Neurologic Examination: Sensory Testing & Reflexes

First thing to do before sensory testing is __ to know if the pt can follow instructions

Mental status testing/Cerebrum test

Superficial sensory testing consists of

Light touch, pin prick, deep pressure, temperature

Which is tested first: Superficial or deep

Superficial

Deep sensory is tested on __

Distal extremities (hand and foot)

Types of deep sensory testing

Proprioception

Kinesthesia

Vibration

Position sense is aka

Proprioception

Movement sense is aka

Kinesthesia

Deep sensory testing:

• Up or down, hold on __

• Left and right, hold on __

• Lateral or medial sides of finger or toe

• Anterior or posterior sides of finger or toe

Another way to test proprioception and kinesthesia aside from moving the finger

Ask pt to copy the position of the finger on the opposite side

(+) __ if pt can mimic the mvmt after its done

Proprioception

(+) __ if pt can mimic the mvmt while PT is doing it

Kinesthesia

Most important sensory test when pt has a stroke or brain problem

Combined cortical

Combined cortical tests:

• 2 point discrimination

• Sterognosis

• Graphesthesia

• Barognosis

• Tactile localization

• Double simultaneous stimulation

• Texture recognition

If __ and __ are intact, all combined cortical senses are intact

2 point discrimination

Stereognosis

2 point discrimination: Use __ make sure it isnt sharp

paperclip

2 point discrimination: Start from __ to __

Wide to narrow

2 point discrimination: End at __

last 2 pts that the pt CAN discriminate

2 point discrimination: If pt senses 1 point only, what do u do

Move wider

2 point discrimination: Normal values

Fingertips: 3-5mm

Dorsum of the hand: 20-30mm

Palms: 8-15mm

Combined cortical: __: Ability to identify objects c eyes closed

Stereognosis

Combined cortical: __: Use familiar objects, intro the object, let them feel c eyes open

Stereognosis

Combined cortical: __: Trace letter/number on pt’s palm (or any body part); ask to identify what was written

Graphesthesia

Combined cortical: __: Wipe a tissue on the pts palm after every ;etter/number

Graphesthesia

Combined cortical: __: Distinguish weights

Barognosis

T or F: To test barognosis, use objects that have different size and weight, but same shape

FALSE

• Same size and shape, diff weight only

Combined cortical: __: Pts eyes closed, place a dot on any part of their skin and ask them to point to where it was placed

Tactile localization

Combined cortical: Tactile localization: What do u measure

Distance of where the PT put the dot and where the pt pointed to

Combined cortical: __: Apply 2 sensations simultaneously on both sides (proximal or distal) or on 1 side (prox or distal). Pt verbally identifies where they felt the sensation (eyes closed)

Double simultaneous stimulation

T or F: The area doesnt really matter when testing for double simultaneous stimulation

TRUE

• As long as both stimuli are done at the same time

Combined cortical: __: There will be absence of sensation of the distal extremities while simultaneously applying proximal sensation.

DSS: Extinction phenomenon

Combined cortical: __: Sensation perceived on proximal ONLY

DSS: Extinction phenomenon

Superficial reflexes

Upper abdominal reflex

Lower abdominal reflex

Plantar scratch

Anal reflex

Superficial reflexes: Upper abdominal reflex: Response

Umbilicus moves in the same direction of the brush (if stimulus is on all 4 sides at the same time → it’ll stay in the middle)

Superficial reflexes: Upper abdominal reflex: Nerve root

T8-T10

Superficial reflexes: Lower abdominal reflex: Nerve root

T10-T12

Superficial reflexes: Plantar scratch: Response

Toe flexion

Superficial reflexes: Plantar scratch: Nerve root

L2-S1

Superficial reflexes: Anal reflex: Response

Winking of anus

Superficial reflexes: Anal reflex: Nerve root

S2-S4

DTRs

• Biceps, brachialis reflex

• Brachioradialis reflex

• Triceps reflex

• Patellar reflex

• Ankle (achilles) reflex

DTR: Biceps, brachialis reflex: Nerve root

C5-C6

DTR: Brachioradialis reflex: Nerve root

C5-C6 / C6-C7

DTR: Triceps reflex: Nerve root

C6-C7 / C7-C8

DTR: Patellar reflex: Nerve root

L2-L4

DTR: Ankle (Achilles) reflex: Nerve root

S1

DTR grading

0: Areflexia (absent)

+ Hyporeflexia (diminished)

++ Normoreflexia (normal)

+++ Hyperreflexia (increased)
++++ Clonus

DTR grade in UMN condition

+++ or ++++ (normal is ++)

DTR grade in LMN condition

0 or +

__ reflexes should be oppressed (should be suppressed at a certain age)

Primitive reflexes

__: Normal in children and for survival

Primitive reflexes

T or F: Physiologic reflexes should exist even when you get old

TRUE

Reflex: __: Righting reactions are defined as automatic reactions that enable a person to assume the normal standing position and maintain stability when changing positions

Righting reflex

Reflex: __: Important for balancing

Equilibrium reflex

Reflex: __: When pushed to the right, shift weight to the left to avoid falling

Equilibrium reflex

Reflex: __: Pt tends to extend extremities when youre about to fall

Protective extension reflex

In normal adults, there should be no response to stimulus that triggers __

Pathologic reflex

Pathologic reflex: For pts c sx of __, do not move the affected limb (no exercises, special tests, reflex testing, etc.)

DVT

Pathologic reflexes:

Babinski

Chaddock

Oppenheim

Gordon

Piotrowski

Brudzinski

Hoffman

Rossolimo

Schaefer

Pathologic reflex: __: Stroking of lateral aspect of sole of foot (firm and brisk)

Babinski

Pathologic reflex: Babinski positive response

Extension of big toe and fanning of four small toes

Pathologic reflex: __: Stroking of lateral side of foot beneath lateral malleolus (J stroke from below lateral malleolus to foot)

Chaddock

Pathologic reflex: Chaddock positive response

Extension of big toe and fanning of four small toes

Pathologic reflex: __: Stroking of anteromedial surface of tibia (stroking of shin and direction should be towards the foot)

Oppenheim

Pathologic reflex: Oppenheim positive response

Extension of big toe and fanning of four small toes

Pathologic reflex: __: Squeezing of calf muscles (gastrocs) firmly

Gordon

Pathologic reflex: Gordon contraindication

DVT

Pathologic reflex: Gordon positive response

Extension of big toe and fanning of four small toes

Pathologic reflex: __: Percussion/tapping (c 2 fingers) of tibialis anterior (immed. lateral to the shin)

Piotrowski

Pathologic reflex: Piotrowski positive response

Dorsiflexion & supination of the foot

Pathologic reflex: __: Passive flexion of one lower limb (flex unaffected limb)

Brudzinski

Pathologic reflex: Brudzinski positive response

Flexion of opposite lower limb (sign of UMN)

Pathologic reflex: __: Tapping of index, middle, or ring finger (distal phalanx; tapping one of the 3 fingers is okay)

Hoffman

Pathologic reflex: Hoffman positive response

Flexion of distal phalanx of thumb (sign of LMN)

Pathologic reflex: __: Tapping of plantar surface of toes

Rossolimo

Pathologic reflex: Rossolimo positive response

PF of toes

Pathologic reflex: __: Pinching (shouldnt be painful) of achilles tendon in middle third

Schaefer

Pathologic reflex: Schaefer positive response

Flexion of foot and toes (sign of LMN)

Pathologic reflexes suggesting UMN

Babinski

Chaddock

Oppenheim

Gordon

Brudzinski

LMN:

• Piotrowski, hoffman, rossolimo (all the tappings)

UMN vs LMN lesion:

• __ reflex

• __ reflex

Increased

Diminished

Note

Oppenheim to gordom (UMN) → same positive response but different stimulus

If you do smth in one part of the body, then an associated reaction will occur

Associated reactions

__ reaction: Usually seen in pts c neurologic problems or brain injury

Associated reactions

Associated reactions

Raimistes phenomenon

Sterlings phenomenon

Marie-foix phenomenon aka Bechterev’s

Soques phenomenon

Homolateral synkinesis

Associated reactions: __: Same with sterlings stimulus and reaction/response but it differs on the body part

Raimistes phenomenon

Associated reactions: __: For LE (hip) abduction

Raimistes phenomenon

Associated reactions: __: Resistance of abduction of the unaffected side = associated abduction on the affected side

Raimistes phenomenon

Associated reactions: __: Pt has stroke manifestations on the R, if PT resists hip abd on the L, whats the reaction

R hip abduction

Associated reactions: __: Same with raimistes stimulus and reaction/response but it differs on the body part

Sterlings phenomenon

Associated reactions: __: For UE (shoulder) abduction

Sterlings phenomenon

Associated reactions: __: Resistance of abduction of the unaffected side = associated abduction on the affected side (shoulder)

Sterlings phenomenon

Associated reactions: __: For LE, Passively flexion the toes on the affected side causes massive flexion of entire LE on ipsilateral side

Marie-Foix phenomenon (Bechterevs)

Associated reactions: __: For UE, passively flexing the shoulder of the affected side will elicit extension of the fingers ipsilaterally (test on affected side)

Soques phenomenon

Associated reactions: __: Can be used for managing flexion synergy

Soques phenomenon

Associated reactions: __: Passively flexing the UE will elicit flexion of the LE (if all UE segments are passively flexed, all LE segments on the ipsilateral side would also flex)

Homolateral Synkinesis

T or F: Homolateral synkinesis can be done on the unaffected side (LE)

FALSE
Test on AFFECTED side and UE will always be the stimulus