CHAPTER 16
The Neurological Exam
CHAPTER PREVIEW
CHAPTER OUTLINE
To complete our journey into the world of neuroscience, we will explore how to evaluate the nervous system. We will first survey how a neurologist performs a neurological exam and then look for areas of overlap with methods used by communication disorders professionals.
IN THIS CHAPTER
In this chapter, we will . . .
■ Explain what a neurological exam is and list what tools are needed for it
■ List and explain the different parts of the neurological exam
■ Compare and contrast the neurological exams used by neurologists with those used by communication disorders professionals
■ Explore the salient signs of neurological injury
LEARNING OBJECTIVES
1. The learner will define what a neurological exam is.
2. The learner will list the steps of the neurological exam and the tools involved.
3. The learner will list and define signs of neurological injury.
■ Introduction
■ The Neurological Exam
• The Tools of the Neurological Exam
• The Steps of the Neurological Exam
■ A Comparison of Neurological Exams by Neurologists and SLPs/ Audiologists
■ Signs of Neurological Disease
• Cranial Nerve Signs
• Motor Signs
• Reflex Signs
• Sensory Signs
• Other Signs
■ Conclusion
■ Summary of Learning Objectives
■ Key Terms
■ Draw It to Know It
■ Questions for Deeper Reflection
■ Case Study
■ Suggested Projects
■ References
► Introduction
Hippocrates (460-370 BCE) was an ancient Greek physician best known for developing the oath that doctors still make today, the Hippocratic Oath (BOX 16-1). In a time when gods and goddesses were seen as the causes of illness, Hippocrates believed that diseases had natural causes (e.g., diet, the environment, living habits). He developed this belief out of his powers of observation. In other words, he believed that observation of the patient was critical to good medical care. Lloyd (1984) summarizes the Hippocratic tradition of observation, using quotes from the Ancient Greek text Prognosis, as follows:
First he should examine the patient’s face, for example the colour and texture of the skin, and especially the eyes, where he should consider whether “they avoid the glare of light, or weep involuntarily,” whether “the whites are livid,” whether the eyes “wander, or project, or are deeply sunken,” and so on. (p. 152)
Following in the Hippocratic tradition, there is no real substitute for a careful, systematic examination of people with neurological conditions. In fact, Blu- menfeld (2010) remarked that before the neuroimaging era, “great clinicians could pinpoint a lesion in the nervous system with often astounding accuracy” (p. 50). Many students rush to get through a patient examination in order to get to the fun stuff—therapy. What they soon learn is that good therapy is built on a good evaluation. It is in the process of evaluating people that both their strengths and their weaknesses are identified. Through this process, weaknesses can be addressed, often using the remaining strengths. In this chapter, the components of a careful neurological exam by a neurologist will be surveyed, and points of overlap with an exam by a communication disorders professional will be considered.
► The Neurological Exam
A neurological exam is a systematic examination of the nervous system. The nervous system is a series of organs that make communication possible throughout the body. The neurological exam is a tool used to explore and identify any pathology affecting the proper functioning of these organs. This exam is systematic, meaning that it involves a method or ordered plan. Neurological exams are typically performed by neurologists, who are doctors with specialized training in nervous system anatomy and physiology as well as its pathologies. We will explore how a neurologist goes about his or her examination of the nervous system and identify areas of overlap with the examination that a speech-language pathologist (SLP) or audiologist would perform.
BOX 16-1 The Hippocratic Oath
I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgment, I will keep this Oath and this contract:
To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.
I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary [medical device] to cause an abortion.
In purity and according to divine law will I carry out my life and my art.
I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.
Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.
Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.
So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.
Reproduced from North, M. (translator) (2002). Greek medicine. Bethesda, MD: History of Medicine Division, National Library of Medicine, National Institutes of Health. Retrieved from http:// www.nlm.nih.gov/hmd/greek/greek_oath.html
The Tools of the Neurological Exam
A neurologist typically uses seven tools in a neurological exam (FIGURE 16-1):
1. The reflex hammer is used to elicit deep tendon reflexes. One well-known deep tendon reflex is the patellar or knee reflex, which involves a slight kick elicited by striking the knee just below the patella. Examples of other common reflexes associated with communication structures can be found in BOX 16-2.
2. A pin is used to test sensory abilities, light touch, and some reflexes. For example, sensory functions of the foot are tested by lightly touching the parts of the foot and asking the patient if they can feel the pin. This occurs often with diabetics who suffer from peripheral neuropathy.
3. An ophthalmoscope is used to observe the structure of the eye and test the pupillary light reflex, which is the reduction in the size of the pupil with the introduction of light.
4. Visual acuity cards are used to test a patient’s visual abilities.
5. Cotton swabs are used to test the corneal reflex (i.e., when the eye blinks in response to something coming near it).
6. Tuning forks, one tuned to 256 hertz (Hz) and the other to 512 Hz, are used to test a patient’s sense of vibration as well as hearing. In terms of hearing, the Rinne test is completed by striking the 512-Hz tuning fork and placing it on the mastoid bone behind the ear. The patient then reports the point when he or she cannot hear the sound anymore. The tuning fork is then held to the ear on the same side, and the patient is asked if it can be heard and if it is louder or softer than behind the ear. The sound should be louder when the tuning fork is next to the ear than behind it. If it is not, then the patient may have a conductive or middle ear hearing loss. A Weber test is done by striking the 256-Hz tuning fork and placing it on the center of the head. If the sound is louder in the affected ear, then the loss is conductive (middle ear); if softer, then the loss is sensorineural (inner ear). Normal hearing results in the sound being heard in the middle.
7. A bar of soap is often used to test a patient’s sense of smell, although some neurologists prefer to use a small vial of coffee grounds. The neurologist asks the patient to close his or her eyes and then places the bar of soap or vial of grounds below the nostrils and asks the patient to identify the scent.
FIGURE 16-1 Seven tools are used in the neurological exam. One of the tools, the pin, is not pictured. The other tools are shown as follows: A. Reflex hammer. B. Tuning fork. C. Ophthalmoscope. D. Visual acuity card. E. Cotton swab. F. Soap.
A. © sfam_photo/ShutterStock. B. © Stockbyte/Thinkstock. C. © Nancy Hixson/ShutterStock. D. © jocic/Shutterstock. E. Daniel R. Burch/iStockphoto/Thinkstock. F. © jocic/ShutterStock.
BOX 16-2 Examples of Reflexes Associated With Communication and Swallowing Structures
Acoustic reflex: The middle ear muscles contract in response to increased sound intensities. This reflex functions to protect middle-ear bones. It appears at birth and persists into adulthood.
Tongue reflex:The tongue thrusts when touched. This reflex appears at birth and disappears between 12 and 18 months.
Jaw jerk reflex: The mandible elevates after a light tap below the lower lip. This reflex is normally absent or only slight. It appears at birth and persists into adulthood.
Rooting reflex: An infant turns his or her mouth toward anything that might come near the mouth. This reflex appears at birth and disappears between 3 and 6 months.
Suckling reflex: An infant displays bursts of rhythmic sucking in response to a finger or nipple near the mouth. This reflex appears at birth and disappears between 6 and 12 months.
Swallowing reflex: Pharyngeal muscles contract to move a bolus through the pharynx to the esophagus. This reflex appears at birth and persists into adulthood.
Bite reflex: When pressure is applied to the gums, the jaw closes and the infant bites down. This reflex appears at birth and disappears between 9 and 12 months.
Gag reflex: When the posterior pharyngeal wall is touched, a vomit-like response occurs, without actual vomiting. This reflex appears at birth and persists into adulthood.
Cough reflex:The vocal cords enable a rapid release of air from lungs. This reflex functions to protect the airway by kicking foreign substances away. It appears at birth and persists into adulthood.
The Steps of the Neurological Exam
Step 1: The Interview
As mentioned at the beginning of this chapter, the neurological exam is systematic in that it follows a certain set of steps. The neurologist begins this systematic review by first interviewing the patient and/or the patient’s family to understand the circumstances of the illness and the patient’s symptoms. A symptom refers to a patient’s subjective report of what he or she is experiencing during the illness. This can be compared to a sign, which is an observation made by an observer, sometimes through use of equipment such as a thermometer or blood pressure reader. Thus, a patient may report “feeling hot” (a symptom), whereas a nurse might report that the patient’s temperature is 101°F (38.3°C) on the thermometer (a sign).
Neurologists differ in how they interview patients, but a common way to begin is to ask why the patient is in the hospital or why the patient has come to see the doctor. This line of questioning is meant to elicit the patient’s chief complaint. Next, questions involving the history of the present illness are typically asked, such as, “When did your symptoms begin?,” “How long have they lasted?,” and “Do they get better or worse?” A patient’s past medical history is then explored, which includes questions about what other illnesses he or she has experienced and the treatment involved in those conditions. Questions may expand to the patient’s family and their history of illness (i.e., family history) because many illnesses are inherited. In addition, the patient may be asked about medications he or she is taking and allergies he or she may have. Sometimes questions about the patient’s social history will be asked (i.e., activities or hobbies) as well as environmental history, focusing on the particular environments the patient spends time (e.g., chemical plant, dry cleaners). The neurologist will then conduct a review of systems where the patient is asked if he or she has any problems with his or her lungs, digestion system, and so on, and if so, what symptoms are being experienced. (Note: The review of systems can be done through an intake form before a patient sees the doctor.)
Step 2: The Physical Exam
The physical exam begins by the neurologist introducing himself or herself to the patient and observing whether the patient is awake, alert, and responsive. Personal hygiene and dress are examined to determine if the patient is capable of self-care. The neurologist then proceeds with an examination of the head, ears, eyes, nose, and throat, which is known as a HEENT exam. Major systems (e.g., heart, lungs) are examined using a stethoscope. The patient’s body posture and motor activity are observed. If the patient leans to one side, there may be weakness issues. Dyskinesias (i.e., movement problems) may indicate nervous system damage. Height and weight are measured to determine if the patient is obese or cachectic (i.e., ill health with emaciation), and vital signs (e.g., blood pressure) are taken. A dysmorphic examination is performed, noting any abnormalities of face or body shape (e.g., low-set ears or wide-set eyes).
Step 3: The Neurological Exam Proper
In many ways, this part of the exam began with the interview and physical exam as the neurologist observed the patient’s mental status and motor activity. During the neurological exam proper, the neurologist performs a more formal assessment of mental status and motor activity as well as reflexes, senses, and equilibrium.
Mental status is the degree of cognitive competence a person has. The neurologist will often begin informally assessing this area by considering the patient’s expressive and receptive language abilities. To do so, the neurologist asks the patient to name items, repeat words, follow commands, read, and write. He or she also tests the patient’s orientation to person, place, time, and purpose (e.g., “Why are you in the hospital?”). To test long-term memory, three unrelated words are usually given, which the patient is asked to recall after 5 minutes. Short-term memory is assessed by asking the patient to recall strings of numbers. Attention and math are evaluated by asking the patient to count backward by 7 from 100. Abstract reasoning is tested by asking the patient to interpret proverbs (e.g., Please explain this proverb: “The grass is always greener on the other side of the fence.”). Formal testing of these abilities can also be done through published tests, such as the Mini-Mental State Examination, the Short Portable Mental Status Questionnaire, and the Galveston Orientation and Amnesia Test.
After assessing the patient’s mental status, the neurologist conducts a cranial nerve evaluation. Humans have 12 pairs of cranial nerves that control motor, sensory, and other functions of the head and neck. Some of the conditions associated with cranial nerve damage will be explored later in this chapter.
Motor testing involves observing posture and how well the patient moves his or her limbs. Neurological damage will sometimes result in paresis (i.e., weakness) or plegia (i.e., paralysis), so the neurologist needs to determine whether these problems exist; if they do, physical and/or occupational therapy can then be ordered. Reflexes, which are the lightning-quick, unconscious responses our body makes to stimuli, are assessed at this time, as is sensation in terms of touch, pain, temperature, and vibration. A patient’s equilibrium (i.e., coordination and balance) is tested by observing gait (i.e., walking) and diadochoki- netic rates (i.e., rapid, alternating motor movements such as quickly saying “pa-ta-ka” as fast as possible).
Step 4: Laboratory Tests
Hematological tests (i.e., blood tests) are routinely ordered to assess a patient’s red and white blood cell counts, among other factors. In addition, neuroimaging studies, which allow neurologists to see visual representations of the nervous system, are routinely ordered when nervous system damage is suspected. Because SLPs and audiologists are often consumers of neuroimaging study reports, which are available in the patient’s medical record, a basic understanding of these techniques is important.
► A Comparison of Neurological Exams by Neurologists and SLPs/Audiologists
Like neurologists, SLPs and audiologists conduct interviews with their patients, asking questions about the chief complaint, history of the present illness, past medical history, review of communication systems, family history, social and environmental history, and allergies and medications. There are many commonalities with the physical exam as well. The neurologist, SLP, and audiologist all assess the patient’s level of consciousness and personal hygiene and dress. They perform a similar HEENT exam, with the exception of the eye exam. Professionals in communication disorders evaluate major communication systems instead of other major body systems. They should also observe posture, motor activity, and dysmorphic signs. In terms of the neurological exam, both types of professionals conduct a mental state evaluation. SLPs and audiologists also test the cranial nerves, but typically only those relevant to speech, hearing, and swallowing. They test reflexes related to communication and observe, and perhaps even formally assess, the patient’s equilibrium. Although professionals in communication disorders do not order laboratory tests, they are consumers of the data from these examinations, especially neuroimaging data.
► Signs of Neurological Disease
The neurological examination, especially the neurological exam proper, will reveal certain signs of neurological disease. In this section, we will further explore some of the signs mentioned in the preceding sections that may stand out during a neurological exam. These signs are arranged in the following categories, reflecting the order given in the neurological exam proper: cranial nerve, motor, reflex, sensory, and other miscellaneous signs, including signs found in the areas of speech and language.
Cranial Nerve Signs
Cranial nerve I is called the olfactory nerve. The term olfaction refers to our sense of smell, which involves specialized sensory cells in the nose that receive odor molecules. These molecules trigger a nerve impulse that is sent through cranial nerve I to the olfactory bulb, a part of the central nervous system that lies just inferior to the brain’s frontal lobes. The nerve impulse finally reaches the olfactory cortex of the temporal lobe where the olfactory impulse is processed and interpreted (e.g., noxious versus pleasant). Damage to cranial nerve I through mechanisms like traumatic brain injury (TBI) can result in anosmia (i.e., an inability to smell), hyper- osmia (i.e., abnormally sensitive smell), or hyposmia (i.e., decreased sense of smell). Zasler, Costanzo, and Heywood (1990) found that the severity of TBI correlated with the amount of olfactory dysfunction. Specifically, 27% of patients with mild TBI and 67% of patients with moderate to severe TBI had some form of olfactory impairment.
Cranial nerves II-IV and VI are all involved in vision, with cranial nerve II being the main conduit for visual information and cranial nerves III, IV, and VI controlling various aspects of eye movement. Cranial nerve II is the optic nerve (FIGURE 16-2), and damage to it can lead to decreased vision and blindness. More specifically, injury to the optic nerve anterior to the optic chiasm (i.e., where the optic tracts cross) results in the loss of a visual field; lesions posterior to the optic chiasm result in contralateral homonymous hemianopsia (i.e., one-sided visual loss). This condition involves partial blindness to half of each visual field opposite to the side where the lesion occurred. Lesions at the optic chiasm lead to a loss of peripheral vision in both visual fields. Damage to cranial nerves III, IV, and/or VI, which are usually tested together, can result in loss of the pupillary light reflex (i.e., when the pupils change in size as light is introduced or removed), deviation of gaze, diplopia or double vision, and nystagmus, which involves involuntary eye movements, sometimes called dancing eyes.
Damage to cranial nerve VII, IX, X, or XII will impair functions related to speech and swallowing. Damage to cranial nerve VII leads to facial plegia or paresis and loss of taste. Often plegia and paresis are on one side of the face only, resulting in conditions called hemiplegia and hemiparesis, where the prefix hemirefers to one sided. Injury to cranial nerves IX and X can result in an absent gag response, absent swallow, loss of soft palate movement, and loss of voice. Cranial nerve XII impairment often results in loss of tongue movement and the wasting away or atrophy of the tongue, with possible fasciculation, a term referring to muscle twitches. These twitches resemble snakes squirming in a bag. Injury to cranial nerve XI results in a droopy shoulder due to impaired function of the sternocleidomastoid muscle.
Cranial nerve VIII is an important nerve for transmitting hearing and balance information from the inner ear to the brain. Harm to this nerve results in hearing loss, vertigo (i.e., dizziness), loss of equilibrium, and tinnitus, which is ringing in the ears.
A cranial nerve evaluation form can be found in BOX 16-3. Function is recorded in the blanks as either N for normal or A for abnormal. Numbers with A in the blank should be circled next to the appropriate cranial nerve at the bottom of the form, which indicates which cranial nerve may be impaired. (Note: Only the cranial nerves involved in speech and hearing are tested, with the exception of cranial nerve II for vision.) An example of a normal cranial nerve exam can be found in BOX 16-4.
BOX 16-3 Cranial Nerve Evaluation
Evaluate the following cranial nerve functions. Place an N on the line to indicate normal function or an A to indicate abnormal function.
Head and Neck:
1. Facial symmetry: Upper: Lower:
2. Chin erect
3. Shoulder symmetry at rest
4. Shoulder symmetry shrugging
5. Head rotation
6. Visual fields intact
Lips:
7. Rest symmetry
8. Smile symmetry
9. Pursing symmetry
10. Diadochokinesis /p/
Mandible:
11. Deviation when depressed
12. Diadochokinesis /j/
13. Lateral resistive strength
14. Opening/closing ability
Teeth:
15. Present (upper/lower) Dentures (upper/lower)
16. Occlusions or deviations present
Tongue:
17. Tremors: Resting Other movements Atrophy
18. Protrusion
19. Elevation
20. Lateral movement
21. Protrusion resistive strength (use tongue depressor)
22. Lateral resistive strength (use tongue depressor)
23. Blade diadochokinesis /t/
24. Back diadochokinesis /k/
25. Rapid alternating movements /p t k/
26. Taste on posterior third of tongue
Velum:
27. Rest symmetry
28. Elevation on phonation (say "ah")
29. Gag reflex (touch back of throat with tongue depressor)
30. Palatal reflex (touch palate with tongue depressor)
Pharynx:
31. Posterior wall constrictions (say forceful "eee")
32. Dysphagia: Liquids Solids
Larynx:
33. Phonation ("ah")
34. Length of prolonged "ah" in seconds
35. Voice quality (breathy, hoarse, harsh, strangled)
36. Cough
37. Vary: Pitch Volume
(continues)
BOX 16-3 Cranial Nerve Evaluation (continued)
Cranial Nerve Assessment (circle numbers that were rated as abnormal):
II (Optic): 6
V (Trigeminal): 11 12 13 14
VII (Facial): 1 2 7 8 9 10
IX (Glossopharyngeal): 24 26 27 28 29 30
X (Vagus): 31 32 33 34 35 36 37
XI (Spinal accessory): 3 4 5
XII (Hypoglossal): 17 18 19 20 21 22 23
BOX 16-4 Example of a Normal Cranial Nerve Exam
CN I: Olfaction normal. Patient able to identify a bar of soap while eyes closed.
CN II: Vision normal. Visual acuity appears to be 20/20 as tested by Snellen eye chart. Pupils equally round and responsive to light stimulation.
CN III, IV, VI: Eye movements are normal. No nystagmus or ptosis.
CN V: Sensory function of face is normal in all three CN V branch areas. Motor function is normal for mastication.
CN VII: Motor function of face muscles is normal. Face is symmetrical.
CN VIII: Hearing equity is normal bilaterally as tested by portable audiometer. Vestibular function appears intact.
CN IX: The velum and uvula elevate symmetrically. Gag reflex is intact. Timely swallow response can be palpated.
CN X: Voice function normal for age and sex in terms of phonation quality, pitch, and intensity.
CN XI: Shoulders are symmetrical upon rest and upon shrugging.
CN XII: Tongue function normal for protrusion, retraction, and lateralization. Resistive strength appears normal for speech and swallowing.
Motor Signs
One of the most common motor signs after neurological injury is muscle weakness, also known as paresis. Extreme weakness is called plegia. After a stroke, many people will suffer paresis or plegia on one side of the body or the other. When this happens, it is called hemiparesis or hemiplegia. Because of contralateral innervation, the paresis or plegia will be on the opposite side of the body from the damage. For example, someone with left hemisphere damage may have right hemiparesis or hemiplegia. Weakness is a characteristic in both upper motor neuron (UMN) and lower motor neuron (LMN) damage; however, LMN lesions result in decreased muscle tone and reflexes as well as muscle atrophy and fasciculations. UMN lesions lead to increased muscle tone and exaggerated reflexes, but no atrophy or fasciculations.
Movement disorders in general are grouped under the term dyskinesias. The various movement disorders that fit within this category are typically involuntary and can be slow or fast in their movement (FIGURE 16-3). Beginning with the slowest and moving to the fastest, bradykinesia is a term that literally means slowed movements. Related to bradykinesia are the terms hypokinesia (decreased movement) and akinesia (absent movement). Hemiparesis and hemiplegia were defined in the previous section; hemiparesis can be thought of as a form of hypokinesia and hemiplegia a form of akinesia. Rigidity denotes stiff muscles that resist passive movement to a limb. Dystonia is a dyskinesia in which sustained muscle contractions result in distorted body postures. Some patients experience athetosis, slow twisting movements of hands and feet, or chorea (which comes from the Greek word for “dance”), which is quick movements of the hands or feet that have a dance-like quality. These two conditions can occur together, resulting in choreoathetosis. Ballism is a rare movement disorder involving the quick flinging of the limbs. It generally occurs on one side of the body and is thus called hemiballismus. Some patients experience tics, which are repetitive involuntary motor and/or vocal behaviors associated with conditions like Tourette syndrome. Other patients may experience myoclonus, or sudden involuntary muscle jerks. Common myoclonic experiences include hiccups or a sudden jerk when falling asleep, but more consistent and extreme experiences can occur after neurological injury.
FIGURE 16-3 Dyskinesias compared.
The most well-known dyskinesia is probably tremor. Tremors are involuntary, rhythmic shaking in which the shaking oscillates at a certain frequency. There are several different types of tremors. Intention tremors occur only when a patient initiates purposeful action; in contrast, resting tremors occur only when a limb is at rest and disappear when the limb is put to purposeful action. Parkinson patients often demonstrate a resting tremor known as a “pill-rolling” tremor in which the thumb oscillates against the index and/or middle fingers as if the patient had clay between them and was trying to roll it into a ball.
In addition to dyskinesias, gait disorders (i.e., walking problems) can occur with neurological injury (Ryan, 2009). For example, patients with Parkinson disease demonstrate a shuffling gait (i.e., Parkinsonian gait), moving through a series of slow, shuffling steps while having a stooped posture and little arm swinging (FIGURE 16-4). Another example of a gait disorder is scissors gait, seen most often in patients with paraparesis (i.e., weakness in both legs). This gait involves stiff-looking legs, toes that scrape the ground, and legs that often cross in front of each other (FIGURE 16-5).
Reflex Signs
Reflexes are lightning-quick body responses to environmental stimuli. They may be absent, diminished, or exaggerated due to neurological injury. Their assessment can help in locating where damage is located in the nervous system.
In addition to the reflexes mentioned in Box 16-2 are reflexes like the corneal, light, plantar, and patellar reflexes. The corneal and light reflexes both involve the eyes. When we close our eyes as a foreign object moves toward them, we are experiencing the corneal reflex that is meant to protect our eyes. The light reflex is also called the pupillary light reflex, which involves the expansion or contraction of the pupil to light (FIGURE 16-6). A lack of pupillary contraction to light can indicate neurological injury.
FIGURE 16-5 Scissors gait.
The plantar reflex is elicited by stroking the bottom of the foot with a blunt object, such as the handle end of a reflex hammer (FIGURE 16-7). A normal response is for the toes to curl and the foot to pull away. Adult patients with neurological injury either will not respond or their big toe will dorsiflex and the other toes will fan out in what is known as a positive Babinski sign. This sign can indicate a UMN lesion. A negative Babinski sign in an adult is consistent with a normal plantar reflex.
FIGURE 16-8 A physician testing a patient's patellar reflex.
FIGURE 16-6 A clinician testing a woman's pupillary reflex.
FIGURE 16-7 Testing of the plantar reflex. A. A positive Babinski sign, which is an abnormal reflex in an adult and indicates possible upper motor neuron damage. B. A negative Babinski sign, which is a normal plantar response in an adult.
The patellar reflex is one of the most recognized reflexes. A doctor tests it by tapping the patient’s knee with a small hammer, causing the knee to jerk in a normal nervous system (FIGURE 16-8). This test evaluates the reflex arc.
Sensory Signs
Our experiences of touch, pain, temperature, vibration, and proprioception are all mediated through the somatosensory system. The first part of this compound word—somato—comes from the Greek word soma, which means “body,” so the seemingly complex term somatosensory simply means the body-sensory system. Neurological injury can affect our sensory system in profound ways. Some patients may experience abnormal amounts of chronic or acute pain. Other patients may experience paresthesias (from the Greek: para = beside; aesthesia = sensation), which include tingling, prickling, or burning sensations. These are also common experiences when one of our limbs falls asleep and we experience first numbness and then a “pins and needles” sensation. Still other patients may suffer from anesthesia (from the Greek: an = without; aesthesia = sensation), in which body parts feel numb. Obviously, this experience can be induced through drugs for the purpose of surgery or dental work, for which we are all thankful.
The conditions discussed so far in this section deal with the loss of feeling, but some patients experience too much sensation in the form of pain. Pain is the unpleasant sensory experience with an emotional component associated with damage to the body. All of us have experienced acute pain, such as stepping on a piece of glass, and this type of pain plays an important role in telling us when something is wrong with our body. Chronic pain, which is often associated with neurological injury, serves no purpose. This pain can involve nerve injury affecting a specific anatomical structure, like the back or a limb. Chronic pain conditions, like fibromyalgia (a chronic condition involving pain throughout the body, especially in response to pressure), involve more diffuse, whole-body pain. Pain medications and protocols have made such improvements today that patients should never have to suffer from chronic pain conditions when under the care of healthcare professionals who have expertise in treating pain (Chelimsky, 2009).
Headaches are painful experiences located in the cranial area and are one of the most common symptoms of neurological disease patients report. Most headaches are not indicative of a serious pathology, but some can be a red flag for a life-threatening condition. Headaches do not involve the brain itself, because the brain has no pain receptors of its own, but rather are sensory experiences associated with scalp, skull, meninges (i.e., layers of tissue around the brain), or blood vessels. Vascular and tension headaches make up the two general types of headache. Vascular headaches, like migraines, are not well understood, but are thought to be caused by a mixture of environmental and genetic factors. Tension headaches involve prolonged contraction of neck and scalp muscles. These are typically the type of headache reported by people after a motor vehicle accident (Blumenfeld, 2010; Slevin & Ryan, 2009).
Changes in special sensory functions, like vision and hearing, can also result from neurological damage. These have already been discussed under cranial nerves.
Other Signs
There are many other signs of neurological dysfunction that may be apparent upon examination. Patients may have muscle tone issues and experience hypertonia (too much tone, resulting in spastic muscles) or hypotonia (too little tone, resulting in flaccid muscles). Hypotonia is also known as “rag doll” where the patient is floppy and unsteady like a child’s doll. Muscle strength may be reduced or lost, and range of motion of limbs may be reduced. All these conditions can lead to problems in walking or gait and with posture.
Some patients may experience syncope due to neurological problems. Syncope is an episode of fainting in which a person loses consciousness. This complete loss of consciousness happens suddenly but is brief in nature and is accompanied by hypotonia. It is often caused by an interruption of blood flow to the cerebrum but can also be caused by a lack of oxygen or glucose, neurotoxins (e.g., lead poisoning), or seizures. Syncope should be differentiated from dizziness, in which a person may feel close to losing consciousness but ultimately does not experience it (Massey, 2009).
Seizures are electrical storms in the brain; there are two basic types, partial and generalized seizures (FIGURE 16-9). The main distinction between these two types of seizures is the extent of the abnormal electrical activity. Partial seizures are focal in nature, meaning they are confined to specific areas of the brain, whereas generalized seizures involve the whole brain (FIGURES 16-10 and 16-11). There are several subtypes of both partial and generalized seizures; the most common are compared in TABLE 16-1. Seizures can be caused by a variety of factors, including high fevers, toxins, head trauma, alcohol or drug withdrawal, and strokes. Approximately 10% to 15% of the population will experience at least one seizure in their lifetime, and 1% of the population suffers from a seizure disorder like epilepsy. Different phases of a seizure are experienced, including the aura, ictal, postictal, and interictal phases; aura refers to a preliminary sense a seizure is coming, and ictal (from the Latin ictus, meaning “a blow”) refers to the physiological event (FIGURE 16-12) (Blumenfeld, 2010; Massey, 2009).
FIGURE 16-9 International classification of epileptic seizures.
Data from Holmes, G. L. (1997). Classification of seizures and the epilepsies. In: S. C. Schachter & D. L. Schomer (Eds.). The comprehensive evaluation and treatment of epilepsy (pp. 1-36). San Diego, CA: Academic Press, with permission from Elsevier.
FIGURE 16-10 A generalized absence or petit mal seizure.
FIGURE 16-11 A generalized tonic-clonic seizure, more popularly known as a grand mal seizure.
Our sense of balance and orientation in space is controlle d through the vestibular system (FIGURE 16-13). Anatomically, this system is housed in the inner ear in the form of three mazes or labyrinths called the semicircular canals. Dizziness is the disagreeable experience of spatial disorientation. There are four general types of dizziness:
■ Vertigo: the sensation of a room spinning
■ Disequilibrium: the feeling of unsteadiness while standing or walking, which often results in falls
■ Presyncope: the feeling that one is going to faint and lose consciousness
■ Psychogenic dizziness: the feeling of being separated from one’s body, associated with stress and anxiety and often related to crowds and confined spaces
There are many possible causes of dizziness, ranging from head trauma to inner ear infections to psychological issues (Lanska, 2009b).
Neurological injury may also affect sleep. Some patients may experience insomnia (i.e., the inability to fall asleep), whereas others may experience hypersomnolence (i.e., excessive sleepiness) (Kovacevic- Ristanovic & Kuzniar, 2009).
Mental changes are common in neurological disorders. Patients may experience acute confusional states, such as lethargy or delirium. Lethargic patients tend to be sleepy, confused, and uninterested in what is going on around them. Delirious patients are the opposite in that they are often apprehensive or angry. There are also chronic confusional states, like dementia. In dementia, a person experiences slow cognitive decline, which may or may not be reversible. Alzheimer disease, an irreversible condition, is the most recognized form of dementia. Related to these states are other emotional problems that may arise, such as anxiety or depression (Lanska, 2009a).
|
TABLE 16-1 Comparison of the Most Common Seizure Types |
||||
|
Seizure |
Types |
Consciousness |
Extent of Brain Involved |
Duration |
|
Partial |
Simple |
Preserved |
Focal |
10-30 seconds |
|
Complex |
Lost |
Focal |
30-120 seconds |
|
|
Evolving |
Eventually lost |
Focal |
Variable |
|
|
Generalized |
Absence (petit mal) |
Preserved |
Diffuse |
10 seconds or less |
|
Tonic-clonic (grand mal) |
Lost |
Diffuse |
30-120 seconds |
|
Data from Blumenfeld, H. (2010). Neuroanatomy through clinical cases. Sunderland, MA: Sinauer Associates.
FIGURE 16-12 Phases of a seizure.
Neurological damage may also lead to changes in speech and language abilities. Language is the code we use to communicate through speaking and writing. Patients with neurological injury may have difficulty understanding language (receptive aphasia) or expressing language (expressive aphasia).
Speech is the motor production or execution of language. Some patients’ motor speech systems become impaired and they experience apraxia of speech (difficulty accessing the motor plans and programs for speech) or dysarthria (difficulty executing the movements for speech).
► Conclusion
Sometimes ancient wisdom is some of the best wisdom. In light of this, we should remember Hippocrates’s sage advice about the power of observation and the wisdom of completing a careful, systematic examination of the communication system. Many students put their faith in formal tests and the score they generate, which are valuable clinical instruments. But, there is no substitute for careful clinical observation.
FIGURE 16-13 The vestibular system's semicircular canals.
SUMMARY OF LEARNING OBJECTIVES
The following were the main learning objectives of this chapter. The information that should have been learned is below each learning objective.
1. The learner will define what a neurological exam is.
• A neurological exam is a systematic examination of the nervous system.
2. The learner will list the steps of the neurological exam and the tools involved.
• Steps in the neurological exam:
□ Step 1: the interview
□ Step 2: the physical exam
□ Step 3: the neurological exam proper
□ Step 4: laboratory tests
• Tools in the neurological exam:
□ Reflex hammer
□ Pin
□ Ophthalmoscope
□ Visual acuity cards
□ Cotton swabs
□ Tuning fork
□ Bar of soap
3. The learner will list and define signs of neurological injury.
• Anosmia: inability to smell
• Hyperosmia: abnormally sensitive smell
• Hyposmia: decreased sense of smell
• Hemianopsia: one-sided visual loss
• Diplopia: double vision
• Nystagmus: involuntary eye movements, usually shaking
• Plegia: paralysis
• Paresis: weakness
• Fasciculation: muscle twitches
• Vertigo: dizziness
• Tinnitus: ringing in the ears
• Bradykinesia: slowed movements
• Hypokinesia: decreased movement
• Akinesia: absent movement
• Rigidity: stiff muscles that resist passive movement
• Dystonia: distorted body postures
• Athetosis: slow, twisting movements of the hands and feet
• Chorea: quick movements of the hands and feet with a dance-like quality
• Ballism: quick flinging of the limb(s)
• Myoclonus: sudden involuntary jerking movements
• Tremor: involuntary rhythmic shaking
• Gait disorders: problems with walking
• Paresthesia: abnormal sensations
• Anesthesia: loss of feeling; numbness
• Pain: unpleasant sensory experience with an emotional component associated with damage to the body
• Headaches: painful experiences located in the cranial area
• Hypertonia: too much muscle tone
• Hypotonia: too little muscle tone
• Syncope: fainting
• Seizures: electrical storms in the brain
• Dizziness: disagreeable experience of spatial disorientation; vertigo
• Aphasia: acquired multimodality language loss
• Apraxia of speech: difficulty pulling up the motor plans for speech
• Dysarthria: difficulty executing the movements for speech
KEY TERMS
Anesthesia Anosmia Athetosis Ballism Bradykinesia Chorea Cranial nerve Diadochokinetic rates Diplopia Dyskinesias Dystonia Equilibrium Expressive aphasia Fasciculation
Gait Hemianopsia Hemiballismus Hypertonia Hypotonia Mental status Myoclonus Neurological exam Neurologists Nystagmus Olfaction Parasthesias Paresis Plegia
Pupillary light reflex
Receptive aphasia
Reflexes
Rigidity
Seizures
Sign
Somatosensory
system
Symptom
Syncope
Tinnitus
Tremor
Vertigo
DRAW IT TO KNOW IT
1. Draw a simple sketch of the visual system (see Figure 16-2), and identify the optic tracts.
2. Draw a simple sketch of a person with Parkinson disease (see Figure 16-4), and write a detailed description under the sketch of the Parkinsonian gait.
QUESTIONS FOR DEEPER REFLECTION
1. Compare and contrast the neurological exam of a neurologist with that of a professional in communication disorders.
2. In your opinion, why is there no substitute for careful clinical observation by a trained professional?
3. How might you apply the information presented in this chapter to a patient interaction?
CASE STUDY
Juan is a 47-year-old male with the diagnosis of traumatic brain injury (TBI). He has been referred to you, one of the hospital SLPs, for a speech and swallowing evaluation. As part of your evaluation, you completed the cranial nerve examination (Box 16-3) and found that he had bilateral difficulty with the following items on the form: 7, 8, 9, 10, 18, 19, 20, 21, 22, 23, 24, 25.
1. What cranial nerves would you report are impaired?
2. How would impairment to these cranial nerves affect his speech and swallowing?
SUGGESTED PROJECTS
1. Pick a partner in class and perform the cranial nerve evaluation (see Box 16-3). Make a list of questions regarding things you do not understand, and ask your professor.
2. Review the parts of the neurological interview. Create a fictitious patient and create a script with your questions and your patient’s answers. Be creative and have fun.
3. Visit the Neuroanatomy Through Clinical Cases website and watch videos of Dr. Blumen- feld performing a neurological examination (Blumenfeld, n.d.).
REFERENCES
Blumenfeld, H. (2010). Neuroanatomy through clinical cases (2nd ed.). Sunderland, MA: Sinauer Associates.
Blumenfeld, H. (n.d.). Neuroanatomy through clinical cases (2nd ed.) website. Sunderland, MA: Sinauer Associates. Retrieved from http://www.neuroexam.com
Chelimsky, T. C. (2009). Pain. In J. Corey-Bloom & R. David (Eds.), Clinical adult neurology (pp. 149-165). New York, NY: Demos Medical.
Kovacevic-Ristanovic, R., & Kuzniar, T. J. (2009). Sleep disorders.
In J. Corey-Bloom & R. David (Eds.), Clinical adult neurology (pp. 167-184). New York, NY: Demos Medical.
Lanska, D. J. (2009a). Acute confusional states. In J. Corey-Bloom & R. David (Eds.), Clinical adult neurology (pp. 185-200). New York, NY: Demos Medical.
Lanska, D. J. (2009b). Vertigo and other forms of dizziness. In J. Corey-Bloom & R. David (Eds.), Clinical adult neurology (pp. 93-111). New York, NY: Demos Medical.
Lloyd, G. E. R. (1984). Hippocratic writings. New York, NY: Penguin Classics.
Massey, A. D. (2009). Syncope and seizures. In J. Corey-Bloom & R. David (Eds.), Clinical adult neurology (pp. 81-91). New York, NY: Demos Medical.
Ryan, S. J. (2009). Disorders of gait. In J. Corey-Bloom & R. David (Eds.), Clinical adult neurology (pp. 113-121). New York, NY: Demos Medical.
Slevin, J. T., & Ryan, M. (2009). Headaches. In J. Corey-Bloom & R. David (Eds.), Clinical adult neurology (pp. 123-147). New York, NY: Demos Medical.
Zasler, N. D., Costanzo, R. M., & Heywood, P. A. (1990). Neuroimaging correlates of olfactory dysfunction after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 71, 814.