Peripheral Nervous System Examination

General

Introduce yourself.Obtain the patients name and age and explain your roleGain consent to proceed with the examinationWash 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 SystemTone PowerReflexesCoordination

Sensory SystemLight TouchPainTemperatureVibrationProprioception

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

ToneTone 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.

PowerA 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 followsGrade0ParalysisGrade1FlickerGrade2Movement when gravity excludedGrade3Movement against gravityGrade4Movement against some resistanceGrade5Normal power

ShoulderAbduction (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 sideFlexion (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.

WristFlexion (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. FingerFlexion (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 resistThumb Adduction (C7,T1)With thumb held up try to push it up towards ceiling and ask patient to resistPincer Grip (Ulnar nerve C8,T1)Bring thumb and index finger together in 0 sign and ask patient to resist examiner pulling them apartGrip 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

ReflexesThe sudden stretching of a muscle usually evokes brisk contraction of that muscle or muscle groups.Reflexes are graded as0 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

CoordinationThe 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 TestingAsk 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 movementAsk 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:1Light touch2Pain3Temperature (not formally assessed)3.Vibration4Proprioception

Light TouchUse 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.

PainUsing 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.

VibrationThe 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)

ProprioceptionGrasp 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.

InspectionLook 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

ToneTone 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.

PowerA 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 followsGrade0ParalysisGrade1FlickerGrade2Movement when gravity excludedGrade3Movement against gravityGrade4Movement against some resistanceGrade5Normal powerHipFlexion(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.

KneeFlexion(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.

AnkleDorsiflexion(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.

ToesPlantar 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.

CoordinationTest for Cerebellar disease using the Heel-Shin TestAsk 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 off and replace it onto knee and repeat action. In cerebellar disease the heel wobbles and may fall off shin.

The Sensory System

Assessment of sensation comprises:1.Light touch2.Pain3.Vibration4.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.

PainUsing 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.

VibrationThe 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)

ProprioceptionGrasp 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 off, arm swing presentnormal or abnormalpainfulunsteadyhemiplegic, foot plantar flexed and leg swung in lateral arcspastic paraparesis, scissors gaitshuffling, parkinsons diseaseproximal myopathy, waddling gaitAsk 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