Neurological Exam Upper Limb Flashcards
What is the hierarchy of body parts which must remain intact for upper limb function to remain normal?
Brain Spinal Cord Peripheral Nervous System Muscles Tendons and attachments Bone
What method pattern should most clinical examinations follow?
Inspection Palpation Percussion Auscultation
What are the 3 Golden rules in neurological examinations?
1). Comparison of right to left 2). Comparison of proximal to distal 3). Differentiation of upper and lower motor neurone lesions
What are the different categories to asses in the examination?
1). Introduction 2). Inspection 3). Assessment of tone 4). Screening Assessment of Power 5). 3 upper limb tendon reflexes + Reinforcement (If required) 6). Assessment of sensation 7). Co-Ordination of upper limb 8). Conclusion
What should you do in the Introduction ?
Introduction: 1). Organise the equipment you need: tendon hammer, cotton wool, disposable neurological pins, 128 Hz tuning fork 2). Wash your hands with water or alcohol gel 3). Approach the patient from his right-hand side 4). Introduce yourself to the patient 5). Check identity by asking name and date of birth 6). Explain procedure to the patient 7). Ask if patient is in any pain or discomfort 8). Obtain verbal consent for examination
What should you do in the Inspection ?
Inspection: 1).Observe the posture of the limbs and look for any asymmetry 2). Observe the symmetry, size and shape of muscles 3). Observe any scars or bruising 4). Observe any abnormal movements 5). Look for fasciculation
What should you do in the Assessment of tone ?
Assessment of tone • Ask the patient to relax their arm and allow you to move it Put each major joint through a full range of movement - Always compare right with left
What should you do in the Screening Assessment of Power ?
Screening Assessment Of Power is based on nerve root values (rather than muscle groups) Rough guide: shoulder abduction C5, elbow flexion C6 elbow extension C7, wrist C7, abduction fingers/thumb C8/T1 Power is assessed by active movements against resistance of each joint in turn; 1). Shoulder abduction [deltoid C5] — “make wings with your arms, keep your arms up, don’t let me push them down” 2). Elbow flexion [biceps C5/6] —”pull me towards you” 3). Elbow extension [triceps C7] —”now push me away” 4). Wrist extension [radial and ulnar extensors C6/7] — “make a fist: push up against my hand” 5). Finger abduction [intrinsic muscles C8/T1] —”spread your fingers apart, don’t let me squash them together” 6). Thumb abduction [abductor pollicis brevis C8/T1] — (hand in anatomical position) “put your thumb up, don’t let me push it down”
What should you do in the 3 upper limb tendon reflexes + Reinforcement (If required) ?
1). Place the patient in a comfortable position where the arms are supported. 2). Ensure the muscle being tested is fully exposed for you to observe the contraction 3). Ask the patient to allow their arm to become floppy and relaxed 4). Biceps Reflex (spinal root level C5/6) • Palpate the biceps tendon and press on it firmly with your non dominant thumb • Strike your thumb with a brisk, staccato tap from the tendon hammer • Observe the response Of the biceps muscle Compare the response with that of the opposite side 5). Brachioradialis Reflex (C5/6) • Hold the patient’s hand with your non dominant hand • Strike the forearm at the level of a watch strap on the radial aspect over brachioradialis • Observe the response of brachioradialis • Compare the response with that Of the opposite side 6). Triceps Reflex (C7) • Strike the triceps tendon directly with a brisk, staccato tap from the tendon hammer • Observe the response Of the triceps muscle • Compare the response with that Of the opposite side 7). Reinforcement If the reflex appears absent, try a second time. If it has not been elicited on the second attempt, try a reinforcement manoeuvre e.g. clenching teeth (for upper limb reflexes) or gripping hands together (for lower limb reflexes).
What should you do in the Assessment of sensation ?
1). Before formal testing, ask the patient if they have noticed any altered sensation, numbness or paraesthesia. 2). Pain or Pinprick (Spinothalamic tract); • Use a disposable neurological pin • Establish a baseline for sharpness on the sternum • Ask the patient to close their eyes and report if the sensation is sharp or blunt • Examine the arms bearing in mind the segmental distribution of the spinal • Dispose of pin in yellow sharps box 3). Proprioception (Dorsal columns); • Test this in the distal aspect of the limb first • Educate the patient by holding the distal phalanx of a finger, moving the tip of the finger, and establishing up and down positions. • Ask the patient to close their eyes, and report if their finger is up or down • Holding the finger along the medial and lateral borders move the patients finger • If there is any abnormality, test again at the next more proximal joint 4). Light touch • Ask the patient to close their eyes and respond verbally to each touch • Touch the skin with a small piece of cotton wool, do not stroke • Ensure irregular time intervals to prevent prediction of the stimulus • Examine the arms bearing in mind the segmental distribution Of the spinal nerves • If an area of numbness is identified, map its distribution • Dispose of cotton wool in clinical waste bins 5). Vibration Sense • Using a vibrating tuning fork, educate the patient by holding the base against the sternum to allow them to identify the sensation • Ask the patient to close their eyes • Hold the vibrating tuning fork against a distal bony prominence e.g. a knuckle • Ask the patient to identify the vibration • If any abnormality repeat the process at a more proximal bony prominence 6). Temperature (Not routinely done. Pain/pin prick sensation travels in the spinothalamic tracts but if an abnormality is detected, additional testing of the spinothalamic tracts can be done using something cold (e.g. metal tuning fork/cold spray) to test further.) • Using the cold stimulus establish a baseline for coldness on the sternum • Ask the patient to report if it is as cold on their arms • Map out any area of decreased temperature sensation
What should you do in the Co-Ordination of upper limb ?
1). Finger-nose; • Hold your index finger at arms length from the patient. • Ask the patient to touch your finger with their right index finger and then to touch their nose. • Repeat the sequence several times as quickly and accurately as possible. • Repeat the test with the patient’s left index finger. 2). Alternating hand movements; • Ask the patient to pronate and supinate his arm rapidly by placing his hand on his other palm and alternating palm and dorsum. • Demonstrate first and ask patient to copy. If this is done slowly and clumsily it is called dysdiadochokinesia. 3). Finger to finger - (additional test, not done routinely); • Ask the patient to hold both arms fully out to the side horizontally. • Then ask him to bring his fingers together in a wide arc and to stop just short of touching. You may have to demonstrate and ask him to copy. • At the same time look for intention tremor and overshooting. 4). Fine movements - (Additional test, not done routinely. Can be affected by conditions causing bradykinesia e.g. Parkinson’s disease); • Ask patient to make fine movements with finger tips e.g. fingertip touching on each hand. Alternatively ask him to unbutton and button his shirt.
What should you do in the Conclusion ?
1). Conclude the examination 2). Thank patient 3). Wash hands
In what conditions might “tone” be increased or decreased?
Hypotonia (decreased muscle tone) - E.g Cerebal Palsy (Neurological problems present at birth that affects a child’s movement and co-ordination Hypertonia (increased muscle tone) - E.g - Parkinson’s disease (Increased muscle tone causes rigidity)
Describe the scoring system below used to assess power ?
The MRC scale of muscle strength uses a score of 0 to 5 to grade the power of a particular muscle group in relation to the movement of a single joint.
Where do nerve impulses from the Brain begin?
Nerve impulses begin in the cerebral codex.
Where do nerve impulses end?
Nerve impulses end at a muscle to start movement.
What do impulses from the motor cortex in the cerebral hemispheres travel in?
In the cerebral hemispheres, impulses from the motor cortex travel in Upper Motor Neurones in the Codicospina/ Tacts (cortex to spinal cord).
Define the term deep tendon reflex.
A deep tendon reflex is often associated with muscle stretching. Tendon reflex tests are used to determine the integrity of the spinal cord and peripheral nervous system, and they can be used to determine the presence of a neuromuscular disease.
Draw a diagram illustrating the physiology behind the biceps reflex.
Below
In which conditions might tendon reflexes be increased? Why?
If there is an upper motor neurone lesion, the reflex is increased because inhibitory factors have been removed. Upper motor neuron lesions occur in the brain or the spinal cord as the result of stroke, multiple sclerosis, traumatic brain injury, cerebral palsy, atypical parkinsonisms, multiple system atrophy, and amyotrophic lateral sclerosis.
Draw a diagram of the dermatomes of the upper limb?
Below
