What is your neurologist looking for? It is simple really. Neurology is very localizing so everything you do from the moment you walk in to the office is being analyzed. You will not know it, but it is. The following is an explanation of the complete neurological exam for the purpose of the MS evaluation:
1. EVALUATE MENTAL STATUS/COMMUNICATION AND ATTENTION SPAN.
A. Does the patient answer questions appropriately and in a timely manner? (Slowness could mean loss of cognitive function)
B. Does the patient have dysartria? Trouble pronouncing "T, M, L, or G". (Could be a sign of IX or IX, or VII cranial nerve palsy).
C. Does the patient have dysphonia? Low voice...trailing off voice. (Could be a sign of X nerve palsy).
D. Are the sentences smooth, or are they short and choppy as seen in MS dysarthria? Are they searching for words?
2. OPTIC NERVE: Cranial nerve II
This nerve is tested by having the neurologist look into your eye with a light and actually view your optic nerve to check for inflammation. This test is limiting in that it can only test for front of the optic nerve swelling not behind the disk swelling.
3. OCULOMOTOR NERVES: Cranial nerves III, IV, and VI
These are tested together if one is not obviously in palsy. Testing is done by having you look up, down, left, right, in an H pattern.
A. A third nerve palsy is when there is a dilated pupil, an eye that deviates outward, ptosis, or a combination of these defects. The lesion is on the same side (Localizing).
B. A forth nerve palsy is when thee is an inability of the opposite side eye to look down and in.
C. A sixth nerve palsy is when the patient is unable to look toward the same side of the lesion.
4. TRIGEMINAL NERVE: Cranial nerve V: Trigeminal nerve has both sensory and motor components. For testing:
A. Sensory: The neurologist will lightly touch your face and forehead and top of scalp with sharp and dull objects on both sides to test for differences.
B. Motor: They will test your motor control by having you clench your teeth and test your jaw muscles.
C. Corneal reflex: They can test by using a wisp of cotton and touching your cornea to see if there is a response. If no response, then the trigeminal nerve is damaged.
5. FACIAL NERVE: Cranial nerve VII:
They will have you raise your eyebrows, move your face around, smile etc. Normal is symmetrical.
6. VESTIBULAR NERVE: Cranial nerve VIII:
They will rub their fingers around your ear to test your hearing. Also test for balance. This is tricky with MS but can be sorted out with other test because of its localizing value.
7. GLOSOPHARYNGEAL AND VAGUS NERVES: Cranial nerves IX and X:
Tested together, IX affects the sensory portion of the pharynx and the ability to taste in the posterior portion of the tongue. Cranial nerve X's function is mainly motor and affects speech and swallowing.
A. Testing: They will listen to your voice. Any hoarseness, or harshness may show deficit. If both sides are affected, difficulty with swallowing will be present.
B. They will look in your throat. If your tongue is not midline, this could be a sign of IX nerve palsy. If your uvula deviates to one side when you say "ah", it could be a sign of X nerve palsy.
C. They will test your gag reflex.
8. SPINAL ACCESSORY NERVE: Cranial nerve XI
This nerve controls the muscles of the neck and shoulder.
A. They will have you push against their hand with your face. Tests for weakness in this nerve.
9. HYPOGLOSSAL NERVE: Cranial nerve XII
This nerve is the motor function that controls tongue movement.
They will have you stick out your tongue. Any deviation or atrophy shows damage to this nerve and can cause problems with speech and swallowing.
ALL OF THESE ARE ROOTED IN THE BRAINSTEM AND ARE IMPORTANT IN THE TESTING OF MS.
Now for the motor part of the exam:
1. WALKING: They will observe you walk to look for subtle weakness in your legs.
2. WALKING ON HEELS: Tells them how much weakness you have in your legs.
3. WALKING ON TOES: Tells them how much spasticity you have in legs.
4. HEEL TO TOE WALKING: Tells them about your balance.
5. HOP ON ONE FOOT: Brings out subtle weaknesses.
6. Hold your arms out in front of you: This assesses three things.
1. If you have overshoot.
2. If you have spacticity in your arms.
3. If you have pronator drift (weakness in your arms).
7. ROMBERGS TEST: Often done with the hold your hands out test. Tests for balance and lesions. It really also tests for inner ear problems. A person with a positive ROMBERG will fall toward the lesion.
8. Strength: push and pull against me:
This assesses both your strength and spasticity. You can have both. In MS people have a cog-wheel spasticity. You don't want to arm wrestle us.
9. BABINSKI REFLEX:
One of the most important tests. This will by far tell the most about what is going on in your brain. Only babies and brain damaged adults have this.
This is when the doc scrapes the heel of your foot with an object and your big toe either goes up, or crunches down.
If it goes up and the other toes fan out, you have the reflex and have some sort of brain damage be it MS or otherwise. This cannot be faked if a good neurologist is doing it. It is a reflex.
10. You will also get the standard pin/cotton tests everywhere...do you feel this, more or less.
11. Vibration: With a tuning fork, the neurologist will strike a bone with this fork and ask you when you stop feeling the vibration, or if you feel it at all, or if it is the same on both sides. They are testing symmetry and lesion location.
I am sure I have missed some, but in the end, neurology is very localizing. You can almost find a lesion by exam and confirm it later by MRI. We do need MRI's, however, nothing replaces a good PE.
1. EVALUATE MENTAL STATUS/COMMUNICATION AND ATTENTION SPAN.
A. Does the patient answer questions appropriately and in a timely manner? (Slowness could mean loss of cognitive function)
B. Does the patient have dysartria? Trouble pronouncing "T, M, L, or G". (Could be a sign of IX or IX, or VII cranial nerve palsy).
C. Does the patient have dysphonia? Low voice...trailing off voice. (Could be a sign of X nerve palsy).
D. Are the sentences smooth, or are they short and choppy as seen in MS dysarthria? Are they searching for words?
2. OPTIC NERVE: Cranial nerve II
This nerve is tested by having the neurologist look into your eye with a light and actually view your optic nerve to check for inflammation. This test is limiting in that it can only test for front of the optic nerve swelling not behind the disk swelling.
3. OCULOMOTOR NERVES: Cranial nerves III, IV, and VI
These are tested together if one is not obviously in palsy. Testing is done by having you look up, down, left, right, in an H pattern.
A. A third nerve palsy is when there is a dilated pupil, an eye that deviates outward, ptosis, or a combination of these defects. The lesion is on the same side (Localizing).
B. A forth nerve palsy is when thee is an inability of the opposite side eye to look down and in.
C. A sixth nerve palsy is when the patient is unable to look toward the same side of the lesion.
4. TRIGEMINAL NERVE: Cranial nerve V: Trigeminal nerve has both sensory and motor components. For testing:
A. Sensory: The neurologist will lightly touch your face and forehead and top of scalp with sharp and dull objects on both sides to test for differences.
B. Motor: They will test your motor control by having you clench your teeth and test your jaw muscles.
C. Corneal reflex: They can test by using a wisp of cotton and touching your cornea to see if there is a response. If no response, then the trigeminal nerve is damaged.
5. FACIAL NERVE: Cranial nerve VII:
They will have you raise your eyebrows, move your face around, smile etc. Normal is symmetrical.
6. VESTIBULAR NERVE: Cranial nerve VIII:
They will rub their fingers around your ear to test your hearing. Also test for balance. This is tricky with MS but can be sorted out with other test because of its localizing value.
7. GLOSOPHARYNGEAL AND VAGUS NERVES: Cranial nerves IX and X:
Tested together, IX affects the sensory portion of the pharynx and the ability to taste in the posterior portion of the tongue. Cranial nerve X's function is mainly motor and affects speech and swallowing.
A. Testing: They will listen to your voice. Any hoarseness, or harshness may show deficit. If both sides are affected, difficulty with swallowing will be present.
B. They will look in your throat. If your tongue is not midline, this could be a sign of IX nerve palsy. If your uvula deviates to one side when you say "ah", it could be a sign of X nerve palsy.
C. They will test your gag reflex.
8. SPINAL ACCESSORY NERVE: Cranial nerve XI
This nerve controls the muscles of the neck and shoulder.
A. They will have you push against their hand with your face. Tests for weakness in this nerve.
9. HYPOGLOSSAL NERVE: Cranial nerve XII
This nerve is the motor function that controls tongue movement.
They will have you stick out your tongue. Any deviation or atrophy shows damage to this nerve and can cause problems with speech and swallowing.
ALL OF THESE ARE ROOTED IN THE BRAINSTEM AND ARE IMPORTANT IN THE TESTING OF MS.
Now for the motor part of the exam:
1. WALKING: They will observe you walk to look for subtle weakness in your legs.
2. WALKING ON HEELS: Tells them how much weakness you have in your legs.
3. WALKING ON TOES: Tells them how much spasticity you have in legs.
4. HEEL TO TOE WALKING: Tells them about your balance.
5. HOP ON ONE FOOT: Brings out subtle weaknesses.
6. Hold your arms out in front of you: This assesses three things.
1. If you have overshoot.
2. If you have spacticity in your arms.
3. If you have pronator drift (weakness in your arms).
7. ROMBERGS TEST: Often done with the hold your hands out test. Tests for balance and lesions. It really also tests for inner ear problems. A person with a positive ROMBERG will fall toward the lesion.
8. Strength: push and pull against me:
This assesses both your strength and spasticity. You can have both. In MS people have a cog-wheel spasticity. You don't want to arm wrestle us.
9. BABINSKI REFLEX:
One of the most important tests. This will by far tell the most about what is going on in your brain. Only babies and brain damaged adults have this.
This is when the doc scrapes the heel of your foot with an object and your big toe either goes up, or crunches down.
If it goes up and the other toes fan out, you have the reflex and have some sort of brain damage be it MS or otherwise. This cannot be faked if a good neurologist is doing it. It is a reflex.
10. You will also get the standard pin/cotton tests everywhere...do you feel this, more or less.
11. Vibration: With a tuning fork, the neurologist will strike a bone with this fork and ask you when you stop feeling the vibration, or if you feel it at all, or if it is the same on both sides. They are testing symmetry and lesion location.
I am sure I have missed some, but in the end, neurology is very localizing. You can almost find a lesion by exam and confirm it later by MRI. We do need MRI's, however, nothing replaces a good PE.
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