Neurological Examination

1
Neurological Examination

• Reflex Testing
• Cranial Nerve Testing

2
PROCEDURE

• A detailed history of the patient
• focus on present neurologic complaints
• Exam
• Directed by the hypothesis generated by the
  subjective history and neurologic signs
• The history and exam address 3 questions
• is neurologic pathology present ?
• where is the lesion ?
• what is the nature of the lesion ?

3
Evaluation

• Important to become familiar with what is normal
  response
• What is normal may vary slightly from patient to
  patient
• Emphasis today is on screening examination
• Must decide if more thorough evaluation
  necessitates referral to specialist

4
Deep Tendon Reflexes
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Deep Tendon ReflexesMonosynaptic Reflex Arc
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Reflex Levels

• Biceps
• C5
• Brachioradialis
• C6
• Triceps
• C7

• Patellar
• L4
• Achilles
• S1

7
Biceps C5
8
Brachioradialis C6
9
Triceps C7
10
Patellar or Knee Jerk L4
11
Achilles or Ankle Jerk S1
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Keys to Success

• Patient relaxation and PT too! ?
• Necessary for accurate response
• Support extremity
• Flick of wrist, not hammering
• Distraction / reinforcement techniques
• Jendrassik Manuever
• UE cross ankles/clench
• LE flexed finger pull
• Document if use
• PRACTICE!

13
Grading

• 0 No response muscle contraction is neither
  palpable/visible
• 1 Minimal response consisting of slight muscle
  contraction without joint movement
• 2 Normal response mild muscle contraction
  associated with minor joint movement
• 3 Brisk response moderate to strong muscle
  contraction associated with obvious joint
  movement
• 4 Hyperactive reflex very strong, brisk muscle
  contraction accompanied by exaggerated joint
  movement associated with clonus

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Interpretation

• Grades 0 and 4 are indicative of pathology
• Grade 0 generally LMN involvement or neural
  shock during first hours
• Grade 4 UMN involvement
• Grades 1 and 3 are normal unless
• Asymmetric
• Associated with other abnormalities

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Abnormal Results

• Asymmetrical reflexes
• Alterations from proximal to distal
• Peripheral neuropathy
• Pendular reflexes
• Cerebellar disease

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Upper/Lower Quarter Neurological Screen
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Pathological Reflexes

• Babinksi
• LE
• Hoffmans
• UE
• Clonus

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Babinski

• Test run end of reflex hammer up the lateral
  aspect of the foot from heel to great toe

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Positive Babinski

• () DF of great toe with fanning of lesser toes

20
Hoffman Response

• Test Press down on patients middle fingernail
  until your fingers flick over the end of
  patients nail

() other fingers flex transiently after middle
finger flicked
21
Clonus

• Test quickly stretch foot passively into DF

() test involuntary oscillations or BEATS
between PF/DF
22
Cranial Nerve Testing
23
CN I Olfactory

• Smell
• Use familiar smells
• Test one nostril at a time
• Eyes closed
• Clinical correlation anosmia

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CN II Optic

• Vision
• Visual acuity
• Peripheral fields
• Bilateral then unilateral
• Allow corrective lenses
• Pupillary light reflex

Clinical correlation blindness
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CN III Oculomotor

• Pupil dilation
• Pupillary light reflex
• (II III)
• Immediate and simultaneous pupil constriction
• Accommodation reflex
• (II III)
• Focus shift far to near
• Eyes converge, pupils constrict
• Eye movement

Clinical correlation dilated and fixed pupil,
ptosis, ipsilateral gaze fixed down and out
26
CN III, IV VI(Oculomotor, Trochlear, Abducens)

• Eye movement
• Visual tracking
• Follow movement of finger with eyes onlylarge
  X
• Suspect weakness? unilateral test

Clinical correlation weakness of downward gaze
or lateral gaze
27
CN V Trigeminal

• Muscles of mastigation
• Open/close mouth,
• Bite down
• Palpate masseter
• Facial sensation
• Forehead, cheek, lower jaw light touch

Clinical correlation loss of general sensation,
loss of corneal reflex, deviation of jaw to
ipsilateral side
28
CN VII Facial

• Facial expression,
• Raise eyebrows, smile, show lower teeth, puff out
  both cheeks
• Taste (ant 2/3)
• Place something salty/sweet on front of tongue
• Clinical correlation flaccid muscles, loss of
  blink, loss of taste, Bells palsy

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CN VIII Vestibulocochlear

• Hearing (Cochlear)
• Gross Hearing Test
• Rub fingers together 12 inches from patients
  ear
• Detect ability to hear left vs. right
• Tuning fork
• Rinne/Weber Tests
• Balance (Vestibular)
• Balance
• Nystagmus
• Pt looks forward, right, left
• Eyes examined for involuntary oscillations
• Past pointing
• PT finger arms length from pt pt alternately
  touch nose and reach toward finger EO/EC

• Clinical correlation deafness, disequilibrium

30
CN IX X

• CN IX Glossopharyngeal
• Taste (posterior 1/3)
• Swallow
• CN X Vagus
• Innervates larynx
• Swallow
• Test
• Gag reflex?
• Swallowing

Clinical correlation loss of gag reflex, loss
of taste, dysphagia, dysarthria
31
CN XI Spinal Accessory

• Trapezius and SCM motor
• Resisted shrug
• Bilaterally
• Unilaterally
• Resisted cervical rotation

Clinical correlation difficulty in turning
head, ipsilateral shoulder drooping
32
CNXII Hypoglossal

• Tongue movement
• Tongue protrusion should occur in midline
• Clinical correlation ipsilateral paralysis of
  tongue