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176 PHYSICAL EXAMINATION

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UNIT 2

developed and tested to assist in these situations. For example, the FLACC tool, which assesses behaviour (

Table 6.8) is useful. Another example is the Abbey Pain

Scale, which measures pain in consumers with dementia who cannot verbalise (Abbey et al., 2004). These tools have been found to be valid and reliable pain measurement scales.

TABLE 6.8 FLACC Behavioural Scale

SCORING

CATEGORIES 0 1 2

Face No particular expression

or smile

Legs Activity Lying quietly, normal

Cry No cry (awake or asleep) Moans or whimpers,

Consolability Content, relaxed Reassured by occasional

Note: Each of the ve categories Face, Legs, Activity, Cry and Consolability is scored from 0 to 2, which results in a total score between 0 and 10.

SOURC E: COPY RIGHT © 200 2, THE REG ENTS OF TH E UNIVER SITY OF MI CHIGAN . ALL RIGHT S RESERV ED.

Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up

position, moves easily

Occasional grimace or frown; withdrawn, disinterested

Squirming, shifting back and forth, tense

occasional complaint

touching, hugging, or being talked to; distractible

Frequent to constant frown, clenched jaw, quivering chin

Arched, rigid or jerking

Crying steadily, screams or sobs; frequent complaints

Difcult to console or comfort

Pain management

One of the most difcult and challenging clinical practice areas is pain management. Acute pain can often be treated with various interventions and is relatively short lived. This is not the case with chronic pain from any aetiology. Ideally, cancer pain and chronic (persistent) pain should be managed in an interdisciplinary team environment that includes the consumer and their family. The goal is to have the individual’s pain managed with pharmacological and non-pharmacological treatments, to allow them to achieve the highest level of functioning possible.

Treatment approaches to pain (acute and chronic) can include pharmacological measures that are appropriate for the type of pain; for example, analgesics, anti-epileptics, nonsteroidal anti-inammatories and opioids, just to name a few. Non-pharmacological interventions include physical therapy, application of hot/ cold therapy, and psychological measures such as cognitive behavioural therapy.

The goal cannot always be to alleviate all of the consumer’s pain. Some chronic pain conditions, such as osteoarthritis and diabetic peripheral neuropathy, have no cure. In cases such as these, the goal is to decrease the severity of the individual’s pain symptoms so that the consumer can lead as normal a life as possible. Conducting regular assessment for consumers who have chronic (persistent) pain is imperative to achieve this, because it is an ongoing process.

REFLECTION IN PRACTICE

Communicating appropriately in difcult situations

You are working in the community health clinic, taking a health history from a new female consumer. She states that she has had acute lower back pain for the past 2 years. She tells you ‘I want a really strong medication because my pain is really bad. Do not tell me to use hot packs. I know how stingy you people can be giving the good stuff.’

> What questions would you ask her? > How would you proceed?

EXAMINATION REQUIREMENTS FOR EVERY CONSUMER 177

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CHAPTER RESOURCES

REVIEW QUESTIONS

For answers to these questions, see Answer section at the end of the book.

1. You are assessing a consumer’s physical status and note that

the consumer looks thin and frail. What condition might this consumer have?

a. Cushing syndrome b. Hypokinetic state c. Malabsorption disease d. Hypothyroidism

2. Smelling an alcohol odour on a consumer may indicate which

of the following conditions?

a. Vaginal infection b. Allergic rhinitis c. Tonsillitis d. Ketoacidosis

3. Which of the following is true about the pulse rate? a. Parasympathetic stimulation causes an increase in pulse rate. b. Medications such as digoxin can increase the pulse rate. c. Caffeine and tobacco decrease the pulse rate. d. The sinoatrial node is the primary controller of pulse rate.

4. You are assessing a consumer who has just presented to

the emergency room after being knocked off his bike. You have just completed taking his vital signs and record his temperature as T 36.2°C (tympanic). What conclusion do you make about the consumer’s temperature?

a. The consumer’s temperature is within normal limits. b. The rectal route is the best method to use in a trauma

consumer to determine temperature.

c. Tympanic thermometers are inaccurate if the consumer

has lost a lot of blood.

d. The Celsius scale is the most accurate scale to use when

documenting temperature.

5. The nurse counts 10 respirations in 1 minute while the

consumer is asleep. What assessment does the nurse make about this consumer?

a. The consumer has obstructive sleep apnoea. b. The consumer has bradypnoea. c. The consumer is hypoxic. d. The consumer is stressed.

6. Your consumer is connected to a heart monitor and you

recognise their electrical rhythm as atrial brillation. You also palpate the consumer’s carotid pulse. Which of the following describes the rhythm of the heart rate and pulse?

a. Regular b. Regularly regular c. Regularly irregular d. Irregularly irregular

7. A consumer’s pulse volume is documented as 1+/4+.

This means the consumer’s pulse is:

a. Absent b. Thready c. Normal d. Bounding

8. The nurse takes a consumer’s blood pressure at the clinic.

The blood pressure is 84/55. The consumer states that this is very low for him. The nurse suspects that an error has occurred during the blood pressure measurement. Which of the following can cause an inaccurately low blood pressure?

a. The blood pressure cuff is too large. b. The consumer smoked a cigarette ve minutes before the

measurement was taken.

c. The blood pressure cuff is too small. d. The brachial artery was positioned below the heart.

9. The nurse obtains a blood pressure of 138/92mmHg on a

consumer’s right arm while he is in the sitting position. What blood pressure classication characterises this reading?

a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

10. Neuropathic pain is characterised by which of the following? a. A change in organ size, such as in acute appendicitis b. Left shoulder pain that is felt during pancreatitis c. A sudden onset that is life-limiting after surgery d. A burning or tingling, such as with herpes zoster

11. Which of these statements is not a misconception regarding pain? a. Medication is the only treatment to be used for pain. b. Consumers will always tell the nurse when they are in pain. c. The consumer should expect to have pain while in hospital. d. Pain is whatever the experiencing person reports.

12. Considerations during an assessment of pain in older people

are that they:

a. Have a decreased pain threshold b. Have a reduction in their sensory perception c. Have an alteration in their mental function d. Are expected to experience chronic pain

CLINICAL SKILLS

The following Clinical Skills are relevant to this chapter and can be found in Tollefson & Hillman, Clinical Psychomotor Skills, 8th edition:

> 10 Temperature, pulse and respiration measurement > 11 Blood pressure measurement > 12 Monitoring pulse oximetry > 13 Pain assessment > 19 Focused respiratory health history assessment and

physical assessment

> 23 Height, weight (BMI) and waist circumference

measurement > Part 8: Pain management > 75 Non-pharmacological pain management interventions –

therapeutic massage > 76 Non-pharmacological pain management interventions –

conventional transcutaneous electrical nerve stimulation.

CHAPTER 6

178 PHYSICAL EXAMINATION

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FURTHER RESOURCES

> Australian Pain Management Association: http://www.

UNIT 2

painmanagement.org.au/

> Heart Foundation (Australia) – Information for Professionals:

http://www.heartfoundation.org.au/Information-forprofessionals/pages/information-professionals.aspx

> Heart Foundation (New Zealand): http://www.heartfoundation.

org.nz/

REFERENCES

Abbey, J., Piller, N., De Bellis, A., Esterman, A., Parker, D., Giles, L., &

Lowcary B. (2004).The Abbey Pain Scale: A 1 minute numerical indicator for people with end stage dementia. Palliative Nursing, 10, 6–13.

Ahmadi, A., Bazargan-Hejazi, S., Zadie, A. H., Euasobhon, P., Ketumarn, R.,

& Mohammadi, R. (2016). Pain management in trauma: a review study. Journal of Injury and Violence Research, 8(2), 89–98. doi: 10.5249/jivr. v8i2.707

Akgun, F. S., Ertan, C., & Yucel, N. (2018). The prognastic efciencies of

modied early warning score and main emergency evaluation score for emergency department consumers. Nigerian Journal of Clinical Practice, 21(12), 1590–5. https://doi.org/10.4103/njcp.njcp_58_18

Australian Commission on Safety and Quality in Health Care (ACSQHC). (2017).

National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state. Retrieved 22 May 2022 from https://www.safetyandquality.gov.au/publications-andresources/resource-library/national-consensus-statement-essentialelements-recognising-and-responding-deterioration-persons-mental-state

Australian Commission on Safety and Quality in Health Care (ACSQHC).

(2021). Delivering and supporting comprehensive end-of-life care: a user guide. Retrieved from https://www.safetyandquality.gov.au/ our-work/end-life-care

Australian Commission on Safety and Quality in Health Care (ACSQHC).

(2022). National Consensus Statement: Essential elements for recognising and responding to acute physiological deterioration (3rd ed.). Retrieved 22 May 2022 from https://www.safetyandquality. gov.au/publications-and-resources/resource-library/nationalconsensus-statement-essential-elements-recognising-andresponding-acute-physiological-deterioration-third-edition

Australian Institute of Health and Welfare (AIHW). (2021). Interfaces

between the aged care and health systems in Australia – where do older Australians die? (June). Retrieved from https://www.aihw.gov. au/getmedia/56c1f616-8b2c-493e-8e1c-2db5083ad59d/aihw-age-106. pdf.aspx?inline=true May 8TH 2021

Berman, A., Snyder, S., Frandsen, G., Kozier, A., & Kozier, B. (2020). Kozier

and Erb’s fundamentals of nursing: Concepts, process and practice (5th Australian ed., 5th adaptation ed.). Frenchs Forest, NSW: Pearson Education Australia.

Burgess, D. J., Phelan, S., Workman, M., Hagel, E., Nelson, D. B., Fu, S. S.,

Widome, R., & van Ryn, M. (2014). The effect of cognitive load and patient race on physicians’ decisions to prescribe opioids for chronic low back pain: A randomised trial. Pain Medicine, 15(6), 965–74. doi: https://doi.org/10.1111/pme.12378

CareSearch. (2021). Care of the dying person – clinical evidence – nding

evidence – evidence. Retrieved 20 May 2022 from https://www. caresearch.com.au/tabid/6220/Default.aspx May 8th 2021

Hellier, J. L. (2016). The ve senses and beyond: The encyclopedia of

perception. ABC-CLIO. pp. 118–19. ISBN 1440834172.

> International Association for the Study of Pain:

http://www.iasp-pain.org

> New Zealand Pain Society: http://www.nzps.org.nz/ > World Health Organization Palliative WHO’s Cancer

Pain Ladder: http://www.who.int/cancer/palliative/ painladder/en/

Hockenberry, M., & Wilson, D. (2018). Wong’s nursing care of infants and

children (11th ed.). St Louis, Missouri: Elsevier.

Hui, D., & Bruera, E. (2014). A personalized approach to assessing and

managing pain in patients with cancer. Journal of Clinical Oncology, 32(16), 1640–6. http://doi.org/10.1200/JCO.2013.52.2508

International Association for the study of Pain (IASP). (2020). ISAP

announces revised denition of pain. Retrieved 29 March 2023 from https://www.iasp-pain.org/publications/iasp-news/iasp-announcesrevised-denition-of-pain/

Joint National Committee on Prevention, Detection, Evaluation, and

Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee (JNC). (2003). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (NIH Publication No. 03-5233). Archives of Internal Medicine, 157.

Keogh, E. (2014). Gender differences in the nonverbal communication

of pain: A new direction for sex, gender, and pain research? Pain, 155(10), 1927–31.

Keogh, E., & Arendt-Nielsen, L. (2004). Sex differences in pain. European

Journal of Pain, 8(5), 395–6.

Kochman, A., Howell, J., Sheridan, M., Kou, M., Shelton Ryan, E. E., Lee, S.,

Zettersten, W., & Yoder, L. (2017). Reliability of the Faces, Legs, Activity, Cry, and Consolability Scale in assessing acute pain in the pediatric emergency department. Pediatric Emergency Care, 33(1), 14–17. doi: 10.1097/PEC.0000000000000995

Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The

FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), 293–7.

National Heart Foundation of Australia. (2016). Guideline for the diagnosis

and management of hypertension in adults – 2016. Retrieved 26 May 2022 from https://www.heartfoundation.org.au/images/uploads/ publications/PRO-167_Hypertension-guideline-2016_WEB.pdf.

Palliative Care Australia. (2018). National Palliative Care Standards

(5th ed). Retrieved 20 May 2022 from https://palliativecare.org.au/ wp-content/uploads/dlm_uploads/2018/02/PalliativeCare-NationalStandards-2018_web-3.pdf

Safdar, B., Heins, A., Homel, P., Miner, J., Neighbor, M., DeSandre, P., &

Todd, K.H. (2009). Impact of physician and patient gender on pain management in the emergency department – A multicenter study. Pain Medicine, 10(2), 364–72. https://doi.org/10.1111/j.1526-

4637.2008.00524.x

Watt-Watson, J., Stevens, B., Garnkel, P., Streiner, D., & Gallop, R. (2002).

Relationship between nurses’ pain knowledge and pain management outcomes for their postoperative cardiac patients. Journal of Advanced Nursing, 36(4), 535–45. https://doi.org/10.1046/j.1365-

2648.2001.02006.x

CHAPTER

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MENTAL STATUS AND NEUROLOGICAL TECHNIQUES

LEARNING OUTCOMES

By the end of this chapter you should be able to:

1 describe the divisions of the nervous system and their functions 2 identify the characteristics of the most common mental health and neurological complaints 3 perform a mental status assessment and document the results 4 examine the neurological system in a systematic manner and document the results 5 explain the pathophysiology of any abnormal results obtained 6 discuss the clinical reasoning in evaluating outcomes of health assessment and physical examination

including documentation requirements for recording information, health education given and referral to other health practitioners as appropriate.

179

BACKGROUND

Hundreds of thousands of people across Australia and New Zealand receive a diagnosis related to mental health and neurological issues each year. The followingis a snapshot of incidence for some selected neurological and mental health disorders.

Alzheimer’s disease, the most common form of dementia, is estimated to have affected around 70000 New Zealanders in 2022 and is expected to increase to approximately 170000 by 2050 (Alzheimers New Zealand, 2022). In Australia, itisestimated that there were more than 400000 Australians living with dementia in2023 (Dementia Australia, 2023), nearly two-thirds of whom are women (AIHW, 2022a). This represents a signicant rise from 2009 gures, when approximately 245000 Australians had dementia. In 2023, there were more than 28000 people with younger-onset dementia (Dementia Australia, 2023). The impact on health and burden on life is very high for people as dementia progresses, but as yet the disease cannot be prevented, cured or slowed.

Parkinson’s disease is a progressive and degenerative neurological condition that impairs the control of movement due to insufcient quantities of dopamine. Parkinson’s disease affects approximately 100000 people in Australia, with an average of 38 new diagnoses of the disease every day (Shake It Up Australia Foundation, n.d.). Twenty per cent of people with Parkinson’s are under 50 years of age, and 10% are diagnosed before age 40 (Shake It Up Foundation Australia, n.d.). In New Zealand approximately 11000 people have Parkinson’s disease, and a recent study has predicted this to double by 2040 (New Zealand Brain Institute, n.d.). Prevalence of Parkinson’s differs by ethnic group; a New Zealand study found that people of European ancestry had the highest incidence of the disease in that country (Pitcher et al., 2018).

180 PHYSICAL EXAMINATION

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UNIT 2

Motor neurone disease (MND) begins with a weakness of the muscles in the hands or feet and eventually leads to generalised paralysis, including the inability to speak or swallow, usually leading to death within approximately three years (Dharmadasa et al., 2017). Motor neurone disease affects more than 2000 people in Australia, and an average of two people are diagnosed each day (Brain Foundation,

2022). Deaths are also rising from MND each year. In 2020, 741 people died from MND, signicantly more than the 457 people who died from MND in 2000 (MotorNeurone Disease Australia, 2020). In New Zealand, the number of people living with MND is around 1 in 15000, meaning there are currently over 400people living with the disease, 35% of whom are under 65 (Motor Neurone Disease New Zealand, 2020).

Stroke is a sudden-onset injury to brain cells that causes cell injury and death. Symptoms appear in the location of the body controlled by the injured part of the brain. as a result of arteries that either become blocked (ischaemic stroke) or burst (haemorrhagic stroke) in the brain (Stroke Foundation, 2018). More people are surviving stroke. By the year 2050, the number of new strokes each year in Australia is expected to top 50000; in 2020, the gure was 27428 (Stroke Foundation, 2020). In Australia, nearly 450000 people are living with the effects of stroke (Stroke Foundation, 2022). Prevalence of stroke in Aboriginal and Torres Strait Islander peoples is higher than for other populations, and in all populations it is 17% higher in regional locations than most metropolitan locations (Stroke Foundation, 2022). In New Zealand, stroke is the second biggest killer and the leading cause of serious disability in adults (Stroke Foundation New Zealand, n.d.). Over 9500 people experience stroke every year in New Zealand, and that number is predicted to rise by 40% by 2028 (Stroke Foundation New Zealand, n.d.). Over 75% of strokes are preventable.

force to the head or body (trauma) that results in impairments for the person (Brain Injury Australia, n.d.). Causes of blunt TBI include road trauma, falls, and being struck by an object or person (O’Reilly et al., 2022). Prevalence and incidence are difcult to determine because of the number of gradations in TBI severity, but it is estimated that around 200000 Australians suffer from a TBI, with 20000 of them hospitalised every year (Connectivity, n.d.). In Australia, males are more than twice as likely to sustain a TBI than females, and Indigenous people are twice as likely as non-Indigenous people to present to emergency departments with a TBI (Esterman et al., 2018). In New Zealand, incidence of TBI is signicantly higher in rural areas than in cities, with higher prevalence in males aged 0−34 and Maˉori people, than inthose of European descent (Bentley, Singhal, Christey & Amey, 2022).

Stroke occurs due to a disruption of blood supply to the brain cells,

Traumatic brain injury (TBI) is an injury to the brain caused by a direct physical

HEALTH EDUCATION

Preventing traumatic neurological injuries

Teach your consumers the importance of reducing the risk for traumatic injury:

> Always wear a helmet when riding a motorcycle or bicycle, rollerblading, skateboarding,

horseback riding, skiing and snowboarding.

> Buckle your seat belt whenever you are in a car, even if it is tted with airbags.

Avoidplacing children in car seats in the front passenger seat of the car if airbags areinstalled.

> When diving into water, look for signs indicating water depth and obey ‘No Diving’ signs.

Enter the water in a safer way (walk in) to identify how deep the water is to avoid other injuries (e.g. fractured lower limbs, pelvis or spinal injuries).

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 181

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Mental health disorders or mental illness are common in Australia and NewZealand. Each year, around one in ve people experience mental illness, and/or medium to high levels of mental distress (Mindframe, 2022; HPA, 2020), some experiencing more than one mental illness at a time. Here are some important considerations for health professionals:

> Over 2 in 5 (44%) of Australians experience a mental disorder in their lifetimes.

Anxiety disorders were the most prevalent (17%), followed by affective disorders

(8%) and substance use disorders (3%) (AIHW, 2022b). Women are more likely to

be diagnosed with depression, and men with substance abuse. Males 16−24years

old were the most likely to have experienced symptoms of a mental health

disorder in the previous 12 months (AIHW, 2022a).

> Mental health disorders are a leading cause of disability burden in Australia

and New Zealand, accounting for 13% of Australia’s disease burden in 2018

(the fourth highest) (AIHW, 2022b) and an estimated cost of $12 billion in

NewZealand (New Zealand Government, 2018). Major depression accounts

for more days lost to illness than almost any other physical or mental

healthdisorder.

> Maˉori and Pasika people have a higher prevalence of mental health disorders

than the general population in New Zealand, and much of this can be accounted

for by socio-demographic disparity (New Zealand Government, 2018).

ForPasika people, time spent in the New Zealand environment is positively

correlated with higher levels of mental health disorders. There is a substantial

difference in the mental health disease burden on Aboriginal and Torres Strait

Islander people compared with non-Indigenous Australians, with the years of

healthy life lost to mental and substance use disorders in First Nations people

found to be 2.4 times higher (AIHW, 2022b).

The nervous system controls all body functions and thought processes and, therefore, will be discussed rst. The complex interrelationships among the various divisions of the nervous system permit the body to maintain homeostasis; to receive, interpret and react to stimuli; and to control voluntary and involuntary processes, including cognition.

CHAPTER 7

ANATOMY AND PHYSIOLOGY

The structure and function of the central nervous system and the peripheral nervous system are discussed.

Macrostructure

The scalp and skull are two protective layers covering the brain. The scalp performs a unique function in that it moves freely, helping to protect and cushion the head from traumatic injury. The skull is a rigid, bony cavity that has a xed volume of approximately 1500mL.

Meninges

There are three layers of meninges (protective membranes), known as the dura mater, arachnoid mater and pia mater, located between the brain and the skull ( The dura mater is the thick, tough outermost layer. Below the dura mater is a small serous space known as the subdural space.

The arachnoid mater lies between the dura mater and the pia mater. Below the arachnoid mater is the subarachnoid space, where cerebrospinal uid (CSF) is circulated. Portions of the arachnoid mater, called arachnoid villi, project into the subarachnoid space (Figure 7.1). These serve to absorb CSF.

The pia mater is thin and vascular. It is the innermost layer of the meninges. Thepia mater helps form the choroid plexuses, which are vascular structures locatedin the ventricles of the brain that produce CSF.

Figure 7.1).

182 PHYSICAL EXAMINATION

Superior sagittal sinus

Subarachnoid space

Falx cerebri Arachnoid villi

Skin

Pia mater

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UNIT 2

Fat

Periosteum

FIGURE 7.1 Location and structure of the meninges

Bone

Dura mater

Arachnoid mater

Subdural space

Central nervous system

The brain and the spinal cord make up the central nervous system (CNS). The brain is divided into four main components: the cerebrum, the diencephalon, the cerebellum and the brain stem. Each of these areas is subdivided into various anatomic areas.

Cerebrum

The cerebrum is the largest portion of the brain. It is incompletely divided into right and left hemispheres by the longitudinal connected by the corpus callosum, which serves as a communication link between the left and right hemispheres.

The cerebral cortex, or the outermost layer of the cerebrum, contains grey matter. Higher cognitive functioning is dependent on the cerebral cortex and its interaction with other parts of the nervous system. The cerebral cortex is involved in memory storage and recall, and conscious understanding of sensation, vision, hearing and motor function. The basal ganglia are located deep within the cerebral hemispheres and function intricately with the cerebral cortex and the cerebellum in regulating motor activity.

Each cerebral hemisphere is divided into four lobes: the frontal, parietal, temporal and occipital lobes. The locations and functions of each of the cerebral lobes are illustrated in Figure 7.2. A fth lobe called the limbic lobe is anatomically part of the temporal lobe and is involved in emotional behaviour and self-preservation.

ssure. The two hemispheres are

Diencephalon

The diencephalon, a relay centre for the brain, is composed of the thalamic structures: the thalamus, the epithalamus and the hypothalamus. The hypothalamus is important in body temperature regulation, pituitary hormone control and autonomic nervous system responses. It also plays a role in behaviour via its connections with the limbic system.

Cerebellum

The cerebellum lies inferior to the occipital lobe and behind the brain stem. It is divided into two lateral lobes and a medial part called the vermis. The vermis is concerned primarily with maintenance of posture and equilibrium. Each cerebellar hemisphere is responsible for coordination of movement of the ipsilateral (same) side of the body.

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 183

Parietal lobe

Brain stem

Includes thalamus, epithalamus, hypothalamus

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Frontal lobe Higher intellectual function Speech production Motor control

Broca’s area Motor speech

Temporal lobe Hearing Memory Speech perception

Respiratory and cardiac regulation Level of awareness Reticular activating system (RAS) Includes midbrain, pons, and medulla oblongata

Primary somatic sensory area

Midbrain Pons

Medulla oblongata

Spinal cord

Wernicke’s area Auditory comprehension

Occipital lobe Vision Visual perception

Diencephalon

Body temperature regulation Cerebellum Coordination

Pituitary hormone control

Autonomic nervous system responses

CHAPTER 7

FIGURE 7.2 The locations and functions of the cerebral lobes, diencephalon, cerebellum and brain stem

Brain stem

The brain stem is located immediately below the diencephalon and is divided into the midbrain, the pons and the medulla oblongata. The reticular formation, a complex network of sensory bres in the brain stem, contains centres that control respiratory, cardiovascular and vegetative functions. The ascending reticular activating system (RAS) is located in the brain stem and extends to the cerebral cortex. The RAS is mostly excitatory and is essential for arousal from sleep, maintaining attention, and perception of sensory input.

The midbrain contains the nuclei of cranial nerves III (oculomotor) and IV(trochlear), which are associated with control of eye movements. The pons is located between the midbrain and the medulla oblongata. Sensory and motor nuclei of cranial nerves V (trigeminal), VI (abducens), VII (facial) and VIII (acoustic) are located in the pons. The medulla oblongata is located between the pons and the spinal cord. It contains the nuclei of cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal accessory) and XII (hypoglossal). Also located in the medulla oblongata are the centres for reexes such as sneezing, swallowing, coughing and vomiting, aswell as the centres regulating the respiratory and cardiovascular systems.

Spinal cord

The spinal cord is a continuation of the medulla oblongata. It exits the skull at the foramen magnum and begins at the upper border of the atlas (C1), continuing downwards to the conus medullaris, a tapered ending of the cord at about the level of the rst or second lumbar vertebrae (see Figure 7.3A). From the conus medullaris, a connective tissue lament called the ‘lum terminale’ continues down to its attachment at the coccyx (see Figure 7.3B).

A cross-section of the spinal cord will show that the central part of the cord isgrey matter. The grey matter is in the shape of an H. White matter surrounds thegrey matter.

184 PHYSICAL EXAMINATION

Coccyx

Cerebellum

A. The spinal cord and spinal nerves

Spinal cord

Motor

neurone

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Thalamus

UNIT 2

Cervical

enlargement

Lumbar

enlargement

Filum

terminale

C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8

T9 T10 T11 T12

L1 L2 L3 L4

L5 S1 S2 S3 S4 S5

Coccyx

Conus medullaris

Cauda equina

Filum terminale

B. Close-up of the caudal region of the spinal nerves

FIGURE 7.3 The spinal cord

cortex

Decussation

Corticospinal tract

Upper motor neurone

Lower motor

Medulla

FIGURE 7.4 Motor pathways of the CNS

The grey matter is made up of nerve cell bodies and short segments of unmyelinated bres. The posterior portion of the H is called the dorsal horn, and the anterior portion is the ventral horn. The dorsal horn contains cell bodies of sensory (afferent) neurones, which receive and transmit sensory messages from the afferent bres in the spinal nerve. The ventral horn contains cell bodies of motor (efferent) neurones, which send axons into the spinal nerves and innervate skeletal muscles, carrying signals from the brain and the spinal cord.

Motor pathways of the CNS

There are three motor pathways in the CNS: the corticospinal or pyramidal tract, the extrapyramidal tract and the cerebellum.

Pyramidal tract

The corticospinal pathway descends from the motor area of the cerebral cortex, through the midbrain, the pons and the medulla. At the level of the medulla, 90% of the bres of the corticospinal tract decussate (cross) to travel down the opposite side of the spinal cord, becoming the lateral corticospinal tract. The remaining bres travel down the spinal cord in a tract known as the anterior corticospinal tract. Fibres of the lateral corticospinal tract synapse in the anterior horn (grey matter) at all levels of the cord just before they leave the cord (Figure 7.4). The motor neurones above this synapse in the anterior horn are known as upper motor neurones. Upper motor neurones connect the cerebral cortex with the anterior horn and are entirely contained within the CNS. Lower motor neurone cell bodies are located in

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 185

Sensory

temp.

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the anterior horn, where they connect with the corticospinal tract. Lower motor neurones innervate skeletal muscle at the myoneural junction. They are responsible for purposeful, voluntary movement.

Extrapyramidal tract

This pathway includes all motor neurones in the motor cortex, basal ganglia, brain stem and spinal cord that are outside the corticospinal, or pyramidal, tract (henceforth referred to as extrapyramidal). The extrapyramidal tract is responsible for controlling body movement, particularly gross automatic movements (e.g.walking), and for controlling muscle tone.

Sensory pathways of the CNS

The sensory portion of the peripheral nervous system consists of afferent neurones divided into somatic afferent and visceral afferent neurones. Somatic afferent bres originate in skeletal muscles, joints, tendons and skin. Visceral bres originate in the viscera. Both types of afferent bres carry impulses from both the external andthe internal environments to the CNS.

Afferent bres containing impulses, or messages, enter the spinal cord through the dorsal roots. From the spinal cord the message travels via the spinothalamic tracts or the posterior column to the thalamus and sensory cortex. The thalamus receives the message and interprets a general sensation. The impulse synapses with another sensory neurone to the sensory cortex, where the message is fully interpreted (

Figure 7.5).

cortex

CHAPTER 7

Decussation

Medulla

Posterior column

Position and vibration

Fine touch

FIGURE 7.5 Sensory pathways of the CNS

Anterior spinothalamic

Crude touch

Thalamus

Lateral spinothalamic

Pain /

Spinal cord

Spinothalamic tracts

In the spinal cord, the spinothalamic tracts synapse with a second sensory neurone and then decussate to the opposite side. The message is then carried up the tract. The lateral spinothalamic tract carries pain and temperature sensations, and the anterior spinothalamic tract carries the sensations of crude or light touch.

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