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Neurological Update MEDICAL SERVICES PROVIDED ON BEHALF OF THE DEPARTMENT FOR WORK AND PENSIONS Training & Development Neurological Update Self-Directed Learning Pack (for all Registered Medical Practitioners and Registered Physiotherapists) MED-CMEP~119 Version: 3 Final 23 April 2013 Medical Services Foreword This training has been produced as part of a training programme for Health Care Professionals (HCPs) approved by the Department for Work and Pensions Chief Medical Adviser to carry out benefit assessment work. All HCPs undertaking assessments must be registered practitioners who in addition, have undergone training in disability assessment medicine and specific training in the relevant benefit areas. The training includes theory training in a classroom setting, supervised practical training, and a demonstration of understanding as assessed by quality audit. This training must be read with the understanding that, as experienced practitioners, the HCPs will have detailed knowledge of the principles and practice of relevant diagnostic techniques; therefore such information is not contained in this training module. In addition, the training module is not a stand-alone document, and forms only a part of the training and written documentation that the HCP receives. As disability assessment is a practical occupation, much of the guidance also involves verbal information and coaching. Thus, although the training module may be of interest to non-medical readers, it must be remembered that some of the information may not be readily understood without background medical knowledge and an awareness of the other training given to HCPs. Office of the Chief Medical Adviser April 2013 Neurological Update 3 Final MED -CME~119 Page 2 Medical Services Document control Superseded documents Version history Version Date Comments 1 Final 25 January 2011 Signed off by CMMS 2a draft 23 January 2012 Schedule 28 Review and amendments Medical Training & Development 2 Final 22 February 2012 Signed off by CMMS 3a Draft 27 March 2013 Schedule 28 update by xxxxxxxx 3 Final 23 April 2013 Signed off by HWD and CMMS Changes since last version Foreword updated References to ‘Medical Manager’ changed to ‘Clinical Manager’ Typos corrected Page 61: NMC added to list of professional bodies Observation form: Title of xxxxxxxxxupdated Outstanding issues and omissions Updates to Standards incorporated Issue control Author: Dr A H based on previous Atos Healthcare material Owner and approver: National Clinical Manager (Performance) Signature: Date: Distribution: Neurological Update 3 Final MED-CMEP~119 Page 3 Medical Services Contents Introduction 7 An introduction to your Learning Pack 7 A guide to using this pack 7 Background to this Learning Pack 8 Section One – Neuroanatomy and Neurophysiology 9 Objectives 9 Duration 9 Cells, Neurons and Neuromuscular Junctions 9 Central Nervous System 10 Peripheral Nervous System 13 Autonomic Nervous System 17 From recall, or review of diagrams on Page 15, you should have responded as follows: 18 Reflexes 18 Upper Motor Neuron versus Lower Motor Neuron Lesions 19 Section Two - Neurological Examination 21 Objectives 21 Duration 21 History 21 Observation 22 Examination 23 Inspection 23 Testing the Motor System 23 Tone 23 Power 24 Reflexes 25 Testing the Sensory system 29 Section Three - Specific Conditions 34 Objectives 34 Duration 34 Neurological Update 3 Final MED-CMEP~119 Page 4 Medical Services Prolapsed Intervertebral Disc and Sciatica 35 Cause 35 Symptoms and Signs 36 Treatment 37 Functional impact 37 Cervical Spondylosis 39 Cause 39 Symptoms and Signs 39 Treatment 40 Functional impact 41 Peripheral Neuropathy 42 Cause 42 Diabetes 42 Alcohol misuse 43 Symptoms and Signs 44 Treatment 45 Functional impact 45 Nerve Compression Syndromes and Focal Neuropathy 47 Median nerve (carpal tunnel syndrome) 47 Symptoms and Signs 48 Treatment 49 Functional impact 49 Ulnar Nerve 49 Symptoms and Signs 50 Treatment 50 Functional impact 50 Radial Nerve 50 Symptoms and Signs 51 Treatment 52 Functional impact 52 Common Peroneal Nerve 52 Symptoms and Signs 52 Neurological Update 3 Final MED-CMEP~119 Page 5 Medical Services Treatment 52 Functional Impact 53 Lateral Cutaneous Nerve of the Thigh 53 Symptoms and Signs 53 Treatment 53 Functional Impact 53 Brachial Plexus Injuries 54 Symptoms and signs 54 Treatment 54 Functional impact 54 Thoracic Outlet Syndrome 55 Symptoms and Signs 55 Treatment 55 Functional Impact 55 Raynaud’s Phenomenon, Hand-Arm Vibration Syndrome and Vibration White Finger 59 Raynaud’s Phenomenon Error! Bookmark not defined. Hand-Arm Vibration Syndrome (HAVS) 60 Vibration White Finger (VWF) 60 Functional Impact 60 Further Reading 61 Section Four – Multiple Choice Questionnaire 62 Duration 62 Neurological Update MCQ 63 Glossary 66 Observation Form 72 Neurological Update 3 Final MED-CMEP~119 Page 6 Medical Services Introduction An introduction to your Learning Pack Welcome to this ‘Neurological Update’ distance learning module for registered medical practitioners (either employed, or self-employed) and registered physiotherapists. The Learning Pack will take you approximately 3 hours to complete, which can be done in one go or at smaller separate “sittings”. It is important that you complete learning activities in the order they are given; by doing so you will reflect, consolidate and build on your learning throughout. You will be asked to interact at various stages during this learning opportunity – writing your responses in the boxes provided – all answers will be found in the body of text, but you should first attempt to recall information before finally reviewing the main body of text to check for definitive answers. Your knowledge and understanding will be further tested by an MCQ, at the end. The completed MCQ must be returned to the Clinical Manager at your local Medical Services Centre (MSC) for marking. The pass mark is 85% or above. If you achieve less than 85%, the Clinical Manager will ask you to read the documents again and then repeat the MCQ, A guide to using this pack The following symbols are used to assist you in completing the learning activities included in this folder. Indicates a time for reading Indicates you should record / write your views and comments Duration Suggests the approximate time needed to complete any particular learning activity Learning Pack Objectives Through completion of this learning pack you should enhance your existing knowledge of: Neuroanatomy and neurophysiology Neurological examinations required in the context of disability assessments Specific neurological conditions Neurological Update 3 Final MED-CMEP~119 Page 7 Medical Services Background to this Learning Pack Neurological symptoms and conditions are common; approximately 10% of GP consultations are about a neurological symptom. In our role as Disability Analysts, roughly 20% of ESA cases examined have a neurological symptom or problem. The nervous system is the most elaborate bodily system. The field of neurology is correspondingly vast and complex. Neurological conditions can range from the simple to the highly complicated. The neurological system is therefore one of the most difficult systems to fully examine. The focus for this training will be on some of the more common neurological conditions that are seen within our sphere of work. Neurological Update 3 Final MED-CMEP~119 Page 8 Medical Services Section One – Neuroanatomy and Neurophysiology Welcome to the first section of your Learning Pack, which contains an overview of the principles of basic neuroanatomy and neurophysiology. The site of a lesion or problem within the neuromuscular system will often lead to a characteristic set of signs and symptoms. Therefore refreshing your knowledge of these principles will assist you assessing neurological cases in your role as a Disability Analyst. Objectives By the end of this section, you will have refreshed your knowledge of: Basic neuroanatomy concepts Basic neurophysiology concepts Dermatomes and myotomes The difference between the terms ‘upper’ and ‘lower’ motor neuron(s) Duration The learning activities during this section should take approximately 50 minutes to complete. Cells, Neurons and Neuromuscular Junctions The neuron is the anatomic and functional building block of the nervous system - each one is composed of a cell body; dendrites (processes leading towards the cell body); and axons (processes leading away from the cell body). Other cells in the nervous system (astrocytes, oligodendrocytes and microglial cells) play a ‘support’ role. A neuron Neurological Update 3 Final MED-CMEP~119 Page 9 Medical Services Many neurons have myelin sheaths (‘myelinated’ neurons) composed of specialised cells called Schwann cells. These wrap around the axon acting as insulation, and so assist in the conduction of electrical impulses. A myelinated neuron Synapses (contacts between cells allowing transmission of signals) use chemical ‘neurotransmitters’ for communication (e.g. dopamine and serotonin). Some synapses are excitatory (making a nerve cell more likely to produce and carry an impulse); some are inhibitory (making a nerve cell less likely to produce and carry an impulse). Communication from a neuron to a voluntary (skeletal muscle) cell occurs at the motor end plate (also known as myoneural junction). One motor neuron usually supplies a number of muscles cells (known as a motor unit). Central Nervous System The central nervous system (CNS) consists of the brain and the spinal cord. The brain is made up of the cerebrum, cerebellum and
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