NEUROLOGICAL

EXAMINATION AND
EVALUATION FOR
PHYSICAL
THERAPISTS
Dominic F. Garrucho, PTRP
Reference:
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AT THE END OF THIS SESSION,
THE INTERN WILL BE ABLE TO:
1. Describe the principles of neurologic examination in physical therapy.
2. Create an assessment plan for a patient with neurological deficits.
3. Perform neurologic examination procedures correctly for a given
patient.
4. Evaluate the applicability of physical therapy interventions to a
specific impairment.
 OUTLINE OF THE
STANDARD NEUROLOGIC
EXAMINATION
1. History and observation
2. Level of Consciousness
3. Cognitive, Speech, and Communication Functions
4. Vital signs and their changes in neurologic disorders
5. Signs of Increased Intracranial Pressure
6. Autonomic Nervous System Function
7. Sensory Function
8. Perceptual and Spatial Function
9. Motor Function (Control, Coordination, Balance, and Posture)
10. Outcome Measures
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HISTORY AND OBSERVATION

• Much of the NE is done during the history.
• Observation is done as the patient answers
questions.
1. Check Dermatomes
Spinal Cord Lesion 2. Assess myotomes
3. Bowel and Bladder function

1. Memory
Cerebral Lesion 2. Aphasia
3. Apraxia
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QUESTION
A Physical Therapist is about to see a patient with Parkinson’s Disease for the first
time. The folks of the patient called earlier that he has not taken his medication yet
but is scheduled for therapy. Which of the following signs would the patient MOST
LIKELY to exhibit during the session?

a. Increased spasticity during ROM of the UE

b. Presence of tremors in the distal hand during vital signs assessment
c. Difficulty with recalling certain events and details in the past
d. Loss of speech with substitution of facial movements for communication
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LEVEL OF CONSCIOUSNESS
✓ Determine orientation to person, place, and time.
✓ Determine response to stimuli
✓ Determine level of consciousness

a. Alert: Responds appropriately

b. Lethargy: Appears drowsy; falls asleep easily
c. Obtunded: Patient can open eyes, look at examiner, but responds slowly and is confused.
d. Stupor: Patient can only be aroused using painful stimuli.
e. Coma: Patient cannot be aroused, eyes remain closed; no response to external stimuli
f. Vegetative state: Return of sleep/wake cycles, vegetative functions, but lack of cognitive
awareness
g. Minimally conscious state: Severely altered consciousness with minimal self or environmental
awareness.
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GLASGOW
COMA
SCALE
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QUESTION:
A physical therapist is assessing a patient’s Glasgow Coma Scale at the bedside.
What is the patient’s score based on these findings: when you arrive to the
patient’s bedside the patient is looking around, the patient tells you they are at a
concert hall and the year is 1960 (it is 2022) but they state their correct name, and
they are open to successfully open their mouth and stick out their tongue.
A. GCS 14 (E4 V4 M6)
B. GCS 11 (E3 V3 M5)
C. GCS 15 (E4 V5 M6)
D. GCS 13 (E4 V3 M6)
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QUESTION
A young adult who is comatose (Glasgow Coma Scale score of 3) is transferred to
a long-term care facility for custodial care. On initial examination, the therapist
determines the patient is demonstrating decerebrate posturing. Which limb or
body position is indicative of this?

a. The upper extremities in flexion and the lower extremities in extension.

b. Extreme hyperextension of the neck and spine with both lower extremities
flexed and the heels touching the buttocks.
c. All four limbs in extension.
d. All four limbs inflexion.
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COGNITIVE FUNCTIONS
Memory:
a. Immediate recall: name three items previously presented
after a brief interval (i.e., 5 minutes).
b. Recent memory (short-term): recall of recent events
(i.e., What did you have for breakfast?).
c. Remote memory (long-term): recall of past events
(i.e., Where were you born? Where did you grow up?).
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COGNITIVE FUNCTIONS
Attention.
a. Length of attention span: digit span retention test
b. Ability to attend to task without redirection (sustained
attention)
c. Ability to shift attention from one task to another (divided
attention)
d. Ability to stay on task in presence of detractors
(focused attention)
e. Ability to follow commands: one- or two-step, multilevel
commands.
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COGNITIVE FUNCTIONS
Emotional Responses/Behaviors

a. Safety, judgment: impulsivity and lack of inhibition.

b. Affect, mood: irritability, agitation, depression, and withdrawal.
c. Frustration tolerance.
d. Self-centeredness (egocentricity).
e. Insight into disability.
f. Ability to follow rules of social conduct.
g. Ability to tolerate criticism
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COGNITIVE FUNCTIONS
Higher Level Cognitive Abilities
a. Judgment, problem solving.
b. Abstract reasoning.
c. Fund of general knowledge: current events, ability to learn new
information, generalize learning to new situations.
d. Calculation: serial 7 test ( count backward from 100 by 7s).
e. Sequencing: ability to order components of cognitive or functional
task; assess if cueing is necessary, frequency of cues.
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QUESTION
A 77 year old male patient with Alzheimer’s disease is scheduled for
therapy. Arriving in the rehab, the therapist decides to use a mirror to
stimulate movements in the upper extremity. What is the rationale for
the procedure?

a. The mirror improves sustained attention for the patient

b. Internal feedback is provided by the mirror
c. Alzheimer’s disease presents with unilateral neglect thus improving
patient awareness
d. The mirror improves long term memory for the patient
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SPEECH AND COMMUNICATION

NONFLUENT VERBAL DYSARTHRIA RECEPTIVE GLOBAL

APHASIA APRAXIA APHASIA APHASIA

Speech is awkward, Impairment of Impairment of

Speech is preserved
restricted, Volitional speech production Impairment in
while auditory
interrupted, auditory articulatory control from damage to speech and auditory
comprehension is
comprehension is due to a cortical central or peripheral comprehension
impaired
preserved lesion nervous system
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QUESTION
In the ICU, the therapist examines a patient with multiple hemorrhagic clots in
the brain. During the assessment of speech, the therapist deems that the patient
has difficulty with repetition but is fluent and can understand given instructions.
What does the patient have?

a. Transcortical Sensory Aphasia

b. Transcortical Motor Aphasia
c. Conduction Aphasia
d. Wernicke’s Aphasia
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VITAL SIGNS
• Examine for any irregularities in pulse: bounding, thread
• Examine for changes in response to activity: normally, HR increases in
direct proportion to intensity of exercise; SBP increases, while DBP
remains the same or decreases moderately (a widening of pulse
pressure).
• With increasing intracranial pressures, examine for changes in HR and
BP that occur late
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VITAL SIGNS
• Cheyne-Stokes respiration: a period of apnea lasting 10-60 seconds
followed by gradually increasing depth and frequency of respirations;
accompanies depression of frontal lobe and diencephalic dysfunction.
• b. Hyperventilation: increased rate and depth of respirations;
accompanies dysfunction of lower midbrain and pons.
• c. Apneustic breathing: abnormal respiration marked by prolonged
inspiration; accompanies damage to upper pons.
• d. Increased body temperature: Indicates infection or damage to the
hypothalamus or brainstem.
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QUESTION
• During vital signs assessment, the patient with a 2 month post-stroke history
complains to the therapist that she is feeling dizzy and lightheaded. She has not
started with the treatment session and she also has a history of type 2 diabetes
mellitus. Which of the following changes in the vital signs is expected for this
patient?

a. Decrease in heart rate and blood pressure

b. Increase in heart rate and decrease in blood pressure
c. Decrease in heart rate and increase in blood pressure
d. Increase in heart rate and blood pressure
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QUESTION
A patient 55 years old male, was admitted to the hospital with the
history of MVA and severe spinal cord injury. During the initial
examination of the patient was sat up on the edge of the bed. On
sitting, the patient showed raised in blood pressure and excessive
sweating with the chief complaint of severe headache. What is the
possible reason for the symptoms?

A. Activation of the sympathetic nervous system

B. Activation of the parasympathetic nervous system
C. Orthostatic hypotension
D. Increased ICP
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CNS INFECTION OR
MENINGEAL IRRITATION
KERNIG SIGN BRUDZINSKY SIGN

a. Patient is positioned in a. Patient is positioned in

supine; flex hip and knee supine; flex neck to chest.
fully to chest, and then b. Positive sign: causes
extend knee. flexion of hips and knees (
b. Positive sign: causes pain drawing up); suggests
and increased resistance to meningeal irritation.
extending the knee due to
spasm of hamstring; when
bilateral, suggests meningeal
irritation.
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INCREASED ICP
✓Restlessness and confusion decreasing levels of
consciousness, unresponsive, and coma
✓Increased BP
✓Widening pulse pressure
✓Bradycardia
✓Cheyne-Stokes respirations
✓Elevated Temperature
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INCREASED ICP
✓Headache and vomiting (Irritation of CN 10)
✓Pupillary changes (CN 3 signs)
- Examine for ipsilateral dilation of pupil, slowed
reaction to light progressing to fixed dilated pupils
(poor prognosis)
✓Progressive loss of motor function
✓Seizures
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QUESTION
A Physical Therapist is treating a patient who is in a persistent vegetative state
following a Traumatic Brain Injury. During PROM, the therapist observes that the
patient has their eyes opened but both pupils are dilated, systolic blood pressure
continues to rise but heart rate plummets down to 45 beats per minute. What is the
BEST course of action of the therapist?

a. Stop the exercise but continue to monitor vital signs

b. Position the head of the patient in a trendelenburg position
c. Position the head of the patient in a reverse trendelenburg position
d. Stop the exercise and call emergency services
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SENSORY FUNCTION
✓ Ask a patient to describe where sensation does not feel normal.
✓ Use sensory dermatomal charts
✓ TEST SUPERFICIAL, FOLLOWED BY DEEP, AND THEN COMBINED
CORTICAL
✓ Occlude vision
✓ Apply stimulus in random, unpredictable order; avoid summation
✓ To assess responses, always pose a choice (e.g., hot or cold)
✓ Examine for objective manifestations: withdrawal, wincing, blinking.
✓ Consider skin condition (calluses, scars) for areas desensitivity.
✓ Look for signs of repetitive trauma, skin lesions.
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QUESTION
The therapist is examining a patient for deep sensation function. If the patient scored
as “2” in the sensory function for the whole upper extremity but “1” in the affected
lower extremity, this would be documented as:

a. Patient manifests normal deep sensation in the UE but absent deep sensation in
the lower extremity.
b. Patient manifests absent deep sensation in the upper and lower extremity.
c. Patient manifests impaired deep sensation in the lower extremity and normal
deep sensation in upper extremity.
d. Patient manifests normal deep sensation in the lower extremity and impaired
deep sensation in upper extremity.
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QUESTION
• A patient with an incomplete spinal cord injury at C7 presents
to physiotherapy. The therapist performs the sensory test
pictured below. The test assesses the integrity of which spinal
tract?
• A. Lateral spinothalamic
• B. Spinocerebellar
• C. Corticospinal
• D. Dorsal column-medial lemniscus
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PERCEPTUAL FUNCTION
• Suspect perceptual dysfunction if the patient has
difficulty with functional mobility skills or activities of
daily living for reasons that cannot be accounted for by
specific sensory, motor, or comprehension deficits.
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PERCEPTUAL FUNCTION
• Test for Homonymous Hemianopsia
Loss of half of visual field in each eye, contralateral to
the side of a cerebral hemisphere lesion.

• Slowly bring two fingers from behind head into the

patient's visual field while asking the patient to gaze
straight ahead; the patient indicates when and where
the fingers first appear.
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PERCEPTUAL FUNCTION
• Body scheme disorder (somatognosia): have patient
identify body parts or their relationship to each other.
• Visual spatial neglect (unilateral neglect): determine
whether patient ignores one side of the body and
stimuli coming from that side.
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PERCEPTUAL FUNCTION
• Right/left discrimination disorder: have patient
identify light and left sides of his or her own body and
your body.
• Anosognosia: severe denial, neglect or lack of
awareness of severity of condition; determine whether
patient shows severe impairments in neglect and body
scheme.
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SPATIAL RELATIONS
• Figure-Ground Discrimination: Have patient pick out
an object from an array of objects.
• Form constancy: Have patient pick out an object from
an array of similarly shaped but different sized objects.
• Spatial Relations: Have patient duplicate a pattern of 2
or 3 blocks.
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SPATIAL RELATIONS
• Position in space: have patient demonstrate different
limb positions
• Topographical disorientation: determine whether
patient can navigate a familiar route on his or her own.
• Depth and distance imperceptions: determine whether
patient can judge and distance
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SPATIAL RELATIONS
• Vertical disorientation: determine whether patient can
accurately identify when something is upright.

AGNOSIA AND APRAXIA
EXAMINE FOR AGNOSIA
• Inability to recognize • Inability to perform
familiar objects with one
sensory modality while
retaining ability to
recognize same object
with other sensory
modalities.
44
EXAMINE FOR APRAXIA
voluntary, learned
movements in the
absence of loss of
sensation, strength,
coordination, attention,
or comprehension.
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MOTOR FUNCTION

MUSCLE BULK, SPASTICITY FLACCIDITY FATIGUE REFLEXES

FIRMNESS
Increased resistance to Deep Tendon,
Examine by PROM Seen in LMN Source of fatigue
Superficial
inspection, • Clasp-Knife Briefly seen in Frequency and
Cutaneous,
palpation, and • Clonus spinal shock severity of fatigue
• Babinski Primitive
girth patients episodes
Reflexes
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SUPERFICIAL CUTANEOUS REFLEXES

Cremasteric Reflex
Stroke the thigh downward with a cotton
tipped applicator or a handle of reflex
hammer. A normal response in the males
is an upward movement of the testicle
(Scrotum) on the same side. The absence
of cremasteric reflex indicates the SCI
distribution at the T12-L1 level
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SUPERFICIAL CUTANEOUS REFLEXES

Abdominal Reflex
Applying as stroking motion a cotton-
tipped applicator (or handle of the reflex
hammer) toward the umbilicus A
positive sign of neurological impairment
is observed if the umbilicus moves
toward the stroke The test can be
repeated in each abdominal quadrant
(upper abdominal T7-9; lower abdominal
T11-12)
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QUESTION
A patient presented to the physiotherapy clinic with the
complaints of pain and loss of balance with recurrence of falls in
last one week. On reading the charts, therapist noticed that
patient suffered distraction injury at the neck and suffered
weakness in the elbow flexion and wrist flexion. Which of the
following would be the best site to elicit the reflex?
A. Elbow for Biceps reflex
B. Elbow for Triceps reflex
C. Elbow for Supinator reflex
D. Elbow for ECRB
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MODIFIED
ASHWORTH SCALE
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PASSIVE MOTION
TESTING
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COORDINATION 51
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POSTURAL CONTROL 52
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QUESTION
A therapist is examining a patient with poor motor coordination. During
observation, when the patient is standing erect and still, she does not
respond appropriately when correcting backward sway of the body. With
the body in a fully erect position a slight backward sway should be
corrected by the body firing specific muscles in a specific order. Which of
the following is the correct firing order?

A. Bilateral abdominals, bilateral quadriceps, bilateral tibialis anterior

B. Bilateral abdominals, bilateral tibialis anterior, bilateral quadriceps
C. Bilateral tibialis anterior, bilateral abdominals, bilateral quadriceps
D. Bilateral tibialis anterior, bilateral quadriceps, bilateral abdominals
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OUTCOMES
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OUTCOME MEASURES

BODY ACTIVITY PARTICIPATION

STRUCTURE/ LIMITATIONS RESTRICTIONS
FUNCTION
EVALUATION:
Task:
1. Describe the method that therapist used
to identify an impairment, activity
limitation, and participation restriction.
2. Given a certain patient, the group must
rationalize their intervention of choice for
a particular impairment.
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