Neurological exam Flashcards
(8 cards)
Adsons Test
Starting Position [2]
The test can be performed with the patient in either sitting or standing with their elbow in full extension
Procedure [2]
- The arm of the standing (or seated) patient is abducted 30 degrees at the shoulder and maximally extended.
- The radial pulse is palpated and the examiner grasps the patient’s wrist.
- The patient then extends neck and turns the head toward the symptomatic shoulder and is asked to take a deep breath and hold it.
- The quality of the radial pulse is evaluated in comparison to the pulse taken while the arm is resting at the patient’s side.
- Some clinicians have patients turn their heads away from the side tested in a modified test.
Positive Test [2]
The test is positive if there is a marked decrease, or disappearance, of the radial pulse. It is important to check the patient’s radial pulse on the other arm to recognize the patient’s normal pulse.
A positive test should be compared with the non-symptomatic side.
A problem with the thoracic outlet tests on the whole is that many asymptomatic subjects will test positive, depending how a positive test is defined.
The heel to shin test is a measure of
coordination and may be abnormal if there is loss of motor strength, proprioception or a cerebellar lesion. If motor and sensory systems are intact, an abnormal, asymmetric heel to shin test is highly suggestive of an ipsilateral cerebellar lesion.
Rapidly Alternating Movement Evaluation
Ask the patient to place their hands on their thighs and then rapidly turn their hands over and lift them off their thighs. Once the patient understands this movement, tell them to repeat it rapidly for 10 seconds. Normally this is possible without difficulty. This is considered a rapidly alternating movement.
Dysdiadochokinesis is the clinical term for an inability to perform rapidly alternating movements. Dysdiadochokinesia is usually caused by multiple sclerosis in adults and cerebellar tumors in children. Note that patients with other movement disorders (e.g. Parkinson’s disease) may have abnormal rapid alternating movement testing secondary to akinesia or rigidity, thus creating a false impression of dysdiadochokinesia.
Gait
Gait is evaluated by having the patient walk across the room under observation. Gross gait abnormalities should be noted. Next ask the patient to walk heel to toe across the room, then on their toes only, and finally on their heels only. Normally, these maneuvers possible without too much difficulty.
Be certain to note the amount of arm swinging because a slight decrease in arm swinging is a highly sensitive indicator of upper extremity weakness.
Also, hopping in place on each foot should be performed.
Walking on heels is the most sensitive way to test for foot dorsiflexion weakness, while walking on toes is the best way to test early foot plantar flexion weakness.
Abnormalities in heel to toe walking (tandem gait) may be due to ethanol intoxication, weakness, poor position sense, vertigo and leg tremors. These causes must be excluded before the unbalance can be attributed to a cerebellar lesion. Most elderly patients have difficulty with tandem gait purportedly due to general neuronal loss impairing a combination of position sense, strength and coordination. Heel to toe walking is highly useful in testing for ethanol inebriation and is often used by police officers in examining potential “drunk drivers”.
Rhomberg Test
Next, perform the Romberg test by having the patient stand still with their heels together. Ask the patient to remain still and close their eyes. If the patient loses their balance, the test is positive.
To achieve balance, a person requires 2 out of the following 3 inputs to the cortex: 1. visual confirmation of position, 2. non-visual confirmation of position (including proprioceptive and vestibular input), and 3. a normally functioning cerebellum. Therefore, if a patient loses their balance after standing still with their eyes closed, and is able to maintain balance with their eyes open, then there is likely to be lesion in the cerebellum. This is a positive Rhomberg.
Also - sit to stand
Acquired ataxias may result from nonhereditary neurodegenerative disorders (eg
, systemic disorders, multiple sclerosis, cerebellar strokes, repeated traumatic brain injury, or toxin exposure, or they may be idiopathic. Systemic disorders include alcoholism (alcoholic cerebellar degeneration), celiac disease, heatstroke, hypothyroidism, and vitamin E deficiency. Toxins include carbon monoxide, heavy metals, lithium, phenytoin, and certain solvents. Toxic levels of certain drugs (eg, antiseizure drugs) can cause cerebellar dysfunction and ataxia.
Sometimes TUMORS
A disproportionate loss of vibratory sense and proprioception (compared to pain sensation) tends to suggest
disease of the dorsal columns (e.g. tabes dorsalis, Vitamin B12 deficiency, multiple sclerosis) or demyelinating neuropathies.
Pronator drift-
Arms held supinate - will pronate, indicating Pyramidal tract lesion contra lateral
