Introduction to the Neurologic Examination

5/22/2018 Introduction to the Neurologic Examination

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Introduction to the Neurologic Examination

Michael F. Nolan, Ph.D.,P.T.


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Introduction to the Neurologic Examination

The neurological history and examination are designed to answer three

fundamental questions regarding the structural and functional integrity of the

nervous system:

1) Is there evidence of an abnormality of structure or function?

2) Where is the abnormality?

3) What is the Nature of the abnormality?


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1) Is there evidence of an abnormality of structure or function?

Information needed to answer this question:

a. An understanding of history and examination findings that fall within

the range of normal for the patient being examined.

What factors influence range of normal?

b. Accurate and reliable history and examination findings from the patient

being examined.


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1) Is there evidence of an abnormality of structure or function? NO

a. history and examination data accurate and reliableno neurologic

abnormality

b. Inaccurate history or unreliable examination datauncertain

neurological status (false negative)

Common causes of inaccurate history or unreliable examination data

1. omissions

2. technique

3. interpretation


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1) Is there evidence of abnormality of structure or function? YES

a. Inaccurate history or unreliable examination datauncertain

neurological status (false positive)

Common causes of false positive findings on history or examination

1. technique

2. interpretation

b. history and examination data accurate and reliableneurologic

abnormality likelyproceed to questions 2 and 3

Question 2 - Where is the abnormality?

Question 3 - What is the nature of the abnormality


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2) Where is the abnormality?

Location

Position

Extent


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2) Where is the abnormality Location

Peripheral nervous system

nerve roots (radiculopathy)

plexus (plexopathy)peripheral nerves (neuropathy)

neuromuscular junction

muscle (myopathy)

Central nervous system

spinal cord

side (R/L)

brainstem

side (R/L)

level (medulla, pons, midbrain)

region (paramedian, ventrolateral, dorsolateral)

cerebellumside (R/L)

region (vermis, hemisphere, peduncle)

cerebrum (encephalopathy)

side (R/L)

lobe (frontal. parietal, occipital, temporal)

region (cortex, subcortical white matter, deep nuclei)


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2) Where is the abnormality Position

Brain

epidural

subdural

subarachnoid

intraparenchymalintraventricular

Spinal Cord

epidural

intrathecal (subarachnoid)intramedullary


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2) Where is the abnormality Extent

focal

multifocal

systemic/diffuse


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3) What is the Nature of the abnormality?

Etiology

responsible cause or disease mechanism that results in cellular orsystemic abnormality

Pathophysiology

processes whereby abnormalities of cellular or systemic mechanisms

result in abnormalities of structure and/or function


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3) What is the nature of the abnormality Etiology

C V V vascular/post vascular

I I I infectious/post infectious

N N T traumatic/post traumatic

E D A autoimmune

M I M metabolic/toxic

A C I idiopathic

A N neoplastic

T T

V E C congenital/hereditary

D degenerative


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3) What is the nature of the abnormality Pathophysiology

Involvement primarilyof nervous system cells and tissues

nerve cells

nerve cell processesglial cells

meninges

choroid/ependymal cells

Involvement secondaryto disease/dysfunction of other cells and organ systemsvascular/ cardiac disease

pulmonary disease

renal disease

gastrointestinal disease

endocrine disease

immunologic disease

orthopedic disease

dermatologic disease

genito-urinary disease

hematopoietic disease


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3) What is the nature of the abnormality Pathophysiology

Involvement primarily of nervous system cells and tissues (expanded)

nerve cells

transmitter proteinsmembrane proteins

receptor proteins

ion channel proteins

cytoskeletal proteins

enzyme systems

cytoplasmicmitochondrial

nerve cell processes

axons

myelin sheath

axonal transport systems

glial cellsastrocytes

oligodendrocytes

meninges

dura mater

arachnoid mater

choroid/ ependymal cells (CSF)


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Components of the Neurological History

Chief Complaint

History of Present Illness

Past Medical (Surgical) History

Pertinent Health InformationFamily History

Social History

Occupational History

Review of Systems


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Components of the Neurological History Review of Systems

review of systems

skin

head, eyes ears, nose throat (HEENT)

breasts

respiratory

cardiacvascular

gastrointestinal

renal and urinary

musculoskeletal

neurologicendocrine

psychiatric

hematopoietic


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Components of the Neurological Examination

Mental Status

Cranial Nerves

Motor Systems (including coordination, station and gait)

Reflexes

Sensory Systems


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Components of the Neurological Examination Mental Status

Level of Consciousness

Attention

Orientation

Language Function

Learning and Memory

Cortical and Cognitive Function

Mood and Affect

Thought Content


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Level of Consciousness

alert

lethargicobtunded

stuporous

comatose

Attention

attentiveinattentive

stablefluctuating

Orientation

person

place

time

(situation)

Language Function

spontaneous speech

fluency

comprehension

repetition

naming and word findingreading and writing


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Learning and Memory

immediate recallshort term

long term (remote)

Cortical and Cognitive Function

fund of knowledge

calculation abilityproverb interpretation

praxia

(gnosia)

Mood and Affect

characterizationappropriate/ inappropriate

Thought Content

coherent, organized (egosyntonic)

incoherent, disorganized (paranoia, delusions, hallucinations, phobias)


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Components of the Neurological Examination Cranial Nerves

Olfactory Nerve (I)

perception (recognition, hallucinations)

Optic Nerve (II)

visual acuity (unaccommodated / accommodated)visual fields

color vision

pupils

visual reflexes

light reflexes (direct / indirect)accommodation reflex

funduscopic exam


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Ocular Motor Nerves (III,IV,VI)

inspectionpalpebral fissures (ptosis, proptosis)

ocular position (strabismus, gaze shifts)

head position (compensation)

spontaneous movements (nystagmus)

common complaints

diplopia

blurred vision

ocular movements (monocular and binocular)

tracking (pursuit)

volitional

ocular motor testing

cover testing (heterotropia/heterophoria)

red glass test

corneal light reflection test


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Trigeminal Nerve (V)

sensory (ophthalmic, maxillary, mandibular)

threshold and symmetry to tactile (and thermal) stimuli

(corneal reflex)

motor

masseter and temporalis strength

reflex

jaw jerk

Facial Nerve (VI)

inspection

forehead, palpebral fissures, nasolabial fold, corner of mouth

motor

upper face (frontalis, orbicularis oculi)

lower face (zygomaticus, orbicularis oris)

enunciation

labial soundsM

(autonomic)

(lacrimation)

(sensory)

(tasteanterior 2/3 of tongue)


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Vestibulocochlear Nerve (VIII)

cochlear division

screening testfinger rub (auditory threshold)

deficit characterization (sensorineural vs. conduction)

Weber

Rinne

vestibular divisioninspection

nystagmus

tests of function

past pointing

marching in place

vestibulo-ocular reflexesoculocephalic reflex (dolls head maneuver)

head thrust and head shake tests

oculovestibular reflex (caloric testing)

walking (oscillopsia)

provocative tests

Dix-Hallpike maneuver (Nylen-Barany )


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Glossopharyngeal (IX) and Vagus (X) Nerves

inspection

position of uvula and soft palate at rest

movement of uvula and soft palate with AAHH

(glottis - position of the vocal folds)auscultation

hoarseness

stridor

enunciation

pharyngeal soundsK(pharyngeal ((gag)) reflex)

(observe swallowing)


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Spinal Accessory Nerve (XI)inspection

atrophy, head tilt

strength testing

(upper) trapeziusshoulder shrug

sternocleidomastoidhead turning

Hypoglossal Nerve (XII)

inspection (tongue in floor of mouth)

atrophy/furrowing

fasciculations

inspection (on protrusion)

midline/deviation

enunciation

lingual sounds - L


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Components of the Neurological Examination Motor Systems

Inspection

Muscle Tone

Strength

Coordination

Station

Gait


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Inspection

symmetry, bulk and contour (atrophy/hypertrophy)

physiological/pathological

posture (dystonic, paretic)

adventitious (abnormal) movements

at rest (tics, tremor, athetosis, chorea, ballismus, titubation, jerks)

with action (paresis, ataxia, dysarthria)

Muscle Tone

normaldecreased (atonia, hypotonia)

increased (spasticity, rigidity, paratonia)


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Strength

upper limb lower limb

shoulder abduction hip flexionelbow flexion knee extension

elbow extension hip adduction

wrist extension ankle dorsiflexion

wrist flexion hip abduction

finger extension toe extensionfinger flexion ankle plantar flexion

finger abduction hip extension

strength grades

5/5 - full ROM against gravity with maximal resistance

4/5 - full ROM against gravity with some resistance

3/5 - full Rom against gravity only

2/5 - full ROM gravity eliminated

1/5 - palpable or visual evidence of contraction without movement


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Components of the Neurological Examination Motor System

Upper Limb Peripheral Nerve Spinal Segment

shoulder abduction axillary C5, C6

elbow flexion musculocutaneous C5, C6

elbow extension radial C6, C7wrist extension radial C6, C7

wrist flexion median C7, C8

finger extension radial C7, C8

finger flexion median/ulnar C8, T1

finger abduction ulnar T1


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Components of the Neurological Examination Motor System

Lower Limb Peripheral Nerve Spinal Segment

hip flexion L1, L2, L3

knee extension femoral L2, L3, L4

hip adduction obturator L2, L3, L4ankle dorsiflexion anterior tibial L4, L5

hip abduction superior gluteal L4, L5, S1

toe extension anterior tibial L4, L5

ankle plantar flexion posterior tibial L5, S1, S2

hip extension inferior gluteal L5, S1, S2


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Coordination

upper limb

finger-to-nose

rapid alternating movements

finger tap/alternate finger tap

check and rebound

lower limbheel-to-shin

rapid alternating movements

foot tap/alternate heel-toe tap

StationRomberg test

Gait

free walking

tandem walking


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Components of the Neurological Examination Reflexes

Muscle Stretch (Myotatic) Reflexes

response characteristics evaluated

threshold

latency

magnitude

amplitude

spread

duration

reflex grades

0 - no visible or palpable muscle contraction with reinforcement

1 - slight muscle contraction with little or no joint movement

2 - distinct muscle contraction with slight joint movement

3 - brisk muscle contraction with moderate joint movement

4 - strong muscle contraction with 1-3 beats of clonus. Spread to the

contralateral side may be noted

(5strong muscle contraction with sustained clonus)


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Muscle Stretch (Myotatic, Tendon) Reflexes

commonly tested reflexes

biceps brachii

brachioradialis

triceps brachii

finger flexor

quadriceps femoris

Achilles

abnormal muscle stretch reflexesmasseter reflex (jaw jerk)

Hoffman


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Upper Limb Peripheral Nerve Spinal Segment

biceps brachii musculocutaneous C5, C6

brachioradialis radial C5,C6, C7

triceps brachii radial C6, C7, C8

finger flexion median/ulnar C7, C8

Lower Limb

quadriceps femoris femoral L2, L3, L4

Achilles posterior tibial L5, S1, S2


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Cutaneous Reflexes

plantar

(abdominal)

(anal sphincter)

(cremasteric)

(bulbocavernosus)

Abnormal Cutaneous Reflexes

Babinski

palmar grasp

persistent glabellarpalmomental

suck, root

snout


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Components of the Neurological Examination Sensory Systems

Evaluations

symmetry

threshold

anesthesia, hypesthesia, hyperesthesia

analgesia, hypalgesia, hyperalgesia, allodynia

paresthesia, dysesthesia

Functional Systems

anterolateral (nociceptive) system

lemniscal (non-nociceptive) system

cortical sensory functions


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Components of the Neurological Examination Sensory Systems

Anterolateral System

pin prick (nociceptive)

thermal sense (thermesthesia)

(deep pain)

Lemniscal System

light touch (thigmesthesia)

tactile localization (topesthesia)2pt discrimination

vibratory sense (pallesthesia)

position sense (proprioception)

movement sense (kinesthesia)

Cortical Sensory Functions

object identification (stereognosia)

traced figure identification (graphesthesia)

double simultaneous stimulation (extinction)


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End

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Introduction to the Neurologic Examination