NEURO EX IN PT Part 4

Sensory testing

How to document sensory testing

O> Neurological sensory testing> 100% sensation intact as to light touch, pain, & temperature on (R) UE

flow in sensory testing

Perform  superficial → deep → combined cortical

how to test for superficial sensations

• Light touch

• Pin prick

• Deep pressure

*if there is a mistake use percentage → if percentage is used → should be bilateral stimulation

10 = sobrang nararamdaman

0 = wala na nararamdaman at all

*can use 0-10 or 0-100%

How to test the deep sensations?

• Proprioception (position sense) 

  • First to test (easier)

  • “Taas, baba, labas, loob” 

  • ask when extremity is positioned – POSITION FIRST 

  • Deep sensation in distal extremities (not sa trunk!)

  • Sasabihin niyo po sir, ito po yung taas, baba, loob, labas. Pikit po sir. Posisyon ko lang po muna, ano pong posisyon to sir?

OR poposition ko po muna, gayahin niyo po

• Kinesthesia (movement sense) 

  • “Pataas, pababa, paloob, palabas

  • ask while moving the extremity – same as proprioception but WHILE MOVING

  • Habang ginagalaw ko po yung daliri niyo, ito po yung pataas baba etc. ito po…

OR sabayan niyo po habang ginagalaw ko (yung good side yung gumagaya)

• Vibration

  • Put on any bony prominence (at least 3 bony prominence)

  • At least 5 trials

Most important sensory test when pt has stroke or brain problem

Combined cortical

Where should you test for combined cortical sensation?

Only on hand

What are the tests for combined cortical sensations?

• 2-POINT DISCRIMINATION

• STEREOGNOSIS

• GRAPHESTHESIA

• BAROGNOSIS

• TACTILE LOCALIZATION

• DOUBLE SIMULTANEOUS STIMULATION

• TEXTURE RECOGNITION

Starts from wide to narrow and ends at the last 2 points where patient can discriminate the 2 points.

2-POINT DISCRIMINATION

What is measured in 2 point discrimination?

• SHORTEST 2 POINTS! NOT 1 POINT!

  • Once the patient senses one-point, move the points 1 point wider

  • Then measure the shortest 2 points

If the patient has INTACT___, other combined cortical sensations are also normal

2-point discrimination and stereognosis

Introduce the object first. Let them feel it with eyes open, even just do it on affected side

STEREOGNOSIS

What Brodmann’s area is affected if there is (-) stereognosis?

BA 5, 7 — Somatosensory area

Trace letter/number on patient’s palm (or any body part) and ask them to identify what was written

GRAPHESTHESIA

• Distinguish weights

• Use the same shape and size of objects. Object must only differ in weight

• Better to use bottled water for pracs

• Pakiramdaman niyo po tong bottle, and ito. Sa right or left, alin po mas mabigat?

BAROGNOSIS

Normal values for 2 point discrimination:

• Fingertips:

• Dorsum of hand:

• Palms:

Normal values for 2 point discrimination:

• Fingertips: 3-5 mm

• Dorsum of hand: 20-30 mm

• Palms: 8-15 mm

how to test for tactile localization

Introduce (paper clip) to unaffected side → say that u will do it to the affected side, then using their unaffected hand they will point where they felt the sensation → you measure the distance to where they pointed from where you actually pricked

• With patient’s eye closed, place a dot on any part of their skin and ask them to point where the dot is placed

• Measure distance of the dot PT inputted from where the pt identified to have felt the sensation

• Remember where you put the sensation

• Can have 2 trials → compare the hand and the forearm

• Tactile Localization > 0 cm

• Using your right hand, pakituro po kung nasan yung sensation… ok pikit po kayo

• Do NOT use ballpen to mark (bc they will see)

• Remember to speak loudly with stroke patients (applicable in general not only here)

how to test for double simultaneous simulation

• Introduce first to unaffected → apply two sensations simultaneously on both sides → ask ilan sensation naffeel → ask ano sensation → ask saan side na ffeel (R/L/both) → ask ano body part

  • Same body part bilaterally

  • 1 distal 1 proximal bilaterally

  • 1 distal 1 proximal unilaterally

• Ask pt to verbally identify, c their eyes closed, where they felt the sensation

  • Same body part, R/L | diff body part, R/L | one side, proximal/distal

  • Area doesn't really matter, as long as you apply two of the same sensation simultaneously

There will be absence of sensation of the distal extremities in DSS. while simultaneously applying proximal sensation during double simultaneous stimulation

EXTINCTION PHENOMENON

how to test for texture recognition

• Use silk and wool/sandpaper; introduce them first -> close eyes 

• Ask pt to answer either silk/wool or smooth/rough

• Not the same as babinski; here toes will flex 

• Scratch parallel to the ball of the foot

• Use brush; if none use tip of reflex hammer

PLANTAR SCRATCH

[reflex testing]

Upper Abdominal Reflex

T8 - T10

[reflex testing]

Lower Abdominal Reflex

T10 - T12

[reflex testing]

Plantar Scratch

L2 - S1

[reflex testing]

Anal Reflex

S2 - S4

[reflex testing]

Biceps, Brachialis Reflex

C5 - C6

[reflex testing]

Brachioradialis Reflex

C5 - C6

C6 - C7

[reflex testing]

Triceps Reflex

C6 - C7

C7 - C8

[reflex testing]

Patellar Reflex

L2-L4

[reflex testing]

Ankle (Achilles) Reflex

S1

How to document reflex testing?

O> Neurological Examination> Reflex testing> Superficial> (+/-) finding

O> Neurological Examination> Reflex testing>DTR> Hyperreflexia on R patellar tendon (or on R quads — can be tendon or muscle) 

> absent abdominal reflex

> DTR > hyperreflexia on R patellar tendon (or R quads)

> gr 3 reflex on R quads

• Should be oppressed at a certain age 

• Normal in children 

• For survival

PRIMITIVE REFLEXES

Should exist when you get old 

Normal reflex in adults 

• absence indicates possible impairment

PHYSIOLOGIC REFLEXES

What are the 3 physiologic reflexes?

REP

• RIGHTING

• EQUILIBRIUM

• PROTECTIVE EXTENSION

are defined as 'automatic reactions that enable a person to assume the normal standing position and maintain stability when changing positions'

RIGHTING REFLEX

Important for balancing

EQUILIBRIUM REFLEX

Pt has the tendency to extend hand when you are about to fall

PROTECTIVE EXTENSION REFLEX

What are the associated reactions?

• RAIMISTE’S

• STERLING’S

• MARIE-FOX

• SOQUE

• HOMOLATERAL SYNKINESIS

• pt has stroke manifestations on the R. If PT will resist hip abduction of the unaffected side (L), then there will be an associated hip abduction on the affected side ®

RAIMISTE’S PHENOMENON

pt has stroke manifestations on the R. If PT will resist shoulder abduction on the unaffected side (L), then there will be an associated abduction on the affected side ® 

STERLING’S PHENOMENON

Passively flexing the toes on the affected side, it will elicit massive flexion of the entire lower extremity on the ipsilateral side

MARIE-FOX PHENOMENON

Passively flexing the shoulder of the affected side will elicit extension of the fingers ipsilaterally 

SOQUE’S PHENOMENON

Passively flexing the UE will elicit flexion of the LE of the same side

HOMOLATERAL SYNKINESIS

[give the positive response and the name of reflex]

Stroking of lateral aspect of sole of foot towards big toe

BABINSKI

• Extension of big toes and fanning of four small toes

[give the positive response and the name of reflex]

Stroking of lateral side of foot beneath lateral malleolus → going distal

CHADDOCK

• Extension of big toes and fanning of four small toes

[give the positive response and the name of reflex]

Stroking of anteromedial surface of tibia distally

OPPENHEIM

• Extension of big toes and fanning of four small toes

[give the positive response and the name of reflex]

Squeezing of calf muscles firmly

GORDON

• Extension of big toes and fanning of four small toes

[give the positive response and the name of reflex]

Percussion of tibialis anterior muscle

PIOTROWSKI

• Dorsiflexion and supination of foot

[give the positive response and the name of reflex]

Passive flexion of one lower limb

BRUDZINKSI

• Flexion of opposite lower limb

[give the positive response and the name of reflex]

Tapping of index, middle, or ring finger (distal phalanx)

HOFFMAN

• Flexion of the distal phalanx of thumb

[give the positive response and the name of reflex]

Tapping of plantar surface of toes

ROSSOLIMO

• Plantarflexion of toes

[give the positive response and the name of reflex]

Pinching of Achilles tendon in middle third

SCHAEFER

• Flexion of foot and toes

FLEXION SYNERGY OF UE

scapular retraction

elevation

hyperextension

shoulder abduction, ER

elbow flexion*

forearm supination 

wrist and finger flexion

What is the strongest component of the flexion synergy of UE?

elbow flexion

EXTENSION SYNERGY OF UE

scapular protraction

shoulder adduction, IR

elbow extension

forearm pronation*

wrist and finger flexion

FLEXION SYNERGY OF LE

hip flexion*, abduction, ER

knee flexion

ankle dorsiflexion, inversion

toe dorsiflexion

What is the strongest component of the extensor synergy of the UE?

forearm pronation

What is the strongest component of the flexor synergy of the LE?

hip flexion

What is the strongest component of the extensor synergy of the LE?

hip adduction

EXTENSION SYNERGY OF LE

hip extension, adduction*, IR

knee extension

ankle plantarflexion, inversion

toe PF

where do you document limb synergy?

O> OI> (+) UE Flexion synergy

spasticity assessment table

O> Palpation> Gr 1 spasticity on R hamstrings

O> spasticity > grade 1 on R biceps

rigidity 2 types

Slow movement

• BOTH COGWHEEL & LEADPIPE SLOW VELOCITY

• cogwheel: matigas, mawawala tigas, matigas, mawala, so on

• leadpipe: throughout matigas

End range slow movement

TIGHTNESS

balance assessment

types of assistance

minimum change of pt in order for them to do ADLs (more important for the pt)

Minimal Clinically Important Difference (MCID)

minimum grade/number change NOT because of measurement error

Minimal Detectable Change (MDC)

A score of __ in the StrokEDGE Scoring Matrix means the tool has good to excellent psychometric properties and clinical utility.

3 or 4

Based on the article table 3

• If __ u CAN use it 

• __ DO NOT use the test 

Based on the article table 3

• 3 is written – if ur pt is acute na 3 then u dan use 5 times sit to stand

• If 3 or 4 u CAN use it 

• 1-2 DO NOT use the test 

  • Ex. isang 3, isang 1 → DO NOT USE STILL