Upper limb Neurological Exam

Intro

• Wash hands, Introduce self, Check patient name and DOB/CHI, Explain procedure and Gain consent

Inspection

• Look at the patient in general, their posture, their gait (if applicable)
• Look at the arms, shoulder girdle and their muscle groups at rest for
  • Tremor; muscle wasting/fasciculations; deformity; injury; abnormal movements
  • Cutaneous signs e.g. neurofibromas, cafe au lait spots, scars

Tone

• Ensure the patient is relaxed
• Taking the patient’s hand in your ipsilateral hand (i.e. right – right) and supporting the patient’s elbow with the opposite hand:
  • Test for rigidity (extrapyramidal) by slowly extending and flexing the wrist(/elbow) and pronating/supinating the arm
    • Cogwheel rigidity may be felt if there is both tremor and rigidity (feels like cogs catching as you supinate the arm)
  • Test for spasticity (pyramidal) by rapidly extending the elbow- spasticity will be felt as a ‘catch’ followed by relaxation
• If any increased tone is felt (particularly spasticity), ask the patient to clench their teeth and repeat manoeuvre (this can increase the features)

Power

• NB Always support the proximal joint to the muscle tested; compare sides like with like, but use a lot of strength (i.e. provide as much resistance to both sides equally)
  • Grade response
    • 0- no movement
    • 1- Flicker/muscle contraction
    • 2- Movement but not against gravity
    • 3- Movement against gravity but not resistance
    • 4- Movement against resistance but not full
      • (4+ is sometimes used to help differentiate further)
    • 5- Full strength
• Movements
  • Shoulder abduction (C5); Elbow flexion (C6); Elbow extension (C7); Wrist extension (C7); Wrist flexion (C7/8); Finger extension (C7- radial); Finger flexion (C8); Finger spread (T1- ulnar); Thumb abduction (T1- median)

Reflexes

• Biceps (C5/6)- Ask the patient to relax their arm across their lap.  Place your index finger across the biceps tendon and strike finger with the tendon hammer.  Observe the biceps for contraction
• Supinator (C6)- In the same position, place a finger over the brachioradialis tendon (lateral forearm) and strike.  Look at the brachioradialis (upper lateral forearm) for contraction.
• Triceps (C7)- Hold the ipsilateral wrist (with your same (right-right) hand) and let their arm go floppy.  Strike the triceps tendon (above the olecranon) and observe for contraction of the triceps.

Coordination (cerebellar)

• Finger nose test (point at your finger then their nose repeatedly) for intention tremor and past-pointing
• Alternate palmar/dorsal clapping (dysdiadokinesia)

Sensation

• NB For light touch and pain, provide example sensation on the sternum first.
• Touch the arm in each dermatome with their eyes closed using a cotton wool bud (light touch) and a pin (pain)
  • Ask whether it feels the same as the sternum; also compare side with side and ask about any differences
• 
• Proprioception
  • Hold the proximal phalanx of the thumb with one hand and the distal phalanx with your finger/thumb on either side of the phalanx.  Show patient the up/down movements.  Ask them to close their eyes and tell you which movement is occurring as you move the thumb.  Repeatedly wiggle it up/down before settling on a position each time.
• Vibration (use 128Hz fork)
  • Start by example on sternum and then work proximally from the thumb DIP, PIP, wrist, elbow (NB if they can feel it distally, unlikely need for testing proximally)
• Temperature may also be tested
  • Usually rough test using the cold of the tuning fork

Finish

• Thank the patient, Wash hands
• Record findings in notes/to examiner/supervisor
• Suggest any further investigations/management
• (suggest examination of the lower limbs and cranial nerves if appropriate)