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Home , Neurological examination, Pronator drift

Clinical Examination Guide

Neurological Examination - Motor

Components of the full

• Cranial • Cognitive • Motor • Sensory • Cerebellar

Systematic approach to motor examination

• General Inspection • Stability and global movement • Upper / lower limb - General Inspection - / Standing and walking - Tone - Power - - Coordination

You may be required to combine elements of the sensory and motor examinations for the upper or lower limbs.

Introduction

• Introduce yourself, confirm patient ID • Explain examination and gain consent. Expose lower limbs. Ask about any weakness, pain, loss of function, numbness, pins and needles or strange sensations • Gel hands

Document Owner: Clinical Skills/LK, ME Last Updated: May 2019

General Inspection

Patient: • Skin: - Scars - Pale/cyanosed/red, shiny, dry skin may be autonomic loss, - Unreported injury/ulceration may be sensory loss • Joints: Deformities may be proprioception loss (Charcot’s joints of the feet) • Muscles: - Wastage may be motor loss - – LMN sign - , tic, myoclonus, choreiform movement

Surroundings: • Mobility aids (for lower limb)

Stability standing and walking (lower limb examination)

Stance • On standing, look at the width of feet - How high feet and knees are lifted • Look for : could be cerebellar / motor / - Disturbance of normal gait by abnormal vestibular / proprioception movements - Arm swing Proprioception - Posture - Ability to turn • If steady, ask them to keep feet together and close their eyes. Heel to toe coordination • If patient becomes unsteady with eyes closed = positive Romberg’s test. • Ask patient to walk as if on a tightrope. This can • Make sure you can steady the patient if they start help to uncover subtle problems with to fall proprioception /

Gait Ankle dorsiflexion • Ask patient to walk to the end of the room and • Ask patient to stand on heels. Difficulty may be due back. to weakness neuropathy or myopathy • Examine: - Symmetry Ankle plantarflexion - Size of paces • Ask patient to stand on toes - Lateral distance between the feet

Pronator Drift (upper limb examination)

• Ask the patient to close their eyes and place arms outstretched forwards with palms facing up • Observe the hands and arms for signs of pronation • If pronation occurs in one of the arms, it indicates upper (UMN) pathology

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Tone

Ask patient to lie on couch at 45o • Try to keep patient relaxed, ask them to stay floppy

Upper limb • Hold the patient’s hand as if shaking hands, supporting the with your other hand • Assess a full range of passive movements of the wrist, elbow and shoulder, with varying speed and direction • Check for hypertonia, hypotonia and rigidity • Note any sign of clasp-knife resistance (rigidity present only at the start of a passive movement); cog-wheel rigidity (jerky resistance), leadpipe rigidity (sustained resistance) • Compare both sides

Lower limb • Roll each leg in turn – the foot should rotate loosely and flop in the opposite direction to knee movement. Compare each side • Sharply lift each knee slightly and let it drop to the couch – in hypertonia the foot will lift off bed. Compare each side • Check for clonus by flexing and supporting the knee. After rotating the foot a couple of times, pull foot back briskly to dorsiflex the ankle. Observe for ankle jerk. Up to 3-4 beats is normal. Compare each side

Power

Test right then left for each part of the limbs being examined so that you can make a comparison. Take the patient through each movement in turn, using your hands to oppose limb movement and stabilise proximal joints as necessary. Upper Limb

Shoulders • Shoulder Abduction C5/6: Ask patient to raise • Shoulder Extension: Ask patient to raise their their straight arm to the side. Say “Stop me from straight arm in front of them. Say “Stop me pushing it down” whilst you push down just above pushing it back” as you push the arm downward the elbow joint. just above the elbow.

• Shoulder Adduction C6/7/8: Ask patient to lower • Shoulder Flexion: Ask the patient to raise their their straight arm from the side. Say “Stop me straight arm behind them. Say “Stop me from lifting it” whilst you try to lift their arm with your pushing it forward” as you push the arm just hands just above the elbow joint. above the elbow.

Elbows • Elbow Extension C7/8: Ask patient to bend their • Elbow Flexion C5/6: Ask patient to bend their elbow to about 500. Say “Don’t let me bend it any elbow to about 500. Say “Stop me straightening it” further” as you push on the forearm just below as you pull on the forearm just below the elbow, the elbow, and stabilising the joint with your non- and stabilising the joint with your non-dominant dominant hand hand. Wrists • Wrist Extension C7/8: Ask patient to flex their • Wrist Flexion C7/8: Ask patient to flex their wrist. wrist. Say “Stop me pushing your wrist down” as Say “Stop me from pushing it back up” as you you push down on the dorsum of their hand, whilst push on the volar surface of their hand, whilst stabilising at the wrist with your non-dominant stabilising at the wrist with your non-dominant hand. hand.

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Fingers and Thumbs • Finger Extension [MCPJ/IPJ] C7/8: Ask patient to • Finger Adduction T1: Ask patient to bring their keep their fingers straight whilst you push on the fingers together whilst you push on them with your dorsal aspect of the fingers with your own and test own to test resistance. resistance • Thumb Extension T1: Ask patient to move their • Finger Flexion C7/8: Ask patient to keep their thumb out to the side whilst you push on it with fingers bent whilst you push on the volar aspect of your own to test resistance. the fingers with your own and test resistance. • Thumb Flexion T1: Ask patient to move their thumb • Finger Abduction T1: Ask patient to keep their in from the side whilst you push on it with your own fingers spread whilst you push on them with your to test resistance. own to test resistance. • Thumb Opposition T1: Ask patient to move their thumb across their hand whilst you push on it from below with your own to test resistance. Lower limb - Start with legs together flat on the bed

Hips Ankles • Hip flexion L2/3: Ask patient to raise their leg and • Ankle dorsiflexion L4/5: Ask patient to bend their keep it straight. Say “Stop me from pushing it ankle and pull their foot up towards their head. down” whilst you push down just above the knee. Say “Stop me pushing your foot down” as you push down on the dorsum of their foot whilst • Hip extension L4/5: Ask them to lower their leg. stabilising at the knee with your other hand Say “Stop me lifting it” whilst you try to lift their leg with your hands just above the knee. • Ankle plantarflexion S1/S2: Ask them to point their foot down towards the bed. Say “Stop me from • Hip Abduction L2/3/4: Starting with the legs pushing it back up” as you push up on the plantar together flat on the bed ask them to slide their leg side of their foot out towards the edge of the bed. Say “Stop me pushing (pulling) it back” as you push (pull) the Feet lateral thigh just above the knee. • Foot inversion L4: Ask them to roll their foot

inwards to push against your hand as you hold your • Hip Adduction L4/5/S1: Starting with the leg held hand against the medial side of their foot. Push to out towards the edge of the bed, ask them to slide test resistance it in to centre. Say “Stop me pulling (pushing) it

back” as you pull (push) the lateral thigh just above • Foot eversion L5/S1: Ask them to roll their foot the knee. outwards to push against your hand as you hold your hand against the lateral side of their foot. Knees Push to test resistance • Knee extension L3/4: Ask patient to bend their knee to about 500. Say “Don’t let me bend it any Hallux: further” as you push on the leg just above the • Extension L5: Ask the patient to point their big toe ankle, and stabilising with your other hand on the up towards the ceiling and stop you from pushing it other knee down.

• Knee Flexion L5/S1: Ask patient to bend their knee Use MRC Scale 1-5 to record power: 0 to about 90 and pull their heel towards their 0 no contraction bottom. Say “Stop me straightening it” as you as you pull on the lower leg just above the ankle and 1 flicker or trace of contraction stabilising at the other knee 2 active movement with gravity eliminated

3 active movement against gravity

4* active movement against gravity and resistance Page 4 of 6 5 normal power

Reflexes

Check to see if reflexes are absent, reduced, normal, brisk or if there is clonus. If reflexes appear to be absent, a reinforcement technique should be used to try to elicit a normal response. • For upper limb examination this is done by asking the patient to clench their jaw • For lower limb examination, this is done by asking the patient to hook together their flexed fingers and pull apart

The reflex should be documented as “normal with reinforcement”. Where a reflex is still found to be absent despite reinforcement, a true absent reflex should be recorded.

Upper limb Lower limb Supinator (C5/6) Knees (L3/4) • Ask the patient to rest their arm to the side • Bend patient’s knee and support their weight. relaxed. Use your non-dominant hand to place two Strike the patellar tendon. fingers over the lateral aspect of the forearm a • Normal reflex will cause contraction of the few centimetres proximal to the wrist joint. Strike quadricep and lower limb to swing forwards and the fingers with the tendon hammer. back once • Normal reflex will cause contraction of the brachioradialis causing the forearm/hand to twitch Ankles (L5/S1) and rotate. • Bend patient’s knee and place ankle dorsiflexed resting on the other shin. Strike Achilles tendon. Biceps (C5/6) • Normal reflex will cause contraction of the • Ask the patient to bend their forearm to 45-50 gastrocnemius and jerk of the foot in plantar degrees and relax their arm across their body. direction Use your non-dominant hand to place two fingers Plantars over the flexor crease of the elbow joint. Strike the fingers with the tendon hammer. • Using your thumbnail/end of tendon hammer, start • Normal reflex will cause contraction of the biceps at the lateral aspect of heel, sharply draw nail up causing the forearm to flex. lateral border to the little toe and across to big toe. • Observe for plantar flexion of the toes as a normal Triceps (C7/8) response. • Dorsiflexion of hallux and abduction (fanning) of • Ask the patient to bend their forearm to 45-50 other toes is a positive Babinski sign (UMN) degrees and relax their arm across their body. Strike the tendon hammer on the extensor surface of the upper arm 2-3cm behind the olecranon. • Normal reflex with cause contraction of the triceps causing the forearm to extend.

Coordination

Upper limb • Ask patient to repeatedly touch their nose and your extended finger with one finger of their dominant hand. • Ask them to do it as fast as possible. • Look for over-exaggeration of the movement [past pointing].

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• Demonstrate for the patient putting the palm of one hand on the palm and dorsum of the other hand. Ask the patient to do this as fast as possible. • Failure indicates dysdiadokokinesia [defect of the ]

Lower limb • Ask patient to slide their heel down their shin from knee to ankle of the opposite leg, lift foot up and back to knee, forming a triangle. Perform a few times. Repeat opposite leg.

Conclusion

• Thank your patient, ask them to get dressed, report/record findings • Consider: upper limb neurological examination, further examination for cerebellar function, lower limb sensory examination

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