Introduction

People who experience neurological disease or dysfunction are often cared for by therapists (physical therapists [PTs] and occupational therapists [OTs]) who are experts in the assessment of and treatment of movement disorders. Movement therapists’ (PT and OT) role in working with patients with neurological dysfunction is to address the impact of the condition on the patient’s functional status and ability to engage in society. The neurological examination is a process used by therapists to determine the implications of a neurological condition on patients’ ability to perform important functional activities. The results gleaned from a neurological examination inform therapists about the movement diagnosis, prognosis, long-term and short-term goals, and plan of care. The neurological exam is performed in part or whole throughout the episode of care to document patient progress and stimulate changes in the plan of care.

Whether the neurological condition is recent/acute or long-standing/chronic, movement therapists must first screen their patients on two levels. First, a medical screening exam is important to answer the question, “is my patient sufficiently medically stable that it is safe to proceed with the examination?” If the therapist notes “red flags,” meaning the patient’s medical condition is unstable and requires immediate and, in some cases, emergent care, treatment from a physician or other health care provider is warranted. When the patient is deemed medically stable, movement therapists must determine appropriateness for therapy and ask, “Am I the appropriate professional to address this patient’s limitations in light of his/her goals and preferences?” If the answer to this question is “no,” the movement therapists must refer the patient to the appropriate professional for the most suitable care.

When the patient is deemed both medically stable and appropriate for therapy, the neurological examination commences. Ideally, the neurological examination begins with a review of the medical record, which can inform the therapist about the following: (1) onset and cause of the condition, (2) comorbid conditions, (3) social context (meaning family and work responsibilities), (4) home environment, (5) avocations, and (6) patient age. This information should help the therapist to formulate questions for the subsequent patient interview and plan the objective evaluation.

A framework for clinical decision making regarding comprehensive examination in the movement therapies is the International Classification of Function developed by the World Health Organization (see Chapter 1 ). There are numerous tools available to measure the impact of neurological conditions at each of the levels of the International Classification of Functioning, Disability and Health (ICF), Body Function and Structure Impairments, Activity Limitations and Participation Restrictions. All tests and measures of each of these levels must be rigorously tested for their psychometric or clinometric properties (validity, reliability, sensitivity, specificity, etc.). Throughout the neurological examination, movement therapists should frame the data they plan to gather and the results they find into the levels of the ICF.

Therapists can use several tools to assess patient status after neurological damage. Multiple body function and structure impairments may contribute to an impaired ability to perform functional activities. Therapists select measurement tools that address specific sensory, motor, or cognitive systems which contribute to activity performance.

Activity measures specifically assess patient functional performance of activities of daily living objectively. These tools typically rate performance on an ordinal or interval scale, which provides the opportunity to measure progress or decline. Although the change in score on a performance measure is objective and reflects decline or improvement in function, it is not possible, simply from the score, to know the cause of this change. The clinician must hypothesize the most likely cause at the body function and structure level and specifically examine the impairment to confirm or deny the hypothesis. In many cases a combination of body function and structure impairments contribute to scores on activity performance measures.

A third category of assessment addresses participation outcome measures (OMs) that are designed to assess a client’s involvement or restriction in domestic, community, social, and civic life situations. Most often these measures address the client’s perspectives regarding the impact of the neurological condition upon quality of life, interpersonal interactions, and quality of involvement in domestic, community, social, and civic life situations.

To evaluate the results of the neurological examination at the body function and structure, activity and participation levels must be synthesized by the therapist to proceed to the meaningful next steps. Therapists must critically evaluate the results to establish the client’s diagnosis, prognosis, and plan of care while considering the individuals’ goals and preferences. In addition, the neurological examination is an ongoing, repetitive process throughout the episode of care. The therapist must constantly assess the patients’ health status to identify evidence of recovery or decline. As the patient recovers the ability to perform more complex movement activities, therapists must consider further assessment at the body function and structure level, as well as the activity level. It may be that changes at the body function and structure level contribute to improved function and interventions should change to reflect this improvement.

In addition, improvement in activities may require a different measurement tool because the patient’s recovery goes beyond the capability of the measure to document change. In other words, the assessment tool may have a ceiling effect to which the patient outperforms. In all cases, the rigor and intensity of therapy interventions must morph to require continual and significant effort on the patient’s part.

Tests of activity and functional performance

Measures at the activity level quantify patient functional status ranging from balance skills to walking ability and other tasks important to everyday function. Tests of skills at the activity level may range from a single item that documents a narrow set of skills to multidimensional tests used to discern the elements of an activity that are most problematic and require skilled therapeutic interventions. Those activity measures that include a single or small set of skills may be used to assess client ability generally. These tests are quick and easy to perform and can screen out those who do not require in-depth study and screen in those with more significant involvement. At the other end of the Activity assessment spectrum are multiple item tests. These multiple item tests are more time consuming but test more skills that might be overlooked when using shorter assessments. One way to consider these is that a short tool can screen for general problems, whereas the multiple-item tests provide information in more detail and can be used as a follow-up to the short, single-item tests. For example, the Timed Up and Go (TUG) test is an excellent measure that predicts risk for falls in many populations. People who score below a “cut-score” on the TUG test are at higher risk for falling. But which dimension(s) of balance should a therapist devote time and attention to minimize the fall risk? One might consider follow-up testing using a multidimensional balance assessment like the Berg Balance Scale, the Fullerton Advanced Balance Scale, or the Mini-Best Test. From these multi-item tests, a clinician can deduce which elements of balance that the client needs to work on the most.

Outcome scales for functional tests may be found in ordinal format (e.g., Functional Independence Measure [FIM], Barthel Index, Katz Index of Independence in Activities of Daily Living). Each has its unique point value and range, varying from a two- to three-point scale (e.g., Tinetti Performance-Oriented Mobility Assessment [POMA]) to a seven-point scale (e.g., FIM). A few tools supply ratio scale data (e.g., the TUG test, Functional Reach Test, and measures of gait velocity). Test data presented in ratio scale format will more clearly show incremental changes, thereby facilitating the comparison of pretherapy to posttherapy performance.

Tests of body functions and structures

After identifying problems with the performance of functional activities, the clinician then focuses on body functions and structures that likely contribute to difficulty in daily activities. Consistent with the ICF model, the intent is to identify which body systems or subsystems are intact and functioning normally and those systems that could be optimized as the patient works to maximize functional tasks and participate in life. Identifying which body systems and subsystems that are not normal may lead the clinician to surmise the likely cause of the functional loss.

Impairment is defined as the loss or abnormality of physiological, psychological, or anatomical structure or function at the organ system level. The clinician must distinguish between primary impairments and secondary impairments. Primary impairments are a direct consequence of the client’s specific disease or pathological condition. Secondary impairments are changes in the structure and function of body systems that could have many causes. Secondary impairments may result from unaddressed primary impairments after the onset of the neurological condition, modified movement patterns after onset resulting in stress or compromise to a body structure or function, normal aging, disuse, repetitive strain, lifestyle, and many more. Secondary impairments may be premorbid. In this case an impairment that did not interfere with activities and skills prior to onset may now interfere with moving adaptively after onset. For instance, someone with a C6 spinal cord injury must have full elbow extension and significant shoulder external rotation to passively lock the elbows for transfers and prop sitting. Prior to the injury, a slight elbow flexion contracture may go undetected, but afterward, the consequences are dire, prohibiting the individual from transferring independently .

Moreover, the clinician must remember that, although functional limitations are usually caused by a combination of specific impairments, it is possible that impairments may not contribute to specific functional problems for some clients. If this is the case, the clinician should decide whether these impairments, if left uncorrected, will result in the development of activity limitations or other complications later. Simultaneously, the patient must be a part of this discussion to prioritize which impairments to address given the patient’s goals.

The ultimate goal of any therapeutic intervention program is to maximize the client’s health and wellness. Measuring progress toward these goals is critical.

Clinicians are challenged with selecting and administering examination tools that reflect the patient’s health, wellness, and response to therapeutic interventions. Examination tools that assess activity limitations typically require a lot of change to be clinically significant. Clinicians should document baseline performance of the functional activity and repeat the performance assessment at regular intervals. However, during rehabilitation programs, therapists address patients’ activity limitations and impairments of body systems that contribute to functional problems. It is reasonable to expect short-term improvement in impairments prior to small change in functional tasks and activities.

Box 7.1 illustrates impairments that may be seen in patients/clients with movement disorders caused by neurological dysfunctions. These impairments are further classified as those that are within the central nervous system and those that are outside the central nervous system and result from interaction with the environment. These impairments are further discussed in detail in various sections of this book.

Range-of-motion (ROM) testing is one example of a common neuromusculoskeletal system examination procedure. Clinicians depend heavily on ROM measurements as an essential component of their examination and consequent evaluation process. It is imperative that the data obtained from this procedure be reliable. It has been suggested that the main source of variation in the performance of ROM testing is the method used. Standardizing methods and procedures will improve the reliability of the data gathered.

An impairment in ROM can be the result of other body system impairments. ROM measurements may be used to determine the effect of tone, balance, movement synergies, pain, and so forth on the neuromuscular system and ultimately on behavior. Most important, the clinician needs to remember that the ROM needed to perform a functional activity is more critical than “normal,” anatomical, biomechanical ROM values and must be considered when labeling and measuring impairments. For example, full ROM in the shoulder is seldom needed unless activities of daily living, work, or leisure activities require it, such as performing a tennis serve or reaching overhead to paint a ceiling. When needed for specific tasks, goniometric measurements of ROM are appropriate, but at other times a functional range measurement may be sufficient.

Muscle strength testing is another commonly used examination procedure. Clinicians use various methods of quantifying strength including “traditional” manual muscle testing (MMT) and the use of a dynamometer. As with ROM, strength should be correlated with the patient’s functional performance. Again, the clinician may find a client to have ⅗ strength in the shoulder flexor muscle groups or find grip strength to be 35 kg, but the more important question should be “What does this mean in terms of the client’s ability to perform activities of daily living, and/or can he use that power in a functional activity?” The clinician is also advised to make the distinction between muscle strength and muscular endurance as it relates to function. A client may have sufficient lower-extremity strength and power to get up from the seated position; however, this does not necessarily mean that the client has muscular endurance to perform the task repeatedly during the day as part of normal everyday activities.

The status of the cardiac, respiratory, and circulatory systems significantly affects a client’s functional performance. Blood pressure, heart rate, and respiration give the clinician signs of the patient’s medical stability and the ability to tolerate exercise. The clinician may also obtain the results of pulmonary function tests for ventilation, pulmonary mechanics, lung diffusion capacity, or blood gas analysis after determining that the client’s pulmonary system is a major factor affecting medical stability and functional progress. Various exercise tolerance tests also attempt to quantify functional work capacity and serve as a guide for the clinician performing cardiac and pulmonary rehabilitation.

A client who has difficulty performing activities of daily living and who has neurological impairments in the central motor, sensory, perceptual, or integrative systems needs to undergo examination procedures to establish the level of impairment of each involved system and to determine if and how that system is contributing to the deficit motor behaviors. Functional evaluation tools used may include the FIM, the Barthel Index, the Tinetti POMA, or the TUG test. The results of these tests will help to steer the clinician toward the most useful impairment tools to use to evaluate limitations in the various body systems. Impairment tools may include the Modified Ashworth Scale for spasticity, the Upright Motor Control Test for lower-extremity motor control, the Clinical Test of Sensory Interaction on Balance (CTSIB), or the Sensory Organization Test (SOT) for balance and sensory integrative problems, or computerized tests of limits of stability on the SMART EquiTest, among others.

The clinician is also advised to investigate the interaction of other organs and systems as they relate to the patient’s functional limitations. For example, electrolyte imbalance, hormonal disorders, or adverse drug reactions may explain impairments and activity limitations noted in other interacting systems.

Tests for participation and self-efficacy

In ICF terminology, participation is defined as an individual’s involvement in a life situation. Domestic life, interpersonal interactions and relationships, and community, social, and civic life are some examples of aspects of participation that can be examined for each individual. Participation restriction is the term used to denote problems that individuals may experience in involvement in life situations. When considering participation, it is important to obtain the individual’s perception of how the medical condition, impairments, and activity limitations affect his or her involvement in life and community. Therefore many of the tests for participation and self-efficacy are in self-report format. The Activities-specific Balance Confidence (ABC) Scale, Short Form 36 (SF-36), and Dizziness Handicap Inventory (DHI) are examples of tests that can be used to gather information under this domain. These tests allow an individual to assess his or her health quality of life after an incident that affected activity and participation.

Choosing the appropriate examination tool

Selecting appropriate OMs is key in clinical decision making, documenting patient change over time and in response to interventions, justifying payment for skilled therapy, and communicating with the health care team, including the patient. Deciding which OMs to use can be a daunting task. One repository of OMs in rehabilitation is the Rehabilitation Measures Database found at the Shirley Ryan Ability Lab ( https://www.sralab.org/rehabilitation-measures ). A brief search of this database using the term “neurologic physical therapy outcome measures” returned more than 400 assessments. This large amount is clearly overwhelming for clinicians looking for assessments for their patients. Some mechanism for organizing outcomes must be used to make wise selections. One useful organizing tool is the aforementioned ICF model in which the clinician can choose measures based on whether they assess limitations in Body Structure and Function, Activity, or Participation. However, categorizing more than 400 measures into these categories is still daunting. In 2006 the American Physical Therapy Association (APTA) in partnership with the Research Section of the APTA formed the Evaluation Database to Guide Effectiveness (EDGE) Task Force in an attempt to standardize OMs and distill them to a core set.

The Academy of Neurologic Physical Therapy (ANPT) formed multiple diagnosis-specific EDGE Task Forces that provided recommendations for measures by level of the ICF, patient, practice setting, utility in research, and entry-level physical therapy education. There are currently six EDGE documents available on the ANPT website ( www.neuropt.org ) that include StrokEDGE, MS EDGE, Traumatic Brain Injury EDGE, Spinal Cord Injury EDGE, Parkinson Disease, and Vestibular Disorders. The EDGE Task Forces’ recommendations for PT education are divided into OMs that “students should learn to administer” and those “students should be exposed to.” Combining the recommendations from each EDGE Task Force and eliminating redundancy, graduates of PT education programs should know how to administer 52 different OMs and be exposed to an additional 55 OMs, making 107 OMs in neurological patient/client management courses alone. The specific EDGE Task Force recommendations are included in Appendix 7.A .

In July of 2018, the Journal of Neurologic Physical Therapy and ANPT identified a core set of OMs for neurological rehabilitation. The authors used the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist to examine the literature related to OMs in neurological rehabilitation. Their criteria were that each measure could be applied to patients at different levels of acuity, with varied neurological conditions and in different practice settings. Nine action statements were addressed with the first six addressing specific activities necessary for function on a daily basis. The seventh addressed documentation, whereas eight and nine made recommendations for using the core set of OMs and their results. The Action Statements and the associated OMs are included in Appendix 7.B .

Another way to approach assessment tools is to categorize them by the type of information that the clinician and patient seek. Those heavily involved with clinical practice may find this type of organization most valuable for their particular circumstances as they could easily identify possible tests and measure to use based on a particular patient problem or presentation that they would like to closely monitor for progress. Please refer to Appendix 7.C .

Moreover, there are OMs that are specifically valuable for the pediatric population. A list of the more common OMs can be found in Appendix 7.D .

For all measures, the reader is referred to the Rehabilitation Measures Database (search “Rehabilitation Measures Database”) for the most recent data and literature for each measure.

The ability to choose the appropriate examination tool(s) for a particular client will depend on several factors:

• 1.
  

  The client’s current functional status (ambulatory vs. nonambulatory)

  
  
• 2.
  

  The client’s current cognitive status (intact vs. confused or disoriented)

  
  
• 3.
  

  The clinical setting in which the person is being evaluated for treatment (acute hospital, rehabilitation, outpatient, skilled care, or home care)

  
  
• 4.
  

  The client’s primary complaints (pain vs. weakness vs. impaired balance)

  
  
• 5.
  

  The client’s goals and realistic expectation for recovery, maintenance, or prevention of functional loss (acute injury, chronic problem, or progressive disease process)

  
  
• 6.
  

  The type of information desired from the test (e.g., if the test is discriminative or predictive). The reader is encouraged to read the two articles on “outcome measures in neurological physical therapy practice” ^, published in the Journal of Neurologic Physical Therapy for a detailed discussion on this subject.

  
  
• 7.
  

  The psychometric properties of the test on the specific patient population/diagnosis

  
  
• 8.
  

  The ability of the test to detect significant change over time

The evaluator should select examination tools that address three objectives: first, to measure the client’s primary problems (activity limitations, impairments, and participation restrictions); second, supply outcome values necessary for setting realistic treatment goals in collaboration with the client and family; and third, to plan efficient and effective intervention strategies.

Many of the examination tools that measure a client’s ability to perform functional activities have been accepted as valid, reliable, and useful for the justification of payment for services rendered. The number of activity limitations and the extent of the client’s participation limitation are often reasons why an individual either has access to therapy services directly or is referred by a medical practitioner. For this reason, the third-party payers expect to receive reports concerning positive changes in the client’s functional status to justify therapeutic services. The initial list of functional or activity limitations or participation restrictions helps the therapist to determine the extent of, expectations for, and direction of intervention, but it does not determine why those limitations exist. The answer to this question is critical in the evaluation process. Examination tests and procedures that identify specific system and subsystem impairments help the therapist to determine causes for existing participation and activity limitations. These tools must be objective, reliable, and sufficiently sensitive to provide needed communication to third-party payers to explain the subsystem’s baseline progress during and after the intervention. These tools should also supply explanations for residual difficulties in the event that the functional problems themselves do not demonstrate significant objective change or show progress within the time frame estimated.

Acknowledgments

The author recognizes Drs. Peggy Roller, Rolando Lazaro, and Darcy Umphred, who authored this chapter in the sixth edition of the text.

References

To enhance this text and add value for the reader, all references are included on the companion Evolve site that accompanies this textbook. This online service will, when available, provide a link for the reader to a PubMed abstract for the article cited. There are 21 cited references and other general references for this chapter, with the majority of those articles being evidence-based citations.

CASE STUDY 7.1 ^a

The patient is a 30-year-old man who was referred to outpatient physical therapy after a 1-week stay in an acute care facility following an exacerbation of relapsing-remitting multiple sclerosis (MS). His height was 2.05 m (6 feet 9 inches), and his weight was 133.81 kg (295 pounds). The patient was first diagnosed with MS 4 years ago. He developed optic neuritis during the exacerbation and was treated with corticosteroid pulse therapy. The patient’s past medical history included depression, gastroesophageal reflux disease, migraine headaches, and hyperlipidemia. After being diagnosed with MS, the patient had to stop working. Before the most recent hospitalization, the patient lived with his sister in a single-story home with five stairs to enter with a railing. At that time he was able to ambulate independently without an assistive device and to complete all activities of daily living without any assistance.

An outpatient physical therapy initial examination was conducted 1 week after the patient was discharged from the hospital. He reported that he was using a wheelchair to get to and from appointments, and inside his home. He was alert and oriented to person, place, and time, although responses were delayed and speech was slightly slurred. There were no complaints of pain, and the patient stated that fatigue and temperature had not affected him.

Several tests of functional movement activities were performed first. The patient was able to roll to the right and left with minimal assistance, with rolling to the right being less difficult for the patient. He needed supervision to move from supine to sitting.

The patient required moderate assistance to perform a sit-to-stand transfer. He was able to ambulate five steps with a front-wheeled walker (FWW) and moderate assistance of one person.

After examination of the patient’s functional movement activities, several tests of body function and structures were then administered. Passive range of motion for all joints in both upper and lower extremities was within normal limits. The patient presented with ⅗ (fair) strength of the right upper and lower extremities and good (⅘) strength of the left upper and lower extremities during MMT. Light touch and superficial pain sensations tested intact from C4 to S2 dermatomes bilaterally.

Sitting balance was scored as ¾ (good) because the patient was able to accept moderate challenges. Standing static balance was 10+/4 (poor plus); the patient was able to maintain balance with handheld support and occasional minimal assistance.

Observational gait analysis was performed, and impairments in gait included the following: decreased step length bilaterally, wide base of support, decreased weight bearing through the right lower extremity, and lack of toe-off. It was also noted that ataxic type movements were present with ambulation.

The Gait Abnormality Rating Scale (GARS) was performed, and the patient scored a ³² ⁄ ₄₈ , indicating increased fall risk. The Tinetti Performance-Oriented Mobility Assessment (POMA) was also administered. The patient scored ⁸ ⁄ ₂₈ , indicating a high risk for falls. Several tests were performed using the Natus Balance Master. The sit-to-stand test showed that the patient had difficulty maintaining balance immediately after rising and had more weight on his left lower extremity. The results were abnormal, based on the norms for the patient’s gender and age. Next, the weight-bearing squat test was done. During this test the patient was not able to maintain equal weight through bilateral lower extremities, with the patient bearing weight more on the left side. The patient then performed the limits of stability test, which revealed an inability to lean his center of gravity (COG) over his right lower extremity, or forward onto his toes. The patient then performed the rhythmic weight-shift test; he was not able to complete the forward-backward component of the rhythmic weight-shift test without falling, and he also had difficulty with directional control and velocity during lateral weight shifting.

Last, tests for participation and self-efficacy were administered. The Activities-specific Balance Confidence (ABC) Scale questionnaire was given to the patient to assess the patient’s balance self-efficacy. The patient had a score of 20%, indicating a low level of physical functioning. He scored 10% on being able to bend down, pick a slipper up off the floor, and reach for a can on a shelf at eye level with the use of an FWW.

The data collected at initial examination revealed limitations in functional performance resulting from impairments in balance, gait, strength, and motor control, giving the therapist the various movement diagnoses that reflected problems. Intervention frequency and duration was set at three times per week for 8 weeks. The prognosis that the patient would be able to ambulate independently in the community with an assistive device in 8 weeks was good, given the patient’s willingness to participate in physical therapy, positive outlook, family support, and positive response to medical interventions. The plan of care that was developed focused on improving activity limitations such as transfers and gait and impairments such as weakness and imbalance. The expected outcomes were set to be achieved in 8 weeks, and anticipated goals were set to be achieved in 4 weeks.

Case study modified from Larsen-Merrill J, Lazaro R: Use of the NeuroCom balance master training protocols to improve functional performance in a person with multiple sclerosis. J Stud Phys Ther Res 21:1–16, 2009.

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