Upper Limb Neurological Exam Overview

What's up Ninjaneurs? In this video today we're going to be talking about how to perform an upper limb neurological exam. Before we get started though we have notes that are very comprehensive and can supplement what we're going to cover in this video today. If you guys want to use those notes. go click down in the description box. We'll have links to our Patreon. You guys can go check that out. Also, if you guys like this video, benefit from this video, please hit that like button, comment down in the comment section, and please subscribe. Also, thank you, Ningeners, for helping us reach 1 million subscribers. We're so thankful, and it's so awesome. All right, Ningeners, we have our patient Q here today. We're going to get started on our neuro exam. Q, I'm going to have you go ahead and pop that shirt off, and I'm going to go ahead and clean my hands here. Well, I gotta get to the gym. Alright, so we have Q here in all his brawn. And what we're going to do here is we're going to start our neuro exam just by assessing him without even touching him. What we're kind of doing here is I'm looking at my symmetry between the right and left arm. I'm looking at bulk. And so what do I mean by that? I'm looking to see if one side is a little bit more atrophied or decreased muscle size than the other. The only reason I like to do that is because if I know that a patient maybe has an underlying lesion, for example, they have atrophy on one side. They have weakness on that side. They have facility. they have decreased reflexes on that side, may be indicative of a lower motor neuron lesion. So that's the first thing I like to look for. Any asymmetry in muscle bulk. For Q, none. Next thing I like to look for is any kind of abnormal posturing. So does he have any contractures? Is he in any particular type of posture that's not normal? In this case, no, so normal posture. The other thing I like to look for is any abnormal movements. Okay, so I like to look for any kind of tremors that may be at rest. That's a common sign on your board exams for something like Parkinson's disease. I like to look for any dyskinesias. So things like chorea, which is kind of like a very quick, non-repetitive, involuntary movement. Another thing is athetosis, which is kind of like a writhing snake-like movement of the hands or usually the digits. And then the other thing I like to look for is just kind of at rest, do I see any kind of fasciculations? present in the upper limbs or extremities there, besides him popping the pecs there, okay? That's awesome. All right, so I see no fasciculations. I see no dyskinesia, no tremors at rest. The other thing I like to look for here is I like to kind of just have him bring his arms up in front of me, and I just kind of look at this movement. So one of the things I also like to look for was there any slow speed in initiating that movement. That could be indicative of what's called bradykinesia, or did he have any tremors? as he was moving. Sometimes that can be indicative of what's called a postural tremor. Okay, so those are things I like to look for. In his case, he had no postural tremors, no resting tremors, no dyskinesia, no asymmetry with muscle bulk, and no fasciculations present. So muscle appearance is good. The next thing I like to move on to is tone. So tone is very important because when we like to look at tone, there's a way that we can score tone. You can use what's called a modified Ashworth score. or scale and it kind of helps you to assess or quantify the level of tone. What I like to do is I like to know if the person is hypotonic. So do they have very little tone or their muscles really floppy? The reason why hypotonia is something I need to know is do they have a again hypotonia, weakness, atrophy, fasciculations, hyporeflexia on one side could be in indicative of a lower motor neuron lesion? Or are they hypertonic? So they have a lot of like tone, or is there a lot of resistance to me moving their arms passively? If that's the case, they have hypertonia, and we'll subclassify that into spasticity and rigidity. a little bit later, but if they have for example spasticity, hypertonia, they have hyperreflexia, they have weakness on one side, it may be more indicative of an upper motor neuron lesion as well. Okay, so we're going to assess his tone here, and what I like to do when I assess tone is just kind of have him relax, let him kind of give me his arm, okay, I kind of want him to be very, very relaxed. I'm going to kind of brace around the elbow here, have him kind of grab my hand, and all I'm going to do here is just have him relax, and I'm going to kind of flex and extend here at the elbow, and I'm just going to assessing the movement there. There should be some normal tone there. You don't want it to be super floppy where he's just like, he has no control over it, okay? And he's just kind of really floppy. None there. So no hypotonia, a little bit of normal tone there, okay? I also don't want to see any hypertonia like we said. So how do I assess this? I do flexion, extension here at the elbow, then I kind of do pronation and supination here at the wrist, then I do extension and flexion here at the wrist as well, and then just kind of a little bit of movement here on around that shoulder joint. And I would compare to the other side to look to see if there's any asymmetry there with tone. In this case he had normal tone but again going back to this one of the things I like to look for with hypertonia is again that subtype of spasticity versus rigidity. So spasticity we commonly refer to as what's called velocity dependent and there's a very specific type of spasticity that we look for, what's called a clasp knife phenomenon. And so what does this mean by velocity dependent? If I were to go back to him, and I'm kind of like just moving normally like I was, but all of a sudden I try to really quickly move his arm, and I catch a lot of resistance as I'm moving it, and then eventually... gives way, that could be something that's called a clasp knife phenomenon. Okay, again, it's velocity dependent. But if I'm doing something where I'm checking and he's rigid, right, his arm is like a lead pipe, me trying to move his arm is like a lead pipe throughout the entire movement, that could be something called lead pipe rigidity. Or if it's really kind of rigid and you see kind of like a cogwheel, so it's kind of like catching as you move throughout the movement, that could also be a sign of rigidity called cogwheel rigidity, which is lead pipe rigidity with an associated tremor. Okay, so I like to look for spasticity, which is velocity. velocity dependent or rigidity, which is velocity independent. And again, grade my tone on that modified Ashworth scale. All right, so we've assessed his muscle appearance. We've assessed muscle tone. Now what I want to do is assess power or strength. Okay, so when we do this we utilize again a scoring system Okay, so a power or strength scoring system from zero to five. So how do I how do I test this? Let's kind of use it cue as an example here real quick So I'm gonna kind of just have you kind of flex your forearm there good. So when we test strength or power And so again, out of a five point score. So five would be, if I'm going to have him again apply, I'm going to apply some resistance, and am I able to kind of pull and he's able to maintain a normal strength against my full resistance? That's a five out of five. If I ask him to do it again, and when I'm pulling, again, pulling resistance and his strength starts kind of giving way a little bit, then that's going to be a four out of five. Now the next thing is if you can't kind of have any strength against resistance and I have to just do it again, do it with gravity. I'm going to hold his elbow and just him move there. That's going to be a three out of five. Okay. Then what I'm going to do is I'm going to remove gravity for him. And then again, I'm going to ask him to flex the forearm there. Good. And that would be a two out of five. Now the last one here or the next one would be if I ask him to flex his forearm and they just get like a flicker of movement, but no actual true movement. That would be a 1 out of 5 and if I say again you flex your forearm and I get no movement whatsoever it's a 0 out of 5. Okay, so again to recap that 5 out of 5, full strength against resistance, 4 out of 5 some mild to moderate strength against resistance, 3 out of 5 you can only do it against gravity. 2 out of 5 is you have to remove gravity. 1 out of 5 is a flicker. And 0 is, again, no movement. All right? So that's how we're going to assess power on Q. And we're going to do that starting with the proximal. shoulder joint and working our way down to the fingers. Okay, so first thing that we're going to assess is we're going to assess abduction. This is facilitated by the deltoid muscle, which is supplied by the axillary nerve, your C5 kind of nerve root. So yeah, we're going to have him kind of pull like this, fists together, and all I'm going to have him do is again just resist me pushing down. Normal strength there. Then we're going to test adduction. There's a bunch of different muscles that are involved in this, C6, C7 nerve roots usually. So I'm going to have him kind of resist me pulling up. and again normal strength there. So the proximal shoulder joint is strong, five out of five there. We're gonna test the flexion and extension at the elbow now. So what I'm gonna do is I'm gonna compare both sides. I did both sides simultaneously of abduction, adduction, but when I do this elbow I gotta do one and compare it to the other. So again what I'm gonna do here is I'm just gonna ask him to resist me pulling away, and again resist me pulling away, normal strength there. Now we're gonna do extension, push here, again normal strength there, push here, normal strength there. So when I test, The flexion of the elbow, we're testing the musculocutaneous nerve, which is going to be your C5, C6 nerve roots. And again, that's supplying the biceps brachii, the brachialis, and the coracobrachialis. When we're testing extension at the elbow, him pushing against me, that's testing the radial nerve. So C6 to C8 nerve roots. And again, that's your triceps brachii and your conius muscle there as well. So again, we've done the proximal shoulder joint. We've done the elbow. Now we're going to move down to the wrist. Okay, so I'm going to have him get perfectly, kind of make a fist, cock that wrist back, and now what we're going to do is test wrist extension. Don't let me pull them down. Again, don't let me pull them down. So wrist extension, five out of five. Switch it over and don't let me pull them down. Don't let me pull them down. So again, wrist extension, a bunch of muscles involved here. Extensor carpi radialis longus, brevis, extensor carpi ulnaris. These are supplied by your radial nerve, okay? And again, that's going to be your C6, C8 nerve roots, okay? And his was five out of five. With flexion at the wrist, there's two nerves. Your median nerve is... is going to supply some of the muscles here, like your flexor carpi radialis and your palmaris longus. And then you're also going to have your... Flexor Carpi Ulnaris, which is going to be supplied by your ulnar nerve, and those are responsible for flexing at the wrist. Okay? So, we've tested wrist extension. We've tested wrist flexion. Now, we're going to test finger extension and finger flexion. Okay? So, I'm going to have them, yep, perfectly bring the fingers out. And what I'm going to do is I'm just going to have them, again, don't let me push your fingers down. strength against that and again push down normal strength against that. I'm gonna flip them over and kind of curl those fingers there and again I'm gonna have them resist me pulling away and again resist me pulling them away. Okay so normal strength there with finger extension again important to remember the entire extensor side is your radial nerve okay and you got a bunch of different muscles here again extensor digitorum, extensor and dices, extensor digiti minimi and again these are the radial nerve c7 c8 nerve roots and then for finger flexion There is your flexor digitorum superficialis, right? And then you also have your flexor digitorum profundus. One half of it is supplied by the median nerve, and you have the other half of the flexor digitorum profundus, which is supplied by the ulnar nerve. So again, you're getting median and ulnar nerve supplying those finger flexors, okay? Sorry, so we've done the finger extension. We've done finger flexion. Now what I'm going to do is I'm going to test what's called abduction, particularly of the first and the pinky. Actually, your index finger and your pinky. So I'm going to have him kind of bring his hands out, kind of spread them a little bit there. And what I'm going to do is I'm going to test the first dorsal interossea. I'm going to have them kind of resist me pushing in. Good, normal abduction there. And again, strength against resistance on that side. Compare it to the other side. Push in, normal strength. Push in, normal strength. So again, when I'm testing finger abduction, you're testing particularly this one is your first dorsal interossei. And then over here on the pinky side, you're testing your abductor digiti minimi. And these are both supplied by your ulnar nerve in this. this case okay as you can say generally like cat1 nerve root region so normal strength there the next thing that we're going to do is we're going to test the thumbs okay so we're going to test thumb abduction we're going to test the abductor pollicis brevis so i'm going to have them kind of bring it there and bring your thumb up like this and what i want to do is compare so i'm going to have them resist me pulling that down resist me pulling that down normal strength against resistance for the thumb abduction and again the abductor pollicis brevis is supplied by the median nerve and again your ch to T1 nerve root if you want to know that, okay? So that's your finger abduction. The next thing we're going to do is we're going to test opposition. So I'm going to have him make a little okay sign there, okay? So then what I'm going to do is have him, again, resist me from pulling those fingers apart and, again, resist me from pulling those fingers apart. So him being able to resist that is, again, testing what's called the opponent's palisus. And, again, that's also supplied by the median nerve as well in this situation. And so, again, all of those are intact. The other thing that you could do is... is you could test grip strength, which tests your C7 to T1 nerve root. Because he's a jacked dude, I don't want him to crush my fingers. I'm going to cross my fingers like this, have him squeeze my fingers really hard and don't let me pull my fingers away. Normal grip strength there as well. So we've assessed power or strength from the proximal shoulder joint all the way down to the digits, five out of five in all his bilateral upper extremities. So to kind of recap, we've covered appearance, we've covered tone, and we've covered power. strength. After I've done that, the next thing I like to do is I like to go straight to my reflexes. So with reflexes, I'm going to have you kind of face forward here Q. I've got my good old reflex hammer. There's a bunch of different reflex hammers that you could use. I'm just going to use this one here and we're going to test a couple different reflexes. The first one I'm going to test is the triceps reflex and so with the triceps reflex I kind of like to have them kind of relax that arm there a little bit and I'm just going to have them kind of tap here and you can kind of see a little reflex there and you'd want to compare it to the other side. I'm not going to do that in this example but again I want to test my reflexes to see the reflex difference on one side of the other. So I tested my triceps reflex the next one I'm going to come to here is my biceps reflex. I'm going to have them kind of relax here and I'm going to kind of grab here my thumb around that tendon and again trying to look for a little bit of a flexion response there. So with your triceps you're looking for an extension kind of response. For the biceps reflex you're looking for a flexion response and then here you also have your brachioradialis reflex. So again I'm going to come down here at this proximal distal part of the forearm and again I'm looking for kind of a flexion response there as well. So with reflexes again it's important, I'm not doing this as an example, but it's important to compare. on both sides. We don't want, if there's asymmetric reflexes that we have to kind of further evaluate that, okay? So when we're talking about reflexes, it's important to remember a couple different things. First thing I like to know is how do I grade my reflexes? Just like strength or power. So with reflexes, we do this in a way that we can grade this on a four point scale. So the first one is, If I had someone who is, let's say, a four reflex. If I were to kind of tap on Q's, let's say, bicipital tendon or his brachioradialis tendon, I tapped and his reflex is super hyperreflexic. Okay, that could be a four. The other way to confirm that is you do what's called, you're testing for clonus. Now this is better seen within the ankle, but you can do it in the wrist as well. So what I would see is if I had a really brisk response from that brachioradialis reflex, and I come here and I really kind of... have them relax a little bit and I pull back on that wrist and I extend it and I see some quick beatings of like clonus that is a grade four or a four plus reflex okay so a plus four reflex again would be indicative of hyperreflexia but also associated clonus this is better seen in the lower extremities but again we can still do that here in the upper extremity so that's a four plus reflex A three is they have hyperreflexia, but they don't have clonus. So it would be the same thing, a very brisk hyperreactive response when I tap on the tendon, but they don't have an associated clonus. Two would be there's a normal reflex. It's not hyperreactive. It's not busting out of everywhere. So for this situation, his was a two-plus reflex, normal reflexia. The next one is a one. So a one is they have hyporeflexia. So hyporeflexia, this can be something that you... you have to further examine. So let's say that I had, for a cue, I had a little bit of a hyperreflexia. So I tap on that tendon there, and I get a very little reflex. If I can accentuate that reflex or kind of reinforce that reflex, what I can do is I can use what's called a reinforcement maneuver or a dendrasic maneuver. And so what I can have him do is a couple different things. Since I'm already testing his upper extremities, one of the ways you can do it when you test lower extremities is have them kind of clinch their hands like this and pull apart, or you can have them clinch on their teeth. And so if I had him clinch on his teeth and I was getting kind of a little bit of a response or no response and I tap on that tendon and I get a little bit more of a response from him using a reinforcement maneuver, that's going to be referred to as a plus one reflex. So again, plus one reflex, just to confirm this, is you may get a little reflex, but it's not super, it's kind of subtle. You have them do a reinforcement maneuver like a dendrasic maneuver, like clench their teeth or pull their hands apart and it kind of accentuates the reflex a little bit more. That's a plus one. If you do it and they have no reflex at all, or areflexia, that is something that you want to be thinking about as a 0 out of 5 reflex score. Okay? So we've gone through all of those reflexes, and we know how to score them. The other thing that we need to know besides knowing the score of reflex for Q was a 2 on his triceps, biceps, and brachioradialis. The other thing is to know, again, the nerve. And again, what root is supplying this? So again, the triceps is going to be your radial nerve, but you're testing particularly that C7, C8. And then the biceps and then your brachioradialis is going to be kind of your C5, C6 nerve roots that you're testing there, okay? So we've tested his reflexes. He has normal reflexia or plus two reflexes. And we didn't test them bilaterally, but he's a healthy guy, so I'm assuming he's plus two bilaterally on his biceps, triceps, and brachioradialis reflexes. So we've assessed muscle appearance, we've assessed the muscle tone, we've assessed power and strength, and now we've done our reflexes. The next thing we're going to do is sensation. Now sensation you test a couple different ways. There's elementary sensations like light touch, pain. temperature, vibration, and proprioception. We're going to forego the temperature, but if you were to assess temperature you would take two different types of temperature, cold temperature and hot temperature, and again apply them to different areas of the upper limbs looking to see if he can identify those. We're going to forego that and we're just going to do light touch, pain, we're going to do vibration, and we're also going to do proprioception. So the first one that I like to do is we're going to test light touch. And you can do this a couple different ways. I like to just use kind of a cotton swab in this example here. And what we're going to do is we're going to try to hit all the different types of dermatomes and assess his ability to identify light touch and also it be the same. on both sides. Okay, so on the right limb, I want it to feel the same as it is on the left limb. So first thing I want him to do is identify what that sensation feels like. So Q, can you feel this sensation here? Yes. All right, so what I want you to do is every time you feel that same sensation in your arms, I want you to say yes for me. The other thing I want to do is I want to make sure that he's not looking where I'm actually touching. So I'm going to have him close his eyes. And what I'm going to do is I'm going to go through all my dermatomes. So I'm going to go ahead and do C5 here. Yes. And I'm going to compare. So when I've done C5, I've got to come over here and compare it. Yes. Then after that, I'm going to move down into my C6 region here. Yes. Yes. Then I'm going to come down here into my C6. 7 region yes yes then I'm going to go into my c8 region yep yep t1 region yep yep and then my t2 region yep So did it feel the same on both sides? Yeah, and so when we're testing again light touch, we're seeing his ability to identify that and then we want them to be symmetrical on both sides. So light touch is intact. Now it's important to remember which part of your spinal cord is responsible. for light touch. That's going to be your dorsal column sensations, right? So inability to identify light touch may be kind of some type of posterior column disorder, something that you have to be thinking about. So we've identified that. The next thing I'm going to do is going to do a pain or kind of a superficial pain. pain. And so you can use a couple different things. There is particular tools, I just have a thumbtack that I'm going to assess here. And again, same thing, can you feel this here for me? Yes. Alright, so again we're gonna have you, anytime you feel that type of sensation, I want you to go ahead and say yes. Okay, so we're gonna close his eyes so that we remove where he we can see us touching him there, okay. And then again, we're going to go ahead and go through all of our kind of dermatomes here, okay. And so we're gonna test C5. Yes. And then we're going to come over here. Yep. And then again C6. Yep. Yep. And again we're going to come down to C7. Yep. Yes. C8. Yes. Yes. T1. Yes. Yes. And T2. Yep. Yes. All right, and did it feel the same? Yes. All right, good. So again, his ability to identify that type of superficial or pinprick sensation, as well as being able to have it the same on both sides, means that his pain pathway is intact. And it's important to remember. What's the pain pathway? Well, if you guys remember, it's going to be what? The anterior lateral system, right? So your lateral spinothalamic tract. So any kind of injury to the lateral spinothalamic tracts could also be indicative of where he might not be able to identify that pain. Now, going back to that, let's say that he... had a decreased sensitivity to the light touch sensation. There is a particular term for that. We call it hypesthesia. If he had an increased sensitivity to that light touch sensation, the cotton swab, it would be called hypesthesia. The other thing is, let's say that he also has kind of like a pins, needles, numbness, tingling type of sensation. That's called paresthesias as well. So that's something to be thinking about with that light touch sensation we did with the cotton swab. Now, if I did the pin prick sensation and he had a decreased sensitivity to that sensation, that's called hypoalgesia. And if he had an increased sensitivity to me picking him with that thumbtack, that'd be called hyperalgesia. So it's important to remember some of those terminology that may be thrown around. So with the pain, hypo, hyperalgesia. And with the light touch, hypesthesia, hyperesthesia, and paresthesias are terms that might get thrown around a lot. So we've assessed light touch. We've assessed pain. We're going to forego the temperature pathways. But again, it's important to remember that that's carried out by those lateral. spinal thalamic tracts as well. Now what we're going to do is we're going to test vibration or palisthesias. And so with vibrations, you'd like to use your tuning fork here. And what I like to do is I like to find a bony prominence. I just like to use a DIP of the thumb, okay, but you can use any of these digits. And then I also like to compare it on both sides, okay. So I like to go distal and I like to compare both sides on like the thumb near the DIP. Then after that, I like to go to the kind of like my acromion processes and I like to compare those at the proximal. point okay so what I'm going to do is I'm going to have you kind of tell me if you can feel this type of sensation here does it feel like vibration right yep all right anytime you feel that sensation I just want you to go ahead and say yes okay okay so again I'm having to close his eyes And again, I'm just going to find that DIP there. Can you feel that? Yes. Good. Does it feel the same like that vibration sense there? Yep. Good. And then what I can also do is I can determine whenever he doesn't feel that vibration sense. So again, I can tap it here. And again, I can say, hey, can you feel this? Yep. Tell me when you can't feel it. No. And so what you can do is you can hold on to this. It should kind of remove the vibrations. And if he's able to identify that, again, that vibration sense is intact there. So I'm going to compare it on both sides. So if I were to go through this all in one go. Can you feel this? Yes. Tell me when you can. No. Good. Come back over here. Can you feel this? Yes. Tell me when you can. No. Good. So the vibration sense is intact bilaterally there. Then I'm going to do the same thing, but I'm going to go a little bit more proximal. Okay. Can you feel this? Yes. Tell me when you can. No. Good. Same thing. Comparing over here. Yep. Okay. And then tell me when you can. No. Good. So again, vibration sense is going to be intact bilaterally at the proximal joints as well as the distal joints. Now, if he was unable to identify that vibration sense, again, you've got to be thinking about what pathway is carrying the vibration sense. That's your posterior column. So if there's any involvement of the posterior column or your dorsal column medial meniscus pathway That could be causing this loss of vibration sense. So it's something to be thinking about. Alright, so now what we're going to do is we're going to test the position sense. Okay, so we've already tested the vibration, let's test position, sense, or proprioception. I like to just do this testing it with like the DIP of one of the digits, right? So I'm just going to grab his finger here. I'm going to kind of isolate that DIP. And I like to grab here on the sides. I don't want to grab on the top of the thumb, on the sides here. And I just want him to know. So close your eyes, Q. This is going to be up. Got it. And this is going to be down. I want you to tell me which direction it's in, okay? And I'm going to move it around a little bit to kind of confuse him. And then I'm going to go boop. Down. Up. And his ability to identify all the positions of that digit means it's intact, that proprioception on that side. But I've got to compare it, right? So same thing, I've got to come over here. Again, isolate that DIP there, hold on the sides there. And again, Q, just so you know, this is up and this is down. Cool. Okay, move it around, try to confuse them a little bit. Down, down, down. All right, so his ability to identify all the positions there. Again, bilaterally intact means that that proprioception is intact. Again, going back to it, what column carries your... your proprioceptive sensations. It's your dorsal column. So the inability to identify the position sense may be indicative of a dorsal column lesion or posterior column lesion. So light touch, proprioception, vibration, any injuries to those could be indicative of a posterior column lesion or any issues with the pain or the temperature is going to be a lateral spinothalamic tract lesion. Okay? All right, so we've tested those essential kind of sensory modalities. The next thing we got to do is we can be a little bit more specific and we're going to and we can do some discriminative sensations. So with the discriminative sensations, we can do a couple of them. One of the ones that you're commonly taught is what's called stereognosis. So stereognosis is the ability to identify an object with your eyes closed, right? A familiar object. And so what I'm gonna, and what that test is, is again, your posterior column, but it also tests your sensory cortex within the parietal lobe as well. So what I want him to do is close his eyes, put his right hand open there for me, and I'm just gonna put something in his hand that I want him to do. I want him to be able to identify just by feel. So can you tell me what you think that is there, Q? It's like a marker. Good, and I would compare it on both sides. And so if he is unable to identify what that familiar object is, what could it be indicative of? Again, this is carried through the posterior column. Could be a posterior column disorder, or could be an injury to the sensory cortex. One of the best things to think about is, for example, if the light touch was intact, the proprioception was intact, and the vibration was intact, and the only... had the inability to identify objects, it's more likely a sensory cortex lesion, not likely a posterior column lesion, okay? So again, inability to identify that object is called a stereognosis, but the ability to identify it is called stereognosis, okay? So that's what we're testing, a stereognosis. Inability to identify it is called a stereognosia. All right, so we've tested stereognosis, one of the different types of discriminative sensations. The other one I can do here is I can test what's called graphesthesia. So graphesthesia is also testing that posterior column, but it's the identity. Ability to identify objects are things that are written onto the patient's hand. So again, I'm going to have you close your eyes here, Q. Give me your right hand. And can you just tell me what type of letter or number I'm writing here on your hand? Three. Good. And that's what I wrote down on his hand. So his ability to identify what number or letter I kind of wrote down on his hand is intact graphesthesia. Again, going back to that, if there's no ability to identify that kind of number, or letter then there may be something going on with the sensory cortex or the posterior column but it's the same thing if the light touch the proprioception vibration is intact and you're only losing the graphesthesia it's more likely a sensory cortex lesion. The other thing you can do here is commonly tested in the neuro ICU from what I do a lot, especially in strokes, is testing for extinction or sometimes formally referred to as neglect. And so what I like to do, just a very simple test, is I kind of have Q close his eyes, and I'm going to say, can you feel me touching you, Q? Yes. Okay. What side am I touching? It's the right side. What side am I touching? Left side. What side am I touching? Both. So he's able to identify and appreciate both sides of his upper limbs. If someone had a stroke, for example, let's say, a right MCA stroke where it really takes out a decent chunk of the parietal lobe area. He might neglect his left side. So, for example, I would have him close his eyes. Let's pretend that Q had a right-sided MCA stroke. You know, we don't want him to have it. But, again, if we're testing it and I would say, okay, can you feel me touch it? What side am I touching? Right side. What side am I touching? Right side. he might not be able to identify that side, but he sometimes may be able to. So the best way to determine this is, let's say that he did say, I can't, yeah, I feel you touching me on my left side. I have him, again, close his eyes, and I double simultaneously stimulate. And if I ask him, which side am I touching you on? He would most likely say the right, because he's extinguishing that left side. He's neglecting the left side. Okay, so that's a big thing to be thinking about when you're examining these patients. So again, for the discriminative sensations, what I like to test is, again, Stereognosis, the ability to identify a familiar object. Graphesthesia, the ability to identify written objects that are written on the hand. And then the next thing is extinction. Again, the inability to identify one side of the body. usually with double simultaneous stimulation. Okay, a very common thing to think about in strokes. All right, so we've assessed those sensations. Now what do we do? All right, so we've gone through, let's kind of review. We've covered muscle appearance, we've covered tone, we've covered power or strength, we've covered reflexes, and we've covered our sensory modalities. The next thing to cover is coordination. So when I assess coordination, the first thing I like to do is, again, I'm testing the upper limbs. So I like to do what's called a finger-to-nose test. So this is really telling me a lot about this patient's cerebellum. So I'm going to test finger to nose, and what I'm looking for is what's called dysmetria. So sometimes if I have him come and touch his nose and come and touch my finger, he may overshoot and then try to correct it. So what we're going to do is I'm going to have you kind of take your finger, touch it to your nose with your right hand, and then touch my finger. And keep doing that a couple times. So he's every single time hitting it right on point. So what I'm looking at is the rate of that movement. I'm looking to see if it's nice and quick. I'm also looking at the rhythm. Is he struggling sometimes to be able to move where I need him to go? Also, is he overshooting it? So is his amplitude... He's coming at it and then overshooting it and then correcting. So that could be a sign of dysmetria. The other thing that I also like to look for is what's called intention tremors. So if he's touching his finger to his nose and then coming to me as he brings his finger closer, and closer the amplitude of that tremor increases as he brings his finger to my finger. So I'm looking for dysmetria, kind of overshooting that movement and then trying to quickly correct. And tension tremors, tremors amplifying and increasing in intensity as they bring their finger towards the target. What else can I test for coordination? And again, it's also, before we move on to that, it's also important to test both sides. So I do the same thing on the left side, finger to nose. Okay, all of that's intact. So again, no dysmetria, no intention tremors seen with that. The next thing I do is like to do rapid alternating movements. And again, you can do this a couple different ways. You could either have them take and tap this portion here of their thumb and do it as quickly as possible to determine the rate, the rhythm, the amplitude. to that movement. Another one I like to do is what's called rapid alternating movements, which is kind of moving their hand back and forth on the other hand. So I'm just cueing, I'm gonna have you kind of do that, and just nice and quick back and forth. Good, same thing on the other side. Good. And so what I'm looking for is I'm looking for someone, again, if they had what's called dysdiatokinesis. So whenever they're doing it, they may have like some difficulties where their rate may be slow, their rhythm may be kind of off. So they're not kind of going back and forth consistently. That could be a sign of dysdiatokinesis. Okay. So we've tested finger to nose looking for dysmetria and tension tremors. We've tested rapid alternating movements to look for dysdiatokinesis. The next thing we can also do is we can do what's called a cerebellar drift. So the cerebellar drift is the same thing as a pronation. but it's the exact opposite. So I'm gonna have you kind of put your hands out in front of you in a supinated position. And again, what I'm gonna have him do is close his eyes. Now, in a pronated drift, it would pronate and go down. In a cerebellar drift, it would pronate and go up. So that's something that you may see in a cerebellar drift. So if they had a right-sided cerebellar lesion, they would have a pronation and upward movement of that right arm, okay? Because usually, again, cerebellar lesions are ipsilateral. All right, so we've tested finger to nose, looking for dysmetria and tension tumors, dysdiatoconiesia. with rapid alternating movements and cerebellar drifts. The other thing you can do is you can do what's called a rebound phenomenon. So for example, if they had a right-sided cerebellar lesion, You can kind of have them resist movement. So I'm going to say, you know, really try to resist my movement as hard as you can. I like to put my hand kind of in front of the patient because if someone has a right cerebral lesion and I let go, they're going to rebound and they might even come and hit themselves in the face because they have no ability to kind of maintain that tone of the agonist and antagonistic muscles. So again, what I like to do is really kind of have my hand here just in case. Really, really pull, pull, pull, pull, pull and I let go. And I'll try to basically, again, I don't want them to hit themselves in the face, but they should stop. Because usually if someone has normal cerebellar function, the tone between the agonist and antagonist should be pretty much kind of normal. Okay? So again, I've tested finger to nose looking for antagonism. tension tremors, dysmetria. I've tested for dystoidokinesis, rapid alternating movements. I've tested for cerebellar drifts, and I've also tested for the rebound phenomenon. That would conclude my, particularly my coordination component of the upper limb neuro exam. as well as complete my entire upper limb neurological exam. So to quickly recap what we would go through in this patient, we would start off by looking at appearance. Then after that, we would assess tone. We would then assess power strength. We would test reflexes. Then we then test sensory modalities, the elementary sensations, then the discriminative sensations. And then after that, we would finish up with our coordination with finger to nose, rapid alternating movements, cerebellar drifts, as well as a rebound phenomenon. All right, Nijner, so in this... video today we talk about how to perform an upper limb neurological exam. I hope that you guys enjoyed it, I hope you guys learned a lot. Also let's give a big shout out, big thanks to Q for being our patient today. If you guys want to go check him out, check out his twitch channel down in the description box, we'll have a link to that down there. Also Ningeners we love you, we thank you, thank you for always supporting us and as always until next time. Thank you

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All right, Ningeners, we have our patient Q here today. We're going to get started on our neuro exam. Q, I'm going to have you go ahead and pop that shirt off, and I'm going to go ahead and clean my hands here. Well, I gotta get to the gym. Alright, so we have Q here in all his brawn.

And what we're going to do here is we're going to start our neuro exam just by assessing him without even touching him. What we're kind of doing here is I'm looking at my symmetry between the right and left arm. I'm looking at bulk.

And so what do I mean by that? I'm looking to see if one side is a little bit more atrophied or decreased muscle size than the other. The only reason I like to do that is because if I know that a patient maybe has an underlying lesion, for example, they have atrophy on one side.

They have weakness on that side. They have facility. they have decreased reflexes on that side, may be indicative of a lower motor neuron lesion. So that's the first thing I like to look for. Any asymmetry in muscle bulk.

For Q, none. Next thing I like to look for is any kind of abnormal posturing. So does he have any contractures? Is he in any particular type of posture that's not normal?

In this case, no, so normal posture. The other thing I like to look for is any abnormal movements. Okay, so I like to look for any kind of tremors that may be at rest. That's a common sign on your board exams for something like Parkinson's disease. I like to look for any dyskinesias.

So things like chorea, which is kind of like a very quick, non-repetitive, involuntary movement. Another thing is athetosis, which is kind of like a writhing snake-like movement of the hands or usually the digits. And then the other thing I like to look for is just kind of at rest, do I see any kind of fasciculations? present in the upper limbs or extremities there, besides him popping the pecs there, okay? That's awesome.

All right, so I see no fasciculations. I see no dyskinesia, no tremors at rest. The other thing I like to look for here is I like to kind of just have him bring his arms up in front of me, and I just kind of look at this movement. So one of the things I also like to look for was there any slow speed in initiating that movement. That could be indicative of what's called bradykinesia, or did he have any tremors?

as he was moving. Sometimes that can be indicative of what's called a postural tremor. Okay, so those are things I like to look for.

In his case, he had no postural tremors, no resting tremors, no dyskinesia, no asymmetry with muscle bulk, and no fasciculations present. So muscle appearance is good. The next thing I like to move on to is tone.

So tone is very important because when we like to look at tone, there's a way that we can score tone. You can use what's called a modified Ashworth score. or scale and it kind of helps you to assess or quantify the level of tone.

What I like to do is I like to know if the person is hypotonic. So do they have very little tone or their muscles really floppy? The reason why hypotonia is something I need to know is do they have a again hypotonia, weakness, atrophy, fasciculations, hyporeflexia on one side could be in indicative of a lower motor neuron lesion?

Or are they hypertonic? So they have a lot of like tone, or is there a lot of resistance to me moving their arms passively? If that's the case, they have hypertonia, and we'll subclassify that into spasticity and rigidity. a little bit later, but if they have for example spasticity, hypertonia, they have hyperreflexia, they have weakness on one side, it may be more indicative of an upper motor neuron lesion as well.

Okay, so we're going to assess his tone here, and what I like to do when I assess tone is just kind of have him relax, let him kind of give me his arm, okay, I kind of want him to be very, very relaxed. I'm going to kind of brace around the elbow here, have him kind of grab my hand, and all I'm going to do here is just have him relax, and I'm going to kind of flex and extend here at the elbow, and I'm just going to assessing the movement there. There should be some normal tone there. You don't want it to be super floppy where he's just like, he has no control over it, okay?

And he's just kind of really floppy. None there. So no hypotonia, a little bit of normal tone there, okay?

I also don't want to see any hypertonia like we said. So how do I assess this? I do flexion, extension here at the elbow, then I kind of do pronation and supination here at the wrist, then I do extension and flexion here at the wrist as well, and then just kind of a little bit of movement here on around that shoulder joint.

And I would compare to the other side to look to see if there's any asymmetry there with tone. In this case he had normal tone but again going back to this one of the things I like to look for with hypertonia is again that subtype of spasticity versus rigidity. So spasticity we commonly refer to as what's called velocity dependent and there's a very specific type of spasticity that we look for, what's called a clasp knife phenomenon. And so what does this mean by velocity dependent?

If I were to go back to him, and I'm kind of like just moving normally like I was, but all of a sudden I try to really quickly move his arm, and I catch a lot of resistance as I'm moving it, and then eventually... gives way, that could be something that's called a clasp knife phenomenon. Okay, again, it's velocity dependent. But if I'm doing something where I'm checking and he's rigid, right, his arm is like a lead pipe, me trying to move his arm is like a lead pipe throughout the entire movement, that could be something called lead pipe rigidity. Or if it's really kind of rigid and you see kind of like a cogwheel, so it's kind of like catching as you move throughout the movement, that could also be a sign of rigidity called cogwheel rigidity, which is lead pipe rigidity with an associated tremor.

Okay, so I like to look for spasticity, which is velocity. velocity dependent or rigidity, which is velocity independent. And again, grade my tone on that modified Ashworth scale.

All right, so we've assessed his muscle appearance. We've assessed muscle tone. Now what I want to do is assess power or strength.

Okay, so when we do this we utilize again a scoring system Okay, so a power or strength scoring system from zero to five. So how do I how do I test this? Let's kind of use it cue as an example here real quick So I'm gonna kind of just have you kind of flex your forearm there good.

So when we test strength or power And so again, out of a five point score. So five would be, if I'm going to have him again apply, I'm going to apply some resistance, and am I able to kind of pull and he's able to maintain a normal strength against my full resistance? That's a five out of five.

If I ask him to do it again, and when I'm pulling, again, pulling resistance and his strength starts kind of giving way a little bit, then that's going to be a four out of five. Now the next thing is if you can't kind of have any strength against resistance and I have to just do it again, do it with gravity. I'm going to hold his elbow and just him move there. That's going to be a three out of five.

Okay. Then what I'm going to do is I'm going to remove gravity for him. And then again, I'm going to ask him to flex the forearm there.

Good. And that would be a two out of five. Now the last one here or the next one would be if I ask him to flex his forearm and they just get like a flicker of movement, but no actual true movement. That would be a 1 out of 5 and if I say again you flex your forearm and I get no movement whatsoever it's a 0 out of 5. Okay, so again to recap that 5 out of 5, full strength against resistance, 4 out of 5 some mild to moderate strength against resistance, 3 out of 5 you can only do it against gravity. 2 out of 5 is you have to remove gravity.

1 out of 5 is a flicker. And 0 is, again, no movement. All right? So that's how we're going to assess power on Q. And we're going to do that starting with the proximal.

shoulder joint and working our way down to the fingers. Okay, so first thing that we're going to assess is we're going to assess abduction. This is facilitated by the deltoid muscle, which is supplied by the axillary nerve, your C5 kind of nerve root. So yeah, we're going to have him kind of pull like this, fists together, and all I'm going to have him do is again just resist me pushing down.

Normal strength there. Then we're going to test adduction. There's a bunch of different muscles that are involved in this, C6, C7 nerve roots usually. So I'm going to have him kind of resist me pulling up.

and again normal strength there. So the proximal shoulder joint is strong, five out of five there. We're gonna test the flexion and extension at the elbow now. So what I'm gonna do is I'm gonna compare both sides. I did both sides simultaneously of abduction, adduction, but when I do this elbow I gotta do one and compare it to the other.

So again what I'm gonna do here is I'm just gonna ask him to resist me pulling away, and again resist me pulling away, normal strength there. Now we're gonna do extension, push here, again normal strength there, push here, normal strength there. So when I test, The flexion of the elbow, we're testing the musculocutaneous nerve, which is going to be your C5, C6 nerve roots.

And again, that's supplying the biceps brachii, the brachialis, and the coracobrachialis. When we're testing extension at the elbow, him pushing against me, that's testing the radial nerve. So C6 to C8 nerve roots. And again, that's your triceps brachii and your conius muscle there as well.

So again, we've done the proximal shoulder joint. We've done the elbow. Now we're going to move down to the wrist. Okay, so I'm going to have him get perfectly, kind of make a fist, cock that wrist back, and now what we're going to do is test wrist extension.

Don't let me pull them down. Again, don't let me pull them down. So wrist extension, five out of five.

Switch it over and don't let me pull them down. Don't let me pull them down. So again, wrist extension, a bunch of muscles involved here. Extensor carpi radialis longus, brevis, extensor carpi ulnaris. These are supplied by your radial nerve, okay?

And again, that's going to be your C6, C8 nerve roots, okay? And his was five out of five. With flexion at the wrist, there's two nerves. Your median nerve is...

is going to supply some of the muscles here, like your flexor carpi radialis and your palmaris longus. And then you're also going to have your... Flexor Carpi Ulnaris, which is going to be supplied by your ulnar nerve, and those are responsible for flexing at the wrist.

Okay? So, we've tested wrist extension. We've tested wrist flexion. Now, we're going to test finger extension and finger flexion. Okay?

So, I'm going to have them, yep, perfectly bring the fingers out. And what I'm going to do is I'm just going to have them, again, don't let me push your fingers down. strength against that and again push down normal strength against that. I'm gonna flip them over and kind of curl those fingers there and again I'm gonna have them resist me pulling away and again resist me pulling them away. Okay so normal strength there with finger extension again important to remember the entire extensor side is your radial nerve okay and you got a bunch of different muscles here again extensor digitorum, extensor and dices, extensor digiti minimi and again these are the radial nerve c7 c8 nerve roots and then for finger flexion There is your flexor digitorum superficialis, right?

And then you also have your flexor digitorum profundus. One half of it is supplied by the median nerve, and you have the other half of the flexor digitorum profundus, which is supplied by the ulnar nerve. So again, you're getting median and ulnar nerve supplying those finger flexors, okay? Sorry, so we've done the finger extension. We've done finger flexion.

Now what I'm going to do is I'm going to test what's called abduction, particularly of the first and the pinky. Actually, your index finger and your pinky. So I'm going to have him kind of bring his hands out, kind of spread them a little bit there.

And what I'm going to do is I'm going to test the first dorsal interossea. I'm going to have them kind of resist me pushing in. Good, normal abduction there. And again, strength against resistance on that side. Compare it to the other side.

Push in, normal strength. Push in, normal strength. So again, when I'm testing finger abduction, you're testing particularly this one is your first dorsal interossei.

And then over here on the pinky side, you're testing your abductor digiti minimi. And these are both supplied by your ulnar nerve in this. this case okay as you can say generally like cat1 nerve root region so normal strength there the next thing that we're going to do is we're going to test the thumbs okay so we're going to test thumb abduction we're going to test the abductor pollicis brevis so i'm going to have them kind of bring it there and bring your thumb up like this and what i want to do is compare so i'm going to have them resist me pulling that down resist me pulling that down normal strength against resistance for the thumb abduction and again the abductor pollicis brevis is supplied by the median nerve and again your ch to T1 nerve root if you want to know that, okay?

So that's your finger abduction. The next thing we're going to do is we're going to test opposition. So I'm going to have him make a little okay sign there, okay? So then what I'm going to do is have him, again, resist me from pulling those fingers apart and, again, resist me from pulling those fingers apart. So him being able to resist that is, again, testing what's called the opponent's palisus.

And, again, that's also supplied by the median nerve as well in this situation. And so, again, all of those are intact. The other thing that you could do is...

is you could test grip strength, which tests your C7 to T1 nerve root. Because he's a jacked dude, I don't want him to crush my fingers. I'm going to cross my fingers like this, have him squeeze my fingers really hard and don't let me pull my fingers away. Normal grip strength there as well. So we've assessed power or strength from the proximal shoulder joint all the way down to the digits, five out of five in all his bilateral upper extremities.

So to kind of recap, we've covered appearance, we've covered tone, and we've covered power. strength. After I've done that, the next thing I like to do is I like to go straight to my reflexes. So with reflexes, I'm going to have you kind of face forward here Q. I've got my good old reflex hammer.

There's a bunch of different reflex hammers that you could use. I'm just going to use this one here and we're going to test a couple different reflexes. The first one I'm going to test is the triceps reflex and so with the triceps reflex I kind of like to have them kind of relax that arm there a little bit and I'm just going to have them kind of tap here and you can kind of see a little reflex there and you'd want to compare it to the other side.

I'm not going to do that in this example but again I want to test my reflexes to see the reflex difference on one side of the other. So I tested my triceps reflex the next one I'm going to come to here is my biceps reflex. I'm going to have them kind of relax here and I'm going to kind of grab here my thumb around that tendon and again trying to look for a little bit of a flexion response there.

So with your triceps you're looking for an extension kind of response. For the biceps reflex you're looking for a flexion response and then here you also have your brachioradialis reflex. So again I'm going to come down here at this proximal distal part of the forearm and again I'm looking for kind of a flexion response there as well. So with reflexes again it's important, I'm not doing this as an example, but it's important to compare.

on both sides. We don't want, if there's asymmetric reflexes that we have to kind of further evaluate that, okay? So when we're talking about reflexes, it's important to remember a couple different things. First thing I like to know is how do I grade my reflexes?

Just like strength or power. So with reflexes, we do this in a way that we can grade this on a four point scale. So the first one is, If I had someone who is, let's say, a four reflex.

If I were to kind of tap on Q's, let's say, bicipital tendon or his brachioradialis tendon, I tapped and his reflex is super hyperreflexic. Okay, that could be a four. The other way to confirm that is you do what's called, you're testing for clonus.

Now this is better seen within the ankle, but you can do it in the wrist as well. So what I would see is if I had a really brisk response from that brachioradialis reflex, and I come here and I really kind of... have them relax a little bit and I pull back on that wrist and I extend it and I see some quick beatings of like clonus that is a grade four or a four plus reflex okay so a plus four reflex again would be indicative of hyperreflexia but also associated clonus this is better seen in the lower extremities but again we can still do that here in the upper extremity so that's a four plus reflex A three is they have hyperreflexia, but they don't have clonus.

So it would be the same thing, a very brisk hyperreactive response when I tap on the tendon, but they don't have an associated clonus. Two would be there's a normal reflex. It's not hyperreactive.

It's not busting out of everywhere. So for this situation, his was a two-plus reflex, normal reflexia. The next one is a one.

So a one is they have hyporeflexia. So hyporeflexia, this can be something that you... you have to further examine. So let's say that I had, for a cue, I had a little bit of a hyperreflexia. So I tap on that tendon there, and I get a very little reflex.

If I can accentuate that reflex or kind of reinforce that reflex, what I can do is I can use what's called a reinforcement maneuver or a dendrasic maneuver. And so what I can have him do is a couple different things. Since I'm already testing his upper extremities, one of the ways you can do it when you test lower extremities is have them kind of clinch their hands like this and pull apart, or you can have them clinch on their teeth. And so if I had him clinch on his teeth and I was getting kind of a little bit of a response or no response and I tap on that tendon and I get a little bit more of a response from him using a reinforcement maneuver, that's going to be referred to as a plus one reflex. So again, plus one reflex, just to confirm this, is you may get a little reflex, but it's not super, it's kind of subtle.

You have them do a reinforcement maneuver like a dendrasic maneuver, like clench their teeth or pull their hands apart and it kind of accentuates the reflex a little bit more. That's a plus one. If you do it and they have no reflex at all, or areflexia, that is something that you want to be thinking about as a 0 out of 5 reflex score. Okay? So we've gone through all of those reflexes, and we know how to score them.

The other thing that we need to know besides knowing the score of reflex for Q was a 2 on his triceps, biceps, and brachioradialis. The other thing is to know, again, the nerve. And again, what root is supplying this? So again, the triceps is going to be your radial nerve, but you're testing particularly that C7, C8. And then the biceps and then your brachioradialis is going to be kind of your C5, C6 nerve roots that you're testing there, okay?

So we've tested his reflexes. He has normal reflexia or plus two reflexes. And we didn't test them bilaterally, but he's a healthy guy, so I'm assuming he's plus two bilaterally on his biceps, triceps, and brachioradialis reflexes.

So we've assessed muscle appearance, we've assessed the muscle tone, we've assessed power and strength, and now we've done our reflexes. The next thing we're going to do is sensation. Now sensation you test a couple different ways. There's elementary sensations like light touch, pain.

temperature, vibration, and proprioception. We're going to forego the temperature, but if you were to assess temperature you would take two different types of temperature, cold temperature and hot temperature, and again apply them to different areas of the upper limbs looking to see if he can identify those. We're going to forego that and we're just going to do light touch, pain, we're going to do vibration, and we're also going to do proprioception.

So the first one that I like to do is we're going to test light touch. And you can do this a couple different ways. I like to just use kind of a cotton swab in this example here.

And what we're going to do is we're going to try to hit all the different types of dermatomes and assess his ability to identify light touch and also it be the same. on both sides. Okay, so on the right limb, I want it to feel the same as it is on the left limb.

So first thing I want him to do is identify what that sensation feels like. So Q, can you feel this sensation here? Yes.

All right, so what I want you to do is every time you feel that same sensation in your arms, I want you to say yes for me. The other thing I want to do is I want to make sure that he's not looking where I'm actually touching. So I'm going to have him close his eyes.

And what I'm going to do is I'm going to go through all my dermatomes. So I'm going to go ahead and do C5 here. Yes.

And I'm going to compare. So when I've done C5, I've got to come over here and compare it. Yes.

Then after that, I'm going to move down into my C6 region here. Yes. Yes. Then I'm going to come down here into my C6.

7 region yes yes then I'm going to go into my c8 region yep yep t1 region yep yep and then my t2 region yep So did it feel the same on both sides? Yeah, and so when we're testing again light touch, we're seeing his ability to identify that and then we want them to be symmetrical on both sides. So light touch is intact.

Now it's important to remember which part of your spinal cord is responsible. for light touch. That's going to be your dorsal column sensations, right?

So inability to identify light touch may be kind of some type of posterior column disorder, something that you have to be thinking about. So we've identified that. The next thing I'm going to do is going to do a pain or kind of a superficial pain. pain.

And so you can use a couple different things. There is particular tools, I just have a thumbtack that I'm going to assess here. And again, same thing, can you feel this here for me?

Yes. Alright, so again we're gonna have you, anytime you feel that type of sensation, I want you to go ahead and say yes. Okay, so we're gonna close his eyes so that we remove where he we can see us touching him there, okay. And then again, we're going to go ahead and go through all of our kind of dermatomes here, okay.

And so we're gonna test C5. Yes. And then we're going to come over here.

Yep. And then again C6. Yep.

Yep. And again we're going to come down to C7. Yep. Yes.

C8. Yes. Yes.

T1. Yes. Yes.

And T2. Yep. Yes. All right, and did it feel the same? Yes.

All right, good. So again, his ability to identify that type of superficial or pinprick sensation, as well as being able to have it the same on both sides, means that his pain pathway is intact. And it's important to remember.

What's the pain pathway? Well, if you guys remember, it's going to be what? The anterior lateral system, right?

So your lateral spinothalamic tract. So any kind of injury to the lateral spinothalamic tracts could also be indicative of where he might not be able to identify that pain. Now, going back to that, let's say that he... had a decreased sensitivity to the light touch sensation.

There is a particular term for that. We call it hypesthesia. If he had an increased sensitivity to that light touch sensation, the cotton swab, it would be called hypesthesia.

The other thing is, let's say that he also has kind of like a pins, needles, numbness, tingling type of sensation. That's called paresthesias as well. So that's something to be thinking about with that light touch sensation we did with the cotton swab.

Now, if I did the pin prick sensation and he had a decreased sensitivity to that sensation, that's called hypoalgesia. And if he had an increased sensitivity to me picking him with that thumbtack, that'd be called hyperalgesia. So it's important to remember some of those terminology that may be thrown around.

So with the pain, hypo, hyperalgesia. And with the light touch, hypesthesia, hyperesthesia, and paresthesias are terms that might get thrown around a lot. So we've assessed light touch.

We've assessed pain. We're going to forego the temperature pathways. But again, it's important to remember that that's carried out by those lateral.

spinal thalamic tracts as well. Now what we're going to do is we're going to test vibration or palisthesias. And so with vibrations, you'd like to use your tuning fork here.

And what I like to do is I like to find a bony prominence. I just like to use a DIP of the thumb, okay, but you can use any of these digits. And then I also like to compare it on both sides, okay. So I like to go distal and I like to compare both sides on like the thumb near the DIP.

Then after that, I like to go to the kind of like my acromion processes and I like to compare those at the proximal. point okay so what I'm going to do is I'm going to have you kind of tell me if you can feel this type of sensation here does it feel like vibration right yep all right anytime you feel that sensation I just want you to go ahead and say yes okay okay so again I'm having to close his eyes And again, I'm just going to find that DIP there. Can you feel that? Yes.

Good. Does it feel the same like that vibration sense there? Yep. Good. And then what I can also do is I can determine whenever he doesn't feel that vibration sense.

So again, I can tap it here. And again, I can say, hey, can you feel this? Yep. Tell me when you can't feel it.

No. And so what you can do is you can hold on to this. It should kind of remove the vibrations. And if he's able to identify that, again, that vibration sense is intact there.

So I'm going to compare it on both sides. So if I were to go through this all in one go. Can you feel this?

Yes. Tell me when you can. No. Good. Come back over here.

Can you feel this? Yes. Tell me when you can.

No. Good. So the vibration sense is intact bilaterally there.

Then I'm going to do the same thing, but I'm going to go a little bit more proximal. Okay. Can you feel this? Yes.

Tell me when you can. No. Good. Same thing. Comparing over here.

Yep. Okay. And then tell me when you can.

No. Good. So again, vibration sense is going to be intact bilaterally at the proximal joints as well as the distal joints.

Now, if he was unable to identify that vibration sense, again, you've got to be thinking about what pathway is carrying the vibration sense. That's your posterior column. So if there's any involvement of the posterior column or your dorsal column medial meniscus pathway That could be causing this loss of vibration sense. So it's something to be thinking about. Alright, so now what we're going to do is we're going to test the position sense.

Okay, so we've already tested the vibration, let's test position, sense, or proprioception. I like to just do this testing it with like the DIP of one of the digits, right? So I'm just going to grab his finger here. I'm going to kind of isolate that DIP. And I like to grab here on the sides.

I don't want to grab on the top of the thumb, on the sides here. And I just want him to know. So close your eyes, Q. This is going to be up. Got it.

And this is going to be down. I want you to tell me which direction it's in, okay? And I'm going to move it around a little bit to kind of confuse him.

And then I'm going to go boop. Down. Up. And his ability to identify all the positions of that digit means it's intact, that proprioception on that side. But I've got to compare it, right?

So same thing, I've got to come over here. Again, isolate that DIP there, hold on the sides there. And again, Q, just so you know, this is up and this is down. Cool.

Okay, move it around, try to confuse them a little bit. Down, down, down. All right, so his ability to identify all the positions there.

Again, bilaterally intact means that that proprioception is intact. Again, going back to it, what column carries your... your proprioceptive sensations. It's your dorsal column.

So the inability to identify the position sense may be indicative of a dorsal column lesion or posterior column lesion. So light touch, proprioception, vibration, any injuries to those could be indicative of a posterior column lesion or any issues with the pain or the temperature is going to be a lateral spinothalamic tract lesion. Okay? All right, so we've tested those essential kind of sensory modalities.

The next thing we got to do is we can be a little bit more specific and we're going to and we can do some discriminative sensations. So with the discriminative sensations, we can do a couple of them. One of the ones that you're commonly taught is what's called stereognosis.

So stereognosis is the ability to identify an object with your eyes closed, right? A familiar object. And so what I'm gonna, and what that test is, is again, your posterior column, but it also tests your sensory cortex within the parietal lobe as well. So what I want him to do is close his eyes, put his right hand open there for me, and I'm just gonna put something in his hand that I want him to do. I want him to be able to identify just by feel.

So can you tell me what you think that is there, Q? It's like a marker. Good, and I would compare it on both sides.

And so if he is unable to identify what that familiar object is, what could it be indicative of? Again, this is carried through the posterior column. Could be a posterior column disorder, or could be an injury to the sensory cortex. One of the best things to think about is, for example, if the light touch was intact, the proprioception was intact, and the vibration was intact, and the only... had the inability to identify objects, it's more likely a sensory cortex lesion, not likely a posterior column lesion, okay?

So again, inability to identify that object is called a stereognosis, but the ability to identify it is called stereognosis, okay? So that's what we're testing, a stereognosis. Inability to identify it is called a stereognosia. All right, so we've tested stereognosis, one of the different types of discriminative sensations. The other one I can do here is I can test what's called graphesthesia.

So graphesthesia is also testing that posterior column, but it's the identity. Ability to identify objects are things that are written onto the patient's hand. So again, I'm going to have you close your eyes here, Q.

Give me your right hand. And can you just tell me what type of letter or number I'm writing here on your hand? Three. Good. And that's what I wrote down on his hand.

So his ability to identify what number or letter I kind of wrote down on his hand is intact graphesthesia. Again, going back to that, if there's no ability to identify that kind of number, or letter then there may be something going on with the sensory cortex or the posterior column but it's the same thing if the light touch the proprioception vibration is intact and you're only losing the graphesthesia it's more likely a sensory cortex lesion. The other thing you can do here is commonly tested in the neuro ICU from what I do a lot, especially in strokes, is testing for extinction or sometimes formally referred to as neglect. And so what I like to do, just a very simple test, is I kind of have Q close his eyes, and I'm going to say, can you feel me touching you, Q? Yes.

Okay. What side am I touching? It's the right side. What side am I touching?

Left side. What side am I touching? Both.

So he's able to identify and appreciate both sides of his upper limbs. If someone had a stroke, for example, let's say, a right MCA stroke where it really takes out a decent chunk of the parietal lobe area. He might neglect his left side.

So, for example, I would have him close his eyes. Let's pretend that Q had a right-sided MCA stroke. You know, we don't want him to have it. But, again, if we're testing it and I would say, okay, can you feel me touch it?

What side am I touching? Right side. What side am I touching? Right side. he might not be able to identify that side, but he sometimes may be able to.

So the best way to determine this is, let's say that he did say, I can't, yeah, I feel you touching me on my left side. I have him, again, close his eyes, and I double simultaneously stimulate. And if I ask him, which side am I touching you on?

He would most likely say the right, because he's extinguishing that left side. He's neglecting the left side. Okay, so that's a big thing to be thinking about when you're examining these patients.

So again, for the discriminative sensations, what I like to test is, again, Stereognosis, the ability to identify a familiar object. Graphesthesia, the ability to identify written objects that are written on the hand. And then the next thing is extinction. Again, the inability to identify one side of the body.

usually with double simultaneous stimulation. Okay, a very common thing to think about in strokes. All right, so we've assessed those sensations.

Now what do we do? All right, so we've gone through, let's kind of review. We've covered muscle appearance, we've covered tone, we've covered power or strength, we've covered reflexes, and we've covered our sensory modalities. The next thing to cover is coordination.

So when I assess coordination, the first thing I like to do is, again, I'm testing the upper limbs. So I like to do what's called a finger-to-nose test. So this is really telling me a lot about this patient's cerebellum. So I'm going to test finger to nose, and what I'm looking for is what's called dysmetria. So sometimes if I have him come and touch his nose and come and touch my finger, he may overshoot and then try to correct it.

So what we're going to do is I'm going to have you kind of take your finger, touch it to your nose with your right hand, and then touch my finger. And keep doing that a couple times. So he's every single time hitting it right on point.

So what I'm looking at is the rate of that movement. I'm looking to see if it's nice and quick. I'm also looking at the rhythm. Is he struggling sometimes to be able to move where I need him to go? Also, is he overshooting it?

So is his amplitude... He's coming at it and then overshooting it and then correcting. So that could be a sign of dysmetria. The other thing that I also like to look for is what's called intention tremors.

So if he's touching his finger to his nose and then coming to me as he brings his finger closer, and closer the amplitude of that tremor increases as he brings his finger to my finger. So I'm looking for dysmetria, kind of overshooting that movement and then trying to quickly correct. And tension tremors, tremors amplifying and increasing in intensity as they bring their finger towards the target. What else can I test for coordination? And again, it's also, before we move on to that, it's also important to test both sides.

So I do the same thing on the left side, finger to nose. Okay, all of that's intact. So again, no dysmetria, no intention tremors seen with that.

The next thing I do is like to do rapid alternating movements. And again, you can do this a couple different ways. You could either have them take and tap this portion here of their thumb and do it as quickly as possible to determine the rate, the rhythm, the amplitude. to that movement.

Another one I like to do is what's called rapid alternating movements, which is kind of moving their hand back and forth on the other hand. So I'm just cueing, I'm gonna have you kind of do that, and just nice and quick back and forth. Good, same thing on the other side.

Good. And so what I'm looking for is I'm looking for someone, again, if they had what's called dysdiatokinesis. So whenever they're doing it, they may have like some difficulties where their rate may be slow, their rhythm may be kind of off.

So they're not kind of going back and forth consistently. That could be a sign of dysdiatokinesis. Okay. So we've tested finger to nose looking for dysmetria and tension tremors.

We've tested rapid alternating movements to look for dysdiatokinesis. The next thing we can also do is we can do what's called a cerebellar drift. So the cerebellar drift is the same thing as a pronation. but it's the exact opposite.

So I'm gonna have you kind of put your hands out in front of you in a supinated position. And again, what I'm gonna have him do is close his eyes. Now, in a pronated drift, it would pronate and go down.

In a cerebellar drift, it would pronate and go up. So that's something that you may see in a cerebellar drift. So if they had a right-sided cerebellar lesion, they would have a pronation and upward movement of that right arm, okay? Because usually, again, cerebellar lesions are ipsilateral. All right, so we've tested finger to nose, looking for dysmetria and tension tumors, dysdiatoconiesia.

with rapid alternating movements and cerebellar drifts. The other thing you can do is you can do what's called a rebound phenomenon. So for example, if they had a right-sided cerebellar lesion, You can kind of have them resist movement. So I'm going to say, you know, really try to resist my movement as hard as you can. I like to put my hand kind of in front of the patient because if someone has a right cerebral lesion and I let go, they're going to rebound and they might even come and hit themselves in the face because they have no ability to kind of maintain that tone of the agonist and antagonistic muscles.

So again, what I like to do is really kind of have my hand here just in case. Really, really pull, pull, pull, pull, pull and I let go. And I'll try to basically, again, I don't want them to hit themselves in the face, but they should stop. Because usually if someone has normal cerebellar function, the tone between the agonist and antagonist should be pretty much kind of normal.

Okay? So again, I've tested finger to nose looking for antagonism. tension tremors, dysmetria.

I've tested for dystoidokinesis, rapid alternating movements. I've tested for cerebellar drifts, and I've also tested for the rebound phenomenon. That would conclude my, particularly my coordination component of the upper limb neuro exam.

as well as complete my entire upper limb neurological exam. So to quickly recap what we would go through in this patient, we would start off by looking at appearance. Then after that, we would assess tone.

We would then assess power strength. We would test reflexes. Then we then test sensory modalities, the elementary sensations, then the discriminative sensations.

And then after that, we would finish up with our coordination with finger to nose, rapid alternating movements, cerebellar drifts, as well as a rebound phenomenon. All right, Nijner, so in this... video today we talk about how to perform an upper limb neurological exam. I hope that you guys enjoyed it, I hope you guys learned a lot.

Also let's give a big shout out, big thanks to Q for being our patient today. If you guys want to go check him out, check out his twitch channel down in the description box, we'll have a link to that down there. Also Ningeners we love you, we thank you, thank you for always supporting us and as always until next time.

Thank you

Transcript for:Upper Limb Neurological Exam Overview

Transcript for:
Upper Limb Neurological Exam Overview