Neuro Assessment Flashcards
What is a gait that lacks coordination and stability?
Ataxic- due to cerebellar disease, loss of position sense or intoxication
What is steppage gait?
“Foot drop”
Pt drags foot/ft or lifts them high, then foot slaps floor
Unilateral or bilateral
What causes steppage gait?
Tibialis anterior and toe extensor weakness
Lower motor neuron/peripheral nerve injury (L4/L5)
What is spastic hemiparesis?
When pt drags toe, circle leg stiffly outward and forward (circumduction) or lean trunk to contralateral side to clear affected leg during walking
Affected leg extensors are spastic, ankles are plantar-flexed and inverted
What occurs in the UE during spastic hemiparesis?
Affected arm is flexed, immobile and held close to side, with elbow, wrists and interphalangeal joints flexed
What causes spastic hemiparesis?
Corticospinal tract lesions (stroke)
What is scissors gait?
Pts advance each leg slowly and thighs tend to cross
Stiff gait and short steps
Look like they’re “walking through water”
What causes scissors gait?
Spinal cord disease and spasticity disorders (cerebral palsey)
What is sensory ataxia?
Unsteady gait and wide based stance
Throw feet forward and outward, first bring down heel then toes with double tap
They watch the ground (probably walk assist device)
What causes sensory ataxia?
Loss of proprioception (polyneuropathy or posterior column damage)
What is a Parkinsonian gait?
Stooped posture with head, arm, hip and knee flexion
Shuffling, short steps, slow to start
Decreased arm swing and stiff turns
Pill rolling tremor
What causes Parkinsonian gait?
Basal ganglia abnormalities (Parkinson disease)
What does coordination require?
Integration of the nervous system (motor, cerebellar-control, vestibular-balance, sensory)
Romberg test
Position sense
Stand with feet together, eyes closed
What is an abnormal Romberg test?
Unable to maintain upright posture Dorsal column disease causing loss of position sense Cerebellar ataxia (can't balance eyes open or closed)
When do you see an abnormal pronator drift test?
Upper motor neuron lesion due to possible stroke
Can’t keep arms at shoulder height or arm pronates/drifts downward
What causes an abnormal heel to shin test?
Cerebellar disease: heel overshoots knee and foot oscillates side to side
Position sense absent: heel lifts too high
What causes an abnormal finger-to-nose test?
Intentional tremor-multiple sclerosis
When do you see an abnormal rapid alternating movements test?
Cerebellar disease: slow, clumsy, irregular movement (dydiadochokinesis)
A and O x 4
Alert and oriented to person, place, time and situation
Abnormal CN I
Anosmia
Head trauma, Parkinsons
Abnormal CN II
Visual field defect, 2 degree retinal emboli, optic neuritis, pituitary tumor, stroke
Abnormal CN III
Vertical and horizontal diplopia
Ptosis=CN III palsy
Abnormal CN IV
Vertical diplopia (might have trouble going down stairs)
Abnormal CN V
Trigeminal neuralgia
Abnormal CN VI
Horizontal diplopia, esotropia
Abnormal CN VII
Peripheral- Bell’s palsy
Central- cerebral infarct
Abnormal CN VIII
Disequilibrium, vertigo, nystagmus
Abnormal CN IX
No gag reflex, loss of taste posterior 1/3 of tongue
Abnormal CN X
Hoarseness, dyspnea, dysarthria, loss of gag reflex
Abnormal CN XI
Trap weakness, atrophy and fasiculations=scapular winging
Abnormal CN XII
Central lesion= tongue deviates away
Peripheral lesion= tongue deviates to weak side
Upper extremity dermatomes
Lateral upper arms (C5) Radial forearm and thumb (C6) Middle finger (C7) Ring and little finger (C8) Ulnar forearm (T1)
Abdomen dermatomes
Nipple (T4)
Umbilicus (T10)
Inguinal region (L1)
Lower extremity dermatomes
Anterior/proximal thigh (L3)
Knee/medial shin (L4)
Lateral shin, dorsal foot to great toe (L5)
Lateral and plantar foot (S1)
Streognosis
Ask patient to recognize a familiar object
Graphesthesia
Number identification
Two point discrimination
Alternate double and single stimulus
Normal <5 mm on finger pads
Extinction
Touch pt in same place on both sides of body
Abnormal body position
Mono or hemiparesis (stroke)
Static tremor
Seen at rest Parkinson disease (pill rolling tremor)
Postural tremor
Seen when affected areas maintains posture
Hyperthyroid, anxiety, fatigue, benign essential
Intention tremor
Absent at rest, appear with movement
Multiple sclerosis
Tics
Brief, repetitive, twitching
Tourette syndrome, medications
Dystonia
Twisted posture of large body parts
Medications, spasmodic torticollis
Dyskinesias
Bizarre, rhythmic, repetitive movements
Parkinsons, psychoses, medications
Akathisia
Inability to sit still
Meds (antipsychotics, Compazine)
Chorea
Brief, jerky, unpredictable movements
Huntingtons, rheumatic fever
Athetosis
Slow, twisting, writhing movements
Cerebral palsy
When do you see muscle bulk?
Lower peripheral nerve problem
What causes hypotonia/flaccidity?
Central and peripheral causes
What causes spasticity?
Central corticospinal tract disease
Increased muscle tone, velocity dependent
What causes rigidity?
Cog-wheel rigidity (Parkinsons)
Increased resistance throughout ROM
Nerve root and peripheral nerve shoulder abduction
C5- axillary
Nerve root and peripheral nerve elbow flexion
C5, C6- musculocutaneous
Nerve root and peripheral nerve elbow extension
C6, C7- radial
Nerve root and peripheral nerve wrist extension
C6, C7- radial
Nerve root and peripheral nerve wrist flexion
C7, C8- median
Nerve root and peripheral nerve finger abduction
C8, T1- ulnar
Nerve root and peripheral nerve thumb opposition
C8, T1- median
Nerve root and peripheral nerve hip flexion
L2, L3- femoral
Nerve root and peripheral nerve hip extension
L4, L5- gluteal
Nerve root and peripheral nerve knee extension
L3, L4- femoral
Nerve root and peripheral nerve knee flexion
L5, S1- sciatic
Nerve root and peripheral nerve ankle dorsiflexion
L4, L5- peroneal
Nerve root and peripheral nerve ankle plantar flexion
S1- plantar
How to rate DTRs
0- no response \+1- diminished \+2- normal \+3- increased \+4- hyperactive, associated with clonus
Hypoactive DTRs
Diminished or absent
Diseases of spinal nerve roots or peripheral nerves
Additional findings in LMN disease (weakness, atrophy, fasciculations)
Hyperactive DTRs
Brisk and can be associated with clonus
CNS lesions along descending corticospinal tract
Additional findings in UMN disease (weakness, spasticity, positive babinski)
What DTRs do you test?
Biceps, brachioradialis, triceps, patella, achilles
How do you test for clonus?
Alternate dorsi and plantar flexing pts ankle, then briskly dorsiflex ankle-evaluate rhythmic oscillation
Can be normal bilaterally (if abnormal check wrist)
When do you see abnormal clonus?
Upper motor neuron disease (4+)
What does Babinski test?
L5, S1- normal for toes to flex
When do you see an abnormal Babinski response?
CNS lesion affecting corticospinal tract (great toe extends and other toes fan out)
When do you see an abnormal superficial abdominal reflex?
Central and peripheral pathologies
When do you see an abnormal cremasteric reflex?
UMN, LMN or L1, L2 nerve injury
Ilioinguinal injury s/p hernia repair
What is Brudzinski sign?
Normal- pts remains relaxed
Abnormal- hip and knee flexion
What is nuchal rigidity?
Place hands behind pts head and flex toward chest
Normal- easy motion
Abnormal- pain and resistance indicating potential meningeal irritation
What is Kernig sign?
Flex pts hip and knee, then straighten knee
Normal- may have tightness in hamstring
Abnormal- back pain and resistance indicating meningeal irritation
