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Ferezy's MSR's

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Ferezy's MSR's Presented By: Joseph S. Ferezy, D.C. 1 Examination Components I. History and mental status II. Cranial nerve (special senses) III.Somatic motor IV.Somatic sensory V. Reflex VI.Tone, posture, station and movement 2 Ferezy’s MSR’S Motor Reflex STV Deep Strength Superficial Tone Visceral Volume Pathologic Sensory Serebellar Deep Station Superficial Movement 3 1 Basic Exam Organization Sitting (Chair) History of Present Illness Observe Mental Status ‐ Include Cleanliness Stream of Talk Mood Content of Thought Intelligence Sensorium (Cognitive) 4 Basic Exam Organization Standing Free, Heel/toe, Tandem Walking/Hopping/Knee Bend Romberg Posture (observe –tremor, asymmetry, atrophy, Etc.) T & L ROM’s 5 Basic Exam Organization • Sitting (Exam Table) ▫ Cranial Nerve Examination. ▫ Motor Tests ‐ Strength, Tone, and Volume (most other then spinal extensors). ▫ Coordination Tests (Drift, Finger To Finger/Nose, Heel to Shin, Rapid Alternating Movements, Etc.). ▫ Intrathecal Tests. ▫ Orthopedic Tests (Most). ▫ Muscle stretch reflexes. 6 2 The Examination of Station, Movement and Gait Station ‐ The place at which someone is positioned or is assigned to remain, the act or manner of standing. Gait ‐ a manner of walking or moving on foot. Station and gait disorders are among the most common reasons patients seek outpatient neurologic consultation. A careful assessment of station and gait provides a quick, reliable snapshot of the integrated function of the patient's motor and sensory systems of both the central and peripheral nervous systems. Often involved in both somatoform (psychogenic) disorders as well as mistaken as psychogenic in etiology. 7 The Examination of Station, Movement and Gait A normal examination requires nervous system function at the highest level, integration and performance. Disorders of motor or sensory systems of the peripheral or central nervous system may affect movement. Each system will affect movement in a characteristic way. Because it is a sensitive (but not specific) test, the good clinician will test movement in even a cursory neurologic examination. Abnormal responses to the integrated testing of station and movement require additional testing to challenge each system independently in order to determine which system is failing and at what level. 8 The Examination of Station, Movement and Gait Patient standing Eyes open Eyes closed Broad base Narrow base Patient sitting (or standing) Arms outstretched and supinated 9 3 The Examination of Station, Movement and Gait Ask patient to walk Free walk Tandem (heel to toe) walk Heel walk Toe walk Ask patient to do a shallow to deep knee bend Ask patient to hop on one foot in place (then the other) Sit down Get up from a seated position 10 Movement Requires extensive pre‐requisite knowledge about multiple motor and sensory systems and how the nervous system integrates function. Brain is the “Puppet Master”. Coordinated movement requires sensory input and integration of four so‐called “motor systems”. Superimposed on tone and posture Tone and posture change instantly with superimposed movement. Creates a sensory‐motor‐sensory‐motor continuous loop 11 Motor Systems ‐ Clinical Classifications Pyramidal (AKA: cotricospinal, UMN, Betz cell, long tracts) –direct influence on lower motor neurons involved in willfully directed muscular contractions. Extrapyramidal – tone, posture, gait and other “pre‐ programmed” movements. Modulates pyramidal system, does not travel in the pyramids. Cerebellar – Balance, tone and fine coordination of willfully directed muscular contractions. Reflex arc – (AKA: LMN, final common pathway) to target muscle. ALL motor systems are useless unless they can affect the muscle. 12 4 Basic clinical concepts of pyramidal system innervation Covered in “Examination of the Somatic Motor System”. Voluntary movements are mediated through the motor cortex (UMN). Each area of this cortex controls an area of the face and body Extrapyramidal and cerebellar systems are also involved. 13 14 Motor cortex neurons Control cranial nerves via corticobulbar tract to lower motor neurons in brainstem nuclei. Descend along cortico‐ spinal path, through brainstem down spinal cord to synapse on LMN’s in anterior horn. 15 5 16 17 Extrapyramidal System A neural network located in the brain. Called "extrapyramidal" to distinguish it from the pyramidal pathways (corticospinal and corticobulbar tracts) as it does not pass through the medullary pyramids. Centers around the modulation and regulation (indirect control) of anterior (ventral) horn cells. 18 6 Extrapyramidal System Extrapyramidal tracts are chiefly found in the reticular formation of the pons and medulla, and target neurons in the spinal cord involved in reflexes, locomotion, complex movements, and postural control. Deeply interconnected to and modulated by the nigrostriatal pathway, the basal ganglia, the cerebellum, the vestibular nuclei, and different sensory areas of the cerebral cortex. All of these regulatory components can be considered part of the extrapyramidal system, in that they modulate motor activity but we tend to discuss sensory and cerebellar areas separately. 19 EXTRAPYRAMIDAL SYSTEM Basal Nuclei (Ganglia) ‐ Caudate, Putamen and Globus Pallidus Subthalamic Red Nucleus Substantia Nigra Parts of Reticular Formation Inferior Olivary Other 20 21 7 22 Basilar Nuclei Nuclei that make up the basal ganglia, along with their major subdivisions, are: the striatum (Huntington’s Disease) putamen caudate nucleus nucleus accumbens (ventral striatum) external segment of the globus pallidus (GPe) internal segment of the globus pallidus (GPi) subthalamic nucleus (STN) substantia nigra (SN) pars compacta (SNc) (Parkinson’s Disease) pars reticulata (SNr) pars lateralis (SNl) 23 Basal Nuclei 24 8 25 26 Basal Nuclei Neurotransmitters Classic Connectivity Diagram showing glutamatergic pathways as red, dopaminergic as magenta and GABA pathways as blue 27 9 Extrapyramidal Pathways 28 EXTRAPYRAMIDAL FUNCTION Regulation of Tone, Movement and Posture Sets Background for Complex Motor Activity by Setting Balance Gamma and Alpha (Lower) Motor Neurons (Final Common Pathway) 29 THE EXTRAPYRAMIDAL SYSTEM The extrapyramidal system can be divided into three controlling systems: the cortically originating indirect pathways, the feedback loops, and the auditory‐visual‐vestibular descending pathways. 30 10 THE EXTRAPYRAMIDAL SYSTEM The extrapyramidal system can be divided into three controlling systems: the cortically originating indirect pathways, the feedback loops, and the auditory‐visual‐vestibular descending pathways. 31 Cortically Originating Indirect Descending Pathways Signals transmitted over the pyramidal system to produce voluntary movement are preceded by activity in neurons of the extrapyramidal system and relayed to the basal nuclei, red nucleus, and brainstem reticular formation (probably mechanism for reinforcement of MSR’s). Basal nuclei contribute to background muscle tone and probably aid in fine tuning motor skills of the distal upper extremity. The impulses projecting to the red nuclei influence spinal cord alpha and gamma motor neurons via rubrospinal and other descending tracts. 32 Feedback Loops Neural circuits in which a signal sample is fed back to a "comparator," which can compare the signal with some pre‐programed desired condition and subsequently take steps to "adjust" or "modify" it. The extrapyramidal system includes two such feedback systems connecting from above and below: cortically originating extrapyramidal system feedback loops (COEPS feedback loops) modifying feedback signals are returned to the cortex via the thalamocortical fibers. proprioceptor originating extrapyramidal system feedback loops (POEPS feedback loops) modifying feedback signals through cerebellum to the spinal cord motor neurons. 33 11 Auditory Visual Vestibular Descending Pathways Postural adjustments in response to auditory (startle reflex), visual (hands protect face), and vestibular signals (veering) is an additional way to regulate the activity of spinal motor neurons. 34 35 EXTRAPYRAMIDAL FUNCTION The basal ganglia have a “limbic” sector whose components are the nucleus accumbens (NA), ventral pallidum, and ventral tegmental area (VTA). VTA efferents provide dopamine to the nucleus accumbens (ventral striatum) same as substantia nigra cells provive dopamine to the striatum. Evidence suggests a central role in reward learning. A number of highly addictive drugs, including cocaine, amphetamines, and nicotine, are thought to work by increasing the efficacy of the VTA→NA dopamine signal. There is also evidence implicating over activity of the VTA dopaminergic projection in schizophrenia. 36 12 Clinical Signs of Basal Nuclei and Related Brainstem Dysfunction Chorea may be associated with dysfunction of the corpus striatum. Sydenham's chorea, may be seen as a complication of rheumatic fever in children. Recovery from this form of the disease is usually complete. Huntington's chorea, is a hereditary disease which becomes progressively worse and often leads to severe mental debilitation loss of motor control and early death. Athetosis is also associated with damage to the striatum and lateral parts of the globus pallidus. 37 Clinical Signs of Basal Nuclei and Related Brainstem Dysfunction Ballismus, monoballismus and hemiballismus is generally associated with damage to the subthalamus and can occur spontaneously or be brought on by the
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