General Neurological Assessment

Shemjaz Arakkal M
 The general neurological exam has the
following components:
• Cerebration - level of consciousness
• Cranial nerves
• Cerebellar function

• Sensory evaluation - note the sensations that travel in the

posterior column versus the spinothalamic column.
– Thalamus - has a general sensory function. The sensory cortex is able
to localize and discriminate various sensations.
– Dermatomes (short spinal nerves or roots versus peripheral
neuropathy)

• Motor evaluation
• Reflexes - including deep and superficial reflexes
 CEREBRATION - Level of consciousness
(arousal)
A Alertness - arousal intact - responds to
questions.
L Lethargy - appears drowsy - responds to
questions (loud voice).
O Obtundation - shake patient gently.
S Stupor - Painful stimulus arouses the patient
from sleep.
C Coma – remains un-arousable with eyes closed.
CRANIAL NERVES
 CEREBELLAR SYSTEM
• The cerebellum receives both sensory and motor
input and
– COORDINATES MUSCULAR ACTIVITY,
– MAINTAINS EQUILIBRIUM AND
– HELPS CONTROL POSTURE.

• Coordination
– precise voluntary movement around a joint requires
• a graded increase of tone in the agonist or prime mover muscles
with
• a corresponding graded decrease of tone in the antagonist group.
• Ataxia
– a loss of coordination in maintaining proper balance and posture.

• Extrapyramidal disease results in

– a change in muscle tone,
– disturbance of posture and gait,
– slowness or lack of spontaneity of automatic movements
(bradykinesia) and
– a variety of involuntary movements.

• Cerebellar disease impairs

– coordination,
– gait , and
– equilibrium and
– is often accompanied by decreased muscle tone.
 Assessment of cerebellar function (coordination)
can be best accomplished by the following tests:
• Rapid alternating movements -
dysdiadochokinesia
– with cerebellar disease these movements are slow,
irregular, and clumsy.

• Point to point movements:

– Finger to nose test
– Heel-to-knee testing - the heel is moved down the
shin towards the big toe.
• Gait and other related body movements:
– Heel-to-heel straight line walking-tandem walking.
– Walk on toes, then on heels.
– Hop in place on each foot in turn.

• Standing in specified ways or stance

– Cerebellar disease is associated with staggering, wavering, and

lurching walk.

– With disease of the mid-cerebellum this occurs in all directions.

– On the other hand, with disease in a cerebellar lobe, the patient

tends to veer towards the affected side.
• The Pronator drift –
– the patient is asked to hold both arms straight
forward
– with the palms up and eyes closed for a period of 20 -
30 seconds.

– Pronation of one forearm suggests

• a contralateral lesion in the corticospinal tract.

– Downward drift of the arm with flexion of the fingers

and elbows
• might also occur constituting the pronator drift.
• In the same position one can tap the arms briskly
downward with the following potential responses:

1. Normal - the arm returns smoothly to the horizontal

position.

2. Weak muscle - easily displaced and may remain so.

3. Abnormal position sense - the patient may not recognize

the displacement and cannot correct adequately.

4. Cerebellar incoordination - the arm will return to original

position but will overshoot and bounce around.
 SENSORY EXAMINATION
Principles of Sensation:
• Crude touch, pain, and temperature travel in the ? tracts
• Fine touch, proprioception (position) and vibration travel in
the ?.

• Hence touch impulses originating on one side of the body

travel up both sides of the cord
– therefore touch sensation is often perceived
• despite partial damage to the cord.

• At the thalamic level, the general quality of sensation is

perceived but fine distinctions are not made.
• At the level of the sensory cortex, full perception,
– that is localization of stimuli and discrimination
occurs.

– Lesions in the sensory cortex might not impair

perception of pain, touch, and position,
• but do impair finer discrimination.

– Therefore a patient with a sensory cortical lesion

• cannot appreciate the size, shape, or texture and
• hence cannot identify the object.
• Dermatomal involvement helps to localize
lesions.
– areas innervated by posterior roots.

• some of the critical dermatomal areas:

Principles of Sensory Examination
1. Compare symmetrical areas on the two sides of the
body.

2. For pain, temperature, & touch –

– compare the distal with proximal areas of the extremities.
– Also sample dermatomes and major peripheral nerves.

3. For vibration and position –

– first test the fingers and the toes.
– If these are normal one can assume that the more
proximal areas are also normal.
4. BEFORE EACH KIND OF TEST, SHOW THE
PATIENT WHAT YOU PLAN TO DO.

5. Vary the pace of testing so that the patient is

not responding to a repetitive rhythm.

6. With an area of reduced sensory function or

hypersensitivity,
– map out the boundaries.
– One should move from the area of
• non sensitive skin to the sensitive areas.
 Some of the techniques
Pain
• Superficial pain results in either
– normal sensation,
– hypalgesia,
– analgesia(absent) or
– hyperalgesia.

• One should use a sharp safety pin

– held lightly between the thumb and index finger
– so that the instrument slides slightly with each pressure.
– That is light stimulation.

• The patient then should comment on whether the sensation was sharp
or dull.
• Do not draw blood and do not reuse the instrument on the next patient.
 Temperature
• Test for temperature using two test tubes
– one containing cold water and the other containing hot
water.

Light touch
• Use a fine wisp of cotton or a shred of gauze.
• With touch, the sensation can either be
– normal,
– anesthesia,
– hypesthesia, or
– hyperesthesia.
 Vibration
• One should use a low pitch tuning fork (128 or
256 Hz).
• The handle of the tuning fork should be placed on
bony prominences.
• Note this is often the first sensation to be lost in
peripheral neuropathy.
• One should start distally and if impaired proceed
proximally.

Position (Proprioception)
• If impaired one should proceed proximally.
 Testing Higher Integrative Functions

• Discriminative sensation of the sensory cortex

• This is useful only when
– the sensations of touch and position are either
intact or only slightly impaired.

• As with the other tests they should be

performed with the eyes closed.
• Stereognosis - Object identification (Astereognosis
occurs in cortical disease).

• Number or letter identification (graphesthesia)

• Two - point discrimination

– The open ends of a paper clip or two pins are placed on
the finger pad simultaneously.

– The minimal distance to differentiate one from two

points is noted.
• Normally
– on the finger pads this is less than 5 millimeters
– on the chest or forearm might be 40 millimeters.
• Point localization - Especially useful on trunk
and legs

• Tactile extinction test - patient may perceive

touch accurately when stimulation is applied
to symmetrical points consecutively.

• Normally both stimuli are felt.

 Evaluation of the Motor System
• The Corticospinal (pyramidal) tract
– mediates voluntary movement,
– integrates skilled,
– complicated, and delicate movements
– and carries impulses that inhibit muscle tone.

• The corticobulbar tract

– carries fibers from the motor cortex
• that connect with the lower motor neurons of the cranial
nerves.
• The Extrapyramidal System –
– This is a more complex system that
• helps maintain muscle tone and
• control body movements
– especially gross automatic movements such as walking.
Evaluation of the motor system involves

1. Evaluation of body position and movements.

Involuntary movements include
– tremors,
– tics,
– fasciculations (flickering, irregular movements in
small groups of muscle fibers).
2. Muscle bulk –
– unilateral or bilateral;
– proximal or distal.
• Alteration in muscle bulk might be:
A. Atrophy
B. Hypertrophy or
C. Pseudohypertrophy (increased muscle bulk
with decreased muscle strength).
3. Muscle tone –
– A normal muscle with an intact nerve supply when
relaxed voluntarily will still have slight residual tension or
TONE.

– Tone is evaluated by the resistance offered to passive

motion.

– A reduction in tone is called HYPOTONIA,

– While increased resistance that varies and is especially

noticeable at the extremes of range =
HYPERTONIA/SPASTICITY.
 – With an upper motor neuron lesion,
• the resistance is worse at the beginning of movement - CLASP
KNIFE RIGIDITY.
• This indicates that the resistance may suddenly cease.

– Resistance that persists throughout the range of motion

in both directions = LEAD PIPE RIGIDITY.

– Resistance demonstrating a series of jerks is referred to

as COGWHEEL RIGIDITY.

• Lead pipe and cogwheel rigidity tend to accompany

extrapyramidal disease.
4. Muscle Strength – (power)

5. Muscle Strength (power) is graded from 0 - 5

– maneuvers that include or exclude gravity and
include or exclude resistance.
 REFLEXES
A. Deep tendon reflexes
– involving specific spinal segments

B. Superficial (cutaneous) reflexes.

– A normal reflex arc depends on
• the integrity of every element in the reflex arc and
• the proper function of motor tracts descending from
levels higher than the reflex center.
Principles for Eliciting Deep Tendon Reflexes

1. Strike sudden blow

2. Over the tendon of insertion of the muscle
3. The muscle should be slightly stretched by:
a) the position of the limb, or
b) by pressure on the tendon by the examiner’s
thumb.
4. The limb must be relaxed
5. Reinforcement might be needed
• Reflexes are graded from 0 - 4+.
– In the presence of a diminished or absent reflex,
REINFORCEMENT should be used.
 REFLEX TECHNIQUE
Biceps (C5, 6)
• The arm
– should be partly flexed at the elbow
– the palm facing down.
– Thumb pressure over the tendon.
• Result
– Flexion at the elbow and
– the biceps contraction might be seen or felt.
 Triceps (C6, 7)
• The arm
– should be flexed at the elbow
– the palm facing towards the body and pulled slightly
against the chest.
• The triceps tendon
– should be tapped directly above the olecranon process.

• Result
– Extension at the elbow and
– Contraction of the triceps.
 Supinator/Brachioradialis (C5, 6)
• The hand
– rests on the abdomen or lap
– the forearm partly pronated.
– The radius is struck
• about 1 to 2 inches above the wrist.

• Result
– Flexion and supination of the forearm.
 Knee (L2, 3, 4)
• The patient should be sitting
– The legs dangling or lying supine
– knees flexed.
– The patellar tendon is tapped
• just below the patella.

• Result
– Contraction of the quadriceps
– Extension at the knee.
 Ankle (S1)

• Supine position
– both the hip and knee
• flexed
• Rotated externally
• Strike the Achilles tendon.

• Result
– Plantar flexion
 Superficial (cutaneous) Reflexes
Abdominal Reflexes (T8,9,10) (T10,11,12)

• Stroke lightly, briskly

– from the midaxillary line toward the midline.

• Applicator
– A key, wooden end of, or tongue blade

• One should inform the patient of the technique to be used.

• Normal –
– Ipsilateral contraction of the abdominal muscles and
– deviation of the umbilicus towards the stimulus.
 Plantar (L5, S1)
• Applicator
– A key or wooden end
• Stroke
– lateral aspect of the sole from the heel forwards and then
across the ball of the foot.

• Normal – Plantar flexion of the toes

• Abnormal – Dorsal flexion of the big toe often

accompanied by fanning of the other toes =
– Babinski Response
 Cremasteric Reflex in the male (L1, L2)

• Stroke
– inner thigh from the pubis distally.

• Normal
– contraction of the cremaster
• with prompt elevation of the testes on the ipsilateral
side.
 Superficial Anal (L1, L2)

• Stroke
– skin of the perianal region.

• Normal
– external and anal sphincter contraction.
 Abnormal Reflexes in Pyramidal Tract
(Corticospinal) Disease
• Altered normal reflexes

a. Complete suppression of normal superficial

reflexes below the level of the lesion.

b. The deep reflexes are hyperactive except

DURING THE STAGE OF SPINAL SHOCK WHEN THEY
ARE USUALLY ABSENT.
• Muscle Clonus
– sustained abnormal response of the stretch reflex from release of
central inhibitions of the reflex arc.
– Consists of rhythmic contraction of muscles initiated by stretching.

a) Knee Clonus (patella, quadriceps) –

a) This is best illicited by sharp downward displacement of the patella.

b) Ankle (gastrocnemius)
a) Partly flexing the knee;
b) then dorsi and plantar flex the foot a few times;
c) then sharply dorsi flex the foot and maintain this position.
d) The result
a) rhythmic oscillations between dorsi and plantar flexion.
c) Wrist Clonus (finger flexor clonus)
a) The technique involves grasping the patient’s fingers and
b) forcibly hyperextending the wrist.
c) The result
a) the wrist will rhythmically alternate between flexion and
extension.

d) Babinski Sign
a) A complete Babinski reflex will result in
a) dorsi flexion of the great toe,
b) fanning of all toes,
c) dorsi flexion of the ankle, and
d) flexion and withdrawal of the hip and the knee.
 Primitive (pathological) Reflexes
All of these signs may represent frontal lobe disease

Grasp Reflex
• This is normal in young infants.

• The palm of the patient is stroked

– the index finger of the examiner.

• The patient grasps the examiner’s index finger

– between the thumb and index finger and does not release it.

• In adults
– usually indicates a lesion of the pre-motor cortex.
 Palmomental Reflex
• Scratching or pricking of the thenar eminence.

• Ipsilateral contraction of the muscles of the

chin.

Snout or Suck Reflex

• Scratching or gentle percussion of the upper
lip.
• Puckering or sucking movement of the mouth.
Meningeal Signs – Meningeal Irritation
• Nuchal Rigidity (Neck Stiffness)
– Normally the neck is supple.

• Brudzinski’s Sign
– Flexion of the neck results in flexion of the hips and knees.

• Kernig’s Sign
– Bilateral pain in the hamstrings and increased resistance to
extension of the knee

• Spinal Rigidity