Occupational therapy assessment in neuro-rehab
Introduction
Occupational therapy assessment focuses on various aspects of human body and it’s movement, here we will talk about a BASIC assessment format that can be used by students and professionals alike. The format may vary from place to place or setup to setup.
FORMAT
- We would begin with asking some basic questions concerning clients identity like:-
Name, age, sex, address, socioeconomic status(very important), occupation(again very important), informant(whether the person giving you the information about his/her condition is the client himself or someone related to him), referral(from relatives or from a doctor or healthcare professional)
- Now we would like to include CHIEF COMPLAINTS in which the client is asked about what are the issues that brought him/her/they to YOU(OT) and it should always be in the patient’s language. Remember to write in points instead of a paragraph format.
- This is the right time to bring out the client’s past & history as it is fundamental in rapport building & treatment planning. History consists of:-
History of present illness- this should include mode of injury, duration, course, onset in a paragraph format- for example, let’s write a history of present illness for a patient suffering from spinal cord injury, we will write it as follows- the patient was apparently well until (mention date, month, year) when he suffered a road traffic accident/fall from height(most common cause of SCI in India), he lost consciousness and was brought to (mention the name of hospital, clinic) for surgery/treatment from where he was referred to YOUR(OT) setup/hospital.
History of past illness- note that it should be related to the present condition and can be written in the same format as above.
Medical history- mention about other conditions faced by the client like diabetes, hypertension, etc
Treatment history – write about treatments received so far with respect to the present condition
Personal history- know about personal habits like smoking, drinking, etc.
Family history – form a pedigree chart and ask about if anyone else is also affected in the family(important in the case of hereditary conditions)
Occupational history- ask about occupations performed by the patient
ON OBSERVATION
Consciousness- check for responses, important in the case of coma
Facial expression
Built- endomorph, mesomorph, ectomorph
speech- mention whether it is slurred, clear, intelligible,etc
Scar/wound
Joint integrity
Deformity
Attitude of limb
Muscle wasting/atrophic changes
Posture- lying, sitting, standing( imagine a plumbline passing through the body in sagittal & frontal plane)
Gait- mention the type of gait and phases of gait cycle
if aids/appliances used
ON PALPATION
Swelling/Edema- can use figure 8 assessment for Edema
Tenderness- use the following grades to assess
Muscle girth — using inch tape
ON EXAMINATION
Pain — mention type of pain, localisation, nature of pain, aggravating factors & factors affecting pain. Use VAS, NPRS to assess.
MOTOR EVALUATION
Range of motion- assess both active, passive range of motion on both sides of the body along with end feel
Muscle tone- very important to assess in neurological cases, assess using modified ashworth scale or modified tardieu scale.
Manual muscle testing- in neurological cases especially in spasticity, MMT has not been considered as a strong indicator of function. Usually in cases where there is low spasticity(less than 1+ on MAS) MMT can be used.
Voluntary motor control- it can be assessed in cases of high spasticity. Following grades are used to assess VMC-:
- 1+ — Gravity eliminated plane with 1/3rd movement possible.
- 1++ — Gravity eliminated plane with 2/3rd movement possible.
- 1+++ — Gravity eliminated plane with full range of motion.
- 2+ — Against gravity 1/3rd movement possible.
- 2++ — Against gravity 2/3rd movement possible.
- 2+++ — Against gravity full range possible.
- 3+ — Against gravity with resistance 1/3rd movement possible.
- 3++ — Against gravity with resistance 2/3rd movement possible.
- 3+++ — Against gravity with resistance full movement possible.
- 4 — Skilled movement.
Good, fair, poor can also be used to assess VMC
Deep tendon reflexes- They are graded as follows:-
4+= hyperactive with clonus
3+= brisker than average, hyperreflexic
2+= average response, normal
1+= somewhat diminished, not normal
0= no response
Clonus- it is a rhythmic, oscillating, stretch reflex, the cause of which is not totally known. It can be evaluated in many joints but is most commonly seen in the ankle joint by briskly dorsiflexing the foot.
Coordination tests
They are of 2 types- equilibrium & non – equilibrium tests
Non- equilibrium tests are performed in sitting while equilibrium tests are performed in standing position.
They are graded as :-
4- normal performance
3- minimal impairment(accomplishes activity but requires supervision)
2-moderate impairment(movements are slow, awkward & unsteady)
1- severe impairment( can only initiate activity without completion)
0- activity impossible
Balance
Assess sitting(short & long sitting) balance both in static and dynamic ways
If the patient can stand, assess standing balance too. You can use various scales like berg balance scale, sitting balance assessment tool or functional reach test.
Cranial nerve examination – read our blog on cranial nerves and it’s examination
T/C/D
Assess for the presence of tightness or contracture using tests like Thomas test, Ely’s test, ober’s test, etc.
Look for the presence of any deformity.
Babinski sign, Hoffman’s sign
SENSORY EXAMINATION
To study about sensory examination- read our blogs on spinal cord injury and assessment in peripheral nerve injury
COGNITIVE AND PERCEPTUAL EXAMINATION
Attention- they are of different types like sustained attention, divided attention, focused attention, alternating attention.
Memory- immediate, short and long term memory
Orientation- time, place, person
Scales that can be used to assess cognition are LOTCA, mini mental status examination, mental status examination, rivermead behavioural memory test, trail making test, etc
To assess for perception, most common components assessed are:-
- visual perceptual skills — form constancy, figure ground discrimination, visual closure, etc
- body scheme — right/left discrimination, agnosia, unilateral neglect, etc
- apraxia — ideomotor & ideational apraxia
Assessment of cognition & perception requires detailed understanding behind each of its components & will be discussed in more detail in upcoming blogs.
ADL examination
Assess for basic and instrumental activities of daily living using scales like functional independence measure, Katz index, barthel index or spinal cord independence measure, etc.
Home and environment evaluation
Using standardised measurements, one can evaluate home and environment with the help of accessible India campaign or Sugamya Bharat Abhiyan launched in 2015.
Problems identified
Should be written in points, can be written in therapists language
Goals & treatment planning
Goals should be divided into short and long term goals( time to achieve both is subjective, at some places short term goals should be achieved in 3 weeks while long term goals are achieved in 3–4 months) there’s no set consensus for it. They should be measurable, reasonable, achievable and timed.
As for treatment planning – important points to remember while writing it are:-
- Mention the repetitions and set
- Mention your rationale/reasoning/logic behind the exercises used
- Mention the approach you are using
- Mention the purpose of the exercises in a functional manner
- It should be concise and understandable
- Treatment should correspond to the patient’s current functional level
- Mention about precautions
That’s how a basic OT assessment in neurology is usually performed. Read our other blog posts and follow us on Instagram. Thank you for reading😊.
