Tutorial Guide. Department of Myotherapy

Transcription

1 Tutorial Guide Department of Myotherapy

2 Neurological Evaluation Department of Myotherapy

3 Neurologic Examination Has two parts History a structured interview with screening questions Tests and measures discussed in later weeks Endeavour College of Natural Health 3

4 Neurologic Examination Screening examination has several purposes Determine whether there is a neurologic disorder. Whether signs and symptoms are consistent with given diagnosis. Whether patient requires referral to another provider. Determine what neural systems require more investigation. Comprehensive Neurological Examination Investigates mental status, CNs, autonomic function, the motor and somatosensory systems, coordination, spinal reflexes, postural control, and gait A comprehensive examination will give meaningful information for planning appropriate interventions. Endeavour College of Natural Health 4 (Lundy-Ekman, 2018, p. 49)

5 Mental Status Testing If patient communicates well and is able to convey a coherent health history, there is no need for formal mental status testing. Level of consciousness and language and speech abilities are tested first. Levels of consciousness are classified as follows: Alert: attends to ordinary stimuli Lethargic: tends to lose track of conversations and tasks; falls asleep if little stimulation is provided Obtunded: becomes alert briefly in response to strong stimuli; cannot answer questions meaningfully Stupor: alert only during vigorous stimulation Coma: little or no response to stimulation Additional mental status tests assess a variety of cerebral cortex functions. Endeavour College of Natural Health 5 (Lundy-Ekman, 2018, p. 50)

6 Language and Speech Test Action Interpretation Comprehension Ask the patient a question similar to: How is my brother's sister related to my parents? Difficulty may be due to receptive aphasia (problem understanding language possibly involving Wernicke's area), expressive aphasia (Broca's area), or a hearing disorder. Naming One minute Catergory Naming Test Reading Ask the patient to identify objects (pencil, watch, paper clip) and body parts (nose, knee, eye). This test asks the patient to generate words within a category. E.g. Name as many animals as you can. Count the number of words the patient can generate in 1 minute Patient to read a simple paragraph aloud. Then ask questions about the paragraph. If the patient can produce automatic social speech (e.g., Hello, how are you? ) but cannot name objects, the difficulty may be due to dysfunction of Wernicke's area A total of fewer than 15 words indicate a language deficit. The lesion is likely to be in the left temporal lobe. Difficulty may be due to a reading disorder, working memory deficit, visual deficit, or illiteracy. Writing Ask the patient to write answers to simple questions. Difficulty may be due to agraphia (inability to write), visual deficit, impaired motor control of the upper limb, or illiteracy. Wernicke's area is the site of dysfunction in agraphia. Endeavour College of Natural Health 6 (Lundy-Ekman, 2018, p. 51)

7 Orientation Assess the patient s orientation to person, place, and time Examples What is your name? Where were you born? What day of the week is it? Where are we now? Why are you here? Why am I evaluating you? Difficulty with answering these questions may indicate dysfunction of the hippocampus; a language or speech disorder; or a generalized cortical processing disorder, due to drug toxicity, psychosis, or extreme anxiety. Endeavour College of Natural Health 7 (Lundy-Ekman, 2018, p. 51)

8 Declarative Memory Essential part of determining whether or not a patient is capable of recalling the therapist s instructions Working Memory Tell the patient that you are going to check her or his memory by asking her or him to remember three words for a few minutes. Give the patient three unrelated words, and have her or him repeat the words. Then converse about other topics, and after 3 minutes, ask what the three words were. People with intact working memory can recall all three words. Examples of words used include clock, telephone, and shoe. Recent Memory Ask the patient about activities in the past several days. For example, What did you have for breakfast? Who visited you yesterday? Long-Term Memory Ask the patient about historical events, or about his or her school and work experience. Declarative memory problems occur with damage to the hippocampus (brain area that processes factual memories) or with temporary disruptions of cerebral function, as may occur during psychosis (a disorder of thinking that interferes with contact with reality), with extreme anxiety, or following acute head trauma. Endeavour College of Natural Health 8 (Lundy-Ekman, 2018, pp. 51-2)

9 Goal-Directed Behavior Involves deciding on a goal, planning, following through with the plan, and monitoring progress toward the goal One-minute naming test: initial letter This test asks the patient to generate as many words as possible that begin with the letter F. Ask the patient, Say as many words as you can that begin with the letter F. Names of people or places, and variations on a word, do not count. Time for 1 minute, and record the number of words. Normal performance is more than 13 words Endeavour College of Natural Health 9 (Lundy-Ekman, 2018, p. 52)

10 Calculation, Stereognosis, and Visual Identification Calculation The purpose of this test is to assess abstract thinking and the ability to maintain attention. Ask the patient to subtract 7 from 100 and to keep subtracting 7 from each result. Difficulty may indicate problems with maintaining attention, or a problem with abstract thinking. Visual Identification Show the patient an object, and ask him or her to identify it. If the patient cannot identify the object visually but can identify the object by touch or another sense, the disorder is visual agnosia. Visual agnosia is caused by damage to secondary visual areas in the cerebral cortex of the occipital lobe. Endeavour College of Natural Health 10 (Lundy-Ekman, 2018, p. 52)

11 Bilateral Simultaneous Stimulation Touch Ask the patient to say left if the left side is touched, right if the right side is touched, and both if both sides are touched. Lightly touch one limb, the opposite limb, or both sides of the body simultaneously. This test assesses whether a patient can attend to stimuli on both sides of the body simultaneously. Vision Show the patient two objects, one in the right visual field and one in the left visual field. Ask the patient to name the objects. If the patient is able to correctly report touch or visual objects presented to one side of his or her midline but is unaware of the stimuli presented to one side when the stimuli are presented bilaterally, the patient has sensory extinction, a form of unilateral neglect. Unilateral neglect is the tendency to behave as if one side of space or one side of the body does not exist.this is a deficit in the ability to pay attention to stimuli on one side of the body. The most common cause of unilateral neglect is a lesion in the contralateral lower parietal lobe. Endeavour College of Natural Health 11 (Lundy-Ekman, 2018, p. 52)

12 Motor Planning Ask the patient to demonstrate hair brushing, using a screwdriver, or buttoning a shirt. Assuming intact sensation, understanding of the task, and motor control, inability to produce specific movements indicates apraxia (motor planning disorder). Apraxia usually occurs as a result of damage to the premotor or supplementary motor areas. Endeavour College of Natural Health 12 (Lundy-Ekman, 2018, p. 53)

13 Comprehension of Spatial Relationships Activities of daily living Observe the patient eating a meal; ask her or him to put on an article of clothing; or ask him or her to perform a grooming task or to get into and out of a bed or a chair. Difficulty may indicate motor impairment, unilateral neglect, or a generalized decline in cerebral function. Assuming intact sensation and motor control, asymmetry of performance usually indicates unilateral neglect. Body scheme drawing Give the patient a blank piece of paper, and ask him or her to draw a person. Asymmetry in the drawing of a person (for example, omitting part of the left side of the body or providing less detail on the left side of the body) indicates unilateral neglect. Endeavour College of Natural Health 13 (Lundy-Ekman, 2018, p. 52)

14 Introduction to Examining Cortical Sensory Function Department of Myotherapy

15 Cortical Sensation Exam 1. Two-Point Discrimination TEST Using a bent paper clip, apply a light equal pressure to the two points. Begin with two points further apart than the mean value for that region of the body (see Figure 7-1). Ask the client to close their eyes and tell me whether your feel one point or two points. Move the points closer together until the client states it feels like one point. Measure the distance between the two points and compare that with the mean value of the region. INTERPRETATION Ability to accurately discriminate in normal ranges indicates the DCML is intact and an inability may indicate DCML lesion or a widening receptive fields either locally or cortically in the somatosensory homunculus. People with diabetic foot ulcers require 14mm before then can discriminate between two points. To prevent anticipation, randomly stimulate with a single point. Only test the hands and feet. For chronic lower back pain, stimulate the region of pain to decipher changes in the cortical sensory perception. Endeavour College of Natural Health Image: (Lundy-Ekman, 2013, p. 123) (Lundy-Ekman, 2018, p. 73 )

16 Cortical Sensation Exam 2. Bilateral Simultaneous Touch TEST INTERPRETATION Touch one limb, then the other then both. Touch the forearms and shins. Ask the client to close their eyes and say left if the left side is touched, right if the right side is touched or both "when both sides are touched. Tests for sensory extinction. Used to determine if the client can attend to both stimuli on both sides of the body simultaneously. If they cannot, it indicates a lesion of the contralateral parietal lobe to the side of the body that where sensory extinction occurs. Endeavour College of Natural Health (Lundy-Ekman, 2013, p. 124)

17 Cortical Sensation Exam 3. Graphesthesia TEST The patients palm should be positioned facing the examiner, with fingers pointed upward as if signalling stop. Ask the client to close their eyes. Ask the patient, Tell me what number I draw in the palm of your hand. Now draw with a fine tipped object on their palm a number. INTERPRETATION Normally the patient is able to correctly identify the number. This tests the dorsal column/ medial lemniscus system and parietal lobe. If touch sensation is intact, yet the patient cannot perform this task, this indicates a lesion in the contralateral parietal cortex or adjacent white matter. Endeavour College of Natural Health (Image: Jarvis, 2016, p. 654) (Lundy- Ekman, 2013, pg.124, Lundy-Ekman, 2018, p. 73)

18 Cortical Sensation Exam 4. Stereognosis TEST Ask the client to close their eyes and tell me what this is and then place an easily recognisable object in their hand such as a key or paper clip. INTERPRETATION If touch sensation is intact and yet they cannot identify the object, this indicates a lesion in the contralateral parietal cortex or adjacent white matter. Endeavour College of Natural Health (Lundy-Ekman, 2013, p. 125) (Image: Jarvis, 2016, p. 654)

19 Introduction to Motor Examination Department of Myotherapy

20 UPPER EXTREMITY 1. Muscle Palpation and Observation The client may be seated or standing. We should observe the following areas: o Head and neck posture o Shoulder levels o Muscle spasm, asymmetry or wasting o Facial expression o Bony and soft tissue contours o Evidence of ischemia in either upper limb (through altered colouration of the skin, ulcers or vein distention). o Normal sitting posture Wasting and hypotonia may suggest lower motor neuron disorder. Hypertonia suggest an upper motor neuron disease. Wasting may be due to disuse post injury and must be ruled out. Endeavour College of Natural Health (Magee, 2008, pp )

21 Motor examination procedure: UPPER EXTREMITY 1. Muscle Palpation and Observation Continued Look for wasting, hypotonia or hypertonia in the following areas: o Hypothenar eminence (ulnar nerve) o Thenar eminence (median nerve) o Forearm extensors (radial nerve) o Biceps Brachii (musculocutaneous nerve) o Triceps Brachii (radial nerve) o Deltoid (axillary nerve) (Magee, 2008, pp )

22 Motor examination procedure: UPPER EXTREMITY 2. Reflexes Reflex Spinal Level Test Interpretation Image Biceps C5-6 Support the clients forearm on yours. Place your thumb on the biceps tendon and strike a blow onto your thumb. Normal response: contraction of the biceps muscle with flexion of the forearm. Brachioradalis C5-6 Hold the clients thumb to ensure the forearm is relaxed. Strike the forearm directly, about 2-3 cm above the radial styloid process. Normal response: flexion and supination of the forearm. (Jarvis, 2016) (Image: Jarvis, 2016, pp )

23 Motor examination procedure: UPPER EXTREMITY 2. Reflexes continued Reflex Spinal Level Test Interpretation Image Triceps C7-8 Tell the client to let their arm go dead as you hold their upper arm. Strike the triceps tendon directly just above the elbow. Normal response: extension of the forearm. It should be noted that hypoactive or diminished reflex can result in changes in various components of the neural circuit, however hyperactive reflexes always result from central changes which allow increased excitatory input to motor neurons. Older patients will generally have reduced reflexes, so consider this when examining them. (Jarvis, 2016) (Butler, 2000) (Image: Jarvis, 2016, pp )

24 Motor examination procedure: UPPER EXTREMITY 3. Motor Tests: Myotomes Myotome Action Testing Peripheral Nerve Motor Tests: Muscle Power Muscles C4-5 Scapular retraction Dorsal Scapular Rhomboids & Levator Scapulae C4 Shoulder Elevation Spinal Accessory Upper Trapezius & Levator Scapulae C5-6 Shoulder Abduction C5-6 Elbow Flexion C6-8 Elbow Extension C7-8 Thumb Tip Extension Axillary Musculocutaneous Radial Nerve Posterior Interosseous Deltoids & Supraspinatus Biceps Brachii & Brachialis Triceps Brachii Extensor Pollicis Longus C7-T1 Fingertip Flexion Anterior Interosseous Flexor Digitourm Profundus C8-T1 Finger Abduction/Adduction Ulnar Interossi & Lumbricals (Butler, 2011)

25 Motor examination procedure: LOWER EXTREMITY 1. Muscle Palpation and Observation The client should be observed in a standing posture and then a seated position. We should observe the following areas: o Body type o Gait o Attitude o Total spine posture o Markings o Step deformity Wasting and hypotonia may suggest lower motor neuron disorder. Hypertonia suggest an upper motor neuron disease. Wasting may be due to disuse post injury and must be ruled out. (Magee, 2008, pp )

26 Motor examination procedure: LOWER EXTREMITY 1. Muscle Palpation and Observation Continued Look for wasting, hypotonia or hypertonia in the following areas: o Gluteus Maximus (inferior gluteal nerve) o Gluteus Medius (superior gluteal nerve) o Quadriceps (femoral nerve) o Gastrocnemius & Soleus (tibial nerve and lower lumbar disc injury) o Extensor Digitorum Brevis (fibular nerve) (Magee, 2008, pp. 703, &905 )

27 Motor examination procedure: LOWER EXTREMITY 2. Reflexes Reflex Spinal Level Test Interpretation Image Quadriceps/ Patella L3-4 The client sitting with legs dangling or in supine (in a supine position, the clients knee should be flexed at approx degrees using a bolster or your knee). Tap the patellar tendon looking for the quadriceps to contract. Normal response: quadriceps contract and the knee extends. Achilles S1-2 The client sitting with legs dangling, however the leg needs to be externally rotated and the foot held in some dorsiflexion. Tap the mid Achilles tendon looking for the calf to contract. Normal response: the calf contracts and the ankle plantar flexes. (Jarvis, 2016) (Image: Jarvis, 2016, p. 658)

28 Motor examination procedure: LOWER EXTREMITY 3. Motor Tests: Myotomes Myotome Action Testing Peripheral Nerve Motor Tests: Muscle Power Muscles L2-4 Hip Flexion L5-S1 Hip Extension L2-4 Knee Extension L5-S1 Knee Flexion L4-S1 Ankle Dorsiflexion L4-S1 Great Toe Extension L5-S1 Ankle Eversion L5-S2 Ankle Plantarflexion L5-S1 Toe Flexion L5-S2 MTP Dorsiflexion Lumbar Plexus to Femoral Inferior Gluteal Femoral Sciatic Deep Peroneal Deep Peroneal Common Peroneal Tibial Posterior Tibial Posterior Tibial Iliacus & Psoas Major Gluteus Maximus Quadriceps Hamstrings Tibialis Anterior Extensor Hallucis Longus Peroneus Longus & Brevis Gastrocnemius & Soleus Flexor Hallucis Longus & Flexor Digitorium Longus Intrinsic Muscle of the foot (Butler, 2011)

29 Introduction to Sensory Testing Procedures Department of Myotherapy

30 Somatosensory Examination Primary Sensation Exam (to rule out central lesions) Ask the client to identify various sensory stimuli to test the intactness of the peripheral nerve fibers, the sensory tracts and higher cortical discrimination. Compare sensation on symmetric parts of the body. Avoid asking leading questions The clients eyes should be closed during each of the tests Take time to explain to the client what will be happening and how exactly you would like them to respond to each stimuli By testing each stimuli on the clients sternum initially, this will demonstrate to them the expected sensation Assess the unaffected side first (Jarvis, 2016, pp )

31 Somatosensory Examination Primary Sensation Exam (to rule out central lesions) Name of Test Test Abnormal Findings 1. Light Touch Using a cotton tip, lightly touch the clients finger tips and their toes with the wisp. Brush it over random sites at irregular intervals. Include the arms, forearms, hands, chest, things and legs. Ask the client to say yes when touch is felt. Compare symmetric points. Hypoesthesia decreased touch sensation Anesthesia absent touch sensation Hyperesthesia increased touch sensation May indicate a lesion in the spinothalamic tract. (Jarvis, 2016, p. 652) (Image: Jarvis, 2016, p. 652)

32 Somatosensory Examination Primary Sensation Exam (to rule out central lesions) Test Name Test Abnormal Findings 2. Vibration Sense Test the clients ability to feel vibrations of a tuning fork over bony prominences. Using a low frequency tuning fork, strike it on the heel of your hand and hold the base on a bony surface of the fingers and great toe. Ask the client to indicate when the vibration starts and stops. If the client feels a normal vibration/buzzing sensation on these distal areas then there is no need to proceed. If no vibration is felt move proximally and test ulnar processes, malleolus, patella and iliac crests. Compare both sides. Unable to feel vibration sense can occur with peripheral neuropathy. This is often the first sensation lost. Peripheral neuropathy is often worse at the feet, and improves as you move proximally. As opposed to specific nerve lesions which has a clear zone of deficit for it s dermatome. Also if no vibration sensation is felt, it may indicate a posterior (dorsal) column tract lesion. (Jarvis, 2016, p. 653) (Image: Jarvis, 2016, p. 653)

33 Somatosensory Examination Primary Sensation Exam (to rule out central lesions) Test Name Test Abnormal Findings 3. Pin Prick Sense Pain is tested by the clients ability to perceive a pin prick. Break a tongue depressor long ways, forming a sharp point and the rounded end as a dull point. Lightly apply the sharp point or the dull end to the person s body in random and unpredictable order. Ask the client to say sharp or dull depending on the sensation felt. (Note the sharp edge is used to test pain, the dull edge is used as a general test for the clients response). Hypoalgesia decreased pain sensation Analgesia absent pain sensation Hyperalgesia increased pain sensation (Jarvis, 2016, p. 652) (Image: Jarvis, 2016, p. 652)

34 Somatosensory Examination Primary Sensation Exam (to rule out central lesions) Test Name Test Abnormal Findings 4. Cold Sense Thermal sensitivity is not routinely tested and is not required if superficial pain sensation is intact. However, for patients who complain of symptoms related to temperature this test should be completed. Using the opposite end of the tuning fork or filling a test tube with cold water from the tap. Place the item over different parts of the hands and feet and ask the client if they feel a cold sensation or not, comparing both sides. Inability to sense cold suggests a lesion in the spinothalamic tract. (Butler, 2000, p. 226) (Beck, 2011, p. 70)

35 Somatosensory Examination Sensory Distribution of the UPPER LIMB Image (Lundy-Ekman, 2018, pp )

36 Somatosensory Examination Sensory Distribution of the LOWER LIMB Image (Lundy-Ekman, 2018, pp )

37 Somatosensory Examination Conscious Proprioception Exam Name of Test Test Abnormal Findings 5. Joint Position Testing the clients ability to perceive passive movements of their extremities. Have the client close their eyes. Move a finger or their big toe up or down ask the client to tell you which way it has moved. Hold the digit by the sides as upward or downward pressure on the skin may provide a clue to the client. Ensure the client understands the instructions originally before commencing with eyes closed. Loss of position sense. A normal response is a detection of movement as little as a few millimetres. (Jarvis, 2016, p. 653) (Image: Jarvis, 2016, p. 653)

38 Introduction to Cerebellar Examination Department of Myotherapy

39 Cerebellum Examination Name of Test Test Abnormal Findings 1. Romberg Test Ask the client to stand up with feet together and arms at side. Once in a stable position, ask the client to close their eyes and to hold the position. Wait for approximately 20seconds. Stand close to the client to catch them in case they fall. Maintaining posture and balance even with visual orientation blocked in the normal response. Slight swaying may occur. Swaying, fall, widening base of feet to avoid falling, opening their eyes or moving their arms to maintain balance is a railed Romberg Test. A positive Romberg Test is a loss of balance with the eyes closed. Occurs with cerebellar ataxia (e.g. Multiple Sclerosis, alcohol intoxication), loss of proprioception and/or loss of vestibular function. (Jarvis, 2016, p. 650) (Image: Jarvis, 2016, p. 650)

40 Cerebellum Examination Name of Test Test Abnormal Findings 2. Finger to Finger Test With the client s eyes open, ask them to use their index finger to touch your finger and then his or her own nose. After a few times, move the location of your finger. The movement should be smooth and accurate. Lack of coordination. Dysmetria = is clumsy movement with overshooting the mark and occurs with cerebellar disorders or acute alcohol intoxication. Past pointing = constant deviation to one side Intention tremor = occurs when reaching to a visually directed object. (Jarvis, 2016, p.648) (Image: Jarvis, 2016, p. 649)

41 Cerebellum Examination Name of Test Test Abnormal Findings 3. Finger to Nose Test Ask the client to close their eyes and stretch out their arms in front of them. Ask him or her to touch the tip of his nose with each index finger, alternating hands and increasing speed. Normally this is done with accurate and smooth movement. Missing nose. Worsening of coordination when their eyes are closed occurs with cerebellar disease or alcohol intoxication. (Jarvis, 2016, p. 649)

42 Cerebellum Examination Name of Test Test Abnormal Findings 4. Heel to Shin Test This tests lower extremity coordination. Client is in a supine position, and we ask them to place their heel on their opposite knee and run it down their shin from the knee to ankle. A normal response is moving the heel in a straight line down the shin. Lack of coordination and/ or heel falls off shin; occurs with cerebellar disease. (Jarvis, 2016, p.649) (Image: Jarvis, 2016, p. 649)

43 Cerebellum Examination Name of Test Test Abnormal Findings 5. Rapid Alternating Movements (RAM) With the client in a seated position, ask them to pat the knees with both hands, lift them up, turn hands over and pat the knees with the backs of their hands. Then ask them to do this faster. This is done with equal turning and a quick, rhythmic pace. Lack of coordination. Slow, clumsy and sloppy responses are termed dysdiadochokinesia and occurs with cerebellar disease. (Jarvis, 2016, p. 648) (Image: Jarvis, 2016, p. 648)

44 Cerebellum Examination Name of Test Test Abnormal Findings 6. Nystagmus of the eye Nystagmus is a rhythmic movement of the eye with an abnormal slow drifting away from a fixation and rapid return. Ask the client to look to both sides. Drifting of eyes with horizontal gaze. Cerebellar nystagmus is greater when the eyes are deviated towards the side of the lesion. (Magee, 2008, pp )

45 Cerebellum Examination Name of Test Test Abnormal Findings 7. Rebound Phenomenon Have the client place their hand in a bicep curl position. Start to resist elbow flexion of the client. A positive sign is seen when an exaggerated rebound occurs with movement in the opposite direction. Without warning, slip your hand out of their grasp. Normal response: the antagonists muscles will contract and stop their arm from moving in the desired direction. In cerebellar disease the response is completely absent causing the limb to move in the desired direction. **Be careful to protect the client from the movement which may cause them to strike themselves if cerebellar disease is predicted.

46 Vestibular Examination Name of Test Test Abnormal Findings 8. Head Impulse Test Assesses gaze stabilisation with rapid head movements. Ask the client to maintain gaze at your nose whilst seated. While they are doing so you rapidly turn the clients neck (holding their head) 20 degrees in both directions from neutral. *ensure no extension or flexion occurs with the rotation. A positive test is when the client cannot maintain their gaze of nystagmus is noted.

47 Vestibular Examination Name of Test Test Abnormal Findings 9. Dix-Hallpike Test Is used to determine whether otoliths are present in posterior semi circular canal. Start with the client seated with legs extended on the table. Turn their head 45 degrees and observe their eyes for 30 seconds. Observe their eyes for 30 seconds in this position. Warn your client you are going to drop them down (supine position) (see image). While holding the clients head, drop them backwards into the supine position with their head extended off the table (20 degrees). If nystagmus occurs up to 1 minute later this indicates Benign Paroxysmal Positional Vertigo (BPPV). Nystagmus occurring up to 1 minute later this indicates Benign Paroxysmal Positional Vertigo (BPPV). (Jarvis, 2016, pp ) Image: (Lundy Ekman 2018, p.450)

48 Introduction to Neurodynamic testing Department of Myotherapy

49 Neurodynamic Testing In order to examine the mobility of the nervous system, a range of specific movements need to be performed to load these tissues. Each test is completed in steps and the client is asked if they have any symptoms at any step. Handing guidelines for all Neurodynamic testing Tell your client exactly what you are going to do and what they should expect. Make them feel comfortable about reporting any symptoms to you. Perform the test on the less painful side or non painful side first Starting position should be consistent every time. Any variations from the normal procedure should be noted down. Watch for antalgic postures and other motor responses during the test. (Butler, 2000 )

50 UPPER LIMB Neurodynamic Testing Process ULNTT RADIAL NERVE RADIAL NERVE 1. Neutral position, with the client lying in supine. Their shoulder girdle hanging off the table. 2. Contralateral lateral flexion of the cervical spine 3. Shoulder girdle depression 4. Wrist, finger and thumb flexion 5. Shoulder medial rotation 6. Elbow extension 7. Ipsilateral lateral flexion of the cervical spine (reliever) 8. Wrist extension if symptoms are the cervical spine. (Petty, 2011) Image: (Petty, 2011, p. 97)

51 UPPER LIMB Neurodynamic Testing Process ULNTT MEDIAN NERVE MEDIAN NERVE 1. Neutral position, with the client lying in supine. Their shoulder girdle hanging off the table. 2. Contralateral lateral flexion of the cervical spine 3. Shoulder girdle depression 4. Shoulder abduction 5. Wrist and finger extension 6. Forearm supination 7. Lateral rotation of the shoulder 8. Elbow extension 9. Ipsilateral lateral flexion of the cervical spine (reliever) (Petty, 2011) Image: (Petty, 2011, p. 91)

52 UPPER LIMB Neurodynamic Testing Process ULNTT ULNAR NERVE ULNAR NERVE 1. Neutral position, with the client lying in supine. Their shoulder girdle hanging off the table. 2. Contralateral lateral flexion of the cervical spine 3. Shoulder girdle stabilisation 4. Wrist and finger extension 5. Forearm pronation 6. Elbow flexion 7. Shoulder abduction 8. Shoulder lateral flexion 9. Further shoulder abduction 10. Ipsilateral lateral flexion of the cervical spine (reliever) (Petty, 2011) Image: (Petty, 2011, p. 91)

53 LOWER LIMB Neurodynamic Testing Process FEMORAL SLUMP FEMORAL NERVE 1. Client in side lying position with the leg to be assessed on top. 2. The client needs to start with the underneath hip flexed to 90 degrees and the client slumped with cervical flexion. 3. Extend the opposite hip into extension and flex the knee to 90 degrees. Take the leg further into extension, assessing for tension or pain in the anterior thigh. 4. Get the client to extend their cervical spine and note if pain or tension reduces, if so it indicates femoral nerve tension. (Petty, 2011) Image: (Petty, 2011, p. 85)

54 LOWER LIMB Neurodynamic Testing Process SLR FIBULAR BIAS 1. Client lies supine 2. Complete a basic SLR: a) Hip adduction b) Hip flexion and knee extension (affecting the sciatic nerve). 3. The move the foot into plantarflexion and inversion to increase neural tension on the fibular nerve. Straight leg raise (SLR) & COMMON FIBULAR NERVE Findings: Normal range of SLR can vary between degrees of hip flexion, but it is important to compare it too the opposite side. A positive test suggests high Neurodynamic tension, which is indicated by pain along the mentioned regions. May also be positive in clients with neuropathic pain involving the fibular nerve. (Petty, 2011) Image: (Petty, 2011, p. 85)

55 LOWER LIMB Neurodynamic Testing SLR & TIBIAL NERVE Process SLR TIBIAL BIAS 1. Client lies supine 2. Complete a basic SLR: a) Hip adduction b) Hip flexion and knee extension (affecting the sciatic nerve). 3. The move the foot into dorsiflexion and eversion to increase neural tension on the tibial nerve. Findings: Normal range of SLR can vary between degrees of hip flexion, but it is important to compare it too the opposite side. A positive test suggests high Neurodynamic tension, which is indicated by pain along the mentioned regions. May also be positive in clients with neuropathic pain involving the tibial nerve. (Petty, 2011) Image: (Petty, 2011, p. 85)

56 Introduction to Cranial nerve examination Department of Myotherapy

57 Cranial Nerves Image: (Lundy-Ekman, 2013, p. 388)

58 Cranial Nerves Examination We do not routinely test cranial nerve I olfactory nerve. Routinely tested as a group Cranial Nerve Name Composition I Olfactory Sensory only II Optic Sensory only III Oculomotor Motor & sensory IV Trochlear Motor & sensory V Trigeminal Motor & sensory VI Abducens Motor & sensory VII Facial Motor & sensory VIII Vestibulocochlear Sensory only IX Glossopharyngeal Motor & sensory X Vagus Motor & sensory XI Spinal Accessory Motor & sensory XII Hypoglossal Motor & sensory Routinely tested as a group (Jarvis, 2016, pp )

59 Cranial Nerve Examination Cranial Nerve II Optic Nerve Test Visual Acuity This can be tested by asking the patient to read signs and describe pictures about 6 metres distance away. Test both eyes, asking her to cover one eye at a time. Abnormal Findings (Butler, 2000) Image: (Jarvis, 2016, p. 318)

60 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Test Check Pupil Size This reflects the balance in tone between parasympathetic and sympathetic nervous system. Best examined in a dark room. Pupils should appear round, regular and equal in size. In adults the resting size is 3-5mm. Abnormal Findings Larger than normal pupil size suggests high sympathetic tone. If in both suggests systemic increase in tone, on one side suggests unilateral overactivity or under activity in the parasympathetic nervous system on the same side. Size variation from right to left must be noted may indicate lesion on either side. (Jarvis, 2016)

61 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Test Pupillary Light Reflex In a dim room, shine the pen light into one of the clients eyes. Test both sides. Normal response: both pupils constricting at the same time and with equal velocity and size of constriction. Direct reflex is demonstrated when the light on one side = pupil constriction on same side Consensual reflex is demonstrated when the light on one side = pupil constriction on the opposite side. Abnormal Findings When a slow or absent response occurs it suggests a lesion of the pathway. (Jarvis, 2016)

62 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Test Visual Fields Get the client to cover their left eye. Using the tip of a pen, move the pen from behind their ear (at a distance of 25cm from their head) into their vidual field. Get the client to say when they see the tip of the pen. Test the opposite side getting them to swap eyes covered. Normal response: demonstrated by the observation of the pen tip just after it passes the ear. Abnormal Findings If the client has lost vision on one side of their visual field it is called homonymous hemianopia normally due to visual pathway lesion. Left visual field loss suggests right side optic tract or occipital lobe lesion. (Jarvis, 2016)

63 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Test Resting Eye Position Ask the client to look straight ahead, examine the height of the space between the upper and lower eyelids and the position of the eyelids relative to the iris and pupil. Then ask the client to look upwards without moving their head. Normal response: The position of the eyelids is symmetric with the upper eyelid covering the upper iris. The eyelid retracts with upwards gaze. Abnormal Findings Asymmetric space between the eyelids and iris the eyelid that is lower does not retract with upwards gaze. Suggest lesion of the oculomotor nerve. CNIII lesions normally will also include dilated pupil, lateral and downwards deviation of the eye when attempting to look forward and diplopia. (Jarvis, 2016)

64 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Test Accommodation Reflex Get the client to look straight ahead at the tip of the pen, slowly move the pen towards the bridge of their nose and watch their eyes. Abnormal Findings One eye does not adduct as much as the opposite side and has early diplopia. Suggests an ipsilateral CNIII lesion. Normal response: both eyes adduct equally and can maintain position. The client reports diplopia only when the pen is close to the nose. Pupils should constrict as eyes focus and as you take the pen away the eyes should dilate. (Jarvis, 2016) Image: (Jarvis, 2016, p. 296)

65 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Tests Visual Pursuits Get the client to follow the tip of a pen in each plane of eye motion side to side, up and down from corner to corner (oblique axis). Normal response: eyes move symmetrically and smoothly. Abnormal Findings Abnormal response: nystagmus/weakness in adduction, depression or elevation of the eye. May be due to single CNIII or VI lesion or an upper motor neuron lesion or medial longitudinal fasciculus lesion. Abducens nerve abnormal response: unable to move eyes laterally and may have nystagmus during the pursuit. (Jarvis, 2016) Image: (Lundy-Ekman, 2013, p. 434)

66 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Image: (Lundy-Ekman, 2013, p. 437)

67 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Tests Inferior Oblique Muscle Test The examiner gets the client to follow the tip of the pen to 50 degrees adduction and then lifts the pen up so the eye goes inwards and up. Normal response: eyes follows the pen tip. Abnormal Findings Eye is unable adduct and elevate. May be due to oculomotor nerve lesion or UMN/medial longitudinal fasciculus lesion. (Jarvis, 2016)

68 Cranial Nerve Examination Cranial Nerve III, IV & VI Oculomotor, Trochlear & Abducens Nerves Tests Trochlear Nerve Test The examiner gets the client to follow the tip of the pen to 50 degrees adduction and then drops the pen so the eyes look down and inwards. Normal response: eyes follow the pen tip. Abnormal Findings Difficulty looking inferomedially and may present with diplopia, difficulty reading and/or difficulty descending stairs. May be due to trochlear nerve lesion or UMN lesion. (Jarvis, 2016)

69 Cranial Nerve Examination Cranial Nerves V Trigeminal Nerve Test Trigeminal Nerve Motor Testing Active resisted testing of jaw opening and closing then palpating the masseters muscles on both sides while the client clenches their teeth, feeling for tone. Normal response: 5/5 in strength and normal resting tone compared with clenching. Abnormal Findings 4/5 or less in strength and high or low tone in masseter/temporalis. Low tone suggests a LMN lesion like trigeminal neuralgia, high tone suggests UMN lesion. (Jarvis, 2016) (Image: Jarvis, 2016, p. 645)

70 Cranial Nerve Examination Cranial Nerves V Trigeminal Nerve Test Trigeminal Nerves Sensory Testing Pin prick, soft touch, vibration and cold testing for the face over the forehead, under the eyes, over the nose, over the cheeks, over the chin and lips. Ask the client to localise, describe and rate the stimulus from one side of the face compared to the other. Abnormal Findings Anesthesia over the face, hyperesthesia over the face, hyperalgesia in pin prick, allodynia in cold, vibration or soft touch. Normal response: symmetry in sensation and localisation. (Jarvis, 2016) (Image: Jarvis, 2016, p. 645)

71 Cranial Nerve Examination Cranial Nerves V Trigeminal Nerve Test Corneal Reflex Using a wisp of cotton touch the outer cornea. Normal response: client blinks both eyes. (afferent = trigeminal, efferent = facial) Abnormal Findings Opposite side and/ or same side does not blink, suggesting a lesion in the CNV or CNVII (indicated if other tests are positive). Test Jaw Jerk Reflex Place your thumb on the clients jaw in a pistol grip fashion. Whilst your thumb is in this position tape on the clients chin with a reflex hammer. Normal response: masseter contraction and mandible elevation. Abnormal Findings Lost/ decreased reflex suggesting CNV lesion or if hypperreflexive suggesting UMN lesion. (Lundy-Ekman, 2013)

72 Cranial Nerve Examination Cranial Nerves VII Facial Nerve Test Facial Expressions Get the client to lift their eye brows, close and open eyes, smile and puff up cheeks. Normal response: symmetry and able to do all movements. Abnormal Findings Asymmetry and paresis/paralysis. If upper and lower face affected this may suggest Bell s palsy. Corticobrainstem/UMN lesion results in paresis/paralysis of lower face. (Jarvis, 2016, p) (Image: Jarvis, 2016, p. 646)

73 Cranial Nerve Examination Cranial Nerves VIII Vestibulocochlear Test Hearing Test Rub your fingers together near the client s ear, then slowly move away from their ears. Ask when they can no longer hear it. Compare both sides. Abnormal Findings Difference in acuity, may suggest reduce function of the same side cochlear nerve or UMN lesion. Normal response: Client hears both sides equally. (Butler, 2000)

74 Cranial Nerve Examination Cranial Nerves VIII Vestibulocochlear Test Weber Test Using a tuning form, place it in the middle of the client s head. Ask the client if the sound is heard better in one ear or both (must be stated while the tuning fork is in the midline of their head). Abnormal Findings - With conductive hearing loss, the sound will localise towards the affected side. - With sensorineural hearing loss, the sound will localise towards the unaffected side. Normal response: sound is symmetrical with no lateralisation. (Butler, 2000)

75 Cranial Nerve Examination Cranial Nerves IX Glossopharyngeal Test Gag Reflex Touch the soft palate with a cotton swab. Normal response: gagging and symmetrical elevation of the soft palate. Abnormal Findings Lack of gag reflex or asymmetrical elevation of soft palate suggesting either CNIX or CNX lesion. (afferent = CNIX, efferent = CNX). (Jarvis, 2016)

76 Cranial Nerve Examination Cranial Nerves X Vagus Nerve Test - Uvula Elevation Depress the tongue and ask the client to say ah and observe the soft palate with your pen light. Normal response: Elevation of the soft palate symmetrically. Abnormal Findings Asymmetry of soft palate elevation and they may be present with voice hoarseness. Hoarse of brassy voice occurs with vocal cord dysfunction, nasal twang occur with weakness of soft palate. (Jarvis, 2016)

77 Cranial Nerve Examination Cranial Nerves XI Spinal Accessory Nerve Test Muscle Strength Check equal strength of the SCM and trapezius muscles. Ask the client to resist cervical rotation, with resistance applied to the side of the chin (see Fig 23-13). Then ask the client to shrug against resistance (see Fig 23-14). Abnormal Findings Atrophy. Muscle weakness or paralysis occurs with a stroke or following injury to the peripheral nerves. Normal response: These movements should feel equally strong on both sides.5/5 strength. (Jarvis, 2016, pp ) (Image: Jarvis, 2016, p. 646)

78 Cranial Nerve Examination Cranial Nerves XII Hypoglossal Nerve Test Tongue Deviation Ask the client to protrude their tongue out. Inspect the tongue but also it s positioning. No wasting or tremors should be present. Not the tongue is forward in the midline. Abnormal Findings Protruded tongue deviates to the side of the lesion. Ipsilateral tongue atrophy may also be observed. Normal response: tongue stays on the midline. (Jarvis, 2016)

79 Cranial Nerve Examination Cranial Nerves XII Hypoglossal Nerve Test Tongue Strength Ask the client to push their tongue to the left and right side of the mouth/cheek. Whilst the client is doing so push their tongue inwards while asking them to resist. Abnormal Findings Tongue s force easily overcome, may suggest CNXII lesion. Normal response: tongue able to resist moderate force. (Butler, 2000)

80 Image References Jarvis, C. (2016). Physical Examination & Health Assessment (7 th ed.). Elsevier: Missouri. Lundy-Ekman, L. (2018). Neuroscience: Fundamentals for Rehanbilitation (5th ed.). Sydney: Elsevier Petty, N. (2011). Neuromusculoskeletal Examination and Assessment : A handbook for therapists (4 th ed.). Edinburgh: Elsevier.

81 References Beck, R.W. (2011). Functional Neurology for Practitioners of Manual Medicine (2 nd ed.). Edinburgh: Churchill Livingstone. Butler, D.S. (2000). The Sensitive Nervous System. Noigroup Publications: Adelaide: City West. Jarvis, C. (2016). Physical Examination & Health Assessment (7 th ed.).missouri: Elsevier. Lundy-Ekman, L. (2018). Neuroscience: Fundamentals for Rehanbilitation (5th ed.). Sydney: Elsevier Magee, D.J. (2013). Orthopedic Physical Assessment, Elsevier (5 th ed.). Elsevier: Missouri.

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