Lower neuro exam

Question 1

UMN vs LMN

Answer 1

UMN:

• no fasciculation or significant wasting
• increased +/- ankle clonus
• hyperreflexia
• pyramidal pattern of weakness
• babinski +ve

LMN:

• wasting and fasciculation
• hypotonia
• different pattern of weakness
• hyporeflexia
• normal plantar reflexes

Question 2

gait types:

stance
stability
arm swing
steps
turning

Answer 2

-broad ataxic gait linked midline cerebellar pathology
-staggered slow and unsteady gait is typical of cerebellar pathology
unilateral cerebellar disease
-absent/reduced in Parkinson’s disease
-cerebellar disease= turning manoeuvre

Question 3

Tandem gait

Answer 3

walk to end of exam room with heels to toes

(exacerbates underlying unsteadiness)

dysfunction of cerebellar vermis
or weakness of flexor muscles of leg/sensory ataxia

Question 4

What are the types of gait abnormalities?

Answer 4

• ataxic gait
• parkinsonian gait
• high stepping gait
• waddling gait
• hemiparetic gait
• spastic paraparesis

Question 5

Explain the types of gait in detail:

Answer 5

Ataxic gait: broad-based, unsteady and associated with either cerebellar pathology or sensory ataxia (e.g. vestibular or proprioceptive dysfunction). In the context of proprioceptive sensory ataxia, patients typically watch their feet intently to compensate for the proprioceptive loss. If a cerebellar lesion is present the patient may veer to the side of the lesion.
Parkinsonian gait: small, shuffling steps, stooped posture and reduced arm swing (initially unilateral). The patient will require several small steps to turn around. The gait appears rushed (festinating) and may get stuck (freeze). Hand tremor may also be noticeable.
High-stepping gait: can be unilateral or bilateral and is typically caused by foot drop (weakness of ankle dorsiflexion). The patient also won’t be able to walk on their heel(s).
Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk. Waddling gait is commonly caused by proximal lower limb weakness (e.g. myopathy).
Hemiparetic gait: one leg held stiffly and swings round in an arc with each stride (circumduction). This type of gait is commonly associated with individuals who have had a stroke.
Spastic paraparesis: similar to hemiparetic gait but bilateral, with both legs stiff and circumducting. The patient’s feet may be inverted and “scissor”. This type of gait is typically associated with hereditary spastic paraplegia.

Question 6

What is Romberg’s test?

Answer 6

assess loss of proprioceptive/vestibular function (sensory ataxia)
NOT CEREBELLAR FUNCTION

need 2 of: proprioception, vestibular function, vision to maintain balance

feet together and arms by side, close their eyes

Falling without correction is abnormal and referred to as a positive Romberg’s sign (= unsteadiness due to sensory ataxia)

Swaying with correction is not a positive result and often occurs in cerebellar disease due to truncal ataxia

Question 7

How to assess tone in legs?

Answer 7

patient lying on exam couch, roll each leg (for muscles rotating hip)

lift each knee off bed and observe movement of leg
normal= knee rises and heel stays in contact with bed
heel lifts if increased tone

Question 8

What is ankle clonus?

How to examine?

Answer 8

clonus= series of involuntary rhythmic muscular contractions and relaxations (linked to UMN lesions of descending motor pathways)

1. position leg so knee and ankle are slightly flexed, support leg with hand under knee
2. dorsiflex and evert foot (stretches gastrocnemius muscle)
3. observe clonus (felt as rhythmic beats of dorsiflexion and plantarflexion) >5 beats= abnormal

Question 9

Hip flexion test

Answer 9

L1/2

raise leg off bed and apply down resistance over anterior thigh

Question 10

Hip extension test

Answer 10

L5/S1/S2

hand under thigh and they resist as you try lift their leg

Question 11

Knee flexion test

Answer 11

S1

flex their knee so foot is flat on bed, apply resistance by pulling lower leg towards you

Question 12

Knee extension test

Answer 12

L3/4

knee still flexed, position hand over anterior portion of lower leg and ask patient to try straighten leg

Question 13

Ankle dorsiflexion test

Answer 13

L4/5

leg flat on bed, dorsiflex foot and resist you trying to push foot down

Question 14

Ankle plantarflexion test

Answer 14

S1/2

leg flat on bed, plantarflex foot and resist trying to push foot up

Question 15

Big toe extension test

Answer 15

L5

leg flat on bed, extend big toe and resist you trying to push it down

Question 16

Knee jerk reflex

Answer 16

L3/4

hang legs over side of bed
limb= relaxed

tap patellar tendon

Question 17

Ankle-jerk reflex

Answer 17

S1

tap achille’s tendon