Understanding the neurologic examination

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Understanding the neurologic examination

• J. Scott Pritchard, DO
• 2012 NADE NATIONAL TRAINING CONFERENCE

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Tools

1. Pins/Needles
2. Hammer
3. Tuning fork
4. Flash light
5. Measuring tape
6. Calipers
7. Monofilaments- Semmes-Weinstein
8. And

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Jendrassik Maneuver
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Symptoms

• 1. numbness- deprived of the power to move or
  feel
• normally
• 2. Tingling - a pricking or stinging
  sensation or
• feeling
• 3. Paresthesia- skin sensation of burning,
  prickling or
• tingling with no apparent
  cause.
• 4. Pain - an intense unpleasant feeling
  caused by
• damaging stimuli

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Three Areas of Importance

• Motor strength assessed per MRC scale
• 0/5 no
  movement-5/5- normal
• - tone - continuous passive
  partial
• contraction of
  a muscle - atrophy-
  loss of muscle mass
• -spasticity- altered tone
  w/stiffness and
• involuntary
  muscle spasms.
• Ashworth scale
  0 to 5

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• 2. Sensory- temperature
• touch
• pinprick
• proprioception
• 2- pt discrimination
• vibration

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• Normal 2- pt discrimination 0-4 mm
• Intermediate 5-7 mm
• Abnormal gt 7mm

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• 3. Coordination primary assessment of
  cerebellar
• function
• - Smooth combination of both spatial direction
  and kinetic(forceful) movement
• - Functional abnormalities can be seen in
  altered gait, truncal ataxias, dysmetrias of the
  extremities, altered rapid alternating movements
  of the upper/lower extremities. (F-T-N and RAM).
  
• - Ataxia impaired coordination

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Gait Dysfunction

• 1. Hemiparetic
• 2. Paraparetic
• 3. Sensory
• 4.Steppage
• 5. Waddling
• 6.Festination
• 7. Retropulsion
• 8. Astasia Abasia

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Carpal Tunnel Syndrome

• Compressive neuropathy of the median nerve
• 1. numbness, tingling of the thumb
  and
• first two digits of the hand
• 2. increased numbness and onset of
  pain
• 3. sense of weakness or dropping
  things
• 4. most intense at night
• 5. progressive motor and sensory loss

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• In one study 64 of 88 hands w/ Phalens test
  has positive EMG findings
• Conversely 51 of 78 hands with negative Phalens
  testing had positive EMG findings
• CTS requires both clinical symptoms, findings and
  EMG evidence to establish its presence and
  severity

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Cubital Tunnel Syndrome

• Compressive neuropathy of the ulnar nerve
• 1. pain and numbness in the elbow
• 2. tingling, especially ring and 5th
  digit
• 3. weakness in the 4th/5th fingers
• 4. decreased ability to pinch
  thumb/5th digit
• 5. decreased overall hand grip
• 6. muscle wasting in the hand
• 7. claw-like deformity of the hand

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Complex Regional Pain Syndrome

• 1. burning pain/allodynia
• 2. increased pain w/onset of swelling
• 3. development of osteoporosis and muscle
  atrophy
• 4. irreversible contractures and immobility
• The affected extremity may be cool to touch and
• appear mottled. Swelling may be present. Extreme
  
• sensitivity of the skin to touch. Often unable to
• tolerate clothing

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• CRPS I no demonstrable nerve lesions (RSD,
• Sudeks atrophy)
• CRPS II obvious nerve damage(causalgia) usually
• more painful and difficult to
  control

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Diagnostic tools

1. History and physical examination
2. Thermography
3. Sweat Testing
4. EMG
5. Bone scan
6. X-ray findings

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Oddities

1. Waddells
2. Leseque(SLR) now nerve stretch test
3. Hoffmans sign
4. Wartenburgs sign
5. Pronator drift
6. Gowers sign
7. Meralgia paresthetica
8. Double-crush syndrome

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THANK YOU!