Neurological Examination

Question 1

What should be included in the intro of the neurological examination?

Answer 1

You should always ask the patient if they have any pain before you commence your
examination. If so, you will need to adapt your examination and your interpretation of the
results accordingly. For example, muscle power often appears diminished around a stiff or
painful joint and you should not mistakenly interpret this as a primary neurological problem.
You will need to check for signs of meningeal irritation like neck stiffness and Kerning sign.
You should check against the Glasgow Coma Scale and conduct a bed side cognitive test like
AMT only if there are concerns about cognition. You should also test the patient’s speech

Question 2

Neurological examination of the upper limbs: What should we ask before we start the examination?

Answer 2

Ask if the patient has any pain (including neck pain) before commencing this examination.
Ask: Is the patient right or left handed? Patients often perform slightly better with the dominant
hand/limb

Question 3

Neurological examination of the upper limbs: What are the key areas of the examination?

Answer 3

Tone
Power (against resistance)
Reflexes
Co-Ordination
Sensation

Question 4

Neurological examination of the upper limbs: what is included in the tone assessment?

Answer 4

Passively move each joint
Is there normal, even or uneven
resistance?
Spasticity is velocity dependent- faster
you move more the resistance. Rigidity is
same irrespective of the speed of the
movement.
Hypertonia (spasticity or rigidity?)
Hypotonia

Question 5

Neurological examination of the upper limbs: What is included in the power assessment?

Answer 5

Pronator drift (UMN lesion) – see below
Shoulders: Flexion, extension, abduction,
adduction
Elbows: Flexion, extension, pronation,
supination
Wrists: Flexion, extension
Fingers: flexion, extension, abduction
Thumb: palmar abduction (median),
adduction (ulnar) and opposition
(median)

Use the MRC grading system (see
below)
Learn the muscle groups being tested,
their nerve roots (myotomes) and their
peripheral nerve supply

Question 6

Neurological examination of the upper limbs: What is included in the reflex assessment?

Answer 6

Biceps
Triceps
Supinator / brachioradialis
Use reinforcement if needed (clench
teeth)

Question 7

Neurological examination of the upper limbs: What is included in the coordination assessment?

Answer 7

Finger to examiners finger then to own
nose repeatedly
Finger to own nose with eyes closed
Fine movements e.g. piano-playing or
touch thumb to each fingertip on same
hand rapidly
Dysdiadochokinesis

Question 8

Neurological examination of the upper limbs: What is included in the sensation assessment?

Answer 8

Soft touch
Pain / pinprick (OSCE: describe only)
Temperature (OSCE: describe only)
Proprioception
Vibration sense (128Hz tuning fork)
Cortical localisation: Stereognosis
(identify coin/key placed in patient’s hand
with eyes closed); 2-point discrimination;
graphaesthesia.

Learn the dermatomes and myotomes being tested

Question 9

Neurological examination of the lower limbs: What is asked before beginning?

Answer 9

Ask if the patient has any pain (including back pain) before commencing this examination.
You will need to perform Romberg’s test and assess the patient’s gait, either at the
beginning or end of this examination (see below)

Question 10

Neurological examination of the lower limbs: What is involved in the inspection?

Answer 10

Posture, wasting, tremor, fasciculations, involuntary movements.

Question 11

Neurological examination of the lower limbs: what is involved in the tone assessment?

Answer 11

Passively move each joint
Is there normal or even resistance?
Hypertonia (spasticity or rigidity?)
Hypotonia
Check for ankle clonus (UMN lesion)

Question 12

Neurological examination of the lower limbs: What is involved in the power assessment?

Answer 12

Hip: abduction, adduction, flexion and
extension
Knee: flexion and extension
Ankle: dorsiflexion, plantarflexion,
eversion, inversion
Big toe: plantarflexion and dorsiflexion

Question 13

Neurological examination of the lower limbs: What is involved in the reflexes assessment?

Answer 13

Knee
Ankle
Use reinforcement if needed (clench
fingers)
Plantar reflex (Babinski response)
Ankle Clonus

Question 14

Neurological examination of the lower limbs: What is involved in the coordination assessment?

Answer 14

Heel-shin test

Question 15

Neurological examination of the lower limbs: What is involved in the sensation assessment?

Answer 15

Soft touch
Pain / pinprick (OSCE: describe only)
Temperature (OSCE: describe only)
Proprioception
Vibration sense (128Hz tuning fork)
Check the trunk for the sensory level if
indicated.

Question 16

Neurological examination of the lower limbs: what is the Romberg’s Test?

Answer 16

The patient stands with feet together, arms outstretched in front of them and hands supinated.
If they cannot do this with the eyes open, it suggests a cerebellar lesion.
If the patient can maintain the position with the eyes open but loses balance when the eyes
are closed, this suggests loss of proprioception.

Question 17

Assessment of gait, how is this done?

Answer 17

Assess the patient’s gait both walking normally and walking heel-to-toe.
Assess their balance, posture, stride length and arm swing

Question 18

What is a hemiplegic gait?

Answer 18

Hemiplegic gait: Arm adducted at the shoulder, flexed elbow and wrist, leg extended
and adducted at the hip, knee extended, and ankle plantar-flexed
The patient lurches his upper body toward the unparalysed side to elevate the pelvis
and swing the paralysed leg round. The plantar-flexed foot scrapes along the ground.

Question 19

What is an apraxic gait?

Answer 19

The gait is slow and shuffling. The stride length is markedly decreased. Can lose
balance while turning.
Gait in Parkinson’s disease: In addition to above, there is loss of arm swinging on
walking. The patient takes increasingly rapid steps forward to maintain an upright
posture (Festinant gait).

Question 20

What is a steppage gait?

Answer 20

Paralysis of the dorsiflexors of the ankle results in a “drop-foot”. The patient flexes the
knee and lifts the foot high to clear the toes from the ground. As it is returned to the
ground, there is a loud slapping noise.
Unilateral drop-foot suggests a common peroneal nerve palsy or spinal lesion.
Bilateral suggests generalised polyneuropathy.

Question 21

What is an ataxic gait?

Answer 21

Ataxic gait- This is a wide based gait. The feet are planted wide apart and patient
sways to one or both sides while walking. Attempting to walk heel-to-toe makes ataxic
gait more pronounced.

Question 22

Describe the MRC grading of power?

Answer 22

5/5 = movement against gravity with full power against resistance
• 4/5 = movement against gravity with reduced power against resistance. (Grades 4-, 4 and
4+ indicate reduced power but the presence of movement against slight, moderate and
strong resistance respectively).
• 3/5 = movement against gravity only without applied resistance
• 2/5 = muscle contraction with active movement only when gravity is eliminated
• 1/5 = flicker of muscle contraction seen, no movement
• 0/5 = no muscle contraction

Question 23

How do you complete the neuro exam?

Answer 23

Thank the patient
• Request them to redress
• Wash your hands