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REHABILITATIONASSESSMENTPingMiao,MDDepartment of Rehabilitation medicineThe second affiliated hospital of Guangzhou Medical University1.REHABILITATIONASSESSMENTPingContentsnIntroductionnMeasuresofimpairment(muscle,joint,cognitive.)nMeasuresofdisability(activityofdailylife.)nMeasuresofhandicap2.ContentsIntroduction2.To find the problemsnWhat 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,and 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 family3.TofindtheproblemsWhatkindTo 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 long-term one From short-term goals to long-term one nMust consider the factorsMust consider the factorsageage、professionprofession、cultural backgroudcultural backgroud、family conditionsfamily conditions4.Tosettreatmentgoalsshort-teAssess treatment effectsnIs our treatment plan effective?Is our treatment plan effective?Yes/NoYes/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/No5.AssesstreatmenteffectsIsour Physical examination and rehabilitation measurement have something in common but not the same.nPurposenTimesnWaysIntroduction6.Introduction6.7.7.8.8.Objectives of MeasurementTo find problemsTo set treatment goalsTo plan treatment schedules To assess the effectivenessTo predict outcomesTo analyze the cost-effecitveReasons for assessing9.ObjectivesofMeasurementTofiLevels should be measuredimpairment disability handicap 10.LevelsshouldbemeasuredimpaiDevelopment of ICIDHDevelopment 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 病病损损 残残 疾疾 残障残障 (器官水平器官水平)()(个体水平个体水平)()(社会水平社会水平)structurestructure ability activity/participationability activity/participation TraditionalModel of MedicineTraditionalModel of Medicine:EtiologyEtiology PathologyPathology clinical featuresclinical featuresLevels11.DevelopmentofICIDHInternatApplicationofICIDHDifferent cousesAmputee in the lower limbCant walkCant go to school/workimpairmentdisabilityhandicapOrgansADLSocial activityAt the level of 12.ApplicationofICIDHDifferentApplicationofICIDHStroke/TBIHemiplagiaCant look afterHim-/her-selfCant work/Join the social life impairmentdisabilityhandicaporgansADLSocial lifeAt the level of 13.ApplicationofICIDHStroke/TBI14.14.IntroductionnPurpose1.Planatreatmentprogramandestablishoutcomes2.Evaluateresultsoftreatmentprogram3.Modifytreatmentprogram15.IntroductionPurpose15.IntroductionnGoodassessmentisdependentupon:KnowledgeoffunctionalanatomyHistoryCompleteexamination16.IntroductionGoodassessmentisClinicalEvaluationSequencenHistorynInspectionnPalpationnFunctionalTestingnNeurologicalTesting17.ClinicalEvaluationSequenceHicategory of measurmentRatio Scales Inerval Scales Ordinal Scales Norminal Scales 18.categoryofmeasurmentRatioScRatioScalesnFeaturesHas 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 value.%is a form of rationExamplesROMLimb lengthTime to complet an activityVital capacityNerve conduction velocity19.RatioScalesFeatures19.Inerval ScalesnFeaturesLack of a zero pointThe unit must be equal sizenExamplesBody temperatureFunctinal scalesPsychological tests20.InervalScalesFeatures20.Ordinal ScalesnFeaturesMay have only 2 categoriesnPresent/absentnDependent/independentnExamplesMMTADLFugle-Meyers scale21.OrdinalScalesFeatures21.Norminal 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,diseasenStroke,nCerebral palsy22.NorminalScalesFeatures22.Quantitative and Qualitative ScalesnUnitsareassumedtobeofequalsizenAcontinuousscaleEqualsizesubunitsnDistance:m,cm,mm,etcnExamplesRatioscalesIntervalscalesnCategorieshavenosizenCantbedivisibleintoequal-sizedsubcategoriesTendonreflexSittingbalancenExamplesNominalscales23.QuantitativeandQualitativeSnvalidnsensitivenspecificnreliable(inter-rater,test-retest)nappropriatenacceptable24.valid24.Procedureswhen to measurewhat to be measuredhow to measure25.ProcedureswhentomeasurewhatWhen to measureInitial stageMiddle stageTerminal stageAt follow-upnDuringthetreatmentandtraining,evaluationcanberepeatedbyseveraltimes.Itusuallystartfromtheevaluationandendontheevaluation.26.WhentomeasureInitialstageMiInitial 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 planningAs the baseline of reassessment27.Initialstage（firstmeasuremenMiddle 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 improvement and its extendTo decide if any adjustment is needed28.Middlestage(repeatedmeasuremeTerminal 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 treatmentnRefered to outpatient or community29.Terminalstage（final）WhenshoFollow-upnWhen should beVariation among patients and diseasesnEach month,2-3months or 6 monthsnobjectivesDetermine the function of patientDecide whether patient needs to futher treatment30.Follow-upWhenshouldbe30.specificPhysical functioncognitionlanguageSocial activitiespsychologyglobalimpairmentdisabilityhandicapWhat to be measured31.specificPhysicalfunctioncogniPhysical functionMuscle toneROMBalanceMMTWalking?Aschworth Spasticity ScaleWhat should be measured in neurorehabMotor Assessment ScaleBerg Balance ScaleComposite Spasticity ScaleThe Timed“Up&Go”testFugle-Meyer Movement AssessmentReach TestBrunnstroum Rovery Stages32.PhysicalfunctionMuscletoneROData collectionMedical historyMedical notesFind the problemsassessmentDecide what to and how to assessStart to assessData recordingData analysisFunctinal diagnosisSet treatment goalsTreatment planAssessment procedues33.DatacollectionMedicalhistoryEvaluation效度效度信度信度sensitivetyvalidreliabilityIntra-raterInter-ratercriterion-related validation content-related validationconstruct-related validationTo evaluate the methodology being used34.Evaluation效度信度sensitivetyvalid Rules of S.O.A.P are widely use all over the world:S(subjectivedata)：maincomplaintandsymptomofthepatients;O(objectivedata)：objectivesymptomandfunctionalbehaviorofthepatientsA(assessment)：analyzeandclassifytheabove-mentionedmaterials;P(plan)：setatreatmentplan.Methodsofevaluation35.RulesofS.O.A.Parewidel.Methodsofevaluation36.Methodsofevaluation36.Specific Evaluation37.SpecificEvaluation37.SpecificEvaluation-MotorabilityevaluationMusclestrengthRangeofmotionMusculartoneMuscularenduranceGaitanalysisBalanceCoordination38.SpecificEvaluation-MotorabilManualmuscletest(MMT)39.Manualmuscletest(MMT)39.ManualMuscleTesting(MMT)nDefinition:subjectivetestingdonebythetherapisttoassessapatientsmusclestrength.Themusclestrengthisgradedtobeeithernormal,good,fair,poor,traceorzero.40.ManualMuscleTesting(MMT)DefMuscleGradesNormal:patientholdscontractionagainstmaximalresistanceatendrangeGood:patientholdscontractionagainstmoderateresistanceatendrangeFair:patientmovesthroughfullrangeofmotionagainstgravitybutunabletoholdagainstresistanceatendrangePoor:patientmovesthroughfullrangeofmotioninagravityminimizedpositionTrace:therapistpalpatesmusclecontractionaspatientattemptstomoveZero:therapistisunabletopalpateanymusclecontractionaspatientattemptstomove41.MuscleGradesNormal:patienthMuscleGradesNormal=5/5Good=4/5Fair=3/5Poor=2/5Trace=1/5Zero=0/542.MuscleGradesNormal=5/542.ImportantpointsonmanualmuscletestingnNeedtoplacepatientinstandardizedpositionnIsolateonlyonejointmotionnDontallowpatienttocompensateforweaknessnComparesamemusclebilaterallynBeconsistentandreliablewithtesting43.ImportantpointsonmanualmusnManualResistanceStabilizelimbproximallyResistanceprovideddistallyonbonetowhichmuscleattachesWatchforcompensation44.ManualResistance44.45.45.nVIDEOnDEMOnPRACTICEnQ&A46.46.AttentionduringtheMMT1.Correctposture,limbpositionandnecessarysettlement.2.Makesurethepatientsunderstandtherequestandpurposeofmovement,sothatavoidingthefakemovementorcompensation.3.Whilethemusclestrengthreachthelevel4,resistanceisprovidedtothedistalareaofthelimb.47.AttentionduringtheMMT47.4.KeepavoidingtheMMTafterlongtimeexercisesormeals.5.Thepositionwhichismeasuredshouldbeexposedtothetherapistsordoctors.6.Remembertocomparewiththecontralaterallimb.48.48.MuscletestMeasurebyequipments1.GeneralequipmenttestGrippingtestPinchingtestDorsalmuscletest.MethodsofEvaluation-Muscletest49.Muscletest.MethodsofEvaluMuscletone(ModifiedAshworthScale)50.Muscletone(ModifiedAshworth51.51.Rangeofmotion(ROM)52.Rangeofmotion(ROM)52.RangeofMotion(ROM)53.RangeofMotion(ROM)53.MeasuringToolsGoniometerInclinometerElectrogoniometer54.MeasuringToolsGoniometer54.55.55.HowtomeasuretheROMofupperlimbs/lowerlimbs/trunk?.MethodsofEvaluation-ROMThreefactors(1)Axis(2)Stationaryarm(3)Movingarm56.HowtomeasuretheROMofuppe57.57.ROMMeasurementnInformedconsentnPositionthepatientnPlacejointinzerostartingpositionnStabilizeproximalsegmentofthejointnMovepatientpassivelythroughavailableROMnDetermineend-feelnPalpatelandmarksnAligngoniometernPassivelyoractivelytakepatientthroughavailableROMnCheckalignmentnReadgoniometer58ROMMeasurementInformedconsen59.59.Shoulderflexion(180)Supinewitharmsatsides-liftoverheadStationaryarm-lateralmidlineofthoraxAxis-midpointoflateralaspectofacromionprocessMovingarm:lateralmidlineofthehumerustowardlateralhumeralepicondyle60.Shoulderflexion(180)60.ShoulderExtension(60)Pronewitharmsatsides-trytoraisearmStationaryArm:lateralmidlineofthoraxAxis:midpointoflateralaspectofacromionprocessMovingArm:lateralmidlineofhumerustowardlateralhumeralepicondyle61.ShoulderExtension(60)61.ShoulderAbductionSupinewithshoulderatsideinanatomicalposition-raisearmoverheadStationaryArm:ParalleltosternumAxis:AnterioraspectofacromionprocessMovingArm:Anteriormidlineofhumerustowardmedialhumeralepicondyle62.ShoulderAbduction62.External/LateralRotationInternal/MedialRotation63.External/LateralRotationInteElbowFlexionSupinewithhandsbysideswithtowelunderarm-flexelbowStationaryarm:lateralmidlineofhumerustowardacromionprocessAxis:LateralepicondyleofHumerusMovingArm:Lateralmidlineofradiustowardradialstyloidprocess64.ElbowFlexion64.65.65.66.66.67.67.68.68.69.69.70.70.RangeofMotion(ROM)nHelpstoassessfunctionalstatusnComparebilaterallynTestjointsproximalanddistaltoinjuredareanOnlyperformifdonotsuspectafracture71.RangeofMotion(ROM)HelpstoImportantpointsonGoniometricmeasurementnMotionsmeasuredcanbeeitheractiveorpassivenStandardizedtechniquesareusedforeachjointnJointsshouldbeadequatelystabilizedduringmeasurement72.ImportantpointsonGoniometriPassiveRangeofMotion(PROM)nClinicalDefinition:Therapistmovesselectedjoint(s)throughfullrangeofmotionwithnoassistancefromthepatientActiveRangeofMotion(AROM)73.PassiveRangeofMotion(PROM)ImportantpointsonpassiverangeofmotionnAdequatelystabilizepatientsjointsasyoumovethem.(somepatientsmayhavenoactivemovement)nDontcausepainotherthanstretchingnPerform5-10motionsperjointmovementnFamiliarizeyourselfwithnormaldirectionsanddegreesofmovementforeachjointnListentopatient74.ImportantpointsonpassiveranContraindicationsPatientisunabletovoluntarilycontractinjuredmusclePatientisunabletoperformAROMUnderlyingfracturesiteisnothealedInvolvedtissuesarenotyethealed75.Contraindications75.MethodsofEvaluation-ROM76.MethodsofEvaluation-ROMElbownflexion0to160nextension145to0 Forarmnpronation(rotationinward)0to90nsupination(rotationoutward)0to90.MethodsofEvaluation-ROM77.EWristnflexion0to90nextension0to70nabduction0to25nadduction0to65.MethodsofEvaluation-ROM78.WristHipnflexion0to125nextension115to0nhyperextension(straighteningbeyondnormalrange0to15nabduction0to45nadduction45to0nlateralrotation(rotationawayfromcenterofbody)0to45nmedialrotation(rotationtowardscenterofbody)0to4579.HipKneeflexion0to130extension120to080.KneeAnkleplantarflexion(movementdownward)0to50dorsiflexion(movementupward)0to2081.AnklMini-MentalStateExamination(MMSE)82.Mini-MentalStateExaminationnTheminimentalstateexamination(MMSE)isa30-pointquestionnairethatisusedextensivelyinclinicalandresearchsettingstomeasurecognitiveimpairment.nItiscommonlyusedinmedicineandalliedhealthtoscreenfordementia.Itisalsousedtoestimatetheseverityandprogressionofcognitiveimpairmentandtofollowthecourseofcognitivechangesinanindividualovertime83.TheminimentalstateexaminatnAdministrationofthetesttakesbetween510minutesandexaminesfunctionsincludingregistration,attentionandcalculation,recall,language,abilitytofollowsimplecommandsandorientation.84.AdministrationofthetesttaknAdvantagestotheMMSEincluderequiringnospecializedequipmentortrainingforadministration,andhasbothvalidityandreliabilityforthediagnosisandlongitudinalassessmentofAlzheimersDisease.nThemostfrequentlynoteddisadvantageoftheMMSErelatestoitslackofsensitivitytomildcognitiveimpairment85.AdvantagestotheMMSEincludenAnyscoregreaterthanorequalto27points(outof30)indicatesanormalcognition.Belowthis,scorescanindicatesevere(9points),moderate(1018points)ormild(1924points)cognitiveimpairment.nTherawscoremayalsoneedtobecorrectedforeducationalattainmentandage.86.AnyscoregreaterthanorequaActivityofdailylife(ADL)87.Activityofdailylife(ADL)87Bathing:includesgroomingactivitiessuchasshaving,andbrushingteethandhairDressing:choosingappropriategarmentsandbeingabletodressandundress,havingnotroublewithbuttons,zippersorotherfastenersEating:beingabletofeedoneself88.Bathing:includesgroomingactTransferring:beingabletowalk,or,ifnotambulatory,beingabletotransferoneselffrombedtowheelchairandbackContinence:beingabletocontrolonesbowelsandbladder,ormanageonesincontinenceindependentlyToileting:beingabletousethetoilet89.Transferring:beingabletowaModifiedBarthelIndexScore(MBI)nTheMBIisameasureofactivitiesofdailyliving,whichshowsthedegreeofindependenceofapatientfromanyassistance.nItcovers10domainsoffunctioning(activities):bowelcontrol,bladdercontrol,aswellashelpwithgrooming,toiletuse,feeding,transfers,walking,dressing,climbingstairs,andbathing.nTotalscoresmayrangefrom0to100,withhigherscoresindicatinggreaterindependence.90.ModifiedBarthelIndexScore(Others91.Others91.BalancenDefinition:MaintainingcenterofmasswithinyourbaseofsupportnOtherTerminologyusedtodescribebalance:nCenterofGravitynEquilibriumnConeofStability92.BalanceDefinition:Maintaining.Methodofevaluation93.Methodofevaluation93.GaitnOthertermsusedtodescribegait:nAmbulation/LocomotionnControlledmovementofyourbaseofsupport.94.GaitOthertermsusedtodescriGaitAssessments95.GaitAssessments95.96.96.nMeasuresofperception-cognition感知、认知评价nMeasuresofanxietyanddepression焦虑和忧郁评估nMeasuresofTraumaticbraininjury脑外伤(TBI)评估nSelf-assessmentandself-efficacyscales自我评价（生活质量评价）97.Measuresofperception-cogniticoordination98.coordination98.Unilateralneglect99.Unilateralneglect99.100.100.DISCUSSIONnHowtoassesstheswellingofthehandafterinjury?nHowtoassessthepatientwithstroke?101.DISCUSSIONHowtoassesstheswAssessment of Patients with Stroke102.AssessmentofPatientswithSAssessment of patients with stroke includes:nLevelofconsciousnessnCognitivefunctionnSpeechandlanguagenCranialnerveintegritynSensoryintegritynJointintegritynMusclestrengthnAssessmentofposturenPosturalcontrolandbalance(includingposturalreactions)103AssessmentofpatientswithstnMuscletoneassessmentnDeeptendonreflexesnClonusandBabinskitestingnPresenceofprimitivereflexesnAssessmentofassociatedreactionsnAssessmentofabnormalsynergynAssessmentofcoordinationnGaitassessmentnAssessmentofperceptionnEndurancetestingnFunctionalassessment104104Mini-MentalStateExamination(MMSE)PainVAS/othersTen-meterwalktest:goodtestforgaitspeedTimedUpandGo(TUG)BergBalanceScale(BBS)TinettiFallsEfficacyScaleActivities-specificBalanceConfidenceScale(ABC)DynamicGaitIndex(DGI):gaitspeedFunctionalGaitAssessment(FGA):gaitspeed105105Five-timesittostand:quadstrength,functionalabilityandendurancetesting30-secondsittostandSix-minutewalkingtest(2-minutewalk,BorgScaleofPerceivedExertion)Hand-helddynamometerMotoricityIndexShortForm36(SF-36):qualityoflifeTheBarthelIndex:ADLRivermeadMotorAssessmentFunctionalIndependenceMeasures(FIM)106106CanadianNeurologicalScale(Stroke)Chedoke-McMasterStrokeAssessmentFugel-MeyerAssessmentofMotorRecoveryAfterStrokeMotorAssessmentScale(MAS)NIHStrokeScale(NIHSS)StrokeImpactScale(SIS)StrokeRehabilitationAssessmentofMovement(STREAM)n30itemsscalenClinicalMeasureofvoluntarymovementsandbasicmobilityfollowingstroke107107n108.Mahalo!multumesc108.
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