Upload
others
View
12
Download
0
Embed Size (px)
Citation preview
ACNBCompetencyRequirementGuide
2019Materials to be used to assist Candidates to prepare for the 2019 ACNB certifying examination for the designation of Chiropractic Neurologist.
AmericanChiropracticNeurologyBoard
1 | P a g e
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
2 | P a g e
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
3 | P a g e
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
4 | P a g e
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
5 | P a g e
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
6 | P a g e
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
7 | P a g e
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
8 | P a g e
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
9 | P a g e
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
10 | P a g e
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
11 | P a g e
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
12 | P a g e
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
13 | P a g e
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
14 | P a g e
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
15 | P a g e
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.
16 | P a g e
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
17 | P a g e
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
18 | P a g e
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
19 | P a g e
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
20 | P a g e
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
21 | P a g e
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
22 | P a g e
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
23 | P a g e
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
24 | P a g e
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
25 | P a g e
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
26 | P a g e
L. Musclepain1. Spasm2. Pull3. Tear
27 | P a g e
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
28 | P a g e
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
29 | P a g e
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,
30 | P a g e
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
31 | P a g e
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
32 | P a g e
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.
33 | P a g e
c. Limbicsystemcontributionsd. Corticalcentersofpainappreciationregarding:
3. Location4. Severityofreceptoractivation5. Effect
B. OtherC. Situational:post‐surgical,cancer,childrenissuesetc.westernpro‐inflammatory
diet,trauma,gamblingaddictions,poornutrition,domesticviolence,elderabuse,neglect
34 | P a g e
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
35 | P a g e
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
36 | P a g e
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
37 | P a g e
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
38 | P a g e
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
39 | P a g e
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
40 | P a g e
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
41 | P a g e
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
42 | P a g e
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
43 | P a g e
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
44 | P a g e
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
45 | P a g e
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
46 | P a g e
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
47 | P a g e
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
48 | P a g e
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
49 | P a g e
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.
50 | P a g e
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.