Lower Limb Neurological Exam Flashcards
Mnemonic for the structure of the exam?
To postpone reflexes constitutes stupidity - Tone, power, reflexes, co-ordination, sensation
Mnemonic for General inspection?
SWIFT- Scars, wasting, involuntary movements, fasciulations, tremor
What are you look for in the examination of gait?
- Delayed initiation (Parkinson’s)
- Loss of arm swing (early sign in Parkinson’s)
- Festination (Parkinson’s)
- Scissoring (proximal muscle weakness)
- Foot drop (LMN lesion, specifically L4/L5 common fibular nerve)
- Heel to toe walking (ataxia)
How do you perform Romberg’s test?
- Ask patient tot stand with their feet together and their eyes closed
- Observe the patient (ideally for one minute)
- Positive test = loss of balance
- Suggests a sensory ataxia (defective proprioceptive or vestibular system)
- Stand behind the patient to avoid them falling over.
What position should the patient be in to examine tone?
Supine on couch. Ask patient to relax and ‘go floppy’.
How to assess tone?
Passively move each joint through as full a range as possible.
Roll leg from side to side, then briskly lift the knee into a flexed position, observing the movement of the foot.
How to check for ankle clonus?
Support patient’s leg, with both knee and ankle resting in 90 degree flexion.
Briskly dorsiflex and partially evert the foot, sustaining the pressure. Clonus is felt as repeated beats of dorsiflexion/plantarflexion.
What to do before power testing?
Ask about any pain that may interfere
How should the patient be positioned for power assessment?
Reclining
What are the 11 movements you need to test for power?
Hip flexion (L1/L2) - Raise leg off bed Hip extension (L5/S1) - Stop from lifting leg Hip abduction (L4/L5) - Move leg away from midline Hip adduction (L2/L3) - Stop from moving leg from midline Knee flexion (S1) - Bend knee, stop from straightening Knee extension (L3/L4) - Stop me from bending leg Dorsiflexion (L4) - point toes up, don't let me push down Plantarflexion (S1/S2) - Press down on hand with sole of foot Inversion (L4) - push foot in against my hand Eversion (L5/S1) - push foot out against my hand Big toe extension (L5) - don't let me push big toe down
What are the two main lower limb reflexes?
Knee (quadriceps) - L3, L4 - Femoral nerve
Ankle (gastrocnemius, soleus) - S1, S2 - Sciatic nerve
How do you reinforce reflexes in the lower limb?
Ask patient to interlock the fingers and pull one hand against the other on your command immediately before you strike the tendon (Jendrassik’s manoeuvre)
What is the other lower limb reflex?
Plantar response (S1/S2)
- Run a blunt object along the lateral border of the sole of the foot towards the little toe.
- Watch both first movement of the great toe and the other leg flexor muscles.
- Normal response is flexion of great toe with flexion of other toes.
- ABNORMAL = Babinski sign - extension of great toe (UMN lesion).
What is the test for co-ordination?
Heel-to-shin test
- With patient lying supine ask him to place his heel on his opposite knee, then slide his heel up and down the shin between knee and ankle.
- Look for dysmetria and intention tremor
- An inability to perform this test may suggest loss of motor strength, proprioception or a cerebellar disorder.
What are the 4 parts of sensation assessment?
Light touch - dorsal/posterior columns and spinothalamic tract.
Pin prick sensation - Spinothalamic tract
Vibration - dorsal columns
Proprioception - dorsal columns
