How to Perform a Neurological Examination

How to Perform a Neurological Examination

Performing a systematic limb examination is essential for identifying whether a neurological deficit originates from the Upper Motor Neurons (UMN) in the brain and spinal cord or the Lower Motor Neurons (LMN) in the peripheral nerves.

Introduction: The WIPER Initial Steps

Before assessing the limbs, ensure the patient is positioned for optimal reflex testing:

• W – Wash: Clean your hands using the WHO 7-step technique.

• I – Introduce: State your name and role clearly.

• P – Permission & Pain: Explain that you will be moving the patient’s limbs and testing their strength. Ask if they have any joint or muscle pain.

• E – Exposure: Ideally, the patient should be in their underwear or a clinical gown to allow full visualization of muscle bulk and fasciculations.

• R – (Re)position: For the Upper Limbs, the patient can sit on the edge of the couch. For the Lower Limbs, the patient should lie supine.

Part 1: Inspection (The Four “B”s)

Before touching the patient, look for these key indicators:

1. Bulk: Look for muscle wasting (atrophy), which suggests an LMN lesion.

2. Bizarre Movements: Note any fasciculations (small muscle twitches) or tremors.

3. Build: Observe for symmetry between the left and right sides.

4. Bones & Skin: Look for surgical scars, neurofibromas, or trophic changes.

Part 2: Tone, Power, and Reflexes (Motor Exam)

Tone

Hold the patient’s hand/foot and move their joints through their full range of motion.

• Hypertonia: Increased resistance (Spasticity/Rigidity), suggesting a UMN lesion.

• Hypotonia: Decreased resistance (“Floppy” limbs), suggesting an LMN or cerebellar lesion.

Power

Test strength against resistance using the MRC Scale (0–5).

• Upper Limb: Test shoulder abduction, elbow flexion/extension, wrist extension, and finger abduction.

• Lower Limb: Test hip flexion, knee flexion/extension, and ankle dorsiflexion/plantarflexion.

Reflexes

Use a tendon hammer to elicit deep tendon reflexes.

• Upper Limb: Biceps ($C_{5}/C_{6}$), Triceps ($C_{7}/C_{8}$), and Supinator ($C_{5}/C_{6}$).

• Lower Limb: Knee ($L_{3}/L_{4}$), Ankle ($S_{1}$), and the Plantar Reflex (Babinski).

Part 3: Coordination

Coordination tests specifically screen for Cerebellar dysfunction:

• Finger-to-Nose Test: Ask the patient to touch their nose and then your finger repeatedly (look for “intention tremor”).

• Dysdiadochokinesia: Ask the patient to clap the palm and back of one hand onto the other rapidly.

• Heel-to-Shin Test: (Lower limb) Ask the patient to run their heel down the opposite shin in a straight line.

Part 4: Sensation

Test sensory modalities following the dermatomes (skin areas supplied by specific spinal nerves). Use a “ladder” pattern to compare sides.

1. Light Touch: Using cotton wool.

2. Pain (Pinprick): Using a clinical neurological pin (Neuropen).

3. Proprioception: Move the patient’s thumb or big toe up/down and ask them to identify the direction with their eyes closed.

4. Vibration: Use a 128Hz tuning fork on a bony prominence (e.g., the malleolus).

Part 5: Completing the Examination

To finalise your OSCE limb assessment, state you would:

1. Assess Gait: Ask the patient to walk normally, then “heel-to-toe” (tandem gait).

2. Perform Romberg’s Test: Check for sensory ataxia by asking the patient to stand with eyes closed.

3. Neurovascular Status: Check peripheral pulses.

4. Cranial Nerve Exam: If not already performed.

Summary: UMN vs. LMN Signs

Video Demonstrations

For a visual guide to motor and sensory testing:

• Upper Limb Neuro Exam – Dr. James Gill

• Lower Limb Neuro Exam – Clinical Skills