NEUROANATOMY

NERVOUS SYSTEM
Central Nervous System – brain & spinal cord
 Develops within the 1st trimester
 Folic acid – for fetal brain development
 ↓ Folic acid during time of pregnancy – Megaloblastic anemia
 Ectoderm is the origin of CNS
Cranial 2/3 – brain
Caudal 1/3 – spinal cord
Peripheral Nervous System – contains the 12 cranial nerves & 31 pairs of spinal nerves
Autonomic Nervous System – consistent part of CNS & PNS
AUTONOMIC NERVOUS SYSTEM
 Conditions that has autonomic dysfunction: CVA, SCI, MS, PD, Autonomic dysreflexia &
PNI
 Originates from the brain & spinal cord
 Only nervous system subserving GVE (General Visceral Efferent) – promotes motor
function for visceral organs
SYMPATHETIC NERVOUS SYSTEM
 thoracolumbar origin (T1- T12, L1 – L2 or L3)
 1st fiber is short, 2nd fiber is long

Preganglionic Terminal Post-ganglionic

terminal Alpha 1 , 2
cholinergic Nor-adrenergic fiber Beta 1, 2
SNS
fibers
Preganglionic nerve end
Preganglionic neuron terminal

Note: if 1 fiber is long, the other fiber is short (v.v)

Preganglionic terminal Post-ganglionic terminal

neurotransmitter Acetylcholine (Ach) Norepinephrine
Deactivator Acetylcholinesterase COMT (Catecho-O-methyl transferase)
(Achase) MAO (Mono-Amine-Oxidase)
Fiber Cholinergic fibers Nor-adrenergic fibers
receptors Alpha 1 & 2, Beta 1, 2
MAO Inhibitors – deactivator of NE that should be deactivated that becomes a tricyclic
antidepressant
 Base drug for anti-depressants
 Rx to px with CPS (Chronic Pain Syndrome)ƒ
Px undergoing stage of grief – Px should have a psychological counseling
Hospice care – for px that has 6 mos to live; 80% done at home, 20% at
other institutions
 Receptors:
Alpha 1 & 2 receptors – commonly seen in blood vessel walls & smooth muscles
 Alpha 1 receptors are widely distributed; effect: vasoconstriction
 Alpha 2 receptors – has a scanty amount; effect: vasodilation
Beta 1 & 2 receptors
 Beta 1 receptors are seen in the heart: effect: Tachycardia & Hypertension
 Beta 2 receptors are seen in the lungs; effect: bronchodilation
 Facilitation of Beta 1, the effect is abrupt
°
If Ach is at the post-ganglionic nerve end terminal, the effect is cholinergic “more
sweating” (sympathetic effect in the swear gland)

Anticholinergic drugs – less sweating

  Effects of SNS: Fight – Flight Response/ Sympathetic Widespread Sustained effect
(SWS)
 SNS ganglia - ganglia
PARASYMPATHETIC NERVOUS SYSTEM (PNS)
 CN 3, 7, 9, 10 & S2, 3, 4
cholinergic Muscarinic
PSNS Nicotinic

Preganglionic terminal Post-ganglionic terminal

neurotransmitter Acetylcholine (Ach) Acetylcholine (Ach)
Deactivator Acetylcholinesterase (Achase) Acetylcholinesterase (Achase)
Fiber Cholinergic fibers cholinergic fibers
receptors Cholinergic receptors
 Receptors:
Muscarinic – located in most of the blood vessel walls
 effect: vasodilation
Nicotinic – located in the Neuromuscular junction (NMJ)
 Acetylcholinesterase (Achase)
Px in heart transplant, will the vagus nerve immediately innervate the heart? No
Note: the vagus nerve does not innervate the heart immediately – fluctuating heart beat
Vagus nerve – innervates the heart
Will the heart beat best determine the exercise intensity? No
Note: best determined by RPE (rate perceived exertion)
 Ganglia of Parasympathetic Nervous System (based on CN)
1. Pterygopalatine ganglia (CN 7) – important for lacrimal gland function
2. Ciliary ganglia (CN 3) – for pupillary constriction (miosis)
Argyll-Robertson Syndrome – condition wherein the pupils do not react to
pupillary light but there is a process of accommodation (pupils dilate but
does not constrict); syphilitic pupils
3. Submandibular ganglia (CN 7) – for salivary glands (submandibular & sublingual
glands)
4. Otic ganglia (CN 9) – for salivary gland (parotid gland)
Which of this 4 ganglia synapting subserving within the Edinger Westphal Nucleus (for pupillary
constriction effect)? Ciliary ganglia
SNS PSNS
Heart Rate ↑ ↓
Blood Pº ↑ ↓
Myocardial contractility ↑ ↓
Blood vessels vasoconstriction vasodilation
Lungs bronchodilation bronchoconstriction
Pupils mydriasis (dilate) myosis (constrict)
GI Motility ↑ ↓
Sweat gland ↑ no significant effect
Salivation/ Lacrimation no significant effect ↑
GI Sphincter contract relax
♀ emission lubrication
Genitalia
♂ ejaculation erection
Myocardial contractility
For px with CHF problem = Rx with Cardiac inotropics (Digitalis)
 Increases myocardial contractility but decreases heart rate
Lungs
 Px with asthma – parasympathetic (bronchospasm)
 ↓ AMP (Adenosine-Mono-Phosphate) – bronchodilation substance
↑ GMP (Guanosine-Mono-Phosphate) – bronchoconstrictor substance
 trigger off by low Tº (cold) & low humidity
(ABCDE – Asthma Bawal Cold, Dry Environment)
Pupils
 Wallenberg Syndrome – only brainstem stroke that affects the medulla (PNS)
 Lateral medulla affectation
 Largely sympathetic tract is affected, parasympathetic manifestation
 Horner’s Syndrome
 Manifestations: ipsilateral, myosis, pseudoptosis (CN 3), enopthalmus (sunken
eyeball; eyeball is displaced posteriorly to the orbit), anhydrosis (loss of facial
sweating)
 Brainstem Stroke
When Weber Midbrain
Both Benedicts Midbrain
Lovers Locked in Pons
Marry Millard-Gubler Pons
Willingly Wallenberg Medulla

CRANIAL NERVES
Based on Name Based on Fxn Based on Origin
Cranial Nerve 1 Olfactory Sensory Cerebral cortex
Cranial Nerve 2 Optic Sensory Cerebral cortex
Cranial Nerve 3 Ophthalmic Motor Midbrain
Cranial Nerve 4 Trochlear Motor Midbrain
Cranial Nerve 5 Trigeminal Mixed Pons
Cranial Nerve 6 Abducens Motor Pons
Cranial Nerve 7 Facial Mixed Pons
Cranial Nerve 8 Vestibulococchlear Sensory Pons
Cranial Nerve 9 Glossopharyngeal Mixed Medulla oblongata
Cranial Nerve 10 Vagus Mixed Medulla oblongata
Cranial Nerve 11 Spinal accessory Motor Medulla oblongata
Cranial Nerve 12 Hypoglossal Motor Medulla oblongata

CN 1 : Olfactory Nerve
 Olfactory bulb located at the Cribriform of ethmoid bone
 First cranial nerve to lose it’s function & the last CN to recover (TBI case)
 Most primitive CN (due to pattern of affectation & pattern of course)
 CN 7 – severely affected CN after TBI
 Olfaction – sense of smell
 To test, use mild odor (tobacco, soap, coffee)
Strong, pungent odor can stimulate CN 7 promoting lacrimation
 Conditions:
1. Anosmia – absence of sense of smell
2. Viral Anosmia – start as allergic rhinitis & in the long run it will becomes a total
Anosmia
CN 2 : Optic Nerve
 Maintained by Vitamin A – Retinol (lipid soluble)
 Retina – photosensitive area of the eye
 Vitamin A – antioxidant together with Vit. C & E
 important for improving bone formation (osteoblastic), bone resorption (osteoclastic)
& cartilage formation (chondroblastic) activities
 overdose: hypervitaminosis (periosteal & subperiosteal new bone formation –
periosteal pain)
 Ulna – most commonly affected in UE
 Metatarsals – most commonly affected in LE (push off most painful part of
gait)
Rx: metatarsal pads with rocker bottom effect on the shoe
 Vitamin A deficiency : Night Blindness (good vision in AM & afternoon)
 Retina – cones: daylight vision/ color vision
rods: night vision (affected vitamin A deficiency)
 Evaluation of Vision: Snellen’s chart
 20/20 (distance from chart (ft) /size of letter (mm)
20/200 legal blindness
 Tests:
Central vision – most acute vision
 Pin-Hole test : if px cannot read the chart using the Pin hole → Scotoma
( common in px with MS)
 Pathologic blindspot
Peripheral vision
 Confrontation test
 PT in front of px, eye to eye contact. PT placed the digit of both hands behind
px’s ears. Ask px if he observed anything
 (N) if px does not see anything
 Conditions:
1.Bitemporal Hemianopsia

2.Glaucoma
 starts from periphery towards the center
 only the central vision if functioning
 ↑ Intraocular Pº (common in px with DM)
 Tunnel vision
3.Cataract
 milky white substance from center to periphery of the eye & makes the lens
opaque
 Surgery: Phaeco-Emulsification (eye irrigation)
 Cataract + Tetany are conditions seen in Hypoparathyroidism
CN 3 : OCULOMOTOR NERVE
 Conditions:
1. Near sightedness (Myopia)
 the eyeball is elongated & the focal pt. of the eye is near or short.
 px can only see on short distance only
 the lens of the eye retains elasticity
 corrective lens: near negative; concave lens
magnifying glass is convex lens
2. Far sightedness (Hyperopia/ Hypermetropia)
 eye ball is shortened & the focal pt. of the eye is far/ long
 the lens of the eye retains elasticity
 corrective lens: far positive; convex lens
3. Presbyopia
 commonly seen in elderly population
 lens of the eye losses elasticity
 the eyeball is shortened & the focal pt. of the eye is far/ long
 corrective lens: far positive; convex lens
4. Astigmatism (eye strain)
 the meridians of the eye have different refractive indices
 can be corrected by the lens of the eyewear
Pupillary Light Reflex
 focus the penlight diagonally on the px’s eye
 afferent limb – sensory; CN 2 brings light towards
the brain
 efferent limb – motor; CN3 constriction response
 Direct response
 Consensual response
 constricted size of the pupils: 1 mm
 Resting size of the pupils: 2 mm

 Pupils Equals Round Reactive to Light (PERRL) – constriction of the pupils when
flash with pen light
 Pupils Equals Round Reactive to Light & Accommodation (PERRLA) – dilation of
the pupils when pen light is a little bit farther from the eye
 Examples:
Case 1: Intact CN 2 & CN 3 of both eyes.
 Flash pen light on ® eye
→ there is a direct response (constriction) on ® eye & a consensual
response on the (L) eye
→ the size of both pupils is 1 mm (PERRL)
 if you place the pen light a little bit farther from the ® eye
→ the pupils will dilate (PERRLA)
Case 2: CN2 is damaged on the ®
 flash the penlight on the ® eye
→ the ® eye has no direct response & consensual response seen
on the (L) eye
→ the size of both pupils is 2 mm
→ pupils are unreactive when tested on ® eye
→ Monocular Blindness
 flash pen light on (L) eye
→ there is a direct response on (L) eye & a consensual response
seen on the ® eye
→ size of both pupils is 1 mm = PERRLA
Case 3: CN 3 is damaged on the (L)
 flash penlight on (L) eye
→ there is no direct response on (L) eye but there is a consensual
response seen on the ® eye
→ Ptosis on (L) eye
→ (L) pupil size = 2 mm Anisocoria
® pupil size = 1 mm (unequal pupillary size)
pseudoptosis – inability to close the eyes completely but can fully
open the eyes
ptosis – inability to open the eyes completely but can fully close the
eyes
 flash penlight on ® eye
→ there is a direct response on the ® eye but no consensual
response seen on the (L) eye
→ ® pupil size = 1 mm (L) pupil size = 2 mm
Case 4: CN 3 on ® & CN 2 on (L) are both damaged
 flash penlight on (L) eye
→ there is no direct response on the (L) eye & no consensual
response seen on the ® eye
→ pupil size = 2 mm
 flash penlight on ® eye
→ there is no direct response on the ® eye but there is a
consensual response seen on the (L) eye
→ ® pupil size = 2 mm
(L) pupil size = 1 mm
Case 5: ® pupil is 10 mm & (L) pupil is 10 mm
→ both dilated = Dead
Argyll Robertson Pupils
 syphilitic pupils
Tabes Dorsalis
 syphilis that affects the dorsal column (conscious proprioception)
 unable to do tandem gait with eyes closed
 (+) Tandem gait – broad base gait with eyes open
 (+) Lhermitte’s test – identifies the dorsal column damage; px in long
sitting postn, PT applies a jerky neck flexion (+) sciatic pain
 in the long run, px can have syphilitic arthritis (neuropathic joint) –
Charcot’s Joint
 neuropathic jt. – start as non-erosive then later on it may become erosive
Charcot’s joint
 most commonly affected jt.: Knee jt.
  commonly seen in conditions such as Syringomyelia, Tabes dorsalis,
Diabetes Mellitus
 CI: deep knee bends
SLE – jaccoud’s jt. (non-erosive)
cPM – DM - most commonly affected jt: knee; px has difficulty from sit to stand

Visual Field Cuts/ Defects
Lateral geniculate body of the thalamus – eye
Medial geniculate body – hearing
Conditions:
 ® Homonymous Hemianopsia – seen in (L) Optic
tract, (L) LGB, (L) Optic nerve radiation & (L) Area
17 damage
 through the use of mirror, px won’t be able to
have difficulty in putting make-up or anything
for grooming
 px will have difficulty in feeding, copying a
figure on a picture frame & UE/LE dressing
 common in (L) CVA – ® Hemiplegia

Damage Visual Field Defect Condition

® (L)
A. (L) CN 2 (L) Monocular Blindness

B. Optic chiasm Bitemporal Heteronymous

Hemianopsia

C. (L) Optic Tract ® Homonymous Hemianopsia

D. (L) Area 17 ® Homonymous Hemianopsia with

Macular Sparing

 Px is a (L) CVA – ® hemiplegia.

→ During ambulation, px will list on the (L) side
Note: Pusher Syndrome – poor prognosis; px push himself away from the
affected side
→ px will have difficulty in crossing from where he came from going to the
other side of the street
→ during group exercise, place the px in his most extreme ® so that he can
see the exercise (adjustment: start from ® going to (L) side)
 ® Homonymous Hemianopsia with Macular sparing
 commonly seen in PCA stroke (occipital lobe affectation)
 Macular sparing – macula densa of the eye is spared
 group exercise of the px should be in a round table
 Optic Radiation
 Because of the process of refraction, the
inferior nasal transmit vision to the
superior temporal, the inferior temporal
transmit vision to the superior nasal, the
superior nasal transmit vision to the
inferior temporal & the superior temporal
transmit vision to the inferior nasal
 superior loop – visualizes the opposite
inferior quadrant of the visual field
 inferior loop – visualizes the opposite
superior quadrant of the visual field
 Damage Visual Field Defects Condition
® (L)
(L) Inferior loop of Optic ® Superior
radiation Quadrantinopsia

(L) Lingual Gyrus ® Superior

Quadrantinopsia with
Macular sparing
 Area 17
1. Cuneus gyrus – cephalad; visualize the opposite inferior quadrant
2. Lingual gyrus – lower; visualize the opposite superior quadrant
(L) ® 1 – (L) lingual
1 2 Lingual 2 – ® lingual
3 – ® cuneus
4 3 Cuneus 4 – (L) cuneus

CN 3, CN 4 : TROCHLEAR NERVE & CN 6 : ABDUCENS NERVE

 these nerves traverses the superior orbital fissure
 CN 3 – other specialized fxn: innervates the ff:
1. Extraocular movement (EOM) except lateral rectus & superior oblique
2. Levator palpabrae superioris (eye opening)
3. pupillary constriction
 CN 4 – only CN at the posterior brainstem; fxn: EOM (superior oblique ms.)
 CN 6 – has the longest intracranial course; fxn: EOM (lateral rectus)
CN 10 – has the longest extracranial course
 Examples:
Case 1: affectation of the ® Midbrain (CN 3 & CN 4 are both affected)
 flash penlight on the (L) eye
→ there is a direct response on the (L) eye but no consensual response seen
on the ® eye
 if px is asked to close the eyes
→ (+) ptosis (CN 3)
 could there be a possibility px can have Bell’s palsy?
→ NO (CN 7)
→ a true ptosis will not have a synkinetic mov’t.
Bell’ Palsy – Special tests:
 Marin Amat – as the px opens the mouth fully, the ptotic eye closes
 Marcus Gunn – as the px closes the eye, the eyeball rolls upward
 Bell’s Phenomenon

 look down: ® SO, (L) IR / (L) SO, ® IR

® (L)  look up: ® SR, (L) IO / ® IO, (L) SR
IO SR IO  squinting: ® & (L) MR
LR MR LR

SO IR SO

Damage Manifestations Condition

® (L)
 CN 3 External strabismus/
Exotropia
(L) Superior Oblique Vertical diplopia [happens when
(CN 4) px looks up to the (L)]
® Lateral Rectus Horizontal diplopia [happens
(CN 6) when px looks up to the (L)
 Horizontal diplopia happens when the px looks to the ®.- the ® eyeball medially
rotates
 to prevent contracture of EOM, cover the good side to rehabilitate the affected side

CN 5 : TRIGEMINAL NERVE
 mixed nerve; 3 Branches
Ophthalmic division Superior Orbital fissure
Maxillary division Foramen rotundum
Mandibular division Foramen ovale
 largest CN from the upper pontine (CN 5, 6)
lower pontine – (CN 7, 8)
 can indirectly subserved to midbrain & medulla
 sensory function
1. skin sensation of the face & scalp
 sensory distribution:
ophthalmic division – imaginary line crossing the portion of the upper lid
up to the portion of the scalp except the skin covering the occiput
maxillary division – imaginary line traversing the portion of lower lid up to
the portion of upper lip
mandibular division – imaginary line from the portion of lower lip up to the
skin covering the mandible
 2 ganglion:
gasserian ganglion – tactile sensation of face & scalp
mesencephalic nucleus – proprioception of the face
 affectation of sensory branch: Trigeminal neuralgia/ Tic doloreux
 affectation of both gasserian ganglion & mesencephalic nucleus
 pain & neck on the face
 common in MS px
 Mx: desensitization TQ [massage (effleurage, tapotement), TENS mode
(high rate; conventional; high frequency, pulse mode)]
2. sensation of cornea
 innervated by the ophthalmic division of Trigeminal nerve

Corneal Blink Reflex

afferent limb – CN 5 (ophthalmic division)
BRAIN
efferent limb – CN 7 (orbicularis oculi)
Stimuli: wisp of a cotton
CN 5 CN 7 CN 5
Case 1: touch the ® cornea, the ® eye close & the (L) eye
will close
® (L) → ® eye has a direct blink response, the (L) eye has
consensual blink response
Case 2: CN 5 damage
→ ® eye test: there is no direct blink response on the ® eye & no
consensual blink response seen on the (L) eye
→ (L) eye test: there is direct blink response on the (L) eye & a consensual
blink response on the ® eye
Case 3: ® Bell’s palsy
→ ® eye test: no direct blink response on the ® eye but there is consensual
blink response on the (L) eye
 → (L) eye test: there is a direct blink response on the (L) eye but no
consensual blink response on the ® eye
3. general sensation of 2/3 of the tongue
anterior 2/3 of tongue – chorda tympani (CN 7)
tactile sensation – CN 5
posterior 1/3 of tongue – CN 9

 sulcus terminale – divider of the tongue

posterior
 chorda tympani (CN 7) - anterior 2/3 of the tongue; taste
1/3
(sweet, sour, salty)
 lingual nerve (mandibular division of CN 5) – general
sulcus
sensation of the tongue (the feeling that there is something
terminale
inside your mouth but you don’t have to taste it
anterior
 CN 9 – taste sensation & general sensation ; bitter
2/3

4. jaw jerk reflex (CN 5 reflex)

 place thumb on the tip of the mandible, mouth slightly open. Tap thumb with
neurohammer
(N) response: mouth closure
 Myasthenia Gravis condition affects the CN 5
(+) jaw hanging
jaw jerk reflex: hyporeflexive or areflexive
 motor function
1. ms. of mastication
Temporalis
Internal/ Medial pterygoid closes the mouth
Masseter
External/ Lateral pterygoid – opens mouth; has 2 fibers
inferior fiber – opens the mandible
superior fiber – holds the disc of condyle superiorly
 Temporalis ms. – keeps the mandible ajar
 fxnal mouth opening: 25 mm
 (N) mouth opening: 40 mm (3 fingerbreadth, 2 knuckles)
> 40 mm – hypermobile < 40 mm - hypomobile
Case 1: ® mandible is hypomobile. There is (-) clicking & (-) pain. Where does
the mandible deviates when mouth opens?
→ mouth deviates to the ® side
→ lateral excursion to the ® side is less than fxnal & there is (L)
hypermobility
hypermobility – mandible deviates to the (N) side
Hypomobility – mandible deviates to the affected side
Case 2: Lateral excursion opposite the ® is less than fxnal in a hypomobile (L)
TMJ. What ms. will deviate the mandible & to what side?
→ mandible will deviate to the ®
→ ® Lateral pterygoid, (L) medial pterygoid
Case 3: Lateral excursion to the (L) is less than fxnal with hypermobile TMJ
→ mandible deviates to the ® - (N) side
→ (L) medial pterygoid, ® lateral pterygoid
Case 4: There is ipsilateral facial sensory loss.(-) pain & clicking when mouth
opens. Lateral excursion to the ® is less than fxnal. What ms. will deviate
the mandible & to what side?
→ mandible will deviate to the (L)
→ (L) lateral pterygoid, ® medial pterygoid
→ lateral excursion opposite the (L) is less than fxnal
2. some suprahyoid ms.
anterior belly of digastric (posterior belly of digastric – CN7)
mylohyoid (geniohyoid – CN 1; stylohyoid – CN 7)
 3. tensor tympani
 tenses the tympanic membrane (vibrates the ear drum)
 paralyzed: Tinnitus
Tinnitus
 caused by ototoxic drugs: Salicylates, Aminoglycosides, Quinines
 sx: mild deafness, vertigo, fullness of the ear, edema within the
membranous labyrinth of the ear
 problem in the inner ear
Meniere’s Disease
 sensorineural hearing loss; Unilateral Vestibular dse.
Conduction hearing loss
 problem in the middle or outer ear
CN 7 : FACIAL NERVE
 mixed nerve;
 main sensory fxn: Nervus intermedius of Wrisberg
 main motor fxn: Facial nerve proper
 originates at the caudal pons traversing the ff:
Internal Auditory Meatus (together with CN 8)
→ cholesteotoma – benign tumor that exist within the temporal lobe that impinges
the area of IAM
Facial canal
→ sensory branch:
1. geniculate ganglion – innervate the skin sensation of the ear, earlobe &
behind the ear; affectation may cause:
 Bell’s palsy – paresthesia of the ear lobe
 Herpes simplex:
² Type 1: Varicella zoster – causes chicken pox
Type 2: Herpes zoster – viral infection caused by varicella zoster
- aka Shingles (vesicles) – lesion that has interstitial fluid
within it
- painful & the vesicles is along the course of the nerve
- to resolve: Acyclovir (Zovirax)
 Ramsay Hunt Syndrome – herpes zoster affecting the geniculate
ganglion; painful vesicular eruption
2. pterygopalatine ganglion (parasympathetic) – important for lacrimation
 subserves the greater superficial petrosal nerve for lacrimal glands
 stimulation of greater superficial petrosal nerve = ↑ lacrimation
 no significant effect of lacrimation in the SNS
 affectation may cause:
Xerophthalmia – dry eyes seen in Sjogren’s syndrome
Crocodile tears - ↑ lacrimation seen in Bell’s palsy
3. submandubular ganglion – subserves the submandibular & sublingual glands
 for salivatory gland fxn
 from superior salivatory nucleus (inferior salivatory nucleus – CN 9)
 affectation may cause:
Sialorrhea - ↑ salivation seen in Bell’s palsy
Xerostomia – dry mouth seen in Sjogren’s syndrome
 Sjogren’s Syndrome
 connective tissue disease
 test: Shirmer’s test – place a lithmus paper near the lacrimal
duct of the eye
(+) Rose Bengal sign – the eyes get rosy red due to no
lacrimation
Bell’s Palsy
 test: Chovstek Test – determines an imminent Bell’s palsy by
tapping the area of parotid gland; also a test for Tetany
(hypocalcemia)
(+) blepharospasm – paroxysmal twitching of the eyelid
(+) hemispasm – paroxysmal twitching of the facial ms.
Generalized Tetany
 test: Trousseau test – wind around BP cuff on the area of the
arm as it becomes tight
(+) carpo-pedal spasm – paroxysmal twitching of the
arm & hand
→ motor branch
Nerve to stapedius – smallest skeletal ms. in the body
 modulates the sound that enters the ear
 paralyzed: Hyperacusis (↑ sensitivity to sound)
→ sensory innervation: Taste sensation of anterior 2/3 of the tongue (chorda
tympani)
Stylomastoid Foramen – as it exits here, it gives 5 motor branches:
1. temporo-facial
2. zygomatico-facial
3. bucco-facial motor for muscles of facial expression
4. manidbulo-facial
5. cervico-facial
→ paralysis: facial sagging/ asymmetry, pseudoptosis (inability to close the eyes
completely)
→ Tests for pseudoptosis: Corneal blink reflex
→ Tests for Bell’s palsy: Marin – Amat Test – as px maximally open the mouth, the
ptotic eye closes
Bell’s Palsy
 aka Anthony’s Palsy
 1st ms. to recover: buccinator (blowing)
last ms. to recover: occipitofrontalis (expression of surprise)
 PT Mx: ES – Interrupted Direct Current with rectangular waveform (abrupt ↑ing intensity,
plateaus then abrupt ↓ intensity)
 placed in some suprahyoid ms. (posterior belly of digastric & stylohyoid)
Brain supranuclear area – above nucleus
Caudate
 UMN (part of CNS)
2 3 4 1 2 3 nuclei infranuclear area – nuclei going to face
 LMN (PNS)
A Corticobulbar tract – cortex to brainstem
1 2 3 4
Facial nuclei 2 ® upper quadrant is dually innervated by the
same cortex & opposite cortex
B
3 (L) upper quadrant is dually innervated by
C the same cortex & opposite cortex
4 (L) lower quadrant is singly innervated by
(R) 2 3 (L) the opposite cortex
1 ® lower quadrant is singly innervated by the
opposite cortex
1 4
  Examples
Case A: Px with ® CVA (non-dominant) = (L) hemiplegia
→ affected (L) lower quadrant (contralateral lower ¼ of the face)
→ Central Facial Palsy (CNS) – Apoplexy
→ Frontal sparing – upper quadrant is spared due to dual innervation
Case B: (L) Bell’s Palsy
→ half of the face is paralyzed on the same side
→ Peripheral Nerve Palsy (Prosopoplegia)
Case C: Px with Myasthenia Gravis
→ dual affectation
→ Bifacial palsy
Mobius Syndrome – bifacial palsy with internal strabismus;
differential diagnosis of MG
Millard – Gubler Syndrome – contralateral hemiplegia with
internal strabismus & brainstem stroke (lateral pons affected)
Foville’s Syndrome – Millard – Gubler case without conjugate
gaze
CN 8 : VESTIBULOCOCCHLEAR NERVE
Vestibular Nuclei Cochlear Nuclei
 Equilibrium  Hearing
 Vestibular ganglion  Spiral ganglion
 5 structures responsible for sense of hearing
1. cochlear nucleus
2. spiral ganglion
3. inferior colliculus
4. MGB (medial geniculate body)
5. Organ of corti
Hearing Fxn
Organ of Corti
 Stimulus: Tick of the clock, let px identify the laterality
Tunning fork: tap it on firm areas
 Tests:
1. Weber test – place tunning fork on the vertex of the head & you have to hear
the sound vibration
2. Rinne test – placing the tunning fork on the mastoid process
 Base of tunning fork determines hearing by bone conduction
 Tip of tunning fork determines hearing by air conduction; heard much longer
AC > BC (feeling of vibration is shorter but hearing by vibration is longer)
AC = BC Ab(N) – there is conductive hearing loss
AC < BC Prob: outer/ middle ear
You place the tunning fork above the vertex & a little bit elevated. You’re testing what? Sound
conduction only (hearing capacity)
→ if place on (L) ear, but heard more on ® ear = sensorineural hearing loss
Prob: inner ear
→ Meniere’s dse – inner ear problem
Equilibrium Fxn
Type fxn organ tests
Static equilibrium posture Maculae: Sacculi, Romberg’s test
Utriculli Fxnal Reach test
Kinetic equilibrium movements Cristae Ampullares Tandem Gait Ax
Get Up & Go test (GUG)
 Romberg’s Test
☺ Px feet together, eyes open & eyes closed – Px remains standing → (-)
Romberg’s test
☺ Eyes closed – px sways → (+) Romberg’s (affectation of CN 8)
☺ Eyes open & eyes closed – px sways → affectation of cerebellum or dorsal
column
Dim area, px outbalance even with eyes open & eyes closed. What is the problem?
Somatosensory system affectation
Difference bet Cerebellum & Dorsal column problem:
Test for Cerebellum: let px sit in a swivel chair, rotate/ spin it several times. If it
stops, the px should still remain seated & does not sway → (+) Piano stool test
Test for Dorsal column: 2 pt. discrimination; Lhermitte’s test
 Functional reach test
☺ Children has much better fxnal reach than elderly (COG is displaced anteriorly)
 Tandem Gait Analysis
☺ Px walks in a straight line
Px do a tandem walk with eyes open in a straight line. Px don’t want to walk in a zigzag line.
Where is the problem? Perceptual deficit (prob: Area 5 & 7: Sensory Association
Area)
Visual Spatial Distortion
- px still recognized when he looks at it but has difficulty perceiving it
 Get Up & Go test
☺ Px seated in a chair, has 3 meter marking. Px walks through it & stop in the
marking then goes back & sit again
☺ Timed GUG – modified GUG test; same as GUG test but has to do it within 10
secs or less
(N) done it 10 secs or less
WNL done it 11 – 20 secs; px is weak & flail
↑ risk of falling done it 20 – 30 secs; young or old px
High risk of falling done it > 30 secs; px needs rails
Vestibular System Problems
1. Unilateral Vestibular Disease (UVD)
2. Bilateral Vestibular Disease (BVD)
UVD case BVD case
 Labyrinthitis (inner ear)  Overdose of SAQ
 Vestibular neuronitis (ear infection caused either by (salicylates,
bacteria or virus) aminoglycosalates
 Otolithiasis (calculi formation within the otolabyrinthine) , quinines) – drug
 Canalithiasis (calculi formation within the semicircular ototoxicity
canal) (bilateral tinnitus)
 Cerebellar medulloblastoma
 Acoustic neuroma (tumor in CN 8)
 Benign Paroxysmal Positional Vertigo (BPPV)
 Meniere’s Dse.
Benign Paroxysmal Positional Vertigo (BPPV)
 Vertigo & nystagmus experienced brought about by sudden change in head
position
 There is a dysfunctional VSR (Vestibulospinal reflex)
Vestibuloocular reflex (VOR)
 causes gaze instability (blurring of vision)
Vestibulospinal reflex (VSR)
 causes postural instability
 problem in VSR can have a VOR problem also
→ problem in vestibular apparatus (giving you a
postural instability & ocular dysfunction)
→ Mx: recalibrate by doing habituation exercise
 Habituation Exercise:
1. Brandt – Daroff exercise
 Px is seated then positioned to sidelying in a vertical position
for a few seconds [® & (L)]
2. Epley’s Maneuver
 Same as Brandt – Daroff exercise
  ® sidelying until vertigo subsides → supine → rotate head 45º to
(L) then ® until vertigo subsides → short seating → (L) sidelying →
supine → rotate head 45º to (L) then ® until vertigo subsides →
short seating
 Do short seating after every position
 Dix – Hall – Pike Manuever – determines a possible BPPV
 place px in a seated position, immediately bring the px to a supine position,
suspend the head, hyperextend, rotate then immediately bring px back to the
seated position.
 Mx: Canalith – Otolith Positioning
Meniere’s Disease
 Inner ear problem
 manifestations:
tinnitus sensorineural hearing loss
fullness of the ear edema of the membranous labyrinthine of the ear
mild deficit
 corrected by Habituation exercise: Canalith or Otolith repositioning
- px in supine position, hold px’s head a bit flexed then distract. Tilt on either
side (flex & rotation combination)

Vestibular Rehabilitation
Materials used: Theraball, Vestibular ball

Sitting, centrally atop of the ball

 erector spinae ms contracting to maintain a good balance

Sitting, slightly anterior atop of the ball

 erector spinae ms contracting to prevent forward fall

Sitting, slightly posterior atop of the ball

 abdominal ms contracting to prevent backward fall

Sitting, centrally atop of the ball, bounce the buttocks

 Abdominal ms contracting (firming the abdomen)

Sitting atop of the ball, forward reach

 Erector spinae ms contracting

Sitting atop of the ball, leaning backward

 abdominals

Sitting atop of the ball, push pelvis anteriorly

 Erector spinae ms

Sitting atop of the ball, push pelvis posteriorly

 abdominals
 The ball is quickly moved anteriorly
 abdominals

The ball is quickly moved posteriorly

 Erector spinae ms

The ball is rolled anteriorly

 Erector spinae ms

The ball is rolled posteriorly

 Abdominals

 Sitting atop of the ball, arm sideward reaching to the ® → (L) lateral trunk flexors
((L) Quadratus Lumborum
 Ball is quickly tilted to the ® → head & trunk tilt to the (L), (L) UE – abduct, ® UE
– adduct, buttocks weight shift to the ®
Facets elongate to the ®, (L) facets closed
 Ball is quickly tilted to the (L) → head & trunk tilt to the ®, (L) UE – adduct, ® UE
– abduct, buttocks weight shift to the (L)
(L) facets elongate, ® facets closed
 Sideward reach to the ® → ® facet elongate, (L) facet closed
Perturbations
 quick & fast
 foot to head
Anterior Posterior
Toes Hyperextend (TP) Flexed
Foot & Ankle PF (TP) DF
Pelvis Anterior pelvic tilt Posterior pelvic tilt
Trunk Extension (erector) Flexion (abdominals)
UE Flexion Extended (shoulder flex, elbow, wrist/ digits extend)
Head Extended

Side Pertubation ® [from (L) to ®] (L) [from ® to (L)]

Pelvis Level (g. med) Level
(L) LE Abducted (eccentric) Abducted
(L) UE / ® UE Abducted/ adducted Adducted / adducted
Trunk Tilt to the (L) Tilt to the (L)
Px with IDDM was having difficulty in maintaining balance in even surface, even/ uneven terrain,
stairclimbing. What is the problem? Visual deficit (glaucoma)
Note: Diabetic Retinopathy – px having difficulty in stairclimbing

CN 9 : Glossopharyngeal Nerve
 mixed nerve
 innervates the external ear (together with CN 10)
 responsible for posterior 1/3 of the tongue (general sensation & taste sensation)
 Otic ganglion – lacrimation; subserved by inferior salivatory nucleus by the parotid gland
Myxovirus – causes mumps/ viral parotitis
Viral parotitis with orchitis – inflammation of testes; may cause sterility of young
boys‰
 Innervates the stylopharyngeal ms (main muscle for deglutation)
3 stages of swallowing:
 a. voluntary stage – the food is pushed from the tongue to the pharynx
b. pharyngeal stage – the food is pushed from pharynx to esophagus
c. esophageal stage – food is pushed from esophagus to the stomach
- no enzymatic reaction
- mainly a conduit of food
2 enzymes in pharyngeal stage
a. lingual lipase – for unsaturated fats
b. amylase – digest starches converting to simple sugar (glucose)
Glucose – anaerobic metabolism → lactic acid
Glucose – aerobic metabolism → pyruvic acid
Note: No protease in oral cavity
Protease is located in pancreas & stomach
Protein uncoat – HCL
Protein digest - Pepsin
 Lesions:
 ® CN 9 affectation: position px in high fowlers, feed px on bad side, chin tuck to
push the food on the (N) side
 Gastric atony: feeding by NGT on a semi-fowlers position

CN 10 : Vagus Nerve
 Longest cranial nerve
 Innervates the GIT (large intestine)
 (L) Colic Flexure – junction of transverse & descending colon
 Spinal Dura – ends at S1; somatosensory
 Gag reflex – motor:CN10; sensory:CN9

 If LMNL, uvula deviates away from the lesion

 In ® CVA, uvula deviates towards the lesion

 In general, the uvula deviates towards the stronger

side

 Innervation: pharynx, larynx, trachea, lungs (bronchoconstriction), esophagus, stomach,

small & large intestine (↑ motility), & other GIT organs
 Relaxation of GI sphincter → ↓ HR & ↓ BP
↓ HR = symptomatic bradycardia → Mx: atropine SO4 (abrupt effect)
 Heart transplant – in this case, HR is not the determinant for exe. instead RPE is used
 Nucleus Ambiguus – innervated by CN 9 & 10
 fxn: swallowing
 damage: dysphagia
 Levator Labii Palatini – when contracted, it goes up
 closes soft palate to also close nasal passage
CN 11 : Spinal Accessory Nerve
 innervates the following:
SCM – when both contracted → neck flexion
- part of anterior cervical triangle
- innervated by CN 11 when it traverse to the jugular fossa
- paralysis: Torticollis
stretch: tight (L) SCM – neck lateral flexion to the ®, rotation to the (L)
Trapezius – innervated when it traverse the foramen magnum
- part of the posterior cervical triangle
- paralysis: winging of scapula (lateral/ sliding door)
 Serratus Anterior – puts UE closer to chest wall
- paralysis: loss of upward abduction (major fxn)
- SA paralysis is more common than trapz paralysis
 To test: resisted shoulder shrug
CN 12 : Hypoglossal Nerve
 Intrinsic ms of the tongue – shapes the tongue
 Extrinsic ms of the tongue – moves the tongue
 Affectation: Dysarthria
 Ms of the tongue:
Genioglossus
Hypoglossus
Styloglossus
Palatoglossus
 In ® CVA, the tongue deviates to (L) d/t
fibers of ms of the tongue goes medially or
the tongue deviates towards the
hemiplegic side away from hemiplegic
lesion

Cerebellar dysarthria – cerebellum affectation

BRAIN
 from primitive neural tube: Cranial 2/3 (brain), Caudal 1/3 (SC)
 ectodermal in origin
 folic acid – important in pregnancy; for brain development of the fetus
if ↓ folic acid – Megaloblastic anemia
 Primitive Brain:
Prosencephalon – forebrain Rhombencephalon – hindbrain
Mesencephalon – midbrain Telencephalon – cerebral hemisphere
Diencephalon –
a.thalamus - emotional tone; sensory relay station (to the brain)
b.Hypothalamus – thermoregulation
 Regulates true emotions
 Sleep wakefulness center (REM – deep sleep)
 Does not have sensory fxn
 Feeding center (satiety center)
(N) Ab(N) Disease
Satiety Full hungry Bulimia Nervosa
Hunger Hungry full Anorexia Nervosa
c. epithalamus
d.subthalamus – coordinated movements
 subthalamic nucleus of Luys – causes hemiballismus
 ex: ® Hemiballismus – prob: (L) subthalamic nucleus of Luys
 Pineal/ Mamillary bodies – for glandular activity
Red nucleus Unconscious ms coordination
Midbrain Superior colliculus For eye
Mesencephalon
(CN 3, CN4) Inferior colliculus For hearing
Tectum/ tegmentum Visual reflexes
Metencephalon Pons (CN 5, 6, 7, & 8) & Cerebellum
Medulla Oblangata Cardiopulmonary center
Rhombencephalon
Myelencephalon Reticular Activating Arousal & conscious center
System (RAS)
 Gray mater – unmyelinated; nerve body
White mater – myelinated; nerve tract
 Longitudinal fissure – divides the (L) & ® hemisphere
Central sulcus of Rolando – divides the anterior & posterior gyrus
anterior part: Motor Precentral gyrus
posterior part: Sensory postcentral gyrus
Lobes
Parietal Lobe
  Sensory & perception area
 Lesion: ® CVA, (L) Hemiplegia (non-dominant)
Frontal Lobe
 Speech, motor, behavior (SMB)
 Lesion: Aphasia – (L) CVA, dominant hemisphere; Broca’s aphasia – Broca’s area
ACA affected
Motor
Fine Motor Gross Motor
2 y.o Hand dominance 2 – 3 mos Holds head up
5 y.o Hand preference 2 – 4 mos Rolls over
2 y.o Vertical ( I ) 3 – 5 mos Prone to supine
2 ½ y.o Horizontal 5 – 7 mos Supine to prone
3 y.o Circle 4 – 6 mos Crawls
4 y.o Cross 5 – 7 mos Sits
5 y.o Square 7 – 9 mos Stands
6 y.o Triangle 10 – 18 mos Walks
7 y.o Vertical diamond can pedal a tricycle
8 y.o Horizontal diamond ascends stairs with alternating feet
9 y.o Broad cross 3 y.o broad jump
stands on 1 limb
can kick a ball
Descending stairs with alternating feet
4 y.o
Hops
5 y.o Skips
6 y.o Skates/
Temporal Lobe
 Auditory fxn
 Lesion: mild deafness at contralateral ear
Occipital Lobe
 Vision fxn
Limbic Lobe
 Fxn: memory/ intellect, emotional behavior (highly logical), sexual drives
 Lesion: dementia (nucleus of meynert), alzheimer’s dse
Central Lobe (Insula/ Island of Reil)
 Fxn: visceral
 Lesion: visceral pain = ↑ HR, ↑ BP
Cerebellum
 Fxn: coordination, equilibrium, ms. tone
 Lobes: posterior/ neocerebellum, flocculonodular/ archi-cerebellum, anterior/
paleocerebellum
 Lesions: hypotonia (unlike with other UMNL – hypertonia)
Coverings of the Brain Tissue (Meninges)
Meninx Primitiva Dura mater – outermost; highly vascular
↓ ↓  Bld supply: middle meningeal artery (MMA)
Ectomeninx=L
Endomeninx Pia mater – highly vascular (MMA); above the brain
↓ ↓  Membrane of nutrition of the brain
Pachymeninx Leptomeninges Arachnoid mater – avascular tissue
(Dura mater) (pia & arachnoid)

Dural Spaces:
Epidural space – space bet. pericranium & dura mater
 Content: arterial blood supply
 Lesion: Epidural hemorrhage (arterial in origin)
Subdural space – space bet dura mater & arachnoid
 Content: venous drainage
 Lesion:
subdural hme – due to close-head injury → hematoma → decerebrate/
decorticate rigidity
subacute subdural hematoma – after injury, px is ok but after 3 -4 of injury, px starts
to vomit (↑ brain herniation, ↑ ICP)
 Place px in a semi-fowlers position, keep px alert & awake

TBI px, keep px lights on to stimulate somatosensory fxn

6 mos – golden pd of TBI

3 mos – if used with multi-modality evoked potential
Subarachnoid space – space bet arachnoid & pia mater; content: CSF (colorless fluid)
Flow of CSF  Choroid plexus - produces CSF
Choroid plexus
↓  Lateral ventricle - anatomically in-lined
Lateral ventricle with cerebrum
↓ - ® & (L) is separated by septum
Foramen Monroe pellucidum)
↓
3rd ventricle  Cisterns- dilated portion of ventricles
(thalamus area) Cisterna magna – largest cistern
↓  Arachnoid villi (Pachonian granulation) -
ITER hairlike venous projection
(Aqueduct of Sylvius)
↓ - reabsorption fxn
4th ventricle - derivatives of arachnoid
(pons varolii area) membrane
↓ ↓
Foramen of Luschka Foramen of Magendie:
↓ Lymphatics
Cisterns Ascites – localized edema
↓ Anisarca – generalized edema
Arachnoid villi (Pachonian granulation)
↓
Superior Sagittal Sinus
↓
Venous system
↓
Great vein of Galen

 Lesion:
Hydrocephalus (macrocephalic) – caused by obstruction of CSF
 Triad: Dementia, Ataxia, Incontinence
 Manifestations: sundowning appearance/ sunset eyes/ setting sun
sign, edema of macula densa of the eye (papilledema), crack pot
sign (hollow sound in percussion of skull area)
 Types:
1.Non-obstructive/ (N) Pº Hydrocephalus – there is (N)
production of CSF by the choroids plexus but there is
malabsorption of arachnoid villi
2.Communicating Hydrocephalus – there is possible infection/
inflammation within the ventricles/ subarachnoid that constrict
the space but allows passage
3.Non-communicating Hydrocephalus – totally obstruct
ventricles of the brain; space-occupying lesion
4.Arnold-chiari malformation – 2º to trauma during delivery → ↑
ICP in brain due to impingement on the junction between the
pons & medulla
5.Dandy – Walker Syndrome – impingement at the area of F.
Luschka or F. Magendie before the CSF flows towards the
cisterns
 PT Intervention:
☺ Ideal position of the child: semifowler’s (2 pillow postn)
☺ Tell mother protect the child from trauma of the head (can
lead to seizure)
Seizure
 Interruption in the intraneural connection of the brain
 Triggers seizure: trauma, infection, fatigue
 Protocol for px having seizure: place px in sidelying
position, clear area of possible obstruction, place roll
 towel on mouth
 Grandmal Seizure – feeling of aura; ictal pd (tonic-clonic
mov’t.), post-ictal pd (px goes to deep sleep)
 Meds: Anticonvulsant/ Anti-seizure
Dilantin (Phenytoin) Valproic acid
Carbamazepine (Tegretol) Phenobarbitals
Klonazepine (Klonapin)
 Surgery: shunts
AV (Atrioventricular) shunt – Arnold-chiari malformation
VP (Ventriculoperitoneal) shunt – most commonly
applied
VP shunt
 Placed in the ® lateral ventricle of the brain going
to the posterior neck then drains to the diaphragm
 Valve is near the base of the skull
 Used if there is an overflowing of CSF in the brain
 Installed by endoscopic surgery
 Manifestations of a displaced shunt:
- child becomes irritable (always crying)
- child becomes more demented
- child cannot walk
- constant urine flow happens (incontinence)
Derivatives of Meninges
 Dura mater
Falx Cerebri – divides ® & (L) cerebral hemisphere
Falx Cerebelli – divides ® & (L) cerebellar hemisphere
Tentorium Cerebelli – divides cerebrum from cerebellum; forms the roof of the
cranial fossa
Diaphragma sellae – encapsulate the pituitary gland
 Pituitary fossa is aka Sella Turcica
 Pituitary adenoma is a glandular tumor that causes visual field
deficit (Bitemporal Homonymous Hemianopsia) because the
pituitary gland lies behind the optic chiasm
Outer periosteal & inner menigeal – dura mater outside the skull
Vertebral layer – meningeal layer (meningeal irritation → (+) Lhermitte’s sign)
 Arachnoid mater
Tela choroidea – produces choroids plexus
Arachnoid villi
 Pia mater
Ligamentum denticulatum or denticulate ligament – ligaments that suspend
the spinal cord within the neural canal
Filum terminale – interconnect the coccygeal nerve to the coccyx
Protocols:
Acute condition – pain is experienced before tissue restriction
 Apply cold (if effective, px should feel numbness)
 Duration: if the part is already numb, stop icing
Subacute condition – pain is experienced within tissue restriction
 apply heat & cold (4:1 x 4x)
 end in hot for 4 mins
Chronic condition – pain is experienced after tissue restriction;
acute exacerbation of a chronic condition
 apply either heat or cold

Brain Tissue : Brodmann’s Area

Area 3, 1, 2 – 1º Sensory Cortex/ 1º Somasthetic Area
 responsible for sensations: pain, Pº, proprioception (3P),
touch & Tº (2T)
 lesion: hemianesthesia (contralateral)
crossed anesthesia ( brainstem stroke;
ipsilateral face, contralateral extremity)

Association Fibers – fibers interconnecting areas of the same hemispheres
Commisural fibers – interconnecting area of opposite hemisphere
corpus callosum – connects ® & (L) cerebral hemisphere
vermis – corpus callosum of cerebellum
Projection fibers – interconnecting brain & spinal cord (v.v)

Area 5, 7 – Sensory Association Area

 responsible for perception
 lesion: perceptual deficit
agnosia – inability to recognized sensation but there is no sensory deficit
Perceptual Deficits
Anosognosia  Inability to recognized his own disease
 px seems to be having CVA but does not recognized its
own dse.
 lesion in MCA (non-dominant hemisphere –(L) hemiplegic)
 px with poor judgement, px with denial
Prosopagnosia  px does not recognized familiar faces
Topographic  px recognized the object but cannot identify the exact
disorientation location of that object; px has (-) amnesia
 POC: arrows, foot steps
Auditory Agnosia  inability to recognized familiar sounds
 lesion: temporal lobe
Visual - Spatial  px has miscalculation of spaces & has difficulty in passing
Distortion doorways or passageways
 px able to walk in a straight line, but unable to walk in a
zigzag line
Vertical disorientation  px does not recognized vertical spaces
 px enters the door but listed on 1 side
 perceptual deficit that will give the px the Pusher syndrome
(px push away from the hemiplegic side)
Spatial Relation deficit  inability to follow instruction & orientation of #’s & hand of a
clock
Spatial neglect/  px is asked to copy a figure from a picture frame but only
Hemineglect drawn half of the figure
 seen in px with ® CVA, (L) hemiplegic
 POC: px should copy the figure on his ® side (extreme ®)
to copy the whole figure
Constructional Apraxia  px is asked to copy a figure but drawn it in a delapsidated
figure
 lesion: Area 40 (Supramarginal gyrus)
Figure – Ground  px cannot recognized a part of the whole
Relationship deficit (by  px cannot recognized the figure from the background to
picture) which it is embedded
Balint’s Syndrome  px only recognized a part of the whole but does not
(Simulatanagnosia) recognized the figure as a whole
Depth Perception deficit  inability of px to place the object within the figure (px
releases the object early)
 px miscalculated the distance
Dysmetria  inability to fix the ROM, there is overstretching the goal
 lesion Cerebellum
Form Constancy deficit  px sees the object but has failed to identify the right object
by mere touch & by the aid of vision
Astereognosis  px was blindfolded & was asked to pick the object by touch
 px failed to identify the right object by mere touch without
the aid of vision
  lesion: dorsal column
Visual Agnosia  Px was asked to watch TV. Instead of picking up the remote
control, he took the handset of the telephone & tried to
open the TV.
 px has performed the right activity but with the wrong object
 lesion: Area 18, 19 (Visual Association area)
Ideational Apraxia  px has the right object but performed the wrong activity
 The px is being trained by holding the burger → release it
→ holding it again → bite it → son on & so forth
 lesion: Area 40
Ideamotor Apraxia  px will not follow the PT upon command but will perform the
activity later on without difficulty
Figure – Ground  px cannot identify the right object presented along with
Relationship deficit (by other object. but when segregated, px identifies the object
the object)
Balint’s Syndrome (by  px can identify a part of the whole but does not recognize
the object) the figure as a whole
Body image deficit  px has inability to pin point a body part as instructed
Body scheme deficit/  px has inability to recognize the relationship of one body
Somatognosia/ part on to the other (what is above, what is below)
Autopagnosia
® & (L) Disorientation  px has inability to identify the right laterality of a body part
deficit
Dysmetria  inability to fix the ROM or px cannot pin point the body part
for several times
 lesion: cerebellum
Tactile Localization  failure to identify the exact location of the touched body
deficit without the aid of vision
 lesion: dorsal column
Bilateral Simultaneous  px is blindfolded & was asked to identify how many body
Stimulation deficit part is touched simultaneously
 inability to identify simultaneously the 2 touched parts of the
body without the aid of vision
Extinction Phenomenon  the most distal stimulus becomes extinct
of BSSD  lesion: dorsal column
 you only identify the proximal stimulus & the distal stimulus
is extinct
Graphesthesia  inability to identify traced letters or object cutaneous
Precentral Gyrus
Area 4 – 1º Motor Cortex
 fxn: motor implementation (gross motor)
fine motor – Basal ganglia area (Extrapyramidal)
 governs pyramidal system → Direct Activity System (DAS)
 2 tracts under Pyramidal System:
1. Corticospinal Tract (CST)
2. Corticobulbar Tract (CBT)
 lesion: Flaccidity/ Hypotonia (inhibition of gamma firing)
 Babinski test is the best way to identify UMNL from LMNL compare to DTR
Babinski Test
 used for CNS problems
 stroke the lateral portion of the heel & sole going to the big toe
 (N) response: flexion of the toes → (-) Babinski
(+) Babinski: extension of the big toe & fanning of small toes
 Babinski0like responses:
1. Chaddock’s Toe sign – stroke the lateral heel beneath the
lateral malleolus
2. Rossolimo’s sign – percussing the plantar tips of the toes (any
of the toes will do)
3. Oppenheim’s sign – stroking the anteromedial tibial crests
 4. Piotrowski’s sign – percuss/ tap the area of TA ms
5. Schaeffer’s sign – pinch the Achilles tendon
6. Gordon’s sign – squeeze the calf ms
7. Stransky’s sign – abduct the little toe
8. Gonda’s sign – flick the little toe
 (+) Babinski sign, (-) fasciculations
 (+) Babinski sign, (+) fasciculation → ALS (both UMNL & LMNL)
ALS – (-) sensory deficit, (+) motor deficit
- frontal lobe lesion (motor & behavior affected)
Flaccidity in a child about 1 y.o. Upon ocular inspection or objective sign, what will you see?
Pithed Frog position
Note: spastic quadriplegic – strap-hanger (shoulder abducted & ER, elbow flexed)
spastic diplegia – Bunny hop, combat crawl (UE moves, LE drag)
dyskinetic/ athetoid – Hand spooning
spastic quadri – UE = LE
spastic diplegia – LE > UE
spastic double hemi – UE > LE
LMNL = (-) Babinski, Flaccid, (+) Fasciculation
Area 6 – Premotor Cortex
 fxn: motor planning
 lesion: spasticity (↑ gamma motor neuron than alpha motor neuron)
rigidity - ↑ alpha than gamma
Different forms of Spasticity:
1. Hyperreflexia (gr. 3)
 Ms stretch reflex (MSR): tap the belly of the ms. (best location to tap)
Deep tendinous Pº - inhibits then ms.
Pº on the ms. belly – facilitate
Pº on the ms. tendon - inhibitory
 MSR & DTR’s are monosynaptic, monosegmental; govern by reflex arc
Polysynaptic – extensor thrust, flexor withdrawal
2. Clasp-knife Phenomenon
 aka Giving Way phenomenon
 quick, passive then it gives way (slow, passive – no response)
 UMNL
3. Clonic (gr. 4 MSR)
 asterixis / liver flap – response to clonus
 alternate flexion & extension of ankle or wrist
 seen in px with hypercapnea
causes tremolous mov’t: ↑ PCO2, ↓ PO2
most imp’t. stimulus to ↑ ventilation: ↑ PCO2
 testing clonus without MSR: do quick, passive lengthening of plantarflexion by
quickly dorsiflexing the foot
 inhibit clonus : slow, passive lengthening of plantarflexors or a maintained
stretch on the plantarflexors
 inhibit clonus by applying prolonged icing
quick icing - facilitate
Theories of Spasticity (all will have an ↑ in gamma firing)
1. Denervation supersensitivity
 condition: MS px
 there is an impaired axon, patchy myelination, (-) myelin sheath, degenerate
oligodendrocytes
 neurotransmitters can easily penetrate with ------ axon due to absence of myelin
sheath → ↑ gamma firing in the cortex (inhibits the inhibitory receptor =
facilitatory)
2. Cortical disinhibition
 condition: CVA (stroke)
 spasticity - ↑ gamma firing
3. Collateral sprouting
 condition: CNS involvement in SCI - spasticity
  there is anomalous synapsing that ↑es gamma firing
Deafferentation of neurons – does not ↑ gamma firing due to amputation
 mistransmission of sensory information to the brain
 theory behind the phantom limb
 to expedite the lose: Desensitization by wt. bearing, massage, TENS (high
frequency/ high rate, low intensity, short duration)
Px with ® transfemoral amputation on a pre-prosthetic training. You would want to promote wt.
shifting on the affected limb. What will you do? Place the affected limb on a footstool
while the (N) limb is on the ground. This will promote callus formation on the distal
aspect of the stump
→ prosthetic training: (N) limb on the stool, affected limb on the ground. This will
promote wt. bearing & wt. shifting
→ Bilateral amputated limb: put stubbies
When px took off the prosthetic limb, px observed hyperemia & blistering on the anterior
surface of the amputated stump. What will you do? you remove some layers of the
socks
→ (+) hyperemia on inferior surface of the stump: you add more socks
Area 8 – Prefrontal cortex/ Frontal Eyefield
 frontal gaze center
 fxn: rapid conjugate gaze/ rapid eye mov’t. / saccadic eye mov’t.
 Frontal eyefield of ® - moves eyeball to the (L) (v.v)
 lesion: (L) CVA, ® Hemiplegia – eyeballs cannot be moved to the ®; eyeball deviates to
the (L)
Px with aphasia (® Hemiplegia) – the eyeballs deviates to the (L)
Area 44, 45 – Broca’s Area/ 1º Motor Speech Area
 the one that response to a question
 lesion: Motor Mr.
Broca’s aphasia – px can understand but cannot response B
Expressive E
Anterior (Frontal lobe) A
Non-fluent N
Broca’s aphonia – px response with nouns or verbs
Area 22 – Wernickes Area/ 1º Sensory Speech Area
 fxn: comprehension
 lesion: Wernickes – px cannot understand the question but does response Winnie
Posterior Pooh
Fluent F
Auditory A
Receptive R
Transcortical sensory T
 Intervention: give simple commands, instructions & questions
Global aphasia – combination of wernickes & brocas
 px does not comprehend & cannot response
 Intervention: flash cards/ pictures to communicate with px
Neologism / Jargon Paraphasia – px invent new words
Semantic / Verbal Paraphasia – px tend to substitute one word for
another
Syntactic Paraphasia – px talks with a telegraphic speech
Area 41, 42 – 1º Auditory Cortex / Transverse Gyrus of Heschl
 1º center for hearing
 lesion: cortical deafness at the contralateral ear
Area 39 – Angular Gyrus
 fxn: reading & writing center
 lesion: illiteracy
dyslexia – px can read but with inverted letters
alexia – inability to read
agraphia – inability to write
Area 40 – Supramarginal Gyrus
  fxn: sensory motor integrator/ collaborator
 lesion: sensory fxn: tactile/ proprioception agnosia
motor fxn: apraxia
Types of Apraxia:
1. Verbal apraxia – failure to count #’s consecutively
2. Ideational apraxia – px follows the PT immediately but
will perform a purposeless activity
3. Ideamotor apraxia – upon command, px will not perform
the activity, but later on, the px will perform it
4. Bucco-facial apraxia – there is oropharyngeal ms.
incoordination; px cannot utter the words correctly
5. Construction apraxia
6. Dressing apraxia
Area 17 – Calcarine Area
 1º Visual Cortex
 lesion: Homonymous hemianopsia with macular sparing
Area 18, 19 – Visual Association Area
 fxn: smooth pursuit eye mov’t. (slow conjugate gaze)
 Occipital gaze center
 lesion: Visual Agnosia – can see but cannot interpret
Blood Supply of the Brain
Anterior Circulation Posterior Circulation
 area of carotid system  from Vertebral Artery
 from Internal Carotid Artery Subclavian System
Common Carotid Artery ↓ ↓
↓ ↓ Axillary Artery Vertebral Artery
Internal Carotid Artery External Carotid Artery Anterior aspect Posterior aspect
(supplies the viscera (supplies the UE)
of the neck)
ophthalmic ACA MCA Lesion in Ophthalmic artery: Amaurosis
Vertebral artery – C1 – C6
(optic canal) Fugax (monocular blindness); also optic
(supplies the eyeball) C7 – cervical vertebra with nor
nerve is affected (lateral to the artery)
intertransverse foramina; resembling the 1st
thoracic vertebra
Px with forward head posture (rounded shoulder, neck flexed, capital extension) was asked to
look upward & that caused dizziness. What is the problem? Vertebral Artery Impingement
Syndrome
Note: VAIS is relieved by chin tuck (cervical extension & capital flexion) & is CI to
traction
Cervical radiculopathy – pain radiates to shoulder to UE
Cervical facet jt. syndrome – painful restriction upon mov’ts. of the neck (AP)
Cervical OA – no pain upon rotation only; C5 – C6 level
Cervical RA – pain upon rotation only; C1 – C2 level

 Anterior Spinal Artery (ASA) – supplies the anterior 2/3

of the spinal cord
 Posterior Spinal Artery (PSA) – supplies the posterior
1/3 of the spinal cord
 Anterior Median Commisure – invagination in which
the ASA pass

Motor Homonculus of the Brain

Anterior Cerebral Artery – supplies the LE
Middle Cerebral Artery – supplies the UE
Posterior Cerebral Artery – supplies the head
 ACA stroke ICA stroke PCA stroke
 contralateral hemiplegia  aphasia  contralateral hemiplegia
 aphasia on dominant  confusion  homonymous hemianopsia
hemisphere (Area 44, 45)  contralateral hemiplegia  loss of superficial touch &
 behavioral changes  UE & LE on 1 side are deep sensation
 incontinence equally severely affected  bulbar manifestations
 LE > UE  can have aphasia if
 One arm drive control WC dominant hemisphere is
affected (Wernickes –
sensory)
MCA stroke (Dominant Hemisphere) MCA stroke (non-Dominant Hemisphere)
 contralateral hemiplegia  contralateral hemiplegia
 contralateral hemianesthesia – ®  contralateral hemianesthesia
 motor & sensory aphasia  neglect
 homonymous hemianopsia – ®  UE > LE
 UE > LE  Homonymous hemianopsia
 Hemiplegic WC  denial of dse (Anisognosia)
Modified WC dimension: seat height  poor judgement
(low)  irritable
 Hemiplegic WC
In px with (L) ACA stroke (® Hemiplegic), if the one arm drive control on (L) is locked (2 controls
working as 1) & px propel the inner hand rim, where does the WC go? hand rim of ®
wheel will go to the (L) side or affected side
If from popliteal fossa to heel = 30 inches, what is the measurement of the seat height for MCA
stroke? 28 Foot plate = 26 inches marking
Note: Leg rest length – measured from popliteal fossa to the heel + 2
Foot plate used: swing away/ detachable foot plate
elevating foot plate – inhibits extensor spasticity

Circle of Willis
Communicating artery – equalize the Pº of blood within
the cerebral artery; collateral circulation in the aorta
Lenticulo-striate Artery – a part of MCA
 aka Artery of Apoplexy

Brainstem Stroke
Superior PICA Syndrome AICA Syndrome
Midbrain → Cerebellar
CN 3, 4 Artery  ataxia  intention tremor
 dysphagia/ dysphonia  nystagmus
(CN 9, 10)  ataxia
Pons  nystagmus  vertigo
CN 5, 6, 7, 8 → Basilar  intention tremor  hypoacusis (CN 8)
Artery  ipsilateral facial
sensory loss (CN 5)
AICA
SUCA Syndrome
PICA  ataxia, nystagmus, ptosis (CN 3)
Medulla  contralateral hemiplegia
CN 9, 10, 11, 12 → Vertebral
Artery  contralateral hemianesthesia
 contralateral hemianalgesia
 PICA Syndrome (Wallenberg Syndrome) Vertebrobasilar Artery Syndrome
 ataxia  aka Locked – in Syndrome
 ipsilateral facial sensory loss  total paralysis of UE, trunk & LE & all of
 dysphagia bulbar ms except eye mov’ts.
 dysphonia
 ipsilateral Horner’s Syndrome
 contralateral loss of pain, Tº & light
touch
 vertigo
 dysphagia (CN 9, 10)
 dysarthria (CN 12)
 Crossed Anesthesia -
Millard Gubler Syndrome
® Wallenberg → ® facial sensory loss, (L)
external sensory loss (pain & Tº); seen only  contralateral hemiplegia with internal
in cerebellum strabismus
Lateral Medullary Syndrome
 affectation of lateral medulla
 Horner’s manifestations:
pseudoptosis
myosis
facial anhydrosis
enophthalmus
Summary:
when Midbrain Weber SUCA Medial Basal MB
both Midbrain Benedict SUCA Tegmentum of MB
lovers Pons Locked - in Vertebrobasilar Bilateral Basal Pons
marry Pons Millard-Gubler AICA Lateral Pons
willingly Medulla Wallenberg PICA Lateral Medulla

Structures affected:
Weber CN 3, Corticospinal Tract
Benedict CN 3, Spinothalamic Tract, Superior Cerebellar peduncle,
Red nucleus – responsible for unconscious ms. coordination
Locked - in CST, Corticobulbar tract
Millard CN 6, CN 7, CST
Wallenberg Spinocerebellar tract – unconscious proprioception
CN 5 – ipsilateral facial sensory loss
STT – contralateral loss of Pain & Tº
Vestibular nuclei – ataxia
Sympathetic tract – ipsilateral Horner’s syndrome
Nucleus Ambiguus - dysphagia

SPINAL CORD
Neurologic Levels & Adaptive Devices
Levels Pre- Ambulation Assistive Device Fxnal
Ambulation Orthosis Progression
device
Thoracic Standing Frame RGO // bars → walker → WC
(8 – 15 mos.) (HKAFO) Forearm crutches
Upper lumbar Standing Frame RGO same WC
(L1 – L2)
Mid Lumbar None HKAFO → same WC
(L3) KAFO →
 AFO
Low Lumbar None KAFO → same Household or
(L4 – L5) AFO Community
ambulatory
Lumbosacral None AFO Walker → Forearm Community
crutches ambulator
Parapodium – 16 mos – 7 y.o; given if child is 14 mos or 15 mos instead of Standing
Frame
Parapodium with swivel – more mobile

Levels of Potential Ambulation

T2 & above – Non-ambulators
T3 – T11 – Physiologic standing (can walk for short distances only)
T12 – L2 – Household ambulators (can walk but has difficulty in doing stair ambulation
L3 & below – Community ambulators
4 criteria for community ambulation:
1. if the px can walk ~ about 1000 yards non-stop
2. if they can negotiate stair ambulation
3. can don & doff the orthosis independently
4. can perform almost all ADL’s with braces on all day

Neurologic Levels & Complications

T6 – kyphoscoliosis (dorsal kyphosis in thoracic)
T12 – hip dislocation
L1, L2, L3 – hip flexion & adduction with dislocation
L4, L5 – lordosis & calcaneovalgus
S1 – calcaneovarus
S2 – toe clawing
S3 – none

Neurologic Levels & Capabilities

C1 – C3 neck flexion, extension & lateral flexion

totally dependent in all aspect of ADL’s (100% PT, 0% Px assistance)
phrenic nerve stimulator or mechanical ventilator (diaphragm is partially
innervated)
GPB (ideal breathing pattern) – px take some gulp of air & make a full blow
can also do Diaphragmatic breathing – px in flat supine initially to place the
diaphragm a little bit dome shape)
Power recliner WC with sip & puff control
Level of Assistance:
Maximum assist – 25% of assistance is given by the px,
75% guided by PT
Moderate assist – 50% by px, 50% by PT
Minimal assist – 75% by px, 25% by PT
Contact guarding – hand assistance & very minimal contact
By supervision – no hand contact but need to observe px &
frequently give feedback
Totally Independent – px can perform activity on their own
without supervision
 Main basis of PT to decide upon if to give a power tilt or
power recliner: Muscle tone

C4 shoulder elevation
can do Pº relief on the upper most back & the portion of the head (by
 protraction & retraction of the shoulders) but no gluteal weighing
breathing pattern: Diaphragmatic breathing
GPB is used to aid in coughing (harsh or rough expiration of phlegm) – no
abdominal ms
Motorized/ Power recliner with chin control or voice activated control
(sensitive to px)

C5 shoulder abduction & elbow flexion

Diaphragmatic breathing pattern
can achieve Pº relief by the use of bed loops & overhead Trapeze (px flex
the elbow to lift his body)
can promote sitting Pº relief in WC by leaning (loosen anterior strap)
can do transfer from bed to WC with the use of swivel bar
can be taught of sliding board transfer but not as effective as C6
Motorized WC with hand control by the use of hand trough (orthosis) to grip
the control
Balance Forearm orthosis
can utilize Manual WC with rim projections but not as effective as C6

C7 wrist extension
Diaphragmatic breathing pattern
can perform assisted coughing independently by clasping both hands, flex
the elbow, then do a jerky elbow flexion mov’t. (like Heimlich maneuver)
can perform independent rolling (ex. turning to the ® - BA D2 F ®, D1 Ex (L)
→ to maximize tenodesis effect, you initially place the wrist into
flexion & fingers extension
train EDC while wrist is flexed
train wrist extensor (ECRB) to maximize finger flexion
→ position to avoid so as not deferring tenodesis effect: wrist
extension, finger extension
→ sliding transfer should be wrist extension, finger flexion
Tenodesis splint: wrist-driven with flexor hinge splint
can do sliding board transfer independently & effectively
→ initially taught: locked elbow lean
shoulder EXADER, elbow extended, forearm
supinated, wrist extended, finger flexed (tripod position)
→ progression: locked elbow lean to forward long sitting position
shoulder EXADIR, elbow extended, forearm pronated, wrist
extended, finger flexed
Manual WC with a vertical rim projection with anti-reverse mechanism

C7 wrist flexion, elbow extension

Diaphragmatic breathing pattern
can do Pº relief by sitting push-ups (clasp both hands, raise up then side to
side)
can do self-ROM with high back rest performed in a high fowler or long
sitting position
→ clasp both hands, by tenodesis effect, px scoop the ® LE up to
knee flexion then do abd & add then the (L) LE
sliding door transfer
Manual standard WC with friction hand rim

C8 long finger flexors

Standard WC
can do sliding board transfer
can perform almost all ADL’s but not heavy household chores
can get up & down curbs (ramps, humps)
→ modification of WC specs if px has difficulty in ascending the
curb: the axis of the casters is moved a little bit posteriorly to
easily tilt the chair backward to go in a wheelie position (displace
 COG posteriorly)
→ modification of WC for Bilateral amputee: casters are moved 2
inches posteriorly to avoid tilting backward
px has a hard time in propelling WC in rough terrains
→ for faster mobility: pneumatic tires

C8 – T1 firm grasp, finger abductors

no difficulty in propelling the WC
THKAFO or RGO (HKAFO framework)
can start to perform the wheelie position but not as effective as T4 – T6
→ T4 – ideally can perform sitting-pivot transfers

T9 – T12 WC to floor mat transfers

abdominal strengthening
hamstring ms. should have good flexibility to promote long sitting position
→ stretching of hamstring in SCI px should be a little bit further after
tissue resistance
→ ms. that should be lengthened, should be stretched
→ ms. that does not need lengthening should not be stretch
ex. SCI px with finger flexors contracture good for tenodesis
effect (grasping)
Scott Craig – KAFO (effective level to use: L1 but not exclusively)