Our second session today is titled Neuromuscular Exam, Sensory Modalities and Reflex Testing, presented by Dr. Divpreet Kaur, with Certified Registered Nurse Practitioner, Ms. Kim Vesic. Dr. Kaur is an Assistant Professor at Penn State Hershey Medical Center, where she is the Neuromuscular Division Chief, Neurophysiology Laboratory Co-Director, and Supervising Director for Neuromuscular Education for Neurology and PM&R Residents. Hello, everybody. I'm Dr. Kaur, and I am the Division Chief for Neuromuscular Division at Penn State Hershey Medical Center Department of Neurology, and I will be performing the Sensory Neurological Exam and reflexes on my APP, Kim Vesic, who works very closely with me in my clinic here. So in the next part of the videos, you're going to see how we perform the sensory examination with different modalities and the reflex examination as well when a patient comes for evaluation of neuropathy in our clinic. All right, thank you. So the first part of the sensory examination that we are going to do today is the light touch and fingerprint examination, and then we'll go to the temperature. We'll go to vibration. We'll go to proprioception. Okay, so let's start with upper extremities. Do you feel this? Yes, about a hand. Do you feel this? Okay, can you roll your sleeves all the way up? Okay. Do you feel it soft or not? It's soft. It's soft, okay. And is it the same on both sides or is it different? It's the same. It's the same, okay. Let's start in the leg. Do you feel this? Yes. All the way? Yep. Okay, and how about here? Yes. Okay, no difference? No difference. It's the same. Okay, all right. So this is the, now we're going to break this, and this is like a sharp object, and let's try the pinprick first. Let's start with the arm again. You can close your eyes. Can you feel this poking like a pin? Yes. All the way? Yep. If there is any difference, you let me know as we move up in the arm. Yes, I feel it. Same? Same. Okay, let's compare it to the other side. Same? Yes. No difference on either side? No. Okay, let's try with the leg. All right, so you can go from distal to proximal, or proximal to distal. I usually like to go from distal to proximal to see if there is a gradient, especially in a patient with an neuropathy exam. All right, let's start here. Do you feel this poking? Yep. Okay. Sorry to poke you. Is it the same on both sides? Yes. Okay, no difference? No difference. Okay, let's try the other leg. Same on both sides? Yes. No difference as I'm moving up? No. Okay, all right. So, the other thing that you have to be careful, do not try to poke too much. All right, so we'll start with the temperature exam, which is the next sensory modality. All right, now do you feel this hot or cold? Cold. Okay, let's do the other side. Hot or cold? Cold. Hot or cold? Hot or cold? Okay. All right, so you can definitely use a tuning fork and test for the cold sensation. If you want to check for a hot or cold sensation separately, you can have like your ice pack or warm pack and check the sensation that way as well. All right, so these are the modalities that we are checking for the spinothalamic tract for the pain, temperature, and the light touch and pinprick sensation. So these are the type of examinations that we test for the spinothalamic tract which can be abnormal in any patient with any kind of polyneuropathy that can involve these tracts. So the next exam that we're going to go in the sensory examination is going to be vibration and proprioception. The vibration and proprioception examination is more to look for the posterior columns or dorsal column examination. All right, Kim, so what I'm going to do is I'm going to, with this tuning fork, and this tuning fork is 128 hertz that we're using, you're going to tell me if you feel this vibration sensation or not, okay? All right, let's start with your legs and then move up with the arms, okay? You can close your eyes. So you snap it and then put it on a bony part. Tell me when it stops. It stopped. It stopped? Okay, that's very good. Alright, let's do it on the other foot. Tell me when it stops. So usually if the patient has distal vibratory sensation preserved, the proximal sensation is usually preserved as well. But just for demonstration purposes, I'm going to show you how we perform it at the ankle and at the knee as well. Do you feel it? Yes. Tell me when it stops. Stop. Okay? Every minute stops. Okay, so similarly you can perform it at the knee. So like I said, typically if the distal vibratory sensation is preserved, there's really no absolute need to perform it at the ankle or the knees, but for demonstration purposes we're going to do it even in the upper extremities as well. Alright Kim, the same thing, do you feel it? Tell me when it stops. So similarly, you can go up to the elbow or shoulders, depending on what the patient is complaining about. Typically, we try to see if there is an asymmetry. If let's say one side is stopping in 10 seconds, the other side is at 20 or 30 seconds, there is an asymmetry that can also give some idea if one side is more affected than the other for polyneuropathy. The next exam that we are going to perform is a proprioception examination. Can you close your eyes and tell me if I'm moving your toe up or down. So the key is always to hold the toe from the side, so you're not actually holding from the top. And try to stabilize that distant joint, so the patient, and do a very little, minimal movement so the patient doesn't have big jerky movements that they can actually feel. Hello, I'm Dr. Kaur, so any questions for me? If anybody has any questions, I'm happy to answer for neurological examinations, specifically for a neuromuscular patient who comes into our clinic for evaluation. Okay, I don't think anybody has any questions, so you can certainly get my email or information to send any message to me from AANEM, and I'll be happy to answer any questions if anybody has any. Thank you so much for your time, Dr. Kaur, we really appreciate it. Sure, thank you. Thank you, and we'll see everybody next week. Have a enjoyable lunch, yes, and we'll see you next week for week five of six. Thank you. Bye, everyone.

Neuromuscular Exam

Sensory Modalities

Reflex Testing

Neuropathy

Sensory Neurological Examination