- Clinical science
Neurological examination is the assessment of mental status, cranial nerves, motor function, sensory function, coordination, and gait for the diagnosis of neurological conditions. Findings should always be compared with the contralateral side and upper limb function should be compared to lower limb function to determine the location of the lesion. This learning card provides information about several examination methods and explains a selection of neurological terms used in the evaluation of neurological conditions.
- The mental status examination is a key component of any neurological examination and involves assessing the following points, based on patient history and clinical observation:
- A more focused mental status examination is performed in the workup of specific neurological disorders and symptoms.
- In emergency settings, the mental status examination focuses on the assessment of orientation and level of consciousness using standardized scales (e.g., ).
- See the article on for a comprehensive discussion of examination elements and possible findings.
|Types of aphasia|
|Location of lesion||Type||Clinical features|
|Broca aphasia (motor aphasia, expressive aphasia)||Broca area (inferior frontal gyrus)|| |
|Wernicke aphasia (sensory aphasia, receptive aphasia)||Wernicke area (superior temporal gyrus)|| |
|Global aphasia||Broca area, Wernicke area, and arcuate fasciculus|| |
|Conduction aphasia (associative aphasia)||Arcuate fasciculus of the parietal lobe|| || |
|Anomic aphasia||Usually, pinpointing the localization of the lesion is not possible.|| || |
|Transcortical aphasia||Transcortical motor aphasia||Supplementary motor area (SMA) in the frontal lobe, with Broca area intact (exception: may occur during recovery phase of Broca aphasia)|| |
|Transcortical sensory aphasia||Various areas of the temporal lobe, with Wernicke area intact|| || |
|Transcortical mixed aphasia||Broca area, Wernicke area, and arcuate fasciculus intact, with the surrounding watershed areas affected|| || |
For information on disorders of the cranial nerves, see .
|Cranial nerve||What is examined?||How is the test performed?|
|Visual field|| |
|Pupillary light reflex|
|, ,||III, IV, VI||Eye movement|| |
|Visual accommodation|| |
|Eyelid ptosis (Levator palpebrae superioris muscle dysfunction)|| |
|Muscle function (muscles of mastication)|| |
|VII||Motor function (muscles of expression)|| |
|Sense of taste|| |
|and||IX, X||Palatal movement|| |
|IX only: sense of taste|| |
|X only (recurrent laryngeal nerve): vocalization|| |
|XI||Trapezius muscle and sternocleidomastoid muscle (motor function)|
|XII||Tongue muscles (motor function)|| |
|Upper motor neuron (UMN) injury vs. lower motor neuron (LMN) injury|
|Upper motor neuron lesion (UMN damage)||Lower motor neuron lesion (LMN damage)|
|Muscle appearance|| |
|Special tests|| || |
- Assessment: inspection and palpation of muscle groups
Abnormal muscle movements
- Tremor: rhythmic, involuntary movements of one or more parts of the body either during rest or motor activity (resting vs. intention tremors)
- Tics: sudden and rapid involuntary, intermittent, nonrhythmic movements or vocalizations without any recognizable purpose
- Motor stereotypies: rhythmic, repetitive movements; commonly seen in
- Grossly disorganized behavior: inadequate goal-directed activity (e.g., purposeless movements) and emotional responses that seem bizarre to others (e.g., smiling or laughing at inappropriate times)
- Dyskinesia: involuntary muscle movements, such as jerking, twitching, or tics, which impair voluntary movement
- Catatonia: abnormal behavior and movement, often including catalepsy, purposeless motor activity, strange postures, negativism, and mutism
- Catalepsy: a state of muscular rigidity and immobility characterized by unresponsiveness to external stimuli
- Bradykinesia: decreased speed of voluntary and involuntary movements
Apraxia: difficulty performing targeted, voluntary movements despite an intact motor function
- Ideomotor apraxia: difficulty imitating actions; mismatch between intended expression and gestures (e.g., instead of waving, a patient will scratch his ear)
- Ideational apraxia: difficulty planning and completing multistep actions when interacting with objects
- Visual motor apraxia: difficulty picking up objects placed in the contralesional visual field
- Akathisia: restlessness; the constant urge to move
- Fasciculation: involuntary, asynchronous contraction of muscle fascicles within a single motor unit; usually benign but can signify a lower motor neuron lesion
- Abnormal posture
Atrophy or hypertrophy (examined bilaterally)
- Muscle groups are measured to compare specific differences in size.
- In neurologic disorders, the small hand muscles are often affected by atrophy.
- Abnormal muscle movements
- Definition: maximal effort a patient is able to exert from an individual muscle or group of muscles
- The patient is asked to flex and extend extremities against resistance
- Muscle power tests should be performed bilaterally for comparison
Muscle power grading
- 0 = no contraction (paresis)
- 1 = flicker or trace of contraction
- 2 = active movement, with gravity eliminated
- 3 = active movement against gravity
- 4 = active movement against gravity and resistance
- 5 = normal power
Patterns of paresis distribution:
- Quadriparesis: weakness in all four limbs
- Hemiparesis: weakness in half of the body
- Paraparesis: weakness affecting both upper or both lower extremities
- Monoparesis: paresis affecting a single limb
- Definition: stretch, monosynaptic reflexes
- During reflex testing, the patient should be relaxed (at least the muscles involved in the reflex test should be relaxed). (→ also see: )
Elderly patients may have reduced or absent lower deep tendon reflexes due to normal aging-related changes in muscles and tendons
- A reflex to test the integrity of a sensory and motor neuron circuit
- Upon tapping of the reflex hammer, activation of the dorsal root ganglion causes firing of the lower motor neuron for the agonist muscle and relaxation of the antagonist muscle, resulting in automatic movement.
- An increased DTR indicates an upper motor neuron issue, whereas decreased DTR indicates a LMN, neuromuscular junction, or muscle issue.
|Nerve root||Tendon reflex||Test|
|Upper limbs||C5–C6||Biceps reflex||First, the examiner places his/her thumb on the patient's biceps tendon, then the examiner strikes his/her thumb with a reflex hammer and observes the patient's forearm movement.|
|Brachioradialis reflex||Striking the lower end of the radius with a reflex hammer elicits movement of the forearm.|
|C7–C8||Triceps reflex||The examiner holds the patient's arm (forearm hanging loosely at a right angle) and taps the triceps tendon with a reflex hammer to induce an extension in the elbow joint.|
|This reflex is induced by tapping the terminal phalanx of a relaxed finger on the palmar side, while the examiner holds the patient's hand in level with the proximal phalanges. The test is positive when there is significant flexion in the terminal phalanx of the tapped finger and the thumb, or when the flexion is very asymmetrical comparing both hands.|
|Lower limbs||L2–L4||Adductor reflex||Tapping the tendon above the medial condyle of femur elicits the adductor reflex.|
|Knee reflex||Striking the tendon just below the patella (leg is slightly bent) induces knee extension.|
|L5||Posterior tibial reflex||The tibialis posterior muscle is tapped with a reflex hammer, either just above or below the medial malleolus. The reflex is positive when an inversion of the foot occurs.|
|S1–S2||Ankle reflex||Striking the Achilles tendon with a reflex hammer elicits a jerking of the foot towards its plantar surface. Alternatively, the reflex is triggered by tapping the ball of a foot from the plantar side.|
- Definition: polysynaptic reflexes elicited by stimulation of the skin
- Superficial reflexes are divided into two subgroups:
|T6–T12||Abdominal reflex||Abdominal reflexes are tested with the patient lying down. The anterior abdominal wall is lightly stroked with a spatula from lateral to medial (bilaterally) in following areas: |
A normal response is a contraction of the abdominal muscles, while the absence of contractions is indicative of nerve root damage.
|L1–L2||Cremasteric reflex||The reflex is elicited by stroking the medial, inner part of the thigh. A normal response is a contraction of the cremaster muscle that pulls up the testis on the same side of the body.|
|S3–S5||Stroking the skin around the anus with a spatula elicits the anal reflex, which results in a contraction of the anal sphincter muscles.|
|Bulbocavernosus reflex||The reflex is elicited by squeezing the glans penis or clitoris, resulting in contractions of the pelvic floor muscles.|
- Brief description: Reflexes that are are normal in newborns and infants, but not in adults, where they may appear in case of diffuse brain injury due to lack of common inhibiting factors
|Stroking the mouth induces sucking activity.|
|Stroking the palms elicits finger flexion.|
|Palmomental reflex||Stroking the ipsilateral thenar eminence from proximal to distal induces a short involuntary contraction of the mentalis muscle.|
- Brief description
|Babinski sign||The examiner strokes the sole of a patient's foot on the lateral edge using, e.g., the handle of a reflex hammer||The sign is positive (pathological) when the big toe extends (dorsiflexes), while the other toes fan out. The test is inconclusive when only the big toe responds.|
|Gordon sign||The examiner compresses the calf muscles|
Do not confuse clonus with myoclonus! Myoclonus is arrhythmical and defined by sudden jerks of a muscle or group of muscles while clonus is rather rhythmic and defined by repetitive contractions and relaxations of a muscle group!
- Definition: resistance of an individual muscle (or a group of muscles) to passive stretching
- Assessment: passive movement of the extremities
|Upper limb||Lower limb|
| || |
| || |
|Clonus|| || |
|Light touch|| |
|Pain and temperature|| |
|Pallesthesia (vibration sense)|| |
A tuning fork is hit and placed on a bony projection (e.g., medial malleolus).
|Proprioception (joint position)|
- See also “Overview” in .
- Evidence for vestibular disorders, sensory or cerebellar ataxia (see “Diagnostics” in )
- Observation of casual gait: The patient is asked to walk a few steps forwards and backwards.
- Normal gait: steady, natural arm swing
- Abnormal gait: broad-based or unsteady gait, short-stepping gait
- Balance test: The patient is asked to place one foot directly in front of the other as if walking on a tightrope
- Foot drop test: The patient is asked to walk on their heels (impossible in the case of deep fibular nerve lesions)
- Walking on tiptoes (impossible in the case of tibial nerve lesions)
- Observation of casual gait: The patient is asked to walk a few steps forwards and backwards.
|Romberg test|| || |
|Unterberger test|| || || |
|Trendelenburg sign|| || |
- Definition: triad of nuchal rigidity; , headache, and photophobia, associated with irritation of the inflamed meninges and/or spinal nerves
- Examination: The examiner passively flexes the neck of the patient lying in the supine position.
- Causes: SAH), bacterial meningitis (, etc.
Additional signs of meningeal or nerve root irritation
- L5–S1) (root
- Kernig sign: : in a supine patient, painful passive extension of the knee when the thigh is flexed at the hip (knee at a 90° angle)
- Brudzinski sign