pe_neuroexam

\u2022 Open paper clip Æ ends ~ 5mm apart 
\u2022 Patient closes eyes
\u2022 Alternately touch w/1 point or 2 \u2013 normal nerve 
function enables them to make distinction
Special Sensory Testing 
(cont)
MONOFILAMENT 
TESTING
\u2022 Screening test for 
diabetic neuropathy
\u2022 Touch monofilament to 5-
7 areas on bottom of 
foot. 
\u2022 Normal =s Patient can 
detect filament when tip 
lightly applied to skin (i.e. 
before it bends).
\u2026Trying To Prevent This!
Sensory Testing\u2026
Reflex Testing
Anatomy and Physiology
\u2022 Reflex arc made has afferent (sensory) & efferent 
(motor) limb 
\u2022 Synapse in spinal cord, @ which point also input from 
upper motor neuron 
\u2022 Disruption of any part of path alters reflexes: e.g. 
\u2013 UMN lesion Æ reflexes more brisk (hyper-reflexia) 
\u2013 LMN or peripheral sensory lesionsÆopposite effect (hypo-
reflexia)
\u2022 Reflexes graded 0-4+ scale: 0 = no reflex, 1+ = 
hyporeflexia, 2+ = normal, 3+ = hyper-reflexia, 4+ = 
clonus (multiple movements after a single stimulus)
Reflex Basics
\u2022 Reflexes generally assessed in 5 places - 3 in 
the arm (biceps, triceps, brachioradialis); 2 in the 
leg (patellar & achilles)
\u2022 Basic Technique for assessing a reflex:
\u2013 Clearly identify tendon of muscle to be tested
\u2013 Position limb so muscle @ rest
\u2013 Strike tendon briskly
\u2013 Observe for muscle contraction & limb 
movement
Reflex Basics (cont)
\u2022 Array of hammers \u2013 all effective
\u2022 Reflex Trouble Shooting:
\u2013 Make sure patient relaxed & that 
you\u2019re striking tendon directly
\u2013 Hammer swings freely
\u2013 Reinforcement (distraction) helps 
if you\u2019re having problems 
\u2022 When testing legs, ask patient to pull 
their hands apart as you strike 
tendon
\u2022 When testing the upper extremities, 
ask them to clench teeth
Patellar Hyper-Reflexia
Biceps (C 5, 6)
\u2022 Identify biceps 
tendonÆhave patient flex 
elbow against resistance 
while you palpate 
antecubital fossa
\u2022 Place arm so it\u2019s bent ~ 
90 degrees
\u2022 Place one of your fingers 
on tendon and strike it 
birskly
\u2022 Muslce should contract & 
forearm flex
Triceps (C 7, 8)
\u2022 Identify triceps 
tendonÆhave patient 
extend elbow against 
resistance while you 
palpate above it
\u2022 Arm can hang down @ 
ninety degrees or have 
hands on hips
\u2022 Strike tendon directly or 
place finger on the 
tendon & strike it
\u2022 Triceps muscle contracts 
& arm extends.
Brachioradialis (C5, 6)
\u2022 Tendon for 
brachioradialis is ~ 10 cm 
proximal to wrist \u2013 you 
cant see or feel it
\u2022 Place arm so resting on 
patient\u2019s thigh, bent @ 
elbow
\u2022 Strike firmly 
\u2022 Muscle will contract & 
arm will flex @ elbow & 
supinate
Patellar (L3, 4)
\u2022 Patellar tendon 
extends below knee 
cap \u2013 it\u2019s thick & 
usually visible & 
palpable \u2013 if not, 
palpate while patient 
extends lower leg
\u2022 Strike firmly on 
tendon
\u2022 Muscle will contract & 
leg extend @ knee
Achilles (S1, S2)
\u2022 Achilles tendonÆthick 
structure connecting 
calf musclesÆheel \u2013 if 
having trouble finding, 
palpate as patient 
pushes their foot into 
your other hand
\u2022 Hold foot @ 90 degrees
\u2022 Strike tendon firmly
\u2022 Muscle will contract & 
foot plantar-flex (move 
downward)
Babinski
\u2022 Firmly stroke bottom of 
foot, starting laterally & 
near heel \u2013 moving up & 
across balls of feet 
(metatarsal heads)
\u2022 Normal =s great toe 
moving downward
\u2022 If UMN lesion (or in 
newborns), great toe will 
extend & other toes fan 
out
Babinski Response \u2013 UMN lesion
Example 
Babinski Reflex
Gait and Romberg Testing
\u2022 Romberg: Test of balanceÆ input from multiple 
systems: proprioception, vestibular, cerebellum
\u2013 Ask patient to stand still w/eyes closed
\u2013 If @ risk for falling, be in position to catch \u2018em (i.e. behind 
them) & get help
\u2022 Gait \u2013 pay attention to:
\u2013 initiation of activity
\u2013 arm, leg movement & position
\u2013 speed & balance
Gait S/P Stroke
Summary of Skills 
\u25a1Wash Hands
\u25a1 Cranial Nerves (review from eye, head & neck)
Motor testing: 
\u25a1 muscle bulk
\u25a1 tone
\u25a1 strength of major groups
Sensory testing - in distal lower & upper extremities: 
\u25a1 pain
\u25a1 light touch
\u25a1 proprioception
\u25a1 vibration
Reflexes
\u25a1 achilles
\u25a1 patellar
\u25a1 brachioradialis
\u25a1 biceps
\u25a1 triceps
\u25a1 Cerebellar function (fingerÆnose, heelÆshin, etc.)
\u25a1 Gait, Romberg
Time Target: < 15 minutes
Hang In There!
	Neuro Exam
	Elements of The Neuro Exam
	Motor/Strength\ufffdAnatomy and Physiology
	Muscles \u2013 Observation/Bulk \ufffdand Palpation
	Muscle Tone; Observe For Tremor
	Anatomic Position\ufffdFlexion/Extension & Abduction/Adduction
	Extension/Flexion, Abduction/Adduction @ Major Joints
	Strength \u2013 Scoring System
	Specific Muscle Group \ufffdTesting
	Muscle Group Testing (cont)
	Cerebellar Testing:\ufffdCoordination & Fine Motor Movement
	Cerebellar Testing (cont)
	Sensory Testing\ufffdAnatomy & Physiology
	Nerves and Their Distributions
	Spinothalamics \u2013 Pain, Temperature & Crude Touch
	Spinothalamics \u2013 Pain, Temperature and Crude Touch (cont)
	Spinothalamics \u2013 Pain, Temperature & Crude Touch (cont)
	Dorsal Columns - Proprioception
	Dorsal Columns \u2013 Proprioception (cont)
	Dorsal Columns \u2013 Vibratory Sensation
	Dorsal Columns \u2013 Vibratory Sensation (cont)
	Special Sensory Testing
	Special Sensory Testing (cont)
	Reflex Testing\ufffdAnatomy and Physiology
	Reflex Basics
	Reflex Basics (cont)
	Biceps (C 5, 6)\ufffd
	Triceps (C 7, 8)\ufffd
	 Brachioradialis (C5, 6)
	Patellar (L3, 4)\ufffd
	Achilles (S1, S2) \ufffd
	Babinski\ufffd
	Gait and Romberg Testing
	Summary of Skills 
	Hang In There!