Primary care provider approach to patients with neurologic complaints 2

Next in the top to bottom neurologic examination is assessment of motor function. One might start by asking the patient to stretch their arms out in front of them with the palms up. Observe for subtle pronation, and drift downward or drift upward of the arm. The former indicates subtle weakness. The latter indicates sensory abnormality and is perhaps localizing to a process in the parietal lobe. One can then assess for the ability to check muscle drifting by tapping the arms in either or both in upward and downward direction. Here you see if the extremity moves excessively before coming back to the original position. This could be indicative of a cerebellar process. Next, observe muscles and test them assessing muscle strength, bulk, and tone. You're also observing for atrophy or fasciculation in the muscle. Muscle strength is graded on a 0-5 scale. Zero is absolutely no muscle contraction. One is scored when there is an observable trace contraction. A score of two represents the ability to move by contracting the muscle with gravity removed. For instance, moving the arm or leg across the bed without lifting it. Three is scored when one has the ability to overcome gravity but not any resistance. Four is scored when there is some weakness against your full resistance. Five is scored when there is full strength against resistance. Tone can be tested by selecting muscles preferably postural muscles and putting them through their range of motion. Postural muscles in the lower limbs are the extensor groups. In the arms postural muscles are the flexor groups. Tone is best assessed with the patient distracted and relaxed. Testing through two joints simultaneously is also helpful. For instance, rotate the wrist while holding the hand and the elbow and simultaneously flexing and extending the elbow. This maneuver is also a good method to test for cogwheel rigidity in Parkinson's disease. When testing power and looking for atrophy, particular attention should be paid to examining muscles that are most relevant to the patient's chief complaint. This could include muscles innervated by a particular nerve root, a portion of the brachial or lumbosacral plexus under consideration for involvement, or any peripheral nerve or branch that may be suspect as the cause of the patient's chief complaint.