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Light touch is best tested with a cotton-tipped swab, but a light finger touch will
often suffice, as long as care is taken to make the stimulus fairly reproducible.
You can test the relative sharpness of pain by randomly alternating stimuli with
the sharp or dull end of a safety pin (always use a new pin for each patient).
70. Pin Prick
brainstem, the thalamus, or sensory cortex. Recall that position and vibration
sense ascend in the posterior column pathway and cross over in the medulla,
while pain and temperature sense cross over shortly after entering the spinal cord
and then ascend in the anterolateral pathway (see Neuroanatomy through
Clinical Cases, Figures 2.13, 2.18 and 2.19). Intact primary sensation with deficits
in cortical sensation such as agraphesthesia or astereognosis suggests a lesion in
the contralateral sensory cortex. Note, however, that severe cortical lesions can
cause deficits in primary sensation as well. Extinction with intact primary
sensation is a form of hemineglect that is most commonly associated with lesions
of the right parietal lobe. Extinction can also be seen in right frontal or
subcortical lesions, or sometimes in left hemisphere lesions causing mild right
hemineglect.
REFLEXES
The deep tendon reflexes and plantar response should be checked in all patients.
Certain other reflexes should also be tested in special situations, as mentioned in
the sections that follow.
Check the deep tendon reflexes using impulses from a reflex hammer to stretch
the muscle and tendon. The limbs should be in a relaxed and symmetric position,
since these factors can influence reflex amplitude. As in muscle strength testing,
it is important to compare each reflex immediately with its contralateral
counterpart so that any asymmetries can be detected. If you cannot elicit a reflex,
you can sometimes bring it out by certain reinforcement procedures. For
example, have the patient gently contract the muscle being tested by raising the
limb very slightly, or have them concentrate on forcefully contracting a different
muscle group just at the moment when the reflex is tested. When reflexes are very
brisk, clonus is sometimes seen. This is a repetitive vibratory contraction of the
muscle that occurs in response to muscle and tendon stretch. Deep tendon
reflexes are often rated according to the following scale:
0: absent reflex
2+: normal
3+: brisk
Deep tendon reflexes are normal if they are 1+, 2+, or 3+ unless they are
asymmetric or there is a dramatic difference between the arms and the legs.
Test the plantar response by scraping an object across the sole of the foot
beginning from the heel, moving forward toward the small toe, and then arcing
medially toward the big toe. The normal response is downward contraction of the
toes. The abnormal response, called Babinski's sign, is characterized by an
upgoing big toe and fanning outward of the other toes. In some patients the toes
are "silent," moving neither up nor down. If the toes are downgoing on one side
and silent on the other, the silent side is considered abnormal. The presence of
Babinski's sign is always abnormal in adults, but it is often present in infants, up
to the age of about 1 year.
59. Plantar Response
There is no precise hand equivalent for the plantar response, however, finger
flexor reflexes can help demonstrate hyperreflexia in the upper extremities. Test
finger flexors by tapping gently on the palm with the reflex hammer.
Alternatively, heightened reflexes can be demonstrated by the presence
of Hoffmann's sign. You can elicit this sign by holding the patient's middle finger
loosely and flicking the fingernail downward, causing the finger to rebound
slightly into extension. If the thumb flexes and adducts in response, Hoffmann's
sign is present.
60. Finger Flexors
usually able to compensate with the eyes open. When the patient closes their
eyes, however, visual input is removed and instability can be brought out. If there
is a more severe proprioceptive or vestibular lesion, or if there is a midline
cerebellar lesion causing truncal instability, the patient will be unable to maintain
this position even with their eyes open. Note that instability can also be seen with
lesions in other parts of the nervous system such as the upper or lower motor
neurons or the basal ganglia, so these should be tested for separately in other
parts of the exam.