Weakness & Sensory Deficit
Describe unique findings in
• Myopathy, NMJ disorder, neuropathy,
plexopathy, radiculopathy
• Myelopathy, motor neuron disease
• Brain stem and cortical lesions
1
Weakness
Pertinent parameters include:
•
•
•
•
Motor power pattern
Sensory findings
Deep tendon reflexes and muscle tone
Others
2
Symptomatology of Motor Dysfunction
1.Muscle mass and contour
• atrophy, hypertrophy, dystrophy
• myopathy, myotonia
2.Muscle tone
• spasticity
• rigidity
• decorticate, decerebrate posture
• hypotonia
3
Symptomatology of Motor Dysfunction
3.Involuntary movement
• tremor, myoclonus, chorea, athetosis,
ballism, dystonia, spasm, tics, clamps
4.Weakness
• paresis, paralysis, -plegia, palsy
• mono-, para-, hemi-, quadri4
Neurologic examination
1.
2.
3.
4.
5.
6.
7.
8.
9.
Cerebral function
Cranial function
Motor function
Sensory function
Reflexes and muscle tone
Coordination
Gait and posture
Meningeal irritation
Funduscopic examination
5
Motor Power
Grading system (British Medical Research Council)
• V normal, full resistance to external force
• IV partial resistance to external force
• III against gravity, not to external force
• II joint movement, not against gravity
• I muscle contraction, no joint movement
• 0 no muscle contraction
6
Sensory Functions
1. Dorsal column system
• proprioception, touch
2. Anterolateral system
• pain (pinprick), temperature
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Reflexes
Deep tendon reflexes
•
•
•
•
•
4+
3+
2+
1+
0
pathological
normal, pathological
normal
normal, pathological
pathological
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Etiology (VINDICATEN_HIM)
V vascular
I infectious/inflammatory
N neoplastic
D degenerative
I intoxicative
C congenital/hereditary
A autoimmune
T traumatic
E endocrinopathic
N neoplastic
H hematologic
I idiopathic
M metabolic & miscellaneous
9
Where is the lesion?
Peripheral lesions
• Myopathy
• Neuromuscular junction
• Peripheral nerve
× polyneuropathy
× mononeuropathy (single, multiple)
× plexopathy
× radiculopathy
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Central lesions
•
•
•
•
•
Motor neuron
Spinal cord
Brainstem
Cerebral hemisphere
Others
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Lower Motor Neuron Lesions
Muscle (myopathy)
• hypokalemia
• myositis, muscular dystrophy
NMJ
• myasthenia gravis
Peripheral nerves (neuropathy)
• Polyneuropathy
• Mononeuropathy (single, multiple)
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Plexus (plexopathy)
• diabetic plexopathy
Nerve root (radiculopathy)
• Guillain-Barre Syndrome (AIDP), CIDP
• herniated disk
Spinal cord (myelopathy)
• motor neuron disease
13
Symptoms/Signs of LMN Lesions
Focal weakness
• monoparesis, selective neuropathy weakness
Flaccid tone
Areflexia, hyporeflexia
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Upper Motor Neuron Lesions
Spinal cord
• cord compression, myelitis
Brain stem, cerebral cortex, cerebellum and
basal ganglia
• cerebrovascular disease, tumor, degenerative
disease
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Symptoms/Signs of UMN Lesions
Diffuse weakness
•
paraparesis, hemiparesis, quadriparesis
Spastic tone
Hyperreflexia
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Hypotonia - Hyporeflexia
Reflex arc dysfunction (any components)
•
•
•
•
•
receptor organs
afferent neurons
reflex center
efferent neurons
effector organs
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Spasticity
Hypertonia
• unidirectional
• velocity-dependent
Hyperreflexia
Seen in upper motor neuron lesion other than
basal ganglia pathology
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Rigidity
Hypertonia
• bidirectional
• velocity-independent
• cog-wheeling
Normoreflexia
Seen in basal ganglia pathology
• Parkisonism, Parkinsonism plus
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Coordination
Equilibratory coordination
• Romberg sign
• Tandem walk
Non-equilibratory coordination
•
•
•
•
finger to nose, finger to finger, nose-finger-nose
dysdiadokokinesia
rebound
past-pointing
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Gait & Posture
• ataxic gait (proprioceptive, vestibular,
cerebellar): wide base, high swing, sway
• festinating gait (Parkinsonism): short, slow, rigid
and shuffling
• steppage gait (polyneuropathy): excessive hip
flexion
• waddling gait (myopathy): body swaying from
side to side like a duck
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0%
RT . HEEL ST RIKE
50%
LT . HEEL ST RIKE
RIGHT ST ANCE
LEFT SWING
0%
100%
RT . HEEL ST RIKE
RIGHT SWING
LEFT ST ANCE
RIGHT ST RIDE LENGT H
50%
100%
•Myopathy
•NMJ
•Peripheral nerve
•Plexus
•Root
•Cord
•Brain
Motor
P>D
P/D with F
D>P
P/D
P/D
focal/diffuse
diffuse
Sensory
normal
normal
impaired
impaired
impaired
impaired
impaired
Reflexes
N, De
N, De
De
De
De
De, I
I
P = proximal, D = distal
N = normal, De = decreased, I = increased
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Sensory Deficits
Spinal sensory Pathways
• Dorsal Column system
• Touch, proprioception, two-point
discrimination, vibratory sense
• Anterolateral system
• Pain (sharp and dull aching)
• Temperature sense
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Sensory Deficits
Cranial sensory pathways
• CN I (olfaction)
• CN II (vision)
• CN V (pain and touch)
• CN VII, IX, X (gustatory, etc)
• CN VIII (hearing and vestibular sense)
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Diabetic neuropathy
Clinical features
- Initial tingling paresthesia
- Pain
- Dysesthesia
- Loss of feeling distally
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Diabetic neuropathy
Distal sensory impairment ascends
symmetrically in legs and arms
Physical exam:
• Glove and stocking pattern
• Hyperalgesia
• Numbness or lack of sensation
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• http://www.metadon.net/
• students
• neurologic-examination.pdf
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