Practical
Assessment
Session 1
Assessment skills
Curtis Wong
(Special acknowledgement to Prof. Margaret Mak
for contributing the presentation slides)
Objectives: To learn the assessment skills for
examining impairments of motor and sensory systems
Assessing impairment
Motor system
Motor system
Joint function
◼ Passive ROM – upper, lower limbs, trunk,
muscle length
Muscle strength
◼ Oxford muscle testing, dynamometer
Isolated (selective) control vs mass pattern
Muscle size
◼ Atrophy
Assessing impairments
Muscle tone
The stiffness or tension within a muscle at rest
Tonic stretch reflex
Stimulus → Response
Testing procedures
◼ Instruct patient to relax
◼ Passively move a joint or trunk through available range
◼ Start with slow to fast movement
Flaccidity: Loss of resistance throughout the movement
Spasticity
◼ Velocity- dependent increase in resistance
◼ Modified Ashworth score:
Shumway-Cook & Wollacott (2022), pp 115-116 & 130
Modified Ashworth Scale - Spasticity
0 No increase
1 Slight increase, minimal resistance at end
range
1+ Minimal resistance < ½ of range
2 Marked increase whole range
3 Marked increase, difficulty in passive
movement
4 Affected side rigid in flexion/extension
Bohannon & Smith, 1987
Reflex
◼ Phasic stretch reflex
◼ Use the whole length of the tendon
hammer
◼ Let the tendon hammer swing
◼ Ensure patient is relax
C5
C7
L3,4
S1,2
Assessing impairments
Balance
◼ SAFETY
◼ Patient – plinth
◼ Therapist – patient
Assessing impairments
Balance
◼ SAFETY
◼ Patient has to stand next to the plinth, or
in front of a plinth during the assessment
◼ Therapist – stands by the side or behind
the patient, and always on the paretic side
Assessing impairments
Balance
◼ Time to maintain a position – sitting ,
standing (double leg stance, one leg
stance)
◼ Response to perturbation
◼ Timed-up-and-go test
◼ Functional reach test
Assessing impairments
Coordination
Usually assess patients with cerebellar lesion
e.g. finger-to-nose test, heel-shin test
Requires integration of sensation and
movement of sufficient strength and range of
movement
To be taught under “Ataxia”
Assessing impairment
Sensory system
Assessing impairments
Light touch sensation, pin prick –
Awareness, Location, % loss
◼ Distal to proximal, move from areas of
sensory loss to areas of normal sensation
◼ Eye close
◼ Awareness – yes, no
◼ Location – where is the sensation
◼ % loss of sensation
◼ Hemi - comparing paretic to unaffected side
◼ SCI - comparing paretic to intact areas
Shumway-Cook and Wollacott (2000), pp 150
Suggested Neurological
patients
sites for
Sensory test
Documentation?
When you
apply tactile
sensation on
L
Recognise
-L
When you Recognise
apply sensation
tactile on side
sensation only
on both
sides…
Sensory
Inattention
Meaning: ______________due to parietal lobe lesion,
usually over non-dominant hemisphere
Sensory Inattention is a
special test that shows
patients may have the
problem of _______________
Sensory inattention – usually found in (R)
sided lesion – L weakness
L R
Non-dominant
Dominant
Assessing impairments
Proprioception
◼ Joint position sense – to test whether someone can feel the
position of the joint on the paretic side.
◼ Joint motion sense – to test whether someone can feel the
movement of the joint on the paretic side.
◼ Eye open – demonstrate the procedure
◼ Eye close
Joint position sense
◼ Passively move ONE joint to a position, ask patient to
specify the direction of joint position OR
mimic the joint position with the sound limb
Joint motion sense
◼ Passively moving ONE joint, ask patient to
specify the direction of joint motion OR
mimic the joint motion with the sound limb
Shumway-Cook & Wollacott (2022), pp 136-137
Proprioception (joint position sense)
Kinesthesia (joint motion sense)
Which joint should be started
UL LL
PT should hold ______________of the limb
Should move one joint at a time
Score: accurate response/time of test
i.e.10/10, or 5/5
For joint position sense, can also read
Gilman S. (2002). Joint position sense and vibration sense: anatomical
organisation and assessment. Journal of neurology, neurosurgery, and
psychiatry, 73(5), 473–477. https://doi.org/10.1136/jnnp.73.5.473
Assessing impairments
2-point discrimination
◼ The ability to discriminate 2 points when
simultaneously applies to
______________________
◼ Support the finger to be examined.
◼ Normal value: __________
Asst skill to be covered by MSK2
Shumway-Cook & Wollacott (2022), pp 136-137
Visual field (Gross visual field)
◼ Sit one arm’s
length away
◼ Eyes are at the
same level
◼ Ask the patient to
Look with both eyes
at your eyes
Indicate which I/F is
moving: R, L or both
◼ Repeat in the
upper and lower
quadrants
Adapted from Fuller G (2020) Neurological Examination Made Easy, pp 54-60
Visual field (Peripheral visual fields)
◼ Sit one arm’s length
away
◼ Eyes are at the same
level
◼ Ask the patient to
Cover right eye
Look at your left eye
Tilt the head to get
eyebrows and nose out of
the way SE
SW
◼ Bring the pin slowly
behind the plane of eyes
from NE/NW/SE/SW
◼ Stop until the patient first
sees the pin
◼ Repeat on left eye
Adapted from Fuller G (2020) Neurological Examination Made Easy, pp 54-60
Assessing disabilities
◼ Postural alignment
◼ Movement analysis
◼ Task analysis
Assessing disabilities
Observation:
Postural alignment
Symmetry
Shape and size of
base of support
Assessing disabilities
Movement analysis
Describe the movement pattern
- Isolated movement, abnormal synergy?
Shoulder elevation through flexion
Assessing disabilities
Task analysis
Describe the movement pattern
- Isolated movement, abnormal synergy?
Why is the movement pattern abnormal?
Assessment
Session 2
Standardised asst scales
Objective: Through active participation, students will be able to
▪ Learn how to determine reliability of measurements
▪ Appreciate the sensitivity of outcome measures
Standardized assessment scale
◼ Using Functional reach and Timed up and
go test to demonstrate ways to ensure a
good test-retest and inter-tester reliability
RATER
RATER 2
Time
Client 1 Client 1 RATER 1 RATER 3
“ 2 “ 2
“ 3 “ 3
Client
etc etc
Standardized assessment scale
◼ Using Functional reach and Timed up and go
test to demonstrate ways to ensure a good test-
retest and inter-tester reliability
◼ Patient starting position
◼ Instruction from therapist
◼ Standardised set-up and testing procedure
◼ Practice trials – familiarization
◼ Test trials
Functional reach test
Starting position
Ref: Duncan, P. W., Weiner, D. K., Chandler, J., & Studenski, S. (1990). Functional
reach: a new clinical measure of balance. Journal of gerontology, 45(6), M192–M197.
Functional reach test
◼ Patient starting position
Arm at 90 deg of flexion, make a fist, feet slightly apart
◼ Instruction from therapist
Reach as far forward as you can without making a step
Not to: rotate the trunk, raise up the heels, touch the wall,
make a step
◼ Standardised set-up and testing procedure
Adjust the ruler to the same level of the shoulder
Measure the initial and final position by a RULER, not with
your hand
◼ Safety
Stand against the patient in case he/she loses balance
◼ 2 practice trials, followed by 3 test trials and take the
average
Duncan et al.,1990
Timed-up-and-go test
◼ Patient starting position
◼ Instruction from therapist
◼ Standardised set-up and testing procedure
Demonstrate the test
Start timing after “start”
Stop when patient’s back touches the back of the
chair
◼ Follow the patient to ensure safety during the
test
◼ 1 practice trial, followed by 3 test trials and take
the average
Ref: Podsiadlo, D., & Richardson, S. (1991). The timed "Up & Go": a test of basic functional
mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142–148.
For Functional reach and Timed up and go test, which domain of ICF
does it measure?
Loss of physiological Activity limitation Participation
functions (Impairment) (Disability) restriction (Handicap)
Simplicity and Sensitivity
Case 1
◼ Mr. Chan is wearing an AFO for his ankle and using a quadripod for
his mobility. He can transfer from a chair to his bed by pushing one
hand on an armrest and the other hand on his quadripod. One
person has to be on the spot during his transfer to ensure safety.
◼ What are Mr. Chan’s scores according to FIM (transfer) and
Barthel index respectively?
◼ Two months later with training by his physiotherapist, Mr. Chan can
transfer himself (with AFO) from a chair to his bed independently.
◼ Is there any difference in his functional level as shown by the 2
scales
◼ Can the measurement scales show the improvement in Mr.
Chan?
◼ Case 2
◼ Mrs. Lee, a person with stroke, walks with moderate
assistance of one person to finish a distance of 13
metres. She has to use her quadripod at the same time.
◼ What does Mrs. Lee score in the FIM and Barthel
index respectively?
◼ After 4 weeks of intensive physiotherapy, Mrs. Lee has
shown good improvement. She can walk with a stick for
50 metres with standby supervision only.
◼ Does Mrs. Lee score differently in the 2
measurement scales
◼ If yes, what make the difference? If no, why not?
Modified Barthel Index
Ambulation
Barthel index
0 1 2 3
immobile Wheelchair Walk with Indep (can
indep help of 1 use aids)
person
Modified barthel indoex
0 3 8 12 15
dependent Mod to max Some Indep Indep
assistance assistance <50M >50M
Ref: Shah, S., Vanclay, F., & Cooper, B.
(1989). Improving the sensitivity of the Barthel
Index for stroke rehabilitation. Journal of
clinical epidemiology, 42(8), 703–709.
Choice of outcome measures
Functional activities - ADL
◼ Modified Barthel ADL index
◼ Functional independence measure
◼ Elderly mobility scale
◼ Modified Rivermead Mobility Index
What activities do each of them measure?
How do they score the performance of the
activities?
Upper limb function
◼ Jebsen Taylor Hand Function Test
◼ Action Research Arm Test
◼ Purdue Pegboard Test
◼ Minnesota Manual Dexterity Test
What outcome measures will you use
to document his performance? Why?
◼ Mr Lee, CVA, R hemiplegia 3 days ago. With
some help, he can turn and sit by the side of the
bed. He can sit independently for about 1
minute. He also require help to transfer from bed
to chair
◼ Mr. Chow, 4 weeks post stroke, can walk with a
quadripod for 10 metres under supervision. He
can raise up his shoulder and make a grasp.
The team would like to know how he can cope
with daily function to plan discharge
Choice of outcome measures
◼ Reliability, validity, sensitivity
◼ Purpose of the measures
◼ Mobility level of the patients
◼ Understanding level, cognitive level
◼ Time
◼ Equipment
◼ Diagnosis
References:
◼ Fuller G. (2020) Neurological Examination Made
Easy (6th Ed), p110-173
◼ Lennon et al. (2018) Physical Management for
Neurological Conditions (4 th Ed), p37-90
◼ Stoke M. (2006) Physical Management in
Neurological Rehabilitation, p 31-37
◼ Shumway-Cook A & Wollacott M. (2022). Motor
Control: Translating Research into Clinical
Practice (6th Ed), p127-138
