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    PNS Examination 15

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    Nolan
    The document provides instructions for performing a neurological examination of the peripheral nervous system, including the upper and lower limbs. It describes examining motor function (including tone, power/strength, and reflexes), sensation (light touch, pain, vibration, and proprioception), and coordination. The upper limb examination includes specific tests of muscles like shoulder abduction/adduction, elbow flexion/extension, wrist flexion/extension, and finger movements. Reflexes like brachioradialis, biceps, and triceps are also tested. Coordination is assessed using finger-to-nose and rapid alternating hand movements. The lower limb exam follows a similar approach.

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    PNS Examination 15

    Uploaded by

    Nolan
    125 views17 pages
    The document provides instructions for performing a neurological examination of the peripheral nervous system, including the upper and lower limbs. It describes examining motor function (including tone, power/strength, and reflexes), sensation (light touch, pain, vibration, and proprioception), and coordination. The upper limb examination includes specific tests of muscles like shoulder abduction/adduction, elbow flexion/extension, wrist flexion/extension, and finger movements. Reflexes like brachioradialis, biceps, and triceps are also tested. Coordination is assessed using finger-to-nose and rapid alternating hand movements. The lower limb exam follows a similar approach.

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    The document provides instructions for performing a neurological examination of the peripheral nervous system, including the upper and lower limbs. It describes examining motor function (including tone, power/strength, and reflexes), sensation (light touch, pain, vibration, and proprioception), and coordination. The upper limb examination includes specific tests of muscles like shoulder abduction/adduction, elbow flexion/extension, wrist flexion/extension, and finger movements. Reflexes like brachioradialis, biceps, and triceps are also tested. Coordination is assessed using finger-to-nose and rapid alternating hand movements. The lower limb exam follows a similar approach.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    125 views17 pages

    PNS Examination 15

    Uploaded by

    Nolan
    The document provides instructions for performing a neurological examination of the peripheral nervous system, including the upper and lower limbs. It describes examining motor function (including tone, power/strength, and reflexes), sensation (light touch, pain, vibration, and proprioception), and coordination. The upper limb examination includes specific tests of muscles like shoulder abduction/adduction, elbow flexion/extension, wrist flexion/extension, and finger movements. Reflexes like brachioradialis, biceps, and triceps are also tested. Coordination is assessed using finger-to-nose and rapid alternating hand movements. The lower limb exam follows a similar approach.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The document outlines the steps and components involved in performing a neurological examination of the upper and lower limbs.

    The components include inspection, assessment of tone, power, reflexes, coordination, and sensory system (light touch, pain, temperature, vibration, and proprioception).

    Shoulder abduction (C5, C6) and adduction (C6, C7, C8) are tested.

    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

    The Upper Limb


    The patient should be in a seated position on bed or chair with
    upper limbs exposed.

    Inspection
    Look for asymmetry, scars, abnormal posture, muscle wasting,
    fasciculations (irregular contractions of small areas of muscles which
    have no rhythmical pattern), involuntary movements such as tremor
    and skin.

    The Motor System


    Tone
    Tone is the assessment of the freedom of movement of a joint when
    moved passively, and is described as normal, reduced/hypotonic
    (lower motor neurone (LMN) lesion) or increased/hypertonic (upper
    motor neurone (UMN) lesion).
    This is tested at both the wrist and elbow. Before commencing ask
    the patient if they are in any pain.
    Supporting above the elbow with one hand and holding the patients
    hand with the other move the elbow through flexion and extension,
    the forearm through pronation and suppination and the wrist
    through flexion and extension. Compare sides. It is here that you
    would notice cogwheel rigidity and lead piping of parkinsons
    disease.
    Power
    A measure of muscle strength. Age, gender and build should be
    taken into account.
    Power is tested by comparing the examiners strength against the
    patients full resistance. 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, C6)
    The patient should abduct the arms with the elbows flexed and
    resist examiners attempt to push them down.
    Adduction (C6, C7, C8)

    The paient should adduct the arms with the elbows flexed and not
    allow the examiner to push them up.
    Elbow
    Remember to support the shoulders to properly assess the power at
    elbow on each side
    Flexion (C5, C6)
    With one hand on the shoulder and the elbow flexed try to
    straighten the elbow asking the patient to resist the movement.
    Extension (C7, C8)
    With one hand on the shoulder and the elbow flexed try to bend the
    elbow asking the patient to resist you.
    Wrist
    Flexion (C6, C7)
    With arms outstretched and supporting the wrist from above ask the
    patient to flex the wrist and not let the examiner straighten it.
    Extension (C7,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.
    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.
    Extension (C7, C8)
    Hold patients hand out with fingers straight supporting wrist with
    one hand push down on the MCPJ and ask patient to resist.
    Abduction (C8,T1)
    Hold patients hand out with fingers spread apart support hand at
    wrist and try to push fingers together asking patient to resist.
    Adduction (C8,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.
    Thumb Abduction (C7,T1)
    With thumb held up try to push it down and ask patient to resist
    Thumb Adduction (C7,T1)
    With thumb held up try to push it up towards ceiling and ask patient
    to resist
    Pincer Grip (Ulnar nerve C8,T1)
    Bring thumb and index finger together in 0 sign and ask patient to
    resist examiner pulling them apart
    Grip Strength (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.
    Remember to compare sides
    Reflexes

    The sudden stretching of a muscle usually evokes brisk contraction


    of that muscle or muscle groups.
    Reflexes are graded as
    0 absent
    + present but reduced
    ++ normal
    +++ increased/possibly normal
    ++++ greatly increased+/- clonus.
    Make sure the patient is resting comfortably
    Brachioradialsis/Supinator (C5,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.

    Biceps (C5,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. Contraction of the biceps muscle occurs and
    flexion of the forearm. The tendon hammer should be held distally.

    If the biceps jerk is absent, test again using a reinforcement


    manoeuvre. Ask the patient to clench their teeth tightly as you let
    the tendon hammer fall.
    Triceps (C7,C8)
    With the elbow partially flexed isolate thte triceps tendon and strike
    the tendon hammer directly or as in the video onto index finger,
    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. 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. Test for cerebellar disease using 2 main maneuvres.
    (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), make sure they have to fully
    stretch their finger before reaching the target. Repeat several times.
    Compare sides. Look for past pointing (where the patients finger
    overshoots the target) and intention tremor (tremor increasing as
    the target is reached). Compare sides.
    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.

    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. Vibration
    4 Proprioception

    Light Touch
    Use cotton wool to test for light touch. Initially touch the anterior
    chest wall (normal area).
    Ask the patient to close their eyes and begin proximally on the
    upper arms and test each dermatome comparing right with left. Ask
    the aptient to say 'yes' everytime the feel something.

    Pain
    Using a sharp object (neurotip) touch the patients anterior chest
    wall (normal area), this is to demonstrate to the patient how it feels
    sharp.
    Ask the patient to close their eyes and begin proximally on the
    upper arm and test each dermatome comparing right with left. Ask
    patient if they can feel object and if it feels sharp or dull.

    Map out the extent of any area of dullness. Always do this by going
    from the area of dullness to the area of normal sensation.
    Vibration
    The base of a vibrating tuning fork (128Hz) is placed on the anterior
    chest wall. It should be explained to the patient that it is the
    sensation of vibration, not cold or touch which is being detected.
    The base of the vibrating tuning fork is then placed on the dorsum
    of the distal phalanx. The patient is asked can they feel it vibrate
    and to indicate when vibration stops.
    They are then asked to repeat this with their eyes closed. Stop the
    tuning fork vibrating by touching it and the patient should be able to
    say exactly when this occurs.
    Compare one side with the other.
    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.
    (ulnar head at wrist, 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. 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. If there is an abnormality, proceed to test
    the wrists and elbows similarly.

    The video link for the upper limb neurological exam:


    http://www.youtube.com/watch?v=S7H1pqRlVqc

    The Lower Limb


    The patient should be lying on the bed with legs and thighs
    exposed.
    Inspection
    Look for asymmetry, scars, abnormal posture, muscle wasting (if
    proximal, distal or general, if symmetrical or asymmetrical),
    fasciculations, involuntary movements eg, tremor and skin eg
    neurofibromatosis. Compare sides.

    The Motor System


    Tone
    Tone is the assessment of the freedom of movement of a joint when
    moved passively, and is described as normal, reduced/hypotonic
    (LMN lesion) or increased/hypertonic (UMN lesion).
    Check the patient is not in pain. With the patient lying on a couch
    place your hands above and below the knee and roll the leg on the
    couch (hip tone), 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). Then move the ankle
    joint in a circular fashion (ankle tone). Compare sides.
    Check for ankle clonus. Clonus is a sustained rhythmical
    contraction of the muscles when put under sudden stretch. It is due
    to hypertonia from an UMN lesion such as stroke. By sharply
    dorsiflexing the foot if clonus is present recurrent ankle plantar
    flexion occurs. greater than 5 beats is thought to be abnormal.
    Power
    A measure of muscle strength. Age, gender and build should be
    taken into account.
    Power is tested by comparing the examiners strength against the
    patients full resistance. 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, 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.
    Extension(L5,S1, S2)
    Ask the patient to keep the leg down and not to let you pull it up.
    Knee
    Flexion(L5,S1) Ask the patient to bend the knee and not to let you
    straighten it.
    Extension(L3,L4) With the knee bent ask the patient to straighten
    the knee and not to let you bend it.
    Ankle

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

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

    Knee jerk(L2,L3, 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.


    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. 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,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. The normal response is plantar flexion of the foot
    with contraction of the gastrocnemius muscle.

    Plantar reflex(L5,S1,S2)

    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.
    The normal response is flexion of the big toe at the
    metatarsophalangeal joint. The extensor response is abnormal
    [Babinski response] and indicates an upper motor neurone lesion.

    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.

    The Sensory System


    Assessment of sensation comprises:
    1.

    Light touch

    2.

    Pain

    3.

    Vibration

    4.

    Proprioception

    Light Touch

    Use cotton wool to test for light touch. Initially touch (do not drag as
    it moves hair fibres) the anterior chest wall (normal area); 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 (the area of skin supplied by a
    vertebral spinal segment) comparing right with left. Ask patient to
    say yes every time they feel something.

    Pain
    Using a sharp object (neurotip) touch the patients anterior chest
    wall (normal area), this is to demonstrate to the patient how it feels
    sharp.
    Ask the patient to close their eyes and begin proximally on the
    upper leg and test each dermatome comparing right with left. Ask
    patient if they can feel object and if it feels sharp or dull.
    Map out the extent of any area of dullness. Always do this by going
    from the area of dullness to the area of normal sensation.

    Vibration

    The base of a vibrating tuning fork (128Hz) is placed on the anterior


    chest wall. It should be explained to the patient that it is the
    sensation of vibration, not cold or touch which is being detected.
    The base of the vibrating tuning fork is then placed on the dorsum
    of the terminal phalanx. The patient is asked can they feel it vibrate
    and to indicate when vibration stops.
    They are then asked to repeat this with their eyes closed. Stop the
    tuning fork vibrating by touching it and the patient should be able to
    say exactly when this occurs.
    Compare one side with the other.
    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.
    (Lateral malleolus, upper part of tibia, iliac crest, costal margin)

    Proprioception
    Grasp the distal phalanx from the sides and move it up and down to
    demonstrate these positions. 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. If there is an abnormality, proceed to test
    the ankles and knees similarly.

    Lower Limb Gait Examination


    The gait examination is routinely performed as part of the lower
    limb neurological examination. Make sure the patients legs are
    clearly visible.
    Ask the patient to walk across the room to a designated spot then
    to turn around and come back, observe gait, normal heel strike and
    toe of, arm swing present
    normal or abnormal
    painful
    unsteady
    hemiplegic, foot plantar flexed and leg swung in lateral
    arc
    spastic paraparesis, scissors gait
    shuffling, parkinsons disease
    proximal myopathy, 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, it is positive if marked
    unsteadiness occurs.
    (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)

    The video link for the lower limb neurological exam:


    http://www.youtube.com/watch?v=Jz_sE4A0nWA

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