Assessment of Function

Question 1

What does the neurological exam test?

Answer 1

Function. There are several tests ranging from easy to difficult (need for sensitive measures to detect small changes). Titrate patients performance to understand the degree of deficit and changes over time. Gives ability to compare across sesions

Question 2

How can the exam be altered for different patients?

Answer 2

Different parts can be completed with more or less detail depending on the clinical suspicion of a particular diagnosis or lesion

Question 3

How long does the exam take?

Answer 3

Around 1 hour

Question 4

What makes testing more difficult?

Answer 4

Lack or minimal consciousness. Attentional and alertness deficits. Lack of cooperation (though elements can still be assessed such as language and reasoning etc). Language/comprehension deficits. Deadness. Malingering. Fatigue

Question 5

Why is it important that the neuroexam is modifiable?

Answer 5

Impairments in one area can affect the patient’s ability to perform other parts of the exam

Question 6

What needs to be taken into account when interpreting exam results?

Answer 6

Pre-morbid status, behaviour during the test situation, and information about aetiology and lesion site

Question 7

What are conditionalities, and why are they important?

Answer 7

Cueing, prompting, repeating questions, clarifying etc. Need to be noted as it can be an indication of deficits. Test results may stay same but if its with less conditionalities, that shows some improvement of functioning

Question 8

What are the stages of the neurological exam?

Answer 8

Assess mental status, test cranial nerves, test motor functions/reflexes, test sensory functions

Question 9

Why is mental status tested first?

Answer 9

Other elements of the exam depend on this

Question 10

What is involved in testing mental status?

Answer 10

Level of alertness, attention and co-operation. Tests of global function (spelling words forwards/backwards, and digit span recall). Also includes memory, language, apraxia, neglect problems

Question 11

What can cause difficulties in tests of mental status?

Answer 11

Subtle attentional deficits may not always be evident in structured testing situations as patients pay more attention in these settings and during the small duration. Relatives/caretakes can clarify how minor difficulties manifest in everyday life

Question 12

What are tests for the orientation for person, time and place?

Answer 12

Patient’s full name, current location, current date

Question 13

What is tested during speech and language evaluations?

Answer 13

Spontaneous speech (fluency/tonal modulation), comprehension, naming, repetition, reading and writing

Question 14

What are tests for recent and remote events?

Answer 14

Ask patient to remember four items/places, ensure it has been registered by immediate recall, ask to recall again after delay of 3-5 minutes of distraction. And for remote events, ask about historical or verifiable personal events that the clinician knows the answer to

Question 15

What is Gerstmann’s syndrome?

Answer 15

Impairment of calculations, right/left orientation, finger agnosia and agraphia, in an otherwise intact patient. Due to lesions in the dominant parietal lobe

Question 16

What is apraxia?

Answer 16

Inability to follow a motor command that is not due to a primary motor or language impairment

Question 17

How is apraxia tested?

Answer 17

Ask patient to do complex tasks using commands such as to pretend to comb hair, copy clinician actions, show them a comb and ask them to demonstrate how to use it, then use it. Using tool should significantly improve copying/miming in patients with apraxic impairments

Question 18

What is hemineglect?

Answer 18

An abnormality in attention to one side (usually left) that is not due to a primary sensory or motor disturbance. Deficit in spatial representations

Question 19

How is hemineglect tested?

Answer 19

Important to assess basic sensory functions before assessing for spatial neglect, but neglect tasks include line bisection, figure copying, drawing from memory and cancellation tasks

Question 20

What are important things to consider when conducting a neglect assessment?

Answer 20

Position of materials. Instructions and cues (such as saying ‘right’ instead of ‘ok’). How to end the task

Question 21

How is logic and abstractions tested?

Answer 21

Ability to solve simple problems. How well they can comprehend similarities. How they interpret proverbs. Important to check educational background first as this can explain abilities or disabilities in certain tasks

Question 22

What are frontal release signs?

Answer 22

Grasp, snout, root and suck reflexes. Primitive reflexes that are normally present in infants but inhibited by the frontal lobes as progress through typical development. Re-emergence of these reflexes is a sign of frontal lobe dysfunction

Question 23

What are graphomotor tasks?

Answer 23

Draw alternating symbols. Preservation: difficulty in changing from one action to the next when asked to perform a repeated sequence of actions (sign of dysexecutive syndrome)

Question 24

What mental health assessments should be completed?

Answer 24

Tests for delusions/hallucinations. Also assessment for depression, anxiety and mania

Question 25

What are the cranial nerves?

Answer 25

12 cranial nerves that are predominantly involved in senses such as smell, taste and vision. They also control behaviours such as head and eye movements, as well as swallowing

Question 26

How are the cranial nerves tested?

Answer 26

Test for various eye movements: extraocular movements (move eyes in 6 directions), smooth pursuit (track object as it moves across field), convergence (track objects as it moves toward/away), saccades (rapid alteration of looking at two objects). Abnormalities can reflect problems with cranial nerves 3 (occulumotor), 4 (trochlear) and 6 (abducens)

Question 27

How is motor function assessed?

Answer 27

Assessment of peripheral nerves, spinal cord, subcortical structures, cerebellum and motor cortex. Observe movements looking for twitches/tremors/posture. Test muscle strength, reflexes and gait/coordination

Question 28

How is muscle strength tested?

Answer 28

Strength graded on scale of 0 (no contraction) to 5 (normal strength). Skill of clinician is to adjust tension to gauge strength. Look for right/left asymmetries and compare upper/lower limbs

Question 29

How are reflexes examined?

Answer 29

Examine elbow, wrist, knee and ankle. Graded on scale of 0 (no reflex) to 5 (sustained clonus). 1-3 is normal, unless asymmetric. 0, 4-5 is abnormal

Question 30

How is gait and coordination tested?

Answer 30

Finger-nose-finger test which involves integrated functioning of multiple sensory and motor subsystems. If primary pathways are intact but patient has coordination difficulties, this indicates a cerebellar lesion

Question 31

How can tests of sensory function be difficult?

Answer 31

Depends a lot on patient co-operation (need to say if they feel something). Suggestion can also modify a patients response. These can be slightly remedied by conducting tests twice (eyes open and shut)

Question 32

What are tests of primary sensation?

Answer 32

Pain and two-point discrimination

Question 33

What are tests of cortical sensation?

Answer 33

Test for graphesthesia (ask to close eyes and identify shapes outlined on palm). Test for stereognosis (ask to identify objects by touch and test each hand independently). Abnormal sensation suggests lesion in contralateral sensory cortex