NMS I - Exam 1 Part 2: Proprioception & Cerebellar Functional Tests

What are the absolute contraindications for adjusting, meaning you don't adjust ANYTHING? (7)

1) Acute arthropathies (inflammation/ligamentous laxity)

2) Acute fractures/dislocations

3) Malignancies involving vertebral column

4) Infections of bones/joints of vertebral column

5) S&S of myelopathy or cauda equine

6) Vertebrobasilar insufficiency syndrome (cervical spinal manipulation)

7) Major artery aneurysm near the proposed manipulation

What are the relative contraindications for adjusting? (5)

1) Articular hypermobility and circumstances where the stability of the joint is uncertain

2) Severe demineralization of bone

3) Benign bone tumors (spine)

4) Bleeding disorders & anticoagulant therapy

5) Radiculopathy w/ progressive neurological signs

What condition can be indicated by sudden onset unilateral head and neck pain?

Vertebral artery dissection

For a cerebral vascular ischemia, what were the 5 key symptoms that the patient presented with?

1) Neck pain and/or stiffness

2) Headaches

3) Dizziness & Vertigo (probably seeing hypoxia to the cerebellum w/ this now, so progressing)

4) Nausea & Vomiting

5) Diplopia

What three tests should you order at the ER for a VAD?

MR angio of the brain

(looking for occlusions/clots)

MR angio of the neck

(vascularity & tear)

MRI of brain

(damage to brain tissue)

What is the Barre-Lieou test?

1) Instruct patient to slowly rotate head from side to side

(this causes compression of the vertebral arteries)

What symptoms indicate a positive Barre-Lieou test?

Vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus

How do you perform the vertebrobasilar artery functional maneuver?

1) Palpate & auscultate the carotid & subclavian arteries for pulsations/bruits

2) If neither pulsates/bruits, instruct patient to rotate & hyperextend the head to one side and then the other

What are symptoms that could indicate a positive test and indicates ischemia for the vertebrobasilar artery functional maneuver?

Vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus

NOTE: same as vertebrobasilar artery functional maneuver

How do you perform the Dekleyn's Test?

1) Patient supine & head off table

2) Instruct pt. to rotate & hyperextend the head to one side and hold this position for 15-45s or until symptoms

3) Repeat w/ other side

What symptoms would indicate a positive test for Dekleyn's test and indicates ischemia?

Vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus

NOTE: same as vertebrobasilar artery functional maneuver & Barre-Lieou

How do you perform the Romberg test?

1) stand erect looking straight ahead w/ feet approximately closed together

--- first w/ eyes OPEN, then CLOSE their eyes

2) Doctor stands near patient to observe

If dizziness occurs w/ eyes only closed its a _________ issue. If dizziness occurs w/ eyes open and closed its a ___________ issue.

Dorsal Column Disease (Proprioceptive)

Cerebellar or Vestibular deficit

What is a normal finding for Romberg's Clinical Test? Abnormal?

Normal = patient maintains posture (little/no swaying)

Abnormal = Patient takes step to maintain posture or falls

Lesion below what level will give just lower extremity findings, and a lesion above this can give upper and lower extremity findings?

C5

Hopping on one foot requires an intact function of the nervous system, including what 4 parts?

1) Long motor & sensory tracts

2) Cerebellum

3) basal ganglia

4) peripheral nerves

What is a normal result for Hopping on one foot? Abnormal?

Normal = patient maintains posture w/ little to no swaying

Abnormal = takes step to maintain posture of falls

Squatting on one foot is a good way to find what?

Minor weakness in the lower extremities

What is a normal result for the Squatting on one foot test? Abnormal?

Normal = patient maintains posture w/ little to no swaying

Abnormal = patient takes a step to maintain posture or falls

With the finger to nose test, what is a normal finding? Abnormal findings?

Smooth & Accurate movement

Dyssynergia (incoordinate movement) & Dysmetria (inaccuracy in measuring distance) --> Past pointing

With the finger to nose to Finger test, what is a normal finding? What is an abnormal finding?

Normal = Smooth/Accurate movement

Abnormal = Dyssynergia (incoordinate movement)

What is the finger to nose to finger test NOT testing for?

NOT testing for proprioception (can't do w/ eyes closed)

What is a normal finding for the heel to shin test? Abnormal findings?

Normal = Smooth/Accurate movement

Abnormal = Dyssynergia (incoordinate movement) & Dysmetria (inaccuracy in measuring distance)

NOTE: eyes open checking cerebellar, eyes closed testing proprioception

What test can be done on a bedridden patient to test for their proprioception?

Heel to shin test

What is the ability to perform rapid alternating movements, such as pronating/supinating hands, patting knees rapidly, tapping forefinger and thumb, or tapping feet? What is an abnormality of this?

Diadochokinesia (succeeding motion)

Abnormality = Dysdiadochokinesia

If you suspect a patient w/ lower extremity dysfunction and a lesion of the spinal cord, where should you image (MRI)?

Thoracic

NOTE: NOT lumbar because there isn't the cord really present in most of lumbar lesion, most likely location is somewhere in thoracics

What is the Holmes Rebound Phenomenon? What important consideration is there for patient safety?

Patient contracts the flexors of forearm against resistance by doctor, then doctor releases arm quickly

Make sure forearm is down and in so if they have dysfunction it doesn't come and hit them in the face (pull towards opposite knee)

What is the normal findings for the Holmes Rebound Phenomenon?

Patient has a normal "check reflex"

What is Tandem Gait?

Patient walks along a straight line on the floor by placing one heel directly in front of the opposite toe with the eyes open, then eyes closed

NOTE: THE MOST SENSITIVE cerebellar/proprioceptive test (most likely to show abnormalities if there is one)W

What is a normal result for Tandem Gait? Abnormal?

Normal = Able to walk w/ eyes open & close

Abnormal = Unable to perform w/ eyes open indicates CEREBELLAR dysfunction; Unable to perform w/ eyes closed indicates Posterior column (proprioception) dysfunction

Proprioceptive vibration is best tested using what tuning fork? Where do you place the tuning fork?

128 or 256 Hz tuning fork

Ankle & Wrist

What is the Joint position test?

Examine one digit of hand or foot by stabilizing hand and foot and grabbing single digit from the sides and flex or extend that digit w/o placing pressure on top or bottom of digit

Ask patient whether you are moving the toe or finger up or down (eyes closed)

What tract is the Joint position test testing for?

Proprioception in Cuneatus (finger; UE) & Gracilis (toe; LE) tract

What is the Abadie's sign?

Testing for deep pain and pinching the achilles tendon

NOTE: deep pain & posterior column)

What is the Pitres sign?

Testing for deep pain and pinching the testicles

What is the Biernachi sign?

Testing for deep pain and striking the ulnar nerve

What is the final way we can test for deep pain by putting pressure in this area or in emergency situations?

Pressure on the eyeball

What is an abnormal finding of the deep pain test? What is a classic example of a finding for this?

Indicative of dorsal column disease

(ex: tabes dorsalis classic example)

What is a combination of both superficial and deep sensations which are then subject to integration with higher cortical funcitons and memory, for example, stereognosis, barognosis, topognoiss, graphognosis, 2 point discrimination, somatognosis, and nosognosis?

Multimodal or combined sensations

What is the ability of a patient to identify a common object in that hand (one hand) with their eyes closed (such as a pin, cap, key, button, paperclip), and is tested bilaterally?

Stereognosis

NOTE: if can't do this an intracranial lesion

What is the ability of a patient to identify/assess different weights, and asking the patient which is heavier in their hands, tested bilaterally?

Barognosis

What is the ability of the patient to touch somewhere on the skin and have them point to the area just touched, and is also done during the sensory exam?

Topognosis

What is the ability of a patient to identify a letter or number when it is written on the patient, and is tested bilaterally?

Graphognosis

What is the point at which a patient can determine 2 different locations of touch not just a single sensation, and is tested bilaterally?

2 point discrimination

Fingertips are capable of detecting 2 point discrimination at a distance of _______mm in a healthy adult and up to _________ in the dorsum of the hand? (TQ)

2 - 4 mm

20-30mm

What is the ability of a patient to know a body part as his own body part, so you place your arm next to the patients arm and ask the patient to touch their arm w/ their finger?

Somatognosis

What is the ability of the patient to know that they are ill, and if faulty in light of the obvious and overwhelming evidence of neurological disease such as hemiplegia, the patient will deny there is a problem?

Nosognosis