5/13/2020 Neurological examination – Knowledge for medical students and physicians

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Clinical science

Neurological examination

Summary
Neurological examination is the assessment of mental status, cranial nerves, motor function, sensory function,
coordination, and gait for the diagnosis of neurological conditions. Findings should always be compared with the
contralateral side and upper limb function should be compared to lower limb function to determine the location
of the lesion. This learning card provides information about several examination methods and explains a
selection of neurological terms used in the evaluation of neurological conditions.

Mental status examination

Levels of consciousness
Types of impaired consciousness
Somnolence
A state of drowsiness from which a patient can be easily aroused.
Patient responds normally except for a slight delay when addressed.
Stupor
A state of insensitivity bordering on unconsciousness; from which the patient is not easily
awoken except if exposed to strong external stimuli; (e.g., if addressed in a loud voice) and
into which the patient returns in the absence of further stimuli.
Communication is not possible and painful stimulus provokes withdrawal response.
Coma: Patient cannot be aroused and there is no response to stimuli.
Glasgow Coma Scale (GCS) quantifies the degree of impaired consciousness

Mental status examination

Full mental status examination components include:
Appearance (e.g., groomed, well dressed)
Behavior (e.g., cooperative, agitated)
Speech: E.g.,
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Mutism: an inability or unwillingness to speak despite the faculties of speech being intact
Akinetic mutism: characterized by decreased motor responses and paucity of speech
Abulia: milder form of akinetic mutism that is characterized by disinterest and a slowed
mental state.
Orientation to person, place, and time
Mood and affect (as well as congruency)
Thought content (e.g., delusional) and process (e.g., logical thinking)
Memory (e.g., short-term vs. long-term memory, assessed by asking the patient to recall a number
of objects immediately and again after a few minutes)
Ability to perform simple calculations (e.g, simple multiplication; determine if appropriate for level
of education)
Insight and judgement (ask patient what they would do in a realistic situation, e.g., if they found a
stamped envelope)
Higher cortical function (e.g., ask patients to explain the meaning of well-known idioms)
Determine levels of consciousness
Mini-mental status examination (MMSE)
Saint Louis University Mental Status Examination (SLUMS)

Findings
Hemineglect
Inability to respond to unilateral stimuli due to a brain lesion (not due to a primary motor or sensory
lesion)
The lesion is usually contralateral to the stimuli
Motor neglect
Sensory or perceptual neglect
Amnesia: loss of memory (e.g., time, content)
Retrograde amnesia: loss of memory-access to events that occurred and/or information acquired
prior to the incident
Anterograde amnesia: loss of memory-access to events that occurred and/or information acquired
after the incident
Global amnesia: loss of memory-access to events that occurred and/or information acquired prior
and after the incident
Aphasia: Inability to communicate (impairment of the ability to either form or understand language)

Location of lesion Clinical features

Broca aphasia (motor
aphasia, expressive
aphasia)
Telegraphic and
grammatically incorrect
nonfluent speech
Comprehension is largely
Broca area (frontal lobe) spared (difficulty
understanding complex
language may occur)
The patient is typically aware
of the deficits

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Location of lesion Clinical features

Fluent speech that lacks

meaning (paraphasic errors,
Wernicke aphasia (sensory neologisms, word salad)
Wernicke area (temporal lobe)
aphasia, receptive aphasia) Comprehension is impaired
The patient is typically
unaware of the deficits

Severe impairment of speech

production and
comprehension
Broca area, Wernicke area, and arcuate
Global aphasia Patient may be mute or
fasciculus
only utter sounds
Inability to
comprehend speech

Mostly intact comprehension

and fluent speech production
Conduction aphasia Impaired repetition with
Arcuate fasciculus of the parietal lobe
(associative aphasia) paraphasia (they substitute or
transpose sounds), which
patients try to correct

Isolated difficulty finding

words
Usually, pinpointing the localization of the
Anomic aphasia Paraphrasing occurs when
lesion is not possible.
patients cannot find the word
they seek.

Difficulty initiating speech

Supplementary motor area (SMA) in the
Transcortical Difficulty in expressing a
cortex, with Broca area intact (exception:
motor thought process
may occur during recovery phase of Broca
aphasia Difficulty producing own
aphasia)
phrases
Transcortical
aphasia
Impaired speech expression
Transcortical and comprehension
Various areas of the temporal lobe, with
sensory Intact echolalia
Wernicke area intact
aphasia Errors in paraphrasing
Poor comprehension

Apraxia: difficulty performing targeted, voluntary movements despite intact motor function
Ideomotor apraxia: difficulty imitating actions; intended expression and gestures do not match
Ideational apraxia: difficulty completing multistep actions.
Visual motor apraxia: difficulty picking up objects placed in the contralesional visual field.
Agnosia: Impairment of recognition of sensory stimulus (most commonly visual) [1]
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Tactile agnosia (astereognosis): Impaired ability to recognize or identify objects by touch alone;
visual recognition is unimpaired.
Visuospatial dysgnosia: inability to orient oneself in space
Prosopagnosia: inability to recognize familiar faces
Autotopagnosia
Anosognosia: inability to recognize one's own neurologic impairment
Alexia: form of visual agnosia with severe reading problems, as a result of interrupted connections
between the visual cortex and language‑related areas. Subtypes include pure alexia without agraphia,
alexia with agraphia, and aphasic alexia.
Acalculia: inability to perform simple calculations (parietal lobe lesion)
Agraphia: inability to write

References:[2][3][4]

Cranial nerve examination

For information on disorders of the cranial nerves, see cranial nerve palsies.

Cranial nerve What is examined? How is the test performed?

Test the patient's ability to detect and identify an

Olfactory nerve I Olfaction
aroma in each nostril

Ask the patient to read from a Snellen chart using one

eye at a time, correct for refractive errors with glasses
Visual acuity
or a pinhole
Test color vision with Ishihara plates

Assess each eye by confrontation using a finger or red

Visual field pin
More accurate testing uses perimetry

Optic nerve II
The examiner shines a light into the patient's eye (e.g.,
a penlight).
A prompt, consensual response should normally be
Pupillary light reflex observable.
Pupillary shape and width: Healthy pupils are isocoric
and of medium width; anisocoric and/or narrow/wide
are suggestive of a disorder (see pupillary disorders).

Fundoscopic examination (e.g., a pale optic disk is

Papilla
indicative of optic nerve atrophy)

Oculomotor III,
nerve, trochlear IV, Patients are asked to follow a finger moving up, down,
nerve, abducens VI Eye movement laterally, and diagonally with their eyes.
nerve Observe if there is paresis, alterations in smooth
pursuit appear, or nystagmus,

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Cranial nerve What is examined? How is the test performed?

The physician moves a finger towards the patient, a

Visual accommodation
normal response is constriction of the pupil.

Eyelid ptosis (Levator

palpebrae superioris The patient is asked to open and close the eyes.
muscle dysfunction)

The examiner lightly touches three distinct facial areas

(the forehead, cheek, and jaw ).
Normally, light touch should be felt by the patient in
Facial sensation all three areas.
If this is not the case, tests for abnormalities of other
sensory modalities (e.g., pain, temperature) should be
performed.

Muscle function The patient is asked to open and close his/her mouth;
(muscles of at the same time, the examiner palpates the masseter
mastication) muscle.
Trigeminal nerve V
Masseter reflex (jaw jerk reflex)
A finger is placed on the patient's chin, while
the patient's mouth remains slightly open
Tapping with a reflex hammer normally induces
jaw closure
If jaw closure is increased, suspect an UMN
Reflexes
lesion
Corneal reflex
The cornea is lightly touched with a cotton
swab (approaching slowly and sideways from
the lid edge)
Touch normally induces closing of the eyelid.

If motor function is intact, the patient should be able

to perform the following:
Forehead wrinkling
Motor function Closing the eyes tightly
(muscles of expression) Nose wrinkling
Inflate the cheeks
Facial nerve VII
Smiling (showing teeth)
Whistling

If the sense is intact, the patient should be able to taste

Sense of taste
sweet, salty, and sour food/drinks.

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Cranial nerve What is examined? How is the test performed?

Basic hearing test: normally, the patient should be able

to hear two fingers rubbing together before the
Vestibulocochlear external acoustic meatus (ear canal).
VIII Hearing
nerve The Weber test and Rinne test allow sensorineural
hearing loss to be differentiated from conductive
hearing loss (see ENT diagnostic testing).

The physician performs a visual inspection of the

uvula and soft palate: asymmetry and uvula deviation
indicate impaired innervation
Gag reflex (pharyngeal reflex):
Palatal movement Normally, evoked by approaching the uvula
quickly and carefully with a spatula/long cotton
swab on each side.
Glossopharyngeal Absence of the gag reflex is indicative of nerve
IX,
nerve and vagus damage
X
nerve

The patient is given a bitter substance to taste: no

IX only: sense of taste
sense of taste indicates impaired innervation.

X only (recurrent
In case of lesion, the patient would have hoarseness or
laryngeal nerve):
bovine cough.
vocalization

Trapezius muscle: the patient's shoulder is elevated

Trapezius muscle and
against resistance
Accessory nerve XI sternocleidomastoid
Sternocleidomastoid muscle: the patient's head is
muscle (motor function)
rotated against resistance

The tongue should be pressed against the cheek from

Tongue muscles (motor
Hypoglossal nerve XII
function)
the inside, while the examiner tests the strength by
pushing from the outside.
Hypoglossal nerve paralysis: when the patients stick
out the tongue, it moves towards the impaired side

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References:[3]

Motor function
Upper motor neuron (UMN) injury vs. lower motor neuron (LMN) injury
Lower motor neuron lesion (LMN
Upper motor neuron lesion (UMN damage)
damage)

Lesion along the descending motor pathways

Lesion anywhere along the nerve
(corticospinal tract or pyramidal tract)
fibers between the ventral horn
Definition Typically before the anterior horn cell of the
of the spinal cord and relevant
spinal cord or motor nuclei of the cranial nerves
muscle tissue
(e.g., along motor cortex, brain stem)

Muscle Atrophied
Atrophy is absent
appearance Fasciculations

Peripheral paresis (flaccid

Central paresis (spastic paresis): pyramidal tract paresis): absent pyramidal tract
signs signs
Characteristics ↑ Tone, spasticity, and clonus ↓ Tone
↓ power in muscle groups ↓ Power in single muscle
Hyperreflexia fibers
Hyporeflexia/areflexia

Bladder Detrusor hyperreflexia and detrusor/external

Overflow incontinence
function urethral sphincter dyssynergia

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Upper motor neuron (UMN) injury vs. lower motor neuron (LMN) injury
Lower motor neuron lesion (LMN
Upper motor neuron lesion (UMN damage)
damage)

Positive Babinski sign (toes point upward,

abnormal)
Pronator drift test
The patient is asked to raise both arms
horizontally up to shoulder level, palms
facing upwards, with the eyes closed (for
30 seconds)
Absent Babinski sign (toes
Lowering or pronation of one arm is
Special tests neutral or point downward,
indicative of paresis.
normal)
Mingazzini test
The patient is asked to lie in the supine
position, with eyes closed, and is asked to
raise and hold both legs for 30 seconds
(90° angle at knee and hip).
Lowering of one leg is indicative of
paresis

Multiple sclerosis, tumor, stroke, Vitamin B12 Peripheral neuropathies,

Common
poliomyelitis (poliovirus), ALS
etiologies deficiency, ALS (both UMN and LMN signs) (both UMN and LMN signs)

Muscle appearance
Assessment: inspection and palpation of muscle groups
Findings
Fasciculation: involuntary, asynchronous contraction of muscle fascicles within a single motor unit;
usually benign but can signify a lower motor neuron lesion
Tenderness
Abnormal movements (e.g., tremor, tic, myoclonus)
Abnormal posture
Atrophy or hypertrophy (examined bilaterally)
Muscle groups are measured to compare specific differences in size.
In neurologic disorders, the small hand muscles are often affected by atrophy.

References:[3]

Power
Definition: maximal effort a patient is able to exert from an individual muscle or group of muscles
Assessment
The patient is asked to flex and extend extremities against resistance
Muscle power tests should be performed bilaterally for comparison
Muscle power grading
0 = no contraction (paresis)
1 = flicker or trace of contraction
2 = active movement, with gravity eliminated
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3 = active movement against gravity

4 = active movement against gravity and resistance
5 = normal power
Patterns of paresis distribution:
Quadriparesis: weakness in all four limbs
Hemiparesis: weakness in half of the body
Paraparesis: weakness affecting both upper or both lower extremities
Monoparesis: paresis affecting a single limb

References:[5]

Reflexes
Tendon reflexes
Definition: stretch, monosynaptic reflexes
Assessment
During reflex testing, the patient should be relaxed (at least the muscles involved in the reflex test
should be relaxed). (→ also see: radiculopathy)
Elderly patients may have reduced or absent lower deep tendon reflexes due to normal aging-related
changes in muscles and tendons
A reflex to test the integrity of a sensory and motor neuron circuit
Upon tapping of the reflex hammer, activation of the dorsal root ganglion causes firing of the
lower motor neuron for the agonist muscle and relaxation of the antagonist muscle, resulting
in automatic movement.
An increased DTR indicates an upper motor neuron issue, whereas decreased DTR indicates a
LMN, neuromuscular junction, or muscle issue.

Nerve root Tendon reflex Test

First, the examiner places his/her thumb on the patient's biceps tendon, then the
Biceps reflex examiner strikes his/her thumb with a reflex hammer and observes the patient's
C5– forearm movement.
C6
Brachioradialis Striking the lower end of the radius with a reflex hammer elicits movement of the
reflex forearm.
Upper The examiner holds the patient's arm (forearm hanging loosely at a right angle) and
limbs Triceps reflex taps the triceps tendon with a reflex hammer to induce an extension in the elbow
joint.
C7– This reflex is induced by tapping the terminal phalanx of a relaxed finger on the
C8 palmar side, while the examiner holds the patient's hand in level with the proximal
Finger flexor
phalanges. The test is positive when there is significant flexion in the terminal
reflex
phalanx of the tapped finger and the thumb, or when the flexion is very
asymmetrical comparing both hands.
Lower Adductor
Tapping the tendon above the medial condyle of femur elicits the adductor reflex.
limbs L2– reflex
L4 Striking the tendon just below the patella (leg is slightly bent) induces knee
Knee reflex
extension.
The tibialis posterior muscle is tapped with a reflex hammer, either just above or
Posterior tibial
L5 below the medial malleolus. The reflex is positive when an inversion of the foot
reflex
occurs.

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Nerve root Tendon reflex Test

Striking the Achilles tendon with a reflex hammer elicits a jerking of the foot
S1–
Ankle reflex towards its plantar surface. Alternatively, the reflex is triggered by tapping the ball
S2
of a foot from the plantar side.

Superficial reflexes
Definition: polysynaptic reflexes elicited by stimulation of the skin
Superficial reflexes are divided into two subgroups:
Physiological reflexes
Pathological superficial reflexes: in case of central motor neuron damage, the reflex response
decreases.

Nerve
Reflex Test
root
Abdominal reflexes are tested with the patient lying down. The anterior abdominal
wall is lightly stroked with a spatula from lateral to medial (bilaterally) in following
areas:

T6– Abdominal below the costal arch

T12 reflex around the umbilicus
above the inguinal ligament

A normal response is a contraction of the abdominal muscles, while the absence of

contractions is indicative of nerve root damage.

The reflex is elicited by stroking the medial, inner part of the thigh. A normal response
L1– Cremasteric
is a contraction of the cremaster muscle that pulls up the testis on the same side of the
L2 reflex
body.
Stroking the skin around the anus with a spatula elicits the anal reflex, which results in
Anal reflex
S3– a contraction of the anal sphincter muscles.
S5
Bulbocavernosus The reflex is elicited by squeezing the glans penis or clitoris, resulting in contractions
reflex of the pelvic floor muscles.

Primitive reflexes
Brief description: Reflexes that are are normal in newborns and infants, but not in adults, where they may
appear in case of diffuse brain injury due to lack of common inhibiting factors

Test
Sucking reflex Stroking the mouth induces sucking activity.
Palmar grasp
Stroking the palms elicits finger flexion.
reflex

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Test
Palmomental Stroking the ipsilateral thenar eminence from proximal to distal induces a short involuntary
reflex contraction of the mentalis muscle.

Corticospinal tract signs

Brief description
Corticospinal tract signs are indicative of damage to the pyramidal tract.
Babinski sign is the most common and thus most reliable pyramidal tract sign.
These reflexes occur physiologically in healthy infants

Test Sign
The examiner strokes the sole of a
Babinski
patient's foot on the lateral edge using, The sign is positive (pathological) when the big toe extends
sign
e.g., the handle of a reflex hammer (dorsiflexes), while the other toes fan out. The test is
Gordon The examiner compresses the calf inconclusive when only the big toe responds.
sign muscles

Babinski sign, although normal in newborns and infants, is always pathological in adults!

Do not confuse clonus with myoclonus! Myoclonus is arrhythmical and defined by sudden jerks of a muscle or
group of muscles while clonus is rather rhythmic and defined by repetitive contractions and relaxations of a
muscle group!

Tone
Definition: resistance of an individual muscle (or a group of muscles) to passive stretching
Assessment: passive movement of the extremities

Tests
Upper limb Lower limb

Elbow: The examiner flexes and fully

extends the patient's elbow.
Forearm: (while elbow in 90° position)
The patient is asked to relax the limbs while
The examiner supinates and pronates the
Tone lying in the supine position and then roll the
patient's hand.
legs from side to side.
Wrist: The examiner flexes and extends
and then twist the patient's wrist from
side to side.

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Tests
Upper limb Lower limb

Velocity-dependent phenomenon
The clasp-knife phenomenon: initial
Spasticity resistance due to increased muscle tone
is followed by a sudden decrease in
resistance.
The arm of the examiner is placed under the
patient's knee and the examiner briskly lifts the
patient's limb → increased muscle tone in limb

Velocity-independent phenomenon
Cogwheel rigidity: A resistance
Stiffness and/or inflexibility regardless of
Rigidity resembling a cogwheel movement is
movement
observed when the joint of a patient's
extremity is moved by the examiner.

Patellar clonus: The examiner grasps the

patient's patella between the index finger and
the thumb, quickly pushes it down distally, and
then holds it in this position.
Foot clonus
The examiner holds the patient's leg,
Wrist: The examiner hyperextends the with both knee and ankle resting in a
Clonus
patient's wrist. 90° flexion.
Then the examiner proceeds to dorsiflex
and partially evert the foot forcefully
multiple times while sustaining the
pressure.
Clonus is seen as a set of involuntary
contractions.

Sensation
Pathway Assessment Finding

To test for symmetry of touch Paresthesia: abnormal

sensation, the examiner touches the sensation (e.g., tingling,
patient's body at different locations prickling, or "pins and
bilaterally. needles")
In cases of suspected radicular Dysesthesia
Dorsal lesions, the particular dermatome Allodynia: painful
Light touch
columns should be examined individually. . sensation triggered by a
In cases of suspected peripheral stimulus that is not
nerve lesions, diagnostics should ordinarily considered
involve checking the areas painful.
innervated by the corresponding Hyperesthesia
sensory nerves. Hypesthesia

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Pathway Assessment Finding

Implements such as a broken

spatula can be used to test pain
sensation bilaterally (e.g., by gently Decreased (hypoalgesia)
prodding the patient with the or increased
Pain and Spinothalamic
object). (hyperalgesia)
temperature tract
Temperature sensation is tested sensitivity to nociceptive
using two objects of different stimuli
temperatures (e.g., two test tubes
with cold and warm water).

Abnormalities of
A tuning fork is hit and placed on a bony vibration are described
projection (e.g., medial malleolus). as mild, moderate, or
Pallesthesia The vibration amplitude and thus severe loss of vibration
Dorsal
(vibration the vibration intensity decrease sense (pallhypesthesia).
columns
sense) over time. Loss of vibration sense
The patient reports when the may also indicate a
vibration stops. peripheral neuropathy or
myelopathy.

To test proprioception, the most

distal joint of the big toe or the
Abnormalities of
distal interphalangeal joint of the
proprioception suggest
Proprioception Dorsal thumb are held by its sides and
peripheral
(joint position) columns moved up and down.
polyneuropathy or
The patient should be able to
myelopathy.
identify the positional change with
eyes closed.

See also “Overview” in incomplete spinal cord syndromes.

References:[3][6]

Coordination
Definition: ability to coordinate fluid movements
Assessment
Finger-to-nose test
Heel-knee-shin test
Rapid alternating movement test
Findings
Dysmetria
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Dysdiadochokinesia
See also cerebellar syndromes.

References:[3]

Gait assessment
Evidence for vestibular disorders, sensory or cerebellar ataxia (see “Diagnostics” in cerebellar syndromes)
Assessment
Observation of casual gait: The patient is asked to walk a few steps forwards and backwards.
Normal gait: steady, natural arm swing
Abnormal gait: broad-based or unsteady gait, short-stepping gait
Balance test: The patient is asked to place one foot directly in front of the other as if walking on a
tightrope
Foot drop test: The patient is asked to walk on their heels (impossible in the case of deep fibular
nerve lesions)
Walking on tiptoes (impossible in the case of tibial nerve lesions)

Description Examination Result

Positive Romberg: closing the

eyes impairs coordination
(patient starts swaying, or
swaying increases), which is
indicative of sensory ataxia.
Negative Romberg
Test for assessing ataxia The patient is Closing the eyes does
(vestibular, sensory, or asked to stand not affect patient's
cerebellar ataxia) with both feet balance (patient's
Romberg test
May help to distinguish together, raise swaying does not
between sensory and the arms, and increase).
cerebellar ataxia. close the eyes. Uncontrollable swaying,
even with eyes open, is
indicative of cerebellar
ataxia.
An increased tendency to fall
sideways after closing the eyes
indicates a vestibular disorder.

The patient is The test is positive when the

asked to walk patient rotates more than 45°
Unterberger Test for vestibular or on the spot around his/her central axis,
test cerebellar lesions with their eyes which is indicative of a
closed for 50 cerebellar lesion or vestibular
paces. impairment.

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Description Examination Result

Physiological: when standing

on one leg, the pelvis remains
level (no compensatory
movements of the upper body)
→ Negative Trendelenburg
sign
Pathological: pelvic drop
Tests for neurological towards the unimpaired,
insufficiency of the gluteus unsupported side → Positive
The patient is
Trendelenburg medius and gluteus Trendelenburg sign
asked to stand
sign minimus muscles, which Duchenne sign: torso tilting
on one leg
are innervated by the towards the contralateral side
superior gluteal nerve compensates the pelvic drop on
the unimpaired side.
Duchenne limp: the Duchenne
sign (frequently occurs
bilaterally) results in a
compensatory to‑and‑fro
movement of the torso during
walking

Signs of meningeal or nerve root irritation

Meningism
Definition: triad of nuchal rigidity; , headache, and photophobia, associated with irritation of the inflamed
meninges and/or spinal nerves
Examination: The examiner passively flexes the neck of the patient lying in the supine position.
Causes: subarachnoid hemorrhage (SAH), bacterial meningitis, etc.

Additional signs of meningeal or nerve root irritation

Straight leg raise test (root L5–S1)
Kernig sign: : in a supine patient, painful passive extension of the knee when the thigh is flexed at the hip
(knee at a 90° angle)
Brudzinski sign
Involuntary lifting of the legs provoked by passive flexion of the neck in a patient in supine position
Lifting of the legs reduces pain associated with tension of the irritated meninges and, especially, the
lumbosacral spinal nerves during neck flexion

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