Impairment Oriented Neuro Exam Flashcards
why is sensation important (3)
- critical to motor learning and motor performance
- guides selection of movement pattern required in a given sensory environment
- used by CNS to modify or adapt ongoing movements
what is sensory integration
CNS ability to organize, interpret, and effectively utilize sensory input
why is sensory integration so important
can feel all the stimuli in the environment (including pain)
- can’t feel all that at once, would be super overwhelming
- brain filters out what isn’t important so you can focus
sensory integration and pain
pain is a stimuli
CNS can filter out the pain so can focus on other things
pathway of somatosensation
originates in sensory receptors
carried via afferent neurons to CNS
somatosensation - conscious vs unconscious
conscious - feeling pain
unconscious - proprioception
how would someone w impaired somatosensation move?
movement is more jerky/robotic
- don’t have the somatosensation to tell you whether movement feels right
what can ataxia be d/t
cerebellar disorders
sensory disorders (ie somatosensation loss)
what is ataxia
person can’t tell how to locate their body in space and tell where the floor is when they take steps
how do you treat ataxia
teach compensations w vision and other sensory means
lots of repetition
what are the 4 main patterns of loss associated w somatosensation
nerve root
peripheral nerve
neuropathy
sensory cortex
what could cause somatosensation loss at the nerve root
disc herniation
sciatica
what does a nerve root somatosensation loss present as
dermatomal pathway loss
- pattern of loss along the dermatomes
what are causes of peripheral nerve somatosensation loss
cuts
trauma
carpal tunnel
what does a neuropathy somatosensation loss present as
stocking/glove pattern
more impaired distally
what can cause neuropathic somatosensation loss
vascular issues
diabetes
what does somatosensation loss at the sensory cortex present like
happens at brain level
- right vs left side differences
not necessarily can’t feel anything but might be certain pathways that are impaired on that side
what can cause somatosensation loss at the sensory cortex level
stroke
TBI
what are the two main parts of somatosensation
- pain, temp, some light touch
- vibration, 2 point discrimination, proprioception
where are vibration, 2 point discrimination and proprioception signals sent to/processed
dorsal/posterior column of SC
where is the majority of light touch (but not all) signals sent to
dorsal/posterior column
fibers detecting pain/temp vs vibration/2 point/proprioception
pain/temp = fibers small & slow
vibration = large & fast
where are pain/temp and some light touch signals sent to/processed
anterolateral column of SC
where is tactile discrimination (light touch) mediated
DCML
where is crude touch (light touch) mediated
anterolateral / spinothalamic pathway
what are some examples of superficial sensations that may be detected
pain
temp
light touch
pressure
how is superficial sensation stimuli received (in general terms)
skin and subQ exteroreceptors
describe how and when a superficial sensation clinical exam would be conducted
when - usually exam first
exam distal to proximal
random fashion
subject in supine w eyes closed
superficial somatosensation: how would you test/measure pain
sharp/dull
- pins or paper clips
superficial somatosensation: how would you test/measure temp
hot/cold
superficial somatosensation: how would you test/measure light touch
cotton balls/swabs
Q tips
monofilaments
superficial somatosensation: how would you test/measure pressure
finger tip
cotton swabs
what are some types of deep sensations
kinesthesia
proprioception
vibration perception
how is deep sensation perceived
proprioceptors transmit info from ms, tendons, ligaments, and joints
kinesthesia vs proprioception
kinesthesia - movement sense
proprioception - joint position
how is kinesthesia tested
passive ROM
verbally describe direction and range WHILE IN MOTION
how is proprioception tested
describe position of joint in a STATIC position
how is vibration perception tested
ability to perceive vibratory stimulus of a tuning fork that vibrates at 128Hz (on a bony prominence)
how would you conduct a deep sensation clinical test in general
have pt close their eyes (usually)
start more distally (toe) and move proximally
what does combined cortical sensations mean
involves both superficial and deep sensation
where is combined cortical sensations transmitted to
cortical sensory association areas
what are types of combined cortical sensations
stereognosis
2-point discrimination
double simultaneous stim
graphesthesia
barognosis
what is stereognosis
object recognition
- could you reach in a bag and touch object and then know what that object is
how do you test 2-point discrimination
2-point discriminator
- two point start close together and move apart gradually to see if person can distinguish b/w 1 or 2 stimuli
how do you test double simultaneous stimulation
apply stimuli in the same spot on contralateral body parts
- identify b/w one or two stimuli
ex: on R knee and L knee
how do you test graphesthesia
identify figures drawn on skin
how do you test barognosis
identify if object is heavier or lighter after lifting them
what is a standardized test/measure of somatosensation in people w SCI
American Spinal Injury Association (ASIA)
what types of tests (in general) are primarily used to measure somatosensation
clinical tests
- self standardize to ensure consistency and validity
what level does motor planning happen at
cortical
what is another word for motor planning
motor praxis
ideational vs ideomotor apraxias
IDEATIONAL - not able to create movement automatically or w command
(ex: brush your teeth command)
IDEOMOTOR - not able to create movement based on command, but if you gave them something that implied what to do - they could do it
(ex: hand them a toothbrush)
what is a motor unit
motor neuron and muscle fibers it synapses upon
location of UMN vs LMN (general terms)
UMN - cortical/brain area
LMN - after the SC
in general what does a lesion to LMNs do
interrupts the LMN
when there is a LMNL what are the treatment options from there and why
brain and SC are fine, but the pathway was broken
can take a different route
or wait until nerves/pathway regenerates and heals
how do LMNL present (s/sx)
flaccid paralysis
hypotonia
dec or absent DTRs
ms fasciculations
dec ms bulk/atrophy
what are two types of LMNs
somatic motor neurons
special visceral motor neurons
what do UMNL result from? what are specific examples of this
results from destruction of neurons in major descending pathways
ex: corticospinal, vestibulospinal, reticulospinal, rubrospinal
how do UMNL impact LMN
LMN might just keep doing whatever they want bc still activated and have potential
- inc tone, can lead to contractures
- could maintain ms bulk bc nerves still can be activating the muscles
how do UMNL present (s/sx)-7
paralysis
hypertonia
inc DTRs
clonus
impaired ACOM
tremors
may have inc or dec in muscle bulk
what does ACOM stand for
active control of movement
aka motor control
what is motor control/ACOM
ability to execute a motor plan and isolate ms or ms groups
how do you test ACOM
begin w observation of postural alignment
test for active movement, patient initiated, volitional
what does healthy ACOM present as
selective isolated volitional movements
presents as typical movement patterns
what does unhealthy ACOM present as
abnormal synergistic patterns
mass obligatory firing of multiple muscle groups
what could abnormal synergistic patterns look like but are different from
posture or positioning
when would abnormal synergistic patterns be triggered
with attempt to actively move limb
what types of patients are abnormal synergistic patterns seen in
UMNL
what are the 5 steps that you should progress through in a clinical exam of ACOM
- is motion absent? initiated?
- is motion completed through full or partial range?
- AG or GM?
- is motion isolated? if yes, then measure MMT
- any abnormal synergistic motion/patterns?
what are two important things to be addressing and looking for when testing for ACOM
isolated
stabilize in position
why might motion not be isolated when testing ACOM
substitution?
abnormal synergy?
consider ability to understand directions
if substitutions are implicated based on tested ACOM not being isolated, what are the next steps
further testing at impairment level
- joint integrity
- sensation
- weakness
what does obligatory flexion synergy patterns look like in the UE
scapular retraction and elevation
shoulder ABD/ER
elbow flexion
forearm supination
wrist/finger flexion
think a shrug w arms out but fingers in fists instead
what does obligatory flexion synergy patterns look like in LE
hip flex/ABD/ER
knee flexion
ankle DF/inversion
think passe, but flexed and sickled foot
what is an important deficit to note with obligatory flexion synergy patterns when addressing them
these patterns don’t work w functional movement
- can’t do their hair, cook a meal, etc.
what does classic extension synergy patterns look like in UE
scap protraction
shoulder ADD/IR
elbow ext
forearm pronation
wrist/finger flexion
think hunching shoulders, making yourself smaller, turning inward - but wrist/finger flexed
what does classic extension synergy patterns look like in LE
hip ext/ADD/IR
knee ext
ankle PF/inv
think back tondu but IR
what is one pro of a classic extension synergy pattern that you can utilize when treating
this pattern can assist w the movement that you want
- ie extension w standing
what is the clinical reasoning when assessing ROM for a neuro vs MS client
w neuro focus on function
what do you document for ROM in a neuro exam
both PROM and AROM
end feel - firm, boggy, tension
joint integrity / joint play
effect of ROM limitations on ACOM/tone
what sensations travel along the lateral spinothalamic tract
non discriminative touch
- pain
- temp
- crude touch
what sensations travel along the dorsal column medial lemniscal tract (DCML)
discriminative touch
kinesthesia
proprioception
vibration
dorsal vs anterior root of the spinal cord
dorsal root = sensory info
anterior = motor
what is the importance of knowing where tracts/nerves synapse and decussate in terms of if there is a lesion on SC
will tell you if sx are ipsilateral or contralateral from lesion on a SC
if there is a lesion on the spinothalamic pathway, how would the sx present? why?
contralateral of the injury
- sensory info crosses over at level is received
if there is a lesion on the DCML how would the sx present? why?
sx will be ipsilateral of the lesion
- sensory info crosses higher up, at the bottom of the medulla
