Sensory, coordination & gait Examination for Undergrad
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The document provides information on examining the sensory system. It discusses the different types of sensation including somatic, visceral, and special senses. It then describes in detail how to examine superficial sensation, deep sensation including vibration, joint position, nerve, and muscle sensation. The document outlines examining dermatomal distribution and patterns of sensory loss. It also discusses examining cortical sensation including tactile localization, two-point discrimination, stereognosis, and other tests. Finally, it provides guidance on examining coordination and gait abnormalities.
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Sensory, coordination & gait Examination for Undergrad
- 1. Email: usamaragab@medicine.zu.edu.eg Slideshare: https://www.slideshare.net/dr4spring/ Mobile: 00201000035863
- 2. The Sensory System • Sensation in general is classified into: 1. Somatic sensation 2. Visceral sensation: carried via autonomics NS from viscera 3. Special sense: smell, taste, vision
- 3. Somatic sensation Superficial Sensation: Pain, temperature, touch Deep sensation: Vibration, joint, nerve, muscle Cortical sensation: mix of refined superficial & deep sensation
- 6. Bottomline – Modalities of sensations
- 7. Again, What to examine? Superficial Sensation Deep Sensation Cortical Sensation
- 8. Examination of the sensory system includes
- 9. 1- Superficial sensation • We examine for pain using a pin & for touch using a piece of cotton.
- 10. 1- Superficial sensation (cont.) • Face: start with C2 then 3 areas of trigeminal • Leg → Arm → Face • Leg:Leg → Arm:Arm → Face:Face • Leg: proximal & distal • Arm: proximal & distal • Leg & arm circumference: to detect radiculopathy • Sensory level: Very important in paraplegia and PN Not done in hemihyposthesia and Normal person
- 11. Dermatomal distribution C2 Angle of jaw, lateral neck. C3,4 Shoulder, down manubrium. C5 Lateral aspect of arm. C6 Lateral aspect of the forearm, thenar eminence & thumb. C7 Middle aspect of the forearm, middle of the palm, middle 3 fingers. C8 Medial aspect of forearm, hypothenar eminence & little finger. T1 Medial aspect of arm. T2 → T7 Thorax (T4 4 nipple). T8 → T12 Abdomen (T10 4 umbilicus), (T12 4 inguinal ligament).
- 12. Dermatomal distribution (cont.) L1 Upper 1/3 front of thigh. L2 Middle 1/3 front of thigh. L3 Lower 1/3 front thigh. L4 Anterolateral aspect of thigh, front of knee, anteromedial aspect of leg,medial aspect of foot & big toe. L5 Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot & middle 3 toes. S1 Posterolateral aspect of thigh & leg, lateral 1/3 of dorsum of foot & little toe. S2 Posterior aspect of thigh, leg & sole of the foot. S3,4,5 Anal, perianal & gluteal region (saddle shaped area) in concentric manner.
- 14. Pattern of sensory loss
- 16. Deep sensation 1. Vibration Sense 2. Position (joint) sense 3. Nerve 4. Muscle
- 17. Vibration sense • Tuning fork 128 • Start on forehead to test thalamus Upper limbs Lower limbs • Styloid process of radius: PN • Clavicle: posterior column (PC) • Forehead: thalamus Medial malleolus: PN ASIS: PC Forehead: thalamus
- 18. Muscle sense • Squeeze the calf muscle. • Loss of muscle sense. Called Abadie's sign as in neurosyphilis • Tender calf muscle in: Diabetic P.N. Nutritional P.N. D.V.T. Myositis GBS
- 19. Joint (Position) sense • First learn the patient: position and whether finger is moved or not • Ask patient to close his eye and test position and movement • Caught finger or toe gently
- 20. Nerve sensation • By pressing the ulnar nerve and the lateral popliteal nerve against the bones. • Normally, it results in an electric like sensation.
- 22. Cortical sensation • They are only examined when the superficial and deep sensation are intact with open and closed eyes. 1. Tactile localization 2. Two-points discrimination 3. Stereognosis 4. Graphesthesia 5. Perceptual rivalry
- 23. Don’t forget to ask patient to close his eye
- 24. Tactile localization •Prick and ask where
- 25. Two-point discrimination • Prick 2 places and ask where
- 26. Stereognosis • Recognize familiar objects within hands
- 27. Graphesthesia • Recognize letter or number on your hand
- 28. Perceptual rivalry • 2 simultaneous pricks in 2 corresponding sites
- 29. Co-ordination
- 30. Ataxia Ataxia means incoordination Disorders of cerebellum = cerebellar ataxia Disorders of Deep sensation = sensory ataxia
- 31. Co- ordination (cont.) • Should be examine after power. • Once while eyes are opened to examine cerebellum • Once while eyes are closed to examine deep sensation
- 32. Upper limb 1- Finger to nose. 2- Finger to finger. 3- Finger to doctor finger (and to moving doctor finger). 4- Adiadokokinesia or Dysdiadokokinesia 5- Rebound phenomenon 6 - Buttoning unbuttoning test (the earliest sign)
- 33. 1- Finger to nose test Try to reach your tip of nose
- 34. 2- Finger to finger test • Touch tip of each of your index fingers from distance
- 35. 3- Finger to doctor’s finger test • The tip of his forefinger from a distance o doctor's forefinger.
- 36. In any of the above tests you may find: Decomposition of movement. Kinetic intention tremors which is evident as the patient's forefinger approaches the target. Dysmetria in the form of Hypometria or hypermetria.
- 37. 4- Adiadochokinesia or Dysdiadochokinesia • Do rapidly alternating movement in pronation and supination of the forearm.
- 38. 5- Rebound phenomenon • The patient is fixed, flexes his arm against resistance. • While suddenly released the patient's forearm may hit his face or shoulder.
- 40. Lower limbs Heel to knee. Heel to doctor finger?? Walking along straight line Romberg test
- 41. 1- Heal to knee test • The patient raise down its heel onto the knee of his other leg then move it down along the shaft of the tibia.
- 42. Again, all above tests are positive if: Intention tremor. Decomposition of movement. Dysmetria.
- 43. Romberg sign • Ask the patient to stand with the heels together, 1st with his eyes open, then with his eyes closed. • Note any swaying or loss of balance. • If present: With eyes open or closed = cerebellar ataxia. Only with closed eyes = sensory ataxia.
- 44. Gait
- 45. Gait Gait is the pattern that you walk. Sometimes, an injury or underlying medical condition can cause an abnormal gait. Certain gait abnormalities are temporary, and others require lifelong management.
- 46. Phases of gait
- 47. To examine gait, we need Intact motor system Intact sensation (esp. deep) Intact Cerebellum Intact musculoskeletal system
- 49. Ask patient to walk tandem • Toe to heel • Or as he wish • Tandem walk, in examination of ataxia
- 50. Hemiplegia = Circumduction gait
- 51. Paraplegia = scissoring gait
- 54. Ferdrich's ataxia (archicerebellum): drunken Marie's ataxia (Neo cerebellum): Unilateral: deviation to one side. Bilateral: Zigzag.
- 60. Thanks
Notes de l'éditeur
- Compare both sides leg to leg, arm to arm & face to face. Compare on each side, the L.L. with the trunk, with the U.L. & with the face. In case of hyposthesia in a limb, test all around it to differentiate between radicular sensory loss & glove & stock hyposthesia. ------------------- Face: start with C2 then 3 areas of trigeminal Leg → Arm → Face Leg:Leg → Arm:Arm → Face:Face Leg: proximal & distal Arm: proximal & distal Leg & arm circumference Sensory level: Very important in paraplegia and PN Not done in hemihyposthesia and Normal person ------------------------------------ Start with C2 1. Compare right with left at (face - upper limb - lower limb) →↓ in one side in hemiplegia. 2. Compare the same side at (face - upper limb - trunk - lower limb) Jacket of sensory loss in intramedullary compression paraplegia. Decrease sensation in lower limb in extramedullary compression paraplegia. 3. Compare proximal with distal (PN). 4. Level. 5. Circumferential to detect radiculopathy
- Dermatomes are areas of skin on your body that rely on specific nerve connections on your spine. In this way, dermatomes are much like a map. There are 8 cervical segments & only 7 cervical vertebra. ----------- The five groups of spinal nerves are: Cervical nerves. There are eight pairs of these cervical nerves, numbered C1 through C8. They originate from your neck. Thoracic nerves. You have 12 pairs of thoracic nerves that are numbered T1 through T12. They originate in the part of your spine that makes up your torso. Lumbar nerves. There are five pairs of lumbar spinal nerves, designated L1 through L5. They come from the part of your spine that makes up your lower back. Sacral nerves. Like the lumbar spinal nerves, you also have five pairs of sacral spinal nerves. They’re associated with your sacrum, which is one of the bones found in your pelvis. Coccygeal nerves. You only have a single pair of coccygeal spinal nerves. This pair of nerves originates from the area of your coccyx, or tailbone. ------------------- Your body has 30 dermatomes. You may have noticed that this is one less than the number of spinal nerves. This is because the C1 spinal nerve typically doesn’t have a sensory root. As a result, dermatomes begin with spinal nerve C2. Dermatomes have a segmented distribution throughout your body. The exact dermatome pattern can actually vary from person to person. Some overlap between neighboring dermatomes may also occur. Because your spinal nerves exit your spine laterally, dermatomes associated with your torso and core are distributed horizontally. When viewed on a body map, they appear very much like stacked discs. The dermatome pattern in the limbs is slightly different. This is due to the shape of the limbs as compared with the rest of the body. In general, dermatomes associated with your limbs run vertically along the long axis of the limbs, such as down your leg.
- Vibration sensation: using tuning fork 128 Place the vibrating fork over the bony prominences: medial malleouls - anterior tibial tubercle - anterior superior iliac spine (ASIS) - styloid process & clavicle. Ask the patient if he feels the fork's vibrations & if they are felt equally on all sites if V.S. is diminished or lost over medial malleolus, check A.S.I.S., if lost, It suggest posterior column lesion, if intact, it suggests P.N. lesion.
- Joint sense (sense of position and movement): first show the patient with his eyes open, the position of his big toe (dorsi-flexed), then with his eyes closed, move the big toe and ask him if he feels it moving and if so in which direction. The big toe should be caught gently, from the sides.
- Causes of thick nerves: Leprotic neuropathy Acromegaly Myxedema Neurofibromatosis Interstitial hypertrophic polyneuropathy
- Ask the patient to close his eyes, then prick his finger & ask him to localize the site of the prick.
- With his eyes closed, the patient is asked to recognize a familiar object placed in his hand.
- With his eyes closed, the patient is asked to recognize a number or letter drawn over his palm.
- Normally if you deliver 2 simultaneous pin pricks at 2 corresponding sites of the body, both pricks are felt; in cortical sensory loss, only the prick on the healthy side is felt.
- Ataxia is a term for a group of disorders that affect co-ordination, balance and speech. Any part of the body can be affected, but people with ataxia often have difficulties with: balance and walking. speaking. swallowing. ----------------- Damage to vermis: Causes truncal ataxia. Damage to cerebellar hemisphere: Causes ipsilateral cerebellar ataxia.
- Integration of Cerebellum → open eye. Deep sensation → closed eye.
- The patient brings the tip of his forefinger from a distance onto the tip of the nose The test is conducted with the eyes open then closed
- The patient brit forefinger from the distance of his out meet each other in the midline.
- Patient is asked to do rapidly alternating movement in pronation and supination of the forearm. In cerebellar ataxia there is failure to perform the movements.
- The patient is fixed, flexes his arm against resistance. While suddenly released the patient's forearm may hit his face or shoulder.
- Hemiplegia: circumduction. Paraplegia: scissoring. P.N.: high stepping. Sensory ataxia: stamping. Ferdrich's ataxia (archicerebellum): drunken. Marie's ataxia (Neo cerebellum): Unilateral: deviation to one side. Bilateral: Zigzag. Parkinsonism: Short steppage. Shuffling. Festinant. Chorea: dancing