Neurological Assessment

Original Editor - Kim Jackson Top Contributors - Manisha Shrestha, Kim Jackson, Shaimaa Eldib, Kirenga Bamurange Liliane, Admin, Rucha Gadgil and Kanzaa Rahim

Introduction

In order to provide the best care and plan the best treatment a thorough assessment must be undertaken. It is the most important step in the rehabilitation process, helps to guide our clinical reasoning and decision when making informed decisions about the rehabilitation process. Johnson & Thompson (1996) outlined that treatment can only be as good as the assessment on which it was based. So in order for us to progress and manage our treatment plan and ensure we are identifying out patients problems the assessment should be an ongoing and continuous process. A neurological assessment focuses on the nervous system to assess and identify any abnormalities that affect function and activities of daily living. It should allow us to create individual, patient-centred goals and ultimately a tailor-made treatment plan based on the client's needs.

So for the proper neurological assessment, we can use a SOAP format as a guide. Below we have a systematic flow for the assessment of the neurological patient.

Subjective Assessment

The subjective assessment is used to provide a detailed picture of how the present condition affects the patient. 

Demographic Data

Name, Age, Gender, Occupation, Dominant hand, Address.

Chief Complain

What is his/her present complaint or problem for which he/she has visited you?

History of Present Condition

• Progression of the Condition.
• Date of Onset of Signs & Symptoms.
• Medical Management.
• Medical Observations.
• Other management.
• Previous Therapy.
• Results of Specific Investigations (X-rays, CT Scans, Blood Tests.....etc

Past Medical History 

• Co-morbidities and other non-related conditions.
• Special Equipment, Technology Dependency.
• Previous Surgery.
• Medication History.
• History of any allergies.

Personal History

Marital status, occupation,

Activity

• Normal Daily Routine.
• Employment.
• Leisure Activities.
• Smoking and drinking habits.

Mobility

• General
• Indoor
• Outdoor
• Steps & Stairs
• Falls

Personal Care

• Washing
• Continence
• Dressing

Other

• Vision.
• Hearing.
• Swallowing.
• Fatigue.
• Pain.
• Perceptions of own Problems/Main Concern.
• Expectations of Treatment.

Family History

Total number of family members, his/her primary caretaker.

Socioeconomic History

• Family income source
• Relationship with community people
• Social Situation
• Family Support
• Accommodation
• Social Service Support

Objective Assessment

On Observation

1. Built.
2. Gait.
3. Pattern of Movement.
4. Mode of Ventilation.
5. Type/ Pattern of Respiration
6. Oedema
7. Muscle Wasting
8. Pressure Sores
9. Deformity
10. Wounds
11. External Appliances
12. Involuntary Movement
    • Tremor
    • Clonus
    • Chorea
    • Associated Reactions

1. Posture and Balance

• Alignment and attitude of limbs
• Neglect
• Sitting Balance
• Standing Balance
  

Vital Signs

Vitals signs include

• Respiratory rate
• Temperature
• Pulse rate
• Blood pressure
• O2 saturation

On Examination

Higher mental function

Communication:

Aphasia ( Broca's, Wernicke's, Global)

Cognition:

• Orientation:
  • Person
  • Place
  • Time
• Calculation
• Registration
• Attention
• Proverb Interpretation
• Memory
  • Immediate
  • Recent
  • Remote
  • Verbal
  • Visual
• Language
• Visuospatial proficiency

There are various outcome tools via which we can address his/her cognitive status incorporating various components.

• Mini-mental Status Examination
• Mini-Cog
• Montreal Cognitive Assessment (MoCA)

Perception:

• Body Scheme/ Body Imaging
• Neglect
• Agnosia
• Apraxia

Common tools to assess perceptual problems are:

• Star Cancellation Test.
• Line Bisection Test.
• Clock Drawing Test.

Sensory examination

Superficial Sensation

• Pain
• Temperature
• Touch
• Pressure

Deep Sensation

• Movement Sense
• Position Sense
• Vibration Sense

Cortical Sensation

• Tactile Localization
• 2 point discrimination
• Stereognosis
• Barognosis
• Graphesthesia
• Texture Recognition
• Double Simultaneous Stimulation

Motor examination

Tone

• Decreased / Flaccid
• Increased
  Spasticity (Clasp-knife)
  Rigidity (Cogwheel or Lead Pipe)
• Outcome tools- Modified Modified Ashworth Scale (MMAS) and Tardieu Scale

Strength

Manual Muscle Testing (MMT) or Myotomes can be used.

Endurance

• Muscular
• Cardiovascular

Reflexes

• Deep Tendon Reflexes
  Biceps (C5/6)
  Triceps (C7/8)
  Knee (L3/4)
  Ankle (S1/2)
• Plantar Response (Babinski’s Sign)

Balance (Static and Dynamic)

Outcome tools: Berg balance scale, Timed up and go test (TUG), BESTest

Coordination

• Equilibrium
• Non-equilibrium
• Romberg's test

Gait

• Step Length
• Stride Length
• Base width
• Cadence
• Biomechanical Deviations

Areas of Occupation

• Basic Activity of Daily Living (feeding, dressing, bathing, grooming)
• Instrumental Activity of Daily Living (Mobility, Budgeting, cooking, cleaning, shopping)
• Education/ Work (Employment, Academics)
• Play/Leisure Activities
• Social Participation (social interaction, community integration)
• Rest/Sleep (sleep hygiene, routine)

Client Factors

• Values (choices, actions, priorities)
• Beliefs (cultural, religious perspectives)
• Spirituality

Performance Patterns

• Habits
• Roles
• Routine/Rituals

Other System review

• Integumentary system: Skin Status, Pressure Sores
• Respiratory system: RS Status, Secretions, Pattern of breathing, Chest wall/Thoracic spine deformity
• Cardiovascular system: Status: Deep Vein Thrombosis
• Musculoskeletal system: Contractures, Subluxations, Joint mobility, Other pathology
• Bowel and bladder function: Urinary Incontinence
• Gastrointestinal system: Status
• Autonomic system: Vasomotor,Pseudomotor, Trophic Changes, Postural Hypotension, Reflex Sympathetic Dystrophy

Functional Assessment

• Functional Independence Measure
• Modified Barthel Index
• Canadian Occupational Performance Measure
• Assessment of Motor and Process Skills
• Role Checklist
• Berg Balance Scale
• Kholman Evaluation of Living Skills

Assessment

Problem List

Problem list can be generated from International Classification of Function, Disability, and Health (ICF).

Plan

Goal Setting

• Short term goal
• Long term goal

Re-assessment

Re-assessment includes re-testing objective measures such as outcome tools after a certain period of intervention. It helps to know the progression of the patient and in the determination of time to achieve the goal set. In re-assessment, it is very necessary to assess both facilitators and barriers for a better outcome. it is vital to let the patient, patient party, and other health professionals know about the result of the re-assessment and compare it with previous assessment results. It helps to plan further in treatment strategies.