Upper Limb Examination
Inspection:
- Muscle wasting
- Fasciculations
- Deformities
- Skin changes
- Ask if the patient has any pain!
Tone:
Move 2 joints at a time. For the patient's right arm, hold the patients right hand with your right hand (as if shaking hands)
and then gently rotate clockwise and anticlockwise. At the same time, support their upper arm with your left hand and gently
flex and extend their arm at the elbow joint.
Tone can be:
- Increased - Upper Motor Neurone (UMN) lesion
- Normal
- Decreased - Lower Motor Neurone (LMN) lesion
- Cog-wheeling/Lead-pipe rigidity - Parkinsonian signs. If the wrist joint feels rigid in a 'step-wise' fashion during flexion and extension,
then this is cog-wheel rigidity (tremor superimposed upon rigidity). Lead-piping is a similar rigidity in the entire arm (movement about the
elbow joint).
Power:
Always compare the two sides, and try and compare with similar forces (so you try and oppose with similar movements). It
may often be best to make the movements yourself to demonstrate first.
- Shoulder abduction (C5, deltoid) - Make "chicken-wings" shape and patient pushes up whilst you push down around the upper humerus. Can
do both sides at once.
Command = 'push up against me as hard as you can'.
- Forearm flexion (C5/6, biceps) - Patient makes a fist and flexes arm at elbow joint, one arm at a time. Whilst supporting yourself on patients
opposite shoulder, you pull their arm away whilst they try and flex.
Command = 'pull me towards you'.
- Forearm extension (C7/8, triceps) - As above, but you push against patient's arm whilst they push you away.
Command = 'push me away'.
- Wrist extension (C7, wrist extensors, radial nerve) - Patient makes a fist and holds one arm out. Support the forearm
with one of your hands and with the other, get the patient to raise their fist up whilst you push down with your fist.
Command = 'hold your arm out straight, make a fist facing downwards and push up against me at your wrist'.
- Finger abduction (T1, palmar interosseus, ulnar nerve) - Patient holds arm out with fingers spread. With a finger of each hand
of your hands, try and push the patients index and little fingers inwards (so you are opposing their fingers with your fingers).
Command = 'spread your fingers and stop me pushing them closed'.
- Thumb abduction (T1, median nerve) - abduction of the thumb is it's movement straight up (as opposed to up and laterally, which
is extension). Tell patient to raise thumb up and you oppose with your thumb.
Command = 'raise your thumb up straight
and stop me pushing your thumb down'.
Remember that the radial nerve supplies the extensors of the wrist, whilst the ulnar nerve supplies all of the intrinsic
muscles of the hand, except for 'LOAF', which are supplied by the median nerve:
L ateral two lumbricals (fingers 2 and 3)
Oppons pollicus
Abductor pollicus brevis
Flexor pollicus brevis
Coordination:
- Finger-nose (intention tremor / past pointing).
Command = 'With your right hand, touch your nose, then my finger, then your nose.
Then repeat as fast as you can'. Remember to move the position of your finger and to keep it at exactly arms length from
the patient.
- Rapid alternating movements (hands) - 'dysdiadochokinesis'. This requires big movements that originates at the shoulder joint as the role
of the cerebellum is generally in the control of large proximal motor groups and not small fine groups.
Command = 'Hold your left palm out still and flat.
Now clap onto it with your right palm. Then raise your right arm up fully and then then clap onto your left palm with the back
of your right hand. Then repeat as fast as you can'.
Reflexes:
Ensure limb is full relaxed. It is often best to move and 'flop' the arm around a bit to ensure this. Practice reflexes with the
patient lying down. Those on the opposite side of the patient's body require some practice as you cannot move over to the
other side of the bed!
- Biceps (C5/6) - rest patient's arms on their abdomen.
- Supinator (C5/6) - rest patient's arms on their legs
- Triceps (C7/8) - examiner lifts the appropriate (flexed) arm by the wrist and supports it against the area of the opposite clavicle to ensure full relaxation.
Remember to use techniques of reinforcement if required, eg. 'when I count to 3, clench your teeth'. Coincide your tendon hammer strike with
the patient's teeth clenching.
Sensation:
Dorsal columns:
- Light touch - use a piece of rolled up cotton wool and compare dermatomes on both limbs. Remember to rub this against the patients forehead
or lower neck area to demonstrate what it feels like first. Press down on the skin - do not 'stroke' as this activates more than just the light touch
response.
- Proprioception - demonstrate this to the patient with their eyes open first so that they understand. Hold either side of the finger tip (not on the
nail bed), whilst supporting their wrist with your other hand. Then move either up or down. Patient should then close their eyes, whilst you move
their fingers at the distal interphalangial joint . Very small movements should produce a response. If they are unable to do the test, then try more
proximal (bigger) joints, such as the wrist.
- Vibration - use a tuning fork on bony prominences. Again, show the patient what this feels like first. Make the fork vibrate first, then place on a joint.
Then dampen the vibration and ask the patient to tell you when it stops vibrating (with their eyes closed).
Spinothalamic tracts:
- Pain - use a 'neurotip' - a small red specially designed disposable pin, in the dermatomal distribution.
- Temperature - you can use the metal of your tendon hammer head as 'cold' and the rubber part of this as 'hot'.
Lower Limb Examination
Inspection:
As for upper limb:
- Muscle wasting
- Fasciculations
- Deformities
- Skin changes
- Gait - asking the patient to walk before you start the examination can help prevent you from forgetting later!
- Romberg's test - you can perform this now, before the patient lies down. See 'sensation' section, below.
- Ask if the patient has any pain.
Tone:
Move 2 joints at a time. You can, for example, move the foot whilst flexing and extending the knee joint. It can be useful to
'pick up' the leg at the knee by flexing it with one palm underneath, and by then (gently) dropping the leg to the bed. If
the tone is normal, it should just flop back onto the bed. With increased tone, it will remain flexed for longer.
Tone can be:
- Increased - Upper Motor Neurone (UMN) lesion
- Normal
- Decreased - Lower Motor Neurone (LMN) lesion
Clonus: Check for this by externally rotating the hip joint and slightly flexing the knee. Then, gently
dorsiflex/plantarflex the foot a few times. Finally, make a sudden dorsiflexion movement of the foot and hold it there.
Observe the calf area, looking for 'beats' or pulsations of the muscle. Greater then 3 beats count as clonus, and is a sign
of an upper motor neurone lesion.
Power:
- Hip flexion (L1/2) - Test one leg at a time. Push down against the quadriceps muscle. In most cases you should not be able to overcome
the strength of this movement. Start with the patients leg already in the air (rather than whilst it is still flat on the bed).
Command = 'keep your leg straight at the knee and raise it off the bed, pushing against my hand'.
- Hip extension (L5/S1) - Keep a flat hand under the patients upper thigh area (hamstrings).
Command = 'push your knees into the bed against my hand'.
Knee flexion (L5/S1) - Get patient to bend the knees and place feet flat on the bed. Use one hand against the patients hamstring area
to steady yourself and the patient whilst pulling the calf towards you.
Command = 'with your knees bent, stop me pulling your legs straight'.
Knee extension (L3/4) - As above.
Command = 'try and straighten your leg/'kick out' towards me'.
Ankle dorsiflexion (L4/5 - Upwards movement (plantar extension) of the foot. Start with the foot dorsiflexed then apply resistance.
Command = 'push your toes up and stop me pushing them down'.
Ankle plantarflexion (S1) - Downwards movement of the foot.
Command = 'push your toes down away from you'.
Coordination:
Hell-shin test: Involves patient running the heel of one foot down from the knee of the other leg to the foot of the other leg, raising the leg
up and repeating as fast as possible. Then repeat with the other leg.
Command = 'Keep your left leg flat on the bed. Raise your right leg into the air, and run the sole of your right
food down from your right knee to your right foot. Then raise your right leg into the air and move it back to over your right
knee. Then place it down again, and repeat as fast as you can'.
Reflexes:
Knee (L3/4) - Flex the knees, by placing your left arm underneath them to support all of the weight. Flop them up and down until the patient
is fully relaxed. Then tap at the patellar tendon.
Ankle (L5/S1) - As for clonus, externally rotate at the hip and lightly flex at the knee. Then, to relax the patient, use your left hand to lift up-and-down
at the upper leg (quadriceps/hamstrings area) a few times. Once relaxed, tap at the Achilles tendon, and observe the calf for a reflex. Practice the
'opposite leg' as this can be tricky (hold your tendon hammer in reverse - almost like you would hold a dart).
Plantar (Babinski) (L5) (S1/S2) - Using a not-too-sharp object (opinions vary - some say the end of a tendon hammer is ok, other examiners
prefer car keys), gently but firmly stroke the outer (lateral) border of the sole of the foot. Start at the base, and come in medially as you approach
the toes. It is the movement of the big toe (hallucis) that you are looking at, not the movement of the other toes. If the test yields no clear result, the
plantars are said to be 'equivocal'.
For reinforcement, you can use the 'teeth grinding' technique as discussed above. Alternatively, get the patient to interlock
their fingers (place left palm flat, place fingers of right palm over left fingers, and interlock by flexing at the MCP joints).
Ask the patient to pull their arms apart (whilst fingers are still interlocked) on the count of 3.
Sensation:
Test all modalities, as for upper limb. It may be worth performing Romberg's test whilst the patient is standing, at the start of the examination.
- Light touch
- Vibration
- Pain and temperature
- Proprioception (inc. Romberg's test)
Romberg's test: determinator of cerebellar (unsteady all the time) vs proprioceptive (peripheral) sensory input deficit
(in which case the patient will be increasingly unsteady with eyes closed). Ask the patient to stand with legs next to
one another and arms by side. Then ask them to close their eyes. Make sure you support them if they are unsteady. A positive
test is when they are more unsteady when their eyes are closed (indicates a peripheral sensory problem).
