Neuro Proforma

NEURO PROFORMA (PHYSIOTHERAPY)

1. Temperature: Heart Rate:
Blood Pressure: Respiratory Rate:

Neurological Physiotherapy Evaluation Form


N I T H I N N A I R



I. Subjective Assessment

Name: Age: Gender: M/F IP/OP
Occupation: Dominance: R/L Education:
Address:
Chief Complaints:



HOPI

Past Medical History:


Personal History:
Family History:

Socioeconomic History:
Symptoms History:
Side: Site:
Onset: Duration:
Type: Severity:
Aggravating Factors:
Relieving Factors:
Vital Signs:

2. II. Objective Examination

a) ON OBSERVATION:
General Condition:
Built:
Nutrition:
Skin and Nail condition:
Attitude of limbs:
Posture:
Pattern of Movement:
Pallor/ Icterus/ Cynosis/clubbing /Oedema
Muscle Wasting:
Pressure Sores:
STAGES DESCRIPTION
Stage I Non blanchable erythema of intact skin
Stage II Partial thickness skin loss (abrasion, blister, or shallow crater)
Stage III Full thickness skin loss (deep crater, with or without undermining of
adjacent tissue)
Stage IV Extensive destruction into muscles and bones
Deformity:
Wounds:
External Appliances:

b) ON PALPATION
Warmth:
Tenderness:
Tone:
Swelling:
1+ indentation is barely detectable
2+ slight indentation visible & returns to normal in 15 sec
3+ deeper indentation & returns to normal in 30 sec
4+ indentation lasts for more than 30 sec

3. c) ON EXAMINATION

HIGHER MENTALFUNCTIONS
(USE MMSE SCALE)
Level of Consciousness:
Orientation:
Person:

Place:
Time:
Memory:
Immediate:
Recent:
Remote:
Verbal:
Visual:
Communication:

Cognition:

Fund of Knowledge:
Calculation:
Proverb Interpretation:
Attention:
Emotional Status:
Perception:
Body Scheme/ Body Imaging: Agnosias/
Apraxias:
Special Senses:

4. Cranial Nerves:

Nerves Comments Nerves Comments
I - Olfactory VII - Facial
II - Optic VIII - VestibuloCochlear
III - Oculomotor IX - Glossopharyngeal
IV - Trochlear X - Vagus
V - Trigeminal XI - Accessory
VI - Abducent XII - Hypoglossal

5. SENSORY SYSTEM:


Location
Upper
Extremity
Lower
Extremity

Trunk

Comments
Sensation Rt. Lt Rt. Lt. Rt. Lt.
Superficial
Pain
Temperature
Touch
Deep
Pressure
Mov. Sense
Pos. Sense
Vibration
Cortical
Tactile Localization
2 pt. discrimination
Stereognosis
Barognosis
Graphesthesia
Texture Recognition
Double Simultaneous
Stimulation




GRADES
DESCRIPTION
S0 Absent sensation in the area supplied by the affected nerve
S1 Return of deep cutaneous pain
S2 Return of some superficial pain and tactile sensibility
S3 Return of superficial pain and tactile sensibility without over-reaction
S3+ Return of two-point discrimination
S4 Normal sensations



MOTOR SYSTEM:

Muscle Girth:

Area Rt.(cm.) Lt.(cm.)
Arm
Forearm
Thigh
Calf

6. Range of Motion:

Joint Side Movement Limitation Limiting factor





Shoulder



Elbow



Forearm



Wrist






Hand & Fingers



Hip



Knee



Ankle & foot

7. Cervical Spine



Thoracic Spine



Lumbar Spine











Limb Length

Side Rt.(cm.) Lt.(cm.)
True
Apparent

8. Muscles

Rt.

Lt.
Hip
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Knee
Flexors
Extensors
Ankle
Dorsiflexors
Plantarflexors
Foot
Invertors
Evertors
Intrinsics
Extrinsics

Muscle Tone:


Muscles

Rt.

Lt.
Shoulder
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Elbow
Flexors
Extensors
Forearm
Pronators
Supinators
Wrist
Flexors
Extensors
Radial Deviators
Ulnar Deviators
Hand
Intrinsics
Extrinsics

GRADES OF TONE:
GRADE DESCRIPTION
0 No response (flaccidity)
1+ Decreased response (hypotonia)
2+ Normal response
3+ Exaggerated response ( mild to moderate hypertonia)
4+ Sustained response (severe hypertonia)

9. Voluntary Control: (BASED ON MOVEMENTS OF UL and LL)
(USE STREAM SCALE)

Side Rt. Lt.
Upper Limb
Lower Limb



Grades of Voluntary control

GRADE DESCRIPTION
0 No contraction or flicker or initiation
1 Flicker of contraction present or initiation of movement
2 Half range of motion in synergy or abnormal pattern

3 Full range of motion in synergy or abnormal pattern
4 Initial half range is performed in isolation and the latter half in pattern
5 Full range of motion in isolation but goes into pattern when resistance is given
6 Full range of motion in isolation and can take resistance like normals

10. MODIFIED ASHWORTH SCALE FOR GRADING SPASTICITY

GRADE DESCRIPTION
0 No increase in muscle tone.
1 Slight increase in muscle tone, manifested by a catch and release or by
minimal resistance at the end of the ROM when the affected parts is
moved in flexion or extension.
1+ Slight increase in muscle tone, manifested by a catch, followed by
minimal resistance throughout the reminder(less than half) of the ROM
2 More marked increase in muscle tone through most of the ROM, but
affected parts easily moved.
3 Considerable increase in muscle tone, passive movement difficult.
4 Affected parts rigid in flexion or extension

11. Muscles

Rt.

Lt.
Hip
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Knee
Flexors
Extensors
Ankle
Dorsiflexors
Plantarflexors
Foot
Invertors
Evertors
Intrinsics
Extrinsics

Trunk Flexors
Trunk Extensors
Trunk Side Flexors
Trunk Rotators

Muscle Power:


Muscles

Rt.

Lt.
Shoulder
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Elbow
Flexors
Extensors
Forearm
Pronators
Supinators
Wrist
Flexors
Extensors
Radial Deviators
Ulnar Deviators
Hand
Intrinsics
Extrinsics

12. Equilibrium tests Grade
Standing: Normal Posture
Standing: Normal Posture with
vision occluded

Standing: Feet together
Standing on one foot
Standing: Lateral trunk flexion
Tandem walking
Walk: Sideways
Walk: Backward
Walk in a circle
Walk on heels
Walk on toes

Reflexes:



Special Reflexes: Hoffmann’s reflex, Wartenberg’s sign, Rossolimo’s reflex, Tromner’s sign


GRADES OF REFLEXES:

GRADE DESCRIPTION
0 No Response
1+ Present but depressed, low
2+ Average, normal
3+ Increased, brisker than average; possibly but not necessarily abnormal
4+ Very brisk, Hyperactive, with clonus; abnormal








Coordination:




Non Equilibrium Tests Rt. Lt.
Finger to nose
Finger opposition
Mass Grasp
Pronation/Supination
Rebound test
Tapping (Hand)
Tapping (Foot)
Heel to knee
Drawing a circle(Hand)
Drawing a circle(Foot)




Reflex Left Right
Superficial Abdominal
Plantar
Deep Biceps
Brachioradialis
Triceps
Knee
Ankle

13. GRADES OF CO-ORDINATION


GRADE DESCRIPTION
4 Normal performance is demonstrated
3 Movement is accomplished with only slight difficulty
2 Moderate difficulty is demonstrated in accomplishing activity; movements are
arrhythmic and performances deteriorates with increased speed.
1 Severe difficulty is noted; movement are very arrhythmic; significant unsteadiness,
oscillations, and/or extraneous movements are noted
0 Patient unable to accomplish activity

14. Involuntary Movements:



Balance: (Use Berg balance scale)
Sitting:
Standing:
Balance Reactions:
Nudge Test:
GRADES DESCRIPTION
Normal Patient able to maintain steady balance without handhold support (static). Patient
accepts maximal challenge and can shift weight easily within full range in all
directions (dynamic)
Good Patient able to maintain balance without handhold support, limited postural sway
(static). Patient accepts moderate challenge; able to maintain balance while
picking objects off floor (dynamic)
Fair Patient able to maintain balance with handhold support; may require occasional
minimal assistance (static). Patient accepts minimal challenge; able to maintain
balance while turning head/trunk (dynamic)
Poor Patient requires handhold support and moderate to maximal assistance to
maintain position (static). Patient unable to accept challenge or move without loss
of balance (dynamic)

Gait (Observational Gait Analysis)

Stance Phase

Swing Phase


Fuctional Evaluation & Hand Functions:
Supine to prone:
Prone to side sit:
Sitting unsupported:
Sit to stand:
Standing/Walking:
Reaching:
Grasping:
Releasing:
Assisstive Devices:

15. III. Systems Review: (just comment if necessary)

INTEGUMENTARY SYSTEM:
Skin Status:
Pressure Sores:
RESPIRATORY SYSTEM:
RS Status:

Secretions:

Pattern of breathing:

Chest wall/Thoracic spine deformity:
CARDIOVASCULAR SYSTEM
CVS Status:

Deep Vein Thrombosis:
MUSCULOSKELETAL SYSTEM
Contractures:
Subluxations:
Joint mobility:
Other pathology:
BLADDER & BOWEL FUNCTIONS
Incontinence:
GASTROINTESTINAL SYSTEM
Status:
AUTONOMIC SYSTEM
Vasomotor:
Pseudomotor:
Trophic Changes:
Postural Hypotension:

Reflex Sympathetic Dystrophy:

16. IV. Functional Assessment: (The Functional Independence Measure)
Evaluation 1: Selfcare
Item 1. Food

Item 2. Care of appearance

Item 3. Hygiene

Item 4. Dressing upper body

Item 5. Dressing lower body

Evaluation 2: Sphincter control

Item 6. Control of bladder

Item 7. Control of bowel movements

Evaluation 3: Mobility

Item 8. Bed, chair, wheel chair
Item 9. To go to the toilets
Item 10. Bath-tub, shower
Evaluation 4: Locomotion

Item 11. Go, wheel chair

Item 12. Staircases

Evaluation 5: Communication

Item 13. Auditive comprehension

Item 14. Verbal expression

Evaluation 6: Social adjustment/cooperation

Item 15. Capacity to interact and to socially communicate

Item 16. Resolution of the problems

Item 17. Memory

Investigation Findings:

17. ICF FORMAT

Health Status:


Structural Impairments:


Functional Impairments:


Activity limitations and Participation Restrictions:
a. Learning and Applying knowledge
b. General tasks and demands
c. Communication
d. Mobility
e. Self Care
f. Domestic life
g. Interpersonal interactions and relationships
h. Major life areas
i. Community, social and civic life


Environmental Factors: (FACILITATORS/ BARRIERS)
a. Products and technology
b. Natural environment and human made changes to environment
c. Supports and relationships
d. Attitudes
e. Services, systems and policies

List of Contextual factors:
a. Environment (home/work place)
b. Water/Electricity/Lighting
c. Sanitation/Gen.Hygiene
d. Space for movement
e. Pollution
f. Accessibility for medical aids
g. Policies/Facilities
h. Care giver’s support
i. Internal/Co-morbid factors
j. Age/education/sex/metabolic
k. Financial support
l. Social support

Grades of Impairment

GRADE IMPAIRMENT FREQUENCY OF AFFECTION
0 Nil affection Never
1 Minimal affection (25%) Very Rarely
2 Moderate affection (50%) Sometimes
3 Severe affection (75%) Frequently
4 Very severe affection (100%) Always/Continuous

18. Grades(Functional/Disability)

FUNCTIONAL
GRADE
ACTIVITY & PARTICIPATION DISABILITY
GRADE
4 No problem in routine function –can do more
(100% performance = capacity)
0
3 Can just complete routine function but cannot do more
(25% performance affection)
1
2 Function completed with help
(50% performance affection)
2
1 Incomplete function inspite of help (75% affection) 3
0 Nil performance (100% performance affection) 4