Neuro Limbs

Equipment

• Tendon hammer (the bigger the better, within reason)

Upper

Initially

• Say "may I examine your arms," and expose the patient's arms.
• Observe for fasciculation, wasting (both can be very subtle).
• Protonator drift: ask the patient to close their eyes with their arms straight out and their palms up, observe to see if arms protonate in.

Tone

• Say "let your arms go floppy and let me take them, don't help me when I do this." Take their hand with your hand (as if to shake it), and flex and extend the patient's arm, supinate and protonate, and rotate their wrist.

Power

• Use your dominant hand and test each muscle group in both arms before proceeding (e.g. flexion in L arm then in R arm). The important muscle groups to test are:
  • Shoulder abduction - C5
  • Elbow flexion - C5, C6
  • Brachioradialis (arm flexion with their palm facing in - as if you would hold a cup) - C6
  • Elbow extension - C7
  • Wrist extension - C7 (radial)
  • Finger extension - C7, C8
  • Finger abduction - T1 (ulnar)
  • Thumb abduction - T1 (median)

  The muscle groups given above are not written in stone so don't worry if they vary from text to text.

Reflexes

• Over the biceps (C5), supinator (C6), and triceps (C7) groups. Hold the tendon hammer like a hammer loosely at its end. Palpate the tendon to be hit, and rather than strike the it let it drop down loosely. Use reinforcement techniques (jaw clenching) if absent.

Coordination

• Finger-nose test: you need to hold your finger far enough away for the patient to have to stretch their hand to touch yours
• Dysdiadochokinesis: the easiest way is to get the patient to put their hand palm down on their lap, then turn it over and repeat as fast as they can.

Sensation

• Get the patient to hold their arms out in the anatomical position, rested on the bed (i.e. palms up, arms and fingers extended).
• For pin-prick, temperature and light touch test in all the dermatomes , comparing sides. Say "can you close your eyes, tell me when I touch you... Does it feel the same on both sides." For light-touch use cotton wool, temperature the base of a tuning fork, and pin-prick a neuro-tip. Neuro-tips are not painful exactly just sharp, so say "does this feel sharp?"
• For vibration and proprioception it is sufficient to test distally and only move proximally if absent. Vibration is tested with a tuning fork. Proprioception is tested by getting the patient to close their eyes, holding the distal phalanx of a finger and moving it lightly up and down, getting the patient to name the movement.

Lower

• Say "may I examine your legs," and expose the patient's legs
• Observe for fasciculation, wasting

Tone

• Say "I'm going to roll your legs, let your legs go floppy." Roll the legs and observe to see if the foot follows immediately (increased tone) or if it lags a bit (normal). Say "I'm going to lift your leg up." Quickly Pull vertically up at the knee and observe if the foot comes off the bed (increased tone, or the patient is tense).

Power

• The important muscle groups to test are:
  • Hip flexion - L1, L2
  • Hip ext - L5, S1
  • Knee ext - L3, L4
  • Knee flexion - L5, S1
  • Dorisiflexion - L5
  • Plantarflexion - S1

Reflexes

• Ankle jerk (S1, S2), Knee jerk (L3, L4). The knee jerk is relatively easy to elicit. Put your arm under their knee and say "let your leg go floppy, and let me take the weight." The leg should feel heavy on your arm. Palpate and hit the tendon with the hammer. The ankle jerk is harder to elicit (and often absent in the elderly). Bend the patients leg, and with your non-dominant hand hold the curve of their feet and slightly flex it, then hit the ankle tendon.

Coordination

• Get the patient to lift up their leg, put their ankle on their knee, draw it down the leg, adn repeat the procedure as fast as they can.

Sensation

• The modalities should be tested the same as in the arms.

Other

• Gait should be tested if practical
• Romberg's test should be performed if the patient has coordination problems. Get the patient to stand up and ask them if they would be unsteady if they closed their eyes. If they say no, then stand close to them at right angles, and put one hand in front and one hand behind, and ask them to close their eyes. It does not look good if you haven't prepared to catch them and they fall over!

Common OSCE stations

1. Upper motor neuron disease: most commonly motor neuron disease and MS
2. Parkinson's disease
3. Cerebellar signs
4. Peripheral neuropathy:  eg diabetic
5. Pes Cavus