Function of Brain and History Taking of a

Neurological Patient

SEMINAR by : ABHILASH DASHEmail ID : physio.abhilash@gmail.com

CONTENTS

Classification of Nervous System

Function of Different Parts of Brain

Function of Autonomic Nervous System

Demographic Data of Patient

Clarifying the “Symptom”

First impression when Patient comes

Systemic Enquiry key Question

References

Ner

vou

s Sy

stem

CN

S

PN

S

Brain

Spinal

cord

Forebrain

Hindbrain

Midbrain

Telencephalon

Diencephalon

Pons

Medulla

oblangata

Cerebellum

Parasympathetic

division

Sympathetic

division

Somatic NS

Autonomic

NS

Spinal

nerve

Cranial

nerve

Functional Area In Frontal Lobe :

1- Primary motor area(area 4)- Controls voluntary motor activity of the opposite half of body by contraction of muscles.

2- Premotor area (area 6)-Responsible for programming the intended movement of primary motor area and controlling the movement in progress.

3-Supplementary motor area- Produces complex movements.

4-Frontal eye field (area 8)- controls movement of eyeball, opening closing of eye lid.

5-Motor speech area of Broca’s (area 44& 45)- For production of expressive and speech by connecting adjacent primary motor area which stimulate muscle of larynx, mouth, tongue, soft palate, respiratory muscle.

6-Prefrontal area (area 9,10,11,12)-Concerned with individual personality, intelligence, judgment of an individual, also emotion, social, moral & ethical awareness.

Lesion cause Difficulty in initiation and performance of limbs, eye, speech movement. Attention disorder, Planning dysfunction, Memory dysfunction, Disorder of abstract thinking, concept formation Language disorder, Behavioral symptom

Parietal lobe

1-Primary sensory area(area 1,2,3)-Concerned with perception of pain, touch, temperature and proprioceptive like vibration, muscle, joint sense sensations from opposite half of body.

2-Secondary sensory area-Relate to pain perception

3-Sensory association area(area 5,7)- Perception of shape, size, roughness & texture or object without seeing it.

4-Sensory speech area of Wernicke(area 22,39,40)- Concerned with interpretation of language through visual and auditory input. Also an essential zone for contact ability or learned word pattern.

Lesion cause Contralateral hemisensory loss. Astereognosis – inability to determine 3-D shape by touch Right-left confusion. Difficulty with writing and language Impaired long term memory. Inability to perceive objects normally Altered sexual behavior

Primary motor & Primary sensory area

Temporal Lobe

1- Primary auditory area(41,42)- Perception of loudness, quality and pitch of sound.2-Secondary auditory area(area 22)- Receives input from primary auditory area and correlate them with the past auditory experience.

Lesion cause- Forgetfulness, Problems with speech and language Problems with hearing, identifying objects, learning new information Problems with memory and changes in your personality. Loss of inhibition of talking

Occipital Lobe

1- Primary visual area/striate area(area 17)- Concerned with reception and perception of isolated visual impression like colour,size,form,motion,illumination & transparency2- Secondary visual area(area 18,19)- Receives fibers from primary visual area and relate information with past experience to recognize, appreciate what he is seeing.

Lesion cause- Patients experience severe vision loss or total blindness. loss of visual capability. Inability to identify colours. Hallucinations.

Basal Ganglia

o Regulate muscle tone so help in smoothening of voluntary motor activity.o Concern with planning and programming of voluntary movement.o Determined speed and range of movement.o Decrease muscle tone and decrease unwanted muscle activity.o Control group movement for emotional expression.

Clinical imp- Parkinsonism Athetosis Wilson’s disease Chorea

.

Thalamuso Sensory integration and relay station of a sensory pathway except olfactory

pathway.o Capable of recognition pain, thermal, other sensation.o Act as a alertness of brain as whole.

Clinical imp-o Sensory problem, o Sensory ataxia,

Midbraino Superior colliculi- Reflex center for visual reflex.o Inferior colliculi- Reflex center for auditory stimuli.o Red nucleus- Involuntary control of muscle tone and posture.o Coordinate the movement of eyes head neck in response to stimulation.o Eye movement and constriction of pupil.o Substantia nigra- Regulate the activity of basal ganglia.

Lesion causes- Weber's Syndrome- Ipsilateral Oculomotor palsy

with contralateral hemiplegia.

Ptosis, pupil unequal and dilated.

Perinaud’s Syndrome- paralysis of upgaze of eye

Parkinsonism

Contralateral hemiparesis of body.

Contralateral lower facial muscles palsy.

Hind brainPonsRegulate the sleep/awake cycle which influence fatigue, motivation, degree of alertness by coordinating with ANS.o Motor roles- Eye movement, facial expressions, chewing, swallowing.o Dreaming and formation of dream.o Respiration control.o Secretion of saliva and tears.

Clinical imp- Pons stroke- patient experiences double vision, dizziness, vertigo, slurred

speech, imbalance, deep coma, hyperpyrexia (deep fever).

Foville’s syndrome- crossed facial palsy due to 7th nerve nucleus lesion.

Crossed facial palsy i.e one side facial palsy with opposite side limb palsy.

Medulla oblangata

o Control autonomic function such as breathing, heart rate, etc.o Regulate respiratory movementso Regulates autonomic reflex such as sneezing, coughing, swallowing, vomiting, blood

vessel dilation and constriction.o Act with cerebellum for coordinated movement.

Lesion cause- Medulla oblongata stroke cause sensory problem, numbness, paralysis, difficulty in

swallowing, and lack of movement control.

Along with autonomic function problem.

Wallenberg's syndrome- Loss of pain and temperature on face and body, loss of gag reflex, dysarthria, ptosis, ipsilateral paralysis of tongue, pharynx, palate, larynx. Patient fall on same side.

Bonnier’s syndrome- double vision, nausea, deafness arm leg weakness, rapid heart rate, vertigo,nystagmus

Cerebellum

o Control of muscle toneo Control of posture and equilibriumo Control of voluntary movement

Lesion cause-• Ataxia-loss of muscle coordination along with blurry vision, difficulty in swallowing,

tiredness, difficulty in muscle control, abnormality of speed , range, rhythm, starting and stopping.

• Tremor- Tremor of hand is common. Also tremor of limb, head, trunk can occur.• Cerebellar dysarthria- Jerky and explosive speech with separated syllables

• Nausea and vomiting

• Ocular motor abnormality, Nystagmus

• Hypotonia- In limbs

• Diadochokinesia- Inability to do rapidalternating movement.

Scanning speech

Reticular Formation(in brain stem)

o Important center like cardiovascular, respiratory, swallowing, vomiting are present.

o Receives and integrates the information from all CNS.

o Regulate the level of consciousness and alertness.

o Modulate impulse in pain pathway.

o Regulate tone of skeletal muscle

Limbic System

o The structures of the limbic system are involved in motivation, emotion, learning, and memory.

o Also sensory processing, time perception, attention, consciousness.o It also regulate autonomic NSo Fight ,flight behavioro Socio sexual behavior

Disorder associated-• Epilepsy , • Schizophrenia, • Anxiety disorder, • Dementia-• Alzheimer's disease-

Symptoms can include problem with language,disorientation, mood swing, loss of motivation,behavioral issue.

Function of Autonomic NS :Sympathetic Nervous system Dilation of pupil Vasoconstriction of blood vessel. Secretion of sweat gland Stimulation of heart Bronchodilation Inhibition of secretion from bronchial gland Inhibition of gastro- intestinal mobility and secretion Contraction of sphincter of bladder and bowel Motor for ejaculation

Parasympathetic Nervous system Contraction of pupil Secretion of respiratory and digestive gland Inhibition of cardiac excitation, conduction, contraction Bronchoconstriction Increase secretion from bronchial gland Inhibition of sphincter Contraction of muscular wall of urinary bladder. Motor initiation and maintenance of erection of penis.

Assessment of Nervous System Disorder

First introduce yourself to the patient, explain who you are and ask permission to take a history and to carry out an examination.

Demographic data Name-

Age- Example- @ age of 20 rapid developing brainstem lesion is due to demyelinating disease, where as in 60s it is due to basilar artery occlusion.

Sex- Example- Myasthenia gravis, Alzheimer's disease are common in female. Parkinsonism is common in male.

Address-

Occupation-

Handedness- right hand/left hand

Clarifying the “Symptom”

KEY POINTS :

What are the Problems- For each symptom describe Onset, Duration ,Course, Severity, Precipitating Factors, Relieving factors. Let the patient to tell a story of the illness without ant interruption.

What is the Main Problem When did it start- Sudden, rapid, gradual on onset. Or any history of trauma.

Site, Character, Time Course of Symptom Exacerbating and Relieving factors, Associated Symptoms

• Patient should describe the problems in its own language.• Therapist should understand the words of patient Ex- “Black out" may means loss

consciousness, loss of vision, loss of memory or just loss of confidence. • Doctor should take seriously the words like "continuous" that whether it is continuous or

frequently repeated.• Patient should clarify the word "pain" .• Patient should indicate exact part his body affected which help the therapist to get whether

it is a sensory dermatome or the distribution of a peripheral nerve.

History Taking

Previous investigation treatment – of the present symptom.

Past medical history- About past medical illness, accidents, operations, infections, seizure, head injury, development abnormality, diabetics, hypertension, stroke. Also enquiry for any disability.

Family history and social history- if any family have with same illness. Ask for bad habit like alcohol intake, smoking.

Gynaecological and obstetrical history- Ask for any contraceptive intake.

Psychological Status- Depressed or Confident

The chronological sequence of events- Therapist should make a

documentation of the events mentioning the date of events, main symptoms, treatment administrate and investigations at the time of episode.

Drugs -About the regularity, dosage of drugs taking. Also ask for any allergies.

Interviewing relatives- When patient is child, unconscious patient, memory defect

patient, or to be sure

Excluding irrelevancies- After gathering a number of data therapist now can

exclude some negative data.

FIRST IMPRESSION WHEN PATIENT COMESMoving from door to chair- check for gait and posture such as kyphosis. scoliosis, torticollis, forward neck bending, parkinsonism.

The size and shape of patient:- Note dwarfism, excessive height, obesity, skeletal deformity etc. Also note abnormal head size such as hydrocephalus, acromegaly, achondroplasia.

Mode of dress- Indicate the personality of patient and mental state.

The hair- Hair and demarcation on skull check to identify any psychological stress or cranial operation.

On sitting down- check for involuntary movement, tremor, tic movements.

Patient on chair- Note for any foreword stooped posture like parkinsonism, lateral slump posture in hemiplegic,

The face- Note for sunken or wasted face, fat and hairy face, exophthalmos, lid retraction, eye blinking, ptosis, tremor of facial muscle, chronic spasm, wrinkled forehead.

The voice- Listen to the volume of sound, clarity of words and content of speech.

Systemic enquiry key question

Change in mood, memory, concentration or sleep

Loss of consciousness or dizzy spells

Loss of vision or double vision

Loss or gain of weight and appetite.

Difficulty in speaking or swallowing

Weakness having in limbs

Difficulty in walking

Pins and needled or numbness in arms, legs or body.

Difficulty in passing urine, bowels, and sexual function.

References

1. BICKERSTAFF ’s Neurological Examination by KAMESHWAR PRASAD

2. Neurological Assessment by RUBEN D. RESTREPO

3. Textbook of Neuro-Physiotherapy by DR. SHALU JAIN

4. Neurological Examination by WILLIAM HOWLETT

5. A Concise Guide to Neurology by REMA PAI

6. Textbook of Neuroanatomy by VISHRAM SINGH

7. Textbook of Human Physiology by A.K JAIN

8. Neurological intervention for Physical Therapy by MARTIN KESSLER

9. Illustrated Textbook of Neuroanatomy by GP PAL

10. Internet