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hi all i have posted this for those without wwweb access and for future archive 'diggers' janet ---------------------------------------------------------- Demystifying the Neurological Examination ---------------------------------------------------------- demonstration and lecture given by Dr. Rick Stell Fourth Australian Multi-Disciplinary Conference on Parkinson's Disease September 1998 in Perth, Western Australia. Today I will be talking about demystifying the neurological examination. For that reason I didn't bring any equipment, there will just be me and the patient. In thinking about what I was going to do today I thought about putting myself in your position answering the questions you might have in your minds. I hope to some extent that I answer those questions. Beth's been very kind to be my 'patient' today so we'll bring her out her to sit on this chair. The reason neurologists see patients and examine them is different for how you think we do it. What we are trying to discover is: 1. Do you have Parkinson's disease or is it some other movements disorder? That is the first thing we want to know. 2. How severe is it? Is it disabling you? Some of this can be determined by the physical examination but obviously a lot depends on your feedback to us on how it interferes on your day to day life. Often, or not infrequently, there are discrepancies between what we find and what you say. We use this information to reach a clearer management strategy. In terms of making a diagnosis of Parkinson's disease, we look for the characteristic things in patients, I'm sure you are aware of. Most patients say they have lost some function, and it is usually motor function or have gained a new function, i.e.. a tremor. The clue as to the diagnosis of Parkinson's disease as far as the neurologist is concerned, is that the symptoms are 'One Sided' or predominantly 'One Sided'. If we encounter a patient with symptoms on both sides equally, we begin to doubt a Parkinson's diagnosis. If we encounter a patient who falls a lot over a long period of time, that makes us doubt a Parkinson's diagnosis. Parkinson's disease is ALWAYS on one side or the other and initially it is 'One Sided'. Walking problems occur and falling problems do not generally occur until late in the disease. During the physical examination, we are looking for the cardinal features of the condition but the examination begins when you walk into the room. We look at the posture. We listen to the speech and the volume of the speech. This is important in the initial diagnosis, making it a disorder of the basal ganglia. We expect a slow soft speech in patients moderately affected, although this may not be present in the early course of the disease. We look at the posture of the person. In the early stages of the disease there is no abnormality of posture. Some patients manifest a very slight rounding of the shoulders. If the person we are examining is a 70 or 80 year old, you might say that is compatible with their age. As the disease progresses, the patient becomes flexed at the hips and also at the knees. Then I observe the patient walking. We are looking for a good arm swing and whether there is a good stride length. There will be an asymmetrical (difference) between one side and the other. While the person is standing up we look at the rigidity of the spine. If there is a marked stiffness of the spinal musculature, particularly at an early stage, makes us doubt that it is Parkinson's disease. We wobble people about. While I am looking at your reactive arm swing, I am also making an assessment of the rigidity of the spine. We also do the same sort of thing with the head relaxed. The observation of no marked axial stiffness of the trunk and reduced arm swing... would indicate more of a likelihood of a diagnosis of Parkinson's disease. We also get a bit rough with people and wobble them about to test for postural stability. In Parkinson's disease especially at the advanced stages, there is an inability to rapidly compensate and regain the balance when suddenly pulled from behind or change direction. We face the patient and tell them to try to maintain their balance as we suddenly pull them towards us by the shoulders and if they feel unbalanced to just take a step forward. Taking the one step to regain the balance is normal. We do the same from behind. If a patient takes more than three steps back, I redo it... 2 steps or less is normal. In some other conditions, not Parkinson's disease, early on there is a marked inability to make postural adjustments. If a person diagnosed with early Parkinson's disease were to fall over, particularly backwards... I would question the diagnosis of Parkinson's disease. I pay particular attention to eye movements, even though this is not something patients complain of. Early Parkinson's patients have normal eye movements whereas patients with some of the other Parkinson's Plus patients will have abnormal eye movements, early on. I have the patients look at the top of a pen I hold. I am looking to see if the eyes are stationary, not jumping about. I then have the patient to follow the pens movement back and forth. Eye movement should be smooth. Then we have the patient follow the pen as it moves up and down. Vertical eye movement impairments can translate into reading and focusing complaints that may affect reading, which is a common complaint. We look for lack of expression on the face. We look at the eyeballing crate area. This is generally reduced. I have patients to close their eyes lightly, and then open them up, and screw their eyes up tightly, and open them up. In some extrapyramidal diseases, abnormalities of eyelid movement is common. These can be two kinds. One is blephrospasm where the eyelids remain tightly closed and make it difficult for the patient to open. The other is apraxia of eyelid opening where the patient is trying to open the eyelids by raising the eyebrows... but can't get the eyelids to open, and have to lift them with their fingers. Both can be seen in Parkinson's disease but uncommonly. Blephrospasm could be the result of post-encephalitic Parkinson's disease. We test for the rapidity of the eyelid movements by having the patient blink the eyes as fast as possible. In Parkinson's, the be a difficulty blinking quickly and the blinking will break down into a tonic. We do the same test with the lips, and look for the same difficulty. We then examine the movements of the tongue, by having the patient put the tongue out and rapidly move it from side to side. There can be a tremor noted on the tongue when it is protruded. None of the tests individually will prove the Parkinson's diagnosis, but together they will prove an extrapyrimidal disorder. We next have the patient stand relaxed with the arms at the side. We look for any spontaneous tremor and also for abnormal involuntary posturing of the elbow, wrist and hands. Many patients will note that when they are walking, all the sudden the arm will come up. This is posturing, it is not moving about and they can consciously put it down but up it will come again, if they are not thinking. Now we have the patient close their eyes and audibly count backwards from 100 by 3s. The answers are important, we are stressing the patient, to being out a tremor as we observe. We now that the patient extend the arms and hand in from of them and look for the posture of the hands and a higher frequency postural tremor. Now we examine the relaxed hands and arm to test for tone. Tone really means, when I move the limb, is it stiffer than I would expect? Now we have the patient raise the other arm, and to rapidly open and close the hand. This stresses or increases tone (stiffness) if it is subclinical. At rest an arm that is quite floppy, is normal. If in the rapidly opening and closing of the hand while I am moving the limb, there is a jerkiness, that is cogwheeling. This cogwheel rigidity is an increase in tone and creates the ratcheting effect and superimposed on that is the tremor. Now we have the patient hold the hands out and wiggle the fingers very quickly. We are looking for a difference on the two sides. Some patients you have to resort to another maneuver of having the patient tap with their index finger the back of the other hand very quickly. It's very difficult to do on the affected side. Now we have the touch your nose procedure. Parkinson's patients will be slow, but accurate. If there is a lot of inaccuracy, it is probably something else other than Parkinson's. On the arm power test, normally the pushing and pulling against my resistance, the power will be slower to build up but given time the power will be normal. If there is weakness, it isn't Parkinson's disease. If there is a coordination problem or weakness, again it is not Parkinson's disease. Next we have the patient put a foot on the ground and alternately tap heel and toe as rapidly as possible. We are looking for differences from side to side. Next is the testing for power, tone and reflexes in the legs. In Parkinson's disease there may be an increase or decrease in reflexes and tone. In summation, we're looking to see if there is a slowness of movement, is there stiffness, is there a rest tremor, are they mainly on one side. Anything else, early falls, weakness, lack of coordination, problems with the eye movements, prominent problems, swelling, we are not looking at Parkinson's disease. ---------------------------------------------------------- janet paterson - 51 now /41 dx /37 onset - almonte/ontario/canada <http://www.newcountry.nu/pd/members/janet/index.htm> [log in to unmask]