Neurologic System

1
Neurologic System

• Adapted from Mosbys Guide to Physical
  Examination, 6th Ed.
• Ch. 22

2
Development

• 1st year of life
• Myelinization of the brain and nervous system
• Any intruding event (infection, trauma, or
  biochemical imbalance), that upsets brain
  development and growth during this time, can have
  profound effects.
• Brain growth continues until 12-15 years

3

• Motor maturation proceeds in a cephalocaudal
  direction
• Control of the head and neck develops first
• Followed by trunk and extremities
• Motor development is a succession of integrated
  milestone
• Many may be developed simultaneously
• Orderly sequence to development
• Considerable variation in timing exists

4
Developmental Milestones

• See Table
• (Musculoskeletal)

5
Infant Exam
6
Infant Cranial Nerve Evaluation

• CN II, III, IV, VI
• Optical blink reflex
• Shine a light at the infants open eyes
• Observe quick closure of the eyes and dorsal
  flexion of the infants head
• No response poor light perception
• Gazes intensely at close object or face
• Focuses on and tracks an object with both eyes
• Dolls eye maneuver (CN VIII)

7

• CN V
• Rooting Reflex
• Touch one corner of the infants mouth
• Infant should open its mouth and turn its head in
  the direction of stimulation
• If recently fed, minimal response is expected
• Sucking reflex
• Place your finger in the infants mouth
• Feel the sucking action
• Tongue should push up against your finger with
  good strength
• Note pressure, strength, and pattern

8

• CN VII
• Observe the infants facial expression when
  crying
• Note ability to wrinkle the forehead
• Symmetry of the smile

9

• CN VIII
• Acoustic Blink Reflex
• Clap your hands about 1 ft. from the infants
  head
• Note the blink in response to sound
• Infant will habituate to repeated testing
• No response after 2-3 days of age may indicate
  hearing problems
• Moves eyes in direction of sound
• Freezes position with high-pitched sound

10

• CN VIII (continued)
• Dolls Eye Maneuver
• Hold the infant under the axilla in an upright
  position
• Head held steady by parent, facing you
• Rotate the infant, first in one direction and
  then the other
• Infants eyes should turn in the direction of
  rotation
• When movement stops, eyes should move in the
  opposite direction
• If not, suspect vestibular problem or eye
  muscle paralysis

11

• CN IX, X
• Swallowing and gag reflex

12

• CN XII
• Coordinated sucking and swallowing ability
• Pinch infants nose
• Mouth will open and tip of tongue will rise in a
  midline position

13
Observation

• Coordinated sucking and swallowing (cerebellum)
• Hands are usually held fisted for the 1st 3
  months (but not constantly)
• After 3 months they open for longer periods
• Observe for spontaneous activity
• Symmetry
• Smoothness of motion

14

• Posture and movement
• Rhythmic twitching
• Facial, extremity, trunk musculature
• Sustained asymmetric posturing
• Paroxysmal episodes associated with seizure
  activity

15

• Sensory function
• Withdrawal of limbs to painful stimulus

16
Reflexes

• Patellar reflex present at birth
• Achilles and brachioradial reflexes appear at 6
  months
• Use a finger to tap the tendon
• Interpret findings as for adults
• NOTE ankle clonus is common

17

• Babinski sign
• Positive fanning of toes and dorsiflexion of
  the great toe
• Retained until 16-24 months of age

18
Primitive Reflexes

• Present in the newborn
• Yawn
• Sneeze
• Hiccup
• Blink at bright light and loud sound
• Pupillary constriction with light
• Withdrawl from painful stimuli
• As the brain develops, some primitive reflexes
  are inhibited
• more advanced cortical functions and voluntary
  control take over

19
Primitive Reflexes

• Used to evaluate posture and movement of the
  developing infant
• Appear and disappear in a sequence corresponding
  with CNS development

20

• Palmar Grasp (birth)
• Infants head midline
• Touch palm of the infants hand from the ulnar
  side
• Note the strong grasp of your finger
• Sucking facilitates the grasp
• Strongest between 1-2 months
• Disappears by 3 months

21

• Plantar Grasp (birth)
• Touch the plantar surface of the infants feet at
  the base of the toes
• Toes should curl downward
• Strong up to 8 months

22

• Moro (birth)
• Infant supported in semi-sitting position
• Allow the head and trunk to drop back to a 30
  degree angle
• Observe symmetric abduction and extension of the
  arms
• Fingers fan out thumb and index finger form a C
• The arms then adduct in an embracing motion,
  followed by relaxed flexion
• Legs follow a similar pattern
• Diminishes in strength by 3-4 months

23

• Placing (4 days)
• Hold the infant upright under the arms
• Touch the dorsum of the foot to the edge of a
  flat surface
• Observe flexion of the hips and knees and lifting
  of the foot (as if stepping up)
• Age of disappearance varies

24

• Stepping (birth-8 weeks)
• Hold the infant upright under the arms
• Allow the soles of the feet to touch the surface
  of the table
• Observe for alternate flexion and extension of
  the legs (walking)
• Disappears before voluntary walking

25

• Asymmetric Tonic Neck (by 2-3 months)
• AKA Fencers
• Infant supine
• Turn head to one side
• Observe for ipsilateral extension contralateral
  flexion of the arms and legs
• Repeat, turning head to the other side
• Diminishes around 3-4 months and disappears by 6
  months
• Must disappear before the infant can roll or
  bring its hands to its face
• Concern if infant never exhibits the reflex or
  seems locked in the fencing position

26

• Galant (birth-4 weeks)
• Suspend the infant prone over your hand
• Stroke paraspinally from the shoulders to the
  buttocks
• Trunk should curve toward the side stroked
• Repeat on the other side

27

• Perez
• Suspend the infant prone over your hand
• Stroke over the spinous processes from sacrum to
  occiput
• infant extends head and brings knees to chest
  urinates

28

• Landau (birth-6 months)
• Suspend the infant prone over both hands
• Observe the infants ability to lift its head and
  extend its spine on a horizontal plane
• Diminishes by 18 months
• Disappears by 3 years

29

• Parachute (4-6 months)
• Hold the infant suspended (prone)
• Slowly lower it head first toward a surface
• Observe the infant extend its arms and legs
  (protecting itself)
• This reflex should not disappear

30

• Neck Righting (3 months after Tonic Neck
  disappears)
• Infant supine
• Turn head to the side
• Observe the infant turn its whole body in the
  direction the head is turned

31
Child Exam

32
Cranial Nerve Examination

• CN II
• Snellen E or Picture Chart may be used to test
  vision
• Visual fields may be tested child may need the
  head immobilized

33

• CN III, IV, and VI
• Have child follow an object with eyes immobilize
  head if necessary
• Move the object through the cardinal points of
  gaze
• video

34

• CN V
• Observe the child chewing note bilateral jaw
  strength
• Touch forehead and cheeks with cotton
• watch the child bat it away

35

• CN VII
• Observe the childs face when smiling, frowning,
  and crying
• Ask child to show teeth
• Demonstrate puffed cheeks and ask the child to
  imitate

36

• CN VIII
• Observe the child turn to sounds (bell or
  whisper)
• Whisper a commonly used word behind the childs
  back and have him or her repeat the word
• Refer for audiometric testing

37

• CN IX and X
• Elicit gag reflex

38

• CN XI and XII
• Instruct older child to stick out the tongue
• Instruct older child to shrug the shoulders or
  raise the arms

39
Observation

• Observe the child at play
• Gait
• Fine motor coordination
• Beginning walker wide-based gait
• VIDEO
• Older child feet closer together, better balance
• VIDEO

40

• Observe skill in reaching for, grasping, and
  releasing toys VIDEO
• No tremors or constant overshooting movements
  should be apparent
• Coordination skills (heel-to-toe walking,
  hopping, and jumping)
• Modify into a game

41
Three Penny Games

• Ask child who is standing to pick up a penny up
  off the floor
• Tests vision and balance
• Stick a moistened coin to the childs nose and
  ask the child to walk across the room
• Observe gait and posturing
• Have child balance a penny on the nose and dorsum
  of each extended hand
• Tests Romberg

42

• Deep Tendon Reflexes VIDEO
• Use same technique as adults
• Responses should be the same
• May use finger instead of reflex hammer (less
  threatening)

43

• Light Touch
• Ask child to close eyes and point to where you
  touch
• Discriminate between rough and soft
• Vibration
• Tuning fork buzzing sensation

44

• Superficial pain
• not routinely tested in kids due to their fear of
  needles and sharp objects

45

• Graphesthesia
• (cortical sensory integration)
• Use geometric figures
• Draw each figure twice and ask the child if the
  figures are the same or different
• May need practice session with eyes open

46
Neurological Soft Signs

• Nonfocal, functional neurologic findings
• Provide subtle cues to an underlying CNS deficit
  or a neurological maturation delay
• Children with multiple soft signs are often found
  to have learning problems

47
Walking, running gait

• Soft Sign Finding
• Stiff-legged with a foot slapping quality,
  unusual posturing of the arms
• Latest Expected Age of Disappearance
• 3 years

48
Heel walking

• Soft Sign Finding
• Difficulty remaining on heels for a distance of
  10 ft
• Latest Expected Age of Disappearance
• 7 years

49
Tip-toe walking

• Soft Sign Finding
• Difficulty remaining on toes for a distance of 10
  ft
• Latest Expected Age of Disappearance
• 7 years

50
Tandem gait

• Soft Sign Finding
• Difficulty walking heel-to-toe, unusual posturing
  of arms
• Latest Expected Age of Disappearance
• 7 years

51
One-foot standing

• Soft Sign Finding
• Unable to remain standing on one foot longer than
  5-10 sec.
• Latest Expected Age of Disappearance
• 5 years

52
Hopping in place

• Soft Sign Finding
• Unable to hop rhythmically on each foot
• Latest Expected Age of Disappearance
• 6 years

53
Motor-stance

• Soft Sign Finding
• Difficulty maintaining stance (arms extended in
  front, feet together, and eyes closed), drifting
  of arms, mild writhing movements of hands or
  fingers
• Latest Expected Age of Disappearance
• 3 years

54
Visual tracking

• Soft Sign Finding
• Difficulty following object with eyes when
  keeping the head still nystagmus
• Latest Expected Age of Disappearance
• 5 years

55
Rapid thumb-to-thumb

• Soft Sign Finding
• Rapid touching thumb to fingers in sequence is
  uncoordinated unable to suppress mirror
  movements in contralateral hand
• Latest Expected Age of Disappearance
• 8 years

56
Rapid alternating movements of hands

• Soft Sign Finding
• Irregular speed and rhythm with pronation and
  supination of hands patting the knees
• Latest Expected Age of Disappearance
• 10 years

57
Finger-nose test

• Soft Sign Finding
• Unable to alternately touch examiners finger and
  own nose consecutively
• Latest Expected Age of Disappearance
• 7 years

58
Right-left discrimination

• Soft Sign Finding
• Unable to identify right and left sides of own
  body
• Latest Expected Age of Disappearance
• 5 years

59
Two-point discrimination

• Soft Sign Finding
• Difficulty in localizing and discriminating when
  touched in one or two places
• Latest Expected Age of Disappearance
• 6 years

60
Graphesthesia

• Soft Sign Finding
• Unable to identify geometric shapes you draw in
  childs open hand
• Latest Expected Age of Disappearance
• 8 years

61
Stereognosis

• Soft Sign Finding
• Unable to identify common objects placed in own
  hand
• Latest Expected Age of Disappearance
• 5 years

62
Common Conditions
63
Generalized Seizure Disorder

• Episodic, sudden, involuntary contractions of a
  group of muscles
• Excessive discharge of cerebral neurons
• Disturbances in
• Consciousness
• Behavior
• Sensation
• Autonomic functioning
• Urinary and fecal incontinence

64

• May be caused by
• Systemic disease
• Head trauma
• Toxins
• Stroke
• Hypoxic syndromes
• Affects 1 of the population
• 75 new cases develop during childhood and
  adolescence

65
Meningitis

• Inflammatory process in the meninges
• Bacterial / viral
• Bacterial meningitis should be treated with
  appropriate antibiotics

66

• Signs symptoms
• Fever
• Chills nuchal rigidity
• Headache
• Seizure
• Vomiting
• Altered level of consciousness

67

• Do not demonstrate nuchal rigidity until 6-9
  months
• Infant Signs symptoms
• Very irritable and inconsolable
• Fever
• Diarrhea
• Poor appetite
• Toxic appearance

68
Encephalitis

• Inflammation of the brain and spinal cord
  (involves meninges)
• Onset is often a mild, febrile viral
  illness

69

• Quiescent stage often precedes the disturbance in
  CNS function
• Headache
• Drowsiness
• Confusion
• Progressing to stupor and coma
• Motor function may also be impaired
• Severe paralysis
• Ataxia

70
Space-Occupying Lesions / Intracranial Tumors

• Abnormal growth of neural or nonneural tissue
  within the cranium
• Primary or metastatic cancer
• Displacement of tissue
• Pressure on the CSF circulation
• Peak age of incidence
• 3-12 years
• 50-70 years

71

• Threaten function by compression or destruction
  of tissue
• Early Signs symptoms
• Vary by location of the tumor
• Headace
• Vomiting
• Change in cognition
• Motor dysfunction
• Seizures
• Personality changes

72
Cerebral Palsy

• Nonprogressive neuromuscular disorders
• Abnormal muscle tone
• Coordination
• Results from insult to the cerebellum, basal
  ganglia, or motor cortex
• Disability depends on the extent of damage
• Some can expect near normal levels of functioning

73

• Signs include
• Delayed gross motor development
• Altered muscle tone
• Abnormal posture
• Abnormal motor performance
• Abnormal reflexes

74
HIV Encephalopathy

• Progressive encephalopathy associated with AIDS
• Impaired brain growth
• (cerebral atrophy)
• Advanced feature of AIDS

75

• Signs symptoms
• Progressive motor dysfunction
• Regression/plateau in developmental milestones
• Generalized weakness
• Signs of UMN lesion
• Less commonly
• Dysphagia (difficulty swallowing)
• Gait ataxia
• Seizures

76
Rett syndrome

• Progressive encephalopathy
• Unknown cause
• Girls between 6-18 months of age
• Develops after normal neurologic and mental
  development

77

• Signs symptoms
• Loss of voluntary hand movement
• Loss of previously acquired hand skills
• Hand wringing movements
• Gradual development of ataxia rigidity of the
  legs
• Growth retardation
• Seizures
• Loss of facial expression
• Deceleration of head growth
• between 5-48 months of age