1. Cerebellum
2. Upper motor neurons (CNS)
3. Lower Motor Neurons (PNS)
4. Muscles

When asseccing the Muscle tone what should you instruct the patient to do?

0= no muscular contraction detected

1=barely detectable flicker or trace of contraction

2=active movement with gravity eliminated

3=Movement against gravity

4=Movement against gravity and some resistence

5=movement against full resistenc (no fatigue)

5 is considered normal muscle strength

flexion--biceps--C6

extension--triceps--C6,7,8

extension--Radial nerve--C6,7,8

Dermatomes tested at hand:

Grip strength--C7,8, T1, median

Abduction--C8,T1, ulnar nerve

Thumb opposition--C8,T1, median nerve

Hip flexion--L2,3,4

Hip extension--S1--gluteus maximus

Hip abduction--L4,5, S1

Hip adduction--L2,3,4--adductor muscles

Knee extension--L2,3,4--quadraceps muscles

Knee flexion--L4,5, S1,2--hamstrings

Dorsiflexion--L4,5--toes toward the ceiling

Plantar flexion--S1--toes toward the floor

Tandem walking (AKA heal to toe) is the most sensitive test for what?

Ataxia

It assess cerebellar function and postiion sense.

Walking on heels assesses?

Walking on toes assesses?

H--L4.5

T--S1

Mainly test position sense (sensory cortex and posterior column)

Patient stands with feet together and then closes eyes for 20-30 seconds.  There shoudl be minimal to no swaying repoted as a negative test.

Testing motor strength (motor cortex, corticospinal column)

Patient holds palms up toward the ceiling and closes eyes for 20-30 seconds.  what for downward drift of the palms.

Finally, tap arms slightly downward and watch for rebound.

1. Triceps--C6,7
2. Biceps--C5,6
3. Brachioradialis--C5,6
4. Abdominal  above umbilicus--T8,9,10  Below--T10,11,12
5. Knee--L2,3,4
6. Ankle--S1
7. Plantar--L5,S1
8. Rectal--S2,4

4+ very brisk, hyperactive

3+ better than average

2+ average, normal

1+ slight movement

0 No response

Dorsiflexion of big toe with fanning of other toes.

Indicates a CNS lesion in the corticospinal tract, with ETOH and drug intoxication, or following a seizure.

1. Is the mental status intact?
2. Are R and L sided findings the same?
3. Does the Causitive lesion lie in the CNS or PNS?

1. Mental status, Speech and language
2. Cranial Nerves
3. Motor system
4. Sensory system
5. Reflexes

Cerebral Lobe Function:

Frontal--motor cortex

Perital--sensory cortex

Temporal--Sound taste smell and balance

Occipital--primary vision center

Lymbics--mediates patterns of behavior, viceral responses to emotion and biological rythms

Aids the cerebrum in voluntary movement

Processes senory information

Reflexive control of muscle tone

Pathway between cerebral cortex and spinal cord

(Pons, medulla, midbrain and diencephalon)

12 cranial nerves

Reticular formation--constanst muscle tone

Thalamus--pain and temp(relay center)

Basal ganglia--fine tunign effect of gross motor movement

Somatic organization of the Cerebrum

(picture)

Posterior nerve root

(contains spinothalamic tract and posterior column)

Anterior nerve root

(contains corticospinal and corticobulbular tract)

Nerve Plexus

Upper motor Neurons

&

Defect signs

--originate in the motor strip of the cerebral cortext

--Synapse with motor nuclie in the brain stem and anterior horn of the spinal cord

Dcreased strength but no atrophy, above brainstem will affect opposite side, hyperactive deep tendon reflex

Lower Motor neurons

&

Defect signs

cell bodies that originate in the anterior horn of the spinal cord

loss of tone, muscle atrophy, weakend deep tendon reflex,

1. Corticospinal tract
2. Basal ganglia
3. Cerebellum

--a lesion at any site will affect movement or reflex activity

motor neuron damage above level of crossover in the medulla:

motor neuron damagae below level of crossover in the medulla:

--motor impairment is seen on opposite side of lesion

--motor impairment is seen on same side as the lesion

motor and sensory loss on contralateral side

increased DTR's

ie: cerebral stroke

motor weakness

No typical sensory findings

increased DTR's

--motor weakness often affecting both sides

--dermatomal sensory deficit often bilateral and seen at site of injury

--increased DTR's

Motor--Bradykinesia, rigidity, tremor

No typical Sensory deficit

DTR's normal or decreased

Motor: hypotonia, nystagmus, ataxia

No sensory findings

DTR's normal or dcreased

1. Spasticity (UMN)--clasp knife
2. Rigidity (basal ganglia)--cog-wheel rigidity
3. Flaccidity (LMN)--guillain Barre
4. Paratonia(hemispheres of frontal lobe)--dementia

1. Anterior horn
2. Spinal roots and nerves
3. Peripheral Nerve-mononeuropathy
4. Peripheral nerve--polyneropathy
5. Neuromuscular Junciton
6. Muscle

motor -focal weakness or atrophy, fasiculations

  sensory - intact, DTR’s - ¯.

  ex: polio, ALS.

  motor- dermatomal weakness, fasiculations

  sensory - corresponding dermatomal deficit,DTR’s - ¯.

 ex: herniated cervical or lumbar disc.

Peripheral nerve--Mononeuropathy

  motor- dermatomal weakness and atrophy

  sensory - corresponding dermatomal deficit, DTR’s - ¯.

ex: trauma

motor- weakness and atrophy distally + fasiculations

 sensory - stocking glove distribution, DTR’s - ¯.

ex: alcoholism, diabetes

motor- fatigability rather than weakness

sensory - intact, DTR’s - normal.

ex: myasthenia gravis

motor- weakness proximally + fasiculations

 sensory - intact. DTR’s - normal or ¯.

 ex: muscular dystrophy

Sensory

Lateral Spinothalamic

Anterior Spinalthalamic

Poterior Column

Anterior and dorsal spinocerebellar

Motor

Lateral and anterior Corticospinal

Medial and Lateral Reticulospinal

Associated with a lesion in the corticospinal tract

Leading to weakness on one side of the body

Associated with foot drop

(ie herniated disc)

associated with loss of position sense in legs as seen in polyneuropathy or posterior collumn damage

+Rhomberg

Patient cannot stand steady with eyes open

 (DZ of cerebellum)

+Rhomberg

1. Lower face is controlled by UMN pathways from opposite side of cortex only
2. Upper face is controlled by UMN pathways from both sides of the cortex

--A L sided stroke will affect the right lower face but will not affect the upper face

Impairment of volume--seen with laryngitis, unilateral vocal cord paralysis

defect in muscle control of lips, tongue, palate or pharynx

--Results in slurred speech

--central or peripheral motor lesions, parkensonism, cerebellar DZ

disorder in producing or understanding language

Wernicke's--receptive deficient

Broca's--expressive deficient

Disorder of inner ear or vestibular nerve damage

Pontine area damage--upbeat

brainstem or cerebelar stroke--downbeat

Basal artery ischemia--vertical gaze disturbance

pons--horizontal gaze disturbacne

Stroke--eye deviation toward lesion side (will resolve in time)

Seizure--eye deviation away from lesion side

Pupils:

Normal

Miotic

Mydriatic

Norm--3-4 mm

miotic--constriction

Mydriatic--dilation

midposition slightly dilated and fixed to light

--suggests structural damage in the midbrain

disruption of the CN III pupillary constrictors

--Warning of herniation of the temporal lobe causing compression of the oculomotor nerver

Rythmic, repetative, bizarre movements of the face, lips, mouth, tongue and jaw

Late manifestation of psychotropic drugs

Speak to the patient in a normal tone of voice.
An alert patient opens the eyes, looks at you,
and responds fully and appropriately to stimuli (arousal intact)

Patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep.

Patient opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased.

Patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment.

the upper arms are held tight to the sides with elbows, wrists, and fingers flexed.  Legs are extended and itnernally rotated with feet plantar flexed

--implies structural corticospinal tract lesion at or near the cerebral hemisphere

Descending Spinal tracts

(all)

Motor

• Lat. and Ant. Corticospinal
• Med. and Lat. Reticulospinal

Minimal distance discrimination

(general)

• tongue has the smallest minimal distance
• finger tips
• toes
• palms
• chest
• back
• thighs