NMS
5/19/99

Motor
•	looking for weakness
1.	strength
2.	tone
•	do not necessarily go together
•	in health they tend to go together
•	in elderly, may not have tone, but have strength
•	in a lesion state (spastic paralysis) strength goes down and tone goes up
•	evaluate two pathways—pyramidal and extrapyramidal
•	get rid of pyramidal pathway and decrease strength
•	get rid of extrapyramidal pathway and increase tone—mainly inhibit LMN
•	UNM lesion—pyramidal and extrapyramidal problems
•	4 A's to a brain problem
1.	agnosia—sensory discrimination problem—akinesthesia (don't know where my finger is in space), light touch, pain is not a good example b/c pain is detected in hypothalamus
2.	aphasia—loss of ability to communicate
3.	ataxia—lesion in cerebellum, pronator sign, Romberg sign, rapid/alternating movements; not correctable by vision; alcohol affects purkinje fibers of cerebellum
4.	apraxia—can't do; weakness and/or paralysis

•	cranial nerve lesions
•	(+) Babinski sign is associated w/apraxia—purely pyramidal—UMN lesion
•	can recover from a (+) babinski
•	in MS w/demyelination and remyelination of peripheral nerves
•	if OD of marijuana, have (+) babinski then return to normal later
•	cauda equina syndrome—not cord compression b/c cord ended at L2—compression on LMN
•	weakness
•	loss of tone
•	absence of reflexes
•	(-) babinski sign

UMN lesion
1.	strength decreases
2.	tone increases
•	annulospiral is the greatest exciter w/a UMN; the muscle spindle doesn't like to be lengthened (stretch)
•	has IA nerve wrapped around it
•	leads to contraction of the muscle which takes stretch off of the muscle spindle
•	has about 10,000 attachments on the MN some inhibit and some facilitate
•	MN is busy w/activity at all times
•	can add a (+) or subtract a (-)
•	lesions subtract and create a deficit
•	facet irritation can lead to muscle spasm by activating the MN
•	subluxation complex that affects the capsule as an irritant can increase facilitation onto the CNS leading to muscle spasm

LMN
•	same as MN
•	located in the anterior horn
•	exits by way of the IVF and goes out to a skeletal muscle
•	myoneural junction
•	all cause weakness, atrophy and decreased tone (disuse)
•	polio is a LMN lesion and leads to atrophy of the muscle
•	root can be afflicted by a radiculopathy
•	spur (osteophyte)
•	disc bulge
•	ligament hypertrophy
•	inflammation
•	infection
•	IVF narrowing
•	plexus
•	thoracic outlet syndromes
•	a number of mechanical reasons that the plexus can be afflicted
•	peripheral nerves
•	peripheral neuropathies
•	carpal tunnel—median nerve
•	lateral femoral cutaneous nerve—meralgia paresthetica
•	ulnar neuropathies
•	tarsal tunnel syndrome
•	diabetes
•	myoneuroal junction
•	myasthenia gravis
•	ptosis
•	weakness
•	atrophy (disuse)
•	decrease tone
•	decrease reflex
•	muscle spindle

DJD—degenerative joint disease
•	C5 is first afflicted
•	decrease tone
•	decrease reflex

•	Problem in afferent sensory branch, how will the tone be affected, lose stimulus, tone will go down, lose reflex, strength will not be affected—purely sensory loss
•	DRG—shingles, tabes dorsalis, ligamentum flavum hypertrophy—only affects the sensory portion—sometimes trauma can afflict
•	99% have LMN will affect both motor and sensory

EMG
•	electro-myogram
•	superficial and needle (done by hospitals)
•	best and most conclusive on motor unit disease
•	things that you may not be able to find in office
•	nerve conduction velocity—usually goes along w/EMG
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