PERIPHERAL NEUROLOGICAL EXAMINATION

1. PERIPHERAL NEUROLOGICAL EXAMINATION Dr Sarah Jones Manchester Royal Infirmary Clinical Skills Department

2. Objectives • Gain a fluent style in performing a standard peripheral neurological examination • Be able to explain to patients what you want them to do • Be able to present your findings clearly and concisely • This is NOT a session about pathology

3. Usual Order of Examination • Gait • Inspection • Tone • Power • Reflexes • Coordination • Sensation

4. Gait • Check the patient is able to walk • Use a short distance • Take care to prevent them from falling • Good opportunity to then do Romberg’s test

5. Inspection • Muscle wasting • Fasciculation • Abnormal posture • Tremor (and type) • Involuntary movements

6. Tone • Reduced muscle tone is hard to detect unless severe • Ask the patient to relax – “let me borrow you arm” • Increased tone is much more important and consists of two main types: • SPASTICITY (ie pyramidal) • RIGIDITY (ie extrapyramidal)

7. Power 1 • Test 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)

8. Power 2 • Work proximal to distal • Isolate the joint • Give mechanical advantage where needed • Compare left with right • Practise clear instructions with someone who doesn’t “speak the language”

9. Power 3: Grading • 5: Normal Power • 4: Weak but some resistance • 3: Just opposes gravity • 2: Moves with gravity eliminated • 1: Visible muscle flicker • 0: Nothing

10. Power 4: Describing weakness • Hemiparesis: weak arm and leg (same side) • Paraparesis: weak legs, normal arms • Tetraparesis: all four limbs weak • Monoparesis: one limb weak • Weakness may be proximal or distal

11. Demonstration and Practice • Gait • Inspection • Tone • Power • Upper and lower limbs

12. Reflexes 1 • They are TENDON reflexes • Patient should be relaxed • Practise both sides of the patient from one side of the bed • Compare one side with the other • Consider reinforcement

13. Reflexes 2 • Upper limb: biceps (C5/6), triceps(C6/7), supinator(C5/6), finger jerk (C8) • Lower limb: knee (L2/3/4), ankle (S1) • Clonus: usually ankle, asymmetry or >4 beats is pathological • Plantar response (do it right and it should be flexor/ upgoing)

14. Grading of Reflexes • +++: Very brisk • ++: Brisk, easy to elicit • +: Present • +/- : Only present with reinforcement • - : Absent

15. Co-ordination • Starts from the moment they walk through the door • Romberg’s test (looking for unsteadiness, differentiate between ataxias) • Finger to nose test • Drift • Rapid alternating movements (looking for dysdiadochokinesis) • Heel to shin test

16. Sensation 1: dermatomes • Test each phenomenon in each dermatome and compare left with right • Know which dermatomes are where and be able to demonstrate this

17. Sensation 2 • In all dermatomes • Light touch • Pain perception • Two point perception • Starting distally • Proprioception • Vibration sense • Demonstrate on the sternum/ eyes open

18. Demonstration and Practice • Reflexes, Co-ordination and Sensation • Upper and Lower limbs

19. UMN lesions • Lesion in the cerebral cortex, brainstem or spinal cord • Weakness • Increased tone (spasticity) • Increased reflexes • Extensor plantar responses

20. LMN lesions • Lesion in the muscle, nerve, plexus, root or anterior horn cells • Weakness • Wasting (after several weeks) • Fasiculations (if active denervation) • Reduced tone (if detectable) • Reduced or absent reflexes • Normal (flexor) plantar responses