Neuromuscular Examination Elements
PTA 204L Neurological Dysfunctions Lab

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

Contact howardc@lanecc.edu for permissions.

Acknowledgements

Movies drawn from the Neurologic Exam and PediNeurologic Exam web sites are used by permission of Paul D. Larsen, M.D., University of Nebraska Medical Center and Suzanne S. Stensaas, Ph.D., University of Utah School of Medicine. Additional materials for Neurologic Exam are drawn from resources provided by Alejandro Stern, Stern Foundation, Buenos Aires, Argentina; Kathleen Digre, M.D., University of Utah; and Daniel Jacobson, M.D., Marshfield Clinic, Wisconsin. Subsequent re-use of any materials outside of this program, presentation, or website requires permission from the original producers.

Neuromuscular Examination Elements

Each physical therapist develops and individualized flow of examination. The Guide to Physical Therapist Practice provides a framework for the key elements of a comprehensive neuromuscular examination. Family members, care givers, staff, and patients will have questions about terminology, function, and functional deficits.

Major components of a neuromuscular system examination include:

• patient history
• review of body systems
• vital signs
• pain
• observations, including
• arousal, attention, and cognition
• sensation (primary and cortical)
• motor (ROM, tone, strength, timing, coordination)
• cranial nerve exam
• functional activity assessment
• standardized tests as indicated
• patient participation factors

These specific examination findings lead the PT to form primary and secondary PT diagnoses, and impairments and limitations that will be addressed with selected interventions. Impairments of the neuromuscular system can lead to changes in musculoskeletal, cardiovascular, pulmonary and integument systems. For example, loss of sensation and active ROM from a CVA can lead to pressure ulcers from malpositioning, contractures and joint dysfunction from abnormal use/disuse of an extremity, decreased endurance from changes in physical activity, and loss of respiratory capacity from changes in trunk strength.

A PT applies knowledge of neuropathology, motor learning, and body systems to examination findings and develops a prognosis, plan of care, and goals that reflect the patients needs and situation.

The linked handout to the right includes some key terms used in documentation for patients with neurological dysfunction. Download the handout on the right as a supplemental resource to aid your understanding of neurological terms.

Cognition and Communication

History taking

A video example of history taking is available in your textbook resources at: http://www.healio.com/books/sites/neuroptavideos/chapter-5.

"Learning to listen" shows how history-taking with the patient can lend insight in to orientation, memory, and motivation. Additionally, history is derived from the medical record, trusted family, friends, teachers and caregivers, lab and imaging outcomes, and prior encounters with the patients.

During the patient interview, the therapist can also note speech production and speech deficits associated with neurological dysfunction. It is important to document and discriminate speech disorders and impacts on command-following, comprehension, and problem-solving prior to initiating treatment.

Pain Assessment

Until recently, pain was referred to as the fifth vital sign. Patients should be interviewed about their pain experience during the examination and treatment processes.

Pain assessment tool selection depends on cognitive status and language function. Primitive withdrawal reflexes, grimacing, or vocalizing may be the only modalities available for your patient to express and respond to painful stimuli. Observations are pivotal in assessing pain and potential risk for injury during physical therapy interventions. Common assessment tools in this patient population include the Visual Analog Scale (VAS), Faces Pain Scale (FPS), and body diagrams. Other standardized tools are available to reliably gather information from non-verbal patients about their pain experience, including infants

http://boneandspine.com/wp-content/uploads/2013/08/faces-pain-scale-revised.png

Arousal, Attention, Memory

In PTA 103L, we practiced assessing A&O status during case simulation. We also practiced using some standardized screening/assessment tools for documenting memory function and information processing. If you'd like to refresh your understanding of language and tools used to assess and document mental function, the PTA 103L A&O activity is available for download on the right.

The videos below demonstrate techniques to assess cognitive status. Compare the outcomes of the normal exam with the abnormal exam. What key differences do you notice?

By reviewing the linked videos, you will prepare for patient communication in skill checks, lab exams and in the clinic.

Examples of Mental Status Exams

Normal Orientation and Memory

Abnormal Orientation and Memory

Language Deficits and Cognitive Assessments

Speech and language deficits may be confused with impaired memory. Individuals who have difficult processing or producing language may have difficulty responding reliably to verbal and/or written questions designed to assess orientation. Speech intelligibility (dysarthria, apraxia) may be decreased when there is weakness of facial muscles, decreased coordination during word/sound formation, or poor breath support during speech. Aphasia describes central losses of language.

Normal Receptive Language

Receptive Aphasia - Abnormal Receptive Language

This speech pattern may also be referred to as "word salad". Receptive patterns can result in nonsense words and disconnected and repetitive phrases. Patients are unable to detect errors in their own speech, therefore, communication and comprehension is significantly impaired. In the "More Resources" link on this page, you can read a sample of a "word salad" exchange from an episode of "Boston Legal"

Normal Expressive Language

Expressive Aphasia - Abnormal Expressive Language

Expressive deficits are characterized by errors in speech production. In general, patients are able to understand speech and commands/requests, yet their responses are incorrect or incomplete. Patients are often aware of their errors in speech production, which can result in frustration and depression.

PTAs can coordinate with health care team members, including Speech and Language Pathologists, to facilitate positive and productive reciprocal communication during therapy sessions and family training.

Sensation

Sensory testing provides valuable information about how information from the outside world and information from the skin and joints is integrated by the nervous system. Sensory testing is used frequently to gauge recovery of cortical systems as well as peripheral nerve function.

Recall from PTA 103L your practice in assessing light touch sensation in the upper and lower extremities. Using a light cotton swab or tissue, you were able to correctly assess light touch by referencing dermatome maps and relating it sensory processing at a specific spinal level. You may wish to review the spinal levels and their respective dermatomes to refresh your memory of this relationship.

Link to LCC PTA Program Sensory Dance Video

Testing sensation in this patient population becomes more specialized beyond those tests learned in PTA 103L. Course readings (Umphred, Chapter 5) describe and summarize the multiple tests which are performed to differentiate sensory function. In this course, we will demonstrate and practice tests for joint position sense (proprioception) and joint motion (kinesthesia)

• Demonstration of sensory testing procedures for your skill check are included in: Somatosensory Examination Tutorial.

• View this screencast for instructions on how to access the demonstration portion of the sensory testing lab activity:
• Sensory testing demonstration and skill check preparation screencast

Motor Function

Basic assessment of motor function include ROM, strength, and tone. Integration sensorimotor function allows the therapist to assess more complex and integrated functional motor responses, such as coordination, timing , accuracy, and balance. Any evidence of abnormal synergies (flexion/extension) during movement is observed and documented

This video provides a simulated example of hemiparetic gait, integrating stereotypical flexion synergies in the affected UE and extension synergies in the affected LE.

Coordination

PTs will assess gross coordination of head and eye movements, limb movements, and trunk and limb coordination as part of the initial examination. Basic postural control hinges on the interactions of the CNS, vestibular, visual, and musculoskeletal systems. Recall that the primary function of the cerebellum is for muscle timing and force, error correction, and coordination of movements. Patients with disorders affecting the cerebellum will present with coordination deficits.

Common coordination tests are available in your Umphred text. See page 134 for a summary of tests which may be selected during a PT examination. Videos are linked below to provide you with examples of abnormal coordination.

Examples of Abnormal Coordination Findings

Dysdiadochokinesia

Abnormal Alternate Nose - to - Finger test

Abnormal Heel - to - Shin test

Coordination tests for nose-finger-nose, rapid alternating movement and heel-to-shin are demonstrated in the 'Coordination and Balance' section of this lecture and described in your Umphred text (p. 134).

Practice performing these tests after viewing the demonstrations provided in "Coordination and Balance". Course readings will support your practice. Include in your practice expectations of processing delays, language impairments (aphasia), and visual neglects so you are practicing in the context of the clinical setting where these tests are most often performed.

Balance

Balance testing includes static ("quiet") and dynamic sitting and standing balance. Functional activities are often included in balance assessment to help describe the impact of poor trunk control and delayed balance responses with everyday activities. Alignment, responses to perturbations, visual disturbance, and weight-bearing surface allow for differential PT diagnosis and prioritized treatment planning.

Cranial Nerves & The Special Senses

Cranial nerves are the pathways to perception of

•Olfaction

•Taste

•Visual system

•Hearing and balance

Cranial nerves reside in throughout the brain: cerebrum, and brain stem (midbrain, pons, and medulla oblongota). PTs will screen and assess gross cranial nerve function through observation of involuntary movement and simple motor commands.

Brainstem: connects spinal cord to brain; integration of reflexes necessary for survival

By Patrick J. Lynch, medical illustrator (Patrick J. Lynch, medical illustrator) [CC-BY-2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

Cranial nerves (CN): part of peripheral nervous system which arises directly from brain. Two pairs of CN arise from cerebrum; ten pairs arise from brainstem. Indicated by

Roman numerals I-XII from anterior to posterior. CNs may have one or more of three functions

• Sensory (special or general)

• Somatic motor (control of skeletal muscles)

• Parasympathetic (regulation of glands, smooth muscles, cardiac muscle)

Subdivisions and Associated Cranial Nerves

Cranial Nerve Tests and Measures

The Wayne State Tutorial is highly detailed and includes a section on "interpretation" which is outside of the PTA scope of practice. We have narrowed the focused of the tutorial by linking the procedures for testing in the table below.

Any patient who reports and/or demonstrates new signs and symptoms of cranial nerve dysfunction may be experiencing a medical emergency.

A PTA should be able to select and perform tests for cranial nerve function. Specific cranial nerve testing procedures are linked below:

For your reference, you can link to the full Wayne State Cranial Nerve Tutorial

Abnormal Cranial Nerve Tests and Measures

Abnormal Cranial Nerve II

Recall that visual fields are dependent on individual eye function as well as convergence of both eyes on an object/image. Damage to central visual processing systems can result in visual disturbances or field cuts.

http://en.wikipedia.org/wiki/Visual_field

The video provides an example of a patient with a R visual field cut.. No sound

Abnormal CN V Sensory Exam

This patient demonstrates unilateral sensory dysfunction in the Trigeminal nerve. Recall that the the Trigeminal nerve is the primary nerve anesthetized during dental procedures.

Abnormal CN VII: Note the asymmetry in facial muscles

Abnormal CN XII (Hypoglossal)

The tongue will deviate toward the affected (weaker) side when the patient is prompted to stick out their tongue

Cranial nerve coordination examination

Sample of Normal VOR

The VOR is also referred to as the "Doll's Eye's" reflex. The examiner (sound only) is assessing both eye motor function and coordination of eye and head motions which includes CN VIII

 Safety Considerations

Examples of possible safety considerations for patients with CN deficits include:

• placing yourself and transfer surfaces within the patients's intact visual field; securing call bell within visual and sensory fields
• orienting the patient to engage in compensatory strategies to accommodate for losses in vision, sensation, etc.
• checking swallowing precautions prior to offering any patient with a neurological condition food/drink
• obtaining a second person for assistance as needed when there is a balance disorder
• applying/utilizing adaptive equipment during therapy based on deficits (eye patch, written/visual instructions (e.g., with hearing loss), soft-restraint to prevent injury to self, positioning/splinting to challenge or rest affected structures.

Functional Assessments

Functional Mobility

This assessment is often individualized based on the contextual factors for the individual patient. Activities are closely aligned with the developmental sequence and home safety. Examples of functional assessments include (but are not limited to):

• rolling
• upright tolerance (supported and unsupported, lying, sitting, and standing)
• getting in and out of bed
• getting in and out of a chair
• sit to stand
• walking, stepping, and climbing
• changing directions
• squatting
• lifting, carrying, and reaching
• negotiating obstacles
• retrieving objects from floor
• getting on and off the floor

Gait / Locomotion

An initial assessment of gait includes

• static posture assessment (seated, standing)
• weight bearing and compensatory patterns
• arm swing / trunk rotation
• stride length and symmetry
• stance time
• assistive devices / assistance level
• endurance
• terrain (level, uneven, curbs, stairs)

Coordination during gait may be included in the gait assessment. PTs and PTAs use observation and appropriate medical terminology to describe abnormal findings. Symmetry, synergies, endurance, and safety considerations may be included in the plan of care and should be reassessed to note progress toward goals and function.

Locomotion includes non-ambulatory mobility. Safety, endurance, requisite posture, and motor planning for maneuvering effectively at home and in the community are included in locomotion assessments.

Normal tandem gait

Abnormal gait examples

Neuropathic gait

Abnormal tandem 

Parkinsonian gait

Ataxic gait

Diplegic gait - video is without sound

Role of the PTA

In each patient encounter, the PTA must think critically, engage diverse values and perspectives, create solutions, communicate effectively, apply learning to ensure skilled physical therapy services. Within each element of the patient encounter, a PTA uses analytical skills to recognize when changes or new data elements may indicate treatment is:

• unsafe or,
• no longer aligns with the current POC

and communicates these findings (subjective and objective) with the supervising PT

The supervising PT analyzes all of the examination elements to develop a treatment prognosis and plan of care designed to progress the patient and meet treatment goals. A PTA must integrate evaluation findings and:

• affirm safety parameters have been met before initiating treatment
• select appropriate interventions and test and measures as directed by the PT
• monitor the patient response (subjective pre-, during, and post-) each encounter
• modify selected interventions as needed based on patient response (safety, comfort, participation, progression)
• document the treatment outcomes as it relates to the POC using relevant and aligned terminology, including:
• accurately interpret neurological terms included in the PT evaluation
• accurately describe observations using neurological terms
• distinguish normal from abnormal responses in tests, measures, and functional activities
• communicate signs and symptoms of emerging neurological changes or deficits
• seek additional direction and supervision when patient is unable to progress as directed or if goals are exceeded or met

The role of the PT is to interpret the examination results, perform and/or delegate interventions in the plan of care, reexamine the patient as needed to assess response to PT, make changes to the treatment plan as needed, and consult with other health care personnel, including the PTA, as needed.

In addition to the essential role elements above, the following table summarizes the role of the PT and of the PTA in the examination and care planning process for patients with neurological dysfunctions:

End of Lecture