OSCE Neuro Lower Limb Flashcards
Introduction:
What is involved for a lower limb neurological examination (5)?
- Introduce yourself (name, role and examination type)
-
Brief summary of the steps of the examination in layman’s terms/ what level of discomfort
is expected. Also need to explain the process of testing pain sensation e.g. “I’ll need to check the sensation on your arms with a pin but it won’t break the skin” - Ask if the patient has any pain in the area to be examined – in the case of lower limb examination – you would need to know if the patient has any joint pain (which may limit movement)
- Duration “This examination should tak around 6-8 minutes to complete”
- Physical exposure “I will need your thighs and legs exposed” (patient wearing shorts, modesty sheet if patient is wearing underwear only (covering pelvis and thighs)
- WASH HANDS
What positioning is required for the patient in the lower limb neurological exam?
Patient standing initially to assess gait and perform the Romberg test.
Lying supine for remainder of examination (Inspection, Tone, Power, Reflexes, Coordination, Sensation)
Name the components of the lower limb neurological exam (8)?
Gait
Rombergs test
Supine Inspection
Tone
Power
Reflexes
Coordination
Sensation
Name the two tests conducted to assess coordination in the lower limb neurological examination
Heel-Shin
Foot tapping
Why utilise coordination tests for a lower limb neurological examination?
Testing coordination is an assessment of the patient’s ability to execute complex
movements.
Coordination requires an intact cerebellum and intact cerebellar connections to cerebral cortex, thalamus and brainstem
Explain the Heel-Shin coordination test and how it is conducted?
Ask patient to run the heel of one foot up and down the shin of the other leg.
Demonstrate the movement passively first.
Normal = able to follow the line of the shin;
Abnormal = heel “wobbles” off shin.
Explain how the Foot tapping coordination test is done
Ask the patient to tap the sole of their foot against your palm as fast as possible. (seated position may be easier here)
Normal = smooth rapid movement.
Abnormal = “slow and clumsy” and referred to clinically
as dysdiadochokinesis.
How is Vibration sense tested in the lower limb neurological exam?
- Demonstrate vibration sensation to the patient by striking the tuning fork on a firm surface and then place on the patient’s sternum as a reference point
- Then ask the patient to their close eyes, strike the fork on a firm surface, place the vibrating fork on the distal interphalangeal joint of the 1st (great) toe
- Ask the patient if they can feel the vibration. If yes - ask the patient to tell you when the vibration stops, then “deaden the tuning fork with your hand”. Patient should detect this within a second.
- Then test the same joint level on the other lower limb.
What is vibration is deficient at the 1st DIP joint?
- If vibration is deficient, test other bony prominences by moving progressively proximally:
medial malleolus
tibial tuberosity
ASIS in lower limb. - Once you reach a level where vibration sensation is normal bilaterally – this is where you can stop.
If normal bilaterally at the IP joint of the first toe then you do not need to test any further
How is proprioception tested in the lower limb neurological exam?
- Hold the terminal phalanx of the 1st (great) toe between your thumb and forefinger (from the sides)
- Indicate direction first – demonstrate what up and down feel like.
- Then ask the patient to close their eyes and move the joint (IP joint of big toe) in a random selection of up/down movements, asking the patient to tell you in which direction
movement has occurred - Movement by even a small degree should be detected if
normal
Explain how the Romberg test is performed?
An assessment of the patients stability
- Ask the patient to stand tall with arms by their sides and feet together
- Place your arms either side of patient (not touching them) in case they start to lose balance.
- Ask the patient to close their eyes. This removes the visual information that assists to maintain position causing the patient to rely on proprioceptive and vestibular input to
maintain balance
What is a normal Romberg test? what about an abnormal Romberg test?
Normal (negative Romberg test) = mild unsteadiness when their eyes are closed.
Abnormal (positive Romberg test) = marked unsteadiness such that the patient has to open their eyes to avoid losing balance/look like they might fall.
Seen where there is a lesion affecting the proprioceptive pathways.
Why conduct the Romberg test? What does it tell us?
BALANCE - To achieve balance, a person requires 2 out of the following 3 inputs to the cortex:
1. Visual confirmation of position
2. Non-visual confirmation of position (including proprioceptive and vestibular input)
3. A normally functioning cerebellum.
Therefore, if a patient loses their balance after standing still with their eyes closed, but is able to maintain balance with their eyes open, this is indicative of pathology affecting the proprioceptive pathway.
Name the 4 components of Gait that are tested in the lower limb neurological exam?
Ask the patient to:
1. Walk forwards for a number of steps then turn and
2. Walk heel-to-toe (cannot do if midline cerebellar disease) back toward you then turn and
3. Walk on toes (requires intact S1 nerve root) for a number of steps then turn and
4. Walk on heels (requires intact L4 and L5 nerve roots)1 back toward you again.
General observation for any neurological exam should include what?
Commenting on:
Patients Conscious Level
Patients Facial expression
Patients Speech
How would normal gait be described (6)?
- Posture is straight and symmetrical - horizontal level between shoulders, hips, knee during stance, and foot fall at heel strike
- Controlled placement of the foot/toes on the ground at heel strike, without foot slap
- Upright trunk at heel strike, not flexed forward
- Little to no pelvic drop or excessive lateral translation during stance phase
- Clear dorsiflexion after the foot leaves the ground
- Controlled smooth movements without segments jerking into a locked position
How to test for clonus in the lower limb neurological examination?
If requested by an examiner in an assessment
- Position the leg with the hip externally rotated, and knee partially flexed
- Then, sharply dorsiflex the ankle and maintain this dorsiflexed position for a few seconds.
- Wait to feel for a “recurrent ankle plantar flexion movement” which is termed “clonus” and is abnormal
Explain the process of testing for pain and light touch sensation
Demonstrate how it feels on the sternal area first
Start at L1 dermatome (Lateral
part of the L1 dermatome is usually level with the shorts waistband laterally) and progress distally dermatome by dermatome, comparing right to left for each dermatome before you move to the next dermatome, test up to and including S2
Pain - use a special neurotip pin
Soft touch - Use cotton wool (dabbing)
Name the components tested for in the “sensation” part of the lower limb examination.
What neuroanatomical structure do these assess?
Pain - Spinothalamic tract
Light touch - Spinothalamic tract (mostly)
Proprioception - Dorsal column medial lemniscus pathway
Vibration sense - Dorsal column medial lemnicus pathway
