Assessment of Neurologic Function

Chapter 60
Assessment of Neurologic
Function
Copyright © 2008 Lippincott Williams & Wilkins.
Function of the Nervous
System
• Controls all motor, sensory, autonomic,

cognitive, and behavioral activities
• The brain itself contains more than 100

billions cells that link the motor and sensory
pathways, monitor the body’s processes,
respond to the internal and external
environment, maintain homeostasis, and
direct all psychological, biologic, and physical
activity through complex chemical and
electrical messages.
Structures of the
Neurologic System
• Central nervous system
–Brain and spinal cord
• Peripheral nervous system
–Includes cranial and spinal nerves
–Autonomic and somatic systems
• Basic functional unit: neuron

Neuron
Dendrites - branch-type
structures for receiving
electrochemical messages
(TOWARD cell body)
Myeline sheath – increases
Axon – long projection that
speed of conduction
carries impulses AWAY
from cell body
Neuroglial cells – serve to support, protect, and nourish neurons; 50x greater in
number than neurons
Neurotransmitters
• Communicate messages from one neuron to another

or to a specific target tissue
• Manufactured and stored in synaptic vesicles
• Neurotransmitters can potentiate, terminate, or

modulate a specific action or can excite or inhibit a
target cell
• Many neurologic disorders are due to imbalance in

neurotransmitters
• Eg: Parkinson’s (↓dopamine), Myasthenia gravis (impaired

binding of acetylcholine to muscle cells)
Neurotransmitters
NEUROTRANSMITTER SOURCE ACTION
Acetylcholine (major transmitter Many areas of the brain; Usually EXCITATORY: parasympathetic
of the parasympathetic autonomic nervous system effects sometimes INHIBITORY
nervous system) (stimulation of heart by vagal nerve)
Serotonin Brain stem, hypothalamus, INHIBITORY, helps control mood and

dorsal horn of the spinal sleep, inhibits pain pathways
cord
Dopamine Substantia nigra and basal Usually INHIBITS, affects behavior

ganglia (attention, emotions) and fine movement
Norepinephrine (major Brain stem, hypothalamus, Usually EXCITATORY; affects mood and
transmitter of the postganglionic neurons of overall activity
sympathetic nervous system) the sympathetic nervous
system
Gamma-aminobutyric acid Spinal cord, cerebellum; INHIBITORY
basal ganglia, some cortical
(GABA)
areas
Enkephalin, endorphin Nerve terminals in the EXCITATORY; pleasurable sensation,

spine, brain stem, thalamus INHIBITS pain transmission
and hypothalamus,
pituitary
Copyright ©gland
2008 Lippincott Williams & Wilkins.
Brain

The Brain
• Accounts for approximately 2% of the total body

weight
• Average young adult = 1400 g
• Average elderly person = 1200 g
3 major areas
• Cerebrum: left & right hemispheres, thalamus,

hypothalamus, basal ganglia
• Brain stem: midbrain, pons, medulla
• Cerebellum
Brain
Gyri – convolutions
(wrinkled appearance
of cerebral cortex);
increases surface
area of brain

Medial View of the Brain
2 hemispheres are joined at the lower portion of the
longitudinal fissure, at the corpus callosum

LOBES
corpus callosum – a thick collection of nerve fibers that

connects the two hemispheres of the brain
- Responsible for the transmission of information from

one side of the brain to the other, such as sensation,
memory and learned discrimination
- RIGHT-HANDED people and some left-handed people

have cerebral dominance on the LEFT SIDE of the
brain for VERBAL, LINGUISTIC, ARITHMETIC,
CALCULATION, and ANALYTIC functions.
- The nondominant hemisphere is responsible for

GEOMETRIC, SPATIAL, VISUAL, PATTERN, and
MUSICAL functions.
LOBES of the cerebral cortex
FRONTAL LOBE
• Largest lobe, located in the front of the brain
• Major functions
• Concentration, abstract thought, information

storage or memory, and motor function
• Contains Broca’s area (motor control of speech)
• Also responsible for a person’s affect, judgment,

personality, and inhibitions

LOBES of cerebral cortex
PARIETAL LOBE
• Predominantly sensory lobe posterior to the frontal

lobe
• Analyzes sensory information to other cortical areas
• Essential to a person’s awareness of body position in

space, size and shape discrimination, and right-left
orientation

LOBES of cerebral cortex
TEMPORAL LOBE
• Located inferior to the frontal and parietal lobes
• Contains auditory receptive areas and plays a role in

memory of sound and understanding of language
and music
OCCIPITAL LOBE
• Located posterior to the parietal lobe
• Responsible for visual interpretation and memory

Topography of the Cortex as
It Relates to Function

CEREBRUM
BASAL GANGLIA
• Masses of nuclei located deep in the cerebral

hemispheres
• Responsible for control of fine motor movements,

including those of the hands and lower extremities
THALAMUS
• Acts primarily as a relay station for all sensation

except smell
• All MEMORY, SENSATION, and PAIN IMPULSES pass

through this section of the brain
CEREBRUM
HYPOTHALAMUS
• Located anterior and inferior to the thalamus
• Important role in the ENDOCRINE system (regulates

pituitary secretion of hormones that influence
metabolism, reproduction, stress response, urine
production
• Maintains fluid balance through hormonal release

and maintain TEMPERATURE regulation by
promoting vasoconstriction or vasodilation
• HUNGER CENTER – involved in appetite control

CEREBRUM
HYPOTHALAMUS
• CENTERS that regulate:
• Sleep-wake cycle
• Blood pressure
• Aggressive & sexual behavior
• Emotional responses (ie, blushing, rage,

depression, panic, fear)
• Controls and regulates the autonomic nervous

system
• (optic chiasm, mamillary bodies)

BRAIN STEM
MIDBRAIN
• Connects the pons and the cerebellum with the cerebral
hemispheres
• Contains sensory and motor pathways and serves as the

center for auditory and visual reflexes
• Origin of CN III and IV

PONS
• Bridge between the two halves of the cerebellum
• Contains motor and sensory pathways
• Portions help regulate respiration
• Origin of CN V through VIII

BRAIN STEM
MEDULLA
• Contains MOTOR FIBERS from the brain to the spinal
cord and SENSORY FIBERS from the spinal cord to the
brain
• Most of these fibers cross, or DECUSSATE, at this level
• CN IX through XII
• REFLEX CENTERS:
• Respiration, blood pressure, heart rate, coughing,

vomiting, swallowing, and sneezing
The RETICULAR FORMATION (arousal & the sleep-

wake cycle) begins in the medulla and connects with
numerous higherCopyright
structures
© 2008 Lippincott Williams & Wilkins.
CEREBELLUM
• Posterior to the midbrain and pons, below the

occipital lobe
• Integrates sensory information to provide smooth

coordinated movement
• Controls fine movement, balance, and position

(postural) sense or proprioception (awareness of
where each part of the body is)

Bones and Sutures of the
Skull

Meninges and Related
Structures

Cerebrospinal Fluid

Cerebrospinal Fluid
• Clear and colorless fluid that is produced in the choroid

plexus of the ventricles and circulates around the
surface of the brain
• Produced at a rate of about 500 mL/day; ventricles and

subarachnoid space contain approximately 150 mL
• Composition :
• LAB ANALYSIS
• Specific gravity (1.007), protein count, WBC count,

glucose, electrolytes
• Also tested for immunoglobulins and bacteria (no

RBCs!!!)
Cerebrospinal Fluid
Produced in choroid plexus of ventricles
Lateral ventricles
Foramen of Monro (interventricular foramen)
Third ventricle
Aqueduct of Sylvius
Fourth ventricle
Subarachnoid space
Absorbed by Arachnoid villi

Cerebrospinal Fluid

Arterial Blood Supply of the
Brain

Cerebral Circulation
• The brain does not store nutrients & requires a constant

supply of oxygen
• Approximately 15% of CO, or 750 mL/min
• Unique:
1. Arterial and venous circulation not parallel
2. Brain has collateral circulation through the circle of

Willis (blood flow can be redirected on demand
3. Blood vessels in the brain have two layers rather

than three (makes them prone to rupture when
weakened or under pressure)
Brain

Brain
Functionally, the posterior

portion of the circulation and
the anterior or carotid
circulation usually remains
separate
However, the circle of Willis

can provide collateral
circulation if one of the
vessels supplying it becomes
occluded or is litigated

• VENOUS CIRCULATION
• NO VALVES, dependent on gravity & BP; not parallel

with arterial circulation; veins reach brain’s surface,
join larger veins then cross the subarachnoid space
and empty into the DURAL sinuses, which further
empties into the internal jugular veins
• BLOOD-BRAIN-BARRIER
• Makes the CNS inaccessible to many substances that

circulate in the blood (eg, dyes, meds, antibiotics)
• Continuous tight junctions that create a barrier to

macromolecules and many compounds
• Astrocytes serveCopyright
as© “gatekeepers”
2008 Lippincott Williams & Wilkins.

Cross Section of the Spinal Cord
Showing the Major Spinal Tracts

SPINAL CORD
• Continuous with the medulla, serves as the connection
between the brain and the periphery
• Approximately 45 cm (18 inches) long, about as thick as a

finger; extends from foramen magnum at the base of the
skull to the lower border of the first lumbar vertebra;
Surrounded by meninges
• Cross-sectional view:
• ANTERIOR HORNS
• Anterior roots (motor) – voluntary and reflex activity

of muscles
• UPPER HORNS
• Posterior roots (sensory) – relay station in the

sensory/reflexCopyright
pathway © 2008 Lippincott Williams & Wilkins.
SPINAL TRACTS
• SIX ASCENDING TRACTS
• Fasciculus cuneatus & Fasciculus gracilis (posterior columns)
• Conduct sensations of deep touch, pressure, vibration,

position, and passive motion from the same side of the
body; cross to the opposite side in the medulla
• Spinocerebellar tracts (anterior & posterior)
• Conduct sensory impulses from muscle spindles, for

coordinated muscle contraction; ascend uncrossed and
terminate in the medulla
• Spinothalamic tracts (anterior & lateral)
• Conduction of pain, temperature, proprioception, fine touch,

and vibratory sense from the upper body; cross to the
opposite side of the cord before ascending; terminates in the
thalamus Copyright © 2008 Lippincott Williams & Wilkins.
SPINAL TRACTS

SPINAL TRACTS
• EIGHT DESCENDING TRACTS
• Corticospinal tracts (anterior and lateral)

• Conduct motor impulses to the anterior horn cells from the opposite
side of the brain, cross in the medulla, and control voluntary muscle
activity
• Vestibulospinal tracts (3)

• Descend uncrossed and are involved in some autonomic functions
(sweating, pupil dilation, circulation) and involuntary muscle control
• Corticobulbar tract
• Conducts impulses responsible for voluntary head and facial

muscle movement and crosses at the level of the brain stem
• Rubrospinal & Reticulospinal tracts
• Conduct impulses involved with involuntary muscle movement

VERTEBRAL COLUMN
• Bones of the vertebral column surround and protect the spinal cord
and normally consists of:
• 7 cervical vertebrae
• 12 thoracic vertebrae
• 5 lumbar vertebrae
• 5 fused vertebrae (sacrum)
• 1 coccyx
• Nerve roots exit from the vertebral column through the

intervertebral foramina (openings)
• Vertebrae are separated by disks (except for the 1st and 2nd
cervical, the sacral and the coccygeal vertebrae)

Peripheral Nervous System
• Cranial nerves
• Spinal nerves
• Autonomic
nervous system

Cranial Nerves

Cranial Nerves
CRANIAL TYPE FUNCTION
NERVE
I Sensory Sense of smell

Olfactory
II Sensory Visual acuity and visual fields

Optic
III Motor Muscles that move the eye and lid, pupillary
Oculomotor constriction, lens accommodation
IV Motor Muscles that move the eye

Trochlear
V Mixed (Both) Facial sensation, corneal reflex, mastication

Trigeminal
VI Motor Muscles that move the eye

Abducens
Cranial Nerves
CRANIAL NERVE TYPE FUNCTION
VII Mixed (Both) Facial expression and muscle movement, salivation and
Facial tearing, taste, sensation in ear
VIII Sensory Hearing and equilibrium
Acoustic
(Vestibulocochlear)
IX Mixed (Both) Taste, sensation in pharynx and tongue, pharyngeal
Glossopharyngeal muscles, swallowing
X Mixed (Both) Muscles of pharynx, larynx, and soft palate; sensation in
Vagus external ear, pharynx, larynx, thoracic and abdominal
viscera; parasympathetic innervation of thoracic and
abdominal organs
XI Motor Sternocleidomastoid and trapezius muscles
Spinal Accessory
XII Motor Movement of the tongue
Hypoglossal
Cranial Nerves
CN TEST
I With eyes closed, patient is asked to identify familiar odors (coffee, tobacco,
Olfactory perfume). Each nostril is tested separately (anosmia – loss of sense of smell)
II Assess vision using a Snellen eye chart. Assess visual fields. Perform
Optic ophthalmoscopic examination.
III Test for eye movement toward the nose, inspect for conjugate movements and
Oculomotor nystagmus. Evaluate papillary size and test for pupillary reactivity to light;
inspect ability to open eyelids.
IV Test for upward eye movement; inspect for conjugate movements and
Trochlear nystagmus.
V Have patient close the eyes. Touch cotton to forehead, cheeks, and jaw.
Trigeminal Sensitivity to superficial pain is also tested in these same three areas (use sharp
and dull ends of a broken tongue blade; if responses are incorrect, test for
temperature sensation (test tubes of cold and hot water are used alternately.
Test for corneal reflex (cotton) – blink & tearing are normal.
Have patient clench and move jaw from side to side. Palpate masseter and
temporal muscles, noting strength & equality
VI Test for lateral eye movement; inspect for conjugate movement.
Abducens Copyright © 2008 Lippincott Williams & Wilkins.
Cranial Nerves
CN TEST
VII Observe for symmetry while patient performs facial movements; smiles,
Facial whistles, elevates eyebrows, frowns, tightly closes eyelids against
resistance (examiner attempts to open them)
Observe face for flaccid paralysis (shallow nasolabial folds). Have patient
extend tongue. Test ability to discriminate between sugar and salt.
VIII Perform whisper or watch-tick test. Test for lateralization (Weber test).
Acoustic Test for air and bone conduction (Rinne test). Assess standing balance with
(Vestibulocochlear) eyes closed (Romberg test)
IX Assess patient’s ability to swallow and discriminate between sugar and salt
Glossopharyngeal on posterior third of the tongue
X Depress a tongue blade on posterior tongue, or stimulate posterior
Vagus pharynx to elicit gag reflex. Note any hoarseness in voice. Check ability to
swallow. Have patient say “ahh.” observe for symmetrice rise of uvula and
soft palate
XI While patient shrugs shoulders against resistance, palpate and note
Spinal Accessory strength of trapezius muscles. Assess strength of sternocleidomastoid
XII While patient protrudes tongue, note any deviations or tremors. Test the
Hypoglossal strength of the tongue by having patient move tongue from side to side
against a tongue depressor.
Spinal Nerves
31 pairs Ventral root – motor and transmit

impulses from the spinal cord to the
• 8 cervical body
• 12 thoracic * May be somatic or visceral (include ANS
• 5 lumbar fibers that control cardiac muscles and
glandular secretions)
• 5 sacral
Dorsal root – sensory and transmit
• 1 coccygeal sensory impulses from specific areas of
the body known as dermatomes to the
dorsal horn ganglia
* May be somatic (pain, temperature,
touch, proprioception) or visceral
(internal organs)
Dermatome Distribution

MOTOR & SENSORY PATHWAYS
Motor pathways
Corticospinal tract begins in the motor cortex, a vertical
band within each frontal lobe, and controls voluntary
movements of the body.
- Tracts cross to the opposite side at the medulla,
continuing to the anterior horn of the spinal cord
- Until this point, neurons are known as UPPER MOTOR
NEURONS (originate in cerebral cortex, cerebellum
and brain stem)
- As they connect to motor fibers of the spinal nerves,
they become LOWER MOTOR NEURONS (located either
in the anterior horn of the spinal cord gray matter or
within cranial nerve
Copyrightnuclei in
© 2008 Lippincott the
Williams brain stem)
& Wilkins.
Upper & lower motor neurons
Upper motor neuron lesions Lower motor neuron lesions
Loss of voluntary control Loss of voluntary control
Increased muscle tone Decreased muscle tone
Muscle spasticity Flaccid muscle paralysis
No muscle atrophy Muscle atrophy
Hyperactive and abnormal reflexes Absent or decreased reflexes

Autonomic Nervous System
• Functions to regulate activities of internal organs

and to maintain and restore internal homeostasis
• Sympathetic NS
– “Fight or flight” responses
– Main neurotransmitter is norepinephrine
– Neurons located primarily in the thoracic and
lumbar segments of the spinal cord
• Parasympathetic NS
– Controls mostly visceral functions
• Regulated by centers in the spinal cord, brain stem,
and hypothalamus Copyright © 2008 Lippincott Williams & Wilkins.
EFFECTS OF THE AUTONOMIC NERVOUS SYSTEM

STRUCTURE OR ACTIVITY PARASYMPATHETIC EFFECTS SYMPATHETIC EFFECTS
Pupil of the eye Constricted Dilated
CIRCULATORY SYSTEM
Rate & force of heartbeat Decreased Increased
Blood vessels
In heart muscle Constricted Dilated
In skeletal muscle * Dilated
In abdominal viscera and * Constricted
skin
Blood pressure Decreased Increased
RESPIRATORY SYSTEM
Bronchioles Constricted Dilated
Rate of breathing Decreased Increased
* No direct effect Copyright © 2008 Lippincott Williams & Wilkins.

DIGESTIVE SYSTEM
Peristaltic movements of Increased Decreased
digestive tube
Muscular sphincters of Relaxed Contracted
digestive tube
Secretion of salivary glands Thin, watery saliva Thick, viscid saliva
Secretions of stomach, Increased *
intestine and pancreas
Conversion of liver glycogen * Increased
to glucose
ADRENAL MEDULLA * Secretion of epinephrine and
norepinephrine

GENITOURINARY SYSTEM
Urinary bladder
Muscle walls Contracted Relaxed
Sphincters Relaxed Contracted
Muscles of the uterus Relaxed; variable Contracted under some
conditions; varies with
menstrual cycle and
pregnancy
Blood vessels of external Dilated *
genitalia
INTEGUMENTARY SYSTEM
Secretion of sweat * Increased
Pilomotor muscles * Contracted (goose-flesh)

Anatomy of the Autonomic
Nervous System

Neurological Assessment—Health History
• Pain
• Seizures
• Dizziness (abnormal sensation of imbalance or
movement) and vertigo (illusion of movement,
usually rotation)
• Visual disturbances
• Weakness
• Abnormal sensations

Neurological Assessment
• Cerebral function: mental status, intellectual function,
thought content, emotional status, perception, motor
ability, and language ability
– The impact of any neurologic impairment on lifestyle
and patient abilities and limitations
• Motor system: posture, gait, muscle tone and strength,
coordination and balance, and Romberg test
• Sensory system: tactile sensation, superficial pain,
vibration, and position sense
• Reflexes: DTRs, abdominal, and plantar (Babinski)

Techniques Eliciting Major Reflexes

Figure Used to Record Muscle Strength

Gerontological Considerations
• Important to distinguish normal aging changes from
abnormal changes
• Determine previous mental status for comparison;
assess mental status carefully to distinguish delirium
from dementia
• Normal changes may include:
– Losses in strength and agility; changes in gait,
posture and balance; slowed reaction times and
decreased reflexes; visual and hearing alterations;
deceased sense of taste and smell; dulling of tactile
sensations; changes in the perception of pain; and
decreased thermoregulatory ability
Diagnostic Tests
• Computed tomography (CT)
• Positron emission tomography (PET)
• Single photon emission computed tomography

(SPECT)
• Magnetic resonance imaging (MRI)
• Cerebral angiography
• Myelography
• Noninvasive carotid flow studies
Diagnostic Tests (cont.)
• Transcranial Doppler
• Electroencephalography (EEG)
• Electromyography (EMG)
• Nerve conduction studies, evoked potential studies
• Lumbar puncture, Queckenstedt’s test, and

analysis of cerebrospinal fluid

Magnetic Resonance Imaging


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Chapter 60

• Controls all motor, sensory, autonomic,

• The brain itself contains more than 100

• Central nervous system

–Brain and spinal cord

• Peripheral nervous system

–Includes cranial and spinal nerves

–Autonomic and somatic systems

• Basic functional unit: neuron

• Communicate messages from one neuron to another

• Manufactured and stored in synaptic vesicles

• Neurotransmitters can potentiate, terminate, or

• Many neurologic disorders are due to imbalance in

• Eg: Parkinson’s (↓dopamine), Myasthenia gravis (impaired

Serotonin Brain stem, hypothalamus, INHIBITORY, helps control mood and

Dopamine Substantia nigra and basal Usually INHIBITS, affects behavior

Enkephalin, endorphin Nerve terminals in the EXCITATORY; pleasurable sensation,

Copyright © 2008 Lippincott Williams & Wilkins.

• Accounts for approximately 2% of the total body

• Average young adult = 1400 g

• Average elderly person = 1200 g

• Cerebrum: left & right hemispheres, thalamus,

• Brain stem: midbrain, pons, medulla

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

corpus callosum – a thick collection of nerve fibers that

- Responsible for the transmission of information from

- RIGHT-HANDED people and some left-handed people

- The nondominant hemisphere is responsible for

• Largest lobe, located in the front of the brain

• Concentration, abstract thought, information

• Contains Broca’s area (motor control of speech)

• Also responsible for a person’s affect, judgment,

Copyright © 2008 Lippincott Williams & Wilkins.

• Predominantly sensory lobe posterior to the frontal

• Analyzes sensory information to other cortical areas

• Essential to a person’s awareness of body position in

Copyright © 2008 Lippincott Williams & Wilkins.

• Located inferior to the frontal and parietal lobes

• Contains auditory receptive areas and plays a role in

• Located posterior to the parietal lobe

• Responsible for visual interpretation and memory

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• Masses of nuclei located deep in the cerebral

• Responsible for control of fine motor movements,

• Acts primarily as a relay station for all sensation

• All MEMORY, SENSATION, and PAIN IMPULSES pass

• Located anterior and inferior to the thalamus

• Important role in the ENDOCRINE system (regulates

• Maintains fluid balance through hormonal release

• HUNGER CENTER – involved in appetite control

Copyright © 2008 Lippincott Williams & Wilkins.

• CENTERS that regulate:

• Aggressive & sexual behavior

• Emotional responses (ie, blushing, rage,

• Controls and regulates the autonomic nervous

• (optic chiasm, mamillary bodies)