Neurology Evaluation for Physical Therapy

This article is all about how to perform a neurology evaluation.  Neurology evaluations are long and sometimes time-consuming. It is not really possible to perform every single item during a session.

A while back I did a Physical Therapy general evaluation format. This was more of a general intake form. Here I want to go a little deep in a specific neurological diagnosis/ category in physical therapy.

For me, I go over the categories and check if there are any deficits, and I move to another category. If a patient is unable to answer or shows deficits in one area, then I will perform a detailed assessment of that area. This helps me to go over the eval quickly and also allows me to concentrate on the areas that are weak.

So here is a neurology evaluation format for physical therapy. You can add/delete some areas based on your population or the needs. I am also going to give you a PDF format to download so you can keep it with you anytime.

The main components of the neurology evaluation are as follow:

1. Mental Status
2. Cranial Nerve Testing
3. Motor Exam
4. Reflexes
5. Sensory Exam
6. Coordination
7. Balance & Gait

Let’s talk about each section in detail now.

Checking Mental Status during Neurology Evaluation :

Level of consciousness:

This is to see how alert and orientated the person is. If your patient has a history of TBI/MVA, you may want to consider performing GCS (Glasgow Coma Scale) or RLA (Ranchos Los Amigos Level of alertness). These scales will determine the level of consciousness of a patient.

Alertness & Orientation:

You can ask some questions like date of birth, place, time, year, any information regarding a major public event, or even a holiday to see whether a patient is alert and oriented.

Speech & Language:

While talking with the patient, you can check the fluency of the speech as well as comprehension. You need to pay attention to check whether the patient is demonstrating any fluency problems, or showing any parietal lobe deficits like aphasia.

In case your patient is aphasic, you need to look into the type of aphasia. It is also advisable to check if the patient shows any other parietal lobe deficits along with aphasia. Knowing this will be beneficial as it is going to directly affect a patient’s performance in the rehab sessions and so their progression.

The parietal lobe plays a vital role in knowing and relaying sensory information from different parts of the body. Damage or an injury to this lobe results in deficits like aphasia, agraphia, akinesthesia, dysdiadochokinesia!! There is going to be a full separate article to discuss these deficits and how to overcome them in the rehab progression. During your evaluation time, note any deficits a person has and check if there is an appropriate diagnosis for it.

Checking a diagnosis is important, as this will let you know if the medical team/ neurologist, PCT, etc are aware of this deficit. Sometimes with brain injury or MVA, there are so many other injuries that some deficits go unnoticed by other medical professionals. Therapists, who directly spend 30 to 45 minutes with a patient, usually notices these deficits first. At that point, it is important to make the PCP and or neurologist aware of this.

Memory:

Next, you can check short term and long term memory. You can ask the patient to repeat any three words that you give after a minute or so. For long term memory, you can ask them about their birth year, any specific event in their life, etc.

Higher-level cognition

The next and important assessment tool is the evaluation of higher-level cognition. This includes executive functioning, problem-solving skills, reasoning, etc.

There is a good amount of research going on in this direction in physical therapy. More and more studies are stressing the relationship between higher levels of cognition with neural recovery, walking speed, etc. so assessing and knowing that your patient has intact executive functioning helps you develop an appropriate plan of care.

Cranial Nerves Testing during Neurology Evaluation :

The next step in the eval process is cranial nerve (CN) testing. As we know there are 12 cranial nerves. If you know your routine, this can really be quick.

CN 1: 

Honestly, I don’t do the cranial nerve 1 (olfactory) testing on day 1 of my neuro eval. Yes, I am aware that having a loss of sense of smell can be a huge safety issue, especially if a person is looking into going home independently. But, I don’t have to make that judgment call on day 1. Plus, loss of function of cranial nerve 1 is not clinically significant of anything.

CN 2: 

So I directly skip to CN 2 (Optic Nerve): we check visual acuity and visual fields here. For Visual acuity, have the patient cover one eye, and ask them to read a Snellen chart from a 14 inches distance.

To assess visual fields, have the patient look into your eyes. Hold your hands midway between you and your patient. Move your finger far enough laterally that you can barely see them out of the ocean of your eyes, without moving your head. Ask the patient to indicate on which side the finger is moving. Repeat it in upper and lower quadrants.

Pupillary Reflex: This reflex tests the pupillary reaction to the light. The Pupillary reflex has sensory innervation from CN 2 and motor innervation from CN 3. This is more for your knowledge, you are not going to need this info clinically unless you have a patient who has one of these two nerves (CN 2 & 3) affected.

CN 3 (Oculomotor), 4 (Trochlear), & 6 (Abducens) :

As you know CN 3,4 & 6 are tested together as they supply ocular muscles. These nerves are tested by testing the gaze in all six (up, down, left, right & oblique) directions.

Here is a picture I like to follow for this movement. I like it as it also identifies the different muscles that are involved with the movement.

Hare, you also have to observe for Saccade, convergence, smooth pursuits, and nystagmus. These are cardinal central signs that differentiate from a peripheral injury.

Saccades:

This is a rapid eye movement from one object to another.

Hold two fingers 3 cm from the midline, around 6 inches away from the patient. Ask the patient to quickly look from one to the other finger without moving their head.

You can test the saccadic movement by holding the finger 3 cm up and 3 cm down from the midline.

While the patient is rapidly moving their eyes, observe for the eye movement, for any undershooting or overshooting.

Smooth Pursuits:

This is a slow movement of the eye. You can hold one finger either vertically or horizontally and ask the patient to slowly follow the fingers from one to the other. Observe the smoothness of the movement.

Convergence: It is a misalignment of the eyes while focusing on the nearby object.

Hold a finger in front of the patient’s nose and gradually bring it close to the nose. Ask the patient when s/he starts seeing the double. You measure the distance from the tip of the nose to the point where your patient sees the double.

The distance is convergence insufficiency for your patient. Around 3 cm of distance for the double vision is considered normal.

Nystagmus:

Nystagmus is the rapid rhythmic oscillatory movement of the eye. It has two phases: a fast phase and a slow phase. It is directional specific and sometimes changes direction. The direction of the fast phase determines the direction of the nystagmus.

Nystagmus can be of many types and due to many reasons. This is one of the very important differential diagnostic signs for a therapist in neuro settings. One can observe nystagmus in upward, downward, left, right, torsional, as well as direction changing. Usually, downward nystagmus and directional changing nystagmus are of a central origin, while others can have a peripheral cause to it.

Vestibular disorders, Ms, stroke, TBI, vascular insufficiency are a few examples where a therapist expects to see nystagmus in the patients.

Knowing a little bit about nystagmus helps to determine whether to treat or not to treat the patient. As always, if there is a new medical finding that we are observing, we should reach out to either PCP or a neurologist.

CN 5 (Trigeminal Nerve):

The trigeminal nerve is a mixed nerve. It has a sensory, motor, and mixed component to it.

The cranial nerve is responsible for the facial sensation from the forehead to the chin. It has three divisions. V 1 (Ophthalmic), V 2 (maxillary) and V 3 ( mandibular). You can check the patient;’s facial sensation by using a cotton swab on different parts of the face and asking the patient whether they feel the swab or not.

In addition to the sensation, it is also responsible for the strength of the temporalis muscle and masseter muscle. To check the muscle strength, ask the patient to clench the teeth, open the mouth, etc.

Clinical significance: Trigeminal Neuralgia is a clinical condition that occurs with an inflammation of the CN 5.

Corneal Reflex: This reflex has sensory supply by CN 5 and motor by CN 7. To test this, lightly touch the peripheral part of the cornea with a swab of cotton and look for a blinking response.

CN 7 (Facial Nerve) :

This nerve is responsible for all facial movement. It supplies all the facial muscles. So to test this, you ask your patient to perform various facial movements like a smile, puff their cheeks, close their eyes, raise eyebrows, etc..

Clinical significance: Facial palsy and a Bell’s palsy are conditions that occur due to damage to a facial nerve. The main differentiation of the conditions mentioned above is based on the site of a lesion. Facial palsy is a UMN while bell’s palsy is an LMN.

CN 8 (Vestibulocochlear Nerve):

This nerve is responsible for mainly hearing. You may have heard terms like sensorineural hearing and conductive hearing, or bone conduction loss and air conduction loss. Those are fancy terminology to describe hearing conduction.

The easiest and fastest way to text the CN 8, is to rub your finger closer to the patient’s ear and ask the patient if they hear your finger.

To test the function of this nerve, use a tuning fork and put it on the mastoid process (behind the ear) of a patient’s ear and ask the patient if they can hear the vibration of the fork. You can also put the tuning fork on the head and ask the patient if s/he hears it on both ears the same. I honestly do not perform these tests on my stroke patient, unless I see a vestibular involvement. Or my patient shows other significant signs like nystagmus, vertigo, loss of balance.

Clinical significance: Vestibular Neuritis is one of the common conditions that involved CN 8.

CN 9 (Glossopharyngeal Nerve) & CN 10 ( Vagus Nerve):

The best and easy way to test the function of these two nerves is by assessing, and testing swallowing, gag reflex, voicing, coughing as well as palate elevation. You can ask the patient to open their mouth wide, ask them to say “AH” and check for palate movement, any deviation, check uvula etc..

Vagus nerve is also responsible for visceral organ function and an important part of a parasympathetic nervous system.

Clinical Significance: Glossopharyngeal neuralgia.

CN 11 (Spinal Accessory nerve):

A therapist needs to check the muscle strength of Trapezius (shrug the shoulder) and sternocleidomastoid (Head rotation) to assess this CN.

CN 12(hypoglossal Nerve):

Check the position, sensation, movement of the tongue to check this CN.

Checking the Motor Systems & Reflexes during Neurology Evaluation

Checking the Motor System:

This is one of the most important exams PTs perform. Here, we check muscle tone, muscle strength as well as endurance of each muscle.

We need to check the muscle strength of each muscle. Now, you and I both know that checking every muscle of the body is not possible in reality. So we check all the myotomes. Here are the important myotomes that you want to check on both sides of your patients:

MYOTOMES:

Name of the muscle	Myotome tested	The function of the muscle
Deltoid	C5 – C 6	Shoulder abduction
Biceps	C5 – C 6	Elbow flexion
Triceps	C6- C 8	Elbow extension
Extensor carpi radialis	C5 – C 6	Wrist extension
Abductor pollicis brevis	C 8 T 1	Thumb abduction
interossei	C8 – T 1	Finger abduction
Iliopsoas	L1, L2, L3	Hip flexion
Quadriceps	L 2, L3, L 4	Knee extension
Hamstrings	L 5 , S 1, S 2	Knee flexion
Tibialis Anterior	L 4 -L 5	Ankle DorsiFlexion
Gastrocnemius/Soleus	S 1 – S 2	Ankle plantarflexion

I am sure you are aware of the grading of manual muscle testing. It goes from grade 0 to grade 5. Here, I am going to include the grading for your reference.

Grades	Description
0/5	No muscle contraction
1/5	Visible muscle contraction but no movement at the joint
2/5	Full movement in gravity eliminated plane but not against gravity
3/5	The full movement against gravity, but the patient can not take any external resistance
4/5	The full movement against gravity, the patient can take a moderate amount of external resistance
5/5	A full movement against gravity, the patient is able to take full resistance.

Testing Reflexes during Neurology Evaluation:

Here is another table that quickly explains each of reflex:

Reflex	Innervation	Testing method
Jaw Jerk Reflex	CN 5	Tap on the chin of the patient with the patient’s mouth slightly open with a reflex hammer.
Biceps	C5-C6 (musculocutaneous N)	With the patient’s elbow slightly flexed, tap on the biceps tendon with a reflex hammer. Observe for either muscle contraction or slight elbow flexion.
Triceps	C 7 (radial Nerve)	Tap the reflex hammer on the triceps tendon with the elbow slightly flexed. Observe a slight extension of the elbow or a triceps muscle contraction.
Brachioradialis	C5 – C 6	Tap on the brachioradialis tendon with the reflex hammer slightly and observe for elbow supination or muscle contraction.
Knee Reflex/ Patellar reflex	L2, L 3, L 4 (Femoral Nerve)	With the patient in sitting knees slightly flexed, tap the hamstrings tendon just below patella,. Observe for slight knee extension.
Achilles Tendon	S1, S2 (Tibial Nerve)	With the patient’s foot dorsiflexion, tap on the Achilles tendon. Observe for ankle plantar flexion.

Note that these are the normal reflexes. There are pathological reflexes that may be present with a neural injury. Here are some example of pathological reflexes:

1. Babinkin’s Sign for Neurology Evaluation:

With a pointed edge of a reflex hammer, you stroke from heel of the foot to the little finger in a “J” shape. Watch the response of the toes.

Normal Response: great toe flexes (moves downwards) with fanning of the other toes inwards. This is a Babinski sign negative or normal response.

Abnormal Response: Great toe moves upwards with fanning of the other toes outwards.

Note that this is a normal response in infants until 12 months. The presence of this response means UMN (upper motor neuron ) lesion. The presence of this response is called a positive Babinski’s sign, which is a pathological response.

2. Hoffman’s Reflex for Neurology Evaluation:

Another pathological response you can check is Hoffman’s sign. Hold the middle finger of your patient’s hand, closer to the fingernail. Observe the movement of other fingers and thumb by “flicking” the nail of the middle finger.

Normally, you should not see any movements of other fingers or a thumb.

Abnormal response: You observe, flexion, and adduction of the thumb and index finger. This identifies the involvement of UMN.

Checking Sensory Systems during Neurology Evaluation:

There are many different types of sensations that one can check. Examples of that being, light touch, pain, temperature, vibration, joint position sense, etc.. In addition to the parietal lobe deficits, I also check the sensory system based on the dermatome level.

I usually check light touch with cotton and pain with the dull end of the safety pin.

I discussed parietal lobe deficits earlier in this article. A few additional deficits one can observe, that involve sensory system are lack of graphesthesia, two-point discrimination, stereognosis, etc.

Coordination Testing during Neurology Evaluation :

Coordination testing can be done by many different tests. Here are a few different tests that one can perform to test a patient’s coordination in neurology evaluation.

1. Toe-tapping
2. Heel to shin
3. Finger to now to finger
4. Rapid alternating movements (RAM)

Balance & Gait assessment during Neurology Evaluation :

Here we are checking posture, gait, sitting, standing balance statically, and dynamically. Depending on your patient’s level, you also want to observe the patient while walking forward, backward, sideways, turning, standing up and sitting down, etc.

You can find my other evaluation format below:

1. PT evaluation format 
2. Cardio-pulmonary evaluation. 

Below is a PDF format (more like a cheat sheet) for a neuro exam.

I hope this article helps you to perform your next neuro eval!!