Neurology- Tone Flashcards
1
Q
Tone examination
A
- ask the patient to lie supine in the bed and relax.
- enquire about pain
- passively move each joint through as full ROM as possible, both slowly and quickly in all anatomically possible directions
- be unpredictable with these movements, in both direction and speed to prevent the patient actively moving with you. We want to assess passive tone
- it may be helpful to distract the patient by asking them to count backwards whilst assessing tone.
2
Q
Time examination- upper limb
A
- hold the patients hand as if shaking, use your other to support their elbow
- assess tone at the wrist/elbow with supination/pronation and flexion/extension moments
- activation is a technique used to exaggerate subtle increase in tone and is particularly useful for assessing extrapyramidal side effects
- ask patient to describe circles in the air with the contralateral limb while assessing tone. An increase in tone is normal
3
Q
Tone examination- lower limb
A
- roll the leg from side to side then briskly flip the knee to into fixed position, observing movement in the foot
- Typically, the heel moves up the bed, but increased time may cause it to lift off the bed for to failure of relaxation
4
Q
Tone examination- ankle clonus
A
- support the patients leg, with both the knee and the ankle resting in 90’
- briskly dorsiflex and partially evert the foot, sustaining the pressure. Clonus is felt as repeated beats of dorsiflexion/plantar flexion
5
Q
Tone examination- Myotonia
A
- ask the patient to make a fist and then relax and open their hand. Watch for speed of relaxation
- using a tendon hammer, percuss the belly of the thenar eminence
- this may induce contraction of the muscles, causing the thumb to adduct, and you may witness dimpling of the muscle belly
6
Q
Hypotonia
A
- decreased tone may occur in lower motor neuron lesion and is usually associated with muscle wasting, weakness and hyporeflexia
- it may also be a feature of cerebellar disease or signal the early phase of cerebral or spinal shock when the paralysed limbs are atonic prior to developing spasticity
- reduced tone can be difficult to elicit
7
Q
Hypertonia- spasticity and rigidity
A
- increased time may occur in 2 main forms: spasticity and rigidity
-spasticity- velocity dependent resistance to passive movement, it is detected with wick movements and is a feature if upper motor lesions - it is usually accompanied weakness, hyperflexia, extensor plantar response
- it is more evident on extension in the upper limbs and flexion in the legs
- rigidity is a sustained resistance throughout the ROM and is easily detected when the limb is moved e.g. PD
8
Q
Power- examination
A
- don’t have to test every muscle
- ask about pain and observe from then in the chair
- ask the patient to lift arms above head
- ask them to play piano- asymmetrical finger may be early sign of cortical or extrapyramidal disease
- observe the patient with arms out (palms out) and eyes closed, check for protinator drift when one arm starts to protonate
- ask if they can overcome gravity, then apply pressure on a single limb
9
Q
Power
A
- upper motor neuron lesions produce weakness of a large group of muscles
- lower motor neuron damage causes paresis of an individual muscle so detailed examination is required
- Look for patterns that suggest a diagnosis
- in pyramidal weakness (e.g. post stroke) extensors are weaker in upper limb than flexors and vice verse in lower limbs
- myopathies tend to cause proximal weakness and neuropathies cause distal patterns
- radiculopathies tend to cause focal weakness
- very few organic disease causes power to fluctuate (fatiguable) e.g. myasthenia
10
Q
Deep tendon reflexes- anatomy
A
- a tendon reflex is the involuntary contraction of a muscle in response to stretch
- it’s mediated mediated by a reflex of afferent (sensory) and efferent (motor) neurons
- muscle stretch activates the muscle spindles that lead to direct efferent impulses causing contraction
- ## most important reflexes are deep tendon and plantar response
11
Q
Tendon reflex exam
A
- ask the patient to lie supine
- strike your finger that is palpating the bicep and supinator tendon or the tendon itself for the tricep, knee and ankle jerk
- record: as increased, decreased, normal, present with reinforcement or absent
12
Q
Principal (deep tendon) reflexes
A
- ensure that both limbs are positioned identically with the same amount of stretch. This is especially important for ankle is passively doriflexed before striking
- compare each reflex. Check for symmetry
- ## reinforce where it appears absent
13
Q
Hoffmanns reflex
A
- place your right index finger under the distal interphalangeal joint of the patients middle finger
- use your thumb to flick the patients finger downwards
- look for reflex flexion in the patients thumb
14
Q
Plantar response
A
- run a blunt object along the lateral border of the sole of the foot upto the little toe
- normal is the great toe should move down.
- extensor plantar response (babinski) signifies an abnormal reflex due to an upper motor neuron lesion
- coincides with contraction of other leg flexor muscles
15
Q
Tendon reflex’s meaning
A
- hyperflexia is a sign of upper motor neuron damage
- diminished or absent jerks are most commonly due to lower motor neuron lesions
- in healthy older people ankle jerk may be lost and in myotonic pupils are associated with loss of some reflex’s
- isolated loss of reflex suggests radiculopathy/mononeuropathy e.g. loss of ankle jerk= compression of S1 (disc prolapse)
- an inverted biceps reflex= root pathology at the spinal level (C5)
- Hoffmann reflex and increased finger jerks suggest hypertonia
- in cerebellar disease the reflexes may be Pendigo and muscle contraction and relaxation tend to be slowed
- ## plantar extension is a sign of upper motor neuron damage and is usually associated with other signs such as spasticity, clonus and hyper-reflexia
