1. EXAMINATION OF LOWER LIMBS MOTOR AND SENSORY FUNCTIONS Mr. Santosh Maharjan University of science and technology Chittagong (USTC), Bangladesh

2. THE MOTOR SYSTEM Assess the motor system under the following headings: inspection and palpation of muscles assessment of tone testing movement and power examination of reflexes testing coordination.

3. INSPECTION AND PALPATION OF THE MUSCLES Examination sequence 1. Completely expose the patient while keeping the patient’s comfort and dignity. 2. Look for asymmetry, inspecting both proximally and distally. Note deformities, e.g. clawing of the hands or pes cavus. 3. Examine for wasting or hypertrophy, fasciculation and involuntary movement

4. ABNORMAL FINDINGS Muscle bulk Lower motor neurone lesions may cause muscle wasting. This is not seen in acute upper motor neurone lesions, although disuse atrophy may develop with longstanding lesions. A motor neurone lesion in childhood may impair growth (causing a smaller limb or hemiatrophy) or cause limb deformity, e.g. pes cavus. Muscle disorders usually result in proximal wasting (the notable exception is myotonic dystrophy, in which it is distal, often with associated temporalis wasting). Certain occupations, e.g. professional sports players, may lead to physiological muscle hypertrophy

5. Fasciculation Fasciculation is irregular twitches under the skin overlying resting muscles caused by individual motor units firing spontaneously. This occurs in lower motor neurone disease, usually in wasted muscles. Fasciculation is seen, not felt, and you may need to observe carefully for several minutes to be sure that this is not present. Physiological fasciculation is common, especially in the calves, but is not associated with weakness or wasting. Myokymia is rapid bursts of repetitive motor unit activity often occurring in an eyelid or first dorsal interosseus, and is rarely pathological.

6. Myoclonic jerks These are sudden shock-like contractions of one or more muscles which may be focal or diffuse and occur singly or repetitively. Healthy people commonly experience these when falling asleep (hypnic jerks). They may also occur pathologically in association with epilepsy, diffuse brain damage and dementia.

8. Tremor Tremor is an oscillatory movement about a joint or a group of joints resulting from alternating contraction and relaxation of muscles. Tremors are classified according to their frequency, amplitude, position (at rest, on posture or on movement) and body part affected. Physiological tremor is a fine (low-amplitude), fast (high-frequency) postural tremor seen with anxiety. A similar tremor occurs in hyperthyroidism and with excess alcohol or caffeine intake, and is a common adverse effect of β-agonist bronchodilators.

9. Essential tremor is the most common pathological cause of an action tremor, typically affecting the upper limbs and head, with postural and action components. It may be improved by alcohol, and often demonstrates an autosomal dominant pattern of inheritance. Parkinson’s disease causes a slow, coarse tremor, worse at rest but reduced with voluntary movement. It is more common in the upper limbs, usually asymmetrical, and does not affect the head.

10. Isolated head tremor is usually dystonic, and may be associated with abnormal neck postures such as torticollis (twisting to one side), anterocollis (neck flexion) or retrocollis (neck extension). Intention tremor is absent at rest but maximal on movement, and is usually due to cerebellar damage. It is assessed with the finger-to-nose test Functional tremors movement disorders, including tremor, are common functional symptoms. They are often inconsistent, with varying frequencies and amplitudes, and may be associated with other signs

11. TONE Tone is the resistance felt by the examiner when moving a joint passively.

12. EXAMINATION SEQUENCE 1. Ask the patient to lie supine on the examination couch, and to relax and ‘go floppy’. Enquire about any painful joints or limitations of movement before proceeding. 2. Passively move each joint tested through as full a range as possible, both slowly and quickly in all anatomically possible directions. Be unpredictable with these movements, both in direction and speed, to prevent the patient actively moving with you; you want to assess passive tone.

13. Lower limb n Roll the leg from side to side, then briskly lift the knee into a flexed position, observing the movement of the foot (Fig. 11.17A and B). Typically the heel moves up the bed, but increased tone may cause it to lift off the bed due to failure of relaxation. Ankle clonus n Support the patient’s leg, with both the knee and ankle resting in 90° flexion. n Briskly dorsiflex and partially evert the foot, sustaining the pressure (Fig. 11.17C). Clonus is felt as repeated beats of dorsiflexion/plantar flexion

15. POWER Examination sequence 1.Do not test every muscle in most patients 2.Ask about pain which may interfere with testing. 3. Test upper limb power with the patient sitting on the edge of the couch. Test lower limb power with the patient reclining. 4. Ask the patient to undertake a movement. First assess whether he can overcome gravity, e.g. instruct the patient ‘Lift your right leg off the bed’ to test hip flexion.Then apply resistance to this movement testing across a single joint, e.g. apply resistance to the thigh in hip flexion, not the lower leg. 5. n Ask the patient to lift his arms above his head. 6.Ask him to ‘play the piano’, checking movements of the outstretched arms (asymmetric loss of fine finger movement may be a very early sign of cortical or extrapyramidal disease).

16. DEEP TENDON REFLEXES Monosynaptic (deep tendon) reflexes and nerve root innervation Reflex (muscle)Nerve root Biceps C5 Supinator (bracheoradialis)C6 TricepsC7 Knee (quadriceps)L3, 4 Ankle ( Gastrocnemius and soleus)S1

17. EXAMINATION SEQUENCE 1. Ask the patient to lie supine on the examination couch with the limbs exposed. He should be as relaxed and comfortable as possible, as anxiety and pain can cause an increased response. 2. Flex your wrist and allow the weight of the tendon hammer head to determine the strength of the blow. Strike the tendon, not the muscle or bone. 3. Record the response as: a. Increased b. Normal c. Diminished d. present only with reinforcement e. absent

19. To reinforce upper limb reflexes, ask the patient to clench the teeth or to make a fist with the contralateral hand. The patient should relax between repeated attempts. Strike the tendon immediately after your command to the patient.

20. SUPERFICIAL REFLEXES Examination sequence Plantar response (S1–2) 1. Run a blunt object (orange stick) along the lateral border of the sole of the foot towards the little toe (Fig. 11.22). 2. Watch both the first movement of the great toe and the other leg flexor muscles. The normal response is flexion of the great toe with flexion of the other toes. 3. A true Babinski sign: a. involves activation of the extensor hallucis longus tendon(not movement of the entire foot, a common ‘withdrawal response to an unpleasant stimulus) b. coincides with contraction of other leg flexor muscle c. is reproducible

22. THE SENSORY FUNCTIONS OF LOWER LIMB Light touch 1. While the patient looks away or closes his eyes, use a wisp of cotton wool (or lightly apply your finger) and ask the patient to say yes to each touch. 2. Time the stimuli irregularly and make a dabbing rather than a stroking or tickling stimulus. 3. Compare each side for symmetry.

23. Superficial pain 1. Use a fresh neurological pin, e.g. Neurotip, not a hypodermic needle. Dispose of the pin after each patient to avoid transmitting infection. 2. Explain and demonstrate that the ability to feel a sharp pinprick is being tested. 3. Map out the boundaries of any area of reduced, absent or increased sensation and compare with Figure 11.28. Move from reduced to higher sensibility: i.e. from hypoaesthesia to normal, or normal to hyperaesthesia. Temperature n Touch the patient with a cold metallic object, e.g. tuning fork, and ask if it feels cold. More sensitive assessment requires tubes of hot and cold water at controlled temperatures but is seldom performed.

25. Vibration 1. Place a vibrating 128-Hz tuning fork over the sternum. 2. Ask the patient, ‘Do you feel it buzzing?’ 3.Place it on the tip of the great toe (Fig. 11.30). 4. If sensation is impaired, place the fork on the interphalangeal joint and progress proximally, to the medial malleolus, tibial tuberosity and anterior iliac spine, depending upon the response. 5. Repeat the process in the upper limb. Start at the distal interphalangeal joint of the forefinger, and if sensation is impaired, proceed proximally. 6. If in doubt as to the accuracy of the response, ask the patient to close his eyes and to report when you stop the fork vibrating with your fingers.

27. Thank you