How do you assess tendon/ stretch reflexes?
- - stretch tendon with a reflex hammer
- - compare left and right arms and legs
- - limb should be in a relaxed and symmetric position
- - if can get a reflex get pt to clench opp fist
What nerve root does biceps tendon test?
What nerve root does triceps reflex test?
What nerve root does patella tendon test?
What nerve root does achilles tendon test?
- Hyporelfexia 0- absent 1+ trace
- 2+ Normal 3+ Brisk
- Hyperreflexia 4+ fatigue clonus
- 5 + sustained clonus
What are increased relexes associated with?
- UMN Lesions
What is clonus?
- a reflex that initiates alternate involuntary mm contaction and relaxation in rapid succession resulting from sudden stretching of a mm
What is clonus a sign of?
- UMN disease
How can clonus be tested?
- - most common in ankles
- - tested by rapidly DF the foot
- it can be tested in the knees by rapidly pushing the patella towards the toes
What are some tests of primitive reflexes?
- - babinski/ plantar
- - glabellar tap
What are primitive reflexes?
- - exhibited by normal infants in response to particular stimuli
- - these reflexes disappear or are inibited by the frontal lobes as a child movemes through normal child development (sucking etc)
- - if present in adults they are indicative of UMN lesions
What is the babinski/ plantar response?
- - reflex occurs in response to cutaneous stim
- - scrap the sole of the foot- move up lateral boarder of foot
- - normal response is flexion of the toes
- - positive babinski sign- hyperextension of the great toe and fanning of other toes
- - it may be able to elicit a response if these is severe weakness
What is and perform glabellar tap?
- - repetitive tapping on forehead
- - subjects blink in response to the first several taps
- - if the blinking persists it is abnormal
- - often associated with parkinsons disease
- - the afferent sensory signals are transmitted by the trigeminal nerve and the efferent signals come back to orbicularis oculi mm via the facial nerve, which in turn reflexly contracts causing blinking
How do you assess spasticity?
How is tone assessed?
- modified ashworth scale
How do you test vision?
- - vision is often affected by neurological conditions
- - need to know if there is a pre- existing sight deficit- do pts need glasses- diabetics, glaucoma, cataract
- - acuity: snellen charts, can you see my finger etc
- - eye movement- pursuit/ tracking, saccades, convergence
- - field loss
What are the assessment of vision?
- - smooth pursuit
- - convergence/ divergence
- - saccades
Perfrom the smooth pursuit eye movement assessment:?
- - ask the pt to follow a target with their eyes (head fixed) through the 6 principles positions of gaze
- - hold a pen 40cm away from the pts face and slowly move across the fields of vision
- - observe for: eye follow; effect of crossing midline; speed of movement; any nystagmus.
- There should be no lagging or jerking
Perfrom theconvergence/ divergence eye movement assessment:?
- - hod object approx 1 metre away
- - ask pt to focus on object
- - slowly, bring object (in midline) close to face
- - observe eye and pupil reactions
- - move object away slowly and again observe reactions
Perfrom the saccades eye movement assessment:?
- - hold your hands 1 m apart and ask pt to tell you look at the wriggling finger without moving head
- - wriggle your fingers on one hand and work out which hand is wiggling
- - eyes should be able to quickly, smoothlu and accurately jump from target to target.
- Note diplopia (test for specific cranial nerves 3, 4, 6)
How do you assess visual field loss?
- a) stand in front of pt and ask the fix gaze on your nose. Bring your fingers from side of head slowly into field of vision. Do one side at a time. Observe any loss quadrantanopia - bring stimuli from high up and thrn low down.
- b) if two people available, one stand in front and observe response and fix gaze while other provides stimuli
- c) if no hemianopia test visual inattention by stimuli to one field and then both together (will also use objective tests such as line cancellation and bisection tasks as per lab 4:1)
Perform an assessment of cranial nerve
Perform the olfactory cranial nerve assessment
- - function- smell
- - test by block one nostril and test with various substances; eg ammonia, cloves, coffee. The detection of smell is more important
Perform the assessment of optic nerve
- - function- special sense: visual acuity and visual fields
- - cover one eye
- Acuity: can pt see number of fingers held up? Use eye charts
- Fields: as per assessment of vision: move pen from outside of field of vision into view and ask pt when they can see.
What causes total blindness in one eye?
lesion before optic chiasm
What causes bitemporal hemianopia (loss of vision of outside of both right and left eyes)?
- leison of optic chiasm
What can cause contralateral homonymous hemianopia (visual loss of same side both eyes)?
lesion of optic tract
Types of visual loss
Test oculotor, trochlear and abducence nerves
- - these nerves control ocular movements by controlling external ocular mm.
- - they work in a coordinated fashion to allow eyes focus on images
- CN3 is also visceral motor (parasympathetic) to pupil lens
- - pursuit
- - convergence
- - saccades
- - pupillary reaction by shinning light in the eye
What causes diplopia?
- if Cn 3, 4 and 6 dont work properly
What are some occulomotor nerve deficits?
- - rectii and levator palpebrae
- - inability to look medially for conjugate gaze
- - lack of convergence for near vision
- - deviation of the eyes laterally
- - partial drooping of the eyelid (ptosis)
- - dilated pupil
- - lack of accommodation for near vision
How do you no if there is a trochlear nerve deficit?
- - superior oblique
- - cannot look down or down to the side without diplopia
How do you no if there is an abduecens nerve deficit?
- - lateral rectus
- - medial strabismus (eyes not aligned properly)
- - inability to look laterally
What are oculomoter dysfunction?
- - mm problems
- - smooth movements
- - tracking problems
- - lose place when reading
What are visual field loss
- - loss of vision in same field in both eyes
- - there are 4 quadrants
What are visuo-perceptual disorders?
- - inability to recognise familiar places
- - objects may appear larger/ smaller then they really are
What are the 6 mm of the eye?
- - superior rectus
- - inferior " "
- - medial " "
- - lateral " "
- - superior oblique
- - inferior " "
What tests do you include in screening tests for vision?
- - acutiy- pt see well pg 40
- -pursuit/ tracking- verticle, horizontal- want smooth movt of eyes
- - saccades- jerking of eyes- shiver, jumpnot smooth
- - convergence- ask pt look @ object you move it and see if they can focus on it
- - field deficits- lok @ nose and wigle finger and tell me when you can see it- do all quadrant, one eye at a time
What can a physio do to help with vision problems?
- - compensation training- with OT
- - mm exercise- strength mm for eye and ROM
- - extra consdierations for safety- ensure good light
- - referral for complete assessment/ aids/ patches/ prisms
Test the trigeminal nerve
- - function- sensory to head and motor supply of mastication (temporalis, masseter, pterygoids)
- 1- sensation of forehead with cottonwool, pain and temp (test and explain on pts chest)
- 2- corneal light refles- with tissue in corner of eye to assess blink (sensory limb)
- 3- motor- opening and closing mouth; close against resistance;- watch for deviation to unaffected side of face when opening mouth, clench teeth)
What are some deficits of the trigeminal nerve?
- - ipsilateral anaesthesia (test light touch) of skin of ant scalp and feace
- - weakness in chewing
- - more sensitivity to sounds (because of paralysis of tensor tympani mm)
- - sometimes, sharp, agonising pain due to cutaneous distribution of one of branches (trigeminal neuralgia)
How do you test the facial nerves?
- - mixed nerve- motor to mm of facial expression, visceral motor to salivary galnds, tears galnds, nao mucosa, special sense of ant 2/3 of the tounge
- - test with sugar on the tip tounge
- - raise eyebrows, clench eyes, puff checks, chow teeth- offer resistance
What are some deficits of the facial nerve?
- - differs if it is an UMNL or LMNL
- - paralysis of ipsilateral facial mm (LMNL)
- - inability to close eyelid (LMNL)
- - loss of motor limb corneal reflex
- - increased sensitivity to sound because of paralysis of stapedium mm in middle ear
- - loss of taste on ipsilateral ant 2/3 of tounge
What are the test for the vestibulocochlear V8 nerve?
- - function- hearing and balance
- - hearing- distract one ear by scrunching hair near the ear and whisper number in the other ear
- - Vestibular system- rot fo body gives nystagmus and change of body tone
What are deficits of the vestibularcochlear nerve?
- - deafness in ipsilateral ear
- - ringing in ipsilateral ear (tinnitus)
- - nystagmus and vertigo which may lead to nausea, vom and distrubances of gait
What is the nerve test for the glossopharyngeal nerve?
- - function- special sense of taste psterior 1/3 of tounge, sensory of pharynx, carotid sinus, visceral motor to salivary glands, motor to mm of pharynx
- - pt says argh/ use spatual... look at uvula
- - test taste with bitter oil of cloves
What are deficits of the glossopharyngeal nerve?
- - lss of sensation and taste on posterior third of tounge and pharynx (ipsilateral)
- - unilateral loss of gag reflex with deviation of uvula to uninvolved side of body
- - difficulty in swallowing (dysphagia)
- - disturbance in carotid sinus reflex may produce a tachycardia
- - increase salvation
How do you test the vagus nerve?
- function- primary visceral motor (parasympathetic) nerve of thorax and gut and organs, somatic motor mms of pharynx and larynx, sensory to dura and tympanic membrane
- - say west essex street- cough
What are dome deficits of the vagus nerve?
- - diffculty swallowing; decreased gag (motor component)
- - deviation of uvula to uninvolved side during phonation, voice may become hoarse and reduce to a whisper (tested by speech pathologist)
- - flaccid soft palate
- - transient tachycardia
How do you test spinal accessory nerve?
- Function- motor only- traps, SCM and mm of larynx and phayrnx (with vagus)
- - shrug and rotate head against resistance and rot jead against resistance
What are the deficits of spinal accessory?
- - weakness in contralateral head rot, weakness of ipsilateral shoulder elevation (shrugging)
- - some weaknedd of neck ext, flex and lat rot
- - possinle ipsilateral shoulder sag
What iare the tests for the hypoglossal nerve?
function- motor only to mm of tounge
- - sticj out tounge, run tounge around lips, wriggle tounge, push tounge into cheek- provide resistance with spatula
What are some deficits of the hypoglossal nerve?
- - presents differs according to whether UMNL or LMNL
- - LMNL- ipsilateral tounge paralysis, tounge deviated on protrusion to sid of lesion. Atrophy, fasciculations
- - UMNL- tounge may deviate away from the side of the lesion (contralateral)- to weak side of body
How do you assess orofacial function?
- - chek dentures- fitting comfortable
- - mm weakness- test facial movements, observe symmetry
tests for the mm of the face
What are the two phases of swallowing?
- 1. vol: tking food to mouth, forming it into a bolus, close teeth and lips, move tounge to roof of mouth and rogressively raise the rest of the tounge
- 2. invol (reflex): soft palate elevates, head held in slight forward flexion to advantage the oesophagus. Theepiglottis elevates and shuts off the trachea
How can you detect problems observe under surface of the chin and elevate the larynx