Examination Of Central Nervous System

Dr Bhawna Verma (PT)

Examination/Assessment
Enable the therapist to know about the nature and extent of the patient s difficulties in his day to day life .

Aim of Neurological Examination

Determine the site and nature of disease of the nervous system . It is an essential part of any routine clinical examination.

Classification Of Examination Of CNS

Subjective Examination Objective Examintaion

Subjective Examination
History -patient/his relatives in case where the patient is either unconscious or child

Subjective Examination
1. Name of the patient-for identity of the patient . 2. Age of the patient Some diseases occur at a particular age group . 3. Sex-Some diseases are more common in males while some in female. 4. Occupation-To get proper understanding of the diseases and for planning the treatment accordingly.

5. Address-To get proper idea of general status of the patient ,his surrounding and his nutritional hygiene level. 6. Past medical history-whether he has got history of chronic illness like diabetes ,hypertension, leprosy, tuberculosis. Because in presence of any diseases, the treatment should be altered and planned accordingly.

7.History of presenting illnessa. Onset of symptomsTime- The patient is asked whether the symptoms appeared gradually over a period of time or they were sudden in origin. Type- The patient is asked about the type of onset of symptoms acute, subacute ,chronic b. Progress of the diseaseThis consist of finding out how the symptoms progressed over a period of time Whether it is progressively worsening disease? It is disease with remission and exacerbation? Is it a disease which come suddenly and subsided over a period of time

8. History of treatmentAny treatment carried out during this period or progress of disease and its effects should be noted . 9. History taking from relatives-when The patient is child The patient suffer from episodes of impairment of consciousness There is obvious memory defect or mental change. Details concerned with other member of the family need to be checked.

10. Social and Family HistoryHow much family support can be expected by the relatives to assist the therapeutic programme at home .

Objective Examination
Observation Examination

Observation
General Appearance Built-Obese/lean/thin/muscular Height-Dwarf/giant ,that is if acromegaly is present or not. Facial Expression-To check if the patient is suffering from myasthenia gravis or Parkinson's disease Skeletal Deformities-Look for any skeletal deformities like spina bifida

 Look for any abnormal size of head such as in Hydrocephalus, Acromegaly,Achondroplasia and Pagets disease. Mode of dressing. The hair look for any premature baldness .very obvious in myotonic dystrophy,Alopecia etc. Skin coluration Muscle atrophy Signs of ill health or malnutrition

Gait and Posture

Shuffling, Circumductory,Ataxic Look for Kyphosis, Scoliosis,Torticollis,and forward drooping of neck profound muscular weakness as in Progressive Muscular Atrophy or Myasthenia Gravis

Handedness
Whether the patient is right handed or left handed as the treatment should be planned accordingly.

Examination
Mental Functiona) Level of consciousness-observation of the patient is done .Level of consciousness is done by GLASGOW COMMA SCALE

GCS
Eye opening(E4) Motor response(M6) Spontaneous 4 Open to sound 3 To painful stimuli 2 None 1 Obeys 6 Localized painful stimuli 5 Withdraws to stimuli 4 Abnormal flexion to stimuli 3 Extensor response to stimuli 2 None 1 Oriented 5 Confused 4 In appropriate speech 3 In comprehensive sound 2 None 1

Verbal response(V5)

Score 3-15 13-15 mild unconscious for <2 min 9-12 Moderate - unconscious for <6 hrs 8 Severe unconscious for >6 hrs GCS- Grade 1-Death 2-vegtative state 3 severe disability 4 moderate disability 5 good recovery

Orientation
Disorientation may occur in Time, Place and Person Ask patient to estimate the approximate time without looking a watch Whether day /night Where he is Whats his name of the hospital Relaion of the person surrounding him Recognize his relatives by nae and relation ,Doctors and nurses

Memory
Test the patients ability to remember events of that day ,previous week ,month or earlier year. Ask what he has recently done ,How he came to building?? Read out him clearly and slowly a series of number and ask him to repeat Ask the patient to recall what he has read in the paper or seen on television.

Emotional State
Mood of the patient Anxious excited Depressed Frightened Apathetic Euphoric

General Intelligence
In case of brain injury or disease . Education Character of his work Work record

Communication
1. Receptive Ability 2. Expressive Ability

Receptive Ability
Is his attention easily held or fleeting Does he show a reasonable degree of interest in surroundings How does he react to the therapist approach and greeting Any usual features in his behavior (Facial Expression or nay inappropriate behavior)

Expressive Ability
Whether his conversation flows easily or not Whether hi is mute, answer only by monosyllables or is over talkative Does he use strange words??

Signs of meningeal irritation

1. Neck Stiffness-Ask patient to flex his neck fully Then therapist passively flexes his neck The chin should normally touch the chest without pain In case of meningeal irritation-Pain in flexion That may radiate to back and movement restricted by spasm in the extensor muscles of the neck

Kernigs Sign
Supine

Passively extend the patients knee when his hip is fully flexed.
If meningeal irritation in lower part of the spinal subarachnoid space is present this movement causes pain and spasm of hamstrings

Straight leg raising test

For nerve root compression Mainly to detect sciatic nerve PASSIVELY EXTEND THE PATENTS LEG WITH THE HAND WHICH IS PLACED BEHIND THE HEEL Pain in back of thigh or calf .hence movement is restricted because of this sciatic pain when spinal roots are entrapped in lumbosacral intervrtebral disc protrusion

Sensory system Examination

Extroceptive or cutaneous sensation sensationderived from outside of the body.these are Pain,light touch ,temprature Proprioceptive sensation sensation derived from body itself-sense of position.passive movement,vibration and deep pain Combined and cortical sensationSterognosis,graphaesthesia,two point discrimination Perceptive sensation-Apraxia,Agnosia,disorder of body scheme

Pain
Choose a part of the patients body which is expected to be normal and touch him precisely not too firmly several times with the point of the pin .then ask him . Whether he can feel any thing and if yes describe what does he feel If he say yes that he can feel a point then whether it is sharp or blunt If it becomes clear that the patient recognize the stimulus ,then compare quickly the sensation in a number of areas including face , shoulder, the inner and outer aspect of the upper limb ,upper and lower chest and abdomen ,lower limb and the buttocks.

Touch
A small piece of cotton wool can be used to check the sensation of light touch, as it does not cause excess pressure to stimulus deep sensibility. Ask the patient to close his eyes and say yes each time he feel ant thing. The cotton wool is shaped to point and the skin is then touched lightly testing in dermatome areas.

Temperature
The patient can compare the temperature of cold object such as tuning fork on the main sensory areas of the body. After this the test tube containing hot water (43degree C)and cold water (7 degree C)are used . Extreme of heat and cold should not be used because these stimulate pain fibres. The patient is ask to close the eyes through out the examination and is asked What he can feel ? Whether there is any difference ,when the outer tube is used ? If he can feel the difference ,then what that difference is ?

Proprioceptive sensation
Position sense close the eyes place limb in particular position then move it away. Ask him first to replace it himself and then to place the opposite limb in a similar position. Ask him to place his heel accurately on his knee. Ask him to place his forefinger accurately on the tip of his nose .Ask him to place his heel accurately on his knee.

Sense of passive movement

Close the eye .The digit (thumb, finger,big toe )is held firmly and moved up and down ,while the patient is asked if he can feel the movement .if he say yes he can feel the movement then he is asked whether his thumb /toes has been moved upwards or downwards

Vibration sense
For testing the vibration tuning fork of 128 hz and 256 hz placed on his clavicle to allow him to identify the sensation of vibration . He is then asked to close the eyes and the fork is struck and placed on bony points starting peripherally at the internal malleoulus and the lower end of the radius. The patient is then ask if he can feel the vibration.

Deep pain or muscle activity

To assess the sensitivity of the muscles .the thumb are firmly pressed into the muscles of the forearm and the calves. If the muscle are abnormally tender then the patient complains of distress even under lighter pressure. But in case of diminished sensitivity the patient will allow all possible forces to be exerted without any complaint. Squeezing the tendoachillis between the finger and the thumb will allow the assessment of diminished deep sensation

Cortical Sensation
Stereognosis-Ability to recognize the object .by shape and size . Object-keys ,coins,combs,pencils.pen etc Close eye ,place object in suspected hand if he fail to recognize then in other hand and comparison of accuracy and speed of response is made

Tactile localization
Ability of an individual to localize touch sensation on his skin Close eyes then touch on some point with the therapists finger or a pin . The patient is then asked to identify the location of the stimuli by either touching the same point with his own finger or verbal description

Two point discrimintion

Ability of an individual to detect that a stimulus consist of two blunt point when the stimulus are simultaneously applied Explain the test to the patient ,first by touching his finger with two point widely separated and with the patients eye opened. Then asked to close the eye and two ends are applied simultaneously with each application the two ends are gradually brought close until the stimuli are perceived as one. The normal ability to distinguish the two point from one varies in different parts of the body.

Graphaesthesia
Ability to recognize letters or number written on skin with a blunt point while he closed his eyes .

Baragnosis
Recognition of weight for this a series of small object of same size but of different weight are used .

Perceptive sensation
Agnosia Apraxia Aphasia Body schema and image

Perceptive sensation
Agnosia-Gnosis in greek means perception (inability to recognize familiar objects) Ability to recognize the thing in absence of lack of intelligence ,mental disorder or any defect in sensory mechanism. It may be of three types Visual-due to lesion in parieto-occipital region Auditory- lesion in temporosphenoidal region Tactile-lesion in parietal lobe behind the posterior central gyrus

Visual Recognition
Show the patient a number of common small objects and then ask him to Name them describe their use Pick the one that are named by the therapist . Next show the patient various different colors and ask him Their name To pick out the duplicates from the other set To arrange them in shades of increasing or decreasing lightness

Auditory recognization
First make sure that hearing in both ears is normal . Close the eyes then identify the sounds made by striking a match, ringing a bell, shaking money ,tearing cloth

Tactile recognization
First make sure that the sensation of both hands are normal .then ask the patient to close his eyes and then place a number of common objects one by one in one or both hands. Then ask the patient to name them ,describe their shape, size and texture and then lastly to indicate their use.

Apraxia
Ability to carry out purposeful movement(inspite of normal tone,normal movement) in the absence of any motor paralysis, ataxia,sensory loss or a difficulty in understanding Types-Ideomotor-patient has ability to do the movement but when we ask he doesnt do that. Ideation patient does not have idea Constructional doesn have ability to proportionate ,he doesnt relates size. Other types-Dressing Apraxia-No relation between garments and parts,

 Apraxia may involve any voluntary movement occular,bulbar or that of extrimities. Lesion in the left parietal lobe produce bilateral apraxia on the right side,while lesion in the anterior part of the corpus callosum and up to the precentral gyrus on the right side produces apraxia on the left side.

Motor aphasia-is apraxia of speech

Method of testing
Ask him to hold out his arms, take out his tongue, show his teeth, etc if he fails to do then note whether this movement are normal when they are automatic eg. Licking the lips, smiling or responding to an offer to shake hands . Next ask him to make a fist ,to scratch his arm and more difficult ,to use a pair of scissors ,a pen and a comb.Any tst which requires three or four different movement ,can be used with or without the use of objects. Give him a series of match sticks and ask him to form a triangle or square. If he fails to d then ask him to copy you. Note how he takes off his coat and jacket and puts them on again, how he buttons his shirt.

Disorder of body schema and image

Body image-is defined as visual and mental image of ones body that include feelings about ones body especially in relation to health and disease. A normal individual is able to tell where each part of his body is and where it lies in relation to surrounding objects. and may even deny If disruption patients remain unaware of the part and may even deny that it is the part of his own body.

Method of testing
Ask the patient that whether he knows his right hand and left hand and leg. Then ask him to point different major parts of his own body according to therapists commands. Then ask him to point the ring finger of his left hand, the forefinger of his right hand, to point the little toes etc. making the test a little bit more complex. Make the more difficulty by asking him to point out individual digits of therapist hands etc. Observe during general examination whether he is aware of his disability or not.

Motor System examination

The main function of Motor system is to control the bodys normal posture and movement. Examination of motor system includesAnatomicalExaminationInspection-observe and compare with opposite side and size could be determined as normal,smaller,larger. Palpation-Feel the muscle /Normal,Softer,harder Menstruation-the girth of one muscle or a group of muscles should be compared by measuring with tape.

Physiological Examination Muscle bulk and wasting Biceps,triceps in UL Quadriceps ,and gastrosoleus in LL Measur cicumference of the limb at 10cm above and below the olecranon for biceps and triceps respectively. 15cm above and 10 cm below the tibial tubrosityfor quadriceps and gastro-soleus repectively.

Range of motion
Active ROM Passive ROM Other points to be observed along with range are 1. The presence of pain with motion . When does the pain appear Severity of pain Patients reaction to the pain 2. The presence of limitation of joints 3. If limitation then cause of limitation 4. Movements of associated joints

Muscle Tone
It is defined as resistance of muscle to assive elongation stretch. Hpertonia-increased muscle tone Hypotonia-decreased muscle tone Dystonia-Absence of muscle tone

Spasticity
There is increase in the tone of one group of muscle ie either agonist or antagonist result from lesion of pyramidal tracts ,inhibitory reticulospinal tracts which leads to increase facilitation of stretch reflex.This lead to increase in phenomenon called as Clasp knife spasticity .where after an initial resistance the muscle gives away Passive stretch of a spastic muscle may produce an initial high resistance followed by a sudden inhibition of resistance termed as CLASP KNIFE REFLEX.

Rigidity
Resistance is uniformly increased in both agonist and antagonist muscle ,making body parts stiff and immovable.when the lesion is in extra pyramidal tracts or basal ganglia which results in exaggeration of tonic stretch reflex. It maybe Cog Wheel Rigidity it is characterized by an alternating contraction with jerky movement producing resistance to movement.(Intermittent resistance throughout the movement ) Lead pipe rigidity-Constant rigidity present throughout the movement (continuous resistance to passive movement )

Clonus
It is defined as repetitive contraction of a particular group of muscle due to exaggeration of dynamic stretch reflex.

Flaccidity
Flaccidity and hypotonia-Absence/decreased muscle tone Resistance to passive movement is diminished Stretch reflexes are dampened and limbs are easily displaced.

Assessment
General clinical scale 0-No response 1-Decreased response 2-Normal response 3- Exaggerated response 4-sustained response

ASHWORTH SCALE
To assess spasticity 0-No increase in muscle tone 1-Slight increase in muscle tone ,manifested by catch and release or by minimal resistance at the end of ROM ,when the affected part is moved in flexion and extension . 1+Slight increase in muscle tone ,manifested by catch ,followed by minimal resistance throughout the remainder of ROM 2-More marked increased in muscle tone through most of the ROM ,but affected part is easily moved 3 Considerable increase in muscle tone, passive movement is difficult . 4-Affected part is held rigid in flexion or extension.

Test for assessing spasticity

Pendulum Test patient sitting or lying with knee flexed over the end of a table The patient knee is fully extended and allows to drop and swing like pendulum. A normal and hypotonic limb will swing freely for several oscillation . Hypertonic limbs are resistant to swinging motion hence will quickly return to the initial starting position .

Drop arm test

In this the therapist suddenly drop a limb that has been held. A normal limb falls momentarily ,then catches and maintains the position. Hypotonic limbs fall abruptly, while hypertonic limbs show a delay and resistance to falling

Motor sensory links

Reflexes Deep-Deep tendon jerks eg Biceps, Triceps, Supinator ,Brachioradialis. Superficial-Abdominal, Plantar reflexes

Involuntary movement
Involuntary movement are unintended movement ,which occur either at rest or during voluntary movement. These are 1. Tremor-It is involuntary oscillatory movement ,which result from alternate contraction of opposing muscle groups. It is rhythmical oscillatory movement of a body part caused by regular muscle contraction.

Types of tremors
1. Physiological-is a universal phenomenon in normal people .A variable degree of tremors are seen which increases by anxiety, tension ,fear etc. 2. Senile-this is a type of postural tremor involving upper limb .seen in old age . 3. Resting tremor/static/postural-in basal ganglia lesion .is occurs when the patient is in static posture . 4. Intentional-in cerebellar lesion . tremor-It occurs during voluntary motion of a limb and increases as the limb reaches near its goal. These are decreased or absent at rest

Chorea
They are flowing or changing irregular purposeful movement which are jerky in nature ,which appears for a short period of time and they fling from one joint to another usually from distal to proximal. They arise because of lesion in basal ganglia mainly globus pallidus and caudate nucleus.

Athetosis
It is characterised by slow, involuntary writhing,twisting ,worm like movement . It is more seen in distal than proximal muscles. The neck ,Face ,tongue and trunk may also be involved. Is is seen in lesion of basal ganglia .

Choreo athetosis
Is is a movement disorder having features of both chorea ans athetosis.

Hemiballismus
Sudden ,jerky, forceful,wild and flailing movement of one side of the body characterizes it. It is almost invariably unilateral and affects the arm more than the leg. The movement may be so violent that it may result in serious injury to the limb.

Dystonia
It involves twisting ,sometimes bizarre movement caused by involuntary contraction of the axial and proximal muscle of the extremities . Torsion spasm are also considered a form of dystonia and the most common among this is Spasmodic torticollis

Voluntary movement
Muscle power charting to assess strength of the muscles

Isolation of the muscle

Isolation is defined as placing of a muscle in detached or non working position to obtain the requires action in a free state. it is actually testing the muscle individually . In isolation of the muscle, the multi-joint muscle is fixed to get the action of a single joint muscle. When one joint and a multi joint ,muscle act together in a movement, the action of one joint muscle can be differentiated from that of multi joint muscle by placing the multi joint muscle at mechanical advantage . Keeping it engaged at joint in full range of motion so that is power to assist a movement at other joint is decreased does this . Eg-Flexing the knee decreases the action of hamstrings at hip as extensor. Here gluteus maximus is isolated from hamstrings.

Inhibition of muscle work

This is compensation made by powerful muscle or muscle group for lack of function of weak or paralyzed muscle. This result in inhibition of the weak muscle and the movement is also called as trck movement. These movement appear somwhat similar to the actual movement but are not actual movement .

Balance
Static and dynamic How much help does he need to maintain particular position His conscious balance assessed by applying pressure and telling him to hold against that pressure .give pressure in various direction ,note his stability. Same with eye closed . Tilt him backward, forward,sideways and rotate him getly ao as to distrb his COG. Notice whether he moves his head ,trunk,UL,LL or all of them to maintain equilibrium Try the same with closed eyes

Gait assessment
Circumductory Gait Hip hiking ,throwing the affected leg outward producing the movement of circumduction and leaning towards the opposite side with arms flexed across the body. Seen in Hemiplegia

High stepping gait

Seen in patient with foot drop due to which he raises the foot high to overcome it

Shuffling gait
In this the movement occurs in a series of small ,flat-footed shuffles seen particularly in parkinsons disease

Ataxic gait
The patient walk with broad base .sways to and fro and looks as if he is being drunk. It is most common in cerebellar ataxia

Waddling gait
There is excessive rotation of pelvis , accompanied by compensatory movement of upper trunk . Seen in congenital dislocation of hip in myopathies.

Functional Assessment
Bathing independent/Dependent Dressing- independent/Dependent Going to toilet- independent/Dependent Continence-independent-if patients urination and defecation are entirly self controlled. Dependent If he has got partial or total incontinene in urination or defecation Has got partial or total control by anemas,cathers or regular use of urinals or bedpans. Transfer- independent/Dependent Feeding - independent/Dependent