Observation of how the patient moves
This part of the assessment can be completed while the patient carries out a functional transfer such as rolling, sitting to lying, lying to sitting, sitting to standing, standing to sitting, walking indoors/outdoors, stairs, running. However, it is equally useful to assess the patient’s movement during functional activities, for example, dressing/undressing, reach and grasp, writing their name, etc.
Patient
The function/s chosen to observe will depend on the patient’s ability. For example, if the patient is unable to move out of bed, then start your assessment with bed mobility. On the other hand, if the patient walks into the department, then the assessment will be set at a higher level of function.
Note: If the patient is able to walk, then the therapist will also need to complete a full gait analysis (S3.19).
Therapist
The aim of observing function is to identify any movement abnormalities and as such, the patient must be physically challenged. However, care should be taken not to fatigue the patient. Ultimately, all transfers will need to be assessed for the therapist to gain a full understanding of functional ability.
While the patient performs the function the therapist needs to note:
Functional ability
That is, how successful the patient is and what assistance they require completing the task. For example, the patient is independent sitting to standing or the patient needs minimal assistance of 1 from lying to sitting.
The quality of performance/movement analysis
The therapist also needs to analyse how they perform the function. In essence this is movement analysis. At this point the therapist is trying to identify any deviations from the normal limits of efficient movement and not necessarily the underlying cause of the deviations. This demands the therapist has a good understanding of the requirements of the task and may require the inexperienced therapist to carry out a task analysis prior to observing the patient. The task analysis should be considered in relation to the wide variation of normal presentations possible. A good understanding of basic biomechanical principles will also facilitate the therapist’s reasoning during this process.
Normal requirements of the task
To facilitate this process, the therapist may choose to base their analysis on the following basic structure:
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Start position – in relation to joint angles
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Finish position – in relation to joint angles
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Muscle action – in terms of how the individual moves from start to finish position. Consider:
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Which muscles are required
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The function of the muscle during the task (agonist, antagonist, synergist)
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Type of muscle contraction (eccentric, isometric, concentric)
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Range of the muscle work (inner, middle, outer).
Caution
The range of strategies implemented within normal limits of efficient movement (i.e. a healthy population) will be wide ranging. Therefore, when setting the normal requirements of any task the therapist should be cautious and flexible in approach.
Patient observation
Based on the analysis of the normal task requirements the therapist should record any deviations from their expectation of what is efficient movement. However they should also note the presentation of any of the following:
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General postural alignment
Are there any obvious asymmetries?
Does the movement adhere to biomechanical principles? Altered alignment could indicate: (1) instability due to hypotonia or weakness; (2) a restriction due to hypertonia, soft tissue shortening or pain, or (3) altered sensation. More detailed postural alignment and differential diagnosis of cause should be investigated later in the assessment.
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Quality of movement
Is the movement smooth, coordinated, well timed, effortless? Poor quality movement could result from a motor or sensory impairment or a problem with integration. Ataxia (
S3.26) also manifests as incoordinated movement of the limbs or trunk but is due to a dysfunction of the cerebellum (
S2.12).
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Compensations
Do they use any trick movements during functional activities?
Is the movement successful in achieving the motor goal? Compensation is defined as a behavioural substitution adopted to complete a task (Shumway-Cook and Woollacott 2007). As motor control is goal orientated, a successful compensatory movement may result in the central nervous system adopting this strategy in the long term rather than finding other solutions. This may limit the individual from recovering to their full potential (Cristea and Levin 2000). While it is acknowledged that compensations also occur within a healthy population, it is this lack of choice of movement solutions in neurologically impaired patients that limits their function (Raine et al. 2009). Therefore perhaps therapy should be aimed at facilitating a choice of compensations or modifying the most inefficient ones.
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Patterns of movement
Do they use normal movement patterns?
Do they use gross movement patterns? This is due to the inability to fractionate or break up a basic pattern of movement in order to make it functional. Fractionation is defined as the ability to move a single joint without simultaneously moving other joints (Shumway-Cook and Woollacott 2007). All tasks require a combination of muscle synergies. For example, the task of reaching requires shoulder flexion, elbow and wrist extension with finger flexion to grip. Therefore, an individual who uses a gross pattern involving flexion at all joints will be ineffective in achieving their goal. This is one of the signs of spasticity (
S3.21).
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Involuntary movements
Do they present with dystonia? Dystonia is a syndrome characterized by abnormal, sustained muscle contractions often resulting in persistent abnormal postures at the extremes of movement range. The movements are often twisting and range in speed and amplitude. Abnormal co-contraction is common and the contractions often elicit pain. Dystonia is associated with lesions of the basal ganglia (
S2.11), particularly the indirect pathway of the putamen nucleus. However, there are several subtypes which may vary in cause.
Do they present with athetoid movements? Athetoid movements are slow writhing twisting movements of small amplitude primarily involving the upper limb.
Do they present with choreiform movements? Choreiform movements are rapid, jerky movements often of large amplitude. This presentation is observed in Huntington’s chorea and caused by a lesion of the basal ganglia (indirect pathway).
Do they present with clonus? Clonus is most commonly seen at the ankle and presents as a rhythmic oscillation between plantar flexion and dorsiflexion. This occurs when a brief stretch of the plantar flexor muscle occurs and the tension is maintained, e.g. when placing the affected lower limb of a patient up onto the footplate of a wheelchair.
Do they present with any associated reactions (ARs)? An AR is a temporary involuntary movement primarily involving the upper limb. The initiating triggers are widely variable and individual to the patient but can include increased effort during movement (Bhakta et al. 2001), muscular instability, yawning, coughing, pain, fear, urinary tract infection. Little evidence exists as to the underlying cause of these reactions but the time delay in onset after the original lesion seems to implicate maladaptive changes which lead to a reduced ability to inhibit unwanted movement. This is one of the signs of spasticity (
S3.21). When associated reactions are evident, it is important that the therapist records:
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When the AR occurs precisely, e.g. during mid-stance of the right lower limb
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The excursion of the movement, e.g. elbow flexion occurs to a maximum of 90°
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The pattern of the movement, e.g. elbow flexion with forearm pronation and some finger flexion
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How long the AR remains, e.g. the upper limb immediately returns to normal when the patient stops walking. There is no AR in standing.
This information will provide clues as to any movement trigger that exists, e.g. an area of instability or poor balance.
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Active range of movement (AROM)
Are there any obvious limitations in AROM? (
S3.28), e.g. taking off a jacket or jumper requires good AROM of the shoulder and trunk in certain directions. Any limitation may be a result of soft tissue shortening, muscle weakness (
S3.30), pain (
S3.29), altered sensation (
S3.23) or altered muscle tone (
S3.21)
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Balance
Do they lose balance or stumble during any activity? (S3.32,
34). This may be a direct result of a deficit affecting the balance systems (vestibular system/vision/proprioception) or a functional consequence of various other symptoms, such as poor trunk stability, altered muscle tone or sensation.
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Lack of confidence
Do they appear anxious during movement? Patients who are fearful of movement will often limit their function. This can be a result of many factors including previous falls.
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Exercise tolerance
Do they fatigue very quickly on activity? Do they become breathless?
Analysis
Having completed the observation of the patient during a functional activity and noted any deviations, the therapist can begin to reason what the potential causes of the dysfunction could be based upon the task requirements. The hypothesis generated will need to be tested and confirmed using the specific assessment tools (S3.19–34).
References
Bhakta BB, Cozens JA, Chamberlain MA, et al. Quantifying associated reactions in the paretic arm in stroke and their relationship to spasticity. Clinical Rehabilitation. 2001;15:195-206.
Cristea MC, Levin MF. Compensatory strategies for reaching in stroke. Brain. 2000;123:940-953.
Raine S, Meadows L, Lynch-Ellerington M. Bobath concept: theory and clinical practice in neurological rehabilitation. Oxford: Wiley-Blackwell; 2009.
Shumway-Cook A, Woollacott MH. Motor control: translating research into clinical practice, ed 3. Philadelphia: Lippincott Williams and Wilkins; 2007.