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pe_neuroexam

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Neuro Exam

Charlie Goldberg, M.D.
Professor of Medicine, UCSD SOM

Charles.goldberg@va.gov

Elements of The Neuro Exam

\u2022 Cranial Nerves
\u2022 Motor \u2013 bulk, tone, strength
\u2022 Cerebellum \u2013 fine movements, balance
\u2022 Sensation \u2013 pain, touch, position sense,

vibration
\u2022 Reflexes
\u2022 Gait

Motor/Strength
Anatomy and Physiology

\u2022 Impulse starts brain
\u2022 Axon (upper motor neuron) crosses opposite

side @ brain stem
\u2022 Travels down spinal cord Æspecific level

Corticospinal (Pyramidal) Tracts
\u2022 Synapses w/2nd neuron (lower motor neuron)

\u2022 Leaves cord & travel to target muscle
\u2022 Muscle moves

Anatomy of Motor Pathways - Wash U, St Louis

Muscles \u2013 Observation/Bulk
and Palpation

\u2022 Bulk (amount of
muscle mass) \u2013
accounting for size
patient, activity level,
age \u2013 if decreased, ?
symmetric

\u2022 Palpation major
muscle groupsÆ
insight to bulk, also ?
any Inflammation,
pain

L calf hypertrophy and
R calf atrophy

L hand muscle wasting
from de-nervation

Muscle Tone; Observe For
Tremor

\u2022 Tone \u2013 move major joints
(wrists, elbows, shoulders, hips,
knees, feet) Æ range of motion

\u2013 normal Æ fluid
\u2013 increased w/UMN lesion;

decreased (flacid) w/LMN lesion
\u2022 Obvious tremor, unintended

movements, fasciculations
(small fibrillations muscleÆ de-

nervation (rare!))

Anatomic Position
Flexion/Extension & Abduction/Adduction

\u2022 Anatomic Position & Planes Of The Body
\u2022 Flexion: Moving forward out of the frontal plane

of the body (except knee and foot)
\u2022 Extension: Movement in direction opposite to

flexion
\u2022 Abduction: movement that brings a structure

away from the body (along frontal plane)
\u2022 Adduction: movement that brings a structure

towards the body (along frontal plane)

Extension/Flexion, Abduction/Adduction @
Major Joints

Wrist Extension

Flexion

Elbow Flexion

Extension

Shoulder Abduction

Adduction

Hip Flexion

Hip Extension Hip
Abducition

Hip
Adduction

Knee
Extension

Knee
Flexion

Plantarflexion

Dorsiflexion

Strength \u2013 Scoring System
Quantify with 0 Æ 5 Scale (quasi-objective)

\u2022 0/5 - No movement
\u2022 1/5 - Barest flicker movement Ænot enough to

move structure to which attached.
\u2022 2/5 - Voluntary movement not sufficient to overcome

force of gravity. E.g. patient able to slide hand across table - but
not lift it from surface.

\u2022 3/5 - Voluntary movement capable of overcoming gravity, not any
applied resistance. E.g. patient raises hand off table, but not w/any

additional resistance applied.
\u2022 4/5 - Voluntary movement capable of overcoming \u201csome\u201d resistance
\u2022 5/5 - Normal strength

+ and \u2013 can be added to allow for more nuanced scoring

Specific Muscle Group
Testing

\u2022 Interossei of Hand \u2013 finger
abduction & adduction

\u2022 Grip strength
\u2022 Wrist - extension & flexion
\u2022 Elbow - flexion & extension
\u2022 Shoulder - abduction &

adduction

Compare right to leftÆshould be
similar (accounting for
handedness).

Muscle Group Testing (cont)
\u2022 Hip - flexion & extension
\u2022 Hip \u2013 abduction & adduction
\u2022 Knee - flexion & extension
\u2022 Ankle \u2013 plantar flexion & dorsiflexion

Pronator Drift: A test for subtle upper extremity
weakness.

\u2013 Have patient stand, close their eyes &
extend both hands, palm up.

\u2013 E.g. If R arm slightly weak, it will pronate
& \u201cdrift\u201d down ward.

Cerebellar Testing:
Coordination & Fine Motor Movement

\u2022 Several tests \u2013 providing same info
\u2022 Testing doesn\u2019t solely examine

cerebellum \u2013 i.e. also requires strength,
crude motor function, joint movement,
vision, etc.

Specifics:
\u2022 Finger-to-nose:

\u2013 Place your finger in space in front of patient
\u2013 Have pt move their index finger between their nose &

your finger tip
\u2022 Heel-to-shin:

\u2013 Have patient run heel of 1 foot up & down opposite
shin

Cerebellar Testing (cont)
Specifics (cont):
\u2022 Rapid Alternating Hand Movement

\u2013 Have patient alternately touch back & then front of 1
hand against palm of other

\u2022 Rapid Alternating Finger Movement
\u2013 Have patient alternately touch tips of ea finger against

thumb of same hand

Normal movement is both smooth & accurate.

Sensory Testing
Anatomy & Physiology

\u2022 2 main pathways: Spinothalamics & Dorsal
columns.

\u2022 Spinothalamics
\u2013 Pain, temperature, crude touch

\u2013 Impulses enter from peripheryÆ cross to other side of
cord within ~ 2 vertebral levelsÆ travel up that side to
brain

\u2022 Dorsal Columns
\u2013 Vibration, position, light touch

\u2013 Impulses from periphery enter cordÆtravel up that
sideÆcross to opposite @ base of brainÆthen travel

to their terminus

Nerves and Their Distributions

\u2022 Specific dermatomes not usually memorzied \u2013
reference chart helpful to pin down deficits

\u2022 Distributions (& spinal root contributions) for
specific peripheral nervesÆ looked up in
appropriate setting

Map of Dermatomes
(http://www.maturespine.com)

Distribution of Cutaneous Sensory Peripheral Nerves
(http://www.neuroguide.com/)

Spinothalamics \u2013 Pain,
Temperature & Crude Touch

\u2022 Break Q-tip in half, creating
sharp, pointy end.

\u2022 Ask patient to close eyesÆ
unable to get visual clues.

\u2022 Start @ top of foot.
\u2013 Orient patient by first touching

w/sharp implement, then non-
sharp object (e.g. the soft end of
a q-tip)Æ clarifies for patient

what you\u2019re defining as sharp &
dull

Spinothalamics \u2013 Pain, Temperature
and Crude Touch (cont)

\u2022 Touch lateral aspect of
foot w/either sharp or dull
toolÆ patient reports their
response.

\u2022 Move medially across top
of foot, noting their
response to ea touch.

\u2022 Temperature tested by
touching test tubes
holding cool v warm
water against region of
interest \u2013 often omitted
for practical reasons

Spinothalamics \u2013 Pain, Temperature
& Crude Touch (cont)

\u2022 Light touch assessed
by gently brushing
your finger against
extremity & asking
patient (eyes closed)
to note when they feel
it

\u2022 Upper extremities
checked in same
fashion

Dorsal Columns - Proprioception
\u2022 Allows body to \u201cknow\u201d where it

is in space
\u2022 Important for balance, walking
\u2022 Ask patient to close eyesÆ

don\u2019t receive any visual cues.
\u2013 Grasp either side of great toe.
\u2013 Orient patient as to up and

down:
\u2022 Flex the toe (pull it upwards)

while telling patient what you\u2019re
doing.

\u2022 Extend toe (pull it downwards)
while informing them of which
direction you\u2019re moving it.

Dorsal Columns \u2013
Proprioception (cont)

\u2022 Alternately deflect toe up
or down w/out telling
patient in which direction
you\u2019re moving itÆ should

be able to correctly
identify movement &
direction \u2013Test both feet.

\u2022 Can be checked @ a
more proximal joint (e.g.
ankle) if abnormal.

\u2022 Upper extremities
assessed in same
fashion, deflecting finger
up & down

Dorsal Columns \u2013 Vibratory
Sensation

\u2022 Ask patient to close eyesÆdon\u2019t
receive visual cues.

\u2022 Grasp 128 Hz tuning fork by stem &
strike forked ends against heel of
your handÆ vibrate.

\u2013 Place stem on top of interphalangeal
joint of great toe

\u2013 Place fingers of your other hand on
bottom-side of joint

\u2013 Ask patient if they can feel vibration.
\u2013 You should be able to feel same

sensation w/fingers on bottom side of
joint.

Dorsal Columns \u2013 Vibratory Sensation
(cont)

\u2022 Patient determines when
vibration stopsÎ correlates

w/when you can\u2019t feel it
transmitted through joint

\u2022 Test both feet.
\u2022 Check more proximal joints

(e.g. ankle) if sensation
impaired.

\u2022 Upper extremities assessed
similarly, w/fork placed on
distal finger joint

Special Sensory Testing

TWO POINT DISCRIMATION
\u2022 2 point discrimination (Dorsal Columns)

particularly useful when assessing for discrete
peripheral nerve injury (e.g. traumatic
disruption)