Lecture 1: The Neurologic Examination (class 1 and 2) Flashcards

Question

Technique used by healthcare providers to gather a patients medical hx * A series of questions asled to identify a patients symptoms or signs. Its a subjective account of the patients experience, and can be used to identify conditions that dont have a specific diagnosis. * Discuss anything new, unusual, unexplained, different * determine need for referral for medical evaluation * **review medical screen and ROS form with the pt - so reviewing their systems w/ the pt - more converstational** Physical therapists seek ifnormation relevant to major body systems through observation and questioning to help determine whether there are symptoms that suggest the need for referral for additional medical evaluation Someone notes something on their past medical hx and I want to know more about it. Then im probing more and getting more information maybe intake just says numbness and tingling. Well I want to know more about that

Answer 1

review of systems

Answer 2

Systems review * S for screening

Answer 3

Person (self) Place Time Situation

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>/ 26 its scored out of 30

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Brocka aphasia They have the words they just can't get them out would want to use yes/no questions

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a language disorder that affects a person's ability to understand and express language, as well as read and write

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Nicki aphasia They're talking loads but the words make 0 sense Non verbal gestures are best here

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Executive function

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20 systolic 10 diastolic 20 BPM all these indicate OH NOTE: this could be failure of the sympathetic NS to adequality constrict blood vessels in the lower body * blood loss * anemia * dehydration NOTE: OH is common in parkinsons, and this is super bad because it can lead to falling Other autonomic testing ( bladder, bowel and sexual functions - questionniare / hx taking

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Resting tension in muscle (resistance to stretch in the muscle) * remember, tone is normal, however you can have too much or to little of it

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Tone * so for most people this tone is enough to support us and keep us upright but that doesnt doesnt really impact a normal ROM. You can have high tone that does stop that full ROM though

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Passively (which is why its always tested in supine) NOTE: If it was active then we would be adding in muscle strength, which is not what were testing

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Minimal - you're not going to resist that person much. Normal resting tone doesnt block you from moving that limb/body part in that ROM

Answer 14

No! you're working in a patients available ROM. * if someone has a contracture or is lacking for range, its not like you're going to push them into that full range. You're just looking for tone issues in their available ROM

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Complete lack of resistance to passive stretch (no tone) - think floppy - you go to pick up their limb and it just falls down * This is LMN pts or the shock phase of a SCI (UMN)

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abnormally low tone (but some tone still exists unlike flacidity) * These again are those LMN pts or the shock phase following a SCI

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Velocity-dependent hypertonia * UMN pts Velocity dependent means that it reacts to speed. When we check it we quickly move that limb to get that reflexive catching of the limb (aka excess tone w/ movement) - the muscle turns on more than it should --> hypertonia * its abnormally high resistance w/ faster movement.

Answer 18

The speed at which you move the limb will affect the outcome * think spasticity where if you move it fast that muscle will start catching and you'll see that increased tone.

Answer 19

UMN injury causes hypertonicity 1) Spasticity 2) Rigidity 3) Dystonia

Answer 20

It's velocity dependent (meaning that depending on if theres velocity that muscle will lock up and present w/ increased tone) It comes from damage to the motor cortex or brainstem * A stroke can cause damage in these areas which is why this is an UMN pathology * This hypertonicity is an UMN pathology

Answer 21

Rigidity is velocity independent - meaning it doesnt matter how fast you're moving you're always going to have that increased muscle tone Comes from damage to the basal ganglia * This hypertonicity is a UMN pathology * NOTE Stiffness in **parkinsons** is due to this (dengeration of those basal ganglia) NOTE: w/ rigidity typically the agonist and antagonist are impacted equally and both have hypertonicity, while in spasticity only one (agonist or antagonist) * again the agonist and anatagonist are fighting eachother, not letting you get through that movement - which causes that rigidity / hypertonicity throughout that entire movement no matter what speed were going

Answer 22

Prolonged involuntary twisting or writhing repetitive movements, increased muscular tone. * damage to the basal ganglia * This hypertonicity is a UMN pathology * NOTE: this is more in huntingtons but is due to any damage of the basal ganglia NOTE: you can have cervical dysontia aka twisting of the neck with the hypertonicity locking those muscles up | I added this picture

Answer 23

1) Hypotonia 2) Flaccidity This is mostly LMN, however, spinal shock (UMN) can behave like this

Answer 24

To determine the resting tension of the muscle in the upper and lower extremeities

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NOTE: This is not specific to spasticity but just for muscle tone

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Spasticity

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In rigidity both the agonist and antagonist muscles are involved while in tone you typically just have the agonist or antagonist

Answer 28

its similar but is rigidity vs hypertonicity

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Nope, this scale is specificly meant for spasticity which is high tone

Answer 30

Cogwheel Rigidity Lead Pipe Rigidity Remember, in rigidity both the agonist and atagonist muscles are resisting the passive stretch * and its velocity independent, meaning speed is not a factor

Answer 31

Tension in a muscle that gives way in little jerks when muscle is passively stretched * just like one of those old cog wheels

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A "smooth" rigidity in flexion and extension that continues through the entire range of a stretched muscle * Think about trying to bend a led pipe - at no point does it get easier to bend it in its ROM

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**Sustained** stretching (not just 4x15) Heat helps Avoiding triggers

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Modified Ashworth Scale * Remember, spasticity is velocity dependent (speed does affect it) which is why when implementing these tests 2/3 trials are with that increased velocity to try and trigger that spasticity.

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Watching someone do an action before you're cueing on how to fix it * gives us a naked eye look at what activity is before fixing it * Obviously you would need to be careful w/ fall risk * Big observation of pt

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1) One to establish ROM --> move limb slowly over a 4 second period to see that ROM (velocity unimportant here) 2/3) We take that limb very quickly through that full ROM twice. This should take 1 second between movements and we do these 2 trials 1 second apart (so barely any time between tests) **Remember this is all passive, we don't want the muscle actively helping**. If you're testing elbow flexion you start in elbow flexion and move into extension * You're strethcing the muscle you want to test to see if it has spasticity

Answer 37

Start in flexion and move to extension. This is true of every body part If we want to test hip abductors we start in hip abduction --> adduction * we start in the shortest postion that muscle can go then lengthen it to see if theres tone problems in that ROM Testing shoulder extension you start in as much shoulder extension as you can, but your in neutral because their in neutral then move into flexion to test the extension To test the ankle plantar flexors your start in PF --> DF

Answer 38

No increase in muscle tone (this is normal for this scale, not 2+)

Answer 39

Slight increase in muscle tone, manifested by a catch and release **or** by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension (so resistance at the end of the motion)

Answer 40

NOTE: This is the only + on the scale - very similar to 1 except its an and instead of or Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM (so not just at the end) * so it doesnt release to nothing

Answer 41

More marked increase in muscle tone through most of the ROM but affected part(s) easily moved * entire ROM is harder to move in * Harder to move but you can still move it

Answer 42

Considerable increase in muscle tone, passive movement difficult * hard to move through that full ROM

Answer 43

Affected part(s) rigid in flexion or extension * basically impossible to move through that full ROM * they're technically rigid here You proably wouldnt use this scale for a 4. Theres no point in adding the velocity because they proably have rigidity which means you can use that other scale for rigidity (2+ = normal) to asses them because you don't need the velocity portion.

Answer 44

3 1 to establish full ROM (4 seconds) 1 to test velocity (1 second) 1 to test velocity (1 second) NOTE: sometimes these tests can trigger spasms NOTE: we would not do this test on someone whos flaccid - that could be a saftey issue

Answer 45

Involuntary beating (>5 beats) * Spasmodic alteration of **antagonistic** muscle contractions via quick stretch, can be elecited in tone testing happens w/ quick stretch (happens with tone testing) * when you hold them in that stretch it beats (once you stop the stretch it stops) You get rid of it by stopping the stretched movement

Answer 46

Static postural control (stability) Body not in motion BOS fixed Example - prone on elbows, quadurped, sitting

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Dynamic postural control BOS fixed Examples - weight shifting, limb movements, reaching

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Examples - rolling, supine to sit, sit to stand, transfers you're actully moving body here

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Skill Examples: gasp/manipulation for UE; locomotion, stair climbing for LE This is combining everything together

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These are our superficial sensations * Light touch * Pain * Temp

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Sharp/dull testing NOTE: Light touch is part of that ull testing

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Deep sensations Kinesthesia Proprioception Vibration

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These are sensations that need several parts of the brain to come together and form (they're more complex) - take more than 1 pathway to form * **Stereognosis** * **Two point discrimination** * Barognosis * Graphesthesia * Tactile localization * Recognition of texture * Double simultaneous stimulation

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Superficial --> Deep --> Combined cortical NOTE: Superificail is super easy to test

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Random, unpredictable manner with variation in timing, distal to proximal * Don't go from finger to shoulder and back and forth, but just don't follow the exact set pattern every single time The distal to proximal is because your deficits are typically distally lost before proximal * However, this is variable

Answer 56

Trial test performed to instruct the pt what to epect and how to respond to application of the specific stimuli **with eyes open** Patients vision occluded during the actual test **eyes closed**

Answer 57

5 points on 1 side (however, if you've going back and forth its 10) this is variable but mak sure you're documenting how many trials and how many they got correct - so you get a percentage document as intact or impaired

Answer 58

Cognitive screen before sensory testing * because if they arent cognitively there then they wouldnt be able to accurately relay information back to you * You can't really do this testing if pt has a profound cognitive impairment After this we do our pre test with eyes open Following that we do the test with the eyes closed

Answer 59

Anything above C4, so you're using the face so when you're showing them what you're doing for the test do the normal side first. If someone has right sided deficits you do it on the left side first to show them what it should feel like, then move to the impaired side * this would be done in the pre test

Answer 60

Ipsialtearl while the rest of the brain is considered contraltarel

Answer 61

Ipsilatearl motor coordination deficits * note: this isnt as much sterength and more motor coordination * Think posture, coordinated movements etc...

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Yes, is named for deficits below the level of the lesion. So if they have a C5 injury they keep elbow flexion. however, they loseC6 (wrist extension)

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Allodynia * it shouldnt hurt but it does

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Analgesia Think getting this if they're on tons of medication

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Dysesthesia (similar to allodynia but is specific to touch)

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Hyperalgesia

Answer 67

Parasthesia Think numbness after a stroke

Answer 68

were focusing on more major tracts, not just particiular nerves. So you don't need to do either of these, you do more of a gross screen.

Answer 69

Light touch

Answer 70

Remember, this is light touch You use a hairbrush, piece of cotton (ball or swab or tissue (she said she just uses her finger but that probs isnt the best) The area lightly touched or stroked The patient is asked to indicate when they recognize that a stimulus has been applied by responding "yes" or "now" * Note: you would do a trial with eyes open then closed * I'm guessing we also show them what it feels like on the uninvoled side as well We should do around 5 per limb (not a hard rule) but the quantiative score is found by dividing the number of correct responses by the number of stimuli applied - you should end up with a percentage * NOTE: missing one or 2 isnt an indication that theres a pathology, you just might be over a calus or something Non verbal: * Hold up one or two fingers (yes/no, hot/cold) * Nodding * Pointing to index cards containing printed responses * Hand gestures

Answer 71

Pain perception tested via sharp/dull discrimination * indicates function of protective sensation HOW: * Tools - large headed safety pin, a reshaped paper clip, or single use protected neurlogical pin * carefully cleaned before testing and disposed of afterward (just in case it breaks the skin) * Randomly applied perpendicularly to the skin * Vary area and timing * Sharp enough to deflect skin but not puncture it Patients response: Answer either sharp or dull to each test Im assuming eyes open and closed trial starting w/ the contralateral extremeity Spinothalamic tract

Answer 72

Tells us if the person has normal / protective extension This would be good for a diabetic w/ peripheral neuropathy, sensory impairments to LE, CNS injuries * this gives us safety information

Answer 73

4.17 (1 g of force)

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5.07 (10g of force)

Answer 75

This allows us to see if the pt can distinguish between warm and cold stimuli How: * Two test tubes with stoppers * Warm water and the other between 104-113 (becuase you dont want to burn them) * Randomly palced in contact with skin area * Also i assume we do contralateral side first and do a trial with eyes open --> closed Patients response: * The pt asked to reply hot or cold after each stimulus application Spinothalamic tract

Answer 76

The point is to test the perception of pressure How: * Therapists fingertip or double-tipped cotton swab - so pressing in (don't w/ this were indeenting skin and w/ light touch were not) * Firm pressure on skin surface firm enough to indent skin and stimulate deep receptors Patients response * The patient is asked to indicate when an applied stimulis is recognized by responding yes or now *

Answer 77

Kinesthesia testing

Answer 78

Involved extremeity or joints moved passively through small ROM Small increments used as joint receptors fire at specific points throughout the range Basically the patient has to tell you which way the extremity is moving before you come to the end of that movement and stop (we stop and ask them at the end of that movement in proprioception testing) Patients response: * verbalize direction (up, down, in, out) **while the extremity is in motion**

Answer 79

Proprioception

Answer 80

**Involved** extremity or joints moved through a ROM and held in a static position * so you're seeing if the involved side can sense where it is in space Small increments of range are used caustion with hand palcements to avoid excessive tactile stimulatoin Patients response: you pick * Patient describes position verbally * Duplicates position with contralatearl exremity (position matching) * Active duplication of position by patient using same limb

Answer 81

How: * Turning fork that vibrates at 128 hz * Place base of vibrating tuning fork on bony prominence * Tines briskly hit against open palm of the examiners opposite hand to initate vobration * Do not touch tines * random application of vibrating and non-vibrating stimui * Always start vibration due to sound, then stop by tines patients response * distinguish between vibrating and non vibrating tuning fork

Answer 82

Combined cortical sensation - so it comes from lots of different parts of the brain Its the ability to recognize form of objects by touch Variety of small, easily obtainable, and culturally familiar objects Differing size and shape are required (ex - keys, button, ring, coins) - something small enough to fit in hand and be deteced by the hand and be familar to pt Object placed in hand Patient manipulates object Pts response: * Identifies item verbally or with picture cards

Answer 83

Combined cortical sensation Its the ability to percieve two points applied to skin simulatensouly How: * Measure of smallest distance between two stimuli * Applied simultaneously and with equal pressure * Perceived as two distinct stimuli Patients reponse: * Patient is asked to identify the perception of "one" or "two" stimuli

Answer 84

Clonus Common in the plantar flexors (think calf cramps) but may also occur in other areas of the body such as the jaw or wrist

Answer 85

Cerebellum (think uncoordinated movement) * however, there are other places as well, but the cerebellum is in charge of coordinating movements however, both gross and fine motor coordination take place in the motor cortex (frontal lobe in the precentral gyrus) - and cerebellum

Answer 86

They test for motor cordination deficits dysdiadochokinesia = rapid alternating movements * can look at this in UE by going back and forth between pronation and supination (UE test) * at the foot we do foot tapping (so tapping back and forth between feet) (LE test) Dysmetria = difficulty reaching a target (problems judging distance or range of motion) * We test this by doing finger to nose (UE test) * Heel to shin (starting at ankle and dragging it up to knee) (LE test) Eyes open initially, however, close eyes to make it more challenging (or just speed up the motion to make it more challenging) * however, eyes open doesnt really matter that much in this because thats pure sensory, while were testing to motor system and its coordination (not the visual system) --> so having the eyes open is okay and were still testing what we want to be testing

Answer 87

Reciprocal motion * this fits more w/ dysdiadochokinesia (rapid alternating movements) - how are the muscles working together and are they doing so effectively

Answer 88

Movement composition or synergy * this fits more w/ dysdiadochokinesia (rapid alternating movements) - how are the muscles working together and are they doing so effectively

Answer 89

Movement accuracy * NOTE: this is like dysmetria * Think of it as not being sure how many meters you went

Answer 90

Fixation or limb holding * this fits more w/ dysmetria

Answer 91

Reciprocal motion * rapid alternating movement

Answer 92

look at slides and go back through these

Answer 93

ability to focus on an object, moving your focus on 1 object to another.

Answer 94

1) Dysarthria - issues speaking (bad articulation) 2) Dysphagia (issues swallowing) 3) Diplopia (double vision) 4) Dysmetria (difficulty reaching targets [misjudge meters]) - think finger to nose 5) Drop attacks 6) Dizziness if they have this they need more investigation

Answer 95

VOR - quick head movement while stabilizing gaze on something * looks at eyes ability to maintain gaze when head is moving * Don't cover their ears and tell them what you're doing first * Make sure they dont have neck problems * jerking fast quick movement - looking to see if their eyes are staying on your nose

Answer 96

Deviates toward uanffected side (note: issue w/ hypoglossal deviates towards affected side [the tongue])

Answer 97

SCM Trap Tested w/ MMT

Answer 98

Tongue deviates toward the side of lesion (deviates ipsilaterally)

Answer 99

Turning head to left and bringing right ear to right shoulder This is because R SCM does contraltaerl rotation (turns head opposite direction its on) and ipsilatearl latearl flexion then for traps lesia just had me raise my shoulder and pushed down

Lecture 1: The Neurologic Examination (class 1 and 2) Flashcards

(190 cards)