James Wight

Examination of the Peripheral Neurological System

Upper limb
Inspection
• Observe for muscle wasting, fasciculations, tremor and abnormal posture. • Ask pt to hold arms at 90°, then shut eyes. Observe for pronator drifting – indicates upper motor neuron pathology

Tone
• Ask patient to completely relax and go floppy • Flex, extend, supinate and pronate wrist and elbow in one fluid movement.

Power
Shoulder Elbow Wrist Fingers Ask patient to make ‘chicken wings’. Push down on their upper arm (testing C5), and push up on their upper arm (testing C6,7,8) Ask patient to put their fists up as if for a fight. Ask them to pull you towards them (testing C5,6), and push you away from them (testing C7,8). Ask patient to extend (testing C6,7) and flex (testing C6,7) against resistance. Ask patient to extend (testing C7,8), flex (testing C7,8) abduct (testing T1), adduct (testing T1) and oppose (testing T1) their fingers against resistance or using a piece of card. Remember to include thumb abduction (90° to palm) and adduction (consider Froment’s sign).

Reflexes
Biceps Supinator Triceps Finger jerk Hoffman Ask the patient to extend their arm, and place one finger on biceps tendon and tap. Tests C5/6 Place one finger over the watch-strap area, and tap. Tests C5/6 Ask patient to place their arm across their abdomen, and tap the triceps tendon, observing the triceps muscle. Tests C7/8 Holding the patient’s fingers hooked beneath your own, tap your own fingers and feel for contractions of the patient’s fingers. Tests C7-T1 The terminal phalanx of the index finger is flicked, while observing for jerking of the thumb

Reinforcement – if reflexes are difficult to elicit, ask patient to clench teeth when you tap.

Coordination
Finger to nose test Dysdiadokinesia Ask the patient to point to their nose, and then reach out to point to your index finger. Ensure that they fully extend their elbow while doing this. Look for intention tremor and over-reaching (indicative of cerebellar pathology) Ask the patient to place one hand on top of the other, and turn the top hand from palm-up to palmdown repeatedly as fast as possible. Inbility to perform this properly is indicative of cerebellar pathology.

Sensation
Sensory loss can be described according to modality (ie pain and temperature loss, or fine touch and proprioception loss) and according to distribution (ie glove and stocking, dermatomal, named nerve or sensory level). Ask patient to shut their eyes during these tests to avoid cheating. “Glove and stocking loss” Using light touch, moving up the arm and ask if sensation changes. Glove and stocking loss is classically seen in diabetes mellitus. Dermatomal loss Test each dermatome Named nerve Test at the index finger medial side (median N), little finger lateral side (ulnar N) and skin overlying the 1st interosseous space (radial N). Sensory level If necessary, work up the sensory levels until sensation is felt

Pain & temperaure Touch Vibration Proprioception

Test using a neurotip. Don’t bother about temperature. Test using monofilament, cotton wool or your finger Test using 128Hz tuning fork Test by holding the distal IP joint and telling the patient which way is up and down, before assessing proprioception. This is often the first modality lost in diabetics.

Lower limb
Inspection
• Ask the patient to walk, observing gait (antalgic, high-stepping, Parkinsonian, Trendelenburg) and hand movements. • Ask patient to walk heel-to-toe (screening for cerebellar pathology). • Ask the patient to shut their eyes while standing with feet together (keeping close to them in case they fall) to assess proprioception (Romberg’s test). • Ask patient to stand up on tiptoe (good screening test for muscle power). • Ask patient to squat and then stand (good screening test for proximal myopathy) • Observe for muscle wasting, fasciculations, tremor, abnormal posture and signs of diabetic foot (ulceration, infection).

Tone
• Ask patient to completely relax and go floppy • Roll the leg from side to side, observing for a ‘stiff foot’ (which would indicate increased tone) • Lift the leg up from the knee, observing for foot coming off the bed (which would indicate increased tone). • Test for clonus by rapidly dorsiflexing the foot (with the knee flexed and hip externally rotated) and holding it in that position for several seconds. 1-2 beats of clonus is normal.

Power
Hip Knee Ankle Big toe Ask patient to raise their leg off the bed, and resist you pushing down on it (testing L2/3). Ask patient to push their leg into the bed, and resist you pulling up on it (testing L4/5). Ask patient to flex their knee to 90°. Ask them to try to extend their knee against resistance (testing L3/4) and flex their knee against resistance (testing L5/S1). Ask patient to dorsiflex (testing L4/5) and plantarflex (testing S1/2) against resistance. Ask patient to extend big toe (testing S1)

Reflexes
Knee Ankle Babinski With knees flexed to 90°, tap the patellar tendon A. Tap the Achilles tendon or B. Dorsiflex the foot and tap your own fingers Run an orange stick or thumbnail up the lateral aspect of the sole of the foot, moving medially at the toes, and observe the first movement of the big toe (normal is downwards movement).

Reinforcement – if reflexes are difficult to elicit, ask patient to hook fingers and pull when you tap (the Jendrassik manoeuvre).

Coordination
Heel to shin test Toe to finger test Dysdiadokinesis Ask the patient to rub their heel up and down the contralateral shin Ask the patient to place their big toe on your finger Ask patient to tap their feet as fast as possible against your hand

Sensation
As above, testing for glove and stocking, dermatomal or sensory level loss, plus loss of different sensory modalities. Start with proprioception (according to OSCE matrix).

Remember to assess pulses if Diabetes Mellitus is suspected.

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