Neurologic Exam. (M-R-S: Motor-Reflex-Sensory)

DTRs How do I grade & document deep tendon reflexes?

By convention the deep tendon reflexes are graded as follows:

0 = no response; always abnormal

1+ = a slight but definitely present response; may or may not be normal

2+ = a brisk response; normal

3+ = a very brisk response; may or may not be normal

4+ = a tap elicits a repeating reflex (clonus); always abnormal

WC: #8

Spinal Posture

Normal

Flat-back Posture

Sway-back Posture

Kyphosis-lordisis posture

WC: #3

Special Tests

Leg Length Discrepancies (LLD)

Femoral LLD

Tibial LLD

Apparent: Umbilicus to distal medial malleolus. A difference of more than 1cm is indicative of abnormal pelvic positioning. Significant discrepancies should be verified via radiography.

True: Measure most distal part of ASIS to most distal part of medial malleolus. A difference of more than 1cm is indicative of discrepancies in either the length of the femur or tibia, or in the angle on the femoral neck inclination (coxa vara or valga)

Valsalva Maneuver

Ask patient to “bear down” or ask history question about pain with bowel movements / sneezing. Increased pain die to increased interthecal pressure, which may be secondary to a space-occupying lesion, herniated disk, tumor, or osteophyte (bone spur) in the cervical canal. Pain may by localized or referred to the corresponding dermatome. Also known as the subarachnoid space, the intrathecal space is the fluid-filled area located between the innermost layer of covering (the pia mater) of the spinal cord and the middle layer of covering (the arachnoid mater)

WC: #3

Unilateral SLR Test

(Lasegue Test)

Supine. Hips & knees extended. Examiner with distal hand around the subject’s heel and the proximal hand on the subject’s distal thigh (anteriorly) to maintain knee extension. The examiner slowly raises the test leg until pain or tightness is notes. The examiner slowly lowers the leg until the pain or tightness resolves. At that point, examiner passively dosiflexes the ankle and instruct the patient to actively flex their neck. Leg and/or back pain occurring with dorsiflexion and/or neck flexion is indicative of dural involvement. Pain at hip flexion angles >70 degrees indicates lumbar or SI joint involvement. If this happens, apply bilateral straight leg raise test to differentiate between lumbar and SI joint involvement.

Bilateral SLR Test

Like Lasegue’s Test but with both legs. LBP occurring @ hip flexion angles < 70 degrees Is indicative of SI joint involvement... >70 is indicative of lumbar spine involvement.

Cross-over sign

(Well Straight Leg Raising Test)

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Supine. Hips & knees extended. Examiner with distal hand around the subject’s heel and the proximal hand on the subject’s distal thigh (anteriorly) to maintain knee extension. The examiner passively flexes subject’s uninvolved hip. c/o pain on the involved side indicates a positive test and may be related to vertebral disk damage

WC: #5

Babinski Reflex Test

Implications: Upper motor neuron lesion. The Babinski reflex occurs normally in newborns and should spontaneously disappear shortly after birth.

WC: #3

Oppenheim Test

A blunt object is run along the crest of the anteromedial tibia. (+) the great toe extends and the other toes splay or the patient reports hypersensitivity to the test. Implications: Upper motor neuron lesion caused by brain or spinal cord trauma or pathology.

WC: #8

Kernig’s/

Brudzinski’s Sign

The subject lies supine with the hands cupped behind the head. Actively flex cervical spine. EACH HIP: Actively flex to no more than 90 degrees (with straight leg). Then actively flex knee to no more than 90 degrees. The test is confirmed by increased pain (local of radiating in to LE) with neck + hip flexion. The pain is relieved when the knee is flexed. The pain is indicative of meningeal irritation, nerve root compression, or dural irritation that is exaggerated by elongating the spinal cord.

Bowstring Test

Passive SLR. If the wubject reports radiating pain with the SLR, the examiner then flexes the subject’s knee to approximately 20 degrees in an attempt to reduce painful symptoms. The examiner then applies pressure to the popliteal area in an attempt to reproduce the radicular pain. If he’s able to reproduce pain, this indicates tension of the sciatic nerve.

Hoover Test

A “malingering” test. Subject relaxed with heels in examiner’s hands. Subject does SLR. If the examiner does not feel increased pressure in the palm that underlies the resting leg, it could indicate a lack of effort by the subject. Perform bilaterally to test consistency of effort.

Stork Standing Test

Complaints of pain in the lumbar region may be related to the pars interarticularis region

Spring Test

Apply PA pressure to spinous processes and to transverse process to assess rotary motion. Examiner notes differences in motion of vertebral segments.

Slump Test

Symtoms are assessed after every adujustment in position. The subject sits on the end of the table and leans forward while the examiners holds the head and chin up. Ask about symptoms. The examiner then flexes the subject’s neck. Ask about symtoms. If no changes are noted, the examiner then passivly extends one of the subject’s knees. With no noted changes the examiner then passivly dorsiflexes the ankle while the knee stays extended. Repeat for other side.

A complaint of sciatic-type pain or any reproduction of symptoms is indiicative of a positive test. Note location of smptomatic changes, as this is often the site of a dural stretch. Some people do this test with active knee extension and dorsiflexion, which is probably easier.

WC: #5

Injuries and Conditions to Know

Café’ au lait Macules

Definition: “coffee with milk” skin hyperpigminted can be an indicator of more extensive, multisystem disease, particularly neurofibromatosis, a condition that is also marked by freckles in the armpit and groin regions, as well as neurofibromas.

MOI: congenital

Sacroiliac Dysfunction

Definition: Excessive movement of SI joints

MOI: injury or degeneration

Disc Pathology Definition: pathology of intervertebral disk e.g. bulge, rupture. Disk herniation will likely lead to symptoms in nerve root compression

MOI: Insidious: degenerative; acute: rupture

Facet Syndrome

Definition: Inflammation or degeneration of the facet itself

MOI: Insidious or acute. Extension, rotation, lateral bending of the vertebrae

Nerve Root Compression

Definition: Compression of nerve root

MOI: disk pathology, intervertebral foramen stenosis

Stenosis Definition: narrowing of Intervertebral foramen or central canal

MOI: DJD, congenital, osteophyte formation after acute injury

Step Deformity Definition: drop-off typically seen when the patient is prone, looking from the frontal plane. Likely present with Spondylolisthesis

MOI: postural, fractures, congenital

Sciatica Definition: a non-descript term for any inflammation involving the sciatic nerve, but does not describe the actual condition that is insulting the nerve and causing the inflammation.

MOI: lumbar disk herniation, SI dysfunction, piriformis syndrome, scar tissue formation around muscle, nerve root inflammation, spinal stenosis, synovial cyst, tumor...

Spondylolysis Definition: Non-displaced fx of pars interarticularis

MOI: acute/chronic hyper extension

Spondylolisthesis

Definition: Forward slippage due to displaced fx @ pars interarticularis

MOI: acute/chronic hyper extension

Spondylitis Definition: inflammation of vertebrae

MOI: trauma, infection, other

Scoliosis Definition: Lateral curvature of spinal column

MOI: Congenital, neuromuscular, idiopathic

Spina Bifida Occulta

Definition: This the mildest form for spina bifida. At least one vertebra is malformed, but the nerves and spinal cord are normal and are covered by a layer of skin. Skin at the site of the lesion may be normal or have hair growing from it (‘Faun’s beard’)

MOI: congenital

WC: #8

Works Cited

WC: #1 Prentice, W.E. (2006). Arnheim’s Principles of Athletic Training: A Competency-Based Approach Ed. 12. New York, NY: McGraw-Hill.

WC: #2 Bratton, R.L. (1999). Assessment and Management of Acute Low Back Pain. American Family Physician, 60(8), 2299-2306.

WC: #3 Hoppenfeld, S. (1976). Physical Examination of the Spine and Extremities. Upper Saddle River, NJ: Prentice-Hall.

WC: #4 Kendall, P. F., McCreary, K. E., Provance, G. P. (1993). Muscles Testing and Function, Ed. 4. Philadelphia, PA: Lippincott Williams & Wilkins.

WC: #5 Konin, G. J., Wiksten, L. D., Isear, A. J., Brader, H. (2006). Special Tests for Orthopedic Examination, Ed. 3. Thorofare, NJ: SLACK Incorporated.

WC: #6 Norkin, C.C., White, J.D. (2003). Measurement of Joint Motion: A Guide to Goniometry, Ed. 3. Philadelphia, PA: F.A. Davis Company.

WC: #7 Reese, N.B. (2010). Muscle and Sensory Testing, Ed. 2. St. Louis, MO: Elsevier Saunders.

WC: #8 Starkey, C., Brown, D. S., & Ryan, J. (2010). Examination of Orthopedic and Athletic Injuries, Ed. 3. Philadelphia, PA: F.A. Davis Company.