MATHEMAGICAL CLINICAL NEUROLOGY

1. MATHEMAGICAL CLINICAL NEUROLOGY Prof.A.V.SRINIVASAN M.D.D.M. Ph.D.F.I.A.N. F.A.A.N. Additional Prof.of Neurology Madras Institute of Neurology TO TEACH IS AN HONOUR THAT IS SACRED MIN - MOTTO

2. Mathemagical Clinical Neurology ABSTRACT OBJECTIVE: To construct a teaching model for easier clinical neurological examination to help the medical students and paramedical personal to understand the neuroanatomy and etiopathological disorders of the nervous system. BACKGROUND: Neurophobia is a fear of neural sciences and clinical neurology and half of the medical students and paramedical personal experience this disorder during their training. We have evolved an easy, faster ten step approach in clinical neurological examination using mathematical numbers. METHODS: One characterizes consciousness / mind, Two represents the two cerebral hemispheres and Three, the major functions of the brain namely cognition, conation and affect. Four represents the four lobes and four ventricles. Five represents five special senses. Six explains the six major functional systems of the brain, basal ganglia (programmer), cerebellum (computer), cerebral and its efferents (output), sensory systems (input), autonomic nervous system (emergency situations) and the limbic system (integrator of all). Seven characterizes the LMN (anterior horn cells anterior nerve root posterior nerve root  peripheral nerve  neuromuscular junction  muscle  intracellular organelles. Eight represents eight language disorders, four with normal repetition and four with abnormal repetition. The Nine etiologies in fingertips Thumb (Tumour, Toxin, Trauma), Index Finger (Infection), Middle finger (Metabolic), Diamond finger (Demyelination), Little finger (vascular) and Hand (Hereditary and nutritional disorders). Ten represents the ten pairs of cranial nerves with olfactory and optic nerves, which are extensions of brain. CONCLUSION: This faster and easier method of neurological examination will help the epidemiological field workers. Ten step approach of clinical neurology teaching will replace Neurophobia with Neurophilia, and will effectively integrate the basic sciences with clinical neurology.

3. ALBERT EINSTEIN EVERY THING SHOULD BE MADE SIMPLE, BUT NOT SIMPLER -

4. AIMS AND OBJECTIVES To Evolve a teaching model for easier, faster clinical neurological examination to help the Neuroscientists including medical students and paramedical personal to understand the Neuroanatomy, Neurophysiology and Etiopathological approach of the nervous system.

5. BACKGROUND Neurophobia is a fear of Neuro sciences and clinical neurology. Most of the medical students and paramedical personal experience this disorder during their training. Physical examination in the chapter of the nervous system in Hutchison’s Clinical methods 2002 W.B.Saunders,London, expanded more than 50% from 19,110 words to 29,632 words,while in Respiratory and Cardiovascular system decreased by 47% and 70% respectively when compared to the first edition of clinical methods-A guide to the practical study of medicine in 1897(Alisdair Mcneill-Practical neurology,2005,5,180-3).Clinical evaluation of the nervous system becoming too unwieldy for routine use and certainly for the modern medical student curriculum.We have evolved an easy, faster ten step approach in clinical neurological examination using mathematical numbers

6. MATHEMAGICAL CLINICAL NEUROLOGY ONE - CONSCIOUSNESS/MIND TWO - CEREBRAL HEMISPHERES THREE - FUNCTIONS OF BRAIN COGNITION CONATION AFFECT FOUR - LOBES OF BRAIN FIVE - SPECIAL SENSES

7. SIX - UPPER FUNCTIONAL MOTOR NEURON SYSTEMS OF BRAIN SEVEN - LOWER FUNCTIONAL MOTOR NEURON SYSTEMS OF BRAIN EIGHT - LANGUAGE DISORDERS NINE - ETIOLOGY TEN - TEN CRANIAL NERVES WITH OLFACTORY AND OPTIC NERVES – EXTENSIONS OF BRAIN

8. TEACHING METHODS-TEN STEPS I AM HAPPY THAT PROF.A.V.SRINIVASAN HAS THOUGHT IT FIT TO INTRODUCE A NEWER CONCEPT OF NEUROLOGICAL EXAMINATION WHICH IS BASED ON AREAS OF ANATOMY AND FUNCTION IN A STEP WISE FASHION STARTING AT THE CORTICAL LEVEL AND RIGHT DOWN TO THE NEUROMUSCULAR LEVEL AND INCURS THE ABILITY TO TRANSLATE THIS INTO A RESORTMENT PATTERN IN NEUROLOGICAL INTERPRETATION.THIS IS A NEW CONCEPT WHICH,HE HAS ENTERED, HAS DONE EXTREMELY WELL TO SHOW IT TO HIS COLLEAGUES.I AM SURE THAT THE ARDENT GROUP OF STUDENTS OF NEUROLOGY AND EVEN STUDENTS OF INTERNAL MEDICINE AND NEUROSURGEONS WILL BENEFIT WITH THIS NEW TECHNIQUE,METHOD OF A WAY OF EVALUATING NEUROLOGICAL DISEASES Prof.K.V.THIRUVENGADAM B.Sc,M.D.,D.Sc(hon).F.R.C.P(EDIN), FAMS,FCCP,FCAI FORMER DIRECTOR OF MEDICINE MADRAS MEDICAL COLLEGE AND GOVT.GENERAL HOSPITAL CHENNAI,TAMIL NADU, INDIA .

9. CLINICAL DIAGNOSIS IN NEUROLOGY IS USUALLY ARRIVED AT BY DETECTING SIGNS WHICH INDICATE DISTURBANCE OF A FUNCTION IN THE CEREBRAL SPINAL AXIS.IN THE PRESENT SYSTEM OF DIAGNOSIS,BY VIRTUE OF COMBINING POSITIVE SIGNS TO FIND A MEANINGFUL LOCATION IN THE CENTRAL NERVOUS SYSTEM OR THE PERIPHERAL NERVOUS SYSTEM.THIS METHOD OF ARRIVING AT CLINICAL DIAGNOSIS HAS STOOD THE TEST OF TIME BUT HAS AN INHERENT DEFECT BEING TIME CONSUMING. THE NEW SYSTEM BY VIRTUE OF DETECTING THE DEFECTS IN THE SYSTEM STRAIGHT WAY BY VIRTUE OF THE SIGNS PICKED UP AT THE TIME OF THE EXAMINATION HELPS IN THE BEDSIDE DIAGNOSIS EASIER AND QUICKER.ELECTROPHYSIOLOGICAL STUDIES AND IMAGING TECHNIQUES ARE USED ONLY TO CONFIRM THE CLINICAL IMPRESSION GIVING EASIER RECOGNITION OF ANATOMICAL LEVELS OF INVOLVEMENT. DEMONSTRATION OF SOME OF THE CASES EXAMINED BOTH WAYS REVEAL THE ACCURACY OF DIAGNOSIS MORE IN THIS SYSTEM AS AGAINST THE CONVENTIONAL ONE. THIS SYSTEM WILL HELP LEARNING AND DIAGNOSING NEUROLOGICAL AILMENTS.IT IS BOTH COMPLIMENTARY AND PRIMARY IN CLINICAL EXAMINATION AT THE BED SIDE PROBABLY GIVING A BETTER INSIGHT TO THE STUDENT REGARDING THE FUNCTIONAL DERANGEMENT CORRELATING WITH FUNCTIONAL ANATOMY AND WILL BE USEFUL IN EVALUATING NATURAL EVOLUTION OF MANY NEUROLOGICAL DISORDERS. WITH THE REDUCTION OF TIME IN THE PRIMARY AND FOLLOW UP EXAMINATION,PATIENT CARE IMPROVES.THIS SYSTEM IS ALSO COMPUTER COMPATIBLE BY PROPER DATA COLLECTION AND ANALYSIS. THIS SYSTEM WILL BE A GREAT BOON IN HELPING QUICKER AND MORE SPECIFIC TREATMENT SCHEDULES. Prof.K.JAGANNATHAN M.D.,D.T.M.,F.R.C.P.,F.A.M.S Former Head and Prof. of Neurology Madras Medical College and Govt.Gen.Hospital Chennai,Tamilnadu, India

10. GLASGOW COMA SCALE EYE OPENING SPONTANEOUS 4 TO LOUD VOICE 3 TO PAIN 2 NIL 1 VERBAL RESPONSE ORIENTED 5 CONFUSED,DISORIENTED 4 INAPPROPRIATE WORDS 3 INCOMPREHENSIBLE SOUNDS 2 NIL 1 MOTOR RESPONSE OBEYS 6 LOCALIZES 5 WITHDRAWS(FLEXION) 4 ABNORMAL FLEXIONPOSTURE 3 EXTENSION POSTURE 2 NIL 1 RANCHO LOS AMIGOS COGNITIVE SCALE NO RESPONSE 1 GENERALIZED RESPONSE 2 LOCALIZED RESPONSE 3 CONFUSED/AGITATED 4 CONFUSED- NOT APPROPRIATE 5 CONFUSED-APPROPRIATE 6 AUTOMATIC-APPROPRIATE 7 PURPOSEFUL-APPROPRIATE 8 EXAMINATION OF CONSCIOUSNESS(COMA)

11. LEFT HEMISPHERE(VERBAL)ANALYSISDEDUCTIONFACTSLOGICAL ORDER MATHEMATICPRACTICAL RIGHT HEMISPHERE (VISUAL) ARTISTIC CREATIVE HOLISTIC INTUITION IDEAS IMAGINATION SPATIAL

12. THREE FUNCTIONS COGNITION -- Perception & Thinking CONATION -- Movement AFFECT -- Motor expression of Emotions

13. EXAMINATION OF COGNITIVE DECLINE-DEMENTIA • IDEAL BED SIDEMMSE • RESEARCH ICD-10 DSM-IV NINCDSADRDA ADDTC-VASCULAR DEMENTIA

14. CONATION–MOVEMENTSECOND FUNCTION OF BRAIN • WHAT ARE THE MOVEMENTS? • IDENTIFY THE OVERALL SYNDROME. • DECIDE THE DISEASE.

15. AFFECT- MOTOR EXPRESSION OF EMOTIONSTHIRD FUNCTION OF BRAIN EXAMINATION OBJECTIVE MEASUREMENT DIFFICULT, SUBJECTIVE SCALES ARE AVAILABLE NORMAL EMOTION EMOTIONAL LABILITY EMOTIONAL INCONGRUITY

16. FOUR LOBES OF CEREBRUM AND FOUR VENTRICLES

17. EXAMINATION OF HIGHER FUNCTIONS AND LOBAR FUNCTIONS HIGHER FUNCTIONS TRADITIONAL FRONTAL LOBEEXECUTIVE FUNCTION EMOTIONAL RESPONSE SOCIAL BEHAVIOUR PARIETAL LOBE CALCULATION STEREOGNOSIS SPATIAL ORIENTATION

18. TEMPORAL LOBE AUDITORY PERCEPTION MUSIC TONE SEQUENCES OLFACTION SPEECH OCCIPITAL LOBE VISION

19. FIVE SPECIAL SENSES SMELL VISION HEARING TASTE TOUCH TRADITIONAL

20. UPPER MOTOR NEURONSIX FUNCTIONAL SYSTEMS OF THE BRAIN (ABOVE FORAMEN MAGNUM) 1. Basal ganglia – Programmer 2. Cerebellum – Computer 3. Cerebral hemisphere & connections - effector system 4. Sensory System 5. Autonomic nervous system – flight or fight 6. Limbic system - Holistic integrator of all TRADITIONALSPINOMOTOR SYSTEM

21. PLENTY OF MOVEMENTS A THETOSIS B ALLISMUS C HOREA D YSTONIA E SSENTIAL TREMOR F ASCICULATIONS M YOCLONUS PAUCITY OF MOVEMENTS AKINETIC RIGID STATES PARKINSONISM DRUG INDUCED IDIOPATHIC WILSONS DISEASE PROGRESSIVE SUPRANUCLEAR PALSY MULTIPLE SYSEM ATROPHY CORTICOBASAL DEGENERATION HUNTINGTONS -JUVENILE VARIANT NIEMMAN-PICK DISEASE TYPE C BASAL GANGLIA-INVOLUNTARY MOVEMENTS

22. CEREBELLUM-(computer) FUNCTIONS-COORDINATION GAIT ANTERIOR LOBE TRUNCAL VERMIS LIMBS AND LANGUAGE HEMISPHERE EYE MOVEMENTS FLOCCULONODULAR LOBE

23. SIGNS OF CEREBELLAR DYSFUNCTION INCOORDINATION OF EYE- NYSTAGMUS HEAD-TITUBATION SPEECH-DYSARTHRIA TRUNK-ATAXIA LIMB-ATAXIA GAIT-ATAXIA WRITING-MACROGRAPHIA

24. CEREBRAL HEMISPHERES(key board) MOVEMENT - FRONTAL LOBE SENSATION -PARIETAL LOBE MEMORY AND HEARING –TEMPORAL LOBE VISION - OCCIPITAL LOBE

25. SYMPATHETIC HEART RATE INCREASED BLOODPRESSURE INCREASED INCREASED BLADDER SPHINCTER TONE DECREASED BOWEL MOTILITY BRONCHODILATATION SWEATING PUPIL DILATATION PARASYMPATHETIC HEART RATE DECREASED BLOOD PRESSURE DECREASED VOIDING (DECREASED TONE) INCREASED BOWEL MOTILITY BRONCHOCONSTRICTION DECREASED SWEATING PUPIL CONSTRICTION FUNCTIONS OF AUTONOMIC NERVOUS SYSTEM

26. SEVEN LOWER MOTOR NEURON SYSTEMS • ANTERIORHORN CELL • ANTERIOR NERVE ROOT • POSTERIOR NERVE ROOT • PERIPHERAL NERVE • NEUROMUSCULAR JUNCTION • MUSCLE • INTRACELLULAR ORGANELLES

27. SPINAL CORD SPASTICITY WEAKNESS FASCICULATIONS EARLY BLADDER AND BOWEL TROPHIC CHANGES ANTERIOR NERVE ROOT SEGMENTAL WEAKNESS SEGMENTAL WASTING POSTERIOR NERVE ROOT PAIN PARESTHESIA NUMBNESS

28. LOWER MOTOR NEURON SYSTEMS-CONTD 4. PERIPHERAL NERVE BILATERAL DISTAL SYMMETRICAL NUMBNESS AND WEAKNESS WITH WASTING(NEUROPATHIC) 5. NEUROMUSCULAR JUNCTION DIURNAL VARIATION WITH FATIGABILITY OF MUSCLES 6. MUSCLE BILATERAL SYMMETRICAL PROXIMAL MUSCLE WEAKNESS AND WASTING( MYOPATHIC) 7. INTRACELLULAR ORGANELLES MITOCHONDRIA, SARCOGLYCANS

29. EIGHT-LANGUAGE

30. DISORDERS OF LANGUAGE ABNORMAL REPITITION • BROCAS APHASIA • WERNICKES APHASIA • GLOBAL APHASIA • CONDUCTION APHASIA

31. DISORDERS OF LANGUAGE NORMAL REPITITION • TRANSCORTICAL SENSORY • TRANSCORTICAL MOTOR • ANOMIC • ALEXIA

32. NINE –ETIOLOGIES THUMB - TUMOR, TOXIN, TRAUMA INDEX FINGER- INFECTION MIDDLE FINGER- METABOLIC DIAMOND FINGER- DEMYELINATION,DEGENERATION LITTLE FINGER - VASCULAR (LITTLE FLOW/ABSENT FLOW) HAND - HEREDITY AND NUTRITIONAL DISORDERS

33. TEN PAIRS OF CRANIAL NERVES CRANIAL NERVES III,IV,VI NERVES - OCULAR MOVEMENTS V NERVE - FACIAL SENSATIONS MUSCLES OF MASTICATION VII NERVE - MUSCLES OF FACIAL EXPRESSION SECRETORY FUNCTIONS IX AND X NERVE - PALATAL AND PHARANGEAL MUSCLES XI NERVE - STERNOMASTOID AND TRAPEZIUS XII NERVE - TONGUE MOVEMENTS

34. MATHEMAGICAL CLINICAL NEUROLOGY ONE - CONSCIOUSNESS/MIND TWO - CEREBRAL HEMISPHERES THREE - FUNCTIONS OF BRAIN COGNITION CONATION AFFECT FOUR - LOBES OF BRAIN FIVE - SPECIAL SENSES

35. SIX - UPPER MOTOR NEURONS SYSTEMS OF BRAIN SEVEN - LOWER MOTOR NEURONS SYSTEMS OF BRAIN EIGHT - LANGUAGE DISORDERS NINE - GENERAL PRAESENS AND OTHER SYSTEMS TEN - ETIOLOGIES

36. ACKNOWELDGEMENTS OUR SINCERE THANKS TO THE HEAD OF THE DEPARTMENT OF NEUROLOGY, DIRECTOR OF INTERNAL MEDICINE OF MADRAS MEDICAL COLLEGE AND ALL THE FACULTY MEMBERS OF THE DEPARTMENT OF NEUROLOGY AND MEDICINE