Download Course - Cat`s TCM Notes

Course:
Class #:
Physical Assessment 2
4
Date:
October 17, 2008
Written test on cranial nerves and stuff from today on Week 5. Know the starred slides from this lecture.
Evaluating the Neuromuscular system
™ Sensory pathways
altered sensation?
™ Reflex Arcs
inability to initiate motor movement
™ Motor output
mechanical problem
Sensory Evaluation
™ Cranial nerves
All sensory evals from previous class plus motor
components
™ Somatic enervation
Spinal nerves – past the spinal column
o Light tough
o Vibration
This is major thing for the dorsal column.
o Position sense
o Two point discrimination
o Heat/cold
o Tickle
o Itch
o Pain
Spinothalamic’s primary sensation complains is
pain
Types of Skin Enervation Mapping
Dermatomes
Paths that spinal nerves follow and terminate into the skin - maps
on the skin where the spinal nerves inervate. C6 for instance is
the thumb. C7 is 2nd and 3rd fingers, C8 is the little and ring
fingers. These are basic rules, but allow for anatomical variance.
***Memorize dermatomes of the arms and legs. ***
C6 – C8 is the elbow down for the most part; L4 – S1 is for the
knee down for the most part.
Dermatomes for the head? Not so much. Mostly cranial nerves here rather than spinal nerves. Dorsal
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rami does enervate the back of the head somewhat.
Example: numbness in the thumb may be due to a bulge at C6 on the spine or lower on the nerve. This is
a common place for spinal degeneration, arthritis, compression, etc.
Pectoral area is C5. Problems here would possibly need some sensory testing to pinpoint nerves
Note: there are only 7 cervical vertebra, but there are 8 cervical spinal nerves. Why? First spinal nerve
comes out between occiput and C1. The 8th comes out below the C7. This doesn’t happen in the thoracic
or lumbar areas, but does in the cervical area.
L1 is in the groin crease. L3 is above the knee and thigh kind of sartorius area and L2 is between L1 and
L2 . The Lumbar nerves seem to come from the lumbar area and wrap diagonally from lateral to medial.
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L5 can be tested between the 1st and 2nd toes. Rub inside and outside of the calf = L4 and L5. Lateral
foot test is S1. These are all sensory tests for the lumbar nerves.
Peripheral Nerve Distribution Maps
Don’t need to memorize
Peripheral nerves have their own interesting mapping system. This is a different map than the
dermatome map. Classic of the median nerve at the wrist for instance will show as numbness in the
thumb, index and middle finger. Ulnar nerves will express as numbness from the ring and pinkie that
extends front and back of the hand.
Other kinds of maps
Don’t need to memorize.
Can get referred pain from muscles (trigger points), meridian referral pain (acupuncture), scleratomes
are for joint referred pain.
Thoracic Dermatome Landmarks
Know: T5 thru the areola and nipple, T10 at the umbilicus, T12 just above the pubis symphysis. These
give good landmarks to help you determine which of the thoracic nerves might be involved. Use light
touch, pinwheel, 2 point discrimination, etc to test enervation.
How is this useful? Example. Sharp shooting pain along a rib line. You poke and feel nothing wrong. Do
some sensory testing and find a sensory change. You see a dermatomal pattern. Herpes zoster/shingles
affects in this nerve pattern for instance and might be what’s going on. Shingles may come on as a stripe
of pain before the bumps show up.
See the sciatic nerve slide for sciatic lower leg possible problem areas. Piriformis area is a common
place for nerve compression.
Visceral referred pain
Understand this information. Refer back to the A and P book if needed.
Usually get pain from the somatic structures. Visceral pain refers in spots that look like the soma having
pain. Here’s a good example: gastric and esophageal problems can express as a pain around the spine
just between the shoulder blades. Often patients will be taking NSAIDs for the back pain and are just
making the gastric problems worse in doing so, so they have more back pain….on and on in a very bad
spiral.
Testing
Tests are specific to the length of nerves. The higher problem (lesion, tumor, entrapment) the bigger the
area is that is affected.
Person has numbness at the shoulder. This nerve goes to the spinal column and then up the
spinothalamic tract to the brain.
Dorsal column testing
Mostly you are testing the areas where the nerves come out of the spine and express. Dorsal
column carries sensation of deep touch, visceral pain and vibration.
Vibration can be tested with a vibrational tuning fork.
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Spinothalamic column.
Spinothalamic carries light touch, tickle, itch, temperature, pressure and pain.
Pinwheel can do light touch as can bristle hairs on some of the ends of the reflex hammers. This
bristle might do tickle as well.
Cold and heat are not often tested, but you could …
Pain sensation – sharp things with enough pressure to cause light pain – either the pinwheel or
the sharp unscrewable part of a reflex hammer.
Two point discrimination – touching 2 points at the same time – open up a paperclip for this for a
quick cheap fix. Remember the sensory homunculous and which areas were biggest: head,
tongue, hands, feet, genitalia. In these areas you can feel 2 points together very close – have
patient close eyes and ask them if it feels like 1 or 2 points. Check this in various dermatomal
areas. In the smaller areas of the homonculous you must spread those points apart more. The
spinothalamic tract sends 2 point information. You are testing this function when doing 2 point.
Testing Reflexes
Remember the reflex arc. Sensory information comes in from the body to the brain, brain makes
a decision about what to do, sends rx down to the area via the nerves.
Example: stretch a muscle, info to brain, brain decides to protect the area, sends info for muscle
to react, muscle contracts.
This is why the reflex hammers are used – tests reflex arcs. Do this after dermatomal testing.
You hammer, tendon may send info, brain has no ability to send response so nothing happens.
Some patients have diminished reflexes by nature – hypothyroid and diabetes will also diminish
reflexes overall.
™ Biceps brachii tendon tests the C5/6. Put your thumb (nail) on the tendon and press down
then whack your thumb with that hammer. If you don’t, the soft tissue will just absorb the
shock. Use the hammer like a pendulum swing.
™ Supinator reflex tests the C6 nerve root. It’s about ½ way between the cubital and wrist
crease – just upstream from Lu 7 perhaps or maybe on the medial side.
If for instance there’s no reflex at the bicep brachii tendon (c5/c6) but has one at
supinator, then you could determine it’s probably c5.
™ Triceps reflex at the funny bone.
™ Lat muscles in the armpit area – C7 innervated muscle. Go behind them, grab that lat,
have them cough and feel for differences. If not even, might be something impinging on
C7.
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™ Patellar Ligament reflex. You hammer directly on this to test the L4 nerve root.
™ Achilles reflex tests the S1 nerve root reflex. Relax the foot and you move the toes up to
dorsiflex. Whack on the Achilles tendon above the calcaneus. Should cause a calf muscle
contraction. Feel for foot flexion.
™ Babinski Reflex is also on the foot
Two point discrimination
Test within one region then more to another region. In the hands for instance there should be about the
same distance between the points. For both this and the pain response test along the dermatome.
Abdominal/Thoracic Reflexes
T7 – T12 represent the thoracic/Abdominal Reflexes. Pin prick and light touch. Check along the
dermatome levels or can cross the areas looking for differences. Vertical checks all the dermatomal
tracts.
Muscle Strength testing
Top to bottom…Goes through the nerve roots again more deeply into the muscle enervation. This is
efferent/output test. Look for weakness and bilateral even-ness/symmetry. Lack of symmetry could be a
problem on the nerve, at the root, in the muscles themselves. You don’t want to overpower the muscle,
so you use like versus like – like use your index finger to test the thumb not your whole arm!
Easiest to test either sitting (preferred) or lying.
™ Deltoid. Check this one bilaterally at the same time or will knock them over. Raise elbows up
and press both down at the same time to see if they are even in resistance. Tests C5
™ Biceps = C5/6.
™ Brachioradialis C5-6
™ C7 is triceps (an extensor), thumb extensor, finger extensors. Good to do multiple tests here.
™ C8 is finger flexors – curl fingers and see if you can uncurl them.
™ Finger abduction and thumb opposition is T1 spinal nerve root. For thumb, hold thumb and
pinkie together and see if you can separate them.
™ Hip flexion is lumbar 1-2. Lift thigh up against hand resistance.
™ Knee extension = L3-4. Push lower leg out against the hand resistance.
™ Hip abduction – push knees out against your resisting hand.
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™ Ankle dorsiflexion – cock foot up toward the ceiling against your resistance. L4. Can also see if
they can walk on their heels only.
™ Big toe extension – L5.
™ Knee Flexion – pull knee backwards against resistance.
™ Ankle plantar flexion = S1 and 2. Push ball of foot down against your hand. Can also see if one
can walk on their toes.
Upper Motor Neuron Lesion could be anywhere from the spinal cord to the brain.
These are bigger problems – tumors, parkinsons, bleed, all kinds of crap. Basically, a lesion in the upper
motor neuron. More of a global problem. Common signs:
™ Loss if distal extreme strength or dexterity– you’ll see this more generally than just one nerve
root.
™ Babinski sign is an abnormal reflex. Run the blunt end of a something up the outside of the sole
then across the ball. Most people will have a little plantar flexion response. Babinski would
dorsiflex. An adult with this has an abnormal response, though this is common in babies.
™ Clonus is also an UMNL sign. Have pt relax the foot, quickly jerk it up and the foot should move
up. With Clonus the foot will have a couple of flaps rather than just one move up. Globally the
patient will probably be hyper-reflexive too.
Lower Motor Neuron Lesions are from the ventral horn out the spinal nerve down to the sensory
distribution or a muscle. Peripheral entrapment is a lower motor neuron thing. So is …
™ Loss of muscle strength/tone or reflexes due to denervation.
™ Muscle wasting/atrophy. You can measure around the muscle on both sides and look for lack of
symmetry to see if there is loss of mass. That’s usually the last thing to occur however, but it’s
not the first thing you’ll see.
™ Small fascicles twitching is a denervation hypersensitivity. These are tiny ongoing contractions
of little bundles of fascicles within a muscle.
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