Neurological Examination - Upper and Lower Limbs

Question 1

Neurological examination of upper limbs

Answer 1

• Inspection of the upper limb
• Motor system assessment of upper limb
• Sensory system assessment – sharp/dull, stereognosis, proprioception
• Coordination in the upper limbs
• Rapid alternating movements in upper limb
• Reflexes – Biceps and Triceps reflex

Question 2

Neurological examination of lower limbs

Answer 2

• Inspection of the lower limb
• Motor system assessment of lower limb
• Sensory system assessment – sharp/dull, proprioception
• Coordination in the lower limbs
• Rapid alternating movements in lower limb
• Reflexes – Patellar reflex, Ankle jerk, Plantar reflex

Question 3

PQRST method of assessing pain

Answer 3

PROVOCATION/PALLIATION
- What caused the pain?
- What makes it better/worse?

QUALITY/QUANTITY
- What does it feel like?
- Is it sharp, dull, stabbing, burning, crushing, throbbing, shooting?

REGION/RADIATION
- Where is the pain?
- Does the pain radiate to somewhere else?

SEVERITY SCALE
- 0-10 numerical scale
- face scale for children/infants

TIMING
- When did it start?
- How long did it last?
- How often does the pin occur?

Question 4

Inspection - Limb

Answer 4

• Size of the limbs:
• proximal to distal
• Compare each muscle groups in the right and left limbs
• Symmetry of the limbs
• Muscle wasting or hypertrophy
• Involuntary movements:
• tremors, fasciculations, chorea, or seizures.
• If any involuntary movement is present, their location, frequency, rate and amplitude should be noted.

Question 5

Motor system assessment - Limb

Answer 5

assess the
motor pathways to skeletal muscles.

Note any changes to:
* Size:
- muscles on right and left should be symmetrical.
- Any reduction called atrophy could indicate nutritional deficiency, poor blood supply, lack of nerve stimulation or use.
- Atrophy common in lower motor neuron diseases due to lack of nerve
stimulation from LMN.

• Muscle tone:
• normal degree of involuntary contraction in relaxed
  skeletal muscles.
• important for proper functioning of muscles.
• Flaccid muscle tone could indicate lower motor neuron
  disease
• Spasticity more common with upper motor neuron lesions.
• Strength:
• strength of muscle groups of extremities, neck and trunk
  would help rule out muscle weakness or paralysis
• should be done by using active resistance in the mid-range of motion.

Question 6

Abnormalities in Muscle Tone - Flaccidity

Answer 6

Decreased tone, or hypotonia.
Muscle feels limp, soft, flabby.
Weak and easily fatigued.
Limb feels like a ragdoll.

Associated with:
Lower Motor Neuron injury
- anywhere from anterior horn cell in spinal cord to peripheral nerve. (peripheral neuritis, poliomyelitis, Guillain-Barre Syndrome)
- early stroke and spinal cord injury are flaccid at first

Question 7

Abnormalities in Muscle Tone - Spasticity

Answer 7

Increased tone, or hypertonia.
Increased resistance to passive lengthening, then may suddenly give way (clasp-knife phenomenon)

Associated with:
Upper Motor Neuron injury
- corticospinal motor tract
(eg paralysis with stroke develops spasticity days or weeks after incident)

Question 8

Abnormalities in Muscle Tone - Rigidity

Answer 8

Constant state of resistance (lead pipe rigidity)
Resists passive movement in any direction
dystonia

Associated with:
injury to Extrapyramidal Motor Tracts
(eg basal ganglia with parkinsonism)

Question 9

Abnormalities in Muscle Tone - Cogwheel rigidity

Answer 9

Increased tone released by degrees during passive range of motion - small, regular jerks

Associated with:
Parkinsonism

Question 10

Upper Motor Neuron Lesion

Answer 10

Occur in cerebral vascular accidents (stroke), cerebral palsy or MS.

Increase motor responses

• muscle spasticity, exaggerated deep tendon reflexes, presence
  of Babinski sign in plantar reflex.

Question 11

Lower Motor Neuron Lesion

Answer 11

Communicate directly with the muscles

Reduce motor responses

• flaccidity in the muscle tone, reduced deep tendon reflexes, presence of abnormal
  muscle movements.

Question 12

Sensory system assessment - Limbs

Answer 12

Test intactness of the peripheral nerve fibres, sensory tracts, higher cortical discrimination.

Involves:
* Checking specific dermatomes for Sharp and dull sensations.
* Upper limbs – Check C2-T2
* Lower limbs – Check L2 –S2

Question 13

Sensory pathways

Answer 13

Anterolateral spinothalamic tracts
- Sensations conducted: pain &
temperature (lateral tract); tickle, itch, crude touch & pressure (anterior tract)

Posterior column medial lemniscus tracts
- Sensations conducted: proprioception, vibration, discriminative touch, weight
discrimination; posture, balance and coordination of skilled movements

Question 14

Sharp Dull Test

Answer 14

• Explain and show the testing with “sharp” and “dull” in an unaffected area.
• Have patient close their eyes.
• Test randomly by using sharp and blunt stimulus, noting patient’s response in each area tested.
• Pain and crude touch sensations both travel up the spinothalamic tracts. Hence it tests for intactness of spinothalamic tracts.

Question 15

Stereognosis

Answer 15

Ability to identify an object by feeling it

• Place familiar object in patient’s hand with eyes closed and ask to identify it.
• Test bilaterally with different objects
• Normally patient manipulates object skillfully and identifies it
  correctly
• Astereognosis = inability to identify object.
• Tests posterior column medial lemniscus pathway

Question 16

Joint Position Sense (Proprioception)

Answer 16

• Stabilize the proximal digit.
• Grasp the sides of the distal digit with thumb and index finger.
• Move joint up and down and
  orient patient to the movement
  with eyes open.
• Repeat with eyes closed and ask the patient to state “up” or
  “down”.
• Inability to identify the movement indicates poor proprioception.
• Tests posterior column medial
  lemniscus pathway.

Question 17

Coordination tests for the Upper limbs

Answer 17

Finger–Nose–Finger test

Question 18

Coordination tests for the Lower limbs

Answer 18

Heel-to-Shin test

Question 19

Rapid alternating movements in upper limb

Answer 19

• Ask the person to pat the knees with both hands, lift-up, turn hands over and pat the
  knees again, with the back of hands. Repeat to do faster.

Or

• Ask the person to touch thumb to each finger on the same hand, starting with index finger, then reverse the direction and repeat to do faster.

Question 20

Rapid alternating movements in lower limbs

Answer 20

• Ask the person sit comfortably on the examination chair with feet touching the ground and tap the ground with alternatingly with each foot.

Or

• Get the person in supine position, and ask them to tap the examiner’s hands with their feet alternatingly.

Question 21

Deep tendon reflexes in upper limb

Answer 21

Biceps reflex
- Performed indirectly by striking practitioner’s thumb placed over client’s biceps tendon.
- Will produce flexion of the forearm as biceps muscle contracts.
- Assesses spinal levels C5-C6

Triceps reflex
- Striking triceps tendon directly
just above the elbow will produce extension of the forearm.
- Assesses spinal levels C7-C8

Question 22

Deep tendon reflexes in lower limb

Answer 22

Patellar reflex
- Assesses the spinal segments
L2-L4.
- Striking the tendon of Quadriceps femoris under the patella will elicit extension of the lower leg as the normal response.

Achilles reflex
- Assesses the segments L5-
S2.
- Striking the Achilles tendon on a dorsiflexed foot, the normal response will be the plantar flexion of the foot.

Question 23

Grading the deep tendon reflexes

Answer 23

4+ Very brisk, hyperactive with clonus, indicative of disease

3+ Brisker than average, may indicate disease, probably normal

2+ Average, normal

1+ Diminished, low normal, or occurs only with reinforcement

0 No response

Question 24

Superficial plantar reflex

Answer 24

Superficial or cutaneous reflex
- assessing spinal segments L4-S2

Normal plantar reflex
- withdrawing the foot when tickled with reflex hammer.

Abnormal response
- Dorsiflexion of foot with fanning of all toes - positive Babinski sign; suggests an upper motor neuron disease

Question 25

Abnormal Muscle movements -Fasciculations

Answer 25

Rapid, continuous twitching of resting muscle or part of muscle without movement of limb, which can be seen by clinicians or felt by patients. Can be fine (occurs with LMN disease, associated with atrophy and weakness) or coarse (occurs with cold exposure or fatigue and is not Significant)

Question 26

Abnormal Muscle movements -Tics

Answer 26

Involuntary, compulsive, repetitive twitching of a muscle group (e.g., wink, grimace, head movement, shoulder shrug); Due to a neurologic cause (e.g., tardive dyskinesias, Tourette syndrome) or a psychogenic cause (habit tic).

Question 27

Abnormal Muscle movements -Chorea

Answer 27

Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face. Occurs at irregular intervals, not rhythmic or repetitive, more convulsive than a tic. Some are spontaneous, and some are initiated; all are accentuated by voluntary acts. Disappears with sleep. Common with Sydenham chorea and Huntington disease.

Question 28

Abnormal Muscle movements -Tremors

Answer 28

Tremors are involuntary contractions of opposing muscle groups. They can be rest tremors which occur when muscles are quiet and supported against gravity (eg. pill rolling movement) or intention tremors that occur when the person is trying to reach towards a visually guided target.

Question 29

Patterns of sensory loss -Peripheral Neuropathy

Answer 29

Loss of sensations involving all sensory modalities, mostly distally in the feet and hands. Can be caused by metabolic disease and nutritional deficiencies.

Question 30

Patterns of sensory loss -Damage to Individual nerves or roots

Answer 30

Decrease or loss of all sensory modalities in the area corresponding to the distribution of the involved nerve. Can be caused by direct trauma or vascular occlusion.

Question 31

Patterns of sensory loss - Spinal cord hemisection

Answer 31

Usually occurs in cases of meningioma, neurofibromas, cervical spondylosis or MS. It causes contralateral loss of pain and temperature one to two segments below the level of lesion and ipsilateral loss of vibration and touch discrimination below the level of the lesion.

Question 32

Patterns of sensory loss - Acute compression of spinal cord

Answer 32

Caused by fractured vertebrae or movement of bone fragments, disc herniation, and movement of vertebral bodies Presents with symmetric loss of sensations below the level of compression, urinary retention, or incontinence.

Question 33

Patterns of sensory loss - Damage to the Thalamus

Answer 33

Contralateral loss of all sensory modalities on the face, arm and leg. Pupils miosis and aphasia. Could be caused by vascular occlusion

Question 34

Patterns of sensory loss - Damage to cerebral cortex

Answer 34

Loss of discrimination on the contralateral side with loss of recognition of shape, weight and finger finding. The sensations of pain, vibration and crude touch will not be affected usually. Can be caused by stroke or parietal lobe lesions.