Lecture 3: ASIA Sensory and Motor Examination for Patients with SCI (Cranial Nerves Added in)

What is a Common Muscle Substitution when testing L4 (Ankle Dorsiflexors) on the ASIA Motor Exam?

Ankle dorsiflexors can be mimicked by the long toe extensors, particularly the extensor hallucis longus. Correct stabilization and observation along with proper patient instruction and palpation can eliminate this substitution.

What is a Common Muscle Substitution when testing L2 (Hip Flexors) on the ASIA Motor Exam?

Any muscle of the trunk that can elevate or rotate the pelvis can trick the examiner into thinking that the hip flexor muscles are active. This could include the rectus abdominus, the adductor muscles, obliques, or the quadratus lumborum. With accurate palpation, correct patient instructions, and observation of any trunk movement, this substitution can be avoided.

How would you grade the Sensory Component of the ASIA?

- 0: Absent - 1: Altered, either decreased/impaired sensation of hypersensitivity - 2: Normal - NT: Not testable OR - 5/5: Intact - 4/5: Minimally impaired - 2-3/5: Moderately impaired - 1/5: Severe impairment - 0/5: Absent

What muscles are tested with ASIA level T1 (Small Finger Abductor)?

- Abductor Digiti Minimi

How do you test for Cranial Nerve III, IV, VI (Extra Ocular Movements- Pursuit Eye Movements)?

- Assess cranial nerve three (oculomotor), cranial nerve four (trochlear), and cranial nerve six (abducens) by testing smooth pursuits across full horizontal and vertical eye movements. Ask your patient to follow the pen with their eyes without moving their heads. First test motion in the horizontal plane. You will know that full motion is achieved when you can no longer see whitespace in a lateral or the medial portion of the eye. Next assess vertical motion, bringing the pen level to your patient's forehead and their chin. Your pen will make the motion of an H. Assess for motion in all direction and nystagmus. - If both eyes are limited in the same direction this is called a gaze palsy and is indicative of a central or an upper motor neuron lesion. A dysconjugate gaze occurs when one eye is limited or both eyes are limited in different directions. This indicates a lower motor neuron lesion or a problem at the neuromuscular junction. - The trochlear nerve innervates the superior oblique muscle. A trochlear palsy can cause weakness with downward or torsional movement of the eye. When weakness in a downward movement of the eye is present the affected eye will drift up at rest as compared to the unaffected eye and your patient will complain of double vision with downward smooth pursuits. Your patient may present at rest with their chin tucked as this position will help move the eyes back together. A trochlear nerve palsy will also affect torsion of the eye, which is the normal response to tilting of the head sideways. With torsion the eyes automatically rotate in an equal and opposite direction so that the environment is unchanged with movement. Patients with the trochlear nerve palsy tilt their heads to the opposite side to compensate for the torsional palsy. The characteristic appearance of patients with fourth nerve palsy's is their head tilted to one side and their chin tucked in. - Cranial nerve six (abducens) innervates the lateral rectus muscle. A cranial nerve six palsy will result in lack of complete lateral eye movement and at rest, the eye will cross inward towards the nose. This inward position of the eye is called estropia.

What muscles are tested with ASIA level C5 (Elbow Flexors)?

- Biceps Brachii - Brachialis

What are the Key Sensory Points of C2, C3, and C4 on the ASIA?

- C2: At least 1 cm lateral to the occipital protuberance at the base of the skull. Alternatively, it can be located at least 3 cm behind the ear. - C3: In the supraclavicular fossa, at the midclavicular line. - C4: Over the acromioclavicular joint

What is the Key Sensory Point of C5 on the ASIA?

- C5: On the lateral (radial) side of the antecubital fossa just proximal to the elbow.

What are the Key Sensory Points of C6, C7, and C8 on the ASIA?

- C6: On the dorsal surface of the proximal phalanx of the thumb. - C7: On the dorsal surface of the proximal phalanx of the middle finger. - C8: On the dorsal surface of the proximal phalanx of the little finger.

What tools do you use when performing the sensory component of the ASIA?

- Cotton ball for light touch - Safety pin for sharp dull

What muscles are tested with ASIA level C6 (Wrist Extensors)?

- Extensor Carpi Radialis Longus - Extensor Carpi Radialis Brevis

What muscles are tested with ASIA level L5 (Long Toe Extensors)?

- Extensor Hallucis Longus

What muscles are tested with ASIA level C8 (Long Finger Flexors)?

- Flexor Digitorum Profundus

How do you test for Cranial Nerve IX, X (Palatal & Pharynx control)?

- For cranial nerve nine, glossopharyngeal, assess for symmetrical elevation of the soft palate and uvula when your patient says ahhh. If a lesion is present the palate and uvula will deviate to the uninvolved side.

How do you test for Cranial Nerve II (Visual Fields)?

- For cranial nerve two, the optic nerve, you will assess vision in each visual quadrant. First ask your patient to fixate on an object behind you and report when they see their finger moving in each quadrant. You will perform this test for each of the four quadrants of each eye covering the eye that is not being tested. - "Alright so pick a spot on that wall and focus on it. Cover one eye with your hand looking at that spot. Say yes when you see my finger move into your visual field. (ipsilateral superior, ipsilateral inferior, contralateral superior, contralateral inferior) (wait for patient response through each field) OK switch sides keep your eyes on the spot (wait for patient response in each field)."

What muscles are tested with ASIA level S1 (Ankle Plantarflexors)?

- Gastrocnemius - Soleus

What is a Common Muscle Substitution when testing L5 (Long Toe Extensors) on the ASIA Motor Exam?

- Great toe extension can be facilitated by plantarflexion. If a patient actively plantar flexes the entire foot, passive extension of extensor hallucis longus can be achieved during the active plantarflexion of the foot. This is a type of tenodesis for the foot and can be avoided by proper stabilization to eliminate foot and ankle movement. - Another possible muscle substitution for L5 can occur when the patient actively flexes the big toe and then relaxes. Passive relaxation into a neutral position can be perceived as active extension.

What muscles are tested with ASIA level L2 (Hip Flexors)?

- Iliopsoas

Describe Anterior Cord Syndrome.

- Incomplete lesion that results in compression and damage to the anterior part of the spinal cord. Mechanism of injury is cervical flexion. - Loss of motor, pain and temperature sense below the lesion due to damage to the corticospinal and spinothalamic tracts.

Describe Brown-Sequard's Syndrome.

- Incomplete lesion usually caused by a stab wound, which causes a hemisection of the spinal cord. - Loss of vibratory and position sense on the same side due to a lesion of the corticospinal tract and dorsal columns. - Loss of pain and temperature on the opposite side due to a lesion of the lateral spinothalamic tract.

Describe Cauda Equina Injury.

- Injury occurs below L1. Can be complete or incomplete due to the amount of nerve roots in this area. Considered a peripheral nerve injury. - Loss of bowel and bladder, flaccidity and areflexia.

Describe Central Cord Syndrome.

- Injury to the central portion of the spinal cord. Mechanism is usually cervical hyperextension. - Loss of motor and sensory components of the body depending on lesion. Damage to spinothalamic, corticospinal and dorsal columns.

What are the Key Sensory Points of L1, L2, and L3 on the ASIA?

- L1: Midway between the key sensory points for T12 and L2 - L2: On the anterior-medial through, at the midpoint drawn on an imaginary line connecting the midpoint of the inguinal ligament and the medial femoral condyle. - L3: At the medial femoral condyle above the knee

What are the Key Sensory Points of L4 and L5 on the ASIA?

- L4: Over the medial malleolus - L5: On the dorsal of the foot at the third metatarsal phalangeal joint.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0 & 1 level C7 (Elbow Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Maintain the grade 2 position with the shoulder in internal rotation and adduction, and the forearm positioned above the abdomen. The forearm is in neutral pronation/supination and the elbow is in 30 degrees of flexion - Examiner Position: Support the arm. For trace function, palpate the distal triceps at its insertion on the olecranon. The belly of the triceps muscle may also be palpated and observed for movement - Instructions to Patient: "Straighten your arm." - Action: The patient attempts to fully extend the elbow.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0 & 1 level L4 (Ankle Dorsiflexors) on the ASIA Motor Exam Guide?

- Patient Position: Place the hip in neutral rotation, neutral adduction/abduction, and neutral flexion/extension. The knee is fully extended and the ankle slightly plantarflexed. - Examiner Position: Palpate the proximal lower leg over the tibialis anterior muscle belly or on the tendon of the tibialis anterior muscle as it crosses the anterior ankle. Observe the muscle belly for movement. - Instructions to Patient: "Bring your toes upward toward your head, letting your ankle bend." - Action: The patient attempts to dorsiflex the ankle.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level C6 (Wrist Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Same as grade 3, except the wrist is fully extended - Examiner Position: Grasp the distal forearm to stabilize the wrist. Apply pressure across the metacarpals in a downward direction toward flexion and ulnar deviation. The force applied should be angled toward the ulnar side of the wrist rather than directly downward, since it is the radial wrist extensors that are being tested - Instructions to Patient: "Hold your wrist up. Don't let me push it down." - Action: The patient resists the examiner's push and attempts to maintain the wrist in the fully extended position.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0 & 1 level L2 (Hip Flexors) on the ASIA Motor Exam Guide?

- Patient Position: Place the patient in the grade 3 position, with the hip in neutral rotation, neutral adduction/abduction and the hip and knee flexed to 15 degrees. - Examiner Position: Support the thigh to eliminate friction while palpating the superficial hip flexors just distal to the anterior superior iliac spine. - Instructions to Patient: Ask the patient to "lift your knee towards your chest as far as you can." - Action: The patient attempts to flex the hip. Note: For Grade 1, the examiner is actually palpating the more superficial hip flexors, i.e. sartorius and rectus femoris rather than the iliopsoas. The insertion of the iliopsoas is too deep to be seen or felt when it possesses only Grade 1 strength. When examining a patient with an acute traumatic lesion below T8, the hip should not be allowed to flex passively or actively beyond 90 degrees. Flexion beyond 90 degrees may place too great a kyphotic stress on the lumbar spine.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0 & 1 level L5 (Long Toe Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Place the patient in the grade 3 position. - Examiner Position: Support the leg and palpate the extensor tendon of the long toe for trace function. - Instructions to Patient: "Lift your big toe upwards toward your knee." - Action: The patient attempts to extend the great toe.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 2 level L2 (Hip Flexors) on the ASIA Motor Exam Guide?

- Patient Position: Place the patient in the gravity eliminated position with the hip in external rotation and 45 degrees of flexion. The knee is flexed at 90 degrees. - Examiner Position: Support the leg - Instructions to Patient: "Try to bring your knee out to the side," or "Try to flex your thigh toward the side of the body." - Action: The patient attempts to move through the full range of motion in hip flexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 0 & 1 level L3 (Knee Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Place the patient with the hip in neutral rotation, neutral adduction/abduction with both the hip and knee in 15 degrees of flexion - Examiner Position: Support the leg. Palpate the patellar tendon or the belly of the quadriceps muscle for trace function. The muscle belly may also be observed for movement. - Instructions to Patient: "Straighten your knee." Note: In this position, asking the patient to push the back of the knee downward toward the exam table may be better to elicit trace contraction in the quadriceps. - Action: The patient attempts to straighten the knee.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0, 1, & 2 level C6 (Wrist Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Position the patient with the arm resting on the exam table. The shoulder is in neutral flexion/extension, neutral rotation, and adducted. The elbow is fully extended. The forearm is in neutral pronation-supination and the wrist fully flexed. The patient may also be positioned with the shoulder in slight flexion, internal rotation, and adducted, with the patient's arm above the abdomen. The elbow is flexed to 90 degrees and the forearm is in full supination. The wrist is flexed. - Examiner Position: Support the forearm and ask the patient to bend the wrist backwards into extension. For trace function, palpate the radial wrist extensors just proximal to the wrist, on the radial aspect of the distal forearm. Observe the muscle belly for movement. - Instructions to Patient: "Bend your wrist backwards." - Action: The patient attempts to extend the wrist through a full range of motion in wrist extension.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level L4 (Ankle Dorsiflexors) on the ASIA Motor Exam Guide?

- Patient Position: Same as grade 3, except the ankle is fully dorsiflexed. - Examiner Position: In the grade 3 position, place the hand on the dorsum of the foot and apply pressure downward in the direction of plantarflexion. - Instructions to Patient: "Hold your ankle in this position. Don't let me push it down." - Action: The patient attempts to resist the examiner and maintain the ankle in full dorsiflexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level C7 (Elbow Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Same as grade 3, except the elbow is in 45 degrees of flexion - Examiner Position: Support the upper arm. Grasp the wrist and apply resistance tp the distal forearm in the direction of elbow flexion - Instructions to Patient: "Hold this position. Don't let me bend your elbow." - Action: The patient resists the examiner's pressure and attempts to maintain the position of the elbow in 45 degrees of flexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level L3 (Knee Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Same as grade 3, except the knee is in 15 degrees of flexion. - Examiner Position: Place the arm under the tested knee and rest the hand on the patient's opposite thigh. Grasp the leg to be tested, just proximal to the ankle. - Instructions to Patient: "Hold this position. Don't let me bend your knee." - Action: Examiner exerts downward force into knee flexion while the patient attempts to hold the knee in 15 degrees of flexion

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level T1 (Small Finger Abductor) on the ASIA Motor Exam Guide?

- Patient Position: Same as grade 3, except the little finger is fully abducted. - Examiner Position: Support the patient's hand, taking care to assure that the MCP joints are stabilized to prevent hyperextension. Use the index finger to apply pressure against the side of the patient's distal phalanx. - Instructions to Patient: "Hold your little finger away from your ring finger. Don't let me push it in." - Action: The examiner exerts a pushing force against the side of the distal phalanx, and the patient attempts to resist the examiner's force and keep the little finger fully abducted.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level L5 (Long Toe Extensors) on the ASIA Motor Exam Guide?

- Patient Position: Same as grade 3, except the toe is fully extended. - Examiner Position: At the patient's side. Place the thumb on the distal phalanx of the great toe and apply pressure downward in the direction of toe flexion. - Instructions to Patient: "Keep your toe lifted upward. Don't let me push it down." - Action: The patient attempts to resist the examiner and maintain the great toe in full extension.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level L2 (Hip Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in 90 degrees of flexion with the knee relaxed - Examiner Position: Brace the anterior superior iliac spine on the opposite side and place a hand on the distal anterior thigh, just above the knee. Pressure is applied in the direction of hip extension - Instructions to patient: "Hold your knee in this position. Don't let me push it down." - Action: The patient attempt to resist the examiner's push and help the hip flexed at 90 degrees.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 2 level L3 (Knee Extensors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in external rotation and 45 degrees of flexion. The knee is flexed to 90 degrees. - Examiner Position: Support the distal thigh and leg - Instructions to Patient: "Straighten your knee." - Action: The patient attempts to move through the full range of motion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 2 level L4 (Ankle Dorsiflexors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in external rotation and 45° of abduction. The knee is flexed, and the ankle is fully plantar flexed. - Examiner Position: Support the leg. - Instructions to Patient: "Lift the toes upward toward the head, allowing the ankle to bend." - Action: The patient attempts to dorsiflex ankle through the full range of motion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0, 1, & 2 level S1 (Ankle Plantarflexors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in external rotation and 45° of flexion. The knee is flexed. - Examiner Position: Support the lower leg. For trace function palpate either the gastrocnemius muscle belly or the achilles tendon, or observe the muscle belly for movement. - Instructions to Patient: "Point your toes downward like a ballet dancer." - Action: The patient attempts to plantar flex the foot through a full range of motion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 2 level L5 (Long Toe Extensors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in external rotation, 45° abduction. The knee is flexed. The ankle and long toe are in a relaxed, neutral position. - Examiner Position: Support the leg. - Instructions to Patient: "Lift your big toe upwards toward the knee." - Action: The patient attempts to extend the great toe through the full range of motion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level L5 (Long Toe Extensors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in neutral rotation, neutral adduction/abduction, and neutral flexion/extension. The knee is fully extended. - Examiner Position: At the patient's side. Support the foot. - Instructions to Patient: "Lift your big toe upwards toward your knee." - Action: The patient attempts to move the great toe through the full range of motion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level L4 (Ankle Dorsiflexors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in neutral rotation, neutral adduction/abduction, with the hip and knee slightly flexed. The hand may be placed under the knee of the tested leg to incorporate slight flexion. The ankle is plantarflexed. - Examiner Position: At the patient's side. Support the leg. - Instructions to Patient: "Pull your toes upward toward your head, letting your ankle bend." - Action: The patient attempts to dorsiflex ankle through a full range of motion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level L3 (Knee Extensors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in neutral rotation, neutral adduction/abduction and 15 degrees of flexion. The knee is in 30 degrees of flexion - Examiner Position: Place the arm under the tested knee and rest the hand on the patient's distal thigh. This causes the tested knee to flex to approximately 30 degrees - Instructions to Patient: "Straighten your knee." - Action: The patient attempts to straighten the knee through the full range of motion in extension

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level S1 (Ankle Plantarflexors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in neutral rotation, neutral flexionextension, and neutral abduction-adduction. The knee is fully extended and the ankle is in full plantarflexion. - Examiner Position: Place one hand on the distal lower leg while the other hand grasps the foot across the plantar surface of metatarsals. Apply pressure on the bottom of the foot in the direction of dorsiflexion. - Instructions to Patient: "Hold your foot pointed down. Don't let me push it up." - Action: Examiner gives pressure on the plantar aspect of the metatarsals in the direction of dorsiflexion. The patient attempts to resist the examiner by maintaining the foot and ankle in full plantarflexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level L2 (Hip Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The hip is in neutral, neutral adduction/abduction, with both the hip and knee in 15 degrees of flexion. - Examiner Position: Support the dorsal aspect of the distal thigh and leg. Do not allow flexion beyond 90 degrees when examining acute thoraco-lumbar injuries due to the kyphotic stress placed on the lumbar spine. - Instructions to Patient: "Lift your knee towards your chest as far as you can, trying not to drag your foot on the exam table." - Action: The patient attempts to flex hip to 90 degrees of flexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level C8 (Long Finger Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The same as grade 3, except the DIP joint is fully flexed - Examiner Position: Stabilize the wrist, MCP and PIP joints as in grade 3. Apply pressure with the tip of the finger or thumb against the distal phalanx of the patient's middle finger - Instructions to Patient: "Hold the tip of your finger in this bent position. Don't let me move it." - Action: The patient attempts to maintain the fully flexed position of the DIP joint, and resist the pressure applied by the examiner in the direction of finger extension

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level T1 (Small Finger Abductor) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in internal rotation adducted, and at 15 degrees flexion. The elbow is at 90 degrees flexion, the forearm is pronated, and the wrist is in neutral flexion/extension. - Examiner Position: Support the patient's hand, taking care to assure that the MCP joints are stabilized to prevent hyperextension. - Instructions to Patient: "Move your little finger away from your ring finger." - Action: The patient attempts to move the little finger through the full range of motion in adbuction.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 2 level C5 (Elbow Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in internal rotation and adducted with the forearm positioned above the abdomen, just below the umbilicus. The elbow is in 30 degrees of flexion. The forearm and wrist are in neutral pronation/supination. Sufficient flexion of the shoulder must be permitted to allow the forearm to comfortably move over the abdomen. - Examiner Position: Support the arm - Instructions to Patient: "Bend your elbow and try to bring your hand to your nose." - Action: The patient attempts to move the elbow through a full range of motion in elbow flexion

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 2 Level C7 (Elbow Extensors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in internal rotation and adducted, with the forearm positioned above the abdomen. The forearm is in neutral pronation/supination. The elbow is fully flexed. When checking Grade 2, sufficient flexion of the shoulder must be permitted to allow the forearm to clear and move over the chest and abdomen - Examiner Position: Support the patient's arm - Instructions to Patient: "Straighten your arm." - Action: The patient attempts to move through the full range of elbow extension

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level C7 (Elbow Extensors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in neutral rotation, adducted, and 90 degrees of flexion. The elbow is fully flexed with the palm of the hand resting by the ear. - Examiner Position: Support the upper arm. - Instructions to Patient: "Straighten your arm." - Action: The patient attempts to move through the full range of elbow extension.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level C8 (Long Finger Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in neutral rotation, neutral flexion-extension, and adduction. The elbow is fully extended with the forearm fully supinated. The wrist is in neutral flexion-extension. The metacarpal phalangeal (MCP) and proximal interphalangeal joints (PIP) are stabilized in extension. - Examiner Position: Using two hands grasp the patient's hand and stterm-42abilize the wrist in neutral. Secure the PIP and MCP joints in extension with both hands while isolating the middle finger for testing. Stabilize the volar aspect of the 3rd middle phalanx with the thumb of the opposite hand. As an alternate method, 1 hand may be used to stabilize instead of 2. The PIP and MCP joints are stabilized as previously described, with the thumb of the stabilizing hand now securing the middle phalanx. - Instructions to Patient: "Bend the tip of the middle finger." - Action: The patient attempts to flex the distal interphalangeal (DIP) joint through the full range of motion in flexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0, 1, & 2 level C8 (Long Finger Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in neutral rotation, neutral flexion-extension, and adduction. The elbow is fully extended. The forearm is in neutral pronation-supination and the wrist in neutral flexion-extension. The MCP and PIP joints are stabilized in extension. - Examiner Position: Stabilize the wrist in neutral and the MCP and PIP joints in extension. For trace function, palpate the tendons of the long finger flexors or observe the muscle belly for movement. - Instructions to Patient: "Bend the tip of your middle finger." - Action: The patient attempts to flex the distal interphalangeal (DIP) joint through the full range of motion in flexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 4 & 5 level C5 (Elbow Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in neutral rotation, neutral flexion/extension, and adducted. The elbow is flexed to 90 degrees and the forearm is fully supinated - Examiner Position: Place a stabilizing hand on the anterior shoulder. Grasp the volar aspect of the wrist and exert a pulling force in the direction of elbow extension. - Instructions to Patient: "Hold your arm. Don't let me move it." - Action: The patient resists the examiner's pull and attempts to maintain the elbow flexed at 90 degrees.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level C6 (Wrist Extensors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in neutral rotation, neutral flexion/extension, and adducted. The elbow is fully extended, the forearm is fully pronated, and the wrist flexed. - Examiner Position: One hand supports the distal forearm to allow the wrist to be pre-positioned in sufficient flexion for testing - Instructions to Patient: "Bend your wrist upwards. Lift you fingers toward the ceiling." - Action: The patient attempts to extend the wrist through a full range of motion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level C5 (Elbow Flexors) on the ASIA Motor Exam Guide?

- Patient Position: The shoulder is in neutral rotation, neutral flexion/extension, and adducted. The elbow is fully extended, with the forearm in full supination. The wrist is in neutral flexion/extension. - Examiner Position: Support the wrist - Instructions to Patient: "Bend your elbow and try to reach you hand to your nose." - Action: The patient attempts to move through the full range of motion in elbow flexion

What are the Key Sensory Points of T8-T12 on the ASIA? (Don't really need to know this, but just in case)

- T8: At the midclavicular line, one half the distance between the level of the xiphisternum and the level of the umbilicus - T9: At the midclavicular line, three quarters of the distance between the level of the xiphisternum and the level of the umbilicus - T10: At the midclavicular line, located at the level of the umbilicus - T11: At the midclavicular line, midway between the level of the umbilicus and the inguinal ligament - T12: At the midclavicular line, over the midpoint of the inguinal ligament

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0 & 1 level C5 (Elbow Flexors) on the ASIA Motor Exam Guide?

- Patient: The patient is in the grade 2 position with the shoulder in internal rotation and adducted. The palm and ventral forearm are positioned above the abdomen. The elbow is in 30 degrees of flexion. The forearm and wrist are in neutral pronation/supination. Sufficient flexion of the shoulder must be permitted to allow the forearm to comfortably move over the abdomen. - Examiner Position: One hand supports the forearm while the other hand palpates the biceps tendon in the cubital fossa. The belly of the biceps brachii muscle may also be palpated or observed for movement - Instructions to Patient: "Bend your elbow and try to bring your hand to your nose." - Action: The patient attempts to move the elbow through a full range of motion in elbow flexion.

What muscles are tested with ASIA level L3 (Knee Extensors)?

- Quadriceps

Describe Posterior Cord Syndrome.

- Rare. Caused by compression of the posterior cord artery. - Loss of proprioception, two-point discrimination and stereognosis. - Motor is preserved.

What are the Key Sensory Points of S1 and S2 on the ASIA?

- S1: On the lateral aspect of the calcaneus - S2: At the midpoint of the popliteal fossa

What are the Key Sensory Points of S3 and S4/5 on the ASIA?

- S3: Over the ischial tuberosity or infragluteal fold (depending on the patient their skin can move up, down or laterally over the ischii). - S4/5: In the perianal area, less than 1 cm lateral to the mucocutaneous junction. Use a q-tip with one side intact and the other side having the q-tip cut off for testing sharp dull of these areas.

What are the Key Sensory Points of T1 and T2 on the ASIA?

- T1: On the medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus. - T2: At the apex of the axilla.

What are the Key Sensory Points of T3 - T7 on the ASIA? (Don't really need to know this, but just in case)

- T3: At the midclavicular line and the third intercostal space, found by palpating the anterior chest to locate the third rib and the corresponding third intercostal space below it. - T4: At the midclavicular line and the fourth intercostal space, located at the level of the nipples. - T5: At the midclavicular line and the fifth intercostal space, located midway between the level of the nipple and the level of the xiphisternum. - T6: At the midclavicular line, located at the level of the xiphisternum - T7: At the midclavicular line, one quarter the distance between the level of the xiphisternum and the level of the umbilicus.

How do you test for Cranial Nerve XII (Tongue Movement)?

- The 12th cranial nerve, hypoglossal, is tested by sticking out the tongue. In a normal test the tongue will protrude in midline. In a positive test the tongue will deviate towards the weak side. In a lower motor neuron lesion tongue deviation will occur ipsilateral to the lesion, look for atrophy or fasciculations of the tongue to further indicate a lower motor neuron lesion. In an upper motor neuron lesion the tongue will deviate contralateral to the lesion, look for other signs such as hemiparesis to further indicate an upper motor neuron lesion.

How do you test for Cranial Nerve II, III (Pupillary Response)?

- The pupillary reflex assesses cranial nerve two optic and cranial nerve three oculomotor. In the pupil are reflex. Cranial nerve two is the afferent nerve and cranial nerve three is efferent nerve. Assess this reflex by asking your patient to focus on a point in the distance. Here observe the diameter of each pupil and assess for symmetry between the pupils. Place your hand on the bridge of your patients nose and shine a light in one eye. A constriction of the pupil should occur. This is called the direct response. - Perform it again in the same eye and check for constriction in the opposite pupil this is called the consensual reflex. Test the other eye. First checking for the direct response, and then checking for the consensual response. A similar response, a constriction of the pupil, should occur when an object moves closer to the pupil. This is called accommodation. Record an intact pupillary reflex when pupils are equal, round, and reactive to light and accommodation.

How do you test for Cranial Nerve VII (Facial Symmetry & Expression)?

- The seventh cranial nerve, the facial nerve, is tested by assessing the strength of the muscles of the face. First assess for asymmetry of the face at rest and with spontaneous movement. Next assess for symmetry with movement: "smile", "puff out your cheeks", "raise your eyebrows", "close your eyes tightly, don't let me open them". - Muscles of the forehead are bilaterally innervated by upper motor neurons. Therefore, if there is weakness to the lower face without weakness at the forehead this is indicative of a central or upper motor neuron injury, such as a stroke. If weakness is noted in both the lower face and the upper face this is a sign of an injury to the seventh cranial nerve.

What muscles are tested with ASIA level L4 (Ankle Dorsiflexors)?

- Tibialis Anterior

How do you test for Cranial Nerve VIII (Weber Test and Rinne Test for Hearing Assessment)?

- To assess cranial nerve eight, vestibulocochlear, assess hearing. Instruct your patient to close their eyes. "When you hear a sound in your left ear tell me left and when you hear a sound in your right ear tell me right." Rub your fingers close to the ear, making sure to not touch the ear or hair. "Does this sound the same as this? (alternating sides)" If sound abnormalities are reported continue to the Weber's test using a 256 Hertz tuning fork. - Weber's test assesses lateralization of sound. Strike the tuning fork on your hand and place it on the top and middle of your patient's head. Ask your patient where they hear the vibration. A normal response is to hear the vibration equally in both ears or at the center of the head at the point of contact. With conduction hearing loss the tuning fork will sound louder in the ear with hearing loss. With unilateral sensorineural hearing loss, the sound will be louder in the intact ear. If your Webber's test is positive use the Rinne test to differentiate conductive versus neural hearing loss. - For the Rhine test strike the tuning fork against your hand and then place the stem on the mastoid process. "Can you hear the vibration here?" If your patient cannot hear the vibration that is a sign of sensorineural hearing loss. "Tell me when you cannot hear that anymore." "Can you hear it now?" If when you move the tuning fork they are unable to hear the vibration that is a sign of conductive hearing loss.

How do you test for Cranial Nerve XI (Neck Motor Function)?

- To assess cranial nerve eleven, spinal accessory nerve, perform a manual muscle test of the upper traps and sternocleidomastoid. "Shrug up your shoulders, hold there, good relax." (Have patient turn head 45 degrees to one side and try to go into a contralateral turn. Repeat in opposite direction) Note for asymmetry in muscle. Straight weakness will be noted on the same side as a lesion.

How do you test for Cranial Nerve V (Sensation)?

- To assess cranial nerve five, the trigeminal nerve, you will test both the strength of the masseter muscle and the sensation of the face. To test the strength of the masseter, first observe for wasting of the muscle belly. Next palpate the masseter and ask your patient to bite down. Feel for symmetrical muscle contraction in both strength and timing. Next assess strength by having her patient open their mouth against resistance applied at the base of their chin. To test for sensation, use a single point and apply lightly. Do not stroke or apply heavy pressure. Test the three major branches of the nerve, including the ophthalmic nerve at the forehead, the maxillary nerve at the cheek, and the mandibular nerve at the jaw. Ask your patient to first identify the presence of a stimulus with their eyes closed and then compare the strength of the stimulus bilaterally. - "Close your eyes say yes when you feel me touch your face." Testing if the can feel the stimulus - "Does this feel the same as this?" Testing each nerve area bilaterally

How do you test for Cranial Nerve X (Gag Reflex)?

- To assess cranial nerve ten, the vagus nerve, test your patient's gag reflex. Do this by depressing the patients tongue with a tongue depressor and lightly touch the pallet bearings or tonsil on one side until the patient gags. Repeat this on the other side.

How do you test for Cranial Nerve I (Olfactory)?

- To test cranial nerve one, the olfactory nerve, present a familiar odor to your patient with their eyes closed. Such odors may include coffee grounds, soap, or mint. Do not use a noxious odor. Test each nostril separately by occluding one nostril at a time. Your patient should be able to identify an odor at about 10 centimeters from the nostril. Ask your patient to rate the strength of smell in each nostril. Testing the first cranial nerve is often omitted, unless lack of smell is reported as a symptom. - "Close your eyes then put your finger over one nostril. Can you identify this smell? Okay good keep your eyes closed and now cover the other nostril and identify this smell. Is there a difference in strength of the smell from side to side?"

What muscles are tested with ASIA level C7 (Elbow Extensors)?

- Triceps

What is a Common Muscle Substitution when testing C8 (Long Finger Flexors) on the ASIA Motor Exam?

- When testing grades 1 through 3, the wrist must be carefully stabilized. Involuntary movement of the distal phalanx can occur in the presence of active wrist extension. This tenodesis movement could be misinterpreted as voluntary contraction of the long finger flexors. - While testing grades 4 and 5, the proximal phalanges must be well stabilized. This will avoid misinterpretation of distal phalanx movement caused by contraction of the hand intrinsics or the flexor digitorum superficialis.

Describe the ASIA.

- With the ASIA, described by the American Spinal Injury Association International Standards for Neurological Classification of Spinal Cord Injury Reference Manual, there are 28 specific skin locations referred to as key sensory points that are recommended in the testing of sharp dull discrimination and light touch appreciation. - When a key sensory point is unavailable for testing because of casting, laceration, dressing, or amputation, any spot within the recommended dermatome may be used as an alternate testing location. - A recommended practical sequence to follow for the sensory examination, is to begin with the sharp dull discrimination testing in a dermatome with a suspected impairment and to proceed in a cephalad direction until a patient reports a change toward normal sharpness. This technique allows an examiner to quickly locate the body region in which the level of neurological impairment will be found. The examiner will then need to proceed with careful testing for sharp dull discrimination grading and light touch appreciation at the specific key sensory points for dermatomes in the impaired region.

What is the ASIA Muscle Function Grading Scale?

0 = total paralysis 1 = palpable or visible contraction 2 = active movement, full range of motion (ROM) with gravity eliminated 3 = active movement, full ROM against gravity 4 = active movement, full ROM against gravity and moderate resistance in a musclespecific position 5 = (normal) active movement, full ROM against gravity and full resistance in afunctional muscle position expected from an otherwise unimpaired person 5* = (normal) active movement, full ROM against gravity and sufficient resistance to beconsidered normal if identified inhibiting factors (i.e. pain, disuse) were not present NT = not testable (i.e. due to immobilization, severe pain such that the patient cannotbe graded, amputation of limb, or contracture of > 50% of the normal range of motion)

What is the ASIA Impairment Scale (AIS)?

A = Complete: No sensory or motor function is preserved in the sacral segments S4-5. B = Sensory Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body. C = Motor Incomplete: Motor function is preserved below the neurological level**, and more than half of key muscle functions below the neurological level of injury (NLI) have a muscle grade less than 3 (Grades 0-2). D = Motor Incomplete: Motor function is preserved below the neurological level**, and at least half (half or more) of key muscle functions below the NLI have a muscle grade > 3. E = Normal: If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

What is a complete lesion spinal cord injury?

Complete loss of motor and sensory components below the lesion.

What is a Common Muscle Substitution when testing S1 (Ankle Plantarflexors) on the ASIA Motor Exam?

Visually monitor the hip flexors to assure that these muscles are not being used to facilitate plantarflexion.

What is a Common Muscle Substitution when testing C7 (Elbow Extensors) on the ASIA Motor Exam?

Elbow extension can be mimicked by externally rotating the shoulder, by quickly flexing the elbow and then relaxing, and with spasticity of the triceps. These substitutions can be minimized by maintaining the correct position for testing, correct instructions to the patient, and avoiding elbow flexion. Palpation of the triceps should be done to confirm the patient is using the correct muscle for the test.

What is a Common Muscle Substitution when testing T1 (Small Finger Abductor) on the ASIA Motor Exam?

Finger extension can mimic 5th finger abduction. Proper positioning and stabilization will minimize this error.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grade 3 level S1 (Ankle Plantarflexors) on the ASIA Motor Exam Guide?

Note: Checking for Grades 3-5 is significantly different from what is described in standard manual muscle testing texts. This departure is required for examining patients in the supine position. - Patient Position: The hip is in neutral rotation and 45° of flexion, with the knee fully flexed and ankle in full dorsiflexion. - Examiner Position: Place one hand behind the knee to assist in stabilizing the leg. The other hand is positioned under the sole of the patient's foot, pushing the foot into dorsiflexion. The patient's heel remains resting on the exam table. - Instructions to Patient: "Push your foot down into my hand and lift your heel off the table." - Action: The patient pushes the forefoot downward into the examiner's hand and raises the heel off the exam table, through a full range of motion in plantarflexion.

What is the Patient Position, Examiner Position, Instructions to Patient, and Action when testing Grades 0, 1, & 2 level T1 (Small Finger Abductor) on the ASIA Motor Exam Guide?

Patient Position: The shoulder is in neutral rotation, neutral flexion/extension, and adducted. The elbow is in full extension. The forearm is in full pronation and the wrist in neutral flexion-extension. The MCP joint is stabilized. An alternate position is with the shoulder in internal rotation, adducted, and neutral flexion/extension. The elbow is in 90 degrees of flexion, the forearm and wrist are in neutral flexion/extension, and the MCP joint is stabilized. - Examiner Position: Stabilize the dorsal wrist and hand by pressing down lightly on the back of the hand. Be sure that the MCP joints are stabilized to prevent hyperextension. Palpate the abductor digiti minimi muscle and observe the muscle belly for movement. - Instructions to Patient: "Move your little finger away from your ring finger." - Action: The patient attempts to abduct the little finger through the full range of motion.

How do you perform the sensory component of the ASIA?

Perform light touch (cotton ball) as well as sharp dull (safety pin) in each sensory point. Ask the patient to close their eyes. You can use the cheek or neck as a reference point for the patient to see how it will feel. Touch each spot 5 times, and ask for a response each time. After performing the test ask the patient, "was that as intense as when I touched your face?"

What is an incomplete lesion spinal cord injury?

Scattered loss of motor and sensory components below the level of lesion. Could be different on opposite side*.

When would you use a cranial nerve examination?

The cranial nerve examination can be used as part of your neuro screen, and to perform a differential diagnosis between an upper motor neuron lesion and a lower motor neuron lesion. There are 12 cranial nerves. Cranial nerves are lower motor neurons and innervate the ipsilateral face. Cranial nerves should be tested bilaterally with results compared side to side.

What is a Common Muscle Substitution when testing C6 (Wrist Extensors) on the ASIA Motor Exam?

Wrist extension can be mimicked by forearm supination and the use of gravity. The examiner needs to make sure the forearm is stabilized and is in proper position.