Neurology Examinations

1. Neurology Examinations By Sam

2. We will cover • Upper Limb Neurological Exam • Lower Limb Neurological Exam

3. We will NOT cover • Cranial nerve exam • Parkinson’s exam • Cerebellar Exam

4. Broadly Speaking • Observe • The • Patient • Really • Carefully • Said (the) • Senior • Observations • Tone • Power • Reflexes • Co-ordination • Sensation • Special Tests/Summary

5. Upper Limb Observation • Remember to Taylor your exam to SWIFT: • Scars • Wasting • Involuntary Movements • Fasciculation • Tremors

6. Upper Limb Tone • Hypotonia= LMN • Hypertonia can be: • Velocity dependent=spasticity, usually stroke • Velocity independent=rigidity, usually Parkinson’s • Either way they’re both UMN

7. Upper Limb Power- always reduced • UMN: • Pyramidal is were the upper limb extensors are weaker than flexors (think curled arm), and lower limb extensors are stronger than flexors (think hyperextended leg). • LMN: • Proximal weakness is muscular disease • Distal weakness is peripheral neuropathy

8. Upper Limb Power Grading • Always stabilise joint • Always compare one against the other (or at least say you would) • Grading the Power: • 5 is normal • 4 is weakened against resistance • 3 is able to move against gravity • 2 is moves with support • 1 is muscle twitches • Nothing/absent

9. Which nerves power which muscles? • Shoulders • ABduction(C5)– “Don’t let me push your shoulders down” • ADduction(C6/7) – “Don’t let me pull your arms away from your sides” • Elbow • Flexion (C5/6) – “Don’t let me pull your arm away from you” • Extension (C7) –“Don’t let me push your arm towards you” • Wrist • Extension (C6) – “Cock your wrists back and don’t let me pull them down” • Flexion (C6/7) – “Point your wrists downwards and don’t let me pull them up” • Fingers • Finger extension(C7) – “Put your fingers out straight and don’t let me push them down” • Finger ABduction(T1) – “Splay your fingers and don’t let me push them together” • Thumb ABduction(C8/T1) – “Point your thumbs to the ceiling and don’t let me push them down”

10. Upper Limb Reflexes • Increased in UMN (due to loss of inhibition from central system) • Decreased in LMN • Three reflexes to check: • Biceps (C5/C6) • Triceps (C7) • Supinator (C6) • Don’t forget you can ask them to potentiate

11. Upper Limb Co-ordination • Variable ways to test this, two common ones • Finger to nose test: • Make sure they’re having to stretch out • Past pointing indicates cerebellar or sensory ataxia • Dysdiadochokinesia • Clap hand one way then the other • A slowness or inability suggests cerebellar or sensory ataxia or Parkinson's.

12. Upper Limb Sensation • Broadly speaking, 4 different ways to test 2 tracks: • Light touch= dorsal/posterior column and spinothalamic tract. Use cotton wool • Pin-prick= spinothalamic tract. Use Neurotip • vibration= dorsal/posterior column. Use tuning fork on bony prominences • Propioception= dorsal/posterior column. Wiggle thumb • In reality its much more complicated • I would recommend to check what's available in the station, start with cotton wool, then vibration then propioception. Start peripherally and move proximally.

13. Upper Limb Quick Screen Guide

14. Upper Limb Special Tests/Summarise • Pronator Drift • Indicates cerebellar dysfunction • NOW PRESENT YOUR FINDINGS

15. Lower Limb Observations • Remember to Taylor your exam to SWIFT: • Scars • Wasting • Involuntary Movements • Fasciculation • Tremors

16. Lower Limb Tone • Hypotonia= LMN • Hypertonia can be: • Velocity dependent=spasticity, usually stroke • Velocity independent=rigidity, usually Parkinson’s • Either way they’re both UMN • In addition, don’t forget clonus

17. Lower Limb Power-always reduced • UMN: • Pyramidal is were the upper limb extensors are weaker than flexors (think curled arm), and lower limb extensors are stronger than flexors (think hyperextended leg). • LMN: • Proximal weakness is muscular disease • Distal weakness is peripheral neuropathy

18. Lower Limb Power Grading • Always stabilise joint • Always compare one against the other (or at least say you would) • Grading the Power: • 5 is normal • 4 is weakened against resistance • 3 is able to move against gravity • 2 is moves with support • 1 is muscle twitches • Nothing/absent

19. Which Nerve Powers Which Muscle? • Hip • Flexion (L1/2) – “raise your leg off the bed and stop me from pushing it down” • Extension (L5/S1) – “stop me from lifting your leg off the bed” • ABduction(L4/5) – “push your legs out” • ADduction(L2/3)  – “squeeze your legs in” • Knee • Flexion(S1)–“bend your knee and stop me from straightening it” • Extension (L3/4) – “kick out your leg” • Ankle • Dorsiflexion (L4) – “keep your legs flat on the bed…cock your foot up towards your face…don’t let me push it down “ • Plantarflexion (S1/2) –“push down like on a pedal” • Inversion (L4) – “push your foot in against my hand” • Eversion (L5/S1) – “push your foot out against my hand” • Big toe • Extension (L5) – “don’t let me push your big toe down”

20. Lower Limb Reflexes • Increased in UMN (due to loss of inhibition from central system) • Decreased in LMN • Three reflexes to check: • Patella/Knee (L3/L4) • Ankle (L5/S1) • Babinski (S1) (goes upwards or extends in UMN) • Don’t forget you can ask them to potentiate

21. Lower Limb Co-ordination • Whilst lying down, ask them to bring their right ankle up to their left knee, slide it down the anterior aspect of their leg and lift back up to the knee. Repeat as fast as possible. • Also consider gait and Rhomberg’s (covered in special tests)

22. Lower Limb Sensation • Broadly speaking, 4 different ways to test 2 tracks: • Light touch= dorsal/posterior column and spinothalamic tract. Use cotton wool • Pin-prick= spinothalamic tract. Use Neurotip • vibration= dorsal/posterior column. Use tuning fork on bony prominences • Propioception= dorsal/posterior column. Wiggle big toe • In reality its much more complicated • I would recommend to check what's available in the station, start with cotton wool, then vibration then propioception. Start peripherally and move proximally.

23. Lower Limb Quick Screen Guide • When assessing pin-prick sensation in the lower limbs, try to start peripherally and move proximal to elicit a “stocking sensation loss” • When using fine touch, assess dermatomes: • L1 is inguinal region • L2 is anterior thigh • L3 is knee (it rhymes) • L4 is medial lower leg • L5 is big toe dorsal aspect • S1 is posterior aspect of foot

24. Lower Limb Special Tests/Summarise • Gait: • Ataxic: broad-based and unsteady. As if drunk. From cerebellar pathology or a sensory ataxia. Often won’t be able to tandem gait either. With a sensory ataxia, the patients watch their feet intently to compensate for proprioceptive loss. In a cerebellar lesion, may veer to one side. • Parkinsonian: small, shuffling steps, stooped posture and reduced arm swing (initially unilateral). Several steps taken to turn. Appears rushed (festinating) and may get stuck (freeze). Hand tremor may be noticeable. • High-stepping: (either unilateral or bilateral) caused by foot drop (weakness of ankle dorsiflexion). Also won’t be able to walk on their heel(s). • Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk. Caused by proximal lower limb weakness, e.g. myopathy. • Hemiparetic: one leg held stiffly and swings round in an arc with each stride (circumduction). • Spastic paraparesis: similar to above but bilateral – both are stiff and circumducting. Feet may be inverted and “scissor”.

25. Lower Limb Special Tests/Summarise • Rhomberg’s Test: • Ask them to stand, feet together, eyes closed for one minute • Positive test – loss of balance (swaying without correction/falling over) – this suggests a sensory ataxia (proprioceptive deficit) • Make sure to stop them falling • Summarize your findings!