CENTRAL NERVOUS SYSTEM SILVERMAN TRANSCRIBED NOTES (CHAPTER 7F)

Common complaints

loss of consciousness

seizure

developmental delay

developmental regression

weakness of parts of the body

unsteady gait

limping

clumsiness

involuntary movements

floppiness

headache Less common

loss of vision

loss of hearing

vertigo EXAMPLES OF HISTORY TAKING LOSS OF CONSCIOUSNESS coma

Onset - sudden, gradual

Trauma - intracranial hemorrhage

LOC at once - severe Intracranial hemorrhage

LOC at lucid interval -middle meningeal bleeding

With headache and vomiting before coma- encephalitis, tumor

With fever before coma-encephalitis, meningitis

Preceding illness - DM, SLE, Sickle cell drug ingestion

SEIZURE nature of involuntary movement? confine to one body? how many attacks? - assess severity, seriousness

GRAND MAL PETIT MAL

tonic-clonic

attack come all at once

< 5 minutes < 10 - 20 seconds

loss of consciousness attack (convulsion)

brief loss of consciousness

loss of balance and fall does not lose balance

loss of bowel and bladder control

loss of bowel and bladder control (rare)

sleep for few hours and appears dazed

After attack momentarily confused, lip smacking and chewing

precipitated by light

MYOCLONIC

sudden, single/repetitive muscle contraction

very brief and momentary movement is so violent that the patient is thrown off the chair or bed

lip smacking/chewing movement after attack

precipitated by startle response

PSYCHOMOTOR ATTACK

complex, purposeful act

less than 2 minutes

perform coordinated acts but is amnestic

may have lip smacking or chewing movement FOCAL MOTOR SEIZURE with march

start in one area of the body and march with definite sequence

AKINETIC SEIZURE

very brief, momentary

sudden loss of tone and patient collapse to floor PHYSICAL EXAM OF SENSORIUM Appearance Normal components include:

awareness

position and spontaneous movement of the body

responsive to touch and handling activity

orientation Awareness

NORMAL CHILD COMATOSE CHILD RETARDED/BLIND

Alert Responsive

Unresponsive but maybe aware of his

surrounding

Vacant look

some child after head injury and meningitis - aware of the surrounding but not able to verbalized

NEUROLOGICAL PROFILE

check on admission and then every 24hours

arousal o verbal o eye opening

pupillary response

eye movement o spontaneous o response to stimuli

corneal response

breathing pattern

motor response

tendon reflex

muscle tone

Severe brain injury no opening at all or open the eyes only in response to a painful stimuli

Coma exaggerated tendon reflexes

Deeper state of coma o No speech o Flaccid o Absence of reflex o Roving conjugate and dysconjugate eye

movement o Abnormal accentuation of flexor or extensor

tone

bobbing unusual type of eye movement

Oculocephalic response not done in patient with severe neck injury

Respiratory pattern only in those patient not in mechanical ventilator

Response to pain squeeze: o Nailbed o Tendon o Glabella

Primitive response withdrawal to painful stimuli

Body Position

Normal child varying styles o On the side with both UE and LE partially flexed o On abdomen with face turned on one side

Does not like to be handled, irritable, lies down with eyes tightly closed, turning head away from light

o Meningitis o Subarachnoid hemorrhage

Opisthotonic with the occiput burrowing into the pillow: o Severe meningeal irritation o Tetanus

Decerebrate rigidity Decorticating rigidity

lower limbs in full extension lower limbs are in extension

upper limbs in extension at the shoulder and elbow

shoulder in external rotation, but the elbow are flexed

thumb adducted thumb adducted into palm

forearm pronated

Severe hypotonia - pithed frog position. Responsiveness

normal happy or reacts adversely to being handled by strangers (absent in those with mental retardation and multiple care takers)

battered afraid of all types of human contact

autistic no eye contact

meningitis, painful condition

does not like to be handled

Activity

Unequal movement of the limbs o Monoplegia o Paraplegia o Hemiplegia o Painful condition (fracture)

Orientation

Normal can identify right and left on their own body by 6 years old and another's body by 9 years old.

Altered orientation o Infection o Toxic o Vasculitic diseases of the brain

Simple questions for orientation: o Where home is? o What day of the week it is? o What time of the day it is? o When he/she is next going to have a birthday?

Memory

To test short term memory (simplest) give set of numbers, ask to repeat them forward and backward

Organic brain syndrome backward repetition is affected

Normal o 6 years old can repeat 5digits forward and

count 3 digits backward o 10 years old can count 6 digits forward and 4

digits backward

To test immediate memory - tell a story and have the child repeat it (will also test attention span, comprehension and confabulation)

To test intermediate memory give the child the name of flower, city and food in the beginning of an examination, after varying interval ask him to repeat the items from memory.

To test long term memory ask his address, telephone number, birth date and names and ages of siblings

Speech Components of speech to be tested:

Presence or absence of speech (spoken and written)

Quantity of speech age appropriateness

Quality of speech o Volume o Phonation o Articulation o Content o Rhythm

Examination of the anatomic structures of mouth, pharynx and larynx

Presence or Absence

May have normal speech but never open his mouth in the presence of strangers on in doctors office.

Complete and thorough speech exam may not be possible rely on history and careful observation.

Abnormal o 18 months - failure to speak any word o 3 years - failure to make meaningful sentences

Mutism - complete absence, may also be evidence of: o Deafness o Mental retardation o Autism

Quality

Intercostal muscle paralysis o not be able to speak long sentences without

frequent pauses o no voice or breathy voice o test: take a large breath and count as many

numbers as possible in one breath; blow out a match held at a distance of 2-5 inches

Vocal cord is essential for phonation

Aphonia (no voice) may have normal respiration and strong respiratory muscles but vocal cords do not move normally.

Deafness - monotonous speech without infection.

Central deafness - very high pitched voice

Prepubertal period - normally have high pitched voice

Articulation o needs coordinated movements of:

tongue palate lips

Test: say ka pa ti ka o Ka-comes from the back of the throat o Pa-produced by the lips o Ti-produced by tongue and palate o If said fast problem of incoordination

Components of articulation: intelligibility and coordination

o Tested by these words: Methodist Episcopal Round the rugged rock the ragged

rascal run

Nasal resonance during phonation suggests: o cleft palate o chronic adenoiditis o palatial paralysis

*if suspected, ask the child to say words ending with NG which he may not be able to pronounce*

CRANIAL NERVES OLFACTORY NERVE/CN1

Very difficult, even in adults

Children more difficult

Present common items to each nostril with the other side closed: o Toothpaste o Oranges o Chewing gum.

Eyes closed and should guess the item from the smell

Infants change of facial expression may be the only clue.

OPTIC NERVE/CN2

Presence or absence of vision o Acuity o Fields o Fundus

Presence of Vision. o simple test to show that a child has intact

cortical vision is to make a menacing gesture, as if to poke the eye.

(+) consistent blink Cortical vision

absent before 10 months of age Normal

Inconsistent response (vision is intact, but the interpretation of vision is impaired

Parietal lobe lesions

Follows a moving light or object intact cortical vision

Acuity

Many tests for visual acuity

Simplest is the illiterate E chart which can be used for children as young as 3 years

The E test is a good as any other for screening.

Es in the chart are in different directions so that the limbs are pointing up, down, right, and left.

The chart is fixed at the childs eye level in a well-lit hallway at a distance of 20 feet from the childs seat

The child asked to show with fingers the direction to which the limbs of the E are pointing.

Test each eye separately and then both together.

>50% of the letters in each line should be recognized correctly by the child to get a pass for that line.

Normally: o Children are far-sighted till 6 to 7 years o Children in the first three grades of school should be

able to read 20/20 or better with each eye.

Compact eye testing machine - electrically projects the charts in front of the childs visual field is even more accurate and takes very little space is an office o Titmus Vision Tester

Field of Vision

Tested by a confrontation method till the child is old enough to cooperate with perimetry.

Some simple methods are: o Use a colorful toy approach the eye from each

side sequentially. Hemianopsia - if the childs turns to the

object when approached from one side but not the other

o Hemianopsia or Muscle imbalance - the child tilts the head to read

o Look at a measuring tape when it is being pulled out of its container fix the eye on the opening in the container from which the tape comes out do it first with the tape coming out from right to left and then from left to right.

Normally: eye will follow the tape for a short distance as it comes out and return back to the opening of the tape container. This is called opticokinetic nystagmus

Hemianopsia - this reflex will be absent in the direction opposite to the hemianopsia

o Sit and look at the examiners eyes (level with the eyes of the child two objects are dangled with threads behind the childs head and are slowly brought forward

Normally, as the peripheral field of the eye catches the object, the child will move the eye.

Field defect - this occurs consistently in one direction but not the other

o Look into the examiners eyes, which are placed at the same level as those of the child examiner takes his hands to the periphery of the visual field with the index figures extended and at diagonally opposite positions. He quickly flexes one of the fingers and the child is asked to show which figure moved. This is repeated at different points in the perimeter of the field.

o False results can be obtained o Staring at a childs eyes can frighten him or her.

Fundus

Examined with an ophthalmoscope

Ophthalmoscope: consist of a handle, batteries, and the ophthalmoscope head.

o Most operate on batteries (3 volts) and are easily carried.

o Some models (particularly those used by ophthalmologists) can be connected to electric outlets through a transformer (12 volts).

o Always use fresh batteries to obtain maximum light and good visualization.

o Head has a rubber guard to prevent scratches to the examiners glasses if he or she wishes to use the instrument with glasses on.

Rotary disc on the head has numbers in red on the left side and numbers in black on the right side of the 0 mark.

Red numbers minus lenses Neutralize myopia

Black numbers plus lenses Neutralize hyperopia

o One can get 15 to 20 diopters of power through these discs.

o Plus 8 to 15 lenses to focus on the iris margin and the lens.

o have devices to give different kinds of beams of light. o the control is usually on top or behind the

instrument head. o two round apertures (one large, one small), a slit, a

grid and a red-free filter are usually provided.

large round large pupils

Small round small pupils

Slit convexity and concavity of the retinal lesions *raised or depressed lesion light from the vertical slit is focused on the lesion and the adjoining normal retina, there will be a steplike distortion of the beam *convex (pointing towards the observer) the lesion is an elevation. *bends away from examinerdefect in the surface of the retina

Grid measure the size of the vessels

Green filter (red-free light)

*makes the blood vessels stand out as dark stripes *allows recognition of small aneurysms and hemorrhages *with fresh batteries, this filter may also help differentiate between: =melanin (not very black) =old hemorrhage (intense black)

Techniques in using the ophthalmoscope : o Many children and infants are curious and

eventually will look directly into the light if you have leave them alone and wait, but if you touch the lid to open the eye, fight will get tougher

o Younger children are best examined when they are lying down. Some older children cooperate better if they are sitting up.

o Some children may require anesthesia. If the problem is significant enough to warrant such a risk, an ophthalmologist should be looking at the eye

o Dilation of the pupil is necessary for a thorough examination of the eye, though a satisfactory examination of the optic nerve head can be accomplished without mydriasis.

Routine: 1 drop of 10% phenylephrine in each eye

For better papillary dilation:

1 year

tropicamide (1%) applied 3x at 10 minute intervals

(+) seizures: 0.5%Tropicamide and 10%neosynephrine applied 2 -3x over a 10 minute period.

Cyclomedrin used once. Examine after 30 to 40 mins.

(-) seizures: Cyclopentolate 1% solution (once)

dark eyes: add Tropicamide 1 percent solution (once). Examine after 20 to 30 minutes

Start + 8 show any scars or large deposits in the cornea as black spots in the midst of the red reflex

+ 10 or + 12, the edge of the iris becomes easily visible. o determine if clear and round. o Iridocyclitis iris edge will show fine

serrations, instead of a smooth round contour.

Red reflex occasionally, the normal red reflex is replaced by a white or yellow reflex, also called the cats eye reflex

White reflex serious eye disease; requires immediate consultation with an ophthalmologist

o Retinoblastoma o Angiomatosis of the retina o Toxocara canis o Retrolental fibroplasias o Congenital cataract

One can judge the point of origin of the reflex by changing the power of the lens.

+ 10 or 12 lens needed to locate the white reflex of a cataract.

Look at the characteristics, periphery of the fundus move slowly toward the optic disc by following the vessels note of the characteristics of the arteries and veins look at the macula.

o fovea is the center of the macula and is located approximately 2 disc diameters temporal

o Major points to look for in the macula are:

Toxoplasmosis pigmented deposits with exudates

Tay Sachs cherry red spot

Important findings to look for in the fundus of children are related to:

o retintis of congenital infections o degenerative disease o phakomatosis o optic atrophy o papolledema.

Jet-black deposits of retinitis pigmentosa starts in the equatorial region, spreading later to the periphery

Yellow- white exudates of congenital syphilis later turns into pigments all over the fundus.

Also look for retinal exudates which appear as faint clusters or masses.

Central retinal artery divides into o Superior segments

Temporal branch Nasal branch

o Inferior segments Temporal branch Nasal branch

*has veins corresponding to these four arties

Normally veins are larger than arteries (3.2) and darker.

The vessels have a central stripe which is more prominent in the arteries.

The arteries and veins are graceful in their course without too many curvatures and acute bends

On locations where the arteries and veins cross each other, the veins pass underneath the arteries.

It is important to be familiar with these normal characteristics, because in:

hypertensive retinopathy *increase in the reflex stripe along the arteriole *loss of reflex stripe of the veins on either side of A-V crossing *narrowing of arterioles

sickle cell disease *increased tortuosity of vessels in black patients

vasculitis *perivascular sheathing

severe papilledema, hypertension, SLE (better with a red- free light.)

*hemorrhages along blood vessels *vascular tumors may be recognized

papilledema *fullness of the veins and loss of venous pulsation of the optic cup

Optic disc; characterize the following features: o Shape o Size o Color o Depth o Edge o Vessels

Normally, the disc is round.

Physiological cup o Central portion of the disk o shallow paler area o vessels fan out o symmetrical; occupies about 30 % of the disc.

glaucoma *cup extends almost of the periphery and is asymmetric *vessels are pushed nasally

primary optic atrophy

*entire disc is white *disc margins are clear and the vessel undisturbed

secondary optic atrophy

*disc is pale (not white) with sheathing of vessels *indistinct margins

Optic neuritis and papilledema

*margins of the disc get indistinct and the color hyperemic (in both) *fullness of veins, loss of pulsation of veins and retinal hemorrhages (in both)

In addition to history, two other useful points in differentiating these two conditions are:

o decreased visual acuity in neuritis as opposed to usually normal vision in papilledema

o presence of inflammatory cells in the vitreous seen in optic neutritis

OCULOMOTOR, TROCHLEAR, ABDUCENT NERVE/ CN 3 4 6

These nerves supply the extraocular muscles and the pupil

Examination of these nerves involves movements of the eyeball spontaneously and on demand

It is obvious that during the examination one should be systematically observe the following: 1. Position of the eyes ate rest; squint 2. Movements of the eyes independently of each other 3. Movements of the eyes together (conjugate) 4. Movements of the eyes in relation to the head

movements and body movement Appearance of fundus Papilledema Papillitis Optic Atrophy

Depth Elevated disc Elevated disc Shallow

Physiological cup obliterated

Physiological cup obliterated

Edge Blurred edge Blurred edge Very sharp

Vessels Engorged Engorged Narrow/few

Color No venous pulse No venous pulse Pale to white

Hyperemic Hyperemic

Hemorrhages Hemorrhages

Vision Good; or enlarged blind spot

Poor vision; or loss of central vision

Reduced vision

Also evaluate: o Nystagmus o Double vision o Pupils

Some of the clinical clues to lesions of the third, fourth, and sixth nerves are:

o ptosis- which is drooping of the evelids o an eye that is deviated down and out o inability to look outwards o diplopia.

Position of Examination o Younger children mothers lap facing the

examiner. o Eyes of the examiner should be at the same level

as the childs. o Covering the eyes can scare the child. o The child should therefore be examined with

both eyes open before examining with the eyes closed.

o Also, the examiner should use his or her own hand to cover the eyes of the child rather than use any occlusive device.

o Use of a flashlight or a sparkler toy is bound to make the child follow with the eye.

Testing for Squint. o With the child looking at the object directly in

front of the eye look for the reflection of the light from the surface of the pupils.

o Normally this should be at comparable points, but in the presence of squint the reflections are at nonconjugate locations.

o Strabismus (squint) which is obvious with both eyes open is called heterotopias.

Esotropia convergent strabismus

Exotropia divergent strabismus

o Tendency for deviation is called phoria.

Esophria tendency to converge

Exophoria tendency to diverge

o Testing for phoria uses the cover uncover test. o Child looks at an object or light cover one

eye, then the other with a cardboard or with your thumb held in front of the eye do it slowly and rapidly look at the uncovered eye always *Phoria - there is definite movement of the uncovered eye on rapid, alternate covering

o When one eye is covered, if the uncovered eye moves to fix on the finger, it was originally not looking at the object now if the covered eye is uncovered (and is found to be moving) to fix on the object, it was obviously deviating when the other was looking at the object. This indicates the presence of a tendency (phoria) for squint.

Independent Eyeball movements. o test for movements of the eyeball in all

directions by having the child follow a bright light or sparkler, first with both eyes moving and then one eye at a time

CN3 *innervates the medial rectus, superior and inferior recti, inferior oblique, levator palpebrae superioris, and the papillary constrictors

Paralysis ptosis, papillary dilatation, and loss of all movements except lateral deviations and downward movement with the eyes in abduction

CN PARALYSIS

CN 4 (superior oblique muscles)

tested by looking for slight upward deviation of the eye in abducted position because the inferior oblique is dominating

CN 6 paralysis of abduction (lateral movement) of the eye

o To test for recti and oblique muscles, one must

test the eyes in either abduction or adduction.

abduction adduction

*superior rectus acts as an elevator *inferior rectus as depressor

*superior oblique is a depressor *inferior oblique is an elevator

o In midline position all these muscles have a rotator component.

Paralysis of each individual eye muscle M N Deviation of Eyeball Diplopia Present

When Looking Direction of Image

IR III Outward (external squint) Toward nose Vertical

SR III Downward and inward Upward and outward Oblique

IR III Upward and inward Downward and outward Oblique

IO III Downward and outward Upward and inward Oblique

SO IV Upward and outward Downward and inward Oblique

LR VI Inward (Internal squint) Toward temple Vertical

Conjugate eyeball movement

*corticulo-bulbar irritative lesion on the opposite side *destructive lesion on the same side

*conjugate deviation of the eyes (both eyes moving parallel) at rest with gaze directed to one side

*frontomesencephalic pathway

*test for conjugate eye movement on command is absent

*head injury conjugate deviation at rest and inability to produce conjugate movement on command

*Parinaud syndrome inability to get superior conjugate movement; denotes a lesion in the corpora quadrigemina

Eyeball and head movements. o Movement of the eye as the position of the

head is changed. o With the eyelids held open, the head is rotated

from side to side. o Positive dolls eye reflex (oculocephalic reflex) is

said to be present if there is conjugate deviation of the eyes in a direction opposite to the direction of movement of the head (head rotated toward right, eyes deviating to left).

o Such a reflex is absent in a normal, awake person but may be present in patients with coma.

Double vision (Diplopia) o definable compliant in older children, but

younger children and infants may not able to explain

o In the presence of diplopia (particularly of recent onset) the infant may refuse to open the eye and may lie down with the eyes buried or

he/she may rotate the head to one side (sixth nerve)

tilt the head (third, fourth nerve) o With both eyes open child look at a finger or

pencil held around the periphery of the field of vision, first to the patients right. *Find out whether two images are seen. A false image appears in the direction toward which the paralyzed muscle usually pulls.

o Repeat the test with the object to the left of the patient, up and down

o A simpler method is to do the cover-uncover test (as in testing for squint) in right, left, up, down, and oblique positions.

o Any deviation of the uncovered eye in any of these positions is likely to be associated with diplopia.

This test does not require the childs response.

Pupils. In evaluating the pupils the points to be looked for are :

(1) Size (2) Shape (3) equality between both sides (4) response to light on the same side (5) response to light on the opposite side (6) response to pain (7) response to accommodation.

o Afferent fibers involved in the light reflex leave the other fibers along the optic tract

before the fibers reach the lateral geniculate body and go to the pretectal region.

o Afferent fibers involved in accommodation reflex course toward the superior colliculi.

o Afferent fibers for papillary control through parasympathetic and sympathetic

fibers. o Pupillary constrictors arise in the Edinger Westphal

nucles and medial nucleus of the third cranial nerve and course along the third nerve to the ciliary muscles.

o Pupilary dilators originate from the cervical sympathetic ganglion and course along the internal carotid artery.

o Both parasympathetic and sympathetic fibers course through the ciliary ganglion and short ciliary nerves

o Small pupils are common in black children o Difficult to see the small dark pupil in the center of a

dark iris. o A trick which one of the authors has used is to cover

the flashlight with yellow cellophane paper and shine the yellow light at an angel.

Very small pupils *normal *head injury *deep coma *drug toxicity

Horner syndrome *small pupil *ptosis *enophthalmos *lack of sweating on the ipsilateral side of the face

Large pupils *third nerve paralysis *fear *anxiety (sympathetic overactivity) certain stages of coma

Ipsilateral hippocampal herniation

fixed dilated pupil without reaction to light in a comatose child

Unequal pupil (can be normal)

may be due to: *small pupil on one side -local use of drugs -Horner syndrome -irritative lesion of CN3 *large pupil on one side -drugs applied locally -Byrne response of pain to one extremity - complete paralysis of the third nerve on one side *aniridia on one side

Reaction to light is tested by having the child looking away from the major source of the light in the room and shining a flashlight on the pupil.

Normally the pupil reacts quickly.

At the same time , the opposite pupil also contracts (consensual light response).

To the test the accommodation reflex, the child is asked to look at as distant object a finger is held close to his or her nose and the child asked to focus on the finger

Normally the eyes should converge and the pupils constrict in attempting to look at a close object.

For the ciliospinal reflex the skin of the neck is pinched this should cause dilation of the pupil

In Byrne reflex, pinching one lower extremity cause dilation of the pupils on the opposite side.

The interpretation of the reflexes described above is as follows:

Lesions of the optic nerve close to the eyeball

(-) Loss of direct pupillary response on one side (-) Loss of consensual response on the other side (+)Retention of accommodation reflex

Lesions past the point where pupillary fibers leave the optic tract

homonymous hemianopsia without loss of pupillary response

Lesions close to the edinger westphal nucleus or ciliary ganglion (Argyll Robertson pupils)

(-) loss of direct and consensual response on the same side (+)retention of accommodation reflex

Lesions of the oculomotor nerve

Absolute paralysis of the pupil on one side

third nerve palsy ptosis on one side in which pupil will be dilated

horner syndrome the pupil will be small

seventh nerve palsy appearance of ptosis may be spurious because of widening of the palpebral fissure on the opposite side

myasthenia bilateral ptosis

TRIGEMINAL NERVE/CN5

motor and sensory

3 divisions o Ophthalmic: sensory o Maxillary: sensory o Mandibular: sensory and motor

MAJOR BRANCHES OF THE TRIGEMINAL NERVE AND THEIR FUNCTIONAL SIGNIFICANCE

BRANCH SENSORY SUPPLY

MOTOR SUPPLY

DISABILITY IF CUT

Ophthalmic

Conjunctiva (except lower lid) Lacrimal gland Medial part of the skin of nose up to its tip Upper eyelids Forehead and scalp, to the vertex

None Loss of corneal reflex Trophic changes in eye Loss of sensation in areas described under Sensory Supply

Maxillary Cheek, front of temple, lower lids and conjunctiva, side of the nose, upper lip, upper teeth, mucous membrane of nose, upper pharynx, root of mouth, soft palate

None Loss of sensation in areas described under Sensory Supply Loss of palatal reflex

Mandibular

Lower part of face Lower lip Tongue, lower teeth and part of ear Salivary glands

Muscles of mastication

Paralysis of masticators Loss of sensation in areas described under Sensory Supply

Check Motor component by: o Clenching the teeth palpate the masseter and

temporalis muscles o Ask to open and close the mouth o If one side is paralyzed, the jaw will be deviated

to the non paralyzed side when mouth is open Check somatic sensory:

o Sensory innervations of the face

o Touch Cotton ball or soft tissue paper, a safety

pin or ball head pin, and a metal tube for hot and cold water

Childs eyes should be closed as the examiner touches the skin gently, going from one area to another in an organized fashion. Cover also the perianal area supplied by S2-S4

Child has to indicate whether he felt the touch by saying now.

Examiner should not give any clues as to whether he is touching or not. He should not ask, Do you feel? every time he touches.

To test for pain similar approach but with the stimulus being the tip of a pin.

Child is instructed to respond by saying sharp or dull, instead of now.

If the child cannot respond verbally, his facial expression and withdrawal of the limb is used as an indication of intact pain sensation

o Temperature Two tubes one filled with cold water,

and one filled with hot water (should not be excessively hot or cold)

The skin is touched first with one tube, then the other, randomly alternating the sequence

Ask the child to respond spontaneously with hot or cold depending on the stimulus

o Interpretation: loss of sensation on one side of the

body (hemianesthesia) is rare and may be seen following a head injury

Hysteria- cutoff point exactly midline True hemianesthesia- cutoff point is

just lateral to the midline A child in pain because of teething will

frequently pull the ear because of transmission along the mandibular portion of the trigeminal nerve

Corneal reflex:

Easiest way is to blow air into the patients eye: blinking

More acceptable: twist a smaller thread out of cotton ball and touch the cornea with it. Have the child look in one direction and approach the cornea from the opposite direction (to avoid visual blink reflex, rather than corneal reflex.) Test both sides.

Jaw reflex:

Open the mouth gently, place a finger at the tip of the mandible and tap it with a percussion hammer.

Normal: mild contraction of the masseter muscle or maybe absent

Exaggerated reflex: upper motor lesion above the fifth nucleus

FACIAL NERVE/CN7

Almost entirely a motor nerve

Supplies all the muscles of the face and scalp (except levator palpebrae superioris), platysma and stapedius

Chorda tympani and Facial nerve - supplies taste to the anterior two-thirds of the tongue.

Autonomic afferent fibers to the lacrimal gland and the submaxillary and submandibular glands also runs with the facial nerve

Motor function:

While talking, observe the patients face and the facial expression.

Unilateral facial paralysis o facial furrows are flattened o saliva may accumulate on the affected side o palpebral fissure may be wider on that side o eyeball may roll up under the upper eyelid

rather than the upper lid moving down on the eyeball

o blinking less forceful on affected side

Unilateral facial weakness o differentiated from weakness of the depressor

anguli oris, lower part of one half of the face below the angle of the mouth is involved.

Hufnagel palsy o congenital absence of depressor anguli oris o only the lower part of of the face below the

angle of the mouth is involved.

Bilateral facial weakness: o Guillain-barre syndrome o various myopathies o Moebius syndrome

Supranuclear lesions o if voluntary movements are lost but emotionally

induced movements such as smiling are intact

Nuclear or Peripheral lesions o voluntary and emotional movements are both

lost

Intranuclear lesion o Movements of lower parts of the face is lost

Lower motor o Movements of both upper and lower halves are

lost Simple tests to evaluate the motor function of the nerve are:

Have the child close the eyes as tightly as possible.

Normal Facial paralysis

upper lid will descend upper lid does not close down

some movement of the eyeball upward

eyeball moves upward (bells phenomenon)

lashes buried inward lashes not buried inward

lifting of the corners of the mouth upward

angle of the mouth either does not move at all or moves much less than on the unaffected side

o Ask the child to whistle o Ask the child to blow up one cheek and try to

push out air against close lips Easier to push air in paralyzed cheek

o Ask the child to show the teeth or smile Face is flat on one side and the pull is

towards the unaffected side. Sensory function (hard to do)

Test of taste over the anterior 2/3 of the tongue

Have the child to put the tongue out as far as possible. Hold the tip with a moist filter paper dry one half of the tongue with filter paper place over the anterior two-thirds of the tongue with an applicator or a small dropper the following substances one at a time:

o 5% glucose solution (sweet) o 3% nacl (salty) o 1% citric acid (sour) o 0.1% quinine hydrochloride (bitter)

Drop should be placed carefully. Child should not draw the tongue in but should indicate the taste with finger clues or pointing to a set of cards with the names of the tastes written on them.

After each drop the tongue is thoroughly washed, and the next taste is tested. Bitter should be the last tested, for obvious reasons

Taste is lost in lesions along the course of the 7th

nerve from the internal auditory meatus to the place where the chorda tympani branches off.

Autonomic functions

Recent lesion of the facial nerve o increased lacrimation o increased salivation

Reflexes Glabellar reflex

elicited by repeated tapping of the glabellar region

Normal: blinking response of the lids 5 to 6 times and then the response extinguishes

Abnormal: persistent blinking response as long as tapping over the glabella is continued

Snout reflex

pouting of the lips, when area of the philtrum (upper lip) is tapped.

Normal: absent in children after first2 months of life

Chvosteks sign: elicited by tapping the facial nerve in front of the ear - marked contractions and spasm following such tapping suggest hypocalcemia *Not a reflex but an increased irritability of nerve fibers to mechanical stimulation

AUDITORY

Two components: o Supplying the cochlea: auditory function o Supplying the semicircular canals for the

equilibrium function

Auditory fibers reach the cochlear nuclei in the pons

Vestibular fibers reach the nuclei in the pons and medulla

From these locations, the secondary tracts decussate partially and terminate in the inferior colliculi and medial geniculate bodies and at the cortical center for hearing, which lies in the temporal lobe

Evaluation of auditory component o Less than 4 yo and retarded children:

hearing test are complex to administer. o Suspect nerve deafness if:

Failure to respond to normal sounds (except very loud sound)

Excessive response to visual stimuli Delayed speech Monotonous voice with normal

motor development o Psychogenic reasons for deafness

Inconsistent response to sounds delayed speech avoiding eye contact ignoring visual clues unusual body movements

o Retardation Normal but delayed response to

sounds, with normal reaction to visual stimuli

delayed development in all areas o Have the child sit on the mothers lap

facing the examiner. Use a rustling piece of paper,

rattle, flicking of nails, a small bell or tuning fork (256-512 cps) to make noise. First on one side and then on the other

Observe the childs face as the noise is made

Evidence of intact hearing: Change in expression of the face, reaction of the pupil and the child turning to the source of sound.

o In older children, one can use a tuning fork, a watch or whisper (with the mouth hidden) to make sounds.

Ask if they hear, if theres difference between one ear and the other

o If theres abnormalities or suspicion do: Tympanometry Audiogram

Evoke response audiometry (younger infant)

Rinne and Weber test Bone conduction > air conduction:

middle ear problem Bone conduction and air

conduction both decreased(but air conduction is better than bone conduction): nerve problem

Rinnes test *Tap a tuning fork (256-512 cps) and hold it next to the ear. If it can be heard place it on the mastoid *If it can be heard again, compare to which is heard louder and longer. *Normal : AC > BC *Middle ear disease: BC > AC

Webers test

*Tap a tuning fork, held over the forehead in midline. *Middle ear disease: sound is heard louder on the affected side. *Loss of nerve conduction: sound is louder on the unaffected side

o Abnormal sounds

Tinnitus ringing of the ear (salicylate toxicity)

Hyperacusis facial nerve paralysis

Auditory hallucination

SLE and psychosis

o Vestibular function

May have imbalance and nystagmus

Children cannot explain vertigo. *Clues: *Unexplained crying

*Trying to bury the face and not wanting to open the eyes

*Vomiting with a change in posture

o Nystagmus Involuntary movement of the

eyeball which may either be rhythmic or nonrhythmic.

Has a fast and slow component Less frequently symmetrical Pendular nystagmus - to and fro

oscillations Maybe physiologic or pathologic It may occur at rest or only on

movement of the eyes may be horizontal or vertical or

rotatory or mixed may be

fine (3mm)

Degrees:

1st

degree mild; eye looking toward the direction of the fast component

2nd

degree moderate nystagmus, seen when the eye is in median position

3rd

degree severe nystagmus, with eye deviated toward the direction of the slow component

Test for nystagmus

Ask child to look at the flashlight or a toy held in front of the eye.

Move the object rather fast, first on one side and then to the other and ask the child to follow

Move it up and down.

End-point fatigue nystagmus: Keep the flashlight or toy in extreme positions for a few seconds to see if the nsytagmus disappears after 5 o 6 beats

Caloric stimulation test

Elicit nystagmus helps identify 8

th nerve

function.

Before the test is done, exclude perforation of the eardrum and blocking of the external meatus with wax.

Place child in a semireclining position (30:)

Cold water is drawn into a 10ml syringe with polyethylene tubing. Tubing placed into the external meatus so that the water when injected will be directed at the tympanic membrane.

Inject water very slowly over a period of 30 seconds and observe

Normal: this produce slow deviation of the eyes toward the side of injection with the rapid phase of nystagmus away from the side of injection

If right vestibular tract is intact and if the right ear is being stimulated, the eyes will slowly deviate to the right with a sudden jump toward the left to bring the eye back to neutral. This response is repetitive, with the eyes again deviating to the right and jumping back to the left. Lost in vestibular

nerve damage Hard to elicit if there

is brain stem damage

GLOSSOPHARYNGEAL, VAGUS AND ACCESSORY

GLOSSOPHARYNGEAL (9th

nerve) o sensory fibers for the posterior third of the

tongue o motor fibers for the stylopharyngeus and middle

constrictors of the pharynx

Unilateral paralysis of 9th

nerve: slight flattening of the arch of the palate on the affected side at rest

VAGUS (10th

nerve) o motor for the soft palate, pharynx and larynx o parasympathetic portion supplies the

respiratory, cardiovascular and gastrointestinal systems

ACCESSORY (11th

nerve) o carries motor fibers only to the SCM and to the

trapezius muscles.

Lesions of the 9th

and 10th

nerves

denervation of the larynx and vocal cords (recurrent laryngeal nerve paralysis)

presence of stridor in the absence of mechanical obstruction

recurrent laryngeal nerve paralysis

hoarse voice

aphonia

loss of swallowing reflex with drooling and choking

palatal weakness nasal regurgitation when swallowing liquids

Ineffective cough reflex

Inability to pronounce words such as egg and words ending with k

Palatal reflex In unilateral paralysis: palate may droop

on the affected side and not move on phonation.

Tested by touching the soft palate with tongue blade.

Produces elevation of the soft palate an retraction of the uvula

9th nerve: sensory 10th nerve: motor

Gag reflex afferent nerve of the 9th nerve and

motor of 10th

nerve Stimulus is produced by touching he

base of the tongue or the pharyngeal wall with a tongue blade.

Normal: elevation of the pharynx and tongue retractions

Loss of sensation of taste in the posterior 1/3 of the tongue

11th

nerve supplies the ff: o Trapezius muscle

Ask to shrug the shoulder against resistance upper part of trapezius

Lie prone arms abducted 90and rotated laterally. Ask to adduct the scapula against resistance lower part of the trapezius

o SCM Ask to rotate the head on one side when

resistance is applied against this movement at the chin

Torticollis rotation of the chin to a direction opposite to that direction of rotation of the occiput, should have no head tilting or spasmodic involuntary movement. Seen in:

athetoid cerebral palsy

hiatus hernia

RA with cervical spine involvement

enlarged lymph node

retropharyngeal abscess

mastoid disease

vocal cord tumors

paralytic torticollis

compensation for visual field cuts and diplopia

HYPOGLOSSAL (12th

nerve)

Pure motor

supplies muscle of tongue and depressor muscles attached to the hyoid bone.

Look at tongue at rest when mouth is slightly open. o If tongue is in midline ask the patient to put the

tongue out Unilateral paralysis: deviated on

unaffected side Difficult to interpret if child has facial

weakness

o Hold a pencil vertically from the midline of the nose and compare the position of the tongue in relation to this midline.

o Ask the child to push against a tongue blade, first on one side and then on the other.

Look for inequality in power o Look for fasciculation (best seen under the

surface of the tongue) and wasting MOTOR SYSTEM A. Strength

a. Kinetic - muscle used to move joint thru range against resistance; strength lost in extrapyramidal conditions

b. Static - muscle is used to keep a joint against the pressure used by the examiner to move the joint in opposite direction; strength retained in extrapyramidal conditions

Tests: *In young children, may have to rely on parents history and observation (unequal moro, poor swinging of one arm while walking, too much wear on the front of the shoe, resistance to examination)

a. Anterior Neck Flexor - lift neck off pillow while supine

b. Deltoid - abduct shoulders 90: c. Elbow Flexors (biceps and brachialis) - flex elbow

against resistance d. Hip Flexors - lie supine with knee flexed. Child is to

flex thigh against resistance e. Hip Extesnors - climb stairs; stand up from sitting

position f. Quadriceps - extend knee while sitting at edge of

table g. Hamstring - flex the knee while lying prone h. Gastrocnemius - walk on tiptoes

True Muscle Weakness vs. Malingering

True Muscle Weakness Malingering

When resistance is withdrawn to a contracted muscle, there will be follow through movement

When resistance is withdrawn to a contracted muscle, there will be no movement

Presence of spontaneous reflex movements (contraction of latissimus dorsi while coughing)

True Hemiplgia vs. Hysterical Paralysis

1. Patient lying on the back 2. Examiners hands are placed under the heels of the

patient 3. Patient is asked to lift one leg off the table and then

the other. 4. When patient lift the paralyzed leg off the table

True Hemiplegia Hysterical Paralysis

Examiner can feel the conterpressure of the nonparalyzed side

Examiner will NOT feel any conterpressure of the normal leg because patient is making no effort to lift the leg (Hoover Sign)

B. Tone testing resistance to passive movements

a. Hypotonia little or no resistance to passive movements, allowing limbs to be placed in various grotesque positions (exclude hyperextensible joints as the cause); Myopathies & Myelomeningocele - Primary muscle disorder; PN lesions; AH cells

dsx (polio); Cerebellar lesions Akinetic Seizure / Syncope - sudden and episodic

b. Increased (Hypertonia, Spascticity, Rigidity) c. Normal

C. Spasticity

Spasticity Rigidity

Increased muscle tone with exaggerated DTR

Resistance to passive stretching and normal DTR

Mild to moderate limitation of ROM and possible contracture

Marked limitation of ROM and no persistent contracture

Resistance occurring as soon as the passive range is started, with intermittent jerky yielding (Clasp-knife Type)

Uniform resistance throughout the range but allows a full or nearly full range (like bending a metallic pipe, Lead-pipe Type)

Pattern and Course Voluntary Movmts in Cerebral Palsy 1. EXTENSOR SYNERGY

- when child is asked to extend great toe against resistance, the lower limb may adduct the hip and extend knee at the table

2. FLEXOR SYNERGY - when the child is asked to open fingers, shoulder

adduct, elbow flexes, wrist flexes and pronates

Spastic Cerebral Palsy Athetoid-EPS (Dyskinetic) CP

- exaggerated stretch reflex

- clonus - arm flexors and leg

extensors - contractures occur

early

- more of continuous resistance to passive stretch

- no clonus - extensors throughout - contracture occur later

Hypertonic - Increased muscle tone; reflex spasm muscles due to

pain - Spasm of hip flexors due to Synovitis of hip and in

Iliopsoas Abscess - Spasm of cervical muscles in Meningeal Irritation - Must rule out disease of the muscle itself

D. COORDINATION Poor Coordination:

- Steadying upper arm against the chest while trying to carry put hand activity

- Frequent falls - Dropping objects - Bumping into furnitures - Poor penmanship - Clumsiness

Proper Coordination: - Strong muscle - Agonist and antagonist shoulf act together - Proprioceptive impulse from muscles anf joints

should be received by cerebellum and cortex - Intact body orientation

Tests: 1. Finger-Nose Test patient touches the nose with the

finger, then touches the tip of the finger of the examiner held in space then touches nose again Cerebellar lesion:

Intention Tremor appears when attempting the test but subsides at rest

Dysmetria inability to coordinate for distance

Past pointing consistently missing the examiners finger on the same side

Chorea: coordination is normal, but periodically interrupted by involuntary movements

2. Rapid Alternating Movement can be done starting 5 y/o - Repeatedly pronate and supinate the forearm by

slapping the thigh with the palm and back of the hand alternately, or

- Repeatedly touch the tip of the index finger with the tip of the thumb as fast as possible, or

- Repeatedly do tapping movements of the forefoot of the patient against examiners palm held close to the foot

- Dysdiadokinesia inability to perform RAM (Cerebellar Lesion and Spasticity)

3. Rebound Test of Holmes patient flexes elbow against resistance by examiner, then examiner suddenly withdraw resistance, if arm flexes uncontrollably and may even hit the face (Cerebellar Lesion)

4. Maintenance of Posture extend arms in front with fingers slightly separated to see if posture is maintained (Chorea, Athetosis, Tremor can be recognized)

5. Others: run, climb stairs, ride a cycle, tie shoes, write,

and draw person.

E. INVOLUNTARY MOVEMENTS 1. Tic purposeless, repetitive

- Not interfere with ADL - Disappear during sleep - Gets worse while others are watching - Eye muscles, facial muscles, upper limb muscles

2. Fasciculation / Fibrillation occur in individual muscle fiber and cannot be seen by naked eye - Rapid twitching movement of bundles of fibers

which leave a furrow on skin over muscles - Dysfunction of AH cell: Polio and Werdnig-

Hoffmann disease (best to look at tongue) 3. Chorea purposeless non repetitive movements

- Aggravated by activity and stress - With hypotonia and poor coordination in activities - May run into objects and hurt themselves

4. Myoclonus intermittent contractions of a single muscle or groups of muscle resulting in quick jerky motion of a limb - Worse by voluntary activity and stress - Brainstem Lesion and Reticular Formation

5. Athetosis slow, rhythmic movements of extremities and face - Brought on by voluntary activity and emotional

stimuli - Limbs take characteristic postures - Distal > proximal muscles

6. Dystonia fluctuations in tone - Involvement of proximal muscles of extremities

resulting in strange postures and torsion spasm - Worse with resistance - Disappears in sleep

7. Tremor rapid oscillatory movements present at rest or elicited by asking child to extend arms in front - Essential Tremor and Wilson Disease

F. Muscle Mass

Wasting / Atrophy Lower motor neuron disease Proximal wasting Myopathies Distal wasting Peripheral Neuritis Wasting from early childhood smaller/shorter limb

Hypertrophy excess use (paraplegic walk with crutches)

- Myotonia, Congenital Hemihypertrophy - Pseudohypertrophy of gastrocnemius

Duchenne Muscle Dystrophy

SENSORY SYSTEM - Very difficult to examine in children; even if child

cooperates he may be correct 50% of the time by chance A. Superficial Sensory

- Touch, Pain, Temperature: hot/cold - Needs cotton ball or soft tissue paper, safety pin or

ball head pin, metal tube for hot and cold water

Method: Touch 1. Childs eyes should be closed 2. Touch the skin gently going from one area of the

body to the other in an organized fashion (neck shoulder outer aspect of upper arm outer aspect of forearm outer aspect of palm inner aspect of palm inner aspect of forarm) complete this one side then go to opposite side

3. Child has to indicate whether he felt the touch by saying now. Examiner should not give clues by asking Do you feel?

Pain 1. Similar approach but using tip of pin 2. Child is instructed to respond by sayin g sharp or

dull everytime he feels the sensation. Facial expression and withdrawal of limb indicates intact pain sensation if cannot respond verbally.

Temperature 1. Similar approach using 2 tubes filled with hot and

cold water 2. Skin is touch randomly alternating the sequence 3. Asking the child saying hot or cold Interpretation: Head Injury loss of sensation to one side of the body (hemianesthesia) Hysteria cutoff is exactly at the midline True Hemianesthesia cutoff is just lateral to the midline Spinal Cord Injury level of anesthesia has to be remembered in relation to injured vertebrae since number of vertebra does not correspond to the spinal cord segment.

Vertebra Spinal Segment

C1 C1

C7 C8

T10 T11

T12 L3

L1 End of cord

Anesthesia 1. Go from above downward, then from below upward Incomplete Cord Lesion loss of sensation is higher at below to upward test than from above downward Myelomeningocele level is never strictly defined; patchy anf uneven between halves of the body Syringomyelia loss of sensation for pain and temperature with retention of sense of touch, position sense, and vibration sense in upper limb Transverse Myelitis, Peripheral Neuritis, Reflex Sympathetic Dystrophy, Herpes Zoster hyperesthesia

B. Deep Sensory - Sensation originate from deeper structures (muscles,

tendon, joints) - Vibration sense is included - Hard to perform

- Impulses originate from muscle spindles and other endings in the muscles and tendons

- Some travel along the spinocerebellar tract to cerebellum

- Others constitute the afferent arc of the stretch reflex

- Others travel through posterior column and medial lemniscus to the thalamus to parietal lobe

Tendon reflex tests the peripheral arc of this system Sense of position tests the spinocerebellar tract Special tests for proprioception tests the entire system Method: Proprioception 1. Explain and demonstrate the procedure with eyed

open 2. With closed eyes, examiner passively move toes up

and down and suddenly stop holding the lateral aspect

3. Child should be able to say whether to is up or down Other tests: a. Touch the tips of corresponding fingers of both

hands in space with eyes closed b. Arrange finger of one hand in space in varying

position with eyes closed and ask to put the finger of opposite hand in the same position

Vibration 1. Using a tuning for 128 Hz, place over various bony

prominences, sometimes with vibratio sonetiems without

2. Ask If he feels the vibration or not Interpretation: Posterior Column lesions loss of proprioception and vibration (Spinocerebellar Ataxia) Cortical Sensory

Subjects for testing include: o Stereognosis o Two-point discrimination o Texture o Weight discrimination

Stereognosis is tested by: o at the bedside by asking the child to close his

eyes and placing in his hands common objects, such as an a coin, a key, or blocks, (from the Denver kit), and asking him to name the object.

o For more precise testing, one has to use standard geometric shapes, such as cubes and spheres

Discrimination of two points is tested by: o using a paper clip or hairpin, the patient must

first understand with the eyes open what one and two mean

o done with the eyes closed o touching the patient with one or two points

should be done at random

o both points should touch simultaneously when testing is done for two points.

o The distance between the two points should be: narrow in fingertips (2 mm) wider (20 mm) in forehead.

Textures (a test for extinction) can be tested using silk, wool, and plastic.

o the child is asked to close the eyes and the examiner touches two parts of the body: both cheeks, both hands, one hand and one cheek, one hand and one foot simultaneously and with equal pressure.

o the child is asked to name or point to the areas that were touched.

o if the child recognizes that the cheek was touched but does not recognize the hand was touched (+) Extinction of distal stimulus

Interpretation:

Parietal lobe syndromes *Loss of stereognosis and of two-point discrimination * Extinction of distal stimulus

REFLEXES

Reflexes can be grouped under four headings: o Superficial

Plantar Cremasteric Abdominal Anocutaneous Palmar

o Deep o Development (infantile automatisms) o Autonomic

SUPERFICIAL REFLEXES Plantar Reflex (Babinski)

The reflex are runs through the tibial nerve to the spinal cord (L4-S1).

o The sole of the foot is stimulated by pressing along the plantar surface of the foot with a blunt instrument (handle of the reflex hammer, key,end of a ball- point pen)

o Start near the heel and carry the stimulus over to the base of the metatarsals, ending near the ball of the great toe.

NORMAL RESPONSE ABNORMAL RESPONSE

*Plantar flexion of great toe *Other toes also flex and adduct. *In ticklish ones, the entire leg may be withdrawn

*Dorsiflexion of the great toe with fanning of other toes pyramid lesion *may be dorsiflexion of the ankle and withdrawal of the entire extremity

In abnormal response: o Do Babinski by stimulating other areas o The afferent area has enlarged.

Some of the other stimuli which may elicit a Babinski response:

Method of:

Oppenheim pressing firmly with thumb and stroking along the anterior border of the tibia.

Gordon squeezing the calf

Gonda flexing and twisting any toe

Bing stroking the big toe along the lateral side

Babinski is considered positive, if the great toe dorsiflexes with or without fanning of the other toes.

Cremasteric Reflex

Only in males by scratching the upper medial aspect of the thigh with a blunt instrument.

NORMAL RESPONSE ABNORMAL RESPONSE

*Contraction of the cremasteric muscle with elevation of the scrotum on the same side.

*lost in lesions above L-2

Abdominal Reflex

elicited by stroking the four quadrants of the abdominal wall with a blunt instrument (key or ball-point pen)

NORMAL RESPONSE ABNORMAL RESPONSE

*Contraction of the abdominal wall at the stimulated quadrant *Movement of the umbilicus toward the quadrant stimulated.

*lost pyramidal lesion above T-8.

Anocutaneous Reflex

Stimulation of the perianal skin by a pinprick.

NORMAL RESPONSE ABNORMAL RESPONSE

*Contraction of the external anal sphincter indrawing of anal opening.

Lost lesions involving S-2, S-3, and S-4.

Palmomental Reflex

By scratching or tapping the thenar eminence of hand.

NORMAL RESPONSE ABNORMAL RESPONSE

*No movements in the face *Contraction of the mentalis and orbiculars oris muscles on the ipsilateral side. *Indicates bilateral frontal lobe lesion

Hoffmans Sign

hand is held at the wrist, palm down and hanging loosely

tip of the middle finger is grasped with the examiners thumb and index finger.

nail of the middle finger is given a snap with the examiners thumb.

NORMAL RESPONSE ABNORMAL RESPONSE

*No movement of the patients thumb.

*thumb on the same side flexes and adducts into the palm *all the other fingers also flex *indicates pyramidal lesion above C-7.

DEEP REFLEXES Biceps Reflex (C5,C6)

arm is held with the elbow in flexion and supported by one hand of the examiner.

thumb of the supporting hand is held over the insertion of the biceps

tendon and the thumb is tapped with a reflex hammer

Normal Response o flexion of the biceps, with or without flexion at

the elbow Triceps (C6-C8)

arm flexed 90 at the elbow, the forearm is supported by the examiner.

sharp tap over the triceps tendon

Normal Response: o contraction of the triceps, with or without elbow

extension Brachioradialis (C5-C6)

patients arm between pronation and supination and the forearm supported by the examiner

styloid of radius is tapped

Normal response o flexion of forearm and supination.

Knee Jerk (L2-L4)

There are various positions in which to test knee jerks: o Patient may sit at the edge of the table with the

knees hanging free and loose o Patient lying supine, the knees are supported by

the examiners hand, relaxed and flexed to 30 or 40

o In newborns, flexing the knee and placing the foot flat over the examiners abdomen.

Tapping the patellar tendon with a reflex hammer procedures visible contraction of the quadriceps.

Response is extension at the knee (sometimes hard to elicit)

o divert the childs attention by talking about some subject of interest to the child.

o augment this reflex by asking the child to hook the fingers and then to pull the fingers apart (Jendrassiks maneuver)

o closing the eyes tightly Ankle Jerk (S1-S2)

The best position is for the patient to be prone with the knee flexed 90 hold the toes down firmly tap the tendoachilles

Another position: patient lying supine, hip flexed and externally rotated, and the knee flexed with the foot lying over the anterior aspect of the other press firmly against the sole of the foot to dorsiflex the ankle and tap the tendoachilles.

NORMAL RESPONSE ABNORMAL RESPONSE (all DTRs)

*Plantar flexion *Pyramidal lesions - exaggerated response is seen with spasticity *Myopathies - decreased deep tendon reflexes *Peripheral nerve lesions - absent reflexes

Clonus

characterized by rapid movements of a particular joint due to alternating contractions of agonists and antagonists

if present caused by sudden stretching of a tendon (such as tendoachilles) and maintaining the stretch.

Ankle clonus is elicted as follows: o patient in the supine position, the knee is flexed

by the examiner. o forefoot is held by the other hand and

dorsiflexed with a quick ,movement and the position maintained.

o If (+) foot will go through plantar flexion-dorsiflexion movements repeatedly.

o Cerebral palsy - elicited just by the ball of the foot touching the floor, thus making it impossible for them to walk.

Patellar clonus is elicited using the following method: o patient is in supine position with the knee in

extension o superior border of the patella is held by the

examiner and quickly pushed toward the foot (caudal) and held.

o If (+) patella will move up and down repeatedly (caudal-cephalic movement).

The significance of clonus is the same as marked hyperreflexia, indicating impairment of higher control, and is seen in pyramidal lesions

fewer than three of four beats of the ankle and knee can be normal tense and hold their muscles tight.

Signs of Meningeal Irritation

Brudzinski sign - patient supine and flat, if passive flexing of the neck causes the knees to flex and rise from the table

Kernig sign - patient supine, the hips are flexed to about 90 and the knees then passively extended.

(+) if the knees cannot be fully extended NEURODEVELOPMENTAL REFLEXES

All children go through neurodevelopmental reflexes before they take the characteristic human form of bipedal walking.

Various kinds of body righting and balancing (automatic) reflexes help to keep the balance by walking

Mediated at the different levels: o Spinal cord o Brain stem o Midbrain o Cortical

They evolve from the caudal toward the cephalic level of control.

Timing of Developmental Reflexes

Spinal cord reflexes are present immediately after birth and disappear within 1 to 2 months.

Brain-stem reflexes start appearing at about the 2nd

week of life and should disappear by the 6

th month.

Spinal cord and brain stem reflexes are primitive reflexes and should disappear by 6 months

Persistence of these reflexes after this time brain damage in utero or in early life

After normal progression reappear in cerebral insults: o head injury o meningitis o anoxia (drowning)

If spinal cord reflexes and brain stem reflexes are dominant cannot walk/ crawl (lie supine in various positions)

TABLE 7F-7. DEVELOPMENTAL REFLEXES

Reflex Mediated at

Group A Flexor withdrawal Extensor thrust Crossed extensor

Spinal cord level

Group B Asymmetric tonic neck Symmetric tonic neck Positive supporting Tonic labyrinthine

Brain stem level

Group C Neck correcting body Labyrinthine right reflex Optical righting reflex

Midbrain

Group D Various balancing reflexes Cortical/cerebellar

Group E Automatic movt reaction Moro reflex

Stretch receptor of the neck

Group F Parachute reflex Landau reflex

Semicircular canals

Midbrain reflexes start appearing at 4th

month but become suppressed by cortical influences after 2 years of age.

o Abnormal persistence after 2 years of age: Cerebral palsy/ insult can crawl easily walking is difficult without protective

devices Those who do not develop the

midbrain reflexes may not be able to walk at all, except on all fours.

Absence of cortical reflexes beyond 2 years is abnormal though it is not incompatible with walking.

o These are balancing reflexes and contribute to safety in walking.

Spinal Cord Reflexes (3) Flexor Withdrawal

Pinch the sole of the foot (without tickling) with the child supine, head in neutral position, and legs in extension.

Response: Dorsiflexion of the foot with uncontrolled flexion at the knee is positive response.

The avoidance response of older normal children is considered a negative reaction.

Extensor Thrust

Patient supine, stimulate sole of foot of flexed leg by pinching the sole.

Response: A nondeliberate extension with adduction is considered a positive reaction.

Crossed Extensor

Patient supine and both lower limbs in extension, stroke the plantar aspect of the foot.

Response: Flexion followed by extension and adduction of the opposite lower limb.

REFLEX NORMAL ABNORMAL

Flexor Withdrawal

*Up to 2 months *avoidance in older children

*Persistence or reappearance after 2 months

Extensor Thrust

*Up to 2 months *Response persisting or recurring after 2 months

Crossed Extensor

*Up to 2 months *Response after 2 months

Brain Stem Reflexes (4) Asymmetric Tonic Neck Reflex

Supine position and arms and legs extended turn the head to one side.

Response: Extension and stiffening of arms and legs on the side toward which the face is turned, together with flexion of arms and legs on the opposite side (occiput side)

Symmetric Tonic Neck Reflex

Support the child prone on the thighs of the examiner who is seated on a chair.

Passively flex the neck; after observing the response of the arms and legs to passive flexion, extend the neck.

Response: When the neck is flexed, arms flex and legs extend. When the neck is extended, arms extend and legs flex.

Positive Supporting Reaction

Pick up the child by the axilla and bounce several times so that the feet touch the floor.

Response: When the feet are in contact with the floor, hold the child in a vertical position. Look for increase of adductor and extensor tone in the legs and ability of the child to bear weight. Look for sustained position in plantar flexion with adduction.

Positive supportive reaction reappears at 6 months in preparation for walking but not with significant adduction or plantar flexion.

Tonic Labyrinthine Reflex

Examine the tone of flexors and extensors of arms and legs with the child in prone and supine position and the head in midline.

Response: Flexor tone dominates when the patient is prone and extensor tone dominates when the patient is supine.

REFLEX NORMAL ABNORMAL

Asymmetric Tonic Neck Reflex

*Up to 4-6 months *After 6 months

Symmetric Tonic Neck Reflex

*Up to 4-6 months *After 6 months

Positive Supporting Reaction

*birth up to 2 or 3 months

*Sustained plantar flexion w/ increased tone of adductors after 4 months

Tonic Labyrinthine Reflex

*Up to 4 months *After 4 months

Midbrain Reflexes (3) Neck on Body Correcting Reflex

Patient lying supine, turn the head toward one side.

Response: Positive neck righting reaction is rotation of the body non-segmentally in the same direction.

. Labyrinthine Righting Reflexes

With the child blindfolded, support the child in space in a prone position.

Repeat the same test by suspending the child in space in a supine position.

Next, hold the child by the pelvis in the vertical position and tilt the body to one side and then the othe

Response: Positive response for the four positions are as follows:

o With the child prone or supine, the head rises to normal position with the face vertical and the mouth horizontal.

o With the child in vertical position, the head tilts back to neutral position with the face vertical and the mouth horizontal.

Optical Righting Reflex

The same way as described for the labyrinthine righting reflex and is interpreted the same way, but here the eyes are open

REFLEX NORMAL ABNORMAL

Neck on Body Correcting Reflex

*non-segmental: birth up to 2 months *mature segmental rotation of the thorax followed by the pelvis appears after 2 months.

*non-segmental: after 6 months *absence of segmental 6 months

Labyrinthine Righting Reflexes/ Optical Righting Reflexes

*(+) prone position after 2 months of age throughout life *(+) other positions come on by 6 to 9 months *They are suppressed by cortical influences after 2 years

*(-) after 2 months in prone position *(-) other positions between 6 months and 2 years.

Cerebral Cortical and Cerebellar Reflexes

These reflexes test the balancing ability of the child and are influenced by the cerebral cortex and cerebellum.

With the child sitting or standing, first push the child to one side (taking care the child does not fall to the opposite side in case these reflexes are not developed) ; then, to the other side.

Response: If the child is sitting, the arm on the side toward which he is falling extends, fingers open, and the neck corrects so that the head is brought to neutral position. If the child is standing, the same response is seen. In addition, the knee on the side toward which the child is falling flexes, the opposite knee extends and tries to cross over toward the direction of the momentum.

Now, with the child standing and held by the axilla, gently push the child forward and then backward. If the child is pushed forward, the neck extends to bring the head to neutral and the child takes forward steps to catch up with gravity; if the child is pushed back, the neck flexes and the child takes backward steps.

What is normal? o Positive response as described above for

balance in sitting position should appear by 6 to 8 months of age.

o Reflexes for balance in standing position should appear by 12 to 15 months of age.

What is abnormal? o Absence of balancing reflexes for sitting after 8

months of age and absence of balancing reflexes for standing after 15 months of age are abnormal; asymmetric responses are also abnormal.

Automatic Movement Reactions (3) Moro Reflex

Produce a sudden noise away from the visual field of the infant.

Another method: support the child in the semi sitting position and suddenly drop the upper part of the body. The upper part of the body is caught by the examiners hand before hitting the table (without of course hurting or dropping the child hard on to the examining table).

Response: Sudden extension and abduction at the shoulders quickly followed by flexion at the shoulder and the elbow in a movement like an embrace. The fingers open during this reflex.

Parachute Response

Hold the child by the waist and tilt the child forward as if to be dropped on the face.

Response: extension and abduction of the upper limbs with extension of the fingers as if to break a fall.

Landau reflex

Suspend the child in space (carefully) in a prone position by supporting the thorax

Response: Neck spontaneously extends with some stiffening of the back and lower extremities.

REFLEX NORMAL ABNORMAL

Moro *Newborns up to 4 months

*After 4 months

Parachute *After 6 to 8 months *Absence after 8 months *Unilateral

Landau *Between 6 months and 2 years

*Failure to develop by 10 to 12 months

Significance and Uses of the Neurodevelopment Reflexes in Pediatric Practice: 1. Abnormal response in these categories suggest brain

damage (e.g.,cerebral palsy, post- head injury, and post- meningitis).

2. Persistence of reflexes mediated by the brain stem and spinal cord after 4 to 6 months of age signifies brain damage.

3. Delay in the appearance of reflexes mediated at the midbrain and cortical level after the appropriate age signifies brain damage.

4. Asymmetric response (such as lack of parachute response on one side and unilateral Moro ) signify hemiplegia.

5. These reflexes may mature at a slower pace in children with cerebral palsy (e.g., Landau reflex may not appear until age 2).

6. Older children with head injury and infectious brain insult lose their advanced reflexes and regress to spinal cord and brain stem level soon after the cerebral insult. They then develop through the various stages during the recovery period.

7. These reflexes are useful as indicators of prognosis in walking for children with cerebral palsy. For example, strong asymmetric tonic reflex, crossed- extensor reflex and Moro together with absence of parachute response give poor prognosis for walking.

8. These reflexes can be useful in physical therapy. For example, rolling an infant over a large beach ball will elicit a parachute response, if present. This will help open a spastic adducted thumb, since opening of the palm and extension of fingers is part of this response. The child with severe persistent tonic labyrinthine reflex may get equinus deformity if he is allowed to remain in the supine position most of the day, because extensor tone is increased in a supine position in the presence of active tonic labyrinthine reflex. If this child is treated in a prone position most of the day, flexor tone is accentuated as part of the same reflex.

ASSOCIATED MOVEMENTS

A normal child has freely swinging arms during walking. o Pyramidal or extrapyramidal disease, this

movement is lost.

A paralyzed upper arm also does not move and swing normally during walking.

The other major associated movement is the mirror movement that occurs when the child attempts rapid, repetitive activity with one hand or foot. This may elicit a spontaneous movement of the corresponding part of the

opposite limb until 5 to 6 years of age. After this age, mirror movements indicate cerebral disease, such as cerebral palsy.

AUTONOMIC REFLEXES

The two areas of importance, other than the vital signs, are skin and sphincters.

The two most important points to observe in the skin are: (1) vasomotor instability and color changes associated with severe pain, as in reflex sympathetic dystrophy, (2) lack of sweating, as in Horner syndrome.

Anal sphincter is first observed to see whether the opening is normal and contracted or patulous

A rectal examination will tell us about sphincter tone.

Anocutaneous reflex o pricking the perianal skin by a pin o Normal response: brisk contraction of the

external sphincter.

Bladder cannot be adequately examined clinically one relies on the history.

o History of dribbling o lack of awareness of full bladder o lack of desire to void o inability to hold urine

*should make one suspicious of neurogenic bladder.

In the presence of bowel and bladder sphincter problems, the motor and sensory systems should be examined carefully to rule out lesions of spinal cord:

o Myelomeningocele o Lipomeningocele

__________________________________________________ ESGUERRA, WINSTON L. 3F