Neurological Examination

NEUROLOGICAL SYMPTOMS

History Taking

Presenting symptoms
Handedness- tell is someone is more dominant on the right or left brain

Ask the pt. to tell the story in their own words without any interruption

How did it start?- timeline can be used to make differential diagnosis

e Complete Visual loss (for 1 minute)- impaired blood flow to the retina (amaurosis
feugax)

e Complete Visual loss for minutes- migraine visual loss

e Complete Visual loss for days slowly improving - Inflammation on the cranial nerve/
etiology

e Complete Visual loss for days slowly worsening= Tumor

Ask for the precipitating or relieving symptoms

If increasing ang headache- possibility of increased intercranial nerve pressure

Talk to patients with open ended question.

History does not make sense at all- difficulty in soeech, memory problem, concentration
problem, dementia, hysteria etc.

After taking the history- summarize and confirm (Chomping and Checking) to make
sure correct imong gibutang

Past medical history- past medical condition

e Hypertension- stroke or increased blood pressure- vascular restriction- hemorrhagic

hypertension

e Diabetes- peripheral neuropathy- increased blood sugar in blood stream- sluggish

circulation- less nutrients maabot sa nerve- decreased conduction velocity

e Drug History- know the side effects

e Family history- most neurological conditions have a genetic basis

Social History-status, community, financial support, family career

e can adjust the PT plan of care based on family- so they can assist them

Neurological Examination
 Level of Consciousness- awareness of our movement regards on person, place , time

e Arousal- level of alertness- Physiologic readiness for activity

Alert- mutubag ang patient ug tarong

Lethargic- tired

Obtunded- need constant stimulus

Stupor- stimulated by noxious stimuli

Coma- no response, unconscious

Glasgow Coma Scale- 3 minimum score

Rj
Apatie Hospitals

Verbal response
4: Spontaneous 5: Oriented 6: Obeys commands
3: Openstoverbalcom- 4: Confused 5: Purposeful movement
mand to pain
2: Opens to pain 3: Inappropriate 4: Withdraws from pain
1: None 2: Incomprehensible 3: Flexion/decorticate
posturing
1: None 2: Extension/decerebrate
posturing
1: None
The best response is recorded. The minimum score is 3.

Highest Score- 15

Neurological Examination
 EYES- 4

MOUTH- 5

MUSCLE- 6

Cognitive Function

e Memory

1. Declarative Memory/ Explicit

2. Procedural Memory

. Semantic Memory
wo

4. Episodic Memory

. Short Term Memory

o1

6. Long term Memory

Amnesia

1. Retrograde (Long term Memory)

2. Anterograde(Short term memory) - Worse

v Attention

e Selective Attention

e Divided Attention

e Alternating Attention

v Emotional Responses/ Behaviors

Vv Higher level cognitive abilities- AKA Executive Function

1. Volition

2. Problem Solving

3. Planning

4. Purposive Action

Cognitive Problems- see book

Mini Mental Status Exam

See notes

Ranchos Los Amigos Level of Cognitive Function- Look for in book

Neurological Examination
 Level
No Response: Total Assistance
I Generalized Response: Total Assistance
Ul Localized Response: Total Assistance
IV Confused/ Agitated: Maximal Assistance
Confused, Inappropriate Non-Agitated: Maximal
Assistance
VI Confused, Appropriate: Moderate Assistance
Automatic, Appropriate: Minimal Assistance for Daily
VII
Living Skills
VIII Purposeful, Appropriate: Stand-By Assistance
IX
Purposeful, Appropriate: Stand-By Assistance on
Request
Purposeful, Appropriate: Modified Independent

Level | No Response Needs Total Assistance

Level Il Generalized Response Needs Total Assistance

Level Ill Localized Response Neads Total Assistance

Level IV Confused-Agitated Response Needs Maximal Assistance

Level V Confused-Inappropriate Response Needs Maximal Assistance

Level V1 Confused-Appropriate Response Needs Moderate Assistance

Level Vil Automatic-Appropriate Response Needs Minimal Assistance

Level Vill Purposeful-Appropriate Response Needs Stand-By Assistance

Speech and Communication

Chain of process and speech (5 levels)

1. Hearing- Hearing loss/ Deafness

2. Understanding- Aphasia

3. Thought and Word finding- Aphasia

4. Voice production- Dysphonia

5. Articulation- Dysarthria

Types of Aphasia

Neurological Examination
 1. Broca’s Aphasia- non-fluent aphasia( MR- MOTOR, B- BROCAS, E-EXPRESSIVE,
A- ANTERIOR, N- NON-FLUENT)

2. Wernicke Aphasia-Fluent aphasia (Receptive, Posterior, Fluent Aphasia)

3. Conductive Aphasia- Damage to arcuate fasciculus

4. Transcortical sensory

5. Transcortical motor

Fluent

Yes No

Understands Understands
Yes No Yes No

| Conduction Aphasia
=» Damage to arcuate Damage to the arcuate fasciculus prevents the patient
from directly transferring speech sounds from Wernicke's
area to Broca’s area. The patient will have considerable
fa SC icu lu S a. difficulty repeating words, phrases, and sentences.

= Speech productionis “”" “route fascias

good. Werke
«» Comprehension is
good.
=» Sound substitutions
Indirect connections between .
are common. Boaisseaslowpainsis, =
speak fairly normally. auciory
=» Repetition is poor. cortex

Dysarthria- muscle weakness (types of dysarthria)

How to assess- Dysphonia- Ask name and address, ask sustained E, cough

Neurological Examination
 Normal ang cough- motor supply sa vocal cords is good

Dysphonia with normal cough- weakness of larynx or hysteria,

Problem with cough- Vocal cord palsy

e Cannot sustain E- possible myasthenia gravis

Vital signs

Blood Pressure Categories ce

meee eal et rere SYSTOLIC mm Hg DIASTOLIC mm Hg
(upper number) (lower number)

HIGH BLOOD
Pita acpi PRESSURE
toon 140 OR HIGHER jo | 90 OR HIGHER

a el
(consult your doctor immediately)
HIGHER THAN 180 HIGHER THAN 120

heart.org/bplevels
American Heart Associatian

Pulse

¢ Pulse abnormalities
— Bradycardia
* Pulse rate less than 60 beats per minute
— Tachycardia
+ Pulse rate greater than 100 beats per minute
— Premature ventricular contraction (PVC)
* Pulsation felt before expected
— Sinus arrhythmia
* Variation of rhythm sometimes occurs during respiration

¢ @ DELMAR ;
a@ CENGAGE Learning’ Copyright © 2010 Delmar, Cengage Learning, ALL RIGHTS RESERVED.

Neurological Examination
 Table 1. Vita | signs: normal
values in adults

Temperature S7°C
Heart rate 60-99
beats per minute
Pulse 60-99
beats per minute
Blood pressure 120/80mmHg
Respiratory rate 12-16
breaths per minute
Oxygen saturation 95-100%

pH hoanho

Table 1. Breathing patterns

Pattern Condition Description
LAPS _Eupnoea Normal breathing rate and pattern
VA Tachypnoea Increased respiratory rate
Svan OBradypnoea Decreased respiratory rate
Apnoea Absence of breathing

WAI Hyperpnoea Increased depth and rate of breathing

VW Cheyne-Stokes Gradual increases and decreases in respirations with
periods of apnoea

VOW BES Abnormal breathing pattern with groups/clusters of

rapid respiration of equal depth and regular apnoea
periods
NWN Kussmaul’s Tachyonoea and hyperpnoea

MMA Apneustic Prolonged inspiratory phase with a prolonged

expiratory phase

Neurological Examination
 GRADING OF TONE

* 0-4+ scale
= 0- No Response (flaccidity)
- 1+ Decreased response (hypotonia)
» 2+ normal response
* 3+ Exaggerated response (Mild to moderate hypertonia)
» 4+ sustained response (Severe hypertonia)

Pathologic Reflexes
Babinski Reflex
- Stimulus: Stroking of lateral
aspect of the sole of the foot
- Response: Big toe extension
and fanning of the 4 lesser toes
-Significanice: UMNL (Pyramidal
Tract Lesion)

Chaddocks Reflex
- Stimulus: Stroking of lateral
side of the foot beneath the
lateral malleolus
- Response: Babinski like
response
See
- UMNL (Pyramidal
Tract lesion

© Al titasheards CD AP Tilashcards

JAW JERK REFLEX- CN5

Neurological Examination
 Qualitative
Grade (%) calc Muscle strength

5 100 Normal rere range of motion (ROM) against gravity,

I 75 Good Complete ROM against gravity, with some resistance

3 50 Fair Complete ROM against gravity, with no resistance
2 25 Poor Complete ROM with a gravity omitted
1 10 ‘Trace Evidence of slight contractility, with no joint motion
0 0 Zero No evidence of muscle contractility

CN NERVE EXITS: https://teachmeanatomy.info/head/cranial-nerves/summary/

Kernig Sign

& Knee is flexed to 90 degrees

ca Hip is flexed to 90 degrees

eS Extension of the knee is painful or limited in extension

Brudzinski Sign

See

od Passive flexion of neck

Neurological Examination
 Dermatomes

SPASTIC VS FLACCID

Upper Motor Neuron (UMN) vs. Lower Motor Neuron (LMN)

—Syndrome
UMN syndrome LMN Syndrome

Type of Paralysis Spastic Paresis Flaccid Paralysis

Atrophy No (Disuse) Atrophy Severe Atrophy

Deep Tendon Reflex Increase Absent DTR

Pathological Reflex Positive BabinskiSign Absent

Superficial Reflex Absent Present

Fasciculation and Absent Could be

Fibrillation Present

Clasp Knife Reflex

Neurological Examination 10
 Clinical Connection:
Clasp-knife Phenomenon
¢« Limb moves freely for a short
distance, followed by a rapid
increase in resistance, followed by a
sudden giving way to movement

¢ Reflects the length dependence of

hyperreflexia

CLASP KNIFE REFLEX

* Oversensitive Golgi tendon
organs (loss of inhibitory
commands from UMN)

&
—,®
BSN,
Wa! | \. A Sy
“~y ie /L

Clonus

Neurological Examination 11
 Do | Have Clonus? Here's a test
Clonus is a condition that results in involuntary muscle spasms.
Several neurological conditions could be the cause of clonus, so there is a test to
determine whether it is clonus or another condition that is causing the muscle spasms.

» Perform a rapid dorsiflexion of the foot

Extension

ASS)
» Hold the foot with a slight tension with the
toes pointed towards you
Flexion

» On releasing the foot, if it jerks over 5 times, | Dorsifiexion

itis a clonus reaction

Sy
» On releasing if the foot returns back to
normal position, there is no clonus present.
» Similar procedure can be conducted on the | Pisa extension
wrist as well, posh oetee nono ernte una oesota none ___.=-Plantartemon|

ge My Healthy Choices For A Better Life

Testing for spasticity in the legs 2

(Clonus)
Position the patient with the
knee flexed and the hip
externally rotated
e Sharply dorsiflex the foot
In most people with normal
tone the foot will not move
Sustained clonusisa ° BUt 2-3 beats of clonus
sign of an upper motor (plantar flexion followed by
neurone problem dorsiflexion of the foot)
can be within normal limits
10A3/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 11

Neurological Examination 12
 Plantar Reflex
O Stroke the lateral aspect
of the sole from the heel
to the ball of the foot,
curving medially across
the ball
O Note movements of the
toes, normally plantar
flexion
Plantar reflex with down going
toes/Negative Babinski
Ante: ao be cometh pf O Np dilate related

Rigidity

Seo Se EG
Relax Lead-pipe rigidity Cog-wheel rigidity Spasticity

Little resistanceUniform resistance On-and-off resistance High to low resistance

E) b c q

DECEREBRATE AND DECORTICATE RIGIDITY

DECEREBRATE RIGIDITY DECORTICATE RIGIDITY

| Upperand lower limb extended Uppeglimb flexed and lower limb extended
Lesion below midbrain Lesion above midbrain
Temperature regulation absent Temperature regulation present
Not better outcome Better outcome
orton!

Neurological Examination 13
 s . TACT Decorticate Posture
Decorticate Posturing iis ,
. u Painful stimulus
A lesion rostralto the red nucleus that q
impairs corticospinal, produces
decorticate posturing. After a noxious
stimulus or spontaneously, the affected =
patient will flex the upper limbs and ,—
extend the lower limbs.
corticospinaltract
interrupted— mainly flexion impaired
* rubrospinaltract intact — flexion of the arms
‘ medullary reticulospinal tract intact— flexion of extremities
‘ pontine reticulospinal tract intact— extension of extremities
- vestibulospinal tracts intact — extension of extremities

Arms
In the arms, the flexor input of the rubrospinal tract is still intact. Hence, there is strong
flexor innervation, which is much greater than the extensor input of pontine reticulospinal
and vestibulospinal tracts.
Legs
For the lower limbs rubrespinal tract has almost no impact, hence the extensor innervation
is much more relevant, so the lower limbs are extended.

Decerebrate Rigidity
¥ Site of lesion > between the
superior and inferior colliculi of
the midbrain , lesion below Red
Nucleus , resulting in
¥ extensive extensor posture of all
extremeties > Rigidity of all 4
limbs
All limbs extended arms extended
<,

by the sides Q rotated internally

(outward)
(hallmark > elbows extended)
% Bekok

Head may be arched to the back

It is due to >
(1) increased general excitability
of the motor neuron pool >
especiallly Gamma efferent
discharge ( due to facilitato
effects of the un inhibited
Vestibulospinal Tract ) .

Neurological Examination
 Pediatrics

Opisthotonos

Definition:

« Opisthotonos isa type of abnormal posturing caused by strong muscle spasms.

* ft mainly affects babies and young children because their nervous systems have not
fully developed.
* Some of the conditions associated with it are serious, 50 prompt medical care is often
needed.

Description:

® The muscle spasms will cause child's back to be severely arched, and child's heels and
head will be bent back to an extreme degree.
« And child's hands and arms will move around ina stiff manner,
« The spasms can come aon suddenly and occur repeatedly,
* They can also occur in adults, but this is much less common.

Causes:
« Meningitis,

* Arnold-Chiari syndrame,
* Subarachnoid hemorrhage.
« Tetanus,
« Adrenergic bronchodilator overdose.

opisthotonus

Reflexes

Stretch reflex

Neurological Examination
 Stretch of muscle

Stretch of muscle spindle

(as intrafusal fibers are present
in parallel with muscle fiber)

Distortion of primary sensory endings

located al the center of nuclear bag fiber

Generation of action potential

in la afferent fibers

Stimulation of a motor neurons in the

spinal cord (as la fiber directly terminates
on a motoneurons in spinal cord)

Patellar Reflex

Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Motor nerve fiber

to quadriceps

@ Tap on patellar ligament excites nerve endings of muscle

Motor spindle in quadriceps femoris.
nerve fiber to - . : :
hamstrings @® Stretch signals travel to spinal cord via afferent nerve fiber
and posterior root.

® Afferent neuron excites motor neuron in spinal cord.

@ Efferent signals in motor nerve fiber stimulate quadriceps to

contract, producing knee jerk.

© Excitatory effect @) At same time, a branch of the afferent nerve fiber stimulates
© Inhibitory effect inhibitory motor neuron in spinal cord.
® That neuron inhibits motor neuron that supplies hamstring
muscles

@ Hamstring contraction is inhibited so hamstrings (knee

flexors) do not antagonize quadriceps (knee extensor}.

Withdrawal / Flexor Reflex

Neurological Examination 16
 Flexor (withdrawal) Reflex
* Step on tack (pain
fibers send signal to
spinal cord
* Interneurons branch to
different spinal cord
segments
* Motor fibers in several
segments are
activated
* More than one muscle
group activated to lift
foot off of tack

Deep tendon reflex

Jaw Jerk reflex

Neurological Examination 17
 Biceps —
wen’ brachii

a | ~ oe

tendon

Biceps Reflex

Superficial Cutaneous Reflex

Abdominal reflexes
The subject should be relaxed and in supine position with the abdomen
uncovered.
A light scratch with a key or blunt point, is given across the abdominal skin,
directed toward the umbilicus, in the upper, middle and lower regions.
Response: a brisk ripple of contraction of the underlying muscles.
Centers:
Upper abdominal: T8,9,10
Middle : T9,10,11
Lower abdominal: 110,11,12 segment of the spinal cord.

These reflexes are absent in : UMN lesions above their segmental level in the
spinal cord. They may indicate the segmental level of thoracic spinal cord
lesion by their absent.
They are difficultto elicit in obese, elderly, anxious subjects and after repeated
pregnancies due to loss of muscle tone.

Cremastieric Reflex

Neurological Examination
 Cremasteric reflex amt
Indication Evaluation of testicular pain in case of (Testicular Torsion).

Examiner strokes OR pinches the skin in the upper medial thigh. gk

Technique C ; 9
It causes contraction of the cramasteric muscle :
Observation | Rise of the Testicle on same side (normal)

NORMAL: It is present with Epididymitis.

interpretation | ABSENT: ino Testicle rise}, Is Suggestive of TESTICULAR TORSION.
iAlso ABSENT in 50% of boys under age 30 months }

Test Sensitivity for Testicular Torsion : 99%

Effica
Y Assumes age over 30 months
(L423)
Nerve
involved | Se"0ry: a o
Femoral branch of (GFN) & lioinguinal

*Do notuse this test under age of 30 months

Primitive or Spinal Reflex

Traction reflex

TRACTION RESPONSE
Sa

> Grasp the baby at his wrist and finger

re} ae o0||muemci|s
Certain degree of head
control is demonstrated and head is
brought forward actively

Grasp reflex

Neurological Examination
 » Begins at 32 weeks of gestation

» Light touch of the palm produces

reflex flexion of the fingers

» Most effective way -- slide the

stimulating object, such as a finger
or pencil, across the palm from the
lateral border

» Disappears at 3-4 months

» Replaced by voluntary grasp at 45

months

ATNR Reflex

Asymmetrical Tonic Neck Reflex

(ATNR)
Integratesby
~ 4-6 months

Flexion
of arm & leg
on the “skull”
side

STNR Reflex

Neurological Examination 20
 physloeulse
oe

Asymmetric Tonic Symmetric Tonic “Tonic Labyrinthine

Neck Reflex (ATNR) Neck Reflex (STNR) (TLR)

= an es
“hele
Carr CEIETIZiiCLD - 4-6 months
- 6 months
“WUerserrrrerre
«4-6 months
"12 monthsGuile ~ supine position, prone
~ flexion or extension of the position Gaui
head
- rotate infant's head to one - suplne: Imerease EXT fone’
side, hold for ¥ sec. Cain EXT of all lirabs
Guay samt ban Oe FLEX Of UEEEXT = _ prone: increase FLX tone’
cE a
ia arecaterie Face with head extension: EXT of WES pitta
2 FIER ot le fae
~ lf persist may interfere with
vif persist tay interfere with ~ It peralat many Interfere with propping jhitistion of ralling, prapping
on
feeding, viaual tracking, mldling eae of armain prane, “s helen elbows with hips extended in prone,
of hands, bilateral hard use, rolling & peaifion, reciprocal crawling, sifting pryg hip flexion froma sepine fo
development of crawting balance when looking around sitting

Positive Suporting

Positive support reflex

JElicited when placing weight on
the sole of the foot or pressure is
given against the sole of the foot
resulting in extension of legs

Associated reactions

Neurological Examination
 Name - Associated reactions
Onset - birth/ 3months
Integrated - 8-9 yrs
Stimulus - Resisted voluntary
movement in any part of body.
Response - Involuntary movements ina
resting extremity.

Manual Muscle Testing

MRC SCALE EXPLANATION i

0 No contraction

1 Flickering contraction

2 Full Range of Motion with eliminated gravity

3 Full Range of Motion with Against gravity

4 Full Range of Motion with Against gravity

with minimal resistance

5 Full Range of Motion with Against gravity

with maximal resistance

Examination for Coordination

Neurological Examination 22
 Principal type of Specific motor skills Motor activities
motor skills

Grass motor skills © Locomotor skills Hopping on ane leg

Long jump
Balance Dynamic Walking heel-to-toe
Jumping in place
Static Squatting with arms
extended horizontally
Standing on one leg
Object Control skills Propulsive skills Vertical throwing
Horizontal throwing
Receptive skills Catching a ball
Catching a bouncing
ball
Fine motor skills Fine Motor Coordination Tying a pencil
Touching fingertips
Fine Motor Integration Copying shapes
Copying letters, words,
and numbers

Modified Clinical test for Sensory interaction in Balance

Neurological Examination
 FALL PROOF PROGRAM: CENTER FOR SUCCESSFUL AGING,
CAL STATE
FULLERTON
Modified Clinical Test of Sensory Interaction in Balance
(CTSIB-M)
* Addmbmiiter goby ony drial per comlition i parrichmant able be cemepdete (led irl) sinbeort Joy of Lines:
Condition One: Eyes Open, Firm Surface
Trial One Total Time: | Mise
Trial Two Total Tire: / Misee
Trial Three Total Time: / Msee

Condition Two: Eyes Closed, Firm Surface

Trial Cme Total Time: / 30sec
Tral Two Total ‘Time: | BMsec
Trial Three Total Time: / see
Condities Tiree: Eyes Open, Foam Surface
Trial Qne Total Time: / Msec
Trai Two Total Time: i Bseec
Trial Three Total Time: / 30sec
Candition Four; Eyes Clased, Foam Surfoce
Trial One Total Time: ( BMsee
Tral Two Total Time: i Mesec
Trial Three Total Tite: {Bi sec
TOTAL: i 20
see

Purpose of Test:

This tes in desipned to meee how well an older adult ie aeing sensory inpum when ono or men: sensary
saicms are compromised. in corslition one, all sensery sysiems (he vnien, somuioemmcey, anil
vestibalar)
are available for maintaining balance. In condiien nan, vision has been removed and che older
adult mort rely on the somatosensory and vestibular systems to balance, In condition three, the
tomatiowemory svilem has been compromised and the older adults must wee vison and the vestibular
avalon te halines. In conditbon four, vision kas been nemoved and tle samatenimory svslom haa boon
compeomingd, “The older adults mun nod rely pearly an the wearibular iepute to balance,

Regie timing each trial esing a storwatch. The trial is over when (a) the participant opens
histher eves in an cyes closed condition, (bj) ruises arms from sides, (c) loses balance ood
requires manual wssistance to preveni a fall.

‘Thiet test prewiles some imeght into whether each of ihe epnesey yates availsble dor halenge are being uml
Ofeviively Filan to maivion balance iy Cities bo imdicoiot thai (he alder adiatie oo viewally dopomient. They
are fot walg) aeUOcreay Inpurs io mamas balance when eves age cloied, Failure to jedisenan balance i
conditions 3 and 4 indicate than the viswal andor vestibular memem & not being eed te maintain balance. Boor
performson thes es) would suggest the nped fier multisensory traimimg if the mediel history dows not indicate that

Neurological Examination 24
 BALANCE modified
;
4 balance conditions: » Patientisasked
areca tranaert iesto
wi hands at sides, feat ae en iE

Patient relies on all 3 sensory systems

Relies on a primary sensory systems With vision removed: pallet must

rely on vestibular & somatosensory

Visual info of where ie}

@ @ our body is relative
to other objects With somatosensory compromised,
patient must rely on vision & vestibular

Al I Il
Info about motion and equilibrium Sitahy-diior reeneuee ane
.
from vestibular system in inner ear scrnntinsenscay corneal
| patient must rely on vestibular

Proprioception (where our body is in

space) from skin, muscle, & joints: S e
and pressure on bottom of foot = =
we ish

Steping Stategies

Ankle strategy Hip strategy

Paraspinals Abdominals

Hamstrings Quadriceps
Forward
sway | Gastrocnemius

Abdominals U Paraspinals ‘Y

Quadrice \ { Hamstrings., |
Backward e \ ’ |
sway Tibialis (
anterior | "

Ankle Strategy- distal to proximal

Neurological Examination
 ( a Ankle Strategy
e Used when
perturbation is
a 4

° Slow
° Low amplitude
e Contact surface firm,
wide and longer than
foot
e Muscles recruited
distal-to-proximal
e Head movements in-
phase with hips

Stepping Strategy

| Stepping Strategy
Vor
f

\(__ ® Used to prevent a fall

~» Used when
perturbations are fast
or large amplitude -
or when other
strategies fail
e BOS moves to “catch
up with” BOS

Hip Strategy- Proximal to distal

Neurological Examination 26
 ip Strategy

Used when
perturbation is fast or
large amplitude
Surface is unstable or
shorter than feet
Muscles recruited
proximal-to-distal
Head movement out-
of-phase with hips

Cranial nerve exits

Neurological Examination 27
 ULTT

WTTI UTT2 = wTT3 UTT4

Median and Anterior Median, Axillary and Radial Nerve Bias Uinar Nerve Bias
Nerve Bias Interosseous Nerve Bias Musculocu taneous Nerve
Bids oe
‘Shoulder | Depression and abduction Depression and Depression and Depression and
(110°) abduction (10°) abduction (10°) abduction (10° to 90°)
with hand to ear
(waiter’s position)
Extension Extension Extension Flexion

Forearm pn ie i
Wrist Extension Extension Flexion and Winar Extension and Radial
deviation deviation
Fingers and Extension EXtension Flexion Extension

Thumb
Shoulder eoereeee Lateral rotation Medial rotation Lateral rotation

ical spi Contralateral side Contralateral

side | ‘Contralateral side Contralateral side
Cervic spine flexion Flexion flexion flexion

ULNT coun
* Shoulder girdle stabilization
* Shoulder abduction
+ WristAlinger extension
+ Forearm supination
* Shoulder external rotation
» Elbow extension
» Structural differentiation
- Cervical sidebending
Release wrist extension

ULNT? sere
» Shoulder circle depression
* Elbeay extension
+ Shoulder external rotation and forearm
supination
+ WristAinger extension
* Shoulder abeuction
* Structural ditferentiation
- Cervical sicebend ng
~ Release shaulcer girdle depression
- Release wrist extension

ULNT, RarMal
+ Shoulder girdle depression
* Elbow extension
* Showlder internal rotation and forearm
pronation
» Wristfinger flexion
» shoulder abduction
* Structural ditferentiation
Cervical sicebending
Release shouleer gine depression
- Release wrist tlexion

ULNT yen
+ Wrist4inger extension
* Forearm pronation
* Eben flexion
* Shoulder external rotation
* Shoulder girdle depression
* Shoulder abouction
* Structural differentiation
Cer <al sicebending
- Release shoulder girdle depression
- Release wrist extension

Neurological Examination 28
 SLR Test

Straight leg raise test (SLR)—

p.347, fig. Box 10-9

Supine with knees extended °* 'f pain does not recur:

PROM hip flexion to point of Tight hamstrings
discomfort or end of range
4 hip flexion and move into
passive dorsiflexion
(+) = pain reproduced and -
recurs with reduced SLR
(-) =pain reproduced but does
not return with reduced SLR

Prone Knee Bend Test

Neurological Examination 29
 Prone Knee Bend Test
Purpose: To determine the contribution of neural
tension to the patient's symptoms.

Test Position: Prone.

Performing the Test: The examiner passively

flexes the patient's knee to end range and
maintains it there for 45 seconds. The hip should
not be rotated. Pain in the anterior thigh may
indicated a tight/strained quadriceps muscle or
neural tension of the femoral nerve. Pain on the
unilateral lumbar area, buttock, or posterior
thigh may indicate lumbar radiculopathy of L2-L3
nerve roots.

Diagnostic Accuracy: Unknown.

Importance of Test: The position knee flexion

puts a stretch on the femoral nerve and its nerve
rootlets due to the nerve passing on the anterior
side of the lower extremity. Should the femoral
nerve become adherent to the tissues it passes
by in the lower extremity, pain or other neural
symptoms may be produced in that area. Since
the test places the entire nerve and its rootlets
on tension, the test may also indicate radicular
pain or pain originating as a result of irritation to
the spinal structures. While the test may indicate
irritation of the nerve roots L2-L3 due to the

Neurological Examination 30
 Brachial plexus

DIVISIONS TERMINAL BRANCHES

cs i
awae ff}
MUSCULOCUTANEOUS RN.

I SUPERIOR 2 #
P = 2 AXILLARY Ni.
cé l o = Pi

N 1 é #
| 7 é é
; ! MIDDLE 2 P |
diy MEDIAN N,

LONG THORACIC HN, \ ; Pz oF \

RADIAL N.

| | ] f o é 1
ce I | P 1 - és I
l if f f
ULNAR N,

a a INFERIOR la | |
I I
n A= ANTERIOR i
l | | I
| | P=POSTERIOR | |

Lumbar Plexus

LUMBAR PLEXUS
ANTERIon Division

Postemok Diwision

Mio NERVE (TI)

ILIOHYPOGASTRIG. NERVE (Li)

——
LI ILIOINGUINAL NERVE (Lt)
GENITOFEMORAL
Nerve (ui, L) LATERAL FEMORAL CUTANEOUS
NERVE (2, L3)
ie
NERVE TD IWAcus
2 SOAS MUSCLES
L3
= OeTURATOR FEMORAL NERVE (Lo, v3, La)
NERVE

L4

L5
LUMBOSACRAL Teun:
(uy,s)

Neurological Examination 31
 https://s3-us-west-2.amazonaws.com/secure.notion-static.com/b975f431-9d48-4
436-8fcc-4f3ca/0b964f/256522176-Brodmann-Areas-and-Cortical-Functions.pdf
Brodmann Area
Functional Area
23 7° somatosensory cortex
4 1° moter cortex
3 somatasensory cortex,
posterior parietal
assochation
6 Supplementary motor
control, supplementary
eye field, premotor
adjacent cortex
Supplementary eye field,
premotor adjacent cortex
Cortex; frontal eve fields
7 Posterior parietal association
5 Frontal eye fields
9,170,171, 12 Prefrontal association
cortex
Frontal eve fields
13, 14, 15, 16
‘ie Primary visual cortex
18 Secondary visual cortex
19 Tertiary visual cortex,
nviddle
Temporal visual area
20 Yisual inferotemporalarea
21 Visual inferotemporal area
22 Higher order auditary cortex
23, 24, 25, 26, 27 Limbic association cortex
28 Primary olfactory cortex,
limbic association cortex
29, 30,31, 42, 33 Limbic association cortex
34, 35, 36 Primary olfactory cortex;
limbic assoclathon cortex
Neurological Examination
Location Function
Postoentral gyrus Touch
Precentral gyrus. Voluntary motor control
Superior parietal lobule Stereagnasis
Precentral gyrus and Limb and eye movement planning
rostral adjacent cortex
Superior parietal lobule Visuomotor control, perception
Superior, middle frontal Satcadic eye movements
Gyrl, medial frontal labe
Superior, middle frontal Thought, cognition
Gyri, medial frontal labe Movement planning
Insular cortex
Banks of calcarine fissure = Vision
Medial aind lateral Vision, depth
Occipital gyri
Medial and lateral Vision, color, motion
Occipital qyri Depth
— Inferlor temporal qyrus Form vision
= Middle temporal gyrus Form vision
Superior temporal gyrus == Hearing, speech
Cingulate gyrus, Emotions
subcallosal area,
retrosplental area,
parahippocampal qyrus
Parahippocampal qynus Smell, emations
Cingulate gyrus and Emotions
limbic association
COntex
Parahippacampal gyrus Smell, emotions.
32