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Laboratory Manual for Neurologic Rehabilitation

Chapter 4: Examination of the Neurologic System

For the Instructor Guide and Worksheet Key please contact user services at userservices@mheducation.com

OUTLINE
Objectives:

The student will appropriately:

1. Observe and practice taking notes while watching a demonstration of a neuro examination/evaluation.

2. Accurately demonstrate examination and handling, of a simulated patient (TA or classmate) in a timely manner.

3. Apply strategies to maximize client position, in order to complete an efficient client examination.

4. Associate a therapist's movement analysis to the choice and administration of specific tests and measures of body structure and function during a
neurologic examination.

5. Demonstrate appropriate communication and cueing in all lab practices.

Activity 1. Examination of the Cranial Nerves, Tone, Reflexes, and Coordination

Students work in pairs to practice performing cranial nerve screening examination of Cranial nerves III through IX, and XI and XII. Students also assess
tone using the Modified Ashworth scale, assess reflexes, sensation, and coordination.

Activity 2. The Neurologic Examination: Observation

Students view a video of an examination of a client with a UMN lesion and take notes using the "Guide for the Evaluation of the Neurologically Involved
Adult".

Activity 3. Practice Examination Techniques

Students are to work in pairs and practice performing an examination, with one partner playing the role of patient with a UMN lesion and the other
partner playing the role of therapist.

WORKSHEET
Activity 1. Examination of the Cranial Nerves, Tone, Reflexes, and Coordination

1. Cranial Nerve Screening: Work with a partner and perform a screening of cranial nerves III through IX, and XI and XII (Table 4-1 unshaded boxes).

Physical therapists rarely examine CN I—the olfactory nerve, as it does not impact motor function. In addition, CN II is not typically examined by
therapists though you could screen it by asking the client to identify objects or to count your fingers. Be sure that any client who uses glasses is
wearing his/her glasses. Cranial nerve X is difficult to examine though you should be careful to observe vitals and use caution if there are signs of
hoarseness as damage to this nerve impacts parasympathetic function and could impact response to activity/exercise. See an example of a full
cranial nerve exam in Video 4-1.

2. Assessing Tone: Tone is assessed by having the person relax while you take the limb through the range of motion (ROM) passively. If you note that
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there is resistance to passive movement when the person is relaxed, this would be an indication of hypertonia. If there is no hypertonia during
Chapter 4: Examination of the Neurologic System, Page 1 / 10
slow, easy ROM, you then passively move the arm through the range rapidly. If tone increases when the speed of passive motion is increased, this
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indicates spasticity. If the individual has hypertonia that does not increase when the speed of passive motion is increased, it is described as rigidity.
 therapists though you could screen it by asking the client to identify objects or to count your fingers. Be sure that any client who uses glasses is
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wearing his/her glasses. Cranial nerve X is difficult to examine though you should be careful to observe vitals and use caution if there are signs of
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hoarseness as damage to this nerve impacts parasympathetic function and could impact response to activity/exercise. See an example of a full
cranial nerve exam in Video 4-1.

2. Assessing Tone: Tone is assessed by having the person relax while you take the limb through the range of motion (ROM) passively. If you note that
there is resistance to passive movement when the person is relaxed, this would be an indication of hypertonia. If there is no hypertonia during
slow, easy ROM, you then passively move the arm through the range rapidly. If tone increases when the speed of passive motion is increased, this
indicates spasticity. If the individual has hypertonia that does not increase when the speed of passive motion is increased, it is described as rigidity.

Assess using the Modified Ashworth Scale (Box 4-1).

3. Reflex Testing: Reflexes are tested using a reflex hammer. The clinician taps the rubber triangular shaped end over key tendon insertions, in the
arms (biceps, triceps, brachioradialis), knees (quadriceps, hamstrings), and heels (Achilles). If there is a difference in response from the left to the
right, there may be an underlying problem that merits further evaluation. A difference in reflexes between the arms and legs usually indicates a
lesion involving the spinal cord. Depressed reflexes in only one limb, while the other limb demonstrates a normal response usually indicates a
peripheral nerve lesion. Hyperactive reflexes indicate a lesion in the central nervous system. Deep tendon reflexes are reported on a numerical
scale (Table 4-2), and at a minimum, the biceps, triceps, quadriceps, and Achilles reflexes should be tested.

Special or Pathological Reflex Testing: The presence of a positive test on the Hoffman's (see Video 4-2) and/or presence of clonus indicates a
possible UMN lesion. The Hoffman test is used to screen for an UMN lesion using the upper extremity (UE), and the Babinski is used to screen for a
UMN lesion using the lower extremity (LE). The wrist and ankle should be screened for the presence of clonus. There are rare muscle disorders that
can also lead to clonus. See Box 4-2 for instructions on testing for the Babinski and the Hoffman reflexes. Clonus is assessed by taking the joint to
end range of wrist extension or ankle dorsiflexion, and then applying a quick overpressure and hold in that position. If clonus is present, the
examiner will feel the body part make rapid jerking motions. Clonus can be sustained (lasts until overpressure is removed) or unsustained (clonus
stops after several beats). If it is unsustained clonus some examiners will count the number of beats and document. For example, "unsustained
clonus of four beats in the right wrist."

4. Sensory Tests: The sensory system contributes to movement and thus should be thoroughly examined. The following tests assess specific domains
within the sensory system. Position the client such that he/she cannot see the area being tested or ask the client to close his/her eyes.

a. Vibration—(Video 4-2 at 31:20 to 35:34) The most accurate method to assess the dorsal column-medial lemniscus pathway is to examine for
vibratory sensation. You will need a 128 or 256 Hz tuning fork for this activity. Tap the tuning fork on your hand and once it is vibrating, place it
first on the head of the first metatarsal bone. If the client is unable to feel vibration here, then move proximally to the medial malleolus.
Continue in this manner until you locate the first bony protuberance on which the client can feel the vibration. Since vibratory and joint position
sensation (conscious proprioception) are both carried in the same tract, testing for vibration allows us to determine whether or not the tract
carrying joint position sense is damaged.

Proprioception:

b. Movement sense—Kinesthesia—is tested by moving the joint to be tested and asking the client to describe how the joint is being moved. The
digit being moved should be grasped lightly on either side of the joint. Start distal at the hallux for the toes and the distal interphalangeal joint
for the fingers, and move proximal until you find a joint with intact movement sense. While the client is watching, demonstrate the movement
for the client and tell the client how to describe the motion. Use simple terms like "up, down, in, and out." Then, have the client close his/her
eyes or cover the extremity so it cannot be seen, and then gently move the joint and ask the client to tell you if the digit was moved and if so in
which direction (see Video 4-2 at around this time—33:00 to 35:34).

c. Position sense—tested by placing a joint in a position and asking the client to tell you the position. Another method is to ask the client to place
his/her opposite extremity in the same position as the examiner placed the tested extremity. This can only be done, if the client has full
antigravity active movement in the opposite extremity.

d. Pain—Pain sensation is carried by the lateral spinothalamic tract. The ability to sense painful stimuli is assessed by doing pinprick testing. Using
a safety pin or other pin that is clean and has not been used before gently prick the skin moving from proximal to distal asking the client to
identify when he/she feels a pin prick. You should also test side to side, asking the client if it feels the same or different side to side.

5. Coordination:

a. Finger-to-nose test: This explores hand-eye coordination, visual tracking, and depth perception. Sitting in front of the client, direct the client to
touch his/her nose and then the tip of your finger, and then back to his/her nose. This movement is repeated and the therapists varies the
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target, moving to all four quadrants as well as varying the proximity to the client. Observe movement of the client's eyes in tracking the
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well as the ability to accurately touch the therapist's finger tip.

b. Heel-to-shin test: This explores lower extremity (LE) coordination. Ask the client to touch the heel of one LE to the shin of the opposite LE, and
 a safety pin or other pin that is clean and has not been used before gently prick the skin moving from proximal to distal asking the client to
identify when he/she feels a pin prick. You should also test side to side, asking the client if it feels the same or different side to side.
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5. Coordination:

a. Finger-to-nose test: This explores hand-eye coordination, visual tracking, and depth perception. Sitting in front of the client, direct the client to
touch his/her nose and then the tip of your finger, and then back to his/her nose. This movement is repeated and the therapists varies the
target, moving to all four quadrants as well as varying the proximity to the client. Observe movement of the client's eyes in tracking the target as
well as the ability to accurately touch the therapist's finger tip.

b. Heel-to-shin test: This explores lower extremity (LE) coordination. Ask the client to touch the heel of one LE to the shin of the opposite LE, and
move the heel up and down the shin. Observe the smoothness of movement and if the heel stays in contact with the shin or not.

c. Dysdiadochokinesia: This is tested by having the client perform rapid, alternating movements of the UEs and if needed the LEs. The client is in a
seated position. Direct him/her to place hands on the lap, with one palm up and one palm down. Ask the client to move both hands to the
opposite position (ie, move from palm-up to palm-down). The client moves both hands at the same time. A demonstration may be needed.
Then, ask the client to do this alternating movement faster. Observe if both hands are moving in an alternate pattern and with symmetrical
timing.

Video 4-1. Cranial nerve examination

Play Video
Table 4-1:
Cranial Nerve Function and Screening

Cranial
Name Function Screening
Nerve

I Olfactory Smell Have client identify familiar smells (vanilla); there are vials that can be purchased or therapists
can make their own.

II Optic Vision Reading close and distant items.

III Oculomotor Eye movement, Eye tracking in all directions, pupillary response to light; at rest, eye will be slightly depressed
pupillary reflexes and rotated toward the nose, when damaged.

IV Trochlear Superior oblique eye Observe eye position at rest; eye(s) will be elevated if impaired.
muscle innervation

V Trigeminal Muscles of Observe jaw motion (resistance to motion, opening, side-to-side mobility); temporalis muscles
mastication & can be palpated.
sensation of the face

VI Abducens Lateral rectus of the Look at eye movement; if damaged, there will be an inability to track outward (abduct the eye).
eye innervation

VII Facial Muscles of facial Look for facial asymmetries; observe motions (raising eyebrows, wrinkling forehead, closing eyes,
expression, taste for frowning/smiling, lip pursing, etc.), taste with common liquids (lemon juice, honey) can also be
the anterior 2/3 tested.
tongue

VIII Vestibulocochlear Hearing & vestibular Can use the "rub test"—rub thumb and forefinger together next to the ear. Ask the client to point
to which ear he/she hears it in. Check both. Look for differences. You can use a tuning fork, which
tests for air conduction and structural problems that can occur inside the ear—strike tuning fork
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IX Glossopharyngeal Sensation & taste for Ask about swallowing, which may be impaired, absent gag reflex is also a sign of damage
posterior tongue (stimulate with tongue depressor; CN IX is the sensory component and CN X is the motor
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Table 4-1:
Cranial Nerve Function and Screening

Cranial
Name Function Screening
Nerve

I Olfactory Smell Have client identify familiar smells (vanilla); there are vials that can be purchased or therapists
can make their own.

II Optic Vision Reading close and distant items.

III Oculomotor Eye movement, Eye tracking in all directions, pupillary response to light; at rest, eye will be slightly depressed
pupillary reflexes and rotated toward the nose, when damaged.

IV Trochlear Superior oblique eye Observe eye position at rest; eye(s) will be elevated if impaired.
muscle innervation

V Trigeminal Muscles of Observe jaw motion (resistance to motion, opening, side-to-side mobility); temporalis muscles
mastication & can be palpated.
sensation of the face

VI Abducens Lateral rectus of the Look at eye movement; if damaged, there will be an inability to track outward (abduct the eye).
eye innervation

VII Facial Muscles of facial Look for facial asymmetries; observe motions (raising eyebrows, wrinkling forehead, closing eyes,
expression, taste for frowning/smiling, lip pursing, etc.), taste with common liquids (lemon juice, honey) can also be
the anterior 2/3 tested.
tongue

VIII Vestibulocochlear Hearing & vestibular Can use the "rub test"—rub thumb and forefinger together next to the ear. Ask the client to point
to which ear he/she hears it in. Check both. Look for differences. You can use a tuning fork, which
tests for air conduction and structural problems that can occur inside the ear—strike tuning fork
on your hand and place behind the ear on the bony surface. Observe balance.

IX Glossopharyngeal Sensation & taste for Ask about swallowing, which may be impaired, absent gag reflex is also a sign of damage
posterior tongue (stimulate with tongue depressor; CN IX is the sensory component and CN X is the motor
and pharynx component of the gag reflex).

X Vagus Innervates epiglottis Voice hoarseness with increased heart and respiration rate are signs of CN X damage; have
& larynx, person say "ahh" and watch for palatal-uvula movement; unilateral nerve damage can yield
parasympathetic asymmetric motion.
innervation of
internal organs

XI Accessory Trapezius & Observe ability to shrug shoulders and turn head to both sides.
sternocleidomastoid
muscle innervation

XII Hypoglossal Tongue muscles Observe tongue protrusion and mobility; unilateral lesions will result in lateral movement when
protruding tongue.

Source: Reproduced, with permission, from Nichols-Larsen DS, Kegelmeyer DA, Buford JA, Kloos AD, Heathcock JC, Basso DM. Neurologic Rehabilitation:
Neuroscience and Neuroplasticity in Physical Therapy Practice. New York, NY: McGraw Hill; 2016.
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BOX 4-1: Modified Ashworth Scale
 XII Hypoglossal Tongue muscles Observe tongue protrusion and mobility; unilateral lesions will result in lateral movement when
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protruding tongue.
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Source: Reproduced, with permission, from Nichols-Larsen DS, Kegelmeyer DA, Buford JA, Kloos AD, Heathcock JC, Basso DM. Neurologic Rehabilitation:
Neuroscience and Neuroplasticity in Physical Therapy Practice. New York, NY: McGraw Hill; 2016.

BOX 4-1: Modified Ashworth Scale

0  No increase in muscle tone.

1  Slight increase in muscle tone, manifested by a catch or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion
or extension.

1+  Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM.

2  More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved.

3  Considerable increase in muscle tone, passive movement difficult.

4  Affected part(s) rigid in flexion or extension.

9  Unable to test.

Table 4-2:
Deep Tendon Reflex Grades

Reflex
Evaluation Response Characteristics
Grade

0 Absent No visible or palpable muscle contraction.

1+ Hyporeflexia Slight or sluggish muscle contraction with little or no joint movement. Reinforcement may be required to elicit a reflex
response.

2+ Normal Slight muscle contraction with slight joint movement.

3+ Hyperreflexia Clearly visible, brisk muscle contraction with moderate joint movement.

4+ Abnormal Strong muscle contraction with one to three beats of clonus. Reflex spread to contralateral side may be noted.

5+ Abnormal Strong muscle contraction with sustained clonus. Reflex spread to contralateral side may be noted.

BOX 4-2: Upper Motor Neuron Screening Tests

Babinski (plantar reflex)—Stroke bottom of foot from heel to toes, using your thumb or the end of a reflex hammer, which should elicit flexion of
the big toe and perhaps the other toes (negative sign); in very young infants (<24 months) and those with UMN injuries (stroke, brain injury, etc.), the
big toe will extend and the other toes will splay out (positive sign).

Hoffman test/reflex—Flick the fingernail of the middle finger; watch for flexion of the thumb's distil phalanx. This should be done on both sides. If
flexion occurs, this is a positive Hoffman sign and can be an indication of upper motor neuron disease. However, some people without neurologic
injury will have a positive Hoffman sign, so the tester should look for asymmetry in this reflex or the emergence of it after a neurologic injury, when it
suggests corticospinal disruption.

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Source: Reproduced, with permission, from Nichols-Larsen DS, Kegelmeyer DA, Buford JA, Kloos AD, Heathcock JC, Basso DM. Neurologic
Chapter 4: Examination of the Neurologic System, Page 5 / 10
Rehabilitation: Neuroscience and Neuroplasticity in Physical Therapy Practice. New York, NY: McGraw Hill; 2016.
©2021 McGraw Hill. All Rights Reserved.   Terms of Use • Privacy Policy • Notice • Accessibility
 4+ Abnormal Strong muscle contraction with one to three beats of clonus. Reflex spread to contralateral side may be noted.

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5+ Abnormal Strong muscle contraction with sustained clonus. Reflex spread to contralateral side may be noted.
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BOX 4-2: Upper Motor Neuron Screening Tests

Babinski (plantar reflex)—Stroke bottom of foot from heel to toes, using your thumb or the end of a reflex hammer, which should elicit flexion of
the big toe and perhaps the other toes (negative sign); in very young infants (<24 months) and those with UMN injuries (stroke, brain injury, etc.), the
big toe will extend and the other toes will splay out (positive sign).

Hoffman test/reflex—Flick the fingernail of the middle finger; watch for flexion of the thumb's distil phalanx. This should be done on both sides. If
flexion occurs, this is a positive Hoffman sign and can be an indication of upper motor neuron disease. However, some people without neurologic
injury will have a positive Hoffman sign, so the tester should look for asymmetry in this reflex or the emergence of it after a neurologic injury, when it
suggests corticospinal disruption.

Source: Reproduced, with permission, from Nichols-Larsen DS, Kegelmeyer DA, Buford JA, Kloos AD, Heathcock JC, Basso DM. Neurologic
Rehabilitation: Neuroscience and Neuroplasticity in Physical Therapy Practice. New York, NY: McGraw Hill; 2016.

Activity 2. The Neurologic Examination: Observation

Observe the examination of a client with a UMN lesion (see Video 4-2). During the observation, take notes on the findings using the "Guide for the
Evaluation of the Neurologically Involved Adult" to assist you in determining areas that may be appropriate for assessment.

Video 4-2. CVA evaluation

Play Video

A Guide for the Evaluation of the Neurologically-Involved Adult

The goal of this guide is to provide a framework or organization to the neurologic examination. This can help you determine information to collect. It is
not intended to be a documentation template.

I. Examination

Ia. History

A. Client Data:

Your notes on your observation of a PT examination of a client with a UMN lesion:

Ib. Systems Review

A. Sensory: Vision and hearing

B. Mental status

C. Integumentary

D. Cardiopulmonary

E. Musculoskeletal

F. Neuromuscular

Your notes on your observation of a PT examination of a client with a UMN lesion:

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Describe the movement strategy or type.
 D. Cardiopulmonary
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F. Neuromuscular

Your notes on your observation of a PT examination of a client with a UMN lesion:

Ic. Movement Analysis

Describe the movement strategy or type.

State level of assistance needed and any assistive devices used, if any

A. Bed Mobility:

Your notes on your observation of a PT examination of a client with a UMN lesion:

B. Transfers:

a. Describe the movement strategy or type.

b. State level of assistance needed and any assistive devices used, if any.

Your notes on your observation of a PT examination of a client with a UMN lesion:

C. Sitting and Standing Posture:

Your notes on your observation of a PT examination of a client with a UMN lesion:

D. Gait:

Your notes on your observation of a PT examination of a client with a UMN lesion:

E. Stair Climbing:

Your notes on your observation of a PT examination of a client with a UMN lesion:

F. Wheelchair Propulsion:

Your notes on your observation of a PT examination of a client with a UMN lesion:

G. Orthotics and Assistive Devices:

Your notes on your observation of a PT examination of a client with a UMN lesion:

Check that you have reflected all orthoses and assistive devices in your movement analysis, or comment on other use in this area.

Consider how the observed movement pattern is similar to a "typical" pattern and how it is different from a "typical" pattern.

How is the client's movement pattern different from "typical"?

Id. Activity Problem List

After movement analysis, make a functional problem list. Consider the value of selecting and administering one or more functional,
standardized tests, which can include self-reported and/or performance-based measures of mobility. These measures can provide an
objective measure for the activity and/or participation domains of the International Classification of Function (ICF) model. Test and retest of
these measures can indicate therapeutic progress and skill acquisition in mobility. For more learning of skills related to selecting,
administering, and interpreting these measures, please see Chapter 5: Examination and Evaluation: Outcome Measure Interpretation.

Ie. Body Structure/Function

A. Cognition and/or Affect: Level of awareness/consciousness, attention, orientation for the environment, memory, safety awareness, level of
cooperation or indifference, ability to attend and interact, emotional responses.

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Your notes on your observation of a PT examination of a client with a UMN lesion:
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B. Communication:

Your notes on your observation of a PT examination of a client with a UMN lesion:

 administering, and interpreting these measures, please see Chapter 5: Examination and Evaluation: Outcome Measure Interpretation.
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Ie. Body Structure/Function
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A. Cognition and/or Affect: Level of awareness/consciousness, attention, orientation for the environment, memory, safety awareness, level of
cooperation or indifference, ability to attend and interact, emotional responses.

Your notes on your observation of a PT examination of a client with a UMN lesion:

B. Communication:

Your notes on your observation of a PT examination of a client with a UMN lesion:

C. Sensation:

1. Hearing

2. Vision (can include visual field testing)

3. Tactile

4. Vibration or position/movement sense

5. Pain

Your notes on your observation of a PT examination of a client with a UMN lesion:

D. Edema:

Your notes on your observation of a PT examination of a client with a UMN lesion:

E. PROM and Tone:

Your notes on your observation of a PT examination of a client with a UMN lesion:

F. Reflexes:

1. Deep Tendon Reflexes (DTRs)—report these per Table 4-2.

2. Babinski or Chaddock test (Chaddocks test is used when a client exhibits significant flexor withdrawal and the Babinski cannot be
performed. It also tests integrity of the corticospinal tract.

3. Hoffman

4. Clonus—indicate if it is sustained or unsustained; if unsustained, identify the number of beats observed.

Your notes on your observation of a PT examination of a client with a UMN lesion:

G. Strength: Divide this section into UE and LE and report on all four extremities. This is where AROM is assessed. First, determine if the client
can actively move their limb through the full range of motion, against gravity. If the client cannot complete this range, note the range that is
completed, and then eliminate gravity. If the client is able to move through full range against gravity, then add resistance to conclude a
manual muscle test score.

Your notes on your observation of a PT examination of a client with a UMN lesion:

H. Balance and Coordination:

Your notes on your observation of a PT examination of a client with a UMN lesion:

Take a moment to reflect upon ways in which the therapist utilized movement analysis of various mobility tasks to prioritize the tests and measures
during the examination.

The next part of this process involves the evaluation, diagnosis, prognosis, and setting short- and long-term goals. You will practice these components
in the "Evaluation of a Client with a Neurologic Lesion/Case Study" lab.

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Activity 3. Practice Examination Techniques
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Work in pairs and practice performing an examination.

One partner is the client. Pretend to be the client from the examination you observed in Activities 2 and 3. The other partner is the therapist.
Take a moment to reflect upon ways in which the therapist utilized movement analysis of various mobility tasks to prioritize the tests and measures
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during the examination.
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The next part of this process involves the evaluation, diagnosis, prognosis, and setting short- and long-term goals. You will practice these components
in the "Evaluation of a Client with a Neurologic Lesion/Case Study" lab.

Activity 3. Practice Examination Techniques

Work in pairs and practice performing an examination.

One partner is the client. Pretend to be the client from the examination you observed in Activities 2 and 3. The other partner is the therapist.

Be sure to include a screen/examination of the following areas:

1. Strength

2. Sensation

3. Tone

4. Reflexes

5. Coordination

6. Functional mobility activities (each partner will focus on one activity but you should assess as many of the relevant activities as you can in the time
allotted)

Partner 1 Examination Role Play:

Start with the partner who is role-playing the client laying supine in bed. Go through an examination of this client, focusing on having the client change
positions as infrequently as possible to avoid fatigue. Clients with UMN lesions become fatigued easily and you will need to consider this in conducting
your examination in order to ensure that the client is able to complete the entire examination.

Focus on your client's ability to ambulate.

Switch Roles:

Partner 2 Examination Role Play:

Start with the partner who is role-playing the client sitting in a wheelchair. Go through an examination of this client, focusing on having the client
change positions as infrequently as possible to avoid fatigue. Clients with UMN lesions become fatigued easily, and you will need to consider this in
conducting your examination in order to ensure that the client is able to complete the entire examination.

Focus on your client's ability to perform transfers.

Switch Roles:

"Take Home"

1. A score of 0 on the Modified Ashworth scale indicates that the individual has normal tone.

2. Reflexes should be compared bilaterally.

3. When doing strength testing in clients who may be very weak, first have the client actively move their limb against gravity. If the client cannot move
the limb through the range against gravity, eliminate gravity and ask the client to move the limb through the range of motion. If the client goes
through the full range of motion against gravity, add resistance.

4. When examining the client with a UMN lesion, it is important to be efficient and minimize position changes as these clients tend to fatigue easily.

5. A therapist can use movement analysis to identify possible deficits in body structures and function. This informs the choice of tests and measures
during the examination so that the therapist can draw appropriate conclusions.

Bibliography
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1. Kegelmeyer DA. Neurologic exam. In: Nichols-Larsen DS, Kegelmeyer DA, Buford JA, Kloos AD, Heathcock JC, Basso DM, eds. Neurologic
Rehabilitation: Neuroscience and Neuroplasticity in Physical Therapy Practice . New York, NY: McGraw Hill; 2016.
 Universidad del Rosario
4. When examining the client with a UMN lesion, it is important to be efficient and minimize position changes as these clients tend to fatigue easily.
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5. A therapist can use movement analysis to identify possible deficits in body structures and function. This informs the choice of tests and measures
during the examination so that the therapist can draw appropriate conclusions.

Bibliography

1. Kegelmeyer DA. Neurologic exam. In: Nichols-Larsen DS, Kegelmeyer DA, Buford JA, Kloos AD, Heathcock JC, Basso DM, eds. Neurologic
Rehabilitation: Neuroscience and Neuroplasticity in Physical Therapy Practice . New York, NY: McGraw Hill; 2016.

2. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J
Geriatr Soc . 2005;53:695–699.

3. Hislop H, Avers D, Brown M. Daniels and Worthingham's Muscle Testing . 9th ed. Elsevier/Saunders; 2013. ISBN: 9781455706150.

4. Pandyan AD, Johnson GR, Price CI, Curless RH, Barnes MP, Rodgers H. A review of the properties and limitations of the Ashworth and modified
Ashworth Scales as measures of spasticity. Clin Rehabil . 1999;13(5):373–383. [PubMed: 10498344]

SKILL CHECK
1. Perform the screening test for Cranial Nerve VI. Explain, what an abnormal finding would look like.

2. Examine the client for the Hoffman reflex. Explain, what an abnormal finding would look like.

Students receive a failing grade, if they are not safe at any time or if they need more than two cues, to appropriately administer the examination
technique.

SKILL CHECK KEY

1. Perform the screening test for Cranial Nerve VI.

Look at eye movement by having the client try to look to the side while keeping the head stable and facing forward. If CN VI is damaged, there will be
an inability to look outward (abduct the eye).

2. Examine the client for the Hoffman reflex.

The examiner uses his/her thumb to flick the fingernail of the client's middle finger; watch for flexion of the thumb's distal phalanx. This should be
done on both sides. If flexion occurs, this is a positive Hoffman sign and can be an indication of upper motor neuron disease. However, some
people without neurologic injury will have a positive Hoffman sign, so the tester should look for asymmetry in this reflex or the emergence of it after
a neurologic injury, when it suggests corticospinal disruption.

Students receive a failing grade if they are not safe at any time, or if they need more than two cues to appropriately administer the examination
technique.

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Chapter 4: Examination of the Neurologic System, Page 10 / 10
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