STARES REFLECTION 3 - assessment

SITUATION
During the last couple of weeks at The Centre for Cerebral Palsy (TCCP) I have been responsible for the physiotherapy management of a school aged client. I have been visiting the client twice a week at his school to conduct my physiotherapy intervention. The client is a 15 year old male adolescent. He has a diagnosis of spastic diplegia, Cerebral Palsy (GMFCS level II). This client has recently undergone multilevel surgery four months ago. This procedure involved bilateral lower limb surgery to correct the client’s abnormal right foot position, abnormal lower limb alignment and abnormal pelvic positioning. Currently the client is very weak in both his lower limbs and has decreased cardio respiratory fitness. At present, the primary aims of his physiotherapy intervention are to improve the client’s lower limb strength and cardio respiratory fitness in order to achieve his short term goal of walking ‘more normally’ over long distances (i.e. between classes at high school) without his axillary crutches. I am primarily interested in strengthening quadriceps, hamstrings, hip abductors, hip flexors and hip extensors to improve his aberrant gait pattern. The client ambulates with bilateral AFO’s therefore it is less important to strengthen the ankle musculature.

TASK
The task that I was required to undertake involved choosing and performing appropriate outcome/objective measures for this client’s lower limb strength. Choosing good measures would provide me with a baseline measurement, allow me to track the client’s progress and judge the efficacy of my interventions.

ACTION
To objectively measure the clients lower limb strength I decided to use handheld dynamometry, and in addition his max RM on the leg press machine. This was the first time that I was going to use the handheld dynamometer in the clinical environment so I thought that it would also be a very useful learning experience for me. I decided to complete my objective measurements at the beginning of the physiotherapy session because I wanted to standardise the measurements and furthermore I did not want any exercise to impact on the results of the test.

I began the session by explaining the procedure of handheld dynamometry and providing a demonstration with my supervisor. I then demonstrated the test procedure on the client’s biceps (elbow flexion) because this is a very simple muscle to isolate and learn about an isometric muscle contraction. Following the demonstration I began the measurements I had planned including hip flexion, knee flexion, knee extension and hip abduction. I tested the clients left and right side for the above measurements. Finally I finished my objective assessment with measuring his max RM on the leg press machine.

RESULTS
At the end of my objective assessment I was confident that I had chosen and completed two very appropriate outcome measures for my client’s lower limb strength. The handheld dynamometry was extremely useful because it provided me with a baseline measure on the left and right for hip flexion, knee flexion, knee extension and hip abduction. These measurements will be very useful for me to track the client’s progress and to judge the efficacy of my physiotherapy intervention. In particular the handheld dynamometry was able to identify which muscles were particularly weak on the one side compared to the other. For example, knee flexion (hamstrings), knee extension (quadriceps) and hip abductors were much weaker on the right compared to the left. This signals to me that these muscles need to become a higher priority to improve when planning my next intervention. Finally whilst the clients max RM on the leg press machine is a very simplistic measure I believe that it is very important in order to gauge the overall or combined strength of his lower limbs. In order to standardise this test I noted that the client was wearing his AFO’s during the test.

EVALUATION
Initially to measure lower limb strength I was tempted to use the Oxford scale which is a very commonly used tool at TCCP. I did not want to use the oxford scale because it would not give me enough detail considering that small improvements in this client’s lower limb strength would help him achieve his goals. Furthermore the Oxford Scale would not allow me to effectively compare left and right. I was extremely lucky at TCCP because they had the resources that allowed me to choose two more advanced objective measures. In different setting I may have not had access to handheld dynamometer or leg press machine.

A weakness of my objective assessment that I would like to reflect on is the testing procedure for handheld dynamometry. I should have been prepared before the beginning of the assessment with my testing procedure. Firstly I should have prepared standardised patient positions for each of the movements tested so that I did not have to come up with them on the spot. Secondly I should have decided before the beginning of the test how many repetitions of movement I should have completed and whether I was going to accept an average or the highest score. Thirdly I should have considered which body segments on the client the physiotherapist needed to stabilise in order to isolate the required movement or muscle contraction. Finally another consideration I should have thought about is which angle to perform the isometric contraction and how to standardise this procedure.

Overall I thought that the testing procedure was fairly good and I was able to obtain my results in a fairly standardised fashion. I recorded the results in the client’s progress notes, including the procedure for each movement tested. At the end of the testing procedure I discussed with the client how the tests are going to be very useful in order to track his progress and any improvements in muscle strength. I think that using this outcome measure as a motivating and goal setting tool for this client will also be very useful idea to implement.

STRATEGIES
During my handheld dynamometry I realised that the therapist instructions needed to be very simple and clear. The client was an appropriate participant for handheld dynamometry but I can understand it would be very difficult to test on other patients that are not compliant with the test procedure and do not understand the therapist instructions. I believe I could improve my instructions and communication by considering how the client might best understand me before the beginning of the assessment and catering to their particular needs. Furthermore in future it would be very beneficial having two therapists available to perform the assessment because one therapist can position the patient correctly and isolate the movement, whilst the other therapist can perform the measurements and record the results.

In future, before I began the test procedure I would like to trial it on a ‘dummy’. This would be a very useful strategy because I would be able to identify problems that should be considered with the test procedure before I am required to effectively complete the real test. Being prepared means that I would need to spend less time on the objective assessment, and therefore have more time available to implement my intervention.

Following completion of this task I would like to take on a small project. I would like to prepare a simple pamphlet so that other novice users of the handheld dynamometer are able to confidently use the tool to assess lower limb strength of children with Cerebral Palsy at TCCP. If I had a resource available to me simply detailing the test procedure, I would have been much more confident using the handheld dynamometer for the first time and subsequently may have achieved far more accurate results. I would also like to include in the pamphlet some normative values for muscle strength of the main muscles groups of the lower limb in the average healthy adolescent of different ages. I think this would be extremely useful but I am not sure if any evidence is available. Finally it would be useful to have some values that indicated what a meaningful increase in muscle strength would be, because it would allow the physiotherapist to draw more firm conclusions about the progress of the patient and the efficacy of the treatment.