Jospt 2022 11281

Does your bedside neurological examination for suspected
peripheral neuropathies measure up?
Cedric Bender1,2, BSc; Lucy Dove1,3, MSc, MCSP; Annina B Schmid1, PhD,
MManipTher, MMACP, MCSP
1 Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford,
OX39DU, United Kingdom

2 Zurich University of Applied Science, School of Health Professions, Institute of
Downloaded from www.jospt.org at on November 1, 2022. For personal use only. No other uses without permission.
Physiotherapy, Winterthur, Switzerland

3 Oxford University Hospitals NHS Trust, Oxford, United Kingdom
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Sources of grant support: This research was funded in whole, or in part, by the
Wellcome Trust [222101/Z/20/Z]. LD is supported by the NIHR Biomedical Research
Centre, based at Oxford University Hospitals Trust, Oxford. CB did not receive any
source of grant support for the development of this Viewpoint.

Journal of Orthopaedic & Sports Physical Therapy®
Ethical Approval: Exempt
Patient and Public involvement: There was no patient or public involvement in the
development of this Viewpoint.
Registration number: Exempt
Authors contributions: All authors contributed to the conception and design of the
work, drafted the work or revised it critically, and approved the final version to be
published.
Data sharing: There are no data in this manuscript.
1
Corresponding Author
Annina B Schmid
Nuffield Department of Clinical Neurosciences, Oxford University
John Radcliffe Hospital, West Wing Level 6
Headley Way
OX39DU Oxford
Telephone: +44(0)1865223254
E-mail: annina.schmid@neuro-research.ch
Link to videos:
https://www.dropbox.com/scl/fo/mihsp581vgrmm5wdollpi/h?dl=0&rlkey=gdu106qi582
02jvq68jb8h8zp
Word count: 1522
Financial disclosure: The authors declare no financial conflicts of interest.
Conflicts of interest: The authors declare no conflict of interest.

Acknowledgements: The authors would like to thank Joel Fundaun and Lucy
Ridgway for their feedback in the final stage of this manuscript. LD is supported by
the NIHR Biomedical Research Centre, based at Oxford University Hospitals Trust,
Oxford. A.B. Schmid is supported by a Wellcome Trust Clinical Career Development
Fellowship (222101/Z/20/Z) and the Medical Research Foundation (Emerging
Leaders Prize in Pain Research). Her research was supported by the National
Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC).
2
1 Abstract
3 Neurological testing is essential for screening and diagnosing suspected peripheral
4 neuropathies. Detecting changes in somatosensory and motor nerve function can also have
5 direct implications for management decisions. Nevertheless, there is considerable variation
6 in what is included in a bedside neurological examination, and how it is performed.
7 Neurological examinations are often used as screening tools to detect neurological deficits,
8 but not used to their full potential for monitoring progress or deterioration.
9 Here, we advocate for better use of the neurological examination within a clinical reasoning
10 framework. Constrained by the lack of research in this field, our viewpoint is based on
11 neuroscientific principles. We highlight six challenges for clinicians when conducting
12 neurological examinations, and propose ways to overcome these challenges in clinical
13 practice. We challenge widely held ideas about how the results of neurological examinations
14 for peripheral neuropathies are interpreted and how the examinations are performed in
15 practice.
16
17 Key words: Peripheral nerve injuries, peripheral neuropathy, neurological examination,

18 sensory testing, motor testing, reflex testing
19
3
20 Introduction
21
22 The bedside neurological examination is essential for diagnosing suspected peripheral
23 neuropathies (e.g., radiculopathy, carpal tunnel syndrome, diabetic neuropathy). The main
24 goal of a neurological examination in the context of suspected peripheral neuropathies is to
25 identify loss of action-potential conductivity. This manifests as hypoaesthesia, muscle
26 weakness or reduced reflexes (loss of function). Loss of function signs are hallmarks of
27 peripheral neuropathies. In contrast, gain of function (e.g., hyperalgesia) is not specific to
28 neuropathies, but is also common in musculoskeletal conditions (e.g., osteoarthritis, muscle
29 strain). Gain of function is not the main focus of peripheral neurological examinations do not
30 focus on gain of function.

31
32 Even though neurological examinations provide essential diagnostic information and have
33 direct implications for management decisions, there is substantial variation in what is
34 included in a neurological examination, and how it is performed.7 The dearth of evidence on
35 the most valid and reliable performance of a neurological examination prevents strict rules.
36
37 In this viewpoint, we use neuroscientific principles to offer suggestions for how clinicians can
38 improve how they perform and interpret the neurological examination within a clinical
39 reasoning framework. We highlight six common challenges and make recommendations on
40 how to overcome these in clinical practice. We focus on the peripheral nervous system
41 (sensation, muscle strength, reflexes), however clinicians should consider tests for
42 proprioception or the central nervous system as required.
43
44
45 Clinical challenge 1: Rethink your approach to dermatomal testing

46 Clinicians typically screen for sensory changes in a dermatomal pattern using key sensory
47 points of least dermatomal overlap optimized to detect nerve root involvement (FIGURE 1).
48 Although dermatomal point testing is fast, it has limitations. First, dermatomal maps vary,4
49 which can limit interpretation. Altered sensation proximal to the anterior knee is attributed to
4
50 L2, L3 or L4 nerve root depending on the dermatomal map used.4 Second, neuropathies
51 affecting distal nerve trunks (e.g., carpal tunnel syndrome, peroneal neuropathy) are more
52 common than nerve root disorders (e.g., radiculopathies). Innervation territories of peripheral
53 nerve trunks do not always coincide with dermatomal points (FIGURE 1) and clinicians may
54 miss them if they rely on dermatomal point testing.
55
56 Recommendation 1
57 Test somatosensation in a circumferential pattern instead of using point testing maps of
58 dermatomes and peripheral innervation territories. Based on innervation maps (but with the
59 caveat that validity studies are required), two circles around both the upper and lower
60 arms/legs followed by single-digit testing (palmar/plantar and dorsal) will cover most
61 dermatomes and peripheral innervation territories (VIDEO 1,2). If you identify changes, map
62 in more detail using star-shaped delineation of sensory changes (VIDEO 3). Use this
63 approach to help to differentiate dermatomal from peripheral innervation patterns.
64
65 Clinical challenge 2: Testing large and small nerve fibres

66 In patients with suspected peripheral neuropathies, neurological screening examinations
67 traditionally focus on light touch, muscle strength, and reflex testing. These tests provide
68 information about the function of large diameter nerve fibres. However, they do not evaluate
69 small Aδ -and C-fibres, which are commonly affected in peripheral neuropathies. Small fibre
70 involvement can be present even in the absence of large fibre deficits (e.g., small fibre
71 neuropathy).8 Solely relying on tests for large nerve fibre integrity is insufficient when
72 screening for suspected peripheral neuropathies.
73
74 Recommendation 2
75 Low-cost tools consisting of mechanical pain and thermal detection thresholds have been
76 suggested for a time-efficient evaluation of small fibre function (TABLE 1). The tools have
77 varying degrees of concurrent validity and inter-tester and intra-tester reliability across
5
78 different parameters. We recommend clinicians include circumferential pin-prick testing as
79 part of a standard neurological screening examination, followed by thermal testing in the
80 maximal pain area (e.g., with coins) if pin-prick testing is normal (VIDEO 1).
81 Clinical challenge 3: Challenges with contralateral comparison

82 Clinicians usually compare sensory and motor responses (muscle strength, reflexes) of the
83 affected side to contralateral asymptomatic sites to correct for normal variation in cutaneous
84 innervation and motor function along the extremities. Recent research using sensitive
85 laboratory equipment suggests that ipsilateral sensory changes seem to be mimicked on the
86 contralateral side, albeit to a lesser degree, even in patients with strictly unilateral
87 neuropathies.2 It remains unclear, whether these subtle contralateral changes can disguise
88 ipsilateral deficits in a clinical examination. But remember, many peripheral neuropathies are
89 bilateral (e.g., diabetic polyneuropathy, lumbar spinal stenosis, majority of carpal tunnel
90 syndrome) and may mask sensory and motor deficits upon contralateral comparison.
91 Bilateral changes can also occur even in healthy people: approximately 1 in 4 healthy adults
92 over the age of 60 have bilateral absence of ankle reflexes.10
93
94 Recommendation 3.
95 When interpreting changes in the presence of bilateral motor or sensory deficits, the
96 contralateral comparison is no longer useful nor sensible. For motor testing, evaluating other
97 muscle groups and reflexes may provide additional information (TABLE 2, Case 1). For
98 sensory testing, evaluating an adjacent (unaffected) proximal area (e.g., abdomen, chest,
99 proximal limb) may add information to help you interpret the results (TABLE 2, Case 2).
100
101 Clinical challenge 4: Things to consider for myotome testing

102 Motor assessment conventionally involves manual myotome testing of reference muscles
103 (VIDEO 3,4) which can be supplemented by functional assessment (e.g., heel (L4) or tiptoe
104 (S1) walking) and identification of atrophies. However, reference muscle testing alone will
105 not help you differentiate between nerve root or distal nerve trunk compromise. Further,
6
106 nerve roots supply a broad range of muscles which can also vary among patients.5 Muscle
107 testing may underestimate the severity of motor deficits, particularly in patients with relatively
108 well-preserved strength (M≥4/5).6 Importantly, manual muscle testing does not examine
109 neuromuscular fatigue, which is common in patients with peripheral neuropathies.9
110
111 Recommendation 4
112 To establish whether an identified weakness on myotome testing is consistent with a nerve
113 root or distal nerve trunk compromise, further testing is required. For example, a weakness
114 of the extensor pollicis longus could be caused by a C8 nerve root or radial nerve lesion. A
115 strategy to aid the clinical reasoning process is 1) testing of a radial nerve but not C8
116 innervated muscle (e.g., brachioradialis) and 2) testing a C8 but not radial nerve innervated
117 muscle (e.g., abductor digiti minimi) (VIDEO 4). When motor symptoms are more related to
118 fatigue than maximal strength, clinicians may consider assessing motor function following
119 physical exertion or using repeated testing9 (TABLE 2, Case 3). Results of myotome testing
120 have to be interpreted in the context of other findings.
121
122 Clinical challenge 5: Interpreting reflex findings

123 While reflex tests are essential to complement a clinical picture, there are a few things to
124 consider. First, the common tendon reflexes do not comprehensively cover all segmental
125 levels. Second, reflexes may not provide accurate information about the affected level: the
126 patellar tendon reflex is reduced in ~30% of patients with L5 radiculopathy.3
127
129 Reflexes are not susceptible to patients’ interpretation, and are not directly influenced by
130 pain—reflexes can therefore provide important objective information. Nevertheless, it is
131 important to interpret findings in the context of a complete neurological examination and a
132 sound clinical reasoning framework.
133
7
134 Clinical challenge 6: Monitoring progress: A call for quantification
135 Quantifying the extent of neurological deficits is not standard in clinical practice, even though
136 it is routine in other musculoskeletal examinations (e.g., shoulder range of motion). If you
137 don’t measure, it is impossible to monitor progress (or deterioration) over time.
138
140 Carefully measure neurological deficits to ensure you are objectively monitoring changes
141 over time. Quantifying the deficits can inform your treatment recommendations (e.g., referral
142 for surgical opinion for progressive neurological deficits in people with radiculopathy) and
143 can help patients maintain motivation (e.g. tracking the extent of neural regeneration over
144 time).
145
146 There are practical solutions to help clinicians quantify the extent of sensory deficits (TABLE
147 3): measure the intensity of sensory perception compared to a control area (TABLE 2, 4),
148 map the size of the area of sensory loss (TABLE 2, Case 5), or use specialist equipment
149 (TABLE 3).
150
151 Muscle strength is routinely graded on the 5-point British Medical Research Council Scale
152 (TABLE 3). While manual muscle testing is easily implemented, a hand-held dynamometer
153 allows for more objective quantification. Although, the validity of dynamometry in peripheral
154 neuropathies is unclear. In healthy people, dynamometry has a moderate to very high
155 correlation with isokinetic testing1 and is superior to manual muscle testing for detecting
156 minor between-side differences and changes over time.6 However, its reliability is influenced
157 by the test position or the strength of the examiner.1
158
159 For reflex testing, two scales can be used for quantifying the extent of reflex change (TABLE
160 3). To our knowledge, the validity or reliability of these reflex scales in patients with mono or
161 polyneuropathies is unknown.
8
162
163 Summary
164
165 We shared 6 recommendations based on neuroscientific principles to help clinicians improve
166 and interpret the results of a neurological examination. We suggested simple methods to
167 quantify neurological changes to monitor progress. Given the complexity of neurological
168 presentations, it is essential that clinicians adjust what they include in and how they perform
169 a neurological examination to suit each individual’s presentation. Interpret the results within
170 a sound clinical reasoning framework. When used in isolation, the diagnostic performance of
171 most tests is low to moderate.7 If used skillfully, the results of neurological examinations can
172 help clinicians provide an accurate diagnosis, monitor the patient’s progress and make
173 informed treatment decisions.
174
175 Key Points
176  Adjust and interpret the neurological screening examination in the context of a sound
177 clinical reasoning framework
178  Understanding the limitations of the neurological examination will improve how you
179 interpret the findings

180  Quantifying neurological deficits is possible and feasible with simple and low-cost
181 methods
182  Quantifying neurological deficits will help you monitor the patient’s progress
183
184
185
9
186 References.
187 1. Chamorro C, Armijo-Olivo S, De la Fuente C, Fuentes J, Javier Chirosa L.

188 Absolute Reliability and Concurrent Validity of Hand Held Dynamometry and
189 Isokinetic Dynamometry in the Hip, Knee and Ankle Joint: Systematic Review
190 and Meta-analysis. Open Med (Wars). 2017;12:359-375.
191 https://doi.org/10.1515/med-2017-0052
192
193 2. Enax-Krumova E, Attal N, Bouhassira D, et al. Contralateral Sensory and Pain
194 Perception Changes in Patients With Unilateral Neuropathy. Neurology.
195 2021;97:e389-e402.
196 https://doi.org/10.1212/WNL.0000000000012229
197
198 3. Ginanneschi F, Mondelli M, Piu P, Rossi A. Pathophysiology of knee jerk
199 reflex abnormalities in L5 root injury. Funct Neurol. 2015;30:187-191.
200 https://doi.org/10.11138/fneur/2015.30.3.187
201
202 4. Lee MW, McPhee RW, Stringer MD. An evidence-based approach to human
dermatomes. Clin Anat. 2008;21:363-373.
203
204 https://doi.org/10.1002/ca.20636
205
206 5. London D, Birkenfeld B, Thomas J, et al. A broad and variable lumbosacral
207 myotome map uncovered by foraminal nerve root stimulation. J Neurosurg
208 Spine. 2022;1-7.

209 https://doi.org/10.3171/2022.3.SPINE2212
210
211 6. Schwartz S, Cohen ME, Herbison GJ, Shah A. Relationship between two
212 measures of upper extremity strength: manual muscle test compared to hand-
213 held myometry. Arch Phys Med Rehabil. 1992;73:1063-1068.
214
215 7. Tawa N, Rhoda A, Diener I. Accuracy of clinical neurological examination in
216 diagnosing lumbo-sacral radiculopathy: a systematic literature review. BMC

217 Musculoskelet Disord. 2017;18:93.
218 https://doi.org/10.1186/s12891-016-1383-2
219
220 8. Terkelsen AJ, Karlsson P, Lauria G, Freeman R, Finnerup NB, Jensen TS.
221 The diagnostic challenge of small fibre neuropathy: clinical presentations,
222 evaluations, and causes. Lancet Neurol. 2017;16:934-944.
223 https://doi.org/10.1016/S1474-4422(17)30329-0
224
225 9. Tsur A, Glass I, Solzi P. Exhausting fatigue influences F-wave and peripheral
226 conduction velocity, following lumbar radiculopathy. Disability and
227 rehabilitation. 2002;24:647-653.
228 https://doi.org/10.1080/09638280210125805
229
230 10. Vrancken AF, Kalmijn S, Brugman F, Rinkel GJ, Notermans NC. The meaning
231 of distal sensory loss and absent ankle reflexes in relation to age: a meta-
232 analysis. J Neurol. 2006;253:578-589.
233 https://doi.org/10.1007/s00415-005-0064-0
234
10
11
2 FIGURE 1. (A) Anterior and posterior body view of the innervation territories of peripheral nerve trunks. The red dots represent the key sensory
3 examination points suggested for dermatomal testing in the extremities (Petty & Ryder). Not all peripheral innervation territories are covered by a
4 dermatomal point. For instance, sensory changes in the territories of the musculocutaneous and the tibial nerve (e.g., tarsal tunnel syndrome) may
5 be missed by using dermatomal point testing. (B) Anterior and posterior body view displaying the innervation territories of peripheral nerve trunks
6 and their corresponding names. Figure adapted from Glynn & Drake (Glynn & Drake).
7
8 Reference can be found in the APPENDIX.

9
12
1 TABLE 1, Low-cost bedside tools to evaluate small fibre loss of function.
2
Clinical test Concurrent validity of clinical tests Reliability
compared to semi-objective tests (i.e.,
quantitative sensory testing)
Thermal detection threshold Agreement Correlation coefficient Inter-tester and
(Zhu et al) Rho (Reimer et al) intra-tester mean
kappa (Reimer et al.;
Wusan et al)
Cold coin: Cold coin: Cold coin:

46.1%-77.5% 0.54-0.61 0.50 (inter-tester)
Warm coin: Warm coin: Warm coin:
53.9%-80.0% 0.19-0.46 0.51 (inter-tester)
Tip Therm
Mechanical pain
threshold
Toothpick:
52.6% -84.6%
Pin-prick 40g:
0.63 (inter-tester)
0.55 (intra-teser)
Monofilament Monofilament 75g: Monofilament 75g

256mN: 0.38-0.39 0.16 (inter-tester)
50.0%-96.2%
4 Pictures courtesy of Dr Liam Peck and Dr Guan Cheng Zhu. References can be found in the
5 APPENDIX.
6
13
8 TABLE 2, Examples of the application of the neurological examination for screening
9 and monitoring progress within a clinical reasoning framework
10
Case scenario Clinical reasoning
Case A 70 year old patient with unilateral calf and Absence of reflexes could indicate
1 foot pain where you want to exclude neurological involvement. However, ~35%
potential neurological contribution. Upon of patients over the age of 60 can have
neurological examination, sensation and absent reflexes. Testing other reflexes, e.g.,
muscle strength are preserved. There is a patellar, upper limb reflexes and using
clear absence of Achilles tendon reflexes facilitatory manoeuvres (e.g., Jendrassik)
bilaterally. may provide more information about
general reflexia. When interpreting the
reflex changes, consider other findings.
Absence of bilateral reflexes in the absence
of other neurological signs reduces your
suspicion of a neurological component.
Case A patient with bilateral distal leg pain and As bilateral symptoms are present, consider
2 tingling, which you suspect are due to which body part to use as a reference area.
lumbar spinal stenosis. In planning your Evaluating the abdomen or proximal leg as a
objective assessment, you want to perform reference area for sensory testing might help
a neurological examination to screen for you interpret the neurological examination.

potential neurological deficits.
Case After acute onset of radicular leg pain 4 Despite improvement in radicular pain,
3 weeks ago, the patient now reports almost fatigue could indicate a new onset of nerve-
complete pain relief. They mention that their related motor involvement (i.e., development
leg feels fatigued at the end of the day and of radiculopathy). It is important to re-test
that they have caught their foot going up motor function even if it was preserved
stairs or a kerb a few times. initially and pain improved. An examination
of fatigue (e.g. maximum time of heel
walking, heel walk, dynamometry or reflex
testing after running/walking) could help you
determine the presence and extent of motor
deficits and guide your decisions on further
management.
Case A patient with cervical radiculopathy, which As numbness is one of their main concerns,
4 started 2 months ago presents to your carefully quantifying sensory function (e.g.,
clinic. While their hand and arm pain slowly weighted monofilaments, thermal tests,
decreases, they report numbness in their neurotip) can help you determine the
thumb and index finger, which is magnitude of the sensory deficit. Regularly
increasingly bothersome. They are worried reassessing (e.g., every month as structural
that the numbness will never get better. nerve regeneration takes time) will help you
decide whether the sensory loss remains
unchanged or gradually improves. Often
patients are unaware of improvements in
sensory deficits as changes are slow.
Quantification may help to reassure the
patient and act as a motivational tool.
Case A patient attends your clinic three months Given the time since reconstruction and
5 after traumatic median nerve injury with expected regeneration times, a decrease in
subsequent median nerve reconstruction in the area of sensory loss would be expected
the wrist. You map out the area of thermal at 3 months with good recovery. No change
and mechanical sensory loss in the hand in the area of sensory loss suggests limited
and notice that the size of the area did not nerve regeneration capacity and should be
change since your first assessment one discussed with the patient and their clinical
week after nerve reconstruction. care team (e.g., surgeons).
11
12
14
13 TABLE 3, Methods to quantify different parameters of the bedside neurological
14 examination.
15
Parameter Tool Quantification methods
A. Somatosensation
Low-cost
bedside
equipment:
Light touch Cotton wool  Quantification of the intensity of the perception on a scale
from -10 to +10, where 0 is defined as the intensity of the
control area (i.e., <0 = reduced intensity; >0 = increased
Cold /warm TipTherm, cold intensity).
and warm coins
 Mapping of the area of sensory deficit. This might be
Toothpick, particularly useful to monitor somatosensory changes after
Pin-prick neurotip traumatic nerve injuries or in length-dependent neuropathies
where changes to the areal extent of sensory loss are
expected with recovery/progression.
Specialised
equipment:
Light touch Weighted  Monofilaments are calibrated hairs of differing strengths. Using
monofilaments ascending and descending strengths of hairs, the mechanical
(weight in detection threshold can be recorded (e.g., lowest weight of
grams or hair that can be perceived, recorded as a mean of 3
milliNewton) repetitions).
Cold/warm Thermotester  This method integrates specialised equipment that allows

(Celsius) gradual changes in temperature to determine the thermal
detection thresholds (e.g., minimal temperature change
perceived recorded as a mean of 3 repetitions ).
Pin-prick Weighted pin-  Weighted pin-pricks can be applied in an ascending and

prick descending order to determine the mechanical pain threshold
stimulators (e.g., minimal weight of pin-prick stimulator that can be
(weight in perceived as sharp, recorded as a mean of 3 repetitions).

grams or
thickness in
mm)
Vibration Graduated  The graduated tuning fork (Rydel Seiffer) quantifies vibration
tuning fork through the smallest detectable amplitude (e.g., recorded as
(Amplitude on a x/8 from an average of 3 repetitions)
scale x/8)
B. Muscle function
Muscle 5-point British  This method involves grading muscle strength on a 0 to 5
strength Medical scale (0 no contraction, 1 flicker or trace of contraction; 2
Research active movement, with gravity eliminated; 3 active movement
Council Scale against gravity; 4. active movement against gravity and
resistance; 5 normal power).
Dynamometer  The use of a hand-held dynamometer allows for quantification

(muscle of force through isometric muscle testing.
strength or
force in kg or
Newton)
Functional tests  Body weight and the maximum number of repetitions could be
used to quantify performance. One example is the heel-raise
15
Muscle test, whereby the maximum number of unilateral heel raises is
fatigue compared between sides. Muscle strength testing following
exertion may also provide information about muscle fatigue.
C. Reflexes
Deep tendon Reflex hammer,  Reflex absent (0); reflex slight, less than normal: includes a
reflexes National trace response or a response brought out only by
Institute of reinforcement (+1); reflex in lower half of normal range (+2);
Neurological reflex in upper half of normal range (+3); reflex enhanced,
Disorders and more than normal: includes a clonus if present which
Stroke Scale optionally can be noted in an added verbal description of the
(NINDS) reflex (+4).
(Hallett et al)
Mayo clinical  Absent (-4); just elicitable (-3); low (-2); moderately low (-1);
reflex scale normal (0); brisk (+1); very brisk (+2); exhaustible clonus (+3);
(Bastron et al) continuous clonus (+4).
16
17 References can be found in the APPENDIX.
18
19
16
20 Appendix
21 Reference for Figure 1
22 Glynn M, Drake WM. Hutchinson’s Clinical Methods: An integrated Approach to Clinical

23 Practice. 24th. Elsevier; 2017.
24
25 Petty N, Ryder D. Musculoskeletal Examination and Assessment. A handbook for therapists.
26 5th. Elsevier; 2018
27
28 References for Table 1
29 Reimer M, Forstenpointner J, Hartmann A, et al. Sensory bedside testing: a simple

30 stratification approach for sensory phenotyping. Pain Rep.
31 2020;5:e820.https://doi.org/10.1097/PR9.0000000000000820
32
33 Wasan AD, Alter BJ, Edwards RR, et al. Test-Retest and Inter-Examiner Reliability of a
34 Novel Bedside Quantitative Sensory Testing Battery in Postherpetic Neuralgia Patients. J
35 Pain. 2020;21:858-868. https://doi.org/10.1016/j.jpain.2019.11.013
36
37 Zhu GC, Böttger K, Slater H, et al. Concurrent validity of a low-cost and time-efficient clinical
38 sensory test battery to evaluate somatosensory dysfunction. European Journal of Pain.
39 2019;23:1826-1838. https://doi.org/10.1002/ejp.1456
40
41 References for Table 2
42 Bastron JA, Bickford RG, Brown JR, et al. Clinical examination in neurology. Mayo Clinic
43 Staff. 1956:188
44
45 Hallett M. NINDS myotatic reflex scale. Neurology. 1993;43:2723.
46
17

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Does your bedside neurological examination for suspected

peripheral neuropathies measure up?

MManipTher, MMACP, MCSP

1 Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford,

OX39DU, United Kingdom

Physiotherapy, Winterthur, Switzerland

Wellcome Trust [222101/Z/20/Z]. LD is supported by the NIHR Biomedical Research

source of grant support for the development of this Viewpoint.

Ethical Approval: Exempt

development of this Viewpoint.

Registration number: Exempt

Data sharing: There are no data in this manuscript.

Nuffield Department of Clinical Neurosciences, Oxford University

John Radcliffe Hospital, West Wing Level 6

Word count: 1522

Financial disclosure: The authors declare no financial conflicts of interest.

Conflicts of interest: The authors declare no conflict of interest.

Oxford. A.B. Schmid is supported by a Wellcome Trust Clinical Career Development

Fellowship (222101/Z/20/Z) and the Medical Research Foundation (Emerging

3 Neurological testing is essential for screening and diagnosing suspected peripheral

5 direct implications for management decisions. Nevertheless, there is considerable variation

6 in what is included in a bedside neurological examination, and how it is performed.

11 neuroscientific principles. We highlight six challenges for clinicians when conducting

12 neurological examinations, and propose ways to overcome these challenges in clinical

17 Key words: Peripheral nerve injuries, peripheral neuropathy, neurological examination,

18 sensory testing, motor testing, reflex testing

24 goal of a neurological examination in the context of suspected peripheral neuropathies is to

25 identify loss of action-potential conductivity. This manifests as hypoaesthesia, muscle

27 peripheral neuropathies. In contrast, gain of function (e.g., hyperalgesia) is not specific to

28 neuropathies, but is also common in musculoskeletal conditions (e.g., osteoarthritis, muscle

30 focus on gain of function.

33 direct implications for management decisions, there is substantial variation in what is

34 included in a neurological examination, and how it is performed.7 The dearth of evidence on

39 reasoning framework. We highlight six common challenges and make recommendations on

42 proprioception or the central nervous system as required.

45 Clinical challenge 1: Rethink your approach to dermatomal testing

54 miss them if they rely on dermatomal point testing.

57 Test somatosensation in a circumferential pattern instead of using point testing maps of

63 approach to help to differentiate dermatomal from peripheral innervation patterns.

65 Clinical challenge 2: Testing large and small nerve fibres

72 screening for suspected peripheral neuropathies.

79 part of a standard neurological screening examination, followed by thermal testing in the

81 Clinical challenge 3: Challenges with contralateral comparison

92 over the age of 60 have bilateral absence of ankle reflexes.10

101 Clinical challenge 4: Things to consider for myotome testing

109 neuromuscular fatigue, which is common in patients with peripheral neuropathies.9

120 have to be interpreted in the context of other findings.

122 Clinical challenge 5: Interpreting reflex findings

126 patellar tendon reflex is reduced in ~30% of patients with L5 radiculopathy.3

130 pain—reflexes can therefore provide important objective information. Nevertheless, it is

132 sound clinical reasoning framework.

149 (TABLE 3).

157 by the test position or the strength of the examiner.1

161 polyneuropathies is unknown.

165 We shared 6 recommendations based on neuroscientific principles to help clinicians improve

173 informed treatment decisions.

175 Key Points

177 clinical reasoning framework

179 interpret the findings

187 1. Chamorro C, Armijo-Olivo S, De la Fuente C, Fuentes J, Javier Chirosa L.

208 Spine. 2022;1-7.

216 diagnosing lumbo-sacral radiculopathy: a systematic literature review. BMC

8 Reference can be found in the APPENDIX.