Neurological Examination UL and LL

Question 1

What are the major categories of neurological diseases?

Answer 1

Infectious
Traumatic
Genetic
Vascular
Degenerative
Toxic
Metabolic
Neoplastic
Inflammatory/Immune

Question 2

What are the four divisions of a neurological examination?

Answer 2

Cranial nerve
Upper limb
Lower limb
Additional exams and tests

Question 3

What is the cranial nerve examination for?

Answer 3

A test of the brain and it’s neuronal pathways to locate where along the nervous system the problem and lesion is occurring

Question 4

What is the difference between UMN and LMN conditions?

Answer 4

Both reduced power however
UMN - increased tone, reflexes, normal muscle bulk and plantar up
LMN - reduced tone, reduced or absent reflexes, wasting and atrophy and platar down

Question 5

What are the general sections of a limb exam?

Answer 5

Inspection
Tone
Power
Reflexes
Co-ordination
Sensation (light touch, vibration, proprioception, pain, temperature)

Question 6

What are you visually inspecting for UL?

Answer 6

SWIFT - scars, wasting, involuntary fasiculations and tremors.
Make sure to take a proper look, compare both sides. Look both inside and outside of the arm.

Question 7

How do we examine UL tone?

Answer 7

Ask patient to go floppy and ask if in any pain.
Test elbow flexion and extension
Test tone in wrist with flexion and extension
Test on pronation and supination

Test one side and then the other immediately to compare the sides.

Question 8

How do we examine power for UL?

Answer 8

Shoulder abduction - put arms up (like the chicken song) and don’t let me push them down
Shoulder adduction - same but push up
Elbow flexion and extension - push me towards and away from you
Wrist and finger extension - cock wrist up and keep it there (apply force)
Small muscles of the hand
- Interossei
dorsal - spread fingers apart
palmer - hold this paper between your fingers and ill try and pull it out

Question 9

What is key about the power examination for UL?

Answer 9

Compare like for like e.g. use your interossei to pull the paper from between their fingers so you can compare your muscles against their’s

Question 10

How do we grade power?

Answer 10

MRS power scale out of 5

Question 11

What reflexes do we test for UL?

Answer 11

Biceps (C5, C6)
Supinator (C5, C6, C7)
Triceps (C6, C7, C8)
(Finger flexors bonus)

Compare both sides!

Question 12

What is the next step if a reflex is absent?

Answer 12

Reinforcement! So to clench their teeth or do the jandrassik movement. If still absent it could be technique or honestly absent!

Question 13

What is hoffman’s sign?

Answer 13

The babinski sign of the UL, flick the third phalynx of middle finger and their thumb will move.

Question 14

How do we examine co-ordination?

Answer 14

1. Rebound - ask to put both arms out and tap them, most people will drop their arms and rebound back, with poor coordination it will bounce for a while first
2. Finger to nose test (pass pointing and intention tremor)
3. Dysdiadokokinesia - rapidly altering movements, so flipping hand back and forward in the palm of the other (left side of brain is effected in left-sided problem)

Question 15

What are the main giveaways for cerebellar dysfunction (poor co-ordination)?

Answer 15

Dysdiadokokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia

Question 16

THIS

Examine a normal patient and present it back!

Answer 16

On slide!

Question 17

What do we inspect on LL exam?

Answer 17

SWIFT again but bony deformities (pes cavus is common), may check gait.

Question 18

How do we assess LL tone?

Answer 18

Ask for any pain in their legs

1. Roll leg from side to side
2. Place hand under knee joint and briskly lift up leg (hard in UMN)
3. With knee flexed check ankles by doing flexion and dorsiflexion, and then examine for clonus (UMN)

Question 19

How do we test power for LL?

Answer 19

Hip flexion - raise leg straight and don’t let me push it down
Hip extension - push down against my hand
Knee flexion and extension - don’t let me straighten knee
Ankle plantar and dorsi flexion (isolate ankle)
Eversion and inversion

Question 20

How do we test reflexes for LL?

Answer 20

Knee jerk (L2-L4) do it at right angles so you're taking the patient's weight
Ankle jerk (S1, L5) tap Achilles tendon and look for gastroc action
Plantar reflex (S1) toes curl down wards if you scrape up the patients foot. If they go up it's pathological. Normal in babies.

Question 21

What is the plantar response?

Answer 21

Blunt instrument across lateral border of foot, normal that big toe curls down, if up then babinski sign/plantar response.

Question 22

UMN and LMN are where in the nervous system?

Answer 22

UMN - brain, spinal cord

LMN - cell body, nerve, neuromuscular junction and muscles

Question 23

What might you see around a patient’s bedside?

Answer 23

A wheelchair
Bottle for urine or catheter
Walking aids
Muscle wasting

Question 24

What is pronator drift?

Answer 24

Whilst trying to supinate the arm, subtle upper limb weakness pronates it. The lesion is an upper motor neurone one, so flexes are stronger than extensors in upper arms. This is reversed in legs.

Question 25

What is the difference between spasticity and rigidity?

Answer 25

Spasticity is where there’s increased tone when you move the limb with greater velocity.
Rigidity is where tone is increased throughout movement, not dependent on velocity.

Question 26

There are four areas of sensation we test, what are they and what tracts control them?

Answer 26

Light touch - dorsal column
Pin prick (alternate between sharp and blunt tip) - spinothalamic
Vibration (using a tuning fork on distal bony prominence, do vibration and then stop and ask patient when it's stopped, move upwards on prominences if they can't identify) - dorsal column
Proprioception - dorsal column

Question 27

What can cause a peripheral neuropathy?

Answer 27

Alcohol abuse
Diabetic neuropathy
Usually a glove and stocking distribution

Question 28

How do we test proprioception?

Answer 28

Move the patients thumb up and down. Ask them to tell you if it’s up or down. Move along arm if it’s wrong e.g. do wrist then elbow until they get it right.

Question 29

How do you assess upper limb coordination?

Answer 29

Testing cerebellar function.
Dysdiadochokinesia.
- Put left hand out, palm up, and then sandwich right on top. Then, flip the right so back of hand is touching. Get them to flip quickly from one to the other.
- Get patient to touch their nose and your finger, whilst you move your finger. They may over shoot, poor depth perception (pass pointing). Do with both hands.

Question 30

What is an intention tremor?

Answer 30

A tremor that gets worse when trying to touch for something.

Question 31

What might we assess during gait assessment?

Answer 31

Speed
Symmetry
Stance
Stability
Arm swinging
Steps
Turning (may be harder or be shuffling)

Question 32

What is a parkinsonian gait?

Answer 32

Shuffling gait

Pill rolling tremor in hands

Question 33

What are the common gait abnormalities?

Answer 33

Ataxic gait (sensory or ataxic)
Parkinsonian gait
High stepping gait
Waddling gait
Hemiparetic gait (one leg is stiff)
Spastic paraparesis

Question 34

What is romberg’s test for ataxia type?

Answer 34

Ask patient to stand with their legs together. Put your hands either side so they don’t fall. Ask them to close their eyes. If patient wobbles - sensory ataxia.
If patient unsteadiness doesn’t change, it is cerebellar.