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The University of Newcastle

Faculty of Medicine and Health Sciences


Bachelor of Medicine
Year 2

Professional Skills

Neurology

YEAR TWO

Prepared by:
Dr I Kerridge
Dr M Parsons
Dr D Williams

THE NEUROLOGICAL EXAMINATION


CONTENTS

Page

NEUROLOGY: PROFESSIONAL SKILLS..............................................................................3


MENTAL STATUS EXAMINATION........................................................................................4
HIGHER CENTRES..................................................................................................................5
SPEECH.....................................................................................................................................6
GAIT 8
CRANIAL NERVES..................................................................................................................9
UPPER LIMBS........................................................................................................................14
LOWER LIMBS.......................................................................................................................17
CEREBELLAR........................................................................................................................20

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NEUROLOGY: PROFESSIONAL SKILLS

The neurological examination may be divided into a number of parts. These are:
1.

MMSE

2.

Higher Centres

3.

Speech

4.

Cranial Nerves

5.

Gait

6.

Cerebellar

7.

Upper limb

8.

Lower limb

Crossover

There is a huge amount of information that can be elicited in a neurological


examination, but a fairly complete examination can be done in 10-15 minutes if the examiner is
well-practised.
The general approach to neurological short case examinations is for the candidate to:
1.

Listen to the examiner.

2.

Be sensitive to the patient. This includes talk to the patients and making any
commands clearly. In many cases the exact wording of commands needs a lot
of practise.

3.

Inspect :

skin, scars
posture
drips/catheters
face
involuntary movements
voice.

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4.

Palpation

5.

Tone

6.

Power

7.

Reflexes

8.

Co-ordination

9.

Sensation

The aim of the neurological examination is to recognize various patterns of signs that allow
you to decide:
1.

What are the findings on examination? e.g.

Hemiparesis

2.

Where is the lesion(s)? e.g.

Cortex

3.

What is the underlying cause? e.g.

CVA

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MENTAL STATUS
EXAMINATION

Folsteins Mini-Mental State Examination (MMSE)


The mini-mental state examination is a test of cognitive dysfunction. It is important
that a low score on a mini-mental state exam should not automatically lead the examiner to
state that the patient has dementia because there are a number of reasons why a person might
have cognitive dysfunction, including delirium and dementia and depression.
The major dificulty with using the MMSE is that the normal range of scores varies
with age and educational level. For example, the median score for a 50 year old with some
higher education is 30 (and the 25th percentile is 28), whereas the median score for n 85 year
old with less than 4 years education is 20 ( and the 25th percentile is 15).
Tables of normal values for the MMSE are available (see for example Crum RM,
Anthony JC, Bassett SS et al. Population-based norms for the Mini-mental State examination
by age and educational level. JAMA 269: 2386-91, 1993., however most clinicians appear to
simply remember a cut off score of about 23 in which those above are thought of as normal
and those below are thought of as impaired. If this approach is used, it must be supplemented
by the examiner -carefully looking at the responses to each question and asking if the response
is consistent with the age and educational level of the patient. For example, a professor of
English literature who cannot spell the word world backwards, has clearly got a degree of
cognitive decline, whereas an illiterate labourer wit the same answer may be perfectly normal.
There are a number of other problems with the MMSE that the user should be aware
of. Some questions are known to be a little unclear, (for example the marking of question 4 is
unclear), and no time limit. Furthermore, other ethnic groups are known to score badly on
some items compared to English speakers (including season, county, spelling, serial
subtraction, and no ifs ands or buts) Some of the questions need to be modified slightly for
other countries (ie county has no meaning in Australia.)
With these limitations in mind, the MMSE is a useful screening test for cognitive
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dysfunction.

Specific Test

Function and Area Tested

Points

1. What is the year/season/day/date/month?

Orientation (frontal)

2. What is the state/county/town/

Orientation (frontal)

3. Repeat three items

Registration (frontal)

4. Serial subtraction of sevens or spell

Concentration (frontal)

Naming (dominant

Score

hospital/floor?

World backwards
5. Name wristwatch and pen

Temporoparietal)

6. Say no ifs, ands, or buts

Expressive speech (dominant

frontal)
7. Take this paper in your right hand, fold it
in half and put it on the table.

8. Read close your eyes and do it

Three-stage command

(frontal)

Reading (dominant

temporoparietal)
9. Remember the three items from
Part 3 above

10. Write a sentence

Short-term memory

(dominant hippocampal)

Writing (dominant

temporoparietal)

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11. Copy intersecting pentagons

Construction (non-

dominant parietal)

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There are a number of alternative tests to the Folsteins MMSE including the Blessed Six
Item Orientation-Memory-Concentration Test.

Total score:

< 8 - normal or minimal impairment;


9 to 19 - moderate impairment;
> 20 - indicates severe impairment.

Reference: Katzman et al American Journal of Psychiatry 140 (1983) 6.

Item

Number of

Score given

errors

for each error

Score

possible

1. What YEAR is it now?

x4

2. What MONTH is it now?

x3

3. About what TIME is it? (Within 1 hour)

x3

4. Count backwards 20 to 1

x2

5. Say the months in reverse order

x3

6. Repeat the memory phrase

x2
TOTAL

/30

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HIGHER CENTRES EXAMINATION

1.

ASK PATIENT IF LEFT OR RIGHT-HANDED:


The text books have very conflicting data about handedness and dominance. One often

quoted figure is :
94% Right-handed persons

Dominant Left hemisphere

60% Left-handed persons

Left dominant

30% Left-handed persons

Mixed dominant

10% Left-handed persons

Right dominant

however there are many other figures suggested. In general, the important fact is that almost
all right handed people have left hemisphere dominance, but that some left-handed people have
right or mixed dominance.

2.

ORIENTATION (MMSE)

3.

SPEECH

4.

PARIETAL LOBE FUNCTION

DOMINANT

: "Gerstmanns"

Acalculia/Agraphia/Left-Right
disorientation/Finger Agnosia

NON-DOMINANT

: Spatial neglect (clockface)/Apraxia (PJ's, house)

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NON-LOCALIZING : Inattention (sensual and visual)/Homonomous


hemionopia.
Cortical sensory loss i.e. Proprioception, 2-point
discrimination, Inattention (visual and sensory),
Touch-localisation, Graphaesthesia (numbers),
Astereognosis (objects).
5.

OCCIPITAL

- Homonomous Hemianopia
- "Cortical" blindness (bilateral)
- Topographical amnesia
- Unable to

: recognize faces (prosopagnosia)


: read (alexia)
: recognize objects (visual agnosia)

6.

TEMPORAL
- STM loss (4 words: honesty, brown, tulip, eyedropper)
- LTM loss (AWhen did WWII start? ... finish?)
- Confabulation (Have we met before?)
- Dysphasia (receptive) and Nominal dysphasia (angular gyms of
temporal lobe)
- Upper Quadrant Hemianopia

7.

FRONTAL
- Anosmia

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- Proverb interpretation
- Gait ataxia (wide-based, shuffling)
- Primitive reflexes: grasp, pout, snout, suck, palmar-mental
- Incontinence
- Expressive dysphasia (Dominant: Broca's area)
- Personality change

: abulic (decreased initiation and spontaneity)


: impaired concentration/attention
: cannot pursue goals
: personality change
: disinhibition

SPEECH

Dysphasia

Disturbance in understanding or production of language.

Dominant hemisphere lesion.

Speech disorder is either fluent or non-fluent:

Fluent -

Sentences are of normal length and words flow


easily but words are used incorrectly and
speech is difficult to understand. Patient
uses paraphrasias,
e g : literal paraphrasia, verbal

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11

paraphrasia and/or neologisms.

Non-fluent -

Speech slurred and lacks fillers (and,


the, so, to) therefore sounds like a
telegram.

Most common dysphasias: expressive, receptive, conductive and


nominal.

Dysarthria

Difficulty with articulation.

Cerebellar disease, bulbar palsy, pseudobulbar palsy, extrapyramidal


disease. (Differentiation is difficult in terms of the quality of speech
alone. Diagnosis can usually be made by the associated neurological
abnormalities!).

Dysphonia

Altered quality of voice.

Laryngeal disease, recurrent laryngeal nerve palsy, hysteria,


myopathy.

To Test:

1.

Introduce yourself and shake hands.

2.

Free speech

How long have you been in hospital?

What sort of work do you do?

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3.

Comprehension

Do you understand what I am saying?

Close your eyes (1-step command).

With your right finger touch your nose and then


your ear (2-step command).

I would like you to pick up this piece of paper,


fold it in half and then place it back on the
bed/table (3-step command).

4.

Repetition/Dysarthria
assessment :

Please repeat after me......No ifs, ands or buts.


...West Register Street.
...British Constitution.

Repeat PUH (lip weakness), TUH (tongue) KUH


(palate).

5.

Naming objects

Shirt, sleeve, cuff, button.


Watch, band, face, hand, tell time.

6.

Reading

Read what it says on this card and do what it


says.

7.

Writing

Please write a sentence.

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TYPES OF DYSPHASIA

NON-FLUENT

FLUENT

EXPRESSIVE

RECEPTIVE

CONDUCTIVE

NOMINAL

Understands but cannot

Speech fluent but

Repeats statements and

Cannot name objects

answer.

disorganized. Unable to

names objects poorly but

but all other aspects

understand written or

can follow commands.

of speech normal.

spoken
words/commands.

SITE

BROCAS AREA

WERNICKES AREA

TEMPORAL LOBE

Dominant Posterior

Dominant Third Frontal

Dominant Temporal

Arcuate Fasciculus

Temporoparietal area:

Gyrus

First Gyrus

Linking W and B area.

Angular gyrus

NAMING

Poor

Poor

Poor

Poor

REPETITION

May be possible with

Poor

Poor

Normal

effort.

COMPREHENSION

Normal

Poor

Normal

Normal

READING

May have dyslexia

Neologisms paraphrasias

Poor

Normal

Abnormal content

Impaired

Normal

Gerstmanns

Paraphrasia

Use long sentences to

WRITING

OTHER

Hemiparesis

Hemianopia

overcome
word-finding
difficulty
(circumlocution)

GAIT

Complex.

For locomotion need

:Basal ganglia
:Locomotor Region (mesencephalon)
:Cerebellum
:Spinal cord
:Sensory input from joints/muscular afferents

1.

Ask ... "May I walk Mr/Mrs ....."

2.

Ask someone else to assist. YOU WATCH

3.

Observe:

posture
arm swing
stride
base
involuntary movements

4.

Tandem Gait (walk heel-to-toe)

5.

Rhombergs (Need 2 of 3: eyes, vestib, JPS)

6.

Screening:

Arms held in front with eyes closed + touch nose + lift arms up
straight and then down to the horizontal.

7.

Stand on toes

(weak gastrocnemius)

8.

Stand on heels

(foot-drop)

9.

Squat

(proximal myopathy)

+/10.

If suspect cerebellar:
1. Walk around chair (fall to side of lesion)
2. March on spot (unterbergers: turn to side of lesion)

COMMON GAIT DISORDERS

1.

High stepping

Unilateral foot drop

2.

High and slapping

1. Bilateral foot drop (Peripheral neuropathy, HMSN)


2. Sensory ataxia (MS, Tabes dorsalis, Spinocerebellar
Degeneration, sensory neuropathy)

3.

Waddling (shoulders swap/tilt trunk/flex knee + hip) Weak hip abductors (proximal
myopathy, OA)

4.

Hemiparetic: Arm flexed, foot extended, circumduction.

5.

"Scissor" (Spastic Paraparetic): both legs circumduct. (Cerebral Palsy, M.S.)

6.

Parkinsonian: (freeze, no arm swing, festination, propulsion, retropropulsion)

7.

Broad-based shuffle and small steps: (marche petit pas) [Normal Pressure
Hydrocephalus (Dementia, incontinence), Multi-infarct Dementia (Hyper-reflexic, brisk
jaw jerk).]

8.

Ataxic/ wide-based.

1.

Unilateral cerebellar (falls to side of lesion)

2.

Midline (staggers in all directions)

CRANIAL NERVES

CN 1: OLFACTORY
sensory
usually not tested
may wish to test in the presence of personality disturbance, hemiparesis or visual loss

Test each nostril separately (use easily recognized substance e.g. peppermint oil, oil of
cloves).

CN 2: OPTIC

1.

Observe

Level of eyelid-

Ptosis (CN 3 lesion, myasthenia,Horners)


-

Lid retraction

2.

Acuity :

Position of eye

Exopthalmos (Graves, tumour)

Enopthalmos (Horners)

(Using two acuity cards - patient may use glasses)


-

"What is the smallest line you can read?" (Snellen card)

If less than 6/60: Counting fingers


:Hand waving
:Perception of light and dark

3.

Gross visual fields/visual inattention: Finger confrontation.

4.

Visual fields (red pin)


Test with red pin:

White objects more easily seen than red.


Central vision Colour : cones
Peripheral vision B+W : rods
Therefore earlier peripheral loss with red pin.

Fig.1.

The visual pathways as seen from above the brain. Letters A-F refer to visual field defects following
lesions in the corresponding brain areas. Circles indicate
what the left and right eyes see (the left and right visual
fields). Black areas represent visual field defects.
A.

Constricted field left eye (e.g. end-stage glaucoma). When constricted fields are bilateral, it
sometimes signifies hysteria.

B.

Central scotoma (e.g. optic neuritis in multiple sclerosis).

C.

Total blindness of the left eye.

D.

Bitemporal hemianopia (e.g. pituitary gland tumor).

E.

Right homonymous hemianopia (e.g. stroke).

F.

Right superior quadrantopia.

5.

Blind spot (red pin)

6.

Pupils
Afferent

optic nerve

Efferent

PNS component of CN 3

20% difference in size -

Normal (Anisocoria)

Small pupil

SNS lesion

Large pupil

PNS lesion

: Light Reflex -

direct

consensual

: Accommodation

: Swinging light test:


Normal

Pupil always constricts

Abnormal

Pupil dilates to light

Afferent pupillary defect

Marcus Gunn pupil

Anterior to chiasm (optic neuritic or


compression of the optic nerve)

Fig. 2. The pathways for the pupillary light reflex and accommodation. LGB, lateral geniculate body. The
depicted lesions presumably also interrupt light reflex fibers crossing from the opposite side of the brian stem.
The pathway shown innervating the eye is highly schematic; the light reflex pathway involves only pupillary
constriction, whereas the accommodation pathway affects both pupillary constriction and ciliary body
accommodation.

7.

Fundoscopy using Opthalmoscope

: Red reflex

: Retina: Locate vessel: follow to disc then periphery


: Venous pulse : (at cup)
: Retinal background
: Dilate pupil with tropic amide (DO NOT USE IN GLAUCOMA)

CN 3: OCULOMOTOR

CN 4: TROCHLEAR

CN 6: ABDUCENS

Motor to eye
Autonomic
Eye movements have complex control including:

1. Saccadic/command (frontal)
2. Pursuit (occipital/parietal)
3. Vestibular/positional
(cerebellar/vestibular nuclei)

Test

1.

2.

Observe: position of head (head tilted away from the side of a CN 4 lesion).
:

eyelid (ptosis suggest CN 3 lesion or a Horners)

eye position (one eye looking up or down suggests skew deviation).

Screen:

Instruct patient to look up, look down, look to the left, look to the
right.

3.

Pursuit movements

: following a pin

4.

Saccadic movements

: finger to fist

5.

Accommodation/convergence

6.

Consider Cover Test

Note: *

: "Look in to the distance ... now at my finger"

Diplopia (double vision) is usually maximal in the direction of gaze of the


affected muscle. This indicates the abnormal cranial nerve.

In diplopia the false image is usually the outer image. This indicates the
abnormal eye,
e.g.

CN 6

Diplopia on lateral gaze.

CN4

Diplopia maximal looking down and in. Images


at an angle. Unable to look down and out.

Comment on Nystagmus

- Nystagmus defined in direction of fast movement.


- When testing take inward looking eye to edge of caruncle - any further
will cause physiological nystagmoid jerks.
- Peripheral (vestibular) disease causes symmetrical nystagmus with the
fast phase away from the side of the lesion. The fast phase remains in
the same direction despite the direction of gaze. The amplitude of
nystagmus is sometimes increased by looking in the direction of the fast
phase.
- Central (brainstem) disease cause asymmetrical nystagmus. It is
rotatory or vertical (always implies brainstem dysfunction in the absence
of drugs) and may demonstrate fast phase changes with change in gaze
direction.

- Cerebellar disease classically cause nystagmus with the fast phase


towards the side of the lesion, however, there is often distortion of the
brainstem and nystagmus may be much more complex. Vermis lesions
can cause up-beating nystagmus.

Internuclear opthalmoplegia: eye movements frequently normal when each eye


tested individually but abnormal when pursuit movements are tested together.
e.g.

Left INO :

Left eye fails to adduct


Right eye develops nystagmus

Fig.3. The pathway for lateral conjugate gaze.


PPRF - pontine paramedian reticular formation.

CN 5: TRIGEMINAL

Sensorimotor
Motor to temporalis and masseter sensory to face.
Large sensory nucleus extending from Pons to upper cervical cord: light touch in
Pons, pain/temparature in Medulla/cervical. (Therefore pontine lesions may
demonstrate loss of light touch with preservation of pain and temperature.

Test:

1.

Corneal reflex (CN5 to feel CN7 to blink)

2.

Sensation: (Test pin-prick/soft-touch in each of the three anatomical


divisions - opthalmic, maxillary and mandibular).

3.

Motor:i Clench your jaw. Palpate temporalis/masseter bulk.


ii

Strength of jaw opening. Hold your jaw open. (Look


for deviation to the side of weakness.)

iii Jaw-jerk.

Fig.4. Trigeminal nerve sensory dermatomes.

CN 7 :

FACIAL

Sensory, motor, autonomic


Motor :

Facial musculature

Ear

Tensor tympani and stapedius

Taste :

( via chordae tympani) to the anterior 2/3 of the tongue.

Test:

1.

"Smile"

2.

"Show me your teeth"

3.

"Screw up your eyes"

4.

"Look up to the ceiling"

5.

"Whistle"

6.

"Blow out your cheeks"

CN 8 :

AUDITORY

Auditory/vestibular function.

Test:

1.

Hearing

: Whispering numbers (at arms length whilst occluding


the opposite ear).

2.

Webers

: 512 Hz tuning fork held on the centre of the head.


"Where is it louder?"

3.

Rinne's:

512 Hz tuning fork held on the mastoid then in front of


the ear to test bone and air conduction. Normally air
conduction better than bone conduction.

4.

Vestibular

: Gait
Nystagmus

not usually part of CN exam

Caloric testing

WEBERS

RINNES IN DEAF EAR

Conductive Deafness

Heard in deaf ear

BC>AC

Sensorineural Deafness

Heard in normal ear

AC>BC

CN 9 :

GLOSSOPHARYNGEAL

Sensory

Posterior 1/3 of tongue, soft palate, pharynx.

Motor

Stylopharyngeus

Test

Gag reflex (bilaterally)

CN 10 :

VAGUS

Sensory

External ear

Motor

Palate, pharynx, larynx (via recurrent laryngeal)

Test

1.

Cough, voice quality

2.

"Say Ahh"- Observe soft-palate movement. If normal uvula


stays in midline
-

If weak uvula deviates (pulled over) to the


normal side.

3.

CN 11:

SPINAL ACCESSORY

Motor :

Test

Gag (Sensory - CN 9, Motor - CN 10)

Supplies

ipsilateral trapezium

ipsilateral sternomastoid

1.

Shoulder elevation (trapezius)

2.

Lateral head rotation (opposite sternomastoid)

3.

Pushing forehead forward against resistance (bilateral


sternomastoid, weakness, myopathy).

CN 12 :

HYPOGLOSSAL

Motor to tongue

Test

1.

Observe in mouth for wasting, fasiculations.

2.

Stick out the tongue: Tongue points toward (pushed) to the weak side.

3.

Test tongue strength.

UPPER LIMBS

1)

OBSERVE THE ENTIRE PATIENT

2)

SHAKE HANDS (Grip strength, co-ordination, myotonia)

3)

ASK PATIENT TO SIT ON THE EDGE OF THE BED

4)

INSPECT:

wasting (distal/proximal)
deformity
fasciculation
tremor

5)

HOLD OUT ARMS/EYES CLOSED

Drift -

UMN weakness

(down)

cerebellar

(up: hypotonia)

post column loss

(impaired JPS)

6)

PIANO PLAYING (SCREENING)

7)

PALPATE

muscle bulk
tenderness
thickened nerves

median:

wrist

ulnar

elbow

8)

TONE :

Clonus (> 3 beats)


Rigidity
Spasticity
Cog-wheeling

9)

POWER (GRADE 0 - 5)
SHOULDER:

Elevation

C3,4 + CN11

Abduction

C5 Deltoid (Axillary n.) + Supraspinatus

Adduction

C7 Pectoralis Major (Pectoral nerves)


Latissimus Dorsi

ELBOW:

WRIST:

Flexion

C6 Biceps (Musculocutaneous n.)

Extension

C7 Triceps (Radial n)

Thumb up

C6 Brachioradialis (Radial n.)

Flexion

C7 Flexor carpi ulnaris (Median)

Extension

C7 Extensor carpi radialis (Radial)


wrist drop.

FINGERS:

Extension

C8 Extensor digitorum (Radial - post


interosseous n.)

Flexion

C8 Flexor digitorum superficialis and


profundus

Abduction

T1 1st Dorsal interossei, Abductor digiti


minimi (Ulnar)

Thumb

T2 Abductor pollicus brevis (Median)

10)

REFLEXES :

Biceps

C5

Triceps

C7

BrachioradialisC6
Finger

11)

C8

CO-ORDINATION :Finger-nose
:Dysdiadokokinesis

12)

SENSORY

With sensory examination consider cortical, intracapsular, cord, dermatomal,


peripheral nerve distribution.

there is significant overlap between dermatomes and between peripheral nerves


therefore the area of sensory loss in dermatome or nerve lesions may be less
than illustrated/expected.

1. Pain/temperature (enters cord and crosses 1-2 segments above):

Pin
Chest wall first
Dermatomal.
Dull or sharp
Start proximally (unless cord compression or
peripheral neuropathy suspected)

Move from abnormal to normal

2. Vibration (128 Hz) (Dorsal column)

3. Proprioception (Spinocerebellar tract: Ipsilateral)

4. Light touch (Posterior column and Anterior spinothalamic tract)

C4 chest to shoulders

T2
Axilla

C5 arm to below elbow

C6 thumb/wrist

T1
elbow
C8
little finger

Median nerve]
NOTE: Small muscles of hand supplied by:

+ T1 nerve root.
Ulnar nerve ]

Therefore look at Abductor digiti minimi, First dorsal interossei, Abductor pollicus
brevis.

1.

APB weak

Median nerve

2.

ADM and 1st DI weak

Ulnar

3.

All three weak

Many causes; cord, root, plexus


lesion. Peripheral neuropathy. Motor
neuron disease etc.

LOWER LIMBS

1)

GAIT : Can I walk Mr/Mrs ...? If yes ... see Gait exam:

Rhombergs
Normal
Heel-toe
Stand on toes
Stand on heels
Squat

2)

LIE DOWN

3)

OBSERVE -

Expose legs (use towel)

?IDUC

Wasting: esp

1.

Generalized

2.

Tibialus Anterior/EDB/Quadriceps

3.

Pes cavus (High arch, clawed toes,


thick foot) HMSN, Friedreichs, Spina
bifida.

4)

PALPATE

Fasciculations

Tremor

Deformities

Tenderness

Bulk

Tap/flick for fasiculations

5)

TONE

Thickened nerves

Leg roll

Knee (lift up with hand in popliteal fossa)

Clonus : ankle (sustained rhythmical contractions UMN)


+/- patella clomnus.

Grade 0 5. Start proximally.

6)

POWER

[1. LMN: Weak, wasted, flaccid, hyporeflexic, fasciculation.


[2. UMN: Spastic, clonus, hyper- reflexic, Babinski,
UMN pattern weakness -

Arm: Abd + Ext]


Leg:

HIP:

Add+Flex]

Flexion

L2

Ilipsoas (Femoral n)

Extension

L5 S1-2

Gluteus Maximus (Inf glueal n)

Abduction

L4-5 S1

Gluteus medium/minimus + Tensor fascia


lata (Sup gluteal n)

KNEE:

ANKLE:

Adduction

L2-3

(Obturator n)

Flexion

L5 S1

Hamstrings (Sciatic n)

Extension

L3

Quadriceps (Femoral n)

Plantarflex

S1

Soleus/Gastrocnemius (tibial n)

Dorsiflex

L4-5

Tibialus Anterior (Common peroneal n)

Eversion

L5 S1

Peroneus Longus (Common peroneal n)


UMN

Inversion

L4

Tibialus Posterior (Tibial n) Root/Plexus

L5 S1

Ext digitarum longus (Deep peroneal n)

L4

Quadriceps

Ankle

S1

Gastrocnemius

Plantar-

S1 Plantar or babinski

Anal

S3-4-5

Ant Abdo

Upper

T6-8

Lower

T10-12

Dorsiflex toe -

7)

8)

REFLEXES: Knee

CO-ORDINATION:

Heel-shin
Finger-toe
Foot-tap

9)

SENSORY:

Pin prick

Vibration sense

] If a sensory level is present: Go to the abdomen

Proprioception

Check saddle sensation

Soft touch

Check anal reflex

10)

BACK:

Deformity
Scars
Neurofibroma

L3

knee

L4

to heel (medial)

L5

lateral leg and large toe

S1

sole + small toe

S2

up middle of leg at posteriorly

CEREBELLAR

FUNCTION: Basically a servocontrol mechanism

1.

Maintain posture/balance

2.

Fine voluntary movements

3.

Co-ordinate smooth tracking movements of eyes

4.

Control trajectory, velocity and acceleration of movements.

STRUCTURE: Complex

Inputs: Ascending

1. spinocerebellar
2. vestib apparatus

Descending

1. pyramidal
2. extrapyramidal

Outputs:

1. Motor cortex
2. Basal ganglia
3. Red nucleus
4. Reticular formation
5. Vestib appartus

EXAMINATION TECHNIQUE

1.

LISTEN:

"This patient has a problem with co-ordination." (DDx : Cerebellar,


posterior column, extrapyramidal lesions)

2.

EYES :

Nystagmus (when look to side of lesion Central


Labyrinthe

3.

:Rapid to side of lesion.)


:Rapid away from lesion.)

SPEECH: Impaired rate, rhythm and amplitude i.e.Jerky, explosive and loud with
irregular separation of syllables:

West Register Street


Irish Constabulatory
British Constitution

4.

UPPER LIMBS

: Drift
: Rebound
: Tremor (agonist hypotonia)
: Hypotonia (loss facilitatory influence on spinal motor neurons)

5.

FINGER NOSE

: Intention tremor
: Past-pointing

6.

RAPID MOVEMENTS

7.

DYSDIADOKOKINESIS

8.

LEGS

: tone
: heel-shin

: foot-tap

9.

SIT ON BED

: truncal ataxia
: reflexes (pendular)

10.

GAIT

PATTERNS

Midline:

Dysarthria gait and truncal ataxia

Hemispheric:

Limb ataxia, tremor, nystagmus, hypotonia

I.

UNILATERAL

Ischaemia (Lateral Medullary Sydnrome), MS,


Tumour, abscess, trauma, PNS

II.

BILATERAL

Drugs (ETOH, Phenytoin), MS, SOL, PNS,


Friedreichs Ataxia, Hypothyroid, Arnold Chiar
malformation.

III.

MIDLINE

IV.

ROSTRAL/VERMIS
(Spares arms)

PNS, Midline tumours

Alcohol