The Neurological Exam is an important physical examination for not just neurologists, but also psychiatrists. This is particularly important to rule out neurological causes of psychiatric disorders, and in even more so in older adults, where neurodegenerative disorders are more prevalent.
Language can also be assessed using common cognitive tests. A focus should be on:
Even healthy individuals can have 1-2 primitive reflexes present (also known as frontal release signs), but if more are present, this suggests a neurodegenerative disorder.
Test | Exam | Pathological Response |
---|---|---|
Glabellar tap | Tap patient's forehead repeatedly | Normal patients will blink in response to the first several taps. However, if the blinking persists, this is known as Myerson's sign, and is often seen in Parkinson's. |
Palmnomental | Use your nail to strike then thenar eminence briskly (you want to give a noxious stimuli) | The ipsilateral mentalis muscle of the lower lip contracts. It is a low sensitivity, high specificity sign.[2] |
Grasp reflex | Grasp patient's hand and rub your hands along the palmar surface | Patient's hand will grasp your hand (watch out, this can sometimes be really strong!) |
Pout reflex | A tongue depressor is pressed on the lips | Pouting of the lips |
Rooting reflex | Gently stroke the lateral upper lip | The mouth to moves toward the stimuli |
Cognitive testing is again relevant in older adults and middle age adults that present with psychiatric symptoms. Some neurodegenerative disorders may present initially with a prodrome of anxiety or depression even prior to the development cognitive symptoms.
Other things to assess for include:
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Smell | Ask patient to identify odours (e.g., mint, soap, coffee) to each nostril while the other nostril is occluded | Patient is able to smell | Anosmia (unable to smell) | Parkinson's, fronto-orbital head trauma, sinus infection | - |
Test | Exam | Normal finding | Pathological Finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Pupil size | Observe the size of the pupils | 2-4mm in bright light 4-8mm in dim light | Unequal pupil size, or diameter beyond normal findings | Can be physiological, pathological or pharmacological | - |
Fundoscopy | Use a fundoscope to examine the back of the eye | Macula can be visualized. Sharp optic discs with no vascular changes. Venous pulsations are present bilaterally. | Engorgement of retinal veins, deep haemorrhages, cotton wool spots and/or optic disc swelling | Macular or vascular disease | - |
Pupillary light reflex | Shine a light directly into the eye and observe for constriction | Pupil constricts when light flashes on same side | Fixed pupils or sluggish constriction | Lesion or disease along retina, optic nerve, and/or brain | - |
Swinging light test | Light is alternately shone into the left and right eyes (“swinging”) | Equal constriction of both pupils at the same time, regardless of which eye the light is directed at (indicates an intact direct and consensual pupillary light reflex) | Relative Afferent Pupillary Defect (RAPD) or also known as Marcus-Gunn pupil. • Light shone in the affected eye → cause only mild constriction of both pupils (due to decreased response to light from the afferent defect). • Light shone in the unaffected eye → cause normal constriction of both pupils | Lesion of optic nerve, visual pathway, retina, or amblyopia | • Relative Afferent Pupillary Defect (RAPD) Example • Relative Afferent Pupillary Defect (RAPD) and Marcus-Gunn pupil |
Visual fields (central and peripheral) | Position yourself at arm's length away from the patient. Your eye should be open to the same side as your patient's open eye (this will align your visual fields). Ask how many fingers are seen in each of the quadrants. | Visual fields are full to confrontation (or full to finger counting) | Visual field defect (e.g. - hemianopia). For example, in homonymous hemi-anopsia, this is the losing of one half of their side vision on the same side in both eyes. “Homonymous” refers to having the same, “Hemi” refers to half and “Anopsia” refers to blindness. | Optic nerve or visual cortex lesions | • Visual Field Testing • Visual Field Defects |
Visual acuity | Use a Snellen chart, and test each eye individually | 20/20 vision in both eyes | Any change in visual acuity | Optic nerve or visual cortex lesions | - |
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Extra-ocular eye movements (EOMs) | Look at the patient's eye movements as they follow yours finger's movement in the H-shape | Eyes are able to track the H-shape fully | Limits in patient's gaze or ability to look in certain directions, such as an Internuclear Ophthalmoplegia (INO) | • Restricted vertical saccades and vertical gaze palsy is suggestive of PSP • INO can be indicative of diffuse MS, stroke, or brain stem lesion | • INO • Vertical Gaze Palsy in PSP • Horizontal and vertical gaze centers |
Smooth pursuit during EOM | Look at the patient's eye movements as they follow yours finger's movement in the H-shape | Smooth pursuit with no nystagmus (no beating movements) | Nystagmus | Smooth pursuit can be impaired in Parkinson's [3] | • Smooth pursuit • Nystagmus |
Saccades | • Reflexive: Ask patient to quickly change focus from one fixed point to another repeatedly (e.g. - finger-pen-finger) • Volitional: Ask patient to look up to the ceiling and down to the ground without shifting head position | Fast and accurate saccades (however, saccades do slow down with age[4]) | Saccadic intrusions such as square wave jerks (SWJ), square wave pulses (SWP), macrosaccadic oscillations, saccadic pulses, ocular flutter, and opsoclonus. | Restricted vertical saccades and vertical gaze palsy is suggestive of PSP. | • Saccades • Saccades • Impaired saccades |
Oculocephalic (“Dolls Eyes”) maneuver | Ask patient to keep eyes locked and fixed onto your face, and move head up, down, left, and right. | Patient will maintain forward gaze as their head is turned | Lesion in the labyrinth or vestibular lesion | If there is impaired gaze, but VOR is normal, then suggestive of PSP | Oculocephalic reflex and its role in PSP diagnosis |
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Sensory (Facial Sensation) | Use cotton swab (or pin) to touch in V1, V2, and V3 distribution of the nerve | Same sensation on both sides | Altered sensation on one side | Trigeminal nerve lesion | - |
Motor (Muscles of mastication) | Observe muscle bulk and atrophy, ask patient to clench jaw and feel for muscles | Good strength bilaterally, feeling of muscle contraction, and no atrophy | Muscle weakness | Trigeminal nerve lesion | - |
Corneal reflex | Out of the corner of patient's eye, use the tip of a tissue paper and lightly brush on the cornea | Reflexive eye blink to the noxious stimuli | Absence of reflexive eye blink | Trigeminal nerve lesion | - |
Jaw jerk reflex | Open the mouth and and gently strike the jaw with a reflex hammer, | Looking for exaggerated response |
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Inspection | Look for facial (eyes, lips) drooping or facial asymmetry | No facial drooping | Facial drooping or weakness | Lesion to facial nerve or stroke | - |
Muscles of facial expression | • Scrunch forehead (wrinkles) • Close eyes tightly (“don't let me open them”) • Show teeth and nice big smile • Puff out cheeks | Good strength bilaterally to muscles of facial expression | Facial drooping or weakness | Lesion to facial nerve or stroke | - |
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Cochlear branch of nerve | • Hearing using gentle whispering in each ear • Weber and Rinne Test | Able to hear whisper on each side | Unable to hear | Weber and Rinne | |
Vestibular branch of nerve | Head Impulse Nystagmus Test of Skew (HINTS) | See video | See video | HINTS Exam | |
Dizziness | Dix-Hallpike Maneuver | See video | See video | Dix-Hallpike Test & Epley Manoeuvre |
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Inspection | Tell patient to say “Ahh” | Palate and uvula midline | Deviation of palate and midline | - | |
Gag reflex | Put tongue in the back of the throat | Gag reflex | - | - | |
Phonation | Listen to patient's voice during exam, ask patient to repeat sounds: “Ka, Ka, Ka” “Ma, Ma, Ma” “La, La, La” | Normal phonation and voice | Hoarse voice | Lesions (e.g. - mediastinal lymphoma, aortic aneurysm) compressing the recurrent laryngeal nerve | - |
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Sternocleidomastoid | Look at sternocleidomastoid, palpate, and tell patient “push against my hand with your neck” | Head turning strength is intact and equal on both sides | Weakness on one or both sides | Lesion of accessory nerve | - |
Trapezius | “Shrug your shoulders up against my hand” | Shoulder shrug strength equal on both sides | Weakness on one or both sides | Lesion of accessory nerve | - |
Test | Exam | Normal finding | Pathological finding | Disease/Lesion | Video |
---|---|---|---|---|---|
Tongue atrophy | Ask the patient to extend the tongue and inspecting it for atrophy | No fasciculations, no atrophy, no weakness or deviation of tongue | Fasculations, atrophy, weakness/deviation | Lesion of hypoglossal nerve | - |
Test | Exam | Pathological Response | Video |
---|---|---|---|
Pronator drift | Patient seated, arms flexed at shoulders at 90 degrees, elbows fully extended, and hands supinated. Then instruct patient to close eyes for 15-30 seconds. | A normal test is the patient should be able to maintain this position for the duration of closing their eyes. In a positive test, the one hand may drift down and away (i.e. - pronation) | Pronator drift |
Forearm rolling (“Satellite sign”) | Patient flexes elbows at 90 degrees, and places forearms parallel to each other in front of the torso, and rotates forearms in front of eah other for 5-10 seconds. | The affected arm will remain stationary, while the unaffected side will revolve around it like a “satellite.” Cortical lesions affect the contralateral arm. Cerebellar lesions affect the ipsilateral arm.[5] | - |
Forearm/thumb rolling | Same as above but with thumb or fingers | Same as above but with thumb or fingers | - |
Sign | UMN Lesion | LMN Lesion |
---|---|---|
Weakness | + | + |
Atrophy | - | + |
Fasciculations | - | + |
Reflexes | ↑ | ↓ |
Tone | ↑ | ↓ |
Babinski | + | - |
Spastic paresis | + | - |
Flaccid paralysis | - | + |
Clasp knife spasticity | + | - |
Hypertonia (i.e. - resistance to movement) can be due to one of 3
causes:[6]
Spasticity | Rigidity | Paratonia | |
---|---|---|---|
Causes | • Stroke, cerebral palsy, multiple sclerosis • Spinal cord disease/compression • Upper motor neuron disease | • Extrapyramidal lesions (e.g. - in Parkinson's) • Extrapyramidal side effects (EPS), most commonly from antipsychotics | • Dementia • Catatonia |
Neuroanatomical Location | Corticoreticulospinal (pyramidal) tracts | Extrapyramidal pathways (most commonly basal ganglia) | Bilateral frontal lobe dysfunction (non-specific) |
Exremity Weakness | Yes | No | No |
Resistance | More resistance in one direction than the other direction | Same resistance throughout | Variable |
Tone | Greater tone in initial part of movement (i.e. - “clasp knife spasticity”) | Same tone throughout (described as the feeling of a metal being bent, i.e. - lead pipe rigidity) | • Gegenhalten (oppositional paratonia) occurs when subjects involuntarily resist to passive movements • Mitgehen (facilitatory paratonia) occurs when subjects involuntary assist passive movements |
Velocity Dependent | Yes (i.e. - the faster you go, the more resistance you feel) | No (does not vary with speed of movement) | Yes (oppositional paratonia increases with movement velocity)[7] |
Other Exam Findings | • Upgoing Babinski reflex • Characteristic pattern: prominent in the flexors of the upper extremity and the extensors of the lower extremity. | • Rigidity can be brought out or aggravated by the activating the contralateral limb (e.g. - by asking patient to open and close their contralateral hand) This is a phenomenon known as activated rigidity.[8] | • Other features of catatonia may be found |
Myoclonus (myoclonic jerks) refers to sudden, (i.e. - quick) brief involuntary twitching or jerking of a muscle or group of muscles. A variety of metabolic disturbances, such as hyperammonemia, electrolyte derangements, uremia, and hypercarbia can all cause myoclonus. Importantly, medications such as opioids and gabapentin can also cause myoclonus (especially in the setting of acute kidney injuries when gabapentin is not able to be cleared).[10]
Test | Exam | Pathological Response |
---|---|---|
Asterixis | The patient extends their arms, dorsiflex their wrists, and spreads their fingers (similar to pushing against a wall or “stopping traffic”) with their eyes closed. | The presence of “flapping” hands indicates the presence of asterixis, which is a non-specific sign for hepatic encephalopathy. |
Clonus, on the otherhand, is rhythmic or regular, and related to lesions in upper motor neurons (e.g. - stroke) and is generally accompanied by hyperreflexia. Syndromes such as serotonin syndrome can also result in clonus.
Test | Exam | Pathological Response |
---|---|---|
Clonus | Examiner dorsiflexes the patient's foot (so their toes are pointing upward), and then holds the foot there. | Normal patients may have one or two beats. A series of beats may indicate clonus. Clonus is a marker of hyperreflexia, which is part of an upper motor neuron syndrome. |
Cogwheel rigidity, a feature of Parkinson's, is really just a combination of rigidity plus tremor. The “cogwheeling” is always the same frequency as the tremor.
Test | Exam | Pathological Response |
---|---|---|
Rapid alternating movements (RAM) | Ask patient to rest one hand and another, then alternate quickly one hand between supination and pronation. | When a patient has cerebellar disease, one movement cannot be quickly followed by its opposite and movements are slow, irregular, and clumsy. This condition is called dysdiadochokinesis. |
Finger-to-nose testing (FNT) | Ask the patient to touch your finger, then touch their nose. Their arms should be close to fully extended. Repeat this task several times. | In a patient with cerebellar disease, movements of the ipsilateral extremity are clumsy, unsteady. It will also varying in speed, force, and direction. This is called dysmetria. FNT also tests for something separate and unrelated: action tremors. This is unrelated to dysmetria. The difference between tremor and dysmetria is that tremors are rhythmic and oscillatory, whereas dysmetria is more unpredictable and usually results in an overshoot or undershoot of a target. |
Exam | Pathological Response | |
---|---|---|
Upper extremity and lower extremity reflexes | Strike areas with tendon hammer to elicit reflex | Hyperreflexia is associated with upper motor neuron disease. Hyporeflexia is associated with lower motor neuron disease or with decreased sensation. |
Babinski sign | Stroke along the sole (bottom) of the foot with a pointed end | A flexor plantar response is the normal response. The Babinski sign consists of dorsiflexion and fanning of the toes and indicates an upper motor neuron lesion |
The mnemonic below can be used to remember the clinical reflexes (bold = main nerve root):