Understanding the neurologic examination

1. Understanding the neurologic examination J. Scott Pritchard, DO 2012 NADE NATIONAL TRAINING CONFERENCE

3. Tools • Pins/Needles • Hammer • Tuning fork • Flash light • Measuring tape • Calipers • Monofilaments- Semmes-Weinstein • And

4. Jendrassik Maneuver

5. 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

6. 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

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

9. Normal 2- pt discrimination 0-4 mm • Intermediate – 5-7 mm • Abnormal > 7mm

10. 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

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

22. 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

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

29. 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

36. 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

37. CRPS I – no demonstrable nerve lesions (RSD, Sudek’s atrophy) CRPS II – obvious nerve damage(causalgia) usually more painful and difficult to control

38. Diagnostic tools • History and physical examination • Thermography • Sweat Testing • EMG • Bone scan • X-ray findings

45. Oddities • Waddell’s • Leseque(SLR) now nerve stretch test • Hoffman’s sign • Wartenburg’s sign • Pronator drift • Gower’s sign • Meralgia paresthetica • Double-crush syndrome

48. THANK YOU!