Upper Limb Neurological Exam

Question 1

Mnemonic for structure of this exam?

Answer 1

To postpone reflexes constitutes stupidity - Tone, power, reflexes, co-ordination, sensation.

Question 2

How much should the patient be exposed?

Answer 2

Expose both upper limbs from shoulders to fingers.

Question 3

Summary of general inspection?

Answer 3

Surroundings - Monitoring (ECG - autonomic problems), treatments (O2, IV infusions), paraphernalia (wheelchair, mobility aids etc.).

Patient - Asymmetry, deformity or abnormal posture (dystonia). Often due to abnormal contraction of one group of muscles.

SWIFT - Scars, Wasting of muscles, Involuntary movements, Fasciculations, Tremor

Question 4

What is writer’s cramp?

Answer 4

Muscles of hand and forearm cramp when patient tries to write.

Question 5

What is wry neck?

Answer 5

Torticollis - painful contraction of SCM which causes the face to point to one side. Other variants possible; retrocollis - head tilts backwards, antecollis - head tilts forwards.

Question 6

What is resting tremor indicative of?

Answer 6

Parkinson’s disease

Question 7

What is intention tremor indicative of?

Answer 7

Cerebellar disorder

Question 8

Common sites of muscle wasting?

Answer 8

Proximally - deltoid, supra/infraspinatus.

Distally - 1st dorsal interosseous muscle.

Question 9

What is fasciculation?

Answer 9

Irregular twitches under the skin overlying resting muscles caused by individual motor units firing spontaneously.

Question 10

What causes pronator drift?

Answer 10

UMN weakness

Question 11

What is psuedoathetosis?

Answer 11

Proprioceptive loss leading to involuntary, slow snake-like movements of distal regions (fingers and toes).

Question 12

What is dysmetria?

Answer 12

Lack of co-ordination (due to cerebellar lesion)

Question 13

What is myoclonus?

Answer 13

Brief jerks that can move a limb. Usually restricted to one muscle group but can be generalised.

Question 14

What are tics?

Answer 14

Borderline psychiatric/neuro in origin. Tend to affect the face. Main manifestation in Tourette’s, but often benign in normal individuals.

Question 15

What is TONE?

Answer 15

The resistance felt by the examiner when moving a joint passively.

Question 16

How do you assess tone in the upper limbs?

Answer 16

• Ask patient to lie supine on examination couch, and to relax and ‘go floppy’. Ask about painful joints or limitations of movement before proceeding.
• Passively move each joint tested through as full a range as possible, both slowly and quickly in all anatomically possible directions.
• Hold the patient’s hand as if shaking hands, using other hand to support elbow. Assess tone at wrist, elbow and shoulder.

Question 17

What is hypotonia associated with?

Answer 17

LMN lesions. Usually associated with muscle wasting, weakness and hyporeflexia.

Question 18

What are the two types of hypertonia?

Answer 18

Spasticity and rigidity - UMN lesions.

Question 19

How do you grade power?

Answer 19

0 - no muscle contraction visible
1 - flicker of contraction but no movement
2 - joint movement when effect of gravity eliminated
3 - movement against gravity but not against examiners resistance
4 - movement against resistance but weaker than normal
5 - Normal power

Question 20

What do you do before assessing power?

Answer 20

Ask if the patient has any pain that may interfere with testing

Question 21

Where do you start when assessing power?

Answer 21

Start proximally

Question 22

How to assess for ‘pronator drift’?

Answer 22

Observe patient with arms outstretched and supinated and eyes closed. When one arm starts to pronate the sign is positive and it is a sign of UMN lesion.

Question 23

Difference between weakness produced by upper and lower motor neuron deficits?

Answer 23

UMN lesions produce weakness of relatively large muscle groups, whereas LMN damage can cause paresis of individual and specific muscles.

Question 24

What are the movements needed to assess power?

Answer 24

Shoulder abduction/adduction - CHICKEN
Elbow flexion/extension - BOXER
Wrist flexion/extension - MOTORBIKE
Finger flexion/extension
Finger abduction
Thumb abduction/adduction

Question 25

How should the patient be positioned for reflexes?

Answer 25

Supine on examination couch with limbs exposed. As relaxed and comfortable as possible.

Question 26

How do you record the response when assessing reflexes?

Answer 26

``` Increased Normal Diminished Present only with reinforcement Absent ```

Question 27

How do you reinforce upper limb reflexes?

Answer 27

Ask patient to clench their teeth or make a fist with the contralateral hand. Patient should relax between repeated attempts. Strike tendon immediately after command to the patient.

Question 28

What are the three reflexes and their nerve roots?

Answer 28

Biceps reflex - C5 Triceps reflex - C7 Supinator jerk - C6

Question 29

How do you ilicit Hoffmann's reflex?

Answer 29

- Place right index finger under distal interphalangeal joint of patient's middle finger. - Use your right thumb to flick the patient's finger downwards. - Look for any reflex flexion of the patient's thumb.

Question 30

How do you ilicit a finger jerk?

Answer 30

Place middle and index fingers across the palmar surface of the proximal phalanges. Tap your own fingers with the hammer. Watch for flexion of the patient's fingers.

Question 31

What are the three aspects of assessment of co-ordination?

Answer 31

Rebound phenomenon Finger to nose test Rapid alternating movements

Question 32

How to test rebound phenomenon?

Answer 32

Ask patient to stretch his arms out and maintain the position. Push patient's wrist quickly downward and observe rebounding movement.

Question 33

How to do finger-to-nose test?

Answer 33

Ask patient to touch their nose with their finger then touch your finger tip as quickly as possible. Make the test more sensitive by changing the position of the target finger as quickly as possible. Repeat with opposite hand. Look for dysmetria or past pointing. There may be a tremor as it approaches the target finger and the patient's own nose (intention tremor). The movement may be slow, disjointed and clumsy (dyssynergia).

Question 34

how to assess rapid alternating movements?

Answer 34

Demonstrate the action of slapping palm repeatedly with the palm and back of opposite hand as quickly and as regularly as possible. Ask patient to repeat your action and repeat with opposite hand. Dysdiadochokinesis = impairment of rapid alternating movement = evident as slowness, disorganisation and irregularity of movement.

Question 35

What are the 6 aspects of assessment of sensation?

Answer 35

``` Light touch Superficial pain Temperature Vibration Proprioception Sterognosis and graphaesthesia ```

Question 36

How to assess light touch sensation/superficial pain?

Answer 36

- With patient's eyes closed, use a wisp of cotton wool/neurological pin and ask the patient to say 'yes' to each touch. - Time stimuli irregularly and use a dabbing rather than stroking motion. - Compare both sides for symmetry

Question 37

How to assess for temperature sensation?

Answer 37

Touch patient with cold metallic object (i.e. a tuning fork) and ask if it feels cold.

Question 38

How to assess for vibration sensation?

Answer 38

- Place a vibrating tuning fork over the sternum and ask the patient if they feel it vibrating. - Place the vibrating tuning fork on the distal IP join of the forefinger. If sensation is impaired, move proximally.

Question 39

How to assess for proprioception?

Answer 39

- With patient's eyes open, demonstrate the procedure. Hold the distal phalanx of the middle finger and explain that you are going to move it up and down, demonstrating as you do so. - Ask the patient to close their eyes and identify the direction of small movements in a random order. - Test both sides. If impaired, test more proximal joint in same limb.

Question 40

How to assess for stereognosis/graphaethesia?

Answer 40

- Ask patient to close their eyes. Place familiar object in their hands and ask them to identify it (i.e. key or coin). - Use blunt end of pencil or orange stick and trace letters or digits on the patient's palm. Ask the patient to identify the figure.

Question 41

End pieces?

Answer 41

Examine the lower limbs and cranial nerves.