the back burner?
should rarely be on the back burner
should be screened frequently
what is the fxn of CN 1(olfactory nerve)?
smell
how is CN 1 tested?
2-3 very distinct smelling items waved under pt’s nose with their eyes closed under each nostril separately
strength of scent should be the same bilaterally
what items can be used for testing CN 1?
coffee beans, peppermint, lemon, cinnamon, cloves
what would be an abnormal finding with CN 1 testing?
anosmia (inability to detect smells)
what is the fxn of CN 2?
afferent
light detection and red saturation
vision
how is CN 2 tested?
Snellen eye chart for visual acuity
have PT read from largest to smallest 20 feet away
perform each eye separately
peripheral vision screen (look at your nose while bringing your finger into from the side and ask when they see it w/o looking away from finger)
what would be abnormal findings in CN 2 testing?
field deficits
blindness, impaired near vision
what does 20/20 vision mean?
subject at 20 feet is equal to visual acuity of a person with normal vision at 20 feet
what does 20/40 vision mean?
visual acuity of subject at a 20 foot distance is equal to visual acuity of a person w/normal vision at 40 feet
what is the fxn of CN 3?
efferent
sup rectus muscle (elevation and adb)
inf rectus (depression and abd)
pupillary constriction
how is CN 3 tested?
have PT follow your finger in an H pattern w/o moving their head
use a pen light to shine in the eyes, contra and ipsi pupil should constrict
what would be abnormal findings in CN 3 testing?
absence of pupillary constriction
lateral strabismus
diploplia pr nystagmus
impaired eye movements
what 3 CNs are tested together?
3, 4, 6
what is the fxn of CN 4?
efferent input to sup oblique muscle (depression and add)
how is CN 4 tested?
H movement
bring your finger towards the pt’s nose - both eyes should converge (move downward and inward)
what would be abnormal finding in CN 4 testing?
lateral strabismus
medial strabismus
diploplia or nystagmus
impaired eye movements
what is the fxn of CN 6?
efferent lateral rectus (abd)
how is CN 6 tested?
H movement
observe specifically for abduction
what is the double H movement assessing?
smooth pursuits
what would be abnormal findings in CN 6 testing?
lat strabismus
med strabismus
diploplia or nystagmus
impaired eye movements
how far should you be from the pt when testing CN 3, 4, 6?
2 feet
what eye muscles in CN 3 responsible for?
sup rectus
med rectus
inf rectus
inf oblique
what eye movements is CN 3 responsible for?
moves eye up, down, and medially
what muscle is CN 4 responsible for?
sup oblique
what eye movement is CN 4 responsible for?
moves the adducted eye downward
what muscle is CN 6 responsible for?
lateral rectus
what eye movements is CN 6 responsible for?
eye abduction
what is the fxn of CN 5?
efferent: muscles of mastication
afferent: facial sensation
how is CN 5 tested?
w/eyes closed, perform light touch of the pt’s face (forehead, cheeks, and lateral jaw
palpate the masseter and temporalis muscles bilaterally with the pt clenches their jaw
direct pt to open jaw slightly and provide resistance to mandibular closing and/or lateral motion (w/tongue depressor)
what would be abnormal findings in CN 5 testing?
loss of facial sensation
trigeminal neuralgia
weakness, wasting of muscles
deviation of the jaw to the ipsi side
assymetry of jaw strength
what is the fxn of CN 7?
afferent: taste (ant 2/3 of tongue)
efferent: facial muscles (facial expression)
how is CN 7 tested?
assess motor fxn of the facial muscles by asking pt to elevate eyebrows, puff out cheeks, smile, and frown
assess taste by having pt close their eyes and stick out their tongue while you place something sweet on the tongue
what would be abnormal findings of CN 7 testing?
paralysis
inability to close eyes
difficulty w/speech articulation
decreased taste
what could unilateral LMN lesion be indicative of?
Bell’s palsy
what could bilateral LMN lesion be indicative of?
GBS
what could unilateral UMN lesion be indicative of?
stroke
what is the fxn of CN 8?
afferent hearing, detection of head movement, balance
how is the cochlear branch of CN 8 tested?
have PT close their eyes and rub the pads of your thumb and forefinger together next to one ear and ask for indication of when sound is heard
how is the vestibular branch of CN 8 tested?
stand unsupported w/eyes closed for 30 sec (Romberg test)
what would be abnormal findings of a CN 8 test?
vertigo
decreased balance
gaze instability
deafness/impaired hearing
is CN 9 assessed frequently?
not really
what is the fxn of CN 9?
afferent: taste (post 1/3 of tongue)
efferent: salivation
how is CN 9 tested?
place something sour/bitter on the posterior 1/3 on the pt’s tongue
have PT open their mouth and say “ahhhh” and observe the uvula (should be centered)
ask pt to swallow
test gag reflex w/tongue depressor
what is the fxn of CN 10?
afferent and efferent pharynx and larynx
viscera
efferent for one extrinsic tongue muscle
how is CN 10 tested?
same as CN 9
what would be abnormal findings for CN 10 testing?
dysphonia (hoarse voice)
dysphagia (difficulty swallowing)
dysarthria (difficulty articulating words)
what is the fxn of CN 11?
efferent upper trap and SCM
how is CN 11 tested?
ask pt to shrug their shoulders and then rotate their head applying resistance and asking the pt to hold the position
what would be abnormal findings in CN 11 testing?
LMN = atrophy, fasciculation
weakness
what is the fxn of CN 12?
efferent tongue movements
how is CN 12 tested?
have the pt stick out their tongue
observe for side to side deviation or atrophy
have PT move tongue side to side and observe for smooth movements
if a pt can’t stick out their tongue straight, what is this indicative of?
a unilateral lesion of CN 12
if there is an UMN lesion of CN 12, what would you see?
deviation do the tongue away from the lesion
if there is a LMN lesion of CN 12, what would you see?
deviation do the tongue towards the lesion
what would be abnormal findings of CN 12 testing?
atrophy or fasciculation of the tongue
impaired movement and deviation of the tongue towards the weak side
when should CN testing be on the front burner?
in the presence of known/suspected brain injury
in known or suspected progressive NM disease that affects BS or brain (ALS)
if there are any changes in facial expression
when should CN testing be on the back burner?
if typical s/s aren’t observed
what is an example of documentation for CN testing?
dysfxn noted B with CN 2 and 3 (pupillary constriction), CN 5(decr masseter and temporalis muscle strength), CN 6 (ocular abduction), CN 8 (decr hearing), and CN 9 and 10 (swallowing)
b4 doing an in depth exam of sensory fxn, we must determine what 2 things?
1) ability to concentrate
2) ability to respond to stimuli
what 5 things are measured in cognition testing?
1) arousal
2) attention span
3) memory
4) orientation
5) cognition
what is arousal?
pt’s ability to respond
responsiveness to sensory stim
what does alert mean?
awake and attentive to normal stimuli
what does lethargic mean?
sleepy, have to redirect to keep on track
what does obtunded mean?
difficult to arouse from a solemn state and confused when awake
what does stupor mean?
semi-comatose state responding only to strong and noxious stim
what does coma mean?
no arousal regardless of stim
what is attention?
selective awareness of the environment
responsiveness to stim/task w/ being distracted by other stim
what is orientation?
a person’s awareness of time, person, place (or space)
how would you document a pt who is alert and oriented to person and time, but not place?
AAO x2 (place)
what is cognition?
method of CNS to process info
the process of cognition includes…
knowledge
understanding
awareness
judgement
decision making
t/f: cognitive and perceptual capacity are pre-requisits for learning
true
what are the components of an exam of cognitive fxn?
orientation
comprehension
memory
executive fxn
problem-solving
cognition and task completion
motor planning
what is the purpose of the mini cog assessment?
cognition SCREENING tool consisting of multiple domains
what are the components of the mini cog assessment?
combo of 3 word recall and clock drawing test
paper and pencil instrument completed by therapist with pt
who is the mini cog assessment used for?
pts with stroke, progressive dementia, and older adults
what is the purpose of the mini mental state exam (MMSE)?
screening cognitive impairment an recording cognitive changes over time
how long does it take to complete the MMSE?
<10 minutes
what population do we use the MMSE on?
adults 18-64 and 65+
what is the MMSE composed of?
paper and pencil instrument scored by the examiner
is the mini cog or MMSE more robust?
the MMSE
how many items are included in the MMSE?
11 items assessing 7 cognitive domains
orientation to time and place
registration and recall of 3 words
attention and calculation
language
visual construction
30 possible points
what are the psychometrics for the MMSE?
for subjects with mild cog impairment-low sensitivity and unable to detect change
adequate interrater reliability
MDC=3 points
what are the considerations for the MMSE?
limited detection of dementia
best to use in conjunction w/other cog testing
criticized for low reliability and “too many easy items”
prone to ceiling effect in pts w/minimal cog impairments
what is the cutoff score for the MMSE?
<24
what does a MMSE score of 24-30 mean?
no cognitive impairment
what does a MMSE score of 18-23 mean?
mild cognitive impairment
what does a MMSE score of 0-17 mean?
severe cognitive impairment
what is the Montreal cognitive assessment (MoCA)?
quick cog assessment of memory, language, attention, visuospatial skills, orientation and abstraction to detect mild cog dysfxn
what is the population for the MoCA?
18-65+
validated for large population
which covers more domains, the MoCA or mini cog?
MoCA
what is the max score of the MoCA?
30
how long does it take to administer the MoCA?
10 minutes
which cognitive assessment requires a training course and certification?
MoCA
what are the psychometrics for the MoCA?
for subjects with mild cog impairements-high sensitivity and able to detect cog change
excellent interrater reliability
what are the considerations for the MoCA?
able to detect mild cog impairments
greater emphasis on attention and executive fxn than MMSE
no ceiling effect
what is the cutoff score of the MoCA?
> 26 is considered normal
what do you do to the MoCA score if a pt has less than 12 years of formal education?
add 1 point to the overall score
t/f: the MoCA has more reliable change when compared to the MMSE
true
what is agnosia?
inability to recognize an object and interpret it (visually or tactilely)
what is apraxia?
impairment of voluntary skilled movements not as a result of impairment of strength, coordination, and attention
when should cognitive assessments be on the front burner?
when the pt or family are reporting “forgetfulness”
there is a hx of or suspected dementia
there is a change in mental status bw days or visits
when should cognitive assessments be on the back burner?
when the pt is young and healthy
when pt has no hx of brain injury or CNS lesions
what is coordination?
ability to execute smooth, accurate, and controlled movements
what NS structures are involved in coordination?
cerebellum, BG, and DMCL pathway
what is the typical progression of difficulty and order of testing for coordination and balance?
unilateral testing–> bilateral symmetrical tasks–> bilateral asymmetrical tasks–> multi limb tasks
what are the 4 keys areas of coordination testing?
1) reciprocal motion
2) movement composition (synergy)
3) movement accuracy
4) fixation or limb holding
what are the UE tests for coordination?
rapid alternating movement (pro/sup)
finger tapping/finger opposition
finger to nose (or chin)
finger to clinician finger (tapping finger as it moves around)
what are the LE tests for coordination?
heel to shin (most common LE coordination test)
toe tapping (something heel to toe)
what are you looking for with coordination testing?
gross and fine motor coordination of specific skills
how long it takes to complete the tasks
eyes open vs closed
accuracy
if speed affects quality
what would an ataxic pt show in heel to shin testing?
inaccurate movements
what would a hyperkinetic pt show in heel to shin testing?
fast movements (increased amplitude)
t/f: documentation of coordination lacks standardization and reliability
true
what should be included in the documentation of coordination testing?
length of time to complete
narrative of impairment (dysmetria, tremor, etc)
what are the types of balance?
static (steady state0 postural control
reactive postural control
proactive (anticipatory) postural control
what are the sensory systems for balance?
vision, somatosensory, and vestibular (need 2/3)
what are the tests for static balance?
Romberg test (feet together EO and EC)
sharpened Romberg position (tendem EO and EC)
single limb stance test (EO and EC)
how do we exam sensory strategies?
Romberg test
sensory organization test
MCTSIB
how should all coordination and balance testing start in terms of positioning?
arms crossed over the chest with EO
time and quality should be measured and documented
what are the reactive balance tests?
nudge/push test
mini best
FIST
functional reach test
what is the procedure for the nudge/push test?
guard the pt
ask pt to stand quietly and comfortably with eyes open
tell pt you will nudge them in various directions and they must maintain upright stance
quickly but gently nudge the pt at random intervals from the front, back, and side (push at sternum, pelvis, or shoulders)
what is the mini BEST test?
lean hard into PT and randomly let go to test the reactive balance
what is the FIST test?
non ambulatory option for reactive sitting balance
what is the fxnal reach test?
screens/assesses pt’s stabil;ity by measuring max distance they can reach while standing/sitting without stepping out of lifting heels (if standing)
fair psychometrics
cutoff score of <18.5 cm (indicates fall risk)
2 practice trials and 3 test trials
how do you document for balance?
Norma, good, fair, poor, absent
when should coordination and balance testing be on the front burner?
hx of falls/episodes of instability
reports of “dizziness”
CNS disorder that affects postural instability
general deconditioning/weakness
recurrent LE injuries (ankle sprains)
use of AD for ambulation
anyone over 65 yo
when should coordination and balance testing be on the back burner?
no known balance difficulties
no hx of falls/FOF
visual, vestibular, somatosensory systems are all perfect
