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Primary sensation - asymmetry, sensory Printer Friendly

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

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Temperature sensation can be tested with a cool piece of metal such as a tuning
fork.
71. Temperature

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Test vibration sense by placing a vibrating tuning fork on the ball of the patient's
right or left large toe or fingers and asking him to report when the vibration
stops. Take care not to place the tuning fork on a bone, since bones conduct the
vibration to much more proximal sites, where they can be detected by nerves far
from the location being tested.
72. Vibration Sense

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Test joint position sense by moving one of the patient's fingers or toes up and
down and asking the patient to report which way it moves. Hold the digit lightly
by the sides while doing this so that tactile inputs don't provide significant clues
to the direction of movement. The digit should be moved very slightly because
normal individuals can detect movements that are barely perceptible by eye.
73. Joint Position Test

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Two-point discrimination can be tested with a special pair of calipers, or a bent
paper clip, alternating randomly between touching the patient with one or both
points. The minimal separation (in millimeters) at which the patient can
distinguish these stimuli should be recorded in each extremity.
74. Two-Point Discrimination Test

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As in other parts of the exam, the patient's deficits, as well as the anatomy of the
nerves, nerve roots, and central pathways, should be used to guide the exam
(seeNeuroanatomy through Clinical Cases Chapters 7, 8, and 9). Comparisons
should be made from one side of the body to the other and from proximal to
distal on each extremity. Note especially if there is a sensory level corresponding
to a particular spinal segment below which sensation abruptly changes, since
such a change may indicate a spinal cord lesion requiring emergency
intervention. Whenever there are uncertainties in the sensory exam, or other
parts of the exam, a good strategy is to repeat the relevant portions of the exam
several times.

Higher-order aspects of sensation, or cortical sensation, should be tested as well.


To test graphesthesia, ask the patient to close their eyes and identify letters or
numbers that are being traced onto their palm or the tip of their finger. To
test stereognosis, ask the patient to close their eyes and identify various objects
by touch using one hand at a time. Test also for tactile extinction on double
simultaneous tactile stimulation. Note that graphesthesia, stereognosis, and
extinction cannot reliably be tested for unless primary sensation is intact
bilaterally.
75. Graphesthesia

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76. Sterognosis

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77. Tactile Extinction

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What is Being Tested?


Somatosensory deficits can be caused by lesions in peripheral nerves, nerve roots,
the posterior columns or anterolateral sensory systems in the spinal cord or

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

1+: trace, or seen only with reinforcement

2+: normal

3+: brisk

4+: nonsustained clonus (i.e., repetitive vibratory movements)

5+: sustained clonus

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.

Reflexes rated as 0, 4+, or 5+ are usually considered abnormal. In addition to


clonus, other signs ofhyperreflexia include spreading of reflexes to other muscles
not directly being tested and crossed adduction of the opposite leg when the
medial aspect of the knee is tapped.
58. Deep Tendon Reflexes

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What is Being Tested?
Deep tendon reflexes (see Neuroanatomy Through Clinical Cases, Figure 2.21)
may be diminished by abnormalities in muscles, sensory neurons, lower motor
neurons, and the neuromuscular junction; acute upper motor neuron lesions; and
mechanical factors such as joint disease. Abnormally increased reflexes are
associated with upper motor neuron lesions. Note that deep tendon reflexes can
be influenced by age, metabolic factors such as thyroid dysfunction or electrolyte
abnormalities, and anxiety level of the patient. The main spinal nerve roots
involved in testing the deep tendon reflexes are summarized in the following
table:
Deep Tendon Reflexes
Reflex
Main Spinal Nerve Roots Involved
Biceps
C5, C6
Brachioradialis
C6
Triceps
C7
Patellar
L4
Achilles Tendon
S1
PLANTAR RESPONSE

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

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What is Being Tested?
Babinski's sign is associated with upper motor neuron lesions anywhere along the
corticospinal tract. Note that it may not be possible to elicit Babinski's sign if
there is severe weakness of the toe extensors. Hoffmann's sign, or heightened
finger flexor reflexes suggest an upper motor neuron lesion affecting the hands.
COORDINATION AND GAIT
Coordination and gait are usually described under a separate section because
cerebellar disorders can disrupt coordination or gait while leaving other motor
functions relatively intact. There is much overlap, however, between the systems
being examined in this section and those examined in the earlier general motor
exam section. Keep in mind that disturbances of coordination and gait can be
caused by lesions in many systems other than the cerebellum.
The term ataxia is often used to describe the abnormal movements seen in
coordination disorders. In ataxia there are medium- to large-amplitude
involuntary movements with an irregular oscillatory quality superimposed on
and interfering with the normal smooth trajectory of movement. Overshoot is
also commonly seen as part of ataxic movements and is sometimes referred to
as past pointing when target-oriented movements are being discussed. Another
feature of coordination disorders is dysdiadochokinesiathat is, abnormal
alternating movements.

Cerebellar lesions can cause different kinds of coordination problems depending


on their location. One important distinction is between truncal ataxia and
appendicular ataxia. Appendicular ataxia affects movements of the extremities
and is usually caused by lesions of the cerebellar hemispheres and associated
pathways. Truncal ataxia affects the proximal musculature, especially that
involved in gait stability, and is caused by midline damage to the cerebellar
vermis and associated pathways
APPENDICULAR COORDINATION
Fine movements of the hands and feet, as discussed earlier under the general
motor exam, should be tested. Rapid alternating movements, such as wiping one
palm alternately with the palm and dorsum of the other hand, should be tested as
well. Perhaps the most popular test of coordination, however, is the fingernose
finger test, in which the patient is asked to alternately touch their nose and the
examiner's finger as quickly as possible. Ataxia is best revealed if the examiner's
finger is held at the extreme of the patient's reach, and if the examiner's finger is
occasionally moved suddenly to a different location. Test for overshoot by having
the patient raise both arms suddenly from their lap to the level of your hand. In
addition, you can apply pressure to the patient's outstretched arms and then
suddenly release it. To test the accuracy of movements in a way that requires very
little strength, you can draw a line on the crease of the patient's thumb and then
ask the patient to touch the line repeatedly with the tip of their forefinger.
Similar tests can be done with the legs. In the heelshin test the patient is asked
to touch the heel of one foot to the opposite knee and then to drag their heel in a
straight line all the way down the front of their shin and back up again. In order
to eliminate the effect of gravity in moving the heel down the shin, this test
should always be done in the supine position. Testing for ataxia is discussed
further inNeuroanatomy through Clinical Cases, Key Clinical Concepts 15.2.
62. Rapid Alternating Movements

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63. Precision Finger Tap

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64. Finger-Nose-Finger

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65. Heel-Shin

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66. Overshoot

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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.
67. Romberg Test

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What is Being Tested?
With the eyes open, three sensory systems provide input to the cerebellum to
maintain truncal stability. These are vision, proprioception, and vestibular sense.
If there is a mild lesion in the vestibular or proprioception systems, the patient is

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.

What is Being Tested?


Normal performance of these motor tasks depends on the integrated functioning
of multiple sensory and motor subsystems. These include position sense
pathways, lower motor neurons, upper motor neurons, the basal ganglia, and the
cerebellum. Thus, in order to convincingly demonstrate that abnormalities are
due to a cerebellar lesion, one must first test for normal joint position sense,
strength, and reflexes and confirm the absence of involuntary movements caused
by basal ganglia lesions. As already mentioned, appendicular ataxia is usually
caused by lesions of the cerebellar hemispheres and associated pathways,
while truncal ataxia
GAIT
A patient's gait can be difficult to describe in a reproducible fashion. Observe the
patient walking toward you and away from you in an open area with plenty of
room. Note stance (how far apart the feet are), posture, stability, how high the
feet are raised off the floor, trajectory of leg swing and whether there
is circumduction (an arced trajectory in the medial to lateral direction), leg
stiffness and degree of knee bending, arm swing, tendency to fall or swerve in any
particular direction, rate and speed, difficulty initiating or stopping gait, and any
involuntary movements that are brought out by walking. Turns should also be
observed closely. When following a patient over several visits, it may be useful to
time him walking a fixed distance, and to count the number of steps he took and
the number of steps he required to turn around. The patient's ability to rise from
a chair with or without assistance should also be recorded.
To bring out abnormalities in gait and balance, ask the patient to do more
difficult maneuvers. Test tandem gait by asking the patient to walk a straight line
while touching the heel of one foot to the toe of the other with each step. Patients
withtruncal ataxia caused by damage to the cerebellar vermis or associated
pathways will have particular difficulty with this task, since they tend to have a
wide-based, unsteady gait, and become more unsteady when attempting to keep
their feet close together. To bring out subtle gait abnormalities or asymmetries, it
may be appropriate in some cases to ask the patient to walk on their heels, their
toes, or the insides or outsides of their feet, to stand or hop on one leg, or to walk
up stairs.

Gait apraxia is a perplexing (and somewhat controversial) abnormality in which


the patient is able to carry out all of the movements required for gait normally
when lying down, but is unable to walk in the standing position, thought to be
associated with frontal disorders or normal pressure hydrocephalus (KCC 5.7).
68. Ordinary Gait, Tandem Gait

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69. Forced Gait

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What is Being Tested?
As with tests of appendicular coordination, gait involves multiple sensory and
motor systems. These include vision, proprioception, lower motor neurons, upper
motor neurons, basal ganglia, the cerebellum, and higher-order motor planning
systems in the association cortex.

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