The Neurological Examination

Question 1

What stage is the neurological exam performed during the basic structure of a musculoskeletal examination?

Answer 1

Second step.

During clinical examinations - immediately following BP.

Question 2

Why do we test the sensory as well as the motor system?

Answer 2

Sensory nerves send information about potential threats/hazards within the environment/pain to the spinal cord and then to the brain.

Motor nerves are responsible for the efferent output, thus a dysfunction such as reduced strength and function of the myotomes will indicate a pathology to the nerve supplying that muscle.

Question 3

What are the 3 general areas tested during a neurological examination?

Answer 3

Sensory system - sensation in the legs and feet
Motor system - muscle wasting, involuntary movements, weakness in legs or feet
Coordination - difficulty walking, balance, coordinated movements

Question 4

Common neurological SYMPTOMS of the lower limb include:

Answer 4

Motor - involuntary movements, weakness in movements (walking up stairs, getting out of a chair) or gait

Coordination - difficulty with walking or balance

Question 5

Common neurological SIGNS of the lower limb include:

Answer 5

Motor - muscle wasting, involuntary movements, weakness of muscles

Coordination - difficulty with gait, balance or completing specific coordination tasks/tests

Question 6

What is the 6 step summary of a lower limb neurological examination?

Answer 6

1 - observation
2 - gait
3 - reflexes
4 - motor testing
5 - coordination
6 - sensory testing

Question 7

What are we looking for during the observation component of a neurological examination of the lower limb?

Answer 7

Muscle bulk/wasting (lower motor neuron dysfunction) and involuntary movements (chorea/tics, resting tremors, fasciculations)

Question 8

What are we looking for during the gait assessment of a neurological examination of the lower limb?

Answer 8

Muscle weakness - hip drop, foot drop
Balanced/controlled movements - wobbling or ataxia
Functional strength - walking on toes and heels
Test balance and coordination - heel-toe walking

Question 9

What is a deep tendon reflex?

Answer 9

Involuntary response (or contraction) at the muscle following a strike at the muscle tendon. Each reflex involves specific spinal segments so can therefore help locate a pathological lesion.

An example of the simplest unit of sensory and motor function as it can involve as little as one sensory neuron (for afferent input) and one motor neuron (for efferent output).

Question 10

How is reflex testing graded?

Answer 10

0 - absent
1+ - diminished
2+ - normal
3+ - hyperactive without clonus
4+ - hyperactive with clonus

Question 11

What are the 4 reflex tests to be performed on the lower limb and what spinal segments do they test?

Answer 11

Knee (patella tendon) - L3-4
Ankle (Achilles tendon) - S1
Babinski (present/absent)
Clonus (present/absent)

Question 12

What are the 2 things we are testing during the motor system assessment or a neurological examination of the lower limb? What are we looking for during these tests?

Answer 12

Strength - graded 0-5, excepted more focused on whether the nerve supplying the particular muscle is functioning properly

Tone - normal nerve supply within a muscle has a certain level of resistance to passive movement = normal tone. Testing for rigidity/spasticity or flaccidity

Question 13

List the movements performed on the lower limb during motor strength neurological testing. Also include the nerve root.

Answer 13

Hip flexion - L1/2
Knee extension - L3/4
Knee flexion or ankle dorsiflexion - L4/5
Great toe extension - L5
Ankle plantarflexion - S1/2

Question 14

How is muscle tone graded?

Answer 14

Normal, increased (rigidity) or decreased (flaccidity)

Question 15

Coordination requires full function of 4 components of the NS. What are they?

Answer 15

1 - motor system - strength
2 - cerebellum - steady posture/rhythm
3 - vestibular system - balance/coordinating head, eye, body movements
4 - sensory system - proprioception

Question 16

What coordination tests do we perform on the lower limb? What do each test for?

Answer 16

Rapid alternating movements = foot-tap; testing for abnormal result = dysdiadochokinesia

Point to point movements = heel-to-shin; testing for abnormal result = dysmetria or intention tremor

Question 17

Sensory testing involves which NS?

Answer 17

PNS

Question 18

Which tracts are tested during sensory testing and during what tests are they being tested?

Answer 18

Spinothalamic tract - pain (sharp/dull test) and temperature

Dorsal columns - proprioception (prop. test) and vibration (tuning fork test)

Both - light touch (cotton wool test)

Question 19

Map out the dermatomes. What is the purpose of sensory testing?

Answer 19

L1-S2

Tests for a lesion or dysfunction at the spinal level that innervates the particular area of skin being tested.

Question 20

During vibration testing, what nerve roots supply the DIPs being tested?

Answer 20

Great toe - L4
Middle toe - L5
Little toe - S1