Clinical Examination of Nervous System - PPT

Clinical Examination of Nervous System - PPT -- By Prof. Dr. R. R. Deshpande
• This PPT explains how to perform Central Nervous System Examination systematically & step by step .This includes (1) Examination for higher functions (2) Examination of cranial nerves (3) Examination of sensory system (4) Examination of motor system (5) Examination of reflexes (6) Examination of gait (7) Examination of spine and cranium (8) Examination for special signs (such as cerebellar signs)
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1. CNS Examination Practical
•Presented By – 
Prof.Dr.R.R.Deshpande 
(M.D in Ayurvdic 
Medicine & M.D. in 
Ayurvedic Physiology)
•www.ayurvedicfriend.c
om
•Mobile – 922 68 10 630
•professordeshpande@g
mail.com
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2. Clinical Examination of
Central Nervous System
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3. Centers in Brain
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4. Examination of Nervous System
•(1) Examination for higher functions
•(2) Examination of cranial nerves
•(3) Examination of sensory system
•(4) Examination of motor system
•(5) Examination of reflexes
•(6) Examination of gait
•(7) Examination of spine and cranium
•(8) Examination for special signs (such as 
cerebellar signs)
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5. Examination of Higher Functions
•(1) Level of consciousness.
•(2) Orientation of time, place and person
•(3) Intelligence
•(4) Memory
•(5) Speech
•Note :- Special tests are required for 
psychiatric patients.
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6. Asking questions for orientation of
Time,Place & Person
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7. Cranial Nerves
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8. Cranial Nerves
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9. Examination of Cranial Nerves
•(1) First cranial nerve - Olfactory nerve –
•This can be tested by asking patient to smell a 
known substance with each nostril like 
camphor ,Eucalyptus
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10. Testing of Olfactory Nerve
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11. 2
nd
Cranial Nerve – Optic Nerve
•This nerve is examined ,under following 
headings
•(A) Acuity of Vision
•(B) Field of Vision
•(C) Colour Vision
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12. Examination of Optic Nerve –
Snellen’s chart
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13. Acuity of vision
•Tested by asking the patient to read "Snellen's
chart" from a distance of 6 m. 
•Suppose, person reads only 2nd line, on which 
distance mentioned is 36 m, then we express his far 
vision as 6/36 (Normal far vision should be 6/6)
•In above case - it is understood that what a normal 
person can read from 36 m, our patient is reading 
from 6 m and so, patient is suffering from Myopia.
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14. Near Vision Testing
•(ii) Near Vision - is tested with the help of 
Jeger's chart .This chart is to be read from a 
distance of 25 cm, which is our near point. 
Each eye should be tested separately and then 
binocular vision.
•Normally the person should read smallest 
print on Jeger's chart.
•This indicates near vision of patient is normal. 
He is not suffering from Hypermetropia.
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15. Examination of Optic Nerve –
Near vision – Jeger’s Chart
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16. Colour Vision
•Tested with 'Ishihara chart’
•This chart is to be tested by each eye 
separately  and the person is asked to 
recognize the figure which are printed in
different colours in the chart.
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17. Examination of Optic Nerve –
Colour vision – Ishihara Chart
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18. Field of vision – Confrontation
Test
•This is done with the help of Perimeter.
•Principle used in this test is that the field of vision of
doctor's right eye is same as field of vision of left
eye of patient . patient sits at a distance of 1 m. Then 
eyeball movements are tested
•- Patient is instructed not to move his neck but 
patient has to move only eyeballs, as doctor is 
moving his finger. (We test the movements, such as - 
abduction, adduction, elevation, depression, internal 
rotation and external  rotation)
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19. Examination of Optic Nerve –
Confrontation Test
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20. Trochlear Nerve – Pupillary Reflex
•(4) Trochlear Nerve - To test pupillary reflex is 
also a part of examination of 3rd cranial nerve.
•For this Light Reflex and accommodation 
reflex should be tested
•For testing the Light Reflex doctor will throw
light on the patients eye and doctor will look
for the response i.e. constriction of pupil.
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21. Examination of Trochlear Nerve –
Pupillary Reflex
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22. Trochlear Nerve – Pupillary Reflex
•Throwing of light in one eye and constriction of pupil 
of the same eye is direct reflex and construction of 
pupil of another eye is indirect reflex
•Accommodation reflex - can be tested by asking the 
patient to look at distant object first and suddenly 
towards the object, near to eye (as close as 25 cm) 
Effect will be constriction of pupil and conversions of 
eyes and bulging of lens.
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23. Examination of Trochlear Nerve –
Accommodation Reflex
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24. Trigeminal Nerve
•(5) Fifth Cranial Nerve - is Trigeminal Nerve.
•Sensory component - can be tested by testing 
sensations from all parts of face.
•Motor component - can be tested by muscle 
of mastication (Temporalis, Masseter muscles). 
We also test medial and lateral pterygoid 
muscle by asking the patient to move his jaw 
sidewise.
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25. Trigeminal Nerve
•For testing sensory component, wick  of 
cotton wool is used for testing touch
sensation
•Temperature sense can be tested by 
taking warm and cold water in test tubes.
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26. Examination of Trigeminal Nerve –
Touch sensation
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27. Examination of Trigeminal Nerve –
Temperature sensation
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28. Examination of Trigeminal Nerve –
Motor component
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29. Facial Nerve
•(7) 7th Cranial nerve - Facial Nerve
•(i) Basically, this is motor nerve which 
supplies superficial muscles of face
•(ii) The doctor will test all movements of 
face
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30. Facial Nerve
•(a) Make wrinkling on forehead (To test 
Occipito frontalis)
•(b) Close eyes tightly (To test Orbicularis 
occuli)
•(c) Blow your cheeks (To test Buccinator)
•(d) Blow whistle (To test orbicularis oris)
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31. Examination of Facial Nerve
Wrinking of Forehead Close Eyes tightly
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32. Examination of Facial Nerve
Blow the cheeks Blow whistle
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33. Facial Nerve
•(iii) Conjunctival and corneal reflexes
•Are also the part examination of facial 
nerve which we have already tested in 
Trigeminal nerve.
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34. Examination of Facial Nerve
Conjunctival ReflexCorneal Reflex
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35. Vestibulo Cochlear Nerve
•(8) 8th Cranial Nerve - Vestibulo cochlear nerve - 
•Cochlear component is concerned with position of 
head and neck (balance of body). 
•To test cochlear component we carry out "Test of
hearing".
•Rinne's test. Scbwabach test, Weber test - Basic 
principle in all these tests is AC > BC, Due to 
Impedance Matching, brought about by Ossicular 
chain.
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36. Hearing Tests
•(A) Rinne's Test - If BC > AC, It indicates conductive 
deafness
•(Nerve deafness can not be detected by Rinne's test)
•(B) Schwabach Test - AC of patient is compared with 
AC of doctor, BC of patient is compared with BC of 
doctor. (If AC < BC  -- conductive deafness) 
•If AC &  BC ,both are reduced , It indicates nerve 
deafness.
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37. Vibrating Tuning fork for
Hearing Test
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38. Examination of
Vestibulo Cochlear Nerve
Rinne’s Test Rinne’s Test
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39. Examination of
Vestibulo Cochlear Nerve
Schwabach Test Schwabach Test
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40. Hearing Test
•(C) In Weber test - We confirm the deafness ,which
is detected By Rinne's test and schwabach test. - 
Vibrating tunning fork is kept on vertex and patient is 
asked on which side he hears better. - Normally, he 
should hear equal on both sides. If it is better on 
Right side it means conductive deafness on Rt side or 
nerve deafness of opposite side
•All tests are done with Tunning fork, having 
frequency 256 and 512. Because our ear is maximum 
sensitive for these frequencies.
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41. Weber Test for Hearing
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42. Examination of 9th, 10th, 11th
cranial nerves
•Glossopharyngeal, Vagus, Accessory
•9th and 10th cranial nerve carry sensation
from post. part of tongue as well as pharynx.
•10th cranial nerve also supplies palate, 
laryngeal muscle.
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43. Glossopharyngeal Nerve
•Patient is asked to open his mouth and say  Aa , 
(Doctor will observe position of Uvula and arches of 
soft palate)
•Post 1/3rd of tongue can be tested by for general 
sensation  touch, as well as special sensations like 
Taste.( Hold the cotton in forcep & touch on 
posterior 1/3
rd
 of  tongue & ask whether the person 
feels touch )
•- Then patient is asked to drink water while 
swallowing movement of larynx is to be tested.
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44. Examination of
Glossopharyngeal Nerve
Say Aa Touch Sensation
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45. Accessory Nerve
•Accessory nerve has 2 components
•Cranial component - Supplying laryngeal 
muscle and another
•Spinal component - Supplying sternomastoid 
and trapezium
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46. Examination of Accessory Nerve
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47. Accessory Nerve
•Speech is tested by asking the patient to speak out 
few words.(Like asking question –What is your Name 
?)
•To test palatal and pharyngeal reflex stick with 
cotton is to be touched to palate or pharyngeal wall 
and reflex is elicited
•Spinal accessory supplies - Trapezium and
Sternomastoid
•Trapezium is tested by asking the patient to elevate 
his shoulder, against resistance.
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48. Examination of Accessory Nerve
Movement of Trapezium Movement of Trapezium
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49. Examination of Accessory Nerve
• To test sternomastoid muscle patient is asked to 
turn his neck on one side and patient is asked to 
press his chin on the hands of the doctor.
•In this process doctor can see prominence of
Sternomastoid muscle
•Palatal or pharyngeal wall reflex is also the part of 
9th, 10th, 11th Cranial Nerve examination.
•Soft palate or post pharyngeal wall is touched with 
tongue depressor or cotton stick. - patient gets 
coughing sensations.
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50. Examination of Accessory Nerve
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51. 9th, 10th, 11th Cranial Nerve examination
•Palatal or pharyngeal wall reflex is also the 
part of 9th, 10th, 11th Cranial Nerve 
examination
•Soft palate or post pharyngeal wall is touched
with tongue depressor or cotton stick. Patient 
gets coughing sensations
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52. Hypoglossal Nerve
•12th Cranial Nerve - Hypoglossal Nerve –
•This is purely motor nerve.
•It supplies all the muscles of tongue, these 
muscles bring out the movement such as 
elevation, depression, protrusion, retraction 
and rolling of tongue.
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53. Examination of Hypoglossal nerve
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54. Hypoglossal Nerve
•The patient is asked as follows ----
•Say Aa, Take Tongue out ,Take tongue in
,Take tongue up ,Take Tongue out & down 
•This is the end of the cranial nerve 
examination.
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55. Clinical Examination of Sensory System
•One should remember the following points while 
carrying out examination of sensory system.
•(1) Subject (patient) should be blind folded (this
means, patient's eyes should be closed) and patient 
has to answer with closed eyes.
•(2) Identical dermatomes are to be compared for 
sensation and usually we go from below upwards (i.e. 
from lower extremities trunk, upper extremities and 
then face)
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56. Clinical Examination of Sensory System
Hair Asthesiometer Compass Asthesiometer
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57. Clinical Examination of Sensory System
Compass Asthesiometere Tuning Fork
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58. Clinical Examination of Sensory System
Key & Coin-SteregnosisCotton wick –Crude Touch
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59. Clinical Examination of Sensory System
Blunt end of Pencil –pressure Hot & Cold water
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60. Clinical Examination of Sensory System
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61. Types of Sensations – Fine Sensation
•(i) Fine touch
•(ii) Tactile localisation
•(iii) Tactile discrimination
•(iv) Vibration sense
•(v) Joint position and muscle movement sense
•Note - By testing fine sensations integrity of dorsal 
column tract is tested.
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62. Types of Sensations – Crude Sensation
•(i) Crude touch
•(ii) Pressure
•(iii) Temperature
•(iv) Pain
•Note - Integrity of spinothalamic tract is tested
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63. Fine sensation & Tactile Localization
•Tested by Warn cruze hair Asthesiometer or even a 
thin wire can be used.
•The patient is suggested as follows
•Ask the patient – Now I am touching this wire to 
different parts of your body
•By closing your eyes ,you can tell ,whether you feel
the touch ? On which part of your body ,you are 
feeling the touch ? On which side you are feeling the 
touch – Right or Left ? 
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64. Examination of Sensory System
Touch on right side Touch on Left side
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65. Fine Sensation –
Fixing of Dermatome
Sr.No Area Dermatome
1 Near ankle  L 5
2 Below knee  L 4 
3 Above knee  L 3
4 Thigh L 2 
5 Above wrist  L 7 
6 Below elbow  L 6 
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66. Tactile Localization
•The patient will locate the area where he is 
felling fine touch ,by closing eyes 
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67. Tactile Discrimination
•Tested by Compass Asthesiometer
•Tell patient as follows – 
•Now I am touching 2 pointers of this 
Instruments – By closing your eyes , you tell 
me ,whether you are feeling touch with 1
pointer or 2 pointers ?
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68. Examination of Sensory System
Touch on Right side Touch on Left side
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69. Sense of Steregnosis
•The patient is asked to recognise ----
•familiar objects (pen, pencil, coin, key) given 
in his hand (by shape, size and texture )  with 
closed eyes
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70. Steregnosis
Identifying Pen Identifying Coin
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71. Vibration sense
•(5) Vibration Sense - A vibrating tunning fork having 
frequency 100 Hz is kept on bony prominence such 
as Tibial Tuberosity or Olecranon and subject is 
asked to recognise vibration sense
•Ask the patient --- Tell ,closing your eyes , whether
you feel vibrations created by this Instrument , 
Tunning fork  ?
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72. Vibration sense
On right side On Left side
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73. Joint position & Muscle movement sense
•To test joint position sense, we do the 
movements of great toe or thumb and 
subject is asked to recognise that movement 
with closed eyes
•Tell patient – That now I am moving your 
thumb up or down .Then by closing your eyes 
,you can tell me ,whether I am moving your 
thumb up or down ? 
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74. Examination for recognizing
Joint Position
Downward Movement Upward Movement
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75. Examination for recognizing
Joint Position

Downward Movement Upward Movement
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76. Fine sensations –Lost
•All above fine sensations are disturbed, if 
Dorsal Column Tract
•Tract is damaged due to "Tabes Dorsalis
(Neuro syphilis) or Tumour
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77. Crude Sensations
•(1) Crude touch
•(2) Pressure
•(3) Temperature
•(4) Pain
•(Integrity of Spinothalamic tract is tested)
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78. Crude Touch
•Tested by wick of  cotton wool
•Identical Dermatomes are to be compared
•Ask the patient ,to tell ,where he is feeling the 
touch of cotton, by closing eyes ? 
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79. Examination for Crude Touch
On Right Side On Left Side
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80. Sense of Pressure
•Blunt end of the pencil is used. It is pressed
on extremities or on face and subject is asked 
to recognise it
•Tell patient – that I am pressing this Pencil 
surface on your body .By closing eyes ,you tell 
me whether you are feeling pressure & on 
which part & on which side ,right or left ? 
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81. Examination for sense of Pressure
On Right Side On Left Side
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82. Temperature sense
•Test tubes containing warm or cold water are 
used Subject is asked to recognise these 
sensations with his feelings
•Tell patient that now you touching 2 test tubes 
of hot & cold water to his body .Ask him to tell 
,by closing eyes ,which temperature touch ,he 
feels –Hot or Cold ? 
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83. Examination for
Sense of Temperature
On Right Side On Left Side
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84. Pain sensation
•Pin is used. Subject is asked to recognise pain
stimulus, given with pin
•Tell patient that you are now touching his 
body with pin prick .Ask the patient to tell ,by 
closing his eyes ,whether he feels pin prick or 
not ,on which part & on which side ? 
•Identical Dermatomes are tested.
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85. Examination of Pain Sensation
On Right Side On Left Side
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86. Crude sensations
•Thus, by testing crude sensations, we have 
tested integrity of Spinothalamic system
• These tracts are damaged, if there is a tumour
pressing on spinal cord or if there is a disease
like "Transverse Myelitis," involving spinal
cord.
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87. Examination of Motor System
•Motor system is examined under following headings. 
These points are very useful in examine the patient 
of Hemiplegia
•(1) Nutrition
•(2) Tone
•(3) Power
•(4) coordination
•(5) Involuntary movements
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88. Examination of Nutrition of
Muscle
•Nutrition is tested by measuring
circumference of muscle, at its bulk and 
comparing circumference of left and right side
•e.g. Circumference of calf muscle can be 
measured by fixing the distance from bony 
prominence.
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89. Examination of Nutrition of Muscle
•e.g. 6 inches below Tibial tuberosity. Measure
the circumference of right and left calf
muscle at a same distance.
•Similarly circumference of thigh muscle, from 
a fixed bony prominence like Tibial Tuberosity 
or ASIS (Anterior Superior Iliac Spine) can be 
compared
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90. Nutrition of Muscle
Measuring from Fixed
distance Measuring Circumference
11/28/2016 Prof.Dr.R.R.Deshpande 90

91. Examination of Nutrition of Muscle
•In the same manner, for the upper extremity - 
circumference of forearm and arm muscles 
can be compared from a fixed bony 
prominence like olecranon process
•When circumference of both right and left
sides is normal it indicates nutrition of these
muscles is normal
11/28/2016 Prof.Dr.R.R.Deshpande 91

92. Nutrition of Muscle
Right side Measuring Circumference
11/28/2016 Prof.Dr.R.R.Deshpande 92

93. Examination of Nutrition of Muscle
•In right sided person circumference of right 
sided muscle can be slightly more. This is 
physiological
•Atrophy of muscle is seen in LMN lesion like
polio myelitis
11/28/2016 Prof.Dr.R.R.Deshpande 93

94. Tone of Muscle
•Tone of a muscle is a partial state of
contraction. It is maintained by stretch reflex.
•Tone of the muscle is tested by 2 ways
•(a) By examining feel of the muscle
•(b) Tone can be seen by Resistance offered to 
passive Movements.
11/28/2016 Prof.Dr.R.R.Deshpande 94

95. Tone of Muscle
Tone of Leg Muscle Tone of Thigh Muscle
11/28/2016 Prof.Dr.R.R.Deshpande 95

96. Tone of Muscle
•Doctor can feel muscle at its bulk and he can 
compare the feel on right and left side 
•e.g. doctor can observe the feel of calf
muscles, thigh and muscles of bicep and
triceps
11/28/2016 Prof.Dr.R.R.Deshpande 96

97. Tone of Muscle
Bicep Muscle ToneTone –Forearm muscle
11/28/2016 Prof.Dr.R.R.Deshpande 97

98. Tone of Muscle
•Normal feel is Elastic.
•Second method of examination of Tone is to 
see resistance offered to passive Movements
•Patient is not moving his extremities but the 
doctor is carrying out passive movements
11/28/2016 Prof.Dr.R.R.Deshpande 98

99. Tone of Muscle
•Doctor can do passive movements at knee 
joint to test the tone of flexors and extensors 
of knee
•When doctor is doing flexion of knee, he is
testing tone in extensors. When doctor is
doing extension at knee he is testing Tone of
flexors
11/28/2016 Prof.Dr.R.R.Deshpande 99

100. Tone of Muscle
Passive movement Passive movement
11/28/2016 Prof.Dr.R.R.Deshpande 100

101. Tone of Muscle
•For testing upper extremities, same 
movements can be done at elbow
•Doctor can test Tone of biceps and triceps and 
he can compare the Tone at other side. When
doctor is carrying flexion at elbow he is
testing Tone in triceps. When doctor is
carrying extension in elbow he is testing tone
in biceps
11/28/2016 Prof.Dr.R.R.Deshpande 101

102. Tone of Muscle
Elbow Flexion Elbow Extension
11/28/2016 Prof.Dr.R.R.Deshpande 102

103. Tone of Muscle
•In lower and upper extremities, when 
resistance offered is moderate, it indicates 
tone is normal
•Hypertonia is seen in UMN lesion
•Hypotonia is seen in LMN lesion
11/28/2016 Prof.Dr.R.R.Deshpande 103

104. Power of Muscles
•Power is graded under fine grades as follows
•Grade O - No movements at all.
•Grade 1 - Only flicking movement are visible but no 
movements possible
•Grade 2 - If movement is occurring horizontally but 
not able to lift against gravity.
•Grade 3 - If subject is able to lift up leg or hand, 
against gravity
•(compare the right and left side)
11/28/2016 Prof.Dr.R.R.Deshpande 104

105. Power of Muscle
Grade 3 Power Grade 3 Power
11/28/2016 Prof.Dr.R.R.Deshpande 105

106. Power of Muscles
•Grade 4 - Patient is able to move his 
extremities against resistance
•Grade 5 - Patient is able to lift the extremities 
against the good resistance applied by the 
doctor.
11/28/2016 Prof.Dr.R.R.Deshpande 106

107. Power of Muscle
Grade 4 Power Grade 4 Power
11/28/2016 Prof.Dr.R.R.Deshpande 107

108. Power of Muscle
Grade 5 Power Grade 5 Power
11/28/2016 Prof.Dr.R.R.Deshpande 108

109. Power of Muscles
•In the same manner, power of 
extensors of hip, flexors of knee (Ask 
the patient to bend the knee ) 
extensors of knee (Extend leg by 
making knee straight ) can be 
compared.
11/28/2016 Prof.Dr.R.R.Deshpande 109

110. Power of Muscles
•Even planter flexors, dorsi flexors of foot can 
be compared
•In upper extremity, flexors and extensors of 
elbow can be compared, flexors and extensors 
of wrist can be compared
•Movements at shoulder such as flexion,
extension, abduction, adduction can be
tested for power
11/28/2016 Prof.Dr.R.R.Deshpande 110

111. Power of Muscles
•For testing power in the neck muscle, patient 
is asked to lift his neck up in lying down 
position
•Ask the patient to lift the neck ,put down the 
head .Then ask patient to lift the neck ,when 
doctor is pressing on forehead 
11/28/2016 Prof.Dr.R.R.Deshpande 111

112. Power of Muscle
Grade 4 Power Grade 4 Power
11/28/2016 Prof.Dr.R.R.Deshpande 112

113. Power of Muscles
•Complete loss of power is called as 'paralysis'
which is typical feature of LMN lesion like 
polio myelitis
•Partial loss of power is called as "paresis" 
which is typically seen in Hemiplegia or 
Paraplegia.
11/28/2016 Prof.Dr.R.R.Deshpande 113

114. Coordination of Muscles
•(A) Coordination of muscles in upper 
extremity is tested by following tests
•(1) Finger - Nose - finger test
•(2) Rapid pronation and supination of palm
(Dysdiadochokinesia)
11/28/2016 Prof.Dr.R.R.Deshpande 114

115. Coordination of Muscles
•(B) for lower extremity, following tests
•(1) Knee - heel test
•(2) Walking in straight line
•All tests of co-ordination should be done with 
open eyes first and then with closed eyes, to 
differentiate between sensory Ataxia and 
cerebellar Ataxia (Motor ataxia)
11/28/2016 Prof.Dr.R.R.Deshpande 115

116. Coordination of Muscles
•Ask the patient ,by closing the eyes ,he should 
try to touch Index finger of the left hand by his 
index finger of right hand & then same right 
hand finger should touch to his nose tip 
•Same procedure is repeated with Left hand 
Index finger
• 
•This is Finger – Nose – Finger Test
11/28/2016 Prof.Dr.R.R.Deshpande 116

117. Coordination of Muscle
Finger- Nose –Finger Test Finger –Nose –Finger Test
11/28/2016 Prof.Dr.R.R.Deshpande 117

118. Coordination of Muscles
•Ask the patient to perform Pronation & 
Supination activity of both hands ,speedily 
(diadochokinesia) ---
•Check ,whether patient can do it for both the 
hands 
11/28/2016 Prof.Dr.R.R.Deshpande 118

119. Coordination of Muscle
Diadochokinesia Diadochokinesia
11/28/2016 Prof.Dr.R.R.Deshpande 119

120. Coordination of Muscles
•Kneel Heel Test – Ask the patient to sit on 
table or lie down on bed 
•First keep right heel on left knee & take the 
heel down along with shin of tibia ,till left foot 
•Perform Same procedure by keeping left heel 
on right knee & taking down heel along with 
the shin of tibia ,up to right foot 
11/28/2016 Prof.Dr.R.R.Deshpande 120

121. Coordination of Muscle
Knee-heel Test Knee –heel Test
11/28/2016 Prof.Dr.R.R.Deshpande 121

122. Coordination of Muscles
•Ask the patient to stand straight ,by keeping both 
feet near to each other – First stand with eyes open 
& then stand with close eyes 
•Doctor has to see ,whether patient can maintain 
balance of his body 
•If patient cannot stand straight, and he swings with 
closed eyes - It is called as, "positive Rhomberg's
sign", which is typical sign of Dorsal column tract
damage.
11/28/2016 Prof.Dr.R.R.Deshpande 122

123. Rhomberg's sign
11/28/2016 Prof.Dr.R.R.Deshpande 123

124. Coordination of Muscles
•Straight line walking Test – Ask the patient to 
stand at one end of the 8 feet straight line 
•Then ask him to walk on this line to & fro –
First with open eyes & then with close eyes  
11/28/2016 Prof.Dr.R.R.Deshpande 124

125. Straight line walking Test
Walk on Straight line Return back –on straight line
11/28/2016 Prof.Dr.R.R.Deshpande 125

126. Coordination of Muscles
•If patient walks correctly with open eyes, but looses 
balance with closed eyes - It indicates damage lies in 
dorsal column tract (which is called as sensory
ataxia)
•If patient is not able to walk with open or closed eyes 
– damage is in cerebellum (it is cerebellar or Motor
ataxia)
11/28/2016 Prof.Dr.R.R.Deshpande 126

127. Involuntary Movements
•3 types
•(1) Fine Tremors – In Thyrotoxicosis
•Tachycardia, weight loss, Intolerance to heat 
atmosphere ,Feeling excessive heat all the 
time
11/28/2016 Prof.Dr.R.R.Deshpande 127

128. Involuntary Movements
•(2) Pin rolling tremors at rest –
•In Parkinsonism – This disease develops due 
to deficiency of Dopamin neutrotransmitter in 
Basal Ganglia  
•Tab Carbidopa is used to compensate this 
deficiency
•(3) Action tremor - In cerebellar diseases
11/28/2016 Prof.Dr.R.R.Deshpande 128

129. Involuntary Movements
Fine Tremors Pin rolling Tremors
11/28/2016 Prof.Dr.R.R.Deshpande 129

130. Involuntary Movements –Action Tremor
11/28/2016 Prof.Dr.R.R.Deshpande 130

131. Advantage of
Motor System Examination
•Advantage of motor system examination, over 
sensory system examination is that --- 
•(1) Even if patients cooperation is not there
we can draw few conclusions like - UMN 
lesion, LMN lesion, Parkinsonism, Cerebellar
•ataxia ,Sensory ataxia.
11/28/2016 Prof.Dr.R.R.Deshpande 131

132. Advantage of
Motor System Examination
•(2) In sensory system examination, if patient is 
non-co-operative then he can not answer the 
doctor's questions and then examination is of 
no value
•However, sensory system examination is
important to detect the level of damage in
spinal cord.
11/28/2016 Prof.Dr.R.R.Deshpande 132

133. Superficial Reflexes – Root values
Sr.No Reflex Root Value
1 Conjunctival reflex 5
th
and 7th cranial nerve
2 Corneal reflex 5
th
and 7th cr. N
3 Pharyngeal reflex 9th, 10th, 11th cr. N
4 Abdominal reflex T6 to L1
5 Plantar reflex L5, Si, S2
11/28/2016 Prof.Dr.R.R.Deshpande 133

134. Deep Reflexes – Root values
Sr.No Reflex Root Value
1 Bicep jerk C5, C6
2 Triceps jerk C6, C7, C8
3 Supinator jerk C5, C6
4 Knee jerk L2, L3, L4
5 Ankle jerk L5, S1, S2
11/28/2016 Prof.Dr.R.R.Deshpande 134

135. Reflexes
•In superficial reflexes --- receptors are in skin 
or mucous membrane
•In deep reflexes ----  receptors are in muscles 
or tendons.
11/28/2016 Prof.Dr.R.R.Deshpande 135

136. Superficial Reflex – Conjunctival Reflex
•Doctor will touch wisp of the cotton wool to 
the white portion of eye i.e. Bulbar  
conjunctiva
•Response is closer of both eyes
11/28/2016 Prof.Dr.R.R.Deshpande 136

137. Conjunctival Reflex
For Right Eye For Left Eye
11/28/2016 Prof.Dr.R.R.Deshpande 137

138. Superficial Reflex –Corneal Reflex
•Doctor will touch the wisp of cotton wool to
black portion of eye i.e. cornea closer of both 
eyes is normal response
•NOTE : Conjunctival and corneal reflexes have 
already been tested in examination of 
trigeminal and facial nerve. If these nerves are 
damaged reflexes are lost
11/28/2016 Prof.Dr.R.R.Deshpande 138

139. Corneal Reflex
For Right Eye For Left Eye
11/28/2016 Prof.Dr.R.R.Deshpande 139

140. Palatal & Pharyngeal Reflex
•Doctor will touch soft palate or post
pharyngeal wall with tongue depressor
•Doctor will expect a response in the form of 
coughing
•If the patient is getting coughing sensation - It 
means 9th, 10th, 11th cranial nerves involving 
in this reflex are normal
11/28/2016 Prof.Dr.R.R.Deshpande 140

141. Palatal & Pharyngeal Reflex
Ready with Tongue DepressorTouch Post Pharyngeal wall
11/28/2016 Prof.Dr.R.R.Deshpande 141

142. Abdominal Reflexes
•Imp precaution to be carried out is that - 
abdomen should be relaxed, by flexing 
knee
•Ask the patient to lie down his back & 
flex the knees & relax abdominal
muscles
11/28/2016 Prof.Dr.R.R.Deshpande 142

143. Abdominal Reflexes
Mid abdominal Reflex Away from Umbilicus
11/28/2016 Prof.Dr.R.R.Deshpande 143

144. Abdominal Reflexes
•Now, blunt end of hammer is moved, 
radiating away from umbilicus in all directions
•While testing this reflex abdominal muscle will 
show a movement, in the form of the 
response
•Abdominal reflexes are classified into upper 
abdominal, mid abdominal and lower 
abdominal reflexes
11/28/2016 Prof.Dr.R.R.Deshpande 144

145. Abdominal Reflex – Root value
Sr.No Part Of Abdomen Root Value
1 Upper abdominal reflex T6 to T9
2 Mid abdominal reflex T9 to T11
3 Lower abdominal reflex T11 to L1
11/28/2016 Prof.Dr.R.R.Deshpande 145

146. Abdominal Reflexes
•In obese patients, abdominal reflexes 
may not be elucidated. In such cases, 
unilateral absence of abdominal reflex is 
important finding
•Abdominal reflexes are lost in UMN
lesion like hemiplegia or paraplegia.
11/28/2016 Prof.Dr.R.R.Deshpande 146

147. Superficial Reflex – Plantar Reflex
•Root value of the plantar reflex is L5, S1, S2.
•Scratch sole of the foot from heel to toes, 
along lateral border and then medially. This 
scratching is done with blunt portion of 
hammer
•Perform it on both sides & compare 
11/28/2016 Prof.Dr.R.R.Deshpande 147

148. Babinski's sign
Left Plantar ReflexRight Plantar Reflex
11/28/2016 Prof.Dr.R.R.Deshpande 148

149. Superficial Reflex – Plantar Reflex
•Normal response is plantar flexion of all toes
•If dorsiflexion of great toe and fanning of
other toes is seen then diagnosis is positive 
Plantar reflex or positive Babinski's sign
•This will be seen UMN lesion like hemiplegia
or in meningeal irritation (Meningitis)
11/28/2016 Prof.Dr.R.R.Deshpande 149

150. Deep Reflex – Bicep Jerk
•For testing deep reflexes, special method is 
adopted which is called as the Jendrassik
maneuver   ---- 
•which is a medical  maneuver wherein the 
patient clenches the teeth, flexes both sets of 
fingers into a hook-like form and interlocks 
those sets of fingers together
11/28/2016 Prof.Dr.R.R.Deshpande 150

151. Deep Reflex – Bicep Jerk
Tap Bicep Tendon Contraction of Bicep muscle
11/28/2016 Prof.Dr.R.R.Deshpande 151

152. Jendrassik maneuver 
•By this manual, gamma motor neuron
discharge is decreased and reflex is obtained 
properly 
•Bicep jerk - Doctor will tap bicep tendon - 
contraction of biceps muscle is important, 
rather than flexion of forearm. 
•We compare the reflex on both sides. Root 
value of this reflex is C5, C6.
11/28/2016 Prof.Dr.R.R.Deshpande 152

153. Deep Reflex – Tricep Reflex
•Doctor will give a tap just above Olecranon
process, which is Tricep tendon
•Do  Jendrassik maneuver
•Contraction of the muscle is more important 
than extension of forearm 
•Compare the reflex on other side. Root value 
of this reflex is C 7, C 8.
11/28/2016 Prof.Dr.R.R.Deshpande 153

154. Deep Reflex – Tricep Reflex
Tap above Olecranon Process Contraction of Muscle
11/28/2016 Prof.Dr.R.R.Deshpande 154

155. Deep Reflex –
Supinator Reflex or wrist Jerk Reflex
•Tap is given just above the head of radius. 
Doctor can see the contraction of 
brachioradialis muscle 
•Compare the reflex on another side
•Root value is C5, C6.
11/28/2016 Prof.Dr.R.R.Deshpande 155

156. Supinator Reflex or
wrist Jerk Reflex
Left Wrist jerk Right wrist jerk
11/28/2016 Prof.Dr.R.R.Deshpande 156

157. Deep Reflex – Knee Jerk
•For testing this reflex, exposer of Quadriceps muscle 
is important, so that the doctor can see the 
contraction of this muscle
•Doctor keeps his hand below the knee, patient is 
asked to relax. Divert the patients attention by 
 Jendrassik maneuver
• Ask the patient to clench the teeth 
•Give a tap on patellar tendon i.e. between patella 
and Tibial Tuberosity.
11/28/2016 Prof.Dr.R.R.Deshpande 157

158. Deep Reflex – Knee Jerk
•Contraction of Quadriceps muscle is 
Important response
•Root value is - L2, L3, L4
11/28/2016 Prof.Dr.R.R.Deshpande 158

159. Deep Reflex – Knee Jerk
Right Knee Reflex Left Knee Reflex
11/28/2016 Prof.Dr.R.R.Deshpande 159

160. Deep Reflex – Ankle Jerk
•For this reflex gastrocnemius muscle should be 
exposed. Tapping of the gastrocnemius
tendon, just above the heel is stimulus 
•Doctor will make forceful dorsiflexion of foot 
and give a tap on tendon. Contraction of 
gastrocnemius is the response. Compare the 
reflex on other side
•Root value is L5, S1, S2
11/28/2016 Prof.Dr.R.R.Deshpande 160

161. Deep Reflex – Ankle Jerk
Right Ankle Jerk Left Ankle Jerk
11/28/2016 Prof.Dr.R.R.Deshpande 161

162. Importance of Testing Reflexes
•Examination of the reflexes is most imp part in 
examination of the nervous system.
•Advantage of this examination than motor and 
sensory examination is that - "It does not require 
patient's co-operation."
•Various diseases, specially UMN lesion and LMN
lesion can be differentiated by examination of deep
reflexes
•Even if patient is unconscious, non-cooperative -
These reflexes will give important clues.
11/28/2016 Prof.Dr.R.R.Deshpande 162

163. Importance of Testing Reflexes
•In UMN lesions - Deep reflexes are
exaggerated 
•(Jerks will be very much prominent)
•Even clonus can be seen at knee and ankle 
(where muscle jerk oscillates for longer time)
•Clonus is always pathological. It is seen in
UMN lesion
11/28/2016 Prof.Dr.R.R.Deshpande 163

164. Examination of Spine & Cranium
•Spine is to be inspected from cervical to sacral 
region for noticeing abnormality
•With knuckles of fingers ,doctor can give
deep pressure on spine and ask the patient
whether he gets pain sensation.
11/28/2016 Prof.Dr.R.R.Deshpande 164

165. Examination of Spine & Cranium
Cervical to Sacral With knuckles
11/28/2016 Prof.Dr.R.R.Deshpande 165

166. Examination of Spine & Cranium
•For testing cranium deep pressure is to be
given on skull, from all angles and patient is 
asked, "Whether he gets pain sensation" ?
•If there are abnormalities of the spine, if 
there are conditions like hydrocephalus. This 
test will give intense pain.
11/28/2016 Prof.Dr.R.R.Deshpande 166

167. Examination of Spine & Cranium
Deep pressure from all angles Deep pressure from all angles
11/28/2016 Prof.Dr.R.R.Deshpande 167

168. Examination of Gait
Sr.No Gait Disease
1 Circumduction gait Hemiplegia
2 Jerky gait Parkinsonism
3 Drunk man's gait Cerebellar disease
4 Spastic gait Paraplegia
5 Flaccid gait Polio-myelitis.
6 Scissors gait Diplegia
11/28/2016 Prof.Dr.R.R.Deshpande 168

169. Abnormal Gait
Circumduction gait Drunken Gait
11/28/2016 Prof.Dr.R.R.Deshpande 169

170. Abnormal Gait
Parkinson’s Gait Polio Gait
11/28/2016 Prof.Dr.R.R.Deshpande 170

171. Abnormal Gait
11/28/2016 Prof.Dr.R.R.Deshpande 171

172. Abnormal Gait – Scissor Gait
11/28/2016 Prof.Dr.R.R.Deshpande 172

173. Examination of Special Signs
•Neck rigidity - in Meningitis
•High Fever, severe Headache, projectile 
vomiting, positive Babinskis sign & positive 
Kerning's sign - usually present in 
Meningococcal Meningitis
11/28/2016 Prof.Dr.R.R.Deshpande 173

174. Prof.Dr.R.R.Deshpande
•Sharing of Knowledge 
•FOR 
•Propagating Ayurved
11/28/2016 174Prof.Dr.R.R.Deshpande