Faculty of Medicine Siriraj Hospital Mahidol University Neurological Society of Thailand Approach to Weakness Naraporn Prayoonwiwat, M.D. Neurology Division, Department of Medicine Siriraj Hospital [email protected] 02 419 7101-2 Neurologic Evaluation Weakness Clinical data gathering History Physical examination: motor system: tone/power; reflex cranial nerves sensory system Interpretation, localization Upper versus lower motor neuron Motor pathway: cortex to muscle d NP Neurologic Evaluation General Concepts Clinical data gathering History ✔︎Chief complaint: clearly defined Present illness: as much as possible ✔︎- Quality of symptoms - Location distinctive features e.g. character, severity, etc. ✔︎- Time course onset: abrupt or insidious subsequent course: improving, d NP worsening, exacerbation-remission Neurologic Evaluation General Concepts Sudden: Progressive:Clinical data gathering - stroke - tumor History - trauma - degenerative ✔Chief complaint: clearly defined Present illness: as much as possible Paroxysmal: Relapsing-remitting: ✔ --epilepsyQuality of symptoms- multiple sclerosis --syncopeLocation distinctive- neuromyelitis features optica e.g. - periodic paralysis character, severity, etc. ✔--transientTime course ischemic attackonset: abrupt or insidious subsequent course: improving, d NP worsening, exacerbation-remission Neurologic Evaluation General Concepts Clinical data gathering History e.g.: exertion (fatigue) Present illness: ✔︎- Factors precipitating/aggravating/ alleviating symptoms systemic ✔︎- Associated symptoms neurologic d NP Neurologic Evaluation General Concepts Clinical data gathering History Past medical history: - illnesses - operations - medication ✔︎- immunization Diet, tobacco, alcohol, substance abuse d NP Neurologic Evaluation General Concepts ClinicalVaccine data: protective gathering against organisms Historycausing neurologic disorders (e.g. Past poliovirus,medical history: tetanus, rabies virus, - illnessesJapanese encephalitis- operations virus, - medicationmeningococcal,✔︎- immunizationpneumococcal, Diet, Hemophilustobacco, alcohol,influenzae substance abuse Post vaccination: immunological reactions i.e. ADEM (Acute Disseminated EncephaloMyelitis d NP Neurologic Evaluation General Concepts Clinical data gathering Family history: First degree relatives: parents, siblings, children Second degree relatives: grandparents, grandchildren Social history: education, occupation d NP Neurologic Evaluation General Concepts Physical examination Mental status ✔︎ Cranial nerves ✔︎ Motor function ✔︎ Reflexes Sensory function Coordination Gait and stance d NP Neurologic Evaluation Weakness Inspection Muscle tone: tension of a muscle at rest examination interpretation Muscle power examination grading system interpretation d NP Neurologic Evaluation Weakness ✔︎ Inspection - Compare both sides Muscle tone:- tensionLook for of muscle a muscle atrophy, at rest asymmetry examination interpretation Muscle power examination grading system interpretation d NP Neurologic Evaluation Weakness Inspection ✔︎ Muscle tone: tension of a muscle at rest examination interpretation Muscle power examination grading system interpretation d NP -NeurologicCompare both Evaluation sides - AlwaysWeakness check for tone i.e. Inspectionresistance to passive movement (muscles relaxed) Muscle tone: tension of a muscle at rest ✔︎ -Tone:Avoid exertupper pressure limbs directly examinationupon muscles interpretation- hold one hand in the “shake hands” position Muscle power examination- support at the elbow grading systemelbow flex/extend interpretationforearm supinate/pronate - hold forearm above the wrist wrist flex/extend d NP -NeurologicCompare both Evaluation sides - AlwaysWeakness check for tone, i.e. Inspectionresistance to passive movement (muscles relaxed) Muscle tone: tension of a muscle at rest ✔︎ -Tone:Avoid lowerexert limbspressure directly examinationupon muscles interpretationhand on knee, “roll” each knee from side to side Muscle power hands under knee, “snap” examination lifting, observe the heel grading system interpretation d NP Neurologic Evaluation Weakness Inspection Muscle tone: tension of a muscle at rest examinationTone: ✔︎ interpretationHypotonia >> flaccid Muscle powerNormotonia examinationHypertonia: spasticity, rigidity grading system interpretation d NP Neurologic Evaluation Weakness Inspection Muscle tone: tension of a muscle at rest examination interpretation Muscle power ✔︎ examination grading system interpretation d NP Upper limbNeurologic Evaluation Shoulder DeltoidWeakness (abduction) ElbowInspectionBiceps (flexion) Muscle tone:Brachioradialis tension of a(flexion) muscle at rest examinationTriceps (extension) Radio interpretation- Pronator ulnar Supinator Muscle power ✔︎Wrist Flexor examinationExtensor Finger grading Handgripsystem (flexion) interpretationExtensor Dorsal interossei (adduction) Palmar interossei (abduction) d NP Upper limbNeurologic Evaluation Weakness -ShoulderDeltoid: ExertDeltoid pressure (abduction) close to ElbowInspectionelbow Biceps (flexion) -MuscleBiceps: tone:PlaceBrachioradialis tension one hand of aat(flexion) muscle patient at’s rest examinationshoulderTriceps to stabilize (extension) -RadioTriceps:interpretation- TestPronator with arm extended is ulnar Supinator Muscleless painful power than with arm flexed ✔︎Wrist Flexor examinationExtensor Finger grading Handgripsystem (flexion) interpretationExtensor Dorsal interossei (adduction) Palmar interossei (abduction) d NP Neurologic Evaluation Weakness MRC Muscle power examination grading system interpretation Triceps Extend elbow Elbow extension against resistance d NP Upper limbNeurologic Evaluation Weakness -ShoulderDeltoid: ExertDeltoid pressure (abduction) close to ElbowInspectionelbow Biceps (flexion) -MuscleBiceps: tone:PlaceBrachioradialis tension one hand of aat(flexion) muscle patient at’s rest examinationshoulderTriceps to stabilize (extension) -RadioTriceps:interpretation- TestPronator with arm extended is ulnar Supinator Muscleless painful power than with arm flexed ✔︎-WristPronatorFlexor sign to detect mild weakness examinationExtensor Finger grading Handgripsystem (flexion) interpretationExtensor Dorsal interossei (adduction) Palmar interossei (abduction) d NP Upper limbNeurologic Evaluation Weakness -ShoulderDeltoid: ExertDeltoidPronator pressure (abduction) sign close to Position:ElbowInspectionelbow Biceps (flexion) --MuscleraiseBiceps: both tone:PlaceBrachioradialis arms tension one forward hand of aat(flexion) muscle patient at’s rest -fullyexaminationshoulder extendTriceps to andstabilize (extension)supinate both arms --RadiofullyTriceps:interpretation -extend TestPronator and with abduct arm extended fingers is ulnar Supinator -Musclecloseless painfulthe power eyes than with arm flexed -WristPronatorFlexor sign to detect mild weakness Interpretation:✔︎ examination test positive if - arm driftExtensor down grading system Minimal arm -Fingerelbow flexHandgrip (flexion) interpretation weakness - forearm pronateExtensor - wrist andDorsal fingers interossei flex (adduction) Palmar interossei (abduction) d NP Lower limbNeurologic Evaluation Hip GluteusWeakness maximus (extension) InspectionIliopsoas (flexion) Muscle tone:Adductor tension of a muscle at rest examinationAbductor Knee interpretationQuadriceps (extension) Hamstring (flexion) Muscle power ✔︎Ankle Gastrosolieus (extension) examinationTibialis anterior (flexion) gradingTibialis system posterior (inversion) interpretationPeroneii (eversion) Toe Flexor Extensor d NP Lower limbNeurologic Evaluation Hip GluteusWeakness maximus (extension) InspectionIliopsoas (flexion) MuscleHints: tone:Adductor tension of a muscle at rest -examinationAvoid Abductorpressing on the thigh Knee-interpretationUse theQuadriceps knee as pressure (extension) point Hamstring (flexion) Muscle power ✔︎Ankle Gastrosolieus (extension) examinationTibialis anterior (flexion) gradingTibialis system posterior (inversion) interpretationPeroneii (eversion) Toe Flexor Extensor d NP Neurologic Evaluation Weakness Grade Character Inspection 0 No movement Muscle tone: tension of a muscle at rest 1 Minimal movement examination 2 Horizontal movement interpretation3 Against gravity, unsustain Muscle4 powerAgainst resistance, partial examination5 Against resistance, strong (normal) ✔︎ grading system Gradinginterpretation system: Medical Research Council (MRC); UK d NP Neurologic Evaluation Weakness Inspection Muscle tone: tension of a muscle at rest examination interpretation Muscle power examination grading system ✔︎ interpretation d NP Neurologic Evaluation Weakness Patterns of weakness Inspection - pyramidal weakness Muscle- proximal tone: weakness tension of a muscle at rest Pyramidal weakness: - examinationdistal weakness upper limb: flexor group stronger -interpretationspecific pattern “decorticate posture” Musclelower limb: powerextensor group stronger examination: upper motor neuron (UMN) grading: corticospinal system tract lesion ✔︎ interpretation d NP Neurologic Evaluation Weakness Patterns of weakness Inspection - pyramidal weakness Muscle- proximal tone: weakness tension of a muscle at rest - examinationdistal weakness Proximal weakness: -interpretationspecific pattern more weakness of proximal group Muscle(arms power and legs) examination: muscle disease e.g. gradingmetabolic system myopathy ✔︎ interpretationmyositis : neuromuscular junction d NP Neurologic