Neurological Examination

Question 1

Red flags associated with neurological problems (immediate medical assistance required)

Answer 1

• loss of consciousness or difficult arouse
• extreme confusion not consistent with premorbid status
• uncontrolled seizure activity
• acute infection with other associated neurologic signs
• rapid onset of focal neurologic deficits
• evidence of spinal column instability
• non responsive autonomic dysreflexia

Question 2

Yellow flags associated with neurological problems (outside referral required)

Answer 2

• acute onset of neurologic signs such as incontinence, saddle paresthesia, abnormal reflexes
• progressive neurologic signs in a known neurologic diagnosis that is not degenerative
• evidence of motor neuron disease
• new onset of involuntary movements or tremor
• change in autonomic status
• bulbar & other cranial nerve signs or symptoms
• constant headache that worsens over time
• neurologic signs inconsistent with medical diagnosis
• signs or symptoms of systemic illness
• significant changes in personality or cognitive status

Question 3

Signs with rapid onset suggesting a stroke in progress

Answer 3

• weakness, numbness, or tingling of face, arm, or leg especially of one side of body
• blurred or decreased vision in one or both eyes or double vision
• loss of speech or trouble understanding speech
• headache that is sudden, severe, and unusual
• dizziness, loss of balance, or loss of coordination with any of the other signs

Question 4

Indications for a neurological exam

Answer 4

• referral
• result from a neurological screening during ROS (review of systems)

Question 5

Examples of clinical indications for neurological exam

Answer 5

• Body structure/functions/impairments: numb feet, muscle weakness, abnormal posture, balance problems
• Functions/activity limitations: difficulty with functional mobility or ADLs
• Participation restrictions: difficulty with home management, work, job, play

Question 6

Components of a comprehensive neurological exam

Answer 6

• Mental status
• Sensation
• Motor function
• Balance/coordination
• Functional skills

Question 7

Why do we test mental status

Answer 7

• tested 1st
• accuracy of data from sensory & motor exam depends on the ability to understand & communicate effectively
• tested to determine pt’s ability to participate in POC, give consent, follow directions, communication needs understand precautions
• Cognitive domains assessed: arousal, attention, orientation, cognition (IQ), memory, communication, calculation, logic/abstraction

Question 8

What cognitive domains are assessed to determine mental status

Answer 8

• Arousal
• Attention
• Orientation
• Cognition (IQ)
• Memory
• Communication
• Calculation
• Logic/abstraction

Question 9

Define arousal/consciousness

Answer 9

• physiological status of being aware with ability to understand/respond to stimuli: readiness for activity
• brainstem and other brain areas control arousal, sleep-wake cycles

Question 10

What are the 5 levels of consciousness

Answer 10

• Alert: fully awake, interactions with PT are appropriate
• Lethargic: drowsy, may fall asleep, difficulty maintaining focus, interactions with PT may get diverted
• Obtunded: sleepy state, difficult to keep awake, confused when awake, interactions with PT are mostly unproductive
• Stupor: responds only to strong noxious stimuli like flexion of great toe, sharp pinch, rubbing knuckles on sternum, & then returns back unconscious state
• Coma: cannot be aroused

Question 11

What are the 3 components of the Glasgow Coma Scale (Gold Standard)

Answer 11

• Eye opening (4 = spontaneous opening of eyes, 3 = opening in response to speech, 2 = eye opening to pain, 1 = no eye opening response)
• Best verbal response (5 = verbal response demonstrate personal orientation to location, 4 = confused conversation is the best verbal response, 3 = inappropriate words in response to question, 2 = incomprehensible sounds, 1 = no verbal response)
• Best motor response (6 = follows motor commands, 5 = localizes a painful stimulus, 4 = withdraws specifically from pain, 3 = abnormal flexion response to pain “decorticate posturing”, 2 = abnormal extensor response to pain “decerebrate posturing”, 1 = no motor response)

Question 12

Standardized tests for assessing level of consciousness (LOC)

Answer 12

• Rancho Los Amigos Levels of Cognitive Function (LOCF): widely used in brain injury, tracks cognitive & behavioral responses of pt, level I = no response to level X = purposeful/appropriate response
• Coma Recovery Scale (CRS-R): better sensitivity. for lower levels - comas <-> veg state <-> minimal conscious state

Question 13

Define orientation

Answer 13

• awareness of person, place, time, & situation
• oriented X1/2/3/4 (example: A&Ox2 = person/place)

Question 14

Define attention

Answer 14

• awareness towards a stimuli in the environment
• Selective attention: awareness towards a stimuli in the environment w/o being distracted by the other stimuli, towards an object, task, or thought
• Sustained attention: time on particular task, repeat letters, words or digits forward or backward, digit span test, test of vigilance
• Alternating/switching attention: attention flexibility, back and forth between 2 tasks
• Divided attention: 2 tasks simultaneously, walkie talkie test (walk 20ft & return saying the alphabet), c-TUG

Question 15

Define memory

Answer 15

• registration, retention, & recall of past experiences & knowledge
• immediate memory (seconds) vs STM (day to day events) vs LTM (remote memory, years)
• explicit/declarative memory vs implicit/procedural/motor memory
• drugs can improve memory (cholinergic agents) or degrade memory (benzodiazepines, anticholinergics)

Question 16

Memory deficits

Answer 16

• injury to medial temporal lobe (limbic lobe/hippocampus) may show deficits in explicit memory, while retaining implicit memory (distributed broadly in CNS motor areas)
• amnesia: anterograde (inability to learn new material after injury) vs retrograde (inability to remember things prior to brain injury) “tip of the tongue phenomenon”
• PTA (post traumatic amnesia): lost of memory of event surrounding brain injury & inability to process info after brain injury

Question 17

Define perception

Answer 17

• integration of sensory info into meaningful info for making decisions & movement
• test after checking that peripheral sensory pathways are WNL: visual, auditory, somatosensory, etc.

Question 18

Perceptual disorders associated with neurologic conditions

Answer 18

• Body image/scheme disorders: unilateral spatial neglect, extinction, R/L discrimination
• Visuo-spatial disorders: depth perception, spatial relationship, figure-ground
• Apraxia: ideomotor, ideation, construction, dressing
• Agnosia: inability to recognize familiar objects, persons, sounds, shapes, or smells, visual, tactile, auditory

Question 19

Tests to assess unilateral spatial neglect

Answer 19

• Clock/house drawing test
• Albert’s cancellation test
• Comb & razor test: scoring using percent bias formula = L-R/total+ambiguous strokes, scoring varies b/w -1 to +1, close to -1 = L USN and close to +1 = R USN

Question 20

How to assess R/L discrimination

Answer 20

• ask pt to point to body part “point to your left elbow”
• pt should be able to point to each part accurately within reasonable time
• need to check for apraxia or aphasia

Question 21

Define dysarthria and aphasia

Answer 21

• Dysarthria: problems in articulation/problems with speech muscles
• Aphasia: lost of ability to understand or express speech due to brain damage, mostly in dominant hemisphere

Question 22

Describe Wernicke’s and Broca’s aphasia

Answer 22

• Wernicke’s/receptive/fluent aphasia: deficits in auditory/written comprehension with well articulated speech marked by nonsense words or substitutions
• Broca’s/expressive/non-fluent aphasia: deficits in articulating speech, limited vocabulary, but comprehension relatively preserved

Question 23

Define cognition

Answer 23

• ability of acquiring, processing, & recalling info, knowledge, & ability to judge/think, calculate

Question 24

3 areas for testing cognition

Answer 24

• Fund of knowledge: sum total individual’s learned information
• Calculation ability: adding/subtracting is easier than multiplying/dividing
• Abstract thinking ability: more sophisticated cognitive function; example: proverb interpretation - a rolling stone gathers no moss

Question 25

Tests for assessing cognition

Answer 25

- Mini mental state examination (MMSE): objective outcome measure, 24-30 = no cognitive impairment, 18-23 = mild cognitive impairment, 0-17 = severe cognitive impairment - MoCA: better sensitivity for detecting mild cognitive impairment, assesses mild cognitive domains - attention & concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, & orientation

Question 26

Testing for sensation

Answer 26

- Superficial receptors/exteroceptors: pain, temp., light tough, pressure - Deep receptors/proprioceptors: sense of relative positions of one's own body parts, awareness of joints at rest or movement, vibration

Question 27

Quality of sensory deficits

Answer 27

- Anesthesia: all sensory modalities lost/absent - Hypoesthesia: partial loss - Hyperesthesia: hypersensitive - Parasthesia: unpleasant sensations like burning, tingling, prickling, numbness with/without sensory stimulus - Allodynia: painful sensation to a normal stimulus that should not be painful

Question 28

How to test for superficial sensations

Answer 28

- Pain: sharp/dull discrimination - Temperature: distinguish b/w warm and cool stimuli, use a Tiptherm for diabetic neuropathy - Light touch: lightly touch/stroke the skin using finger, cotton, or tissue - Pressure: apply firm pressure enough to indent the skin

Question 29

How to test for deep sensations

Answer 29

- Awareness of joint position at rest/proprioceptive awareness: place body part in a static position & have pt identify if it's within initial, mid, or end range - Awareness of extremities in motion/kinesthesia awareness: move joint passively through relatively small ROM with minimal tactile stimulation & have pt indicate direction & ROM - Vibration: use a tuning fork (usually 128hz), hit tines against open palm & place fork base on pt skin

Question 30

How to test combined cortical sensations

Answer 30

- Two-point discrimination: ability to perceive 2 simultaneous touch stimuli as distinctly separate - Stereognosis: ability to recognize form of objects by touching & feeling, without visual input -Barognosis: ability to distinguish weights of different objects by holding them - Graphesthesia: ability to recognize letters, numbers, or designs 'written' on skin - Texture recognition: silk, cotton, wool - Double simultaneous stimulation for tactile extinction: ability to perceive simultaneous stimuli on opposite sides of body or proximally/distally on same side - All need intact superficial, deep sensory mechanisms & cortical sensory association areas

Question 31

How to test quantitative sensory

Answer 31

- Simple quantitative scoring for pain, temp., and light touch, take percentage of # of stimulus identified correctly - Von-Frey Monofilaments: to quantify touch using graduated filaments that bend at specified forces - TSA-II Thermal Sensory Analyzer + VSA 3000: to quantify both temp. and vibration senses - Bio-thesiometer/Vibrator: for quantifying vibration - SENSEBox: for measuring touch and pain thresholds - Algometer: for 'pain-pressure' threshold measurements

Question 32

General steps for a sensory exam

Answer 32

- gather required equipment - posture: pt can be supine or sitting - fully explain the purpose of the test - do a trial run make sure they understand the sensation to be felt - begin with superficial sensations & go from distal to proximal - once a deficit area is noted then do elaborate tests to assess exact skin boundaries & severity of involvement - data to be documented: modality, surface area involved, severity - perform bilaterally

Question 33

Dermatomes C2-S3

Answer 33

C2: posterior half of skull C3: medial end of clavicle C4: medial acromion below clavicle C5: lateral elbow C6: 1st digit/thumb C7: 3rd digit/middle finger C8: 5th digit/pinky T1: medial elbow T2: anterior axilla T4: nipple line T6 or T7: xiphoid process T10: umbilicus T12: anterior iliac crest/pubic symphysis L1: inguinal region/upper medial thigh L2: medial thigh mid-distance L3: medial knee L4: medial malleolus L5: base of great toe S1: lateral heel/lateral malleolus S2: posterior knee S3: ischial tuberosity

Question 34

Patterns of sensory deficits

Answer 34

- Unilateral (Hemiparetic) distribution: cerebral or brainstem pathology - Para/tetra-paretic distribution - Non-specific peripheral distribution - Stocking and glove distribution: peripheral neuropathies - Dermatomal distribution - Sporadic distribution - MS

Question 35

Elements of a motor exam

Answer 35

- tone - reflex integrity - muscle performance - voluntary movement patterns

Question 36

Assessment of tone for hypertonia

Answer 36

- Force/velocity dependent increased resistance to stretch - Clasp-knife response - Modified Ashworth Scale (0-4 grades) -Sing of UMN lesion - pyramidal tracts - Associated UMN signs: abnormal synergies, clonus, + babinski sign

Question 37

Assessment of tone for rigidity

Answer 37

- resistance to stretch is independent of force/velocity - Lead-pipe response: constant resistance - Cogwheel response: ratchet-like jerkiness - Sign of UMN lesion: extra-pyramidal tracts, basal ganglia lesions like Parkinson's - Associated signs: tremor, bradykinesia, loss of postural control

Question 38

Describe the modified Ashworth scale

Answer 38

- assessed during PROM with pt in supine - if testing a muscle that primarily flexes a joint place the joint in max flexion and move into max extension over 1 sec and vic versa for a primarily extension muscle

Question 39

General tone assessment scoring

Answer 39

- 0 = no response (flaccidity) - 1+ = decreased response (hypotonia) - 2+ = normal response - 3+ = exaggerated response (mild to moderate hypertonia) - 4+ = sustained response (severe hypertonia)

Question 40

MAS scoring for assessing spasticity

Answer 40

- 0 = no increase in muscle tone - 1 = slight increase in muscle tone (a catch followed by minimal resistance at end ROM) - 1+ = slight increase in muscle tone (a catch followed by minimal resistance throughout less than half the ROM) - 2 = more marked increase in muscle tone (through most of the ROM) - 3 = considerable increase in muscle tone (passive movement difficult) - 4 = affected part(s) rigid in flexion or extension

Question 41

Causes of hypotonia and associated LMN signs

Answer 41

- Genetic causes: Down syndrome, MD, CMT disease (Charcot-Marie Tooth disease), Marfan's syndrome, Euler's Danlos syndromes (connective tissue problems) - Congenital UMN causes: cerebral palsy (CP) - Acquired UMN causes: brain injury (BI), acute stroke, meningitis - Acquired LMN causes: Polio, myasthenia gravis - Associated LMN signs: spontaneous muscle fasciculations (visible movements), fibrillations (invisible) with denervation of motor units, muscle atrophy

Question 42

Categories for assessing reflex integrity

Answer 42

- Deep tendon reflexes (DTRs): stretch reflexes elicited by stretching muscle spindles by tapping sharply over muscle tendon - Cutaneous reflexes: elicited by a stroke on the skin, response his a specific muscle contraction (ex: babiski's sign) - Primitive/tonic reflexes: should be integrated during infancy, can persist with delayed development or re-emerge following brain injury; tonic reflexes change postural tone rather than producing overt movements

Question 43

Grading of reflexes integrity

Answer 43

- 0 = no reflex - 1+ = hypo-reflexive - 2+ = normal - 3+ = hyper-reflexive - 4+ = Clonus - UMN lesion = increased/brisk reflexes - LMN/peripheral sensory lesion = hypo-reflexive

Question 44

Define Jendrassik maneuver

Answer 44

- use of a distraction if DTRs are difficult to elicit, to enhance responses, ex: hook hands together & pull apart, clench teeth, make fist with contralateral extremity

Question 45

Less common reflexes tested

Answer 45

- finger flexion reflex - Hoffman sign (flicking of the middle fingers distal phalanx, pos. = thumb & index finger move toward each other) - Jaw jerk reflex - Pronator teres - Abnormal clonus

Question 46

Cutaneous reflexes

Answer 46

- Plantar reflex: stroking the lateral side of sole of foot from heel to ball using a blunt object, Normal response = toes flex downwards, Pos. = toes extend/babinski sign - Babinski Sign: big toe extends & other toes fan out, normal in infants up to 1 years old & should be integrate by 2-3 years - Abdominal reflex

Question 47

Assessment of muscle performance

Answer 47

- Muscle bulk: observe/measure limb girth, in some muscular dystrophies apparent girth increases but muscle gets weaker - Muscle strength: MMT (0-5 grades), handheld dynamometers, isokinetic dynamometer - Muscle endurance - Issues with muscle testing: validity problems with UMN lesions due to presence of abnormal synergies, watch for substitutions

Question 48

Myotomes from C1-S2

Answer 48

- C1‐C2 Neck Flexion/Extension - C3 and CN XI Neck Side Flexion (Side Bending) - C4 and CN XI Shoulder Elevation - C5 Shoulder Abduction / Shoulder Lateral Rotation / Elbow Flexion - C6 Elbow Flexion, Wrist Extension - C7 Elbow Extension, Wrist Flexion - C8 Thumb Extension, Ulnar Deviation, Finger Flexion - T1 Hand Intrinsics, Abduction/Adduction - L2 Hip Flexion - L3 Knee Extension - L4 Ankle Dorsiflexion - L5 Toe Extension - S1 Ankle Plantar Flexion, eversion and hip extension - S2 Knee Flexion

Question 49

Assessment of function/activities/tasks

Answer 49

- Activities can be categorized as: self care, functional mobility tasks (transfers/bed mobility), & locomotion (gait, stairs, w/c mobility) - Activities/tasks can also be categorized depending on the stage of motor control involved: Transitional mobility (rolling/scooting) -> Stability (static sitting/standing) -> Controlled mobility (reaching, dynamic sitting/standing) -> Skills (transfers, gait)