LORMA COLLEGES

COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

PT EVALUATION AND EXAMINATION

Laboratory Activity #1
MOTOR ASSESSMENT

Name: Abdulrahman Salim Saad Zgama Date: 2/27/2022 Score:____________

 ESSAY: ANSWER THE FOLLOWING QUESTIONS WITH NOT LESS THAN THREE SENTENCES.
1. Differentiate between recovery of function and compensation. (5 pts)

Recovery of function:
It is the reacquisition of movement skills lost through injury.
- The movements recovered may be performed exactly as before. In the patient with
neurological disease, mostly the movements are modified and not performed exactly as
before.

Compensation of function:
It refers to the adoption of alternative behavioral strategies to complete a task.
- Movements utilize different muscles and strategies to substitute for the loss function.

2. Describe the examination of consciousness and arousal. How can the levels of consciousness and
arousal influence the motor function examination? (10 pts)

Examination of conscience is a review of one's past thoughts, words, actions, and

omissions for the purpose of ascertaining their conformity with, or deviation from, the moral
law.
Arousal is the aspect that is present in wakefulness and reduced in sleep. Awareness refers
to the “content” of consciousness – this might take visual, auditory, olfactory or other
forms.

Consciousness refers to a state of arousal accompanied by awareness of one's

environment. A conscious patient is awake, alert, and oriented to his or her surroundings.
Like in Lethargy or Coma.

3. A patient with stroke exhibits abnormal control of eye muscles and is unable to move the eyes
smoothly in all directions. Cranial nerve testing should include what nerves and tests? Explain the
procedure. (10 pts)

Cranial nerve testing should include: Cranial nerves such as 3rd - Oculomotor nerve, 4th -
Trochlear nerve and 6th, Abducent nerves are responsible for extra ocular muscle
movement.

4th Nerve and the Tests:

o Observe position of eye. Test eye movements.
o Trochlear nerve.
5th Nerve and Tests:
o Test eye movements.
 o Abducent nerve.
6th Nerve and Test:
o Observe position of eye.
o Test eye movements.

4. Define stability. How should it be examined? ( 5pts)

Stability is defined as the ability to maintain control of joint movement or position by

coordinating actions of surrounding tissues and the neuromuscular system.
The therapist should observe and examine the following key elements:
o Base of support.
o The position and stability of center of mass within the base of support.
o The degree of postural sway.
o The level and type of assistance required.
o Environmental constraints that influenced performance.

5. What are the issues of validity for using manual muscle testing as part of the examination of a
patient with UMN syndrome (stroke) who exhibits strong spasticity and strong obligatory synergies?
( 5 pts)

Strength testing measures MMT – Manual Muscle Testing were used to examine motor
function in patients with polio – LMN disease. There are validity issues in patients with UMN
disease:

• The presence of abnormal co-activation, spasticity, and abnormal posturing may preclude
the patient's ability to perform isolated joint movements.
• These barriers to normal movement as termed active restraint.

6. Describe the examination of a hyperactive patellar deep tendon reflex. What scores are used to
document an increased DTR? ( 5 pts)

Deep tendon reflexes results from stimulation of the stretch-sensitive afferents of

neuromuscular spindle producing muscle contraction via a monosynaptic pathway.

o Muscle – Quadriceps
o Nerve - Femoral nerve (L2, L3, L4)
o Position – Patient is sitting with knee flexed, foot unsupported
o Stimulus – Tap tendon of quadriceps muscle between patella and tibial tuberosity
o Response – slight contraction of knee extensors

7. A patient with multiple sclerosis reports fatigue as the number one symptom that impairs functional
independence in the home environment. How should this patient’s fatigue be examined and
documented? (10 pts)

The fatigue of a patient with multiple sclerosis can be examined by using the Modified
Fatigue Impact Scale (MFIS). It includes questions on the cognitive and social domains, as
well as physical performance.
 o The therapist should carefully document the patient’s level of fatigue, as well as a level of
independence, modified independence, or level of assistance required.
o During performance testing, perceived level of fatigue can be documented using the Borg
Scale for Rating Perceived Exertion.

 CASE ANALYSIS
The patient is a 17-year-old female who is 6 months post–motor vehicle accident (MVA). At the
time of admission to the hospital, she was comatose and decerebrate. CT scan revealed intracranial
bleeding into the right occipital horn. She received a tracheostomy and a gastrostomy. Two months
post MVA, she was transferred to a long-term care facility specializing in TBI. On initial admission she
was able to open her eyes to verbal and tactile stimuli but was unable to visually track. She withdrew
her upper and lower extremities in response to stimulation but was not able to move them on
command. She was alert but confused, and was unable to carry on a conversation. ROM was within
normal limits (WNL) except for right elbow flexion (20° to 100°) and right knee flexion (10° to 110°).
She demonstrated increased tone (Modified Ashworth Scale 3) in her left upper extremity (LUE), 4 in
her right upper extremity (RUE), and 4 in both lower extremities (BLEs). She exhibited 4+ bilateral
ankle clonus. She was unable to sit unsupported. During supported sitting in the wheelchair, her head
and trunk control was poor, with persistent posturing to the left side. She is now 6 months post-MVA
and is currently being examined for transfer to active rehabilitation status.

 PHYSICAL THERAPY EXAMINATION FINDINGS

I. Consciousness/Arousal
 Fully awake; responds appropriately to varying stimuli.
 Oriented to person; some confusion with orientation to place and time.
 Can become agitated with minimal stimulation, especially when tired.
II. Cognition/Behavior
 Demonstrates difficulty with concentration and attention.
 Able to follow simple instructions (one- or two-level commands) but occasionally forgets
what is asked of her.
 Reaction time is slowed as the number of choices is increased.
 Easily forgets what she is doing.
III. Sensory Integrity
 Aware of sensory input (pinprick, vibration, light touch) to all extremities.
 Unable to discern common objects placed in either hand for stereognosis discrimination.
IV. Joint Integrity and Mobility
 RLE: plantarflexion contracture (40° to 50°); flexion contractures at the hip (10° to 120°) and
knee (10° to 120°).
 RUE: flexor contracture at the elbow (10° to 110°).
 Full passive ROM in the LUE and LLE.
V. Tone
 Increased bilaterally (R > L).
 On Modified Ashworth Scale: RUE and RLE 3; LUE and LLE 2.
VI. Reflex Integrity
 Hyperactive, 3+ DTRs RUE, RLE.
 3+ bilateral ankle clonus.
VII. Cranial Nerve Integrity
 Dysphagia and dysphonia are present.
VIII. Muscle Performance
 Strength is decreased in the RUE, RLE, and trunk (unable to test with MMT).
 She is unable to sustain R knee extension during standing.
IX. Voluntary Movement Patterns
 RUE moves in partial range, obligatory mass flexor synergy pattern only.
 RLE moves in flexor and extensor synergy patterns with no variation.
 LUE and LLE demonstrate full voluntary control with isolated joint movements. Coordination
is decreased. Unable to reach directly to an object that is held out to her and demonstrates
foot placement problems with the LLE in sitting or in standing.
 Demonstrates problems with coordinating limb and trunk movements
X. Postural Control and Balance
 Demonstrates good head control in all positions.
 Sitting: can sit independently for up to 5 minutes. Demonstrates difficulty in maintaining
weight equally on both buttocks. Tends to list to the right side while placing weight primarily
on her left buttock. Able to reach to the left and forward; demonstrates loss of balance (LOB)
with minimal reaching to right.
 Standing: able to stand in parallel bars with minimal assistance 1 for up to 2 minutes. Has to
be reminded to place weight on RLE. Tends to lose her balance easily if she moves quickly;
associated with brief episodes of dizziness and vertigo.
XI. Functional Mobility Skills
 Rolling: requires supervision and occasional minimal assistance with rolling to the right; she
requires maximal assist when rolling to the left.
 Supine-to-sit: able to come to sitting by rolling to the L side and pushing up with her LUE;
requires minimal assistance.
 Transfers: able to perform stand pivot transfers with minimal assistance of 1.
 Gait: does not initiate ambulation on her own. Can ambulate the length of the parallel bars
(2 m or 6 ft) with maximal assistance of two persons. Requires posterior splint to stabilize R
knee.
 Propels wheelchair by using the LUE and both feet for pushing; requires supervision for
safety.
XII. Motor Learning
 Demonstrates profound deficits in short-term memory; unable to remember new information
presented during therapy. Her memory for events and learning that occurred before the
MVA is good.

 QUESTIONS:
Based on your evaluation of the data presented in the case history and the physical therapy
examination, answer the following questions:

1. Determine the GCS score and RLA of the patient upon admission and on the current
evaluation. (6 pts)
2. Based on the current evaluation of the patient, what are the affected cranial nerves? (4 pts)

Vagus nerve (10th cranial nerve)

3. How has this patient’s level of consciousness/arousal changed from admission to the long-
term care facility to the current evaluation? How might this influence the examination of
motor function? (10 pts)
 Patient’s level of consciousness/arousal changed from admission to long term care
facility to current evaluation:
Patient consciousness is state of arousal that is accompanied with awareness of an
individual’s environment. The patient was considered to be in comatose and
decerebrate state while joining in the hospital.
An unconscious patient is considered to be in coma state and cannot be aroused.
The eyes of the patient remains closed with no sleep wake cycles and do not respond
to any painful stimuli being dependent on ventilator.
Later, past 6 months of motor vehicle accident (MVA) the consciousness was tested
to be fully awake and appropriate reaction to varied stimuli.

Influences over examination of motor function:

The motor function demonstrated deficits like short term memory. The patient was
unable to remember newly fed information in the therapy. But memory on events that
had occurred before the event of motor vehicle accident (MVA) is good.

4. Give the FIM grading of the current evaluation of the patient on functional mobility skills: (6
pts)

a. Bed Mobility:
 Rolling: requires supervision and occasional minimal assistance with
rolling to the right; she requires maximal assist when rolling to the left.
 Supine-to-sit: able to come to sitting by rolling to the L side and pushing up
with her LUE; requires minimal assistance.
b. Transfers: able to perform stand pivot transfers with minimal assistance of 1.
c. Gait: does not initiate ambulation on her own. Can ambulate the length of the
parallel bars (2 m or 6 ft) with maximal assistance of two persons. Requires
posterior splint to stabilize R knee.

5. Develop a physical therapy problem list. Categorize the patient’s problems in terms of (a)
direct impairments, (b) indirect impairments, and (c) functional limitations. (24 pts)

Direct impairments:
o Unable to discern common objects placed in either hand for stereognosis
discrimination.
o Demonstrates profound deficits in short-term memory

Indirect impairments:
o Can become agitated with minimal stimulation, especially when tired.
o Her memory for events and learning that occurred before the MVA is good.

Functional limitations:
o Dysphagia and dysphonia are present.
o RLE: plantarflexion contracture (40° to 50°); flexion contractures at the hip (10° to
120°) and knee (10° to 120°).
o RUE: flexor contracture at the elbow (10° to 110°).
o Full passive ROM in the LUE and LLE.