Clinical Physiology V

Fundamental Physiologic Basis of the Neurologic

Exam – part 1

Dr. Fast BMS 100

Week 5
The Neurologic System
Divisions of the Nervous System
Central, peripheral, enteric
Major anatomic structures of the central and peripheral
nervous system
Basic Functional Anatomy of the Nervous System
Components of the motor system and their roles
Components of the sensory system relevant to the motor
system
The Neurologic Physical Exam – Part 1
Reflexes
Cerebellar signs
Other signs that evaluate the motor system
 Nervous tissue - review
1. The peripheral nervous system detects
a stimulus and relays it to the central
nervous system (sensory)
2. The central nervous system
(brain, spinal cord)
integrates this information
→ a response
3. The response is carried to
effectors (muscles, glands,
blood vessels) via the
peripheral nervous system
(motor)
 Nervous tissue - review
The cells of the nervous system
include:
• Neurons – an excitable cell that:
▪ receives a stimulus from a
neuron or a receptor
• dendrites

▪ integrates it (ranks it,

compares it to other stimuli)
• Cell body, axon hillock

▪ Passes along another stimulus

if it is adequately stimulated
• axon
 Nervous tissue - review
• Axons are carried in bundles
▪ Nerves in the peripheral system
▪ Tracts in the central nervous system
• Most neuronal cell bodies reside in the
CNS, with a few exceptions:
▪ Dorsal root ganglia –
neuronal cell bodies for the
axons that bring most
sensory information from the
PNS to the CNS
▪ Autonomic ganglia – help
regulate the activities of the
autonomic nervous system
▪ Enteric ganglia – help
regulate the activity of the
gut
 Overview of the Nervous System
The Central Nervous System -
Structures
• Brain
• Cerebrum
• Cortex
• Basal Ganglia
• Limbic structures
• Thalamus
• Hypothalamus
• Cerebellum
• Brainstem
• Midbrain
• Pons
• Medulla
Functions – the Cerebrum
Cerebral Cortex
• Responsible for most of our “higher functions”
▪ Formation, storage, retrieval of memory
• Together with the limbic structures
▪ Speech & language
▪ Abstract thinking, math, planning and executing plans
• Also responsible for “what we’re conscious of”
▪ Perception (i.e. what we consciously sense)
▪ Voluntary movements, both simple and complex
Basic Functional Anatomy of the Cortex
Frontal Lobe
• Simple movements – pre-
central gyrus
• Complex motor plans –
anterior portions + pre-
central gyrus
• Motor aspects of speech –
anterior and inferior to the
precentral gyrus
• Planning, abstract
thinking, social behaviour
(executive functions) –
distributed throughout
frontal and parietal lobes
Basic Functional Anatomy of the Cortex
Parietal Lobe
• Perception of touch,
temperature, vibration –
postcentral gyrus
• Perception of “where
our limbs are”
(proprioception) – post-
central gyrus
• Memory, executive
functions, abstract
reasoning – distributed
throughout the parietal
lobe
Basic Functional Anatomy of the Cortex

Temporal Lobe
• Hearing
• Scent, taste
• Recognition of speech
• Memory
▪ In cooperation with
the limbic structures
below it
Basic Functional Anatomy of the Cortex

Occipital Lobe
• Vision
• Areas that relate visual
stimuli to “actual
things” – i.e.
association cortex
• Memories related to
what has been seen
 Memory and the Cerebrum
General statements about
memory:
• Memory formation
requires attention and
structures that “process”
and form new memories
• Attention → prefrontal
loge
• Memory “processors” →
the structures of the limbic
lobe below the temporal
lobe
▪ Hippocampus, amygdala
Memories tend to be stored in the cortex
• Memory “storage” → “close to” the sensation they’re associated with
• i.e. – memory of a voice or word is likely in
or close to the temporal lobe
The Cerebrum – the Basal Ganglia
• Structures that lie below the cortex, close to the middle
of the parietal and temporal lobes
• Serve to refine and regulate behaviours or movements
▪ Movements to be “inhibited” → tics, unnecessary
movements, non-speech vocalizations
▪ They allow or “encourage” intended movements
• Impaired in several diseases – when they lose function:
▪ Tremors, rigidity, difficulty initiating movements
▪ Random, purposeless movements
▪ Tics, vocal utterances
▪ Personality changes
 Deep Structures in the Cerebrum

• Basal ganglia:
▪ Striatum
▪ Globus pallidus
▪ Subthalamic nuclei
• Limbic structures
▪ Approximate location
of the amygdala and
hippocampus:
 The Thalamus and Hypothalamus
Thalamus – major roles
• Relays information from
sensory receptors in the
peripheral nervous system to
the cortex
▪ Joint/limb position and
movement
▪ Pain, touch, temperature
• Relays information from brain
areas to refine motor
planning
▪ Cerebellum, basal ganglia
Hypothalamus – major roles
• Controls much of the
endocrine system, along with
the pituitary gland
• Regulates temperature,
activity of the autonomic
nervous system, fluid balance
• Some thalamic nuclei
modulate emotion and
memory formation
The Thalamus and Hypothalamus
The Cerebellum
• About 10% of the mass of the brain
▪ Highly folded, complex structure
• General function:
▪ Compares information from the receptors that sense:
• Joint position and movement
• Gravity and equilibrium
▪ Uses this information to adjust movements that are
formulated in the prefrontal cortex
• It very quickly “error-corrects” movements that are
planned by comparing them to data from the receptors
described above
The Cerebellum
 The Brainstem
• Composed of the midbrain,
pons, and medulla
• Many functions that will be
explored next day
▪ Cranial nerve nuclei are found
throughout the brainstem
• All of the pathways that bring
sensory information into the
brain (from the PNS) or send
motor information out of the
brain (to the PNS) pass through
the brainstem
▪ We will discuss discrete
structures and functions next
week
Central Nervous System – Spinal Cord
• Like the brain
▪ isolated from the peripheral nervous system and rest of
the body by a set of membranes (meninges)
▪ bathed in unique extracellular fluid (cerebrospinal fluid)
▪ Neurons or axons do not usually regenerate after they
have been damaged
• Regeneration is common after damage to axons in
the PNS
• Different (simpler) structure than the brain
▪ Dorsal components tend to carry sensory information to
the brain
▪ Ventral components tend to carry motor information
away from the brain to effectors (muscles in particular)
Functional Anatomy – Spinal Cord
• Gray matter (yellow-coloured in this picture):
▪ Mostly cell bodies mixed with unmyelinated or lightly-
myelinated axons
▪ Divided into two horns
• Ventral horns – cell bodies of neurons that activate
skeletal muscles
• Dorsal horns – cell bodies of neurons that relay and
integrate sensory information
• White matter
▪ Divided into columns – these are myelinated axons, no
cell bodies
 Functional Anatomy – Spinal Cord
• Gray matter (yellow-
coloured in this
picture):
▪ Mostly cell bodies
mixed with
unmyelinated or
lightly-myelinated
axons
▪ Divided into two
horns
• White matter
▪ Divided into columns
– these are
myelinated axons, no
cell bodies
▪ Dorsal, lateral, and
ventral columns
 Functional Anatomy – Spinal Cord
• Gray matter
▪ Dorsal horn – cell
bodies and axons
that integrate and
transmit sensory
information to the
brain
• Which
sensations?
▪ Ventral horn –
mostly cell bodies
of neurons that
control skeletal
muscles
 Functional Anatomy – Spinal Cord
• White matter
▪ Dorsal columns –
proprioception
(joint/limb
position), vibration
sense, fast pain
fibres – sensory to
brain
▪ Anterior and lateral
columns – pain,
temperature, itch –
sensory to pain
▪ Anterior columns –
motor information
to skeletal muscles
General Motor Systems
• Corticospinal tract:
▪ Motor plan formed (prefrontal cortex) →
▪ Activation of neurons in the primary motor cortex (prefrontal
lobe) →
▪ Axons travel through the brainstem (medullary pyramids) and
cross over to the opposite side →
▪ Activation of primary motor neurons in the ventral horn that
stimulate skeletal muscle contraction
OR
▪ Activation of motor neurons in the ventral horn that modify
reflexes
• Lateral corticospinal tract – fine movements of extremities
• Anterior corticospinal tract – movements of the trunk
• Corticospinal tract –
simplified
• Synapses are not shown
• Note the location of the
ascending, sensory tracts as
well
• It’s estimated that up to 90%
of corticospinal output is to
“shut down” reflexes that
would oppose voluntary
movements
General Motor Systems
Cerebellar modification of motor plans:
• cerebellum integrates information from proprioceptors
(spinocerebellar tract) and the inner ear
(vestibulocerebellar tract)
▪ Keeps the cerebellum “up-to-date” on the actual position of
the body in general and specific joints
• compares this information with information from the
motor “plan” generated by the frontal lobe
▪ relayed through the pons
• cerebellum “adjusts” the motor plan by communicating
(via the thalamus) with the frontal lobe and refining the
movements relayed by the corticospinal tract
Sensory Pathways and the Motor System
• The motor system depends heavily on input from receptors
about the position of a joint, tension across a joint, and
tension in a skeletal muscle
▪ Together, these are known as proprioceptors
• Proprioceptors inform the cortex, the cerebellum and
neurons in the spinal cord about the actual position of the
body
▪ Dorsal column-medial lemniscal system
• proprioceptor → dorsal horn → dorsal column →
thalamus → post-central gyrus of the parietal lobe
▪ Spinocerebellar system
• propriceptor → dorsal horn → dorso-lateral columns
→ cerebellum
Reflexes
• A motor reflex is a fast, involuntary sequence of
muscular movements that:
▪ do not need higher brain centres – brainstem or spinal
cord circuits are adequate
▪ are simple – usually only a connections between groups
of neurons are needed
▪ have a protective or stabilizing function – they help you
pull away from a painful stimulus or help you stand
▪ need to be inhibited in order to perform purposeful,
complex movements
• The inhibition often comes from higher brain centres
• Muscle spindle = a
Reflexes – the stretch
proprioceptor that reflex
senses muscle stretch
• As the muscle is
stretched:
▪ activates the
muscle to contract
against the stretch
by stimulating the
motor neuron in
the ventral horn
▪ inhibits the
antagonist muscle
• Stretch caused by
hitting the tendon
with a reflex hammer
Types of reflexes
• Stretch reflex – helps to maintain posture
• Tendon reflex
▪ When a tendon is stretched, the antagonist muscle contracts
and the agonist relaxes
▪ Thought to help prevent tearing the tendon during excessive
force generation
• Withdrawal reflex
▪ In response to a painful stimulus, muscles of flexion are
activated to withdraw a limb
• Plantar reflex
▪ In response to an irritating stimulus, the foot plantar flexes
(foot flexes “down”) and the toes curl
The Neurological Physical Exam
• Deep Tendon Reflexes (DTRs)
▪ These are simple stretch reflexes activated by striking
the tendon with a reflex hammer → contraction of the
agonist muscle
▪ Examples – patellar reflex, triceps reflex
▪ Causes of absent DTRs:
• normal variation (some people are really difficult to
get reflexes from)
• damage to sensory or motor nerves innervating the
muscle being tested
▪ Causes of excessive DTRs
• loss of inhibition of reflexes from higher brain
centres – usually the corticospinal tract (so damage
to the corticospinal tract)
• Reflexes are easier to interpret as abnormal when they are
asymmetrical – one side greater/less than the other side
The Neurological Physical Exam
• Plantar reflex
▪ When the lateral side of the foot is stroked firmly,
the foot should plantar flex (ankle moves foot
downwards) and toes should curl
▪ This develops as we learn to walk – it depends on
the corticospinal tract providing specific feedback to
particular segments of the spinal cord (S1)
▪ If the foot dorsiflexes and the toes spread, this
indicates that the corticospinal input to the lower
limb is poor
▪ an “upgoing” plantar reflex is usually an abnormal
finding
Cerebellar Tests in the Neurological
Exam
• Cerebellar tests include:
▪ rapid alternating movements (RAMS)
▪ point-to-point movements (i.e. patient touches his nose
then rapidly touches your finger, and repeats)
▪ heel to shin movements
▪ Gait – how coordinated is the patient’s gait?
• All of these tests rely on the ability of the cerebellum to
evaluate the body’s position and provide feedback to
the rest of the motor system
• If the cerebellum has lost function, then these
movements are often clumsy, uncoordinated, and slow
Romberg sign
• This test is thought to evaluate the function of the
dorsal columns
▪ Sensory input from proprioceptors to the cerebellum
and the parietal cortex – key for joint and limb position
sensing
• Patient stands with feet together and closes her
eyes
▪ If the patient loses balance and starts to fall (support the
patient!), indicates that the dorsal columns could be
damaged
• visual input is no longer available to help the patient
keep her balance
Corticospinal tract test – pronator drift
• The brain structures in the corticospinal tract can be
damaged in a wide variety of ways
▪ stroke, trauma, demyelinating disease, tumours
▪ structures include the precentral gyrus and prefrontal
cortex
• Corticospinal tract damage often results in a pattern of loss
of muscle strength – extensors and supinators of the arm
are weaker than the pronators or flexors
• Patient stands with arms outstretched, palms up, hand
open, eyes closed
▪ The arm “drifts” to a more pronated position, the hand
closes, and the arm tends to descend