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11.	scissoring
12.	wide base of support
4.3	 Neurological examination
	 Neurologické vyšetření
General considerations
1.	 Explain each examination technique to the patient prior to as-
sessment.
2.	 Always consider left to right symmetry.
3.	 Consider central vs. peripheral deficits.
4.3.1	 Mental status/Cognition
	 Psychický stav/kognice
1.	 Level of consciousness (LOC)	 úroveň vědomí
2.	 Orientation (to person, time,	 orientace (osobou, časem,
	 place, situation)		 místem, situací)
3.	 Level of cognitive functioning	 kognitivní funkce
4.	 Ability to follow commands	 schopnost plnit povely
5.	 Language ability		 jazykové schopnosti a porozumění
	 and comprehension
6.	 Neglect, perceptual 		 opomíjení, poruchy percepce
	impairments
7.	 Safety awareness		 povědomí o bezpečnosti
The common scale for measuring level of consciousness is Glasgow
Coma Scale.
4.3.2	 Motor assessment
	 Vyšetření motoriky
ƒƒ Involuntary movements
ƒƒ Mimovolní pohyby
Tremor, oscillation, chorea, dystonia, hemiballismus, fasciculation.
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ƒƒ Muscle bulk
ƒƒ Svalová hmota
Muscle symmetry (left to right, proximal versus distal)
Atrophy or hypertrophy (pay particular attention to the hands,
shoulders, and thighs)
ƒƒ Muscle tone
ƒƒ Svalový tonus
For assessment in the upper extremities, the patient may be lying or
sitting. In the lower extremities, tone is best assessed with the patient
lying down. Ask the patient to relax. Flex and extend the patient’s
fingers, wrist, and elbow. Flex and extend patient’s ankle and knee.
There is normally a small, continuous resistance to passive movement.
Observe for decreased (flaccid) or increased (rigid/spastic)
tone. Use special tests for further evaluation of muscle tone (Modified
Ashworth Scale etc.)
Spasticity („clasp knife“) is velocity dependent and should be assessed
by a quick flexion/extension of the knee or the elbow or quick
supination/pronation of the arm.
Rigidity („cogwheel“) is continuous and not velocity dependent so
the testing movement should be performed slowly. There is a resistance
to passive movement that may make the limb feel like a „lead pipe.“
When rigidity and tremor are present at the same time, the examiner
may be able to feel „cogwheeling.“ Rigidity may be enhanced by having
the patient activate the opposite limb („Activated“ rigidity).
ƒƒ Myotome testing
ƒƒ Testování myotomů
Myotome is a group of muscles supplied by a single nerve root. To test
muscle strength in myotomes have the patient perform: upper cervical
flexion (C1 and C2 root), cervical lateral flexion (C3), shoulder
girdle elevation (C4), shoulder abduction (C5), elbow flexion (C6),
elbow extension (C7), thumb extension and finger flexion (C8), finger
abduction and adduction (T1), hip flexion (L2), knee extension (L3),
dorsiflexion (L4), great toe extension (L5), eversion, contract buttock,
knee flexion (S1), knee flexion and toe standing (S2).
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4.3.3	Reflexes
	Reflexy
ƒƒ Deep tendon reflexes (DTR, also called jerks or muscle stretch reflexes)
ƒƒ Šlachookosticové reflexy
include the biceps (C5, C6), triceps (C6, C7), brachioradialis (C5,C6),
patellar (knee jerk, L2, L3, L4), and the Achilles tendon (S1, S2) reflex.
An instrument called a reflex hammer is used to assess DTR.
Although deep tendon reflexes aren’t routinely assessed, they should
be tested in any patient with a spinal cord injury or with the signs of
nerve root irritation. Reflexes can be reinforced by having the patient
perform isometric contraction of other muscles (clenched teeth).
Tendon Reflex Grading Scale:
0	Absent
1+	Hypoactive
2+	Normal
3+	 Hyperactive without clonus
4+	 Hyperactive with clonus
ƒƒ Pathologic reflexes
ƒƒ Patologické reflexy
Clonus
If the reflexes seem hyperactive, test for ankle clonus: more then three
rhythmic contractions of the plantar flexors in response to sudden
passive dorsiflexion. Clonus indicates upper motor neurone lesion.
Plantar response (Babinski)
The plantar reflex is a superficial reflex that should be tested in comatose
patients and in those with suspected injury to the L4–5 or S1–2
areas of the spinal cord.
Stroke the lateral aspect of the sole of each foot with the handle of
a reflex hammer or key. Note movement of the toes, normally plantar
flexion. Extension of the big toe with fanning of the other toes is
abnormal. This is referred to as a positive Babinski. It indicates upper
motor neurone lesion except in children younger than 2 years.
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ƒƒ Superficial reflexes
ƒƒ Kožní reflexy
Abdominal – above umbilicus (T8, T9, T10) and below umbilicus
(T10, T11, T12). Use a blunt object such as a key or tongue blade.
Stroke the abdomen lightly on each side in an inward and downward
direction above (T8, T9, T10) and below the umbilicus (T10, T11,
T12). Note the contraction of the abdominal muscles and deviation
of the umbilicus towards the stimulus.
ƒƒ Brain stem reflexes
ƒƒ Kmenové reflexy
Physicians assess brain stem reflexes in stuporous or comatose patients
to determine if the brain stem is intact. They include oculocephalic,
or doll’s eye, reflex and the oculovestibular reflex (also
known as the ice caloric or cold caloric reflex).
4.3.4	Coordination
	Koordinace
ƒƒ Upper extremity
Rapid alternating hand movements: Ask the patient to strike one
hand on the thigh, raise the hand, turn it over, and then strike it back
down as fast as possible.
Finger tapping: forefinger on thumb: Ask the patient to tap the distal
thumb with the tip of the index finger as fast as possible.
Finger to nose testing: Hold up your finger and ask the patient to
touch your index finger and their nose alternately several times. Then
have him alternately touch his nose with his right and left index fingers.
Finally, have him repeat these tasks with his eyes closed. The
movements should be precise and smooth and without tremors.
ƒƒ Lower extremity
Heel-shin: Ask the patient to place one heel on the opposite knee
and run it down the shin to the big toe. Repeat with the patient’s eyes
closed.
Foot tapping: Ask the patient to tap your hand with the ball of each
foot as fast as possible. Ask the patient to perform rapid foot taps.
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ƒƒ Speech
ƒƒ Řeč
Note any abnormalities such as aphasia, dysarthria, slurred speech,
and slow speech.
4.3.5	 Balance and gait
	 Rovnováha a chůze
ƒƒ Romberg
If the patient is able to stand you can assess his balance using the
Romberg test. Ask the patient to stand with the feet together arms at
the sides, and eyes open; he should be able to stand upright with no
swaying. If he can do that, have him close his eyes and stand the same
way for 5–10 seconds without support. If the patient falls or breaks
his stance after closing his eyes, the Romberg test is positive, indicating
proprioceptive or vestibular dysfunction.
ƒƒ Berg balance scale (BBS)
This test is designed to measure balance of the older adult in a clinical
setting. The fourteen tasks evaluated in the Berg Balance Scale test
include:
  1.	sitting unsupported
  2.	change of position: sitting to standing
  3.	change of position: standing to sitting
  4.	 transfers
  5.	standing unsupported
  6.	standing with eyes closed
  7.	standing with feet together
  8.	tandem standing (with one foot in front)
  9.	standing on one leg
10.	turning trunk to look behind (feet fixed)
11.	picking up object from floor
12.	turning 360 degrees
13.	stool stepping
14.	reaching forward with arm outstretched while standing
Eva Jansa (eva.jansa.eu@gmail.com) [1566823]
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These tasks are measured on a 5 point ordinal scale. Maximum
score is 56, a higher score reflects better balance; score of 45 required
for independent safe ambulation.
Gait assessment is described in the chapter 4.2.9 page 84.
4.3.6	 Sensory assessment
	 Vyšetření čití
Include the evaluation of sensation in your neuro assessment if
there’s a specific need, as in spinal cord injury (SCI) or stroke. The
patient must be able to cooperate with the exam. He’ll need to tell you
whether he feels the sensation and whether both sides of his body feel
it equally. Also compare distal and proximal areas of the extremities.
Check dermatomes when needed. The sensory exam is performed
with the patient’s eyes closed. Remember, guessing will yield correct
answers 50% of the time.
ƒƒ Vibration
ƒƒ Vibrační čití
To test vibratory sensation, use a low pitched tuning fork (128 Hz).
Place the stem of the fork over the distal interphalangeal joint of the
patient’s index fingers and big toes. Ask the patient to tell you if they
feel the vibration. If vibration sense is impaired proceed proximally:
wrists, elbows etc.
ƒƒ Light touch
ƒƒ Lehký dotyk
Use cotton-tipped swabs or your fingers to touch the skin lightly. Ask
the patient to respond „yes“ whenever a touch is felt. Also test both
sides simultaneously. Ask the patient to tell you if there is difference
from side to side or other „strange“ sensations. Test the following
areas:
1.	 Shoulders (C4)
2.	 Inner and outer aspects of the forearms (C6 and T1)
3.	 Thumbs and little fingers (C6 and C8)
4.	 Front of both thighs (L2)
5.	 Medial and lateral aspect of both calves (L4 and L5)
6.	 Little toes (S1)
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ƒƒ Position sense
ƒƒ Polohocit
Grasp the patient’s big toe and hold it away from the other toes to
avoid friction. Show the patient „up“ and „down“. With the patient’s
eyes closed ask the patient to identify the direction you move the
toe. Test the fingers in a similar fashion. If position sense is impaired
move proximally to test the ankle joint or the metacarpophalangeal
joints etc.
If vibration, position sense, and light touch are normal in the
fingers and toes you may assume the rest of this exam will be nor-
mal.
ƒƒ Pain
ƒƒ Bolest
Test superficial pain sensation with a clean, unused safety pin. Be
sure not to break the skin. Also, test sensation using a dull object. The
patient should be able to distinguish sharp from dull. Test the same
areas as with the light touch.
ƒƒ Temperature
ƒƒ Teplota
Often omitted if pain sensation is normal.
Use a tuning fork heated or cooled by water or test tubes (specimen
tubes) with hot and cold water and ask the patient to identify
„hot“ or „cold“. Test the same areas as with the light touch.
ƒƒ Discrimination
ƒƒ Diskriminace
Two point discrimination
Use a bent paper clip to touch the patient’s finger pads alternating
randomly between touching the patient with one or both points. Ask
the patient to identify „one“ or „two.“ Find and record the minimal
distance at which the patient can discriminate.
Graphesthesia
Explain to the patient that you will be drawing a number in the palm
of their hand. Show him what is up and down, the distal side is usua­
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lly up as this is a typical orientation of the palm. Demonstrate with
eyes open. Ask the patient to close their eyes. With the blunt end of
a pen or your fingertip, draw a large number in the patient’s palm and
ask the patient to identify it.
Stereognosis
Explain to the patient that you will be placing a familiar item in their
hand which they should then manipulate and identify with their eyes
closed. Objects include a coin, a paper clip, a pencil, a key etc.
ƒƒ Extinction (double simultaneous stimuli)
ƒƒ Extinkce (dva simultánní stimuly)
Tactile (sensory) extinction: With eyes open demonstrate to the patient
that you will touch them on the left side, the right side or both.
Have the patient close their eyes and as you deliver a gentle touch,
report whether they feel it on the left side, right side or both sides.
Visual extinction: Wiggle a finger in the left, right or both visual
fields and ask the patient to report where they see it.
Auditory extinction: Snap your fingers on the left, right or both
sides and have the patient report where they hear the stimulus.
4.3.7	 Cranial nerve assessment
	 Vyšetření hlavových nervů
ƒƒ Observation
Ptosis (III)
Facial Droop or Asymmetry (VII)
Hoarse Voice (X)
Articulation of Words (V, VII, X, XII)
Abnormal Eye Position (III, IV, VI)
Abnormal or Asymmetrical Pupils (II, III)
ƒƒ Olfactory nerve (CN I)
Usually not tested by a PT.
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ƒƒ Optic nerve (CN II)
1.	 Fundoscopy: examination of the fundus by ophthalmoscope,
done by an ophthalmologist.
2.	 Visual acuity: this assessment is usually done by a physician
3.	 Visual field (extent of vision of a non moving eye)
Visual fields are assessed by confrontation, i.e. the examiner compares
the patient’s visual field to their own and assumes that theirs
is normal.
ƒƒ Oculomotor, trochlear and abducens (CNs III, IV,VI)
1.	 Observe pupil size.
2.	 Observe eyes: resting position: aligned or one eye is different, deviation,
any abnormal movement (e.g. nystagmus).
3.	 Pupillary light reflex: Dim the lights, ask the patient to look into
the distance, shine a bright light (approaching laterally) into one
eye. Observe for the direct response (same eye) and consensual
response (opposite eye).
4.	 Accommodation: Ask the patient to focus on far object, then
on a closer object. Note what happens to pupil. „perrla“ stands
for „pupils equal, round, reactive to light, accommodation“. This
acronym is used when documenting assessment of pupils.
5.	 Eye movements (extraocular movements): Ask the patient to follow
your finger with their eyes without moving their head. Check
gaze in the six cardinal directions using a cross or „H“ pattern.
Check convergence by moving your finger toward the bridge of
the patient’s nose.
ƒƒ Trigeminal (CN V)
1.	 Facial sensation: Same principles apply as in sensory examination
of rest of the body (touch, pain, temperature).
2.	 Corneal reflex: Ask the patient to look up and away. From the
other side, touch the cornea lightly with a fine wisp of cotton.
Look for the normal blink reaction of both eyes. Repeat on the
other side.
3.	 Motor function (muscles of mastication): Ask if there is fatigue
during chewing meat or other food. Ask the patient to open their
mouth and repeat this against resistance. Observe for any deviation
of the jaw to one side. With their mouth open, ask the patient
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to protrude their jaw to either side against resistance. Test the jaw-jerk
reflex.
ƒƒ Facial nerve (CN VII)
Observe for any facial droop or asymmetry
1.	 Facial muscles: Ask the patient to do the following, note any lag,
weakness, or asymmetry:
raise eyebrows and wrinkle forehead
purse his lips and puff out their cheeks
close their eyes tightly (and against resistance)
show their teeth
2.	 Sense of taste: limited to anterior 2/3 of tongue
3.	 Salivation and lacrimation
A lower motor neuron lesion causes weakness of the entire side
of the face with equal involvement of upper and lower facial muscles.
An upper motor neuron lesion results in weakness primarily of
lower facial muscles. The upper muscles of facial expression (frontalis and
orbicularis oculi) are much less affected because the facial nucleus that
innervates them receives partial input from the ipsilateral hemisphere.
ƒƒ Vestibulocochlear nerve (CN VIII)
Cochlear nerve
1.	 Hearing acuity: tuning fork, ticking watch, rubbing fingers toge-
ther
	 speech discrimination: whisper numbers in each ear
2.	 Rinne test (air versus bone conduction): Place the vibrating tuning
fork against the mastoid process. Use the 512 Hertz tuning
fork. Ask the patient when they can no longer hear it, then place it
in front of the ear.
3.	 Lateralization test (Weber test): Place the vibrating tuning fork
to the centre of the forehead and ask the patient where they hear it.
Vestibular nerve
The vestibular component of the auditory nerve is tested by observing
for nystagmus when extraocular movements are assessed.
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ƒƒ Glossopharyngeal-vagus nerve complex (CN IX and X)
1.	Swallowing: Ask the patient to take a sip of water and observe
them swallow, note any difficulty.
2.	Phonation: Listen to the patient’s speech. Is there a hoarse or nasal
quality?
3.	 Palatial elevation: Ask the patient to say „Ah“ to observe soft palate
rising on both sides.
4.	 Gag reflex: Assess the gag reflex by gently stroking the soft palate
on each side.
ƒƒ Accessory nerve (CN XI)
The accessory nerve supplies the trapezius and sternocleidomastoid
muscles.
Observe trapezius for atrophy and asymmetry. Ask the patient
to shrug shoulders against resistance. Ask the patient to turn their
head against resistance. Watch and palpate the sternocleidomastoid
muscle on the opposite side. Ask the patient to flex their head against
resistance.
ƒƒ Hypoglossal nerve (CN XII)
The hypoglossal nerve is motor to the tongue.
1.	 Observation: tongue appearance and bulk of tongue (look for
atrophy)
	 abnormal movement (fasciculation)
2.	 Ask the patient to show his tongue. Note any deviation. Ask the
patient to move the tongue quickly from side to side. Ask the patient
to push the tongue into each cheek, apply resistance. Compare
the two sides.
3.	 Listen to the articulation of the patient’s words.
4.3.8	 Neural tension tests
	
(neural provocation tests, neurodynamic tests)
	 Napínací testy
These tests are used by clinical practitioners to assess the mobility of
neural tissue in the extremities and spinal cord. A positive neurodynamic
test will reproduce the patient’s symptoms, the test response
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can be altered by movement of distant body parts and there are differences
from right side to left side. A positive test indicates abnormalities
of neural structures (e.g. intervertebral disc herniation causing
pressure on a nerve root).
ƒƒ Straight leg raise (SLR) test (also called Lasègue’s sign)
ƒƒ Lasègueova zkouška
This is a test for sciatic nerve (or L5/S1 root) irritation. With the patient
lying supine, legs fully extended, the examiner lifts the patient’s
leg keeping the knee straight. The test is considered positive if pain is
reproduced or increased in the lower back or leg.
ƒƒ Prone knee bend (PKB) test
ƒƒ Obrácená Lasègueova zkouška
With the patient prone, flex both knees together to 90 degrees, and
then bring the heels together toward the buttocks. This test is considered
positive if symptoms are reproduced when bending both knees
together past 90 degrees. Pain in the anterior thigh indicates shortening
of the hip flexors or irritation of the L4 nerve root. To differentiate
between the nervous tissue and the muscles, this test can be
performed in side lying with the head and trunk flexed. That allows
cervical extension to be added as a desensitizing test.
ƒƒ Passive neck flexion
In the supine position the clinician flexes passively the patient’s head.
ƒƒ Slump test
In essence, this test comprises the following components, performed
in sitting:
1.	 Thoracic and cervical flexion
2.	 Knee extension
3.	 Foot dorsiflexion
4.	 Release of cervical flexion (to determine symptom response)
The slump test may be quite uncomfortable and provocative, so
care must be taken with the test. The slump test helps the therapist
to differentiate between local causes of the symptoms (e.g. muscle
tightness) and distant causes (e.g. nerve root irritation).
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ƒƒ Upper limb tension tests (ULTT)
ƒƒ Neurodynamické testy horních končetin
These tests were devised to evaluate the neural mobility of the upper
limb. They are sometimes called the „SLR of the arm“. They are
used in the diagnosis of nerve (root) and plexus lesions of the upper
extremity.
4.3.9	Vocabulary
Tab. 4.4  Neuro examination vocabulary
English Czech Synonyms
a drooping upper eyelid pokles horního víčka, ptóza ptosis
absent chybějící, nepřítomný
accommodation akomodace
affected postižený
alternately střídavě
appearance vzhled
blink mrknout, mrknutí
blunt tupý dull
clasp knife zavírací nůž
clench one's teeth zatnout zuby
cogwheel ozubené kolo
consider vzít v úvahu, zvážit, považovat
consideration zřetel, hlavní bod
cotton-tipped swab vatová tyčinka
demonstrate předvést
determine určit identify
deviation odchylka, úchylka
differentiate (between) rozlišit (mezi)
distinguish rozlišovat tell the
difference
equal pupils izokorické zornice
extraocular movements pohyby očních bulbů
facial droop pokles tváře