PCS - Study Sheet 6

What are the 12 cranial nerves and what is the function of each?

1 - Olfactory - Type: Sensory - Function: Smell 2 - Optic - Type: Sensory - Function: Vision 3 - Oculomotor - Type: Motor - Function: muscles of the eye 4 - Trochlear - Type: Motor - Function: muscles of the eye 5 - Trigeminal - Type: Mixed - Function: sensory: face area, motor: muscles of the eye 6 - Abducens - Type: Motor - Function: muscles of the eye 7 - Facial - Type: Mixed - Function: sensory: tongue area, motor: muscles of facial expression 8 - Vestibulocochlear - Type: Sensory - Function: hearing, equilibrium sensation 9 - glossopharyngeal - Type: mixed - function: sensory: taste, pharynx, middle ear, Motor: muscles of pharynx 10 - Vagus - Type: mixed - Function: Sensory: heart, lungs, GI tract; Motor: heart, lungs, GI tract 11 - Spinal Accessory - Type: Motor - Function: Sternocleidomastoid and trapezius muscles 12 - Hypoglossal - Type: motor - Function: muscles of the tongue On Old Olympus Towering Tops A Finn And German Viewed Some Hops

Describe in your own words what a test of provocation is.

A variety of tests used to detect whether neural tissue is being stretched or compressed. These can include the upper limb neurodynamic test, straight leg raise, and slump tests.

List the 3 phase of nerve recovery and the management guidelines for each.

Acute Phase - pain and edema management, movement, orthosis management, patient education. Recovery Phase - motor retraining, desensitization, discriminitative sensory re-education, patient education. Chronic Phase - when the potential for reinnervation has peaked and there are minimal or no signs of reinnervation, emphasize training for compensatory function.

What is a dermatome?

An area of skin supplied with the sensory fibers of a spinal nerve.

List all of the common sites for peripheral nerve injuries and how they present. (this will be a long list)

Axillary Nerve: C5, 6 - shoulder abduction and lateral rotation are impaired. Musculocutaneous Nerve: C5, 6 - patient is unable to flex the elbow with the forearm supinated and may have some instability in the shoulder. Median Nerve: C6 - 8 - entrapment of the median nerve in the tunnel leads to Carpal Tunnel Syndrome, causing sensory changes and muscle weakness. Ulnar Nerve: C8-T1 - trauma or entrapment of this region causes sensory changes and progressive weakness of muscles innervated distal to the site, resulting in a partial-claw hand deformity. Radial Nerve: C6-8, T1 - Injury proximal to the elbow results in wrist drop and inability to actively extend the wrist and fingers. Injury to the radial nerve in the proximal forearm affects only the supinator muscles and extrinsic abductor and extensory pollicic longus muscles. Femoral Nerve: L2-4 - injury causes weakness in hip flexion and loss of knee extension. Obturator Nerve: L2-4 - adduction and external rotation of the thigh are impaired, with the individual having difficulty crossing his/her legs. Sciatic Nerve: L4, 5; S1-3 - The sciatic nerve can innervate through the piriformis muscle, compressing it and causing pain and irritation. Tibial/Posterior Tibial Nerve: L4, 5; S1-3 - Entrapment, usually caused by a space-occupying lesion, causes tarsal tunnel syndrome. Can cause foot strain, painful heel, and pain in the pes cavus foot. Common Peroneal Nerve: L4, 5; S1, 2 - pressure can cause neuropathy, sensory changes, and weakness in the muscles of the anterior and lateral compartments of the leg.

What are the common peripheral pathologies and what are their causes?

Bells Palsy - involves the facial nerve (cranial nerve VII) which controls movement of facial muscles. Scapular Winging - occurs when an injury to the long thoracic nerve weakens or paralyzes the serratus anterior muscles, causing the medial border of the scapula to rise away from the rib cage. Thoracic Outlet Syndrome - occurs when the nerves of the brachial plexus and/or the subclavian artery and vein become compressed in the thoracic outlet - the space between the clavicle and first rib. Burner (Stinger) Syndrome - can occur following a stretch or compression injury to the brachial plexus from a blow to the head or shoulder. Erb's Palsy - a traction injury to a baby's upper brachial plexus and occurs most commonly during a difficult childbirth. Saturday Night Palsy - occurs when the radial nerve becomes compressed as it spirals around the mid-humerus. Wrist Drop - comes from a high radial nerve injury. Carpal Tunnel Syndrome - occurs from compression of the median nerve as it passes within the carpal tunnel. Cubital Tunnel Syndrome - occurs when the ulnar nerve crosses the medial border of the elbow as the nerve runs through a bony passageway. When hit, it causes a tingling sensation. Ape Hand - loss of thumb opposition due to a median nerve injury. Pope's Blessing/Hand of Benediction - Inability to flex the thumb and index and middle fingers due to a median nerve injury. Claw Hand - loss of the intrinsic muscles due to ulnara nerve damage. Sciatica - caused by irritation of the sciatic nerve roots, with pain radiating down the back of the leg. Foot Drop - damage to common fibular nerve. Morton's Neuroma - an enlarged nerve and usually occurs between the third and fourth toes (branches of the tibial nerve.) The enlargement usually involves nerve compression in a confined space.

What are the components of the CNS?

Brain and spinal cord.

What are the 3 parts of the nervous system and their subdivisions?

Central Nervous System - brain and spinal cord. Peripheral Nervous System - cranial nerves, brachial, spinal, and lumbosacral plexuses. Autonomic Nervous System - Sympathetic and Parasympathetic nervous system.

What muscles are innervated by spinal nerve level?

Cervical - diaphragm and trapezius, deltoid and biceps, wrist extensors and triceps. Thoracic - hand intrinsics, intercostals, abdominals Lumbar - hip and leg muscles, foot muscles. Sacral - bowel and bladder, foot muscles.

Name the 3 main nerve plexuses of the body and where they are located?

Cervical Plexus - made up of C1 through C4 spinal nerves, innervates the muscles of the neck. The Brachial Plexus - made up of C5 through T1, innervates the muscles of the upper limb. The lumbosacral Plexus - made up of L1 through S5, innervates muscles of the lower limb.

What are the 6 common types on mechanisms of nerve injury?

Compression, laceration, stretch, radiation, electricity, and injection (local anesthesia, steroids, or antibiotics.)

What are the three types of neurons and briefly describe them.

Efferent - carry signals from the anterior horn, down through peripheral nerves to a motor end plate of a muscle fiber. Afferent - starts in the skin with sensory fibers that carry signals up to the brain. Interneuron - integrates signals from one or more sensory neurons and relay impulses to motor neurons.

What are the five possible outcomes for nerve regeneration?

Exact reinnervation of its native target organ with return of function. Exact reinnervation of its native target organ but no return of function due to degeneration of the end organ. Wrong receptor reinnervated in the proper territory; therefore, improper input. Receptor reinnervation in wrong territory causing false localization of input. No connection with an end organ.

What are the 3 Upper Quadrant neural testing techniques and what nerves do they test?

Median Nerve - ULNT 1 (Passive) this maneuver is used when examining and treating symptoms related to median nerve distribution, including carpal tunnel syndrome. Radial Nerve - ULNT 2 this maneuver is used when examining and treating symptoms related to shoulder girdle depression, radial nerve distribution, and differentiating between tennis elbow and radial tunnel syndrome. Ulnar Nerve - ULNT 3 this maneuver is used when symptoms are related to the lower brachial plexus or ulnar nerve and differentiating between medial epicondylosis and pronator syndrome.

What are the factors that will affect nerve recovery?

Nature and level of injury. Timing and technique of repair. Age and motivation of the patient.

Explain in specific terms, the anatomy of a neuron?

Neurons have a few different components, and are made of white and grey matter. White matter is myelin, a form of fat that insulates neurons and helps facilitate faster action potentials. Grey matter is the stuff of the nerve itself. Each neuron has a cell body, a circular component that houses the organelles of the nerve. Extending from this is the axon, a long thin piece that is sometimes covered in myelin. Branching from this are dendrites, long spindly forms that connect nerve to nerve.

List the 3 classifications of nerve injury and their characteristics.

Neuropraxia segmental demyelination action potential slowed/blocked at point of demyelination; normal above and below point of compression. Muscle does not atrophy; temporary sensory symptoms. The results of mild ischemia from nerve compression or traction. Recovery is usually complete. Axonotmesis loss of axonal continuity but connective tissue coverings remain intact. Wallerian degeneration distal to lesion. Muscle fiber atrophy and sensory loss. The result of prolonged compression or stretch causing infarction and necrosis. Recovery is incomplete - surgical intervention may be required. Neurotmesis Complete severance of nerve fiber with disruption of connective tissue coverings. Wallerian degeneration distal to lesion. Muscle fiber atrophy and sensory loss. The result of gunshot or stab wounds, avulsion, rupture. No recovery w/o surgery - recovery depends on surgical intervention and correct regrowth of individual nerve fibers in endoneuroal tubes.

What are the 2 ramus and what does each innervate?

Posterior (Dorsal) Ramus: It innervates the muscles and skin of the posterior trunk. Anterior (Ventral) Ramus: innervate all muscles and skin areas not innervated by the posterior ramus.

Describe the position for each of the tests in question 14.

Straight Leg Raise Pt is Supine. Tested leg is raised with hand on knee to ensure full extension, and other hand on foot internally rotating the hip and dorsiflexion of foot. Slump-Sitting Maneuver Pt is sitting upright. Therapist has one leg in full extension, with one hand on foot pulling it into dorsiflexion and the other on the top of the pts head, pushing neck in flexion. Prone Knee Bend Pt is laying prone, spine is neutral. Knee is flexed. Do not let spine come into extension.

What are the 3 Lower Quadrant neural testing techniques and what nerves do they test?

Straight Leg Raising Sciatic Nerve Slump-Sitting Maneuver Sciatic Nerve Prone Knee Bend Femoral Nerve

Provide a summary of Thoracic outlet syndrome, list causes, symptoms, related diagnoses, possible sites of entrapment, the common activity limitations and how it is managed.

Summary: The thoracic outlet is the region of the body where the chest lies. Medially, it is bordered by the scalene muscles and first rib; posteriorly by the upper trap and scap, anteriorly by the clavicle, coracoid, pec minor, and deltopectoral fascia, and laterally by the axilla. Symptoms: pain, paresthesia, numbness, weakness, discoloration, swelling, and loss of pulse, headaches. Causes: Compressive neuropathy, faulty posture, entrapment of neural tissue from scar tissue or pressure. Related Diagnoses - True neurogenic TOS - a rare condition where the pt presents with anatomical abnormalities such as cervical rib or elongated C7 transverse process. Disputed , Symptomatic, or nonspecific neurogenic TOS - most common form of TOS. No evidence of bony abnormalities, muscle atrophy. Involves intermittent compression of the neruovascular bundle due to poor posture. Vascular TOS - Arterial - rare. Usually the result of structural abnormalities. Compression of the subclavian or axillary artery with arm motion. Vascular Syndromes - venous - compression of the subclavian or axillary vein. Sites of Compression or Entrapment - interscalene triangle; costoclavicular space; rectopectoralis minor space. Common Activity limitations and participation restrictions - sleep disturbances; inability to carry briefcase/backpack/purse, ect, or other weighted objects on involved side. Inability to maintain prolonged overhead reaching position; inability to do sustained computer or desk work; inability to do sustained overhead work. Management - patient education; correct impaired posture; mobilize restricted neuro tissue; mobilize restricted joints, connective tissue, and muscles; improve muscle performance; correct faulty breathing patterns; progress functional independence.

Provide a summary of Complex Regional Pain Syndrome, list causes, symptoms, related diagnoses, possible sites of entrapment, the common activity limitations and how it is managed.

Summary: CRPS is a painful, disabling, and often chronic condition with a prevalence of an estimated 50k new cases diagnosed in the USA every year. Causes: surgery and trauma - limb fractures, limb surgery, hand surgery. Signs and Symptoms: pain, sensory abnormalities, trophic changes, impairment of motor function, emotional/psychological response. Activity Limitations: pain avoidance behaviors; slower at initiating movement; gait abnormalities; limitations in ability to participate in gainful employment, housework, and ADLs; limitations in ability to enjoy leisure activities. Management: Modalities, retrograde massage, compression/elevation. Correct Sensorimotor Incongruence: mirror therapy, graded motor imagery. Increase mobility: gentle active motion specific to involved extremity. Improve muscle performance: active loading, distraction. Improve total body circulation: low impact aerobic exercise; aquatic exercise. Desensitize the area Pt education.

Provide a summary of Carpal Tunnel Syndrome, list causes, symptoms, related diagnoses, possible sites of entrapment, the common activity limitations and how it is managed.

Summary: The carpal tunnel is a confined space between the carpal bones dorsally and transverse carpal ligament volarly. The median nerve is susceptible to pressure as it courses through the tunnel. Causes: synovial thickness, scarring in tendon sheaths, irritation, inflammation, swelling of the tendon, repetitive or sustained wrist flexion, extension, or gripping activities. Symptoms: increasing pain and paresthesia in the hand with repetitive use; progressive weakness or atrophy in the thenar muscles and first two lumbricals; irritability or sensory loss in the median nerve distribution; decreased joint mobility in the wrist and metacarpaophalangeal joints; sympathetic nervous system changes; faulty forward head posture. Related Diagnoses: double-crush injury; the nerve develops symptoms at other areas along its course as well as the primary site. Sites of Entrapment: Carpal tunnel Common Impairments of Function: decreased prehension in tip-to-tip, tip-to-pad, and pad-to-pad activities requiring fine neuromuscular control. Avoidance of using the area of the hand where there is decreased sensation, inability to perform provoking sustained or repetitive wrist or finger motion; sleep disturbances.

Describe the nerve structure as described in Kisner?

The Kisner text primarily discusses peripheral nerves as they innervate tissue. These structures include the nerve bodies themselves, axons, and tissue that surrounds individual axons called endoneurium.

What are the contents of peripheral nerves and the location of their cell bodies?

The contents of peripheral nerves are as follows: Alpha motor neurons (somatic efferent fibers) - the cell bodies are located in the anterior column of the spinal cord and they innervate skeletal muscle. Gamma motor neurons (efferent fibers) - the cell bodies are located in the lateral columns of the spinal column; they innervate intrafusal muscle fibers of the muscle spindle. Sensory neurons (somatic afferent fibers) - the cell bodies are located in the dorsal root ganglia; they innervate sensory receptors. Sympathetic neurons (visceral afferent fibers) - cell bodies located in sympathetic ganglia; innervate sweat glands, blood vessels, visera, and glands.

Looking at a cross section of the spinal cord, what are the different sections noted and what does each one do?

The spinal cord is protected by a few layers of tough tissue. The grey matter of the spinal cord is surrounded by white matter, which is turn is covered by pia matter, arachnoid matter, and dura matter. Dura mater is a touch sheath of protective tissue. Arachnoid mater is thinner than dura mater, and pia matter is relatively delicate and contains blood vessels that run to the brain.

Describe how the nerve roots exit the spinal column in relations to their corresponding vertebra and how it differs for the cervical spine vs the rest of the spine?

The spinal cord runs down from the medulla into the vertebral foramen. They extend through individual vertebrae. Each vertebrae has a bony body, which is anterior weight-bearing, and a neural arch, which is posterior. Somewhat between the two is the intervertebral foramen, which are on the sides of the spinal column, where nerve roots exit.

Describe the position for each of the tests in question 12.

ULNT 1 - pt is supine. One hand supports the pt's shoulder, the other grasps the pts hand. The arm is then abducted to 100 degrees, with the elbow at 90 degrees. Supinate the forearm then laterally rotate the shoulder. ULNT 2 - pt is supine. Arm is abducted, shoulder girdle depressed; elbow is in extension, shoulder in medial rotation and forearm is pronated. Wrist is in ulnar deviation. ULNT 3 - Pt is Supine. Shoulder girdle is depressed. Shoulder is externally rotated and abducted. Elbow is flexed and forearm pronated.

What are the clinical differences between an upper motor lesion and a lower motor lesion?

Upper Motor Neuron insults result in signs like spasticity, hyperreflexia, and a present babinski reflex and clonus. Lower Motor Neuron insults result in signs like flaccid paralysis, muscle atrophy, fasiculations and fibrillations, hyporeflexia, and absent babinski reflex and absent clonus.

List the key muscles and nerve roots for testing upper and lower quarter myotomes/

Upper Quarter - Brachial Plexus C1-2 - cervical flexion C3 - Cervical side flexion C4 - Scapular elevation C5 - Shoulder abduction C6 - Elbow flexion and wrist extension C7 - Elbow extension and wrist flexion C8 - thumb extension - Brachial Plexus T1 - finger abduction - Brachial Plexus Lower Quarter - Lumbosacral Plexus L1-2 hip flexion L3 - Knee extension L4 - ankle dorsiflexion L5 - Big toe extension S1 - ankle eversion and plantar flexion, hip extension S2 - Knee flexion - Lumbosacral Plexus S3 - no specific test action; intrinsic foot muscles (except abductor allucis)

What are the two types of foremen of the spine and what passes through them?

Vertebral foramen - passageway for the spinal cord. Intervertebral foramen - the spinal nerves exit the vertebral canal.

What are the principles of neural mobilization?

the intensity of the maneuver should be related to irritability of the tissue, pt response, and change in symptoms. The greater the irritability, the gentler the technique. The technique, when applied properly, should be symptom free, slow, and rhythmic, utilizing an oscillatory motion.