L5/6: Neurological Systems and Examination Flashcards
What is an upper motor neuron lesion?
Lesion above the anterior horn cell
Lesions in the CNS that create neurological injuries
Where are 3 places that an upper motor neuron lesion occur?
- spinal cord
- brain stem
- motor cortex
What are 3 examples of upper motor neuron lesions?
- Stroke
- traumatic brain injury
- spinal cord injury
What is an lower motor neuron lesion?
Lesion in the anterior horn cell or distal to the anterior horn cell
Where does an lower motor neuron lesion occur?
Cranial nerve nuclei/nerves and in spinal cord: anterior horn cell, spinal roots, peripheral nerve
What are 5 examples of lower motor neuron lesions?
- Polio
- Guillain Barre
- Peripheral nerve injury
- Peripheral neuropathy
- Radiculopathy
What is the comparison of upper motor neuron and lower motor neuron lesions: reflexes, strength and muscle bulk?
What is the effect of upper motor neuron lesion on reflexes?
Increased: hyperreflexia, clonus
What is the effect of upper motor neuron lesion on strength?
Weakness or Paralysis: ipsilateral or bilateral
What is the effect of upper motor neuron lesion on muscle bulk?
Disuse atrophy: variable, widespread distribution, especially of antigravity muscles
What is the effect of lower motor neuron lesion on reflexes?
Decreased or absent
What is the effect of lower motor neuron lesion on strength?
Ipsilateral weakness or paralysis; Limited distribution: segmental or focal pattern
What is the effect of upper motor neuron lesion on muscle bulk?
Neurogenic atrophy: rapid, focal distribution, severe wasting
What are 5 red flags for cord signs?
- Cervical spine: bilateral sensory symptoms in hands &feet
- Thoracic spine (maybe upper Lsp): bilateral sensory symptoms in feet
- Reports of unsteadiness with walking (Cervical – also clumsiness using hands)
- Weakness in groups of muscles
- Increased reflexes – below level Immediate medical referral necessary
Radiculopathy is always _____ (unilateral/bilateral). _____ (unilateral/bilateral) symptoms are always a red flag
unilateral; bilateral
- Have you had it for a long time?
- Have you had any previous medical injuries?
- Have you only noticed these pins and needles when your back pain started?
If a patient says they have bilateral numbness and/or pins and needles (upper motor neuron lesion) Does this require a medical referral?
If it is related to onset of symptoms and not usual for the patient
What are 2 red flags for cauda equina signs (lower motor neuron lesion)?
- Paraethesia, anaesthesia in the perineum
- Bladder retention, bowel dysfunction (incontinence)
Immediate medical referral
What are 3 questions to ask patient about if they have cauda equina signs (lower motor neuron lesion)?
- Have you had any changes in your bowel functions since your back pain started?
- Does it feel like you need to urine but you can’t - OR - Do you have any incontience?
- Have you had any P&;N, numbness or tingling around your groin area?
What are the 4 problems with having cauda equina (lower motor neuron lesion)?
Why is cauda equina a medical emergency?
If damaged and left untreated –> permanent effect
What is the main cause of cauda equina sign?
posterior disc herniation (as opposed to more common postero-lateral)
The prevalence of cauda equina among patients with low back pain is approximately ____ in 10 000
four
What are the 2 common levels that are affected by cauda equina?
- L4/5 level
- L5/S1 level
Patients may be predisposed to cauda equina if they have a congenitally ______ (wide/narrow) spinal canal or have acquired ______
narrow; spinal stenosis
Cauda Equina syndrome can be ____ and _____.
acute; chronic
Can develop suddenly, but may take weeks or months
How does the acute onset of cauda equina syndrome occur?
rapid development of symptoms that often includes severe low back pain and significant loss of bladder and bowel function.
Sensory and motor deficits in the lower body typically develop within 24 hours.
Sudden onset of back pain
Did the numbness, P&N starts at the same time as back pain
How does the gradual onset of cauda equina syndrome occur?
- develops progressively and symptoms may occur on/off over several weeks or months.
- Recurring or persistent low back pain with muscle weakness and numbness and bladder and/or bowel dysfunction.
- May occur with bilateral or ipsilateral radicular pain.
- Bowel and bladder functions has deteriorated slowly
- Back pain also gradually become worse
What are 4 symptoms from compromise of nerve root or peripheral nerve?
- Decreased sensation in dermatome (or peripheral nerve) of involved nerve – usually distal
- Sensory changes in dermatome – or peripheral nerve distribution
- Weakness/atrophy in muscles predominantly supplied by that nerve
- Decreased or absent reflexes in the muscle/s supplied by that nerve compared to the other side
What is a neurological examination in the musculoskeletal setting?
EXAM QUESTION
An evaluation of the patients nervous system conduction by assessing sensory and motor responses
What are 3 reasons to use the neurological examination in the musculosketeal setting?
EXAM QUESTION
- a screening examination (ie to confirm there are no abnormalities in the patient when there is no expected abnormalities) or
- an investigative examination where there are abnormalities expected (ie the patient who reports sensory changes) to confirm and determine the extent.
- It is also an important re-assessment tool to monitor neurological signs or symptoms.
What is the purpose of the investigative examination of the neurological exam?
- Which nerves are effected and how much they are compromised
- Changes in neurologial systems over time - Getting better (otherwise need to refer)
What are 4 reasons for undertaking a neurological examination for the LBP/Pelvic patient?
- When the patient reports symptoms of abnormal conduction
- Pins and needles/tingling or other ‘description’ of abnormal sensation which relate to the history of the complaint
- Numbness
- Weakness
- Other symptoms indicating of an upper motor neuron lesion (clonus, decreased control of active movement, difficulty walking or loss of balance)
- Neuropathic symptoms (burning, shooting)
- ANY symptoms extending below the buttock
What is the procedure for undertaking a neurological exam?
Symptoms below butt - Even if feels a bit “tight”
Symptoms - Numbness - Tingling - Stabbing
Undertake neurological exam and then refer OR Refer straight away
What are 3 things that happen in the neurological exam?
- Sensory system (sensation)
- Motor system (strength)
- Reflexes
When you re-test in the neurological exam, what is important?
Important to retest (at least) the positive signs on each visit
But only need to check the area that is affected unless they have more changes in sensation (then will need to check the area that is above previous area)
Once retesting, if there is significant progression in neurological signs or symptoms it requires immediate________
medical referral
What are the areas in the neurological sensation test?
EXAM QUESTION
- L1 - groin/upper/inner thigh
- L2 - mid/lower/inner thigh
- L3 - medial knee
- L4 - lower medial shin and also inside dorsum of foot
- L5 - big toe and across toes
- S1 - lateral border of foot
- S2 - medial heel
Light touch if +ve – rate out of 10 and map
What are 2 features for mapping for reducing sensation?
•Important for ensuring only one dermatome is affected and to monitor symptoms. •Using a paper clip can allow sensation testing with mapping to be more localised.
What are questions when undertaking a neurological sensation exam?
Does this feel the same as this? Each side
- If not
- If good side is 10/10
- What is the rating of bad side
- Good idea of how bad the loss of sensation is
- Then compare the whole dermatomal area
- Need to do this to make sure the area hasn’t gotten worse
What are areas in the muscle strength (myotome) test?
- L2 - iliopsoas
- L3 - quadriceps
- L4 - tibialis anterior
- L5 - EHL, EDL, peronei
- S1/2 - calf, EDL, peronei, hamstrings
- S2 - FDL
How should the neurological muscle strength test be undertaken?
- Perform in neutral/comfortable position
- Do inner range tests – put in position and ask to hold 4-5 secs
STANDING
- Plantarflexors (S1/2) in standing (repetitions – 6 x)
SUPINE
- Hip flexors (L2) – lifting patients thigh to 90 deg hip flexion and holding against resistance
- Quadricep (L3) – arm in under knee and resist extension OR complete in sitting
- Dorsiflexors (L4) – lift foot up and ask to hold against resistance
- Big toe extension (L5) – hold toe up against resistance
- Eversion (L5/S1) – do each leg individually
- Toe flexion (S2) – try to pull toes straight against resistance
How should the neurological reflexes test be undertaken?
- Monosynaptic
- Increased reflex = UMNL (brain + spinal cord affected)
- Decreased reflex = LMNL (nerve root and below affected i.e. peripheral nerve)
Why should an neurological reflex test be taken?
- How much is being affected
- Whether there is an upper motor neuron lesion
How should the calf raises be done in the neurological exam?
- Done 6 times on each side
- Not asking about pain –> It is a visual test for physio to see whether they have difficulty or fatigue, full range and full strength
- Can also aks patient about whether it feels the same as other side
- Must hold hand
- Provide balance (table- too much and no hands - too little)
What should be asked in the neurological sensation test?
Does that feel the same as that?
How many times must the reflexes be hit to be tested?
6 times - get patient relaxed
What is the order of the neurological exam?
- Standing- calf raises (myotomes)
- Supine- Rest of the myotomes
- Supine- Reflexes
- Supine- Sensations (dermatome)
If everything is normal with the neurological exam –> give the patients some ______. If not normal –> give an _____ (often get some changes..etc but give re-assurance as well)
reassurance ; explanation
What happens when you find a dermatome that has been affected?
- go back to the one that you though was a bit different
- If this is normal 10/10 –> then what would this be the same as
- Get boundaries
- Then do sharp and blunt
- Get rating again and get boundaries
What is a neurodynamic examination?
How the nervous system is moving and can tolerate stretching
What are 3 aims and outcomes of neurodynamic testing?
- To support or reject hypotheses made following the patient interview, postural & active movement examination
- To determine if the patient’s symptoms are associated with mechanosensitivity of neural structures (may be LBP, Pelvic pain or lower limb symptoms)
- How much of sensitivity of movement contributes to pain
- Helps with management
- High levels of mechanosensitivity
- To provide information for clinically reasoning management approaches.
What is the primary function of the nervous system? What does it need to be able to do?
Primary function of the nervous system is impulse conduction
Need to allow impulse conduction in any posture or activity
Therefore NS must be able to move, shorten, lengthen & contort
What are 2 components of the nervous system?
- Neural tissue - impulse conduction
- Connective tissue - protects neural tissue and allows NS to adapt to movement
What are 2 things to happen with movement?
- Development of tension or pressure within the system and its attachments
- Movement
- of the whole neurosystem relative to its mechanical interface
- within the neurosystem neural elements in relation to connective tissue
What is neural mechanosensitivity?
abnormal electrical activity related to mechanical forces, loading or changes that lead to or contribute to symptoms.
What is the mechanical interface?
any interface that the nerve passes through (most is connective tissue but can be bone..etc)
What are 6 things we see in altered neurodynamics/mechanosensitivity?
- Postural variations - protective - deloading
- Active movements: impairment to movement reinforced with additional manouvres
- Passive movement impairment (SLR, PKB, PNF)
- Nerve trunk hyperalgesia (areas of superficial tenderness)
- Specific areas of local pain or symtpoms (signs at the interface - e.g. Local pain)
- History of recurrent pain states such as recurrent hamstring or calf sprain/tear
If a patient has radiculopathy, what is a sign of mechanosensitivity?
Lateral shift (to unload off tissue)
What are 4 vulnerable sites (Lesions affecting the elasticity and movement of the nervous system tend to occur at vulnerable sites)?
- Soft tissue or osseous tunnels e.g. IVF, carpal tunnel, piriformis
- Nerve branching e.g. head of fibula
- Where NS is relatively fixed e.g. PIN, C6/T6/L4
- Site of trauma e.g. fracture, ankle inversion sprain, whiplash
What are 6 contraindications for a neurodynamic examination?
- Severe or worsening neurological signs
- Not going to do this if it will significantly aggravate symptoms
- Cauda equina symptoms
- Spinal Cord Symptoms
- Severe pain including severe headache
- Significant dizziness and/or nausea
- Presence of obvious serious pathology e.g. cancer.
What are 5 cautions for a neurodynamic examination?
Delay or restrict testing in the presence of:
- Altered pathological status of other structures along the neural pathway that will be affected by the test
- Sprain, tear or fracture –> moving nerves through injured areas)
- Systemic disorders e.g. rheumatoid arthritis, diabetes
- Altered vascular conditions/responses.
- Neurological signs Loss of sensation, reduced reflexes
- Particularly careful as nerve conduction has been affected
- Known possibility of a latent response
- Wont be able to give good indication at the time but may aggravate afterwards
What are 4 features of a positive finding in a neurodynamic examination (reproduction of all or part of the patient’s symptoms)?
- Decreased range of motion when compared to the test performed on the opposite side (SLR and PKB) or in relation to the expected normal range
- Altered resistance through range or
- An altered end-feel to the movement
- A physiological response that is different to that normally expected
- i.e. a different order of onset and radiation of areas of response or a response in a different to normal area.
- Record whether test was positive AND any differences between sides relating to measurement, end feel and other responses
- Use estimation–> no need to use gonio (too hard unless with an aide)
What are 3 routine tests done in the neurodynamic examination?
- Cervical F (PNF): cephalad movement of the neuro-axis
- SLR: L4, L5, S1, S2 nerve roots, sciatic nerve and peripheral divisions
- PKB: L2, L3, L4 roots &the femoral nerve
What is a progressed test for the neurodynamic examination?
Slump: maximal test of trunk & neck flexion with superimposed SLR.
Used as a progression when all other tests are negative.
When is a passive neck flexion test done?
- Those who we are careful to do a SLR with –> high mechanosensitive patients
- Hold head on one hand and stabilise chest with other hand
- If pain comes on –> do not move on If no pain –> move on to straight leg raise
What are 5 things happening during straight leg raise?
- The lumbosacral nerve roots move caudally
- The sciatic and tibial nerve superior to the knee move distal
- Inferior to the knee the nerve moves proximal
- Posterior to the knee where there is no movement in relation to the interface.
- Nerve movement starts distally and moves proximally with greater ranges of SLR.
In the straight leg raise, when the heel is raised about ____cm above the supporting surface, movement of the nerve at the greater sciatic notch has begun. At about ______ degrees, the roots begin to move at the IVF.
1cm; 35
What are 6 other clinical uses for straight leg raise (lower limb presentation)?
- Hamstring tears
- Calf pain/tears
- Buttock pain
- Superior fibula pain
- Heel and foot pain
- Lateral ankle sprains.
In general, the more acute and irritable a presentation, the more likely it is that a test _____ (added/removed) from the area of symptoms may reproduce or influence them.
removed
Any pain produced during SLR may come from other structures Sensitising manoeuvres are essential to confirm the neural tissue as the likely source of symptoms to ________ from non-neural tissue
differentiate
The object of these tests is to move or further lengthen the neural tissue without any change in the stress on the other joint and muscle structures in the area of symptoms reproduced on the _____ test.
SLR
What are 5 sensitising manoeuvres?
- Ankle dorsiflexion
- Hip internal rotation
- Hip adduction
- Cervical flexion
- Plantar flexion and Inversion (PF/IN)
What are characteristics of SLR (straight leg raise)?
- Lift leg up and keep knee straight –> when you first feel something (stretch –> where?)
- Hold where it’s the end or “range” (stretch)
- Dorsiflexion with foot - Hip IR and ER from knee “Does it change anything?” Or “Does it make it better, worse or no change”
- Don’t say “Does it feel worse?” –> leading questions
What is a progression of the SLR?
Slump test
Significant care needed – only where symptoms are mild, low irritability
What are 4 components of the Slump Test?
- Trunk flexion
- Cervical flexion
- Dorsiflexion
- Knee extension (and measure)
What is the prone knee bend (PKB) used for?
Used to test mechanosensitivity of femoral nerve and L2-4 Nerve Roots
What are 3 movements if the femoral nerve is indicated (symptoms into anterior thigh)?
- Passive Knee Flexion
- Passive Hip Extension added
- Patient instructed to lift head – reduction in leg symptoms if positive (to differentiate between quad and femoral nerve)
How to tell whether its quads stretch or nerve sensation in a prone knee bend?
- If lifting head changes (improves) –> nerve (as it gets offloaded)
- If lifting head no changes —> quadriceps stretch
- If lift leg (hip extension) changes –> quadriceps stretch
- If lifting head while in hip extension –> no change (quadriceps stretch)
- If lifting head while in hip extension –> change (nerve)
How to tell whether its quads stretch or nerve sensation in a prone knee bend? If lifting head changes (improves)?
nerve (as it gets offloaded)
How to tell whether its quads stretch or nerve sensation in a prone knee bend? If lifting head no changes?
Quadriceps stretch
How to tell whether its quads stretch or nerve sensation in a prone knee bend? If lift leg (hip extension) changes?
Quadriceps stretch
How to tell whether its quads stretch or nerve sensation in a prone knee bend? If lifting head while in hip extension (no changes)?
Quadriceps stretch
How to tell whether its quads stretch or nerve sensation in a prone knee bend? If lifting head while in hip extension –> change
Nerve
What is the alternative prone knee bend?
Side lying Opposite leg kept in hip flexion Passive knee flexion and hip extension Cervical flexion or extension added as sensitising manoeuvres Flexion- aggravate symptoms Extension - relive
What are 2 things that need to be recorded in the findings or the neurodynamic examination?
- Whether test was positive
- Range of motion
What needs to be recorded in PNF?
Patient response
What needs to be recorded in SLR?
Hip Flexion degrees & patient response
What needs to be recorded in PKB?
Knee Flexion degrees & patient response
What does PNF stand for?
Prone neck flexion
What does SLR stand for?
Straight leg raise
What does PKB stand for?
Prone knee bend
What are 4 neurological symptoms?
- Tingling
- Pins and needles
- Numbness
- Muscle weakness
What is referred pain?
Pain perceived as occurring in a region of the body topographically distinct from where the actual source of pain is located.
What is radicular pain?
Distinguished from nociception by the axons being stimulated along their course. Activation may occur as a result of: •mechanical deformation of a dorsal root ganglion •mechanical stimulation of nerve roots •inflammation of a dorsal root ganglion •ischemia to dorsal root ganglia
What are 4 ways that activation may occur as a result of radicular pain?
- mechanical deformation of a dorsal root ganglion
- mechanical stimulation of nerve roots
- inflammation of a dorsal root ganglion
- ischemia to dorsal root ganglia
Radiculopathy can occur in the ________ of pain and radicular pain can occur in the absence of _______.
absence; radiculopathy
Radiculopathy is the term given to a range of symptoms that can rise from ______ compromise/irritation, including pain and neurological symptoms
nerve root
Radicular Pain is a single symptom (pain) that can arise from one or more spinal _____.
nerve roots
The criteria specify that a lesion or disease of the nervous system (either central or peripheral) is identifiable and that pain is limited to a “_________” distribution
neuroanatomically plausible
Most common cause of ______ pain which affects 20% to 35% of patients with mechanical LBP
neuropathic
What are 5 things that people with neuropathetic pain often present with high levels of when compared to patients with non-specific LBP?
- Pain
- Disability
- Anxiety
- Depressive symptoms
- Reduced quality of life
Patient with neuropathic back pain have ____ (better/worse) outcomes compared with mechanical back pain. What does this mean?
worse
Longer rehab and problems
______ is most common cause of radiculopathy
Disc herniation
What are 2 of the most common radiculopathy?
- L4-5
- L5-S1
What are Two Nerve Roots at Each Level?
Two nerves cross each disc level and only one exits the spine at that level.
What is the exiting nerve root?
The nerve root that exits the spine at a particular level.
What is the transversing nerve root?
Another nerve root goes across the disc and exits the spine at the next level below. Example: The L5 nerve root is the traversing nerve root at the L4-L5 level, and is the exiting nerve root at the L5-S1 level.
In Lumbar Radiculopathy – the ________ nerve root is more commonly affected
TRANSVERSING
Relatively high sensitivity but uncertain specificity for a _______. Symptoms are usually a ______ response (eg. scarring) rather than a mechanical force (eg. “pressing” on nerve) on the nerve root.
herniated intervertebral disc; chemical
Therefore, Radiculopathy is sometimes referred to as a ‘__________’
symptomatic disc herniation
What are 4 main causes of radiculopathy?
- Chemical irritation (Starts out painful but symptoms no longer hurts (MRI still shows the herniation) –> reducing of pain due to chemical irritation settling down)
- Compression / traction
- Repetitive mechanical irritation (friction)
- Anoxia
What is the relationship of lumbar radiculopathy to disc pathology?
A study of 377 patients with sciatica revealed that self- reported sensory loss (assessed through history taking) doubled the odds of having nerve root compression, and tripled the odds of having disc herniation
What are 3 other structures (apart from a disc heriation) which cause a radiculopathy?
- Chemical/inflammatory response
- Z Jt / Uncovertebral joint (cervical spine > lumbar spine) thickening/exostoses effusion of Z Jt capsule (traumatic synovitis)
- Developmental (congenitally narrow canal, especially lumbar spine, trifoil canal)
What are 4 symptoms that can predict symptomatic disc herniation (lumbar radiculopathy)?
- Dermatomal radiation
- more pain on coughing
- sneezing or straining
- positive straight leg raise can be used to predict symptomatic disc herniation
What is neuropathetic (radiculopathy) pain?
EXAM QUESTION
Sensory dysfunction should be neuro-anatomically logical
What is central sensitisation?
EXAM QUESTION
Increased sensitivity at sites segmentally unrelated to the primary source of pain
The physical examination for radiculopathy depends on _____ and ______, be prepared to limit examination Patients often assume a protective deformity Perform active movements to seek position of ease
severity; irritability
**Neurological examination (static MMTS, reflexs, sensation) is mandatory** If appropriate - examine ______. Manual examination to confirm the ______ level (can delay initially if can determine level from neurological findings & pain is severe and irritable)
mechanosensitivity; segmental
Most Lumbar Radiculopathies are caused by a ______ but the specificity is low as a large proportion of people have one or more non-symptomatic disc herniations on imaging
disc herniation
Neurological examination as a screening OR investigation for ALL patients with _______symptoms
referred
Care required with Neurodynamic assessment ESPECIALLY in the presence of _____ symptoms – we can delay the Neurodynamic
Neurological
Lumbosacral plexus: ___ to ___ levels Lumbar plexus = ___ to ____ roots Sacral plexus = ___ to ____ roots
L1 to S4; L1 to L4; L4 to S4
Lower lumbar and upper sacral plexus = sciatic nerve - divides into the posterior_____ and common _____ nerves at the popliteal fossa.
tibial; peroneal
Branches from both the lumbar and sacral plexus also form the inferior and superior _____nerves
gluteal
Branches from the sacral plexus alone converge to form the _____ nerves, innervating the pelvic floor.
pudendal
The femoral nerve descends beneath the ______ ligament
inguinal
The saphenous nerve - continues down the ______leg to the foot.
medial
The obturator nerve exits pelvis through the ________ where it innervates the thigh adductors and a small cutaneous area in the medial thigh.
obturator foramen
The lateral femoral cutaneous nerve, also has its origin directly from the plexus. Travels lateral to the femoral nerve underneath the_______ ligament to innervate the skin of the lateral thigh.
inguinal
What are 4 characteristics of femoral nerve compromise?
- Hip or pelvic fractures or masses within the iliacus (such as hematoma)
- Weakness of quadricep with sparing of adduction.
- Sensory loss of anterior thigh, medial thigh, medial shin to the region of the arch of the foot.
- Quadricep reflex loss
What are 3 characteristics of saphenous nerve compromise?
- Due to trauma or compromise within adductor canal/ space
- Occasionally the infrapatellar branch of the saphenous nerve is damaged due to mild trauma or knee surgery.
- Loss of sensation below the knee, medial shin to arch of foot and/or parasthesia
What are 3 characteristics of lateral femoral cutaneous nerve compromise?
- Compromise or trauma of the LFCT nerve as it traverses below the inguinal ligament
- Paresthesias, pain and/or numbness down lateral aspect of the thigh
- Risk factors = obesity, pregnancy, trauma, sometimes clothing
What are 2 tests to do for lateral femoral cutaneous nerve compromise?
- PNB
- nerve glides
What are the key differences between neuropathetic pain and central sensitisation? How do they overlap?
