Assessing the Neuromuscular System

Recently a patient with low back pain also had complaints of UE symptoms. She had awakened that morning with burning in her L lateral 3 finger tips. Even though I was seeing her for her back, I quickly looked at her UE symptoms in order to give the patient some information about the impairments. Since she had neural complaints in her lateral 3 fingers, I thought it would be wise to assess neural tension of the median nerve. Upon placing the limb in a partially tensioned position, the patient exhibited clonus of elbow flexion. Questioning myself, I took the patient out of the tensioning position and immediately did rapid elbow extension without any resistance. Placing the limb back into the median nerve tensioned position slowly resulted in clonus again. This lead me to do a slightly more thorough neuromuscular screening. The patient had a history of decreased sensation on the R side and had seen a neurologist 5 years ago, which resulted in negative EMG studies. The patient denied any constitutional symptoms and had negative gait ataxia, Hoffman's, slump test and Inverted Supinator Sign. On the R side, she did present with some odd neuromuscular signs. With Babinski, she reacted with involuntary hip flexion on the R while L side was negative. With tensioning of the R median nerve, the patient rolled out of the tensioned position involuntarily. She was hyperreflexive on the R side as well. Due to this atypical presentation, I referred the patient to a neurologist. Afterwards I consulted with several physical therapist, including my mentor, all of whom had never heard of clonus with a neural tension test.

The reason I present this patient encounter is to review the essential components of a neuromuscular screening. Due to the fast pace of the clinic and the fact I was seeing her for her back, I was unable to do a thorough exam. Below I will include all things I should have looked at:

-Dermatomes: looking for altered sensation along different spinal levels

-Myotomes: looking for weakness along different spinal levels

-Reflexes: looking for either hyporeflexia (Lower Motor Neuron lesion) or hyperreflexia (Upper Motor Neuron lesion)

-Cluster for Cervical Myelopathy:
    -Gait Ataxia
    -Babinski
    -Inverted Supinator Sign
    -Hoffman's Sign
    -Age >45

-Slump Test and SLR: tensioning of the neural system from the LE

-ULNT's: tensioning of the neural system from the UE

-Clonus: looking for potential Upper Motor Neuron lesion

-S&S:
    -NIght Pain
    -S&S of Cauda Equina Syndrome
    -Bowel &Bladder Changes
    -Nausea & Vomiting
    -Significant Changes in Weight in Last 6 Months
    -Fever
    -Hx of Cancer
    -Unusual Fatigue
    -Tolerance to Heat and Cold

The above list is many of the aspects one needs to consider in your neuromuscular examination. Our normal exams will also look for spinal and peripheral joint mobility and the joint's response to repeated loading. However, when concerned about a potential neuromuscular disease, we should be aware of the accumulation of these S&S. For example, with this patient's young age (20), history of decreased sensation on one side, difficulties with heat/cold, and odd reactions with neural tensioning diagnoses such as multiple sclerosis come to mind. It is for this reason that it is essential we screen our patients thoroughly for systemic conditions of all types. 


What other exam measures do you include in your neuromuscular screening?

-Chris