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Lower Neurological Motor Examination

From Mediwikis

Both motor examinations follow the same general sequence.

Observation Tone Power Reflexes Co-ordination

Observe The Patient Really Carefully

The lower limb also has CLONUS and FUNCTION.


Wash hands

Introduction, Explanation, Consent

  • Ask about pain or problems in movement
  • Exposure - pelvic region below
  • Positioned lying down 45 degrees

Inspection

  • Generally well

W T Actual F Dumbledore

  • Wasting
  • Tremor
  • Asymmetry
  • Fasiculation
  • Deformity

Tone

  • Ask patient to relax legs
  • With your hand between knee and ankle, roll the leg from side to side. The ankle should flop around as the leg moves.
  • With your hand under the knee, quickly lift the knee up and then drop it back down onto the bed. The ankle should drag up the bed and down again, without breaking contact with the bed.
    • Hypotonia - reduced tone
    • Hypertonia - increased tone
      • Spasticity - velocity-dependent
      • Rigidity - not velocity-dependent

Clonus

  • Support patient's knee with one hand and the ankle with the other, and ask them to completely relax their foot. Rotate the ankle a couple of times before sharply jerking the foot up.
  • 3 or below beats of the foot is normal, 4 or above indicates an upper motor neuron lesion

Power

Active & Passive

  • HIP
    • Flexion/Extension
  • KNEE
    • Flexion/Extension
  • ANKLE
    • Dorsiflexion/Plantarflexion
  • BIG TOE
    • Dorsiflexion/Plantarflexion

Power is scored out of 5: 0: No movement 1: Flicker of contraction 2: Movement, but not against gravity 3: Movement against gravity, but without resistance 4: Decreased movement against resistance 5: Normal

Reflexes

Ask patient to relax. Do reflexes on both sides to check for symmetry, and comment o strength.

  • KNEE JERK - put your arm under patient's knee and ask them to completely relax and give you the weight of their leg. Tap the tendon below the patella and feel for a jerk of the lower leg.
  • ANKLE JERK - externally rotate the hip, then have the knee at 90 degrees and the ankle at 90 degrees to that - so the leg is a zig-zag shape. Take the weight of the foot in one hand and tap the calcaneus tendon with the other at the back of the ankle. You should feel a twitch/flicker up the foot in your hand.
  • PLANTAR RESPONSE - run a blunt object up the foot from the lateral side up towards the big toe. You should see the toes curl down towards the floor. If the toes extend then this is a positive Babinski sign, and a sign of an upper motor neurone lesion.
  • Babinski Sign, Courtesy of All Access Medicine.

Reinforcement

  • Interlocking their fingers and pulling one hand against the other.

Coordination

  • HEEL-SHIN TEST - ask patient to put their heel below the knee of the other leg, and then slide it down towards ankle and back up again. Ask them to increase the speed if they can, and remember to do the test on both sides.

Function

  • Gait
    • Any abnormalities

As always, end your examination by thanking the patient, allowing them to cover themselves up, and washing your hands. ===Thank Patient

Wash Hands

Summary