Neuro Practical 1

1. Muscle tone
Biceps: sitting, hold elbow and wrist
Quads: supine, hold knee and ankle
Ask patient to relax and check ROM
Passive stretching in normal speed for 2 times
Passive stretching in faster speed for 2 times with control stop
 Spasticity: increase in resistance due to tonic stretch reflex (UMNL)
 Flaccidity: loss of resistance (LMNL)

- Modified Ashworth Scale

0 No increase
1 Slight increase, minimal resistance at end range
1+ Minimal resistance in <1/2 of range
2 Marked increase in whole range
3 Marked increase, difficulty in passive movement
4 Affected side rigid in F/Ext

2. Reflex
C5 elbow F: sitting, tap Biceps tendon through our thumb
C7 elbow Ext: sitting, tap Triceps tendon
L3-4 knee Ext: sitting, tap patellar tendon
S1-2 ankle PF: supine, ankle DF and tap Achilles tendon
 Allow the tendon hammer to swing
 Hyperreflexia: phasic stretch reflex (UMNL)
 Hyporeflexia: loss of reflex (LMNL)

3. Joint position sense (proprioception)

Ankle: supine with pillow under leg
Knee: sitting or supine with leg hanging over plinth
 Distal to proximal (big toe or thumb): move one joint at a time
 Hold sides: minimize tactile sensation
Eye open: demonstrate joint moving “up” and “down” using good side
Eye closed: move the joint to different position and hold for 3s
Ask whether the joint moved “up” or “down”
Patient with expressive dysphasia: mimic the joint position using good side
 5 times all correct: intact
 Not all correct: move up to knee joint

4. Joint motion sense (kinesthesia)

Same as joint position sense: repeat in a faster manner
Ask whether the joint moved “up” or “down”
Patient with expressive dysphasia: mimic the joint movement using good foot

5. Tactile sensation: light touch, pin prick, sensory inattention

Sole: supine, use cotton wool to touch the skin
 Distal to proximal
Eye open: demonstrate touching using good side
Eye closed: touch on paretic side
Ask whether the patient can feel the touch and where is the touch
Test on both sides and ask if the sensation are the same
 If not the same: ask percentage loss
 Test more points to map out the area of sensation loss
 If only can feel on good side: sensory inattention
 Usually due to parietal lobe lesion over non-dominant R hemisphere

6. 2-point discrimination
Fingertip: sitting
Eye open: demonstrate touching (fingertip turns to little white)
Eye closed: touch on paretic side and ask whether it is 1-point or 2-point
2-point with larger distance: test 3 times
2-point with smaller distance: test 10 times
 At least 7 out of 10 times correct
 Normal value <5mm

7. Timed-up-and-go-test
Check visual field: hold one pen in midline and move another pen
Point the pen forwards: patient will see the pen before our hand
 Upper quadrant: head to ear level
 Lower quadrant: ear to jaw level
 Normal value = 140°
Starting position: sitting with back on chair, knee 90° F, feet touching the line
Say “start” and ask patient to walk with comfortable speed
Cross the opposite line, turn around, walk back and sit with back on chair
Demonstrate first, 1 practice trial and 3 test trials: take average
 Follow the patient on paretic side
 <10s: good fitness
 <30s: adequate for ADL independently

8. Functional reach test

Starting position: shoulder in 90° F, make a fist, feet slightly apart
Ask patient to reach as far as he can using good arm without making a step
Do not rotate the trunk, raise the heel, touch the wall
2 practice trials and 3 test trials: take average
 Ruler at acromion level, measure distance using 3rd metacarpal
 ≥25cm: no risk of falling

9. Balance test: motor strategies

Maintenance of posture
 Feet apart, feet together: 2mins
 Feet tandem with good leg in the back, single leg stance: 30s
Anticipatory postural adjustment
 Rapid arm raise with sandbag, rise to toes: 30s
 Body leans backward
Postural adjustment to voluntary movement
 Sitting and standing: tap body sideways, forward, backward for righting reaction
 Patient moves voluntarily: arm, leg, trunk movement
Reaction to external perturbation
 Standing: push patient gently to disturb balance
 Speed of ankle and hip strategies, step strategy, protective arm reaction

10. Balance test: sensory organization test

Ask patient to stand still with eyes open
Assess duration of stance, amplitude and frequency of body sway
Dominance: using wrong sensation even if there is available correct sensation
Dominance of visual system
 Romberg test: stand with feet together with eyes closed or wearing a dome
 Eyes closed removes input while the dome provides wrong input: no sway
 Duration <30s, increase in postural sway
Dominance of somatosensory system
 Stand on a foam with eyes open
 The foam provides wrong input: body leans forward or backward
 Increase in postural sway, loss balance
Under-use of vestibular system
 Stand on a foam with eyes closed: no vision, wrong somatosensation
 Duration <30s, increase in postural sway

11. Berg’s balance scale

12. MiniBest test

13. Purdue pegboard test

L: 15 marks
R: 15 marks
Both hands: 13 marks
Assembly: 40 marks

14. Minnesota manual dexterity test

Placing test: 242s
Turning test: 192s