examination of central nervous system

7/31/2019 Examination Of Central Nervous System

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Examination OfCentral Nervous

System

Dr Bhawna Verma (PT)


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Examination/Assessment

Enable the therapist to know about the nature

and extent of the patient s difficulties in his

day to day life .


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Aim of Neurological Examination

Determine the site and nature of disease of the

nervous system .

It is an essential part of any routine clinical

examination.


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Classification Of Examination OfCNS

Subjective Examination

Objective Examintaion


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History -patient/his relatives in case where

the patient is either unconscious or child


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1. Name of the patient-foridentity of thepatient .

2. Age of the patientSome diseases occur at a

particular age group .3. Sex-Some diseases are more common in

males while some in female.

4. Occupation-To get proper understanding ofthe diseases and for planning the treatmentaccordingly.


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5. Address-Toget proper idea of general status

of the patient ,his surrounding and his

nutritional hygiene level.

6. Past medical history-whether he has got

history of chronic illness like diabetes

,hypertension, leprosy, tuberculosis. Because

in presence of any diseases, the treatment

should be altered and planned accordingly.


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7.History of presenting illness-

a. Onset of symptoms-

Time- The patient is asked whether the symptomsappeared gradually over a period of time or theywere sudden in origin.

Type- The patient is asked about the type of onsetof symptoms acute, subacute ,chronic

b. Progress of the disease-

This consist of finding out how the symptomsprogressed over a period of time

Whether it is progressively worsening disease? It is disease with remission and exacerbation?

Is it a disease which come suddenly andsubsided over a period of time


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8. History of treatment-

Anytreatment carried out during this period orprogress of disease and its effects should be noted.

9. History taking from relatives-when

The patient is child

The patient suffer from episodes of impairment ofconsciousness

There is obvious memory defect or mental

change. Details concerned with other member of thefamily need to be checked.


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10. Social and Family History-

How much family support can be expected

by the relatives to assist the therapeutic

programme at home .


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Objective Examination

Observation

Examination


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Observation

General Appearance

Built-Obese/lean/thin/muscular

Height-Dwarf/giant ,that is if acromegaly ispresent or not.

Facial Expression-To check if the patient issuffering from myasthenia gravis or

Parkinson's disease Skeletal Deformities-Look for any skeletal

deformities like spina bifida


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Look for any abnormal size of head such as in

Hydrocephalus, Acromegaly,Achondroplasia

and Pagets disease.

Mode of dressing.

The hairlook for any premature baldness

.very obvious in myotonic dystrophy,Alopecia

etc.

Skin coluration

Muscle atrophy

Signs of ill health or malnutrition


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Handedness

Whether the patient is right handed or left

handed as the treatment should be planned

accordingly.


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Examination

Mental Function-

a) Level of consciousness-observation of the

patient is done .Level of consciousness is

done by GLASGOW COMMA SCALE


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GCSEye opening(E4) Spontaneous 4

Open to sound 3

To painful stimuli 2None 1

Motor response(M6) Obeys 6

Localized painful stimuli 5

Withdraws to stimuli 4

Abnormal flexion to stimuli 3

Extensor response to stimuli 2

None 1

Verbal response(V5) Oriented 5

Confused 4

In appropriate speech 3

In comprehensive sound 2

None 1

Score 3-15

13-15 mildunconscious for


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Orientation

Disorientation may occur in Time, Place and Person

Ask patient to estimate the approximate time without

looking a watch

Whether day /night

Where he is

Whats his name of the hospital

Relaion of the person surrounding him Recognize his relatives by nae and relation ,Doctors

and nurses


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Memory

Test the patients ability to remember events of that

day ,previous week ,month or earlier year.

Ask what he has recently done ,How he came to

building?? Read out him clearly and slowly a series of number

and ask him to repeat

Ask the patient to recall what he has read in the paperor seen on television.


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Emotional State

Mood of the patient

Anxious

excitedDepressed

Frightened

ApatheticEuphoric


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General Intelligence

In case of brain injury or disease .

Education

Character of his workWork record


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Communication

1. Receptive Ability

2. Expressive Ability


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Receptive Ability

Is his attention easily held or fleeting

Does he show a reasonable degree of interest

in surroundings

How does he react to the therapist approach

and greeting

Any usual features in his behavior (FacialExpression or nay inappropriate behavior)


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Expressive Ability

Whether his conversation flows easily or not

Whether hi is mute, answer only by

monosyllables or is over talkative

Does he use strange words??


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Signs of meningeal irritation

1. Neck Stiffness-Ask patient to flex his neck fully

Then therapist passively flexes his neck

The chin should normally touch the chest without pain

In case of meningeal irritation-Pain in flexion

That may radiate to back and movement restricted by

spasm in the extensor muscles of the neck


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Kernigs Sign

Supine

Passively extend the patients knee

when his hip is fully flexed.

If meningeal irritation in lower part of the spinal

subarachnoid space is present this movement

causes pain and spasm of hamstrings


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Straight leg raising test

For nerve root compression

Mainly to detect sciatic nerve

PASSIVELY EXTEND THE PATENTS LEG WITH

THE HAND WHICH IS PLACED BEHIND THEHEEL

Pain in back of thigh or calf .hence movement is

restricted because of this sciatic pain when spinalroots are entrapped in lumbosacral intervrtebral disc

protrusion


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Sensory system Examination

Extroceptive or cutaneous sensation

sensationderived from outside of the body.these are

Pain,light touch ,temprature

Proprioceptive sensationsensation derived frombody itself-sense of position.passive

movement,vibration and deep pain

Combined and cortical sensation-

Sterognosis,graphaesthesia,two point discrimination

Perceptive sensation-Apraxia,Agnosia,disorder of

body scheme


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Pain

Choose a part of the patients body which is expected to benormal and touch him precisely not too firmly several times

with the point of the pin .then ask him .

Whether he can feel any thing and if yes describe what does he

feel If he say yes that he can feel a point then whether it is sharp or

blunt

If it becomes clear that the patient recognize the stimulus ,then

compare quickly the sensation in a number of areas includingface , shoulder, the inner and outer aspect of the upper limb

,upper and lower chest and abdomen ,lower limb and the

buttocks.


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Touch

A small piece of cotton wool can be used to

check the sensation of light touch, as it does

not cause excess pressure to stimulus deep

sensibility.

Ask the patient to close his eyes and say yes

each time he feel ant thing. The cotton wool is

shaped to point and the skin is then touchedlightly testing in dermatome areas.


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Temperature

The patient can compare the temperature of cold object such astuning fork on the main sensory areas of the body.

After this the test tube containing hot water (43degree C)and

cold water (7 degree C)are used .

Extreme of heat and cold should not be used because thesestimulate pain fibres.

The patient is ask to close the eyes through out the examination

and is asked

What he can feel ? Whether there is any difference ,when the outer tube is used ?

If he can feel the difference ,then what that difference is ?


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Proprioceptive sensation

Position senseclose the eyes

place limb in particular position then move it away.

Ask him first to replace it himself and then to place

the opposite limb in a similar position. Ask him to place his heel accurately on his knee.

Ask him to place his forefinger accurately on the tip

of his nose .Ask him to place his heel accurately onhis knee.


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Sense of passive movement

Close the eye .The digit (thumb, finger,big toe )is

held firmly and moved up and down ,while the

patient is asked if he can feel the movement .if he say

yes he can feel the movement then he is askedwhether his thumb /toes has been moved upwards or

downwards


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Vibration sense

For testing the vibration tuning fork of 128 hz

and 256 hz placed on his clavicle to allow him

to identify the sensation of vibration .

He is then asked to close the eyes and the fork

is struck and placed on bony points starting

peripherally at the internal malleoulus and the

lower end of the radius.

The patient is then ask if he can feel the

vibration.


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Deep pain or muscle activity

To assess the sensitivity of the muscles .the thumb are

firmly pressed into the muscles of the forearm and the

calves.

If the muscle are abnormally tender then the patientcomplains of distress even under lighter pressure. But

in case of diminished sensitivity the patient will allow

all possible forces to be exerted without any

complaint.

Squeezing the tendoachillis between the finger and

the thumb will allow the assessment of diminished

deep sensation


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Cortical Sensation

Stereognosis-Ability to recognize the object .by

shape and size .

Object-keys ,coins,combs,pencils.pen etc

Close eye ,place object in suspected hand if he

fail to recognize then in other hand and

comparison of accuracy and speed of response

is made


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Tactile localization

Ability of an individual to localize touch

sensation on his skin

Close eyes then touch on some point with the

therapists finger or a pin .

The patient is then asked to identify the

location of the stimuli by either touching the

same point with his own finger or verbal

description


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Two point discrimintion

Ability of an individual to detect that a stimulus consist of two blunt

point when the stimulus are simultaneously applied

Explain the test to the patient ,first by touching his finger with two

point widely separated and with the patients eye opened.

Then asked to close the eye and two ends are applied

simultaneously with each application the two ends are gradually

brought close until the stimuli are perceived as one.

The normal ability to distinguish the two point from one varies in

different parts of the body.


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Graphaesthesia

Ability to recognize letters or number written

on skin with a blunt point while he closed his

eyes .


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Baragnosis

Recognition of weight

for this a series of small object of same size

but of different weight are used .


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Perceptive sensation

Agnosia-Gnosis in greek means perception (inability to

recognize familiar objects)

Ability to recognize the thing in absence of lack of

intelligence ,mental disorder or any defect in sensorymechanism.

It may be of three types

Visual-due to lesion in parieto-occipital region

Auditory- lesion in temporosphenoidal region

Tactile-lesion in parietal lobe behind the posterior

central gyrus


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Visual Recognition

Show the patient a number of common small objects and then

ask him to

Name them

describe their use

Pick the one that are named by the therapist .

Next show the patient various different colors and ask him

Their name

To pick out the duplicates from the other setTo arrange them in shades of increasing or decreasing lightness


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Auditory recognization

First make sure that hearing in both ears is

normal .

Close the eyes then identify the sounds made by

striking a match, ringing a bell, shaking money

,tearing cloth


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Tactile recognization

First make sure that the sensation of both hands

are normal .then ask the patient to close his

eyes and then place a number of common

objects one by one in one or both hands.

Then ask the patient to name them ,describe their

shape, size and texture and then lastly to

indicate their use.


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Apraxia

Ability to carry out purposeful movement(inspite of

normal tone,normal movement) in the absence of any

motor paralysis, ataxia,sensory loss or a difficulty in

understandingTypes-Ideomotor-patient has ability to do the

movement but when we ask he doesnt do that.

Ideationpatient does not have idea

Constructionaldoesn have ability to proportionate

,he doesnt relates size.

Other types-Dressing Apraxia-No relation between

garments and parts,


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Apraxia may involve any voluntary movement

occular,bulbar or that of extrimities.

Lesion in the left parietal lobe produce

bilateral apraxia on the right side,while lesion

in the anterior part of the corpus callosum and

up to the precentral gyrus on the right sideproduces apraxia on the left side.

Motor aphasia-is apraxia of speech


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Method of testing

Ask him to hold out his arms, take out his tongue, show his

teeth, etc if he fails to do then note whether this movement are

normal when they are automatic eg. Licking the lips, smiling

or responding to an offer to shake hands .

Next ask him to make a fist ,to scratch his arm and moredifficult ,to use a pair of scissors ,a pen and a comb.Any tst

which requires three or four different movement ,can be used

with or without the use of objects.

Give him a series of match sticks and ask him to form atriangle or square. If he fails to d then ask him to copy you.

Note how he takes off his coat and jacket and puts them on

again, how he buttons his shirt.


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Disorder of body schema and image

Body image-is defined as visual and mental image of

ones body that include feelings about ones body

especially in relation to health and disease.

A normal individual is able to tell where each part ofhis body is and where it lies in relation to surrounding

objects. and may even deny

If disruption patients remain unaware of the part and

may even deny that it is the part of his own body.


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Method of testing

Ask the patient that whether he knows his right handand left hand and leg.

Then ask him to point different major parts of his

own body according to therapists commands. Then ask him to point the ring finger of his left hand,

the forefinger of his right hand, to point the little toes

etc. making the test a little bit more complex.

Make the more difficulty by asking him to point out

individual digits of therapist hands etc.

Observe during general examination whether he is

aware of his disability or not.


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Motor System examination

The main function of Motor system is to control the

bodys normal posture and movement.

Examination of motor system includes-

AnatomicalExamination-Inspection-observe and compare with opposite side and

size could be determined as normal,smaller,larger.

Palpation-Feel the muscle /Normal,Softer,harderMenstruation-the girth of one muscle or a group of

muscles should be compared by measuring with tape.

Physiological Examination


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Physiological Examination

Muscle bulk and wasting

Biceps,triceps in UL

Quadriceps ,and gastrosoleus in LL

Measur cicumference of the limb at-

10cm above and below the olecranon forbiceps and triceps respectively.

15cm above and 10 cm below the tibial

tubrosityfor quadriceps and gastro-soleusrepectively.


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Range of motion

Active ROM

Passive ROM

Other points to be observed along with range are

1. The presence of pain with motion . When does the pain appear

Severity of pain

Patients reaction to the pain

2. The presence of limitation of joints3. If limitation then cause of limitation

4. Movements of associated joints


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Spasticity

There is increase in the tone of one group of muscle ie

either agonist or antagonist result from lesion of

pyramidal tracts ,inhibitory reticulospinal tracts

which leads to increase facilitation of stretchreflex.This lead to increase in phenomenon called as

Clasp knife spasticity .where after an initial resistance

the muscle gives away

Passive stretch of a spastic muscle may produce aninitial high resistance followed by a sudden inhibition

of resistance termed as CLASP KNIFE REFLEX.


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Rigidity

Resistance is uniformly increased in both agonist and antagonist

muscle ,making body parts stiff and immovable.when the

lesion is in extra pyramidal tracts or basal ganglia which

results in exaggeration of tonic stretch reflex.

It maybe

Cog Wheel Rigidityit is characterized by an alternating

contraction with jerky movement producing resistance to

movement.(Intermittent resistance throughout the movement )

Lead pipe rigidity-Constant rigidity present throughout themovement (continuous resistance to passive movement )


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Clonus

It is defined as repetitive contraction of a

particular group of muscle due to exaggeration

of dynamic stretch reflex.


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Flaccidity

Flaccidity and hypotonia-Absence/decreased

muscle tone

Resistance to passive movement is diminished

Stretch reflexes are dampened and limbs are

easily displaced.


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Assessment

General clinical scale

0-No response

1-Decreased response

2-Normal response

3- Exaggerated response

4-sustained response


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ASHWORTH SCALE

To assess spasticity

0-No increase in muscle tone

1-Slight increase in muscle tone ,manifested by catch and release

or by minimal resistance at the end of ROM ,when the affected

part is moved in flexion and extension .

1+Slight increase in muscle tone ,manifested by catch ,followed

by minimal resistance throughout the remainder of ROM

2-More marked increased in muscle tone through most of the

ROM ,but affected part is easily moved

3 Considerable increase in muscle tone, passive movement is

difficult .

4-Affected part is held rigid in flexion or extension.


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Test for assessing spasticity

Pendulum Testpatient sitting or lying with knee

flexed over the end of a table

The patient knee is fully extended and allows to drop

and swing like pendulum. A normal and hypotonic limb will swing freely for

several oscillation .

Hypertonic limbs are resistant to swinging motion

hence will quickly return to the initial starting

position .


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Drop arm test

In this the therapist suddenly drop a limb that has

been held.

A normal limb falls momentarily ,then catches

and maintains the position.

Hypotonic limbs fall abruptly, while hypertonic

limbs show a delay and resistance to falling


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Motor sensory links

Reflexes

Deep-Deep tendon jerks eg Biceps, Triceps,

Supinator ,Brachioradialis.

Superficial-Abdominal, Plantar reflexes


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Involuntary movement

Involuntary movement are unintended movement ,which occur

either at rest or during voluntary movement.

These are

1. Tremor-It is involuntary oscillatory movement ,which result

from alternate contraction of opposing muscle groups. It is

rhythmical oscillatory movement of a body part caused by

regular muscle contraction.


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Types of tremors

1. Physiological-is a universal phenomenon in normal

people .A variable degree of tremors are seen which

increases by anxiety, tension ,fear etc.

2. Senile-this is a type of postural tremor involvingupper limb .seen in old age .

3. Resting tremor/static/postural-in basal ganglia lesion

.is occurs when the patient is in static posture .

4. Intentional-in cerebellar lesion . tremor-It occurs

during voluntary motion of a limb and increases as

the limb reaches near its goal. These are decreased

or absent at rest


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Chorea

They are flowing or changing irregular

purposeful movement which are jerky in

nature ,which appears for a short period of

time and they fling from one joint to anotherusually from distal to proximal.

They arise because of lesion in basal ganglia

mainly globus pallidus and caudate nucleus.


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Athetosis

It is characterised by slow, involuntary

writhing,twisting ,worm like movement .

It is more seen in distal than proximal muscles.

The neck ,Face ,tongue and trunk may also be

involved.

Is is seen in lesion of basal ganglia .


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Choreo athetosis

Is is a movement disorder having features of

both chorea ans athetosis.


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Hemiballismus

Sudden ,jerky, forceful,wild and flailing

movement of one side of the body

characterizes it.

It is almost invariably unilateral and affects thearm more than the leg.

The movement may be so violent that it may

result in serious injury to the limb.


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Dystonia

It involves twisting ,sometimes bizarre

movement caused by involuntary contraction

of the axial and proximal muscle of the

extremities .

Torsion spasm are also considered a form of

dystonia and the most common among this is

Spasmodic torticollis


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Isolation of the muscle Isolation is defined as placing of a muscle in detached or non working

position to obtain the requires action in a free state. it is actually testing the

muscle individually .

In isolation of the muscle, the multi-joint muscle is fixed to get the action

of a single joint muscle.

When one joint and a multi joint ,muscle act together in a movement, theaction of one joint muscle can be differentiated from that of multi joint

muscle by placing the multi joint muscle at mechanical advantage .

Keeping it engaged at joint in full range of motion so that is power to assist

a movement at other joint is decreased does this .

Eg-Flexing the knee decreases the action of hamstrings at hip as extensor.Here gluteus maximus is isolated from hamstrings.


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Inhibition of muscle work

This is compensation made by powerful

muscle or muscle group for lack of function of

weak or paralyzed muscle.

This result in inhibition of the weak muscleand the movement is also called as trck

movement.

These movement appear somwhat similar tothe actual movement but are not actual

movement .


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Balance

Static and dynamic

How much help does he need to maintain particular position

His conscious balance assessed by applying pressure and

telling him to hold against that pressure .give pressure in

various direction ,note his stability.

Same with eye closed .

Tilt him backward, forward,sideways and rotate him getly ao

as to distrb his COG. Notice whether he moves his head

,trunk,UL,LL or all of them to maintain equilibrium

Try the same with closed eyes


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Gait assessment

Circumductory GaitHip hiking ,throwing the

affected leg outward producing the movement

of circumduction and leaning towards the

opposite side with arms flexed across the body. Seen in Hemiplegia


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High stepping gait

Seen in patient with foot drop due to which he

raises the foot high to overcome it

S


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Shuffling gait

In this the movement occurs in a series of

small ,flat-footed shuffles seen particularly in

parkinsons disease

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Ataxic gait

The patient walk with broad base .sways to

and fro and looks as if he is being drunk.

It is most common in cerebellar ataxia

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Waddling gait

There is excessive rotation of pelvis ,

accompanied by compensatory movement of

upper trunk .

Seen in congenital dislocation of hip inmyopathies.

F i l A


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Functional Assessment

Bathingindependent/Dependent

Dressing- independent/Dependent

Going to toilet- independent/Dependent

Continence-independent-if patients urination and defecation

are entirly self controlled. DependentIf he has got partial or

total incontinene in urination or defecation

Has got partial or total control by anemas,cathers or regular

use of urinals or bedpans.

Transfer- independent/Dependent

Feeding - independent/Dependent


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examination of central nervous system

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