Neurological Exam – the Basics of Neurology

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An Enlightened Neurological Exam

By Gordon Johnson

Call me at 800-992-9447

What is needed is a return to the enlightened idea of the neurological exam. I use the term enlightened neurological exam, not because the traditional methodology is wrong, but because rarely is this exam performed today the way it was traditionally taught.  The traditional neurological exam is a complex functional test. The neurological exam could be surprisingly sensitive for the footprints of pathology. But the the examiner must step back far enough to see the full picture.

The older the neurological textbook, the better the description of what the neurological exam should consist of.  I believe that the implementation of the neurological exam has deteriorated because of CT and MRI. Thingomometers have created the illusion that the physican no longer has to worry about the invisible injury, because the invisible injury could now be imaged.

Makeup of the Neurological Exam

A full neurological exam includes not only the classic tests to determine whether the nervous system is working properly, but also a rudimentary assessment of cognitive function.  Most important, it is supposed to contain a clinical interview.  The clinical interview is only of value, however, the diagnosis is not presumed at the beginning.

Far too often in concussion cases, the exam is limited to a quick check for focal neurological deficits. The quick step exam will rarely identify the type of deficits typically associated with a mild brain injury.   The physical aspect of the exam should be a diligent, and detailed evaluation.  A diligent neurologist may uncover focal deficits, which were missed at the time of the injury. Sadly, the one focal deficit which is most likely to be effected by a concussion, the sense of smell, is the one which is least often checked.

The areas of the physical exam which are most sensitive to post-concussional changes include examination the IV, V and VIII nerves, those which to some degree involve the eyes. Before a physician concludes that a  neurological exam is “normal” Cranial Nerve I, the Olfactory Nerve, must be tested. Damage to sense of smell (and related problems with taste) are very associated common symptoms of brain injury.  Such deficits also correlate to disturbing executive function problems in associated geographic areas of the brain, the orbital frontal area. Significant research points to these orbital frontal problems being central to unsuccessful reintegration of the brain injured person into the outside world. Such problems have a remarkable correlation to serious employability concerns.

Today, the clinical interview may not consist of more than a superficial inquiry as to why the patient is there.  Yet the interview is the most important part of the exam.  It is the chance for the physician to assess how well the patients brain is working.  Questions should encourage the patient to give answers longer than a few words. Without open ended questions, the doctor will miss an opportunity to spot significant deficits in cognitive function.

The neurological exam is often thought of as the objective answer as to whether the nervous system is working properly. While this may be how the test is used for diagnostic purposes, the neurological exam is no more objective than other footprint type evaluations. Even more important is that a complete neurological exam is not just a test of cranial nerves and reflexes.

Rather than devaluing the neurological exam, technology has the opportunity to make it better. An enlightened modern exam can be constructed on the foundation of the traditional neurological exam.   Technology can be used to supplement the observations during the exam, rather than supplanting them.

A modern neurological exam, built on the foundations of the traditional exam would include evaluation of the following thingomometers if either the exam itself or the history indicate potential malfunction in the appropriate areas.

  • The ENG[1] test or other vestibular testing if there is a concern about vertigo, dizziness or balance issues.  For more on the vestibular issues, click here.
  • A postural test of blood pressure and pulse, supplemented by a posture platform test if there is concern about lightheadedness, not vestibular related dizziness or feinting/syncope.
  • A review of advanced neuroimaging techniques, discussed later elsewhere on  Key to the use of advanced neuroimaging techniques is that the treating doctor, make a clinical correlation of what pathology is shown on such scan to the symptoms of the patient.

The proper neurological exam should also include a detailed history.  Particularly, with mild brain injury diagnosis, the patient’s history before the trauma needs to be understood. Yet considerations of history, particularly emotional history, should not be used as excuses to question the brain injury.  The doctor needs to embrace that history as a characteristic that might make an individual concussion patient, more likely to suffer disability post-concussion. Age, prior concussions, psychiatric issues, anxiety all make disability more likely.  These challenges pre-morbidly are not a reason to doubt organic disability but to predict it.

For More on the Neurological Exam, click here.

Next – Post-Concussion Imaging

[1] Electronystamogram.

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Gordon Johnson

Attorney Gordon Johnson is one of the nations leading brain injury advocates. He is Past-Chair of the TBILG, a national group of more than 150 brain injury advocates. He has spoken at numerous brain injury seminars and is the author of some of the most read brain injury web pages on the internet.

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