Assessment of Children With Moderate to Severe TBI
Physical Measurements for TBI Evaluation
Functional Mobility
Assessed through observation of the
following:
- Mobility: rolling, crawling, & walking;
- Bed Mobility: rolling, supine to sit;
- Transitions: supine to sit, sit to 4-point (hands & knees)
position, sit to stand, pivot transfers, floor to stand via kneel and/or half
kneel position, transfers to/from toilet and bathtub, etc.
- Ambulation: Physical therapists analyze a child's gait pattern and
compare it to the normal gait cycle. A child with deficits in strength or
balance may require use of an assistive device during gait i.e.crutches or a
walker. Higher level gait activities such as galloping skipping, running,
hopping, jumping, and stair skills are assessed as appropriate. The need for
assistive device is assessed with concerns for safety or endurance/distance with
ambulation.
- Wheel Chair Mobility: Due to functional deficits a child may require
the use of a wheelchair temporarily or for a prolonged period of time. The
therapist would assess child's ability to do the following:
- Propel the wheelchair
- Maneuver in confined areas
- Maneuver up and down curbs and ramps
- Transfer in and out of wheelchair
Adaptive
Equipment
- The need for adaptive equipment is assessed through observation of a child's
performance of Activities of Daily Living (ADL's) and interview of the parent
and/or child. Depending on the extent and location of the child's brain injury,
various types of equipment may be helpful for the child to function as
independently as possible. Secondary to deficits with safety and awareness, a
toilet safety frame, shower or tub bench, and/or grab bars may be needed to
increase independence in the bathroom. If the child has physical limitations,
additional bathroom equipment including a long-handled sponge, soap on a string
and reacher may be of assistance. Equipment to assist with dressing may include
a reacher, sock-aid, long-handled shoe horn, velcro fasteners for shoes, shirts,
etc. Examples of adaptive equipment for feeding include utensils with built-up
handles or straps on the handle to secure them to the hand, long-handled
utensils, dishes/plates with raised edges and/or suction cups to secure them to
the table, cups with lids and/or spouts, straws, etc. (Case-Smith, Allen, &
Pratt, 1996).
- It may also be necessary to access the need for a device used during
ambulation and transfers to improve balance, efficiency and safety. Examples
are: walker, crutches, etc.
Positioning
- Splinting/orthotics: may be necessary to ensure proper alignment and
joint mobility, to prevent or reduce contractures, foot drop, and/or abnormal
patterns of muscle tone. The goals of splinting and casting are to decrease
abnormal tone and increase the child's functional movement; therefore, they
require frequent adjustment. Education regarding wearing schedule and skin
breakdown prevention is essential (Trombly,
1995).
- Seating System: Assessment includes initial measurements as well as
monitoring adequate fit and pressure relief. One must ensure education for
wheelchair parts management.
Adaptive Equipment
- The need for adaptive equipment is assessed through observation of a child's
performance of Activities of Daily Living (ADL's) and interview of the parent
and/or child. Depending on the extent and location of the child's brain injury,
various types of equipment may be helpful for the child to function as
independently as possible. Secondary to deficits with safety and awareness, a
toilet safety frame, shower or tub bench, and/or grab bars may be needed to
increase independence in the bathroom. If the child has physical limitations,
additional bathroom equipment including a long-handled sponge, soap on a string
and reacher may be of assistance. Equipment to assist with dressing may include
a reacher, sock-aid, long-handled shoe horn, velcro fasteners for shoes, shirts,
etc. Examples of adaptive equipment for feeding include utensils with built-up
handles or straps on the handle to secure them to the hand, long-handled
utensils, dishes/plates with raised edges and/or suction cups to secure them to
the table, cups with lids and/or spouts, straws, etc. (Case-Smith, Allen, &
Pratt, 1996).
- It may also be necessary to access the need for a device used during
ambulation and transfers to improve balance, efficiency and safety. Examples
are: walker, crutches, etc.
Standardized Assessments
(can be used to monitor progress, identify deficits or qualify for
services):
- AIMS: Gross motor tool which is standardized for children 0-19
months.
- Bayley Scales of Infant Development – Second Edition: This assessment
may be used to evaluate gross-motor, fine-motor, cognitive, language and social
skills of children ages 1 month to 42 months. Time for administration depends on
the age of the child, ranging from 25 to 60 minutes. The test contains 3
complimentary scales: motor scale, mental scale, & behavior rating scale (Bayley,
1993).
- Peabody Developmental Motor Scales (PDMS): This assessment is an
individually administered standardized test that measures gross and fine motor
skills of children from birth to 83 months. Fine motor scale consists of tasks
that require precise movement of the small muscles of the body. Skills are
classified into four categories including: grasping, hand use, eye-hand
coordination, and manual dexterity. Gross motor scale consists of tasks that
require large motor movement and are classified into five skill categories
including: reflexes, balance, non-locomotor, locomotor, and receipt and
propulsion of objects. This test can be administered to a child in approximately
45 to 60 minutes (Folio & Fewell,
1983).
- Bruininks-Oseretsky Test of Motor Proficiency (B & O): This is a
test of gross-motor, upper limb coordination, and fine-motor abilities
standardized for children between the ages of 4 ½ to 14 ½ years of age. Each
area of motor functioning is divided into specific key subtests. Subtests
include: running speed and agility, balance, bilateral coordination, strength,
upper-limb coordination, response speed, visual-motor control, and upper-limb
speed and dexterity. The test allows flexible administration, with the option to
complete all subtests for a battery composite or the option to obtain a
fine-motor or gross motor composite separately. Scores include point score,
standard score, percentile rank, stanine, and age-equivalency. Administration
time for the complete test is approximately 45 to 60 minutes when performing the
entire test and 15-20 minutes when administering the short form (Bruininks,
1978).
- Motor-Free Visual Perception Test – Revised (MVPT-R): This test is a
test of visual perception that avoids any motor involvement. The benefit of a
visual-perception test that does not require motor activity is to separate a
motor problem from influencing the results of a visual skills test. The MVPT-R
was devised for children from 4 to 11.6 years of age. Visual perception is
categorized into the following 5 types: spatial relationships, visual
discrimination, figure-ground, visual closure, and visual memory (Colarusso &
Hammill, 1996).
- The Berry-Buketenica Developmental Test of Visual-Motor Integration
(VMI): This assessment examines the developmental sequence of geometric
forms to be copied with pencil and paper. The full, 27-item VMI can be
administered to individuals or to a group in approximately 10-15 minutes. A
short, 18-item version is available for ages 3-7 years. The full 27 item VMI can
be used for individuals aged 7 through adult. The VMI is designed to assess the
extent to which children can integrate their visual and motor abilities (Berry,
1997).
Non-Standardized Assessments &
Observations
PEDI: Used to assess motor, adaptive, cognitive and social skills of
community function.
Range of Motion (ROM): Goniometric measurements are taken initially to
establish a baseline. An appropriate size goniometer should be utilized for
large and small joints to obtain an accurate measurement. When measuring
children with increased muscle tension or tone, general relaxation should be
utilized prior to measurement to reduce potential pain and to ensure
documentation of the child's maximum available range. When recording information
it is important to take in to consideration the amount of Active Range of Motion
(AROM), Passive Range of Motion (PROM), or Active Assist Range of Motion (AAROM)
the patient is able to achieve. Precautions to consider include, but are not
limited to: shoulder subluxation, bone fractures, and precautions or limited
ranges due to various medical equipment (i.e. IV placement) (Kovich & Bermann,
1988).
Strength: Manual muscle testing should be completed for bilateral
upper and lower extremities to establish baseline scores and also to compare
right and left sides of the body. Postural strength throughout the trunk should
also be observed and abnormalities should be noted. When assessing upper
extremity (U/E) strength it is important to consider the shoulder girdle
musculature initially secondary to the significant impact on other areas of U/E
function. When documenting scores, the numbers 0-5/5 can be utilized to label
specific strengths with 5 being maximal strength. Grip strength may be evaluated
by using a dynamometer (Kovich & Bermann,
1988). Strength testing requires ability to understand directions and follow
commands.
Activities of Daily Living: Daily living skills include all activities
performed throughout a person's day including self-care, homemaking, work,
leisure activities, prevocational, education/school and community living tasks.
When evaluating a specific task, consideration should be given to whether or not
the task can be performed adequately, what components of the task the child
needs assistance with, the type/amount of assistance or cueing required, and
whether or not the child can perform the task in the appropriate sequence.
Consideration must also be given as to whether or not the child can perform the
tasks safely and whether or not adaptive equipment is required to successfully
complete the tasks. Each area evaluated is then given a specific label for the
amount of assistance required. The most commonly used labels include:
- Independent
- Independent with Adaptive Equipment
- Minimal Assistance (patient performs 75% or more of the task)
- Moderate Assistance (patient performs 50% to 75% of the task)
- Maximal assistance (patient performs 25 to 50% of the task)
- Dependent (patient performs less than 25%) (Kovich & Bermann,
1988).
Vision: Visual perception and visual motor functioning can be
evaluated through standardized testing, such as the MVPT-R and VMI. Other areas
or skills to consider include color recognition, occulomotor range of motion
(which may include tracking of a novel stimulus in a horizontal, vertical, and
oblique plane of movement), convergence, saccades, and pursuits. Observing a
child during play activities, such as completing mazes, reading or coloring, may
also provide information regarding visual skills (Kovich & Bermann,
1988).
Muscle Tone: Muscle tone is the resistance a muscle offers to passive
stretch. Muscle tone is assessed by feeling the child's movements and/or
resistance to movement with the child in various positions. It is relatively
passive, requiring the child's cooperation more than participation. Key factors
that help predict the child's potential for motor learning and skill development
are the ability to control abnormal muscle tone. Observation of the child's
movement patterns will also provide information regarding muscle tone (Trombly,
1995).
Sensation: Methods for testing sensation usually occur with the
child's vision occluded including sharp/dull, hot/cold, 2 point discrimination,
touch localization, propioception and stereognosis. A cotton ball, pen or
Semmes-Weinstein monofilaments may be used to evaluate touch localization.
Stereognosis is the identification of objects using ones hands while vision is
occluded. Proprioception can be evaluated by placing extremities in various
angles in space and having the child identify the position of the extremity (Trombly,
1995).
Play: Informal observations of movement patterns, interaction with
others/environment, purposeful use of toys and structure of play may be used to
assess the child's social, physical, perceptual and cognitive functioning (Smith, Allen &
Pratt, 1996).