Pat. Ass. Neuro anatomy
when do purposeful movements begin in an infant
2 months
How fair apart is two point discrimination on the fingers and toes
2-8mm apart
how many months are an infants hands are held in fist
3 months
how many pairs of spinal nerves are there
31
how far is two point discrimination on the back, chest or forearm
40-70mm
when do infants take objects with one hand
6 months transfers objects hand to hand at 7 months
how long should the plantar grasp be strong for
8 months
What reflexes appear at 6 months of age
Achilles and brachioradial tendon
Testing CN II (Optic)
Distance and near vision Fundoscopic exam
What is the motor function of CN IV (trochlear)
Downward, inward eye movement
spastic diplegia (scissoring) is due to an injury of what system
Due to injury to the pyramidal system
what kind of gait pattern is associated with lordosis
Dystrophic (waddling)
Stereogenesis
Familiar object in hand
Testing CN V (trigeminal)
Inspect for atrophy and tremors Jaw muscles with clenched teeth Superficial pain and touch Corneal reflex
Testing CN XII (hypoglossal)
Inspect tongue for symmetry, tremors, and atrophy Move tongue toward nose and chin Tongue strength Lingual speech sounds
What is the motor function of CN V (trigeminal)
Jaw opening and clenching, chewing and mastication
What spinal nerves are tested when doing the Patellar reflex
L2-L4
What spinal nerves are tested when doing the plantar reflex
L5-S2
What is the motor function of CN VII (facial)
Movement of facial expression muscles except JAW, close eyelids, labial speech sounds (bah)
How do you differentiate between peripheral single nerve loss vs multiple peripheral nerve loss (polyneuropathy
Multiple will have a glove and stocking distribution of sensory loss and all forms of sensory dicrimination will be lost while single will be in the nerves anatomical position and may still have some sensory function
Testing CN I (olfactory)
Odors -1 naris at a time with eyes closed
What test are used to test the corticospinal tracts
Rapid rhythmic movement voluntary movement deep tendon reflexes plantar reflex
What is proprioception
Recognition of body parts and awareness of body posistion
What is the function of the diencephalon and thalamus
Relays impulses between cerebrum, cerebellum, pons, and medulla Conveys ALL sensory impulses (EXCEPT OLFACTION) Integrates impulses between motor cortex and cerebrum; influencing voluntary movements and motor response Controls state of consciousness, abstract feeling
What spinal nerves are tested when doing the achillesreflex
S1-S2
What are intention tremors
Seen during intentional movements (writing, pouring water, FINGER TO NOSE test) Does not occur at rest Cerebellar disorders - multiple sclerosis or alcohol abuse
What is a resting tremor
Seen when limb is at rest Slow supination-pronation (pill-rolling) movements parkinson disease
What are enhanced physiologic tremor
Seen with arms extended and disappears while at rest caused by drug or alcohol withdraw Hyperthyroidism Hypoglycemia Medication toxicity
What is the sensory function of CN V (trigeminal)
Sensation to the cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear , facial skin
What type of gait is associated with a positive romberg sign
Sensory ataxia
What is the sensory function of CN I (olfactory)
Smell reception and interpretation
What is stepping, when does it appear
Stepping: touch soles of the feet to touch the surface of the table, observe for alternate flexion and extension of the legs Appears: birth to 8 weeks
when in the palmar grasp the strongest and when does it disappear
Strongest 1-2 months Disappears: 3 months
What test are used to test the integrity of the lateral spinothalamic tract
Superficial pain Temperature
What exams test primary sensory function
Superficial touch Superficial pain Temperature and Deep pressure Vibration Position of joint
What reflexes are associated with the medulla oblongata
Swallowing, coughing, vomiting, sneezing and hiccuping
what is the motor function of CN XII (hypoglossal)
Tongue movement for speech sound articulation (l,t,d,n) and swallowing
Testing CN XI (spinal accessory)
Trapezius and sternocleidomastoid muscle strength
What is asymmetric tonic neck or fencing, when does it appear, and when does it disappear
Turn head, observe for extension of the arm and leg on the same side and flexion of the opposite arm and leg Appears: by 2-3 months disappears by 6 months
How do you differentiate upper and lower motor neuron disease in the face
Upper (stroke): voluntary movements paralyzed but emotional movements are intact: can raise eyebrow Lower (bell palsy): all facial movements are paralyzed
What motor neuron injury would result in initial paralysis followed by partial recovery over and extended period
Upper motor neuron injury
What test are used to test the integrity of the posterior column
Vibration Deep pressure Position sense Sterogenosis Point location Two point discrimination
Testing CN III (oculomotor), CN IV (trochlear), CN VI (abducens)
Visual fields Eyelid drooping Pupil size, response, and accommodation Extraocular movements
what is the motor function of CN IX (glossopharyngeal)
Voluntary muscles for swallowing and phonation (guttural)
Where is the reception and interpretation of speech located
Wernicke area
Testing CN VIII (acoustic)
Whisper test Rinne Weber
What do cortical or discriminatory sensory functions test
ability to interpret sensations Inability to perform these test indicate a lesion in the sensory cortex or the posterior columns of the spinal cord
How do you test CN VIII in an infant
acoustic blink reflex: loudly clap hand and the blink should occur
Sensation in upper motor neuron disorder
affect the entire limb
what neuron initiate reflex arches
afferent (sensory) neurons
What is another name for sensory neuron
afferent neuron
what is the function of the cerebellum
aids the motor cortex of the cerebrum in the integration of voluntary movement
what is sensory function is lost in a complete transverse lesion of the spinal cord
all forms of sensation below the lesion, pain, temperature and touch are lost one to two dematomes below the lesion
when does the neuro exam begin?
as soon as the patient walks into the office
What does the white matter contain
ascending and decending spinal tracts
what areas of the body need a stronger stimulus
back, buttocks, and heavily callused areas
what is the function of the afferent (sensory) fibers of the posterior root
carry impulses from sensory receptors of the body to the spinal cord then to the brain for interpretation
what is the function of the efferent (motor) fibers of the anterior root
carry impulses from the spinal cord to the muscles and glands of the body
how does motor maturation proceed
cephalocaudal direction
What does a positive romberg test indicate
cerebellar ataxia, vestibular disfunction or sensory loss
what does a delay in sitting and walking indicate
cerebellar disorder
What is another name for the corpus callosum
commissural fibers
What is the function of the descending spinal tracts
convey impulses from the brain to various muscle groups by inhibiting or exciting spinal activity role in the control of muscle tone, posture, and precise motor movements
What are the descending spinal tracts
corticospinal reticulospinal cestibulospinal
what does absence of the abdominal reflexes indicate
corticospinal tract lesion on the side of the absent reflex
location of insult in upper motor neuron disorder
damage above the brainstem affect opposite side of body Damage below the brainstem affect the same side of the body
location of insult in lower motor neuron disorders
damage affects muscle on same side of the body
Muscle tone in lower motor neuron disorders
decreased tone, flaccid
What is the area of body distribution supplied by spinal nerves
dermatome
What is graphestesia
drawing in the hand
What do the commissural fiber interconnect
each hemisphere
what is another name for a motor neuron
efferent neuron
What are the posterior (dorsal) column spinal tracts
fasciculus gracilis and fasciculus cuneatus
what are the classic signs of acute meningitis
fever, stiff neck, altered mental status need a lumbar puncture to diagnose
What do the dorsal spinal tracts carry?
fibers for the sensation of fine touch, two-point discrimination and proprioception
What do the spinothalamic tracts carry
fibers for the sensations of light and crude touch, pressure, temperature and pain
What is the kernig sign
flexing the leg at the knee and hip when the patient is supine, then attempting to straighten the leg
What is the cerebral cortex responsible for?
general movement visceral functions perception behavior integration of all these functions
where do you test position of joint
great toe of each foot and finger
What is the sensory function of CN VIII (acoustic)
hearing and equilibruim
What is the doll's eye maneuver
hold infant under axilla in upright position, head held steady facing you, rotate the infant in one direction then the other; infants eyes should turn in the direction of rotation and then the opposite direction when rotation stops
What is the function of the pituitary gland
hormonal control of growth, lactation, vasoconstriction and metabolism
Reflexes in upper motor neuron disorder
hyperactive babinski sign is positive
When do you test temperature and deep pressure
if superficial pain sensation is not intact
what is tactile agnosia
inability to recognize objects by touch
what is a positive jolt accentuation of headache
increased headache over baseline sign for diagnostic for meningitis
muscle tone in upper motor neuron disorder
increased, spastic, contractures
what is Decerebrate or extensor posturing associated with (arms are fully extended with forearms pronated, wrist and fingers are flexed and jaw is clenched. Feet are planter flexed)
injury to the brainstem
what is decorticate or flexor posturing associated with (upper arms held tightly to the sides of the body, elbows, wrists, and fingers are flexed and the feet are plantar flexed; fine tremors or stiffness)
injury to the corticospinal tracts above the brainstem
what are reflexes dependent on
intact afferent neurons functional synapses in the spinal cord intact efferent neurons functional neuromuscular junctions competent muscle fibers
What is the function of the thalamus
integrating center for perception of various sensations such as pain and temperature Relays sensory aspects of motor information between the basal ganglia and cerebellum
what is a positive brudzinski sign
involuntary flexion of the hips and knees when flexing the neck
What is the motor function of CN VI (abducens)
lateral eye movement
muscle atrophy in upper motor neuron disorder
little to none, but decreased strength
muscle atrophy in in lower motor neuron disorders
loss of muscle strength, muscle wasting
what motor neuron injury results in permanent paralysis
lower motor neuron
what does a positive brudzinski sign indicate
meningeal irritation
What is another name for protective sensation
microfilament
What does the corticobulbar tract innervate
motor functions of the cranial nerve
What does the gray matter contain
nerve cell bodies associated with sensory pathways and the autonomic nervous system
what are upper motor neurons
nerve cell bodies for the motor pathways that all begin and end within the central nervous system
What does the absence of a reflex indicate
neuropathy or lower motor neuron disorder
where is the primary vision center
occipital
what are some risk factors for falls in older adults
one or more falls in the past year Hx of stroke Neurologic conditions Disorder of gait or balance lower extremity weakness or sensory loss impaired vision use of assistive device
How can upper motor neurons affect movement
only through the lower motor neurons
motor effect in lower motor neuron disorders
paralysis of muscles
motor effect of upper motor neuron disorder
paralysis of voluntary movments
What lobe is used for proprioception
parietal lobe
What does tactile agnosia suggest
parietal lobe lesion
what reflexes are present at birth
patellar tendon
what is the brainstem and what is its function
pathway between the cerebral cortex and spinal cord controls many involuntary functions
what is a positive kernig sign
patient has pain in the lower back and resistance to straightening the leg at the knee - indicates meningeal irritation
What is jolt accentuation of headache
patient is asked to move his head horizontally at a rate of 2-3 rotation per second
discribe cerebellar gait (cerebellar ataxia)
patients feet are wide-based, staggering and lurching from side to side accompanied by swaying of the trunk
What does loss of positional sense of joint
peripheral neuropathy Symmetric loss indicated polyneuropathy
what does loss of sensation to touch during the microfilament test
peripheral neuropathy loss of protective pain sensation that alerts patients o skin breakdown and injury
besides the medulla oblongata where else is a portion of the respiratory center located
pons
What test are used to test the reticulospinal tracts
posture and romberg gait instinctual motor reactions
fasciculations in lower motor neuron disorders
present
when is the rooting reflex present and when does it disappear
present: at birth Disappear: 3-4 months of age
what are reflexes that are present at birth
primitive reflexes
What is the function of the hypothalamus
processing center of internal stimuli for autonomic nervous system Maintains temperature, metabolism, osmolarity, and feeding
What test are used to test the integrity of the spinocerebellar tract
proprioception
What is the parasympathetic function of CN III
pupillary constriction, change lens shape
What does the babinski sign indicate
pyramidal tract disease Dorsiflexion of the great toe expected finding in children younger than 2
What is the function of the midbrain
reflex center for eye and head movement Auditory relay pathway
What is the function of the medulla oblongata
respiratory, circulatory and vasomotor activities (house the respiratory center)
what stimulates a brisk contraction in a reflex
response is transmitted outward by efferent neuron in the anterior horn via the spinal nerve and peripheral nerve of the skeletal muscle
How do you test CN V in an infant
rooting reflex: touch corner of the infants mouth; infants mouth should turn in the direction of the stimuli Sucking reflex: place your finger in the infants mouth
what is the parasympathetic function of CN X
secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract
What is the parasympathetic function of CN VII
secretion of saliva and tears
What is the parasympathetic function of CN IX
secretion of salivary glands, carotid reflex
What is the sensory function of CN X (Vagus)
sensation behind ear and part of external ear canal
What is the sensory function of CN IX
sensation of nasopharynx, gag reflex, taste (posterior 1/3 of tongue)
sensation in lower motor neuron disorders
sensory loss follows dermatomes
What is the function of the epithalamus
sexual development and behavior
How do you test CN 2,3,4,6 in an infant
shine light into babies eyes - should quickly close eyes and dorsal flex the infants hand tracts an object with both eyes Doll's eye maneuver
What is extinction
simultaneously touching two areas on each side of the body
What does the corticospinal (pyramidal) tracts permit
skilled, delicate, and purposeful movemnts
What does the vestibulospinal tract cause
the extensor muscles of the body to suddenly contract when an individual starts to fall
Where does the corticospinal tracts extend from
the primary motor area into the spinal cord
What is circumduction
toe circled stiffly outward and forward
What is point location
touching an area on the patients skin and withdrawing and having the patient to point where you were touched
What is the function of lower motor neurons
transmit neural signals directly to the muscles to permit movement
What is the function of the pons
transmits information between the brainstem and the cerebellum while relaying motor information from the cerebral cortex to the contralateral cerebellar hemisphere
what is the motor function of CN XI (spinal accessory)
turn head, shrug shoulders, some actions for phonation
what does a hyperactive reflex indicate
upper motor neuron disorder
What does the ascending spinal tracts (spinothalamic, spinocerebellar) mediate
various sensations that are necessary to perform complex discrimination tasks
with what system does the cerebellum use sensory data for reflexive control of muscle tone, balance, and posture to produce steady and precise movements
vestibular system
What is the sensory function of CN II (optic)
visual acuity and visual fields
reflexes in in lower motor neuron disorders
weak or absent
What sensory loss distribution is there when two or more nerve roots are affected
zone of sensory loss surrounded by partial loss Loss of deep tendon reflexes
What functions as the extrapyramidal pathway and processing station between the cerebral motor cortex and the upper brainstem
Basal ganglia system
What are essential tremors
Bilateral, symmetric primarily seen in hands or outstretched arms, intention tremors Worse with stress or fatigue, MAY IMPROVE WITH ALCOHOL Progressive Autosomal dominant inheritance pattern
What spinal nerves are tested when doing the biceps reflex
C5-C6
What spinal nerves are tested when doing the brachioradial reflex
C5-C6
What spinal nerves are tested when doing the tricepts reflex
C6-C8
what CN are associated with the Diencephalon and Thalamus
CN I and II
what is done in the shorter screening examination for neurologic screening
CN II - XII (taste is usually not tested) Proprioception and Cerebellar function (rapid rhythmic alternating movements, accuracy of movements, balance, gait, heel-toe walking) Sensory function (superficial touch and pain, vibration and position senses of the great toe) Deep tendon reflex (All reflexes except plantar reflex and clonus)
What CN are associated with the midbrain
CN III and IV
What CN are associated with the medulla oblongata
CN IX to XII
What CN are associated with the pons
CN V to VIII
What does pass pointing indicate
Cerebellar disease
where is sensory information from the eyes, ears, touch receptors, and musculoskeletal
Cerebellum
What part of the brain houses the higher mental functions
Cerebral cortex
what lobe contains the motor cortex associated with voluntary skeletal movement and control of eye movements
Frontal lobe
Where should you have the patient identify various sensory stimuli
Hands, lower arms, abdomen, feet and lower leg
what is tandem gait
Heel-toe walking
What is the motor function of CN III (oculomotor)
Raise eyelids, most extraocular movements
Where do the descending corticospinal tracts decussate (cross to the contralateral side)
Medulla oblongata
What structures are included in the brainstem
Medulla oblongata Pons Midbrain Diencephalon
What lobe is responsible for processing sensory data as it is received?
Parietal lobe
what is Brown-Sequard syndrome
Partial spinal sensory syndrome Pain and temperature sensation are lost one or two dermatomes below the lesion on the opposite side of the body Proprioceptive loss and motor paralysis occur on the lesion side of the body
what is placing, when does it appear?
Placing: hold infant upright under the arms and touch dorsal side of the foot to the table or chair edge, observe flexion of the hips and knees and lifting of the foot as if stepping Appears: 4 days of age
What reflexes are associated with the pons
Pupillary action and eye movement
Testing CN VII (facial)
Symmetry of facial features (smile, frown, puffed cheeks, wrinkled forehead) Taste on anterior 2/3 of tongue
What spinal neves are tested when doing the lower abdomen reflex
T10-T12
What spinal nerves are tested when doing the cremasteric reflex
T12-L2
What spinal nerves are tested when doing the upper abdomen reflex
T8-T10
Testing CN IX (glossopharyngeal) and CN X (vagus)
Taste (CN IX) Gag reflex and swallowing Palate and uvula Guttural speech sounds
What is the sensory function of CN VII
Taste - anterior 2/3 of tongue
what lobe is responsible for perception and interpretation of sounds and determination of their source
Temporal lobe
what is nuchal rigidity
stiff neck associated with meningitis and intracranial hemorrhage
What test are used to test the integrity of the anterior spinothalamic tract
superficial touch deep pressure
beside meningitis and hemorrhage what else can cause nuchal rigitdy
swollen lymph nodes and superficial trauma
What does the parietal lobe assist in the interpretation of
tactile sensations visual, taste, smell and hearing sensations
how do you test the moro reflex, when does it appear and when does it disappear
test: allow truck to drop back to a 30 angle - should have symmetric abduction and extension of the arms Appear: birth disappear 6 months
what interconnections help the basal ganglia refine motor movements
thalamus, motor cortex, reticular formation, and spinal cord
Where do lower motor neurons originate from
the anterior horn of the spinal cord and extend to the peripheral nervous system
Where do upper motor neurons comprise
the descending pathways from the brain to the spinal cord Primary role is influencing, directing and modifying spinal reflex arcs and circuits