NEUROLOGICAL ASSESSMENT

Dr. Madhu S M
General Demographics

• Age
• Gender
• Primary language
• Education
• Employment
Chief Complaint(s)
 Chief complaints these are one or more of the symptoms
or other concerns for which the patient is taking care or
advise.
 Use simple words in patients own language.
 Main aim of asking is to make the patient independent in
his day to day life and hence chief complaints are given as
inability to eat, difficulty dressing, difficulty in working.
 Nothing can give more pleasure to the patient than getting
rid of the chief complaints.
 Complete relief from chief complaint is main aim of any
intervention towards which whole assessment get directed.
History
 Present History - Present illness it includes how the
patient thinks and feels about the illness how the illness
has affected the patients daily life and function.

 Past History - Patients childhood illness and any history of

adult medical illness it includes previously done surgeries
or gynecologic events, psychiatric conditions, accidents
and injuries, transfusions etc.

 Socioeconomic History – Modified Kuppuswami Scale

History
 Family History – It helps to assess the patients risk of
developing certain diseases and may also suggest family
experience is relevant to the patients concern many
neurological problems have genetic basis so a detailed
family history is very important in making the diagnosis.

 Social History
• Cultural beliefs and behaviors
• Family and caregiver resources
• Social interactions, social activities, and support system
History
 Medical/Surgical History
• Cardiovascular
• Endocrine/metabolic
• Gastrointestinal
• Genitourinary
• Gynecological
• Integumentary
• Musculoskeletal
• Neuromuscular
• Obstetrical
• Prior hospitalizations, surgeries, and preexisting medical and other
health related conditions
• Psychological
• Pulmonary
History
 Drug History (Medications)
• Medications for current condition
• Medications previously taken for current condition
• Medications for other conditions

 Personal History
• Sleep
• Smoking and Alcohol
• Bowel and Bladder
Objective Examination
 ON OBSERVATION
 Attitude of limbs
 Built
 Posture
 Gait
 Pattern of Movement
 Mode of Ventilation
 Type/ Pattern of Respiration
 Oedema
 Muscle Wasting
 Pressure Sores
 Deformity
 Wounds
 External Appliances

Objective Examination
 ON PALPATION
 Warmth
 Tenderness
 Tone
 Swelling

 Grades of Tenderness
 Grade 1 - patient complains of pain
 Grade 2 - patient complains of pain an winces
 Grade 3 - patient complains of pain and withdraws
 Grade 4 - patient will not allow to palpate / touch
Neurological Examination
 Neurological disease may produce systemic signs and
systemic disease may affect the nervous system.
 A complete general examination must therefore
accompany that of the central nervous system.
 In particular, note the following – Temperature; Evidence
of weight loss; Septic source, e.g. teeth, ears; Blood
pressure; Breast lumps; Skin marks, e.g. rashes; Neck
stiffness; Lymphadenopathy; Pulse irregularity; Hepatic
and splenic enlargement; Carotid bruit; Cardiac murmurs;
Prostatic irregularity; Cyanosis/respiratory insufficiency.
CONSCIOUS LEVEL ASSESSMENT
 A wide variety of systemic and intracranial problems
produce depression of conscious level.
 Accurate assessment and recording are essential to
determine deterioration or improvement in a patient’s
condition.
 In 1974 Teasdale and Jennett, in Glasgow, developed a
system for conscious level assessment.
 They discarded vague terms such as stupor, semicoma and
deep coma, and described conscious level in terms of
 EYE opening
 VERBAL response and
 MOTOR response.
EYE OPENING – 4 categories

4 – Spontaneous
3 – To Speech
2 – To Pain
1 – No Response

VERBAL RESPONSE – 5 categories
5 – Orientated – Knows place, e.g. Southern General
Hospital and time, e.g. day, month and year
4 – Confused – Talking in sentences but disorientated in
time and place
3 – Inappropriate Words – Utters occasional words rather
than sentences
2 – Incomprehensible Sounds – Groans or grunts, but no
words
1 – No Response
MOTOR RESPONSE – 6 categories

6 – Obeys Command, e.g. ‘Hold up your arms’

5 – Moves to localised pain, e.g. Apply a painful stimulus to the
supraorbital nerve, e.g. rub thumb nail in the supraorbital
groove, increasing pressure until a response is obtained.
4 – Flex to withdraw from pain e.g. If the patient does not
localise to supraorbital pressure, apply pressure with a pen or
hard object to the nail bed. Record elbow flexion as ‘flexing to
pain’.
3 – Abnormal Flexion
2 – Abnormal Extension
1 – No Response
Higher Cerebral Function – Cognitive Skill
o Dominant Hemisphere Disorders
 Listen to language pattern
 Hesitant - Expressive dysphasia
 Fluent - Receptive dysphasia
 Does the patient understand simple/complex spoken commands?
e.g. ‘Hold up both arms, touch the right ear with the left fifth finger.’ -
Receptive dysphasia
 Ask the patient to name objects - Nominal dysphasia
 Does the patient read correctly? - Dyslexia
 Does the patient write correctly? - Dysgraphia
 Ask the patient to perform a numerical calculation,
e.g. serial 7 test, where 7 is subtracted serially from 100. - Dyscalculia
 Can the patient recognise objects?
e.g. ask patient to select an object from a group. - Agnosia
Higher Cerebral Function – Cognitive Skill
o Non-dominant Hemisphere Disorders
 Note patient’s ability to find his way around the ward or
his home. - Geographical agnosia
 Can the patient dress himself? - Dressing apraxia
 Note the patient’s ability to copy a geometric pattern,

e.g. ask patient to form a star with matches or copy a

drawing of a cube. - Constructional apraxia
 Higher Cerebral Function – MEMORY TEST
 Testing requires alertness and is not possible in a confused or dysphasic
patient.
 IMMEDIATE memory – Digit span – ask patient to repeat a sequence of
5, 6, or 7 random numbers.
 RECENT memory – Ask patient to describe present illness, duration of
hospital stay or recent events in the news.
 REMOTE memory – Ask about events and circumstances occurring more
than 5 years previously.
 VERBAL memory – Ask patient to remember a sentence or a short story
and test after 15 minutes.
 VISUAL memory – Ask patient to remember objects on a tray and test
after 15 minutes.
Note:
 Retrograde amnesia – loss of memory of events leading up to a brain
injury or insult.
 Post-traumatic amnesia – permanent loss of memory of events for a
period following a brain injury.
REASONING AND PROBLEM SOLVING
 Test patient with two-step calculations, e.g. ‘I wish to buy
12 articles at 7 Rs each. How much change will I receive
from 100Rs?’
 Ask patient to reverse 3 or 4 random numbers.
 Ask patient to explain proverbs.
 Ask patient to sort playing cards into suits.
 The examiner must compare patient’s present reasoning
ability with expected abilities based on job history and/or
school work.
EMOTIONAL STATE
Note:
 Anxiety or excitement
 Depression or apathy
 Emotional behaviour
 Uninhibited behaviour
 Slowness of movement or responses
 Personality type or change.
Cranial Nerve examination

 OLFACTORY NERVE (I)

 Test both perception and identification using aromatic
non-irritant materials that avoid stimulation of trigeminal
nerve fibres in the nasal mucosa, e.g. soap, tobacco.
 One nostril is closed while the patient sniffs with the
other.
Cranial Nerve examination
 OPTIC NERVE (II)
Visual acuity
Can patient see
• light?
• movement?

Can patient count fingers?

Record reading acuity with wall or hand chart.
Cranial Nerve examination
 Jaeger Chart for near vision
 Snellen Chart for far vision
 Ishihara Chart for Colour Vision
 Visual acuity is expressed as: d/D

d – Distance between individual and chart (6 meters)

D - Distances at which patient is expected to read letters
(meters)
Note : Test each eye separately.
Cranial Nerve examination
 Visual fields
 Gross testing by CONFRONTATION.
 Compare the patient’s fields of vision by advancing a
moving finger or, more accurately, a red 5 mm pin from
the extreme periphery towards the fixation point.
 The patient must fixate on the examiner’s pupil.
Cranial Nerve examination
 Pupils - Note:
• Size (small = miosis / large = mydriasis)
• Shape
• Equality
• Reaction to light: both pupils constrict when light is shone
in either eye
• Reaction to accommodation and convergence: pupil
constriction occurs when gaze is transferred to a near point
object.
 A lesion of the optic nerve will abolish pupillary response to
light on the same side as well as in the contralateral eye.
 When light is shone in the normal eye, it and the
contralateral pupil will constrict.
Cranial Nerve examination
 OCULOMOTOR (III), TROCHLEAR (IV) AND
ABDUCENS (VI) NERVES
 A lesion of the 3 nerves produces impairment of eye and
lid movement as well as disturbance of pupillary response.
 Pupil: The pupil dilates and becomes ‘fixed’ to light.
 Shine torch in affected eye – contralateral pupil constricts
(its III nerve intact). Absent or impaired response in
illuminated eye.
 When light is shone into the normal eye, only the pupil on
that side constricts.
Normal – Both pupils contract
CN3 lesion – loss of consensual pupillary light reflex
CN 2 lesion – loss of direct pupillary light reflex
Cranial Nerve examination
 Ptosis: Ptosis is present if the eyelid droops over the pupil
when the eyes are fully open. Since the levator palpebrae
muscle contains both skeletal and smooth muscle, ptosis
signifies either a III nerve palsy or a sympathetic lesion and
is more prominent with the former.

 Ocular movement : Steady the patient’s head and ask him to

follow an object held at arm’s length. Observe the full
range of horizontal and vertical eye movements.
• Note any malalignment or limitation of range.
• Examine eye movements in the six different directions of
gaze representing maximal individual muscle strength.
Cranial Nerve examination
 Conjugate movement: Note the ability of the eyes to move
together (conjugately) in horizontal or vertical direction or
tendency for gaze to fix in one particular direction.
 Nystagmus: This is an upset in the normal balance of eye
control. A slow drift in one direction is followed by a fast
corrective movement. Nystagmus is maximal when the
eyes are turned in the direction of the fast phase.
Nystagmus ‘direction’ is usually described in terms of the
fast phase and may be horizontal or vertical. Test as for
other eye movements, but remember that ‘physiological’
nystagmus can occur when the eyes deviate to the
endpoint of gaze.
Cranial Nerve examination
 TRIGEMINAL NERVE (V) - Test
Sensory examination
Over whole
• pain (pin prick) sensation face
• temperature (cold object or hot/cold tubes)
• light touch
 Compare each side.
 Map out the sensory deficit, testing from the abnormal to the
normal region.
 Corneal reflex - Test corneal sensation by touching with wisp
of wet cotton wool. A blink response should occur bilaterally.
• This test is the most sensitive indicator of trigeminal nerve
damage
Cranial Nerve examination
Jaw jerk
• Ask patient to open mouth and relax jaw.
• Place finger on the chin and tap with hammer:

Slight jerk – normal

Increased jerk – bilateral upper neuron lesion
Cranial Nerve examination
Motor examination
• Observe for wasting and thinning of temporalis muscle –
‘hollowing out’ the temporalis fossa.
• Ask the patient to clamp jaws together. Feel temporalis
and masseter muscles.
• Attempt to open patient’s jaws by applying pressure to
chin.
• Ask patient to open mouth.
• If pterygoid muscles are weak the jaw will deviate to the
weak side, being pushed over by the unopposed pterygoid
muscles of the good side.
Cranial Nerve examination
 FACIAL NERVE (VII)
• Observe patient as he talks and smiles, watching for:

– eye closure
– asymmetrical elevation of one corner of mouth
– flattening of nasolabial fold.
• Patient is then instructed to:

– wrinkle forehead (frontalis) (by looking upwards)

– close eyes while examiner attempts to open them
(orbicularis oculi)
– purse lips while examiner presses cheeks (buccinator)
– show teeth (orbicularis oris)
Cranial Nerve examination
 Sensory examination
 Taste may be tested by using sugar, tartaric acid or sodium
chloride. A small quantity of each substance is placed
anteriorly on the appropriate side of the protruded tongue.
Cranial Nerve examination
 AUDITORY NERVE (VIII)
• Cochlear component Test by whispering numbers into one
ear while masking hearing in the other ear by occluding
and rubbing the external meatus.
• If hearing is impaired, examine external meatus and the
tympanic membrane with auroscope to exclude wax or
infection. Differentiate conductive (middle ear) deafness
from perceptive (nerve) deafness by:
Cranial Nerve examination
1. Weber’s test: Hold base of tuning fork (512 Hz) against
the vertex. Ask patient if sound is heard more loudly in
one ear.
 NORMAL - Hearing equally on both the sides.
 CONDUCTIVE DEAFNESS - Sound is louder in affected
ear since distraction from external sounds is reduced in
that ear.
 NERVE DEAFNESS - Sound is louder in the normal ear.
Cranial Nerve examination
2. Rinne’s test: Hold the base of a vibrating tuning fork
against the mastoid bone. Ask the patient if note is heard.
When note disappears – hold tuning fork near the external
meatus. Patient should hear sound again since air
conduction via the ossicles is better than bone
conduction.
• In conductive deafness, bone conduction is better than air
conduction.
• In nerve deafness, both bone and air conduction are
impaired.
Cranial Nerve examination
 GLOSSOPHARYNGEAL NERVE (IX): VAGUS NERVE
(X)
 These nerves are considered jointly since they are
examined together and their actions are seldom
individually impaired.
• Note patient’s voice – if there is vocal cord paresis (X
nerve palsy), voice may be high pitched. (Vocal cord
examination is best left to an ENT specialist.)
• Note any swallowing difficulty or nasal regurgitation of
fluids.
• Ask patient to open mouth and say ‘Ah’. Note any
asymmetry of palatal movements (X nerve palsy).
Cranial Nerve examination
 Gag reflex
• Depress patient’s tongue and touch palate, pharynx or
tonsil on one side until the patient ‘gags’. Compare
sensitivity on each side (afferent route – IX nerve) and
observe symmetry of palatal contraction (efferent route –
X nerve).
• Absent gag reflex = loss of sensation and/or loss of motor
power. (Taste in the posterior third of the tongue (IX) is
impractical to test).
Cranial Nerve examination
 ACCESSORY NERVE (XI)
• Sternomastoid - Ask patient to rotate head against
resistance. Compare power and muscle bulk on each side.
Also compare each side with the patient pulling head
forward against resistance. The left sternomastoid turns
the head to the right and vice versa.
• Trapezius - Ask patient to ‘shrug’ shoulders and to hold
them in this position against resistance. Compare power
on each side. Patient should manage to resist any effort to
depress shoulders.
Cranial Nerve examination
 HYPOGLOSSAL NERVE (XII)
• Ask patient to open mouth; inspect tongue. Look for –
evidence of atrophy (increased folds, wasting) –
fibrillation (small wriggling movements).
• Ask patient to protrude tongue. Note any difficulty or
deviation. (N.B. apparent deviation may occur with facial
weakness – if present, assess tongue in relation to teeth.)
• Protruded tongue deviates towards side of weakness.
• Non protruded tongue cannot move to the opposite side.
• Dysarthria and dysphagia are minimal.
Perceptual examination
Body scheme/ Body image disorders:
 Body image includes feelings about one’s body, especially in
relation to health and disease.
 Body scheme includes the relationship of body parts to each
other and the relationship of the body to the environment.
(a)Unilateral neglect :
 it is the inability to register and integrate stimuli and
perceptions from one side of the body and the environment.
 Clinically, the patient may ignore the left half of the body
when dressing and forget to put on the left sleeve or left
pants leg.
(b) Anosognosia :
 It is a severe condition including denial and lack of
awareness of the presence or severity of one’s paralysis.
 It is assessed by asking to the patient what happened to
him, whether he is paralysed.
 Patient may deny the paralysis.

(c) Somatoagnosia :
It is the lack of awareness of the body structure and the
relationship of body parts to oneself or to other.
Patient may have a hard time participating in exercise that
require some body parts to be removed.
(d) Right – left discrimination :
 It is the inability to identify the right and left sides of
one’s own body.
 Clinically the patient can not tell the therapist which is the
right arm which is the left.
(e) Finger agnosia :
It is the inability to identify the finger of one’s own hands or
of the hands of the examiner.
Spatial relation disorders
 It encompasses a difficulty in perceiving the relationship
between the self and two or more objects.

(a) Figure-ground discrimination :

 it is the ability to visually distinguish a figure from the
background in which it is embedded.
 Clinically, the patient can not locate items in a pocket book or
drawer, locate buttons on a shirt.

(b) Form discrimination :

 It is the inability to perceive differences in form and shape.
 Clinically the patient may confuse a pen with a toothbrush.
(c) Position in space
 It is the inability to perceive and to interpret spatial
concepts such as up, down, under, over, in out, in front of
and behind.
 Clinically, if s patient is asked to raise the arm “above” the
head, the patient may behave as if he or she does not
know what to do.
(d) Topographic disorientation :
It refers to difficulty in understanding and remembering the
relationship to one location to another.
Clinically the patient cannot find the way from his room to
the physical therapy clinic.
(e) Depth and distance perception:
 The patient experiences inaccurate judgement of
directions, distance and depth.
 Clinically the patient may have difficulty navigating
stairs, may miss the chair when attempting to sit.

(f) Vertical disorientation :

It refers to a distorted perception of what is vertical.
Agnosia
 It is the inability to recognise or make sense of incoming information.
(a) Visual object agnosia
 It is the inability to recognise familiar objects.
 The patient may not recognise people, possessions and common
objects.
(b) Auditory agnosia :
It refers to the inability to recognise non speech sounds or to discriminate
between them.
the patient with auditory agnosia can not tell the difference between the
ring of a doorbell and that of a telephone.
(c) Tactile agnosia or astereognosis:
it is the inability to recognise forms by handling them.
If patient is handed an object like key, comb, safety pin with vision
occluded, the patient will fail to recognize it.
Apraxia
 It is the inability to perform purposeful movement.
(a) Ideomotor :
the patient with ideomotor apraxia is able to carry out habitual
tasks automatically and describe how they are done but is
unable to imitate gestures or perform on command.
(b) Ideational :
It is the inability to perform a purposeful motor act, either
automatically or on command.
(c) Constructional:
It is the inability to produce two or three dimensional forms by
drawing, constructing or arranging blocks or objects
spontaneously or on command.
SENSORY EXAMINATION
 Sensory integration is the ability of the brain to organize,
interpret, and use sensory information.
 This integration provides an internal representation of the
environment that informs and guides motor responses.
 These sensory representations provide the foundation on which
motor programs for purposeful movements are planned,
coordinated, and implemented.
 Ayers defined sensory integration as “the neurological process
that organizes sensation from one’s own body and from the
environment and makes it possible to use the body effectively
within the environment.”
 In an intact system, sensory integration occurs automatically
without conscious effort.
Sensory Integration
 The three divisions of sensory receptors include those that
mediate the (1) superficial, (2) deep, and (3) combined
(cortical) sensations.
 Superficial Sensation - Exteroceptors are responsible for the
superficial sensations. They receive stimuli from the external
environment via the skin and subcutaneous tissue.
Exteroceptors are responsible for the perception of pain,
temperature, light touch, and pressure.
 Deep Sensation - Proprioceptors are responsible for the deep
sensations. These receptors receive stimuli from muscles,
tendons, ligaments, joints, and fascia, and are responsible for
position sense and awareness of joints at rest, movement
awareness (kinesthesia), and vibration.
Sensory Integration
 Combined Cortical Sensations - The combination of both
the superficial and deep sensory mechanisms makes up the
third category of combined sensations. These sensations
require information from both exteroceptive and
proprioceptive receptors, as well as intact function of
cortical sensory association areas. here cortical combined
sensations include stereognosis, two-point discrimination,
barognosis, graphesthesia, tactile localization, recognition
of texture, and double simultaneous stimulation.
Superficial sensation (thalamic sensation)
(a) Fine touch:
 the area to be tested is lightly touched or stroked.
 The patient is asked to indicate when she recognizes that a
stimulus has been applied by responding “yes” or “no”.
(b) Pain :
 Sharp end of the safety pin is used.
 Patient is asked to verbally indicate when a stimulus is felt.

(c) Temperature :
 Two test tubes with stoppers are required for this assessment, one
should be filled with warm water and the other with crushed ice.
 Patient is asked to indicate when a stimulus is felt and to reply
“warm”, “cold” or “ unable to tell”
Deep sensation
(a) Joint position sense:
 The joint to be assessed is moved through a ROM and held in a static
position.
(b) Kinesthesia :
 This test examines awareness of movement .
 The joint to be assessed is moved passively through a relatively small
ROM.
 The patient is asked to describe the direction and range of movement.

(c) Vibration :
 The ability to perceive a vibratory stimulus is tested by placing the
base of a vibrating tuning fork on a bony prominence.
 The patient is asked to respond by verbally identifying the stimulus as
vibrating or non vibrating.
Cortical sensation
(a) Stereognosis:
 Testing for tactile object recognition requires use of items of differing size
and shape like keys, coins, etc..
 The patient is asked to name the object verbally.
(b) Two point discrimination:
 This test assesses the ability to localise touch sensation on the skin.
 Patient is asked to identify the location of the stimuli by pointing to the
area.
(c) Barognosis:
 To assess recognition of weight, a series of small objects of the small size
but of graduated weight is used.
 The patient responds by indicating that the object is “heavier” or “lighter”.
(d) Graphesthesia:
 The recognition of letters, numbers or designs traced on the skin is assessed
by the use of the eraser end of a pencil.
 The patient is asked to identify verbally the figures drawn on the skin.
Dermatomes of the whole body
MOTOR EXAMINATION - ROM
Active Range of Motion
 The examination of joint motion begins by testing active range of
motion (AROM).
 Active motion is the unassisted voluntary movement of a joint.
 The patient is asked to move a body part through the
osteokinematic motions at the involved and other biomechanically
related joints.
 Osteokinematics refers to the gross angular motions of the shafts
of bones.
 These motions are described as occurring in the three cardinal
planes of the body: flexion and extension in the sagittal plane,
abduction and adduction in the frontal plane, and medial and
lateral rotation in the transverse plane.
MOTOR EXAMINATION - ROM
 Active motion is a good musculoskeletal screening
procedure to further focus the physical examination.
 The amount, quality, and pattern of motion, as well as the
occurrence of pain and crepitus, should be noted.
 For purposes of musculoskeletal screening, AROM can be
visually estimated to determine if motion is within
functional limits (WFL); however, use of a goniometer is
required for the more objective and accurate
measurements needed to establish a pathological baseline
and to evaluate treatment response.
MOTOR EXAMINATION - ROM
Passive Range of Motion
 Passive motions are movements performed by the
therapist without the assistance of the patient.
 The term passive range of motion (PROM) typically refers
to the amount of osteokinematic motion available when
the patient’s joint is moved without the patient’s
assistance.
 Normally, PROM is slightly greater than AROM because
joints have a small amount of motion at the end of the
range that is not under voluntary control.
MOTOR EXAMINATION – MUSCLE
POWER
Manual Muscle Testing
 Manual muscle testing was developed by Wright and
Lovett beginning in 1912 as a means of testing and
grading muscle strength based on gravity and manually
applied resistance.
 Generally, the patient is positioned so that the muscle or
muscle group being tested has to move or hold against the
resistance of gravity.
 If this is well tolerated, the therapist applies manual
resistance gradually to the distal end of the body part in
which the muscle inserts, and in a direction opposite to the
torque produced by the muscle(s) being tested.
MOTOR EXAMINATION – MUSCLE
POWER
MOTOR EXAMINATION – MUSCLE TONE
Tone
 Tone is defined as the resistance of muscle to passive
elongation or stretch.
 It represents a state of slight residual contraction in normally
innervated, resting muscle, or steady-state contraction.
 Tone is influenced by a number of factors, including (1)
physical inertia, (2) intrinsic mechanical-elastic stiffness of
muscle and connective tissues, and (3) spinal reflex muscle
contraction (tonic stretch reflexes).
 Tonal abnormalities are categorized as hypertonia (increased
above normal resting levels), hypotonia (decreased below
normal resting levels), or dystonia (impaired or disordered
tonicity).
MOTOR EXAMINATION – MUSCLE TONE
Hypertonia
 Spasticity
 Spasticity is a motor disorder characterized by a velocity
dependent increase in muscle tone with increased resistance
to stretch; the larger and quicker the stretch, the stronger the
resistance of the spastic muscle.
 During rapid movement, initial high resistance (spastic catch)
may be followed by a sudden inhibition or letting go of the
limb (relaxation) in response to a stretch stimulus, termed
clasp-knife response.
 Chronic spasticity is associated with contracture, abnormal
posturing and deformity, functional limitations, and disability.
MOTOR EXAMINATION – MUSCLE TONE
 Rigidity
 Rigidity is a hypertonic state characterized by constant resistance
throughout ROM that is independent of the velocity of movement
(lead-pipe rigidity).
 It is associated with lesions of the basal ganglia system
(extrapyramidal syndromes) and is seen in Parkinson’s disease.
 Patients demonstrate stiffness, inflexibility, and significant
functional limitation.
 Cogwheel rigidity refers to a hypertonic state with superimposed
ratchet-like jerkiness and is commonly seen in upper extremity
movements (e.g., wrist or elbow flexion and extension) in
patients with Parkinson’s disease. It may represent the presence
of tremor superimposed on rigidity.
MOTOR EXAMINATION – MUSCLE TONE
 Decorticate and Decerebrate Rigidity
 Severe brain injury can result in coma with decorticate or
decerebrate rigidity.
 Decorticate rigidity refers to sustained contraction and posturing
of the upper limbs in flexion and the lower limbs in extension.
The elbows, wrists, and fingers are held in flexion with shoulders
adducted tightly to the sides while the legs are held in extension,
internal rotation, and plantarflexion.
 Decerebrate rigidity (abnormal extensor response) refers to
sustained contraction and posturing of the trunk and limbs in a
position of full extension. The elbows are extended with
shoulders adducted, forearms pronated, and wrist and fingers
flexed. The legs are held in stiff extension with plantarflexion.
MOTOR EXAMINATION – MUSCLE TONE
 Opisthotonus is characterized by strong and sustained
contraction of the extensor muscles of the neck and trunk,
resulting in a rigid, hyperextended posture. Extensor
muscles of the proximal limbs may also be involved.
These postures are considered exaggerated and severe
forms of spasticity.
 Dystonia is a prolonged involuntary movement disorder
characterized by twisting or writhing repetitive
movements and increased muscular tone. Dystonic
posturing refers to sustained abnormal postures caused by
cocontraction of muscles that may last for several minutes,
for hours, or permanently.
MOTOR EXAMINATION – MUSCLE TONE
Hypotonia
 Hypotonia and flaccidity are the terms used to define
decreased or absent muscular tone.
 Resistance to passive movement is diminished, stretch
reflexes are dampened or absent, and limbs are easily moved
(floppy).
 Hyperextensibility of joints is common.

Modified Ashworth Scale

 The Modified Ashworth Scale (MAS) is a clinical scale used
to assess muscle spasticity that is in commonly used in many
rehabilitation facilities and spasticity clinics.
Modified Ashworth Scale
Grade - Description
0 - No increase in muscle tone.
1 - Slight increase in muscle tone, manifested by a catch and
release or by minimal resistance at the end of the ROM
when the affected part(s) is moved in flexion or extension.
1+ - Slight increase in muscle tone, manifested by a catch,
followed by minimal resistance throughout the remainder
(less than half) of the ROM.
2 - More marked increase in muscle tone through most of the
ROM, but affected part(s) easily moved.
3 - Considerable increase in muscle tone, passive movement
difficult.
4 - Affected part(s) rigid in flexion or extension.
MOTOR EXAMINATION - Reflex Integrity
Deep Tendon Reflexes
 A reflex is an involuntary, predictable, and specific response to a
stimulus dependent on an intact reflex arc (sensory receptor,
afferent neurons, efferent neurons, and responding muscles or
gland).
 The deep tendon reflex (DTR) results from stimulation of the
stretch-sensitive 1A afferents of the neuromuscular spindle
producing muscle contraction via a monosynaptic pathway.
 DTRs are tested by tapping sharply over the muscle tendon with a
standard reflex hammer or with the tips of the therapist’s fingers.
 To ensure adequate response, the muscle is positioned in midrange
and the patient is instructed to relax.
 Stimulation can result in observable movement of the joint (brisk
or strong responses).
MOTOR EXAMINATION - Reflex Integrity
 Weak responses may be evident only with palpation
(slight or sluggish responses with little or no joint
movement).
 The quality and magnitude of responses should be
carefully documented. In the medical record, reflexes are
graded on a 0 to 4+ scale:
0 Absent, no response
1+ Slight reflex, present but depressed, low normal
2+ Normal, typical reflex
3+ Brisk reflex, possibly but not necessarily abnormal
4+ Very brisk reflex, abnormal, clonus
MOTOR EXAMINATION - Reflex Integrity
Deep Tendon reflexes
 Jaw Jerk (CN V)
 Biceps Musculocutaneous nerve (C5, C6)
 Brachioradialis (supinator) Radial nerve (C5, C6)
 Triceps Radial nerve (C6, C7)
 Finger flexors Median nerve (C6–T1)
 Hamstrings Tibial branch, sciatic nerve (L5, S1, S2)
 Quadriceps (patellar, knee jerk)Femoral nerve (L2, L3,
L4)
 Achilles (ankle jerk) Tibial (S1–S2)
MOTOR EXAMINATION - Reflex Integrity
Superficial Cutaneous Reflexes
 Superficial cutaneous reflexes are elicited with a light
stroke applied to the skin.
 The expected response is brief contraction of muscles
innervated by the same spinal segments receiving the
afferent inputs from the cutaneous receptors.
 A stimulus that is strong may produce irradiation of
cutaneous signals with activation of protective withdrawal
reflexes.
 Cutaneous reflexes include the plantar reflex, confirming
toe signs (Chaddock), and abdominal reflexes.
Superficial reflexes
Plantar :
 It is tested by applying a noxious stroking stimulus on the sole of the foot along
the lateral border and up across the ball of the foot.
 Normal response consists of flexion of the big toe.
 An abnormal response (positive babinski sign) consists of dorsiflexion of the big
toe, with fanning of the lateral four toes.
Chaddock sign :
 It is elicited by stroking around the lateral ankle and up the lateral dorsal aspect
of the foot.
 It produces dorsiflexion of the big toe.
Abdominal :
 It is elicited with quick, light strokes over the skin of the abdominal muscle.
 Umbilical deviation in a superior/lateral direction indicates integrity of spinal
segment T6 and T9.
 Deviation in a inferior/lateral direction indicates integrity of spinal segment T11
and L1.
 Loss of response is abnormal, indicative of corticospinal pathology
Deep reflexes
Biceps (C5-C6) :
 Patient is sitting with arm flexed and supported.
 Place thumb over the biceps tendon in the cubital fossa,
stretching it slightly.
 Tap thumb or directly on tendon.
 Slight contraction of muscle normally occurs.

Triceps(C7-C8) :
 Patient is sitting with arm supported in abduction, elbow flexed.
 Palpate triceps tendon just above olecranon.
 Tap directly on tendon.
 Slight contraction of muscle normally occurs(elbow extends).
Patellar (L2,L3, L4) :
 Patient is sitting with knee flexed, foot unsupported.
 Tap tendon of quadriceps muscle between the patella and tibial
tuberosity.
 Contraction of muscle normally occurs (knee flexes).

Ankle (S1,S2) :
 Patient is prone with foot over the end of the plinth or sitting
with knee flexed and foot held in slight dorsiflexion.
 Tap tendon just above its insertion on the calcaneus.
 Maintaining slight tension on the gastrocnemius –soleus group
improves the response.
 Slight contraction of muscle normally occurs(foot plantarflexes).
MOTOR EXAMINATION - Reflex Integrity
Primitive and Tonic Reflexes
 Primitive and tonic reflexes are present during infancy as a
stage in normal development and become integrated by
the CNS at an early age.
 Once integrated, these reflexes are not generally
recognizable in adults in their pure form.
 They may continue, however, as adaptive fragments of
behavior, underlying normal motor control.
 Automatic reactions
Name Position of stimulus Negative Positive appears disappear
patient response response

Landaus Prone Active or No Trunk 3- 8-10months,

reflex suspension passive response extension 5months by this time
with chest extension of increases child
and head and hip develops
abdomen extended voluntary
supported control of
neck
Gallant/ Prone Stimulate No Lateral birth 2months
incurvatum from response flexion of
reflex shoulder to trunk to
buttock same side
3cm lateral of stimulus
to spine

Parachute Hold child Lower the No Protective 5- Present

reflex horizontally head with response extension- 6months through out
in space moderate abduction life
under axilla speed of upper
 Spinal reflexes
Name Position of Stimulus Negative Positive Appears Disappears
the patient response response

Flexor Supine with Stimulate No Sudden birth 2 moths

withdrawal lower limb sole of one response jerky
extension foot flexion of
stimulated
leg
Extensor Supine with Stimulate No Stimulated birth 2 months
thrust one limb in sole of response foot will go
flexion and flexed foot into
other limb extension
in extension
Crossed Supine one Stimulate No Free leg birth 2 months
extension limb in sole of response flexes,
flexion and extended adducts and
other in foot then
extension extends
 Neonatal reflexes
name position stimulus Negative Positive Appears disapears
response response
sucking No Finger intro to No Sucks birth 3 months
specific child’s mouth response
position
rooting No Touch corners No Turns lips or birth 3 months
specific of lips response head to that
position direction
Automatic Hold Sole of foot No Reciprocal birth 2 months
walking child touches the response flex & ext as
upright plinth if walking
Moro’s Supine Sudden loud No abd-ext of UL birth 3-4 months
reflex noise or clap response &LL
followed by
add & flx
Palmar No Press finger No Flexion of birth 3 months
reflex specific into child’s response fingers &
position palm tight grasp
Plantar No Press fingers No Curling of birth 3 months
reflex specific on plantar response toes
position surface of toes
Placing Hold Dorsum of foot No Flexes hip & birth Varies
reflex child touches the response knee above 1month to
 Brainstem reflexes
Name position stimulus -ve +ve response Appears disappea
response rs
ATNR supine Laterally No Ext /increase tone 2 months 4-5
rotate head response of limbs of face months
to one side side and flex
tone on skull side
STNR Quadruped Ext of head No Ext of UL, flex of 4 months 6 months
response LL
Flex of Flex of UL & Ext
head of LL
TLR Supine Ext /increases
tone of all limbs
prone Flex /increase
tone of all limbs
+ve Upright Sole No Ext of hip and birth 3-4
supportive with axilla touches the response knee with plantar months
reaction support plinth flex of ankle
-ve Upright Sole No Child sinks or birth 3-5
supportive with axilla touches the response sudden flex of LL months
reaction plinth
 Midbrain reflexes (proprioception and vestibular stimulus)
Name Position Stimulus -ve +ve response Appears Disappe
response ars

Neck Supine Turn the head No Turning of body as Birth to 3 Through

righting and blind to any one side response a whole to same months out life
reflex fold side

Labyrinthin Supine Change body No Head will right 6 months Through

e righting and blind position prone response itself according to out life
reaction fold to supine or body
vice versa
Body on Supine Rotate any one No Segmental 6 months Through
body and blind limb rt knee to response righting of lower out life
fold one side so trunk, then
that pelvis middle, moving to
rotates upper and finally
to shoulder girdle
Optical Supine Change body No Child corrects 1-2 Through
righting position prone response head and eyes also months out life
to supine or moves acc to
vice versa position of body
 Cortical reactions (protective reactions)
name Position Stimulus -ve +ve Appears Disappears
response response

Supine or On tilt Tilt the No Maintains 6 months through out

prone board board response balance life

Quadruped On tilt Tilt the No Maintains 8 months through out

board board response balance life

sitting On tilt Tilt the No Maintains 10-12 through out

board board response balance months life

Kneel On tilt Tilt the No Maintains 15 months through out

standing board board response balance life

standing On tilt Tilt the No Maintains 18 months through out

board board response balance life
MOTOR EXAMINATION - Reflex Integrity
Primitive and tonic reflexes are graded using a 0 to 4+
scale:

0+ Absent
1+ Tone change: slight, transient with no movement of the
extremities
2+ Visible movement of extremities
3+ Exaggerated, full movement of extremities
4+ Obligatory and sustained movement, lasting for more
than 30 seconds
MOTOR EXAMINATION - Reflex Integrity

Primitive / Spinal Reflexes Tonic / Brainstem Reflexes

 Flexor withdrawal  Asymmetrical tonic neck
 Crossed extension (ATNR)
  Symmetrical tonic neck
Traction
 Moro (STNR)
 Symmetrical tonic
 Grasp
labyrinthine (TLR or
STLR)
 Positive supporting
Co-ordination Examination
 Coordination is the ability to execute smooth, accurate,
controlled movement.
 Coordinated movement involves multiple joints and
muscles that are activated at the appropriate time and with
the correct amount of force so that smooth, efficient, and
accurate movement occurs.
 Thus, the essence of coordination is the sequencing,
timing, and grading of the activation of multiple muscles
groups.
Co-ordination Examination
 Coordination tests generally can be divided into two main
categories: gross motor movements and fine motor movements.
 Gross motor tests include body posture, balance, and extremity
movements involving large muscle groups. Examples of gross
motor activities include crawling, kneeling, standing, walking,
and running.
 Fine motor tests address movements concerned with utilization of
small muscle groups that involve skillful, controlled manipulation
of objects. Examples of fine motor activities include finger
dexterity tasks such as buttoning a shirt, typing, or handwriting.
 Two subdivisions of coordination tests (nonequilibrium and
equilibrium) have traditionally been used for providing structure
and organization to administration of the tests.
Co-ordination Examination
 Non-equilibrium tests address components of limb movements.
 Equilibrium or balance tests consider the ability to maintain
the body in equilibrium with gravity both statically (i.e., when
stationary) and dynamically (i.e., while moving).
 Nonequilibrium Co-ordination Tests :

 Finger to Nose
 Finger to Therapists Finger
 Finger to Finger
 Pronation / Supination
 Alternate heel-to-knee; heel-to-toe; etc..
 Rebound phenomenon
Impairments
Finger-nose testing :
 Ask the patient to touch his nose with finger(eyes open).
 Look for jerky movements – DYSMETRIA or an INTENSION
TREMOR (tremor only occuring on voluntary movement).
 Ask the patient to alternately touch his own nose then the
examiners finger as fast as he can.
 This may exaggerate the intension tremor and may
demonstrate DYSDIADOCHOKINESIA(inability to perform
rapidly alternating movements.
 This may also be shown by asking the patient to rapidly
supinate and pronate the forearms or to perform rapid and
repeated tapping movements.
Equilibrium coordination tests
 Normal stance
 Stance (narrow base of support)
 Tandem stance
 One leg stance
 Pertubations: displace balance unexpectedly
 Standing, functional reach test : forward trunk flexion
with UE reach.
 Standing, laterally flex trunk to each side.
Cont…
 Romergs test : inability to maintain an upright posture without visual
input is referred to as positive rombergs sign.
 Sharpened romberg :standing in tandem position from EO to EC.
 Tandem walking : heel to toe walk.
 Walking along a straight line or place feet on floor markers while
walking.
 Walk sideways, backwards, or cross stepping
 March in place
 Start and stop abruptly
 Walk and pivot on command(turn 90, 180, or 360)
 Walk with horizontal and vertical head turns on command.
 Step over or around obstacles.
 Stair climbing with or without using handrails.
 Jumping jacks
 Sitting in a therapy ball
Grading for non-equilibrium and
Equilibrium tests
5- Normal performance
4- minimal impairement : able to accomplish, slightly less
than normal speed, requires supervision/minimal contact
guarding.
3- moderate impairement : able to accomplish activity,
movements are slow, awkward, and unsteady; requires
moderate contact guarding.
2- severe impairement : Able only to initiate activity without
completion, requires maximal contact guarding.
1 – Activity impossible
Balance Examination
 Balance is the condition in which all the forces acting on the body
are balanced such that the center of mass (COM) is within the
stability limits, the boundaries of the base of support (BOS).
Romberg Test
 The Romberg Test is historically one of the oldest sensory tests for
postural control.
 During the test, the patient is instructed to stand with feet together,
eyes open (EO) unaided for 20 to 30 seconds. (If the patient
demonstrates significant sway or instability with EO, the test is
over.)
 The patient is then asked to stand with eyes closed (EC). If the test
is negative, there is no change or only minimal worsening with
EC. If the test is positive, the patient is able to stand with EO but
demonstrates significant increase in sway and/or instability with
EC.
Functional Balance Grades
4 Normal - Patient able to maintain steady balance without handhold
support (static). Patient accepts maximal challenge and can shift
weight easily within full range in all directions (dynamic).
3 Good - Patient able to maintain balance without handhold support,
limited postural sway (static). Patient accepts moderate challenge; able
to maintain balance while picking up object o ff floor (dynamic).
2 Fair - Patient able to maintain balance with handhold support; may
require occasional minimal assistance (static). Patient accepts minimal
challenge; able to maintain balance while turning head/trunk
(dynamic).
1 Poor - Patient requires handhold support and moderate to maximal
assistance to maintain position (static). Patient unable to accept
challenge or move without loss of balance (dynamic).
0 Absent - Patient unable to maintain balance
Gait Analysis
 One of the major purposes of rehabilitation is to help patients
achieve the highest level of function given their specific
impairments so they can participate optimally in activities of
interest.
 Human ambulation, or gait, is one of the basic components of
independent function commonly affected by either disease or
injury.
 Consequently, the desired outcome of many physical therapy
interventions is to restore or improve a patient’s ambulatory status.
 Gait, defined as the manner in which a person walks (e.g.,
cadence, step length, stride length, speed and rhythm) differs from
locomotion, which refers to an individual’s capacity to move from
one place to another.
Gait Cycle
 The fundamental unit of walking is the gait cycle, which
has both spatial (distance) and temporal (time) parameters.
 In normal walking, a gait cycle begins when the heel of
the reference extremity contacts the supporting surface
and ends when the heel of the same extremity contacts the
ground again.
 In some abnormal gaits, the heel may not be the first part
of the foot to contact the ground, so the gait cycle may be
considered to begin when some other portion of the
reference limb contacts the ground.
 The cycle ends with the next ipsilateral contact of that
same portion of the foot with the ground.
Gait cycle

Initial Loading Mid Terminal Pre Swing Initial Mid

Terminal
Contact Response Stance Stance Swing Swing Swing
Gait cycle
 Classification of the gait cycle involves two main phases:
1. Stance phase : occupies 60%
2. Swing phase : occupies 40%
Gait involves a combination of open and close chain activities.
More detailed classification of gait recognises eight phases :
1. Heel strike
2. Foot flat
3. Mid stance
4. Terminal stance
5. Pre swing
6. Initial swing
7. Mid swing
8. Late swing
Abnormal gait syndromes
In general gait deviations fall under four headings :
 Pain
 Joint range of motion (ROM) limitation
 Muscular weakness/paralysis
 Neurological involvement (UMN,LMN)
 Leg length discrepancies
Abnormal gait
 Hemiplegic gait
 Scissors gait/ diplegic gait
 Myopathic gait
 Steppage gait
 Parkinson gait &propulsive gait
 Sensory gait
Hemiplegic gait
 Unilateral weakness on the affected side.
 Hip into extension, adduction and medial rotation
 Knee in extension
 Ankle in drop foot with plantarflexion and inversion (equinovarus),
which is present during stance and swing phases.
 In order to clear the foot from ground the knee and hip should flex
 Foot clearence
 Hip flexor weakness
 Plevis retracted
 Weakness in distal muscles(foot drop) and extensor hypertonia in lower
limb
 Most commonly seen in stroke with mild hemepresis, loss of normal arm
swing.
 Slight circumduction may be the only abnormality.
Scissor gait/diplegic gait
 Patient have involvement on both sides with spasticity in
lower extremities worse than upper extremities.
 The patient walks with an abnormally narrow base,
dragging both legs and scraping the toes.
 This gait is seen in bilateral periventricular lesions, such
as those seen in cerebral palsy.
 Extreme tightness of hip adductors which can cause legs
to cross the midline referred to as a scissors gait.
Myopathic gait
 Hip girdle muscles are responsible are responsible for keeping the pelvis
level when walking.
 If you have weakness on one side, this will lead to a drop in the pelvis
on the contralateral side of the pelvis while walking (trendelenburg
sign).
 With bilateral weakness, you will have dropping of the pelvis on both
sides during walking leading to waddling.
 This gait is seen in patient with myopathies, such as muscular dystrophy.
 c/f :

 abductor weakness
 Trendlenberg sign positive
 Pelvis drop on opposide side and trunk sway on same side.
 Waddling gait
Ataxic gait
 Most commonly seen in cerebellar disease, this gait is described as
 Clumpsy
 Staggering movements with a wide based gait.
 Patients will not be able to walk from heel to toe or in a straight
line.
 The gait of acute alcohol intoxication will resemble the gait of
cerebellar disease.
An unsteady uncoordinated wide base feet thrown out
 To maintain balance the child with ataxia walks bent forward with
feet wide apart.
 She takes irregular steps, like a sailor on a rough sea or someone
who is drunk.
Steppage gait
 Seen in patients with foot drop (weakness of foot
dorsiflexion), the cause of this gait gait is due to an
attempt to lift the leg high enough during walking so that
tha foot does not drag on the floor.
 If unilateral, causes include peroneal nerve palsy and L5
radiculopathy.
 If bilateral, causes include amylotrophic lateral sclerosis,
charcot-marie-tooth disease.
Leg is lifted high so toes can clear the ground flat slap at
initial contact
Festinating / parkinsonian gait
 In this gait, the patient will have rigidity and bradykinesia.
 He or she will be stooped with the head and neck forward, with flexion at
the knees.
 The whole upper extremity is also in flexion with the fingers usually
extended.
 The patient walks with slow little steps petits pas.
 Patient may also have difficulty initiating steps.
 The patient may show an involuntary inclination to take acclerating steps,
known as festination.
 This gait is seen in parkinson’s disease or any other condition causing
parkinsonism, such as side effects from drugs.
 Involuntarily moves short steps
 Short steps
 Accelerating steps
 Difficult to start
 Difficult to stop
Propulsive gait
 Stiff neck and head
 Excessive force to propel body
 Upper trunk stiffness
Proprioceptive loss: sensory ataxia
 As our feet touch the ground, we receive proprioceptive
information to tell us their location.
 The sensory ataxic gait occurs when there is loss of this may
lift their legs very high to hit the
 Wide, irregular, uneven steps
 Unsteady, wide based gait
 Throw feet forward and out and bring them down firston heels
and then toes (double tapping sound)
 Watch ground
 Positive romberg (cannot stand with feet together and eyes
closed)
 Friedrich ataxia
Muscular weakness gait
1. Gluteus medius gait
 One side gluteus medius paralysis results in
trendelenberg gait.
 Both the side paralysis results in duck walking or
waddling gait
2. Duck walking gait
 Both abductors of hip paralysed
 The patient bends his trunk towards the stance phase
3. Gluteus maximus gait
 If paralysed, posterior tilting
 COG shifts towards to stance hip
 So, while walking forward and backwards movement of
the trunk occurs is called as ‘rocking horse gait’.
Quadriceps (hand to knee gait)
 Quadriceps paralysis
 During midstance, to transmit the weight on the stance
lower leg.
 The knee should be locked.
 This knocking is not possible if the quadriceps are
paralyzes.
Genu recruvatum gait
 Hamstring muscle paralyzes,
 Knee goes off for hyperextension in mid stance while
transmitting the weight on stance leg, the knee goes in
hyperextension due to lack of counter effect of hamstrings
commonly seen in polio
Thank you