7.21 Neuromuscular Flashcards
Seven tests of mental status
a. General appearance and behavior
b. Level of consciousness
c. Orientation
d. Attention
e. Language
f. Memory
g. Abnormalities on mental status infer the cerebral cortex is not functioning
Seven Components of an Excellent Neurological Exams
1) Mental status (cerebral cortex)
2) Cranial nerves
3) Motor exam
4) Sensory exam (spinothalamic, posterior column tract)
5) Coordination
6) Deep tendon reflexes
7) Romberg / Gait
Muscle strength scale
- 0: No muscular contraction detected
- 1: A barely detectable flicker or trace of contraction
- 2: Active movement of the body part with gravity eliminated
- 3: Active movement against gravity
- 4: Active movement against gravity and some resistance
- 5: Active movement against full resistance without evident fatigue. (This is normal muscle strength).
Little piece of bone coming off the scapula (Removed during shoulder cuff surgery)
Acromion
Formation of elbow joint
Formed by the humerus and the two bones of the forearm (radius, ulnar)
What nerves go through carpal tunnel? (3)
- Median nerve
- Ulnar nerve
- Radial nerve
Phalen’s Test
Carpal Tunnel Test
• Dorsal part of hand together with fingers pointing down
• Have pt hold this for 60 seconds
• Ask pt if there is any numbness
Tinel’s Sign
Carpal Tunnel Test
• Tap underside of patient’s wrist with finger. Ask about numbness.
Osteoarthritis (Now called “Degenerative joint disease”) 7 characteristics
- Cartilage starts to destruct
- Hard, nontender nodules
- “Osteophyte” – bone spur.
- 2 to 3 mm or more in size
- Heberden’s nodes (DIP), bony overgrowth
- Bouchard’s nodes (PIP) – less common
- Metacarpophalangeal joints are spared: NOT involved in osteoarthritis.
Rheumatoid Arthritis (4)
- Tender, painful stiff joints
- Can happen at any age.
- Progressive autoimmune disease
- Symmetric involvement (if one wrist is affected, the other is affected
Joints invovled in rheumatoid arthritis
Joints involved:
• Proximal interphalangeal (PIP)
• Metacarpophalangeal joints (MCP)
Nature of deformaties in Rheumatoid Arthritis (9)
- Boutonniere deformity
- Permanent flexion of the PIP
- Hyperextension of the DIP
- Swan neck deformity
- Hyperextention of the PIP
- Permanent flexion of the DIP
- Ulnar Deviation
- Not so much the wrist, but the middle, ring and pinky fngeer
- Joints are swollen
What makes up the knee joint?
Femur, Tibea, actual knee cap
Where is the meniscus?
Cusions between kneecap and tibea
Where is the largest bursae in the body?
Knee, goes up 6cm behind quadracep muscle
33 bones in spine:
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 3-4 coccyx
Frontal lobe function (2)
- Concerned with personality, behavior, emotions, intellectual functions
- Primary motor area located here
Parietal lobe function
Primary center for sensation
Occipital lobe function
Visual receptors
Temporal lobe Function (3)
- Hearing
- Taste
- Smell
Wernicke’s Area
- Speech comprehension
* COMPREHENSION / HEARING ASPECT OF SPEECH FORMATION.
Broca’s Area Function
Mediates motor aspect of speech formation
Which side of brain is dominant in most people? Give percent.
Left side of brain is dominant even if they’re left handed. (95% of people)
Diencephalon components
- Basal ganglia
- Thalamus
Basal ganglia function
• Affects our movement, Eg arms swinging
Parkinson’s affects what area of the brain? What happens?
Basal ganglia
o No arm swinging
o Hunched
o Little shuffly steps
Thalamus functions (2)
o Anger
o Sex drive
Hypothalamus functions
Homeostasis
Brainstem is composed mostly of _____
Nerve Fibers
Components of brainstem (4)
o Midbrain
o Pons
o Medulla
o PYRIMIDAL DECUSSATION occurs in the brainstem area.
Midbrain - anatomical components
- Most anterior part of brainstem
* Still has tubular structure of spinal cord – merges with thalamus and hypothalamus
Pons is composed of…
Ascending and descending nerve fibers
Medulla is composed of…
- Continuation of the spinal cord
* Also has ascending and descending nerve fibers
What happens at the pyramidal decussation?
Nerve fibers crossing from R to L and L to R
Functions of cerebellum
- Coordination of voluntary movements
- Equilibrium
- Muscle tone (amt of resistance in muscles normally)
Works completely below the conscious level
Location of spinal cord
Medulla to 1st or 2nd lumbar vertebrae.
Where is lumbar puncture usually done?
Lumbar puncture usually done at the 3rd or 4th interspace so that you don’t hit the spinal cord
Cauda equina
- Location
- Appearance
-
- At L1 & L2
- Nerve roots start to spread out like a hores’s tail
- Damage causes incontinence
Spinal column entrance, exist
- Posterior: Afferent
* Anterior: Efferent
Major motor pathways (5)
o Upper motor neurons = talking about the CNS,
o Lower motor neurons = talking about the PNS
o Corticospinal or pyramidal (puh RAM id ul) tract
o Extrapyramidal tracts
o Cerebellar system
Corticospinal or pyramidal (puh RAM id ul) tract (3 characteristics)
- Voluntary movement
- Integrates skilled, purposeful movements.
- Efferent fibers
Pathway of the Cortical / Pyramidal Tract
• Originate in motor cortex of the brain, travel down into the medulla, cross to the other side (pyramidal decussation), continue downward into the spinal column and synapse with the anterior horn cells.
Extrapyramidal tracts (5)
- Pons
- cerebellum
- medulla
- lower motor neuron
- spinal cord.
Role of extrapyramidal tracts
Maintain muscle tone, control our gross motor movements (eg walking)
Roles of cerebellar system (2)
- Just coordinates movements – doesn’t initiate any movement.
- Deals with posture, position in space
Two major sensory pathways
- Spinothalamic Tract
- Posterior (Dorsal) Column
Function of thalamus
& 3 iterations of this
General sensation
- Pain
- Temperature
- Crude v Light touch
What distinguishes fine sensation?
Motor cortex
Function of posterior column (3)
- Proprioception
- Vibration
- Fine localized touch
4 anatomical parts of the posterior column
• Medulla, Pons, Thalamus, Cortex of brain.
o 31 pairs of spinal nerves:
- 8 cervical
- 2 thoracic
- 5 lumbar
- 5 sacral
- 1 coccygeal
Dermatome
The part of the skin that gets innervated by a single sensory route
Why do dermatomes tend to overlap?
Biological reassurance / backup system
What is a reflex arc?
“An involuntary but stereotypical response” that can involve as few as two neurons (one sensory, one motor).
In order for a reflex to fire, you have to have these 5 things:
1) An intact sensory nerve
2) A functional synapse in the cord
3) An intact motor nerve
4) An intact neuromuscular junction
5) A competent muscle
3 Questions to ask about the nervous system:
- 1) Is mental status intact?
- 2) Are right and left sided findings the same or symmetric?
- 3) If findings are asymmetric or otherwise abnormal, do the causative lesions lie in the central nervous system or the peripheral nervous system
Spastic tone
Upper motor neuron of the corticospinal tract at any point from the cortex to the spinal cord
o Increased resistance to passive lengthening, then may suddenly give way.
o Clasp-knife phenomenon.
Two pathologies seen with spastic tone
Polio, Guillian Barre
Disease process of Guillian Barre
Ascending paralysis of all muscles
• First get weak in feet, legs, then respiratory muscles
Usually descends and goes away
• Reverses in same order
A dysfunction in what part of the brain would cause rigid tone?
Basal ganglia system
Lead pipe rigidity
- What happens?
- What pathology causes this?
An increase in muscle tone causes a sustained resistance to passive movement throughout the whole range of motion, with no fluctuations.
Parkinson’s.
Cogwheel rigidity
A combination of leadpipe rigidity and tremor which presents as a jerky resistance to passive movement as muscles tense and relax.
Parkinson’s.
What is responsible for flaccid muscle tone?
• Lower motor neuron at any point from the anterior horn cell to the peripheral nerves
Define fasiculation
Rapid continuous twitching of resting muscle or part of muscle.
Define Tic
Normal movements of muscle groups such as winking or grinning that occur involuntarily and seemingly appropriately.
Tetany
- Define
- Two pathologies
Involuntary muscle spasms
- Low Calcium levels
- Low magnesium levels
Define myclonus
Rapid sudden jerk or short series of jerks at fairly regular intervals
Myoclonus of the diaphragm are…
HICCOUGHS
Define Tremor
Oscillation movements caused by involuntary contraction of muscle groups
Three types of tremor & cause
1) Resting tremor (Parkinson’s)
2) Intention tremor (Muhammed Ali)
3) Fine Tremor (Can be benign, due to nervousness)
Two ways to test tactile descrimination
Stereognosis
Graphesthesia
How would you test for extinction?
With patient’s eyes closed, poke dorsal part of each hand. People who recently had a stroke might not be able to feel one of their hands.
What disease process would prevent you from walking heel-to-toe?
Parkinson’s
Characteristics of Synovial joints (5)
- Bones do not touch each other
- Joint articulations are freely movable
- Synovial membrane lines cavity
- Synovial fluid secreted
- Joint capsule surrounds synovial membrane – strengthened by ligaments
Characteristics of cartilaginous joints (2) and an example
- Slightly movable fibrocartilaginous discs separate the bony surfaces
- Center of each disc = nucleus pulposus (cushion)
- Example: Spine
Characteristic of a fibrous joint and an example
Bones are almost in direct contact – no appreciable movement. Skull.
Three types of synovial joints
- Spheroidal (ball and socket)
- Hinge
- Condylar
2 examples of a SPHEROIDAL joint
Movement
Shoulder
Hip
Wide-range movement
2 examples of HINGE joints
Movement
Interphalangeal joints
Elbow
Movement in one plane (flexion, extension
2 examples of CONDYLAR joints
Movement
Knee
TMJ
Movement of two articular surfaces not dissociable
Synovial sacs that allow adjacent muscles or muscles and tendons
to glide over each other during movement
Bursae
Ropelike bundles of collagen fibrils that connect bone to bone.
Ligaments
Collagen fibers connecting muscle to bone. Another type of
collagen matrix forms the cartilage that overlies bony surfaces.
Tendons
