Neurological Examination - Limbs and Gait

Question 1

What is the order of the examination of the Limbs & Gait?

Answer 1

Observation

Tone

Power

Coordination

Reflexes

Sensation

Gait

Question 2

What are we looking for when inspecting the upper limbs?

Answer 2

Muscle atrophy

Fasciculations

Scars

Skeletal deformity

Involuntary movements

Tremor

Question 3

What does muscle atrophy suggest?

Answer 3

LMN lesion

Long term UMN lesion, due to disuse

Question 4

What do fasciculations indicate?

Answer 4

LMN lesion (hard to see)

Question 5

How is a tremor described?

Answer 5

Speed and amplitude

Is it worse at rest or during movement

Question 6

What are the 2 commonly found tremors and what are their features?

Answer 6

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

Question 7

What is tone and how it described?

Answer 7

This is the resistance felt by examinaer when moving a joint through its range of motions

Increased or decreased tone

Question 8

What are the 2 main types of increased tone?

Answer 8

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.

Question 9

What is important to consider when testing for tone?

Answer 9

• 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

Question 10

Which areas of the upper limb are tested for power?

Answer 10

Shoulder

Elbow

Wrist

Fingers

Intrinsic hand muscles

Pronator drift

Question 11

How is power graded?

Answer 11

0-5 on MRC scale

0 = no power

5 = full power

Question 12

What is an important point to consider when testing joint power?

Answer 12

Stabilise the limb above the joint being tested so only one joint is being tested (e.g support forearm when testing wrist power)

Question 13

How is the power of the shoulder tested?

Answer 13

Patient extend elbows to 90 degrees

Push hard up against you as you push down

Question 14

How is the power of the elbow tested?

Answer 14

Hold patients hand

Stabilise joint by holding arm above elbow joint

‘Pull me towards you’

‘Push me away’

Repeat on other arm

Question 15

How is the power of the wrist tested?

Answer 15

• Stabilise wrist joint by holding forearm
• Patient makes a fist
• Push up against your hand
• Push down against your hand
• Repeat on other arm

Question 16

How is the power of the hands assessed?

Answer 16

• 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

Question 17

How is pronator drift assessed?

Answer 17

• Arms stretched out, palms to ceiling
• Close eyes
• Watch for any drifitng of arms downwards or pronating

Question 18

How is coordination of the upper limb tested?

Answer 18

• 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

Question 19

What reflexes are tested in the upper limb and what nerve levels are being tested in each?

Answer 19

Biceps (C5/6)

Supinator (C6)

Triceps (C7)

Question 20

How are reflexes recorded?

Answer 20

+ reduced

++ normal

+++ exagerrated

+- present only with reinforcement

• absent

Question 21

If a reflex cannot be elicted normally, what additional step must be performed?

Answer 21

Reinforcement - ask the patient to squeeze the opposite hand just as you strike the tendon

Question 22

What are the components of testing sensation in the upper limb?

Answer 22

Light touch

Pin prick

Vibration

Joint position sense

Question 23

How is light touch sensation assessed in the upper limb and which dermatomes are being tested?

Answer 23

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)

Question 24

How is pinprick sensation assessed?

Answer 24

1) Ask patient to close their eyes
2) Touch them with neurotip in same areas as with cotton wool

Question 25

How is vibration sense assessed?

Answer 25

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

Question 26

How is joint position sense assessed?

Answer 26

• 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