ASSIGNMENT

ON

NEUROLOGICAL ASSESSMENT

BPT.401: PT IN NEUROLOGY AND PSYCHOSOMATIC DISORDERS

SUBMITTED TO:

Dr. Simratjeet Kaur (PT)

SUBMITTED BY:

Sumandeep Kaur

(17501033)
 NEUROLOGICAL ASSESSMENT
History taking
Ask the present complaint of the patient; symptoms
the part affected, duration, onset.
Ask any other associated symptoms like
 Headache
 Numbness, pins and needles, cold and warmth
 Weakness, unsteadiness, stiffness or
clumsiness
 Nausea
 Vomiting
 Visual disturbance

Assessment
Assessing a patient’s mental health includes:
1.Mental status examination
2.Reflexes
3.Cranial Nerve examination
4.Motor system assessment
5.Sensory system assessment
6.Balance and co-ordination
 Mental Status Examination
This part is categorized into two general categories.
1.Arousal level, attention span, orientation and
cognition
2.Memory, hearing and visual acuity
Arousal
It is the physiological readiness of the human
system for activity. It is described as
a.Alert: the patient is awake and attentive to
normal levels
b.Lethargic: appears drowsy or may fall asleep if
not stimulated in any way
c. Obtunded: difficult to arouse from somnolent
state and frequently confused when awake
d.Stupor: responds only to strong, generally
noxious stimuli and return to unconscious state
when stimulation is stopped
e.Coma: cannot be aroused by any stimulation
Attention
It is selective awareness of the environment or
responsive to stimuli or task without being distracted
by other stimuli.
It is examined by asking the patient to repeat items
on a progressively more challenging list or to spell
words backwards.
Orientation
It refers to the patient’s awareness of time, person,
and place.
A series of simple questions is posed to the patient.
Person
• What is your name?
• Do you have a middle name?
• How old are you?
• When were you born?

Place
• Do you know where you are right now?
• What kind of a place is this?
• Do you know what city and state we are in?
• What city or town do you live in?
• What is your address at home?

Time
• What is today’s date?
• What day of the week is it?
• What time is it?
• Is it morning or afternoon?
• What season is it?
• What year is it?
• How long have you been here?

Memory
Both long and short term memory should be
assessed.
Long term memory: ask information like date or
place of birth, number of siblings, school attended,
historic facts.
Short term memory: give a series of words verbally
and ask to repeat immediately.
Hearing
A gross examination can be conducted by observing
patient’s response to conversation.
Visual Acuity
It can be checked by:
a.Snellen chart
b.Peripheral field vision examination

Reflex
A reflex is an involuntary, predictable, and specific
response to a stimulus dependent on an intact reflex
arc (sensory receptor, afferent neurons, efferent
neurons, and responding muscles or gland).
It is assessed further as:
1.Deep tendon reflexes
2.Superficial cutaneous reflexes
3.Primitive and Tonic reflexes
 Deep Tendon Reflexes
DTRs are tested by tapping sharply over the muscle
tendon with a standard reflex hammer or with the
tips of the therapist’s fingers.
Reflexes are graded on a 0 to 4+ scale:
0 Absent, no response
1+ Slight reflex, present but depressed, low normal
2+ Normal, typical reflex
3+ Brisk reflex, possibly but not necessarily
abnormal
4+ Very brisk reflex, abnormal, clonus
Examination of Deep Tendon Reflexes
Jaw (CN V): Patient is sitting, with jaw relaxed and
slightly open. Place finger on top of chin; tap
downward on top of finger in a direction that causes
the jaw to open.
Response: jaw rebounds and closes.
Biceps, Musculocutaneous nerve (C5, C6): Patient
is sitting with arm flexed and supported. Place
thumb over the biceps tendon in the cubital fossa,
stretching it slightly. Tap thumb or directly on
tendon.
Response: Slight contraction of elbow flexors.
Brachioradialis (supinator), Radial nerve (C5, C6):
Patient is sitting with arm flexed onto the abdomen.
Place finger on the radial tuberosity and tap finger
with hammer.
Response: Slight contraction of elbow flexors, slight
wrist extension or radial deviation.
Triceps, Radial nerve (C6, C7): Patient is sitting with
arm supported in abduction, elbow flexed. Palpate
triceps tendon just above olecranon. Tap directly on
tendon.
Response: Slight contraction of elbow extensors.
Finger flexors, Median nerve (C6–T1): Hold hand in
neutral position. Place finger across palmar surface
of distal phalanges of four fingers and tap.
Response: Slight contraction of finger flexors.
Hamstrings,Tibial branch, sciatica nerve (L5, S1,
S2): Patient is prone with knee semiflexed and
supported. Palpate tendon at the knee. Tap on
finger or directly on tendon.
Response: Slight contraction of knee flexors.
Quadriceps (patellar, knee jerk),Femoral nerve(L2,
L3, L4): Patient is sitting with knee flexed, foot
unsupported. Tap tendon of quadriceps muscle
between the patella and tibial tuberosity.
Response: Slight contraction of knee extensors.
Achilles (ankle jerk), Tibial (S1–S2): Patient is prone
with foot over the end of the plinth or sitting with
knee flexed and foot held in slight dorsiflexion. Tap
tendon just above its insertion on the calcaneus.
Maintaining slight tension on the gastrocnemius-
soleus group improves the response.
Response: Slight contraction of plantarflexors.
Superficial Cutaneous Reflexes
These are elicited with a light stroke applied to the
skin. Response will be brief contraction of muscles
innervated by same spinal segments receiving the
afferent inputs from the cutaneous receptors.
1.Plantar (S1, S2): With blunt object (key or
wooden end of applicator stick), stroke the
lateral aspect of the sole, moving from the heel
to the ball of the foot, curving medially across
the ball of the foot.
Alternate stimuli for plantar (for sensitive feet):
o Chaddock: stroke lateral ankle and lateral
aspect of foot.
o Oppenheim: stroke down tibial crest
Response: Normal response is flexion
(plantarflexion) of the great toe, and sometimes
the other toes (negative Babinski sign).
Abnormal response, termed a positive Babinski
sign, is extension (dorsiflexion) of the great toe
with fanning of the four other toes (indicates
UMN lesions).
2.Abdominal reflexes: Position patient in supine,
relaxed. Make brisk, light stroke over each
quadrant of the abdominals from the periphery
to the umbilicus.
Response: Localized contraction under the
stimulus, causing the umbilicus
 Above umbilicus = T8–T10: Masked by obesity.
  Below umbilicus = T10–T12: Can be absent in
both UMN and LMN disorders.
Primitive and Tonic Reflexes
Primitive and tonic reflexes are graded using a 0 to
4+ scale:
0+ Absent
1+ Tone change: slight, transient with no movement
of the extremities
2+ Visible movements of extremities
3+ Exaggerated, full movement of extremities
4+ Obligatory and sustained movement, lasting for
more than 30 seconds

Cranial Nerve Examination

An examination of CN integrity should include a
determination of
(1) Specific cranial nerves tested
(2) The degree of abnormality observed (specific
deficits)
(3) The effects of abnormal cranial nerve integrity on
function.
The patient’s perceptions of loss of function should
also be identified.
 Motor System Assessment
It is divided into the following:
1.Muscle tone
2.Muscle strength
Muscle Tone:
Atrophy, the loss of muscle bulk (wasting), occurs as
a result of the loss of functional mobility (disuse
atrophy), LMN disease (neurogenic atrophy), or
protein-calorie malnutrition. Disuse atrophy is evident
after periods of inactivity, developing in weeks or
months. Neurogenic atrophy accompanies LMN injury
(e.g., peripheral nerve injury, spinal root injury) and
occurs rapidly, generally within 2 to 3 weeks.
Examination of Muscle Bulk
During the examination, the therapist should visually
inspect the muscle symmetry and shapes,
comparing and contrasting their size and contour.
Muscles looking flat or concave are indicative of
atrophy.
 Comparisons between and within limbs for bulk
– Atrophy
  Limb girth measurements - Neurogenic atrophy
(compare with the corresponding normal limb)
 Palpation at rest and during muscle contraction -
muscle tension
 Girth measurements or volumetric displacement
measures (e.g., hands or feet) - visual
inspection findings.
MUSCLE STRENGTH
Patients with impairments in motor control and
neurological injury pose unique challenges for the
examination of muscle performance. Weakness is the
inability to generate sufficient levels of force and can
vary from paresis (partial weakness) to plegia
(absence of muscle strength). Weakness is seen in
patients with UMN syndrome, along with spasticity
and hyperactive reflexes. Patients may present with
hemiplegia (one-sided paralysis), paraplegia (LE
paralysis), or tetraplegia (quadriplegia). Weakness
also appears in patients with LMN lesions. Patients
with stroke demonstrate significant changes in
muscle performance, including altered recruitment
patterns; abnormal times to achieve force, and
decreased motor unit firing rates.
Examination of Muscle Strength and Power
The clinical examination of muscle strength and
power utilizes standardized methods and protocols
(e.g., manual muscle testing [MMT], handheld
dynamometers, and instrumented isokinetic
systems).
MMT GRADES:
Estimates of strength can be made based on
observations during active functional movements
using the following criteria:
• Muscles with visible movement that is unable to
overcome gravity and move throughout the ROM
receive a poor grade.
• Muscles those are able to move against gravity
throughout the range but can take no additional
resistance receive a fair grade.
• Muscles that can move against gravity throughout
the range and against some resistance (moderate
resistance) receive a good grade.
• Muscles that can move throughout the range and
against strong resistance receive a grade of normal.
 Sensory Examination
For each sensory test, the following data will be
generated:
• the modality tested
• 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)
Superficial sensations
 Pain
 Temperature
 Touch
 Pressure
Deep sensation
 Kinesthesia awareness
 Vibration perception
Combined cortical sensations
 Stereognosis perception
 Tactile localization
 Two- point discrimination
 Double simultaneous stimulation
 Graphesthesia
 Recognition of texture
 Barognosis

Co-ordination
Rapid alternating movements
Ask the patient to strike one hand on the thigh, raise
the hand, turn it over, and then strike it back down
as fast as possible.
Ask the patient to tap the distal thumb with the tip of
index finger as fast as possible.
Ask the patient to tap your hand with the ball of each
foot as fast as possible
Point to Point movements
Ask the patient to touch your index finger and their
nose alternatively several times. Move your finger
about as the patient performs this task.
Hold your finger still so that the patient can touch it
with one arm and finger outstretched.
Ask the patient to move their arm and return to your
finger with their eyes closed.
Romberg
Be prepared to catch the patient if they are unstable.
Ask the patient to stand with the feet together and
eyes closed for 5-10 seconds without support.
The test is said to be positive if the patient is
unstable.

Balance
Grades for balance assessment:
4 Normal: Able to maintain steady balance without
handhold support (static) Accepts maximal
challenge and can shift weight easily within full
range in all directions (dynamic)
3 Good: Able to maintain balance without handhold
support, limited postural sway (static) Accepts
moderate challenge; able to maintain balance while
picking object off floor (dynamic)
2 Fair: Able to maintain balance with handhold
support; may require occasional minimal assistance
(static) Accepts minimal challenge; able to maintain
balance while turning head/trunk (dynamic)
1 Poor: Requires handhold support and moderate to
maximal assistance to maintain position (static)
Unable to accept challenge or move without loss of
balance (dynamic)
0 Absent: Unable to maintain balance
Balance Test
 Sitting in a normal comfortable position
 Sitting, weight shifting in all directions
 Sitting, multidirectional functional reach
 Sitting, picking an object up off floor
 Standing in a normal comfortable posture
 Standing, feet together (narrow base of support)
 Standing on one foot
 Standing, with one foot directly in front of the
other (tandem position)
 Standing: eyes open (EO) to eyes closed (EC)
(Romberg Test)
 Standing in tandem position: EO to EC
(Sharpened Romberg Test)
 Standing, multidirectional functional reach
 Walking, placing feet on floor markers
 Walk: sideways
 Walk: backwards
 Walk: cross-stepping
 Walk: in a circle, alternate directions
 Walk: on heels
 Walk: on toes
 March in place
 Walk with horizontal and vertical head turns
 Step over or around obstacles
 Stairclimbing with handrail
 Stairclimbing without handrail
 Stairclimbing: one step at a time