neurological exam Flashcards
objective assessment
Your initial observation …….other considerations Posture? Motor function present/absent? Sensory function Transfers – level of assistance? Gait Function Vision, Speech, Swallow Comprehension/Higher function
Skin condition Colour Wasting Joint instability Contracture Deformity Trick movements Tremor
Perception – ability to follow instructions
Facial palsy – weakness one side of face
Drooling – poor orofacial control
Presence of NG or Peg tube – implications?
Urinary catheter – what does this mean?
Assistive devices – splints or use of mobility aid
Posture
POSTURE Is it normal ? What is alignment of head trunk limbs? Is there symmetry between R & L? Contracture - present, where? Spastic patterns? Presence of abnormal postures? Can be found after stroke, head injury
Motor system - movement assessment
Movement Assessment* Screen UL, LL, Trunk active movements What is the quality of movement? Range of movement - active/passive? Is there loss of ROM? Why? Abnormal movement? Why?
motor system - abnormal movement
Abnormal movement
Loss of co-ordination - cerebellar lesion
Bradykinesia - Parkinson’s disease (slowed movement)
Involuntary movement - tremor / chorea (brief, involuntary, non-rhythmic movements)
Intention tremor - cerebellar
Non-intention tremor - Parkinson’s
Loss of range - contracture
Loss of voluntary movement UMNL, CVA.
lower motor neuron
Upper motor neuron
Lower motor neuron: A neuron whose cell body lies in the central nervous system, and whose axon leaves the CNS through a foramen, and terminates on an effector.
Upper motor neuron: A neuron which lies entirely within the CNS and causes movement because it terminates on a lower motor neuron.
Motor system - POWER
Muscle Power Assessment
Resisted movement joint ranges
Upper & Lower limb
Grading - Oxford Scale 0 No movement 1 Flicker 2 Movement no gravity 3 Movement & gravity 4 Movement & gravity & resistance 5 Normal
Myotomes - Upper & Lower limb - REVISE
motor system - abnormal muscle power - weakness
Abnormal Muscle Power (Weakness) Muscle pathology Neuromuscular junction defect Central - UMNL Anterior horn cell damage/pathology Nerve root injury Nerve plexus Peripheral – Peripheral nerve lesion (PNL)
motor system - TONE
muscle tone assessment procedure
Muscle Tone Assessment Procedure
Assessment Steps (position supine lying)
1. OBSERVE Appearance of limb
2. Palpation / Feel muscle
How does it react to stretch PROM – UL, LL, Trunk
3. PROM; Proximal to distal direction for test
Grading Ashworth Scale or Modified Ashworth* see handout VLE
ashworth scale
- No increase in muscle tone.
- Slight increase in muscle tone - manifested by a catch & release or by minimal resistance at the end of the range of movement when the affected part(s) is moved in flexion/extension.
1+Slight increase in muscle tone, manifested by a catch followed by minimal resistance through the remainder (less than half) of the range of movement.
- More marked increase in tone through most of the range of movement but affected part(s) easily moved.
- Considerable increase in muscle tone, passive movement difficult.
- Affected part(s) rigid in flexion or extension.
assessment of motor system, findings
Abnormal Muscle Tone
Normal tone
Increased tone
Resistance suddenly - spasticity / clasp knife
Resistance through range - lead pipe rigidity
Intermittent resistance through range - cogwheel
Decreased tone
Loss of resistance through range hypotonia/flaccid
decorticate vs decerebrate rigidity
Both are primitive behaviour responses to brain injury.
Decorticate posturing, the hands or arms are posturing towards the spine (inward), which is a primitive protective response.
Decerebrate posturing the hands are directed away from the body or spine, which is no attempt to guard the body at all.
Usually, decerebrate posturing indicates more extensive brain damage.
decorticate rigidity
Lesion at a higher level extensor tone LL flexor tone UL Pattern UL Flexion and internal rotation Pattern LL Extended - Adducted - Internally rotated - Feet plantarflexed and inverted.
decerebrate rigidity
Lesion at midbrain
extensor tone 4 limbs
Trunk – Opisthotonus (severe hyperextension & spasticity).
Pattern UL
Extension - Internal rotation - Wrist flexion
Pattern LL
Extended - Adducted - Internally rotated - Feet plantarflexed and inverted
motor system - reflexes
Reflexes* Upper limb Biceps C5,6 Triceps C6,7 Supinator C5,6
Lower limb
Knee jerk L2,3,4
Ankle L5,S1
Plantar (Babinski sign)
Grading - diminished \+ Normal \++ Brisk responses \+++ Clonus (rhythmic oscillations)
Reinforcement
Jendrassik’s manoeuvre
(patient flexes both sets of fingers into a hook-like form and interlocks those sets of fingers together. The patellar reflex is elicited, whilst in this manoeuvre. The elicited response is compared with the reflex result of the same action when the manoeuvre is not in use. Often a larger reflex response will be observed when the patient is occupied with the maneuver, as the maneuver may prevent the patient from consciously inhibiting or influencing his or her response to the hammer)
abnormal reflexes - plantar reflex
Abnormal Reflexes (Plantar reflex)
Toes flex - reflexor plantar response - normal/negative Babinski’s sign.
Hallux extends, toes spread - extensor plantar response- positive Babinski’s sign. Indicates – UMNL.
objective assessment 0 sensory system
cutaneous sensations pain/pinprick temp light touch pressure 2 point discrimination
proprioceptive sensations
vibrations
joint position sense
movement
integrative sensation
bilateral simultaneous
sensory appreciation
stereognosis
posterior column - medial leminiscal pathways
Conveys:
Proprioception (awareness of position of muscles, tendons, joints & body movements).
Fine discriminative touch (ability to feel exactly which part of body is being touched).
Stereognosis (ability to recognise by feel the size,shape and texture of an object).
Vibration sense.
Weight discrimination (ability to determine the weight of an object).
anterolateral pathways
Including spinothalamic tract (anterior & lateral) and other associated tracts that convey: Pain Temperature sense (hot / cold) Crude touch (poorly localised) touch Pressure Tickle Itch
Primary Sensation Light touch - cotton wool Temperature Pinprick / pain Vibration sense Joint position sense 2 point discrimination Dermatomes
Sensory Testing Instructions Clear instructions / demonstration What you need? Light touch - cotton wool Vibration - tuning fork Pinprick - neurotips Temperature - test-tubes hot / cold Find level of normality Test both sides sharp-blunt assess with neurotips
sensory system
Joint Position Sense
Upper limb
Patients eyes open demonstrate.
Hold distal phalanx DIP joint index finger .
Illustrate bent & straight.
Patient closes eyes & is asked to report if joint is bent or straight.
Test distal joints first.
Lower limb
As above DIP joint, test hallux.
higher order sensationGraphesthesia - ability to recognize writing on the skin purely by the sensation of touch.
Stereognosis/tactile gnosis - ability to perceive & recognise the form of an object using cues from texture, size, spatial properties, and temperature (mediated by the posterior column-medial lemniscus pathway). Stereognosis tests determine whether or not the parietal lobe of the brain is intact.
Sensory inattention /sensory neglect - patient recognises stimuli when presented independently but recognises only one side when stimulus is presented simultaneously. Indicates Parietal lobe lesion.
The above cannot be tested unless primary sensation intact bilaterally.
upper limb coordination
Finger-tip to nose test
Hold finger at arms length in front of patient. Ask patient to touch the finger with index finger then touch their nose. Change speed/position of target.
Repeated movements
lower limb coordination
Heel to shin test
Patient in supine. Lift leg and place heel on knee. Slide heel down along shin.
trunk coordination
tandem walking
rapid pronation/suppination
Dysdiadokokenesis
Rapid alternating pronation / suppination
functional mobility
Balance Sitting balance Standing balance Static, dynamic, functional Bed mobility Rolling Lying to sitting Sitting to standing Transfers What is the level of assistance? What pattern of movement did you see? Balance Base of support? Stability?
balance test
Balance
Sitting - static / dynamic / functional
Standing - static / dynamic / functional
Righting and equilibrium reactions
Other - base of support / posture
Challenging - sensory / visual components
Balance tests
rhomberg test
Rhomberg Test Patient stands with feet together Reassure If patient is falling discontinue If not proceed hold position with eyes open and closed
Interpretation
Unsteady eyes closed - sensory ataxia
Unsteady eyes open + closed
gait assessment
Appropriately undressed Starting position Initiation of gait Level of assistance Use of aid/device Alignment Stability Base of support Swing phase Stance phase Arm swing Trunk rotation Foot placement/clearance Timing/co-ordination
abnormal gait
Hemiplegic Parkinsonian Ataxic: sensory or cerebellar (lack of voluntary co-ordination). High stepping Trendellenburg
speech language and swallow
Dysphasia - partial or complete impairment of the ability to communicate resulting from brain injury.
Expressive / Receptive / Global
Dysarthria - is a motor speech disorder characterised by poor articulation, it is a condition in which problems occur with the muscles that help one talk; this makes it very difficult to pronounce words.
Dysphonia - disorders of the voice: an impairment in the ability to produce voice sounds using the vocal organs (it is distinct from dysarthria which means disorders of speech, that is, an impairment in the ability to produce spoken words).
Dysphagia - swallow impairment.
Broca’s Area
Inferior frontal gyrus of dominant hemisphere (usually the left)
Associated with motor or expressive dysphasia
Wernicke’s Area
Temporal lobe
Sensory or receptive dysphasia
vision
visual field defect
visual inattention
cranial nerve exam
I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal
glasgow coma scale
Total possible score: 15 Minimal score: 3 GCS <9 severe brain injury GCS 9-12 moderate brain injury (controversial) GCS ≥13 minor brain injury
AMTS - irish version
Score 1 point for each question answered correctly 1 Age of the patient 2 Time to nearest hour 3 Address given for recall at the end of test - ‘42 West Street’. 4 Name of hospital 5 Year 6 Date of birth of patient 7 Month 8 Year of the First World War (1914) 9 Name of President of Ireland 10 Count backwards from 20 to 1
concluding neurological exam
Fitting the information into the POMR framework
Decide on the patient’s problem list
Goal setting short and long term, with timelines?
What is the treatment plan, specific to problems?
Will you use outcome measures?
Other considerations e.g. video gait?
