NEUROPrelims - Cranial Nerves and Neurological Examination

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CRANIAL NERVES and NEUROLOGICAL EXAMINATION HOMEWORK AND SEATWORK | June 26, 2015 | NEUROLOGY

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CRANIAL NERVES and THEIR FUNCTIONS

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AFFERENT FIBERS EFFERENT FIBERS

General Somatic Afferent (GSA) General Somatic Efferent (GSE)

Special Somatic Afferent (SSA) General Visceral Efferent (GVE)

General Visceral Afferent (GVE) Special Visceral Efferent (SVE)

Special Visceral Afferent (SVA)

# Name Location of

Nerve Cell

Bodies

Cranial Exit Motor Function Sensory Function

I OLFACTORY Olfactory Epithelium

(Olfactory Cells)

Foramina in Cribriform Plate

of Ethmoid Bone

SVA: SMELL from nasal

mucosa of roof of each

nasal cavity and

superior sides of nasal

septum and superior

concha

II OPTIC Retina

(Ganglion Cells)

Optic Canal SSA: VISION from

retina

III OCULOMOTOR Somatic Motor:

Motor: Midbrain

Visceral Motor:

Presynaptic:

Midbrain

Postsynaptic:

Ciliary Ganglion

Superior Orbital

Fissure GSE: Motor to superior,

inferior, and medial

recti, inferior oblique,

and levator palpebrae

superioris muscles

that raise superior

eyelids and direct gaze

superiorly, inferiorly,

and medially

GVE: Motor to superior,

inferior, and medial

recti, inferior oblique,

and levator palpebrae

superioris muscles

that raise superior

eyelids and direct gaze

superiorly, inferiorly,

and medially

IV TROCHLEAR Midbrain GSE: Motor to

superior oblique that

assists in directing

gaze infero laterally (or

inferiorly from the

adducted position)

V TRIGEMINAL V1, V2:

Trigeminal

Ganglion

V3:

Pons

V1: Superior

Orbital Fissure

V2: Foramen

Rotundum

V3: Foramen

Ovale

Mandibular Branch (V3)

SVE: Motor to muscles

of mastication,

mylohyoid, anterior

belly of digastric, tensor

veli palatini, and tensor

tympani

Ophthalmic Branch (V1)

GSA: Sensation from

cornea, skin of

forehead, scalp,

eyelids, nose, and

mucosa of nasal cavity

and paranasal sinuses

Maxillary Branch (V2)

GSA: Sensation from

skin of face over

maxilla, including

upper lip, maxillary

teeth, mucosa of nose,

maxillary sinuses, and

palate

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Mandibular Branch (V3)

GSA: Sensation from

skin of face overlying

mandible including

lower lip, mandibular

teeth,

temporomandibular

joint, mucosa of mouth

and anterior two thirds

of tongue

VI ABDUCENS Pons Superior Orbital

Fissure GSE: Motor to lateral

rectus that directs gaze

laterally

VII FACIAL Somatic Motor:

Pons

Special Sensory:

Geniculate

Ganglion

Visceral Motor:

Presynaptic:

Pons

Postsynaptic:

Pterygopalatine

Ganglion;

Submandibular

Ganglion

Internal Acoustic

Meatus; Facial

Canal;

Stylomastoid

Foramen

GVE: Parasympathetic

innervation of

submandibular and

sublingual salivary

glands, lacrimal gland,

and glands of nose and

palate


of facial expression and

scalp; also supplies

stapedius of middle

ear, stylohyoid, and

posterior belly of

digastric

SVA: Taste from

anterior two thirds of

tongue and palate

VIII VESTIBULOCOCHLEAR Vestibular:

Vestibular

Ganglion

Cochlear: Spiral

Ganglion

Internal Acoustic

Meatus

Vestibular

SSA: Vestibular

sensation from

semicircular ducts,

utricle, and saccule

related to position and

movements of head

Cochlear

SSA: Hearing from

spiral organ

IX GLOSSOPHARYNGEAL Somatic Motor:

Medulla

Visceral Motor:

Presynaptic:

Medulla

Postsynaptic:

Otic Ganglion

Visceral Sensory:

Superior

Ganglion

Special Sensory,

Somatic Sensory:

Inferior Ganglion

Jugular Foramen GVE: Parasympathetic

innervation to parotid

gland

SVE: Motor to

stylopharyngeus that

assists with swallowing

GSA: Cutaneous

sensation from

external ear

GVA: Visceral

sensation from parotid

gland, carotid body

and sinus, pharynx,

and middle ear

SVA: Taste from

posterior third of

tongue

X VAGUS Somatic Motor:

Medulla

Visceral Motor:

GVE: Parasympathetic

innervation to smooth

muscle and glands of

trachea, bronchi,

digestive tract,

GSA: Sensation from

auricle, external

acoustic meatus, and

dura mater of posterior

cranial fossa

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Presynaptic:

Medulla

Postsynaptic:

Viscera

Visceral Sensory:

Inferior Ganglion

Special Sensory:

Inferior Ganglion

Somatic Sensory:

Superior

Ganglion

coronary arteries, and

nodes of conduction

system of heart


of pharynx (except

stylopharyngeus).

intrinsic muscles of

larynx, muscles of

palate (except tensor

veli palatini), and

striated muscle in

superior two thirds of

esophagus

GVA: Visceral

sensation from base of

tongue, pharynx,

larynx, trachea,

bronchi, heart,

esophagus, stomach,

and intestine to left

colic flexure

SVA: Taste from

epiglottis and palate

XI SPINAL ACCESSORY Spinal Cord Cranial Root

SVE: Muscles of soft

palate (except tensor

veli palatine), pharynx

(except

stylopharyngeus), and

larynx (except

cricothyroid) in

branches of the vagus

Spinal Root

SVE: Motor to

sternocleidomastoid

and trapezius

XII HYPOGLOSSAL Medulla Hypoglossal

Canal GSE: Motor to intrinsic

and extrinsic muscles

of tongue (except

palatoglossus)

Reference: Moore, K.L., Dalley, A.F., & Agur, A.M.R. (2014). Moore’s clinically-oriented anatomy [7th ed.]. pp. 1058-1059.

Philadelphia, PD: Wolters Kluwer Health, Lippincott Williams & Wilkins

NEUROLOGICAL ASSESSMENT

Text in BLUE are ABNORMAL FINDINGS in the videos found at

http://library.med.utah.edu/neurologicexam/html/home_exam.html

A. MENTAL STATUS EXAMINATION

The cerebral hemispheres represent the highest and most

complex level of neurological function. There is so much

integration of cortical function that whatever system is used

to clinically "examine" the cerebral hemispheres will be an

over simplification and somewhat artificial

compartmentalization. Although a lot of mental status reflects

integration of cortical function, it can still be divided into parts

that correspond to the divisions of the cerebral hemispheres.

This anatomy review will be a brief overview of areas of

cortical function that can be examined by components of the

mental status exam.

Frontal Lobes

The frontal lobes are important for attention, executive

function, motivation, and behavior. Tests for frontal lobe

function include working memory (digit span, spelling

backward), judgment, fund of knowledge, task organization

and set generation such as naming lists of things in a certain

category.

Temporal Lobes

The temporal lobes are important for emotional response

(amygdala and its connections to the hypothalamus and

frontal lobes) and memory (hippocampus and limbic

connections). Clinically the main tests for temporal lobe

function are those of memory, particularly declarative

memory.

Language- Temporal and Frontal Lobes

The principle area for receptive language is Wernicke's Area,

which is located in the posterior part of the superior temporal

gyrus of the dominant temporal lobe. The major region for

expressive language is Broca's Area located in posterior part

of the inferior frontal gyrus of the dominant hemisphere.

Homologous regions of the non-dominant hemisphere are

important for the non-verbal contextual and emotional

aspects as well as the prosody (rhythm) of language. Tests for

written and spoken receptive and expressive language are

used to "view" these language centers.


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Parietal Lobes

The parietal lobes are important for perception and

interpretation of sensory information especially

somatosensory information. The non-dominant parietal lobe

is particularly important for visual-spatial function. The

dominant parietal lobe is important for praxis, which is the

formation of the idea of a complex purposeful motor act while

the frontal lobes are important for the execution of the act.

The Gerstmann Syndrome, which consists of the constellation

of acalculia, finger agnosia, right-left confusion and agraphia,

occurs with damage to the dominant inferior parietal lobe.

Clinical tests for parietal lobe function include tests for

agnosia (such as inability to identify objects by tactile

exploration), apraxia (inability to perform purposeful motor

acts on command), constructional apraxia (inability to draw

objects which require use of visual spatial organization) and

testing for elements of Gerstmann's syndrome.

Occipital Lobes

The occipital lobes are important for perception of visual

information. Areas in the inferior temporal visual association

cortex are important for recognition of color and shape as well

as the recognition of faces. Projections from the occipital lobe

to the superior temporal-parietal area are important for

perceiving motion of objects. Tests that are used to examine

the occipital lobes and its connections include visual fields

(see Cranial Nerve 2), naming of objects, naming of colors and

recognition of faces.

1. ORIENTATION, MEMORY Asking questions about month, date,

day of week and place tests orientation,

which involves not only memory but

also attention and language. Three-

word recall tests recent memory for

which the temporal lobe is important.

Remote memory tasks such as naming

Presidents, tests not only the temporal

lobes but also heteromodal association

cortices.

This patient has difficulty with

orientation questions. The day of the

week is correct but he misses the

month and date. He is oriented to

place. Orientation mistakes are not

localizing but can be due to problems

with memory, language, judgement,

attention or concentration. The patient

has good recent memory (declarative

memory) as evidenced by the recall of

three objects but has difficulty with long

term memory as evidenced by the

difficulty recalling the current and past

presidents.

2. ATTENTION-WORKING

MEMORY

Digit span, spelling backwards and

naming months of the year backward

test attention and working memory

which are frontal lobe functions.

The patient has difficulty with digit span

backwards, spelling backwards and

giving the names of the months in

reverse order. This indicates a problem

with working memory and maintaining

attention, both of which are frontal lobe

functions.

3. JUDGEMENT-ABSTRACT

REASONING

These frontal lobe functions can be

tested by using problem solving, verbal

similarities and proverbs

The patient gives the correct answer for

a house on fire and his answers for

similarities are also good. He has

problems with proverb interpretation.

His answers are concrete and consist of

rephrasing the proverb or giving a

simple consequence of the action in the

proverb. Problems with judgement,

abstract reasoning, and executive

function can be seen in patients with

frontal lobe dysfunction.

4. SET GENERATION This is a test of verbal fluency and the

ability to generate a set of items which

are frontal lobe functions. Most

individuals can give 10 or more words

in a minute.

Set generation tests word fluency and

frontal lobe function. The patient starts

well but abruptly stops after only four

words. Most individuals can give more

then 10 words in one minute.

5. RECEPTIVE LANGUAGE Asking the patient to follow commands

demonstrates that they understand the

meaning of what they have heard or

read. It is important to test reception of

both spoken and written language.

Patients with a receptive aphasia

(Wernicke’s) cannot comprehend

language. Their speech output is fluent

but is devoid of meaning and contains

nonsense syllables or words

(neologisms). Their sentences are

usually lacking nouns and there are

paraphasias (one word substituted for

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another). The patient is usually unaware

of their language deficit and prognosis

for recovery is poor.

This patient’s speech is fluent and

some of her sentences even make

sense but she also has nonsense

sentences, made up of words and parts

of words. She can’t name objects

(anomia). She doesn’t have a pure or

complete receptive aphasia but pure

receptive aphasias are rare.

6. EXPRESSIVE LANGUAGE In assessing expressive language it is

important to note fluency and

correctness of content and grammar.

This can be accomplished by tasks that

require spontaneous speech and

writing, naming objects, repetition of

sentences, and reading

comprehension.

This patient with expressive aphasia

has normal comprehension but her

expression of language is impaired. Her

speech output is nonfluent and often

limited to just a few words or phases.

Grammatical words such as

prepositions are left out and her speech

is telegraphic. She has trouble saying

“no ifs , ands or buts”. Her ability to

write is also affected.

Patients with expressive aphasia are

aware of their language deficit and are

often frustrated by it. Recovery can

occur but is often incomplete with their

speech consisting of short phrases or

sentences containing mainly nouns and

verbs.

7. PRAXIS The patient is asked to perform skilled

motor tasks without any nonverbal

prompting. Skills tested for should

involve the face then the limbs. In order

to test for praxis the patient must have

normal comprehension and intact

voluntary movement. Apraxia is typically

seen in lesions of the dominant inferior

parietal lobe.

The patient does well on most of the

tests of praxis. At the very end when he

is asked to show how to cut with

scissors he uses his fingers as the

blades of the scissors instead of acting

like he is holding onto the handles of

the scissors and cutting. This can be an

early finding of inferior parietal lobe

dysfunction.

8. GNOSIS Gnosis is the ability to recognize objects

perceived by the senses especially

somatosensory sensation. Having the

patient (with their eyes closed) identify

objects placed in their hand

(stereognosis) and numbers written on

their hand (graphesthesia) tests

parietal lobe sensory perception.

With his right hand the patient has

more difficulty identifying objects then

with his left hand. One must be careful

in interpreting the results of this test

because of the patient’s motor deficits

but there does seem to be

astereognosis on the right, which would

indicate left parietal lobe dysfunction.

This is confirmed with graphesthesia

where he definitely has more problems

identifying numbers written on the right

hand then the left (agraphesthesia of

the right hand).

9. DOMINANT PARIETAL LOBE

FUNCTION

Tests for dominant inferior parietal lobe

function includes right-left orientation,

naming fingers, and calculations.

This patient has right-left confusion and

difficulty with simple arithmetic. These

are elements of the Gertsmann

syndrome, which is seen in lesions of

the dominant parietal lobe. The full

syndrome consists of right-left

confusion, finger agnosia, agraphia and

acalculia.

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10. NON-DOMINANT PARIETAL

LOBE FUNCTION

The non-dominant parietal lobe is

important for visual spatial sensory

tasks such as attending to the

contralateral side of the body and

space as well as constructional tasks

such as drawing a face, clock or

geometric figures.

The patient’s drawing of a clock

demonstrates a problem with

visuospatial construction tasks, which

reflects parietal lobe dysfunction. He

doesn’t neglect the left side of space

but he lists the numbers of the clock in

two columns and then draws a line

between the 8 and the 3 for 8:15.

11. VISUAL RECOGNITION Recognition of colors and faces tests

visual association cortex (inferior

occiptotemporal area). Achromatopsia

(inability to distinguish colors), visual

agnosia (inability to name or point to a

color) and prosopagnosia (inability to

identify a familiar faces) result from

lesions in this area.

Colors are correctly identified but the

patient has difficulty correctly

identifying the face of a president that

he is familiar with. Further testing would

be necessary to make sure this is

prosopagnosia rather then a problem

with attention or long term memory.

B. CRANIAL NERVES

Examination of the cranial nerves allows one to "view" the

brainstem all the way from its rostral to caudal extent. The

brainstem can be divided into three levels, the midbrain, the

pons and the medulla. The cranial nerves for each of these

are: 2 for the midbrain (CN 3 & 4), 4 for the pons (CN 5-8),

and 4 for the medulla (CN 9-12). It is important to remember

that cranial nerves never cross (except for one exception, the

4th CN) and clinical findings are always on the same side as

the cranial nerve involved. Cranial nerve findings when

combined with long tract findings (corticospinal and

somatosensory) are powerful for localizing lesions in the

brainstem.

Cranial Nerve 1

Olfaction is the only sensory modality with direct access to

cerebral cortex without going through the thalamus. The

olfactory tracts project mainly to the uncus of the temporal

lobes.

Cranial Nerve 2

This cranial nerve has important localizing value because of

its "x" axis course from the eye to the occipital cortex. The

pattern of a visual field deficit indicates whether an

anatomical lesion is pre- or postchiasmal, optic tract, optic

radiation or calcarine cortex.

Cranial Nerve 3 and 4

These cranial nerves give us a view of the midbrain. The 3rd

nerve in particular can give important anatomical localization

because it exits the midbrain just medial to the cerebral

peduncle. The 3rd nerve controls eye adduction (medial

rectus), elevation (superior rectus), depression (inferior

rectus), elevation of the eyelid (levator palpebrae superioris),

and parasympathetics for the pupil.

The 4th CN supplies the superior oblique muscle, which is

important to looking down and in (towards the midline).

Pontine Level

Cranial nerves 5, 6, 7, and 8 are located in the pons and give

us a view of this level of the brainstem.

Cranial Nerve 6

This cranial nerve innervates the lateral rectus for eye

abduction. Remember that cranial nerves 3, 4 and 6 must

work in concert for conjugate eye movements; if they don't

then diplopia (double vision) results. The medial longitudinal

fasciculus (MLF) connects the 6th nerve nucleus to the 3rd

nerve nucleus for conjugate movement.

Major Oculomotor Gaze Systems

Eye movements are controlled by 4 major oculomotor gaze

systems, which are tested for on the neurological exam.

They are briefly outlined here:

1. Saccadic (frontal gaze center to PPRF (paramedian

pontine reticular formation) for rapid eye movements

to bring new objects being viewed on to the fovea.

2. Smooth Pursuit (parietal-occipital gaze center via

cerebellar and vestibular pathways) for eye

movements to keep a moving image centered on the

fovea.

3. Vestibulo-ocular (vestibular input) keeps image

steady on fovea during head movements.

4. Vergence (optic pathways to oculomotor nuclei) to

keep image on fovea predominantly when the viewed

object is moved near (near triad- convergence,

accommodation and pupillary constriction).

Cranial Nerve 5

The entry zone for this cranial nerve is at the mid pons with

the motor and main sensory (discriminatory touch) nucleus

located at the same level. The axons for the descending tract

of the 5th nerve (pain and temperature) descend to the level

of the upper cervical spinal cord before they synapse with

neurons of the nucleus of the descending tract of the 5th

nerve. Second order neurons then cross over and ascend to

the VPM of the thalamus.

Cranial Nerve 7

This cranial nerve has a motor component for muscles of

facial expression (and, don't forget, the strapedius muscle

which is important for the acoustic reflex), parasympathetics

for tear and salivary glands, and sensory for taste (anterior

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two-thirds of the tongue). Central (upper motor neuron-UMN)

versus Peripheral (lower motor neuron-LMN) 7th nerve

weakness- with a peripheral 7th nerve lesion all of the

muscles ipsilateral to the affected nerve will be weak whereas

with a "central 7th ", only the muscles of the lower half of the

face contralateral to the lesion will be weak because the

portion of the 7th nerve nucleus that supplies the upper face

receives bilateral corticobulbar (UMN) input.

Cranial Nerve 8

This nerve is a sensory nerve with two divisions- acoustic and

vestibular. The acoustic division is tested by checking auditory

acuity and with the Rinne and Weber tests. The vestibular

division of this nerve is important for balance. Clinically it be

tested with the oculocephalic reflex (Doll's eye maneuver) and

oculovestibular reflex (ice water calorics).

Medullary Level

Cranial nerves 9, 10, 11, and 12 are located in the medulla

and have localizing value for lesions in this most caudal part

of the brainstem.

Cranial Nerves 9 and 10

These two nerves are clinically lumped together. Motor wise,

they innervate pharyngeal and laryngeal muscles. Their

sensory component is sensation for the pharynx and taste for

the posterior one-third of the tongue.

Cranial Nerve 11

This nerve is a motor nerve for the sternocleidomastoid and

trapezius muscles. The UMN control for the

sternocleidomastoid (SCM) is an exception to the rule of the

ipsilateral cerebral hemisphere controls the movement of the

contralateral side of the body. Because of the crossing then

recrossing of the corticobulbar tracts at the high cervical level,

the ipsilateral cerebral hemisphere controls the ipsilateral

SCM muscle. This makes sense as far as coordinating head

movement with body movement if you think about it

(remember that the SCM turns the head to the opposite side).

So if I want to work with the left side of my body I would want

to turn my head to the left so the right SCM would be

activated.

Cranial Nerve 12

The last of the cranial nerves, CN 12 supplies motor

innervation for the tongue.

1. CRANIAL NERVE 1- OLFACTION This CN is tested one nostril at a time

by using a nonirritating smell such as

tobacco, orange, vanilla, coffee, etc.

Detection of the smell is more

important than the actual identification.

This patient has difficulty identifying the

smells presented. Loss of smell is

anosmia. The most common cause is a

cold (as in this patient) or nasal

allergies. Other causes include trauma

or a meningioma affecting the olfactory

tracts. Anosmia is also seen in Kallman

syndrome because of agenesis of the

olfactory bulbs.

2. CRANIAL NERVE 2- VISUAL

ACUITY

The first step in assessing the optic

nerve is testing visual acuity. This can

be done with a standard Snellen chart

or with a pocket chart (Rosenbaum).

Have the patient use their glasses if

needed to obtain best-corrected vision.

Have the patient hold the pocket chart

at the focal length that is best for them

which is usually 14 inches. Have them

recite the line with the smallest letters

that they can read and record the

acuity.

This patientâs visual acuity is being

tested with a Rosenbaum chart. First

the left eye is tested, then the right eye.

He is tested with his glasses on so this

represents corrected visual acuity. He

has 20/70 vision in the left eye and

20/40 in the right. His decreased visual

acuity is from optic nerve damage.

3. CRANIAL NERVE 2- VISUAL

FIELDS

There are several different screening

tests that can be used to assess visual

fields at the bedside. First hold up both

hands superiorly and inferiorly and ask

the patient if they can see both hands

and do they look symmetric. Then test

each eye individually using your fingers

in the four quadrants of the visual field

and ask the patient to count fingers

held up or point to the hand when a

finger wiggles using yourself as a

control. A second screening test is to

use a grid card. Have the patient focus

on the dot in the center of the grid then

The patient's visual fields are being

tested with gross confrontation. A right

sided visual field deficit for both eyes is

shown. This is a right hemianopia from

a lesion behind the optic chiasm

involving the left optic tract, radiation or

striate cortex.

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ask if any part of the grid is missing or

looks different. A third method is to use

a cotton tip applicator. Testing one eye

at a time ask the patient to say "now" as

soon as they see the applicator come

into their side vision as they focus on

the examiner's nose. All of these tests

are screening tests. Formal perimetry is

the most accurate way of assessing

visual fields

4. CRANIAL NERVE 2-

FUNDOSCOPY

Direct visualization of the optic nerve

head is an important and valuable part

of assessing CN 2. Systematically look

at the optic disc, vessels, retinal

background and fovea.

The first photograph is of a fundus

showing papilledema. The findings of

papilledema include:

1. Loss of venous pulsations

2. Swelling of the optic nerve head so

there is loss of the disc margin

3. Venous engorgement

4. Disc hyperemia

5. Loss of the physiologic cup and

6. Flame shaped hemorrhages.

This photograph shows all the signs

except the hemorrhages and loss of

venous pulsations.

The second photograph shows optic

atrophy, which is pallor of the optic disc

resulting form damage to the optic

nerve from pressure, ischemia, or

demyelination.

5. CRANIAL NERVES 2 & 3-

PUPILLARY LIGHT REFLEX

The afferent or sensory limb of

the pupillary light reflex is CN2 while the

efferent or motor limb is the

parasympathetics of CN3. Shine a

flashlight into each eye noting the direct

as well as the consensual constriction

of the pupils.

The swinging flashlight test is used to

test for arelative afferent pupillary

defect or a Marcus Gunn pupil.

Swinging the flashlight back and forth

between the two eyes identifies if one

pupil has less light perception than the

other. Shine the flashlight at one eye

noting the size of both pupils. Then

swing the flashlight to the other eye. If

both pupils now dilate then that eye has

perceived less light stimulus (a defect

in the sensory or afferent pathway) than

the opposite eye.

The swinging flashlight test is used to

show a relative afferent pupillary defect

or a Marcus Gunn pupil of the left eye.

The left eye has perceived less light

stimulus (a defect in the sensory or

afferent pathway) then the opposite eye

so the pupil dilates with the same light

stimulus that caused constriction when

the normal eye was stimulated.

6. CRANIAL NERVES 3, 4 & 6-

INSPECTION AND OCULAR

ALIGNMENT

Before checking ocular movements it is

important to inspect the eyes. Look for

ptosis. Note the appearance of the eyes

and check for ocular alignment (the

reflection of your light source should fall

on the same location of each eyeball).

This patient with ocular myasthenia

gravis has bilateral ptosis, left greater

than right. There is also ocular

misalignment because of weakness of

the eye muscles especially of the left

eye. Note the reflection of the light

source doesn't fall on the same location

of each eyeball.

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VERSIONS

Testing extraocular range of motion

with both eyes open and following the

target (conjugate gaze) is

called versions. The patient is asked to

follow a target through the six principle

positions of gaze. Note any

misalignment of the eyes or complaint

of diplopia (double vision).

The first patient shown has incomplete

abduction of her left eye from a 6th

nerve palsy.

The second patient has a left 3rd nerve

palsy resulting in ptosis, dilated pupil,

limited adduction, elevation, and

depression of the left eye.


DUCTIONS

If there is any misalignment of the eyes

or diplopia on versions it is important to

then examine each eye with the other

covered (this is called ductions). The

patient should follow an object through

the six principle positions of gaze so

each extraocular muscle's function is

tested.

Each eye is examined with the other

covered (this is called ductions). The

patient is unable to adduct either the

left or the right eye. If you watch closely

you can see nystagmus upon abduction

of each eye. When both eyes are tested

together (testing versions) you can see

the bilateral adduction defect with

nystagmus of the abducting eye. This

isbilateral internuclear

ophthalmoplegia often caused by a

demyelinating lesion effecting the MLF

bilaterally. The adduction defect occurs

because there is disruption of the MLF

(internuclear) connections between the

abducens nucleus and the lower motor

neurons in the oculomotor nucleus that

innervate the medial rectus muscle.

9. SUPRANUCLEAR GAZE

SYSTEMS

The purpose of supranuclear control of

gaze is to insure that the image that is

being looked at is centered or

maintained on the fovea of the retina.

The following maneuvers test the major

systems that control eye movements.

10. SACCADES Saccades are tested by holding up your

two hands about three feet apart and

instructing the patient to look at the

finger that is wiggling without moving

their head. The patient's eyes should be

able to quickly, smoothly and accurately

jump from target to target.

11. SMOOTH PURSUIT To test Smooth Pursuit ask the patient

to keep watching the target without

moving their head. Then move the

target slowly from side to side and up

and down. The eyes should be able to

follow the target smoothly without

lagging behind or jerking to catch up

with the target.

The patient shown has progressive

supranuclear palsy. As part of this

disease there is disruption of fixation by

square wave jerks and impairment of

smooth pursuit movements. Saccadic

eye movements are also impaired.

Although not shown in this video,

vertical saccadic eye movements are

usually the initial deficit in this disorder.

12. OPTOKINETIC NYSTAGMUS Optokinetic Nystagmus is a test of

smooth pursuit with quick resetting

saccades. Use a tape with repeating

shapes on it and ask the patient to look

at each new object as it appears as you

run the tape between your fingers to

the right, left, up, and down. The patient

will have brief pursuit eye movements

in the direction of the tape movement

with quick saccades or jerks in the

This patient has poor optokinetic

nystagmus when the tape is moved to

the right or left. The patient lacks the

input from the parietal-occipital gaze

centers to initiate smooth pursuit

movements therefore her visual

tracking of the objects on the

tape is inconsistent and erratic.

Patients who have a lesion of the

parietal-occipital gaze center will have

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opposite direction. The resetting

saccades are easier to observe than the

brief pursuit movement.

absent optokinetic nystagmus when the

tape is moved toward the side of the

lesion.

13. VESTIBULO-OCULAR REFLEX The vestibulo-ocular reflex is obtained

by having the patient visually fixate on

an object straight ahead, then rapidly

turning the patient's head form side to

side and up and down. The eyes should

stay fixed on the object and turn in the

opposite direction of the head

movement.

The vestibulo-ocular reflex should be

present in a comatose patient with

intact brainstem function. This is called

intact "Doll’s eyes" because in the old

fashion dolls the eyes were weighted

with lead so when the head was turned

one way the eyes turned in the opposite

direction. Absent "Doll’s eyes" or

vestibulo-ocular reflex indicates

brainstem dysfunction at the midbrain-

pontine level.

14. VERGENCE Vergence eye movements occur when

the eyes move simultaneously inward

(convergence) or outward (divergence)

in order to maintain the image on the

fovea that is close up or far away. Most

often convergence is tested as part of

the near triad. When a patient is asked

to follow an object that is brought from

a distance to the tip of their nose the

eyes should converge, the pupil will

constrict and the lens will round up

(accommodation).

Light-near dissociation occurs when the

pupils don't react to light but constrict

with convergence as part of the near

reflex. This is what happens in the

Argyll-Robertson pupil (usually seen

with neurosyphilis) where there is a

pretectal lesion affecting the

retinomesencephalic afferents

controlling the light reflex but sparing

the occipitomesencephalic pathways for

the near reflex.

15. CRANIAL NERVE 5- SENSORY Test for both light touch (cotton tip

applicator) and pain (sharp object) in

the 3 sensory divisions (forehead,

cheek, and jaw) of CN 5.

There is a sensory deficit for both light

touch and pain on the left side of the

face for all divisions of the 5th nerve.

Note that the deficit is first recognized

just to the left of the midline and not

exactly at the midline. Patients with

psychogenic sensory loss often identify

the sensory change as beginning right

at the midline.

16. CRANIAL NERVES 5 & 7 -

CORNEAL REFLEX

The ophthalmic division (V1) of the 5th

nerve is the sensory or afferent limb

and a branch of the 7th nerve to the

orbicularis oculi muscle is the motor or

efferent limb of the corneal reflex. The

limbal junction of the cornea is lightly

touched with a strand of cotton. The

patient is asked if they feel the touch as

well as the examiner observing the

reflex blink.

A patient with an absent corneal reflex

either has a CN 5 sensory deficit or a

CN 7 motor deficit. The corneal reflex is

particularly helpful in assessing

brainstem function in the unconscious

patient. An absent corneal reflex in this

setting would indicate brainstem

dysfunction.

17. CRANIAL NERVE 5- MOTOR The motor division of CN 5 supplies the

muscles of mastication (temporalis,

masseters, and pterygoids). Palpate the

temporalis and masseter muscles as

the patient bites down hard. Then have

the patient open their mouth and resist

the examiner's attempt to close the

mouth. If there is weakness of the

pterygoids the jaw will deviate towards

the side of the weakness. The last test

for this nerve is testing for a jaw jerk,

which is a stretch reflex. Have the

patient slightly open their mouth then

place your finger on their chin and

strike your finger with a reflex hammer.

The first patient shown has weakness

of the pterygoids and the jaw deviates

towards the side of the weakness

(without sound).

The second patient shown has a

positive jaw jerk which indicates an

upper motor lesion affecting the 5th

cranial nerve (with sound).

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Normally there is no movement. If there

is a jaw jerk it is said to be positive and

this indicates an upper motor neuron

lesion.

18. CRANIAL NERVE 7- MOTOR The motor division of CN 7 supplies the

muscles of facial expression. Start from

the top and work down. Have the

patient wrinkle forehead (frontalis

muscle), close eyes tight (orbicularis

oculi) show their teeth (buccinator), and

purse lips or blow a kiss (orbicularis

oris). If there is weakness especially in

a bilateral upper motor neuron

distribution, get the patient to smile by

telling a joke or funny story. With a

pseudobulbar palsy automatic or

emotional facial expression will be more

complete than movements to

command.

The first patient has weakness of all the

muscles of facial expression on the

right side of the face indicating a lesion

of the facial nucleus or the peripheral

7th nerve.

The second patient has weakness of

the lower half of his left face including

the orbicularis oculi muscle but sparing

the forehead. This is consistent with a

central 7th or upper motor neuron

lesion.

19. CRANIAL NERVE 7- SENSORY,

TASTE

Taste is the sensory modality tested for

the sensory division of CN 7. The

examiner can use a cotton tip

applicator dipped in a solution that is

sweet, salty, sour, or bitter. Apply to one

side then the other side of the extended

tongue and have the patient decide on

the taste before they pull their tongue

back in to tell you their answer.

The patient has difficulty correctly

identifying taste on the right side of the

tongue indicating a lesion of the

sensory limb of the 7th nerve.

20. CRANIAL NERVE 8- AUDITORY

ACUITY, WEBER & RINNE TESTS

The cochlear division of CN 8 is tested

by screening for auditory acuity. This

can be done by the examiner lightly

rubbing their fingers by each ear or by

using a ticking watch. Compare right

versus left. Further screening for

conduction versus neurosensory

hearing loss can be accomplished by

using theWeber and Rinne tests. The

Weber test consists of placing a

vibrating tuning fork on the middle of

the head and asking if the patient feels

or hears it best on one side or the

other. The normal patient will say it is

the same in both ears. The patient with

unilateral neurosensory hearing loss

will hear it best in the normal ear while

the patient with a unilateral conductive

hearing loss will hear it best in the

abnormal ear. The Rinne test consists

of comparing bone conduction (placing

the tuning fork on the mastoid process)

versus air conduction (placing the

tuning fork in front of the pinna).

Normally, air conduction is greater than

bone conduction. For neurosensory

hearing loss air conduction is still

greater than bone conduction but for

conduction hearing loss bone

conduction will be greater than air

conduction.

This patient has decreased hearing

acuity of the right ear. The Weber test

lateralizes to the right ear and bone

conduction is greater than air

conduction on the right. He has a

conductive hearing loss.

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21. CRANIAL NERVE 8- VESTIBULAR The vestibular division of CN 8 can be

tested for by using the vestibulo-ocular

reflex as already demonstrated or by

using ice water calorics to test

vestibular function. The later test is

usually reserved for patients who have

vertigo or balance problems or in the

comatose patient when one is testing

brainstem function.

Patients with vestibular disease

typically complain of vertigo – the

illusion of a spinning movement.

Nystagmus is the principle finding in

vestibular disease. It is horizontal and

torsional with the slow phase of the

nystagmus toward the abnormal side in

peripheral vestibular nerve disease.

Visual fixation can suppress the

nystagmus. In central causes of vertigo

(located in the brainstem) the

nystagmus can be horizontal, upbeat,

downbeat, or torsional and is not

suppressed by visual fixation.


MOTOR

The motor division of CN 9 & 10 is

tested by having the patient say "ah" or

"kah". The palate should rise

symmetrically and there should be little

nasal air escape. With unilateral

weakness the uvula will deviate toward

the normal side because that side of

the palate is pulled up higher. With

bilateral weakness neither side of the

palate will elevate and there will be

marked nasal air escape.

When the patient says "ah" there is

excessive nasal air escape. The palate

elevates more on the left side and the

uvula deviates toward the left side

because the right side is weak. This

patient has a deficit of the right 9th &

10th cranial nerves.


SENSORY AND MOTOR: GAG

REFLEX

The gag reflex tests both the sensory

and motor components of CN 9 & 10.

This involuntary reflex is obtained by

touching the back of the pharynx with

the tongue depressor and watching the

elevation of the palate.

Using a tongue blade, the left side of

the patient's palate is touched which

results in a gag reflex with the left side

of the palate elevating more then the

right and the uvula deviating to the left

consistent with a right CN 9 & 10

deficit.

24. CRANIAL NERVE 11- MOTOR CN 11 is tested by asking the patient to

shrug their shoulders (trapezius

muscles) and turn their head

(sternocleidomastoid muscles) against

resistance.

When the patient contracts the muscles

of the neck the left sternocleidomastoid

muscle is easily seen but the right is

absent. Looking at the back of the

patient, the left trapezius muscle is

outlined and present but the right is

atrophic and hard to identify. These

findings indicate a lesion of the right

11th cranial nerve.

25. CRANIAL NERVE 12- MOTOR The 12th CN is tested by having the

patient stick out their tongue and move

it side to side. Further strength testing

can be done by having the patient push

the tongue against a tongue blade.

Inspect the tongue for atrophy and

fasciculations. If there is unilateral

weakness, the protruded tongue will

deviate towards the weak side.

By having the patient say lah-pah-kah,

the examiner is testing the motor

components of CN 12, 7, and 9 & 10.

Notice the atrophy and fasciculation of

the right side of this patient's tongue.

The tongue deviates to the right as well

because of weakness of the right

intrinsic tongue muscles. These findings

are present because of a lesion of the

right 12th cranial nerve.

C. COORDINATION

The principle area of the brain that is examined by the

coordination exam is the cerebellum. The cerebellum is

important for motor learning and timing of motor activity. It

fine-tunes the force of agonist and antagonist muscle activity

simultaneously and sequentially across multiple joints to

produce smooth flowing, goal directed movements.

Cerebellar dysfunction results in decomposition of

movements and under and over shooting of goal directed

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movements (dysmetria). Decomposition of movement and

dysmetria are the main elements of ataxia.

Subdivisions

The cerebellum has 3 functional subdivisions, which function

as feedback and feed forward systems.

Vestibulocerebellum

The first is the vestibulocerebellum. This consists of the

connections between the vestibular system and the

flocculonodular lobe. Dysfunction of this system results in

nystagmus, truncal instability (titubation), and truncal ataxia.

Spinocerebellum

The 2nd subdivision is the spinocerebellum. This system

consists of the connections between the cutaneous and

proprioceptive information coming from the spinal cord to the

vermis and paravermis regions with corrective feedback

predominantly to the muscles of truncal stability and gait.

Dysfunction of this system results in gait and truncal ataxia.

Midline Ataxia

Clinically, the ataxic syndromes caused by vestibulocerebellar

and spinocerebellar disease are lumped together and are

called midline or equilibratory (gait) ataxias. The hallmarks of

these midline ataxic syndromes are truncal instability

manifested by titubation (tremor of the trunk in an anterior-

posterior plane at 3-4 Hz) and gait ataxia (wide based,

irregular steps with lateral veering).

Cerebrocerebellum

The 3rd subdivision of the cerebellum is the

cerebrocerebellum. This system consists of connections from

the cerebral cortex (predominantly motor) to the cerebellar

hemispheres then back to the cerebral cortex. This system is

important in motor planning. Dysfunction of the cerebellar

hemispheres results in ataxia of speech (scanning dysarthria)

and ataxia of the extremities (appendicular ataxia). It is

important to remember that ataxia caused by disease of the

cerebellar hemispheres will be ipsilateral to the dysfunctional

hemisphere. The findings of appendicular ataxia are

hypotonia, decomposition of movement, dysmetria, and

difficulty with rapid alternating movements

(dysdiadochokinesia).

EXAM TESTS

The following tests of the neuro exam can be divided

according to which system of the cerebellum is being

examined:

Vestibulocerebellum and Spinocerebellum (Midline):

Station

Walking

Tandem Gait

Cerebrocerebellum (Appendicular):

Rapid Alternating Movements

Finger-to-Nose

Toe-to-Finger

Heel-to-Shin

Rebound and Check Reflex

Speech

1. SPEECH RAPID ALTERNATING

MOVEMENTS

Having the patient say lah-pah-kah can

test rapid alternating movements of the

tongue, lips, and palate.

Impaired speech articulation of

cerebellar origin is characterized by

being slow, indistinct, and scanning

(scanning refers to decomposition of

words into monosyllabic parts and loss

of normal phrasing and intonation).

2. TREMOR Patient's arms are held outstretched

and fingers extended. Watch for

postural or essential tremor.

A cerebellar intention tremor (1st scene

in this movie) arises mainly from limb

girdle muscles and is maximal at the

most demanding phase of the active

movement. This must be distinguished

from a postural tremor (fine distal 8-13

Hz)(2nd scene) or resting tremor

(coarse distal 5-6 Hz pill-rolling type of

tremor)(3rd scene).

3. REBOUND Tap outstretched arms. Patient's arms

should recoil to original position.

Increased range of movement with lack

of normal recoil to original position is

seen in cerebellar disease.

4. CHECK REFLEX Examiner pulls on actively flexed arm

then suddenly releases. The patient

should be able to check or stop the

arm's movement when released.

The patient is unable to stop flexion of

the arm on sudden release so the arm

may strike the chest and doesn't recoil

to the initial position. This is most likely

due to failure of timely triceps

contraction.

5. HAND RAPID ALTERNATING

MOVEMENTS

Finger tapping, wrist rotation and front-

to-back hand patting. Watch for the

rapidity and rhythmical performance of

Movements are slow and irregular with

imprecise timing. Inability to perform

repetitive movements in a rapid

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the movements noting any right-left

disparity.

rhythmic fashion is

called dysdiadochokinesia.

6. FINGER-TO-NOSE The patient moves her pointer finger

from her nose to the examiner's finger

as the examiner moves his finger to

new positions and tests accuracy at the

furtherest outreach of the arm.

Under (hypometria) and over

(hypermetria) shooting of a target

(dysmetria) and the decomposition of

movement (the breakdown of the

movement into its parts with impaired

timing and integration of muscle

activity) are seen with appendicular

ataxia.

7. FOOT RAPID ALTERNATING

MOVEMENTS

Patient taps her foot on the examiner's

hand or on the floor.

Movements are slow and irregular with

imprecise timing of agonist and

antagonist muscle action.

8. TOE-TO-FINGER The patient touches her toe to the

examiner's finger repetitively as the

examiner moves his finger to new

positions.

Same as finger-to-nose except for the

lower extremities. For both the upper

and lower extremities, it is important to

always compare right versus left.

9. HEEL-TO-SHIN The patient places her heel on the

opposite knee then runs the heel down

the shin to the ankle and back to the

knee in a smooth coordinated fashion.

The patient with ataxia of the lower

extremity will have difficulty placing the

heel on the knee with a side-to-side

irregular over- and undershooting as

the heel is advanced down the shin.

Dysmetria on heel-to-shin can be seen

in midline ataxia syndromes as well as

cerebellar hemisphere disease so there

is overlap between the two types of

ataxias for this finding.

10. STATION Have the patient stand still. Note the

position of the feet and how steady the

patient is with eyes open. In the

demonstrated exam, the patient is

asked to hop and pat at the same time.

This is a good way to test upper and

lower extremity coordination and

balance simultaneously.

Patient's feet will be placed wider apart

then usual in order to maintain balance

(broad or wide-based station). Midline

ataxias cause instability of station with

eyes opened or closed.

11. NATURAL GAIT The patient should be observed walking

as she normally would.

Wide-based, unsteady, irregular steps

with lateral veering; ataxia is most

prominent when sudden changes are

needed such as turning, standing up or

stopping.

12. TANDEM GAIT The patient is asked to walk heel-to-toe.

Note steadiness. Tandem gait requires

the patient to narrow the station and

maintain balance over a 4-5 inch width.

Patients with midline ataxias have

difficulty with tandem gait.

Patients with ataxia have difficulty

narrowing the station in order to walk

heel to toe. Tandem gait is helpful in

identifying subtle or mild gait ataxia.

D. MOTOR FUNCTION

When one thinks of the motor system it is usually reduced to

the direct corticospinal tract and the lower motor neuron

(LMN). Although these 2 components are main stage players,

it is important to add a few more components to our

oversimplified scheme of the motor system.

Control Circuits

First, we need to add two "control circuits" that influence the

corticospinal tract- the basal ganglia and the cerebellum.

Brainstem Motor Control Centers

There are also the indirect brainstem motor control centers

and their pathways (rubrospinal, vestibulospinal, and

reticulospinal) that tonically activate lower motor neurons,

especially those that innervate axial and antigravity muscles

(those motor neurons that are in the medial part of the ventral

horn).

Upper Motor Neuron Lesion

The corticospinal tract has its main influence on the motor

neurons that innervate the muscles of the distal extremities-

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the hand and the foot (motor neurons in the lateral part of the

ventral horn). The corticospinal tract also (and this a key

point) has collaterals that modulate and control the indirect

brainstem motor centers so that we are not a stiff statue

opposing gravity but rather we can move at will and have just

the right amount of supporting tone. So when there is a lesion

of the upper motor neuron (the UMN is the corticospinal tract

and it's collaterals to the brainstem motor nuclei) the clinical

findings are a combination of the loss of direct effect of the

corticospinal tract on the LMN plus the loss of control and

modulation of the indirect brainstem motor control centers.

UMN Lesion Clinical Findings

The clinical findings from a UMN lesion will include loss of

distal extremity strength, dexterity and a Babinski sign (loss

of direct corticospinal effect) plus increased tone,

hyperreflexia, and the clasp-knife phenomenon (from loss of

control of the indirect brainstem centers).

LMN Lesion Clinical Findings

Lesions of the LMN, "the final common pathway", result in loss

of strength, tone and reflexes with the denervated muscle

showing wasting and denervation hypersensitivity-

fasciculations.

UMN Syndrome

The UMN syndrome is a combination of loss of the direct

corticospinal tract effect on the LMN and the loss of

regulation of the indirect brainstem motor control centers.

Decorticate vs. Decerebrate

A UMN lesion above the level of the red nucleus will result in

decorticate posture (thumb tucked under flexed fingers in

fisted position, pronation of forearm, flexion at elbow with the

lower extremity in extension with foot inversion) while a lesion

below the level of the red nucleus but above the level of the

vestibulospinal and reticulospinal nuclei will result in

decerebrate posture (upper extremity in pronation and

extension and the lower extremity in extension). The reason

for this is that the red nucleus output reinforces antigravity

flexion of the upper extremity. When its output is eliminated

then the unregulated reticulospinal and vestibulospinal tracts

reinforce extension tone of both upper and lower extremities.

If there is a lesion in the medulla then all the brainstem motor

nuclei as well as the direct corticospinal tract would be out

and the patient would be flaccid acutely. If the patient were to

survive, tone would return because of interneuronal activity at

the spinal cord level.

Localizing a UMN Lesion

An UMN lesion is on the opposite side of the clinical findings

for a lesion above the decussation of the pyramids (where the

corticospinal tracts cross) whereas it is on the same side as

clinical findings if the lesion is in the spinal cord.

Spinal Cord Lesions

Spinal cord lesions often give UMN signs below the level of

the lesion (from effect on the corticospinal tract) and LMN

signs at the level of the lesion (from effect on the ventral horn

or ventral nerve root). LMN signs are good for locating the

level of a spinal cord lesion.

EXAM TESTS

Clinical testing of the motor system:

Muscle Strength

Tone

Reflexes

Pathological Reflexes

1. UPPER EXTREMITIES –

INSPECTION AND PALPATION

The muscles are inspected for bulk and

fasciculations and, when indicated,

palpated for tenderness, consistency

and contractures.

In this patient there are fasciculations

(spontaneous contraction of a motor

unit) noted in the deltoid muscle as well

as atrophy. There is also atrophy of the

interosseous muscles of the hands.

These findings can be seen in motor

neuron disease such as amyotrophic

lateral sclerosis.

2. TONE – UPPER EXTREMITY Muscle tone is assessed by putting

selected muscle groups through

passive range of motion. The most

commonly used maneuvers for the

upper extremities are flexion and

extension at the elbow and wrist.

There is increased tone in the right

upper extremity that is rate dependent

with the clasp-knife phenomena noted

when the arm is flexed. This is spasticity

from an upper motor neuron lesion.

3. STRENGTH TESTING Muscle strength is tested from the

proximal to the distal part of the

extremity so that all segmental levels

for the extremity are tested (for the

upper extremity that is C5 to T1 – see

table). Muscle power is graded on a

scale of 0-5 (see table).

With an UMN lesion the fine,

fractionated movements of the fingers

and hand are lost. Distal extremity

weakness is greater than proximal

weakness. With greater effort to move

the paretic hand, there is overflow

activation of proximal muscles and

even of the contralateral hand, which

produces mirror or synkinetic

movements.

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Strength Testing

C5 – Shoulder extension

C6 – Arm flexion

C7 – Arm extension

C8 – Wrist extensors

T1 – Hand grasp

Muscle Strength Grading

0 – No contraction

1 – Slight contraction, no movement

2 – Full range of motion without gravity

3 – Full range of motion with gravity

4 – Full range of motion , some

resistance

5 – Full range of motion, full resistance

4. STRETCH OR DEEP TENDON

REFLEXES

Levels for DTR's

Biceps – C5-6

Brachioradialis – C5-6

Triceps – C7

Finger Flexors – C8

Grading DTR's

0 – Absent

1 – Decreased but present

2 – Normal

3 – Brisk and excessive

4 – With clonus

It is always important to compare right

vs. left. The first patient shown has

hyperreflexia or 3+ DTR's of the right

biceps, triceps and brachioradialis. The

second patient has hyperreflexia of the

right finger flexors. Hyperreflexia is one

of the signs of a UMN lesion.

5. TESTING FOR PRONATOR

DRIFT

The patient extends their arms in front

of them with the palms up and eyes

closed. The examiner watches for any

pronation and downward drift of either

arm. If there is pronator drift this

indicates corticospinal tract disease.

With an UMN lesion there is pronation

and downward drift of the outstretched

supinated arm. This is because the

pronators overpower the weaker

supinators. Another name for this sign

is a pronator Babinski.

6. LOWER EXTREMITIES –

INSPECTION AND PALPATION

The muscles are inspected for bulk and

fasciculations and, when indicated,

palpated for tenderness, consistency

and contractures.

There is hypertrophy of this patient's

left leg. Closer inspection of that

extremity shows hyperpigmented skin

lesions suggesting segmental

neurofibromatosis. A thorough skin

search can provide important clues to

diagnosis especially in the

neurocutaneous syndromes.

7. TONE - LOWER EXTREMITY Muscle tone is assessed by putting

selected muscle groups through

passive range of motion. The most

commonly used maneuvers for the

lower extremities are flexion and

extension at the knee and ankle.

There is spasticity on passive range of

motion of the patient's right ankle with

decrease range of motion and clonus

which is caused by repetitive

contraction of the stretched

gastrocnemius muscle. Range of

motion at the knee would also

demonstrate spasticity. These findings

are part of the UMN syndrome.

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8. STRENGTH TESTING Muscle strength is tested from the

proximal to the distal part of the

extremity so that all segmental levels

for the extremity are tested (for the

lower extremity that is L2 to S1 – see

table). Muscle power is graded on a

scale of 0-5 (see table).

Strength Testing

L2 – Hip flexion

L3 – Knee extension

L4 – Knee flexion

L5 – Ankle dorsiflexon

S1 – Ankle plantar flexion

Muscle Strength Grading

0 – No contraction

1 – Slight contraction, no movement

2 – Full range of motion without gravity

3 – Full range of motion with gravity

4 – Full range of motion, some

resistance

5 – Full range of motion, full resistance

Testing of the muscle strength in this

patient shows 1/5 weakness of

dorsiflexion, plantar flexion, inversion

and eversion of the right ankle with

normal proximal strength.

9. STRETCH OR DEEP TENDON

REFLEXES

A brisk tap to the muscle tendon using

a reflex hammer produces a stretch to

the muscle that results in a reflex

contraction of the muscle. The muscles

tested, segmental level, and grading of

DTR's is listed below.

Levels for DTR's

Patellar or Knee – L2-4

Ankle – S1-2

Grading DTR's

0 – Absent

1 – Decreased but present

2 – Normal

3 – Brisk and excessive

4 – With clonus

There is hyperreflexia of the right knee

jerk (3+) with a rightsided crossed

adductor response (the crossed

adductor contraction occurred because

of the increased right leg tone which

resulted in reflex contraction of the

adductor magnus with the very slight

stretch of this muscle caused by

tapping the opposite knee). There is

also hyperreflexia with clonus (4+ DTR)

of the right ankle. The second patient

demonstrates a 4+ ankle jerk on the

left with sustained clonus.

Hyperreflexia is one of the signs of the

UMN syndrome.

10. PLANTAR REFLEX The plantar reflex is a superficial reflex

obtained by stroking the skin on the

lateral edge of the sole of the foot,

starting at the heel advancing to the

ball of the foot then continuing medially

to the base of the great toe. The normal

response is flexion of all the toes. The

abnormal response is called a Babinski

signand consists of extension of the

great toe and fanning of the rest of the

toes.

The patient has a Babinski sign on the

right with an up going great toe and

dorsiflexion and fanning of the other

toes. This is an important indication of

UMN disease.

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11. PATHOLOGICAL REFLEXES-

FRONTAL RELEASE SIGNS-

SNOUT, ROOT, PALMOMENTAL

These patterned behavior reflexes

appear when there is damage to the

frontal lobes, which inhibits these

primitive reflexes. In the normal person

these reflexes are absent.

Pressing a tongue blade on the lips

tests for thesnout reflex. The abnormal

response is a pouting of the lips.

The root reflex is tested for by gently

stroking the lateral upper lip. The

abnormal response is movement of the

mouth towards the stimuli.

Stroking the palm of the hand while

watching for contraction of the

ipsilateral mentalis muscle of the lower

lip tests for the palmomental reflex.

These patterned behavior reflexes

appear when there is damage to the

frontal lobes, which normally inhibits

these primitive reflexes.

A snout reflex occurs when a tongue

blade is pressed on the lips and there is

pouting of the lips.

A root reflex occurs when gently

stroking the lateral upper lip causes the

mouth to moves toward the stimuli.

A palmomental reflex occurs when

stroking the palm of the hand causes

the ipsilateral mentalis muscle of the

lower lip to contract.

12. STRENGTH TESTING USING

SQUAT & RISE, HEEL & TOE

The strength of the powerful muscles of

the lower extremities is often best

assessed by using the patient's own

weight. Having the patient squat and

rise tests the pelvic girdle and upper leg

muscles while heel and toe walking

tests the muscles of the foreleg.

This patient has proximal pelvic girdle

weakness which is demonstrated by his

using his hands to climb the wall and

then pushing on his thighs to get his

trunk upright. When a patient uses his

hands to climb up his legs to get to a

standing position is this called a

Gowers' sign.

E. SENSORY FUNCTION

Clinically, there are 2 major somatosensory pathways that are

examined. The first is the spinothalamic (ST) part of the

anterolateral system and the second is the dorsal column-

medial lemniscus (DCML) system. The principle sensory

modalities for the ST system are pain and temperature. The

principle sensory modalities for DCML system are vibratory,

position sense and discriminatory or integrative sensation.

Spinothalamic

The anatomical pathways for the 2 major sensory systems is

as follows:

ST- the axons from the 1st order neuron located in the dorsal

root ganglion enter the dorsal root entry zone and within

several segments synapse with 2nd order neurons in the

dorsal horn. Axons from the 2nd order neuron cross

immediately via the ventral white commissure to the

anterolateral quadrant of the spinal cord then ascend as the

spinothalamic tract to the ventral posterior lateral nucleus

(VPL) of the thalamus. The axons of the 3rd order neurons

project to the postcentral gyrus or somatosensory cortex

(there are also projections to the insular and anterior

cingulate cortex but we are mainly focusing on the primary

somatosensory cortex).

Dorsal Column-Medial Lemniscus

The axons from the 1st order neurons located in the dorsal

root ganglion enter the dorsal root entry zone and then

ascend in the dorsal columns on the same side of the cord

until they reach the 2nd order neurons in the medulla. Axons

from the 2nd order neurons cross at the level of the medulla

and then travel near the midline in the medial lemniscus. By

the time the medial lemniscus reaches the rostral pons it has

moved laterally and at this point it is in close proximity to the

spinothalamic tract as it ascends to the VPL of the thalamus.

The 3rd order neuron projects to the primary somatosensory

cortex in the postcentral gyrus.

Trigeminal System

The trigeminal system is the somatosensory system for the

face, which is clinically tested in the cranial nerve exam. For

the trigeminal system it is important to remember that the

descending tract of the trigeminal nerve, which serves pain

and temperature, descends to the level of the upper cervical

spinal cord and then axons from the 2nd order neurons cross

over to the opposite side and ascend to the ventral posterior

medial (VPM) nucleus of the thalamus.

LEVEL OF CROSSING

The level of crossing of the axons of the 2nd order neurons is

immediate for the ST system and not until the medulla for the

DCML system.

Location of Tracts

The ST tract is lateral in the cord and lower brainstem while

the DCML system is dorsal and medial in the cord and medial

in the lower brainstem. It is not until the rostral pons that the

2 tracts are anatomically close to each other.

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Trigeminal Crossing

The descending trigeminal tract is ipsilateral to its origin and

axons from the 2nd order neurons cross at the lower medulla-

upper cervical spinal cord level.

FINDINGS

Sensory Dissociation

Spinal cord and lower brainstem lesions can result in sensory

dissociation, which means one sensory system is affected

without the other one.

Crossed Findings

Crossed or alternating findings. For example one side of the

face is affected and the opposite side of the body for

brainstem lesions. In the spinal cord, lesions can cause DCML

system findings on one side of the body and ST findings on

the opposite side.

EXAM TESTS

The ST is examined by testing:

Pain

Temperature

The DCML is examined by testing:

Vibratory sensation

Position sense

Discriminative sensation (must have intact DCML

plus intact parietal cortex):

o Tactile direction

o 2-point discrimination

o Graphesthesia

o Stereognosis

o Double simultaneous Stimulation

1. LIGHT TOUCH Light touch (thigmesthesia) is used as a

screening test for touch. Both the

spinothalamic and DCML systems serve

this sensation so it is not specific for

either one. A cotton tip applicator or

fine hair brush is used. Select areas

from different dermatomes and

peripheral nerves and compare right

versus left.

With light touch the patient indicates

that the perception of the stimulus is

different over the left side of the face.

The feeling has an abnormal quality to

it described as different, uncomfortable

or burning. This would be called

paresthesia or dysesthesia. Light touch

causing pain would be allodynia.

2. PAIN – UPPER EXTREMITIES Pain is one of the principle sensory

modalities of the spinothalamic system.

The sharp end of a broken wooden

cotton tip applicator can be used then

discarded. It is important for the patient

to be able to identify the sensation as

sharp and then compare between

dermatomes, distal versus proximal and

right versus left for the upper

extremities.

A sharp wooden stick is used to

delineate the area of decreased sharp

sensation. There is loss over the ulnar

side of the right hand as well as the

ulnar aspect of the forearm but the arm

is normal. This loss is constant with a

C8-T1 dermatome distribution.

3. PAIN – LOWER EXTREMITIES Pain is one of the principle sensory

modalities of the spinothalamic system.

The sharp end of a broken wooden

cotton tip applicator can be used then

discarded. It is important for the patient

to be able to identify the sensation as

sharp and then compare between

dermatomes, distal versus proximal and

right versus left for the lower

extremities.

This patient has a sensory level at T3

with decreased pain sensation below

the level including the leg. The sensory

level is one to two spinal cord segment

levels below the actual anatomical cord

lesion because the spinothalamic axons

ascend several spinal cord levels prior

to crossing. The left sided T3 sensory

level combined with this patient's upper

extremity sensory finding indicates a

lesion of the right side of the spinal

cord at the C8-T1 level.

4. TEMPERATURE Temperature is the other sensory

modality that is used to test the

spinothalamic system. Tubes or vials of

hot and cold water can be used but this

is usually impractical. Using a tuning

fork, which is normally perceived as

cool or cold to the touch, compare

between dermatomes and right versus

left.

The patient is unable to distinguish the

difference between a hot and cold test

tube simultaneously applied to the

ulnar side of the right hand and arm

and the left leg. This deficit is in the

same distribution as the pain deficit

noted when testing sharp sensation.

Pain and temperature sensation are

tests for spinothalamic tract function.

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5. VIBRATORY Vibratory sensation (pallesthesia) is one

of the sensory modalities of the DCML

system. It is tested by using a 128 Hz

tuning fork and placing the vibrating

instrument over a bone or boney

prominence. By varying the force of

vibration and comparing the patient to

yourself you can detect any deficits.

Compare distal versus proximal and

right versus left.

Vibratory sensation is decreased on the

right great toe compared to the left.

This could be due to a peripheral

neuropathy but it also could be

secondary to DCML deficit, which is

actually the case for this patient.

6. POSITION SENSE Position sense (proprioception), another

DCML sensory modality, is tested by

holding the most distal joint of a digit by

its sides and moving it slightly up or

down. First, demonstrate the test with

the patient watching so they

understand what is wanted then

perform the test with their eyes closed.

The patient should be able to detect 1

degree of movement of a finger and 2-3

degrees of movement of a toe. If the

patient can't accurately detect the

distal movement then progressively test

a more proximal joint until they can

identify the movement correctly.

The patient makes more mistakes

identifying the correct direction of toe

movement on the right then left

indicating a proprioceptive loss. For this

patient this is secondary to a lesion

effecting the dorsal column on the right

side of the spinal cord.

7. TACTILE MOVEMENT Tactile movement as well as the

remaining sensory tests are

discriminatory sensory tests that

examine cortical somatosensory

(parietal lobe) function and require an

intact DCML system. Tactile movement

tests the patient's ability to detect the

direction of a 2-3 cm cutaneous

stimulus.

When comparing left vs. right, the

patient has more difficulty on the right

side again indicating dorsal column

dysfunction. If the dorsal column

pathways are intact, then tactile

movement is a sensitive test of parietal

cortical function.

8. TWO-POINT DISCRIMINATION Two-point discrimination is tested by

using calipers or a fashioned paper clip.

The smallest and most dense sensory

units are located in those areas that

have the greatest somatosensory

cortical representation. The patient

should be able to recognize two-point

separation of 2-4 mm on the lips and

finger pads, 8-15 mm on the palms and

3-4 cm on the shins.

Patients with a lesion of the primary

somatosensory cortex will have

difficulty with two-point discrimination

on the opposite side of the body. The

peripheral nerve and DCML pathway

must be intact for this test to be a test

of parietal cortical function.

9. GRAPHESTHESIA Graphesthesia is the ability of the

patient to identify characters that are

written on the skin using a dull pointed

object. The examiner demonstrates the

test by writing single numbers on the

palm of the hand while the patient is

watching. The patient then closes their

eyes and identifies numbers that are

written by the examiner.

This patient has more difficulty

identifying numbers written in the right

hand than in the left hand. This is called

agraphesthesia and is from a lesion of

the somatosensory cortex in the left

parietal lobe.

10. STEREOGNOSIS Stereognosis is the ability to identify

objects that are placed in the hand

when the eyes are closed. The patient is

given common objects and asked to

identify them without looking at them.

The inability to do this

The patient is asked to identify objects

placed in both the right and left hand

with his eyes closed. He knows that

something is in his right hand but he is

unable to identify it while he readily

identifies the same object placed in the

left hand. This is called astereognosis.

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calledastereognosis and indicates

parietal lobe dysfunction.

The patient has a lesion involving the

left parietal lobe.

11. DOUBLE SIMULTANEOUS

STIMULATION

The patient should be able to attend to

and identify a tactile stimulus that is

applied to both sides of the body at the

same time. Double simultaneous

stimulation (DSS) is tested by touching

homologous parts of the body on one

side, the other side or both sides at

once with the patient identifying which

side or if both sides are touched with

their eyes closed. If the patient neglects

one side on DSS

(extinction or simultanagnosia) this

indicates dysfunction of the

contralateral posterior parietal lobe.

When the patient is touched on the

right or left he correctly identifies the

side touched but when both sides are

touched simultaneously he neglects the

stimulus on the right. This is extinction

or simultanagnosia and indicates a

lesion in his left parietal cortex.

12. ROMBERG TEST The Romberg test is a test of

proprioception. This test is performed

by asking the patient to stand, feet

together with eyes open, then with eyes

closed. The patient with significant

proprioceptive loss will be able to stand

still with eyes open because vision will

compensate for the loss of position

sense but will sway or fall with their

eyes closed because they are unable to

keep their balance.

With his eyes open, the patient is able

to hold still but when his eyes are

closed he sways and loses his balance.

He has a significant loss of

proprioception.

F. GAIT EXAM

All levels of the neuroaxis contribute to gait although most gait

abnormalities are motor in nature. In assessing gait it is

important to not only watch the lower extremities but also the

upper extremities for normal associated movements.

Localizing Value

There are 7 basic pathological gaits that should be recognized

by their characteristic pattern. These pathological gaits are:

Hemiplegic

Spastic diplegic

Neuropathic

Myopathic

Parkinsonian

Chorea

Ataxic

These gaits have localizing value because they can indicate

levels (an "y" axis as well as an "x" axis) of neurological

disease or systems abnormalities (such as cerebellar or basal

ganglia).

Normal gait is demonstrated in the normal neuro exam

section of this tutorial.

1. STATION The patient should be able to stand still with her feet less then shoulder width apart.

2. NATURAL GAIT The patient should be able to walk with a smooth, coordinated gait. There should be

normal associated movement of the upper extremities.

3. HEEL AND TOE WALKING A good way to test balance as well as strength of the distal lower extremities is to

have the patient heel and toe walk.

4. TANDEM GAIT Have the patient walk heel-to-toe. The patient should be able to balance without

falling or stepping to the side.

ABNORMAL GAITS

HEMIPLEGIC GAIT The patient has unilateral weakness

and spasticity with the upper extremity

held in flexion and the lower extremity

in extension. The foot is in extension so

the leg is "too long" therefore, the

patient will have to circumduct or swing

the leg around to step forward. This

type of gait is seen with a UMN lesion.

This girl has a right hemiparesis. Note

how she holds her right upper extremity

flexed at the elbow and the hand with

the thumb tucked under the closed

fingers (this is "cortical fisting"). There is

circumduction of the right lower

extremity.

DIPLEGIC GAIT The patient has spasticity in the lower

extremities greater than the upper

This man has an UMN lesion affecting

both lower extremities. He has

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extremities. The hips and knees are

flexed and adducted with the ankles

extended and internally rotated. When

the patient walks both lower extremities

are circumducted and the upper

extremities are held in a mid or low

guard position. This type of gait is

usually seen with bilateral

periventricular lesions. The legs are

more affected than the arms because

the corticospinal tract axons that are

going to the legs are closest to the

ventricles.

spasticity and weakness of the legs and

uses a walker to steady himself. There

is bilateral circumduction of the lower

extremities.

NEUROPATHIC GAIT This type of gait is most often seen in

peripheral nerve disease where the

distal lower extremity is most affected.

Because the foot dorsiflexors are weak,

the patient has a high stepping gait in

an attempt to avoid dragging the toe on

the ground.

This girl has weakness of the distal right

lower extremity so she can't dorsiflex

her foot. In order to walk she has to lift

her right leg higher then the left to clear

the foot and avoid dragging her toes on

the ground.

MYOPATHIC GAIT With muscular diseases, the proximal

pelvic girdle muscles are usually the

most weak. Because of this the patient

will not be able to stabilize the pelvis as

they lift their leg to step forward, so the

pelvis will tilt toward the non-weight

bearing leg which results in a waddle

type of gait.

This young boy has pelvic girdle

weakness, which produces a waddling

type of gait. Note the lumbar

hyperlordosis with the shoulders thrust

backwards and the abdomen being

protuberant. This posture places the

center of gravity behind the hips so the

patient doesn't fall forward because of

weak back and hip extensors.

PARKINSONIAN GAIT This type of gait is seen with rigidity and

hypokinesia from basal ganglia disease.

The patient's posture is stooped

forward. Gait initiation is slow and steps

are small and shuffling; turning is en

bloc like a statue.

This man's gait is bradykinetic and his

steps are smaller then usual. There is

also the pill-rolling tremor in his hands.

He turns en bloc and there is decreased

facial expression.

CHOREIFORM GAIT This is a hyperkinetic gait seen with

certain types of basal ganglia disorders.

There is intrusion of irregular, jerky,

involuntary movements in both the

upper and lower extremities.

Note the involuntary, irregular, jerky

movements of this woman's body and

extremities, especially on the right side.

There are also choreiform movements

of the face. A lot of her movements

have a writhing, snake-like quality to

them, which could be called

choreoathetoisis.

ATAXIC GAIT The patient's gait is wide-based with

truncal instability and irregular lurching

steps which results in lateral veering

and if severe, falling. This type of gait is

seen in midline cerebellar disease. It

can also be seen with severe lose of

proprioception (sensory ataxia).

This woman's gait is wide-based and

unsteady. She has to use a walker or

hold on to someone in order to

maintain her balance (note how hard

she has to work with the hand that

she's holding on with in order to

maintain her balance). Her ataxia is

even more apparent when she tries to

turn.

Reference: University of Utah. (2015). Neurologic Examination


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PEDIATRIC NEUROLOGIC EXAMINATION

DEVELOPMENTAL ANATOMY

Major Events in Brain Development

Brain and spinal cord development begins with formation of

the neural tube closure, which is completed by 28 days of

gestation. Prosencephalization then occurs to form the

cerebral hemispheres and diencephalon. At 2 to 4 months

gestation, there is neuronal proliferation followed by

migration at 3 to 5 months. Formation of the gyri begins with

the major fissures being formed in the 5th month, the

secondary sulci by 7 months, and the tertiary sulci by 9

months gestation. Finally, neuronal organization and

myelination starts in the 3rd trimester and continues on well

after birth. Organization and myelination are the major

processes that account for brain growth and maturation.

Brain Growth

The newborn brain weighs 400 grams. At one year of age the

brain weighs 1,000 grams. By 2 years of age the brain has

reached 80 percent of its adult size. By 18 years of age the

brain has reached its adult weight of 1400 grams.

Neuronal Growth and Organization

By 36 weeks gestation, the process of neuronal proliferation

is nearly complete. Although there is some limited

proliferation of neurons throughout life, their contribution to

brain growth is negligible. Growth of the individual neurons

plus the elaboration and proliferation of dendritic and axonal

processes and connections is responsible for most of the

brain’s growth.

The diameter of a neuroblast is 5 microns while a mature

neuron can measure 50 microns, a 1,000-fold increase in cell

volume. Increase in the size of glial cells also occurs. During

the organization process of brain development there is

increasing dendritic arborization, synaptogenesis, and axonal

connections, which make a significant contribution to brain

growth as well as the maturation and development of brain

function.

Myelination and Development

The next developmental process that greatly contributes to

brain growth and maturation is myelination. Myelination

begins early in the 3rd trimester with the most rapid period of

myelination occurring in the first two years of life. The

myelination process follows a specific time course and

pattern. The acquisition of neurodevelopmental milestones

parallels and reflects this pattern. Myelination occurs early for

motor-sensory roots, special senses and the brainstem; those

structures necessary for reflex behavior and survival.

The corticospinal tract starts to myelinate at 36 weeks

gestation and myelination is completed by the end of the 2nd

year of life. Myelination of the corticospinal tract begins at the

proximal portion of the axon and the shortest axons are the

first to myelinate. The axons for the upper extremities and the

trunk myelinate next. The axons for the lower extremities,

which are the longest axons, are the last to myelinate with the

process being completed by 24 months of age. This

myelination pattern correlates with the progressive head-to-

toe acquisition of developmental milestones.

The motor patterns of the immature brain are predominately

under brainstem control and lack cortical modulation until

there is the necessary maturation of these higher brain center

connections.

Cerebral Hemisphere Myelination

The areas of the cerebral hemispheres that are first to

myelinate are the posterior portion of the frontal lobes, the

parietal lobes and areas of the occipital lobes. The frontal

and temporal lobes then myelinate and by the end of the

second year, myelination of the cerebrum is largely

completed, although there are interconnections of the

association cortex that are still being myelinated into the

2nd and 3rd decades of life.

NEWBORN

Behavior

This 5-day-old infant is in the alert, quiet state. He has spontaneous movements, which have a

smooth flowing quality to them and are not excessive, jerky or asymmetric. He seems to be

attentive to the environment. He makes attempts to organize and comfort himself by sucking on

his fists, which is a favorable behavioral response. When a bright light is directed towards his

eyes he has a definite response, which consists of blinking and avoiding the light. With repeated

stimulus there is habituation, a diminished response to the stimulus. He responds to sound by

quieting and even turning is head and eyes toward the sound. The above observations are the

baby equivalent to the adult mental status exam.

Cranial Nerves

Examination of the baby’s cranial nerve function is often accomplished by observing

spontaneous activity. During crying, facial movement (Cranial Nerve 7) is observed for fullness or

asymmetry. The quality and strength of the cry is a way of looking at Cranial Nerves 9 and 10

function. Sucking and swallowing assesses Cranial Nerves 5, 7, 9, 10, and 12 because all of

these cranial nerves are involved in this complex act. Eye movements (Cranial Nerves 3, 4 and 6)

can be assessed by using the vestibulo-ocular reflex (doll’s eyes maneuver). When the head is

turned, there is conjugate eye movement in the opposite direction. Testing a baby’s behavior

response to light (Cranial Nerve 2) and sound (Cranial Nerve 8) also adds to the cranial nerve

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exam. Pupillary light reflex, corneal reflex, gag reflex and funduscopic exam are done in the same

manner as the adult exam.

Tone - Resting Posture

For a term newborn the resting posture is flexion of the extremities with the extremities closely

adducted to the trunk. After the first few days of life, the extremities are still predominantly in the

flexed position but they are not as tightly adducted as they are in the first 48 hours of life.

Tone - Upper Extremity Tone

Assessing motor function of the upper extremities begins with passive range of motion. This is

done by rotating each extremity at the shoulder, elbow and wrist and feeling the resistance and

the range of movement. Too little or too much resistance reflects hypotonia or hypertonia.

Further testing helps to better define tone and any tone abnormalities.

Tone - Arm Traction

Arm traction is done with the baby in the supine position. The wrist is grasped and the arm is

pulled until the shoulder is slightly off the mat. There should be some flexion maintained at the

elbow. Full extension at the elbow is seen in hypotonia.

Tone - Arm Recoil

Arm recoil tests tone and action of the biceps. The arms are held in flexion against the chest for

a few seconds, then are quickly extended and released. The arms should spring back to the

flexed position. The hyotonic infant will have slow incomplete recoil. Asymmetry to this response

with lack of recoil would be seen with Erb’s or brachial plexus palsy.

Tone - Scarf Sign

The tone of the shoulder girdle is assessed by taking the baby’s hand and pulling the hand to the

opposite shoulder like a scarf. The hand should not go past the shoulder and the elbow should

not cross the midline of the chest.

Tone - Hand Position

A newborn baby’s hand is held in a fisted position with the fingers flexed over the thumb. The

hand should open intermittently and should not always be held in a tight fisted position. Rubbing

the ulnar aspect of the hand or touching the dorsum of the hand will often cause extension of

the fingers. Over the first 1 to 2 months of life, the baby’s hand becomes more open. Persistence

of a fisted hand is a sign of an upper motor neuron lesion in an infant.

Tone - Lower Extremity Tone

Assessing motor function of the lower extremities begins with passive range of motion. This is

done by flexing the hips, then abducting and adducting the hips. Next, flex and extend the hips,

the knees and ankles. Further testing helps to better define the tone and any tone abnormalities.

Tone - Leg Traction

Leg traction is done by holding the leg by the ankle. The leg is pulled upward until the buttock

starts to be lifted off the mat. The knee should maintain a flexed angle. Full extension of the

knee with little resistance to pulling on the leg is a sign of hypotonia.

Tone - Leg Recoil

To test leg recoil, the legs are fully flexed on the abdomen for a few seconds, then the legs are

quickly extended and released. The legs should spring back to the flexed position. Legs that

remain extended could be due to either hypotonia or abnormal extensor tone.

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Tone - Popliteal Angle

The popliteal angle is an assessment of the tone of the hamstring muscles. It is done one leg at

a time. The thigh is flexed on the abdomen with one hand and then the other hand straightens

the leg by pushing on the back of the ankle until there is firm resistance to the movement. The

angle between the thigh and the leg is typically about 90 degrees. Extension of the leg beyond

90 to 120 degrees would be seen in hypotonia.

Tone - Heel to Ear

Holding the baby’s foot in one hand, draw the leg towards the ear to see how much resistance

there is to the maneuver. The foot should go to about the level of the chest or shoulder, but not

all the way to the ear. If the foot can be drawn to the ear then there is hypotonia.

Tone - Neck Tone

The tone of the neck can be assessed by passively rotating the head towards the shoulder. The

chin should be able to rotate to the shoulder but not beyond the shoulder. If the chin goes

beyond the shoulder then there is hypotonia of the neck muscles, which is associated with poor

head control.

Tone - Head Lag

Starting in the supine position, the baby is pulled by the arms to the sitting position. The head

and the arms are observed during the maneuver. The arms should remain partially flexed at the

elbow and the head may lag behind the trunk, but should not be fully flexed backwards. When

the baby is in the sitting position, the head should be able to come to the upright position for at

least a few seconds before dropping forward or backward.

Tone - Head Control

The strength and tone of the neck extensors can be tested by having the baby in sitting position

and neck flexed so the baby’s chin is on the chest. The baby should be able to bring the head to

the upright position. The neck flexors can be tested by having the head in extension while in the

sitting position. The baby should be able to bring the head to the upright position. These tests are

an extension of the test for head lag and are done at the same time.

Positions - Prone

In the prone position, the baby should be able to extend the neck to the point where the head

can be turned side to side. When the arms are extended by the side of the trunk, the baby should

be able to bring them forward into a flexed position. The buttock should be somewhat elevated

because the hips are flexed and adducted. A baby that is flat on the mat and can’t turn the head

back and forth has low tone and weakness.

Positions - Ventral Suspension

The baby is placed in the prone position, suspended in the air by the hand placed under the

chest. The baby’s head position, back and extremities are observed. The head should stay in the

same plane as the back. The back should show some resistance to gravity and not be simply

draped over the hand on the chest. The extremities should maintain some flexion tone and not

dangle in extension. Ventral suspension is a very good way to assess a baby’s neck and trunk

tone.

Positions - Vertical Suspension

The examiner holds the baby in the upright position with feet off the ground by placing the hands

under the arms and around the chest. The baby should be suspended in this position without

slipping through the hands of the examiner. If there is shoulder girdle weakness the arms will

extend upwards and the examiner will have to reposition their grasp of the baby to avoid the

baby slipping through their hands. It feels like trying to hold on to a slippery fish.

Reflexes - Deep Tendon Reflexes

Testing deep tendon reflexes is an important part of the newborn neurological exam. They can be

technically difficult to do. The first thing is to use a reflex hammer, not a finger or a stethoscope.

Ideally, the baby is in a quiet alert state with the head in the midline. The head turned to one side

can reinforce the tone and reflexes on that side. I usually start with the knee jerk because is the

easiest to obtain. Take control of the leg with the hand under the knee and the leg at about a 90

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degree angle at the knee. Then strike the patellar tendon with the reflex hammer using a

pendular action rather a chopping action.

Reposition the leg and try several times if you have trouble getting a knee jerk. Next, I go to the

ankle jerk. If I can’t get an ankle jerk in the conventional fashion, I place my fingertips on the

plantar aspect of the foot, flex the foot slightly, then strike the back of my fingers. For the bicep

jerk, have the arm flexed at the elbow, thumb over the bicep tendon, then strike the thumb with

a pendular action. Because of the predominantly flexor tone of the newborn, it is rare to obtain a

triceps jerk.

Absence of deep tendon reflexes is a much more important finding than hyperreflexia in the

newborn. A normal newborn can have hyperreflexia and still be normal, if the tone is normal, but

absent reflexes associated with low tone and weakness is consistent with a lower motor neuron

disorder. Preserved or exaggerated reflexes associated with low tone is the hallmark of what is

called central or cerebral hypotonia and the cause is an upper motor neuron lesion.

Reflexes - Plantar Reflex

The normal response to stroking the lateral aspect of the plantar surface of the foot is extension

of the great toe and fanning of the other toes. If the stimulus is brought across the ball of the

foot then a grasp reflex will be elicited and the toes will plantar flex. The up going toes or

“Babinski sign” is normal in the infant and may be present for the first year of life because of the

incomplete myelination of the corticospinal tracts.

Primitive Reflexes - Suck, Root

The baby should have a strong coordinated suck reflex with good stripping action of the tongue.

There should be resistance to pulling out the pacifier. A root reflex is obtained by gently stroking

the cheek towards the lips. The baby should open the mouth towards the stimulus and turn the

head to latch on to the object.

Primitive Reflexes - Moro

The Moro reflex is obtained by holding the baby’s head and shoulders off of the mat with the

arms held in flexion on the chest. The examiner suddenly lets the head and shoulders drop back

a few inches while releasing the arms. The arms should fully abduct and extend, then return

towards the midline with the hand open and the thumb and the index finger forming a “C” shape.

An absent or incomplete Moro is seen in upper motor neuron lesions. An asymmetric Moro is

most often seen with a brachial plexus lesion. The brachial plexus palsy is on the side of the

poorly abducted arm.

Primitive Reflexes - Galant

The Galant reflex (trunk incurvation) is obtained by placing the baby in ventral suspension, then

stroking the skin on one side of the back. The baby’s trunk and hips should swing towards the

side of the stimulus.

Primitive Reflexes - Stepping

The stepping or walking reflex is obtained by holding the baby upright over the mat with the sole

of the foot touching the mat. This initiates a reciprocal flexion and extension of the legs and it

looks like the baby is walking.

Primitive Reflexes - Grasp

Placement of the examiner’s finger in the palm of the hand or on the sole of the foot will cause

flexion and grasping of the fingers or toes. One should avoid touching the dorsum of the hand

while eliciting the grasp reflex because stimulating the back of the hand causes a hand opening

reflex to occur. With the two competing reflexes, the grasp response will be incomplete or

inconsistent. You can actually see this happen with the baby that is being examined. The grasp

reflex can be reinforced by applying traction on the arm.

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Head Shape and Sutures

The head should be closely inspected as part of the neurological examination. There can be

molding of the head, which is an expected finding in a newborn. Palpate the sutures and outline

the anterior and posterior fontanelles.

Head Circumference

It is very important to measure the head circumference, which sometimes is referred to as the

OFC (occipital-frontal circumference) because the measurement is obtained by placing the

measuring tape around the most prominent aspect of the frontal and occipital bones. The most

accurate measurements are obtained with a plastic tape measure rather than a paper tape

measure because the paper can stretch. The head circumference measurement should be

plotted on a standardized head growth chart for the appropriate sex.

3 MONTH OLD

Behavior

This baby is almost 3 months old. He is alert and attentive to the environment and the examiner.

He visually tracks. He has a social smile and is able to frown. There is definite social awareness

and interaction.

Cranial Nerves

The vestibulo-ocular reflex evokes a full range of conjugate eye movements. The baby should

also be able to visually track 180 degrees in the horizontal plane. Facial expression is full and

symmetric.

Motor - Upper Extremity Tone

In the newborn, flexor tone is predominate. After the first few weeks, the flexor tone is less.

Passive range of motion is still met with resistance but with the appropriate amount. The hand

pulled across the body to the opposite shoulder still does not extend beyond the shoulder.

Motor - Hand Movements

The hand is now held in a more open position. The infant will hold on to an object when placed in

his hand but will not yet reach for the object. At this age, the infant may start to bat at objects.

He also watches his hands.

Motor - Lower Extremity Tone

Tone in the lower extremities is present with the appropriate resistance to passive range of

motion. The tight flexor tone of the newborn is no longer present.

Motor - Head and Trunk Control

When pulled to a sitting position, a baby this age should be able to have only slight head lag and,

when sitting, the head should be upright but there may still be some wobbling of the head. The

back is still rounded, so the baby slumps forward.

Positions - Supine

In the supine position, the baby’s extremities are held off the mat and there is spontaneous

movement of all extremities. During the first 3 months of life, babies will often lie with their head

turned to one side or the other. This may be associated with extension of the arm that the head

is turned towards. This is part of the asymmetric tonic neck reflex, which is most prominent

during this time but diminishes by 3 to 4 months of age and is gone by 6 months of age.

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Positions - Prone

In the prone position, the baby is now able to bring his head up and look forward with the head

being 45 to 90 degrees off the mat. Weight is borne on the forearms. When the head and chest

are well off the mat, the baby is ready to start to roll from the prone to the supine position.

Rolling front to back usually occurs at 3 to 5 months of age. Rolling over too early can be due to

excessive extensor tone.

Positions - Ventral Suspension

In ventral suspension, the baby’s posture is very similar to the prone position. The trunk and legs

are in the same plane and the back is kept straight. The head is above the body looking forward.

The baby is able to maintain a forward-looking position.

Positions - Vertical Suspension

In vertical suspension with the feet touching the mat, the baby should start to support some

weight with his legs. Bearing weight on the legs is the earliest postural reflex to appear and

usually is present at 3 to 4 months of age. The baby’s shoulder girdle is strong and there is no

slipping through the examiner’s hands.


One of the main obstacles to obtaining deep tendon reflexes at this age is catching the extremity

at rest. Positioning the extremity is also important. As demonstrated in this baby, a crossed

adductor can be seen at this age and still be normal but should not persist beyond 7 months of

age. A few beats of ankle clonus can be normal in the first few weeks of life but sustained ankle

clonus at any age is abnormal.


Stroking the lateral aspect of the plantar surface of the foot still elicits a strong “Babinski sign”

which is an up-going great toe and fanning of the other toes.

Primitive Reflexes - Root

The baby still has a root reflex and turns the mouth towards the stimulus. The rooting reflex

disappears at about 4 months of age.

Primitive Reflexes - Moro

The baby no longer has a Moro reflex. Usually the Moro reflex is absent by 4 to 5 months of age.

Persistence of the Moro reflex beyond this time can be seen with upper motor neuron disorders.

Primitive Reflexes - Galant

The Galant reflex is still present but should diminish and be gone by 4 months of age.

Primitive Reflexes - Grasp

The palmer grasp reflex is still present for this baby. The grasp reflex is usually gone by 4 to 6

months of age for the hands and 6 to 12 months for the toes. The reflex palmer grasp is

gradually replaced by the voluntary activity of reaching and grasping with the hand.

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Primitive Reflexes - Asymmetric Tonic Neck

The asymmetric tonic neck reflex is present in the first 3 to 4 months of life. When the head is

turned to one side, the ipsilateral arm and leg will extend while the contralateral extremities will

be in flexion. The baby should be able to overcome this reflex and move out of this posture. If the

asymmetric reflex is obligate (the infant can not move out of or overcome the reflex) or if the

reflex persists beyond 6 months of age, then it is abnormal and can be seen in upper motor

neuron disorders.

6 MONTH OLD

Behavior

The baby is sitting comfortably in his mother’s lap. He is socially aware, inquisitive and readily

responds to visual objects and sounds. He smiles, laughs, and jabbers. At this age a baby will

start to make repetitive speech sounds that are nonspecific such as da, ma, or ba.

Cranial Nerves

The baby is able to visually track an object throughout the horizontal and vertical planes. An

interesting or colorful object is most helpful. To test visual fields, have the baby focus on an

object in front of him and then bring a second object from behind him until he sees the object in

his peripheral vision. He should turn toward the new object. Saccadic eye movements are tested

by using interesting toys and sounds and watching the eyes jump from object to object. To test

hearing, produce a sound out of the baby’s sight and then watch the baby turn and localize the

sound. Facial movements are noted as the baby smiles or cries.

Motor - Sitting

Independent sitting is accomplished by 6 to 8 months. This baby has good sitting posture (head

erect and spine straight) and has enough stability to reach for objects with both hands. He even

stretches to obtain an object without loosing his balance.

Motor - Hand

The baby is able to reach out and pick up an object and bring it to the midline, usually to his

mouth. He reaches equally well with either hand. Hand preference before one year of age is

always abnormal and indicates a motor deficit in the non-preferred hand.

At this age, the baby is able to transfer an object from hand to hand. By 5 to 6 months, a baby

grasps objects that are the size of a cube. An ulnar or palmer grasp is a raking motion with the

fingers trapping the object against the palm.

The next stage of hand development is to use the thumb in concert with the fingers to grasp an

object. This is called a whole hand grasp. The baby is starting to use the thumb so has developed

a whole hand grasp. A thumb-finger pincer grasp develops at 7 to 9 months.

Motor - Tone

Tone is assessed for the upper and lower extremities by passive range of motion when the baby

is cooperative. Distraction is a great way to get that cooperation. Babies at this age have found

their feet and can suck on their toes. On passive range of motion, the lower extremity should be

flexible enough to bring the foot to the baby’s mouth. There shouldn’t be any ankle clonus.

Motor - Traction

On traction, which is pulling to a sitting position, the baby has good head and trunk control. The

head and shoulders are flexed forward and the arms are flexed. The baby actively helps himself

to get to the sitting position by pulling with the arms. Also notice that the legs are flexed at the

hips and are off the mat as the baby pulls himself to sitting. On being laid back down to the

supine position, the baby doesn’t flop back, but is able to control the lowering of his head and

trunk to the mat.

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Position - Prone

In the prone position, the baby brings his chest all the way off the mat and supports his weight

on his hands, not his forearms. He works for toys out of his reach. He is close to crawling. He can

roll over from front to back and back to front.


It is hard to get the baby relaxed and cooperative enough to get the limb in the optimal position

for obtaining deep tendon reflexes. At this age, all the deep tendon reflexes tested in an adult

exam should be obtainable.


There is still a lot of plantar grasp at this age as well as withdrawal, which makes testing for the

plantar response difficult at this age. The toes are still up going until one year of age. The most

useful finding at this age is if there is asymmetry in the toe findings.

Primitive Reflexes

At six months of age this baby has lost the Moro reflex and the asymmetric tonic neck reflex.

Persistence of either one of these primitive reflexes would be abnormal.

Postural Reflexes - Positive Support Reflex

Some consider the positive support reflex as a primitive reflex, but others consider it a postural

reflex. I think it is a postural reflex because it is necessary for erect posture and blends into

volitional standing. Infants with prenatal or perinatal corticospinal tract disease will often refuse

to support their weight on their feet.

The positive support reflex is the first postural reflex to develop and is present by 3 to 4 months

of age. When the baby is placed in vertical suspension with the feet touching the mat, the baby

will extend the legs and attempts to support his weight while being balanced by the examiner. By

5 to 6 months of age the baby fully supports his weight while standing and by 7 months enjoys

bouncing.

Postural Reflexes - Landau

The Landau is an important postural reflex and should develop by 4 to 5 months of age. When

the infant is suspended by the examiner’s hand in the prone position, the head will extend above

the plane of the trunk. The trunk is straight and the legs are extended so the baby is opposing

gravity. When the examiner pushes the head into flexion, the legs drop into flexion. When the

head is released, the head and legs will return to the extended position. The development of

postural reflexes is essential for independent sitting and walking.

Postural Reflexes - Lateral Propping

Lateral propping or protective extension is essential for the baby to be able to sit independently.

This postural reflex develops at 5 to 7 months of age. Anterior propping actually develops first,

then lateral propping. For anterior propping the baby will extend the arms forward to catch

himself and prevent falling forward. Lateral propping occurs when the baby is falling to one side

or the other and he extends the arm laterally to catch himself. Asymmetric lateral propping can

be an early sign of hemiparesis. The baby will prop on one side but on the paretic side he will not

extend the arm to catch himself.

Postural Reflexes - Parachute

The parachute reflex is the last of the postural reflexes to develop. It usually appears at 8 to 9

months of age. When the baby is turned face down towards the mat, the arms will extend as if

the baby is trying to catch himself. Prior to developing this reflex, the baby will actually bring the

arms back to the plane of the body and away from the mat.

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Head Examination

The head circumference should be measured and plotted. This is usually done at the end of the

exam because babies usually resent the restriction of head movement necessary to obtain an

accurate measurement. Head shape should be noted and the sutures palpated.

Craniosynostosis (premature closure of the suture) can cause a misshaped head. Bone growth

occurs perpendicular to the suture. If one suture is closed, compensatory growth will occur in the

remaining open sutures. Synostosis of the sagittal suture (the most common type of synostosis)

results in scaphocephaly (a thin elongated head). Synostosis of the coronal sutures results in

brachycephaly (a wide flat head). Synostosis of the metopic suture results in trigonocephaly (a

triangular shaped head).

The most common cause of a misshapen head is flattening of the occipit on one side and is not

from lambdoid synostosis but is positional in nature (caused from the baby lying supine with the

head turned to one side as a preferred position).

It is important not only to palpate the sutures but also the fontanelles. The posterior fontanelle

cannot be palpated after six weeks. The anterior fontanelle is often small by six months. Closure

of the anterior fontanelle occurs between 10 and 20 months. The anterior fontanelle should be

palpated while the child is sitting and quiet and it should be flat or slightly concave. A full, slightly

bulging fontanelle can be seen with a child that is supine or crying.

12 MONTH OLD

Behavior - Shy

Infants at 12 months of age are often shy and have stranger anxiety. Most of the neurological

exam can be performed with the child on his parent’s lap. The parent helps reassure the child

and facilitates the exam. This infant is shy and frequently looks to his father for reassurance. The

examiner uses toys to try to engage the child in play and overcome the shyness.

Behavior - Social and Language

Infants this age imitate activities, wave bye-bye, and play pat-a-cake. They can follow simple

instructions especially if the desired action is demonstrated. They feed themselves finger foods.

They usually have one or two meaningful words, usually mama and dada.

Cranial Nerves

A colorful finger puppet is used to attract the infant’s attention and test extra ocular range of

movement. For testing visual fields, a finger puppet is again used to get the infant to visually

fixate, and then a dangling measuring tape is used to test peripheral vision.

Motor - Tone

Passive range of motion for both the upper and lower extremities is tested. Transforming the

movements into a game makes the exam less threatening to the infant.

Motor/Reflexes - Deep Tendon Reflexes

A reflex hammer can be a threatening object to the infant. By turning the reflex hammer into an

imaginary horse and adding sound effects, the infant is not threatened and cooperates for the

exam. Because using a reflex hammer can be a threat to the child, deep tendon reflexes are

usually done late in the exam and when the child is on the parent’s lap.

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Motor/Reflexes - Plantar Reflex

At 12 months of age the toes can go up or down. Generally, they are down going. In this age

group it’s hard not to get withdrawal of the foot. An abnormality of the plantar reflex is most

diagnostic if there is reproducible asymmetry.

Motor/Postural Reflexes - Parachute

The parachute is the last of the postural reflexes to develop. It usually appears at 8 to 9 months

and certainly is present by 12 months of age. The reflex is elicited by turning the child up side

down. The arms should come forward and the hands spread out to catch the fall. Asymmetry of

the reflex is abnormal and may indicate paresis in the non-extended extremity.

Motor/Coordination - Pincer Grasp

Fine motor coordination of the hand progresses in a definite pattern. At 6-7 months the hand is

used as a rake and objects are raked into the palm with the fingers. At 8-9 months the thumb

and the radial fingers are used to grasp an object and smaller objects are picked up. At 10-12

months, the fine pincer grasp is developed. This enables an infant to pick up a small object

between the distal thumb and index finger.

Both infants in this exam have developed a pincer grasp. The first infant uses the pincer grasp to

feed himself a cheerio. The second infant demonstrates a pincer grasp by grabbing the tip of a

measuring tape and pulling the tape out. The pincer grasp should be equal in either hand.

Handedness does not develop until after 12 months of age. Early handedness and asymmetric

fine motor skills are seen with a hemiparesis.

Motor/Coordination - Beads in the Cup

This test is a combination of understanding instructions, as demonstrated, and using a pincer

grasp to place the small bead in a container.

Motor/Coordination - Play Ball

The infant plays the simple game of throw the ball. His throw is not an overhand throw which is

seen in an 18 month old but rather a pushing away and dropping type of throw that is typical for

this age.

Motor - Transition in and out of Sitting

As far as gross motor skills, the infant is able to get in and out of the sitting position with ease

and creeps well.

Motor - Creeping

Crawling is a commando type of crawl which is an arm over arm propulsion forward with the

trunk on the ground and legs dragging. Crawling is usually seen at 7 to 9 months. Creeping is

crawling on hands and knees with the trunk off of the ground. Creeping is usually seen at 8 to 12

months.

Motor - Stoop and Recover

At one year, this infant has developed the ability to walk without support. Although still wobbly,

he can stoop down to pick up an object and stand back up without falling. He can maintain his

balance as he inspects and manipulates the toy. An infant usually develops the ability to stoop

and recover at 11 to 14 months of age.

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Motor/Gait - Stand, Walks with Support

The first infant demonstrates the ability to pull himself to a stand while holding on.

The second infant can stand, pull to a stand and cruise (not demonstrated because the baby is

upset). Cruising is walking along a piece of furniture while holding on. It usually develops

between 10 to 12 months. Along with cruising, the infant can take steps while holding on but

he’s not ready to walk unsupported.

Motor/Gait - Toddler’s Gait

Independent walking is achieved between 11 and 15 months of age. An infant is delayed if they

aren’t walking by 16 months. This 12 month old infant has a typical gait of an infant that has just

learned to walk. He has a wide base, is unsteady, and toddles. His arms are held at near

shoulder level in a high guard position. This is a protective position and probably aids in his

balance. As he matures, his arms will come down to a low guard position, then into the usual

associated arm movements seen with mature walking.

Head Circumference

The first attempt to measure the head circumference is easy but the examiner reads the

measurement as 50.6 cm, which is above the 98th percentile. Second attempt is much more

difficult because the infant doesn’t want the tape measure around his head. The measurement

however is read as 47.7 cm, which is at the 50th percentile. A third attempt verifies that the

47.7 cm measurement is correct. Always take at least two measurements and save the head

circumference to the last.

18 MONTH OLD

Behavior/Mental Status - Wants

At this age, the child indicates his wants by pointing, gesturing and using vocalizations other than

crying. At 18 months, he should have a vocabulary of 10 or more words and will use single words

to indicate wants. Social interaction at this age is rich and increasing in complexity as seen in

this child.

Behavior/Mental Status - Understanding

The toddler understands the use of objects and knows how things work. He’s trying to get the

pen to work. He will follow simple commands, but still needs reinforcement and at times

demonstration.

Behavior/Mental Status - Points to Pictures

The toddler is asked to point to pictures of a cat, horse, bird and dog. These pictures are part of

the Denver II assessment tool. An 18 month old should be able to point to at least 2 of the

pictures. This toddler identifies 4 pictures and repeats the name of 3.

Behavior/Mental Status - Points to Body Parts

When asked to point to body parts on the finger puppet, the toddler identifies eyes and mouth

correctly. The naming of 2 body parts is normal for an 18 month old. Between 18 and 30 months

the toddler should learn to identify 6 out of 8 body parts.

Cranial Nerves

Conjugate eye movements and the near reflex can be tested with an interesting object like a

finger puppet. Facial movement is noted as the toddler smiles.

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Fine Motor/Coordination - Blocks in Cup

The toddler shows good coordination as he takes blocks and puts them in the cup. He is able to

control the cup as well as reaching for the blocks.

Fine Motor/Coordination - Beads in Cup

He is able to pick up small beads and place them in a small container with good fine motor

control. By using both blocks and beads, one is testing increasing levels of difficulty of fine motor

control and coordination.

Fine Motor/Coordination - Stacking Blocks

Even more demanding than placing blocks or beads in a container is the task of stacking blocks.

The number of blocks that a child can stack is correlated with their level of motor development. A

15 month old can stack 2 blocks while an 18 month old should be able to stack at least 4

blocks. This toddler is able to stack 5 blocks.

Fine Motor/Coordination - Pincer Grasp and Handedness

The toddler has a good pincer grasp as he grasps the end of a tape measure and pulls on it. He

uses both hands well, but now the parents identify that he is starting to use the right hand more

than the left hand. Handedness develops in the 2nd year of life.

Fine Motor/Coordination - Drawing/Scribbling

An 18 month old child can hold a pen and imitates scribbling or can scribble spontaneously. At

this age he is holding the pen between the thumb and first 3 fingers and is developing a tripod

position of the hand for drawing.

Motor - Tone

Passive range of motion is tested for both the upper and lower extremities. Toddlers can be

apprehensive about having the examiner move his arms and legs, but reassurance and

distraction usually work to get an adequate exam.

Motor/Reflexes - Deep Tendon Reflexes/ Plantar Reflex

By making the reflex hammer into a play object and adding sound effects, the child usually

cooperates enough to adequately obtain deep tendon reflexes. Testing for the plantar reflex

shows that the toes are definitely down going.

Motor - Throwing Ball

The toddler is able to throw the ball overhand and shows pleasure in playing the game of

throwing and chasing after the ball.

Motor/Gait - Walking

The 18 month old has a much more steady and secure gait than the infant that is just learning to

walk. He still has a wide-based gait but no wobbling. His arms are held in a low guard position- at

the level of his waist. He squats without falling and is able to get up in the middle of the floor

without pulling himself up. Notice how he gets up from the supine position. He first rolls to his

stomach, then steadies himself with his hands on the floor to get up. As he gets older he’ll do a

sit up rather than rolling over and he will be able to get up without using his hands. Importantly,

there is no evidence for proximal pelvic girdle weakness as he gets up from the ground or walks.

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2 ½ YEAR OLD

Behavior/Mental Status - Establishing Relationship

This 2.5 year old is apprehensive about being examined and isn’t quite sure she wants to be

there. The finger puppets are used in attempt to establish rapport and involve the child in play.

The child’s social interactions and motor skills are observed during this time. The child is also

examined on the mother’s lap.

Behavior/Mental Status - Follows Commands

At this age verbal instructions without demonstration are understood. The child can follow two-

step commands.

Behavior/Mental Status - Points to Pictures

The girl is first asked to name the pictures but doesn’t cooperate enough to determine if she

knows their names. So the examiner switches strategy and asks her to point to the picture he

names. She is able to do this for all five pictures. She asserts her autonomy by using her foot

instead of her finger. These pictures are from the Denver II.

Behavior/Mental Status - Names Pictures

Later on in the exam she cooperates enough to demonstrate that she is able to name all five

pictures that are shown to her, which is the next developmental level above pointing to them.

The next level after naming would be identification by the action of the picture, such as asking

which one flies. Pointing to 4 pictures should be accomplished by 2.5 years, naming by 3 years

and identification by action by 4 years.

Behavior/Mental Status - Response to Questions

The girl is shown a picture in an attempt to get her to talk. She is shy and doesn’t talk much but

responds to questions with yes and no. She is putting two words together in a simple sentence.

A child’s earliest sentences usually contain important content words and lack grammatical

words. A 3 year old forms a 3 to 4 word sentence and uses pronouns and plurals.

Behavior/Mental Status - Pointing to and Naming Body Parts

The girl is able to point to 8 out of 9 body parts. She can identify them on herself as well as

others. A 2.5 year old should be able to point to 6 out of 8 body parts.

Fine Motor/Coordination - Using Puppets

Using finger puppets facilitates coordination testing. First the girl is asked to place the puppets

on her finger, which shows that she accurately reaches a target without ataxia. The girl is then

taught how to do finger to nose by having her touch the puppet’s nose then her nose.

Fine Motor/Coordination - Using Measuring Tape

A measuring tape can also be used to test coordination. As the girl reaches for the tip of the

tape to pull it out and has to extend the arm to reach the target, she is being tested for

dysmetria. Having her manipulate the tape measure and work the control button is testing hand

coordination. The examiner tries to get her to click the button but she doesn’t do it. This was an

attempt to test repetitive movements.

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Fine Motor/Coordination - Block Tower

The girl is able to build a 5 block tower and almost gets to 6 blocks. She’s not sitting in the best

position nor does she have the most stable platform to build a tower. A 2.5 year old should be

able to build a 6-8 block high tower. At 3 years, the child is able to build a 3-block bridge.

Assessing if a child is developmentally age appropriate is not based on one particular test but

rather how they do on several different tests as well as their overall performance.

Fine Motor/Coordination - Drawing

The girl imitates drawing a horizontal line as well as making circular shapes. At 3 years of age a

child should be able to draw a circle and at 4 years old can copy a cross.

Motor - Tone

Upper and lower extremity tone is tested using passive range of motion. The girl is apprehensive

about this but using the finger puppet as part of the exam helps.

Motor/Reflexes - Deep Tendon Reflexes

This segment of the exam illustrates the problems associated with obtaining deep tendon

reflexes. The reflex hammer is turned into a horse and initially she allows the examiner to test

the right upper extremity. Notice that after testing for the brachioradialis reflex she becomes

uncooperative. One of the ways to reduce apprehension in the child is to place your thumb or

index finger over the tendon to be examined and tap on it rather than directly tapping on the

child’s tendon. It’s less threatening.

Motor - Kicking and Throwing a Ball

At this age, the child is able to kick the ball and throws the ball overhand to the examiner. A ball

is a good tool to use during the neurological examination because the child enjoys playing with it

and it allows the examiner to see both fine and gross motor skills that the child has developed.

Motor/ Gait - Walking, Running

At this age, the gait is steady, well coordinated and no longer wide-based. The arms are down to

the side and there are normal associated movements. The hands are no longer used when

getting up off the floor or sitting down on the floor. The child is able to run.

Reference: University of Utah. (2015). Neurologic Examination


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NEUROPrelims - Cranial Nerves and Neurological Examination

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