Unit 5 neurological system

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Chapter 23: Neurologic SystemChapter 23: Neurologic System

Structure and FunctionStructure and Function

Nervous system divided into two parts:Nervous system divided into two parts: Central nervous system (CNS), which includes Central nervous system (CNS), which includes

brain and spinal cordbrain and spinal cord Peripheral nervous system (PNS), which includes Peripheral nervous system (PNS), which includes

all nerve fibers outside brain and spinal cordall nerve fibers outside brain and spinal cord• Includes 12 pairs of cranial nerves, 31 pairs of spinal Includes 12 pairs of cranial nerves, 31 pairs of spinal

nerves, and all their branchesnerves, and all their branches

• Carries sensory (afferent) messages Carries sensory (afferent) messages toto CNS from CNS from sensory receptorssensory receptors

• Motor (efferent) messages Motor (efferent) messages fromfrom CNS to muscles and CNS to muscles and glands, as well as autonomic messages that govern glands, as well as autonomic messages that govern internal organs and blood vesselsinternal organs and blood vessels

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Central Nervous SystemCentral Nervous System

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[PRODUCTION NOTE: Please insert Figure 23-2 (from Jarvis Physical Examination and Health Assessment, 5e, ISBN: 978-1-4160-3243-4)]

© Pat Thomas, 2006.



Structure and Function:Structure and Function:Central Nervous System (CNS)Central Nervous System (CNS)

Cerebral cortexCerebral cortex Cerebral cortex is cerebrum’s outer layer of nerve Cerebral cortex is cerebrum’s outer layer of nerve

cellscells Cerebral cortex is center of functions governing Cerebral cortex is center of functions governing

thought, memory, reasoning, sensation, and thought, memory, reasoning, sensation, and voluntary movementvoluntary movement• Each half of cerebrum is hemisphereEach half of cerebrum is hemisphere

• Each hemisphere divided into four lobes: frontal, parietal, Each hemisphere divided into four lobes: frontal, parietal, temporal, and occipitaltemporal, and occipital

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(cont.)(cont.) Cerebral cortex (cont.)Cerebral cortex (cont.)

Lobes have areas that mediate specific functions:Lobes have areas that mediate specific functions:• Frontal lobe concerned with personality, behavior, Frontal lobe concerned with personality, behavior,

emotions, and intellectual functionemotions, and intellectual function Precentral gyrus of frontal lobe initiates voluntary Precentral gyrus of frontal lobe initiates voluntary

movementmovement

• Parietal lobe’s postcentral gyrus is primary center for Parietal lobe’s postcentral gyrus is primary center for sensationsensation

• Occipital lobe is primary visual receptor centerOccipital lobe is primary visual receptor center

• Temporal lobe behind ear, has primary auditory Temporal lobe behind ear, has primary auditory reception center, taste, and smellreception center, taste, and smell

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Lobes have areas that mediate specific functions Lobes have areas that mediate specific functions (cont.):(cont.):• Wernicke’s area in temporal lobe associated with Wernicke’s area in temporal lobe associated with

language comprehensionlanguage comprehension When damaged in the person’s dominant hemisphere, When damaged in the person’s dominant hemisphere,

receptive aphasia results; person hears sound, but it has receptive aphasia results; person hears sound, but it has no meaning, like hearing a foreign languageno meaning, like hearing a foreign language

• Broca’s area in frontal lobe mediates motor speech Broca’s area in frontal lobe mediates motor speech When injured in dominant hemisphere, expressive aphasia When injured in dominant hemisphere, expressive aphasia

results; person cannot talk; person can understand results; person cannot talk; person can understand language and knows what they want to say, but can language and knows what they want to say, but can produce only garbled soundproduce only garbled sound

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Damage to specific cortical areas produces a Damage to specific cortical areas produces a corresponding loss of function:corresponding loss of function:• Motor weaknessMotor weakness

• Paralysis Paralysis

• Loss of sensationLoss of sensation

• Impaired ability to understand and process languageImpaired ability to understand and process language

Damage occurs when highly specialized Damage occurs when highly specialized neurologic cells are deprived of blood supply, such neurologic cells are deprived of blood supply, such as when a cerebral artery becomes occludedas when a cerebral artery becomes occluded

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Cerebral CortexCerebral Cortex

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(cont.)(cont.) Basal gangliaBasal ganglia

Large bands of gray matter in two cerebral Large bands of gray matter in two cerebral hemispheres that form subcortical associated hemispheres that form subcortical associated motor system (extrapyramidal system)motor system (extrapyramidal system)• Initiate and coordinate movement and control automatic Initiate and coordinate movement and control automatic

associated movements of bodyassociated movements of body

ThalamusThalamus Main relay station where sensory pathways of Main relay station where sensory pathways of

spinal cord, cerebellum, and brain stem form spinal cord, cerebellum, and brain stem form synapsessynapses

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(cont.)(cont.) HypothalamusHypothalamus

Major respiratory center with many basic Major respiratory center with many basic functions, such as appetite, sex drive, functions, such as appetite, sex drive, temperature, heart rate, blood pressure, sleep, temperature, heart rate, blood pressure, sleep, anterior and posterior pituitary gland regulation, anterior and posterior pituitary gland regulation, and coordination of autonomic nervous system, and coordination of autonomic nervous system, stress response, and emotional statusstress response, and emotional status

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(cont.)(cont.) CerebellumCerebellum

Coiled structure located under occipital lobe Coiled structure located under occipital lobe concerned with coordination of voluntary concerned with coordination of voluntary movements, equilibrium, and muscle tonemovements, equilibrium, and muscle tone

Does not initiate, but coordinates and smoothes Does not initiate, but coordinates and smoothes movementsmovements• Coordinates many different muscles needed in playing Coordinates many different muscles needed in playing

piano, swimming, or jugglingpiano, swimming, or juggling

• Adjusts and corrects voluntary movements, but operates Adjusts and corrects voluntary movements, but operates entirely below conscious levelentirely below conscious level

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(cont.)(cont.) Brain StemBrain Stem

Central core of brain consists of nerve fibers:Central core of brain consists of nerve fibers:• Cranial nerve (CN) III through XII originate from nuclei in Cranial nerve (CN) III through XII originate from nuclei in

brain stembrain stem• Midbrain: most anterior part of brain stem with tubular Midbrain: most anterior part of brain stem with tubular

structure of spinal cord; merges into thalamus and structure of spinal cord; merges into thalamus and hypothalamus; contains many motor neurons and tractshypothalamus; contains many motor neurons and tracts

• Pons: enlarged area containing ascending sensory and Pons: enlarged area containing ascending sensory and descending motor tractsdescending motor tracts

• Medulla: continuation of spinal cord in brain; contains all Medulla: continuation of spinal cord in brain; contains all fiber tracts connecting brain and spinal cordfiber tracts connecting brain and spinal cord

Has vital autonomic centers (respiration, heart, Has vital autonomic centers (respiration, heart, gastrointestinal function); nuclei for CN VIII through XIIgastrointestinal function); nuclei for CN VIII through XII

Pyramidal decussation (crossing of motor fibers)Pyramidal decussation (crossing of motor fibers)

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(cont.)(cont.) Spinal Cord Spinal Cord

Long cylindrical structure of nervous tissue that Long cylindrical structure of nervous tissue that occupies upper two thirds of vertebral canal from occupies upper two thirds of vertebral canal from medulla to lumbar vertebrae L1 to L2medulla to lumbar vertebrae L1 to L2

Main highway for ascending and descending fiber Main highway for ascending and descending fiber tracts that connect the brain to spinal nerves, and tracts that connect the brain to spinal nerves, and it mediates reflexesit mediates reflexes

Nerve cell bodies, or gray matter, arranged in Nerve cell bodies, or gray matter, arranged in butterfly shape with anterior and posterior “horns”butterfly shape with anterior and posterior “horns”

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(cont.)(cont.) Pathways of CNSPathways of CNS

Crossed representation is notable feature of nerve Crossed representation is notable feature of nerve tractstracts• Left cerebral cortex receives sensory information from Left cerebral cortex receives sensory information from

and controls motor function to right side of the bodyand controls motor function to right side of the body

• Right cerebral cortex likewise interacts with left side of Right cerebral cortex likewise interacts with left side of bodybody

Knowledge of where fibers cross midline will help Knowledge of where fibers cross midline will help interpret clinical findingsinterpret clinical findings

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(cont.)(cont.) Sensory pathwaysSensory pathways

Millions of sensory receptors are embroidered into Millions of sensory receptors are embroidered into skin, mucous membranes, muscles, tendons, and skin, mucous membranes, muscles, tendons, and visceraviscera• Monitor conscious sensation, internal organ functions, Monitor conscious sensation, internal organ functions,

body position, and reflexesbody position, and reflexes

• Sensation travels in afferent fibers in peripheral nerve, Sensation travels in afferent fibers in peripheral nerve, through posterior (dorsal) root, and into spinal cordthrough posterior (dorsal) root, and into spinal cord

There, may take one of two routes: spinothalamic There, may take one of two routes: spinothalamic tract or posterior (dorsal) columnstract or posterior (dorsal) columns

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(cont.)(cont.) Sensory pathways (cont.)Sensory pathways (cont.)

Spinothalamic tractSpinothalamic tract• Contains sensory fibers that transmit sensations of pain, Contains sensory fibers that transmit sensations of pain,

temperature, and crude or light touchtemperature, and crude or light touch Fibers enter dorsal root of spinal cord and synapse with a Fibers enter dorsal root of spinal cord and synapse with a

second sensory neuronsecond sensory neuron At thalamus, fibers synapse with third sensory neuron, At thalamus, fibers synapse with third sensory neuron,

carrying message to sensory cortex for full interpretationcarrying message to sensory cortex for full interpretation

Posterior (dorsal) columnsPosterior (dorsal) columns• These fibers conduct sensations of position, vibration, These fibers conduct sensations of position, vibration,

and finely localized touchand finely localized touch

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(cont.)(cont.) Sensory pathways (cont.)Sensory pathways (cont.)

Sensory cortex arranged in corresponding “map” Sensory cortex arranged in corresponding “map” of body; pain in right hand perceived at specific of body; pain in right hand perceived at specific spot on left cortex mapspot on left cortex map

Some organs absent from brain map, such as Some organs absent from brain map, such as heart, liver, or spleen; you know you have one, but heart, liver, or spleen; you know you have one, but have no “felt image” of ithave no “felt image” of it• Pain originating in these organs is referred, e.g., pain in Pain originating in these organs is referred, e.g., pain in

heart referred to chest, shoulder, and left arm, neighbors heart referred to chest, shoulder, and left arm, neighbors in fetal development; pain originating in spleen felt on left in fetal development; pain originating in spleen felt on left shouldershoulder

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Sensory PathwaysSensory Pathways

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(cont.)(cont.) Motor pathwaysMotor pathways

Corticospinal or pyramidal tract fibers mediate Corticospinal or pyramidal tract fibers mediate voluntary movement, particularly very skilled, voluntary movement, particularly very skilled, discrete, purposeful movements, such as writingdiscrete, purposeful movements, such as writing• Motor nerve fibers travel to brain stem crossing to Motor nerve fibers travel to brain stem crossing to

opposite, contralateral side, (pyramidal decussation) and opposite, contralateral side, (pyramidal decussation) and then pass down in lateral column of spinal cordthen pass down in lateral column of spinal cord

• Permits very skilled and purposeful movementsPermits very skilled and purposeful movements

• Arranged in pattern called somatotopic organizationArranged in pattern called somatotopic organization

• Parts whose movements are relatively more important Parts whose movements are relatively more important occupy proportionally more space on this brain mapoccupy proportionally more space on this brain map

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(cont.)(cont.) Motor pathways (cont.)Motor pathways (cont.)

Extrapyramidal tracts include motor nerve fibers Extrapyramidal tracts include motor nerve fibers originating in motor cortex, basal ganglia, brain originating in motor cortex, basal ganglia, brain stem, and spinal cord outside pyramidal tractstem, and spinal cord outside pyramidal tract• Subcortical motor fibers maintain muscle tone and Subcortical motor fibers maintain muscle tone and

control body movements, especially gross automatic control body movements, especially gross automatic movements, such as walkingmovements, such as walking

• Cerebellar system coordinates movement, maintains Cerebellar system coordinates movement, maintains equilibrium and posture; receives information on position equilibrium and posture; receives information on position of muscles and joints, body’s equilibrium, and kind of of muscles and joints, body’s equilibrium, and kind of motor messages sent from cortex to musclesmotor messages sent from cortex to muscles

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Motor PathwaysMotor Pathways

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(cont.)(cont.) Upper and lower motor neuronsUpper and lower motor neurons

Upper neuronsUpper neurons• Complex of descending motor fibers that can influence or Complex of descending motor fibers that can influence or

modify lower motor neuronsmodify lower motor neurons

• Located completely within CNS; convey impulses from Located completely within CNS; convey impulses from motor areas of cerebral cortex to lower motor neurons motor areas of cerebral cortex to lower motor neurons

• Examples of upper motor neuron diseases are Examples of upper motor neuron diseases are cerebrovascular accident, cerebral palsy, and multiple cerebrovascular accident, cerebral palsy, and multiple sclerosissclerosis

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Structure and Function Central Structure and Function Central Nervous SystemNervous System

Upper and Lower Upper and Lower Motor NeuronsMotor Neurons

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Subjective DataSubjective Data (cont.)(cont.)

Seizures (cont.)Seizures (cont.) Postictal phase: After having a seizure, do you Postictal phase: After having a seizure, do you

sleep? Do you have confusion, weakness, headache, sleep? Do you have confusion, weakness, headache, or muscle ache? Are you on any medication?or muscle ache? Are you on any medication?

Coping strategies: How have seizures affected daily Coping strategies: How have seizures affected daily life and your occupation?life and your occupation?

TremorsTremors Any shakes or tremors in hands or face? When did Any shakes or tremors in hands or face? When did

these start?these start? Do they seem to grow worse with anxiety, intention, Do they seem to grow worse with anxiety, intention,

or rest? Do they affect daily activities?or rest? Do they affect daily activities?

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(cont.)(cont.) Upper and lower motor neurons (cont.)Upper and lower motor neurons (cont.)

Lower motor neuronsLower motor neurons• Final common pathway, providing final contact with Final common pathway, providing final contact with

musclemuscle

• Located in anterior gray column of spinal cord, but nerve Located in anterior gray column of spinal cord, but nerve fibers extend to musclefibers extend to muscle

• Movement must be translated into action by lower motor Movement must be translated into action by lower motor neuron fibersneuron fibers

Examples of lower motor neurons are cranial nerves and Examples of lower motor neurons are cranial nerves and spinal nerves of peripheral nervous systemspinal nerves of peripheral nervous system

Examples of lower motor neuron diseases are spinal cord Examples of lower motor neuron diseases are spinal cord lesions, poliomyelitis, and amyotrophic lateral sclerosislesions, poliomyelitis, and amyotrophic lateral sclerosis

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Structure and Function:Structure and Function:Peripheral Nervous SystemPeripheral Nervous System

Reflex ArcReflex Arc Reflexes: basic defense mechanisms of nervous Reflexes: basic defense mechanisms of nervous

system system • Involuntary; below level of conscious control permitting Involuntary; below level of conscious control permitting

quick reaction to potentially painful or damaging quick reaction to potentially painful or damaging situationssituations

Four types of reflexes: Four types of reflexes: • Deep tendon reflexes (myotatic), e.g., knee jerkDeep tendon reflexes (myotatic), e.g., knee jerk

• Superficial, e.g., corneal reflex, abdominal reflexSuperficial, e.g., corneal reflex, abdominal reflex

• Visceral, e.g., pupillary response to lightVisceral, e.g., pupillary response to light

• Pathologic (abnormal), e.g., Babinski’s reflex or extensor Pathologic (abnormal), e.g., Babinski’s reflex or extensor plantar reflexplantar reflex

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Reflex ArcReflex Arc

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(cont.)(cont.) Cranial nervesCranial nerves

Enter and exit brain rather than spinal cord Enter and exit brain rather than spinal cord CN I and II extend from cerebrum; cranial nerves CN I and II extend from cerebrum; cranial nerves

III to XII extend from lower diencephalon and brain III to XII extend from lower diencephalon and brain stemstem

12 pairs of cranial nerves supply primarily head 12 pairs of cranial nerves supply primarily head and neck, except vagus nerve, which travels to and neck, except vagus nerve, which travels to heart, respiratory muscles, stomach, and heart, respiratory muscles, stomach, and gallbladdergallbladder

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Structure and Function of Central Nervous Structure and Function of Central Nervous SystemSystem

Cranial Cranial NervesNerves

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(cont.)(cont.) Spinal nervesSpinal nerves

31 pairs of spinal nerves arise from length of 31 pairs of spinal nerves arise from length of spinal cord and supply rest of bodyspinal cord and supply rest of body

Named for region of spine from which they exit:Named for region of spine from which they exit:8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and1 coccygeal1 coccygeal

““Mixed” nerves, they contain both sensory and Mixed” nerves, they contain both sensory and motor fibersmotor fibers

Each innervates particular segment of bodyEach innervates particular segment of body Dermal segmentation is cutaneous distribution of Dermal segmentation is cutaneous distribution of

various spinal nervesvarious spinal nerves

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Structure and Function of Central Structure and Function of Central Nervous SystemNervous System

Spinal Nerves Spinal Nerves and and DermatomesDermatomes

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(cont.)(cont.) Spinal nerves (cont.)Spinal nerves (cont.)

DermatomeDermatome• Circumscribed skin area supplied mainly from one spinal Circumscribed skin area supplied mainly from one spinal

cord segment through particular nervecord segment through particular nerve

• Dermatomes overlap; if one nerve is severed, most of Dermatomes overlap; if one nerve is severed, most of sensations are transmitted by one above and one below sensations are transmitted by one above and one below

Useful landmark dermatomesUseful landmark dermatomes• Thumb, middle finger, fifth finger are C6, C7, and C8; Thumb, middle finger, fifth finger are C6, C7, and C8;

Axilla at T1; Nipple at T4; Umbilicus at T10;Axilla at T1; Nipple at T4; Umbilicus at T10;Groin in region of L1; Knee at L4Groin in region of L1; Knee at L4

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(cont.)(cont.) Autonomic nervous systemAutonomic nervous system

Peripheral nervous system composed of cranial Peripheral nervous system composed of cranial nerves and spinal nervesnerves and spinal nerves

Carry fibers divided functionally into two parts:Carry fibers divided functionally into two parts:• Somatic fibers innervate skeletal (voluntary) musclesSomatic fibers innervate skeletal (voluntary) muscles

• Autonomic fibers innervate smooth (involuntary) Autonomic fibers innervate smooth (involuntary) muscles, cardiac muscle, and glandsmuscles, cardiac muscle, and glands

Autonomic system mediates unconscious activityAutonomic system mediates unconscious activity

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Structure and Function:Structure and Function:Developmental CompetenceDevelopmental Competence

InfantsInfants Neurologic system not completely developed at Neurologic system not completely developed at

birth birth • Movement directed primarily by primitive reflexes Movement directed primarily by primitive reflexes

• Persistence of primitive reflexes is an indication of CNS Persistence of primitive reflexes is an indication of CNS dysfunctiondysfunction

• Sensory and motor development proceed with gradual Sensory and motor development proceed with gradual acquisition of myelin needed to conduct most impulsesacquisition of myelin needed to conduct most impulses

• As myelinization develops, infant able to localize As myelinization develops, infant able to localize stimulus more precisely and make more accurate motor stimulus more precisely and make more accurate motor responseresponse

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(cont.)(cont.) Aging adultAging adult

Atrophy with steady loss of neuron structure in Atrophy with steady loss of neuron structure in brain and spinal cordbrain and spinal cord• Causes loss of weight and volume with thinning of Causes loss of weight and volume with thinning of

cerebral cortex, reduced subcortical brain structures, and cerebral cortex, reduced subcortical brain structures, and expansion of the ventriclesexpansion of the ventricles

• People over 65 show signs that, in younger adult, would People over 65 show signs that, in younger adult, would be considered abnormal such as general loss of muscle be considered abnormal such as general loss of muscle bulk, loss of muscle tone in face, neck, and around bulk, loss of muscle tone in face, neck, and around spine, decreased muscle strength, impaired fine spine, decreased muscle strength, impaired fine coordination and agility, loss of vibratory sense at anklecoordination and agility, loss of vibratory sense at ankle, , decreased or absent Achilles reflex, pupillary miosis, decreased or absent Achilles reflex, pupillary miosis, irregular pupil shape, and decreased pupillary reflexesirregular pupil shape, and decreased pupillary reflexes

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(cont.)(cont.) Aging adultAging adult (cont.)(cont.)

Atrophy with steady loss of neurons in brain and Atrophy with steady loss of neurons in brain and spinal cord (cont.)spinal cord (cont.)• Velocity of nerve conduction decreases making reaction Velocity of nerve conduction decreases making reaction

time slower in some older personstime slower in some older persons

• Increased delay at synapse results in diminished Increased delay at synapse results in diminished sensation of touch, pain, taste, and smellsensation of touch, pain, taste, and smell

• Motor system may show general slowing down of Motor system may show general slowing down of movement; muscle strength and agility decreasemovement; muscle strength and agility decrease

• Progressive decrease in cerebral blood flow and oxygen Progressive decrease in cerebral blood flow and oxygen consumption may cause dizziness and loss of balanceconsumption may cause dizziness and loss of balance

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence

African Americans African Americans More likely than whites to have high blood More likely than whites to have high blood

pressurepressure Tend to have strokes earlier in life and with more Tend to have strokes earlier in life and with more

severe results than whitessevere results than whites Have almost twice risk of first stroke compared Have almost twice risk of first stroke compared

with whiteswith whites

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence (cont.)(cont.)

American IndiansAmerican Indians Ages 65 to 74, annual rates per 1000 population of Ages 65 to 74, annual rates per 1000 population of

new and recurrent strokes are 6.1 for men and 6.6 new and recurrent strokes are 6.1 for men and 6.6 for womenfor women

Mexican Americans Mexican Americans Age 20 and older, 2.6% of men and 1.8% of Age 20 and older, 2.6% of men and 1.8% of

women have had strokewomen have had stroke

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Subjective DataSubjective Data

HeadacheHeadache Have you had any unusually frequent or severe Have you had any unusually frequent or severe

headaches? When did this start? How often does headaches? When did this start? How often does it occur?it occur?

Where do you feel headaches? Do headaches Where do you feel headaches? Do headaches seem to be associated with anything?seem to be associated with anything?

Head injuryHead injury Have you ever had any head injury? What part of Have you ever had any head injury? What part of

head was injured? Describe.head was injured? Describe. Did you have loss of consciousness? For how Did you have loss of consciousness? For how

long?long?

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Dizziness; vertigoDizziness; vertigo Do you ever feel a lightheaded, swimming Do you ever feel a lightheaded, swimming

sensation, like feeling faint? When have you sensation, like feeling faint? When have you noticed this? How often does it occur? Does it noticed this? How often does it occur? Does it occur with activity or a change in position?occur with activity or a change in position?

Do you ever feel a sensation called vertigo, a Do you ever feel a sensation called vertigo, a rotational spinning sensation? Do you feel as if the rotational spinning sensation? Do you feel as if the room spins, or do you feel you are spinning? Does room spins, or do you feel you are spinning? Does it come on suddenly or gradually?it come on suddenly or gradually?

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SeizuresSeizures Ever had any convulsions? When did they start? Ever had any convulsions? When did they start?

How often do they occur?How often do they occur?• When seizure starts, do you have warning sign?When seizure starts, do you have warning sign?

• Motor activity: Where in your body do seizures begin? Motor activity: Where in your body do seizures begin? Do seizures travel through your body? Do they occur on Do seizures travel through your body? Do they occur on one side or both? one side or both?

• Do you have any associated signs, such as color change Do you have any associated signs, such as color change in face or lips, loss of consciousness, or incontinence?in face or lips, loss of consciousness, or incontinence?

• Are there any precipitating factors? Does anything seem Are there any precipitating factors? Does anything seem to bring on seizures, such as activity, discontinuing to bring on seizures, such as activity, discontinuing medication, fatigue, stress?medication, fatigue, stress?

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Seizures (cont.)Seizures (cont.) Postictal phase: After having a seizure, do you Postictal phase: After having a seizure, do you

sleep? Do you have confusion, weakness, headache, sleep? Do you have confusion, weakness, headache, or muscle ache? Are you on any medication?or muscle ache? Are you on any medication?

Coping strategies: How have seizures affected daily Coping strategies: How have seizures affected daily life and your occupation?life and your occupation?

TremorsTremors Any shakes or tremors in hands or face? When did Any shakes or tremors in hands or face? When did

these start?these start? Do they seem to grow worse with anxiety, intention, Do they seem to grow worse with anxiety, intention,

or rest? Do they affect daily activities?or rest? Do they affect daily activities?

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WeaknessWeakness Is this generalized or local? Is this generalized or local? Does weakness occur with particular movement? Does weakness occur with particular movement? Is it hard to get up out of a chair or reach for an Is it hard to get up out of a chair or reach for an

object?object? With distal or small muscle weakness, it is hard to With distal or small muscle weakness, it is hard to

open a jar, write, use scissors, or walk without open a jar, write, use scissors, or walk without tripping?tripping?

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IncoordinationIncoordination Do you have any problem with balance when Do you have any problem with balance when

walking? Any falling? Which way? Do your legs walking? Any falling? Which way? Do your legs seem to give way? Any clumsy movement?seem to give way? Any clumsy movement?

Numbness or tinglingNumbness or tingling Does it ever feel like pins and needles? When did Does it ever feel like pins and needles? When did

this start? Where do you feel it? Does it occur with this start? Where do you feel it? Does it occur with activity?activity?

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Difficulty swallowingDifficulty swallowing Do you have difficulty swallowing solids or liquids?Do you have difficulty swallowing solids or liquids? Have you experienced excessive saliva or drooling?Have you experienced excessive saliva or drooling?

Difficulty speakingDifficulty speaking Do you have difficultly forming words or saying what Do you have difficultly forming words or saying what

you intend? When did you first notice this? How long you intend? When did you first notice this? How long did it last?did it last?

Significant historySignificant history Do you have a history of stroke (cerebrovascular Do you have a history of stroke (cerebrovascular

accident), spinal cord injury, meningitis or encephalitis, accident), spinal cord injury, meningitis or encephalitis, congenital defect, or alcoholism?congenital defect, or alcoholism?

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Environmental and occupational hazards?Environmental and occupational hazards? Are you exposed to insecticides, organic solvents, Are you exposed to insecticides, organic solvents,

or lead?or lead? Are you taking any medications now?Are you taking any medications now? How much alcohol do you drink? Each week? How much alcohol do you drink? Each week?

Each day?Each day? How about mood-altering drugs, such as How about mood-altering drugs, such as

marijuana, cocaine, barbiturates, and marijuana, cocaine, barbiturates, and tranquilizers?tranquilizers?

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Additional history for infants and childrenAdditional history for infants and children Did mother have any health problems during Did mother have any health problems during

pregnancy, such as infections or illnesses, pregnancy, such as infections or illnesses, medications taken, toxemia, hypertension, alcohol medications taken, toxemia, hypertension, alcohol or drug use, or diabetes?or drug use, or diabetes?

Was infant premature or full term? What was the Was infant premature or full term? What was the infant’s birth weight?infant’s birth weight?

Was there any birth trauma? Did infant breathe Was there any birth trauma? Did infant breathe immediately?immediately?• Were you told infant’s Apgar scores?Were you told infant’s Apgar scores?

• Were there any congenital defects?Were there any congenital defects?

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Additional history for infants and children (cont.)Additional history for infants and children (cont.) Reflexes: What have you noticed about infant’s Reflexes: What have you noticed about infant’s

behavior? Do infant’s sucking and swallowing seem behavior? Do infant’s sucking and swallowing seem coordinated? Does infant turn head toward touch? coordinated? Does infant turn head toward touch? Does infant startle with a loud noise? Does infant Does infant startle with a loud noise? Does infant grasp your finger?grasp your finger?

Does child seem to have problem with balance? Has Does child seem to have problem with balance? Has there been any unexplained falling clumsy or there been any unexplained falling clumsy or unsteady gait, progressive muscular weakness, or unsteady gait, progressive muscular weakness, or problems going up or down stairs or getting up from problems going up or down stairs or getting up from lying position?lying position?

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Additional history for infants and children (cont.)Additional history for infants and children (cont.) Has child had any seizures? Did it occur with high Has child had any seizures? Did it occur with high

fever? Was there any loss of consciousness? How fever? Was there any loss of consciousness? How long? long?

Did motor or developmental milestones come at Did motor or developmental milestones come at about right age? Does child seem to be growing about right age? Does child seem to be growing normally? How does development compare to that normally? How does development compare to that of siblings or age-mates?of siblings or age-mates?

Has child had any environmental exposure to lead?Has child had any environmental exposure to lead? Is there any family history of seizure disorder, Is there any family history of seizure disorder,

cerebral palsy, or muscular dystrophy?cerebral palsy, or muscular dystrophy?

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Additional history for aging adultAdditional history for aging adult Any problem with dizziness? Any problem with dizziness?

• Does it occur when you first sit or stand up, when you Does it occur when you first sit or stand up, when you move your head, get up and walk, or after eating? Does move your head, get up and walk, or after eating? Does it occur with any medications?it occur with any medications?

• (For men) Do you ever get up at night and feel faint while (For men) Do you ever get up at night and feel faint while standing to urinate?standing to urinate?

• How does dizziness affect your daily activities? Are you How does dizziness affect your daily activities? Are you able to drive safely and maneuver within your house able to drive safely and maneuver within your house safely?safely?

• What safety modifications have you applied at home?What safety modifications have you applied at home?

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Additional history for aging adult (cont.)Additional history for aging adult (cont.) Have you noticed a decrease in memory or a change Have you noticed a decrease in memory or a change

in mental function? Have you felt any confusion? Does in mental function? Have you felt any confusion? Does it come on suddenly or gradually?it come on suddenly or gradually?

Have you noticed any tremor in hands or face? Is it Have you noticed any tremor in hands or face? Is it worse with anxiety, activity, or rest? Does it seem to be worse with anxiety, activity, or rest? Does it seem to be relieved with alcohol, activity, or rest? Does it interfere relieved with alcohol, activity, or rest? Does it interfere with daily or social activities?with daily or social activities?

Have you had any sudden vision change or fleeting Have you had any sudden vision change or fleeting blindness? Did this occur along with weakness? Did blindness? Did this occur along with weakness? Did you have any loss of consciousness?you have any loss of consciousness?

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Objective DataObjective Data (cont.)(cont.)

PreparationPreparation Perform screening neurologic examination on well Perform screening neurologic examination on well

persons with no significant findings from historypersons with no significant findings from history Perform complete neurologic examination on Perform complete neurologic examination on

persons with neurologic concerns, e.g., headache, persons with neurologic concerns, e.g., headache, weakness, loss of coordination, or who have weakness, loss of coordination, or who have shown signs of neurologic dysfunctionshown signs of neurologic dysfunction

Perform neurologic recheck examination on Perform neurologic recheck examination on persons with demonstrated neurologic deficits who persons with demonstrated neurologic deficits who require periodic assessments, e.g., hospitalized require periodic assessments, e.g., hospitalized persons or those in extended carepersons or those in extended care

Slide 23-51




Preparation (cont.)Preparation (cont.) Integrate steps of neurologic examination with Integrate steps of neurologic examination with

examination of particular part of bodyexamination of particular part of body• Test cranial nerves while assessing head and neck; test Test cranial nerves while assessing head and neck; test

superficial abdominal reflexes while assessing abdomensuperficial abdominal reflexes while assessing abdomen

• Record all neurologic data together as a functional unitRecord all neurologic data together as a functional unit

• Use following sequence for complete neurologic Use following sequence for complete neurologic examinatinonexaminatinon

Mental statusMental status Cranial nervesCranial nerves Motor systemMotor system Sensory systemSensory system ReflexesReflexes

Slide 23-52




Preparation (cont.)Preparation (cont.) Equipment needed:Equipment needed:

• PenlightPenlight

• Tongue bladeTongue blade

• Cotton swabCotton swab

• Cotton ballCotton ball

• Tuning fork: 128 Hz or 256 HzTuning fork: 128 Hz or 256 Hz

• Percussion hammerPercussion hammer

Slide 23-53



Objective Data:Objective Data:Test Cranial NervesTest Cranial Nerves

Cranial nervesCranial nerves Cranial nerve I: olfactory nerve (not tested Cranial nerve I: olfactory nerve (not tested

routinely)routinely)• Test sense of smell in those who report loss of smell, Test sense of smell in those who report loss of smell,

head trauma, and abnormal mental status, and when head trauma, and abnormal mental status, and when presence of intracranial lesion suspectedpresence of intracranial lesion suspected

• With person’s eyes closed, occlude one nostril and With person’s eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee, orange, present familiar aromatic substance, e.g., coffee, orange, vanilla, soap, or peppermintvanilla, soap, or peppermint

• Normally, person can identify an odor on each side of Normally, person can identify an odor on each side of nose; normally decreased with aging; any asymmetry in nose; normally decreased with aging; any asymmetry in sense of smell is importantsense of smell is important

Slide 23-54



Objective Data:Objective Data:Test Cranial NervesTest Cranial Nerves (cont.)(cont.)

Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerve II: optic nerveCranial nerve II: optic nerve

• Test visual acuity and visual fields by confrontationTest visual acuity and visual fields by confrontation

• Using ophthalmoscope, examine ocular fundus to Using ophthalmoscope, examine ocular fundus to determine color, size, and shape of optic discdetermine color, size, and shape of optic disc

Slide 23-55




Cranial nerves (cont.)Cranial nerves (cont.) Cranial Nerves III, IV, and VI: oculomotor, Cranial Nerves III, IV, and VI: oculomotor,

trochlear, and abducens nervestrochlear, and abducens nerves• Palpebral fissures usually equal in widthPalpebral fissures usually equal in width

• Check pupils for size, regularity, equality, direct and Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodationconsensual light reaction, and accommodation

• Assess extraocular movements by cardinal positions of Assess extraocular movements by cardinal positions of gazegaze

• Nystagmus is back-and-forth oscillation of eyesNystagmus is back-and-forth oscillation of eyes

Slide 23-56




Cranial nerves (cont.)Cranial nerves (cont.) Cranial Nerves III, IV, and VI: oculomotor, Cranial Nerves III, IV, and VI: oculomotor,

trochlear, and abducens nerves (cont.)trochlear, and abducens nerves (cont.)• Assess nystagmus carefully, noting:Assess nystagmus carefully, noting:

Presence of nystagmus in one or both eyesPresence of nystagmus in one or both eyes Pendular movement (oscillations move equally left to right); Pendular movement (oscillations move equally left to right);

or jerk (a quick phase in one direction, then a slow phase or jerk (a quick phase in one direction, then a slow phase in other)in other)

Amplitude: degree of movement: fine, medium, or coarseAmplitude: degree of movement: fine, medium, or coarse Frequency: constant, or fades after a few beatsFrequency: constant, or fades after a few beats Plane of movement: horizontal, vertical, rotary, or Plane of movement: horizontal, vertical, rotary, or

combinationcombination

Slide 23-57




Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerve V: trigeminal nerveCranial nerve V: trigeminal nerve

• Motor function: assess muscles of mastication by Motor function: assess muscles of mastication by palpating temporal and masseter muscles as person palpating temporal and masseter muscles as person clenches teeth clenches teeth

• Muscles should feel equally strong on both sides; try to Muscles should feel equally strong on both sides; try to separate jaws by pushing down on chin; normally you separate jaws by pushing down on chin; normally you cannotcannot

• Sensory function: with person’s eyes closed, test light Sensory function: with person’s eyes closed, test light touch sensation by touching a cotton wisp to designated touch sensation by touching a cotton wisp to designated areas on person’s face: forehead, cheeks, and chin areas on person’s face: forehead, cheeks, and chin

• Tests all three divisions of CN V: ophthalmic, maxillary, Tests all three divisions of CN V: ophthalmic, maxillary, and mandibularand mandibular

Slide 23-58



Testing Cranial Nerve VTesting Cranial Nerve V

Slide 23-59




Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerve V: trigeminal nerve (cont.)Cranial nerve V: trigeminal nerve (cont.)

• Corneal reflex: omit test, unless person has abnormal Corneal reflex: omit test, unless person has abnormal facial sensation or abnormalities of facial movement facial sensation or abnormalities of facial movement

• Remove any contact lenses; with person looking forward, Remove any contact lenses; with person looking forward, bring wisp of cotton in from side (to minimize defensive bring wisp of cotton in from side (to minimize defensive blinking) and lightly touch cornea, not conjunctivablinking) and lightly touch cornea, not conjunctiva

Normally, person will blink bilaterallyNormally, person will blink bilaterally Corneal reflex may be decreased or absent in those who Corneal reflex may be decreased or absent in those who

have worn contact lenseshave worn contact lenses

• This procedure tests sensory afferent in cranial nerve V This procedure tests sensory afferent in cranial nerve V and motor efferent in cranial nerve VII (muscles that and motor efferent in cranial nerve VII (muscles that close eye)close eye)

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Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerve VII: facial nerveCranial nerve VII: facial nerve

• Motor function:Motor function: Note mobility and facial symmetry as person responds to Note mobility and facial symmetry as person responds to

requests to smile, frown, close eyes tightly (against your requests to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teethattempt to open them), lift eyebrows, show teeth

Have person puff cheeks, then press puffed cheeks in, to Have person puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sidessee that air escapes equally from both sides

• Sensory function: (not tested routinely)Sensory function: (not tested routinely) Test only when you suspect facial nerve injuryTest only when you suspect facial nerve injury When indicated, test sense of taste by applying cotton When indicated, test sense of taste by applying cotton

applicator covered with solution of sugar, salt, or lemon applicator covered with solution of sugar, salt, or lemon juice to tongue and ask person to identify tastejuice to tongue and ask person to identify taste

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Testing Cranial Nerve VIITesting Cranial Nerve VII

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Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerve VIII: acoustic nerve Cranial nerve VIII: acoustic nerve

(Vestibulocochlear)(Vestibulocochlear)• Test hearing acuity by ability to hear normal conversation Test hearing acuity by ability to hear normal conversation

and by whispered voice testand by whispered voice test

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Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerves IX and X: glossopharyngeal and Cranial nerves IX and X: glossopharyngeal and

vagus nervesvagus nerves• Motor functionMotor function

Depress tongue with tongue blade, and note pharyngeal Depress tongue with tongue blade, and note pharyngeal movement as person says “ahhh” or yawns; uvula and soft movement as person says “ahhh” or yawns; uvula and soft palate should rise in midline, and tonsillar pillars should palate should rise in midline, and tonsillar pillars should move mediallymove medially

Touch posterior pharyngeal wall with tongue blade, and Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth, not strainednote gag reflex; voice should sound smooth, not strained

• Sensory functionSensory function Cranial nerve IX does mediate taste on posterior one third Cranial nerve IX does mediate taste on posterior one third

of tongue, but technically too difficult to testof tongue, but technically too difficult to test

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Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerve XI: spinal accessory nerveCranial nerve XI: spinal accessory nerve

• Examine sternomastoid and trapezius muscles for equal Examine sternomastoid and trapezius muscles for equal sizesize

• Check equal strength by asking person to rotate head Check equal strength by asking person to rotate head against resistance applied to side of chinagainst resistance applied to side of chin

• Ask person to shrug shoulders against resistance Ask person to shrug shoulders against resistance

• These movements should feel equally strong on both These movements should feel equally strong on both sidessides

Slide 23-65



Testing Cranial Nerve XITesting Cranial Nerve XI

Slide 23-66




Cranial nerves (cont.)Cranial nerves (cont.) Cranial nerve XII: hypoglossal nerveCranial nerve XII: hypoglossal nerve

• Inspect tongue; no wasting or tremors should be presentInspect tongue; no wasting or tremors should be present

• Note forward thrust in midline as person protrudes Note forward thrust in midline as person protrudes tonguetongue

• Ask person to say “light, tight, dynamite,” and note that Ask person to say “light, tight, dynamite,” and note that lingual speech (sounds of letters l, t, d, n) is clear and lingual speech (sounds of letters l, t, d, n) is clear and distinctdistinct

Slide 23-67



Objective Data: Inspect and Objective Data: Inspect and Palpate Motor SystemPalpate Motor System

MusclesMuscles Size: inspect all muscle groups for sizeSize: inspect all muscle groups for size

• Compare right side with left; muscle groups should be Compare right side with left; muscle groups should be within normal size limits for age and should be symmetric within normal size limits for age and should be symmetric bilaterallybilaterally

• If muscles in extremities are asymmetric, measure in If muscles in extremities are asymmetric, measure in centimeters and record difference; difference of 1 cm or centimeters and record difference; difference of 1 cm or less is not significantless is not significant

• Note that it is difficult to assess muscle mass in very Note that it is difficult to assess muscle mass in very obese peopleobese people

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Objective Data: Inspect and Objective Data: Inspect and Palpate Motor SystemPalpate Motor System (cont.)(cont.)

Muscles (cont.)Muscles (cont.) Strength: test muscle groups of extremities, neck, Strength: test muscle groups of extremities, neck,

and trunkand trunk Tone: normal tension in relaxed musclesTone: normal tension in relaxed muscles

• Persuade person to relax completely, and move each Persuade person to relax completely, and move each extremity smoothly through a full range of motion; extremity smoothly through a full range of motion; normally, note mild, even resistance to movementnormally, note mild, even resistance to movement

Involuntary movementsInvoluntary movements• Normally none occur; if present, note location, frequency, Normally none occur; if present, note location, frequency,

rate, and amplitude; note if movements can be controlled rate, and amplitude; note if movements can be controlled at willat will

Slide 23-69




Cerebellar functionCerebellar function Balance TestsBalance Tests

• Gait: observe as person walks 10 to 20 feet, turns, and Gait: observe as person walks 10 to 20 feet, turns, and returns to starting point; normally person moves with a returns to starting point; normally person moves with a sense of freedom; gait is smooth, rhythmic, and effortless; sense of freedom; gait is smooth, rhythmic, and effortless; opposing arm swing is coordinated; person turns smooth; opposing arm swing is coordinated; person turns smooth; step length about 15 inches from heel to heelstep length about 15 inches from heel to heel

• Ask person to walk straight line in heel-to-toe fashion; this Ask person to walk straight line in heel-to-toe fashion; this decreases base of support and accentuates any problem decreases base of support and accentuates any problem with coordination; normally person can walk straight and with coordination; normally person can walk straight and stay balancedstay balanced

• You may also test for balance by asking person to walk You may also test for balance by asking person to walk on toes, then on heels for a few stepson toes, then on heels for a few steps

Slide 23-70




Cerebellar function (cont.)Cerebellar function (cont.) Romberg test: Romberg test:

• Ask person to stand up with feet together and arms at Ask person to stand up with feet together and arms at sides; when in stable position, ask person to close eyes sides; when in stable position, ask person to close eyes and to hold position for about 20 secondsand to hold position for about 20 seconds

Normally, person can maintain posture and balance even Normally, person can maintain posture and balance even with visual orienting information blockedwith visual orienting information blocked

• Ask person to perform shallow knee bend or hop in Ask person to perform shallow knee bend or hop in place, first on one leg, then otherplace, first on one leg, then other

Demonstrates normal position sense, muscle strength, and Demonstrates normal position sense, muscle strength, and cerebellar functioncerebellar function

Some individuals cannot hop because of aging or obesitySome individuals cannot hop because of aging or obesity

Slide 23-71



Testing Cerebellar FunctionTesting Cerebellar Function

Slide 23-72




Coordination and skilled movementsCoordination and skilled movements Rapid Alternating Movements (RAM)Rapid Alternating Movements (RAM)

• Ask person to pat knees with both hands, lift up, turn Ask person to pat knees with both hands, lift up, turn hands over, and pat knees with backs of hands; then hands over, and pat knees with backs of hands; then ask person to do this fasterask person to do this faster

Normally done with equal turning and quick rhythmic paceNormally done with equal turning and quick rhythmic pace

• Alternatively, ask person to touch thumb to each finger Alternatively, ask person to touch thumb to each finger on same hand, starting with the index finger, then on same hand, starting with the index finger, then reverse directionreverse direction

Normally done quickly and accuratelyNormally done quickly and accurately

Slide 23-73




Coordination and skilled movements (cont.)Coordination and skilled movements (cont.) Rapid Alternating Movements (RAM)Rapid Alternating Movements (RAM)

• Finger-to-finger test: with eyes open, ask person to use Finger-to-finger test: with eyes open, ask person to use index finger to touch your finger, then their own nose; index finger to touch your finger, then their own nose; then move your finger to continue testthen move your finger to continue test

Person’s movement should be smooth and accuratePerson’s movement should be smooth and accurate

• Finger-to-nose test: ask person to close eyes and stretch Finger-to-nose test: ask person to close eyes and stretch out arms and touch tip of their nose with each index out arms and touch tip of their nose with each index finger, alternating hands and increasing speedfinger, alternating hands and increasing speed

Normally this is done with accurate and smooth movementNormally this is done with accurate and smooth movement

• Heel-to-shin test: ask person in supine position to place Heel-to-shin test: ask person in supine position to place heel on opposite knee and run it down shin to ankleheel on opposite knee and run it down shin to ankle

Normally, person moves heel in straight line down shinNormally, person moves heel in straight line down shin

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Objective Data: Objective Data: Assess Sensory SystemAssess Sensory System

Ask person to identify various sensory stimuli Ask person to identify various sensory stimuli in order to test intactness of peripheral nerve in order to test intactness of peripheral nerve fibers, sensory tracts, and higher cortical fibers, sensory tracts, and higher cortical discriminationdiscrimination Routine screening procedures include testing Routine screening procedures include testing

superficial pain, light touch, and vibration in few superficial pain, light touch, and vibration in few distal locations, and testing stereognosis distal locations, and testing stereognosis

Complete testing of sensory system warranted in Complete testing of sensory system warranted in those with neurologic symptoms (e.g., localized those with neurologic symptoms (e.g., localized pain, numbness, and tingling) or if you discover pain, numbness, and tingling) or if you discover abnormalitiesabnormalities

Slide 23-75



Objective Data: Objective Data: Assess Sensory SystemAssess Sensory System (cont.)(cont.)

Compare sensations on symmetric parts of Compare sensations on symmetric parts of bodybody When you find definite decrease in sensation, map When you find definite decrease in sensation, map

it by systematic testing in that areait by systematic testing in that area Proceed from point of decreased sensation toward Proceed from point of decreased sensation toward

sensitive area; ask person to tell you where sensitive area; ask person to tell you where sensation changes; you can map exact borders of sensation changes; you can map exact borders of deficient area; draw results on diagramdeficient area; draw results on diagram

Person’s eyes should be closed during tests Person’s eyes should be closed during tests Take time to explain what will be happening and Take time to explain what will be happening and

exactly how you expect person to respondexactly how you expect person to respond

Slide 23-76




Spinothalamic tractSpinothalamic tract Pain: tested by person’s ability to perceive pinprick Pain: tested by person’s ability to perceive pinprick Temperature: test temperature sensation only Temperature: test temperature sensation only

when pain sensation is abnormal; otherwise, you when pain sensation is abnormal; otherwise, you may omit it because the fiber tracts are much the may omit it because the fiber tracts are much the same.same.

Light touch: apply wisp of cotton to skin in random Light touch: apply wisp of cotton to skin in random order of sites and at irregular intervals; include order of sites and at irregular intervals; include arms, forearms, hands, chest, thighs, and legs; arms, forearms, hands, chest, thighs, and legs; ask person to say “now” or “yes” when touch is feltask person to say “now” or “yes” when touch is felt

Compare symmetric pointsCompare symmetric points

Slide 23-77




Posterior column tractPosterior column tract Vibration: test person’s ability to feel vibrations of Vibration: test person’s ability to feel vibrations of

tuning fork over bony prominencestuning fork over bony prominences• Compare right side with left side; if you find a deficit, note Compare right side with left side; if you find a deficit, note

whether gradual or abruptwhether gradual or abrupt

Position (kinesthesia): test person’s ability to Position (kinesthesia): test person’s ability to perceive passive movements of extremitiesperceive passive movements of extremities

Slide 23-78




Posterior column tract (cont.)Posterior column tract (cont.) Tactile discrimination (fine touch): tests also Tactile discrimination (fine touch): tests also

measure discrimination ability of sensory cortexmeasure discrimination ability of sensory cortex• Stereognosis. test person’s ability to recognize objects Stereognosis. test person’s ability to recognize objects

by feeling their forms, sizes, and weightsby feeling their forms, sizes, and weights• Graphesthesia: ability to “read” a number by having it Graphesthesia: ability to “read” a number by having it

traced on skintraced on skin• Two-point discrimination: test ability to distinguish Two-point discrimination: test ability to distinguish

separation of two simultaneous pin points on skinseparation of two simultaneous pin points on skin• Extinction: simultaneously touch both sides of body at Extinction: simultaneously touch both sides of body at

same point; normally, both sensations are feltsame point; normally, both sensations are felt• Point location: touch skin and withdraw stimulus Point location: touch skin and withdraw stimulus

promptly; ask person to put finger where you touchedpromptly; ask person to put finger where you touched

Slide 23-79



Objective Data: Objective Data: Test the ReflexesTest the Reflexes

Deep tendon reflexes (DTRs)Deep tendon reflexes (DTRs) Measurement of stretch reflexes reveals Measurement of stretch reflexes reveals

intactness of reflex arc at specific spinal levels and intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levelsnormal override on reflex of higher cortical levels

Limb should be relaxed and muscle partially Limb should be relaxed and muscle partially stretchedstretched

Stimulate reflex by directing short, snappy blow of Stimulate reflex by directing short, snappy blow of reflex hammer onto muscle’s insertion tendonreflex hammer onto muscle’s insertion tendon

Compare right and left sides: responses should be Compare right and left sides: responses should be equalequal

Slide 23-80



Objective Data: Objective Data: Test the ReflexesTest the Reflexes (cont.)(cont.)

Deep tendon reflexes (DTRs) (cont.)Deep tendon reflexes (DTRs) (cont.) Reflex response graded on 4-point scaleReflex response graded on 4-point scale

• 4 = very brisk, hyperactive with clonus, indicative of 4 = very brisk, hyperactive with clonus, indicative of diseasedisease

• 3 = brisker than average, may indicate disease3 = brisker than average, may indicate disease

• 2 = Average, normal2 = Average, normal

• 1 = diminished, low normal, or occurs with reinforcement1 = diminished, low normal, or occurs with reinforcement

• 0 = no response0 = no response

Subjective scale requires clinical practice; scale Subjective scale requires clinical practice; scale not completely reliable; a wide range of normal not completely reliable; a wide range of normal exists in reflex responsesexists in reflex responses

Slide 23-81




Biceps reflex, C5 to C6Biceps reflex, C5 to C6 Support the person’s forearm on yours; place your Support the person’s forearm on yours; place your

thumb on biceps tendon and strike a blow on your thumb on biceps tendon and strike a blow on your thumbthumb• Normal response is contraction of biceps muscle and Normal response is contraction of biceps muscle and

flexion of forearmflexion of forearm

Triceps reflex, C7 to C8Triceps reflex, C7 to C8 Tell person to let arm “just go dead” as you strike Tell person to let arm “just go dead” as you strike

triceps tendon directly just above the elbowtriceps tendon directly just above the elbow• Normal response is extension of forearmNormal response is extension of forearm

Slide 23-82




Brachioradialis reflex, C5 to C6Brachioradialis reflex, C5 to C6 Hold person’s thumbs to suspend forearms in Hold person’s thumbs to suspend forearms in

relaxation and strike forearm directly, about 2 to 3 relaxation and strike forearm directly, about 2 to 3 cm above radial styloid processcm above radial styloid process• Normal response is flexion and supination of forearmNormal response is flexion and supination of forearm

Quadriceps reflex, L2 to L4 (“knee jerk”)Quadriceps reflex, L2 to L4 (“knee jerk”) Let lower legs dangle freely to flex knee and Let lower legs dangle freely to flex knee and

stretch tendons; strike tendon directly just below stretch tendons; strike tendon directly just below patellapatella• Normal response is extension of lower legNormal response is extension of lower leg

Slide 23-83




Achilles reflex, L5 to S2 (“ankle jerk”)Achilles reflex, L5 to S2 (“ankle jerk”) Position person with knee flexed; hold foot in Position person with knee flexed; hold foot in

dorsiflexion and strike Achilles tendon directly dorsiflexion and strike Achilles tendon directly • Normal response is foot plantar flexes against your handNormal response is foot plantar flexes against your hand

Slide 23-84




Clonus: test when reflexes hyperactiveClonus: test when reflexes hyperactive Support lower leg in one hand and with other Support lower leg in one hand and with other

hand, move foot up and down to relax muscle; hand, move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing foot; then stretch muscle by briskly dorsiflexing foot; hold the stretchhold the stretch• Normal response: you feel no further movement Normal response: you feel no further movement

• When clonus present, you will note rapid rhythmic When clonus present, you will note rapid rhythmic contractions of calf muscle and movement of footcontractions of calf muscle and movement of foot

Slide 23-85




Superficial (cutaneous) reflexesSuperficial (cutaneous) reflexes Sensory receptors in skin rather than in muscles; Sensory receptors in skin rather than in muscles;

motor response is localized muscle contractionmotor response is localized muscle contraction Abdominal reflexes: upper: T8 to T10;Abdominal reflexes: upper: T8 to T10;

lower: T10 to T12lower: T10 to T12• Person in supine position, knees slightly bent; use Person in supine position, knees slightly bent; use

handle end of reflex hammer to stroke skinhandle end of reflex hammer to stroke skin

• Move from each corner toward midline at both upper and Move from each corner toward midline at both upper and lower abdominal levelslower abdominal levels

• Normal response is ipsilateral contraction of abdominal Normal response is ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward muscle with observed deviation of umbilicus toward strokestroke

Slide 23-86




Superficial (cutaneous) reflexes (cont.)Superficial (cutaneous) reflexes (cont.) Cremasteric reflex, L1 to L2 (not routinely done)Cremasteric reflex, L1 to L2 (not routinely done)

• On male, lightly stroke inner aspect of thigh with reflex On male, lightly stroke inner aspect of thigh with reflex hammer or tongue bladehammer or tongue blade

Note elevation of ipsilateral testicleNote elevation of ipsilateral testicle

Plantar reflex, L4 to S2Plantar reflex, L4 to S2• Position thigh with slight external rotationPosition thigh with slight external rotation

• With reflex hammer, draw a light stroke up lateral side of With reflex hammer, draw a light stroke up lateral side of sole of foot and inward across ball of foot, like an upside-sole of foot and inward across ball of foot, like an upside-down “J”down “J”

Normal response is plantar flexion of toes and inversion Normal response is plantar flexion of toes and inversion and flexion of forefootand flexion of forefoot

Slide 23-87



Objective Data:Objective Data:Developmental CompetenceDevelopmental Competence

InfantsInfants Note if milestones normally expected for each Note if milestones normally expected for each

month achieved, and more primitive reflexes month achieved, and more primitive reflexes eliminated from baby’s repertory when expectedeliminated from baby’s repertory when expected

Observations of infant’s spontaneous waking Observations of infant’s spontaneous waking activity, responses to environmental stimuli, and activity, responses to environmental stimuli, and social interaction with parents and otherssocial interaction with parents and others• By 2 months, baby smiles and recognizes parent’s faceBy 2 months, baby smiles and recognizes parent’s face

• Babbling occurs at 4 months, and one or two words Babbling occurs at 4 months, and one or two words (mama, dada) used nonspecifically after 9 months(mama, dada) used nonspecifically after 9 months

Slide 23-88




(cont.)(cont.) Infants (cont.)Infants (cont.)

Motor systemMotor system• Observe spontaneous motor activity for smoothness and Observe spontaneous motor activity for smoothness and

symmetry; smoothness of movement suggests proper symmetry; smoothness of movement suggests proper cerebellar function, as does coordination involved in cerebellar function, as does coordination involved in sucking and swallowingsucking and swallowing

• Screen gross and fine motor coordination using Denver II Screen gross and fine motor coordination using Denver II test with its age-specific developmental milestonestest with its age-specific developmental milestones

• Assess muscle tone by first observing resting posture Assess muscle tone by first observing resting posture Newborn favors flexed position; extremities symmetrically Newborn favors flexed position; extremities symmetrically

folded inward, hips slightly abducted, and fists tightly flexedfolded inward, hips slightly abducted, and fists tightly flexed

Slide 23-89





Sensory systemSensory system• You will perform very little sensory testing with infants You will perform very little sensory testing with infants

and toddlersand toddlers

• Newborn normally has hypoesthesia and requires strong Newborn normally has hypoesthesia and requires strong stimulus to elicit a responsestimulus to elicit a response

• Baby responds to pain by crying and a general reflex Baby responds to pain by crying and a general reflex withdrawal of all limbswithdrawal of all limbs

• By 7 to 9 months, infant can localize stimulus and shows By 7 to 9 months, infant can localize stimulus and shows more specific signs of withdrawalmore specific signs of withdrawal

• Other sensory modalities not testedOther sensory modalities not tested

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ReflexesReflexes• Infantile automatisms: reflexes that have predictable Infantile automatisms: reflexes that have predictable

timetable of appearance and departuretimetable of appearance and departure

• For screening examination, just check rooting, grasp, For screening examination, just check rooting, grasp, tonic neck, and Moro reflexestonic neck, and Moro reflexes

• Rooting reflex: brush the infant’s cheek near mouth; note Rooting reflex: brush the infant’s cheek near mouth; note whether infant turns head toward that side and opens whether infant turns head toward that side and opens mouth mouth

Appears at birth; disappears at 3 to 4 months Appears at birth; disappears at 3 to 4 months

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(cont.)(cont.) InfantsInfants (cont.)(cont.)

Reflexes (cont.)Reflexes (cont.)• Palmar grasp: place baby’s head midline to ensure Palmar grasp: place baby’s head midline to ensure

symmetric response; offer finger from baby’s ulnar side, symmetric response; offer finger from baby’s ulnar side, away from thumb; note tight grasp of all baby’s fingersaway from thumb; note tight grasp of all baby’s fingers

Present at birth; strongest at 1 to 2 months; disappears at Present at birth; strongest at 1 to 2 months; disappears at 3 to 4 months3 to 4 months

• Plantar grasp: touch your thumb at ball of baby’s foot; Plantar grasp: touch your thumb at ball of baby’s foot; note that toes curl down tightlynote that toes curl down tightly

Reflex present at birth; disappears at 8 to 10 monthsReflex present at birth; disappears at 8 to 10 months

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Reflexes (cont.)Reflexes (cont.)• Tonic neck reflex: with baby supine, turn head to one Tonic neck reflex: with baby supine, turn head to one

side with chin over shoulder; note ipsilateral extension of side with chin over shoulder; note ipsilateral extension of arm and leg, and flexion of opposite arm and leg; the arm and leg, and flexion of opposite arm and leg; the “fencing” position; turning head to opposite side, “fencing” position; turning head to opposite side, positions will reverse positions will reverse

Appears by 2 to 3 months; decreases at 3 to 4 months; Appears by 2 to 3 months; decreases at 3 to 4 months; disappears by 4 to 6 monthsdisappears by 4 to 6 months

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Reflexes (cont.)Reflexes (cont.)• Moro reflex: startle infant by jarring crib, making a loud Moro reflex: startle infant by jarring crib, making a loud

noise, or supporting head and back in semi-sitting noise, or supporting head and back in semi-sitting position and quickly lowering infant to 30 degreesposition and quickly lowering infant to 30 degrees

• Baby looks as if he or she is hugging a tree; symmetric Baby looks as if he or she is hugging a tree; symmetric abduction and extension of arms and legs, fanning abduction and extension of arms and legs, fanning fingers, and curling of index finger and thumb to C fingers, and curling of index finger and thumb to C position; infant then brings in both arms and legsposition; infant then brings in both arms and legs

Present at birth; disappears at 1 to 4 monthsPresent at birth; disappears at 1 to 4 months

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(cont.)(cont.) Preschool and school-age childrenPreschool and school-age children

Assess the child’s general behavior during play Assess the child’s general behavior during play activities, reaction to parent, and cooperation with activities, reaction to parent, and cooperation with parent and with youparent and with you

Much of motor assessment can be derived from Much of motor assessment can be derived from watching child undress and dress and manipulate watching child undress and dress and manipulate buttons; indicates muscle strength, symmetry, joint buttons; indicates muscle strength, symmetry, joint range of motion, and fine motor skillsrange of motion, and fine motor skills

Use Denver II to screen gross and fine motor skills Use Denver II to screen gross and fine motor skills appropriate for child’s ageappropriate for child’s age

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(cont.)(cont.) Preschool and school-age children (cont.)Preschool and school-age children (cont.)

Note child’s gait both walking and running; allow Note child’s gait both walking and running; allow for normal wide-based gate of toddler and normal for normal wide-based gate of toddler and normal knock-kneed walk of preschoolerknock-kneed walk of preschooler

Normally, child can balance on one foot for about Normally, child can balance on one foot for about 5 seconds by 4 years, for 8 to 10 seconds at 5 5 seconds by 4 years, for 8 to 10 seconds at 5 years, and can hop at 4 yearsyears, and can hop at 4 years

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Observe child as rising from supine position to Observe child as rising from supine position to sitting position, then to a stand; note muscles of sitting position, then to a stand; note muscles of neck, arms, legs, and abdomenneck, arms, legs, and abdomen• Normally child curls up midline to sit up, then pushes off Normally child curls up midline to sit up, then pushes off

with both hands against floor to standwith both hands against floor to stand

Assess fine coordination using finger-to-nose test Assess fine coordination using finger-to-nose test • Demonstrate procedure first, then ask child to do test Demonstrate procedure first, then ask child to do test

with the eyes open, then with eyes closedwith the eyes open, then with eyes closed

• Fine coordination not fully developed until child is 4 to 6 Fine coordination not fully developed until child is 4 to 6 years; consider it normal if younger child can bring finger years; consider it normal if younger child can bring finger to within 2 to 5 cm of noseto within 2 to 5 cm of nose

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Testing sensation very unreliable in toddlers and Testing sensation very unreliable in toddlers and preschoolerspreschoolers

May test light touch by asking child to close eyes May test light touch by asking child to close eyes and point to spot where you touchand point to spot where you touch

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When you need to test DTRs in young child, use When you need to test DTRs in young child, use your finger to percuss tendonyour finger to percuss tendon

Use reflex hammer only with an older child; coax Use reflex hammer only with an older child; coax child to relax, or distract and percuss discreetly child to relax, or distract and percuss discreetly when child not paying attentionwhen child not paying attention

Knee jerk present at birth; then ankle jerk and Knee jerk present at birth; then ankle jerk and brachial reflex appear; and triceps reflex present brachial reflex appear; and triceps reflex present by 6 monthsby 6 months

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(cont.)(cont.) Aging adultAging adult

Use same examination as with younger adultsUse same examination as with younger adults Cranial nerves mediating taste and smell not Cranial nerves mediating taste and smell not

usually tested, may show some decline in functionusually tested, may show some decline in function Decrease in muscle bulk most apparent in hand; Decrease in muscle bulk most apparent in hand;

dorsal hand muscles often look wasted, even with dorsal hand muscles often look wasted, even with no apparent arthropathy; grip strength remains no apparent arthropathy; grip strength remains relatively goodrelatively good

Senile tremors occasionally occur; these benign Senile tremors occasionally occur; these benign tremors include an intention tremor of hands, head tremors include an intention tremor of hands, head nodding, and tongue protrusionnodding, and tongue protrusion

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(cont.)(cont.) Aging adult (cont.)Aging adult (cont.)

Dyskinesias: repetitive stereotyped movements in Dyskinesias: repetitive stereotyped movements in jaw, lips, or tongue may accompany senile jaw, lips, or tongue may accompany senile tremors; no associated rigidity presenttremors; no associated rigidity present

Gait may be slower and more deliberate than in Gait may be slower and more deliberate than in younger person; may deviate from midline pathyounger person; may deviate from midline path

Rapid alternating movements, e.g., pronating and Rapid alternating movements, e.g., pronating and supinating hands on thigh, may be difficult to supinating hands on thigh, may be difficult to performperform

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After 65 years of age, loss of sensation of After 65 years of age, loss of sensation of vibration at ankle malleolus common; loss of ankle vibration at ankle malleolus common; loss of ankle jerk; tactile sensation may be impaired; may need jerk; tactile sensation may be impaired; may need stronger stimuli for light touch; and especially for stronger stimuli for light touch; and especially for painpain

DTRs less brisk; those in upper extremities usually DTRs less brisk; those in upper extremities usually present, but ankle jerk commonly lost; knee jerks present, but ankle jerk commonly lost; knee jerks may be lost; because aging people find it difficult may be lost; because aging people find it difficult to relax limbs, always use reinforcement when to relax limbs, always use reinforcement when eliciting DTRseliciting DTRs

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Plantar reflex may be absent or difficult to Plantar reflex may be absent or difficult to interpret; often, you will not see a definite normal interpret; often, you will not see a definite normal flexor response; still should consider definite flexor response; still should consider definite extensor response abnormalextensor response abnormal

Superficial abdominal reflexes may be absent, Superficial abdominal reflexes may be absent, probably because of stretching of musculature probably because of stretching of musculature through pregnancy or obesitythrough pregnancy or obesity

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Neurologic checkNeurologic check• Some hospitalized persons have head trauma or a Some hospitalized persons have head trauma or a

neurologic deficit due to systemic disease processneurologic deficit due to systemic disease process Must be monitored closely for any improvement or Must be monitored closely for any improvement or

deterioration in neurologic status and for any indication of deterioration in neurologic status and for any indication of increasing intracranial pressureincreasing intracranial pressure

• Signs of increasing intracranial pressure signal Signs of increasing intracranial pressure signal impending cerebral disaster and death and require early impending cerebral disaster and death and require early and prompt interventionand prompt intervention

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(cont.)(cont.) Aging adultAging adult (cont.)(cont.)

Neurologic check (cont.)Neurologic check (cont.)• Use abbreviation of neurologic examination in following Use abbreviation of neurologic examination in following

sequence:sequence: Level of consciousnessLevel of consciousness Motor functionMotor function Pupillary responsePupillary response Vital signsVital signs

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Abnormal FindingsAbnormal Findings

Abnormalities in cranial nervesAbnormalities in cranial nerves CN I, olfactory nerveCN I, olfactory nerve

• AnosmiaAnosmia

CN II, optic nerveCN II, optic nerve• Defect or absent central visionDefect or absent central vision

• Defect in peripheral vision, hemianopsiaDefect in peripheral vision, hemianopsia

• Absent light reflexAbsent light reflex

• PapilledemaPapilledema

• Optic atrophyOptic atrophy

• Retinal lesionsRetinal lesions

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Abnormal FindingsAbnormal Findings (cont.)(cont.)

Abnormalities in cranial nerves (cont.)Abnormalities in cranial nerves (cont.) CN III, oculomotor nerveCN III, oculomotor nerve

• Dilated pupil, ptosis, eye turns out and slightly downDilated pupil, ptosis, eye turns out and slightly down

• Failure to move eye up, in, downFailure to move eye up, in, down

• Absent light reflexAbsent light reflex

CN IV, trochlear nerveCN IV, trochlear nerve• Failure to turn eye down or outFailure to turn eye down or out

CN V, trigeminal nerveCN V, trigeminal nerve• Absent touch and pain, paresthesiasAbsent touch and pain, paresthesias

• No blinkNo blink

• Weakness of masseter or temporalis musclesWeakness of masseter or temporalis muscles

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Abnormalities in cranial nerves (cont.)Abnormalities in cranial nerves (cont.) CN VI, abducens nerveCN VI, abducens nerve

• Failure to move laterally, diplopia on lateral gazeFailure to move laterally, diplopia on lateral gaze

CN VII, facial nerveCN VII, facial nerve• Absent or asymmetric facial movementAbsent or asymmetric facial movement

• Loss of tasteLoss of taste

CN VIII, acoustic nerveCN VIII, acoustic nerve• Decrease or loss of hearingDecrease or loss of hearing

CN IX, glossopharyngeal nerveCN IX, glossopharyngeal nerve

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Abnormalities in cranial nerves (cont.)Abnormalities in cranial nerves (cont.) CN X, vagus nerveCN X, vagus nerve

• Uvula deviates to sideUvula deviates to side

• No gag reflexNo gag reflex

• Voice quality:Voice quality: Hoarse or brassyHoarse or brassy Nasal twangNasal twang HuskyHusky

• Dysphagia, fluids regurgitate through noseDysphagia, fluids regurgitate through nose

CN XI, spinal accessory nerveCN XI, spinal accessory nerve• Absent movement of sternomastoid or trapezius musclesAbsent movement of sternomastoid or trapezius muscles

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Abnormalities in cranial nerves (cont.)Abnormalities in cranial nerves (cont.) CN XII,CN XII, hypoglossal nervehypoglossal nerve

• Tongue deviates to sideTongue deviates to side

• Slowed rate of tongue movementSlowed rate of tongue movement

Abnormalities in muscle toneAbnormalities in muscle tone FlaccidityFlaccidity SpasticitySpasticity RigidityRigidity Cogwheel rigidityCogwheel rigidity

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●● Abnormalities in muscle movement:Abnormalities in muscle movement: ParalysisParalysis FasciculationsFasciculations TicTic MyoclonusMyoclonus Seizure disorderSeizure disorder

TremorTremor Rest tremorRest tremor Intention tremorIntention tremor ChoreaChorea AthetosisAthetosis

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Abnormal gaits:Abnormal gaits: Spastic hemiparesisSpastic hemiparesis Cerebellar ataxiaCerebellar ataxia Parkinsonian (festinating)Parkinsonian (festinating) ScissorsScissors Steppage or footdropSteppage or footdrop WaddlingWaddling Short legShort leg

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Common patterns of motor system Common patterns of motor system dysfunction:dysfunction: Cerebral palsyCerebral palsy Muscular dystrophyMuscular dystrophy HemiplegiaHemiplegia ParkinsonismParkinsonism CerebellarCerebellar ParaplegiaParaplegia Multiple sclerosisMultiple sclerosis

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Common patterns of sensory lossCommon patterns of sensory loss Peripheral neuropathyPeripheral neuropathy

• Loss of sensation involves all modalities; loss most Loss of sensation involves all modalities; loss most severe distally at feet and handssevere distally at feet and hands

Individual nerves or rootsIndividual nerves or roots• Decrease or loss of all sensory modalities; corresponds Decrease or loss of all sensory modalities; corresponds

to distribution of involved nerveto distribution of involved nerve

Spinal cord hemisection (Brown-Séquard Spinal cord hemisection (Brown-Séquard syndrome)syndrome)• Loss of pain and temperature, contralateral side, loss of Loss of pain and temperature, contralateral side, loss of

vibration and position discrimination on ipsilateral sidevibration and position discrimination on ipsilateral side

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Common patterns of sensory loss (cont.)Common patterns of sensory loss (cont.) Complete transection of spinal cordComplete transection of spinal cord

• Complete loss of all sensory modalities below level of Complete loss of all sensory modalities below level of lesion; associated with motor paralysis and loss of lesion; associated with motor paralysis and loss of sphincter controlsphincter control

ThalamusThalamus• Loss of all sensory modalities on face, arm, and leg; Loss of all sensory modalities on face, arm, and leg;

contralateral to lesioncontralateral to lesion

CortexCortex• Loss of discrimination on contralateral side; loss of Loss of discrimination on contralateral side; loss of

graphesthesia, stereognosis, recognition of shapes and graphesthesia, stereognosis, recognition of shapes and weights, finger findingweights, finger finding

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Abnormal posturesAbnormal postures Decorticate rigidityDecorticate rigidity

• Upper extremitiesUpper extremities Flexion of arm, wrist, and fingersFlexion of arm, wrist, and fingers Adduction of arm: tight against thoraxAdduction of arm: tight against thorax

• Lower extremitiesLower extremities

• Extension, internal rotation, plantar flexion; indicates Extension, internal rotation, plantar flexion; indicates hemispheric lesion of cerebral cortexhemispheric lesion of cerebral cortex

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Abnormal postures (cont.)Abnormal postures (cont.) Decerebrate rigidityDecerebrate rigidity

• Upper extremities: stiffly extended, adducted, internal Upper extremities: stiffly extended, adducted, internal rotation, palms pronatedrotation, palms pronated

• Lower extremities: stiffly extended, plantar flexion; teeth Lower extremities: stiffly extended, plantar flexion; teeth clenched; hyperextended backclenched; hyperextended back

More ominous than decorticate rigidity; indicates lesion in More ominous than decorticate rigidity; indicates lesion in brain stem at midbrain or upper ponsbrain stem at midbrain or upper pons

Flaccid quadriplegiaFlaccid quadriplegia• Complete loss of muscle tone and paralysis of all four Complete loss of muscle tone and paralysis of all four

extremities, indicating nonfunctional brain stemextremities, indicating nonfunctional brain stem

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Abnormal postures (cont.)Abnormal postures (cont.) OpisthotonosOpisthotonos

• Prolonged arching of back, with head and heels bent Prolonged arching of back, with head and heels bent backward; indicates meningeal irritationbackward; indicates meningeal irritation

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Health & Medicine

Unit 5 neurological system