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CNS EXAMINATION.pptx , Ayurveda MD RNVV
- 2. Examination of Nervous System (1) Examination for higher functions (2) Examination of cranial nerves (3) Examination of sensory system (4) Examination of motor system (5) Examination of reflexes (6) Examination of gait (7) Examination of spine and cranium (8) Examination for special signs (such as cerebellar signs)
- 3. Examination of Motor System Motor system is examined under following headings. These points are very useful in examine the patient of Hemiplegia. (1) Nutrition (2) Tone (3) Power (4) coordination (5) Involuntary movements
- 4. Examination of Nutrition of Muscle Nutrition is tested by measuring circumference of muscle, at its bulk and comparing circumference of left and right side e.g. Circumference of calf muscle can be measured by fixing the distance from bony prominence. e.g. 6 inches below Tibial tuberosity. Measure the circumference of right and left calf muscle at a same distance. Similarly circumference of thigh muscle, from a fixed bony prominence like Tibial Tuberosity or ASIS (Anterior Superior Iliac Spine) can be compared.
- 5. Nutrition or Bulk of Muscle In right sided person circumference of right sided muscle can be slightly more. This is physiological.
- 6. Hypertrophy of Muscle Muscle hypertrophy is an increase in the size of a muscle Hypertrophy is an increase in mass of a muscle that can be induced by a number of stimuli. The most familiar of these is exercise. Pathologically in Acromegaly disease there is pathological muscle hypertrophy affecting mainly the type (1) skeletal fibers
- 7. Atrophy of Muscle Muscle atrophy is defined as a decrease in the mass of the muscle Physiologically: Muscle mass, muscle strength, and bone density decrease in the elderly Disuse atrophy of muscles can occur after prolonged immobility such as extended bed- rest,or having a body part in a cast. - This type of atrophy can usually be reversed with exercise.
- 8. Tone Of Muscles Tone of a muscle is a partial state of contraction. It is maintained by stretch reflex. Tone of the muscle is tested by 2 ways (a) By examining feel of the muscle (b) Tone can be seen by Resistance offered to passive Movements. Doctor can feel muscle at its bulk and he can compare the feel on right and left side e.g. doctor can observe the feel of calf muscles, thigh and muscles of bicep and triceps
- 9. Tone of Muscle Tone of Leg Muscle Tone of thigh Muscle Tone of Biceps Muscle Tone of Forearm Muscle
- 10. Tone of Muscle Normal feel is Elastic. Second method of examination of Tone is to see resistance offered to passive Movements. Patient is not moving his extremities but the doctor is carrying out passive movements Doctor can do passive movements at knee joint to test the tone of flexors and extensors of knee. When doctor is doing flexion of knee, he is testing tone in extensors. When doctor is doing extension at knee he is testing Tone of flexors.
- 11. Tone Of Muscle For testing upper extremities, same movements can be done at elbow Doctor can test Tone of biceps and triceps and he can compare the Tone at other side. When doctor is carrying flexion at elbow he is testing Tone in triceps. When doctor is carrying extension in elbow he is testing tone in biceps.
- 12. Tone Of Muscle with passive movement Passive Movement of Leg Passive movement of Elbow
- 13. Hypertonia and hypotonia A. HYPOTONIA B. HYPERTONIA
- 14. Power of muscle Power is graded under fine grades as follows Grade O - No movements at all. Grade 1 - Only flicking movement are visible but no movements possible Grade 2 - If movement is occurring horizontally but not able to lift against gravity. Grade 3 - If subject is able to lift up leg or hand, against gravity (compare the right and left side) Grade 4 - Patient is able to move his extremities against resistance Grade 5 - Patient is able to lift the extremities against the good resistance applied by the doctor.
- 15. Power of muscle Grade 3 Power Grade 3 Power Grade 4 Power Grade 4 Power
- 16. Power of muscle Garde 5 Power Grade 5 Power
- 17. Power Of Muscle In the same manner, power of extensors of hip, flexors of knee (Ask the patient to bend the knee ) extensors of knee (Extend leg by making knee straight ) can be compared. Even planter flexors, dorsi flexors of foot can be compared. In upper extremity, flexors and extensors of elbow can be compared, flexors and extensors of wrist can be compared. Movements at shoulder such as flexion, extension, abduction, adduction can be tested for power.
- 18. Power of Muscles For testing power in the neck muscle, patient is asked to lift his neck up in lying down position. Ask the patient to lift the neck, put down the head Then ask patient to lift the neck, when doctor is pressing on forehead. For testing power in the neck muscle, patient is asked to lift his neck up in lying down position. Ask the patient to lift the neck, put down the head Then ask patient to lift the neck, when doctor is pressing on forehead . Complete loss of power is called as 'paralysis' which is typical feature of LMN lesion like polio myelitis. Partial loss of power is called as "paresis" which is typically seen in Hemiplegia orParaplegia.
- 19. Power of Muscle Grade 4 Power Grade 4 Power
- 20. Grading Of Muscle Strength
- 21. Coordination of Muscles (A) Coordination of muscles in upper extremity is tested by following tests (1) Finger - Nose - finger test (2) Rapid pronation and supination of palm(Dysdiadochokinesia) (B) for lower extremity, following tests (1) Knee - heel test (2) Walking in straight line All tests of co-ordination should be done with open eyes first and then with closed eyes, to differentiate between sensory Ataxia and cerebellar Ataxia (Motor ataxia)
- 22. Finger nose finger test Ask the patient ,by closing the eyes he should try to touch Index finger of the left hand by his index finger of right hand & then same right hand finger should touch to his nose tip Same procedure is repeated with Left hand Index finger This is Finger - Nose - Finger Test
- 23. Rapid pronation and supination of palm Ask the patient to perform Pronation & Supination activity of both hands ,speedily (diadochokinesia) . Check ,whether patient can do it for both the hands
- 24. Kneel Heel Test Ask the patient to sit on table or lie down on bed. First keep right heel on left knee & take the heel down along with shin of tibia ,till left foot. Perform Same procedure by keeping left heel on right knee & taking down heel along with the shin of tibia ,up to right foot
- 25. Rhomberg's Test Ask the patient to stand straight ,by keeping both feet near to each other - First stand with eyes open & then stand with close eyes. Doctor has to see, whether patient can maintain balance of his body. If patient cannot stand straight, and he swings with closed eyes - It is called as, "positive Rhomberg's sign", which is typical sign of Dorsal column tract damage.
- 26. Straight line walking Test Ask the patient to stand at one end of the 8 feet straight line. Then ask him to walk on this line to & fro -First with open eyes & then with close eyes. Walk on Straight line Return back on straight line
- 27. If patient walks correctly with open eyes, but looses balance with closed eyes - It indicates damage lies in dorsal column tract (which is called as sensory ataxia) If patient is not able to walk with open or closed eyes - damage is in cerebellum (it is cerebellar or Motor ataxia).
- 28. Involuntary Movements 3 types (1) Fine Tremors - In Thyrotoxicosis Tachycardia, weight loss, Intolerance to heat atmosphere ,Feeling excessive heat all the time (2) Pin rolling tremors at rest In Parkinsonism - This disease develops due to deficiency of Dopamin neutrotransmitter in Basal Ganglia. 3) Action tremor In cerebellar diseases
- 29. 1) Fine Tremors 2)Pin rolling tremors 3) Action tremor
- 30. Advantage of Motor System Examination Advantage of motor system examination, over sensory system examination is that --- (1) Even if patients cooperation is not there we can draw few conclusions like - UMN lesion, LMN lesion, Parkinsonism, Cerebellar,ataxia, Sensory ataxia. (2) In sensory system examination, if patient is non-co-operative then he can not answer the doctor's questions and then examination is ofno value. However, sensory system examination is important to detect the level of damage in spinal cord.
- 31. Reflex In superficial reflexes --- receptors are in skin or mucous membrane In deep reflexes ---- receptors are in muscles or tendons.
- 32. Reflex
- 33. Reflex
- 34. Superficial Reflex - Conjunctival Reflex Doctor will touch wisp of the cotton wool to the white portion of eye i.e. Bulbar conjunctiva Response is closer of both eye.
- 35. Superficial Reflex -Corneal Reflex Doctor will touch the wisp of cotton wool to black portion of eye i.e. cornea closer of both eyes is normal response. NOTE: Conjunctival and corneal reflexes have already been tested in examination of trigeminal and facial nerve. If these nerves are damaged reflexes are lost
- 36. Palatal & Pharyngeal Reflex Doctor will touch soft palate or post pharyngeal wall with tongue depressor. Doctor will expect a response in the form of coughing. If the patient is getting coughing sensation - It means 9th, 10th, 11th cranial nerves involving in this reflex are normal.
- 37. Abdominal Reflexes Imp precaution to be carried out is that - abdomen should be relaxed, by flexing knee. Ask the patient to lie down his back & flex the knees & relax abdominal muscles. Now, blunt end of hammer is moved , radiating away from umbilicus in all directions. While testing this reflex abdominal muscle will show a movement, in the form of the response. Abdominal reflexes are classified into upper abdominal, mid abdominal and lower abdominal reflexes.
- 39. Abdominal reflexes Mid Abdominal Reflex Away From Umbilicus
- 40. Abdominal Reflexes In obese patients, abdominal reflexes may not be elucidated. In such cases, unilateral absence of abdominal reflex is important finding. Abdominal reflexes are lost in UMN lesion like hemiplegia or paraplegia.
- 41. Superficial Reflex - Plantar Reflex Root value of the plantar reflex is L5, $1, S2. Scratch sole of the foot from heel to toes, along lateral border and then medially. This scratching is done with blunt portion of hammer. Perform it on both sides & compare
- 42. Babinskis Sign Left Planter Reflex Right Planter Reflex
- 43. Deep Reflex For testing deep reflexes, special method is adopted which is called as the Jendrassik maneuver . Which is a medical maneuver wherein the patient clenches the teeth, flexes both sets of fingers into a hook-like form and interlocks those sets of fingers together. By this manual, gamma motor neuron discharge is decreased and reflex is obtained properly.
- 44. Bicep jerk Doctor will tap bicep tendon - contraction of biceps muscle is important, rather than flexion of forearm. We compare the reflex on both sides. Root value of this reflex is C5, C6.
- 45. Deep Reflex - Triceps Reflex Doctor will give a tap just above Olecranon process, which is Tricep tendon. Do Jendrassik maneuver. Contraction of the muscle is more important than extension of forearm. Compare the reflex on other side. Root value of this reflex is C 7, C 8.
- 46. Deep Reflex - Triceps Reflex Tap above Olecranon Process Contraction of Muscle
- 47. Deep Reflex Supinator Reflex or wrist Jerk Reflex Tap is given just above the head of radius. Doctor can see the contraction of brachioradialis muscle Compare the reflex on another side Root value is C5, C6.
- 48. Deep Reflex - Knee Jerk For testing this reflex, exposer of Quadriceps muscle is important, so that the doctor can see the contraction of this muscle. Doctor keeps his hand below the knee, patient is asked to relax. Divert the patients attention by Jendrassik maneuver. Ask the patient to clench the teeth. Give a tap on patellar tendon i.e. between patella and Tibial Tuberosity. Contraction of Quadriceps muscle is Important response. Root value is - L2, L3, L4
- 49. Deep Reflex Knee Jerk Right Knee Reflex Left Knee Reflex
- 50. Deep Reflex - Ankle Jerk For this reflex gastrocnemius muscle should be exposed. Tapping of the gastrocnemius tendon, just above the heel is stimulus. Doctor will make forceful dorsiflexion of foot and give a tap on tendon. Contraction of gastrocnemius is the response. Compare the reflex on other side Root value is L5, $1, S2
- 51. Deep Reflex - Ankle Jerk Right Ankle Jerk Left Ankle Jerk
- 52. Importance of Testing Reflexes Examination of the reflexes is most imp part in examination of the nervous system. Advantage of this examination than motor and sensory examination is that - "It does not requirepatient's co-operation. Various diseases, specially UMN lesion and LMN lesion can be differentiated by examination of deep reflexes. Even if patient is unconscious, non-cooperative -These reflexes will give important clues. In UMN lesions - Deep reflexes are exaggerated (Jerks will be very much prominent). Even clonus can be seen at knee and ankle (where muscle jerk oscillates for longer time). Clonus is always pathological. It is seen in UMN lesion.
- 53. Examination of Spine & Cranium Spine is to be inspected from cervical to sacral region for noticeing abnormality. With knuckles of fingers, doctor can give deep pressure on spine and ask the patient whether he gets pain sensation. For testing cranium deep pressure is to be given on skull, from all angles and patient is asked, "Whether he gets pain sensation" ? If there are abnormalities of the spine, if there are conditions like hydrocephalus. This test will give intense pain.
- 54. Examination of Spine & Cranium Cervical To Sacral With Knuckles Deep Pressure from All Angles
- 57. Festinating Gait
- 58. Ataxic gait/ drunk men's gait
- 59. Spastic Gait
- 60. Scissor Gait
- 61. Flaccid Gait