The assessment of the restoration of the nervous system helps identify what a person who has a state of the nervous system can do at present, what respect they need help in, what precautions in respect of safety there should be, and how the progress should be measured

This process is more than examining whether the patient can walk or move the arm on the side that has been affected or not. A state of the nervous system may affect the balance, the tone of the muscles, sensation, communication, memory, swallowing, endurance, caring for oneself, and confidence at the same time

Before beginning the treatment, the physician and the therapist set the baseline information in respect of functioning and identify the goals that are meaningful to the patient. What is found leads to a combination of treatment specific to the individual between physiotherapy, occupational therapy, speech therapy, training of cognition, the giving of knowledge to the carer, assistive equipment, and restoration that uses technology to support it

Why the assessment is the foundation of the restoration of the nervous system

Those who have the same diagnosis may have very different needs in respect of restoration

After cerebrovascular disease, one person may be able to walk by themselves but have a problem of balance, concentration, or the coordination of the hand, while another person may need much help in sitting, standing, transferring the body, and communicating basic needs

A person who has Parkinson's disease may have slow movement, symptoms of freezing of gait, instability, exhaustion, tremor, and difficulty in doing the daily routine in different forms

The assessment of the restoration of the nervous system helps the clinical team be able to set:

What the patient can do independently
Which activities need help
What is limiting the movement or the participation
Whether a medical or neurological risk affects the training or not
Which fields of restoration should take part
How the intensity of the treatment should be increased
Which results should receive a repeated assessment

The goal is not merely to make the score of any one test better. The World Health Organization (opens in a new tab) explains that restoration is care that holds the person as its centre, in order to increase functioning, reduce disability, and support participation in meaningful roles of life

The states that may require the restoration of the nervous system

The restoration of the nervous system may be suitable when a state that affects the brain, the spinal cord, or the nervous system gives rise to difficulty in respect of movement, cognition, communication, or functioning in daily life

The states that may require an assessment are:

Cerebrovascular disease
Parkinson's disease and other disorders of movement
Injury of the brain
Injury of the spinal cord
A state of dementia or Alzheimer's disease
The degeneration of memory, communication, or executive functioning
Other states of the nervous system that affect movement and independence

The purposes of the treatment differ. A person who is recovering after a neurological event that has just arisen may aim to restore the ability that has been lost, while a person who has a progressive state may aim to maintain movement, reduce the risk of falling, adjust daily activities, and keep their independence

The suitability, the length of time of the programme, the intensity of the treatment, and the progress expected depend on the diagnosis, the medical stability, the current functioning, the result of the assessment, the tolerance of the treatment, and the goals specific to the individual

What happens before the physical testing?

The assessment usually begins from a review of the diagnosis, the medical history, the treatment that has been received, and the current concerns. The NICE guideline on the restoration of chronic states of the nervous system (opens in a new tab) recommends a holistic assessment, instead of looking at any one symptom without considering the fatigue, the cognition, the communication, the mental well-being, the routine, and the participation

The physician of rehabilitation medicine may ask about:

The neurological diagnosis and the date the symptoms began
Stays in hospital, surgery, or procedures that have passed
The medicine used at present
The restoration that has been received
Falls or near-falls
Pain, symptoms of numbness, or changed sensation
Exhaustion and the tolerance of the treatment
Medical events that are connected
Supporting orthoses, walking aids, or a wheelchair
The help needed at home
What the patient gives importance to and the concerns of the family

The medical records and the medical images that exist may also be reviewed. The goal is to come to understand the medical stability of the patient and the effect of the state of the nervous system on the current functioning, instead of repeating the previous examinations automatically

Neurological symptoms that arise anew or worsen quickly should receive a suitable medical assessment before beginning restoration as usual

The medical and neurological examination

The examination by the physician helps identify which problems may be connected with the state of the nervous system, and whether it is necessary to examine further or not

The assessment may include:

Alertness and the ability to follow commands
The movement of the arms, the legs, and the trunk
The strength and the tone of the muscles
Sensation
Coordination
The range of movement of the joints
Pain
Balance
Other neurological findings that are connected

What is found also affects the safety. A patient who has reduced sensation may not perceive pressure or the posture of a joint normally, while a person who has deficient concentration may need commands and supervision different from a patient whose limitations are mainly physical

The assessment of walking and of functional movement

The assessment of walking is more than counting the number of steps. The therapist may observe:

The ability to stand
The bearing of weight between both legs
The length of the step and the symmetry
The lifting of the foot clear of the ground
The control of the hip and the knee
The position of the trunk
Beginning, stopping walking, and turning the body
The speed and the endurance in walking
The use of a walking stick, a walking aid, an orthosis, or physical support
The safety on different surfaces

Functional movement may include turning over in bed, changing from lying to sitting, getting up to stand from a chair, transferring the body between the bed and the wheelchair, reaching to pick things up, and managing a step or stairs

The patient does not need to be able to walk independently before beginning restoration connected with walking. The goal in the first stage may be the control of the trunk, standing with support, the transfer of weight, transferring the body safely, or the tolerance of the upright posture

The assessment of movement with technology to help

When it is clinically relevant, measurement with instruments, such as a force plate or three-dimensional analysis of movement, may give further information about the balance, the bearing of weight, the symmetry, and the pattern of movement

These measurements should be interpreted together with the physical examination and the functioning in daily life. Information created by technology should support the clinical decision; it should not set the programme by itself

The assessment of balance and of the risk of falling

Balance depends on strength, sensation, seeing, coordination, concentration, and the ability to respond to a change of posture

The therapist may assess whether the patient can:

Maintain the sitting or the standing posture
Transfer the weight safely
Reach without losing control
Turn the body and change direction
Reduce the use of the hands for support
Recover from a slight disturbance
Walk while doing another task when suitable

The team also considers whether the patient is aware of their own limitations or not. A person who tries to stand without understanding that they need help may have a character of risk different from a person whose body is weaker but who is suitably careful

The result helps set the supervision, the walking aid, the precautions in respect of the environment, and the beginning level of the training

Strength, the control of movement, and the tone of the muscles

A state of the nervous system may affect both the amount of force that the muscle can create and the ability of the nervous system to control that force

The assessment may examine:

The ability to activate the muscle
The strength throughout the various ranges of movement
The control of the trunk
The difference between the two sides
The ability to separate movements
The coordination between joints
Repeated movement and fatigue
The control of the arm and the hand
Grasping and releasing an object

What is found should be connected with the functioning. Reduced control of the ankle may affect the lifting of the foot while walking, while limited opening of the hand may disturb hygiene, dressing, or holding objects

The tone of the muscles is the basic resistance that exists when the muscle is moved. Some states of the nervous system make increased tension arise, while some states make the tone low and make it difficult to support or activate the area that has been affected

The team may assess whether the tone of the muscles gives rise to pain, limits movement, or disturbs standing, walking, arranging the posture, dressing, or caring for oneself or not. The tone should not be treated separately from the context. The intervention should support meaningful functional goals

The assessment of the upper arm and the hand

The functioning of the arm and the hand is more than raising the arm on the side that has been affected

The assessment may consider:

The position of the shoulder and the pain
The movement of the elbow, the wrist, and the fingers
The tone of the muscles and the sensation
Coordination
Reaching
Grasping and releasing
Using both hands together
The participation of the arm on the side that has been affected in daily activities

The result helps set whether the treatment should give importance to arranging the posture, movement with an assistant, the prevention of pain, opening the hand, strengthening, training in doing activities, or compensating strategies

A robotic system for the upper arm may support repeated practice for selected patients, but it should be used only when there is a clinical and functional purpose that has been set clearly

The assessment of cognition, communication, and swallowing

A state of the nervous system may affect abilities that may not appear clearly in a short conversation

Cognition and perception

The assessment may consider:

Concentration and memory
The perception of the day, the time, the place, and the person
Planning and problem-solving
Making decisions
The ability to follow commands
The awareness of the limitations
The recognising of objects and of space
The awareness of one side of the body
The ability to carry out a sequence of movements once learned

These abilities directly affect the physical restoration. A patient may have enough strength to stand, but not be able to remember the recommendations in respect of safety or perceive obstacles consistently

Speech and communication

The assessment of communication may examine:

The understanding of questions and commands
The ability to communicate basic needs
The recall of words
The clarity of the speech and the voice
Reading and writing when relevant
The use of gestures or of a device to help communication
The effect on making decisions and on participation in daily life

The result may affect the way in which every member of the team of restoration communicates with the patient. It may be necessary to shorten the commands, demonstrate, repeat, or supplement with visual cues

Swallowing and eating

Some neurological patients have a state of difficulty in swallowing, or dysphagia. The concerns that may be met are coughing or choking during meals, a changed voice after drinking water, food remaining in the mouth, difficulty managing saliva, or taking an abnormally long time to eat

It may be necessary to assess the swallowing before adjusting the texture of the food, the thickness of the drinks, the arranging of the posture, or the strategies of feeding. The family should not adjust the existing recommendations on swallowing by themselves without receiving advice from a specialist who has been suitably trained. The NICE guideline on restoration after cerebrovascular disease (opens in a new tab) also lays down that a state of difficulty in swallowing must receive an assessment and be followed by a specialist who has suitable skills

The assessment of the daily routine

The most important question is usually not whether the patient can do the movement during the examination or not, but whether they can take that ability to be used in daily life or not

An occupational therapist may assess:

Eating food and drinking water
Dressing and grooming
Bathing and using the bathroom
Using the telephone
Movement inside the house
Managing the wheelchair
Doing simple housework
Participation in family or working roles

The therapist considers whether the patient needs to restore the original skill, compensating strategies, equipment, adjustment of the environment, or help from a carer or not

How the assessment shapes the form of the programme of recovery

After the assessment, the multidisciplinary team gathers what has been found into a single coordinated plan

The programme may set:

Functional goals in the short term and the long term
The frequency and the intensity of the treatment
The fields of restoration that are necessary
The precautions in respect of safety and the assistive equipment
Whether a robot or other technology may support the training or not
The adjustment of the communication or of the cognition
The giving of knowledge to the carer
The results that will be assessed again
The activities that will be continued outside the formal periods of therapy

The goals should be specific and meaningful. Instead of aiming merely to "increase the strength", the programme may aim for transferring the body using less help, walking to the bathroom safely, opening the hand in order to clean it, sitting to eat food without needing support, communicating basic needs, or dressing while needing to be told less

Formal measurement sets the baseline information, but the progress should also be considered from what the patient can do more safely and more independently in daily life. The guidelines of neurological physiotherapy (opens in a new tab) recommend recording the goals that the patient identifies and using standard measures that suit the ability and the goals, not using every test with everyone

Who may take part in the assessment

The assessment may involve a physician of rehabilitation medicine or a neurologist, a physiotherapist, an occupational therapist, a speech correction specialist, a nurse of restoration, a psychologist or neuropsychologist, a dietitian, an orthotist, a specialist in the social field, and family members or the carer whom the patient chooses, depending on the needs

The team should connect what is found medically and neurologically with movement, balance, the working of the arm, cognition, communication, swallowing, the routine, mental well-being, the environment, and the personal goals. Not everyone needs every field, test, or technology. The choice should match the clinical question, the ability, the safety, the needs, and the effect it may have on the plan of care

Beginning with clear baseline information in respect of functioning

The restoration of the nervous system should not begin from a list of instruments or a standard set of exercises. It should begin from a clear understanding of the state of the patient, the current ability, the needs in respect of safety, the limitations in daily life, and what they give importance to

The assessment by a multidisciplinary team gives the baseline information necessary for choosing the treatment that is suitable, setting goals that are real, and measuring whether the restoration brings about a meaningful functional change or not

Patients and families can prepare themselves by bringing the medical records that are relevant and explaining which activities at present need help. After that the clinical team can set which assessments must be used and how the programme of recovery should be adjusted specifically to the individual