Peripheral Neurological Examination Flashcards
What exposure is required for a peripheral neurological examination?
- From shoulders downwards
- From thigh downwards
What position is required for a peripheral neurological examination?
- Supine position with 45o upper body elevation
What peripheral general inspection does one observe in a peripheral neurological examination (4)?
- Walking aids
- Hearing aids
- Visual aids
- Prescriptions
What head general inspection does one observe in a peripheral neurological examination (5)?
- Speech abnormalities
- Facial asymmetry
- Eyelid abnormalities
- Pupillary abnormalities
- Strabismus
What head general inspection does one observe in a peripheral neurological examination (11)?
- Scars
- Wasting of muscles
- Tremor
- Fasciculations
- Pseudoathetosis
- Chorea
- Myoclonus
- Tardive dyskinesia
- Hypomimia
- Ptosis and frontal balding
- Ophthalmoplegia
What causes muscle wasting (2)?
- Lower motor neuron lesions
- Disuse atrophy
What causes fasciculations (1)?
- Lower motor neuron pathology
What causes pseudoathetosis (1)?
- Failure of proprioception
What causes chorea (1)?
- Huntington’s disease
What causes myoclonus (1)?
- Several specific forms of epilepsy
What causes tardive dyskinesia (1)?
- Secondary to treatment with neuroleptic medications
What causes hypomimia (1)?
- Parkinson’s disease
What causes ptosis and frontal balding (1)?
- Myotonic dystrophy
What causes ophthalmoplegia (1)?
- Wide range of neurological disorders (i.e. multiple sclerosis & myasthenia gravis)
How is tone assessed in the shoulder (4)?
- Always ask about any pain in the shoulder, elbow or wrist.
- Ask the patient to relax “go floppy” and allow you to fully control the movement of their arm
- Passively circumduct at the shoulder joint to detect stiffness or reduced tone.
- Feel for abnormalities of tone as you assess each joint (e.g. spasticity, rigidity, cogwheeling, hypotonia)
How is tone assessed in the elbow (4)?
- Always ask about any pain in the shoulder, elbow or wrist.
- Ask the patient to relax “go floppy” and allow you to fully control the movement of their arm
- Passively flex and extend at the elbow joint to detect stiffness or reduced tone.
- Feel for abnormalities of tone as you assess each joint (e.g. spasticity, rigidity, cogwheeling, hypotonia)
How is tone assessed in the radioulnar joint (4)?
- Always ask about any pain in the shoulder, elbow or wrist.
- Ask the patient to relax “go floppy” and allow you to fully control the movement of their arm
- Passively pronate and supinate at the radioulnar joints to detect stiffness or reduced tone
- Feel for abnormalities of tone as you assess each joint (e.g. spasticity, rigidity, cogwheeling, hypotonia)
How is tone assessed in the wrist (4)?
- Always ask about any pain in the shoulder, elbow or wrist.
- Ask the patient to relax “go floppy” and allow you to fully control the movement of their arm
- Passively flex and extend at the wrist joints to detect stiffness or reduced tone
- Feel for abnormalities of tone as you assess each joint (e.g. spasticity, rigidity, cogwheeling, hypotonia)
What is hypotonia associated with (1)?
- LMN lesions
What is spasticity associated with (1)?
- Pyramidal tract lesions (UMN lesions) (e.g. stroke)
What is rigidity associated with (1)?
- Extrapyramidal tract lesions (UMN lesions) (e.g. Parkinson’s disease)
What is cogwheel rigidity associated with (1)?
- Parkinson’s disease
What is lead pipe rigidity associated with (1)?
- Neuroleptic malignant syndrome
What is the MRC Muscle Power scale? How many levels does it have?
What myotome is assessed in shoulder abduction power? What muscles are assessed in shoulder abduction power? How is shoulder abduction power assessed?
- Myotome assessed: C5 (axillary nerve)
- Muscles assessed: deltoid (primary) and other shoulder abductors
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Assessment:
- Ask the patient to flex their elbows and abduct their shoulders to 90°: “Bend your elbows and bring your arms out to the sides like a chicken.”
- Apply downward resistance on the lateral side of the upper arm whilst asking the patient to maintain their arm’s position: “Don’t let me push your shoulder down.”
What myotome is assessed in shoulder adduction power? What muscles are assessed in shoulder adduction power? How is shoulder adduction power assessed?
- Myotomes assessed: C6/7 (thoracodorsal nerve)
- Muscles assessed: teres major, latissimus dorsi and pectoralis major
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Assessment:
- Ask the patient to adduct their shoulders to 45° bringing their elbows closer to their body: “Now bring your elbows a little closer to your sides.”
- Apply upward resistance on the medial side of the upper arm whilst asking the patient to maintain their arm’s position: “Don’t let me pull your arms away from your sides.”
What myotome is assessed in elbow flexion power? What muscles are assessed in elbow flexion power? How is elbow flexion power assessed?
- Myotomes assessed: C5/6 (musculocutaneous and radial nerve)
- Muscles assessed: biceps brachii, coracobrachialis and brachialis
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Assessment:
- Ask the patient to flex their elbow: “Put your hands up like a boxer.”
- Apply resistance by pulling the forearm whilst stabilising the shoulder joint: “Don’t let me pull your arm away from you.”
What myotome is assessed in elbow extension power? What muscles are assessed in elbow extension power? How is elbow extension power assessed?
- Myotome assessed: C7 (radial nerve)
- Muscles assessed: triceps brachii
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Assessment:
- With the patient’s elbows still in the flexed position, apply resistance by pushing the forearm towards the patient whilst stabilising the shoulder joint: “Don’t let me push your arm towards you.”
What myotome is assessed in wrist extension power? What muscles are assessed in wrist extension power? How is wrist extension power assessed?
- Myotome assessed: C6 (radial nerve)
- Muscles assessed: extensors of the wrist
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Assessment:
- Ask the patient to hold their arms out in front of them with their palms facing downwards: “Hold your arms out in front of you, with your palms facing the ground.”
- Ask the patient to make a fist and extend their wrist joints, keeping their wrists in this position whilst you apply resistance: “Make a fist, cock your wrists back and don’t let me pull them downwards.”
What myotome is assessed in wrist flexion power? What muscles are assessed in wrist flexion power? How is wrist flexion power assessed?
- Myotomes assessed: C6/7 (median nerve)
- Muscles assessed: flexors of the wrist
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Assessment:
- With the patient still holding their arms out in front of them, now ask them to flex their wrist joints and keep them in this position whilst you apply resistance: “Ok now point your wrists downwards and don’t let me pull them up.”
What myotome is assessed in finger extension power? What muscles are assessed in finger extension power? How is finger extension power assessed?
- Myotome assessed: C7 (radial nerve)
- Muscles assessed: extensor digitorum
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Assessment:
- Ask the patient to hold their fingers out straight whilst you apply downwards resistance: “Hold your fingers out straight and don’t let me push them down.”
What myotome is assessed in finger abduction power? What muscles are assessed in finger abduction power? How is finger abduction power assessed?
- Myotome assessed: T1 (ulnar nerve)
- Muscles assessed: First dorsal interosseous (FDI) & Abductor digiti minimi (ADM)
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Assessment:
- Ask the patient to abduct their fingers against resistance. You should assess abduction in FDI and ADM separately using the equivalent finger of your own to apply resistance: “Splay your fingers outwards and don’t let me push them together.”
What myotome is assessed in thumb abduction power? What muscles are assessed in thumb abduction power? How is thumb abduction power assessed?
- Myotomes assessed: T1 (median nerve)
- Muscle assessed: abductor pollicis brevis
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Assessment:
- Ask the patient to turn their hand over so their palm is facing upwards and to position their thumb over the midline of the palm. Advise them to keep it in this position whilst you apply downward resistance with your own thumb: “Point your thumbs to the ceiling and don’t let me push them down.”
How is the biceps reflex (C5/6) assessed?
- With the patient’s arm relaxed, locate the biceps brachii tendon which is typically found at the medial aspect of the antecubital fossa
- Place the thumb of your non-dominant hand over the tendon and then tap your thumb with the tendon hammer
- Observe for a contraction of the biceps muscle and associated flexion of the elbow
How is the supinator (brachioradialis) reflex (C5/6) assessed?
- Locate the brachioradialis tendon which can be found on the posterolateral aspect of the wrist approximately 4 inches proximal to the base of the thumb
- With two fingers positioned over the tendon, tap your fingers with the tendon hammer
- Observe for a contraction of the brachioradialis muscle and associated flexion, pronation or supination of the forearm at the elbow
How is the triceps reflex (C7) assessed?
- Position the patient’s arm so that the triceps tendon is relaxed: this is commonly achieved by resting the patient’s elbow in 90º flexion on their lap or by supporting the patient’s forearm
- Locate the triceps tendon, which can be found superior to the olecranon process of the ulna
- Tap the tendon with the tendon hammer and observe for a contraction of the triceps muscle
How is upper limb sensation (dermatomes) assessed?
- Light touch sensation involves both the dorsal columns and spinothalamic tracts.
- Ask the patient to close their eyes and touch their sternum with the wisp of cotton wool to provide an example of light touch sensation.
- Ask the patient to say “yes” when they feel the sensation.
- Using the wisp of cotton wool, begin to assess light touch sensation across each of the upper limb dermatomes, comparing each side as you go by asking the patient if it feels the same.
What does leg roll and leg lift assess? How is it performed?
- Briefly assess tone in the muscle groups of the hip, knee and ankle on each leg, comparing each side as you go. Ask the patient to keep their legs fully relaxed throughout the assessment.
- With the patient lying on the examination couch, roll each leg to assess tone in the muscles responsible for the rotation of the hip
- Lift each knee briskly off the bed (warning the patient first) and observe the movement of the leg
- In patients with normal tone, the knee should rise whilst the heel remains in contact with the bed (the heel will typically lift off the bed if there is increased tone)
What does ankle clonus assess? How is it performed?
- Clonus is a series of involuntary rhythmic muscular contractions and relaxations that is associated with upper motor neuron lesions of the descending motor pathways (e.g. stroke, multiple sclerosis, cerebral palsy).
- Position the patient’s leg so that the knee and ankle are slightly flexed, supporting the leg with your hand under their knee, so they can relax
- Rapidly dorsiflex and partially evert the foot to stretch the gastrocnemius muscle
- Keep the foot in this position and observe for clonus
- 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
What myotome is assessed in hip flexion power? What muscles are assessed in hip flexion power? How is hip flexion power assessed?
- Myotome assessed: L1/2 (iliofemoral nerve)
- Muscles assessed: iliopsoas
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Assessment:
- Ask the patient to raise their leg off the bed and apply downward resistance over the anterior thigh: “Lift your leg off the bed and don’t let me push your leg down.”
What myotome is assessed in hip extension power? What muscles are assessed in hip extension power? How is hip extension power assessed?
- Myotome assessed: L5/S1/S2 (inferior gluteal nerve)
- Muscles assessed: gluteus maximus
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Assessment:
- Place your hand under the patient’s thigh and ask them to resist you trying to lift their leg: “Don’t let me lift your leg off the bed.”
What myotome is assessed in knee flexion power? What muscles are assessed in knee flexion power? How is knee flexion power assessed?
- Myotome assessed: S1 (sciatic nerve)
- Muscles assessed: hamstrings
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Assessment:
- Ask the patient to flex their knee so that their foot is flat on the bed and then apply resistance by pulling the lower leg towards you: “Bend your knee so that your foot is flat on the bed and then don’t let me pull your leg towards me.”
What myotome is assessed in knee extension power? What muscles are assessed in knee extension power? How is knee extension power assessed?
- Myotome assessed: L3/4 (femoral nerve)
- Muscles assessed: quadriceps
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Assessment:
- With the patient’s knee still flexed, position your hand over the anterior portion of the lower leg and ask the patient to try and straighten their leg: “Try and straighten your leg whilst I try to stop you.”
What myotome is assessed in ankle dorsiflexion power? What muscles are assessed in ankle dorsiflexion power? How is ankle dorsiflexion power assessed?
- Myotome assessed: L4/5 (deep peroneal nerve)
- Muscles assessed: tibialis anterior
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Assessment:
- Ask the patient to position their legs flat on the bed, dorsiflex their foot and resist you trying to push their foot downwards: “Put your legs flat on the bed, cock your foot backwards and don’t let me push your foot down.”
What myotome is assessed in ankle plantarflexion power? What muscles are assessed in ankle plantarflexion power? How is ankle plantarflexion power assessed?
- Myotome assessed: S1/2 (tibial nerve)
- Muscles assessed: gastrocnemius, soleus
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Assessment:
- With the patient’s legs still flat on the bed, ask them to plantarflex their foot and resist you trying to pull their foot upwards: “Point your foot downwards like you’re pushing a car pedal and don’t let me pull it up.”
What myotome is assessed in big toe extension power? What muscles are assessed in big toe extension power? How is big toe extension power assessed?
- Myotome assessed: L5 (deep peroneal nerve)
- Muscles assessed: extensor hallucis longus
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Assessment:
- With the patient’s legs still flat on the bed, ask them to extend their big toe and resist you trying to push it down: “Point your big toe up towards your head and don’t let me push it down.”
How is the knee-jerk reflex (L3, L4) assessed?
- Remove the weight from the patient’s lower limb by either supporting it or asking the patient to hang their legs over the side of the bed & ensure the patient’s lower limb is completely relaxed before assessing the knee-jerk reflex
- Tap the patellar tendon with the tendon hammer (making sure to hold the tendon hammer handle at its end to allow gravity to aid a good swing)
- If a reflex appears absent make sure the patient is fully relaxed and then perform a reinforcement manoeuvre
How is the ankle-jerk reflex (S1) assessed?
- With the patient on the examination couch support their leg so that their hip is slightly abducted, the knee is flexed and the ankle is dorsiflexed
- Tap the Achille’s tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated plantarflexion of the foot
How is lower limb sensation (dermatomes) assessed?
- Light touch sensation involves both the dorsal columns and spinothalamic tracts
- Ask the patient to close their eyes and touch their sternum with the wisp of cotton wool to provide an example of light touch sensation.
- Ask the patient to say “yes” when they feel the sensation.
- Using the wisp of cotton wool, begin to assess light touch sensation across each of the lower limb dermatomes, comparing each side as you go by asking the patient if it feels the same.
How does one read an MRI (ABCD)?
- Alignment
- Bone
- Cord
- Discs
