PACES - Limbs Flashcards
How would you test power of shoulder abduction?
‘Lift your arms into a chicken position, don’t let me push down’
How would you test power of arm flexion?
Put your arms in front of you like a boxer
Stop me from pulling you arms out
How would you test power of arm extension?
‘Put your arms in front of you like a boxer, push against my hand’
How would you test power of wrist flexion?
How you arms straight out and make a fist.
Hand under fist, push my hand down towards the ground
How would you test power of wrist extension?
Now cock your wrists back
Hold forearm, stop me from pushing your fist down
How would you test power of finger abduction?
Spread your fingers
Stop me from pushing your fingers together
How would you test power of thumb abduction?
Turn hand palm up, bring the thumb towards the ceiling. Stop me from pushing your thumb down
How would you test power of hip flexion?
‘Keeping your knee straight, lift your leg off the bed’
Hold their thigh, ‘stop me from pushing your leg down’
How would you test power of hip extension?
Push your leg down, hold underneath their thigh. ‘Push your leg into the bed’
How would you test power of knee flexion?
“Bend your leg at the knee and rest your foot flat on the bed.”
Hold their leg around the back of the calf. “Don’t let me straighten your leg/Pull your heel in towards your bottom”
How would you test power of knee extension?
Holding their leg on the shin.
“Try to straighten you leg, push against my hand away with your leg”
How would you test power of dorsiflexion?
Place leg straight again: point toes toward face. Place your hand on the dorsum of foot.
“Stop me from pulling your foot down”
How would you test plantar flexion?
Place your hand on the sole of the foot. “Push down against my hand”
Which anatomy are you testing with hip flexion?
1: Psoas
2: L2
3: Femoral
Which anatomy are you testing with hip extension?
1: Gluteus Maximus
2: L5/S1
3: Inf. gluteal nerve
Which anatomy are you testing with knee flexion?
1: Hamstrings
2: L5
3: Sciatic
Which anatomy are you testing with knee extension?
1: Quads
2: L3/4
3: Femoral
Which anatomy are you testing with dorsiflexion?
1: Tibialis anterior (and others)
2: L4/5
3: Deep Peroneal
Which anatomy are you testing with plantar flexion?
1: Gastronemeus (and others)
2: S1/2
3: Tibial nerve
How would you test for arm fasciculations?
Gently flick the deltoid if clinical suspicion
How do spasticity and rigidity differ?
Spasticity = velocity dependent (fast = more resistance)
Rigidity = constant resistance
Describe the muscle power grading system
0 = Absent contraction
1= Feeble (ie. twitching)
2 = Can move with gravity eliminated (ie. can move leg horizontally when lying on a bed)
3 = Move against gravity (Can lift heel off bed)
4 = Movement against partial resistance
5 = Full strength
What is Jendrassik’s Manoeuvre?
Reinforces reflexes
Ask them to clench their teeth or grasp their hands together and pull apart
What does a positive Romberg’s test mean and how would you carry it out?
Sensory ataxia (Peripheral neuropathy)
Tabes Dorsalis (Sensory pathways of spinal cord)
Ask them to stand with their feet close together and stretch out their arms.
Ask to close their eyes. If they fall, lack of proprioceptive input.
If cerebellar, unsteady when eyes are pen and closed.
how would a hemiparesis present?
UMN signs (Increase tone, brisk reflexes, upgoing plantars, Clonus)
Hemiparetic Gait
Sensory Loss
Visual Field defect?
What would your differential be in a pt presenting with hemiparesis?
Anterior circulation stroke
SOL
Cerebral Palsy
Stroke Mimic (Sepsis, Hypoglycaemia, Demyelination)
How would you manage a patient with a stroke?
A-E approach
Thrombolysis if <4.5h
Thrombectomy if <6h
Admit to Hyperacute stroke unit
Regular neuro obs,
CT Head
Aspirin, Statin
SALT, Rehab, Physiotherapy, OH assessment
Lifestyle advice
DVLA advice (4weeks)
Chadvasc/Hasbled anticoag advice
how would a spastic paraparesis present?
Bilateral increased tone
Pyramidal Weakness bilaterally
Increased reflexes
Upgoing plantars/clonus
Spastic scissoring gait
What are the main causes of a spastic paraparesis?
MS
Cord Compression
Trauma
Anterior horn cell MND
Cerebral Palsy
What is the likely cause if a patient presents with a spastic paraparesis and a clear sensory level?
Cord compression
Cord Infarction
Transverse Myelitis
What is the likely cause if a patient presents with a spastic paraparesis and UMN signs in the upper limbs?
cervical Myelopathy above C5
What is pyramidal weakness?
Weakness in upper limb extensors and lower limb flexors
What are the key signs of dorsal column pathology?
Loss of vibration
Loss of joint position sense
What are the key signs of a cerebellar syndrome?
Ataxic wide-based gait
Inability to walk heel to toe
Rhomberg Negative
Dysdiadokinesis, past pointing, intention tremor,
Nystagmus
Ataxid Dysarthria
Should be reduced tone,
What can cause a bilateral cerebellar syndrome?
MS
Paraneoplastic Syndromes
Stroke/SOL of Posterior Circulation
How might a peripheral neuropathy present?
Loss of sensation
Loss of proprioception
Charcot Joint?
What can cause a peripheral neuropathy?
B12 def
Diabetes
Alcohol
GBS
CMT
Amyloidosis
How is B12 def managed?
IM Hydroxycobalamin.
3/wk for 2 wks. then 3 monthly
What is charcot marie Tooth syndrome?
Peripheral Motor and sensory neuropathy
Distal wasting of legs and hands
Weakness, mild sensory loss
Arreflexia
Bilateral foot drop
high stepping gait
How common is CMT?
Fairly
1 in 2500
How does friedrich’s ataxia present?
Spastic Paraparesis
Absent lower limb reflexes
Cerebellar Signs
Has spinocerebellar signs, corticospinal tract signs, dorsal column signs
How is friedrich’s ataxia inherited?
Autosomal Recessive
Which investigations should you ask for in most neuro stations?
Bedside:
Bloods: B12/Folate, BMs, Syphylis
Nerve Conduction Studies
MRI/CT Head/Spine
AMTS?
Full CN screen
Gene check if ?inherited
How would you manage complex neuro cases?
MDT Approach
Involve specialist, SALT, OT, physio, geneticist etc
Screen family
Manage complications (Cardiac, Ortho, Endo)
How does a flacid paraparesis present?
Reduced tone bilaterally
Wasting and weakness
Reduced/absent reflexes
Downgoing plantars
What can cause a flaccid paraparesis?
Anterior horn -> Nerve Root -> Plexus -> Peripheral Nerve -> NMJ -> Muscle
AH - MND, Polio
NR - Compression (disc herniation, abscess, mets)
Plexus -> Lumbosacral Plexopathy
Nerve - GBS, Infection, CMT, Amyloid etc (Lots for this)
NMJ - MG, LE, Botulism
Myopathy - Poly/Dermatomyositis
Connective tissue disorders
Cancer
Drugs (Statins)
Lots others (Surgical sieve)
Pt presents with high stepping gait?
Common peroneal nerve palsy
L5 Radiculopathy
CMT
What can cause a mix of umn and lmn signs?
MND
Friedrich’s ataxia
Subacute combined degeneration of the cord
Taboparesis
Syringeomyelia
Which spinal cord tracts are motor in function?
Pyramidal = voluntary movement (corticospinal)
Extrapyradimal = Involuntary movements (reflexes, tics, posture)
Which spinal tracts are sensory in function?
Dorsal Column - Fine touch, proprioception, (crosses at medulla)
Spinocerebellar - proprioception
Spinothalamic - pain and temperature, crosses at level
Where would you test C5
Deltoid
Where would you test c6?
Thumb
Where would you test c7?
Middle finger
Where would you test c8?
Little finger
Where would you test T1?
Ulnar side of forearm
Carpal tunnel scar
What is clasp-knife spasticity?
Initial resistance to movement followed by sudden drop in tone (velocity dependent)
UMN lesions
Either flexors or extensors
What is lead pipe rigidity?
Hypertonicity which persists through range of movement (PD)
What is cogwheeling?
Start and stop movements (PD if has tremor)
What might cause an ataxic gait?
Cerebellar lesion (Veer to one side)
Sensory Ataxia (Watch feet, no proprioception)
What might cause a waddling gait?
Proximal lower limb weakness (myopathy)
How might someone with a unilateral/bilateral spastic paraparesis walk?
Bi - Scissoring, inverted feet, internal rotation of hips
Uni - Circumdating, one leg stiff and swings round in an arc with each stride
What is brown-sequard syndrome?
Hemisection of spinal cord
Complete sensory loss at level
Impaired pain and temperature ipsilaterally
Impaired fine touch, vibration contralaterally
What would be your differential for UMN signs?
Stroke
SOL
MS
What can cause a unilateral lower limb hemiparesis (One side completely spastic, the other side effectively normal)?
Hemisphere - Stroke, MS, SOL, Cerebral Palsy
Hemicord - MS, Cord Compression
What can cause a spastic paraparesis?
Common = MS, Corc compression (LMN at level, UMN below level), Cervical Myelopathy, Cord trauma, Cerebral Palsy
How do you perform Romberg’s test
30s with eyes together. Eyes closed
Positive = loss of balance = sensory ataxia (proprioceptive deficit)
Investigations for UMN lesion?
MRI cord and brain
Lumbar Puncture for MS (oligoclonal bands)
FBC for infection, CXR for malignancy
B12/Folate for subacute combined degeneration
What is the supportive management for UMN lesions?
MDT = gpm radiologist, neurosurgeon, physio, OT
Motility aids,
Catheterisation
Baclofen for spasticity
What can cause a stroke in a young person?
SLE/APLS/Vasculitis/Carotid artery dissection/SCA
What would your ddx for someone with stroke symptoms?
head injury, hypo/hyperglycaemia, Infection
Stroke rehab?
MENDS
MDT
Eating
neurorehab
DVT Prophylaxis
Sore avoidance
Most common symptoms of MS?
TEAM
Tingling
Eye (Optic neuritis)
Ataxia (+ Cerebellar signs)
Motor (Spastic Paraparesis)
Lhermitte’s Sign (electric shock down neck)
What is the diagnosis criteria for MS called?
McDonald’s Sign
MS management?
MDTapproach
Acute = steroids
Disease modifying = IFN-B
Biologics = Natalizumab
Symptomatic (pain - amitryptiline, spasticity baclofen
What can cause bilateral distal symmetrical LMN signs?
Motor peripheral Polyneuropathy - CMT, lead poisoning, paraneoplastic
What might cause bilateral symmetrical proximal LMN signs?
Muscular dystrophy
Poly/Dermatomyositis
Cushing’s Thyrotoxicosis
Steroids, Statins
Paraneoplastic
What might cause unilateral LMN signs?
Group of muscles with same supply = Peripheral mononeuropathy or nerve root damage
What can cause hand wasting
Anterior Horn: Syringeomyelia, MND, Polio
Roots: Spondylosis (C8,T1)
Brachial Plexus: Cervical Rib
Neuropathy: CMT, Mononeuritis Multiplex
Muscle: Myotonic Dystrophy, RA
How does a peripheral neuropathy (sensory) present?
DM, Alcohol, B12
bilateral, symmetrical, glove and stocking distribution. Loss of tendon reflexes. Signs of trauma/deformity. Loss of proprioception
How does a peripheral neuropathy (motor) present?
CMT, Paraneoplastic, GBS
Bilateral, symmetrical LMN weakness
Low tone, hyporefllexia
How would you investigate peripheral neuropathy?
urine dip
FBC (Infection), LFTs with GGT (Alcohol), U&E (CKD), Glucose and HBA1c, TFTs, B12, Folate
CXR (Paraneoplastic)
Nerve conduction studies
Nerve Biopsy
MRI if in doubt about location of lesion
CMT
CMT
Pt has:
peripheral muscle wasting
Stepping Gait
Weak dorsiflexion
Absent ankle jerk
Variable sensory loss
CMT
MDT, foot care, orthoses
Parkinson’s presentation
Inspection: asymmetric resting tremor, mask-like facies, dysphonia
Gait: Shuffling, absent arm swing
Arms: Cogwheeling/lead pipe rigidity, normal power/reflexes, tremor, bradykinesia, coordination
Eyes: Vertical gaze palsy if PSP, nystagmus if MSA
Function: Struggles with buttons/tying shoes
Mask-Like facies
Vertical gaze palsy - PSP
Parkinson’s Ix
Full history
LL/CN Exam - look for PSP/MSA
Lying Standing BP
MMSE
Test for micrographia
Drug Chart (Iatrogenic)
Bloods - FBC, U&Es, LFTs, Lipids, HBA1c, Copper studies
CT/MRI
Parkinson’s Mx
MDT
L-dopa + Carbidopa
Dopamine agonists
MAO-B Inhibitors
Parkinsonism syndrome causes
PD
PSP, MSA, LBD
Vascular
Metoclopramide, Prochlorperazine
PSP
PD plus postural instability, vertical gaze palsy
MSA
PD plus autonomic failure (cerebellar signs, postural hypotension)
Side effects of L-Dopa?
Dyskinesia
On/Off
Insomnia
Cerebellar signs
DANISH
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Scanning dysarthria
Hypotonia
Causes of cerebellar syndrome
DAISIES
Demyelination
Alcohol
Infarct
SOL
Inherited (ataxia telangiectasia, Friedrich’s)
Epilepsy meds
System Atrophy
CN 5,6,7,8 + cerebellar signs
Vestibular Schwannoma
Pt presents with:
Pes cavus
Bilateral Cerebellar Ataxia
Leg wasting
Arreflexia
Loss of vibration and proprioception
Friedrich’s Ataxia
AR mitochondrial disorder
Degeneration of dorsal column, spinocerebellar tracts and corticospinal tracts
Cerebellar exam
Inspection
Gait
Romberg
Arms
Coordination
Eyes
Speech
What might cause bilateral ptosis?
MG
Myotonic Dystrophy
