Limbs Exam (RCT)

Neurological Examination Of The Limbs by Dr. Rosie C Taylor 1. General Introduce yourself to the patient Explain to the patient what you are about to do by asking them “I would like to examine your arms and legs, do I have your permission to do this?”

In order to examine the limbs, the patient's arms and legs should be fully exposed but it is possible to leave the trunk covered with a blanket. A neurological examination of the limbs can be subdivided into inspection and the assessment of motor function, coordination, sensory function and gait. A useful mnemonic for this is "when testing plantar reflexes, carefully stroke" which stands for wasting (inspection), tone, power, reflexes, coordination and sensation. The arms are traditionally considered before the legs.

2. Inspection Look at the patient from the end of the bed, making it clear to the examiners that you are doing this. The diagnosis may be evident from inspection alone. The features of the following common neurological conditions may be instantly recognisible: • • •

Parkinson's Disease-expressionless face with sunken cheeks and doesn't blink often. Pill rolling tremor of hands. Hemiplegia-muscle wasting on one side of the body. Affected arm is held flexed and affected leg is extended. Motor Neurone Disease-wasting of all the muscles of the body. Fasciculation, the irregular involuntary contractions of small bundles of muscle fibres, may be present.

Make sure you glance around the bed, paying special attention to the presence of mechanical aids e.g. a wheelchair. You may be stopped before you have a chance to see the patient's gait, so extra information such as this may prove to be valuable. If the examiner asks you what you are inspecting for at this point, you should respond: "I am inspecting for evidence of... • abnormal posture • abnormal movements • tremor • muscle wasting • fasciculation"

3. Screening Test of Arm Function This test is a rapid way to assess function of the arms and should reveal any gross motor defect. Tell the patient "I would like to test how the muscles of the arms are working Please place both your arms outstretched in front of you (demonstrate this yourself). Now please close your eyes"

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Watch the patient's arms for about 10 seconds. If one or both arms drift downwards and medially this may be a sign that the patient has a pyramidal tract weakness (most often caused by an old cerebrovascular accident). It also gives you a chance to check for intention tremor, a feature of cerebellar disease. This is a tremor that is often absent at rest but appears when the patient is asked to perform a task. With the patient's arms still outstretched and their eyes shut, touch the index finger of one of their hands and say, "I would like you to touch your nose with the finger that I am touching". This is a sensitive test of muscle power and coordination.

4. Motor assessment of the Arms Tone Tell the patient "I would like to test how the arms move when the muscles are relaxed. For this test I would like you to let the arms go floppy and let me move them." Start off by flexing and extending the elbow through a wide arc and the try to quickly supinate the patient's wrist. Abnormal muscle tone may fit into one of the following patterns: •

• •

Pyramidal (e.g. cerebrovascular accident)-there is increased tone, which is more obvious when trying to flex the elbow. In addition the tone may be "clasp knife", initially high but then decreasing with movement. A supinator catch may be present-this is when supination of the wrist is initially difficult but proceeds more easily with movement. Extrapyramidal (e.g. Parkinson's disease)-there is increased tone which is uniform throughout movement. This is called "lead pipe rigidity". If a tremor is superimposed on this, this is called "cogwheeling". Hypotonia occurs in lower motor neurone lesions, recent upper motor neurone lesions and cerebellar disorders.

Power Tell the patient "I would now like to test how strong the arms are. Please could you place your arms up in front of you with your elbows bent and hold that position" (demonstrate this position to the patient. The shoulders should be abducted to 90º and the elbow fully flexed). Now test the power of the shoulder joint by holding the patient's elbows and asking them to "Stop me from pushing your arms downwards" (tests abduction) and "Push down on my hands" (tests adductors). Now movements of the elbow joint should be assessed by asking the patient "Please could you place both your arms outstretched in front of you" (demonstrate this to the patient). Hold the patient's forearms with your wrists and ask them to "Pull me towards you, bending your elbow" (tests extension) and "Push me away" (tests flexion). Wrist flexion and extension are also assessed with the patient's arms outstretched in front of them. Ask the patient to "cock your wrists back towards your head and stop me from straightening them out". Now assess wrist extension by pushing down on the extended wrists. Now test flexion by asking the patient to "straighten the wrists out, don't let me stop you" as you oppose this movement. Test the power of the intrinsic muscles of the hand by offering the patient the index and middle fingers of your hands and asking them to "squeeze my fingers as hard as you can". The median nerve can be tested by asking the patient to "make an okay sign between the first finger and thumb" and asking the patient to "stop me pulling the thumb and finger apart". Another test of median nerve function is thumb abduction. Ask the patient to "lift the thumb towards the ceiling. Stop me from pushing it down"

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The ulnar nerve is assessed by the card test which involves the patient trying to resist the movement of a piece of card which is placed between his adducted ring and little fingers. Also test ulnar nerve function by asking the patient to "turn your hands so that the palms are facing downwards (give them time to do this), now spread your fingers and stop me from pushing them together". In order for this to be a fair test, you should attempt to push their fingers together with your index fingers. Power is traditionally given a score out of 5, as follows: Table 1 Score 0 1 2 3 4 5

Power no movement flicker of movement movement but not against gravity movement against gravity but no resistance weak movement against resistance normal

Reflexes Test the following reflexes: Supinator-this is tested for by tapping the distal end of the radius with the tendon hammer. Its root value is C5-6 Biceps-this is tested for by tapping your thumb as it is placed over the biceps tendon with the tendon hammer. Its root value is C5-6. Triceps-hold the arm across the chest to tap the triceps tendon with your tendon hammer. Its root value is C7-8 If the reflexes are absent, try the Jendrassik manouvre. This involves asking the patient to clench the teeth or grip the fingers of one hand with the other shortly before you test the reflex. Reflexes are described as absent, present with reinforcement, present or brisk. Decreased reflexes occur in the following conditions: • lower motor neurone lesion • recent upper motor neurone lesion Increased reflexes occur in established upper motor neurone lesions. Coordination Test coordination in both arms unless power is markedly reduced. In such an instance, turn to the examiner and tell them "I shall not test coordination as it will not be an accurate assessment in view of the reduced muscle power" This is examined by the finger-nose test. Tell the patient "I would like to assess your coordination. For this test I would like you to touch your nose with this finger (touch their index finger), now please touch my finger (hold out your index finger at a distance of about 0.5m from the patient), now touch your nose again, and back to my finger. Please now try to do this as fast as you can.

5. Sensory assessment of the arms The following sensory modalities should be tested: • light touch

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• • •

pin prick vibration proprioception

Light touch Ask the patient "Is there any part of the arms that you have noticed are numb?" This will enable you to direct more time to these areas. Take a piece of cotton wool and explain to the patient "I would like to test the sensation in your arms by touching you several times with this piece of cotton wool. Please close your eyes and tell me when you feel the cotton wool". Touch the right and left arms in each successive dermatome at irregular intervals to prevent the patient guessing the timing of the next stimulus.. If there is an area of sensory loss, map it out fully by going from the numb area to the area of normal sensation.

Pin prick Take a sterile pin and ask the patient I would now like to test whether or not you can feel this pin as a sharp object, it means that I will have to touch your skin with the sharp end of this pin. Do I have your permission to do this?" If the patient agrees, touch the sternum with the pin and ask them "does this feel sharp, like a pinprick?" As this is the reference point, you should press a bit harder if the patient doesn't recognise the stimulus as sharp but do not draw blood. Touch each successive dermatome comparing the right and left arms. Continue asking the patient them "does this still feel sharp?" If there is an area of sensory loss, map it out fully by going from the numb area to the area of normal sensation

Vibration Take a 128Hz vibrating tuning fork and place the base of it on the patient's sternum and ask them "can you feel this vibrating?" As this is the reference point, you should try again if patient doesn't sense the vibration. Now place the base of the vibrating tuning fork on one of the metacarpophalangeal joints and ask the patient "can you feel this vibrating?" Only if vibration sense is absent at the MCP joint, should you test more proximally. A suggested sequence is: • distal end of radius • malleolus of the elbow

Proprioception Hold the patient’s index finger with your index finger and thumb either side of the distal phalanx. Show the patient what you are doing "I would now like to move your finger up and down, that is up (move the finger upwards slightly) and that is down (move the finger downwards slightly.) Please now close your eyes and tell me whether I am moving your finger up or down" Move the finger up and down at irregular intervals to prevent patient cooperation. The slightest movement should be a sufficient stimulus.

Remember that there are two separate ascending pathways that convey different sensory modalities:

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• •

Dorsal column medial lemniscus conveys proprioception and vibration sense. The fibres run in the ipsilateral side of the spinal cord. Spinothalamic tract fibres convey light touch, pain and temperature sense. The fibres cross over to the contralateral side of the spinal cord after ascending a few segments of the cord.

6. Motor assessment of the legs You should now uncover the patient’s legs Tone Tell the patient "I would like to test how the legs move when the muscles are relaxed. For this test I would like you to let the legs go floppy and let me move them. Do you have any pain in the hip joint?" Start off by internally and externally rotating the hip then try to quickly lift the patient’s knee up of the bed. If the tone is increased, the patient's foot will not lag behind the hip rotation and it will lift off the bed when the knee is raised.

Power Tell the patient "I would now like to test how strong the legs are. Please could you lift your right leg off the bed (allow them to do this), now please stop me from pushing it down" (push downwards on the patients right thigh) now ask the patient to "Push my hand down onto the bed" (place the hand under the thigh). Now repeat this for the patients left leg. Now movements of the knee joint should be assessed by asking the patient "Please could you bend both your knees slightly". Hold the patient's right ankle and ask them to "Pull your foot me towards your bottom, bending your knee" (tests flexion) and "Push my hand away" (tests extension). Now repeat this for the patients left leg Ankle flexion and extension are also assessed with the patient's legs straight. Ask the patient to "bend your toes up towards your head and stop me from pushing down on them". Now assess ankle extension by placing both your hands on the soles of the patient feet and asking the patient to "push down on my hands like you are pressing down on the accelerator pedal on your car, don't let me stop you" as you oppose this movement. Score power out of 5, as shown in the previous table. Reflexes Test the following reflexes: Knee jerk-this is tested for by placing the forearm under both knees and getting the patient to relax the knees in a partially flexed position. Tap the patellar tendon with the tendon hammer. Its root value is L3-4 Ankle jerk-this is tested for by fully flexing the ankle by pressing on the ball of the patient' foot. Tap your hand as it is placed over the sole with the tendon hammer. Its root value is S1-2. It is often absent in the elderly. Plantar reflex-stroke the lateral border of the sole of the foot from the heel to the little toe with an orange stick and then come around to the big toe. Do not use the end of your tendon hammer to do this in an exam. Some examiners get annoyed at this. Note the first movement of the big toe as you do this. The normal plantar response is flexor (big toe initially moves away from the patient's head). An extensor response occurs in upper motor neurone lesions. If the reflexes are absent, try the Jendrassik manouvre. This involves asking the patient to clench the teeth or grip the fingers of one hand with the other shortly before you test the reflex.

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Describe reflexes as absent, present with reinforcement, present or brisk as discussed previously.

Coordination Test coordination in both legs unless power is markedly reduced. In such an instance, turn to the examiner and tell them "I shall not test coordination as it will not be an accurate assessment in view of the reduced muscle power" This is examined by the heel-shin test. Tell the patient "I would like to assess your coordination. For this test I would like you to place the heel of your right foot onto your left knee (give them time to do this), now please run your heel down your shin all the way to the ankle (give them time to do this), now lift up the ankle and place it on your knee again. Please now try to do this as fast as you can. A patient with cerebellar dysfunction will have an intention tremor, dysmetria (inability to accurately reach the target, either overshooting or undershooting)

7. Sensory assessment of the legs The following sensory modalities should be tested: • light touch • pin prick • vibration • proprioception Light touch Ask the patient "Is there any part of the legs that you have noticed are numb?" This will enable you to direct more time to these areas. Take a piece of cotton wool and explain to the patient "I would like to test the sensation in your legs by touching you several times with this piece of cotton wool. Please close your eyes and tell me when you feel the cotton wool". Touch the right and left legs in each successive dermatome at irregular intervals to prevent patient guesswork influencing the results. If there is an area of sensory loss, map it out fully by going from the numb area to the area of normal sensation.

Pin prick Take a sterile pin and ask the patient I would now like to test whether or not you can feel this pin as a sharp object, it means that I will have to touch your skin with the sharp end of this pin. Do I have your permission to do this?" If the patient agrees, touch the sternum with the pin and ask them "does this feel sharp, like a pinprick?" As this is the reference point, you should press a bit harder if the patient doesn't recognise the stimulus as sharp but do not draw blood. Touch each successive dermatome comparing the right and left legs. Continue asking the patient them "does this still feel sharp?" If there is an area of sensory loss, map it out fully by going from the numb area to the area of normal sensation

Vibration Take a 128Hz vibrating tuning fork and place the base of it on the patient's sternum and ask them "can you feel this vibrating?" As this is the reference point, you should try again if patient doesn't sense the vibration.

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Now place the base of the vibrating tuning fork on one of the medial aspect of the base of the big toe and ask the patient "can you feel this vibrating?" Only if vibration sense is absent at the base of the big toe, should you test more proximally. A suggested sequence is: • medial malleolus of the ankle • patella • anterior superior iliac spine

Proprioception Hold the patient’s big toe with your index finger and thumb either side of it. Show the patient what you are doing "I would now like to move your big toe up and down, that is up (move the toe upwards slightly) and that is down (move the toe downwards slightly.) Please now close your eyes and tell me whether I am moving your toe up or down" Move the toe up and down at irregular intervals to prevent patient cooperation. The slightest movement should be a sufficient stimulus.

Describe any loss of sensory modalities as to whether the modality belongs to the dorsal column medial lemniscus system or the spinothalamic tract as discussed previously.

8. Finishing off the examination It is very important at this stage say to the patient “thank-you, you may sit back now” and to cover them up with the blanket.

You should complete any neurological examination of the limbs by turning to the examiner and saying: "I would also like to see the patient's gait"

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