Opinion
VIEWPOINT
The Future of the Neurologic Examination
Michael J. Aminoff, The development of precision medicine, gene thera-
MD, DSc, FRCP pies, advanced imaging techniques, novel monitoring
Department of systems, ingestible or injectable sensors, and remote
Neurology, School of
medical care (telemedicine) is leading to remarkable
Medicine, University
of California, changes in health care. But the increasing ability to
San Francisco. deliver care remotely will also reduce physical interac-
tions between physicians and patients, with implica-
tions that have barely been explored.
There is no doubt that the art of the neurologic
examination is already being lost, as some of these
advances come to supplant rather than complement the
clinical examination. Indeed, the modern trainee neurolo-
gist can perhaps be pardoned for wondering about the
place of the clinical examination when, for example,
magnetic resonance imaging or computed tomography
can detect, localize, and provide prognostic information
about a central lesion in just a few minutes and genetic
studies can diagnose certain disorders regardless of the
clinical findings. The neurologic examination requires
time, patience, effort, and expertise and may have to be
performed in difficult or unpleasant circumstances,
whereas an imaging or laboratory study simply requires
completion of a request form and the responsibility is
passed to a colleague. Why, then, examine the patient?
A competent examination helps to confirm the
diagnostic impression obtained from the history, to se-
lect any investigations that may be useful, and to avoid
unnecessary testing. It provides a guide to the extent and
prognosis of many disorders and may be the only means
of evaluating patients in circumstances where ad-
vanced technologies are not available, such as in devel-
oping countries. The examination findings also help to
determine the relevance and clinical significance of ab-
normalities revealed by sophisticated imaging or labo-
ratory testing. For example, in a patient with backache,
the clinical relevance of degenerative changes on imaging
the lumbar spine is enhanced if examination reveals cer-
tain motor, sensory, or reflex changes in the lower limbs.
The neurologic examination typically is tailored to
the problem suggested by the history and need not
involve a complete or lengthy examination. Often, a few
minutes is sufficient, for example, to detect signs of
meningeal irritation, distinguish essential from parkin-
sonian tremor, and differentiate between carpal tunnel
and thoracic outlet syndrome. After trainees have
Corresponding
learned the complete examination, they must learn when
Author: Michael J.
Aminoff, MD, DSc, and how it can be focused. For example, in a patient with
FRCP, Department carpal tunnel syndrome, it is not necessary to examine
of Neurology, the fundi but is important to examine the ankle jerks.
School of Medicine,
University of California,
The examination must thus be considered in clinical
San Francisco, 505 context and with the individual patient in mind.
Parnassus Ave, Room It is sometimes held, somewhat absurdly, that the
795-M, San Francisco,
clinical examination loses its value because patients can
CA 94127-0114
(michael.aminoff fake the findings. The purpose of the examination is to
@ucsf.edu). detect faking, not to be fooled by it. Babinski described
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a number of signs to distinguish organic from psycho-
genic weakness, the famous extensor plantar response
being just one of these signs. For example, when a re-
cumbent person sits up while the arms are folded across
the chest, involuntary flexion of the weak leg occurs in
organic hemiplegia and of both legs in organic paraple-
gia; by contrast, in psychogenic weakness, the affected
leg typically does not flex. Again, loss of an ankle jerk in
a patient with low back pain may be helpful in suggest-
ing involvement of the S1 root. There are many other
aspects of the examination that can suggest whether
motor or sensory findings are being elaborated on a
nonorganic basis. The challenge to the clinician is to
make that determination. A well-conducted examina-
tion allows the neurologist to do so.
The value of individual components of the neuro-
logic examination has been questioned and merits fur-
ther study. Even so, components of the examination
should not be evaluated in isolation, for it is not a mat-
ter of the utility of one or another component but of the
company it keeps and thus of the examination as a whole.
A common but ill-informed criticism of the exami-
nation is that the findings are not objective and vary with
time. Of course they do, as also may certain laboratory
or other seemingly more objective data. The state of the
patient is not fixed but dynamic, and the examination
findings will simply reflect this as well as the expertise
of the examiner. Indeed, the changes or variability that
occurs may suggest the underlying diagnosis or
provide prognostic information, as in patients with
disorders of consciousness, with metabolic or toxic
disorders, with an evolving stroke, or with defective
neuromuscular transmission. When such variability is
lacking in the medical records, the possibility bears con-
sideration that the findings are simply being copied from
one person to another, from one day to the next.
The widespread introduction of new technologies
into clinical practice holds promise for improvements in
the detection, diagnosis, treatment, and prognosis of
disease and of reversing a disease even before it mani-
fests clinically. The proper use of such technologies
should facilitate or enhance the value of the neurologic
examination. For example, genetic studies may sug-
gest where or what abnormalities are likely to develop
and thus help to focus the examination, permitting early
detection of clinical involvement. Again, computerized
techniques or rating scales that quantify specific neu-
rologic findings provide objective measures that allow
disease progression to be followed and thereby should
enhance the value of repeated clinical examinations,
even by different observersbut the quality of the
inputted data then becomes crucial.
It thus remains important that the art of the clinical
examination is not lost and that poor examination
technique does not lead to misleading information, with
(Reprinted) JAMA Neurology Published online October 2, 2017 E1
 Opinion Viewpoint

self-deception a consequence. As an example, trainees often fail to
understand that patients cannot visually track a finger moving at
speed, and they thus mistake saccadic for tracking movements.
Similarly, many attempt forlornly to elicit the corneal reflex by touch-
ing a wisp of cotton wool to the insensitive sclera. Even when
performed correctly, an examination that lacks fluidity and a
systematic elegance may not engender the trust elicited by a con-
fident approach. It is up to the present generation of neurologists
to ensure by their teaching and example that the skills of the neu-
rological examination are passed intact to their successors.
An especially important aspect of the physical examination is
that it establishes a bond between physician and patient, helping
to establish a special relationshipof mutual understanding and
respectthat is difficult to appreciate for those who themselves have
never (yet) been a patient. The art of clinical neurology involves the
ability to interact with patients on a human level and to relate any
findings, whether clinical or investigative, to the context in which
they were obtained. If medicine becomes dehumanized by tech-
nology, the quality of health careor certain aspects of it
inevitably will deteriorate, in much the same way that voicemail,
which facilitates communication, commonly engenders uncer-
tainty, frustration, and impatience because direct human contact is
lacking. The neurologic examination restores the physician-patient
relationship and allows clinical problems to be viewed in context
so that clinical common senseimperiled by simplistic algorithmic
approachescan be used to manage them.

ARTICLE INFORMATION Conflict of Interest Disclosures: Dr Aminoff is the Elsevier, Wolters Kluwer, McGraw-Hill, and Oxford
Published Online: October 2, 2017. author or editor of books, chapters, or electronic University Press.
doi:10.1001/jamaneurol.2017.2500 resources on clinical neurology published by

E2 JAMA Neurology Published online October 2, 2017 (Reprinted) jamaneurology.com

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