neuro assessments Flashcards
What basic observations should be done at the start of a neuro assessment?
Scars
Wasting of muscles
Involuntary movements
Fasciculations
Tremor
What aspects of involuntary movement may be observed?
Tremor
Clonus
Chorea
Associated reactions
What aspects of posture and balance should be observed?
Alignment and attitude of limbs
Neglect
Sitting balance
Standing balance
What are aspects of sensory examination?
Superficial and deep
Superficial:
Pain
Temperature
Touch
Pressure
Deep:
Movement sense
position
vibration
How should a neuro assessment be started?
By confirming patient name, introducing self and checking if in any pain
How is upper limb tone assessed for?
Elbow should be supported
With hand hold passively with different speeds move hand through range, then elbow then shoulder
What does hypertonia mean?
Excess resistance when moving through passive range
Can be sign of upper motor neuron lesion
What is rigidity and what can it mean?
Rigidity is independent of velocity
Also known as “lead pipe” + tremor -> cog wheel
Can be seen in Parkinsons
What is spasticity and what is it a sign off?
Velocity dependent resistance
Pyramidial causes such as stroke
What is hypotonia associated with?
Lower motor neuron lesions
Lack of tone
What is cog-wheeling and rigidity a sign of?
Can be a sign of Parkinson’s
What might increased tone be a sign of?
Can be a sign of stroke
Which regions should be tested for strength and what are their corresponding nerve roots in the upper limbs?
Shoulder abduction - C5
Shoulder adduction - C6/C7
Elbow flexion - C5/C6
Elbow extension - C7/C8
Wrist extension - C7
Wrist flex - C6/7
Finger ext - C7
Finger flex - C8
FInger abd - T1 (ulnar nerve)
Thumb abduction - T1 median nerve
What would upper limb extensor weakness be a sign of?
Extensor weakness with less affect on flexors suggests upper motor neuron lesion
How do lower motor neuron lesions present?
Present with focal patterns of weakness
What other muscle test can be done in the upper limb?
Pronator drift
With pt both arms straight, eyes closed and palms facing ceiling
Observe for pronation and lowering
- lesion contralateral corticospinal tract causing weak supinator than pronators
How should reflex tests be performed and which areas should be tested in the upper limb?
Supinator / brachioradialis
Biceps
Triceps
For supinator and biceps a finger should be placed over the area and then hammer applied
How should sensation be assessed?
Light touch with cotton wool over dermatome areas
Same areas should then be assessed using a neurotip
If disturbance occurs continue to see if normal after as may show disturbance in that spinal level
Why are deep tendon reflexes assessed?
To differentiate between upper and lower motor neuron lesions
What is hoffman’s sign?
When flicking 3rd finger distal phalanx
Flexion of other digits is produced
Suggests upper motor neuron lesion
What does hyperreflexia suggest
Suggests upper motor neuron lesion
What does hyporeflexia suggest?
Suggests lower motor neuron disease
What should be assessed prior to co-ordination?
Muscle power as reduced muscle power can appear as poor coordination
How can proprioception be assessed?
Move specific joints up and down and assess if patient can feel this occurring?
How can coordination be assessed in the upper limb?
Via having the patient touch their finger to their nose and then back to your finger, examiner should move finger
Can also put one hand over the other and supinate and pronate as fast as possible over and over
What may be observed during a coordination test?
Dysmetria and tremors
What is dysmetria?
When patient misses finger in finger to nose test
Indicates ipsilateral cerebellar lesions
What is dysdiadochokinesia?
inability to perform fast alternating movement
Indicates ipsilateral cerebellar lesion
What do the different modalities of sensory assessments test for?
Light touch is for spinothalamic and dorsal column
Pin prick assesses pain through spinothalamic
Vibration tests the dorsal column - column in tact if can feel stop of vibration
In general what indicates a upper motor neuron lesion in an upper limb assessment?
Increased tone
Increased reflexes
Hoffman’s sign
Decreased power in a pyramidal pattern (extensors)
In general what is are signs of lower motor neuron lesion in the upper limbs?
Reduced tone
Reduced reflexes
No hoffmans
Reduced power
What is normal scapulohumeral rhythm?
Coordinated movement of humerus scapula and clavicle to achieve abduction and elevation
What does a disturbed scapulohumeral rhythm indicate?
Dynamic functioning of stabilisers and humerus are disturbed if dysfunction
What are the phases of scapulo thoracic rhythm
1st stage 30* elevation
- scapula stays same
- humerus 30*
- clavicle 0-5
2nd stage
- humerus 40* abduction (up to 90)
- Scapula 20* lateral rotation
- Clavicle 15* elevation
3rd stage
- humerus 60* abduction , 90 lat rotation to avoid impingement
- scapula 30-40* lateral rotation
- Clavicle 30-50* rotation posteriorly, 15* elevation
How should scapulohumeral rhythm be observed?
Both ascending and descending
Important to observe both as weakness of muscles that control scapula more obvious in descending phase or scapula jumping
If scapula moves more than humerus may be reverse scapulohumeral rhythm
What position should most neurological examinations be conducted in?
Supine with upper body at 45 degrees
How should gait be assessed?
Check can walk without help
Stand without arms
Walking normal in line
Tandem walking
Toe walking
Heel walking
What does standing without arms assess?
Proximal arm weakness
What should be assessed in normal gait?
Speed
Symmetry
Balance
Arm swing
or
Posture
Arm swing
Stability, stride length and height
Turning
What does toe walking test?
Plantarflexion strength
What does heel walking assess?
Dorsiflexion strength
What is romberg’s test?
Feet together
Hands by side
Eyes closed
Positive if lose balance and suggests if pt has ataxia is sensory in nature
What is romburg’s test a sign of?
Proprioception
How is tone assessed in the lower limb?
Leg roll
Knee lift
Ankle clonus - more than 5 contractions in a row show clonus
Passive movements
How will knee lift vary with tone?
Excess tone heel will raise with knee
What lower limb muscle groups are assessed for strength and what are their corresponding nerve roots?
Hip flexors: L1/L2
Hip extensors: L5/S1/S2
(Adductors: L2/L3
Abductors: L4/L5)
Knee extension: L3/L4
Knee flexion: L5/S1
Dorsiflexion: L4/L5
Plantarflexion: S1/S2
Great toe extension: L5
(Ankle inversion: L4
Ankle eversion: L5/ S1)
What do changes in strength in the lower limbs indicate?
Lower limb flexion affected greater than extensors shows upper motor neuron lesion
Focal pattern of weakness suggests lower motor neuron lesion
What reflexes should be tested in the lower limbs
Knee jerk: L3/L4
Achilles: L5/ S1
Externally rotate leg and dorsiflex foot
Plantar reflex (babinski): S1
What is indicated if babisnki is positive?
Upper motor neuron lesion
How is proprioception assessed in the lower limb?
Moving toes
Moving leg
How is coordination assessed in lower limb?
Heel to shin, fast as possible
Fast feet tapping against hands
What does an abnormal heel-shin indicated?
Lower limb weakness
Impaired joint proprioception
Cerebellar disorder
What movements can be done if absent?
Jaw clench
Jendrassic’s manouevre
What are common co-ordination abnormalities?
Shuffling gait
Ataxic gait
Waddling gait
High stepping gait
What is the trunk control test?
4 item test battery
- Each item scored 0, 12 or 25 points
- 0 if can’t without assistance
- 12 if can do with non muscular assistance, abnormal well or arms to stabilise in sitting
- 25 if patient is able to complete task normal
What is the trunk control test for?
Impairments in muscle function in those that have suffered a stroke or similar disorders
What are the 4 items of the trunk control test
- Lie in supine and roll to weak side
- Roll to strong side
- Sit on side of bench for 30 s without arms to support self
- Sit up from supine lying position
Can assist patient with tasks and ensure safety by staying close to patient and ensure safe
How is the trunk control test evaluated?
50 or less 6 weeks post-stroke indicates poor recovery
What scale can be used to assess spasticity?
Modified ashworth scale
0- no increase in tone
1- slight increase in tone with a catch and release or minimal resistance at end of range
2 = as before but with minimal resistance through range following catch
3 = more marked increase tone through ROM
4 = considerable increase in tone, passive movement difficult
5 = affected part rigid
How can reach be assessed?
Functional reach test
Cone reaching task
How can balance be assessed?
4 square step test
Single leg stand
Functional reach test
4 stage balance test
