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Understanding the neurologic examination. J. Scott Pritchard, DO 2012 NADE NATIONAL TRAINING CONFERENCE. Tools. Pins/Needles Hammer Tuning fork Flash light Measuring tape Calipers Monofilaments- Semmes-Weinstein And. Jendrassik Maneuver. Symptoms.
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Understanding the neurologic examination J. Scott Pritchard, DO 2012 NADE NATIONAL TRAINING CONFERENCE
Tools • Pins/Needles • Hammer • Tuning fork • Flash light • Measuring tape • Calipers • Monofilaments- Semmes-Weinstein • And
Symptoms 1. numbness- deprived of the power to move or feel normally 2. Tingling - a pricking or stinging sensation or feeling 3. Paresthesia- skin sensation of burning, prickling or tingling with no apparent cause. 4. Pain - an intense unpleasant feeling caused by damaging stimuli
Three Areas of Importance • Motor – strength – assessed per MRC scale 0/5 no movement-5/5- normal - tone - continuous passive partial contraction of a muscle - atrophy- loss of muscle mass -spasticity- altered tone w/stiffness and involuntary muscle spasms. Ashworth scale – 0 to 5
2. Sensory- temperature touch pinprick proprioception 2- pt discrimination vibration
Normal 2- pt discrimination 0-4 mm • Intermediate – 5-7 mm • Abnormal > 7mm
3. Coordination – primary assessment of cerebellar function - Smooth combination of both spatial direction and kinetic(forceful) movement - Functional abnormalities can be seen in altered gait, truncal ataxias, dysmetrias of the extremities, altered rapid alternating movements of the upper/lower extremities. (F-T-N and RAM). - Ataxia – impaired coordination
Gait Dysfunction 1. Hemiparetic 2. Paraparetic 3. Sensory 4.Steppage 5. Waddling 6.Festination 7. Retropulsion 8. Astasia Abasia
Carpal Tunnel Syndrome Compressive neuropathy of the median nerve 1. numbness, tingling of the thumb and first two digits of the hand 2. increased numbness and onset of pain 3. sense of weakness or dropping things 4. most intense at night 5. progressive motor and sensory loss
In one study 64% of 88 hands w/+ Phalen’s test has positive EMG findings • Conversely 51% of 78 hands with negative Phalen’s testing had positive EMG findings • CTS requires both clinical symptoms, findings and EMG evidence to establish its presence and severity
Cubital Tunnel Syndrome Compressive neuropathy of the ulnar nerve 1. pain and numbness in the elbow 2. tingling, especially ring and 5th digit 3. weakness in the 4th/5th fingers 4. decreased ability to pinch thumb/5th digit 5. decreased overall hand grip 6. muscle wasting in the hand 7. claw-like deformity of the hand
Complex Regional Pain Syndrome 1. burning pain/allodynia 2. increased pain w/onset of swelling 3. development of osteoporosis and muscle atrophy 4. irreversible contractures and immobility The affected extremity may be cool to touch and appear mottled. Swelling may be present. Extreme sensitivity of the skin to touch. Often unable to tolerate clothing
CRPS I – no demonstrable nerve lesions (RSD, Sudek’s atrophy) CRPS II – obvious nerve damage(causalgia) usually more painful and difficult to control
Diagnostic tools • History and physical examination • Thermography • Sweat Testing • EMG • Bone scan • X-ray findings
Oddities • Waddell’s • Leseque(SLR) now nerve stretch test • Hoffman’s sign • Wartenburg’s sign • Pronator drift • Gower’s sign • Meralgia paresthetica • Double-crush syndrome