The Neurologic Exam 2

What are the techniques of the motor exam?

- Inspect for abnormal movements, tics, fasciculations, atrophy

- Inspect for tremors (rhythmic oscillatory involuntary movements)

- Assess bulk & muscle tone

- Assess muscle strength

- Assess coordination and cerebellar tension

What is bulk?

symmetric of bilateral muscle masses

What is tone?

normal residual tension in voluntary relaxed muscle

How do you assess tone?

resistance of passive movement

What is normal tone?

mild, even resistance to movement

What is flaccidity?

decreased resistance, hypotonia (lower motor neuron)

What is spasticity?

increased tone that results in continuous resistance to stretching, hypertonia (upper motor neuron)

What is rigidity?

constant state of resistance; resists passive movement in any direction, dystonia

What is cogwheel rigidity?

increased tone is released by degrees during passive ROM, small regular jerks

Describe the scale for grading muscle strength.

5 = active movement against full resistance without evident fatigue (normal muscle strength)

4 = active movement against gravity and some resistance

3 = active movement against gravity

2 = active movement of the body part with gravity eliminated (planar motion)

1 = a barely detectable flicker or trace of contraction

0 = no muscular contraction detected

During the motor examination, what do you assess for upper extremities?

- deltoid (C5)

- biceps (C5, C6)

- triceps (C6, C7, C8)

- wrist extension (C5, C6, radial nerve)

- wrist flexion (C7, C8, median nerve)

- intrinsics (C8, T1, ulnar nerve)

- thumb opposition (C8, T1, median nerve)

- grip (C7, C8, T1)

Which movements should you test against resistance to determine upper extremity strength?

- elbow flexion & extension

- wrist extension

- grip strength

- finger abduction

- opposition of thumb

During the motor examination, what do you assess for lower extremities?

- iliopsoas (L2, L3, L4)

- hip adductors (L2, L3, L4)

- hip abductors (L4, L5, S1, gluteus min/med)

- hip extensors (S1, gluteus max)

- quadriceps (L2, L3, L4)

- hamstring (L4, L5, S1, S2, hamstrings)

- foot dorsiflexion (L4, L5, anterior tibialis)

- plantar flexion (S1, S2, gastrocnemius)

- toe dorsiflexion (L5, S1, EHL)

Which movements should you test against resistance to determine lower extremity strength?

- hip flexion & extension

- knee extension & flexion

- dorsiflexion of foot

- plantarflexion of foot

What findings are consistent with upper motor neuron lesions?

spasticity, hyperreflexia, clonus, Babinski sign, weakness

What findings are consistent with lower motor neuron lesions?

atrophy, fasciculations, decreased tone, hyporeflexia, weakness

What does cerebellar testing assess?

coordination

What systems affect coordination?

motor strength, cerebellar system, vestibular system, and sensory system

How do you perform cerebellar testing?

- rapid alternating movements

- point-to-point movements

- assess gait

- assess stance

What are the point-to-point movements?

- finger-nose-finger

- heel-to-shin

How do you assess stance?

- pronator drift

- Romberg testing

What should you observe when performing rapid alternating movements?

speed, rhythm, and smoothness of movements

How can you perform rapid alternating movements?

- have the patient pat the knees with both hands, alternately using the palms and back of hands

- have the patient touch thumb to each finger in sequence

- have the patient tap balls of feet in turn

What is important to note when performing rapid alternating movements?

non-dominant hand may perform worse

How do you perform the finger-to-nose test?

ask patient to touch your index finger and then their nose, back and forth several times; move your index finger throughout testing

What should you assess for when performing the finger-to-nose test?

accuracy and smoothness of movement

How else can you perform the finger-to-nose test and what should you assess for in this instance?

with eyes closed, keeping the provider's finger in place to see if they can reach back from finger to nose, then finger again; assess for past pointing

How do you perform the heel-to-shin test?

place heel on opposite knee, then run it down the shin to the big toe; repeat for position sense with eyes closed

What should you observe for during point-to-point testing?

smoothness and accuracy

When assessing gait, what should you observe?

posture, rhythm, and sequence of stride and arm movements

How can you assess gait?

- walk across room

- tandem gait (heel-to-toe)

- heel/toe walk

- hop in place

- shallow knee bend

- rise from sitting

What is ataxia?

uncoordinated gait with reeling and instability

What does Romberg test evaluate?

balance and position sense (stance)

How do you perform Romberg test?

ask patient to stand with heels together, with eyes open, then eyes closed for 30-60 seconds without support

What is a positive Romberg test?

loss of balance when eyes are closed (normal swaying is minimal)

In a Romberg test, what might cerebellar dysfunction produce?

loss of balance when eyes are open or closed

How do you perform pronator drift?

sit or stand with both arms held forward with palms up for 20-30 seconds with eyes closed; keep arms out and shut eyes, tap arms downward (normal = return to horizontal position)

What is an abnormal pronator drift?

one forearm and palm turn inward and down

What is an abnormal pronator drift test concerning for?

corticospinal tract lesion in the contralateral hemisphere

How is sensory function tested?

with the patient's eyes closed

What should you observe all sensory function tests for?

- side-to-side differences

- interpretation of sensation

- discrimination

- location

What sensations go with what different spinal tracts?

- pain and temperature (spinothalamic tracts)

- position and vibration (posterior column)

- light touch (both pathways)

During a sensory exam, what should you do if impairments are found?

map boundaries by dermatome

How do you test primary sensory function?

test sensory responses to:

- superficial touch

- superficial pain

- temperature and deep pressure

How do you test superficial touch?

cotton wisp or fingertip

How do you test superficial pain?

broken Q-tip vs soft cotton tip

When are temperature and deep pressure tested?

only when superficial pain sensation is not intact

What should you compare on extremities?

distal to proximal areas

What areas of the upper extremities should you compare?

- both shoulders (C4)

- inner and outer aspects of forearms (C6 and T1)

- thumbs and little fingers (C6 and C8)

What areas of the lower extremities should you compare?

- front of both thighs (L2)

- medial and lateral aspects of both legs (L4 and L5)

- little toes (S1)

Describe the vibratory response.

to tuning fork over joints or bony prominences on upper and lower extremities (start with DIP of finger and interphalangeal of great toe)

What Hz tuning fork should be used to assess vibratory response?

128 Hz

What should the patient feel during the vibratory response test?

vibration; can ask patient to confirm when vibration stops and mute fork

If vibratory response is abnormal, what should you do?

move proximally

Vibratory sense is often the first sensation lost in what pathology?

peripheral neuropathy

Where should you perform protective sensation testing?

on several sites of the foot

What populations should have protective sensation testing performed?

diabetes mellitus and peripheral neuropathy

What should you use to assess protective sensation?

5.07 monofilament or Wartenberg wheel

Describe a proprioception assessment?

evaluate perception of position sense with movement of the great toes or a finger on each hand

How can you assess proprioception?

- grasp sides of digit

- patient reports "up" or "down" positioning with eyes closed

What does testing of cortical sensory function assess?

cognitive ability to interpret sensations

What should the inability to perform cortical sensory function tests make you suspect a lesion in?

- sensory cortex (specifically if touch and position sense are intact)

- posterior columns of the spinal cord

How do you test graphesthesia?

identify numbers being traced onto the palm or the tip of a finger

What is normal graphesthesia?

can identify most numbers

What does abnormal graphesthesia indicate?

a lesion in the sensory cortex

How do you test stereognosis?

identify a familiar object (key, coin) by touch and manipulation

In what patient population should sterognosis be tested cautiously?

patients with severe arthritis or issues with manipulation of item; although unrelated to sensation, this may impair their ability

What is normal stereognosis?

manipulate skillfully and ifentify correctly within 5 seconds

What is abnormal stereognosis?

tactile agnosia (aka asterognosis)

What is tactile agnosia (aka asterognosis) and what does it suggest?

inability to recognize objects by touch, suggesting a parietal lobe lesion or posterior column disease

What is two-point discrimination?

distance at which the patient can no longer distinguish two points

Where is normal two-point discrimination?

varies with body parts; normal <5mm on the finger pads

How should the limb and muscle be when performing reflex testing?

limb should be relaxed, muscle partially stretched

How can you stimulate the reflex?

by directing a short, snappy blow on the tendon

How should you hold the reflex hammer, and where is the action?

relax your hold on the hammer, action in the wrist

How should you perform the reflex test?

bounce up and do not rest the hammer on the tendon; use distraction techniques if needed

What are the upper extremity deep tendon reflexes?

- biceps (C5, C6)

- triceps (C6, C7)

- brachioradialis (C5, C6)

What are the lower extremity deep tendon reflexes?

- patellar (L2, L3, L4)

- Achilles (S1)

Why is it important to assess deep tendon reflexes bilaterally?

increased or diminished reflexes can be normal if symmetrical

DTR Grade 4

very brisk, hyperreactive, with clonus

DTR Grade 3

brisker than average

DTR Grade 2

average; normal

DTR Grade 1

somewhat diminished, low normal

DTR Grade 0

reflex absent, no response

What nerve roots does the biceps reflex assess?

C5 and C6

How do you elicit the biceps reflex?

- elbow flexed and forearm with palm down pronated; thumb placed on biceps tendon and strike hammer onto digit

- assess for contraction of the biceps muscle, may also see flexion of the elbow

What nerve roots does the triceps reflex assess?

C6 and C7

How do you elicit the triceps reflex?

- flex arm at elbow, palm towards body and slightly across mudline, strike triceps tendon

- assess for triceps muscle contraction and extension at the elbow

What nerve roots does the brachioradialis reflex assess?

C5 and C6

How do you elicit the brachioradialis reflex?

- forearm pronated partially, resting on lap or abdomen, strike the radius with the flat edge of hammer, 1-2 inches above the wrist

- assess for supination of the forearm and flexion

What nerve roots does the patellar reflex assess?

L2, L3, L4

How do you elicit the patellar reflex?

- knee flexed, tap patellar tendon just below patella

- assess for contraction of the quadriceps and associated extension at the knee

What nerve root does the Achilles reflex assess?

S1 (primarily)

How do you elicit the Achilles reflex?

- partially dorsiflex the ankle, strike the Achilles tendon

- assess for plantarflexion at the ankle

What does the clonus test?

if reflexes seem hyperreactive

How do you test for clonus?

knee partially flexed, dorsiflex and plantarflex the foot a few times to relax the patient, then sharply dorsiflex and maintain dorsiflexion

What is an abnormal finding on a clonus test?

rhythmic oscillating movements

True or False: Clonus must be present to grade as a 4 reflex.

True

What is the superficial reflex?

- plantar reflex (L5, S1) -> Babinski

- cremasteric reflex (L1, L2)

- abdominal reflex (upper T8, T9, T10/lower T10, T11, T12)

- anal reflex (S2, S3, S4)

How do you perform the Babinski (plantar) reflex?

stroke the lateral side of the foot from the heel to the ball and then curve across the ball of the foot to the medial side