Neurological Assessment Randa M. Albusoul
Anatomy The nervous system can be divided into: Central Nervous System (CNS) Peripheral Nervous System (PNS) # CNS includes brain and spinal cord #PNS includes 12 pairs of Cranial Nerves (CN) and 31 pairs of spinal nerves.
The brain consists of: • Cerebrum: vast network of interconnecting neurons. Nerve cell = cell body and axon. Brain tissue may be gray or white matter. Gray matter (neuronal cell bodies) White matter: (neuronal axons). • Why cerebral cortex is gray? Because it lacks myelin
• Hemisphere: is a half of the cerebrum. • Each hemisphere has 4 lobes. • Each lobe mediate specific function. • Frontal lobe: personality, behavior, emotions, and intellectual function. • Contains Broca’s area that mediates motor speech; when injured lead to expressive aphasia; person cannot talk.
• Parietal lobe: primary center for sensation. • Occipital lobe: primarily visual receptor center. • Temporal lobe: primarily auditory reception center. • It also contains Wernicke’s area for language comprehension (receptive aphasia: hear sounds but have no meaning for him).
• Basal Ganglia: movement. Example; Arm and leg swinging during movement. • Thalamus: processes sensory impulses and relays them to the cerebral cortex. • Hypothalamus: maintain homeostasis, regulates temperature, heart rate, blood pressure, sleep center, emotional behavior, pituitary gland regulator. • Cerebellum: voluntary movements, equilibrium, and muscle tone. • Brain Stem: midbrain, pons, medulla (has vital autonomic centers: respiratory, heart, gastro).
Spinal Cord: • Long structure that connect the brain with the spinal nerves. • It can mediates reflexes. • Ends at 1 st or 2 nd lumber vertebra.
Pathways of the CNS: Sensory pathways: • There are sensory receptors in skin, mucosa, muscles, tendons, and viscera.. • The brain monitor the organ sensation, position, function…
Sensation of position: proprioception; without looking you know where your body parts are in space and in relation to each other. Sensation of vibration: feeling vibrating objects. Localized touch: stereognosis; without looking you can identify familiar objects by touch. Note that Lt cerebral cortex receives sensory info from and controls motor function to the Rt side of the body and visa verse this is called crossed representation.
The PNS: The Cranial Nerves (CN): emerge from cranium; CN I and II from the brain. CN III to XII fro diencephalon and the brainstem.
The peripheral nerves: • 31 nerve; 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal. • Each nerve has an anterior root containing motor fibers, and posterior root containing sensory fiber. • The anterior and posterior roots merge together to form spinal nerve.
Reflexes: involuntary mechanism that permit a quick reaction to painful or damaging situation. Types of reflexes: • deep tendon reflex.
• Superficial reflexes: such as corneal reflex and abdominal reflex. • Visceral reflexes (organic): pupillary response to light and accommodation. • Pathologic (abnormal) reflexes: such as Babinski’s reflex. Reflex arc: Sensory stimulus, posterior root, spinal cord, synapse with a motor neuron in the anterior horn, anterior root, muscle.
Dermatomes: • Band of skin that is innervated by the sensory root of a single spinal nerve • Help to localize the lesion to a specific spinal cord segment.
Subjective Data Common symptoms Headache Dizziness or vertigo Weakness Numbness or loss of sensation Loss of consciousness Seizure Tremors Difficult swallowing Difficult speaking
Objective Data 1) Mental status and level of Consciousness. Is the pt oriented to time, place, and person? 2) CN: *Olfactory (I) (S): test sense of smell. *Optic (II) (S): test visual acuity and fields (by confrontation).
*Oculomotor (III), Trochlear (IV), Abducens (VI) (M): Pupils size, reflex, accommodation, & upper lid movement (III) & asses extra ocular movement.
*Trigeminal (V) (M/S): • Assess the muscles, jaw clenching for temporal and masseter, lateral jaw movement for lateral pterygoids. • Assess all three devision of the nerve (ophthalmic, maxillary, and mandibular). Compare between sharp and dull or hot and cold sensations in each side.
• Corneal reflex: make the pt look up and away from you. Touch the cornea by cotton, the normal reaction is blinking, the sensory of this reflex is carried by CN (V), and the motor by CN (VII).
*Facial (VII) (M/S): • M / facial expression during movements; smile, close eyes then open, frown, lift eyebrows, show teeth, puff cheeks, close mouth. • S / taste (sugar, salt, sour, bitter) on the anterior two third of the tongue.
*Acoustic (VIII) (S): hearing acuity; whisper, Weber, Rinne. *Glossopharyngeal (IX) & Vagus (X) (M/S): M / uvula (in midline) & soft palate rise, positive gag reflex (CN X), S / taste on posterior 1/3 of the tongue (salty, sweet, sour, bitter) CN (IX).
*Spinal accessory (XI) (M): assess the muscles, shoulder shrug (trapezius), turn head to each side against your hand (sternomastoid).
*Hypoglossal (XII) (M): Ask the pt to protrude the tongue, look for symmetry/midline, ask pt to talk (CN V, VII, X, XII). 3) The motor system: Coordination requires muscle strength, cerebellar system, vestibular system, and sensory system (position sense). • Assess rapid alternating movement: Ask the pt to strike one hand on the thigh, raise the hand, turn it over, and then strike the back of the hand down n the same place.
Point-to-point movements: • Finger to nose; smooth & accurate movement; move your finger, or fix it and make the pt close her eyes. • Heel to shin: moves heel in a straight line down the shin.
• Gait: Assess pts walking across the room (posture, balance, swinging of the arms..). Walk heel-to-toe in a straight line. Walk on the toes. Hop in place. Do a shallow knee bend. Rise from a sitting position.
• Stance: Romberg test: ask the person to stand up with feet together and arms at sides, close eyes. Maintain posture & balance with slight swaying. Pronator drift:
4) The sensory system: To evaluate the sensory system, test the following: ● Pain and temperature (spinothalamic tracts) ● Position and vibration (posterior columns) ● Light touch (both spinothalamic and posterior) ● Discriminative sensations, which depend on some of the above sensations but also involve the cortex. *compare symmetrical areas and proximal and distal areas. *vary the pace of your testing. *Map out the boundaries.
• Pain: you can use broken tongue blade and cotton swap. • Show the pt both sensations before closing his eyes. • Use lightest pressure needed. • If pain assessment is normal no need for temperature assessment. • Light touch: see if the pt feel the touch and can compare between sides. • Vibration: if he can feel it and when it stops. • Proprioception: up and down.
• Discriminative sensation: • Stereognosis: • Graphesthesia: number identification.
• Two point discrimination: • Find minimal distance in different body parts. • Point localization. • Extinction; simultaneously stimulate corresponding areas on both sides of the body and ask where the pt feel it.
5) Dermatomes: Assess dermatomes of the pt, some landmarks may be: C3: Front of the neck T4: Nipples T10: Umbilicus L1: Inguinal 6) Tendon reflexes: • Encourage the pt to relax before beginning the procedure. • In documentation, follow the following grading scale:
The knee reflex (Patellar Reflex) (L2, L3, L4): • The pt may be sitting or lying but knee should be flexed. • Tap the patellar tendon below the paterlla. • Note contraction of the quadriceps with extension of the knee.
The knee reflex (Patellar Reflex) The Plantar response (L5,S1): • Stroke the foot from the heel moving up toward the small toe to the ball of the foot, curving medially across the ball. • The normal response is a downward contraction of the toes, called the plantar response.
• The abnormal response is called Babinski response. Babinski response Plantar response
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