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E&M Neurological Exam Lecture
E&M DPT2012 UMDNJ
79
Medical
Graduate
10/08/2009

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Term
Nonequilibrium tests
Definition
-Do NOT require balance
-Preform with eyes open then eyes closed
Ex: finger to nose, finger to finger, mass grasp, rebound test, etc
Term
Static equilibrium tests
Definition
-patient holds a position where a slight change of COG occurs

Ex: Standing (EO/EC), standing with feet together, tandem stance, unilateral standing, alter arm position in standing, etc
Term
Dynamic equilibrium tests
Definition
-testing in motion

Ex: marching in place,walking tandem, walking a line, waltering walking speed, walk in a circle, walk and pivot, stair climbing, agility activities, etc
Term
Recording for testing
Definition
-number of extremities involved
-distrobution(proimal/distal)
-situation that alter coordination/balance
-amount of time to perform
-level of safety
-history of falls
Term
A pt comes in and you conclude that the pt has hypertonia. You find though testing that their hypertonia increases at increased speeds. What type of Hypertonia to they show signs of?
Definition
Spasticity
Term
A pt comes to you with hypotonia and you check thier UE reflexes. What do you expect to find?
Definition
There will be a decrease in DTRs (0, 1+ range on your tonal examination)
Term
A pt comes to you and they go to shake you hand and miss. You begin by performing nonequilibrium tests. The pt has trouble putting thier finger to their nose. What would you call this characteristic?
Definition
Dysmetria
Term
A patient comes to you with a CNS disorder. During your examination, you decide to do that Babinski reflex test. If the test was abnormal what would you expect to find?
Definition
Abnormal: Extension of great toe, abduction of toes or fanning of the lateral four toes

(Normal: Flexion and aadduction of toes)
Term
Muscle tone
Definition
The resistance to of a muscle to passive stretch

May be due to
-physical inertia
-intrinsic mechanical-elastic stiffness of muscle and connective tissue
-reflex muscle contraction
Term
Hypertonia
Definition
Increased muscle tone
Term
Spasticity
Definition
Hypertonia.
Increased muscle tone at increased speeds
Term
Clasp-knife reflex
Definition
Hypertonia.
Initial increased resistance then no resistance
Term
Clonus
Definition
Hypertonia.
Involuntary muscle contractions and relaxations
Term
Rigidity
Definition
Similar amount of hypertonia at all speeds
-cogwheel
-leadpipe
-decerebrate (ext. of all extremities) [brain stem]
-Decorticate (UE flexed, LE extrended) [separated cortex from rest of system]
Term
Hypotonia
Definition
Decreased muscle tone
-decreased DTRs
-may appear weak

Flaccidity
Term
Dystonia
Definition
Sustained muscle contractions that result in twisted movements and abnormal posture
-segmental/focal
- hemidystonia
-generalized

Subclassified
-Action induced
-Posture induced
Term
Torticalis
Definition
SCM contracts resulting ins lateral flex. And rotation to the opposite side
Term
Barry Albright dystonic scale
Definition
How much time (hours in a day)
Measures 6 body parts –eyes, mouth, neck, trunk, UE and LE
0-NORMAL
1-Slight (<10 %)
2-Mild (<50%)
3-Moderate (>50 % and/or INTERFERES with normal positioning/functioning)
4-Severe (>50% and/or PREVENTS with normal positioning/functioning)
Term
General Tonal Grading
Definition
0-No response, flaccid
1-Decreased response, hypotonia
2-NORMAL
3-Exaggerated response, mild to moderate hypertonia
4-Sustained response, severe hypertonia
Term
Ashworth scale
Definition
For Spasticity
Test muscle at different speeds
Term
Ashworth scaling
Definition
0 - No increase in tone, NORMAL
1 - Slight increase, catch and release
1+ - slight increase, initial catch followed by minimal resistance through partial range
2 – increased tone throughout most ROM
3 - increased tone, PROM difficult
4 - Rigid in ext. or flex.
Term
Scale for spasticity
Definition
Tardieu scale – more objective, tested at three speeds (slow, speed of gravity, fast) and based on 2 factors – quality and angle of catch
Term
Tonal examination
Definition
Pendulum test
-assess spasticity
Drop Arm Test
-Used to test integrity of automatic proprioceptive reactions as limb falls
Term
Factors that influence tone (7)
Definition
-Position and interaction with tonic reflexes
-Stress and anxiety
-Volitional effort and movement
-Medications
-State of CNS arousal
-Environmental Temperature
-General health
-fever, infection, metabolic/electrolyte imbalance
Term
STNR (symmetrical)
Definition
Normal: no reaction to neck extension/flexion
Abnormal: neck extends(arms extend and legs flex) or neck flexion(arms flex and legs extend)
Term
Righting Reactions
Definition
Serve to maintain body alignment and/or orientation to the environment
Term
Protective Reaction
Definition
When center of mass moves too far beyond base of support
Term
Equilibrium reaction
Definition
Attempt to maintain center of mass over base of support
-lifting versus postural fixation
Term
Balance
Definition
Defined as the stability produced on each side of a vertical axis: COM over BOS
-acheived using multiple CNS inputs/outputs
--Assessed using standardized tools or observation of functional activities
Term
Coordination
Definition
Definition: Ability to execute smooth, accurate, controlled movements
-deficits are often related to CNS disorders
Term
Ataxia
Definition
Inability to make smooth, accurate coordinated movements
Term
Dysmetria
Definition
Disturbance in distance or range of movement
Term
Athelosis
Definition
Involuntary, slow, twisting, writhing, continuous movements especially seen in distal parts of extremities and perioral area
Term
Chorea
Definition
Involuntary, abrupt, rapid, bried, unsustained, arhymical random movements
Term
Tremor
Definition
rythmical oscillating movements
2-4Hz (cerebral disease)
4-5Hz (Parkinson's)
6-12Hz (postural when body is held against gravity)
Term
Tics
Definition
(Simple or Complex)
repetitive, stereotyped, involuntary movements that occur randomly
Term
Bradyskinesia
Definition
Slowness of movement
Term
Dysdiadokinesis
Definition
Inability to perform rapidly alternating movements
Term
Nonequilibrium Tests
Definition
-Finger to nose
-Finger to finger
-Rebound test
-Heel to shin
-Alternate heel to knee, heel to toe
-Drawing circle
Term
Coordination Examinations
(5 main areas of assessment)
Definition
-Alternate or reciprocal movement
-Movement synergy/composition
-Movement accuracy
-Fixation or limb hooking
-Equilibrium and posture holding
Term
Superficial cutaneous reflexes
Definition
examples: plantar (Babinski's), Chaddock's (Babinski's with LE flexion), and abdominal
Term
Primitive reflexes
Definition
flexor withdrawal and crossed extension
Term
Abdominal Reflexes
Definition
-Begin at T7 and test each dermatome down to T12
-Normal response is contraction of abdominals with umbilical deviation toward the stimulus
Term
Plantar or Babinski reflex
Definition
-pressure is firm but not painful
-Normal response: flexion and adduction of toes, can be accompanied by hip and knee flexion
Term
Babinski sign
Definition
abnormal resonse to Babinski reflex test. Extension of great toe along with abduction or fanning of lateral four toes.
Term
Developmental reflexes
Definition
-Tonic Labyrinthine
-symmetrical or asymmetrical Tonic neck
Term
Tonic labyrinthine (prone)
Definition
-Normal repsonse (negative): no increase in flexor tone
-abnormal response (positive): unable to extend head, trunk, arms or legs or retract shoulders
Term
Tonic labyrinthine (supine)
Definition
-Normal response (negative): no increase in extensor tone
-Abnormal response (positive): unable to flex head, trunk, arms, or legs
Term
ATNR (symmetrical)
Definition
-Normal response: no reaction to head rotation
-abnormal response: extension on face side or increase in extensor tone, flexion on skull side or increase in flexor tone
Term
STNR (symmetrical)
Definition
-Normal response: no reaction to neck extension/flexion
-Abnormal response: -neck extends and arms extend or increase in extensor tone and legs flex or increase in flexor tone - or neck flexes and arms flex or increase flexor tone and legs extend or increase extension tone
Term
STNR (symmetrical)
Definition
-Normal response: no reaction to neck extension/flexion
-Abnormal response: -neck extends and arms extend or increase in extensor tone and legs flex or increase in flexor tone - or neck flexes and arms flex or increase flexor tone and legs extend or increase extension tone
Term
Neurological Exam

Components-1 to 7
Definition
There were 15 components of a neuro exam given in lecture.

The first 7 are:

Neurological history
􀂄 Cognition
􀂄 Communication
􀂄 Mental status
􀂄 Sensation
􀂄 Perception
􀂄 Muscle tone
Term
Neurological Exam

Components-8 to 15
Definition
There were 15 components of a neuro exam given in lecture.

The last 8 are:

􀂄 Strength
􀂄 Reflexes
􀂄 Cranial nerves
􀂄 Movement patterns
􀂄 Balance
􀂄 Coordination
􀂄 Gait
􀂄 Functional abilities
Term
Neurological Exam

Components-History
Definition
􀂄 Disturbance of consciousness
􀂄 Seizures
􀂄 Headaches
􀂄 Altered vision
􀂄 Tinnitus
􀂄 Vertigo, dizziness
􀂄 Nausea, vomiting
􀂄 Weakness, stiffness
􀂄 Paresthesias
􀂄 Disturbances in bowel & bladder
control
􀂄 Speech disorders
􀂄 Incoordination
Term
Neurological Exam

Components-Cognition
Definition
Exam for Cognition includes

– memory
judgement
attention span
Term
Neurological Exam

Components-Communication
Definition
Exam for Communication includes

articulation deficits
receptive/expressive language disorders
(ex Aphasia/Dsyphasia)
Term
Neurological Exam

Components-Mental Status
Definition
Exam of mental status includes

Orientation (to familiar or current environment)
– Attention and state of consciousness
Term
Neurological Exam

Components-Examination of Mental Status
Definition
Two common instruments are:

MiniMental State Exam (MMSE)
• <24 cognitive impairment
• <20 dementia/affective disorder
• sensitivity .91
specificity .92

– Mini-Cog (repeat 3 items, clock drawing, recall 3 items)
sensitivity .99/specificity .93
Term
Neurological Exam

Components-Sensation
Definition
Protective Sensation
– pain
– temperature
light touch
crudely localized touch

Discrimatory
– vibration
– proprioception
-stereognosis
– barognosis
– graphesthesia
– texture
– 2 point discrimination
Term
Neurological Exam

Components-Perception
Definition
– body scheme/image
– spatial relations
– agnosias-The inability to recognize and identify objects or persons previously known.
– apraxias-loss of the ability to execute learned purposeful movements, despite having desire and the physical ability to do so.
• ideomotor-inability to carry out a motor command
• ideational-inability to create a plan for or idea of a specific movement
ex. 'pick up this pen and write your name'
Term
Neurological Exam

Components-Tone
Definition
Examination for Tone includes:
Observation
– At rest and during movement
􀂄 Palpation (consistency)
􀂄 Passive movement
– Changing speed and performing reversals
􀂄 Deep tendon reflexes (DTRs)
Term
Neurological Exam

Components-Tone-DTRs
Definition
Deep Tendon Reflexes (DTRs) reaveal information about the nerves that control the muscle and tendon tested.

– jaw (trigeminal nerve)
– biceps (C 5)
– brachioradialis(C 6)
– triceps (C 7-8)
– patellar (L 2-4)
– ankle (S 1-2)
Term
Neurological Exam

Components-Tone-DTRs-Tendon/Nerve relationships
Definition
– jaw (trigeminal nerve)
– biceps (C 5)
– brachioradialis(C 6)
– triceps (C 7-8)
– patellar (L 2-4)
– ankle (S 1-2)
Term
Neurological Exam

DTRs-Tendon/Nerve relationships

JAW
Definition
Trigeminal Nerve (CN V)
Term
Neurological Exam

DTRs-Tendon/Nerve relationships

Biceps
Definition
C5 (Root of musculocutaneous nerve)
Term
Neurological Exam

DTRs-Tendon/Nerve relationships

Brachioradialis
Definition
C6 (Radial Nerve)
Term
DTRs-Tendon/Nerve relationships

Triceps
Definition
C7-8 (Radial Nerve)
Term
DTRs-Tendon/Nerve relationships

Patella
Definition
L2-L4
Term
DTRs-Tendon/Nerve relationships

Ankle
Definition
S1-2 (Tibial Nerve)
Term
Neurological Exam

Components-Tone-DTRs-Scoring
Definition
• 0 = no response
• 1+ = decreased response
• 2+ = normal response (slight muscle
contraction with slight movement)
• 3+ = exaggerated response (brisk muscle contraction with moderate joint movement
• 4+ = clonus (1-3 beats)
• 5+ = sustained clonus
Term
Neurological Exam

Components-Tone-DTRs-Clonus definition
Definition
a rhythmic series of alternating contractions and partial relaxations of a muscle that in some nervous diseases occurs in the form of convulsive spasms. Results from alteration of the normal pattern of motor neuron discharge
Term
Neurological Exam Components-Tone-DTRs-Charting
Definition

Charting of DTRs is done graphically:

[image]

Term
Neurological Exam

Components-Muscle Tone
Definition
Muscle tone can be indicated by
􀂄 Appearance
– atrophy
– pseudohypertrophy
– fasciculations
􀂄 Flexor or extensor spasms
Term
Neurological Exam

Components-Muscle Tone-Definition
Definition
Definition: the resistance of muscle to passive stretch
Term
Neurological Exam

Components-Muscle Tone-Causes
Definition
may be due to
– physical inertia
– intrinsic mechanical-elastic stiffness of muscle and connective tissue
– reflex muscle contraction
Term
Neurological Exam

Components-Muscle Tone-Categories
Definition
– hypertonia
– hypotonia
– dystonia
Term
you are treating a child who when laying supine and turns his head to the right to look at you, the right side of his body goes into extension, and his left into flexion. what implications would this have on your treatment for him?
Definition
the child is exhbiting ATNR (asymetric tonic neck reflex) and this would hinder you teaching him how to roll.
Term
you are conducting a neuro exam with a pt and they report that a few weeks ago there were a few times that they just couldn't speak when then wanted to, but it passed so they aren't worried about it. upon further exam you find that they also have weakness, what might this pat be exhibiting early sxs of?
Definition
TIA's of "brain attacks" weakness, and periods of being unable to talk that pass are the first two signs
Term
you are seeing a pt in your clinic and you have very limited time but you want to administer a congition test, which one would you choose?
Definition
mini-cog, it is quicker than the mini-mental
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