Neurology upper and lower limbs evaluation

1. Neurology upper and lower limbsevaluation

2. BY Dr. NIRMAL NARAYAN M.P.T(ORTHO) SRINIVAS COLLEGE OF PHYSIOTHERAPY

3. Inspection Tone Power Reflexes Coordination Sensation Gait Upper and lower limbs

4. Involuntary Movements Muscle Symmetry Left to Right Proximal versus Distal Atrophy Inspection

5. UPPER LIMB Take one hand in yours and support the elbow Flex and extend the fingers, wrist, elbow and shoulder Should move easily and smoothly with little resistance LOWER LIMB Roll the leg sideways backwards and forwards on the bed Lift the knee and let it drop If heel lifts off bed increased tone Tone: resistance to passive stretchAsk the patient to relax‘Let me do all the work here’

6. Clonus - excessive muscle tone and hyperreflexia • a series of involuntary contractions of stretched muscle • flexing the knee slightly and rapidly dorsiflexing the foot and keeping it dorsiflexed

7. Muscle power • test from the proximal to the distal part of the extremity so that all segmental levels for the extremity are tested • power or strength is tested by comparing the patient’s strength against your own • always compare one side to another • grade strength using Medical Research Council (MRC) scale

8. Muscle Strength Grading 0 – no contraction1 – slight contraction, no movement2 – full range of motion without gravity3 – full range of motion with gravity4 – full range of motion, some resistance5 – full range of motion, full resistance 

9. Deltoid muscle (C5) SHOULDER EXTENSION Put your arms out to the side like wings. Do not let me push them down

10. Biceps muscle (C6) ARM FLEXION Pull me towards you

11. Triceps muscle (C7) ARM EXTENSION Now push me away

12. Radial nerve (C7) FINGER FLEXION ‘Hold your fingers out straight. Stop me from bending them’

13. Ulnar nerve (T1) FINGER ABDUCTION Spread your fingers apart. Stop me pushing them together

14. Median nerve (C8, T1) THUMB ABDUCTION Point your thumb to the ceiling. Stop me from pushing it down

15. Hip flexion (L2) • Lift your leg straight up: stop me pushing it down • Place your hand on the patient’s upper thigh and providing resistance

16. Knee extension (L3) Bend your knee: push me away

17. Knee flexion (L4) Bend your knee: pull me towards you

18. Dorsiflexion (L5) Cock your up your foot and point your toes to the ceiling: stop me pushing your foot down

19. Plantar flexion (S1) Bend you foot down: push my hands away

20. Tendon reflexes • A brisk tap to the muscle tendon using a tendon hammer produces a stretch to the muscle that results in a reflex contraction of the muscle • Position of limbs are key • Compare right and left

21. UPPER LIMB Biceps C5-6 Brachioradialis C5-6 Triceps C7 Reinforcement- clench teeth LOWER LIMB Knee L3- L4 Ankle S1- S2 Reinforcement- ‘hold fingers together and try and pull them apart like this’ Tendon reflexes

22. Tendon reflexes grading • 1+ or + hypoactive • 2+ or ++ normal • 3+ or +++ hyperactive with no clonus • 4+ or ++++ hyperactive with clonus

23. Biceps (C5 and C6) • arm flexed at the elbow, place your thumb on the biceps tendon and strike thumb with the tendon hammer • here should be a reflex contraction of the biceps brachii muscle (elbow flexion) • repeat and compare with the other arm

24. Brachioradialis (C5 and C6) • strike the brachioradialis tendon above the wrist and observe the reflex rotation of the wrist and forearm such that the palm of the hand is facing upward • repeat and compare with the other arm

25. Triceps (C6 and C7) • strike the triceps tendon directly with the tendon hammer whilst holding the patient’s arm across their chest • there should be a reflex contraction of the triceps muscle (elbow extension) • repeat and compare with the other arm

26. Knee (L3, L4) • lift up the leg under the knee, and tap the patellar tendon with a tendon hammer • there should be a reflex contraction of the quadriceps muscle (knee extension)

27. Ankle (S1, S2) • externally rotate at the hip, and gently dorsiflex the foot, tapping the Achilles tendon with a reflex hammer • normal response is contraction of the gastrocnemius and plantar flexion of the foot

28. Plantar reflex • starting at the heel advancing to the ball of the foot then continuing medially • normal: flexion of all the toes (move downwards) • abnormal (Babinski sign): extension of the great toe and fanning of the rest of the toes

29. Dermatome Testing

30. Dermatomes C5 — ClaviclesC5, 6, 7 — Lateral parts of upper limbsC8, T1 — Medical sides of upper limbsC6 — ThumbC6, 7, 8 — HandC8 — Ring and little fingersT4 — Level of nipplesT10 — Level of umbilicusT12 — Inguinal or groin regionsL1, 2, 3, 4 — Anterior and inner surfaces of lower limbsL4 — Medial side of great toeS1, 2, L5 — Posterior and outer surfaces of lower limbsS1 — Lateral margin of foot and little toeS2, 3, 4 — Perineum

32. Myotome Testing

34. List of Myotomes of Commonly Injured Nerve Roots

35. C5 – The deltoid muscle (abduction of the arm at the shoulder). • C6 – The biceps (flexion of the arm at the elbow). • C7 – The triceps (extension of the arm at the elbow). • C8 – The small muscles of the hand. • L4 – The quadriceps (extension of the leg at the knee). • L5 – The tibialis anterior (upward flexion of the foot at the ankle). • S1 – The gastrocnemius muscle (downward flexion of the foot at the ankle).

36. Myotomes • L1-2 hip flexion • L3 Knee extension • L4 Ankle dorsiflexion • L5 Gt toe extension, hip abduction • S1 PF ankle, eversion , knee flexion • S2 Hip extension

37. Each of the spinal nerves controls certain muscles   The muscles (or muscles) controlled by a particular nerve root are called its myotome.  Nerves from the neck levels control the muscles in the arms.  Those from the thoracic spine control the chest and abdominal muscles.  The nerves from the low back control the muscles in the legs. For example, when the C6 nerve is pinched, there is weakness in the biceps muscle.  When the biceps is weak, bending the arm at the elbow is difficult.  When the L5 nerve is pinched, there is weakness in the tibialis anterior muscle in the shin.  With L5 weakness, extending the ankle (to walk on the heels) is difficult. 

38. CRANIAL NERVES TESTING

39. The 12 pairs of cranial nerves are part of the peripheral nervous system. • The Roman numeral is based on descending order of the cranial nerve's attachment to the CNS. • As a rule, cranial nerves do not cross in the brain. • Cranial nerves may be sensory, motor both somatic or parasympathetic, or have mixed function. General Characteristics:

40. CN I - OLFACTORY ORIGIN: Cerebral hemisphere INNERVATION: Nasal mucous membranes. FUNCTION: Sense of smell DYSFUNCTION:Anosmia • Use aromatic substances, i.e. coffee, lemon, garlic, etc. • Test each nostril separately. CLINICAL EVALUATION

41. CN II - OPTIC CLINICAL EVALUATION • VISUAL ACUITY: Snellen chart for distant vision, newspaper or fingers for near vision. • VISUAL FIELDS: Confrontation. • FUNDI AND OPTIC DISCS: Visualization of the termination of the optic nerve by looking through pupil with ophthalmoscope. • Blurred vision or complete blindness. • Ipsilateral vision loss- Optic atrophy, retinal/optic nerve lesions, trauma. • Visual loss (one or both eyes)- Optic chiasm or occipital lobe lesions. • Cortical blindness - Lesion of occipital cortex bilaterally, pupil reflexes intact. • Papilledema- Optic nerve tumor, venous obstruction, chronic increased ICP. • Optic atrophy - MS, optic neuritis, increased ICP. • Scotomas- (Abnormal blind spots on visual fields) - optic neuritis or atrophy. • Hemianopia - (loss of half of visual field in one or both eyes) - Lesions of optic chiasm, tracts, or radiations. SPECIFIC DYSFUNCTIONS

42. CN III - OCULOMOTOR ORIGIN:Midbrain INNERVATION: EOM's; eyelid; ciliary; and sphincter of iris. FUNCTION: Eye movement inward (medially), upward, downward, and outward; pupil constriction, shape and equality; elevates upper eyelid; accommodation reflex. DYSFUNCTION:Unable to look up, down, or medial (dysconjugate gaze); ptosis, pupil dilatation - bilateral or ipsilateral, and loss of accommodation reflex. • Observe for eye opening and symmetry. • Direct light response - brisk, sluggish, or non-reactive. • Consensual response - present or absent. • Pupil size and shape. • Accommodation. • Extraocular movement (EOM's) (Abducens). CLINICAL EVALUATION

43. CRANIAL NERVE FUNCTION & MUSCLE INNERVATION RELATIVE TO EYE MOVEMENT Inferior oblique CN III Superior rectus CN III Lateral rectus CN VI Medial rectus CN III Superior oblique CN IV Inferior rectus CN III

44. CN IV - TROCHLEAR CN VI - ABDUCENS • Extraocular movements (EOM's) • CN IV (Trochlear) and CN VI tested with CN III (Oculomotor) ORIGIN: Midbrain INNERVATION:Superior oblique muscle. FUNCTION:Down and inward movement of the eye. DYSFUNCTION:Loss of downward, inner movement of eye, dysconjugate gaze. ORIGIN: Pons INNERVATION:Lateral rectus muscle. FUNCTION:Outward, lateral movement of eye. DYSFUNCTION: Loss of lateral eye movement, dysconjugate gaze. CLINICAL EVALUATION

45. CN V - TRIGEMINAL ORIGIN: Pons. The sensory nucleus extends from the pons to the midbrain, and also to the medulla and spinal cord. INNERVATION: Three branches of CN V: Ophthalmic, maxillary, & mandibular. Motor innervation to masseter & temporal muscles. Sensory innervation to skin & mucous membranes in head; teeth, tongue, external auditory canal, and cornea. FUNCTION: Sensation of pain, touch, hot, & cold; motor movement of masseter & temporal muscles. Nerve Root Patterns DYSFUNCTION: Loss of sensation - if affecting all three branches, indicative of peripheral injury. Brainstem or upper cervical cord injury may result in loss of sensation to one or more branches of the trigeminal nerve. - Loss of corneal reflex. - Paresthesia and/or severe pain indicative of nerve compression or irritation (Trigeminal neuralgia) -Deviation of jaw, loss of sensation. Inability to bite down and chew, inability to close jaw. Brain Stem = Onion skin sensory deficit

46. CN V - TRIGEMINAL CLINICAL EVALUATION • SENSATION: Test with patients eye closed. Evaluate pain, temperature, & light touch to jaw, cheeks, and forehead. Observe response and symmetry. • MOTOR: Open jaw, check for deviation. Have patient bite down, palpate masseter and temporal muscles. Move jaw laterally against resistance to evaluate weakness or paralysis. • CORNEAL REFLEX: Cotton wisp across cornea, observe for blink (function of CN III) • JAW JERK: Tap lower jaw with mouth open - check for slight elevation of mandible.

47. CN VII- FACIAL ORIGIN: Pons & medulla. INNERVATION: Anterior two-thirds of tongue; facial muscles, scalp, ear, and neck. FUNCTION: - Control of facial muscles (expressions) - Motor limb of blink & corneal reflexes - Secretion of salivary & lacrimal glands - Sensation of taste, anterior two-thirds tongue. DYSFUNCTION: Motor = Facial asymmetry - Ipsilateral weakness/paralysis, right or left, indicative of damage to motor nucleus or peripheral component (lower motor neuron lesion) EX: Bell's palsy Contralateral weakness/paralysis of lower face indicative of contralateral motor cortex damage (upper motor neuron lesion) or hemispheric lesion, i.e. massive CVA. Bilateral weakness or paralysis , E.g. myasthenia gravis or Guillian Barre. Parasympathetic -Loss or excessive tearing or salivation Sensory= Loss of taste Combined problem = speech difficulty and drooling/difficulty handling food

48. CN VII - FACIAL CLINICAL EVALUATION • Observe for facial symmetry • Ask patient to wrinkle forehead, puff cheeks, smile, show teeth, open eyes against resistance, and whistle. • Test each side of tongue separately. • Test for sweet (tip of tongue); sour (sides of tongue); salty (over most of tongue, but concentrated on sides). • Give sip of water between tastes. MOTOR FUNCTION: SENSORY FUNCTION:

49. CN VIII - ACOUSTIC ORIGIN: Pons and medulla INNERVATION:Cochlear - ear Vestibular - ear FUNCTION: Cochlear - Hearing Vestibular - Balance, maintenance of body position, and proprioception. DYSFUNCTION (Cochlear) - Unilateral deafness - Loss of sound appreciation - Tinnitis - (Rinne Test) AC >BC or both diminished indicative of nerve damage, BC> AC middle ear disease. - (Weber Test) Lateralization to good ear is nerve damage, lateralization to bad ear is, middle ear disease. DYSFUNCTION (VESTIBULAR) - Vertigo - Balance disturbances Vestibular branch normally not tested unless patient gives history of vertigo or balance Disturbance history is positive, caloric testing is done by physician.

50. CN VIII - ACOUSTIC CLINICAL EVALUATION • HEARING: Test bilaterally, whisper or watch tick • CONDUCTION: Weberand Rinnetests (Differentiate between conduction deafness and nerve deafness) Weber Test: Evaluates lateralization. Use vibrating tuning fork on top of patient's head, ask patient where he hears it (one or both sides). Rinne Test: Evaluates air (AC) and bone conduction (BC). Place the base of a vibrating tuning fork on the mastoid process until patient can no longer hear sound; then quickly move tuning fork near ear canal. Ask the patient if he hears it, compare hearing times. Rinne test: AC > BC normal result.