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Understanding the Neurological and MSK Physical Exam.pptx
- 2. Review of Anatomy - Upper Extremity Brachial Plexus - Network of nerves responsible for motor and sensory innervation of the upper extremities (shoulders, arms, and hands) - Different categories of the brachial plexus - Roots, trunks, divisions, and cords - E.g. The radial nerve comes from the
- 3. Review of Anatomy - Upper Extremity ❏ Triceps - Elbow extension ❏ Biceps - Elbow flexion, supination ❏ Brachioradialis - only elbow flexion ❏ Wrist Flexors - wrist flexion ❏ Wrist Extensors - wrist extension ❏ Hand muscles - abduction, adduction, and opposition (thumb only)
- 4. Review of Anatomy - Lower Extremity Lumbosacral Plexus - A group of nerves responsible for innervation of parts of the genital area and lower extremity
- 5. Review of Anatomy - Lower Extremity ❏ Illiopsoas - Hip flexion ❏ Gluteus maximus - Hip extension ❏ Rectus femoris - knee extension ❏ Biceps femoris - knee flexion ❏ Adductors - Leg adduction ❏ Tibialis anterior - foot dorsiflexion ❏ Gastrocnemius - foot plantarflexion
- 6. Review of Anatomy (cont.) Myotomes - Group of muscles innervated by single spinal root
- 7. Review of Anatomy (cont.) Dermatomes (30 total) - Specific area of skin innervated by certain nerve root Assessment - Light touch test - Pinprick test Pathologies - Disc herniation - Reactivated shingles
- 8. Breaking Down the Motor Examination Muscle Strength testing - Can reveal information of neurological deficits and where the lesion may occur (e.g. disc herniation) - Graded out of 5 0/5 No muscle activation 1/5 Trace muscle activation 2/5 Muscle activation w/o gravity 3/5 Can hold against gravity 4/5 Against some resistance 5/5 Against full resistance
- 9. Breaking Down the Motor Examination Upper Extremity Testing - Arm abduction - Elbow flexion - Elbow extension - Wrist flexion - Wrist extension - Finger abduction - Finger adduction - Thumb opposition Lower Extremity Testing - Hip flexion - Leg abduction/adduction - Knee extension - Knee flexion - Foot dorsiflexion - Foot plantarflexion
- 10. Clinical Example Spasticity Patient Typical Presentation Shoulder - Internal rotation Elbow - Flexion Forearm - Pronation Wrist - Flexion
- 11. Clinical Example (cont.) Botulinum toxin injection for spastic patients - Weakens the muscle activation for ~ 2 months - If a spastic patient presents with pronation of the forearm - many physicians perform a brachialis botox injection as opposed to the biceps as the biceps helps with supination!!!
Editor's Notes
- Here we have the brachial plexus. This is the network of nerves that are responsible for both sensory and motor nerve. When trying to localize a lesion in the neuro/musculoskeletal exam, it’s important to understand the differences between a lesion at the ROOT and a lesion of the NERVE itself (e.g. median nerve lesion presents differently than a C8 lesion - even though the median nerve is derived from part of the C8)
- This is a heavy slide, but the most important things is that on the humeral part of the upper extremity, you have the biceps brachii, the triceps, the coracobrachialis, and part of the brachioradialis. Then on the forearm, you have the wrist extensors and the wrist flexors.
- This is another heavy anatomy slide but the most important things to take out of it is the main muscles involved in the movements of the lower extremity. Every muscle was not included, such as the sartorius being involved in knee extension. When testing the lower extremity on the motor examination - keep in mind what muscles you are testing and what nerves are innervating it.
- Myotomes are similar to dermatomes but instead for muscle innervation of the nerve roots
- You have 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral dermatomes. Common pathologies relating to dermatomes Disc herniation: numbness and tingling to site Shingles: Herpes zoster virus hides in the ganglion of the nerve root and reactivates in a dermatomal pattern
- When testing muscle strength, it can be difficult at first to get a hold of what is 5/5 and what is ⅘. The table lists some standards for muscle strength testing. With more practice, you will be able to tell the difference on physical examination.
- It’s important to stabilize the proximal joint when testing the muscles so that you isolate the area (e.g. stabilize elbow when testing wrist extensors and flexors).
- Patients with spasticity (cerebral palsy, post-stroke, etc.) have different presentations, but this is a common example of how they may present.
- The main thing about understanding anatomy for botox injections for spasticity is understanding the actions of the muscles. Remember that the typical presentation if a flexed elbow and pronated forearm. If you inject at the biceps brachii (which is involved in supination), you may get worsening pronation. Therefore, an alternative is the brachialis muscle which is solely an elbow flexor.