The key aim is to identify the anatomical site of the lesion: central (UMN – brain and spinal cord)versus peripheral (LMN – nerve roots and peripheral nerves).
• NB – neurological examination of the limbs tests both the peripheral and central nervous systems.
The pattern of signs is usually more important than a single sign (e.g. glove-and-stocking sensory loss, left-sided UMN weakness etc.)
Examination of the cranial nerves should be performed with neurological examination of the limbs as part of a complete neurological examination.
Mnemonic:
To Postpone Reflexes Constitutes Stupidity
Tone, Power, Reflexes, Co-ordination, Sensation
To start – WIPE | • Wash your hands • Introduce yourself to the patient • Permission – to examine the patient • Position – start with the patient sitting • Pain – check that the patient has no pain • Exposure – both upper limbs from shoulders to fingers | ||||||||||||||||||||||||||||||||
End of the bed | Surroundings • Monitoring: ECG (autonomic problems) • Treatments: O2, IV infusions (IV Ig) • Paraphernalia: wheelchair, mobility aids Patient • Asymmetry, deformity or abnormal posture • Resting tremor • Wasting (proximally quadriceps; distally tibialis anterior) • Fasciculation (quadriceps; gastrocnemius) Ask patient to walk away, turn around and walk back •Delayed Initiation (Parkinson’s) •Loss of arm swing (early sign in Parkinson’s) •Festination (Parkinson’s) •Scissoring (due to spasticity i.e. UMN lesion) •Waddling (proximal muscle weakness) •Foot drop (LMN lesion, specifically L4, L5 or common peroneal nerve) •Heel to toe walking (ataxia) •Romberg’s (proprioceptive loss) | ||||||||||||||||||||||||||||||||
Tone | Ask patient to relax • “Pastry-roll” each leg to test ankle tone • Lift knee suddenly – heel lifts off bed if tone increased • Ankle clonus (>5 beats; test with knee bent) | ||||||||||||||||||||||||||||||||
Power | MRC scale of 0-5 Start proximally When describing weakness, think in terms of: • Proximal versus distal • Unilateral versus bilateral
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Reflexes | Hold tendon hammer at the end, let it fall in a fluid movement. If unable to elicit a reflex try with reinforcement – Jendrassik manoeuvre (patient locks their fingers together and pulls) Look at the muscle belly when testing a reflex
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Coordination | Tests cerebellar function – omit if upper limbs are weak. • Heel shin test (look for dysmetria and intention tremor) • Tap feet on floor or end of bed (dysdiadochokinesis) | ||||||||||||||||||||||||||||||||
Sensation | Test distally to proximally. Look for “glove” or dermatomal loss. • Light touch with fingers (tests spinothalamic pathway) • Get the patient to close their eyes and look for extinction • Test rapidly, running up the arms then work down the arms specifically testing dermatomes as per the diagram • If deficit detected, consider refining deficit by using wisp of cotton wool (dorsal columns) as well as pin prick and testing temperature sensation (spinothalamic columns) • Proprioception or vibration sense (tests dorsal columns) | ||||||||||||||||||||||||||||||||
Closure | • Thank the patient • Make sure the patient is comfortable and clothed • Wash your hands • Put your findings together – is the lesion central or peripheral? | ||||||||||||||||||||||||||||||||
To Finish | • Examine the upper limbs and cranial nerves Only if relevant to findings so far: • Other cerebellar signs: DANISH • Visual fields (UMN weakness suspected stroke) • Speech examination (UMN weakness suspected stroke) • FVC (Guillain Barré) | ||||||||||||||||||||||||||||||||
MRC Power Scale
0 | No movement |
1 | Flicker of Movement |
2 | Movement with gravity but not against |
3 | Movement against gravity but not resistance |
4 | Reduced power against resistance |
5 | Normal power against resistance |
Pattern of findings in UMN vs LMN lesion
UMN | LMN | |
Inspection | Spastic posture | Wasting after 2 – 3 weeks Fasciculation |
Tone | Increased +/- clonus | Decreased |
Power | Weakness (in a pyramidal pattern if cortical UMN lesion) | Weakness in distribution of nerve/root/muscle group |
Reflexes | Hyperreflexic, extensor plantars | Hyporeflexic, flexor plantars |
Dermatomes
