Neurological assessment - introduction Why assess neurological function?

a This lecture aims to: a Few neurological disorders originate in the foot but…
 Provide overview of purpose of neuro. Assessment  You may be managing the sequelae of neuro. disorder in
 Outline aspects of neuro. assessment from podiatric the foot
viewpoint  Common example is peripheral neuropathy due to diabetes
 Describe process of each aspect of assessment  Need to be able to determine risk and organise treatment in
 Make you aware of how to conduct the assessment and accordance with appropriate measures for that disorder
what are normal values  May recognise previously undiagnosed neurological
 Describe laboratory testing for neurological assessment disorders which manifest in lower extremity
 Should be part of a complete patient examination in
situation of multiple or complex problem
a This lecture does not:
 Cover neuro anatomy in any great detail- you are expected
to know this
 Cover neurological disorders of gait or otherwise - this is
covered in 3rd year lectures

Overview Neurological symptoms:

a Neurological examination different to any other: a Headache a Disorders of olfaction

 Observations are indirect a Dizziness (smelling)
 Central nervous system cannot be visualised, palpated, a Seizure like episodes a Difficulty performing daily
percussed etc. so it’s intactness deduced by functional a Altered consciousness motor activities
testing a Personality change a Difficulty with speech,
 Major part of exam is technique of stimulus-response swallowing or chewing
a Memory loss/confusion
 Gross findings can be observed directly, but stimuli testing a Insomina, drowsiness and
a Weakness disorders of sleep
very important a Sensory phenomena or
 Must then correlate responses with pt. symptoms and a Tremors and involuntary
disordered sensations movements
knowledge of nervous system pathology to come to a Altered libido
diagnosis
a Disorders of sight/hearing

First impressions: Patient history

a Coming though the door: a Like any other examination history is very important
 Stooping, flexed, rigid posture ?? Parkinsonism a Especially so with neurological exam.
 Reel into door frame ?? Cerebella ataxia  Detailed history of symptoms required
a Size and shape of pt.  Most important to let pt use their own words
 Not dwarfism, excessive ht. Obesity, wasting and skeletal  Must clarify what the patient actually means for example
deformities
a Gait and posture WRITE DOWN WHAT YOU THINK I MEAN BY
 Try and observe without the pt. knowing
‘PINS AND NEEDLES’
 Look for kyphosis, scoliosis etc
 Muscular weakness, footdrop, circumduction of limb,
muscle spasticity etc.
a Try and correlate observations with known disorders

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Patient history Patient history

a Could mean: a Try and date the onset of symptoms - may be difficult
 Spontaneous tingling sensation - PARESTHESIA  Slow evolving lesions can be compensated for
 Absense of sensation - ANESTHESIA  Find out what makes it better / worse etc
 Decreased sensation - HYPOESTHESIA a Get thorough personal and family history
 Unpleasant sensation with innocuous stimuli - ALLODYNIA  Look for clues - disorders that can affect nervous system
a Similarly pts may complain of ‘weakness’ a Surgical history
 Could mean number of things  Obvious iatrogenic nerve damage
 True lack of power  Nerve damage caused by tourniquets or positions of
 Easy fatigability stretch held for a long time
 Incoordination a Social history
a VERY IMPORTANT TO ENSURE PT SYMPTOMS ARE  Occupational or recreational pursuits
UNDERSTOOD AS ACCURATELY AS POSSIBLE  Exposure to toxic substances or environmental hazards

Major sections of neuro. exam From podiatric viewpoint:

a MENTATION a Suggested by Spadone, (1999)

a CRANIAL NERVES a Natural observation of the patient
a MOTOR SYSTEM a Formal sensory examination
a SENSORY SYSTEM a Formal motor examination
a REFLEXES a Integrated sensory-motor function examination (reflexes)
a CEREBELLAR FUNCTION
a OTHER SIGNS

Sensory assessment: Sensory system:

a Evaluation of this system is least objective a The sensory system allows the individual to interact with
a Must rely on their environment
 Patient report of what they feel a Every sensation depends on impulses which are
 May vary with fatigue, suggestibility, attitude concerning recognised by receptors
illness and rapport with examiner and ability to a These impulses are then carried via afferent nerves to
communicate
the higher centres of the brain for interpretation
a Try and avoid tiring the patient with the examination
a Receptors are situated in:
a May need to break it up if too repetitive  Skin
a Always explain carefully what you are going to do  Subcutaneous tissue
a Can check reliability by repeating assessment on  Muscles
another occasion  Tendons
 Periosteum
 Visceral structures

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Sensory system: Altered sensations

a Abnormalities of sensation may be: a Increased sensation:

 Increased sensation  Usually manifested by pain
 Perversion  Can result from excessive stimulation of sense organs,
 Impairment fibres or tracts
 Or loss of feeling  Often a protective feature to avoid tissue damage
a Perversions of sensation:
 Paresthesia (tingling, pins and needles)
 Dysesthesia (disagreeable sensation caused by ordinary
stimuli)
 Phantom sensations (sensations from absent body parts)
 May be irritation of receptors, fibres or tracts

Altered sensations Purpose of sensory examination

a Impairment or loss of feeling a “The sensory examination is performed to discover

 Lessening of acuity of sense organs whether areas of absent, decreased, exaggerated,
 Decreased conductivity of fibres or tracts perverted or delayed sensation are present. The quality
 Dysfunction of higher centres lowering the power of and type of sensation that is affected, the quantity and
recognition or perception degree of involvement and the localization of the change
should be dermined.”
– DeJong, (1992)

a “To demonstrate clearly and consistently the limits of

any area of abnormal sensation. To determine which
modalities are involved within those limits. To compare
the findings with known patterns of abnormal sensation.”
– Bickerstaff & Spillane (1989)

Definition of terms: What do you test?

a ANALGESIA - absence of pain sensation a EXTEROCEPTIVE SENSATIONS:

a ANAESTHESIA - absence of sensation to touch  Pain, light touch and temperature
a HYPESTHESIA - diminished sensitivity to touch
a HYPALGESIA - diminished pain sensation a PROPRIOCEPTIVE SENSATIONS:
 Sense of position, passive movement, vibration and deep
a HYPERESTHESIA - increased sensation to touch pain sensation
a DYSESTHESIA - bizarre sensation or sensations
elicited by a stimulus a DISCRIMINATIVE OR CORTICAL SENSATIONS:
a PARESTHESIA - spontaneous abnormal sensations  Stereognosis, graphesthesia, two-point discrimination
such as pins and needles  These assessments are not usually part of the podiatric
a HYPERPATHIA - exaggerated pain response, usually to assessment as any suggestion of a central nervous system
lesion should prompt a referral
a stimulus

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Exteroceptive sensations: Assessment of pain

a Pain a Equipment:
 Mediated by slow conducting, poorly myelinated fibres  Pin or other sharp object, preferably with the other end
 Makes synaptic connection in posterior horn spinal cord blunt
 Second order neurone crosses within few segments  Avoid using sterile needles because they very sharp and
 Axon ascends to the thalamus (spinothalamic tract) can often draw blood
 Third order neurone continues to the sensory (parietal)  Safety pin OK or use disposable ‘Neurotips’
cortex
a Preparation of patient:
a So….. You are testing the integrity of above structures  Explain to patient what you are going to do
 Expose the whole lower limb
 Test on uninvolved skin to allow patient to feel the stimulus
 Ask the patient “do you feel this” and “is it sharp” to
determine that they can feel the difference

Assessment of pain

a Give patient instructions that they must say “SHARP” or

“DULL” in response to the stimulus when it is applied
a Get patient to close their eyes and keep them closed
a Alternate the use of sharp or blunt stimuli in a systematic
and logical manner
a Also ask the patient if the stimulus feel different in
different areas - move from impaired to normal sensation
a If you find an area of reduced or absent sensation you
must endeavour to map out this region to see if it follows
a dermatomal or peripheral nerve sensory pattern
a Can give clue to
 Peripheral nerve, sensory root, plexus, polyneuropathy or
central nervous system involvement

Exteroceptive sensations:

a Light touch
 Mediated by fast conducting, myelinated fibres
 Makes synaptic connection in posterior horn spinal cord
 Second order neurone crosses within few segments
 Axon ascends to the thalamus (spinothalamic tract)
 Third order neurone continues to the sensory (parietal)
cortex

a So….. You are testing the integrity of above structures

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Assessment of light touch Assessment of light touch

a Equipment: a Give patient instructions that they must say “YES” or

“NOW” in response to the stimulus when it is applied
 Small ball of cotton wool or feather or other soft light
substance a Get patient to close their eyes and keep them closed
a Also ask the patient where the stimulus is felt to avoid
a Preparation of patient: cheating
 Explain to patient what you are going to do a If you find an area of reduced or absent sensation you
 Expose the whole lower limb must endeavour to map out this region to see if it follows
 Test on uninvolved skin to allow patient to feel the stimulus a dermatomal or peripheral nerve sensory pattern
 Ask the patient “do you feel this” and “what does it feel a Always move from impaired to normal sensation
like” to determine that they can feel the stimulus
a Can give clue to
 Peripheral nerve, sensory root, plexus, polyneuropathy or
central nervous system involvement

Assessment of light touch Exteroceptive sensations:

a Keep in mind a Temperature sensation for hot and cold conduted via
 You must be systematic - keep a dermatome/peripheral same pathway as for pain
nerve diagram with you when testing a Keep in mind hot should not be too hot or it will stimulate
 Testing is very subjective - rely on patient communication pain fibres
and understanding of what you are trying to achive
 Try and use just a light touch and be consistent in the
amount of stimulus you supply

Assessment of temperature Assessment of temperature

a Equipment: a Give patient instructions that they must say “HOT” or

“COLD” in response to the stimulus when it is applied
 Test tubes of ice or cold water and hot water, or metal
canisters with hot and cold substances in them a Get patient to close their eyes and keep them closed
a Preparation of patient: a Also ask the patient where the stimulus is felt to avoid
 Explain to patient what you are going to do cheating
 Expose the whole lower limb a If you find an area of reduced or absent sensation you
 Test on uninvolved skin to allow patient to feel the stimulus must endeavour to map out this region to see if it follows
 Ask the patient “do you feel this” and “what does it feel a dermatomal or peripheral nerve sensory pattern
like” to determine that they can feel the stimulus - can they
differentiate between hot and cold
a Always move from impaired to normal sensation
a Can give clue to
 Peripheral nerve, sensory root, plexus, polyneuropathy or
central nervous system involvement

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Assessment of temperature Proprioceptive sensations

a Keep in mind a Most impulses carrying proprioception travel in posterior

 You must be systematic - keep a dermatome/peripheral columns of spinal cord
nerve diagram with you when testing a These sense organs are located in muscles, tendons
 Testing is very subjective - rely on patient communication and joints
and understanding of what you are trying to achive
 Cold stimulus should be around 5 - 10 degrees C a They respond to pressure, tension and stretching
 Hot stimulus should be around 40 - 45 degrees C  Travel along heavily myelinated fibres to dorsal root
ganglion
 In almost every instance, absence of sensation for one
stimulus is accompanied by the absence of the other  Then ascend on ipsilateral side to lower medulla where
synapse occurs
 Fibres then ascend to thalamus

Position/motion sense Position/motion sense

a These often tested together a Heel to knee to toe test…

a Simple test of position of digit... a This can also examine the pt. ability to detect position
a Patient should have their eyes closed and motion sense
a Examiner grasps hallux or lesser digit on MEDIAL AND a Pt. is asked to close eyes and move their heel of one
LATERAL ASPECT foot onto the knee and run it down the tibia to the toe
a Move digit up and down
a Pt should be able to discern between positions

Position/motion sense Vibratory perception

a Romberg sign a Use a tuning fork 128 Hz which produces strong

 Pt is asked to stand with feet together and eyes closed vibration
 Pt should be able to stand steadily with eyes open prior to a Pt is asked to close their eyes
testing with eyes closed
a Vibrating object is usually placed on bony prominences
 Ability to stand with eyes closed depends on integrity of the
proprioceptive information from sensory endings in the foot e.g. apex of hallux, medial 1st MTPJ, lateral 5th MTPJ,
ascending up the posterior column medial and lateral malleoli, anterior tibia
 It is thus a test of posterior column function a Patient is asked if they can feel vibration or not
 Test is POSITIVE if pt. sways markedly and suggests a a Can use tuning fork without vibration to test for cheating
posterior column disorder
a Don’t press instrument into skin

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Vibratory perception

a Bio-Thesiometer
 Instrument designed to quantify VPT (vibratory perception
threshold)
 Delivers vibration via plastic post at fixed frequency of 120
Hz
 Amplitude gradually increased
 Can read off level at which vibration is first perceived

Deep pain sensation

a Travels in proprioceptive pathways and is lost or

diminished in patients with diseases of the posterior
roots
a Test by squeezing the Achilles tendon

Discriminative or cortical sensation Stereognosis

a Refers to sensory decisions requiring perception and a Ability to identify an object by its feel, shape, texture and
integration of sensory information at the parietal cortex weight
a Sensory pathways and proprioception must be intact a With eyes closed object is placed in patients hand
 STEREOGNOSIS a They should not transfer object to other hand
 GRAPHESTHEISA
a Try and limit auditory information prior to giving the test
 TWO-POINT DISCRIMINATION
 E.g. Don’t clink around with keys or search for coins in your
pocket

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Graphesthesia Two point discrimination

a Ability to identify letters or numbers written on the skin a Ability to detect that a stimulus consists of two blunt
with a blunt point. points when applied
a Patient closes eyes - letters or numbers are traced out a Use dorsum of foot
on the palm of the hand, thigh or lower leg a Ability to discriminate between two points varies with
a If peripheral sensation is lost graphesthesia will be different parts of body
absent a Fingertips - possible less than 5mm separation
a Foot probably 5cm
a Depends on the integrity of light touch

From podiatric viewpoint: Formal motor examination

a Suggested by Spadone, (1999) a This will be covered in lectures on musculoskeletal

a Natural observation of the patient assessment
a Formal sensory examination a Keep in mind you are looking for:
 Strength, spasticity, tone and weakness of muscles
a Formal motor examination
 Atropy
a Integrated sensory-motor function examination (reflexes)
 Fasciulations

Reflexes

a Reflexes require the integrated function of:

 Muscle fibres
 Sensory afferents to spine
 Spinal internuncial neurones
 Motor efferents from spine
 Extrafusal muscle fibres
a Decreased reflexes can be caused by:
 Lesions of lower motor neurone
 Primary sensory neurone
 Lesions of spinal cord segment
a Increased reflexes can be caused by:
 Lesions of upper motor neurone

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 Reflexes

a Should be about same magnitude throughout body and

equal on left and right
a Patient should be relaxed
a Extremity should be hanging loosely or resting
comfortably
a Any muscle tension may alter reflex
a Minimal reflexes can be exaggerated by asking patient
to forcefully contract muscle group not involved in the
exam - ‘JENDRASSIK REINFORCEMENT’ - indicate the
reflex was obtained with augmentation in your records

Patellar reflex The ankle jerk - achilles reflex

a Peripheral nerve - FEMORAL a Peripheral nerve - TIBIAL

a Spinal segment - L2 - L4 a Spinal segment - S1-S2
a Patellar tendon should be lightly tapped with reflex a A little difficult to elicit
hammer a Position pt. with limb externally rotated and slight knee
a Important that pt. is relaxed initially flexion
a Look for extension of lower leg and/or visible contraction a Slightly dorsiflex patient’s foot to put provide tension
of the quadriceps a Strike achilles tendon and look for p.flexion of foot and
contraction of calf muscles
a ALTERNATIVE - mobile pt. could kneel on chair with
both feet projecting over the edge - can then strike
tendon from above.

Exaggerated reflexes: Absent or diminished reflexes:

a Excessively brisk a Reduced reflex may occur in normal individuals but

 Movement sudden and short - often seen in lesion of the become normal on reinforcement
upper motor neurones (pyramidal system) a True reduction or absence can occur from:
a Excessively prolonged  Break in any part of reflex arc, sensory, anterior horn cell,
 Cerebella lesions - large amplitude slow speed peripheral motor nerve, muscle itself
 Myxoedema - movement slightly retarded  Cerebral or spinal shock which occurs after cerebral or
a Clonic: spinal injury
 Rigidity, spasticity or muscle contracture splint a joint so
 Muscle which has been stretched goes into clonic
no movement can occur. Can occur in advanced spastic
contraction - common in knee and ankle reflex - usually
paraplegia or very anxious patients
means pyramidal system disease

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Superficial reflexes: Plantar reflex

a Many superficial reflexes - a Position pt. with knee slightly flexed and thigh externally
a Applied with light scratch with sharp point until response rotated
is obtained a Outer aspect of foot lying on couch
a These reflexes are polysynaptic - depend on intact a Warn pt. of test
corticospinal pathway a Outer aspect of sole firmly stroked with a blunt point
a Abnormal response usually indicates functional or such as key or end of percussion hammer
anatomical lesion of the corticospinal, pyramidal or a Move the object forwards and then inwards toward
upper motor neuron system middle of foot across mets.
a Stimulus must be firm but not painful

Normal result Babinski response

a Watch for movement of hallux and then lesser toes a EXTENSION of the great toe at MTPJ
a Hallux should flex at MTPJ a Usually the lesser digits will open out in a fanwise
a At same time lesser toes will also flex and close together manner and are dorsiflexed
a Movement is usually slow
a Can indicate a disturbance of the function of the
pyramidal system
a NOTE… this is a normal response in children less than
1 or 2 years of age
a Babinski response may also been seen in patients who
are in a comatose state

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