Neurologic Examination Description of Skills and Testing Procedures

Components
The Neurologic examination consists of the following components:

Mental Status
Cranial Nerves
Sensory Testing
Motor Strength *
Reflexes
Coordination Testing *
Special Signs *

Of these, only those in Bold Italics * will be tested in the Practical Examination.
In SIM, you have clearly demonstrated your ability to examine the cranial nerves and muscle stretch
reflexes, and thus they will be omitted from Practical Exam testing. The one exception to this is the
Babinski reflex, which I have included because it was inexplicably absent from the reflex
testing I saw in SIMs.
Mental Status assessment is covered in your Behavior Medicine System and Sensory testing does
not lend itself well to Practical Examination.
Motor Strength
There are many instances where the Musculoskeletal and Neurologic examinations overlap, and
manual muscle testing is one such example. Normal muscle function requires both muscle strength
and nervousinnervation. For the purposes of our study, manual muscle testing has been included
within the Neurologic examination.
Manual Muscle Testing: For purposes of examination and actual manual muscle testing in the clinical
setting, each muscle should be in a fully contracted position and then the student should demonstrate
either their ability to break the contraction or attempt to break the contraction.
There are different techniques by different authors in the literature regarding how to test muscle
strength and motion. The general rule we will be teaching and evaluating with is that each muscle will
be fully contracted, then the student/examiner will try to break/ overpower the contraction, and
should be able to do so unless otherwise noted. Typically, in neurologic weakness, there will be
gradual movement of the joint. Patients will sometimes demonstrate give-way weakness where they
will abruptly stop their resistance and movement of the joint against resistance will be fast. In these
cases it is NOT possible to tell, with certainty, whether the muscle is neurologically weak or if the
weakness is due to pain inhibition or less than full effort on the part of the patient.
Grading Scale
5-Normal = Complete active range of motion against gravity with full resistance.
4-Good =Complete active range of motion against gravity with some/not full resistance
3-Fair = Complete active range of motion against gravity with no resistance
2-Poor= Complete active range of motion with gravity eliminated
1-Trace= Evidence of muscle contractility but no/very little joint motion
Page1

0-Zero= NO evidence of muscle contractility/function

For each of the following joint motions, you should be familiar with (and be prepared to verbalize
during testing) the muscle involved, nerve root level and peripheral nerve that supplies the
innervation. (Note that references may differ somewhat on the nerve roots innervating specific
motions, particularly when multiple levels contribute to a motion. For the purpose of testing
in EPC IV, the gold standard shall be the information contained in this document.)
For each muscle, you will find a description of the testing method, a link to a video demonstration,
and a screenshot from the video.
Upper Extremity
Shoulder abduction Deltoid,: the examiner should have the
patient place their shoulder into full abduction and then pull
down (adduct) the arm and break the contraction
Innervation: primarily C5 level, Axillary nerve.

Manual Muscle Testing - Deltoid

http://mediasite.lmunet.edu/Mediasite/Play/29c57613cdcd4bc89fb972431e520dc21d?catalog=b731f0
64-988e-42ce-9952-04964c178f67
-----------------------------------------------------------------------------------------------------------------------------Elbow flexion, Biceps,: This examination is usually done
seated, and is begun with the arm to be tested flexed at the
elbow to 90 degrees. The patient will then attempt to flex the
elbow while the examiner resists the movement.
Innervation: C5-6, Musculocutaneous nerve

Manual Muscle Testing - Biceps

http://mediasite.lmunet.edu/Mediasite/Play/a908e94934cd48dfb02bbf3095876ee41d?catalog=b731f0
64-988e-42ce-9952-04964c178f67
------------------------------------------------------------------------------------------------------------------------------

Page2

Elbow extension, Triceps: The examiner will begin with the

patient seated or standing with the shoulder in forward flexion and
elbow in an extended position. The examiner will then brace the
upper arm and attempt to flex the elbow. The examiner may not
be able to break this muscle.
Innervation: C7, Radial nerve.

Manual Muscle Testing - Triceps

http://mediasite.lmunet.edu/Mediasite/Play/cf9f2bd753ad4de2813916dd0a1051d41d?catalog=b731f0
64-988e-42ce-9952-04964c178f67
-----------------------------------------------------------------------------------------------------------------------------Wrist extension, Extensor Carpi Radialis (Longus and
Brevis): The examiner has the patient extend their wrist and,
while bracing the forearm, will break the contraction by putting
pressure on the hand and forcing flexion of the wrist. This can
also be done by having the patient place their forearm on
an exam table and pressing down on the extended wrist.
Innervation: primarily C-6, Radial nerve.

Manual Muscle Testing - Extensor Carpi Radialis Longus and

Brevis
http://mediasite.lmunet.edu/Mediasite/Play/dcdaf90b07ce4a2eb2862c8cc725f5531d?catalog=b731f0
64-988e-42ce-9952-04964c178f67
-----------------------------------------------------------------------------------------------------------------------------Thumb abduction, Abductor Pollicis Brevis: The examiner
will position the patients hand with the palm facing upward
and the thumb abducted (pointing upward), will then force the
thumb into adduction with pressure over the
metacarpophalangeal (MCP) joint with bracing of the hand.
Innervation: C-8/T-1, Median nerve.

Manual Muscle Testing - Abductor Pollicis Brevis

http://mediasite.lmunet.edu/Mediasite/Play/8cb4a20c20154876a5dbb1c1a8f27ac51d?catalog=b731f0
64-988e-42ce-9952-04964c178f67
Page3

Finger abduction, First Dorsal Interosseous,: The examiner

will ask the patient to abduct the digits fully. The examiner will
then brace the patients hand and attempt to adduct the
patients finger while using their own abducted finger to do
this, thus comparing their abduction to the patients.
Innervation: C8/T1, Ulnar nerve

Manual Muscle Testing - First Dorsal Interosseous Muscle

http://mediasite.lmunet.edu/Mediasite/Play/573b4f7cfbc942b88d1c917917229d461d?catalog=b731f0
64-988e-42ce-9952-04964c178f67
-----------------------------------------------------------------------------------------------------------------------------Lower Extremity
Hip abduction, Gluteus Medius,: The patient
will be sidelying and then instructed to fully
abduct their leg. The examiner will then apply
pressure distal to the knee and attempt to force
it into adduction.

Innervation: L-5, Superior gluteal nerve.

Manual Muscle Testing Gluteus Medius

http://mediasite.lmunet.edu/Mediasite/Play/764c6ace9c454e47929b7b236b5cd48e1d?catalog=b731f
064-988e-42ce-9952-04964c178f67
----------------------------------------------------------------------------------------------Knee extension, Quadriceps: From the sitting position, the patient will
extend the knee and the examiner will attempt to flex the knee. In
normal circumstances the examiner will often not be able to break this
muscle contraction.
Innervation: L-2,3,4, Femoral nerve.

Manual Muscle Testing Quadriceps

http://mediasite.lmunet.edu/Mediasite/Play/e03eca6df1e948fc86bee433807d40151d?catalog=b731f0
64-988e-42ce-9952-04964c178f67
Page4

Ankle dorsiflexion,Anterior Tibialis/Tibialis

Anterior: In the standing position, the examiner asks
ask the patient to stand on their heel and dorsiflex their
The examiner will apply pressure to the dorsum of the
try to push the foot to the ground.

the will
ankle.
foot and

Innervation: L-4-5, Peroneal/fibular nerve

Manual Muscle Testing Anterior Tibialis
http://mediasite.lmunet.edu/Mediasite/Play/19edf61298834a83b64128703850b35c1d?catalog=b731f
064-988e-42ce-9952-04964c178f67
-----------------------------------------------------------------------------------------------------------------------------Great toe dorsiflexionExtensor Hallucis (Longus
and
Brevis),: From the seated or supine position, the
examiner instructs the patient to extend the
metatarsophalangeal (MTP) joint of their great toe. The
examiner then attempts to flex the toe by applying
pressure on the proximal phalanx.

Innervation: L-5 , Peroneal/fibular nerve.

Manual Muscle Testing Extensor Hallucis Longus and Brevis)

http://mediasite.lmunet.edu/Mediasite/Play/7b24dbdee0e741ed8d4fbec4170054121d?catalog
=b731f064-988e-42ce-9952-04964c178f67
------------------------------------------------------------------------------------------------------------------------------

Page5

Ankle plantar flexion,Gastrocnemius: Standing on one leg, the

patient will place one finger on a table to balance, stand on one leg,
keep their knee straight , and then go up on their toes (plantar flex) ten
(10) times (N.B., number of repetitions required is debated, and may
vary with strength of patient.)

Innervation: S-1, Tibial nerve

Manual Muscle Testing Gastrocnemius Lift Off Test

http://mediasite.lmunet.edu/Mediasite/Play/16b8c878e3374a49af2bb6e3078e59a01d?catalog=b731f
064-988e-42ce-9952-04964c178f67
------------------------------------------------------------------------------------------------------------------------------

SUMMARY OF MUSCLE ACTIONS & INNERVATIONS

Page6

Neurologic Examination Maneuvers

Here are descriptions of a number of neurologic special tests that one would perform to evaluate
specific aspects of neurologic function. For each examination maneuver, you will find a description of
the testing method, an illustrative diagram and a Mediasite link to a video demonstration. (The
individual videos are contained within the Neurologic Exam Demonstration Video, and the time in
this video at which the particular exam is demonstrated is included.)
You should be able to demonstrate each examination, and in addition, you should be familiar with
(and be prepared to verbalize during testing) what constitutes a positive finding, and/or what a
positive finding implies.
Finger-to-Nose Testing : With the patient seated,
position your index finger at a point in space in front
of the patient. Instruct the patient to move their index
finger between your finger and their nose.
Reposition your finger after each touch. Then test the
other hand.
Interpretation : An abnormal test is the inability to do
this at a reasonable rate of speed, trace a straight
path, and hit the end points accurately. Missing the
mark, known as dysmetria, may be indicative of
cerebellar dysfunction. (If the movement is accurate
and smooth but slow, the likely problem is muscle
weakness, and less likely cerebellar dysfunction.)

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video 20:00
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67

--Heel to Shin Testing: Direct the patient to place the heel of one foot
on the opposite knee, and then move the heel down the center of the
shin. Then test the other foot.
Interpretation : The movement should trace a straight line along the
top of the shin and be done with reasonable speed. An inability to do
so constitutes an abnormal test and may be indicative of cerebellar
dysfunction. (If the movement is accurate and smooth but slow, the
likely problem is muscle weakness, and less likely cerebellar
dysfunction.)

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video 20:30
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67

Page7

Romberg Test : Ask the patient to stand with their feet together
(touching each other). Then ask the patient to close their eyes.
Remain close at hand in case the patient begins to sway or fall. Loss
of balance when eyes closed is a positive test
Interpretation : With the eyes open, three sensory systems provide
input to the cerebellum to maintain truncal stability. These are vision,
proprioception, and vestibular sense. If there is a mild lesion in the
vestibular or proprioception systems, the patient is usually able to
compensate with the eyes open. When the patient closes their eyes,
however, visual input is removed and instability can be brought out.
With a cerebellar lesion, the patient will be unable to maintain this
position even with their eyes open.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam

Demonstration Video 33:45
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67

---Pronator Drift : Ask the patient to extend both arms with the palms pointing upwards, and then
maintain that posture with the eyes closed.
Interpretation : An abnormal test results in the arm drifting downward and the hand pronating. An
abnormal pronator drift tests indicates an upper motor neuron lesion. It is often seen in patients who
have a mild hemiparesis.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video 34:15
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67

Page8

Asterixis: Ask the patient to extend both arms,

and then to dorsiflex the wrists.
Interpretation : An abnormal test results in the
episodic loss of this posture, with the wrists
briefly straightening and then resuming the
dorsiflexed posture. (This is often referred to
colloquially as flapping, and the patient is
(informally) said to have a flap.) An abnormal
result indicates encephalopathy, and is most
commonly associated with hepatic
encephalopathy.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video 29:12
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67

----Kernigs Sign : With the patient supine, flex the patients knee and hip. Then, extend the knee.
Interpretation : Pain or resistance to extension of the knee is a positive test, and indicates
inflammation of the meninges such as might be seen in meningitis or subarachnoid hemorrhage.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video 29:42
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67

-----

Page9

Brudzinski Sign : With the patient supine, passively flex the patients neck forward until the chin
touches the chest.
Interpretation : Pain or resistance to the motion constitutes a positive test. There may also been
flexion of the patients hips and knee with flexion of the neck.
U

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video 29:42
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67
-----

Babinski Reflex (aka Plantar Response) : The patient may either sit or lie supine. Use the handle
end of your reflex hammer (the one that is comes to a point) or a similar metallic object such as a key.
Start at the lateral aspect of the foot, near the heel. Apply steady pressure with the end of the
hammer as you move up towards the ball (area of the metatarsal heads) of the foot. When you reach
the ball of the foot, move medially, stroking across this area.
Interpretation : In a normal response, the initial movement of the great toe should be downwards (i.e.,
plantar flexion.) In an abnormal test, the great toe will dorsiflex and the remainder of the other toes
will fan out, and an abnormal test indicates upper motor neuron dysfunction (usually in the pyramidal
tract).
N.B. Sometimes you will be unable to generate any response, even in the absence of disease.
Responses must therefore be interpreted in the context of the rest of the exam. Withdrawal of the
entire foot (due to unpleasant stimulation), is not interpreted as a positive response.

Additional Videos / Neuromuscular Evaluation Videos / Neurologic Exam Demonstration Video 18:53
http://mediasite.lmunet.edu/Mediasite/Play/b62d4fc549544ab5af2e119368319a0d1d?catalog=b731f064-988e-42ce-995204964c178f67

Page10

Page11