THE NEUROLOGICAL EXAMINATION

Evan D. Murray, MD. And Bruce H. Price, MD

KEY POINTS

Cognitive impairment, behavioral changes, and psychiatric symptoms occur

frequently in association with neurological conditions

A well-performed mental status and neurological examination are essential for
the identification of medical and neurological condition that impact cognition,

behavior, and mood

The objective of the neurological examination is to verify the integrity of the
central and peripheral nervous systems and to achieve neuroanatomical
localization of signs and symptoms. Localization is a crucial step for the

generation of a rational differential diagnosis

The neurological examination can be conceived of as being conducted along of
continuum of complexity that build on information acquired during its
performance. It is fluidly adapted during its performance with components

added, as needed, to clarify findings.

The interpretation of findings requires careful and effective integration with

knowledge of neuroanatomy and the clinical history.

A well-organized and rehearsed examination promotes consistency and
comprehensiveness of technique while reducing omissions of elements of the
examination

OVERVIEW
Proficiency in performing a neurological examination is advantageous to the
psychiatrist. All behavior and perception occurs as a result of neural activity. Neural
activity arises from brain circuitry that is developmentally sculpted through the
interaction of environmental factors with human genetic potential. 1 Neural circuitry is
susceptible to malfunction and damage in a host of ways; this results in many
recognizable patterns of cognitive and behavioral impairments. The neurological
examination is of tremendous utility for identifying these patterns and thereby
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allowing for recognition of neurological processes that may be treated. Neurological

conditions are frequently co-morbid with psychiatric symptoms. Such symptoms may
stem from the stress of illness, be a direct function of brain pathology, or result from a
combination of the two. Psychiatric symptoms and behavioral changes may precede
other key physical manifestations of the disorder or occur at any time during the
disease course.2 An effective and reliable neurological examination may afford
opportunities for earlier detection of treatable conditions, anticipation of psychiatric
manifestation, and avoidance of adverse events (e.g., neuroleptic sensitivity of
patients with Lewy body dementia) in person who are at particular risk.
By the late nineteenth century the elementary neurological examination was
refined with objective, consistent, and reproducible findings. 3 The practice of
examination is considered most effective when the clinician has formed a hypothesis
that is based on observation and history and is prepared to fluidly adapt both the
examination and the hypothesis as new information and finding appear. A wellrehearsed examination prevents omissions and ensures consistency of technique. A
well-reasoned examination with an array of alternative techniques that verify findings
ensures greater accuracy and confidence in those findings. The complexity of
planning, performing, and interpreting the neurological examination is a challenge
that persists throughout the entirely of a physicians career.
The neurological examination is performed routinely for most psychiatric
admissions but is uncommonly performed in outpatient psychiatric settings. In some
circumstances,a careful history alone may establish a neurological diagnosis;
however, this is often not the case. The examination is helpful for corroborating the
history, establishing the severity of a condition, and directing treatment. The overall
assessment approach should use a reproducible methodology for obtaining and
interpreting the history, performing the examination, and analyzing both. A
comprehensive neurological examination is unnecessary in every patient. The
clinician must learn to focus or expand the examination as needed. A good
examination can be instrumental in discerning primary psychiatric illness from
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secondary symptoms that occur in association with a multitude of neurological

conditions (such as stroke, Alzheimers disease, Huntingtons disease, Parkinsons
disease, and demyelinating disease). (See box 73-1 for a summary of major
neurological findings and associated conditions that frequently manifest by
psychiatric symptoms). Malingering and conversion disorder need to be distinguished
from deficits that localize to specific neuroanatomy.4 Medication side effects, such as
parkinsonism and dystonia, need to be identified, treated, and followed clinically.
General principles include:

Assess for side-to-side symmetry during the neurological examination. One side
of the body serves as a control

for the other. Determine if there is focal

asymmetry.
Determine if dysfunction originates from the central nervous system (CNS),

peripheral nervous systwm (PNS), or both.

Consider if the finding (or findings) can be explained by a single lesion or

whether a multi-focal process is required.

Establish the lesions location. If the process involves the CNS, clarify if it
cortical, subcortical, or multi-focal. If subcortical, clarify if it is in the white

matter, basal ganglia, brainstem, cerebellum, or spinal cord.

If the process involves PNS, determine if it localizes to the nerve root, plexus,
peripheral nerve, neuromuscular junction, muscle, skin, or if it is multi-focal.
Some of this localization, particularly to the PNS, will exceed the expertise of

most psychiatrists. These principles are presented as tools to organize thinking.

There is no clear consensus among experts as to the order of performing and
presenting the neurological examination. However, there is little dispute about the
mental status portion being performed first followed by examination of the cranial
nerves. Thereafter, there are variations in the sequence, selected components of the
examination, methods of performance, terminology used to describe findings, and the
interpretationof various finding. Clinicians should decide on a sequence, practice and
become proficient at it, and then use it consistently. This improves performance and
speed, provides a database of variations in responses, and reduces the likehood of
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forgetting to perform aspects of the examination. A common approach and

examination sequence will be offered along with some options for expanding the
examination and validating findings with use of other maneuvers (Boxes 73-2, 73-3,
and 73-4).
BOX 73-1

Neurological Abnormalities That Suggest Diseases Associated with

Psychiatric Symptoms
EXAMINATION ABNORMALITIES ND THEIR POSSIBLE UNDERLYING
ETIOLOGY
Vital sign

Marked hypertension (hypertensive encephalopathy, serotonin syndrome,

neuroleptic malignant syndrome, pre-eclampsia)

Tachypnea (delirium caused by systemic infection)
Hypoventilation (hypoxia, alcohol withdrawal, sedative intoxication)

Cranial nerve

Hyposmia, anosmia or odor misidentification (traumatic brain injury,

Alzheimers and Parkinsons disease)

Visual field deficit (stroke, mass, multiple sclerosis, systemic lupus
erythematosus)

Pupils

Argyll Robertson (neurosyphilis)

Unilateral dilatation (brain herniation, porphyria)
Horners syndrome (stroke, carotid disease, demyelinating disease)

Ophtalmoplegia

Vertical gaze palsy (progressive supranuclear palsy)

Mixed (Wernicke-Korsakoff syndrome, chronic basilar meningitis)

Cornea

Kayser-Fletscher rings (Wilsons disease)

Lens

Cataracts (chronic steroids, Downs syndrome)

Fundi
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Papilledema (intracranial mass lesion, multiple sclerosis)

Optic pallor (multiple sclerosis, porphyria, Tay-Sachs disease)

Extrapyramidal (Parkinsons disease, Lewy body disease, Huntingtons disease,

stroke, Wilsons disease, numerous others)
Cerebellar (alcohol, hereditary degenerative ataxias, paraneoplastic, use of phenytoin)
Motor neuron (amyotrophic lateral sclerosis, frontotemporal dementia with motor
neuron disease)
Peripheral nerve (adrenoyeloneuropathy, metachromatic leukodystrophy, vitamin B12
deficiency, porphyria)
Gait

Apraxia (normal pressure hydrocephalus, frontal dementias)

Spasticity (stroke, multiple sclerosis)
Bradykinesia (multi-infarct dementia, Parkinsons disease,

progressive

supranuclear palsy, Lewy body disease)

BOX 73-2 Components of Elemental Neurological Examination
CRANIAL NERVES
Olfaction
Vision II

Visual fields (VF)

Acuity
Optic disks/vessels (performed after VF and acuity)

Pupillary reflexes II, III

Eye movements III, IV, VI
Facial sensation/jaw strength V
Facial movement VII
Hearing VIII
Palate IX, X
Speech/disarthria IX, X, XII
Head rotation XI
Shoulder shrug XI
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Tongue movement XII

MOTOR
Involuntary movements/adventitious movements
Muscle bulk
Tone
Strength
Hand drift/pronation/posturing
SENSATION
Light touch
Joint position sense
Vibration
Pinprick (pain)/temperature (pick one of these)
Romberg
COORDINATION
Finger to nose/follow the target
Fine motor movements
Rapid alternating movements
Heel to shin
GAIT
Station
Spontaneous ambulation
Toe/heel/tandem
Postural reflexes
REFLEXES
Deep tendon reflexes
Cutaneous reflexes
Plantar responses
Atavistic or primitive reflexes
THE EXAMINATION
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Patient well-being and examiner safety are important concerns from the
outset. To safeguard these, assessment of the patients receptiveness to evaluation,
ability to cooperate, cultural sensitivities, and mental state should be accomplished at
the earliest time. If one anticipates that the evaluation will agitate the patient or that
conditions are deemed unsafe, then the evaluation should be discontinued or delayed
until such a time when condition are more favorable. The patient should be
forewarned about elements of the examination that might produce discomfort. In
some cases the patient may have a heightened sensitivity to an examiner of the same
or opposite gender. In such circumstances, a chaperone can provide useful
reassurance during the interview and examination. Vital sign should be reviewed to
assess for factors that may contribute to behavioral changes, such as very elevated
blood pressure, fever, and hypoxia. Changes in blood pressure, pulse, and respirations
may occur in a variety of contexts, such as with agitation, psychosis, alcohol
withdrawal, complex partial seizures, and medical conditions, to name only a few.
The examination begins when entering a patients room or encountering the patient in
the hallway. Initial observations are made wherever the patient is found, be it walking
down the hall to meet you or lying in bed. Whether the patient is aware of being
observed can be important since behavior may change when out of the physicians
view.
Text book have been dedicated to various aspects of cognitive assessment.
This section will introduce the fundamental aspects of the cognitive examination;
some helpful anatomical and neuropsychiatric consideration will also be presented.

BOX 73-3 Elements of the Psychiatric Mental Status Examination

General appearance
Behavior
Attitude
Mood
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Affect
Speech (rate, volume, prosody)
Thought process
Thought content

Suicidal ideation/homicidal ideation

Obsessions
Delusions: paranoia, idea of reference, thought broadcasting

Perception

Auditory, visual, olfactory, and tactile hallucinations; illusions

Insight
Can be discerned often from perception of circumstance judgement

BOX 73-4 Elements of the Neurological Mental Status Examination

Arousal
Orientation
Attention/concentration
Memory

Registration
Short-term memory at 3-5 minutes
Long-term memory
Recent: current events
Remote: past and current events; may require family corroboration

Language

Fluency
Naming
Language repetition
Reading
Writing
Comprehension of written and spoken language

Calculation
Knowledge of current events
Visual-spatial/constructional
Abstraction
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Stereognosis/graphesthesia/double simultaneous stimulation

Neglect
Praxis (can often be discerned during the examination)
The Psychiatric Portion of the Mental Status Examination
The separation of the mental status examination into psychiatric portions and
neurological portions represents a historical difference in emphasis rather than
purpose; this distinction will be continued for the purpose of clarity. (See box 73-3 for
a summary of the components of the psychiatric portion of the mental status
examination).
Initial Observation of the Patient
General Appearance. Observations start with determination as to whether the patient
appears morphologically normal. Consider stature, hair-line, level of ears, distance
between eyes, presence of philtrum, length of neck, and body characteristics (such as
gynecomastia, obesity, and digit length). These may be indicative of a genetic
syndrome or a genetic disorder. Mention of these caharacteristics is intended as a
reminder rather than a comprehensive review of this topic.
Behavioral Appearance. Hygiene, body odor, posture, demeanor, cooperativeness,
motivation, spontaneity, eye contact, speed of movement, the manner of dress, social
graces, and attitude toward the examiner should be noted. A patient may be anxious,
inattentive, engaged, cooperative, apathetic, disinhibited, angry, hostile, or extremely
courteous.
Speech. Manifestations of speech include speed, fluency, volume, and prosody. A
person with a history of 4 days of speaking very quickly and being hard to interrupt in
conversation may be manic or be under the influence of drugs. Prosody describes the
melodic patterns of intonation in language that convey shades of meaning.
Impairment may be in production prosody, or in the comprehension of another
persons prosody. Testing prosody is uncommonly done. If clinically indicated,
appreciation of prosody can be tested by situating oneself behind the patient and
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saying a short sentence, such as Im going home now with dour different emotional
tone (e.g., happy, sad, angry, neutral). Being positioned behind the patient prevents
the patient from interpreting the expression of your face. One should ask the patient
to identify the emotional state of each of your theatrical renditions. Prosody
production may be tested by asking the patient to repeat the same sentence in each of
the emotional states previously listed. Listening for the patients spontaneous prosody
is also essential.
Mood and Affect. Mood is the patients report of his or her emotional state. Affect is
te outward expression of the patients mood to the world. Descriptions of the affect
include the terms flat, constricted, elevated, sad, expansive, and labile.
A patient with a stooped posture, slow speech, and flat affect could be
manifesting signs of depression. If his stated mood is sad or depressed, his mood
and affect are congruent. Some neurological conditions may be associated with a
disassociation of mood and affect. A condition now known as involuntary emotional
expression disorder (IEED),5 previously named pseudobulbar affect or palsy, is
characterized by episodes of involuntary or exaggerated emotional expression. This
result from brain disorders affecting structure of a neural network involving the
frontal lobe, limbic system, brainstem, cerebellum, or the inter-connecting white
matter tracts. Extremes of emotional expression (from crying to, less often, laughing)
occur without the patient actually feeling these emotion or without the patient feeling
the concordant degree of the emotion expressed. IEED can occur in association with a
number of neurological conditions including dementia (including Alzheimers
disease, vascular dementia, and frontotemporal dementia), amyotrophic lateral
sclerosis (ALS), multiple sclerosis, stroke, and traumatic brain injury (TBI).
Thought Process. Normal thought, as demonstrated in casual conversation and most
other circumstances, is goal-directed; it does not require great effort to follow the
logical progression of ideas. Some common descriptive terms include linear thinking,
loose association, circumstantial thought, tangential ideas, flight of ideas,
disorganized thinking, incoherent thought, and perseverative thinking.
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Thought Content. This can be derived from what the patient tells you, from what
you can infer from the patients history, and from your observations of personal
interactions. A patient may be extremely guarded and careful about when, and if, to
reveal his or her true beliefs. Terms that commonly refer to thought content include
preoccupations, ruminations, obsessions, paranoia, delusions, idea of reference, and
suicidal or homicidal ideation. There can also be a poverty of content.
Terms such as paranoia, thought blocking, and ideas of reference may be
interpreted as involving perceptions, thought process, or content.6
Perceptions. Hallucinations may be auditory, visual, tactile, gustatory, or olfactory.
They may be simple (as in a flash of light) or complex (as in seeing panoramic scenes
or feeling a kiss). The content of hallucinations and their relationship to mood are
important to identify. Psychiatric disorders more often than not have mood-congruent
hallucinations. Insight regarding the hallucination is an important characteristic that
may aid in the differential diagnosis. For example, some person with Lewy body
dementia or an infarct to the midbrain peduncle (leading to peduncular hallucinosis)
and most every person with Cahrles Bonnet syndrome will realize that their visual
hallucinations are nor real. Illusions, or perceptual distoions, may also occur.
Insight/Awareness/Concern. The level of insight is commonly derived from the
patients description of his or her circumstances and relates to how the patients
problems evolved and how they are understood. The patients comportment (behavior
and self-conduct) is an indicator of insight.
Judgement. Determination of jugdement is usually derived from aspects of the
history. The patients interaction with family, friends, and health care professional can
be used to assess social appropriateness, social graces, and comportment.
Disinhibition or poor judgement may be ascertained through observation or elements
of the history.
The Neurological Portion of the Cognitive Mental Status Examination

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The following sequence affords the opportunity to evaluate cognition in a hierarchy

of increasing complexity. Subsequent performance on complex tasks requires that
more basic aspects of cognition are intact. (See Box 73-4 for more complete summary
of the components of the nuerological mental status examination).
Level of Consciousness
Consciousness is most commonly viewed as being a function of the level or arousal.
The lowest level of consciousness has many descriptive terms, some of which imply a
pathological state, such as coma. A patient might appear to be comatose yet actually
be in non-convulsive status epilepticus.7 An awareness of the nuances of descriptive
terms will help avoid confusion in most circumstances. One common method is to
describe arousability with respect to pain, loud noise, voice, and command. The
relative case or difficulty of arousability wih these stimuli is also noted.
Attention
After determination of the level of consciousness, the ability to sustain attention and
the speed of task completion should be assessed. The perceived level of effort should
be documented when performance is reduced. Common tasks used to assess attention
and processing speed include the following:
Performance of Serial 7s. Ask the patient to subtract 7 from 100. Then ask the
patient to continue subtracting 7 (and to state the results); have the patient stop when
he or she reaches 65. Serial 3s from 100 or counting backwards from 20 by is may
also be used. The patient should be able to maintain attention on task after starting
without having the instructions repeated. This test must be interpreted in the context
of the patients background, education, and mathematical ability.
Spelling Tests. Have the patient spell the word world, march, chair, or radio
forward, backward, and then alphabetized. Forward-spelling is a test of simple
attention. Backward-spelling requires concentration and verbal working memory.
This testing presumes some degree of spelling ability.
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Other Tests. Have the patient state the days of the week (or months) forward then
backward. Digit span also tests attention. It is a test during which a patient is
presented with successively longer strings of random digits starting at two or three
digits and with each rendition increasing the string by one digit until the patient
reaches a string between five and seven digits. Performance, to some degree, depends
on age; however, there is little decay in this ability with normal aging. This test may
also be performed backwards. Normal performance is seven digits forward and five
digits backwards. However, recalling six digits forward and four digits backwards is
probably acceptable. It is considered normal to have a difference of two between
forward and backward testing.8
Language
Language is a term that can refer to a variety of types of thought expression that can
include facial expressions, sign language, and symbolic communication, as well as
written and spoken language. During a screening examination, concerns should focus
on the assessment of spoken and written language. The intent is to determine whether
the patient has difficulties producing language, comprehending language, or both.
The examiners answers to the following questions provide a basic screen.
Does the patients speech sound like language? Is the speech fluent or nonfluent? Fluency has been described as speech that is flowing rapidly and effortlessly.
Non-fluent speech is uttered in single words or short phrases with frequent pauses and
hesitations. Fluency can usually be appreciated during conversation with the patient.
The examiner should observe the patients use of grammatical structure. Fluency can
be independent of content and comprehensibility. Testing the ability to name visually
presented objects screens for aphasia. A key, stapler, coin, pencil or pen, watch,
clothing, and furniture are commonly used.
Comprehension. Comprehension is often easily assessed while taking the history and
performing the physical examination. When there is difficulty, one can request that
the patient perform a one-to three-step command. If the patient appears impaired, the
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examiner should start with simple questions that can be answered in a yes/no fashion.
Asking a patient to point at objects or to show his or her thumb or another body part
are alternatives. Bear in mind that more complex commands will require intact
attention and comprehension of grammar and language. Having the patient read an
instruction aloud and perform it is a brief screen of reading comprehension. Examples
include point to the window and close your eyes.
Repetition. Asking the patient to repeat no ifs, ands, or buts is a common phrase
used to test repetition. If greater sensitivity is desired, the examiner can use sentences
that are progressively longer, that use words of greater sophistication, that have a
lower frequency of use, or that have more complex structures.9
Memory
Memory is associated with a collection of systems with specific neuroanatomical
structures and functions. These systems support the neural processing of information
in such a way as to have it available for use at a later time, with or without conscious
awareness. Conceptually, memory can be divided into declarative and non-declarative
systems. Declarative or explicit memory is memory for events that can be
consciouosly recalled. Non-declarative or implicit memory is memory that is
expressed as change in behavior; it is often unconscious. Three types of declarative
memory are commonly tested at the bedside: episodic, semantic, and working
memory. Episodic memory refers to the memory system used to recall personal
experiences (such as what you had for dinner last night or the experience of a recent
walk in the park). Semantic memory systems are used to recall conceptual and factual
knowledge that is not related to any specific memory of a personal experience. For
example, what number of items constitutes a dozen? The working memory system
refers to the ability to maintain and to manipulate information (such as retaining a
phone number in your mind while searching for a pen and paper to write it down).
This system is particularly dependent on attention, concentration, and short-term
memory. Components of the working memory system have traditionally been referred
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to as the verbal, visuospatial, and executive (allocates attentional resources)

systems.10
Memory system testing at the bedside is generally viewed as having three
components. A commonly used classification divides it into immediate, short-term,
and long-term recall.11 Each of these types of recall will involve variable
contributions from semantic and episodic memory systems depending on the
individual patients memory skills, natural associations with other semantic and
episodic memories, and emotional valences of the particular memory items selected.
Semantic and episodic memories are declarative and explicit.
Immediate Recall. This is the type of memory that is used when retaining a phone
number in your mind until you can write it down. This require intact attention to
register the memory items. In the office or at the bedside it is common to choose at
least three items from different categories and to have the patient repeat them after
you have said them. Repetition confirms immediate registration. Then have the
patient repeat the items until all of them have been registered. Then record the
number of repetitions necessary before all the memory items were repeated correctly.
This reflects the ability to focus attention. If an increased complexity of memory
testing is desired, items of more abstract nature should be selected (such as charity,
honesty, or loyalty). More sensitive assessment may use a greater number of
recall items, incorporate compound nouns, or use combinations of adjectives and
nouns (e.g., red bicycle). Other portion of the mental status examination can be
performed after the memory items have been registered, thus serving as a distracter
before formal short-term memory recall is tested. Distraction ensures that information
is encoded in a more normal fashion and then recalled rather than allowing the patient
to repeat the memory items over and over, possibly allowing some degree of
compensation for faulty memory systems.
Short-term Memory. Short-term memory requires the storage or encoding of
information followed by the recall of information after 3 to 20 minutes. The examiner
should ask the patient to recall the three (or more) memory items previously given.
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One should provide categorical cueing followed by multiple-choice option to aid

recall if needed. An inability to recall any items, even after being provided with
multiple-choice option, may be suggestive of a primary attentional problem or
memory encoding impairment. When memory items can only be recalled with cueing
or multiple-choice options, this may be suggestive of a memory retrieval problem.
Long-term Memory. This type memory can be considered to include both recent and
remote memory. Asking details about the patients early life is helpful, but it requires
the presence of a family member or friend to verify the information. Questions about
salient historical events are often used to background, culture, education, and home of
origin. What happened on September 11th, 2001? and How did John F. Kennedy
die? are common test questions.
Visuospatial/Constructional Skills
These skills sre tasted at the bedside, most commonly with clock drawing. The
examiner should ask the patient to draw a circle and then fill in the numbers to make
it look like the face of a clock. Then one should ask the patient to set the hands to a
time requiring the use of both left and right visual fields; examples include 11:10 and
10 minutes to 2. Abnormalities may include the crowding together of number within
the circle or having the numbers, hands or all of these on one side of the page,
neglecting to put any detail on the other side. A common syndrome is that of the right
parietal stroke, which may be associated with a left hemispatial neglect 12 that causes
crowding of detail to the right side of the clock drawing. Attentional or executive
dysfunction may cause difficulty planning the clock; the patient may write numbers
in unusual locations, write the time on the clock (rather than setting the hands), or use
strange hand construction or placement (Figure 73-1). Other commonly used tests
include asking the patient to copy drawings provided by the examiner (such as a
Greek cross, intersecting pentagons, or a three-dimensional cube). Simple
handwriting may also be an indicator of visuospatial function.

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Figure 73-1. Examples of clocks. (A) Left hemispatial neglect. (B) Executive
dysfunction. (C) Executive dysfunction. Note the absence of attention to detail on the
left and the crowding of detail to the right in example A. Example B demonstrates
poor planning and an inability to set the time properly to 10 minutes after 11.
Example C demonstrates perseveration and difficulty conceptualizing a clock face
and setting the time

Describing the Result

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The patients actual responses should be documented as clearly as possible in the

medical record. Terms that are interpretive or diagnostic should be avoided.
More in-depth assessment of cognition can include tests of cortical sensory
modalities, abstraction, praxis, and executive function.
Cortical Sensory or Secondary Sensory Modalities. Higher-level processing of
sensory information occurs primarily in the parietal lobes. 13 This testing requires the
relative preservation of primary cutaneous and proprioceptive sensory functions.
Intact language function is particularly required for testing of stereognosis and
graphesthesia.
Stereognosis is the recognition and interpretation of tactile sensory
information. Astereognosis is the inability to recognize object by touch. This can be
tested by placing common objects (such as coins, keys, paper clips, or closed safety
pins) in the patients hands and asking the patient to close his or her eyes and name
the objects. Characteristics (such as size and shape) can be described by patient.
Often, people can identify the denomination of coins.
Graphesthesia is the ability to recognize letters or numbers written on the skin
of palm or finger pad using a sufficiently pointed object, without ink.
Double Simultaneous Stimulation. This maneuver tests for somatosensory
extinction, neglect, or inattention when two simultaneous tactile stimuli are provided
to opposite sides of the body. Extinction occurs when one side is not perceived. Other
types of double simultaneous extinction tests involve the visual and auditory systems.
Patients can be exposed to simultaneous visual stimuli in the left and right visual
fields or to simultaneous auditory stimuli on both sides of the body (potentially
revealing hemispatial neglect, inattention, or extinction). The patient may perceive
tactile, visual, or auditory information on the side or region of the body that
demonstrates extinction when the stimulus is presented as a single stimulus without
competition.
Abstraction. Asking the patient to identify three similarities between an apple and an
orange can test abstraction. It is important that the patient identify the category (i.e.,
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fruit). Other questions about similarities include the following: How are a bicycle
and an airplane alike? How are a sculpture and poem alike? Additional testing can
include proverb interpretation.14 One can ask the patient what a particular proverb
means. Examples include the following: People who live in glass houses shouldnt
throw stones, A shallow stream makes the most noise, The tongue is the enemy
of the throat, and Dogs bark, and the caravan moves on can be useful for the
assessment of the patients range of abilities to generate novel interpretations. They
may afford an opportunity to catch a glimpse of the psychodynamics of the
individual, and allow subtle psychotic features to manifest in the substance of the
patients interpretation.15 Performance, again, must be interpreted in the context of the
patients culture and education.
Praxis (Greek for Action). Apraxia is the acquired inability to perform a complex
or skilled motor act in the absence of impairments of arousal, attention, language,
comprehension, motivation, or sensorimotor function. More commonly described
varieties include limb kinetic, buccofacial, ideomotor, and ideational apraxia. Limb
kinetic apraxia is the loss of ability to make precise, coordinated fine motor
movements. It has been argued that this category should not exist because its deficits
are related to mild weakness secondary to a lesion in the motor pathways. 16 In
buccofacial apraxia, patients are unable to perform (on request) complex acts
involving the lips, mouth, and face (e.g., whistling, blowing out a match, sticking out
the tongue, or coughing). Persons with ideomotor apraxia are unable to perform (on
command) complex motor acts with one or all extremities. The patient may be unable
to demonstrate on-command activities (such as saluting, waving goodbye, blowing a
kiss, or pantomiming the brushing of teeth, combing of hair, hammering of a nail, or
the use of scissors). Patients may incorrectly use their body parts as tools. Some of
these patients are able to spontaneously perform these acts. The inability to perform
an ideational plan consisting of a sequence of acts is referred to as an ideational
apraxia.17-19

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Executive Function. Executive function tasks are strongly dependent on intact

frontal-subcortical circuits. Impaired performance on tasks that require attention and
concentration occur in many patients with executive dysfunction. If attention and
visuospatial skills are intact, clock-drawing20 and shape-copying assess executive
functions (such as planning, organization, and execution of a task). 21 Shapes that are
commonly copied include those of a cube or of intersecting pentagons. Executive
function deficits may include the inability to formulate goals or carry them out,
deficits in abstraction and insight, impaired judgement, the inability to retrieve stored
information from memory, and motor perseveration or impersistence.
Persons with executive dysfunction may have difficulty changing from one
action to the next when asked to performed a repeated sequence of actions. For
example, when asked to continue drawing a pattern of alternating triangles and
squares, they may perseverate on one shape and keep drawing triangles. The Luria
alternating hand sequencing task, in which the patient is asked to tap the table with a
fist, open palm, and side of open hand and then to repeat the sequence as quickly as
possible, is also useful to test for perseveration. This task is demonstrated to the
patient before they are asked to perform it. The auditory Go-No-Go test assesses the
ability to maintain a rule for performing a task and suppress inappropriate behaviors.
In one version of this task the patient is asked to move a finger in response to one
tapping sound (provided by the examiner), but must keep still in response to two
tapping sounds.
Principles of Interpretation of the Mental Status Examination
The sequence of the neurological examination proceeds from elementary observations
about the level of consciousness to a more in depth assessment of specific abilities.
Higher cognitive functions require prerequisite abilities that sometimes involve
several domains. Each domains performance must be interpreted in the context of
function in other domains. For example, if an individual is found to be distractible, to
be unable to spell world backward, and to make two errors on serial 7s, but has
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intact language, a more likely interpretation is an attention problem rather than a

specific deficit in either calculation or language. If all other portions of the cognitive
examination are intact yet the patient makes numerous errors on serial 7s and basic
calculations, this may have significance for localization. The relationship between a
patients cognitive function, test performance, and real-life function are often
complex. Test performance is rarely pathognomonic. Factors that may confound test
interpretation include confusion or delirium, medication side effects, anxiety, sleep
deprivation, alterations in mood or motivication, psychosis, low intellectual function,
aphasia, and dyslexia. Interpretation must take into account the patients age, gender,
education, cultural background, and life accomplishments. In the event that the results
of mental status testing are unclear, confounding, or insufficient to delineate the
extent of the cognitive difficulty, adjunctive formal neuropsychological testing can be
indispensable. Input from friends and family members may provide invaluable
corroboration of history and day-to-day functioning.
CRANIAL NERVES
Olfaction (Cranial Nerve [CN] I)
This is an important sensory modality because olfactory symptoms in psychiatric and
neurological patients are frequent. Unfortunately, psychiatrists rarely perform this
portion of the examination and neurologists uncommonly complete it. The olfactory
bulbs and tracts run along the inferior surface of the frontal lobes and project to
limbic areas, as well as to regions important for memory.22 Head trauma may be
associated with loss of smell23; disinhibition may result from orbital frontal injury.24
Tumors in the mid-line frontal region, known to cause apathy or abulia, may cause
loss of smell. When testing is necessary, non-irritating stimuli should be used.
Alcohol and ammonia may stimulate the trigeminal nerve, and the response to this
stimulation may be confused with olfaction. One should bear in mind that the patient
may not be able to name unfamiliar or less commonly encountered scents (such as
clove or nutmeg); therefore, coffee, peppermint, wintergreen, or vanilla should be
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used. Each nostril should be tested individually. Abnormalities may include

hyposmia, anosmia or misidentification of a smell.25-27

Optic Nerve (CN II)

Ocular processes (such as cataract, old hemorrhages, and macular degeneration)
should be cautiously taken into account when interpreting eye findings. Funduscopy
should be performed after portions of the examination that require vision.
Visual Acuity (CN II)
Visual acuity should be checked in each eye separately; customarily, the right eye is
tested first. The most common method is to ensure that the patient is wearing
whatever corrective lenses are normally worn and then to place a visual acuity card
14 inches in front of each eye while the other eye is covered (Figure 73-2). The
examiner should ensure that good lighting is present in the room. Poor visual acuity
can play a role in visual illusions and in hallucinations.28

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Figure 73-2. Rosenbaum visual acuity card with pupil gauge. (Copyright 2004-2007
Armstrong Optical Service Co. All rights reserved)

Visual Fields (CN II)

Visual fields are tested in the clinic and at the bedside using a confrontation method.
The examiner (you) should have the patient cover their left eye while situating
yourself directly in front of the patient with your face 2 to 3 feet from the patients
face (Figure 73-3). The objective is to match your visual field to the patients. each
quadrant should be tested by moving an object or by wiggling a finger into the
patientt visual field from periphery at a distance that is mild-way between you and
the patient. Then the other eye should be tested. Another method is to have the patient
count the number of fingers held up in each quadrant. The visual system spans from
eye to occiput. The characteristics of visual field abnormalities can be very useful for
localizing lesions (Figure 73-4).

Figure 73-3. Confrontation visual field testing

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Figure 73-4. Anatomy of visual system. Visual field defects associated with different
anatomical lesions
Pupillary Responses (CNs II and III)
The pupils should be examined in a darkened room. The examiner should shine a
penlight from below so as to illuminate both eyes just enough to compare papillary
size simultaneously. Next, the light should be shone to directly illuminate the right
pupil and watch for constriction. After 1 to 2 seconds, the light should be moved to
the left eye and the pupils observed for symmetry and size. Both pupils should
constrict symmetrically, with a light shone in either eye. This is termed the
consensual response. After 1 to 2 seconds, the light should be swung back to the other
eye. The pupils should remain roughly symmetric in size while swinging the light
from side to side. Dilation of a pupil to direct light during the swinging flashlight test
is abnormal. Absence of reactivity, slow reactivity, or large pupil asymmetrics are
abnormal. Pupil size in both light and darkness should be documented. Papillary
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abnormalities may be seen in diseases that affect the sympathetic nervous system and
in those that affect components of the visual system from the pupil, retina, optic
nerve, to the brainstem. The convergence response does not involve the specific use
of light (except to visualize both pupils for response). The patient should be asked to
visually track your finger as you move it from a distance toward the patient in the
mid-line. This will normally cause the eyes to converge and the pupils to constrict
symmetrically.
Funduscopy (CN II) and the Retina
The eye is the only location in the body in which a nerve and blood vessels can be
directly visualized. Optic disk swelling (papilledema) may indicate increases
intracranial pressure,29 optic disk atrophy may be present in demyelinating disease, 30
and optic disk and retinal abnormalities both may occur in vascular disease.31
Ocular Movements (CNs III, IV, and VI)
These three cranial nerves control eye movements and lid elevation. Any spontaneous
eye movements in primary resting forward gaze should be observed. The range of
conjugate gaze (tested by holding your finger about 2 feet away) should be assessed
next. The finger should be moved slowly to allow for assessment of voluntary smooth
pursuits in the up, down, oblique, left, and right directions (Figure 73-5). Patients
with Parkinsons disease manifest jerky smooth pursuits.32,33 The examiner should
ask the patient to hold his or her head still. At the limit of conjugate gaze in each
direction the examiner should hold gaze for several seconds and then observe for
nystagmus. When present, this is referred to as gaze-evoked nystagmus. Barbiturates,
tranquilizers, ethanol, and anticonvulsants commonly cause gaze-evoked nystagmus
in both directions of gaze.34 Normal saccades are involuntary, fast, conjugate changes
of eye position between fixations. Saccades are tested by having the patient fixate on
your nose and then look quickly toward your finger and then back your nose. Your
finger should be held in the up, down, left, and then right positions. The accuracy and
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speed of saccades should be assessed. The patient should be assessed for

overshooting (hypermetric saccades) back to target. Hypermetric saccades may occur
in conditions with cerebellar involvement (such as the cerebellar presentation of
multi-system atrophy). The patient should also be assessed for undershooting
(hypometric saccades), requiring several saccades to reach the target. Patient with
Parkinsons disease may manifest hypometric saccades.35 Slowed saccades or
saccades smooth pursuits can be present in Wilsons disease. 36 Slowed vertical
saccades often mark progressive supranuclear palsy.37 Slowed and hypometric
saccades may be associated with Huntingtons disease, 38 and anticonvulsant toxicity.39
These are just a few examples of neurological conditions with associated eye
movement abnormalities. Ptosis of the eyelids should also be noted.

Figure 73-5. Diagram of two options for testing eye movement range
Trigeminal Nerve (CN V)
The trigeminal nerve provides sensory innervations to the face, cornea, and much of
the mouth and tongue (Figure 73-6). Its motor component innervates the muscles of
mastication. Unless the patient has a specific sensory complaint, it is sufficient to use
light touch (tested with finger or gauze) or temperature (tested with a cold metal
tuning fork) and ask the patient if it feels the same or similar on both sides. Testing of
the corneal reflex is not routinely necessary.

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Figure 73-6. Trigeminal nerve sensory distribution. V1, V2, and V3 sensory
distributions in blue, yellow, and red, respectively.
Muscles of Mastication
Brief observation of the jaw at rest and with movement is adequate in a patient
without complaints. Having the patient move his or her chin from side to side, then
open his or her mouth widely, helps assess the function of these muscles. Further
testing can involve opening and closing the jaw against resistance.
Facial Nerve (CN VII)
The facial nerve provides motor innervations to the muscles of facial expression and
taste to the anterior two-thirds of the tongue. The facial nerves other motor and
sensory components would uncommonly be tested. The examiner should ask the
patient to raise the eyebrows, to wrinkle the forehead, to squeeze the eyes shut, and to
smile (or show the teeth). One should also look for symmetry of facial markings
(such as the nasolabial fold), at rest and with movement. Further testing can be
involve testing the strength of facial muscles by overcoming them (by trying to open
the closed eyes or to pull the closed lips apart manually). Subtle facial asymmetries
are common and not necessary pathological. It is helpful to have a family member or
an old photo (e.g., a drivers license) to verify the long-standing nature of a subtle
asymmetry. Dysarthria can result from weakness of the orbicularis oris. Labial sounds
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can be tested by asking the patient to say pa.papa. The speed and clarity of
speech should also be assessed. A central pattern of facial weakness is characterized
by weakness in lower face, with sparing of the forehead. This is due to the bilateral
corticobulbar innervation of the portion of the facial nucleus subserving the forehead.
A peripheral pattern of weakness is characterized by hemifacial weakness without
forehead sparing. This can be caused by disruption of the facial nerve or nucleus
(Figure 73-7). Taste is uncommonly tested unless there are specific indications.

Figure 73-7. Depiction of (A) central facial weakness and (B) peripheral facial
weakness
Vestibulocochlear Nerve (CN VIII)
Lesions of this nerve can be associated with vertigo, hearing loss, or both. One should
ensure that the external ear canal is not occluded with cerumen. Holding your fingers
several inches away from the patients ears and rubbing the fingers together softly
allows for a quick, but usually adequate, assessment. Alternatively, you can ask the
patient to repeat a word or numbers that you whisper into the ear while occluding the
other ear. More in-depth testing can include the Rinne test, which involves the use of
a vibrating tuning fork (128 to 512 Hz) applied to the mastoid bone until it can no
longer be heard. It is then placed next to the ear. This comparison determines whether
hearing is better with air or bone conduction. Conduction hearing loss is characterized
by hearing the sound better with tuning fork applied to the mastoid than next to the
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ear. In sensorineural hearing loss, the sound is better perceived next to the ear than via
mastoid bone. The Weber test uses a tuning fork placed in the mid-line at the vertex
or forehead to determine on which side the sound is heard best. Sound referred to an
ear with decreased acuity indicates conductive hearing loss.40 Sound referred to the
opposite (unaffected) ear occurs with sensorineural hearing loss. These tests are crude
compared to audiologic testing. Hearing loss can be exacerbate auditory
hallucinations and paranoia.41
Glossopharyngeal and Vagus Nerves (CNs IX and X)
These nerves will be discussed together because of their intimately related functions.
CNs IX and X serve the motor and sensory functions of the palate and vocal cords.
Speech (CNs IX and X)
Speech may be hoarse, with vocal cord weakness. An inability to swallow secretions
can lead to drooling. (See CN VII)
Palate (CNs IX and X)
This is assessed by asking the patient to say aaah and watching for the degree of
palate elevation and symmetry. Palatal speech dysfunction can be assessed by
evaluating the clarity and speed of palatal sounds such as gagaga. Labial,
lingual, and palatal sounds can be tested together by having the patient repeat pa
taka.
Inspection of the oral cavity is sufficient in an asymptomatic individual. The
gag reflex is uncommonly tested in the screening neurological examination. When
there is reasonable suspicion that swallowing is impaired, when the palate is weak, or
when there are voice changes, the gag reflex should be checked. Symmetry of the
response on each side should be noted.

Spinal Accessory Nerve (CN XI)

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This nerve innervates the trapezius and the sternocleidomastoid (SCM) muscles. The
trapezius can be assessed with a shoulder shrug against resistance. The SCM is
evaluated with head rotation against resistance. The head should be fully rotated in
the direction of testing, and then resistance should be applied. The right SCM turns
the head to the left and the left SCM turns the head to the right. SCM muscles bulk
should be inspected with the head facing forward. Asymmetry of muscle bulk can
often be seen in cases of torticollis.
Hypoglossal Nerve (CN XII)
The hypoglossal nerve is involved in speech production as is CNs VII, IX, and X. The
hypoglossal nerve provides motor innervations to the tongue. Gross inspection of the
tongue may reveal atrophy or fasciculations in the setting of a peripheral nerve lesion.
A lisp may be clinically apparent during conversation. The examiner should ask the
patient to protrude his or her tongue in the mid-line and to look for deviation to one
side. Lingual speech dysfunction can be evaluated by assessing the speed and clarity
of lingual sounds, such as lalala. Parkinsonian, familial, medication-induced,
and thyrotoxic tremors may be apparent in the tongue. 42,43 Degenerative diseases and
neuropleptic medications can induce dyskinesias of the tongue and the oromandibular
region.44
MOTOR EXAMINATION
Muscle Bulk
The muscles should be inspected for atrophy, hypertrophy, and fasciculations.
Atrophy is an important sign of lower motor neuron disease. It is not seen
prominently in weakness of CNS origin except in association with non-use.
Hypertrophy can be normal when seen as a feature of dystonia or selected muscular
dystrophies.

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Tone
Muscle tone is the residual tension present in a voluntarily relaxed muscle. This is
clinically assessed by determining the degree of resistance present to passive
movement of a limb or the head. Relaxation can be difficult for many patient, and
distraction, such as engaging the patient in conversation or asking the patient to
perform a simple activity with a contralateral limb (such as opening and closing the
hand held up in the air) may be necessary. It is important to know about a variety of
different tone abnormalities. Lead-pipe rigidity is characterized by a consistent and
relatively stable degree of increased tone throughout the range of movement of a
limb; it is not affected by velocity of movement. Cogwheel rigidity is a rhythmic
increase in tone, similar to a tremor, throughout the range of movement. Spasticity is
a type of hypertonicity that increase with an increase in the velocity of movement.
Slow movement may reveal little abnormal tone and fast movements may result in a
sudden increase in tone. Gegenhalten is a paratonia that manifests as an increase in
resistance from the patient in proportion to the effort of the examiner. It is often
reduced by distraction. Mitgehen is another type of paratonia that is characterized by
the patient who actively assists the examiner throughout the range of motion. Both
types of paratonia are thought to suggest diffuse bilateral frontal lobe disease or
diffuse cerebral disease.45
Strength
It is beyond the scope of a screening examination in the outpatient or inpatient
psychiatric setting to perform a comprehensive neuromuscular evaluation. Practical
assessment of strength in an asymptomatic patient should assess the deltoid, biceps,
triceps, and brachioradialis muscles, as well as grip strength and gait assessment. The
patient should be able to rise independently from a sitting position without using his
or her arms. A normal casual gait, toe, and heel walk in most circumstances rules out
a significant motor deficit. Strength is most commonly graded using the Medical
Research Councils five-level scale (Table 73-1).46
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TABLE 73-1
0

Medical Research Council Scale of Muscle Strength Table

No contraction

A flicker or trace of contraction

Active movement with gravity eliminated

Active movement against gravity

4-

Active movement against gravity and slight resistance

Active movement against gravity and moderate resistance

4+

Active movement against gravity and strong resistance

Normal power

Abnormal Movements
Abnormal voluntary or involuntary movements may occur during the history and
physical examination and should be described. The psychiatrist should be familiar
with the following terms :

Tremor is usually an involuntary, rhythmic oscillation produced by rhythmic

contractions of agonist and antagonist muscles. Tremors may be present with
movement, sustained postures or at rest. Tremors may affect the voice, tongue,
face, head, limbs, and trunk. The frequency and amplitude of tremors are

important features.
Myoclonus is characterized by involuntary, non-rhythmic, brief, sometimes
repetitive muscle contractions that are irregular in frequency and amplitude.
They are often asynchronus and asymmetric. They may be symmetric in spinal

myoclonus. They may be cortical, subcortical, or spinal in origin.

Clonus is characterized by involuntary, rhythmic contations and relaxations of a

muscle or group of muscles.

Chorea is manifest by involuntary, non-rhythmic, jerky, rapid movements of

muscle groups.
Asterixis is also known as liver flap or negative myoclonus. This movement is
characterized by an abrupt loss of voluntary muscle tone. It is commonly elicited
by asking the patient to hold his or her arms outstretched with the wrists
extended. When asterixis is present, the hands, with or without the arms, may

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suddenly drop downward and then quickly recover, which causes an irregular

and slow flapping motion.

Athetosis is manifest by involuntary, slow, irregular, sinuous, snake-like

writhing movements.
Dystonia is an involuntary movement or sustained posture that result from
abnormal tonicity of muscle. Movements may be characterized as having
prolonged or repetitive muscle contractions that may result in twisting or jerking

movements of the body or body part.

Tics are defined in several ways. They are characterized by simple or complex
coordinated movements or vocalizations that are repetitive, stereotyped,
compulsive, and often abrupt, and over which the patient feels he or she has little
or no control. Tics are experienced as almost irresistible impulses to perform a

particular activity. Some tics can be suppressed.

Fasciculations are brief, irregular twitches of a muscles. They may be localized
to a muscle or limb or be diffuse, depending on the etiology. Fasciculations occur
as a benign phenomenon, as well as manifestation of various neuropathies (e.g.,
amyotrophic lateral sclerosis [ALS] or diabetic peripheral neuropathy),
radiculopathies, and thyrotoxicosis, and they can be occur in association with
anticholinesterase use.

SENSORY EXAMINATION
Sensory function is divided into primary and secondary modalities. The primary
sensor modalities commonly tested include touch, proprioception, vibration, pain, and
temperature. Secondary sensory modalities are a synthesis and interpretation of
primary modality information that occurs in the parietal sensory and association
cortices. Testing of secondary sensory modalities is discussed in he neurological
portion of the mental status examination.
Testing for two-point discrimination is not indicated in an asymptomatic
patient. Testing of light touch and either pain (sharp) or temperate sensation is usually

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sufficient. Having the patient close his or her eyes can increase the sensitivity of the
examination and is required for proprioceptive testing.
Light touch can be tested by touching the patient lightly with your finger or a
piece cotton.
Proprioception can be tested by using the finger and thumb of one hand, and
stabilizing the distal interphalangeal joint of a digit slightly up or down, the patient is
asked to identify the direction of movement. Romberg testing is also useful for
position-sense testing. One should ask the patient to stand with both feet together as
closely as possible to maintain balance with the eyes open. Then one should ask the
patient to close their eyes. If the patient loses his or her balance with the eyes closed
(but not when the eyes are open), he or she is Romberg positive. If swaying occurs
without loss of stance, this should be described in your note.
Vibration can be tested using a 128-Hz tuning fork on a distal bony
prominence or distal interphalangeal joint. One should assess when use the same
anatomical region on your self for comparison.
Pain can be tested with the use of disposable sterile pins. Temperature can be
tested using a cold metal tuning fork. You may run it under cold or warm water to
ensure a clear temperature change from your pocket or from room termperature.

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Figure 73-8. Sensory nerve distributions and dermatomes (From Gilroy J. Basic
Neurology, ed 2, New York, 1990, Pergamon Press, p.41)
COORDINATION TESTING
Coordination testing is the preffered term, rather than cerebellar testing. The specific
abilities involved in coordination testing require intergration and processing of
information from diverse system that include visual, sensory, motor, basal ganglia,
cortical association, and cerebellar systems.
Finger-to-nose can be assessed by positioning yourself directly in front of the
patient and asking them to touch the tip of your index finger with the tip of their
index finger and then touch the tip of their nose with the same finger. One can have
the patient continue alternating this maneuver, ensuring that the patients arm is
extended, so as to reach for your finger. Then you should move your target finger
from the patients right side to a stationary position in front and then to a position on
the left. This should be repeated with the patients other hand. One should look for
accuracy of movement, speed, and tremor. An alternative maneuver is to have the
patient follow your finger as a target with their same finger (of either hand) without
actually touching your finger. This should be performed within a plane equidistant
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from both of you while seated facing each other. Your finger should be moved around
in space from left to right and up and down to various stationary positions, while the
patient attempts to closely mirror your movements, dynamically following your
movements to various stationary positions without touching you or drifting off target.
This is a more sensitive assessment of the precision of movement.
Heel to Shin
This maneuver is optimally performed with the patient in the supine position. One
should ask the patient to smoothly run their heel up and down the opposite shin along
a line from below the knee to the ankle. The patient should be urged to be as accurate
with the movements as possible. One should look for precision, range of motion,
speed, and presence of tremor. The maneuver is then repeated on the other side.
Gait Testing
Walking is a complex form of motor coordination that requires the integrated function
and synthesis of input from various systems. Some of these systems include the
sensory, motor, cerebellar, basal ganglia, and vestibular systems. Gait can be affected
through dysfunction in any of these components, with many characteristic
manifestations. Sensory deficits may result in a wide-based stance. Basal ganglia
disorders may cause slowing of gait, reduced stride length, and festination. Gait
assessment should be part of every neurological examination.
Casual stance and gait should be inspected. Posture, gait legs, arm swing, and
turning capabilities should be observed. Toe and heel-walking will test strength and
balance. Tandem walking is useful to detect mid-line instability that is commonly
seen as a result of chronic alcohol use. Postural reflexes may be assessed by asking
the patient to stand with his or her feet together and eyes closed (as in the Romberg
maneuver). The patient should be reassured that you will be testing the patients
balance by pushing them a bit in various directions, but you will not allow the patient
to fall. (Take care to ensure that the patient does not fall). At the patients shoulder
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level you can variably and sequentially give the patient a nudge forward, backward,
to one side, and then to the other side. Retropulsion is commonly seen in patients
with parkinsonian symptoms.
REFLEX ASSESSMENT
Deep Tendon Reflexes
Deep tendon reflexes (DTRs) are also commonly called muscle stretch or
proprioceptive reflexes. These reflexes are elicited by tapping the muscles tendon or
sometimes by tapping a portion of the muscle itself. Muscle stretch receptors are
activated and sensory information is transmitted to the spinal cord within which is
simple, monosynaptic reflex arc is generated by synapsing directly on an alpha motor
neuron (causing a muscle contraction). The descending corticospinal tracts modulate
this system. The activity of a DTR is judged by the latency, speed, amplitude,
duration, and spread of a response. Abnormalities in DTRs can yield useful
information about the integrity of the central and peripheral nervous system portions
of the reflex. Commonly tested muscle stretch reflexes include the biceps, triceps,
brachioradialis quadriceps (patellar), and gastrocnemius (Achilles or ankle jerk) 48
(Table 73-2). DTRs, under normal circumstances, do not change significantly with
aging.
Grading of reflexes is on a 4-point scale with 2+ usually considered to be
normal (Table 73-3). It should be noted that what is normal for one person may be
hypoactive or brisk when compared to another individual. There is a wide range of
normal responses. Symmetry of reflexes, absence of interval changes, and absence of
pathological reflexes are more important. Reflex gradients (for example, a diminished
ankle reflex compared to the more proximal patella reflex) and clonus should also be
assessed. In some individuals the DTRs may be diminished or apparently absent.
Under such circumstances, reinforcement techniques (such as the Jendrassik
maneuver)49 are often helpful to facilitate the reflex slightly.50 This is a maneuver

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during which the reflexes his or her fingers and hooks them together (palms facing
each other), and attempts to pull the hands apart.
Cutaneous or Superficial Reflexes
Stroking or scratching the skin elicits these reflexes. One should use care, because a
painful stimulus may cause a guarding or defensive response rather than a reflex.
Examples of this reflex include the plantar reflex, abdominal reflexes, the cremasteric
reflex, and anal wink.
Plantar Reflex
This reflex is the most important of the cutaneous reflexes for the psychiatrist to
incorporate into the examination. It is useful for detecting corticospinal tract
dysfunction. It is tested by stroking the bottom of the foot from the heel forward with
only so such firmness as needed to elicit a consistent response. The normal response
is plantar flexion of the foot and toes after the first 12 to 18 months of life. Disease of
the corticospinal system may be associated with extension of the toes that has been
described as up-going. The up-going great toe with fanning of the other four toes is
referred to as the Babinski sign. This may also be referred to as the extensor plantar
response. Some authorities recommend stroking the lateral aspect of the plantar
surface rather than the medial one, so as to avoid a plantar grasp response. Patients
who are very ticklish may voluntarily withdrawal from the stimulus and demonstrate
flexion of the hip and knee (usually with plantar flexion of the foot and toes). A
triple-flexion response is a spinal reflex characterized by hip and knee flexion
accompanied by ankle dorsiflexion (Figure 73-9).

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Figure 73-9. (A) Plantar reflex. (B) Babinski sign. (C) Plantar stimulus
Primitive Reflexes or Atavistic Reflexes (Mistakenly Called Frontal Release
Signs)
These reflexes are present at birth and disappear in most people in early infancy.
There is a large portion of the normal population in which a single primitive reflex
persists. This is less concerning when it is a single reflex (such as a snout, glabellar,
or palmomental reflex). A grasp or suck reflex is considered more worrisome.
Asymmetry or multiple primitive reflexes are considered abnormal. Primitive reflexes
are not believed to be useful for localization purposes. 51,52 If they reappear in later life
they may be suggestive of diffuse cerebral, subcortical, or bilateral frontal lobe
pathology.53-55
The snout reflex can be assessed by gently tapping over the patients upper lip.
If this reflex is present, a puckering of the lips will be seen. The snout reflex is
present in 30% to 50% of healthy adults over age 60 (Figure 73-10).
A suck reflex may also be elicited and is considered a more worrisome reflex.
When present, the suck reflex is elicited by stimulation of the lips; this is following
by sucking movements of the lips, tongue, and jaw.
The palmomental reflex is an ipsilateral contraction of the mentalis and
orbicularis oris after stimulation of the thenar region of the hand. This reflex is
present in 20% to 25% of healthy adults in their thirties and forties. The glabellar
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reflex is assessed by tapping the patients glabellar ridge between the eyes with your
finger. It is best to stand to the side of or behind a seated patient so as to not cause a
visual threat response. The patient should be asked not to blink. The reflex is present
if there is persistence of blinking with gentle tapping.
The grasp reflex is elicited after first instructing the patient not to hold on to
the examiners hand, followed by stroking the palm between the thumb and forefinger
of the patients hand. This is but one version of several as to how this maneuver is
accomplished. The reflex is present if the patients fingers flex or the hand closes.

Figure 73-10. (A) Snout. (B) Snout reflex

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