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Picture

Assessing the Neuromuscular System

12/8/2014

2 Comments

 
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.
Picture
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
2 Comments
Jarod Hall
12/11/2014 09:21:18 pm

Chris,
For doing a quick screen on the fly I think you did a great job! Good eye to pick up the clonus by the way! This is a great case study to show the importance of medical screening as well as our evaluation skills as PTs! My only addition (as MS also immediately came to my mind reading the case) would be to also add in a quick Lhermitte's sign test.

Thanks again for the post!

Reply
motor lamination stacks link
7/15/2024 08:05:45 am

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  • Home
  • About Us
  • TSPT Academy
  • Resources
    • Newsletter
    • Orthopedic Blog
    • Featured Articles
    • Research Articles
    • Residency Corner
  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test