THE NEUROLOGICAL EXAMINATION Prof Mohammad Abduljabbar

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NEUROLOGICAL EXAM 1- MENTAL STATUS 2- CRANIAL NERVES 3- MOTOR EXAM - Tone - Strength (Power) - Reflexes - Cerebellum ( Gait ) 4- SENSATION

MOTOR EXAMINATION

Motor Examination

Motor Examination Observe: Look for any twitches, tremors, abnormal movements or postures. Look carefully for hypokinesia , decreased eye blinking or staring which could be indicative or an extrapyramidal disorder such as Parkinson’s disease. In suspected lower motor neuron disorders , look for muscle wasting or fasciculation. Palpate muscles in cases of suspected myopathy to check for muscle tenderness. Passively move each limb to check muscle tone. Ask the patient to relax before beginning.

MUSCLE OBSERVATION ( Inspection ) Atrophy (wasting) Abnormal movement Deformity Fasciculation

ABNORMAL MOVEMENTS TREMOR CHOREA ATHETOSIS REST WITH ARMS OUTSTRETCHED INTENTION CHOREA ATHETOSIS

TONE Normal. Hypotonia: in lower motor neuron lesion Hypertonia: in upper motor neuron lesion - Cogwheel - Clasp knife

Motor Examination Test for subtle weakness first by checking pronator drift and pronation/supination movements. Then check individual muscles for strength using the MRC scale to rate strength

STRENGTH GRADING( 0-5 ) 0 - NO MOVEMENT 1 - FLICKER 2 - MOVEMENT WITHOUT GRAVITY 3 - MOVEMENT AGAINST GRAVITY 4 - MOVEMENT AGAINST RESISTANCE 5 - NORMAL STRENGTH

STRENGTH EXAM UPPER AND LOWER EXTREMITIES DISTAL AND PROXIMAL MUSCLES GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH

REFLEXES

MUSCLE STRETCH REFLEXES (DEEP TENDON REFLEXES) (GRADED 0–5) 0 – Absent. 1 - Present with reinforcement. 2 - Normal 3 - Enhanced 4 – Unsustained clonus 5 - Sustained clonus

Deep tendon reflexes Biceps Brachioradialis Triceps Knee Ankle

OTHER REFLEXES Upper motor neuron dysfunction Frontal release signs BABINSKI HOFMAN’S JAW JERK Frontal release signs GRASP SNOUT SUCK PALMOMENTAL

Plantar Response Test the plantar response by scraping an object across the sole of the foot beginning from the heel, moving forward toward the small toe, and then arcing medially toward the big toe. The normal response is downward contraction of the toes. The abnormal response, called Babinski's sign, is characterized by an upgoing big toe and fanning outward of the other toes. The presence of Babinski's sign is always abnormal in adults, but it is often present in infants, up to the age of about 1 year.

CEREBELLAR FUNCTION Gait ( TANDEM ) RAPID ALTERNATING MOVEMENTS FINGER TO FINGER TO NOSE TESTING HEEL TO SHIN Gait ( TANDEM )

Gait evaluation Include walking and turning Examples of abnormal gait High steppage Waddling Hemiparetic Shuffling

Romberg Sign Stand with feet together - assure patient stable - have them close eyes Romberg is positive if they do worse with eyes closed Measures: Cerebellar function Frequently poor balance with eyes open and closed Proprioception Frequently do worse with eyes closed Vestibular system

SENSORY EXAMAMINATION

Sensory Examination The sensory exam relies to a large extent on the ability or willingness of the patient to report what he is feeling. It can therefore often be the most difficult and unreliable part of the neurologic exam

Primary Sensation - Superficial: •Light touch •Pinprick •Temperature - Deep: •Vibration •Joint position

Start distally and move proximally Sensory Examination Start distally and move proximally PIN PRICK TEMPERATURE VIBRATION ( 128 HZ TUNING FORK ) JOINT POSITION SENSE

HIGHER CORTICAL SENSATIONS GRAPHESTHESIA STEREOGNOSIS DOUBLE SIMULTANEOUS STIMULATION BAROSTHESIA TEXTURES

Cortical sensation Graphesthesia Sterognosis Double Simultaneous Stimulation Intact primary sensation with deficits in cortical sensation such as agraphesthesia or astereognosis suggests a lesion in the contralateral sensory cortex. Note, however, that severe cortical lesions can cause deficits in primary sensation as well. Extinction with intact primary sensation is a form of hemineglect that is most commonly associated with lesions of the right parietal lobe. Extinction can also be seen in right frontal or subcortical lesions, or sometimes in left hemisphere lesions causing mild right hemineglect