hello welcome to this webinar titled introduction to the neurologic screen and observation my name is Dr Lily Jimenez I'm a physical therapist who specializes in neurologic care and today we're going to learn um about the neuroscreen how is it different from the neuro exam and what are the parts of it for our overview we are going to understand the difference between neurologic screen versus exam as I said we're going to describe and learn the components of an efficient neural screen and we're going to learn to interpret results of a neural screen but first we're going to talk about why do we do a neural screen first we do one because we want to screen for red flags we want to check changes in our patient's status if we see one we use a neural screen to screen for referral it is used as a differential diagnostic tool to help identify altered sensory and motor functions that may rule in or out impairments of the nervous system and we use it because it's fun to perform I think but first let's talk about the difference between the screen and examination so a screen is something that's going to be very very quick it is used when we see some red flags and we want to remember out any involvement of the nervous system um and also we use the screen to uh determine if the patient will need further neurologic care or testing if needed so remember when you find something abnormal whether cognitive motor or sensory it becomes necessary to analyze this problem in a more elaborate fashion so meaning turning from screen to examination and remember the examination will vary from PT to PT depending on the experience and the practice but all the neuro exam will have the components that we're going to talk today as well as the neural screen and you'll find that these two have this similar Parts but what makes it a screen versus an exam is how detailed the testing is so here are the components of neural screen and you will see that also these are the components of a neuro exam but as I said neuroscreen are more quick and straightforward so we have observation mental status cranial nerves motor reflexes sensation coordination and balance and gait we're going to start with observation so you have your patient in front of you you're going to observe how do they look like what's their posture do they demonstrate symmetry are they leaning to one side are they demonstrating facial drooping are they showing some involuntary movements how's their muscle bulk which will focus on this point the muscle bulk in our motor exam but we're just looking we're looking to see what is going on if you find some involuntary movements this can hint as basal ganglia so basal ganglia is the the anatomical part of the brain where um you can find let's say someone has problems with their basal ganglia they will show either decreased movement or excessive movement so if you have someone with excessive movement like an involuntary movement this can hint us to basal ganglia disorder so then we move on to mental status so a change in the behavior or mentality slash cognition is significant so this includes a level of Consciousness is a patient alert are they awake are they lethargic are they sleepy are they stuporous so you're going to see what their level of Consciousness if that changes from normal this is significant orientation memory are they demonstrating any unusual behavior um so all these things are going to be um very important to check now remember a more extensive examination will be needed if any problems with these is is found during your assessment any problems with these will prompt you to think there's some central nervous system involvement now for orientation you know where you need to ask your typical AO times four now the other way you can assess your mental status is through the acronym fogs which can use can be used as a guide for you um on how to screen cognition so for f um we're going to ask the patient um or we're going to see there has been any history of memory loss in the family orientations or orientation questions that we talked about general information like you can ask something like who's a president or who's a vice president or any recent event and for spelling you want to ask the patient to spell the word world forward and backward if patient can spell the word World forward it indicates that the patient can spell and in the absence of any neurologic deficits the patient should be able to spell the same word backwards um so like if the patient cannot spell then maybe they cannot spell because the lover of literacy then you can maybe ask the patient to count backwards from 100 by threes or ask the patient to repeat a seven digit number to assess the patient's ability to perform mental manipulations or hold information in their brain now as they respond you need to also be paying attention on the quality of their speech which can tell us um information about cranial nerve 7 9 10 and 11 12. so then the next talking about cranial nerves is the cranial nerve screen now cranial nerves um here we're going to do a screen when we do testing of cranial nerves this is going to be more specific but here we're going to start with um asking them a question and then we move in to the crayon of a screen so the first question is have you noticed any changes in smell yes or no right so that will tell us something about their Factory nerve then we move into pupils and peripheral vision so shedding a lie over their pupils to see if they contract um and their peripheral vision for cranial nerve between three smooth Pursuit through the h test three four six facial sensation meaning to slight touch on the face can you feel this um and mastication maybe they can um squeeze um their their teeth together for cranial number five trigeminal facial movements can you smile can you erase your eyebrows for seven finger rubs so seeing if they can hear that rub um of my fingers close to their ears for cranial nerve eight palette elevation and speech can you see ah for nine and ten shoulder shrug for 11 spinal accessory and tongue can you show me your tongue and can you wiggle it side to side for cranial nerve 12. so again this is a quick screen very very quick um assessment and if you find anything we start um assessing further okay motor all right so now we're going to look at the arms okay can you show me your hands can you show me your arms just wanted to take a look at that um you're assessing to see if there's any atrophy any fasciculations any uh difference in muscle bulk size um anything like that just to assess um that you can assess for any outbreaks from any drift so pronators are going to tell the patient to um supinate their hands and then they're going to bring their arms in front of them outstretch and they're going to close their eyes and you're going to count to 10 and see if there's any what we call a pronator drift which is when the affected arm will start pronating that is any signs of a stroke if you see any upward drift versus a pronation and a downward drip which happens with stroke if you see any upward drift this can be a cerebellar involvement now you're looking for Tremor any abnormal movement so you're observing and then from here we start our strength screen now here with the screen this is not your mmt formal assessment this is a quick screen is there any weakness or that you want to just find quickly so you can ask the patient um any weakness that you've experienced lately if they say yes okay where you know in my arm so we do a quick screen of everything and then we if we find something in their arms then we do a formal mmt assessment okay so simple straightforward if we find something we move into exam so um again we screened them the major myotomes um bilaterally now here I have to say there's two muscle groups that I would recommend testing in a different way which is hip extensors and plantar flexors or calves so these are better screened through a sit-to-stand um so you can um move these two muscle screens towards the end when you're going to do gait just through a sit-to-stand um if you see any trouble with sit to stand then you can move into your formal mmt assessment of hip extension in prone and of course of calves through the unilateral heel rays but I would do set of Standards to a quick screen of the hip extensors and the plantar flexors since this or assessed the patient from sitting to standing so for tone here this can be part of our um uh like range of motion SS screen because tone we need to feel the tone so here you after you screen all the other arms or or legs or even before you do that you can just move the the limbs passively and you can feel for any hypotonia which can tell you it's a lower motor neuron or hypertonia for upper motor neuron or if there's rigidity Um this can tell you basal ganglia Disorder so just passively moving the limb through through the range of motion to feel the tone as a screen if you find something significant then again you move into an examination which is what the modify Ashworth skill for reflexes you do your your normal reflex testing um so here you can also add some other abnormal reflexes like the clonas babinsky Hoffman so just a quick screen of those reflexes and of course document if you find something um that is significant for instance the resensory starts with the question any numbness or tingling anywhere in your body any burning sensation any pins and needles if they say yes okay you ask okay where oh you know in my you know right arm okay we're gonna just screen the whole body and then I'll focus on your right arm okay so you do a quick screen light touch arms and legs different parts of arms and legs and if you find something you do your testing like touch perception pain prick temperature now if the patient tells you something like oh you know I do have some numbness or tingling in my right foot and also sometimes I feel like I don't know where it is in space like I don't know where I'm placing my foot then that gives you a clue of proprioception so then you will go ahead and Screen sensory all the body and then focus on proprioception so the patient will give you Clues on what things you need to focus on as well now the pattern of sensory laws will determine where in the pathway so this is what I mean let's focus on the left um here on this side so that letter A so this is a right side weakness so this corresponds to a left side hemispheric lesion so brain so maybe a stroke B so here we have ipsilateral facial sensation loss and contralateral body uh sensation loss so this is course this is corresponding to a um left brain stem lesion here we have Hemi body so this is a complete spinal cord injury this we have half and half so less of X sensation and loss of another sensation so this is called the bronzacard and then here we have oh it's a peripheral nerve injury uh so here like we have um some involvement of the foot and the back of the foot so maybe some foot drop also with common peroneal nerve here or we have a radial nerve injury so this is a peripheral nerve and here we have a polyneuropathy with seen with diabetes or cancer-related neuropathy Etc so again the pattern of sensory loss corresponds to uh where in the pathway we have a loss now here I'm going to talk about extension or inattention so it's a higher order sensory so this corresponds to a parietal cortex lesion so if someone had a parietal stroke they're gonna exhibit extension or also called an attention or sensory inattention so now what you're going to do is you're going to test both sides individually and they will be able to feel it each side but when you test both sides simultaneously they cannot feel the side that's involved so like on this picture here this is someone who had a right side stroke which someone with a right side stroke will exhibit left side hemesthesia so so if you test right individually they will say yes I feel it on the right side then you touch the left and they'll say left so they're able to feel it individually when a single stimulus is presented but when you touch both sides they only feel the on involved side which is the right because they're I have a right size stroke and they demonstrate left side Hemi paresis I mean sorry hemisthesia so again if only one of them is perceived that is the parietal cortex is involved in that side the opposite side of non-perception may be abnormal okay so this is called extension then the next is coordination we do our typical coronation tests fingertips test heel to Shin these are tests for dysmetria rapid alternating movement this is a test for this diet of kinesia one of my favorite words and then we can do finger or toe tapping the amplitude Rhythm and accuracy can tell you a little bit more of where in the brain is the lesion then we have our balance screen which also comes together with gate so for balance screen you do the Romberg so be together Hands Across chest eyes closed hold for 30 seconds if they lose their balance on this position this is sensory Ataxia so it's a sensory deficit in the lower legs bar you can also have loss of balance with a vestibular something molar basal ganglia or cerebellum so please if you find something with our balance system examine them with further balance testing like balance maybe a modified cat sip test uh things like that and then the gate screen you have them you know ambulate and observe and then if you find something you you start doing your observational gain analysis as the formal testing so this is your neuro screen observation mental status you're observing that mental status okay can you tell me where you are uh what's your name why are you here I'm going to tell you three words and I'm gonna have you repeat them back to me in a couple minutes or can you spell the word world forward and backwards if you want to screen their short-term memory or long-term memory oh can you tell me what you had for breakfast or for long-term memory can you tell me where you grew up cranial nerve screen so you go through your screen reflexes quick motor okay I'm gonna check um now your strength first I'm just gonna have you just bring your arms in front of you straight in front of you I'm just going to be observing your muscle and your muscle bulk um just to see if everything looks uh normal and you you know you feel I'm gonna take your arm your elbow through some movements just to feel that um muscle tone and you can just explain your muscle tone it's is something it's a property of a muscle sometimes it's there's increased resistance sometimes there's less resistance so here I'm just feeling and see what it feels like okay now I'm gonna just check your strength uh both in your arms and legs a quick test um you know and you tell them okay hold for major myotomes right and then all right so now we're going to move on to sensation um now the first thing I want to ask you do you feel any numbness tingling pins and needles burning sensation anything different anywhere in your body and then if they tell you you know whatever okay I'm just gonna do a quick test with this gonna be with eyes closed I'm going to be touching different parts of your arms unless you're going to tell me yes if you feel it or you can tell me yes and point to where you're feeling it okay then you do your testing all right we have two more things can you do this and we're going to do the finger finger opposition test pan flip for decided kinesia heel to Shin so you're going to demonstrate can you do this can you do this as quick as possible we'll do it five times five finger up position five flips and five heel to Shin just so you can see the accuracy last thing we're going to stand up and here's where you would assess hip extension and calf strength through functional waist and the last thing I'm going to have you is put your feet together as close as the as you can you're going to put your arms across your chest and you're going to close your eyes and we're going to hold it for 30 seconds and I'm going to see how your body responds to this I'm going to be right next to you just in case you feel you lose your balance I'm here to hold you um you can put your gate belt or whatever and you do your Romberg test if you find something else you you know you can obviously node make a note and then perform an outcome measure and then the last thing I'm going to have you just walk from here to the end of this wall and um back and forth and then we're done so your quick screen very very quick screen of the neuro exam so this can be completed in less than 15 minutes with practice okay in any abnormal finding will prompt us to move um to a more detailed neural exam so now we're going to look at a video um about uh or not about of a neural screen um and I'm going to pull it up this is a demonstration of a brief neurologic exam one that might be used in a general screening exam or in the case of the patient who comes in with undifferentiated neurologic complaints now I normally would begin with a testing of the mental status but in this case based on the history it's very clear that the patient's mental status is entirely normal so I'll now turn to the cranial nerve exam the first parts of that exam include examination of the fundus and testing of visual Acuity but we'll assume that that's already been done at this point so to begin I'm going to test your peripheral vision and to do this I'm going to be moving my fingers out here in the periphery when you see a finger move I want you to point to it with your hand but I want you to look directly at the center of my face while we do this okay so look right here and as soon as you see a finger moved going to it so this is cranial nerve two and three for peripheral vision okay now if you could look the opposite wall in the room cranial nerve two optic nerve for constriction you can use your phone light for this or a pen light if you have some I'm going to test the movement of your eyes so if you could look at where my fingers meet keep your head still and just follow my fingers so this is cranial nerve 346 good okay now I'm going to test sensation can you feel this yes and that's yeah is it the same on both sides same on both sides same okay and what does this feel like same on both sides yes cranial nerve five facial sensation same yes okay now if you could raise your eyebrows real cranial nerve seven and now close your eyes as tight as you can good show me your teeth okay good can you hear this crayon or eight open your mouth and say ah one more time good please shrug your shoulders relax turn your head towards my hand good in the opposite direction good and if you could just open your mouth and let your tongue sit where it does lightly and now stick it out and wiggle back and forth crayon nerve 12th good all right now I'm going to test up aspects of your motor function so to begin I'm just going to look at your muscles okay good and if you could just now make your arms as Loose as you can check in for a tone and the same with your legs good now if you could put your arms straight out in front of you Palms up fingers straight out and keep them just like this and close your eyes and we're going to do this for about 10 seconds or so okay now I'm going to test some of your muscles for their strength if you could just put your forearm like this and push me away as strong as you can okay good and the same thing here push good and pull in and same thing here pull in good put both both of your wrists up and don't let me bend them down and now this one oh please good real strong good now put your fingers straight out don't let me bend them down good same here real strong good spread your fingers don't let me bend them in real strong we'll throw great now let's try your legs if you could lift up this late please straight up good don't let me push down and down with this good now pull your ankle in towards the bottom of the bed here and pull in as hard as you can good and same thing here pulling real strong good bend this ankle up as strong as you can and now this one and both toes up please real strong real strong good I'm going to test your reflexes you can just let your arms be loosen by your side just let your arms just drop down very good okay just let your legs be nice and loose and test your ankles I'm now going to test a couple of uh sensory functions so if you could again bring your arms right here can you feel this and this does it feel the same on both sides either in here yes here and here great and how about in your legs let's try that as well can you feel that yeah same on both sides yes and how about this what does that feel like cool same on the both sides okay clearing here here okay I'm gonna touch you on your right hand your left hand or both and when you close your eyes and tell me when I touch you left left good okay uh I'm gonna test some coordination if we take your right hand go like this tap tap tap tap good now your left hand up good now take your right index finger and touch your nose and come back out and touch my finger and go back and forth good now with your left hand now here I don't recommend um doing um the finger finger um like following your hand and you moving your hand around because some patients will have a struggle doing this so you can do either both stationary finger and then you can do moving finger depending on how they do now with your feet if you could just tap your foot on my hand rapidly tap tap tap tap tap good afternoon good s all right the last thing will be to test your stance and gate and for that we'll go out into the Hall all right now I'm going to test your balance so if you could stand here with your feet together good and now close your eyes and stand there I'm I won't let you fall great now if you could just walk down the hall normally as though you're walking down a sidewalk and turn around and walk up on your heels you can do that for dorsiflexion strength turn around and walk up on your toes for a heel strength and and that is it thank you so much for your attention I will see you next time