Overview of subjective Ax
Involves gaining information about the patient and how their condition affects them as a person
• Personal to a particular patient but may originate from individuals other than the patient (relatives, carer, member of MDT)
• May be gathered through various communication methods including medical notes, conversations/ meetings and patient interview
• In terms of the ICF, the subjective examination gains information relating to: activity, participation, environmental factors and personal factors
aims of subjective Ax
- Provide a detailed picture of how the present condition affects the patient from a holistic viewpoint
- Identify the patient’s main problems as perceived by the patient
- Assist in setting of short and long term goals in collaboration with the patient
- Assist in the development of a relevant treatment plan
- Build rapport with the patient
what information do i get from the medical record
personal details diagnosis date of admission - hospital / rehab ward Hx of presenting illness CVA- location and type of lesion SCI- level of lesion, complete/incomplete TBI: location and type of lesion progressive neuro condition : type and progression relevant PMH surgical Hx results of Ix meds SHx PLOF med/speech/OT/Nursing entries
Information from bed chart
recents observations (HR, BP, O2, Sats, Temp) Current Meds
Pt Interview
• History of presenting illness
• Any symptoms that may affect physiotherapy treatment:
chest pain, dyspnoea, dizziness/ vertigo
• Respiratory: SOB, cough, wheeze, chest pain, secretions
• Vision: presence of diplopia or visual field loss
• Sensation: P&N/N
• Strength and power
• Coordination and balance
• Pain: specify shoulder and other pain (where, when, how
much, what gives relief)
• Dominance
• Past or present physiotherapy treatment
• Social history: family (dependents/ support), assistance/
services from external agencies (hygiene, meals, community access), accommodation (home environment – stairs, hobs, rails, assistive devices/ modifications), occupation, hobbies/ recreation, community mobility (driving, public transport)
• Previous level of function: home and community mobility (level of assistance, aids, exercise tolerance, independence with ADLs)
• Falls history: number of falls in last 6/12, causative factors, associated injuries
Patient’s perception of present level of function
• Patient’s perception of present ability to participate in daily
routines
• Patient’s perception of major problems
• Treatment goals
Overview of Objective Ax
- Involves gaining information related to the patient’s movement disorder and functional status using measurable tools and movement analysis
- In practical terms, assess how the patient moves and then investigate more specifically the reasons for the these movement patterns or behaviours
- In terms of the ICF, the objective examination gains information relating to: body structures and function and activity
- During ongoing treatment, continually re-assess the evaluate change and improvement
Aims of Objective Ax
- Identify the patient’s movement problems and potential causes of those problems in order to appropriately focus treatment
- Provide a baseline from which suitable short term and long term goals can be agreed with patient and from which the effectiveness of treatment can be evaluated
initial observations for Ox
- Level of consciousness
- General appearance
- Posture or deformities
- Skin condition
- Oedema
- Quality of spontaneous movement/ general movement patterns (weakness, tremor, dysdiadochokinesia etc)
- Facial symmetry and expression
- Speech
- Apparent neglect
- Presence of attachments
- Aids and appliance
- Gait and / or use of wheelchair
- Respiration – RR, breathing pattern, cough
- Attachments (O2, IV, IDC, IV, cardiac monitoring etc)
vision
- Visual acuity
- Eye movements – CN III, IV, VI
- Eye follow
- Convergence/ divergence
- Visual fields
- Hemianopia
- Visual inattention
sensation
- Light touch
- Double simultaneous stimulation
- Pinprick
- Temperature
- Proprioception
- Passive movement sense • Joint position sense
- Vibration
- Stereognosis
Flexibility, tone and spasticity
- Flexibility • PROM
- Muscle tone
- Resistance to PROM
- Spasticity
Quality of mvmt
- During testing movement and motor recovery always note:
- Is there spontaneous movement?
- Is it isolated?
- Is there evidence of patterning? If so, describe. • Is the movement antigravity?
- Trunk
- Lower Limbs
- Upper Limb
Muscle power
Oxford grading scale
• Standard muscle strength tests can only be recorded if the movement is fully isolated and tone is normal
• Use standard muscle tests on standard charts
co-ordination
• Co-ordination should only be assessed when full, isolated active movement is present. When testing co- ordination, the following should be noted: • Speed • Smoothness of the movement • Presence of dysmetria (undershooting or overshooting) • Timing / rhythm • Ability to follow a sequence • Upper limb • Finger to nose • Pronation/ supination • Hand tapping • Finger strumming • Lower limb • Foot tapping • Heel/knee/shin • Alternate hip flexion • Alternate hip and knee flexion • Cycling of legs
functional task analysis
- Functional task analysis involves observation of the functional movement and analysis of the components of the movement present / absent
- The primary aim is to observe the movement disorder and decide why the movement is abnormal
- When assessing functional tasks, analyse the following:
- Level of independence
- Independent
- Supervision
- Verbal cueing
- Minimal assistance X 1
- Movement components
- Causal factors
- Moderate assistance X 1 • Minimal assistance X 2
- Moderate assistance X 2 • Unable to perform
- When assessing functional tasks, analyse the following:
- Level of independence
- Independent
- Supervision
- Verbal cueing
- Minimal assistance X 1
- Movement components
- Causal factors
- Moderate assistance X 1 • Minimal assistance X 2
- Moderate assistance X 2 • Unable to perform
Balance
• Complete as part of the functional assessment
• Key tips for safety
• Start with easy measures and progress to more difficult ones
• Progress from sitting to standing
• Progress from static to dynamic
• Progress from wide base to narrow base
• Balanced Sitting
• Static sitting
• Dynamic sitting
• Balanced Standing
• Static standing
• Dynamic standing
High level balance and function • Heel-toe walking
• Braiding
• Running
• Skipping
• Hopping
• Star jumps
• Scissor jumps • Bouncing ballsgait
Complete as part of the functional assessment
• Assess safety of client to walk alone or with assistance
• Record level of independence and use of aids/ orthoses
• Note effect of footwear
• Describe general gait characteristics:
• Speed, step length and cadence • Symmetry
• Arm swing
• Trunk rotation
• Test gait over a variety of surfaces (carpet, concrete, grass, sand, ramps, stairs …)
gait stance phase
• Anterior / posterior hip control – hip should extend throughout stance
• Medial / lateral hip control
• Knee control – knee should flex from heel strike to mid
stance; extend at midstance; flex prior to toe-off
• Foot contact (heel strike)
• Rollover (amount of dorsiflexion occurring at ankle)
• Push-off
Gait swing phase
- Hip flexion
- Knee flexion
- Dorsiflexion
- Internal rotation of pelvis
- Knee extension
other systems
- A complete neurological examination requires the assessment of any other system that may be compromised
- Neurological disorders are highly associated with both respiratory and circulatory dysfunction and it is of the highest priority that these systems are assessed in acute or progressive conditions
resp Ax
observation
palpation
auscultation
cough/sputum
circ Ax
obs
palp
Homan’s test
Pulses
