COLLEGE OF HEALTH SCIENCE

EXAMINATION OF THE CENTRAL NERVOUS

SYSTEM
Dr. Tsion H. ,MD
2024
 Learning objectives

• Demonstrate the essential methods of taking neurologic

history

• Demonstrate the essential steps of performing nervous

system examination

• Appropriately interpret the result of nervous system

examination
 Components of neurologic history

COMMON NEUROLOGIC SYMPTOMS COMMON NEUROLOFIC SYMPTOMS

Any history of seizures or unexplained Weakness, difficulty moving, abnormal

loss of consciousness movements
Headache Numbness, tingling

Vertigo or dizziness Tremor

Problems with gait, balance, or coordination
Loss of vision

Diplopia Difficulty with sphincter control or sexual

function
Difficulty hearing
Difficulty with thinking or memory
Tinnitus
Problems sleeping or excessive sleepiness
Difficulty with speech or swallowing Depressive symptoms
 NEUROLOGIC EXAMINATION

Neurologic examination starts the moment the patient enters

the examination room!
 Neurologic examination
GENERAL MEDICAL
EXAMINATION
An internist or other primary
care practitioner would like to
learn how to incorporate the NE
into the general PE,
While a neurologist would like to
incorporate as much of the
general PE as possible into the
NE.
VITAL SIGNS, BMI AND G/A
SYSTEM EXAMINATION
NERVOUS SYSTEM
EXAMINATION
Time consuming and requires
precision, skill and patience.
No particular rules of steps but
many agree with conventional
steps.
MENTAL STATUS EXAMINATION
CRANIAL NERVE EXAMINATION
MOTOR EXAMINATION
SENSORY EXAMINATION
GAIT AND COORDINATION
SPECIFIC TESTS
Neurologic examination set: For medical students

REFLEX HAMMER

TUNING FORK: 256 &128 HZ

OTOSCOPE

OPTHALMOSCOPE

RUBBER NEEDLE & COTTON

TORCH

RED HEADED PIN

 Nervous system examination: Components

1. MENTAL STATUS EXAMINATION

2. CRANIAL NERVE EXAMINATION

3. MOTOR SYSTEM EXAMINATION

4. SENSORY SYSTEM EXAMINATION

5. GAIT; STATION and CEREBELLAR

EXAMINATION If your findings are abnormal,
begin to group them into
6. SPECIFIC EXAMINATION patterns of central or peripheral
disorders.
 I. MENTAL STATAUS EXAMINATION

CONCIOUSNESS /SENSORIUM = AWARENESS + CONTENT

MSE Helps to differentiate

Neurological disease as opposed to psychiatric disease.

Sub-cortical or cortical lesions
Diffuse or focal brain lesions

The screening exam begins with taking the history, which serves as a fair
barometer of the mental status.

As you gather the health history, you will quickly discern the patient’s level
of alertness and orientation, speech, mood, attention, and memory.

As the history unfolds, you will learn about the patient’s insight and
judgment, as well as any recurring or unusual thoughts or perceptions.
Components of Mental status functions

LEVEL OF
CONSCIOUSNESS

ATTENTION

MEMORY
Components of Mental status functions

ORIENTATION

PERCEPTION

THOUGHT

INSIGHT
Components of Mental status functions

JUDGMENT

AFFECT

MOOD

LANGUAGE

HIGHER CORTICAL
FUNCTIONS
 Before assessing MSE

USUALLY PERFORMED DURING HISTORY TAKING

The examiner should ensure that the patient is alert, cooperative,

attentive, and has no language impairment.

To avoid upsetting the patient, it is desirable, when possible, to

examine the mental functions unobtrusively by asking questions that
gently probe memory, intelligence, and other important functions
without obvious inquisition.

Careful observation of the patient during the history may aid in

evaluating her emotional status, memory, intelligence, powers of
observation, character, and personality.
 Before performing MSE: Assess Appearance and behavior

1. Posture and Motor Behavior:

Does the patient lie in bed, or prefer to walk about? Note body posture and
the patient’s ability to relax.
Observe the pace, range, and character of movements. Do they seem to be
under voluntary control? Are certain parts immobile?
Do posture and motor activity change with topics under discussion or with
activities or people around the patient?

2. Dress, Grooming, and Personal Hygiene.

How is the patient dressed? Is clothing clean, pressed, and properly fastened?
How does it compare with clothing worn by people of comparable age and
social group? Note the patient’s hair, nails, teeth, skin, and, if present, beard.
How are they groomed? How do the person’s grooming and hygiene compare
with those of other people of comparable age, lifestyle, and socioeconomic
group? Compare one side of the body with the other.
 Before performing MSE: Assess Appearance and behavior

3. Facial Expression.

Observe the face, both at rest and when the patient is interacting with
others. Watch for variations in expression with topics under discussion. Are
they appropriate? Or is the face relatively immobile throughout?

4. Manner, Affect, and Relationship to Persons and Things.

Using your observations of facial expressions, voice, and body movements,

assess the patient’s affect. Does it vary appropriately with topics under
discussion, or is the affect labile, blunted, or flat? Does it seem
inappropriate or extreme at certain points? If so, how? Note the patient’s
openness, approachability, and reactions to others and to the surroundings

5. Assess the Level of consciousness

 I. MSE: LEVEL OF CONSCIOUSNESS

LOC: Alertness or state of awareness to the environment

Aware/alert – Lethargy – Obtunded – Stupor – Coma

Assess LOC either:

Speak to the patient by name and in a loud voice

Shake the patient gently, as if awakening a sleeper.
Use painful stimuli: using your knuckles or thumb

While assessing LOC observe simultaneously:

Posture and motor response; facial expression and response

Manner, affect and interaction to your verbal or painful stimuli.

 I. MSE: LOC

ABNORMAL RESPONSES
A lethargic patient appears drowsy
but opens the eyes and looks at you,
responds appropriately to questions,
and then falls asleep quickly.

An obtunded patient opens the

eyes and looks at you, but responds
slowly and is somewhat confused.

A stuporous patient arouses from

sleep only after painful stimuli.
Verbal responses are slow or even
absent. The patient lapses back into
an unresponsive state when the
stimulus ceases
A comatose patient remains unarousable with eyes
closed. There is no evident response to inner need
or external stimuli.
 LOC: GCS = 15

INTERPRETATION

GCS = 15 : ALERT
GCS = 8 – 14 : STUPOR – LETHARGY
GCS = 3 – 7 : COMA
Posturing responses with verbal or painful stimuli
 I: MSE: If GCS is 15/15 or patient is alert and aware,….

• Consciousness – Content of consciousness will be assessed.

– Orientation

– Attention and calculation

– Memory

– Insight and judgment

– Abstract thinking

– Higher cortical functions

 Screening Tools for MSE: MMSE

The MMSE has a series of

scored questions that provides
a localization based overview of
cognitive function, but it does
not assess any function in
detail.

The maximum score is 30.

Minimum normal performance

depends on age and
educational level, but it has
been variously stated as
between 24 and 27.

Abnormal if less than 24

 I. MSE: Orientation
The formal mental status examination usually begins with an assessment of
orientation.

Normally, patients are said to be “oriented times three” if they know who
they are, their location, and the date.
Some examiners assess insight or the awareness of the situation as a fourth
dimension of orientation.

On History for example; you can ask quite naturally for specific dates and
times, the patient’s address and telephone number, the names of family
members, or the route taken to the hospital

Assess orientation
Time (e.g., the time of day, day of the week, month, season, date and year,
duration of hospitalization)
Place (e.g., the patient’s residence, the names of the hospital, city, and state)
Person (e.g., the patient’s own name, and the names of relatives and
professional personnel)
 I. MSE: Attention
Patients may appear grossly alert but are actually inattentive, distractible,
and unable to concentrate: Focus/registration and maintaining attention

When testing attention, you are actually evaluating patient’s ability to focus,
maintain attention and registration.

Explain that you would like to test the patient’s ability to concentrate,
perhaps adding that people tend to have trouble with that when they are
in pain, or ill, or feverish.

LETTER A SELECTION TEST

LINE CANCELLATION TEST REGISTRATION & FOCUS
DIGIT SPAN: Forward and Backward
SPELLING BACKWARDS

SERIAL 7’ AND SERIAL 3’

THREE STEP TASK: MAINTAIN ATTENTION
 I. MSE: Memory
A commonly used memory classification includes: Immediate (working
memory or registration), Recent (short-term), and Remote (long-term).

Patient’s orientation, attention and language should be normal

Immediate memory, a very short-term function in which the material is not
actually committed to memory.

Digit span; spelling words; repeating three different objects immediately

after called by the examiner.

A patient's fund of information reflects her remote memory.

The fund of information includes basic school facts, such as state capitals,
famous presidents, and important dates, as well as current information, such as
the sitting president, vice-president, governor, and similar public officials.
The patient should also know personal information, such as her address, phone
number, social security number, wedding anniversary date, and names of
children
 I. MSE: Memory

Recent, or short-term, memory is tested by giving the patient items to recall

after few minutes: this evaluates the ability to learn new information:
Better classified as Retention and retrieval.

The recall items may be simple objects, such as orange, umbrella and
automobile, or more complex, such as “John Brown, 42 Market St., Chicago.”

The items should be from different categories.

After ensuring the patient has registered the items, proceed with other
testing. After approximately 5 minutes, ask the patient to recall the items.

Interpretation: if repeated immediately: Registration /attention

if repeating after five minutes: Recall memory
Retention Vs Retrieval
 I. MSE: Insight and Judgment

JUDGMENT
Process of comparing and evaluating alternatives when deciding on a
course of action; reflects values that may or may not be based on reality
and social conventions or norms.

INSIGHT
Awareness that symptoms or disturbed behaviors are normal or abnormal;
for example, distinguishing between daydreams and hallucinations that
seem real

Common insight and judgment questions—such as asking the patient what

she would do if she found a sealed, addressed, stamped letter on the
sidewalk, or if she smelled smoke in a crowded theater: Judgment

Determining if the patient has insight into her illness and the implications of
any functional impairment: Insight
 I. MSE: Higher cortical function

Assessed by vocabulary, fund of

information, abstract thinking, Abstract thinking: Proverb
calculations, construction of interpretation; similarities and
objects that have two or three differences among objects with the
dimensions. same category

Highly affected by the person’s Calculation: Serial 7’s; simple

educational status and language. mathematical questions

Fund of information
Assess Constructional abilities
Abstract thinking

Calculation
Construction skills
 I. MSE: Speech and language
SPEECH = PHONATION + ARTICULATION + LANGUAGE

ABNORMAL SPEECH = DYSPHONIA / DYSARTHRIA/ APHASIA or DYSPHASIA

Properly articulated speech requires coordination between the respiratory

muscles and the muscles of the larynx, pharynx, soft palate, tongue, and lips.
All of these components are referred to as the vocal (oral) tract: Phonation

For theses vocal muscle to operate in a coordinated manner, Cranial nerves

and the brainstem tracts are required: Articulation

A complex symbolic system for expressing, receiving, and comprehending

words is governed by different regions of the cortex: Language

Articulation and phonation are assessed by:

Pronunciation and Rate of speech

Resonance and Prosody
Pitch: rhythm: stress on pronunciation
 Language function and assessment

Fluency Brocha’s area

P
Comprehension Wernicke’s area
F
Repeatition Arcuate fasciculus
Naming O Supra-marginal
T gyrus
Writing
Angular gyrus
Reading
Exner’s writing
Non verbal center
language
 Assessment of Language

Fluency

This involves the rate, flow, and melody of speech; and the content and
use of words.
Be alert for abnormalities of spontaneous speech such as:
Hesitancies and gaps in the flow and rhythm of words
Circumlocutions, in which phrases or sentences are substituted
for a word
Paraphasias, in which words are malformed, wrong or invented
Types of language disturbances

AF

B&W
 II. CRANIAL NERVE EXAMINATION

MIDBRAIN
CN III, IV

PONS
CNV-VIII

MEDULLA
CNIX-XII

M2 P4 Me4
 CN I: Olfactory nerve
Before starting examination Anosmia has many causes,
including:
Make sure that the nasal passages are
patent Nasal disease, head trauma,
Avoid irritant stimuli Smoking, and the use of cocaine.
Test the sense of smell by presenting It may be congenital or aging
the patient with familiar odorants Bilateral vs unilateral

First be sure that each nasal passage is open by compressing one side of the
nose and asking the patient to sniff through the other.

The patient should then close both eyes.

Occlude one nostril and test smell in the other with such substances as cloves,
coffee, soap, or vanilla.

Ask if the patient smells anything and, if so, what: PERCEPTION/RECOGNITION

Test the other side

 CN II: Optic Nerve

Optic nerve function is tested by examining the various modalities of

vision:

The visual acuity,

The VFs, and

Special components of vision, such as:

color vision and day and night vision

Direct visualization by funduscopy

Before performing the optic nerve examination, look for local ocular
abnormalities: the cornea, the lens, the conjuctiva…
 Optic N: Visual acuity

Visual acuity refers to the ability of

our vision to detect

The minimum separability of two

objects and the minimum visibility
of an object.
Visual acuity describes the details of
visual object.

Adequate light is important and

adequate space is crucial
Test each eye separately by closing
the untested eye.
Adjusted refraction of the lens
Vision of 20/200 means that from
Sneller’s chart 20 feet the patient can read a print
Rosenbaum near card that a person with normal vision
can clearly see at 200 feet
 Optic N. Visual field

A visual field is the entire area seen

by an eye when it looks at a central
point.

Fields are conventionally

diagrammed on circles from the
patient’s point of view.

The center of the circle represents

the focus of gaze. Visual fields are normally limited by
The circumference is 90° from the the brows above, by the cheeks
line of gaze. below, and by the nose medially.

Each visual field, shown by the A lack of retinal receptors at the

white areas below, is divided into optic disc produces an oval blind
quadrants spot in the normal field of each eye,
15° temporal to the line of gaze.
Close cooperation, good fixation, Optic N. Visual field
and adequate illumination are
essential for proper evaluation of Ask the patient to look with both eyes
the visual fields into your eyes.

Gross assessment is possible in While you return the patient’s gaze,

uncooperative or lethargic patients. place your hands about 2 feet apart,
lateral to the patient’s ears mid-way
Visual confrontation test between you and the patient

Instruct the patient to point to your

fingers as soon as they are seen.

Then slowly move the wiggling

fingers of both your hands along the
imaginary bowl and toward the line of
gaze until the patient identifies them.

Repeat this pattern in the upper and

OPTIMETRY lower temporal quadrants.
Optic nerve: Visual Field Abnormalities
 Optic nerve: Color vision

Color plates or pseudo-isochromatic

plates (Ishihara, Hardy-Ritter-Rand, or
similar) formally and quantitatively
assess color vision.

Having the patient identify the colors

in a fabric, such as a tie or a dress, can
provide a crude estimate.

Desaturation to red, or red washout,

describes a graying down or loss of
intensity of red.

The bright red cap on a bottle of

mydriatic drops is a common test
object
Optometry and Funduscopic examination
 Cranial Nerves III, IV and VI: Ocular muscles

The responsible CNs for ocular

movement are

Oculomotor N. CNIII

Trochlear N. CNIV

Abducent N. CNVI

Para-sympathetic input
from the brain stem to
CNIII

Sympathetic input from

the spinal cord to CNIII
Ocular muscles
Ocular motor nerves: Supra-nuclear control of gaze

Control the coordinated

movement of ocular muscles to
a different direction: horizontal
or vertical

Frontal lobe; parapontine

1 reticular formation and medial
longitudinal fasciculus control
2 gaze

Cerebellum; basal ganglia and

other parts of brainstem
modulate the process of ocular
movement
CNIII, IV & VI: Ocular motor nerves

1. Examination of the orbit

and eye lids.

Orbit alignment with the eye

globe and the limbus

Proptosis,
Exophthalmos or Enophthalmos

Eye lids

Ptosis: Complete or partial

Lid retraction
Lid lag
 Ocular motor nerves: Examination

2. Check pupils

Pupilary function is used to assess

the function of CN II and the
autonomic component of CNIII.

The function of the pupil is to

control the amount of light
entering the eye, ensuring optimal
vision for the lighting conditions.
The pupils should be equal in size,
round, regular, centered in the iris,
and should exhibit specific reflex
responses
When assessing pupils function
Use darker room
Use an appropriate flash light
Assess the size, shape, equality,
position of pupils
Assess pupilary reflexes: Direct;
Consensual and accommodation
reflexes.
Pupilary function abnormalities
 Ocular muscles: Clinical examination

3. Ocular motility

– Spontaneous and induced

– Gaze at station and
movement
– Nystagmus: OKN

• EOM

– Observe ocular alignment at

steady state
– Then check the eye movement
in all six directions
– Assess gaze at all direction of
movements: H shape
Ocular muscles: Ocular disorders and localization
 Cranial nerve V: Trigeminal Nerve

Has motor function for mastication

Sensory function for facial

sensation

Ophthalmic division: V1
Maxillary division: V2
Mandible division: V3

Transmit pain senses from head

and neck

Sensory input for corneal reflex

Involve in the mechanism of

headache occurrence
 Trigeminal Nerve:
Motor examination
Examination

Inspect the temporal and masseter muscles

for atrophy

While palpating the temporal and

masseter muscles in turn, ask the patient
to clench his or her teeth.

Note the strength of muscle

Contraction and equality of the strength on
both sides.

Also try to appreciate the contour of the

muscles for atrophy

Assess the pterygoids by asking the person

to open his mouth while you resisting it.
 Trigeminal Nerve: Examination
Sensory examination

After explaining what you plan to do,

test the forehead, cheeks, and jaw on
each side for pain sensation.
The patient’s eyes should be closed.

Use a safety pin or other suitable

sharp object, occasionally
substituting the blunt end for the
point as a stimulus.

Ask the patient to report whether it is

“sharp” or “dull” and to compare
sides. Reflexes
Nasal (sneeze) reflex
Test for temperature and light touch Corneal reflex
in a similar manner Jaw jerk reflex
 Cranial nerve VII: Facial Nerve

The facial, or seventh cranial nerve is

a predominantly motor nerve that
innervates the muscles of facial
expression and the muscles of the
scalp and ear.

In addition, it carries para-

sympathetic secretory fibers to the
submandibular and sublingual salivary
glands, the lacrimal gland and to the
mucous membranes of the oral and
nasal cavities.

The facial nerve is used for taste for

the anterior two third of the tongue
 Facial Nerve: Clinical examination

Motor assessment

Inspect the face, both at rest

and during conversation with
the patient.

Observe Facial expression at

rest and Note symmetry;

Note facial atrophy and

fasciculation; Spontaneous
facial movement and blinks
Observe the nasolabial fold

Observe the face during

spontaneous talks, smile…
 Facial Nerve: Clinical examination

Ask the patient to:

Raise both eyebrows; Frown.

Close both eyes tightly so that
you cannot open them.

Show the teeth; smile; puff of the

cheeks.

Then observe symmetry,

persistence and fatigue during
command.

Reflex assessment

Corneal reflex
Frontal release signs SENSORY: SPECIAL SENSE: TASTE
Facial nerve lesion abnormality: Interpretation

SUPRA-NUCLEAR CONTROL
OF FACIAL NERVE

The upper part of the face is

supplied by both sides of the
hemispheres

The lower part of the face is

only supplied by the opposite
FN hemisphere.

Supra-nuclear lesions spare

the upper face
Infra-nuclear lesions affects
both the upper and the
lower faces
 Facial nerve lesion abnormality: Interpretation

Infra-nuclear facial palsy Supra-nuclear facial palsy

LMNL (PNS) UMNL (CNS)

Both upper and the If the lower part of

lower parts of the the face is involved
face are involved
Sensory function
Sensory function normal
affected
Autonomic
Autonomic function functions normal.
affected
 Cranial nerve VIII: Vestibulo-cochlear nerve

The vestibulo-cochlear, acoustic,

or eighth cranial nerve (CN VIII)
has two components:
The vestibular and the cochlear,
blended into a single trunk.

The cochlear portion sub

serves hearing;

The vestibular nerve sub

serves equilibration,
coordination, and
orientation in space.
 Cranial nerve VIII (cochlear) examination

First otoscope evaluation

OTOSCOPE
Note signs of deafness, such
as
A tendency to turn the
head when listening,
Lip reading, or WEBER
Speaking with a loud
voice

Finger rub, ticking watch

Weber for lateralization

RINNE
Rinne for better conduction
Cochlear (acoustic) Nerve abnormality: Interpretation

Responses of normal
auditory function:

Normal auditory acuity

Weber radiates to both

ears or to the forehead

Rinne will be positive

 CN IX & X: Glossopharyngeal and Vagus nerves

When assessing bulbar function we

assess speech
A and swallowing B

Listen to the patient’s voice.

Is it hoarse or does it have a nasal
quality?
Use the phrase Pa.. Ta… Ka/Ga…

Assess for difficulty in swallowing,

if there is for liquid or solid meals?
Ask the patient to say “ah” or to
yawn as you watch the movements
of the soft palate and the pharynx
REFLEX: swallow; cough and gag R.
The soft palate normally rises
symmetrically,
The uvula remains in the midline,
Each side of the posterior pharynx
moves medially, like a curtain.
Cranial nerve XI:
Accessory nerve
 Cranial nerve XII: Hypoglossal nerve
Listen to the articulation of the patient’s
words. In ambiguous cases, ask the
patient to push the tongue
Inspect the patient’s tongue as it lies on against the inside of each
the floor of the mouth cheek in turn as you palpate
externally for strength.
Look for any atrophy or fasciculations
(fine, flickering, irregular movements in
small groups of muscle fibers).

Then, with the patient’s tongue protruded,

look for asymmetry, atrophy, or deviation
from the midline.

Ask the patient to move the tongue from

side to side, and note the symmetry of the
movement.
 III. The Motor system examination

Both the peripheral and central nervous systems participate in motor

activity, and various functional components have to be evaluated
individually.

Our motor systems move our bodies in space, move parts of the body in
relation to one another, and

They also maintain postures and attitudes in opposition to gravity and

other external forces.

When analyzing your findings, think about whether the abnormality is

central or peripheral in origin, and begin to learn which nerves innervate
the affected muscles.

Pyramidal level – extra-pyramidal level – segmental level – motor unit level

 Organization of the motor system

Basal ganglia Motor Cortex

EP
P

Spinal cord Cerebellum and

UMN level Brainstem
P: PYRAMIDAL EP
S

EP: EXTRA PYRA. Motor unit

LMN level
S: SEGMENTAL M

M: MOTOR UNIT MOTOR

ACTION
 III. Motor system examination

Components of motor examination:

1. Posturing and position of limbs; abnormal movements

2. Bulk or muscle volume and contour

3. Muscle tone and reflexes

4. Muscle strength or power

Motor system examination: 1. Posture and movement

Body position
Observe also
Put the limbs in their normal
anatomic position Presence of scarring; trauma.

Observe the patient’s body position Skin dryness; hair loss…

during movement and at rest.

Abnormal movements

Watch for involuntary movements such as

tremors, tics, or fasciculation.
Induce the muscle bulk for
Note their location, quality, rate, rhythm, and fasciculation by hitting it
amplitude, and their relation to posture, with reflex hammer
activity, fatigue, emotion, and other factors.
Motor examination: 2. Bulk
Muscle bulk
Compare the size and contours of
muscles.
Do the muscles look flat or concave,
suggesting atrophy?
If so, is the process unilateral or
bilateral?
Is it proximal or distal?
Measure the muscle bulk with tape
meter.
When looking for atrophy, pay
particular attention to the
hands, shoulders, and thighs.
The thenar and hypothenar
eminences should be full and
convex, and the spaces between
the metacarpals, where the
dorsal interosseous muscles lie,
should be full or only slightly
depressed
 Motor system examination: 3. Muscle tone

Muscle tone has been defined as the tension in the relaxed

muscle, or the resistance to passive movement when
voluntary contraction is absent.

Because of resting tone, normal muscles have slight

resistance to passive movement even in the relaxed state.

The inherent attributes of muscle tissue—such as viscosity,

elasticity, and extensibility—contribute to resting tone.
 Motor system examination: 3. Muscle tone
First put the limbs in normal position
resting and observe whether they
maintain the position
Assessed best by feeling the muscle’s
resistance to passive stretch.
Persuade the patient to relax.
Move the limbs at all joints and
appreciate the passive resistance first
with slow movement and then with
faster movement.
Palpating the muscles also assess
tone
Take one hand with yours and,
while supporting the elbow, flex
and extend the patient’s fingers,
wrist, and elbow, and put the
shoulder through a moderate
range of motion
To assess muscle tone in the legs,
support the patient’s thigh with
one hand, grasp the foot with the
other, and flex and extend the
patient’s knee and ankle on each
side.
Note the resistance to your
movements.
 Motor system examination: 3. Muscle tone
interpretation

Normally the hand moves back and forth freely

but is not completely floppy.
FLACCID
If you suspect decreased resistance, hold the (HYPOTONIA)
forearm and shake the hand loosely back and
forth. Do the same with the legs

If resistance is increased, determine whether it

HYPERTONIA
varies as you move the limb or whether it persists
throughout the range of movement and in both
SPASTIC
directions.
RIGIDITY
Note the resistance changes with speed of limb
movement.
PARATONIA
Note resistance increases with repeated attempt
 THE REFLEX ARC
MOTOR EXAMINATION:
PHYSIOLOGY OF REFLEXES The stimulus is received by the
receptor, which may be a
REFLEX CENTER sensory ending in the skin,
mucous membranes, muscle,
tendon, or periosteum.
MODULATORS
OF REFLEX MOTOR F. Receptor stimulation initiates
an impulse that travels along
SENSORY F. the afferent pathway to the
spinal cord, where there is a
synapse in a reflex center that
activates the cell body of the
EFFECTORS efferent N.
RECEPTORS The efferent neuron transmits
the impulse to the effectors:
the cell, muscle, gland, or blood
vessel that then responds
 Motor system examination: Reflexes
Reflexes can be deep
When a normal muscle is passively tendon reflex or
stretched, its fibers resist the stretch by superficial reflexes
contracting.

The stretch may be caused by gravity,

manipulation, or other stimuli.

In reflex responses, the contraction results

from stimulation of the sensory organs in
the muscle, either directly or indirectly
through a stimulus applied to its tendons,
the bone to which it is attached, or the
overlying skin.

REFLEX assess the sensory input; spinal cord

response and the motor unit.
 Motor system examination: Reflexes

Relax the patient and put the tendon in a

relaxed position

Use the reflex hammer to stretch the

tendon or the skin.

Use reinforcing maneuver if stretching not

adequate

Elicit clonus.

Grade the reflex from zero to 4.

The normal response is slight contraction

of muscle proximal to the joint elicited
 DTR: Clinical examination

Biceps reflex Triceps reflex

 DTR: Clinical examination

Brachio-radialis Reflex Finger flexor Reflexes

Tromner’s
technique

Hoffman’s
technique
 DTR: Clinical examination

Patellar Reflexes Ankle Reflexes

 Motor system examination: DTR interpretations
Before reflex interpretation we need to be sure we appropriately used the
techniques:

Strike a crisper blow: Make sure you have swung the hammer, not pecked with it
Change the mechanical tension on the muscle: Flex or extend the joint
somewhat to alter the tension on the tendon; compress the tendon slightly more
or slightly less…
Reinforcing techniques: Jendrassik’s maneuver; counter-pressure method

+3 & +4 :
HYPERREFLEXIA
Modulator and reflex
center

+1: HYPOREFLEXIA
Motor or sensory fibers
0: AREFLEXIA
 Clonus and cutaneous reflexes

Superficial Reflexes Clonus

Plantar

Other
superficial R.

Cremasteric R.
Abdominal Bulbo-
cavernouses R.
 Motor system examination: Muscle strength

Normal individuals vary widely in their

strength, and your standard of normal,
while admittedly rough, should allow for
such variables as age, sex, and muscular Screening tests like
training. Pronator drift

A person’s dominant side is usually Grade it from zero to 5

slightly stronger than the other side.

Ask to raise their limbs against resistance; Describe the

distribution of the
If weaker then ask to raise them only weakness
against gravity;

If weaker ask them to slide the limbs over

the bed or flicker their fingers.
Pronator Drift: Ask the patient to stretch his arms forward with
wrists supinated and eyes closed
Motor examination: Muscle strength interpretation

Paraplegia / paraparesis

Hemiplegia/ hemiparesis

Triplegia/ triparesis

Quadriplegia/quadriparesis

Monoplegia/ monoparsis

Proximal vs distal

GRADING OF MUSCLE STRENGTH

DISTRIBUTION OF WEAKNESS
 Motor system: Interpretation

• After we examine thoroughly the next step is analysis of

the weakness with regards to;

– Severity of the weakness

– Pattern of distribution of the weakness

– Organic vs non organic

– Possible localization of the deficit

– Possible reason of the deficit
 Pattern of muscle weakness

UMNL LMNL

• Distribution of weakness • Distribution of weakness

– CST distribution – Generalized and symmetric

– Predominantly proximal
– Hemiplegia, monoplegia
– Predominantly distal
– Paraplegia, quadriplegia

• Deep tendon reflex

• Deep tendon reflex
– Normal or decreased
– Increased
– Decreased in atrophy and spinal shock
• Muscle tone

• Muscle tone increased – Normal or decreased

 Pattern of muscle weakness

UMNL LMNL

• Superficial reflexes absent • Superficial reflexes are normal

• Pathologic reflex present • Pathologic reflex absent

• Sensory abnormality has central • Sensory loss; None, stock and glove,
pattern PN or root distribution

• Sphincter function affected • Sphincter function is normal

• Pain usually not seen • Pain seen sometimes

• Other CNS abnormality seen • Other CNS signs not seen

 Patterns of limb weakness that convey diagnostic information

Proximal and Indicates primary muscle disease.

axial

Worse in the leg flexors than leg extensors. In the arm,

Pyramidal shoulder abduction and small hand muscles may be weaker
(unilateral or than other muscles. Found in stroke and other focal CNS
bilateral) disease.

Distal Indicates a polyneuropathy.

Focal/regional In the distribution of a single peripheral nerve, plexus or

nerve root.

Suggests non-organic illness. Try to describe the pattern and

Global or check it for consistency in repeated examinations. Consider
random additional clinical evidence, such as reflex or sensory
findings. Often a rather random pattern actually reflects
multiple nerve root involvement.
 IV. The sensory system examination

• The sensory system places the individual in relationship to the

environment.

• Every sensation depends on impulses that arise by stimulation of

receptors, or end-organs.

• These impulses are carried to the central nervous system (CNS) by

sensory nerves, and then conveyed through fiber tracts to:

– Higher centers for conscious recognition,

– reflex action, or other consequences of sensory stimulation.

• Somatic sensation is all senses other than the special senses

 IV. The sensory system examination

• Three forms of sensory functions

• Exteroceptive sensation provides information about the external

environment, including somato-sensory functions and special senses.

• The interoceptive system conveys information about internal

functions, blood pressure, or the concentration of chemical
constituents in bodily fluids.

• Proprioception senses the orientation of the limbs and body in space.

 IV. The sensory system examination

-- - - Proprioception
- Pain & temp.
• Receptor level

• PNS and DRG level

• Spinal cord level

Medulla

• Thalamus level

• Primary and secondary DRG

sensory cortices level
 Exteroception: Clinical examination
• PAIN
– Use sharper instruments
– Right angle to the skin
– Ask the patient what he feels or
observe his reaction
– Sharp or dull
– Ask him to locate the area of the
stimulus
– Compare it with proximal or distal
simulation as well as the opposite
site.
– Relative sensory loss
– Sensory level
• TEMPERATURE
– Use warm test tube (40-50oc)
– Cold instruments (5-10oc) like
tuning fork
– Assess as pain assessment
– Sensory level
• TOUCH
– Use graded filaments, Fury hairs
or cotton
– Assess as pain examination
 Proprioception: Clinical examination

• VIBRATION

– Use tuning fork

– Apply to the joint prominent
– Ask the patient what he feels
– Ask him to tell you when it stops
– Compare it to the distal and
proximal joints as well as
opposite joint and yourself
– Sensory level

• POSITION

– Demonstrate and compare

 Cortical sensory tests

• Cerebral sensory functions are

those which involve the
primary sensory areas of the
cortex to perceive the stimulus,
and

• The sensory association areas

to interpret the meaning of the
stimulus and place it in context

– Sterognosis
– Graphestesia
– Two point discrimination
 Sensory distribution and localization

A. Cortical and thalamic lesion

B. Brain stem lesions

C. Spinal cord complete

D. Spinal cord central cord lesion

E. Peripheral neuropathy
F. Brown Sequard SC syndrome

G. Dermatomal at cervical
H. Dermatomal at lumbar
 V. Stance and coordinated movement: tips

• The cerebellum is tasked with bringing finesse to the motor system.

– Although not primarily involved in the mechanisms for production of

muscle power, it is necessary for normal control and regulation of muscle
contraction.

• The major function of the cerebellum, from a clinical point of view, is the
coordination of movement.

– In order to perform any movement — especially a complex act involving

many muscle groups — contractions of the agonists, antagonists,
synergists, and muscles of fixation must be adequately coordinated.
 Coordination tests

• Tests of non equilibratory

coordination assess the
patient's ability to carry out
discrete, oftentimes relatively
fine, intentional movements
with the extremities.

– Finger to nose test

– Rapid alternating test
– Impaired check and
rebound phenomenon
– Deviation and past pointing
 Stance and gait: Clinical examination

• Station is tested by asking the

patient to stand with legs close and
observe the posture, steadiness…

– Then with eyes closed, or

– On heels or in tandem position,
or with one leg…..
– Romberg’s test

• Gait is tested by asking the patient

walk and

– Observe the base, steppage, arm

swing….
– Tandem walk
 Abnormal Gait and stance
LOCATION OF NS TYPICAL GAIT ABNORMALITIES

Waddling: An excessive drop of the hip and trunk tilting to the

MUSCLE side opposite the foot placement

Steppage gait: An excessive flexion of the hips and knees with

PERIPHERAL N every step and the foot hits floor heavy

SPINALCORD Scissoring gait: Legs tend to cross in front of each other

Vestibular ataxic gait: A tendency for the patient to veer or
BRAINSTEM even fall to the side of the lesion worse with eyes closed
Parkinsonian gait; hemiplegic gate

Cerebellar ataxic gait: cautious gate with wide based stance

CEREBELLUM and eyes look down while walking

BASAL GANGLIA Various gate abnormalities; dystonic; choreoic, parkinsonian

CORTEX Magnetic gait; gait apraxia; hemiplegic gait; paratonic

Abnormal Gait and stance
Abnormal Gait and stance
 VI. Special neurologic examinations

• Meningeal signs
– Nuchal rigidity
– Kerning’s sign
– Brudiniski’s sign

• Signs of tetany
– Troussoue’s sign
– Chevostek’s sign
 Referrences
• Huchison’s clinical methods 22nd edition
• Bate’s guide to physical examination
• Harrison’s principles of internal medicine 21st
edition
• Thank you