Neurological Examination
Station 1
Examination of the Motor System
Dr. A. Cassim
At this station you there will be an S. P. and a clinical teacher.
Station Objectives:
1. Perform a competent examination of the Motor System.
2. Familiarise yourself with the signs of neurological disease
3. Develop a systematic approach to interpreting abnormal neurological signs on
physical examination.
The purpose of the Neurological Examination is to determine:
1. The presence / absence of neurological malfunction
2. The location, type and extent of nervous system lesions
3. The degree to which the healthy portion of the patient’s system can be used
for Rehabilitation.
Components of the Neurological Examination:
1.
2.
3.
4.
5.
6.
Mental State Examination
Cranial Nerve Examination
Motor System
Reflexes
Sensory System
Examination of Co-ordination and Gait.
The Motor System (Pyramidal Pathways)
The examination of the patient begins as he walks into the room.
Observations can be made on the presence of abnormal postures, abnormal
movements, muscle wasting and abnormal general appearances.
•
Shake hands with the patient and assess the quality of the grip (is there any
myotonia?)
Position:
Seat the patient on the edge of a couch.
• Ask the patient to hold out both hands with the arms extended - observe for
drift of the arms.
a. May be d/t weakness as in upper motor neurone lesions
b. Cerebellar disease as a result of hypotonia
c. Loss of propioception.
Next conduct a systematic examination of each muscle group and compare to
the corresponding muscles on the opposite side.
The Components of the Motor Examination includes an assessment of:
1.
2.
3.
4.
Muscle Size
Muscle Tone
Muscle Strength (Power)
Involuntary Movements
1. Muscle Size
Inspection and Palpation
• Observe for symmetry of muscle contours and outlines, muscle
Size/bulk
• Consistency
• Presence of atrophy, muscle wasting
• Fine tremors
• Fasciculations (fine irregular, non rhythmic muscle fibre contractions
• Tap the muscles lightly for the presence of myotonia.
A tape measure is used to compare corresponding parts of the upper arms, calves
and thighs.
Fasciculations are often a feature of Lower motor Neurone disease
2. Muscle Tone
Muscles are palpated at rest and the resistance to passive movements noted as
the examiner moves the limbs.
Tone may be normal, reduced (hypotonic) or increased (hypertonic)
Increased tone (hypertonia) may be due to: spasticity or rigidity
Spasticity may be the result of an Upper Motor Neurone Lesion and is noted with a
velocity dependent increase in resistance to movement. So it is important to ensure
that one increases the velocity of movement while assessing tone, feeling for a
‘catch’ or a clasp- knife phenomenon of spasticity.
Rigidity on the other hand is not velocity dependent and is felt as an increase in tone
throughout the range of movement of the limb. It is usually a sign of extrapyramidal
disease like e.g. Parkinson’s disease where the cogwheel rigidity is a particular form
of rigidity.
3. Muscle Strength
The strength of muscles is tested by assessing joint movement e.g. flexion,
extension and other joint movement
• Without resistance with and without gravity
• With the examiner offering resistance.
Corresponding muscles are then compared.
Shoulder. Abduction (C5, C6)
Patient abducts arms with elbows flexed and resists examiner’s attempt to push them
down
Elbow. Flexion (C5, C6)
In A below, the patient bends elbow & resists examiner’s attempt to straighten it.
Elbow Extension (C7,C8)
In B below, the patient forces his hand straight and prevents the examiner from
bending it.
A
B
Wrist Flexion (C6, C7)
Patient bends wrist & prevents examiner from straightening it.
Wrist Extension (C7, C8)
Patient extends wrist and does not allow examiner to bend it.
Fingers. Extension (C7, C8)
Patient extends fingers and does not allow examiner to bend them
C
Resisted knee flexion
In D below the patient bends the knee and prevents the examiner’s attempt to
straighten it.
Resisted hip flexion
In E below the patient attempts to bend the hip against resistance from the examiner
D
E
Resisted ankle/plantar flexion (S, S2)
Patient pushes foot down whilst examiner attempts to push it up (F)
Resisted dorsiflexion (L4, L5)
Patient attempts to bring the foot up against resistance from examiner trying to push
it down (G)
F
G
If muscle power is reduced assess if this is:
• symmetrical/asymmetrical,
• which muscle groups are affected and
• whether this is proximal or distal.
Examples of conditions causing asymmetrical muscle weakness include upper motor
neurone, mononeuritis multiplex, root and brachial plexus lesions.
Muscle weakness suggests a lesion in the motor pathway at;
Cerebrum, Brain stem and Spinal cord
In the Peripheral Nerves
At Neuromuscular junction, or
In the muscles themselves.
GRADING OF POWER
Grade
0
1
2
Interpretation
No muscle contraction/Paralysis
A flicker of contraction whilst examiner palpates muscle and patient
attempts contraction
Movement possible with gravity eliminated
3
Movement possible against gravity but with resistance eliminated
4
Movement is possible against some resistance
5
Normal Strength
5. Involuntary Movements
Usually detected on Inspection
Comprise: dystonic twisting (intermittant episodes of sustained contraction of one
or more muscle groups which causes a twisting/distortion of that part of the body
resulting in an abnormal posturing or positioning)
choreiform (Chorea is the ceaseless occurrence of rapid, jerky
involuntary movements. The face, tongue and limbs may all be involved. There is
associated hypotonia and inability to maintain a posture.
group)
myoclonic jerks (sudden, severe involuntary contraction of any muscle
tics (involuntary, compulsive, repetitive, stereotyped movements. They
usually involve the face and shoulders)
tremors (Rhythmic oscillatory (to-and-fro) movements of muscle groups)
Suggests a lesion of the Extrapyramidal Motor Pathways
REFERENCES:
1. Tally N., O’ Connor. Clinical Examination Third Edition.
2. University of New York Medical School, The Motor System Examination.
3. The American Medical Association. Essentials of the Neurological Examination.
Acknowledgements to the following sources for the images used in this
presentation:
A–G
Texas Univ., The Screening neurological examination. Dr Randall Light
Station 2
At this station there will be an S. P. and a clinical teacher.
Examination of the Sensory System
Dr. A. Cassim
Station Objectives:
1. Perform a competent examination of the Sensory System.
2. Familiarise yourself with the signs and symptoms of neurological disease
3. Revise the anatomy of the Sensory Pathways and the dermatomal
arrangement on the peripheral Nerves.
Components of the sensory examination:
A. Primary forms of Sensation
1.
2.
3.
4.
Light touch
Pain and temperature
Vibration sense
Position sense
B. Cortical and Discriminatory Forms of Sensation
1. 2 point discrimination
2. Graphesthesia
3. Stereognosis
The Sensory Pathways
Acknowledgements: The American Medical Association. Essentials of the
Neurological Examination
A. Primary Forms of Sensation
Examination Technique:
•
Patients should be adequately undressed but attempt to preserve modesty.
•
Examine systematically, e.g. begin distally and move proximally covering all
areas of skin including the perineal and perianal areas.
•
The patient should keep his eyes closed.
•
Sensitise the patient to the stimulus to check the patient’s ability to perceive
the sensation being tested e.g. apply a pinprick to an area and ask the patient
if he/she can feel anything and can the identify the source of the stimulus.
•
Compare both sides of the body and corresponding parts of extremities.
When necessary assess whether the sensory changes involve an entire side of
the body, are dermatomal in distribution or confined to a peripheral nerve
1. Superficial tactile sensation (light touch)
•
•
•
•
•
•
Use a cotton wisp
Apply stimulus gently to the skin – do not stroke the skin.
Ask the patient to report by saying “yes” each time he feels it.
Compare corresponding areas the body as you proceed with your examination
Compare the sensitivity of the proximal part of an extremity to that of the
corresponding distal part.
NB in recent times it has been accepted that a light finger touch is as effective
as cotton wool these days. (MRC 1943, 2000; Aids to the Examination of the
Peripheral Nervous System 4th Edition; and; Swash, M. ed. 1995 Hutchinson’s
Clinical Methods, 20th ed.)
2. Pain sensation
•
•
•
•
•
•
Hands should be gloved.
Use a similar procedure as that for testing touch.
Use a pinprick as the stimulus.
Be careful not to injure the patient or yourself
Ask the patient to report whether they feel the sensation as sharp / blunt as
you proceed at each area of examination
Dispose of the pin after use in the sharps safe container.
Note: The patient’s eyes should be closed.
3. Temperature Sensitivity
•
•
Use the same procedure described above
Apply test tubes containing hot / water cold water as the stimulus, covering
all areas systematically.
The patient should report if he perceives a hot or a cold stimulus each time
the test tube is applied.
•
4. Sensitivity to Vibration.
•
A vibrating tuning fork of 128Hz. is applied to the bony prominences such as
the DIP joint of the toes, ankle, knee, hip, shoulder, elbow, wrist and DIP
joins of the fingers.
The patient first reports if he perceives the vibration stimulus
Start distally at the IP joint of the great toe in the feet as demonstrated
below.
Note that the examiner’s index finger below the toe should also feel the
vibration to ensure an adequate stimulus.
The patient then reports when the stimulus stops.
Compare sensation in opposite limbs and in proximal and distal areas of the
extremities.
•
•
•
•
•
D
5. Position Sense
•
•
•
•
•
With the patient’s eyes open demonstrate to the patient that you will be
moving their digit “up” (towards their head) or “down” (towards the bed)
Stabilize the distal interphalangeal joint of the digit with the thumb and
index finger on either side.
The patient should now close his eyes.
The fingers or toes are then moved passively and the patient is asked to
indicate the direction of movement as well as the final position of the digit.
Care should be taken to prevent pressure on the skin that would give the
patient a clue as to the position of the digit (see figure below – NB that this
is Not how to do it because it is providing pressure at numerous points and
clues to the position of the digits.)
A.
. Dermatomes and Peripheral Nerves of the Human Body
Acknowledgements: The Neurological Examination Faculty of Medicine, Univ of
Toronto
B. Cortical and Discriminatory forms of Sensation
These are complex somatic sensory impressions which require interpretation by the
Cerebral Cortex.
1.
2.
3.
4.
5.
Two point Discrimination
Point Localisation
Stereognosis
Graphesthesia
Texture Discrimination
1. Two - point Discrimination
•
•
The skin of the patient is touched simultaneously with 2 sharp objects e.g. the
prongs of a caliper or pins.
With the eyes closed the patient reports whether he perceives one or two
objects touching him when prompted each time.
Note: The minimum distance between the two objects that can be perceived by a
patient on different parts of the body varies.
E.
2. Point localization
•
The patient indicates with his eyes closed where on his body a stimulus is
being applied.
3. Stereognosis
•
The patient with eyes closed is asked to identify various familiar objects
placed in his hand.
B.
4. Graphesthesia
•
With eyes closed the patient is asked to identify various letters or numbers
that are written with a blunt object on parts of his body e.g. palms of hands
or the back.
C.
Comparisons of Upper & Lower Motor Neurone Lesions
Upper
Lower
Fasciculations
No
Yes
Wasting
Only with prolonged disuse Yes
Tone
Increased, spastic
Decreased, flaccid
Weakness
Yes
Yes
Reflexes
Exaggerated
Depressed / absent
Clonus
Yes
No
Plantar response
Extensor
Flexor
Important Neurological Syndromes
Spinal Cord Syndromes
Clinical Features
Central cord syndrome
More common in the cervical cord,
Arms are often weak with preservation of
strength in the legs
Variable sensory and reflex deficits
Most affected sensory modalities are pain
and temperature (lateral spinothalamic tract
fibers cross just ventral to the central canal)
Ipsilateral paralysis, loss of vibration and
position sense below the level of the lesion,
hyperreflexia, and an extensor toe sign all
Ipsilateral segmental anesthesia observed at
the lesion level.
Loss of pain and temperature
contralaterally below the level of the lesion
Brown-Séquard syndrome
REFERENCES:
1. Clinical Examination, Tally & O’Connor
2. Essentials of the Neurological Examination. The American Medical Association.
3. The Screening Neurological Examination. R. Light. M.D. University of Texas
Medical School
4. The Precise Neurological Examination. Russel S, Triola M. New York University
Medical School
5. The Neurological Examination Faculty of Medicine, Univ of Toronto
Acknowledgements to the following sources for use of the following images used in
this presentation:
A, B and C: University of New York Medical School
D and E:
University of Texas Medical School
UPPER BRACHIAL PLEXUS INJURIES
Dr. R.M. Alexandrescu
The brachial plexus is formed in the neck by the union of the ventral rami of C5
through C8 nerves and the greater part of the ventral ramus of T1.
Roots:
The ventral rami of the last four cervical and the first thoracic nerves form the
roots of the brachial plexus; they usually pass through the gap between the
anterior and middle scalene muscles with the subclavian artery.
Trunks:
In the inferior part of the neck, the roots of the brachial plexus unite to
form three thrunks:
- Superior trunk- from the union of the C5 and C6 roots;
- Middle trunk- a continuation of C7 root;
- Inferior trunk- from the union of the C8 and T1 roots.
Each trunk of the brachial plexus divides into anterior and posterior division
as the plexus passes posterior to the clavicle, through the cervicoaxillary canal
(Clinical oriented Anatomy. KL Moore& A Dalley. Fourth Edition).
Cords:
The divisions of the brachial plexus form three cords:
- lateral cord
- medial cord
- posterior cord
Branches:
- supraclavicular branches & infraclavicular branches
UPPER AND LOWER ROOT LESIONS
Lesion
Motor Deficits
Sensory Deficits
Erb’s
Palsy (C
5,6 )
Loss of abduction, flexion
and rotation at shoulder ;
Weak shoulder extension deltoid, rotator cuff
Posterior and lateral
aspect of arm - axillary n.
Axillary,
Suprascapular,
Upper and Lower
subscapular
Very weak elbow flexion
and supination of
radioulnar joint - biceps
brachii & brachialis
Radial side of Forearmmusculocutaneous n.
Thumb and 1st finger superficial br. of radial;
digital brs. - Median n.
Musculocutaneous
; Radial N. brs. to
supinator &
brachioradialis
muscles
Susceptible to shoulder
dislocation - loss of rotator
cuff muscles
Nerves
Suprascapular,
Upper and Lower
subscapular
“Waiters Tip”position
Klumke’s Loss of opposition of thumb Ulnar side of forearm ,
Palsy
-Thenar muscles
hand & & ulnar 1 1/2 &
(C8, T1 )
digits - ulnar and medial
antebrachial cutaneous
Thenar branch of
Median nerve
Loss of adduction of thumb
- Adductor pollices
Ulnar nerve
Loss of following finger
movements: abduction and
adduction of M.P. joints ;
flexion at M.P. & extension
of I.P.joints. Lumbricals &
interossei
Deep branch of
Ulnar & Median
Very weak flexion of
P.I.P.& D.I.P. joints Fl.
Digit. Super. & Profund.
Ulnar and Median
Page Maintained by: Barry Berg
Last updated: August 18, 1999
All contents copyright© 2000, SUNY Upstate Medical University
Station 3
At this station there will be a computer based on – line tutorial.
Common Neurological Syndromes
Dr. R. M. Alexandrescu
Station Objectives:
1 Familiarise yourself with the signs and symptoms of common neurological
disorders.
2.Attempt to identify the level of neurological lesions using clinical on – line exercises
provided.
The Neurological History
Dr. R.M. Alexandrescu
In many cases the diagnosis can be based on the patient’s history!
1. Biographical information:
- name of the patient
- age
- place of birth
- handedness
- occupation
- level of education
2. The presenting symptom or symptoms:
- Sensory system: numbness, paraesthesiae, warmth, cold
- Motor system: weakness, clumsiness, stiffness, unsteady gait
- Headache and facial pain
- Faints and fits, involuntary movements or tremor
- Nausea, vomiting
- Neck or back pain
- Disturbance of speech and swallowing
- Dizziness or vertigo
- Disturbances of vision, hearing or smell
- Psychological changes (e.g. depression or elevation, weeping, agitation,
sleep, change in energy and libido, appetite disturbance).
Presenting complaint: - Time relationship (The temporal course of the
illness)!
- Localization (Which levels of the nervous
system are
involved and whether the disease process is
localized or
diffuse).
- Trigger factors
- Associated features
Past medical history: - Birth/ pregnancy (length of term; intrauterine
problems,
normal, assisted or operative delivery)
- Neonatal health (severe jaundice, respiratory
difficulty,
infections and convulsions).
- Infancy (infections, convulsions, injuries)
- Head/spine injury
Family history:
Infections (meningitis/encephalitis)
Sexually transmitted diseases (STD), including HIV
Surgical procedures
Drug therapy
- Hypertension
- Diabetes mellitus
- Hyperlipidaemia
- Epilepsy
- Migraine
- Multiple sclerosis
- Stroke, cerebral aneurysm
- Muscle disorders
- Dementia
- Spinocerebellar degenerations and neuropathies.
Social history:
- Occupation
- Marital status and any change of the lifestyle
- Smoking habits
- Alcohol consumption
- Exposure to toxic chemicals
- Use of recreational drugs
- Sexual orientation and habits
- Recurrent overuse to of certain joints (e.g. carpal tunnel
syndrome).
REFERENCES:
1. Tally and O’Connor, Clinical Examination, 3rd Edition
2. Macleod’s Clinical Examination. 3rd Edition
3. Epstein’s Clinical Examination