STARES 1; Neuro Assessment

SITUATION
My patient, Mr S, is a 63yr male who has been attending rehabilitation at Shenton Park hospital for the past 2 months following a left LACS (from an internal capsule infarct in the area of the L anterior choroidal artery), presenting with right sided ataxic hemiparesis symptoms.

From his history I expected his main impairments to be co-ordination deficits in his right upper and lower limbs possibly combined with altered tone (likely hyperreflexia) and hemianopia. Consequently, a reduced functional capacity and an inability to ambulate were also aspects I considered prior to meeting the patient.
Mr S is a very positive and motivated patient with an extremely supportive family.

Prior to his stroke he worked full time as a farmer and is very keen to get back to work and return to playing golf. From reading his progress notes, he appears to have progressed well so far with his rehab.
No discharge date has been set for the patient as yet.


TASK
Prioritised re-assessment of the patient in a 60 minute time frame identifying key measures most important to determine an initial impairment list based on my findings so that I could begin to build a treatment plan for this patient. As neuro examinations are timely I was not expected to complete the full assessment in the one session but prioritise so that the rest of the tasks could be completed in later sessions.


ACTION
After introducing myself to the patient, performing a brief subjective assessment and explaining what I was going to be doing, I began the re-assessment process.
I chose to objectively assess, time permitting, vision, co-ordination, tone, joint ROM and Gowlands motor recovery scale in my initial examination.
In an attempt to use my time effectively, I began with the vision and coordination tests with the patient sitting over the edge of the bed with their feet supported, and then I moved onto the tone and joint ROM assessments in supine and concluded with Gowlands.

Vision was an essential inclusion to ensure patient is able to see what you as therapist are doing as well as identifying any hemianopias/quadrantopias that may be present increasing the likelihood of neglect/inattention. I assessed visual field, visual acuity, eye follow, convergence and divergence to thoroughly examine if any of the cranial nerves involved in vision were affected. These tests were all negative.

The ataxic presentation required a thorough assessment of co-ordination to determine the extent of any cerebellar signs and as this was a re-assessment, whether there had been any improvements made since the initial assessment. The tests I included were rebound phenomenon, finger-thumb/heel-knee, rapid supination-pronation/toe-tap, finger-nose/heel-shin, pendular reflexes and bridging. I examined the unaffected side first to have a reference point as to what was probably normal for the patient. I then moved to the affected signs where Mr S demonstrated a mild level of co-ordination difficulties with the right upper limb and a moderate level in his right lower limb.

As patients with ataxia often fix their limbs to feel safe and supported, assessing tone and joint ROM to determine if any specific areas were becoming stiff and sore, potentially limiting function, had arisen I believed was very important. I was most concerned with the shoulder and hip joints as they are most at risk of developing further musculoskeletal complications if tone is increased and joint ROM is lost.

Due to the time limitations I only assessed tone, using the Tardieu scale, in key muscles which in the upper limb were biceps, triceps and wrist and finger flexors; and in the lower limb, hip adductors, hamstrings, quadriceps and gastrocnemius/soleus. The patient had increased tone in his right hip adductors (Tardieu = 2) and right plantarflexors (Tardieu = 3). I found no abnormalities in tone on the left side.

I assessed ROM in were the shoulder giving the number of degrees of flexion, abduction and external rotation and then the elbow, wrist, hip, knee and ankle stating whether the patient had full, ¾, ½, ¼, or no range in that joint. These were all assessed in supine, except for hip extension range which I assessed in prone. Reduced range into abduction and external rotation were noted on the right side but the patient did not report any pain with these movements. Reduced range was also apparent in the right ankle into dorsiflexion and hip into adduction and flexion. No loss of range was evident on the left side.

The Gowlands motor recovery scale is a measure of voluntary control which has been validated within the stroke population. This assessment also allowed me to have a general look at the patient performing functional movements as well as aspects of a balance assessment. The patient was positioned according to the standard starting instructions and although ideally I would have assessed his unaffected side first, I was running short of time so just documented that it wasn’t tested. The patient scored a 4 – postural control, 4 – leg, 2 – foot, 5 – arm, 4 – hand.


RESULTS
Although I managed to complete all the essential components (except for Gowlands on the left side) it took me 75 minutes, 15 minutes longer than the time frame I was given. Luckily the patient didn’t have any other appointments to go to so I was able to take the extra time required to finish.

My supervisor agreed with the assessment tasks I had chosen however said that for next time I should include a better assessment of functional tasks and mobility level for reassessment as his mobility status on the ward may be able to be changed.


EVALUATION
Although the assessment was completed to an adequate standard for my first attempt, there are a few things I will be able to work on and improve. Firstly, my time management skills were not the greatest, however I think the reason it took me longer than anticipated was due to the fact my handling was not ideal and I was not familiar with all the tests so lacked a degree of confidence. As a result of this I performed some tests, for example tone, a number of times to be sure I was certain of my result.

When I realised that I was running short of time, I got nervous and flustered, losing my place in the Gowlands and getting mixed up with the scoring on a couple of occasions. Although it probably didn’t contribute excessively to time, my handling was not optimal in terms of patient comfort and providing good, firm sensory input to the affected limbs.


STRATEGIES
I believe that the best strategy for me to improve my assessment skills is practice, practice, practice! Not only will this help to improve my confidence, but also have better handling skills and feel like I only need to perform an assessment once to have a definite result. With an improvement in all of these factors I think my assessment will be more efficient and not so time consuming.

Another way I plan to improve my time management is to make a list of which Gowland stages are performed in each position so the patient doesn’t have to change position all the time. I also plan to watch video of the Gowlands assessment do improve that specific aspect of my assessment.

Furthermore, I asked my supervisor if there were any resources I could revise on assessment protocols and how to be as efficient as possible, she said she would have a look and get back to me but went through specific aspects of my assessment with me which she believed could be improved.