Week 1 Neurological Exam Flashcards
What should be in a neurological exam?
Observation!!!! - Hit the mute button
Diaphoresis? Pain? Difficulty breathing Obesity/cachexia Smell Skin
The best tool for any neurological exam should be simply watching the patient. Hit the mute button and look at people move.
Got it
Subjective
What questions should you ask?
Always think about what is the patient trying to get better at? Did they just have a stroke and are trying to get their independence back?
Got it
Vital Signs
Blood Pressure
Greater than / = HTN
Admitting dx
Heart Rate
Normal: - bpm
Respiration / Oxygen
Oxygen Saturation (SpO2) >_% is normal
- breaths/minute is normal
Supplemental O2?
Medical Precautions?
Documentation (Objective) Location Value Positioning Circumstances
Have to take vital signs at the start of every neurological exam. This is nonnegotiable.
130/80; 60-100; 88; 12-20
Vital Signs Continued
Should ALWAYS be taken and documented EVERY session
THIS IS A PATIENT SAFETY ISSUE
When else might you take vital signs?
What other factors can change baseline vital signs?
Should be taken either during exercise or immediately after (Especially when first starting to work with individual) or if there’s an acute change in presentation (i.e. changes in alertness, c/o headache, dizziness, etc.)
VS influenced by multiple factors, such as normal diurnal patterns, environmental temperature, physical activity, and emotions.
Got it
Pain
Why?:
Hospital accreditation
Changes between sessions, within a session
Judge impact of treatments (Assessment)
How (Objective): Location - neck Type - achy, sharp Description Response - is the pain going up or down with the intervention NRS - 0-10 scale
Got it
Skin Integrity
Why do we need to assess?
Patient’s with neurological deficits may not be able to feel and/or move certain body parts
Increases pressure injury risk
Bracing and/or seating potential
What areas are at higher risk for pressure injuries?
Heels, sacrum, occiput, elbows
What are safer alternatives?
Supine
sitting
What are safer alternatives?
Supine – semi sidelying position
Sitting – midline, feet supported, supportive surface, arms supported
People with neurological deficits might not be able to heal everything whether it is a global or local aspect of an injury.
Supine – semi turns
Sitting – neutral-upright position
Safer alternatives – distribute pressure on a (muscle/bone) based body part rather than a (muscle/bony) part. Try to (increase/decrease) the surface area by having them shift to one side.
muscle; bony; increase
Weight Shifting - redistributing body weight to areas of the body that can take more force
Documentation (Objective):
Method - standing, tilting back in the wheelchair, forward weight shifting in the chair
Duration - how long
Frequency
Do not stage unless given permission by facility -stage 1,2,3, etc. Describe the nature of the skin abnormality.
Consideration of different surfaces?
Mattress vs. wheelchair
Education
Patient and/or caregiver
Got it
CN III (Oculomotor) & CN IV (Trochlear) arises from the ____ and exits at the _____
midbrain; midbrain
CN V (Trigeminal), CN VI (Abducens), & CN VII (Facial) is located in the ____ and exits at the _____
pons; pons
CN VIII (Auditory) is located in the middle of the ____ and ____, and exits at the _____
pons and medulla; pons
CN IX (glossopharyngeal), CN X (vagus), CN XI (spinal accessory), & CN XII (hypoglossal) are located on the _______ and all exit on the ______
brain stem; medulla
Cranial nerve I (Olfactory): Examine (visual/olfactory) acuity using non-noxious odors such as lemon oil, coffee, cloves, or tobacco.
olfactory
Cranial nerve II (Optic): Examine (olfactory/visual) acuity using a (Snellen/Weber) chart; both central and peripheral vision is tested.
visual; Snellen
Cranial nerves _ (oculomotor), _ (trochlear), and _ (abducens): Determine equality and size of pupils; reaction to light; presence of strabismus (loss of ocular alignment); ability of eyes to follow a moving target without head movement; presence of ptosis of eyelid.
III; IV; VI
Cranial nerve V (Trigeminal): Sensory tests of (ear/face) (sharp/dull discrimination, light touch); open and close jaw against resistance; jaw jerk reflex.
face
Cranial nerve VII (Facial) : Examine any asymmetry of (ear/face) at rest and during voluntary contraction.
face
Cranial nerve VIII (Auditory): Test (auditory/visual) acuity using a vibrating tuning fork (Snell/Weber) test placed on vertex of skull or forehead; patient indicates on which side the tone is louder. Rub fingers together at a distance and gradually bring toward patient; note distance when first heard. Alter volume of conversation. (Snell/Rinne) test (conductive hearing loss), vibrating tuning fork placed on mastoid process, then near external ear canal; note hearing acuity.
auditory; Weber; Rinne;
Cranial nerve IX (Glossopharyngeal): Examine (smell/taste) on (anterior/posterior) one-third of tongue; examine (acid/gag) reflex.
taste; posterior; gag;
Cranial nerve _ (____): Examine swallowing; observe uvula and soft palate for any asymmetry (tongue depressor).
X; vagus
Cranial nerve XI (Spinal accessory): Examine strength of the ______ and _____ muscles.
SCM; trapezius
Cranial nerve _ (_____): With tongue protruded, examine ability to move tongue rapidly from side to side.
XII; Hypoglossal
Light touch, proprioception, and vibration start and end in the spinal cord through the (dorsal column medial lemniscus/spinothalamic tract).
dorsal column medial lemniscus
Pin/prick is more of pain modality and that looks at the (spinothalamic tract/dorsal column medial lemniscus).
spinothalamic tract
Sensory Tracts
Anterolateral Spinothalamic Pathway:
(discriminative/nondiscriminative) sensations such as pain, temperature, tickle, itch, and sexual sensations
DCML:
Sensations transmitted by the dorsal column–medial lemniscal pathway include (discriminative/nondiscriminiative) touch, stereognosis, tactile pressure, barognosis, graphesthesia, recognition of texture, kinesthesia, two-point discrimination, proprioception, and vibration.
Spinocerebellar Tracts: (conscious/unconscious) proprioception
nondiscriminative; discriminative; unconscious
CN Documentation
Got it
Sensation
Why? Makes sense with admitting dx Bracing considerations Safety concerns Identification of lesion site/ nervous system involvement
What should be done before testing?
Assess (height/cognition)
How to test?
Tested with eyes (open/closed)!
(Singular/Random) pattern
Description of sensation
Potential Sensory items:
Light touch – usually with a cotton swab
Pin/prick – paper clip
Proprioception- Movement of single joint with minimal tactile information. Can repeat 5x
Vibration: 128Hz tuning fork on a bony prominence (such as the sternum, elbow, or ankle).
Random pattern – random dermatomal pattern: something that the patient can’t guess.
Light touch, proprioception, and vibration start and end in the spinal cord through the (DCML/spinothalamic tract)
Pin/prick is more of pain modality and that looks at the (DCML/spinothalamic tract).
You can be efficient in testing and test one of the DCML pathways and then test the spinothalamic tract or another pathway, just be efficient.
Demonstration videos: (Slide 18)
https://neurologicexam.med.utah.edu/adult/html/sensory_normal.html
cognition; closed; random; DCML; spinothalamic tract
Joint Sense
(Proprioception/Kinesthesia)
Joint position senseand theawareness of joints at rest.
The extremity or joint(s) is moved through a ROM and held in a static position – Ex: Moving the thumb up and down up and down, then held. Ask the pt, is your thumb up or down? Don’t take the joint to (midrange/extremes) because you can get false negatives and people can tell if it is all the way up or down. You are also stretching the muscle and skin so for those who do have proprioceptive deficits can cheat the system if you test in (midrange/end range).
Minimal tactile information – grab (bony prominences/muscle bellies), not the (bone/muscle) because they’ll get more information that way!.
Assess _ times
The patient is asked to describe the position verbally or to duplicate the position of the extremity or joint(s) with the contralateral extremity (position matching)
No gold standard clinical test existed
The proprioception portion of the Fugl-Meyer Assessment Scale was found to be the most valid and reliable tool for screening patients in clinical settings. (Jamal et. al 2022)
(Proprioception/Kinesthesia)
‘Unconscious’ awareness of movement.
The extremity or joint(s) is moved passively through a relatively small range of motion (ROM).
The patient may also respond by simultaneously duplicating the movement with the contralateral extremity.
^^^^ Move a joint and the pt has to match the amount of force you used.
Ex of proprioception: Can you tell that your finger is pointed up versus pointed down?
Vibration and proprioception follow the same pathway to the brain so if vibration is off, one could logically assume proprioception is off.
Unconscious proprioception follows the (spinothalamic/spinocerebellar) tract. The (cerebrum/cerebellum) is responsible for a lot of proprioception.
extremes; end range; bony prominences; muscle; 5; spinocerebellar; cerebellum
- The modality tested – light touch, vibration, etc
- The quantity of involvement or body surface areas affected (pattern identification)
- The degree or severity of involvement (e.g., absent, impaired, or delayed responses)
- Localization of the exact boundaries of the sensory impairment
- The patient’s subjective feelings about changes in sensation
- The potential impact of sensory loss on function (i.e., activity limitation, disability)
MAS – Modified Ashworth Score – test of spasticity
Seating – wheelchair, so you wanna know where they are flexible or inflexible.
Look at (AROM/PROM) first and then if it doesn’t look symmetrical or normal, dive deeper into (AROM/PROM).
Strength testing – looking at big ticket myotomes and seeing if they can produce force and can they move their joint through the full ROM.
Stroke or SCI – (UMN/LMN) injury
Polio – (UMN/LMN) injury
Will assign a grade if they can at least move through full AROM, then afterwards you can describe what you felt if one of the above impairments is present during testing (coactivation, spasticity, etc
AROM; PROM; UMN; LMN
Documentation
Got it
Deep Tendon Reflexes
Definition An (involuntary, predictable/voluntary, unpredictable) response to a stimulus which is dependent on an intact reflex arc
UMN vs LMN response
UMN
With UMN response, might expect it to be (hyporeflexic/hyperreflexic), you’ll get something like a (0/4) on the grading scale
LMN?
might get a (1+ or 0/ 3 or 4) because that information doesn’t get to the spinal cord period because the peripheral nerve has been compromised in someway.
Grading scale
(0/1+): Absent, no response
(1+/2+): Slight reflex, present but depressed
(2+3+): Normal, typical reflex
(3+/4+): Brisk reflex, possibly but not necessarily abnormal
(4+5+): Very brisk reflex, abnormal, clonus
Impact on function?
involuntary, predictable; hyperreflexic; 4; 1+ or 0; 0; 1+; 2+; 3+’ 4+
Muscle Tone
Definition Resistance to (active/passive) stretching
UMN Injury
(Hypertonia/Hypotonia)
Stroke is an UMN, most likely will have (hypertonia/hypotonia) – the muscle has more tension in it than a normal person.
LMN Injury
(Hypertonia/Hypotonia) – muscle is just lacking tone
UMN injury can lead to:
Co-contraction - Think contraction of the biceps and triceps
Abnormal motor synergies (active) - Coupled movements that lead to appropriate or inappropriate accomplishments of tasks. Think of movements in a synergistic pattern, things like picking up a glass of water.
(Hypertonicity/Hypotonicity) - Muscle is so tight
(Hyporeflexia/Hyperreflexia) - (0/4+)
Paresis
tissue changes - ms, connective, ligaments etc
Passive; Hypertonia; hypertonia; hypotonia; hypertonicity; hyperreflexia; 4+
(Rigidity/Flaccidity) – can’t get muscle to activate
(Rigidity/Flaccidity) –resistant to motion whether active or passive and the muscle belly has a firmness or tightness to it
Flaccidity; Rigidity
Muscle Tone
Hypotonia - Definition (Increased/Decreased) or absent (flaccidity) muscle tone Common pathologies? Down Syndrome Cerebellar Very acute (UMN/LMN) lesions No formal grading scale *different than flaccidity
Dystonia
prolonged involuntary movement disorder characterized by twisting or writhing repetitive movements and (increased/decreased) muscular tone.
Generally indicative of a (basal ganglia/cerebellar) disorder
Decreased; UMN; increased; basal ganglia
Hypertonia
Spasticity:
Velocity (dependent/independent), (AROM/PROM)
Spasticity presents with (UMN/LMN) injuries – injuries to the brain or the spinal cord
Graded via Modified Ashworth Scale
Clonus: cyclical contraction and relaxation in response to stretch of the spastic muscle
Most common in the (knee flexors/plantarflexors)
Documentation: # of beats or sustain
Rigidity
“hypertonic state that is characterized by constant resistance throughout the (entire/mid) range”
Seen in the Parkinsons population
Velocity (dependent/independent), (PROM/AROM)
Will still feel resistance no matter the velocity of which you move the joint
Cogwheel or leadpipe phenotypes
Cogwheel – little jumps through your ROM testing in terms of resistance
Leadpipe – a gross resistance throughout the entire ROM
Velocity dependent – have to stretch the muscle quickly in a passive sense. When you test spasticity you have to move the joint through its full ROM passively and you have to stretch it quickly.
dependent; PROM; UMN; plantarflexors; entire; independent; PROM
Rigidity
“hypertonic state characterized by stiffness and resistance to movement that is (independent/dependent) of the velocity of movement” **seen mainly in disorders of the basal ganglia (i.e. parkinsons)
Pic on the left:
Decorticate - *level of (brainstem/diencephalon)
(Flexion/extension) of the arms, (flexion/extension) of the legs
Think of arms being held close to the CORE
Pic on the right:
Decerebrate - *level of (diencephalon/ brainstem/midbrain)
(Flexion/Extension) of the arms and legs
Decorticate rigidity is indicative of a corticospinal tract lesion at the level of the diencephalon (below/above) the superior colliculus, whereas decerebrate rigidity indicates a corticospinal lesion in the brain stem (above/between) the superior colliculus and vestibular nucleus.
Leadpipe rigidityrefers to a constant (increase/decrease) in muscular tone and stiffness of affected muscles.
Cogwheel rigidityrefers to the coexistence of rigidity with tremor producing stiffness and a ratchet-like jerkiness when a body part is manipulated.
independent; diencephalon; flexion; extension; brainstem/midbrain; Extension; above; between; increase;
Spasticity Grading
Modified Ashworth Scale
(0/1): No increase in muscle tone
(0/1): Catch and release at the start of the ROM OR minimal resistance noted at the end of the available ROM
(1/1+): Catch followed by minimal resistance throughout the remainder (less than 1/2) of available ROM
(1/2): Marked increase in tone through most of available ROM, but affected part is easily moved
(2/3): Considerable increase in muscle tone, passive movement difficult
(3/4): Affected part is rigid in flexion or extension
0; 1; 1+; 2; 3; 4
Spasticity clarification
Spasticity/stiffness are (active/passive) phenomena and has little impact on (active/passive) movement
Secondary effects of paresis and posturing are more significant
Many clinicians use the word “spasticity” to refer to ALL motor changes post (UMN/LMN) injury/disease:
Paresis
Muscular/soft tissue changes
Co-contraction
Hyperreflexia
Spasms
Compensatory motor patterns
passive; active; UMN;
Coordination
Ability to appropriate time and sequence single or multi-joint movement to achieve desired outcome
Mainly seen in pathologies involving (cerebellum and/or basal ganglia/cerebrum and/or triceps)
Why?
Determine the need for further testing
Determine if a referral to another practitioner is warranted
Narrow the origin of symptoms
Identify possible causes of activity limitation
MANY tests (but here are a few):
Finger to nose – bring their finger to their nose and then they’ll touch the clinicians finger and you’ll be looking for accuracies or if they miss it.
RAM – Rapid Alternating Movement – the ability to sequence certain movements bilaterally
Heel-to-shin – taking the heel of one leg and move to the opposite knee and slide down in a coordinated fashion. Those who have pathologies with cerebellum and/or basal ganglia will struggle with that.
cerebellum and/or basal ganglia;
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Balance Documentation
(I) – Independent
Just describe the balance you see when documenting. Don’t use the grading scales because they don’t tell you much
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Balance Strategies
Ankle
(Small/Large) perturbation
Firm surface
Adequate ROM, strength and motor control of ankles
Hip
(Smaller, slower/Larger, faster) perturbations
Support surface is compliant, or shorter than feet
Inadequate ROM, strength or motor control of ankles
*Can use both strategies in certain situations
Small; Larger, faster
Static Balance
Sensory organizational test – Typical foam and dome testing. Looks at 6 different conditions that tinker with the 3 variables (visual, vestibular, and somatosensory). It has a force plate to see where you shift your weight and how much strategy you are using from your ankle and hips.
Low-tech – Flat surface eyes open > flat surface eyes closed > piece of foam eyes open > piece of foam eyes closed
These are both simple ways to see how people use those 3 variables discussed earlier.
Got it
Step 1 – (Verbal cues only/No help):
Position yourself so that you can prevent patient from
injuring herself, then ask the patient to perform the activity.
! Step 2 – (Verbal cues only/No help):
Observe the strategy the patient attempts to use, and if key
components needed to complete the task are missing,
verbally cue the patient to perform those components.
! Step 3 – (Provide the minimal assist needed/Verbal cues only):
If patient is unable to perform critical components even with
verbal cueing, provide tactile cueing or the minimum
amount of active assistance needed to help the patient
complete the task.
In the spirit of recovering from something like a stroke or SCI, you want that person to do the hard thing, not the easiest because that is what helps remodel the brain.
No help; verbal cues only; Provide the minimal assist needed;
Functional Mobility Documentation
Level of assistance
Total assistance – pt is doing _% of the work
Maximal assistance – pt is doing _% of the work
Moderate assistance – pt is doing _% of the work
Minimal assistance – pt is doing -% of the work
Contact Guard assistance – hand is resting on someone but not physically moving them in any capacity. Ex: hand resting on the GAIT belt
Supervision (close supervision > distant supervision) – Within arms length of someone but not physically touching them.
Modified independent – the person is doing the task with increased time, they are using AD
Independent – person is doing the activity like a normal person
FIM levels are no longer used
FIM – Functional Independent Measures
0; 25; 50; 75-99;
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Functional Mobility Documentation Example
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https://www.neuropt.org/practice-resources/neurology-section-outcome-measures-recommendations
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What are the four components of a good goal?
Who? What? How much? Why?
Goal Setting
In the first good goal, answer Who? - What? - How much? - Why? -
Who – the pt
What – will ambulate on level tile surface
How much – 50 ft
Why – to improve independence with household ambulation
Assessment
Should link your (subjective/objective) findings to (functional deficits/impairments)
Should NOT relist objective findings in isolation
Helps justify your POC
This is where you show how smart you are!
objective; functional deficits;
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Prep Question
A patient recovering from right MCA stroke demonstrates lack of light touch sensation in the left hand. What additional sensory tests should the therapist perform? Test for pain and temperature Test for two-point discrimination Test for stereognosis Test for barognosis
What is the answer?
A
Test for pain and temperature because you need to think about, hey I have light touch sensation which follows the DCML, so to test something else within the DMCL would be redundant. So if I had something like vibration or proprioception that would be an inappropriate answer, whereas pain and temperature follows a different tract and I want to kind of clear it to support that that tract isn’t compromised based on the stroke.
The other 3 answers aren’t sensory tests, more so cortical processing to see how someone interprets the sensory tests. 2 point discrimination also looks at DCML.
