Neurological Exam

Examination Technique:

• use a 128 hertz vibration fork
• apply the stimulus over the distal phalanx of the index finger or large toe.
• ask the patient to report whether they feel vibration sense and then to report when it stops in order to assess the minimal threshold to perceive the stimulus.
• compare to your own extremities.

Examination Technique:

• demonstrate to the patient initially with eyes open that you will be moving their digit up (towards their head) or down (towards their feet).
• ask the patient to close their eyes.
• stabilize the distal interphalangeal joint of the upper extremity and make minimal movements upwards or downwards and ask the patient to report after each movement the direction of movement.
• similarly in the lower extremities, stabilize the interphalangeal joint and move the large toe up or down.

Pain – Examination Technique:

• use a disposable pin.
• ask the patient to close their eyes and report whether they feel sharp or dull.
• be sure to apply the sharp stimulus to all sites since if only the dull stimulus is applied, pain sensation has not been assessed.

Temperature – Examination Technique:

• use a cold vibration fork.
• if necessary, the fork can be cooled by running it under cold water.
• ask the patient if they perceive the vibration fork as cold.

Examination Technique:

• use a cotton wisp.
• apply a gentle touch (do not drag the stimulus).
• ask the patient to close their eyes and report “yes” every time they perceive the stimulus.

Components of the sensory examination:

1. Light touch
2. Pain and temperature
3. Vibration sense
4. Position sense
5. 2 point discrimination
6. Graphesthesia
7. Stereognosis
8. Double simultaneous stimuli (extinction)

Examination Technique:

• patients should be sufficiently undressed but draped to preserve modesty.
• begin distally and move proximally and avoid calloused areas.
  compare right to left.
• when necessary assess for a sensory level, peripheral nerve or dermatomal sensory impairment.

Extinction (Double simultaneous stimuli)

Examination Technique:

1. Tactile (sensory)

• with eyes open demonstrate to the patient that you will touch them on the left side, the right side or both.
• this should only be done if the patient can perceive a unilateral stimulus (i.e. if there is loss of pain and temperature or light touch on one side, there would be no point assessing extinction).
• have the patient close their eyes and as you deliver a gentle touch, report whether they feel it on the left side, right side or both sides.

2. Visual extinction

• wiggle a finger in the left, right or both visual fields and ask the patient to report where they see it.

3. Auditory extinction

• snap your fingers on the left, right or both sides and have the patient report where they hear the stimulus.
• when testing for extinction, it is important to deliver bilateral stimuli simultaneously with no time lag in between.

Examination Technique:

• explain to the patient that you will be placing an item in their hand which they should then manipulate and identify with their eyes closed.
• stimuli include different coins, a key, a safety pin, a paper clip, a coin, etc.

Examination Technique:

• explain to the patient that you will be drawing a number in the palm of their hand.
• explain to the patient what is up and down, the distal side is usually up as this is a typical orientation of the palm.
• demonstrate with eyes open.
• ask the patient to close their eyes.
• with a blunt item such as your fingertip draw a number across the palm and ask the patient to identify it.

Two Point Discrimination

Examination Technique:

• use either calipers or a opened paper clip with two parallel ends.
• demonstrate to the patient with eyes open by applying either one or two points of the stimulus to the fingerpad.
• ask the patient to close their eyes.
• deliver the stimulus and ask the patient to report whether they feel one or two points.

Normal Response:

• normal values over the fingerpads are 2-4 mm.