Clinical Examination of Nervous System - PPT

CNS Examination Practical
• Presented By –
Prof.Dr.R.R.Deshpande
(M.D in Ayurvdic
Medicine & M.D. in
Ayurvedic Physiology)
• www.ayurvedicfriend.c
om
• Mobile – 922 68 10 630
• professordeshpande@g
mail.com
11/28/2016 1Prof.Dr.R.R.Deshpande

Clinical Examination of
Central Nervous System
11/28/2016 Prof.Dr.R.R.Deshpande 2

Centers in Brain

Examination of Nervous System
• (1) Examination for higher functions
• (2) Examination of cranial nerves
• (3) Examination of sensory system
• (4) Examination of motor system
• (5) Examination of reflexes
• (6) Examination of gait
• (7) Examination of spine and cranium
• (8) Examination for special signs (such as
cerebellar signs)

Examination of Higher Functions
• (1) Level of consciousness.
• (2) Orientation of time, place and person
• (3) Intelligence
• (4) Memory
• (5) Speech
• Note :- Special tests are required for
psychiatric patients.

Asking questions for orientation of
Time,Place & Person

Cranial Nerves

Examination of Cranial Nerves
• (1) First cranial nerve - Olfactory nerve –
• This can be tested by asking patient to smell a
known substance with each nostril like
camphor ,Eucalyptus

Testing of Olfactory Nerve

2nd Cranial Nerve – Optic Nerve
• This nerve is examined ,under following
headings
• (A) Acuity of Vision
• (B) Field of Vision
• (C) Colour Vision

Examination of Optic Nerve –
Snellen’s chart

Acuity of vision
• Tested by asking the patient to read "Snellen's
chart" from a distance of 6 m.
• Suppose, person reads only 2nd line, on which
distance mentioned is 36 m, then we express his far
vision as 6/36 (Normal far vision should be 6/6)
• In above case - it is understood that what a normal
person can read from 36 m, our patient is reading
from 6 m and so, patient is suffering from Myopia.

Near Vision Testing
• (ii) Near Vision - is tested with the help of
Jeger's chart .This chart is to be read from a
distance of 25 cm, which is our near point.
Each eye should be tested separately and then
binocular vision.
• Normally the person should read smallest
print on Jeger's chart.
• This indicates near vision of patient is normal.
He is not suffering from Hypermetropia.

Near vision – Jeger’s Chart

Colour Vision
• Tested with 'Ishihara chart’
• This chart is to be tested by each eye
separately and the person is asked to
recognize the figure which are printed in
different colours in the chart.

Colour vision – Ishihara Chart

Field of vision – Confrontation
Test
• This is done with the help of Perimeter.
• Principle used in this test is that the field of vision of
doctor's right eye is same as field of vision of left
eye of patient . patient sits at a distance of 1 m. Then
eyeball movements are tested
• - Patient is instructed not to move his neck but
patient has to move only eyeballs, as doctor is
moving his finger. (We test the movements, such as -
abduction, adduction, elevation, depression, internal
rotation and external rotation)

Confrontation Test

Trochlear Nerve – Pupillary Reflex
• (4) Trochlear Nerve - To test pupillary reflex is
also a part of examination of 3rd cranial nerve.
• For this Light Reflex and accommodation
reflex should be tested
• For testing the Light Reflex doctor will throw
light on the patients eye and doctor will look
for the response i.e. constriction of pupil.

Examination of Trochlear Nerve –
Pupillary Reflex

Trochlear Nerve – Pupillary Reflex
• Throwing of light in one eye and constriction of pupil
of the same eye is direct reflex and construction of
pupil of another eye is indirect reflex
• Accommodation reflex - can be tested by asking the
patient to look at distant object first and suddenly
towards the object, near to eye (as close as 25 cm)
Effect will be constriction of pupil and conversions of
eyes and bulging of lens.

Examination of Trochlear Nerve –
Accommodation Reflex

Trigeminal Nerve
• (5) Fifth Cranial Nerve - is Trigeminal Nerve.
• Sensory component - can be tested by testing
sensations from all parts of face.
• Motor component - can be tested by muscle
of mastication (Temporalis, Masseter muscles).
We also test medial and lateral pterygoid
muscle by asking the patient to move his jaw
sidewise.

Trigeminal Nerve
• For testing sensory component, wick of
cotton wool is used for testing touch
sensation
• Temperature sense can be tested by
taking warm and cold water in test tubes.

Examination of Trigeminal Nerve –
Touch sensation

Temperature sensation

Motor component

Facial Nerve
• (7) 7th Cranial nerve - Facial Nerve
• (i) Basically, this is motor nerve which
supplies superficial muscles of face
• (ii) The doctor will test all movements of
face

Facial Nerve
• (a) Make wrinkling on forehead (To test
Occipito frontalis)
• (b) Close eyes tightly (To test Orbicularis
occuli)
• (c) Blow your cheeks (To test Buccinator)
• (d) Blow whistle (To test orbicularis oris)

Examination of Facial Nerve
Wrinking of Forehead Close Eyes tightly

Blow the cheeks Blow whistle

Facial Nerve
• (iii) Conjunctival and corneal reflexes
• Are also the part examination of facial
nerve which we have already tested in
Trigeminal nerve.

Conjunctival Reflex Corneal Reflex

Vestibulo Cochlear Nerve
• (8) 8th Cranial Nerve - Vestibulo cochlear nerve -
• Cochlear component is concerned with position of
head and neck (balance of body).
• To test cochlear component we carry out "Test of
hearing".
• Rinne's test. Scbwabach test, Weber test - Basic
principle in all these tests is AC > BC, Due to
Impedance Matching, brought about by Ossicular
chain.

Hearing Tests
• (A) Rinne's Test - If BC > AC, It indicates conductive
deafness
• (Nerve deafness can not be detected by Rinne's test)
• (B) Schwabach Test - AC of patient is compared with
AC of doctor, BC of patient is compared with BC of
doctor. (If AC < BC -- conductive deafness)
• If AC & BC ,both are reduced , It indicates nerve
deafness.

Vibrating Tuning fork for
Hearing Test

Examination of
Rinne’s Test Rinne’s Test

Examination of
Schwabach Test Schwabach Test

Hearing Test
• (C) In Weber test - We confirm the deafness ,which
is detected By Rinne's test and schwabach test. -
Vibrating tunning fork is kept on vertex and patient is
asked on which side he hears better. - Normally, he
should hear equal on both sides. If it is better on
Right side it means conductive deafness on Rt side or
nerve deafness of opposite side
• All tests are done with Tunning fork, having
frequency 256 and 512. Because our ear is maximum
sensitive for these frequencies.

Weber Test for Hearing

Examination of 9th, 10th, 11th
cranial nerves
• Glossopharyngeal, Vagus, Accessory
• 9th and 10th cranial nerve carry sensation
from post. part of tongue as well as pharynx.
• 10th cranial nerve also supplies palate,
laryngeal muscle.

Glossopharyngeal Nerve
• Patient is asked to open his mouth and say  Aa ,
(Doctor will observe position of Uvula and arches of
soft palate)
• Post 1/3rd of tongue can be tested by for general
sensation  touch, as well as special sensations like
Taste.( Hold the cotton in forcep & touch on
posterior 1/3rd of  tongue & ask whether the person
feels touch )
• - Then patient is asked to drink water while
swallowing movement of larynx is to be tested.

Examination of
Glossopharyngeal Nerve
Say Aa Touch Sensation

Accessory Nerve
• Accessory nerve has 2 components
• Cranial component - Supplying laryngeal
muscle and another
• Spinal component - Supplying sternomastoid
and trapezium

Examination of Accessory Nerve

Accessory Nerve
• Speech is tested by asking the patient to speak out
few words.(Like asking question –What is your Name
?)
• To test palatal and pharyngeal reflex stick with
cotton is to be touched to palate or pharyngeal wall
and reflex is elicited
• Spinal accessory supplies - Trapezium and
Sternomastoid
• Trapezium is tested by asking the patient to elevate
his shoulder, against resistance.

Movement of Trapezium Movement of Trapezium

• To test sternomastoid muscle patient is asked to
turn his neck on one side and patient is asked to
press his chin on the hands of the doctor.
• In this process doctor can see prominence of
Sternomastoid muscle
• Palatal or pharyngeal wall reflex is also the part of
9th, 10th, 11th Cranial Nerve examination.
• Soft palate or post pharyngeal wall is touched with
tongue depressor or cotton stick. - patient gets
coughing sensations.

9th, 10th, 11th Cranial Nerve examination
• Palatal or pharyngeal wall reflex is also the
part of 9th, 10th, 11th Cranial Nerve
examination
• Soft palate or post pharyngeal wall is touched
with tongue depressor or cotton stick. Patient
gets coughing sensations

Hypoglossal Nerve
• 12th Cranial Nerve - Hypoglossal Nerve –
• This is purely motor nerve.
• It supplies all the muscles of tongue, these
muscles bring out the movement such as
elevation, depression, protrusion, retraction
and rolling of tongue.

Examination of Hypoglossal nerve

Hypoglossal Nerve
• The patient is asked as follows ----
• Say Aa, Take Tongue out ,Take tongue in
,Take tongue up ,Take Tongue out & down
• This is the end of the cranial nerve
examination.

Clinical Examination of Sensory System
• One should remember the following points while
carrying out examination of sensory system.
• (1) Subject (patient) should be blind folded (this
means, patient's eyes should be closed) and patient
has to answer with closed eyes.
• (2) Identical dermatomes are to be compared for
sensation and usually we go from below upwards (i.e.
from lower extremities trunk, upper extremities and
then face)

Hair Asthesiometer Compass Asthesiometer

Compass Asthesiometere Tuning Fork

Key & Coin-Steregnosis Cotton wick –Crude Touch

Blunt end of Pencil –pressure Hot & Cold water

Types of Sensations – Fine Sensation
• (i) Fine touch
• (ii) Tactile localisation
• (iii) Tactile discrimination
• (iv) Vibration sense
• (v) Joint position and muscle movement sense
• Note - By testing fine sensations integrity of dorsal
column tract is tested.

Types of Sensations – Crude Sensation
• (i) Crude touch
• (ii) Pressure
• (iii) Temperature
• (iv) Pain
• Note - Integrity of spinothalamic tract is tested

Fine sensation & Tactile Localization
• Tested by Warn cruze hair Asthesiometer or even a
thin wire can be used.
• The patient is suggested as follows
• Ask the patient – Now I am touching this wire to
different parts of your body
• By closing your eyes ,you can tell ,whether you feel
the touch ? On which part of your body ,you are
feeling the touch ? On which side you are feeling the
touch – Right or Left ?

Examination of Sensory System
Touch on right side Touch on Left side

Fine Sensation –
Fixing of Dermatome
Sr.No Area Dermatome
1 Near ankle L 5
2 Below knee L 4
3 Above knee L 3
4 Thigh L 2
5 Above wrist L 7
6 Below elbow L 6

Tactile Localization
• The patient will locate the area where he is
felling fine touch ,by closing eyes

Tactile Discrimination
• Tested by Compass Asthesiometer
• Tell patient as follows –
• Now I am touching 2 pointers of this
Instruments – By closing your eyes , you tell
me ,whether you are feeling touch with 1
pointer or 2 pointers ?

Examination of Sensory System
Touch on Right side Touch on Left side

Sense of Steregnosis
• The patient is asked to recognise ----
• familiar objects (pen, pencil, coin, key) given
in his hand (by shape, size and texture ) with
closed eyes

Steregnosis
Identifying Pen Identifying Coin

Vibration sense
• (5) Vibration Sense - A vibrating tunning fork having
frequency 100 Hz is kept on bony prominence such
as Tibial Tuberosity or Olecranon and subject is
asked to recognise vibration sense
• Ask the patient --- Tell ,closing your eyes , whether
you feel vibrations created by this Instrument ,
Tunning fork ?

Vibration sense
On right side On Left side

Joint position & Muscle movement sense
• To test joint position sense, we do the
movements of great toe or thumb and
subject is asked to recognise that movement
with closed eyes
• Tell patient – That now I am moving your
thumb up or down .Then by closing your eyes
,you can tell me ,whether I am moving your
thumb up or down ?

Examination for recognizing
Joint Position
Downward Movement Upward Movement

Fine sensations –Lost
• All above fine sensations are disturbed, if
Dorsal Column Tract
• Tract is damaged due to "Tabes Dorsalis
(Neuro syphilis) or Tumour

Crude Sensations
• (1) Crude touch
• (2) Pressure
• (3) Temperature
• (4) Pain
• (Integrity of Spinothalamic tract is tested)

Crude Touch
• Tested by wick of cotton wool
• Identical Dermatomes are to be compared
• Ask the patient ,to tell ,where he is feeling the
touch of cotton, by closing eyes ?

Examination for Crude Touch
On Right Side On Left Side

Sense of Pressure
• Blunt end of the pencil is used. It is pressed
on extremities or on face and subject is asked
to recognise it
• Tell patient – that I am pressing this Pencil
surface on your body .By closing eyes ,you tell
me whether you are feeling pressure & on
which part & on which side ,right or left ?

Examination for sense of Pressure

Temperature sense
• Test tubes containing warm or cold water are
used Subject is asked to recognise these
sensations with his feelings
• Tell patient that now you touching 2 test tubes
of hot & cold water to his body .Ask him to tell
,by closing eyes ,which temperature touch ,he
feels –Hot or Cold ?

Examination for
Sense of Temperature

Pain sensation
• Pin is used. Subject is asked to recognise pain
stimulus, given with pin
• Tell patient that you are now touching his
body with pin prick .Ask the patient to tell ,by
closing his eyes ,whether he feels pin prick or
not ,on which part & on which side ?
• Identical Dermatomes are tested.

Examination of Pain Sensation

Crude sensations
• Thus, by testing crude sensations, we have
tested integrity of Spinothalamic system
• These tracts are damaged, if there is a tumour
pressing on spinal cord or if there is a disease
like "Transverse Myelitis," involving spinal
cord.

Examination of Motor System
• Motor system is examined under following headings.
These points are very useful in examine the patient
of Hemiplegia
• (1) Nutrition
• (2) Tone
• (3) Power
• (4) coordination
• (5) Involuntary movements

Examination of Nutrition of
Muscle
• Nutrition is tested by measuring
circumference of muscle, at its bulk and
comparing circumference of left and right side
• e.g. Circumference of calf muscle can be
measured by fixing the distance from bony
prominence.

Examination of Nutrition of Muscle
• e.g. 6 inches below Tibial tuberosity. Measure
the circumference of right and left calf
muscle at a same distance.
• Similarly circumference of thigh muscle, from
a fixed bony prominence like Tibial Tuberosity
or ASIS (Anterior Superior Iliac Spine) can be
compared

Nutrition of Muscle
Measuring from Fixed
distance Measuring Circumference

• In the same manner, for the upper extremity -
circumference of forearm and arm muscles
can be compared from a fixed bony
prominence like olecranon process
• When circumference of both right and left
sides is normal it indicates nutrition of these
muscles is normal

Nutrition of Muscle
Right side Measuring Circumference

• In right sided person circumference of right
sided muscle can be slightly more. This is
physiological
• Atrophy of muscle is seen in LMN lesion like
polio myelitis

Tone of Muscle
• Tone of a muscle is a partial state of
contraction. It is maintained by stretch reflex.
• Tone of the muscle is tested by 2 ways
• (a) By examining feel of the muscle
• (b) Tone can be seen by Resistance offered to
passive Movements.

Tone of Muscle
Tone of Leg Muscle Tone of Thigh Muscle

Tone of Muscle
• Doctor can feel muscle at its bulk and he can
compare the feel on right and left side
• e.g. doctor can observe the feel of calf
muscles, thigh and muscles of bicep and
triceps

Tone of Muscle
Bicep Muscle Tone Tone –Forearm muscle

Tone of Muscle
• Normal feel is Elastic.
• Second method of examination of Tone is to
see resistance offered to passive Movements
• Patient is not moving his extremities but the
doctor is carrying out passive movements

Tone of Muscle
• Doctor can do passive movements at knee
joint to test the tone of flexors and extensors
of knee
• When doctor is doing flexion of knee, he is
testing tone in extensors. When doctor is
doing extension at knee he is testing Tone of
flexors

Tone of Muscle
Passive movement Passive movement

Tone of Muscle
• For testing upper extremities, same
movements can be done at elbow
• Doctor can test Tone of biceps and triceps and
he can compare the Tone at other side. When
doctor is carrying flexion at elbow he is
testing Tone in triceps. When doctor is
carrying extension in elbow he is testing tone
in biceps

Tone of Muscle
Elbow Flexion Elbow Extension

Tone of Muscle
• In lower and upper extremities, when
resistance offered is moderate, it indicates
tone is normal
• Hypertonia is seen in UMN lesion
• Hypotonia is seen in LMN lesion

Power of Muscles
• Power is graded under fine grades as follows
• Grade O - No movements at all.
• Grade 1 - Only flicking movement are visible but no
movements possible
• Grade 2 - If movement is occurring horizontally but
not able to lift against gravity.
• Grade 3 - If subject is able to lift up leg or hand,
against gravity
• (compare the right and left side)

Power of Muscle
Grade 3 Power Grade 3 Power

Power of Muscles
• Grade 4 - Patient is able to move his
extremities against resistance
• Grade 5 - Patient is able to lift the extremities
against the good resistance applied by the
doctor.

Power of Muscle

Power of Muscles
• In the same manner, power of
extensors of hip, flexors of knee (Ask
the patient to bend the knee )
extensors of knee (Extend leg by
making knee straight ) can be
compared.

Power of Muscles
• Even planter flexors, dorsi flexors of foot can
be compared
• In upper extremity, flexors and extensors of
elbow can be compared, flexors and extensors
of wrist can be compared
• Movements at shoulder such as flexion,
extension, abduction, adduction can be
tested for power

Power of Muscles
• For testing power in the neck muscle, patient
is asked to lift his neck up in lying down
position
• Ask the patient to lift the neck ,put down the
head .Then ask patient to lift the neck ,when
doctor is pressing on forehead

Power of Muscle

Power of Muscles
• Complete loss of power is called as 'paralysis'
which is typical feature of LMN lesion like
polio myelitis
• Partial loss of power is called as "paresis"
which is typically seen in Hemiplegia or
Paraplegia.

Coordination of Muscles
• (A) Coordination of muscles in upper
extremity is tested by following tests
• (1) Finger - Nose - finger test
• (2) Rapid pronation and supination of palm
(Dysdiadochokinesia)

• (B) for lower extremity, following tests
• (1) Knee - heel test
• (2) Walking in straight line
• All tests of co-ordination should be done with
open eyes first and then with closed eyes, to
differentiate between sensory Ataxia and
cerebellar Ataxia (Motor ataxia)

• Ask the patient ,by closing the eyes ,he should
try to touch Index finger of the left hand by his
index finger of right hand & then same right
hand finger should touch to his nose tip
• Same procedure is repeated with Left hand
Index finger
•
• This is Finger – Nose – Finger Test

Coordination of Muscle
Finger- Nose –Finger Test Finger –Nose –Finger Test

• Ask the patient to perform Pronation &
Supination activity of both hands ,speedily
(diadochokinesia) ---
• Check ,whether patient can do it for both the
hands

Diadochokinesia Diadochokinesia

• Kneel Heel Test – Ask the patient to sit on
table or lie down on bed
• First keep right heel on left knee & take the
heel down along with shin of tibia ,till left foot
• Perform Same procedure by keeping left heel
on right knee & taking down heel along with
the shin of tibia ,up to right foot

Knee-heel Test Knee –heel Test

• Ask the patient to stand straight ,by keeping both
feet near to each other – First stand with eyes open
& then stand with close eyes
• Doctor has to see ,whether patient can maintain
balance of his body
• If patient cannot stand straight, and he swings with
closed eyes - It is called as, "positive Rhomberg's
sign", which is typical sign of Dorsal column tract
damage.

Rhomberg's sign

• Straight line walking Test – Ask the patient to
stand at one end of the 8 feet straight line
• Then ask him to walk on this line to & fro –
First with open eyes & then with close eyes

Straight line walking Test
Walk on Straight line Return back –on straight line

• If patient walks correctly with open eyes, but looses
balance with closed eyes - It indicates damage lies in
dorsal column tract (which is called as sensory
ataxia)
• If patient is not able to walk with open or closed eyes
– damage is in cerebellum (it is cerebellar or Motor
ataxia)

Involuntary Movements
• 3 types
• (1) Fine Tremors – In Thyrotoxicosis
• Tachycardia, weight loss, Intolerance to heat
atmosphere ,Feeling excessive heat all the
time

• (2) Pin rolling tremors at rest –
• In Parkinsonism – This disease develops due
to deficiency of Dopamin neutrotransmitter in
Basal Ganglia
• Tab Carbidopa is used to compensate this
deficiency
• (3) Action tremor - In cerebellar diseases

Fine Tremors Pin rolling Tremors

Involuntary Movements –Action Tremor

Advantage of
Motor System Examination
• Advantage of motor system examination, over
sensory system examination is that ---
• (1) Even if patients cooperation is not there
we can draw few conclusions like - UMN
lesion, LMN lesion, Parkinsonism, Cerebellar
• ataxia ,Sensory ataxia.

Advantage of
Motor System Examination
• (2) In sensory system examination, if patient is
non-co-operative then he can not answer the
doctor's questions and then examination is of
no value
• However, sensory system examination is
important to detect the level of damage in
spinal cord.

Superficial Reflexes – Root values
Sr.No Reflex Root Value
1 Conjunctival reflex 5th and 7th cranial nerve
2 Corneal reflex 5th and 7th cr. N
3 Pharyngeal reflex 9th, 10th, 11th cr. N
4 Abdominal reflex T6 to L1
5 Plantar reflex L5, Si, S2

Deep Reflexes – Root values
Sr.No Reflex Root Value
1 Bicep jerk C5, C6
2 Triceps jerk C6, C7, C8
3 Supinator jerk C5, C6
4 Knee jerk L2, L3, L4
5 Ankle jerk L5, S1, S2

Reflexes
• In superficial reflexes --- receptors are in skin
or mucous membrane
• In deep reflexes ---- receptors are in muscles
or tendons.

Superficial Reflex – Conjunctival Reflex
• Doctor will touch wisp of the cotton wool to
the white portion of eye i.e. Bulbar
conjunctiva
• Response is closer of both eyes

Conjunctival Reflex
For Right Eye For Left Eye

Superficial Reflex –Corneal Reflex
• Doctor will touch the wisp of cotton wool to
black portion of eye i.e. cornea closer of both
eyes is normal response
• NOTE : Conjunctival and corneal reflexes have
already been tested in examination of
trigeminal and facial nerve. If these nerves are
damaged reflexes are lost

Corneal Reflex
For Right Eye For Left Eye

Palatal & Pharyngeal Reflex
• Doctor will touch soft palate or post
pharyngeal wall with tongue depressor
• Doctor will expect a response in the form of
coughing
• If the patient is getting coughing sensation - It
means 9th, 10th, 11th cranial nerves involving
in this reflex are normal

Palatal & Pharyngeal Reflex
Ready with Tongue Depressor Touch Post Pharyngeal wall

Abdominal Reflexes
• Imp precaution to be carried out is that -
abdomen should be relaxed, by flexing
knee
• Ask the patient to lie down his back &
flex the knees & relax abdominal
muscles

Abdominal Reflexes
Mid abdominal Reflex Away from Umbilicus

Abdominal Reflexes
• Now, blunt end of hammer is moved,
radiating away from umbilicus in all directions
• While testing this reflex abdominal muscle will
show a movement, in the form of the
response
• Abdominal reflexes are classified into upper
abdominal, mid abdominal and lower
abdominal reflexes

Abdominal Reflex – Root value
Sr.No Part Of Abdomen Root Value
1 Upper abdominal reflex T6 to T9
2 Mid abdominal reflex T9 to T11
3 Lower abdominal reflex T11 to L1

Abdominal Reflexes
• In obese patients, abdominal reflexes
may not be elucidated. In such cases,
unilateral absence of abdominal reflex is
important finding
• Abdominal reflexes are lost in UMN
lesion like hemiplegia or paraplegia.

Superficial Reflex – Plantar Reflex
• Root value of the plantar reflex is L5, S1, S2.
• Scratch sole of the foot from heel to toes,
along lateral border and then medially. This
scratching is done with blunt portion of
hammer
• Perform it on both sides & compare

Babinski's sign
Left Plantar Reflex Right Plantar Reflex

Superficial Reflex – Plantar Reflex
• Normal response is plantar flexion of all toes
• If dorsiflexion of great toe and fanning of
other toes is seen then diagnosis is positive
Plantar reflex or positive Babinski's sign
• This will be seen UMN lesion like hemiplegia
or in meningeal irritation (Meningitis)

Deep Reflex – Bicep Jerk
• For testing deep reflexes, special method is
adopted which is called as the Jendrassik
maneuver ----
• which is a medical maneuver wherein the
patient clenches the teeth, flexes both sets of
fingers into a hook-like form and interlocks
those sets of fingers together

Deep Reflex – Bicep Jerk
Tap Bicep Tendon Contraction of Bicep muscle

Jendrassik maneuver
• By this manual, gamma motor neuron
discharge is decreased and reflex is obtained
properly
• Bicep jerk - Doctor will tap bicep tendon -
contraction of biceps muscle is important,
rather than flexion of forearm.
• We compare the reflex on both sides. Root
value of this reflex is C5, C6.

Deep Reflex – Tricep Reflex
• Doctor will give a tap just above Olecranon
process, which is Tricep tendon
• Do Jendrassik maneuver
• Contraction of the muscle is more important
than extension of forearm
• Compare the reflex on other side. Root value
of this reflex is C 7, C 8.

Deep Reflex – Tricep Reflex
Tap above Olecranon Process Contraction of Muscle

Deep Reflex –
Supinator Reflex or wrist Jerk Reflex
• Tap is given just above the head of radius.
Doctor can see the contraction of
brachioradialis muscle
• Compare the reflex on another side
• Root value is C5, C6.

Supinator Reflex or
wrist Jerk Reflex
Left Wrist jerk Right wrist jerk

Deep Reflex – Knee Jerk
• For testing this reflex, exposer of Quadriceps muscle
is important, so that the doctor can see the
contraction of this muscle
• Doctor keeps his hand below the knee, patient is
asked to relax. Divert the patients attention by
Jendrassik maneuver
• Ask the patient to clench the teeth
• Give a tap on patellar tendon i.e. between patella
and Tibial Tuberosity.

• Contraction of Quadriceps muscle is
Important response
• Root value is - L2, L3, L4

Right Knee Reflex Left Knee Reflex

Deep Reflex – Ankle Jerk
• For this reflex gastrocnemius muscle should be
exposed. Tapping of the gastrocnemius
tendon, just above the heel is stimulus
• Doctor will make forceful dorsiflexion of foot
and give a tap on tendon. Contraction of
gastrocnemius is the response. Compare the
reflex on other side
• Root value is L5, S1, S2

Deep Reflex – Ankle Jerk
Right Ankle Jerk Left Ankle Jerk

Importance of Testing Reflexes
• Examination of the reflexes is most imp part in
examination of the nervous system.
• Advantage of this examination than motor and
sensory examination is that - "It does not require
patient's co-operation."
• Various diseases, specially UMN lesion and LMN
lesion can be differentiated by examination of deep
reflexes
• Even if patient is unconscious, non-cooperative -
These reflexes will give important clues.

Importance of Testing Reflexes
• In UMN lesions - Deep reflexes are
exaggerated
• (Jerks will be very much prominent)
• Even clonus can be seen at knee and ankle
(where muscle jerk oscillates for longer time)
• Clonus is always pathological. It is seen in
UMN lesion

Examination of Spine & Cranium
• Spine is to be inspected from cervical to sacral
region for noticeing abnormality
• With knuckles of fingers ,doctor can give
deep pressure on spine and ask the patient
whether he gets pain sensation.

Cervical to Sacral With knuckles

• For testing cranium deep pressure is to be
given on skull, from all angles and patient is
asked, "Whether he gets pain sensation" ?
• If there are abnormalities of the spine, if
there are conditions like hydrocephalus. This
test will give intense pain.

Deep pressure from all angles Deep pressure from all angles

Examination of Gait
Sr.No Gait Disease
1 Circumduction gait Hemiplegia
2 Jerky gait Parkinsonism
3 Drunk man's gait Cerebellar disease
4 Spastic gait Paraplegia
5 Flaccid gait Polio-myelitis.
6 Scissors gait Diplegia

Abnormal Gait
Circumduction gait Drunken Gait

Abnormal Gait
Parkinson’s Gait Polio Gait

Abnormal Gait

Abnormal Gait – Scissor Gait

Examination of Special Signs
• Neck rigidity - in Meningitis
• High Fever, severe Headache, projectile
vomiting, positive Babinskis sign & positive
Kerning's sign - usually present in
Meningococcal Meningitis

Prof.Dr.R.R.Deshpande
• Sharing of Knowledge
• FOR
• Propagating Ayurved
11/28/2016 174Prof.Dr.R.R.Deshpande

Clinical Examination of Nervous System - PPT

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