Neurological Exam

Accessory Nerve

Nerve Function: Controls trapezius and sternocleidomastoid (SCM) muscles.

Inspection: Inspect the shoulders for asymmetry and atrophy

Trapezius Power: Ask the patient to shrug their shoulders against resistance

SCM Power: Ask the patient to turn their head to either side against resistance. Observe and palpate the SCM muscles.

Vibration Sense

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.

512Hz Tuning Fork

Position Sense

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 and Temperature

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.


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.

Discrimination – Graphesthesia

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.

Discrimination – 2 Point

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.