[01.25b] Overview of the Neurological Examination (Part 2) V2

General Introduce yourself, ask the patient for their name, briefly talk about what the exam will be about, and ask the patient to sit down.

What four initial steps should be taken when beginning the neurological examination?

Inspection, determination of the motor tone, and assessment of the strength of the individual muscles.

What are the three main steps in the examination of the motor system?

Inspection Relax.

What should you ask the patient to do before starting the inspection part of the motor examination?

Symmetry/Asymmetry, Atrophy/Hypertrophy, Joint Contractures, Involuntary Movements (Tremors, jerks, chorea, athetosis, dystonia, resting hand tremor, postural tremor of essential tremor and hyperthyroidism, chorea of Huntington's disease, dystonia and hemiballismus), and Fasciculations.

What six general observations should you inspect for in the motor system?

Raise both hands forward and close their eyes.

What procedure is used to inspect for tremors?

Checking for Muscle Tone Engaging them in conversation.

How should you persuade the patient to relax when checking for muscle tone?

Passively flex, extend or rotate all the joints of the left and right upper and lower extremities (Wrist, Elbow, Shoulder, Thigh, Foot, Finger).

What is the general procedure for checking muscle tone?

Normotonic, hypertonic, or hypotonic.

What three determinations should be made regarding muscle tone?

Increased resistance to passive stretch independent from the velocity or force applied.

What defines rigidity?

Lead pipe rigidity.

What form of rigidity remains uniform throughout all range of passive motion?

Cogwheel rigidity.

What form of rigidity presents as a stop and start, like little jerks, when muscle flexion is being applied?

Increased resistance to passive stretch that is dependent on velocity or force applied.

What defines spasticity?

Clasp-knife spasticity.

What type of spasticity involves initial resistance followed by sudden release on further application of force?

Palpation.

Which step in the motor examination was listed but not discussed in the source?

Special Tests for Subtle Weakness Ask patient to close both eyes and raise arms in front with palms facing up, then observe for pronation of the weak arm.

What is the procedure and observation for checking pronator drift?

Ask patient to roll their arms forward, then backward, and demonstrate the motion to guide them.

What is the procedure for checking Libarnes roll?

Subtle weakness.

What is the Libarnes roll checking for?

Muscle Strength Testing The patient follows the examiner’s instruction, systemic assessment of each individual muscle group should be based on the action of the muscles being tested, the examiner should immediately perform the same test on the contralateral side to detect any asymmetry, and grade the strength of each muscle group tested.

What four general principles are important in muscle strength testing?

0.

What muscle strength grade indicates complete paralysis?

1.

What muscle strength grade indicates only a flicker of contraction but no movement of the extremity?

2.

What muscle strength grade indicates movement of part of the extremity in its horizontal plane but not against gravity?

3.

What muscle strength grade indicates movement of part against gravity but not against any resistance?

4.

What muscle strength grade indicates movement of part against some resistance by the examiner?

5.

What muscle strength grade indicates normal strength?

To suggest muscle vs. nerve diseases.

Why is it important to compare the strength of proximal versus distal muscles?

Muscle Strength of Upper Extremities Deltoid.

What muscle is primarily tested for shoulder abduction?

Axillary.

What nerve innervates the deltoid muscle for shoulder abduction?

C5, C6.

What nerve roots are associated with shoulder abduction?

Biceps brachii.

What muscle is primarily tested for elbow flexion?

Musculocutaneous.

What nerve innervates the biceps brachii for elbow flexion?

C5, C6.

What nerve roots are associated with elbow flexion?

Triceps.

What muscle is primarily tested for elbow extension?

Radial.

What nerve innervates the triceps for elbow extension?

C6, C7, C8.

What nerve roots are associated with elbow extension?

Extensor carpi radialis, Extensor carpi ulnaris.

What muscles are primarily tested for wrist extension?

Radial.

What nerve innervates the wrist extensors?

C6, C7, C8.

What nerve roots are associated with wrist extension?

Flexor carpi radialis, Flexor carpi ulnaris.

What muscles are primarily tested for wrist flexion?

Median / Ulnar.

What nerves innervate the wrist flexors?

C7, C8.

What nerve roots are associated with wrist flexion?

First dorsal interosseous.

What muscle is primarily tested for finger abduction?

Ulnar.

What nerve innervates the first dorsal interosseous for finger abduction?

C8, T1.

What nerve roots are associated with finger abduction?

Second palmar interosseous.

What muscle is primarily tested for finger adduction?

Ulnar.

What nerve innervates the second palmar interosseous for finger adduction?

C8, T1.

What nerve roots are associated with finger adduction?

Extensor digitorum.

What muscle is primarily tested for finger extension?

Posterior interosseous.

What nerve innervates the extensor digitorum for finger extension?

C7, C8, T1.

What nerve roots are associated with finger extension?

Flexor digitorum superficialis, Flexor digitorum profundus.

What muscles are primarily tested for finger flexion?

Median / Ulnar.

What nerves innervate the finger flexors?

C7, C8, T1.

What nerve roots are associated with finger flexion?

Muscle Strength of Lower Extremities Illiopsoas.

What muscle is primarily tested for hip flexion?

Lumbosacral plexus.

What nerve innervates the illiopsoas for hip flexion?

L1, L2, L3.

What nerve roots are associated with hip flexion?

Gluteus medius, Gluteus minimus.

What muscles are primarily tested for hip abduction?

Superior gluteal.

What nerve innervates the gluteus medius and minimus for hip abduction?

L4, L5, S1.

What nerve roots are associated with hip abduction?

Obturator externus, Gracilis, Adductor longus, Adductor magnus, Adductor brevis.

What muscles are primarily tested for hip adduction?

Obturator.

What nerve innervates the hip adductors?

L2, L3, L4.

What nerve roots are associated with hip adduction?

Gluteus maximus.

What muscle is primarily tested for hip extension?

Inferior gluteal.

What nerve innervates the gluteus maximus for hip extension?

L5, S1, S2.

What nerve roots are associated with hip extension?

Quadriceps femoris (Rectus femoris, Vastus medialis, Vastus intermedius, Vastus lateralis).

What muscle group is primarily tested for knee extension?

Femoral.

What nerve innervates the quadriceps femoris for knee extension?

L2, L3, L4.

What nerve roots are associated with knee extension?

Hamstrings (Biceps femoris, Semitendinosus, Semimembranosus).

What muscle group is primarily tested for knee flexion?

Sciatic.

What nerve innervates the hamstrings for knee flexion?

L5, S1, S2.

What nerve roots are associated with knee flexion?

Tibialis anterior.

What muscle is primarily tested for foot dorsiflexion?

Deep peroneal.

What nerve innervates the tibialis anterior for foot dorsiflexion?

L4, L5.

What nerve roots are associated with foot dorsiflexion?

Gastrocnemius.

What muscle is primarily tested for foot plantar flexion?

Posterior tibial.

What nerve innervates the gastrocnemius for foot plantar flexion?

S1, S2.

What nerve roots are associated with foot plantar flexion?

Tibialis posterior.

What muscle is primarily tested for foot inversion?

Tibial.

What nerve innervates the tibialis posterior for foot inversion?

L4, L5.

What nerve roots are associated with foot inversion?

Peroneus longus, peroneus brevis.

What muscles are primarily tested for foot eversion?

Superior peroneal.

What nerve innervates the peroneus longus and brevis for foot eversion?

L5, S1.

What nerve roots are associated with foot eversion?

Lateral aspect of the foot.

When testing for foot eversion, on which part of the foot should the examiner place their hand?

Extensor digitorum brevis.

What muscle is primarily tested for toe extension/dorsiflexion?

Deep peroneal.

What nerve innervates the extensor digitorum brevis for toe extension/dorsiflexion?

S1.

What nerve root is associated with toe extension/dorsiflexion?

General Under Motor Examination and are performed after the Cerebellar Examination.

According to the text, how are reflex tests sequenced within the neurological examination?

Deep Tendon Reflexes and Superficial Reflexes.

What are the two main types of reflexes examined?

Hold it at the distal third and use a wrist movement (swing, don’t stab it).

What are the proper techniques for using a neurological hammer?

Avoid telling the patient to relax (causes tension) and divert patient’s attention by asking questions.

What two instructions should be given or avoided when preparing a patient for reflex testing?

The tendon, not the muscle belly.

What part should be hit with the neurological hammer?

Deep Tendon Reflex Testing Biceps Reflex, Brachioradialis Reflex, and Triceps Reflex.

What three deep tendon reflexes are tested in the upper extremities?

Knee Reflex and Achilles Reflex.

What two deep tendon reflexes are tested in the lower extremities?

Musculocutaneous, C5, (C6).

What nerve and nerve roots are associated with the biceps reflex?

Jerk-like reaction of the arm.

What is a normal finding for the biceps reflex?

Radial, C6, (C5).

What nerve and nerve roots are associated with the brachioradialis reflex?

Flexion and supination of the forearm.

What is a normal finding for the brachioradialis reflex?

Radial, C7.

What nerve and nerve root are associated with the triceps reflex?

Arm extension.

What is a normal finding for the triceps reflex?

Femoral, L3-L4.

What nerve and nerve roots are associated with the knee reflex?