• Clinical science

Neurological examination

Abstract

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.

Mental status examination

Levels of consciousness

  • Types of impaired consciousness
    • Somnolence
      • A state of drowsiness; from which a patient can be easily aroused.
      • Patient responds normally; except for a slight delay when addressed.
    • Stupor
      • A state of insensitivity bordering on unconsciousness; from which the patient is not easily awoken except if exposed to strong external stimuli; (e.g., if addressed in a loud voice) and into which the patient returns in the absence of further stimuli.
      • Communication is not possible; and painful irritation provokes withdrawal response.
    • Coma: Patient cannot be aroused and there is no response to stimuli.
  • Glasgow Coma Scale (GCS) quantifies the degree of impaired consciousness

Assessment cognitive decline or dementia

  • Full mental status examination components include:
    • Appearance (e.g., groomed, well dressed)
    • Behavior (e.g., cooperative, agitated)
    • Orientation (e.g., to person, place, time)
    • Mood and affect (as well as congruency)
    • Thought content (e.g., delusional) and process (e.g., logical thinking)
    • Memory (e.g., short-term vs. long-term memory, assessed by asking the patient to recall a number of objects immediately and again after a few minutes)
    • Ability to perform simple calculations (e.g, simple multiplication; determine if appropriate for level of education)
    • Insight and judgement (ask patient what they would do in a realistic situation, e.g., if they found a stamped envelope)
    • Higher cortical function (e.g., ask patients to explain the meaning of well-known idioms)
    • Determine levels of consciousness
  • Mini-mental status examination (MMSE)
  • Saint Louis University Mental Status Examination (SLUMS)

Findings

  • Hemineglect
    • Inability to respond to unilateral stimuli due to a brain lesion (not due to a primary motor or sensory lesion)
    • The lesion is usually contralateral to the stimuli
      • Motor neglect
      • Sensory or perceptual neglect
  • Amnesia: loss of memory (e.g., time, content)
    • Retrograde
    • Anterograde
    • Global
  • Aphasia: Inability to communicate (impairment of the ability to either form or understand words)
Location of lesion Clinical features
Broca aphasia (motor aphasia, expressive aphasia) Broca area, frontal lobe
  • Telegraphic and grammatically incorrect speech
  • Comprehension is largely spared (difficulty understanding complex language may occur)
Wernicke aphasia (sensory aphasia, receptive aphasia) Wernicke area, temporal lobe
  • Word salad (neologisms, meaningless speech)
  • Comprehension is impaired
  • The patient is unaware of these deficits
Global aphasia Broca area, Wernicke area, and arcuate fasciculus
  • Severe impairment of speech expression and comprehension
    • Patient may be mute
    • Patient may only utter sounds
    • Inability to comprehend verbal commands
Conduction aphasia (associative aphasia) Arcuate fasciculus of the parietal lobe
  • Preserved comprehension but cannot encode phonological information for production
  • Impaired repetition with paraphasia (they substitute or transpose sounds), which patients try to correct
Anomic aphasia Usually, pinpointing the localization of the lesion is not possible.
  • Difficulty finding words
  • Paraphrasing occurs when patients cannot find the word they seek.
Transcortical aphasia Motor Supplementary motor area (SMA) in the cortex, with Broca area intact (exception: may occur during recovery phase of Broca aphasia)
  • Difficulty initiating speech
  • Difficulty in expressing a thought process
  • Difficulty producing own phrases
Sensory Various areas of the temporal lobe, with Wernicke area intact
  • Impaired speech expression and comprehension
    • Intact echolalia
    • Errors in paraphrasing
    • Poor comprehension
  • Apraxia: difficulty performing targeted, voluntary movements despite intact motor function
  • Agnosia: Visual and auditory recognition is impaired (no elementary deficits in the sensory system)
    • Tactile agnosia (astereognosis): Impaired ability to recognize or identify objects by touch alone; visual recognition is unimpaired.
    • Visuospatial dysgnosia: inability to orient oneself in space
    • Prosopagnosia: inability to recognize familiar faces
    • Autotopagnosia
  • Anosognosia: inability to recognize neurologic impairment
  • Pure alexia: : form of visual agnosia with severe reading problems; , as a result of interrupted connections between the visual cortex and language‑related areas.
  • Acalculia: inability to perform simple calculations (parietal lobe lesion)
  • Agraphia: inability to write

References:[1][2][3]

Cranial nerve examination

For information on disorders of the cranial nerves, see cranial nerve palsies.

Cranial nerve What is examined? How is the test performed?

Olfactory nerve

I Olfaction
  • The patient is exposed to aromatic substances (e.g., coffee) and asked to identify the odor
Optic nerve II Vision
  • The patient is asked to identify objects/letters from predefined distances.
Visual field
  • The examiner wags a finger towards the patient's visual field from all sides.
Pupillary light reflex
  • The examiner shines a light into the patient's eye (e.g., a penlight).
  • A prompt, consensual response should normally be observable.
  • Pupillary shape and width: Healthy pupils are isocoric and of medium width; anisocoric and/or narrow/wide are suggestive of a disorder (see pupillary disorders).
Papilla
Oculomotor nerve, trochlear nerve, abducens nerve III, IV, VI Eye movement
  • Patients are asked to follow a finger moving up, down, laterally, and diagonally with they eyes.
  • Observe if paresis, nystagmus, or alterations of smooth pursuit appear.
Visual accommodation
  • The physician moves a finger towards the patient.
  • If visual accommodation is intact, the finger is clearly visualized by the patient at all times.
Eyelid ptosis (Levator palpebrae superioris muscle dysfunction)
  • The patient is asked to open and close the eyes.
Trigeminal nerve V Facial sensation
  • The examiner lightly touches three distinct facial areas (the forehead, cheek, and jaw ).
  • Normally, light touch should be felt by the patient in all three areas.
  • If this is not the case, tests for abnormalities of other sensory modalities (e.g., pain, temperature) should be performed.
Muscle function (muscles of mastication)
  • The patient is asked to open and close his/her mouth; at the same time, the examiner palpates the masseter muscle.
Reflexes
  • Masseter reflex (jaw jerk reflex)
    • A finger is placed on the patient's chin, while the patient's mouth remains slightly open
    • Tapping with a reflex hammer normally induces jaw closure
    • If jaw closure is increased, suspect an UMN lesion
  • Corneal reflex
    • The cornea is lightly touched with a cotton swab (approaching slowly and sideways from the lid edge) →
    • Touch normally induces closing of the eyelid.
Facial nerve VII Motor function (muscles of expression)
  • If motor function is intact, the patient should be able to perform the following:
    • Forehead wrinkling
    • Closing the eyes tightly
    • Nose wrinkling
    • Inflate the cheeks
    • Smiling (showing teeth)
    • Whistling
Sense of taste
  • If the sense is intact, the patient should be able to taste sweet, salty, and sour food/drinks.
Vestibulocochlear nerve VIII Hearing
Glossopharyngeal nerve and vagus nerve IX, X Palatal movement
  • The physician performs a visual inspection of the uvula and soft palate: asymmetry and uvula deviation indicate impaired innervation
  • Gag reflex (pharyngeal reflex):
    • Normally, evoked by approaching the uvula quickly and carefully with a spatula/long cotton swab on each side.
    • Absence of the gag reflex is indicative of nerve damage
IX only: sense of taste
  • The patient patient is given a bitter substance to taste: no sense of taste indicates impaired innervation.
X only (recurrent laryngeal nerve): vocalization
  • In case of lesion, the patient would have hoarseness or bovine cough.
Accessory nerve XI Trapezius muscle and sternocleidomastoid muscle (motor function)
Hypoglossal nerve XII Tongue muscles (motor function)
  • The tongue should be pressed against the cheek from the inside, while the examiner tests the strength by pushing from the outside.
  • Hypoglossal nerve paralysis: when the patients stick out the tongue, it moves towards the impaired side


References:[2]

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)
Definition
  • Lesion along the descending motor pathways (corticospinal tract or pyramidal tract)
  • Typically before the anterior horn cell of the spinal cord or motor nuclei of the cranial nerves (e.g., along motor cortex, brain stem)
Muscle appearance
Characteristics
Bladder function
Special tests
  • Positive Babinski sign (toes point upward, abnormal)
  • Pronator drift test
    • The patient is asked to raise both arms horizontally up to shoulder level, palms facing upwards, with the eyes closed (for 30 seconds)
    • Lowering or pronation of one arm is indicative of paresis.
  • Mingazzini test
    • The patient is asked to lie in the supine position, with eyes closed, and is asked to raise and hold both legs for 30 seconds (90° angle at knee and hip).
    • Lowering of one leg is indicative of paresis
Common etiologies

Muscle appearance

  • Assessment: inspection and palpation of muscle groups
  • Findings
    • Fasciculation: involuntary, asynchronous contraction of muscle fascicles within a single motor unit; usually benign but can signify a lower motor neuron lesion
    • Tenderness
    • Abnormal movements (e.g., tremor, tic, myoclonus)
    • 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.

References:[2]

Power

  • Definition: maximal effort a patient is able to exert from an individual muscle or group of muscles
  • Assessment
    • 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

References:[4]

Reflexes

Tendon reflexes

  • Definition: : stretch, monosynaptic reflexes
  • Assessment
    • During reflex testing, the patient should be relaxed (at least the muscles involved in the reflex test should be relaxed). (→ also see: radiculopathy)
    • Elderly patients may have reduced or absent lower deep tendon reflexes due to normal aging-related changes in muscles and tendons
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.

Finger flexor reflex

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.
S1S2 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.

Superficial reflexes

  • Definition: polysynaptic reflexes elicited by stimulation of the skin
  • Superficial reflexes are divided into two subgroups:
    • Physiological reflexes
    • Pathological superficial reflexes: in case of central motor neuron damage, the reflex response decreases.
Nerve root Reflex Test
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:
  • below the coastal arch
  • around the umbilicus
  • above the inguinal ligament

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

Anal reflex

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.

Primitive reflexes

  • 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
Test
Sucking reflex Stroking the mouth induces sucking activity.
Palmar grasp reflex 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.

Corticospinal tract signs

  • Brief description
Test Sign
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

Babinski sign, although normal in newborns and infants, is always pathological in adults!

Do not confuse clonus with myoclonus! Myocloni are arrhythmical and sudden jerks of a muscle or group of muscles while cloni are rather rhythmic and repetitive contractions and relaxations of a muscle group!

Tone

  • Definition: resistance of an individual muscle (or a group of muscles) to passive stretching
  • Assessment: passive movement of the extremities
Tests
Upper limb Lower limb
Tone
  • Elbow: The examiner flexes and fully extends the patient's elbow.
  • Forearm: (while elbow in 90° position) The examiner supinates and pronates the patient's hand.
  • Wrist: The examiner flexes and extends and then twist the patient's wrist from side to side.
  • The patient is asked to relax the limbs while lying in the supine position and then roll the legs from side to side.
Spasticity
  • Velocity-dependent phenomenon
  • The clasp-knife phenomenon: initial resistance due to increased muscle tone is followed by a sudden decrease in resistance.
  • The arm of the examiner is placed under the patient's knee and the examiner briskly lifts the patient's limb → increased muscle tone in limb
Rigidity
  • Velocity-independent phenomenon
  • Cogwheel rigidity: A resistance resembling a cogwheel movement is observed when the joint of a patient's extremity is moved by the examiner.
  • Stiffness and/or inflexibility regardless of movement
Clonus
  • Wrist: The examiner hyperextends the patient's wrist.
  • Patellar clonus: The examiner grasps the patient's patella between the index finger and the thumb, quickly pushes it down distally, and then holds it in this position.
  • Foot clonus
    • The examiner holds the patient's leg, with both knee and ankle resting in a 90° flexion.
    • Then the examiner proceeds to dorsiflex and partially evert the foot forcefully multiple times while sustaining the pressure.
    • Clonus is seen as a set of involuntary contractions.

Sensation

Pathway Assessment Finding
Light touch
  • To test for symmetry of touch sensation, the examiner touches the patient's body at different locations bilaterally.
  • In cases of suspected radicular lesions, the particular dermatome should be examined individually. .
  • In cases of suspected peripheral nerve lesions, diagnostics should involve checking the areas innervated by the corresponding sensory nerves.
  • Paresthesia
  • Dysesthesia
  • Allodynia
Pain and temperature
  • Implements such as a broken spatula can be used to test pain sensation bilaterally (e.g., by gently prodding the patient with the object).
  • Temperature sensation is tested using two objects of different temperatures (e.g., two test tubes with cold and warm water).
  • Decreased (hypoalgesia) or increased (hyperalgesia) sensitivity to nociceptive stimuli
Pallesthesia (vibration sense)

A tuning fork is hit and placed on a bony projection (e.g., medial malleolus).

  • The vibration amplitude and thus the vibration intensity decrease over time.
  • The patient reports when the vibration stops.
  • Abnormalities of vibration are described as mild, moderate, or severe loss of vibration sense.
  • Loss of vibration sense may also indicate a peripheral neuropathy or myelopathy.
Proprioception (joint position)
  • To test proprioception, the most distal joint of the big toe or the distal interphalangeal joint of the thumb are held by its sides and moved up and down.
  • The patient should be able to identify the positional change with eyes closed.

References:[2][5]

Coordination

References:[2]

Gait assessment

  • Evidence for vestibular disorders, sensory or cerebellar ataxia (see “Diagnostics” in cerebellar syndromes)
  • Assessment
    • 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)
Description Examination Result
Romberg test
  • Test for assessing ataxia (vestibular, sensory, or cerebellar ataxia)
  • May help to distinguish between sensory and cerebellar ataxia.
  • The patient is asked to stand with both feet together, raise the arms, and close the eyes.
  • Positive Romberg: closing the eyes impairs coordination (patient starts swaying, or swaying increases), which is indicative of sensory ataxia.
  • Negative Romberg
    • Closing the eyes does not affect patient's balance (patient's swaying does not increase).
    • Uncontrollable swaying, even with eyes open, is indicative of cerebellar ataxia.
  • An increased tendency to fall sideways after closing the eyes indicates a vestibular disorder.
Unterberger test
  • Test for vestibular or cerebellar lesions
  • The patient is asked to walk on the spot with their eyes closed for 50 paces.
  • The test is positive when the patient rotates more than 45° around his/her central axis, which is indicative of a cerebellar lesion or vestibular impairment.
Trendelenburg sign
  • The patient is asked to stand on one leg
  • Physiological: when standing on one leg, the pelvis remains level (no compensatory movements of the upper body) → Negative Trendelenburg sign
  • Pathological: pelvic drop towards the unimpaired, unsupported side → Positive Trendelenburg sign
  • Duchenne sign: torso tilting towards the contralateral side compensates the pelvic drop on the unimpaired side.
  • Duchenne limp: the Duchenne sign (frequently occurs bilaterally) results in a compensatory to‑and‑fro movement of the torso during walking

Signs of meningeal or nerve root irritation

Meningism

Additional signs of meningeal or nerve root irritation

  • Lasègue sign (root L5–S1)
  • 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
    • Involuntary lifting of the legs provoked by passive flexion of the neck in a patient in supine position
    • Lifting of the legs reduces pain associated with tension of the irritated meninges and, especially, the lumbosacral spinal nerves during neck flexion

  • 1. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston, MA: Butterworths; 1990.
  • 2. Hauser S, Josephson SA. Harrison's Neurology in Clinical Medicine. McGraw-Hill Education; 2016.
  • 3. Delmar Publishers. The Mental Status Examination. http://www.delmarlearning.com/companions/content/0766826899/res/mentstatexam.asp. Updated April 6, 2017. Accessed April 6, 2017.
  • 4. Medical Research Council. Aids to the examination of the peripheral nervous system . London, England: The Stationery Office Books; 1976.
  • 5. Lewis SL. Field Guide to the Neurologic Examination. Lippincott Williams & Wilkins; 2004.
last updated 08/13/2018
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