When a neurologic disorder is suspected, doctors usually evaluate all of the body systems during the physical examination, but they focus on the nervous system. They do a neurologic examination, which includes evaluation of mental status, cranial nerves, motor and sensory nerves, reflexes, coordination, balance, walking (gait), regulation of internal body processes (by the autonomic nervous system), and blood flow to the brain. Doctors may evaluate some areas more thoroughly than others depending on what type of disorder they suspect.

What Is a Neurologic Symptom? Neurologic symptoms—symptoms caused by a disorder that affects part or all of the nervous system—can vary greatly because the nervous system controls so many different body functions. Symptoms can include all forms of pain, including headache and back pain. Muscles, skin sensation, the special senses (vision, taste, smell, and hearing), and other senses depend on nerves to function normally. Thus, neurologic symptoms can include muscle weakness or incoordination, abnormal sensations in the skin, and disturbances of the senses. Neurologic disorders can interfere with sleep, making a person anxious or excited at bedtime and thus lethargic and sleepy during the day. Neurologic symptoms may be minor (such as a foot that has fallen asleep) or life threatening (such as coma due to stroke). The characteristics and pattern of symptoms help doctors diagnose the neurologic disorder. The following are some relatively common neurologic symptoms: Pain Back pain Neck pain Headache Pain along a nerve pathway (as in sciatica or shingles) “Central” pain (arising from abnormal nerve circuits) Muscle malfunction Weakness Tremor Paralysis Involuntary movements (such as tics) Abnormalities in walking Clumsiness or poor coordination Muscle spasms Rigidity, stiffness, and spasticity Slowed movements Changes in sensation Numbness of the skin Tingling or a pins-and-needles sensation Hypersensitivity to light touch Loss of sensation for touch, cold, heat, or pain Loss of position sense Changes in the special senses Disturbances of smell and taste Visual hallucinations Partial or complete loss of vision Double vision Deafness Ringing or other sounds originating in the ears (tinnitus) Other symptoms Vertigo Loss of balance Difficulty swallowing Slurred speech (dysarthria) Sleep problems Difficulty falling or staying asleep Uncontrollable leg movements Falling asleep uncontrollably (as in narcolepsy) or sleeping too much Changes in consciousness Fainting Confusion or delirium Seizures Coma Stupor Changes in cognition (mental ability) Difficulty understanding language or using language to speak or write (aphasia) Poor memory Difficulty performing common motor skills, such as striking a match or combing one's hair, despite normal strength (apraxia) Inability to recognize familiar objects (agnosia) Inability to sustain concentration when performing a task Inability to distinguish right from left Inability to perform simple arithmetic (acalculia) Poor visual-spatial comprehension (for example, inability to draw a clock; becoming lost driving in a familiar neighborhood) Dementia (dysfunction of multiple cognitive functions)

Mental Status: Doctors evaluate the following:

• Attention
• Orientation to time, place, and person
• Memory
• Various abilities, such as thinking abstractly, following commands, using language, and solving math problems
• Mood

The evaluation consists of a series of questions and tasks, such as naming objects, recalling short lists, writing sentences, and copying shapes. The person's answers are recorded and scored for accuracy. If the person reports feeling depressed, doctors ask if there have been any thoughts of suicide.

Mental Status Testing What People May Be Asked To Do What This Test Indicates State the current date and place, and name specific people Orientation to time, place, and person Repeat a short list of objects Attention Recall the short list of objects after 3 to 5 minutes Immediate recall Describe an event that happened in the last day or two Recent memory Describe events from the distant past Remote memory Interpret a proverb (such as “a rolling stone gathers no moss”), or explain a particular analogy (such as “why the brain is like a computer”) Abstract thinking Describe feelings and opinions about the illness Insight into illness Name the last five presidents and the state capital Fund of knowledge Tell how they feel on this day and how they usually feel Mood Follow a simple command that involves three different body parts and requires distinguishing right from left (such as “put your right thumb in your left ear and stick out your tongue”) Language comprehension Name simple objects and body parts, and read, write, and repeat certain phrases Ability to use language Without looking, identify small objects held in the hand and numbers written on the palm, and discriminate between being touched in one or two places Ability of the brain to process and interpret complex sensory information from the hand Copy simple and complex structures (for example, using building blocks) or finger positions, and draw a clock, cube, or house Ability to understand spatial relationships Brush the teeth or take a match out of a box and strike it Ability to perform an action Do simple arithmetic Ability to calculate numbers

Cranial Nerves: There are twelve cranial nerves, which connect the brain with the eyes, ears, nose, face, tongue, throat, neck, upper shoulders, and some internal organs (see Testing Cranial Nerves ). How many nerves doctors test depends on what type of disorder they suspect. For example, the 1st cranial nerve (the nerve of smell) is not usually tested when a muscle disorder is suspected, but it is tested in people recovering from serious head trauma (because smell is often lost). A cranial nerve may be damaged anywhere along its length as a result of injury, impaired blood flow, an autoimmune disorder, a tumor, or an infection. The exact site of the damage can often be identified by testing the functions of a particular cranial nerve.

Motor and Sensory Nerves: Motor nerves carry impulses from the brain and spinal cord to voluntary muscles (muscles controlled by conscious effort), such as muscles of the arms and legs. Weakness or paralysis of a muscle may indicate damage to the muscle itself, a motor nerve, or its connection to the muscle (synapse), the brain, or the spinal cord. Doctors look for abnormalities such as the following:

• Tremor and other involuntary muscle movements
• Muscle twitching
• Decrease in muscle size (wasting or atrophy)
• Increase in muscle size
• Increase (spasticity, rigidity) or decrease in muscle tone
• Pattern of weakness
• Dexterity

The doctor inspects the muscles for size, unusual movements, tone, strength, and dexterity. A muscle wastes away (atrophies) when the muscle or the nerves supplying it are diseased or when the muscle has not been used for months for other reasons (such as being in a cast).

Muscles may move without the person meaning them to. For example, tiny muscle twitches (fasciculations) indicate nerve damage to that muscle. Other possible involuntary movements are rhythmic movements of a body part (tremor), twitches (tics), sudden flinging of a limb (hemiballismus), quick fidgety movements (chorea), or snake-like writhing (athetosis), all of which suggest disease in areas of the brain (called basal ganglia) that control motor coordination.

When doctors move a person's limb passively around a joint, they note the degree of resistance to movement (muscle tone). Muscle tone that is uneven and suddenly increased (spasticity) may be due to a stroke or spinal cord injury. Muscle tone that is evenly increased (rigidity) may be due to disease of the basal ganglia, such as Parkinson's disease. Muscle tone is severely reduced (flaccid) immediately and temporarily after a spinal cord injury produces paralysis.

Doctors test muscle strength by asking the person to push or pull against resistance or to do maneuvers that require strength, such as walking on the heels and tiptoes or rising from a chair. Sometimes weakness is evident when a person uses one limb more than another (for example, when swinging the arms while walking or when holding the arms up with the eyes closed). Weakness that affects the muscles of the upper arms and legs more than the hands and feet may indicate a disorder that affects all of the muscles (myopathy). Myopathies tend to affect the largest muscles first. The person may have difficulty combing hair or climbing stairs. When the hand and feet are weaker than the upper arms and legs, the problem is often a polyneuropathy—a disorder that affects all of the nerves outside of the brain and spinal cord (peripheral nerves). Polyneuropathies tend to affect the longest nerves first (those in the hands and feet). The person may have the most trouble with fine finger movements. When weakness is limited to one side of the body, doctors suspect a disorder affecting one side of the brain, such as a stroke. Weakness that affects the body below a certain part may be caused by a spinal cord disorder. For example, an injury to the thoracic spine causes the legs but not the arms to be paralyzed. An injury in or above the neck causes paralysis of all four limbs. Weakness may also occur in other patterns, such as those corresponding to one or more particular peripheral nerves. Strength may decrease with repetitive activity, as occurs in myasthenia gravis.

Sensory nerves carry information from the body to the brain about such things as touch, pain, heat, cold, vibration, the position of body parts, and the shape of objects. Abnormal sensations or reduced perception of sensations may indicate damage to a sensory nerve, the spinal cord, or certain parts of the brain. Information from specific areas on the body's surface, called dermatomes (see Spinal Cord Disorders: Dermatomes), is carried to a specific location (level) in the spinal cord, then to the brain. Thus, doctors may be able to pinpoint the specific level of damage to the spinal cord by identifying the areas where sensation is abnormal or lost.

The surface of the body is tested for loss of sensation. Usually, doctors concentrate on the area where the person feels numbness, tingling, or pain. A pin and a blunt object (such as the head of a safety pin) are used to see if the person can tell the difference between sharp and dull. Doctors also test the person's ability to feel gentle touch, heat, and vibration. To test position sense, doctors move the person's finger or toe up or down and ask the person to describe its position without looking.

Reflexes: A reflex is an automatic response to a stimulus. For example, the lower leg jerks when the tendon below the kneecap is gently tapped with a small rubber hammer. The pathway that a reflex follows (reflex arc) does not directly involve the brain. The pathway consists of the sensory nerve to the spinal cord, the nerve connections in the spinal cord, and the motor nerves back to the muscle. Doctors test reflexes to determine whether all parts of this pathway are functioning. The reflexes most commonly tested are the knee jerk and similar reflexes at the elbow and ankle.

Reflex Arc: A No-Brainer A reflex arc is the pathway that a nerve reflex, such as the knee jerk reflex, follows. A tap on the knee stimulates sensory receptors, generating a nerve signal. The signal travels along a nerve to the spinal cord. In the spinal cord, the signal is transmitted from the sensory nerve to a motor nerve. The motor nerve sends the signal back to a muscle in the thigh. The muscle contracts, causing the lower leg to jerk upward. The entire reflex occurs without involving the brain.

The plantar reflex may help doctors diagnose abnormalities in the nerve pathways involved in the voluntary control of muscles. It is tested by firmly stroking the outer border of the sole of the foot with a key or other object that causes minor discomfort. Normally, the toes curl downward, except in infants aged 6 months or younger. Having the big toe go upward and the other toes spread out is a sign of an abnormality in the brain or spinal cord.

Testing other reflexes can provide important information. For example, doctors learn the extent of injury in a comatose person by noting whether the pupils constrict when light is shined on them (pupillary light reflex), whether the eyes blink when the cornea is touched (corneal reflex), and how the eyes move when the person's head is turned or when water is flushed into the ear canal. Seeing the anus constrict when lightly touched (anal wink) is a good sign in a person with a spinal cord injury.

Coordination, Balance, and Gait: Coordination and walking (gait) require integration of signals from sensory and motor nerves by the brain and spinal cord. To test these abilities, doctors ask a person to walk in a straight line, placing one foot in front of the other. They ask the person to use the forefinger to reach out and touch the doctor's finger, then the person's own nose, and then to repeat these actions rapidly. The person may be asked to do these actions first with the eyes open, then with the eyes closed.

For the Romberg test, the person stands still with both feet together as close as possible without losing balance. Then the eyes are closed. If balance is lost, information about position from the legs is not reaching the brain, usually because the nerves or spinal cord is injured.

Autonomic Nervous System: The autonomic (involuntary) nervous system regulates internal body processes that require no conscious effort, such as blood pressure, heart rate, breathing, and temperature regulation through sweating or shivering. An abnormality of this system may cause a fall in blood pressure when a person stands up (orthostatic hypotension), reduction or absence of sweating, or sexual problems such as difficulty initiating or maintaining an erection. Doctors may do a variety of tests, such as measuring blood pressure and heart rate while the person is lying down, sitting, and standing.

Blood Flow to the Brain: A severe narrowing of the arteries to the brain reduces blood flow and increases the risk of stroke. The risk is higher for people who are older, who smoke cigarettes, or who have high blood pressure, high cholesterol levels, diabetes, or disorders of the arteries or heart. Doctors place a stethoscope on the neck (over the carotid artery) and listen for turbulent blood flow through a narrowed or irregular artery (the sound of turbulent blow flow is called a bruit). However, the best way to diagnose disorders of the arteries is to use ultrasound (called carotid duplex and transcranial ultrasonography), magnetic resonance angiography (MRA), computed tomography angiography (CTA), or cerebral angiography. Blood pressure may be measured in both arms to check for blockages in the large arteries that branch off from the aorta. Such blockages sometimes result in stroke.

Turbulent Blood Flow

Last full review/revision October 2007 by Michael Jacewicz, MD