Stroke examination: Lower limb examination Flashcards
(28 cards)
What is the general order of a lower limb stroke examination?
Look at clinical signs
Muscle tone
Clonus
Sensation: Light touch, vibration sensation, pain perception
Power: Myotomes and resisted movements
Reflexes: Knee, ankle, plantar response with tendon hammer
Cerebellar function: Coordination (intention/action tremor), dysdiadochokinesia, gait
Joint proprioception
Which clinical signs should you look for in a lower limb stroke examination? SWIFT
Scars
Wasting
Involuntary movements eg. is patient leaning to one side
Fasciculations
Tremor
Which 2 types of tremor should you look for in an lower limb examination?
Resting tremor
Holmes tremor
When assessing tone in an lower limb stroke examination, which 3 muscle groups are being tested?
Hip
Knee
Ankle
How do you test tone in lower limb stroke examination?
- Ask patient to completely relax leg
- Hip rotation Roll the leg side to side at the hip
- Knee flexion: Lift the knee and allow it to fall, watch heel to see if it stays on bed (hypertonia: heel comes off bed)
- Ankle dorsiflexion, plantarflexion, eversion, inversion
How do you assess sensation in lower limb stroke examination with light touch?
Use a cotton wool to touch the center of patient’s neck and say that this is what normal sensation should feel like
Swipe once on leg and say ‘can you feel this’
Swipe once of on other leg and say ‘can you feel this’
Swipe both legs and say ‘which side can you feel’
Do this in quadrant areas from hip to toes
How do you assess sensation in lower limb stroke examination with pin-prick/pain sensation?
Use a neurotip to touch the center of patient’s neck and say that this is what normal sensation should feel like
Tell patient that you are going to lightly press neurotip on different areas of skin, and ask to tell if it feels the same, weaker or stronger
Press once on leg and say ‘can you feel this’
Press once of on other leg and say ‘can you feel this’
Press both legs and say ‘which side can you feel’
Do this in quadrant areas from hips to toes
How do you test sensation in lower limb stroke examination with vibration perception?
- Use a 128 Hz tuning fork
- Ask patient to close their eyes, and tell them that you are going to press the tuning fork to different bony areas and to tell you when the vibration stops
- Tap the tuning fork on your elbow to start vibrations then press to bony areas, squeeze prongs to stop vibration
Which 4 bony landmarks should be assessed in vibration perception, in the lower limb stroke examination?
IP joint of great toe
1st MTP joint
Medial or lateral malleolus
Tibial tuberosity
How do you assess the knee-jerk reflex, and what myotome is this assessing?
- Remove the weight from the patient’s lower limb by either supporting it (put your arm under their knee) or asking the patient to hang their legs over the side of the bed.
- Tap the patellar tendon with the tendon hammer (making sure to hold the tendon hammer handle at its end to allow gravity to aid a good swing)
- Should see quadriceps contract
L3, L4
What do you tell the patient before you test reflexes?
- Show patient the tendon hammer and tell them that you are going to tap lightly on the muscles with the hammer and see if this causes a reaction
- Ask patient to completely relax
How do you assess the ankle-jerk reflex, and what myotomes is this assessing?
- With the patient on the examination couch support their leg so that their hip is slightly abducted (can tell them to rest leg on the other), the knee is flexed and the ankle is dorsiflexed ‘like a frog-leg’
- Keep ankle in dorsiflexed position to stretch achilles tendon
- Tap the Achilles tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated plantarflexion of the foot
S1
How do you assess the babinski/plantar reflex, and what does it indicate?
- Explain that you are going to scratch the foot with a blunt stick and that this will feel briefly uncomfortable. Ensure the patient consents before proceeding.
- Fix the foot in position by holding the ankle (if the left foot is being assessed, use your left hand to hold the ankle and vice versa).
- Run the blunt object along the lateral edge of the sole of the foot, moving towards the base of the little toe and then turn medially to run across the transverse arch of the foot under the toes.
- Observe the big toe, all toes should flex (curl up)
Normal result: flexion of the big toe and flexion of the other toes.
Abnormal (Babinski sign): extension of the big toe and spread of the other toes (suggestive of an upper motor neuron lesion).
If reflexes are hard to illicit in the lower limb stroke examination, what can you ask the patient to do?
Make sure the patient is fully relaxed and then perform a reinforcement manoeuvre by asking the patient to clench their teeth together
Can also ask patient to clench hands together tightly
After checking tone, what should you assess in the lower limb stroke examination?
Clonus: Involuntary rhythmic muscular contractions and relaxations that is associated with upper motor neuron lesions
How do you check for clonus in the lower limb stroke examination?
- Position the patient’s leg so that the knee and ankle are slightly flexed, supporting the leg with your hand under their knee, so they can relax.
- Rapidly dorsiflex and partially evert the foot to stretch the gastrocnemius muscle.
- Keep the foot in this position and observe for clonus. Clonus is felt as rhythmic beats of dorsiflexion and plantarflexion
How do you test joint proprioception in the lower limb stroke examination?
- Demonstrate movement of the big toe “upwards” and “downwards” to the patient whilst they watch.
- Ask the patient to close their eyes and state if you are moving their big toe up or down.
- Move the big toe up or down 3-4 times in a random sequence to see if the patient is able to accurately identify joint position with their eyes closed.
- Hold the sides of the distal phalanx of the thumb (not the top/bottom to avoid pressure cues).
- Compare to other leg
How do you test cerebellar coordination in the lower limb stroke examination?
Heel-to-shin test:
1. Make sure patient is lying on back or sitting with legs extended
- “Please take the heel of your right foot and run it straight down the front of your left shin from the knee to the ankle’
- Ask patient to repeat this and do it as fast as they can
What is the normal finding in the heel-to-shin test?
Smooth steady movements with heel making contact with leg, no tremors or oveshooting
Give 4 abnormal findings in the heel-to-shin test?
Wobbling or falling off shin: Ipsilateral cerebellar lesion
Slow or uncoordinated movement: Ataxia (cerebellar or sensory)
Unable to locate shin with heel: Loss of proprioception
Overshooting or undershooting: Dysmetria (cerebellar sign)
How should you grade power, in the lower limb stroke examination?
Grade power from 0-5 with MRC muscle power scale:
Grade 0: No movement
Grade 1: Flickering movement
Grade 2: Movement but not against gravity
Grade 3: Movement against gravity
Grade 4: Movement against gravity but not resistance
Grade 5: Normal power
How do you test power of L1/L2 myotome?
Ask the patient to raise their straight leg off the bed and apply downward resistance over the anterior thigh
“Lift your leg off the bed and don’t let me push your leg down.”
How do you test power of the L3 myotome?
Knee extension: Ask patient to lie on bed and flex their knee to 90 degrees, ask them to try to extend knee whilst you push on anterior calf
“Try and straighten your leg whilst I try to stop you.”
How do you test power of the L4 myotome?
Dorsiflexion
Ask patient to lie on back with straight legs, then to point foot/toes towards their face whilst you push down on dorsum
“Put your legs flat on the bed, point your foot towards your face and don’t let me push your foot down.”
