what are the overall steps of this examination?
- general inspection
- gait and Romberg’s test
- tone
- power
- reflexes
- sensation
- coordination
what equipment is required?
- tendon hammer
- neurotip
- cotton wool
- tuning fork (128Hz)
what clinical signs should be looked for in general inspection?
- scars
- muscle wasting
- tremor
- fasciculations
- pseudoathetosis
- chorea
- myoclonus
- tardive dyskinesia
- hypomimia
- ptosis and frontal balding
- ophthalmoplegia
how should gait be assessed?
- normal gait
- tandem gait
- look at stance, stability, arm swing, steps, turning
what is ataxic gait?
broad-based, unsteady and associated with cerebellar pathology or sensory ataxia
what is Parkinsonian gait?
small, shuffling steps, stooped posture and reduced arm swing (initially unilateral). several small steps to turn, rushed gait, getting stuck, hand tremor
what is high stepping gait?
can be unilateral or bilateral and is typically caused by foot drop; won’t be able to heel walk
what is waddling gait?
shoulders sway from side to side, legs lifted off ground with aid of tilting the trunk; commonly cause by proximal lower limb weakness
what is hemiparetic gait?
one leg held stiffly and swings round in an arc with each stride; associated with stroke
what is spastic paraparesis?
similar to hemiparetic gait but bilateral, with both legs stiff and circumducting; feet may be inverted and scissor; associated with hereditary spastic paraplegia
how is Romberg’s test performed?
- position yourself within arms reach of patient
- ask patient to put feet together and keep arms by sides
- ask patient to close eyes
- positive sign= falling without correction
what is a positive sign of Romberg’s test?
falling without correction; indicates unsteadiness due to sensory ataxia (deficit of proprioceptive or vestibular function)
what are causes of proprioceptive dysfunction?
joint hypermobility, B12 deficiency, Parkinson’s, ageing
what are causes of vestibular dysfunction?
vestibular neuronitis and Meniere’s disease
what movements are used to assess tone?
- leg roll and leg lift
2. ankle clonus
how is the leg roll and leg lift performed?
- assesses tone in muscles of hip, knee and ankle
- ask patient to keep legs fully relaxed throughout
- with patient lying on couch, roll each leg to assess tone in muscles responsible for rotation of hip
- lift each knee briskly off the bed (warn them first) and observe movement
- the knee should rise whilst the heel remains in contact with the bed
what is clonus?
series of involuntary rhythmic muscular contractions and relaxations that’s associated with UMN lesions
how is ankle clonus assessed?
- position the patient’s leg so the knee and ankle are slightly flexed, supporting the leg with your hand under their knee
- rapidly dorsiflex and partially evert the foot to stretch the gastrocnemius muscle
- keep foot in this position and observe for clonus; if more than 5 beats of clonus are present, this is abnormal
what movements are used to assess power?
- hip flexion
- hip extension
- knee flexion
- knee extension
- ankle dorsiflexion
- ankle plantarflexion
- big toe extension
what reflexes are assessed?
- knee-jerk reflex (L3,4)
- ankle-jerk reflex (S1)
- plantar reflex (L5, S1)
how is the knee-jerk reflex assessed?
- remove weight from the patient’s lower limb by supporting it or asking them to hand their legs over the side of the bed
- tap patellar tendon with the hammer
how is the ankle-jerk reflex assessed?
- with patient on exam couch, support their leg so their hip is slightly abducted, the knee is flexed and the ankle is dorsiflexed
- tap the Achilles tendon with hammer
- observe for contraction in the gastrocnemius muscle with associated plantarflexion of the foot
how is the plantar reflex assessed?
- with patient on couch, explain you’re going to scratch the foot with a blunt stick and it will be uncomfortable
- fix foot in position by holding ankle
- run blunt object along lateral edge of the sole of the foot, moving towards the base of the little toe and turn medially to run across the transverse arch of the foot under the toes
- observe the big toe
- normal result = flexion of big toe and other toes
- abnormal result = Babinski sign
where is the L1 dermatome located?
inguinal region and very top of medial thigh
