Neurological Examination Flashcards
1
Q
Red flags associated with neurological problems (immediate medical assistance required)
A
- loss of consciousness or difficult arouse
- extreme confusion not consistent with premorbid status
- uncontrolled seizure activity
- acute infection with other associated neurologic signs
- rapid onset of focal neurologic deficits
- evidence of spinal column instability
- non responsive autonomic dysreflexia
2
Q
Yellow flags associated with neurological problems (outside referral required)
A
- acute onset of neurologic signs such as incontinence, saddle paresthesia, abnormal reflexes
- progressive neurologic signs in a known neurologic diagnosis that is not degenerative
- evidence of motor neuron disease
- new onset of involuntary movements or tremor
- change in autonomic status
- bulbar & other cranial nerve signs or symptoms
- constant headache that worsens over time
- neurologic signs inconsistent with medical diagnosis
- signs or symptoms of systemic illness
- significant changes in personality or cognitive status
3
Q
Signs with rapid onset suggesting a stroke in progress
A
- weakness, numbness, or tingling of face, arm, or leg especially of one side of body
- blurred or decreased vision in one or both eyes or double vision
- loss of speech or trouble understanding speech
- headache that is sudden, severe, and unusual
- dizziness, loss of balance, or loss of coordination with any of the other signs
4
Q
Indications for a neurological exam
A
- referral
- result from a neurological screening during ROS (review of systems)
5
Q
Examples of clinical indications for neurological exam
A
- Body structure/functions/impairments: numb feet, muscle weakness, abnormal posture, balance problems
- Functions/activity limitations: difficulty with functional mobility or ADLs
- Participation restrictions: difficulty with home management, work, job, play
6
Q
Components of a comprehensive neurological exam
A
- Mental status
- Sensation
- Motor function
- Balance/coordination
- Functional skills
7
Q
Why do we test mental status
A
- tested 1st
- accuracy of data from sensory & motor exam depends on the ability to understand & communicate effectively
- tested to determine pt’s ability to participate in POC, give consent, follow directions, communication needs understand precautions
- Cognitive domains assessed: arousal, attention, orientation, cognition (IQ), memory, communication, calculation, logic/abstraction
8
Q
What cognitive domains are assessed to determine mental status
A
- Arousal
- Attention
- Orientation
- Cognition (IQ)
- Memory
- Communication
- Calculation
- Logic/abstraction
9
Q
Define arousal/consciousness
A
- physiological status of being aware with ability to understand/respond to stimuli: readiness for activity
- brainstem and other brain areas control arousal, sleep-wake cycles
10
Q
What are the 5 levels of consciousness
A
- Alert: fully awake, interactions with PT are appropriate
- Lethargic: drowsy, may fall asleep, difficulty maintaining focus, interactions with PT may get diverted
- Obtunded: sleepy state, difficult to keep awake, confused when awake, interactions with PT are mostly unproductive
- Stupor: responds only to strong noxious stimuli like flexion of great toe, sharp pinch, rubbing knuckles on sternum, & then returns back unconscious state
- Coma: cannot be aroused
11
Q
What are the 3 components of the Glasgow Coma Scale (Gold Standard)
A
- Eye opening (4 = spontaneous opening of eyes, 3 = opening in response to speech, 2 = eye opening to pain, 1 = no eye opening response)
- Best verbal response (5 = verbal response demonstrate personal orientation to location, 4 = confused conversation is the best verbal response, 3 = inappropriate words in response to question, 2 = incomprehensible sounds, 1 = no verbal response)
- Best motor response (6 = follows motor commands, 5 = localizes a painful stimulus, 4 = withdraws specifically from pain, 3 = abnormal flexion response to pain “decorticate posturing”, 2 = abnormal extensor response to pain “decerebrate posturing”, 1 = no motor response)
12
Q
Standardized tests for assessing level of consciousness (LOC)
A
- Rancho Los Amigos Levels of Cognitive Function (LOCF): widely used in brain injury, tracks cognitive & behavioral responses of pt, level I = no response to level X = purposeful/appropriate response
- Coma Recovery Scale (CRS-R): better sensitivity. for lower levels - comas <-> veg state <-> minimal conscious state
13
Q
Define orientation
A
- awareness of person, place, time, & situation
- oriented X1/2/3/4 (example: A&Ox2 = person/place)
14
Q
Define attention
A
- awareness towards a stimuli in the environment
- Selective attention: awareness towards a stimuli in the environment w/o being distracted by the other stimuli, towards an object, task, or thought
- Sustained attention: time on particular task, repeat letters, words or digits forward or backward, digit span test, test of vigilance
- Alternating/switching attention: attention flexibility, back and forth between 2 tasks
- Divided attention: 2 tasks simultaneously, walkie talkie test (walk 20ft & return saying the alphabet), c-TUG
15
Q
Define memory
A
- registration, retention, & recall of past experiences & knowledge
- immediate memory (seconds) vs STM (day to day events) vs LTM (remote memory, years)
- explicit/declarative memory vs implicit/procedural/motor memory
- drugs can improve memory (cholinergic agents) or degrade memory (benzodiazepines, anticholinergics)
16
Q
Memory deficits
A
- injury to medial temporal lobe (limbic lobe/hippocampus) may show deficits in explicit memory, while retaining implicit memory (distributed broadly in CNS motor areas)
- amnesia: anterograde (inability to learn new material after injury) vs retrograde (inability to remember things prior to brain injury) “tip of the tongue phenomenon”
- PTA (post traumatic amnesia): lost of memory of event surrounding brain injury & inability to process info after brain injury
17
Q
Define perception
A
- integration of sensory info into meaningful info for making decisions & movement
- test after checking that peripheral sensory pathways are WNL: visual, auditory, somatosensory, etc.
18
Q
Perceptual disorders associated with neurologic conditions
A
- Body image/scheme disorders: unilateral spatial neglect, extinction, R/L discrimination
- Visuo-spatial disorders: depth perception, spatial relationship, figure-ground
- Apraxia: ideomotor, ideation, construction, dressing
- Agnosia: inability to recognize familiar objects, persons, sounds, shapes, or smells, visual, tactile, auditory
19
Q
Tests to assess unilateral spatial neglect
A
- Clock/house drawing test
- Albert’s cancellation test
- Comb & razor test: scoring using percent bias formula = L-R/total+ambiguous strokes, scoring varies b/w -1 to +1, close to -1 = L USN and close to +1 = R USN
20
Q
How to assess R/L discrimination
A
- ask pt to point to body part “point to your left elbow”
- pt should be able to point to each part accurately within reasonable time
- need to check for apraxia or aphasia
21
Q
Define dysarthria and aphasia
A
- Dysarthria: problems in articulation/problems with speech muscles
- Aphasia: lost of ability to understand or express speech due to brain damage, mostly in dominant hemisphere
22
Q
Describe Wernicke’s and Broca’s aphasia
A
- Wernicke’s/receptive/fluent aphasia: deficits in auditory/written comprehension with well articulated speech marked by nonsense words or substitutions
- Broca’s/expressive/non-fluent aphasia: deficits in articulating speech, limited vocabulary, but comprehension relatively preserved
23
Q
Define cognition
A
- ability of acquiring, processing, & recalling info, knowledge, & ability to judge/think, calculate
24
Q
3 areas for testing cognition
A
- Fund of knowledge: sum total individual’s learned information
- Calculation ability: adding/subtracting is easier than multiplying/dividing
- Abstract thinking ability: more sophisticated cognitive function; example: proverb interpretation - a rolling stone gathers no moss
25
Tests for assessing cognition
- Mini mental state examination (MMSE): objective outcome measure, 24-30 = no cognitive impairment, 18-23 = mild cognitive impairment, 0-17 = severe cognitive impairment
- MoCA: better sensitivity for detecting mild cognitive impairment, assesses mild cognitive domains - attention & concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, & orientation
26
Testing for sensation
- Superficial receptors/exteroceptors: pain, temp., light tough, pressure
- Deep receptors/proprioceptors: sense of relative positions of one's own body parts, awareness of joints at rest or movement, vibration
27
Quality of sensory deficits
- Anesthesia: all sensory modalities lost/absent
- Hypoesthesia: partial loss
- Hyperesthesia: hypersensitive
- Parasthesia: unpleasant sensations like burning, tingling, prickling, numbness with/without sensory stimulus
- Allodynia: painful sensation to a normal stimulus that should not be painful
28
How to test for superficial sensations
- Pain: sharp/dull discrimination
- Temperature: distinguish b/w warm and cool stimuli, use a Tiptherm for diabetic neuropathy
- Light touch: lightly touch/stroke the skin using finger, cotton, or tissue
- Pressure: apply firm pressure enough to indent the skin
29
How to test for deep sensations
- Awareness of joint position at rest/proprioceptive awareness: place body part in a static position & have pt identify if it's within initial, mid, or end range
- Awareness of extremities in motion/kinesthesia awareness: move joint passively through relatively small ROM with minimal tactile stimulation & have pt indicate direction & ROM
- Vibration: use a tuning fork (usually 128hz), hit tines against open palm & place fork base on pt skin
30
How to test combined cortical sensations
- Two-point discrimination: ability to perceive 2 simultaneous touch stimuli as distinctly separate
- Stereognosis: ability to recognize form of objects by touching & feeling, without visual input
-Barognosis: ability to distinguish weights of different objects by holding them
- Graphesthesia: ability to recognize letters, numbers, or designs 'written' on skin
- Texture recognition: silk, cotton, wool
- Double simultaneous stimulation for tactile extinction: ability to perceive simultaneous stimuli on opposite sides of body or proximally/distally on same side
- All need intact superficial, deep sensory mechanisms & cortical sensory association areas
31
How to test quantitative sensory
- Simple quantitative scoring for pain, temp., and light touch, take percentage of # of stimulus identified correctly
- Von-Frey Monofilaments: to quantify touch using graduated filaments that bend at specified forces
- TSA-II Thermal Sensory Analyzer + VSA 3000: to quantify both temp. and vibration senses
- Bio-thesiometer/Vibrator: for quantifying vibration
- SENSEBox: for measuring touch and pain thresholds
- Algometer: for 'pain-pressure' threshold measurements
32
General steps for a sensory exam
- gather required equipment
- posture: pt can be supine or sitting
- fully explain the purpose of the test
- do a trial run make sure they understand the sensation to be felt
- begin with superficial sensations & go from distal to proximal
- once a deficit area is noted then do elaborate tests to assess exact skin boundaries & severity of involvement
- data to be documented: modality, surface area involved, severity
- perform bilaterally
33
Dermatomes C2-S3
C2: posterior half of skull
C3: medial end of clavicle
C4: medial acromion below clavicle
C5: lateral elbow
C6: 1st digit/thumb
C7: 3rd digit/middle finger
C8: 5th digit/pinky
T1: medial elbow
T2: anterior axilla
T4: nipple line
T6 or T7: xiphoid process
T10: umbilicus
T12: anterior iliac crest/pubic symphysis
L1: inguinal region/upper medial thigh
L2: medial thigh mid-distance
L3: medial knee
L4: medial malleolus
L5: base of great toe
S1: lateral heel/lateral malleolus
S2: posterior knee
S3: ischial tuberosity
34
Patterns of sensory deficits
- Unilateral (Hemiparetic) distribution: cerebral or brainstem pathology
- Para/tetra-paretic distribution
- Non-specific peripheral distribution
- Stocking and glove distribution: peripheral neuropathies
- Dermatomal distribution
- Sporadic distribution - MS
35
Elements of a motor exam
- tone
- reflex integrity
- muscle performance
- voluntary movement patterns
36
Assessment of tone for hypertonia
- Force/velocity dependent increased resistance to stretch
- Clasp-knife response
- Modified Ashworth Scale (0-4 grades)
-Sing of UMN lesion - pyramidal tracts
- Associated UMN signs: abnormal synergies, clonus, + babinski sign
37
Assessment of tone for rigidity
- resistance to stretch is independent of force/velocity
- Lead-pipe response: constant resistance
- Cogwheel response: ratchet-like jerkiness
- Sign of UMN lesion: extra-pyramidal tracts, basal ganglia lesions like Parkinson's
- Associated signs: tremor, bradykinesia, loss of postural control
38
Describe the modified Ashworth scale
- assessed during PROM with pt in supine
- if testing a muscle that primarily flexes a joint place the joint in max flexion and move into max extension over 1 sec and vic versa for a primarily extension muscle
39
General tone assessment scoring
- 0 = no response (flaccidity)
- 1+ = decreased response (hypotonia)
- 2+ = normal response
- 3+ = exaggerated response (mild to moderate hypertonia)
- 4+ = sustained response (severe hypertonia)
40
MAS scoring for assessing spasticity
- 0 = no increase in muscle tone
- 1 = slight increase in muscle tone (a catch followed by minimal resistance at end ROM)
- 1+ = slight increase in muscle tone (a catch followed by minimal resistance throughout less than half the ROM)
- 2 = more marked increase in muscle tone (through most of the ROM)
- 3 = considerable increase in muscle tone (passive movement difficult)
- 4 = affected part(s) rigid in flexion or extension
41
Causes of hypotonia and associated LMN signs
- Genetic causes: Down syndrome, MD, CMT disease (Charcot-Marie Tooth disease), Marfan's syndrome, Euler's Danlos syndromes (connective tissue problems)
- Congenital UMN causes: cerebral palsy (CP)
- Acquired UMN causes: brain injury (BI), acute stroke, meningitis
- Acquired LMN causes: Polio, myasthenia gravis
- Associated LMN signs: spontaneous muscle fasciculations (visible movements), fibrillations (invisible) with denervation of motor units, muscle atrophy
42
Categories for assessing reflex integrity
- Deep tendon reflexes (DTRs): stretch reflexes elicited by stretching muscle spindles by tapping sharply over muscle tendon
- Cutaneous reflexes: elicited by a stroke on the skin, response his a specific muscle contraction (ex: babiski's sign)
- Primitive/tonic reflexes: should be integrated during infancy, can persist with delayed development or re-emerge following brain injury; tonic reflexes change postural tone rather than producing overt movements
43
Grading of reflexes integrity
- 0 = no reflex
- 1+ = hypo-reflexive
- 2+ = normal
- 3+ = hyper-reflexive
- 4+ = Clonus
- UMN lesion = increased/brisk reflexes
- LMN/peripheral sensory lesion = hypo-reflexive
44
Define Jendrassik maneuver
- use of a distraction if DTRs are difficult to elicit, to enhance responses, ex: hook hands together & pull apart, clench teeth, make fist with contralateral extremity
45
Less common reflexes tested
- finger flexion reflex
- Hoffman sign (flicking of the middle fingers distal phalanx, pos. = thumb & index finger move toward each other)
- Jaw jerk reflex
- Pronator teres
- Abnormal clonus
46
Cutaneous reflexes
- Plantar reflex: stroking the lateral side of sole of foot from heel to ball using a blunt object, Normal response = toes flex downwards, Pos. = toes extend/babinski sign
- Babinski Sign: big toe extends & other toes fan out, normal in infants up to 1 years old & should be integrate by 2-3 years
- Abdominal reflex
47
Assessment of muscle performance
- Muscle bulk: observe/measure limb girth, in some muscular dystrophies apparent girth increases but muscle gets weaker
- Muscle strength: MMT (0-5 grades), handheld dynamometers, isokinetic dynamometer
- Muscle endurance
- Issues with muscle testing: validity problems with UMN lesions due to presence of abnormal synergies, watch for substitutions
48
Myotomes from C1-S2
- C1‐C2 Neck Flexion/Extension
- C3 and CN XI Neck Side Flexion (Side Bending)
- C4 and CN XI Shoulder Elevation
- C5 Shoulder Abduction / Shoulder Lateral Rotation / Elbow Flexion
- C6 Elbow Flexion, Wrist Extension
- C7 Elbow Extension, Wrist Flexion
- C8 Thumb Extension, Ulnar Deviation, Finger Flexion
- T1 Hand Intrinsics, Abduction/Adduction
- L2 Hip Flexion
- L3 Knee Extension
- L4 Ankle Dorsiflexion
- L5 Toe Extension
- S1 Ankle Plantar Flexion, eversion and hip extension
- S2 Knee Flexion
49
Assessment of function/activities/tasks
- Activities can be categorized as: self care, functional mobility tasks (transfers/bed mobility), & locomotion (gait, stairs, w/c mobility)
- Activities/tasks can also be categorized depending on the stage of motor control involved: Transitional mobility (rolling/scooting) -> Stability (static sitting/standing) -> Controlled mobility (reaching, dynamic sitting/standing) -> Skills (transfers, gait)
