NMS 2 Exam 1

Muscles controlled by C5

Biceps, brachioradialis, deltoid, supraspinatous

Muscle movement controlled by C6

Wrist extension

Muscle movement controlled by C7

Triceps, finger extension, wrist flexion

Muscle movement controlled by C8

Finger flexion

Muscle movement controlled by T1

Finger abduction, finger adduction

Decreased sensation, if sensation is dermatomal this would represent nerve root compression

Hypoesthesia

Increased sensation, if sensation is dermatomal this would represent nerve root irritation

Hyperesthesia

Abnormal sensation, numbness, tingling, burning, if sensation is dermatomal it would be nerve root irritation

Paresthesia

Absent sensation, if it is dermatomal this would be nerve root compression

Anesthesia

Injury and or localized inflammation, type A fibers relay information to dorsal horn

Nociceptive pain

Sense aching, burning type of pain, transmit via dorsal horn of spinal cord and thalamus

Type C fibers

Pain generated and sustained by nervous system either in PNS or CNS, typically chronic pain (diabetes, postherapetic neuralgia, phantom limb, trigeminal neuralgia)

Neuropathic pain

Conveys sensory fibers to the posterior longitudinal ligament, dura and reaching outer border of annulus

Recurrent nerve of luschka AKA sinuvertebral nerve

Transmission and modulation of noxious stimuli, density of fibers is proportional to sensitivity of specific tissues, spinal joints receive most

Nociception

Occurs when NR's are irritated

Radicular pain

Occurs when any of the pain receptors in your tissues, such as muscles, bone or skin are activated

Somatic pain

Which tissues don't have nociceptors?

- articular cartilage

- inner annulus

- nucleus of intervertebral disc

- synovial membranes

Nociceptive system inactive, to activate must have noxious stimuli which may be mechanical, thermal or chemical

Normal joint

May be caused by acute trauma/repetitive microtrauma

Noxious mechanical stimuli

Associated with activities that increase pressure within intervertebral disc like sitting, bending forward, coughing and sneezing

Discogenic pain

Innervate facet joints, annulus fibrosis, IVD, and ligaments/periosteum of spinal canal, carries pain and proprioception sensation

Sinuvertebral nerve

Sclerotogenous referred pain from inflamed cervical zygapophyseal joints, "dull achy pain found on passive motion"

Facet syndrome

Receive stimuli in dermatomal pattern

Nerve roots

Receive stimuli in peripheral nerve pattern

Peripheral nerves

Is the typically chiropractic patient more likely to have hyperesthesia or hypoesthesia?

Hyperesthesia

What tract carried light touch?

Anterior spinothalamic

Bilateral medial thigh and buttock pain, bowel/bladder dysfunction, sensory exam S3-S5 is decreased or absent for light or sharp touch, medical emergency

Cauda equina syndrome

Bilateral leg pain, bowel and bladder function normal or maybe some leaker, sensory exam is normal, evaluate and monitor

Sacral sparing syndrome

Disc herniation, synovial cyst and spinal stenosis, vascular, rheumatologic, infectious, iatrogenic and other MSK etiologies

Common causes for lumbar radiculopathy

What age does lumbar radiculopathy occur?

44, more common in men

- disc herniations

- bone

- tumor

- hemorrhage

- infection

- muscle

- ligament

Causes of hypoesthesia of a NR

Imbalance of endolymph, ADH, low sodium diet, limit alcohol, get more rest, eliminate smoking, may lead to progressive hearing loss, tinnitus and feeling of fullness in ear

Menieres disease

Reposition of debris in the canals, delay of 2-5 seconds before onset of nystagmus with peripheral lesions, nystagmus and vertigo will fade away within about 30 seconds (fatiguing), with central lesions nystagmus starts immediately with no fatiguing

Benign paroxysmal positional vertigo (BPPV)

Bacteria or viral infection with hearing loss, inner ear affected otitis media or meningitis

Labyrinthitis

Hearing loss with vertigo and dizziness/tinnitus, benign schwannoma of CN 8, cerebellopontine angle, tumor grows may compression brain stem (5, 7, 8)

Acoustic neuroma

End point is common, pathological starts well before patient is at visual end feel

Nystagmus

1. Patient seated, auscultate and palpate carotid and subclavian arteries (w diaphragm and bell)

2. If no bruits, instruct patient to rotate and hyperextend head to one side then the other

3. Symptoms of vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus = positive

VBAI functional maneuver

- have patient seated and instruct patient to slowly rotate the head side to side

- symptoms of vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus are a positive test

Barre-lieou sign

- patient supine with head extending off table

- patient rotates and hyperextends neck to one side and holds position for 15-45 seconds, count backwards from 20 seconds

- symptoms of vertigo, dizziness, visual disturbances, nausea, syncope, nystagmus are a positive test and indicates ischemia from vertebrobasilar circulation compromise

Dekleyns test

Dull achy pain with passive motion

Ligament sprain

Bilateral dermatomal radiating pain

Spinal cord injury

Sharp pain on motion

Joint injury

Throbbing pain

Vascular pain

Unilateral multi-dermatomal radiating pain

Brachial plexus/peripheral nerve injury

If patient does no feel vibratory sensation equally from side to side, what is the problem?

Dorsal columns

If patient does not feet vibratory sensation at all, what is the problem?

Neuropathy

Hypoesthesia and hyperesthesia during a sensory examination of the lower extremity could mean what?

- dermatomal problem

- peripheral nerve pattern

- brachial plexus pattern

- vascular insufficiency pattern

- spinal stenosis

- intermittent claudication

- thrombophlebitis

- visceral pain referral pattern

1. Touch between T2 spinous and T4 spinous comparing side to side

2. Touch between T4 spinous and T7 spinous

3. Touch between T7 spinous and T10 spinous

4. Touch between T10 spinous and T12 spinous

Light/sharp touch sensory exam of thoracic region

- laceration

- severe bruising

- gunshot wound

- stretching

- fracture

- drug injection injury

- electrical injury

- disease

- inflammation

Causes of injury to peripheral nerve network

Elevated levels of substance P found in these patients, cause fairly normal stimuli to result in exaggerated nociception

Fibromyalgia

Hypertrophic uncinate process changes at the vertebrae in the cervical spine effect what NRs?

The same level

Ex: C6 hypertrophic unicate process changes affect C6 NR

What levels are herniated discs MC?

L4-L5 and L5-S1

When checking L1 with a sharp pinprick, what tract is being tested?

Lateral spinothalamic

Initiated in the cerebral cortex, located primarily in the motor cortex, frontal lobe on the pre central gyrus

Voluntary motor impulses

See spasticity, hypertonic, hyperreflexia and pathological reflexes in muscles

UMNL

See flaccidity, hypotonia and hyporeflexia within muscles

LMNL

Muscle twitching, contraction of muscle fibers brought on by fatigue, cold, caffeine and motor neuron diseases

Fasciculations

What muscles are tested during hip abduction?

Gluteus medius/minimus, piriformis, sartorius and tensor fasciae latae

What muscles are tested during hip adduction?

Adductor brevis, adductor longus, adductor magnus, pectineus, gracilis, quadratus femoris, obturator externum and hamstrings

L4 NR compression can lead to weakness of what muscles?

Adductor muscles

- direct injury

- SOL affecting the nerve

- prolonged immobilization

- pelvic fracture

- hemorrhage

- catheter placed into the femoral artery

- diabetes

- weakness of the leg with knee extension

Causes of femoral nerve compression

Localized sensory symptoms (lateral femoral cutaneous nerve L1-L3), caused by wearing tight clothing, heavy belts, weight gain, trauma to the hip

Meralgia paraesthetica

Pressure, deformity, trauma, paresthesia, anesthesia of the lateral upper thigh, worse with walking, standing and extension of the hip, improved with sitting

Meralgia paraesthetica

What nerves innervate psoas major?

L1-L4

What nerves innervate iliospoas?

L2-L4

What nerves innervate the psoas minor?

L1-L2

What muscle is tested in hip extension?

Gluteus maximus

What muscles are tested in hip flexion?

Psoas major, iliopsoas, and psoas minor

What muscle is tested in knee extension?

Quadriceps

What muscle is tested in knee flexion?

Hamstrings

What muscles are tested in ankle dorsiflexion?

Tibialis anterior, extensor digitorum longus, extensor hallucis longus

What muscles are tested in ankle plantar flexion?

Gastrocnemius, soleus, flexor digitorum longus, flexor hallucis longus

What muscles are tested in ankle inversion?

Tibialis posterior

What muscles are tested in ankle eversion?

Peroneus longus, brevus

Lesions where cause loss of strength/power and is generally involved with the whole extremity or gross movements?

Extrapyramidal and corticospinal tracts

Areflexia

Grade 0

Sluggish or diminished reflexes

Grade 1+

Normal reflexes

Grade 2+

Slightly hyperactive reflexes

Grade 3+

Hyperactive reflexes with transient or sustained clonus

Grade 4+

Have the patient squeeze his/her glutes, knees, bite down as the examiner is testing the reflex

Jendrassiks maneuver

Ulnar nerve damage, pinky stuck in abduction, "gets stuck on pocket"

Wartenbergs sign

Ulnar nerve flexion of the 4th and 5th digits, from a more proximal lesion

Bishop/benediction hand

Ulnar nerve damage from a distal lesion, hand deformity

Claw hand

What NR is primarily tested with the patellar reflex?

L4

With S1 NRC, what 2 reflexes are decreased?

Achilles and external hamstring

Absence of patellar reflex

Westphals sign

Pull muscle up above joint line

Adductor reflex

Strike tendons at joint line

External/internal hamstring reflex

Lesions to the corticospinal or pyramidal system, loss of inhibition effect of the corticospinal system on the anterior horn

Hyperreflexia

ROM for cervical flexion

50 degrees

ROM for cervical extension

60 degrees

ROM for cervical lateral flexion

45 degrees

ROM for cervical rotation

80 degrees

Short segment structural thoracolumbar kyphosis resulting in sharp angulation

- congenital: hypothyroidism or achondroplasia

- acquired

Gibbus

Young patient (13-17), male MC, complains of mid back pain and fatigue, increased kyphosis, result of vertebral growth plate trauma, anterior wedging > 5 degrees in 3 consecutive vertebra, decreased disc height and end plate irregularity

Scheuermanns disease

Testing for hyperkyphosis, persistence of kyphosis indicates structural, if kyphosis improves its function, patient lays prone and extends their upper body off the table

Prone extension test

Patients stiff in ROM, chest expansion decreased, tenderness noted over manubriosternal joint, costochondral junctions and entire thoracic spine, HLA-B27, men MC, eye inflammation, compression fractures, heart problems, IBS, plantar fasciitis, negative RF

Ankylosing spondylitis

When testing superficial reflexes, reflex change is _____ to a lesion above the pyramidal decimation and _____ to a lesion below the pyramidal decussation

Contralateral, ipsilateral

Affects heel walk

L5