Adobe Systems 1 NEUROLOGY: MEDICAL HISTORY, PRINCIPLES OF NEUROLOGICAL EXAMINATION, EXAMINATION OF CRANIAL NERVES, REFLEXES, DIFFERENT TYPES OF PARESIS, MUSCLE TONE Doc. MUDr. Eva Vlčková Ph.D., Department of Neurology, University Hospital Brno [USEMAP] Adobe Systems Department of Neuroiogy, University hospital Brno 2 NEUROLOGY ̶a branch of medicine dealing with DISORDERS OF THE NERVOUS SYSTEM ̶deals with the diagnosis and treatment of conditions and disease involving: ̶CENTRAL AND PERIPHERAL nervous systems including their coverings, blood vessels ̶MUSCLES including neuromuscular junction ̶ → NO STETOSCOPE → NEUROLOGICAL HAMMER https://i.ebayimg.com/images/g/YikAAOSwYYpcFxBR/s-l1600.jpg Image result for neurological hammer [USEMAP] Adobe Systems Department of Neuroiogy, University hospital Brno 3 DISEASES OR CONDITIONS ̶Stroke (ischemic or hemorrhagic) ̶Epilepsy (https://el.lf1.cuni.cz/epilepsie/default/Videa/video8.html) ̶Parkinson's disease (https://el.lf1.cuni.cz/pn/default/kazuistiky/kazuistika1.html) ̶Multiple sclerosis ̶Brain/spinal cord tumors ̶Migraine + other headaches ̶Carpal tunnel syndrome ̶Neuromuscular diseases ̶Spine + spinal cord diseases [USEMAP] Adobe Systems 4 MEDICAL HISTORY – PRESENT ILLNESS = getting information from the patient or – in some cases – from other observer (important in seizures, dementia, aphasia…) ̶Start with the PATIENT´S CHIEF COMPLAINT („what brings you to see me?“) these data focus attention on particular questions to be addressed in taking the history and clinical examination ̶HISTORY OF PRESENT ILLNESS including a history of development of particular symptoms: ̶mode of onset ̶duration a and progression are critical in investigating the etiology! (sudden onset x paroxysmal episodes x exacerbations and remissions x fast or slow progression) ̶CHARACTERISTICS OF THE SYMPTOMS (intensity – VAS, Likert scale, localisation, what relieves/makes the symptom worse) ̶ ̶ [USEMAP] Adobe Systems MEDICAL HISTORY – OTHER DATA ̶history of MEDICAL ILLNESSES AND PREVIOUS SURGICAL PROCEDURES: ̶neurological system is affected by many non-neurological diseases (DM) ̶adversely neurological diseases may involve the function of many systems (Parkinson disease, diabetic neuropathy) ̶Neurological presentation may be a part of multiorgan involvement (sarciodosis, vasculitis, mitochondrial diseases, storage diseases) ̶current (and sometimes previous) MEDICATIONS AND ALLERGIES previous – chemotherapy, izoniazid, neuroleptic agents current – hypolipidemics, corticoid hormones, neuroleptics, opioids, hypnotics…. ̶ [USEMAP] Adobe Systems MEDICAL HISTORY – OTHER DATA ̶timing of developmental milestones (sitting, walk, first words) in infants and young children in adults whose illness started during childhood also the ̶personal and social history occupation marital status excessive stress at home, in school or in the workplace ̶did the patient ever use of alcohol, tobacco? ̶or did he used any other prescription or illegal drugs (dependence)? ̶family history (cave! misinterpreting symptoms and sings! – consequence of aging, family secret…) [USEMAP] Adobe Systems CLINICAL NEUROLOGICAL EXAMINATION ̶FULL NEUROLOGICAL EXAMINATION tests in detail every central nervous system region, peripheral nerve, muscle, sensory modality and reflex ̶→ too lengthy to perform in practice. ̶in practice: FOCUSED NEUROLOGICAL EXAMINATION to examine in detail the neurological functions that are relevant to the history ̶+ then SCREENING NEUROLOGICAL EXAMINATION to briefly check remaining parts of the nervous system ̶both presence and absence of abnormalities may be of diagnostic importance (separation of hemiparesis arising from spinal cord and right cerebral cortex lesion….) [USEMAP] Adobe Systems SCREENING NEUROLOGICAL EXAMINATION =QUICK EVALUATION OF: ̶mental status ̶cranial nerves ̶motor system ̶strength ̶muscle tone and tendon reflexes ̶presence of involuntary movements and postures ̶coordination ̶gait and balance ̶sensation ̶ [USEMAP] Adobe Systems NEUROLOGICAL EXAMINATION ̶STARTS ALREADY DURING THE INTERVIEW: ̶mental status, memory disturbace ̶changes of facial expresion or mimics hypomimia ptosis ̶pattern of speech (dysarthria, aphasia), ̶presence of abnormal involuntary movements ̶….. [USEMAP] Adobe Systems EXAMINATION OF THE LIMBS/TRUNK Separate testing of each limb: ̶Presence OF INVOLUNTARY MOVEMENTS, ABNORMAL LIMB POSITION (pain release, flexion, extension) ̶MUSCLE MASS (atrophy x (pseudo- hypertrophy)) ̶MUSCLE TONE in response to passive flexion and extension ̶ACTIVE MOVEMENTS in particular segments or joints (pasive motility?) ̶Paretic signs + ++Power of main muscle groups ̶DEEP TENDON REFLEXES ̶Plantar responses or other ABNORMAL REFLEXES ̶COORDINATION [USEMAP] Adobe Systems MOTOR PATHWAYS ̶1. (central) motoneuron (central paresis)= GYRUS PRECENTRALIS ̶ ̶è PYRAMIDAL TRACT ̶Branches towards cranial nerves nuclei ̶ ̶CROSS OVER IN THE MEDULLA LEVEL ̶resulting in muscles being controlled by the opposite side of the brain ̶ ̶2. (peripheral) motoneuron (peripheral paresis)= ANTERIOR HORN OF THE SPINAL CORD (or cranial nerve nuclei) ̶ ̶è PERIPHERAL NERVE è MUSCLE ̶ [USEMAP] Adobe Systems 12 MOTOR SYSTEM •Consists of 2 basic types of movements: •VOLUNTARY MOVEMENTS •EASY (locomotion, rythmic movements) •COMPLICATED (piano playing) •REFLEX RESPONSES = fast, stereotypic, involuntary, evoked by a stimulus •A part of many voluntary movements •E.g. Maintain muscle tone, relax antagonists during agonist contraction ̶ABNORMAL MOTOR FUCTION RESULTS TO MUSCLE WEAKNESS= PARESIS = loss of voluntary movements (reflex movements may be perserved) ̶ • • •ft [USEMAP] 13 DEEP TENDON REFLEXES •Intact REFLEX ARC • •BASIC PRINCPLE : •Blow upon the tendon with a hammer •→ short muscle stretching •→ leads to muscle contraction of the same muscle • •Quantification: 180px-Kladivko GRADE Reflex 0 (--) Absent 1 (-) Decreased (hypoactive) 2 (N) Normal 3 (+) Increased (hyperactive) without clonus 4 (++) Hyperactive with clonus [USEMAP] Adobe Systems PROPRIOCEPTIVE REFLEXES (DTR) General interpretation: ̶Decreased DTR = periheral paresis (flaccid) ̶Increase DTR = central paresis (spastic) ̶ ̶In physiological conditions: symmetrical and intraindividually ± stable ̶Note interindividual differences ̶Note possible asymmetry ̶Note possible changes during the patient follow-up (decrease? Increase?) ̶ ̶ DEEP TENDON REFLEXES [USEMAP] 15 DEEP TENDON REFLEXES - UE Biceps reflex (C5-6): reflex contraction of the biceps muscle and jerk of the forearm. Styloradial (pronatinon) (C6) (periosteal): tapping the processus styloideus radii (elbow in flexed in 90 degrees and semiproned forearm) leads to the slight forearm pronation Triceps reflex (C6-8,mainly C7): tapping the triceps tendon while the forearm is hanging loose at a right angle to the arm causes the forearm extension. Reflex of finger flectors (C8): tapping the ligamentum carpi transversum leads to slight flection of the fingers [USEMAP] Adobe Systems 16 DEEP TENDON REFLEXES - LE Patellar reflex L2-L4 (knee-jerk) = striking the patellar tendon with a hammer just below the patella causes the quadriceps femoris contraction and shank extension Ankle jerk reflex S1/S2 (Achilles reflex) occurs when the Achilles tendon is tapped while the foot is dorsi-flexed leading to the jerking of the foot towards its plantar surface [USEMAP] Adobe Systems MUSCLE MASS, ATROPHY ̶ [USEMAP] Adobe Systems MUSCLE TONE ̶MUSCLE'S RESISTANCE TO PASSIVE STRETCH DURING RESTING STATE ̶DECREASED (flaccidity) in lower motor neuron/ peripheral nerve disseases ̶INCREASED in central nervous system disease: spasticity or rigidity ̶ ̶SPASTICITY is caused by stretch reflex exaggration and accordingly is dependent on stretch rate: ̶if the muscle is slowly stretched, tone may be normal ̶if the muscle is stretched more rapidly, increasing amounts of resistance occur ̶⇒ rate-sensitive, preferential involvement of extensors ̶„clasp knife“ or pocket knife fenomenon ̶central motor neuron dysfunction/lesion/disease ̶RIGIDITY: increased muscle tone, not depending on the rate of movement. ̶found equally in both extensors and flexors (leadpipe rigidity, cogwheel phenomenon) ̶caused by extrapyramidal disease (or side effect of antidopaminergic drugs) [USEMAP] Adobe Systems ACTIVE MOVEMENT TESTING ̶PARETIC SIGNS = signs of paresis (Not much used in English sources) ̶FUNCTIONAL TESTS OF MUSCLE ENDURANCE, reflect global impairment of muscle strength in particular extremity, not only the dysfunction of pyramidal tracks ̶ ̶UE: Mingazzini – holding the extended arms raising forward, eyes closed (15 seconds or more) (decrease?) Duffour (pronator drift) – supination in the same position (pronation?) ̶LE: Mingazzini – in lying position, lower extremities flexed in hipps and knees (90 degrees angle) ̶ ̶ [USEMAP] Adobe Systems ACTIVE MOVEMENT TESTING ̶Shoulders - abduction ̶Elbow – flection, extension ̶Wrist – flection, extension ̶Make a pinch ̶Hip – flection ̶Knee – extension, flection ̶Ankle – dorsal and plantar extension ̶Movements of the big toe ̶ ̶ ACTIVE MOVEMENT IN EACH BIG JOINT [USEMAP] Adobe Systems WEAKNESS (MUSCLE STRENGTH) 5-POINT MEDICAL RESEARCH COUNCIL (MRC) GRADING SCALE ̶Grade 5 represents normal strength. ̶Grade 4 = ability to move the limb only against gravity and resistance, but not full strength: represents “weakness” somewhere between 3 and 5. Covers such a large range, that should be expanded into mild, moderate, or severe: 4+, 4, and 4– ̶Grade 3 = ability to move the limb only against gravity (not against resistance) ̶Grade 2 = active movement only with gravity eliminated ̶Grade 1 = is just a flicker or trace of contraction (visible contraction without visible joint movement). ̶Grade 0 = no contraction ̶ [USEMAP] Adobe Systems ABNORMAL REFLEXES (EXTENSION) ̶„Atavistic reflex“ (physiological in early infancy) ̶Elicited by scratching the skin (not painful!) of the bottom of the foot along its lateral aspect from the heel forward ̶A = Plantar reflex (normal response = flection of the foot and toes) ̶B = Babinski sign (extensor plantar response ) ̶C= Triple flexion response (a spinal reflex characterized by hip and knee flexion accompanied by ankle dorsiflexion) [USEMAP] Adobe Systems ABNORMAL REFLEXES - LE ̶Other abnormal reflexes with EXTENSOR RESPONSE: ̶Roch - scratching the skin of lateral aspect of the foot from the heel forward to the half of the distance hell-fingers ̶Chaddock - scratching the skin below the external ankle ̶Oppenheim – stimulation of the skin of anterior aspect of the shank (crura) by the examinator thumb and second finger ̶Gordon – distal calf massage ̶ ̶Abnormal reflexes with FLEXOR RESPONSE: ̶Rossolimo: tapping the balls of the fingers (from plantar aspect) by hammer produces their flection [USEMAP] Adobe Systems ABNORMAL REFLEXES - UE ̶JUSTER PHENOMENON (CUTANEOUS OR SUPERFICIAL REFLEX) ̶counterpart of an extensor plantar reflex, a positive proof of pyramidal tract dysfunction) ̶Elicited by scratching the skin of the palm along its lateral aspect (antithenar side) in the distal direction and then along the metacarpo-phalangeal joints to the thumb. ̶Normal reaction = no reaction ̶Slow tonic slight adduction of the thumb with slight opposition represents abnormity = sign of pyramidal dysfunction ̶ ̶ ̶ [USEMAP] Adobe Systems ABNORMAL REFLEXES - UE ̶TRÖMNER´S SIGN - with the fingers of the patient partially flexed, the tapping of the volar aspect of the tip of the middle or index finger ̶https://www.youtube.com/watch?v=59Tw9hbbAZE ̶A HOFFMANN REFLEX — evoked by flicking a dorsal aspect of the relaxed finger tip with the fingers held in semiflexion ̶https://www.youtube.com/watch?v=saUkeRHkeCw ̶positive response in both of them = flexion of all four fingers and thumb; ̶simply implies increased muscle tone ̶not a direct counterpart of an extensor plantar reflex, which is positive proof of pyramidal tract dysfunction ̶ [USEMAP] Adobe Systems FLACCID VS. SPASTIC PARESIS (CENTRAL VS. PERIPHERAL) ̶The term "flaccid" indicates the absence of spasticity or other signs of disordered central nervous system motor tracts such as hyperreflexia, clonus, or extensor plantar responses or other abnormal reflexes ̶ ̶SPASTIC PARESIS = CENTRAL (upper motor neuron dysfunction) ̶FLACCID PARESIS = PERIPHERAL (lower motor neuron dysfunction) ̶ ̶Following the sudden development of central paresis (stroke…), the central paresis is flaccid for few days (weeks?) ̶ ̶ ̶ [USEMAP] Adobe Systems 27 FLACCID VS. SPASTIC PARESIS (CENTRAL VS. PERIPHERAL) SPASTIC PARESIS FLACCID PARESIS MUSCLE STRENGTH ↓↓ ↓↓ MUSCLE TONE ↑↑ ↓↓ DEEP TENDON REFLEXES ↑↑ ↓↓ MUSCLE MASS Without pronaunced atrophies (only mild as a result of inactivity) Atrophies (take some time to develop) ABNORMAL REFLEXES Present Absent DISTRIBUTION Hemiparesis, paraparesis, sometimes monoparesis Particular nerve/root/plexus. Para-/ quadriparesis [USEMAP] Adobe Systems CASE REPORT 1 ̶Patient MD, man, 49 years old ̶No regular medication, no important medical history ̶For 2 months slow progression of headache (increasing intensity) and weaknes of left arm and leg and slight articulation problems ̶decline of psychomotor speed according to his relatives ̶Clinically: decreases muscle strength in left extremities, increased deep tendon reflexes, spasticity (↑ muscle tone), Babinsky sign ̶ ̶= CENTRAL (SPASTIC) HEMIPARESIS (+ dysartria + ↓ PM speed) in patient with brain tumor (MR →) ̶ T1-weighted axial gadolinium-enhanced MRI demonstrates an enhancing tumor of the right frontal lobe – glioblastoma multiforme [USEMAP] Adobe Systems CASE REPORT 2 ̶TR, women, 73 years old ̶Diabetes mellitus type II (25 years) ̶BMI 31, hypertension, hypercholesterolemia… ̶For 10 years slow progression of sensory symptoms (numbness in feet, speading proximally) and later motor weakness in distal parts of her lower legs. ̶Peroneal (and calf) atrophies (→), ↓ muscle tone, ↓ deep tendon reflexies, peroneal paresis, stocking-like dysesthesia ̶PERIPHERAL PARESIS – FLACCID in patient with severe diabetic polyneuropathy [USEMAP] Adobe Systems 30 OTHER TYPES OF PARESIS -FLACCID CENTRAL PARESIS – initially following acute-onset central motor neuron lesion (it takes few hours or days to develop spasticity) •Muscle tone and proprioceptive (deep tendon) reflexies are decreased •Abnormal reflexes (Babinsky) are frequently negative at the initial phase •No atrophies, no fasciculation •Note the distribution (hemi?, para? mono?) • -MIXED upper and lower motor neuron lesion (e.g. Amyotrophic lateral sclerosis) •Muscle tone and proprioceptive (deep tendon) reflexies may be ↓ or ↑ (more frequently ↑) •Abnormal reflexes (Babinsky) frequently positive •Fasciculations and atrophies •No sensory distrubance!!! (unless the association with other neurological diseases occurs) • ̶ ̶ [USEMAP] Adobe Systems CASE REPORT 3 EF, woman, 63 years old ̶Medical history: Diabetes mellitus type 2 (for 17 years), arterial hypertension, hypercholesterolemia, smoking 20 cigarettes per day since the age of 20 → many vascular risk factors ̶Present illness: During the dinner, she realized a sudden onset of impaired speach, which was not fluent. The patient was not able to express what she wanted, but was able to understand quite well. Furthermore, the right sided weakness also developed within few minutes. ̶The symptoms remained, so she called emergency and was brought to the emergency department. ̶Clinical findings: NONFLUENT (BROCCAS´) APHASIA AND RIGHT SIDED FLACCID HEMIPARESIS (decreased muscle strength and positive paretic signs, decreased proprioceptive reflexes, negative Babisky sign, no atrophies, no fasciculations). ̶Acute CT = negative = ACUTE ISCHEMIC STROKE ̶The patient treated with systemic thrombolysis with partial effect (regression of the symptoms, but not complete) ̶Subacute MR confirmed the ischemic region in corresponding area. Akutní infarkt - mírné vymizení sulků na postižené straně Acute CT: no clear abnormities Subacute MR – ischemic region in left posterior F lobe. [USEMAP] Adobe Systems 32 CASE REPORT 4 GH, man, 56 years old ̶Medical history: no relevant chronic disease, no regular treatment ̶Present illness: 1,5 year ago the patient started to feel clumsiness of his right hand. He was not able to button up shirts as effectively as he used to do previously. The problems slowly progressed and spread proximally. Later on, he noticed the slowly progressive loss of muscle mass in his righ UE and specific jerks in these muscles (fasciculations). During next months, similar symptoms appeared in the left hand and right lower extremity (frequent tripping due to a foot drop). He also noticed some difficulties during swallowing and speaking. ̶Clinical findings: Dysartria, dysphagia, tongue with atrophies and fasciculations. ↓↓ muscle strength in all four extremities, neck/head and the trunk with the loss of muscle mass and fasciculations (signs of peripheral motor neuron dysfunction) together with increased deep tendon reflexes and the presence of abnormal reflexes (signs of central motor neuron dysfunction) = mixed quadriparesis. Normal sensitivity. ̶MR of the brain, C, Th and LS spine: no relevant explanation, CSF normal. ̶EMG: pure motor axonal lesion with the signs of denervation and reinnervation and fasciculation in UE, LE, head/neck and trunk ̶The diagnosis of AMYOTROPHIC LATERAL SCLEROSIS established ALS fasciculations (Amyotrophic lateral sclerosis)(Motor neuron disease) - YouTube [USEMAP] 33 PSYCHOGENNIC PARESIS (FUNCTIONAL WEAKNESS, NON-ORGANIC PARALYSIS) -weakness of an arm or leg without evidence of damage or a disease of the nervous system -psychogennic trigger -a manifestation of 'dissociative motor disorder' or CONVERSION DISORDER -or FEIGNING (the patient is just pretending the symptom) -both INTERNALLY INCONSISTENT and incongruent with any neurological disease. -Only „weakness“ (decreased strength + paretic signs – note Dufour!) -without any other neurological symptoms •Normal reflexes (both proprio- and exteroceptive), normal muscle tone •No abnormal reflexes (Babinsky) •No atrophies, no fasciculations •Fluctuating (unstable) weakness severity, not respecting anatomic distributions •Frequent atypical features (predominant plantar flexion weakness, not able to flex UE in the elbow…) [USEMAP] Adobe Systems EXAMINATION OF CRANIAL NERVES – I, II I: Gross assessment: ask patient about the ability to smell and changes of food flavor ̶More detailled testing: in all persons who experience spontaneous loss of smell in patients suspected to have Parkinson's disease and in patients who have suffered head injury ̶familiar odoriferous substance (using a small bottle of coffee, oil of cloves, or oil of peppermint, soap) held beneath each nostril in turn while the other is occluded by a finger, eyes closed II: Each eye: Gross visual acuity (optotypes, reading, fingers) ̶Visual fields by confrontation (perimeter) ̶Funduscopy ̶ Image result for optotypy Image result for optotypy Image result for perimeter eyes [USEMAP] Adobe Systems 35 EXAMINATION OF CRANIAL NERVES: III, IV, VI ̶Horizontal and vertical eye movements (full range of movements/ limitations) ̶Position of the ocular bulbi: parallel, squint: diplopia (subjective, head tilt) strabismus (objective) – convergent, divergent ̶Presence of nystagmus or other ocular oscillations Nystagmus: direction, degree, amplitude, frequency ̶Pupil size (norma – midposition, miotic, mydriatic, symmetry – isocoria, anisocoria) ̶Pupil shape (round, irregular) ̶Pupillary response to light – direct (illuminated pupil), indirect (consesual) ̶Ability of convergence and pupilary reaction to it (constriction) ̶ ̶ ̶ Oculomotor nerve palsy dx Abducens palsy dx [USEMAP] Adobe Systems EXAMINATION OF CRANIAL NERVES: V, VII, VIII V: pressure to points where the 3 divisions emerge from the bone - painful ? Corneal reflex (trigemino-facia), masseter reflex (trigeminal) Touch and/or pinprick sensation on face (compare both sides) Chewing muscles movements and strength (masseter, temporalis, pterygoid muscles) VII: facial symmetry in rest and action (Close eyes, show teeth: wrinkles, eyebrows, mouth angle drop) VIII: Perception of whispered voice in each ear or rubbing of fingers; if hearing is impaired, look in external auditory canals and use tuning fork for lateralization of bone versus air sound conduction. Vertigo? Tinnitus? [USEMAP] Adobe Systems EXAMINATION OF CRANIAL NERVES: IX-XII IX, X: Palate (uvula) in rest in the midline position, ̶lifts symetrically during phonation, ̶dysarthria? dysphonia (hoarse voice)? Gag reflex (pharyngeal reflex) = a reflex contraction of the back of the throat evoked by light touching the soft palate (e.g. by cotton wool bud) Palate reflex: particular (left or right) palatine arch lifts slighly in a response to slight touch of particular arch XI: Shrug shoulders, turn (rotate) the head against counteraction ̶ XII: Protrude tongue (tongue position in rest in the mouth and during protrusion) (mid-position,no atrophy,no fasciculations) ̶ ̶ [USEMAP]