The goal of the neurological examination for the physiatrist is to confirm the diagnosis and identify deficits that will affect an individual’s function. This enables the development of rehabilitation goals and a timeline for the patient to reach those goals. This is important in educating families and caregivers and for providing training to safely care for the patient upon transition either to home or another facility.
Brain injuries can be diffuse or focal, and the deficits are not always consistent with the neurological injury. Phenomena such as diaschisis can also complicate the clinical picture because it can produce deficits in areas distant from the injury. In addition, brain-injured patients often have complicated neurosurgical and medical courses, and their mental status may fluctuate day to day. Cognitive and/or communication deficits also may limit the efficacy of the interview. It is important to perform serial neurological examinations to identify if there is a new focal neurological deficit that warrants acute intervention, and if the neurological examination is stable, it can be reassuring to the physiatrist and prompt investigation of a non–brain-injury cause for a change in medical stability.
Glasgow coma scale
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The Glasgow Coma Scale (GCS) is the primary initial assessment tool in the field or emergency department.
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The score is based on the best visual, verbal, and motor responses ( Table 13.1 )
TABLE 13.1
Glasgow Coma Scale
Adapted from Braddom R. Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier Saunders; 2011:10.
Function
Rating
Eye Opening
Spontaneous
4
To speech
3
To pain
2
No response
1
Best Motor Response
Obeys commands
6
Localizes to stimuli
5
Withdraws to pain
4
Flexion response
3
Extensor response
2
No response
1
Verbal Response
Oriented
5
Confused conversation
4
Inappropriate words
3
Incomprehensible sounds
2
No response
1
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The scores range from 3 to 15, and a score of 3T is given if the patient is intubated (see Table 13.1 ).
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Used to define severity of injury
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Mild: 13 to 15
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Moderate: 8 to 12
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Severe: 3 to 8
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Mental status examination
The mental status examination (MSE) describes the mental state and behaviors of the patient and can help discriminate between mood and thought disorders, such as depression and schizophrenia, and cognitive impairment caused by brain injury. This is important because there is a prevalence of psychiatric disorders after traumatic brain injury (TBI). Socioeconomic and cultural factors and language barriers, including aphasia, can affect the MSE and must be taken into account. The physiatric MSE emphasizes the cognitive examination and level of consciousness.
- 1.
Level of consciousness:
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Consciousness requires an intact pontine reticular activating system.
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Lethargic: The patient is easy to arouse but with slowing of speech and movement.
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Obtunded: The patient is difficult to arouse and once aroused is confused.
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Stuporous: The patient arouses to pain but with minimal response.
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In acute settings, the GCS can be used to assess consciousness.
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- 2.
Orientation: understanding of one’s situation in space and time
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Includes orientation to person, place, time, and situation
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Orientation to person is usually intact and if impaired may be suspicious for malingering versus a more severe brain injury
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- 3.
Attention: ability to focus and direct one’s intellect
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Can test by asking patient to repeat increasing lengths of numbers forward and backward.
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The average individual should be able to repeat seven numbers forward and five backward.
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- 4.
Memory:
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Testing memory requires first that the patient is able to register the information you are asking them to remember.
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Registration: the ability to repeat information immediately
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Short-term memory: recall of three words after 5 minutes
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Long term memory: recall past details
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Example: Name past presidents.
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- 5.
Speech:
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Includes assessment of fluency, repetition, comprehension, naming, writing, reading, prosody, and quality of speech
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- 6.
Abstract thinking is the understanding of the meaning of words beyond the literal interpretation.
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Requires a higher intellectual function
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Example: How are an apple and orange alike?
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Abstract answer: both fruit
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Concrete answer: both round
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- 7.
Insight:
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Awareness of impairment and understanding that treatment might be helpful
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A lack of insight is associated with decreased employability and community integration after brain injury. ,
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- 8.
Judgment:
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Ability to make measured decisions and reach reasonable conclusions
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Judgment requires insight into one’s situation.
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- 9.
Mood and affect:
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Mood: The patient may be able to describe their mood or the evaluator infers from the interview.
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Anhedonia may also be observed here, which is a decreased ability to feel pleasure or engage in pleasurable activities.
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Affect is a description of the current emotional state that is observed by the examiner. It includes type, range, reactivity, and appropriateness.
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- 10.
Thought process and content:
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Thought process includes form of thinking and flow of thought and ranges between goal-directed and disconnected thoughts.
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Common descriptors include logical, tangential, circumstantial, and closely or loosely associated.
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Thought content is what the patient is thinking about, for example, if they have obsessions, phobias, or delusions.
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Communication
- 1.
Left hemisphere communication disorders:
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Damage to the dominant hemisphere, which is usually the left hemisphere, typically results in aphasia. This is where the language centers are, such as Broca’s and Wernicke’s area, and damage to these areas or to any of their communications may result in aphasia ( Fig. 13.1 ).
• Fig. 13.1
Language-related areas in the brain.
(From Braddom R. Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier Saunders; 2011:54.)
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Key components of examination include naming, repetition, comprehension, and fluency ( Fig. 13.2 ).
• Fig. 13.2
Flow chart to assess aphasia types.
(From Braddom R. Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier Saunders; 2011:55.)
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- 2.
Right hemisphere communication disorders:
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Characterized by cognitive linguistic deficits and are often accompanied by some level of left-sided neglect, which is a phenomenon in which the patient does not recognize the left side of their body or objects in the left field of vision
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Highlights the effects that attention, memory, problem solving, and interpretive language have on communication
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The patient may seem socially inappropriate or uninterested in conversation.
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See Table 13.2 for the difference between aphasia (left hemisphere) and right hemisphere communication disorders.
TABLE 13.2
Comparison Between Aphasia (Left Hemisphere) and Right Hemisphere Communication Deficits
From Braddom R. Physical Medicine and Rehabilitation . 4th ed. Philadelphia, PA: Elsevier Saunders; 2011:58.
Aphasia
Right Hemisphere Disorder
Pure linguistic deficits dominant
Linguistic deficits not dominant
More severe problems in naming, fluency, auditory and comprehension, reading, and writing
Only mild problems
No left-sided neglect
Left-sided neglect
No denial of illness
Denial of illness
Speech generally relevant
Speech often irrelevant, rambling
Generally normal affect
Often lacks affect
Recognizes familiar faces
May not recognize familiar faces
Simplification of drawings
Rotation and left-sided neglect of drawings
No significant prosodic defect
Significant prosodic defect
Appropriate humor
Inappropriate humor
May retell the essence of a story
May retell only nonessential, isolated details
May understand implied meanings
Understands only literal meanings
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- 3.
Dysarthria:
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Articulation of speech is impaired with intact content and comprehension.
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- 4.
Apraxia of speech:
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Impairment of oral motor planning in the absence of muscle weakness
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Can be tested by asking the patient to repeat words with increasing number of syllables
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Cranial nerve examination
- 1.
Olfactory:
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This is the most commonly injured cranial nerve in mild TBI. It occurs at a higher rate in moderate and severe TBI, but the incidence is difficult to ascertain given the difficulty in examining the nerve in an unresponsive patient and in those who are conscious but have communication and cognitive impairments.
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Close eyes, compress opposite nostril, and smell common substances
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- 2.
Optic:
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Visual acuity: central vision
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Ophthalmoscope examination: observe the optic disc, retinal vessels, and fovea.
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In increased intracranial pressure may see blurring of the optic disc
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Visual fields: this involves confrontational testing. This can be difficult to do with brain injury patients because cognitive impairments may make it difficult to follow commands for testing.
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Visual extinction: typically occurs after unilateral brain damage. Patients will be unable to identify two bilateral stimuli presented simultaneously but can identify single stimuli presented in each visual field independently.
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- 3.
Oculomotor:
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The oculomotor nerve innervates all extraocular muscles except superior oblique and lateral rectus.
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Medial rectus: adducts the eye
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Superior rectus: elevates the eye
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Inferior oblique: elevates the eye
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Inferior rectus: depresses the eye
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Levator palpebrae: elevates eyelid
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Pupilloconstrictor muscle: constricts the pupil
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Ciliary muscle: controls thickness of lens in accommodation
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- 4.
Trochlear:
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Controls the superior oblique muscle: depresses the eye primarily while in adduction
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- 5.
Trigeminal:
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Sensation to face, mucous membranes of nose, mouth, and tongue
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Consists of three divisions: ophthalmic (V1), maxillary (V2), and mandibular (V3)
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Test each division with pinprick, light touch, and temperature.
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Motor muscles of mastication: masseters, pterygoids, and temporalis
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- 6.
Abducens:
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Lateral rectus: abducts the eye
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- 7.
Facial:
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Motor innervation to muscles of facial expression
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Central lesion: sparing of forehead
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Peripheral lesion: no sparing of forehead; upper and lower face is involved
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Sensation to anterior two-thirds of the tongue and external acoustic meatus
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Innervates stapedius muscle; functions to dampen ossicle movement and decrease volume
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Hyperacusis may occur in facial nerve palsy
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Innervates secretomotor fibers to lacrimal and salivary glands
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- 8.
Vestibulocochlear:
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Cochlear nerve: auditory nerve
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Screen by rubbing fingers near each ear; if there is asymmetry, perform the Rinne and Weber tests. ,
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Weber test: conductive hearing loss
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Place the tuning fork on top of the patient’s head; it will be louder on the side with conductive hearing loss.
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Rinne test: air conduction versus bone conduction
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Place the tuning fork on the mastoid prominence; then place near the ear once the patient can no longer hear it. If the bone conduction is greater than the air conduction, there is a conductive hearing impairment.
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If there is a sensorineural hearing loss, the vibration is heard substantially longer than usual in the air.
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Vestibular nerve:
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Dix-Hallpike maneuver can differentiate between a peripheral or central vestibular dysfunction.
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- 9.
Glossopharyngeal:
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Taste to posterior one-third of tongue; sensation to the pharynx and middle ear
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Tested together with the vagus nerve by performing the gag reflex
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- 10.
Vagus:
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Innervates the muscles of the larynx and pharynx
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Damage to this nerve may result in dysphagia.
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Recurrent laryngeal nerve: Damage can lead to hoarseness.
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The vagus nerve also supplies parasympathetic fibers.
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- 11.
Spinal accessory:
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Innervates the trapezius and sternocleidomastoid muscles
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The ipsilateral sternocleidomastoid rotates the head to the contralateral side and brings the ear to ipsilateral shoulder.
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- 12.
Hypoglossal:
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Controls the intrinsic muscles of the tongue
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Peripheral lesion: Tongue points to side of the lesion.
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Central lesion: Tongue points away from the lesion.
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Cranial nerve reflexes
- 1.
Pupillary light reflex :
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Afferent: optic nerve (cranial nerve [CN] II)
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Efferent: oculomotor nerve (CN III)
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Shining light in one eye results in both pupils constricting.
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Anisocoria up to 1 mm asymmetry is physiological (but it has to be observed in the light and dark).
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- 2.
Gag reflex :
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Afferent: glossopharyngeal nerve (CN IX)
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Efferent: vagus nerve (CN X)
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Touching the pharynx with a long Q-tip on both the left and right side should elicit a gag or cough.
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- 3.
Corneal reflex :
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Afferent: trigeminal nerve (V)
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Efferent: facial nerve (VII)
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Touching the cornea with a cotton wisp will elicit a blink response in both eyes.
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Oculomotor examination
- 1.
Fixation :
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Alternately focus on an object 1 m away and then an object 6 m away.
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Monitor for abnormal eye movements such as nystagmus, which can indicate dysfunction of the vestibular system.
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- 2.
Saccadic movements :
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Voluntary rapid eye movements; patient’s gaze fixates alternately on two targets
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Monitor for saccadic slowing and dysmetria.
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Saccadic dysmetria occurs with over- or undershooting a target; to a small degree is normal but should decrease with repetitive testing
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- 3.
Pursuit movements :
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Moving an object with the patient’s head held still will normally result in smooth movement of the eyes as they track the object.
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Corrective saccades will be seen if the eyes cannot keep up with the object.
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- 4.
Convergence :
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In the average individual, the location of maximum convergence is approximately 8 to 10 cm.
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In brain-injured patients, the location of maximum converge is typically longer than this.
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- 5.
Opticokinetic nystagmus :
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This is a normal nystagmus that is elicited by tracking of a movement and is typically performed by observing the patient track a sequence of moving stimuli. A normal response is the eyes tracking the object then rapidly moving in the opposite direction to pick up the next object.
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When performing this, the examiner should observe regularity, smoothness, and duration of the optokinetic response.
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- 6.
Vestibular system :
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This can be tested by assessing for the vestibulo–ocular reflex. With a normally functioning vestibular system, the patient should have the ability to keep the fovea centered on a target despite movements of the head.
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Dysphagia
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Oropharyngeal dysphagia:
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Commonly a result of weakness or motor apraxia in the muscle of the larynx and pharynx
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Dysphagia can result in aspiration pneumonia, dehydration, and malnutrition.
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Bedside screen for dysphagia:
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Performed by having the patient drink a small sip of water
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Observe for any coughing, dyspnea, or change in voice quality.
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Often misses silent aspiration
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Videofluorographic swallow study (VFSS):
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The standard of care for assessing dysphagia
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Observes oral, pharyngeal, and esophageal phases of swallowing and can identify functional or structural abnormalities
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Fiberoptic endoscopic evaluation of swallowing (FEES):
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Evaluates pharyngeal and laryngeal anatomy and vocal fold function
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Does not visualize the oral and esophageal phases of swallowing
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It may be performed if VFSS is contraindicated, if aspiration is still suspected despite normal VFSS, or if vocal cord dysfunction is suspected.
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Motor
- 1.
Strength:
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Manual motor muscle testing :
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0: No movement
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1: Trace muscle movement is felt when examiner is palpating the muscle
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2: Full active range of motion (AROM) with gravity eliminated
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3: Full AROM against gravity but not against resistance
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4: Full AROM and provides moderate resistance
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5: Full AROM and provides maximal resistance
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- 2.
Motor apraxia:
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Impaired motor planning when performing tasks or movements despite understanding of the request or command and without muscular or sensory impairment
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- 3.
Involuntary movements
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This includes tremors, dystonia, myoclonus, choreiform movements, and akathisia.
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- 4.
Tone:
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Spasticity: velocity-dependent involuntary increase in tone; commonly measured using one of two scales:
- A.
Modified Ashworth Scale (MAS)
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See Table 13.3
TABLE 13.3Related posts:
TBI by pattern: Penetrating, nonpenetrating, and blast injury
Intensity of services, specialized rehabilitation therapies, and interdisciplinary team management
Neuroendocrine, metabolic and hormonal conditions
Emotional dyscontrol
Geriatric traumatic brain injury
Dual diagnosis of traumatic brain injury and spinal cord injury
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