neuro examination procedures

what are the 3 components a PTA may be involved in?

patient history

identify changes in body systems

identify when a re-exam is needed

how is a checklist of non verbal pain indicator used?

scored 0 or 1 based on observation of pain behavior

reliable & valid for older adults with chronic or acute pain, patients in ICU or with dementia

what is consciousness and arousal?

the physiological readiness for activity; responsiveness to stimulation

what is orientation?

ability to cognitively adapt within an unfamiliar environment, allowing for accurate awareness of person, place, time, & situation

what is attention?

ability to stay focused on a task

what does mental status included?

consciousness & arousal

orientation

attention

states of altered consciousness

alert

delirium

syncope

minimally conscious state

vegetative state

obtunded

stupor

coma

what is delirium?

oriented only to self; delusions or hallucinations may be present

what is a minimally conscious state?

severely impaired consciousness; can follow simple commands with gestures or verbal yes/no

may present non-reflexive movements

what is vegetative state?

cycles of arousal with eye opening in unresponsive pt, has regular sleep/wake cycles

over 30 days is persistent

what is obtunded?

slower response to stimulus; increased need for sleep with difficult to rouse

pt is confused & drowsy when awake

what is stupor?

arousable only by continuous, vigorous stimuli but unable to interact

returns to unconscious state when stimuli removed

what is a coma?

unable to arouse even with strong stimuli, eyes closed

what are the 4 types of attention?

selective

sustained

alternating

divided

mini mental state exam

most common, 8 sections: orientation, immediate recall, attention, delayed verbal recall, naming, 3 stage command, reading, writing

cognitive abilities screening instrument (CASI)

examines 6 cognitive abilities: digit span or mental tracking, verbal fluency, reasoning, expressive language, visual construction, immediate/delayed free verbal recall, cued verbal recall

anterolateral spinothalamic pathway

slow conducting fibers, small diameter, unmyelinated

transmits crude touch, pressure, temp, pain info

dorsal column medial lemmiscal pathway

fast conducting, large diameter, highly myelinated

transmits fine touch, proprioception, vibration, & 2 point discrimination

pathway of the anterolateral tract

dorsal root ganglia → crosses in SC → brainstem → thalamus → somatosensory cortex

differences in anterolateral pathways

anterior portion: carries crude touch & firm pressure

lateral portion: carries pain & temp

pathway of the dorsal column

dorsal root ganglia → crosses in the brainstem (medulla) → thalamus → somatosensory cortex → sensory association areas

what is the association cortex?

where sensory info is processed & interpreted

what is involved in the association cortex?

episodic memory, visualspatial processing, consciousness, detects errors

homunculus

area of cortex represents density of sensory input to/from certain areas of the body & importance of input

3 major categories of sensation

superficial, deep, combined cortical sensory function

superficial sensation

receive stimuli from external environment via skin & subcutaneous tissue

pain, temp, light touch, pressure

deep sensation

receive stimuli from muscles, tendons, ligaments, joints, fascia

proprioception, kinesthesia, vibration

combined cortical sensory function

uses exteroception & proprioception & interprets it in the brain via sensory association areas

stereognosis, graphesthesia, 2 point discrimination, touch localization, double simultaneous simulation, barognosis, texture recognition

light touch superficial sensory testing

wisp of cotton or tissue, eyes closed, lightly touch

say yes when you feel it

pain superficial sensory testing

sharp/dull, eyes closed

use random application of sharp or dull

proprioception deep sensory testing

joint position, fingertip grip on bony prominences

move joint & pt will identify the end position verbally or duplicate with other

kinesthesia deep sensory testing

joint movement, fingertip grip on bony prominences move

instruct with position ie, straight or bent, pt identifies direction & range verbally

vibration deep sensory testing

tuning fork placed on bony prominence

stereognosis

with eyes closed pt is given a small, easily obtained, culturally familiar object & manipulate to identify object

barognosis

same as stereognosis but identify weight

graphesthesia

with fingertip or eraser end of pencil, trace a letter or number on palm of hand

clear hand between tracing

2 point discrimination

most practical & easily duplicated test

2 points move closer until subject unable to distinguish 2 points

bilateral simultaneous touch

can be done same location on extremity on opposite sides of body, proximal & distal opposite or same side of body

can pt attend to info coming from 2 areas

touch localization

pt points to where they felt it

monofilament

apply perpendicular to skin

if cannot feel → loss of protective sensation is noted in that area of the foot

corticospinal tract

skilled fine motor control of distal limbs

lateral: 90% crosses over medulla

anterior: 10% cross at cervical or upper thoracic of spinal cord

common deep tendon reflexes

jaw: C5

biceps: C5-C6

triceps: C6-C7

hamstrings: L5-S1

quads: L2-L4

achilles: S1-S2

DTR grading

0 no response

1+ diminished (may or may not be normal)

2+ normal response

3+ exaggerated response (may or may not be normal)

4+ hyperactive (abnormal)

motor cortex in coordination

sends signal to direct movement of body

basal ganglia in coordination

goal of movement & strategy to best meet goal

plan & executes by facilitating with inhibition of unwanted movement

cerebellum in coordination

sequences muscles required to smoothly & accurately meet goal by regulating postural control & tone

error detection/correction

brainstem & SC in coordination

execution; activation of motor neurons & interneurons for movement & adjustments as needed

two types of coordination test

non-equilibrium: static & dynamic while sitting

equilibrium: static & dynamic posture/balance when standing

what is akinesia?

inability to initiate movement

common in parkinson’s pt

what is asthenia ?

generalized weakness

common in cerebellar pathology

what is ataxia?

inability to perform coordinated movements

what is athetosis?

involuntary movements combined with instability of posture

what is chorea?

movements that are sudden, random, involuntary

what is dysdiadochokinesia?

inability to perform rapid alternating movements

what is dysmetria?

inability to control the range of a movement and force of muscle activity

under or overshoot

what is dystonia?

similar to athetosis, larger axial muscle involvement

what is hemiballism?

involuntary & violent movement of a body part

non-equilibrium test

finger to nose (dysmetria)

heel shin (ataxia)

rapid tapping (ataxia)

rapid alternating movements (dysdiadochokinesia)

what is an example of a equilibrium test?

regular rhomberg: balance EO/EC feet together for 30 secs

sharpened rhomberg: one foot in front of the other EO/EC for 30 secs

upper motor neuron symptoms

hypertonia

spasticity/rigidity

hyperflexia

muscle spasms

synergistic movement patterns

weakness/paralysis not segmental

lower motor neuron symptoms

hypotonia

flaccidity

hyporeflexia

fasciculations (twitching)

no synergistic patterns

weakness/paralysis segmental

grading of spasticity: tardieu rating scale

0: no resistance

1: slight resistance throughout with no clear catch

2: clear catch at precise angle followed by release

3: fatigable clonus (<10 secs)

4: non fatigable clonus (>10 secs)

5: joint immobile

how do you grade spasticity with tardieu?

assesses the response of the muscle to stretch applied at specific velocities

how is the fugl-meyer assessment used?

stroke specific, pt starts at abnormal synergy & attempts to move out