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

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!

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.

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

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

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

Time course

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

Motor system ‘Corticospinal tract’ ‘Pyramidal tract’

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

Muscle wasting

Thenar and Hypothenar eminence

Intrinsic muscles

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)

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

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

Pronator drift

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

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

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

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

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

Lower limb reflexes Knee jerk L3/4 Ankle Jerk S1

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

Inverted reflex

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

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……

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

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

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

Paralysis…… Some examples recently……..

“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.

“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

“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

“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

“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)

“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

“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

“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

“Weak hand….joiner”

“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

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!