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NEUROLOGICAL EXAMINATION OF THE LIMBS

NEUROLOGICAL EXAMINATION OF THE LIMBS. GENERAL ORDER OF EXAMINATION. Gait (if appropriate) Inspection Tone Power Reflexes Coordination Sensation. SOME ABNORMAL GAITS. Spastic Hemiparetic Parkinsonian Footdrop Ataxic Waddling myopathic. INSPECTION.

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NEUROLOGICAL EXAMINATION OF THE LIMBS

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  1. NEUROLOGICAL EXAMINATION OF THE LIMBS

  2. GENERAL ORDER OF EXAMINATION • Gait (if appropriate) • Inspection • Tone • Power • Reflexes • Coordination • Sensation

  3. SOME ABNORMAL GAITS • Spastic • Hemiparetic • Parkinsonian • Footdrop • Ataxic • Waddling myopathic

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

  5. 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

  6. 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

  7. TREMORS • Tremors may be resting, postural or action • Resting tremor often unilateral and due to Parkinson’s 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

  8. SOME OTHER INVOLUNTARY MOVEMENTS • Focal seizures • Chorea • Athetosis • Myoclonic jerks

  9. TONE • Reduced muscle tone is hard to detect unless severe. Don’t worry about it. • Increased tone is much more important and consists of two main types: • 1) SPASTICITY (ie pyramidal) • 2) RIGIDITY (ie extrapyramidal)

  10. 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)

  11. 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

  12. 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

  13. 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

  14. 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

  15. GRADING OF REFLEXES • +++: VERY BRISK • ++: BRISK, EASY TO ELICIT • +: PRESENT • +/- : ONLY PRESENT WITH REINFORCEMENT • - : ABSENT

  16. COORDINATION • Tandem gait • Romberg’s test • Finger to nose test • Rapid alternating movements (looking for dysdiadochokinesis) • Heel to shin test

  17. 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

  18. 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!

  19. PATTERNS OF SENSORY LOSS • Sensory peripheral neuropathy • Individual nerve lesions • Mononeuritis multiplex • Root lesions • Plexus lesions • Spinal cord lesions • Brainstem syndromes

  20. SENSORY PERIPHERAL NEUROPATHY • Distal symmetrical sensory loss • Affects legs> arms • May affect predominantly large fibres (vibration sense, proprioception), or small fibres (pain and temperature), or both

  21. 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

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

  23. UPPER MOTOR NEURON LESIONS • Weakness • Increased tone (spasticity) • Increased reflexes • Extensor plantar responses

  24. 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

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