lower limb neuro

Question 1

inspection

Answer 1

around the bed - patient looks well, posture, walking aids, orthoses, habitus, other signs of neurological conditions ge hypomimia or facial muscle wasting

closer - SWIFT

plantar foot easting and for dorsal foot guttering (LMN lesion), fasiculations and associated bony deformity (pes cavus)

skin - neurofibromas, cafe au lait spots

look at gait

Question 2

how do you examine gait

Answer 2

first ask if they need assistance walking

ask pt to walk normally: see if parkinsonian, foot drop, hemiplegic, spastic, ataxic, myopathic (waddling), if cerebellum problem = wide gait

walk heel to toe (see if ataxia)

stand on heels (tests distal power)

romberg’s test

Question 3

describe romberg test

Answer 3

close pt eyes while standing - check for stability - positive test = move around when close eyes = sensory ataxia ie reduced joint position sense

to maintain balance have to have 2 of 3: vestibular, proprioception and vision

romberg test takes away vision - so if proprioception is gone = lose balance

reduced stability = sensory ataxia ie reduced position sense

Question 4

test tone

Answer 4

roll each leg on bed with hand either side of the knee and see if increased or decreased tone

spasticity - lift knee of bed - if foot lifts off = increased tone (UMN)

clonus - raise leg (flexed knee) and force foot flex and hold firmly feel for invol rhythmic beats of gastrocnemius contraction - if foot hit twice that is normal, if more than twice - not = stroke/MS (UMN)

Question 5

UMN sign tone

Answer 5

increased

Question 6

LMN lesion sign tone

Answer 6

decreased

Question 7

how do you report power

Answer 7

MRC

Question 8

myotomes for hip flexion

Answer 8

L1/2

Question 9

myotomes for hip extension

Answer 9

L4/5

Question 10

Knee extension

Answer 10

L3/4

Question 11

Knee flexion myotomes

Answer 11

L5/S1

Question 12

ankle dorsiflexion

Answer 12

L4/5

Question 13

ankle plantar flexion myotomes

Answer 13

S1/S2

Question 14

big toe extension

Answer 14

L5

Question 15

summarise leg reflexes

Answer 15

knee - L3/4 (3 4 kick the door) - hold knee up with your L wrist = relaxed leg, and strike the tendon

ankle - S1/2 buckle my shoe - externally rotate the pts leg and flex their knee, hold your foot with the L hand and gently passively dorsiflex their ankle, strike the achilles tendon with the hammer in your R hand

plantar response - babinski reflex - warn the pt then scrape the plantar surface of their foot in a semi-circle from the heel, around the lateral edge and to the ball of the big toe

Question 16

UMN sign reflex

Answer 16

brisk

Question 17

LMN lesion sign reflex

Answer 17

no reflex

problem with peripheral nerves/muscles

Question 18

what is a positive babinski reflex

Answer 18

extension of toes and fanning

UMN lesion - brain and spinal cord

Question 19

sensation

Answer 19

go through all the dermatomes +- peripheral nerves if suspect nerve/nerve rooyt pathology

go from distal to proximal in 3 lines in expecting glove and stocking sensory loss or a sensory level

light touch (dorsal column)

pain (spinothalamic)

proprioception (dorsal column) - gold top and bottom of prox phalanx of big toe, and sides of distal, and move distal up and down if they get it wrong move up - metatarsophalangeal joint, ankle etc

vibration - 128Hz tuning fork over sternum then interphalangeal joint of big toe, then metatarsophalangeal joint, then medial malleolus, then tibial tuberosity etc

temperature (spinothalamic)

Question 20

coordination

Answer 20

heel to shin test - ask pt to touch heel to contralateral knee, move heel down tibia to contralateral ankle, now get them to move it back up through the air back to knee - repeat 3 times each side

check for dysmetria

incoordination = cerebellar palsy

if weak on one side you would have coordination issues anyway - so take in context of other cerebellar signs

Question 21

to complete…

Answer 21

would like to examine the cranial nerves

do other limb neurological examination

summarise and suggest other investigations

Question 22

summarise signs of LMN lesions

Answer 22

inspect - fasiculations, wastage

tone - decreased (hypotonia) or normal

power - weakness - specific muscle gps affected eg proximal muscles in muscle disease and distal muscles in peripheral neuropathies

reflexes - hyporeflexia or absent (areflexia)

ie everything is decreased (also have UMN inhibition = decreased responses)

Question 23

summarise signs of UMN lesions

Answer 23

inspect - no fasiculations or muscle wasting (can have atrophy if havent used the muscle for a long time)

tone - increased, pronator drift may be present, ankle clonus, spasticity

power - usually whole limbs, pyramidal pattern: upper limb extensers are weak, lower limb flexors are weak

reflexes - increased ‘‘brisk’’, babinski - upgoing/extensor plantar

Question 24

assess power of hip flexion

Answer 24

pt lift leg of bed with knee extended

stabalise contralateral hip joint with one hand and push down on quads just above knee of leg being tested

'’dont let me push your leg down’’

Question 25

assess hip extension

Answer 25

with leg still elevated to about 30 degrees, stabalise the ipsilateral hip joint with 1 hand and hold the underside of the knee with the other hand

'’push my hand down to the bed’’

Question 26

assess knee extension

Answer 26

with the knee flexed to 90 degrees

stabalise the ipsilateral knee joint with 1 hand and hold the anterior side of the ankle with your other hand and try and push it towards them

’’ try and kick your leg out, dont let me push it towards you’’

Question 27

assess knew flexion

Answer 27

in same position - hold posterior side of ankle - try and pull it away

'’try and pull your heel towards you bottom , dont let me pull it away’’

Question 28

assess ankle dorsiflexion

Answer 28

with leg straight on bed and ankle actively dorsiflexed, stabalise the ankle with one hand and make a fist with your other hand and use the dorsal side of fist to try and push the pts foot downwards

'’point your foot upwards towards your head and dont let me push it down’’

Question 29

assess ankle plantar flexion

Answer 29

in the same position but with their ankle actively plantar flexed, try and pull it up with your fingers on the ball of the pt’s foot

'’point your foot downwards towards the bottom of the bed, dont let me pull it up’’

Question 30

assess big toe extension

Answer 30

with their big toe actively flexed, isolate the toe’s metatarsophalangeal joint with 1 hand adn try and push it down with the index finger of your other hand

'’point your big toe upwards towards your head, and dont let me push it down’’