Exam Study Notes

Facial Nerve & Sensory Assessment

• Facial Nerve (Motor): Controls facial muscles.

• Sensory: Innervates the anterior 2/3 of the tongue for taste.

• Muscle Function: Closes eyes tightly, puffs out cheeks, smiles showing teeth.

Vestibulocochlear Nerve (VIII)

• Responsible for hearing and balance.

• Hearing: Transmits auditory information to the brain.

• Balance: Transmits information about balance to the brain.

• Air Conduction: Sound travels through outer, middle, and inner ear.

• Bone Conduction: Sound vibrates through the skull to the inner ear.

• Types of Hearing Loss:

  • Conductive Hearing Loss: Bone conduction is better than air conduction. Often due to middle ear issues.

  • Sensorineural Hearing Loss: Air conduction is better than bone conduction. Indicates inner ear or nerve damage.

Hearing Tests

• Crude Test: Assess gross hearing ability.

• Rinne Test: Compares air and bone conduction using a tuning fork placed on the mastoid process.

  • Positive Rinne: Air conduction > bone conduction (normal or sensorineural loss).

  • Negative Rinne: Bone conduction > air conduction (conductive loss).

• Weber Test: Tuning fork placed on the forehead to detect lateralization (sound louder in one ear).

  • In sensorineural hearing loss, sound lateralizes to the better ear.

  • In conductive hearing loss, sound lateralizes to the worse ear.

Vestibular Function

• Vestibular Problems: Can cause vertigo (sensation of spinning).

• Hallpike Test: Assesses for Benign Paroxysmal Positional Vertigo (BPPV). Burn head 45 degrees to one side and lie down quickly, then turn to the other side. Sensory for one is positive.

Cranial Nerve Assessment

• Glossopharyngeal (IX): Sensory and motor functions related to the pharynx and tongue.

• Vagus (X): Motor and sensory functions, including taste sensation from the posterior tongue.

• Accessory Spinal Nerve (XI): Controls sternocleidomastoid and trapezius muscles (shoulder elevation).

• Hypoglossal (XII): Motor nerve controlling the tongue; loss of function leads to tongue deviation.

Superficial Sensory Assessment

• Pain: Assessed using a pin or sharp object; patient should close their eyes.

• Touch: Light touch sensation.

• Temperature: Use tubes filled with hot (40-45°C) and cold (5-10°C) water.

Deep Sensation Assessment

• Pressure: Apply pressure with thumb and finger tip.

• Vibration: Use a tuning fork.

• Joint Position Sense (Static): Assess awareness of joint position while stationary.

• Joint Kinesthetic Sense (Dynamic ROM): Assess awareness of joint movement.

Combined Cortical Sensation

• Stereognosis: Ability to identify objects by touch.

• Two-Point Discrimination: Ability to distinguish two closely placed points.

• Tactile Localization: Ability to point to the area touched.

• Double Stimulus Stimulation: Identifying simultaneous touches in different locations.

• Graphesthesia: Ability to recognize letters or numbers traced on the skin.

Reflex Assessment

• Purpose: Helps identify the level of neurological lesion and the relationship between sensory and motor functions, differentiates between Upper Motor Neuron (UMN) and Lower Motor Neuron (LMN) lesions.

Superficial Reflexes

• Pupillary Reflex: Use light in a darkened room to observe pupillary constriction.

• Corneal Reflex: Touch the cornea with cotton to elicit eye closure. Tested by putting cotton to the pupil.

• Plantar Reflex: Stroking the sole of the foot.

  • Normal response: Plantar flexion (toes curl down).

  • Abnormal response (Babinski sign): Toe extension (UMN lesion).

• Abdominal Reflex: Stroking the abdomen causes contraction of abdominal muscles.

Deep Tendon Reflexes

• Biceps: C5-C6 nerve roots.

• Triceps: C6-C7 nerve roots.

• Brachioradialis: C5-C6 nerve roots.

• Knee (Patellar): L3-L4 nerve roots.

• Ankle (Achilles): S1-S2 nerve roots.

Reflex Grading

• 0: No response

• 1+: Diminished response

• 2+: Normal response

• 3+: Brisk response

• 4+: Hyperreflexive (clonus may be present); hyperactive, muscle contraction.

Lesion Localization

• Levels: Muscle, peripheral nerve, nerve root, neuromuscular junction, spinal cord/brain, cerebellum, basal ganglia, cerebral cortex.

• LMN Lesion: No response or depressed reflexes, superficial reflexes depressed.

• UMN Lesion: Hyperreflexia below the level of the lesion.

• Spinal Shock: At the level of the lesion, reflexes are hypoactive. causes hypoactive and pendular movement.

• Unilateral Hyperreflexia: Suggests lesion on the contralateral side of the brain.

Bowel and Bladder Assessment

• Neurogenic Bladder: Bladder dysfunction due to neurological condition.

  • UMN Neurogenic Bladder (Spastic): Lesion above S2-S4; detrusor and sphincter overactive, incomplete bladder emptying.

  • LMN Neurogenic Bladder (Flaccid): Lesion below S2-S4; detrusor and external sphincter areflexic.

• Assessment Questions:

  • History: Medical, surgical, medications.

  • Symptom Onset: How long have you had symptoms?

  • Aggravating Factors: What makes symptoms worse?

  • Frequency: How often do you need to go to the toilet?

  • Urgency: Do you need to rush to the toilet?

  • Leakage: Do you ever leak urine (cough, laugh, sneeze)?

  • Stream: Is the urine stream continuous or intermittent?

  • Emptying: Do you feel like you completely empty your bladder?

  • Infections: Have you had any urinary tract infections in the last 6 months?

Balance and Coordination Assessment

• Romberg Test: Assesses balance; standing with eyes open and closed to observe any swaying.

• Single Leg Stance (Static): Standing on one leg to assess static balance.

• Alternative Single Leg Stance (Dynamic): Alternating standing on each leg to assess dynamic balance.

• Coordination Tests:

  • Finger-Nose Test: Touching the nose with the index finger.

  • Finger-to-Examiner Test: Alternately touching the examiner's finger and the nose.

  • Heel-Shin Test: Sliding the heel down the shin of the opposite leg.

  • Circle Drawing Test: Drawing circles with upper and lower extremities.

  • Tandem Walking Test: Walking heel-to-toe.

  • Hound Walking Test: Walking around objects without touching them.

  • Alternative Box Walking Test.

  • Eight Drawing Walk Test.

Musculoskeletal System Assessment

• Subjective Assessment:

  • Patient Information: Age, name, gender, address, phone number, occupation, referral source.

  • Chief Complaint: Reason for seeking treatment.

  • History: Past and present (onset, aggravating/relieving factors, duration, character, radiation, severity).

  • Family and Personal History.

• Objective Assessment:

  • Observation: Swelling, redness, posture, gait.

  • Palpation: Tenderness, muscle tone, skin temperature, edema (pitting/non-pitting).

  • Measurements: Muscle power and tone, ROM.

  • Movements: AROM and PROM assessment.

  • Special Tests.

  • Vital Signs: HR, BP.

Motor Assessment

• Spasticity: Velocity-dependent increase in muscle tone (UMN lesion).

  • Clasp-Knife Test: Initial resistance followed by sudden release.

  • Cogwheel Rigidity: Resistance with superimposed ratchet-like jerks.

• Rigidity: Increased resistance throughout the ROM.

  • Lead-Pipe Rigidity: Constant resistance.

• Muscle Tone Decreased: Floppy body.

  • Hypotonia/Atonia: Decreased or absent muscle tone.

  • Cataplexy: Sudden loss of muscle tone.

Tone Assessment Tests

• Dropping Test: Assesses tone by observing how a limb drops.

• Head Lag Test: Pull to sit and observe head control.

• Shoulder Shaking: Assess tone by shaking the shoulder.

• Arm Test: Observe arm position and movement.

Assessment of Tone (Upper and Lower Extremities)

• Observe for:

  • Ms

  • adduction/abduction.

  • Elbow flexion/extension.

  • Wrist and finger flexion/extension.

  • Hip flexion/extension.

  • Knee flexion/extension.

  • Ankle plantarflexion/dorsiflexion.

  • Inversion/Eversion.Clonus

• Rhythmic, involuntary muscle contractions, often assessed at the ankle (plantarflexion, dorsiflexion).

Lumbar Spine Tests

• Slump Test:

  • Patient Position: Sitting at the edge of the table.

  • Technique: Patient bends forward without neck flexion, then extends the knee with dorsiflexion while therapist applies pressure to the neck and shoulders.

  • Positive Sign: Pain, indicating stretch in the meninges of the spinal cord.

• Straight Leg Raise (SLR) Test (Lasegue's Test):

  • Patient Position: Supine with medial rotation and adduction of the hip, knee extended.

  • Technique: Raise the leg with extended knee. Lower leg slightly and then dorsiflex the ankle.

  • Positive Sign: Excruciating pain at 70°, indicating disc herniation.

• Brudzinski's Sign:

  • Patient Position: Supine with medial rotation and adduction of the hip, knee extended.

  • Technique: Similar to SLR, but neck is flexed passively.

  • Positive Sign: Pain, indicating dura matter stretch or lesion in the spinal cord.

• Modified SLR Test:

  • Patient Position: Side lying with test leg positioned superiorly, hip and knee flexed to 90°.

  • Technique: Therapist supports the pelvis and slowly extends the knee.

  • Positive Sign: Pain in the lower back, indicating disc herniation.

• Lhermitte's Sign (Cross-over Test):

  • Patient Position: Supine lying.

  • Technique: Leg of the unaffected side is lifted gradually.

  • Positive Sign: Pain in the opposite leg, indicating disc herniation.

• Prone Knee Bending Test:

  • Patient Position: Prone lying.

  • Technique: Flex the knee to the maximum ensuring no hip rotation.

  • Positive Sign: Pain in lumbar region, buttock, or posterior thigh, indicating L2/L3 nerve root lesion.

• Bowstring Test:

  • Patient Position: Supine lying.

  • Technique: Therapist places the subject's affected leg on his shoulder girdle with the knee extended and applies pressure to the popliteal fossa then the common peroneal nerve.

  • Positive Sign: Pain radiating in the lumbar area, indicating sciatic nerve compression.

• One Leg Standing Lumbar Extension Test (Stork Standing):

  • Patient Position: Stands on one leg.

  • Technique: Subject extends his/her back while standing on one leg.

  • Positive Sign: Back pain, indicating stress fracture of pars interarticularis (spondylolisthesis).

• Stoop's Test:

  • Patient Position: Standing or walking.

  • Technique: Patient performs brisk walk for hardly 50 m.

  • Positive Sign: Pain in the gluteal region and lower limbs, indicating intermittent claudication.

Pelvis Tests

• Gapping Test:

  • Patient Position: Supine lying.

  • Technique: Therapist applies pressure over ASIS with arms crossed in a downward and outward direction.

  • Positive Sign: Pain in one side/buttocks or in posterior aspect of the leg, indicating sprain in SI ligament.

• Approximation Test:

  • Patient Position: Side lying.

  • Technique: Therapist applies pressure over the upper part of the iliac crest in a downward direction.

  • Positive Sign: Pain in the SI joint, indicating SI joint lesion.

• Sacral Apex Pressure (Prone Springing) Test:

  • Patient Position: Prone lying.

  • Technique: Therapist applies pressure over the apex of the sacrum with the hands.

  • Positive Sign: Pain in the SI joint, indicating SI joint lesion.

• Gillet's (Sacral Fixation) Test:

  • Patient Position: Standing.

  • Technique: Therapist commands the patient to stand on one leg with other knee flexed to his chest while places his/her one thumb over PSIS and other over the sacrum.

  • Positive Sign: Placed thumb over sacrum moves up, indicating SI joint dysfunction.

• Genslen's Test:

  • Patient Position: Side lying with upper leg hyperextended.

  • Technique: Therapist asks the patient to hold the lower leg towards the chest. Later while stabilizing the pelvis, therapist extends the hip of the upper leg.

  • Positive Sign: Pain in the sacral region, indicating SI joint lesion.