Essentials of Neurological

3 Assessment

Accurate clinical assessment is the key component in the care of a

neurological patient. It can help the therapist to:
• Detect the presence of a neurological disease or injury
• Shortlist the nature of problems created by the disease or injury
• Monitor progression of the disorder
• Determine the type of care the patient needs, and the expected
outcome of therapeutic interventions.
The initial assessment of a patient with neurogenic dysfunction should
be a comprehensive clinical examination, covering following critical areas
concerning the function of the nervous system:
• Level of consciousness and orientation
• Function of cranial nerves
• Presence or lack of movement
• Presence or lack of sensation
• Cerebellar function, indicated by the presence or lack of balance
• Presence or lack of coordination
• Muscle tone, power, deep tendon and superficial reflexes.
This initial examination will establish baseline data with which to
compare subsequent assessment findings. Once a thorough neurological
examination has been done at the time of admission or at the beginning
of physiotherapy intervention, subsequent assessments should be
problem-oriented, focusing only on the parts of the nervous system
affected by the patient’s condition. The patient’s diagnosis and the acuity
of the clinical condition will determine how extensive the problem-
oriented assessments will be and how frequently it will need to be
repeated. On an average, the review assessments may be done every
three weeks.

ASSESSMENT OF NEUROLOGICAL DISORDERS

The crisis of the neurological system can be the most challenging to
monitor and evaluate. This is because of the inability of medical science
to control neurological symptoms as easily as we do in case of the
 28 Handbook of Practical Neurophysiotherapy

cardiopulmonary or gastrointestinal crisis. The neurological system is

still quite out of our control. Sometimes, the only option is to allow a
neurologically compromised person to die, while monitoring, charting
the progression, reporting to the physician, and holding the hands of
those involved. The therapist and the nurse are essential participants in
these processes. Whether it’s a brief check of neurological status or a
comprehensive neurological evaluation, in a crisis your assessment may
uncover critical nervous system dysfunction before it is too late.
Three key aspects of the neurological assessment are:
• The interview
• The physical examination
• The specific diagnostic tests.

History Taking: The Art of Interviewing the Patient/Care-giver

History taking is not about hearing, but about really listening to the
patient. One of the most essential skills for a clinician is the ability to
listen to the account of the sufferer, stated as far as possible in his or her
own words, with undivided attention, trying to hear what is being said
and even what may remain unsaid. Only then a clear picture of the
sequence of events leading to the present problems affecting the patient
may be ellicitated, based on which the clinician may develop a working
hypothesis about the disorder in question. In many cases, the neurological
patient is disoriented or unable to talk. It may be necessary to obtain the
interview from the patient’s family or close friend.

Key Questions
Ask the patient/relative if there is any:
• A history of past neurological disorders
• Record in detail the description of the development of the current
signs and symptoms
• Ascertain the time of onset, the duration of signs and symptoms
• The precipitating factors and the sequence of signs and symptoms
• Question if there were any recent illnesses, such as a head cold or
sore throat
• Document the patient’s medications, both prescribed and over the
counter, including vitamins and herbal remedies
• Conclude the interview with a review of symptoms.
Any or all the preceding information collected during the interview
may give clues to the cause of the neurological damage.
• For example, if the patient has a history of chronic atrial fibrillation
and does not adhere to his anticoagulant drug regime, this may
explain why he developed CVA.
 A Primer toEssentials
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Assessment 29

While interviewing the patient, be careful not to suggest symptoms,

with close ended questions such as:
“Do you have a stabbing headache?”
Instead use open-ended sentences, such as:
“Can you describe the type of pain you are feeling in your head?”
Note down the details, as far as possible, in own words of the patient.
The precipitating factors, mode of onset and the course of the current
illness are particularly important. Document the progression of the signs
and symptoms. While interviewing a relative, be sure that the person
who is giving the information is oriented and knowledgeable of the
patient’s problems and current illnesses.
In particular, inquire if the patient has a history of diabetes mellitus,
pernicious anemia, cancer, chronic infections, thyroid disease,
hypertension or any addiction, since these factors may affect the nervous
system.
Medication, prescribed by a doctor or obtained by the patient over
the counter, may be significant in producing neurological symptoms. A
person with history of chronic neurological disease may be taking
antiseizure medications such as Phenobarbital, Carbamazepine (Tegretol),
or Phenitoin (Dilantin), which may give rise to some neurological
symptoms such as diplopia, ataxia, drowsiness or mental slowing. These
side effects may be misinterpreted by the patient and cause non-
compliance with the regime of medication. Document the medication,
dosage, schedule and when the patient last took the medication.

Points to Ponder
• Note the onset, progression and the nature of the presenting
symptoms to get an insight into the condition you are dealing with.
• Check the past history to identify other pre-existing conditions,
surgeries and health related issues.
• Take note of the social history to specify current living conditions,
family/social support, level of education, employment and lifestyle
of the patient.

GENERAL EXAMINATION OF NEUROLOGICAL DISORDERS

OBSERVATIONS
Level of Consciousness (LOC)
The single most important aspect of neurological assessment is the
assessment level of consciousness and cognition. Worsening of either
indicates deteriorating neurological status.
 30 Handbook of Practical Neurophysiotherapy

Points to Ponder
The following terms are commonly used to describe various stages of
decreased LOC, so it is useful to be familiar with them:
• Full consciousness: The patient is alert, attentive, and follows
commands. If asleep, he responds promptly to external stimulation
and, once awake, remains attentive.1
• Drowsiness: The patient is drowsy but awakens—although not fully—
to stimulation, he will answer questions and follow commands, but
will do so slowly and inattentively.1
• Semi conscious: The patient is difficult to arouse and needs constant
stimulation in order to follow a simple command. He may respond
verbally with one or two words, but will drift back to sleep between
stimulation.
• Stupor: The patient arouses to vigorous and continuous stimulation;
typically, a painful stimulus is required. He may moan briefly but
does not follow commands. His only response may be an attempt to
withdraw from or remove the painful stimulus.
• Coma: The patient does not respond to continuous or painful
stimulation. He does not move—except, possibly, reflexively—and
does not make any verbal sounds.
Since these and other terms used to categorize LOC are frequently
used imprecisely, you’d be wise to avoid using them in your
documentation, instead, describe how the patient responds to a given
stimulus. For example, write: “the patient moans briefly on painful
stimulus, but does not open eyes or follow commands.” Bear in mind
that recognizing and describing a change in LOC is more important than
appropriately naming it.
When assessing LOC, there are several tools you can choose from.
Typically, though, it is the Glasgow Coma Scale (GCS) that is dedicated
and internationally accepted neurological assessment tool. It’s especially
useful for evaluating patients during the acute stages of head injury.

Glasgow Coma Scale (See Annexure 1)

The Glasgow Coma Scale allows us a standard reference for monitoring
or assessing a patient with confirmed or suspected brain damage. A GCS
score is based on three patient responses to stimuli:
• Eye opening
• Motor response
• Verbal response.
To each of these responses, a score is assigned and the GCS is interpreted
as follows.

Scoring of GCS
• The patient receives a score for best response in each of these areas,
and the three scores are added together.
 A Primer toEssentials
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• The total score will range from 3 to 15; the higher the number, the
better the level of consciousness.
• A score of 8 or lower usually indicates coma.
• A score of 15 is the highest, and 3, the lowest.
• An awakened person, who has orientation to person, time and place,
and can also follows simple commands, such as squeeze my hand,
has a Glasgow score of 15.
• A patient, oriented to self, but not to time and place, yet follows all
simple commands, has a score of 14.
• An aphasic person may score a 2 on verbal response, but then total
a twelve, as he will follow simple commands and open eyes
spontaneously.
Any change in the level of consciousness is an important indicator of a
person’s neurological status. Impaired cerebral blood flow results in an
altered LOC. Frequent assessments are necessary on the person at risk,
because the sooner the neurological compromise is recognized, the better
the prognosis.

Orientation
If the patient is alert or awake enough to answer questions, you’ll also
need to assess orientation. Determine if he is oriented to person, place,
and time by asking questions like: What is your name? Where are you right
now? Why are you here? What year is it? Who is the president of India?
A comprehensive evaluation of orientation will include tests of higher
intellectual function, as well. To test abstract reasoning, for example, you
might ask the patient to interpret a well-known proverb.

Abnormal posturing
Abnormal flexion or extension of the head, neck, trunk and limbs are
ominous signs of central nervous system malfunction.
Abnormal flexion or Decorticate posture is an abnormal body posture
indicated by adducted and flexed arms, with the wrists and fingers flexed
on the chest, the legs internally rotated and stiffly extended, with plantar
flexion of the feet (Fig. 3.1).

Fig 3.1: Decorticate posture

 32 Handbook of Practical Neurophysiotherapy

Decorticate posture indicates damage to the corticospinal tract, the

pathway between the brain and spinal cord. Although a serious sign, it
is usually more favorable than decerebrate posture. Decorticate posture
may progress to decerebrate posture, or the two may alternate. The
posturing may occur on one or both sides of the body.

Common Causes of Decorticate Posturing

• Brain abscess
• Primary brain tumor
• Secondary brain tumor
• Increased intracranial pressure from any cause
• Stroke
• Head injury.
Abnormal Extension or Decerebrate posturing is an abnormal body
posture indicated by rigid extension of the arms and legs, downward
pointing of the toes, and backward arching of the head. A severe injury
to the brain at the level of the brainstem is the usual cause (Fig. 3.2).

Common Causes of Decerebrate Posturing

• Cerebral infarction (stroke)
• Intracranial hemorrhage
•· Primary brain tumor
• Secondary brain tumor
• Encephalopathy
• Head injury
• Increased intracranial pressure from any cause
• Brainstem tumor
• Hepatic encephalopathy.

Points to Ponder
• Opisthotonus, a severe muscle spasm of the neck and back may
accompany decerebrate posture in severe cases.
• Usually, decerebrate posture indicates organic damage to the
structures of the nervous system, particularly the upper brainstem.
• Decerebrate posture may occur in many patterns. It can occur on one
side, on both sides, or in just the arms.

Fig. 3.2: Decerebrate posturing

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the Anatomy of the Nervous
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Assessment 33

• It may alternate with decorticate posture, i.e. abnormal posturing

due to corticospinal tract injury.
• A person can have decorticate posture on one side and decerebrate
posture on the other.
• The key difference between the two terms, is that in decorticate the
upper limbs are flexed inward towards the center of the body, i.e.
toward the core of the body.
• Generally speaking, with both decorticate and decerebrate posturing,
the patient is either non-responsive or responds to pain stimulus by
adopting abnormal posture.

Abnormal Pupillary Reactions

Pupils are another important component of the neurological examination.
Assessing them is especially important in a patient with impaired LOC.
Like a change in LOC, a change in pupil size, shape, or reactivity can
indicate increasing intracranial pressure (ICP) from a mass or fluid.
Always check pupils as part of the cranial nerve assessment.

Points to Ponder
• The therapist will need to frequently assess the pupils of the patient
at risk neurologically.
• If the patient is unable to open the eyes to request, gently lift the
upper lids.
• Compare the two pupils for size, shape and equality.
• Utilize a chart in order to evaluate pupil size more precisely.
• The pupil size ranges from 1 to 6 millimeters.
• Unequal pupils are not always abnormal. Additionally, eye surgery
may have altered the shape and size of the pupil.

Method of Testing the Pupillary Reaction

• Obtain a penlight and darken the room to assess the pupils’ direct
light response.
• Hold one eyelid open and shine the light directly into the eye. The
pupil will constrict immediately.
• When the light is removed, the pupil will dilate immediately.
• Now ask the patient to hold both eyes open, shine the light into one
eye and watch for consensual response. Normally, the eye not
exposed to light will also constrict.
• To assess accommodation, hold a finger six inches from the patient’s
nose. Ask the patient to focus on the finger, then to focus on an
object farther away, such as a wall clock. The pupils should dilate as
they focus on objects farther away, and constrict when the object is
closer.
 34 Handbook of Practical Neurophysiotherapy

• The assessment of pupils is not always easy. It may be difficult to see

the pupils clearly on people with dark eyes. If you are unsure, ask
for a second opinion, particularly if you notice other neurological
alterations. The extra effort you make may save your patient’s life.

ASSESSMENT OF VITAL SIGNS

Though it is a common convention that vital signs are checked and
monitored by physicians and nurses, the therapist attending an unstable
patient in ICU, with a neurological disorder, must be aware of and be
able to interpret changes in vital signs to alert the physician in time to
prevent a crisis.

Points to Ponder
• Slower heart rate, widening of pulse and irregular respiration, known
as Cushing’s triad, may be present in CVA or TBI, along with a
change in body temperature. These are indications of active
inflammatory changes taking place in the CNS and should be watched
very carefully during therapy.
• Detailed documentation and prompt reporting of any change in LOC,
Pupilary reaction, BP, Pulse rate, SaO2 and ECG trace is necessary to
alert others of the patient’s current status, so any subtle changes will
be obvious.
• At times, it may be tempting to allow a neuro-patient to sleep through
a neuro-check, but “the sleep” may be end up being permanent if
neuro-checks aren’t frequently performed.

What do Vital Signs Reveal About Neuro Status?

• Because the brainstem and vagus nerve (CN X) play an important
role in vasomotor tone, conditions affecting these areas can cause
vital signs to change. A change in vital signs, however, is not a
reliable indicator of neurological deterioration, as they tend to change
too late to prevent irreversible brain damage.
• Raised intracranial pressure produces a specific set of changes known
as Cushing’s triad. Present in herniation syndromes, Cushing’s triad
consist of: increasing systolic blood pressure with a widening pulse
pressure, bradycardia, and bradypnea.6
• Cushing’s triad is a late sign of increased ICP. Once this pattern of
vital signs occurs, brainstem herniation is already in progress and it
may be too late to reverse it. To detect increasing ICP before it reaches
this point, be alert for earlier signs, for example a subtle change in
LOC or pupils.
• Accurate and consistent documentation helps ensure that subtle
changes in neuro status are caught early on. Whether the unit you’re
working in uses computerized charting, flow sheets, or hand-written
 A Primer toEssentials
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notes, it’s essential that you compare your findings to those of previous
exams. Through comparison, you’ll be able to spot changes and trends
and, when necessary, intervene quickly and appropriately.
• Verbal communication is important, too. In many ICU, a bedside
neuro exam is done as a part of the change-of-shift report, so that the
off-going and oncoming nurses and therapists can assess the patient
together. The off-going staff can then verify that the patient’s status
is unchanged, perhaps saving the patient an unnecessary CT scan.

RADIO IMAGING
• The Computed Axial Tomography commonly called the CAT scan
is used to visualize the blood vessels and to identify disruptions of
the blood-brain barrier. It is a noninvasive procedure, although an
intravenous injection of radiopaque contrast material may be given
to enhance visualization of the vessels. The X-rays are done at
progressive levels along the brain, resulting in a series of “slices” of
the brain in black and white pictures. The computer detects differences
in tissue densities and radiation absorption too subtle to be picked
up by conventional radiography. A variety of disorders may be
diagnosed utilizing the CAT scan, including hemorrhages, cysts,
infarction, tumors, brain atrophy and cerebral edema. Remove all
objects, such as hair pins or a wig, from the patient’s head before the
scan. The patient should be fasting for at least six hours prior to the
CAT to prevent nausea and vomiting that may be provoked by the
injection of the contrast. Upon administration, the contrast may cause
a warm, flushed feeling and a metallic taste in the mouth. The scan
with contrast takes about an hour, and without contrast, takes about
twenty minutes. If the patient receives contrast, encourage the patient
to drink extra fluids after the scan.
• Magnetic Resonance Imaging (MRI) is used to visualize structures
in the base of the brain and the posterior fossa. While placed within
a large magnetic field, bursts of radiofrequency magnetism are applied
at an angle to the larger magnetic field. This process causes hydrogen
protons to escape from alignment and then to realign. The signals
are used to generate an MRI picture, which will readily detect brain
edema or infarcted tissue. Gadolinium is a magnetic enhancing agent,
which may be given intravenously to allow for better interpretation.
All metal objects must be removed from the patient prior to magnetic
scanning. A person with a metal hip prosthesis, pacemaker or other
implanted metal object may not undergo the MRI procedure or be in
the exam room. When a healthcare provider is required to enter the
MRI room with an unstable patient during the magnetic scan, the
provider must remove all jewelry, metal objects and ID badge. The
MRI takes about one hour to complete. For both the MRI and the CT,
the patient must lie very still in a small confined space. Because
 36 Handbook of Practical Neurophysiotherapy

some people have fear of small, confined spaces (claustrophobia),

the physician may order an anti-anxiety medication, such as valium,
to relax the patient and promote compliance.

PHYSICAL EVALUATION
Assessing for Signs of Motor Dysfunction (See Annexure 2)
A neuro assessment almost always includes an evaluation of motor
function. Since you’ll be assessing the ability to move on command, it is
important that the patient must be awake, willing to cooperate, and able
to understand what you are asking to be done.

Changes in Muscle Tone

Clinically, the muscle tone is defined as resistance offered by a resting
muscle to rapid passive movement, while the patient is attempting to
maintain a relaxed state of muscle activity. It is assessed clinically using
rapid passive movements about a joint to determine the degree of muscular
resistance to the passive movement. Muscle tone is perceived by an
examiner but not directly perceived by the patient. Assessment should
include palpation of muscles to estimate the resting (baseline) state of
muscle activity.

Points to Ponder
• Abnormalities of muscle tone are an integral component of many
chronic neurological disorders.
• These disorders may result from diseases or injury to the developing
or mature motor pathways in the cortex, basal ganglia, thalamus,
cerebellum, brainstem, central white matter, or spinal cord.
• When such a disorder is seen in children before 2 years of age, the
term cerebral palsy (CP) is often used; when it occurs in adults, a
variety of descriptive labels have been applied, depending on the
cause.
Neurogenic motor disorders are commonly classified into hypertonia or
hypotonia on the basis of the abnormality of muscle tone.

Hypertonia (See Annexure 2A, C and D)

Hypertonia is defined as abnormally increased resistance to passive movement
of a joint. It may be caused by spasticity, dystonia, rigidity, or a
combination of these features. Physiotherapists should, as far as possible,
use the terms spastic hypertonia, dystonic hypertonia or rigid hypertonia
to distinguish the primary clinical feature of the underlying disorder.
Mechanisms that lead to increased tone may also contribute to poor
voluntary motor performance or involuntary muscle contractions, but
assessment of muscle tone is independent of strength, dexterity,
coordination, or involuntary movements.
 A Primer toEssentials
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Assessment 37

Spasticity
Spasticity is a velocity-dependent resistance offered to passive stretch by any
hypertonic muscle. This resistance must be different for high versus low
speeds of passive movement and for flexion versus extension about the
joint. A “spastic catch” is often felt during passive movement and that
may represent the threshold for onset of the stretch reflex in the affected
muscle.

Points to Ponder
• Spasticity can vary depending on patient’s state of alertness, activity,
or posture.
• Spasticity can be increased by anxiety, emotional state, pain, surface
contact, base of support or other non-noxious sensory inputs.
• Spasticity may worsen with low base of support or antigravity posture.
• The presence of spasticity suggests the presence of hypertonia, thus
the terms spasticity and spastic hypertonia are used interchangeably.
• Electrophysiological studies of spastic muscles show changes in the
threshold of the tonic stretch reflex, so that resistance increases in
magnitude or occurs sooner as speed of passive movement increases.

Dystonia
Clinically dystonia can be defined as a movement disorder in which
involuntary sustained or intermittent muscle contractions cause twisting and
repetitive movements, abnormal postures, or both.

Points to ponder
• Dystonia may cause hypertonia, but hypertonia is not always present in
dystonia
• Dystonia is commonly triggered or exacerbated by attempted
voluntary movement and may fluctuate in severity in an individual
at different times, depending upon body position, specific tasks,
emotional state, or level of consciousness.
• However, if dystonia is present at rest and causes an involuntary
posture, then it may be a cause of hypertonia, giving rise to the term
dystonic hypertonia.
• To diagnose dystonic hypertonia, there must be observable dystonic
postures that do not relax during the examination of tone. The body
part being examined must be supported against gravity to ensure
that postural muscle activity is not contributing to the apparent
increase in tone.
In Dystonic hypertonia we can find all of the following:
1. Resistance to passive joint movement is present at very low speeds of
movement and is not depend on speed or angle of movement.
 38 Handbook of Practical Neurophysiotherapy

2. Simultaneous co-contraction of agonists and antagonists may occur,

and this is reflected in an immediate resistance to a rapid reversal of
the direction of passive movement about a joint.
3. The limb tends to return toward a fixed involuntary posture, and
when symptoms are severe, the limb tends to move toward extremes
of joint angles.
4. Hypertonia is triggered or worsened by voluntary movement or
posture of the affected and other body parts and may be strongly
dependent on a particular movement or posture attempted or the
activity of distant muscle groups.
5. The pattern as well as the magnitude of involuntary muscle activity
varies with arousal, emotional and behavioral state, tactile contact, or
attempted task.
Dystonia may be sub-classified as:
• Action induced
• Posture induced.

Points to Ponder
• In adults, the actions that lead to dystonia may be restricted to certain
attempted tasks, although task specificity is less common in children.
• When dystonia is present at rest or with posture, certain attempted
postures may be impossible to attain.
• Dystonia may be triggered or worsened by self-consciousness,
distraction, startle, overuse, fatigue, touch, or pain.
• Dystonia is sensitive to antigravity posture and it must therefore be
tested in sitting, standing, supine, and with major joints in both flexion
and extension.
• Dystonia is not necessarily a primary disorder of muscle tone, but it
may appear because of the inability to relax the muscles fully.
• Dystonia may be focal when it affects a single body part, segmental
when it affects one or more contiguous body parts, multifocal when
it affects two or more noncontiguous body parts, generalized when it
affects one leg and the trunk plus any other body part or both legs
plus any other body part, and hemidystonia when it affects only one
half of the body.
• The anatomic localization of lesions that lead to dystonia has not yet
been identified with certainty. It is likely that lesions in the basal
ganglia cause them.

Rigidity
Rigidity is a common muscle tone disorder in which the resistance to passive
movement is independent of posture and speed of movement. In adults it is
frequently seen in Parkinsonism. The presence of rigidity suggests the
 A Primer toEssentials
the Anatomy of the Nervous
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Assessment 39

presence of hypertonia; thus, the terms rigidity and rigid hypertonia may be
used interchangeably.
Clinically rigidity may defined as a hypertonia in which all of the
following are present:
1. Unlike in spasticity, the resistance to passive movement in rigidity
does not depend on speed, and angle. Further the limb does not tend
to return toward a particular fixed posture or extreme joint angle as
in dystonia, i.e. Absence of synergy.
2. Simultaneous co-contraction of agonists and antagonists may occur,
and this is reflected in an immediate resistance to a reversal of the
direction of movement about a joint, i.e. Lead Pipe.
3. Voluntary activity in distant muscle groups does not lead to
involuntary movements about the rigid joints, although rigidity may
fluctuate, i.e. Cogwheel.
4. At rest the rigid muscles may exhibit fluctuating tone, i.e. Tremor.
5. Rigidity may be associated with bradykinesia, tremor, flexed posture,
and gait instability, known as Parkinsonism. Other forms of
hypertonia.
Resistance to passive movement may be due to disorders of spinal cord,
peripheral nerve, muscle, or connective tissue. Such disorders include
startle syndromes, stiff person syndrome, MND, myotonia, neuro
myotonia, myokymia, and childhood movement disorders such as
athetosis, chorea, ataxia, as well as the hyper kinetic features of dystonia,
myoclonus, tremor, and tic disorders.

Assessment of Muscle Power

Most commonly accepted format of assessment of muscle power is the
MRC scale. Power of a muscle is graded from 0-5 depending upon its
ability to generate torque, from complete inactivity to maximum
power (See Annexure 2B).

TESTING REFLEXES
Reflex assessment encompasses deep tendon, superficial, and brainstem
reflexes.
• Deep tendon reflexes include the triceps jerk, biceps jerk, brachio-
radialis jerk, patellar tendon jerk, and achilles tendon jerk
(Annexure 3).
Although all deep tendon reflexes aren’t routinely assessed, they
should be tested in any patient with suspected CNS disorders, neuropathy,
and peripheral nerve or spinal cord injury.
• The plantar reflex is the only superficial reflex that’s commonly
assessed and should be tested even in comatose patients and in those
with suspected injury to the lumbar 4-5 or sacral 1-2 areas of the
spinal cord as well as in neuropathy and peripheral nerve injuries.
 40 Handbook of Practical Neurophysiotherapy

Points to Ponder
1. Stimulate the sole of the foot with the handle of a reflex hammer or
the tip of a key.
2. Begin at the heel and move up the foot, in a continuous motion,
along the outer aspect of the sole and then across the ball of the toes
to the base of the big toe.
3. The normal response is plantar flexion (curling under) of the toes.
Extension of the big toe, known as the Babinski’s sign is abnormal,
except in children younger than the age of 2 years.
• Brainstem reflexes must be assessed in drowsy or comatose patients
to determine if the brainstem is intact. Brainstem reflexes are mainly
protective.

Points to Ponder
1. You’ll need to check for the protective reflexes, i.e. coughing, gagging,
and the corneal response, as part of the cranial nerve assessment.
2. To test the oculo-cephalic, or doll’s eye reflex, turn the patient’s
head briskly from side to side; the eyes should move to the left while
the head is turned to the right, and vice versa. If this reflex is absent,
there will be no eye movement.
3. To test the oculo-vestibular reflex, also known as the ice caloric or
cold caloric reflex, a physician will instill at least 20 ml of ice water
into the patient’s ear. In patients with an intact brainstem, the eyes
will move laterally toward the affected ear. In patients with severe
brainstem injury, the gaze will remain at midline.

EVALUATING SENSATION (ANNEXURE 4)

The sensory exam evaluates the patient’s ability, or inability to perceive
and identify specific sensations with her eyes closed. It is done only if
there’s a specific need, as in spinal cord injury or peripheral nerve lesions.
The patient must be alert enough to be able to cooperate with the
examination and to tell whether she feels the sensation and whether both
sides of her body feel it equally. Testing must begin with the feet and
move up the body to the face, comparing one side with the other.

Points to Ponder
• To assess sensation to light touch use your fingertips or cotton.
• To test superficial pain sensation, use a clean, unused, blunted safety
pin. Be sure not to break the skin, and discard the pin appropriately
after you’ve finished using it on a patient. Also, test sensation using
a blunt object, like point of a key. The patient should be able to
distinguish sharp from dull.
 A Primer toEssentials
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Assessment 41

• To test temperature sensation, you can use test tube of hot and cold
water.
• To test vibratory sensation, use a tuning fork.
• To test proprioception, or position sense, move the patient’s toes and
fingers up or down. Grasp the digit by its sides and ask the patient
tell you which way it’s pointing.

EVALUATING CEREBELLAR FUNCTION

Move on to the cerebellar assessment, if indicated. It may not be necessary
in a specific problem-focused examination for nerve or spinal injury, and
it can’t be done if the patient can’t or won’t follow commands.

Points to Ponder
• If the patient is in bed, you may not be expected to assess the balance
and gait. In that case, limiting the testing to coordination only is
acceptable. Hold up your finger and have the patient quickly and
repeatedly move her finger back and forth from your finger to her
nose. Then have her alternately touch her nose with her right and
left index fingers. Finally, have her repeat these tasks with her eyes
closed. The movements should be precise and smooth.
• To assess the lower extremities, have the patient bend her leg and
slide that heel along the opposite shin, from the knee to the ankle.
This movement, too, should be accurate, smooth, and without tremor.
• If the patient is able to stand and not restricted to bed, you can assess
balance using the Romberg test. Have the patient stand with her feet
together, arms at the sides, and eyes open; she should be able to
stand upright with no swaying. If she can do that, have her close her
eyes and stand the same way. If she falls or breaks her stance after
closing the eyes, the Romberg test is positive, indicating Proprioceptive
or Vestibular dysfunction.

ASSESSING THE CRANIAL NERVES (ANNEXURE 5)

There are 12 pairs of cranial nerves—some sensory, some motor, and
some both. The table in Annexure 5 lists the functions of each nerve and
explains how to test them.

Points to Ponder
A summary of focused Neurological Exam for Physiotherapist
The following passage attempts to provide the reader with a brief
but comprehensive review of the neurological examination. An
understanding of neuroanatomy is necessary to appreciate the fine points
of the neurological examination. In any case, neuroanatomy has to be
reviewed several times before a complete understanding is obtained
(Table 3.1).
 42 Handbook of Practical Neurophysiotherapy

A physiotherapist should conduct any neurological assessment to

answer the following questions:
1. Is there a lesion?
2. Where is the lesion?
3. What caused the lesion?
4. What are the key losses of function?
5. What are the necessary therapeutic interventions?

Table3.1: Key functional areas to be tested

Exam Localization
Mental status Cortex
Cranial nerves Brainstem
Motor and reflexes Upper motor and lower motor neurons
Sensory Sub cortical (thalamus), spinal cord
Coordination Cerebellum

The mental status is indicated by four basic parameters (Table 3.2).

• Level of consciousness: GCS score is often used to establish a baseline
LOC. Orientation to person, place and time should also be determined.
• Concentration and attention: Patients should be asked to perform serial
seven subtractions that is count backwards from 100 decreasing by
seven each time.
• Language by fluency of the patient’s speech, testing for comprehension
of simple commands such as repetition of words, naming of objects,
writing a sentence and reading a phrase.
• Memory should be tested regarding immediate, recent and remote
events.

Table 3.2: Interpretation of what each area of brain does in terms of mental status
Frontal cortex Intellectual function, production of speech (i.e. non-
fluent ‘expressive’ aphasia’s), motor control
Parietal cortex Analysis of sensory information, also serves a role in
intellectual function (e.g. visual-spatial neglect)
Temporal cortex Comprehension of speech (i.e. fluent ‘receptive’
aphasia)
Occipital cortex Vision

• The cranial nerve examination is an excellent way to localize a

brainstem lesion. Most cranial nerves originate in the brainstem,
because their nucleus resides there. A lesion in the cortex will cause
a contralateral deficit of the cranial nerve while an infranuclear
lesion will cause an ipsilateral deficit.
 A Primer toEssentials
the Anatomy of the Nervous
of Neurological System
Assessment 43

• The cortex controls motor function. It begins in the upper motor

neurons. (Betz cells of the precentral gyrus). The axons project via
the posterior limb of the internal capsule, travel through the brainstem
(the pyramidal tract), cross in the lower medulla, then descend in the
spinal cord (corticospinal tract within the lateral column) to the lower
motor neurons in the spinal cord.
• The lower motor neuron originates from the anterior column of the
spinal cord and ends in the motor end plate. The distinction between
an upper motor and lower motor neuron is important because a
lesion in either of the pathways gives markedly different clinical
presentation.
• The standard motor examination should include five areas, strength,
tone, posture, involuntary movements and reflexes. A rating scale
for motor examination is important for two reasons. Identifying
motor deficits allows for localization (i.e., which side of the brain is
involved). With the rating of the motor deficits one can follow
progression or improvement that has important
prognostic implications.
• Muscular bulk and tone will help in differentiating between upper
and lower motor neuron deficits.
• Abnormal postures–Decorticate and Decerebrate. Decorticate
posturing is extension of the lower extremities and flexion of the
upper extremities whereas decerebrate rigidity is extension and
internal rotation of all extremities. Both are upper motor neuron
problems.
• Decorticate posturing suggests a supratentorial pathology whereas
decerebrate posturing indicates an infratentorial pathology. Because
the lesion goes deeper in the brainstem, decerebrate posturing has a
worse prognosis.
• Involuntary movements indicate involvement of the extra-pyramidal
system, which includes complicated neuronal tracts between the basal
ganglia and cerebellum.
• Deep tendon reflexes are important to note because they give
information about the upper motor neuron verses lower motor neuron
lesions and lateralization. Symmetric abnormality verses asymmetric,
indicating systemic verses isolated neurological pathology.
• Superficial reflex such as the Babinski sign, i.e. toe fanning and
extension of big toe upon stimulation of the lateral aspect of the sole
of the foot from heel to big toe is important to note. The presence of
a Babinski sign indicates an upper motor lesion.
• Sensory examination is often difficult because it is a very subjective
examination. With an uncooperative patient the sensory exam may
be impossible to perform accurately. But when it can be done, the
sensory exam will reveal information about where lesions are located.
 44 Handbook of Practical Neurophysiotherapy

• Sensations are transmitted from the peripheral nerves to the spinal

cord. Once in the spinal cord, the nerve transmissions ascend through
several tracts or columns.
• Pain and temperature are located in the lateral column and decussates
(cross to the other side) at the level of entry.
• Proprioception and vibration travels through the posterior columns
and decussate at the level of the brainstem.
Superficial touch travels through both the lateral and posterior
columns, proving that the body has redundant systems for important
functions.
• Dermatomes are the peripheral distribution of the specific spinal
cord roots.
• Coordination and gait is an integration of multiple tracts including
the pyramidal, extra pyramidal, posterior columns and cerebellar
tracts and together, coordination and gait can be thought of as the
“final exam of the nervous system”. Many patients deemed “non-
focal and intact” might reveal significant dysfunction in Coordination
and gait.
• Ataxia is the classic neurological abnormality indicating cerebellar
dysfunction, which can be in the upper extremities, the lower
extremities or in the trunk. Ataxia is manifested by a lack of smooth
and coordinated movements.

POINTS TO PONDER
How to Localize a Lesion?
Knowing where the lesion is not just an intellectual exercise to be
completed by the therapist to prove that they know their neuroanatomy.
Localization of a lesion has important implications in terms of
diagnostic and therapeutic interventions.
The four major areas of lesion in the nervous system are as follows:
A. Cortex
B. Sub cortex: Thalamus, basal ganglia and internal capsule
C. Brainstem
D. Spinal cord.

Features of Cortical Lesions

There are five major findings associated with lesions in the cortex.
1. Dysphasia: Any disorder of language, which includes expressive,
receptive, global aphasia, naming and reading.
Geographic area: Frontal or temporal cortex.
2. Cortical Sensory loss: Which includes an inability to identify objects
in your hand (stereognosis), loss of two point discrimination and the
inability to discern writing on one’s palm (graphesthesia).
Geographic area: Post central gyrus.
 A Primer toEssentials
the Anatomy of the Nervous
of Neurological System
Assessment 45

3. Weakness of face and extremity muscles with possible paresthesia:

• If the arm is more involved, the lesion is in the middle cerebral
artery territory. If the leg is more involved, then it is in anterior
cerebral artery territory.
4. Conjugate Gaze Palsy: There are three gaze centers, two reside in
the cortex and one in the brainstem. The major one is the frontal
cortex gaze center.
The eyes will deviate toward the cortical lesion, because the right
frontal gaze center is responsible for looking to the left and vice
versa. The eyes will look towards the lesion.
So when the right frontal cortex gaze (Fig. 3.3) center is knocked
out, the conjugate gaze will be toward the right and vice versa. And
if the eyes deviate together at all, the most likely lesion is in the
frontal cortex.

Fig. 3.3: Frontal cortex

5. Seizures: Seizures associated with hemiplegia or TBI are most likely

due to a cortical lesion. Seizures generally originate in the cortex.

Features of Sub-cortical Lesions

This comprises lesions of internal capsule, basal ganglia and thalamus
1. Visual field defects: When a patient has difficulty with detecting
simultaneous movements in certain visual fields, the lesion is likely
to be in the cortex or the sub cortical area. For example, presence of
the left homonymous hemianopsia (Fig. 3.4) indicates a sub cortical
lesion in the visual pathway.

Fig. 3.4: Homonymous hemianopsia

 46 Handbook of Practical Neurophysiotherapy

2. Dystonia: Unusual, uncoordinated movements such as

choreoathetosis (involuntary jerky movements), hemiballismus (slow,
bizarre movements of half the body), or simply a loss of harmony of
refined movements is indicative of basal ganglia lesions. Remember
that the basal ganglia help modulate movement, and refine the motor activity
of the pyramidal system.
3. Face and extremity weakness: When the face, arm and leg are equally
involved then the lesion must reside in the internal capsule.
4. Dense Sensory Loss: Loss of pain and touch in face and extremities
signifies a lesion in the thalamic area. The thalamus is a sensory
relay switch as well as a primary receptive center, so in a thalamic
lesion there will be abnormality of the sensation in the face and extremities.

Features of Brainstem Lesions

Brainstem consists of midbrain, pons and medulla, and cerebellum.
Lesions in the brainstem result in crossed abnormalities.
1. Crossed hemiplegia: The cranial nerves will be affected on one side,
while the extremity motor deficits are on the other side. The brainstem
lesion will affect the infranuclear cranial nerves ipsilaterally, and the
motor tract contralaterally, because the motor tract decussates (crosses)
just above the spinal cord.
2. Cerebellar findings: Ipsilateral ataxia, dysmetria (misjudge distance
between finger to nose).
3. Nystagmus: The medial longitudinal fasciculus helps to coordinate
eye movement and resides in the brainstem axis. It connects the two
nuclei of CNIII and CNVI, which allow conjugate gaze to occur. A
problem in the brainstem could result nystagmus. The nystagmus
could be horizontal, vertical or rotary.
4. Lower cranial nerve findings: Cranial nerves VIII-XII project from
the lower brainstem. Thus lesions in this area will cause hearing loss
and vertigo (CN VIII), dysarthria (difficulty with articulation),
dysphagia (CN IX-X) (difficulty with swallowing), and tongue
deviation (XII).

Features of Spinal Cord Lesions

Lesions in the spinal cord cause predictable deficits. Assuming there is
normal cortical, sub cortical and brainstem functions, the possible findings
are listed below.
1. Motor deficits can be in one extremity (monoplegia), both lower
extremities (paraplegia), one side of the body (hemiplegia) and in
four extremities (quadriplegia).
In the case of monoplegia or hemiplegia, the lesion will be
ipsilateral.
 A Primer toEssentials
the Anatomy of the Nervous
of Neurological System
Assessment 47

2. Sensory loss may be bilateral or ipsilateral or contralateral because

pain and temperature fibers cross immediately after entering the cord.
A sensory level along with a no man’s land may be present in most
cases.

Clinical Implication of Dominance

• The controlling hemisphere in most human beings is the left side of
the brain.
• The dominant hemisphere really controls most things in the body.
• Physiotherapists should know whether a patient is right-handed or
left-handed.
• Right-handed people are left hemisphere dominant.
• Most left handed people are also left hemisphere dominant except
for about 10% which will be right hemisphere dominant.
• The reason dominance is so important is that a stroke in a dominant
hemisphere for the same sized lesion can be more disabling.
• The speech centers are located in the cortex of the dominant
hemisphere. Aphasia does not occur when the non-dominant
hemisphere is involved.

When the Non-dominant Hemisphere is Involved, the Following

Symptoms May Result
a. Inattention and denial: These patients neglect the left side of the
body despite having significant deficits. These patients will not see
you if you stand on their left. They may not shave the left side of
their face. They remain unconcerned about their deficits; because
they do not believe they have any damaged side.
b. Constructional apraxia: Patients are unable to do a motor task without
having any motor deficit. They just won’t be able to do it. They may
not be able to open the door even though they have the motor
capability to do so.
c. Spatial Disorientation: Patients are able to get lost in their own
home.
d. Confusional State: This occurs infrequently in severe lesions.

Final Word of Caution

• No matter how brief or extensive your neuro assessments are,
comparing your findings to those of previous exams is essential.
• When assessing motor response in an unconscious patient, use sternal
pressure judiciously. Deep sternal pressure can cause bruising.
• In many ICUs, a bedside neuro exam is done as a part of the change-
of-shift report so that both sets of nurses and therapists can assess
the patient together. This facilitates any change of status to be detected
at the earliest.
 48 Handbook of Practical Neurophysiotherapy

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5. Messner R, Wolfe S. RN’s pocket assessment guide. Montvale, NJ: Medical
Economics 1997.
6. Vos H. The neurological assessment. In E Barker (Ed), Neuroscience nursing:
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