Lower limb neuro examination Flashcards
What is the first part of any introduction to an examination?
Wash hands
Intro self
Pt details
Explain a LLN exam to a patient
I’ve been asked to examine your lower limbs today, it’s going to involve moving your legs about a bit, asking you to walk, testing your reflexes, sensation and coordination, would that be alright?
What else would you include in your intro?
Expose ok?
Chaperone?
Pain or discomfort?
Handiness of the pt?
When inspecting the bedside what do you look for?
Wheelchair.
Walking stick.
When generally inspecting the what do you look for?
Any limb deformity or posturing.
What does SWIFT stand for when inspecting in a LLN exam?
S - Scars.
W - Wasting of muscles.
I - Involuntary movements (dystonia, chorea, myoclonus).
F - Fasciculations.
T - Tremor (Parkinson’s disease)
What do you look for when assessing gait?
Assess the patient’s gait walking normally + any issues turning –
- Look at balance, posture, stride length + arm swing.
Assess the patient’s gait walking tandem (heel-to-toe) –
- Abnormal may suggest weakness, impaired
proprioception or a cerebellar disorder.
How do you perform Romberg’s test?
What instructions would you give to the patient?
What is indicated in the following?
a) Unable to do with eyes open
b) Unable to do with eyes closed
Feet together, arms outstretched in front of them + hands supinated.
Can you just put your feet together + arms out in front of you with your palms facing upwards and I’ll be here to catch you if you feel unsteady… now can you close your eyes?
a) Unable with eyes open = cerebellar lesion.
b) Unable with eyes closed = loss of proprioception.
What tests do you do to test tone in the LLN exam?
What should you ask the patient to do before performing them?
Leg roll
Leg lift
Ankle clonus
Ask the patient to let their legs go fully relaxed + floppy.
How do you perform a leg roll?
Roll the patient’s leg + watch foot (it should flop independently of the leg)
How do you perform a leg lift?
Briskly lift leg off the bed at the knee joint (heel should remain in contact with the bed)
How do you perform ankle clonus?
What is considered normal?
Position the patient’s leg so the knee + ankle are slightly flexed, support the leg with your hand under their knee so they can relax.
Rapidly dorsiflex + partially evert foot then leave it dorsiflexed.
Clonus felt as rhythmical beats of dorsi/plantar flexion, >5 abnormal.
What is the best way to asses power in a ULN exam?
Assess power one side at a time + compare like for like (finger test toe).
Stabilise + isolate the joint when testing.
MRC muscle power assessment scale for scoring
What is the best way to asses power in a ULN exam?
Assess power one side at a time + compare like for like (finger test toe).
Stabilise + isolate the joint when testing.
MRC muscle power assessment scale for scoring
Where do you want to assess power in a ULN exam?
Hip
Knee
Ankle
Big toe
What hip movements do you want to assess?
What instructions do you give to the patient?
Flexion (L1/2) – “Raise your leg off the bed and stop me pushing it down”.
Extension (L5/S1) – “Stop me from lifting your leg up”.
ABduction (L4/5) – “Push your legs out against me”.
ADduction (L2/3) – “Squeeze your legs in against me”.
What knee movements do you want to assess?
What instructions do you give to the patient?
Flexion (S1) – “Bend your knee and stop me from straightening it”.
Extension (L3/4) – “Kick your leg out against me”.
What ankle movements do you want to assess?
What instructions do you give to the patient?
“Keep your legs flat on the bed and…”
Dorsiflexion (L4) – “Don’t let me push your foot down”.
Plantarflexion (S1/2) – “Don’t let me push your foot up”.
Inversion (L4) – “Push your foot in against my hand”.
Eversion (L5/S1) – “Push your foot out against my hand”.
What big toe movements do you want to assess?
What instructions do you give to the patient?
Extension (L5) – “Don’t let me push your big toe down”.
Flexion (?) – “Don’t let me push your big toe up”.
What reflexes do you want to check in a ULN exam?
Knee jerk (L3/4)
Ankle jerk (L5/S1)
Plantar reflex (S1)
What reinforcement manoeuvre can do you to accentuate a reflex?
Clench teeth
How to do test the knee jerk reflex?
Hold under the knee joint + strike tendon hammer at the patellar tendon
How to do test the ankle jerk reflex?
Bend leg + let it flop out to the side, relax your ankle then dorsiflex it.
How to do test the plantar reflex?
What is a normal response?
What is babinski sign?
Run a blunt object along the lateral edge of the sole of the foot, moving towards the little toe then medially under toes, observing big toe, warn might be a bit ticklish.
Normal = flexion of the big toe + other toes.
Abnormal (Babinski sign) = extension of big toe + spread of other toes 🡪 UMN lesion.
How do you assess coordination in the LLN exam?
What instructions do you give to the patient?
What does an inability indicate?
Heel to shin test
“Put your heel on your knee, run it down your shin, lift it up and repeat as fast as you can”.
Loss of motor strength, proprioception or a cerebellar disorder.
How do you assess the sensation in the LLN exam?
Assess dermatomes L2–S1.
Provide a comparison point (sternum/forehead) and then ask patient to close eyes.
Ask patient to say yes when they are touched.
Compare left to right + ask if it feels the same on both sides.
What does light touch sensation test?
What do you use?
Assesses dorsal/posterior columns + spinothalamic tracts.
Use cotton wool.
What does vibration sensation test?
Assesses dorsal/posterior columns.
How do you assess vibration sense?
Place on distal phalanx joint of big toe + ask if they can feel it buzzing + if they feel it stop.
If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints –
- Proximal phalanx
- Ankle
- Knee
- Hip
What does proprioception sensation test?
Assesses dorsal/posterior columns.
How do you asses proprioception in the LLN exam?
Hold the distal phalanx of their big toe by its sides.
Demonstrate the movement of the toes upwards + downwards to the patient whilst they watch.
Ask patient to close their eyes + state if you are moving toes up/down.
If patient is unable to correctly identify the direction then move to a more proximal joint –
- Big toe.
- Ankle.
- Knee.
- Hip.
Upon completing the exam what do you do first?
Thank patient
Wash hands
To complete my exam…
To complete my examination, I’d like to do an upper limb neurological examination and a full cranial nerve examination
Summarise a normal LLN exam
Today I performed a LLN exam on ___ a ___ y/o __
On general inspection ___ appeared comfy at rest
There were no abnormalities in posture, deformities, muscle wasting or fasciculations detected
Gait was normal and Romberg’s -ve
Tone was normal throughout
Power was 5/5 in all muscle groups bilaterally
Reflexes were normal + present at knee + ankles bilaterally
Plantars were down going bilaterally
Coordination was intact
Sensation was normal in all modalities tested
In summary, this was consistent w/ a normal ULN exam
