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Examination OfCentral Nervous
System
Dr Bhawna Verma (PT)
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Examination/Assessment
Enable the therapist to know about the nature
and extent of the patient s difficulties in his
day to day life .
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Aim of Neurological Examination
Determine the site and nature of disease of the
nervous system .
It is an essential part of any routine clinical
examination.
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Classification Of Examination OfCNS
Subjective Examination
Objective Examintaion
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Subjective Examination
History -patient/his relatives in case where
the patient is either unconscious or child
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Subjective Examination
1. Name of the patient-foridentity of thepatient .
2. Age of the patientSome diseases occur at a
particular age group .3. Sex-Some diseases are more common in
males while some in female.
4. Occupation-To get proper understanding ofthe diseases and for planning the treatmentaccordingly.
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5. Address-Toget proper idea of general status
of the patient ,his surrounding and his
nutritional hygiene level.
6. Past medical history-whether he has got
history of chronic illness like diabetes
,hypertension, leprosy, tuberculosis. Because
in presence of any diseases, the treatment
should be altered and planned accordingly.
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7.History of presenting illness-
a. Onset of symptoms-
Time- The patient is asked whether the symptomsappeared gradually over a period of time or theywere sudden in origin.
Type- The patient is asked about the type of onsetof symptoms acute, subacute ,chronic
b. Progress of the disease-
This consist of finding out how the symptomsprogressed over a period of time
Whether it is progressively worsening disease? It is disease with remission and exacerbation?
Is it a disease which come suddenly andsubsided over a period of time
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8. History of treatment-
Anytreatment carried out during this period orprogress of disease and its effects should be noted.
9. History taking from relatives-when
The patient is child
The patient suffer from episodes of impairment ofconsciousness
There is obvious memory defect or mental
change. Details concerned with other member of thefamily need to be checked.
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10. Social and Family History-
How much family support can be expected
by the relatives to assist the therapeutic
programme at home .
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Objective Examination
Observation
Examination
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Observation
General Appearance
Built-Obese/lean/thin/muscular
Height-Dwarf/giant ,that is if acromegaly ispresent or not.
Facial Expression-To check if the patient issuffering from myasthenia gravis or
Parkinson's disease Skeletal Deformities-Look for any skeletal
deformities like spina bifida
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Look for any abnormal size of head such as in
Hydrocephalus, Acromegaly,Achondroplasia
and Pagets disease.
Mode of dressing.
The hairlook for any premature baldness
.very obvious in myotonic dystrophy,Alopecia
etc.
Skin coluration
Muscle atrophy
Signs of ill health or malnutrition
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Handedness
Whether the patient is right handed or left
handed as the treatment should be planned
accordingly.
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Examination
Mental Function-
a) Level of consciousness-observation of the
patient is done .Level of consciousness is
done by GLASGOW COMMA SCALE
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GCSEye opening(E4) Spontaneous 4
Open to sound 3
To painful stimuli 2None 1
Motor response(M6) Obeys 6
Localized painful stimuli 5
Withdraws to stimuli 4
Abnormal flexion to stimuli 3
Extensor response to stimuli 2
None 1
Verbal response(V5) Oriented 5
Confused 4
In appropriate speech 3
In comprehensive sound 2
None 1
Score 3-15
13-15 mildunconscious for
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Orientation
Disorientation may occur in Time, Place and Person
Ask patient to estimate the approximate time without
looking a watch
Whether day /night
Where he is
Whats his name of the hospital
Relaion of the person surrounding him Recognize his relatives by nae and relation ,Doctors
and nurses
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Memory
Test the patients ability to remember events of that
day ,previous week ,month or earlier year.
Ask what he has recently done ,How he came to
building?? Read out him clearly and slowly a series of number
and ask him to repeat
Ask the patient to recall what he has read in the paperor seen on television.
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Emotional State
Mood of the patient
Anxious
excitedDepressed
Frightened
ApatheticEuphoric
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General Intelligence
In case of brain injury or disease .
Education
Character of his workWork record
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Communication
1. Receptive Ability
2. Expressive Ability
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Receptive Ability
Is his attention easily held or fleeting
Does he show a reasonable degree of interest
in surroundings
How does he react to the therapist approach
and greeting
Any usual features in his behavior (FacialExpression or nay inappropriate behavior)
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Expressive Ability
Whether his conversation flows easily or not
Whether hi is mute, answer only by
monosyllables or is over talkative
Does he use strange words??
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Signs of meningeal irritation
1. Neck Stiffness-Ask patient to flex his neck fully
Then therapist passively flexes his neck
The chin should normally touch the chest without pain
In case of meningeal irritation-Pain in flexion
That may radiate to back and movement restricted by
spasm in the extensor muscles of the neck
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Kernigs Sign
Supine
Passively extend the patients knee
when his hip is fully flexed.
If meningeal irritation in lower part of the spinal
subarachnoid space is present this movement
causes pain and spasm of hamstrings
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Straight leg raising test
For nerve root compression
Mainly to detect sciatic nerve
PASSIVELY EXTEND THE PATENTS LEG WITH
THE HAND WHICH IS PLACED BEHIND THEHEEL
Pain in back of thigh or calf .hence movement is
restricted because of this sciatic pain when spinalroots are entrapped in lumbosacral intervrtebral disc
protrusion
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Sensory system Examination
Extroceptive or cutaneous sensation
sensationderived from outside of the body.these are
Pain,light touch ,temprature
Proprioceptive sensationsensation derived frombody itself-sense of position.passive
movement,vibration and deep pain
Combined and cortical sensation-
Sterognosis,graphaesthesia,two point discrimination
Perceptive sensation-Apraxia,Agnosia,disorder of
body scheme
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Pain
Choose a part of the patients body which is expected to benormal and touch him precisely not too firmly several times
with the point of the pin .then ask him .
Whether he can feel any thing and if yes describe what does he
feel If he say yes that he can feel a point then whether it is sharp or
blunt
If it becomes clear that the patient recognize the stimulus ,then
compare quickly the sensation in a number of areas includingface , shoulder, the inner and outer aspect of the upper limb
,upper and lower chest and abdomen ,lower limb and the
buttocks.
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Touch
A small piece of cotton wool can be used to
check the sensation of light touch, as it does
not cause excess pressure to stimulus deep
sensibility.
Ask the patient to close his eyes and say yes
each time he feel ant thing. The cotton wool is
shaped to point and the skin is then touchedlightly testing in dermatome areas.
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Temperature
The patient can compare the temperature of cold object such astuning fork on the main sensory areas of the body.
After this the test tube containing hot water (43degree C)and
cold water (7 degree C)are used .
Extreme of heat and cold should not be used because thesestimulate pain fibres.
The patient is ask to close the eyes through out the examination
and is asked
What he can feel ? Whether there is any difference ,when the outer tube is used ?
If he can feel the difference ,then what that difference is ?
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Proprioceptive sensation
Position senseclose the eyes
place limb in particular position then move it away.
Ask him first to replace it himself and then to place
the opposite limb in a similar position. Ask him to place his heel accurately on his knee.
Ask him to place his forefinger accurately on the tip
of his nose .Ask him to place his heel accurately onhis knee.
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Sense of passive movement
Close the eye .The digit (thumb, finger,big toe )is
held firmly and moved up and down ,while the
patient is asked if he can feel the movement .if he say
yes he can feel the movement then he is askedwhether his thumb /toes has been moved upwards or
downwards
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Vibration sense
For testing the vibration tuning fork of 128 hz
and 256 hz placed on his clavicle to allow him
to identify the sensation of vibration .
He is then asked to close the eyes and the fork
is struck and placed on bony points starting
peripherally at the internal malleoulus and the
lower end of the radius.
The patient is then ask if he can feel the
vibration.
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Deep pain or muscle activity
To assess the sensitivity of the muscles .the thumb are
firmly pressed into the muscles of the forearm and the
calves.
If the muscle are abnormally tender then the patientcomplains of distress even under lighter pressure. But
in case of diminished sensitivity the patient will allow
all possible forces to be exerted without any
complaint.
Squeezing the tendoachillis between the finger and
the thumb will allow the assessment of diminished
deep sensation
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Cortical Sensation
Stereognosis-Ability to recognize the object .by
shape and size .
Object-keys ,coins,combs,pencils.pen etc
Close eye ,place object in suspected hand if he
fail to recognize then in other hand and
comparison of accuracy and speed of response
is made
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Tactile localization
Ability of an individual to localize touch
sensation on his skin
Close eyes then touch on some point with the
therapists finger or a pin .
The patient is then asked to identify the
location of the stimuli by either touching the
same point with his own finger or verbal
description
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Two point discrimintion
Ability of an individual to detect that a stimulus consist of two blunt
point when the stimulus are simultaneously applied
Explain the test to the patient ,first by touching his finger with two
point widely separated and with the patients eye opened.
Then asked to close the eye and two ends are applied
simultaneously with each application the two ends are gradually
brought close until the stimuli are perceived as one.
The normal ability to distinguish the two point from one varies in
different parts of the body.
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Graphaesthesia
Ability to recognize letters or number written
on skin with a blunt point while he closed his
eyes .
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Baragnosis
Recognition of weight
for this a series of small object of same size
but of different weight are used .
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Perceptive sensation
Agnosia-Gnosis in greek means perception (inability to
recognize familiar objects)
Ability to recognize the thing in absence of lack of
intelligence ,mental disorder or any defect in sensorymechanism.
It may be of three types
Visual-due to lesion in parieto-occipital region
Auditory- lesion in temporosphenoidal region
Tactile-lesion in parietal lobe behind the posterior
central gyrus
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Visual Recognition
Show the patient a number of common small objects and then
ask him to
Name them
describe their use
Pick the one that are named by the therapist .
Next show the patient various different colors and ask him
Their name
To pick out the duplicates from the other setTo arrange them in shades of increasing or decreasing lightness
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Auditory recognization
First make sure that hearing in both ears is
normal .
Close the eyes then identify the sounds made by
striking a match, ringing a bell, shaking money
,tearing cloth
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Tactile recognization
First make sure that the sensation of both hands
are normal .then ask the patient to close his
eyes and then place a number of common
objects one by one in one or both hands.
Then ask the patient to name them ,describe their
shape, size and texture and then lastly to
indicate their use.
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Apraxia
Ability to carry out purposeful movement(inspite of
normal tone,normal movement) in the absence of any
motor paralysis, ataxia,sensory loss or a difficulty in
understandingTypes-Ideomotor-patient has ability to do the
movement but when we ask he doesnt do that.
Ideationpatient does not have idea
Constructionaldoesn have ability to proportionate
,he doesnt relates size.
Other types-Dressing Apraxia-No relation between
garments and parts,
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Apraxia may involve any voluntary movement
occular,bulbar or that of extrimities.
Lesion in the left parietal lobe produce
bilateral apraxia on the right side,while lesion
in the anterior part of the corpus callosum and
up to the precentral gyrus on the right sideproduces apraxia on the left side.
Motor aphasia-is apraxia of speech
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Method of testing
Ask him to hold out his arms, take out his tongue, show his
teeth, etc if he fails to do then note whether this movement are
normal when they are automatic eg. Licking the lips, smiling
or responding to an offer to shake hands .
Next ask him to make a fist ,to scratch his arm and moredifficult ,to use a pair of scissors ,a pen and a comb.Any tst
which requires three or four different movement ,can be used
with or without the use of objects.
Give him a series of match sticks and ask him to form atriangle or square. If he fails to d then ask him to copy you.
Note how he takes off his coat and jacket and puts them on
again, how he buttons his shirt.
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Disorder of body schema and image
Body image-is defined as visual and mental image of
ones body that include feelings about ones body
especially in relation to health and disease.
A normal individual is able to tell where each part ofhis body is and where it lies in relation to surrounding
objects. and may even deny
If disruption patients remain unaware of the part and
may even deny that it is the part of his own body.
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Method of testing
Ask the patient that whether he knows his right handand left hand and leg.
Then ask him to point different major parts of his
own body according to therapists commands. Then ask him to point the ring finger of his left hand,
the forefinger of his right hand, to point the little toes
etc. making the test a little bit more complex.
Make the more difficulty by asking him to point out
individual digits of therapist hands etc.
Observe during general examination whether he is
aware of his disability or not.
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Motor System examination
The main function of Motor system is to control the
bodys normal posture and movement.
Examination of motor system includes-
AnatomicalExamination-Inspection-observe and compare with opposite side and
size could be determined as normal,smaller,larger.
Palpation-Feel the muscle /Normal,Softer,harderMenstruation-the girth of one muscle or a group of
muscles should be compared by measuring with tape.
Physiological Examination
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Physiological Examination
Muscle bulk and wasting
Biceps,triceps in UL
Quadriceps ,and gastrosoleus in LL
Measur cicumference of the limb at-
10cm above and below the olecranon forbiceps and triceps respectively.
15cm above and 10 cm below the tibial
tubrosityfor quadriceps and gastro-soleusrepectively.
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Range of motion
Active ROM
Passive ROM
Other points to be observed along with range are
1. The presence of pain with motion . When does the pain appear
Severity of pain
Patients reaction to the pain
2. The presence of limitation of joints3. If limitation then cause of limitation
4. Movements of associated joints
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Spasticity
There is increase in the tone of one group of muscle ie
either agonist or antagonist result from lesion of
pyramidal tracts ,inhibitory reticulospinal tracts
which leads to increase facilitation of stretchreflex.This lead to increase in phenomenon called as
Clasp knife spasticity .where after an initial resistance
the muscle gives away
Passive stretch of a spastic muscle may produce aninitial high resistance followed by a sudden inhibition
of resistance termed as CLASP KNIFE REFLEX.
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Rigidity
Resistance is uniformly increased in both agonist and antagonist
muscle ,making body parts stiff and immovable.when the
lesion is in extra pyramidal tracts or basal ganglia which
results in exaggeration of tonic stretch reflex.
It maybe
Cog Wheel Rigidityit is characterized by an alternating
contraction with jerky movement producing resistance to
movement.(Intermittent resistance throughout the movement )
Lead pipe rigidity-Constant rigidity present throughout themovement (continuous resistance to passive movement )
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Clonus
It is defined as repetitive contraction of a
particular group of muscle due to exaggeration
of dynamic stretch reflex.
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Flaccidity
Flaccidity and hypotonia-Absence/decreased
muscle tone
Resistance to passive movement is diminished
Stretch reflexes are dampened and limbs are
easily displaced.
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Assessment
General clinical scale
0-No response
1-Decreased response
2-Normal response
3- Exaggerated response
4-sustained response
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ASHWORTH SCALE
To assess spasticity
0-No increase in muscle tone
1-Slight increase in muscle tone ,manifested by catch and release
or by minimal resistance at the end of ROM ,when the affected
part is moved in flexion and extension .
1+Slight increase in muscle tone ,manifested by catch ,followed
by minimal resistance throughout the remainder of ROM
2-More marked increased in muscle tone through most of the
ROM ,but affected part is easily moved
3 Considerable increase in muscle tone, passive movement is
difficult .
4-Affected part is held rigid in flexion or extension.
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Test for assessing spasticity
Pendulum Testpatient sitting or lying with knee
flexed over the end of a table
The patient knee is fully extended and allows to drop
and swing like pendulum. A normal and hypotonic limb will swing freely for
several oscillation .
Hypertonic limbs are resistant to swinging motion
hence will quickly return to the initial starting
position .
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Drop arm test
In this the therapist suddenly drop a limb that has
been held.
A normal limb falls momentarily ,then catches
and maintains the position.
Hypotonic limbs fall abruptly, while hypertonic
limbs show a delay and resistance to falling
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Motor sensory links
Reflexes
Deep-Deep tendon jerks eg Biceps, Triceps,
Supinator ,Brachioradialis.
Superficial-Abdominal, Plantar reflexes
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Involuntary movement
Involuntary movement are unintended movement ,which occur
either at rest or during voluntary movement.
These are
1. Tremor-It is involuntary oscillatory movement ,which result
from alternate contraction of opposing muscle groups. It is
rhythmical oscillatory movement of a body part caused by
regular muscle contraction.
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Types of tremors
1. Physiological-is a universal phenomenon in normal
people .A variable degree of tremors are seen which
increases by anxiety, tension ,fear etc.
2. Senile-this is a type of postural tremor involvingupper limb .seen in old age .
3. Resting tremor/static/postural-in basal ganglia lesion
.is occurs when the patient is in static posture .
4. Intentional-in cerebellar lesion . tremor-It occurs
during voluntary motion of a limb and increases as
the limb reaches near its goal. These are decreased
or absent at rest
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Chorea
They are flowing or changing irregular
purposeful movement which are jerky in
nature ,which appears for a short period of
time and they fling from one joint to anotherusually from distal to proximal.
They arise because of lesion in basal ganglia
mainly globus pallidus and caudate nucleus.
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Athetosis
It is characterised by slow, involuntary
writhing,twisting ,worm like movement .
It is more seen in distal than proximal muscles.
The neck ,Face ,tongue and trunk may also be
involved.
Is is seen in lesion of basal ganglia .
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Choreo athetosis
Is is a movement disorder having features of
both chorea ans athetosis.
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Hemiballismus
Sudden ,jerky, forceful,wild and flailing
movement of one side of the body
characterizes it.
It is almost invariably unilateral and affects thearm more than the leg.
The movement may be so violent that it may
result in serious injury to the limb.
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Dystonia
It involves twisting ,sometimes bizarre
movement caused by involuntary contraction
of the axial and proximal muscle of the
extremities .
Torsion spasm are also considered a form of
dystonia and the most common among this is
Spasmodic torticollis
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Isolation of the muscle Isolation is defined as placing of a muscle in detached or non working
position to obtain the requires action in a free state. it is actually testing the
muscle individually .
In isolation of the muscle, the multi-joint muscle is fixed to get the action
of a single joint muscle.
When one joint and a multi joint ,muscle act together in a movement, theaction of one joint muscle can be differentiated from that of multi joint
muscle by placing the multi joint muscle at mechanical advantage .
Keeping it engaged at joint in full range of motion so that is power to assist
a movement at other joint is decreased does this .
Eg-Flexing the knee decreases the action of hamstrings at hip as extensor.Here gluteus maximus is isolated from hamstrings.
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Inhibition of muscle work
This is compensation made by powerful
muscle or muscle group for lack of function of
weak or paralyzed muscle.
This result in inhibition of the weak muscleand the movement is also called as trck
movement.
These movement appear somwhat similar tothe actual movement but are not actual
movement .
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Balance
Static and dynamic
How much help does he need to maintain particular position
His conscious balance assessed by applying pressure and
telling him to hold against that pressure .give pressure in
various direction ,note his stability.
Same with eye closed .
Tilt him backward, forward,sideways and rotate him getly ao
as to distrb his COG. Notice whether he moves his head
,trunk,UL,LL or all of them to maintain equilibrium
Try the same with closed eyes
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Gait assessment
Circumductory GaitHip hiking ,throwing the
affected leg outward producing the movement
of circumduction and leaning towards the
opposite side with arms flexed across the body. Seen in Hemiplegia
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High stepping gait
Seen in patient with foot drop due to which he
raises the foot high to overcome it
S
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Shuffling gait
In this the movement occurs in a series of
small ,flat-footed shuffles seen particularly in
parkinsons disease
A i i
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Ataxic gait
The patient walk with broad base .sways to
and fro and looks as if he is being drunk.
It is most common in cerebellar ataxia
W ddli i
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Waddling gait
There is excessive rotation of pelvis ,
accompanied by compensatory movement of
upper trunk .
Seen in congenital dislocation of hip inmyopathies.
F i l A
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Functional Assessment
Bathingindependent/Dependent
Dressing- independent/Dependent
Going to toilet- independent/Dependent
Continence-independent-if patients urination and defecation
are entirly self controlled. DependentIf he has got partial or
total incontinene in urination or defecation
Has got partial or total control by anemas,cathers or regular
use of urinals or bedpans.
Transfer- independent/Dependent
Feeding - independent/Dependent
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