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Physiotherapy in Neurology: Pre & Post Assessment and Treatment Demonstrations

What Examiners Can Ask — Demonstration Format

1. Pre-treatment Assessment (history + neurological examination)
2. Treatment/Physiotherapy Intervention
3. Post-treatment Reassessment (outcome measures + progress monitoring)

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GENERAL FRAMEWORK — Apply to ALL Conditions

Step-by-Step Pre-Assessment Demonstration

• Chief complaint, onset, duration, progression
• Mechanism of injury (for trauma cases)
• Prior functional level (baseline ADLs, mobility)
• Medications, comorbidities, surgical history
• Social history: home setup, caregiver support

1. Mental Status: GCS (Glasgow Coma Scale), MMSE/MoCA for cognitive assessment
2. Cranial Nerves: CN I–XII screening
3. Motor Examination:
   • Muscle tone (spasticity scale: Modified Ashworth Scale 0–4)
   • Muscle power (MRC Grade 0–5 for each muscle group)
   • Coordination (finger-nose test, heel-shin test, Romberg)
4. Sensory Examination: Light touch, pain/temperature, vibration, proprioception (dermatomal pattern)
5. Reflexes: Deep tendon reflexes (0–4+), pathological reflexes (Babinski, Hoffman)
6. Gait Analysis: Observe stance, swing, stride length, arm swing, posture
7. Functional Assessment: Transfers, bed mobility, sitting balance, standing balance

• Barthel Index (ADL independence 0–100)
• FIM (Functional Independence Measure)
• Berg Balance Scale (0–56)
• 10-Meter Walk Test / 6-Minute Walk Test
• Visual Analogue Scale (VAS) for pain

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CONDITION-BY-CONDITION DEMONSTRATION GUIDE

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1. SPINAL CORD TRAUMA (SCI)

1. Establish level of injury: Test sensation and motor power from sacral to cervical dermatomes/myotomes
2. ASIA Impairment Scale (AIS) — mandatory classification:
   • A: Complete (no motor/sensory below level)
   • B: Sensory incomplete
   • C: Motor incomplete (<3/5 key muscles below)
   • D: Motor incomplete (≥3/5 key muscles below)
   • E: Normal
3. Assess sacral sparing (perianal sensation, voluntary anal contraction) — determines complete vs. incomplete
4. Check for autonomic dysfunction: blood pressure, bladder/bowel, temperature regulation
5. Skin assessment: pressure ulcer risk (Waterlow/Braden scale)

• Acute phase: Positioning, passive ROM, respiratory physiotherapy (esp. cervical SCI), prevention of contractures
• Rehabilitation phase:
  • Strengthening: Target intact muscles above lesion and partially preserved muscles
  • Functional electrical stimulation (FES)
  • Gait re-education: Parallel bars → walking aids (for incomplete SCI)
  • Wheelchair mobility training (complete SCI)
  • Mat activities: rolling, bridging, sitting balance
  • Transfer training: bed ↔ wheelchair, floor transfers

• Repeat ASIA grading
• Functional independence re-evaluation (FIM)
• Walking Index for Spinal Cord Injury (WISCI II)
• Monitor for complications: spasticity increase, heterotopic ossification, autonomic dysreflexia

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2. HEAD TRAUMA (Traumatic Brain Injury — TBI)

1. GCS (Eyes 1–4, Verbal 1–5, Motor 1–6) — classify severity:
   • Mild: GCS 13–15, Moderate: 9–12, Severe: ≤8
2. Rancho Los Amigos Levels of Cognitive Functioning (LOCF) — I to X:
   • I: No response → IV: Confused/agitated → VIII: Purposeful/appropriate
3. Post-traumatic amnesia (PTA) duration
4. Cranial nerve assessment (esp. CN VII, VIII, XII)
5. Motor: spasticity, weakness, coordination deficits
6. Swallowing screen (risk of aspiration)
7. Visual field and oculomotor assessment

• ICU/acute: Sensory stimulation (for low-level patients), positioning to prevent contractures, respiratory management, limb ROM
• Rehabilitation:
  • Cognitive rehabilitation (orientation, attention tasks with OT collaboration)
  • Postural control and balance retraining
  • Gait training: step sequence, weight shifting, obstacle navigation
  • Dual-task training (cognitive + motor simultaneously)
  • Spasticity management: stretching, splinting, positioning, botulinum toxin preparation

• Repeat GCS, LOCF level
• Functional Assessment Measure (FAM) + FIM
• Community Integration Questionnaire (CIQ)

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3. BRAIN TUMORS

1. Identify location of tumor → predict deficits (frontal: behavior/weakness; temporal: memory/language; cerebellar: ataxia; brainstem: cranial nerve deficits)
2. Neurological exam focusing on tumor-related deficits
3. Baseline functional status (Karnofsky Performance Scale 0–100)
4. Fatigue assessment (Cancer-Related Fatigue scale)

• Pre-op: Education on post-op exercises; breathing exercises; optimize fitness
• Post-op:
  • Early mobilization (24–48 hrs if stable)
  • Balance and coordination training (especially after cerebellar tumors)
  • Strength training for hemiplegia/hemiparesis
  • Management of cancer-related fatigue: graded aerobic exercise
  • Cognitive-motor dual task training
  • Edema management

• Karnofsky scale
• FACT-G (Quality of Life)
• Berg Balance Scale
• Monitor for seizure activity during sessions

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4. TUMORS OF SPINE, SPINAL CORD & PERIPHERAL NERVES

1. Dermatomal sensory mapping (light touch, pinprick, vibration)
2. Myotomal motor testing
3. Signs of cord compression: Brown-Séquard syndrome, anterior cord syndrome
4. For peripheral nerve tumors: assess specific nerve distribution (e.g., sciatic, ulnar, median nerve)
5. EMG/NCS reference (interpret results)

• Pre/post-surgical stabilization exercises
• Nerve gliding/neurodynamic mobilization techniques for peripheral nerve tumors
• Orthosis fitting and training
• Decompression and progressive weight-bearing

• Sensory mapping repeat
• Neurodynamic test re-assessment (SLR, upper limb tension tests)
• Grip strength dynamometry for peripheral nerve

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5. CEREBRAL ANEURYSM & SUBARACHNOID HEMORRHAGE (SAH)

1. Hunt-Hess Scale (Grade I–V) or World Federation of Neurological Surgeons scale — severity of SAH
2. CT scan findings: Fisher Grade (for vasospasm risk)
3. Neurological deficits from mass effect or ischemia
4. Vital signs monitoring: ICP precautions (keep head elevated 30°)

• Avoid Valsalva maneuver, isometric exercises, straining
• Monitor BP during sessions (avoid hypertension)
• Vasospasm window: Days 4–14 post-bleed — high-risk period

• Acute: Passive ROM, positioning, respiratory care
• Post-vasospasm window: gradual progressive mobilization
• Cognitive and motor rehabilitation as per neurological deficits
• Graded activity: sitting → standing → ambulation

• Repeated neurological examination
• Modified Rankin Scale (mRS 0–6)
• Berg Balance Scale

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6. EPILEPSY

1. Type of seizures (focal, generalized, tonic-clonic, absence)
2. Frequency, duration, postictal period
3. Trigger identification: exercise-induced seizures (rare but important)
4. Todd's paralysis: post-ictal focal weakness — document
5. Medications and side effects (ataxia, sedation from AEDs)

• NOT seizure treatment, but management of consequences:
  • Post-ictal weakness rehabilitation
  • Balance and fall prevention (seizure-related fall injury)
  • Aerobic exercise program (evidence shows exercise reduces seizure frequency)
  • Pool therapy contraindicated unless supervised

• Know seizure first aid: move hazards, lateral position, do NOT restrain
• Avoid aquatic therapy unless controlled
• Document any seizure during session

• Seizure diary (frequency monitoring)
• Falls Efficacy Scale
• Balance re-assessment

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7. PARKINSON'S DISEASE

1. UPDRS (Unified Parkinson's Disease Rating Scale) — Parts I–IV:
   • Part I: Non-motor experiences
   • Part II: Motor experiences in daily life
   • Part III: Motor examination (tremor, rigidity, bradykinesia, gait, posture)
   • Part IV: Motor complications
2. Hoehn and Yahr Scale (Stage 1–5)
3. Demonstrate assessment of:
   • Resting tremor (pill-rolling at rest, diminishes with action)
   • Cogwheel rigidity (passive movement of wrist/elbow — ratchet feel)
   • Bradykinesia (rapid alternating movements — show rapid finger tapping test)
   • Postural instability (pull test — stand behind patient, pull shoulders backward)
4. Gait: festination, freezing of gait, reduced arm swing, forward stoop
5. Speech: hypophonia, monotone (refer to SLP)

• LSVT BIG protocol: High-amplitude, high-effort movements
• Treadmill training with cueing
• Visual/auditory cueing for freezing of gait (floor lines, rhythmic music)
• Facial and axial rigidity exercises
• Balance training: tandem stance, perturbation training
• Tai Chi (evidence-based for fall prevention)
• Flexibility: stretching for axial rotation, hip flexors

• Repeat UPDRS III motor score
• 10-Meter Walk Test (OFF and ON medication)
• Timed Up and Go (TUG) test
• Berg Balance Scale

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8. CHOREA & HEMIBALLISMUS

1. Characterize involuntary movements:
   • Chorea: Random, brief, irregular, flowing movements (affects limbs/face)
   • Hemiballismus: Violent, flinging, proximal movements — usually one side (subthalamic nucleus lesion)
2. Assess functional impact: feeding, dressing, writing, walking
3. Safety risk assessment (fall risk from involuntary movement)

• Weighted vests/wrist weights (dampening involuntary movement — used cautiously)
• Relaxation techniques
• Functional task training in stable positions
• Adaptive equipment training
• Joint protection techniques

• Abnormal Involuntary Movement Scale (AIMS)
• Functional task performance timing

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9. PSYCHIATRIC DISORDERS (Neurological Physiotherapy Context)

1. Cognitive status: MMSE/MoCA
2. Functional mobility and deconditioning (prolonged inactivity/medication side effects)
3. Extrapyramidal side effects of antipsychotics:
   • Tardive dyskinesia
   • Drug-induced Parkinsonism
   • Akathisia (restlessness)
4. Depression/anxiety: assess exercise tolerance and motivation

• Aerobic exercise (proven antidepressant effect — 30 min, 3×/week)
• Management of drug-induced movement disorders
• Social engagement through group exercise
• Breathing and relaxation techniques (anxiety management)
• Mind-body: yoga, tai chi for depression/anxiety

• PHQ-9 (depression), GAD-7 (anxiety)
• Re-assess extrapyramidal signs

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10. MALFORMATIONS OF THE NERVOUS SYSTEM (e.g., Cerebral Palsy, Arnold-Chiari)

1. Type of malformation: Arnold-Chiari (cerebellar tonsil herniation), Dandy-Walker, cortical dysplasia
2. Developmental milestones (for pediatric cases)
3. Muscle tone assessment (hypotonia vs. hypertonia)
4. Primitive reflex persistence
5. Gross Motor Function Classification System (GMFCS) for cerebral palsy (I–V)

• Neurodevelopmental Treatment (NDT / Bobath approach):
  • Key points of control (proximal control to facilitate distal movement)
  • Handling techniques to normalize tone
• Sensory integration therapy
• Hydrotherapy for tone management
• Adaptive seating, positioning aids

• Repeat GMFCS level
• PEDI (Pediatric Evaluation of Disability Inventory)

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11. CAROTID ARTERY STENOSIS

1. TIA/stroke history: focal neurological signs
2. Blood pressure monitoring (labile BP common)
3. Cranial nerve assessment (CN VII, IX, X, XII — at risk during surgery)
4. Neck range of motion and wound assessment (post-CEA)

• Early mobilization post-CEA
• BP monitoring throughout session (avoid hypotension with position changes)
• Neck exercise: gradual ROM (avoid extreme rotation initially)
• Stroke prevention education (lifestyle modification)
• Aerobic conditioning (secondary prevention)

• ABI (Ankle-Brachial Index) for vascular status
• Neurological re-examination
• 6-Minute Walk Test

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12. ARTERIOVENOUS MALFORMATION (AVM)

1. Location of AVM → predict neurological deficits
2. Hemorrhage-related deficits: hemiplegia, aphasia, visual field defect
3. Seizure history (AVMs commonly cause seizures)
4. Spetzler-Martin grade (I–V) — surgical complexity indicator

• Same framework as stroke/hemorrhagic stroke rehabilitation
• Spasticity management, gait training, balance
• Constraint-Induced Movement Therapy (CIMT) for upper limb
• Task-specific training

• Monitor ICP signs: headache, nausea, pupil changes — stop session
• Avoid isometric exercises and Valsalva

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13. SPINA BIFIDA

1. Type:
   • Spina bifida occulta: Often asymptomatic
   • Meningocele: Meninges protrude, usually intact neurological function
   • Myelomeningocele: Spinal cord protrudes — neurological deficits
2. Level of lesion → motor/sensory level (same framework as SCI)
3. Assess lower limb muscle strength and sensation
4. Assess hydrocephalus (if VP shunt present — assess for malfunction signs)
5. Bowel/bladder function
6. Hip and lower limb deformities (clubfoot, hip dislocation)
7. Skin integrity (insensate areas)

• Strengthening: above-lesion muscles
• Orthoses: AFO, KAFO depending on level
• Ambulation training: forearm crutches, reverse walker, wheelchair
• Hydrotherapy
• Education: skin care, pressure relief, positioning
• Transition to wheelchair use for higher lesion levels

• Repeat motor level and functional mobility
• PEDI (Pediatric Evaluation of Disability Inventory)
• Ambulation status: community vs. household ambulator vs. non-ambulatory

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UNIVERSAL OUTCOME MEASURES — Quick Reference Table

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KEY PRECAUTIONS TO DEMONSTRATE AWARENESS OF

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HOW TO STRUCTURE YOUR VIVA/PRACTICAL DEMONSTRATION

1. Introduction: State the condition and your assessment plan
2. Consent & Explanation: Briefly explain to the (simulated) patient what you will do
3. Observation before touching: Posture, involuntary movements, facial asymmetry, assistive devices
4. Systematic examination: Head-to-toe, proximal-to-distal
5. Score and grade: Apply relevant scale (ASIA, UPDRS, Ashworth, etc.)
6. Problem list: Summarize deficits found
7. Goal setting: Short-term (2 weeks) and long-term (3 months) goals — SMART goals
8. Treatment plan: Sequence techniques logically (positioning → passive → active-assisted → active → functional)
9. Demonstrate at least 2–3 specific techniques for that condition
10. Reassessment plan: State which outcome measures you will repeat and when

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