Neurological Sheet PDF Horus 2024

Neurological sheet I-HISTORY: Essential ( Motor, sensory, coordination, ADL, gait) Non- essential (Mental , speech,...

Neurological sheet I-HISTORY: Essential ( Motor, sensory, coordination, ADL, gait) Non- essential (Mental , speech, cranial nerves) 1. PERSONAL HISTORY: Name: To be familiar with the patient and for documentation. Age: As certain diseases are more common in certain ages e.g. 1st & 2nd decades: progressive muscular Dystrophy, 3rd & 4th decades: MS ,5th & 6th decades: Cerebrovascular strokes. 1  Sex: Motor neuron disease (M.N.D.) is common in males. Migraine is commoner in females. Ask about contraceptive pills as they may cause headache, depression. Marital status: For possible sterility, impotence or still-births (as in syphilis). Occupation: Persons in certain occupations are more susceptible to certain diseases e.g. disc prolapse is commoner in drivers while lead neuropathy is commoner in printers. Residence: e.g. migraine is commoner in urban areas while nutritional diseases are commoner in rural areas. Special habits: e.g. alcohol can lead to peripheral neuropathy, smoking can lead to cardiovascular diseases. Handedness: In right-handed people (over 90% of population), the dominant hemisphere is the left. 2. CHEIF COMPLAINT Put it in the patient's own words & list his complaints according to their importance. 3. PRESENT HISTORY "analysis of the complaint” It includes Onset, course, duration & Sequence of Events in Chronological order e.g.: The condition started since... (duration) by acute or gradual (onset) & regressive or progressive (course) of... Tell the story of the disease chronologically & in details. 4. PAST HISTORY: Trauma: Usually severe: in cases of paraplegia, quadriplegia, cauda lesions & coma. Mild trauma to the head might cause subdural haematoma in old alcoholics 2  Fever: specially near the onset of the disease. In cases of: Meningitis encephalitis & myelitis.  Diabetes Mellitus (polyuria, polydipsia, polyphagia & weight loss): In cases of peripheral neuropathy, cranial N. palsy & impotence. Hypertension (headache, tinnitus, epistaxis): In cases of hemiplegia, cerebral hemorrhage, encephalopathy. T.B. (haemoptysis, symptoms of toxaemia as night fever, night sweats, loss of weight and appetite & anti-TB drug intake), In cases of paraplegia (Potts). Syphilis (chancre, recurrent still-births, abortions), In cases of sensory ataxia (Tabes). Rheumatic fever & Rheumatic heart disease (arthritis, epistaxis...): In cases of hemiplegia & chorea. Otitis media (ear discharge): In cases of facial palsy, brain abscess & lateral sinus thrombosis. Previous drug intake Previous similar attacks: In cases of Multiple sclerosis & Transient ischemic attacks. 5. FAMILY HISTORY; ( e.g heredofamilial myopathy)Ask about: * Similar conditions in the family. *Consanguinity between parents II. EXAMINATION 1. GENERAL EXAMINATION; Before proceeding to the examination of the nervous system conduct a thorough general examination: General appearance, pulse, temperature, blood pressure, heart, chest & abdomen 3 2. NEUROLOGICAL EXAMINATION : A-NON-ESSENTIAL EXAMINATION: ❖ EXAMINATION OF THE MENTAL FUNCTION Report on: 1) State of consciousness: State Consciousnes Response to external = Or by using GLASGOW COMA SCALE: In this scale, the level of consciousness is evaluated, according to the patient's response to external stimuli, using 3 criteria:  eye opening verbal response motor response Each response is given a score. The total score is summed to give an overall value of the level of consciousness from 3-14. 4  Eye opening Verbal response Motor response Severe, GCS < 8–9 Moderate, GCS 8 or 9–12 Minor, GCS ≥ 13. 2) Orientation for time & place: Ask: "What time is it? What place is this?" 3) Memory: -It is the ability to retain & recall information & experiences. -It is mainly the function of the limbic system of the temporal lobe. -Test for: a. Immediate memory: Tell the patient a group of digits (numbers) & ask him to repeat them. Find out the no. of digits he can repeat correctly after one hearing (e.g. 5, 9, 7, 12...). Normally he should recall 7 digits. b. Recent memory: Ask the patient if he remembers some recent events e.g. "What did you have for breakfast yesterday?" & check his answers with his surrounding family. c. Remote memory: Ask the patient if he remembers some old events e.g. "What year was the Egyptian Revolution?" -Diminution of memory is termed AMNESIA which includes: a. Anterograde amnesia: loss of memory for immediate & recent events. b. Retrograde amnesia: loss of memory for remote events. 5 c. Transient global amnesia (circumscribed amnesia): sudden total loss of memory lasting for less than one day in a middle-aged healthy person, it may be precipitated by physical or emotional stress. It may be due to temporal lobe ischaemia & the condition is benign. 4) Mood & Affect: Mood is the patient's inner feelings while Affect is the outward expression of emotion. **Abnormalities in Mood and Affect include: ^Depression. ^Emotional lability. ^Euphoria. ^Apathy or indifference. +The commonest causes of abnormalities of Mood Affect are: - MS - Cerebral atherosclerosis - Pseudo-bulbar palsy. - Psychosis and Neurosis. 5) Intelligence: - It is usually assessed by special "Intelligence Quotient" (I.Q.) tests. For simplicity, the patient is considered of average intelligence when he and the doctor can understand each other. 6) Behavior: It is the overall manner in which the patient sits, dresses, talks and cooperates with the doctor. In case of a normal mentality report as follows: The patient is fully conscious, well oriented for time and place, with normal 6 memory and mood; he is cooperative and of average intelligence. N.B. : -Hallucination: is a sensation without an external stimulus. It might be visual, auditory, olfactory or tactile. -Illusion: is misinterpretation of an external stimulus. -Delusion: is a false fixed belief, not correctable by reasoning and not shared by others of the patient's same culture. -Delirium: is a transient state of acute confusion (disorientation) in which there is restlessness, hyperexcitability and where the patient suffers from illusion and hallucinations. It occurs in acute infective fevers, alcoholism (delirium tremens), certain drug intoxication (belladonna, amphetamine). ❖ EXAMINATION OF SPEECH Noticed during history taking and comment. >>The process of Speech involves into 2 Stages 1- Speech Formulation 2- Speech Articulation 1) Formulation Speech, whether spoken or written , is the product of 3 cooperating systems: a- Sensory System 1- Visual areas : areas 17 , 18 , 19 & 39 2- Auditory areas: areas 41 , 42 & 22 b- Motor System 7 1- Broca's area 44 2- Exner's area 45 c-Associative System : area 37 * Difficulty or inability of this stage will produce Aphasia 2) Articulation Articulation of Speech is the function of the following a- Pyramidal tracts b- Cranial nuclei concerned with articulation (5, 7, 10, 12) their nerves & muscles they Supply c- Cerebellum for coordination of muscles of speech d) Extrapyramidal system for speech to be expressive * Difficulty or inability of this stage will produce Dysarthria 8  Aphasia Definition: Difficulty or inability of the formulation of speech, in absence of lesions of the sense organs or of mental defects Types: 1) Sensory or perceptive aphasia: due to defect of perception: 1* Visual: a- Visual agnosia: lesion in areas (18 & 19), The patient sees but doesn't recognize b- Alexia: lesion in area 39, The patient sees but can't read because he doesn't understand letters & numbers. 2*Auditory Auditory agnosia: lesion in area 22, The patient hears but doesn't recognize sounds 2) Motor or executive aphasia: due to defect of execution 1* Verbal aphasia: lesion in Broca's area, Although the patient can understand visual & Auditory stimuli, yet he can't express in spoken words 2* Agraphia: lesion in Exner's area, Although the patient can understand visual & Auditory stimuli as well as letters & numbers, yet he can't express his ideas in writing 3) Jargons aphasia: due to defect of association lesion in associated area (37), The patient can speak ,but meaningless & have no relation to each other (Word Salad) 9 Dysarthria Definition: Difficulty in articulation of speech, though the formulation process is normal Types: 1) Slurred Speech the production of consonants especially labial (e.g. B,M) & Dental(e.g. D,T,C) due to a- Bilateral pyramidal tract lesion (lesions of Cortico-bulbar fibers) as in Pseudobulbar palsy b- lesions involving L.M.N of Cranial nerves concerned with Speech e.g.: -Nuclear: True Bulbar Palsy -Nerve: Facial nerve palsy -Neuromuscular: myasthenia - Muscles: Facio-Scapula-humeral Myopathy -Staccato Speech - Speech is explosive with separation of syllables, It occurs in Cerebellar lesions (Ataxia) - Scanning Speech (Slurred Staccato) also seen in cerebellar lesions - Monotonous Speech  Speech is expressionless & Monotonous  It occurs in Extrapyramidal Lesions as in Parkinsonism 10 ❖ EXAMINATION OF THE CRANIAL NERVES Cranial Nerve Type Function Lesion symptoms (Cr.) I Olfactory Sensory Smell Anosmia, Parosmia. II Optic Sensory Vision Decrease acuity of vision, Field defects III, Ocular Nerves Motor, Eye Diplopia IV, (Occulomotor, Autonomic(Cr. movement VI Trochlear & 3) Abducent nerves). V Trigeminal Sensory, Face Difficult mastication sensation, (motor), Abnormal face Motor Mastication sensation (sensory) VII Facial Sensory, Facial Accumulation of food Motor, expression, behind cheek Autonomic Taste VIII Cochleo— Sensory Hearing, Decrease acuity of hearing, vestibuar Balance Tinnitus (cochlear). Vertigo (vestibular). IX, Glossopharyngeal Sensory, Taste, Gag , Motor, Reflex Dysphagia, Dysarthria, Autonomic Dysphonia (hoarseness of X Vagus Sensory, Gag Reflex, voice)& Nasal Motor, Parasympathat regurgitation. Autonomic Ic 11 XI Accessory Motor e.g. Shoulder shrug & SCM XII Hypoglossal Motor Tongue ms. 1. OLFACTORY NERVE: Examine for the sense of smell using a familiar non irritant substance (e.g. ground coffee). Each nostril is tested separately with the patient’s eyes closed. 2. OPTIC NERVE: Examine for: a) Acuity of Vision: - Using Snellen’s chart or finger counting from a distance of 6 meters. - In case of failure to count the fingers at this distance repeat at a shorter distance - If at a distance of 30 cm the patient still fails to count the fingers test for vision using hand movements. - If the patient does not see, test for light perception using the torch. Snellen Chart For Acuity Testing 12 - If there is no perception, then the patient is blind. Each eye should be examined separately − Field of Vision: use confrontation test. - Sit in front of the patient at a distance of 60-100 cm. Keep your - eyes at the level of the patient’s eyes. - Let the patient close one eye and you close the opposite eye. Insist that the patient looks into your eye and nowhere else. − Examine for the field of vision of the patient’s open eye by bringing your finger slowly from the periphery inwards. Test for the whole field by bringing your finger from above, below, left and right. 13 N.B.: The patient’s field of vision is normal when he notices the movement of your finger at the periphery of the field at the same time that you do. Then test for the other eye in the same manner. 2. Colour of vision for colour blindness. 3,4,6 OCULAR NERVES: Examine for: a) Ptosis which may be due to: Oculomotor nerve paralysis where the ptosis is complete and there is associated mydriasis and divergent squint. Sympathetic paralysis (Homer's syndrome) where the ptosis is partial and there is associated miosis, enophthalmos and anhydrosis. Third N. Sympathetic Degree Complete Partial pupil Dilated and fixed (Mydriatic) Small (Miotic) Association Divergent squint Enophthalmos, anhydrosis To determine whether the ptosis is partial or complete, the action of the frontalis muscle should be abolished. Press a finger over the superior orbital margin, then ask the patient 14 to open his eye: if he can, the ptosis is partial while if he cannot, the ptosis is complete. N.B: Myasthenia gravis is the commonest cause of ptosis; however, the ptosis is usually bilateral, the pupil is normal and there are other myasthenic manifestations. b) Pupils: They should be equal, round and reactive to light, and accommodation. ⮚ The light reflex: If you expose one eye to light, while shading the other, normally there is constriction of the pupil of the exposed eye (direct reaction) as well as of the other eye (consensual reaction),Both pupil constriction. The accommodation (near) reflex: When the patient is asked to follow your finger with both his eyes from a far to a near point, the following triad normally occurs: a) Convergence. b) Miosis. c) Accommodation. ⮚ Cilia-spinal reflex: Pinching the skin on one side of the neck results in dilatation of the ipsilateral pupil. This reflex is absent in cervical sympathetic lesions (Homer’s syndrome). c) Extra ocular movements: 15 − Test for the abducent nerve (supplying the lateral rectus muscle) by asking the patient to look laterally. − Test for the trochlear nerve (supplying the superior oblique muscle) by asking the patient to look inwards & downwards. − Test for the oculomotor nerve (supplying the superior, medial and inferior rectus and the inferior oblique muscles) by asking the patient to look in all other directions. ❖ These tests are done for each eye alone: If their results are normal this indicates that the ocular nerves are intact. ❖. Then repeat the same tests on both eyes simultaneously for conjugate movement; if normal then the centres for conjugate movements present in the brain stem, and in the frontal and occipital lobe cortex are intact. d) Nystagmus: Ask the patient to look at your finger placed laterally, upwards then downwards at some distance from his eyes. If nystagmus is present comment: − If it is spontaneous or on fixation. − If it has rapid and slow phases; the direction of the nystagmus is that of the rapid phase. 16  5. TRIGEMINAL NERVE: a) Motor Part: 1. Test for the power of thc muscles of mastication: − Temporalis: Ask the patient to clench his jaws while you put your hands over the temples to palpate the muscles. − Masseters: The patient clenches his jaws while you palpate the contracted muscle between four fingers over its posterior border and the thumb over its anterior border. − Pterygoids: Ask the patient to open his mouth while you fix his head. Unilateral paralysis: Deviation of the jaw to the diseased side. Bilateral paralysis: No deviation, but inability to open the mouth against resistance. 2. Jaw reflex: (afferent Cr. 5 efferent Cr. 5) While the mouth is slightly open, place your index finger on the lower jaw, and then tap it. − Normally the reflex is absent or minimal. − An exaggerated reflex, shown by closure of the jaws, denotes a bilateral U.M.N.L. above the motor nucleus of the 5th cranial nerve i.e., above the pons as in pseudobulbar palsy. 17 b) Sensory part 1. Test for sensations including pain (using a pin) and touch (using a piece of cotton) over the face and compare between: a) Both sides of the face. b) The ophthalmic, maxillary and mandibular division on each side. c) The inner and outer parts of the face. 2. Corneal & Conjunctival reflexes (afferent: Cr.5; efferent Cr 7 bilaterally): Ask the patient to look upwards and inwards. Touch the corneo-conjunctival junction from the lateral side (to avoid direct photic stimulation) using a thin piece of cotton. * Normally stimulation of one eye results in blinking of both eyes. * Absence of blinking on one side denotes facial paralysis of that side. * Absence of blinking on both sides denotes: −Sensory trigeminal affection of the stimulated side. −Bilateral facial paralysis. −Organic type of coma. 18 7. FACIAL NERVE a) Motor Part: Examine for the muscles of expression of the face: 1. Upperface (Frontalis and Orbicularis oculi): - Test for raising of the eyebrows. 2. Lower face (Orbicularis oris, Buccinator and Retractor anguli): Look for absent nasolabal fold and dropping of the angle of the mouth, present in facial paralysis. Test for whistling, blowing the cheeks and showing the teeth. 19 Differentiation between U.M.N. and L.M.N. facial paralysis U.M.N. L.M.N. 1. Paralysis of the muscles of lower half of Paralysis of the muscles of the upper face on the opposite side of the lesion and lower halves of the face of the same side of the lesion. 2. Paralysis involves the voluntary Paralysis affects voluntary, emotional movement but spares the emotional and and associative movements, associative movements. 3. Paralysis is associated with Paralysis is associated with hypotonia hypertonia and hyperreflexia. and hyporeflexia. 4. There is associated hemiplegia on the If there is hemiplegia, it is on the same side of the paralysis. opposite side of the paralysis (crossed hemiplegia). 20 b) Sensory Part: (Chordatympani) Examine for the taste sensation over the anterior two-thirds of the tongue by drying the patient’s tongue and then applying a drop of sweet, bitter or salty solution on its tip. See if the patient can properly recognise the taste. 21 C) Glabellar Reflex: In the normal adult, tapping the glabella (root of the nose) results in blinking (contraction of Orbicularis oculi muscles); this blinking stops after 2 3 taps (due to habituation). In Parkinsonism the blinking continues with the taps as long as the stimulus is applied. 8. COCHLEOVESTIBULAR NERVE: a) Cochlear Part: Test for the acuity of hearing using: 1. The Watch test: If there is diminution of the patient’s hearing do the following: 2. Rinne’s test: Using the vibrating tuning fork, compare air conduction (fork placed in front of patient’s ear) with hone conduction (fork placed on patient’s mastoid process). 3. Weber’s test: Place the tuning fork in the middle of the forehead. 22  Watch test Rinne’s test Weber’s test Normal The acuity of the patient’s Air conduction is The vibrations hearing is similar to that better than bone are heard in the of the examiner. conduction. middle of the forehead. Nerve The patient’s hearing is Both air and bone The vibrations deafness less than that of the conductions are arediminished. heard in the examiner’s. normal ear. Conductiv e The patient’s hearing is Bone conduction isThe vibrations deafness less than that of the better than air are heard in the examiner’s. conduction. affected ear. b) Vestibular Part: Caloric test, rotating chair tests and electronystagmography (E.N.G.). 9. GLOSSOPHARYNGEAL&10. VAGUS NERVES: 1. Open the patient’s mouth and inspect the uvula. Normally it is central. If it is deviated, it is towards the healthy side. 23  2. 2. Palatal Reflex (afferent Cr 5, efferent Cr 10). Normally stimulation of the soft palate leads to its elevation. 3. Pharyngeal Reflex (Gag Reflex) (afferent Cr 9, efferent Cr 10): Use 2 tongue depressors, one to depress the tongue & the other to stimulate the pharynx, This results in local contraction& Gag reflex N.B: −Palatal and pharyngeal reflexes are lost in true bulbar palsy and exaggerated in pseudobulbar palsy. −Isolated lesions of the glossopharyngeal nerve are unknown; it is usually damaged with the vagus and accessory nerves at the jugular foramen. 11. ACCESORY NERVE: The spinal part is tested by: −Ask the patient to raise his shoulders against resistance (Trapezius). −Ask the patient to turn his chin against resistance (Sternocleidomastoid). 24  Trapezius Sternocleidomastoid (SCM) 12. HYPOGLIOSSAL NERVE: a. Inspect the tongue for: 1. Deviation: when it is deviated, it is towards the diseased Side (LMNL), opposite (UMNL). 2. Wasting which indicates a L.M.N.L. 3. Fasciculations indicate a nuclear lesion as in M.NID. & syringobulbia. 4. Abnormal movements as in Chorea. 5. Dimpling of the tongue on tapping it, in cases of myotonia. 6. Inspection may also reveal: − Glazed tongue as in deficiency diseases. − Fissuredtongue as in mongolism. − Ulcers as in Behcet’s disease, Herpes simplex. b. Test for the power of the muscles of the tongue by asking the patient to push the inner side of his cheek with tip of his tongue. 25 SOME REFLEXES OF CRANIAL NERVES Reflex afferent Efferent Application Light Reflex 2 3 Accommodation Reflex 2 3 Jaw Reflex 5 5 Corneal Reflex 5 7 Palatal Reflex 5 10 Glabellar Reflex 7 7 Vestibulo_ocular Reflex 8 3, 4, 6 Pharyngeal (Gag) Reflex 9 10 26  B-ESSENTIAL EXAMINATION EXAMINATION OF THE SENSORY system * Sensory system components: Receptors: extroreceptors (of skin). proprioceptors (of joint and muscles). 27 *Dermatomes for UL ,LL: 28 EXAMINATION OF THE SENSORY SYSTEM Superficial Deep Cortical sensation joint sense tactile pain (movment and localization position) 2 point temprature discrimination sense of touch vibration stereognosis ms. sense graphesethia nerve sense perceptual rivelary romberg test texture sense barognosis Deep sensations Fine touch /cortical sensation 29 There are certain considerations for sensory exams:  Properly expose the area to be examined.  Accuracy of data from examination of sensory function relies on the patient’s ability to respond to application of multiple somatosensory stimuli.(patient’s ability to concentrate on, and respond to, the battery of sensory test items).  Explain to the patient what you are going to do and how they should respond to your question (remember sensory examination require good cooperation and communication with the subject).  Apply the stimulus to a possible normal site so that the patient is aware of what the normal sensation feels like.  When testing a sensation compare two sides and ask the patient whether the sensations are equal on both sides or not.  Start from distal to proximal  To accurately map the area of abnormal sensations, examine randomly with unpredictable manner and changed timing till area of abnormality is detected then start a more specific examination. This will avoid consistent pattern of application which might provide the patient with “clues” to the correct response.  With each sensory test assign the following data: - The modality used -The quantity of involvement or body areas affected(pattern of involvement (e.g circumferential as in diabetic polyneuropathy glove and stoke or dermatomal in radicular involvement ) -The quality/severity of the impairment (e.g absent/anesthesia diminished/hypothesis ,impaired/ parathesis,….) -The impact of sensory loss on function ( i.e activity limitation, disability , upnormal gait, etc).  Care must be taken about skin condition, scar tissue or callused areas are generally 30  less sensitive and will demonstrate diminished response to sensory stimuli.  Use sterilized tools to avoid contamination.  When using toothpicks or pricks, care should be taken to stabilize the testing tool in proper stabilized position between index and thumb in 30° to assure equal application at all stimulation sites. Preparation:  Environment.  Patient.  Tools/Equipment The environment: Should be well lighted, quite, well ventilated and comfortable. The patient: Patient should be an active participant in examination so p.t. should explain the tests to the patient clearly and tell him what the exact answer needed for each test. The equipment: Should prepare all equipment that will be used in sensory exam. 1- SUPERFICIAL SENSATIONS *They are usually examined first, as they consist of more primitive responses. They include pain, temperature , touch and pressure. 31  Touch For: determines perception of tactile touch input. Equipment: A camel-hair brush, piece of cotton (ball or swab), or tissue is used. 32  Test: the area to be tested is lightly touched or stroked. Pt. response: he patient is asked to indicate when he or she recognizes that a stimulus has been applied by responding “yes” or “now.” Note: A quantitative score for pain perception, temperature, and light touch awareness can be obtained by dividing the number of correct responses by the number of stimuli applied (normal response would be 100%). Temperature For: determining the ability to distinguish between warm and cool stimuli. Equipment: Two test tubes with stoppers are required for this examination; one should be filled with warm water and the other with crushed ice. Ideal temperatures for cold are between (5°C) and (10°C) and for warmth, between (40°C) and (45°C). Caution should be exercised to remain within these ranges, because exceeding these temperatures may elicit a pain response and consequently inaccurate test results. 33 Temperature 34  +Dermatome chart: ✔ After application of the stimulus ask the patients “do you feel?” and whether or not the feeling is equal at all application sites. *Patterns of sensory loss : 35 36 2. DEEP SENSATIONS: they include: 37 Clinical tip: First show the patient, with his eyes open, the position of his big toe (dorsi-flexed, plantar- flexed); then with his eyes closed, move the big toe and ask him if he feels it moving and if so which direction. The big toe should be caught gently, from the sides to avoid tactile stimulation. 38 - Move the joint in a limited range to avoid stretching the skin hence the tactile input. -examine from distal to proximal. * Hit the fork briskly against the open palm of the examiner (for the sound to be heard by the patient), care must be taken not to touch the tines ( head of the fork) as this will stop the vibration. * Place the base of the vibrating fork over the bony prominences: medial malleolus - ant. tibial tubercle - ant. superior iliac spine (A.S.I.S.) – elbow -clavicle – sternum. -Ask the patient if he feels the fork's vibrations or not & if they are felt equally on all sites. -Apply from distal to proximal. -If vibration sense is diminished or lost over med. malleolus, check A.S.I.S.; if lost, it suggests posterior column lesion; if intact, it suggests peripheral neuropathy lesion 39 * Muscle sense: by pinching the calf. The muscle sense may be normal where the patient feels a disagreeable sensation. It may be lost (Abadie's sign) as in neurosyphilis or exaggerated (tender calf) as in myositis. * Nerve sense: by pressing and rolling the superficial ulnar nerve and the lateral popliteal nerve against the bones. Normally, it results in an electric- like sensation. * Romberg's test: while surrounding the patient and ensuring his safety ask the patient to stand with the heels together , 1st with his eyes open, then with his eyes closed. Note any swaying or loss of balance. If present: With eyes open or closed = cerebellar ataxia. Only with closed eyes = sensory ataxia. 3-CORTICAL SENSATIONS: >>They are only examined when the superficial & deep sensations are intact and when UMNL is expected. * Tactile localization/Topognosis: The ability to localize touch sensation. ask the patient to close his eyes; then touch his finger by cotton swap or fingertip & ask him to localize the site of the touch, note that the patient here is required to accurately describe the site of stimulation or to localize with the other hand not just to perceive the touch. 40 * Two-points discrimination: The ability to perceive two points applied to the skin simultaneously. Its also a measure of the smallest distance between two stimuli applied simultaneously and with equal pressure, that can be perceived as two distinct stimuli. the patient's eyes closed, deliver 2 simultaneous pricks (or the two point discriminator tool or aesthesiometer), e.g. on the finger (5 mm apart in UL) or on the legs (5 cm apart in LL). The patient is asked to identify the perception “one” or “two” stimuli.Normally the 2 pricks are felt distinct from each other. * Stereognosis: The ability to recognize the form of objects by touch. To be tested ,use a variety of small , easily obtainable and culturally familiar of different sizes and shapes, with patient eyes closed, the patient is asked to recognize an object placed in his hand e.g key, pen ,coin ……. The patient is asked to express verbally about the object, if there is a speech impairment a group of images can be used. *Graphesthesia: The ability to recognize letters and numbers or designs written on the skin. with his eyes closed, the patient is asked to recognize a series familiar numbers or letters drawn over his palm using a fingertip or eraser end of pencil. Between each separate drawing the palm should be gently wiped to clearly indicate a change of figures to the patient. Graphesthesia can compensate for stereognosis test in patients with 41 paralyzed hand. * Perceptual rivalry: The ability to perceive simultaneous ouch stimuli ,normally if you deliver 2 simultaneous pin pricks at 2 corresponding sites of the body e.g the two arms, both pricks are felt; in cortical sensory loss, only the prick on the healthy side is felt. Use two reshaped paper clips or two pinpricks, then simultaneously and with equal pressure touch: identical locations at opposite side of the body, distally and proximally. The patient is asked about the number of touch stimuli felt. * Barognosis: The ability to recognize different weights. Use small objects or bottles with same size and shape but of graduated weight, apply them serially on the same hand one at atime, or place different weights on both hands simultaneously, then the patient is asked to identify the comparative weights of objects “heavier” or “lighter”. *Recognition of texture: The ability to differentiate among various textures. Use varying textures including cotton, wool, silk…..etc. After the patient manipulate the sample texture, he is asked to identify them by name (silk, cotton…) or by texture(rough, smooth…) Motor Assessment 1. Observation 2. Muscle power / test 3. Muscle tone 4. Reflexes (superficial –deep). 5. ROM. 42 1. Observation:  Patient should be in supine position and be bare skin as much as possible. Therapist stands at patient head or at his feet. A) State of muscle: normal or wasting or hypertrophied.  If there is wasting, describe it in details:  Which part is affected?  Unilateral or bilateral?  If bilateral, symmetrical or asymmetrical  Distal more than proximal or vice versa.  If there is hypertrophy, distinguish if true hypertrophy or pseudo hypertrophy.  True hypertrophy: associated with increase MS power by MS test e.g. athletes.  Pseudo hypertrophy: associated with decrease MS power by MS test e.g. myopathy. B) Fasciculation or fibrillation (indication of irritative A.H.C lesion)  Fibrillation is a spontaneous contraction of single muscle fibers. It is hardly visible except in tongue.  Fasciculation is a spontaneous contraction of group of muscle fibers. It is visible and palpable.  Fasciculation may be physiological or pathological 43  C) Involuntary movements as chorea, athetosis or tremors. If they are present , describe them in details:  Static or dynamic  Rhythmic or not rhythmic.  What increase or decrease them?  Tremors:  Static tremors: appear at rest and disappear during movement e.g. Parkinsonism.  Intention kinetic tremors: appear during movement and disappear at rest. It increases when reach the target e.g. ataxia.  Chorea: involuntary static, irregular sudden jerky movements affecting more the proximal parts (trunk and head).  Athetosis: involuntary static, irregular slow snake- like movements affecting more extremities (especially hands & fingers) and head on each side. D) Skeletal deformities (as pes cavus, hallus valgus or varum) or abnormal positions (as droop foot, claw hand). E) Trophic changes (as brittle nails, loss of hair, ulcers). 2. Muscle power assessment:  Three types of Ms test:  Individual ms test: in case of 44  o LMNL, peripheral nerve injury, polyneuropathy, certain affected myotome.  Group ms test: in case of o UMNL with mild spasticity, moderate case of myopathy  Functional MS test: in case of o UMNL with moderate spasticity, severe myopathy, facial ms. N.B – no individual MS test for UMNL -severe spasticity not indicated for P.T. -Clinical part demonstrated before and should be revised. Myotome of UL & LL: 45 Grades of MMT: 0: No muscular contraction. 1: Visible muscle contraction, but no movement at joint. 2: Movement at the joint, but not against gravity. 3: Movement against gravity_ but not against resistance. 4: Movement against some resistance, but (full). 5: Movement against full resistance; normal strength 3. Muscle tone: -Def: is the resistance to passive stretch or passive movement. -It may be normal, hypertonia or hypotonia. -Hypotonia (Flaccidity) is a decrease in the resistance to passive movement. It is due to L.M.N.L, cerebellar lesion, post column lesion, rheumatic chorea or shock stage of U.M.N.L. - Hypertonia is an increase in the resistance to passive movement. Hypertonia appears in the form of spasticity or rigidity. It is due to pyramidal or extrapyramidal lesions. Spasticity Rigidity Site of lesion Pyramidal tract lesion Extra pyramidal tract lesion Character Clasp knife phenomena: Lead pipe or cog wheel initial resistance to movement  Lead pipe: steady increase is suddenly overcome. of resistance through the ROM.  Cog wheel: resistance is interrupted by tremors. 46  Distribution -Affects more the antigravity -Affects both MS group but MS (flexors of UL and flexors more than extensors. extensor of LL). -proximal more than distal. -Distal more than proximal. Depends on Speed dependent Length dependent Reflexes Hyper reflexia Hypo reflexia Methods to assess the muscle tone:  Shaking method.  Drop arm test.  Speed test  Gower's method  EMG biofeedback  Passive movement  Shaking methods  Done for distal joints only (wrist and ankle)  Therapist holds the limb by both hands just above the joint (wrist or ankle) and shakes the limb.  Hypertonia: decrease the resistance for shaking  Normal tone: normal resistance for shaking 47   Hypertonia: increase the resistance for shaking.  Disadvantages; may cause subluxation especially in hypotonic cases.  Drop arm test: - From sitting or standing position: therapist passively holds the patient arm in 90 degree shoulder flexion or abduction and then suddenly release his arm - Normally: initial sudden drop and then catch. - In Hypotonia: arm suddenly drops. - In Hypertonia; the arm doesn't descend or gradual slow lowering.  Speed test: (will be demonstrated in details in hemiplegic patients).  Gower's method: - Done for myopathy (shoulder joint). - Therapist grasps the patient from under axilla and elevates both shoulders. - Normally: shoulders elevated upto level of ear. - In hypotonia: shoulders elevated more than normal and head drops between shoulders.  EMG biofeedback: is objective method. -H/M ratio is measured. Normally ratio is around 1. In Spasticity, ratio