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17 Cards in this Set
- Front
- Back
Pathologic reflexes
(UMN/corticospinal tract lesion) |
Significance: UMN descend on LMN tracts
Lower extremity: a) Babinski: stroke lateral aspect of sole of the foot |
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Sensory Testing-Upper
Extremity (test bilaterally compare & contrast) |
UE:
1) C5/Axillary n./shoulder 2) C5/Radial n./lateral shoulder 3) C6/Musculocutaneous n./Biceps 4) C6/Median n./palm thumb 5) C7/Median n./middle finger 6) C8/Ulnar n,/medial forearm 7) C8/Medial Antebrachial Cutaneous n./medial forearm 8) T1/Medial Antebrachial & Brachial n./medial elbow 9) T2/Medial Brachial Cutaneous n./medial biceps |
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Sensory Testing-Lower
Extremity (test bilaterally compare & contrast) |
LE:
1) L1/Lateral Femoral Cut. & Femoral n./proximal thigh 2) L2/Lateral Femoral Cut., Femoral, & Obturator n./mid-thigh 3) L3/Lateral Femoral Cut. & Femoral n./distal thigh 4) L4/Saphenous n./medial shin, medial foot, (big toe) 5) L5/Peroneal n./lateral shin, dorsum of foot, (big toe) 6) S1/Sural n./lateral calf, lateral foot, & little toe |
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What is the significance of SENSATION?
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Sensation should be bilaterally equal, as well as equal to adjacent areas on the
same side. Sensory alteration may involve: • Decreased sensation or sensory loss (hypoesthesia, hypoalgesia) • Increased sensation (hyperesthesia, hyperalgesia) • Pain provoked by normally non-painful stimuli (dysesthesia, allodynia) Sensory alteration may occur due to: • PNS lesion (peripheral neuropathy, radiculopathy) • CNS lesion (ascending tracts in spinal cord & brainstem, thalamus, & somatosensory cortex) DDX is based on: 1) Distribution of the sensory alteration (dermatomal, peripheral nerve distribution, etc) 2) Associated w/ motor & reflex findings 3) Hx & physical In this scenario, the most likely diagnosis is: • Radiculopathy due to IVD herniation or IVF stenosis • Peripheral Neuropathy • CNS lesion (ascending sensory tracts in spinal cord-brainstem thalamus, or somatosensory cortex) |
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Muscle Strength Testing-Upper
Extremity (test bilaterally compare & contrast) |
Muscle Strength Grading Scale:
5: full ROM against gravity & normal resistence 4: full ROM against gravity & some resistence 3: full ROM against gravity 2: full ROM w/ gravity removed 1: no motion, but slight contractility 0: no motion, no contractility UE • C5/Deltoid/Axillary n. • C6/elbow flexors (biceps)/Musculocutaneous n. • C7/elbow extensors (triceps)/Radial n. • C6/wrist extensors/Radial n. • C7/wrist flexors/median & Ulnar n. • C7/finger extensors/Radial n. • C8/finger flexors/Median & Ulnar n. • T1/interossei/Ulnar n. |
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Muscle Strength Testing-Lower
Extremity (test bilaterally compare & contrast) |
Muscle Strength Grading Scale:
5: full ROM against gravity & normal resistence 4: full ROM against gravity & some resistence 3: full ROM against gravity 2: full ROM w/ gravity removed 1: no motion, but slight contractility 0: no motion, no contractility LE: 1) L1,2,3/Psoas/branches of the lumber plexus 2) L2-4/Quadriceps/femoral n. 3) L2-4/Adductors/Obturator n. 4) L4/Anterior Tibialis/deep peroneal n. 5) L5/Dorsiflexors/deep peroneal n. 6) L5/Extensor Hallicus Longus (EHL)/deep peroneal n. 7) S1/plantar flexors/tibial n. 8) S1/Evertors/superficial peroneal n. 9) L5/Gluteus medius/superior gluteal n. 10) S1/Gluteus maximus/inferior gluteal n. |
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What is the significance of Muscle
Strength? |
Normal muscle strength should be bilaterally symmetrical & should allow
complete ROM against full resistence (grade 5/5). Weakness graded from 4/5- 0/5 is abnormal. Muscle strength is a function of the UMN-LMN pathway, the NMJ, & muscle. So, weakness may result from a lesion of any of these. Weakness may also be due to pain caused by testing. DDX is based upon: 1) The distribution of weakness 2) Additional findings on the neurological exam (motor, sensory, reflex) 3) Hx & physical exam In this scenario, the most likely diagnosis is: • LMN lesion due to radiculopathy (IVD herniation, IVF stenosis) • LMN lesion due to peripheral nerve disorder (peripheral neuropathy) • UMN lesion (CVA, MS) • NMJ dx (ex. Myasthenia gravis) • Muscle dx-myopathy (ex. Muscular Dystrophy, polymyositis) |
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DTR
(test bilaterally compare & contrast) |
UE: may reinforce by clenching teeth
1) C5/biceps/musculocutaneous n. 2) C6/Brachioradialis/radial n. 3) C7/triceps/radial n. LE: may reinforce by clasping hands together 1) L4/quadriceps/femoral n. 2) L5/posterior tibialis/tibial n. 3) L5/medial hamstring/sciatic n. 4) S1/gastroc-soleus/tibial n. Grading Scale: 4+: hyperactive; assoc.w/ clonus 3+: brisker than avg. 2+: normal 1+: present, but diminished 1+(R ): only present w/ reinforcement 0+(R ): absent (areflexia) |
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What is the significance of DTR?
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DTR activity reflects the integrity of the reflex arc (involving the muscle spindle
receptor, Ia sensory fiber, LMN, & muscle), & the UMN’s inhibitory activity. A lesion affecting the reflex arc (radiculopathy, peripheral neuropathy) leads to decreased or absent DTR (hyporeflexia or areflexia), graded 1+. 1+(R), 0(R) An UMN lesion (CNS) leads to hyperreflexia (4+) Bilaterally symmetrical sluggish or brisk reflexes, in the absence of other neurologic symptoms & exam findings, are typically normal. DTR findings should be correlated w/ other aspects of the reflex exam such as pathologic reflexes, & motor & sensory exam results. In this scenario, the most likely diagnosis is: • Lesion affecting the LMN and/or sensory component of the DTR arc, due to radiculopathy (IVD herniation or IVF stenosis), or Peripheral neuropathy. • UMN lesion (CNS ex. CVA, MS, Spinal Cord Injury) |
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ROMBERG
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Procedure:
1) While standing near the Pt ready to support them if they b/c unstable, instruct the Pt to bring their feet together. Observe balance. 2) Instruct the Pt to close their eyes & again observe the Pt balance. Finding & interpretation: 1) Only (+) when Pt balance b/c worse when eyes are closed. 2) (+) indicates that visual input was compensating for a balance problem, & sensory ataxia (impaired conscious proprioception/JPS) or vestibular ataxia is suggested. 3) Cerebellar dysfunction is associated w/ motor ataxia. No difference if eyes open or closed. |
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Gait
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Regular gait
1) Instruct the Pt to walk back & forth across the room 2) Observe: a. Symmetry b. Balance c. Distance b/t feet (width) d. Length of stride e. Arm swing f. Heel strike Tandem gait (heel-to-toe walk) 1) Support Pt in case unstable, ask Pt to walk as if on a tightrope, placing the heel of one foot directly in front of the other foot. Heel & toe walk 1) Ask Pt to walk across the room on their heel, & to walk back on their toes. a. Weak dorsiflexion (heel walk) i. L5 (common peroneal n.) b. Weak plantarflexion (toe walk) i. S1 (tibial n.) |
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Muscle Bulk Assessment
Procedure |
• Visually compare symmetry of muscle bulk & coverage of bony
prominences. • Measure the circumference of the limbs (“girth”) w/ a tape measure o UE: measure 3”above & below (olecranon) o LE: measure 6” above & below (joint line) • Normal variation is 1 inch b/t dominant & non-dominant hand • Significance: LMN Lesion |
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Two-point discrimination
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Significance: involvement of type II 1st order neurons or dorsal column
system • Tip of tongue: 1-2mm • Lips: 2-3mm • Finger tips: 2-5mm • Dorsum of fingers: 4-6mm • Palm of hand: 8-15mm • Dorsum of hands: 20-30mm • Feet: 30-40mm • Shins: 30-40mm • Back: 4-5mm Procedure: Explain to Pt that you will be touching them w. 1 or 2 points and ask them to identify how many points that they feel. Demo what 1 & 2 points feel like. Have the Pt close their eyes and proceed w/ the testing. Go widest then narrow b/t points. (+): inability to distinguish b/t 1 & 2points at the normal degree of point separation for the area, or significant side-to-side differences. |
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Conscious Proprioception/Joint Position
Sense (JPS) |
Procedure:
Explain & demo. (grasp the Pt big toe by the sides, and move it upward and downward, “this is up & this is down”. now tell Pt that u will be asking them to identify “up”, & “down” movements w/ their eyes closed). Have Pt close their eyes and do the test. 7/8 correct responses is necessary to established validity. (+): side-to-side alteration, or decreased sensitivity (greater movements required) Significance: involvement of type II 1st order neurons or dorsal column system; some cortical participation is also necessary for JPS. |
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Cortical Sensory Tests aka
“Gnosis” |
• Stereognosis (Steroagnosis):
o Procedure: Pt eyes closed. Put a familiar object (clip, coin), is placed in the Pt’s hand & the Pt is asked to identify it. The Pt should be able to correctly identify the object. • Graphognosis (Graphesthesia/Agraphognosis) o Explain to Pt that you will be drawing a #/letter in their hand and they should be able to identify it w/ their eyes closed. Make sure to draw it right side up form Pt perspective. Demo 1st w/ eyes open to make sure they understand. • Extinction (Double simultaneous stimulation test) o In some Pt, simultaneous bilateral stimulation may reveal an inability to perceive sensation from one side. o Procedure: explain to Pt that you will be touching them either on R/L/both sides, & asking them where they felt the touch. Ask Pt to close eyes & proceed.(+): the Pt feels both on R/L when touched, but when touched bilaterally, only feels one side. • Significance: lesion of the somatosensory association cotex (parietal lobe) Contralaterally. |
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Assessing Coordination of the
Limbs |
(Cerebellar Function)
Point-to-Point tests UE: • Finger-to-nose test: Touch the index finger of each hand to the tip of their nose. (+): any past pointing/dysmetria/intention tremor. • Finger-to-finger-to-nose test: Pt to touch their nose & reach out to touch Dr fingers. (+): dysmetria/intention tremor LE • Heel-to-shin test: Pt is supine & place heel of 1 foot on the opposite kneecap & slide down shin. (+): zig-zag/dysmetria • Toe-to-finger test: Pt supine toe touch Dr fingers (note: dysmetria/intention tremor) Rapid Alternating Movement tests UE: • Diadochokinesis: Patting the thing. Pronation-supination. (+): clumsy. Irreg, slow LE: • Ask Pt to tap your hand as quickly as possible w/ the ball of their foot. • Ask the Pt to tap the knee several times w/ the alternate heel. This may be combined w/ the heel-to-shin test. |
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HOLME’S REBOUND TEST
(a test of rapid alternating movement tests) |
• Ask Pt to flex their forearm against the examiner’s resistance (turn Pt
face away & shield w/ your other hand). Suddenly remove your resistance. • Normally the Pt can quickly check the movement of the forearm. w/ CB dysfunction. There is failure of the antagonists to contract & agonists to relax. And the forearm continues to swing upward. |