neurological examination

Neurological Examination : 

Neurological Examination Presented by: Anup Shrestha,MBBS Dalian medical University Pre-Intern ,WRH

Examination of Motor System : 

Examination of Motor System

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The motor system consists of 1. Upper motor neurons 2. Lower motor neurons 3. Extra pyramidal motor system 4. Cerebellar system

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The assessment of motor system is considered under following headings. Inspection and palpation of muscles Assessment of tones Examination of reflexes Testing movement and power Testing co-ordination

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1.Inspection and Palpation of Muscles - Requires full exposure of muscles. - Look for assymetry,inspecting both proximally and distally. - Note any deformities. - Examine specially for wasting or hypertrophy,fasciculation and involuntary movement. - Palpate muscles to assess their bulk

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Common abnormalities 1. Muscle bulk :Lower motor neuron lesions cause wasting in specific muscles. Upper motor neuron damage can cause disuse atrophy of muscle groups. Certain occupation and sports leads to muscle hypertrophy.The wasting of muscle is associated with diseases like rheumatoid arthritis, cachexia. 2.Fasciculation: Looks likes irregular ripples or twitches under the skin overlying muscles at rest commonly seen in LMN lesions. Caneat is a fasciculation with muscle atrophy or without association of LMN signs. They may be benign(physiologic) or drug induced (cholinergic).

3.Myclonic jerk: : 

3.Myclonic jerk: It is the sudden shock like contractions of one or more muscles. - Associated with epilepsy, diffuse brain damage and dementias .

4. Tremor: : 

4. Tremor: It is oscillatory movement about a joint or a group of joints resulting from alternating contraction and relaxation of muscles. Common Types i. Physiological tremor :- hyperthyroidism, alcoholic, excess coffee. ii. Coarse tremor (slow) :-Parkinson's disease. iii. Intention tremor :- Cerebellar damage iv. Rubral tremor :-lesions of rod nucleus and sub-thalmic nucleus, vascular disease or multiple sclerosis.

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Tone: Tone is the resistance felt by the examiner when moving a joint passively through its range of movement. Site to check the tone: Upper Extremities - wrist and elbow joint Lower Extremities - knee level,ankle joint. Common abnarmalities: Muscle tone may be decreased (hypotonia) or increased (hypertonia).

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a. Hypotonia : It is decreased tone and usually associated with muscle wasting,weakness and hyporeflexia. Feature of cerebellar disease and occurs in early phases of cerebral or spinal shock There are 2 principal types hypertonia 1.Spasticity 2.Rigidity

Spasticity : 

Spasticity Spasticity means increased tone throughout range of motion, and then there is a sudden release (catch). Seen in UMN lesion. Spasticity is velocity dependent(sudden release). Usually accompanied by # weakness # hyperreflexia # extensor planter response # clonus

Rigidity : 

Rigidity Rigidity: increased tone throughout the range of motion. If intermittent and regular interruption to the movement gives jerky feeling, is called cogwheel rigidity, which is seen in extrapyramidal diseases such as Parkinson’s disease. Rigidity is not velocity dependent (continuous)

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Reflexes 1.Superficial Reflexes - elicited by stroking skin or mucous membranes a. Plantar Response (S1-2) - Run a blunt object (car key,orange stick) along the lateral border of the sale of the foot toward the little toe. - Normal response is flexion of large toe and adduction of other toes.

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Babinski sign Chaddock sign Oppenheim sign Gordon sign Schaefer sign Some of the other methods to test extensor-planter response :

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b. Abdominal Reflexes (T8-12) - The patient should be supine and relaxed. - Use an orange stick and stroke briskly but lightly in a medical direction across the upper and lower quadrant of the abdomen. - The normal response is contraction of the underlying muscle with the umbilicus moving laterally and up or down depending upon the quadrant tested. Abnormalities Plantar response -Extension of large toe. - Unequivalent sign of UMN damage. Abdominal reflexes -Lost in upper motor lesion

c. Cremasteric reflex(L1-2) : 

c. Cremasteric reflex(L1-2) Abduct and externally rotate the patient's thigh medial aspect of the thigh. Use an orange stick to stroke the upper medial aspect of the thigh. Normally the testicle on the side stimulated will rise briskly. - used to identify the level of spinal cord lesion after injury.

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2. Deep tendon Reflexes : - Rapid muscle contraction response when deep receptors in the muscle or in the tendons are stimulated. 1. Hoffman's Reflex : - Place your right index finger under the distal inter-phalanges joint of the patient's middle finger - Using your right thumb flick the patient's finger downward. - Look for any flexion of patient's thumb. 2. Finger jerk : - Place your middle and index fingers across the palmer surface of patient's proximal phalanges. - Observe the flexion of the patient's finger

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Bicaps reflex (C5-C6) - Flexion at the elbow when the biceps tendon is struck. Triceps jerk (C6,7) - Extension at the elbow when the triceps tendon is struck. Knee jerk reflex (L2,L4) - Extension at the knee when the patellar tendon is struck. Ankle reflex (S1,2) - Plantar flexion at the foot a when Achilles tendon is struck. Common abnormalities: Abnormal brisk reflexes - Sign of UMN damage. Disminished of absent jerk - Due to LMN lesion but also occur in myopathies and myasthenia. Positive Hoffman's reflex and finger jerk indicate hypertonia. NEXT PAGE

Pathological or Primitive reflexes : 

Pathological or Primitive reflexes 1. Snout Reflex:With an index finger lightly tap the lips. An abnormal response is exaggerated protrusion. 2.Glabellar reflex:This sign is elicited by repetitive tapping between the patient's eyebrows. The normal response is to blink a few times and then stop. The reflex is positive when the patient continues to blink each time you tap. 3. Grasp Sign:Firmly stroke the palm from the radial side.in abnormal response, your finger is grasped by the patient’s hand. 4.Palmomental reflex: Apply firm pressure to the palm nest to thenar eminence with a tongue depressor. An abnormal response is puckering of the chin.

Strength : 

Strength The Medical Research Council Scale for muscle power. 0. No muscles contraction visible. 1. Flicker of contraction but no movement. 2. Joint movement when effect of gravity eliminated. 3. Movement against gravity but not against examiner's resistance. 4. Movement against resistance but weaker than normal. 5. Normal power.

Clinical Examination : 

Clinical Examination Isometric testing: Ask the patient to contract a group of muscles to maintain a position and resist your attempt to displace the limb. Isotonic testing: Ask the patient to put the joint through a movement while you try to oppose the action.

Clinical Hints : 

Clinical Hints Unilateral weakness because of an UMN lesion can be detected by the following testing:• Pronator drift sign: Ask the patient to hold the arms out in front with the palmsup and fingers open, and close the eyes. Downward drifting of the arms withpronation of the hand indicates weakness because of UMN. • Test strength of the wrist extensors.Weakness of these muscles is seen early in the course of a UMN lesion.

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Ask the patient to rapidly tap the fingers together. Slowness or clumsiness is indicative of an early UMN lesion. This sign, however, should be interpreted within the context of the clinical history. Foot-circling sign: For subtle weakness of distal lower extremity because of UMN lesion, the patient is unable or does a clumsy job when asked to circle the foot. Forearm-rolling test: The affected forearm cannot roll around the other

Paralysis : 

Paralysis Paralysis refers to weakness or loss of voluntary movement. Based on the clinical types, paralysis may be classified as: 1)Monoplegia: a paralysis of one extremity only 2)Paraplegia:a symmetric paralysis of both extremities 3)Quadriplegia (tetraplegia): a paralysis of all 4 extremities 4)Hemiplegia: a paralysis of one side of the body limited by the median line 5)Crossed paralysis: a paralysis of one or more ipsilateral cranial nerves and contralateral hemiplegia.

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②Based on the location, paralysis may be classified as: 1)Neurogenic paralysis: caused by lesion of motor neurons or peripheral nerves 2)Myogenic paralysis: caused by muscular diseases

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Common abnormalities: UMN lesion: - Muscle weakness - Increased deep tendon reflexes - Depressed abdominal responses - Extensor plantar responses - Spasticity LMN lesion: - Muscle weakness - Depressed deep tendon reflexes - Fasciculation - Wasting - Flaccidity

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5.Co-ordination: Examination to detect complex movements smoothly and efficiently. a. Rebound phenomenon b. Finger-nose test c. Heel-shin test d. Rapid alternating movements Apraxia: It is difficulty or inability to perform a motor action despite the patient understanding the task. Common abnormalities: 1. Ideational apraxia - cannot initiate task 2. Ideomotor apraxia - perform tasks in odd fashion 3. Constructional apraxia - difficulty drawing a figure. 4. Dressing apraxia - Neglect the normal dressing >>

Rebound test. : 

Rebound test. Ask the patient to flex at the elbow and resist you as you try to extend the arm. Place your other hand on the patients shoulder and turn the patient’s head toward the other direction, to shield the patient’s face and eyes. Let the arm go suddenly. Do one side at a time. Arm returns to steadying position—normal. Arm oscillates several time then stays—abnormal rebound. <<

Rapid alternating movements : 

Rapid alternating movements . Demonstrate to the patient (finger tapping, hand tapping, etc.), first in slow motion, and then faster. Do one hand at a time. If the patient is able to do the task with normal rate and rhythm—normal. If movements are irregular, disorganized, dysrhythmic, uncoordinated—dysdiadochokinesia <<

Heel-to-shin test : 

Heel-to-shin test For best results, this test needs to be done in the supine position. Ask the patient to lift one leg up and place the heel on the shin of the other leg, and then smoothly rub it along the shin down toward the toes. The test is abnormal if movement is irregular or the heel falls off the leg. Make sure the patient rubs the heel on the shin, and not the pad of the foot. <<

Finger-nose test : 

Finger-nose test This is best done in the sitting position. Stay in front of the patient and hold your index finger about one arm’s length from the patient. Ask the patient to touch your finger with his or her index finger, then to the tip of the nose. Make sure the patient’s arm is extended. You may move your target finger in different directions. The task is to be done slowly at first, and then faster. Do one arm at a time. 1. Patient accurately performs the task: normal. 2. Patient develops tremor when approaching the target (your finger or his nose)—intention tremor: cerebellar disease. 3. Patient misses the target: past-pointing or dysmetria <<

Sensory System : 

Sensory System

Examination of Sensory system : 

Examination of Sensory system There are several sensory modalities for routine test. Vibration b. Joint position c. Light touch d. Pin prick e. Temperature f. Stereognosis and Graphesthesia h. two-point discrimination i. double-simultaneous stimulation >>>>

Two point discrimination : 

Two point discrimination Ask patient to look away of close the eyes.Use a two point discriminator and apply either one point or two points on patient forefinger and ask whether one or two stimuli were felt. Then adjust the distance and determine the minimal separation at which they are felt separately. back

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Stereognosis: Ask the patient to close the eyes. Place familiar object (e.g. coin, key) in patient’s hand and ask the patient to identify the object after feeling them. Graphesthesia: Use the blunt end of pencil and trace letters and digits on patient palm. Ask them to identify the figure. back

Light touch : 

Light touch Use a small piece of cotton or, alternatively, a fingertip. You must dab the skin and not rub the skin. Explain to the patient when an area of the body is touched to say “yes.” Do this while the patient’s eyes are closed. You can quantitate the test comparing between touch and non-touch. Give a few seconds between each touch. The area of abnormality can be mapped. back

Vibration. : 

Vibration. Use a 128-Hz tuning fork. Demonstrate to the patient (by placing the fork over the chin or forehead) to be sure that the patient understands that the patient has to report “buzzing” or “humming” and not the sense of being touched by the fork. Ask the patient to close the eyes, and place the tuning fork over a bony prominence or over the ball of the large toe or fingers. Start distally and move proximally. However, if distally normal, you do not have to move proximally. Determine the threshold by perceiving vibration to the lowest intensity. Ask the patient to report to you when he or she no longer feels vibration and compare the patient’s perceptions with your own. You can objectively test vibration by comparing buzzing to touch feeling. <<<

Rombergism : 

Rombergism Romberg test: important because it suggests sensory disorder associated to position of the limbs and joints and tension of the muscles. Ask the patient to stand up, put the feet together, place the arm in front of the face.Ask the patient to close the eyes, if the patient falls when the eyes are closed, Romberg test is positive <<<

Pinprick : 

Pinprick Use a safety pin. Explain to the patient and demonstrate what you are going to do (sharp versus dull, symmetry). Try to establish the threshold to the least-intensity stimulus. Start from an abnormal area and move toward a more normal area. Similarly, begin distally and move proximally to assess the distribution. You assess the difference between sharp and dull objectively. The pinprick examination can map out the sensory loss. <<<

Temperature : 

Temperature You can informally check coldness by using the metal part of your percussion hammer and compare it to the rubber head of the hammer (warmer). Some neurologists suggest doing the temperature test instead of pinprick, because it is painless and gives you the same information. <<<

Double simultaneous stimulation. : 

Double simultaneous stimulation. Ask the patient to close the eyes and randomly touch different parts of the body with a cotton ball or the tip of your finger, one spot at a time or two different spots simultaneously. Abnormal double simultaneous stimulation is suggestive of a non-dominant parietal lobe lesion. <<<

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Gait: Gait is function of motor, sensory, vestibular, visual and cerebellar systems. Important abnormal types of gait: Antalgic gait : is one which is altered to reduce pain:It results in “dot-dash” mode of walking. Acute Lumber disc herniation Short stepped gait :walks with a rigid trunk, reduced arm swing, slow and short steps, and a tendency for the knees to be flexed Parhinson’s disease or diffuse cerebrocascular disease Paraplegic(scissoring) :Legs crossed over— cerebral palsy, UMN lesions. Ataxic gait : Patient has broad-based, uncoordinated gait and staggers cerebellar disease

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Dystrophic(Waddling) : Weakness of the hip muscles, particularly the gluteus medius, results in an excessive drop of the hip and trunk tilting to the side opposite the foot placement. The hips oscillate up and down with every step, making the patient seem to waddle ---myopathy Hemiplegic(Circunduction ): On leg swing out and adduction—UMN lesion Steppage Gait(Foot drop) :excessive flexion of the hips and knees with every step. With sensory loss, the heel tends to strike the ground heavily. peroneal palsy, L5 root lesion, Guillian-Barre syndrome. • gait apraxia —: Patient has difficulty initiating walk consider normal pressure hydrocephalus.

Common abonoramities : 

Common abonoramities Abnormalities on sensory testing are best considered where the lesion(s) lies. Peripheral nerve and dorsal root. @ peripheral neuropathies: touch and prick sensation, vibration and joint position sense, rombergism. Spinal cord. @ Traumatic and compressive lesions of the spinal cord cause loss or impairment of sensation in dermatomal distribution below the level of the lesion.

Ant spinal artery syndrome: loss of spinothalamic sensation and motor function.Syringomyelia: pain and temperature loss and sparing of dorsal column sensation loss.Brown-Sequard syndrome: ispilateral weakness and loss of vibration and joint position with contralateral loss of pain and temp.Intracranial: Alternating analgesia: loss of pain and temp sensation on one side of the face and opposite side of the body and occurs and lower brain stem lesionsThalamic lesions may cause patchy sensory impairment on the opposite side with a very unpleasant, poorly localized pain often of burning quality. : 

Ant spinal artery syndrome: loss of spinothalamic sensation and motor function.Syringomyelia: pain and temperature loss and sparing of dorsal column sensation loss.Brown-Sequard syndrome: ispilateral weakness and loss of vibration and joint position with contralateral loss of pain and temp.Intracranial: Alternating analgesia: loss of pain and temp sensation on one side of the face and opposite side of the body and occurs and lower brain stem lesionsThalamic lesions may cause patchy sensory impairment on the opposite side with a very unpleasant, poorly localized pain often of burning quality.

Reference : 

Reference Greenberg clinical Neurology Macleod’s Clinical Examination Harrison’s principle of medicine Practicing Neurology by Rahman Pourmand

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