Assessment of Neurological Conditions Self Directed Learning Pack (MED-CMEP~119) 4th September 2018 Assessment of Neurological Conditions Foreword This training has been produced as part of a training programme for Healthcare Professionals (HCPs) who conduct assessments for the Centre for Health and Disability Assessments on behalf of the Department for Work and Pensions. All HCPs undertaking assessments must be registered practitioners who in addition, have undergone training in disability assessment medicine and specific training in the relevant benefit areas. The training includes theory training in a classroom setting, supervised practical training, and a demonstration of understanding as assessed by quality audit. This training must be read with the understanding that, as experienced practitioners, the HCPs will have detailed knowledge of the principles and practice of relevant diagnostic techniques and therefore such information is not contained in this training module. In addition, the training module is not a stand-alone document, and forms only a part of the training and written documentation that the HCP receives. As disability assessment is a practical occupation, much of the guidance also involves verbal information and coaching. Thus, although the training module may be of interest to non-medical readers, it must be remembered that some of the information may not be readily understood without background medical knowledge and an awareness of the other training given to HCPs. MED- CMEP~119 Page 2 of 79 Assessment of Neurological Conditions Document control Superseded documents Assessment of Neurological Conditions for Registered Nurse (Pre-course Reading) – MED-RNEXNEURO~001(a) Version history Version Date Comments 6 Final 10th January 2017 Signed off by SH&S 7a draft 18th December 2017 Review and update 7 Final 25th May 2018 Final document 8a Draft 26th July 2018 Update in line with neuro examination best practice CME 8 Final 2nd August 2018 Final document 9a Draft 4th September 2018 Anatomical update 9 Final 4th September 2018 Signed off by SH&S Changes since last version Page 17 – diagram of wrist extension and flexion updates Page 19 – wrist flexors and extensors updated Outstanding issues and omissions Updates to Standards incorporated Issue control Author: Clinical Training Team Owner: Department for Work and Pensions MED- CMEP~119 Page 3 of 79 Assessment of Neurological Conditions Contents Introduction 6 Guide to using this Learning Pack 6 Section One – Neuroanatomy and Neurophysiology 9 Cells, Neurons and Neuromuscular Junctions 9 Central Nervous System 11 Peripheral Nervous System 14 Autonomic Nervous System 18 Reflexes 20 Upper Motor Neuron versus Lower Motor Neuron Lesions 21 Section Two - Neurological Examination 24 History 24 Observation 25 Examination 26 Inspection 26 Testing the Motor System 26 Tone 26 Power 27 Reflexes 28 Testing the Sensory system 33 Section Three - Specific Conditions 39 Prolapsed Intervertebral Disc and Sciatica 40 Cervical Spondylosis 45 Peripheral Neuropathy 49 Nerve Compression Syndromes / Focal Neuropathy 54 Median nerve (carpal tunnel syndrome) 54 Ulnar Nerve 57 Radial Nerve 58 Common Peroneal Nerve 59 Lateral Cutaneous Nerve of the Thigh 60 MED- CMEP~119 Page 4 of 79 Assessment of Neurological Conditions Brachial Plexus Injuries 61 Thoracic Outlet Syndrome 62 Raynaud’s phenomenon, Hand-Arm Vibration Syndrome and Vibration White Finger 69 Raynaud’s phenomenon 69 Hand-Arm Vibration Syndrome (HAVS) 70 Vibration White Finger (VWF) 70 Further Reading 71 Glossary 73 Learning Experience and Reflections Note 78 Observation Form 79 MED- CMEP~119 Page 5 of 79 Assessment of Neurological Conditions Introduction Welcome to this self directed learning module on the Assessment of Neurological Conditions. Neurological symptoms and conditions are common, resulting in disability in approximately 1 in 50 of the UK population. Approximately 10% of GP consultations are about a neurological symptom.1 The nervous system is the most elaborate bodily system. The field of neurology is correspondingly vast and complex. Neurological conditions can range from the simple to the highly complicated. The neurological system is therefore one of the most difficult systems to fully examine and assess. The focus for this training will be on some of the more common neurological conditions that are seen within our sphere of work. During the filework process of the Work Capability Assessment, advice is given on the appropriate practitioner type to complete the assessment for any cases called for a face-to-face assessment. Currently complex neurological cases are usually assessed by Registered Medical Practitioners and Registered Physiotherapists. HCPs should be aware of the document ‘Neurological Condition list by Practitioner type’ and any relevant Update to Standards, available on the internal online knowledge portal, to ensure that the current guidance on conditions which are suitable to be assessed by the various practitioner types is followed. Learning Pack Objectives Through completion of this learning pack, you should enhance your knowledge of: Neuroanatomy and neurophysiology Neuro-terminology Neurological examinations required in the context of disability assessments Specific neurological conditions Guide to using this Learning Pack Any case examples in this Learning Pack are fictitious and have been solely designed to support learning activities. There is a glossary at end of this Learning Pack which you may find useful. It contains definitions of neurological and medical terms used within this Learning Pack. 1 https://www.nice.org.uk/guidance/gid-cgwave0800/documents/final-scope (Accessed online 26/7/18) MED- CMEP~119 Page 6 of 79 Assessment of Neurological Conditions A Learning Experience and Reflections Note is provided at the end of the Learning Pack to aid reflective practice. The following symbols are used to assist you in completing the learning activities included in this Learning Pack: Indicates you should record / write your views and comments Suggests the approximate time needed to complete any particular learning activity Learning Pack Information for Registered Nurses and Registered Occupational Therapists This Learning Pack is intended as Pre-course reading for the neurological examination training course for Registered Nurses and Registered Occupational Therapists who are already trained and approved in performing face-to-face Work Capability Assessments (WCA). Following completion of this reading you will progress to a facilitated learning event. Within each section there are several questions with text boxes to assist self reflection and aid learning. You should make a note of your answers and bring this document with you to the facilitator-led event. All the answers are found in the body of text, but you should first attempt to recall the information before reviewing the main body of text to check for definitive answers. These may be discussed further during the facilitator-led event. You also have to complete and pass a Multiple Choice Questionnaire (MCQ) before attending the facilitator-led event. The MCQ is completed online and you will receive an automatic e-mail, to your work e-mail address, from ‘The Test Factory’ containing the link to access this. If you do not receive this e-mail, please contact your Training Support Manager in your local Business Support Centre (BSC). The MCQ is split into sections and once you have completed reading each small part of this pre-course reading document, you will need to complete the relevant MCQ for that particular part. You are allowed access to your reading material at all times; the tests are all ‘open book tests’. There are 53 questions in total. Once you have completed all the parts of the MCQ test, your score will be automatically displayed. A score of 84% (45 questions correct) or above indicates a pass. If you fail the MCQ, you will be allowed to re-sit the test once. You will need to contact the Training Support Manager in your local BSC to arrange re-assignment of the test. Once the test has been re-assigned to you, you will receive a further e-mail from the Test Factory with the link to access the on-line re-sit. You should however re-read the pre-course reading before attempting the re-sit of the test. MED- CMEP~119 Page 7 of 79 Assessment of Neurological Conditions This pre-course reading must be read and the online MCQ completed and passed prior to attending the facilitator-led event. If the MCQ is not completed, or a satisfactory score in the MCQ is not reached, then you will not be able to progress to the facilitator-led event. This facilitator-led event will not cover the majority of the topics in the pre-course reading again, but will build on the knowledge within this document to develop the skills necessary to assess claimants with specific neurological conditions. It is anticipated that this pre-course reading and associated questions will take you about 3.5 hours in total. You may find it easier to break the reading into smaller amounts. 3.5 CPD points are allocated for the completion of this pre-course reading and associated questions. Learning Pack Information for Registered Medical Practitioners and Registered Physiotherapists This Learning Pack is intended as a neurological update for all Registered Medical Practitioners and Registered Physiotherapists. As Registered Medical Practitioners and Registered Physiotherapists, you should be more familiar with neurological terminology, examination and conditions, and therefore this Learning Pack should take you approximately 3 hours to complete. This includes 20 minutes for the completion of a Multiple Choice Questionnaire. This Learning Pack can be completed in one go or at smaller separate “sittings”. It is important that you complete learning activities in the order they are given; by doing so you will reflect, consolidate and build on your learning throughout. You will be asked to interact at various stages during this learning opportunity – writing your responses in the boxes provided – all answers are found in the body of text, but you should first attempt to recall the information before reviewing the main body of text to check for definitive answers.