Neurological Examination

SUMMARY

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Equipment Needed

• Reflex Hammer
• 128 and 512 (or 1024) Hz Tuning Forks
• Wooden Handled Cotton Swabs
• Paper Clips

General Considerations

• Always consider left to right symmetry
• Consider central vs. peripheral deficits
• Organize your thinking into seven categories:

1. Mental Status
2. Cranial Nerves
3. Motor
4. Coordination and Gait
5. Reflexes
6. Sensory
7. Special Tests

Motor

Observation

• Involuntary Movements
• Muscle Symmetry
  • Left to Right
  • Proximal vs. Distal
• Atrophy
  • Pay particular attention to the hands, shoulders, and thighs.
• Gait

Muscle Tone

1. Ask the patient to relax.
2. Flex and extend the patient's fingers, wrist, and elbow.
3. Flex and extend patient's ankle and knee.
4. There is normally a small, continuous resistance to passive movement.
5. Observe for decreased (flaccid) or increased (rigid/spastic) tone.

Muscle Strength

• Test strength by having the patient move against your resistance.
• Always compare one side to the other.
• Grade strength on a scale from 0 to 5 "out of five":

Grading Motor Strength
Grade	Description
0/5	No muscle movement
1/5	Visible muscle movement, but no movement at the joint
2/5	Movement at the joint, but not against gravity
3/5	Movement against gravity, but not against added resistance
4/5	Movement against resistance, but less than normal
5/5	Normal strength
Grade	Description
0/5	No muscle movement
1/5	Visible muscle movement, but no movement at the joint
2/5	Movement at the joint, but not against gravity
3/5	Movement against gravity, but not against added resistance
4/5	Movement against resistance, but less than normal
5/5	Normal strength

• Test the following:

1. Flexion at the elbow (C5, C6, biceps)
2. Extension at the elbow (C6, C7, C8, triceps)
3. Extension at the wrist (C6, C7, C8, radial nerve)
4. Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1)
5. Finger abduction (C8, T1, ulnar nerve)
6. Oppostion of the thumb (C8, T1, median nerve)
7. Flexion at the hip (L2, L3, L4, iliopsoas)
8. Adduction at the hips (L2, L3, L4, adductors)
9. Abduction at the hips (L4, L5, S1, gluteus medius and minimus)
10. Extension at the hips (S1, gluteus maximus)
11. Extension at the knee (L2, L3, L4, quadriceps)
12. Flexion at the knee (L4, L5, S1, S2, hamstrings)
13. Dorsiflexion at the ankle (L4, L5)
14. Plantar flexion (S1)

Pronator Drift

1. Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed.
2. Instruct the patient to keep the arms still while you tap them briskly downward.
3. The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motor neuron disease.

Coordination and Gait

Rapid Alternating Movements

1. Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible.
2. Ask the patient to tap the distal joint of the thumb with the tip of the index finger as fast as possible.
3. Ask the patient to tap your hand with the ball of each foot as fast as possible.

Point-to-Point Movements

1. Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task. [p519]
2. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed.
3. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed.

Romberg

1. Be prepared to catch the patient if they are unstable.
2. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support.
3. The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).

Gait

Ask the patient to:

1. Walk across the room, turn and come back
2. Walk heel-to-toe in a straight line
3. Walk on their toes in a straight line
4. Walk on their heels in a straight line
5. Hop in place on each foot
6. Do a shallow knee bend
7. Rise from a sitting position

Reflexes

Deep Tendon Reflexes

• The patient must be relaxed and positioned properly before starting.
• Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response.
• Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth).
• Reflexes should be graded on a 0 to 4 "plus" scale:

Tendon Reflex Grading Scale
Grade	Description
0	Absent
1+ or +	Hypoactive
2+ or ++	"Normal"
3+ or +++	Hyperactive without clonus
4+ or ++++	Hyperactive with clonus
Grade	Description
0	Absent
1+ or +	Hypoactive
2+ or ++	"Normal"
3+ or +++	Hyperactive without clonus
4+ or ++++	Hyperactive with clonus

• Biceps (C5, C6)

1. The patient's arm should be partially flexed at the elbow with the palm down.
2. Place your thumb or finger firmly on the biceps tendon.
3. Strike your finger with the reflex hammer.
4. You should feel the response even if you can't see it.

• Triceps (C6, C7)

1. Support the upper arm and let the patient's forearm hang free.
2. Strike the triceps tendon above the elbow with the broad side of the hammer.
3. If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest.

• Brachioradialis (C5, C6)

1. Have the patient rest the forearm on the abdomen or lap.
2. Strike the radius about 1-2 inches above the wrist.
3. Watch for flexion and supination of the forearm.

• Abdominal (T8, T9, T10, T11, T12)

1. Use a blunt object such as a key or tongue blade.
2. Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12).
3. Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.

• Knee (L2, L3, L4)

1. Have the patient sit or lie down with the knee flexed.
2. Strike the patellar tendon just below the patella.
3. Note contraction of the quadraceps and extension of the knee.

• Ankle (S1, S2)

1. Dorsiflex the foot at the ankle.
2. Strike the Achilles tendon.
3. Watch and feel for plantar flexion at the ankle.

Clonus

If the reflexes seem hyperactive, test for ankle clonus:

1. Support the knee in a partly flexed position.
2. With the patient relaxed, quickly dorsiflex the foot.
3. Observe for rhythmic oscillations.

Plantar Response (Babinski)

1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
2. Note movement of the toes, normally flexion (withdrawal).
3. Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.

Sensory

General

• Explain each test before you do it.
• Unless otherwise specified, the patient's eyes should be closed during the actual testing.
• Compare symmetrical areas on the two sides of the body.
• Also compare distal and proximal areas of the extremities.
• When you detect an area of sensory loss map out its boundaries in detail.

Vibration

• Use a low pitched tuning fork (128Hz).
• Test with a non-vibrating tuning fork first to ensure that the patient is responding to the correct stimulus.

1. Place the stem of the fork over the distal interphalangeal joint of the patient's index fingers and big toes.
2. Ask the patient to tell you if they feel the vibration.

• If vibration sense is impaired proceed proximally:

1. Wrists
2. Elbows
3. Medial malleoli
4. Patellas
5. Anterior superior iliac spines
6. Spinous processes
7. Clavicles

Position Sense

1. Grasp the patient's big toe and hold it away from the other toes to avoid friction.
2. Show the patient "up" and "down."
3. With the patient's eyes closed ask the patient to identify the direction you move the toe.
4. If position sense is impaired move proximally to test the ankle joint.
5. Test the fingers in a similar fashion.
6. If indicated move proximally to the metacarpophalangeal joints, wrists, and elbows.

Subjective Light Touch

• Use your fingers to touch the skin lightly on both sides simultaneously.
• Test several areas on both the upper and lower extremities.
• Ask the patient to tell you if there is difference from side to side or other "strange" sensations.

Dermatomal Testing

If vibration, position sense, and subjective light touch are normal in the fingers and toes you may assume the rest of this exam will be normal.

Pain

• Use a suitable sharp object to test "sharp" or "dull" sensation.
• Test the following areas:

1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. Little toes (S1)

Temperature

• Often omitted if pain sensation is normal.
• Use a tuning fork heated or cooled by water and ask the patient to identify "hot" or "cold."
• Test the following areas:

1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. Little toes (S1)

Light Touch

• Use a fine whisp of cotton or your fingers to touch the skin lightly.
• Ask the patient to respond whenever a touch is felt.
• Test the following areas:

1. Shoulders (C4)
2. Inner and outer aspects of the forearms (C6 and T1)
3. Thumbs and little fingers (C6 and C8)
4. Front of both thighs (L2)
5. Medial and lateral aspect of both calves (L4 and L5)
6. Little toes (S1)

Discrimination

Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal.

• Graphesthesia

1. With the blunt end of a pen or pencil, draw a large number in the patient's palm.
2. Ask the patient to identify the number.

• Stereognosis

1. Use as an alternative to graphesthesia.
2. Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.).
3. Ask the patient to tell you what it is.

• Two Point Discrimination

1. Use in situations where more quantitative data are needed, such as following the progression of a cortical lesion.
2. Use an opened paper clip to touch the patient's finger pads in two places simultaneously.
3. Alternate irregularly with one point touch.
4. Ask the patient to identify "one" or "two."
5. Find the minimal distance at which the patient can discriminate.