Lower Limbs Neuro

Question 1

What do you do before you start the examination?

Answer 1

1. Wash hands
2. Introduce yourself
3. Identify the patient
4. Gain consent (walking, power in legs etc)
5. Ask if they have any pain
6. Ask them to expose their legs

Question 2

What do you look for on environment inspection?

Answer 2

walking sticks, orthotics, brace, roller frame etc

Question 3

What do you look for on inspection of the patient?

Answer 3

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1. Posture
2. Wasting
3. Scars
4. Tremor
5. Fasciculations
6. Involuntary movements

Question 4

What do you assess after inspection?

Answer 4

Gait: normal, tandem, then on toes, then on heels

Romberg’s test

Question 5

What do you look for when assessing standard walking gait?

Answer 5

PASTA

Posture/pelvic tilt, Armswing, Stride length, Turning, Asymmetry (also balance)

Question 6

What is Romberg’s Test? What do results suggest?

Answer 6

Stand with feet together, hands supinated and out in front of them. Eyes open and the closed.
If struggle with eyes open to maintain balance - cerebellar lesion
If fine eyes open, but eyes closed struggle - loss of proprioception

Question 7

How would you assess lower limb tone?

Answer 7

Passively move each joint: Roll legs, leg lift, ankle clonus

Question 8

How do you test for ankle clonus? What is it a sign of?

Answer 8

Bend the knee, take weight of leg and roll ankle and quickly jerk the foot so it dorsiflexes. Positive result is plantar flexion of the ankle. This is a sign of a UMN lesion (hypertonia)

Question 9

How do you assess power for each joint?

Answer 9

Hip: abduction, adduction, flexion, extension
Knee: flexion, extension (bent knee, push and pull)
Ankle: dorsiflexion, plantarflexion
Big toe: dorsiflexion, plantarflexion

Question 10

Describe MRC power grading scores

Answer 10

5/5: Full power resistance
4/5: Resistance against slight, moderate and strong resistance (4-, 4, 4+)
3/5: movement against gravity but not against resistance
2/5: Muscle contraction and movement once gravity eliminated
1/5: Muscle contraction but no movement
0/5: No muscle contraction

Question 11

Describe the myotome innervation of the lower limb

Answer 11

L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: great toe extension
S1: ankle plantarflexion

Question 12

Describe how you would test lower limb reflexes

Answer 12

Use tendon hammer to tap patellar tendon, dorsiflex ankle and tap on Achille’s tendon
Plantar reflex: use blunt object and run from heel up to little toe and then to big toe. Normal/negative Babinski’s sign is dorsiflexion of big toe
Ankle clonus if not already done

Question 13

How would you test coordination in lower limbs?

Answer 13

Heel to shin, lift off and put back to knee and start again. Test both legs

Question 14

What modalities of sensation do you test in the OSCE and which do you state you would test?

Answer 14

Test: Light touch sensation, vibration, proprioception
Say: Temperature, Pain/pinprick

Question 15

How would you test soft-touch sensation?

Answer 15

Use cotton wool and ask patient to close eyes. Ask if they can feel it on their sternum. Then ask them to say “yes” when they feel it on their legs. Test each dermatome on each leg. When finished, ask if it felt different in either leg or region.

Question 16

How would you test vibration?

Answer 16

Make 128Hz tuning fork vibrate and place on sternum. Ask if they can feel it. Then place vibrating fork on big toe and ask if they can feel it vibrating and feel it stop. Do on each leg. If sensation lost, then move up the leg.

Question 17

How would you test proprioception?

Answer 17

Place fingers medial and lateral to big toe joint. Move distal part up and down and ask patients to close eyes and tell you when it’s up or down.

Question 18

Describe a hemiplegic gait

Answer 18

Arm adducted at shoulder, elbow and wrist flexed, hip adducted, knee extended and ankle plantar-flexed. Swings paralysed side round to unparalysed side. Plantar-flexed foot can scrape along the ground.

Question 19

Describe a Parkinsonian gait

Answer 19

Slow, shuffling, asymmetrical reduced armswing, stride length is decreased
Festinant gait: increasingly rapid steps forward to maintain upright posture

Question 20

Describe a Steppage gait

Answer 20

Paralysis of dorsiflexors results in drop-foot. Flexes knee to clear foot from ground. Loud slapping noise as foot returns to ground.
(unilateral = spinal or common peroneal nerve palsy)
(bilateral = generalised polyneuropathy)

Question 21

Describe an ataxic gait

Answer 21

Sways to both sides while attempting to do heel-to-toe walking. Can sway to just one side.

Question 22

How would you complete the examination?

Answer 22

1. Thank the patient
2. Ask them to redress
3. Wash your hands