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Juice Plus + Provides the nutritional essence of 17 different fruits, vegetables The latter two plexuses, which innervate the lower limbs, are often considered together and grains in a convenient as the lumbosacral plexus. This text will focus on the brachial plexus and lumbosacral capsule form. Click here to plexus from level T12/L1 to S1. learn more. Spinal nerves have motor fibers and sensory fibers. The motor fibers innervate certain muscles, while the sensory fibers innervate certain areas of skin. A skin area innervated by the sensory fibers of a single nerve root is known as a dermatome. A group of muscles primarily innervated by the motor fibers of a single nerve root is known as a myotome. Although slight variations do exist, dermatome and myotome patterns of distribution are relatively consistent from person to person. Nerves are typically injured through compression or tensile forces. When a nerve root in the brachial or lumbosacral plexus is damaged, certain patterns of motor and sensory deficits occur in the corresponding limbs. Dermatomes and myotomes are used to evaluate these deficits. To test for nerve root damage, the corresponding dermatomes supplied by that nerve root may be tested for abnormal sensation and the myotomes may be tested for weakness. To test for sensitivity of a dermatome, a pinwheel, cotton ball, paper clip, the pads of the fingers or fingernails may be used. The patient should be asked to provide feedback regarding their response to the various stimuli. Following are possible responses to abnormal sensation: Hypoesthesia (decreased sensation). Hyperesthesia (excessive sensation). Anesthesia (loss of sensation). Paresthesia (numbness, tingling, burning sensation). Dermatome patterns and their corresponding root nerve spinal derivation are illustrated below: To test for decreased muscle strength, the following standardized grading scale can be used: Grade Value Muscle Strength
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5 4 3 2 1 0
Complete range of motion (ROM) against gravity with full resistance Complete ROM against gravity with some resistance Complete ROM against gravity with no resistance; active ROM Complete ROM with some assistance and gravity eliminated Evidence of slight muscular contraction, no joint motion evident No evidence of muscle contraction
Muscles should be tested on a regular basis in order to determine improvement or deterioration of function. It should be noted that the unaffected side should always be tested as well as the affected side for comparison. The following section will identify the myotomes within the neurologic levels of the brachial and lumbosacral plexuses, provide detailed illustrations of each level (to include additional illustrations of dermatomal patterns), and site tests which can be performed to check for muscle strength at each level. (Illustrations of reflex testing at each level will also be included, but will not be discussed in this text.)
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patients anterior leg above the ankle. Offer resistance to knee extension, and note the amount of resistance the patient can overcome. Test both limbs in order to compare the strength of each, and evaluate them according to the standardized grading scale for muscle strength. Following is a detailed illustration of the dermatomes of the lower extremities and of the above- mentioned test for knee extension. Neurologic Level L4: The muscle predominantly innervated at this root nerve level is the tibialis anterior, which does dorsiflexion with inversion. To test this muscle, ask the patient to sit on the treatment table. With one hand, stabilize the patients leg by holding it just above the ankle. Instruct the patient to dorsiflex and invert h/her foot. With your free hand, hold the patients foot and ask h/her to resist your attempt to move the foot into plantarflexion and eversion. Test both feet in the same manner in order to compare the strength of each, and evaluate them according to the standardized grading scale for muscle strength. Following is an illustration of neurologic level L4 and of the above-mentioned muscle test for dorsiflexion with inversion: Neurologic Level L5: The muscles found within this myotome are the extensor hallucis longus (big toe extensor), extensor digitorum (heel walk) and the gluteus medius (the most powerful abductor of the hip.) A common test for hip abduction is to ask the patient to lie on h/her side with both legs extended, careful not to flex at the hip. Place one hand on h/her pelvis to stabilize it and ask h/her to fully abduct it. Place your free hand on the lateral knee at the joint and ask the patient to resist your attempt to push the leg into adduction. Test both sides in the same manner in order to compare the strength of each, and evaluate them according to the standardized grading scale for muscle strength. Following is an illustration of neurologic level L5 and of the above-mentioned test for hip abduction: Neurologic Level S1: The muscles found within this myotome are the peroneus longus (plantarflexion with eversion) peroneus brevis (toe walk) and gluteus maximus (hip extension.) To test for hip extension, ask the patient to lie face down on the treatment table and bend the leg at the knee (this relaxes the hamstrings.) Stabilize the hip by placing your forearm over the iliac crest, and ask the patient to hyperextend h/her hip. Place your other hand on the thigh below the gluts and ask the patient to resist your attempt to push the thigh back down on the table. Test both sides in the same manner in order to compare the strength of each, and evaluate them according to the standardized grading scale for muscle strength. Following is an illustration of neurologic level S1 and of the above-mentioned test for hip extension. As healthcare professionals, Therapeutic Massage Therapists need to be as educated and knowledgeable about the workings of the human neuromuscular system as possible. Knowledge not only enables us to better educate our clients as to the injury and recovery process, it also helps us facilitate our clients recovery process from myofascial pain and dysfunction. Having knowledge of dermatomes and myotomes may help us to differentiate between dysfunction resulting from myofascial trigger points and that resulting from nerve root injury. Myofascial trigger points dont match dermatomal and myotomal patterns; knowing the patterns of each may help a Massage Therapist to discern between them. However, since numbness and tingling may be due to either myofascial tightness impinging on a nerve or nerve root damage, and since Massage Therapists do not diagnose, its important to refer a client to a physician for a definitive diagnosis of symptoms.
BIBLIOGRAPHY
1. K. Anderson, J. Hall. Sports Injury and Management: Philadelphia: Williams & Wilkins, 1995. 2. Cramer, A. Darby. Basic and Clinical Anatomy of the Spine, Spinal Cord, and Ans. Carlsbad, California: Mosby, 1995. 3. Hoppenfeld, Stanley. Orthopaedic Neurology. Philadelphia: J.B. Lippincott Co., 1997. 4. Marieb, Elaine N. Essentials of Human Anatomy and Physiology, 4 th ed. Redwood City, California: The Benjamin/Cummings Publishing Co., Inc., 1993. 5. Tyldesley, J. Grieve. Muscles, Nerves and Movement, Kinesiology in Daily Living. Oxford, London: Blackwell Scientific Publications, 1989.
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