Physical therapy examination for Neurological conditions.pptx

This presentation in includes Higher mental examination and cranial nerve examination for Neurological conditions

1. NEUROLOGICAL ASSESSMENT

2. HIGHER MENTAL FUNCTION Level of consciousness Orientation Memory Speech Reading Language Writing Calculations Reasoning and judgement

3. Consciousness and Arousal Examination of consciousness and arousal is important in determining the degree to which an individual is able to respond . Consciousness refers to a state of arousal accompanied by awareness of one’s environment . Five different levels of consciousness have been identified. 1. Alert 2. Lethargic 3. Obtunded 4. Stupor 5. Coma

4. ALERT/CONSCIOUS A conscious patient is awake, alert, and oriented to his or her surroundings.

5. LETHARGIC Lethargy refers to altered consciousness in which a person’s level of arousal is diminished. Lethargic patient appears drowsy but when questioned can open the eyes and respond briefly. Easily falls asleep if not continually stimulated and does not fully appreciate the environment. Questions should be simple and directed toward the individual (e.g., How are you feeling?).

6. OBTUNDED Obtunded state refers to diminished arousal and awareness . The obtunded patient is difficult to arouse from sleeping and once aroused, appears confused . The patient responds slowly and demonstrates little interest in awareness of the environment. Therapist should shake the patient gently as if awakening someone from sleep and again use simple questions.

7. STUPOR Stupor refers to a state of altered mental status and responsiveness to one’s environment. The patient can be aroused only with vigorous or unpleasant stimuli (e.g., painful stimuli such as flexion of the great toe, sharp pressure or pinch, or rolling a pencil across the nail bed). Patient demonstrates little in the way of voluntary verbal or motor responses. Mass movement responses may be observed in response to painful stimuli or loud noises.

8. COMA Unconscious patient is said to be in a coma and cannot be aroused. Eyes remain closed No sleep–wake cycles Patient does not respond to repeated painful stimuli May be ventilator dependent

9. Glasgow Coma Scale GCS is a gold standard instrument used to document level of consciousness in acute brain injury. Three areas of function are examined: eye opening, best motor response, and verbal response. Total GCS scores -15. A total score of 8 or less is indicative of severe brain injury and coma. Score between 9 and 12 is indicative of moderate brain injury. Score from 13 to 15 is indicative of mild brain injury.

10. Eye Opening Spontaneous 4 To speech 3 To pain 2 No response 1 Motor Response Follows motor commands 6 Localizes 5 Withdraws 4 Abnormal flexion 3 Extensor response 2 No response 1 Verbal Response Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1

11. Rancho Los Amigos Scale The Rancho Los Amigos Levels of Cognitive Functioning (LOCF) scale is a descriptive scale used to examine cognitive and behavioural recovery in individuals with TBI. This scale does not address specific cognitive deficits, but is useful for communicating general cognitive and/or behavioural status and for treatment planning. The eight categories describe typical cognitive and behavioural progress after a brain injury. Reliable and valid measure of cognitive and behavioural function for individuals with brain injury.

12. Attention Attention is selective awareness of the environment or responsiveness to a stimulus or task without being distracted by other stimuli. It is the directing of consciousness to a person, thing, perception, or thought . It is dependent on the capacity of the brain to process information from the environment or from long-term memory. Attention deficits are typically seen in individuals with delirium, brain injury, dementia, mental retardation, or performance anxiety.

13. Ask the patient to attend to a particular task. For example, ask the patient to repeat a short list of numbers forward or backward (digit span test) Normally individuals can recall seven forward and five backward numbers. Sustained attention is examined by determining how long the patient is able to maintain attention on a particular task (time on task). Alternating attention is examined by requesting the patient to alternate back and forth between two different tasks (e.g., add the first two pairs of numbers, then subtract the next two pairs of numbers). Requesting the patient to perform two tasks simultaneously is used to determine divided attention.

14. Orientation Orientation refers to the patient’s awareness of time, person, and place. Time • What is today’s date? • What day of the week is it? • What time is it? • Is it morning or afternoon? • What season is it? • What year is it? • How long have you been here?

15. Person • What is your name? • Do you have a middle name? • How old are you? • When were you born? Place • Do you know where you are right now? • What kind of a place is this? • Do you know what city and state we are in? • What city or town do you live in? • What is your address at home?

16. Cognition Cognition is defined as the process of knowing and includes both awareness and judgment . Three areas for testing cognition-dependent functions: fund of knowledge calculation ability proverb interpretation. Fund of knowledge - individual’s learning and experience in life Sample questions • Who is the president? • Who is Dr. Abdul Kalam? • What would you add to your food to make it sweeter?

17. Calculation ability - foundational mathematical abilities . Two associated terms are acalculi (inability to calculate) and dyscalculia (difficulty in accomplishing calculations). Test should be initiated with simple problems and progress to the more difficult. E.g., 4 + 4 = ____ 10 + 22 = ____

18. Proverb interpretation - patient’s ability to interpret use of words outside of their usual context or meaning. During the screening, the patient should be asked to describe the meaning of the proverb. Sample proverbs include the following: • Practice makes perfect a friend in need is a friend indeed.

19. Memory Long-term memory can be examined by requesting information on date and place of birth, date of marriage. Short-term memory can be addressed by verbally providing the patient with a series of words or numbers. For example, short sentence could also be used to test short-term memory. To ensure understanding of the task, the patient should repeat the sequence immediately. Individuals with normal memory function should be able to recall the list 5 minutes later and at least two of the items from the list after 30 minutes.

20. Hearing Observe patient’s response to conversation Note should be made of how alterations in voice volume and tone influence patient response.

21. Communication Repetition and naming can be tested (Repeat after me). Problems with articulation ( dysarthria ) are evidenced by speech errors, such as difficulties with timing, vocal quality, pitch, volume, and breath control. Problems of fluency, word flow without pauses or breaks, should be noted. Speech that flows smoothly but contains errors, nonsense words, misuse of words, and word substitution is indicative of fluent aphasia (i.e., Wernicke’s aphasia). Speech that is slow and hesitant with limited vocabulary and impaired syntax is indicative of nonfluent aphasia (i.e., Broca’s aphasia).

22. CRANIAL NERVE EXAMINATION Olfactory Function – Smell Test: Test sense of smell on each side (close off other nostril), use common, nonirritating odors. Possible abnormal findings: Anosmia (inability to detect smells), seen with frontal lobe lesions.

23. Optic Function: Vision Test: Test visual acuity. Central: Snellen eye chart; test each eye separately (covering other eye); test at distance of 20 ft. Test peripheral vision (visual fields) by confrontation. Possible abnormal findings: Blindness, myopia (impaired far vision), presbyopia (impaired near vision) Field defects: homonymous hemianopsia

24. Optic and oculomotor Function: Pupillary reflexes Test: Test pupillary reactions (constriction) by shining light in eye light; if abnormal, test near reaction. Examine pupillary size/shape. Possible abnormal findings: Absence of pupillary constriction Anisocoria (unequal pupils) Horner’s syndrome, CN III paralysis

25. Oculomotor, trochlear, and abducens Function - Extraocular movements Test - Test saccadic (patient is asked to look in each direction) and pursuit eye movements (patient follows moving finger). Possible abnormal findings: Strabismus (eye deviates from normal conjugate position) Impaired eye movements, Double vision

26. III - Occulomotor Function: Medial, superior, and inferior rectus: inferior oblique; turns eye up, down, in. Elevates eyelid. Test: Observe position of eye. Test eye movements. Strabismus: eye pulled outward by CN VI Eye cannot look upward, downward, inward movements. May see ptosis, pupillary dilation

27. IV - Trochlear Superior oblique: turns eye down when adducted. Test: Test eye movements. Possible abnormal findings: Eye cannot look down when eye is adducted VI - Abducens Lateral rectus: turns eye out. Test: Observe position of eye. Test eye movements. Possible abnormal findings: Esotropia (eye pulled inward) Eye cannot look out.

28. V Trigeminal - Ophthalmic, maxillary, mandibular divisions Function: Sensory: face Sensory: cornea Motor: muscles of mastication Test: Test pain, light touch sensations: forehead, cheeks, jaw (eyes closed). Test corneal reflex: touch lightly with wisp of cotton. Palpate temporal and masseter muscles. Observe spontaneous movements. Have patient clench teeth, hold against resistance. Possible abnormal findings: Loss of facial sensations, numbness with CN V lesion Trigger area with trigeminal neuralgia Loss of corneal reflex ipsilaterally (blinking in response to corneal touch) Weakness, wasting of muscles When opened, deviation of jaw to ipsilateral side

29. VII Facial Functions: Facial expression, Taste to anterior two thirds of tongue Test: Test motor function facial muscles. Raise eyebrows, frown. Show teeth, smile. Close eyes tightly. Puff out both cheeks. Apply saline solution and sugar solution using a cotton swab. Possible abnormal findings: Paralysis: Inability to close eye, Drooping corner of mouth, Difficulty with speech articulation Unilateral LMN: Bell’s palsy (PNI) Bilateral LMN: Guillain-Barré Unilateral UMN: stroke Incorrectly identifies solution

30. VIII Vestibulocochlear Functions: Vestibular function, Cochlear function Test: Test balance. Test eye–head coordination: vestibular ocular reflex (VOR). Test auditory acuity. Test for lateralization (Weber test): place vibrating tuning fork on top of head, mid-position; check if sound heard in one ear, or equally in both. Compare air and bone conduction (Rinne test): place vibrating tuning fork on mastoid bone, then close to ear canal; sound heard longer through air than bone.

31. IX Glossopharyngeal Functions: Sensory to posterior one third of tongue, pharynx, middle ear Test: Apply saline solution and sugar solution. Not typically tested Possible abnormal findings: Incorrectly identifies solution.

32. IX, X Glossopharyngeal and Vagus Functions: Phonation, Swallowing, Palatal, pharynx control, Gag reflex Test: Listen to voice quality. Examine for difficulty in swallowing glass of water. Have patient say “ah”; observe motion of soft palate (elevates) and position of uvula (remains midline). Stimulate back of throat lightly on each side. Possible abnormal findings: Dysphonia, Dysphagia Paralysis

33. XI Spinal accessory Functions: Motor function: Trapezius muscle, Sternocleidomastoid Test: Examine bulk, strength. Possible abnormal findings: LMN: atrophy, fasciculations, ipsilateral weakness, Inability to shrug ipsilateral shoulder, shoulder droops Inability to turn head to opposite side UMN: weakness of ipsilateral sternocleidomastoid and contralateral trapezius

34. XII Hypoglossal Function: Tongue movements Test: Listen to patient’s articulation. Examine resting position of tongue. Examine tongue movements: ask patient to protrude tongue, move side-to-side Possible abnormal findings: Dysarthria, Atrophy or fasciculations of tongue, Impaired movements, deviation to weak side UMN lesion: tongue deviates away from side of cortical lesion.