1 Weakness & Sensory Deficit Describe unique findings in Myopathy, NMJ disorder, neuropathy,...

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Weakness & Sensory DeficitWeakness & Sensory Deficit

Describe unique findings in• Myopathy, NMJ disorder, neuropathy,

plexopathy, radiculopathy• Myelopathy, motor neuron disease• Brain stem and cortical lesions

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WeaknessWeakness

Pertinent parameters include:• Motor power pattern• Sensory findings• Deep tendon reflexes and muscle tone• Others

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Symptomatology of Motor DysfunctionSymptomatology of Motor Dysfunction

1.Muscle mass and contour• atrophy, hypertrophy, dystrophy• myopathy, myotonia2.Muscle tone• spasticity• rigidity• decorticate, decerebrate posture• hypotonia

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Symptomatology of Motor DysfunctionSymptomatology of Motor Dysfunction

3.Involuntary movement• tremor, myoclonus, chorea, athetosis,

ballism, dystonia, spasm, tics, clamps4.Weakness• paresis, paralysis, -plegia, palsy• mono-, para-, hemi-, quadri-

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Neurologic examinationNeurologic examination

1. Cerebral function2. Cranial function3. Motor function4. Sensory function5. Reflexes and muscle tone6. Coordination7. Gait and posture8. Meningeal irritation9. Funduscopic examination

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Motor PowerMotor Power

Grading system (British Medical Research Council)• V normal, full resistance to external force• IV partial resistance to external force• III against gravity, not to external force• II joint movement, not against gravity• I muscle contraction, no joint movement• 0 no muscle contraction

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Sensory FunctionsSensory Functions

1. Dorsal column system• proprioception, touch

2. Anterolateral system• pain (pinprick), temperature

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ReflexesReflexes

Deep tendon reflexes• 4+ pathological• 3+ normal, pathological• 2+ normal• 1+ normal, pathological• 0 pathological

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Etiology (VINDICATEN_HIM)Etiology (VINDICATEN_HIM)

V vascular

I infectious/inflammatoryN neoplasticD degenerativeI intoxicativeC congenital/hereditaryA autoimmuneT traumaticE endocrinopathicN neoplastic

H hematologic

I idiopathic

M metabolic & miscellaneous

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Where is the lesion?Where is the lesion?

Peripheral lesions• Myopathy• Neuromuscular junction• Peripheral nerve

× polyneuropathy× mononeuropathy (single, multiple)× plexopathy× radiculopathy

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Central lesions• Motor neuron• Spinal cord• Brainstem• Cerebral hemisphere• Others

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Lower Motor Neuron LesionsLower Motor Neuron Lesions

Muscle (myopathy)• hypokalemia• myositis, muscular dystrophy

NMJ• myasthenia gravis

Peripheral nerves (neuropathy)• Polyneuropathy• Mononeuropathy (single, multiple)

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Plexus (plexopathy)• diabetic plexopathy

Nerve root (radiculopathy)• Guillain-Barre Syndrome (AIDP), CIDP• herniated disk

Spinal cord (myelopathy)• motor neuron disease

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Symptoms/Signs of LMN LesionsSymptoms/Signs of LMN Lesions

Focal weakness• monoparesis, selective neuropathy weakness

Flaccid tone

Areflexia, hyporeflexia

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Upper Motor Neuron LesionsUpper Motor Neuron Lesions

Spinal cord• cord compression, myelitis

Brain stem, cerebral cortex, cerebellum and basal ganglia

• cerebrovascular disease, tumor, degenerative disease

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Symptoms/Signs of UMN LesionsSymptoms/Signs of UMN Lesions

Diffuse weakness• paraparesis, hemiparesis, quadriparesis

Spastic tone

Hyperreflexia

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Hypotonia - HyporeflexiaHypotonia - Hyporeflexia

Reflex arc dysfunction (any components)• receptor organs• afferent neurons• reflex center• efferent neurons• effector organs

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CST+

VST+

RST+RST -

DRG +CST+

VST+

RST+RST -

DRG +

CST+

VST+

RST+RST -

DRG +CST+

VST+

RST+RST -

DRG +

A

C

B

D

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SpasticitySpasticity

Hypertonia• unidirectional• velocity-dependent

Hyperreflexia

Seen in upper motor neuron lesion other than basal ganglia pathology

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RigidityRigidity

Hypertonia• bidirectional• velocity-independent• cog-wheeling

Normoreflexia

Seen in basal ganglia pathology• Parkisonism, Parkinsonism plus

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CoordinationCoordination

Equilibratory coordination• Romberg sign• Tandem walk

Non-equilibratory coordination• finger to nose, finger to finger, nose-finger-nose• dysdiadokokinesia• rebound• past-pointing

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Gait & PostureGait & Posture

• ataxic gait (proprioceptive, vestibular, cerebellar): wide base, high swing, sway

• festinating gait (Parkinsonism): short, slow, rigid and shuffling

• steppage gait (polyneuropathy): excessive hip flexion

• waddling gait (myopathy): body swaying from side to side like a duck

0% 50% 100%

RT. HEEL STRIKE LT. HEEL STRIKE RT. HEEL STRIKE

RIGHT STANCE RIGHT SWINGLEFT STANCELEFT SWING

RIGHT STRIDE LENGTH0% 50% 100%

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MotorP > DP/D with FD > PP/DP/Dfocal/diffusediffuse

Sensorynormalnormalimpairedimpairedimpairedimpairedimpaired

ReflexesN, DeN, De

DeDeDe

De, II

•Myopathy•NMJ•Peripheral nerve•Plexus•Root•Cord•Brain

P = proximal, D = distalN = normal, De = decreased, I = increased

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Sensory DeficitsSensory DeficitsSpinal sensory Pathways• Dorsal Column system

• Touch, proprioception, two-point discrimination, vibratory sense

• Anterolateral system• Pain (sharp and dull aching)• Temperature sense

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Sensory DeficitsSensory DeficitsCranial sensory pathways• CN I (olfaction)• CN II (vision)• CN V (pain and touch)• CN VII, IX, X (gustatory, etc)• CN VIII (hearing and vestibular sense)

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Diabetic neuropathyDiabetic neuropathy

Clinical features- Initial tingling paresthesia- Pain- Dysesthesia- Loss of feeling distally

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Diabetic neuropathyDiabetic neuropathyDistal sensory impairment ascends

symmetrically in legs and armsPhysical exam:• Glove and stocking pattern• Hyperalgesia • Numbness or lack of sensation

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• http://www.metadon.net/• students• neurologic-examination.pdf