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Stroke Part 3: Examination Considerations
20 Plays9 days ago
Begin with the end in mind! In the third of a multi-part series on stroke, Dr. Michael Powers advocates for starting the examination with collaborative goal setting focused on participation. He outlines how working backward from participation to activity and then body function and structure optimizes therapeutic alliance and helps drive neuroplasticity by emphasizing what is salient to the patient. He then discusses the importance of the review of systems and systems review (and how to distinguish these potentially confusing terms!), before concluding with an evidence-based framework for movement and task analysis.
Key Takeaways
- Importance of collaborative goal setting with emphasis on participation
- Biopsychosocial model and impact on salience and neuroplasticity
- Stroke Impact Scale
- Key factors impacting Quality of Life after stroke
- Prevalence and impact of depression after stroke
- Evidence-based screening for depression
- Review of systems and systems review
- Using the Movement Continuum to analyze tasks
- Standardizing terminology - glossary of terms for movement analysis
References
- O'Sullivan & Schmitz's Physical Rehabilitation, 8th ed.
- ICF Health-Based Rehabilitation Program Promotes Activity and Participation
- Goal Setting with ICF and Multidisciplinary Team Approach in Stroke Rehabilitation
- Therapeutic Alliance in Physical Rehabilitation
- Stroke Part II: Examination and Evaluation
- Stroke Impact Scale
- Diagnostic and Clinical Utility of the PHQ-2
- Prevalence and Natural History of Depression After Stroke
- Impact of Depression on Stroke Outcomes Among Stroke Survivors
- A Framework for Movement Analysis of Tasks: Recommendations from the Academy of Neurologic Physical Therapy's Movement System Task Force
All music courtesy of Free Music Archive and used via attribution 4.0 international license.
- Intro and Outro: Stylin' by JMHBM
- Transitional: Our Reality by Ketsa
Connect
- email: neuropowerhour@drmichaelpowers.com
Recommended
Transcript
Introduction and Series Overview
00:00:09
Speaker
Welcome to the NeuroPowerHour. I'm your host and neurological navigator, Dr. Michael Powers, physical therapist, board-certified in neurologic physical therapy and clinical electrophysiology.
00:00:20
Speaker
Let's get started. Today's episode examination planning for stroke. And this is the third in a multi-part series about stroke. As I keep recording these, I'm realizing that there's going be more and more parts of this series because stroke is such an all-encompassing topic.
Previous Topics Recap and Today's Focus
00:00:37
Speaker
Quick recap, in episode one, we kind of talked about the prevalence, incidence of stroke, gave some background information. In part two, I talked about synergies and spasticity, making sure that you had a good handle or understanding of how that can impact movement.
00:00:53
Speaker
And today I want to talk about examination planning.
Holistic Examination Approach
00:00:56
Speaker
And it may not be in the order or the topics that you were initially thinking, because we're actually going to start with more of the end in mind and look at this in a holistic perspective and really following what both the O'Sullivan textbook and materials posted on APTA recommend.
00:01:13
Speaker
which is looking at participation first, really looking at the patient if from a holistic perspective. So this may be different than if you were thinking, well, we're going to talk about our muscle testing, our sensory testing, our neuro exam.
00:01:27
Speaker
That's all going to be part of what we talk about to a small extent, but I really want to set the stage or set the table for a big picture view on the examination.
Biopsychosocial Model and History Taking
00:01:37
Speaker
Topics for today are going to be framing the examination within a biopsychosocial model, talking in detail about the importance of the history taking, the review of systems, and the systems review.
00:01:48
Speaker
And if you're confused about the difference between review of systems and systems review, you're not alone. I didn't come up with these terms. They actually do represent different aspects of the examination. So we'll talk about that.
00:02:01
Speaker
Then I wanted to conclude with movement analysis and some discussion there because a big part of your examination is going to be collaborating with the patient on goals that relate more to participation, maybe some to activity.
00:02:15
Speaker
You're going to select some tasks and activities that you'd like to see how the patient does. And so here we're going to need that movement analysis. Now later, of course, you will be doing your tests and measures, some of your hands-on assessment. Maybe you're looking at sensory testing, you're looking at, you're assessing spasticity, but really what's recommended to the fullest extent possible, can we start by analyzing the movement, developing some hypotheses,
00:02:44
Speaker
and then doing further guided clinical exam to support or refute our hypotheses.
Participation Goals and Examination Strategy
00:02:50
Speaker
So without further ado, let's get started. Again, I want to start with the end in mind, both the O'Sullivan textbook and the excellent APTA reference. APTA has a three-part series on stroke. I'll link that in the show notes.
00:03:05
Speaker
But both references recommend starting with collaborative goal setting with the patient that's focused on participation. We have that in mind. So we think about our ICF model.
00:03:16
Speaker
We're thinking about participation. What are the key things that the patient or the client really does to fulfill so their societal role, their identity? Are they a parent?
00:03:27
Speaker
Do they enjoy going to church? Are they a student? What things are really important from a participation perspective? Then as we think about the participation goals, breaking these down into tasks and activities, then analyzing the movement during activities,
00:03:45
Speaker
generating some hypotheses, and then diving further, if we think of the ICF model, into body function and structure. This approach might be inverted or different from what you're used to. If you're used to, I'm going to go in, say hi introduce myself, and then get my hands on the patient. Let's check reflexes. Let's do a sensory exam.
00:04:05
Speaker
Really, instead, starting out with this biopsychosocial approach and starting out at participation. I do acknowledge this might be difficult for novices, so please hang with me as we go through this. But I do think if there's mental work on your part if that's involved with approaching the examination this way, it's more than going to pay off in terms of your therapeutic alliance, in terms of your goal setting, in terms of knowing if your interventions are truly having an impact on your patients.
Examination Components and Care Planning
00:04:36
Speaker
The examination, if we look at textbook definitions, according to the Guide to Physical Therapy Practice, during the examination, the physical therapist gathers data to establish the diagnosis, prognosis, and plan of care. So that's what we're talking about today is the planning of the examination.
00:04:55
Speaker
Your examination should include a history and your physical examination. So your subjective history, taking the history from the patient, and your review of systems. So the review of systems is subjective.
00:05:09
Speaker
It's verbal, maybe also observational, and used to determine the need for further workup and or referral. Remember that physical therapists are movement system experts, and that movement system is kind of in the center of all the other body systems. We're going to talk about those body systems in a little bit in terms of how we might ask questions or observe these systems as part of our review of systems.
Clarifying Systems Review vs. Review of Systems
00:05:36
Speaker
But then when we go into our physical examination, that's the systems review. That is the physical examination of systems. So our review of systems is a verbal and observational.
00:05:50
Speaker
Our systems review is the actual physical exam of systems. I don't know that there's an easy way to distinguish those two. Perhaps if you think about systems review, systems comes first.
00:06:04
Speaker
So if I think about that, okay, if I hear systems review, I'm actually examining the systems. Kind of works for me. Also in the physical examination, you're going to be performing tests and measures to confirm or reject your clinical hypothesis and support clinical judgments about diagnosis, prognosis, and your development of plan.
00:06:24
Speaker
And let me give a quick theoretical here. Let's say maybe someone's had a stroke. And they say, it's really important for me to be able to leave the house and go to church. So that's maybe the participation goal that you're looking at. And so you think, okay, we need to be able to stand. We need to be able to walk. We need to be able to transfer.
00:06:42
Speaker
We may need to be able to walk sideways if we're getting into, let's say, a pew at church, depending on how the church is set up. So those would all be tasks or activities that you may want to analyze the movement or ask the patient to do.
00:06:56
Speaker
And maybe as the patient is walking, you're analyzing gait, you're seeing that there's maybe a bit of a toe drag, they're having difficulty advancing the limb, you're generating a hypothesis, okay, do they have weak dorsiflexors? Is there a synergy or spasticity component?
00:07:11
Speaker
Can they not accept the weight on the involved side? And then you go into further tests and measures to confirm or reject or modify your hypothesis.
Improving Outcomes with the Biopsychosocial Model
00:07:21
Speaker
So that would be how that works in actual practice. Just a quick little snippet there of that approach.
00:07:27
Speaker
I do want to call attention to the biopsychosocial model. And we can conceptualize this as a Venn diagram. And I'm such a nerd. I love the Venn diagrams. But really, we've got the biology, so the medical condition, the tissues that are involved.
00:07:43
Speaker
We've got the psychology, so how the person thinks about things, maybe their culture, maybe ways that they were brought up. And then we've got the social environment, and that could be anything from the environment through which they have to move, but also environmental constraints.
00:07:59
Speaker
And that social environment could be their support system as well, friends and family, etc. Then your examinations, does not exist purely as the medical diagnosis, not even just as the movement problem or the physical therapy diagnosis.
00:08:16
Speaker
We want to acknowledge that our examination and our outcomes are going to be improved if we acknowledge this biopsychosocial model. So absolutely, we acknowledge in this case, we're talking about stroke.
00:08:29
Speaker
Someone has had a stroke, but the our examination approach and our treatment plan and our outcomes are are going to be impacted by the person's psychology and their social environment.
00:08:40
Speaker
And I really want us to keep that in mind that we are not only with stroke, but in everyone we work with, we're acknowledging the importance of the biopsychosocial model. And the reason I'm harping on the biopsychosocial model so much and really advocating that we start with participation-based goals is that regardless, again, of the underlying condition,
00:09:02
Speaker
a sense of purpose, salience, having some collaborative goals, all of that has an outsized effect on therapeutic alliance and patient outcomes. Recall in episode two, I talked about optimal theory and highlighted the importance of goal setting in terms of increasing dopamine and improving motor outcomes. So we really want to collaborate with our patients in terms of goal setting.
00:09:28
Speaker
And it shouldn't be a goal. If I'm working with a patient, it shouldn't be a goal that's important to me. It needs to be a goal that's relevant to the patient. Salience and importance and purpose drive neuroplasticity and motivation. So let's highlight that.
00:09:45
Speaker
Salience drives neuroplasticity and motivation. So if you're wanting to implement evidence-based treatments and you're not figuring out what's salient or important to the patient, you're not going to get the outcomes that the patient deserves and you're not going to get the outcomes that you as a clinician want.
Social Determinants and Mental Health Screenings
00:10:03
Speaker
Now, if we're looking at this biopsychosocial approach, before we go further into some examination specifics, I want to do another callback. And this is episode six, being human.
00:10:14
Speaker
Here, I talked about quality of life across various neurologic conditions. And I want to recap or review in stroke or after someone's had a stroke,
00:10:25
Speaker
Being employed was associated with having the highest quality of life. Quality of life was also positively correlated with higher education. This really calls into sharp focus the importance of these social determinants of health.
00:10:41
Speaker
If we think about, and we've talked about social determinants of health before, but someone who has sustained a stroke, who is employed and has received a higher education, has more of a buffer in many ways, possibly has more resources, going to be associated with a higher quality of life.
00:11:00
Speaker
Other factors that influence quality of life include stroke severity, So worse stroke severity is going to have lower quality of life. But over time, people do adapt to what's happening. So within the boundary of what and how someone initially felt, quality of life tended to stabilize three months post-stroke across all stroke types Another consideration calling us back to social determinants of health is that higher quality of life for those with higher monthly incomes.
00:11:31
Speaker
So if we're going into an examination, we don't want to be biased if someone maybe has a lower income, not highly educated. I'm advocating more to consider quality of life as something we want to keep in mind as we're working with our clients.
00:11:46
Speaker
On a positive note regarding quality of life and the impact that physical rehabilitation can have, function, self-care, and activity are absolutely improved with physical rehabilitation.
00:11:58
Speaker
The evidence indicates pain is a little bit improved, but less so improved. And real importantly, there's no significant changes in anxiety or depression whatsoever.
00:12:08
Speaker
with physical rehabilitation. So having said that, I do want to talk a little bit about depression and stroke before we then go into talking about the patient history and an al outcome measure known as the stroke impact scale.
00:12:24
Speaker
I think depression in general is probably under-recognized and under-appreciated by physical therapists. And if we accept the biopsychosocial model, we need to acknowledge that depression can have an impact on our outcomes, on patient motivation, on patient adherence to what we're trying to do.
00:12:42
Speaker
I'll link all the references for the next few items or data points I'll talk about here. A 2023 systematic review estimated the prevalence of depression post-stroke between 24 to 29 percent.
00:12:56
Speaker
So about one in four or so. and it makes sense. And this could be from adapting to changes due to the stroke itself. It could be changes to the brain from the stroke. So for many reasons, about 24 to 29% patients will experience depression.
00:13:15
Speaker
What's really interesting to me is that if someone is depressed three months after stroke, keep in mind, we said that quality of life tends to stabilize after about three months. So about three months post-stroke, the evidence is indicating not that people have fully adjusted, but you get to kind of an equilibrium.
00:13:34
Speaker
But if someone's depressed within three months of their stroke, 53% of those individuals experience persistent depression. So this is ongoing persistent depression.
00:13:46
Speaker
This is important because another 2023 systematic review indicated depression is associated with premature mortality and worse functioning. I think in general, from an ethical perspective, it's important to know if our patients are depressed.
00:14:01
Speaker
But if we're just looking purely at outcomes, depression is associated with premature mortality and worse functioning. you And remember, the evidence suggests that physical rehab does not significantly alter depressive symptoms.
00:14:15
Speaker
I do want to question that finding a little bit in terms of there might be, in my opinion, new evidence within the next little bit because a lot of the treatment, and we're not talking treatment in this episode, but we will be in future
Rehabilitation Intensity and Depression Screening
00:14:30
Speaker
episodes.
00:14:30
Speaker
But as physical therapy has moved towards high intensity training in this population, especially in the chronic population, high intensity gait training and there's good evidence that exercise has anti-depressive effects.
00:14:45
Speaker
I wonder if in the future will we be seeing this finding or this evidence that PT doesn't alter depressive symptoms? Will that change as we build out more high intensity rehab in this population? So fingers crossed the evidence isn't there currently, but I'm wondering if that's going to be coming up in the future.
00:15:06
Speaker
What I would recommend then from a depression perspective is get comfortable screening for it at least. We get to spend as PT so much time with our patients. We might get a sense or a gut feeling about it.
00:15:18
Speaker
But one thing I think that's pretty easy to administer is the patient health questionnaire two. It's called the PHQ two. Some health clinics or some areas will use this as a screening tool, maybe by the medical tech, maybe by the nursing assistant, maybe by the nurse.
00:15:35
Speaker
But i think PTs, we can do this relatively easily as well. It's just a two-item questionnaire that asks, over the past two weeks, how often have you been bothered by the following problems?
00:15:47
Speaker
Question one, little interest or pleasure in doing things. Question two, feeling down, depressed, or hopeless. Patient will score this from a zero to three. Zero is not at all.
00:15:58
Speaker
One is several days. Two is more than half the days. Three is nearly every day. If a patient scores three or higher, that's a positive screen. Now, remember, that's a screen. We're not making the diagnosis that someone has depression.
00:16:12
Speaker
But if you get that, then you can feel comfortable that this person probably should be further evaluated. If you feel comfortable, you could use the PHQ-9, which has more items.
00:16:24
Speaker
I think since I consider my role to be, I'm going to do physical rehabilitation, I would use a positive PHQ2 as a trigger or mechanism for possible mental health referral.
00:16:36
Speaker
And I think here you can do some work on yourself to get comfortable recommending a mental health referral to patient because I've worked with a lot of students and novice clinicians who are very uncomfortable having this conversation.
00:16:50
Speaker
And I think working through how you would administer the PHQ-2 and how you would follow up on the results is really going to be a benefit to your patients. And it's going to help you get better clinical outcomes because if your patient does have depression, you've made the referral and they're successfully being treated, you're going to get better outcomes because that depression is not kind of pulling down your treatment efficacy and you're reducing the patient's risk of premature mortality.
Patient History and Holistic Assessment
00:17:20
Speaker
Let's move then to the general patient history, again, with the lens on participation. So we're going to start out, we take a history and I'll talk about some other questions you can ask when we talk about the review of systems.
00:17:33
Speaker
But let's talk about some general big picture questions. really collaborating on goals with the emphasis on participation. We're going break that participation down into tasks and activities to analyze and to work on. So this is setting us up this initial patient history of what's important to them from a participation perspective is going to help us plan our examination in terms of what tasks and activities we want to be looking at.
00:18:01
Speaker
Once we've determined those, we can then move on to our task and movement analysis. and I'll be talking about movement analysis towards the end of this episode. As needed, think about a communication cognition screen.
00:18:14
Speaker
Maybe you're thinking about a many mental state exam or the MOCA. Communication, assess what you can. Maybe you're working working also with speech language pathology there. Any pertinent information about social history, cultural beliefs, behaviors.
00:18:29
Speaker
And I don't think you have to make necessarily a big deal about this. Just if someone is looks different from you or has a different upbringing, those aren't the only people we need to ask. We don't want to make assumptions. If someone looks different,
00:18:41
Speaker
Like you do, you don't want to assume they have the same beliefs or behaviors. So just asking about what's important to them, how do they like to spend their free time? There's many ways to get at some of the important information here.
00:18:54
Speaker
Obviously, a living environment and support. What kind of housing setup do they have? Do they stairs they need to navigate? Where's the bedroom? Where's the bathroom? Where's bathroom? people around to help, that's going to be important.
00:19:07
Speaker
And then general health status, recalling again to a prior episode about social determinants of health, we really want to know and I think about social determinants of health as not necessarily barriers, but I think about, okay, what are some positive aspects of what are maybe some barriers or some limiting factors based on social determinants of health? What does the patient have access to from a holistic perspective?
Using Stroke Impact Scale Effectively
00:19:30
Speaker
perspective. I do want to mention an outcome measure that can be useful here called the stroke impact scale. This is a patient self-report outcome measure of 59 items.
00:19:41
Speaker
And per the stroke edge group from the ANPT, this is highly recommended in subacute and chronic CVA. So anything from two months to beyond, not necessarily recommended acutely under two months, less seem to be less reliable or useful if someone's had a stroke of under two months.
00:20:00
Speaker
Makes sense. Again, we're coming back to that idea that maybe the first few months someone's getting their equilibrium or they're adapting to the stroke. So again, the Stroke Edge recommends or highly recommends the Stroke Impact Scale after about two months post-stroke.
00:20:16
Speaker
And it is recommended that students learn to administer the tool. I'll put a link on how to find the tool in the show notes. couple of key caveats here. patient The patient should be able to follow three-step commands and score above a 16 on the mente many mental state exam.
00:20:33
Speaker
So there needs to be the cognitive ability to complete this. So if you're thinking about a stroke impact scale and you're maybe not sure if this would be appropriate, perhaps you plan ahead, think I'm going to implement a mini mental state or ask maybe did speech or OT, give an MMSE, then you can use that score to kind of inform or guide whether you want to administer the stroke impact scale to your patients.
Systems Review Components
00:21:03
Speaker
Let's then move into the review of systems and the systems review. And I don't know why, but for me, I always get these confused because they're the same word just flipped around and my brain does not love that.
00:21:16
Speaker
Again, I'm going to argue or advocate that when you hear systems review, since system here systems review, that's going to be our physical examination of the systems.
00:21:27
Speaker
When we hear review of systems, that's asking about maybe observing what's going on. I'm pulling a lot of this information from the reference from the APTA website. I don't want you to take this as all encompassing.
00:21:41
Speaker
There may be additional questions, additional follow up items, but I think what we're going to cover here for review of systems is going to be helpful. to just set a general framework. And it's also helpful to think about the main systems that we want to be looking at. So for our review of systems, first, starting off for all systems, we can ask about any known health conditions. So really looking at that medical history,
00:22:05
Speaker
And we can take that subjectively. But also, I really hope you're doing a good chart review. i love doing a thorough chart review because any knowledge I get before I see the patient just helps me tremendously, really helps guide me where I'm going. So the review of systems should include a good chart review. And the systems we're looking at here are going to be cardiovascular.
00:22:27
Speaker
pulmonary, integumentary, musculoskeletal, endocrine, and nervous. So those are the six systems we're going to be reviewing. For cardiovascular, some questions or items to consider would be any history or any issues with leg cramps,
00:22:47
Speaker
slow healing wounds, irregular heartbeat, chest pain. Now notice that these questions are somewhat general and then you can ask about these items. You may need to ask additional follow up items and these may indicate how you will change your physical exam when you get to the systems review.
00:23:06
Speaker
But for the review of systems, we're again asking questions and observing. Then for review of systems in the pulmonary system, any shortness of breath, difficulty breathing, wheezing, coughing.
00:23:20
Speaker
Integumentary, any wounds or pressure areas. Musculoskeletal, any weakness? Now, weakness is going to fall, kind of be shared between musculoskeletal and the nervous system.
00:23:32
Speaker
We may also be wondering, was there any premorbid weakness, any problems before the stroke? Also definitely want to know about any joint pain. Endocrine system, fatigue, weight gain or loss.
00:23:46
Speaker
And if someone has diabetes, what's the usual blood sugar? Again, we're going to be challenging these patients with activities, hopefully some high intensity exercise.
00:23:56
Speaker
So we do want to know what the usual blood sugar is if someone is diabetic. For the nervous system, we're looking at weakness, sensory changes, vision changes, dizziness, headaches, balance issues, cognition, memory changes, behavior changes, and or difficulty swallowing. So we see for the review of systems,
00:24:18
Speaker
and this would be expected, the nervous system has the biggest area that we're thinking about. Do keep in mind though, that all of these systems can interact and are important after stroke, particularly thinking about cardiovascular. We know a stroke is essentially a cardiovascular event.
00:24:37
Speaker
So very likely that there's going to be some cardiovascular issues to keep in mind. And then also integumentary between both difficulty moving, we're worried about pressure areas, but also if there's spasticity, if someone's getting somewhat rigid in a position, we worry about pressure areas there as well.
Core Outcome Measures in Neuro Exams
00:24:58
Speaker
So that was the review of systems. That is us taking a history, also observing. What about the systems review? So this could be part of your physical examination.
00:25:10
Speaker
And there's a mix of hands-on that we'll do, but also some outcome measures that'll be very helpful. And many of these outcome measures should be a review because many of them that I'll mention will be part of the core outcome measures from the Academy of Neurologic Physical Therapy.
00:25:29
Speaker
Systems review for cardiovascular, we're looking at blood pressure, heart rate, assessing for lower extremity edema, assessing a pedal pulse, and if we wanted to use an outcome measure,
00:25:41
Speaker
We could look at the six-minute walk test, which is a core outcome measure. We can also look at the two-minute walk test if we wanted a little bit shorter one. Even though the two-minute walk test isn't a core outcome measure, it's still a valid one to use.
00:25:53
Speaker
And so you could consider using that if you wanted to use that as part of your cardiovascular system review. For the pulmonary systems review, you're looking at oxygen saturation, nail and lip color, respiratory rate, and possibly the six-minute walk test and or the two-minute walk test. So a lot of overlap or some overlap between cardiovascular and pulmonary systems review in terms of the outcome measure that you're using of six-minute walk test and or two-minute walk test.
00:26:24
Speaker
In tegumetra, you're looking at skin color and integrity, wound and scar integrity. Depending on someone's amount of mobility, you may need to be looking at bony prominences. And even if someone's ambulatory, i will typically still take a look at the feet, take a look at those bony prominences.
00:26:44
Speaker
Especially if we're considering maybe some bracing down the road, I want to look and see, okay, do we have anything here that's going to make ambulation or putting pressure on the lower extremities contraindicated?
00:26:56
Speaker
Musculoskeletal systems review, we're looking at posture and symmetry, gross active range of motion and strength. And if we wanted to use an outcome measure, we could look at the five times sit to stand as well.
00:27:09
Speaker
For strength, yes, we can do a muscle test. That may not be the most reliable because what we see after stroke is it's not always merely a force production issue.
00:27:19
Speaker
Then if you have issues getting full range of motion because of synergies and or spasticity, Are you now grading a muscle through partial range? how are you going about it? But I do understand in many facilities or many clinics, you just have a form that says what's their strength and we're somewhat constrained. We have to document according to the system we're given.
00:27:39
Speaker
So I do recognize that assigning that muscle grade is part of the examination in most areas. Endocrine systems review, really we're talking about a six-minute walk test and or a two-minute walk test.
00:27:53
Speaker
um It could be also getting a blood sugar. Now, in most settings, PTs would not be the ones to do that. But if someone is self-managing or monitoring their blood sugar at home, getting that reading beforehand is helpful. Or if you're in a clinic,
00:28:09
Speaker
And there's access to knowing what someone's blood sugar is pre-exercise and post-exercise. That's going to be helpful. I previously worked in a setting where the prevalence of diabetes was very high and I needed to know where someone's blood sugar was at before and after treatment.
00:28:25
Speaker
Systems review for the nervous system really is going to be your neuro exam. So we're talking about many aspects here. If we think it's almost like a buffet, you've got many things to choose from here, many of which are going to be important to do after stroke, such as your sensory exam, strength testing,
00:28:44
Speaker
reflexes, coordination, vision, vestibular, essentially a cranial exam is going to be indicated. I put vision and vestibular, but you're really doing a cranial nerve exam.
00:28:56
Speaker
You're going to look at gait as well. And then for outcome measures, you have one that isn't on the core measures, but it's still very useful, which is the timed up and go. gives you a sit to stand, gives you a gait, it gives you a turn and sitting back down.
00:29:12
Speaker
So timed up and go is a pretty easy one to administer. From the core outcome measures, many ones that you might want to consider would include the bird balance scale, activity-specific balance confidence scale, five times sit to stand.
00:29:27
Speaker
And if someone's very high level in terms of their ambulation, you may figure to do the functional gait assessment or its close cousin, the dynamic gait index. Let's recap briefly then. And if we think about our examination, we've talked with the patient and or caregivers, depending on patient's ability to communicate. We've engaged in some collaborative goal setting around participation.
00:29:52
Speaker
We've done our review of systems, identified areas that may warrant further workup. We've done our systems review. So we've looked at blood pressure, heart rate, oxygen saturation. We've assessed for any wounds,
00:30:04
Speaker
We've done some of our neuro exam. And let me pause here as our systems review will take place. And then when it gets to the neuro exam, you've got a little bit of a choice. How much of the neuro exam do you do first before doing some activities?
00:30:18
Speaker
Or do you do some task analysis and then your neuro exam? And I think you could go either direction. I do think, though, if you're a novice or just starting out, maybe you do components of your neuro exam to get an idea of what you think you might see during the tasks and activities. So I think that's reasonable.
00:30:37
Speaker
Some more experienced clinicians may decide that based on the history and the other systems review, I'm going to get the patient up. I'm going to check transfers, see how they do walking. And then I'm going to do more parts of my neuro exam after I've done the functional tasks.
00:30:53
Speaker
Again, I would argue that if you're more on the novice side, probably doing your neuro exam after you've done your review of systems and as part of your systems review is okay to do before you do your task analysis, movement analysis.
00:31:08
Speaker
But I think if you're more experienced, you could probably go the other direction. Either way you decide, though, please remember, you're always generating hypotheses. You're gathering data to support or reject that hypothesis.
00:31:21
Speaker
And you're also gathering data to inform your diagnosis, prognosis, and plan of care.
Movement Analysis and the Movement Continuum
00:31:27
Speaker
With that being said, we're going to conclude then with movement analysis and how we're going to conceptualize the movement continuum and some glossary of terms that we're going to be using in the neuro population and therefore with patients who have had a stroke.
00:31:49
Speaker
For movement analysis, I'm going to be relying heavily on the Quinn et al. article that came out in 2021. And this was an update of movement continuum that's been around for a while. I believe it was Hedman that initially proposed it.
00:32:03
Speaker
So Quinn et al. pulled forward the movement continuum and then also discussed core tasks for us to look at in neurologic physical therapy. and glossary of key terms. So really what we're trying to do here in the neuro world is standardize our approach to analyzing movement.
00:32:21
Speaker
Doesn't mean that we're all going to be robots doing everything exactly the same way, but if there's a best way to do things or if there's a standardized way, we really want to minimize variability between providers.
00:32:32
Speaker
We want to have, we want to get to the point where the best evidence is recommending, okay, here's our approach. Here's what we're going to do. you're still going to have tremendous freedom and autonomy in setting up your plan.
00:32:44
Speaker
But we want to look at things through the same lens so that patients are getting the best care. And also so as clinicians, we're speaking the same language. Let's talk about the movement continuum first.
00:32:57
Speaker
And it's really a stepwise process of looking at a movement from start to finish. Some key assumptions here are that you as a clinician really get to decide when the task or the movement starts and stops.
00:33:12
Speaker
For instance, if you're looking at how someone does sit to stand, you can decide in your analysis, does the sit to stand task include them scooting forward in the chair and then standing from once they're scooted up?
00:33:26
Speaker
Or are you only interested in the actual kind of power and control and stability needed to go from sitting to standing and you don't really care about that portion of scooting forward.
00:33:37
Speaker
Both will be important in terms of our our plan of care, but in terms of movement analysis you decide really what you're assessing or analyzing. From then the movement continuum you're looking first at initial conditions And this is how is the person set up initially, what's going on in the environment.
00:33:58
Speaker
If we're doing a sit to stand task, let's say I'm looking at the task of starting when the person actually stands. So I don't care about scooting forward. I'm looking at, are they symmetrical? Where are they positioned? What's their posture look like?
00:34:11
Speaker
Are we on carpet? Are we on a hardwood floor? Are they wearing shoes? These are all the initial conditions. These can also be modified in subsequent trials. One thing I should have mentioned for the sit to stand, chair height is a big one.
00:34:24
Speaker
Does the chair have armrests or not? These can all impact performance of the task. After initial conditions is preparation, and you're assessing, did the patient understand your instructions and task requirements?
00:34:39
Speaker
There's really not a great way to assess this. This is kind of invisible. This is almost like the black box. If you think about airplanes that record things and we don't really see it in the moment. This is the patient understanding what we ask. And really the way we infer this is that the patient does what we ask of them.
00:34:56
Speaker
So maybe I've got a patient, I say, okay, when I say one, two, three, I'd like you to stand. I say one, two, three, they don't do anything. I'm wondering, okay, could this be a preparation problem? Is there some cognition issue going on?
00:35:10
Speaker
That's what I would be thinking about. Then for the actual movement, we break the movement down into three parts. initiation, execution, and termination.
00:35:21
Speaker
And we do this because there are specific conditions and diagnoses within neuro that may have bigger challenges at different parts of the movement. Initiation is when the body parts first start moving.
00:35:34
Speaker
Execution is performance of the movement. Termination is stopping the movement safely. Let's use the sit to stand example. Initiation would be when I first start to see maybe the trunk start to flex, the bottom starts to lift.
00:35:49
Speaker
Execution is getting into the fully upright position. Termination is the person is standing and balanced. So let's cite a few examples. Maybe if someone has Parkinson's disease, initiating the task might be difficult.
00:36:02
Speaker
So you may see that more of a treatment emphasis is needed to initiate the task. Versus someone with cerebellar ataxia may have trouble terminating the movement.
00:36:13
Speaker
They can stand, but they seem to sway or they cannot really get their center of mass well controlled within their base of support. And maybe someone who's had a stroke has trouble with execution. They really have a tough time attaining that standing.
00:36:27
Speaker
To recap then, for using the movement continuum, I'd like you to take a look at those initial conditions. Determine if preparation was adequate, if the patient understood your instructions.
00:36:39
Speaker
When the movement is happening, we're going to look at initiation, starting the movement, executing the movement, so performing it, and terminating the movement. Then you further assess did the was the outcome achieved.
00:36:52
Speaker
And if it was, you can do the task again and maybe make it a little bit harder. So maybe you put someone in a lower chair, you remove the armrest, you really want to challenge them. And this is, again, part of your examination. You're getting an idea of what they can do.
00:37:08
Speaker
If they're not be able to do it, then maybe you repeat it, but with what's called a task regression. So maybe you need to give them more physical help, and maybe they need an assistive device.
00:37:18
Speaker
Maybe you need to raise the chair height if they're trying to perform a sit to stand. I mentioned then during performance of the sit-to-stand task, when I'm looking at initial conditions, maybe I'm looking, are they symmetrical? I'm looking at their posture.
00:37:32
Speaker
In the same Quinn et al. article, they do list a glossary of movement terms that I'd like to mention here, I would highly recommend you go back to the original article and work through some of these terms because these terms are tremendously useful and they help ensure that we're using a shared language when we're talking about movement analysis.
00:37:53
Speaker
In the Quinn article, they talk about observable constructs and they cite examples or definitions. As I work through this material, i kind of bucket these terms or these constructs into three main buckets where I've got kind of a general bucket, I've got a postural control bucket, and then I've got a coordination bucket. And I do think they present it that way as well. And then a fourth one is symptom provocation. I'm leaving that off right now for simplicity.
00:38:21
Speaker
Let's talk about the three main buckets. So the first bucket is a couple of general terms that I think make sense to most people. The observable constructs and movement analysis here are going to be symmetry.
00:38:34
Speaker
speed, amplitude, and alignment. So symmetry makes sense. Is someone symmetrical right versus left? And a very easy example would be someone who's had a stroke is probably not going to sit or stand symmetrically for multiple reasons, but they're probably going to be shifted to where more of the weight bearing is through the less involved or the unaffected side. So we're going to see some asymmetry there.
Evaluating Movement in Stroke Patients
00:39:00
Speaker
Speed is going to be how quickly someone moves. And here we can think about maybe someone with Parkinson's disease where their speed of movement is not going to be what we expect. So speed is an observable construct.
00:39:14
Speaker
Amplitude is the size of the movement. This is one of my favorite constructs because I think it helps me quite a bit in developing a hypothesis. If I see a motion that's smaller than I think it should be, I'm looking at, okay, is there not enough force production?
00:39:30
Speaker
Is there a lack of range of motion? What is constraining either the limb or the movement that I need to further explore? So I'm initially thinking or I'm automatically thinking I need to check force production.
00:39:45
Speaker
I need to check biomechanical constraints, need to see what's happening if our amplitude is not good. Then alignment is the biomechanical relationship of body segments to one another.
00:39:56
Speaker
Here, maybe an example might be if someone's got bad knee arthritis and maybe you see a varus or a valgus deformity or a positioning. So the alignment's not really there where it's needed to be optimal.
00:40:10
Speaker
So those observable constructs represent, in my mind, one bucket. Those are symmetry, speed, amplitude, and alignment. We can be applying these, some of these to the initial conditions. We're looking at symmetry, maybe an alignment.
00:40:22
Speaker
Then as I'm asking someone to do the sit to stand, I could be looking at speed and amplitude of movement. And these are all informing my hypothesis of why someone may have difficulty with the movement.
00:40:34
Speaker
The next bucket is postural control. And we've got verticality and stability. Verticality is Ability to orient the body in relation to line of gravity.
00:40:45
Speaker
So staying upright. Many of you are probably too young to remember the V8 commercial that used to be on where v a was this horrible vegetable tree. And the commercial was if someone didn't have their V8, they would walk leaning to the side or they weren't vertical.
00:41:01
Speaker
That's kind of what we're talking about with verticality. A classic example here might be in someone who's had a stroke who exhibits pusher syndrome. They're going to absolutely have difficulty with verticality.
00:41:12
Speaker
Postural control stability is what we commonly think of the ability to control the center of mass within the base of support. both in static conditions and dynamic conditions. So are they stable? can They control the center of mass within the base of support. So that person, I made an earlier example of cerebellar ataxia. Maybe I've got someone with cerebellar ataxia performs a sit to stand and they can't terminate the movement. They're wobbly, for lack of a better term.
00:41:41
Speaker
They have a stability problem. They're struggling to maintain their center of mass within their base of support. And then finally, coordination is the last bucket. There's four key constructs here.
00:41:54
Speaker
Smoothness, sequencing, timing, and accuracy. So smoothness, we can think finger to nose testing. If as a patient's touching their nose and reaching out to touch my finger,
00:42:05
Speaker
their course of their finger or their their movement deviates. So instead of a straight line or straight trajectory, there's a lot of movement. That's a coordination issue in terms of smoothness.
00:42:17
Speaker
Sequencing are the movements across the limb is the timing involved. Is that smooth and coordinated? Timing, we can look at that this in terms of reaction time, relative timing measures.
00:42:31
Speaker
And then accuracy, we go back to finger to nose. Is the patient able to touch their nose and my finger? Or do they have some form of what's called dysmetria, which is inaccuracy with the targeting or judging distance?
00:42:45
Speaker
So to recap, the three main buckets. When we're looking at movement analysis, some of the recommended terms that we're using are going to be symmetry, speed, amplitude, alignment.
00:42:58
Speaker
Postural control verticality, postural control stability. And then for coordination, we've got four kind of subheadings under coordination. We can look at smoothness, sequencing, timing and accuracy.
00:43:13
Speaker
We apply these glossary this glossary of movement terms in the movement continuum, in the task analysis. So we're thinking about how is the person looking across these terms, across initial conditions,
00:43:26
Speaker
preparation, the initiation of movement, the execution of movement, and the termination of movement. And as you start to get more comfortable with this process, you can see that you can take this template and way of analyzing movement and really apply it to any movement, to any task, really independent of diagnosis.
00:43:47
Speaker
I would argue that if you're not in the clinic right now, maybe you're a student, start thinking about this process. Just analyze people moving out in the community or start analyzing how people are moving, thinking about, okay, where did the movement start and stop?
00:44:02
Speaker
How was the symmetry? How was the speed? The more reps you get, then the more practice you've gotten, the more automatic it becomes, and it's easier to do in the clinic.
Conclusion: Effective Examination Planning
00:44:12
Speaker
That was then the examination planning for stroke, which may have gone in a different direction than you were expecting because we didn't go heavy into the neuro screen or the neuro testing here, but that was intentionally done because I wanted to frame the examination within the biopsychosocial model.
00:44:29
Speaker
We're going to start by collaborating with the patient on goal setting. emphasizing participation, and then working backwards from there. Once we have some participation goals, think about how to break those into task activities and utilize movement analysis to assist in hypothesis generation.
00:44:48
Speaker
Because depression is so common in someone who's had a stroke, really recommend the PHQ-2 as a depression screen and getting comfortable with talking to patients about mental health referrals if needed.
00:45:01
Speaker
Also recommend the stroke impact scale as an outcome measure if you're working with someone who's had a stroke greater than two months duration. And then finally, and this is probably more for my own benefit because I always get to mixed up, recall that review of systems is the history taking across the systems.
00:45:20
Speaker
Systems review is using tests and measures to assess the systems. And recall that both are important aspects of your examination.
00:45:31
Speaker
Thanks so much for listening to the NeuroPowerHeld. I'm your host, Dr. Michael Powers, and I hope to catch you next time to continue learning.