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Neurological examination Neurology RHS 332 Practical Lecture 1 Mrs: Muneera AL-murdi Neurological examination The neurological examination is primarily carried out to localize the site of the pathology in the neuraxis, innervations pattern of the cranial and peripheral nerves, and the major fiber tracts in the brain and spinal cord. Neurological examination The international classification of impairment, disability and handicap. Impairment Disability Handicap Loss or abnormality of body structure or appearance, organ or system function resulting from any cause. Ex. Muscle weakness of lower limbs. Lack or restriction of ability ,resulting from impairment , representing disturbance at the level of the person. Ex. Inability to climb stairs. The disadvantage experienced by the individual, as a result of impairments or disabilities which prevent them from fulfilling their normal role. Ex. Mobility- social restriction of being confined to one level. General neurological assessment : Reading file History taking( present and past history) Family history Taking patient’s history is often more important than the clinical examination. Examination of the mental functions level of consciousness Orientation for time and place Memory assessment ( recent, immediate and remote memory) Examination of the mental functions AMNESIA is diminution of memory, which includes: Anterograde amnesia: loss of memory for immediate and recent events. Retrograde amnesia: loss of memory for remote events. Transient global amnesia: sudden total loss of memory for less than one day. Examination of the mental functions patient’s Mood Intelligence behaviour Examination of speech The main speech disturbances include: Aphasia: inability to formulate speech. Types: 1. sensory aphasia 2. motor aphasia dysarthria: difficulty to articulate speech properly. Neurological examination 1. Sensory examination: • Superficial sensation • Deep sensation 2. Motor examination Neurological examination Superficial sensation: •Pain •Temperature •Light touch •Light pressure Neurological examination Deep sensation (proprioceptive): 1. Kinesthesia 2. Position sense 3. Vibration Neurological examination Deep sensation: Combined (cortical ) sensation: 1. Stereagnosis 2. bargnosis 3. Tactile pressure 4. Two point discrimination 5. Graphethesia 6. Recognition of texture Examination of the Cranial Nerves Cranial Nerve I Olfactory nerve II Optic nerve III, IV,VI Ocular nerve V Trigeminal nerve VII Facial nerve VIII Cochlear-vestibular nerve IX,X,XI,XII Glossopharyngeal, vagus,cranial accessory and hypoglossal Examination of the Cranial Nerves I - Smell II - Visual acuity, visual fields III - Pupillary reactions III,IV,VI - Extra-ocular movements, including opening of the eyes V - Facial sensation, movements of the jaw, and corneal reflexes VII - Facial movements and gustation VIII - Hearing and balance Examination of the Cranial Nerves (CN I ) : Smell (CN II): Visual acuity, and visual fields Examination of the Cranial Nerves Extra-ocular movements (oculomotor, trochlear, and abducent nerve) The Trochlear nerve (CN IV) is tested along with the oculomotor nerve as it is also involved in eye movements. Examination of the Cranial Nerves The Trigeminal nerve (CN V) is involved in sensory supply to the face and motor supply to the muscles of mastication. • test the sensory branches by by lightly touching the face with a piece of cotton wool on three places on each side – around the jawline, on the cheek and on the forehead Examination of the Cranial Nerves Examination of the Cranial Nerves For the motor part. (1) ask the patient to clench their teeth together, observing and feeling the bulk of the masseter muscles. (2) jaw reflex Examination of the Cranial Nerves The Abducent nerve (CN VI) is tested in the same manner as the oculmotor nerve, again in eye movements. Examination of the Cranial Nerves The Facial nerve (CN VII) supplies motor branches to the muscles of facial expression. Therefore, this nerve is tested by asking the patient to crease up their forehead (raise their eyebrows), close their eyes and keep them closed against resistance, puff out their cheeks and show you their teeth. Examination of the Cranial Nerves (CN VII) facial nerve, motor part of upper and lower parts of the face. Examination of the Cranial Nerves Examination of the Cranial Nerves The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus of the ear •List of Dermatomes of Commonly Injured Nerve Roots C5 – The area over the shoulder. C6 – The thumb and part of the forearm. C7 – The middle finger. C8 – The smallest fingers and part of the forearm. L4 – The thigh. L5 – The medial part of the calf and foot, the big toe. S1 – The lateral part of the calf and foot, the smaller toes. Examination of the muscle tone Muscle tone may be abnormally increased (hypertonia) or decreased (hypotonia). The main types of hypertonia are: Spasticity Rigidity Examination of the muscle tone Clinically, usually assesses muscle tone in two ways: 1. By passive movement 2. By shaking method for wrist and ankle only to observe how a limb responds. The greater resistance to movement ( the greater muscle tone). Examination of muscle tone Spasticity: is a velocity-dependent increase in resistance to passive stretch of a muscle with exaggerated tendon reflexes. Rigidity: increased resistance to relatively slowly imposed passive movements Comparison of spasticity and rigidity spasticity rigidity Pattern of muscle involvement Upper limb flexors, lower limb extensors Distal more than proximal Flexors and extensors equally Proximal more than distal Nature of tone Velocity –dependent increase in tone (claspknife) Constant throughout movement , (lead pipe)or (cog-wheel) intermittent deep reflexes hyperreflexia hyporeflexia Clinical significance Upper motor neurone (pyramidal) sign Extrapyramidal sign Modified Ashworth scale for grading spasticity grade description 0 No increase in muscle tone 1 Slight increase in muscle tone at the end of ROM 1+ Slight increase in muscle tone less than half of the ROM 2 More marked increase in muscle tone through most of the ROM ( more than half) but affected parts easily moved. 3 Considerable increase in muscle tone, passive movement difficult. 4 Affected parts are rigid Deep tendon reflexes • • • • • Biceps reflex Triceps reflex Hamstring reflex Patellar reflex Ankle reflex Reflexes • Babiniski-sign reflex: is a scratching method on the lateral aspect of the sole of the foot from the heel towards the toes. • Clonus reflex: is a rhythmical series of contractions in response to sudden stretch of the tendon of the muscle. ( ex, ankle & wrist) Balance assessment good balance requires a well integrated nervous system with a adequate afferent information, joints, and muscles. Faults in any of theses factors will influence the patient’s ability to balance. Balance is the ability to maintain a position 1. Static balance 2. Dynamic balance Coordination assessment coordination is the ability to perform smooth, accurate and controlled movements. Coordinated movements are characterized by appropriate speed, distance, direction, and rhythm. Balance and coordination Balance and coordination depend on the interaction of multiple body organs and systems including the eyes, ears, brain and nervous system, cardiovascular system, and muscles. Examination of any of these organs or systems may be necessary to determine the causes of disturbance of balance. Coordination assessment Finger to finger Finger to doctor’s finger Finger to nose Finger opposition Pronation and supination Patting Heel to knee to toe Tapping foot Walking