L12: Neuro & Sports Physical Flashcards
Gait: Inspection
What are you looking for?
What is an abnormal gait?
What does an abnormal gait indicate (generally?)
- Observe posture and gait
- Patient walks toward and away from you
- Toe walk, heel walkTandem gait
- Abnormal = gait that lacks coordination and stability
- CNS or PNS abnormality
Steppage Gait
What is it?
Description of gait?
If unilateral?
If bilateral?
- Steppage Gait AKA Neuropathic gait
- Foot drop:
- Patient drags foot/feet or lifts them high, then foot slaps floor
- Unilateral → peroneal nerve injury, spinal nerve compression
- Bilateral → amyotrophic lateral sclerosis (ALS), Charcot-Marie-Tooth disease and other peripheral neuropathies
Spastic Hemiparesis
What is it?
Description of gait?
Cause?
Example?
- Drag toe, circle leg stiffly outward and forward (circumduction), or lean trunk to contralateral side to clear affected leg during walking.
- Affected arm is flexed, immobile, and heldclose to the side, with elbow, wrists, and interphalangeal joints flexed.
- Affected leg extensors are spastic; ankles are plantar-flexed and inverted.
- Seen in corticospinal tract lesions
- Stroke
Scissors Gait
What is it?
Description of gait?
Cause?
Example?
- Patients advance each leg slowly and thighs tend to cross
- Stiff gait and short steps
- Seen in spasticity disorders
- Cerebral palsy
Sensory Ataxia
What is it?
Description of gait?
Cause?
Example?
- Unsteady gait and wide based stance
- Throw feet forward and outward, first bring down heel then toes with double tap
- Watch ground
- Due to loss of proprioception
- Peripheral neuropathy
- Posterior column damage
Parkinsonian Gait
What is it?
Description of gait?
Cause?
Example?
- Stooped posture with head, arm, hip and knee flexion
- Shuffling, short steps; slow to start
- Decreased arm swing and stiff turns
- Due to basal ganglia abnormalities
- Parkinson disease
Trendelenburg Gait
What is it?
Description of gait?
Unilateral?
Bilateral?
Trendelenburg Gait AKA Myopathic gait
- Pelvic drop leading to waddling gait
- Due to hip abductor weakness
- Unilateral → spinal nerve compression, superior gluteal nerve injury
- Bilateral → muscular dystrophy
Coordionation
What does it require?
Ataxia: define
Dysmetria: define
- Requires integration of the nervous system:
- Motor
- Cerebellar
- Vestibular
- Sensory
-
Neurologic Terms:
- Ataxia: Impaired coordination of muscle (out of proportion to weakness)
- Dysmetria: Improper measure of distance
Romberg Test
What does it test?
How to test?
Abnormal test? Indication?
- Position sense
- Ask patient to stand with feet together, watch for swaying, then ask patient to close eyes
-
Abnormal –> unable to maintain upright posture
- Posterior column disease
- Cerebellar abnormality
Pronator Drift
What does it test?
How to test?
Abnormal test? Indication?
- Ask patient to elevate arms to shoulder level w/ palms up. Should hold position w/ eyes closed ~20 sec.
- Variation – Firmly tap one arm; Patient should bring arm back up
-
Abnormal –> unable to keep arm at shoulder height and/or arm pronates/drifts downward
- UMN lesion (stroke)
- Oscillating – cerebellar
Heel to Shin Test
What does it test?
How to test?
Abnormal test? Indication?
- Place heel at opposite knee, slide down leg then back up
- Should be able to keep contact with opposite leg
-
Abnormal
- Cerebellar disease: Heel overshoot’s the knee, foot oscillates side to side
- Post. column damage: Heel lifts too high
Finger-to-Nose Test
What does it test?
How to test?
Abnormal test? Indication?
- Hold your finger out in front of patient, then ask them to touch their nose then touch your finger with theirarmfullyextended. Moveyourfingerin different planes.
- Patient should be steady and accurate
- Abnormal = dysmetria (past pointing)
- Cerebellar disease
- Intention tremor – multiple sclerosis
Rapid Alternating Movements
What does it test?
How to test?
Abnormal test? Indication?
- Patient places hands on thighs with palms down then palms up, perform as quickly as possible
- Rapid finger tap – tap the distal joint of thumb with index finger
-
Abnormal = dysdiadokinesia (slow, clumsy, irregular movement)
- Cerebellar disease
Aphasia
Define
Cause
Aphasia: inability to express or understand language
Often secondary lesion in dominant/left hemisphere
Dysarthria
Define
Cause
-
Dysarthria: abnormal pronunciation of speech
- Many poss. causes.
- Lesion involving muscles of articulation (CN V, VII, IX, X, XII) vs. central process
Neglect
Define
Cause
-
Neglect: abnormality in attention to one side
- Most often secondary lesion in the nondominant/right hemisphere (seen on the left)
Mental Status
How to assess for:
Appropriate behavior
Orientation
Ability to concentrate & focus attention
-
Appropriate behavior:
- Observation of speech, dress, hygiene, personal interaction, etc.
-
Orientation: A and O x 3 (or x 4)
- Level of alertness/consciousness
- Degree of orientation
- Person
- Place
- Time
- Situation
-
Ability to concentrate and focus attention:
- Serial 7s, spell WORLD backwards, etc.
Mental Status: Memory
Define:
Immediate recall
Recent memory
Remote memory
Immediate recall: give patient 3 words to repeat
Recent memory: repeat the 3 words after 5 minutes
Remote memory: well known events/people, dates, or locations
Cranial Nerves
CN I
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN I: Olfactory (S)
-
Function:
- Sense of smell
-
Test:
- Could have patient smell familiar scent
-
Abnormal:
- Anosmia
- Head trauma, Parkinson disease
Cranial Nerves
CN II
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN II: Optic (S)
-
Function:
- Vision
-
Test:
- Visual fields
- Acuity
- Funduscopic
- Pupillary light reflex
-
Abnormal:
- Visual field defect 2° retinal emboli, optic neuritis, pituitary tumor, stroke
Cranial Nerves
CN III
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN III: Oculomotor (M)
-
Function:
- Eye movement
- Raises upper eyelid
-
Test:
- EOMs
- Pupillary light reflex
-
Abnormal:
- Vertical and horizontal diplopia
- Ptosis
Cranial Nerves
CN IV
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN IV: Trochlear (M)
-
Function:
- Downward, internal rotation of the eye
-
Test:
- EOMs
-
Abnormal:
- Vertical diplopia
Cranial Nerves
CN V
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN V: Trigeminal (B)
-
Function:
- Motor – temporal, masseter and lateral pterygoids
- Sensory – 3 divisions
-
Test:
- Clench jaw and lateral jaw movement
- Check facial sensation
-
Abnormal:
- Trigeminal neuralgia
Cranial Nerves
CN VI
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN VI: Abducens (M)
-
Function: Motor
- Lateral deviation of the eye
-
Test:
- EOMs
-
Abnormal:
- Horizontal diplopia, esotropia
Cranial Nerves
CN VII
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN VII: Facial (B)
-
Function:
- Motor – facial movements
- Sensory – taste, ant. tongue
-
Test:
- Raise eyebrows, smile, frown, puff out cheeks
-
Abnormal:
- Central – Cerebral infarct (that spares the forehead)
- Peripheral –Bell’s palsy (ipsilateral weakness of entire face)
Cranial Nerves
CN VIII
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN VIII: Acoustic (S)
-
Function:
- Hearing and balance
-
Test:
- Gross hearing, gait
-
Abnormal:
- Unilateral hearing loss, disequilibrium, vertigo, nystagmus
Cranial Nerves
CN IX
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN IX: Glossopharyngeal (B)
-
Function:
- Motor – pharynx
- Sensory – posterior tongue
-
Test:
- Palate elevation, gag reflex
-
Abnormal:
- No gag reflex, loss of taste posterior 1/3 of tongue
Cranial Nerves
CN X
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN X: Vagus (B)
-
Function:
- Motor - Palate, pharynx, larynx
- Sensory – Pharynx, larynx
- Cardiac, thorax and abdomen
-
Test:
- Palate elevation, quality of “ah” and uvula midline
-
Abnormal:
- Hoarseness, dyspnea, dysarthria, loss of gag reflex
Cranial Nerves
CN XI
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN XI: Spinal Accessory (M)
-
Function:
- Sternocleidomastoid and upper trapezius motor function
-
Test:
- Shoulder shrug and head rotation
-
Abnormal:
- Trapezius weakness, atrophy and fasciculation’s = scapular winging
Cranial Nerves
CN XII
Name
Sensory/Motor/Both
Function
Test
Abnormal
- CN XII: Hypoglossal (M)
-
Function:
- Tongue movement
-
Test:
- Wag tongue, push tongue into cheek
-
Abnormal:
- Central lesion = contra. weakness/tongue deviates away
- Peripheral lesion = ips. weakness/tongue deviates to weak side
Name that CN
- What are 3 CN’s involved in articulation?
- An abnormality in what CN would cause shoulder to droop?
- Damage to which CN results in anosmia?
- Patient w/ vertigo and nystagmus could be due to damage to which CN?
- In patient with asymmetric smile and loss of nasolabial fold, what CN is affected?
- What are 3 CN’s involved in articulation?
- CN V, VII, IX, X, XII
- An abnormality in what CN would cause shoulder to droop?
- CN IX (Glossopharyngeal)
- Damage to which CN results in anosmia?
- CN I (Olfactory)
- Patient w/ vertigo and nystagmus could be due to damage to which CN?
- CN VIII (Acoustic)
- In patient with asymmetric smile and loss of nasolabial fold, what CN is affected?
- CN VII (Facial)
Sensory Terms: Touch
Define:
Anesthesia
Hypoesthesia
Hyperesthesia
Anesthesia: absence of touch sensation
Hypoesthesia: decreased sensation to touch
Hyperesthesia: increased sensitivity to touch
Sensory Terms: Pain
Define:
Analgesia
Hypoalgesia
Hyperalgesia
Allodynia
Analgesia: absence of pain sensation
Hypoalgesia: decrease in pain awareness
Hyperalgesia: increased sensitivity to pain
Allodynia: pain elicited from non-painful stimulus
Sensory Exam Components
How to test for:
Light touch
Pain
Temperature
Position
Vibration
- Compare bilaterally, evaluate distal to proximal
-
Light touch:
- Cotton swab/ball, pad of finger
- Don’t apply too much pressure
-
Pain:
- Sharp end of cotton swab, do not pierce skin
-
Temperature:
- Compare hot/cold (if unable to feel pain sensation)
-
Position:
- Hold sides of digit, demonstrate position
-
Vibration:
- Place vibrating tuning fork on DIP joint, ask what patient feels
Dermatomes: Upper Extremity
What are the dermatome levels for:
- Lateral upper arms
- Radial forearm and thumb
- Middle finger
- Ring and little finger
- Ulnar Forearm
Dermatomes are helpful when patient has complaint of sensory loss in a specific distribution
- Lateral upper arms (C5)
- Radial forearm and thumb (C6)
- Middle finger (C7)
- Ring and little finger (C8)
- Ulnar Forearm (T1)
Dermatomes: Landmarks
What are the dermatome levels for:
- Nipple line
- Umbilicus
- Inguinal region
Dermatomes are helpful when patient has complaint of sensory loss in a specific distribution
- Nipple line (T4)
- Umbilicus (T10)
- Inguinal region (L1)
Dermatomes: Lower Extremities
What are the dermatome levels for:
- Anterior/proximal thigh
- Knee/medial shin
- Lateral shin, dorsal foot to great toe
- Lateral and plantar foot
Dermatomes are helpful when patient has complaint of sensory loss in a specific distribution
- Anterior/proximal thigh (L3)
- Knee/medial shin (L4)
- Lateral shin, dorsal foot to great toe (L5)
- Lateral and plantar foot (S1)
Specialized: Discriminative Sensations
- What are these/how to test for?
- Stereognosis
- Graphesthesia
- Two-point discrimination
- What is normal?
- Extinction
- Indication if abnormal?
- Will depend on touch and position sense
- Stereognosis – ask patient to recognize familiar objects
- Graphesthesia – number identification
-
Two-point discrimination – alternate double and single stimulus.
- Normal <5mm on finger pads
-
Extinction – touch patient in same place on both sides of body
- Test for neglect
- Abnormal – sensory cortex pathology
Motor Exam Componnets
What are you evaluating for?
- Body Position
- Involuntary Movements
- Muscle Bulk
- Muscle Tone
- Muscle Strength
Involuntary Movements: Tremors
Define & eaxmples:
Static
Postural
Intention
-
Static tremor: seen at rest
- Parkinson disease (pill-rolling tremor)
-
Postural tremor: seen when affected area maintains posture
- Hyperthyroid, anxiety, fatigue, essential tremor
-
Intention tremor: absent at rest, appear with movement
- Multiple sclerosis
Involuntary Movements: Tics
Define
Eaxample
-
Tics: brief, habitual motion of particular muscles
- Tourette syndrome, medications
Involuntary Movements: Dystonia
Define
Example
-
Dystonia: twisted posture of large body parts
- Medications, spasmodic torticollis
Involuntary Movements: Dyskinesias
Define
Example
-
Dyskinesias: bizarre, rhythmic, repetitive movements
- Parkinson disease, psychoses, medications
Involuntary Movements: Akathisia
Define
Example
-
Akathisia: inability to sit still
- Medications (antipsychotics, Compazine)
Involuntary Movements: Chorea
Define
Example
-
Chorea: brief, jerky, rapid unpredictable movements
- Huntington disease, rheumatic fever
Involuntary Movements: Athetosis
Define
Example
-
Athetosis: slow, twisting, writhing movements
- Cerebral palsy
Muscle Bulk
Muscle Tone
Define:
Hypertonia vs hypotonia
Spasticity
Rigidity
-
Hypertonia vs. hypotonia?
- Central vs. peripheral causes
-
Spasticity: increased muscle tone, velocity dependent
- UMN pathology
-
Rigidity: increased resistance throughout range of motion
- Basal ganglia lesion
- Cog-wheel rigidity –> Parkinsonism
Muscle Strength
What are the grades of muscle function?
UE: what are the nerve root & peripheral nerve for:
Shoulder abduction
Wrist Extension
Finger abduction
Thumb opposition
- Shoulder Abduction
- C5, C6
- Axillary n.
- Wrist Extension
- C6, C7
- Radial n.
- Finger Abduction
- C8, T1
- Ulnar n.
- Thumb opposition
- C8, T1
- Median n.
LE: What are the nerve root(s) for:
Hip Flexion
Hip Adduction
Knee Extension
Hip Abduction
Knee Flexion
Ankle Dorsiflexion
Ankle Plantarflexion
- Hip Flexion, Hip Adduction, Knee Extension
- L2, L3, L4
- Hip Abduction
- L4, L5, S1
- Knee Flexion
- L5, S1
- Ankle Dorsiflexion
- L4, L5
- Ankle Plantarflexion
- S1
Deep Tendon Reflexes (DTRs)
How to rate response?
- How to rate response:
- 0 = No response
- 1+ = Diminished/Hypoactive
- 2+ = Normal
- 3+ = Increased/Hyperactive
- 4+ = Hyperactive, associated with clonus
DTRs: Hypoactive vs. Hyperactive
Define
Cause
Additional findings in LMN/UMN disease
-
Hypoactive
- Diminished or absent
- Diseases of spinal nerve roots or peripheral nerves
- Additional findings in LMN disease:
- Weakness
- Atrophy
- Fasciculations
-
Hyperactive
- Brisk and can be associated with clonus
- CNS lesions along descending corticospinal tract
- Additional findings in UMN disease:
- Weakness
- Spasticity
- Positive Babinski
DTRs: What is the nerve root for:
- UE
- Biceps
- Brachioradialis
- Triceps
- LE
- Patella
- Achilles
- UE
- Biceps: C5, C6
- Brachioradialis: C5, C6
- Triceps: C6, C7
- LE
- Patella: L4
- Achilles: S1
Clonus
What does it test?
How to test?
Abnormal test? Indication?
- Alternate dorsi- and plantar flexing patient’s ankle, then brisklydorsi-flexankle. Evaluateforrhythmicoscillations.
- Compare bilaterally, can be normal
- If abnormal, check at wrist
- Abnormal:
- UMN pathology
Babinski
What does it test?
How to test?
Abnormal test? Indication?
- L5, S1
- Stroke lateral aspect of plantar foot from heel to ball
- Normal for toes to flex
- Abnormal:
- Great toe extends and other toes fan out
- UMN pathology
Superficial Abdominal Reflex
What does it test?
How to test?
Abnormal test? Indication?
- Stroke abdomen toward umbilicus
- Muscle contracts toward stimulus
- Rated as present or absent
- Should get a muscle contraction
- Abnormal: no muscle contraction
- Central (UMN) and peripheral (LMN) pathologies
Cremateric Reflex
What does it test?
How to test?
Abnormal test? Indication?
- Stroke proximal medial thigh
- Normal for ipsilateral testicle to rise
- Rated as present or absent
- Abnormal:
- UMN, LMN
- L1, L2 nerve injury
- Ilioinguinal injury s/p hernia repair
Brudzinski Sign
What does it test?
How to test?
Abnormal test? Indication?
- Minengeal Signs
- Patient is supine, then flex patient’s neck
- Normal→patient remains relaxed
- Abnormal→hip and knee flexion; meningeal inflammation
Nuchal Rigidity
What does it test?
How to test?
Abnormal test? Indication?
- Meningeal Signs
- Place hands behind patient’s head and flex head toward chest
- Normal→easy motion
- Abnormal → pain and resistance indicating potential meningeal inflammation
Kernig Sign
What does it test?
How to test?
Abnormal test? Indication?
- Meningeal Signs
- Flex patient’s hip and knee, then straighten knee
- Normal→may have tightness in hamstring
- Abnormal→neck pain and resistance indicating meningeal irritation
Name that test:
Abnormal gait due to loss in proprioception?
How to test?
Abnormal test? Indication?
Sensory ataxia
- Unsteady gait and wide based stance
- Throw feet forward and outward, first bring down heel then toes with double tap
- Watch ground
- Due to loss of proprioception
- Peripheral neuropathy
- Posterior column damage
Name that test:
What test(s) do you perform to evaluate a patients position sense?
How to test?
Abnormal test? Indication?
-
Romberg
- Position sense
- Ask patient to stand with feet together, watch for swaying, then ask patient to close eyes
- Abnormal –> unable to maintain upright posture
- Posterior column disease
- Cerebellar abnormality
- Joint position
Name that test:
What test is performed by placing a familiar object in patient’s hand?
How to test?
Abnormal test? Indication?
Stereognosis: ask patient to recognize familiar objects
Name that test:
What test(s) help evaluate cerebellar function?
How to test?
Abnormal test? Indication?
-
Heel to shin
- Place heel at opposite knee, slide down leg then back up
- Should be able to keep contact with opposite leg
- Abnormal
- Cerebellar disease: Heel overshoot’s the knee, foot oscillates side to side
- Post. column damage: Heel lifts too high
-
Fnger-to-nose
- Hold your finger out in front of patient, then ask them to touch their nose then touch your finger with theirarmfullyextended. Moveyourfingerin different planes.
- Patient should be steady and accurate
- Abnormal = dysmetria (past pointing)
- Cerebellar disease
- Intention tremor – multiple sclerosis
-
and/or RAMs
- Patient places hands on thighs with palms down then palms up, perform as quickly as possible
- Rapid finger tap – tap the distal joint of thumb with index finger
- Abnormal = dysdiadokinesia (slow, clumsy, irregular movement)
- Cerebellar disease
