1. ‘Paralysis for the General physician’
Joe Guadagno
Consultant Neurologist
RVI

2. Outline General principles for assessing paralysis (but not vascular)
Central causes (UMN signs)
- unilateral (hemispheric)
- bilateral (spinal mainly)
Peripheral causes (LMN signs)
- root, plexus, nerve, neuromuscular junction
Mixed
remember muscle!

3. General principles:
A. Localizing the disease is the first step in diagnosing a neurological disorder.
B. Time course of the disease (acute, subacute, or chronic) indicates the pathophysiological process.
C. Anatomical pattern of neurological diseases can be focal, multifocal or diffuse.
D. Neurological diseases produce symptoms that are positive (eg. Pain) or negative (eg. Weakness).
E. Neurological disorders follow recognizable patterns:
upper v. lower motor neuron; hemiplegia v. paraplegia; root v. nerve; cerebellar v. extrapyramidal.

4. Neurological history taking
Presenting complaint
One or several? Useful to list. Significance of many (inverse symptom law)!
Allow uninterrupted narrative, so far as possible
Clarify
Date of onset
Frequency of recurrence
Duration of episodes
Evolution
Nature of main symptom, in detail
Tempo
Associated features
Triggers
Exacerbating/relieving factors
Treatment

5. Neurological history taking
Diagnostic hypothesis – where, then what?
Where?
Muscle
NMJ
Peripheral nerve
Spinal cord
Brain
Brain stem, cerebellum, thalamus, basal ganglia, cortex/lobe

6. Neurological history taking
Diagnostic hypothesis – where, then what?
What?
e.g. spinal cord syndrome:
Compression
Disc
tumour
Demyelination
Stroke…

7. Time course

8. Definition
Paralysis is a loss or impairment of motor function in one or more muscle groups as a result of a lesion of the neuromuscular mechanism.
‘Paralysis’ – paresis v plegia

9. Motor system
‘Corticospinal tract’
‘Pyramidal tract’

10. Motor System Examination
Appearance
– asymmetry
- fixed posturing
- muscle wasting (amyotrophy)
- muscle fasiculation

11. Muscle wasting

12. Thenar and Hypothenar eminence

13. Intrinsic muscles

14. Tone
– velocity dependant change in tone (spastic catch): pyramidal
lead pipe or cogwheeling rigidity: extrapyramidal
Hypotonia (cerebellar)
(N.b. in general, spasticity is less severe with cerebral lesions than with spinal cord lesions)

15. Patterns of weakness
in pyramidal lesions – remember chronic stroke patients
Hemiparesis (hemispheric)
Tetraparesis (cervical cord, brainstem, brain)
Paraparesis (spinal cord below cervical region)
Proximal weakness (UL + LL) – more likely to be muscle/neuromuscular
Distal weakness (UL+LL) – with sensory changes more likely to be LMN (neuropathy),
(n.b. LL distal weakness, saddle anaesthesia plus dropped reflexes - think of conus lesions).
Extrapyramidal syndromes e.g. IPD do not cause weakness

16. Pyramidal pattern of weakness - remember Hemiplegic posture
extended at hip and knee
foot plantarflexed
circumduction on walking

17. Pronator drift

18. Plantar response noxious but not injurious orange stick for exams
hallux extends, toes fan
beware withdrawal response

19. Method lateral border of foot medially over ball
not across flexor crease
first movement of hallux
flexor or extensor: not +ve/-ve
Oppenheimer’s

20. MRC scale 1 2 3 4 5 no active contraction contraction without movement
no active contraction 1
contraction without movement 2
movement with gravity eliminated 3
movement against gravity 4
movement against gravity and resistance but not full power 5
normal power

21. Reflexes Compare like for like – look for asymmetry
V. Brisk reflexes with spread? Clonus? Plantars then important.
Dropped reflex (mononeuropathy, radiculopathy)
Dropped reflexes (neuropathy)

22. Upper limb reflexes Biceps C5/6 Supinator C5/6 Triceps C7
Finger jerks C7/8 (80% normals)
Hoffman’s C7/8 (25% normals)

23. Lower limb reflexes
Knee jerk L3/4
Ankle Jerk S1

24. Deep tendon reflexes absent even with reinforcement (-)
present only with reinforcement (+/-)
present but diminished (+)
present and normal (++)
exaggerated (+++)
cloniform (++++)

25. Inverted reflex

26. Central causes (UMN signs)
- Mono or hemiparesis (unilateral signs) – mainly hemispheric with or without face involvement
Brain tumour
Migraine (hemiplegic)
CVT
Infection/abscess
Inflammatory (MS?) – hemisphere or cord
N.b. cervical disc disease marked asymmetry

27. Central causes (UMN signs)
- bilateral signs with/without arm involvement
Quadraparesis or paraparesis
Cervical disc
Transverse Myelitis
Spinal cord infarct
Spinal AVM
Nb Lumber disc causing cauda equina syndrome (LMN signs!)
Neurodegenerative – eg Hereditary Spastic Paraparesis, Primary lateral sclerosis
Inflammatory/degenerative – PPMS, SPMS
Parasagittal meningioma……

28. Peripheral causes (LMN signs) - Unilateral
- Focal, patchy, or multifocal
Cervical radiculopathy
Brachial neuritis (Parsonage-Turner syndrome
Amyotrophic lateral sclerosis (MND) – monmellic presentation
Entrapment neuropathies – Ulner, median, radial, CPN
Mononeuritis multiplex (multifocal)
Diabetic amyotrophy

29. Peripheral causes (LMN signs) - Bilateral
- Symmetrical or asymmetrical, upper limbs and lower limbs?
AIDP
CIDP
Other neuropathies
Myasthenia gravis
ALS (MND)
Myopathy?

30. Mixed upper and lower motor neuron signs
Anterior Horn cell disorder (ALS)
Cervical myeloradiculopathy

31. Paralysis……
Some examples recently……..

32. “68 yr old Difficulty walking…..”
gait difficulties last few weeks with falls and worsening leg weakness following a fall. Found to have dropped biceps reflex, and a mild spastic paraparesis, some ankle clonus with soft sensory level and bladder dysfunction.

33. “weak leg…..”
28 yr old primary school teacher presents with right lower limb weakness over days. She has an odd sensory disturbance in the bath noticeable on the left side to her chest. No bladder disturbance
O/e right pyramidal weakness of MRC grade 4+ with exaggerated reflexes on that side and an impaired JPS on that side with altered PP and temp of the left leg to T4. R plantar upgoing.
Brown-Sequard syndrome

34. “weak arm…..”
45 yr old postman developed a severe deep set ache in his right shoulder over days. 3 days later he had a markedly weak right arm with some patchy numbness. He presented 2 months later with marked weakness.
o/e
He had marked muscle wasting of his right deltoid, infra and supra spinatus and biceps with winging of his scapula. He had marked weakness of shoulder abduction, internal and external rotation and elbow flexion but elsewhere preserved power. Sensory deficit around his deltoid and upper arm. His biceps jerk was lost. Nil else on exam.
Brachial neuritis

35. “weak arm…..”
22 yr Uni student presents with 3 day history of worsening headache, 1 day hx of blurred vision on looking to right and new left sided arm weakness.
O/e mildly decreased VA, mild papilloedema, R partial VI th N palsy and a Left upper limb mild paresis with brisker reflexes and a supinator catch. No sensory.
Proceeded to have a GTC seizure with head turning to the left iniatilly.
CVT

36. “56 yr old with difficulty walking….”
CSF – protein 0.75, wcc 5
56 yr old taxi driver had been unwell over Christmas with a virus. 2 weeks later he then noticed difficulty with using the hand brake for a day before developing more widespread weakness affecting his arms then legs, with marked difficulty walking. He had no sensory deficit and bladder hesitation.
o/e alert fully orientated, mild O.occuli and O.oris weakness with neck flexion weakness of MRC 4+. He had a pyramidal distribution weakness of upper and lower limbs of grade 4-. Reflexes were preserved but diminished in Upper limbs but absent ankle jerks. Plantars were downgoing.
NCS – consistent with AIDP
Guillain-Barre syndrome (motor variant)

37. “Weak leg….”
62 yr old NIDDM presents with marked pain in his right thigh with marked weakness coming on over days. This was then followed by evidence of wasting of his quads, and difficulty walking.
o/e
Slightly high BMI. Upper limbs had dimished but present reflexes and a v mild fingertip sensory disturbance. Lower limbs revealed marked wasting of right quads (mildly so on L) with hip adductors wasted to a lesser extent. MRC grade 4- for hip flexion on right with knee extension 3 (flexion 5). Dropped Knee jerk on right and at ankles. Sensory deficit bilaterally to knees. Plantars unresponsive.
BM 14, chol 6.4
Diabetic amyotrophy

38. “weak arm…..”
48 yr old pilot with a 3 mth history of gradually worsening weakness of his left hand. Thought CTS at first then progressed to involve more proximal muscles with some stiffness evident as well as weakness
o/e Systemically well. No wasting but held slightly adducted at the shoulder and flexed at the elbow and wrist. Spastic tone with exaggerated reflexes. Global weakness most marked distally. Minimal sensory deficit of hand.
Nil else.
Brain Tumour

39. “weak arm and leg…..”
22 yr old hairdresser presents with a unilateral headache and left sided sensory disturbance and left sided weakness. Collapsed in MAU with possible brief LOC but responding immediately afterwards appropriately.
o/e
Head tremor apparent. No papilloeadma. Abnormal gait dragging left leg and falling. ‘Give way’ weakness throughout examination with no obvious pronator drift. No tonal or reflex changes and downgoing plantars. Left sided hemisensory disturbance.
Blood tests and CT scan normal
Functional hemiparesis

40. “Weak hand….joiner”

41. “weak hand…….”
74 yr old previously fit and well chap, notices weakness of his hand with some wasting. He has mild neck pain.
o/e
Normal CNS, but mild neck flexion weakness. Wasting of forearm muscles and intrinsic hand muscles. Some fasics noted in hand and around both shoulder girdles. He has a supinator catch on that side and brisker reflexes in that arm. No sensory defict.
Anterior horn cell disorder

43. Additional points: repeat examination often helpful eg reflexes
Check CK for muscle disease…..
beware of conus lesions…….
watch out for excessive pain and a LMN/plexus picture – infiltrative lesions
functional patients very difficult!!
vasculitic neuropathies!
Mononeuritis multiplex!