CNS Examination

CENTRAL NERVOUS SYSTEM (CLINICAL EXAMINATION) Group d batch 15 1) Examination in Parkinson’s disease 2) Examination of Cerebellar Disease 3) Examination of III, IV, VI Cranial Nerves 4) Examination of VII Cranial Nerve 5) Examination of Upper Limb 6) Examination of Lower Limb

EXAMINATION OF PARKINSON PATIENT Introduce and greet patient, position patient (sitting position) , Consent, Sanitize. IN SITTING POSITION A) Inpection  Masked like facies – staring  Reduced blinking of eyes  Dribbling of saliva  Greasy skin  Resting tremors  Titubation (Tremors of the head)  Posture – flexed, few spontaneous movements B) Assess patient  Assess speech - Talk to the patient. Patient speech will be soft, monotonous, rapid, indistinct  Head o Axial rigidity o Glabella tap – keeping your finger out of the patient’s line of vision, tap the middle of the forehead with your middle finger. Positive sign when patient continues to blink as long as the examiner taps . Normal people just blink a few times then stop o Greasiness/ sweatiness of the eyebrow o Eyes – H test (upward gaze weakness) o Tongue – tremors  Assess rigidity and tremors– check for muscle tone at the wrist. o Increased tone (cogwheel / plastic (lead pipe) – tone is increased in interrupted nature, muscles giving way with series of jerks o Resting tremors observed , some may have pill rolling pattern. Tremors will disappear when patient is asked to take her flexed and extend her arm.  Assess bradykinesia –slowness in initiating and repeating movements (positive in Parkinsonism) o Finger tapping (ask patient to tap fingers on surface repeatedly , quicly and with both hands ar once) Or o Hands twiddling(rotating hands around each other in front of the body) Or o Finger-thumb opposition test STANDING UP POSITION (Assess bradykinesia, rigidity) 1) Ask the patient to stand, stand next to him and guard him incase of fall.  When getting up from standing, patient may have postural hypotension 2) Ask patient to walk a distance (walk with him) and quickly turn around  Festinating gait – slow to start, short strides, reduced arm swing, once begins the patient hurries (festination)  Shuffling gait –slow to start, short stride small steps, reduced arm swing  Has difficulty in stopping  Having difficulty to turn the body – imbalance

EXAMINATION OF CEREBELLAR DISEASE

IN SITTING POSITION Speech  assess patients speech patients will pronounce the words in the sentences with jerky,loud,explosive and irregular separation syllables  provide several sentences with prominent syllables ( LAH PAH KAH ) Nystagmus  do H test ( remember to do it at the eye level and do the test slowly as doing it fast may mimic nystagmus)  fast phase toward side of cerebellar lesion Finger to nose test Ask patient to fully extend arm then touch nose or ask them to touch their nose then fully extend to touch your finger You increase the difficulty of this test by adding resistance to the patient's movements or move your finger to different locations ( do at least 3 positions )  This is to check for patients coordination, intention tremor and 'pastpointing'

Rapid alternating movements Ask patient to place one hand over the next and have them flip one hand back and forth as fast as possible (alternatively you can ask the patient to quickly tap their foot on the floor as fast as possible) if abnormal, this is called dysdiadochokinesia Rebound phenomenon Ask the patients to extend both their arms push the arms downwards in a normal person: regain position back quickly in patients with cerebellar disease : arm will take a while to regain the position back (Be careful that you protect the patient from the unarrested movement causing them to strike themselves.) Pronator drift  Hold both arms fully extended at shoulder level, palm upwards  unable to maintain the position (positive) Heel to shin test Have patient run their heel down the contralateral shin by putting your hands at a certain height ( not too high), ask patient to lift their leg to touch your hands repeat the procedure Abnormal exam occurs when they are unable to keep their foot on the shin

Hypotonia “pendular” knee jerk, leg keeps swinging after knee jerk more than 4 times (4 or less is normal)  can even check the tone for both the limbs

PATIENT IN STANDING POSITION ( do provide support at all times )

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Ask patient to stand up NOTE: patients are supported  observe posture, steadiness

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Gait:

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Tandem gait (Heel-to-toe gait) walk heel-to-toe usually patient will not be able to do so

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Romberg's Test  close the eyes , stand unaided with the arms at the side of the body , feet close together  patient would sway or loose balance

 command given to walk a distance turn quickly and return  observe the gait, arm swing, balance commonly wide based and staggering They may fall to the side of the lesion NOTE: patients are supported

DIFFERENCES BETWEEN CEREBELLAR AND PARKINSON'S DISEASE

Cerebellar Inspection

Parkinson's Stooped position Mask-like facies Reduced blinking of eyes Salivation

Gait

Wide-based gait Fall to the side of lesion

Festinant gait , Bradykinesia - Slow in initiating walk - Rapid small stride - Reduced arm swing - Shuffling gait - Impaired balance in turning

Tremors ( finger-to-nose test)

Intention tremors

Resting tremors - coarse, complex movements, 'pill-rolling'

Tone

Hypotonia

Cogwheel rigidity (upper limb) Lead pipe rigidity (lower limb)

Speech

Stacatto Speech - speaks slowly with scanning syllables

Monotonous, soft, rapid, indistinct

H-test

Nystagmus present

Reduced upward gaze

Knee-jerk

Pendulous

Clonus

Not present

Present

Romberg's test

Positive if the posterior colum is affected

Negative

Pronator drift

Positive

Negative

Heel-to-shin test

Positive

Negative

Rapid alternating test

Positive

Negative

Examination of cranial nerve III, IV, VI

Cranial nerve III 1. Ask the patient to look at your finger at a distance of 2 feet from his eyes. Note if there is ant squint. Also ask if he has double vision (diplopia). 2. You then also inspect if the patient has ptosis (complete/partial). 3. Ask the patient to open his eyes; the affected eyelid won’t be able to open. 4. When you try to lift the affected eyelid, you will notice the patient will be gazing inferolaterally (superior oblique and lateral rectus muscles are intact). 5. Keeping the eyelid lifted, ask the patient to follow your finger and go across from lateral to medial (finger moved at patient’s chest level). 6. You than also check for pupil size and shape.  Dilated pupil + complete ptosis: complete III nerve palsy  Normal pupil + complete ptosis: Diabetes mellitus (vasa novorum ischaemia)  Normal pupil + partial ptosis: myasthenia gravis  Constricted pupil + partial ptosis: Horner’s syndrome *Painful III nerve palsy: Posterior communicating artery aneurysm Direct and indirect pupillary light reflex 1. Patient is asked to fix his gaze on a distant object. You should explain to the patient to not look away from the distant object and also not look at the light. 2. Shine the light from the side and and observe for pupil constriction on the side of the light. 3. Again, shine light to the same eye, and now observe for pupil constriction of the opposite eye. 4. The light should never be shone directly into the eye. Accomodation 1. Ask the patient to fix his gaze at an distant object. Explain to him what you are about to do. 2. Place your finger at a one arm length. As you move your finger towards the patient, ask him to follow your finger movement. 3. You should note if the eyeballs converge.

Cranial nerve 7 ( Facial nerve ) MOTOR FUNCTION -carefully inspect the whole face for any asymmetry or for differences in blinking or eye closure on one side.(any drooling of saliva at one side of the mouth,dropping of one side of the mouth) -watch for spontaneous or involuntary movement.minor asymmetry of the face is common and rarely pathological.ask the patient’s partner if they have noticed a difference. -ask the patient to wrinkle the forehead or look up above his head (which has the same effect) -ask the patient to bare the teeth.demonstrate this yourself: asking the patient to mimic you helpful.look for asymmetry. -test power by saying “screw your eyes tightly shut and stop me from opening them”,then “blow out your cheeks with your mouth closed” th

-test for bell’s phenomenon : ask patient to close the eyes,in 7 nerve palsy,patient will have inability to closed the eyes,once patient closed the eyes,the eyeball will roll upward ,exposing the conjunctiva below the cornea. -test for hyperacusis (high pitched sounds appearing unpleasantly louder than normal): test the hearing patient by rubbing both hands towards patient ear.do at the both side.ask patient which one the loudest)

TASTE SENSATION -instruct the patient not to speak during the test. -ask the patient to put out his tongue rd

-apply them one at the time to the anterior 2/3 of the tongue. (in exam,no need to do this test,time consuming)

EXAMINATION OF UPPER LIMBS Introduce yourself and obtain consent. Expose the upper limbs including the shoulder girdle adequately. Motor: Inspection: from proximal to distal - Muscle bulk for wasting of muscle - Fasciculation - Tremor - Involuntary movement - Deformity - drifting Coordination: -

Finger-to-nose test o Ask the patient to touch his nose with index finger and turn the finger around and touch the examiner’s outstretched forefinger at full extension of the shoulder and elbow. o Look for abnormalities :  Intention tremor – tremor increasing as the target is approached.  Past-pointing – patient’s finger overshoots the target towards the side of cerebellar abnormalities - Rapid-alternating movement o Ask patient to pronate and supinate one hand on the dorsum of the other hand. o Presence of slow and clumsy movement is called dysdiadochokinesia - Rebound phenomenon o Ask patient to lift up the arm rapidly from the sides and stop o Hypotonia cases delay in stopping the arms Motor: Palpation: Palpate the muscle to assess their bulk a) Tone – hypotonia/hypertonia/normal - Tone is tested at both the wrist and elbows - Rotation of the wrist with supination& pronation of the elbow joints should be performed. Cogwheel rigidity of Parkinson disease should be recognized. -

Ask the patient to move the other arm up and down as the examiner moves the hand and forearm

b) Power Shoulder - Abduction : mostly deltoid and supraspinatus ( C5,C6) - Adduction : Mostly Pectoralis major and latissimus dorsi ( C6,C7,C8)

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Abduction : Patient should abduct the arms with the elbows flexed and resist the exminers’s attempt to push them down Adduction : Patients should adduct the arms with the elbow flexed and not allow examiner to separate them

Elbow - Flexion : Biceps and brachialis ( C5,C6) - Extension : Triceps brachii ( C7,C8) o Flexion : patient to bend the elbow and pull, don’t let examiner straighten it out. o Extension : patient to bend the elbow and push. Wrist - Flexion : flexor carpi ulnaris & radialis ( C6,C7) - Extension : Extensor carpi group ( C7,C8) o Flexion : patient is to bend the wrist o Extension : patient is to extend the wrist Fingers - Extension: Ext. digitorum communis, ext. indicis, ext. digiti minimi ( C7,C8) o Ask patient to straighten the fingers, push with the side of hand across the patient’s MCP joints - Flexion : Flexor digitorum profundus and sublimis (C7,C8) o Ask patient to squeeze 2 of the examiner’s fingers - Abduction : Dorsal interossei (C8,T1) o Ask patient to spread out the fingers and examiner push them together - Adduction : Volar interossei (C8,T1) o Ask patient to hold the fingers together and try to prevent examiner from separating them. c) Reflexes - Triceps jerk – tap over the triceps tendon - Biceps jerk – tap over the biceps tendon - Supinator jerk – tap over the lower end of radius above the wrist Sensory: Due to the common neurological pathway shared by these sensory modalities and for saving time in the exam. Perform: 1. Pain 2. Vibration – 128Hz tuning fork 3. Propioception Firstly, allow the patients to get the feeling of each object by placing them on the sternum. Next, examine the sensation of upper limbs based on dermatomes. Peripheral nerves of upper limb. Radial nerve It supplies the triceps and brachioradialis and extensor muscles of hand. Motor: Look for Wrist drop, -

Ask the patient flex the elbow, pronate the forearm and extend the wrist and fingers

- Patient will have inability to flex the wrist and fingers If the lesion is at the upper third of the upper arm, triceps muscle is affected.Therefore, patient is unable to do elbow extension. Sensory: test over the anatomical snuff box. Sensation is lost at here. Ulnar nerve It contains motor supple to all small muscles of hand (except LOAF muscles), FCU, ulnar half of FDP. Abnormalities: - Wasting of small muscle of the hand - Clawing of the little and ring fingers( hyperextension at the MCP joint and flexion of IP joints) Froment’s sign- ask the patient to grasp a piece of paper between the thumb and lateral aspect of the forefinger with each hand - Affected thumb will flex due to loss of adductor of the thumb Median nerve It contains the motor supply to all the muscles on the front of the forearm except FCU and ulnar half of FDP, LATERAL 2 LUMBRICALS, OPPONENS POLLICIS, ABDUCTOR POLLICIS BREVIS, FLEXOR POLLICIS BREVIS. a. Lesion at carpal tunnel Use pen-touching test to assess for weakness of abductor pollicis brevis. Ask the patient to lay the hand flat, palm upwards on the table, attempt to abduct the thumb vertically to touch the pen held above it. b. Lesion at cubital fossa Ochsner’s clasping test. – ask the patient to clasp the hands firmly together. The index finger of the affected side fails to flex . Sensory : area of loss are palmar aspect of thumb,index, middle and lateral half of the ring fingers WHAT IS Ulnar Paradox? ‘High lesions’ occur with elbow fractures and dislocations. The hand is not markedly deformed because the ulnar half of the flexor digitorum profundus is paralysed and the fingers are therefore less ‘clawed’ (the high ulnar paradox). Otherwise, motor and sensory loss is the same as in low lesions. (The ulnar nerve also innervates the medial half of the FDP. If the ulnar nerve lesion occurs more proximally (closer to the elbow), the FDP may also be denervated. As a result, flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand. (Instead, the 4th and 5th fingers are simply paralyzed in their fully extended position.) This is called the "ulnar paradox" because one would normally expect a more debilitating injury to result in a more deformed appearance.)

EXAMINATION OF LOWER LIMBS Wash your hands, introduce , informed consent Ideally the patient should have their lower body exposed/wear shorts. 1. INSPECT for the following:  Wasting/positional abnormality/asymmetry/ Fasiculation  Prominent tibia in anterior tibialis atrophy in common peroneal nerve palsy  Deformity /High arched foot / pes cavus/ charcot’s arthropathy 2. PALPATE:  General and localized wasting-flabby feel  Myositis-tender  Rhabdomyolysis (acute muscle necrosis)-woody feel 3. MEASUREMENT of muscle bulk : diameter 18 cm above patella, 10 cm below tibial tuberosity. Vastus medialis of quadriceps first muscle to get wasted. Compare bilaterally check if there is wasting. 4. TONE. Flick the thigh and calf to test for fasciculation ( fasciculation is due to anterior horn cell lesion such as motor neurone disease/ peripheral nerve/ NMJ lesion). Roll the leg on the bed to see if it moves easily, then pull up on the knee to check its tone. Check for ankle clonus by placing the patients leg turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing and partially everting the foot, sustain the pressure. Any further movement of the joint may suggest clonus. Knee clonus: use thumb and index finger and rapidly push the patella towards foot, sustain pressure. 5. POWER. Again, start at the hip asking the patient to abduct, adduct, flex and extend against your hand so you can assess how much force they can overcome. Do the same for flexion and extension at the knee and ankle as well as the toes. Movement Hip Flex Hip Ext Knee Ext Knee Flex Ankle dorsiflexion Ankle plantarflexion Big toe Ext

Muscle Iliopsoas Gluteus maximus Quadriceps Hamstrings Tibialis anterior

Root L1, L2 L5, S1 L3, L4 S1 L4

Nerve Femoral Inf gluteal Femoral Sciatic Deep peroneal

Gastrocnemius

S1, S2

Tibial

Ext hallucis longus

L5

Deep peroneal

MRC POWER SCALE: 0 No movement 1 Flicker of Movement 2 Movement with gravity but not against 3 Movement against gravity but not resistance 4 Reduced power against resistance 5 Normal power against resistance 6. REFLEXES. Look at the muscle belly when testing a reflex Reflex Knee Ankle Plantar (Babinski)

Root Nerve L3, L4 Femoral S1 Sciatic Extensor (great toe dorsiflex, other toes flex and abduct)-UMN lesion Flexor: toes curve down and inwards, foot evertsNormal

7. FUNCTION/COORDINATION: i. Heel to shin test. Heel to shinExaminer’s handFloor (dysmetria, intention tremor and coordination) ii. Assess patient walking (Gait). Ask patient to walk away, get something, turn around and walk back (Remember to make sure patient does not fall to the ground!!)  Delayed Initiation (Parkinson’s)  Loss of arm swing (early sign in Parkinson’s)  Festination (Parkinson’s)  Scissoring (due to spasticity i.e. UMN lesion)  Waddling (proximal muscle weakness)  Foot drop (LMN lesion, specifically L4, L5 or common peroneal nerve) iii. Heel to toe walking (ataxia) iv. Romberg’s test. Ask the patient to stand with their feet apart and then close their eyes. Any swaying may be suggestive of a posterior column pathology. 8. SENSATION: Test light touch, pin prick, vibration, and joint position. Compare bilaterally. Ask the patient to place their legs out straight on the bed. -FINE TOUCH: Lightly touch the patient’s sternum with a piece of cotton wool so that they know how it feels. With the patient’s eyes shut, lightly touch their leg with the cotton wool. The places to touch the patient should test each of the dermatomes. Tell the patient to say yes every time they feel the cotton wool as it felt before. -PAIN: Then repeat this using a light pin prick.

-VIBRATION: 128 Hz tuning fork. Place the fork on the patient’s sternum to show them how it should feel. Now place on great toe and ask if it feels the same. If it does, no need to check any higher. If it feels different, move to the tibial epicondyle and then to the greater trochanter until it feels normal. -PROPRIOCEPTION. Hold the distal phalanx of the great toe on either side so that you can flex the interphalangeal joint (hold at the sides, not above and below). Show the patient that when you hold the joint extended, that represents ‘Up’ whereas when you hold it flexed that represents ‘Down’. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position – up or down. Ask the patient which position the joint is in.   

Glove and stocking and patchy polyneuropathy – peripheral nerve lesion Cut off point – spinal cord lesion Dermatone _ Nerve root lesions Excuse me sir, I would like to complete my examination by testing anal tone, anal reflex, spinal sensation ( S2- S4), spine to look for surgical / traumatic scar/ tumour, upper limb examination, cranial nerve examinations, other cerebellar signs.

IMPORTANT NOTES Upper motor neuron vs lower motor neuron lesions Upper motor neuron lesion

Lower motor neuron lesion

Muscles become hypertonic No muscles wasting No fasiculation seen Paralysis affects movement of group of muscles Deep reflexes are hyperactive(hyperreflexia) Babinski: positive

Muscles become hypotonia Muscle wasting present Fasiculation present Individual group of muscle is paralysed All reflexes are absent Babinski: Negative