Table 10: Neurological Exam
| Physical Sign / Manoeuvre | Rationale | Technique(s) | Interpretation | Evidence | Pre-Clerkship | Clerkship |
|---|---|---|---|---|---|---|
| Gross contextual screening | Orientation to person, place and time | Gross assessment of connection to context (confusion) | Impaired consciousness K value of 0.65-0.88 McGee, 2001. | 2 | ||
| Folstein Mini Mental (see also mental status section) | Test for cognitive impairment | Standard administration | Dementia | +LR of 14.5 for scores< 21 McGee, 2001, p56. K:0.28-0.80 McGee, 2001, p56. | 2 | 3 |
| clock-drawing test (see also mental status section) | Test for cognitive impairment | Standard administration | Dementia | +LR of 14 to rule in dementia Juby, 2002. K:0.73 | 2 | |
| Glasgow coma scale | Assessment of brain injury | Standard clinical record | Grading and evolution of brain injury | Consistency of scoring highest for best motor response. Gabbe, 2003. | 2 | 4 |
| Fundoscopy | Assessment of retina and optic nerve abnormalities | Examination of eye with ophthalmoscope or retinography | Increased intracranial pressure, retinal complications of hypertension, diabetes mellitus | No value in the management of HBP van den Born, 2005. Useful in DM if combined with retino-graphy O’Hare, 1996. Harding, 1995. Papilledema: high sensitivity, low specificity Johnson, 1991. Overall K: 0.65 | 2 | 3 |
| CN1 | Gross assessment of olfactory dysfunction | Test smell with readily available scents | Anosmia | None available | 1 | 1 |
| CN2 | Understanding of dysfunction and topography of lesions in the visual pathways | Visual field testing by confrontation, if abnormal needs further testing. Visual acuity. Papillary reaction to light and accommodation | Retinal disease Optic nerve damage Occipital lobe stoke Screening Coma, optic nerve, drug effects stroke syndromes | V.F. has a +LR between 4.2-18.3. Hemianopia is 98% specific in unilateral cerebral disease McGee, 2001. V.A. no evidence found when it is used as gross screening. PRLA :High sensitivity for optic nerve disease, ipsilateral brain herniation, and post communicating art aneurism. Very high sensit/specif for Horner’s syndrome McGee, 2001. | 3 | 4 |
| CN3 | Understanding of dysfunction and topography of lesions in the visual pathways | Observation of pupils, upper eye lid and examination of eye movements. | Diseases of the external eye muscles. Injury to CN 3 or disease of mid/brain stem nucleae. Increased ICP | Isolated palsy is most commonly caused by posterior communicating artery aneurysm or ischemic infarct. Pupil reaction +/- spared. Evidence not qualified. | 3 | 4 |
| CN4 | Understanding diplopia and its neurologic causes | Examination of eye movements. | Diseases of the external eye muscles. Head, cavernous sinus or orbital injuries. Disease of mid brain nucleae | Isolated palsy most commonly seen in head trauma (34%) and ischemic infarcts (22%). Evidence not quantified. | 3 | 4 |
| CN6 | Understanding diplopia and its neurologic causes | Examination of eye movements. | Diseases of the external eye muscles. Head, cavernous sinus or orbital injuries. Disease of brain stem nucleae | Isolated palsy most frequently seen in increased ICP, ischemia and lesions in the base of the skull. Evidence not quantified. | 3 | 4 |
| CN5 | Understand facial sensation, mastication | Test V1, V2, V3, sensation and corneal reflex. Test jaw clenching | Tic dolorous, stroke, cerebellopontine lesions. Herpes zoster | High sensitivity in thalamic or hemispheric injury but low specificity McGee, 2001. | 3 | |
| CN7 | Understanding facial expression dysfunction | Observation Motor | Peripheral versus central nerve palsies Stroke syndromes Bell’s palsy | No appraisal of evidence found. Facial palsy, present or absent has a K value of 0.48-0.68 McGee, 2001. | 3 | |
| CN8 | Understanding hearing and vertigo | Whispered voice, Rinne and Weber not useful for general screening of hearing problems. Dix-Hallpike test BPPV. | Hearing Vestibular dysfunction | Whispered voice test has high sensitivity, good specificity and +LF of 6 for hearing loss. Dix-Hallpike test, widely used but accuracy not appraised Olaleye, 2001. | 3 | 4 |
| CN 9, 10 | Understanding swallowing | Test together Swallow test, gag reflex, observe for dysphonia | Stroke Aspiration risk Brain stem lesions | Water swallow test, reasonable sensitivity, specificity and +LR of 5.6 K value: 1 McGee, 2001. | 3 | 4 |
| CN 11 | Understanding of sternocleidomastoid muscle function | Turning of the head and shoulder elevation | Neck trauma Cerebral hemispheric lesions Medullary and high spinal lesions | No appraisal of evidence found | 3 | 4 |
| CN12 | Understanding of tongue motor function | Motor | Brain stem lesions Lesions associated with lower cranial nerves. Lesions in upper neck and base of skull | No appraisal of evidence found | 3 | 4 |
| 10 g monofilament | Screening for future complications of PDN | Use instrument Test 10 times on dorsum and plantar aspect | Peripheral neuropathy, risk for diabetic foot ulcer | Moderate to high predictor of foot ulcers, osteomyelitis and amputations. +LR of 2.9-7.2 McGee, 2001. Lee, 2003. K: 0.72-0.83. | 2 | 4 |
| Light touch, pain sense | Mapping of sensory defects | Use non-reusable sharp object such as broken tongue depressorLight touch – spindle | Peripheral nerve, spinal cord lesions, stroke syndromes | Quite accurate in mapping peripheral nerve injuries, radiculopathy, spinal cord syndromes, lateral medullary, thalamic and hemispheric syndromes K: 0.41-0.63 McGee, 2001. | 3 | 4 |
| Vibration sense | Adjunct in the investigation of certain neuropathies | Use 128 Hz tuning fork | Peripheral neuropathy and spinal cord disease | Diminished in peripheral neuropathies and spinal cord disease K: 0.45-0.54 McGee, 2001. | 3 | 4 |
| Proprioception (Joint position sense) | Adjunct in the investigation of certain neuropathies. Associated with vibration sense. | Slightly hold sides of digit and move up and down | Peripheral nerve, spinal cord disease, posterior column lesions and severe hemispheric disease | Diminished in peripheral neuropathies, spinal cord disease and cortico-hemispheric disease. No appraisal found | 3 | 4 |
| Two point discrimination, stereognosis, graphesthesia | Complex sensation that requires intellectual elaboration | Two pressure points applied simultaneously to the skin. Recognition of a object in the hand. Recognition of numbers traced on the palm of the hand | Lesions in the posterior parietal cortex | Altered in lesions of the posterior parietal (sensory) cortex. No appraisal found | 3 | 4 |
| Dermatomes | Mapping of spinal cord lesions and radiculopathy | Light touch and pain sensory examination | Peripheral nerves, spinal cord and nerve root lesions | Fairly accurate examination defining the level of spinal cord injury. High specificity with high +LR in C6, C7, C8 radiculopathy in sensory loss of thumb, middle and little finger McGee, 2001. | 3 | 4 |
| Muscle bulk | Associated with muscle disease or denervation | Inspection of muscle groups for wasting, hypertrophy and fasciculations | Muscle disease, upper and lower MN disease or injury, nerve and neuromuscular end plate disease | Comparative calf wasting accurate, indicates low radicular compression due to disc herniation, +LR 5.2. K:0.32-0.81 McGee, 2001. | 3 | 4 |
| Muscle tone | Associated with neurophysiologic control of muscle function | Test for flaccidity, spasticity, cogwheel rigidity | Stroke Spinal cord lesions Neuromuscular junction Extrapyramidal disease (Parkinson’s disease) | Rigidity alone in the diagnosis of Parkinson’s disease has low sensitivity, low specificity and low +LR. Accuracy increases with the presence of bradykinesia and typical pill-rolling tremor. Spasticity/rigidity have a K value 0.21-01.64 McGee, 2001. | 2 | 4 |
| Muscle Power | Assessment of corticospinal and neuromuscular function | British Medical Research Council (MRC) Scale for grading muscle strength
Medical Research Council, 1976. | Assessment and progression of upper and lower MN disease and myopathy | Moderate to good sensitivity. Good to very good specificity. Good +LR. K:0.69-0.93 McGee, 2001. | 3 | 4 |
| Pronator drift | Hemispheric lesion | Hold arms up in pronated position, eyes closed | Unilateral cerebral hemispheric disease | High sensitivity: 79% Very high specificity, 98% and +LR, 33 McGee, 2001. | 3 | 4 |
| Reflexes (DTRs) | Assessment of motor neuron and peripheral nerve disease | Triceps, biceps, bracheoradialis, patellar, ankleGrade, reflex, amplitude0-4 | Abnormal DTRs have diagnostic value ONLY when they are asymmetric or accompanied by other signs of motor neuron disease (McGee, 2001) | Diminished DTRs have a general moderate sensitivity but high specificity 90%+, and high +LR in the diagnosis of radiculopathy. K: 0.34-0.94 McGee, 2001. | 3 | 4 |
| Plantar Reflex (Babinski) | Adjunct in assessment of hemispheric and pyramidal tracts disease | Scratching the lateral aspect of the sole of the foot with a hard, pointed object | Spino-cortical (pyramidal)tract lesion Severe metabolic disturbance | Highly specific, 98% with high +LR, 19, for pyramidal tract lesions. K values: 0.17-0.61 McGee, 2001. | 3 | 4 |
| Primitive reflex (palmomental, glabellar and grasp) | Adjunct in the assessment of dementia, frontal lobe and Parkinson’s disease and advanced AIDS | Scratching of hand palm and twitching of chin. Tapping on glabella triggers sustained blinking. Sliding a finger on the patient’s hand – the hand grasps the clinician’s finger | These are frontal release reflexes. The palmomental and glabellar reflexes can be found in normal people. | Grasp reflex has a high specificity, 99%, and high +LR, 20.1 in the diagnosis of frontal, cortical, subcortical and thalamic nuclei lesions, with a K value of 0.46-1.0 McGee, 2001. | 2 | 4 |
| Gait | Assessment of ambulation | Observation of ambulation | Stroke, Parkinson’s disease, myelopathy, peripheral neuropathy and cerebellar disease | 8.8 +LR as predictor of falls Diagnosis of abnormal gait has a K value of 0.11-0.52 McGee, 2001. | 3 | 4 |
| Coordination/cerebellar | Assessment of cerebellar function | Ataxia (gate, finger-nose test and rapid alternating movements), nystagmus, hypotonia, dysarthria | Cerebellar disease | Positive cerebellar signs present with variable frequency in unilateral cerebellar disease, 10-93%, being the most frequent gate ataxia, 85% in unilateral disease, to 100% in alcoholic cerebellar syndromes Finger-nose test has a K value of 0.55-0.79 McGee, 2001. | 3 | 4 |
| Rhomberg | Not much rationale for teacing/performing this test. Has historic value. | Ability to stand for 60 seconds with feet together and eyes closed | Doubtful as it is very unspecific and has very low inter-observer agreement (not quantified) | Very unspecific and has very low inter-observer (K) agreement (not quantified) | 3 | 4 |
| Irritative/provocative tests | ||||||
| Meningismus (Kernig/Brudzinski) | Acute, critical and treatable CNS pathology | Passive neck stiffness Kernig’s (patient resists extension of the knee from the hip/knee flexed position) Brudzinski’s (passive flexion of the neck elicits flexion of hips/knees | Meningeal irritation | Meningimus K value: 0.76 Neck stiffness frequency in bacterial meningitis 57-92% Neck stiffness in SAH: sensitivity 59%, specificity 94%, +LR 10 McGee, 2001. | 3 | 4 |
| Tinel’s and Phalen’s | Carpal tunnel syndrome | Tinel’s (percuss median nerve over the carpal tunnel) Phalen’s (forcible palmar flexion of the wrist produces symptoms) | Median nerve compression Median nerve compression | Sens: 23-60% Spec: 64-87% +LR 1.4 McGee, 2001. Sens. 10-91% Spec. 33-86% +LR 1.3 McGee, 2001. | 3 | 4 |
| Straight leg raising test Crossed straight leg raising test | Lumbar nerve root compression | Patient supine and posterior pain when raising the straight affected leg. Crossed test:pain in the affected leg when raising the straight opposite leg | Lumbar disc herniation | Sens: 73-98% Spec: 11-61% +LR 1.3 McGee, 2001. Sens: 23-43% Spec: 88-98% +LR 4.3 Overall K value:0.33-0.68 McGee, 2001. | 3 | 4 |
| Reliability or physical findings or inter-observer agreement is expressed by Kappa (K), 0 being a level of agreement as expected by chance and 1 being perfect - 100% -- agreement. According to convention, 0-0.2 indicates slight agreement; 0.2-0.4 fair agreement; 0.4-0.6 moderate agreement; 0.6-0.8 substantial agreement; and 0.8-1 almost perfect agreement. | ||||||
References
- Gabbe BJ, et al. The status of the Glasgow Coma Scale. Emerg.Med.(Fremantle) 2003 Aug;15(4):353-360.
- Harding SP, et al. Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study. BMJ 1995 Oct 28;311(7013):1131-1135.
- Johnson LN, et al. Accuracy of papilledema and pseudopapilledema detection: a multispecialty study. J.Fam.Pract. 1991 Oct;33(4):381-386.
- Juby A, et al. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. CMAJ 2002 Oct 15;167(8):859-864.
- Lee S, et al. Clinical usefulness of the two-site Semmes-Weinstein monofilament test for detecting diabetic peripheral neuropathy. J.Korean Med.Sci. 2003 Feb;18(1):103-107.
- McGee SR. Evidence-based physical diagnosis. Philadelphia, PA: Saunders; 2001.
- Medical Research Council (Great Britain), University of Edinburgh. Dept. of Surgery. Aids to the examination of the peripheral nervous system. London: H. M. Stationery Off.; 1976.
- O'Hare JP, et al. Adding retinal photography to screening for diabetic retinopathy: a prospective study in primary care. BMJ 1996 Mar 16;312(7032):679-682.
- Olaleye D, et al. Evaluation of three screening tests and a risk assessment model for diagnosing peripheral neuropathy in the diabetes clinic. Diabetes Res.Clin.Pract. 2001 Nov;54(2):115-128.
- van den Born BJ, et al. Value of routine funduscopy in patients with hypertension: systematic review. BMJ 2005 Jul 9;331(7508):73.