Lower Limb Neuro Exam

what's up ninja nerds in this video today we're going to be talking about how to perform a lower limb neurological exam we have our patient here maddie today a gymnast enthusiast here we're going to get started here in a second but before we do please go down in the description box below we'll have links to our patreon where we have comprehensive notes where you guys should go download those and follow along with this lecture also if you guys do benefit from this video you like it it helps you support us by subscribing hitting that like button and commenting down in the comment section all right ninjas let's get into it all right maddie we're gonna go ahead and get started just get into a comfortable position here for me whoa okay that's pretty cool maddie but yeah i meant comfortable and is laying in the bed please all right matty there's some pretty cool stuff there but uh let me show you how we do it in engineered style [Music] [Music] all right ninja so now that we have maddie in a proper position we're going to go ahead and start on our lower limb neurological exam and the first thing i like to look for is symmetry between the two limbs i like to see if one side is a little bit more atrophied than the other or if they're symmetric in bulk if there was atrophy on one side there was weakness on this side there was fasciculations on this side and she had a decreased deep tendon reflex on the side i'm thinking maybe there's a lower motor neuron lesion somewhere that i have to be thinking about in this situation but again i don't appreciate any atrophy or any asymmetry in bulk in this situation the next thing i like to look for is i like to look for any abnormal movements so do i see any fasciculations present any twitching of the muscles i don't see any i don't appreciate any fasciculations the next thing is do i see any kind of really chaotic movements and some of these things could be like korea so if she was like moving her leg very quickly involuntarily and it was very arrhythmic that could be something like korea if she was flailing her legs around it could be something like belismis and that could be sometimes seen with like a subthalamic nuclear lesion the next thing i like to assess here is not just any abnormal movements as well and any fasciculations or any asymmetry in bulk but i just want to have her kind of lift her leg up can you go ahead and lift this right leg up here for me and then again do the same thing for the other leg and the other thing i like to do and you can put that down the things the reason why i want to do that is i want to see how smooth the movement is and if she has any difficulty initiating that movement because if there is difficulty that could be indicative of like maybe some bradykinesia as well so again on muscle appearance on mattie i appreciate no atrophy no fasciculations no abnormal movements no tremors and again no bradykinesia so that concludes the appearance part of our lower limb neuro exam the next thing we're going to do is a very important part of your neural exam is assessing tone tone is very important because you want to know a couple things is their normal tone some normal resistance to movement okay or is there hypotonia are the muscles really flaccid are they really floppy or is there hypertonia there's a significant resistance to me trying to move her legs if that's the case i have to further think about why let's try to think really quickly if she has hypotonia the there's a lot of flacidity in the movements when she's kind of just giving her leg to me that could be indicative if combined with atrophy hyporeflexia as well as fasciculations it may be indicative of a lower motor neuron lesion if she has a hypertonia then i have to further evaluate that if her muscles are really really having a lot of resistance to me moving them i want to know is it velocity dependent in other words if i move her leg really fast i kind of lose a little bit of that resistance that could be a sign of spasticity or if i move her legs fast or slow it doesn't really matter that resistance is the same throughout that movement that could be indicative of rigidity and those are big things to differentiate because spasticity is more indicative of upper motor neuron lesions whereas rigidity is more likely a symptom of something like parkinson's disease okay so how do we assess tone so maddie i just want you to kind of just relax your legs don't worry about tightening them up just kind of let them relax and what i like to do is very simple i just kind of take here and just move the leg side to side and i'm just assessing the tone there i want to see if it's there should be a little bit it shouldn't be super floppy but it shouldn't be super resistant to me moving them then i'm going to do the same thing on the other side and just compare you always want to compare one side from the other and again i don't notice i don't appreciate any hypertonia or any hypotonia the next thing i like to do is is i just like to kind of flex and kind of extend the knee here just to assess any resistance to that there as well and i didn't appreciate i like to do this one a little bit slower okay just to see if there's anything there so that's kind of giving me my velocity independent aspect of things then i again i just want it to nice and relaxed i'm going to quickly flex and extend the leg okay and i'm just seeing do i catch any resistance that again gives way as i really provide a quick movement there and the same thing i'm just going to do the same thing kind of relax your legs here i just want to assess the same thing here with the legs here in the lower extremities as well and again i'm just kind of assessing any tone any hypotonia or hypertonia so again to recap it just kind of assessing here moving side to side again slow movement slow movement and then a little bit quicker to see if you catch any kind of resistance that you break through okay and then again come down to lower extremity just provide some movements there and see if you catch any kind of rigidity or spasticity okay none is appreciated there the next thing i like to do is again tone is something that you can actually quantify you can utilize it by um what's called a modified ashworth score scale and so that's another way that we can quantify or further assess tone um and so we're going to have that here in the the side of the video that you guys can follow along with but the other thing i like to look at is while i'm already in this position and i'm already assessing the patient's tone there's something else i like to do so we're already kind of moving the legs around here i like to just take here and i want to inspect something called clonus this will go along with the reflexes and we'll kind of further talk about this a little bit later but what i like to do is i kind of like really kind of support the ankle joint here i like to come down here just relax relax relax and i like to really dorsiflex here and what i'm looking for is if i dorsiflex really hard and she starts patting that foot quickly that could be indicative of clonus so as you see here just wanted to relax relax relax and i'm dorsiflexing i don't see any clonus and you guys shouldn't either here same thing relax relax and i'm going to dorsiflex and i'm looking for any clonus the reason why we want to do that and again we'll kind of recap a little bit later is going if she had something like hypertonia she also had some weakness on one side and i also noticed that her reflexes are so intense that she could kick me in the face with them then i'm thinking okay maybe there's an upper motor in her own legion something's going on there and i've got to further evaluate that so again appearance good nothing abnormal appreciated tone normal tone no clonus present here on matty okay after we've assessed tone the next thing we're going to do is we're going to move on to power or strength whichever one you want to assess in that situation and there's different ways that there's a scale that we can use just like we can assess tone or quantify tone we can quantify strength and so the way that we do that is we use a power scale or a strength scale and it goes from zero to five five being full strength zero being none so now we're going to do is we're gonna assess this from the proximal hip joint all the way down to the little piggies okay so how do we start this off first thing we're going to do is we're going to assess hip flexion there's a bunch of muscles that are involved in these processes some of the big ones is like the iliacus the psoas major the pectineus muscle and they're supplied by the femoral nerve particularly root level is if you guys really want to know and it's important to remember this even though i'm giving a root level i'm using particular textbooks baits netters and consistent with the other videos that we've done on the lumbosacral plexus of what nerve root level you're going to have again these can differ from book to book so just keep that in mind but for this situation here hip flexion is primarily controlled by the femoral nerve l2 to l4 nerve roots so how are we going to assess this we're going to try to get her to flex at the hip so you can do this a couple ways you can do this at the extreme point of the movement or you can just do that at the actual relaxing point so in this situation i just want to go ahead and i want to stabilize this hip here and what i'm going to have you do here maddie is i'm going to have you try to lift this whole leg off the bed good and i assess that that's definitely she has full strength against my full resistance i'm going to do the same thing here i'm going to hold down and stabilize this hip go ahead and lift up good full strength against my resistance hip flexion 5 out of 5. next thing we're going to do is we're going to assess hip extension hip extension there's a bunch of muscles that are involved in this as well the nerve that's actually responsible for this is the inferior gluteal nerve and the inferior gluteal nerve has again its nerve root level is generally from l5 to about s2 and so what we're going to do here is i'm going to have her go ahead and lift her leg up this whole leg and what i'm going to do is i'm going to stabilize this hip here again and push down as hard as you can good and she has full strength against my full resistance same thing go ahead and lift this leg up here i'm going to stabilize this hip push down as hard as you can good full strength against resistance on that extension that's a five out of five the next thing i'm going to do is i'm going to assess adduction so hip adduction is controlled by a bunch of other muscles too your abductor muscles magnus longus brevis your operator externus there's a gracilis a ton of them right but it's primarily supplied by the obturator nerve and that's usually your l2 to l4 nerve root so how do we assess this so what i'm going to have her do is we're going to kind of just spread here a little bit and i'm going to go ahead and put my fist in here and i'm gonna have her try to push against my fist there yep good so hip adduction five out of five in this situation so we've assessed adduction so now we're gonna do is we're gonna assess abduction now again we're not we're not in a position we're kind of removing gravity here for her but we want to have gravity kind of supporting us in this kind of action here but when we're doing hip abduction we're assessing a couple different muscles there's the gluteus medius there's the gluteus minimus this is supplied primarily by the superior gluteal nerve and this is around your l4 s1 nerve root and so again the way we're going to do this in this position here is is going to be a little bit modified because we don't want her moving all around the table here but what we're going to do is we're just going to have her push out against good and that's assessing the abduction there five out of five strength and all uh this types of muscles there okay so hip abduction five out of five we've assessed flexion at the hip extension at the hip hip adduction hip abduction now we're gonna do is we're gonna move down to the next joint we're going to move to the knees so with the knees we're going to assess knee flexion and we're going to assess knee extension all right so what we're going to do now is it's easier to assess the knee extension and knee flexion kind of with the legs hanging a little bit it's a lot easier it's also more of the proper way to do these as well so what we're going to do is now we're going to assess knee extension so kicking her leg out right and so this is controlled by a bunch of the quadriceps muscles and this is again primarily innervated by the femoral nerve alter l2 to l4 nerve roots and so again what you kind of want to do here is is i'm just going to go ahead and anchor here and i'm going to have her kick out against me good full strength against my full resistance on this side we're going to compare it looking for any asymmetry go ahead and kick out against me there full strength against my resistance so 5 out of 5 for the knee extension now we're going to do is we're going to assess knee flexion and again these are a lot of the hamstring muscles that are supplying uh that are responsible for this type of function now these muscles the hamstring muscles are primarily innervated by the sciatic nerve that's your generally your l5 to s3 kind of nerve roots and there is a kind of a mixture of these nerves we'll talk about them a little bit later the tibial nerve and you also have the common fibular nerve but with the sciatic nerve supplying these hamstring muscles we're going to test the knee flexion so what i'm going to have her do is i'm going to bring her leg out like this and what i'm going to have her do is again pull her leg in towards the bed good good full strength against my resistance there same thing i'm going to compare on this side go ahead and pull your leg in there again full strength against my resistance so that in this situation the actual knee flexion five out of five okay so now that we've done the knee extension and knee flexion the next joint we'll go down to is the angle joint all right ninja so we talked about the knee joint let's now move on to the ankle joint and what we're going to do now is we're going to assess some dorsiflexion some plantar flexion some inversion and some eversion and the reason why we should know again what these these actions are and also know the nerve that is supplying those is that if there is any injury to the nerve if there's any compression of the nerve if there's any demyelination of the nerve those muscles that are performing those particular functions are not going to work properly and we'll see some obvious potentially asymmetry in those movements when we're examining the patient so we should again just be thinking about the nerve and again what the function of that nerve is all right so now we're going to do is we're going to assess some dorsiflexion so dorsiflexion is bringing the toes backwards towards her right and so there is going to be a particular nerve the deep fibular nerve that supplies those muscles and it's going to be primarily your l4 l5 nerve root and so what we want to do is we're just going to go ahead and kind of isolate just this movement here at the ankle joint and i'm going to have her kind of pull her toes towards her whole ankle yep good full strength against my resistance there same thing kind of just isolate this joint there go ahead and pull your toes back good full strength against my resistance bilaterally same thing plantar flexion i'm going to have uh test the muscles primarily in the posterior part of the calf and this is going to be supplied by and in this case it's generally the tibial nerve s1 s two nerve roots and so what i'm gonna do is again just isolate that ankle joint and have her push down like she's pushing on the gas pedal flying down the freeway same thing push down on this side again no asymmetry five out of 5 strength bilaterally the next thing we're going to do is we're going to assess inversion and you can do this a couple different ways one of the ways i like to do it is assessing at the extreme point of contraction of those muscles and then trying to have her resist me pulling it out of that movement and so the nerve that is supplying those particular muscles the inverters is the tibial nerve um and that's generally going to be your l4 l5 nerve root levels so what i'm going to do is have her kind of turn her the sole inwards here yep and then again what i'm going to do is just isolate that ankle joint and then don't let me pull it outwards good and she's able to have full strength against my resistance on this side i'm not going to compare but again what you would do is compare this bilaterally to notice any asymmetry that you might have okay same thing we're going to do e version of the ankle so now what i'm going to do is i'm going to have her kind of turn her sole of the foot outwards yep and again i'm going to isolate this and i'm going to tell her don't let me come pull her foot inwards and again she has full strength against my resistance trying to pull it inwards which is going against the eversion e-version there's a bunch of muscles that are responsible for this a lot of the fibularis brevis and longus there's a superficial fibular nerve that also is responsible for this and that's generally going to be around your your l5 to s1 nerve root level okay so in this situation here we've assessed from the proximal hip joint the knee joint the ankle joint you could go even further if you wanted to and assess the digits especially the big toe as well in this case we're going to forego that and defer that in this part of our exam but on maddie i appreciate 5 out of 5 strength and the proximal hip joint knee joint and ankle joint so now that we've assessed power or strength we've finished appearance we've finished tone we've done power strength the next thing i like to do is go into reflexes and since i kind of already have maddie in this kind of position where her legs are perfectly in this position for you guys to see it i like to just start off with doing what's called the babinski reflex this is very important reflex especially in patients who have some type of upper motor neuron lesion like a stroke and what happens with the babinski reflexes the normal sign is you want the toes to curl right if someone has an upper motor neuron lesion what will happen is their big toe will kind of dorsiflex so it'll come back towards her and then her toes will fan out and that could be a sign of an upper motor neuron lesion so what i like to do here is i just kind of like to take and i'm going to take the pointy end of my reflex hammer i'm going to start here at the heel and i'm just going to kind of work my way inwards in this fashion here and generally what should happen is she might not be that ticklish in this case situation but generally the toes will kind of curl down and that's this case she has a normal finding but again what would be abnormal and concerning is if we see that big toe dorsiflex and those toes fan out and we don't appreciate anything there so again the babinski reflex in this case is absent okay same thing we should compare bilaterally take here at the heel work our way upwards and we're trying to look again look for if you see curling of the toes but again what we don't want is that big toe to dorsiflex and those fan those toes to fan out okay so this is a pathological reflex you can assess this if you see some other abnormal reflexes or for example when i go and do her patellar and her ankle reflex if i notice some hyperreflexia if i noticed also that she has some particular maybe weakness on one side i might go down and do the babinski reflex because i'm trying to see is this an upper motor neuron lesion because if they had hyperreflexia they have weakness and they have a babinskis i might be thinking i got to do some further examination and figure out what is the reason for this and what kind of upper motor neural lesion do they have all right so that kind of takes us into reflexes right so we finished up strength and power and we already started off with a pathological reflex just because it's convenient in this location but now we've got to do is move on to the other reflexes the patellar and then the ankle reflex so let's go ahead and put her in a more comfortable position not on her head but with the legs kind of dangling down here and we're going to go ahead and examine that all right ninja so now we're going to assess reflexes here on matti okay so we've already talked a little bit about the babinski's reflex the pathological reflex now we're going to do is we're going to assess the patellar reflex and we're going to assess the ankle reflex in this situation here so the patellar reflex is going to be l2 to l4 nerve root and then the ankle reflex is going to be your s1 to s2 now when we're assessing reflex we we kind of use a scoring system or a scale in this situation we grade it from zero to four so we go zero plus one one plus uh two plus three plus and four plus okay and this scenario here what i want us to do is just try to figure out what this would be if we're going through it on maddie so zero would be someone is a reflexic they have no reflex okay or it's very even difficult to see any reflex present one a one plus would be hyporeflexic so it's very subtle very maybe slight reflex that you see whenever you're tapping maybe on the patellar tendon ways that i like to see if it really is a one plus versus like a zero is i like to do what's called a gingrasic maneuver or reinforcement maneuver so say that i tapped on that he's a patellar tendon and i got a very very like small reflex i'm still not sure if it was a good one or not i can have her kind of take her fist and pull them apart as well as clinch down on her teeth and sometimes that can really accentuate the reflex a little bit more and make it a little bit more noticeable when it's kind of subtle a two plus is a normal reflex so in this case hers are pretty normal and then the next one is a three plus where they're hyper reflexic okay they're coming out and really kicking at you all right and then a plus a four plus would be they have hyper reflexia with that term that i talked to you guys a little bit about before with clonus okay and if you guys remember that was where i was taking kind of maddie's foot here i was having a relaxing and then i was dorsiflexing and looking for those pats okay so again zero a reflexic one plus hyporeflexic that you can accentuate with a gingrasic maneuver two plus normal three plus is hyperreflexia without clonus four plus is a hyperreflexia with clonus okay so how do we assess that here on maddie so we're gonna go ahead and test the patellar reflex so again i'm just gonna kind of isolate here look for that patellar tendon and give it a good whack there okay nice little reflex there two plus reflexes right and again same thing over here good reflex there for maddie as well okay so we're going to come down do the ankle reflex here i like to just dorsiflex the foot a little bit come here behind and then tap and again you see that nice little reflex there as well do the same thing over here to compare bilaterally and again see nice little uh plantar flexion there as well so again normal patellar reflex two plus here two plus for her uh her ankle reflexes as well all right so we've already assessed reflexes on maddie now we're gonna do is we're gonna assess sensation so sensation we can do this in a couple different ways we can assess it via light touch we can assess this via pain we can assess it via temperature vibration and proprioception those are pretty much our essential kind of sensory modalities for the discriminative sensations that we did in the upper limb where we tested stereognosis we tested graphesthesia and we tested extinction we're going to defer that on this exam but again you could kind of apply the same concept there as well so it's the same as what we did in the upper limbs we can do that in the lower limbs let's focus primarily though on those essential modalities light touch being the first one i like to just use a cotton swab i wanted to identify what this should feel like and so i use a central location first i'm gonna have you close your eyes maddie and can you feel this yes anytime you feel this sensation your legs just say yes okay so we're going to go ahead and start then so we're going to apply we're going to try to apply the light touch sensation throughout all the dermatomal patterns here so here we go yes yes so that's our l1 did it feel the same yes yes yes did it feel the same yes that was our l2 yes yes that was our l3 does that feel the same yes yes yes that's our l4 did that feel the same yes yes yes that's our l5 did that feel the same yes yes yes that's our s1 did that feel the same and again we could even move a little bit more up the back of the calf for s1 and then into the hamstrings for the s2 dermatomal areas but again in her situation light touch is intact what does that mean that means that her dorsal column with her spinal cord the dorsal calamity lemniscus pathway is working properly now terminology that gets thrown along around a lot with this one is the terms aesthesias so if she had loss of sensation she wasn't able to identify that that would be called anesthesia if she had decreased sensitivity to that sensation that would be called hyposthesis if she had an increased sensitivity to that light touch sensation that would be called hypersthesis and if she felt like a numbness or a burning or a tingling type of sensation that would be referred to as a paresthesias okay important to remember that especially in diabetic patients who maybe have decreased sensations and the distal limbs particularly in bilaterally we call that kind of a stocking glove neuropathy and you see that commonly in diabetics so important to be thinking about that but in this case light touch is intact bilaterally the next thing we can assess is pain now you can do this with a couple different there's different types of tools i just have a cotton tip applicator with a nice little pointy end and so again i wanted to be able to know what this should feel like on her lower limbs so maybe close your eyes and can you feel this and anytime you feel that sensation on your limbs just say yes okay so again we're going to go ahead and start down the lower limbs yes yes that's our l1 did it feel the same yes yes yes that's our l2 did it feel the same yes yes yes l3 did that feel the same yes yes l4 yes did that feel the same yes yes yes l5 did that feel the same yes yes yes that's s1 did that feel the same yes good and again i could come back up through the calf a little bit more for s1 come back to the hamstrings for s2 as well so no um so there's no inability to identify pain stimuli so what does that tell me that means that her lateral spinal thalamic tract within the spinal cord is intact there's no issues with that so that is good there's no problems there there's no lesions there's no spinal cord compression no no problems with that and so there's terminology that likes to get thrown around for the pain pathway as well and that's algesia so if she had a decreased sensitivity to a painful stimulus that'd be called hypoalgesia if she had an increased sensitivity to the pain stimulus that would be called hyperalgesia and so it's just things that we need to be aware of when people are throwing that terminology around okay so pain intact i could do the same exact thing that i did testing the same pathway but just a different sensory modality and that's temperature i could use hot and cold temperatures and apply it over those dermatomes in the same way asking her to identify if she can feel hot and cold temperatures if she is that means that lateral spinal that lateral spinal thalamic tract is also intact so it's the same kind of thing that we did with pain just a different sensory modality okay so we've tested light touch we've tested pain we've explained the same thing that you would do with the temperature the next thing we would do is a vibration sense so vibration is a very important one because if there is any lesions usually of the dorsal column this is one of the since the first sensations to usually go so with vibration sense you can use a tuning fork and you can apply this on a bony prominent i like to start distal first if they can't identify that distal sensation then i go up to a proximal point and see if they can identify it there so what i want to do is i wanted to know what this vibration sense should feel like at a central location so maybe close your eyes maddie and can you feel this yes anytime you feel this sensation just say yes okay so we're going to come down here to this distal point of this digit here at the bony prominence on the big toe we're going to go ahead and hit on our tuning fork and place it there yes tell me when you can't feel the sensation good and i just dampen i kind of remove the vibrations and she should be able to identify when the sensation is there and when it is gone so that means the vibration is intact on this side let's compare it bilaterally yes tell me when you can't feel it good so vibration is intact bilaterally what does that tell me that tells me that there is no issues with that dorsal column pathway also not just the dorsal column of the spinal cord but the sensory nerves that are taking that information from that that big toe all the way up to her spinal cord there's no neuropathy as well so there's no neuropathy and there's also no problems with her dorsal column medial meniscus pathway okay vibration is beautiful again if she wasn't able to identify that i could further evaluate that at the asis a more proximal joint all right so vibration is tested let's now test proprioceptions another essential modality proprioception is going to be again carried via your dorsal column pathway but again your sensory nerves have to be functioning as well in order for that to be completely normal so again we test proprioception just like we did with all the other sensations we want to know what what the sensation should feel like so what i'm going to do is i'm going to isolate her kind of her big toe here i'm going to have you close your eyes maddie okay so this is up this is down i'm going to move your toes around a couple times i want you to tell me in what position it is okay good so she's able to identify the position of her big toe in a three-dimensional space with her eyes closed it's only depending now upon that sensory pathway because her eyes are closed now we're going to compare this bilaterally okay so again go ahead and isolate over here pull on the sides of the toes there and again matti this is going to be up this is going to be down okay so just tell me what position it's in up up good so she's able to identify the position of her big toes in the three-dimensional space bilaterally proprioception is intact what does that tell me that tells me that the dorsal column medial meniscus pathway is intact and the nerves that are bringing that sensation to the spinal cord are also intact any inability to identify that could be indicative of a neuropathy or dorsal column spinal cord lesion okay so we've assessed our essential modalities if we really wanted to we could do a discriminative type in this situation it could be very very simple extinction formerly known as neglect close your eyes maddie okay tell me which side i'm touching you good so i did double simultaneous stimulation if she had for example the best type of example for this is strokes if she had a right mca stroke for example particularly maybe involving a little bit more of the lower extremities she may neglect one side of her body so for example she had a right mca stroke if i asked her to tell me which side i'm touching and i was touching both legs simultaneously she would probably only say i can only feel you touching the right because she'll neglect the left side okay so that would be testing extinction also formerly known as neglect so in this scenario maddie is able to identify all light touch pain we did forego temperature vibration proprioception and there is no extinguishing one side of the body that would cover our sensation part of the upper the lower limb neuro exam the last part of the lower limb neuro exam is going to be assessing coordination carried out by the cerebellum so how do we do this when we were up in the upper limbs one of the things that we did is we did what's called a finger to nose test we can do somewhat of a similar type of test looking for what's called dysmetria in the same way so dysmetria is having an inability to kind of really move the heel up and down the shin there's a lot of ataxia that can be seen there so what i'm going to have here is what's called the heel to shin test so maddie i'm going to have you take your heel put it here on the top of your shin run it down all the way and back up do that one more time good all right and you can bring that one down and you're going to do the same thing for the other side and we're going to compare so bring this heel up to the top and slide that down and go up and down two times there one more good and you can go and lay that down there so what am i doing when i'm assessing her heel going up and down the shin i'm looking for the the rate i want it to be a decent rain i don't want her to be going super super slow but i don't want her to actually be going too fast right i just i want a nice smooth rate i want the rhythm i want it to flow nicely so if she's like having a hard time where she's kind of catching at different points and she's sliding off and then she's can't keep it on her shin that might be telling me something that something's going on maybe with the cerebellum so again i look for the rate i look for the rhythm of that and i also look for the amplitude now here's the thing that sometimes can be difficult with seeing heel to shin testing if someone's naturally weak or they have lower limb weakness it can be sometimes relatively difficult to distinguish between actually having some ataxia or dysmetria present okay so again testing for dysmetria or any signs of abnormalities with the cerebellum what would i do i do the heel to shin any inability to to do that may indicate some dysmetria and potentially a taxi as something is going on with the cerebellum and if she has problems on one side more for example if she had problems moving her right leg up and down the left it might tell me that something's wrong with her right cerebellum because again cerebellum and the problems are usually ipsilateral okay all right so that's how we would assess the heel to shin looking for any dysmetria any type of limb a taxi in this situation the next thing is remember how we did this we did you can do it a couple ways in the upper limbs rapid movements right we did it in this way or we also did it kind of in this this pattern we can do the same thing i can just have her tap on my hands and so what i can do here is i'll do one at a time maddie i'm just gonna have you take your right foot and tap on my hand as quick as you can good and the same thing with the left good and i'm just looking at the rate i'm looking at the rhythm i'm looking at the amplitude of the movement if she was really having difficulty doing that it was very slow the rhythm was really really out of whack she was going like one and then she would take a long time and maybe do two and then she was taking a long time and maybe she'd do three it just wasn't a consistent rhythm it wasn't a normal rate i might be thinking there's some dysdiato kinesis present okay so again if there was a right cerebellar lesion she may have difficulty with that rapid movement on the right side and that could be indicative of some dysdiato kinesis the last thing that i could test while we're already here we talked about what's called a cerebellar drift with the upper extremities where they would have like a pronation and lifting their leg upward lifting their arm upwards we're not going to assess that here what we would do is sometimes you can see what's called a pendulous kind of knee swinging after you do what's called a patellar reflex so really quickly if i were to kind of just lower this down here for maddie if i were to do a patellar reflex on maddie and i i tapped her her patellar tendon and her leg after i did that she just kept kind of like swinging like this afterwards on that right side that could be indicative of a right cerebellar lesion so sometimes they have what's called a pendulous type of movement or swinging after a knee-jerk reflex or a patellar reflex and that also could be indicative of some type of cerebellar lesion so to recap one of the ways that we test coordination on the lower limbs we can do the same thing heel to shin looking for any dysmetria we can do quick tapping of the foot on the person's on the the clinician's hands looking for dysdiato kinesis and then again when you were doing that patellar reflex go back and think was their legs swinging a lot afterwards after you did that reflex because that could also be indicative of a pendulous type of swinging after a knee-jerk reflex which could be indicative of a cerebellar lesion okay so that's how we would attest our coordination in this sense and that would conclude our lower limb neurological exam all right ninja nerds so in this video today we talk about how to perform a lower limb neurological exam i hope it made sense i hope that you guys did enjoy it and learned a lot big thanks to our patient here maddie give her some big shout outs down in the comments section for being here for us today helping us out with this exam and engineers we thank you we love you and as always until next time [Music] you

Channel: Ninja Nerd

Views: 63,114

Rating: 4.9529581 out of 5

Keywords: Ninja Nerd Lectures, Ninja Nerd, Ninja Nerd Science, education, whiteboard lectures, medicine, science

Id: kZgTq5ZPBiQ

Length: 36min 52sec (2212 seconds)

Published: Mon May 03 2021