Temperature: Heart Rate:

Blood Pressure: Respiratory Rate:

Neurological Physiotherapy Evaluation Form N I T H I N N A I R

I. Subjective Assessment

Name: Age: Gender: M/F IP/OP

Occupation: Dominance: R/L Education:

Address:

Chief Complaints:

HOPI

Past Medical History:

Personal History:

Family History:

Socioeconomic History:

Symptoms History:

Side: Site:

Onset: Duration:

Type: Severity:

Aggravating Factors:

Relieving Factors:

Vital Signs:

II. Objective Examination

a) ON OBSERVATION:

General Condition:

Built:

Nutrition:

Skin and Nail condition:

Attitude of limbs:

Posture:

Pattern of Movement:

Pallor/ Icterus/ Cynosis/clubbing /Oedema

Muscle Wasting:

Pressure Sores:

STAGES DESCRIPTION

Stage I Non blanchable erythema of intact skin

Stage II Partial thickness skin loss (abrasion, blister, or shallow crater)

Stage III Full thickness skin loss (deep crater, with or without undermining of adjacent tissue)

Stage IV Extensive destruction into muscles and bones

Deformity:

Wounds:

External Appliances:

b) ON PALPATION

Warmth:

Tenderness:

Tone:

Swelling:

1+ indentation is barely detectable

2+ slight indentation visible & returns to normal in 15 sec

3+ deeper indentation & returns to normal in 30 sec

4+ indentation lasts for more than 30 sec

c) ON EXAMINATION

HIGHER MENTALFUNCTIONS

(USE MMSE SCALE)

Level of Consciousness:

Orientation:

Person:

Place:

Time:

Memory:

Immediate:

Recent:

Remote:

Verbal:

Visual:

Communication:

Cognition:

Fund of Knowledge:

Calculation:

Proverb Interpretation:

Attention:

Emotional Status:

Perception:

Body Scheme/ Body Imaging: Agnosias/

Apraxias:

Special Senses:

Cranial Nerves:

Nerves Comments Nerves Comments

I - Olfactory VII - Facial

II - Optic VIII - VestibuloCochlear

III - Oculomotor IX - Glossopharyngeal

IV - Trochlear X - Vagus

V - Trigeminal XI - Accessory

VI - Abducent XII - Hypoglossal

SENSORY SYSTEM:

Location Upper

Extremity Lower

Extremity

Trunk

Comments

Sensation Rt. Lt Rt. Lt. Rt. Lt.

Superficial

Pain

Temperature

Touch

Deep

Pressure

Mov. Sense

Pos. Sense

Vibration

Cortical

Tactile Localization

2 pt. discrimination

Stereognosis

Barognosis

Graphesthesia

Texture Recognition

Double Simultaneous Stimulation

GRADES

DESCRIPTION

S0 Absent sensation in the area supplied by the affected nerve S1 Return of deep cutaneous pain S2 Return of some superficial pain and tactile sensibility S3 Return of superficial pain and tactile sensibility without over-reaction S3+ Return of two-point discrimination S4 Normal sensations

MOTOR SYSTEM:

Muscle Girth:

Area Rt.(cm.) Lt.(cm.)

Arm

Forearm

Thigh

Calf

Range of Motion:

Joint Side Movement Limitation Limiting factor

Shoulder

Elbow

Forearm

Wrist

Hand & Fingers

Hip

Knee

Ankle & foot

Cervical Spine

Thoracic Spine

Lumbar Spine

Limb Length

Side Rt.(cm.) Lt.(cm.)

True

Apparent

Muscles

Rt.

Lt.

Hip

Flexors

Extensors

Abductors

Adductors

External Rotators

Internal Rotators

Knee

Flexors

Extensors

Ankle

Dorsiflexors

Plantarflexors

Foot

Invertors

Evertors

Intrinsics

Extrinsics

Muscle Tone:

Muscles

Rt.

Lt.

Shoulder

Flexors

Extensors

Abductors

Adductors

External Rotators

Internal Rotators

Elbow

Flexors

Extensors

Forearm

Pronators

Supinators

Wrist

Flexors

Extensors

Radial Deviators

Ulnar Deviators

Hand

Intrinsics

Extrinsics

GRADES OF TONE:

GRADE DESCRIPTION

0 No response (flaccidity)

1+ Decreased response (hypotonia)

2+ Normal response

3+ Exaggerated response ( mild to moderate hypertonia)

4+ Sustained response (severe hypertonia)

Voluntary Control: (BASED ON MOVEMENTS OF UL and LL)

(USE STREAM SCALE)

Side Rt. Lt.

Upper Limb

Lower Limb

Grades of Voluntary control GRADE DESCRIPTION

0 No contraction or flicker or initiation

1 Flicker of contraction present or initiation of movement

2 Half range of motion in synergy or abnormal pattern

3 Full range of motion in synergy or abnormal pattern

4 Initial half range is performed in isolation and the latter half in pattern

5 Full range of motion in isolation but goes into pattern when resistance is given

6 Full range of motion in isolation and can take resistance like normals

MODIFIED ASHWORTH SCALE FOR GRADING SPASTICITY GRADE DESCRIPTION

0 No increase in muscle tone.

1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected parts is moved in flexion or extension.

1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the reminder(less than half) of the ROM

2 More marked increase in muscle tone through most of the ROM, but affected parts easily moved.

3 Considerable increase in muscle tone, passive movement difficult.

4 Affected parts rigid in flexion or extension

Muscles

Rt.

Lt.

Hip

Flexors

Extensors

Abductors

Adductors

External Rotators

Internal Rotators

Knee

Flexors

Extensors

Ankle

Dorsiflexors

Plantarflexors

Foot

Invertors

Evertors

Intrinsics

Extrinsics

Trunk Flexors

Trunk Extensors

Trunk Side Flexors

Trunk Rotators

Muscle Power:

Muscles

Rt.

Lt.

Shoulder

Flexors

Extensors

Abductors

Adductors

External Rotators

Internal Rotators

Elbow

Flexors

Extensors

Forearm

Pronators

Supinators

Wrist

Flexors

Extensors

Radial Deviators

Ulnar Deviators

Hand

Intrinsics

Extrinsics

Equilibrium tests Grade

Standing: Normal Posture

Standing: Normal Posture with vision occluded

Standing: Feet together

Standing on one foot

Standing: Lateral trunk flexion

Tandem walking

Walk: Sideways

Walk: Backward

Walk in a circle

Walk on heels

Walk on toes

Reflexes:

Special Reflexes: Hoffmann’s reflex, Wartenberg’s sign, Rossolimo’s reflex, Tromner’s sign GRADES OF REFLEXES: GRADE DESCRIPTION

0 No Response

1+ Present but depressed, low

2+ Average, normal

3+ Increased, brisker than average; possibly but not necessarily abnormal

4+ Very brisk, Hyperactive, with clonus; abnormal

Coordination:

Non Equilibrium Tests Rt. Lt.

Finger to nose

Finger opposition

Mass Grasp

Pronation/Supination

Rebound test

Tapping (Hand)

Tapping (Foot)

Heel to knee

Drawing a circle(Hand)

Drawing a circle(Foot)

Reflex Left Right

Superficial Abdominal

Plantar

Deep Biceps

Brachioradialis

Triceps

Knee

Ankle

GRADES OF CO-ORDINATION GRADE DESCRIPTION

4 Normal performance is demonstrated

3 Movement is accomplished with only slight difficulty

2 Moderate difficulty is demonstrated in accomplishing activity; movements are arrhythmic and performances deteriorates with increased speed.

1 Severe difficulty is noted; movement are very arrhythmic; significant unsteadiness, oscillations, and/or extraneous movements are noted

0 Patient unable to accomplish activity

Involuntary Movements:

Balance: (Use Berg balance scale)

Sitting:

Standing:

Balance Reactions:

Nudge Test:

GRADES DESCRIPTION

Normal Patient able to maintain steady balance without handhold support (static). Patient

accepts maximal challenge and can shift weight easily within full range in all

directions (dynamic)

Good Patient able to maintain balance without handhold support, limited postural sway

(static). Patient accepts moderate challenge; able to maintain balance while

picking objects off floor (dynamic)

Fair Patient able to maintain balance with handhold support; may require occasional

minimal assistance (static). Patient accepts minimal challenge; able to maintain

balance while turning head/trunk (dynamic)

Poor Patient requires handhold support and moderate to maximal assistance to

maintain position (static). Patient unable to accept challenge or move without loss

of balance (dynamic)

Gait (Observational Gait Analysis) Stance Phase Swing Phase

Fuctional Evaluation & Hand Functions:

Supine to prone:

Prone to side sit:

Sitting unsupported:

Sit to stand:

Standing/Walking:

Reaching:

Grasping:

Releasing:

Assisstive Devices:

III. Systems Review: (just comment if necessary)

INTEGUMENTARY SYSTEM:

Skin Status:

Pressure Sores:

RESPIRATORY SYSTEM:

RS Status:

Secretions:

Pattern of breathing:

Chest wall/Thoracic spine deformity:

CARDIOVASCULAR SYSTEM

CVS Status:

Deep Vein Thrombosis:

MUSCULOSKELETAL SYSTEM

Contractures:

Subluxations:

Joint mobility:

Other pathology:

BLADDER & BOWEL FUNCTIONS

Incontinence:

GASTROINTESTINAL SYSTEM

Status:

AUTONOMIC SYSTEM

Vasomotor:

Pseudomotor:

Trophic Changes:

Postural Hypotension:

Reflex Sympathetic Dystrophy:

IV. Functional Assessment: (The Functional Independence Measure)

Evaluation 1: Selfcare

Item 1. Food

Item 2. Care of appearance

Item 3. Hygiene

Item 4. Dressing upper body

Item 5. Dressing lower body

Evaluation 2: Sphincter control

Item 6. Control of bladder

Item 7. Control of bowel movements

Evaluation 3: Mobility

Item 8. Bed, chair, wheel chair

Item 9. To go to the toilets

Item 10. Bath-tub, shower

Evaluation 4: Locomotion

Item 11. Go, wheel chair

Item 12. Staircases

Evaluation 5: Communication

Item 13. Auditive comprehension

Item 14. Verbal expression

Evaluation 6: Social adjustment/cooperation

Item 15. Capacity to interact and to socially communicate

Item 16. Resolution of the problems

Item 17. Memory

Investigation Findings:

ICF FORMAT

Health Status:

Structural Impairments:

Functional Impairments:

Activity limitations and Participation Restrictions:

a. Learning and Applying knowledge b. General tasks and demands c. Communication d. Mobility e. Self Care f. Domestic life g. Interpersonal interactions and relationships h. Major life areas i. Community, social and civic life

Environmental Factors: (FACILITATORS/ BARRIERS) a. Products and technology b. Natural environment and human made changes to environment c. Supports and relationships d. Attitudes e. Services, systems and policies

List of Contextual factors:

a. Environment (home/work place) b. Water/Electricity/Lighting c. Sanitation/Gen.Hygiene d. Space for movement e. Pollution f. Accessibility for medical aids g. Policies/Facilities h. Care giver’s support i. Internal/Co-morbid factors j. Age/education/sex/metabolic k. Financial support l. Social support

Grades of Impairment

GRADE IMPAIRMENT FREQUENCY OF AFFECTION

0 Nil affection Never

1 Minimal affection (25%) Very Rarely

2 Moderate affection (50%) Sometimes

3 Severe affection (75%) Frequently

4 Very severe affection (100%) Always/Continuous

Grades(Functional/Disability)

FUNCTIONAL

GRADE

ACTIVITY & PARTICIPATION DISABILITY

GRADE

4 No problem in routine function –can do more

(100% performance = capacity)

0

3 Can just complete routine function but cannot do more (25% performance affection)

1

2 Function completed with help

(50% performance affection)

2

1 Incomplete function inspite of help (75% affection) 3

0 Nil performance (100% performance affection) 4