clinical examination of nervous system - ppt

CNS Examination Practical • Presented By – Prof.Dr.R.R.Deshpande (M.D in Ayurvdic Medicine & M.D. in Ayurvedic Physiology)

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11/28/2016 1Prof.Dr.R.R.Deshpande

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Clinical Examination of Central Nervous System

11/28/2016 Prof.Dr.R.R.Deshpande 2

Centers in Brain


Examination of Nervous System

• (1) Examination for higher functions• (2) Examination of cranial nerves• (3) Examination of sensory system• (4) Examination of motor system• (5) Examination of reflexes• (6) Examination of gait• (7) Examination of spine and cranium• (8) Examination for special signs (such as cerebellar signs)


Examination of Higher Functions

• (1) Level of consciousness.• (2) Orientation of time, place and person• (3) Intelligence• (4) Memory• (5) Speech

• Note :- Special tests are required for psychiatric patients.


Asking questions for orientation of Time,Place & Person


Cranial Nerves


Examination of Cranial Nerves

• (1) First cranial nerve - Olfactory nerve –

• This can be tested by asking patient to smell a known substance with each nostril like camphor ,Eucalyptus


Testing of Olfactory Nerve


2nd Cranial Nerve – Optic Nerve

• This nerve is examined ,under following headings

• (A) Acuity of Vision

• (B) Field of Vision

• (C) Colour Vision11/28/2016 Prof.Dr.R.R.Deshpande 11

Examination of Optic Nerve – Snellen’s chart


Acuity of vision

• Tested by asking the patient to read "Snellen's chart" from a distance of 6 m.

• Suppose, person reads only 2nd line, on which distance mentioned is 36 m, then we express his far vision as 6/36 (Normal far vision should be 6/6)

• In above case - it is understood that what a normal person can read from 36 m, our patient is reading from 6 m and so, patient is suffering from Myopia.


Near Vision Testing

• (ii) Near Vision - is tested with the help of Jeger's chart .This chart is to be read from a distance of 25 cm, which is our near point. Each eye should be tested separately and then binocular vision.

• Normally the person should read smallest print on Jeger's chart.

• This indicates near vision of patient is normal. He is not suffering from Hypermetropia.


Examination of Optic Nerve – Near vision – Jeger’s Chart


Colour Vision

• Tested with 'Ishihara chart’

• This chart is to be tested by each eye separately and the person is asked to recognize the figure which are printed in different colours in the chart.


Examination of Optic Nerve – Colour vision – Ishihara Chart


Field of vision – Confrontation Test

• This is done with the help of Perimeter.• Principle used in this test is that the field of vision of

doctor's right eye is same as field of vision of left eye of patient . patient sits at a distance of 1 m. Then eyeball movements are tested

• - Patient is instructed not to move his neck but patient has to move only eyeballs, as doctor is moving his finger. (We test the movements, such as - abduction, adduction, elevation, depression, internal rotation and external rotation)


Examination of Optic Nerve – Confrontation Test


Trochlear Nerve – Pupillary Reflex

• (4) Trochlear Nerve - To test pupillary reflex is also a part of examination of 3rd cranial nerve.

• For this Light Reflex and accommodation reflex should be tested

• For testing the Light Reflex doctor will throw light on the patients eye and doctor will look for the response i.e. constriction of pupil.


Examination of Trochlear Nerve – Pupillary Reflex


Trochlear Nerve – Pupillary Reflex

• Throwing of light in one eye and constriction of pupil of the same eye is direct reflex and construction of pupil of another eye is indirect reflex

• Accommodation reflex - can be tested by asking the patient to look at distant object first and suddenly towards the object, near to eye (as close as 25 cm) Effect will be constriction of pupil and conversions of eyes and bulging of lens.


Examination of Trochlear Nerve – Accommodation Reflex


Trigeminal Nerve

• (5) Fifth Cranial Nerve - is Trigeminal Nerve.• Sensory component - can be tested by testing sensations from all parts of face.

• Motor component - can be tested by muscle of mastication (Temporalis, Masseter muscles). We also test medial and lateral pterygoid muscle by asking the patient to move his jaw sidewise.


Trigeminal Nerve

• For testing sensory component, wick of cotton wool is used for testing touch sensation

• Temperature sense can be tested by taking warm and cold water in test tubes.


Examination of Trigeminal Nerve – Touch sensation


Examination of Trigeminal Nerve – Temperature sensation


Examination of Trigeminal Nerve – Motor component


Facial Nerve

• (7) 7th Cranial nerve - Facial Nerve

• (i) Basically, this is motor nerve which supplies superficial muscles of face

• (ii) The doctor will test all movements of face


Facial Nerve

• (a) Make wrinkling on forehead (To test Occipito frontalis)

• (b) Close eyes tightly (To test Orbicularis occuli)

• (c) Blow your cheeks (To test Buccinator)• (d) Blow whistle (To test orbicularis oris)


Examination of Facial Nerve

Wrinking of Forehead Close Eyes tightly



Blow the cheeks Blow whistle


Facial Nerve

• (iii) Conjunctival and corneal reflexes

• Are also the part examination of facial nerve which we have already tested in Trigeminal nerve.



Conjunctival Reflex Corneal Reflex


Vestibulo Cochlear Nerve

• (8) 8th Cranial Nerve - Vestibulo cochlear nerve - • Cochlear component is concerned with position of head and neck (balance of body).

• To test cochlear component we carry out "Test of hearing".

• Rinne's test. Scbwabach test, Weber test - Basic principle in all these tests is AC > BC, Due to Impedance Matching, brought about by Ossicular chain.


Hearing Tests

• (A) Rinne's Test - If BC > AC, It indicates conductive deafness

• (Nerve deafness can not be detected by Rinne's test)

• (B) Schwabach Test - AC of patient is compared with AC of doctor, BC of patient is compared with BC of doctor. (If AC < BC -- conductive deafness)

• If AC & BC ,both are reduced , It indicates nerve deafness.


Vibrating Tuning fork for Hearing Test


Examination of Vestibulo Cochlear Nerve

Rinne’s Test Rinne’s Test


Examination of Vestibulo Cochlear Nerve

Schwabach Test Schwabach Test


Hearing Test

• (C) In Weber test - We confirm the deafness ,which is detected By Rinne's test and schwabach test. - Vibrating tunning fork is kept on vertex and patient is asked on which side he hears better. - Normally, he should hear equal on both sides. If it is better on Right side it means conductive deafness on Rt side or nerve deafness of opposite side

• All tests are done with Tunning fork, having frequency 256 and 512. Because our ear is maximum sensitive for these frequencies.


Weber Test for Hearing


Examination of 9th, 10th, 11th cranial nerves

• Glossopharyngeal, Vagus, Accessory

• 9th and 10th cranial nerve carry sensation from post. part of tongue as well as pharynx.

• 10th cranial nerve also supplies palate, laryngeal muscle.


Glossopharyngeal Nerve

• Patient is asked to open his mouth and say Aa , (Doctor will observe position of Uvula and arches of soft palate)

• Post 1/3rd of tongue can be tested by for general sensation touch, as well as special sensations like Taste.( Hold the cotton in forcep & touch on posterior 1/3rd of tongue & ask whether the person feels touch )

• - Then patient is asked to drink water while swallowing movement of larynx is to be tested.


Examination of Glossopharyngeal Nerve

Say Aa Touch Sensation


Accessory Nerve

• Accessory nerve has 2 components

• Cranial component - Supplying laryngeal muscle and another

• Spinal component - Supplying sternomastoid and trapezium


Examination of Accessory Nerve


Accessory Nerve

• Speech is tested by asking the patient to speak out few words.(Like asking question –What is your Name ?)

• To test palatal and pharyngeal reflex stick with cotton is to be touched to palate or pharyngeal wall and reflex is elicited

• Spinal accessory supplies - Trapezium and Sternomastoid

• Trapezium is tested by asking the patient to elevate his shoulder, against resistance.



Movement of Trapezium Movement of Trapezium



• To test sternomastoid muscle patient is asked to turn his neck on one side and patient is asked to press his chin on the hands of the doctor.

• In this process doctor can see prominence of Sternomastoid muscle

• Palatal or pharyngeal wall reflex is also the part of 9th, 10th, 11th Cranial Nerve examination.

• Soft palate or post pharyngeal wall is touched with tongue depressor or cotton stick. - patient gets coughing sensations.


9th, 10th, 11th Cranial Nerve examination

• Palatal or pharyngeal wall reflex is also the part of 9th, 10th, 11th Cranial Nerve examination

• Soft palate or post pharyngeal wall is touched with tongue depressor or cotton stick. Patient gets coughing sensations


Hypoglossal Nerve

• 12th Cranial Nerve - Hypoglossal Nerve –

• This is purely motor nerve.

• It supplies all the muscles of tongue, these muscles bring out the movement such as elevation, depression, protrusion, retraction and rolling of tongue.


Examination of Hypoglossal nerve


Hypoglossal Nerve

• The patient is asked as follows ----

• Say Aa, Take Tongue out ,Take tongue in ,Take tongue up ,Take Tongue out & down

• This is the end of the cranial nerve examination.


Clinical Examination of Sensory System

• One should remember the following points while carrying out examination of sensory system.

• (1) Subject (patient) should be blind folded (this means, patient's eyes should be closed) and patient has to answer with closed eyes.

• (2) Identical dermatomes are to be compared for sensation and usually we go from below upwards (i.e. from lower extremities trunk, upper extremities and then face)



Hair Asthesiometer Compass Asthesiometer



Compass Asthesiometere Tuning Fork



Key & Coin-Steregnosis Cotton wick –Crude Touch



Blunt end of Pencil –pressure Hot & Cold water


Types of Sensations – Fine Sensation

• (i) Fine touch• (ii) Tactile localisation• (iii) Tactile discrimination

• (iv) Vibration sense• (v) Joint position and muscle movement sense

• Note - By testing fine sensations integrity of dorsal column tract is tested.


Types of Sensations – Crude Sensation

• (i) Crude touch• (ii) Pressure

• (iii) Temperature• (iv) Pain

• Note - Integrity of spinothalamic tract is tested


Fine sensation & Tactile Localization

• Tested by Warn cruze hair Asthesiometer or even a thin wire can be used.

• The patient is suggested as follows• Ask the patient – Now I am touching this wire to different parts of your body

• By closing your eyes ,you can tell ,whether you feel the touch ? On which part of your body ,you are feeling the touch ? On which side you are feeling the touch – Right or Left ?


Examination of Sensory System

Touch on right side Touch on Left side


Fine Sensation – Fixing of Dermatome

Sr.No Area Dermatome

1 Near ankle L 5

2 Below knee L 4

3 Above knee L 3

4 Thigh L 2

5 Above wrist L 7

6 Below elbow L 6


Tactile Localization

• The patient will locate the area where he is felling fine touch ,by closing eyes


Tactile Discrimination

• Tested by Compass Asthesiometer

• Tell patient as follows –

• Now I am touching 2 pointers of this Instruments – By closing your eyes , you tell me ,whether you are feeling touch with 1 pointer or 2 pointers ?


Examination of Sensory System

Touch on Right side Touch on Left side


Sense of Steregnosis

• The patient is asked to recognise ----

• familiar objects (pen, pencil, coin, key) given in his hand (by shape, size and texture ) with closed eyes


Steregnosis

Identifying Pen Identifying Coin


Vibration sense

• (5) Vibration Sense - A vibrating tunning fork having frequency 100 Hz is kept on bony prominence such as Tibial Tuberosity or Olecranon and subject is asked to recognise vibration sense

• Ask the patient --- Tell ,closing your eyes , whether you feel vibrations created by this Instrument , Tunning fork ?


Vibration sense

On right side On Left side


Joint position & Muscle movement sense

• To test joint position sense, we do the movements of great toe or thumb and subject is asked to recognise that movement with closed eyes

• Tell patient – That now I am moving your thumb up or down .Then by closing your eyes ,you can tell me ,whether I am moving your thumb up or down ?


Examination for recognizing Joint Position

Downward Movement Upward Movement


Fine sensations –Lost

• All above fine sensations are disturbed, if Dorsal Column Tract

• Tract is damaged due to "Tabes Dorsalis (Neuro syphilis) or Tumour


Crude Sensations

• (1) Crude touch• (2) Pressure

• (3) Temperature• (4) Pain

• (Integrity of Spinothalamic tract is tested)


Crude Touch

• Tested by wick of cotton wool

• Identical Dermatomes are to be compared

• Ask the patient ,to tell ,where he is feeling the touch of cotton, by closing eyes ?


Examination for Crude Touch

On Right Side On Left Side


Sense of Pressure

• Blunt end of the pencil is used. It is pressed on extremities or on face and subject is asked to recognise it

• Tell patient – that I am pressing this Pencil surface on your body .By closing eyes ,you tell me whether you are feeling pressure & on which part & on which side ,right or left ?


Examination for sense of Pressure



Temperature sense

• Test tubes containing warm or cold water are used Subject is asked to recognise these sensations with his feelings

• Tell patient that now you touching 2 test tubes of hot & cold water to his body .Ask him to tell ,by closing eyes ,which temperature touch ,he feels –Hot or Cold ?


Examination for Sense of Temperature



Pain sensation

• Pin is used. Subject is asked to recognise pain stimulus, given with pin

• Tell patient that you are now touching his body with pin prick .Ask the patient to tell ,by closing his eyes ,whether he feels pin prick or not ,on which part & on which side ?

• Identical Dermatomes are tested.


Examination of Pain Sensation



Crude sensations

• Thus, by testing crude sensations, we have tested integrity of Spinothalamic system

• These tracts are damaged, if there is a tumour pressing on spinal cord or if there is a disease like "Transverse Myelitis," involving spinal cord.


Examination of Motor System

• Motor system is examined under following headings. These points are very useful in examine the patient of Hemiplegia

• (1) Nutrition• (2) Tone• (3) Power• (4) coordination• (5) Involuntary movements


Examination of Nutrition of Muscle

• Nutrition is tested by measuring circumference of muscle, at its bulk and comparing circumference of left and right side

• e.g. Circumference of calf muscle can be measured by fixing the distance from bony prominence.



• e.g. 6 inches below Tibial tuberosity. Measure the circumference of right and left calf muscle at a same distance.

• Similarly circumference of thigh muscle, from a fixed bony prominence like Tibial Tuberosity or ASIS (Anterior Superior Iliac Spine) can be compared


Nutrition of Muscle Measuring from Fixed distance Measuring Circumference



• In the same manner, for the upper extremity - circumference of forearm and arm muscles can be compared from a fixed bony prominence like olecranon process

• When circumference of both right and left sides is normal it indicates nutrition of these muscles is normal


Nutrition of Muscle

Right side Measuring Circumference



• In right sided person circumference of right sided muscle can be slightly more. This is physiological

• Atrophy of muscle is seen in LMN lesion like polio myelitis


Tone of Muscle

• Tone of a muscle is a partial state of contraction. It is maintained by stretch reflex.

• Tone of the muscle is tested by 2 ways

• (a) By examining feel of the muscle• (b) Tone can be seen by Resistance offered to

passive Movements.


Tone of Muscle

Tone of Leg Muscle Tone of Thigh Muscle


Tone of Muscle

• Doctor can feel muscle at its bulk and he can compare the feel on right and left side

• e.g. doctor can observe the feel of calf muscles, thigh and muscles of bicep and triceps


Tone of Muscle

Bicep Muscle Tone Tone –Forearm muscle


Tone of Muscle

• Normal feel is Elastic.• Second method of examination of Tone is to see resistance offered to passive Movements

• Patient is not moving his extremities but the doctor is carrying out passive movements


Tone of Muscle

• Doctor can do passive movements at knee joint to test the tone of flexors and extensors of knee

• When doctor is doing flexion of knee, he is testing tone in extensors. When doctor is doing extension at knee he is testing Tone of flexors


Tone of Muscle

Passive movement Passive movement


Tone of Muscle

• For testing upper extremities, same movements can be done at elbow

• Doctor can test Tone of biceps and triceps and he can compare the Tone at other side. When doctor is carrying flexion at elbow he is testing Tone in triceps. When doctor is carrying extension in elbow he is testing tone in biceps


Tone of Muscle

Elbow Flexion Elbow Extension


Tone of Muscle

• In lower and upper extremities, when resistance offered is moderate, it indicates tone is normal

• Hypertonia is seen in UMN lesion

• Hypotonia is seen in LMN lesion


Power of Muscles

• Power is graded under fine grades as follows• Grade O - No movements at all.• Grade 1 - Only flicking movement are visible but no movements possible

• Grade 2 - If movement is occurring horizontally but not able to lift against gravity.

• Grade 3 - If subject is able to lift up leg or hand, against gravity

• (compare the right and left side)


Power of Muscle

Grade 3 Power Grade 3 Power


Power of Muscles

• Grade 4 - Patient is able to move his extremities against resistance

• Grade 5 - Patient is able to lift the extremities against the good resistance applied by the doctor.


Power of Muscle



Power of Muscles

• In the same manner, power of extensors of hip, flexors of knee (Ask the patient to bend the knee ) extensors of knee (Extend leg by making knee straight ) can be compared.


Power of Muscles

• Even planter flexors, dorsi flexors of foot can be compared

• In upper extremity, flexors and extensors of elbow can be compared, flexors and extensors of wrist can be compared

• Movements at shoulder such as flexion, extension, abduction, adduction can be tested for power


Power of Muscles

• For testing power in the neck muscle, patient is asked to lift his neck up in lying down position

• Ask the patient to lift the neck ,put down the head .Then ask patient to lift the neck ,when doctor is pressing on forehead


Power of Muscle



Power of Muscles

• Complete loss of power is called as 'paralysis' which is typical feature of LMN lesion like polio myelitis

• Partial loss of power is called as "paresis" which is typically seen in Hemiplegia or Paraplegia.


Coordination of Muscles

• (A) Coordination of muscles in upper extremity is tested by following tests

• (1) Finger - Nose - finger test

• (2) Rapid pronation and supination of palm (Dysdiadochokinesia)



• (B) for lower extremity, following tests• (1) Knee - heel test• (2) Walking in straight line

• All tests of co-ordination should be done with open eyes first and then with closed eyes, to differentiate between sensory Ataxia and cerebellar Ataxia (Motor ataxia)



• Ask the patient ,by closing the eyes ,he should try to touch Index finger of the left hand by his index finger of right hand & then same right hand finger should touch to his nose tip

• Same procedure is repeated with Left hand Index finger

• • This is Finger – Nose – Finger Test


Coordination of Muscle

Finger- Nose –Finger Test Finger –Nose –Finger Test



• Ask the patient to perform Pronation & Supination activity of both hands ,speedily (diadochokinesia) ---

• Check ,whether patient can do it for both the hands



Diadochokinesia Diadochokinesia



• Kneel Heel Test – Ask the patient to sit on table or lie down on bed

• First keep right heel on left knee & take the heel down along with shin of tibia ,till left foot

• Perform Same procedure by keeping left heel on right knee & taking down heel along with the shin of tibia ,up to right foot



Knee-heel Test Knee –heel Test



• Ask the patient to stand straight ,by keeping both feet near to each other – First stand with eyes open & then stand with close eyes

• Doctor has to see ,whether patient can maintain balance of his body

• If patient cannot stand straight, and he swings with closed eyes - It is called as, "positive Rhomberg's sign", which is typical sign of Dorsal column tract damage.


Rhomberg's sign



• Straight line walking Test – Ask the patient to stand at one end of the 8 feet straight line

• Then ask him to walk on this line to & fro –First with open eyes & then with close eyes


Straight line walking Test

Walk on Straight line Return back –on straight line



• If patient walks correctly with open eyes, but looses balance with closed eyes - It indicates damage lies in dorsal column tract (which is called as sensory ataxia)

• If patient is not able to walk with open or closed eyes – damage is in cerebellum (it is cerebellar or Motor ataxia)


Involuntary Movements

• 3 types

• (1) Fine Tremors – In Thyrotoxicosis

• Tachycardia, weight loss, Intolerance to heat atmosphere ,Feeling excessive heat all the time



• (2) Pin rolling tremors at rest – • In Parkinsonism – This disease develops due to deficiency of Dopamin neutrotransmitter in Basal Ganglia

• Tab Carbidopa is used to compensate this deficiency

• (3) Action tremor - In cerebellar diseases



Fine Tremors Pin rolling Tremors


Involuntary Movements –Action Tremor


Advantage of Motor System Examination

• Advantage of motor system examination, over sensory system examination is that ---

• (1) Even if patients cooperation is not there we can draw few conclusions like - UMN lesion, LMN lesion, Parkinsonism, Cerebellar

• ataxia ,Sensory ataxia.


Advantage of Motor System Examination

• (2) In sensory system examination, if patient is non-co-operative then he can not answer the doctor's questions and then examination is of no value

• However, sensory system examination is important to detect the level of damage in spinal cord.


Superficial Reflexes – Root values Sr.No Reflex Root Value

1 Conjunctival reflex 5th and 7th cranial nerve

2 Corneal reflex 5th and 7th cr. N

3 Pharyngeal reflex 9th, 10th, 11th cr. N

4 Abdominal reflex T6 to L1

5 Plantar reflex L5, Si, S2


Deep Reflexes – Root values

Sr.No Reflex Root Value

1 Bicep jerk C5, C6

2 Triceps jerk C6, C7, C8

3 Supinator jerk C5, C6

4 Knee jerk L2, L3, L4

5 Ankle jerk L5, S1, S2


Reflexes

• In superficial reflexes --- receptors are in skin or mucous membrane

• In deep reflexes ---- receptors are in muscles or tendons.


Superficial Reflex – Conjunctival Reflex

• Doctor will touch wisp of the cotton wool to the white portion of eye i.e. Bulbar conjunctiva

• Response is closer of both eyes


Conjunctival Reflex

For Right Eye For Left Eye


Superficial Reflex –Corneal Reflex

• Doctor will touch the wisp of cotton wool to black portion of eye i.e. cornea closer of both eyes is normal response

• NOTE : Conjunctival and corneal reflexes have already been tested in examination of trigeminal and facial nerve. If these nerves are damaged reflexes are lost


Corneal Reflex

For Right Eye For Left Eye


Palatal & Pharyngeal Reflex

• Doctor will touch soft palate or post pharyngeal wall with tongue depressor

• Doctor will expect a response in the form of coughing

• If the patient is getting coughing sensation - It means 9th, 10th, 11th cranial nerves involving in this reflex are normal


Palatal & Pharyngeal Reflex

Ready with Tongue Depressor Touch Post Pharyngeal wall


Abdominal Reflexes

• Imp precaution to be carried out is that - abdomen should be relaxed, by flexing knee

• Ask the patient to lie down his back & flex the knees & relax abdominal muscles


Abdominal Reflexes

Mid abdominal Reflex Away from Umbilicus


Abdominal Reflexes

• Now, blunt end of hammer is moved, radiating away from umbilicus in all directions

• While testing this reflex abdominal muscle will show a movement, in the form of the response

• Abdominal reflexes are classified into upper abdominal, mid abdominal and lower abdominal reflexes


Abdominal Reflex – Root value

Sr.No Part Of Abdomen Root Value

1 Upper abdominal reflex T6 to T9

2 Mid abdominal reflex T9 to T11

3 Lower abdominal reflex T11 to L1


Abdominal Reflexes

• In obese patients, abdominal reflexes may not be elucidated. In such cases, unilateral absence of abdominal reflex is important finding

• Abdominal reflexes are lost in UMN lesion like hemiplegia or paraplegia.


Superficial Reflex – Plantar Reflex

• Root value of the plantar reflex is L5, S1, S2.• Scratch sole of the foot from heel to toes, along lateral border and then medially. This scratching is done with blunt portion of hammer

• Perform it on both sides & compare


Babinski's sign

Left Plantar Reflex Right Plantar Reflex


Superficial Reflex – Plantar Reflex

• Normal response is plantar flexion of all toes

• If dorsiflexion of great toe and fanning of other toes is seen then diagnosis is positive Plantar reflex or positive Babinski's sign

• This will be seen UMN lesion like hemiplegia or in meningeal irritation (Meningitis)


Deep Reflex – Bicep Jerk

• For testing deep reflexes, special method is adopted which is called as the Jendrassik maneuver ----

• which is a medical maneuver wherein the patient clenches the teeth, flexes both sets of fingers into a hook-like form and interlocks those sets of fingers together


Deep Reflex – Bicep Jerk

Tap Bicep Tendon Contraction of Bicep muscle


Jendrassik maneuver

• By this manual, gamma motor neuron discharge is decreased and reflex is obtained properly

• Bicep jerk - Doctor will tap bicep tendon - contraction of biceps muscle is important, rather than flexion of forearm.

• We compare the reflex on both sides. Root value of this reflex is C5, C6.


Deep Reflex – Tricep Reflex

• Doctor will give a tap just above Olecranon process, which is Tricep tendon

• Do Jendrassik maneuver• Contraction of the muscle is more important than extension of forearm

• Compare the reflex on other side. Root value of this reflex is C 7, C 8.


Deep Reflex – Tricep Reflex

Tap above Olecranon Process Contraction of Muscle


Deep Reflex – Supinator Reflex or wrist Jerk Reflex

• Tap is given just above the head of radius. Doctor can see the contraction of brachioradialis muscle

• Compare the reflex on another side

• Root value is C5, C6.


Supinator Reflex or wrist Jerk Reflex

Left Wrist jerk Right wrist jerk


Deep Reflex – Knee Jerk

• For testing this reflex, exposer of Quadriceps muscle is important, so that the doctor can see the contraction of this muscle

• Doctor keeps his hand below the knee, patient is asked to relax. Divert the patients attention by Jendrassik maneuver

• Ask the patient to clench the teeth • Give a tap on patellar tendon i.e. between patella and Tibial Tuberosity.



• Contraction of Quadriceps muscle is Important response

• Root value is - L2, L3, L4



Right Knee Reflex Left Knee Reflex


Deep Reflex – Ankle Jerk

• For this reflex gastrocnemius muscle should be exposed. Tapping of the gastrocnemius tendon, just above the heel is stimulus

• Doctor will make forceful dorsiflexion of foot and give a tap on tendon. Contraction of gastrocnemius is the response. Compare the reflex on other side

• Root value is L5, S1, S2


Deep Reflex – Ankle Jerk

Right Ankle Jerk Left Ankle Jerk


Importance of Testing Reflexes

• Examination of the reflexes is most imp part in examination of the nervous system.

• Advantage of this examination than motor and sensory examination is that - "It does not require patient's co-operation."

• Various diseases, specially UMN lesion and LMN lesion can be differentiated by examination of deep reflexes

• Even if patient is unconscious, non-cooperative - These reflexes will give important clues.


Importance of Testing Reflexes

• In UMN lesions - Deep reflexes are exaggerated

• (Jerks will be very much prominent)• Even clonus can be seen at knee and ankle (where muscle jerk oscillates for longer time)

• Clonus is always pathological. It is seen in UMN lesion


Examination of Spine & Cranium

• Spine is to be inspected from cervical to sacral region for noticeing abnormality

• With knuckles of fingers ,doctor can give deep pressure on spine and ask the patient whether he gets pain sensation.



Cervical to Sacral With knuckles



• For testing cranium deep pressure is to be given on skull, from all angles and patient is asked, "Whether he gets pain sensation" ?

• If there are abnormalities of the spine, if there are conditions like hydrocephalus. This test will give intense pain.



Deep pressure from all angles Deep pressure from all angles


Examination of Gait Sr.No Gait Disease

1 Circumduction gait Hemiplegia

2 Jerky gait Parkinsonism

3 Drunk man's gait Cerebellar disease

4 Spastic gait Paraplegia

5 Flaccid gait Polio-myelitis.

6 Scissors gait Diplegia


Abnormal Gait

Circumduction gait Drunken Gait


Abnormal Gait

Parkinson’s Gait Polio Gait


Abnormal Gait


Abnormal Gait – Scissor Gait


Examination of Special Signs

• Neck rigidity - in Meningitis

• High Fever, severe Headache, projectile vomiting, positive Babinskis sign & positive Kerning's sign - usually present in Meningococcal Meningitis


Prof.Dr.R.R.Deshpande

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11/28/2016 174Prof.Dr.R.R.Deshpande

clinical examination of nervous system - ppt

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