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My Quick Upper Limb Neurological Examination

So what are your criteria for conducting a neurological examination and what do you include when you do complete one?

Like all questions there are provisos, so rather than list them all I thought I would explain my basic neurological examination and depending on the results I build from that. When to check? Generally if symptoms extend beyond the shoulder or hip, I would consider at least a basic examination. If the history included descriptions of pins and needles, numbness then again I would include a neurological examination. How long should it take, around 3-5 minutes. Here is my upper quadrant examination.

In my type of clinical practice I am focusing on the hard signs of a neurological examination associated with lower motor neurone compression; I am looking for power, reflex and sensation. Here I am attempting to determine what is the segmental level of involvement. Think dermatonal sensation charts and segmental muscle weakness. Reflexes would be reduced/depressed, as the nerve function being interrupted is a lower motor neurone.

For power testing I use the following; deltoid C5 (axillary nerve), biceps C56 (musculocutaneous nerve), triceps C678 (radial nerve), EPL C8 (deep radial nerve) and interossei T1 (ulna nerve). Because C6 and C7 are the most commonly injured/degenerative levels I see in private practice, I use wrist extension C7 and wrist flexion C8, to help differentiate a weak triceps test. How weak is weak? For me it is not so much that the test is weak, more that the muscle test gives way - with no substance when challenged.

For reflex testing I use biceps C56, triceps C78 and pronator quadratus C8. Always compare to other side, as many people have reduced reflex response (more so with increased age) and we are not looking for generalities, rather specific variations. Also consider using alternative positions or the Jendrassik manoeuvre in situations of poor reflex testing. For increasing upper limb reflex responses, I normally use the thigh adduction squeeze, but apparently the teeth clench is more appropriate. In general in private practice you will be seeing clients with reduced or absent reflexes due to nerve compression, however be alert to the rarity that presents with hyper reflexia - indicating an upper motor neurone involvement.

In some ways sensation testing lacks the most clarity with regards to testing. Remember when testing sensation due to suspected nerve compression, you are initially testing for the reduction or absence of sensation. Clients often say an area feels numb, to which I ask, if I placed a lit cigarette on it would you feel it? Invariable the answer is 'yes I would feel it', so what they are describing is altered sensation rather than lack of sensation and this can have many causes. Vibration (placing a tuning fork on boney prominences) and pressure are conveyed by large myelinated fibers and these sensations are lost first when a nerve is compressed. I don't routinely test these clinically, rather I test light touch/pain/temperature using a monofilament as these sensations are lost after a period of compression. Monofilaments are traditionally used for testing diabetic related sensation loss, but are also a great way to have a calibrated applied pressure for skin sensation testing. Light touch is conveyed by the thinly myelinated (A delta) and un-myelinated nerve fibers (C fibers).

With regards to sensation, it is important to consider non-dermatonal sensation. Some upper quadrant muscles (myotomes) project pain and pins & needle sensations into the arms. Diabetic neuropathy needs to be considered if symptoms are bilateral, peripheral and nocturnal in nature. Also elements of chronic pain can be neuropathic, with non-dermatonal patterns, expanding receptive fields and sensitivity to cold testing.

In addition to nerve compression, I routinely give some consideration to nerve irritability (upper limb nerve provocation tests). Clients often present with dermatonal symptoms of pain and maybe parathesia, but no hard neurological signs and in this case I am thinking chemical nerve irritation due to injury in the vicinity of a nerve root, but no direct compression.​ Keep an eye out for older clients that have root level(s) chronically compressed (central or lateral stenosis) resulting at times in no symptoms (but +ve signs if tested) and no irritability.

You can view a video of this examination here.

 

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