Neurological Assessment

The Brain


Cerebrum
     

General movement Visceral functions Perception Behavior Voluntary movement Interpretation of sensory data Muscle tone Equilibrium Posture

Cerebellum
  

The Brain


Brainstem
 

Involuntary functions Perception of sensations Motor and sensory functions Processing station between cerebrum and upper brainstem Gross intentional movement without conscious thought

Cranial Nerves


Basal Ganglia


The Spinal Cord and Tracts



Descending (Motor) Tracts



Convey information from brain to muscle groups

Facilitative  Inhibitory


 

Control of muscle tone and posture Pyramidal tract



Carries impulses for voluntary movement

Motor Tracts

The Spinal Cord and Tracts



Ascending Tracts
 

Mediate various sensations Facilitate sensory signals



Dorsal (posterior column) tract



Discrimination of touch, deep pressure, vibration, position, stereognosis, two point discrimination Discrimination of light and crude touch, pressure, temperature, pain

Spinothalamic tract


Sensory Tracts

The Spinal Cord and Tracts



Spinal Nerves
  

31 pairs Supply and receive information in specific dermatomes Within the spinal cord, separate into
 

Ventral root (motor)



Carry impulses from the spinal cord to the muscles Carry impulses from sensory receptors to the body of the spinal cord
 

Dorsal root (sensory)



Then to brain for interpretation OR Initiate a reflex response

Reflex Arc

Review of Related History



Current Problems


Current Problems
  

Seizures/convulsions
     

Character Aura? LOC Frequency Associated manifestations Timing

  

Pain Gait coordination Weakness or paresthesia



Paresthesia: unusual sensation such as numbness, tingling, or burning

Duration Time of day Activities

 

Changes in mental status Changes in the 5 senses

Medications

Review of Related History



Past Medical History

      

Trauma CVA Meningitis, encephalitis Deformities Hypertension Neurologic disorder Brain surgery

Review of Related History



Family History


Family History
  

Hereditary disorders
   

Tay-Sachs Huntingtons chorea Muscular dystrophy Neurofibromatosis

  

Alcoholism Mental Retardation Epilepsy or other seizure disorder

  

Alzheimer disease Learning disorders Weakness or gait disorders Thyroid disease Diabetes Hypertension

Review of Related History



Personal and Social History

      

Environmental or occupational hazards Hand, eye, foot dominance ADL Sleeping patterns Use of alcohol and tobacco Use of mood-altering drugs Anxiety

Equipment and Techniques



Equipment
   

Equipment
 

  

Penlight Tongue blade Tuning fork Familiar objects (coin, key, paper clip) Cotton wisp Reflex hammer Aromatic substances

Flavored substances Test tubes of hot and cold water DDST Inspection Palpation

Techniques
 

General Comments


The neurologic system can be examined almost constantly while the rest of the body is explored. In fact, we have already covered the bulk of the neurologic examination as we examined other systems. There are 6 portions to complete neurologic assessment

Six Portions


Mental Status
 

Review from General Assessment (Module 4) Also

Pupil Size  Glasgow Coma Scale


Pupil Size


Normal range: 2 - 6 mm
 

Drugs: pinpoint pupils Increased intracranial pressure: pupils begin to dilate



Dilated and fixed, poor prognosis

Glascow Coma Scale



Score BEST response in each category Highest score = 15  (normal) Lowest score = 3  (deep coma)

Eye Opening
Spontaneous To Voice To Pain None 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Best Verbal
Oriented Confused Inappropriate Words Incomprehensible Sounds None

Best Motor
Obeys Commands Localizes Pain Withdraws to Pain Flexion to Pain (decorticate) Extension to Pain (decerebrate) None

Six Portions


Cranial Nerves


Review from  Assessment of the Head and Neck  Assessment of the Ears  Assessment of the Eyes Review from Musculoskeletal Assessment

Muscle Tone and Strength



Six Portions


That leaves only 3 more!

  

Proprioception and Cerebellar Function Sensory Function Reflex Function

Proprioception/Cerebellar Function


Proprioception


The sensation of position and muscular activity originating from within the body which provides awareness of posture, movement, and changes in equilibrium Coordination and Fine Motor Skills Balance

Test
 

Proprioception/Cerebellar Function


Coordination and Fine Motor Skills



Rapid rhythmic alternating movements

Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR  Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed  person should be able to do these movements smoothly, maintaining rhythm, with increasing speed  Observe for slow, stiff, non-rhythmic, or jerky movements


Proprioception/Cerebellar Function


Coordination and Fine Motor Skills



Accuracy of movement


Finger-to-finger test with persons eyes open

 

Movements should be rapid, smooth, and accurate Consistent past pointing may indicate cerebellar impairment Movement should be smooth, accurate, and rapid Should move heel from knee up and down the shin in a straight line, without irregular deviations to the side

Finger to nose test with persons eyes closed



Heel-to-shin with person supine, sitting, or standing



Proprioception/Cerebellar Function


Coordination and Fine Motor Skills



Balance: Equilibrium


Romberg test
 

 

Have person stand with arms at side and feet together Have person perform initially with eyes open and then with eyes closed Stand close to prevent falls person should maintain position with eyes open or closed for 20 seconds with only minimal swaying If the Romberg is positive (i.e. there is significant swaying or the person has to take a step to maintain/regain balance) DO NOT DO OTHER TESTS OF BALANCE

Proprioception/Cerebellar Function


Coordination and Fine Motor Skills



Balance: Equilibrium


Have person stand with feet slightly apart



Examiner pushes shoulders with enough effort to throw person off balance Recovery should be quick

Ability to balance on one foot with eyes closed for at least 5 seconds  Ability to hop in place on one foot for at least 5 seconds


Proprioception/Cerebellar Function


Coordination and Fine Motor Skills



Balance: Gait
Covered in Musculoskeletal Assessment  Heel-toe walking will exaggerate any unexpected finding in gait evaluation


Sensory Function


Primary Sensory Functions

 

Always with the persons eyes closed Sites

 

Vision, hearing, smell, taste and facial sensations



Part of CN Assessment

Hands  Lower arms  Abdomen  Feet  Lower legs

Sensory Function


Primary Sensory Functions



Superficial touch
Use a cotton wisp  Have the person point to the area touched


Superficial pain
Sharp and dull sensations  Allow 2 seconds between each stimulus


Temperature and deep pressure



ONLY TESTED when superficial pain sensation is not intact

Sensory Function


Primary Sensory Functions



Vibration
  

Place stem of tuning fork against bony prominences Begin distally Sites
  

Sternum Finger wrist elbow - shoulder Toes ankle shin

Position of joints (great toes, one finger on each hand)

 

Up Down

Sensory Function


Cortical Sensory Functions

 

Always with the persons eyes closed Stereognosis



Ability to identify a familiar object by touch and manipulation



Tactile agnosia: inability to recognize objects

Graphesthesia
With a blunt pen, draw a letter or number on the palm  Should be readily recognized


Sensory Function


Cortical Sensory Functions



Point location


Touch an area of the body and ask the person to point to where you have touched


This is being tested the same time as superficial touch

Extinction phenomenon
Simultaneously touch one or both sides of the body  Ask the person to point to where you have touched


Sensory Function


Cortical Sensory Functions



Two-point discrimination
Use two pointed objects, alternate touching skin with one or two points  Find the distance at which the person can no longer discriminate 2 points

    

Fingertips Toes Palms Forearms Upper arms and thighs

2 - 8 mm 3 - 8 mm 8-12 mm 40 mm 75 mm

Reflexes


Superficial Reflexes
  

Abdominal reflex: See Abdominal Assessment Cremasteric reflex: See Male Genitalia Plantar reflex

Reflexes


Superficial Reflexes


Plantar reflex


Stroke lateral side of foot from heel to the ball, then across to the medial side


Normal response is a positive plantar reflex  Plantar flexion of all toes Abnormal response is the Babinski sign in those u 2 yoa  Dorsiflexion of the great toe with or without fanning of the other toes

Reflexes


Deep Tendon Reflexes

  

Have person relaxed Position limb with slight tension on the tendon to be tapped Grading
    

0 1+ 2+ 3+ 4+

No response Sluggish or diminished Active or expected response More brisk than expected Hyperactive with or without clonus

When the reflexes are absent try eliciting it after reenforcing (Jendrassik maneuver), by asking the person to interlock and pull flexed fingers

Reflexes


Deep Tendon Reflexes



Biceps
Antecubital fossa  With the arm gently flexed at the elbow, find the biceps tendon with your thumb.



Strike your own thumb with the hammer

Response contraction of biceps muscle causing flexion of the elbow

Reflexes


Deep Tendon Reflexes



Brachioradialis
1-2 inches above the wrist  Support the relaxed arm either on the lap or semipronated on your forearm  Strike above the styloid process a few centimeters above the wrist on the thumb side  Response flexion and supination of the forearm


Reflexes


Deep Tendon Reflexes



Triceps
Back of elbow  With the elbow in flexion, tap the triceps tendon, just proximal to the elbow, with a reflex hammer.  The arm could also be abducted at the shoulder for this maneuver  Response contraction of the triceps muscle with extension of elbow


Reflexes


Deep Tendon Reflexes



Patellar
Knee jerk  Slightly lift up the leg under the knee, and tap the patellar tendon with a reflex hammer



If performed in a sitting position, have the legs dangle over the edge of the chair or table

Response contraction of the quadriceps muscle with extension of lower leg

Reflexes


Deep Tendon Reflexes



Achilles
At level of ankle  Slightly externally rotate at the hip  Gently dorsiflex the foot  Tap the Achilles tendon with a reflex hammer  Response contraction of the gastrocnemius muscle with plantar flexion of foot


Reflexes


Deep Tendon Reflexes



Clonus
Test if reflexes are hyperactive  Sharply dorsiflex the foor and maintain in that position  Clonus is when the foot continues to tap



Count beats

Sustained clonus may represent neoropathy or hyperreflexia

Screening Examination


When the history and PE findings prior to the neuro exam have revealed no potential neurological problem, a screening exam is all that is necessary
 

CN II-XII (without smell and taste) Proprioception and Cerebellar Function



One test in each area Superficial touch and pain at a distal point on each extremity Vibration and position of great toes

Sensory function
 

Reflexes: DTRs (except plantar reflex and clonus)

Developmental Variations


Neonates


Primitive reflexes
Palmar grasp  Plantar grasp  Moro (Startle)  Stepping  Tonic neck (Fencing)


Muscle strength and tone especially important

Developmental Variations


Infants
  

Purposeful movement begins at about 2 months Transferring objects at about 7 months Purposeful releasing at about 10 months

Developmental Variations


Children
 

Denver DTRs not usually tested in child who demonstrates appropriate development Positive Babinski sign normal through age 2 Paresthesias Headaches

Pregnancy
 

Developmental Variations


Older Adults
 

 

Medications can impair much of the neuro exam May have markedly diminished sense of taste and smell May have reduced ability to differentiate colors Tactile, position, and vibratory senses may be diminished Less brisk or absent DTRs

Review Questions


In what direction does development occur in infants and children?



Cephalocaudal

What questions would you ask a person about seizure activity?

Review Questions


What are the 6 portions of the neuro exam?

     

Mental status Cranial nerves Muscle tone and strength Proprioception and cerebellar activity Sensory function Reflexes

Review Questions


Demonstrate the following tests:

    

Graphesthsia Biceps reflex Stereognosis Equilibrium Accuracy of movement

What reflex finding is normal in an infant but abnormal in an adult?



Babinski sign

Videos of Neurological Exam



Copy these URLs and paste into your Web browser:



http://medstat.med.utah.edu/neurologicexam/ho me_exam.html OR http://www.conntutorials.com/chapter3.html OR http://medinfo.ufl.edu/other/opeta/neuro/NE_mai n.html