OSCE - Neuro Upper Limb

Question 1

Upper Motor Neuron Lesion:
Two motor tracts potentially involved are?

Answer 1

1. Corticospinal Tract
2. Corticobulbar Tract

Question 2

Causes of UMN lesions are?:

Answer 2

Stroke
Multiple sclerosis
MND
Vitamin B12 deficiency
Tumour

Question 3

Causes of LMN lesions are?

Answer 3

Peripheral neuropathies (Diabetes mellitus) MND

Question 4

Why does hyperreflexia occur in UMN lesions?

Answer 4

UMN are responsible for inhibiting the activity of LMNs
When there is damage to the UMNs, this inhibition is lost, causing increased activity and sensitivity of LMNs

Question 5

Upper limb neurological exam is split into what?

Answer 5

Examination of Motor and sensory systems

Question 6

Describe how motor systems are examined in an upper limb neurological exam?

Answer 6

Motor:
1. General inspection
- Posture
- Muscle bulk
- Abnormal movements
- Fasciculations
2. Tone (passive tension)
3. Power (active tension)
4. Reflexes
5. Coordination

Question 7

Describe how sensory systems are examined in an upper limb neurological exam

Answer 7

Sensory system:
1. Pain
2. Vibration and proprioception
3. Light touch

Question 8

Patient positioning for the upper limb neurological exam?

Answer 8

Seated on a chair or the edge of the examination bed

Question 9

How is Tone tested in an upper limb neurological exam?

Answer 9

• Ask the patient to relax their arm
• Hold patient’s hand as you would if you were going to shake hands and use your other hand to support their elbow
• Test tone by pronation and supination of the patient’s forearm, flexion and extension of elbow and wrist (this is done passively)

Question 10

How is tone described?

Answer 10

Describe findings as:
1. Normal tone exhibited throughout the upper limb musculature of both the left and right arms
2. Increased (hypertonic)
- UMN/extrapyramidal lesion
- Due to progressive loss of inhibitory input in descending pathways
3. Decreased (hypotonic)
- Occurs when LMN stimulatory function is affected but the inhibitory influences from upper remain

Question 11

How is power described in the upper limb neurological exam?

Answer 11

To decide whether the power is normal, the patient’s age, sex and build should be taken into account

0 No movement, complete paralysis
1 Flicker of muscle contraction
2 Movement possible when gravity excluded (movement in horizontal plane)
3 Movement possible against gravity, but not resistance
4 Moderate movement against resistance
5 Normal power - equal to the examiner

Question 12

If normal power is found in all upper limb movements, how is this described?

Answer 12

” Patient exhibits 5 out of 5 power for all movements in the left and right upper limb”

Question 13

List the movements in the upper limb neurological exam that are tested for power

Answer 13

10 total movements:
2 shoulder (abduction, adduction)
2 elbow (flexion, extension)
2 wrist (flexion, extension)
4 finger (flexion, extension, abduction, adduction)

Question 14

Explain how to test for power at the shoulder

Answer 14

Can do both arms at once
Abduction:
“Put your arm up like chicken wings and resist me pushing them down”
Adduction:
“Arms in by your sides (same bend elbow position as abduction) and resist me pulling them up”

Question 15

Describe the muscles tested and myotomes for the following movements:
a) Elbow flexion
b) Elbow extension

Answer 15

a)
Muscles: Biceps, brachialis
Myotomes: C5, C6
b)
Muscles: Triceps
Myotomes: C7, C8

Question 16

Describe the muscles tested and myotomes for the following movements:
a) Wrist flexion
b) Wrist extension

Answer 16

a)
Muscles: Flexor carpi ulnaris & radialis
Myotomes: C6, C7
b)
Muscles: Extensor carpi ulnaris & radialis
Mytotomes: C7, C8

Question 17

Describe how to test wrist flexion and extension power

Answer 17

Wrist flexion
“Place arms out in front of you and bend your wrists under, keep them under while I push up”
Wrist extension
“Place arms out in front of you and bend your wrist back, like stopping traffic, keep the back while I try to pull them down”

Question 18

Describe how to test the 4 finger movements for power

Answer 18

Finger flexion
“Make a fist using your fingers and Squeeze my two fingers, don’t let me pull them out”
Finger extension
“Hold your fingers out straight and don’t let me push the down”
Finger abduction
“Fan out your fingers and don’t let me push them together”
Finger adduction
“Interlace your fingers with mine and don’t let me pull them out”

Question 19

List the muscles tested and the specific myotomes for the following movements:

a) Finger Flexion
b) Finger Extension
c) Finger Abduction
d) Finger Adduction

Answer 19

a)
Muscles: Flexor Digitorum Superficialis/Profundus
Myotomes: C7, C8
b)
Muscles: Extensor digoitorum, Extensor Indices, Extensor digiti minimi, Interossei (Interphalageal joints)
Myotomes: C7, C8
c) & d)
Muscles: Palmar and Dorsal Interossei
Myotomes: C8, T1

Question 20

Explain how power is tested in sequence

Answer 20

Ask the patient to do the movement first - if they are able to it demonstrates movement is possible against gravity = grading is 3/5 at least
- Then provide resistance by applying an opposing force with your own hands.
- Test the same movement on both sides before progressing to the next movement
- Test power by isolating the joint you are testing - you need to stabilise the limb

Question 21

List the reflexes tested in the upper limb neurological examination (4):

Answer 21

Biceps
Triceps
Brachioradialis
Finger jerk

Question 22

Explain the Bicep reflex, including:
a) How to test
b) Normal response
c) Nerve root assessed

Answer 22

a) Place your finger (or thumb) on the biceps
tendon and tap your finger (or thumb) with the hammer
b) Elbow flexion
c) C5 C6

Question 23

Explain the Tricep reflex, including:
a) How to test
b) Normal response
c) Nerve root assessed

Answer 23

a) Support patient’s arm with your arm (or
hand) and tap over the triceps tendon (can
be done with the shoulder abducted, in
neutral, or adducted)
b) Elbow extension
c) C7, C8

Question 24

Explain the Brachioradialis reflex, including:
a) How to test
b) Normal response
c) Nerve root assessed

Answer 24

a) Place two fingers over the lateral side of
radius (just proximal to the wrist) and tap your fingers with the hammer
b) Elbow flexion
c) C5, C6

Question 25

Explain the Finger Jerk reflex, including: a) How to test b) Normal response c) Nerve root assessed

Answer 25

a) Ensure patient has hand resting with palm upwards and fingers partially flexed. Place your fingers over patient fingers on palmar side and strike your own fingers with the hammer. b) Finger flexion c) C8

Question 26

List and the two tests for coordination in the upper limb neurological examination

Answer 26

Tests used to test coordination, or the patients ability to execute complex movement (thus, cerebellar function) 1. Finger-nose test 2. Rapidly alternating hand movement

Question 27

Describe the finger-nose test, including normal and abnormal findings

Answer 27

- Test both L and R index fingers - Ask patient to reach out and touch your index finger, then touch your nose, repeat 5-6 times Normal: No tremor as finger approaches your finger (if tremor present - called intention tremor) Abnormal: Past pointing (cerebellar disease)

Question 28

Describe the rapdily alternating hand movement test, including normal and abnormal findings

Answer 28

- Demonstrate movement to patient - Ask the patient to pronate and supinate one hand on the dorsum of the other as fast as possible - Repeat on both sides Normal - smooth rapid movement Abnormal - slow and clumsy and referred to clinically as dys-diado-cho-kinesis

Question 29

How is pain sensation tested in an upper limn neurological exam?

Answer 29

Use a Neurotip pin Demonstrate to patient that this feels sharp by touching a normal area (sternal area or skin) Patient closes eyes and ask them to say "sharp" or "blunt" when they feel you touch them Start at C5 dermatome and progress distally dermatome by dermatome (comparing left to right for each)

Question 30

How is light touch sensation tested in an upper limb neurological examination?

Answer 30

Use cotton wool and dab Touch irregularly not in a regular rhythm so that the patient cannot anticipate your touch Same process as pain: Demonstrate how it feels on sternal area Ask patient to close eyes and say "yes" when they feel you touch them Start at C5 dermatome and progress distally dermatome by dermatome (comparing left to right for each) Ask patient if the sensation is felt the same on both arms

Question 31

Explain how proprioception is tested in the upper limb neurological exam

Answer 31

Use the distal interphalangeal joint of the patient’s finger (hold the sides) (first digit??). When the patient has his or her eyes open, grasp the distal phalanx from the sides (not the top and bottom) and move it up and down to demonstrate these positions. Start with big movements so the patient gets the idea, and progress to smaller movements. E.g., Up and Down - show patient these movements first then close eyes Then ask the patient to close the eyes while these manoeuvres are repeated random As a rule, sense of position is lost before sense of movement, and the little finger is affected before the thumb

Question 32

Explain how vibration sense is tested in the upper limb neurological exam

Answer 32

- Tuning fork on bony points - 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 so they know what it should feel like. - 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 index finger. - 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 upper limb

Question 33

If vibration sense is deficient, what should be done next to further test this?

Answer 33

If vibration is deficient, test other bony prominences by moving progressively proximally – ulnar head, olecranon, acromion in upper limb. Once you reach a level where vibration sensation is normal bilaterally – this is where you can stop. If normal bilaterally at the DIP joint then you do not need to test any further (i.e. no need to progress proximally)

Question 34

To complete the upper limb neurological examination, what other tests would be performed?

Answer 34

I would perform the other two components of the neurological examination: 1. Lower limb neurological examination 2. Cranial nerve examination

Question 35

Explain how reflexes are graded in an upper limb neurological examination

Answer 35

0 Absent + Present but reduced (hyporeflexia and occur with interruption of the reflex arc at any of its levels) ++ Present and normal +++ Increased - this can be normal or abnormal (d hyperreflexia and occur with upper motor neuron lesions so that there is no descending inhibition of the stretch reflex arc)

Question 36

How would you present findings if power is not normal?

Answer 36

The pattern needs to be described, and can be described in the following ways: * Symmetrical or asymmetrical * Proximal or distal * Particular muscle involved * Particular nerve root affected NOTE: This can be as you perform each movement (saves remembering it all at the end)