CENTRAL NERVOUS SYSTEM

EXAMINATION
 CENTRAL NERVOUS SYSTEM EXAMINATION
• HIGHER FUNCTIONS
• CRANIAL NERVES
• MOTOR SYSTEM
• SENSORY SYSTEM
• REFLEXES
HIGHER FUNC
 HIGHER FUNCTIONS
• CONSCIOUSNESS
• ORIENTATION TO TIME, PLACE, PERSON

• BEHAVIOUR
• EMOTIONAL STATE
• INSIGHT
• INTELLIGENCE
• MEMORY
• SPEECH
• THOUGHT CONTENT

• DELIRIUM/DELUSIONS/HALLUCINATIONS
 CONSCIOUSNESS
• State of awareness of one’s
• Self &
• Environment
• SLEEP
• State of mental & physical inactivity
• From which pt can be aroused to normal consciousness
• CATATONIA
• State of rigid plastic postures of limbs for long hours
• Person immobile, mute, unresponsive
• In Frontal lobe/Hypothalamic lesions, Psychosis
• AKINETIC MUTISM
• State of immobility & mutism
• BUT follows movements slowly w eyes
• AND allows himself to be fed
• In Brainstem & Diencephalon lesions
• DROWSINESS
• Pathological state resembling normal sleep
• Pt can be aroused w external stimuli
• BUT reverts to drowsy state on withdrawal of stimuli
• SEMI-COMA
• Pathological state
• Pt can be aroused w STRONGER stimuli
• Reflexes normal
• STUPOR
• SYNONYMOUS TO SEMI-COMA
• Some regard it as state btw drowsiness & semi-coma
• COMA
• Deepest level of unconsciousness
• Reflexes absent
 EMOTIONAL STATE
• Depressed/Euphoric/Hostile
• CAUSES
• Cerebral arteriosclerosis, Multi-infarct state
• Multiple sclerosis
• Pseudobulbar palsy
 INSIGHT
• LACK OF INSIGHT SEEN IN
• Lesions of frontal lobe
• Deteriorating intelligence
 MEMORY
• DEFECT IN REGISTRATION
• Due to inattention
• CAUSES
• Manic states
• Senile dementia
• Toxic delirium
• DEFECT IN RETENTION
• Organic cerebral disturbances
• CAUSES
• Frontal lobe lesion
• GPI
• Senile dementia
• DEFECT IN RECALL
• CAUSES
• Epilepsy
• Ganser’s syndrome
• Hysteria
• Korsakoff’s psychosis
• Post traumatic state
 THOUGHT CONTENT
• SUDDEN ONSET OF DEPRESSION & FEAR
• Before epileptic attack
• Points to temporal lobe origin
• MIGRAINE + TEICHOPSIA
• Ocipital visual hallucination
• GRANDIOSE DELUSIONS
• GPI (Neurosyphillis)
 DELIRIUM/DELUSIONS/HALLUCINATIONS
• DELIRIUM • DELUSIONS
• Acute State of confusion • False belief
• W excitement & hyperactivity • CANNOT be corrected in spite of evidence to
• CAUSES contrary
• DEFICIENCY : Thiamine • CAUSES
• INF : Septicemia, Typhoid, Cerebral malaria • HOLISTIC :
• METABOLIC : Renal failure • Delusion of diseased.disordered body
• OVERDOSE/TOXIC : Amphetamine. Aspirin • E.g. Body cancerous, Sex changing
• WITHDRAWAL STATE : Alcohol • In Schizophrenia
• DELUSION OF GUILT :
• Blames himself excessively
• In Depressive states
• DELUSION OF GRANDEUR :
• Believes something he is not
• In GPI mania
• HALLUCINATIONS • ILLUSION
• False perception of sensation • Altered perception of sensory stimuli
• In absence of sensory stimuli • E.g. Mirage in desert
• E.g.
• Humming in ears when NO sound
• Seeing somebody NON existent
CRANIAL NERVES
MOTOR SYSTEM
 SPINOMOTOR SYSTEM
• FUNC : Execution of coordinated smooth voluntary movements
• COMPONENTS
• PYRAMIDAL SYSTEM : Corticobulbar + Corticospinal (UMN)
• EXTRAPYRAMIDAL SYSTEM : Basal ganglia + Cerebellum
• NEUROMUSCULAR SYSTEM : (LMN)
• INITIATION OF IMPULSE IN
• Areas of cortex associated w Acquired motor skills (praxis)
•  Motor cells of precentral cortex  Pyramidal tracts  Ant horn cells  Motor units
• LESIONS OF MOTOR SYSTEM 
• Total weakness – Paralysis
• Partial weakness – Paresis
• Involuntary movements
• Ataxia
 SIGNS OF SIGNS OF
PYRAMIDAL SYS - TRACT/UMN LESION NEUROMUSCULAR SYS/LMN LESION
MUSCLE WASTING NO YES
• BUT occur in late stages due to disuse
atrophy
MUSCLE TONE ↑ - HYPERTONIA ↓ - HYPOTONIA
• Clasp knife spasticity affecting
• Antigravity muscles
• Flexor group of muscles in upper
limb
• Extensor group ofmuscles in
lower limb
PARALYSIS OF VOLUNTARY MUSCLES MUSCLES SUPPLIED BY AFFECTED ANT
• EARLY DISTAL WEAKNESS INVOLVING HORN CELLS/AXONS
• 1ST : Fine movements of hand
• ALSO : Other muscles
• Shoulder abductors
• Muscles of hand grip
• Hip flexors
• Foot dorsiflexors
NOTE
• WEAKNESS MORE IN
• Extensors of upper limbs &
• Flexors of lower limbs
• Opposite to tone distribution
• GROUP OF MUSCLES AFFECTED 1ST
• Last to recover
• i.e. fine distal movements of
hand
FASCICULATIONS PRESENT
• Brief spontaneous contraction • In affected muscle group
affecting small no. of muscle fibres 
Flicker of movement under skin
• Sign of
• Degenerating ant horn cells/
• Irritative lesions of nerve roots/
peripheral nerves
ABDOMINAL REFLEX ABSENT
BABINSKI’S SIGN +  Plantar extension -  Plantar flexion
DEEP TENDON REFLEXES BRISK/EXAGGERATED – HYPERREFLEXIA ABSENT/REDUCED – HYPORREFLEXIA
 EXAMINATION OF MOTOR SYSTEM
• SYMPTOMS • EXAMINATION HEADINGS
• Difficulty in standing, walking, working • NUTRITION – Size of muscles
• Involuntary abnormal movements • Hypertrophy, Wasting
• Painful movements • TONE
• Partial/Total inactivity • Normal, Hypertonia, Hypotonia
• ↓ Size of muscles • POWER – Strength of muscles
• Graded
• CO-ORDINATION
• Finger-nose test
• Knee heel test
• Rapid alternative movements at wrist

• ABNORMAL/INVOLUNTARY MOVEMENTS
• ATAXIA

• GAIT
• POSTURE
• REFLEXES
 NUTRITION
• PROC IN ALAGAPPAN • NOTE
• Measure circumference of limbs • Compare w normal side
• At level where max muscle tissue present • Observe distribution of nutritional change
• IN UPPER LIMBS • Predominantly Proximal/Distal
• 10 cm above olecranon • Both
• 10 cm below olecranon
• IN LOWER LIMBS
• 18 cm above sup border of patella
• 10 cm below tibial tuberosity
• Observe difference btw rt & lt
OR
• Assess by palpation of muscle
• Flabby, Smaller, Softer = Atrophic muscles
• When Hard, Inelastic, Shortened
• = Associated fibrosis
• Firm & Rubbery = Hypertrophic muscle
• Due to excessive fat deposition
• ABNORMALITIES • GENERALISED WASTING
• HYPERTROPHY OF MUSCLES • Advanced systemic illness
• PHYSIOLOGICAL • i.e. CNS, CVS, RS, Renal, IDDM
• Big Powerful Normal consistency • Motor neuron disease
• PATHOLOGICAL • Muscular dystrophies
• Pseudohypertrophy of muscular dystrophy • Malignancy
• Shoulder girdles, Buttocks, Thighs,
Calves involved
• Thyrotoxicosis
• Abnormally globular
• W rubbery consistency
• WASTING OF MUSCLES
• SIGN OF LMN LESIONS/1° MUSCLE DISEASE
• TYPES
• GENERALISED WASTING
• UPPER LIMB WASTING
• PROXIMAL PREDOMINANCE
• DISTAL PREDOMINANCE
• BOTH PROXIMAL + DISTAL
• HAND MUSCLE
• LOWER LIMB WASTING (less common)
• UPPER LIMB WASTING
• PREDOMINANTLY PROXIMAL MUSCLE
• Compressive lesion at C5-C6 level
• Cervical spondylosis
• Late stages of muscular dystrophies
• Duchenne type of muscle dystrophy
• Dystrophia myotonica
• Facioscapulohumeral dystrophy
• Proximal limb girdle dystrophy
• Lesion of upper brachial plexus
• Erb’s paralysis
• Inflammatory muscle disease
• Neuralgic amyotrophy
• Poliomyelitis
• Polymyositis
• Motor neuron disease
• Spinal muscular atrophy, Syringomyelia
• PREDOMINANTLY DISTAL MUSCLE
• Cervical cord tumours
• Affect segmental levels C8, T1
• Cervical glandular enlargement
• Cervical ribs
• Lesion of lower brachial plexus
• Klumpke’s paralysis
• Pancoast syndrome
• Sup pulmonary sulcus tumour
• Traumatic lesions of nerves
• Radial
• Median
• Ulnar
• Motor neuron disease
• Syringomyelia
 TONE
• DEF
• ML
• Resistance
• On moving jt passively
• Felt by examiner
• A
• Tension in muscle
• At rest

• NOTED AS
• Normal
• ↑ - Hypertonia
• ↓ - Hypotonia
• ASSESS TONE BY
• Inspection of muscle group
• Palpation of muscle group
• Passive movement at various joints

• CRITERIA FOR ACCURATE ASSESSMENT OF TONE

• Comfortable, Confidant, Relaxed Pt

• EXAMINATION SEQUENCE
• Pt supine on examination couch
• Enquire abt limitation of movement/painful jt before proceeding

• Ask pt to relax (i.e. go floppy)

• Move each jt passively in all anatomically possible directions
• NOTE
• Be unpredictable in direction & speed of movements
• To prevent active movement
• EXAMINATION SEQUENCE (CONTD)
• UPPER LIMB
• Hold pts hand as if shaking hands
• Other hand support pts elbow
• Assess tone at wrist & elbow
• NOTE
• Activation exaggerates subtle ↑ tone
• LOWER LIMB
• Roll leg side to side
• Then, Lift knee into flexed position briskly
• RESULT
• Heel moves up bed = NORM
• Heel lift off bed = ↑ Tone
• Due to failure of relaxation
• ANKLE CLONUS
• Support pts leg
• Knee & Ankle in 90° FLEXION
• Dorsiflex & Partially evert foot briskly
• Sustaining pressure
• RESULT
• Clonus felt as repeated beats of dorsiflexion/plantar flexion
 HYPERTONIA
• ↑ MUSCLE TONE
• INDICATES UMN LESION

• INSPECTION
• MUSCLE GROUP : Stand out prominently + ↑ Convexity of muscle bellies
• PALPATION
• MUSCLE GROUP : Firm in consistency
• PASSIVE MOVEMENTS OF JOINTS
• Resistance
• Rigidity
• Spacticity
 RIGIDITY SPASTICITY
STATE OF HYPERTONIA STATE OF HYPERTONIA
SIGN OF EXTRAPYRAMIDAL TRACT LESION PYRAMIDAL TRACT LESION – UMN
TONE IN ↑ UNIFORMLY IN BOTH > IN ANTIGRAVITY MUSCLE GROUP
AGONIST & ANTAGONIST • i.e. TONE IN
GROUP OF MUSCLES • UPPER LIMB : Flexor group of
muscles > Extensor group
• LOWER LIMB : Vice versa
↓
CLASP-KNIFE SPASTICITY
VELOCITY DEPENDENT × /

ABDOMINAL REFLEX PRESERVED LOST

BABINSKI’S SIGN -  Plantar flexion +  Plantar extension
DEEP TENDON REFLEXES ABSENT/REDUCED – HYPORREFLEXIA BRISK/EXAGGERATED – HYPERREFLEXIA

CLONUS ABSENT SUSTAINED

 RIGIDITY
COG WHEEL RIGIDITY
RESISTANCE TO INTERRUPTED
PASSIVE MOVEMENTS • By alternate contractions of
agonist & antagonist muscles
• Due to presence of
tremor
SEEN IN COP
• Carbon monoxide poisoning
• Overdosage w CPZ/reserpine
• Parkinson’s disease
DETECTION • On slow movements
• Sustained resistance
throughout range of
movement
SPASTICITY
LEAD PIPE/PLASTIC RIGIDITY CLASP-KNIFE SPASTICITY
UNIFORM /
• Basal ganglia neoplasms
• Catatonia
• Parkinsonism
• Post-encephalitic
On quick movements
MILD CASES
As ‘catch’ at beginning/end of
passive movements
SEVERE CASES
Limited range of movement
Associated w contracture
UPPER LIMBS
• More obvious on extension
LOWER LIMB
• More obvious on flexion
 HYPOTONIA
• ↓ MUSCLE TONE
• INDICATED LMN LESION

• INSPECTION
• MUSCLE GROUP : Lax + Pendulous shape when allowed to hang freely
• PALPATION
• MUSCLE GROUP : Flabby
• PASSIVE MOVEMENTS OF JOINTS
• ↓ Resistance  ↑ Range of movements
• CAUSES OF HYPOTONIA
• LESIONS OF SENSORY SIDE OF REFLEX ARC
• Tabes dorsalis
• Herpes-zoster
• Carcinomatous neuropathies
• LESIONS OF MOTOR SIDE OF REFLEX ARC
• Peripheral nerve injuries
• Poliomyelitis
• Polyneuritis
• COMBINED MOTOR AND SENSORY LESIONS
• Syringomyelia
• Gross cord destruction
• Cord/Root compression

• LESIONS OF MUSCLE
• Myopathies
• STATE OF SPINAL SHOCK IN UMN LESION

• Benzodiazopine overdose
• Cerebellar lesions
• Chorea
• Periodic paralysis (i.e. K disorders)
• REM sleep
 MYOTONIA
• MUSCLE CONTRACTION
• BEYOND PERIOD OF TIME REQUIRED FOR PARTICULAR MOVEMENT
• BEST SEEN IN
• Face muscles
• PROC
• Ask pt to grip examiner’s finger
• Then let go immediately
• RESULT
• Delay in relaxation of grip noted
• Hand muscles
• PROC
• Ask pt to smile
• Then relax facial muscles
• RESULT
• Delay in relaxation of muscle noted
• i.e. Smile remains fixed on face for longer duration – Transverse smile
• COND CAUSING MYOTONIA
• Myotonia congenita
• Myotonic dystrophy
• Paramyotonia congenita
• Myotonia occurs on exposure to cold
 CLONUS
• RHYTHMIC SERIES OF CONTRACTIONS
• EVOKED BY : Sudden stretch of muscle & tendon
• BEST ELICITED AT
• Ankle
• Knee

• ANKLE CLONUS PROC

• Flex hip & Knee
• Dorsiflex foot
• PATELLAR CLONUS PROC
• Move patellar downwards

• ASSESS FOLLOWING
• Palpate muscle groups
• AIM : To elicit tenderness
• Percuss muscle groups
• Esp
• Extensor group of muscles of forearm
• Thenar eminence
 SUSTAINED CLONUS ILL-SUSTAINED/ UNSUSTAINED CLONUS
> 6 Beats < 6 Beats
IN • After straining
• Defaecation
• Recent frightening experience
• Very tense people
INDICATE Pyramidal tract/UMN lesion Physiological
 POWER
• DEF
• Force of contraction
• Generated by muscle voluntarily
• PT POSITION
• UPPER LIMB : Sitting on edge of couch
• LOWER LIMB : Reclining
• PROC
• Commonly tested muscles listed below
• Do NOT test every muscle
• Ask pt to undertake a movement
• Assess whether can overcome gravity
• E.g. Lift rt leg off bed – Tests hip flexion
• Then apply resistance to same movement

• Ask pt to lift arms above head

• Ask to play piano
• RESULT : Asymmetric loss of fine finger movement = EARLY SIGN OF CORTICAL/EXTRAPYRAMIDAL DISEASE
• Ask pt to get up from chair & walk
• Ask pt to sit up from lying position
• AIM : To test truncal strength
 UPPER LIMB
MOVEMENT MUSCLE NERVE/ROOT
SHOULDER ABDUCTION Deltoid Axillary C5

ELBOW FLEXION Biceps Musculocutaneous C5, 6

Brachioradialis Radial C6
ELBOW EXTENSION Triceps Radial C7
MEDICAL RESEARCH COUNCIL, MRC SCALE FOR MUSCLE POWER
0 NO muscle contraction visible
1 Flicker of contraction
• BUT NO movement
2 Gravity eliminated movement
• i.e. Lat movements in bed
3 Movement against gravity
• BUT NOT against examiner’s resistance
4 Movement against resistance
• BUT weaker than norm
5 Normal power
 CAUSES OF MUSCLE WEAKNESS
ANATOMICAL AETIOLOGY ASSOCIATED FEATURES
FUNCTIONAL WEAKNESS • Hoover’s sign
• Inconsistent weakness
• NO ‘hard’ neurological signs
MYOPATHIES Proximal weakness usually
LMN Fasciculations
Hypotonia
Reflexes – Absent/Diminshed
Wasting
UMN ‘Patterned weakness’
• Flexed arm, Extended leg
Hypertonia
Hyperreflexia
NO Wasting
COMMON CAUSES
• Conversion disorders
• Alcohol
• Corticosteroids
• Inflammatory myopathies
• Muscular dystrophies
• Radiculopathies
• Ant horn cell damage
• Motor neurone disease
• Poliomyelitis
• Mononeuropathies
• Peripheral neuropathies
• Stroke
• Brain tumor
• Multiple sclerosis
• Spinal cord pathology
• LESIONS AT DIFF SITES PRODUCE DIFF CLINICAL PATTERNS OF
WEAKNESS
 COORDINATION
• COORDINATED ACTION OF MUSCLES
• UNDER : Cerebellar control
• INFLUENCED BY : Extrapyramidal system
• ESSENTIAL FOR SATISFACTORY MOVEMENT
• Intact Proprioceptive sense + Accurate Image of one’s own body + Its relationship to environment
• Lesions in these sites  Incoordination
• PROC
• Explain proc properly to patient
• So that pt can perform act smoothly
• All tests for coordination
• Initially done w eyes open
• Then w eyes closed
• AIM : To detect post column lesions
• Examine limbs on both sides
• Compare results
• NOTE
• Coordination of limbs tested effectively
• ONLY when Power of muscle > Grade 3
 TESTING COORDINATION IN UPPER LIMBS
• FINGER-NOSE TEST
• FINGER-FINGER-NOSE TEST
• TAPPING IN A CIRCLE TEST
• DYSDIADOCHOKINESIS

FINGER-NOSE TEST
• PROC
• Ask pt to outstretch upper limb
• Then touch Tip of nose w Forefinger
• Repeat act
• Note ability to carry out action smoothly
• Compare w opposite limb (Fig. 8.48)

FINGER-FINGER-NOSE TEST
• AIM : To detect mild degrees of incoordination (Fig. 8.49)
• PROC
• Perform in similar manner as finger-nose test
• Except Ask pt to touch Examiner’s finger before touching Nose
 TESTING COORDINATION IN UPPER LIMBS
TAPPING IN A CIRCLE TEST
• PROC
• Draw circle of 1 cm diameter
• Give pt pencil
• Ask pt to tap out series of dots
• All within circle
• RESULT
• ATAXIA = Pt spread dots irregularly over wide area, outside as well as inside circle

DYSDIADOCHOKINESIS
• FAILURE TO EFFICIENTLY PERFORM RAPIDLY ALTERNATING MOVEMENTS
• PROC
• Ask pt to alternatively & rapidly pronate and supinate forearm and hand
• Clapping other hand
• RESULTS
• INCOORDINATION = Alternating rapid movement NOT carried out smoothly
Testing Coordination in the Lower Limbs
 PROPRIOCEPTIVE SENSATIONS
• PROPRIOCEPTIVE

• POSITION SENSE
• ROMBERG’S TEST
• JOINT SENSE (I.E. SENSE OF PASSIVE MOVEMENT)
• VIBRATION SENSE
 POSITION SENSE
PROC
• Pt’s eye closed while testing
• Place arm in particular position
• Move it away
• Ask to replace it
• Then ask to place opposite limb in similar position
• Ask to touch forefinger of 1 hand w forefinger of other
• In different positions
• Ask to place
• Forefinger on Tip on nose
• Heel on Knee
• Ask to raise leg to touch own outstretched hand w big toe
 ROMBERG’S TEST FOR POSITION SENSE
• PROC
• Pt stands upright w feet together
• Eyes closed
• RESULT
• Impaired balance when eyes closed = Proprioceptive/Vestibular deficit
• NOTE
• Ask pt to stand on toes w eyes closed to demonstrate minimal lesions
SUPERFICIAL REFLEXES
 PLANTAR REFLEX
AFFERENT SEGMENT EFFERENT
Tibial n L5, S1, 2 Tibial n
TECHNIQUE
• Position pt
• Knee slightly flexed
• Thigh externally rotated
• Fix ankle jt
• By holding it
• Stroke outer aspect of sole
• W blunt point (i.e. Key)
• Direct stroke
• Forwards
• Then inwards along metatarsophalangeal joints
• Little  Big toe

NORM RESPONSE
• GREAT TOE flex at metatarsophalangeal jt
• OTHER TOES also flex
 ABNORM PLANTAR REFLEX RESPONSES
• BABINSKI’S SIGN/EXTENSOR PLANTAR RESPONSE
• EQUIVOCAL BABINSKI SIGN
• MINIMAL PLANTAR RESPONSE
• PSEUDO-BABINSKI SIGN
 BABINSKI’S SIGN/EXTENSOR PLANTAR RESPONSE
• RESPONSE
• Dorsiflexion of GREAT TOE
• Extension & Fanning out of OTHER TOES
• MARKED RESPONSE
• Dorsiflexion of ANKLE
• Flexion at KNEE & HIP
• IN
• Lesions of corticospinal tract (i.e. pyramidal tract)
• Thick soles

• NOTE
• Repeated stimulation  Fatigue  Extensor plantar response NOT elicitable
• As lesion becomes dense  ↑ Reflexogenic area  Response elicitable even over med aspect of foot

EQUIVOCAL BABINSKI SIGN

• EQUIVOCAL RESPONSE
• Rapid BUT Brief Extension of TOES
• Followed by Flexion/Predominant flexion
• Followed by Extension
• ONLY extension of GREAT TOE
• Extension of GREAT TOE
• Flexion of SMALL TOES
• NO response
• Flexion of KNEE & HIP
• NO movement of TOES
 MINIMAL PLANTAR RESPONSE
• RESPONSE
• NO movement of toes
• ∴ ASSESS POSITIVE PLANTAR RESPONSE BY
• Feeling contraction of tensor fascia lata & adductors of thigh

PSEUDO-BABINSKI SIGN
• IN
• Strong/Painful stimulus
• Overtly sensitive individuals  Voluntary withdrawal
• Plantar hyperesthesia

• LMN lesion  Paralysis of short flexors of toes  Inversion of plantar reflex

• Athetosis/Chorea
• BIG TOE extend as response to dystonic posturing
 BABINSKI SIGN PSEUDO-BABINSKI SIGN
CONTRACTION OF HAMSTRING MUSCLES Felt NO
PRESSURE ON BASE OF GREAT TOE WHILE Does NOT inhibit extensor response Inhibit withdrawal extensor response
ELICITING PLANTAR REFLEX
 BABINSKI SIGN
IN ABSENCE OF PYRAMIDAL TRACT LESION
• Infancy (up to 1 year of age)
• Deep sleep

• Alcohol intoxication
• Coma
• 2° to metabolic disturbances
• Deep anaesthesia
• ECT
• Narcotic overdose
• Post-ictal state
• Post-traumatic states

• In Cheyne-Stokes respiration
• Extensor response appear during period of apnoea
OTHER METHODS OF OBTAINING
PLANTAR REFLEXES
• OPPENHEIM REFLEX
• PROC
• Stroke firmly w finger & thumb
• Either side of ant border of tibia
• GORDON REFLEX
• PROC : Squeeze calf muscles
• CHADDOCK REFLEX
• PROC : Stroke lat malleolus lightly

• INDICATION
• Uncooperative pts
• Extremely sensitive pts