Hey, I’m Lauren And I’m Ben and we’re both doctors here in Sydney Ben is a neurology fellow Lauren is a radiation oncology registrar and we’ll be performing the neurologic examination of the upper limb Okay, so first off what you need to do is get HIPED for the examination, spelt H-I-P-E-D The first thing is Hygiene, and I’ve just washed my hands off-camera, the second is “I” for Introduction and obtaining consent I’ll do that now, my name is Ben I’m one of the doctors Hi, I’m Lauren Is it okay if I examine your upper limb today. Moving on, we then go to position.
Positioning for the upper limb neurologic examination is with the patient sitting on the side of the bed, the chair will suffice for today moving on to “E”. “E” is for exposure. In the case of the upper limb examination we need to make sure that the shoulder girdle is exposed Ideally the patient would be in a gown and we’d be able to see the muscles of the shoulder girdle a little easier but for the purpose of the video we’ll work with this. We’re looking towards the back of the shoulder and we’re looking for quite some time for any fasciculations We’re also looking for any scars or indications she’s had any surgery or trauma and then involuntary movements is another important thing, including tremors and fasciculations as I already stated and any wasting that’s actually occurred in the the area, including the peripheries and more proximally. And if there’s any proximal weakness or indeed in any examination It’s important to feel for tenderness, particularly of the proximal muscles. Is it tender if I feel here. No. And I’ll move on to the other side now is it’s very important to compare side to side Looking again for fasciculations, many can be seen in the posterior part of the shoulder girdle And then feeling for any tenderness is there any tenderness? No Okay, so it’s important to look for any pain or discomfort in the patient and Be mindful of this throughout now what we move on to with any examination is Is a screening test, so in the screening test what we do is … pop your arms out for me? I want you to pop your arms out straight palms to the sky And when you’re comfortable right there, I want you to close your eyes So the patient will close their eyes and what you’re actually looking for is any downward drift or any pronator drift That’s actually showing any imbalance of the muscles or any pyramidal weakness Opening up your eyes, so as we can see that was fine. I’m going to move to the right side of the patient now In most examinations the right side of course is the correct side however we need to be flexible at times Now, moving on I’ll move to tone so I want you to just relax your arm for me, Lauren, and I’m just going to move it So move the arm around moving the wrist and also the elbow the tone feels normal, okay, and then may I have your left arm Moving the left arm around the tone again feels very normal. If there were any difficulty in obtaining tone or you had a feeling that somebody was helping you. You would distract them with movements of the other arm or Turning the head from side to side or even some mental arithmetic Moving on to power Can I get you to pop your arms up like that, like a chicken? So often these funny cues will help quite a bit, and you’d be surprised how many people understand exactly what to do when you say something like that? What I want you to do is keep this up really strong for me. Up, up, up, up, up! Very good and try and do one side at a time Keep the left side up. Very good. Now I want you to go like this for me Okay, and just keep it there Nice and strong. Good. Always keep the patient in a position of power Keeping that there for me, really strong!
Very good. Comparing side by side now.
Push me away, push away, push! Good! A lot of encouragement helpful for for reproducibility of your assessment. Now are you right or left-handed? Right. So this will help us interpret any slight discrepancies in power from side-to-side We’ll move to the next joint I want you to pop your arms out there for me and just cock your wrists back Okay, keep that up for me really strong, up, up, up! Very good And now we move on to the left wrist extensors, up! Very good, now pop them down for me Keep it down really strong! Stronger! Good, keep it down for me, strong! Okay, excellent. Now, put your fingers out for me Keeping these up testing finger extension at the metacarpophalangeal joint Keeping that up! Stronger! Okay. Now, I want you to squeeze my fingers for me, are you able to squeeze both of them you can do this one at the same time.
Harder, harder, harder, and just relax, and you get a sense of a person’s strength. Give them two fingers, not three otherwise you’re going to get injured. Okay, moving on … I want you to pop your palms to the sky for me and thumbs pointing to the ceiling. Perfect, so this is where we’re actually testing a muscle called abductor pollicis brevis and it’s supplied by the median nerve Keep this up for me. Really strong, up, up, up! Very good, very strong. We can see the thenar eminence has a nice bulk We wouldn’t expect any weakness, but it’s important we test. Keep it up for me, really strong. Up! You’ll also note that I’m using a similar although not exactly the same muscle to test and have sort of a control for each of these tests. The last thing to test are the ulnar innervated muscles I want you to put your fingers apart there Lauren. Keep them apart, really strong. Stronger! Very good. Keep these apart for me, really strong. Strong! Very good. If there were any problems, and you wanted to standardise it. Again, you could use your similar muscle here being the first dorsal interosseous to try and keep that finger Or compare that finger’s abduction to yours and you could use your abductor digiti minimi here. Those two are ulnar innervated muscles. Keeping that apart And we’ve already tested radial with wrist extension and of course elbow extension And that’s all we need to do for power We’re then going to move on to reflexes, so I’ll turn to my trusty tendon hammer And ask the patient to just relax their hands in their lap like Lauren’s doing here Position your fingers over the radial side of the wrist, just proximal to the wrist, in fact. Then, strike. As you can see she has a reflexive contraction of the brachioradialis Which is very normal and 2+. I would then move on to the biceps. The tendon is found here, just medially. Feeling the tendon is important even though we can see the contraction of her bicep, you can feel the tendon move underneath your finger … We then move to the tricep Just making sure that our patient is relaxed and comfortable and a little tap there and we can see very easily Those reflexes are 2+ and normal. We need to compare to the other side I’ll move around for that purpose. As I said side to side is probably best. Right brachioradialis … Left However for the purpose of the video I’ll try not to turn sides too much As we can see we’re getting a reflexive contraction there Biceps also present Just relaxing your arm for me, and we’re also present here Okay, if your patient has any signs of hyperreflexia then you may want to see if it is significant and if you could score at 4+ which is easier in the lower limbs as we have plantar response and clonus at the ankle But in the case of the upper limbs what we have is the pectoral reflex And so, it can be a bit uncomfortable, make sure you ask the patient first. Keeping your hands in your lap Is it okay if I tap you on the front of your shoulder there to look for a reflex? Yes. Thank you So you pop your hand over the front here and just give a little tap and we’re looking for any contraction of the pectoral muscles that actually adducts (and internally rotates) the arm Moving to the other side A little tap on this side And there’s no pectoral reflex, which tells us that her reflexes even if they were scored at 3+. They’re certainly not 4+ They are symmetrical and very unlikely to be pathologic Moving on, the next part of our examination is coordination So, the important things in coordination are both finger-nose-finger testing and looking for dysdiadochokinesis So, starting with finger-nose-finger. Lauren, can you get your right index finger and touch the tip of my right index finger and touch the tip of your nose Keep going for me. I want you to be very accurate and go a little bit faster I’m moving away now. I’m looking for any increase in her tremor as I move the target away, and I’m looking for any inaccuracy, so called dysmetria So that’s perfect now your left hand for me. The left index finger touching my right index finger. Keep going If it starts to shake as she gets closer or she misses the target we start to think about cerebellar disease but there is a wider differential if somebody is unable to perform finger-nose-finger testing. That’s perfect. The second thing the for coordination is dysdiadochokinesis.
Lauren, can you do this for me? Tap and turn and tap and turn and tap and turn. As you can see, she’s very accurate and there is no clumsiness. You would then try on the left side. Could you do that on your left side? Tap and turn and tap and turn and tap and turn Very good, so even in the non-dominant upper limb, there is no clumsiness and no sign of cerebellar disease. The final segment of this examination is sensation. In sensation, it’s actually very subjective and difficult which is why it’s at the end if you don’t come into it with some sort of hypothesis you’re really not going to find a whole lot because it’s very challenging Our hypothesis in this case is that her sensation will be normal, but nonetheless … We’re thorough and we make sure that we test There are two modalities we’re testing or two pathways which carry different modalities. Spinothalamic with pain, temperature coarse touch and also the dorsal column pathways with vibration, proprioception and fine touch. I’ll proceed with spinothalamic As you can see we need the Neurotip for this part. We twist off the cap to reveal the sharp surface Now, demonstrate to the patient that it’s going to be sharp, but it won’t break the skin Does that feel sharp? Yes. Okay. Now, can you turn your hands over for me, please? Thank you. Alright, does it feel just as sharp down here, Lauren? Yes. So test the fingers, test the extremities Looking for any sign of any loss of pain.
Normal on that side as well? Yes. Now, we’re looking for roughly normal. There’s often going to be very subtle signs, but we don’t want to make too much of these as they’re probably not predominant features unless there is frank numbness or reduction in sensation now that we’ve demonstrated that, we want to move to dermatomes. Lauren does that roughly feel like that, which roughly feels like that. Yes. And if we continue to compare the sensation Is it pretty normal here and what about over here. Yes. And here and here? Yes. One must be careful not to lead the patient in saying yes. However at the same time, it is difficult with the subjective examination, that is sensation and you’ll learn your technique the more you practice I’ll move on to the other side now Doing the same thing here, Lauren. Does that roughly feel like that, which feels like that? Yes. Fantastic, and then when I check over here, is that similar again? Yes. And then here, compared to here? Yes. Fantastic, so what we’ve done there is the the dermatomes. So, here is C5 Here is going to be C6, which continues into the thumb. That’s C7, there in the middle finger C8 is the fifth digit T1 on the inside of the forearm, and then T2 on the inside of the upper arm. You’ll see different textbooks but that’s roughly the average approach, if you will Moving on, what we’ll now test is the dorsal column pathways for vibration and proprioception In this instance I’m going to proceed with proprioception or joint sense And I take your hand here. What we need to do is look at the most distal joint in the third digit of the hand which is arguably going to be the longest nerve and thus the most metabolically vulnerable So what I want you to do, Lauren, is close your eyes. This feeling is up and this feeling is down. Okay. Tell me did we go up or down Up or down? Down. Up or down? Down. Up or down? Up. As you can see, if the person has normal cognition. It’s very easy to move quickly through this part of the examination, as people are exquisitely sensitive to joint position sense, especially in the hands We move on to the left upper limb now This feeling is up, this feeling is down. Up or down? Up. Up or down? Down. Up or down? Down. Up or down? Down Perfect. So, proprioception is intact. If it weren’t, then we would proceed to other modalities within the dorsal columns, that being vibration or potentially fine touch and one can also look at cortical sensation So that concludes the neurologic examination of the upper limb. Always be sure to ensure that the patient is comfortable and also thank them for their time. Thanks very much, Lauren. You’re welcome.