Neurological Assessment

Original Editor - Kim Jackson Top Contributors - Manisha Shrestha and Kim Jackson

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[1]. 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. [2]

Demographic Data

Name, Age, Gender, Occupation, Dominant hand, Address[3]

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)

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
[4]
  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

Level of consciousness: Glasscow coma scale (GCS)
[5]
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.[6]

Perception:

Common tools to assess perceptual problems are:

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

Cranial nerve (CN) examination

[8]

Sensory examination

Superficial Sensation
  • Pain
  • Temperature
  • Touch
  • Pressure
Deep Sensation
Cortical Sensation
  • Tactile Localization
  • 2 point discrimination
  • Stereognosis
  • Barognosis
  • Graphesthesia
  • Texture Recognition
  • Double Simultaneous Stimulation

Motor examination

[9]
Tone
Range of Motion
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)
[10]
Tightness/ Muscle length testing
Limb length measurement
Limb girth measurement

Balance (Static and Dynamic)

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

Co-ordination

Gait

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

Other System review

Functional Assessment

Assessment

Problem List

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

Physiotherapy Diagnosis/Functional Diagnosis

Plan

Goal Setting

  • Short term goal
  • Long term goal

Treatment

Re-assessment

Re-assessment includes retesting 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.

References

  1. Johnson J, Thompson AJ. Rehabilitation in a neuroscience centre: the role of expert assessment and selection. British Journal of Therapy and Rehabilitation. 1996 Jun;3(6):303-8.
  2. O'Sullivan SB, Schmitz TJ, Fulk G. Physical rehabilitation.F6th Edition.A Davis; 2019 Jan 25.
  3. Neurological Physiotherapy Evaluation Form. Available from: https://fac.ksu.edu.sa/sites/default/files/neurological_physiotherapy_evaluation_form_2_0.pdf. Lasted accessed: 4.3.2021
  4. Life Changing Surgery Halts Essential Tremors & Parkinson's Disease Symptoms. Available from: https://www.youtube.com/watch?v=8pGGGMUObQ4 Lasted accessed: 2021.4.3
  5. Glasgow Coma Scale made easy. Available from: https://www.youtube.com/watch?v=h2SIN7Mn0YA. Lasted accessed: 2021.4.3
  6. Cognition. Stroke engine. Available from:https://strokengine.ca/en/assessments-by-topic/#assess-cog Lasted accessed: 2021.4.3
  7. PHYSIOTHERAPY EVALUATION IN NEUROLOGICAL PATIENTS. Ozden Gokcek and Esra Dogru Huzmeli. Hatay Mustafa Kemal University Health Science Faculty, Physiotherapy and Rehabilitation Department,Hatay, Turkey
  8. greeky Medics. Cranial Nerve Examination - OSCE Guide (New Version). Available from: https://www.youtube.com/watch?v=sJBpai74tlU. Lasted Accessed: 2021.4.3
  9. UBC Medicine - Educational Media. UBC Medicine Neurology Clinical Skills - Motor, Sensory, and Reflex ExaminationAvailable from: https://www.youtube.com/watch?v=5ob5uJMgZOs Lasted accessed: 2021.4.3
  10. How to test the Neurological Babinski Reflex for Upper Motor Neurone Lesion. Available from: https://www.youtube.com/watch?v=vkM-xX7KRR4. lasted accessed: 2021.4.3