CS- 3-Motor neurology

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CS- 3-Motor neurology
2011-03-05 02:11:48
Clinical skills nervous system

Motor function in neurological examination
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  1. Fasciculations
    • Irregular contractions of small areas of muscle which have no particular pattern, looks like ripples of twitches under the skin.
    • Occurs at rest + not during voluntary movement.
  2. Tremor is...
    Described by...
    An oscillatory movement about a joint or a group of joints resulting from alternting contraction + relaxation of muscles. Tremors described by- Speed(fast, slow), amplitude(fine, coarse), maximal at rest? maintaining a posture? or on carrying out an active movement?
  3. Slow coarse tremor
    • Parkinsons disease--pin rolling tremor is worst at rest + reduced by voluntary movement.
    • More common in upper limbs + usually asymmetrical.
  4. Physiological tremor
    • Anxiety, fine, fast postural tremor.
    • Hyperthyroidism.
    • Excess alcohol or caffeine.
  5. Absent tremor at rest, maximal on movement (action or intention tremor)
    Cerebellar damage is the most common cause.
  6. Coarse, violent, action tremors ....
    • Associated with lesion of the red nucleus (rubral tremor) and subthalamic nucleus.
    • Often caused by damage from vascular disease or MS.
  7. Dystonia
    The slow development of an abnormal posture, often of the limb or the neck, which is maintained.
  8. Chorea
    Writhing movement, irregular, jerky and bried
  9. Athetosis
    • Writhing movement, slower, more sustained than Chorea.
    • Choreoathetoid is something between athetosis and chorea.
  10. Dyskinesia
    a group term for these types of involuntary movements especially when they arise as an adverse effect of neuroleptics and antiparkinsonian agents. Tremors=> uncontrollable movement.
  11. Tics or habit spasms
    more stereotyped and essentially normal movements that recur involuntarily. They are fragments of normal movements (or sounds) that occur out of context.
  12. Gait
    • The pattern of motion that carries the body forwards. Generally smooth + symmetrical with each leg 50% out of phase with the other. Swing+stance. Toeoff-heelstrike.
    • Ataxic
    • Antalgic
    • Apraxic
  13. Ataxic gait
    an unsteady, uncoordinated walk with a wide base of support + the feet thrown outward (eg. excess alcohol)
  14. Antalgic gait
    a limp adopted to avoid pain on a weightbearing structure -hip, knee, ankle injuries,+ is characterised by a very short stance phase on the injured side
  15. Apraxic gait
    loss of ability to carry out familiar, purposeful movements in the absence of paralysis or other motor or sensory impairment
  16. Dysdiadochokinesis
    • impairment of rapid alternating movements such that they are slow, disorganised + irregular.
    • Typical of cerebellar disorders + may be seen in Parkinsons.
  17. Tone
    • The resistance felt by the examiner when moving a joint passively through its range of movement.
    • Reduced-hypotonia. Increased-Hypertonia
  18. Hypotonia
    • Difficult to detect in a relaxed pt. Excess hypotonia/flaccidity, may occur in lower motor neurone lesions + usually ass w/ ms wasting, weakness + hyporeflexia
    • May be a feature of cerebellar disease + occur in the early phases of cerebral or spinal shock when the plegic limbs are atonic prior to dev spasticity.
  19. Hypertonia
    may be spastic or rigid
  20. Spasticity
    • UMN lesion, is a dynamic response often greater at the beginning of a movement or if the movement is fast- the ms is fighting you.
    • Form of hypertonia..
  21. Rigidity
    • dull, fairly uniform reluctance to move
    • Form of hypertonia
  22. Lead pipe/cogwheel rigidity
    • Form of hypertonia.
    • Nearly always due to parkinsons.
    • steady but slow progression
    • superimposed tremor giving the impression that the passive movement proceeds in little steps like a worn cogwheel.
  23. Clonus
    • rhythmic series of contractions evoked by sudden stretch of the muscles. Can occus in healthy indiv, when tired/apprehensive.
    • When sustained indicated UMN damage w spasticity.
  24. Motor function, similar to MS
    • Look-invol abnormal movements? abn gait? wasting/hypertrophy? posture trunk, limbs abnormal/deformed?
    • Feel- palpate ms to assess bulk + tenderness, assess ms tone
    • Move- ms strength - overcome pt full vol ms resistance, persuafe to exert max F-age, exercise, occupation
    • Compare sides. Coordination + reflex tests.
    • Ability to function.
  25. Move
    Muscle strength
    • 0 no visible/detectable ms activity
    • 1 flicker of contraction visible but no active m
    • 2 m with gravity eliminated
    • 3 m against gravity
    • 4 m against gravity + some R (4- 4 4+)
    • 5 normal

    Not standardised, so must write down details. Prox, distal, general, symm? only particular ms groups? is painful jt, ms dz affecting assessment?

    Test in the ms groups mid range of its working length.
  26. Assess upper limbs...
    • Shoulder add, abd, F, E
    • Elbow F + E
    • Wrist F + E
    • Finger E, F, Ab, Ad, opposition of thumb to pinky
  27. Assess lower limb
    • Hip F, E, ab, ad
    • Knee F + E
    • Ankle DF, PF, E, I
    • Great toe PF and DF
  28. Co-ordination
    ability to perform complex movements smoothly + efficiently depends on intact sensory + motor function. Testing coord involves assessing cerebellar function, but may also be influenced by any ms weakness, proprioceptive loss or extrapyramidal dysfunction.
  29. Reflexes
    • Apply a sudden stretch to the ms, which contracts reflexly. Deep tendon reflexes are elicited by a sharp tap from a tendon hammer near the tendon insertion.
    • not size of response but min size of stimulus needed.
    • Symmetry? (position identically)
    • Reflexes can be increased, decreased or absent.
    • Hyperactive +++
    • Normal ++
    • Diminished +
    • Absent -
    • _+ only present when using reinforcement
  30. If reflex appears to be absent
    • test with a reinforcement manoeuvre
    • to reinforce the UL reflexes= clench teeth
    • LL- interlock fingers and pull one hand against others
    • The superficial reflexes (plantar, abdominal and cremasteric) are elicited by cutaneous stimulation.
  31. Coordination tests
    • Finger nose test
    • Rapid alternating movements
    • Heel-shin test
    • Foot-tapping test
  32. Fingernose test
    • Ask pt to touch his nose with finger + reach out to touch my finger just within pts arms reach.
    • Ask to repeat btwn nose + target finger fast, slowly, # of times, eyes open and closed.
    • To make test more sensitive, move target finger
    • Intention tremor= tremor increasing as the target is approached- no tremor at rest
    • Past-pointing- the pt finger overshoot the target towards the side of the cerebellar abnormality
  33. Rapid alternating movements
    • Repeatedly pat palm and back of hand on opposite hand as quick and regularly as possible.
    • ask pt to do the same, repeat with opp hand.
    • Dysdiadochokinesis- impairment of rapid, alt movement, slow, disorganised and irregular, cerebellar disorders + parkinsons.
  34. Heel-shin test
    • Lie supine on couch.
    • raise one leg and place the heel on the opposite knee and then slide the heel tip up and down the shin between knee and ankle as accurately as possible.
    • Cerebellar disease the heel wobbles.
    • LL eq of fingernose, toe finger test can also be down, touch big toe to examiners finger.
  35. Foot-tapping test
    • Rapidly alternating movements are tested by getting the pt to tap the sole of the foot quickly on examiners hand or tap the heel on the opposite shin.
    • Look for loss of rhythmicity.
  36. Reflex tests notes
    • Anxiety and pain can increase reflex
    • Finger on biceps/suppinator, prevent hitting too hard
    • Use gravity to hit
  37. Plantar reflex
    • s1 s2
    • Blunt object along lateral border of the sole of the foot towards the little toe and curve inwards before it reaches the toes, moving towards the middle MTP.
    • Flexion at MTP joint is normal >1 yr old