Neurological Examination of Limbs

Question 1

What are the overall steps to a neuro exam of the limbs?

Answer 1

Arms and legs:

• Inspection
• Tone
• Power
• Coordination
• Reflexes
• Sensation

Gait

Question 2

What are you looking for on inspection?

Answer 2

Scars/skeletal deformities
Wasting of the muscle
Involuntary movements - dystonia, chorea/athetosis, ballismus, ticks
Fasciculations
Tremor

Question 3

How do you check tone of the arms? What are you looking for

Answer 3

Elbow flexion/extension
Forearm pronation/supination
Wrist flexion/extension

Compare both sides
Consider sudden movements to ensure no voluntary muscle contraction from patient

Looking for spasticity (UMN lesion) or rigidity (extra-pyramidal)

Question 4

How do you check power of the arms?

Answer 4

Shoulder abduction
Elbow flexion/extension
Wrist flexion/extension
Fingers - flexion (squeeze), extension (use side of hand to push), intrinsic (spread fingers and stop from pushing in), thumb abduction
Pronator drift

Grade on MRC 0-5

Question 5

How do you test coordination in the arms?

Answer 5

Outstretched arms (tremor/dystonia)
Finger-nose test - both sides
Rapid alternating hand movements - dysdiadochokinesis - both sides

Question 6

How do you test the reflexes in the arm, and which spinal levels are they testing?

Answer 6

Biceps - C5/6
Supinator - C6
Triceps - C7

Both sides
Reinforce with teeth clench or hand squeeze

Question 7

How do you test sensation in the upper limb?

Answer 7

Light touch - cotton wool
- C5-8, T1
Pinprick sensation - same areas
Vibration sense - small tuning fork (128Hz) - on joint, move proximal until felt
Joint position sense

Question 8

How do you assess tone of the legs?

Answer 8

Hip rotation
Knee drop
Ankle clonus - sudden, but fairly small, dorsiflexion

Question 9

How do you assess power in the legs?

Answer 9

Hip flexion/extension (push thigh against hand and push down)
Knee flexion/extension (bend knee and push/pull)
Ankle dorsiflexion/plantarflexion
Bit toe extension

Question 10

How do you assess coordination in the legs?

Answer 10

Heel-shin test

Question 11

What reflexes are tested in the lower limb and which spinal levels do they correspond with?

Answer 11

Knee - L3,4
Ankle - S1
Plantar response (normal is down)
Reinforce by interlocking fingers and pulling

Question 12

How is sensation tested in the lower limb?

Answer 12

Light touch - L2-5, S1
Pinprick - same areas
Vibration sense
Joint position sense

Romberg’s test

Question 13

How is gait assessed?

Answer 13

Rise from sitting without using arms
Walking and turning
Tandem walking
Walking on tiptoes and heels