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MD1 PCP > Basic Neurological Exam of Lower Limbs > Flashcards

Basic Neurological Exam of Lower Limbs Flashcards

1
Q

What are the main steps in the neurological exam of the lower limbs?

A 
Prepare patient
Hand hygiene
Gait
Inspection
Tone
Power
Deep tendon reflexes
Coordination
Sensory exam
Completing exam
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2
Q

How do you prepare the patient?

A

Explain reason for exam
In general what it involves
Ask about pain in legs
Advise them to inform you if exam uncomfortable or causes pain
Adequately expose legs - dignity maintained
Check if ready to proceed

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3
Q

How do you measure gait?

A 
Ask patient to walk away from you and then back
Observe
Ease and fluidity of movement
Way feet strike floor
Note asymmetry
Joint problems can affect gait
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4
Q

How do you perform an inspection?

A 
Check lumbar region of back whilst patient standing
- Scars
- Deformity
Ask them to lie down on bed - can raise head rest
Inspect lower limbs
- Posture
- Muscle bulk
- If muscle wasting, note pattern
- Fasciculations
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5
Q

What is a decrease in muscle volume or bulk called?

A

Muscle atrophy

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6
Q

What is an increase in muscle volume or bulk called?

A

Muscle hypertrophy

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7
Q

What are fasciculations?

A

Muscle twitches due to involuntary contractions of muscle fibres

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8
Q

How do you assess tone?

A 
Assess passive resistance against movement at knee and ankle
Patient must relax limbs
- Let me take the weight of your legs
- Make your legs go loose and floppy like a rag doll
At knee
- Hold patient's foot with one hand
- Support leg with other
- Swing gently a couple of time
- Suddenly flex knee with hand not holding foot
At ankle
- Swivel ankle gently a few times
- Rapidly dorsi-flex foot
Repeat on other leg
Look for clonus
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9
Q

What is tone?

A

Partial contraction continuously present that helps maintain normal posture

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10
Q

Define hypotonia

A

Abnormally low tone

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11
Q

Define hypertonia

A

Abnormally high tone

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12
Q

What is clonus?

A

Rapid jerky muscle contractions

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13
Q

When can clonus occur?

A

If muscle suddenly stretched

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14
Q

What type of clonus considered abnormal?

A

Sustained clonus

More than 5 beats

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15
Q

How do you assess power?

A

Systematically check individual muscles
Ask patient to resist efforts to move particular body part
Correct positioning important so only particular muscle in question being tested
When testing strong muscles use maximum mechanical advantage so slight weakness not missed
- Normal muscle may appear weak if placed at mechanical disadvantage
Main movements at each major joint examined
One side compared with other
Start at hips
Progress distally
Provide clear and explicit instructions
- Verbal
- Non-verbal

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16
Q

What influences the results of a neurological exam?

A 
Patient's:
- Motivation
- Pain
- Changes in tome
Your own muscle strength
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17
Q

How do you test the power of hip flexion?

A

Ask patient to flex hip to about 40 degrees

Ask them to keep leg in this position as you apply downward pressure just proximal to knee joint

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18
Q

What are the nerve roots controlling hip flexion?

A

L2

L3

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19
Q

How do you test the power of hip extension?

A

Ask patient to push their heel down on couch and stop you raising it

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20
Q

What are the nerve roots controlling hip extension?

A

L4
L5
S1

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21
Q

How do you test the power of hip abduction?

A

Place hands on outside of patient’s thighs

Ask them to push their knees apart

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22
Q

What are the nerve roots for hip abduction?

A

L4
L5
S1

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23
Q

How do you test the power of hip adduction?

A

Place hands on inside of patient’s thighs

Ask them to push knees together

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24
Q

What are the nerve roots for hip adduction?

A

L2
L3
L4

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25
Q

How do you test the power of knee flexion?

A

Ask patient to bend their knee
Ask them to try to move heel along couch towards their bottom
You apply resistance

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26
Q

What are the nerve roots for knee flexion?

A

L5

S1

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27
Q

How do you test the power of knee extension?

A

Ask patient to straigten leg as you apply pressure distal to knee

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28
Q

What are the nerve roots for knee extension?

A

L2
L3
L4

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29
Q

How do you test the power of ankle dorsiflexion?

A

Place your hands over dorsal aspect of patient’s foot

Ask them to push foot towards face against your resistance

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30
Q

What are the nerve roots for ankle dorsiflexion?

A

L4

L5

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31
Q

How do you test the power of ankle plantar flexion?

A

Place fist over plantar aspect of patient’s foot

Ask them to push their foot down against your resistance

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32
Q

What are the nerve roots for ankle plantar flexion?

A

S1

S2

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33
Q

How do you test the power of inversion of the foot?

A

Plantar-flex patient’s foot

Ask them to keep foot turned that way as you pull the other way

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34
Q

What are the nerve roots for inversion of the foot?

A

L4

L5

35
Q

How do you test the power of eversion of the foot?

A

Dorsi-flex patient’s foot

Ask them to keep foot turned that way as you pull the other way

36
Q

What are the nerve roots for eversion of the foot?

A

L5

S1

37
Q

How do you test the power of great toe extension?

A

Ask patient to pull toe towards their face as you apply resistance

38
Q

What are the nerve roots for great toe extension?

A

L4
L5
S1

39
Q

What must muscle strength be graded against?

A

Patient’s maximum effort for particular muscle group

40
Q

What is conventionally used to grade muscle strength?

A

Medical Research Council (MRO) scale
Best available grading system
Has limitations

41
Q

What are the categories for the MRO scale?

A 
0 = complete paralysis
1 = flicker or trace of contraction
2 = Active movement with gravity eliminated
3 = Active movement against gravity
4 = Active movement against gravity and resistance
5 = normal power
42
Q

How else can muscle power be assessed?

A 
Using functional testing
Test groups of muscles
Useful for:
- Detecting mild weakness
- Monitoring progression of neurological problem
43
Q

How can mild upper limb weakness be tested functionally?

A

Ask patient to close eyes
Hold arms straight out with palms facing upwards for one minute
If reduced strength, patient’s arm starts to pronate and drift down = pronator drift

44
Q

How do you test the strength of the pelvic girdle muscles functionally?

A

Ask patient to stand from chair or squatting position

45
Q

What should you describe if muscle weakness is detected on examination?

A

Pattern

  • Symmetric or asymmetric
  • Proximal or distal
46
Q

What does the suffix “-plegia” mean?

A

Paralysis = complete loss of strength

47
Q

What does paresis mean?

A

Incomplete loss of strength

48
Q

Define hemiplegia

A

Paralysis on one side of body

49
Q

Define hemiparesis

A

Paresis on one side of body

50
Q

Define monoplegia

A

Paralysis of one limb

51
Q

Define monoparesis

A

Paresis of one limb

52
Q

Define paraplegia

A

Paralysis of both lower limbs

53
Q

Define paraparesis

A

Paresis of both lower limbs

54
Q

Define quadriplegia

A

Paralysis of all four limbs

55
Q

Define quadriparesis

A

Paresis of all four limbs

56
Q

What happens in a deep tendon reflex?

A

Muscle tendon tapped with tendon hammer
Muscle normally contracts
Because of two-neuron reflex involving spinal segment innervating muscle
Provides information about integrity of central and peripheral nervous systems
Patient must be relaxed for test - anxiety makes reflexes difficult to elicit

57
Q

What should you do if the tendon reflex seems to be absent?

A

Ask patient to curl their fingers, lock them together, and pull tight while you repeat manoeuvre
Isometric contraction of another muscle group can help increase reflex

58
Q

How do you do the knee jerk test?

A

Patient’s knee slightly flexed
Place arm under both knees to support them
Use tendon hammer to tap patella tendon between patella and tibial tuberosity
Look for contraction of quadriceps and extension of knee

59
Q

What nerve roots control the knee jerk?

A

L2
L3
L4

60
Q

How do you do the ankle jerk test?

A

Externally rotate patient’s hip
Slightly flex knee
Place Achilles tendon on small amount of stretch by dorsiflexing foot at ankle
Tap over tendon to elicit ankle jerk
Look for plantar flexion at ankle and contraction of gastrocnemius muscle
Can also be tested with patient kneeling in chair

61
Q

What nerve roots control the ankle jerk?

A

S1

S2

62
Q

How do you test the plantar (Babinski) reflex?

A

Warn patient this test can be a little uncomfortable
Run thumb nail or blunt object along lateral aspect of patient’s sole and then across metatarsal heads
Big toe flexes down
Abnormal response: big toe extends up
- Indicates upper motor neuron lesion
Abnormal plantar reflex in absence of other neurological signs is unlikely to be of significance

63
Q

What do decreased reflexes indicate?

A

PNS problem

64
Q

What do increased reflexes indicate?

A

CNS problem

65
Q

What is the conventional grading system for reflexes?

A 
0 = absent
1+ or + = hypoactive
2+ or ++ = normal
3+ or +++ = hyperactive without clonus
4+ or ++++ = hyperactive with clonus
66
Q

What are the nerve roots controlling the plantar reflex?

A

L5
S1
S2

67
Q

How do you test coordination?

A 
Tested after motor strength
Reduced power can make test difficult
Heel-shin test:
- Lift foot to touch elevated finger
- Place heel of that foot on patella of opposite leg
- Run heel down shin to ankle
- Repeat on other side
68
Q

How do you close the examination?

A

Say you’re done

Offer assistance if required

69
Q

What clinical signs does an upper motor neuron lesion cause?

A 
Slight atrophy
Increased (spacity) tone
Hyper-reflexia +/- clonus
Upgoing plantar reflex
Absent fasciculations
70
Q

What clinical signs does a lower motor neuron lesion cause?

A 
Marked atrophy - up to 70-80% muscle mass
Decreased (flaccidity) tone
Decreased or absent reflexes
Normal or absent plantar reflexes
Fasciculations may be present
71
Q

What might affect the results of a sensory exam?

A 
Patient's ability to respond to your instructions
Tiredness
Anxiousness
Unable to concentrate
Unclear instructions
72
Q

What sort of changes should you focus on in a sensory exam?

A

Major changes rather than subtle variations

73
Q

What are the two main types of sensation tested in the clinical situation?

A

Primary sensation

Cortical sensory function

74
Q

What does primary sensation testing mean?

A 
Reflects integrity of PNS
Assessing patient's response to
- Pain
- Touch
- Vibration
- Thermal stimulus
- Proprioception
75
Q

What does cortical sensory function testing mean?

A 
Reflects integrity of CNS
Includes
- 2 point discrimination
- Graphaesthesia
- Stereognosis
- Bilateral simultaneous stimulation
76
Q

What is required for the testing of cortical sensory function?

A

Normal primary sensation

77
Q

What are the main modalities used to test primary sensation?

A 
Pain
Light touch
Thermal sensation
Vibration sense
Proprioception
78
Q

How do you test for pain?

A

Use sharp instruments like Neurotips or new toothpicks
Don’t reuse
Don’t use needles
Test in unaffected area first like upper chest
Test in middle of each dermatome from L1-S2, comparing sides

79
Q

How do you test for light touch?

A

Test with wisp of cotton wool
If unavailable, use tip of finger
Test in unaffected area like upper chest
Test in middle of each dermatome from L1-S2, comparing sides

80
Q

How do you test for thermal sensation?

A

Don’t need to for OSCE if pain sensation normal
Use cold tuning fork
Difficult to test in routine clinical situation

81
Q

How do you test for vibration sense?

A

Use tuning fork
Ask patient to close eyes
Place vibrating tuning fork on tip of great toe/interphalangeal joint
Ask patient what feeling they get
Alternative: deaden vibration and ask them to tell you when it stops
If reduced/absent test proximally to determine level of abnormality

82
Q

How do you test for proprioception?

A

Tested at great toe
Place toe in neutral position
Grasp on either side between thumb and forefinger
Use other hands to stop other toes from touching
Move in plantar or dorsal direction
Ask patient to close eyes and say which way toe has been moved

83
Q

If just assessing the sensory aspect, what does the exam begin with?

A

Gait

Inspection of the back and lower limbs

MD1 PCP (43 decks)

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