Neuro Exam Pearls: Upper limb

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I don’t know about you, but I’ve always wanted to be able to perform a neurological exam and pick the lesion and look good doing it. Over the years I’ve tried to get better at it. What I have put together is a series of ‘PEARLS’ that sometimes help me decipher the cryptic world of Neurology. Here are a few.

1  ARM DRIFT

When holding the arms outwards, with palms upwards, three types of drift may occur:

  1. The Pyramidal Drift (Pronator Drift)
  2. The Cerebellar Drift
  3. The Parietal Drift

PRONATOR DRIFT (Barre’s Sign)

If you can perform only one test of upper limb motor function, this is the test to do. It can pick up subtle changes that would not be picked up by a routine motor examination.

HOW TO PERFORM IT.

Ask the patient to extend both arms in front of them at shoulder height with palms facing upwards, as if they were carrying a tray. They first do this with eyes open for 10 seconds and then they hold the position and close their eyes and count to 10.

A Normal Response will result in either no movement, or a slight pronation of both sides ie., symmetrical.

This should be done with eyes open and closed as this test may be positive in both motor weakness and proprioceptive involvement.(1)


Eyes Open
: If there is an upper motor neuron(UMN) lesion, the affected arm will pronate and drop. This occurs because in an UMN lesion that is not resulting in upper limb flaccid paralysis, may minimally affect the corticospinal tracts(CST). If these are  affected, those muscles such as the flexors and pronators that are unaffected will overpower the weaker muscles ie.,  supination is weaker than pronation.

Eyes Closed: If the Pronator Drift is positive with eyes closed but not when the eyes are open there may be proprioceptive involvement ie., posterior columns.

CEREBELLAR DRIFT

In cerebellar disease the arm may drift up and outwards(usually towards the side of the lesion), or may drift aimlessly.  A further test is overcorrection ie., give the palm or the arm a tap and it will overcorrect, never going back to its original position.

If there is a suspicion of cerebellar disease, move onto the rest of the cerebellar examination which will include:

  • Speech
  • Nystagmus
  • Past Pointing(finger nose)
  • Dysdiadochokinesia(rapid alternating movements)
  • Rebound
  • Heel-Shin
  • Pendular reflexes
  • Gait

Another form of the rebound test, other than tapping on the arm and seeing if it corrects appropriately, is to ask the patient to push or pull against you with their arm. You hold a constant amount of force against the limb, then suddenly let go(being careful not to injure the patient or yourself). Usually the antagonist muscles will stop the limb after a short movement. In cerebellar disease, the rebound phenomenon is absent and the arm will continue to move, hitting either you or the patient.

PARIETAL DRIFT

Upward and outward drift is specific for a contralateral parietal lesion. The parietal lobe is responsible for joint position sense and two point discrimination. When perfoming this test on someone with a parietal lesion, they cannot discern the position of their limb in space, with the result usually being an upward drift.(2)

CONVERSION DISORDER

Downward drift of the arm without pronation, is usually the result of functional paresis. Conversion Disorder is a Psychiatric Disorder and the finding of ‘Pronation without Drift’ appears to be very sensitive and specific for this(3).

2  UPWARD THUMB SIGN

In this test the patient is asked to hold their arms outstretched on their laps, with palms facing each other and thumbs resting on the index finger. They are then asked to raise them upwards quickly to shoulder level. Those with involvement of the corticospinal tracts have an upping thumb(4).

It has been found to be a sensitive and reliable marker of UMN disease(5).

 

References

  1. Today I et al. Pronation Test: eyes closed or open? Eur Neurol. 2007;58(2):65-9.
  2. Raju S A et al. Distinguishing Motor Weakness from Impaired Spatial Awareness: A Helping Hand! Clin Med Insights Case Rep. 2017; 10
  3. Daum C et al. Validity of the “Drift without pronation” sign in conversion disorder. BMC Neurol. 2013; 13: 31.
  4. Hachinski V. The Upping Thumb Sign. Letters to the Editor. Arch Neurol. 1992;49(4):346.
  5. Hachinski V et al. Upping Thumb Sign. A sensitive indicator for brain involvement? Neurology. 2017 Jul 25;89(4):370-375

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

55 Comments

  1. John P Woodall on 10/08/2020 at 9:06 am

    G’day Peter,

    Thanks for your succinct and clear summary of Pronator Drift. Refreshing to see clinical engagement of examination and clinical reasoning before CT.

    • Dr Peter Kas on 07/11/2020 at 5:32 pm

      Thanks John
      I especially like these when, the pronator drift does not fit the clinical picture ie., there’s no pronation. Then the full Neuro exam gets pulled out.

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  10. Melissa B on 16/09/2021 at 3:12 pm

    I want to share a message that has been spreading all over the internet that concerns the times we are living in. Whether you believe in God or not, this is a must read message!

    We can see throughout time how we have been slowly conditioned to come to this point where we are on the verge of a cashless society. Would it surprise you to know that the Bible foretold of this event? Don’t believe me? This may be the most imporant message you will read in these times…please do not ignore this!

    This messsage reveals what the Mark of the Beast is, and the meaning behind counting a number people have been pondering for centuries, 666. This message also shares why Barack Obama is the Antichrist. This is truly a message from God!

    In the Revelation of Jesus Christ given to the apostle John, we read:

    “He (the false prophet who deceives many by his miracles) causes all, both small and great, rich and poor, free and slave, to receive a mark on their right hand or on their foreheads, and that no one may buy or sell except one who has the mark or the name of the beast, or the number of his name.

    Here is wisdom. Let him who has understanding calculate the number of the beast, for it is the number of a man: His number is 666” (Revelation 13:16-18 NKJV).

    Referring to the last generation, this could only be speaking of a cashless society. Why? Revelation 13:17 tells us that we cannot buy or sell unless we receive the mark of the beast. If physical money was still in use, we could buy or sell with one another without receiving the mark. This would contradict scripture that says we must have the mark to buy or sell. So, it deduces itself to this conclusion.

    These verses could not be referring to something spiritual as scripture references two physical locations (our right-hand or forehead) stating the mark will be on one “OR” the other. It once again deduces itself to this conclusion.

    Also, how could you determine who truly has a spiritual mark so that they may buy or sell? And, as you will read further in this article, to have the mark of the beast is the same to have the name of the beast, or the number of its name. You will begin to see even more clearly why this mark cannot be something purely spiritual.

    Here is where it really starts to come together. It is shocking how accurate the Bible is concerning the RFID microchip. These are notes from a man named Carl Sanders who worked with a team of engineers to help develop this microchip in the late 1960’s.

    “Carl Sanders sat in seventeen New World Order meetings with heads-of-state officials such as Henry Kissinger and Bob Gates of the C.I.A. to discuss plans on how to bring about a one-world system. The government commissioned Carl Sanders to design a microchip for identifying and controlling the peoples of the world—a microchip that could be inserted under the skin with a hypodermic needle (a quick, convenient method that would be gradually accepted by society).

    Carl Sanders, with a team of engineers behind him, with U.S. grant monies supplied by tax dollars, took on this project and designed a microchip that is powered by a lithium battery, rechargeable through the temperature changes in our skin. Without the knowledge of the Bible (Brother Sanders was not a Christian at the time), these engineers spent one-and-a-half-million dollars doing research on the best and most convenient place to have the microchip inserted.

    Guess what? These researchers found that the forehead and the back of the hand (the two places Revelation says the mark will go) are not just the most convenient places, but are also the only viable places for rapid, consistent temperature changes in the skin to recharge the lithium battery. The microchip is approximately seven millimeters in length, .75 millimeters in diameter, about the size of a grain of rice. It is capable of storing pages upon pages of information about you. All your general history, work history, crime record, health history, and financial data can be stored on this chip.

    Brother Sanders believes that this microchip, which he regretfully helped design, is the “mark” spoken about in Revelation 13:16-18. The original Greek word for “mark” is “charagma,” which means a “scratch or etching.” It is also interesting to note that the number 666 is actually a word in the original Greek. The word is “chi xi stigma,” with the last part, “stigma,” also meaning “to stick or prick.” Carl believes this refers to a hypodermic needle (see photo).

    Mr. Sanders asked a Boston Medical Center doctor what would happen if the lithium contained within the RFID microchip leaked into the body. The doctor responded that if the microchip broke inside a human body, the lithium would cause a severe and painful wound filled with pus. This is what the book of Revelation says:

    “And the first (angel) went, and poured out his vial on the earth; and there fell a noisome and grievous sore on the men which had the mark of the beast, and on them which worshipped his image” (Revelation 16:2).

    THE HIDDEN MEANING BEHIND THE NUMBER 666 REVEALED!

    What I first want to mention, before I share what the Holy Spirit has revealed to me concerning the number of the beast, is that God confirms in threes. We can see this throughout scripture:

    “For there are three that bear witness in heaven: the Father, the Word, and the Holy Spirit; and these three are one” (1 John 5:7 NKJV).

    “and that He was buried, and that He rose again the third day according to the Scriptures” (1 Corinthians 15:4 NKJV).

    “…Holy, holy, holy, Lord God Almighty, Who was and is and is to come!” (Revelation 4:8 NKJV).

    There are many more examples, but I thought I would just share three of them to make the point.

    Examining Revelation 13:16,17,18, the first group of three I would like to point out is that the mark of the beast is described in three separate verses, 16, 17 and 18.

    The next three I see is in verse 16, “He causes all…” is followed by three contrasting categories of people,

    1 – “both small and great,
    2 – rich and poor,
    3 – free and slave…”.

    Then unto verse 17, it opens with, “and that no one may buy or sell except one who has…”, followed by three explanations of what one must have to buy or sell,

    1 – “…the mark
    2 – or the name of the beast,
    3 – or the number of his name”.

    Now unto verse 18, we read “Let him who has understanding calculate…”, which is followed by,

    1 – “the number of the beast,
    2 – for it is the number of a man:
    3 – His number is 666”.

    The last three I see is the number “6” being used three times in a row. The reason I’m making this point about God confirming in three is because it is the key to unlocking how to calculate the number 666.

    Throughout the centuries there have been people trying to calculate numbers based on titles and names that come up to the number 666 to identify one person, the Antichrist; but from Revelation 13:18, I do not see where God is telling us to count up to 666, but rather to count the number of the beast. This number is identified as 666. So the verse is telling us to count the number 666.

    What does it mean to count? It means to add up. So how could we add up 666? Remember my previous point about God confirming in threes is key to unlocking the number 666. So logically, what would be the best way to count the number 666? To count it equally by using the rule of three based off the number.

    We cannot count it equally as 600+60+6, this would also bring us back to the start.

    We cannot count it as 600+600+600, or 60+60+60 because there are no zeroes in between or at the end of 666.

    The only logical option is 6+6+6=18.

    What is interesting is that the verse that reveals for us to count the number itself is verse 18 (there a total of 18 verses in Revelation Chapter 13), being the third verse out of the three verses that describe the mark of the beast in Revelation 13:16,17,18. What is 18 divided by 3? 6. So 3×6=18, or 6+6+6=18.

    Another interesting point is the only two other combinations (making a total of three possible combinations) for placing a “+” symbol in between 666 are:

    66+6=72 and 6+66=72.

    Add both 72’s together and you get 144.

    Why the number 144 is worth our attention is because the verse following Revelation 13:18 is the first time in the Bible where the 144,000 are being described in detail:

    “Then I looked, and behold, a Lamb standing on Mount Zion, and with Him one hundred and forty-four thousand, having His Father’s name written on their foreheads…” (Revelation 14:1).

    Now if you add up all three numbers from counting 666 by moving the “+” symbol around, it would be 72+72+18=162. What is compelling about the number 162, is, if you divide 144,000 by 162, you get 888. The name of Jesus in Greek gematria adds up to 888. The New Testament was originally written in the Greek language. Revelation 14:1 not only mentions the 144,000, but also the Lamb who is Jesus.

    Now what is interesting about the number for Jesus, 888, is that if you apply the same formula that was used to count 666, you get 8+8+8=24. Why the number 24? Revelation chapter 4 tells us there are 24 elders seated around the throne of God. This is the same throne where Jesus sits.

    Now if you take:

    8+8+8=24

    8+88=96

    88+8=96

    you get 24+96+96=216.

    Take 144,000 divided by 216 and you get 666.

    Remember that this was the same exact formula we used to count the number 666 that ultimately brought forth the number 888.

    Here is a quick recap to demonstrate how this formula confirms itself as being the true way to count 666:

    1: 6+6+6=18 > 66+6=72 > 6+66=72 > 18+72+72=162

    2: 144,000 divided by 162=888

    3: 8+8+8=24 > 88+8=96 > 8+88=96 > 24+96+96=216

    4: 144,000 divided by 216=666

    1: 6+6+6=18 > 66+6=72…

    As you can see, it is perpetual. And remember that we consistently used a formula that worked in threes being the number that God uses for confirmation.

    So what could this mean? Well we know in this world we are identified by numbers in various forms. From our birth certificate to social security, as well as our drivers license; being identified based on a system of ruler ship. So it is possible that this RFID microchip will contain a new identification that has a total of 18 characters (6+6+6).

    “here the wisdom is, the one having the mind let him calculate the number of the wild beast, number for “of human” it is, and the number of it 666″ (Revelation 13:1, Greek Translation).

    The Greek word “anthrōpos” being used in verse 18 where it says “of human” is the Greek strongs concordance G444. The first two definitions of the word are “a human being, whether male or female”, and, “generically, to include all human individuals”. Could the number of the beast apply to all mankind?

    In the Greek (the New Testament was originally written in the Greek language), and other translations, you will notice the beast is described as an “it”, instead of “him”. The reason I’m making this point is because when a translation says “His number is 666”, this would imply a singular person, the Antichrist. But by saying “the number of it 666”, implies that it is of the beast system as a whole.

    We can know the number of the beast cannot be to identify products (like a new barcode) to buy or sell because scripture says we cannot buy or sell without the number of the beast. What am I getting at? There will be instances where you could buy something someone made themselves and it wouldn’t have a store branded identification on it. But for this number to be in our chips, that is where it must be to conclude ultimately that we cannot buy or sell without having the number of the beast. As previously mentioned in Revelation 13:18, the number of the beast (6+6+6=18) is a “human number”, definition “generically, to include all human individuals”.

    “Why did the Biden campaign choose 30330? 2020 divided by 666 = 3.0330 Who believes this to be a coincidence? October 2020 Isaiah 53:6 Someone said we are being whipsawed in 2020. Truly a great division is taking place between good and evil—both symbolically and literally (riots, unrest, politics). If you take the current year 2020 and divide it by the number 666 (known for its satanic implications) you will get the number 30330 (repeated). This number 30330 happens to be the number used to vote for Joe Biden and Kamala Harris. Freaky? Supernatural? Odd for sure. Whatever this means, it doesn’t seem good to me. First, why would anyone knowingly choose those particular numbers for their campaign? If they weren’t knowingly chosen, then it appears to be a supernatural act by the evil one himself and I would want to change those numbers ASAP. And if the numbers were chosen knowing their significance, are you satanic? Is this campaign satanic? Either way I do not believe this is a coincidence. And one thing is certain, 2020 is truly being divided by Satan. He is the master deceiver and spreader of chaos. Jesus calls him the father of lies.”

    So I looked up this number 30330 concerning Joe Biden, and I found this information:

    If you send a text to that number (at that time), you would get a response asking to support Joe’s campaign to take down Donald Trump, with one part in caps saying “CHIP IN >>” pointing to a link to go and donate.

    “CHIP IN”? Obama has used this phrase in the past on his twitter and people believe it is a subliminal message to receive the mark of the beast, that is to say the implantable RFID microCHIP that will go IN our body.

    Go to: http://voice-truth.org to see all the proof!

    Is your name written in the Lamb’s book of life? Jesus says that we must be born again to enter the kingdom of God in the Gospel of John chapter 3.

    “Then a third angel followed them, saying with a loud voice, “If anyone worships the beast and his image, and receives his mark on his forehead or on his hand, he himself shall also drink of the wine of the wrath of God, which is poured out full strength into the cup of His indignation. He shall be tormented with fire and brimstone in the presence of the holy angels and in the presence of the Lamb. And the smoke of their torment ascends forever and ever; and they have no rest day or night, who worship the beast and his image, and whoever receives the mark of his name” (Revelation 14:9-11).

    BARACK OBAMA IS THE ANTICHRIST:

    In the Islamic religion they have man called the Mahdi who is known as their messiah of whom they are waiting to take the stage. There are many testimonies from people online who believe this man will be Barack Obama who is to be the biblical Antichrist based off dreams they have received. I myself have had strange dreams about him like no other person. So much so that I decided to share this information.

    He came on stage claiming to be a Christian with no affiliation to the Muslim faith…

    “In our lives, Michelle and I have been strengthened by our Christian faith. But there have been times where my faith has been questioned — by people who don’t know me — or they’ve said that I adhere to a different religion, as if that were somehow a bad thing,” – Barack Obama

    …but was later revealed by his own family members that he indeed is a devout Muslim.

    So what’s in the name? The meaning of someones name can say a lot about a person. God throughout history has given names to people that have a specific meaning tied to their lives. How about the name Barack Obama? Let us take a look at what may be hiding beneath the surface…

    “And He (Jesus) said to them (His disciples), ‘I saw Satan fall like lightning from heaven'” (Luke 10:18).

    In the Hebrew language we can uncover the meaning behind the name Barack Obama.

    Barack, also transliterated as Baraq, in Hebrew is: lightning

    baraq – Biblical definition:

    From Strongs H1299; lightning; by analogy a gleam; concretely a flashing sword: – bright, glitter (-ing, sword), lightning. (Strongs Hebrew word H1300 baraq baw-rawk’)

    Barak ‘O’bamah, The use of bamah is used to refer to the “heights” of Heaven.

    bamah – Biblical definition:

    From an unused root (meaning to be high); an elevation: – height, high place, wave. (Strongs Hebrew word H1116 bamah baw-maw’)

    The day following the election of Barack Obama (11/04/08), the winning pick 3 lotto numbers in Illinois (Obama’s home state) for 11/5/08 were 666.

    Obama was a U.S. senator for Illinois, and his zip code was 60606.

    The names of both of Obama’s daughters are Malia and Natasha. If we were to write those names backwards we would get “ailam ahsatan”. Now if we remove the letters that spell “Alah” (Allah being the God of Islam), we get “I am Satan”. Coincidence? I don’t think so.

    These are just a few of many evidences why Barack Obama is the Antichrist. You can see many more in my article on the website above, as well as read about the dreams I’ve had concerning this man. I’m more than convinced that God has shown me that he is without a doubt the Antichrist, and we will see him rise to power in the not so dinstant future.

    Jesus stands alone among the other religions who say to rightly weigh the scales of good and evil, and to make sure you have done more good than bad in this life. Is this how we conduct ourselves justly in a court of law? Bearing the image of God, is this how we project this image into our reality?

    Our good works cannot save us. If we step before a judge, being guilty of a crime, the judge will not judge us by the good that we have done, but rather the crimes we have committed. If we as fallen humanity, created in God’s image, pose this type of justice, how much more a perfect, righteous, and Holy God?

    God has brought down His moral law’s through the 10 commandments given to Moses at Mt. Sinai. These laws were not given so we may be justified, rather that we may see the need for a savior. They are the mirror of God’s character of what He has put in each and every one of us, with our conscious bearing witness that we know that it is wrong to steal, lie, dishonor our parents, and so forth.

    We can try and follow the moral laws of the 10 commandments, but we will never catch up to them to be justified before a Holy God. That same word of the law given to Moses became flesh over 2000 years ago in the body of Jesus Christ. He came to be our justification by fulfilling the law, living a sinless perfect life that only God could fulfill; even bringing the law to it’s truest light by stating, “You have heard that it was said to those of old, ‘You shall not commit adultery.’ But I say to you that whoever looks at a woman to lust for her has already committed adultery with her in his heart” (Matthew 5:27-28).

    The gap between us and the law can never be reconciled by our own merit, but the arm of Jesus is stretched out by the grace and mercy of God. And if we are to grab on, through faith in Him, He will pull us up being the one to justify us. As in the court of law, if someone steps in and pays our fine, even though we are guilty, the judge can do what is legal and just and let us go free. That is what Jesus did almost 2000 years ago on the cross. It was a legal transaction being fulfilled in the spiritual realm by the shedding of His blood.

    Because God is Holy and just, the wrath that we deserve could not go unnoticed. Through the perfect righteousness and justice of God’s character, it must be dealt with, it must be quenched, it must be satisfied.

    For God takes no pleasure in the death of the wicked (Ezekiel 18:23). This is why in Isaiah chapter 53, where it speaks of the coming Messiah and His soul being a sacrifice for our sins, why it says it pleased God to crush His only begotten Son.

    This is because the wrath that we deserve was justified by being poured out upon His Son. If that wrath was poured out on us, we would all die and go to hell. God created a way of escape by pouring it out on His Son whose soul could not be left in Hades, but was raised to life on the third day and seated at the right hand of God in power.

    So now when we put on the Lord Jesus Christ (Romans 13:14), God no longer sees the person who deserves His wrath, but rather the glorious image of His perfect Son dwelling in us, justifying us as if we received the wrath we deserve, making a way of escape from the curse of death.

    Now what we must do is repent and put our trust and faith in the savior, confessing and forsaking our sins. This is not just a head knowledge of believing in Jesus, but rather receiving His words, taking them to heart, so that we may truly be transformed into the image of God. Where we no longer live to practice sin, but rather turn from our sins and practice righteousness through faith in Him.

    Jesus answered, “Most assuredly, I say to you, unless one is born of water and the Spirit, he cannot enter the kingdom of God. That which is born of the flesh is flesh, and that which is born of the Spirit is spirit. Do not marvel that I said to you, ‘You must be born again'” (John 3:5-7).

    Come before the Lord with a contrite spirit, humble yourself, ask Him for His forgiveness, to receive the free gift of His salvation, to receive His Holy Spirit, so that you may be transformed into a new creature, into a child of the living God.

    There is a reason why the words of Jesus have been translated in to over 2000 languages, and nothing comes remotely close (the Quran just over 100), because there is a God in heaven who desires to have a relationship with you, to know Him through His word, as that is how we personally get to know anybody. There is a reason why it is the year 2021, because Jesus came to earth just over 2000 years ago fulfilling major prophecy causing a divide in our timeline.

    Jesus loves you! Seek Him while He may be found! We must repent and turn from practicing sin…for if we are not following Jesus, we are following the devil. There is no neatural ground. We are either living in the lie, or the truth. God bless you!

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