AL-Iraqia University / College of Medicine / 2nd stage

Neurophysiology / Sensory Pathways / Higher Interpretation Centers

M.S. Ali Khalid Turki

Group D

Primary and Secondary Somatosensory Cortex

The primary somatosensory area provides touch, vibration, joint proprioception sense and tow
point discrimination. The secondary somatosensory area receives information on pain and
temperature from the primary somatosensory area. For this reason, the sensory line in scalp
acupuncture is used often for somatic pain disorders.

Superior and Inferior Parietal Lobes

The superior parietal lobe plays a role in spatial awareness. Damage from stroke can cause
hemispatial neglect. The inferior parietal lobe plays a role in both spatial awareness and body
image, and damage to this area can cause different types of apraxia, which can be of
movement, but also of speech.
An important consideration when discussing the functions of parietal lobes is that they differ
slightly from left to right. The left inferior parietal lobe specifically, the angular gyrus, is
involved in word comprehension – both written and spoken. Brain imaging studies show
extensive activity in the left angular gyrus during the planning and execution of writing.
Following concussions and traumatic brain injury, people commonly report difficulty with
speech and reading comprehensions, difficulty putting thoughts into fluent sentences, “word
salad” and often notice a decline in handwriting.
The parietal lobe also highly integrated with vision and eye movements. The areas of the
parietal lobe involved in visual pathways are the dorsal visual pathway and intraparietal areas.
The dorsal visual pathway is an important aspect of parietal lobe function that allows the brain
to process “where” objects are in space. Smooth pursuit eye movement that track where
targets are moving rely on the parietal lobe function.
The intraparietal area is involved in various types of eye movements and visual processing.
Strokes and brain injuries affecting the parietal lobe can result in eye movement disorders.
When working with people with chronic pain, it is important to appreciate that chronic pain
lives in the brain and involves complex circuits that include the parietal lobe, amygdala,
anterior cingulate gyrus, and hippocampus. Identifying poor parietal lobe function by
assessing not only the somatosensory cortex, but also the superior, inferior and intraparietal
regions while distinguishing whether the deficit is in the right, left or both lobes can provide
important information to direct acupuncture treatment strategies.
Functional Examination of the Parietal Lobes
There are some simple bedside tests that can be done to assess the parietal lobes. We know
that the left parietal lobe contains a map of the tight side of the body, and the right parietal
lobe contains a map of the left side of the body. The right parietal lobe also has a redundant
map of the right side of the body; however, for the purpose of assessment, we focus on the
contralateral aspect.
When performing functional exams, it is essential that we never “hang our hat” on one single
finding. This is why a combination of history, intake and exam should all add up to a
meaningful understanding of the issue. For this reason, there are several different parietal lobe
tests.

Toe Identification: with the patient laying supine, eyes closed, touch a toe and ask them
to identify which toe is being touched. Move back and forth between feet, testing different
toes and even coming back to ones incorrectly identified. Document the percentage of
accuracy. Next, perform a quick joint position sense test, move the 2nd toe either toward the
patient or away from the patient, and have them tell you which direction they sense the toe
moving.

Palm “Reading”: A graphesthesia test is another good parietal lobe test. Take the sharp
end of a reflex hammer and with the patient’s eyes closed, draw capital letters on the palm of
the hand (tell them the letters will be facing you) and have them identify which letters are
being drawn. Do 10 letters on each hand and document the accuracy.

Tracking the Thumb: due to the parietal lobe’s involvement in smooth pursuit eye
movements, we can use slow pursuits as another functional way to assess the parietal lobe.
Assess rightward pursuits separate from leftward pursuits. Have the patient follow your thumb
from center to the right (go approximately 18 inch laterally) several times, and then do the
same going to the left. Look for differences in the smoothness of the movement. Are the eyes
staying on the target, or do they look like they are skipping to keep up? Rightward pursuits
provide an evaluation of the right parietal lobe; leftward pursuits provide an evaluation of the
left parietal lobe.

How does all of the information add up?

Let’s say you have a patient with a history of multiple concussions, and their main complaint
coming into your clinic is chronic right shoulder pain and neck pain. If you observe that this
person gets 100 percent correct on the left for toe identification and 50 percent correct on the
right; 100 percent correct on graphesthesia testing on the left and 60 percent correct on the
right; and their slow pursuit eye movements are more jerky going right, these fingings would
indicate poor functioning of the left parietal lobe. This deficit may include the region of the
left somatosensory cortex that contains a map of the right shoulder. This may be contributing
to chronic right shoulder pain that is not responding to care.
Adding in scalp acupuncture over the left somatosensory line as well as the left apraxia area,
paired with local and distal points on the affected channel on the right side of the body, can
have a powerful effect on this type of chronic pain. Following treatment, re-evaluating toe
identification, graphesthesia, and pursuits provides valuable information on how the treatment
changed sensory integration in the brain.

When it comes to treating chronic pain and neurological disorders, an evaluation of both the
peripheral nervous system and the central nervous system is important in establishing the root
of the disorder, and in differentiating a local problem from one involving cortical or
subcortical structures.