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Neuro Exam Workshop AAO Convocation, 2018 Drew Lewis, DO, FAAO, FAOCPMR Associate Professor, OMM Department Des Moines University

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Neuro Exam Workshop AAO Convocation, 2018 Drew Lewis, DO, FAAO, FAOCPMR Associate Professor, OMM Department Des Moines University Neuro Exam Workshop AAO Convocation, 2018 Drew Lewis, DO, FAAO, FAOCPMR Associate Professor, OMM Department Des Moines University Table of Contents I. Neuro Exam Screen ................................................................................................................ 2 A. Inspection .................................................................................................................................. 2 B. Reflexes ...................................................................................................................................... 2 C. Upper Extremity Manual Muscle Strength Testing ................................................................... 2 D. Lower Extremity Manual Muscle Strength Testing .................................................................... 2 E. Sensory ....................................................................................................................................... 2 II. Reflexes ................................................................................................................................3 A. Deep Tendon Reflexes (Muscle-Stretch Reflexes) ..................................................................... 3 B. Additional Muscle-Stretch Reflexes ........................................................................................... 5 C. Superficial Reflex (Skin to Muscle Reflex) .................................................................................. 5 III. Upper Extremity Muscle Strength Testing ...............................................................................6 A. Muscle Strength Scales .............................................................................................................. 6 B. C5: Elbow Flexors ....................................................................................................................... 6 C. C6: Wrist Extensors .................................................................................................................... 6 D. C7: Elbow Extensors ................................................................................................................... 7 E. C8: Long Finger Flexors .............................................................................................................. 7 F. T1: Small Finger ABductor .......................................................................................................... 7 IV. Lower Extremity Muscle Strength Testing ...............................................................................8 A. L2: Hip Flexors ............................................................................................................................ 8 B. L3: Knee Extensors ..................................................................................................................... 8 C. L4: Ankle Dorsiflexors ................................................................................................................ 8 D. L5: Long Toe Extensors .............................................................................................................. 9 E. S1: Ankle Plantarflexors ............................................................................................................. 9 V. Sensory Testing .................................................................................................................... 10 A. ASIA Key Sensory Points........................................................................................................... 10 VI. Neurological Exam Practical ................................................................................................. 11 A. Version A .................................................................................................................................. 11 B. Version B .................................................................................................................................. 12 © 2018 Des Moines University Neuro Exam 1 I. Neuro Exam Screen A. Inspection 1. During inspection, have patient stand directly underneath the lighting in the room. 2. Physician then inspects the patient by directly visualizing the skin. (Patient in gown and shorts) 3. Physician is looking for: a. Signs of Atrophy (decreased muscle mass), in lower motor neuron injuries b. Fasciculation of the muscles, in lower motor neuron injuries c. Increased tone: posturing of spastic muscles, decreased tone: flaccid muscles d. Gross postural changes: side-to-side differences, front to back differences B. Reflexes Grading Description R L 0/4 Absent reflex (Areflexia) 1/4 Diminished but present (Hyporeflexia) Brachior. Biceps 2/4 Normal reflex Triceps 3/4 Hyperactive (Hyperreflexia) 4/4 Hyperreflexia w/ clonus (Achilles & Patella only) Patellar Plantar Reflex (Circle Arrow): Flexor / Extensor /Equivocal Finger Flexor Reflex/Hoffman’s (Circle One): Positive or Negative Achilles Ankle Clonus (Circle): Positive or Negative; R or L C. Upper Extremity Manual Muscle Strength Testing (Grading 1-5/5) UE: SAbd SER SIR EF WE WF EE LFF ADM FDI APB C5 C5 C5 C5 C6 C7 C7 C8 T1 T1 T1 Right Left SAbd: Shoulder Abduction SER: Shoulder Ext.Rot. SIR: Shoulder Int.Rot. EF: Elbow Flexion EE: Elbow Extension WF: Wrist Flexion WE: Wrist Extension LFF: Long Finger Flexion ADM: Abd. Digiti Minimi FDI: First Dorsal Interosseus APB: Abductor Pollicis Brevis D. Lower Extremity Manual Muscle Strength Testing (Grading 1-5/5) LE: HF HE KF KE HAbd HAdd ADF EHL APF A Inv. A Ev. L2 S1 S1 L3 L4-S1 L2-4 L4 L5 S1 L5-S1 L4-L5 Right Left HF: Hip Flexion HE: Hip Extension KF: Knee Flexion KE: Knee Extension HAbd: Hip Abduction HAd: Hip Adduction ADF: Ankle Dorsiflexion EHL: Extensor Hallucis Longus A. inv.: Ankle Inversion A Ev.: Ankle Eversion APF: Ankle Plantarflexion E. Sensory (Grading 2 = normal; 1 = impaired; 0 = absent) Level Light Touch R L Level Light Touch R L C3 Supraclavicular Fossa L2 Medial Anterior Thigh C4 Top of AC Joint L3 Medial Anterior Knee C5 Lateral Antecubital Fossa L4 Medial Malleolus C6 Dorsal, Proximal Thumb L5 Medial Dorsal Foot C7 Dorsal, Proximal 3rd Finger S1 Inferior Lateral Malleolus C8 Dorsal, Proximal 5th Finger S2 Popliteal Fossa T1 Medial Antecubital Fossa S3 Ischial Tuberosity 2 Neuro Exam © 2018 Des Moines University II. Reflexes A. Deep Tendon Reflexes (Muscle-Stretch Reflexes) C5: Biceps Brachii Reflex 1. The patient is sitting up straight with the arm at the side of the body and the back of the wrist resting on the thigh. 2. Find the tendon of the biceps brachii muscle with your thumb and press down so as to put the tendon on stretch. 3. Hit the distal knuckle of your thumb with the rubber head of your reflex hammer to elicit the biceps brachii reflex. 4. If no reflex is found, consider augmentation (have the patient hold the forearm in the air instead of resting on the thigh) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. C6: Brachioradialis Reflex 1. The patient is sitting up straight with the arm at the side of the body and the back of the wrist resting on the thigh. 2. Have the patient relax their forearm and wrist on their thigh. 3. Hit the brachioradialis tendon as it courses over the radius. a. You may use an indirect technique by placing your thumb or index finger over the tendon and hitting your finger instead. 4. You are looking for ELBOW FLEXION when testing the brachioradialis reflex. Movement of the wrist does NOT correspond to this reflex. 5. Be careful not to over-test this reflex due to the risk of causing transient injury to the radial nerve. If there is discomfort for the patient, place your finger over the tendon and hit your finger with the hammer. 6. If no reflex is found, consider augmentation (have the patient hold the forearm in the air instead of resting on the thigh) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. C7: Triceps Reflex 1. Hold the patient’s arm with a FLAT hand on the biceps muscle rather than the web of your hand so as to prevent the dampening of the reflex response. 2. Have the patient relax their arm and shoulder. 3. Hit the triceps tendon before it crosses the elbow joint, being cautious not to hit the ulnar nerve (a.k.a. “funny bone”). 4. If no reflex is found, consider augmentation (have the patient hold the forearm up slightly) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. © 2018 Des Moines University Neuro Exam 3 (Cont.) Deep Tendon Reflexes (Muscle-Stretch Reflexes) L4: Patellar Reflex 1. Locate the patellar tendon between the patella and the tibial tuberosity. Avoid hitting these two bony structures as it may be painful for your patient. 2. Use the metal shaft of the reflex hammer to elicit this reflex. 3. If no reflex is found, consider augmentation (have the patient push with the leg slightly on one finger) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. S1: Achilles Reflex 1. By placing your hand on top of the foot and close to the ankle when testing the Achilles reflex, you can monitor the tendons crossing the ankle joint and detect if the patient is helping you by dorsiflexing their foot. For accurate results, the patient must be completely relaxed. 5. Use the metal shaft of the reflex hammer to elicit this reflex. 6. If no reflex is found, consider augmentation (have the patient push down with the foot slightly) a. Then if a reflex is obtained during augmentation,
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