i bc27f85be50b71b1 (78 page)

Distal radius;

Closed reduction with

See Distal radius;

illtra-articul:ar,

external fixation

intra-articular, above

comminuted

ORIF

Bone grafting

Splinr

:t: = with or widlOuf; l',,rWB = non weight bearing; ORIF = open-reduction internal fixation.

Sou rce: Adapted from DL Fernandez, AK Palmer. Fracture of the Distal Radius. In OP

Green, RN Hotchkiss, WL Pederson (eds), Green's Operative Hand Surgery, Vol. I (4th

cd). New York: Churchill Livingstone, 1998;950.

4

Nervous System

Michele P. West

Introduction

The nervous system is linked ro every system of the body and is

responsible for the integration and regulation of homeostasis. It is

also involved in the action, communication, and higher cortical

function of the body. A neurologic insult and its manifestations

therefore have the potential ro affect multiple body systems. To

safely and effectively prevent or improve the neuromuscular, systemic, and functional sequelae of altered neurologic status in the acme care setting, the physical therapist requires an understanding

of the neurologic system and the principles of neuropathology. The

objectives of this chapter are ro provide the following:

1 .

A brief review of the structure and function of the nervous

system

2.

An overview of neurologic evaluation, including the physi-

cal examination and diagnostic tests

3.

A description of common neurologic diseases and disor-

ders, including clinical findings, medical and surgical management,

and physical therapy interventions

259

260 AClffE CARE HANDBOOK FOR PHYSICAL ll-IERAPISTS

Structure and Function of the Nervous System

The nervous system is divided as follows:

1 .

The central nervous system (CNS), consisting of the brain

and spinal cord

2.

The peripheral (voluntary) nervous system, consisting of

efferent and afferent somatic nerves outside the CNS

3.

The autonomic (involuntary) nervous system, consisting of

the sympathetic and parasympathetic systems

Central Neroous System

Brain

The brain is anatomically divided into the cerebral hemispheres,

diencephalon, brain stem, and cerebellum. A midsagittal view of the

brain is shown in Figure 4-1A. Although each portion of the brain

has its own function, it is linked to other portions via traces and

rarely works in isolation. When lesions occur, disruption of these

functions can be predicted. Figure 4- 1 B shows the basal ganglia and

rhe internal capsule. Tables 4-1 and 4-2 describe the basic structure,

function, and dysfunction of the cerebral hemispheres, diencephalon, brain stem, and cerebellum.

Protective Mechanisms

The brain is protected by the cranium, meninges, ventricular system,

and blood-brain barrier.

Cranium

The cranium encloses the brain. It is composed of eight cranial and

14 facial bones connected by sutures and contains a pproximately

85 foramen for the passage of the spinal cord, cranial nerves

(CNs), and blood vessels.' The cranium is divided into rhe cranial

vault, or calvaria (the superolateral and posterior aspects), and the

cranial floor, which is composed of fossae (the anterior fossa sup

POrtS the frontal lobes; the middle fossa supports the temporal

lobes; and the posterior fossa supports the cerebellum, pons, and

medulla).2

NERVOUS SYSTEM

261

............... """'.

-""" ..

MlClIO'ML",., I'OITCltmlAL

GnU)

.. .......

A

Inlemal

B

Figure 4-1. A. Medial (midsagittal) view of a hemisected brain. (\Vith permission from S Gilman, S W Newman ledsJ. Manter and Gatz's Essentials of Neuroanatomy and Neurophysiology [7th edJ. New York: Oxford University

Press, 1987;9.) B. Horizontal section of the cerebrum showing the basal gang[ia. ( With permission from RJ Love. we Webb [eds[. Neuro[ogy for the Speech-Language Pathologist [4th ed]. Boston: Butte nvorth- Heinemaml,

2001 ;38.)

Table 4-1. Structure, Function, and Dysfunction of the Cerebral Hemispheres

N

'"

N

Lobe of

>

Cerebrum

Structure

Function

Dysfunction

g '"

Frontal

Precentral gyrus

Voluntary mmor cortex of contralateral

Contralateral mono- or hemiparesis

()

>

lobe

face, arm, trunk, and leg

or hemiplegia

"

'"

Supplementary

Advanced motor planning

Conualateral head and eye paralysis

J:

>

motor area

Contralateral head and eye turning

Z

"

'"

(connections to cranial nerves Ill, N, VI,

"

"

IX, X, and Xll nuclei)

'"

�

Prefrontal pole

Personaliry center, including abstract ideas,

Loss of inhibition and demonstradon of

"

"

concern for mhers, conscience, initia-

antisocial behaviors

�

J:

rive, judgment, persistence, and planning Ataxia, primitive reflexes, and hypertoniciry

-<

�

Paracentral

Bladder and bowel inhibition

Urinary and bowel incontinence

n

>

lobule

r

-l

Broca's a rea

D: Mmor speech center

Broca's (expressive) aphasia

J:

'"

"

ND: Appreciation of intonation and

>

�

gestures with vocalization

�

Parietal

Postcentral gyrus

Somatosensory cortex of contralateral

Contralateral sensation loss

lobe

pain, posture, proprioception, and touch

of arm, trunk, and leg

Parietal pole

D: Abiliry to perform calculations

D: Acalculia, agraphia, finger agnosia