acnb competency requirement guide-2014 exam competency requirement guide...3....

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.