Nervous System

Examination Prompt
Introduce yourself and wash your hands

General Observation
• Posture
• Dysmorphic features
• Interaction and facial expression
• Aids:
o Wheelchair
o Frame
o Orthoses
• Movements
o Leg scissoring
o Decreased movements on one side
o Decreased movements overall

ARMS
Inspect
• Muscle bulk
• Symmetry
• Scars (tendon release)
• Contractures
• Fasciculations

Tone
Ask permission first, and check if it’s painful!
• Elbow joint
• Wrist joint
• Test for clonus at the wrist joint

Power
• Shoulder abduction: C5 - C6
• Shoulder adduction: C6 - C8
• Elbow flexion: C5 - C6
• Elbow extension: C7 - C8
• Wrist flexion: C6 - C7
• Wrist extension: C6 - C7
• Finger abduction: C8 - T1

Reflexes
Remember about the Jendrassik manoeuvre if you need to reinforce the reflexes. Think
carefully about how you’ll explain this to the child!
 • Biceps: C5 - C6
• Brachoradialis: C5 - C6
• Triceps: C6 - C7

Coordination
• Finger-tip
• Finger-nose

Sensation

LEGS
Inspect
• Muscle bulk
• Symmetry
• Scars (tendon release)
• Contractures
• Fasciculations

Gait
• Inspect the legs first
• Ask the child if they are able to stand/walk
• Check if they would feel more comfortable with somebody with them
• Walk to the end of the room; turn around; come back

Tone
Ask permission first, and check if it’s painful!
• Knee joint
• Ankle joint
• Check for clonus at the ankle (up to 2 beats are normal if <1 year)

Power
• Hip flexion: L1 - L2
• Hip extension: L5 - S1
• Hip adduction: L2 - L4
• Hip abduction: L4 - L5
• Knee extension: L3 - L4
• Knee flexion: S1 - S2
• Foot dorsiflexion: L4 - L5
• Foot plantar flexion: S1 - S2
• Foot inversion: L4 - L5
• Foot eversion: L5 - S1

Reflexes
Remember about the Jendrassik manoeuvre if you need to reinforce the reflexes. Think
carefully about how you’ll explain this to the child!
• Knee: L2 - L4
• Ankle: S1
 • Plantar: S1

Coordination
• Heel along shin

Sensation
1. Light touch (spinothalamic)
2. Proprioception (dorsal column)
a. Big toe
b. Ankle

To finish
• Offer to inspect the spine (looking for scars)

CEREBELLAR
Using the mnemonic DANISH to remember cerebellar signs doesn’t always mean that I
could examine for them. (Dysdiadokinesis; Ataxia: Nystagmus; Intention tremor; Scanning
speech; Heel-shin coordination).
It’s also one thing knowing what the movements are, but trying to explain them to a young
child often very difficult. Practice how you describe the actions, and how you will explain
them to the child so that they can carry them out.

Inspect
• Telangiectasia
• Pes cavus
• Scars

Dysarthria
• Pay attention to the child’s speech during the introduction and when you are talking
to them
• Ask them to repeat specific words: “baby hippopotamus”

Ataxia
1. Gait:
a. Broad based
b. Unsteady (especially when turning in a circle)
c. Leaning towards a unilateral lesion
2. Sitting:
a. Truncal ataxia

Romberg’s sign
You may observe a child that has a classic ataxic gait that is classically seen in cerebellar
disease. However, a similar gait can be seen if there is a proprioception deficit. One way
of distinguishing between the two is to check for Romberg’s sign.
In a sensory deficit, Romberg’s sign will be present
In a cerebellar problem, Romberg’s signs will be absent.
Nystagmus
Check eye movements in a H pattern. Horizontal nystagmus increases on the side of the
lesion

Coordination
1. Finger-nose
a. Intention tremor
b. Dysmetria (over-shooting)

Dysdiadochokinesia
The impaired ability to perform rapid, alternating movements.
Hand tapping. I usually find it easier (and more successful) to ask the child to tap “front”
several times, and then tap “back” several times, and then change to “front-back-front-
back”.

This is useful for several reasons.

1. It lets you assess the child doing something easy first, and then build up in
complexity. If a child can’t manage tapping “front”, then they’re unlikely to
manage rapid & alternating movements.
2. It’s also easier to explain what you’re doing if you build up to it gradually