Clinic Entrance - Neuroexam

Front 1

Pathologic reflexes
(UMN/corticospinal tract
lesion)

Back 1

Significance: UMN descend on LMN tracts
Lower extremity:
a) Babinski: stroke lateral aspect of sole of the foot

Front 2

Sensory Testing-Upper
Extremity
(test bilaterally compare & contrast)

Back 2

UE:
1) C5/Axillary n./shoulder
2) C5/Radial n./lateral shoulder
3) C6/Musculocutaneous n./Biceps
4) C6/Median n./palm thumb
5) C7/Median n./middle finger
6) C8/Ulnar n,/medial forearm
7) C8/Medial Antebrachial Cutaneous n./medial forearm
8) T1/Medial Antebrachial & Brachial n./medial elbow
9) T2/Medial Brachial Cutaneous n./medial biceps

Front 3

Sensory Testing-Lower
Extremity
(test bilaterally compare & contrast)

Back 3

LE:
1) L1/Lateral Femoral Cut. & Femoral n./proximal thigh
2) L2/Lateral Femoral Cut., Femoral, & Obturator n./mid-thigh
3) L3/Lateral Femoral Cut. & Femoral n./distal thigh
4) L4/Saphenous n./medial shin, medial foot, (big toe)
5) L5/Peroneal n./lateral shin, dorsum of foot, (big toe)
6) S1/Sural n./lateral calf, lateral foot, & little toe

Front 4

What is the significance of SENSATION?

Back 4

Sensation should be bilaterally equal, as well as equal to adjacent areas on the
same side.
Sensory alteration may involve:
• Decreased sensation or sensory loss (hypoesthesia, hypoalgesia)
• Increased sensation (hyperesthesia, hyperalgesia)
• Pain provoked by normally non-painful stimuli (dysesthesia, allodynia)
Sensory alteration may occur due to:
• PNS lesion (peripheral neuropathy, radiculopathy)
• CNS lesion (ascending tracts in spinal cord & brainstem, thalamus, &
somatosensory cortex)
DDX is based on:
1) Distribution of the sensory alteration (dermatomal, peripheral nerve
distribution, etc)
2) Associated w/ motor & reflex findings
3) Hx & physical
In this scenario, the most likely diagnosis is:
• Radiculopathy due to IVD herniation or IVF stenosis
• Peripheral Neuropathy
• CNS lesion (ascending sensory tracts in spinal cord-brainstem thalamus,
or somatosensory cortex)

Front 5

Muscle Strength Testing-Upper
Extremity (test bilaterally compare &
contrast)

Back 5

Muscle Strength Grading Scale:
5: full ROM against gravity & normal resistence
4: full ROM against gravity & some resistence
3: full ROM against gravity
2: full ROM w/ gravity removed
1: no motion, but slight contractility
0: no motion, no contractility
UE
• C5/Deltoid/Axillary n.
• C6/elbow flexors (biceps)/Musculocutaneous n.
• C7/elbow extensors (triceps)/Radial n.
• C6/wrist extensors/Radial n.
• C7/wrist flexors/median & Ulnar n.
• C7/finger extensors/Radial n.
• C8/finger flexors/Median & Ulnar n.
• T1/interossei/Ulnar n.

Front 6

Muscle Strength Testing-Lower
Extremity (test bilaterally compare &
contrast)

Back 6

Muscle Strength Grading Scale:
5: full ROM against gravity & normal resistence
4: full ROM against gravity & some resistence
3: full ROM against gravity
2: full ROM w/ gravity removed
1: no motion, but slight contractility
0: no motion, no contractility
LE:
1) L1,2,3/Psoas/branches of the lumber plexus
2) L2-4/Quadriceps/femoral n.
3) L2-4/Adductors/Obturator n.
4) L4/Anterior Tibialis/deep peroneal n.
5) L5/Dorsiflexors/deep peroneal n.
6) L5/Extensor Hallicus Longus (EHL)/deep peroneal n.
7) S1/plantar flexors/tibial n.
8) S1/Evertors/superficial peroneal n.
9) L5/Gluteus medius/superior gluteal n.
10) S1/Gluteus maximus/inferior gluteal n.

Front 7

What is the significance of Muscle
Strength?

Back 7

Normal muscle strength should be bilaterally symmetrical & should allow
complete ROM against full resistence (grade 5/5). Weakness graded from 4/5-
0/5 is abnormal.
Muscle strength is a function of the UMN-LMN pathway, the NMJ, & muscle. So,
weakness may result from a lesion of any of these. Weakness may also be due
to pain caused by testing.
DDX is based upon:
1) The distribution of weakness
2) Additional findings on the neurological exam (motor, sensory, reflex)
3) Hx & physical exam
In this scenario, the most likely diagnosis is:
• LMN lesion due to radiculopathy (IVD herniation, IVF stenosis)
• LMN lesion due to peripheral nerve disorder (peripheral neuropathy)
• UMN lesion (CVA, MS)
• NMJ dx (ex. Myasthenia gravis)
• Muscle dx-myopathy (ex. Muscular Dystrophy, polymyositis)

Front 8

DTR
(test bilaterally compare & contrast)

Back 8

UE: may reinforce by clenching teeth
1) C5/biceps/musculocutaneous n.
2) C6/Brachioradialis/radial n.
3) C7/triceps/radial n.
LE: may reinforce by clasping hands together
1) L4/quadriceps/femoral n.
2) L5/posterior tibialis/tibial n.
3) L5/medial hamstring/sciatic n.
4) S1/gastroc-soleus/tibial n.
Grading Scale:
4+: hyperactive; assoc.w/ clonus
3+: brisker than avg.
2+: normal
1+: present, but diminished
1+(R ): only present w/ reinforcement
0+(R ): absent (areflexia)

Front 9

What is the significance of DTR?

Back 9

DTR activity reflects the integrity of the reflex arc (involving the muscle spindle
receptor, Ia sensory fiber, LMN, & muscle), & the UMN’s inhibitory activity.
A lesion affecting the reflex arc (radiculopathy, peripheral neuropathy) leads to
decreased or absent DTR (hyporeflexia or areflexia), graded 1+. 1+(R), 0(R)
An UMN lesion (CNS) leads to hyperreflexia (4+)
Bilaterally symmetrical sluggish or brisk reflexes, in the absence of other
neurologic symptoms & exam findings, are typically normal.
DTR findings should be correlated w/ other aspects of the reflex exam such as
pathologic reflexes, & motor & sensory exam results.
In this scenario, the most likely diagnosis is:
• Lesion affecting the LMN and/or sensory component of the DTR arc, due
to radiculopathy (IVD herniation or IVF stenosis), or Peripheral
neuropathy.
• UMN lesion (CNS ex. CVA, MS, Spinal Cord Injury)

Front 10

ROMBERG

Back 10

Procedure:
1) While standing near the Pt ready to support them if they b/c unstable,
instruct the Pt to bring their feet together. Observe balance.
2) Instruct the Pt to close their eyes & again observe the Pt balance.
Finding & interpretation:
1) Only (+) when Pt balance b/c worse when eyes are closed.
2) (+) indicates that visual input was compensating for a balance problem,
& sensory ataxia (impaired conscious proprioception/JPS) or vestibular
ataxia is suggested.
3) Cerebellar dysfunction is associated w/ motor ataxia. No difference if
eyes open or closed.

Front 11

Gait

Back 11

Regular gait
1) Instruct the Pt to walk back & forth across the room
2) Observe:
a. Symmetry
b. Balance
c. Distance b/t feet (width)
d. Length of stride
e. Arm swing
f. Heel strike
Tandem gait (heel-to-toe walk)
1) Support Pt in case unstable, ask Pt to walk as if on a tightrope, placing
the heel of one foot directly in front of the other foot.
Heel & toe walk
1) Ask Pt to walk across the room on their heel, & to walk back on their
toes.
a. Weak dorsiflexion (heel walk)
i. L5 (common peroneal n.)
b. Weak plantarflexion (toe walk)
i. S1 (tibial n.)

Front 12

Muscle Bulk Assessment
Procedure

Back 12

• Visually compare symmetry of muscle bulk & coverage of bony
prominences.
• Measure the circumference of the limbs (“girth”) w/ a tape measure
o UE: measure 3”above & below (olecranon)
o LE: measure 6” above & below (joint line)
• Normal variation is 1 inch b/t dominant & non-dominant hand
• Significance: LMN Lesion

Front 13

Two-point discrimination

Back 13

Significance: involvement of type II 1st order neurons or dorsal column
system
• Tip of tongue: 1-2mm
• Lips: 2-3mm
• Finger tips: 2-5mm
• Dorsum of fingers: 4-6mm
• Palm of hand: 8-15mm
• Dorsum of hands: 20-30mm
• Feet: 30-40mm
• Shins: 30-40mm
• Back: 4-5mm
Procedure:
Explain to Pt that you will be touching them w. 1 or 2 points and ask them to
identify how many points that they feel. Demo what 1 & 2 points feel like. Have
the Pt close their eyes and proceed w/ the testing. Go widest then narrow b/t
points.
(+): inability to distinguish b/t 1 & 2points at the normal degree of point
separation for the area, or significant side-to-side differences.

Front 14

Conscious Proprioception/Joint Position
Sense (JPS)

Back 14

Procedure:
Explain & demo. (grasp the Pt big toe by the sides, and move it upward and
downward, “this is up & this is down”. now tell Pt that u will be asking them to
identify “up”, & “down” movements w/ their eyes closed). Have Pt close their
eyes and do the test. 7/8 correct responses is necessary to established validity.
(+): side-to-side alteration, or decreased sensitivity (greater movements
required)
Significance: involvement of type II 1st order neurons or dorsal column system;
some cortical participation is also necessary for JPS.

Front 15

Cortical Sensory Tests aka
“Gnosis”

Back 15

• Stereognosis (Steroagnosis):
o Procedure: Pt eyes closed. Put a familiar object (clip, coin), is
placed in the Pt’s hand & the Pt is asked to identify it. The Pt
should be able to correctly identify the object.
• Graphognosis (Graphesthesia/Agraphognosis)
o Explain to Pt that you will be drawing a #/letter in their hand and
they should be able to identify it w/ their eyes closed. Make sure
to draw it right side up form Pt perspective. Demo 1st w/ eyes
open to make sure they understand.
• Extinction (Double simultaneous stimulation test)
o In some Pt, simultaneous bilateral stimulation may reveal an
inability to perceive sensation from one side.
o Procedure: explain to Pt that you will be touching them either on
R/L/both sides, & asking them where they felt the touch. Ask Pt to
close eyes & proceed.(+): the Pt feels both on R/L when
touched, but when touched bilaterally, only feels one side.
• Significance: lesion of the somatosensory association cotex (parietal
lobe) Contralaterally.

Front 16

Assessing Coordination of the
Limbs

Back 16

(Cerebellar Function)
Point-to-Point tests
UE:
• Finger-to-nose test: Touch the index finger of each hand to the tip of
their nose.
(+): any past pointing/dysmetria/intention tremor.
• Finger-to-finger-to-nose test: Pt to touch their nose & reach out to touch
Dr fingers.
(+): dysmetria/intention tremor
LE
• Heel-to-shin test: Pt is supine & place heel of 1 foot on the opposite
kneecap & slide down shin. (+): zig-zag/dysmetria
• Toe-to-finger test: Pt supine toe touch Dr fingers (note:
dysmetria/intention tremor)
Rapid Alternating Movement tests
UE:
• Diadochokinesis: Patting the thing. Pronation-supination. (+): clumsy.
Irreg, slow
LE:
• Ask Pt to tap your hand as quickly as possible w/ the ball of their foot.
• Ask the Pt to tap the knee several times w/ the alternate heel. This may
be combined w/ the heel-to-shin test.

Front 17

HOLME’S REBOUND TEST
(a test of rapid alternating movement tests)

Back 17

• Ask Pt to flex their forearm against the examiner’s resistance (turn Pt
face away & shield w/ your other hand). Suddenly remove your
resistance.
• Normally the Pt can quickly check the movement of the forearm. w/ CB
dysfunction. There is failure of the antagonists to contract & agonists to
relax. And the forearm continues to swing upward.