1、.1REHABILITATIONASSESSMENTPing Miao,MDDepartment of Rehabilitation medicineThe second affiliated hospital of Guangzhou Medical University.2ContentsnIntroductionnMeasures of impairment (muscle,joint,cognitive.)nMeasures of disability (activity of daily life.)nMeasures of handicap.3To find the problem
2、snWhat kind of dysfunctionWhat kind of dysfunctioncongenitalcongenital：heart problemsheart problems，etc.etc.postnatpostnata al l：CPCP，strokestroke，SCI,TBI,etcSCI,TBI,etcsecodarysecodary：contracture following fracturecontracture following fracture，muscle muscle atrophy after peripheral nerve injury,a
3、nd so onatrophy after peripheral nerve injury,and so onnHow many dysfunctionsHow many dysfunctionsPhysically,speech,psychological,social aspectPhysically,speech,psychological,social aspectnHow severity of dysfunctions How severity of dysfunctions On patient and his/her familyOn patient and his/her f
4、amily.4To set treatment goalsnshort-term goalsshort-term goalsCan be touched by effortsCan be touched by effortswithin a few days or weekswithin a few days or weeksnlong-term goalslong-term goalsCan be achieved for long time(terminal)Can be achieved for long time(terminal)From short-term goals to lo
5、ng-term one From short-term goals to long-term one nMust consider the factorsMust consider the factorsageage、professionprofession、cultural backgroudcultural backgroud、family conditionsfamily conditions.5Assess treatment effectsnIs our treatment plan effective?Is our treatment plan effective?Yes/NoYe
6、s/NonShould the treatment plan be continiuned Should the treatment plan be continiuned or should be adjusted according to or should be adjusted according to measurementsmeasurementsYes/NoYes/No.6 Physical examination and rehabilitation measurement have something in common but not the same.nPurposenT
7、imesnWaysIntroduction.7.8.9Objectives of MeasurementTo find problemsTo set treatment goalsTo plan treatment schedules To assess the effectivenessTo predict outcomesTo analyze the cost-effecitveReasons for assessing.10Levels should be measuredimpairment disability handicap.11Development of ICIDHDevel
8、opment of ICIDH International Classification of Impairments,Disabilities,and International Classification of Impairments,Disabilities,and Handicaps(Handicaps(ICIDH)ICIDH)19801980，WHO WHO disease impairment disability handicapdisease impairment disability handicap 疾病疾病 病损病损 残残 疾疾 残障残障 (器官水平器官水平)()(个体
9、水平个体水平)()(社会水平社会水平)structurestructure ability activity/participationability activity/participation TraditionalModel of MedicineTraditionalModel of Medicine:EtiologyEtiology PathologyPathology clinical featuresclinical featuresLevels.12Application of ICIDHDifferent cousesAmputee in the lower limbCant
10、 walkCant go to school/workimpairmentdisabilityhandicapOrgansADLSocial activityAt the level of.13Application of ICIDHStroke/TBIHemiplagiaCant look afterHim-/her-selfCant work/Join the social life impairmentdisabilityhandicaporgansADLSocial lifeAt the level of.14.15IntroductionnPurposenPlan a treatme
11、nt program and establish outcomesnEvaluate results of treatment programnModify treatment program.16IntroductionnGood assessment is dependent upon:Knowledge of functional anatomyHistory Complete examination.17Clinical Evaluation SequencenHistory nInspectionnPalpationnFunctional TestingnNeurological T
12、esting.18category of measurmentRatio Scales Inerval Scales Ordinal Scales Norminal Scales.19Ratio ScalesnFeaturesHas a zero point that represtns the complet absence of the quatity represented.The intervals among all successive units on the scale must be equal in sizeCant have a minus or negative val
13、ue.%is a form of rationExamplesROMLimb lengthTime to complet an activityVital capacityNerve conduction velocity.20Inerval ScalesnFeaturesLack of a zero pointThe unit must be equal sizenExamplesBody temperatureFunctinal scalesPsychological tests.21Ordinal ScalesnFeaturesMay have only 2 categoriesnPre
14、sent/absentnDependent/independentnExamplesMMTADLFugle-Meyers scale.22Norminal ScalesnFeaturesThe units are category without indicating the order or rank of the differencesMay be labeled with numberals,letters,or words,but the lables do not idicate order or ranknExamplesClassification of genders,dise
15、asenStroke,nCerebral palsy.23Quantitative and Qualitative ScalesnUnits are assumed to be of equal size nA continuous scaleEqual size subunitsnDistance:m,cm,mm,etcnExamplesRatio scalesInterval scalesnCategories have no sizenCant be divisible into equal-sized subcategoriesTendon reflexSitting balancen
16、ExamplesNominal scales.24nvalidnsensitivenspecificnreliable(inter-rater,test-retest)nappropriatenacceptable.25Procedureswhen to measurewhat to be measuredhow to measure.26When to measureInitial stageMiddle stageTerminal stageAt follow-upnDuring the treatment and training,evaluation can be repeated b
17、y several times.It usually start from the evaluation and end on the evaluation.27Initial stage（first measurement)nWhen should be conductedBefore phyiotherapynobjectivesFind the problems and its statusInvestigate the potential of rehabilitation and related factors As evidence of the treatment plannin
18、gAs the baseline of reassessment.28Middle stage(repeatedmeasurements)Middle stage(repeatedmeasurements)nWhen should be repeatedOnce at 1-2 wks for those with quick recoverynEarly phase or inpatientsOnce at 3-4 wks for those with slow recoverynChronic phase or outpatientsnobjectivesTo find any improv
19、ement and its extendTo decide if any adjustment is needed.29Terminal stage Terminal stage（finalfinal）nWhen should be measuredBefore finishing the physiotherapy or at dischargenobjectivesTo investigate the rehab effectivenessnAchivements has been reachedTo plan dischage program nContinuine treatmentn
20、Refered to outpatient or community.30Follow-upnWhen should beVariation among patients and diseasesnEach month,2-3months or 6 monthsnobjectivesDetermine the function of patientDecide whether patient needs to futher treatment.31specificPhysical functioncognitionlanguageSocial activitiespsychologygloba
21、limpairmentdisabilityhandicapWhat to be measured.32Physical functionMuscle toneROMBalanceMMTWalking?Aschworth Spasticity ScaleWhat should be measured in neurorehabMotor Assessment ScaleBerg Balance ScaleComposite Spasticity ScaleThe Timed“Up&Go”testFugle-Meyer Movement AssessmentReach TestBrunnstrou
22、m Rovery Stages.33Data collectionMedical historyMedical notesFind the problemsassessmentDecide what to and how to assessStart to assessData recordingData analysisFunctinal diagnosisSet treatment goalsTreatment planAssessment procedues.34Evaluation效度效度信度信度sensitivetyvalidreliabilityIntra-raterInter-r
23、atercriterion-related validation content-related validationconstruct-related validationTo evaluate the methodology being used.35 Rules of S.O.A.P are widely use all over the world:S(subjective data)：main complaint and symptom of the patients;O(objective data)：objective symptom and functional behavio
24、r of the patientsA(assessment)：analyze and classify the above-mentioned materials;P(plan)：set a treatment plan.Methods of evaluation.36.Methods of evaluation.37Specific Evaluation.38Specific Evaluation-Motor ability evaluationMuscle strengthRange of motionMuscular toneMuscular enduranceGait analysis
25、Balance Coordination.39Manual muscle test(MMT).40Manual Muscle Testing(MMT)nDefinition:subjective testing done by the therapist to assess a patients muscle strength.The muscle strength is graded to be either normal,good,fair,poor,trace or zero.41Muscle GradesNormal:patient holds contraction against
26、maximal resistance at end rangeGood:patient holds contraction against moderate resistance at end rangeFair:patient moves through full range of motion against gravity but unable to hold against resistance at end rangePoor:patient moves through full range of motion in a gravity minimized positionTrace
27、:therapist palpates muscle contraction as patient attempts to move Zero:therapist is unable to palpate any muscle contraction as patient attempts to move.42Muscle GradesNormal=5/5Good =4/5Fair =3/5Poor =2/5Trace =1/5Zero =0/5.43Important points on manual muscle testingnNeed to place patient in stand
28、ardized positionnIsolate only one joint motionnDont allow patient to compensate for weaknessnCompare same muscle bilaterallynBe consistent and reliable with testing.44nManual ResistanceStabilize limb proximallyResistance provided distally on bone to which muscle attachesWatch for compensation.45.46n
29、VIDEOnDEMOnPRACTICEnQ&A.47Attention during the MMT1.Correct posture,limb position and necessary settlement.2.Make sure the patients understand the request and purpose of movement,so that avoiding the fake movement or compensation.3.While the muscle strength reach the level 4,resistance is provided t
30、o the distal area of the limb.484.Keep avoiding the MMT after long time exercises or meals.5.The position which is measured should be exposed to the therapists or doctors.6.Remember to compare with the contralateral limb.49Muscle testMeasure by equipments1.General equipment testGripping testPinching
31、 testDorsal muscle test.Methods of Evaluation-Muscle test .50Muscle tone(Modified Ashworth Scale).51.52Range of motion(ROM).53Range of Motion(ROM).54Measuring ToolsGoniometerInclinometerElectrogoniometer.55.56How to measure the ROM of upper limbs/lower limbs/trunk?.Methods of Evaluation-ROM Three fa
32、ctors(1)Axis(2)Stationary arm(3)Moving arm.5758ROM MeasurementnInformed consentnPosition the patient nPlace joint in zero starting positionnStabilize proximal segment of the jointnMove patient passively through available ROMnDetermine end-feelnPalpate landmarksnAlign goniometernPassively or actively
33、 take patient through available ROMnCheck alignmentnRead goniometer.59.60Shoulder flexion(180)Supine with arms at sides-lift over headStationary arm-lateral midline of thoraxAxis-midpoint of lateral aspect of acromion processMoving arm:lateral midline of the humerus toward lateral humeral epicondyle
34、.61Shoulder Extension(60)Prone with arms at sides-try to raise arm Stationary Arm:lateral midline of thoraxAxis:midpoint of lateral aspect of acromion processMoving Arm:lateral midline of humerus toward lateral humeral epicondyle.62Shoulder AbductionSupine with shoulder at side in anatomical positio
35、n-raise arm over head Stationary Arm:Parallel to sternumAxis:Anterior aspect of acromion processMoving Arm:Anterior midline of humerus toward medial humeral epicondyle.63External/Lateral RotationInternal/Medial Rotation.64Elbow Flexion Supine with hands by sides with towel under arm-flex elbowStatio
36、nary arm:lateral midline of humerus toward acromion processAxis:Lateral epicondyle of HumerusMoving Arm:Lateral midline of radius toward radial styloid process.65.66.67.68.69.70.71Range of Motion(ROM)nHelps to assess functional statusnCompare bilaterallynTest joints proximal and distal to injured ar
37、eanOnly perform if do not suspect a fracture.72Important points on Goniometric measurementnMotions measured can be either active or passivenStandardized techniques are used for each jointnJoints should be adequately stabilized during measurement.73Passive Range of Motion(PROM)nClinical Definition:Th
38、erapist moves selected joint(s)through full range of motion with no assistance from the patientActive Range of Motion(AROM).74Important points on passive range of motionnAdequately stabilize patients joints as you move them.(some patients may have no active movement)nDont cause pain other than stret
39、chingnPerform 5-10 motions per joint movementnFamiliarize yourself with normal directions and degrees of movement for each jointnListen to patient.75nContraindications Patient is unable to voluntarily contract injured musclePatient is unable to perform AROMUnderlying fracture site is not healedInvol
40、ved tissues are not yet healed.76.Methods of Evaluation-ROM .77 Elbownflexion 0 to 160nextension 145 to 0 Forarmnpronation(rotation inward)0 to 90nsupination(rotation outward)0 to 90.Methods of Evaluation-ROM .78 Wristnflexion 0 to 90nextension 0 to 70nabduction 0 to 25nadduction 0 to 65.Methods of
41、Evaluation-ROM .79 Hipnflexion 0 to 125nextension 115 to 0nhyperextension(straightening beyond normal range 0 to 15nabduction 0 to 45nadduction 45 to 0nlateral rotation(rotation away from center of body)0 to 45nmedial rotation(rotation towards center of body)0 to 45.80 Kneeflexion 0 to 130extension
42、120 to 0.81 Ankleplantar flexion(movement downward)0 to 50dorsiflexion(movement upward)0 to 20.82Mini-Mental State Examination(MMSE).83nThe minimental state examination(MMSE)is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment.nIt is
43、commonly used in medicine and allied health to screen for dementia.It is also used to estimate the severity and progression of cognitive impairment and to follow the course of cognitive changes in an individual over time.84nAdministration of the test takes between 510 minutes and examines functions
44、including registration,attention and calculation,recall,language,ability to follow simple commands and orientation.85nAdvantages to the MMSE include requiring no specialized equipment or training for administration,and has both validity and reliability for the diagnosis and longitudinal assessment o
45、f Alzheimers Disease.nThe most frequently noted disadvantage of the MMSE relates to its lack of sensitivity to mild cognitive impairment.86nAny score greater than or equal to 27 points(out of 30)indicates a normal cognition.Below this,scores can indicate severe(9 points),moderate(1018 points)or mild
46、(1924 points)cognitive impairment.nThe raw score may also need to be corrected for educational attainment and age.87Activity of daily life(ADL).88Bathing:includes grooming activities such as shaving,and brushing teeth and hairDressing:choosing appropriate garments and being able to dress and undress
47、,having no trouble with buttons,zippers or other fastenersEating:being able to feed oneself.89Transferring:being able to walk,or,if not ambulatory,being able to transfer oneself from bed to wheelchair and backContinence:being able to control ones bowels and bladder,or manage ones incontinence indepe
48、ndentlyToileting:being able to use the toilet.90Modified Barthel Index Score(MBI)nThe MBI is a measure of activities of daily living,which shows the degree of independence of a patient from any assistance.n It covers 10 domains of functioning(activities):bowel control,bladder control,as well as help
49、 with grooming,toilet use,feeding,transfers,walking,dressing,climbing stairs,and bathing.n Total scores may range from 0 to 100,with higher scores indicating greater independence.91Others.92BalancenDefinition:Maintaining center of mass within your base of supportnOther Terminology used to describe b
50、alance:n Center of GravitynEquilibriumn Cone of Stability.93.Method of evaluation.94GaitnOther terms used to describe gait:nAmbulation/LocomotionnControlled movement of your base of support.95Gait Assessments.96.97nMeasures of perception-cognition 感知、认知评价n Measures of anxiety and depression 焦虑和忧郁评估
