NMS II OSCE 1 -- Sensory & Motor Examination

T/F: Sensory exam is primarily a subjective examination.

TRUE

What tract is involved with light touch in the cord?

Anterior spinothalamic tract (Anterior spinal cord)

What tract/part of the cord is involved w/ pain and temperature?

Lateral spinothalamic tract (Lateral spinal cord)

What tract/part of the cord is the vibratory sensation and deep pain?

Posterior columns (Posterior aspect of spinal cord)

What are the skin areas innervated by specific segments of the cord?

Dermatomes

What dermatome chart is performed posterior root sections?

Sherrington & Foerster

What dermatome chart is studied herniated disks with the blocking of a single nerve root?

Keegan

What is the normal length of time for acute injury phase (the time it takes to maximally swell)? What is the purpose of this?

2-4 days

Autoimmune response to bring in all the materials to help heal the area (ex: fibrogen)

How long does it take before all the swelling is gone (how long is the sub-acute phase)? What is occuring during this phase?

2-4 weeks

Healing

(fibrogen bonds)

What does the adjustment do for an individual?

Breaks up the disordered fibrogen bonds/cross fibers

(the bonds not within the stress lines of the ligament which lead to fixation, so we are hoping to break down the cross-fibers to allow the ligament/tendon to function properly and allow nice movement)

NOTE: Fibrogen bonds are a chaotic disorganized restitching (ex: a blind seamstress), causing binds/knots

With an initial injury to the facet joint (an injury this morning for example), we find that sensory and motor are good but there is irritation. Should we adjust this patient day one?

NO since the ligaments would be loose

-- we adjust fixations, not laxity

NOTE: should not adjust during acute stages because they hare HYPERMOBILE

What is the #1 cause of irritation?

Subluxation

How can you differentiate between irritation & compression?

Compression would have sensory and/or motor deficit

NOTE: Normal sensory & normal motor = irritation

T/F: Both compression & irritation decrease the transmission of that nerve

FALSE

Compression = decrease

Irritation = increase

What are the 3 parts of the nerve root?

1) Autonomic

2) Sensory

3) Motor

Why does the edema affect the nerve more in the IVF than in the proximity?

Proximal are guarded/protected by epineurium & perineurium

(not guarded in the IVF by this)

With nerve root irritation: when you irritate the sensory nerve, what does the patient perceive? Irritate motor component? Irritate autonomic component?

Sensory = Pain

Motor = Spasm (changes threshold)

Autonomic = Constriction of blood vessels

If the needle swings towards the side of pain (warmer on side of subluxation), is this irritation or compression?

COMPRESSION

If the needle swings away from the side of pain (warmer on opposite side of subluxation), is this irritation or compression?

IRRITATION

T/F: Mild compression (first signs of compression) on a nerve will affect the sensory function of the nerve root first

FALSE

-- affects AUTONOMICS first

Why does it get hot/warm on the side of subluxation with compression?

Not sending signals to arteries, so the arteries dilate (making it warmer)

Why does it get colder on the side of subluxation with irritation?

Sending extra signals to arteries, so arteries constrict (making it cooler since it is warmer on the other side)

What is the rule for instrumentation to equilibrate?

20-20 rule

(20 minutes undressed at 20C)

How do you objectify the sensory examination? (5)

1) Patient keeps eyes open

2) Introduces cotton ball and pin-wheel

3) Doctor stimulates the patient with a cotton ball and a pin-wheel and ask can you feel the difference

4) Patient closes their eyes

5) Doctor then stimulates the patient a few times with a cotton ball and a pin-wheel and ask the patient to tell what they feel

What is the primary reason the patient came into your office and is a reliable indicator for underlying pathophysiology as well as help you find the subluxation?

Pain

How do you perform the light touch and pain examination of L1-S4? (4)

1) Patient stands and closes eyes

2) Tell patient that you are going to touch them with cotton to compare side to side

3) Doctor touches the patient with the cotton on both sides over the dermatomes starting at L1 comparing side to side with the question "Does it feel about the same on both sides?"

4) Doctor then continues through all of the dermatomes comparing side to side from L1-S4

Which tuning fork is for vibratory sensation? Hearing?

Vibratory = 128 or 256

Hearing = 512

How do you perform the sensory examination of vibration for L1-S4? (4)

1) Patient SITS and closes eyes

2) Tell patient you are going to touch them w/ a tuning fork on the ankles and the wrists to compare side to side

3) Using 128 or 256 Hz, touch the patients styloid process of distal radius bilaterally & medial malleolus bilateral, asking patient "what do you feel?"

4) Instruct patient going to touch those same areas again w/ tuning fork and ask "is the intensity of vibration equal on both sides in both the wrists and ankles?"

T/F: The heel is the best spot to check for the S2 sensory dermatome

FALSE

-- we never test heel for sensory (S2) because most of the time it calloused and dry skin, would have to pierce deeply in order to penetrate enough for sensory exam

How do you perform the light touch or pain sensory examination of the thoracic region? (7)

1) Patient stands & closes eyes

2) Tell patient you'll touch them w/ cotton or pinwheel to compare side to side

3) Touch back of patient w/ cotton on both sides of back in 4 areas on both sides

4) Touch at point between T2 spinous and T4 spinous comparing side to side

5) Touch at a point between T4 spinous and T7 spinous comparing side to side

6) Touch at a point between T7 spinous and T10 spinous to compare side to side

7) Touch at a point between T10 spinous and T12 spinous comparing side to side

NOTE: not touching all 12 dermatomes, just 4 sections (side to side making 8); also do it on the back, not the front of patient.

If all the muscles are functioning good (no weakness), but there is a sensory deficit from T4-T7, what could this indicate?

Lesion of the Post Central Gyrus

(sensory homunculus; abscess or tumor)

-- this area is ALL sensory!

If there is muscle weakness and sensory deficit from T4-T7, what could this indicate?

Nerve Root compression

If there is muscle weakness and sensory deficit starting in the T4-T7 dermatome area and down the remainder of the body, what would this indicate?

Cord compression

What 3 dermatomes are from the clavicle to the nipple?

T2-T4

What dermatome is at the level of the nipple?

T4

What 4 dermatomes is from the level of the nipple to the level of the epigastric?

T4-T7

What dermatome is at the level of the xiphoid process (epigastric)?

T7

What 4 dermatomes are from the level of the epigastric tot he umbilicus?

T7-T10

What dermatome is at the level of the umbilicus?

T10

What 3 dermatomes are right below the umbilicus?

T10-T12

What dermatome is at the level of the inguinal region/ligament (groin)?

L1

What dermatome is at the level of the anterior upper 1/3 of the thigh, on the back & front of the thigh to knee?

L2

What dermatome is at the level of the middle 1/3 of the anterior thigh and medial knee?

L3

What dermatome is at the level of the distal 1/3 of the anterior and medial thigh/knee, medial calf, medial malleolus, medial aspect of foot (big toe), with the 3 areas checked are the anterior knee, anterior leg, and medial foot?

L4

(L4 to the floor)

What dermatome is at the level over the back (wrap around buttocks) radiating down the anterior-lateral side of the lower leg and over the dorsal foot to include middle 3 toes and lateral aspect of the heel, with the 2 places checked being the anterior lateral lower leg & dorsal foot?

L5

What dermatome is at the posterior aspect of the buttocks, thigh, & leg, including the lateral aspect of the foot & lateral aspect of little toe, with the 3 locations you are checking being the posterior lateral thigh & calf w/ lateral anterior foot?

S1

What dermatome wraps around the medial aspect of the buttocks, straight down the posterior (medial) leg/calf and thigh, diving into the medial side of the heel, with the 2 locations your checking the posterior medial thigh & calf?

S2

What dermatome is over the ischial tuberosity?

S3

What dermatome is over the perineum, genitals, and lower sacrum?

S4

What dermatome is over the perianal region?

S5

When testing temperature, the cold and hot receptors, through intense stimulation by either extreme temperature (especially hot) will stimulate ________________ and therefore cause pain?

Stimulate free nerve endings therefore cause pain

T/F: The pathway for temperature sensation seems to be identical for that of pain, however it is believed that temperature is superior for specialized localization of deficits

TRUE

During temperature testing, cold stimuli should be between ____-_____ F.

41-50 F

During temperature testing, hot stimuli should be between _____-_____ F.

104-113 F

T/F: The temperature examination needs to be done even if the pain examination is negative

FALSE

Need NOT be done if pain examination was negative since it is testing the SAME tract (Lateral spinothalamic tract)

A patient complains of pain and numbness sensation in the right L5 dermatome, and your sensory examination reveals no deficits to light touch, pinprick, or vibration bilaterally.

What could this indicate?

L5 nerve root irritation

-- most likely secondary to inflammation associated with subluxation

A patient complains of pain and numbness sensation in the right L5 dermatome and the sensory exam reveals a deficit to light touch and pinprick over the right L5 dermatome, but vibration is normal bilaterally.

What could this indicate?

L5 nerve root compression

-- due to SOL at level of L4 disc (L4 disc herniation)

A patient complains of numbness sensation on the right side of the body from the right nipple down the entire right side of the body, while the sensory exam reveals a deficit to light touch from the right nipple down the entire right side of the body with pinprick and vibration was found to be normal bilaterally.

What does this indicate?

Compression of the anterior spinal thalamic tract in the cord at approx level of T2 on the left

A patient complains of numbness sensation on the right side of the body from the right nipple down the entire right side of the body, with a sensory exam revealing a deficit to pinprick form the right nipple down the entire right side of the body, with light touch and vibration found to be normal bilaterally.

What does this indicate?

Compression of the lateral spinal thalamic tract in cord at approx level of T4 on left

A patient complains of numbness sensation on the right side of teh body from the umbilicus down the entire right side of the body with sensory exam revealing a deficit to vibration at the right medial malleolus and light touch/pinprick normal bilaterally.

What does this indicate?

Compression of RIGHT gracilis tract

-- exact location difficult to identify so documented as "Possible SOL compressing right gracilis tract at or below C5"

What instrument is used to measure light touch?

Monofilimant

Why do most disc herniations herniate posterior-lateral?

Anterior Longitudinal Ligament (ALL) wraps around front but doesn't wrap around back; the PLL covers back but it does NOT meet up with ALL so there is a weak gap present

What is a tear of the PLL on MRI called and is associated with a posterior central disc herniation?

True Rent

What is the likelihood a person has normal sensory results with radicular symptoms?

97%

-- 97% of patients don't have compression; 3% have true compression

If there is normal sensory, motor, and reflex results, what is causing the radicular pain in an individual?

Noxious stimuli to nociceptive fibers

-- Edema (noxious stimuli) stimulating/irritating the sensory nerve root in that area (causing perception of pain)

What are the two ligaments of the capsule that are involved in a subluxation?

1) Posterior capsule

2) Ligamentum flavum

How long can we leave an end organ in a hypoxic state, or a compressive state on a nerve root, until they will no longer regenerate?

We don't know

-- depends on health of patient

If we have a patient with TRUE compression on a nerve, do we adjust the patient day 1?

NO

What is the MC cause of compression?

Disc herniation

What is a medical emergency including pain, numbness, tingling, LBP radiating to the legs, and depending on the nerve roots affected can cause weak plantar flexion with foot drop (S1-S2) or loss of bowel/bladder, muscle weakness, sensory loss (S3-S5), often caused by tumor, spinal stenosis, herniated disc, cancer, infection, or inflammation?

Cauda Equina Syndrome

-- 18 nerve roots are in the cauda equine at the base of the spine

If there is a SOL on the left of the L4 disc, what NR could this be affecting for cauda equina syndrome?

Left L5 root

If there is a SOL on the left of the L5 disc, what NRs could this be affecting for cauda equina syndrome?

Left L5 & S1 root

If there is a bilateral SOL on the L4 disc, what NRs could be affected in cauda equina syndrome?

Everything below this level is affected!

(L5-S5)

How long can we treat a patient until no change or worsening in condition indicates we should refer out (standard protocol)?

2 weeks

What test should be ordered if there is a decrease in sensory/motor/reflex (true Hypo) indicating a possible SOL?

MRI

If there is true numbness & muscle weakness (Hypo), but the MRI comes back negative for any SOLD, what does this mean?

Chronic subluxation

-- causes vasoconstriction which leads to hypoxia to nerve/nerve root; tissue in state of hypoxia dies leading to symptoms

7% of the time this happens

T/F: There is no rigid organization and the brain plasticity is considerable in the motor homunculus.

TRUE

What is the easiest and best way to check motor nerve function as it checks the impulse from cortex to the muscles?

Muscle testing

Testing the muscle will supply information on upper, lower, or both motor neurons? What 3 areas are assessed?

Upper & Lower motor neurons (both)

1) Strength

2) Tone

3) Volume

T/F: True weakness is a smooth movement in muscle testing in the lower extremity

TRUE

NOTE: not the same as muscle testing in AK exams

When documenting muscle testing, what ranking is complete paralysis?

0

When documenting muscle testing, what ranking is a twitch of movement?

1

When documenting muscle testing, what ranking is moderate to severe paralysis?

2

When documenting muscle testing, what ranking is moderate paresis?

3

NOTE: barely used since once resistance is placed on the arm it goes form a 2 to a 4 if there is weakness

When documenting muscle testing, what ranking is mild paresis?

4

When documenting muscle testing, what ranking is normal?

5

What are the nerve roots tested in Hip Flexion? Peripheral Nerve?

L1-L4

Femoral nerve

How do you perform Hip Flexion? (4)

1) Patient supine (or seated)

2) Instruct patient to flex hip to 90 and knee to 90

3) Instruct patient to flex hip against resistance

4) Pain?

NOTE: name of the test tells you what patient doing, patient flexing hip

In Hip Flexion, what nerve roots innervate the Psoas major? Iliacus through the femoral nerve? Psoas Minor?

L2-L4

NOTE: Why its Psoas + Iliacus = Iliopsoas

Minor = L1-L2

What are the nerve roots tested in Hip Extension? Peripheral Nerve?

L5-S2

Inferior Gluteal nerve

How do you perform Hip Extension?

1) Patient prone

2) Stabilize w/ one hand on sacrum

3) Maintain position against resistance

4) Pain?

What are the nerve roots tested in Hip Abduction? Peripheral nerve?

L4-S1

Superior gluteal n.

How do you perform Hip Abduction?

1) Patient lying on their side w/ affected hip up

2) Patient abducts affected thigh to 45

3) Doctor places hands over thigh just proximal to knee joint

4) Dr instructs patinet to abduct thigh against resistance

5) Pain?

NOTE:

Easier method --

Patient laying involved hip up

They abduct their leg (scissored leg appearance)

Doc pushes down using their gravity and patient resists

What are the nerve roots tested in Hip Adduction? Peripheral nerve?

L2-L4

Obturator Nerve

How do you perform Hip Adduction?

1) Patient lying on affected side w/ unaffected side foot brought up and placed in front of patients affected thigh

2) Have patient adduct affected leg off table

3) Place hand overa ffected thigh just proximal to knee joint

4) Dr instructs patient to adduc tthigh against resistance

5) Pain?

NOTE:

Easier method --

Patient laying involved hip down

Asymp Leg brought up & over (like a lateral x-ray position)

Symp leg raised off table

Dr uses gravity & weight to provide resistance

What is the nerve root for Knee Flexion? Peripheral nerve?

L5-S2

Tibial n.

How do you perform Knee Flexion?

1) Prone

2) Patient flex knee to 90

3) Dr places hand around ankle & instructs patient to flex knee against resistance

4) Pain?

What is the nerve root tested for Knee Extension? Peripheral nerve?

L2-L4

Femoral Nerve

How do you perform Knee Extension?

1) Prone

2) Patient flex knee to 90

3) Dr places hands around ankle & instructs patient to extend knee against resistance

4) Pain?

What is the nerve roots tested for Plantarflexion of the Ankle? What is the primary nerve root? Peripheral nerve?

S1-S2

Primary = S1

Tibial N