NEUROLOGICAL EXAMINATION OF THE LIMBS

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NEUROLOGICAL EXAMINATION OF THE LIMBS
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GENERAL ORDER OF EXAMINATION

• Gait (if appropriate)
• Inspection
• Tone
• Power
• Reflexes
• Coordination
• Sensation

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SOME ABNORMAL GAITS

• Spastic
• Hemiparetic
• Parkinsonian
• Footdrop
• Ataxic
• Waddling myopathic

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INSPECTION

• Muscle wasting and/or fasiculation
• Abnormal posture
• Tremors
• Involuntary movements

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MUSCLE WASTING

• A lower motor neuron sign, ie due to lesion in
  the muscle, nerve,plexus, root or anterior horn
  cells
• Takes several weeks to develop
• May be generalised or focal
• If focal can help to localise a lesion

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FASICULATION

• A lower motor neuron sign
• Occurs in actively denervating muscles
• Represents spontaneous discharges of single motor
  units
• Lesion in the nerve, plexus, root or anterior
  horn cells

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TREMORS

• Tremors may be resting, postural or action
• Resting tremor often unilateral and due to
  Parkinsons disease associated with rigidity,
  gait disturbance and bradykinesia
• Physiological tremor enhanced by caffeine,
  anxiety, beta agonist drugs
• Benign essential tremor a postural tremor often
  familial and alcohol-responsive
• Cerebellar and midbrain tremors are action
  tremors highly disabling

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SOME OTHER INVOLUNTARY MOVEMENTS

• Focal seizures
• Chorea
• Athetosis
• Myoclonic jerks

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TONE

• Reduced muscle tone is hard to detect unless
  severe. Dont worry about it.
• Increased tone is much more important and
  consists of two main types
• 1) SPASTICITY (ie pyramidal)
• 2) RIGIDITY (ie extrapyramidal)

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POWER

• The standard neurological examination involves
  testing power of two movements at each joint
  (agonists and antagonists)
• The history may suggest more localised problems
  which require examination of individual muscles
  (eg nerve lesions of the hand)
• Clear instructions (with demonstrations)

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MRC GRADING OF MUSCLE POWER

• GRADE 5 NORMAL POWER
• GRADE 4 WEAK BUT SOME RESISTANCE
• GRADE 3 JUST OPPOSES GRAVITY
• GRADE 2 MOVES BUT CANNOT OPPOSE GRAVITY
• GRADE 1 VISBLE MUSCLE FLICKER
• GRADE 0 NOTHING

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PATTERNS OF WEAKNESS

• Weak arm and leg (same side) HEMIPARESIS (or
  hemiplegia)
• Weak legs, normal arms PARAPARESIS
• All four limbs weak TETRAPARESIS
• One limb weak MONOPARESIS
• Proximal muscle weakness
• Distal muscle weakness

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EXAMPLES OF LESIONS CAUSING PATTERNS

• Hemiparesis hemispheric stroke, tumour, abscess
• Paraparesis spinal cord lesion below cervical
  spine
• Tetraparesis cervical cord lesion
• Monoparesis Tumour at brachial plexus
• Proximal weakness myopathy
• Distal weakness peripheral neuropathy

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REFLEXES

• Reflexes examined in a systematic fashion,
  comparing one side with the other
• UPPER MOTOR NEURON LESIONS increased tendon
  reflexes, reflex spread and extensor plantar
  responses
• LOWER MOTOR NEURON LESIONS reduced or absent
  reflexes, may be generalised eg neuropathy, or
  focal eg single nerve or root lesion

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GRADING OF REFLEXES

• VERY BRISK
• BRISK, EASY TO ELICIT
• PRESENT
• /- ONLY PRESENT WITH REINFORCEMENT
• - ABSENT

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COORDINATION

• Tandem gait
• Rombergs test
• Finger to nose test
• Rapid alternating movements (looking for
  dysdiadochokinesis)
• Heel to shin test

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CO-ORDINATION (cont.)

• Two main types of ataxia
• Cerebellar ataxia (lesions of the cerebellum and
  its connections)
• Sensory ataxia peripheral neuropathies and
  spinal cord lesions where dorsal columns are
  affected

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SENSATION

• Tailored sensory examination if the history and
  motor examination suggests it is needed
• IN ORDER TO PERFORM A MEANINGFUL SENSORY
  EXAMINATION, YOU NEED TO KNOW WHAT PATTERN OF
  SENSORY LOSS YOU ARE LOOKING FOR!

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PATTERNS OF SENSORY LOSS

• Sensory peripheral neuropathy
• Individual nerve lesions
• Mononeuritis multiplex
• Root lesions
• Plexus lesions
• Spinal cord lesions
• Brainstem syndromes

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SENSORY PERIPHERAL NEUROPATHY

• Distal symmetrical sensory loss
• Affects legsgt arms
• May affect predominantly large fibres (vibration
  sense, proprioception), or small fibres (pain and
  temperature), or both

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INDIVIDUAL NERVE OR ROOT LESIONS

• Reduced sensation solely in the distribution of a
  single nerve eg numbness of medial one and a half
  fingers of the hand in an ulnar mononeuropathy
• Reduced sensation in the distribution of a single
  root eg numbness of the lateral border of the
  foot in an L5/S1 disc prolapse

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SPINAL CORD LESIONS

• ABDOMINAL OR THORACIC SENSORY LEVEL AN EXTREMELY
  IMPORTANT LOCALISING SIGN
• Special situations Brown-Sequard syndrome
  (hemicord), anterior spinal artery syndrome etc.

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UPPER MOTOR NEURON LESIONS

• Weakness
• Increased tone (spasticity)
• Increased reflexes
• Extensor plantar responses

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LOWER MOTOR NEURON LESIONS

• Weakness
• Wasting (after several weeks)
• Fasiculations (if active denervation)
• Reduced tone (if detectable)
• Reduced or absent reflexes
• Normal (flexor) plantar responses