Equipment needed
Cotton wool
Neurotip
Tuning fork - 128hz - the longer one.
Tendon hammer.
Introduction
Wash hands
Introduce yourself
Confirm the patient’s identity - ODB, Name.
Explain the examination
Gain consent
Expose patients appropriately - Uncovered legs, can keep underwear and top on.
General inspection
For the end of bed inspection it is always useful to use the SWIFT acronym.
S - Scars
W - Wasting of muscles.
I - Involuntary movements
F - fasciculation
T - tremor.
At the same time as assessing the patient themselves it is necessary that you look at the patient’s surroundings for any beside the bed clues or prompts.
Gait
Ask patient to walk normally to the other side of the room and back.
In doing this look for any abnormal movements such as altered posture or decreased swing or stance phases of the walk
Tandem (heel-to-toe) gait
Ask the patient to do heel toe walking in a straight line.
Patient’s are often unable to do this if they have an ataxic gait, hence why it is also commonly used to test how drunk people are.
It may demonstrate impaired proprioception or weakness too.
Heel walking
Assess muscles in the anterior compartment of the lower leg/ dorsiflexors.
Tip toe walking
Assess muscles in the posterior compartment of the leg/ plantar flexors.
Romberg’s test
This is a test used to assess the patient’s balance, if they test positive then they might have a sensory ataxia.
Ask the patient to stand with their feet together and eyes closed for around 1 minute.
Throughout the minute, you should have one arm either side of the patient for support so that if they should lose balance, they won’t get injured.
Tone
The test for Tone consists of 2 parts.
Leg roll.
To do this then ask the patient to get onto the examination couch and sit with their legs straight.
Hold the leg with two hands and roll side ot side.
If the tone is normal then the food should flop independently to the leg, and should lag slightly behind it in motion.
If hypertonic then both leg and foot will move together.
Leg lift
Again with the leg relaxed and laid fully extended.
Lift the patients knee joint with two hands, one on either side of the joint, around 5-7 cm off the couch.
Then drop it back down.
Repeat this around 3 times.
If the patient is hypertonic then there the heel will lift off the bed also.
Power
The assessment for power consists of testing across 4 different joints and graded using the MRC muscle power assessment scale with a score of 1-5.
Remember to test one joint on both sides and then move on to the next joint.
Work in a proximal to distal fashion or vice versa.
Hip
Flexion - stabilize the hip with one hand and ask the patient to push up into your other hand, when placed on the anterior thigh.
Extension - Again stabilize the hip with one hand and ask the patient to stop you lifting their leg off the bed, using the other hand to push the posterior thigh upwards.
Abduction - Use one hand to stabilize and one hand on the lateral thigh and ask the patient to push against you.
Adduction - Ask the patient to push into you hand again, placing it on the medial thigh.
Do this for both legs!
Knee
Test extension and flexion in the knee.
Do this by placing one hand above and one hand below the knee and pulling in the appropriate directions to resist the patient’s actions.
Ankle
Dorsiflexion - Ask them to push the dorsal surface of their foot into your hand whilst keeping their leg flat on the bed.
Plantar flexion - Ask the patient to push down as if they were accelerating a car into your hand, once again keeping their leg flat.
Inversion - Support the patients ankle, with one hand, ask them to push inwards with their foot into the other.
Eversion - Again support the patient’s ankle with one hand, ask the patient to push outwards into your hand on the other side.
Big toe.
Extension - Hold the foot and ask the patient to resist you trying to bend their big toe.
Coordination
The test for this is called the heel to shin test.
It basically does what it says on the tin.
Ask the patient to put one heel on their other leg, just above the lateral tibial plateau.
Then ask them to slide it down towards their foot and repeat it around 3 times.
Inability to do this indicates, loss of motor strength, proprioception or a cerebellar disorder.
Reflexes
Knee jerk
To test this reflex, support the knee from underneath so that it is no longer resting on the bed.
Then hit the knee just in the space below the patella and above the tibial tuberosity.
Do this on both legs.
Ankle jerk
There are 2 ways to test this reflex.
The first is only suitable for a mobile patient.
Get them to knee on the bed and tap the tendon hammer on the posterior aspect of the Achilles tendon, if the reflex is present then the foot should plantar flex.
The second way to do it is flex the knee and then laterally rotate the whole leg, moving the knee towards the bed.
After this, support the foot from underneath and put it in a dorsiflexed position.
Once again, hit the now stretched achilles tendon and plantar flexion occurs reflexes are present.
Plantar reflex (Babinski’s sign)
To assess this then you will need the patient to take their socks off if they have not already been removed.
Run a blunt object up the lateral aspect of the sole of the foot towards the little toe and then towards the big toe.
If this reflex is normal then the toes should flex.
IF the test is positive (abnormal) the toes will extend, a sign of a upper motor neuron lesion.
Ankle clonus
Ask the patient to fully relax their legs onto the bed, so that they are extended.
Support the leg at the knee.
With the other hand, hold the foot across the tarsals/ metatarsals, adn roll it gently in a circular motion.
Suddenly dorsiflex and partially evert the foot, keep the foot in this position afterwards.
Clonus is felt if there are rhythmical beats of dorsiflexion/ plantar flexion.
Sensation
Light touch sensation
Ask the patient to close their eyes.
Tell the patient you are going to touch them on their chest to make sure they can feel it, do so lightly with the cotton wool bud on the sternum.
If they say yes, ask them to continue doing so each time they feel the same sensation down their legs.
Test each dermatome individually with the same method.
This is done to test the dorsal column medial lemniscus pathway.
Pin prick sensation
Do the same steps as with light touch, but with a sharp object or neurotip.
Before you do this, make sure (as you did at the start of the exam) that the patient is not in any pain.
Vibration sensation
Ask the patient to close their eyes.
Place a 128hz tuning fork on the distal interphalangeal joint of the hallux.
Make sure the patient can feel the buzzing and is also able to define when it has stopped too.
If the patient cannot feel vibration at this joint, move one joint more proximal until they can.
Proprioception.
Hold the very tip of the hallux by its sides.
Also hold the sides of the distal interphalangeal joint with the other hand.
Move the toe, up or down and show the patient which is which.
Then ask the patient to close their eyes and do the same again.
Ask the patient whether the toe is up or down.
If they are unable to do this then move one joint more proximal.
Completing the examination:
Thank patient
Wash hands
Summarise exam
Suggest further test - Cranial nerve exam, Upper limb exam, Spinal imaging tests e.g. CT or MRI.
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