NMS I - Exam 1 (VBI, CB, DC, ect.)

If a pt has head and neck pain, what should be evaluated

think vascular = VBI (stenosis)

Cerebral vascular ischemia

heachaches, diplopia, drop attacks, dysarthria, dysphagia

Absolute contraindications

VBI

major artery aneurysm

acute arthropathies and acute freactures

malignancies

myelopathy or cauda equina symptoms

Relative contraindications

hypermobility

demineralization of bone

benign bone tumors

bleeding disorders

radiculopathy w/progressive neurological signs

Stethoscope for bruits

diaphragm = high sounds

bell = low sounds

Barre-Lieou

causes compression of vertebral arteries to try to elicit symptoms

If any of the VBI tests (VBA functional maneuver, Barre-Lieou, DeKleyn’s) are positive what three further imaging should be done

1) MR angiogram of head

2) MR angiogram of neck

3) MRI of head

The body will fall ____ the side of the cerebellar lesion

towards

Six cardinal fields of gaze revealed nystagmus in right eye when looking to the right

cerebellar lesion on right involving flocculonodular lobe

Cerebellar tracts are _________ and produce ipsilateral findings

double crossed

Where does cerebellar tracts cross

1st - superior cerebellar peduncle in midbrain

2nd - corticospinal and rubrospinal tracts (pyramidal decussation)

Cerebellar lobe functions - Hemispheres

appendicular coordination (UE + LE)

• finger to finger, finger to nose, heel to shin

Cerebellar lobe functions - Vermis

gait and axial coordination (walking and trunk)

• tandem gait, hopping on one leg, squatting on one leg

Cerebellar lobe functions - Flocculonodular/Vestibulocerebellum

connections with vestibular nuclei (eye and gross balance)

• vestibular function and connections w/labyrinth

Pt falls with only eyes closed = DC deficit below lesion

sensory ataxia

• classic findings of Tabes dorsalis or B12 deficiency (MC)

• syringomyelia

What poisons vermis producing a widened gait

alcohol

Hypermetria vs Hypometria (finger to nose, finger to finger)

hypermetria = over shooting

hypometria = undershooting

What abnormality can be found in finger to nose to finger (eyes open ONLY)

dyssynergia (incoordinate movement)

What two things can be found in heel to shin

dyssynergia

dysmetria (inaccuracy in measuring distance)

Abnormality found in RAM (diadochonkinesia)

dysdiadochonkinesia = cerebellar dysfunction

Abnormality from Holmes Rebound test (eyes open and closed)

loss of check reflex

What part of the cerebellum is being evaluated during tandem gait

vermis

Posterior cord syndrome (infarction of posterior spinal artery)

loss of vibration, proprioception, reflexes below level of lesion

**Note: pain, temperature, muscle strength are spared

Anterior spinothalamic tract carries what sensation

light touch

Lateral spinothalamic tract carries what sensation

sharp pain and temperature

Cuneatus tract (UE) and Gracilis (LE) of dorsal columns carry what sensation

vibratory sensation, proprioceptive info, 2pt touch discrimination

Posterior cervical disc herniation affects _____ part of the spinal cord first

anterior

• effects anterior and lateral spinothalamic tracts

Discriminating local touch name

topesthesia

Deep pain and topesthesia is initiated by

corpuscles of Meissner

Sensation is carried by primary large diameter heavily myelinated fibers through

posterior/dorsal spinal cord district

Your static and motion palpation exam findings reveal that your pt experiences pain BEFORE end range with your passive ROM

pt has an acute condition

Your static and motion palpation exam findings reveal that your pt experiences pain AS end range is reached with your passive ROM

pt has a subacute condition

Your static and motion palpation exam findings reveal that your pt experiences pain AFTER end range with your passive ROM

pt has a chronic condition

Resisted muscle testing of right triceps muscle reveals that is painful and strong

pt has a minor sTrain (Tendon)

2pt touch discrimination normal values

Finger tips = 2-4mm

Dorsum of fingers = 4-6mm

Palm = 8-12mm

Dorsum of hand = 20-30mm

Nosognosis

ability for pt to know that they are ill (pt will deny there is a problem)

Medial side of ring finger is innervated by

ulnar C8

Lateral side of ring finger is innervated by

median C8

Nerve root Irritation (NRI)

hyper’s (inc sympathetics)

instrumentation break AWAY from involved side (vasoconstriction/hypothermia)

Nerve root compression (NRC)

hypo’s (dec sympathetics)

instrumentation break TOWARDS involved side (vasodilation/hyperthermia)

NRC means the nerve is

dying

Sensory/Motor/DTRs exams exhibit abnormal or decreased findings with NRC, what sensations are lost 1st

1) autonomics

2) light touch

3) sharp pain and temp

4) vibratory sensation

Sensory/Motor/DTRs exams exhibit abnormal or decreased findings with NRC, what sensations are regained 1st

1) vibratory sensation

2) proprioception

3) pain and temp

4) light touch

Paresthesia (abnormal sensation like tingling/burning) + instrumentation break AWAY from involved side

NR irritation

Anesthesia (absent sensation) + instrumentation break TOWARDS involved side

NR compression

SOL in Cervicals (L)

IVF = same as disc level (C5 IVF)

Disc = below NR level (C5 disc)

NR = C6

SOL in Thoracics (I)

IVF = same as disc level (T7 IVF)

Disc = same as NR level (T7 disc)

NR = T7

SOL in Lumbar (C)

IVF = same as NR level (S1 IVF)

Disc = below NR level (L5 disc)

NR = S1

What is the easiest and best way to check motor nerve function

strength tests

In a motor exam, the voluntary motor impulses are initiated in the

primary motor cortex of frontal lobe in pre-central gyrus

Muscle exams assess

strength, tone, and volume

UMNL symptoms

spacticity, hypertonia, hyperreflexia

Spasticity

increased muscular resistance felt by examiner during quick joint movement that quickly fades away

• Clasped knife (tension at first followed by decreased tension as joint is opened)

Cogwheel rigidity

joint give way with passive motion (seen in Parkinson’s)

Hypertonia (Gooseneck rigidity)

resistance felt through its entire ROM

lesions of extrapyramidal tract

Release phenomena

exaggerations of normal neurological function due to loss of cortical inhibition

LMNL (NRC) symptoms

flaccidity, hypotonia, hyporeflexia

Hypotonia

neurological damage at the level of the reflex arc

• example: cerebellar disease (intention tremor)

Deficit phenomena

reductions in muscle tone, DTRs, muscle strength, muscle volume

Neural shock that caused injury first cause ONLY

peripheral type neurological findings (3-4wks before becoming hyperactive)

Antigravity muscles are _____ than their antagonists

stronger

Kinetic power

force exerted on a changing position (lifting barbell off rack in bench press)

Static power (-)

exerted in resisting movement (lowering barbell to chest in bench press)

Extrapyramidal syndrome ______ kinetic power while static remain normal

DECREASE

Muscle grading

0/5 - no evidence of contraction

1/5 - evidence of slight contraction but no joint motion

2/5 - complete ROM gravity eliminated

3/5 - complete ROM enough strength to put joint through normal ROM

4/5 - complete ROM against gravity with some resistance

5/5 - complete ROM against gravity with full resistance

Muscle strength - Supraspinatus

C4, 5, 6

Suprascapular N

Muscle strength - Deltoid

C5 + 6

Axillary N

Muscle strength - Biceps

C5 + 6

Musculocutaneous N

Muscle strength - Brachioradialis

C5 + 6

Radial N

Muscle strength - Wrist extension

C6, 7, 8

Radial N

Muscle Strength - Triceps

C6, 7, 8

Radial N

Muscle strength - Wrist flexion

C6, 7, 8

Median/Ulnar N

Muscle strength - Finger extension

C6, 7, 8

Radial N

Muscle strength - Finger flexion

C7, 8, T1

Median/Ulnar N

Muscle strength - Finger abduction

C8 + T1

Ulnar N

Muscle strength - Finger adduction

C8 + T1

Ulnar N

DTRs

Biceps = C5

Brachioradialis = C6

Triceps = C7

Finger flexion = C8

Grading DTRs

0 - areflexia

+1 - sluggish or diminshed

+2 - normal

+3 - slightly hyperactive

+4 - hyperactive w/transient or sustained clonus

Jandrassik’s maneuver (reinforcement)

pt squeezes their glutes, knees, bites down, hand in hand pull apart

**Can’t say diminished unless tried reinforcement first

Cervical spine - midline disc herniations create

myelopathies (cord lesion)

Cervical spine - lateral disc herniations compresses

NR below

Cervical spine - hypertrophic changes of C5 uncinate will compress

C5 NR (SAME LEVEL)

Lumbar spine - midline disc herniations compresses

NR below

Lumbar spine - Foraminal (far lateral) disc herniation compresses

NR at same level

If lesion is in brain, clonus will be on

contralateral side

If lesion is in spinal cord, clonus will be on

ipsilateral side