1. Neurology upper and lower limbs evaluation

2. BY Dr. NIRMAL NARAYAN
M.P.T(ORTHO)
SRINIVAS COLLEGE OF
PHYSIOTHERAPY

3. Upper and lower limbs Inspection Tone Power Reflexes Coordination
Sensation
Gait

4. Inspection Involuntary Movements Muscle Symmetry Left to Right
Proximal versus Distal
Atrophy

5. Tone: resistance to passive stretch Ask the patient to relax ‘Let me do all the work here’
UPPER LIMB
Take one hand in yours and support the elbow
Flex and extend the fingers, wrist, elbow and shoulder
Should move easily and smoothly with little resistance
LOWER LIMB
Roll the leg sideways backwards and forwards on the bed
Lift the knee and let it drop
If heel lifts off bed increased tone

6. Clonus - excessive muscle tone and hyperreflexia
a series of involuntary contractions of stretched muscle
flexing the knee slightly and rapidly dorsiflexing the foot and keeping it dorsiflexed

7. Muscle power
test from the proximal to the distal part of the extremity so that all segmental levels for the extremity are tested
power or strength is tested by comparing the patient’s strength against your own
always compare one side to another
grade strength using Medical Research Council (MRC) scale

8. Muscle Strength Grading
0 – no contraction 1 – slight contraction, no movement 2 – full range of motion without gravity 3 – full range of motion with gravity 4 – full range of motion, some resistance 5 – full range of motion, full resistance 

9. Deltoid muscle (C5) SHOULDER EXTENSION
Put your arms out to the side like wings. Do not let me push them down

10. Biceps muscle (C6)
ARM FLEXION
Pull me towards you

11. Triceps muscle (C7)
ARM EXTENSION
Now push me away

12. Radial nerve (C7)
FINGER FLEXION
‘Hold your fingers out straight. Stop me from bending them’

13. Ulnar nerve (T1)
FINGER ABDUCTION
Spread your fingers apart. Stop me pushing them together

14. Median nerve (C8, T1)
THUMB ABDUCTION
Point your thumb to the ceiling. Stop me from pushing it down

15. Hip flexion (L2) Lift your leg straight up: stop me pushing it down
Place your hand on the patient’s upper thigh and providing resistance

16. Knee extension (L3)
Bend your knee: push me away

17. Knee flexion (L4)
Bend your knee: pull me towards you

18. Dorsiflexion (L5)
Cock your up your foot and point your toes to the ceiling: stop me pushing your foot down

19. Plantar flexion (S1)
Bend you foot down: push my hands away

20. Tendon reflexes
A brisk tap to the muscle tendon using a tendon hammer produces a stretch to the muscle that results in a reflex contraction of the muscle
Position of limbs are key
Compare right and left

21. Tendon reflexes UPPER LIMB LOWER LIMB Biceps C5-6 Knee L3- L4
Brachioradialis C5-6
Triceps C7
Reinforcement- clench teeth
LOWER LIMB
Knee L3- L4
Ankle S1- S2
Reinforcement- ‘hold fingers together and try and pull them apart like this’

22. Tendon reflexes grading
1+ or + hypoactive
2+ or ++ normal
3+ or +++ hyperactive with no clonus
4+ or hyperactive with clonus

23. Biceps (C5 and C6)
arm flexed at the elbow, place your thumb on the biceps tendon and strike thumb with the tendon hammer
here should be a reflex contraction of the biceps brachii muscle (elbow flexion)
repeat and compare with the other arm

24. Brachioradialis (C5 and C6)
strike the brachioradialis tendon above the wrist and observe the reflex rotation of the wrist and forearm such that the palm of the hand is facing upward
repeat and compare with the other arm

25. Triceps (C6 and C7)
strike the triceps tendon directly with the tendon hammer whilst holding the patient’s arm across their chest
there should be a reflex contraction of the triceps muscle (elbow extension)
repeat and compare with the other arm

26. Knee (L3, L4)
lift up the leg under the knee, and tap the patellar tendon with a tendon hammer
there should be a reflex contraction of the quadriceps muscle
(knee extension)

27. Ankle (S1, S2)
externally rotate at the hip, and gently dorsiflex the foot, tapping the Achilles tendon with a reflex hammer
normal response is contraction of the gastrocnemius and plantar flexion of the foot

28. Plantar reflex
starting at the heel advancing to the ball of the foot then continuing medially
normal: flexion of all the toes (move downwards)
abnormal (Babinski sign): extension of the great toe and fanning of the rest of the toes

29. Dermatome Testing

30. Dermatomes
C5 — Clavicles C5, 6, 7 — Lateral parts of upper limbs C8, T1 — Medical sides of upper limbs C6 — Thumb C6, 7, 8 — Hand C8 — Ring and little fingers T4 — Level of nipples T10 — Level of umbilicus T12 — Inguinal or groin regions L1, 2, 3, 4 — Anterior and inner surfaces of lower limbs L4 — Medial side of great toe S1, 2, L5 — Posterior and outer surfaces of lower limbs S1 — Lateral margin of foot and little toe S2, 3, 4 — Perineum

32. Myotome Testing

34. List of Myotomes of Commonly Injured Nerve Roots

35. C5 – The deltoid muscle (abduction of the arm at the shoulder).
C6 – The biceps (flexion of the arm at the elbow).
C7 – The triceps (extension of the arm at the elbow).
C8 – The small muscles of the hand.
L4 – The quadriceps (extension of the leg at the knee).
L5 – The tibialis anterior (upward flexion of the foot at the ankle).
S1 – The gastrocnemius muscle (downward flexion of the foot at the ankle).

36. Myotomes L1-2 hip flexion L3 Knee extension L4 Ankle dorsiflexion L5
Gt toe extension, hip abduction S1
PF ankle, eversion , knee flexion S2
Hip extension

37. Nerves from the neck levels control the muscles in the arms.
 Each of the spinal nerves controls certain muscles
  The muscles (or muscles) controlled by a particular nerve root are called its myotome. 
Nerves from the neck levels control the muscles in the arms. 
Those from the thoracic spine control the chest and abdominal muscles. 
The nerves from the low back control the muscles in the legs.
For example, when the C6 nerve is pinched, there is weakness in the biceps muscle. 
When the biceps is weak, bending the arm at the elbow is difficult.  When the L5 nerve is pinched, there is weakness in the tibialis anterior muscle in the shin.  With L5 weakness, extending the ankle (to walk on the heels) is difficult. 

38. CRANIAL NERVES TESTING

39. General Characteristics:
The 12 pairs of cranial nerves are part of the peripheral nervous system.
The Roman numeral is based on descending order of the cranial nerve's attachment to the CNS.
As a rule, cranial nerves do not cross in the brain.
Cranial nerves may be sensory, motor both somatic or parasympathetic, or have mixed function.

40. CN I - OLFACTORY CLINICAL EVALUATION ORIGIN: Cerebral hemisphere
INNERVATION: Nasal mucous membranes.
FUNCTION: Sense of smell
DYSFUNCTION: Anosmia
CLINICAL EVALUATION
Use aromatic substances, i.e. coffee, lemon, garlic, etc.
Test each nostril separately.

41. SPECIFIC DYSFUNCTIONS
CN II - OPTIC
CLINICAL EVALUATION
VISUAL ACUITY: Snellen chart for distant vision, newspaper or fingers for near vision.
VISUAL FIELDS: Confrontation.
FUNDI AND OPTIC DISCS: Visualization of the termination of the optic nerve by looking through pupil with ophthalmoscope.
SPECIFIC DYSFUNCTIONS
Blurred vision or complete blindness.
Ipsilateral vision loss - Optic atrophy, retinal/optic nerve lesions, trauma.
Visual loss (one or both eyes) - Optic chiasm or occipital lobe lesions.
Cortical blindness - Lesion of occipital cortex bilaterally, pupil reflexes intact.
Papilledema - Optic nerve tumor, venous obstruction, chronic increased ICP.
Optic atrophy - MS, optic neuritis, increased ICP.
Scotomas- (Abnormal blind spots on visual fields) - optic neuritis or atrophy.
Hemianopia - (loss of half of visual field in one or both eyes) - Lesions of optic chiasm, tracts, or radiations.

42. CN III - OCULOMOTOR CLINICAL EVALUATION ORIGIN: Midbrain
INNERVATION: EOM's; eyelid; ciliary; and sphincter of iris.
FUNCTION: Eye movement inward (medially), upward, downward, and outward; pupil constriction, shape and equality; elevates upper eyelid; accommodation reflex.
DYSFUNCTION:Unable to look up, down, or medial (dysconjugate gaze); ptosis, pupil dilatation - bilateral or ipsilateral, and loss of accommodation reflex.
CLINICAL EVALUATION
Observe for eye opening and symmetry.
Direct light response - brisk, sluggish, or non-reactive.
Consensual response - present or absent.
Pupil size and shape.
Accommodation.
Extraocular movement (EOM's) (Abducens).

43. CRANIAL NERVE FUNCTION & MUSCLE INNERVATION RELATIVE TO EYE MOVEMENT
Inferior oblique
CN III
Superior rectus
CN III
Lateral rectus
CN VI
Medial rectus
CN III
Superior oblique
CN IV
Inferior rectus
CN III

44. CLINICAL EVALUATION CN VI - ABDUCENS CN IV - TROCHLEAR
ORIGIN: Midbrain
INNERVATION: Superior oblique muscle.
FUNCTION: Down and inward movement of the eye.
DYSFUNCTION: Loss of downward, inner movement of eye, dysconjugate gaze.
ORIGIN: Pons
INNERVATION: Lateral rectus muscle.
FUNCTION: Outward, lateral movement of eye.
DYSFUNCTION: Loss of lateral eye movement, dysconjugate gaze.
CLINICAL EVALUATION
Extraocular movements (EOM's)
CN IV (Trochlear) and CN VI tested with CN III (Oculomotor)

45. Brain Stem = Onion skin sensory deficit
CN V - TRIGEMINAL
ORIGIN: Pons. The sensory nucleus extends from the pons to the midbrain, and also to the medulla and spinal cord.
INNERVATION: Three branches of CN V: Ophthalmic, maxillary, & mandibular. Motor innervation to masseter & temporal muscles. Sensory innervation to skin & mucous membranes in head; teeth, tongue, external auditory canal, and cornea.
FUNCTION: Sensation of pain, touch, hot, & cold; motor movement of masseter & temporal muscles.
Nerve Root Patterns
DYSFUNCTION: Loss of sensation - if affecting all three branches, indicative of peripheral injury. Brainstem or upper cervical cord injury may result in loss of sensation to one or more branches of the trigeminal nerve.
- Loss of corneal reflex.
- Paresthesia and/or severe pain indicative
of nerve compression or irritation (Trigeminal neuralgia)
-Deviation of jaw, loss of sensation.
Inability to bite down and chew, inability to close jaw.
Brain Stem = Onion skin sensory deficit

46. CN V - TRIGEMINAL CLINICAL EVALUATION
SENSATION: Test with patients eye closed. Evaluate pain, temperature, & light touch to jaw, cheeks, and forehead. Observe response and symmetry.
MOTOR: Open jaw, check for deviation. Have patient bite down, palpate masseter and temporal muscles. Move jaw laterally against resistance to evaluate weakness or paralysis.
CORNEAL REFLEX: Cotton wisp across cornea, observe for blink (function of CN III)
JAW JERK: Tap lower jaw with mouth open - check for slight elevation of mandible.

47. CN VII- FACIAL ORIGIN: Pons & medulla.
INNERVATION: Anterior two-thirds of tongue; facial muscles, scalp, ear, and neck.
FUNCTION: - Control of facial muscles (expressions)
- Motor limb of blink & corneal reflexes
- Secretion of salivary & lacrimal glands
- Sensation of taste, anterior two-thirds tongue.
DYSFUNCTION:
Motor = Facial asymmetry - Ipsilateral weakness/paralysis, right or left, indicative of damage to motor nucleus or peripheral component (lower motor neuron lesion) EX: Bell's palsy
Contralateral weakness/paralysis of lower face indicative of contralateral motor cortex damage (upper motor neuron lesion) or hemispheric lesion, i.e. massive CVA.
Bilateral weakness or paralysis , E.g. myasthenia gravis or Guillian Barre.
Parasympathetic -Loss or excessive tearing or salivation
Sensory= Loss of taste
Combined problem = speech difficulty and drooling/difficulty handling food

48. CN VII - FACIAL CLINICAL EVALUATION MOTOR FUNCTION: SENSORY FUNCTION:
Observe for facial symmetry
Ask patient to wrinkle forehead, puff cheeks, smile, show teeth, open eyes against resistance, and whistle.
Test each side of tongue separately.
Test for sweet (tip of tongue); sour (sides of tongue); salty (over most of tongue, but concentrated on sides).
Give sip of water between tastes.
SENSORY FUNCTION:

49. CN VIII - ACOUSTIC ORIGIN: Pons and medulla
INNERVATION: Cochlear - ear
Vestibular - ear
FUNCTION: Cochlear - Hearing
Vestibular - Balance, maintenance of body position, and proprioception.
DYSFUNCTION (Cochlear)
- Unilateral deafness
- Loss of sound appreciation
- Tinnitis
- (Rinne Test) AC >BC or both diminished indicative of nerve damage,
BC> AC middle ear disease.
- (Weber Test) Lateralization to good ear is nerve damage, lateralization to bad ear is, middle ear disease.
DYSFUNCTION (VESTIBULAR)
- Vertigo
- Balance disturbances
Vestibular branch normally not tested unless patient gives history of vertigo or balance Disturbance history is positive, caloric testing is done by physician.

50. CN VIII - ACOUSTIC CLINICAL EVALUATION
HEARING: Test bilaterally, whisper or watch tick
CONDUCTION: Weber and Rinne tests (Differentiate between conduction deafness and nerve deafness)
Weber Test: Evaluates lateralization. Use vibrating tuning fork on top of patient's head, ask patient where he hears it (one or both sides).
Rinne Test: Evaluates air (AC) and bone conduction (BC). Place the base of a vibrating tuning fork on the mastoid process until patient can no longer hear sound; then quickly move tuning fork near ear canal. Ask the patient if he hears it, compare hearing times.
Rinne test: AC > BC normal result.

51. CN IX- GLOSSOPHARYNGEAL and CN X - VAGUS
Glossopharyngeal (IX)
Vagus (X)
ORIGIN:
Medulla
Medulla
Mucous membranes of tonsils, pharynx, posterior one-third of tongue, pharyngeal muscles, carotid sinus and carotid body
Muscles of larynx, pharynx, and soft palate. Parasympathetic innervation of thoracic and abdominal viscera.
INNERVATION:
Muscles of larynx, pharynx, and soft palate;- Sensation conveyed from the heart, lungs, digestive tract, carotid sinus, & carotid body; Efferent limb of gag and swallow
Taste from posterior one-third of tongue - Afferent limb of gag, swallow, and cardiac reflexes.
FUNCTION:
Loss of gag & swallow reflex; Loss of carotid sinus & oculocardiac reflex; Dysphagia
DYSFUNCTION:
Loss of taste; Neuralgia

52. CN IX- GLOSSOPHARYNGEAL and CN X - VAGUS
CLINICAL EVALUATION
CN IX and X considered jointly, actions are seldom compared separately; they are always tested together.
- Evaluate voice quality (hoarseness or dysarthria)
- Ask patient to open mouth, say "ah", observe for elevation of soft palate, midline position of uvula.
- Gag reflex, bilaterally
- Swallowing
- Taste (bitter) posterior one-third tongue*
*usually not tested
Negative Findings
- Loss of voice quality, (dysarthria or hoarseness)
- Deviation of uvula toward non-paralyzed side
- Swallowing difficulty or nasal regurgitation
- Vagal irritation (bradycardia)

53. CN XI - SPINAL ACCESSORY
ORIGIN: Medulla
INNERVATION: Sternocleidomastoid & trapezius muscles
FUNCTION: Motor function sternocleidomastoid & trapezius
DYSFUNCTION: Muscle weakness.
CLINICAL EVALUATION
Palpate trapezius muscle as patient shrugs shoulders against resistance; evaluate strength.
Ask patient to turn head to one side and push against examiners hand, palpate and evaluate strength of sternocleidomastoid muscle.
Evaluate both right and left side, compare for symmetry.

54. CN XII -Hypoglossal ORIGIN: Medulla INNERVATION: Muscles of the tongue
FUNCTION: Movement of the tongue
DYSFUNCTION:
Unilateral Flaccid paralysis (peripheral lesion) - Tongue deviates to side of lesion. - Isilateral atrophy - Fasciculation Spastic paralysis (cortical pathways) - Tongue deviates to opposite side of lesion - No atrophy - Dysarthria and ataxia of tongue
Bilateral
Flaccid paralysis (medullary lesion, MG)
- Dysphagia
- Dysarthria
- Difficulty chewing food

55. CRANIAL NERVES I Olfactory II Optic III Oculomotor IV Trochlear
CEREBRAL
HEMISPHERE
II Optic
III Oculomotor
MIDBRAIN
IV Trochlear
V Trigeminal
VI Abducens
PONS
VII Facial
VIII Acoustic
MEDULLA
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal

56. Sensation SPINOTHALAMIC TRACTS DORSAL COLUMNS temperature light touch
position sense (proprioception)
vibration sense
SPINOTHALAMIC TRACTS
temperature
pain
loss of one modality in a conduction system is often associated with the loss of the other modalities conducted by the same tract in the affected area

57. Sensation: light touch/pain
check patient can feel the sensation of light touch (cotton wool) on the sternum
ask the patient to close their eyes
begin to test from proximal to distal
select areas from different dermatomes and peripheral nerves and compare right versus left

58. Sensation: light touch/pain
‘Close your eyes’
‘Say now when you feel the cotton wool’
Check both sides feel the same

59. Sensation: vibratory
it is tested by using a 128 Hz tuning fork and placing the vibrating instrument over a bone or bony prominence
start distally using a bony prominence of a distal interphalangeal joint/big toe
If sensation not present check wrist and then elbow in arm and ankle and knee in leg

60. Sensation: proprioception
hold the thumb/big toe on its sides with your thumb and index finger
I am just going to move your thumb/big toe up and down, identifying each position as the patient watches
ask patient to close their eyes
move thumb/big toe up and down in an irregular sequence
if the patient can't accurately detect the distal movement then progressively test a more proximal joint (wrist and elbow in arm and ankle then knee in leg) until they can identify the movement correctly

61. Coordination (upper limb)
HAND RAPID ALTERNATING MOVEMENTS
tap quickly on the back of your hand like this
FINGER TO NOSE TEST
touch my finger and then touch your nose, backwards and forwards as quickly as you can

62. Coordination (lower limb)
RAPID ALTERNATING MOVEMENTS (as fast as possible!)
Tapping feet on examiners hand
POINT TO POINT MOVEMENTS
‘Put your heel just below your knee and move it smoothly down to your shin and up again ‘

63. Gait ask the patient to walk to a defined point and back
ask to patient to walk heel to toe
ask the patient to walk on his toes and on his heels

64. Romberg’s test (position sense)
ask the patient to stand, feet together with eyes open, then with eyes closed
positive if more unsteady with eyes closed indicates loss of proprioceptive control

65. Pronator drift
patient extends arms in front of them with the palms up and eyes closed. The examiner watches for any pronation and downward drift of either arm
Instruct the patient to keep the arms still while you tap them briskly downward
the patient will not be able to maintain extension and supination with upper motor neurone disease.

66. Upper and lower motor neurone lesions
UMN: Lesion of corticospinal tracts
Muscle weakness
No muscle wasting
Increased tone
Brisk tendon reflexes
Clonus
Upgoing plantars
LMN: Lesion of motor pathway from anterior horn cells
Muscle weakness
Muscle wasting
Reduced tone
Decreased or absent reflexes
Fasciculation (involuntary movements)