What are the overall steps to a neuro exam of the limbs?
Arms and legs:
- Inspection
- Tone
- Power
- Coordination
- Reflexes
- Sensation
Gait
What are you looking for on inspection?
Scars/skeletal deformities Wasting of the muscle Involuntary movements - dystonia, chorea/athetosis, ballismus, ticks Fasciculations Tremor
How do you check tone of the arms? What are you looking for
Elbow flexion/extension
Forearm pronation/supination
Wrist flexion/extension
Compare both sides
Consider sudden movements to ensure no voluntary muscle contraction from patient
Looking for spasticity (UMN lesion) or rigidity (extra-pyramidal)
How do you check power of the arms?
Shoulder abduction Elbow flexion/extension Wrist flexion/extension Fingers - flexion (squeeze), extension (use side of hand to push), intrinsic (spread fingers and stop from pushing in), thumb abduction Pronator drift
Grade on MRC 0-5
How do you test coordination in the arms?
Outstretched arms (tremor/dystonia) Finger-nose test - both sides Rapid alternating hand movements - dysdiadochokinesis - both sides
How do you test the reflexes in the arm, and which spinal levels are they testing?
Biceps - C5/6
Supinator - C6
Triceps - C7
Both sides
Reinforce with teeth clench or hand squeeze
How do you test sensation in the upper limb?
Light touch - cotton wool - C5-8, T1 Pinprick sensation - same areas Vibration sense - small tuning fork (128Hz) - on joint, move proximal until felt Joint position sense
How do you assess tone of the legs?
Hip rotation
Knee drop
Ankle clonus - sudden, but fairly small, dorsiflexion
How do you assess power in the legs?
Hip flexion/extension (push thigh against hand and push down)
Knee flexion/extension (bend knee and push/pull)
Ankle dorsiflexion/plantarflexion
Bit toe extension
How do you assess coordination in the legs?
Heel-shin test
What reflexes are tested in the lower limb and which spinal levels do they correspond with?
Knee - L3,4
Ankle - S1
Plantar response (normal is down)
Reinforce by interlocking fingers and pulling
How is sensation tested in the lower limb?
Light touch - L2-5, S1
Pinprick - same areas
Vibration sense
Joint position sense
Romberg’s test
How is gait assessed?
Rise from sitting without using arms
Walking and turning
Tandem walking
Walking on tiptoes and heels
