Ernest Butler; Week 6 MED1022; Clinical Skills
Spastic (pyramidal)/hemiparetic- stiff-legged
Parkinsonian (extrapyramidal)- slow, shuffling
Ataxic (cerebellar)- incoordination or unbalanced
Apraxic (cortical)- loss of skilled movement
Foot-slapping (common perineal nerve palsy, cannot dorsiflex)
High-stepping (sensory i.e. dorsal column)
Waddling (proximal muscle weakness)
Mechanical e.g. hip arthritis
Psychogenic or hysterical
Watch patient stand and walk: tandem walk- walk in a straight line like a tightrope, walk on heels (dorsiflexion; S4/5) and toes (S1)
Stand with feet together and ask to close eyes (dorsal column/proprioceptor problem will make them fall over). Can get them to squat and then get up, good test of proximal muscle power in both legs.
Peripheral nerves most commonly affected: upper limb: Median n. (at wrist), ulnar n. (at elbow), radial n. (at radial groove); lower limb: Common peroneal nerve (around head of fibula), lateral femoral cutaneous nerve (from ASIS through inguinal ligament)
Testing ulnar nerve- abduct and adduct fingers due to interossei, do touch testing for 5th and half of 4th digit. Radial nerve test for weakness of wrist and finger extensors, sensory loss on hand dorsum at anatomical snuffbox
Common perineal nerve palsy has foot drop; lateral femoral cutaneous has sensory loss in the antero-lateral aspect of leg
C7 usually have neck/scapular pain and pain running down the arm, most commonly affected, can be due to prolapsed disc or other degenerative parts of spine
Sciatica is L4-5 disc herniation which will give sensory loss in dermatomal distribution of L5 generally, may or may not have weakness/wasting, L5 has no reflex change, S1 gives loss of ankle joint PPT
Sensory modalities include dorsal column pathway sensation (lesion of this causes ataxia): proproception, vibration sense. Spinothalamic pathway sensation (lesion causes numbness, paraesthesiae, pain): pain, temperature. Cortical sensation (lesion causes ‘neglect’): proprioception, stereognosis, graphaesthesia, 2 point discrimination.
Peripheral neuropathy- longest nerves affected, legs >arms, ‘gloves and stocking loss’. Spinal cord sensory loss will get dissociated sensory loss. Subcortical sensory loss e.g. capsule, half the body has sensory loss.