EXAMINATION OF THE NERVOUS SYSTEM
Three important questions govern the neurological examination:
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Is the mental status intact?
Are right-sided and left-sided findings in the patient symmetric to each other?
If the findings are asymmetric or abnormal, does the causative lesion lie in the
central nervous system or the peripheral nervous system?
TECHNIQUES
|
OF
EXAMINATION
EXAMINATION |
OF MENTAL
STATUS
EXAMINATION |
OF CRANIAL
NERVES
EXAMINATION
OF THE
SENSORY
SYSTEM
TECHNIQUES OF EXAMINATION:
Following should be examined in a patient during the nervous system examination.
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Top
Mental status: Appearance and behavior, speech and language, mood, thoughts and
perceptions, cognition.
Cranial Nerves I to XII
Motor system: Muscle bulk, tone, and strength; coordination, gait, and stance.
Sensory system: Pain, temperature, position, vibration, light, touch discrimination.
Deep tendon reflexes and superficial reflexes.
EXAMINATION OF MENTAL STATUS:
Top
Examination of mental status begins with history taking. While taking the patient’s history
carefully examine the patient’s level of alertness and orientation, mood, attention and
memory. You will also learn about the patient’s insight and judgment, as well as any
recurring or unusual thoughts or perceptions.
Components of the mental status examination include:
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Appearance and behavior
Speech and language
Speech and language
Thoughts and perceptions
Cognitive function, including memory, attention, information and vocabulary,
calculations, and abstract thinking and constructional ability.
APPEARANCE AND BEHAVIOR:
This aspect can be assessed during the history taking. Doctor must make a note of the aspects
like level of consciousness, posture and motor behavior, dress, grooming, and personal
hygiene, facial expression, manner, affect, and relationship to persons and things.
LEVEL OF CONSCIOUSNESS –
First consider the patient's level of consciousness, as this may determine what can be done
with the rest of the examination. Observe if the patient is awake and alert. Does the patient
seem to understand your questions and respond appropriately and quickly, or is there a
tendency to lose track of the topic and fall silent or even fall asleep? Lethargic patients are
drowsy but open their eyes and look at you, respond to questions, and then fall asleep.
Obtunded patients open their eyes and look at you, but respond slowly and are somewhat
confused.
Clouding of consciousness may occur as a result of acute diffuse cerebral dysfunction, e.g. in
cerebral hypoperfusion, metabolic disease or encephalitis. Focal lesions of the thalamus,
especially if medial and bilateral, can also cause delirium, and lesions of the brainstem,
reticular activating system cause a markedly impaired conscious level. If a wide-awake
patient without severe dementia fails to respond, he or she may have a specific aphasia in the
domain of repetition, or hysterical or depressive pseudo-dementia.
If the patient doesn’t seem to respond to the questions asked, you can further stimulate his
senses by either speaking to the patient by calling out his name in a loud voice or shaking the
patient gently as if rousing the patient from sleep. If there is no response to these stimuli,
then assess the patient for stupor or coma.
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Coma is a term, describing a state in which the patient's response to external stimuli
or inner needs is grossly impaired. The Glasgow Coma Scale (GCS) is used to assign
a numerical value to the patient's responses to defined stimuli. It is particularly useful
for quantifying changes in conscious level over time.
Stupor is described as a state where the patient, although inaccessible, shows some
response to painful stimuli.
POSTURE AND MOTOR BEHAVIOR –
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? Does
the patient lie in bed, or prefer to walk about?
DRESSING, GROOMING AND PERSONAL HYGIENE –
Note the patient’s clothes, hair, nails, teeth, skin, beard, etc. How is the patient groomed?
How does the person’s grooming and hygiene be compared with those of people of
comparable age, lifestyle, and socioeconomic group?
FACIAL EXPRESSION –
Observe the face while the patient rests and when the patient is interacting with others.
Watch for variations in expression. Are they appropriate? Or is the face relatively immobile
throughout?
MANNER, AFFECT, AND RELATIONSHIP TO PERSONS AND THINGS –
Using your observations of facial expressions, voice and body movements, assess the
patient’s affect. Is the affect labile, blunted, or flat? Does it seem inappropriate or extreme at
certain points? If it is inappropriate then, how is it so? Note the patient’s openness,
approachability, and reactions to others around and to that of the surroundings. Does the
patient seem to hear or see things that you do not or seem to be conversing with someone
who is not there?
SPEECH AND LANGUAGE:
Throughout the interview, note the characteristics of the patient’s speech, with respect to the
following:
QUANTITY –
Is the patient talkative or relatively silent? Are his comments spontaneous or only responsive
to direct questions?
RATE –
Is speech fast or slow?
LOUDNESS –
Is speech loud or soft?
ARTICULATION OF WORDS –
Are the words spoken clearly and distinctly? Is there a nasal quality to the speech?
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:
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Hesitancies and gaps in the flow and rhythm of words.
Disturbed inflections, such as a monotone.
Circumlocutions, in which phrases or sentences are substituted for a word the person
cannot think of, such as “what you read” for “book”.
Paraphasias, in which words are malformed (“I read a cook”), wrong (“I read a
back”), or invented (“I write with a dack”).
It becomes obvious while talking with the patient, whether or not there is a major
communication problem, and whether this is dysphasia (speech language problem),
dysarthria (speech articulation problem) or dysphonia (impaired control of air flow). Ask the
patient to recite the months of the year. If this simple request is not understood, it is likely
there is a major dysphasia or cognitive problem. The large number of long words in the
months, with their simple meaning, allows easy detection of a dysarthria or dysphonia.
MOOD:
Moods include sadness and deep melancholy; contentment, joy, euphoria, and elation; anger
and rage; anxiety and worry; and detachment and indifference. Find out about the patient’s
usual mood level and how it has varied with life events. The reports of relatives and friends
may be of a great value.
Ask for the questions like - What has the patient’s mood been like? How intense has it been?
Has it been labile or fairly unchanging? How long has it lasted? Is it appropriate to the
patient’s circumstances? In case of depression, have there also been episodes of an elevated
mood (suggesting a bipolar disorder)?
In case of suspected depression, assess its depth and any associated risk of suicide.
THOUGHT AND PERCEPTIONS:
THOUGHT PROCESSES
Assess the aspects like logic, relevance, organization, and coherence of the patient’s thought
processes in his words and speech throughout the interview. Listen for patterns of speech that
suggest disorders of thought processes.
THOUGHT CONTENT
You may follow appropriate leads as they occur rather than using preformed lists of specific
questions to assess the patient’s thought content. You may need to make more specific
inquiries. If so, couch them in tactful and accepting terms. Abnormalities in thought content
include compulsions, obsessions, phobias, anxieties, feeling of unreality, feeling of
depersonalization, delusions, illusions, hallucinations, etc.
COGNITIVE FUNCTIONS:
ORIENTATION –
You can ask for specific dates and times, the patient’s address and telephone number, the
names of family members, or the route taken to the hospital. In either of these ways,
determine the patient’s orientation for the following:
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Time (the time of day, day of the week, month, season, date and year)
Place (the patient’s residence, the names of the hospital, city, and state)
Person (the patient’s own name, the names of relatives and professional personnel)
COGNITIVE FUNCTIONS:
MEMORY –
Inquiry must be done with regards to remote as well as recent memory.
For remote memory, inquire about birthdays, anniversaries, social security number, names of
schools attended, jobs held, or past historical events relevant to the patient’s past. For recent
memory testing, ask the patient about the day’s weather, today’s appointment time,
medications or laboratory tests taken during the day. Ask questions with answers that you
can check against other sources so that you will know whether or not the patient is
confabulating.
Memory deficits often relate to temporal lobe disease and are at times modality specific.
Verbal memory is more impaired in dominant temporal disease and visual memory is
impaired in non-dominant hemisphere disease. Bilateral mesial temporal lobe damage leads
to memory loss, visual agnosia for objects, a tendency to explore objects by putting them in
the mouth, indiscriminate sexual behavior, especially to inanimate objects, and a flat affect
(Kluver-Bucy syndrome), illustrating the importance of the temporal lobes in memory,
language function and emotional behavior.
VOCABULARY –
Information and vocabulary, when observed clinically, provide a rough estimate of a
person’s intelligence. Note the person’s grasp of information, the complexity of the ideas
expressed, and the vocabulary used. More directly, you can ask about specific facts.
These aspects are relatively unaffected by any but the most severe psychiatric disorders, and
may be helpful for distinguishing mentally retarded adults (whose information and
vocabulary are limited) from those with mild or moderate dementia (whose information and
vocabulary are fairly well preserved).
CALCULATING ABILITY –
Test the patient’s ability to do arithmetical calculations, starting at the rote level with simple
addition and multiplications.
Poor performance may be a useful sign of dementia or may accompany aphasia, but it
must be assessed in terms of the patient’s intelligence and education.
EXAMINATION OF CRANIAL NERVES:
Top
EXAMINATION OF CRANIAL NERVE I – OLFACTORY NERVE:
Testing of the sense of smell can be carried out by presenting the patient with familiar and
nonirritating odors. A prior examination of each nasal passage should be done to check if it 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
substances like cloves, coffee, soap, or vanilla. Ask if the patient smells anything and, if so,
what. Test the other side. A person should normally perceive odor on each side, and can often
identify it.
Loss of smell may occur as a result of nasal diseases, head trauma, smoking, aging, local
diseases of the cribriform plate, sub-arachnoid haemmorrhage, neoplastic tumors in olfactory
groove or frontal lobe, tabes dorsalis, meningitis, Refsum’s disease, Paget’s disease,
hypoparathyroidism, Zinc deficiency, abuse of cocaine, hysteria and idiopathic. It may also
be congenital.
Paraosmia (perversion of smell) and cacosmia (Unpleasant odours) are rare phenomena and
may be seen following head injury or some psychiatric illnesses.
EXAMINATION OF CRANIAL NERVE II – OPTIC NERVE:
Examination of the optic nerve can be carried out under the following headings:
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Acuity of vision
Field of vision
Colour vision
Pupillary reflexes
ACUITY OF VISION –
The visual acuity of each should be tested separately for near and distant vision. Formal
testing ideally involves a Snellen’s chart held 6 m from the patient, examining each eye in
turn. Acuity better than 6/60 is dependent on central (macular) vision. Visual acuity for near
vision is tested by Jaeger’s chart where in the test types are of varying sizes.
Acuity can be examined at bed-side with finger counting at a distance of 1 meter.
Visual acuity is most commonly impaired in conditions with compressive and noncompressive lesions of the optic nerve.
VISUAL FIELDS –
The visual field is the whole extent of the field of vision in each eye. It can be tested as
follows:
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Moving finger test.
Sit or stand in front of the patient. The patient covers one eye and fixes his gaze on
your eye. Bring your wiggling finger slowly into view from out of the patient's view.
The finger should be kept more than mid-way between you and the patient. Each of
the upper temporal, lower temporal, upper nasal and lower nasal quadrants of the
visual field are tested separately.
This test sensitively detects mild partial temporal field defects, such as would result
from a pituitary tumour slowly growing into the optic chiasm and affecting the
crossing temporal field fibres.
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Red pin confrontation test.
This test uses a large red hatpin, held equidistant between yourself and the patient,
using exactly the same conditions as above. The patient again covers the eye not to be
tested, while you face them about 1.5m away and cover your own eye. Determine the
field limit by checking whether you and the patient see the pin at the same time.
This test is accurate in detecting paracentral scotomas or paracentral colour
desaturation in optic neuritis, and for comparing the size of the patient's blind spot
with your own.
Visual field defects include Type
Meaning
Conditions of occurrence
Concentric
diminution
Vision restricted all around the
periphery.
Hysteria, Papilledema, retinal lesions
Central
Scotoma
Vision lost in the centre of the
visual field.
Optic neuritis, retrobulbar neuritis,
pressure on optic nerves, choroidal
macular lesion
Hemianopia
Vision is lost in one half of the
visual field.
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Homonymous – Blindness
in one half of both sides of
the eyes.
Quadrantic – Blindness in
quarter of the normal visual
field.
Bi-temporal – Blindness in
temporal halves of both the
fields.
Bi-nasal – Blindness in the
nasal halves of both the
fields.
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Homonymous – Lesions of the
optic tract or radiations on the
opposite side.
Quadrantic – Partial lesions of
the optic radiations, lesions of
the occipital lobes.
Bi-temporal – lesion of nasal
halves of both the optic nerves,
pituitary tumors.
Bi-nasal – Lesions of
uncrossed optic fibres of both
the fields.
COLOR VISION –
This is tested using coloured plates that have patterns of coloured spots, some forming
numbers and others a random background. It can also be tested by using pseudoisochromatic
plates of Ishihara.
Colour vision is mainly confined to the macular field; acquired abnormalities in colour vision
are therefore a sensitive test for optic neuritis and certain retinal diseases. Also, patients with
bilateral lesions of infero-medial occipital region have colour blindness.
EXAMINATION OF PUPILS –
Pupils must be examined and compared for their size, shape and mobility.
LIGHT REFLEX:
On shining a powerful light beam into one or both the eyes, the pupils of both the eyes
immediately contract. It is tested by shielding one eye and a bright beam is thrown into
another eye. The beam must be brought from the side onto the patient. A brisk contraction of
pupil will be observed as a response.
Consensual light reflex demonstrates constriction of the pupils of both the eyes when the light
is thrown on only one eye.
In lesion of optic nerve there will be no constriction of pupils on both the sides. In lesion of
III cranial nerve the reflex is absent only on that side, when light is shown, in either yes
sensory arc is intact in both the eyes.
ACCOMMODATION REFLEX:
It is tested by asking the patient to look at a distance and then fix his eyes either on the tip of
the nose or on the examiners fingers which are brought about 9 inches in the front of the
bridge of the nose.
It is affected or lost in midbrain lesions.
EXAMINATION OF CRANIAL NERVES III, IV AND VI – OCULOMOTOR,
TROCHLEAR AND ABDUCENS
It includes:
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Examination of eye balls
Examination of light reflex
Examination of the reaction to accommodation
MOVEMENTS OF THE EYE BALLS –
Movements of the eye balls are tested in all directions with the help of index finger being
moved in various directions. Hold each deviation for atleast 5 seconds. Examiners finger
must be kept at a distance of 12 inches from the patient’s eyes. Care must be taken that the
patient’s head remains fixed while carrying out the test to ensure movements carried out by
the eye balls only. For this the physician may use his left hand to hold the patient’s head and
fix it.
Observe for the following:
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Ptosis
Lagging of one or either eye
Squint/ Strabismus
Nystagmus
Inability to move the eye balls outwards indicates VI nerve palsy.
Inability to move the eye balls upwards and medially, indicate III nerve palsy.
A slight difference in the width of the palpebral fissures may be noted in about one third of
all normal people.
EXAMINATION OF CRANIAL NERVE V – FACIAL NERVE:
SENSORY EXAMINATION –
Sensation in the face is best tested using a pin. Test for each of the three divisions separately,
checking for symmetry of perceived pinprick intensity of the two sides. The patient’s eyes
should be closed. If there is reduced sensation, delineate its extent by testing from a normal to
an abnormal area. Patients with trigeminal pain, e.g. trigeminal neuralgia, will be reluctant to
allow sensory testing.
If you find an abnormality, confirm it by testing temperature sensation. Two test tubes, filled
with hot and ice-cold water, are used as stimuli. A tuning fork may also be used. It usually
feels cool. Touch the skin and ask the patient to identify “hot” or “cold.”
The corneal reflexes should be tested by touching a wisp of cotton wool on the corneal
surface at its margin with the conjunctiva. This is usually quite unpleasant for the patient.
There should be a brisk bilateral blink response.
Unilateral decrease in or loss of facial sensation suggests a lesion of Trigeminal nerve or of
interconnecting higher sensory pathways.
MOTOR EXAMINATION –
While palpating the temporal and masseter muscles in turn, ask the patient to clench his or
her teeth. Note the strength of muscle contraction.
Weak or absent contraction of the temporal and masseter muscles on one side suggests a
lesion of this nerve. Bilateral weakness may result from peripheral or central involvement.
Test the pterygoid muscles by forceful opening of the jaw against resistance: with unilateral
lateral pterygoid weakness the jaw deviates to the ipsilateral side as it opens. The jaw jerk is a
fifth-nerve stretch reflex. The reflex is increased in corticobulbar tract disease.
EXAMINATION OF CRANIAL NERVE VII – FACIAL NERVE:
Inspect the face, both at rest and during conversation with the patient. Note any asymmetry
(e.g., of the naso-labial folds), and observe for any tics or abnormal movements.
Ask the patient to carry out the following activities and note for any weakness or asymmetry:
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Raise both eyebrows.
Frown.
Close both eyes tightly so that you cannot open them. Test muscular strength by
trying to open them.
Show both upper and lower teeth.
Smile.
Puff out both cheeks.
In unilateral facial paralysis, the mouth droops on the affected side when the patient smiles or
grimaces. Flattening of the naso-labial fold and drooping of the lower eyelid suggest facial
weakness. A peripheral injury to Facial nerve, as in Bell’s palsy, affects both the upper and
the lower face; a central lesion affects mainly the lower face.
ASSESSMENT OF TASTE –
Test the sense of taste using strong solutions of sugar and common salt, and weak solutions
of citric acid and quinine, as tests for 'sweet', 'salty', 'sour' and 'bitter' respectively. Apply
these solutions to the surface of the protruded tongue with a small swab on a spatula. The
patient should be asked to indicate perception of the taste before the tongue is withdrawn in
order to decide whether taste is disturbed anteriorly or posteriorly. After each test the mouth
must be rinsed. The bitter quinine test should be applied last, as its effect is more lasting than
that of the others.
Positive taste symptoms, e.g. taste hallucinations, may constitute the aura of temporal lobe
epilepsy.
EXAMINATION OF CRANIAL NERVE VIII – AUDITORY NERVE:
Assess hearing. If hearing loss is present, test for lateralization, and compare air and bone
conduction.
AIR AND BONE CONDUCTION –
If hearing is diminished, try to distinguish between conductive and sensorineural hearing loss.
You need a quiet room and a tuning fork, preferably of 512 Hz or possibly 1024 Hz. These
frequencies fall within the range of human speech (300 Hz to 3000 Hz). Set the fork into light
vibration by briskly stroking it between thumb and index finger or by tapping it on your
knuckles.
TEST FOR LATERALIZATION (WEBER TEST).
Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head or on the
mid-forehead. Ask where the patient hears it: on one or both sides. Normally the sound is
heard in the midline or equally in both ears. If nothing is heard, try again, pressing the fork
more firmly on the head.
COMPARE AIR CONDUCTION (AC) AND BONE CONDUCTION (BC) (RINNE’S
TEST).
Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level
it with the canal. When the patient can no longer hear the sound, quickly place the fork close
to the ear canal and ascertain whether the sound can be heard again. Here the “U” of the fork
should face forward, thus maximizing its sound for the patient. Normally the sound is heard
longer through air than through bone (AC > BC).
In unilateral conductive hearing loss, sound is lateralized to the impaired ear. It occurs in
conditions like
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Acute otitis media,
Perforation of the eardrum,
Obstruction of the ear canal
Cerumen.
In unilateral sensorineural hearing loss, sound is heard in the good ear. In conductive hearing
loss, sound is heard through bone as long as or longer than it is through air (BC = AC or BC
> AC). In sensorineural hearing loss, sound is heard longer through air (AC > BC).
EXAMINATION OF CRANIAL NERVE IX – GLOSSOPHARYNGEAL NERVE:
The glossopharyngeal nerve is rarely damaged alone. Examine the following:
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Test for Taste sensation on the posterior part of the tongue.
Elicit pharyngeal reflex contraction after tickling the back of the pharynx with a small
cotton-covered stick. A response of posterior pharyngeal wall contraction is normally
observed.
Unilateral absence of this reflex suggests a lesion of CN IX.
EXAMINATION OF CRANIAL NERVE X – VAGUS NERVE:
EXAMINATION OF PALATE:
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Nasal regurgitation. Weakness of the soft palate leads to failure of palatal elevation,
failure of closure of the nasopharynx and nasal regurgitation of fluids during
swallowing.
Palatal dysarthria. The patient cannot pronounce words requiring complete closure of
the nasopharynx, e.g. 'egg' pronounced as 'eng'. In unilateral paralysis these symptoms
are less obvious.
Palatal elevation. Ask the patient to open the mouth and say 'aah'. Use a tongue
depressor to obtain a good view of the soft palate and uvula. Unilateral paralysis
results in elevation only of the normal side and deviation of the uvula towards the
normal side. In a UMN lesion the palate may be tonically elevated more on the
affected side and may move less on phonation.
EXAMINATION OF LARYNX
Check for hoarseness of voice. Unilateral damage to the superior laryngeal branch of the
vagus nerve is usually symptomless, but bilateral involvement causes paralysis of the
cricopharyngeus. This reduces tension on the vocal cords, preventing singing or speaking
higher notes. Recurrent laryngeal nerve palsy causes vocal cord paralysis; there is inability to
phonate normally (a 'breathy voice'), and the cough is loose and 'bovine' because the vocal
cords cannot properly come together to seal off the airway. In bilateral paralysis these
features are much more pronounced; the paralysed cords tend to lie in an adducted position
and there is a risk of stridor and respiratory obstruction. Breathing is noisy and partially
obstructed.
EXAMINATION OF CRANIAL NERVE XI – SPINAL ACCESSORY NERVE:
EXAMINE THE UPPER TRAPEZIUS MUSCLE FIBRES:
Ask the patient to shrug their shoulders while you press downward on them. The shrug may
be weak on the affected side.
EXAMINE THE STERNOMASTOID MUSCLE:
Ask the patient to turn the head while you resist with a hand on the side of the face. Observe
the contraction of the activated sternomastoid muscle on the side opposite to the direction of
movement. In weakness of sternomastoid the patient is unable to turn his head to the opposite
side.
EXAMINATION OF CRANIAL NERVE XII – HYPOGLOSSAL NERVE:
Listen to the articulation of the patient’s words. Inspect the patient’s tongue as it lies on the
floor of the mouth. Look for any atrophy or fasciculations (fine, flickering, irregular
movements in small groups of muscle fibers). Some coarser restless movements are often
seen in a normal tongue. 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. In ambiguous cases, ask the patient to push the
tongue against the inside of each cheek and in turn you can palpate externally for its strength.
Following abnormalities can be diagnosed by observing the tongue movements:
Tongue condition/Movement type
Associated Diseases
Wasting and fasciculation in a relaxed
tongue
Lower motor neuron lesion involving nucleus
and nerve
Small pointed stiff tongue
Upper motor neuron lesion
Bilateral fasciculation
Motor neuron disease, amyotrophic lateral
sclerosis
Unilateral wasting fasciculation
Skull base tumors
Tremors of tongue
Parkinson’s disease
EXAMINATION OF THE MOTOR SYSTEM:
Examination of motor system includes the following:
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Inspection
Palpation
Tone
Power
Reflexes
Coordination
Posture and abnormal movements
Stance and gait
INSPECTION:
Observe the patient’s body position during movement and at rest. Note the size of the
muscles in all four limbs and compare them on both the sides. Note for any wasting or
hypertrophy.
PALPATION:
One can confirm the inspection findings by palpating the muscles and measuring their bulk
by measuring their respective limb circumferences.
Generally, nutrition of the muscle is judged by noting the circumference of extremities at the
level where maximum muscle mass is present. Compare the measurements of both the sides.
Muscular atrophy refers to a loss of muscle bulk (wasting). It occurs in diseases like
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Diabetic neuropathy
Motor neuron diseases
Disuse of the muscles
Rheumatoid arthritis
Protein-calorie malnutrition.
Hypertrophy refers to an increase in bulk with proportionate strength, while increased bulk
with diminished strength is called pseudohypertrophy (as in Duchenne muscular dystrophy).
TONE:
When a normal muscle with an intact nerve supply is relaxed voluntarily, it maintains a slight
residual tension known as muscle tone. This can be assessed by feeling the muscle’s
resistance to a passive stretch. Complete relaxation is important. 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. On each side, note muscle tone, i.e. the
resistance offered to your movements, the degree of movement and the range of movement.
Tone must be tested for upper extremity as well as the lower extremity.
Decreased resistance suggests
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
Disease of the peripheral nervous system
Cerebellar disease
Acute stages of spinal cord injury
Marked floppiness indicates hypotonic or flaccid muscles.
Increased resistance that varies, commonly worse at the extremes of the range, is called
spasticity. Resistance that persists throughout the range and in both directions is called leadpipe rigidity.
POWER:
The strength of individual muscle groups is tested by comparing them with the examiner's
own strength or by comparison with what the examiner judges to be normal.
Grades of
Power
Muscle Movement
Grade 0
Complete paralysis
Grade 1
A flicker of contraction only
Grade 2
Power detectable only when gravity is excluded by appropriate postural
adjustment.
Grade 3
The limb can be held against the force of gravity, but not against the
examiner's resistance.
Grade 4
The limb can be held against gravity and against some resistance, but is not
normal.
Grade 5
The limb can be held against gravity and normal resistance. Normal power.
REFLEXES:
Reflex is an involuntary response to an adequate sensory stimulus. They are classified
into two types as:


Superficial Reflexes
Deep Reflexes
SUPERFICIAL REFLEXES –
These are polysynaptic reflexes elicited in response to cutaneous stimuli. They do not depend
on muscle stretch receptors. The abdominal and plantar reflexes are particularly important.

Corneal and palatal reflexes.
See Cranial nerves, above.

Scapular reflex (C5-T1).
Stroke the skin between the scapulae. The scapular muscles contract.

Superficial abdominal reflexes (T7-12).
The patient lies relaxed and in supine position, with the abdomen uncovered. A thin
wooden stick or the reverse end of the tendon hammer is dragged quickly and lightly
across the abdominal skin in a dermatomal plane from the loin towards the midline. A
ripple of contraction of the underlying abdominal muscles follows the stimulus.
Abdominal reflexes are absent in UMN lesions above their spinal level, as well as in
lesions of the local segmental thoracic root or the spinal cord. Abdominal reflexes are
difficult to elicit in obese or multiparous women. An anxious patient will have brisk
abdominal reflexes as well as brisk tendon reflexes.

Cremasteric reflex (L1/2).
Stroke the skin at the upper inner part of the thigh. In response the testicle moves
upwards on the side of stimulation.
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The plantar reflex (L5, S1).
The muscles of the lower limb should be relaxed. The outer edge of the sole of the
foot is stimulated by firmly scratching a key or a stick along it from the heel towards
the little toe. The normal response is plantar flexion of the toes. The plantar reflex is
important in identifying a UMN lesion.
Abnormal response observed called Babinski’s sign shows dorsiflexion of great toe
and fanning of other toes.
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Conjunctival Reflex.
Touch the conjunctiva with a wisp of cotton wool. In response, blinking of the eyes is
observed.
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Pupillary Reflex.
See Cranial nerve examination.
DEEP REFLEXES –
When the tendon of a partially stretched muscle is struck a single sharp blow with a soft
rubber hammer, thereby, suddenly stretching the muscle, the muscle contracts briefly. This is
called the deep tendon reflex, or the monosynaptic stretch reflex.
To elicit a deep tendon reflex, persuade the patient to relax, position the limbs properly and
symmetrically, and strike the tendon briskly, using a rapid wrist movement.
The briskness of deep tendon reflexes varies according to the individual and can sometimes
only be elicited in normal individuals by applying reinforcement. Ask the patient to make a
strong voluntary muscular effort, e.g. hooking the fingers of the two hands together and then
pulling them against one another as hard as possible, making a fist with one hand, or
clenching the teeth. Compare each reflex side to side.
Grade tendon reflexes as follows:
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0 Absent
1 Present (as a normal ankle jerk)
2 Brisk (as a normal knee jerk)
3 Very brisk
4 Clonus
Various Deep Reflexes:
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Jaw jerk.
Ask the patient to keep the mouth slightly open and keep your keep your finger over
the chin. Strike the finger over the chin with the hammer. A normal response observed
is closure of the jaw.
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Biceps jerk C5, C6.
Flex the patient's elbow to almost a right-angle with the forearm in semi-prone
position. With your index finger on the biceps tendon, strike it firmly with the patellar
hammer. The biceps contracts in response resulting in flexion of the elbow.
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Supinator jerk C5, C6.
A blow on the styloid process of the radius stretches the supinator, causing supination
of the forearm. The patient's elbow should be slightly flexed and slightly pronated, in
order to avoid contraction of brachioradialis. With midcervical lesions (cervical
myelopathy) the supinator or bicep jerks may be absent but brisk flexion of the fingers
may occur instead. This is inversion of the reflex and suggests hyperexcitability of
anterior horn cells below the affected level.
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Triceps jerk C6, C7.
Flex the patient's elbow with the forearm resting across the chest or in their lap. Tap
the triceps tendon just above the olecranon process. The triceps contracts resulting in
extension of the elbow.
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Knee jerk L2, L3, L4.
With the patient supine, pass your hand under the knee to be tested so that it supports
the relaxed leg with the knee flexed at a little less than 90°. Strike the patellar tendon
midway between its origin and its insertion. Look for a contraction of the quadriceps
resulting in extension of the knees.
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Ankle jerk S1, S2.
Slightly dorsiflex the ankle so as to stretch the Achilles tendon and, with your other
hand, strike the tendon on its posterior surface, or on the sole of the foot. A quick
contraction of the calf muscles results in plantar flexion of the foot.
CO-ORDINATION:
It is the co-operation of separate muscles or group of muscles in order to accomplish a
definite act.
TESTING COORDINATION IN THE UPPER LIMBS –
Finger-nose test:
Ask the patient to touch the point of the nose and then the tip of your finger, held at arm's
length in front of the patient's face, using their index finger. Ask the patient to repeat the test
with the eyes closed; any additional irregularity suggests impairment of position sense in the
limb.
Dysdiadochokinesis:
Ask the patient to tap your palm with the tips of the fingers of one hand, alternately in
pronation and supination, as fast as possible. Minor degrees of inco-ordination can be both
felt and heard. All normal people can do this very rapidly, but usually slightly less rapidly
with the non-dominant than with the dominant hand. Dysdiadochokinetic movements are
slowed, irregular, incomplete, and may be impossible. Parkinsonism may also impair rapid
movements, with slowing, reduced amplitude and prominent fatigue, but without irregularity.
TESTING CO-ORDINATION IN LOWER LIMBS –
Tandem Walk:
Ask the patient to walk along a straight line.
Heel-shin test:
While the patient is lying supine on the couch, ask them to lift one leg and then to bend the
knee, place the heel on the opposite knee and slide this heel down the shin towards the ankle
under visual guidance. In cerebellar ataxia, a characteristic, irregular, side-to-side series of
errors in the speed and direction of movement occurs. Also, watch the patient draw a large
circle in the air with the toe. The circle should be drawn smoothly and accurately, but in
ataxia it is 'squared off' irregularly.
Romberg’s Test:
Ask the patient to stand with his feet close together with his eyes open and then with his eyes
closed. If the patient sways or falls the Romberg’s test is positive and co-ordination is absent.
POSTURE AND ABNORMAL MOVEMENTS:
Postural control of the upper limbs is assessed by asking the patient to hold the arms
outstretched with the eyes closed. Posture of the trunk and lower limbs is assessed separately
with gait.
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Pyramidal drift describes a tendency for the hand to move upward and supinate if the
hands are held outstretched in a pronated position (palms downward), or to pronate
downward if the hands are held in supination.
Cerebellar drift is generally upward, with excessive rebound movements if the hand is
suddenly displaced downward by the examiner.
Parietal drift is an outward movement on displacing the ulnar border of the supinated
hand.
Observation must be done to identify any abnormal movements. They involve involuntary
muscle contractions of various types.
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Rest tremor occurs in Parkinson's disease and is typically a 'pill-rolling' tremor of one
or both hands, where the thumb is moved repetitively back and forth across the tips of
the fingers.
Postural tremor or essential tremor is a relatively symmetrical tremor and involves the
upper limbs more than the legs. It may also affect the head and tongue. A typical
parkinsonian tremor may also be worse during posture. Postural tremor also typifies
adrenergic tremors, e.g. physiological or anxiety tremor and thyrotoxicosis. Tremor
may also occur in sensory ataxic neuropathy.
Action tremor, a terminal tremor in which the finger overshoots and oscillates when
approaching a visual target, is indicative of cerebellar ataxia or sensory ataxia.
Hysterical tremor tends to involve a limb or the whole body, to occur at rest and be
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fast and violent. During distraction by the examiner it disappears.
Rubral tremor is unilateral or bilateral and occurs in rest, posture and action,
sometimes building up over a few seconds of posture. It reflects brainstem disease,
including paraneoplastic limbic encephalitis.
Pseudoathetosis describes fidgety movements of the fingers when in posture with the
eyes closed and is due to a proprioceptive deficit, including a large fibre sensory
neuropathy or a lesion of the nucleus cuneatus at the synaptic termination of the
dorsal columns, e.g. from foramen magnum stenosis. Similar small finger movements
can be the result of fasciculatory contractions of pathologically large motor units in
motor neuron disease.
Myoclonus is involuntary jerky movement of a body part or parts, or sometimes of the
whole body. When rhythmic, it may appear as a rest or action tremor. Its origin can be
cortical, e.g. focal epilepsy or, if ongoing, epilepsia partialis continua. Myoclonus of
body segments is usually spinal in origin, whereas that of the whole body usually
originates in the brainstem and can occur normally on falling asleep, or pathologically
as an exaggerated startle or shivering response or as part of a generalized epileptiform
disorder. When a muscle is voluntarily tonically activated, brief myoclonic relaxation
may interrupt the activation. This is called negative myoclonus. An example is
asterixis of liver disease, in which maintained wrist extension is irregularly
interrupted, producing a 'flapping' motion. Rarely, negative myoclonus in the
quadriceps muscles while standing may result in collapse.
Chorea is a translation of the word 'dance', which accurately portrays its fidgety, fluid,
random and semipurposeful quality. The involuntary movements tend to embellish
voluntary movements, such as walking, or picking up a cup and saucer. Voluntary
actions are performed surprisingly well despite the constant interruption. Its causes
include Huntington's disease, Sydenham's chorea, lupus and pregnancy, and it may
also occur idiopathically in the elderly. Finally, chorea and other involuntary
movements may arise as side effects of dopaminergic or antidopaminergic drugs; in
this context the involuntary movement is termed dyskinesia.
Ballism is a violent movement of the proximal limb and trunk. Hemiballismus
(unilateral ballism) is almost always due to a stroke affecting the contralateral
subthalamic nucleus in the midbrain.
Athetosis is a complex, writhing involuntary movement, usually more pronounced in
distal than in proximal muscles and of lower amplitude than chorea.
Dystonia describes any abnormal posturing of the body. Its origin may be
symptomatic of underlying disease, such as cerebral palsy, pyramidal lesions or
generalized inherited or metabolic extrapyramidal diseases. Often, however, dystonia
is idiopathic, probably inherited, generalized, limited to particular body segments (e.g.
torticollis), or focal and perhaps task specific (e.g. writers' cramp or musician's
dystonia).
Tics are simple, normal movements that become repeated unnecessarily to the point
where they become an embarrassment. They often occur in the context of psychiatric
disorders. In contrast to other involuntary movement disorders they can be readily
imitated and voluntarily suppressed, albeit briefly. Head nodding and facial twitching
are common examples. In Tourette's syndrome tics manifest as embarrassing
scatological vocalizations.
Tetany is due to hypocalcaemia or alkalosis. There is a characteristic cramped posture
of the affected hand so that fingers and thumb are held stiffly adducted and the hand
partially flexed at the metacarpophalangeal joints; the toes may be similarly affected
(carpopedal spasm). Ischaemia of the affected limb, produced by a
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sphygmomanometer cuff inflated above the arterial pressure for 2 or 3 minutes, will
augment this sign or produce it if it is not already present (Trousseau's sign). Another
useful test is to tap lightly with a patellar hammer at the exit of the facial nerve from
the skull, about 3-5cm below and in front of the ear. The facial muscles twitch briefly
with each tap (Chvostek's sign).
Cramp is a spontaneous contraction of part or the whole of a muscle. It is common in
healthy people, especially in the calf, and may occur with neurogenic muscle
weakness. Other causes of cramp include motor neuron disease or metabolic
disorders, e.g. hyponatraemia and hypomagnesaemia. Poor relaxation of muscle,
myotonia, is a feature of primary muscle disease due to abnormal ion transport across
the muscle cell membrane, often as the result of a genetic channelopathy such as
congenital myotonia, paramyotonia or myotonic dystrophy. Myotonia in some types
of hereditary muscle channelopathy is worsened in the cold or induced by active
contraction, such as hand gripping; the patient is unable to let go again immediately.
Similar difficulty in opening the eyes occurs after forceful closure. Percussion
myotonia is an enhanced myotatic response elicited by tapping the thenar eminence or
the surface of the tongue. Neuromyotonia is a continuous muscular activity caused by
dysfunction in nerve fibres; as part of a generalized acquired neuropathy it is called
Isaac's syndrome.
STANCE AND GAIT:
STANCE:
The following two tests can often be performed concurrently. They differ only in the patient’s
arm position and in what you are looking for. In each case, stand close enough to the patient
to prevent a fall.
The Romberg test:
Refer Co-ordination in lower limbs.
Test for pronator drift:
The patient should stand for 20 to 30 seconds with both arms straight forward, palms up, and
with eyes closed. A person who cannot stand may be tested for a pronator drift in the sitting
position. In either case, a normal person can hold this arm position well. Now, instructing the
patient to keep the arms up and eyes shut, tap the arms briskly downward. The arms normally
return smoothly to the horizontal position. This response requires muscular strength,
coordination, and a good sense of position.
The pronation of one forearm suggests a contralateral lesion in the corticospinal tract;
downward drift of the arm along with flexion of fingers and elbow may also occur. These
movements are called a pronator drift.
GAIT:
Ask the patient to do various lower limb movements like walking, tandem walk, walk on the
toes, hop, etc.
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A gait that lacks coordination, with reeling and instability, is called ataxic. Ataxia
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may be due to cerebellar disease, loss of position sense, or intoxication.
Tandem walking may reveal an ataxia not previously obvious.
Walking on toes and heels may reveal distal muscular weakness in the legs. Inability
to heel-walk is a sensitive test for corticospinal tract weakness.
Difficulty with hopping may be due to weakness, lack of position sense, or cerebellar
dysfunction.
EXAMINATION OF THE SENSORY SYSTEM:
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In carrying out sensory testing, the examiner must be aware of the entire dermatomal and
peripheral nerve distribution of sensations in the body. This knowledge is necessary to
appreciate that a certain distribution of abnormal sensation results from a lesion of a
particular peripheral nerve, nerve root or at the spinal segmental level.
To evaluate the sensory system, following sensation types need to be tested:
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Pain and temperature
Position and vibration
Light touch
Discriminative sensations
While carrying out the examination, Compare symmetric areas on the two sides of the body,
including the arms, legs, and trunk. Before each test, show the patient what you plan to do
and how would you do it. The patient’s eyes should be closed during actual testing, unless
specified.
PAIN:
Use a sharp pin or other suitable tool. Occasionally, substitute the blunt end for the pointed
one. Ask the patient to identify if it is sharp or blunt. When comparing ask the patient if he
feels the same sensation on both the sides. Apply the lightest pressure needed for the stimulus
to feel sharp.
Specific terms are used to describe various positive and negative pain symptoms and signs:
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Analgesia - the absence of sensibility to pain
Hypoalgesia - reduced pain sensibility
Hyperalgesia - an increased pain sensibility to mildly painful stimuli
Allodynia - pain perception from a normally non-painful stimulus
Hyperpathia - pain perception that spreads out from the point of the stimulus or
outlasts the stimulus in time
Paraesthesiae - tingling sensations sometimes so intense as to be painful, occurring
spontaneously or in response to light cutaneous stimuli.
TEMPERATURE:
Use two test tubes, filled with hot and cold water, or a tuning fork heated or cooled by water.
Touch the skin and ask the patient to identify if he feels hot or cold.
LIGHT TOUCH:
With a fine wisp of cotton, touch the skin lightly, avoiding pressure. Ask the patient to
respond whenever a touch is felt, and compare sensation felt in one area with the another.
VIBRATION:
Use a relatively low-pitched tuning fork of 128 Hz. Tap it on the heel of your hand and place
it firmly over a distal interphalangeal joint of the patient’s finger and then over the
interphalangeal joint of the big toe. Ask what the patient feels. If you are uncertain whether it
is pressure or vibration, ask the patient to tell you when the vibration stops, and then touch
the fork to stop it. If vibration sense is impaired, proceed to more proximal bony prominences
like wrist, elbow, anterior superior iliac spine, clavicle, etc.
POSITION:
Grasp the patient’s big toe, holding it by its sides between your thumb and index finger, and
then pull it away from the other toes so as to avoid friction. Demonstrate “up” and “down” as
you move the patient’s toe clearly upward and downward. Then, with the patient’s eyes
closed, ask for a response of “up” or “down” when moving the toe in a small arc. Repeat
several times on each side, avoiding simple alternation of the stimuli. If position sense is
impaired, move proximally to test it at the ankle joint. In a similar fashion, test position in the
fingers.
Loss of position sense, like loss of vibration sense, suggests either posterior column disease
or a lesion of the peripheral nerve or root.
DISCRIMINATIVE SENSATIONS:
As discriminative sensations are dependent on touch and position sense, they are useful only
when these sensations are either intact or only slightly impaired. The patient’s eyes should be
closed during all these tests.
STEREOGNOSIS –
Stereognosis refers to the ability to identify an object by feeling it. Place a familiar object
such as a coin, paper clip, key, pencil, or cotton ball in the patient’s hand and ask the patient
to identify it. Normally a patient will identify it correctly. Asking the patient to distinguish
“heads” from “tails” on a coin is a sensitive test of stereognosis.
Astereognosis refers to the inability to recognize objects placed in the hand.
TWO-POINT DISCRIMINATION –
Using the two ends of an opened paper clip, or the sides of two pins, touch a finger pad in
two places simultaneously. Alternate the double stimulus irregularly with a one-point touch.
Be careful not to cause pain. Find the minimal distance at which the patient can discriminate
one from two points (normally less than 5 mm on the finger pads).
Lesions of the sensory cortex increase the distance between two recognizable points.
POINT LOCALIZATION –
Briefly touch a point on the patient’s skin. Then ask the patient to open both eyes and point to
the place touched. Normally a person can do so accurately.
Lesions of the sensory cortex impair the ability to localize points accurately.
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DR.AR WADGAONKAR,PSPMMHMC,SOLAPUR