Upper Limb Neuro Exam

Question 1

What are the first steps for the upper limb neuro examination?

Answer 1

Introduce yourself 
Confirm name and date of birth
Explain examination 
Gain consent
Expose patient’s arms

Question 2

What is the equipment needed?

Answer 2

Tendon hammer
Neurotip
Cotton wool
Tuning fork

Question 3

What is important to look for during inspection?

Answer 3

Scars
Wasting of muscles
Involuntary movements
Fasciculations
Tremor

(SWIFT)

Question 4

How do you test the pronator drift?

Answer 4

Close your eyes and place your arms outstretched forwards with palms facing up

Question 5

If you find pronation in one of the arms, what does it mean?

Answer 5

Upper motor neuron (UMN) pathology.

Question 6

How do you test tone in the upper limbs?

Answer 6

Ask the patient to let their arm go floppy , whilst you move each of the major joints.

Question 7

What do you need to note when examining the tone?

Answer 7

Note the character of the movement – smooth / ↑tone/ ↓ tone (flaccid)

Question 8

What does cogwheeling mean?

Answer 8

It is an indicative of Parkinson’s disease

Question 9

How do you differentiate spasticity and rigidity?

Answer 9

Tone is increased in both, but:
Spasticity is “velocity dependent” i.e. the faster you move the limb, the worse it is.
Rigidity is “velocity independent” i.e. it feels the same if you move the limb fast or slowly.

Question 10

What do spasticity and rigidity indicate?

Answer 10

Spasticity indicates an UMN lesion and rigidity indicates an extrapyramidal lesion (Parkinsonism).

Question 11

When testing power, which scale should be used?

Answer 11

MRC Muscle Power Scale

Question 12

Describe muscle power according to MRC Muscle Power Scale

Answer 12

0 - No contraction
1 - Flicker or trace of contraction
2 - Active movement, with gravity eliminated
3 - Active movement against gravity
4 - Active movement against gravity and resistance
5 - Normal power

Question 13

How do you test shoulder abduction?

Answer 13

“Don’t let me push your shoulders down” - C5

Question 14

How do you test shoulder adduction?

Answer 14

“Don’t let me pull your arms away from your sides” - C6/C7

Question 15

How do you test elbow flexion?

Answer 15

“Don’t let me pull your arm away from you” - C5/C6

Question 16

How do you test elbow extension?

Answer 16

“Don’t let me push your arm towards you” - C7

Question 17

How do you test wrist flexion?

Answer 17

“Point your wrists downwards and don’t let me pull them up” - C6/C7

Question 18

How do you test wrist extension?

Answer 18

“Cock your wrists back and don’t let me pull them down” - C6

Question 19

How do you test finger extension?

Answer 19

“Put your fingers out straight and don’t let me push them down” - C7

Question 20

How do you test finger abduction?

Answer 20

“Splay your fingers and don’t let me push them together”- T1

Question 21

How do you test thumb abduction?

Answer 21

“Point your thumbs to the ceiling and don’t let me push them down” - C8/T1

Question 22

What deep tendon reflexes do you test in the arms?

Answer 22

Biceps reflex
Triceps reflex
Supinator reflex

Question 23

Where do you test the biceps reflex?

Answer 23

Antecubital fossa - C5/C6

Question 24

Where do you test the triceps reflex?

Answer 24

Place forearm rested at 90º flexion – tap your finger overlying the triceps tendon - C7

Question 25

Where do you test the supinator reflex?

Answer 25

4 inches proximal to base of the thumb - C6

Question 26

What modalities of sensation are tested?

Answer 26

Light touch sensation
Pin-prick sensation
Vibration sensation
Proprioception

Question 27

What instrument do you use to test light touch sensation?

Answer 27

A wisp of cotton wool

Question 28

What instrument do you use to test pin-prick sensation?

Answer 28

A neurotip

Question 29

What instrument do you use to test vibration sensation?

Answer 29

A 128 Hz tuning fork

Question 30

Where do you place the tuning fork to test vibration sensation?

Answer 30

Place onto the distal interphalangeal joint of the forefinger and ask them if they can feel it buzzing.

Question 31

How do you test proprioception?

Answer 31

1. Hold the distal phalanx of the thumb by its sides
2. Demonstrate movement of the thumb “upwards” and “downwards” to the patient (whilst they watch)
3. Then ask the patient to close their eyes and state if you are moving the thumb up or down

Question 32

How do you test coordination in the upper limbs?

Answer 32

1. Finger to nose test

2. Dysdiadochokinesia

Question 33

How is the finger to nose test?

Answer 33

1. Ask the patient to touch their nose with the tip of their index finger, then touch your fingertip
2. Position your finger so that the patient has to fully outstretch their arm to reach it
3. Ask them to continue to do this finger to nose motion as fast as they are able to
4. Repeat the test using the patient’s other hand

Question 34

What does an abnormal finger to nose test mean?

Answer 34

An inability to perform this test accurately (past pointing/dysmetria) may suggest cerebellar pathology.
It can also be impaired in a sensory ataxia (caused by loss of proprioception) or if there is weakness in the arm.

Question 35

How do you test dysdiadochokinesia?

Answer 35

1. Demonstrate patting the palm of your hand with the back/palm of your other hand to the patient
2. Ask the patient to mimic this rapid alternating movement
3. Encourage them to do this alternating movement as fast as they are able to
4. Repeat test using the patient’s other hand

Question 36

What does dysdiadochokinesia mean?

Answer 36

An inability to perform this rapidly alternating movement (very slow/irregular) suggests cerebellar ataxia (also can be impaired in a sensory ataxia or with Parkinsonism)