Neurological Examination - Limbs and Gait Flashcards
What is the order of the examination of the Limbs & Gait?
Observation
Tone
Power
Coordination
Reflexes
Sensation
Gait
What are we looking for when inspecting the upper limbs?
Muscle atrophy
Fasciculations
Scars
Skeletal deformity
Involuntary movements
Tremor
What does muscle atrophy suggest?
LMN lesion
Long term UMN lesion, due to disuse
What do fasciculations indicate?
LMN lesion (hard to see)
How is a tremor described?
Speed and amplitude
Is it worse at rest or during movement
What are the 2 commonly found tremors and what are their features?
Physiological tremor - Fine, fast upper limb tremor caused by alcohol, anxiety, drugs, hyperthyroidism
Parksonian tremor - Coarse, slow, greater at rest and mostly asymetrical in upper limbs
What is tone and how it described?
This is the resistance felt by examinaer when moving a joint through its range of motions
Increased or decreased tone
What are the 2 main types of increased tone?
Spasticity - velocity dependent resistance to passive movement, the resistance of tone varies throughout the range of joint movements
Rigidity - sustained resistance to joint movement, even with slow movement. The increased tone is constant throughout the entire movement of joint. Lead-pipe rigidity = throughout movement, cog-wheel rigidity = jerky feel, present in Parkinsons.
What is important to consider when testing for tone?
- Ensure the movements are passive and the patient is totally relaxed
- Quick but gentle movements can help ensure they patient is relaxed
- Ensure to check for any pain before proceding
Which areas of the upper limb are tested for power?
Shoulder
Elbow
Wrist
Fingers
Intrinsic hand muscles
Pronator drift
How is power graded?
0-5 on MRC scale
0 = no power
5 = full power
What is an important point to consider when testing joint power?
Stabilise the limb above the joint being tested so only one joint is being tested (e.g support forearm when testing wrist power)
How is the power of the shoulder tested?
Patient extend elbows to 90 degrees
Push hard up against you as you push down
How is the power of the elbow tested?
Hold patients hand
Stabilise joint by holding arm above elbow joint
‘Pull me towards you’
‘Push me away’
Repeat on other arm
How is the power of the wrist tested?
- Stabilise wrist joint by holding forearm
- Patient makes a fist
- Push up against your hand
- Push down against your hand
- Repeat on other arm
How is the power of the hands assessed?
- Put fingers out straight
- Try and hold them there as I push down
- Squeeze my fingers
- Spread fingers wide and try to help them apart as I try push them together
- Turn hand over so palm facing upwards
- Push their thumb up as you try to push it down
How is pronator drift assessed?
- Arms stretched out, palms to ceiling
- Close eyes
- Watch for any drifitng of arms downwards or pronating
How is coordination of the upper limb tested?
- Arms outstrecthed and look for any postural tremor
- Finger-nose test:
- Touch my finger with your index finger, then touch your nose then touch my finger again
- Please repeat this is as quickly as you can
- Test both sides
- Rapid alternating hand movements:
- Hold left hand out flat and tap it repeatedly with the right hand
- The tap and turn the right hand over rapidly
- Repeat with the opposite hands
What reflexes are tested in the upper limb and what nerve levels are being tested in each?
Biceps (C5/6)
Supinator (C6)
Triceps (C7)
How are reflexes recorded?
+ reduced
++ normal
+++ exagerrated
+- present only with reinforcement
- absent
If a reflex cannot be elicted normally, what additional step must be performed?
Reinforcement - ask the patient to squeeze the opposite hand just as you strike the tendon
What are the components of testing sensation in the upper limb?
Light touch
Pin prick
Vibration
Joint position sense
How is light touch sensation assessed in the upper limb and which dermatomes are being tested?
Using cotton wool and with patients eyes closed:
1) Touch thumb (C6), middle (C7) and little finger (C8) with cotton wool and ask if patient can feel it
2) Touch the medial and lateral aspects of forearm (C6 & T1)
3) Medial and lateral aspects of upper arm (C5 & T1)
How is pinprick sensation assessed?
1) Ask patient to close their eyes
2) Touch them with neurotip in same areas as with cotton wool
How is vibration sense assessed?
Use the 128 HZ tuning fork (large one)
- Start distally and place the vibrating fork over the most distal join of the finger
- Only move more proximally if it cannot be felt distally
How is joint position sense assessed?
- Patient closes their eyes and make small movements of one of their fingers when holding the joint laterally
- Ask if the movement is up or down
- Explain to the patient the movements with their eyes open before proceding with eyes closed
