CS - Neurological Examination Part 1 Flashcards
What does the term fasciculation mean and describe the physiology underlying it ?
Fasciculation or muscle twitch is a small, local, involuntary muscle contraction and relaxation which may be visible under the skin.
They arise as a result of spontaneous depolarisation of a lower motor neuron (LMN) leading to the synchronous contraction of all the skeletal muscle fibres within a single motor unit.
What are 2 conditions that may cause bilateral wasting of the small muscles of the hands?
Muscular Dystrophy
Amyotrophic lateral sclerosis
Multiple sclerosis
Define muscle tone?
Muscle tone is the amount of tension (or resistance to movement) in muscles. Our muscle tone helps us to hold our bodies upright when we are sitting and standing. Changes in muscle tone are what enable us to move. Muscle tone also contributes to the control, speed and amount of movement we can achieve.
What might cause an increased or decreased tone?
Increased;
- UMN lesion
- Trauma
- Stroke
- Brain tumors
- Toxins
- Multiple sclerosis
- Parkinson’s disease
- Cerebral palsy
Decreased;
LMN lesion or damage to the brain, spinal cord, nerves, or muscles
What is the scoring system used to assess power ?
The MRC scale of muscle strength uses a score of 0 to 5 to grade the power of a particular muscle group in relation to the movement of a single joint.
Revision
Grade Medical Research Council scale for muscle power
0 - No muscle contraction discernable
1 - Flicker of contraction but no movement
2 - Joint movement when effect of gravity eliminated
3 - Movement against gravity but not examiner’s resistance
4 - Movement against resistance is weaker than normal
5 - Normal power
Define the term deep tendon reflex?
A deep tendon reflex is often associated with muscle stretching. Tendon reflex tests are used to determine the integrity of the spinal cord and peripheral nervous system, and they can be used to determine the presence of a neuromuscular disease.
Can you draw a diagram illustrating the physiology behind the knee jerk reflex?
Image
What are the features of upper and lower motor neuron lesions?
Upper MN;
- Pyramidal muscle weakness
(hemipariesis)
- No muscle atrophy
- No fasciculation
- Increased muscle tone (spasticity)
- Increased stretch reflexes
- Abnormal reflexes (Babinski)
Lower MN;
- Muscle weakness (lesion dependant)
- Muscle atrophy
- Fasciculation
- Reduced muscle tone
- Reduced stretch reflexes
Draw a diagram of the dermatomes of the upper limb?
Image
What common disease may result in impaired vibration senses?
Diabetes
What is peripheral neuropathy ?
Peripheral neuropathy develops when nerves in the body’s extremities, such as the hands, feet and arms, are damaged
What is “glove and stocking” pattern?
A glove and stocking pattern of sensory loss suggests an axonal polyneuropathy.
Nerve root lesions cause sensory loss in a dermatomal pattern. Numbness in a single nerve territory suggests trauma or entrapment neuropathy.
What is mononeuritis?
Mononeuritis multiplex (MNM) is a disorder of the nervous system. It can result in severe pain, loss of motor ability, and loss of sensation in at least two separate areas of the body. The areas affected by MNM depend on the underlying cause of the condition.
What are the features of a cerebellar lesion ?
Cerebellar lesions are most often associated with the clinical findings of ataxia, which may affect the limbs, trunk, or even speech (producing a specific type of dysarthria known as scanning speech), dysequilibrium as manifested by a wide-based gait, and muscular hypotonia.
What is extrapyramidal syndrome?
he term “extrapyramidal effects” describes involuntary movements that you cannot control. These side effects are most common when taking antipsychotic medications? When you experience extrapyramidal effects, movements that were once voluntary happen without your control.
(rubrospinal, reticulospinal, tectospinal and vestibulospinal)
What is the most common tremor at rest and on action?
At rest - Parkinson’s
On action - Essential tremor
(tumour ?)
(both sides of the body, but is often noticed more in the dominant hand because it is an action tremor)
What is foot drop and the neurological causes?
Foot drop, sometimes called drop foot, is a general term for difficulty lifting the front part of the foot. If you have foot drop, the front of your foot might drag on the ground when you walk.
Foot drop usually results from lesions affecting the peripheral neural pathway related to dorsiflexor muscles, especially the peroneal nerve
What is hemiplegia ?
Hemiplegia (sometimes called hemiparesis) is a condition, caused by a brain injury, that results in a varying degree of weakness, stiffness (spasticity) and lack of control in one side of the body
UMN;
- Arm extensors weaker than flexors (flexors stronger)
- Leg flexors weaker than extensors (extensors stronger)
What is paraplegia ?
Paraplegia refers to the loss of movement and sensation in both legs and, sometimes, part of the lower abdomen.
What is quadriplegia?
Quadriplegia affects all four limbs and, sometimes, parts of the chest, abdomen, and back
What is proximal myopathy ? what actions would a patient have difficulty with and which diseases are associated with proximal myopathy ?
Proximal myopathy presents as symmetrical weakness of proximal upper and/or lower limbs
The patient will have difficulty combing hair, difficulty climbing up the stairs, difficulty standing from a sitting position, and/or difficulty in getting up from bed
There is a broad range of underlying causes including drugs, alcohol, thyroid disease, osteomalacia, idiopathic inflammatory myopathies (IIM), hereditary myopathies, malignancy, infections and sarcoidosis.
What is an upper motor neuron ?
Upper motor neurons are first-order neurons which are responsible for carrying the electrical impulses that initiate and modulate movement. Various descending UMN tracts are responsible for the coordination of movement. The major UMN tract that initiates voluntary movement is the pyramidal tract
What are lower motor neurons?
The lower motor neuron is responsible for transmitting the signal from the upper motor neuron to the effector muscle to perform a movement. There are three broad types of lower motor neurons: somatic motor neurons, special visceral efferent (branchial) motor neurons, and general visceral motor neurons
Distal muscle wasting can cause a classic appearance in the legs of “inverted champagne bottles” what condition most typically causes this?
- Charcot-Marie-tooth disease
Name 2 conditions which would give a mixture of upper motor neurone and lower motor neurone signs?
- ALS (amyotrophic lateral sclerosis)
- Paralytic Poliomyelitis
Describe a grading system for reflex response?
Reflexes are graded using a 0 to 4+ scale:
o 0: Absent
o 1+: Hypoactive
o 2+: normal
o 3+: Hyperactive, without clonus
o 4+ : Hyperactive, with clonus
—2 is normal—
What is Babinski’s sign?
Dragging a stimulus over sole of foot, should have a normal plantar response with toes curling up. Abnormal and positive sign will see extensor plantar response with toes pointing upwards
UMN Lesion
Who was Babinski ?
Joseph Babinski was a French-Polish professor of neurology. He is best known for his 1896 description of the Babinski sign, a pathological plantar reflex indicative of corticospinal tract damage.
What is a superficial reflex? Give 3 examples?
Plantar response,
abdominal reflex, cremastic reflex, corneal reflex.
(stroke superficially for response)
What are 3 deepl reflex? Give 3 examples?
Biceps, Brachioradialis, Triceps, Knee jerk, and ankle jerk.
(Use tendon hammer)
Draw a diagram of the dermatomes of the lower limb?
Image
What is paraesthesia?
Paresthesia refers to a burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body. The sensation, which happens without warning, is usually painless and described as tingling or numbness, skin crawling, or itching.
Define allodynia?
Allodynia is defined as “pain due to a stimulus that does not normally provoke pain.” An example would be a light feather touch (that should only produce sensation), causing pain
What are the different sections and the order we need to test them in a neurological examination?
Introduction
General Inspection
Inspection and palpation of limbs
Tone
Power
Reflexes
Sensation of limbs
Co-ordination and GAIT
Cerebellar function
Conclusion
What should you do upon general inspection?
GENERAL INSPECTION;
A. Around the bed (e.g. walking stick, frame).
B. Posture, symmetry, muscle wasting, abnormal movements
C. Skin e.g. scars, neurofibromatosis, rash (herpes zoster)
Examination of any part of the body should start with inspection. Inspect the patient’s environment for signs of neurological pathology. Stand back and observe from end of bed.
Look for:
normal or abnormal posture
abnormal or involuntary movements
scars (operations, old injuries)
evidence of neurofibromatosis - “café au lait” (coffee with milk) blotches
rash (herpes zoster)
What should you do upon Tone ?
TONE;
A. Test tone in upper limbs
B. Test tone in lower limbs
Assessment of tone;
Ask the patient to relax their arms and allow you to move them
Put each wrist and elbow through a full range of movement
Test tone in legs
Always compare right with left
Upper limbs testing tone;
Hold the patient’s hand as if shaking their hand and use the other hand to support the elbow.
Rotate the forearm, flex and extend the wrist and elbow
Lower limbs testing tone;
Begin by rolling the right leg from side to side with the flat of both your hands. A normal leg will roll very easily. Next place your hand under one knee and abruptly pull upwards to flex the knee and drop it back onto the bed. In the patient with normal tone leg will drag along the couch and flop back onto the couch. If the patient has increased tone (hypertonia) you will feel resistance and the ankle will come off the bed. Repeat lifting and flexing the other knee.
If you suspect increased or decreased tone go on to examine the tone of the lower limb in more detail at hips, knees and ankle
Repeat on left leg
What should you do upon Power ?
POWER;
A. Test power in upper limbs
B. Test power in lower limbs
Assessment of power;
Power is assessed by active movements against resistance of each joint in turn.
Use MRC scale for muscle power!
A full examination (as compared to a simplified screening examination - see below) with comprehensive tests, may be done to test the power of particular muscles and groups.
Examples of specific muscle testing:
Example 1: hip abduction L4/5/S1 hands on outside of knees “don’t let me push your knees together.” (Gluteus medius and minimus, sartorius and tensor fascia latae.)
A simplified screening examination of muscle power based on nerve root values,
involving a selection of commands (see below), should always be made to cover testing all the nerve root values C5 to T1 and L1 to S2. Demonstration of competence in this simplified screening examination will be assessed in your OSCE.
Simplified screening of power and nerve root integrity in the upper limb C5-T1
Screening based on nerve root values.
Rough guide: shoulder C5, elbow C6, C7, wrist C7, long muscles hand C8, small muscles hand T1
Power is assessed by active movements against resistance
- C5: shoulder abduction (deltoid C5) – “make wings with your arms, keep your arms up, don’t let me push them down”
- C5/6: elbow flexion (biceps C5/6 musculocutaneous n. ) – “pull me towards you”
- C7: elbow extension (triceps C7 radial n.) –“now push me away”
- C6/7: wrist extension –“make a fist, push up against my hand”
- C8/T1: finger abduction (intrinsic muscles T1 ulnar n.) – “spread your fingers
apart, don’t let me squash them together” - C8/T1: thumb abduction (abductor pollicis brevis T1 median n.) – “put your
thumb up, don’t let me push it down”
Simplified screening of power and nerve root integrity in the lower limb L1-S2
- L1/2: hip flexion (iliopsoas L1/2 iliofemoral n.) – your hand on right knee “lift your leg up, don’t let me push it down” Repeat on left leg.
- Hip extension [gluteus maximus L4/L5/S1 Sciatic n.] – with your hands under the heels “press your feet into the couch”
- Knee flexion [ hamstring L5/S1 Sciatic n.] – “bend your knee and try to pull your heel towards your bottom”
- Knee extension [quadriceps L3/4 Femoral n.] – with the knee starting from a flexed position, “try to straighten your leg out”
5). Ankle dorsiflexion [tibialis anterior L4/5 Deep Peroneal n.]- “pull your foot up towards you, don’t let me straighten it”
6). Great toe dorsiflexion [extensor hallucis longus L5 Deep Peroneal n.] –“curl your big toe up towards you, don’t let me push it down”
7). S1/2: ankle plantar flexion (gastrocnemius, plantaris, soleus S1/2 Tibial n.) – hand on bottom (ball) of foot “point your foot down, don’t let me push your foot up” Repeat on LL.
(A very quick screening test of lower limb power (HOWEVER not for an OSCE) is: Ask the patient to:
1. Stand up on the heels (L4, L5)
2. Stand up on toes (S1)
3. Squat and stand again (L3, L4)
This tests ankle, knee, and hip power. Inability to perform any of the tests requires more formal testing of power.)
What should you do upon Reflexes ?
REFLEXES;
A. Test reflexes in upper limb
B. Test reflexes in lower limb
C. Test for clonus in lower limb
D. Elicit plantar reflex
Reflexes are graded absent to greatly increased. It is very important to compare side with side
To elicit the 3 upper limb tendon reflexes:
Place the patient in a comfortable position where the arms are supported.
Ensure the muscle being tested is exposed. (Look at the muscle for
contraction)
Ask the patient to allow their arm to become floppy and relaxed
Biceps Reflex C5/6;
Palpate the biceps tendon and press on it firmly with your non dominant thumb
Strike your thumb with the tendon hammer (thumb protects the tendon from
rupture)
Observe the response of the biceps muscle
Compare the response with that of the opposite side
Brachioradialis Reflex C5/6 (sometimes called the supinator reflex);
Hold the patient’s hand loosely with your non dominant hand
Strike the forearm at the level of a watch strap on the radial aspect over
brachioradialis
Observe the response of brachioradialis
Compare the response with that of the opposite side
Triceps Reflex C7;
Relax the arm
Strike across the triceps tendon directly (no thumb) with the tendon hammer
Observe the response of the triceps muscle
Compare the response with that of the opposite side
To elicit the 2 lower limb tendon; reflexes and clonus
The patient should lie in a comfortable position with the legs relaxed
Ensure the muscle being tested is exposed
Knee Jerk L3/4;
With your non-dominant hand lift the knee up slightly, ensure you have the weight of the patient’s leg i.e. the patient is relaxed
Strike the patella tendon with a brisk, staccato tap from the tendon hammer
Observe the response of the quadriceps muscle
Compare the response with that of the other side
Ankle Jerk S1;
Flex the leg at the knee out to the side
Hold the foot in gentle dorsiflexion
Strike the Achilles tendon with a brisk staccato tap from the tendon hammer
Observe the response in the calf muscle
Reinforcement;
If the reflex appears absent, try a second time. If it has not been elicited on the second attempt, try a reinforcement manoeuvre e.g. clenching teeth (for upper limb reflexes) or gripping hands together (for lower limb reflexes).
Test for clonus:
Ankle clonus: support the patient’s leg with both the knee and ankle resting in
90 ̊ flexion. Rotate the ankle (as a distraction) then briskly dorsiflex and partially evert the foot and sustain pressure. More than four beats of clonus (rhythmical jerking) is usually pathological (but can be slightly present if patient anxious).
Knee clonus: with the patient relaxed and the knee extended, grip the lateral borders of the patella between your thumb and fingers. Sharply pull down towards the foot sustaining the pressure for a few seconds. If clonus is present the patella will jerk up and down rhythmically.
Plantar Reflex Examination S1;
Explain to the patient what you are going to do!
With blunt end of a spatula stroke up the lateral aspect of the sole of the patient’s foot, then medially across under the toes.
Normal response is down going, a flexor plantar response. The big toe flexes at the metatarsophalangeal (MTP) joint.
Extensor plantar response ONLY use the term Babinski’s sign when the response is pathological and the great toe dorsiflexes and the others fan out, a sign suggesting an UMN lesion
What should you do upon Sensation of limbs ?
SENSATION;
A. Test sensation in upper limb
B. Test sensation in lower limb
Before formal testing, ask the patient if he has noticed any numbness.
Think of sensory modalities and tracts associated!
Pain or Pinprick (Spinothalamic tract);
Use a disposable neuropin. (Dispose in sharps bin)
Establish a baseline for sharpness on the sternum
Ask the patient to close their eyes and report if the sensation is sharp or blunt
Examine the arms and legs bearing in mind the segmental distribution of the
spinal nerves
Proprioception (Dorsal columns);
Test this in the distal aspect of the limb first
Educate the patient by holding the distal phalanx of a finger, moving the tip of
the finger, and establishing up and down positions.
Ask the patient to close their eyes, and report if their finger is up or down
Holding the finger along the medial and lateral borders move the patients
finger
If there is any abnormality, test again at the next more proximal joint
Repeat on legs
Vibration Sense;
Using a vibrating tuning fork, educate the patient by holding the base against
the sternum to allow them to identify the sensation
Ask the patient to close their eyes
Hold the vibrating tuning fork against a distal bony point ( usually great toe)
Ask the patient to identify the vibration, then report when it stops [when damped
by the examiners fingers]
If any abnormality repeat the process at a more proximal bony prominence
Light touch;
Ask the patient to close their eyes and respond verbally to each touch
Touch the skin with a small piece of cotton wool, do not stroke
Ensure irregular time intervals to prevent prediction of the stimulus
Examine the arms trunk and legs bearing in mind the segmental distribution of
the spinal nerves
If an area of numbness is identified, map its distribution
Temperature;
(Not routinely done. Pain/pin prick sensation travels in the spinothalamic tracts but if an abnormality is detected, additional testing of the spinothalamic tracts can be done using something cold (e.g. metal tuning fork/cold spray) to test further.);
- Using the cold stimulus establish a baseline for coldness on the sternum
- Ask the patient to report if it is as cold on their arms and legs
- Map out any area of decreased temperature sensation
What should you do upon Co-ordination and GAIT?
A). Test co-ordination in upper limbs - finger nose test, dysdiadochokinesia
B). Test co-ordination in lower limbs - heel shin test
C). Romberg’s test (differentiates between cerebellar and dorsal column (sensory) ataxia) D). Observe gait
Point-to-Point Movements & Rapid Alternating Movements;
This section assesses cerebellar function, but the tests described may be influenced by any muscle weakness, proprioceptive loss or extrapyramidal dysfunction
Finger-nose test: Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task.
Dysdiadochokinesia;
Demonstrate what you would like the patient to do. Tap your right hand on your left wrist or thigh, first with your palm, then with the dorsal aspect.
Heel-shin test;
Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. The patient should then lift their heel off and repeat from the knee. (not slide heel up and down). In cerebellar disease the heel wobbles and overshoots. Repeat with the patient’s eyes closed. Closing eyes makes little difference to this in cerebellar disease, but if there is posterior (dorsal) column, loss the movements are made worse with eyes closed. (as in Romberg’s test: “sensory ataxia”.)
Sensory Ataxia;
Stance Romberg’s test;
Ask patient to stand with feet close together. Stand close to patient to catch them if required. (your arms front and back.) When steady ask patient to close their eyes for 5- 10 seconds. The test is positive if the patient becomes unstable (indicating a proprioceptive or sensory problem) i.e. in a proprioceptive/sensory defect will get a Positive Romberg’s test
Tandem gait;
Ask the patient to walk across room, turn and then walk heel to toe in a straight line (tandem gait) Observe gait for e.g. foot drop, stamping, ataxia, hemiplegic.
Fuller tests of Gait Ask the patient to:
Walk across the room, turn and come back
Walk heel-to-toe in a straight line
Walk on their toes in a straight line
Walk on their heels in a straight line
Hop in place on each foot
Do a shallow knee bend
Rise from a sitting position
What should you do upon
Cerebellar function ?
1). Intro + Ask if patient is in any pain or discomfort
Before each test explain clearly, what you are going to do, and what you would like the patient
to do. Demonstrate if necessary.
2). General Inspection (patient sitting down) - Observe for posture and tremor
3) Nystagmus;
A. Examine for nystagmus
4). Speech
Looking for ataxic speech slurring, scanning, staccato rhythm during history taking and
introduction and whole examination
A. Ask patient to say some key phrases: British constitution, baby hippopotamus, West Register
Street, etc.
5). Tone;
A. Test tone in both arms - shoulder, elbow, and wrist – looking for hypotonia
6). Co-ordination in upper and lower limbs;
A. Assess for tremor in the hands
B. Assess for dysdiadochokinesia
C. Finger-to-nose test both arms observe for past pointing, intention tremor (dysmetria)
D. Heel-to-shin test
E. Repeat the test with the other leg
F. Cerebellar drift and rebound are additional signs which can be assessed
7). Standing
A. Feet together eyes open (ensuring patient safety) (swaying: cerebellar ataxia)
B. Romberg’s test: feet together eyes open, and feet together eyes closed (ensuring patient
safety)
Positive Romberg’s suggests sensory ataxia- NB Romberg’s test is not a test of cerebellar dysfunction
(Differentiates between dorsal column (sensory) ataxia and cerebellar ataxia)
8). GAIT;
Looking for ataxic gait/wide based gait /falling to the side of lesion
A. Ask patient to walk across room, turn and return.
B. Observe patient’s arm swing and how he turns around (involves good balance and co-
ordination.)
C. Heel-to-toe test (tandem gait)
9). Conclusion
DANISH: Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia
What should you do upon Inspection and palpation of limbs?
INSPECTION and PALPATION upper and lower limbs;
A. Observation of posture, symmetry, abnormal movements
B. Shake hands with patient. Ask if right or left handed.
C. Look for fasciculation
Move to the right hand side of the patient.
The patient’s arms and legs should be fully exposed. Always compare right with left.
Shake hands with your patient. (A patient with myotonia cannot relax his grip.) Ask if your patient is right or left handed. (This will help in your later assessment of power.)
observe the posture of the individual limbs, look for any asymmetry
observe the symmetry, size and shape of large muscle groups
observe any abnormal movements and tremor
ask patient to rest arms on their lap:-
look for fasciculation in the large muscle groups arms and legs
Posture; - Hemiplegia - flexed upper limb, extended lower limb
- Wrist drop - radial nerve palsy
Muscle wasting - Symmetrical or asymmetrical - Proximal or distal
- Generalised or local
Abnormal movements; - Chorea – brief random purposeless movements.
Tremor;
- Resting - e.g Parkinsonism
- Postural; when limb present and increasing as finger reaches target
- Intention; present and increasing as finger reaches target
Fasciculation;
- fine involuntary muscle fibre tremor present at rest (nb Fibrillation is only detected by EMG)
- fasciculation with weakness suggests LMN degeneration
What are the innervations of the muscle groups in the upper and lower limbs?
Upper limbs;
Deltoid (C5)
Biceps (C5/6)
Triceps (C7)
Wrist Extensors (C6/7)
Lower limbs;
Hip flexors (L1/2)
Hip extensors (L4/5/S1)
Knee flexors (L5/S1)
Knee extensors (L3/4)
Intrinsic muscles of the hand (C8/T1)
Ankle plantarflexion (S1/2)
What is the significance of clonus?
Significance of clonus: The presence of sustained clonus implies an UMN lesion of the affected limb. It is really an exaggerated sustained repetitive tendon reflex, but it may be conveniently tested after testing for tone. (Remember that weakness, increased tone, increased reflexes, including clonus, are the features of UMN lesions.)
What is Sensory Ataxia?
Sensory ataxia is a form of ataxia (loss of co-ordination) caused, not by cerebellar dysfunction, but by loss of the sensory input into the control of movement.
Sensory ataxia is distinguished from cerebellar ataxia by the presence of near-normal co-ordination when the movement in question is visually observed by the patient, but there is marked worsening of coordination when the eyes are closed Sensory ataxiais present in sensory peripheral neuropathies and conditions causing dysfunction of the dorsal columns of the spinal cord.
Why is a positive Romberg’s test classified as a sensory ataxia and not a cerebellar?
This dorsal column ataxia is a “sensory” as opposed to a “cerebellar” ataxia which is swaying with eyes open and closed. (Normally vision compensates for proprioceptive loss.) Patient complains of loss of balance in the dark, typically when closing their eyes in the shower or removing clothing over the head. In cerebellar ataxia – you get swaying with eyes open and closed.
What are some signs of cerebellar disease?
Signs of cerebellar disease include;
nystagmus
dysarthria
dysdiadochokinesia
in-coordination
intention tremor
past pointing
cerebellar drift and rebound
hypotonia
Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia make up a helpful acronym - DANISH
What are some final tests you should do?
To finish;
- Test for signs of meningeal irritation:
Neck stiffness and Kernigs sign - Straight leg raising should be done for nerve root irritation
- 2 point discrimination and testing sensation with a monofilament are further
sensory tests which are done looking for neuropathy, particularly in the context
of diabetes.
