What are the overall steps to a neuro exam of the limbs?
Arms and legs:
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
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
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?
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)
Bit toe extension
How do you assess coordination in the legs?
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
Joint position sense
How is gait assessed?
Rise from sitting without using arms
Walking and turning
Walking on tiptoes and heels