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Course:
Class #:
Physical Assessment 2
1
Date:
September 26, 2008
Mostly orthopedic and neurological evaluations in this class.
Today, head (heavy on the cranial nerves) and cognitive evaluations + MMSE (mini mental state
evaluation) which is a small test for dementia. You use this as a baseline, do it as the patient keeps
coming in to see you and evaluate how they are pro- or regressing.
Email: [email protected]
Nervous system functions
Overview
• Rapid Communication
• Sensory Input
• Integration of sensory input into homeostatic control and decisions
• Motor output
• Reflexes
• Higher brain function, homeostasis, integration and coordination with other sys (endocrine,
muscular)
Nervous system has 2 basic divisions:
CNS
Or Central Nervous system, consisting of the brain and spinal cord
Interneurons or association neurons are confined to the CNS and receive/send signals to the PNS
sensory and motor divisions.
PNS
Or Peripheral Nervous System, i.e., everything outside of the spinal cord, starting at the spinal nerves.
There are 2 major divisions of the PNS:
• Sensory
Sensory or afferent neurons conduct signals from receptors to the CNS
o Visceral
Internal organs, brain, spinal cord are all the viscera.
Heart (blood pressure), GI tract
o Somatic
Bones, muscles, joints and stuff.
Pressure, texture, vibration, etc. coming from the skin. Position and status in the body.
• Motor
Motor or efferent neurons conduct signals form the CNS to the effectors such as muscles and
glands.
o Visceral motor
ƒ Sympathetic
ƒ Parasympathetic
Primary drive here comes from the vagus nerve.
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o Somatic motor
Controls bone, muscles, joints. Big focus of the class.
CNS
Brain
• Cerebrum
higher brain functions – thoughts, feelings, math, language
• Cerebellum
neuromuscular control, coordination movements, smooth motions through the world.
Proprioception.
• Brainstem
• Diencephalon: thalamus, hypothalamus, epithalamus
Spinal Cord
CNS: Brain – Cerebrum
Have a general understanding of this.
Frontal Lobes
Responsible for attention, executive function, motivation and behavior. Tests for this
include working memory (digit spans, spelling backwards). Also responsible for
judgment, fundamental knowledge, task organization, and set generation (lists of stuff)
Temporal Lobe
Important for emotional responses. Located low and to the sides…temples. Amygdala
and it’s connections to the hypothalamus and frontal lobes. Also responsible for memory
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(hippocampus and limbic connections). Clinically the main tests for temporal lobe
functions are those of memory, mostly declarative.
Antioxidants help keep this healthy as do omega 3 fatty acids, exercise moving oxygen
and increasing profusion, brain plasticity exercises, acupuncture which increases nitrous
oxide in the brain.
Language – Frontal and Temporal lobes
The principle area for receptive language is the Wernicke’s area. This is located in the
posterior part of the superior temporal gyrus of the dominant temporal lobe. The major
region for expressive language is the Broca’s area located in posterior part of the inferior
frontal gyrus of the dominant hemisphere. Homologous regions of the non-dominant
hemisphere are important for the non-verbal contextual and emotional aspects as well as
the prosody/rhythm of language. Tests for written and spoken receptive and expressive
language are used to “view” the centers.
Both are commonly affected in a stroke or brain damage.
(Refer back to the scalp acupuncture notes from Advanced Acupuncture Tech 1)
Parietal Lobes
The parietal lobes are imp for perception and interpretation of sensory info especially
somato-sensory info. Non-dominant parietal lobe = imp for visual/spatial function. Dom
parietal lobe is imp for praxis or the formation of the idea of a complex purposeful motor
act. Frontal lobes by contrast are important for execution of the act.
Clinical tests for parietal lobe function include tests for agnosia (can you identify stuff by
touch), apraxia (can you do purposeful motor acts upon command), constructional
apraxia (can you draw objects which require use of visual spatial organization – simple
objects).
Occipital lobe
Visual area and visual perception of info. Areas in inferior temporal visual assoc cortex
are imp for recognition of the color and shape as well as the recognition of faces.
Projections from the occipital lobe to the superior temporal parietal area are important for
perceiving motion of objects.
Tests include….
Evaluating the cerebrum
Orientation and memory
Month/day/date, day of week, place tests for orientation. This involves not only memory but
attention and lang. 3 word recall tests. Remote memorization tasks such as naming presidents,
which area not only temporal but also heteromodal association cortices.
Immediate memory – give you 3 words, do you remember them immediately? Go thru more
stuff, ask again in 5 minutes…
Working memory/attention
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Digit span, spelling backwards, naming months of the year backwards. This tests attention and
working memory – frontal lobe function.
Judgment-abstract reasoning
Frontal lobe functions can be tested using problem solving, verbal similarities, proverbs.
Examples:
• What do you do when you see a house on fire?
• How are apple and orange similar?
• What is the meaning of “bird in the hand is worth 2 in the bush?”
Set generation
Test of verbal fluency and the ability to generate a set of items which are frontal lobe functions.
Most people can give 10 or more in a minute.
Receptive language
Ask patient to follow commands that demonstrate understanding of what they have heard and
read. I.e., act like you are sucking thru a straw, playing tennis, air guitar, etc.
Expressive language
Normal use of language accompanied by tasks that require spontaneous speech/writing and
naming objects, repetition of sentences, reading comp. I.e., can you write this sentence (and then
give them one to write).
Praxis
Perform skilled motor tasks without verbal prompting. Apraxia is usually due to the somatic
inferior parietal. Examples: wink, pretend to suck thru a straw or drink from a cup.
Gnosis
Ability to recognition of objects perceived by the senses especially somato-sensory. Have the pt
w/eyes closed identify objects in the hand, numbers written on hand, etc.
Dominant parietal lobe functions
Calculation, right/left orientation, naming fingers. Touch left little finger to right elbow, id the
right index finger. Serial sevens – starting at 100, count backwards dropping 7 each time. That
last one is hard for lots of people! Odd subtractions work brain harder than evens.
Non-dominant parietal lobe
Visual spatial sensory tasks…attending to the contralateral side of the body and space as well as
constructional tasks such as drawing a face, clock, geo figures.
Draw a face/clock, copy a geometric design.
Visual recognition
Colors, faces, etc.
Brain
<<See slides! I took the rest of the notes in the slides so you will find my additions there. >>
Physical Assessment 2 – Fall 2008
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