Neurological physiotherapy assessment: what to record, and why

Neurological rehabilitation, for stroke, Parkinson's disease, spinal cord injury, multiple sclerosis, head injury and peripheral nerve conditions, depends on an assessment that looks at the whole person moving, not one joint. This is what to record, section by section, and why each part matters.

Patient and condition

• diagnosis and date of onset or of the event (for example, the date of the stroke)

• side affected, and whether it is the dominant side

• investigations and the medical team's notes, if available

• medicines, especially those affecting tone, alertness or blood pressure

• other conditions: diabetes, heart disease, vision or hearing problems

History

• what happened, and the course since: improving, stable, or worsening

• previous level of activity and independence

• home: stairs, bathroom, who lives with the patient and who helps

• the patient's and family's goals, in their words

Consciousness, communication and cognition

• alert, drowsy, or fluctuating

• able to follow one-step and multi-step commands

• speech and understanding

• memory, attention and safety awareness

These decide how you teach exercises and how much a carer needs to be involved.

Vital signs and safety

Blood pressure and heart rate at rest and with activity, especially after a stroke, and any history of falls.

Tone

Assess tone in each limb at rest and on movement. Use a recognised scale such as the Modified Ashworth Scale for spasticity, and note rigidity or reduced tone. Record which muscle groups and which side.

Power and range

Muscle power graded for the main groups on both sides, and passive range of motion, especially at the shoulder, ankle and hand, where stiffness and contractures develop.

Sensation

Light touch, pain, temperature, joint position sense and vibration, by area. Loss of position sense changes how a patient balances and walks.

Coordination

Finger to nose, heel to shin, rapid alternating movements. Record speed and accuracy on each side.

Balance

Sitting balance, then standing balance with eyes open and closed, and reactions to a nudge. A recognised balance scale gives you a number to track.

Transfers and mobility

• rolling, lying to sitting, sitting to standing

• transfers from bed to chair and onto the toilet

• level of help needed for each: independent, supervision, one person, two people

Gait

Walking aid, distance, speed, quality and safety. Note specific features such as foot drop, circumduction or a shuffling, festinating gait. A timed walk over a fixed distance is easy to repeat.

Upper limb function

Reach, grasp, release and fine movements such as buttoning or writing.

Function and independence

Daily activities: eating, dressing, washing, toileting. A recognised index of independence helps you and the family see progress.

Assessment and goals

• the main problems in order of importance

• short-term goals for the next two to four weeks, and long-term goals

• goals written so they can be checked, for example "walk to the bathroom with a stick and supervision"

Plan

Treatment approach, home programme for the patient and carer, equipment needed, how often you will see the patient, and when you will reassess.

Recording it in PhysioDesk

• Open a diagnosis for the neurological condition on the patient's record.

• Write the assessment in the first session note (subjective, objective, assessment, plan).

• Record measures such as walking distance, balance or strength as progress measures, so each reassessment is charted against the first.

• Book repeat sessions at home or in the clinic in one step, daily, on alternate days or on chosen weekdays.

• Prescribe the home programme so the patient and their family see it on their phone.

• Record consent, noting when a family member or carer signed for the patient.

See it in the 30-minute demo from the pricing page.