EONS review

Cognitive screen (4) orientation for a left frontal lobe stroke in supine. — Explain how to do so

1) Person — Name and date of birth

2) Place — location “can you tell me where we are?”

3) Time — date “what is today?” or “what is the day of the month”

4) Situation — why they’re there “what brought you here?”

Attention to task test

spell WORLD backwards

Short term memory recall test

Recall 3 unrelated words throughout the exam

ex: apple, penny, table

why test cognition early in the examination?

to orientate and find any yellow/red flags

Pt examination who is returning to home; ask 3 relevant pt history questions

PLOF — amount of assistance at home, home environment, equipment available

Precautions

Medication

Goals

Systems screen older adult who had a stroke; 3 relevant questions related to systems beyond the neurologic system.

1) comorbidities

2) functional abilities, maybe even before the stroke

3) precautions

Why screen early in the examination, say for the stroke pt earlier?

Helps understand the patient more holistically and become aware of precautions you may have missed otherwise.

Under what circumstances would an attention to task and memory test be given?

When there is a deficit in orientation; like a left temporal lobe stroke.

— assess the nature / extent of cognitive impairment

Test CN I and IX (name them)

“Are things smelling and tasting normal to you?”, pot have them smell mint or vanilla.

CN I — Olfactory — smell

CN IX — Glossopharyngeal — assess taste for post 1/3 tongue

Give 2 reasons why it is good to perform the CN screen early in the exam.

1) early detection of neurologic conditions

2) exam direction

CN II (name); right occipital lobe stroke. Perform the acuity test and a separate test for visual field / spatial neglect in supine.

CNII — Optic N

Acuity — clock

visual field — read the chart from x distance

spatial neglect — look at my nose, keep your eyes on my nose… now point to the finger that’s moving.

Test CN III, IV, VI (name them), left hemisphere stroke in sitting.

• Normal response?

• Two potential abnormal findings?

CN III, IV, VI — Oculomotor, trochlear and abducens

Perform a “H” motion and follow with eyes

• Norm — follows finger without head motion

• Abn — Moves their head or nystagmus

Test CN V (name); right parietal lobe stroke in sitting.

CN V — trigeminal

Light touch these three branches:

• V1 — ophthalmic — skin superior to eyebrow

• V2 — maxillary — on maxilla

• V3 — mandibular — on mandible

If they lack sensation of the face on one side, what may this predict later on in the exam?

May show sensation neglect on ipsilateral arm, trunk or leg

Test CN VII (name); left hemisphere stroke in supine.

• Supranuclear lesion representation…

• Peripheral lesion representation…

CN VII — Facial

Upper quadrant — raise eyebrows, lower quadrant — smile

• Supranuclear — contra lower ¼ only

• Peripheral — ipsi hemiparalysis; upper and lower ¼

Test CN VIII (name); left brainstem stroke test in supine. What can help identify neglect

CN VIII — vestibulocochlear

Test with rubbing fingers by the ear; identify neglect with bilateral simultaneous finger rub and with eyes closed.

• Additionally — test balance

Test CN X (name); what would you ask and what would you listen for? Potential risk offering food or medication?

CN X — Vagus

• Ask — any difficulty swallowing

• Listen for — excessive throat clearing

• Risk — aspiration

Test CN XI (name); right front lobe stroke in supine.

• Quantify results when pt can only move through partial ROM on contralateral side

CN XI — Spinal accessory

• Assess strength of upper traps or SCM

• Grade 1 — palpable or visible contraction

• Grade 2 — AROM full in gravity eliminated

Test CN XII (name); right front lobe stroke in sitting.

• due to lesion location, where is the deviation expected

CN XII — Hypoglossal

Stick your tongue out and move it side-to-side

• supranuclear location — deviates towards contralateral (weak) side

• intranuclear location — deviates towards ipsilateral (weak) side

Light touch sensation test for suspected cerebral deficits in sitting.

• if they pass, why is deep pressure / proprioception tests unnecessary in most cases

Using a cotton swab lightly graze dermatomal sites on the LE and UE in an unrhythmic fashion, expecting the most deficit at the distal LE.

• If they are sensitive enough to pass the light touch test, they’ll pass the less sensitive tests easy — safe time

Why use a cotton ball and not your finger when testing light touch?

easy to use too much pressure with a finger tip, as well as the associated heat one may feel with the finger — the cotton ball is the purer exam

Describe the light touch test in terms of the DCML pathway.

The dorsal column–medial lemniscal (DCML) tract carries fine touch, vibration, and conscious proprioception from the body to the brain. It ascends ipsilaterally in the dorsal columns of the spinal cord (fasciculus gracilis for the lower body, fasciculus cuneatus for the upper body), then decussates in the medulla and continues as the medial lemniscus to the thalamus. From there, information is relayed to the primary somatosensory cortex for conscious perception and localization.

AIS — A = ….

Complete. No sensory or motor function preserved in sacral segments

AIS — B …

Sensory incomplete. Sensory spared in levels below lesion, no motor function preserved 3+ levels below bilaterally

AIS — C …

Motor incomplete. motor function preserved at sacral, partial motor function sparing on either side of the body. (less than half the mm score 3 or lower)

AIS — D …

Motor incomplete. Same as AIS —C, except more than half the mm score 3 or higher

AIS — E …

Normal, for those with previous SCI. Those without prior SCI do not receive the ASIA scale.

Sensory grading (reflexes); list the relevant scores

• Absent

• Altered

• Normal

• Not testable

Absent — 0

Altered — 1

Normal — 2

Not testable — NT

Muscle function grading, list them

0 — paralysis

1 — palpable / visible contraction

2 — full AROM in gravity eliminated

3 — full AROM against gravity

4 — full AROM against gravity, mod resistance

5 — full AROM against gravity, full resistance

NT — due to immobilization, severe pain, contracture

What is the ashworth scale for?

to measure spasticity through PROM flex / ext

ashworth scale define the grades 0-4

0 — no increase in mm tone

1 — slight increase in mm tone, catch of resistance then subsides

1+ — slight increase in mm tone, catch of resistance then minimal resistance to PROM

2 — increase of mm tone, affected parts easily moved

3 — considerable increase in mm tone, PROM resisted

4 — affected mm are rigid

Test deep pressure sensation; left middle cerebral artery stroke in supine

• When are deep pressure sensation tests indicated

similar to light sensation except with additional force

• when a light sensation examination is unsatisfactory

Test pain sensation for random spinal level, know key sensory level in supine.

Get to knowing dermatomes

Why must pain sensation be tested for spinal and brainstem lesion but not necessary for cerebral lesions?

pain pathway (spinothalamic tract) is anatomically distinct from the dorsal column–medial lemniscus (DCML) pathway, and damage in these regions can selectively impair pain and temperature without affecting other sensory modalities. In contrast, cerebral lesions (e.g., in the thalamus or cortex) usually result in global sensory deficits (affecting all modalities—light touch, pain, temperature, proprioception) on the contralateral side of the body due to the convergence of sensory pathways at higher levels.

Therefore, testing pain sensation is crucial to localize spinal cord or brainstem lesions where selective tract involvement (like dissociated sensory loss) may occur. It is less diagnostically necessary in cerebral lesions, where multiple sensory modalities are typically affected together.

How would you score a pt who says dull when you press the sharp side during a pain sensation exam?

0, they are just feeling touch and not pain.

Why is supine the required testing position for all sensory and motor AIS testing?

It is a position the virtually all people with a spinal cord
injury could assume.

• It is a way to standardized the testing, increasing intra
  and intertester reliability

Describe the pain pathway from start to finish.

1) sensory detects noxious stimulus

2) Post horn

crosses to…

3) Lateral spinothalamic tract

ascends to…

4) Lat nucleus of Thalamus

5) somatosensory homunculus

How would you perform a proprioception test?

Show what you’re going to do, have them close eyes, move their digit, “tell me is it open or closed” stop and grade

Performance on the proprioception examination is predictive of what other impairment level test to come?

Kinesthesia, same element and higher difficulty

What pathway is being tested in a proprioception examination…

1) origin

2) cross point

3) termination

1) Muscle spindles, Golgi tendon organs, joint and cutaneous mechanoreceptors.

ascends then crosses at…

2) internal arcuate fibers via medial lemniscus

3) via VPL of thalamus terminates at the primary somatosensory cortex (homunculus)

Describe the difference between kinesthesia and proprioception and which would be harder to detect.

Kinesthesia — sense of limb position — dynamic, how and in which direction

Proprioception — sense of limb position — static, where it is

• Kinesthesis is harder for pts to detect, demands the pt be able to determine movement onset, speed and direction.

Double simultaneous stimulation test, quickly explain how to perform it for a right hemisphere stroke in supine.

test either one side or both sides simultaneously. Ask pt to say left, right or both, grade.

For double simultaneous stimulation… what findings would trigger the need for this examination and how could abn findings affect function.

If the pt was demonstrating inattention to one side, difficulty distinguishing each side, and functional asymmetries

• if (+) contralateral neglect

• would make it harder to dress/groom and navigate environments

How would you perform stereognosis for a R MCA stroke, UE mainly affected in sitting.

recognition of familiar objects within the hand

Why would a PT use the stereognosis test on a pt who passes the light touch and proprioception tests?

While light touch and proprioception assess primary sensory pathways (DCML tract), stereognosis evaluates the ability of the brain—particularly the contralateral parietal lobe to integrate somatosensory input and recognize object characteristics

Why would a PT choose to use a graphesthesia test over a stereognosis test?

• briefly show how to perform said test

pt demonstrates hemiparesis, spasticity, or weakness

• graphesthesia requires no movement, so test won’t be floored

If the Hoffman reflex for a C4 injury is positive bilaterally, what are you likely to find when testing deep tendon reflexes in UE?

Indicative of a UMN lesion; expecting hyperreflexia for biceps, brachioradialis and triceps reflexes

What neural pathway is being tested in a Babinski reflex?

1) origin

2) cross

3) termination

Corticospinal tract

1) primary motor cortex, precentral gyrus

2) 90% at medullary pyramids (lateral corticospinal tract), remainder makes the anterior CST

3) terminates on the anterior horn of the spinal cord, synapsing with LMN → peripheral nerves move the mm

Describe the reflex arc for the biceps tendon reflex (C5)

1

Stimulus

A quick tap on the biceps tendon (typically with a reflex hammer) stretches the muscle spindle fibers in the biceps brachii.

2

Receptor

Muscle spindles (intrafusal fibers) detect the sudden stretch.

3

Afferent pathway

The Ia afferent fibers carry the signal from the muscle spindle to the dorsal root ganglion, then into the dorsal horn of the spinal cord (mainly at C5).

4

Integration center

The afferent fiber synapses monosynaptically on an alpha motor neuron in the anterior (ventral) horn of the same spinal segment (C5).

5

Efferent pathway

The alpha motor neuron sends a signal through the musculocutaneous nerve to the biceps brachii.

6

Effector

The biceps contracts, producing elbow flexion as the observable reflex response.

When a brachioradialis DTR is performed, 2+ DTR in the right and 3+ DTR on the left is recorded… which pathway is likely damaged?

CST issue

Right side — DTR of 2+ = normal

Left side — DTR of 3+ = brisk/increased

Likely R side stroke, left side demonstrates hyperreflexia

Describe why deep tendon reflexes usually become hyperreflexic in the presence of damage to the associated corticospinal pathway

Loss of descending cortical input

Removes inhibition of reflex arc

Disinhibited alpha motor neurons

Heightened response to stretch

Impaired modulation of reflex sensitivity

Exaggerated reflexes at rest

Patellar DTR for a conus medullaris injury… How would you document your findings if no response is elicited on the left and only a palpable muscle contraction on the right?

Left: Absent (0) – No response elicited

Right: Diminished (1+) – Palpable contraction of quadriceps with no visible movement

Achilles DTR, how would you score for elicited clonus?

Achilles Reflex: 4+ (clonus elicited)

R to PROM for UEs, R stroke.

• What is the scale being used?

• Difference between 1 and 1+

Ashworth scale for spasticity

1 — slight mm tone increase, catch and release

1+ — slight mm tone increase, catch and min R through remainder

R to PROM of UE; Describe how you would document/score a considerable increase in muscle tone, with difficulty moving the UE into shoulder external rotation, though still able to go through the motion

Ashworth scale for spasticity

3 — considerable increase in mm, PROM difficult

Describe the purpose of taking the pt through slow arc phase first

slow movement allows the clinician to assess the resting tone of the muscle without activating velocity-dependent stretch reflexes.

• distinguishing spasticity from rigidity, contracture, or soft tissue restriction.

R to PROM; describe how a score of 2 in bilateral hip add could affect walking.

Ashworth scale for spasticity: 2 — mod spasticity

• Narrowing the base of support

• Altering swing phase mechanics

• Interfering with balance and leg positioning

• Reducing gait efficiency

Strength/ROM Screen UEs in patient who had Left MCA stroke. The patient only partially raises the affected arm against gravity. Test in sitting.

• After performing the full screen, what muscle grade would you score on the affected side for shoulder flexion?  

Shd flexion = 3–

Parkinson’s disease pt LE strength/ROM screen; why test sensation before testing muscle strength?

Sensation is tested before strength because intact sensory input is essential for accurate and safe performance of muscle strength testing

AIS myotome strength testing; what muscle grade would be given for partial range in gravity eliminated.

partial AROM in gravity eliminated… 2

AIS myotome strength testing; what score would you give a pt with full AROM against gravity but can only withstand mild R?

full AROM against gravity, mild R… 3 maybe 3+

Why is all ASIA Impairment Scale (AIS) testing done in supine?

It is an orientation that the majority of SC injury pts can withstand and helps standardize the results

pronation/supination diadochokinesia test, what purpose does closing the eyes have?

Removes visual compensation, increases proprioceptive reliance (DCML)

Alternate Nose-to-Finger; which specific aspect of non-equilibrium coordination is being tested?

Accuracy, if sensory or cerebellar ataxia is suspected

Finger opposition, L MCA stroke

• describe the spinocerebellar pathway.

The spinocerebellar pathway transmits unconscious proprioceptive information from muscles, tendons, and joints to the ipsilateral cerebellum to support coordination, posture, and fine motor control.

• For the UEs, the cuneocerebellar tract originate in the spinal cord or medulla, do not decussate, and terminate in the cerebellum via the superior cerebellar peduncle

Foot tapping test for a R thalamic stroke, which side would likely be affected?

Left foot likely affected

• Foot tapping is a non-equilibrium coordination task that evaluates rhythm, speed, and alternating motor control, typically reflecting cerebellar, basal ganglia, or thalamic function

Check Reflex (Rebound test) R cerebellar infarction

• what is the purpose of this test?

cerebellar assessment; the patient's ability to modulate and inhibit antagonist muscle activity following the sudden removal of resistance

Alternate heel-to-knee and heel-to-toe, L int capsule stroke

• what purpose does increasing speed serve?

Adding speed increases the complexity of the motor task, enhancing detection of coordination deficits, dysmetria, and motor planning errors, particularly in patients with lesions to the internal capsule, which disrupts descending motor output to the contralateral limbs (CST)

dynamic sitting balance, MS

• how would you test for full reaching in all directions?

• how would you document your findings?

MS pt likely kyphotic

• hips and knees at 90, feet flat, surrounded by padded surface and use of a gait belt for PT

• Ant / post / lat R / lat L / post lat L / post lat R

  • document their D reached and assist required

Equilibrium progression in standind, T2 injury

• In addition to determining the maximum sustained position, what other qualitative assessments should be made?

1. Trunk pos over BOS

2. hip / knee / shd alignment

3. amount of ext support required

4. stepping strategies present or delayed — perturbation

5. amount of sway and recovery from

6. transitions smooth or hesitant

7. does balance decline over time — fatigue rate