Finals_Assessing Neurological System and Mental Status Examination Flashcards
Its Components of Nervous System
- Central Nervous System (CNS)
- Peripheral Nervous System
Component of CNS
Brain and Spinal Cord
It connects the brain and peripheral nervous system
Spinal Cord
It carries messages to and from the CNS
Peripheral Nervous System
Components of Peripheral Nervous System
- Somatic Nervous System
- Autonomic Nervous System
Controls voluntary muscles and transmits sensory information to the CNS
Somatic Nervous System
Controls involuntary body functions
Autonomic Nervous System
Arouses body to expend energy
Sympathetic Nervous System
Calms body to conserve and maintain energy
Parasympathetic Nervous System
Components of Cerebrum
- Frontal
- Parietal
- Temporal
- Occipital
It has right and left hemispheres joined by the corpus callosum
Cerebrum
- aggregation of neuronal cell bodies
- mediates higher level function like memory, perception, communication, initiation of voluntary movements
Gray Matter
Identify which of the four lobes is being described:
- regulates emotional, expression, behavior, intellect
- influence personality
- control voluntary movement
Frontal Lobe
Identify which of the four lobes is being described:
- Perceives and interpret sensory inputs like pain, temp, touch, texture, and proprioception
Parietal Lobe
Identify which of the four lobes is being described:
- Influence hearing, smell, taste, and memory
Temporal Lobe
Identify which of the four lobes is being described:
- perceive and interpret visual stimuli like spatial relationships
- influence the ability to read with understanding
Occipital Lobe
Parts of the Diencephalon
- Thalamus
- Hypothalamus
Clusters multiple stimuli into a coherent whole
Thalamus
It regulates production of several hormones. Stimulates visceral responses such as heart rate in response to emotions. Regulates temp by prompting shivering and sweating
Hypothalamus
Parts of the Brainstem
- midbrain
- Pons
- Medulla Oblongata
Identify which part of the brainstem is being described:
- regulates visual, auditory, and other reflexes
- controls eye movements, focusing, and pupil dilation
Midbrain
Identify which part of the brainstem is being described:
- helps control respiration function, facial movement and sensation, and eye movement
Pons
Identify which part of the brainstem is being described:
- Regulates heart and respiratory rate and BP
- Regulates protective reflexes like swallowing, vomiting, sneezing, and coughing
Medulla Oblongata
- Responsible for the coordination and smoothing of voluntary movements
- maintain equilibrium
- maintains muscle tone
Cerebellum
Where is the spinal cord located
vertebral canal
- It extends from the medulla oblongata to the first lumbar vertebra
- Conducts sensory impulses up the ascending tracts of brain
- conducts motor impulses down descending tracts to neurons that stimulate glans and muscles
- responsible for simple reflex activity
Spinal Cord
2 ways impulses travel
- afferent - towards brain
- efferent - away from brain
Identify the Sensory Ascending Neural Pathways:
- Sensations of pain, temperature, and crude light touch travel here
Spinothalamic tract
Identify the Ascending Neural Pathways:
- Sensations of positions, vibration and fine touch travel here
Posterior columns
Pyramidal Tracts
- Corticospinal Tracts
- Corticobulbar tracts
Identify which pyramidal tract is being described:
- control voluntary skilled movement of the extremities and fine movement of fingers
Corticospinal Tract
Identify which pyramidal tract is being described:
responsible of voluntary control of face, head, and neck
This tract crosses over to the opposite side then travels down the spinal cord. It then carries it to the muscles and produce voluntary movement
Pyramidal tract
This tract is responsible for involuntary control and modulation like tone and balance. It originates from the brain stem.
Extrapyramidal Tracts
Extrapyamidal Tracts
- Rubrospinal Tract
- Reticulospinal Tract
- Vestibuospinal Tract
- Tectospinal (Colliculospinal) Tract
Identify which Extrapyramidal tract is being described:
- responsible for motor control
Rubrospinal tract (midbrain)
Identify which Extrapyramidal tract is being described:
- Has Pons: facilitates contraction and increases tone
- has Medulla: inhibits contraction, decreases tone, and automatic breathing
Reticulospinal Tract
Identify which Extrapyramidal tract is being described:
- involved in balance and posture
Vestibulospinal tract
Identify which Extrapyramidal tract is being described:
- Involved in coordination of head and eyes
Tecotospinal (Colliculospinal) Tract
What are the 12 Cranial Nerves
1.Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Vestibulochochlear
9. glossopharyngeal
10. vagus
11. spinal accessory
12. hypoglossal
Identify which cranial nerve is being described:
- Carries Smell impulses from nasal mucous membrane to the brain
Olfactory Nerve (I)
Identify which cranial nerve is being described:
- Carries visual impulses from eye to brain
Optic Nerve (II)
Identify which cranial nerve is being described:
- contracts eye muscles to control eye movement
Oculomotor Nerve (III)
Identify which cranial nerve is being described:
- Contracts superior oblique muscle to control inferomedial eye movement
Trochlear Nerve (IV)
Identify which cranial nerve is being described:
- has 3 divisions: Ophthalmic, Maxillary, and Mandibular
- Motor: chewing and jaw opening and clenching
- Sensory: conveying sensory data from eyes, nose, mouth, teeth, jaw, forehead, scalp, and facial skin
Trigeminal Nerve (V)
Identify which cranial nerve is being described:
- Control Lateral Eye Movement
Abducens (VI)
Identify which cranial nerve is being described:
- Motor: Closing Eyes, closing mouth, moving lips, and other facial expression, salivation, and lacrimation
- Sensory: Tasting on anterior tongue
- Branches: Temporal, Zygomatic, Buccal, Mandibular, Cervical
Facial Nerve (VII)
Identify which cranial nerve is being described:
- Contains sensory fibers for hearing and balance
Acoustic/ Vestibulocochlear Nerve (VIII)
2 phases of hearing
Conductive and Sensorineural Phase
Identify which phase of hearing is being described:
- from the external ear through middle ear
Conductive Phase
Identify which phase of hearing is being described:
- involves the cochlea and cochlear nerve
Sensorineural Phase
Identify which cranial nerve is being described:
- Sensory: Contains sensory fibers for taste and posterior third of tongue and sensory fibers of pharynx (results in the gag reflex when stimulated)
- Motor: Provides Secretory Fibers to the parotid salivary glands; promotes swallowing movements
Glossopharyngeal Nerve (IX)
Identify which cranial nerve is being described:
- Carries sensation from throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera
- Promotes swallowing, talking, and production of digestive juices
Vagus Nerve (X)
Identify which cranial nerve is being described:
- Innervates neck muscles that promote movement of the shoulders and head rotation
- promotes movement of larynx
Spinal Accessory Nerve (XI)
Identify which cranial nerve is being described:
- innervates tongue muscles that promote the movement of food and talking
Hypoglossal Nerve (XII)
How many pairs of spinal nerves do we have
38 pairs
- 8 cervical
- 12 thoracic
- 5 sacral
- 1 coccygeal
What does the sensory root of each spinal nerve innervate
Dermatome
Pathway in spinal cord
Each nerve attached to spinal cord by two nerve roots. Sensory (afferent) fiber that enters through the dorsal (posterior) root and the motor (efferent) fiber that exits through the ventral (anterior) roots of the cord
Components of the Autonomic Nervous System
Sympathetic and Parasympathetic Nervous system
Its activated during stress sand elicits responses such as decreased gastric secretions, bronchiole dilation, increased pulse rate, and pupil dilation. It arises from thoracolumbar level T1 to L2
Sympathetic Nervous System
It restores and maintains normal body functions like decreasing heart rate; arise
from craniosacral regions (S1 to S4 and CN III, VI, IX, and X
Parasympathetic Nervous System
What to consider for patient’s biographical data
- age and education level
- age related neurological disorders
- Job history and possible exposure to neurotoxins
- head and/or back injury
- marital status
- spiritual beliefs
What to consider for patients Current Health Status
- chief complaint
- common neurologic symptoms are headache, memory loss, confusion, dizziness, loss of consciousness, numbness, sensory loss, and problems with any of five senses
What methods can u use to collect patient’s current health status
- PQRST
- COLDSPA
- OLDCAART
- Most common pain.
- Can be mild or severe,
- acute or chronic,
- localized generalized
- 90% benign
- 10% have underlying pathology
Headache
What to ask with patient experiencing seizures
- altered or loss of consciousness
- what happens before it occurs and which part of the body does it start
- loss of bladder control
- medications taken for seizure
- what aura does the patient observe
An auditory, visual, or motor sensation that forewarns the client that a seizure will occur
Aura
Its the early indication of change in neurological status. may begin as forgetfulness, memory loss, or inability to concentrate, or rapidly proceeds to unconsciousness.
Mental changes
It may be caused by neurologic problems, fluid and electrolyte
imbalance, hypoxia, low perfusion states, nutritional deficiencies,
infections, renal and liver disease, hyper- or hypothermia, trauma,
medications, and drug and alcohol abuse
Mental changes
fainting” sensation
Dizziness
sensation that the
surroundings are spinning around or that the person is spinning around; often accompanied by nausea and vomiting, nystagmus,
and tinnitus
Vertigo
temporary loss of consciousness
Syncope
numbness or tingling. caused by diabetes and neurologic, metabolic,
cardiovascular, renal, and inflammatory diseases
Paresthesia
Identify which CN is affected when these fail:
- sense of smell
CN I
Identify which CN is affected when these fail:
- visual acuity, pupillary constriction, and extraocular movement
CN II, III, IV, and VI
Identify which CN is affected when these fail:
- taste
CN VII and IX
Identify which CN is affected when these fail:
- hearing
CN VIII
Identify which CN is affected when these fail:
- somatic sensations
CN V and dermatomes
Difficulty Speaking can result to….
- Difficulty understanding when people are talking
- Difficulty making others understand
- Difficulty forming words or comprehending and expressing thoughts
Speech Disorders
- Aphonia
- Dysphonia
- Dysarthria
- Aphasia
Speech Disorders:
- loss of voice that accompanies disease affecting the larynx or its nerve supply
Aphonia
Speech Disorders:
- less severe impairment in the volume, quality, or pitch of the voice and may be caused by laryngitis, laryngeal tumors, and
unilateral vocal cord paralysis (CN X)
Dysphonia
Speech Disorders:
- defect in the muscular control of speech apparatus (lips, tongue, palate, or pharynx); words may be nasal, slurred, or
indistinct
Dysarthria
Speech Disorders:
- disorder in producing or understanding language
Aphasia
May be related to stroke, Parkinson’s disease, myasthenia gravis, Guillain-Barre syndrome, dysfunction of cranial nerves IX, X, or XII
difficulty swallowing
What to ask if you want to assess patients muscle control
- Ask about loss in bowel or bladder control, or retention of urine
- Ask about muscle weakness or any loss of movements
- Ask about repetitive involuntary trembling, quivering, shaking, or
other movements. Describe.
Questions for patient’s health history
- History of head injury or seizures
- History of surgery or other treatment involving the nervous system
- History of a serious injury
- History of other medical problems
- Stroke, hypertension, diabetes, syphilis, recent upper respiratory tract infections, seizures, cancer
- Immunizations
- Allergies
- Medications
Questions for patients family history
- History of hypertension, stoke, multiple sclerosis, seizures, amyotrophic lateral sclerosis, Huntington’s chorea, Alzheimer’s disease,
or cancer - History of substance abuse or psychiatric problems
Questions for Lifestyle and Health Practices of Patient
- Prescription or nonprescription medications
- Alcohol intake
- Recreational drug use
- Smoking
- Use of seatbelts or protective gears when driving or riding a bicycle or playing sports
- Exposure to lead, insecticides, pollutants, or other chemicals
- Frequent lifting of heavy objects or performing repetitive motions
- Activities of daily living
- Effect of neurologic problem to self-esteem
Assessment of CN I (Olfactory Nerve)
Normal Findings
- Correctly identifies scent
presented to each nostril
Abnormal
- Inability to smell (neurogenic anosmia) or identify the correct
scent
Causes of abnormal findings in CN I
- Olfactory tract lesion or tumor
- Frontal lobe lesion
- Congenital
- Nasal or sinus problems
- Viral upper respiratory tract
infection - Smoking
- Use of cocaine
a tumor that grows in the nasal cavity
Olfactory Neuroblastoma /
Esthesioneuroblastoma
- A congenital disorder.
- Normally (embryogenesis), GnRH neurons originate in the olfactory mucosa which later on migrates to the hypothalamus.
- Defective formation of the olfactory bulb leads to defective migration
of the GnRH cells to the hypothalamus. The deficit in the GnRH hormone production by the hypothalamus results in decreased levels of sex steroid responsible for sexual maturity and development of
secondary sexual characteristics - Presents with absence of secondary sex characteristics (enlarged
breasts, widening of hips, facial hair, Adam’s apples, pubic hair) and hypo- or anosmia
Kallmann Syndrome
Assessment of CN II (Optic Nerve)
- Use Snellen chart
- ask patient to read something to assess near vision
Normal Findings of CN II
- vision
- Client has 20/20 vision on
both eyes - Client reads print at 14
inches without difficulty
Abnormal Findings of CN II
- Vision
- Difficulty reading chart, missing letters, leaning forward, and squinting
- Reads print by holding closer than14 inches or holds print farther
away as in presbyopia, which occurs with aging
Normal Findings of CN II
- visual Field
Full visual fields
Abnormal Findings of CN II
- visual Field
Loss of visual fields may be seen in retinal damage or detachment, with lesions of the optic nerve, or with
lesions of the parietal cortex
Normal Findings of CN II
- using ophtalmoscope to view retina and optic disc
Normal Findings
- Round red reflex is
present, optic disc is 1.5
mm, round or slightly
oval, well-defined margins, creamy pink with paler physiologic cup. Retina is pink
Abnormal Findings
- Papilledema (swelling of the optic nerve) results in blurred optic disc margins and dilated, pulsating
veins.
- Optic atrophy occurs with brain tumors
Assessment of
CN III (Oculomotor),
IV (Trochlear), and
VI (Abducens)
- Inspect margins of the
eyelids of each eye
Normal Findings
- Eyelid covers about 2mm
of the iris
Abnormal Findings
- Ptosis (drooping of the eyelid) is seen with weak eye muscles such
as in myasthenia gravis
occurs with brain
tumors
Optic atrophy
(drooping of the eyelid)
Ptosis
Assessment of
CN III (Oculomotor),
IV (Trochlear), and
VI (Abducens)
- Assess extraocular
movements. If
nystagmus is noted,
determine the direction of the fast and slow phases of movement
Normal Findings
- Eyes move in a smooth,
coordinated motion in all
directions (the six
cardinal fields)
Abnormal Findings
- Nystagmus
- Limited eye movement through the six cardinal fields of gaze: increased intracranial pressure
- Paralytic strabismus:
(rhythmic oscillation
of the eyes): cerebellar
disorder
Nystagmus
paralysis
of CN III, IV, or VI nerves
Paralytic strabismus
Assessment of
CN III (Oculomotor),
IV (Trochlear), and
VI (Abducens)
- Assess pupillary
response to light
(direct and indirect)
and accommodation in
both eyes
Normal Findings
- Bilateral illuminated
pupils constrict
simultaneously. Pupil
opposite the one
illuminated constricts
simultaneously
Abnormal Findings
- Dilated pupils (6-7mm):
oculomotor nerve paralysis
- Argyll Robertson pupils: CNS syphilis, meningitis, brain tumor, alcoholism
- Constricted, fixed pupils:
narcotics abuse or damage to the pons
- Unilaterally dilated pupil
unresponsive to light or
accommodation: CN III damage
- Constricted pupils unresponsive to light or accommodation: lesion of the sympathetic nervous system
- Bilateral muscle weakness is seen with PNS or CNS
dysfunction
- Unilateral muscle weakness may indicate a lesion of cranial nerve
V (trigeminal)
Assessment of CN V (Trigeminal nerve)
- Test motor function.
Ask client to clench
the teeth while you
palpate the temporal
and masseter muscles
for contraction
Normal Findings
- Temporal and masseter
muscles contract bilaterally
Abnormal Findings
- Decreased contraction in one of both sides. Asymmetric strength in
moving the jaw may be seen with lesion or injury to CN V
- Pain occurs with clenching of the teeth
Assessment of CN V (Trigeminal nerve)
- Test sensory function.
Assess by touching
pt’s forehead, cheeks,
and chin with a sharp
or dull side of this
paper clip. Repeat test
for light touch with a
wisp of cotton
Normal Findings
- Correctly identifies sharp
and dull stimuli and light
touch the forehead,
cheeks, and chin.
Abnormal Findings
- Inability to feel and correctly identify facial stimuli occurs with
lesions of the trigeminal nerve or lesions in the spinothalamic tract
or posterior columns
- Described as the most excruciating pain known to humanity
- Cause unknown, but may be due to compression of the trigeminal nerve
secondary to a tumor, cyst, facial injury, etc - Intense, stabbing, electric shock-like pain in the forehead, cheek, and
lower jaw - Unilateral
Trigeminal Neuralgia
(Tic Doloreux)
Assessment of CN V (Trigeminal nerve)
- Test corneal reflex. Ask
the client to look away
and up while you lightly touch the cornea with a fine wisp of cotton. Repeat on the other side
Normal Findings
- Eyelids blink bilaterally
Abnormal Findings
- An absent corneal reflex may be noted with lesions of the trigeminal nerve or lesions of the motor part
of cranial nerve VII (facial).
Assessment of CN VII (Facial nerve)
- Test motor function.
Ask client to:
* Smile
* Frown and wrinkle
forehead
* Show teeth
* Puff out cheeks
* Purse lips
* Raise eyebrows
* Close eyes tightly
against resistance
Normal Findings
- Client smiles, frowns,
wrinkles forehead, shows
teeth, puffs out cheeks,
purses lips, raises
eyebrows, and closes eyes
against resistance.
Abnormal Findings
- Inability to close eyes, wrinkle forehead, or raise forehead along with paralysis of the lower part of the face on the affected side is seen with Bell’s palsy (a peripheral
injury to cranial nerve VII [facial]). Paralysis of the lower part of the face on the opposite side affected may be seen with a central lesion that affects the upper motor
neurons,
a peripheral
injury to cranial nerve VII [facial])
Bell’s palsy
- Inability to wrinkle brow
- Drooping eyelid: Inability to close eye
- Inability to puff cheek; asymmetrical smile
- Drooping corner of mouth; dry mouth
Facial Nerve Palsy
Assessment of CN VIII
(Vestibulocochlear
nerve)
- Assess hearing with
the whispered voice
test. Ask the patient to
repeat numbers whispered into one ear
while blocking or
rubbing your fingers
next to the contralateral ear.
Normal Findings
- Client hears whispered
words from 1–2 feet. Client
is able to identify the
combination of letters
and numbers on both ears
Abnormal Findings
- Inability to identify the
combination of letters and
numbers may indicate hearing loss.
Note: If hearing loss is present, determine if the loss is conductive
or sensorineural by conducting the
Weber and Rinne test
Assessment of CN VIII
(Vestibulocochlear
nerve)
- Test the client’s
hearing ability in each
ear and perform the
Weber and Rinne tests
to assess the cochlear
(auditory) component
of cranial nerve VIII
Normal Findings
- Weber test: Vibration
heard equally well in both
ears. Rinne test: AC > BC
(air conduction is twice as
long as bone conduction).
Abnormal Findings
- Vibratory sound lateralizes to good
ear in sensorineural loss. Air conduction is longer than bone conduction, but not twice as long, in a sensorineural loss
Assessment of CN IX
(Glossopharyngeal nerve) and X (Vagus)
- Listen to the patient’s
voice. Is it hoarse?
Does it have a nasal
quality?
Abnormal Findings
- Hoarseness occurs in vocal cord paralysis; nasal voice in paralysis
of the palate
- The greater palatine, nasopalatine nerve, and lesser palatine nerve,
branches of the maxillary nerve, innervate the hard and soft palate
Assessment of CN IX
(Glossopharyngeal nerve) and X (Vagus)
- Check the client’s
ability to swallow by
giving the client a
drink of water
Normal Findings
- No difficulty in swallowing
Abnormal Findings
- Difficulty in swallowing suggests pharyngeal or palatal weakness
Assessment of CN IX
(Glossopharyngeal nerve) and X (Vagus)
- Test motor function.
Ask the client to open
mouth wide and say
“ah” while you use a
tongue depressor on
the client’s tongue
Normal Findings
- Uvula and soft palate rise
bilaterally and symmetrically on phonation.
Abnormal Findings
- Soft palate does not rise with bilateral lesions of cranial nerve X (vagus). Unilateral rising of the soft
palate and deviation of the uvula to the normal side are seen with a unilateral lesion of cranial nerve X
(vagus).
soft palate fails to rise and the uvula deviates to the opposite side (points away from the lesion
Cranial Nerve X Paralysis
Assessment of CN IX
(Glossopharyngeal nerve) and X (Vagus)
- Test gag reflex by
touching the posterior
pharynx with the
tongue derpressor
Normal Findings
- Gag reflex is intact.
Abnormal Findings
- An absent gag reflex may be seen with lesions of cranial nerve IX (glossopharyngeal) or X (vagus).
- Ask the client to shrug
the shoulders against
resistance to assess
the trapezius muscle
Normal Findings
- There is symmetric, strong contraction of the
trapezius muscles.
Abnormal Findings
- Asymmetric muscle contraction or drooping of the shoulder may be seen with paralysis or muscle
weakness due to neck injury or torticollis.
- Derived from two Latin words, tortus = twisted,
and collum = neck - Contraction or contracture of the muscles of the neck that causes the head to tilt to one side
- May be acquired or congenital
Torticollis
Acquired torticollis or Congenital torticollis:
- may be caused by irritation to the cervical ligaments from a viral infection, injury, or vigorous movement
Acquired torticollis
Acquired torticollis or Congenital torticollis:
- may be caused by
ischemia, trauma during childbirth and intrauterine malposition
Congenital torticollis
Assessment of CN XI (Spinal Accessory Nerve)
- Ask the client to turn
the head against
resistance, first to the
right then to the left,
to assess the
sternocleidomastoid
muscle
Normal Findings
- There is strong
contraction of
sternocleidomastoid
muscle on the side
opposite the turned face.
Abnormal Findings
- Atrophy with fasciculations may be
seen with peripheral nerve disease.
Note: A supine patient with
bilateral weakness of the
sternocleidomastoid muscles has difficulty raising the head off the
pillow
Assessment of CN XII (Hypoglossal Nerve)
- To assess strength and
mobility of the tongue,
ask the client to protrude tongue, move it to each side against the resistance of a tongue depressor, and then put it back in the
mouth.
Normal Findings
- Tongue movement is
symmetric and smooth,
and bilateral strength is
apparent.
Abnormal Findings
- Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease. Deviation
to the affected side is seen with a unilateral lesion.
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Assess condition and
movement of muscles.
-Assess the size and
symmetry of all
muscle groups
Normal Findings
- Muscles are fully
developed and symmetric
in size (bilateral sides may
vary 1 cm from each
other).
Abnormal Findings
- Muscle atrophy may be seen in diseases of the lower motor neurons or muscle disorders
- Injury of the central spinal cord
- anterior cord syndrome.
- posterior cord syndrome.
- Brown-Séquard syndrome.
It is associated with extremity weakness.
injury of the central spinal cord
Loss of motor function, pain and temperature seen in what?
anterior cord
syndrome.
Loss of proprioception seen in what?
posterior cord syndrome
A loss of strength, proprioception,
pain and temperature is seen in?
Brown-Séquard syndrome.
- Injury results in sacral
sparing and preferentially
upper- more than lower-
extremity weakness. - “cape-like” sensory deficit
Central Cord Syndrome
Injury results in loss of
proprioception and variable preservation of motor function and pain and temperature sensation
Posterior Cord Syndrome
A hemisection of the spinal cord resulting in ipsilateral loss of strength and proprioception and
contralateral loss of pain and temperature
Brown-Sequard Syndrome
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Assess the strength
and tone of all muscle
groups
Normal Findings
- Relaxed muscles contract
voluntarily and show mild,
smooth resistance to
passive movement. All
muscle groups equally
strong against resistance,
without flaccidity,
spasticity, or rigidity
Abnormal Findings
- Soft, limp, flaccid muscles are seen with lower motor neuron involvement. Spastic muscle tone is noted with involvement of the corticospinal motor tract. Rigid muscles that resist passive movement are seen with abnormalities of the
extrapyramidal tract.
Assessing Muscle Strength Factors to Consider
- Age
- Sex
- Muscular training
- Dominant vs. Non-dominant side
Test flexion (C5, C6 – biceps and brachioradialis)
and extension (C6, C7, C8 – triceps) at the elbow
having the patient pull and push against your hand
Test extension at the wrist (C6, C7, C8, radial nerve— extensor carpi radialis longus and brevis
asking the patient to make a fust and resist as you press down
Test the grip (C7, C8, T1) of both arms simultaneously
Ask the patient
to squeeze two of your fingers as hard
as possible and not let them go
Test finger abduction (C8, T1, ulnar nerve)
Position the patient’s hand with palm down and fingers spread. Instruct
the patient to prevent you from moving any fingers as you try to force them
together
Note: Weak finger abduction occurs in ulnar
nerve disorders
Test opposition of the thumb (C8, T1, median nerve)
Ask the patient to touch
the tip of the little finger with the thumb, against your resistance
Test flexion at the hip (L2, L3, L4—iliopsoas)
by placing your hand on the patient’s mid-thigh and asking the patient to raise the leg against your hand
Test adduction at the hips (L2, L3, L4— adductors)
Place your hands firmly on
the bed between the patient’s knees. Ask the patient to bring both legs
together.
Test abduction at the hips (L4, L5, S1— gluteus medius and minimus
Place your hands firmly outside the patient’s
knees. Ask the patient to spread both legs against your hands
Test extension at the hips (S1— gluteus maximus)
Have the patient push the mid posterior thigh down against your hand
Test extension at the knee (L2, L3, L4—quadriceps)
Support the knee in
flexion and ask the patient to straighten the leg against your hand.
The quadriceps is the strongest muscle in the body, so expect a forceful response
Test flexion at the knee (L4, L5, S1, S2 hamstrings)
Position the patient’s leg so that the knee is flexed with the foot resting on the bed. Tell the patient to keep
the foot down as you try to
straighten the leg
Test foot dorsi flexion (mainly L4, L5—tibialis anterior) and plantar
flexion (mainly S1—gastrocnemius,
soleus) at the ankle
asking the patient to pull up and push down
against your hand.
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Note any unusual
involuntary movements such as fasciculations, tics, or tremors
Normal Findings
- No fasciculations, tics, or
tremors are noted
Abnormal Findings
- Fasciculations
- Tremors
- Pill-rolling
- Tics
- Myoclonus
- Chorea
- Athetosis
Abnormal Findings during ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- continuous, rapid twitching of resting muscles
Fasciculations
Abnormal Findings during ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- involuntary contraction
of opposing group of muscles
Tremors
Abnormal Findings during ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- tremors of the thumb
and opposing finger seen in Parkinson’s disease
Pill-rolling
Abnormal Findings during ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- involuntary repetitive twitching movements seen in Tourette’s syndrome, habit psychogenic tics or tardive dyskinesias
Tics
Abnormal Findings during ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- sudden jerks of
arms and legs often seen in generalized seizure
Myoclonus
Abnormal Findings during ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- sudden rapid, jerky
voluntary and involuntary
movements of limbs, trunk, or face seen in Huntington’s disease and
Syndenham’s chorea
Chorea
Abnormal Findings during ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- twisting, writhing,
slow continuous movements seen in cerebral palsy
Athetosis
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS
- Evaluate gait and
balance. To assess gait
and balance, ask the
client to walk naturally
across the room. Note
posture, freedom of
movement, symmetry,
rhythm, and balance
Normal Findings
- Gait is steady; opposite
arm swings
Abnormal Findings
- Gait and balance can be affected by disorders of the motor, sensory, vestibular, and cerebellar systems.
Therefore, a thorough examination of all systems is necessary when an
uneven or unsteady gait is noted
Abnormal Gaits:
* Wide-based, staggering, unsteady
* Romberg test result are positive
* Seen with cerebellar disease or alcohol or drug intoxication
Cerebellar Ataxia
Abnormal Gaits:
* Shuffling gait, turns accomplished in very stiff manner
* Stooped-over posture with flexed hips and knees
* Typically seen in Parkinson’s disease and drug-induced
parkinsonian because of effects on the basal ganglia
Parkinsonian Gait
Abnormal Gaits:
* Stiff, short gait; thighs overlap each other
with each step
* Seen with partial paralysis of the legs
Scissors Gait
Abnormal Gaits:
* Flexed arm held close to the body while client
drags toe of leg or circles it stiffly outward and
forward
* Seen with lesions of the upper motor neurons in
the corticospinal tract, such as occurs in stroke
Spastic Hemiparesis
Abnormal Gaits:
* Client lifts foot and knee high with each step, then slaps
the foot down hard on the ground
* Client cannot walk on heels
* Characteristic disease of the lower motor neuron
Footdrop/Steppage Gait
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Ask the client to walk
in heel-to-toe fashion
(tandem walking); next
on the heels, then on
the toes. Demonstrate
the walk first; then
stand close by in case
the client loses
balance.
Normal Findings
- Client maintains balance
with tandem walking.
Walks on heels and toes
with little difficulty
Abnormal Findings
- An uncoordinated or unsteady gait that did not appear with the client’s normal walking may become apparent with tandem walking or when walking on heels and toes.
Ask the client to walk
in heel-to-toe fashion
(tandem walking); next
on the heels, then on
the toes. Demonstrate
the walk first; then
stand close by in case
the client loses
balance.
Heel-to-Toe / Tandem Walking
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Perform the Romberg
test. Ask the client to
stand erect with arms at
side and feet together.
Note any unsteadiness
or swaying. Then with
the client in the same
body position, ask the
client to close the eyes
for 20 seconds. Again
note any imbalance or
swaying
Normal Findings
- Client stands erect with
minimal swaying, with
eyes both open and
closed.
Abnormal Findings
- Positive Romberg test: Swaying and moving feet apart to prevent fall is
seen with disease of the posterior columns, vestibular dysfunction, or
cerebellar disorders.
Notes: Ataxia – presence of abnormal, uncoordinated movements
Romberg Test: 3 sensory systems that regulate body posture
- Vision
- Proprioception
- Vestibular system
Notes:
- send info to Cerebellum to maintain body posture
Romberg Test: No Damage
With eyes open
- not swaying
With eyes closed
- slight swaying but wont fall
Romberg Test: Proprioceptive damage (Sensory Ataxia)
With eyes open
- Slight swaying
With eyes closed
- Person may sway uncontrollably or fall
Romberg Test:
With vestibular damage (Vestibular Ataxia)
With eyes open
- Slight swaying
With eyes closed
- Person may sway uncontrollably or fall
Romberg Test:
With cerebellar damage (Cerebellar Ataxia)
Note:
The side to which the person sways more
or falls, depends on which part of the cerebellum is affected
With eyes open
- Marked swaying even with the eyes open
With eyes closed
- Worsened swaying or person may fall
With cerebellar damage (Cerebellar Ataxia)
- falls any direction
Cerebellar vermis
With cerebellar damage (Cerebellar Ataxia)
- towards the affected side
Cerebellar hemisphere
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Now ask the client to
stand on one foot and
to bend the knee of
the leg the client is standing on. Then ask
the client to hop on
that foot. Repeat on
the other foot.
Normal Findings
- Bends knee while
standing on one foot;
hops on each foot without
losing balance
Abnormal Findings
- Inability to stand or hop on one foot is seen with muscle weakness or disease of the cerebellum.
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Assess coordination.
Ask the patient to touch
your index finger and
then his or her nose
alternately several times.
Move your finger so that
the patient has to change
directions and extend the
arm fully to reach your
finger. Observe the
accuracy and smoothness
of movement, and watch
for any tremors
Finger-to-Nose test
Normal Findings
- Client touches finger to
nose with smooth,
accurate movements, with
little hesitation
Abnormal Findings
- Uncoordinated, jerky movements and inability to touch the nose may be seen with cerebellar disease.
- Dysmetria
the inability to control the
distance, speed, and range of motion
necessary to perform smoothly coordinated
movements
Dysmetria
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Assess rapid
alternating movements. Have the client sit down. First, ask the client to
touch each finger to
the thumb and to
increase the speed
as the client progresses. Repeat with the other side
Normal Findings
- Client touches each
finger to the thumb
rapidly.
Abnormal Findings
- Inability to perform rapid
alternating movements may be seen with cerebellar disease, upper motor neuron weakness, or extrapyramidal disease.
- Dysdiadochokinesia
inability to perform rapid alternating movements
Dysdiadochokinesia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Assess rapid alternating
movements. Show the
patient how to strike one
hand on the thigh, raise
the hand, turn it over,
and then strike the back
of the hand down on the
same place. Urge the
patient to repeat these
alternating movements
as rapidly as possible
Normal Findings
- Client rapidly turns palms
up and down
Abnormal Findings
- Uncoordinated movements or tremors are abnormal findings. They are seen with cerebellar disease (dysdiadochokinesia).
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Perform the heel-to-
shin test. Ask the
client to lie down
(supine position) and
to slide the heel of the
right foot down the
left shin
Normal Findings
- Client is able to run each
heel smoothly down each
shin
Abnormal Findings
- Deviation of heel to one side or the other may be seen in cerebellar
disease.
In Cerebellar damage, remember DANISH
Dysdiadochokinesia/Dysmetria
Ataxia
Nystagmus
Intention tremor
Speech – slurred or scanning
Hypotonia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- Assess light touch, pain, and temperature sensations. For each
test, ask clients to close both eyes and tell you what they feel and
where they feel it. Scatter stimuli over the distal and proximal parts of all extremities and the trunk to cover most of the dermatomes. It is not
necessary to cover the entire body surface unless you identify abnormal
symptoms such as pain, numbness, or tingling
Normal Findings
- Client correctly
identifies light touch
Abnormal Findings
- Many disorders can alter a person’s ability to perceive sensations correctly. These include peripheral neuropathies (due to diabetes mellitus, folic acid deficiencies, and alcoholism) and lesions of the ascending spinal cord, brain stem, cranial nerves, and cerebral cortex
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
- To test light touch sensation, use a wisp of cotton to touch the client.
- To test pain sensation, use the blunt and sharp ends of a safety pin or paper clip.
- To test temperature sensation, use test tubes filled with hot and cold
water. (performed only if patient is unable to perceive touch and pain)
Normal Findings
- Client correctly
differentiates
between dull and
sharp sensations
and hot and cold
temperatures over
various body parts
Abnormal Findings
- Anesthesia
- Hypesthesia
- Hyperesthesia
- Analgesia
- Hypalgesia
- Hyperalgesia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
Abnormal Findings
- absence of
touch sensation
Anesthesia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
Abnormal Findings
- decreased sensitivity to touch
Hypesthesia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
Abnormal Findings
- increased sensitivity to touch
Hyperesthesia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
Abnormal Findings
- absence of pain
sensation
Analgesia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
Abnormal Findings
- decreased
sensitivity to pain
Hypalgesia
ASSESSMENT OF THE MOTOR AND CEREBELLAR
SYSTEMS:
Abnormal Findings
- increased
sensitivity to pain
Hyperalgesia
