Introduction

Assessment in neurological physiotherapy is a process of collecting information about disordered movement patterns, underlying impairments, activity restrictions, and societal participation of people with neurological pathology for the purpose of intervention planning(Ryerson, 2009). The purpose of assessment is to help the therapist determine the best intervention (Bernhardt & Hill 2005, p. 16). Assessment is regarded as the first step of neuro-rehabilitation (Lexell & Brogardh, 2014) and therefore it can be deducted that its proper execution is a major influencer of the neuro-rehabilitation process.

International Classification of Functioning, Disability and Health (ICF) in physiotherapy assessment.

A study (Jelsma & Scott, 2011) found out that using the ICF framework for assessing patients lead to more function-related information, resulting in a more holistic assessment. This will in turn lead to a more appropriate intervention plan.

The ICF was created to ‘provide a unified and standard language and framework for the description of health and health-related states.’ (WHO, 2001). The ICF based rehabilitation plan utilizes the terminology from the ICF and provides us with a universal framework for describing all aspects of a disability (i.e., Impairments, and Activity limitations and Participation restrictions). In addition, the ICF also includes contextual factors, i.e., Environmental factors and Personal factors, which allow us to describe the impact of the environment on a person’s functioning and disability. (Lexell & Brogardh, 2014)

Subjective Assessment

In subjective assessment the therapist gathers general information from the medical record, the various members of the multidisciplinary team (MDT) and the patient and/or family.(Ryerson, 2009)

Medical records and members of the multidisciplinary team

The medical chart screening provides data about past and present medical histories and helps the therapist determine if the patient is medically stable and ready for therapeutic intervention. (Ryerson, 2009) It also helps the physiotherapist to understand:

1. The management of the condition being undertaken.
2. How stable the patient is after being managed, if physiotherapy indicated.
3. How other managements scheduled will affect assessment and physiotherapy intervention.
4. If physiotherapy has been involved already.
5. Results of specific investigations i.e. MRI, CT scans, Lumbar Puncture etc.

Interview patient/family

The interview with the patient and/or family gives the therapist a sense of the patient’s previous level of functioning and personal needs. This is a time when the therapist establishes rapport and trust and may gain insight into the patient’s goals and concerns. The interview also allows the therapist to note the patient’s spontaneous posture, movements, mental status, and orientation and may identify areas for immediate objective assessment.(Ryerson, 2009)

Framework for Subjective Assessment

Patients Bio-Data

Will include details like patients name, age, gender, occupation, nationality

Presenting condition/complaints (C/C)

Diagnosis i.e. in the inpatient scenario or the patient’s complaints.

History of presenting condition/complaint (HPI/HPC)

Explains the patient’s condition or his complaints in deeper detail can be done in narrative form.

To expand further and get the details necessary the SOCRATES mnemonic can help the therapist get all the information necessary without skipping or forgetting.

S – site of the complaints

O – onset

C – character

R – radiation

A – Associated symptoms

T – Timing (Duration, course, pattern)

E – Exacerbating and relieving factors

S – Severity

Other issues to look include how the patient has tried managing the complaints.

Past medical history

Past medical history will go a long way to help understand the intervention options. It will include:

• Co -morbidities – other existing medical conditions, if any exist they will have an impact on the interventions.
• History of Previous Neurological Conditions
• History of surgery
• Special equipment that the patient requires of is using
• Risk factors that could be related to further neurological incidents
• Allergies

Drug history

Current ongoing medications

Social history

H – Home, (Support structure /family)

E – Environment/ Education / Employment / Eating

      What type of environment do they live in? stairs, elevators etc.

      Social background

A – Activities (Recreational, Level of Physical Activity)

D – Drugs (Caffeine, Alcohol, Smoking etc.)

S – Sexuality S – Suicide/Depression

Other considerations

Health Insurance.

Mobility – previous mobility levels in general areas, indoors, outdoor, steps and stairs, history of falls especially in geriatric patients.

Personal care – How did they manage personal care before the neurological event. Did they use assistive devices?

Vision – Do they wear glasses? Why?

Hearing – Do they use hearing aids?

History of challenges in:

• Cognition
• Communication
• Swallowing
• Fatigue
• Pain
• Perception

Lastly you should understand the patient’s expectation of treatment. What do they expect from physiotherapy? What is their understanding of the condition?

Objective Assessment

The objective assessment consists of observation and examination; it begins with the observation of activity level and voluntary movement control. Observational assessment allows the therapist to evaluate how the patient uses movement during a task and how their mental, cognitive, communicative and behavioral abilities affect task performance. (Ryerson, 2009)

Objective assessment in physiotherapy can be seen as being divided into two:

1. Identification of impairments
2. Functional assessment

However, the assessment itself can be carried out all at once.

Identification of impairments

To identify impairments various different tests and procedures are used:

Category	Tests
Mental Status Examination	Glasgow Coma scale to assess level of consciousness Mini mental state examination to assess mental status
Cranial Nerve Examination	The cranial nerves are assessed each by its purpose i.e.   Snellen chart to assess visual acuity (cranial nerve I) Alcohol pad to assess sense of smell
Motor System Examination	Weakness is assessed through muscle strength Postures Muscle Tone and rigidity assessment Tremors
Reflexes	Deep tendon reflexes i.e. Bicep tendon Achilles tendon reflexes Plantar reflexes i.e. Babinskis reflexes
Sensory Examination	Sensory examination in: Light touch Pain Temperature Vibration Proprioception
Cerebellum	Dysmetria Finger nose test Ankle over tibia Dysdiadochokinesis Rapid pronation and supination Ataxia Gait assessment Nystagmus
Somatosensory/Proprioceptive System Vestibular System Visual System	All these systems interact to Maintain balance. Tests that assess balance assess one or more of the system

Number of tests that can be carried out under neurological physiotherapy are so many however they can be grouped into tests that assess:

1. Posture
2. Balance
3. Voluntary movement
4. Involuntary movement
5. Tone
6. Reflexes
7. Sensation

Functional Assessment

Functional activities are linked trunk and extremity movement (Ryerson & Levit 1997). It is therefore not surprising that the trunk control and extremity control will influence just how functionally independent a patient can be.

Assessment of functional daily living activities will ensure that ensure the patient receives the level of support required on the ward and it will also help in goal setting and in creation of treatment plans.

During examination, the therapist should refrain from physically assisting the patient, but may offer verbal cues or demonstration to determine potential for improved performance. Assessing the functional ability of a patient will involve assessing:

• Bed Mobility – ability to change positions in bed, supine – side lying, prone vice versa.
• Transfers – Movement from bed to chair/ wheelchair
• Sitting Balance
• Sit to Stand – Its proper is an important goal in neurological rehabilitation. 
• Standing Balance
• Upper Limb Function
• Lower Limb Function
• Mobility
• Stairs

Harmonization of the functional abilities of the patient compared to impairments helps form a better clinical picture and help in creation of intervention strategies and in formulation of goals.

The following is an example of an ICF based rehabilitation plan. The plan was extracted from (Lexell & Brogardh, 2014)

References

Bernhardt J, Hill K. We Only Treat What It Occurs to us to Assess: The Importance of Knowledge-based Assessment. Science-based Rehabilitation: Theories into Practice. 2005:15-48.

World Health Organization. International classification of functioning, disability and health. Geneva: WHO; 2001

Ryerson SJ, Levit KK 1997 Functional movement reeducation: a contemporary model for stroke rehabilitation. Churchill Livingstone, New York

Jelsma, J., & Scott, D. (2011). Impact of using the ICF framework as an assessment tool for students in paediatric physiotherapy : a preliminary study. Physiotherapy, 97(1), 47–54. https://doi.org/10.1016/j.physio.2010.09.004

Lennon, S., Ramdharry, G., & Verheyden, G. (2018). Physical Management for Neurological Conditions (4 th). Elsevier.

Lexell, J., & Brogardh, C. (2014). The use of ICF in the neurorehabilitation process The use of ICF in the neurorehabilitation process. (DECEMBER). https://doi.org/10.3233/NRE-141184

Rekand, T. (2010). Clinical assessment and management of spasticity : a review. 122, 62–66.

Ryerson, S. (2009). Neurological assessment: the basis of clinical decision making. In Pocketbook of Neurological Physiotherapy (p. 308). Elsevier Health Sciences.

Thonnard, Jean-Louis ; Penta, M. (n.d.). “Functional assessment in physiotherapy. A literature review.”

Tyson, S., Watson, A., Moss, S., Troop, H., Dean-lofthouse, G., Jorritsma, S., & Shannon, M. (2008). Development of a framework for the evidence-based choice of outcome measures in neurological physiotherapy. 30(2), 142–149. https://doi.org/10.1080/09638280701216847