Neurological examination is the assessment of mental status, cranial nerves, motor and sensory function, coordination, and gait for the diagnosis of neurological conditions. Findings should always be compared with the contralateral side and upper limb function should be compared to lower limb function to determine the location of a lesion. Subtle central nervous system defects can be detected with careful observation of patients performing tasks that require the simultaneous activation of multiple cerebral areas. This article provides information about several examination methods and explains key terms relevant to the evaluation of neurological conditions.
Mental status examination
- The mental status examination is a key component of any neurological examination and involves assessing the following points, based on patient history and clinical observation:
- A more focused mental status examination is performed in the workup of specific neurological disorders and symptoms.
- In emergency settings, the mental status examination focuses on the assessment of orientation and level of consciousness using standardized scales (e.g., ).
- See “” for a comprehensive discussion of examination elements and possible findings.
Types of aphasia
- Aphasia is the inability to either form or understand language not attributed to the motor ability to produce speech. It is caused by damage to different areas of the dominant hemisphere (usually left).
|Types of aphasia|
|Location of lesion||Type||Clinical features|
|Broca aphasia (motor aphasia, expressive aphasia)|| || |
|Wernicke aphasia (sensory aphasia, receptive aphasia)|| |
|Global aphasia|| |
|Conduction aphasia (associative aphasia)|| || |
|Anomic aphasia|| || || |
|Transcortical aphasia||Transcortical motor aphasia|| |
|Transcortical sensory aphasia|| || |
|Transcortical mixed aphasia|| || |
The cranial nerve examination is used to identify problems with the cranial nerves by physical examination. For information on disorders of the cranial nerves, see “ .” The assessment includes the following components:
|Overview of cranial nerve examination |
|Cranial nerve||What is examined?||How is the test performed?|
| || |
|, ,||III, IV, VI|
| || |
| || |
|V|| || |
| || |
|VII|| || |
|and||IX, X|| || |
The motor system examination allows to quantify the degree of motor function impairment and often to differentiate between central and peripheral lesions. The fundamental elements of the examination include muscle appearance, muscle strength (power), tone, and reflexes.
|Upper motor neuron (UMN) injury vs. lower motor neuron (LMN) injury|
|UMN lesion||LMN lesion|
| || |
- Assessment: inspection and palpation of muscle groups
Abnormal muscle movements
- Tremor: rhythmic, involuntary movements of one or more parts of the body either during rest or motor activity (resting vs. intention tremors)
- Motor stereotypies: rhythmic, repetitive movements; commonly seen in
- Grossly disorganized behavior: inadequate goal-directed activity (e.g., purposeless movements) and emotional responses that seem bizarre to others (e.g., smiling or laughing at inappropriate times)
Dyskinesia: involuntary muscle movements, such as jerking, twitching, or tics, which impair voluntary movement.
- Tics: sudden and rapid involuntary, intermittent, nonrhythmic movements or vocalizations without any recognizable purpose
- Chorea: involuntary, sudden, irregular, nonrepetitive, arrhythmic movements of the limbs and/or head
- Athetosis: involuntary, “snake-like,” writhing movements particularly of the hands and fingers
- Ballismus: involuntary, proximal, violent, and large-amplitude (wild flailing) movements of one or both extremities (e.g., kicking, flinging); typically unilateral (hemiballismus).
- Catatonia: abnormal behavior and movement, often including catalepsy, purposeless motor activity, strange postures, negativism, and mutism
- Catalepsy: a state of muscular rigidity and immobility characterized by unresponsiveness to external stimuli
- Bradykinesia: decreased speed of voluntary and involuntary movements
- Akathisia: restlessness; the constant urge to move
- Involuntary, asynchronous contraction of muscle fascicles within a single motor unit
- Usually benign but can signify a lower motor neuron lesion, which results in spontaneous action potentials and/or compensatory increase in the concentration of nicotinic acetylcholine receptors on the cell membrane located at the neuromuscular junction
- Abnormal posture
- Atrophy or hypertrophy (examined bilaterally)
- Abnormal muscle movements
- Definition: maximal effort a patient is able to exert from an individual muscle or group of muscles
- The patient is asked to flex and extend the extremities against resistance.
- Muscle power tests should be performed bilaterally for comparison.
Muscle power grading
- 0: no contraction (paresis)
- 1: flicker or trace of contraction
- 2: active movement, with gravity eliminated
- 3: active movement against gravity
- 4: active movement against gravity and moderate resistance
- 5: normal power (i.e., full range of motion against gravity and full resistance)
Patterns of paresis distribution
- Quadriparesis: weakness in all four limbs
- Hemiparesis: weakness in half of the body
- Paraparesis: weakness affecting both lower extremities
- Monoparesis: paresis affecting a single limb
Pronator drift test
- The patient is asked to raise both arms horizontally up to shoulder level, palms facing upwards, with the eyes closed (for 30 seconds).
- Lowering or pronation of one arm is indicative of paresis.
- Mingazzini test
- Pronator drift test
|Routinely assessed muscles|
|Deltoid||C5–C6 (axillary nerve)||Abduction of upper arm to horizontal level|
|Biceps brachii||C5–C7 (musculocutaneous nerve)||Flexion of the forehand at elbow|
|Triceps brachii||C6–C8 (radial nerve)||Extension of the forehand at elbow|
|Flexor carpi ulnaris||C8–Th1 (muscular branches of the ulnar nerve)||Palmar flexion of the hand at wrist|
|Extensor carpi radialis||C5–C8 (radial nerve)||Dorsiflexion of the hand at wrist|
|Abductor pollicus brevis||C8–Th1 (median nerve)||Thumb abduction|
|Interossei||C8–Th1 (deep branch of the ulnar nerve)||Finger abduction|
|Iliopsoas||L1–L3 (femoral nerve)||Flexion of the leg at hip|
|Quadriceps femoris||L2–L4 (femoral nerve)||Extension of the leg at knee|
|Hamstrings||L5–S2 (sciatic nerve)||Flexion of the leg at knee|
|Tibialis anterior||L4–L5 (deep peroneal nerve)||Foot dorsiflexion|
|Gastrocnemius||S1–S2 (tibial nerve)||Foot plantar flexion|
Deep tendon reflexes (DTR)
- Definition: a reflex to test the integrity of a sensory and motor neuron circuit
- An increased DTR indicates an upper motor neuron issue, whereas decreased DTR indicates an LMN, neuromuscular junction, or muscle issue.
- Elderly patients may have reduced or absent lower DTR due to normal aging-related changes in muscles and tendons
- Reinforcing maneuvers (e.g., Jendrassik maneuver) can be used to elicit a reflex that initially seems to be absent.
|Deep tendon reflex testing|
|Nerve root||Tendon reflex||Test|
|Upper limbs||C5–C6||Biceps reflex||First, the examiner places his/her thumb on the patient's biceps tendon, then the examiner strikes his/her thumb with a reflex hammer and observes the patient's forearm movement.|
|Brachioradialis reflex||Striking the lower end of the radius with a reflex hammer elicits movement of the forearm.|
|Triceps reflex||The examiner holds the patient's arm (forearm hanging loosely at 90° position) and taps the triceps tendon with a reflex hammer to induce an extension in the elbow joint.|
|Lower limbs||L2–L4||Adductor reflex||Tapping the tendon on the medial epicondyle of femur elicits the adductor reflex.|
|Knee reflex||Striking the tendon just below the patella (leg is slightly bent) induces knee extension.|
|L5||Posterior tibial reflex||The tibialis posterior muscle is tapped with a reflex hammer, either just above or below the medial malleolus. The reflex is positive when an inversion of the foot occurs.|
|S1–S2||Ankle reflex||Striking the Achilles tendon with a reflex hammer elicits a jerking of the foot towards its plantar surface. Alternatively, the reflex is triggered by tapping the ball of a foot from the plantar side.|
|Deep tendon reflex scale |
|2+|| || |
|3+|| || |
|4+|| || |
Use the following poem to remember which nerve roots correspond to which reflexes:
Buckle my shoe (ankle reflex)
Kick the door (knee reflex)
Pick up sticks (biceps reflex and brachioradialis reflex)
Lay them straight (triceps reflex)
- Definition: polysynaptic reflexes elicited by stimulation of the skin
Interpretation: superficial reflexes are considered
- Physiological, when there is a contraction of a group of muscles after the stimulation
- Pathological, when there is reduced or no contraction as a consequence of lower motor neuron and/or the reflex arc
|Superficial reflex testing|
|T6–T12|| || |
Definition: a type of reflex that is normal in newborns and infants, but not in adults
- When present in adults, they may indicate diffuse brain injury due to a lack of common inhibiting factors.
- See “.”
- Corticospinal tract signs
|Overview of most important corticospinal tract signs|
|Upper limb signs|
|Finger flexor reflex||Tromner sign|
|Hoffmann sign|| |
|Lower limb signs|
|Babinski sign|| |
|Gordon sign|| |
|Schaeffer sign|| |
- Definition: resistance of an individual muscle (or a group of muscles) to passive stretching
Assessment: passive movement of the extremities
- Upper limb
- Lower limb: The patient is asked to relax the limbs while lying in the supine position. The examiner then rolls the legs from side to side.
- Spasticity: characteristic of pyramidal tract lesions
Rigidity: suggests abnormalities of the extrapyramidal system
- Lead pipe rigidity: an increase in tone that is constant throughout the passive movement
- Extreme stiffness of the joint of the limb that makes movement difficult
- When the examiner flexes or extends the limb, the movement is jerky, resembling the ratcheted rotation of a cogwheel
Paratonia: a change in tone that is uneven throughout the passive movement due to involuntary opposition or facilitation by a patient
- Occurs in patients with frontal lobe dysfunction (e.g., due to trauma, stroke, tumor, neurodegenerative disorders such as frontotemporal dementia)
- The degree of paratonia increases with the speed of passive movement, the amount of applied force, and with attempts to relax the patient.
- Oppositional paratonia: an apparent increase in tone due to the patient's involuntary resistance to movement
- Facilitatory paratonia: an apparent decrease in tone due to the patient's involuntary assistance to movement
Clonus: a series of involuntary, rhythmic muscular contractions
- Patellar clonus: The examiner grasps the patient's patella between the index finger and the thumb, quickly pushes it down distally, and then holds it in this position.
- Foot clonus
- Wrist clonus: The examiner hyperextends the patient's wrist.
Modified Ashworth scale: a scale that is most commonly used for assessment of the muscle tone 
- 0: no increase in muscle tone
- 1: slight increase in muscle tone, with minimal resistance at the end of the range of passive motion
- 1+: slight increase in muscle tone followed by abrupt resistance (catch) that continues through the remainder (less than half) of the movement
- 2: a marked increase in muscle tone throughout most of the range of motion, but passive movement is easy
- 3: considerable increase in muscle tone, with passive movement difficult
- 4: affected parts rigid in flexion or extension
Do not confuse clonus with myoclonus. Myoclonus is arrhythmical and defined by sudden jerks of a muscle or group of muscles, while clonus is rather rhythmic and defined by repetitive contractions and relaxations of a muscle group. Moreover, myoclonus is usually associated with metabolic abnormalities (e.g., renal and liver failure).
Examination of the sensory system is aimed at evaluating any abnormality affecting the patient's perception to provoked sensations like touch, pain, and temperature. In contrast to motor function, sensation is subjective to the patient and therefore the interpretation of the exam strongly depends on the patient accurately reporting what they experience.
For more information about the patterns of sensory loss in spinal cord lesions, see “Overview” in “.”
|Focused examination of sensation |
|Light touch|| || |
|Pallesthesia (vibration sense)|| |
|Proprioception (joint position)|
|Pain and temperature|| || |
During the examination of coordination, the patient's ability to correctly perform point-to-point and rapidly alternating movements is evaluated. This component of the neurological exam is particularly important in patients with suspected diseases of (or affecting) the cerebellum.
- Definition: the ability to coordinate fluid movements
- Finger-to-nose test: The patient is asked to touch the tip of their nose with the index finger.
- Heel-knee-shin test: The patient is asked to slide the heel of one foot down the shin of the opposite leg.
- Rapid alternating movement test: The patient is asked to rapidly screw in an imaginary light bulb simultaneously with both hands.
- Findings: See “Clinical features” in “.”
Multiple systems are required for proper walking, such as those responsible for sensory and motor functions (including reflexes), as well as the cerebellum and the vestibular system. During the examination of the patient's gait, particular attention should be paid to body and limb posture (e.g., base of support and arm swing), steps (length, speed, and rhythm), steadiness, and turning.
|Examination of gait |
|Observation of casual gait|| || || |
|Heel to toe walking|| || |
|Foot drop test|| || || |
|Walking on tiptoes|| || |
|Romberg test|| || |
|Unterberger test|| || || |
|Trendelenburg sign|| || |
|Abnormal gait patterns |
|Ataxic gait|| |
|Gait apraxia|| || |
|Choreiform gait|| |
|Sensory ataxic gait|
- Definition: the triad of
- Etiology: : due to inflammatory (bacterial/viral meningitis; ) or noninflammatory (e.g., subarachnoid hemorrhage) causes
Signs of nerve root irritation
∼Signs of nerve root irritation indicate an inflammatory and/or irritative process occurring at the point where the spinal nerves exit the vertebral column. Testing for signs of nerve root irritation can help determine suspected spinal root compression (e.g., by a tumor or herniated disk).
- L5–S1): In a supine patient, lifting the extended leg (< 45°) induces pain along the distribution of the lumbar roots (i.e., back pain radiating down the ipsilateral leg). (root
- Crossed straight leg raise test: In a supine patient, lifting the extended leg (< 45°) induces pain in the contralateral leg with radiation into the motor/sensory area of the affected nerve root.
- See “Diagnostics” in “.”
- Etiology: conditions that can lead to compression of the nerve roots (e.g., degenerative disk disease, spinal tumor, spinal epidural hematoma)
- Definition: an involuntary, repetitive, and twitching movement of one or both eyes
Classification: There are several types of nystagmus. The most commonly seen ones are listed below. 
- Jerk nystagmus: a slow movement of the eyes towards a defined direction followed by a fast, corrective movement backward (the name of the nystagmus is determined by the direction of movement in the fast phase, i.e., left-beating, right-beating, downbeat, upbeat)
- A type of jerk nystagmus in which the eyes move horizontally
- Movement in the fast phase is either to the left or the right (left-beating, right-beating).
- A type of jerk nystagmus in which the eyes move vertically
- Movement in the fast phase is either upwards or downwards (upbeat nystagmus, downbeat nystagmus)
- Torsional nystagmus: a type of jerk nystagmus with rotary oscillations of the eye along its anteroposterior axis (clockwise, counterclockwise )
- Mixed nystagmus
- A type of nystagmus defined by sinusoidal oscillating movements of one or both eyes
- Often related to
- Always considered pathological
Etiology: Nystagmus can be physiological or pathological.
- Physiological nystagmus
- Pathological nystagmus can either be congenital (e.g., sensory deficiency, oculomotor abnormality) or acquired (i.e., lesions of the cerebellum, brainstem, and/or ).
|Overview of pathological nystagmus |
Spontaneous nystagmus (without external provocation)
|Gaze-evoked nystagmus |
- Clinical features 
Diagnostics: caloric testing 
- A test to differentiate between peripheral and central nystagmus by infusing warm (∼44°C) or cold (∼30°C) water into the external ear canal
- Water infusion physiologically triggers horizontal nystagmus.
The nystagmus always directs towards the more activated vestibular sensory organ.
COWS: Cold: Opposite side; Warm: Same side (rule for the direction of nystagmus).