Introduction to the Neurologic Examination

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

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

a. history and examination data accurate and reliable no neurologic
abnormality

b. Inaccurate history or unreliable examination data uncertain
neurological status (false negative)

Common causes of inaccurate history or unreliable examination data

1. omissions
2. technique
3. interpretation


1) Is there evidence of abnormality of structure or function? YES
a. Inaccurate history or unreliable examination data uncertain
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 reliable neurologic
abnormality likely proceed to questions 2 and 3

Question 2 - Where is the abnormality?

Question 3 - What is the nature of the abnormality

2) Where is the abnormality?


Location

Position

Extent

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)
cerebellum
side (R/L)
region (vermis, hemisphere, peduncle)
cerebrum (encephalopathy)
side (R/L)
lobe (frontal. parietal, occipital, temporal)
region (cortex, subcortical white matter, deep nuclei)
2) Where is the abnormality Position
Brain
epidural
subdural
subarachnoid
intraparenchymal
intraventricular

Spinal Cord
epidural
intrathecal (subarachnoid)
intramedullary

2) Where is the abnormality Extent




focal

multifocal

systemic/diffuse
3) What is the Nature of the abnormality?



Etiology
responsible cause or disease mechanism that results in cellular or
systemic abnormality

Pathophysiology
processes whereby abnormalities of cellular or systemic mechanisms
result in abnormalities of structure and/or function

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
3) What is the nature of the abnormality Pathophysiology
Involvement primarily of nervous system cells and tissues
nerve cells
nerve cell processes
glial cells
meninges
choroid/ependymal cells

Involvement secondary to disease/dysfunction of other cells and organ systems
vascular/ cardiac disease
pulmonary disease
renal disease
gastrointestinal disease
endocrine disease
immunologic disease
orthopedic disease
dermatologic disease
genito-urinary disease
hematopoietic disease
3) What is the nature of the abnormality Pathophysiology
Involvement primarily of nervous system cells and tissues (expanded)
nerve cells
transmitter proteins
membrane proteins
receptor proteins
ion channel proteins
cytoskeletal proteins
enzyme systems
cytoplasmic
mitochondrial
nerve cell processes
axons
myelin sheath
axonal transport systems
glial cells
astrocytes
oligodendrocytes
meninges
dura mater
arachnoid mater
choroid/ ependymal cells (CSF)
Components of the Neurological History
Chief Complaint
History of Present Illness
Past Medical (Surgical) History
Pertinent Health Information
Family History
Social History
Occupational History
Review of Systems
Components of the Neurological History Review of Systems
review of systems
skin
head, eyes ears, nose throat (HEENT)
breasts
respiratory
cardiac
vascular
gastrointestinal
renal and urinary
musculoskeletal
neurologic
endocrine
psychiatric
hematopoietic
Components of the Neurological Examination
Mental Status
Cranial Nerves
Motor Systems (including coordination, station and gait)
Reflexes
Sensory Systems
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
Components of the Neurological Examination Mental Status
Level of Consciousness
alert
lethargic
obtunded
stuporous
comatose

Attention
attentive inattentive
stable fluctuating

Orientation
person
place
time
(situation)

Language Function
spontaneous speech
fluency
comprehension
repetition
naming and word finding
reading and writing



Components of the Neurological Examination Mental Status

Learning and Memory
immediate recall
short term
long term (remote)

Cortical and Cognitive Function
fund of knowledge
calculation ability
proverb interpretation
praxia
(gnosia)

Mood and Affect
characterization
appropriate/ inappropriate

Thought Content
coherent, organized (egosyntonic)
incoherent, disorganized (paranoia, delusions, hallucinations, phobias)

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



Components of the Neurological Examination Cranial Nerves

Ocular Motor Nerves (III,IV,VI)
inspection
palpebral 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
Components of the Neurological Examination Cranial Nerves
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 sounds M
(autonomic)
(lacrimation)
(sensory)
(taste anterior 2/3 of tongue)
Components of the Neurological Examination Cranial Nerves
Vestibulocochlear Nerve (VIII)
cochlear division
screening test
finger rub (auditory threshold)
deficit characterization (sensorineural vs. conduction)
Weber
Rinne

vestibular division
inspection
nystagmus
tests of function
past pointing
marching in place
vestibulo-ocular reflexes
oculocephalic reflex (dolls head maneuver)
head thrust and head shake tests
oculovestibular reflex (caloric testing)
walking (oscillopsia)
provocative tests
Dix-Hallpike maneuver (Nylen-Barany )
Components of the Neurological Examination Cranial Nerves


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 sounds K
(pharyngeal ((gag)) reflex)
(observe swallowing)

Components of the Neurological Examination Cranial Nerves
Spinal Accessory Nerve (XI)
inspection
atrophy, head tilt
strength testing
(upper) trapezius shoulder shrug
sternocleidomastoid head turning

Hypoglossal Nerve (XII)
inspection (tongue in floor of mouth)
atrophy/furrowing
fasciculations
inspection (on protrusion)
midline/deviation
enunciation
lingual sounds - L

Components of the Neurological Examination Motor Systems

Inspection

Muscle Tone

Strength

Coordination

Station

Gait


Components of the Neurological Examination Motor Systems
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
normal
decreased (atonia, hypotonia)
increased (spasticity, rigidity, paratonia)

Components of the Neurological Examination Motor Systems
Strength
upper limb lower limb
shoulder abduction hip flexion
elbow flexion knee extension
elbow extension hip adduction
wrist extension ankle dorsiflexion
wrist flexion hip abduction
finger extension toe extension
finger 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
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, C7
wrist extension radial C6, C7
wrist flexion median C7, C8
finger extension radial C7, C8
finger flexion median/ulnar C8, T1
finger abduction ulnar T1
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, L4
ankle 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
Components of the Neurological Examination Motor Systems

Coordination
upper limb
finger-to-nose
rapid alternating movements
finger tap/alternate finger tap
check and rebound
lower limb
heel-to-shin
rapid alternating movements
foot tap/alternate heel-toe tap

Station
Romberg test

Gait
free walking
tandem walking
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
(5 strong muscle contraction with sustained clonus)
Components of the Neurological Examination Reflexes
Muscle Stretch (Myotatic, Tendon) Reflexes
commonly tested reflexes
biceps brachii
brachioradialis
triceps brachii
finger flexor
quadriceps femoris
Achilles

abnormal muscle stretch reflexes
masseter reflex (jaw jerk)
Hoffman
Components of the Neurological Examination Reflexes
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



Components of the Neurological Examination Reflexes
Cutaneous Reflexes
plantar
(abdominal)
(anal sphincter)
(cremasteric)
(bulbocavernosus)

Abnormal Cutaneous Reflexes
Babinski
palmar grasp
persistent glabellar
palmomental
suck, root
snout
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

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)
End