Evaluation

• Evaluation process


  1. Interpretation of findings

  2. Develop plan of care

  3. Identify and prioritize problems

  4. Evaluate from enablement and disablement perspectives

  5. Summarize movement problem
• Plan of care

  Based on synthesis of patient's goals and expectations, task performance, patient's resources and impairments, and medical diagnosis and prognosis
• Determining patient's goals


  1. Assess if goals are realistic and appropriate

  2. Negotiate goals through shared decision-making
• Synthesizing information


  1. Relate to patient's main concerns, aspirations, and life circumstances

  2. Evaluate relationships among findings

  3. Weigh patient's resources and impairments

  4. Analyze direct and indirect effects of disorder
• Identifying body systems involved


  1. Determine which of the 6 body systems contribute to activity limitations and participation restrictions

  2. Identify body systems not involved

  3. Identify body systems enhancing activity and participation
• Identifying personal and environmental factors

  Determine relevant factors that positively or negatively affect ability to achieve goals or participate in rehabilitation
• Analysis and summary of movement problem


  1. Determine environmental contexts of task difficulty

  2. Identify issues related to environmental context

  3. Determine how movement problem manifests in temporal sequence of task

  4. Identify underlying impairments affecting task performance

  5. Determine difficulty coordinating muscle synergies
• Chronic Stroke


  • Difficulty with grasp and manipulation phase of taking tissue from box
  • Abnormal scapular movements from trunk alignment
  • Inability to generate force or precision for task
  • Compensatory trunk movements interfere with task
• Unilateral Vestibular Disorder


  • Unstable when walking and climbing stairs
  • Difficulty with execution and termination of movement in standing and walking
  • Malalignment in standing contributing to balance issues
  • Difficulty stabilizing body segments, moving between postures, and coordinating movements
  • Impairments in flexibility, sensory organization, and motor control
• Movement system diagnoses are not consistently used in physical therapist practice or education programs, and there is no single standardized nomenclature
• Movement system diagnoses

  Identify movement problems at body structure/function level and describe relationship to activity limitations and participation restrictions
• Motor control impairments from neurologic pathology


  • Weakness
  • Paresis
  • Abnormal muscle tone or spasticity
  • Loss of selective muscle activation
  • Abnormal synergies
  • Coactivation of additional muscles
• Motor impairments from cerebellar pathology


  • Hypotonia
  • Ataxia
  • Action or intention tremor
  • Impaired error correction impacting motor learning
• Motor impairments from basal ganglia pathology


  • Akinesia
  • Hypokinesia
  • Micrographia
  • Bradykinesia
  • Rigidity
  • Resting tremor
  • Hyperkinesia
  • Dystonia
• Sensory system impairments affecting motor control

  • Reduced ability to detect and perceive somatosensory inputs
  • Impaired integration of somatosensory inputs with other modalities
  • Visual system pathology impacting spatial awareness and body position
  • Vestibular system pathology affecting gaze stabilization, posture, balance, and vertigo
  • Right hemisphere spatial and nonspatial deficits
• Primary CNS lesion impairments lead to secondary impairments like contractures, decreased ROM, further weakness, and deconditioning
• Postural control impairment types


  • Steady state postural control deficits
  • Anticipatory postural control deficits
  • Reactive postural control deficits
• Steady state postural control deficits


  • Inability to maintain stable sitting or standing position
  • Impairments in relationship of body segments to each other and environment
  • Increased effort required to support body against gravity
• Reactive postural control deficits


  • Impaired coordination of postural muscle synergies for in-place and change-in-support strategies
  • Sequencing problems, coactivation, delayed responses, inability to modify strategies
  • Disruption in triggering centrally organized postural synergies
• Anticipatory postural control deficits


  Loss of anticipatory processes that activate postural adjustments before potentially destabilizing voluntary movements
• Factors contributing to postural control deficits

  • Sensory problems
  • Perceptual problems
  • Cognitive/attentional problems
  • Decreased balance confidence and falls self-efficacy
• Motor, sensory/perceptual, and cognitive impairments contribute to abnormal gait patterns leading to walking-related activity limitations and participation restrictions
• Neuromuscular problems affecting steady-state gait

  • Paresis or weakness
  • Abnormal muscle tone
  • Loss of selective control or abnormal synergies
  • Coordination problems
• Self-efficacy


  Can contribute to postural control deficits
• Factors contributing to abnormal gait patterns

  • Motor impairments
  • Sensory/perceptual impairments
  • Cognitive impairments
• Paresis or weakness

  Affects ability to generate forces to move the body forward and unrestrained motions resulting from lack of control, which affects the postural control requirements of gait
• Spasticity

  Results in inappropriate activation of a muscle at points during the gait cycle when it is being rapidly lengthened, and alters the mechanical properties of a muscle, producing increased stiffness which affects the freedom of body segments to move rapidly with regard to one another
• Inability to selectively recruit muscles

  Often associated with abnormal coupling of muscles, resulting in abnormal synergies that manifest during gait as total extension or total flexion patterns
• Impaired coordination

  Can manifest as increased activation of muscles, abnormal phasing of multijoint movement leading to poor intersegmental coordination, and coactivation of agonist and antagonist muscles
• Impaired adaptation of gait

  Occurs with reactive balance deficits
• Abnormal somatosensory inputs and vestibular deficits

  Result in gait ataxia
• Vision deficits

  Contribute to anticipatory postural control deficits and impairments to the ability to make adaptations during gait
• Perceptual problems such as body image deficits

  Can result in alignment problems, inappropriate foot placement, and difficulty controlling the center of mass
• Spatial relation disorders

  Affect ability to navigate safely through the environment including avoiding collisions with obstacles
• Impairments in dual-task walking

  Occur due to the higher attentional demands required for postural control during gait in persons with impaired balance
• Prognosis for physical therapist practice refers to the predicted optimal level of functional improvement that can be expected and the amount of time required for the patient to reach that level
• The purposes of making a prognosis are to provide the patient and physical therapist with information about the patient's likely recovery from the neurologic lesion, likely response to intervention, and likely duration of treatment, and to inform shared decision-making
• Establishing a prognosis begins with the physical therapist's diagnostic process which identifies discrepancies that exist between the level of function that is desired by the person, their current capabilities, and the capacity of the person to achieve that level
• Making a prognosis involves a complex synthesis of information and is based on an understanding of the pathology, foundational knowledge, theory, evidence, experience, and examination findings in the context of the patient's social, emotional, and motivational status
• Prognostic statements inherently have much more uncertainty than do most diagnostic judgments