Neurological examination

Motor function Observe look for signs of wasting or fasciculation (LMNL) Tonus see definition below Clonus see definition below

What is Tonus? basically the resting tone of muscles (or more specifically the muscles resistance to passive stretching during the resting state). Test: Roll LEx & UEx along their long axis. Pick up knee and drop Types of Tonus: Hypotonia (associated with LMNLs) Hypertonia (associated with UNMLs) Spasticity is velocity dependent and should be assessed by quick passive movement flex/ext pronation/sup (eg clasp knife) Rigidity is continuous non-velocity dependent eg lead-pipe Causes: UMNL (Spasticity), MS, Cerebral palsy What is Clonus? Simply the sustained repetitive maintenance of the reflex arc with stretch of the muscle (or series of involuntary, rhythmic, muscular contractions & relaxation ie. large movements normally initiated by a reflex). Clonus is a clinical sign of certain neurological conditions, particularly associated with UMNLs, and in many cases is, accompanied by spasticity. Unlike small, spontaneous twitches known as fasciculations (LMNL), clonus causes large motions that are usually initiated by a reflex Question when would you check for clonus? When you suspect an UMNL Types of Clonus: Physiological Pathological

Due to stress, exhaustion, fatigue, SNS. Repeat test. Tends to wear off. CNS lesion. Repeated response. Normal: no beats (sometimes few). Tests: Repetitive Dorsiflex ankle/wrist. Stretch Quads above patella.

Power Active resisted movements. Root C2, 3 C3,4 C5 C5 (6) C(5)6 C7 C8 T1 L1,2 L2,3 L3,4 L4 L5 S1 S2 Action Flex neck Shrug shoulders Abduct GH Flex elbow (palm up) Flex elbow (thumb up) Extend elbow Flex fingers Adduct fingers Flex hip Adduct thighs (need a wee) Extend knee (kick the door) Dorsiflex Talocrural Extend Hallux Flex knee Flex Hallux Muscle SCM Trapezius Deltoid Biceps Brachioradialis Triceps Flexor digitorum profundus Dorsi Interossei Iliopsoas Adductors Quadriceps Tib ant Extensor Hallucis Hamstrings Flexor Hallucis Brevis Peripheral Nerve CNXI CNXI Axillary Musculocutaneous Radial Radial Ulnar (2 med) Median (2 lat) Ulnar From spinal segment Obturator Femoral Deep fibular Deep fibular Sciatic Tibial

Combined motor/sensory function Types of Reflexes Internal (visceral), External (pupil, light), Deep Tendon / Superficial (Cutaneous Autonomic/visceral Internal (Pancreatic activity when eating) Stretch Reflex (Patella Hammer) A stretch reflex is a muscle contraction in response to stretching within the muscle. The central nervous system can influence the stretch reflex via the gamma motoneurons (which control the sensitivity of the reflex). Inhibitory signals arrive at gamma neurons through the reticulospinal tract What are we testing when we test reflexes? Generally we are testing for a defect in nerve conduction but its important to remember that any link in the chain can cause a defect

Deep Tendon Reflexes Process/Structures of a Reflex Arc: a muscle lengthens > the muscle spindles are stretched causing an action potential travels up the sensory axon to the spinal cord where it synapses with a motorneuron > contraction of a muscle. Therefore Reflexes test the: response of muscles to stretch (reticulospinal tract): the sensory neuron, the synapse at that level of the spinal cord, motor neuron, and the motor end plates and the muscle). What is a mono-synaptic reflex? Its a reflex arc consisting of a single synapse between one sensory neuron and one motor neuron. Egs. Patella reflex What is a poly-synaptic reflex? By contrast one of more interneurons connect the afferent and efferent signals. Most reflexes are polysynaptic allowing for processing or inhibition of the reflexes

Reflex Jaw Biceps Supinator Triceps Fingers Knee jerk Adductor Ankle / Achilles / Soleus / Gastrocs

Muscle Mms of mastication Biceps Brachioradialis Triceps Flexor digitorum Quadriceps femoris Adductor Tibial

Nerve CNV Musculocutaneous C5 (6) Radial C(5) 6 Radial C7 Median / Ulnar C8 Femoral L3,4 Obturator L2, 3 S1, 2

Skin/superficial Cutaneous stimulus causes skin distortion caused by pilorum muscles. Reflex Abdominal Plantar Test Navel toward stimulus. UMNLsuppress reflex Scrape up along lateral foot then inwards along MCPs. Normal response: flexion of big toe (adult) dorsiflex in babies Is an extension of int oblique. T12, L1,2 Nerve L5, S1

Cremaster

Genitofemoral nerve and illioinguinal nerve

Co-ordination Observe Static posture Balance/swaying. Terms: Ataxia lack of voluntary coordination of movement Hemiplegia total paralysis of the arm, leg, trunk on same side of the body. It is a form of spasticity Paraplegia - Quadriplegia Diplegia paralysis affecting symmetrical parts of the body (common in kids with Cerebral Palsy) Spasticity hypertonia (see tonus above) Gait Wide stance, trunk jerk sideways, difficult to balance. Test heel to toe. Cerebellar Circumduction, drag+ int rot of affected leg, ipsilateral arm bend + fist LEX>UEX. Flex hip/knees. Tight adductors, extend+ int rot ankles. LEX swinging bilateral gait. UEXlow guard (arms bent) Weak unstable pelvis with sideway sway/drop and hyperlordosis Pt cant dorsiflexfoot dropfoot drag or high step to lift foot of ground Hyperkinetic. Balanced + involuntary movements Loss of sensation/joint position. Dorsal column. Walk on the spot (eyes open/closed) CNVII (turning toward lesion)

Ataxic (lack of voluntary coordination movement) Hemiplegic Diplegic

Myopathic Neuropathic Choreiform Stamping

Tremor Intention Resting

Cerebellum (shake when moving closer to target) Cerebrum (Parkinsons) Cerebellum Cerebellum Cerebellum

Finger-nose test Heel-shin test Rapid alternating movements

Sensory function Observe, Light Touch, Pinprick, Deep touch/pain/squeeze, Joint position sense, Vibration, Temperature sense.

Spinal Roots C5 C5/6 C6 C7 C6 C7 C8

Movement Shoulder Abduction Elbow flexion Elbow flexion Elbox extension Radial wrist extension Finger extension Finger flexion

Upper Extremity Weakness implies UMNL Reflex + + + +

Named nerve Axillary nerve Musculotcutaneous nerve Radial nerve Radial nerve Radial nerve Posterior interosseus nerve Anterior interosseus nerve

T1

Finger abduction

Lower Extremity Weakness implies UMNL Reflex + + +

Ulnar nerve Ulnar nerve Median nerve Named nerve Obturator nerve Sciatic nerve Sciatic nerve Femoral nerve Deep peroneal nerve Superficial peroneal Tibial nerve Deep peroneal nerve

Muscle Deltoid Biceps brachii Brachioradialis Triceps Extensor carpi radialis longus Extensor digitorum communis Flexor pollicis longus Flexor digitorum profundus (index) Flexor digitorum profundus (ring & little) First dorsal interosseous Abductor pollicis brevis Muscle Illiopsoas Adductors Gluteus maximus Hamstrings Quadriceps Tibialis anterior Peroneus longus & brevis Gastrocnemius & Soleus Extensor hallucis longus

Spinal Roots L1/2 L2/3 L5/S1 S1 L3/4 L4 L5/S1 S1/S2 L5

Movement Hip flexion Hip adduction Hip extension Knee flexion Knee extension Ankle dorsiflexion Ankle eversion Ankle plantarflexion Big toe extension

Named Nerve Musculocutaneous nerve

Motor supply Coracobrachialis Biceps brachii Brachialis Deltoid Teres minor Triceps - all 3 heads Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Supinator Extensor carpi ulnaris Extensor digitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensive indicis

Upper Extremity Sensory supply Lateral cutaneous nerve of the forearm

Sensory pattern Lateral half of forearm elbow to wrist anterior and posterior

Axillary nerve

Upper cutaneous nerve of the forearm

Sergents stripes on superiolateral arm

Radial nerve

Superficial radial nerve

Thin strip down the posteriolateral aspect of arm and forearm including back of up to base of thumb and 1st two fingers

Pronator teres Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor digitorum profundus 1 & 2 Flexor pollicis longus Pronator quadratus Abductor pollicis brevis Flexor pollicis brevis

Lesions in the forearm: From wrist to finger tips of thumb to half of 4th finger on palmar surface Tips of thumb and up to half of 4th finger from distal joint

Median nerve

Palmar branch of median nerve Lesions in carpal tunnel: Tip of thumb from distal joint and length of fingers up to half of 4th finger on palmar surface Tips of thumb and up to half of 4th finger from distal joint Medial cutaneous nerve of the arm Including: Dorsal cutaneous branch Palmar cutaneous branch Superficial terminal branches

Opponens pollicis 1st & 2nd lumbricals Flexor carpi ulnaris Flexor digitorum profundus 3 & 4 Adductor pollicis Flexor pollicis brevis Interssoei abductor digiti minimi Opponens digit minimi Flexo digiti minimi

Medial half of forearm elbow to wrist anterior and posterior

Ulnar nerve

Lesions from elbow to first cutaneous branch: From wrist to fingers tips of little and half ring finger on palmar and dorsal surfaces

Named Nerve

Motor supply

Lower Extremity Sensory supply Lateral cutaneous nerve of the thigh

Sensory pattern Small patch on lateral aspect of thigh just superior to knee Anterior aspect of thigh beginning at mid thigh on medial aspect, extending in the midline back up towards the groin, covering across the knee and medial aspect of the leg to ankle Posterior acpect of thigh beginning at mid thigh on medial aspect, covering medial 1/3 posterior knee and medial aspect of leg to ankle Medial anterior and posterior aspects of leg from knee to ankle and small piece on medial arch of foot Middle 1/3 lateral aspect of thigh

Femoral nerve

Quadriceps femoris: Rectus femoris Vastus lateralis Vastus intermedius

Medial cutaneous nerve of the thigh Intermediate cutaneous nerve of the thigh

Vastus medialis

Saphenous nerve Obturator nerve Adductor brevis Adductor longus Gracilis Adductor magnus Gluteus medius Gluteus minimus Tensor fascia latae Gluteus maximus Cutaneous branch of obturator nerve

Superior gluteal nerve Inferior gluteal nerve

Semitendinosus Semimebranosus Sciatic nerve

Posterior cutaneous nerve of the thigh

Triangular middle 1/3 of posterior aspect of thigh with base of triangle at crease of buttocks and point at back of knee Lesions from trunk of sciatic nerve: Lateral half of anterior and posterior leg from below the knee to the ankle, and the foot except the immediate area around medial malleolus to the first 1/2 of medial aspect of foot

Adductor magnus Biceps femoris

Peroneus longus

Common peroneal

Peroneus brevis Common peroneal nerve

Superficial peroneal nerve

Lateral cutaneous nerve of the calf

Lateral half of anterior and posterior leg from below the knee to the ankle, and the foot except the immediate area around calcaneous and lateral border of the foot, includes dorsum of foot except distal tips of toes Posterior acpect of thigh beginning at mid thigh on medial aspect, covering medial 1/3 posterior knee and medial aspect of leg to ankle Small oval patch on lateral aspect of leg just below knee, extending to 1/3 anterior and posterior leg

Tibialis anterior Extensor digitorum longus Extensor hallucis longus Peroneus tertius Extensor digitorum brevis

Deep peroneal nerve

Small horseshoe patch over web space between great and 2nd toe including half of each toe

Gastrocnemius Soleus Tibialis posterior Flexor digitorum longus Flexor hallucis longus Tibial nerve Calcaneous and sole of foot, including dorsum tips of toes

Calcaneal branch Abductor hallucis Tibial nerve Flexor digitorum brevis Flexor hallucis brevis Cutaneous branches Abductor digiti minimi Flexor digiti minnimi Adductor hallucis Interssoei Cutaneous branches Lateral plantar nerve Medial plantar nerve

Calcaneous and dorsal 1/2 of platar surface of foot

Medial 2/3 of plantar surface of foot, including toes to middle of 4th toe and excluding calcaneous

Lateral 1/3 of plantar surface of foot, including toes to middle of 4th toe and excluding calcaneous

Sural nerve Mix of Tibial and Common peroneal nerves

Small slice on lateral arch of foot but not including little toe and lateral aspect of ankle surrounding lateral malleolus