Upper Limb Neurological Exam

Upper Limb Neurological Exam Overview

  • The purpose of the video is to explain how to perform an upper limb neurological exam.

  • Comprehensive notes are available for use on Patreon.

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Patient Introduction

  • The patient, referred to as "Q," is introduced for the neurological examination.

  • The examiner states their intent to start the neuro exam, emphasizing cleanliness by washing hands.

Initial Assessment

Observation without Contact

  • Symmetry Assessment:

    • Observing symmetry between right and left arms.

    • Assessing muscle bulk; looking for atrophy, especially if there are lesions indicating a lower motor neuron issue.

    • No asymmetry or atrophy noted.

  • Posture:

    • Looking for abnormal posturing or contractures.

    • Normal posture observed.

  • Abnormal Movements:

    • Checking for resting tremors, dyskinesias (e.g., chorea, athetosis).

    • No abnormal movements or fasciculations observed.

Muscle Tone Assessment

  • Importance of Tone:

    • Tone is critical to assess; classified as hypotonic (floppy) or hypertonic (increased resistance).

    • Hypotonia indicates possible lower motor neuron lesions.

    • Hypertonia may indicate upper motor neuron lesions, subclassified into spasticity and rigidity.

    • Modified Ashworth Scale: To score muscle tone during assessment.

Testing Procedures:

  • The examiner instructs the patient to relax and tests tone through flexion and extension at different joints:

    • Elbow Flexion/Extension.

    • Wrist Pronation/Supination.

    • Assessing for normal tone and comparing to the opposite side.

  • Hypertonia Testing:

    • Spasticity: Velocity-dependent (e.g., clasp knife phenomenon).

    • Rigidity: Velocity-independent, may present as lead-pipe or cogwheel rigidity.

Strength Assessment

  • Scoring Strength:

    • Utilizes a scale from 0 to 5 for assessment:

    • 5: Full strength against resistance.

    • 4: Mild to moderate strength against resistance.

    • 3: Movement against gravity only.

    • 2: Movement with gravity removed.

    • 1: Flicker of movement.

    • 0: No movement.

  • Strength Testing in Q:

    • Shoulder Abduction: Deltoid muscle (C5 - axillary nerve).

    • Shoulder Adduction: (C6 - C7), multiple muscles.

    • Elbow Flexion: (C5 - musculocutaneous nerve).

    • Elbow Extension: (C6 - C8, radial nerve).

    • Wrist Flexion/Extension: (C6 - C8, median and ulnar nerves).

    • Finger Flexion/Extension: Radial nerve and median/ulnar nerves.

    • Testing thumb movements and grip strength, comparing to the opposite side.

Reflex Examination

  • Utilizing a reflex hammer to assess:

    • Triceps Reflex: Extension response (C7 - C8).

    • Biceps Reflex: Flexion response (C5 - C6).

    • Brachioradialis Reflex: Flexion response (C5 - C6).

  • Grading Reflexes:

    • 4+: Hyperreflexic with clonus.

    • 3+: Hyperreflexic without clonus.

    • 2+: Normal reflex.

    • 1+: Hyporeflexic.

    • 0: A-reflexic.

  • Comparisons made bilaterally in reflex responses.

Sensory Assessment

Types of Sensation Tested

  1. **Elementary Sensations:

    • Light touch (Dorsal column pathway).

    • Pain (Lateral spinothalamic tract).

    • Vibration (Dorsal column pathway).

    • Proprioception (Dorsal column pathway).

  2. **Procedure:

    • Light touch with a cotton swab, checking dermatomes (C5 to T2).

    • Pain sensation assessed with a pinprick test, checking symmetry on both sides.

    • Vibration sense checked with a tuning fork at distal and proximal joints.

    • Proprioception tested by moving a digit and asking the patient to identify the direction (up or down).

  3. **Stereognosis and Graphesthesia:

    • Stereognosis: Ability to identify objects by feel (posterior column and sensory cortex).

    • Graphesthesia: Ability to identify numbers/letters written on the hand, tested bilaterally.

    • Extinction Neglect Test: Ability to identify simultaneous stimuli on both sides.

    • Loss of sense indicates posterior column or sensory cortex issues.

Coordination Assessment

  • Tests for Coordination:

    • Finger to Nose Test: For dysmetria, looking for intent tremors.

    • Rapid Alternating Movements: Identifying delays or rhythm issues (dyskinesia).

    • Cerebellar Drift: Testing for upward movement of an arm when instructed to hold it steady.

    • Rebound Phenomenon: Testing resistance to movement and the ability to maintain tone post-release.

Recap of the Exam

  • The upper limb neurological exam includes following components:

    • Appearance and Posture

    • Muscle Tone

    • Strength/Power

    • Reflexes

    • Sensory Modalities (including elementary and discriminative sensations)

    • Coordination (finger-to-nose, alternate movements, cerebellar drift, rebound phenomenon).

  • Acknowledgment of patient Q's cooperation and skills in the assessment.

  • Encouragement for viewers to check out related resources or supportive material.