An upper limb neurological examination is part of the

neurological examination A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical his ...

, and is used to assess the motor and sensory neurons which supply the upper limbs. This assessment helps to detect any impairment of the nervous system, being used both as a screening and an investigative tool. The examination findings when combined with a detailed history of a patient, can help a doctor reach a specific or differential diagnosis. This would enable the doctor to commence treatment if a specific diagnosis has been made, or order further investigations if there are differential diagnoses.

Structure of examination

The examination is performed in sequence: # General inspection # Muscle tone # Power # Reflexes # Coordination # Sensation

General inspection

The upper body is exposed and a general observation is made from the end of the bed. Signs of neurological disease include: *

Wasting In medicine, wasting, also known as wasting syndrome, refers to the process by which a debilitating disease causes muscle and fat tissue to "waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is believed that epis ...

: May suggest

motor neuron disease Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or—in the United States—Lou Gehrig's disease (LGD), is a rare, terminal neurodegenerative disorder that results in the progressive loss of both upper and low ...

or a lower motor neuron lesion. It could also indicate local infiltration of nerves such as the

brachial plexus The brachial plexus is a network of nerves (nerve plexus) formed by the anterior rami of the lower four Spinal nerve#Cervical nerves, cervical nerves and first Spinal nerve#Thoracic nerves, thoracic nerve (cervical spinal nerve 5, C5, Cervical spi ...

, in apical lung tumours, causing wasting of the small muscles of the hand. *

Fasciculation A fasciculation, or muscle twitch, is a spontaneous, involuntary muscle contraction and relaxation, involving fine muscle fibers. They are common, with as many as 70% of people experiencing them. They can be benign, or associated with more seriou ...

: These are small contractions of muscles seen as movements under the skin. They occur in lower motor neuron lesions. * Involuntary movements: Different types exists, all of which are distressing to the patient and cause of embarrassment in public. They are classified into

tremor A tremor is an involuntary, somewhat rhythmic muscle contraction and relaxation involving neural oscillations, oscillations or twitching movements of one or more body parts. It is the most common of all involuntary movements and can affect the h ...

chorea Chorea, or (rarely) choreia, () is an abnormal involuntary movement disorder, characterized by quick movements of the hands or feet. It is one of a group of neurological disorders called dyskinesias. The term ''chorea'' is derived , as the move ...

, athetosis, hemiballismus,

dystonia Dystonia is a neurology, neurological Hyperkinesia, hyperkinetic Movement disorders, movement disorder in which sustained or repetitive muscle contractions occur involuntarily, resulting in twisting and repetitive movements or abnormal fixed po ...

, myoclonus, and

tics A tic is a sudden and repetitive motor movement or vocalization that is not rhythmic and involves discrete muscle groups. Tics are typically brief and may resemble a normal behavioral characteristic or gesture. Tics can be invisible to the obs ...

Muscle tone

The hand is grasped like a handshake and the arm is moved in various directions to determine the tone. The tone is the baseline contractions of the muscles at rest. The tone may be normal or abnormal which would indicate an underlying pathology. The tone could be lower than normal (floppy) or it could be higher (stiff or rigid).

Power

The strength of the muscles are tested in different positions against resistance.

Reflexes

There are 3 reflexes in the upper arm that are tested. These are the biceps, triceps and supinator reflex. The reflexes may be abnormally brisk or absent. In the latter, the reflex could be elicited through reinforcement by asking the patient to clench their jaw.

Coordination

Three separate aspects of coordination are tested:

Finger-nose test

This maneuver tests for

dysmetria Dysmetria () is a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye. It is a type of ataxia. It can also include an inability to judge distance or scale. Hypermetria an ...

. The examiner holds their hand in front of the patient, who is then asked to repeatedly touch their index finger to their nose and the examiner's finger. The distance between the examiner's hand and patient's nose should be larger than the forearm length of the patient, so that the patient need to move both their shoulder joint and elbow joint during the test instead of just moving the elbow joint. Healthy individuals can touch accurately on their nose and examiner's hand with ease, while dysmetria patients will constantly miss the nose and the hand.

Rapid pronation-supination

This maneuver tests for dysdiadochokinesia. The patient is asked to tap the palm of one hand with the fingers of the other, then rapidly turn over the fingers and tap the palm with the back of them, repeatedly. The patient is asked to perform the clapping as quickly as he could. Dydiadochokinesia patient will be impaired in the rate of alternation, the completeness of the sequence, and in the variation in amplitude involving both motor coordination and sequencing.

Pronator drift

The arms are outstretched and patient is instructed to close their eyes. If the hands do not move, it is normal.

Sensation

The five aspects of sensation are tested: # Light touch - tested using cotton wool #

Pain Pain is a distressing feeling often caused by intense or damaging Stimulus (physiology), stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sense, sensory and emotional experience associated with, or res ...

- tested with a neurological pin #

Proprioception Proprioception ( ) is the sense of self-movement, force, and body position. Proprioception is mediated by proprioceptors, a type of sensory receptor, located within muscles, tendons, and joints. Most animals possess multiple subtypes of propri ...

(sense of joint position) - tested by moving the thumb while the patients eyes are closed. Patient is then asked whether the thumb is moved up or down. # Vibration - tested with a 128 Hz tuning fork placed at the first joint of the thumb # Temperature - tested with hot and cold test tubes. Alternatively the cold tuning fork used for vibration sense, could be used.

References

External links

Upper limb neurological exam from Patient UK

Upper limb neurological exam from Fastbleep
{{Nervous system symptoms and signs Neurology procedures Physical examination