NEUROLOGICAL

ASSESSMENT
DR. CHINTAN SHAH
MPT(NEUROLOGY)
It consists of :

1) SUBJECTIVE ASSESSMENT

2) OBJECTIVE ASSESSMENT

SUBJECTIVE ASSESSMENT:

DEMOGRAPHIC DATA:

NAME:
It is important to address the patient

AGE:
Some disease are common in certain age
groups
 Ex: Cerbral palsy and DMD in children
  SEX:
Certain disease are common in male and some in
females
EX: Stroke in male

 OCCUPATION:
It gives information about current or prior work
activity.
In addition to this, occupation gives us idea
about premorbid state of patient i.e. whether the
patient lives sedentary life-style or does any
skilled work.
This helps in further rehabilitation and
management of the patient.
 ADDRESS:
It helps to know about the condition of the
house
I.e. Whether at height so having how many
steps and so on..

CHIEF COMPLAIN:

It is always taken in the words of patient.

It is the list of problems and patient’s
disabilities in his own words.
Dominanace/ Handedness:

It helps in the prognosis of the patient.

 HISTORY:

1) PRESENT HISTORY

2) PAST HISTORY

- past medical history
- past surgical history

3) FAMILY HISTORY

4) SOCIO-ECONOMIC HISTORY

5) PERSONEL HISTORY

6) WORK HISTORY

1) PRESENT HISTORY:

Sequential stages of the symptoms of the patient is

called as history of present illness.
It includes the following:

Mechanism of injury: How it happened

Onset: sudden or gradual
Duration:
Associated Signs/Symptoms: seen at that stage
Associated injury:

Example: In a stroke patient, ask him how it

happened, whether the onset was sudden or
gradual, ask the exact date, time and duration and
also the signs & symptoms seen at the same time.
  2) Past history:
It is important to know whether the patient had
previous attacks of same disease before or any
relevant disease in the past.
Ex: Ischemic heart disease
 Deep vein thrombosis

To gain information regarding past history, we

should ask following questions:
Q: how he was before the symptoms
Q: whether he had previous episodes of this
Q: whether he had noticed any signs of
weakness before?
Q: Whether he was admitted in a hospital for a
longer duration? why?
Past history can also be obtained from:
1) past records
2) by verbal response of the patient but it should
be confirmed.

Past history comprises of:

1) past medical / surgical history
2) drug history

a) Past Medical/ Surgical history:

Any prior hospitalisation, surgeries, or pre-
existing medical and other health related
condition
Pregnancy, deliveries, neuromuscular,
orthopaedic, cardio-pulmonary conditions if any
b) Past Drug history:

Example:

Medication of diabetes or hypertension

Antidepressant therapy
 3) Family history:

Itis important because hereditory plays an

important role in disease transmission.

Example:
Parkinson,
Epilepsy
Multiple sclerosis
 4) Socio-Economic history:

From social history, We can know the

interaction with family member, work
place and surrounding environment

We can know the level of understanding

of the patient and family members

From economic history, We can also about

the whether the particular treatment
would be affordable to the patient or not.
 5) Personel History:

Itincludes:
 HABITS:
Smoking,
Tobacco,
Alcohol,
Drug abuse.

 TYPE OF PERSONALITY:

Introvert-
Extrovert
Mood swings
 6) Work history:
Patient gives information about the
ergonomic problems
- nature of work
- type of work

Stress in work whether mental or physical

leads to:

Insomnia
Lossof apetite
Weakness
Hypertension
 On Observation:

1. Status of the patient

2. Built
3. Attitude of limb
4. Wasting of muscle
5. Swelling
6. Involuntary Movement
7. Facial Expression
8. Posture
9. Gait
10. External Appliances
11. Skin Changes
1) Status of patient:

Unconscious state:

Conscious state:
Stupor
Coma
Vegetative state
Persistent vegetative state
Locked in state
Brain death
2) Built:

It can be of the following 3:

1) Endodermic - thin

2) Mesodermic - moderate

3) Ectodermic - obese

3) Attitude of limb:

Abnormal Position of the limb following any

neurological insult.

It is observed without touching the patient

from head to toe.

It can be flexion attitude or extension

attitude.
4) Wasting of muscle:

To differentiate between Flaccid &

Spastic muscle.

Flaccid:( hypotonia)

Reduce Tone
Diminish DTR
Babinski Negative
MMT should be done
Spastic: ( Hypertone)

Increase Tone
Exaggerated DTR
Babinski Positive
Voluntary Control Grading should be done
Spasticity should be measured
5) Swelling:

Assess for upper limb and lower limb.

Compare by assessing on both the sides.

6) Involuntary movement:

Athetosis
(involuntary twisting)
Sinuous writhing movement of the fingers and hands.

Ataxia
(gross lack of coordination of muscle
movements)

Ballismus
(violent involuntary rapid and irregular
movements)

Chorea (rapid, involuntary movement)

This usually affects the head, face or limbs.
The focus may move from one part of the body to
another at random.
Dystonia (sustained contraction)
 A dystonia is a sustained muscle contraction,
frequently causing abnormal posture
Occurs in hands (writer’s cramp)

Ticdisorders (involuntary, compulsive,

repetitive, stereotyped)
These are repetitive stereotyped movements
and occurs while speaking
 The patient can initiate them voluntarily and
can also intentionally suppress them for a
short time.

Tremor (involuntary oscillations)

7) Facial Expression:

It is mostly seen in Parkinson patient.

8) Posture:

Posture is observed in 3 positions:

1) Lying
2) Sitting
3) Standing

Posture is observed in 3 views:

1) Anterior view

2) Posterior view
3) Lateral view
9) Gait:

High stepping gait

Antalgic gait
Circumductory gait

Also observe the following :

Foot drop
Limp
Ataxia
10) External Appliances:

Crutches
Sticks
Walkers
Wheel chair
Ventilators

Other appliances to be observed are:

Braces
Splints
Orthosis
Prosthesis
11) Skin changes:

Redness
Hair loss
Scar
Pigmentation
 On Palpation:

1) Tenderness:

2) Warmth:

3) Muscle spasm:

4)Bony abnormality:

5) Oedema:
1) Tenderness:
It is defined as pain on palpation

2) Warmth:
It can be done by measuring the normal
body temperature.

3) Muscle spasm:

It is the continuous contraction of specific
muscle due to overuse of the particular
muscle
4) Bony abnormality:

5) Oedema:

 Pitting oedema:

Pitting edema can be demonstrated by applying pressure to

the swollen area by depressing the skin with a finger. If the
pressing causes an indentation that persists for some time
after the release of the pressure, the edema is referred to as
pitting edema.
 Non-pitting oedema:

In non-pitting edema, which usually affects

the legs or arms, pressure that is applied to
the skin does not result in a persistent
indentation
 On Examination:
1) Vital signs:
Temperature:
 Avg temp: 98.2 ± 0.7 degree F

Blood pressure:
Avg BP: 120/80 mm of Hg

Heart rate:
Avg HR: 60-100 beats/min

Respiratory rate:
Avg RR: 12-15 breaths/min
2) Higher Mental Functions:

1) Memory
2) Consciousness
3) Behaviour
4) Orientation
5) Speech
“MCBOS”

6) Intelligent capacity

7) Counting and Calculation
8) Reading and Writing
1) Memory:
A) Short term memory
B) Long-term memory
C) Immediate-term memory

A) Short-term memory:

Retrieval of information from several
minutes or hours
Ex: ask him about recent meals, when he
came to the hospital, with whom he came,
at around what time he got up in the
morning, name of the doctor attending to
him, etc
B) Long-term memory:

Retrieval of information after days, months

or years.

Ex: ask information regarding chronological

events like date and place of birth, age,
year when he started school, date of
marriage, reciting nursery rhymes,
alphabets, etc.
C) Immediate-term memory:

Immediate recall or repetition of word,

sentence or events.

To test the patient’s ability to immediately

recall he may be given name, address,
phone numbers and asked to recall it after
3 min, 15 min, 30 min and after 1 hour.
Mini-Mental Status Examination:
2) Consciousness:

Conscious state:
1) Stupor
2) Coma
3) Vegetative state
4) Persistent vegetative state
5) Locked in state
6) Brain death

1) Stupor:

Itis a state in which the patient is

unresponsive but can be aroused briefly
by a strong stimulus (like sharp pain)
2) Coma:
It is the state in which the patient is totally
unconscious, unresponsive, and
unarousable.

Even doesn’t respond to any stimulus and

also donot follow the sleep-wake cycle as
patients eyes are always closed.

Coma is usually for a short duration and in

some patients it takes a long time and in
some it may progress to vegetative state
and even some die.
) Vegetative state:

Patient is unconscious and unresponsive but

follows the sleep-wake cycle.

Unlikecoma, patient opens their eyes and

also may move, groan or shows reflex.
4) Persistent vegetative state:
Patient who donot recover from vegetative
state within 30 days are said to be in
Persistent vegetative state.

Thelonger the patient in PVS state, the

more severe are the disabilities.

After a year, the chances of patient in PVS

to regain consciousness is very less.
5) Locked In syndrome:
In this state the patient is aware and awake
but cannot move or communicate due to
complete paralysis of body.

They communicate through movements and

blinking of their eyes.

Mostof such patients never regain complete

motor control.
6) Brain death:

There is total lack of all brain functions and

mostly results in death of person.
Some Final Points to Consider.
1. Progression from coma to full consciousness
is often a gradual occurrence (especially in the
case of head trauma).
 For example, an individual may experience
coma that lasts for 8 weeks in duration, followed
by 4-6 weeks of restlessness and agitation, and
then one day become fully conscious.

2. Recovery from an altered level of

consciousness is influenced by:
1) age (under 20 years of age, prognosis is
better)
2) type of injury
3) premorbid health
3.The longer the coma the worse the
outcome.

4. Absence of corneal , gag, pupillary

reflexes, is equivalent with poor prognosis.

5. Very poor prognosis is associated with

abnormal flexion, abnormal extension or
flaccidity.
Clinical Rating System:(Scales of TBI)
1) Glassgow coma Scale:
It is based on motor, verbal and eye
response.

Motor - Max 6
Eye - Max 4
Verbal -Max 5

Thus overall it is a 15 point scale.

It helps to assess the severity of injury.
Eye opening:
Spontaneous 4
To speech 3
To pain 2
Nil 1

Best motor response:

Obeys commands 6
Localizes response 5
Withdraws 4
Abnormal flexion 3
Extensor response 2
No response 1
Verbal Response:

Oriented 5
Confused conversation 4
Inappropriate words 3
Inappropriate sounds 2
No response 1
The result of 3 tests added up to determine
the level of consciousness of patient.

Total score is 3-15

Score of 3-8 indicates severe head injury-
state of coma
Score of 9-12 indicate moderate head
injury
Score of 13-15 indicate mild head injury
3) Behaviour:
The patient behaviour may be:

irritable, hostile, over anxious, resistive, shy,

tense, agitated, fearful, inhibited, negative,

frank, social or friendly or co-operative.

3) Orientation:
The patient’s orientation to 3 things are
checked:
1) Time
2) Place
3) Person

He may be asked following questions:

1) Time:
what time is it now, at what time he got up in
the morning
2)Place:
Where is he at present, where is his home?

3) Person:

Ask him to identify the close relatives

Ask him who brought him to the hospital
4) Speech:
The patient should be tested for his ability to
understand and respond to a question in a
correct manner.

The clarity of speech, tone , smoothness and

articulation is to be tested.

They may suffer from:

1) sensory aphasia
2) motor aphasia
3) dysarthria
Some patients may experience aphasia.
In Broca’s aphasia or motor aphasia,
they may speak in broken phrases and
pauses frequently.

In Wernick’s aphasia or sensory

aphasia, they speak in complete phrases
and proper grammer but they use non-
essential and invented words.

They also suffer from dysarthria because

they cannot use the muscles needed to
form words and produce sounds.
5) Intelligence:
It is important for diagnostic and prognostic
view.
Intelligent patient are generally sharp in
grasping the exercise program designed for
them which facilitates the treatment
procedures.
Estimation of intelligence can be made from
his educational and professional level and also
social development.
Various tests are there to assess the
intelligence like Binet-Simon test, Weschler’s
intelligence scale, etc
6) Counting and calculation:

It can be done by simple test.

The various tests are to count forward &

backward, count coins, can be given addition
and subtraction etc.
 Some mathematical problem can be given
like if one earns 100 rs per day then how
many days he will take to earn 1000 rs.
Such problems solving ability will give a clear
idea about the counting and calculation of
the person.
7) Reading and writing:
For reading ability, the ppatient must be
asked to read loudly the newspaper, or any
magazine, article etc.
The assessment should include the clearity,
voice and the accuracy of the words and
sentences.

For writing ability, patient should be made

to write the dictated words, copy any article
from newspaper etc.
3) Cranial Nerve
Assessment:
They are the nerves that emerge directly
from brain.

They are numbered according to their

nuclei lie in brainstem.

CN III leavas the brainstem at higher

position than CN XII whose origin is
located at lower level than other cranial
nerves.

CN III onwards arise from the brainstem.

1) Olfactory – Temporal lobe
2) Optic - Occipital lobe
3) Occulomotor - Midbrain
4) Trochlear - Midbrain
5) Trigeminal- opthalmic - Pons
 maxillary
 mandibular
6) Abducens - Pons
7) Facial- Temporal - Pons
Zygomatic
Buccal
Marginal mandibular
Cervical
8) Vestibulo-Cocclear - Cerebellum

9) Glosso-pharyngeal - Medulla Oblongata

10) Vagus - MedullaOblongata

11) Spinal Accessory - Medulla

Oblongata

12) Hypoglossal - Medulla

Oblongata
Olfactory, Optic and Vestibulo-
Cocclear are Sensory CN.

Occulomotor, Trochlear, Abducent,

Accessory and Hypoglossal are Motor CN.

Trigeminal, Facial,
Glossopharyngeal and Vagus are Sensory
as well as Motor CN.
CN I Olfactory (sensory):
Function:Smell;
Test:Coffee, Olive, Lemon etc..

Each nostril examined separately.

CN II Optic (sensory):
Function:Vision and Colour vision;

Test:count fingers or movement in

all quadrant and periphery
in each eye;
CN III Oculomotor (motor):
Function: moves

eyes in all directions except

outward and down & in, pupil

reactivity to light

Test: Eyelid movement

CN IV Trochlear (motor):
Function:moves eyes
down and in….
Test: ask patient to look down
and in
 CN VI Abducent (Motor):
Function:moves
eyes outward
Test: movement of
eye

For cranial naerves

III, IV VI, EOM’s(Extra
Ocular Momt)
(extraoccular movement)
assessment movement in all
directions – lat, med,
upward & lat, downward and
lat, upward & med,
downward and med, directly
upwards, directly
downwards and finally
convergence
CN V Trigeminal (Both):
Function:Motor part-Chewing,
Sensory part-facial sensation

Test: Touch face with cotton

Touch cornea with
cotton

CN VII Facial (both):

Function:Motor-moves the
face;
Sensory- taste.
Test: Facial expression of
patient
CN VIII Vestibulocochlear
(Sensory):
Function:2 branches, cochlear
(hearing)
and vestibular (balance)
Test: Tuning fork for hearing
Equilibrium board for balance

CN IX Glossopharyngeal (Mixed):

Function: Motor- swallowing

Sensory - taste

Test:
Sensory part-Taste sensation
Motor part – Swallowing ability is
checked, movement of pharynx is
checked.
CN X Vagus( Both):

Function: Motor-gagging
and swallowing
Sensory -speech

Test:
Motor part – Swallowing
ability is checked,
movement of pharynx is
checked.
Sensory-
Voice quality assessment
CN XI Spinal Accessory (motor):

Function: turns head and elevates

shoulders
Test: shrug shoulder,
turn head side to side,
CN XII Hypoglossal:(Motor)

Function: tongue movement

Test: move tongue from cheek to cheek

Screening Tests for Cranial nerves:
CN 1:(olfactory)
By using non-noxious odours like lemon oil,
coffee, cloves or tobacco.

CN 2: (optic)
Examine visual acquity using a:
Snellen’s chart (far vision)
Jager’s chart (near vision)

Examine visual field by:

Compare the patient’s field of vision by
advancing a moving finger or a pin from
periphery to a fixation point
CN 3,4,6: (occulomotor, troclear,
abducent nerves)
Determine size, shape, constriction,
dilatation of pupil
Examine reaction to light
Examine ability of eyes to follow a moving
target without head movement.
Presence of ptosis of eye-ball
CN 5: ( Trigeminal)
Sensory examination:
Corneal reflex
Sensory tests of face- light touch, sharp/dull
discrimination

Motor examination:
Jaw-jerk reflex
Open & close jaw against resistance
CN 7: ( facial)
Sensory examination:
Ant 2/3 rd of tongue – use sugar, salt,
tartaric acid etc

Motor examiantion:
Observe patient when he talks, smiles, and
watch for eye closure, wrinkles of forehead,
eyebrows, etc
CN 8: (vestibulo-cocclear)
test auditory acquity using a tuning fork
Weber’s test:
Hold base of tuning fork against vertex of
skull or forehead, ask patient if sound is
heard on which side is louder

Rinne’ test:
Hold base of tuning fork against mastoid
process and ask if sound is heard, then hold
the fork near external meatus and note
hearing acquity. ( Air conduction via ossicles
is better than bone conductio)
CN 9:(glosso-pharyngeal nerve)
Sensory examination:
Taste sensation on posterior 1/3 rd of tongue

Motor examination:
Gag reflex is tested
Depress patient’s tongue and touch palate,
pharynx, tonsil or uvlva until patient gags
CN 10: (vagus nerve)
Note any swallowing difficulty
Observe the uvlva and soft palate for
assymetry
Note patient’s voice - if any vocal paresis

CN 11: ( Spinal accessory)

Examine strength of SCM and trapezius.

SCM- to rotate head against resistance

Trapezius- Shrug the shoulder and hold
against resistance
CN 12: (hypoglossal)
Ask patient to open mouth and inspect
tongue
Ask patient to protrude tongue and when
tongue protruded, examine ability to move
tongue rapidly from side- to side.
4) Sensory Assessment:
Motor learning is highly dependent on
sensory information and feedback
mechanism.

Classification:
1) Superficial sensation:

1) Touch- light(brush, cotton)

crude( finger tip, blunt object)
2) Pain
3) Temperature
4) Pressure
2) Deep Sensation:

1) Propioception
2) Kinesthesia
3) Vibration

3) Combined Cortical sensation:

1) Stereognosis
2) Barognosis
3) Graphesthesia
4) 2 Point Discrimination
5) Tactile Localisation
  Superficial Sensation:

◦ 1)Touch
 Use a cotton wisp
 Have the person point to the area touched

◦ 2)Pain
 Sharp and dull sensations
 Allow 2 seconds between each stimulus

◦ 3)Temperature
 Tested by using two test tubes filled with hot & cold
water.

4) Pressure:
 Therapist’s finger tips are used to apply pressure and
pressure should be enough to stimulate deep
receptors
 Deep Sensation:
1)Vibration:
• Place stem of tuning fork against bony
prominences (128Hz)
• Begin distally
• Sites
–Sternum
–Finger – wrist – elbow - shoulder
–Toes – ankle – shin
2)Proprioception:(joint position
sense):
◦ great toes, one finger on each hand

◦ Response: while extremity is held in static

position, patient asked to describe position
verbally or duplicate the position on
contralateral extremity
3) Kinesthesia: (joint motion
sense)

Response: Patient asked to describe verbally

the direction and ROM (up’ down, in, out etc)
while the extremity is in motion
Also can duplicate on opposite side.
 Cortical Sensation
1)Stereognosis:
 Ability to identify a familiar object by touch and
manipulation
◦ Tactile agnosia: inability to recognize objects

2)Graphesthesia:
 With a blunt pen, draw a letter or number on the palm
 Should be readily recognized

3)Tactile Localization:
 Touch an area of the body and ask the person to point
to where you have touched
◦ This is being tested the same time as superficial touch
4) Two-point discrimination:
 Use two pointed objects, alternate touching skin with
one or two points
 Find the distance at which the person can no longer
discriminate 2 points
◦ Fingertips 2.5 - 8 mm
◦ Toes 3 - 8 mm
◦ Palms 8-12 mm
◦ Forearms 30-35 mm
◦ Upper arms and thighs 35-40 mm

5)Barognosis:
• Ability to identify weight given in patients hand with
closed eye.
DERMATOMES & MYOTOMES:
Spinal
nerve have motor fibres and
sensory fibres
Motor fibres innervate certain muscles
Sensory fibres innervate certain areas of
skin

 Dermatomes:
A skin area innervated by the sensory fibres
of single nerve root is called as dermatome.
Dermatomes are named according to the
spinal nerves which supplies them.
There are eight cervical nerves (C1 being an
exception with no dermatome), twelve
thoracic nerves, five lumbar nerves and five
sacral nerves.
Each of these nerves relays sensation
(including pain) from a particular region of
skin to the brain.

 Although the general pattern is similar in all

people, the precise areas of innervation are
as unique to an individual as fingerprints.
Clinical significance of checking dermatomes:
Symptoms that follow a dermatome (e.g. like pain
or a rash) may indicate a pathology that involves
the related nerve root.

Examples include somatic dysfunction of the spine

or viral infection.
 Referred pain usually involves "referred" location
so is not associated with a dermatome.
Viruses that hibernate in nerve ganglia (e.g.
Varicella zoster virus, which causes both
chickenpox and herpes zoster) often cause either
pain, rash or both in a pattern defined by a
dermatome. However, the symptoms may not
appear across the entire dermatome.
Myotomes:
A group of muscles innervated by the motor
fibres of single spinal nerve root is called
as Myotomes.

Each muscle in the body is supplied by

particular segment of spinal cord and
corresponding spinal nerves.

Themuscle and its nerve make up a

myotome.
Clinical Significance of checking
myotomes:
In humans Myotome testing can be an
integral part of neurological examination as
each nerve root coming from the spinal cord
supplies a specific group of muscles.
 Testing of myotomes, in the form of
isometric resisted muscle testing, provides
the clinician with information about the level
in the spine where a lesion may be present.
Results may indicate lesion to the spinal cord
nerve root, or intervertebral disc herniation
pressing on the spinal nerve roots.
Dermatomes and Myotomes correspond
closely to each other hence knowing
dermatome will guide clinician to know
appropriate myotomes.
C5 Clavicle level
C5-6-7 Lateral side of UL
C8, T1 Medial side of UL
T4 Nipple level
T10 Level of umblicus
T12 Inguinal or groin region
L1-2-3-4 Anterior & inner surface of LL
L5-S1-S2 Posterior & outer surface of LL
S2-3-4 Perinium
MOTOR EXAMINATION:
a) MUSCLE POWER

b) MUSCLE TONE

c) REFLEX ASSESSMENT

d) OTHERS:
Deformity
Contractures
Wastings
Hand function
 a)
MUSCLE POWER:
Muscle power can be assessed by normal
MRC Gradings:

0- no movement
1- Flicker of contraction
2- movement with gravity eliminated plane
3- movement against gravity
4- movement against moderate resistance
5- movement against maximum resistance
(normal strength)
Inmany conditions like all type of Strokes,
Multiple Sclerosis, MND, etc, where MRC
Gradings cannot be used, VOLUNTARY
CONTROL GRADING is to be used.

VCG is mainly used in UMN syndrome in

which the common clinical features are
 Spasticity
Exaggerated reflex
Babinski’s sign positive
Hypertonicity / Rigidity
Voluntary Control Grading:
0- No movement
1- Flicker of movement
2- Half ROM done in synnergy pattern
3- Full ROM done in synnergy pattern

4- Initial ROM in isolation, later goes into

synnergy pattern

5- Able to perform normal movements but

when applied resistance goes into synnergy
pattern

6- Normal
  b) MUSCLE TONE:
Muscle tone is the resistance of muscle to passive
elongation or stretch.

It is done by Modified Ashworth Scale for Spasticity

Modified Ashworth Scale for grading Spasticity:

0 - No tone

1 - Slight increase in muscle tone

(catch and release felt at the end of movement)

1+ - Slight increase in muscle tone

(catch or resistance felt on half of the ROM)
2- moderate increase in tone
(resistance felt throughout ROM, passive
movement are easy to perform)

3-marked increase in tone

( resistance felt throughout ROM, passive
movement are difficult to perform)

4- severe increase in tone

 c) REFLEX ASSESSMENT:

Reflex Grading System:

0 - No response
1+ - Hyporeflexia(+)
2+ - Normal (++)
3+ - Hyperreflexia (+++)
4+ - Exaggerated with clonus (++++)
3 types of reflexes are:

1) Superficial reflex

2) Deep reflex

3) Pathological reflex

1) SUPERFICIAL REFLEXES:
These are the reflexes which are initiated by
stimulating appropriate receptors of skin or
mucous membrane.

Example:
Abdominal reflex
Corneal reflex
Plantar reflex
 Superficial reflex:

1) Pupillary (light) reflex

2) Conjunctival or Corneal reflex
3) Scapular reflex
4) Abdominal reflex
5) Palmar reflex
6) Anal reflex
7) Gluteal reflex
8) Cremasteric reflex
9) Bulbocavernous reflex
1) Anal Reflex:
Method: scratching perineal region
Result: Contraction of external spincter

2) Bulbo-cavernous Reflex:

Method: stimulation of glans penis

Result:contraction of bulbo cavernous

muscles
3) Abdominal Reflex:
A) lower:
Method: scratching of abdomen above
inguinal ligament
Result: Contraction of lower abdominal
muscles

B) Upper:
Method: scratching in the line of nipple
Result: contraction of epigastrium
4) Conjunctival(Corneal) Reflex:
Method: touching cornea with cotton
Result: winking by the contraction of
orbicularis oculi
Segment involved: 5th and 7th cranial nerve

5)Cremasteric Reflex:
Method: scratching inner side of thigh

Result: drawing up of the testicles

6)Pupillary (light) Reflex:
Method: fall of light on eye
Result: contraction of pupil
Segment involved: 3rd cranial nerve

7) Palmer Reflex:

Method: scratching of shin of palm

Result: flexion of palm

8)Scapular reflex:
Method: scratching of interscapular region

Result: contraction of scapulae muscles

Segment involved: C5 and T1

9)Gluteal reflex:
Method: scratching of skin of buttock

Result: contraction of gluteal muscles

 Deep reflex:
2) Deep reflexes:
These are elicited on stroking the tendon.
They are also called as tendon reflex
Example:

1) Biceps jerks

2) Triceps jerks
3) Brachioradialis jerks (Supinator jerk)
4) Knee jerk (Pattelar or Quadriceps jerk)
5) Ankle jerk (Gastronemus or Soleus jerk)
 3)
Pathological reflex:
Method: Gentle scratch of sle of foot

Result: Extension of great toe and fanning

out of other toes.
D) Others:

1) Contractures: DMD

2) Deformity:

3) Wastings: LMN

4)Hand function:
Power grip
Precision grip
 COORDINATION ASSESSMENT:

Coordinated movements are those that

appear to be smooth, purposeful and
accurate and is brought about by integrated
action of many muscles superimposed upon
a basis of efficient postural activity.

Two types:

1) Non Equillibrium coordinated tests

2) Equillibrium coordinated tests

 Non equilibrium test:

1) Finger to nose test

2) Finger to finger
3) Finger to therapist finger
4) Alternate nose to therapist finger
5) Alternate heel to knee, heel to toe, heel
to shin
6) Drawing a circle
1) Finger to nose test:
The tip of the index finger is brought near to
the tip of the nose

2) Finger to finger:

The patient is asked to bring both the hands
towards the midline and approximate the
index fingers from opposing hands.

3) Finger to therapist finger:

The patient and the therapist sit opp to each
other
The patient is asked to touch the tip of the
index finger to the therapist index finger.
4) Alternate nose to therapist finger
The patient alternately touches the tip of the
nose and the tip of the therapist finger with
the index finger.

5) Alternate heel to knee, heel to toe,

heel to shin
The heel of one foot is slided up and down
the knee of the opp lower extremity.
Similarly, the heel of one foot is slided up and
down the toe of the opp lower extremity
Again, the heel of one foot is slided up and
down the shin of opp lower extremity.
6) Drawing a circle
The patient draws an imaginary circle in the
air with either upper or lower extremity(table
or floor may also be used)
  Equilibrium test:

1) Standing in normal comfortable position

2) Standing with feet together(narrow BOS)
3) Standing on one foot
4) Walk side ways, backwards, cross steps
5) Walk in circles
6) Walk on heel or toes

7) Tandem walking- walking by placing the heel

of one foot directly in front of toe of opposite foot

8)Romberg sign- Standing to test the ability to

maintain an upright posture closing the eyes.
 Balance Assessment:
Each moment of our life, we asopt so many
different positions
Each position needs a different combination
of neuromuscular work for which proper
postural mechanism is necessary.
Without balance it is impossible to perform
any task
Hence Balance assessment is very essential
for neurologically disabled patient.

Some of the tests that are used consists of:

1)Romberg test:
Make the patient stand with feet parallel to
each other with a normal width between the
feet
Close the eyes for 20-30 secs
The therapist observes for the sway
Mild sway is present even in normal
individual for first few seconds.
But patient with disease sway maximally and
even fall
If the patient sways even with open eyes.en
there is gross balance deficit.
2) Sharpened Romberg:
It consists of the patient to stand with the
feet in a tandem stance attitude(heel of front
foot in contact with the toe of back foot), arm
folded across the chest and stand for about
one minute.

3) One leg stance:

It consists of testing both legs alternately.
The patient may be given 5 trials with 30 secs
in each trial to stand without fall.
4) Berg Balance Scale:
BBS consists of 14 different tasks.
The therapist has to score the activities from
0 to 4
0 is unable to perform
4 is ability to perform without difficulty

14 different functional tasks are:

1) sitting to standing
2) standing unsupported for 2 min without
holding an external support
3) sitting unsupported with feet on floor for 2
mins
4) Standing to sitting
5) Transfers
6) Standing unsupported with eyes closed for
10 secs
7) Standing unsupported with feet together
8) Reaching forward with outstretched hand
9) Pick up object from the floor
10) Turning to look behind over the left and
right shoulder
11) turning 360 degrees
12) Count number of times the step stool is
touched with the foot
13) standing unsupported one foot in front
14) standing on one leg
 ANS Assessment:
The main autonomous function which is
usually assessed is sweat function

Sweat function test can be checked by

Ninhydrin test.

Ninhydrin is a powder which is spread on the

body part to be examined

When it comes in contact with sweat, it

changes its colour.Part with impaired
sweating will not show any change in colour
 Functional Assessment:
The various activities of daily living such as
feeding, dressing, hygiene, mobility and
transfer needs to be assessed in detail
Various way of grading has been followed like
Barthel Index, Katz index of ADL, FIM etc.
Any one scale is to be taken at the time of
disability
Later the same scale is to be taken for the
follow up
The difference in the scores will give an idea
of the functional improvement in the
patients.
Differential Diagnosis:

Provinsional Diagnosis:

Problem list:

Goals:
a) short term goal
b) long term goal

Treatment:
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