LOCAS Neuro MPT and sensory examination

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LOCASNeuroMPT and sensory examination

• Carys Jones
• Isobel Salter
• 12/01/09

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Contents

• Motor system
• Sensory
• Interpretation and questions
• Parkinsons
• Demonstration!

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To start.

• Smile and be nice!
• Introduce, check identity, consent, expose
• Wash hands!
• General inspection
• Speech and posture
• Look around the bed for clues!
• Inspection
• Muscle wasting, fasciculations, involuntary
  movements e.g. tremor, chorea, myoclonus.

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Tone- upper limb

• Arms outstretched in supination to check for
  pronator drift.
• Ask them to relax their arms, and check tone.
• Feel for spasticity, cogwheeling, and clasp-
  knife and leadpipe rigidity.

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Power- Grading

• 0- No muscle contraction visible
• 1- Flicker of contraction but no movement
• 2- Joint movement when effect of gravity elimited
• 3- Movement against gravity but not against
  examiner's resistance
• 4- Movement against resistance but weaker than
  normal
• 5- Normal power

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Power- upper limbs

• Start proximally
• Shoulders abduction and adduction
• Elbows- flexion and extension
• Wrists- flexion and extension
• Fingers- abduction, adduction, extension and
  flexion.
• Thumb- abduction and opposition

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Nerve roots- upper limbs

• A quick check of nerve roots
• C5 shoulder abduction
• C6 elbow flexion (half supinated)
• C7 wrist extension
• C8 finger flexion
• T1 finger abduction

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Reflexes- upper limb

• Biceps (C5)
• Supinator (C6)
• Triceps (C7)
• Remember reinforcement before you give up!

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Coordination- upper limb

• Finger- nose test
• Test for
• dysdiadochokinesis

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Extra bits for upper limb

• Ulnar nerve Ulnar MAFIAS
• M Medial lumbricals weak- priests blessing
• A Adductor pollicis weak- Froments sign
• F First dorsal interosseous wasting
• I Interossei weak and wasted
• A Abduction little finger weak
• S Sensory loss over small and ulnar half ring
  finger.

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• Median nerve
• Thenar eminence
• LOAF 1st and 2nd Lumbricals
• Opponens pollicis
• Abductor Pollicis brevis
• Flexor pollicis longus
• Sensory disturbance thumb and 2.5 fingers

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Tone- Lower limb

• Ask pt to relax
• Roll the leg and look at the foot
• Lift the knee into flexed position and let go
• Remember to test for clonus! More than 3 beats-
  abnormal.

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Power- Lower limb

• Grading as previously
• Hip- flexion, extension, abduction and adduction.
• Knee- flexion and extension
• Ankle- Dorsiflexion, plantar flexion, inversion,
  eversion.
• Big toe- extension

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Nerve roots- Lower limbs

• Quick check
• L2 Hip flexion
• L3 Knee extension
• L4 Ankle dorsiflexion
• L5 Big toe extension
• S1 Ankle plantar flexion

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Reflexes- Lower limbs

• Knee (L3/4)
• Ankle (S1/2)
• Plantar response
• Reinforcement

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Coordination- lower limbs

• Heel-shin test.
• As an extra, you may test gait and Rombergs
  (proprioception)
• Gait- posture, arm swing, step size,
  circumduction, ataxia

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Testing sensation

• Know dermatomes!
• Test each side simultaneously.
• Light touch- cotton wool.
• Pain- neuro-tip (dispose in sharps bin!!)
• Temperature
• Vibration- start distally on bony points
• Proprioception- JPS

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Presenting your findings

• Thank the patient- remember to cover them up.

• To complete the examination I would like to
  examine the lower limbs, gait, sensory system and
  cranial nerves.

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• Turn to examiner This is a 60 yr old lady. On
  general inspection she is comfortable at rest and
  alert. She has a visible resting tremor. On motor
  examination of the upper limbs she has increased
  tone in both arms with cogwheeling. There were no
  other abnormal findings.

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Interpretation of signs

• Locate the lesion.
• UMN or LMN?
• Cerebellar D dysdiadochokinesis
• A ataxia
• N nystagmus
• I intention tremor
• S slurred speech
• H hypotonia

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• Think systematically

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Be prepared for questions

• After locating the lesion
• Differentials remember common things are common!
• Underlying pathology- brief.
• Basic management.

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Parkinsons disease

• Common and has some distinctive signs
• TRAP T- tremor
• R- rigidity
• A- akinesia/ bradykinesia
• P- postural instability

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PD- inspection

• Mask-like expression
• Flexed extrapyramidal position gun- slinger
  position
• Loss of arm swing
• Hesitancy
• Shuffling
• Festination (hurrying)
• Retropulsion

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PD

• Tremor- pill rolling and resting
• Voice- quiet and monotonous
• Bradykinesia
• Increased tone- rigidity
• Lead pipe
• Cog wheeling
• Glabellar tap response

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PD- Questions

• Pathology- loss of dopaminergic cells in
  substantia nigra of basal ganglia
• Treatment- dopamine agonists, levodopa, COMT and
  MAO type B inhibitors.
• MDT approach!!

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Summary

• Start off with a smile and good intro etc
• Dont hurt the patient
• Take your time
• Be systematic
• Dont panic
• Practice, practice, practice!

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• GOOD LUCK!