Comprehensive Guide to Neurological Examination: Motor, Sensory, Reflexes, Coordination, and Gait Assessment

Introduction

The neurological examination is a systematic process that evaluates the integrity of the central and peripheral nervous systems. It proceeds from higher mental functions and cranial nerves to the motor system, reflexes, coordination, sensory modalities, and finally gait.

Motor System Examination

1. Inspection

• Look for muscle wasting, hypertrophy, or asymmetry.
• Measure limb circumference above and below joints if needed.
• Observe for fasciculations (irregular muscle twitches) by gentle tapping.

2. Tone

• Definition: Resistance of a relaxed muscle to passive movement.
• Types:
• Hypertonia – increased tone (spasticity or rigidity).
  • Spasticity: “clasp‑knife” pattern, lesion of corticospinal tract.
  • Rigidity: uniform resistance; can be "lead‑pipe" or "cog‑wheel" (jerky).
• Hypotonia – reduced tone, often due to lower motor neuron lesions.
• Assessment Techniques:
• Upper limbs: flex/extend wrist and elbow, feeling resistance.
• Lower limbs:
  1. Flex/extend knee while palpating muscle.
  2. Roll the leg over the bed surface.
  3. Quick thigh lift – observe leg kick (spastic) vs. dragging (floppy).

3. Muscle Power (Medical Research Council Scale)

• Pyramidal (corticospinal) tract lesion clue: Pronator drift – patient extends arms, palms up, eyes closed; the affected arm drifts down and pronates.
• Root or peripheral nerve lesion: Test individual muscle groups.

4. Specific Muscle Testing (Upper Limb)

• Serratus anterior: Push against wall; winged scapula indicates weakness.
• Deltoid: Shoulder abduction against resistance.
• Biceps: Elbow flexion against resistance.
• Triceps: Elbow extension against resistance.
• Brachioradialis: Elbow flexion with hand in mid‑pronation.
• Extensor digitorum: Extend fingers against resistance.
• Extensor pollicis (long & brevis): Thumb extension.
• Flexor digitorum profundus: Finger flexion against pull.
• Opponens pollicis: Touch base of little finger with thumb against resistance.
• First dorsal interosseous & abductor digiti minimi: Finger abduction against resistance.

5. Specific Muscle Testing (Lower Limb)

• Hip flexors (iliopsoas): Pull thigh toward abdomen.
• Hip extensors (gluteus maximus): Push down on examiner’s hand.
• Knee flexors (hamstrings): Flex knee against resistance.
• Knee extensors (quadriceps): Extend knee against resistance.
• Hip abductors (gluteus medius/minimus): Abduct leg against resistance.
• Hip adductors: Adduct leg against resistance.
• Dorsiflexors (tibialis anterior): Lift foot against resistance.
• Plantar flexors (gastrocnemius/soleus): Push down on examiner’s hand.
• Great toe extensors (extensor hallucis longus): Extend big toe against resistance.
• Inversion (tibialis posterior) & eversion (peroneus longus/brevis): Move foot inward/outward against resistance.

Reflex Examination

Deep Tendon Reflexes (DTRs)

• Upper limb: Supinator (radial), Biceps, Triceps.
• Lower limb: Patellar (knee jerk), Achilles (ankle jerk).
• Technique: Use a reflex hammer; compare sides.
• If DTRs are absent: Perform the "Jendrassik maneuver" (patient clenches teeth or interlocks fingers) to facilitate response.

Superficial Reflexes

• Abdominal reflex: Light stroking from outer to inner quadrants; look for concentric contraction.
• Cremaster reflex: Not demonstrated here.
• Plantar reflex: Stroke lateral sole to toe tip. Normal = flexion of great toe with adduction of other toes. Babinski sign (extension of great toe with fanning) indicates corticospinal tract lesion.
• Additional plantar elicitation methods:
• Oppenheim (open‑hand) sign: Firm pressure on tibial shaft.
• Gordon’s reflex: Pressure on calf.
• Schaefer’s sign: Pressure over Achilles tendon.

Coordination and Cerebellar Testing

• Upper limb:
• Finger‑to‑nose: Assess dysmetria and intention tremor.
• Rapid alternating movements (dysdiadochokinesia): Flip hands rapidly; inability suggests cerebellar dysfunction.
• Lower limb:
• Heel‑to‑shin: Slide heel from knee to ankle; a smooth, straight line indicates normal coordination.

Sensory Examination

Modalities

• Spinothalamic tract: Pain and temperature.
• Dorsal columns: Vibration and proprioception (joint position sense).

Pain & Temperature

• Use a sterile pin for pain; explain sensation before testing.
• Use warm and cold test tubes for temperature.
• Test in a systematic pattern, noting patient’s count of stimuli with eyes closed.

Proprioception (Joint Position Sense)

• Move patient’s finger or toe up/down with eyes closed; patient reports direction.
• If distal joint is impaired, test a more proximal joint.

Vibration Sense

• 128 Hz tuning fork placed on distal joints (ankle, great toe, then progressively proximal). Patient signals when vibration ceases.

Cortical Sensations (Higher‑order sensory testing)

• Two‑point discrimination: Determine minimal distance at which patient perceives two separate points (better on hand than foot).
• Sensory inattention (perceptual rivalry): Touch one or both hands; patient identifies which hand(s) were touched.
• Stereognosis: Place an object (e.g., coin) in hand; patient identifies it with eyes closed.
• Graphesthesia: Draw numbers/letters on palm; patient names them.

Gait Assessment

• Romberg test: Stand feet together, eyes open → eyes closed. Sway with eyes open → cerebellar/cerebral lesion; sway only with eyes closed → dorsal column lesion (sensory ataxia).
• Gait types:
• Festinating gait: Short, rapid steps, stooped posture – Parkinson’s disease.
• Circumduction gait: Stiff limb, foot drags in a circular path – pyramidal tract lesion.
• Cerebellar (wide‑based) gait: Unsteady, “drunken” appearance – cerebellar disease.

Summary of Examination Sequence

1. Higher mental functions
2. Cranial nerves I‑XII
3. Motor system – bulk, tone, power, reflexes, coordination
4. Sensory system – pain, temperature, vibration, proprioception, cortical sensations
5. Gait and balance (Romberg)

The systematic approach integrates findings to pinpoint the level and nature of neurological pathology.

A thorough, step‑by‑step neurological exam—starting with inspection, tone, and power, followed by reflexes, coordination, detailed sensory testing, and gait analysis—provides essential clues to localise lesions within the central or peripheral nervous system, enabling accurate diagnosis without the need for video demonstration.