Neuro Exam Workshop AAO Convocation, 2018 Drew Lewis, DO, FAAO, FAOCPMR Associate Professor, OMM Department Des Moines University Table of Contents I. Neuro Exam Screen... 2 A. Inspection... 2 B. Reflexes... 2 C. Upper Extremity Manual Muscle Strength Testing... 2 D. Lower Extremity Manual Muscle Strength Testing... 2 E. Sensory... 2 II. Reflexes... 3 A. Deep Tendon Reflexes (Muscle-Stretch Reflexes)... 3 B. Additional Muscle-Stretch Reflexes... 5 C. Superficial Reflex (Skin to Muscle Reflex)... 5 III. Upper Extremity Muscle Strength Testing... 6 A. Muscle Strength Scales... 6 B. C5: Elbow Flexors... 6 C. C6: Wrist Extensors... 6 D. C7: Elbow Extensors... 7 E. C8: Long Finger Flexors... 7 F. T1: Small Finger ABductor... 7 IV. Lower Extremity Muscle Strength Testing... 8 A. L2: Hip Flexors... 8 B. L3: Knee Extensors... 8 C. L4: Ankle Dorsiflexors... 8 D. L5: Long Toe Extensors... 9 E. S1: Ankle Plantarflexors... 9 V. Sensory Testing... 10 A. ASIA Key Sensory Points... 10 VI. Neurological Exam Practical... 11 A. Version A... 11 B. Version B... 12 2018 Des Moines University Neuro Exam 1
Brachior. I. Neuro Exam Screen A. Inspection 1. During inspection, have patient stand directly underneath the lighting in the room. 2. Physician then inspects the patient by directly visualizing the skin. (Patient in gown and shorts) 3. Physician is looking for: a. Signs of Atrophy (decreased muscle mass), in lower motor neuron injuries b. Fasciculation of the muscles, in lower motor neuron injuries c. Increased tone: posturing of spastic muscles, decreased tone: flaccid muscles d. Gross postural changes: side-to-side differences, front to back differences B. Reflexes Grading Description R Biceps Triceps L 0/4 Absent reflex (Areflexia) 1/4 Diminished but present (Hyporeflexia) 2/4 Normal reflex 3/4 Hyperactive (Hyperreflexia) 4/4 Hyperreflexia w/ clonus (Achilles & Patella only) Patellar Plantar Reflex (Circle Arrow): Flexor / Extensor /Equivocal Finger Flexor Reflex/Hoffman s (Circle One): Positive or Negative Achilles Ankle Clonus (Circle): Positive or Negative; R or L C. Upper Extremity Manual Muscle Strength Testing (Grading 1-5/5) UE: SAbd SER SIR EF WE WF EE LFF ADM FDI APB C5 C5 C5 C5 C6 C7 C7 C8 T1 T1 T1 Right Left SAbd: Shoulder Abduction SER: Shoulder Ext.Rot. SIR: Shoulder Int.Rot. EF: Elbow Flexion EE: Elbow Extension WF: Wrist Flexion WE: Wrist Extension LFF: Long Finger Flexion ADM: Abd. Digiti Minimi FDI: First Dorsal Interosseus APB: Abductor Pollicis Brevis D. Lower Extremity Manual Muscle Strength Testing (Grading 1-5/5) LE: HF HE KF KE HAbd HAdd ADF EHL APF A Inv. A Ev. L2 S1 S1 L3 L4-S1 L2-4 L4 L5 S1 L5-S1 L4-L5 Right Left HF: Hip Flexion HE: Hip Extension KF: Knee Flexion KE: Knee Extension HAbd: Hip Abduction HAd: Hip Adduction ADF: Ankle Dorsiflexion EHL: Extensor Hallucis Longus A. inv.: Ankle Inversion A Ev.: Ankle Eversion APF: Ankle Plantarflexion E. Sensory (Grading 2 = normal; 1 = impaired; 0 = absent) Level Light Touch R L Level Light Touch R L C3 Supraclavicular Fossa L2 Medial Anterior Thigh C4 Top of AC Joint L3 Medial Anterior Knee C5 Lateral Antecubital Fossa L4 Medial Malleolus C6 Dorsal, Proximal Thumb L5 Medial Dorsal Foot C7 Dorsal, Proximal 3 rd Finger S1 Inferior Lateral Malleolus C8 Dorsal, Proximal 5 th Finger S2 Popliteal Fossa T1 Medial Antecubital Fossa S3 Ischial Tuberosity 2 Neuro Exam 2018 Des Moines University
II. Reflexes A. Deep Tendon Reflexes (Muscle-Stretch Reflexes) C5: Biceps Brachii Reflex 1. The patient is sitting up straight with the arm at the side of the body and the back of the wrist resting on the thigh. 2. Find the tendon of the biceps brachii muscle with your thumb and press down so as to put the tendon on stretch. 3. Hit the distal knuckle of your thumb with the rubber head of your reflex hammer to elicit the biceps brachii reflex. 4. If no reflex is found, consider augmentation (have the patient hold the forearm in the air instead of resting on the thigh) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. C6: Brachioradialis Reflex 1. The patient is sitting up straight with the arm at the side of the body and the back of the wrist resting on the thigh. 2. Have the patient relax their forearm and wrist on their thigh. 3. Hit the brachioradialis tendon as it courses over the radius. a. You may use an indirect technique by placing your thumb or index finger over the tendon and hitting your finger instead. 4. You are looking for ELBOW FLEXION when testing the brachioradialis reflex. Movement of the wrist does NOT correspond to this reflex. 5. Be careful not to over-test this reflex due to the risk of causing transient injury to the radial nerve. If there is discomfort for the patient, place your finger over the tendon and hit your finger with the hammer. 6. If no reflex is found, consider augmentation (have the patient hold the forearm in the air instead of resting on the thigh) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. C7: Triceps Reflex 1. Hold the patient s arm with a FLAT hand on the biceps muscle rather than the web of your hand so as to prevent the dampening of the reflex response. 2. Have the patient relax their arm and shoulder. 3. Hit the triceps tendon before it crosses the elbow joint, being cautious not to hit the ulnar nerve (a.k.a. funny bone ). 4. If no reflex is found, consider augmentation (have the patient hold the forearm up slightly) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. 2018 Des Moines University Neuro Exam 3
(Cont.) Deep Tendon Reflexes (Muscle-Stretch Reflexes) L4: Patellar Reflex 1. Locate the patellar tendon between the patella and the tibial tuberosity. Avoid hitting these two bony structures as it may be painful for your patient. 2. Use the metal shaft of the reflex hammer to elicit this reflex. 3. If no reflex is found, consider augmentation (have the patient push with the leg slightly on one finger) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. S1: Achilles Reflex 1. By placing your hand on top of the foot and close to the ankle when testing the Achilles reflex, you can monitor the tendons crossing the ankle joint and detect if the patient is helping you by dorsiflexing their foot. For accurate results, the patient must be completely relaxed. 5. Use the metal shaft of the reflex hammer to elicit this reflex. 6. If no reflex is found, consider augmentation (have the patient push down with the foot slightly) a. Then if a reflex is obtained during augmentation, it is downgraded one level but not to zero. 4 Neuro Exam 2018 Des Moines University
B. Additional Muscle-Stretch Reflexes 1. Finger Flexor Reflex (Hoffman s Method) a. Procedure: i. The physician grasps the patient s wrist in one hand and with the other hand scissors the patient s middle finger between their index and middle fingers. ii. The physician then extends the patient s middle finger (MCP and PIP joints are extended) and briskly flicks the distal phalanx into flexion with their thumb. This allows the finger to flip-up (extend) sharply, which stretches the flexor muscles. b. Interpretation: The thumb and fingers will flex if the patient has hyperreflexia (3/4 or greater reflexes) 2. Ankle Clonus a. Definition: The to-and-fro, rhythmic oscillation of a body part, elicited by a quick stretch that is sustained. i. Demonstrates hyperactive muscle stretch reflexes caused by an UMN lesion. b. Procedure: i. Flex the patient s knee to relax the gastrocnemius muscle. ii. With your hand on the sole of the patient s foot, briskly jerk their foot up and outward (dorsiflexion and eversion) and maintain this pressure. c. Interpretation: If the foot will jerk between flexion and extension for as long as the physician maintains the dorsiflexion pressure, this is called sustained clonus. i. In mature adults, 0-2 beats of clonus is considered to be normal, but sustained clonus is likely pathologic. C. Superficial Reflex (Skin-to-Muscle Reflex) 1. Plantar Reflex (Babinski) a. Procedure: i. The patient should be either supine or seated. ii. Hold the patient s ankle with one hand to keep the foot in place. iii. With the sharp end of the reflex hammer, start at the heel of the foot and slowly stroke the lateral margin of the sole of the foot and along the base of the toes until you reach the base of the large toe. b. Interpretation: i. Flexor plantar response or an absent Babinski Sign big toe flexion; considered a normal response ii. Extensor plantar response or a present Babinski sign big toe extension; considered an abnormal response, indicating a possible UMN lesion. c. The small toes may fan but this does not constitute a consistent or clinically important part of the reflex. White arrow shows the direction of stroke made with sharp end of reflex hammer. 2018 Des Moines University Neuro Exam 5
III. Upper Extremity Muscle Strength Testing A. Muscle Strength Scale 1. 5/5: Full strength with full range of motion 2. 4/5: Diminished strength with full range of motion 3. 3/5: Full Range of motion against gravity 4. 2/5: Full range of motion without gravity 5. 1/5: No motion of the joint, muscle twitch observed or palpated 6. 0/5: No motion of the joint, muscle twitch not observed nor palpated B. C5: Elbow Flexors and Shoulder Abduction 1. Muscles tested include: a. EF: Biceps Brachii, Brachialis, Brachioradialis b. SA: Shoulder Abductors 2. Procedure for Elbow Flexion: a. Start with the elbow in FULL FLEXION b. Stabilize the ipsilateral shoulder c. Attempt to extend patient s elbow 3. Procedure for Shoulder ABduction: d. Start with arm in FULL ABDUCTION e. Stabilize the contralateral shoulder i May stabilize same shoulder if more comfortable for physician ii If physician is very small compared to the patient, he/she may use both hands on the distal forearm of the patient as long as the patient can stabilize themselves well f. Attempt to ADduct the shoulder C. C6: Wrist Extensors 1. Muscles tested include: Extensor Carpi Radialis Longus and Brevis a. Start with forearm in pronation and resting on the patient s leg. b. Bring wrist into FULL EXTENSION. c. Stabilize at the wrist. d. Attempt to flex wrist. 6 Neuro Exam 2018 Des Moines University
D. C7: Elbow Extensors 1. Muscles tested include: Triceps a. The patient holds their arm straight out at shoulder height, internally rotated with palm facing medially. b. The physician places one hand on the anterior portion of the patient s arm and the other hand on the posterior portion of forearm. c. The patient is asked to attempt to bend the elbow E. C8: Long Finger Flexors 1. Muscles tested include: Flexor Digitorum Profundus a. Start with the 3 rd finger of patient s hand flexed and wrist slightly extended. b. Stabilize at the wrist. c. With the physician s flexed 3 rd finger, attempt to extend patient s 3 rd finger. F. T1: Small Finger ABductor 1. Muscles tested include: Abductor Digiti Minimi a. Start with fingers extended and abducted. b. Stabilize at the wrist. c. With the physician s 5 th finger, attempt to bring the patient s 5 th finger towards their other fingers. 2018 Des Moines University Neuro Exam 7
IV. Lower Extremity Muscle Strength Testing A. L2: Hip Flexors 1. Muscles tested include: Iliopsoas a. Start with hip in full flexion. b. Have patient support themselves by grasping the back of the table. c. Physician pushes the thigh down towards the table. B. L3: Knee Extensors 1. Muscles tested include: Quadriceps a. Start with patient s knee fully extended. b. Physician pushes down towards the floor on the distal portion of the leg, until buttock raises from the table or knee bends. c. Note: If pain is produced with knee extension or when patient extends lumbar spine while bracing themselves, this might indicate a nerve impingement of the sciatic nerve root (L4, L5, S1) C. L4: Ankle Dorsiflexors 1. Muscles tested include: Tibialis Anterior a. Start with knee bent and ankle in full dorsiflexion b. Stabilize at the Achilles tendon. c. Physician attempts to plantar flex the foot. 8 Neuro Exam 2018 Des Moines University
D. L5: Long Toe Extensors 1. Muscles tested include: Extensor Hallucis Longus a. Start with the knee bent and 1 st toe pointing up towards ceiling. b. Stabilize the foot c. Physician s thumb attempts to push down on patient s 1 st toe. E. S1: Ankle Plantarflexors 1. Muscles tested include: Gastrocnemius, Soleus a. Patient is asked to stand on their toes on one leg with that knee extended fully. b. Physician may hold onto patient s hands or patient may be supported against the wall. c. Patient is requested to come up/down on their foot at least 10 times. 3. Grading for Ankle Plantarflexors Only: a. 5/5: Patient can do 10 or more repetitions. b. 4/5: Patient can only do between 2 and 9 repetitions. c. 3/5: Patient can only do it once. d. 2/5: Patient is placed in the lateral recumbent position so as to reduce gravity. In this position, they have full range of motion in plantarflexion. e. 1/5: Patient is lateral recumbent and only a muscle twitch is either felt or visualized. f. 0/5: Patient is lateral recumbent and no movement is felt or visualized in the ankle joint 2018 Des Moines University Neuro Exam 9
V. Sensory Testing A. ASIA Key Sensory Points 1. Note: All sensory testing MUST be done directly ON SKIN. 2. To perform this test: a. To establish the patient s baseline or normal sensation to light touch, start by lightly brushing the face bilaterally. b. Brush the skin lightly at each level bilaterally so as to compare side-to-side differences. c. Ask your patient if the light brushing feels BOTH normal and the same from side-toside. C3: In the supraclavicular fossa, at the midclavicular line. C4: Over the acromioclavicular joint. C5: On the lateral (radial) side of the antecubital fossa just proximal to the elbow T1: On the medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus. L2: On the anterior-medial thigh, at the midpoint drawn on an imaginary line connecting the midpoint of the inguinal ligament and the medial femoral condyle L3: At the medial femoral condyle above the knee C5 T1 C3 C4 L2 L3 L4: Over the medial malleolus L5: On the dorsum of the foot at the third metatarsal phalangeal joint S1: On the lateral aspect of the calcaneus, i.e., inferior and posterior to the lateral malleolus S2: At the midpoint of the popliteal fossa L5 L4 S2 S1 C6: On the dorsal surface of the proximal phalanx of the thumb. C7: On the dorsal surface of the proximal phalanx of the middle finger. C8: On the dorsal surface of the proximal phalanx of the little finger C6 C8 C7 10 Neuro Exam 2018 Des Moines University