Neurological Examination

Neurological Examination. 1

Speech. 1

Upper Limb. 2

Reflexes. 3

Lower Limb. 4

Reflexes. 4

Sensation. 5

Sensory map. 5

Rhomberg’s test 7

Gait 8

Weakness. 9

Speech

Elements to test

1. Comprehension

2. Fluency

3. Repetition

4. Naming

5. Quality

6. Articulation/rhythm

Examination

• Ask patient
• Their name
• To describe the room (alternatively describe picture)

· Repeat “ No ifs ands or buts”

• Abnormal with - Conductive or receptive aphasia
• Repeat
• West-register Street or British constitution
• Test articulation/rhythm
• Repeat
• Puh – test lips
• Tuh – test tongue
• Kuh – test palate
• Staged commands – one, two, three
• Tests comprehension (receptive) - abnormal suggests receptive problem

· Questions – further test comprehension – and hence receptive

• “Do you put your socks on before your shoes?”
• “Do you close the car door before you get in?”
• Word-finding/naming
• Name animals in one minute NR18-22)
• All words staring with a particular letter, usu f or s, in 1 min NR>12)
• Name objects getting more specific
1. Watch – dial, hands, Pen – tip,
• Abnormal with all types of dysphasia however if other aspects normal except for this then could be a specifically nominal aphasia
• Jaw jerk
• Brisk if pseudobulbar palsy

· Further Ax

o Look for facial asymmetry and potentially assess facial nerve

o Look for hemiparesis

o Co-ordination or nystagmus – suggestive of cerebellar dysfunction

Findings:

Dysphonia

· Altered quality of the voice with normal fluency but change in volume

• Vocal cord disease – e.g. recurrent laryngeal nerve palsy

Dysarthria

· Difficulty articulating

• DDX:
• LMN lesions
1. Cranial nerves – CNVII – slurred speech
2. Bulbar palsy – Nasal speech
• UMN lesions
1. Pseudobulbar palsy – spastic dysarthria – trying to squeeze out words
• Extrapyramidal conditions
1. Monotonous speech
• Cerebellar lesions
1. Slow, slurred, sometimes explosive speech
2. May be broken up into syllables – scanning speech

Aphasia/Dysphasia

1. Wernike’s aphasia
1. Poor comprehension, fluent but meaningless. No repetition.
2. Broca’s aphasia
1. Preserved comprehension, non-fluent speech. No repetition.
3. Conductive aphasia
1. Loss of repetition with preserved comprehension and output.
4. Transcortical sensory aphasia
1. As 1. but with preserved repetition.
5. Transcortical motor aphasia
1. As in 2. but with preserved repetition
6. Nominal apahsia
1. Only difficulty with naming
2. Dominant posterior temporoparietal lesion (most commonly)

Upper Limb

Upper Limb
Shoulder
Abduction	C5-C6	Axillary	Deltoid
Adduction	C6-C7-C8	Thoracodorsal Pecoral nerves	Latissimus dorsi Pectoralis major
External rotation	C5-C6	Suprascapular	Infraspinatus
Internal rotation	C5-C6-C7	Subscapular	Subscapularis
Elbow
Flexion	C5-C6	Musculocutaneous Radial	Biceps (when supine) Brachialis (all positions) Brachioradialis (in mid-position)	C5-C6 C5-C6 C5-C6
Extension	C6-C7-C8	Radial	Triceps	C6-C7-(C8)
Wrist
Flexion	C6-C7-C8	Median Ulnar	FCR Palmaris longus FDS (minor) FCU	C6-C7 C7-C8 C7-C8 C7-C8
Extension	C6-C7-C8	Radial	ECR- main muscle with normal wrist extension ECU	C6-C7 C7-C8
Finger
Flexion	C7-C8	Median Ulnar	FDP – Digit 2-3, FDS Lumbricals FDP – Digit 4, 5 Lumbricals	C7-C8 C7-C8 C8-T1 C8-T1 C8-T1
Extension	C7-C8	Radial	Extensor digitorum EIP	C7 C7-C8
Abduction	C8-T1	Ulnar	Dorsal interossei	C8-T1
Adduction	C8-T1	Ulnar	Palmar interossei	C8-T1
Thumb
Flexion	C8-T1	Median	FPL FPB	C7-C8 C8-T1
Extension	C8	Radial	EPL	C7-C8
Abduction	C8-T1	Median	APB	C8-T1
Adduction	C8-T1	Ulnar	Adductor pollicis	C8-T1

Reflexes

Upper Limb
Biceps	C5-C6
Triceps	C7-C8
Brachioradialis	C5-C6
Finger

Lower Limb

Lower Limb
Hip
Flexion	L1-L2-L3-L4	Femoral plexus Femoral nerve	Iliopsoas Rectus femoris	L2-L3 L2-L3
Extension	L5-S1-S2	Inferior gluteal	Gluteus maximus	L5-S1
Abduction	L4-L5-S1	Superior gluteal nerve	Gluteus medius, Tensor fasciae latae
Adduction	L2-L3-L4	Obturator
Knee
Flexion	L5-S1-S2 (L5-S1)	Sciatic	Semimembranous/tendinous Biceps femoris Adductors	L4-L5-S1 L5-S1 L2-L4
Extension	L2-L3-L4	Femoral	Quadriceps	L3-L4
Ankle
Plantar Flexion	S1-S2	Tibial	Gastrocnemius Soleus	L5-S1-S2 S1-S2
Dorsi Flexion	L4-L5	Deep peroneal	Tibialis anterior	L4-L5
Eversion	L5-S1	Superficial peroneal	Peroneus longus and brevis	L5-S1
Inversion	L5-S1	Tibial	Tibialis posterior	L5-S1
Toes
Plantar flexion toes	L5-S1-S2	Tibial	Flexor digitorum longus, Flexor halluces longus
Dorsi flexion toe	L5-S1	Deep peroneal	Extensor hallucis longus Extensor digitorum longus	L5-S1 L5-S1

Reflexes

Lower Limb
Patella/Knee	L3-4
Ankle	S1-S2
Plantar	L5, S1, S2

Sensation

Head
C2	Back of scalp
C3	Supraclavicular fossa
Upper limb
C4	Tip of clavicle
C5	Lateral cubital fossa (just proximal)
C6	Thumb
C7	Middle finger
C8	Little finger
T1	Medial cubital fossa (just distal)
Trunk
T4	Nipple
T10	Umbilicus
Lower Limb
L2	Mid anterior thigh
L3	Medial femoral condyle
L4	Medial malleolus
L5	Dorsum of 2^nd/3^rd MTPJ
S1	Lateral malleolus/heel
S2	Popliteal fossa
S3	Ischial tuberosity

Upper arm sensory

· Lateral (antebrachial) cutaneous nerve of forearm

• Terminal branch of MSC nerve
• Medial cutaneous nerve of forearm
• Arises directly from brachial plexus
• Posterior cutaneous nerver of the arm
• Branch of the radial nerve

Sensory map

Rhomberg’s test

· Worsening of balance after eyes closed – requires 60sec technically

• Three elements feed into balance:
• Visual input
• Vestibular function
• Proprioception
• If the patient is unsteady before closing eyes
• Cerebellar dysfunction (i.e. synthesis of information)
• Vestibular function (being fed the wrong information)
• If the patient gets unsteady after the eyes are closed
• Then likely proprioceptive failure as vestibular function not adequate to maintain posture on its own

Gait

Elements of the gait assessment

Posture

• Trunk – stooped vs upright

• Postural rexlexes – pull test

• Stance – narrow vs wide

Walking

• Initiation – hesitation, shuffling, magnetic

• Stepping

o Rhythm/Cadence (regular, irregular)

o Length (normal, short

o Trajectory (shallow, high-stepping)

o Speed

• Associated movements

o Trunk – sway (as in trendelenberg)

o Arm swing

Special manoeuvres

• Heel-toe

• Romberg’s test

• Walking backwards or running

Gait patterns

Gait	Description	Cause	Cadence/Rhythm	Step length	Base
(Spastic) Hemiparetic gait	One leg held stiffly and follows an arc (circumduction)	Hemiplegia	Slow	Short	Narrow
Spastic (paraparetic) gait	As above however bilateral	‘New’ onset paraparesis
Scissoring gait	As above however tendency to adduction of legs as well Short, slow steps as if wading through water	(Longstanding) Spastic paraparesis CP, hereditary spastic paraplegia
Parkinsons	Shuffling gait with reduced arm swing	Parkinson’s	Slow but can festinate	Short	Normal
Apraxic/Prefrontal Marche a petits pas	Similar to parkinsons with wider base Feet appear glued to floor (‘magnetic feet’), difficulty initiating and turning.	Lacunar infarcts NPH	Slow	Short	Slightly wide
Waddling gait	Swinging shoulders from side to side. Lifting foot with help of trunk movt rather than hip adduction.	Proximal myopathy Muscular dystrophy Hip pathology – OA or congenital dislocations.	Normal	Normal	Slightly wide
High stepping – unilateral	High step, foot hangs down.	Foot drop
High stepping – bilateral (Steppage gait)	As above. Feet may slap the ground	Bilateral foot drop Peripheral neuropathy – CMT MND	Normal	Normal	Normal
High stepping, broad based gait (Sensory ataxic)	High stepping, no foot drop, clumsy slapping down of feet, board base. Searching, patient watching feet.	Posterior column lesion – B12 or other sensory neuropathy MS Spinocerebellar degeneration.	Normal	Short	Often only slightly wide
Cerebellar ataxia - truncal	Loss of truncal balance, increased body sway, disequilibrium Wide based	Midline cerebellar structures	Irregular, overall often normal speed	Slightly short	Wide
Cerebellar ataxia - peripheral	Irregular steps with variable timing, length and direction. Fall to side of lesion. If midline is involved as well there may also be truncal imbalance	Cerebellar lobes
Spastic Ataxia “bouncing gait”	The combination of increased tone, clonus and ataxia result in very unsteady gait bouncing from one leg to the other and
Dystonic	Twisting, athetoid or dystonic movements disrupt the gait May be task specific – e.g. may disappear when walking backwards or running	Dystonia	Slow	Normal	Erratic

Wide based gait	Sensitive for a neurological disease, but not specific Atypical parkinsonism Cerebellar, sensory or vestibular ataxia Higher level gait disorders NPH Functional
Normal base	PD
Narrow base	Parkinson’s disease* Spastic paraparesis
Very narrow/scissoring	Spastic paraparesis Huntington’s disease (due to chorea) Functional
Anterocollis/head drop	MSA Myasthenia MND Polymyositis Focal posterior cervical myositis
Retrocollis	PSP Cervical dystonia Young onset PD Drug induced dystonia

* Patients with PD maintain good mediolateral stability late into the disease. Remain able to ride a bicycle late into disease.

Reference for this table: Nonnekes et al. Neurological disorders of gait, balance and posture. Nat Rev Neurol 2018

Weakness

UMN	Ischaemic, focal lesion, vasculitis
Anterior horn cells	SMA, Lead, ALS, Poliomyelitis, Paraneoplastic - (SLAPP)
Spinal root	Should cause weakness AND matching sensory loss
Peripheral nerve	GBS, Leprosy, Myeloma, Amyloid, DM, Lead
NM Junction	MG, LEMS, Botulism, Organophosphate
Muscle	Polymyositis, dermatomyositis, steroid, thyroid, hypoglycaemia, HIV, Muscular dystrophy.

Approach to Weakness