NEUROLOGICAL SYSTEM

Sympathetic division prods body into action during times of physiologic and
psychologic stress.
Parasympathetic division functions in complementary and counterbalancing manner
to conserve body resources and
maintain day-to-day functions such as digestion and elimination.
Three major units of the brain are: cerebrum, cerebellum, brainstem

CRANIAL NERVES FUNCTION

Olfactory (I) Sensory Not checked unless suspected problems – test for
patency
Test ability to identify familiar aromatic odors, eyes
closed, one naris at a time
Sense of smell may diminish with age
Anosmia – loss of sense of smell or inability to
discriminate odors
Optic (II) Sensory Central vision - checked with Snellen Chart
Test visual fields by confrontation and extinction of
vision
Oculomotor Motor Inspect eyelids for drooping
(III)
Trochlear (IV) Motor Pupils’ size for equality and their direct and consensual
response
Trigeminal (V) Motor / Check chewing for muscle tone and strength, superficial
Sensory pain and touch sensation (sharp, dull); test corneal
reflex
Abducens (VI) Motor Test extraocular eye movements
Facial (VII) Motor / Test for facial movement and symmetry; check anterior
Sensory 2/3 of tongue (salty/sweet)
Acoustic (VIII) Sensory Test sense of hearing with whisper test; test for bone
and air conduction and lateralization of sound with
Weber Test (tuning fork)
Vestibular function is tested with Romberg Test (stand
still w/eyes closed)
Glossopharyng Motor / Test ability to identify sour and bitter and swallowing
eal (IX) Sensory and gag reflex
Vagus (X) Motor / Observe for swallowing difficulty; evaluate guttural
Sensory speech sounds – speaking; inspect palate and uvula
movement
Spinal Motor Test for trapezius and sternocleidomastoid muscle
Accessory (XI) strength
Hypoglossal Motor Inspect tongue symmetry, movement and strength;
(XII) evaluate quality of speaking
On Old Olympus’ Towering Tops A Finn And German Viewed Some Hops

SPINAL NERVES – 31 pair arise from spinal cord and exit at each intervertebral foramen
dermatome - sensory and motor fibers of each spinal nerve supply and
receive information in a specific body
 distribution

DEVELOPMENTAL VARIATIONS
INFANTS AND CHILDREN
- primitive reflexes are present in newborn: yawn, sneeze, hiccup, blink at
bright light and loud sound,
papillary constriction with light and withdrawal from painful stimuli
- motor control of head and neck develops first, followed by trunk and
extremities
- brain growth continues until 12 – 15 yrs old

PREGNANT WOMEN
- physiologic alterations that may occur are: contraction or tension headaches
and acroparesthesia
(numbness and tingling of hand) which may be confused with carpal
tunnel syndrome
- during 1st trimester, increase in naptime and sleeptime, but may not feel
rested even with increased sleep
- late in pregnancy, more frequent night awakenings and less sleep time

OLDER ADULTS
- changes are more physiologic than anatomic - cerebral neurons decrease
beginning at 50
- velocity of nerve impulse conduction declines so that responses to
various stimuli take longer
- sensory perceptions of touch and pain stimuli may be diminished

II. SUBJECTIVE ASSESSMENT

A. HISTORY OF PRESENT ILLNESS
Seizures or Convulsions – sequence of events; level of consciousness
(LOC); muscle tone,
relationship of seizure to time of day, meals, fatigue, emotional
stress, excitement, menses,
and discontinuing medications or poor compliance with
medications; activity before attack;
frequency; medications (anticonvulsants, alternative or
complementary therapies,
antidepressants, tranquilizers, antitremor)
Pain – onset, quality and intensity, location or path, efforts to treat
Gait Coordination – balance, falling, legs simply give way, stiffness of
limbs, associated problems
(rheumatoid arthritis, stroke, sensory changes)
Weakness or Paresthesia – onset, character (generalized, ascending or
transient), associated
symptoms (tingling, limb feels encased in tight bandage, SOB,
stiffness of joints, spasms),
concurrent chronic illness such as HIV, nutritional or vitamin
deficiency
Vertigo, dizziness, loss of balance
Difficulty Swallowing
B. PAST MEDICAL HISTORY
Trauma – head, spinal cord, or localized injury; CNS insult; birth trauma;
cerebrovascular accident or
stroke
Meningitis, encephalitis, plumbism, poliomyelitis
Deformities, congenital anomalies
Neurologic disorder, brain surgery, residual effects Psychiatric
Counseling
Cardiovascular, circulatory problems: HTN, aneurysm, stroke

C. FAMILY HISTORY
Hereditary Disorders – muscular dystrophy, Tay-Sachs disease
Alcoholism Mental Retardation
Epilepsy or seizure disorder, headaches Alzheimer
Disease
Learning Disorders Weakness or gait
disorders
Medical or Metabolic Disorder – thyroid disease, HTN, diabetes

D. PERSONAL AND SOCIAL HISTORY

Environmental or Occupational Hazards – exposure to lead, arsenic,
insecticides; operate farm or
other dangerous equipment; work at heights or in water
Hand, Eye, Foot dominance; family patterns of dexterity and dominance
Ability to care for self – hygiene, ADL, finances, communication, shopping
Sleeping or Eating Disorders
Use of alcohol or street drugs (especially mood-altering drugs)

III. OBJECTIVE ASSESSMENT

A. TEST CRANIAL NERVES (SEE CHART)

B. OBSERVE BALANCE, COORDINATION, AND GAIT

1. RAPID RHYTHMIC ALTERNATING MOVEMENTS – have patient pat knees, alternately
turning up palm and
back of hands and increasing rate gradually
- have patient touch thumb to each finger on same hand (index
finger to little finger and back)
- observe for stiff, slowed, nonrhythmic, or jerky clonic movements
2. ACCURACY OF MOVEMENTS – finger-to-finger test performed with pt’s eyes
open
- use index finger and alternately touch nose then your finger (changing
location several times)
- movements should be rapid, smooth, and accurate
- finger-to-nose test performed with pt’s eyes closed, touching nose
alternating with index finger of
each hand and gradually increasing speed
- movements should be smooth, rapid, and accurate
- heel-to-shin test performed with pt standing, sitting or supine, running
heel of one foot up and down
 shin (knee to ankle) of opposite leg
- should move heel up and down shin in straight line, without
irregular deviations to side

3. BALANCE
a. Equilibrium – Romberg Test, with eyes open then closed, have
patient stand, feet together
and arms at sides
- slight swaying is expected, but not to extent that
there is danger of falling
- loss of balance is positive sign
- with staggering or loss of balance, postpone other
tests
- test with pt standing with feet slightly apart, push shoulders
with enough effort to
throw him/her off balance
- recovery of balance should occur quickly
- test with pt standing on one foot, eyes closed, and arms
straight at sides
- balance on each foot should be maintained for 5
seconds, but slight
swaying is expected
- test with eyes open, have pt hop in place first on one foot
and then the other
- note any instability, need to continually touch floor, or
tendency to fall

b. Gait – observe walk without shoes, first with eyes open then closed
- note simultaneous arm movements and upright posture
- note any shuffling, widely placed feet, toe walking, foot flop,
leg lag, scissoring, loss
of arm swing, staggering or reeling
- pt should continuously sequence both stance and swing,
step after step
- gait should have smooth, regular rhythm and symmetric
stride length
- trunk posture should sway with gait phase, and arm swing
should be smooth and
symmetric
- heel-toe walking will exaggerate any unexpected findings
- pt walk straight line, first forward then backward,
w/eyes open, arms at sides
- touch toe of one foot with heel of other
- note any extension of arms for balance, instability,
tendency to fall, or lateral
staggering and reeling
- consistent contact between heel and tow should
occur, slight swaying is
expected
C. TEST FOR SENSORY ABILITIES
- routinely evaluate hands, lower arms, abdomen, feet, and lower legs
- sensory discrimination of face is determined with cranial nerve
evaluation
- each sensory discrimination is tested with pt’s eyes closed
- use minimal stimulation initially, increasing gradually
- stronger stimulus is needed over back, buttocks, and heavily
cornified areas (lower levels of
sensitivity)
- pt should compare perceived sensations, side to side; there should be:
- minimal differences - correct interpretation of sensations
(hot/cold, sharp/dull)
- discrimination of side of body tested - location of sensation
and whether proximal or distal
1. PRIMARY SENSORY FUNCTIONS (PROTECTIVE)
a. Superficial Touch – touch with cotton wisp or fingertips using light
strokes
- avoid stroking areas w/hair - have pt point to area touched/
tell when felt

b. Superficial Pain – alternating sharp and smooth edges of split

tongue blade, touch skin in
unpredictable pattern
- have pt identify each sensation as sharp or dull and where it
was felt
- combine evaluation of superficial pain and touch

c. Temperature – use only when superficial pain sensation is not intact

- roll test tubes of hot and cold water alternately against skin,
in unpredictable pattern,
evaluating temperature sensation
- ask pt to indicate which temperature is perceived and where
it is felt
- deep pressure is tested by squeezing trapezius, calf, or
biceps muscle (should
experience discomfort)

d. Vibration – place stem of vibrating tuning fork against several bony

prominences, beginning at
most distal joints
- buzzing or tingling sensation should be felt - tell when /
where vibration is felt

e. Position of Joints – hold joint being tested by lateral aspects to

avoid giving clue about
direction moved
- with eyes closed, begin in neutral position, raise or lower
digit, and ask pt to tell
which way it was moved - return to neutral position
 proprioception – awareness of body in space

2. CORTICAL OR DISCRIMINATIVE SENSORY FUNCTIONS – tests cognitive ability to

interpret sensations
- inability should indicate lesion in sensory cortex or posterior
columns of spinal cord
- eyes should be closed for these procedures

a. Stereognosis – hand pt familiar object (key, coin) identify by touch

and manipulation
tactile agnosia – inability to recognize objects by touch;
suggests parietal lobe lesion

b. Two-Point Discrimination – with wooden end of two q-tips,

alternately touch pt’s skin with one
or both points simultaneously at various locations
- find distance at which pt can no longer distinguish two
points

c. Extinction – simultaneously touch check, hand, or other area on

each side of body
- ask pt to tell you how many stimuli there are and where
they are
- bilateral sensations should be felt

d. Graphesthesia (Number Identification) – with blunt pen or

applicator stick, draw letter or
number on palm of pt’s hand
- ask pt to identify figure
- letter should be readily recognized

e. Point Location – touch area on pt’s skin and withdraw stimulus

- ask pt to point to area touched
- no difficulty localizing stimulus to should be noted
- performed simultaneously with superficial tactile sensation
D. TEST FOR DEEP TENDON REFLEXES
- performed with pt relaxed, either sitting or lying down
- focus pt’s attention on alternate muscle contraction (pulling clenched
hands apart)
- position limb with slight tension on tendon to be tapped
- palpate tendon
- hold reflex hammer loosely between thumb and index finger and
briskly tap tendon with flick
of wrist
- symmetric visible or palpable responses should be noted

1. BICEPS REFLEX – (C5, C6) - flex pt’s arm to 45° angle with thumb over
tendon and fingers under elbow
- palpate biceps tendon
- strike thumb with reflex hammer
 - contraction causes visible or palpable flexion of elbow

2. BRACHIORADIAL REFLEX – (C5, C6) - flex pt’s arm to 45° angle, strike
brachioradial tendon (~1 –
2”above wrist) directly w/ reflex hammer
- pronation of forearm and flexion of elbow should occur

3. TRICEPS REFLEX – (C6, C8) - flex pt’s arm to 90° angle and rest pt’s hand
against side of body
- palpate triceps tendon and strike it directly with reflex hammer,
just above elbow
- contraction causes visible or palpable extension of elbow

4. PATELLAR REFLEX – (L2, L4) - flex knee to 90° angle, allowing lower leg to
hang loosely
- support upper leg, not allowing it to rest against exam table
- strike patellar tendon just below patella
- contraction of quadriceps causes extension of lower leg

5. ACHILLES REFLEX – (S1, S2) - pt sitting, flex knee to 90° angle with ankle in
neutral position, holding
heel
- pt may kneel on chair with toes pointing toward floor, strike
Achilles tendon at ankle level
- contraction causes plantar flexion of foot

Babinski Sign – plantar response (Dorsiflexion) indicative of

pyramidal tract disease in all
over 2 yrs
- fanning of toes and dorsiflexion of great toe - found until 16
– 24 mos

6. Meningeal Signs – nuchal rigidity = stiff neck, sign associated with

meningitis and intracranial
hemorrhage
- pt supine, raise head, flexing neck
- try to make pt’s chin touch sternum, but don’t force it
- raising shoulders slightly will help relax neck, making
determination of true stiffness
- pan and resistance neck motion are associated with nuchal
ridigity

Brudzinski Sign – neck stiffness

- involuntary flexion of hips and knees when flexing neck is
positive sign for
meningeal irritation

Kernig Sign – flex leg at knee and hip with pt supine, attempting
to straighten leg
 - pain in lower back and resistance of straightening is positive
sign, indicating
meingeal irritation

IV. DEVELOPMENTAL VARIATIONS

A. INFANTS
- suspect neurologic problems when child is not doing something we
expect them to do, rather than
because we find a problem on exam
- cranial nerves are not directly tested, observations are made in physical
exam
- observe spontaneous activity for symmetry and smoothness of
movement
- coordinated sucking and swallowing is function of cerebellum
- hands usually held in fists for first 3 months of life, but not
constantly
- purposeful movement begins at ~2 mos., taking objects with one
hand at 6 mos., transferring
objects hand to hand at 7 mos., purposefully releasing object
by 10 mos.
- should be no tremors or constant overshooting of movements
- withdrawal of all limbs from painful stimulus provides measure of
sensory integrity
- other sensory function is not routinely tested
- patellar tendon reflexes are present at birth
- Achilles and brachioradial tendon reflexes appear at 6 mos
- when testing deep tendon reflexes use finger to tap tendon
- posture and movement should be inspected for rhythmic twitching of
facial, extremity and trunk
musculature, as well as for sustained asymmetric posturing

Moro (birth) – infant supported in semi-sitting position, allow head and

trunk to drop back to 30° angle
- observe symmetric abduction and extension of arms; fingers fan
out and thumb and index
finger form a C; arms adduct in embracing motion followed
by relaxed flexion; legs
may follow similar pattern; reflex diminishes in strength by 3
– 4 mos., disappears by
6 mos.

Stepping (between birth & 8 wks) – infant upright under arms and allow
soles of feet to touch surface
- observe alternate flexion and extension of legs, simulating
walking; it disappears before
voluntary walking

B. CHILDREN
- neurologic exam is done by observing neuromuscular developmental
progress and skills displayed
 during exam - exam of cranial nerves is often by playing a game to
elicit response
- observe child at play, noting gait and fine motor coordination
- beginning walker exhibits wide-based gait
- older child walks with feet closer together, with better balance,
and recovers more easily with
unbalanced
- observe skill in reaching for, grasping, and releasing toys
- no tremors or constant overshooting movements should be present
- heel-to-toe walking, hopping, and jumping are all coordination skills that
develop

3 Penny Test (tests vision, extraocular movements, hearing)

coin dropped on floor = ask child who is standing to pick it up,
testing vision and balance
moistened coin on child’s nose = ask child to walk across room,
observing gait and any
posturing
balanced coin = have child balance coin on nose and dorsum of
each extended hand, testing
Romberg

- deep tendon reflexes are not routinely tested because poor cooperation
is often a problem
- reflexes tested, use same techniques described for adults -
responses should be same
- evaluate light touch sensation by having child close his/her eyes and
point to where you touch or
tickle
- use tuning fork to evaluate vibration sensation, asking child to point to
area where buzzing sensation
is felt
- superficial pain sensation is not routinely tested
- when checking cortical sensory integration, use geometric figures
- draw each figure twice and ask child if figures are the same or
different
- practice may be needed with eyes open to get good compliance
- soft signs can be found in gross motor, fine motor, sensory, and reflex
functional areas
- multiple soft signs are often found with learning problems

C. PREGNANT WOMEN
- reflexes increase signs of preeclampsia (HTN usually accompanied with
edema and proteinuria)

D. OLDER ADULTS
- exam is identical to adult
- medications can impair CNS function and cause slowed reaction time,
tremors, and anxiety
 - markedly diminished senses of smell and taste - sweet and salty tastes
usually impaired first
- common cranial nerve changes include reduced ability to differentiate
colors, reduced upward gaze,
slower adjustment to lighting changes, decreased corneal reflex,
middle to high frequency hearing loss, and reduced gag reflex

Tinetti Balance and Gait Assessment Tool – used for any older adult
thought to be at risk for falls,
or for people who have difficulty performing daily activities (rising
from chair, task that involves
unsupported standing)

- tactile, vibratory sensation and position sense are impaired

- may need stronger stimuli to detect sensation
- deep tendon reflex changes
- less brisk or even absent reflexes w/ response diminishing in lower
extremities before upper
- Achilles and plantar reflexes may be absent or difficult to elicit
- superficial reflexes may disappear
- increase in benign essential tremor
- fine motor coordination and agility may be impaired

V. COMMON ABNORMALITIES
A. MULTIPLE SCLEROSIS – debilitating, degenerative disorder in which blood-brain
barrier breaks down and permits
immune cells to pass into myelinated white matter of brain or spinal cord
tissue
- myelin is destroyed and axons no longer permit nerve impulse
transmission
- brain mass decreases
- progression is gradual, with or without remissions
- primary symptoms include fatigue, bowel and bladder dysfunction,
sexual dysfunction, sensory
changes, muscle weakness, and cognitive and emotional changes
- onset occurs between 20 – 40 yrs old and affects women twice as often
as men

B. GENERALIZED SEIZURE DISORDER – characterized by episodic, sudden, involuntary

contractions of a group of
muscles, resulting from excessive discharge of cerebral neurons
- may be caused by systemic disease, head trauma, toxins, stroke, or
hypoxic syndromes
- disturbances in consciousness, behavior, sensation, and autonomic
functioning often occur

C. MENINGITIS – inflammatory process in meninges, caused by bacteria and viruses

- signs and symptoms include fever, chills, nuchal rigidity, headache,
seizures, and vomiting, followed
by alterations in LOC
 - young infants do not demonstrate nuchal rigidity; those affected
generally will be very irritable and
inconsolable and have fever, diarrhea, poor appetite, and toxic
appearance
- bacterial form is life-threatening if not rapidly treated with appropriate
antibiotics

D. ENCEPHALITIS – inflammation of brain and spinal cord that also involves meninges
- onset is often mild, febrile viral illness followed by disturbance in CNS
function and characterized by
headache, drowsiness, and confusion, eventually progressing to
stupor and coma
- motor function may be impaired with severe paralysis or ataxia

E. CEREBROVASCULAR ACCIDENT (BRAIN ATTACK OR STROKE) – CVA; sudden, focal

neurologic deficit resulting from
impaired circulation of brain, associated with cardiovascular disease
- thrombosis, embolism, or hemorrhage causes circulation impairment

Major Warning Signs:

• sudden weakness, numbness, or paralysis of arms or legs,
especially one side
• sudden blurred vision or blindness in one or both eyes
• sudden difficulty speaking, understanding speech, confusion, or
slurred speech
• sudden severe headache without apparent reason
• sudden loss of balance or falling without apparent reason

- signs and symptoms include headache, progressive sudden neurologic

deficits (restlessness,
lethargy, changes in LOC), vital sign and pupil changes, nausea and
vomiting, impaired
communication, shock, and cardiac arrest

F. GUILLAIN-BARRE’ SYNDROME – acute polyneuropathy that commonly follows

nonspecific infection that occurred
10 – 14 days earlier and primarily affects motor autonomic peripheral
nerves
- characterized by ascending symmetric weakness (w/sensation
preserved) that increases in severity
over days or weeks
- motor paralysis and respiratory muscle failure may result, requiring life
support
- 85% eventually have full functional recovery after recovery period
lasting several wks or mos.

G. PERIPHERAL NEUROPATHY – disorder of PNS that results in motor and sensory loss in
distribution of one or
more nerves
 - sensation of numbness, tingling, burning and cramping
- most common cause is diabetes, but may be caused by toxins
- moderate to severe diabetic neuropathy has wasting of foot muscles,
absent ankle and knee
reflexes, decreased or no vibratory sensation below knees, and loss
of pain or sharp touch sensation to mid-calf
- temperature sensation may be less impaired
- loss of pain sensation leads to loss of protective reflex or awareness of
injury
- loss of skin integrity can lead to ulceration and infection
- compounded by impaired circulation that results in poor healing and
may result in amputation

H. Parkinson Disease – slowly progressive, degenerative neurologic disorder of

brain’s dopamine neuronal
systems
- results in poor communication between parts of brain that coordinate
and control movement and
balance
- may be genetic, environmental, viral, vascular, toxic, or other factors
associated with onset
- pts over 50 are most often affected
- symptoms begin with tremors at rest and with fatigue, disappearing
with intended movement and
sleep, respectively
- progresses with tremor of head, slowing of voluntary movements,
and bilateral pillrolling of
fingers
- motor impairment causes delays in execution of movement,
masked facial expression, and
poor blink reflex
- muscular rigidity interferes with walking, leading to gait of short,
shuffling steps with trunk in
forward flexion posture
- speech becomes slowed, slurred, and monotonous
- behavioral change and dementia occur in 10 – 15%