Nervous system examination

1. Neuro-Musculo skeletal
system
In the
diagnosis of a neurological disease it is the history,
rather than the examination, that is paramount

2. Components
• Mental Status Assessment
• Cranial Nerves Assessment
• Testing Motor Functions
• Sensory System Assessment
• Examination of the Peripheral Nerves
• Testing Reflexes
• Examination of signs of Meningeal Irritation

3. NS-Examination
• Nervous system-central and peripheral divisions
• Control and maintenance of all body functions through voluntary and
autonomic responses.
• Neurological assessment cuts across human body activities: cognition
and behaviour, motor, sensory and autonomic functions.

4. Mental status assessment
• 1. Appearance; dressing, grooming, personal hygiene
• Personal hygiene and grooming may deteriorate in depression,
schizophrenia and dementia
• Excessive neatness and attention to personal looks and fastidiousness
may be seen in obsessive compulsive disorder
• One-sided neglect may result from a lesion in the opposite parietal
cortex

5. MSA cont..
• 2. Level of consciousness; person’s alertness and state of awareness
of the environment
• Attention; attentive person; has the ability to concentrate or focus
over a time or one activity/task. Distractible person has difficulty in
giving history/responding to issues
• Memory; short term(recent; interval of minutes, hours, days), long
term(remote; over intervals of years)
• Orientation; awareness of whom or what they are in relation to time,
place and persons; NOTE; it depends on both memory and attention

6. MSA cont..
• 3. Speech; what and how they speak can reflect their status
• quantity- talkative/relatively silent, are comments spontaneous or
only responsive to direct question?
• Slow speech- depression, rapid and loud-manic syndrome
• Rushing stream of ideas with some connection or without logical
connection; may signify mental disorder referred to as flight of ideas
• Articulation of words- dysarthria; a defect in the muscular control of
the speech apparatus- words may be nasal, slurred, or indistinct with
the language remaining intact

7. MSA
• APHASIA; a disorder in speaking or understanding language
• A) neologism- usage of strange words
• B) word salad- real words strung together oddly
• C) hesitancies and gaps in the flow and rhythm of words
• D) circumlocutions- phrases or sentences substituted with words one
fails to think of.
• E) paraphrasias- speech where words are malformed; unintended
sounds

8. MSA cont.
• 4) Emotional status- mood
• Is there general impression of happiness, distress or depression
• Emotionally distressed; abnormal sleep patterns- sleeping habits?
• 5) Behaviour/actions-
• Patient’s body posture and ability to relax
• Pace, range and character of movements. Are they under voluntary
control;

9. MSA CONT..
• Are certain parts of the body immobile?
• Do posture and motor activity change with topics?
• Anxiety; tense posture, restlessness,
• Agitated depression; crying, paced, hand wringing
• Depression; hopeless slumped posture and slowed movement
• Singing, dancing and expansive movements (manic episodes)

10. MSA
• Features supporting a diagnosis of depression
• Persistent/pervasive low mood, often tearfulness
• Diurnal variation of mood, typically worse in the morning
• Loss of motivation/interest
• Anhedonia, i.e. inability to experience pleasure in normally
pleasurable activities
• Irritability and/or poor concentration
• Lethargy, fatigue and lack of energy

11. MSA
• Features supporting a diagnosis of depression
• Sleep disturbance, usually early-morning waking
• Appetite and weight loss (increased in atypical depression)
• Constipation and/or loss of libido
• Ideas of hopelessness, worthlessness, guilt, persecution, nihilism
• Loss of confidence and social withdrawal

12. MSA
• Features supporting a diagnosis of depression
• More severe depression
• Self-deprecation and/or self-neglect
• Motor retardation, leading to depressive stupor seen in catatonic
depression
• Retardation of speech, or muteness
• Paradoxical agitation
• Psychotic symptoms with mood
• Congruent delusions and auditory hallucinations

13. ABNORMAL BELIEVES
• The main types of abnormal belief are primary and secondary delusions,
overvalued ideas and sensitive ideas of reference.
• Primary delusions (also called true delusions) are delusions that are not
secondary to other abnormal mental processes such as abnormal mood or
hallucinations.
• A particular example of a primary delusion is a delusional perception in
which a patient has a normal perception to which is attached a delusional
significance.
• For example, a patient may see a waiter pick up a glass (a normal
perception) and the patient realises immediately that the waiter is an
envoy of the devil (delusional significance).

14. DELUSIONS
• A. Primary delusions are generally associated with schizophrenia
provided they occur in clear consciousness (i.e. they are not occurring
in an organic confusion state).
• Secondary delusions (also called delusion-like ideas) are secondary to
an abnormal mood state or hallucinatory experience.
• Unlike primary delusions, they are understandable in the light of the
patient’s mood and life history. For example, a severely depressed
mother may become convinced that she is evil and that she is not
worthy to bring up her child.

15. DELUSIONS
• B. Secondary delusions lack diagnostic specificity but their content
may relate to the diagnosis.
• Sensitive ideas of reference can be described when patients falsely
believe that things actually occurring in their environment are
specifically referring to themselves.
• These experiences typically occur in depression, body dysmorphic
disorder (BDD); spent a lot of time worrying about their appearance,
paranoid states and paranoid personality types. For example, patients
may feel that others are looking or laughing at them

16. MSA; DELUSIONS; TYPES
• 1. Persecutory delusions
• ‘Do you ever have the feeling that people are against you or out to get
you in some way?’
• They may occur in organic psychoses such as confusional states,
dementia, alcohol and drug-induced psychoses, in stress-induced
psychogenic psychoses and sometimes in people with paranoid
personalities, particularly with advancing age and in whom sensory
deficits such as visual and hearing impairment occur.
• They may also occur in schizophrenia.

17. DELUSIONS
• 2. Delusional misinterpretation
• This is a type of delusion of reference.
• Patients will ascribe particular significance to normal objects in their
environment.
• For example, they will see a coded message intended for them in a
car number plate

18. DELUSIONS
• 3. Delusions of grandeur
• Patients are unrealistically convinced that they are special in some
way, for example they have been given a special purpose by God or
that they are famous.
• It is characteristic of syphilitic general paralysis of the insane (now
rarely seen).
• They can also occur in mania and schizophrenia but are uncommon.

19. DELUSIONS
• 4. Hypochondriacal delusions
• Patients believe that some part of their body is abnormal or diseased.
• This is common in depressive psychosis, as are delusions of guilt, self-
blame and poverty.

20. DELUSIONS
• 5. Nihilistic delusions
• Seen in severe psychotic depression,
• they involve a delusional belief that parts of one’s body (internal
organs usually) are rotting away or even no longer exist (‘no
stomach’).

21. DELUSIONS
• 6. Delusions of jealousy
• This is a delusional conviction that one’s spouse or partner is being
unfaithful.
• It occurs in substance misuse (especially alcohol misuse), in
schizophrenia and in people with a suspicious/possessive personality
style.
• It is important to take these delusional beliefs seriously and do a full
risk assessment.

22. DELUSIONS
• 7. Erotomanic delusions
• Patients hold delusional beliefs that someone (usually famous) is in
love with them.
• They occur mainly in schizophrenia and in organic psychoses.
• They may lead to stalking behaviour, so take these delusions seriously
and do a full risk assessment.

23. DELUSIONS
• 8. Fantastic delusions
• These are bizarre delusions – for example, that aliens have landed
and are causing things to change in some way or they are involved in
some other attempts to interfere with the patient’s life.
• These occur in schizophrenia.

24. DELUSIONS
• 9. Delusional memory
• The patient describes remembering things which are clearly
delusional.
• For example, the patient remembers and can give graphic
descriptions of being abducted by aliens and experimented upon.

25. DELUSIONS
• 10. Delusions of passivity
• These are a group of bizarre phenomena in which the core experience
is of loss of the normal sense of boundary between the self and the
outside world (ego boundaries).
• They include;
• a) Thought insertion (the experience that one’s thoughts are not
one’s own) and the accompanying belief that thoughts have been
inserted into one’s mind;

26. DELUSION of passivity
• b) Thought broadcasting;
• where the patient experiences his mind as open to others so that
thoughts can leave it and be picked up by others; and
• C) Thought withdrawal
• where patients feel that thoughts are actually extracted from their
heads.
• NOTE: These experiences are very specific and, in the absence of
organic brain disease, are diagnostic of schizophrenia.

27. HALLUCINATIONS
• Hallucinations are perceptions that are not based on any real external
stimulus.
• 1. AUDITORY HALLUCINATIONS
• They can occur in any sensory modality but the commonest are
auditory, for example, a voice being heard by the patient but no one
else hears it.
• Auditory hallucinations occur in many disorders including
schizophrenia, organic brain disease and bipolar disorder.
• Voices can be heard speaking in the second or third person.

28. HALLUCINATIONS
• In severe depression, voices are often second person and the content
may be mood congruent, for example ‘Look at you, you’re useless,
why not do away with yourself?’.
• By contrast, manic patients may hear God’s voice telling them they
have special powers or that they have been chosen to do something
special.
• Third person hallucinations (e.g. the patient being addressed as ‘He’
or ‘She’) in the absence of organic disease suggest schizophrenia

29. HALLUCINATIONS
• 2. VISUAL HALLUCINATIONS
• They are uncommon in psychiatric illness and are more suggestive of
organic conditions, particularly an acute brain syndrome (e.g.
delirium), illicit drug use (e.g. LSD) or drug withdrawal (e.g. delirium
tremens).
• However, they do occasionally occur in schizophrenia or bipolar
disorder.
• Visual hallucinations vary from the elementary, for example flashes of
light (from visual pathways and the occipital lobe) to complex visions
of objects or scenes (from visual processing areas and the temporal
lobes).

30. HALLUCINATIONS
• In confusional states, small animals are often seen, typically at the
periphery of vision.
• In temporal lobe epilepsy, complex visual hallucinations (scenic) may
occur as may polymodal ones (involving multiple sensory modalities).

31. HALLUCINATIONS
• 3. OTHER FORMS
• Hallucinations may also occur in other sensory modalities, for
example olfactory, gustatory and tactile.
• Some patients with epilepsy commonly have olfactory and gustatory
hallucinations (smelling odd smells or tasting unusual tastes). These
experiences often precede an epileptic seizure.
• Patients with severe depression may have olfactory hallucinations,
perceiving themselves as smelling unpleasant (cacosmia).

32. Cont..
• Tactile hallucinations are difficult to distinguish from illusions.
• In cocaine psychosis, patients may complain that insects are crawling
over them (formication).
• Patients with schizophrenia may describe tactile hallucinations which
may be incorporated into their delusional beliefs, for example, a
patient may feel sensations on the skin and believe this is due to, for
example, an animal or insect biting them. A specific subcategory of
illness, delusional parasitosis, leads to constant dermatological
referrals and the conviction of some persisting infestation. In the
absence of organic brain disease, tactile hallucinosis is otherwise a
first-rank symptom of schizophrenia

33. Psychiatry history order
• Presenting complaint
• History of presenting complaint (HPC)
• Previous medical history – psychiatric and physical
• Current medication/treatment
• Family history
• Personal history – Childhood – Schooling – Occupation – Psychosexual
history including relationships and marriage – Reproductive history (in
women) – Children – Present social circumstances – Social support –
Forensic history (if relevant)
• Premorbid personality: personality traits prior to illness

34. Personality disorders
• 1.
• 2.
• 3.
• 4.
• 5.

35. CRANIAL NERVE ASSESSMENT
• Olfactory nerve; sensory, nerves of the sense of smell
• Sensory receptors and fibres originate in the upper part of the
mucous membrane (beneath the nasal epithelium) of the nasal cavity,
(Their central axons project in numerous bundles, not as a discrete
nerve), pass upwards through the cribriform plate of the ethmoid
bone and then go to the olfactory bulb.
• The nerves then proceed backwards as the olfactory tract, to the area
for the perception of smell in the temporal lobe of the cerebrum

36. CRANIAL NERVE ASSESSMENT
• Testing for Olfactory nerve function;
• Test ability to identify aromatic odours, one nostril at a time with eyes
closed.
• Anosmia; a state where the sense of smell is absent
• Parosmia; a state where pleasant odours seem offensive
• II; Optic nerve; sensory, nerves of the sense of sight
• The fibres originate in the retinae of the eyes and they combine to
form the optic nerves.

37. Cranial nerve assessment
• They are directed backwards and medially through the posterior part
of the orbital cavity.
• They then pass through the optic foramina of the sphenoid bone into
the cranial cavity and join at the optic chiasma.
• The nerves proceed backwards as the optic tracts to the lateral
geniculate bodies of the thalamus. Impulses pass from these to the
centre for sight in the occipital lobes of the cerebrum and to the
cerebellum.

38. Cranial nerve assessment cont..
• In the occipital lobe sight is perceived, and
• in the cerebellum the impulses from the eyes contribute to the
maintenance of balance, posture and orientation of the head in space.
• Testing;
• 1. Visual acuity and colour vision
• Visual acuity for each eye is measured using the Snellen chart . Severe loss
of acuity (less than 6/60, the top letter on the Snellen
• chart) is documented as ability to count fingers at 1 metre, ability to
perceive hand movements, perception of light only and no perception of
light.

39. Cranial nerve assessment
• Acquired unilateral loss of colour vision is a characteristic feature of
optic neuropathy, and loss of colour vision can occur when visual
acuity is well preserved.
• Thus, testing colour vision using Ishihara plates may be a sensitive
bedside test for mild optic neuropathy.
• 2. Visual field
• visual field defects in one eye indicate a retinal or optic nerve
disorder.

40. Cranial nerve assessment
• They may affect any part of the field of the affected eye or nerve.
Lesions at the optic chiasm or lesions behind the chiasm in the optic
tracts, visual radiations or occipital cortex give rise to visual field
defects affecting both eyes.
• 3. Fundoscopy
• The neurological examination focuses on papilloedema, optic atrophy,
pigmentary retinal degeneration and vascular disease.

41. III, IV, VI (oculomotor, trochlear, abducens)
• They control eye lids, pupillary reactions and extra-ocular muscles;
• 1. Inspect; eye lids for drooping-sign of paralysis of 3rd nerve, compare
size and shape of both pupils
• 2. Test pupillary reaction to light; dim the light in the room to
facilitate the dilatation of the pupils
• 3. Test for accommodation; note pupils constrict at near object and
dilate at a distant object

42. III, IV, VI
• Test extra-ocular muscles; the six muscles ensure full movement of
the eye; Lateral rectus supplied by 6th cranial nerve, Superior oblique-
4th nerve, lastly Superior rectus, inferior rectus, medial rectus and
inferior oblique; supplied by the 3th cranial nerve
• Abnormalities of eye movements may result from disorders of the
cerebral hemispheres; brainstem; cerebellum; cranial nerves III, IV
and VI; the neuromuscular junctions between oculomotor nerves and
eye muscles; the eye muscles themselves and from lesions affecting
the structure and contents of the orbits.

43. Cranial nerves assessment
• Terminology in eye movements;
• Horizontal movement of the eye outwards (laterally) is termed
abduction and inwards (medially) is termed adduction.
• Vertical movement upwards is termed elevation and downwards is
depression.
• The eye is also capable of diagonal movements (version).
• Rotary movements are those in which the eye twists on its anterior–
posterior axis.

44. Cranial nerve assessment
• Intorsion is rotation such that the upper part of the eye moves
medially and the lower part of the eye moves laterally. Extorsion is
the opposite.
• Convergence refers to adduction of both eyes to fixate on a near
object.
• Lateral rotation of the head causes reflex movement of the eyes in
the opposite direction (adduction of one eye, abduction of the other).
• A squint (the eyes point in different directions) is described as
convergent or divergent strabismus, depending on whether the eyes
point towards or away from each other.

45. Cranial nerve assessment
Diplopia testing; double vision
In patients who have obvious, easily visible paresis of movement of one
or both eyes, the reason for diplopia is self-evident.

46. V, trigeminal; mixed
• The nerve trunk emerges from the pons as sensory and motor roots
• Divided into 1.ophthalmic (sensory- lacrimal glands, conjunctiva of
the eyes, forehead, eye lids, anterior aspect of the scalp and mucous
membrane of the nose), 2.maxillary (sensory- cheeks, upper gums,
upper teeth and lower eyelids), 3.mandibular (mixed-largest of the
three, they supply the teeth and gums of the lower jaw, pinnae of the
ears, lower lip and tongue; motor fibres supply muscles of
mastication-masseter, buccinators, temporalis, orbicularis oris)
• Chief sensory nerves for the face and head(oral and nasal cavities and
teeth)

47. V, TRIGEMINAL, MIXED
• Observe for muscle atrophy, jaw/face deviation, fasciculation
• Palpate the jaw for tone and strength
• Closing of eyes; test for sensations; ask the patient to differentiate
• Test for corneal reflex; using a wisp of cotton

48. Facial Nerve
• Supply the muscles of facial expression
• Sensory fibres convey impulses from the taste buds in the anterior
2/3 of the tongue to the taste perception area in the cerebral cortex.

49. VII, FACIAL, MIXED
• Motor function;
• Whistle, smile, frown, puff cheeks, raise eyebrows, squeeze eyes shut
• Observe for symmetry, facial conformation,
• Listen to speech, note any difficulty in enunciating labial sounds; b, m,
p
• One side of the mouth drooping, flattened naso-labial fold, and lower
eyelid sagging- muscle weakness

50. FACIAL
• Sensory component;
• Test ability to identify sweet and salty tastes on each side of the
tongue;

51. Auditory nerves
• Vestibular nerves arise from the semi-circular canals of the inner ear
and convey impulses to the cerebellum. Associated with maintenance
of posture and balance.
• Cochlear nerves originate in the spiral organ (of Corti) in the inner ear
and convey impulses to the hearing areas in the cerebral cortex
where sound is perceived.

52. VIII, VESTIBULOCOCHLEAR(AUDITORY);
SENSORY
• ASSESS HEARING;
• 1.Use normal voice at a distance,
• 2.Place a wrist watch near a patient’s ear
• 3.Whisper phonetically balanced words,
• 4.Perform Rinne test; air and bone conduction; strike the tuning fork
of 512 Hz (frequency), in normal subjects air conduction is
better(louder) than bone conduction( Rinne test –positive). This
response is also found in those patients with sensory-neural deafness
• In conductive deafness bone conduction is better than air conduction

53. VIII, (vestibulocochlear)
• 5.Perform Weber’s test
• Strike tuning fork; place it on the vault of the skull(on the mid-line)
• The sound is normally loudest in the midline; also true if hearing is
symmetrically reduced;
• In unilateral sensori-neural hearing loss the hearing will be louder in
the normal ear
• In purely conductive hearing loss the hearing will be louder on the
side with the conductive deficit

54. IX Glossophayrngeal; mixed
• Motor fibres a rise from nuclei in the medulla oblongata and
stimulate the muscles of the tongue and pharynx and the secretory
cells of the parotid (salivary) glands.
• Sensory fibres convey impulses to the cerebral cortex from the
posterior 1/3 of the tongue, the tonsils and pharynx.
• Essential for the swallowing and gag reflexes.

55. IX, GLOSSOPHARYNGEAL, mixed
• NOT tested routinely
• pharyngeal sensation can be tested using a tongue depressor to touch
lightly the mucosa of the posterior pharyngeal wall.
• This requires tolerance and cooperation on the part of the patient.
• In stuporous or comatose patients, testing the gag reflex may be
useful.

56. X Vagus
• More extensive distribution than any other cranial nerve.
• Pass down through the neck into the thorax and abdomen, form an
important part of the parasympathetic nervous system
• Motor fibres a rise from nuclei in the medulla and supply the smooth
muscles and secretory glands of the pharynx, larynx, trachea, heart,
oesophagus, stomach, intestine, exocrine pancreas, gall bladder, bile
ducts, spleen, kidney, ureter and blood vessels in the thoracic and
abdominal cavities.
• Sensory fibres convey impulses from the membranes lining the same
structures to the brain

57. X,Vagus, mixed
• A patient with a proximal unilateral lesion of the vagus nerve may
complain of dysphagia and nasal regurgitation of swallowed fluids.
There will be weakness of the muscles of the soft palate on the
affected side.
• Attempted voluntary elevation of the soft palate (ask the patient to
say ‘Ahh’, preferably fairly high pitched) reveals the weakness of
elevation of the palate on the affected side, along with deviation of
the uvula to the unaffected side, because of the unopposed action of
the palatal muscles on that side.

58. XI, SPINAL ACCESSORY (motor)
• Arise from nuclei in the medulla oblongata and in the spinal cord.
• Innervates the larynx, pharynx, sternocleidomastoid and trapezius
muscles
• Trapezius muscle strength; ask the patient to shrug the shoulder as
you apply resistance to them with your hands
• Sternocleidomastoid; ask the patient to turn the head to each side
against resistance

59. XII, HYPOGLOSSAL (motor)
• Arise from nuclei in the medulla oblongata; Supply the tongue and
hyoid bone depressors (muscles)
• Inspect the tongue; at rest and when protruded
• Note any fasciculation, asymmetry, atrophy or deviation
• Note any difficulties in movement
• Test tongue muscle strength; as him to push the tongue against the
cheek as you apply resistance with a finger; assess the strength
• Assess the quality of lingual speech; L, T, D, N; weakness in the tongue
and deficit in the nerve will make it difficult to pronounce

60. MOTOR FUNCTIONS
• A) RAPID RHYTHMIC MOVEMENT;
• 1. Ask the seated patient to pat his thighs with both hands with palms
and back of the hands alternatively, and increase the rate gradually
• 2. Or ask the patient to touch the thumb to each finger on the same
hand, sequentially from the index to the little finger and back
• Observe for stiff, slowed, non-rhythmic, or jerky clonic movements
• B) ACCURACY OF MOVEMENTS
• 1. Finger-to-finger test; ask the patient to use the index finger and
alternatively touch his nose and your finger

61. MOTOR FUNCTIONS CONT..
• Change location several times during the test
• Repeat with the other hand
• The movements should be rapid, smooth, and accurate
• 2. finger-to-nose test
• Ask the patient to close both eyes and touch his nose with the index
finger of each hand
• Alternate hands and increase speed gradually

62. MOTOR FUNCTIONS CONT..
• 3. Heel-to-shin test
• Perform with the patient standing, sitting, or supine
• Ask patient to run the heel of one foot up and down the shin; knee to
ankle; both legs
• The movement should be in a straight line; watch for irregular
deviations
• C) BALANCE; Equilibrium

63. MOTOR FUNCTIONS CONT..
• Romberg’s test;
• Ask the patient to stand with his feet together side by side. Having
established that his balance is satisfactory with his eyes open, ask him
to close his eyes, having reassured him that nothing untoward will
happen.
• If he loses balance with his eyes closed, the test is positive
• D) GAIT
• Observe the patient walk without shoes across the room along a line
forwards and then backwards; first with eyes open and then closed:

64. MOTOR FUNCTIONS CONT..
• Observe:
• a. spastic gait- difficulty in bending knees and drags feet as if they are glued
to the floor
• b. hemiplegic gait- spastic gait in which only one leg is affected
• c. high stepping gait- adopted in order to avoid tripping from the toe
catching the ground. There is weakness of the extensor muscles of the feet;
for instance in common peroneal nerve palsy
• d. cerebellar ataxia- sign of cerebellar disease. Drunken gait
• e. sensory ataxia- in tabes dorsalis. Walks by stamping feet as she raises the
feet very suddenly and abnormally high and then jerks them forward and
bringing them to the ground with a stamp with heel first.

65. Motor functions cont..
• f. festinant gait- a sign of Parkinson’s disease. The patient bends
forwards and advances in rapid short shuffling steps
• g. waddling gait- walking like a duck- in myopathies and muscle
dystrophies

66. SENSORY SYSTEM ASSESSMENT
• Primary sensory functions; loss of sensory modalities may indicate
peripheral neuropathy. Symmetric sensory loss indicates a
polyneuropathy
• 1; superficial touch;
• 2; Superficial pain
• 3; temperature and deep pressure
• 4; vibration
• 5; Position of joints
• NB; patient’s eyes should be closed during the tests

67. sensory
• Cortical sensory functions; test cognitive ability to interpret
sensations associated with coordination abilities; inability to perform
these tests should make one to suspect a lesion in the sensory cortex
or the posterior columns of the spinal cord.
• 1. stereognosis; hand the patient a familiar object to identify by touch
• Tactile agnosia; inability to recognize objects by touch suggests a
parietal lobe lesion
• 2. two point discrimination; find distance at which the patient can no
longer distinguish two points

68. Sensory
• 3. Graphesthesia; let the patient identify a drawing on the palms

69. Peripheral nerves
• 1. Muscle tone- a state of tension or contraction found in healthy
muscles; its maintenance depends on the reflex arc;
• Estimation of tone in muscle is done by handling the limbs and
moving them passively at their joints.
• Hypertonia is seen in upper motor neurone lesions; whereas
• Hypertonia occurs in lower motor neurone lesions
• In grading the muscle power; ask the patient to relax the affected
limb and request him/her to move the limb as you observe

70. Peripheral nerves
• Grade 0- no movement and therefore complete paralysis
• Grade I- trace or flicker of contraction only
• Grade II- movement detectable only when gravity is excluded by
appropriate postural adjustment
• Grade III- the limb can be held against force of gravity, but not against
the examiner’s resistance
• Grade IV- movement possible against gravity and minimal resistance
• Grade V- normal full range of motion against gravity and resistance

71. Peripheral nerves
• 2. sensation
• Patient placed in a relaxed position and with eyes closed, he/she is
asked to respond as follows:
• A) touch sensation; stroke the skin with cotton wool,
• B) pain sensation;
• D) temperature sensation;

72. Specific nerves
• Failure to use thumb and index finger- may mean peripheral nerve
palsy of the median nerve
• Inability to flex the knee- sciatic nerve palsy
• Abnormal posturing; wrist drop-radial nerve
• Foot drop; unable to dorsi-flex; tibia nerve defect

73. Testing of reflexes
• 1. Deep tendon reflexes;
• Biceps jerk
• Place the patient in sitting/supine position
• Flex the elbow to a right angle and place the forearm in a semi-
pronated position
• Place your own thumb or index finger on the biceps tendon and strike
with the patellar hammer; observe the biceps for contractions

74. Reflexes; deep tendon
• Triceps jerk;
• Place the patient in sitting or supine position
• Flex the elbow and allow the forearm to rest across the patient’s
chest
• Tap the triceps tendon just above the olecranon process
• Observe the triceps for contractions

75. Reflexes; deep tendons
• Supinator jerk;
• Place the elbow in a slightly flexed and slightly pronated position in
order to avoid contraction of the brachioradialis
• Hit the styloid process of the radius with a tendon hammer; this
stretches the supinator
• Observe supination of the elbow

76. Reflexes; deep tendon
• Knee jerk; patellar reflex;
• Supine/sitting
• Strike the knee with patellar hammer directly on the patellar tendon
midway between its origin and insertion
• There will be a brief extension of the knee due to contraction of the
quadriceps

77. Reflexes; deep tendon
• With the foot hanging loose, slightly dorsiflex patient’s foot so as to
stretch the Achilles tendon, strike it on the posterior.
• Normal result; quick contraction of the calf muscle

78. Reflexes;
• Jaw Jerk;
• Ask the patient to open the mouth moderately
• Place a finger firmly on the chin
• Tap it suddenly with the other hand as in percussion
• A contraction of the muscles that close the jaw results. This reflex is
sometime absent in healthy people and increased in upper motor
neurone lesions.

79. Reflexes; deep tendon
• Clonus;
• Bend the patient’s knee slightly and support it with one hand
• Grasp the forepart of the foot with the other hand
• Suddenly dorsflex the foot
• Sudden stretch causes a reflex contraction of the calf muscles
followed by relaxation
• Continued stretch causes a regular oscillation of contraction and
relaxation, which is called clonus
• Sustained clonus is abnormal and evidence of upper neurone lesion

80. Grading Tendon Reflexes
• 1. absent
• 2. Present
• 3. brisk
• 4. very brisk
• 5. clonus

81. Superficial Spinal Reflexes
• Anal reflex; stroke/scratch- contraction of anal sphincter skin near
anus;
• Level of spinal cord; 3rd and 4th sacral segments

82. Superficial spinal reflexes
• Bulbocavernosus; pinch dorsum of glans penis- contraction of
bulbocavernosus; 3rd and 4th sacral segment

83. Superficial Spinal Reflexes
• Plantar; stroke sole of the foot- flexion of toes and foot
• Level of spinal cord- lower part of lumbar enlargement ; 5th lumbar
and 1st sacral segments

84. Superficial Spinal Reflexes
• Cremasteric; stroke skin at upper inner part of thigh- upward
movement of testicle;
• 1st and 2nd lumbar segment

85. Superficial Spinal Reflexes
• Abdominal; stroke abdominal wall below costal margin at level of the
umbilicus and iliac fossa- contraction of abdominal muscles;
• 7th and 12th thoracic segments

86. Superficial Spinal Reflexes
• Scapula; stroke skin in inter-scapular region; contraction of scapular
muscles
• 5th cervical to 1st thoracic segment

87. SIGNS OF MENINGEAL IRRITATION
• 1. examination of neck stiffness;
• With the patient supine, slip your hand under the head and raise it
flexing the neck; try to make the patient’s chin touch the sternum,
but do not force it
• Nuchal rigidity is associated with meningitis and intracranial
haemorrhage

88. Meningeal irritation
• 2. Brudzinki sign; during assessment of neck stiffness- involuntary
flexion of the hips and knees when flexing the neck is a positive
Brudzinki sign
• 3. Kernig’s sign;
• Flexing the leg at the knee and hip when patient is supine; attempt to
straighten the leg;
• Pain in the lower back and resistance to straightening the leg at the
knee constitute a positive Kernig’s sign

89. Motor neurons
• Motor neurons are nerve cells in your brain and spinal cord that
control movement
• They command your muscles to contract; enable walking, talking,
body movement
• Divided into upper and lower motor neurons
• UMNs- relay messages between the cerebral cortex and the spine
• LMNs-relay messages from the spine to the muscles

90. Neurone lesions
• Lesions are areas of damage to motor neurons
• UMNLs- lesions of the neural pathway above the anterior horn of the
spinal cord or motor nuclei of the cranial nerves
• LMNL- affects nerve fibres travelling from the anterior horn of the
spinal cord to the associated muscle
• NB; when the spinal cord develops, the posterior part becomes
responsible for managing most aspects of sensation, and the anterior
is more responsible for movement.

91. LMNL
• Characterised by weakness limited to focal or root innervated pattern
• Muscle wasting- prominent in a focal pattern
• Reflexes- absent or reduced
• Fasciculations- present
• Babinski response- absent

92. UMNL
• Characterised by muscle weakness
• Muscle wasting- absent or slight
• Hyper-reflexia
• Hypertonia
• Clonus- repeated often rhythmic contractions
• Spasticity
• No fasciculations