Physical Exams 2: Block 1 Flashcards
What are the two motor pathways and what do they control?
Corticospinal (pyramidal)- cerebral cortex connecting to spinal motor neurons to control torso and limbs
Corticobulbar- upper motor neurons of CNs to control muscles of face, head and neck and terminate in the motor neurons in the brainstem
How does the L side of the brain control the R side of the body?
What happens of these motor neurons are damaged?
Corticospinal tracts cross the spinal cord in the medulla
Above- motor impairment on contralateral side
Below- motor impairment on ipsilateral side
Damage to an Upper Motor neuron results in ?
Damage to a Lower Motor neuron results in ?
UMN- increased muscle tone and exaggerated DTRs
LMN- absent muscle tone and DTRs
What neuron tract carries the impulse that inhibits muscle tone?
What is the sequence of flow for sensory pathways?
Corticospinal tract
Impulses from skin/muscle/tendons/viscera
Peripheral nerves/dorsal roots
Spinal cord (pain, temp, position, touch)
Spinothalamic tract/Posterior Column
Sensory cortex of brain
Once sensations like pain, temp and crude touch synapse w/ secondary neurons, how to they get to the thalamus?
How are sensations like postition, vibration and fine touch perceived?
Cross and ascend in Spinothalamic tract
Directly into posterior columns
What type of sensation are and are not sensed in the thalamus?
How is full perception of stimuli achieved?
Perceives pain, cold, pleasant
No fine distinctions are made
Third group of neurons send impulses to sensory cortex and higher discrimination is made
A lesion in the sensory cortex may impair ? but leaves ? intact
What type of PT presentation suggests Dz of posterior columns?
Impaired perception of pain, touch and position; leaves finer discrimination intact (person can’t tell size/shape/texture of object in hand)
Loss of position and vibration senses but other senses are preserved
What Sxs mean transection of spinal cord
What are the 4 guiding questions of a neuro exam?
Loss of all sensation, paralysis and hyperactive DTRs
Does PT have Dz
Is there localization/symmetry
What is the pathophysiology of the finding
Wat is the DDx
General assessment of a PTs mental status starts where?
How is orientation assessed?
How to assess cognitive function?
How intellectual function assessed?
First meeting- LOC, Appearance, Affect
ANO x 3
Long term- presidents
Short term- 3 words
Count back by 7s, spell 5 letter word
Chart on Slide 28
Pg 147-171
Where do CNs 3-12 arise from?
Where do CNs 1 and 2 originate?
Diencephalon and brain stem
Brain
What CNs control pupil constriction, opening eye lid and most EOMs?
Which ones control EOM?
2 and 3
3, 4, 6
What CNs control swallowing, raising of palate and gag reflex
Which ones contribute to voice and speech?
9 and 10
5 7 9 10 12
While assessing EOMs, a loss of conjugate movements in any direction will cause ?
How are nystagmus’ names?
Diplopia
Direction of quick component
Define 3rd nerve palsy?
Define Anisocoria
Ptosis- drooping of upper eye lid
Difference of >0.4mm of pupil diameters
Table 7-10,
Pg 277
A lesion on ? CN causes an absent blinking reflex with the corneal reflex test?
What is the different results of a peripheral injury, like Bell’s Palsy, and a central lesion, like a stroke, on the muscles of the face?
Sensory 5 or Motor 7
Palsy- affects upper and lower face
Stroke- only lower face
What nerves are the motor area and pull the palate up during “aahh”?
How are both motor and sensory areas of these nerves tested?
A lesion here will cause what result to be seen?
9 and 10
Gag reflex
Paralysis causes pulling the uvula to unaffected side
A lesion on ? CN will cause hoarseness or difficulty swallowing during the gag reflex?
What are the functions of CN11?
Unilateral lesion on 10, vagus
Unilateral absence of reflex can mean lesion on 9 or 10
Carry efferent motor fibers to innervate SCM (turn head) and Trap muscles (raise shoulders)
Trapezius muscle weakness with atrophy and fasciculations indicates ?
What type of result will be seen in the shoulder as a result of the muscle’s weakness?
Peripheral nerve d/o
Drooped shoulder, scapula is displaced down and laterally
A unilateral cortical lesion of CN12 causes ? result?
A distal lesion of C12 will cause what tongue result?
Protruded tongue deviates away from side of lesion
Deviates to weak side
Sensory system carries stimuli such as pain/temp, position/vibration, light touch and discriminative sensation through which pathways?
Pain/temp- spinothalamic
Position/vibration- posterior column
Light tough- both paths
Discriminative sensation- cerebral cortex
When testing vibration and sensory sensation, what areas of the body are tested first?
Mapping out dermatomes help with an exam how?
Finger and toe
Localize neurological lesions to a specific level of the spine, particularly in spinal cord injuries
What is the organization that own dermatome mapping?
What are the land mark dermatome levels?
American Spinal Injury Association
C3- front of neck C6- thumb C8- ring and little finger T4- nipples T10- umbilicus L1- inguinal L4- knee L5- anterior ankle/foot L4,L5,S1- posterior ankle and foot S5- perianal
Define Analgesia
Define Hypalgesia
Define Hyperalgesia
Absence of pain sensation
Decreases sensitivity to pain
Increased sensitivity to pain
Which dermatomes need to be checked bilaterally?
All 3 branches of trigeminal C5-T2 T4 T10 T12 L2-S1
What part of a sensory test is often omitted if pain sensation is normal?
What size of tuning fork is used to test PTs vibration sense?
Temp
128Hz
What tests are included in testing discriminatroy sensations?
Stereognosis- name objects held in hand
Graphesthesia- numbers drawn on hand
2 point discrimination- normal <5mm on finger pads
Point localization
Define Asterognosis
When is graphesthesis testing used?
Inability to recognize objects held in hand
If stereognosis is too painful or difficult for PT
How do we grade motor strength
0: no contraction detected
1: barely detectable flicker
2: movement w/ gravity eliminated
3: movement against gravity only
4: movement w/ some resistance
5: movement against full resistance w/out fatigue
How many muscle groups represent the motor innervation by the cervical/lumbar spinal cord
What muscles are not tested
10 groups
Abdominal muscles, T10-11
Hamstrings- innervated by levels of other muscles
What nerves control areas of the upper extremity?
C5- elbow flexor (bicep) C6- radial; wrist extensor C7- elbow extensor (tricep) C8- median; grip and thumb opposition T1- ulnar; pinky abduction
What nerves control areas of the lower extremity?
L2- psoas hip flexion L3- quad, knee extension L4- tibialis anterior, ankle dorsiflexion, inversion L5- hallucis longus, great toe extension S1- gastrocnemius, plantar flexion
What neurons are innervated during DTR tests?
In order for a DTR to fire, what all needs to be intact?
Afferent and Efferent
Sensory, spinal cord synapse, motor fibers, neuromuscular junction, muscle fibers
What is the path of a signal to elicit a DTR response?
How are reflexes graded?
Tapping - sensory - peripheral nerve - spinal cord - anterior horn - crosses neuromuscular junction - contraction/completion
4- very brisk w/ clonus 3- brisker than average, not specifically indicative of Dz 2- normal 1- low normal 0- absent
An abnormal reflex at tricep, bicep, brachioradialis, patellar or achilles means a lesion where?
Bicep- C5 Brachioradialis- C6 Tricep- C7 Patellar- L4 Achilles- S1
A cutaneous reflex on upper/lower abdomen, plantar or anal region signify what areas of the NS?
Upper abdomen- T8-10
Lower abdomen- T10-12
Plantar- L5-S1
Anal- S2-4
Hyperactive reflexes can indicate lesions where?
How do you prove/disprove an issue?
Descending corticospinal tract
Weakness, Spasticity, Pos Babinski
Hypo active/absent reflexes imply ? issue
How do you prove/disprove these issues?
Dz in spinal nerve roots, spinal nerves, plexus or peripheral nerves
Lower motor neuron findings of weakness, atrophy or fasciculations
What type of reinforcement can accent/increase a PTs diminished/difficult reflexes
Isometric contraction
Diminished arm reflexes- clench teeth, squeeze knees together
Diminished leg reflexes- lock fingers and pull against each other
Define the Babinski reflex
Plantar reflex- normal is toe flexion
Abnormal=positive, dorsiflexion and toe fanning from CNS lesion in corticospinal area or unconscious from drug/alcohol intoxication or postictal period
If a reflex seems hyperactive, what is the follow on test?
What part of the brain helps w/ keeping the body upright in space?
Test for ankle clonus
Sustained clonus= CNS dz
Cerebellum
Coordination of muscle movement requires what four areas of the NS to function together?
What function is usually not tested in a routine neuro exam?
Motor- strength
Cerebellar- rhythm/posture
Vestibular- balance/coordination
Sensory- position
Vestibular function
How do you assess PTs coordination during a cerebellar exam?
Rapid alternating movements
Point to point movements
Gait
Standing- Romberg, Pronator drift
Define Dysdiadochokinesis
Define Dysmetria
Cerebellar issues- one rapid movement can’t be followed by follow on rapid movement
Finger over shoots target when PT point nose to out stretched finger target and worsened by eyes closed
What PE finding suggests a PT has a loss of position sense?
What do abnormal Heel-to-Shin tests mean?
Nose to finger test is over shot by PT
Cerebellar Dz if heel over shoots knee and oscilates side to side down shin
Lost position sense of heel lifted too high and PT tries to look
Define Ataxic
What type of gait test can reveal hidden ataxia?
Uncoordinated gait and can be due to cerebellar Dz, loss of position sense or intoxication
Tandem walking
What PE test mainly tests a PTs position sense?
What abnormal findings can be seen and what do the represent?
Romberg
Ataxia- from dorsal column dz and loos of position sense
Cerebellar ataxia- PT has difficulty standing w/ feet together regardless if eyes are open or not
What PE test is both sensitive and specific for a corticospinal tract lesion?
Other than drifting, what other finding can be indicative of an issue?
Pronator drift, signifies lesion in contralateral hemisphere
Downward drift of arm w/ flexion of fingers and elbow
Define Brudzinski sign
Define Kernig Sign
Elevated head bends/elevates knees
Extends knee from raised leg position, positive is pain in neck, back or head upon knee extension
Define Articular Structures
Define Extra-Articular Structures
Capsule, Articular Cartilage, Synovium/Fluid, lIgaments, Juxta-Bone
Periarticular Ligaments, Tendons, Bursae, Muscle, Fascia, Bone, Nerve and Overlying sking
What are the 3 types of joints?
Synovial- freely moveable, bones don’t touch and are covered by articular cartilage and separated by synovial cavity which is lined by membrane and secretes fluid, membrane surrounded by joint capsule
Cartilage- slightly moveable, discs separate surfaces- ribs-sternum, epiphyseal plates of long bones
Fibrous- immoveable, bones connected by fibrous CT, intervening layers of tissue holds bones together- sutures, distal talofibular joingt, teeth/socket
What are the 5 types of synovial joints?
What is the most active joint in the body?
B/Socket, Condylar, Saddle, Hinge, Pivot
TMJ
What type of joints are in between the tib/fib and along the plates of the cranium?
What type are between the spinal vertebrae and the manubrium-rib?
Syndesmosis, Suture
Symphisis, Synchondrosis
What is assessed during the General Information part of a MSK exam?
What is assessed during the inspection?
What is assessed in the surrounding areas?
Appearance, Proportions, Ease of movement
Malalignment, deformity, fasciculation or tremors
Skin changes and atrophy
Acute involvement of only one joint suggests ? issue
What issue affects several joints symmetrically
Trauma, Septic arthritis, Gout
RA
How do you grade muscle strength?
0- no contraction detected 1- barely detectable/flicker 2- movement w/ no gravity 3- movement against gravity only 4- movement w/ some resistance 5- movement against full resistance and no fatigue
What muscle opens the jaw?
What muscles close it?
External pterygoids
Masseter, Temporalis and Internal pterygoids
Define TMJ Syndrome
What finding wold be seen 2-3wks post-rotator cuff tear?
Unilateral chronic pain w/ chewing/clenching often associated w/ stress
Can have swelling/dec ROM and Trismus
Atrophy of Supraspinatus and Infraspinatus
Lateral to medial, what are the bony land marks of the shoulder?
Which landmark do the rotator cuff muscles insert?
Great tubercle, AC joint, Coracoid process
Great tubercle
What movements are Flex, Extend, Abd, Add, Internal and External rotation movements for the shoulder?
Flex= raise arm up and over head (0-180)
Extend= raise arms behind (0-60)
Abduct- raise arms out and overhead
Add= cross arms across body
Internal- reach behind, touch scapula
External- brush hair/arm to shoulder level, bend elbow and rotate forearm to ceiling
What does each special test assess in the shoulder? Cross over Apley scratch Neers/Hawkins Suprspinatus strength (empty can) Infraspinatus strength Drop arm Forearm supination
ACJ Overall rotation Cuff tendonitis/tear Cuff tendonitis/tear Cuff of biceps tendonitis Cuff tear Bicep tendonitis
What special test is done to assess the subscapularis Muscles?
Where is the ulnar nerve in relation to the olecranon?
Lift off test
Posterior between olecranon process and medial epicondyle
What do each of the following movements use for muscles? Flexion Extension Supination Pronation
Flex- bicep, brachialis, brachioradialis
Extend- tricep
Supinate- bicep, supinator
Pronate- pronator teres/quadratus
Thenar or hyperthenar atrophy are signs of ? issue
What structures make up the snuff box?
Thenar- median nerve compression
Hypothenar- ulnar nerve compression
Distal to radial styloid
Extensor Pollicis Brevis and Abductor Pollicus Longus
What are the movements of the thumb?
Flex- move across palm to 5MCP joint Extend- across palm and away from fingers Abduct- anterior and away from palm Adduct- toward palm Opposition- touch thumb to each finger
What parts of the hand are innervated by nerves from the carpal tunnel.
What tests can be done to assess for carpal tunnel?
Median Nerve-> pulp of index finger
Ulnar nerve-> pulp of pinky finger
Radial nerve-> dorsal web space of thumb and finger
Tinel Sign- tap median nerve
Phalen Sign- hold wrist flexed x 60sec and assess for numb/tingling; Pos= median nerve affected
Finklesteins- fist the thumb w/ wrist ulnar deviation; Pain= de Quervian Tenosynovitis
What does C5 do for Motor, Reflex and Sensation
M: deltoid and bicep
R: bicep
S- outter upper arm
What does C6 do for Motor, Reflex and Sensation
M: bicep curl, wrist extendors- carpi rad longus and brevis
R: forearm
S: outter lower arm and thumb
What does C7 do for Motor, Reflex and Sensation
M: tricep extension, wrist flexion, finger extension
R: back of elbow
S: middle finger
What does C8 do for Motor, Reflex and Sensation
M: interossei muscles, finger flexors
R: NONE
S: medial forearm and pinky/ring finger
What does T1 do for Motor, Reflex and Sensation
M: interossei muscles
R: none
S: medial elbow
When assessing gait, define Stance Phase
When do most gait problems occur?
Define the Swing Phase
Foot on ground and bears weight
Weight bearing/stance phase
Foot moving forward and bears no weight
How far wide should the gait base be ?
What is the only part of the gait that does NOT have knees flexed?
2-4”
Heel strike
Top of the iliac crest is at what lumbar level?
Pubic symphsis should be at the same level of ? structure
L4
Greater trochanter
How is the inguinal ligament best palpated during exam?
What is the sequence of structures that bisect w/ the inguinal ligament
Ipsilateral heel on opposite knee
NAVEL
What are the 3 bursae in the hip and how are the palpated?
Psoas- below inguinal ligament on deeper plane
Trochanteric- overlying greater trochanter
Ischiogluteal- overlying the ischial tuberosity and NOT palpable unless inflamed
What muscles are involved for movements of Flex, Extend, Abd, Add, Internal and External rotation movements for the hip?
Flex- ilipsoas Extend- gluteaus max Abduct- max and minimus Adduct- adductors, pectineus, gracilis External- obterator, quad femoris, gemuli Internal- gluteus medius and minimus
