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It's just gone live now. Lovely. Okie Doke. Um Yeah, to kick things off, I'll hand you over to Katie. Um and she can walk you through the upper and lower limb neuro examinations over to you, Katie. Thanks. Will. Um Hi, everyone. So as as will said, um my name is Katie. I'm one of the I MT twos. I'm currently working in Cambridge. Um So I'm gonna run you through the process of doing upper and lower limb neuro examinations. Um If at any point you have any questions or anything that you wanted to clarify or go into more depth on. Um then just drop a message in the chat. I'll be happy to happy to answer anything. Um So what we're going to do is recap the process of the examination and hopefully develop a simple systematic approach to recognize important findings. Um We'll end with some quick case studies just to demonstrate how to summarize and present your findings before you go into a bit more detail in your breakout groups. So before we recap the examination, because the neuro exam has quite a, a few components which I found could be a bit confusing to draw together and make sense of. I just wanted you to start thinking about how to group together your findings and spot patterns. So we're going to come back to this slide after we've gone through the examination. So don't worry about it just yet. Um But just to start and get you thinking, I find it useful to always consider whether the pattern fits up or a lower motor neuron. Then think about whether it's distributed to one side, whether there's a glove and stocking distribution or whether it could be um affecting for just one n nerve, for example, and we'll come back to this in terms of the sensory impairment, thinking about which pathways you're actually testing and just to recap again. Just so it's clear what I'm talking about upper motor neurons, I'm sure you know this um travel from the motor cortex down the spinal cord and they synapse and that's where lower motor neurons start. They travel from the anterior horn cells of the spinal cord and they travel along spinal nerves to the neuromuscular junction. So I'm going to go through both upper and lower limb at the same time because they're both examined in the same structured way if that's OK. Um And as always before you start, make sure to introduce yourself, uh confirm patient details, et cetera, explain roughly what you're going to do and just gain their consent to examine you. I would always check if they're in any pain or if there's anything in particular that you need to avoid doing, when you look around the bed, you might see a wheelchair, you might see orthotics or walking aids. Er, the top right picture is an orthotic for foot drop. For example, I would say, don't let that sort of thing put you off or make any assumptions because the aim is to complete as much of the examination as possible whilst keeping the patient comfortable and dignified. So, for example, you might ask just to check, are you able to walk any steps at all? And they might be able to walk a few steps or they might say, no, I can't do that. So you just move on and that's fine when you're looking at the limbs, you want to see if one side looks obviously different to the other. Um For example, the right arm might look much smaller than the left. There could be muscle wasting and you want to have a closer look for any fasciculations which just tiny flickers in the muscle, like little tiny twitches. Um You could also see that the arm is held in that abnormal posture. So for example, that, that picture on the left um shows fixed posturing of the right arm. So you can see the shoulder is internally rotated, the arm is pronated, the wrist is flexed and the fingers are clenched. This is actually a classical what we might call pyramidal posturing. Um which suggests an upper motor neurone lesion. And again, we'll come back to that later. And then you can see the picture on the bottom, right, shows significant wasting of the right er phar evidence. So this is your basic examination sequence, which it's good to have in your head without having to really think about it. So you'll inspect, and then when examining the lower limbs, I like to start with examining the gait because this gives you quite a lot of clues before you even start it. Then you'll test tone, power reflexes, sensation and coordination. You can do coordination before sensation. Um I've started doing that because it's a bit quicker. Um But whichever works for you and then you might finish with special tests, which I'm not gonna cover in detail today but can be helpful. So these are the um different types of gait. I would suggest typing these into youtube and watching a few videos of these classical types. Um Patients don't usually have such obvious abnormalities as the videos do online. Um But it's a really good starting point um to, to see those and then you can pick up more subtle signs. So just to run through those, a broad based ataxic gait suggests cerebellar pathology. Um shuffling gait um is often seen in parkinsonism and then high stepping gait is where in foot drop, inability to dorsiflex, the ankle means they're having to kind of lift the whole leg higher to clear the ground. Um, wobbling gait is when they're, they kind of move side to side more because of weakness in the muscle, stabilizing the pelvic girdle. And that's seen in proximal myopathy. And then circumduct means when the leg has increased tone and can't flex so easily at the hips, the hips or the knees. So the leg instead moves out to the sides and if that happens bilaterally, then you get a scissor gait. So when you're looking at tone, you're basically just moving the joint around to see if it feels stiff or moves easily. Um you want to start moving the joints slowly. And then if you feel increased tone throughout the movement, this could be consistent with rigidity in parkinsonism. And then also, especially if you move the wrist pronate and supinate and feel cog wheeling that would fit with that picture. And then if tone feels more initially, after moving it slowly, you want to move the joint more quickly and see if that makes it kind of catch and that is velocity dependent tone or sometimes called cast knife um in the arms. So you want to move the shoulders, elbows and wrists and turn and then I'll also check for pronatal drift. So like in the picture, you ask the patient to hold their arms out straight with the palms facing up and get them to close their eyes. And you look for one limb dropping down and just turning inwards slightly and if present, this suggests a contralateral upper motor neurone lesion and then the legs, um, roll the legs and look for the foot kind of wobbling normally from side to side or whether it looks stiff. And then that test when you're lifting the knees up, um, sort of quickly off the bed again, check if they have pa pain in the knee before doing that. Um, what you're looking to see is whether the heel of the foot lifts off the bed, which would be abnormal and then check for clonus as well, um, which is an up motor neuron sign. Um, and then when testing power, my best tips are to make sure that you firstly support that, support the joint. You're testing, um, examiners don't like it when you don't do that. And the reason is um to isolate the joint. So for example, if you're testing elbow extension without supporting the elbow, the patient could be struggling actually because they've got weakness at the shoulder, which makes it hard to keep holding the whole arm up rather than true weakness at the elbow. And my other tip would be to practice the instructions, um, especially when you are under pressure. It's easy to get your words mixed up and to give confusing instructions. And you might have heard people saying things like pull me towards you push me away, which can work sometimes but not always, particularly with knee flexion and extension. I'd suggest finding a way to explain this that works for you. Um So I like to say, I'm going to hold your ankle and I want you to pull your ankle in towards your body and don't let me straighten your leg. Um It doesn't always make sense, but um sometimes you have to explain it a couple of times and always make sure that you test like for like so left hip flexion against right hip flexion and then move down. OK. Um And then with reflexes really the best way to get better at this is just a practice on lots of people. Um and make sure that the muscles are nice and relaxed when and it's kind of in a neutral position. It is, it, it is kind of a good idea to learn the nerve root because reflexes can start tell you about to tell you about the level of an injury I mentioned about sort of spinal cord levels earlier. So for example, you can see here biceps, brachial radialis and triceps that come come from different levels if your biceps is normal or reduced, for example, and then your triceps reflex is brisk, that could indicate an injury above C seven because the um the triceps reflex is is brisker when it's below the level of the lesion because it's an upper motor neurone lesion. Um And then with sensation again to kind of test like the like um and start by showing the patient how it should feel, for example, you can use the sternum. If someone's got um, a spinal cord injury in the cervical region, then they may not feel it at the sternum. That's just the one caveat that most patients that would be fine for. Um And these diagrams here just show where the little points show you where that you can test the dermatomes in one spot apart from, I like to test L3 on the top of the knee because I find that easy to remember. Um It's best to test each dermatome just once because it looks much slicker. You know, don't keep prodding them with the neurotips several times. Cos again, examiners tend not to like that. Um I would start proximately and work down. Um But with pro pro pro perception and vibration, don't forget to start distally and then work upwards if they can't feel it. So you're starting with distal bony prominences and then if the sensation is abnormal in the feet or in the hands, you can then go proceed to test for glove and stocking just um lost by. So if you take the cotton wool and start at the tips of the toes, ask if they can feel it and then just move it up the leg, up the foot and up the leg proximately gradually and ask them to tell you when they can feel it and when it starts to become normal, it's probably not necessary in your medical school, ay, but it's, it's really easy to do and it would look really good if you did that and you could pick up that there's glove and stocking loss and then just for the table on the left. Um in terms of the ascending pathways in the spinal cord, when you're testing fine touch, prick, reception and vibration, you're testing the dorsal column and pinprick and temperature test the spinothalamic pathways. Um You wouldn't usually be expected to test temperature in exam setting, but it can be helpful. Um I once saw a patient who realized that something wasn't right because he sprayed deodorant under his arm and he couldn't feel the coldness of the spray. Um And it turned out he was actually having a stroke. Um, um I'm sure you know, that coordination tests for cerebellar pathways. One thing to remember when you're testing finger, nose coordination going between uh nose and your finger is to make sure that you're making them reach their arm out almost straight when they're reaching towards you because otherwise, um you can miss the presence of subtle pass pointing, which just isn't apparent when they're only having to reach out slightly in front of them. Um And then once you've finished, thank the patient. And I would suggest you'd like to complete by also examining the upper limbs if you examine the lower and vice versa and the cranial nerves and take a history. So then I would take a step back and think, do the signs fit an up motor neurone lesion, lower motor neuron or a mix of both. And generally with upper motor neurone, you'd see brisk reflexes increased tone and they could be wasting but wasting in that setting is actually due to just not using the muscle. Whereas in lower motor neuron issues wasting is actually much more pronounced and can also be seen with circulations. So that's what I mean by disuse atrophy. Um in upper motor neurone lesions, you would see increased tone in a chronic picture. Um You might have seen patients with increased tone and spasticity after a stroke. But in an acute setting, like someone who's actively having a stroke, you would actually see reduced tone. Um and then with coordination with both types, they may have found the test difficult, but this actually could just be due to weakness of the arm rather than true cerebellar dysfunction. So you want to put this together with your other findings. And if you're not sure, just tell the examiner say that, you know, finger nose test was abnormal. But I think this reflected more a problem with power than true um in coordination. So I'm gonna come back to that slide I had before with our init initial systematic approach. So we've spoken about deciding whether it's up or lower motor neuro or both what the distribution is. So we've thought about whether it's one side, both sides, whether there's um glove and stocking sensory loss. Um And, and then if there's sensory loss, whether it's all modalities or just some of them, hence, whether it's likely to be affecting the dorsal column or spinothalamic heart pathways. Um I've added one more consideration here which you don't need to factor in if it's not helpful. But you may have heard people talk about pyramidal weakness, which I found really confusing until I simplified it. So I just kind of wanted to mention it in case it's helpful. Um There isn't a hard and fast rule here. But uh so, so let's say you have a stroke affecting the motor cortex and that damages the start of the tracts which go down the spine, pass through the medullary pyramids and tell the muscles to contract or relax. So that's the corticospinal tracts. And that gives you a classic upper motor, your own picture, as we said, of weakness, hypertonia and hyperreflexia. And you might see that fixed flexed pyramidal posturing that we spoke about on the first um earlier on. But so that's kind of a classical pattern and that's what we mean by pyramidal. But maybe you've examined someone and it doesn't quite fit that pattern. So maybe the power and sensation are normal, but you notice some other changes, maybe involuntary movements or maybe just a problem with coordination. This basically means that other tracks are likely to have been damaged. So maybe those involved in balance or coordination or voluntary and involuntary muscle tone. So this could come from, for example, a cerebellar problem or something with the basal ganglia like in Parkinson's and those areas send information down the spine via the extra pyramidal tracts. So if it's not all fitting together neatly, just think, maybe could this be extra pyramidal? Um And just have a look again, maybe you've missed a, a subtle tremor or something. Um I don't know whether that's helpful or overcomplicated. So, feel free to ignore it if it's a matter. Um And then following on from that, I found this diagram really helpful to organize my thoughts. Once you've examined someone, of course, if you just examined the upper limbs or the lower limbs, you don't have all this information, but you might get some clues. Um As we said, if it's lateralized, you might be looking at something in the brain. If it's below a certain level, this could be a cord issue. Um if there's glob in glove and stocking distribution that suggests a polyneuropathy and if there's largely proximal weakness, this is more suggestive of a muscle problem or a myopathy. I think spinal cord levels can be the most confusing to work out because um you need to learn the dermatomes and myotomes ideally, but I use AFA few phrases to help me out. So um L3 knee with the reflex and also with knee extension, um L4 dorsiflexion. So L4 off the floor and then L5 toe extension, L5 high five, I again, I don't know if that's helpful. But um and then again, with mononeuropathies, I won't go to into these in detail because I think these are generally covered pretty well in your sort of anatomy classes. Um But that's the other thing just to keep in mind is whether things actually just fit into the distribution of one peripheral nerve. Um So coming back to the picture we saw earlier with this wasting of the thenar eminence. This can be seen in carpal tunnel syndrome, which is a problem with the median nerve. And then this list is maybe just a few to have a quick think about before going into your Aussies. Um how to distinguish those, er, but the most common would definitely be carpal tunnel syndrome. Um Now I remember being told multiple times at medical sto medical school to use a surgical sieve. Um and II wasn't that convinced by them, but I realized when I got to my, my paces exam that, um which is postgraduate that w when you're under pressure and your brain kind of just goes to mush. This can actually be really helpful to keep your thoughts systematic and come up with a few sensible differentials. Um at medical school, it's best to stick to the most common causes things like stroke, diabetes and Parkinson's. Um but um we'll come through some, some cases in just a moment, but this can just sometimes be helpful to, to work through in your head. Um, ok, so just some very quick cases. Um, you examined this man's lower limbs. You notice there's a walking aid at the beds bedside and you notice that the limbs just look a bit different. The right arm is just held in that fixed flex posturing. Um, you ask him to walk and the right leg looks more stiff when he's walking and that's making him walk with this circumduct gait that I was talking about earlier. Then when you examine, um the tone is increased in the right leg, the power is reduced, sensation is reduced. And you notice the reflex of the brisk coordination is really tricky to examine because he struggles to lift the right leg at the hip, but everything is normal on the left. So you might have some thoughts about that initially. Um But just to sort of wonder how to uh summarize this, let's say you've also examined the upper limbs for argument's sake and you know, just the same pattern. So here, because both the upper and the lower limbs are affected in entirety, even without looking at the cranial nerves, you know, this must or is most likely to be an injury either at or above the high cervical cord levels because the arm starts to be supplied from C three onwards. So you could um present this as I examined this patient's lower limbs. There is a right sided, upper motor neuron pattern of weakness and sensory impairment involving the upper and lower limbs. So then you, you don't need to proceed here. But if they ask you, you say that could suggest a lesion of the left side of the brain and the most common cause of this would be a stroke. Um So second case, um, you examine the lower limbs of a patient who has a wheelchair at the bedside and you're unable to examine gait because they can't do more than transfer between bed and chair. So when you're examining the limbs, you notice that um increased, the tone is increased in the legs bilaterally and power is reduced throughout the legs. It might not be. Um So I've just seen that question, I will come back to that. Um So the, the the reduction in power might not be completely uniform. Um So maybe they're weaker at the hips than they are at the knees. It might be a mixture of, you know, two out of 53 out of five, for example. But the pattern here is that it's globally reduced in both legs and also sensation is reduced to all modalities throughout the legs. And again, coordination is, is tricky to examine because of weakness. So putting those signs together, you could present this as there's a bilateral upper motor neurone pattern, sensory and motor weakness in the lower limbs. And this could suggest a lesion in the spinal cord above the high lumbar region. So going back to that surgical, there may have been trauma, spinal stroke, spinal ischemia, an abscess or demyelination such as in multiple sclerosis. And then just the last one, you examine the lower limbs and before you even start looking at the patient, you notice there's insulin and a blood glucose monitor at the bedside. Um the tone and power are normal but reflexes are reduced or absent are really tricky, tricky to get. Despite using reinforcement tactics, um, sensation is reduced in the feet wall modalities. But you do the sort of that test that I mentioned and you notice that sensation starts to become normal above the ankles and coordination is normal. Um, so you can present this as there is bilateral sensory loss in the lower limbs in a stocking distribution to above the ankles. This suggests peripheral neuropathy of which the most common causes are diabetes and alcohol. This patient has an incident at the bedside suggesting the cause could be diabetes. Ok. So, um, just to summarize and, and my last top tips, I think with neuro practice is really the main, the main thing and definitely watch videos to see the different types of gait and also type in involuntary movements, things like career form movements in Huntington's cos you won't see those very commonly on the wards. Don't forget to test like for like and don't panic if it doesn't all fit together. Exactly. Cos patients aren't textbooks just say what you see and if you haven't found anything, remember, it could be a normal examination. Um OK. So that's, that's all I have planned. Um So I think it's just a question in the box. Was that from, is that from a student or a? Yeah, that was from a student. Yeah. Um Yeah. If bilateral carpal tunnel syndromes, do you investigate for systemic amyloidosis? Yep. Um That is definitely a cause of bilateral carpal tunnel syndrome. There are a few conditions um which can cause bilateral carpal tunnel. You would also wanna think about other things like acromegaly. Um And there's also a rare type of um of neuropathy. So, hereditary motor and sensory neuropathy with a liability to pressure palsy. It's quite a long name. Um That is kind of probably not that important at medical school level and systemic amyloidosis. I definitely didn't come up in my finals. Um But yes, good point. Is there are there any other questions from anyone? Yeah. Right. I think, I think that's, yeah, all of the questions then. Um Yeah, amazing. Thank you, Katie. Um That was a really good run through of the um upper and lower limb neuro exam um and some really useful tips for everyone as well to take forward. Um So now we'll, we'll move everyone into breakout rooms um with the tutors. Um I'll just post the er the room numbers for everyone. So for the facilitators as room 1 to 4 and then for viewers as well. Um, if you just go into your assigned rooms, um, it should take roughly 2020 minutes to go through the cases. Um, and if we aim to, to come back for maybe 10 to 8, um, just to wrap up the session, I think there's only two cases. Er, so it shouldn't take, it shouldn't take too long. Um, but yeah, if you, if you, um, go, go to your breakout rooms, there's a tab on the left hand side called breakout sessions. Um, and then just go to the one that you're allocated to, um, and then, um, en enjoy the, the case based discussions. Thank you very much.