You are on page 1of 17

Peripheral Nervous System Examination

General
Introduce yourself.
Obtain the patients name and age and explain your role
Gain consent to proceed with the examination
Wash hands (see hand hygiene folder)
The Upper and Lower Limbs are examined separately.
Remember always to compare sides.
Expose all areas neccessary to complete full exam.
Always ask the patient if they are in any pain prior to proceeding
with examination
The examination is divided into distinct parts
Inspection
Motor System

Tone
Power
Reflexes
Coordination

Sensory System
Light Touch
Pain
Temperature
Vibration
Proprioception

Power is graded as follows Grade 0 Paralysis Grade 1 Flicker Grade 2 Movement when gravity excluded Grade 3 Movement against gravity Grade 4 Movement against some resistance Grade 5 Normal power Shoulder Abduction (C5. the forearm through pronation and suppination and the wrist through flexion and extension. Supporting above the elbow with one hand and holding the patients hand with the other move the elbow through flexion and extension. involuntary movements such as tremor and skin. Before commencing ask the patient if they are in any pain. muscle wasting. scars. C7. Age. This is tested at both the wrist and elbow. Power A measure of muscle strength. Power is tested by comparing the examiners strength against the patients full resistance. It is here that you would notice cogwheel rigidity and lead piping of parkinsons disease. gender and build should be taken into account. and is described as normal. Adduction (C6.The Upper Limb The patient should be in a seated position on bed or chair with upper limbs exposed. The Motor System Tone Tone is the assessment of the freedom of movement of a joint when moved passively. Inspection Look for asymmetry. C8) . Compare sides. abnormal posture. fasciculations (irregular contractions of small areas of muscles which have no rhythmical pattern). C6) The patient should abduct the arms with the elbows flexed and resist examiners attempt to push them down. reduced/hypotonic (lower motor neurone (LMN) lesion) or increased/hypertonic (upper motor neurone (UMN) lesion).

Remember to compare sides Reflexes . C6) With one hand on the shoulder and the elbow flexed try to straighten the elbow asking the patient to resist the movement.The paient should adduct the arms with the elbows flexed and not allow the examiner to push them up.T1) With thumb held up try to push it up towards ceiling and ask patient to resist Pincer Grip (Ulnar nerve C8. Wrist Flexion (C6.C8) With arms outsrtetched and supprorting the wrist from above ask the patient to extend the wrist and not to let the examiner bend it. C8) Hold patients hand out with fingers straight supporting wrist with one hand push down on the MCPJ and ask patient to resist. Thumb Abduction (C7.T1) Bring thumb and index finger together in 0 sign and ask patient to resist examiner pulling them apart Grip Strength (C5. Extension (C7.T1) Ask patient to hold piece of paper between ring and middle finger and examiner tries to pull peice of paper out using same fingers on same hand ask the patient to resist. Extension (C7. Elbow Remember to support the shoulders to properly assess the power at elbow on each side Flexion (C5.T1) Place your index and middle finger in palm of patients hand and ask them to grip your fingers and don't let you pull them out. Finger Flexion (C7. C8) Hold patients hand out with fingers straight supporting wrist with one hand push up on the MCPJ and ask patient to resist. C7) With arms outstretched and supporting the wrist from above ask the patient to flex the wrist and not let the examiner straighten it.T1) Hold patients hand out with fingers spread apart support hand at wrist and try to push fingers together asking patient to resist.T1) With thumb held up try to push it down and ask patient to resist Thumb Adduction (C7. Extension (C7. Abduction (C8. C8) With one hand on the shoulder and the elbow flexed try to bend the elbow asking the patient to resist you. Adduction (C8.

The tendon hammer should be held distally. Contraction of the biceps muscle occurs and flexion of the forearm.The sudden stretching of a muscle usually evokes brisk contraction of that muscle or muscle groups.clonus.C6) With the elbow partially flexed and relaxed find the biceps tendon and place forefinger of non dominant hand on it and strike tendon hammer onto finger. Reflexes are graded as 0 absent + present but reduced ++ normal +++ increased/possibly normal ++++ greatly increased+/. .C6) With the elbow flexed place index and middle finger of non dominant hand over lower radius just above wrist strike the tendon hammer onto fingers which causes contraction of brachioradialus muscle and elbow flexion. Make sure the patient is resting comfortably Brachioradialsis/Supinator (C5. Biceps (C5.

(Testing for a pronator drift is beyond the scope of JC3 clinical competencies course) Finger-Nose Testing Ask the patient with their index finger to touch their nose and then the examiners finger(the target). . causing contraction of the triceps muscle and extension of the forearm. Remember to compare sides for each reflex NB The video link for the upper limb moves to sensation after reflexes. make sure they have to fully stretch their finger before reaching the target. test again using a reinforcement manoeuvre. Compare sides. Look for past pointing (where the patients finger overshoots the target) and intention tremor (tremor increasing as the target is reached). Repeat several times. Compare sides.If the biceps jerk is absent. Rapidly alternating movement Ask the patient to pronate and supinate their hand on the dorsal surface (in the video the the palmar surface is used but the dorsum is more widely accepted) of the other hand as rapidly as possible.C8) With the elbow partially flexed isolate thte triceps tendon and strike the tendon hammer directly or as in the video onto index finger. Test for cerebellar disease using 2 main maneuvres. This is not the normal sequence and it would be expected of you to do co-ordiantion next if you were completing a full upper limb neurological examination Coordination The cerebellum plays an integral role in coordinating voluntary movement. Triceps (C7. Ask the patient to clench their teeth tightly as you let the tendon hammer fall.

Ask the aptient to say 'yes' everytime the feel something. Initially touch the anterior chest wall (normal area). Ask the patient to close their eyes and begin proximally on the upper arm and test each dermatome comparing right with left.This movement is slow and clumsy in cerebellar disease and is called dysdiadochokinesis The Sensory System Assessment of sensation comprises: 1 Light touch 2 Pain 3 Temperature (not formally assessed) 3. this is to demonstrate to the patient how it feels sharp. . Vibration 4 Proprioception Light Touch Use cotton wool to test for light touch. Ask the patient to close their eyes and begin proximally on the upper arms and test each dermatome comparing right with left. Ask patient if they can feel object and if it feels sharp or dull. Pain Using a sharp object (neurotip) touch the patients anterior chest wall (normal area).

Should vibration sense be lost or impaired distally then the tuning fork should be moved proximally in order to establish the level at which it is normally appreciated.youtube. if symmetrical or asymmetrical). Compare sides. Inspection Look for asymmetry. It should be explained to the patient that it is the sensation of vibration. involuntary movements eg. If there is an abnormality. olecranon at elbow and then the shoulders) Proprioception Grasp the distal phalanx from the sides and move it up and down to demonstrate these positions. The video link for the upper limb neurological exam: http://www. muscle wasting (if proximal. not cold or touch which is being detected. Vibration The base of a vibrating tuning fork (128Hz) is placed on the anterior chest wall. distal or general. Compare one side with the other.com/watch?v=S7H1pqRlVqc The Lower Limb The patient should be lying on the bed with legs and thighs exposed. Always do this by going from the area of dullness to the area of normal sensation. proceed to test the wrists and elbows similarly.Map out the extent of any area of dullness. They are then asked to repeat this with their eyes closed. Then ask the patient to close the eyes while these manoeuvres are repeated and ask them to tell you the movement ie up or down. abnormal posture. fasciculations. (ulnar head at wrist. The base of the vibrating tuning fork is then placed on the dorsum of the distal phalanx. . Stop the tuning fork vibrating by touching it and the patient should be able to say exactly when this occurs. tremor and skin eg neurofibromatosis. scars. The patient is asked can they feel it vibrate and to indicate when vibration stops.

Compare sides. reduced/hypotonic (LMN lesion) or increased/hypertonic (UMN lesion). Then move the ankle joint in a circular fashion (ankle tone). Power is tested by comparing the examiners strength against the patients full resistance. this should occur without resistance Then place one hand under the knee and abruptly pull upwards causing flexion then allow it to fall onto the bed (knee tone). Extension(L3.S1. Ankle . L3) Ask patient to lift up their straight leg. Place your hand on the leg above the knee and attempt to push the leg down asking the patient not to let you push it down. Clonus is a sustained rhythmical contraction of the muscles when put under sudden stretch. and is described as normal. S2) Ask the patient to keep the leg down and not to let you pull it up. With the patient lying on a couch place your hands above and below the knee and roll the leg on the couch (hip tone).The Motor System Tone Tone is the assessment of the freedom of movement of a joint when moved passively. gender and build should be taken into account. By sharply dorsiflexing the foot if clonus is present recurrent ankle plantar flexion occurs. Check the patient is not in pain. greater than 5 beats is thought to be abnormal. Power A measure of muscle strength. Power is graded as follows Grade 0 Paralysis Grade 1 Flicker Grade 2 Movement when gravity excluded Grade 3 Movement against gravity Grade 4 Movement against some resistance Grade 5 Normal power Hip Flexion(L2. Check for ankle clonus.S1) Ask the patient to bend the knee and not to let you straighten it.L4) With the knee bent ask the patient to straighten the knee and not to let you bend it. Age. It is due to hypertonia from an UMN lesion such as stroke. Extension(L5. Knee Flexion(L5.

L5) Ask the patient to bring the foot up and not to let you push it down. Dorsiflexion(L4.Dorsiflexion(L4. Plantar flexion(S1. .S2) Ask the patient to push the foot down and not to let you push it up.S2) Ask the patient to plantar flex the big toe and not to let you push it up. Toes Plantar flexion(S1.L5) Ask the patient to bring the big toe up and not to let you push it down.

Reflexes Make sure the patient is resting comfortably.L3. Knee jerk(L2. . L4) Slide the left arm under the knees so they are slightly bent and supported.

The tendon hammer is allowed to fall on to the infrapatellar tendon. The normal response is plantar flexion of the foot with contraction of the gastrocnemius muscle. Contraction of the quadriceps causes extension of the knee. If the knee jerk appears to be absent it should be tested again following a reinforcement manoeuvre.S2) Have the foot in the mid-position at the ankle with the knee bent and thigh externally rotated. The hammer is allowed to fall on the Achilles tendon. Ask the patient to interlock the fingers and then to pull apart hard at the moment before the hammer strikes the tendon (Jendrassik's manoeuvre) Ankle jerk(S1.S1. Plantar reflex(L5.S2) .

The Sensory System Assessment of sensation comprises: 1. Coordination Test for Cerebellar disease using the Heel-Shin Test Ask the patient to place one heel on the opposite knee and to slide the heel accurately down the front of the shin to the ankle take it of and replace it onto knee and repeat action. In cerebellar disease the heel wobbles and may fall of shin. Vibration 4. The extensor response is abnormal [Babinski response] and indicates an upper motor neurone lesion. The normal response is flexion of the big toe at the metatarsophalangeal joint. Proprioception Light Touch .After explaining to the patient what is going to happen. Use a blunt object draw slowly along the lateral border of the foot from the heel towards the big toe until a response is elicited. Pain 3. Light touch 2.

Ask the patient to close their eyes and begin proximally on the upper leg and test each dermatome (the area of skin supplied by a vertebral spinal segment) comparing right with left. Ask patient if they can feel object and if it feels sharp or dull. Ask patient to say ‘yes’ every time they feel something. Always do this by going from the area of dullness to the area of normal sensation.Use cotton wool to test for light touch. this is to demonstrate to the patient how it feels. Ask the patient to close their eyes and begin proximally on the upper leg and test each dermatome comparing right with left. Pain Using a sharp object (neurotip) touch the patients anterior chest wall (normal area). Map out the extent of any area of dullness. this is to demonstrate to the patient how it feels sharp. Initially touch (do not drag as it moves hair fibres) the anterior chest wall (normal area). Vibration .

(Lateral malleolus. The base of the vibrating tuning fork is then placed on the dorsum of the terminal phalanx. Should vibration sense be lost or impaired distally then the tuning fork should be moved proximally in order to establish the level at which it is normally appreciated. costal margin) Proprioception Grasp the distal phalanx from the sides and move it up and down to demonstrate these positions. They are then asked to repeat this with their eyes closed. Compare one side with the other. Stop the tuning fork vibrating by touching it and the patient should be able to say exactly when this occurs. It should be explained to the patient that it is the sensation of vibration. .The base of a vibrating tuning fork (128Hz) is placed on the anterior chest wall. Then ask the patient to close the eyes while these manoeuvres are repeated and ask them to tell you the movement ie up or down. The patient is asked can they feel it vibrate and to indicate when vibration stops. If there is an abnormality. proceed to test the ankles and knees similarly. not cold or touch which is being detected. upper part of tibia. iliac crest.

.

observe gait. Ask the patient to walk across the room to a designated spot then to turn around and come back. scissors gait shuffling. it is positive if marked unsteadiness occurs. Make sure the patients legs are clearly visible. parkinsons disease proximal myopathy. foot plantar flexed and leg swung in lateral arc spastic paraparesis.Lower Limb Gait Examination The gait examination is routinely performed as part of the lower limb neurological examination. (Rombergs test is not shown in the video link but will be covered in tutorials and therefore is part of the clinical competenies JC3 course) . normal heel strike and toe of. waddling gait Ask the patient to walk heel to toe midline cerebellar lesion Perform Rombergs test by asking the patient to stand with there feet together and then close their eyes. arm swing present normal or abnormal painful unsteady hemiplegic.

The video link for the lower limb neurological exam: http://www.youtube.com/watch?v=Jz_sE4A0nWA .