Stroke examination: Upper limb examination

Question 1

What is the general order of an upper limb stroke examination?

Answer 1

Look at clinical signs

Muscle tone

Sensation: Light touch, vibration sensation, pain perception

Power: Myotomes and resisted movements

Reflexes: Biceps, supinator, triceps with tendon hammer

Cerebellar function: Coordination (intention/action tremor), dysdiadochokinesia

Joint proprioception

Question 2

Which clinical signs should you look for in an upper limb stroke examination? SWIFT

Answer 2

Scars

Wasting

Involuntary movements eg. is patient leaning to one side

Fasciculations

Tremor

Question 3

Why should you look for scars in an upper limb stroke examination?

Answer 3

They can indicate previous spinal, brain or upper limb surgery or trauma

These could cause muscle and nerve injury

Question 4

Why should you look for wasting in an upper limb stroke examination?

Answer 4

Muscle wasting is indicative of a lower motor neuron lesion (originate in brainstem or spinal cord)

Upper motor neuron lesions (originate in brain) don’t cause muscle wasting

Question 5

What are fasciculations and why should you look for them in an upper limb stroke examination?

Answer 5

Involuntary rapid muscle twitches that are too weak to move a limb but are easily felt and seen

Indicate lower motor neuron lesion

Fasciculations don’t occur in upper motor neuron lesions

Question 6

What is a resting tremor, and how and why should you look for them in an upper limb stroke examination?

Answer 6

Shaking that occurs when a body part is relaxed and supported against gravity

Ask patient to rest hands in lap and see if hands start shaking slowly and in rhythm, looks like someone is trying to roll a pill between thumb and fingers

Indicates damage to cerebellum or basal ganglia

Question 7

Which 2 types of tremor should you look for in an upper limb examination?

Answer 7

Resting tremor

Holmes tremor

Question 8

What is a Holmes/rubral tremor, and why should you look for them in an upper limb examination?

Answer 8

Irregular, low-frequency (slow movement) tremor that can be present at rest, during posture, and with intentional movement

Indicates stroke affecting thalamus, midbrain or cerebellum

Question 9

When assessing tone in an upper limb stroke examination, which 3 muscle groups are being tested?

Answer 9

Shoulder
Elbow
Wrist

Question 10

How do you test tone in upper limb stroke examination in 5 steps?

Answer 10

1. Hold patients hand and elbow to support the upper limb
2. Ask patient to completely relax their arm
3. Shoulder circumduction: Move shoulder joint around in circles
4. Elbow flexion/extension: Bend and straighten elbow joints
5. Wrist circumduction: Move wrist joint around in circles

Question 11

What is hypotonia, how do you identify it when checking tone and give 5 indicated conditions?

Answer 11

Hypotonia: Reduced muscle tone and ability to maintain posture

Upper limb is floppy and when release from hold it will hang straight down

Cerebral palsy, very recent stroke, hypoglycemia, congenital hypothyroidism, genetic conditions eg. Downs

Question 12

What is hypertonia and what are the 3 types to look for?

Answer 12

Hypertonia: Increased muscle tone and ability to maintain posture

Spasticity (velocity-dependent): The faster you move the joint the more resistance there will be, so limb will feel stiffer

Clasp-knife spasticity: Sudden release of resistance at the end of a stretch, so limb goes very stiff then suddenly floppy

Rigidity (velocity-independent): Stiffness of joint remains constant throughout all movements

Question 13

Which conditions are indicated by spasticity and clasp-knife spasticity?

Answer 13

Spasticity: Upper motor neuron lesions eg. spinal cord injury, multiple sclerosis, stroke, cerebral palsy

Clasp-knife spasticity: Stroke

Question 14

Which conditions are indicated by rigidity?

Answer 14

Basal ganglia disorders eg. Parkinson’s, Huntington’s

Autoimmune conditions eg. SLE, fibromyalgia

Question 15

How do you assess sensation in upper limb stroke examination with light touch?

Answer 15

Use a cotton wool to touch the center of patient’s neck and say that this is what normal sensation should feel like

1. Swipe once on arm and say ‘can you feel this’
2. Swipe once of on other arm and say ‘can you feel this’
3. Swipe both arms and say ‘which side can you feel’

Do this in quadrant areas from shoulder to fingers

Question 16

How do you assess sensation in upper limb stroke examination with pin-prick/pain sensation?

Answer 16

Use a neurotip to touch the center of patient’s neck and say that this is what normal sensation should feel like

Tell patient that you are going to lightly press neurotip on different areas of skin, and ask to tell if it feels the same, weaker or stronger

1. Press once on arm and say ‘can you feel this’
2. Press once of on other arm and say ‘can you feel this’
3. Press both arms and say ‘which side can you feel’

Do this in quadrant areas from shoulder to fingers

Question 17

How do you test sensation in upper limb stroke examination with vibration perception?

Answer 17

1. Use a 128 Hz tuning fork
2. Ask patient to close their eyes, and tell them that you are going to press the tuning fork to different bony areas and to tell you when the vibration stops
3. Tap the tuning fork on your elbow to start vibrations then press to bony areas, squeeze prongs to stop vibration

Question 18

Which 2 sensory pathways are assessed when testing sensation with light touch, and what do these pathways do?

Answer 18

Dorsal column: Fine touch, vibration, proprioception

Spinothalamic tract: Pain, temperature

Question 19

Which sensory pathway is assessed when testing sensation with pin-prick/pain sensation?

Answer 19

Spinothalamic tract: Pain, temperature, noxious stimuli

Question 20

Which sensory pathway is assessed when testing sensation with vibration perception?

Answer 20

Dorsal column: Fine touch, vibration, proprioception

Question 21

Which 4 bony landmarks should be assessed in vibration perception, in the upper limb stroke examination?

Answer 21

1. Interphalangeal joint of thumb
2. Metacarpophalangeal joint of thumb
3. Styloid process of radius
4. Olecranon process of elbow

Question 22

When testing light touch sensation in the upper limb stroke examination, what is a normal and abnormal finding?

Answer 22

Normal finding: Cotton wool swipe feels normal

Abnormal finding: Cotton wool swipe feels weaker or stronger

Question 23

If sensation feels stronger than normal, what does this indicate and what is the specific term?

Answer 23

Tactile hyperesthesia

Diabetes, multiple sclerosis, shingles, HIV, hypothyroidism

Question 24

If sensation feels weaker than normal, what does this indicate and what is the specific term?

Answer 24

Tactile hypoesthesia

Stroke, TIA, trauma, compression from tumours or hernia, B12 deficiency

Question 25

What pattern of hypoesthesia presents in a hemisphere (affecting left or right side of brain) or thalamic stroke?

Answer 25

Unilateral numbness in arm and/or leg and/or face (affects one side of the body), on contralateral side to stroke lesion

Question 26

What pattern of hypoesthesia presents in a brainstem stroke?

Answer 26

Numbness in facial side that is ipsilateral to stroke lesion, but numbness in arm and/or leg is on contralateral side to stroke lesion

Question 27

What pattern of hypoesthesia presents in a central cord syndrome?

Answer 27

Central cord syndrome: Incomplete traumatic injury to cervical spine Numbness below level of lesion, usually affecting arms and hands

Question 28

What pattern of hypoesthesia presents in a peripheral neuropathy?

Answer 28

'Gloves and stockings' pattern: Symmetrical sensory loss in the hands and feet

Question 29

Give examples of conditions that can cause impaired joint proprioception, in the upper limb stroke examination?

Answer 29

Stroke, MS, ALS, peripheral neuropathy Alcohol, arthritis, joint replacements, amputations

Question 30

Which 3 reflexes do you assess in the upper limb stroke examination?

Answer 30

Biceps reflex Supinator (brachioradialis) reflex Triceps reflex

Question 31

How should the patient be positioned when assessing upper limb reflexes?

Answer 31

1. Elbow bent with arm lying across chest and hand resting on lap 2. Ask patient to completely relax 3. Show patient the tendon hammer and tell them that you are going to tap lightly on the muscles with the hammer and see if this causes a reaction

Question 32

How do you assess the biceps reflex, and which myotomes is this testing?

Answer 32

In middle of inner elbow, above antecubital fossa 1. Put your thumb over the distal biceps tendon, then tap tendon hammer on your thumb 2. Should see biceps contraction and elbow flexion Tests C5/C6

Question 33

How do you assess the triceps reflex, and which myotomes is this testing?

Answer 33

In middle of outer elbow, above olecranon process 1. Tap tendon hammer on distal triceps tendon: Don't need to put thumb over 2. Should see triceps contraction and elbow extension Tests C7

Question 34

How do you assess the supinator reflex, and which myotomes is this testing?

Answer 34

On posterolateral aspect of the wrist approximately 4 inches proximal to the base of the thumb. 2. Put thumb over brachioradialis tendon, the tap tendon hammer on your thumb 3. Should see contraction of the brachioradialis muscle and associated flexion, pronation or supination of the forearm at the elbow. Tests C5/C6

Question 35

If reflexes are hard to illicit in the upper limb stroke examination, what can you ask the patient to do?

Answer 35

Make sure the patient is fully relaxed and then perform a reinforcement manoeuvre by asking the patient to clench their teeth together

Question 36

What conditions cause hyperreflexia?

Answer 36

Upper motor neuron lesions Stroke, MS, ALS, hyperthyroidism, CNS tumour, myelopathy

Question 37

What conditions cause hyporeflexia?

Answer 37

Lower motor neuron lesions Nerve root impingement, peripheral neuropathy, Bell's palsy

Question 38

How do you test cerebellar coordination in the upper limb stroke examination?

Answer 38

Finger-to-nose test 1. Position your finger so that the patient has to fully outstretch their arm to reach it. 2. Ask the patient to touch their nose with the tip of their index finger and then touch your fingertip. 3. Ask the patient to continue to do this finger to nose motion as fast as they are able to 4. Move your finger from left to right as they do this 5. Repeat with other arm

Question 39

What is the normal finding in the finger-to-nose test?

Answer 39

Patient's finger should move smoothly and accurately between their nose and the examiner's finger, without any tremor or overshooting

Question 40

Which 2 abnormal findings in the finger-to-nose test can indicate stroke, and why?

Answer 40

Intention tremor: A tremor that only appears as the finger approaches the target (nose or examiner's finger) Dysmetria: Difficulty judging the distance to the target, leading to undershooting or overshooting Both indicate cerebellar stroke/loss of function

Question 41

What is dysdiadochokinesia?

Answer 41

Inability to perform coordinated, rapid muscle movements

Question 42

How do you assess dysdiadochokinesia?

Answer 42

Ask patient to place one hand on top of the other, then keep turning the hand on top Ask patient to do this as fast as they can

Question 43

What conditions can cause impaired dysdiadochokinesia?

Answer 43

Cerebellar stroke, MS, Parkinson's

Question 44

When testing sensation in the stroke examination, why do you not test each dermatome?

Answer 44

Stroke affects the brain (cortex, subcortex, brainstem), not the nerve roots or spinal cord. Therefore, sensory loss will follow a hemisensory or body-region distribution, not specific dermatomes.

Question 45

How do you test power of the myotome C5, and which muscle does this isolate?

Answer 45

Deltoid Ask patient to bend elbows and bring abduct shoulder to 90 degrees 'chicken arms' Push down on tops of their upper arm, tell them to resist

Question 46

How do you test power of the myotome C6 in 2 ways, and which 2 muscles does this isolate?

Answer 46

1. Elbow flexors: biceps brachii, coracobrachialis and brachialis Ask patient to flex elbows, try to pull their forearms towards you and tell them to resist (stabilise shoulder joint by holding elbow) 2. Wrist extensors: Tell patient to make fist and point wrist to ceiling, you push down

Question 47

How do you test power of C7 myotome in 3 ways, and which muscle is isolated?

Answer 47

1. Triceps brachii Ask patient to flex elbows, try to push their forearms towards them and tell them to resist (stabilise shoulder joint by holding elbow) 2. Wrist flexors: Tell patient to make fist and point wrist to floor, you pull up 3. Ask the patient to hold their fingers out straight whilst you apply downwards resistance: “Hold your fingers out straight and don’t let me push them down.”

Question 48

How do you test power of C8 myotome?

Answer 48

Finger flexion: Tell patient to grip your fingers in their fist and to not let you pull out of grip

Question 49

How do you test power of T1 myotome?

Answer 49

Finger abduction

Question 50

How should you grade power, in the upper limb stroke examination?

Answer 50

Grade power from 0-5 with MRC muscle power scale: Grade 0: No movement Grade 1: Flickering movement Grade 2: Movement but not against gravity Grade 3: Movement against gravity Grade 4: Movement against gravity but not resistance Grade 5: Normal power

Question 51

What pattern of motor function normally occurs in strokes affecting the upper limb?

Answer 51

Flexors are stronger than extensors Patient often holds arm flexed at the elbow and wrist Weaker extensors (e.g. wrist and finger extension)

Question 52

How do you test proprioception in the upper limb stroke examination?

Answer 52

1. Ask the patient to close their eyes (or look away). 2. Hold the sides of the distal phalanx of the thumb (not the top/bottom to avoid pressure cues). 3. Gently move the thumb up or down about 1–2 cm. 4. Ask: “Is your thumb moving up or down?” 5.Repeat a few times in random directions. 6. Compare to the other hand.

Question 53

Which 3 sensory change patterns can occur in stroke?

Answer 53

Sensory ataxia (lack of co-ordination due to reduced sensory feedback) Sensory inattention (inability to recognise stimuli from one side when presented with bilateral sensory input) Tactile agnosia (inability to recognise objects my touch)