Principles of Physical Therapy Evaluation

for Neurological Conditions

What are Neurology:

"It is a medical specialty dealing with disorders of the

nervous system. Specifically, it deals with the diagnosis and treatment of
all categories of disease involving the central, peripheral, and autonomic
nervous systems, including their coverings, blood vessels, and all effector
tissue, such as muscle."

Neurology is the medical application of neuroscience which is the

scientific study of the nervous system.

Neurological physical therapy is a field focused on working with

individuals who have a neurological disorder or disease. These include
Alzheimer's disease, Polyneuropathies, MND, brain injury, multiple
sclerosis MS, Parkinson's disease, spinal cord injury, and stroke.
Common impairments associated with neurologic conditions include
impairments of vision, balance, ambulation, activities of daily living
(ADL), movement, muscle strength and loss of functional independence.
Neurological Physiotherapy can address many of these impairments and
aid in restoring and maintaining function, slowing disease progression,
and improving quality of life. Using specific neurological physical
therapy techniques such as Neurodevelopmental technique, P.N.F.
technique, Motor Relearning Program.
A large number of neurological disorders have been described.
These can affect the central nervous system CNS (brain and spinal cord),
the peripheral nervous system PNS, or the autonomic nervous system
ANS.
Central Nervous System Diseases
Definition: Diseases of any component of the brain (including the
cerebral hemispheres, diencephalon, brain stem, and cerebellum) or the
spinal cord.
 C.N.S Disorders include:
1. Stroke (Hemiplegia) and T.I.As. (Δ tract lesion).
2. Extra Δ lesions (e.g. Parkinsonism).
3. Cerebellar lesions (Ataxias).
4. Spinal Cord Injuries S.C.I.
5. Multiple Sclerosis M.S.
6. Motor Neuron Disorders (M.N.D).

Peripheral Nervous System Disorders

Definition: Diseases of the peripheral nerves external to the brain
and spinal cord, which includes diseases of the nerve roots, ganglia,
plexus, autonomic nerves, sensory nerves, and motor nerves.
 P.N.S include:
1. Polyneuropathy.
2. Peripheral nerve lesions (Facial Palsy).
3. Muscle diseases (Myopathy).
4. Motor Neuron Disorders (M.N.D)

Clinical Examination of a Neurological Patients

Medical Interview:
Three core objectives at the heart of every medical interview:
1- Information gathering.
2- Developing rapport and responding to patient emotions.
3- Patient education and motivation.
 Communication Techniques:
1. Non-Verbal Communication:
- Maintain eye contact with your patients and try to keep an open
body position, with your head and body leaning slightly
forward.
2. Ask open-ended questions:
- Ask non directive questions: Allows the patient to describe the
nature of the problem in its correct context.
- Closed questions: Are best suited as follow up items when the
topic of discussion require more specific focus
3. Facilitate Comments:
- Encourage the patient to continue by using phrases such as “
Can you tell me more” and “Go on”.
4. Clarify Comments:
- Use this technique to fully and accurately appreciate the
patient’s problem. You might clarify a patient’s problem.
5. Review fact for accuracy (Checking):
- A valuable tool for insuring accuracy and avoiding
misinterpretations.
6. Empathize:
- Using nonverbal as well as conversational empathy lets the
patients know that you understand, accept and appreciate the
problem
7. Partner:
- This technique increases patients’ participation in their care.
You can involve patient in decision-making process by using
phrases such as “ After we finish with the examinations let’s see
if we can come up with some solutions”
 Neurological Examinations

During a neurological examination, the physical therapist reviews

the patient's health history with special attention to the current condition.
The patient then takes a neurological exam. Typically, the exam tests
mental status, function of the cranial nerves (including vision), strength,
coordination, reflexes and sensation. This information helps the therapist
determine if the problem exists in the nervous system and the clinical
localization. Localization of the pathology is the key process by which
therapist develop their differential diagnosis. Further tests may be needed
to confirm a diagnosis and ultimately guide therapy and appropriate
management.

Neurological Sheet:

- The sheet consist of two main parts which are:

1. Histories (Personal, C.C, Present, Past and Family)
2. Neurological examinations

A- Histories
 It include:
1. Personal History:
- Name: to be familiar with the patient.
- Age: as certain diseases are more common in certain ages (1st
and 2nd decades: Progressive muscular dystrophy, 3rd and 4th
decades: DS and 5th and 6th decades: Cerebro-vascular strokes).
- Sex: motor neuron disease (MND) is common in males.
Migraine is commoner in females. Ask about contraceptive pills
as they may cause headache, depression or DVT.
- Occupation: Persons in certain occupations are more
susceptible to certain diseases (disc prolapse is common in
drivers, while lead neuropathy is common in printers).
- Marital state: For possible sterility, impotence or still-births.
- Residence: Migraine is common in urban areas, while
nutritional diseases are common in rural areas.
- Special habits: Alcohol can lead to peripheral neuropathy.
- Handedness: In right-handed people (over 90% of population),
the dominant cerebral hemisphere is the left.
2. Diagnosis and Chief Complain C.C.:
- Diagnosis: must be referred from any related medical specialty.
- Chief Complain (C.C.): Write it by patient's own words and
list his complaints according to their importance.
3. Present History:
- Onset: beginning of the disease (sudden, gradual).
- Course:
- Progressive (increased severity of the disease & the patient
become bad).
- Regressive (decreased severity of the disease & the patient
become good).
- Remission & Relapse (fluctuating increase and decrease of
severity of symptoms with regular increase of it) like in
Multiple Sclerosis disease.
- Stationary (No increase or decrease of the severity of the
disease) and it is very rare.
- Duration: either of the beginning of symptoms or duration of
admission to the hospital.
 4. Past History: include
- Past related disease: such as DM, Hypertension, Heart
diseases,….etc.
- Past related surgeries: such as Open heart surgery,
orthopaedic surgery, …..etc.
- Past related medications: Such as Insulin, Hypertensive drugs,
Analgesics,…..etc.
(Diseases, Surgeries and medication).
5. Family History:
- Similar conditions: to inform about similar cases in the same
family.
- Relation between parents (Consanguinity): if there are
genetic relation between both parents it called (+ve
consanguinity).

EXAMINATION

A- General Examination
 It include:
1. General appearance
2. Body Temperature
3. Heart sounds and Pulse Rate
4. Blood Pressure
5. Chest and Respiratory Rate
 B- Neurological Examination
1- Examination of the mental Function:
- To investigate mental abilities of the patients such as:
i. State of consciousness: Glascow Coma Scale, evaluating
the patients according to response to external stimuli , using three
criteria: *eye response *verbal response *motor response
The following terms are commonly used to describe a decreased
LOC, so it helps to be familiar with them:
Full consciousness. The patient is alert, attentive, and follows
commands. If asleep, He responds promptly to external stimulation
and, once awake, remains attentive.
Lethargy. The patient is drowsy but awakens—although not
fully—to stimulation. He will answer questions and follow commands,
but will do so slowly and inattentively.
Obtundation. The patient is difficult to arouse and needs
constant stimulation in order to follow a simple command. He may
respond verbally with one or two words, but will drift back to sleep
between stimulation.
Drowsiness. Drowsiness refers to feeling abnormally sleepy
during the day. People who are drowsy may fall asleep in inappropriate
situations or at inappropriate times.
Stupor. The patient arouses to vigorous and continuous
stimulation; typically, a painful stimulus is required. He may moan
briefly but does not follow commands. His only response may be an
attempt to withdraw from or remove the painful stimulus.
Semicoma. A partial or mild comatose state; a coma from
which a person may be aroused by painful stimuli. No verbal response,
only reflex response to painful stimuli.
 Coma. A state of prolonged unconsciousness, including a lack
of response to any stimuli, from which it is impossible to rouse a
person. No verbal or reflex response to painful stimuli.
ii. Orientation: to (time, place and person).
- Orientation to time include time of the day, day, date (day, month,
season and year)
- Orientation to place include local position, surrounded area, city
and country.
- Orientation to persons include knowing surrounded persons related
to him.
i. Memory: it is the ability to retain and recall information and
recent and remote memory.
- Diminution of memory is termed amnesia which includes:
*Antrograde amnesia (inability of the patient to remember recent events)
*Retrograde amnesia (inability of the patient to remember old events)
*Transient global amnesia (circumscribed amnesia): Sudden total loss
of memory, lasting for less than one day in a middle-aged healthy person.
It may be precipitated by physical or emotional stress. It may be due to
temporal lobe ischemia and the condition is benign.
ii. Mood and affect: Like depression, emotional labiality,
euphoria and apathy or indifference.
iii. Intelligence: it is assessed by intelligence quotient (IQ).
Most of people within average intelligence.
iv. Behavior: it is an overall manner in which the patient sits,
dress, talk and co-operate with doctors.
- MMSE is one of the most common screening tools for
examining mentality. Usually we use it in most of researches.
 - In case of a normal mentality reports as follows:
"The patient is fully conscious. Well oriented for time, place and
persons with normal memory and mood; he is cooperative and of
average intelligence."
2- Examination of Speech:
- It observed during history taking.
- The main speech disturbances include:
i. Aphasia: inability to formulate speech (Sensory & Motor)
ii. Dysartheria: Difficulty to articulate speech properly. Such as:
- Staccato speech: In cerebellar lesions.
- Slurred speech: In pyramidal and LMN lesions of speech muscles.
- Monotonous speech: In Parkinsonism.
3- Examination of the Cranial nerves:
- Twelve pairs of cranial nerves must be checked.
- 1st, 2nd and 8th are pure sensory nerves.
- 3rd, 4th and 6th are related to eye movement.
- 5th are for face sensation with Ms of mastication.
- 7th are for facial Ms and partial tongue sensation.
- 9th, 10th, 11th and 12th are bulbar nerves.
4- Examination of the Motor System:
- By Inspection:
A- Position of limb in bed
B- The state of the muscle (normal, hypertrophied, wasted).
C- Skeletal deformities (pes cavus , hallux valgus).
D- Trophic changes (ulcers, loss of hair and brittle nails)
E- Involuntary movement (tremor)
 - By Palpation:

- Muscle tone assessment

- Muscle power assessment
- Reflex assessment (Superficial and Deep)
- Range of motion assessment (ROM)
Muscle tone assessment:
Normal muscle tone can be defined as: “It is resistance to passive
movement while the examiner moves the joint passively & the patient is
completely relaxed.”
Spasticity: is defined as abnormal increase of resistance to passive
movement;
 such abnormal resistance due to spasticity is encountered in:
Upper limb: The arm, hand and finger with all movement of extention,
abduction, external rotation, supination and abduction and extension of
the finger and thumb.
Lower Limb: The leg resistance is encountered with all movement of
flexion of the hip, knee, and ankle, and dorsiflexion of the toes as well as
eversion.
 Modified Ashworth scale (MAS) of spasticity explained the
degree of spasticity from zero to four (with 1+).
Factors affecting & changing muscle tone:
Level of stress, Bladder distension, Subject& head position,
 Clinical assessment of muscle tone:
There are many methods for evaluation of muscle tone e.g. observation,
passive movement, held methods, tendon jerks and EMG.
 Observation:
*The patient who is supine with the lower limb in extension and planter
flexion having increased extensor tone.
*Posture of the limb in fixed position is also suggestive of increased
muscle tone.
* Limbs that appear floppy and leg rolled in external rotation having
decreased muscle tone.
 Manual passive stretch:
During passive movement test, the therapist should maintain firm and
constant manual contact and moving the limb at a slow and then increase
the speed while the patient is instructed to be completely relaxed in a
comfortable supine lying position.
*There are many method of examination the muscle tone the best method
is the passive movement.
General consideration during performing passive movement
(1) The patient is in relaxed comfortable position
(2) Avoid putting the patient in any stress condition such as:
*bladder destination *Anxiety
*Stress * Air draft
(3)The head in mid position.
(4)The trunk in mid position.
(5)Gentle, firm & fixed grasp.
(6)Don’t touch sensitive area of palm of hand or ball of foot.
(7)Avoid traction at the start and pressure at the end.
(8)At the first the movement should be done slowly then increase the
speed.
Advantages of passive movement
- Simple. - Easy. - Not expensive.
- Conducted in a short time. - Applied at any time.
- Determine type of tone if normal or increased (hypertonia) or
decreased (hypotonia)
- In cases of hypertonia determine which type: spasticity or rigidity
 - Determine the degree of spasticity (according to modified Acworth
scale 0, 1, 2, 3, 4, 5)
- Determine the distribution of muscle tone
Muscle power assessment:
Clinical assessment of muscle power via traditional manual muscle
tests may be invalid with the presence of spasticity, reflexes, and synergy
dominance.
*An estimation of strength can alternately be made from observation
of performance during functional tasks, depend on the degree of
spasticity.
*In cases of mild spasticity or LMNL; group muscle test is
performed (0, 1, 2, 3, 4, 5) grade
*while in cases of moderate spasticity a functional muscle test is
performed (normal, subnormal, zero).
Reflex assessment (Superficial and Deep): It includes Superficial and
Deep reflexes.
Deep tendon reflexes are present from birth but require much skill to
elicit and observe.
*It may be (Normal or Hyperreflexia or Hyporeflexia)
Superficial reflexes include:
Abdominal reflex. (T6-T12)
Cremastric reflex (Anal reflex). (L1)
planter reflex (Babiniski’s response). (S1,2)
It lost in case of upper motor neuron lesion below the level of the
lesion
*Babiniski’s response: normally when the planter surface of the foot
is stimulated following a scratch is made on the lateral aspest of the sole
of the foot from the heel toward the toes resulting in planter flexion of the
toes.
 *If there is dorsiflexion, with or without fanning of the toes, it
denotes and U.M.N.L. however, dorsiflexion may occur physiologically
in deep sleep and in infant below one year.
Deep reflexes:
Upper limb: Lower limbs
 Biceps reflex C5 Qudricebs reflex L3,4
 Triceps reflex C7 Ankle reflex S1
 Brachioradialis reflex C6
Range of motion assessment (ROM):
It is very important to detect if there is contractures, frozen shoulder,
joint limitation or muscle shortening.
5- Examination of the Sensory System:
Key to Grading the sensation:
1. Intact: Normal response.
2. Decreased: Impaired ability to perceive a stimulus.
3. Hypersensitive: Increased perception of a stimulus.
4. Absent: Unable to perceive a stimulus.
Examination of Superficial sensation: include pain, temperature
and crude touch
 Examination of Deep sensation: They include
- joint sense ( sense of position and movement
- Muscle sense: by pinching the bulky muscle
- Nerve sense. by rolling the nerve against bone.
- Vibration sense: by using tuning fork at bony
prominence.
Examination of Cortical sensory system:
They are only examined when the superficial & deep sensations are
intact.
1. Tactile localization: the patient localize the site of the prick.
2. Two- points discrimination: deliver 2 simultaneous pricks at the
same time, Normally the 2 pricks are felt distinct from each other.
3. Stereognosis: recognition of a familiar object placed in the hand.
4. Graphosthesia: recognition of a number or letter drowns over ther
palm.
5. Paragonsis: recognition of different weight of the same shape.
6. Perceptual rivalry: recognition of two simultaneous pin pricks at
corresponding sides of the body.
6- Examination of Coordination:
Co-ordination can be defined as the ability to use the right muscle at the
right time with proper intensity to perform purposeful movement include:
- Assessment of Equilibrium coordination:
It involves evaluation of static & dynamic balance
Static balance: ability of the patient to maintain static position (non
mobile position).
Dynamic balance: ability of the patient to maintain balance during
movement & changing position.
- Therapist observes the following component:
*Reaction time * Speed *Accuracy
 - Assessment of Non-Equilibrium coordination: It includes
specific tests e.g
- Finger to nose test
- Finger to finger test
- Finger to Doctor finger test
- Adiadokokinesia
- Rebound phenomena
- Heel to knee test
- Romberg test.
Therapist observes the following component
 Control : If the movement is directed and precise
 Response orientation: correct response regarding the stimuls.
 Reaction time : if the patient perform the movement in a
reasonable time or not
 Speed : if any changes regarding to increasing or decrease
speed affect the performance
 Rate control : if changing the rate affect the performance
 Steadiness : if the movement is steady or not
 Accuracy: placing movement are exact or the ability to judge
the distance.
7- Examination of Activity of Daily Living ADL:
- Assessment of Self-Care activity (Hygiene).
- Assessment of Bed activities.
- Assessment of Transfer Activities.
- Assessment of Communication Activities (House-Hold
Operation).
- Assessment of Miscellaneous Activities (Hand Function).
Grading functional tests:
N = Patient is completely independent.
S = Patient need supervision.
A = Patient need assistant.
L = Patient has to be lifted.
X = Patient is completely dependent, and the activity is not indicated.
8- Examination of Gait:
 Normal human walking is a complex motor task involving the
interaction of the neuromuscular system acting on the musculo-
skeletal system processes
 The gait cycle is divided into two distinct periods of stance and
swing.
 The stance period of the gait cycle includes :
 initial contact, loading response, midstance, terminal stance and
preswing.
 The swing period includes initial swing, midswing, and terminal
swing.
 Examination of gait include:
- Observational Analysis.
- Biomechanical Analysis (Spatial - Temporal).
 Most common Abnormal gait in neurologic patients are:
- Circumduction gait and Hip hiking gait in Hemiplegia.
- Shuffling gait in sever parkinsonism.
- Drunken gait in ataxia.
- Scissor gait in spastic paraplegia.
- High steppage gait and Stamping gait in polyneuropathy.
General Considerations about Neurological Sheet:

 When finishing all examination (Essential and Non-essential), it

lead to extract problem list.
 Sequence of problem list is according to its importance not to its
consequence.
 Problems must be expressive and can be treated in someway.
 The neuro assessment is a key component in the care of the
neurological patient. It can help you detect the presence of
neurological disease or injury and monitor its progression,
determine the type of care you'll provide, and gauge the patient's
response to your interventions.