PERIPHERAL NERVOUS SYSTEM Flashcards
(43 cards)
1
Q
PNS - WHAT MAKES UP A PNS EXAM?
A
- General inspection
- Gait
- Myotomes
- Tone
- Deep tendon reflexes
- UMNL Vs LMNL
2
Q
PNS - GENERAL INSPECTION - SCARS
A
- Scars: may provide clues regarding previous spinal, axillary or upper limb surgery.
3
Q
PNS - GENERAL INSPECTION - WASTING OF MUSCLES
A
- Wasting of muscles: suggestive of lower motor neuron lesions or disuse atrophy.
4
Q
PNS - GENERAL INSPECTION - TREMOR
A
- Tremor: there are several subtypes including resting tremor and intention tremor.
5
Q
PNS - GENERAL INSPECTION - FASICULATIONS
A
- Fasciculations: small, local, involuntary muscle contraction and relaxation which may be visible under the skin. Associated with lower motor neuron pathology (e.g. amyotrophic lateral sclerosis).
6
Q
PNS - GENERAL INSPECTION - MYOCLONUS
A
- Myoclonus: brief, involuntary, irregular twitching of a muscle or group of muscles. All individuals experience benign myoclonus on occasion (e.g. whilst falling asleep) however persistent widespread myoclonus is associated with several specific forms of epilepsy (e.g. juvenile myoclonic epilepsy).
7
Q
PNS - GENERAL INSPECTION - HYPOMIMIA
A
- Hypomimia: a reduced degree of facial expression associated with Parkinson’s disease.
8
Q
PNS - GAIT
A
- Gait and stance are reliant upon many factors: Vision, Sensation, Proprioception, Motor output.
- Unsteadiness on standing with the eyes open is common in cerebellar disorders – Cerebellar Ataxia
9
Q
PNS - CEREBELLAR ATAXIA
A
- Cerebellar dysfunction leads to a broad-based, unsteady (ataxic) gait, which usually makes tandem walking (walking heel to toe in a straight line) impossible
- Instability which only occurs, or is markedly worse, on eye closure is indicative of proprioceptive sensory loss, referred to as Sensory Ataxia
10
Q
PNS - ABNORMAL GAIT EXAMPLES
A
- Bilateral upper motor neuron damage causes a scissor-like gait due to spasticity. (Spasticity – incr muscle tone & spasm)
- Propulsive gait – a stooped, stiff posture with the head and neck bent forward
- Scissors gait – legs flexed slightly at the hips and knees like crouching, with the knees and thighs hitting or crossing in a scissors-like movement
- Spastic gait – a stiff, foot-dragging walk caused by a long muscle contraction on one side
- Steppage gait – foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking
- Waddling gait – a duck-like walk that may appear in childhood or later in life
11
Q
PNS - GAIT AND COORDINATION TESTS
A
- For cerebullum ataxia/Co-ordination impairment. Common in MS
- Rombergs sign/pronator drift – stand with feet togther and arms out in front for 30secs the repat with eyes closed. Or in supination, observe if patients pronate involuntaily. +Ve if Pt cannot remain balenced
- Finger-nose test – Pt touches nose then practintioners finger, which is moving left to rght & forward/backwards. +Ve if Pt over shoots and misses – issues with depth perception. False posative may by an optic injury.
- Heel/shin test
- Dysdiadochokinesis – Pt places palm ontop of palm in supination, then pronation, then repated again and again.
12
Q
PNS - MYOTOMES
A
- A group of muscles which is innervated by single spinal nerve root
- Ranked from 1 to 5. 1 being no visible contraction, 3 movement against gravity and 5 normal power.
- First ask Pt to do the movement first to check they can do the movement against gravity, tells you there are already a three.
13
Q
PNS - UPPER MYOTOMES
A
- C1-T1 myotomes for the upper body
- C1 Chin Tuck
- C2 Head back
- C3 - CSP SB
- C4 – Shoulder elevation
- C5 – Shoulder Abduction
- C6 – Elbow extension
- C7 - Elbow flexion
- C8 – Thumb extension
- T1 Finger Abduction, adduction.
14
Q
PNS - LOWER MYOTOMES
A
- L2-S2 myotomes for the lower body
- L2 Hip flexion, knee bent Pt drives knee to chest then down into
- L3 kick the door (Knee extension)
- L4 Dorsiflex and invert foot, resist Pt pulling back to neutral
- L5 - Big toes – Pt tries to extend
- S1 Plantar flex
- S2 Heel to bum (Knee flexion)
15
Q
PNS - ASSESSING TONE
A
- Tone – passive resistance to stretch, common in Parkinson’s and MS
- Wrist – flex/extend
- Elbow - flex/extend
- Shoulder – abduction, adduction
- Hips - ‘roll’
- Knee - flexion
- Tone is graded from 0 -4 (No response, Hypotonia, Normal response, Mild-moderate hypertonia, Severe hypertonia)
- Stiffness – compliance to deformation
16
Q
PNS - DEEP TENDON RELFEXES
A
- Biceps C5
- Brachioradialis C6
- Triceps C7
- Patella L4
- Achilles S1
- Use Jendrassik manoeuvre – smile/grit their teeth, grip hands and try to pull apart, distracts them from the reflex
17
Q
PNS - LOSS OF DEEP TENDON REFLEX IMPLICATION
A
- Peripheral neuropathies secondary to diabetes, alcohol abuse, or inflammation.
18
Q
PNS - SUPERFICIAL REFLEXES
A
- Umbilical T8-12 – Absent with corticospinal tract lesion.
- Babinskis L5-S1 – Usually accompanied with Hyperreflexia, Clonus and increased tone. ADULTS: Normal – digital flexion Abnormal – digital fanning pattern. INFANTS – Normal digital fanning Abnormal – digital flexion.
19
Q
PNS - UPPER MOTOR NEURONE LESION
A
- Anything that effects the brain (Stroke, infection, SOL, Parkinsons, MS etc) prior to the anterior horn of the spinal cord.
20
Q
PNS - LOWER MOTOR NEURONE LESION
A
- Anything that effects the neuron from anterior horn to the muscle it innervates (Peripheral nerve injury, bells palsy, Myasthenia Gravis, Guilain Barre syndrome)
21
Q
PNS - SPINAL TRACTS
A
- Spinothalamic
- Spinocerebellar
- Dorsal column
22
Q
PNS - SPINAL TRACTS - SPINOTHALAMIC
A
- Anterior: crude touch
- Lateral: Pain & Temperature
23
Q
PNS - SPINAL TRACTS - SPINOCEREBELLAR
A
- Muscle spindle
- Golgi tendon ORGAN
24
Q
PNS - SPINAL TRACTS - DORSAL COLUMN
A
- Conscious proprioception
- Vibration
- Fine touch
- affected by diabetes. Leading to a loss of vibration sense.
25
PNS - SPINAL TRACTS (DESCENDING)
- **PYRIMIDAL** conscious control of muscles from the cerebral cortex to the muscles of the body and face
- **EXTRA-PYRIMIDAL**: unconscious, reflexive or responsive control of muscles from various brainstem structures to postural or anti-gravity muscles
26
PNS - WHAT IS A DERMATOME?
- An area of skin in which sensory nerves derive from a single spinal nerve root
27
PNS - DERMATOME TESTS
- Cotton wool
- Sharp/Soft
- Temperature
- Vibration
- Scored 0-2.
0 =Absent
1 = Altered sensation
2= Normal
28
PNS - DERMATOME TESTS - COTTON WOOL TEST
- Light Touch – Dorsal Column (Medial Lemniscus)
- With patient’s eyes closed use a soft piece of material (cotton wool)
- Time stimuli irregularly
- Use a dabbing motion rather than stroking
29
PNS - DERMATOME TESTS - SHARP SOFT
- Superficial Pain - Spinothalamic
- Use a fresh neurological pin (or toothpick)
- Explain that you are attempting to elicit a sharp sensation
- Ask patient (eyes closed) to tell you when they feel sharp sensation
- Assess each dermatome
30
PNS - DERMATOME TESTS - TEMPERATURE
- Temperature - Spinothalamic
- Place a cold metallic object on the patients skin at set sensory nerve testing points
- Ask if it feels cold
31
PNS - DERMATOME TESTS - VIBRATION SENSE
- Dorsal column
- Place a tuning fork (128hz) over bony prominences working distally to proximal ask the patient to report when they can not feel the buzzing sensation.
- Lower limb:tip of great toe, IP joint, medial malleolus,tibial tuberosity, ASIS
- Upper limb: DIP of forefinger, radial styloid,olecronon,acromion
- First sense affected in certain conditions e.g. Peripheral Neuropathy. But is often absent distally in healthy older people.
32
PNS - JOINT POSITION SENSE
- Joint Position Sense - Dorsal Column (Medial Lemniscus)
- Demonstrate the procedure so pt can see
- Ask pt to say up or down as you flex or extend the big toe from the side
- Pt closes eyes, perform random movements of up or down
33
PNS - 3 SYMPTOMS OF MENINGITIS
- 3 symptoms
1. Pyrexia
2. Nuchal ridigity
3. Headaches
34
PNS - MENINGITIS TEST - L'HERMITTES
- **L’hermittes** – Passive CSP flexion – Positive sign is ‘electric’/radiating pain in the arms/legs
35
PNS - MENINGITIS TEST - KERNIGS
- **Kernigs** – Flex the hip to 90 and slowly extend the knee. Resistance/Pain is positive Kernig’s
36
PNS - MENINGITIS TEST - BRUDZINSKI'S
- **Brudzinski’s** – L’hermittes (Passive or active) followed by knee/hip flexion is a positive Brudzinskis sign.
37
PNS - TESTING COORDINATION
Finger to nose
Romberg’s sign/pronator drift- feet together, arms in front. Close eyes for 30s, looking for wobbling and pronation of hands
Heel/shin test- second stage, rub heel on shin
Dysdiadochokinesis- clap whilst turning hand. Diadochokinetic- ability to turn hand
38
PNS - GAIT
Waddling- developmental dysplasia
Spastic- cerebral palsy, MS
Shuffling- PD
Steppage- spinal injury, PD, MS
Scissor- MS, cerebral palsy
39
PNS - CLONUS
Rhythmic oscillating stretch reflex, related to upper motor neuron lesion, dorsi foot quickly to elicit a response
40
PNS - MYOTOME GRADING
No visible contraction- 0
Flicker but no movement- 1
Jt movement when gravity eliminated- 2
Movement against gravity- 3
Movement against resistance but weaker than normal- 4
Normal power- 5
41
PNS - DEEP TENDON REFLEX GRADING
Absent- 0
Hyporeflexia- 1
Normal- 2
Hyperreflexia- 3
Brisk/clonus- 4
42
PNS - VIBRATION AND JOINT POSITION SENSE - DORSAL COLUMN
Hallux
Medial malleoli
Tibial tuberosity
Patella
ASIS
Thumb/index IP
Radial styloid
Olecranon
Acromion
Diabetics lack sensation as it affects the dorsal column
43
PNS - MENINGEAL IRRITATION TESTS
Triad- fever, rigidity, headaches
L’Hermittes- flex head whilst supine
Brudzinski’s sign- hips will flex whilst head is flexed (+ve)
Kernig’s- flex knee + hip to 90, straighten, +ve spinal P
