Neurologic Exam Skills

8/18/2019 Neurologic Exam Skills

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Neurologic Examination – Description of Skills and Testing Procedures

ComponentsThe Neurologic examination consists of the following components:

Mental Status

Cranial Nerves

Sensory Testing

Motor Strength * Reflexes

Coordination Testing *

Special Signs *

Of these, only those in Bold Italics * will be tested in the Practical Examination.

In SIM, you have clearly demonstrated your ability to examine the cranial nerves and muscle stretchreflexes, and thus they will be omitted from Practical Exam testing. The one exception to this is theBabinski reflex, which I have included because it was inexplicably absent from the reflextesting I saw in SIMs.

Mental Status assessment is covered in your Behavior Medicine System and Sensory testing doesnot lend itself well to Practical Examination.

Motor Strength

There are many instances where the Musculoskeletal and Neurologic examinations overlap, andmanual muscle testing is one such example. Normal muscle function requires both muscle strengthand nervous innervation. For the purposes of our study, manual muscle testing has been includedwithin the Neurologic examination.

Manual Muscle Testing: For purposes of examination and actual manual muscle testing in the clinicalsetting, each muscle should be in a fully contracted position and then the student should demonstrateeither their ability to “break” the contraction or attempt to “break” the contraction.

There are different techniques by different authors in the literature regarding how to test musclestrength and motion. The general rule we will be teaching and evaluating with is that each muscle willbe fully contracted, then the student/examiner will try to “break”/ overpower the contraction, andshould be able to do so unless otherwise noted. Typically, in neurologic weakness, there will begradual movement of the joint. Patients will sometimes demonstrate “give-way” weakness where theywill abruptly stop their resistance and movement of the joint against resistance will be fast. In thesecases it is NOT possible to tell, with certainty, whether the muscle is neurologically weak or if the

weakness is due to pain inhibition or less than full effort on the part of the patient.

Grading Scale5-Normal = Complete active range of motion against gravity with full resistance.4-Good =Complete active range of motion against gravity with some/not full resistance3-Fair = Complete active range of motion against gravity with no resistance2-Poor= Complete active range of motion with gravity eliminated1-Trace= Evidence of muscle contractility but no/very little joint motion



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0-Zero= NO evidence of muscle contractility/function

For each of the following joint motions, you should be familiar with (and be prepared to verbalizeduring testing) the muscle involved, nerve root level and peripheral nerve that supplies theinnervation. (Note that references may differ somewhat on the nerve roots innervating specificmotions, particularly when multiple levels contribute to a motion. For the purpose of testingin EPC IV, the ‘gold standard’ shall be the information contained in this document.)

For each muscle, you will find a description of the testing method, a link to a video demonstration,and a screenshot from the video.

Upper Extremity

Shoulder abduction Deltoid,: the examiner should have thepatient place their shoulder into full abduction and then pulldown (adduct) the arm and “break” the contraction

Innervation: primarily C5 level, Axil lary nerve.

Manual Muscle Testing - Deltoid http://mediasite.lmunet.edu/Mediasite/Play/29c57613cdcd4bc89fb972431e520dc21d?catalog=b731f064-988e-42ce-9952-04964c178f67 ------------------------------------------------------------------------------------------------------------------------------

Elbow flexion, Biceps,: This examination is usually doneseated, and is begun with the arm to be tested flexed at theelbow to 90 degrees. The patient will then attempt to flex theelbow while the examiner resists the movement.

Innervation: C5-6, Musculocutaneous nerve

Manual Muscle Testing - Biceps http://mediasite.lmunet.edu/Mediasite/Play/a908e94934cd48dfb02bbf3095876ee41d?catalog=b731f064-988e-42ce-9952-04964c178f67

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Elbow extension, Triceps: The examiner will begin with thepatient seated or standing with the shoulder in forward flexion andelbow in an extended position. The examiner will then brace theupper arm and attempt to flex the elbow. The examiner may notbe able to “break” this muscle.

Innervation: C7, Radial nerve.

Manual Muscle Testing - Triceps http://mediasite.lmunet.edu/Mediasite/Play/cf9f2bd753ad4de2813916dd0a1051d41d?catalog=b731f064-988e-42ce-9952-04964c178f67 ------------------------------------------------------------------------------------------------------------------------------

Wrist extension, Extensor Carpi Radialis (Longus andBrevis): The examiner has the patient extend their wrist and,while bracing the forearm, will “break” the contraction by puttingpressure on the hand and forcing flexion of the wrist. This canalso be done by having the patient place their forearm onan exam table and pressing down on the extended wrist.Innervation: primarily C-6, Radial nerve.

Manual Muscle Testing - Extensor Carpi Radialis Longus and

Brevishttp://mediasite.lmunet.edu/Mediasite/Play/dcdaf90b07ce4a2eb2862c8cc725f5531d?catalog=b731f064-988e-42ce-9952-04964c178f67

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Thumb abduction, Abductor Pollicis Brevis : The examinerwill position the patient’s hand with the palm facing upwardand the thumb abducted (pointing upward), will then force thethumb into adduction with pressure over themetacarpophalangeal (MCP) joint with bracing of the hand.

Innervation: C-8/T-1, Median nerve.

Manual Muscle Testing - Abductor Pollicis Brevishttp://mediasite.lmunet.edu/Mediasite/Play/8cb4a20c20154876a5dbb1c1a8f27ac51d?catalog=b731f064-988e-42ce-9952-04964c178f67



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Finger abduction, First Dorsal Interosseous,: The examiner

will ask the patient to abduct the digits fully. The examiner will

then brace the patient’s hand and attempt to adduct the

patient’s finger while using their own abducted finger to do

this, thus comparing their abduction to the patient’s.

Innervation: C8/T1, Ulnar nerve

Manual Muscle Testing - First Dorsal Interosseous Musclehttp://mediasite.lmunet.edu/Mediasite/Play/573b4f7cfbc942b88d1c917917229d461d?catalog=b731f064-988e-42ce-9952-04964c178f67 ------------------------------------------------------------------------------------------------------------------------------

Lower Extremity

Hip abduction, Gluteus Medius,: The patientwill be sidelying and then instructed to fullyabduct their leg. The examiner will then applypressure distal to the knee and attempt to forceit into adduction.

Innervation: L-5, Superior gluteal nerve.

Manual Muscle Testing – Gluteus Mediushttp://mediasite.lmunet.edu/Mediasite/Play/764c6ace9c454e47929b7b236b5cd48e1d?catalog=b731f 064-988e-42ce-9952-04964c178f67 -----------------------------------------------------------------------------------------------Knee extension, Quadriceps: From the sitting position, the patient willextend the knee and the examiner will attempt to flex the knee. Innormal circumstances the examiner will often not be able to “break” thismuscle contraction.

Innervation: L-2,3,4, Femoral nerve.

Manual Muscle Testing – Quadricepshttp://mediasite.lmunet.edu/Mediasite/Play/e03eca6df1e948fc86bee433807d40151d?catalog=b731f064-988e-42ce-9952-04964c178f67



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Ankle dors if lexion, Anterior Tibialis/Tibialis Anterior : In the standing position, the examiner asks the willask the patient to stand on their heel and dorsiflex their ankle.The examiner will apply pressure to the dorsum of the foot andtry to push the foot to the ground.

Innervation: L-4-5, Peroneal/fibular nerve

Manual Muscle Testing – Anterior Tibialis

http://mediasite.lmunet.edu/Mediasite/Play/19edf61298834a83b64128703850b35c1d?catalog=b731f 064-988e-42ce-9952-04964c178f67 ------------------------------------------------------------------------------------------------------------------------------Great toe dorsi flexion Extensor Hallucis (Longus andBrevis),: From the seated or supine position, theexaminer instructs the patient to extend themetatarsophalangeal (MTP) joint of their great toe. Theexaminer then attempts to flex the toe by applyingpressure on the proximal phalanx.

Innervation: L-5 , Peroneal/fibular nerve.

Manual Muscle Testing – Extensor Hallucis Longus and Brevis)

http://mediasite.lmunet.edu/Mediasite/Play/7b24dbdee0e741ed8d4fbec4170054121d?catalog=b731f064-988e-42ce-9952-04964c178f67

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Ankle plantar f lexion, Gastrocnemius: Standing on one leg, thepatient will place one finger on a table to balance, stand on one leg,keep their knee straight , and then go up on their toes (plantar flex) ten(10) times (N.B., number of repetitions required is debated, and mayvary with strength of patient.)

Innervation: S-1, Tibial nerve

Manual Muscle Testing – Gastrocnemius Lift Off Test

http://mediasite.lmunet.edu/Mediasite/Play/16b8c878e3374a49af2bb6e3078e59a01d?catalog=b731f 064-988e-42ce-9952-04964c178f67

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SUMMARY OF MUSCLE ACTIONS & INNERVATIONS



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Neurologic Examination Maneuvers

Here are descriptions of a number of neurologic “special tests” that one would perform to evaluatespecific aspects of neurologic function. For each examination maneuver, you will find a description ofthe testing method, an illustrative diagram and a Mediasite link to a video demonstration. (Theindividual videos are contained within the “Neurologic Exam Demonstration Video”, and the time inthis video at which the particular exam is demonstrated is included.)

You should be able to demonstrate each examination, and in addition, you should be familiar with(and be prepared to verbalize during testing) what constitutes a positive finding, and/or what a

positive finding implies.

Finger-to-Nose Testing : With the patient seated,position your index finger at a point in space in frontof the patient. Instruct the patient to move their indexfinger between your finger and their nose.Reposition your finger after each touch. Then test theother hand.

Interpretation : An abnormal test is the inability to dothis at a reasonable rate of speed, trace a straightpath, and hit the end points accurately. Missing themark, known as dysmetria, may be indicative ofcerebellar dysfunction. (If the movement is accurateand smooth but slow, the likely problem is muscleweakness, and less likely cerebellar dysfunction.)

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video – 20:00http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-9952-04964c178f67

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Heel to Shin Testing: Direct the patient to place the heel of one footon the opposite knee, and then move the heel down the center of theshin. Then test the other foot.Interpretation : The movement should trace a straight line along thetop of the shin and be done with reasonable speed. An inability to doso constitutes an abnormal test and may be indicative of cerebellardysfunction. (If the movement is accurate and smooth but slow, the

likely problem is muscle weakness, and less likely cerebellardysfunction.)




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Romberg Test : Ask the patient to stand with their feet together(touching each other). Then ask the patient to close their eyes.Remain close at hand in case the patient begins to sway or fall. Lossof balance when eyes closed is a positive test

Interpretation : With the eyes open, three sensory systems provideinput to the cerebellum to maintain truncal stability. These are vision,

proprioception, and vestibular sense. If there is a mild lesion in thevestibular or proprioception systems, the patient is usually able tocompensate with the eyes open. When the patient closes their eyes,however, visual input is removed and instability can be brought out.With a cerebellar lesion, the patient will be unable to maintain thisposition even with their eyes open.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam

Demonstration Video – 33:45http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-9952-04964c178f67

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Pronator Drift : Ask the patient to extend both arms with the palms pointing upwards, and thenmaintain that posture with the eyes closed.Interpretation : An abnormal test results in the arm drifting downward and the hand pronating. Anabnormal pronator drift tests indicates an upper motor neuron lesion. It is often seen in patients whohave a mild hemiparesis.




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Aster ix is: Ask the patient to extend both arms,and then to dorsiflex the wrists.Interpretation : An abnormal test results in theepisodic loss of this posture, with the wristsbriefly straightening and then resuming thedorsiflexed posture. (This is often referred tocolloquially as “flapping”, and the patient is

(informally) said to have “a flap”.) An abnormalresult indicates encephalopathy, and is mostcommonly associated with hepaticencephalopathy.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video – 29:12http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-9952-

04964c178f67

- - - - -Kernig’s Sign : With the patient supine, flex the patient’s knee and hip. Then, extend the knee.Interpretation : Pain or resistance to extension of the knee is a positive test, and indicatesinflammation of the meninges such as might be seen in meningitis or subarachnoid hemorrhage.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video – 29:42http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-9952-

04964c178f67 - - - - -



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Brudzinski Sign : With the patient supine, passively flex the patient’s neck forward until the chintouches the chest.Interpretation : Pain or resistance to the motion constitutes a positive test. There may also beenflexion of the patient’s hips and knee with flexion of the neck.

U


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Babinski Reflex (aka “ Plantar Response” ) : The patient may either sit or lie supine. Use the handleend of your reflex hammer (the one that is comes to a point) or a similar metallic object such as a key.Start at the lateral aspect of the foot, near the heel. Apply steady pressure with the end of thehammer as you move up towards the ball (area of the metatarsal heads) of the foot. When you reachthe ball of the foot, move medially, stroking across this area.Interpretation : In a normal response, the initial movement of the great toe should be downwards (i.e.,plantar flexion.) In an abnormal test, the great toe will dorsiflex and the remainder of the other toeswill fan out, and an abnormal test indicates upper motor neuron dysfunction (usually in the pyramidaltract).N.B. Sometimes you will be unable to generate any response, even in the absence of disease.Responses must therefore be interpreted in the context of the rest of the exam. Withdrawal of the

entire foot (due to unpleasant stimulation), is not interpreted as a positive response.




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