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Neurological examination

Last updated: September 21, 2021

Summarytoggle arrow icon

Neurological examination is the assessment of mental status, cranial nerves, motor and 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 with lower limb function to determine the location of a lesion. Subtle central nervous system defects can be detected with careful observation of patients performing tasks that require the simultaneous activation of multiple cerebral areas. This article provides information about several examination methods and explains key terms relevant to the evaluation of neurological conditions.

  • Aphasia is the inability to either form or understand language not attributed to the motor ability to produce speech. It is caused by damage to different areas of the dominant hemisphere (usually left).
Types of aphasia
Location of lesion Type Clinical features
Broca aphasia (motor aphasia, expressive aphasia)
  • Nonfluent
  • Telegraphic and grammatically incorrect speech
  • Comprehension is largely spared (difficulty understanding complex language may occur).
  • The patient is typically aware of the deficit and feels frustrated about it.
  • Impaired repetition
Wernicke aphasia (sensory aphasia, receptive aphasia)
  • Fluent
  • Fluent speech that lacks sense (paraphasic errors, neologisms, word salad)
  • Comprehension is impaired.
  • The patient is typically unaware of the deficits.
  • Impaired repetition
  • Reading and writing are often severely impaired.
Global aphasia
  • Nonfluent
  • Severe impairment of speech production and comprehension
    • Patient may be mute or only utter sounds
    • Inability to comprehend speech
Conduction aphasia (associative aphasia)
  • Fluent
  • Mostly intact comprehension and fluent speech production
  • Impaired repetition with paraphasia (patients substitute or transpose sounds and try to correct mistakes on their own)
Anomic aphasia
  • Usually, pinpointing the localization of the lesion is not possible.
  • Fluent
  • Isolated difficulty finding words
  • Paraphrasing occurs when patients cannot find the word they seek.
Transcortical aphasia Transcortical motor aphasia
  • Nonfluent
  • Difficulty initiating speech
  • Difficulty in expressing a thought process
  • Difficulty producing own phrases
  • Intact repetition and comprehension
Transcortical sensory aphasia
  • Fluent
  • Impaired speech expression and comprehension
    • Errors in paraphrasing
    • Poor comprehension
  • Intact repetition
Transcortical mixed aphasia
  • Nonfluent
  • Poor comprehension of spoken and written language

The Broca's area is broken in Broca aphasia.
Speech of patients with Wernicke aphasia is like a Word salad
In Conduction aphasia, the arCuate fasciculus is affected.

Overview of cranial nerve examination

The cranial nerve examination is used to identify problems with the cranial nerves by physical examination. For information on disorders of the cranial nerves, see “Cranial nerve palsies.” The assessment includes the following components:

Overview of cranial nerve examination [1]
Cranial nerve What is examined? How is the test performed?

Olfactory nerve

I
  • Test the patient's ability to detect and identify an aroma in each nostril.
    • Ask the patient to block one nostril with the finger, close the eyes, and sniff repetitively.
    • Place a vial of a nonirritating substance (e.g., vanilla, lemon, coffee, tobacco) and ask to tell you when an odor is detected and to identify it if recognized.
Optic nerve II
  • Ask the patient to identify (with both eyes) a number or shape within the Ishihara plates, which contain dots of different color and size.
  • Assess each eye by confrontation (i.e., by comparing the patient’s visual fields to your own) using a finger or red pin.
    1. Facing the patient at 0.6–1.0 meters (2–3 feet), place your hands at the periphery of your visual fields (the hands should be equidistant between you and the patient) and inform the patient that you are going to move your index fingers.
    2. Ask the patient to look directly at the center of your face and to tell you when and which index fingers (left, right, or both) are moving.
    3. Test the inferior and the superior quadrants on both sides. The index fingers can be moved both alternatively and simultaneously.
  • More accurate testing uses perimetry.
Oculomotor nerve, trochlear nerve, abducens nerve III, IV, VI
  • Patients are asked to look back and forth between two widely spaced targets (e.g., one finger on the two hands) held by the examiner in front of the patient to evaluate saccades (i.e., the ability to rapidly fixate the eyes from one object to another).
  • Patients are asked to follow a finger moving up, down, laterally, and diagonally with their eyes. Observe for the following:
    • Paresis: absence of movement of one or both eyes
    • Alterations in smooth pursuit (e.g., saccades)
    • Nystagmus: involuntary, repetitive movement of one or both eyes
      • Direction: vertical (upbeat or downbeat in vestibular nystagmus, depending on whether the fast phase is upwards or downwards, respectively), horizontal, torsional, or any combination of the above
      • Monocular or binocular
  • The physician moves a finger towards the patient. A normal response is constriction of the pupil.
  • The patient is asked to open and close their eyes.
Trigeminal nerve V
  • Facial sensation
  • The examiner lightly touches three distinct facial areas, typically the forehead, cheek, and jaw. ).
  • Normally, light touch should be felt by the patient in all three areas.
  • If this is not the case, additional tests for abnormalities of other sensory modalities (e.g., pain, temperature) should be performed in the same areas.
  • The patient is asked to open and close their mouth.
  • At the same time, the examiner
    • Inspects the masseter muscles for asymmetry
    • Palpates them to investigate if there is pain elicited by palpation
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)
  • If the sense is intact, the patient should be able to taste sweet, salty, and sour food/drinks.
Vestibulocochlear nerve VIII
Glossopharyngeal nerve and vagus nerve IX, X
  • Palatal movement
  • The physician asks the patient to open the mouth and performs a visual inspection of the uvula and soft palate: Palate and uvula should be symmetrical and not deviate.
  • The uvula and throat are better visible when the tongue is pressed down with a stick and the patient says "ah".
  • If the sense is intact, the patient should be able to taste bitter substances.
  • If the nerve is intact, the patient would not have hoarseness or a bovine cough.
Accessory nerve XI
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.
  • The tongue should be symmetrical and not deviate when the patient sticks out the tongue.

Overview of cranial nerve reflexes

Cranial nerve reflexes
Reflex Afferent limb Efferent limb Examination technique Normal response
Pupillary reflex
  • Note the pupil size and shape at rest.
  • Consecutively illuminate the pupils with a flashlight, observing for direct and indirect reaction to light.
Corneal reflex
  • Touch the cornea with a clean soft material (e.g., tissue, cotton ball)
Conjunctival reflex
  • Touch the conjunctiva with a clean soft material (e.g., tissue, cotton ball)
Lacrimation reflex
  • Touch the conjunctiva with a clean soft material (e.g., tissue, cotton ball)
Jaw jerk reflex
  • Ask the patient to open their mouth slightly.
  • Place a finger on their chin.
  • Strike the finger with a reflex hammer.
Gag reflex
Cough reflex
  • Not routinely examined

The motor system examination allows to quantify the degree of motor function impairment and often to differentiate between central and peripheral lesions. The fundamental elements of the examination include muscle appearance, muscle strength (power), tone, and reflexes.

Upper motor neuron (UMN) injury vs. lower motor neuron (LMN) injury
UMN lesion LMN lesion
Definition
Muscle appearance
Characteristics
  • Central paresis (spastic paresis) is a condition characterized by the inability of voluntary movement in combination with:
  • Peripheral paresis (flaccid paresis) is a condition characterized by the inability of voluntary movement in combination with:
    • ↓ Tone (no clasp knife phenomenon)
    • ↓ Power in single muscle fibers
    • Hyporeflexia/areflexia
Bladder function
Babinski sign
  • Upgoing (also referred to as present or positive)
    • Big toe points upward while toes 2–5 fan out and downward
    • Pathological response
  • Downgoing (also referred to as absent or negative)
    • Toes are neutral or point downward (including big toe)
    • Physiological response
Common etiologies

In LOWer motor neuron lesions, muscle mass, tone, power, and reflexes are LOW. In UPper motor neuron lesions, muscle tone, reflexes, and toes (Babinski sign) are UP.

Findings [1]

Overview of abnormal muscle movements

Abnormal muscle movements
Disorder Description Causes
Myoclonus
  • Sudden brief contraction of an isolated muscle group
Asterixis
  • An abrupt loss of muscle tone during sustained contraction (negative myoclonus)
  • Can be assessed by asking the patient to extend their arms with eyes closed, dorsiflex their wrists, and spread their fingers: Affected patients will be unable to maintain the posture, resulting in a flapping motion of the hands.
Akathisia
  • Subjective feeling of restlessness manifesting in the inability to stay still
Athetosis
  • Involuntary writhing movements of the fingers, hands, feet, and, less commonly, arms, legs, and neck
Chorea
  • Continuous, irregular movements of the extremities and trunk
Dystonia
Tremor Rest
Intention
  • A low-frequency tremor that occurs as the patient reaches the target of a voluntary and purposeful movement (e.g., reaching for a cup)
Postural
  • Tremor that occurs in limbs, trunk, or neck while maintaining a posture against gravity (e.g., while maintaining the hands outstretched)
Ballismus
  • A high-amplitude movement of the extremities, potentially of a flailing or kicking quality
  • Typically unilateral (hemiballismus)
Tic
  • Recurrent sudden, involuntary, nonrhythmic movements (motor tics) or vocalizations (phonic tics)
  • Generally preceded by a strong urge to move
  • Can be voluntarily suppressed
  • 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 the extremities against resistance.
    • Muscle power tests should be performed bilaterally for comparison.
  • Muscle power grading
    • 0: no contraction (complete paralysis)
    • 1: flicker or trace of contraction
    • 2: active movement, with gravity eliminated
    • 3: active movement against gravity
    • 4: active movement against gravity and moderate resistance
    • 5: normal power (i.e., full range of motion against gravity and full resistance)
  • Patterns of paresis distribution
    • Quadriparesis: weakness in all four limbs
    • Hemiparesis: weakness in half of the body
    • Paraparesis: weakness affecting both lower extremities
    • Monoparesis: paresis affecting a single limb
  • Special tests
    • 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 subtle paresis.
Routinely assessed muscles
Muscle Innervation Movement
Upper extremity
Deltoid C5–C6 (axillary nerve) Abduction of upper arm to horizontal level
Biceps brachii C5–C7 (musculocutaneous nerve) Flexion of the forehand at elbow
Triceps brachii C6–C8 (radial nerve) Extension of the forehand at elbow
Flexor carpi ulnaris C8–T1 (muscular branches of the ulnar nerve) Palmar flexion of the hand at wrist
Extensor carpi radialis C5–C8 (radial nerve) Dorsiflexion of the hand at wrist
Abductor pollicus brevis C8–T1 (median nerve) Thumb abduction
Interossei C8–T1 (deep branch of the ulnar nerve) Finger abduction
Lower extremity
Iliopsoas L1–L3 (femoral nerve) Flexion of the leg at hip
Quadriceps femoris L2–L4 (femoral nerve) Extension of the leg at knee
Hamstrings L5–S2 (sciatic nerve) Flexion of the leg at knee
Tibialis anterior L4–L5 (deep peroneal nerve) Foot dorsiflexion
Gastrocnemius S1–S2 (tibial nerve) Foot plantar flexion

References:[3]

A tendon reflex is a single monosynaptic reflex (stretch). The reflex arc consists of only one synapsis connecting two neurons: an afferent sensory neuron and an efferent motor neuron.

Deep tendon reflexes (DTR)

  • Definition: a reflex to test the integrity of a sensory and motor neuron circuit
  • Assessment
  • Interpretation
    • An increased DTR indicates an upper motor neuron issue, whereas decreased DTR indicates an LMN, neuromuscular junction, or muscle issue.
    • Elderly patients may have reduced or absent lower DTR due to normal aging-related changes in muscles and tendons
    • Reinforcing maneuvers (e.g., Jendrassik maneuver) can be used to elicit a reflex that initially seems to be absent.
Deep tendon reflex testing
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 90° position) and taps the triceps tendon with a reflex hammer to induce an extension in the elbow joint.
Lower limbs L2–L4 Adductor reflex Tapping the tendon on the medial epicondyle 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.
Deep tendon reflex scale [4]
Grade Description Interpretation
0
  • No response even with reinforcement (areflexia)
1+
  • Considered normal if none of the following features is present:
    • A substantial asymmetry between sides
    • Difference between the upper and lower extremities
    • Other signs of LMN lesion affecting the same zone
2+
  • Brisk response
  • Normal
3+
  • Considered normal if none of the following features is present:
    • A substantial asymmetry between sides
    • Difference between the upper and lower extremities
    • Other signs of UMN lesion affecting the same zone
4+
  • Abnormal
  • Suggests UMN lesion when combined with the following: muscle weakness, increased muscle tone, and pathological reflexes

Use the following poem to remember which nerve roots correspond to which reflexes:
S1–S2
Buckle my shoe (ankle reflex)
L2–L4
Kick the door (knee reflex)
C5–C6
Pick up sticks (biceps reflex and brachioradialis reflex)
C7–C8
Lay them straight (triceps reflex)

Superficial reflexes

  • Definition: polysynaptic reflexes elicited by stimulation of the skin
  • Interpretation: superficial reflexes are considered
    • Physiological, when there is a contraction of a group of muscles after the stimulation
    • Pathological, when there is reduced or no contraction as a consequence of lower motor neuron and/or the reflex arc
Superficial reflex testing
Nerve root Reflex Test
T6–T12
  • Abdominal reflex
L1–L2
  • Cremasteric reflex
  • The reflex is elicited by stroking the medial, inner part of the thigh.
  • A normal response is 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 contraction of the anal sphincter muscles.
  • Bulbocavernosus reflex

Use the following poem to remember some of the superficial reflexes:
L1–L2
Testicle move (cremasteric reflex)
S3–S5
Winking by (anal wink reflex)

Primitive reflexes

Overview of most important corticospinal tract signs
Sign Test Result
Upper limb signs
Finger flexor reflex Tromner sign
  • The examiner taps the terminal phalanx of a relaxed finger (usually the middle finger) on the palmar side while holding the patient's hand in level with the proximal phalanges.
  • The sign is positive when either of the following is present
    • There is significant flexion in the terminal phalanx of the tapped finger and the thumb
    • When the flexion is very asymmetrical comparing both hands.
Hoffmann sign
  • The examiner flicks the nail of the middle finger downward while loosely holding the patient's hand, allowing it to flick upward reflexively.
  • The sign is positive when there is quick flexion and adduction of the thumb and/or index finger on the same hand.
Lower limb signs
Babinski sign
  • The examiner strokes the sole of the patient's foot on the lateral edge using, e.g., the handle of a reflex hammer.
  • The sign is positive (i.e. upgoing/present/pathological) when the big toe extends (dorsiflexes), while the other toes fan out.
  • An exception are children up to the age of 2 years, in which case an upgoing Babinski sign is considered physiological.
  • The test is inconclusive when only the big toe responds.
Gordon sign
  • The examiner compresses the calf muscles.
Oppenheim sign
Schaeffer sign

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

  • Definition: resistance of an individual muscle (or a group of muscles) to passive stretching
  • Assessment: passive movement of the extremities
    • Upper limb
      • Elbow: The examiner flexes and fully extends the patient's elbow.
      • Forearm: With the elbow in the 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.
    • Lower limb: The patient is asked to relax the limbs while lying in the supine position. The examiner then rolls the legs from side to side.
  • Findings [4][6]
    • Spasticity: characteristic of pyramidal tract lesions
      • Velocity-dependent phenomenon: Spasticity is more pronounced with increased speed of movement.
      • Clasp knife phenomenon: initial resistance due to increased muscle tone is followed by a sudden decrease in resistance
      • See “Spasticity
    • Rigidity: suggests abnormalities of the extrapyramidal system
      • Velocity-independent phenomenon
      • Lead pipe rigidity: an increase in tone that is constant throughout the passive movement
      • Cogwheel rigidity
        • Extreme stiffness of the joint of the limb that makes movement difficult
        • When the examiner flexes or extends the limb, the movement is jerky, resembling the ratcheted rotation of a cogwheel
    • Hypotonia
    • Paratonia: a change in tone that is uneven throughout the passive movement due to involuntary opposition or facilitation by a patient
      • Occurs in patients with frontal lobe dysfunction (e.g., due to trauma, stroke, tumor, neurodegenerative disorders such as frontotemporal dementia)
      • The degree of paratonia increases with the speed of passive movement, the amount of applied force, and with attempts to relax the patient.
      • Oppositional paratonia: an apparent increase in tone due to the patient's involuntary resistance to movement
      • Facilitatory paratonia: an apparent decrease in tone due to the patient's involuntary assistance to movement
    • Clonus: a series of involuntary, rhythmic muscular contractions
      • 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.
      • Wrist clonus: The examiner hyperextends the patient's wrist.
  • Modified Ashworth scale: a scale that is most commonly used for assessment of the muscle tone [7]
    • 0: no increase in muscle tone
    • 1: slight increase in muscle tone, with minimal resistance at the end of the range of passive motion
    • 1+: slight increase in muscle tone followed by abrupt resistance (catch) that continues through the remainder (less than half) of the movement
    • 2: a marked increase in muscle tone throughout most of the range of motion, but passive movement is easy
    • 3: considerable increase in muscle tone, with passive movement difficult
    • 4: affected parts rigid in flexion or extension

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. Moreover, myoclonus is usually associated with metabolic abnormalities (e.g., renal and liver failure).

Examination of the sensory system is aimed at evaluating any abnormality affecting the patient's perception to provoked sensations like touch, pain, and temperature. In contrast to motor function, sensation is subjective to the patient and therefore the interpretation of the exam strongly depends on the patient accurately reporting what they experience.

For more information about the patterns of sensory loss in spinal cord lesions, see “Overview” in “Incomplete spinal cord syndromes.”

Focused examination of sensation [1][8]
Modality 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.
  • Monofilament test can be used to quantitatively assess light touch sensation. [9][10]
  • Paresthesia: abnormal sensation (e.g., tingling, prickling, "pins and needles")
  • Dysesthesia: a spontaneous or evoked abnormal unpleasant sensation, such as itching, burning, pain
    • Allodynia: a subtype of dysesthesia that manifests with a painful sensation triggered by a stimulus that is not ordinarily considered painful
    • Hyperesthesia: a subtype of dysesthesia that manifests with exaggerated
      perception of sensory stimuli
  • Hypesthesia: decreased perception of sensory stimuli (anesthesia is the most extreme case of hypesthesia)
Pallesthesia (vibration sense)
  • A tuning fork is hit and placed on a bony projection (e.g., medial malleolus). [11]
  • The vibration amplitude and thus the vibration intensity decrease over time.
  • The patient reports when the vibration stops.
Proprioception (joint position)
Pain and temperature sensation
  • A broken spatula or a toothpick can be used to test pain sensation bilaterally (e.g., by gently prodding the patient).
  • Temperature sensation is tested using two objects of different temperatures (e.g., two test tubes; one with cold water and the other with warm water).
  • Decreased (hypoalgesia) or increased (hyperalgesia) sensitivity to nociceptive stimuli

General considerations

  • The following tests are used to test for the ability to coordinate movements, which depend on cerebellar and basal ganglia function, proprioceptive input, and muscle power.
  • Limb ataxia: a lack of coordination of voluntary movements of the upper and lower extremities, is the main finding; most commonly results from lesions in the cerebellar hemispheres. [1]

Finger-to-nose test and finger-to-finger test

  • Procedure
    • Finger-to-nose test: The patient is asked to touch the tip of their nose with the index finger
    • Finger-to-finger test: The patient is asked to alternate between touching the tip of their nose and the examiner's finger as quickly as possible with the index finger
    • The tests should be performed once with the patient's eyes open and again with the eyes closed
  • Findings
    • Normally, the patient would be able to reach the target (either their nose or examiner's finger) without tremor or overshoot.
    • Patients with dysmetria are unable to touch the tip of their nose with their index finger.
    • Improvement of test results with eyes open indicates visual compensation of dysmetria, which is characteristic of sensory impairment.
    • In patients with intention tremor, the fingers will begin to shake just as they reach their nose.
    • Patients with kinetic tremor will have a tremor throughout the movement.

Heel-knee-shin test

  • Procedure: The patient is asked to touch the opposite knee with a heel and slide down the shin.
  • Findings
    • Normally, the patient will be able to slide the heel of one foot down the shin of the opposite leg.
    • In patients with dysmetria, the heel will deviate to alternate sides , which indicates that the patient has limb ataxia.

Rapid alternating movement test

  • Procedure: The patient is asked to rapidly screw in a large imaginary light bulb using both hands.
  • Findings
    • Normally, a patient is able to perform the movement.
    • Patients with dysdiadochokinesia are unable to perform rapidly alternating agonistic-antagonistic movements and thus perform the test slowly, in an uncoordinated manner.

Multiple systems are required for proper walking, such as those responsible for sensory and motor functions (including reflexes), as well as the cerebellum and the vestibular system. During the examination of the patient's gait, particular attention should be paid to body and limb posture (e.g., base of support and arm swing), steps (length, speed, and rhythm), steadiness, and turning.

Gait examination

Overview [12]
Test Purpose Examination Interpretation
Observation of casual gait
  • Detection of gait abnormalities
  • The patient is asked to walk a few steps forward and backward.
  • Normal gait is steady with natural arm swing.
Heel to toe walking
  • The patient is asked to place one foot directly in front of the other as if walking on a tightrope.
  • The test is positive when the patient is unable or has difficulty in placing one foot directly in front of the other.
Foot drop test
  • Test for assessing neuropathic gait
  • The patient is asked to walk on his/her heels.
  • The test is positive when the patient is unable to walk on his/her heels, which may be indicative of deep fibular nerve lesions or peripheral neuropathies.
Walking on tiptoes
  • The patient is asked to walk on his/her toes.
  • The test is positive when the patient is unable to walk on his/her toes, which may indicate tibial nerve lesions or peripheral neuropathies.
Romberg test
  • Test to differentiate between the causes of truncal ataxia
  • Used 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
    • The patient's coordination is impaired when the eyes are closed and the patient starts swaying or swaying increases
    • Indicates sensory ataxia
    • An increased tendency to fall sideways after closing the eyes can also indicate a vestibular disorder. In the case of a unilateral vestibular disorder, the patient usually falls towards the side of the lesion.
  • Negative Romberg
    • Closing the eyes does not affect the patient's balance (i.e., swaying does not increase).
    • Uncontrollable swaying, even with the eyes open, is indicative of cerebellar ataxia.
Unterberger test
  • Test for detecting the presence of 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 their central axis.
  • A positive test indicates a cerebellar lesion or vestibular impairment.
Trendelenburg sign
  • The patient is asked to stand on one leg.
  • Negative Trendelenburg sign (physiological): The pelvis remains level as it is stabilized by the gluteus medius and minimus.
  • Positive Trendelenburg sign (pathological): Because of insufficiency of the gluteus medius and minimus on the side of the standing leg, the pelvis drops towards the contralateral, unimpaired side.
  • Duchenne sign: The torso tilts toward the contralateral side, compensating the pelvic drop on the unimpaired side.
  • Duchenne limp: The Duchenne sign, which frequently occurs bilaterally, results in a compensatory to‑and‑from movement of the torso during walking.

Abnormal gait patterns

Overview of abnormal gait patterns [12]
Type Description Associated disease
Hemiplegic gait
  • Loss of natural arm swing and dragging of the affected leg in a semicircle (circumduction)
  • On the affected side, the arm may be flexed, adducted, and internally rotated, while the leg is extended and the foot is plantarflexed.
Myopathic gait
  • Drop of the pelvis on the unaffected side (Trendelenburg sign) or on both sides (waddling) when walking.
  • Respectively caused by unilateral or bilateral weakness of one or multiple pelvic girdle muscles (especially gluteus muscles)
Neuropathic gait
  • Seen in patients with unilateral or bilateral foot drop (i.e., weakness of foot dorsiflexion) who lift one or both legs when walking, respectively, in order to prevent the foot dragging on the floor.
Ataxic gait Cerebellar ataxic gait
  • Unsteady and wide-based gait with irregular, uncoordinated movements
  • Staggering gait
  • Inability to walk from heel to toe or in a straight line
Sensory ataxic gait
  • Stooped, stomping gait
  • Gait is exacerbated when patients cannot see their feet (e.g., in the dark)
  • Romberg test is positive.
Parkinsonian gait
  • Small, slow steps (bradykinesia), shuffling, and sometimes accelerating, with the head, neck, and trunk leaning forward and flexion at the knees
  • Difficulty initiating steps (rigidity)
Gait apraxia
  • Inability to raise the foot off of the floor (magnetic gait), resulting in shuffling
  • Poor balance and truncal mobility
  • Difficulty initiating steps
Choreiform gait
  • Walking associated with irregular, jerky, involuntary movements in the limbs
  • Definition: the triad of
  • Examination
    • Kernig sign: In a supine patient, extension of the knee when the thigh is flexed at the hip causes pain (knee at a 90° angle).
    • Brudzinski sign: In a supine patient, passive flexion of the neck provokes involuntary lifting of both legs.
  • Etiology: : due to inflammatory (bacterial/viral meningitis; ) or noninflammatory (e.g., subarachnoid hemorrhage) causes

∼Signs of nerve root irritation indicate an inflammatory and/or irritative process occurring at the point where the spinal nerves exit the vertebral column. Testing for signs of nerve root irritation can help determine suspected spinal root compression (e.g., by a tumor or herniated disk).

Definition

Nystagmus is an involuntary, repetitive, and twitching movement of one or both eyes.

Classification

There are several types of nystagmus. The most commonly seen ones are listed below. [13][14]

  • Jerk nystagmus: a slow movement of the eyes towards a defined direction followed by a fast, corrective movement backward (the name of the nystagmus is determined by the direction of movement in the fast phase, i.e., left-beating, right-beating, downbeat, upbeat)
  • Horizontal nystagmus
    • A type of jerk nystagmus in which the eyes move horizontally
    • Movement in the fast phase is either to the left or the right (left-beating, right-beating).
  • Vertical nystagmus
    • A type of jerk nystagmus in which the eyes move vertically
    • Movement in the fast phase is either upwards or downwards (upbeat nystagmus , downbeat nystagmus )
  • Torsional nystagmus: a type of jerk nystagmus with rotary oscillations of the eye along its anteroposterior axis (clockwise, counterclockwise )
  • Mixed nystagmus
  • Pendular nystagmus
    • A type of nystagmus defined by sinusoidal oscillating movements of one or both eyes
    • Often related to multiple sclerosis
    • Always considered pathological

Etiology

Nystagmus can be physiological or pathological.

Overview of pathological nystagmus [16][17]
Characteristics Etiology

Spontaneous nystagmus (without external provocation)

Peripheral nystagmus

Central nystagmus

  • Jerk or pendular nystagmus
  • Originates within the central system
  • Can be physiological or pathological
  • Rarely accompanied by vertigo
  • Can not be suppressed with visual fixation
Gaze-evoked nystagmus [18]
  • Jerk nystagmus
  • Caused by maintenance of eccentric eye position
  • Most common type of nystagmus
  • Can be provoked by testing oculomotor eye movements to the extreme horizontal point of gaze
  • Fast corrective phase towards the eccentric eye position
  • Movements last > 20 seconds

Pure upbeat, pure downbeat, and pure horizontal nystagmus almost always originate from central lesions. Mixed horizontal and torsional nystagmus patterns are typical of peripheral lesions.

The nystagmus always directs towards the more activated vestibular sensory organ.

Clinical features [13]

Diagnostics

  • Caloric testing [15]
    • A test to differentiate between peripheral and central nystagmus by infusing warm (∼44°C) or cold (∼30°C) water into the external ear canal
    • Water infusion physiologically triggers horizontal nystagmus.
      • Warm water: towards the stimulated side (same side)
      • Cold water: away from the stimulated side (opposite side)
      • Ice-cold water: Absence of nystagmus can indicate brainstem death in comatose patients.

COWS: Cold: Opposite side; Warm: Same side (rule for the direction of nystagmus).

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