OSCE Sensory/Cognitive/Vision/Motor Test

How to Conduct the Test: alerted and oriented

Oriented x 4 for documentation Person, place, time and situation. Who are you? Where are you? Date and time? Why just happened or is happening? or Why are you here?

Scoring: light touch

Absent Impaired Intact

Scoring: proprioception

Absent Impaired Intact

Scoring: sharp/dull

Absent Impaired Intact

Scoring: thermal sensation

Absent Impaired Intact

Scoring: two-point discrimination

Absent Impaired Intact

Scoring: vibration sensation

Absent Impaired Intact

Scoring: deep pressure

Absent Impaired (impaired if everything is dull and not sharp; they are detecting something but not the appropriate something) Intact

Clinical interpretation of: kinesthesia

An individual with a loss of joint movement sense is at greater risk for loss of balance and falls. An individual with a loss of joint movement sense exhibits decreased coordination. Joint movement sense is necessary to maintain appropriate postural control during functional activities, such as sitting, transfers, standing, and walking.

How to Conduct the Test: MMT

Apply pressure opposite to the way you want client to move the body part.

How to Conduct the Test: ocular pursuits screen/h-test

Ask client to follow wand with eyes without moving head. Hold wand 18" away from eyes Move wand in "H" (up, down, left and right) for H-Test Move wand in "t" (up down, left and right then diagonal both ways and then clockwise circle, then counterclockwise circle Observe jerky eye movements and head movements Make sure client doesn't move their head

How to Conduct the Test: rhomberg test

Ask if they are able to stand Eyes open Try to throw their balance off Pressure on posterior, anteriorly, side, and side Then repeat test with eyes closed Test to see how much individuals use visualization to stabilize (if they can't stabilize, then they have proprioception of the lower extremities Max assist for stand, don't do this test If scored poor with eyes close, but good with eyes open: next step is proprioception of the ankle

Scoring: saccadic eye movement screen (rapid eye movement)

Describe individual's eye movements during this screening in documentation

Scoring: peripheral/confrontation

Describe the degree at which client lost sight of object (for with one person) Put angle of the target when it is detected (for with two people)

Scoring: alerted and oriented

Document their orientation status (Example, Mr. Smith oriented x 2 (person and place)

What does this test do? functional activity of strength

have client participate in a functional activity to determine if they have enough strength to do an activity (ex: walking to the bathroom, lifting groceries, etc.)

Scoring: ROM

record degree from goniometer

What does this test do? convergence

required for near vision

Visual Screens

saccadic eye movement screen ocular pursuit screen/H-Test convergence near/far peripheral/confrontation

What does this test do? alerted and oriented

simple way and fast way to test an individual's orientation status (oriented x 4 for documentation) person, place, time, and situation

What does this test do? rhomberg test

test of the body's sense of positioning (proprioception), which requires healthy functioning of the dorsal columns of the spinal cord

What does this test do? memory recall

to assess an individual's ability to memory recall

What does this test do? peripheral/confrontation

to assess an individual's ability to notice objects out of their peripheral field (important for driving and scanning the environment around)

What does this test do? 9-hole peg test

to assess an individual's fine motor coordination and hand-eye coordination (assesses arm and hand function)

What does this test do? pinchometer

to assess an individual's pinch strength (two-point/palmer, three-point, lateral/pinch)

What does this test do? manual muscle test (MMT)

to assess an individual's specific muscle strength

What does this test do? dynamometer

to assess an individuals grip strength

What does this test do? near/far

to assess any changes in vision

What does this test do? clock drawing test

to assess for visuospatial abilities (could also determine visual neglect) may reflect both attention and executive function

What does this test do? thermal sensation

to determine client's ability to discriminate between extremes of hot and cold

What does this test do? deep pressure

to determine client's ability to sense deep pressure

What does this test do? ocular pursuits screen/H-Test

to determine if client is able to track moving objects (looking at the extraocular muscles)

What does this test do? two-point discrimination

to determine the ability to distinguish between two direct stimuli and recognize things (a higher level of sensibility assessment)

What does this test do? vibration sensation

to determine the ability to perceive vibratory stimulus (dorsal column medial lemniscus pathway)

What does this test do? sharp/dull

to make a gross evaluation of superficial pain sensitivity

What does this test do? Light touch

to test light touch and also can test localization of the light touch

What does this test do? saccadic eye movement screen (rapid eye movements)

to track a client's ocular movement from left to right

What does this test do? function activity ROM

have client participate in a functional activity to determine their range of motion

What does this test do? stereognosis

identifying objects through tactile information, cognition and touch to provide cues from texture, size, spatial properties and temperature no vision needed

What does this test do? kinesthesia

joint motion to assess the individual's ability to perceive the active change in position of a joint

What does this test do? proprioception

joint position sense to evaluation client's sense of position (wrist, ankle, shoulder, elbow, finger, etc.) Tests the dorsal column medial lemniscus pathway

Sensory Screens

light touch deep pressure thermal sensation sharp/dull proprioception kinesthesia two-point discrimination vibration sensation stereognosis rhomberg test

Strength Screens

manual muscle test (MMT) functional activity dynamometer pinchometer 9-hole peg test

How to Conduct the Test: ROM

measure using goniometer compare degree to the norm for the body movement

How to Conduct the Test: near/far

(can you read my nametag, can you read the clock) Use objects like a pen and a clock on the wall Ask client for the time on the clock and ask what you are holding Tell the client to look back and forth Looking to see how smooth the client is able to transition back and forth between the objects and if the client overshoots the object

Scoring: MMT

5: Hold for a count of 3 against pressure; active = passive 4: Hold for a count of 2 against pressure; active = passive 3+: Hold for a count of 1 against pressure; active = passive 3: does not hold against pressure; active = passive 3-: active >= half of passive ROM 2: active < half of passive ROM 1: muscle twitch Record score of muscle strength

Clinical interpretation of: sharp/dull

A patient with an absence of pain (i.e., inability to perceive sharp stimulus) has a greater risk of injury. Pain and temperature typically recover before touch

Clinical interpretation of: deep pressure

A patient with an absence of pressure sensation has a greater risk of injury.

Clinical interpretation of: two-point discrimination

Ability to discriminate within normal ranges indicates that the dorsal column medial lemniscus is intact from the periphery. Inability to discriminate within normal ranges may indicate PNS, central pathway, or parietal lobe lesion.

Scoring: kinesthesia

Absent Impaired Intact

How to Conduct the Test: light touch

Can use a cotton ball, Q-Tip, or brush. Always start proximal to distal because regeneration will occur closer to trunk and work its way out if there is neurological damage Always do unaffected side (if they have stroke, etc.) Have patient close their eyes "Every time you feel a touch, say yes" Go in random patterns to look at all the dermatome patterns If not sensing in an area, go back and test again; then if it still isn't there, note the area on the sheet; diminished area, mark it on the sheet

How to Conduct the Test: kinesthesia

Hard to do non affected side first if they are unable to do it on the affected side Arm has to be moving Be on the individual's affected side moving through patterns (out to side, up above, in front) Ask that the unaffected side is going through the same movements Have the client close their eyes

How to Conduct the Test: proprioception

Have client close their eyes close Move body part in certain direction and have them tell you if it is up or down Start on nonaffected side "Tell me what position your elbow/wrist/finger is in" If they are not able to verbalize what is happening, have they mimic with their affected side what you just did with the affected side Don't do this on someone who is not reliable on their responses Can follow this with kinesthesia

How to Conduct the Test: clock drawing test

Have client draw a familiar object such as a clock. (Sheets provided in class and located on rehabmeasures.org)

How to Conduct the Test: Strength Functional Activity

Have client participate in a functional activity to determine if they have enough strength to do the activity ( i.e. walking to bathroom, lifting groceries, etc.)

How to Conduct the Test: memory recall

Have the client remember three words/objects and then have them recall them 5-10 minutes later. (Ex. book, red, dog)

How to Conduct the Test: vibration sensation

Hit the end to cause vibration and the other end on the patient See how long it takes for them to stop feel the vibration See if they can feel the vibration Disturbance in vibration if they still feel a vibration even though you have already stopped it Client closes eyes Usually do more on fingers because of peripheral nerves

How to Conduct the Test: saccadic eye movement screen (rapid eye movement)

Hold two wands 16" away from client's eyes. Ask client to shift eyes back and forth. Client should be able to move eyes between objects without turning head.

Clinical interpretation of: thermal sensation

Important for clients to be aware of thermal sensation impairments for safety reasons (i.e. touching the stove, taking a shower, washing hands, etc.)

Clinical interpretation of: proprioception

Joint position sense is an interoceptive sense that provides the status of the body internally. An inner ear infection may affect a patient's sense of proprioception. An individual with a loss of joint position sense is at greater risk for loss of balance and falls. An individual with a loss of joint position sense will exhibit decreased coordination. Joint position sense is necessary to maintain appropriate postural control during functional activities, such as sitting, transfers, standing, and walking.

Scoring: ocular pursuits screen/h-test

Look for smooth movements and describe the individual's eye movements in documentation

Clinical interpretation of: mini-mental exam (MMSE)

MMSE tests global cognitive function, with items assessing orientation, word recall, attention and calculation, language abilities and visuospatial ability. Used as a screen for dementia or cognitive impairment, mainly in geriatric populations. Scores decline with advancing age and increase with higher educational level. It's possible to achieve a very high score but still have significant cognitive deficits, especially in areas such as executive functioning that the MMSE is not designed to test for. Ask education level before screening, there are different screens for higher/lower education. Also, be mindful of primary language, as it can be a barrier and skew scoring.

Scoring: convergence

Mark if eyes are not coming in uniformly to the object Mark how far away the pen was when the client started to see the 2 objects

How to Conduct the Test: thermal sensation

One cup hot: 115-120 degrees One cup cold: 40 degrees As you're testing, the stick will cool off, so need to put it back in to get to correct temperature One hot and one cold tube in your hands Test on unaffected, then affected side Random hot and cold pattern Important to make sure you don't burn your hand like in the shower or something Client has eyes closed and will tell if they feel hot or cold Random pattern of hot and cold; don't alternate between hot and cold or else clients will pick up on it. Do some cold back to back or hot back to back

How to Conduct the Test: Dynamometer

Outside is kilograms and the inner rings are in pounds We read in pounds (read the inside number) No matter what, stay consistent with what you are reading and then convert to pounds Females: put on second setting Males: on third setting because of hand span Arm at side, flexed Start with dominant hand If they can't use one hand, don't test with that Demonstrate for them Squeeze as hard as the client can Alternate between dominant and non-dominant hand Trial of 3 and then average the scores Can do a redo if need to if it seems off Do both sides three times each and document the average of the three on that particular side (i.e. record the average of the three for both the right and left side)

How to Conduct the Test: convergence

Place object approximately 16" in midline and move closer to nose. Client should be able to maintain eye contact with object up until approximately 3 inches Refer to ophthalmologist or optometrist is having difficulties with convergence

Scoring: rhomberg test

Poor Fair Good Lost balance with eyes closed, then say "balance lost with eyes closed"

How to Conduct the Test: Pinchometer

Pounds are on the outside and kilograms are in the inside Lateral Pinch: (between thumb and point finger) -alternate hands -start with dominate -average them 2 point pinch/palmar pinch/pad pinch (pointer and thumb pads) -alternate hands -start with dominate -average them -have digits 3-5 curled into hand 3 point pinch/3 jaw chuck (pointer, middle, and thumb pads) --alternate hands -start with dominate -average them Each pinch has their own set of norms Do each pinch (two-point, three-point, lateral) three times each and document the average for each particular pinch

ROM Screens

ROM ROM dance function activity

Scoring: mini-mental exam (MMSE)

Scores on the MMSE range from 0 to 30, with scores of 25 or higher being traditionally considered normal. Scores less than 10 generally indicate severe impairment, while scores between 10 and 19 indicate moderate dementia. However, scores may need to be adjusted or interpreted differently to account for a person's age, education, and race/ethnicity

How to Conduct the Test: mini-mental exam (MMSE)

Screening tool that tests global cognitive function with items assessing orientation, word recall, attention and calculation, language abilities and visuospatial ability Used mainly in geriatric populations Scores decline with advancing age and increase with higher educational level You can have a high score but still have significant cognitive deficits Does not test for executive functioning Mindful of primary language Ask for education level (different screens for higher/lower education)

How to Conduct the Test: 9-hole peg test

Sit beside the hand being tested (to pick up pegs to save the client time, since it is a time test) Start with dominant hand, do all three times on same hand before switching Test to see how fast fingers move Pick up pegs, one at a time, and place them in as fast as you can; then remove them and return to table one peg at a time Watch to make sure that they only pick up one at a time Time when the start to when they returned the last peg to the table Record time First time is typically the slowest Take the average of the tree tests Pegs are on the side of the hand being tested; board is in the center Client can use opposite hand not being tested to stabilize the board Look at normative values to compare Put the pegs on the side that is being tested (if they do not complete after five minutes, stop).

How to Conduct the Test: ROM Dance

Start with hands to side Palms facing in, thumbs on top, bring arms up as far as you can go (Shoulder Flexion/Extension) Palms facing forward, thumbs on top, bring arms up on the side like a jumping jack (Shoulder abduction/adduction) Touch back of head with both arms (External Rotation) Touch behind lower back with both arms (Internal Rotation) Cross arms and touch opposite shoulders (Horiz. Adduction) Uncross arms and touch shoulders (Horiz. Abduction) Straighten arms out front (Elbow Flexion/Extension) Turn palms up and down (Supination/Pronation) Bring wrists up and down (Wrist Flexion/Extension) Touch each finger to thumb (MP, PIP, DIP Flexion/Extension) Grip strength

Clinical interpretation of: stereognosis

Stereognosis integrates touch, pressure, joint position sense, and temperature in order to identify an object. Intact cognitive processes are required to interpret the multiple sensory inputs from the object. If language is an issue while testing stereognosis, the patient can draw or point to a picture of the object.

Scoring: 9-hole peg test

Take average of three for both sides and compare to the normative ranges located on sheet

Scoring: Dynamometer

Take average of three for both sides and compare to the normative ranges located on sheet

Scoring: Pinchometer

Take average of three for both sides and compare to the normative ranges located on sheet

Clinical interpretation of: convergence

Tests ability to focus (i.e. on a small object while it's slowly moved toward individual or to read close up Signs and symptoms may include eyestrain, headaches, difficulty reading (i.e. words blur or seem to move on the page), double vision, etc.

How to Conduct the Test: peripheral/confrontation

Therapist sits in front of client Hold two wands Client keeps eyes on therapist's nose Move wands to different visual fields (asks client when they are not able to see the wand/pencil any longer) and record. Need an object like a pen With 2 people: one person in front making sure eyes are staying focused with the assessor and the other coming behind the client to see when the object comes into view With 1 person: sit face to face with client, have them look at their nose, take pen to either side and tell the client to tell you when they can't see the pen anymore

How to Conduct the Test: deep pressure

Use a pencil, or bottom of the little pressure Administered same way as light touch Put pressure in and see if client feels it Client shuts their eyes to see if they are sensing the sensation and not the vision for seeing it occur If wasn't feeling anything: absent Felt some but not others: impairment

How to Conduct the Test: sharp/dull

Use a safety pin or a paper clip Sterilize before you use it Explain it: I want to see how you are sensing sharp and dull (make sure you can sense if you are brushing up against a sharp edge) Demonstrate it to client Test unaffected side first, then affected Eyes are closed for client Random pattern (proximal to distal) Sharp side: pin Dull side: is the head of the pin

How to Conduct the Test: stereognosis

Use random objects (finite as discrimination against coins or get as gross as using shapes) Test in unaffected hand first and then the affected Sometimes, if they can't use the affected hand, help them manipulate the shapes Can also point to object (via pictures on the table) If they don't know what the object is, have them describe it to you "Not able to tell me, describe it to me" Can give them another attempt if they realized it was a different shape (thought penny was a dime, then felt dime and realized oh the penny is actually a penny)

How to Conduct the Test: two-point discrimination

Use the "Chinese star" and the two-point tool Test on the unaffected side and then the affect side This is seen a lot in a hand clinic 3 mm is small; switch between the 1 mm and the 5 mm Do they feel one point or the two? Have them state which one they feel Client closes their eyes Random pattern going from proximal to distal mixing up between one point and two points "Chinese star" is more appropriate for the hand because of all of the nerves; glide it instead of just poking No concern if hard to tell between one and two on the arm 2 - 4 mm is standard for it Demonstrate with it side-by-side

Clinical interpretation of: rhomberg test

Used to investigate the cause of loss of motor coordination (ataxia) Maintaining balance while standing in the stationary position relies on intact sensory pathways, sensorimotor integration centers and motor pathways. If unable to maintain balance with eyes closed = client relies heavily on visual input for balance.

Clinical interpretation of: vibration sensation

Vibration testing is intended to specifically evaluate the Meissner's and Pacinian corpuscle receptors. Scoring is normal if the vibration stimuli feel the same when comparing both sides. (Can help identify a fracture if placed on the bony prominence of the fracture site)

Clinical interpretation of: light touch

a patient with an absence of touch awareness has a greater risk of injury diminished touch awareness may lead to decreased fine motor coordination. If the upper limb is involved, the patient may only be able to use it to assist with functional activities and/or rely on vision to guide its movement

Cognitive Screens

alerted and oriented memory recall clock drawing test mini-mental exam (MMSE)

What does this test do? mini-mental exam (MMSE)

brief screening tool to provide a quantitative assessment of cognitive impairment to record cognitive changes over time