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This 18 page Study Guide was uploaded by Brittany Morris on Tuesday September 9, 2014. The Study Guide belongs to a course at University of Massachusetts taught by a professor in Fall. Since its upload, it has received 112 views.
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Date Created: 09/09/14
SENSORYAFFERENT PATHWAY Dorsal column Medial Lemniscal System Anteriolateral System PROTOPATHIC SENSATION PAIN ew EPICRITIC SENSATION Fine TEMP WI discrimination T I D Z Z Q i Q F Grac39l39s F C taneo s 1 1 u u Anterior Lateral Spinothalamic SENSORYquotgtLOWER SENSORY quotgt Upper Spinothalamic Tract tract lt3 E HALF OF BODY Face E g Q2 I 419 Spinocerebellar Tract CRUDE TOUCH PAIN TEMPERATURE Ventral Dorsal Cuneo Contralateral info gtgtgirgle pelvis legs Ipsilateral infogtgtlegs thighs pelvis abs Ipsilateral info gtgt upper neck and limbs Direct amp Indirect Activation Pathways Innervated by the manstress Basal Ganglia A t o transient 0 transient transient tonic Basal Ganglia Dopamine can be and MOTOREFFERENT PATHWAYS Overview of DAP amp IDAP See detailed diagrams below Direct Activation Indirect Activation Pathway Vounta ry Pathway nvountary Corticospinal Corticobulbar Cortlcoretlcular Corticovestibular tract Corticorubral tract SPNAL NERVE CRANAL NERVE NNERVATON NERVATON There are more pathways but these are most pertinent to IDAP DIRECT ACTIVATION PATHWAY DAP Neuronal Pathway Cortex gt Corona Radiata gt INTERNAL CAPSULE gt BRAINSTEM DAP Facilitory gt FINAL COMMON PATHWAY Conscious skilled controlled rapid movement Deficits to capsular region leads to widespread MOTOR deficits since there are numerous fibers in one compact Internal Capsule Defined I White matter separates the caudate I I nucleus thalamus from the putamenglobus pallidus Contains ascending descending axonal fibers that run between the cerebral cortex amp pyramids of the Corticobulbar Lower 13 motor humunculus BULB Nose eyes face lips Corticospinal Upper 1 3 motor humunculus medulla CRANIAL NERVES Gen1tal1a toes head hands SPINAL NERVES V VII IX X XI XII Parts of Internal Capsule PquotPost Ce t 31GY 5 Premotr Cortex 1 Anterior Limb 2 Genu Corticobulbar Ii I 3 Posterior Limb Corticospinal J Anterior 10 Lateral 9 0 Contralateral Ipsjlateral Contralateral Innervation DAP NEURONAL PATHWAY REVISITED Corona Internal Cortex J J Radiata J J Capsule J JBraInstem Part of IC Where it goes 1 Anterior Limb Anterior thalamic radiations Prefrontal corticopontine fibers 2 Genu Cortibobu1barDAP Corticoreticular fibers IDAP Corticospinal fibers DAP Frontopontine fibers 3 Posterior Limb posterior compared to prefrontal Superior thalamic radiation PostC gyrus IDAP fibers corticorectal corticorubral corticoreticular Anterior Limb Anterior thalamic Ir Prefrontal corticopontine fibers IDAP I I I Anterior Limb J Pneumonic Aunt ANT kicks Thal in the prefrontal quotma PONS PONTS I Corticobular DAP if Corticoreticular IDAP Genu Pneumonic genius light BULB turns on GENESISGod was aware Posterior Limb k Corticospinal DAP P e m iC IDAP fibers iheidleg the 3 ll1 h my Posterior Limb m a me O Cortlcorectal fibers and scored on o Corticorubral THAL in the superior o Corticoreticular upper 90 but 1 hit my SPINE on the far post and k Frontopontine fibers A Superior thalamic radiations o Post Central Gyrus 1 1111 1111 11 1111 11 rubbed my rectum on the ground Rediculous A Assists with skilled and muscle tone associated with DAP activities discrete actions Corticoreticular tract Corticorubral tract Corticovestibulartra DAP LESIONS Decrease Loss VOLUNTARY Movement oims Unilateral UMN lesions Loss to contralateral LMN side Weakness paralysis Usually normal MSR re exes but brisk Bilateral weakness paralysis BILATERAL UMN lesions Spasticity DAP IDAP Brisk re exes IDAP IDAP functions IDAP notes A Regulates reflexes it Extra pyramidal Ir Maintains posture DAP multiple synapses to FCP k UNCONSCIOUS Ct Cortex gt Reticular formation In PonsMedulla Cortex gt Red Nucleus Reticular formation r r r r r Conscious ascending info Facilitates inhibits re exes Facilitates mediates cortically medicated voluntary movement and ascending sensory info Adjusts muscle tone PAG AREA Phasic respiratory activities for speech phonation vegetative function and swallowing CN 10 nucleus ambiguous In medulla neuronal network to subclavian artery to breathe Cortex gt Vestibular Nucleus Red nucleus A In midbrain tegmentum k Rubrospinal tract facilitates exors inhibits extensors Relay station Lesions A Above decorticate posture A Below decerebate posture above vestibular nucleus Vestibular Nucleus Ir Vestibulospinal tract excites the hyperexcitable extensor motor neurons Lesions A Above 9decerebrate posture below red nucleus A Below 9 hypotonia hypore exia wiping out reticular formation input output widespread weakness sensory loss Postural responses to noxious stimuli Decorticate ABOVE red nucleus Decerebate Below red nucleus Above vestibular nucleus Below Vestibular Nucleus See above Inhibits input to red nucleus amp excitatory input to MRF inhibitory 9 muscles Vestibulospinal tract excites the hyperexcitable extensor motor neurons Wipes out input output to reticular formation Increased extensor tone to legs extend and resist bending Increased exor tone in arms ex and resist EXTENSOR POSTURING Total loss of muscle tone Loss of muscle stretch re exes Hypotonia Hypore exia Widespread weakness sensory loss I m fighting death Let me protect myself I m ready for death take me Jesus I m sleepy and or on a lot of drugs I ve been reduced to vegetable status k If present these re exes suggest there is damage to CNS Postural re exes k Aid in localization to differential diagnosis 9 Levels UMN brainstem LMN k Patient might be non verbal or unconscious DAP vs IDAP UMN Lesions DAP IDAP Loss of skilled movement Spasticity Hypotonia Hypertonia Hypore exia Hypere exia Weakness dista1gtproximal Clonus weakness Absent abdominal re exes Decorticate vs decerebrate posture Babinski Hyperactive gag re ex No atrophy or fasiculations LMN Relationship between UMN and LMN systems A Both are contained within the CNS k Doesn t include BG cerebellar control circuits r Includes corticobulbar corticospinal tract predominately DAP system Affected areas and symptoms A UMN lesions frequently affect DAP and IDAP A May include Spasticity and hypereflexia IDAP Loss of skilled movement DAP Weakness IDAP DAP Final Common Pathway Characteristics Functions Damage LMN system Activates skeletal or Abolishesdecreases somatic muscles reflexes Includes PNS cranial Gamma motor neurons are Damage to peripheral Spinal nerves influenced by BG and speech pathways IDAP which maintain muscle tone IN SUM Activates muscles Integrates activity between LMN lesions maintains muscle tone peripheral system and DAP hypotonia integrates systems to and IDAP to achieve hyporeflexia achieve movement movement muscle atrophy fasiculations UMN vs LMN lesions Presentation UMN LMN Weakness Yes Yes Atrophy No Yes Fasiculations No Yes Re exes Increased Decreased Tone Increased Decreased Babinski Re ex Present Absent Bilateral UMN Primarily Unilateral UMN Trigeminal Facial nerve 9 lower face at Facial 9 upper face Accessoryesegments that Glossopharyngeal receive unilateral innervations Vagus 9 all branches sternoclediomastoidtrapezius at Accessory 9 primarily Hypoglossal 9 Contralateral contralateral UMN innervations Oculomotor Ill TrochearlV Abducens VI 9 contralateral Tonque deviation Deviates towards side of weakness on protrusion Lesion is IPSILATERAL to side of weakness OR k Unilateral UMN lesion producing weakness to contralateral side Eve movement six muscles tract movinq obiectsfixation k CN Ill medial rectus superior rectus inferior rectus inferior oblique k CN IV contralateral superior oblique k CN VI innervates ipsilateral lateral rectus Look left Cranial nerve test at Assessing synergy of all eye Ir Relaxation of opposing muscles muscles 9 Contracts 0 Medial rectus of L eye Ill o Lateral rectus of L eye VI 0 Later rectus f R eye VI 0 Medial rectus of R eye Ill Basal qanqlia network Marv s Manstress Characteristics Function of BG Structures Individual BG nuclei Caudate nucleus Network of A Excite or inhibit the cortex Gmbus pamdus subcortical A Striatum usually inhibits can Ir Putamen nuclei GXCWG A Depending on if dopamine s Striatum CN Putamen effect is excitatory or inhibitory thalatntts subtiltasllamju nucleus afvV39ll O K sui bsta1139tia IquotIjgr Interconnected with the cortex Collectively BG nuclei thalamus and midbrain k Inhibit dampen the cortex Think of the feedback loop Rich in neurotransmitters BG GROUP ALSO Ach GABA Dopamine r Regulates muscle tone A Maintains posture I know you hate it but think of the V039U taW Skmed feedback loop movementmuscle contractions DAP A Modulate speed amplitude initiation of movement A Form templates for overlearned tasks k Play a role in new motor learning MOTOR LOOPS VL Striatum Red Substantla Nigra Cerebellum Thalamic Cortex CN Nucleus I NUC 939 Putamen Cerebellar networks Marv s Pool Boy think Legally Blonde Defined Control Circuit that has multiple sensory and motor connections Pathways Cortical Agonists Spinal cord Bramstem Antagonists O O O O O Midbrain Subcortical Coordinates timing scale and size of muscular action Auditory and proprioceptive feedback to joints tendons and muscles Reciprocal connections to brainstem IDAP cortex BG and thalamus Assists with planningprogramming of learned movements Feedforward feedback system for cortexmuscles De ned Unidirectional signals through system from input to output with little recurrence The small amount of recurrence that does occur is mutually inhibitive no excitatory circuits Unlike the cerebral cortex cannot generate selfsustaining neural activity Does not initiate movement BG role but it contributes to coordination precision and accurate timing of movements DOES NOT decide which movements to execute either instead calibrates form of a movement ROLE or THE CEREBELLUM Mom Com Cerebrum Corpus Callosum Red Nucleus O Axon of Cranial Nerve XII C Muscle Midbrain Cercbellum C Cortico Bulbar Tract C Cortico Pontine Cerebellar Tract C Cercbellum Red Nucleus Cortex Impairment effects o Ataxic gaitspeech o Impairment of coordinationbalance o Dizziness headaches nausea o Problems with motor control ipsilateral to damaged cerebellum 0 Can still generate motor activity but it loses precision erratic uncoordinated or incorrectly timed movements How to test cerebellar function thanks Wikibedia my best friend Ask client to reach for a target with the tip of hisher finger that is an arm s length away A person with a normally functioning cerebellum will move the fingertip in a rapid straight trajectory If cerebellum is damaged the person will reach slowly and erratically with many midcourse corrections Basal Ganglia Tremors Cerebellar tremors Rhythmic periodic 45 Hz lntention motion tremors do not Parkinson s slowness of initiations occur at rest but when movement occurs onset of tremor Tremors occur during initiation of Tremor becomes more severe as movement target is approached Differential Diagnosis of Lesions Pertinent examples from class lt4 UMN Ftight MCA UMN L MCA LMN esion Below eye cortically Aphasia is possible Entire L side of face based lesion affected Lips droop Apraxia pars Eye open 9 VII triangularis brainstem malfunction Might have pragmatic Nonverbal oral apraxia Eye closed 9 ptosis suprasegmental LMN Ill malfunction intonation left neglect Left limbs may be affected Must follow commands Tongue deviates depending on lesion segment of BDAEIll towards left side location that assesses 12 step commands Determine how much they understand If not have them imitate you during OME Cranial Nerves Number Name Location ampFunction Ssensory M motor Bboth Nerve Type Func on Test I Olfactory S Location Cortex o Smell 0 Useful test for those with Dementia as they tend to lose their sense of smell which explains why they might not be eating Have the client identify nonirritating items via their scent ie cinnamon tobacco ll Optic S o Sight o Pupillary reflex Location Cortex 0 Vision test lll0culomotorB EYE MOVEMENT Ill Location Midbrain and Open eye upper pons region in the PAGA IV TrochlearM Location Midbrain VI AbducensM Location Pons Oculomotor 0 Controls medial rectus superiorinferior rectus and inferior oblique o Assists in opening eyelid if damaged ptosis Trochlear o lnnervates Contralateral superior oblique moves eye down and laterally Abducens o lnnervatesipsilateral lateral rectus moves eye laterally AI Pupillary reflex Follow objects with eyes all directions Look up down side to side V Trigeminal B Sensory Sensory Location Pons o Types of information o Brush mandible and o Pain maxilla o Temperature o Brush bottom of the eye o Discriminative touch lateral nose and top lip o Kinesthetic Motor aWareneSS 0 Open amp close jaw move 0 PF0l3Fi0C9l3 fiV9 jaw side to side jaw awareness jerk VWL flt3 o Puff out cheeks resist 0 Head i809 Oral o Openclose mouth say cavity see below bAbAbA pApApA i o Bite down on tongue 139 0Ptha39amiC 9T0UCha depressor or chewy tube pain proprioception to head scalp eyelid Re exes nose sinuses bite tentorium Suck 2 Maxilliary 9 nose cheeksupperHp palate maxiliary gingival upper teeth EAM tympanic membrane 3 Mandibular lower teeth mouth proprioception to anterior 13 of tongue Motor o Muscles of mastication and speech o Pterygoidsteporalis masseter diagastric muscles o Tensor velli palatine o Tensor tympani o corneal not pathological VII Facial B Location Pons Internal Auditory Sensory o Taste to the anterior 23 of the tongue o Skin around pinna auricle Sensory Taste foods on anterior 23 of tongue use sour salty sweet tasting foods Meatus Motor o Brush skin around pinna o Innervates all muscles and expression muscles of the Motor face scalp glands of the o Move forehead scrunch it eyes and nasal mucosa then relax o Submandibular and o Raiselower eyebrows sublingual glands that o Squeeze eyelids keep them create saliva and lacrimals shut with resistance o Posterior belly of the o Smile make facial digastrics muscle and expressions stylohypoid M9 W o Stapedius 9 stabilizes the stapes dampens the stapes vibrations and prevents excess movement to control sound waves to protect the ear from high noise levels Sensory Sensory Vm o Senses sound rotation o Hearing test and gravity o Evaluate balance OT motor Vestibulocochlear S Pons Internal Auditory Meatus o vestibular branch carries impulses for equilibrium o cochlear hearing test battery Not usually our scope of practice IX GlossopharyngealB Medulla Sensory o Reflexes pain temperature tension o Taste to the posterior 13 of the tongue o Sensation to pharynx pharyngeal structures tonsils faucial pillars o Sensory info is sent to N solitarus XI X XI and N Ambiguous IX X o Gag Motor o Triggers swallow o Stylopharyngeus Sensory Taste of posterior 23 tongue Say kquot kquot kquot Say gquotgquot gquot Motor Swallow Reflexes gag X Vagus B Medulla BranchesSensorimotor 1 Pharyngeal nerve o Raises velum o 3 constrictor muscles and Ievator palatini velum 2 Superior laryngeal nerve o Pulls VF anterior and posteriorly PITCH o Internal laryngeal sensory to VF s and larynx o External laryngeal motor to cricothyroid 3 Recurrent laryngeal nerve o Adductabduct VF 0 Motor 9 all laryngeal muscles Sensory 90 o Parasympathetic fibers to Larynx pharynx esophagus trachea lungs heart stomach o Taste from epiglottis Motor 10 o Laryngea pharyngeal musces controls them for voice resonance phonation swallow Reflexes o For survival swallow sneeze vomit BRANCHES PN 0 Say ahh examine velum o Nasals vs nonnasals check for emissions with mirror or use nasomater SLN o Prolong vowels and raiselower pitch RLN o Cough o Glottal attack Reflexes o Swallow o Sneeze XI Accessory M o lnnervates SCM amp o Shrug shoulders Medulla trapezius o Turn head side to side Hyp0gQssa M o lnnervates all tongue Examine at rest and during Meduua muscles both extrinsic protrusion and intrinsic 0 SYmm9 IFiC o Reflexive network eating 0 9V39at39quot 7 T 7 o asicu ations remor sucking chewing O Atrophy 0 ROM 0 Coordination 0 Strength o Say kquot kquot kquot dquottquot Iquot pataka buttercup Nerve Pathology SLP s NOTE VTrigeminal Ipsilateral loss of sensation to face tongue teeth gingival nose orbits mouth Sneezing blinking impaired Trigeminal neuralgia burning pain Neuropathy LMN jaw deviates towards side of weakness absent reflex UUMN mild affect on mastication BUMN low hanging jaw Impaired Mastication Tismus can t open mouth Bite reflex be careful Speech characteristics Bilabials stops impaired If jaw is hanging slurred slow speech Vll Facial Eye remains open Loss of taste to anterior 23 tongue Facial muscle weakness Neuropathy LMN Bell s Palsy ipsilateral lesion entire 2 of face droops weakness BUMN Supranuclear Palsy bilateral upperlower facial weakness spasticity ridigity Difficulty producing bilabial stops labiodentals bilabial glide w IX Glossopalatal Taste loss absent gag secretions Unable to trigger swallow Difficulty producing velars X Vagus Above pharyngeal branch SLN RLN 0 Velum hangs lower o VF paralyzed o Weak larynx Below pharyngeal branch o Velum intact o VF paralyzed o Weak larynx Above pharyngeal branch o Hypernasal o Breathy horse voice Below pharyngeal branch o Breathy horse voice XII Hypoglossal o LMN lesion o Difficulty producing velar o Ipsilateral weakness stops palatal fricatives o Atrophy palatal africates alveolar fricatives alveolar stops liquids o Tongue deviates towards side of weakness interdental fricatives o UUMN lesion o imprecise articulation o Contralateral o Garbled speech weakness 0 Tongue deviates towards side of weakness 0 Clumsy tongue for articulation and ea ng Damaqe from UMN involvinq speech mechanism a Unilateral UMN lesions produce relatively mild deficits on the contralateral side of speech mechanism marked by weakness and loss of skilled movement imprecision a With the exception of some CN s that receive predominantly contralateral innervations Motor Speech Disorders Disorder Definition MSD s Realm of speech disorders resulting from neurologic impairments affecting the planning programming control or execution of speech Dysarthria Abnormalities in strength speed range steadiness tone or accuracy of movements required for breathing phonatory resonatory articulation or prosody of speech production These disturbances of controlexecution are due to sensorimotor abnormalities Weakness spasticity incoordination involvement or excessive reduced or variable muscle tone Apraxia of Speech Neurologic speech disorder Impaired motor planningprogramming Sensorimotor commands necessary for directing movements that are responsible for phoneticallyl prosodically normal speech Can occur in absence of disturbance in any component of language Can occur in absence of physiologic disturbances associated with dysarthria Distinct clinical entity nature is different due to localization pars triangularis and management Major types of MSDs and their localization and neuromotor basis Type Location Neuromotor Neuromotor Bases Bases General Specific DYSARTHRIA Flaccid LMN FCP Execution Weakness Motor unit Spastic Bilateral UMN Execution Spasticity DAP IDAP Ataxic Cerebellum Control lncoordination control circuits Hypokinetic BG control circuit Control Rigidity decreased extrapyramidal ROM scaling problems Hyperkinetic BG control circuit Control Involuntary extrapyramidal movements Unilateral UMN Unilateral UMN BOTH UMN weakness incoordination or spasticity Mixed More than one Execution andor More than one area control Undetermined APRAXIA OF SPEECH Apraxia Left dominant Motor planning Planningprogramming hemisphere and programming errors Speech Characteristics of the Dysarthrias Type Details Flaccid LMN Weakness paralysis Hypernasal breathy Spastic Bilateral UMN lesions Harsh strained speech slow rate Decreased pitch imprecise articulation rigid brisk reflexes Hyperkinetic Variable rate Excessive variation loudnessl timing Distorted vowels Hypokinetic Decreased loudness pitch monotone lmprecise articulation Decreased ROM Increased rate Ataxic Irregular prosody Explosions of sound Abnormal excessive stress on syllables Differential Diagnosis of Lesions 9 Pertinent Examples from Class 1 Why would UUMN be underestimated or overlooked a DOUBLE INNERVATION 9 Because the majority of CN receive bilateral UMN innervations Usually symptoms are negligible unless VII and XII are affect as they do not follow the bilateral UMN rule The lower face and tongue receive primarily contralateral innervations
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