Neurological Assessment
- Fysiobasen
- Oct 5
- 11 min read
A thorough neurological assessment is essential to provide optimal care and plan effective rehabilitation. This is the most critical step in the rehabilitation process, as it guides clinical reasoning and supports informed decisions about the patient’s recovery.
Johnson & Thompson (1996) emphasized that treatment can only be as effective as the assessment on which it is based⁽¹⁾.
To develop and manage a treatment plan while identifying the patient’s problems, the assessment must be a continuous and ongoing process.
Purpose of Neurological Assessment
A neurological assessment focuses on examining the nervous system to identify abnormalities that affect function and activities of daily living. It provides the foundation for setting patient-centered goals and developing a tailored treatment plan based on individual needs.
To perform a systematic and comprehensive neurological assessment, the SOAP format (Subjective, Objective, Assessment, Plan) can be used as a structured guide.Below is a systematic approach to evaluating neurological patients.
Subjective Assessment
The subjective assessment provides a detailed picture of how the patient’s current condition affects their daily life and functional abilities⁽²⁾.This phase is a vital source of information that forms the foundation for the objective examination and the treatment plan.
When evaluating a patient in a physiotherapy context, detailed information must be collected to gain a comprehensive understanding of their situation. Each category of data helps build an accurate clinical profile of the patient’s health, challenges, and rehabilitation potential.
Demographic Data
Name: Ensures correct identification and fosters a personal connection between therapist and patient.
Age: Provides insight into age-related health conditions such as osteoarthritis in older adults or growth-related issues in younger patients.
Gender: Some conditions are more prevalent in one sex, e.g., hip instability in women or certain sports injuries in men.
Occupation: Indicates occupational strain, posture demands, and repetitive stress factors such as repetitive strain injury among office workers.
Dominant hand: Helps identify functional challenges, especially in upper limb impairments.
Address: Useful for planning home-based exercises or evaluating access to rehabilitation services.
Why this matters: These data provide essential context about risk factors and daily physical demands that may affect health and recovery.
Chief Complaint
What is the main problem? The patient’s primary concern defines the focus of the entire evaluation and ensures the treatment addresses what the patient perceives as most important.
Why this matters:Identifying the main complaint ensures treatment is aligned with the patient’s goals and priorities.
History of Present Condition
Progression: Understanding how symptoms have evolved helps distinguish between acute and chronic conditions.
Onset date: Determines whether the condition is acute, subacute, or chronic.
Previous treatments: Provides insight into what has been tried and which interventions have or have not been effective.
Why this matters: A detailed understanding of the condition’s course is crucial for identifying potential causes and planning effective interventions.
Past Medical History
Comorbidities: Other health conditions (e.g., diabetes) can affect prognosis and treatment tolerance.
Surgeries: Prior operations may result in lasting anatomical or functional changes.
Medications: Current medication use can explain symptoms or influence exercise tolerance.
Why this matters: Knowledge of the patient’s medical background helps identify risk factors, contraindications, and influences on recovery.
Personal History
Comorbidities: Other health conditions (e.g., diabetes) can affect prognosis and treatment tolerance.
Surgeries: Prior operations may result in lasting anatomical or functional changes.
Medications: Current medication use can explain symptoms or influence exercise tolerance.
Why this matters: Knowledge of the patient’s medical background helps identify risk factors, contraindications, and influences on recovery.
Personal History
Marital status and social network: Offers insight into emotional and practical support systems.
Daily routines and hobbies: Reveals activities most important for independence and rehabilitation goals.
Why this matters: Understanding the personal context enables truly individualized rehabilitation and strengthens patient engagement.
Mobility
Indoor and outdoor mobility: Assesses independence and the need for assistive devices.
History of falls: Identifies safety risks and the need for preventive measures.
Why this matters: Mobility assessment helps determine the patient’s functional level and potential risk of further injury.
Additional Factors
Vision and hearing: Affect participation in therapy and comprehension of instructions.
Pain: Baseline pain mapping helps evaluate treatment effectiveness.
Expectations: Understanding the patient’s goals encourages shared decision-making.
Why this matters: These factors ensure treatment is appropriately tailored to the patient’s specific needs and expectations.
Socioeconomic History
Income sources: Determines access to care, medication, and equipment.
Community involvement: Reveals social support and available local resources.
Family support: Identifies caregivers who can assist with daily activities.
Housing situation: Provides insight into physical barriers (stairs, narrow spaces) that may require modification.
Why this matters: Socioeconomic context influences compliance, accessibility, and long-term treatment success.
Objective Assessment
Once the subjective evaluation is complete, it directs the focus of the objective examination.A detailed and structured objective assessment is essential to create an individualized treatment plan that addresses the patient’s unique presentation and goals.
Observation
General Appearance
Overall health and alertness.
Posture and muscle tone.
Symmetry of facial and body movements.
Gait Analysis
Observe gait pattern and rhythm.
Note asymmetry, limp, or compensatory movements.
Movement Pattern
How the patient performs activities such as standing up or bending forward.
Identify abnormal or restricted movement patterns.
Respiratory Pattern
Observe breathing rate, rhythm, and accessory muscle use.
Note any dyspnea or irregular respiration.
Edema
Location and severity, often in lower limbs.
May indicate circulatory or venous insufficiency.
Muscle Atrophy
Identify wasting in specific muscle groups suggestive of inactivity or neural involvement.
Pressure Sores
Check skin integrity, especially in immobile patients.
Assistive Devices
Observe use of orthoses, splints, or other aids.
Involuntary Movements
Note tremors, clonus, or chorea indicating possible neurological dysfunction.
Posture and Balance Tests
Limb alignment and posture: Assess the ability to maintain proper alignment in sitting and standing.Look for neglect or asymmetry, especially in stroke patients.
Sitting balance: Test ability to maintain upright posture without external support.
Standing balance: Observe static and dynamic balance control.
Vital Signs
Respiratory rate: Detects breathing irregularities.
Body temperature: Reveals infection or fever.
Pulse: Assesses rhythm, rate, and strength.
Blood pressure: Evaluates cardiovascular stability.
Oxygen saturation (SpO₂): Indicates oxygen delivery efficiency.
Clinical significance:These measurements provide essential information about the patient’s physiological stability and overall health status, guiding safe and effective rehabilitation.
Importance of Observation and Vital Signs
Observation and vital sign monitoring give the therapist a comprehensive understanding of the patient’s condition.They serve as a baseline for comparison, enabling measurement of progress and treatment effectiveness over time.
Examination: Cognitive and Higher Mental Functions
A thorough examination of cognitive and higher mental functions provides valuable insight into a patient’s ability to communicate, process information, and perform activities of daily living. This is especially important in neurological conditions, where changes in cognition and perception can influence the rehabilitation process
Higher Mental Functions
1) Level of Consciousness
Glasgow Coma Scale (GCS): Assesses eye opening, verbal response, and motor response.
Scale: 3–15, with higher scores indicating better function.⁽⁵⁾
2) Communication
Aphasia subtypes:
Broca’s aphasia: Non-fluent output; comprehension relatively preserved.
Wernicke’s aphasia: Fluent but meaningless speech; impaired comprehension.
Global aphasia: Combined deficits in expression and comprehension.
3) Cognition (screen each domain below)
Orientation: Person, place, time.
Calculation: Basic arithmetic tasks.
Registration: Ability to encode and store new information.
Attention: e.g., digit span, sustained focus on a simple task.
Proverb interpretation: Tests abstract reasoning.
Memory:
Immediate memory: Repeat recently presented items.
Recent memory: Recall of events from the last hours/days.
Remote memory: Biographical or long-past events.
Language: Comprehension and expression (naming, repetition, fluency, following commands).
Visuospatial skills: Spatial relations; drawing or figure copy.
Supplementary Cognitive Screens
Mini-Mental State Examination (MMSE): Orientation, memory, attention, language, visuoconstruction.
Mini-Cog: Three-word recall + clock drawing.
Montreal Cognitive Assessment (MoCA): Broad screen sensitive to mild cognitive impairment.
Perception
Body schema & body image: Awareness of body parts and their position.
Neglect: Failure to attend to one side of body/space.
Agnosia: Inability to recognize objects, sounds, or people despite intact sensation.
Apraxia: Impaired ability to carry out purposeful movements despite normal strength.
Perceptual Tests
Star Cancellation Test: Screens for visuospatial neglect.
Line Bisection Test: Midpoint judgment of a drawn line.
Clock Drawing Test: Assesses visuospatial ability, planning, and memory.
Clinical relevance: Identifying cognitive and perceptual limitations enables individualized treatment plans and supports more effective rehabilitation and functional recovery.
Betydningen av Kognitiv og Persepsjonell Undersøkelse
Ved å identifisere kognitive og perseptuelle begrensninger, kan terapeuten utvikle individualiserte behandlingsplaner som adresserer pasientens spesifikke utfordringer. Dette sikrer en mer effektiv rehabilitering og optimal funksjonsgjenvinning.
Examination of Cranial Nerves (CN)
A structured cranial nerve exam is key to evaluating brainstem and cortical function. (Test each nerve I–XII systematically where indicated by history and presentation.)
Note: The following sensory and motor sections complement CN testing and capture somatosensory and motor pathway integrity.
Neurological Examination: Sensory, Motor, and Reflexes
Sensory Examination
Superficial Sensation
Pain (sharp/dull): Discriminate noxious vs. non-noxious stimuli.
Temperature: Warm vs. cold stimulus.
Light touch: Cotton or soft brush.
Deep pressure: Firm palpation to assess pressure sense.
Deep Sensation (Proprioception)
Kinesthesia (movement sense): Detect passive movement.
Joint position sense: Identify final joint position with eyes closed.
Vibration: 128-Hz tuning fork over bony prominences.
2. Cortical (Discriminative) Sensation
Tactile localization: Identify the location touched.
Two-point discrimination: Minimal separation perceived as two points.
Stereognosis: Identify objects by touch.
Barognosis: Discriminate small weight differences.
Graphesthesia: Recognize numbers/letters traced on skin.
Texture recognition: Differentiate surface qualities.
Double simultaneous stimulation: Detect bilateral, simultaneous touch.
3. Motor Examination
Tone
Reduced/flaccid: Hypotonia.
Increased (hypertonia):
Spasticity: Velocity-dependent “clasp-knife” phenomenon.
Rigidity: Uniform resistance (e.g., “lead-pipe,” “cogwheel”).
Outcome measures:
Modified Modified Ashworth Scale (MMAS): Spasticity grading.
Tardieu Scale: Muscle response at different stretch velocities.
4. Range of Motion (ROM)
Document active and passive ROM; note end-feel and any pain/limits.
5. Strength
Manual Muscle Testing (MMT) and/or myotomal assessment where indicated.
6. Endurance
Muscular endurance: Ability to sustain force/repetitions.
Cardiorespiratory endurance: Functional tasks or standardized tests.
Reflexes
eep Tendon Reflexes (DTRs):
Biceps (C5/6)
Triceps (C7/8)
Knee—Patellar (L3/4)
Ankle—Achilles (S1/2)
Pathological Reflex
Plantar response (Babinski): Great toe dorsiflexion ± toe fanning suggests pyramidal tract dysfunction.
Clinical significance: DTR asymmetry or hypo/hyperreflexia localizes to segmental/peripheral vs. central lesions and informs further testing and imaging.
Muscle Tightness and Limb Measurements
Muscle Tightness / Length Testing
Rationale: Identifies mobility restrictions and functional limitations that hinder daily activity; guides targeted intervention.
Limb Length Measurement
True length: e.g., ASIS → medial malleolus.
Apparent length: Captures discrepancies due to alignment/posture.
Girth (circumference): Monitors edema or atrophy.
Balance Assessment (Static and Dynamic)
Outcome measures:
Berg Balance Scale: Multi-task assessment of static/dynamic balance.
Timed Up and Go (TUG): Timed functional mobility and fall risk.
BESTest: Comprehensive balance assessment (biomechanical constraints and sensory strategies).
Coordination
Equilibrium: Tester for postural kontroll i oppreist posisjon.
Non-equilibrium: Tester bevegelseskoordinasjon når pasienten sitter eller ligger.
Rombergs test: Evaluerer balanse og propriosepsjon med pasienten stående, både med åpne og lukkede øyne.
Equilibrium coordination: Postural control in standing.
Non-equilibrium coordination: Limb coordination in sitting/supine (e.g., finger-to-nose, heel-to-shin).
Romberg Test: Feet together; eyes open/closed—screens proprioceptive dependence.
Gait Analysis
Step length: Heel strike to next ipsilateral heel strike.
Stride length: Heel strike of one foot to heel strike of the same foot.
Base of support: Inter-heel midpoint distance.
Cadence: Steps per minute.
Biomechanical deviations: Identify compensations and phase-specific abnormalities.
Functional Domains
ADL (Basic Activities of Daily Living)
Feeding, dressing, bathing, personal hygiene.
IADL (Instrumental Activities)
Mobility, cooking, cleaning, shopping, financial management.
Education/Work
Academic/vocational functioning and accommodations needed.
Leisure and Play
Social participation and engagement in meaningful activities.
Sleep/Rest
Sleep hygiene and routine; impact on recovery.
Patient Factors
Values: Drive priorities and shared goals.
Beliefs: Influence engagement with rehabilitation.
Spirituality: May affect coping and psychosocial outlook.
Performance Patterns
Habits: Repetitive behaviors affecting health.
Roles: Life roles that shape goal setting.
Rituals: Cultural/personal practices relevant to care.
Systems Review
Skin: Integrity, pressure injuries, wounds.
Respiratory: Work of breathing, secretions, deformities.
Cardiovascular: DVT status, circulation.
Musculoskeletal: Contractures, subluxations, joint mobility.
Bowel/Bladder: Continence and autonomic function.
Autonomic: Vasomotor/sudomotor abnormalities.
Functional Outcome Measures
Functional Independence Measure (FIM): Global independence.
Modified Barthel Index: ADL performance.
Canadian Occupational Performance Measure (COPM): Patient-centered goals (performance & satisfaction).
Berg Balance Scale: Balance ability.
Kohlman Evaluation of Living Skills (KELS): Essential living skills.
Assessment
An assessment is a comprehensive process involving a systematic evaluation of the patient’s problems and an analysis of how these affect function and quality of life. The goal is to establish a detailed problem list, formulate a functional physiotherapy diagnosis, and develop an integrated treatment plan based on the patient’s needs, priorities, and goals.
Problem List
The problem list is a central element of the assessment process, providing a structured approach to identify and prioritize the patient’s difficulties. Problems should be classified according to the International Classification of Functioning, Disability and Health (ICF) — a framework developed by the World Health Organization (WHO) to understand health and function.
Components of a Problem List
Body Functions and Structures:
Identify physical or physiological impairments such as muscle weakness, reduced joint mobility, pain, spasticity, or sensory loss.
Assess anatomical changes such as swelling, deformities, or contractures.
Activities:
Determine which daily activities the patient struggles with (e.g., walking, dressing, eating, or standing up).
Quantify limitations using time taken, assistive device use, or degree of dependence.
Participation:
Describe how health problems limit social participation, work, leisure, or family engagement.
Assess environmental barriers such as inaccessibility or lack of support.
Personal Factors:
Include psychological or emotional aspects such as fear of movement, low motivation, or negative treatment expectations.
Consider cultural and individual preferences that influence rehabilitation.
Environmental Factors:
Identify environmental barriers and resources, such as family support, housing conditions, and healthcare access.
Physiotherapy / Functional Diagnosis
A physiotherapy diagnosis differs from a medical diagnosis by focusing on impairments, activity limitations, and participation restrictions rather than the underlying pathology. The diagnosis should be specific, functional, and based on a holistic assessment.
Elements of a Functional Diagnosis
Main Problem:
Summarize the primary complaint, such as pain during walking or impaired balance.
Causative Factors:
Identify underlying contributors, e.g., quadriceps weakness causing difficulty with stair climbing.
Functional Impact:
Explain how the problem limits the patient’s ability to perform daily tasks or activities.
Prognosis:
Outline what is realistically achievable through treatment, including expected timeframes and influencing factors.
Plan
The treatment plan serves as a roadmap for physiotherapy intervention. It should be goal-oriented, flexible, and adjustable as the patient progresses.
Elements of the Treatment Plan
Goals:
Short-Term Goals: Achievable within a few weeks (e.g., pain reduction, improved balance).
Long-Term Goals: Broader objectives that may take months (e.g., return to work or resuming social participation).
Interventions: Specify the therapeutic approaches to be used, such as:
Joint mobilization to improve range of motion.
Strength training to enhance muscular capacity.
Balance exercises to reduce fall risk.
Patient education on ergonomics or activity modification.
Follow-Up and Evaluation:
Schedule regular reassessments to monitor progress and adjust interventions accordingly.
Patient Involvement:
Engage the patient in goal setting and planning.
Encourage self-management through home exercise programs or progress tracking.
Interdisciplinary Collaboration:
When relevant, include cooperation with other healthcare professionals (e.g., occupational therapists, physicians, social workers) for a holistic approach.
Re-Evaluation
Re-evaluation is an essential part of the rehabilitation process, involving repeated measurements and observations to assess patient progress. It determines whether goals have been achieved and whether interventions require modification for optimal outcomes.
Elements of Re-Evaluation
Re-testing of Objective Measures:
Compare outcome tools and data from the initial assessment (e.g., balance, strength, or pain intensity).
Progress Analysis:
Identify areas of improvement and persistent challenges.
Assess whether initial goals have been achieved or require revision.
Barriers and Facilitators:
Evaluate factors influencing progress, such as motivation, engagement, environmental conditions, or new medical issues.
Reinforce facilitators that support continued improvement.
Communication:
Share re-evaluation results with the patient, family, and healthcare team.
Compare current findings with baseline data to visualize progress.
Future Planning:
Adapt treatment strategies based on current status.
Establish new short-term and long-term goals tailored to the patient’s updated condition.
Re-evaluation should be a continuous, dynamic process. Regular follow-up strengthens patient trust, enhances collaboration, and ensures treatment remains targeted, effective, and personalized.
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