acnb competency requirement guide-2014 exam competency requirement guide...3....
TRANSCRIPT
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ACNBCompetencyRequirementGuide
2019Materials to be used to assist Candidates to prepare for the 2019 ACNB certifying examination for the designation of Chiropractic Neurologist.
AmericanChiropracticNeurologyBoard
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TableofContentsAnatomy & Physiology Indicated as Important on Job Analysis ............................................................... 4
A&P‐Neuron .......................................................................................................................................... 4
A&P‐ Receptor ...................................................................................................................................... 4
A&P‐Peripheral Nerve ........................................................................................................................... 4
A&P‐Spinal Cord .................................................................................................................................... 5
A&P‐Brain Stem .................................................................................................................................... 6
A&P‐Cranial Nerve ................................................................................................................................ 6
Physiology‐Cranial Nerve ...................................................................................................................... 6
A&P‐Head & Face Pain .......................................................................................................................... 7
A&P‐Cerebellum ................................................................................................................................... 7
Functional Physiology ‐ Cerebellum ...................................................................................................... 8
A&P‐Basal Ganglia ................................................................................................................................. 8
A&P‐Reflexogenic System ..................................................................................................................... 9
A&P‐Autonomic Nervous System ....................................................................................................... 10
A&P‐Limbic System ............................................................................................................................. 11
A&P‐Lobes of the Brain ....................................................................................................................... 11
A&P Brain & Its Environment .............................................................................................................. 12
A&P‐Neuroendocrine .......................................................................................................................... 14
A&P‐Pain ............................................................................................................................................. 15
Disorders & Diagnoses ............................................................................................................................ 16
Red Flag/Scope of Practice ................................................................................................................. 16
Disorders‐Peripheral Nerve ................................................................................................................ 16
Disorders‐Spinal Cord ......................................................................................................................... 17
Disorders‐Brain Stem .......................................................................................................................... 17
Disorders‐Cranial Nerve ...................................................................................................................... 18
Disorders‐Head & Face Pain................................................................................................................ 18
Disease Processes‐Cerebellum ........................................................................................................... 18
Disorders & Diagnoses‐Basal Ganglia ................................................................................................. 19
Diseases‐Reflexogenic ......................................................................................................................... 19
Disorders‐Autonomic Nervous System ............................................................................................... 19
Disease/Diagnoses‐Limbic System ...................................................................................................... 19
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Disorders‐Lobes of the Brain .............................................................................................................. 20
Disease Processes‐Brain & Its Environment ....................................................................................... 20
Disorders‐Neuroendocrine ................................................................................................................. 21
Disease Processes/Diagnoses‐Pain ..................................................................................................... 25
Diagnostic Issues Relevant to Each Neuro Area ..................................................................................... 27
Diagnostic Issues ‐ Receptors .............................................................................................................. 27
Diagnostic Procedures‐Peripheral Nerve ............................................................................................ 27
Diagnostic Issues‐SC ............................................................................................................................ 28
Diagnostic Issues‐Brain Stem .............................................................................................................. 28
Diagnostic Issues‐Cranial Nerve .......................................................................................................... 28
Diagnostic Issues‐Head and Face Pain ................................................................................................ 28
Diagnostic Issues‐Cerebellum ............................................................................................................. 29
Diagnostic Issues‐Basal Ganglia .......................................................................................................... 29
Diagnostic Issues‐Autonomic Nervous System ................................................................................... 30
Diagnostic Issues‐Limbic System ......................................................................................................... 31
Diagnostic Issues‐Lobes of the Brain .................................................................................................. 32
Diagnostic Issues‐Brain & Its Environment ......................................................................................... 32
Diagnostic Issues‐Pain ......................................................................................................................... 32
Treatment & Rehabilitation .................................................................................................................... 34
Rehab for Neuron ............................................................................................................................... 34
Rehab Principles‐Receptors ................................................................................................................ 34
Rehabilitation Applications‐Receptor ................................................................................................. 34
Referral Principles for Peripheral Nerves ............................................................................................ 34
Treatment Modalities Peripheral Nerve ............................................................................................. 35
Rehab Principles Peripherial Nerve ..................................................................................................... 35
Rehab Principles Spinal Cord .............................................................................................................. 35
Rehab Applications Spinal Cord .......................................................................................................... 35
Rehab Principles ‐ Brain Stem ............................................................................................................. 36
Rehab Applications ‐ Brain Stem ......................................................................................................... 36
Rehab Principles ‐ Cranial Nerve ......................................................................................................... 36
Rehab Applications ‐ Cranial Nerve .................................................................................................... 37
Rehab Principles‐Head & Face Pain .................................................................................................... 38
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Rehabilitation Applications‐Head & Face Pain ................................................................................... 38
Rehabilitation Principles‐Cerebellum ................................................................................................. 39
Treatment Issues‐Cerebellum ............................................................................................................. 39
Rehabilitation Applications‐Cerebellum ............................................................................................. 39
Rehabilitation Principles ‐ Basal Ganglia ............................................................................................. 40
Rehabilitation Principles‐Autonomic Nervous System ....................................................................... 41
Rehabilitation Principles‐Limbic System ............................................................................................. 41
Rehab Principles‐Lobes of the Brain ................................................................................................... 42
Rehab Applications‐Lobes of the Brain ............................................................................................... 42
Rehab Principles‐Brain & Its Environment .......................................................................................... 43
Rehab Applications‐Neuroendocrine .................................................................................................. 43
Rehab Principles‐Pain.......................................................................................................................... 44
Treatment Modalities‐Pain ................................................................................................................. 45
Special Studies by Neuraxis Area and Overall ......................................................................................... 46
Special Studies Neuron ....................................................................................................................... 46
Diagnostic Procedures/Special Studies‐Peripheral Nerve .................................................................. 46
Diagnostic Testing Modalities‐Limbic System ..................................................................................... 47
Special Studies for Diagnosing & Treating Patients ............................................................................ 47
Other Special Studies Mentioned in Open Ended Survey Responses ................................................. 49
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Anatomy&PhysiologyIndicatedasImportantonJobAnalysis
A&P‐NeuronA. CellwallB. NucleusC. MitochondriaD. AxxonsE. DendritesF. Receptors
1. Ca2. K3. Na4. NMDA
G. Golgiapparatus
A&P‐ReceptorA. Retinalreceptors‐rodsandconesB. Olfactoryreceptors‐chemoreceptors‐notintegratedthroughthalamus‐memory
linked‐directlinktolimbicC. Gustatoryreceptors‐taste‐chemoreceptors‐integratedthroughthalamus‐sweet,
salty,bitter,sourD. Auditory‐choclea‐mechanoreceptor‐hertzanddecibel‐speechperception(512)‐low
tone(128)‐midlevel(256)‐localization‐phase‐reflex(orienting)‐dampeningreflex(CN5&7)‐
E. Vestibular‐semicircularcanals,utricle,saccule‐haircellsarethereceptors‐dynamicandstaticdivision‐connectedwitheyesandeyemovements‐8thCN‐cerebellumconnection(vestibularnuclei)
F. Cutaneousreceptors‐freeandencapsulatedG. Proprioceptors‐jointmechanoreceptors,musclespindles,golgitendonorgansH. Visceral‐mechano(stretch/baro)andchemoreceptors
A&P‐PeripheralNerveA. Grossanatomyandrelationshipofaroottothevertebralcolumn
1. Motorroots2. Sensoryroots3. bothMotorandSensoryRoots
B. GrossanatomyoftheBrachialPlexus1. upper,middleandlowertrunk2. lateral,medialandposteriorcord
C. SensoryD. PeripheralNerves
1. lateralantibrachialcutaneous2. medialantibrachialcutaneous3. median4. palmarmedian
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5. ulnar6. palmarulnar7. dorsalulnar8. superficialradial9. radial10. sural11. superficialperoneal12. medialandlateralplantar13. saphenous14. lateralfemoral15. cutaneous16. clunealnerves17. obturator
E. MotorPeripheralNerves1. axillary2. radial3. deepradial4. ulnar5. median6. anteriorinterosseous7. femoral8. obturator9. superiorgluteal10. inferiorgluteal11. sciatic12. superficialperoneal13. deepperoneal14. tibial15. medialandlateralplantar
A&P‐SpinalCordA. GrossanatomyandrelationshipwithvertebralcolumnB. MainNucleargroups:DorsalHornC. MainNucleargroups:IntermediateD. MainNucleargroups:VentralHornE. MainNucleargroups:(RexedLamina)F. Whitematterpathways:SensoryG. Whitematterpathways:MotorH. SpinalnervesandtheirrootsI. Functionalrelationships:SegmentalreflexesJ. Functionalrelationships:HomologouscolumnsK. Vasculature
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A&P‐BrainStemA. GrossanatomyandrelationshipwithcranialstructuresB. NeocorticalandPaleocorticalrelationshipsC. RelationshipswithdeepcerebralnucleiandcerebellumD. MedullaPathwaysE. MedullaCranialnervesandtheirnucleiF. MedullaOthernucleiandreticularformationG. MedullaVasculatureH. PonsPathwaysI. PonsCranialnervesandtheirnucleiJ. PonsOthernucleiandreticularformationK. PonsVasculatureL. MesencephelonPathwaysM. MesencephelonCranialnervesandtheirnucleiN. MesencephelonOthernucleiandreticularformationO. MesencephelonVasculature
A&P‐CranialNerveA. Olfactory‐tract‐bulb‐olfactorycortexB. Opticnervechiasm‐tract‐lateralgeniculateC. Oculomotornerve‐midbrain
1. Edinger‐WestphalnucleusD. Trochlearnerve‐midbrainE. Trigeminalnerve‐pons/midbrainF. Abducensnerve‐ponsG. Facial‐nerve‐pons
1. Superiorsalvatoryn.H. Vestibularcochlear‐ponssva(specialvisceralafferent)I. Glossopharyngeal–medulla
1. Inferiorsalvatoryn.J. Vagusnerve‐medulla
1. NucleustractussolitariusK. Spinalaccessory‐medulla/cordL. Hypoglossal‐nerve‐medulla
Physiology‐CranialNerveA. Sensory
1. GSA(generalsomaticafferent)‐‐touch,pain,temperature,proprioception‐V,VII,IX,X’
2. SSA(specialsomaticafferent)‐‐hearing,balance‐VIII3. GVA(generalvisceralafferent)‐‐mechanical,chemosensory‐V,VII,IX,X4. SVA(specialvisceralafferent)‐‐taste,olfaction‐I,VII,IX,X
B. Motor
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1. GSE(generalsomaticefferent)‐‐skeletalmusclecontrol‐III,VI,IX,XII2. GVE(generalvisceralefferent)‐‐autonomiccontrol‐III,VII,IX,X3. SVE(specialvisceralefferent)‐‐brachiomericcontrol‐V,VII,IX,X,XI
A&P‐Head&FacePainA. Cranialbones,sutures,foraminaB. PotentialsitesofneuralcompressionC. PainsensitivestructuresoftheheadD. UppercervicalspinalcordanatomyE. LocationofcranialnervesandtheirnucleiF. NeocorticalandPaleocorticalrelationshipsG. RelationshipswithdeepcerebralnucleiandcerebellumH. Vasculature
A&P‐CerebellumA. Deepcerebellarnuclei
1. Fastigial2. Interpossitus(Emboliform,Globus)3. Dentate
B. CortexLayers1. Granularlayer‐granule,golgicells2. Purkinjelayer‐purkinjecells3. Molecularlayer‐stellate&basketcells,parallelfibers
C. Pathways1. AfferentPathway‐
a. Mossyfiberi. destination:deepcerebellarnuclei&granularcells;originatefrom:
1) DSCT/VSCT(descendingspinocerebellartract,vestibulospinaltract)2) pontinereticularformation
b. Climbingfibers1) Destination:deepcerebellarnuclei&purkinjecells2) Originatefrom:inferiorolive3) Parallelfibersactivatedbyclimbingfibersinmolecularlayer:4) Destination5) Origination
c. Peduncles1) Superior‐brachiumconjunctiva2) Rednucleus‐parvocellular3) Middle‐brachiumpontis4) Rednucleus‐magnocellular5) Ventrallateralventralanteriorn.thalamus6) Inferior‐restiformbody7) Mossy‐body
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d. Cortex1) SpinalCord2) BrainStem
e. EfferentPathway1) SpinalCord2) BrainStem
f. CortexD. FunctionalAnatomy
1. Cerebrocerebellum‐lateral2. Spinocerebellum‐intermediate3. Vestibulocerebellum‐midline
E. Developmentalfunctionalanatomy1. Neocerebellum2. Paleocerebellum3. Archeocerebellum
FunctionalPhysiology‐CerebellumA. Feedback
1. DataofmotoricactivitythatactuallytookplaceasmeasuredbythevariousreceptorsthatissentbacktoCNSbyafferentproprioceptivesystemviaDSCTandSCT.
2. SensoryinputintocerebellumB. Feedforward
1. Datathatisfedforwardtothecortexbythedentatepriortoandduringexecutionofcommands.
2. InputintocortexC. Efferentcopy:Define:Brainrelayscopyofmotoriccommandstocontralateral
cerebellumviaipsipontinereticularformationtobeanalyzedbycontracerebellum(comparingcommandversusactualexpressionthatistakingplacesothatmodulationcanbeimplemented.)
D. Initiating1. Movement2. Thought
E. Cessation1. Movement
F. SurroundInhibition‐primingofbasketandstellateactiveinhibitionofpurkinjesystemtoalloweaseofsummationofdeepcerebellarnucleirelatedtoanexpectedsummationasaconsequenceofcarriedoutpatternsofmovement.
A&P‐BasalGangliaA. Striatum/Neostriatum,usedinterchangeably
1. Caudate:concernedwithemotionandheadandface2. Putamen:concernedwithneckandbelow
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3. GlobusPallidus:maininhibitorysystemanddevelopmentallylinkedtoSubstantiaNigra
4. GlobusPallidusExterna(GPe)5. GlobusPallidusInterna(GPi)
B. SubstantiaNigra1. SubstantiaNigraParsCompacta(SNc)2. SubstantiaNigraParsReticulata(SNr)3. SubthalamicNucleus(STN)4. DirectPathway:multiplebrainareas,primarypremotorfrontalareas,fireto
exciteNeostriatum,whichfirestoinhibitGPi,whichinhibitsthalamicnucleithatexcitefrontalmotorareas:excitationofinhibitionofinhibitionresultsallowsforthalamicexcitationoffrontalmotorareas.
C. IndirectPathway:multiplebrainareasexciteneostriatumwhichfirestoinhibitGPe’sinhibitionofSTN’sexcitationofGPi:excitationofinhibitionofinhibitionofexcitationofinhibitionultimatelyresultsininhibitionofmotoricoutput.
D. Functionaloutputisnotalwaysdirectorindirect,i.e.,indirectpathwaymayinhibitmotoricoutputthatisantagonistictoexcitationofanactionthatwillcontradictamovementthatwillresultininstability.
E. SubstantiaNigra(Mesencephalon)1. reticulata:functionssimilarlytothepallidum2. compacta:neurotransmitterdopaminetotheneostriatum
a. D1receptorsinDirectPathwayareexcitatoryb. D2receptorsinIndirectPathwayareinhibitory
F. LimbicComponent1. nucleusaccumbens(NA)2. ventralpallidum3. ventraltegmentalarea(VTA):VTAefferentsprovidedopaminetoNAinreward
learning.
A&P‐ReflexogenicSystemA. Monosynapticreflex‐(MSR)(DTR)‐musclespindle(1a)‐ventralhorncellB. Disynapticreflex‐musclespindle(1A)‐1Ainterneuron‐antogonistventralhorncellC. Multisynapticreflex‐suprasegmentalcontrol,modulation,ofventralhorncellD. Pyramidalsystem‐corticospinal,corticobulbarE. Extrapyramidalsystem‐basalganglia,nigrostriatal,cerebellum,vestibularF. RubrospinalG. ReticularformationH. MedialI. lateralJ. VestibulospinalK. MedialL. LateralM. TectalspinalN. Superiorcollicular
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O. Inferiorcollicular
A&P‐AutonomicNervousSystemA. Mostrostralportionthehypothalamuswithsympatheticandparasympathetic
divisions1. Sympathetic:fightorflight;increaseshr,dilatespupils(10%controlofsize),
sweatstimulated,blooddivertedfromGItracttoskeletalmuscles,sphinctorsofalimentarytractareclosed
2. Parasympathetic:adaptstheeyesforcloseupviewing,constrictspupils(90%controlofsize),slowshr,promotessecretionofsalivaryandintestinaljuices,acceleratesintestinalperistalsis.
3. SympatheticandparasympatheticcombinedinsexualintercourseB. Sympathetic&Parasympathetic
1. Controllingfibersinhypothalamusandbrainstemsendcentralfiberstosynapseuponthepreganglionicfibersinthebsandspinalcord(IML)
2. FromIML,preganglionicneuronsprojectoutofCNStosynapseuponneuronsinautonomicganglia.
3. Unmyelinatecpostganglionicfibersemergeandformterminalnetworksintargettissues
C. Sympatheticpostganglionicfiberssynapse:1. Nearestgangliontoaccompanyspinalnervesandsupplysweatandvessels2. Ascendtosynapseinsuperior,middle,orstellateganglion(fusionofinferiorand
firstthoracicganglia)andpostganglionicfiberssupplyhead,neck,upperlimbsandheart
3. Descendtosynapseinlumbarorsacralgangliaandpostganglionicfibersenterlumbosacralplexusforbloodvesselsandskinoflowerlimbs
D. Parasympatheticpostganglionicfibers1. CranialPSSystem:pregangfibersemergeinfourcranialnervestosynapseon:
a. inCNIIItociliarygang:postgangfiberstosphinctorofpupilandciliarymuscle(accommodationreflex).
b. inCNVIItopterygopalatinegang:lacrimalandnasalglands;inCNVIItosubmandibulargangtosubmandibularandsublingualglands.
c. inCNIXtooticgang:parotidgland.d. inCNXtomuralorintramural:toheart,lungs,loweresophagus,stomach,
pancreas,gallbladder,smallintestine,andascendingtransversepartsofcolon.
E. Neurotransmission1. Symppregang:Ach2. PSpregang:Ach3. Symppostgang:norepinephrine(exceptsweat=Ach)4. PSpostgang:Ach
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A&P‐LimbicSystemA. Brainstem
1. Ventraltegmentum2. Reticularformation3. Locuscoeruleus4. Lateraldorsaltegmentalnucleus5. Pedunculopontinenuclues
B. Deepbrainstructures1. Amygdala
2. Hippocampus3. Nucleusaccumbens4. Parahippocampus5. Subiculum6. Perirhinalcortex7. Hypothalamus8. Entorhinalcortex9. Cingulategyrus10. Septalnuclei
A&P‐LobesoftheBrainA. GrossanatomyandrelationshipwithcranialstructuresB. MainanatomicareasforeachLobe
1. Frontala. Gyri‐precentral,superior,paracentral,cingulate,middle,inferior
2. Parietala. Gyri‐postcentral,superior,inferior(angular,supramarginal),
paracentral,precuneus,cingulate3. Occipital
a. Cuneus,lingual,lateral4. Temporal
a. Superior,middle,inferior,lingual,parahippocampal5. Insula6. Additionallandmarks‐saggitalsulcus,centralsulcus,sylvianfissure,parieto‐
occipitalsulcus,calcarinefissure,temporal‐occipitalnotch,uncusofthetemporallobe,frontal/temporal/occipitalpole
7. Generalizedfunctionaldesignationsforneocortexa. Paleo‐neocortexb. Neo‐neocortex
8. Functionalareasofthefrontallobea. Motor,premotor,prefrontal
9. Sixlayersofhumancerebralcortex10. Localizationofprimarysensoryandmotorfunctions11. Relationshipswithdeepnuclei,brainstem,spinalcordandcerebellum
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A&PBrain&ItsEnvironmentA. Brain
1. Brain:a) Developsembryologicallyfromneuroectodermaltube(adultventricles)b) Medialsurfacesofthediencephalonformthewallsofthe3rdventriclec) 3rdventricle:i. OpensintolateralventriclesthruinterventricularforamenofMonroii. ContinuousposteriorlywithcerebralaqueductofSylviusiii. Continuouswiththe4thventricle(ponsandmedulla)d) 4thventricle:i. Continuouswithcentralcanalofthecaudalmedullaandspinalcord
e) Foursulci:i. Centralii. Lateraliii. Parietooccipitaliv. Calcarinef) Fourlobes:i. Frontalii. Parietaliii. Temporaliv. Occipitalg) Insula:overliessitewheretelencephalonanddiencephalonfusedduring
embryologicaldevelopment2. Environment
a) Meningesb) Epiduralspacec) DuraMaterd) ArachnoidMatere) PiaMaterf) Subduralspaceg) CSFh) Bloodbrainbarrier
3. Duralvenoussinuses:a) Superiorsagittalsinustransversesinusesb) Severalsmallersinusesi. inferiorsagittalsinusii. occipitalsinus,andiii. inferiorc) superiorpetrosalsinuses
4. Duralvasculatureandinnervation:a) Maxillaryarteryb) Themiddlemeningealarteryc) Ophthalmicarteryd) Occipitalarterye) Vertebralarteries
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f) Primarysensoryinnervationg) Sensoryinnervationoftheposteriorfossaofthedura
5. CerebrospinalFluid:Formedbyfiltrationofbloodthroughthefenestrationsofthechoroidalcapillariesthatcirculatesthroughtheventriclesofthebrain.
6. BloodSupplyofBrain:a) ArterialInternalcarotidsystem:i. Internalcarotidarterypathwayandbifurcationii. posteriorcommunicatingarteryiii. anteriorchoroidalarteryb) AnteriorCerebralArteryi. Branchesii. Supplyfrontal&parietallobeiii. Occlusion‐restrictedcontralateralmotorandsomatosensorydeficitsc) MiddleCerebralArteryi. Largeii. Manybranchesiii. Suppliesdeepbrainstructuresiv. Lenticulostriatearteries
1) Ganglionicorpenetratingbranchescollectanteriortothebaseofthebrainandarecalledtheanteriorandposteriorperforatedsubstances.
2) Frequentlyinvolvedinstrokes.3) Smalldamagetothesearteriescanequaldisproportionatedamage4) VertebralBasilarsystem:
a) Pathwayb) Branches
i. Theposteriorspinalarteryii. Theanteriorspinalarteryiii. Theposteriorinferiorcerebellarartery
d) TheBasilarArtery1) Pathway2) Supplies
a) AnteriorInferiorCerebellarArteryi. Suppliesinferiorsurfacecerebellum(flocculus)ii. Suppliespartsofponsiii. SuppliesInternalAuditoryArtery‐occulsioncangiveriseto
vertigoandipsilateraldeafnessb) SuperiorCerebellarArteryi. Suppliessuperiorsurfaceofcerebellumii. Suppliescaudalbrainiii. Suppliesrostralponsiv. UnnamedBranchesiv. SupplyPontinearteriesv. Supplyremainderofthepons
e) PosteriorCerebralArtery1) Pathway
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2) Suppliesthemedialandinferiorsurfacesoftheoccipitalandtemporallobes.
3) GivesrisetothePosteriorChorodialArteriesa) Supplythechoroidplexusofthethirdventricleb) Supplybodyofthelateralventricle.
4) Occlusionofaposteriorcerebralarteryatitsoriginleadstovisualfieldlosses.
a) CircleofWillis:5) Composition6) Resultofocclusion
a) VenousDrainage7) Superficialgroups
a) Pathwayb) Drainage
8) Deepgroupsa) Initialdrainageb) Drainageintostraightsinus
9) Basalveina) Drainssomedeepstructuresb) Emptiesintothestraightsinus.
A&P‐NeuroendocrineA. Neuroendocrinecells
1. Endocrinesystem2. Nervoussystem3. Hypothalamic/pituitaryportalsystem
B. Hypothalamus1. Supraopticandparaventricularnuclei
C. PituitaryGland1. Anteriorpituitary(adenohypophysis)i.e.Rathke’pouch2. Bloodsupply
a. Superiorhypophysialarteriesb. Internalcarotidarteriesc. Posteriorpituitary(neurohypophysis)i.Pituitarystalk
3. Otherstructuresinformationandrelationshipsbetweenthehypothalamusandpituitary:a. Infundibulumb. Medianeminencec. Tubercineriumd. Sellaturcicae. Bloodbrainbarrierf. Mamillarybodies
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A&P‐PainA. Spinothalamicpathway,alateralpainpathway:3neuronpathway
1. TrunkandLimbs:2ndorderneuroninposteriorgrayhornandcrossestoascendviaspinothalamicpathwaytoventralposterallateralnucleusofthalamusandthentoprimarysomaticsensorycortex(location,severity)andlateralsulcus(visualattentiontostimulussource).
2. HeadandNeck:2ndorderneuroninthespinalnucleusofthetrigeminalnerveandtravelsviatrigeminalthalamicprojectiontocontralateralventralposteriormedialnucleusandthentoprimarysomaticsensorycortexandlateralsulcus.
B. Spinoreticular/trigeminoreticular1. Polysynapticviaspinoreticularandtrigeminoreticulartracksto1)the
contralateralmedialdorsalthalamicnucleusandthenontotheinteriorcingulatecortex(concernedwitheffective/emotionalcomponentofpain)and2)reticularformationofmedullaandpons.Manyfibersdonotcrossthemidline.
C. Spinomesencephalic:viaanterolateralquadrantofspinalcordprojectsneuronsfromlaminaeIandVtomesencephalicreticularformationandperiaqueductalgrayandthenviaspinoparabrachialtracttotheparabrachialnucleithatthenprojecttotheamygdalathatisinvolvedwiththeaffective/emotionalcomponentofthepainexperience.
D. Cervicothalamictract:nociceptiveneuronsinlaminaeIIIandIVmostlycrossthemidlineandascendinthemediallemniscusofthebrainstemtolateralcervicalnucleusinthemidbrainandthentotheventroposteriorlateralandposteromedialnucleiofthethalamus.SomeaxonsfromlaminaeIIIandIVprojectthroughthedorsalcolumnsofthespinalcordandterminateinthegracileandcuneatenucleiofthemedulla.
E. Spinohypothalamictract:nuronsinlaminaeI,V,andVIIIprojectdirectlytothesupraspinalautonomiccontrolcentersandactivatesneuroendocrineandcardiovascularresponsesassociatedwithpain.
F. Fibers1. Cfibers(unmyelinated,.5–2m/s);dull,acheypain;polymodalnociceptors
(mechanicaldeformation,intenseheat/cold,andirritantchemicals.2. deltafibers(myelinated,25m/s);sharppain;severemechanicaldeformationof
theskin.G. 1storderpainneuronsactivatesegmentalIMLH. Mesencephalicpaininhibition
1. Peri‐aquaductalgraymatter(PAG)sendsexcitatoryprojectionstotheNucleusRapheMagnusthatsendsbilateralcaudalprojections(serotonergic)viaLissauer’stracttoterminateinthesubstantiagelatinosaatalllevelsofthespinalcordtoexciteenkephalinergicinternuncials(GABA‐ergic)thatareinhibitorytothesecondorderpainneuron.
2. Locusceruleusneurons(noradrenergic)descendtoinhibitthesecondorderpainneuron.
I. Segmentalpaininhibition:Afibers(mechanoreceptors)activateinhibitoryinternuncialsthatinturninhibitexcitatoryinternuncialsandsecondorderneuronofthepainpathway.
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Disorders&Diagnoses
RedFlag/ScopeofPracticeMeningitis:neckrigidity,severeheadacheandhighfeverIncreasedintracranialpressure:eyeexamophthalmoscope‐bulgingopticdiscwithsevereheadacheonsamesideBloodpressure:diastolic110+orsystolic180+;headacheBloodpressureadult:diastolic50‐orsystolic80‐withpresentingsymptomsHeartRate/Rhythm:presentation:SOB,diaphoresis,chestpain,leftarmpain,thoracicbackpain;Rateabove140+atrestwithnomedicationindicatorCaudaEquinaSyndrome‐discpatients:saddlepain,inabilitytourinate,urinateordefecatewithoutknowingitCavernousSinusSyndrome:fever,head/facepain,infectioninnasaltriangleSubarachnoidhemorrhage(subdural,epidural):“worstheadacheI’veeverhad”Bloodsugarnon‐fasting:below50mgBloodsugarnon‐fasting:above300mg/desiliterwithnohistoryofdiabetesandwithdiaphoresis,loweredlevelofalertnessSepsis:Bloodsugarabove120fastinginnon‐diabeticpatient:lookforsepsisandship;feverorabnormallylowforindividual(>97<100);HR>100bpm;Resprate>20cpmEmergentStroke:lethargy,lowerlevelofconsciousnessRespiration:below7andabove20ORinaknownpatientplusorminus5eitherdirectionatrestwithalteredbreathsoundsVisualfielddefects:Pieinsky/floor;hemifieldloss;Quadrantanopia;lossofcentralvision;peripheralvisualloss(tunnelvision)Temperature:hypothermiabelow96core/95oral;hyperthermiaabove103core/102oral;historyofvomitingProjectilevomitingorunremittingvomiting
Disorders‐PeripheralNerveA. motorrootlesionB. sensoryrootlesionC. motor&sensoryrootlesionD. compressiverootmechanisms
1. disclesion2. inflammatorylesion(Sclerotogenouspainreferral)
E. trauma1. biomechanical,i.e.,lifting2. motorvehicleaccident3. vertebralfracture4. vertebralcompressionfracture
F. lumbosacralplexuslesions1. lumbarplexuslesion
G. intrapmentneuropathies1. radialnerve
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2. mediannervea. pronatorsyndromeb. carpaltunnelsyndrome
3. ulnarnerve4. sciaticpalsy5. systemicperipheralneuropathy
a. diabeticneuropathy6. rheumatoidarthritis
Disorders‐SpinalCordA. SpinalCordInjury:LaterallesionB. SpinalCordInjury:AnteriorlesionC. SpinalCordInjury:PosteriorlesionD. SpinalCordInjury:CompletelesionE. CompressivemechanismsF. SyrinxG. VentralhorncelldiseaseH. MultiplesclerosisI. DorsalcolumndiseaseJ. VasculardiseaseK. CaudaEquinaSyndrome
Disorders‐BrainStemA. WhitematterdiseaseB. VentricularlesionsC. MedullaventralD. MedullaLateralE. MedullaCraniocervicaljunctionF. MedullaIntegrativeG. PonsVentralH. PonsDorsalI. PonsLateralJ. PonsParamedianK. PonsIntegrativeL. MesencephelonTegmentalM. MesencephelonTectalN. MesencephelonIntegrative
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Disorders‐CranialNerveA. Tumors‐locationsB. Vasculature
1. TIA—transientischemicattack2. Stroke3. AVM—arteriovenousmalformation4. aneurysm
C. TraumaD. InfectionE. CongenitalanomaliesF. Plasticity/deafferentationG. HemisphericityH. Maculardegeneration,RAPD—relativeafferentpapillarydefectI. Nervepalsies—CNIII,Facial
Disorders‐Head&FacePainA. MigraineB. ClusterheadacheC. CervicogenicheadacheD. TensiontypeheadacheE. TemporalneuritisF. SubarachnoidhemhorrageG. TrigeminalneuralgiaH. AtypicalfacialpainI. Temporo‐mandibularjointpain
DiseaseProcesses‐CerebellumA. AtrophyB. InjuryC. ToxicityD. GeneticdiseasesE. ConcomitantdeafferentationF. Pathwaydisease‐spinocebellarG. TumorH. StrokeI. IschemiaJ. Location‐tremor‐symptoms
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Disorders&Diagnoses‐BasalGangliaA. MovementDisorders
1. Parkinson’sDisease:lossofSNcdopaminetoneostriatum2. Huntington’sdisease:damagetoneostriatum3. Ballismus:STNdamage4. Tourette’ssyndrome:lackofinhibitionofpathwaysresultinginmotorticsand
atleastonephonictic.5. Obsessive‐Compulsivedisease:dopaminergichyperfunctionintheprefrontal
cortexandserotonergichypofunctioninthebasalganglia.6. Dystonia:increasedandsustainedoutputofmotoriccenters;beginsfocallyand
spreadsunilaterallyandthenbilaterally.7. Wilson’sDisease:hepatolenticulardegeneration(coppermetabolism)
Diseases‐ReflexogenicA. TumorB. Vasculature‐obstruction/tonemodulation
1. Stroke2. TIA3. Aneurism
C. DeafferentationD. GeneticdiseaseE. ToxicityF. Hemisphericity
Disorders‐AutonomicNervousSystemA. SympatheticEscape(decreasedpontinecontrol)
1. Endorganeffect:i.e.,tachycardiaonrightandarythmiaonleft;2. Endorganeffect:i.e.,intestinalhypofunction;3. Other
B. Reynaud’sphenomenonC. ComplexRegionalPainSyndromeD. Sympatheticaggravationofimmuneresponse(asthma)E. Horner’ssyndrome
Disease/Diagnoses‐LimbicSystemA. DepressionB. AnxietyC. Autonomicdysregulation/autonomiaD. Emotionalmanifestationsorlackof:
1. Righthemisphere‐sadness,fear,disgust2. Lefthemisphere‐euphoria,anger,excessivesurprise,unwarrantedbliss
E. R.NeurodegenerativedisordersF. DevelopmentaldisordersG. Dysautonomia
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Disorders‐LobesoftheBrain
A. Functionalcategories1. Attentional2. Emotional3. Memory4. Sensory5. Sensorimotorintegration&MovementExcecution6. Interhemisphericdisconnection7. Dementia
B. Anatomiccategories1. Occipital2. Temporal3. Parietal4. Frontal5. Callosal
C. TerminologyofSymptoms‐1. Neglect2. Akinesia3. Perseveration4. Echolalia5. Akinetic6. Hallucinations7. Agnosia8. Alexia9. Dysgraphia10. Aphasia11. Anomia12. Apraxia13. Acalculia14. Palsy15. Hemianopia
DiseaseProcesses‐Brain&ItsEnvironmentA. StrokeB. Transientischemicattacks
1. Hardlesion(clot)2. Physiologicallesion
C. AneurysmsD. ArteriovenousmalformationsE. MeningitisF. EncephalitisG. LeakageofCSFH. IncreasedintracranialpressureI. Cavernoussinussyndrome/thrombosis
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Disorders‐NeuroendocrineA. Hyperprolactinemia
1. Associatedconditionsa. Hypogonadismb. Amenorrheac. Galactorrhea
2. Diseasestatesa. Pituitarytumors
i. Prolactinomasii. AdenomassecretingGHandprolactiniii. AdenomassecretingACTHandprolactin(Cushing’sdisease)iv. Nonfunctioningchromophobeadenomascompressingpituitarystalk
b. Hypothalamusi. Sarcoidosisii. Craniopharyngiomas iii. Cranialirradiationiv. Emptysellasyndromev. Aneurysm
c. Otherdiseasesi. Primaryhypothyroidismii. Chronicrenalfailureiii. Cirrhosisiv. Chestwalltrauma
B. Hypoprolactinemia1. Panhypopituitarism
C. GrowthHormone(Somatotropin)1. Acromegaly2. Gigantism
D. PituitaryDwarfism1. Gonadotropin:
a. Ectopicsecretioni. Germinomasii. Precociouspubertyiii. Pituitaryadenomas
1) FSHsecreting2) LHsecreting
2. Thyrotropina. GH
i. Acromegalyii. Depression
1) Hyperthyroidism2) Primaryhypothyroidism3) Secondaryhypothyroidism
a) Pituitarydiseaseb) Hypothalamicdisease
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iii. PituitaryorTSHinducedhyperthyroidism1) Tumors2) Resistancetothyroidhormone3) AdrenocorticotropicHormone(ACTH):
a) ExcessACTHa. Cushing’ssyndromeb. Nelson’sSyndrome
ii. CausesofexcessCortisol:a. PituitaryACTHb. EctopicACTHc. Adrenaltumorsd. Exogenouscorticosteroidadministration
iii. ACTHDeficiency:a. Afterprolongedglucocorticoidadministration
E. DeficiencyofVasopressin(DiabetesInsipidus)1. Causesaffectingpituitaryorhypothalamus:
a. Neoplasticlesionsb. Infiltrativelesionsc. Surgeryd. Isotopicablativetherapye. Severeheadinjuries
F. SyndromeofInappropriateAVPSecretion(SIADH):1. Causes
a. Lungcarcinomai. Smallcellii. Oatcell
b. Nontumorouslungtissuei. TBii. Pneumoniaiii. Otherpulmonarydiseases
G. ThyroidDisorders1. Sickeuthyroid2. Simplenontoxicgoiter
a. Iodinedeficiency3. Hypothyroidism
a. Inchildren–Cretinismb. Inadults
4. Thyrotoxicosisa. Abnormalthyroidstimulator
i. Grave’sdisease1) Hyperthyroidism2) Diffusegoiter3) Opthalmopathy4) Dermopathy
a) Trophoblastictumorb) Intrinsicthyroidautonomy
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i. Hyperfunctioningadenomaii. Toxicmultinodulargoiter
c) Disordersofhormonestoragei. Thyoiditis
a. Subacuteb. Chronic
ii. Ectopicthyroidtissuea. Functioningfollicularcarcinoma
d) Complicationsofthyrotoxicosisi. Thyrocardiacdiseaseii. Thyrotoxiccrisis
e) Thyroiditisf) Thyroidtumors
i. Adenomasii. Carcinomas
H. DiseasesoftheAdrenalCortex1. HyperfunctionoftheAdrenalCortex
a. Excesscortisola) Cushing’ssyndromeb) Causes
i. adrenalhyperplasiaii. neoplasiaiii. exogenous
b. Aldosteronisma) Hypersecretionofaldosteroneb) Primaryaldosteronism
i. adrenaladenomaii. adrenalcarcinoma
c) Secondaryaldosteronismi. reninangiotensinsystemii. Syndromesofadrenalandrogenexcess
a. Hirsutism1. Oligomenorrhea2. Acne3. Virilization4. Causesinwomen
I. FamilialJ. IdiopathicK. PolycysticovariesL. TumorM. Congenitaladrenalhyperplasia;
1. HypofunctionoftheAdrenalCortex2. Addison’sdisease
a. Primaryadrenocorticalinsufficiencya) Causes
i. Idiopathic
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ii. surgicalremovaliii. destructionfrominfectioniv. hemorrhagev. tumor
b. Secondaryadrenocorticalinsufficiencya) Causes
i. Hypopituitarismii. exogenoussteroidiii. steroidfromtumor
c. Acuteadrenocorticalinsufficiencya) Causes
i. Sepsisii. surgicalstressiii. hemorrhagicdestructionofbothadrenalglands
a. anticoagulanttherapyb. sometimesduringpregnancy
I.Pheochromocytoma1. Chromaffintumors
a. Catecholaminesb. Adrenalmedulla
2. Familiala. Autosomaldominantb. NeurofibromatosistypeIIc. Tumorsarebilateral
3. Extraadrenala. abdomenganglia
i. celiacii. superiormesentericiii. inferiormesenteric
4. Associateddiseasesa. medullarycarcinomaofthyroidinMENb. TypeIIandIIIneurofibromatosis
J.DiabetesMellitis1. TypeI(IDDM)2. TypeII(NIDDM)3. Secondarydiabetes
a. Pancreaticdiseaseb. hormoneabnormalitiesc. drugorchemicalinducedd. insulinreceptorabnormalitiese. geneticsyndromes
i. ComplicationsofDMa. i.Diabeticketoacidosisb. Hyperosmolarcomac. LateComplications
1) Circulatoryabnormalities
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2) Retinopathy3) Diabeticfootulcers4) DiabeticNeuropathy5) Peripheralpolyneuropathy6) Mononeuropathy
a) Autonomicneuropathyb) Varietyofskinlesions
K.AbnormalitiesofTesticularFunction1. Hypothalamic/Pituitary2. Testicular
a. KlinefeltersSyndromeorXXmaleb. Acquireddefectsdueto
i. viralinfectionii. traumaiii. radiationdrugsiv. systemicdiseases
3. SpermtransportL.AbnormalitiesoftheOvaries
1. Ovaries2. MenstrualCycle3. Menopausei.Osteoporosis
M.DisordersaffectingMultipleEndocrineSystems1. MultipleEndocrineNeoplasia,TypeI(Wernersyndrome)2. MultipleEndocrineNeoplasia,TypeII(Sipplesyndrome)3. MultipleEndocrineNeoplasia,TypeIII
DiseaseProcesses/Diagnoses‐PainA. ComplexregionalpainsyndromeB. Neurogenicinflammation:localCfiberreleaseofoneormorepeptidesubstances,
notablysubstanceP,whichbindswithreceptorsonthewallsofarterioles,leadingtoarteriolardilatation,andalsobindswithreceptorsonthesurfaceofmastcells,stimulatingthemtoreleasehistaminewhichincreasescapillarypermeabilityandleadstolocalaccumulationoftissuefluid,thewhealresponse.
C. Chronicpainassociatedwithdecreasedbrainstemfunction.D. Chronicpainassociatedwithdecreasedinternuncialfunction.E. HypoxicnociceptivedepolarizationF. Neuropathicpain:secondarytodirectinjurytonerveG. FibromyalgiaH. LaborpainI. PostsurgicalacutepainJ. CancerrelatedpainK. Arthriticpain
1. Rheumatoid2. Osteo
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L. Musclepain1. Spasm2. Pull3. Tear
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DiagnosticIssuesRelevanttoEachNeuroArea
DiagnosticIssues‐Receptors
A. Historytakingdifferentiatingpossibledisordersofenvironmentalreceptororgansvsothercauses
B. CompleteneurologicalexaminationC. Visualexaminationusingotoscopeandopthalmoscopeofthefundus,auditorycanal,
oralcavity,nasalcavityD. VisualacutitytestingusingSnellenEyechartE. Auditoryacuitytestingusingtones,WeberandRinnetestsF. basicsmelltesting,tastetestingG. DifferentialtestingforperipheralvscentralvertigoH. Rhomberg'stest,fingertonoseandobservationofsmoothpursuitsI. Dix‐HallpikemaneuverJ. Interpretationofauditory,visualandvestibularfunctionspecialtestingK. Assessmentofmuscletone,strength,jointpositionsense,jointrangeofmotionand
positionL. Assessmentofcutaneousmodalitiesofwarm/cold,sharp/dull,painperception,two
pointdiscrimination,graphesthesia
DiagnosticProcedures‐PeripheralNerve
A. CervicalMRIB. ThoracicMRIC. LumbosacralMRID. ShoulderMRI
1. brachialplexus2. shouldersofttissue
E. UpperextremityNerveconductionvelocitytestingwithoutneedleEMGF. UpperextremityNerveConductionvelocitytestingwithneedleEMGG. LowerextremityNerveconductionvelocitytestingwithoutneedleEMGH. LowerextremityNerveConductionvelocitytestingwithneedleEMGI. Laboratorytesting
1. heavymetals2. serumB123. CompleteBloodCount4. ComprehensiveMetabolicProfile5. Urinalysis6. Genetictesting
J. Cardiactesting1. Doppler2. ECG3. EchoCardiogram4. CardiacStresstest
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K. Xray:1. Cervicalspine2. Thoracicspine3. Lumbosacralspine4. Shoulderseries5. Elbowseries6. Wristseries7. Handseries8. Hipseries9. Kneeseries10. Ankleseries11. Footseries
DiagnosticIssues‐SC
A. HistorytakingdifferentiatingspinalcordlesionsfromlesionselsewhereB. Completeneurologicalexaminationwithemphasison:MusclespindlereflexesC. Completeneurologicalexaminationwithemphasison:StrengthD. Completeneurologicalexaminationwithemphasison:PrimitivereflexesE. Completeneurologicalexaminationwithemphasison:AssessmentoftoneF. Completeneurologicalexaminationwithemphasison:TactilesensationtestingG. LocalizationofspinalcordlesionsatdifferentlevelsH. Differentiatingbetweenasinglelesion,multiplelesionsandsystemiclesions
DiagnosticIssues‐BrainStem
A. HistorytakingdifferentiatingspinalcordlesionsfromlesionselsewhereB. Completeneurologicalexaminationwithemphasison:MusclespindlereflexesC. Completeneurologicalexaminationwithemphasison:StrengthD. Completeneurologicalexaminationwithemphasison:PrimitivereflexesE. Completeneurologicalexaminationwithemphasison:AssessmentoftoneF. Completeneurologicalexaminationwithemphasison:TactilesensationtestingG. LocalizationofspinalcordlesionsatdifferentlevelsH. Differentiatingbetweenasinglelesion,multiplelesionsandsystemiclesions
DiagnosticIssues‐CranialNerve
Eg.DistinguishingHorners’syndromefromcranialnervedisorderSimpleversuspathologicalanisocoria
DiagnosticIssues‐HeadandFacePain
A. Historytakingdifferentiatingprimaryheadpainlesionswithsecondaryorsinisterones
B. Completeneurologicalexaminationwithemphasison:a. Cranialnervetestingb. Autonomicassessment
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c. Musclespindlereflexesd. Strengthe. Primitivereflexesf. Assessmentoftoneg. TactilesensationtestingC. UseofdiagnosticimagingD. Differentiatingbetweenasinglelesion,multiplelesionsandsystemiclesions
DiagnosticIssues‐Cerebellum
A. Neurologicalexam1. Extremityexecutionofcoordinatedmovements2. Coreexecutionofcoordinatedmovements
B. Differentiatingtremors1. Resting2. Dystonic3. Orthostatic4. Essential5. Intention6. Parkinsonian7. Physiologic8. Rubral
C. Oculomotorabnormalities1. Hypometria/hypermetria2. Saccades\pursuits3. Canalrelatedmovements
D. Frankpathology1. Tumors2. Geneticdisease3. Degenerativedisease4. Toxicities
DiagnosticIssues‐BasalGanglia
A. Historytakingdifferentiatingcentral/basalganglioniclesionsfromperipherallesions.
1. Historyofareasoffunctiona. Motoricfunctionb. Frontalrelatedfunction:
1) Rightandleftexecutivecontrol2) Troublewithsaccadefunction3) Hypertonia4) Postureofpyramidalparesis
c. Cerebellumrelatedfunction:1. balance,2. coordination,
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3. dizziness(spin)4. Eyecontrolproblems,5. Repetitivesprain/strains,6. Hypotonia
d. Mesencephalon1. Troublewithlight2. Heartrate(maybeperceivedaspanicattacks)3. Visualproblems4. Sleepproblems5. Decreasedenergy6. Guttrouble7. Activatedbyinflammatoryimmunecytokinereceptors?
e. Emotionandcontrolorphysicaloutputsecondarytoemotion(caudate/limbic)
B. Completeneurologicalexaminationwithemphasison:a. Frontaloutput:
1. Saccades2. Verticaloptokinetics3. Monotoneandmelodicsequencing4. Analysiscapability5. Understandinghumor
b. Cerebellumc. Mesencephalond. Thalamus:
1. Perceptionrightvs.leftvision,2. Sound3. Touchmodalities
e. ANSf. Heart,Lungs,Abdomeng. Posture:
1. pyramidalparesis2. Flexortone3. Hemiparesis
DiagnosticIssues‐AutonomicNervousSystem
A. HistorytakingincludinglifestylefactorsB. Completeneurologicalexaminationwithemphasison:
1. Pupilaryresponse2. Cornealreflex(pontinecis)3. Hr4. SpO25. Skincolor6. Capillaryfilling7. Limbicchangestoabove(suchasemotionaltestimony)8. Gutfunction
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9. Adrenalfunction(labtestingorabilitytosleepthroughnight)10. ALLcranialnerves
DiagnosticIssues‐LimbicSystem
A. Neurologicalexam1. Evaluationofemotionalexpressionandmanifestation
a. Responsestohumorb. Responsestopainc. Responsestosufferingd. Responsestojoye. Responsesoutofcontextf. Responsestosadness
2. SexualIssuesa. Drivesb. Frequencyc. Ability
i. Erectionii. Lubricationiii. Arousaliv. Orgasm
3. Relationshiptacticsa. Aggressiveb. Submissivec. Argumentatived. Perspectivee. Optimistic/pessimisticf. Complimentaryg. Lengthofrelationships
4. Autonomica. Anxietyb. Bowelregularityc. Bladderregularityd. Bloodpressuree. Heartratef. Sweatingg. Extremitytemperaturesh. Emotionaleffectsofautonomics
5. Reflexes6. Blindspots
B. Spiritual1. Hallucinations
a. Visualb. Auditoryc. Somatosensoryd. Olfactory
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e. Gustatory2. Introversion/extroversion
DiagnosticIssues‐LobesoftheBrain
A. HistorytakingdifferentiatinghemisphericlesionsfromlesionselsewhereB. Completeneurologicalexaminationwithemphasison:
1. Hemisphericlocalization2. Cognitivefunctions3. Primaryandsecondarysensoryandmotorfunctions4. Related“lower/reflexive”functions
C. LocalizationoflesionsgospecificorgroupedbygyriD. Differentiatingbetweenasinglelesion,multiplelesionsandsystemiclesionsE. UseofBroadman’staxonomy.
DiagnosticIssues‐Brain&ItsEnvironment
A. SpecialStudiesforDiagnosis(referred):1. CTangiography2. MRI/MRAofbrain3. Lumbarpuncture
B. Completeneurologicalexaminationbyclinician.C. Emergentvascularaccident‐gettransporttoEDD. Discriminatebetweenocclusivetransientischemiaandphysiologicischemia
DiagnosticIssues‐Pain
A. Historytakingdifferentiating:1. Nociceptivereceptoractivation2. Decreasedsupra‐segmentalpaininhibition3. Neuropathic4. Centrallesions5. Organicpain6. Situationalissuespotentiatingpain7. Other(textbox)
a. Divorceb. Griefc. Financialdifficultyd. Lossofanysort(emptynest,lossofstatus,movetonewlocal,etc.)e. Drug&/oralcoholabusef. Chronicprescriptiondruguseg. Other(textbox)
B. Completeneurologicalexaminationwithemphasison:1. AutonomicNervousSystem2. Completebrainstemfunction
a. Mesencephalicb. Pontine.
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c. Limbicsystemcontributionsd. Corticalcentersofpainappreciationregarding:
3. Location4. Severityofreceptoractivation5. Effect
B. OtherC. Situational:post‐surgical,cancer,childrenissuesetc.westernpro‐inflammatory
diet,trauma,gamblingaddictions,poornutrition,domesticviolence,elderabuse,neglect
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Treatment&Rehabilitation
RehabforNeuron
A. Rehabilitationortreatment1. Increaseactivation2. Inhibitactivation3. Promotecellproliferationbyincreasingfueldeliverybutnotexceedingthe
metabolicrateoftheareabeingstimulatedB. SpecificadjustmentswillincreaseO2C. SpecificAdjustmentswillincreaseactivationD. Nutritiontoincreaseactivation.
RehabPrinciples‐Receptors
A. EnvironmentalreceptorstransduceexternalstimulusintoanelectrochemicaleventthatmaychangetheCNS
B. ToachievegreatprobabilityofCNSchange:fastadaptingreceptorsneedtobestimulatedwithvaryingamplitudesorpatterns
C. ToachievegreatprobabilityofCNSchange:slowlyadaptingreceptorswillmaintainachangeinfiringratewithanew,butconstantstimulus
D. Receptorsthatfirefrequently(slowlyadaptingorassociatedwithafrequentlychangingsystem)andareveryresponsivetochange(highsensitivity)oftenhavethegreatestCNSinput;thesearemostlyproprioceptorsandvestibularreceptors
RehabilitationApplications‐Receptor
A. VisualstimulusandfilteringB. Auditorytrainingwithtones,clicksandmusicC. OlfactoryandgustatorystimulustechniquesD. Vestibulartraining(yaw,pitchandroll)E. TheraputiccaloricF. CanalithrepositioningG. CrudeandaccuratetouchstimulationH. ChiropracticadjustingtechniqueI. Rangeofmotiontherapeutics(resistancetraining,stretch,musclework)
ReferralPrinciplesforPeripheralNerves
A. Referonlyuntiladefinitivecauseisknown:1. OrthopedicSurgeon2. Neurosurgeon3. Cardiologist4. Endocrinologist5. PrimaryCarePhysician(ifnotyou)6. Rheumatologist
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B. ReferandCo‐treatwithotherpractitioner1. Occupationaltherapist2. PrimaryCarePhysician(ifnotyou)
C. TreatwithoutCo‐ManagementD. Referbaseduponoutcomeofinitialtrialtherapy
TreatmentModalitiesPeripheralNerve
A. SpinalmanipulationB. ExtremitymanipulationC. Nutritionalsupport(vitamins,minerals)D. Muscletonemodulation
1. Electricalmusclestimulation2. Myofacialrelease3. Massage4. Faststretch5. Slowstretch
E. Thermotherapy(hotorcold)F. Centralintegratedstate(toincreaseordecrease)
RehabPrinciplesPeripherialNerve
A. PhysicalRehabinofficeB. PhysicalRehabathomeC. Corticalstimulation
RehabPrinciplesSpinalCord
A. CentralvsPeripheralnervelesionsandlimitationstoregenerationB. SegmentalrelationshipsC. PeripheralsignalingintocordD. Supra‐segmentalsignalingintocordE. DecompressionandvascularcontrolsF. MetaboliccapacityG. CentralintegratedstateandpotentialforplasticchangeH. ToachievegreatprobabilityofCNSchange:fastadaptingreceptorsneedtobe
stimulatedwithvaryingamplitudesorpatternsI. ToachievegreatprobabilityofCNSchange:slowlyadaptingreceptorswillmaintain
achangeinfiringratewithanew,butconstantstimulusJ. Receptorsthatfirefrequently(slowlyadaptingorassociatedwithafrequently
changingsystem)andareveryresponsivetochange(highsensitivity)oftenhavethegreatestCNSinput;thesearemostlyproprioceptorsandvestibularreceptors
RehabApplicationsSpinalCord
A. CrosscrawlB. SegmentalspindleandGTOreflexes
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C. VestibularreflexesD. BladdercontrolE. GaitretrainingF. BrainbasedtherapiesG. Crudetouch,pain,temperatureandaccuratetouchmodalitiesH. ChiropracticadjustingtechniqueI. Rangeofmotiontherapeutics(resistancetraining,stretch,musclework)J. Mentalimagery
RehabPrinciples‐BrainStem
A. CentralvsPeripheralnervelesionsandlimitationstoregenerationB. SegmentalrelationshipsC. PeripheralsignalingintocordD. Supra‐segmentalsignalingintocordE. DecompressionandvascularcontrolsF. MetaboliccapacityG. CentralintegratedstateandpotentialforplasticchangeH. ToachievegreatprobabilityofCNSchange:fastadaptingreceptorsneedtobe
stimulatedwithvaryingamplitudesorpatternsI. ToachievegreatprobabilityofCNSchange:slowlyadaptingreceptorswillmaintain
achangeinfiringratewithanew,butconstantstimulusJ. Receptorsthatfirefrequently(slowlyadaptingorassociatedwithafrequently
changingsystem)andareveryresponsivetochange(highsensitivity)oftenhavethegreatestCNSinput;thesearemostlyproprioceptorsandvestibularreceptors
RehabApplications‐BrainStem
A. CrosscrawlB. SegmentalspindleandGTOreflexesC. VestibularreflexesD. BladdercontrolE. GaitretrainingF. BrainbasedtherapiesG. Crudetouch,pain,temperatureandaccuratetouchmodalitiesH. ChiropracticadjustingtechniqueI. Rangeofmotiontherapeutics(resistancetraining,stretch,musclework)J. Mentalimagery
RehabPrinciples‐CranialNerveA. Restore/maintain‐fuelB. Surgicalreferral–removal/eliminate/repairfrankpathologyC. MonitormetaboliccapacityD. ImproveplasticityE. ActiveactivationF. Activeinhibition
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G. Createsymmetry/balanceinfunctionalityfromrightandleft
RehabApplications‐CranialNerve
A. Olfaction:1. Olfactionidentification‐peppermint/lavender2. Olfactionlocalization
B. Visual:1. Hemi‐fieldstimulation2. Colorstimulation3. Optokineticstimulation4. Accommodationexercises5. Localization6. Blockingtechniques
C. Oculomotor:1. .saccades2. 3/4/63. Pursuits4. VOR—vestibularOcularreflex5. OPK—optokinetic6. Memorizedtargets
D. Edinger‐Westphal:1. Lightstimulation‐frequency/color/intensity2. Accommodation‐near/farexercises
E. Trigeminal:1. therapeuticexercises–chewing2. Myofascialrelease3. Manipulation4. Sensorystimulation‐V‐I,V‐II,V‐III
F. Facial:1. Muscleactivation2. Corticalbasedfacialexpression3. Limbicbasedfacialexpression
G. SSN:1. Cornealstimulation2. Gagstimulation3. Caloricstimulation4. Odorstimulation
H. Cochlear:1. Tonerecognition2. Soundlocalization3. Rhythm4. Metronome5. Music
I. Vestibular:1. Angularacceleration
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2. Linearacceleration3. Visualization4. Glossopharyngeal5. Tastestimulation
J. Vagus:1. Carotidcompression2. Angularacceleration3. Cornealstimulation4. Other(textbox)
K. Spinalaccessory:1. Myofascialrelease2. Therapeuticexercises3. Manipulation4. Slow/faststretch5. Other(textbox)
L. Hypoglossal:1. Therapeuticexercises
RehabPrinciples‐Head&FacePain
A. CentralvsPeripheralnervelesionsandlimitationstoregenerationB. CranialnervesensoryandmotorrelationshipsC. PeripheralsignalingintobrainstemD. Supra‐segmentalsignalingintobrainstemE. MetaboliccapacityF. CentralintegratedstateandpotentialforplasticchangeG. ToachievegreatprobabilityofCNSchange:a.fastadaptingreceptorsneedtobe
stimulatedwithvaryingamplitudesorpatterns1. slowlyadaptingreceptorswillmaintainachangeinfiringratewithanew,but
constantstimulusH. Receptorsthatfirefrequently(slowlyadaptingorassociatedwithafrequently
changingsystem)andareveryresponsivetochange(highsensitivity)oftenhavethegreatestCNSinput;thesearemostlyproprioceptorsandvestibularreceptors
RehabilitationApplications‐Head&FacePain
A. SympatheticinhibitionB. MechanismsofnervedecompressionC. Oxygenation(decreasedCO2)D. VestibularreflexesE. AutonomiccontrolsF. GaitretrainingG. BrainbasedtherapiesH. Crudetouch,pain,temperatureandaccuratetouchmodalitiesI. ChiropracticadjustingtechniqueJ. Rangeofmotiontherapeutics(resistancetraining,stretch,musclework)K. Mentalimagery
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L. DesensitizationM. SleeppatterningN. Breathingexercises
RehabilitationPrinciples‐Cerebellum
A. Location:1. Midline2. Intermediate3. Lateral
B. SidednessC. MetabolicindicatorsD. Manifestation:
1. Disdiadochokinesia2. Dysmentria3. Tremor4. Balance5. Speech6. Bradykinesia7. Limbicrelationships8. Vestibularinteractions
E. Canalrelationships/AngularaccelerationF. Otolithicrelationships/Linearacceleration
TreatmentIssues‐Cerebellum
A. SupplementationB. FueldeliveryC. MetabolicstabilityD. ModulationE. Medicalreferral
RehabilitationApplications‐Cerebellum
A. Cross‐crawl1. Bilateral2. Ipsilateral
B. Finger‐to‐noseC. Balance
1. Rhomberg2. TandemGait3. Onelegstanding
D. Fingertofinger 1. Ipsilateral2. Contralateral3. Targetshifting
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4. ComputerizedtargetshiftingE. Rapidcoordinatedfingermovements‐PianoplayingF. TemperaturegradientandmodulatedcaloricsG. NovelandknownfacesH. AlternatingmovementsI. Activepassive/movementJ. VisualizationK. Vestibularintegration
1. Linear/angularacceleration2. Ocularactivation
a. VORb. Pursuit/cicadetargeting
L. ExtremitytemperatureM. Electricalmodulation:
1. Passive2. Active
N. Visualizationactivity
RehabilitationPrinciples‐BasalGanglia
A. CISassessmentofcomponentnucleiB. Activationofappropriatenuclei:
1. frontalmechanismstoactivatestriatums2. mesencephalicactivationtoactivatefrontallobe3. mesencephalicinhibitiontolimitactivepathwayandfrontallobe4. cerebellumactivationorinhibitiondependinguponstateofcontralateral
mesencephalon5. cerebellummossyfiberorclimbingfiberactivationforincreasedsurround
inhibitionorforpurkinjeinhibitionC. Measurementofmetaboliccapacity
1. ANS:a. SpO2b. HRc. Respirationd. Skincolore. Capillaryfillingf. skintemperature
D. MeasurementofcomponenttissueCentralIntegratedState(CIS),withexampleofmesencelphalon:1. Pupillaryresponse2. CNIII
a. Ipsimedrectusb. Infrectus,c. Infobliqued. Allipsisubrectuse. Contrasuprectus
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3. Contralaterallimbflexors,ocularconvergence,bilateralactivationofsympatheticpathway.
RehabilitationPrinciples‐AutonomicNervousSystem
A. PontineinhibitionofsympatheticsB. FrontalactivationofpontinecentersC. LimbicactivationofhypothalamusD. AdrenalactivationofsympatheticsE. Measurementofmetabolicrate:
1. Pulseoximetry2. Heartrate3. Pupillaryresponse4. Respiratoryrate5. Erectorpilar6. Muscleactivation7. Skincolor
RehabilitationPrinciples‐LimbicSystem
A. SidednessB. MetabolicindicatorsC. Sensorystimulation
1. Lighta. Quadrantspecificstimulationb. Lightfrequencies‐colorc. Intensityd. Quality
i. Barsii. Opkiii. Still/movement
2. Sounda. Localizationb. Pitchc. Music
i. hemispherespecificii. emotionspecificiii. rhythmiv. tempo
3. Olfactiona. Pleasantversusnon‐pleasantb. Olfactorylocalization
Olfactoryidentification4. Touch
a. Vibrationb. Localizationc. Pressure
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d. Pain/pleasure5. Gustatory
a. Bitterb. Sweetc. Sour
D. Connotationofaparagraphforrighthemisphere.(interpretivemeaning)E. Enteroceptionconcentration(focusonbodypartorsystem)forrighthemisphere.F. Vocalizationoftextforlefthemisphere.G. Spatialawarenessforrighthemisphere.H. MathematicalcalculationsforlefthemisphereI. Spatialawarenessandmanipulationrighthemisphere
RehabPrinciples‐LobesoftheBrain
A. FunctionalvsPathologicallesionsB. Left‐rightrelationshipsC. AscendinganddescendingrelationshipsD. MetaboliccapacityE. CentralintegratedstateandpotentialforplasticchangeF. CentralchangesassociatedwithcorrectionofjointbiomechanicsG. Frequency,intensityanddurationsfactorsinpromotingcentralplasticity
RehabApplications‐LobesoftheBrain
A. Right‐lefthemisphererelationshipswithjointmechanoreceptoractivityB. Localbrainfunctionsasrehab
1. (Openendedbox)C. Visualstimulation
1. Generala. Hemi‐fieldglassesb. Eyelightsc. Other(OpenEndedBox)
2. Rightbraina. Modalitiesyouuse(openendedbox)
3. Leftbraina. Modalitiesyouuse(openendedbox)
4. Auditorystimulationa. RightBrain
i. Novelii. Natureiii. Poetryviaaudioiv. Other(openendedbox)
b. Leftbraini. Familiarii. Strongbeatiii. Proseviaaudio
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iv. Other(openendedbox)5. Olfactorystimulation6. Gustatorystimulation7. Tactilestimulation
a. Vibrationb. Lighttouchc. Texturesd. Eyesclosedidentification
8. Cognitiveactivationa. Rightbraini. Mazesii. Spatialtasksiii. Novelfacesiv. Other(openendedbox)b. Leftbraini. Wordproblems/gamesii. Sequencingactivitiesiii. Planningactivitiesiv. Other(openendedbox)
9. Vestibularactivity10. Categorizing,sequencing11. Decisionmaking12. Spatialrelationships13. Memory14. Accuratetouch
RehabPrinciples‐Brain&ItsEnvironment
A. SpecialStudiesforDiagnosis(referred):1. CTangiography;2. MRI/MRAofbrain3. Lumbarpuncture
B. Completeneurologicalexaminationbyclinician.C. Emergentvascularaccident‐gettransporttoEDD. Discriminatebetweenocclusivetransientischemiaandphysiologicischemia
RehabApplications‐Neuroendocrine
A. RehabApplication1. Laboratory
a. SerumProlactinlevelsb. Glucosetolerancetestsc. SerumT3,T4andFT4Id. Calciumlevelse. Potassiumlevelsf. VitaminDlevelsg. BasalandrandomGHlevels
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h. Hormonelevelsi. Osmolality
1) Plasma2) Urinary
j. Dehydrationtestk. 24Hrurinel. CortisolResponse
i. Plasmacortisolii. Urinarycotisol
m. UrinepHn. Urinaryglucoseandketones
2. Radiographicallya. CT/MRIscanningofhypothalamus/pituitaryareaofbrainb. Conventionalskullx‐raysc. CTscanofabdomen
3. Clinicallya. Historyi. Sexualii. Menstrualiii. Breastiv. Visionv. Headachesvi. Menstrualvii. Sleepcycleb. PhysicalandNeurologicalexami. CranialNervesii. Palpationiii. Visualfieldiv. Cardinalgazev. Pupillaryresponsesvi. Skinandhairtextureanddistributionvii. Coretemperaturec. RehabPrinciplei. Patienteducationii. Referoutformedicalmanagement
1. Drugtherapy2. Surgery
RehabPrinciples‐Pain
A. SegmentalrelationshiptopaininhibitionB. MesencephalicrelationshiptopaininhibitionC. Supra‐segmentalsignalingintocordD. HypoxicreliefE. Metaboliccapacity
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F. CentralintegratedstateandpotentialforplasticchangeG. ToachievegreatprobabilityofCNSchange:
a. Fastadaptingreceptorsneedtobestimulatedwithvaryingamplitudesorpatterns
b. Slowlyadaptingreceptorswillmaintainachangeinfiringratewithanew,butconstantstimulus
H. Receptorsthatfirefrequently(slowlyadaptingorassociatedwithafrequentlychangingsystem)andareveryresponsivetochange(highsensitivity)oftenhavethegreatestCNSinput;thesearemostlyproprioceptorsandvestibularreceptors.ProprioceptorsinhibitpainsegmentallyandvestibularreceptorsactivatepontineinhibitionofIML.
I. Corticalstimulationleftand/orright
TreatmentModalities‐Pain
A. Thermal1. Ice/coldpacks2. Heatpacks3. Alternatingheatandcold4. Other(textbox)
B. InterferentialC. UltrasoundD. MassageE. Corticalstimulation
1. Rightbrainmodalities2. Leftbrainmodalities
F. ExerciseG. VibrationH. LighttouchI. AdjustmentsJ. Oxygentherapy(gainreferralifnecessaryinyourstate/province)K. ReferralforallopathicinterventionL. Other(textbox)
1. Vestibularstimulation/spins,calorics,OPK,Metronome,visualstimulation,auditorystimulation,olfactorystimulation,etc.
2. Vestibularspinorup/down3. Coldlaser4. Light,sound,tens,balance,vestibular,eyemotions,saccades,pursuits,smell
andothertherapiesforbrainbasedrehab5. OxygentherapyisnotallowedinKY6. Referralwhenindicated7. OxygentherapynoallowedinNY8. Anti‐inflammatorynutritionandvitamintherapy9. Laser,Needleacupuncture10. LowLevelLaser11. ColdLaserTherapy
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SpecialStudiesbyNeuraxisAreaandOverall
SpecialStudiesNeuron
A. BloodworkB. SPO2C. EMG&NCV
DiagnosticProcedures/SpecialStudies‐PeripheralNerveA. CervicalMRIB. ThoracicMRIC. LumbosacralMRID. ShoulderMRI
1. Brachialplexus2. Shouldersofttissue
E. UpperextremityNerveconductionvelocitytestingwithoutneedleEMGF. UpperextremityNerveConductionvelocitytestingwithneedleEMGG. LowerextremityNerveconductionvelocitytestingwithoutneedleEMGH. LowerextremityNerveConductionvelocitytestingwithneedleEMGI. Laboratorytesting
1. Heavymetals2. SerumB123. CompleteBloodCount4. ComprehensiveMetabolicProfile5. Urinalysis6. Genetictesting
J. Cardiactesting1. Doppler2. ECG3. EchoCardiogram4. CardiacStresstest
K. Xray: 1. Cervicalspine2. Thoracicspine3. Lumbosacralspine4. Shoulderseries5. Elbowseries6. Wristseries7. Handseries8. Hipseries9. Kneeseries10. Ankleseries11. Footseries
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DiagnosticTestingModalities‐LimbicSystem
A. MRIB. MRaC. EEG
SpecialStudiesforDiagnosing&TreatingPatients
A. Howimportantisyourknowledgeaboutthefollowingspecialstudiesindiagnosingandtreatingyourpatientsandhowfrequentlydoyouorderthem?Howdoyoumanagethespecialstudies(performyourself,refer,etc.)
1. Imagingstudies:i. Arteriograms/Angiographyii. BariumStudies
2. LowerGIi. Bonedensityscanii. CTScansiii. DiagnosticUltrasoundiv. DopplerVascularStudiesv. fMRIvi. MRIvii. MRaviii. Myelogramix. NuclearMedicineBoneScanx. PlainFilmRadiologyxi. PETxii. Regionalcerebralbloodflowxiii. SPECTxiv. Otherimagingstudies(textbox)
3. Electro‐diagnosticStudies:i. EvokedPotentials
1. BrainstemAuditoryEvokedPotentials2. VisualEvokedPotentials3. SomatosensoryEvokedPotentials
ii. Electrocardiogram1. Exercisestresstest2. Chemicalstresstest
iii. Electroencephalographyiv. Electronystagmographyv. NeedleElectromyographyvi. NerveConductionVelocityvii. QuantitativeElectroencephalography
4. OtherdiagnosticStudiesi. AuscultatoryExamination:
1. Subclavianbruit2. Carotidbruit
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3. Temporalbruit4. Intracranial(Orbital)bruit5. Heart6. Lungs7. Abdomen
ii. AudiometricExaminationiii. Typanographyiv. Bronchoscopyv. BalanceTestingvi. Bimanualpelvicexamvii. CaloricTestingviii. Colonscopyix. Diagnosticeducationaltestingx. Endoscopyxi. Fundoscopyxii. JustNoticeableDifferenceTesting
5. Touchanddistanceapart6. Mammogram7. Neuro‐psychologictesting8. Behavioraltesting9. PAP10. Posturography11. QuantitativeStrengthTesting12. Skintemperature13. Spirometry14. Videonystagmography15. Visualstudies
i. Anslergridii. Floresceiniii. Retinalphotpgraphyiv. Visualfield,perimetry
16. LaboratoryStudiesi. BasicMetabolicProfileii. Biopsy
1. Bowel2. Lung3. Nerve4. Muscle5. Liver6. Kidney7. Skin8. Stomach,otherGI9. Cervical10. Ovarian11. Uterine12. Cysts
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a. CBCb. CBCwithdiffc. Culture&sensitivityd. Cytokinelevels
13. DNAtesting14. Foodallergy/sensitivity15. Genetictesting16. Heavymetaltesting17. HemoglobinA1C18. HIV19. TestingforIllegaldrugs20. Kidneypanel21. Liverpanel22. LumbarPuncture
a. Hemorrhageb. Cellsc. Elecrophoresild. Glucosee. Openingpressure
23. Lymetesting24. Ova&Parasite25. Pharmicokineticstesting‐monitortherapeuticbloodlevels,
detectingearlytoxicity26. Postprandialbloodglucose27. Salivarycortisol28. SerumFolate29. SerumVitB1230. Serum25hydroxy‐vitaminD31. Sputumculture32. Stoolanalysisfatcontent33. ThyroidFunction
a. TSHb. FreeT4c. CalculatedFreeT3d. ReverseT3e. T3uptakef. ThyroidAntibodies
34. UAwithmicroscopic,cast35. 24hrVMA36. 24hrUrinaryhalidewithIodineloading
OtherSpecialStudiesMentionedinOpenEndedSurveyResponses
ReverseT3andT3uptakenotofferedbymylab(Canada)otherwiseIwoulddothem.
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Thevastmajorityofthetime,MRIandothervisualization/radiologyexamshavealreadybeendone,suchasopeningpressureonlumbarpunctureorSPECTorPETorMRIorfMRIorbiopsy,EMG,NCV,EEG,ECGandifIsuggestorordersuchtestsitisalwaysincoordinationwiththeprimarycarephysicianorspecialist.Ofcourse,ifIfindsomethingonindependentmanagementthatrequiresprimarycare,thereisareferralorconsultation.
Overall,thissurveyhasbeenagreatreviewofwhatIknowandagreatreminderofwhatIdon'tknoworneedtolearnmoreabout.Thanks.
Hormonepanels:someofthesetestsarenotfamiliartome.Thisisalsoverydependentonlocation.InEurope,muchharderforDCtoorderlabs,mustgothroughGP...alsocannottakeownx‐rays,etc.
Cardiacpanel,DHEA,Serotonin,Glucose,Catecholamines,IworkasanFNP.
HLAB27,RAlatex,Fluorescentantinuclearantibodies,UricAcid,Creactiveprotein,Cardiacenzymes,inAustralia,wecannotorderanyofthesetests.Irungeneralchemistriesinmyofficeandroutinelyorderbloodworkonmypatients.