What should the patients response be when the examiner tests the patients Cremasteric reflex?

Summary

Neurological examination is the assessment of mental status, cranial nerves, motor and sensory function, coordination, and gait for the diagnosis of neurological conditions. Findings should always be compared with the contralateral side and upper limb function should be compared with lower limb function to determine the location of a lesion. Subtle central nervous system defects can be detected with careful observation of patients performing tasks that require the simultaneous activation of multiple cerebral areas. This article provides information about several examination methods and explains key terms relevant to the evaluation of neurological conditions.

Mental status examination

The mental status examination is a key component of any neurological examination and involves assessing the following points, based on patient history and clinical observation:
- Appearance and behavior
- Sensorium and cognition
- Mood and affect
- Speech
- Thought process
- Thought content
- Perceptual disturbances
- Insight and judgment
A more focused mental status examination is performed in the workup of specific neurological disorders and symptoms.
In emergency settings, the mental status examination focuses on the assessment of orientation and level of consciousness using standardized scales [e.g., Glasgow coma scale].
See “Mental status examination” for a comprehensive discussion of examination elements and possible findings.

Types of aphasia

Types of aphasiaLocation of lesionTypeClinical featuresBroca aphasia [motor aphasia, expressive aphasia]Wernicke aphasia [sensory aphasia, receptive aphasia]Global aphasiaConduction aphasia [associative aphasia]Anomic aphasiaTranscortical aphasiaTranscortical motor aphasiaTranscortical sensory aphasiaTranscortical mixed aphasia

Broca area [inferior frontal gyrus]	Nonfluent	Telegraphic and grammatically incorrect speech Comprehension is largely spared [difficulty understanding complex language may occur]. The patient is typically aware of the deficit and feels frustrated about it. Impaired repetition
Wernicke area [superior temporal gyrus]	Fluent	Fluent speech that lacks sense [paraphasic errors, neologisms, word salad] Comprehension is impaired. The patient is typically unaware of the deficits. Impaired repetition Reading and writing are often severely impaired.
Broca area, Wernicke area, and arcuate fasciculus	Nonfluent	Severe impairment of speech production and comprehension Patient may be mute or only utter sounds Inability to comprehend speech
Arcuate fasciculus of the parietal lobe	Fluent	Mostly intact comprehension and fluent speech production Impaired repetition with paraphasia [patients substitute or transpose sounds and try to correct mistakes on their own]
Usually, pinpointing the localization of the lesion is not possible.	Fluent	Isolated difficulty finding words Paraphrasing occurs when patients cannot find the word they seek.
Supplementary motor area in the frontal lobe, with Broca area intact [exception: may occur during the recovery phase of Broca aphasia]	Nonfluent	Difficulty initiating speech Difficulty in expressing a thought process Difficulty producing own phrases Intact repetition and comprehension
Various areas of the temporal lobe, with the Wernicke area intact	Fluent	Impaired speech expression and comprehension Errors in paraphrasing Poor comprehension Intact repetition
Broca area, Wernicke area, and arcuate fasciculus intact, with the surrounding watershed areas affected	Nonfluent	Poor comprehension of spoken and written language

The Broca's area is broken in Broca aphasia.
Speech of patients with Wernicke aphasia is like a Word salad
In Conduction aphasia, the arCuate fasciculus is affected.

Cranial nerve examination

Overview of cranial nerve examination

The cranial nerve examination is used to identify problems with the cranial nerves by physical examination. For information on disorders of the cranial nerves, see “Cranial nerve palsies.” The assessment includes the following components:

Overview of cranial nerve examination [1]Cranial nerveWhat is examined?How is the test performed?

Olfactory nerve

IOptic nerveIIOculomotor nerve, trochlear nerve, abducens nerveIII, IV, VITrigeminal nerveVFacial nerveVIIVestibulocochlear nerveVIIIGlossopharyngeal nerveand vagus nerveIX, XAccessory nerveXIHypoglossal nerveXII

Olfaction	Test the patient's ability to detect and identify an aroma in each nostril. Ask the patient to block one nostril with the finger, close the eyes, and sniff repetitively. Place a vial of a nonirritating substance [e.g., vanilla, lemon, coffee, tobacco] and ask to tell you when an odor is detected and to identify it if recognized.
Visual acuity	Ask the patient to read from a Snellen chart using one eye at a time, and correct for refractive errors with glasses or a pinhole.
Color vision [color blindness]	Ask the patient to identify [with both eyes] a number or shape within the Ishihara plates, which contain dots of different color and size.
Visual field	Assess each eye by confrontation [i.e., by comparing the patient’s visual fields to your own] using a finger or red pin. Facing the patient at 0.6–1.0 meters [2–3 feet], place your hands at the periphery of your visual fields [the hands should be equidistant between you and the patient] and inform the patient that you are going to move your index fingers. Ask the patient to look directly at the center of your face and to tell you when and which index fingers [left, right, or both] are moving. Test the inferior and the superior quadrants on both sides. The index fingers can be moved both alternatively and simultaneously. More accurate testing uses perimetry.
Papilla	Fundoscopic examination: uses the ophthalmoscope to examine elements of the fundus of the eye Optic disc [papilla]: examine color , size, degree of swelling, and elevation Retina: examine color, texture, and retinal vessels [size, presence of hemorrhages or exudates]
Pupillary light reflex	The examiner shines a light into the patient's eye. A prompt, consensual [i.e., equally in both eyes] response [i.e., constriction of the pupil] should normally be observable. Pupillary shape and width: Healthy pupils are isocoric and 2–8 mm in size; anisocoric and/or narrow/wide pupils suggest a disorder [see “Physiology and abnormalities of the pupil”].
Eye movement	Patients are asked to look back and forth between two widely spaced targets [e.g., one finger on the two hands] held by the examiner in front of the patient to evaluate saccades [i.e., the ability to rapidly fixate the eyes from one object to another]. Patients are asked to follow a finger moving up, down, laterally, and diagonally with their eyes. Observe for the following: Paresis: absence of movement of one or both eyes Alterations in smooth pursuit [e.g., saccades] Nystagmus: involuntary, repetitive movement of one or both eyes Direction: vertical [upbeat or downbeat in vestibular nystagmus, depending on whether the fast phase is upwards or downwards, respectively], horizontal, torsional, or any combination of the above Monocular or binocular
Visual accommodation	The physician moves a finger towards the patient. A normal response is constriction of the pupil.
Eyelid ptosis [Levator palpebrae superioris muscle dysfunction]	The patient is asked to open and close their eyes.
Facial sensation	The examiner lightly touches three distinct facial areas, typically the forehead, cheek, and jaw. ]. Normally, light touch should be felt by the patient in all three areas. If this is not the case, additional tests for abnormalities of other sensory modalities [e.g., pain, temperature] should be performed in the same areas.
Muscle function [muscles of mastication]	The patient is asked to open and close their mouth. At the same time, the examiner Inspects the masseter muscles for asymmetry Palpates them to investigate if there is pain elicited by palpation
Motor function [muscles of expression]	If motor function is intact, the patient should be able to perform the following: Forehead wrinkling Closing the eyes tightly Nose wrinkling Inflate the cheeks Smiling [showing teeth]
Sense of taste	If the sense is intact, the patient should be able to taste sweet, salty, and sour food/drinks.
Hearing	Basic hearing test: Normally, the patient should be able to hear two fingers rubbing together before the external acoustic meatus [ear canal]. The Weber test and Rinne test allow sensorineural hearing loss to be differentiated from conductive hearing loss [see “Tuning fork tests”].
Vestibuloocular reflex [VOR]: a brainstem reflex elicited by activating the vestibular system, e.g., via head movement; can also be activated by caloric stimulation [see “Caloric testing” in “Nystagmus” below]	Head impulse test
Sense of balance [ability]	Romberg test Heel to toe walking [see “Gait assessment” below] Unterberger test [see details in “Gait assessment” below] Timed Up and Go test Tinetti-Test A test to assess an individual's balance and gait; typically used in older adults The balance test assesses the individual's ability to sit, stand upright, and turn 360°. The gait test assesses the individual's ability to walk at normal speed, turn around, and walk back.
Palatal movement	The physician asks the patient to open the mouth and performs a visual inspection of the uvula and soft palate: Palate and uvula should be symmetrical and not deviate. The uvula and throat are better visible when the tongue is pressed down with a stick and the patient says "ah".
CN IX only: sense of taste	If the sense is intact, the patient should be able to taste bitter substances.
CN X only [recurrent laryngeal nerve]: vocalization	If the nerve is intact, the patient would not have hoarseness or a bovine cough.
Trapezius muscle and sternocleidomastoid muscle [motor function]	Trapezius muscle: The patient's shoulder is elevated against resistance. Sternocleidomastoid muscle: The patient's head is rotated against resistance.
Tongue muscles [motor function]	The tongue should be pressed against the cheek from the inside, while the examiner tests the strength by pushing from the outside. The tongue should be symmetrical and not deviate when the patient sticks out the tongue.

Motor function

The motor system examination allows to quantify the degree of motor function impairment and often to differentiate between central and peripheral lesions. The fundamental elements of the examination include muscle appearance, muscle strength [power], tone, and reflexes.

Upper motor neuron [UMN] injury vs. lower motor neuron [LMN] injuryUMN lesionLMN lesionDefinitionMuscle appearanceCharacteristicsBladder functionBabinski signCommon etiologies

Lesion along the descending motor pathways [pyramidal tracts, i.e., corticospinal tract and/or corticobulbar tract] Typically above the anterior horn cell of the spinal cord or motor nuclei of the cranial nerves [e.g., motor cortex, brain stem]	Lesion anywhere along the nerve fibers between the anterior horn of the spinal cord and relevant muscle tissue
Atrophy is absent. Fasciculations are absent.	Atrophy Fasciculations [2]
Central paresis [spastic paresis] is a condition characterized by the inability of voluntary movement in combination with: ↑ Tone [clasp knife phenomenon], spasticity, and clonus ↓ Power in muscle groups Hyperreflexia	Peripheral paresis [flaccid paresis] is a condition characterized by the inability of voluntary movement in combination with: ↓ Tone [no clasp knife phenomenon] ↓ Powerin single muscle fibers Hyporeflexia/areflexia
Detrusor hyperreflexia and detrusor/external urethral sphincter dyssynergia	Overflow incontinence
Upgoing [also referred to as present or positive] Big toe points upward while toes 2–5 fan out and downward Pathological response	Downgoing [also referred to as absent or negative] Toes are neutral or point downward [including big toe] Physiological response
Multiple sclerosis, tumor, stroke, vitamin B12 deficiency, ALS [both UMN and LMN signs]	Peripheral neuropathies, poliomyelitis [poliovirus], ALS [both UMN and LMN signs]

In LOWer motor neuron lesions, muscle mass, tone, power, and reflexes are LOW. In UPper motor neuron lesions, muscle tone, reflexes, and toes [Babinski sign] are UP.

Appearance

Findings [1]

Abnormal muscle movements [see table below]
Fasciculation
- Involuntary, asynchronous contraction of muscle fascicles within a single motor unit
- Usually benign but can signify a lower motor neuron lesion, which results in spontaneous action potentials and/or compensatory increase in the concentration of nicotinic acetylcholine receptors on the cell membrane located at the neuromuscular junction
Catatonia: abnormal behavior and movement, often including catalepsy, purposeless motor activity, strange postures, negativism, and mutism
Catalepsy: a state of muscular rigidity and immobility characterized by unresponsiveness to external stimuli
Grossly disorganized behavior: inadequate goal-directed activity [e.g., purposeless movements] and emotional responses that seem bizarre to others [e.g., smiling or laughing in inappropriate situations]
Motor stereotypies: rhythmic, repetitive movements; commonly seen in stereotypic movement disorder
Abnormal posture
Atrophy or hypertrophy [examined bilaterally]

Power

Definition: maximal effort a patient is able to exert from an individual muscle or group of muscles
Assessment
- The patient is asked to flex and extend the extremities against resistance.
- Muscle power tests should be performed bilaterally for comparison.
Muscle power grading
- 0: no contraction [complete paralysis]
- 1: flicker or trace of contraction
- 2: active movement, with gravity eliminated
- 3: active movement against gravity
- 4: active movement against gravity and moderate resistance
- 5: normal power [i.e., full range of motion against gravity and full resistance]
Patterns of paresis distribution
- Quadriparesis: weakness in all four limbs
- Hemiparesis: weakness in half of the body
- Paraparesis: weakness affecting both lower extremities
- Monoparesis: paresis affecting a single limb
Special tests
- Pronator drift test
- Mingazzini test
  - The patient is asked to lie in the supine position, with eyes closed, and is asked to raise and hold both legs for 30 seconds [90° angle at knee and hip].
  - Lowering of one leg is indicative of subtle paresis.

References:[3]

Reflexes

A tendon reflex is a single monosynaptic reflex [stretch]. The reflex arc consists of only one synapsis connecting two neurons: an afferent sensory neuron and an efferent motor neuron.

Deep tendon reflexes [DTR]

Definition: a reflex to test the integrity of a sensory and motor neuron circuit
Assessment
Interpretation
- An increased DTR indicates an upper motor neuron issue, whereas decreased DTR indicates an LMN, neuromuscular junction, or muscle issue.
- Elderly patients may have reduced or absent lower DTR due to normal aging-related changes in muscles and tendons
- Reinforcing maneuvers [e.g., Jendrassik maneuver] can be used to elicit a reflex that initially seems to be absent.

Deep tendon reflex testingNerve rootTendon reflexTestUpper limbsC5–C6C7–C8Lower limbsL2–L4L5S1–S2

Biceps reflex	First, the examiner places his/her thumb on the patient's biceps tendon, then the examiner strikes his/her thumb with a reflex hammer and observes the patient's forearm movement.
Brachioradialis reflex	Striking the lower end of the radius with a reflex hammer elicits movement of the forearm.
Triceps reflex	The examiner holds the patient's arm [forearm hanging loosely at 90° position] and taps the triceps tendon with a reflex hammer to induce an extension in the elbow joint.
Adductor reflex	Tapping the tendon on the medial epicondyle of femur elicits the adductor reflex.
Knee reflex	Striking the tendon just below the patella [leg is slightly bent] induces knee extension.
Posterior tibial reflex	The tibialis posterior muscle is tapped with a reflex hammer, either just above or below the medial malleolus. The reflex is positive when an inversion of the foot occurs.
Ankle reflex	Striking the Achilles tendon with a reflex hammer elicits a jerking of the foot towards its plantar surface. Alternatively, the reflex is triggered by tapping the ball of a foot from the plantar side.

Use the following poem to remember which nerve roots correspond to which reflexes:
S1–S2
Buckle my shoe [ankle reflex]
L2–L4
Kick the door [knee reflex]
C5–C6
Pick up sticks [biceps reflex and brachioradialis reflex]
C7–C8
Lay them straight [triceps reflex]

Superficial reflexes

Superficial reflex testingNerve rootReflexTestT6–T12 L1–L2S3–S5

Abdominal reflex	Abdominal reflexes are tested with the patient lying down. The anterior abdominal wall is lightly stroked with a spatula from lateral to medial [bilaterally] in the following areas: Below the costal arch Around the umbilicus Above the inguinal ligament A normal response is the contraction of the abdominal muscles, while the absence of contractions is indicative of nerve root damage.
Cremasteric reflex	The reflex is elicited by stroking the medial, inner part of the thigh. A normal response is contraction of the cremaster muscle that pulls up the testis on the same side of the body.
Anal reflex [anal wink]	Stroking the skin around the anus with a spatula elicits the anal reflex, which results in contraction of the anal sphincter muscles.
Bulbocavernosus reflex	The reflex is elicited by squeezing the glans penis or clitoris, resulting in contractions of the pelvic floor muscles.

Use the following poem to remember some of the superficial reflexes:
L1–L2
Testicle move [cremasteric reflex]
S3–S5
Winking by [anal wink reflex]

Primitive reflexes

Definition: a type of reflex that is normal in newborns and infants, but not in adults
- When present in adults, they may indicate diffuse brain injury due to a lack of common inhibiting factors.
- See “Child development and milestones.”
Corticospinal tract signs
- Indicate damage to the pyramidal tract
- Babinski sign is the most common and thus most reliable pyramidal tract sign.
- Although these reflexes are a normal physiological response in healthy infants, they are pathological in adults.

Overview of most important corticospinal tract signsSignTestResultUpper limb signsFinger flexor reflexTromner signHoffmann signLower limb signsBabinski signGordon signOppenheim signSchaeffer sign

The examiner taps the terminal phalanx of a relaxed finger [usually the middle finger] on the palmar side while holding the patient's hand in level with the proximal phalanges.	The sign is positive when either of the following is present There is significant flexion in the terminal phalanx of the tapped finger and the thumb When the flexion is very asymmetrical comparing both hands.
The examiner flicks the nail of the middle finger downward while loosely holding the patient's hand, allowing it to flick upward reflexively.	The sign is positive when there is quick flexion and adduction of the thumb and/or index finger on the same hand.
The examiner strokes the sole of the patient's foot on the lateral edge using, e.g., the handle of a reflex hammer.	The sign is positive [i.e. upgoing/present/pathological] when the big toe extends [dorsiflexes], while the other toes fan out. An exception are children up to the age of 2 years, in which case an upgoing Babinski sign is considered physiological. The test is inconclusive when only the big toe responds.
The examiner compresses the calf muscles.
The examiner strokes the patient's anterior tibia downward.
The examiner squeezes the Achilles tendon.

Babinski sign, although normal in newborns and infants, is always pathological in adults.

Tone

Definition: resistance of an individual muscle [or a group of muscles] to passive stretching
Assessment: passive movement of the extremities
- Upper limb
  - Elbow: The examiner flexes and fully extends the patient's elbow.
  - Forearm: With the elbow in the 90° position, the examiner supinates and pronates the patient's hand.
  - Wrist: The examiner flexes and extends and then twist the patient's wrist from side to side.
- Lower limb: The patient is asked to relax the limbs while lying in the supine position. The examiner then rolls the legs from side to side.
Findings [4][6]
- Spasticity: characteristic of pyramidal tract lesions
  - Velocity-dependent phenomenon: Spasticity is more pronounced with increased speed of movement.
  - Clasp knife phenomenon: initial resistance due to increased muscle tone is followed by a sudden decrease in resistance
  - See “Spasticity”
- Rigidity: suggests abnormalities of the extrapyramidal system
  - Velocity-independent phenomenon
  - Lead pipe rigidity: an increase in tone that is constant throughout the passive movement
  - Cogwheel rigidity
    - Extreme stiffness of the joint of the limb that makes movement difficult
    - When the examiner flexes or extends the limb, the movement is jerky, resembling the ratcheted rotation of a cogwheel
- Hypotonia
  - A decrease in muscle tone
  - Can occur in peripheral nervous system lesions [e.g., polyneuropathy], lower motor neuron lesions [e.g., spinal muscular atrophy], or cerebellar lesions
- Paratonia: a change in tone that is uneven throughout the passive movement due to involuntary opposition or facilitation by a patient
  - Occurs in patients with frontal lobe dysfunction [e.g., due to trauma, stroke, tumor, neurodegenerative disorders such as frontotemporal dementia]
  - The degree of paratonia increases with the speed of passive movement, the amount of applied force, and with attempts to relax the patient.
  - Oppositional paratonia: an apparent increase in tone due to the patient's involuntary resistance to movement
  - Facilitatory paratonia: an apparent decrease in tone due to the patient's involuntary assistance to movement
- Clonus: a series of involuntary, rhythmic muscular contractions
Modified Ashworth scale: a scale that is most commonly used for assessment of the muscle tone [7]
- 0: no increase in muscle tone
- 1: slight increase in muscle tone, with minimal resistance at the end of the range of passive motion
- 1+: slight increase in muscle tone followed by abrupt resistance [catch] that continues through the remainder [less than half] of the movement
- 2: a marked increase in muscle tone throughout most of the range of motion, but passive movement is easy
- 3: considerable increase in muscle tone, with passive movement difficult
- 4: affected parts rigid in flexion or extension

Do not confuse clonus with myoclonus. Myoclonus is arrhythmical and defined by sudden jerks of a muscle or group of muscles, while clonus is rather rhythmic and defined by repetitive contractions and relaxations of a muscle group. Moreover, myoclonus is usually associated with metabolic abnormalities [e.g., renal and liver failure].

Sensory function

Examination of the sensory system is aimed at evaluating any abnormality affecting the patient's perception to provoked sensations like touch, pain, and temperature. In contrast to motor function, sensation is subjective to the patient and therefore the interpretation of the exam strongly depends on the patient accurately reporting what they experience.

For more information about the patterns of sensory loss in spinal cord lesions, see “Overview” in “Incomplete spinal cord syndromes.”

Focused examination of sensation [1][8]ModalityPathwayAssessmentFindingTactile sense

Sharp/dull discrimination and pain [9][10]

Light touchPallesthesia [vibration sense]Proprioception [joint position]

Temperature sensation

Dull sensation: dorsal columns Sharp sensation/pain: spinothalamic tract	To test for dull sensation, the examiner applies an object with a dull end [e.g., cotton bud, spatula] to areas of the body where nerve lesions are suspected [e.g., the hands and feet in individuals with type 2 diabetes]. To test for sharp sensation and/or pain sensation, the examiner applies an object with a sharp end [e.g., sterile safety pin, broken spatula, toothpick] to the patient's extremities.	Paresthesia: a spontaneous abnormal sensation [e.g., tingling, prickling, "pins and needles"] Dysesthesia: an abnormal unpleasant sensation [e.g., itching, burning, pain, electric shock] evoked by a neutral stimulus [e.g., a light touch on the surface of the patient's ankle] Allodynia: a subtype of dysesthesia that manifests with a painful sensation triggered by a stimulus that is ordinarily painless Hyperesthesia: a subtype of dysesthesia that manifests with an exaggerated perception of sensory stimuli Hypesthesia: decreased perception of sensory stimuli [anesthesia is the most extreme case of hypesthesia]
Dorsal columns Proprioception only: spinocerebellar tract [see “Unconscious proprioception”]	To test for symmetry of touch sensation, the examiner touches the patient's body at different locations bilaterally. In cases of suspected radicular lesions, the particular dermatome should be examined individually. In cases of suspected peripheral nerve lesions, diagnostics should involve checking the areas innervated by the corresponding sensory nerves. Monofilament test can be used to quantitatively assess light touch sensation. [11][12]
A tuning fork is hit and placed on a bony projection [e.g., medial malleolus]. [13] The vibration amplitude and thus the vibration intensity decrease over time. The patient reports when the vibration stops.	Pallhypesthesia: diminished or lost sense of vibration sense [e.g., due to trauma, peripheral neuropathy, myelopathy]
To test proprioception, the most distal joint of the big toe or the distal interphalangeal joint of the thumb is held at the sides and moved up and down. The patient should be able to identify the positional change with eyes closed.	Abnormalities of proprioception: diminished or lost sense of proprioception [e.g., due to peripheral polyneuropathy or myelopathy]
Spinothalamic tract	To test for temperature sensation, the examiner applies two objects of different temperatures [e.g., a test tube filled with cold water and a test tube filled with warm water] to the patient's forearms and/or shanks.	Hypoalgesia: decreased sensitivity to nociceptive stimuli Hyperalgesia: increased sensitivity to nociceptive stimuli

Coordination

General considerations

The following tests are used to test for the ability to coordinate movements, which depend on cerebellar and basal ganglia function, proprioceptive input, and muscle power.
Limb ataxia: a lack of coordination of voluntary movements of the upper and lower extremities, is the main finding; most commonly results from lesions in the cerebellar hemispheres. [1]

Finger-to-nose test and finger-to-finger test

Procedure
- Finger-to-nose test: The patient is asked to touch the tip of their nose with the index finger
- Finger-to-finger test: The patient is asked to alternate between touching the tip of their nose and the examiner's finger as quickly as possible with the index finger
- The tests should be performed once with the patient's eyes open and again with the eyes closed
Findings
- Normally, the patient would be able to reach the target [either their nose or examiner's finger] without tremor or overshoot.
- Patients with dysmetria are unable to touch the tip of their nose with their index finger.
- Improvement of test results with eyes open indicates visual compensation of dysmetria, which is characteristic of sensory impairment.
- In patients with intention tremor, the fingers will begin to shake just as they reach their nose.
- Patients with kinetic tremor will have a tremor throughout the movement.

Heel-knee-shin test

Procedure: The patient is asked to touch the opposite knee with a heel and slide down the shin.
Findings
- Normally, the patient will be able to slide the heel of one foot down the shin of the opposite leg.
- In patients with dysmetria, the heel will deviate to alternate sides , which indicates that the patient has limb ataxia.

Rapid alternating movement test

Procedure: The patient is asked to rapidly screw in a large imaginary light bulb using both hands.
Findings
- Normally, a patient is able to perform the movement.
- Patients with dysdiadochokinesia are unable to perform rapidly alternating agonistic-antagonistic movements and thus perform the test slowly, in an uncoordinated manner.

Gait assessment

Multiple systems are required for proper walking, such as those responsible for sensory and motor functions [including reflexes], as well as the cerebellum and the vestibular system. During the examination of the patient's gait, particular attention should be paid to body and limb posture [e.g., base of support and arm swing], steps [length, speed, and rhythm], steadiness, and turning.

Gait examination

Overview [14]TestPurposeExaminationInterpretationObservation of casual gaitHeel to toe walking Foot drop testWalking on tiptoesRomberg test

Unterberger test

Trendelenburg sign

Detection of gait abnormalities	The patient is asked to walk a few steps forward and backward.	Normal gait is steady with natural arm swing.
Assessment of gait ataxia [vestibular, sensory, or cerebellar]	The patient is asked to place one foot directly in front of the other as if walking on a tightrope.	The test is positive when the patient is unable or has difficulty in placing one foot directly in front of the other.
Test for assessing neuropathic gait	The patient is asked to walk on his/her heels.	The test is positive when the patient is unable to walk on his/her heels, which may be indicative of deep fibular nerve lesions or peripheral neuropathies.
The patient is asked to walk on his/her toes.	The test is positive when the patient is unable to walk on his/her toes, which may indicate tibial nerve lesions or peripheral neuropathies.
Test to differentiate between the causes of truncal ataxia Used to distinguish between sensory and cerebellar ataxia	The patient is asked to stand with both feet together, raise the arms, and close the eyes.	Positive Romberg The patient's coordination is impaired when the eyes are closed and the patient starts swaying or swaying increases Indicates sensory ataxia An increased tendency to fall sideways after closing the eyes can also indicate a vestibular disorder. In the case of a unilateral vestibular disorder, the patient usually falls towards the side of the lesion. Negative Romberg Closing the eyes does not affect the patient's balance [i.e., swaying does not increase]. Uncontrollable swaying, even with the eyes open, is indicative of cerebellar ataxia.
Test for detecting vestibular impairment which may indicate the presence of vestibular lesions	The patient is asked to close their eyes with arms outstretched and march in place for 50 steps.	The test is positive when the patient rotates more than 30° around their central axis. A positive test indicates a unilateral vestibular impairment.
Test for neurological insufficiency of the gluteus medius and gluteus minimus muscles, which are innervated by the superior gluteal nerve	The patient is asked to stand on one leg.	Negative Trendelenburg sign [physiological]: The pelvis remains level as it is stabilized by the gluteus medius and minimus. Positive Trendelenburg sign [pathological]: Because of insufficiency of the gluteus medius and minimus on the side of the standing leg, thepelvis drops towards the contralateral, unimpaired side. Duchenne sign: The torso tilts toward the contralateral side, compensating the pelvic drop on the unimpaired side. Duchenne limp: The Duchenne sign, which frequently occurs bilaterally, results in a compensatory to‑and‑from movement of the torso during walking.

Abnormal gait patterns

Overview of abnormal gait patterns [14]TypeDescriptionAssociated diseaseHemiplegic gaitMyopathic gaitNeuropathic gaitAtaxic gaitCerebellar ataxic gaitSensory ataxic gaitParkinsonian gaitGait apraxiaChoreiform gait

Loss of natural arm swing and dragging of the affected leg in a semicircle [circumduction] On the affected side, the arm may be flexed, adducted, and internally rotated, while the leg is extended and the foot is plantarflexed.	Stroke
Drop of the pelvis on the unaffected side [Trendelenburg sign] or on both sides [waddling] when walking. Respectively caused by unilateral or bilateral weakness of one or multiple pelvic girdle muscles [especially gluteus muscles]	Myopathies [e.g., muscular dystrophies, inflammatory myopathies]
Seen in patients with unilateral or bilateral foot drop [i.e., weakness of foot dorsiflexion] who lift one or both legs when walking, respectively, in order to prevent the foot dragging on the floor.	Unilateral: peroneal nerve palsy, L5 radiculopathy Bilateral: amyotrophic lateral sclerosis, peripheral neuropathies [e.g., Charcot-Marie-Tooth disease, diabetic neuropathy]
Unsteady and wide-based gait with irregular, uncoordinated movements	Staggering gait Inability to walk from heel to toe or in a straight line	Cerebellar diseases Acute alcohol intoxication
Stooped, stomping gait Gait is exacerbated when patients cannot see their feet [e.g., in the dark] Romberg test is positive.	Disorders of the dorsal columns [e.g., vitamin B12 deficiency, tabes dorsalis] Peripheral neuropathies
Small, slow steps [bradykinesia], shuffling, and sometimes accelerating, with the head, neck, and trunk leaning forward and flexion at the knees Difficulty initiating steps [rigidity]	Parkinson disease Parkinsonism [e.g., due to medications, repeated head trauma]
Inability to raise the foot off of the floor [magnetic gait], resulting in shuffling Poor balance and truncal mobility Difficulty initiating steps	Bilateral frontal lobe disorders Cerebrovascular disease
Walking associated with irregular, jerky, involuntary movements in the limbs	Huntington disease Sydenham chorea

Meningism

Definition: the triad of
- Nuchal rigidity [stiff neck]: inability to flex the neck forward
- Headache
- Photophobia
Examination
- Kernig sign: In a supine patient, extension of the knee when the thigh is flexed at the hip causes pain [knee at a 90° angle].
- Brudzinski sign: In a supine patient, passive flexion of the neck provokes involuntary lifting of both legs.
Etiology: : due to inflammatory [bacterial/viral meningitis; ] or noninflammatory [e.g., subarachnoid hemorrhage] causes

Signs of nerve root irritation

Signs of nerve root irritation indicate an inflammatory and/or irritative process occurring at the point where the spinal nerves exit the vertebral column. Testing for signs of nerve root irritation can help determine suspected spinal root compression [e.g., by a tumor or herniated disk].

Examination
- Straight leg raise test [root L5–S1]: In a supine patient, lifting the extended leg [< 45°] induces pain along the distribution of the lumbar roots [i.e., back pain radiating down the ipsilateral leg].
- Crossed straight leg raise test: In a supine patient, lifting the extended leg [< 45°] induces pain in the contralateral leg with radiation into the motor/sensory area of the affected nerve root.
- See “Diagnostics” in “Degenerative disk disease.”
Etiology: conditions that can lead to compression of the nerve roots [e.g., degenerative disk disease, spinal tumor, spinal epidural hematoma]

Nystagmus

Is the cremasteric reflex normal?

Even among normal boys, the presence of the cremasteric reflex is somewhat variable. One study evaluated the reflex in 225 normal boys from newborn to 12 years of age. The reflex was present in 48% of newborns, 45% of boys between 1 and 30 months, and in 100% of boys between 30 months and 12 years.

What does a positive cremasteric reflex mean?

This reflex is elicited by stroking or pinching the medial thigh, causing contraction of the cremaster muscle, which elevates the testis. The cremasteric reflex is considered positive if the testicle moves at least 0.5 cm.

What is Cremasteric response?

The cremasteric reflex is a superficial reflex found in human males that is elicited when the inner part of the thigh is stroked. Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal.

How do you assess the cremasteric reflex?

The cremasteric reflex is elicited in males by stroking the inner aspects of the thigh in a caudal–rostral direction and observing the contraction of the scrotum.