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Yr 3 - Clinical Examinations > Peripheral Nerve Exam - Lower Limb > Flashcards

Peripheral Nerve Exam - Lower Limb Flashcards

1
Q

What is the main purpose of a neurological examination?

A

to localise where in the nervous system the problem is – is it UMN (brain, spinal cord) or LMN (nerve roots, peripheral nerve, NMJ or muscle)?

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2
Q

Define ataxia

A

Lack of muscle control or coordination of voluntary movements

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3
Q

Define fasciculation

A

A brief spontaneous contraction affecting a small number of muscle fibres, often causing a flicker of movement under the skin (i.e. muscle twitch).

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4
Q

Define choreiform

A

Involving involuntary movement that resembles chorea (jerky involuntary movements affecting especially the shoulders, hips and face)

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5
Q

Define athetosis

A

abnormal muscle contraction causes involuntary writing movements (affects some people with cerebral palsy)

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6
Q

Describe how athetosis and choreiform differ

A

Chorea is ongoing** jerky involuntary movements whereas athetosis is a **slow continuous, writing movement that prevents maintenance of stable posture.

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7
Q

UMN lesion vs LMN lesion → fasciculations?

A

UMN → no fasciculation

LMN → fasciculation of muscles

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8
Q

UMN lesion vs LMN lesion → wasting of muscle?

A

UMN → no significant wasting (may be disuse atrophy or contractures)

LMN → wasting of muscles

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9
Q

UMN lesion vs LMN lesion → tone?

A

UMN → increased tone (spasticity or rigidity)

LMN → decreased (hypotonia) or normal

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10
Q

UMN lesion vs LMN lesion → patterns of weakness?

A

UMN → Pyramidal patterns of weakness (extensors weaker than flexors in arms, vice versa in legs)

LMN → Different patterns of weakness depending on cause (e.g. proximal weakness in muscle disease, distal weakness in peripheral neuropathy)

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11
Q

Define a pyramidal pattern of weakness

A

Pyramidal weakness, that is, the weakness that preferentially spares the antigravity muscles, is considered an integral part of the upper motor neuron syndrome.

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12
Q

UMN lesion vs LMN lesion → reflexes

A

UMN → exaggerated or brisk (hyperreflexia)

LMN → reduced or absent (hyporeflexia/areflexia)

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13
Q

UMN lesion vs LMN lesion → plantar reflexes?

A

UMN → up going/extensor (Babinski positive)

LMN → normal (down going/flexor) or mute (no movement)

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14
Q

What 4 pieces of equipment is needed in a lower limb peripheral nerve exam?

A
  1. Tendon hammer
  2. Neurotip
  3. Cotton wool
  4. Tuning fork
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15
Q

Give the overall structure of a lower limb neuro exam

A
  1. Introduction
  2. General inspection: clinical signs (SWIFT), objects & equipment
  3. Gait
  4. Romberg’s sign
  5. Tone: leg roll, leg lift, ankle clonus
  6. Power: hip, knee, ankle, big toe
  7. Reflexes: knee jerk, ankle jerk, plantar
  8. Coordination: heel to shim, toe tapping
  9. Sensation: light touch, pinprick, vibration, proprioception
  10. Conclusion
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16
Q

The SWIFT acronym can be used when assessing the clinical signs during a lower limb neuro exam. What does this stand for?

A

S - Scars

W - Wasting of muscles

I - Involuntary movements

F - Fasciculations

T - Tremor

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17
Q

Would the presence of fasciculations be indicative of an UMN or LMN lesion?

A

LMN lesion e.g. amyotrophic lateral sclerosis

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18
Q

Give 2 types of tremors

A

Resting tremor

Intention tremor

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19
Q

Give some examples of involuntary movements that may be present

A
  • Chorea
  • Pseudo-athetosis
  • Myoclonus
  • Tardive dyskinesia
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20
Q

What is myoclonus?

A

Brief, involuntary, irregular twitching of a muscle or group of muscles

All individuals experience on occasion (e.g. whilst falling asleep) but persistent widespread myoclonus is associated with specific forms of epilepsy (e.g. juvenile myoclonic epilepsy)

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21
Q

What is persistent widespread myoclonus associated with?

A

specific forms of epilepsy (e.g. juvenile myoclonic epilepsy)

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22
Q

What is tardive dyskinesia? What can it occur 2ary to?

A

involuntary, repetitive body movements e.g. protrusion of tongue, smacking and grimacing which can develop 2ary to treatment with neuroleptic medications e.g. antipsychotics and antiemetics

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23
Q

Hypomimia may be present in certain neurological conditions. What is this? What condition is it associated with?

A

Reduced degree of facial expression associated with Parkinson’s disease

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24
Q

Ptosis and frontal balding are signs typically associated with which neuro disease?

A

Myotonic dystrophy

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25
Q

Ophthalmoplegia may be present in certain neuro conditions. What is this? Give some conditions where it might be present

A

weakness/paralysis of one or more extraocular muscles responsible for eye movement (e.g. multiple sclerosis, myasthenia gravis)

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26
Q

What screening question. should be asked before assessing the patient’s gait?

A

Are you able to walk unaided

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27
Q

When assessing the patient’s gait, what signs are you looking for?

A
  • Stance
  • Stability
  • Arm swing
  • Steps
  • Turning
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28
Q

What may a broad-based, ataxic gait indicate?

A

A midline cerebellar pathology e.g. a lesion in multiple sclerosis or degeneration of the cerebellar vermis 2ary to chronic alcohol excess)

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29
Q

What may a staggering, slow and unsteady gait indicate?

A

Cerebellar pathology → in unilateral cerebellar disease, patients will veer towards the side of the lesion

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30
Q

How is arm swing affected in Parkinson’s disease?

A

Often absent or reduced (typically unilateral initially)

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31
Q

What type of steps may be seen in Parkinson’s?

A

Small, shuffling

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32
Q

High-stepping steps may indicate the presence of what?

A

Foot drop

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33
Q

What is the purpose of assessing the patient’s tandem (heel-to-toe) gait?

A

This exacerbates underlying unsteadiness, making it easier to identify more subtle ataxia.

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34
Q

What is the purpose of assessing the patient’s tandem (heel-to-toe) gait?

A

This exacerbates underlying unsteadiness, making it easier to identify more subtle ataxia.

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35
Q

What is the tandem (heel-to-toe) gait particularly sensitive at identifying?

A

Dysfunction of the cerebellar vermis (e.g. alcohol-induced cerebellar degeneration)

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36
Q

What is the purpose of Romberg’s test?

A

Test used to assess for loss of proprioceptive or vestibular function (sensory ataxia) but does NOT assess cerebellar function (i.e. used to quickly screen for non-cerebellar causes of balance issues).

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37
Q

What is a positive Romberg’s sign? What does this indicate?

A

Falling without correction

Indicates unsteadiness due to sensory ataxia i.e. deficit of proprioceptive or vestibular function, rather than cerebellar function.

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38
Q

What is proprioception

A

Proprioception is the body’s ability to sense its location, movements, and actions.

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39
Q

Give some causes of proprioceptive dysfunction

A
  • Joint hypermobility (e.g. Ehlers-Danlos syndrome)
  • B12 deficiency
  • Parkinson’s disease, ageing (presbypropria)
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40
Q

Which vitamin deficiency can lead to a positive Romberg’s sign?

41
Q

What are some causes of vestibular dysfunction?

A
  • Vestibular neuronitis
  • Meniere’s disease
42
Q

Is swaying with correction a positive Romberg’s result?

43
Q

What is the typical cause of swaying with correction in a Romberg’s test?

A

often cerebellar disease (due to truncal ataxia)

44
Q

How should the patient be positioned when assessing tone/

A

Examine patient sat on bed with their legs extended in a relaxed position in front of them.

45
Q

What are the 3 parts of the ‘tone’ assessment?

A
  1. Leg roll
  2. Leg lift
  3. Ankle clonus
46
Q

What are you assessing during the leg roll?

A
  • Assessing tone in the muscles responsible for rotation of hip
  • Observe foot movement to gauge if any increase/decrease in muscle tone
47
Q

What are you assessing during the leg lift? How would increased tone present?

A

Normal tone: knee should rise whilst heel remains in contact with bed

Increased tone: heel will typically lift off bed

48
Q

What is ankle clonus? Does clonus indicate UMN or LMN lesion? Give some conditions

A

Clonus is a series of involuntary rhythmic muscular contractions and relaxations that is associated with UMN lesions of the descending pathways (e.g. stroke, multiple sclerosis, cerebral palsy).

49
Q

How would ankle clonus present? What is considered abnormal?

A

Clonus is felt as rhythmic beats of dorsiflexion and plantarflexion

If more than 5 beats of clonus are present, this would be classed as an abnormal finding

50
Q

Spasticity and rigidity are both are features of increased tone seen in UMN lesions.

How does the location of the lesion differ between spasticity and rigidity?

A

Spasticity → Associated with pyramidal tract lesions (e.g. stroke)

Rigidity → Associated with extrapyramidal tract lesions (e.g. Parkinson’s disease)

51
Q

Does Parkinson’s involve an extrapyramidal or pyramidal lesion?

A

Extrapyramidal tract lesion

52
Q

Is spasticity or rigidity velocity dependent?

A

Spasticity is velocity dependent → i.e. faster you move limb, the worse it is

Rigidity is NOT velocity dependent → i.e. feels the same if you move limb slowly or rapidly

53
Q

What is ‘clasp-knife’ spasticity?

A

Initial resistance (increased tone) followed by sudden reduction in resistance to movements

54
Q

What are the 2 main subtypes of rigidity?

A
  1. Cog-wheel rigidity
  2. Lead-pipe rigidity
55
Q

Cogwheel vs lead pipe rigidity?

A

Lead pipe rigidity is defined as a constant resistance to motion throughout the entire range of movement.

Cogwheel rigidity refers to resistance that stops and starts as the limb is moved through its range of motion.

56
Q

What condition is cog wheel rigidity associated with?

A

Parkinson’s disease

57
Q

What condition is lead pipe rigidity associated with?

A
  • Detected in disorder of basal ganglia
  • Associated with neuroleptic malignant syndrome (a potentially life-threatening reaction to antipsychotic drugs or major tranquilizers)
58
Q

What 4 components are tested in ‘power’?

A
  1. Hip
  2. Knee
  3. Ankle
  4. Big toe
59
Q

What 4 aspects are tested in ‘hip’ power?

A
  1. Flexion
  2. Extension
  3. Abduction
  4. Adduction
60
Q

What myotome is being tested in hip flexion? Which nerve? Which muscle?

A

Myotome → L1 / L2

Nerve → Iliofemoral nerve

Muscle → Iliopsoas

61
Q

What myotome is being tested in hip extension? Which nerve? Which muscle?

A

Myotome → L5/S1/S2

Nerve → inferior gluteal

Muscle → gluteus maximus

62
Q

What myotome is being tested in hip abduction?

A

Myotome → L4/L5

63
Q

What myotome is being tested in hip adduction?

64
Q

What 2 aspects are tested in ‘knee’ power?

A

Extension & flexion

65
Q

What myotome is being tested in knee flexion? Which nerve? Which muscle?

A

Myotome → S1

Nerve → Sciatic nerve

Muscle → Hamstrings

66
Q

What myotome is being tested in knee extension? Which nerve? Which muscle?

A

Myotome → L3/L4

Nerve → Femoral nerve

Muscle → Quads

67
Q

What 2 aspects are tested in ‘ankle’ power?

A
  1. Dorsiflexion
  2. Plantarflexion
68
Q

What myotome is being tested in ankle dorsiflexion? Which nerve? Which muscle?

A

Myotome → L4/L5

Nerve → Deep peroneal nerve

Muscle → Tibialis anterior

69
Q

What myotome is being tested in ankle plantarflexion? Which nerve? Which muscle?

A

Myotome → S1/S2

Nerve → Tibial nerve

Muscle → Gastrocnemius, soleus

70
Q

What 2 aspects are tested in ‘big toe’ power?

A
  1. Flexion
  2. Extension
71
Q

What myotome is being tested in big toe extension? Which nerve? Which muscle?

A

Myotome → L5

Nerve → Deep peroneal nerve

Muscle → Extensor hallucis longus

72
Q

Is a pyramidal pattern seen in UMN or LMN lesions?

73
Q

How does a pyramidal pattern of weakness affect the lower limb and upper limb extensors and flexors?

A

Disproportionately affects the lower limb flexors and upper limb extensors (i.e. lower limb flexors weaker than extensors in a neurological assessment)

74
Q

What pattern of weakness does a LMN cause?

A

Cause a focal pattern of weakness – only the muscles directly innervated by the damaged neurons affected

75
Q

What is the MRC muscle power assessment scale?

A

Uses a score of 0-5 to grade the power of a particular muscle group in relation to the movement of a single joint.

76
Q

What 3 reflexes should be assessed?

A

Knee jerk

Ankle jerk

Plantar

77
Q

What nerve roots does the knee jerk reflex test?

What is the normal response?

A

L3/L4

Normal response: Kicking motion of lower leg

78
Q

What nerve roots does the ankle jerk reflex test?

What is the normal response?

A

S1

Normal → Contraction in gastrocnemius with associated plantarflexion of foot

79
Q

What nerve roots does the plantar reflex test?

What is the normal response?

A

L5/S1

Normal → Flexion of big toe and flexion of other toes

80
Q

Which piece of equipment is used to test the plantar reflex?

81
Q

What is Babinski’s sign?

A

Extension of big toe and spread of other toes → UMN lesion

82
Q

Why do UMN lesions (e.g. stroke, spinal cord injury) lead to hyperreflexia?

A

due to loss of inhibition from higher brain centres which normally exert a degree of suppression over LMN reflex arc

83
Q

Why do LMN lesions (e.g. brachial plexus pathology, peripheral nerve injuries) lead to hyporeflexia?

A

due to loss of efferent and afferent branches of normal reflex arc

84
Q

In cerebellar disease, how are reflexes described?

85
Q

What does pendular mean?

A

less brisk and slower in their rise and fall

86
Q

Which pieces of equipment are used to assess sensation?

A

Light touch → cotton wool

Pin prick → neurotip

87
Q

Where should you demonstrate normal sensation for the patient?

A

Over sternum

88
Q

Dermatomes for sensation:

A
  • L1: Inguinal region and very top of medial thigh
  • L2: Middle and lateral aspect of anterior thigh
  • L3: Medial aspect of knee
  • L4: Medial aspect of lower leg and ankle
  • L5: Dorsum and medial aspect of big toe
  • S1: Dorsum and lateral aspect of little toe
89
Q

Which type of sensation involves both the dorsal columns and spinothalamic tracts?

A

Light touch

90
Q

Which type of sensation involves only the spinothalamic tracts?

91
Q

If loss of sensation is noted peripherally, what should you then do?

A

Test for “stocking” distribution of sensory loss by moving distal to proximal.

If necessary, keep going all the way up the leg and trunk until an area of normal sensation is identified. This may reveal a “sensory level”, which is suggestive of a spinal lesion (e.g. if there is abnormal sensation up to the level of the umbilicus, this suggests a spinal lesion at around T10).

92
Q

What does stocking distribution of sensory loss indicate?

A

Peripheral neuropathy

93
Q

if there is abnormal sensation up to the level of the umbilicus, what spinal level is the lesion likely at?

A

around T10

94
Q

What piece of equipment is used to assess vibration sensation?

A

128 Hz tuning fork

95
Q

Where is the tuning fork placed to test vibration sensation?

A

Interphalangeal joint of big toe (both sides)

96
Q

If vibration sensation is impaired at DIP of big toe, where should you assess next?

A

continue to sequentially assess more proximal joints (e.g. MTPJ big toe → ankle joint → knee joint) until patient is able to accurately identify vibration

97
Q

What 2 aspects are involved in assessing ‘coordination’?

A
  1. Heel-to-shin test
  2. Toe tapping
98
Q

Why should power be assessed before coordination?

A

Weakness (e.g. from UMN lesion) can produce apparent incoordination of movements.

99
Q

What could dysmetria (i.e. incoordination) when performing the heel-to-shin test indicate?

A

Suggestive of ipsilateral cerebellar pathology

Yr 3 - Clinical Examinations (11 decks)

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