Examinations
CPSA · Clinical examination · Neurological
Upper limb neurological examination
Inspection → tone → power → reflexes → sensation → coordination. The distribution of weakness (pyramidal, root, nerve) plus the reflex/tone pattern separates UMN from LMN.
Practise it out loudPosition: Patient seated, arms exposed.
The routine
Inspection
- 1Wasting, fasciculations, tremor, posture (pronator drift), scars
Tone
- 1Assess at wrist and elbow — spasticity (UMN), rigidity, or flaccidity (LMN)
Power
- 1Test shoulder abduction (C5), elbow flexion (C5/6)/extension (C7), wrist ext (C6/7), finger ext (C7), finger abduction (T1), grade MRC 0–5
Reflexes
- 1Biceps (C5/6), supinator (C6), triceps (C7) — brisk (UMN) or absent/reduced (LMN)
Sensation
- 1Light touch, pinprick, vibration, proprioception — map by dermatome/nerve territory
Coordination
- 1Finger-to-nose (past-pointing/intention tremor), dysdiadochokinesia
Signs & what they mean
Increased tone, brisk reflexes, pronator drift, pyramidal weaknessUpper motor neurone lesion
Wasting, fasciculations, reduced tone, absent reflexesLower motor neurone lesion
Wasting + fasciculations AND brisk reflexes (mixed UMN/LMN)Motor neurone disease
Loss of pain/temperature with preserved proprioceptionSpinothalamic (anterolateral) lesion
To complete, I would…
- Examine the lower limbs, cranial nerves and cerebellar function
- Assess the neck and consider imaging
OSCE tips
- Pronator drift is a sensitive early sign of a pyramidal (UMN) lesion.
- Fasciculations + brisk reflexes together should make you think MND.
- Grade power with the MRC scale (0–5), not vague terms.