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The Neurological Assessment

The neurological history and examination is unique in Medicine. Whereas doctors can see skin conditions, broken bones, and feel many organs in the body, it is usually not possible to directly see a neurological problem. As a result, we need to perform a specialized examination following a history in order to see how the nervous system is functioning.

 

 

The most important part of a neurological assessment is the patient's history. This must be performed before any other procedures except in unusual circumstances such as with coma. There are several important factors learned during the medical history including:

  • Onset and duration of main symptoms and thre presence of associated symptoms

    • this helps the Neurologist determine if the complaint is acute, subacute, or chronic

  • ​We will ask about handedness in order to establish which area of the brain is likely to contain language function

  • The main complaint will be understood thoroughly

  • It is important to determine the interval of the complaint, as this can help aid the diagnosis

  • For example, vascular disorders (such as strokes) occur very frequently over minutes or hours, whereas chronic disorders (such as Alzheimer's disease) occur over a matter of years.[2]

  • We will ask about past history to determine if any conditions of relevance may be present. Knowing your medications and how they may impact upon the nervous system is also important. Any history of smoking, alcohol or illicit drug use may be asked about depending upon the clinical situation.

  • Family history can be critical to determine for some forms of neurological disorders. Heredity is important for conditions such as Alzheimer's Disease, Lou Gehrig's Disease, and forms of Epilepsy. We may compose a family tree containing your family's history.

  • The impact of a neurological disorder upon work, activities of daily living and social activities can be severe or non-existant. We will ask questions about how you have been impacted by the condition.

  • Sometimes, symptoms unrelated to the nervous system may help to determine the nature of a neurological disorder. The Neurologist may ask questions about shortness of breath, pulse rate, and even the appearance of your urine in sorting out your condition.

 

The next step is the neurological examination. Carrying out a 'general' examination is just as important as the neurological exam, as it may lead to clues to the etiology of the complaint. Therefore, in some neurological assessments, you will have your heart, lungs, skin or other body parts also examined. After that, the neurological examination will be completed in steps:

 

  • Mental status examination

    • We assess level of consciousness, awareness and orientation

    • A mental status examination, such as the mini mental state examination (MMSE) or Montreal Cognitive Assessment (MOCA) or Frontal Assessment Battery (FAB) may be performed. Often, extra tests of cognition may be required

    • A global assessment of higher functions which may include executive function testing may be performed.

 

  • Cranial nerve examination is next. The cranial nerves (I-XII) have various functions: sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX, X), tongue movements (XII). These are tested by their individual purposes (e.g. the visual acuity can be tested by a Snellen chart).

  • Also, we assess for intracranial pressure by performance of fundoscopy - this involves looking into the eye to see the optic disc as shown below.

This is the back of your eye, with blood vessels appearing red. Neurologists are most interested in looking at the optic disc, seen as a yellow circle at 3:00. This is the window to the brain that tells us about the optic nerve well being, but also about pressure levels in the brain.

  • Examination of the motor system requires several steps.

    • ​Muscle strengthis tested to examine your power of each individual muscle. We will often use the MRC scale 0 to 5, where 0 = complete paralysis and 5 = normal power.

    • Muscle tone will be examined by moving your arms and legs while you have held them loose.

    • Signs of rigidity and bradykinesia may be tested for if there is concern about Parkinson's Disease or related conditions

    • Resting tremor will also be examined if there is concern about Parkinson's Disease or related conditions

    • We may be examining for any abnormal or extra movements such as with muscle twitching (fasciculations)

    • It may seem odd, but standing in one place with your arms outstretched like you are holding a bowl of water is one of our best tests - we are looking for something called a pronator drift

  • Deep tendon reflexes are a way of testing the reflex arc along the nerves and through the spinal cord. Everyone likes watching their knees kick out uncontrollably. We may test reflexes by tapping with a reflex hammer at the chin, arm tendons, leg tendons (including knees and ankles), and sometimes some extra tests. It is usual to have a plantar test, in which a scratch is applied to the bottom of your feet looking for a Babinski sign.  A reflex hammer like the one below is used for this testing.

This is called a Queen Square reflex hammer. Other types of reflex hammers are sometimes used also. This is the best tool for checking deep tendon reflexes.

  • Sensation is examined by testing the sensory system. We will use small objects to test this, such as with a cotton ball (fine touch), a safety pin (pain) and something cold (temperature). Sometimes, we examine ability to feel fine touch with a monofilament. These are called small fiber sensations, although light touch is also considered a large fiber sensation too. Pictures of these articles used to test sensation are shown below.

  • Vibration is tested at your joints starting in your toes with a tuning fork. A complementary test is that of position sense, in which we will ask you to identify small movements of a joint.

  • In some cases, special sensory testing will be performed to test the brain's ability to put together more complex stimuli:

    • Graphesthesia - this involves drawing a number on your body, and asking you to identify it

    • Stereognosis - this involves placing an object in your hand and asking you to identify it without looking at it

    • Double Simultaneous Stimulation - this will identify if your brain is able to identify stimuli at different locations in your body, sometimes presented at the same time.

  • Although it may not seem like it, a Romberg test is a type of sensory test. You will be asked to stand with feet together with eyes closed. When we stand, 2 out of the following 3 must be intact to maintain balance: i. vision ii. vestibulocochlear system iii. joint position sensation. Closing your eyes takes away on of these, so this test examines the other two functions.

  • There can be other sensory tests done in certain circumstances.

Cotton balls, or sometimes other objects, like the blunt side of a pin or stick, are used to test light touch.

A sterile safety pin, or sometimes other objects, like the sharp portion of a tongue depressor, are used to test pain sensation.

Tuning forks are used to test vibration sensation, and sometimes are used as a cold object for temperature sensation, or for tests of hearing.

  • The cerebellum is the coordination center of your brain. We test this by looking at eye movements, performing a finger to nose test and heel-shin test. Also, rapid alternating movements of the hands can be examined. Looking at your walking ability, or gait, can be another important test, and we will ask you to perform a heel-toe walk, like you are on a tightrope. It is important to determine if there is any tremor in different positions and during different tasks. There may be other cerebellar testing as well.

  • In some cases, it may be important to determine how your musculoskeletal system is functioning. This may involve feeling over bony and muscular areas, testing the range of motion of your joints, and other specialized tests.

 

  • Depending upon all of the above findings, there may be reason to perform other specific testing for particular findings.

  • Once all of this is completed, the results of testing which may include blood tests, scans of the body (including brain and spine), EMG and EEG testing, amongst other tests will be reviewed in detail. It is important to ensure that clinical findings are put in perspective with the results of testing.

  • After all of this, a diagnosis (what you have) may be reached. In some cases, further testing may be required to determine the cause of your symptoms. In other cases, it may not be obvious what the condition actually is due to. Neurological conditions can be complex, and follow-up of the condition over months, and sometimes even years, may be required to achieve a diagnosis.

  • If a diagnosis is achieved, then there can be discussion about prognosis (how things are expected to turn out). In some cases, neurological conditions are considered "benign" and have good outcomes. In other cases, prognosis may not be as good.

  • Then, consideration of other testing that could be required as well as possible therapies will be discussed with you. In some cases, neurological conditions can be managed. In a few situations, a cure may be possible. In other conditions, medical science has not yet allowed us to arrive at possible treatments for some neurological disorders.

  • Depending upon the condition, follow-up may be suggested, indicating that we will follow your condition over time and determine how it progresses. In other cases, treatments may require regular follow-up to determine their benefits or risk for side effects. In some cases, once the diagnosis is made, no further follow-up may be required.

  • If you have questions, please be sure to ask them while you are seeing the Neurologist. If not, be sure to bring questions with you at any follow-up visits that were scheduled.

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