Neurology: Clinical Skills - Motor, Sensory, & Reflex Neurological Exam #neurology #ubcmedicine

this video will cover in detail the motor sensory and reflex components of the neurological examination we will divide the exam into motor reflex and sensory sections however please note that there are many ways to organise the neurological exam depending on the clinical context and environment hi Paulina my name is dr. Blair area today we're gonna be doing the motor examination with reflexes sensory examination is that okay with you okay so we will start with the motor examination which includes inspection pronator drift tone and power inspect the patient look specifically for both general and limb posture muscle bulk and involuntary movements look for common abnormalities such as tremor which is the rhythmic oscillation around a joint or fasciculations which are involuntary repetitive muscle contractions best examined under tangential lighting on general inspection there is normal muscle bulk no evidence of atrophy or fasciculations and no abnormal movements such as tremor and we're gonna start with can you extend your arms and palms facing to the ceiling and just hold it there and close your eyes for me this test has a high sensitivity for detecting weakness due to motor neuron lesions in the corticospinal tracts if pronator drift is present the patient's hand will pronate and their arm will drift downward it may take several seconds for pronator drift to occur so be sure to hold this pose for at least 15 seconds excellent thank you okay so we'll move on to tone I take your ham tone is the amount of residual resistance offered by a muscle when it's moved passively assessed tone in the upper limb by rotating the wrist and flexing and extending the elbow feel for constant stiffness which indicates rigidity on the other side caching which indicates spasticity and decreased tone which indicates flaccidity being able to distinguish normal and abnormal tone will come with practice okay so tone is normal there's no evidence of virginity or spasticity and then we will move on to power testing when assessing muscle power use the MRC scale to quantify your findings grade five is normal strength against full resistance grade 4 is reduced strength against resistance and can be further broken down into 4 plus 4 and 4 minus grade 3 is movement against gravity with resistance removed grade 2 is movement only when gravity is removed grade 1 is a flicker of movement in the muscle and grade 0 is no movement at all to test muscle power use a systematic approach neurologists usually like to test proximal to distal we will focus on testing only a few key muscle groups in this video ok can you hold your arms out like this and just resist me good and now hold your arms out like this and pull in when testing power it's important to isolate the muscle being tested and now I'm gonna get you to push out use one hand to immobilize the proximal joint always compare muscle power on both sides before moving on to the next muscle ok I'm gonna ask you to extend your wrist like this now the other side now can you turn your arm over and make a fist and bring it in and resist me good now turn your hand over again and extend your fingers keep them strong good now turn over again flex your fingers remember to apply pressure that's appropriate to the muscle being tested and now can I get you to extend your fingers like this when testing finger abduction use your index and pinky fingers to apply pressure excellent now turn your hand over bring your thumb in just like that and up towards the ceiling and hold it strong so there's full-power and the distal upper extremities so we're gonna continue with the motor exam of the lower limbs starting with tone ten get you to lie back comfortably and relax your lower limbs to assess tone in the lower limbs gently roll the legs back and forth next lift the patient's leg up from the knee first slowly then quickly as with tone in the upper limb feel for rigidity spasticity and flaccidity we will now examine the ankles for clonise clonise is a series of involuntary rhythmic muscle contractions and relaxations to elicit clonise support the patient's leg briskly dorsi flex the foot and sustained the dorsiflexion clonise may be a sign of an upper motor neuron lesion but a few beats of clonise can also be a normal finding I guess you to take this leg and lift it up towards your chest and hold it right there at that angle as strong as you can good and now relax that and same with the other leg and hold it there as strong as you can excellent and down and now I'm gonna ask you to take your heel and keep it into the bed as strong as you can hold a strong strong strong strong excellent now this side the same thing keep it as strong as you can into the bed excellent now just bend your legs halfway slightly and push in against my hands push in excellent now push out against my hands excellent and now relax okay now can I get you to bring your knee up again and hold it in this position as strong as you can and bring your heel downwards excellent and relax now same with this leg bring it at a 90 degree angle and bring it downwards excellent and now relax I'll bring this leg up the same position and extend your leg as much as you can excellent and now this sight extend as much as you can excellent and then I'll relax can you bring your feet just your feet back up towards your nose and hold it as strong as you can good good and now can you bring your feet inwards like this excellent and now go to this way and now down like on a gas pedal excellent we will divide the reflex section of the exam into upper limb reflexes and lower limb reflexes testing reflexes is a good way to examine sensory neurons motor neurons and descending inhibitory neurons in the spinal cord when assessing reflexes used the deep tendon reflex grading scale to quantify your findings note that this scale is somewhat subjective and requires some experience to distinguish normal from abnormal a grade 0 reflex is no reflex a grade 1 reflex is diminished and often requires a reinforcement maneuver such as the gin drastic maneuvers shown here a grade 2 reflex is a normal reflex a grade 3 reflex is pathologically brisk a grade 4 reflex is pathologically brisk with clonise broadly speaking reflex hammers can be divided into waited and non-weighted hammers and each type requires a different technique for weighted hammers use the weight of the hammer and swing it like a pendulum for unweighted hammers use a flicking motion with your wrist it's important that you become comfortable with whichever type of hammer you will be using ok just relax your arm feel for the biceps tendon in the patient's cubital fossa and apply some tension with your fingers feel for contraction of the biceps tendon under your fingers and observe for contraction of the muscle feel for the brachioradialis tendon in the anterior radial part of the arm tap the tendon and observe for slight wrist extension and elbow flexion relax arm as much as you come support the patient's arm and feel for the triceps tendon tap the triceps tendon and observe for slight elbow extension palpate then tap the tendon and observe for knee extension if you are having difficulty eliciting a reflex try performing the jenn drastic maneuver to bring out a stronger response pull with your hands and bite down on the count of 3 1 2 3 okay and you can relax your arms and now can I get you to lie back on your back just relax your leg here dorsiflex the patient's foot slightly to stretch the Achilles tendon relax your leg tap and observe for slight plantar flexion of the foot now I'm going to tickle the bottom of your foot for the plantar reflex gently scratch the sole of a patient's foot with a blunt instrument side start from the lateral heel and move up along a curve to the ball of the foot in healthy adults the foot inverts and toes are drawn downwards in patients with an upper motor neuron lesion the big toe will Dorsey flex and the other toes will fan out this pathological outcome is known as babinski's sign there are five main sensory modalities that are generally tested for in the neurologic exam temperature pain non discriminative touch vibration and proprioception ok so now we're going to test sensory modalities assess temperature sensation by applying a warmed or cooled tuning fork to the skin is that cold yes is that cold yes assess pain sensation by applying a sharp object such as a safety pin or broken tongue depressor to the skin can you close your eyes is this sharp or dull sharp dull sure good assess non discriminative touch by applying a soft object such as a cotton ball or tissue to the skin if you feel that do you feel that yeah assess vibration sensation by placing a vibrating 128 Hertz tuning fork to a bony prominence close your eyes do you feel the buzzing yes okay can you tell me when that goes away okay good assess proprioception by stabilizing the joint and moving the distal end up and down ask the patient to report what they feel I'm gonna move your hand up or down tell me which direction it's moving can you close your eyes excellent sensory information travels to the brain along one of two main pathways in the spinal cord the spinothalamic tract and the posterior column medial lemniscus tract test for one modality from each spinal tract to assess both pathways in your exam due to the large number of areas and modalities that can be assessed during the sensory exam this part of the exam must be tailored depending upon the clinical context focus your efforts on the affected area in order to determine the pattern of sensory abnormality depending on the site of the lesion sensory deficits can present in a variety of patterns for example a lesion of the spinal nerve level will present in a dermis homo pattern in contrast a lesion at the peripheral nerve level will present in a peripheral nerve pattern either as a mono neuropathy where one nerve is affected or a polyneuropathy where multiple nerves are affected if you detect an abnormal sensation on the middle finger it may be due to a median nerve problem or it may be due to a c7 spinal nerve problem these two lesions can be differentiated by carefully mapping out sensation on the rest of the hand it's important to note that other patterns of abnormal sensation exists but carefully mapping out any abnormalities and comparing this pattern to a dermatome 'el and peripheral nerve distribution is a great place to start so that's the completion of the neurological exam the motor and sensory components thank you for your time [Music] you [Music]

Channel: UBC Medicine - Educational Media

Views: 1,420,555

Keywords: neurology, neurological exam, motor skills, sensory skills, relfexes, ubc medicine, medicine

Id: 5ob5uJMgZOs

Length: 16min 0sec (960 seconds)

Published: Thu Jun 28 2018