Upper limb neurological examination

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Upper limb neurological examination
Nerves of the left upper extremity.gif
Distribution of nerves in the upper limb
Purposeassess the motor and sensory neurons which supply the upper limbs

An upper limb neurological examination is part of the neurological examination, and is used to assess the motor and sensory neurons which supply the upper limbs. This assessment helps to detect any impairment of the nervous system, being used both as a screening and an investigative tool. The examination findings when combined with a detailed history of a patient, can help a doctor reach a specific or differential diagnosis. This would enable the doctor to commence treatment if a specific diagnosis has been made, or order further investigations if there are differential diagnoses.

Contents

Structure of examination

The examination is performed in sequence: [1]

  1. General inspection
  2. Muscle tone
  3. Power
  4. Reflexes
  5. Coordination
  6. Sensation

General inspection

The upper body is exposed and a general observation is made from the end of the bed. Signs of neurological disease include: [2]

Muscle tone

The hand is grasped like a handshake and the arm is moved in various directions to determine the tone. [1] The tone is the baseline contractions of the muscles at rest. The tone may be normal or abnormal which would indicate an underlying pathology. The tone could be lower than normal (floppy) or it could be higher (stiff or rigid).

Power

The strength of the muscles are tested in different positions against resistance. [1]

Reflexes

There are 3 reflexes in the upper arm that are tested. [1] [2] These are the biceps, triceps and supinator reflex. The reflexes may be abnormally brisk or absent. In the latter, the reflex could be elicited through reinforcement by asking the patient to clench their jaw. [2]

Coordination

Three separate aspects of coordination are tested: [1]

Finger-nose test

This maneuver tests for dysmetria.

The examiner holds their hand in front of the patient, who is then asked to repeatedly touch their index finger to their nose and the examiner's finger. The distance between the examiner's hand and patient's nose should be larger than the forearm length of the patient, so that the patient need to move both their shoulder joint and elbow joint during the test instead of just moving the elbow joint.

Healthy individuals can touch accurately on their nose and examiner's hand with ease, while dysmetria patients will constantly miss the nose and the hand.

Rapid pronation-supination

This maneuver tests for dysdiadochokinesia.

The patient is asked to tap the palm of one hand with the fingers of the other, then rapidly turn over the fingers and tap the palm with the back of them, repeatedly. The patient is asked to perform the clapping as quickly as he could.

Dydiadochokinesia patient will be impaired in the rate of alternation, the completeness of the sequence, and in the variation in amplitude involving both motor coordination and sequencing. [3] [4]

Pronator drift

The arms are outstretched and patient is instructed to close their eyes. If the hands do not move, it is normal.

Sensation

The five aspects of sensation are tested:

  1. Light touch - tested using cotton wool
  2. Pain - tested with a neurological pin
  3. Proprioception (sense of joint position) - tested by moving the thumb while the patients eyes are closed. Patient is then asked whether the thumb is moved up or down.
  4. Vibration - tested with a 128 Hz tuning fork placed at the first joint of the thumb
  5. Temperature - tested with hot and cold test tubes. Alternatively the cold tuning fork used for vibration sense, could be used.

Related Research Articles

Ataxia is a neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormality, speech changes, and abnormalities in eye movements, that indicates dysfunction of parts of the nervous system that coordinate movement, such as the cerebellum.

<span class="mw-page-title-main">Tremor</span> Involuntary muscle contraction

A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the hands. In some people, a tremor is a symptom of another neurological disorder.

<span class="mw-page-title-main">Clonus</span> Set of involuntary and rhythmic muscular contractions and relaxations

Clonus is a set of involuntary and rhythmic muscular contractions and relaxations. Clonus is a sign of certain neurological conditions, particularly associated with upper motor neuron lesions involving descending motor pathways, and in many cases is accompanied by spasticity. Unlike small spontaneous twitches known as fasciculations, clonus causes large motions that are usually initiated by a reflex. Studies have shown clonus beat frequency to range from three to eight Hz on average, and may last a few seconds to several minutes depending on the patient’s condition.

Hypotonia is a state of low muscle tone, often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases and disorders that affect motor nerve control by the brain or muscle strength. Hypotonia is a lack of resistance to passive movement, whereas muscle weakness results in impaired active movement. Central hypotonia originates from the central nervous system, while peripheral hypotonia is related to problems within the spinal cord, peripheral nerves and/or skeletal muscles. Severe hypotonia in infancy is commonly known as floppy baby syndrome. Recognizing hypotonia, even in early infancy, is usually relatively straightforward, but diagnosing the underlying cause can be difficult and often unsuccessful. The long-term effects of hypotonia on a child's development and later life depend primarily on the severity of the muscle weakness and the nature of the cause. Some disorders have a specific treatment but the principal treatment for most hypotonia of idiopathic or neurologic cause is physical therapy and/or occupational therapy for remediation.

<span class="mw-page-title-main">Patellar reflex</span> Monosynaptic reflex

The patellar reflex, also called the knee reflex or knee-jerk, is a stretch reflex which tests the L2, L3, and L4 segments of the spinal cord. Many animals, most significantly humans, have been seen to have the patellar reflex, including dogs, cats, horses, and other mammalian species.

Dysmetria is a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye. It is a type of ataxia. It can also include an inability to judge distance or scale.

Hypertonia is a term sometimes used synonymously with spasticity and rigidity in the literature surrounding damage to the central nervous system, namely upper motor neuron lesions. Impaired ability of damaged motor neurons to regulate descending pathways gives rise to disordered spinal reflexes, increased excitability of muscle spindles, and decreased synaptic inhibition. These consequences result in abnormally increased muscle tone of symptomatic muscles. Some authors suggest that the current definition for spasticity, the velocity-dependent over-activity of the stretch reflex, is not sufficient as it fails to take into account patients exhibiting increased muscle tone in the absence of stretch reflex over-activity. They instead suggest that "reversible hypertonia" is more appropriate and represents a treatable condition that is responsive to various therapy modalities like drug or physical therapy.

<span class="mw-page-title-main">Vestibulospinal tract</span> Neural tract in the central nervous system

The vestibulospinal tract is a neural tract in the central nervous system. Specifically, it is a component of the extrapyramidal system and is classified as a component of the medial pathway. Like other descending motor pathways, the vestibulospinal fibers of the tract relay information from nuclei to motor neurons. The vestibular nuclei receive information through the vestibulocochlear nerve about changes in the orientation of the head. The nuclei relay motor commands through the vestibulospinal tract. The function of these motor commands is to alter muscle tone, extend, and change the position of the limbs and head with the goal of supporting posture and maintaining balance of the body and head.

Intention tremor is a dyskinetic disorder characterized by a broad, coarse, and low-frequency tremor evident during deliberate and visually-guided movement. An intention tremor is usually perpendicular to the direction of movement. When experiencing an intention tremor, one often overshoots or undershoots one's target, a condition known as dysmetria. Intention tremor is the result of dysfunction of the cerebellum, particularly on the same side as the tremor in the lateral zone, which controls visually guided movements. Depending on the location of cerebellar damage, these tremors can be either unilateral or bilateral.

The triceps reflex, a deep tendon reflex, is a reflex that elicits involuntary contraction of the triceps brachii muscle. It is sensed and transmitted by the radial nerve. The reflex is tested as part of the neurological examination to assess the sensory and motor pathways within the C7 and C8 spinal nerves.

Primitive reflexes are reflex actions originating in the central nervous system that are exhibited by normal infants, but not neurologically intact adults, in response to particular stimuli. These reflexes are suppressed by the development of the frontal lobes as a child transitions normally into child development. These primitive reflexes are also called infantile, infant or newborn reflexes.

Focal neurologic signs also known as focal neurological deficits or focal CNS signs are impairments of nerve, spinal cord, or brain function that affects a specific region of the body, e.g. weakness in the left arm, the right leg, paresis, or plegia.

Hoffmann's reflex is a neurological examination finding elicited by a reflex test which can help verify the presence or absence of issues arising from the corticospinal tract. It is named after neurologist Johann Hoffmann. Usually considered a pathological reflex in a clinical setting, the Hoffmann's reflex has also been used as a measure of spinal reflex processing (adaptation) in response to exercise training.

<span class="mw-page-title-main">Cranial nerve examination</span> Type of neurological examination

The cranial nerve exam is a type of neurological examination. It is used to identify problems with the cranial nerves by physical examination. It has nine components. Each test is designed to assess the status of one or more of the twelve cranial nerves (I-XII). These components correspond to testing the sense of smell (I), visual fields and acuity (II), eye movements and pupils, sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing and balance, taste, pharyngeal movement and reflex, tongue movements (XII).

Clasp-knife response refers to a Golgi tendon reflex with a rapid decrease in resistance when attempting to flex a joint, usually during a neurological examination. It is one of the characteristic responses of an upper motor neuron lesion. It gets its name from the resemblance between the motion of the limb and the sudden closing of a claspknife after sufficient pressure is applied.

In medicine, pronator drift refers to a pathologic sign seen during a neurological examination. Jean Alexandre Barré is credited with having first described it; thus it is sometimes known as the Barré test or sign. A positive result indicates palsy. This sign can appear due to an upper motor neuron lesion or various other conditions which include palsy as a symptom.

The Golgi tendon reflex (also called inverse stretch reflex, autogenic inhibition, tendon reflex) is an inhibitory effect on the muscle resulting from the muscle tension stimulating Golgi tendon organs (GTO) of the muscle, and hence it is self-induced. The reflex arc is a negative feedback mechanism preventing too much tension on the muscle and tendon. When the tension is extreme, the inhibition can be so great it overcomes the excitatory effects on the muscle's alpha motoneurons causing the muscle to suddenly relax. This reflex is also called the inverse myotatic reflex, because it is the inverse of the stretch reflex.

<span class="mw-page-title-main">Babinski–Nageotte syndrome</span> Medical condition

Babinski–Nageotte syndrome is an alternating brainstem syndrome. It occurs when there is damage to the dorsolateral or posterior lateral medulla oblongata, likely syphilitic in origin. Hence it is also called the alternating medulla oblongata syndrome.

Upper motor neuron syndrome (UMNS) is the motor control changes that can occur in skeletal muscle after an upper motor neuron lesion.

<span class="mw-page-title-main">Cutaneous reflex in human locomotion</span>

Cutaneous, superficial, or skin reflexes, are activated by skin receptors and play a valuable role in locomotion, providing quick responses to unexpected environmental challenges. They have been shown to be important in responses to obstacles or stumbling, in preparing for visually challenging terrain, and for assistance in making adjustments when instability is introduced. In addition to the role in normal locomotion, cutaneous reflexes are being studied for their potential in enhancing rehabilitation therapy (physiotherapy) for people with gait abnormalities.

References

  1. 1 2 3 4 5 Longmore, Murray; B. Wilkinson, Ian; Baldwin, Andrew; Wallin, Elizabeth (2014). Oxford Handbook of Clinical Medicine. Oxford University Press. pp. 72–73. ISBN   9780199609628.
  2. 1 2 3 Cox, Niall; A. Roper, T (2009). Clinical Skills. Oxford University Press. pp. 201–217. ISBN   9780192628749.
  3. Deshmukh, A; Rosenbloom, MJ; Pfefferbaum, A; Sullivan EV (2002). "Clinical signs of cerebellar dysfunction in schizophrenia, alcoholism, and their comorbidity". Schizophr. Res. 57 (2–3): 281–291. doi:10.1016/s0920-9964(01)00300-0. PMID   12223260. S2CID   3198795.
  4. Diener, HC; Dichgans, J (1992). "Pathophysiology of Cerebellar Ataxia". Movement Disorders. 7 (2): 95–109. doi:10.1002/mds.870070202. PMID   1584245. S2CID   19100385.