By Marcello Cherchi, MD PhD
For patients
Here are answers to some of the most common questions about physical examination.
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What is this test? |
Physical examination in neurology assesses the function of parts of the nervous system (brain, spinal cord, peripheral nerves). |
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What is this test looking for? |
Physical examination can identify abnormal findings that help your doctor diagnose the cause of your symptoms. |
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Is this test experimental or investigational? |
Physical examination is part of routine medical evaluation. It is not a “test” in the traditional sense. |
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What happens during this test? |
Your doctor will use physical examination techniques to assess the functions like strength, touch, reflexes, coordination, gait, balance, and nerves in the face and head. |
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Is this test uncomfortable? |
Physical examination for otoneurology is generally not uncomfortable. |
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How long does this test take? |
Physical examination takes about 10 – 15 minutes. |
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Do I have to prepare for this test? |
There are no specific preparations for physical examination. |
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Are there any special instructions for what to do after the test? |
There are no special instructions for what to do after physical examination. |
For clinicians
Practical summary
Every clinician develops their own routine of physical examination. A clinician adjusts the examination (usually augmenting it) depending on any positive findings along the way. An otoneurologist uses many of the examination techniques employed in other subspecialties, though there are several that are more specific to otoneurological diseases. Here we review a number of examination techniques; this is not a comprehensive list.
Introduction
There are many beautiful textbooks for physical examination (LeBlond et al. 2020), and several focused on the neurological examination (Mayo Clinic. Department of Neurology. 1998). There is a modest literature regarding physical examination techniques specifically for patients with suspected otovestibular disorders (Cohen 2019; Davies 2004; Eggers and Zee 2003; Huh and Kim 2013; Shemesh and Gold 2020; Walker and Zee 2000).
Drawing on these resources, we review some of the physical examination techniques that we commonly employ. We do not use every technique on every patient; as with any physical examination, we tailor the evaluation based on a patient’s history, course-correcting along the way as merited by any identified abnormalities. The neurological examination for otoneurology can typically be accomplished in 10 – 15 minutes.
General neurological examination
Most clinicians include:
- Strength.
- Muscle tone, including cervical tone (e.g., hypertonia with distraction in progressive supranuclear palsy).
- Sensation.
- Myotatic reflexes.
- Plantar responses.
Cerebellar examination
A number of otoneurological diseases (such as spinocerebellar ataxias, paraneoplastic syndromes, CANVAS and others) include cerebellar deficits, so many clinicians will expand this section of the general neurological examination.
Appendicular cerebellar function:
Relevant techniques include:
- Finger-to-nose testing (Swaine et al. 2005).
- Rapid alternating movements, to assess for dysdiadochokinesia, first described by Joseph Babinski (Babinski 1902).
- Heel-to-shin testing (Bodranghien et al. 2016).
- Checking.
- Rebound phenomenon of Stewart-Gordon (Angel 1977; Holmes 1917; Stewart and Holmes 1904).
- Quix test for past-pointing (Hart 1983; Quix 1924).
Midline cerebellar function:
Relevant features include:
- Dysarthria, hoarseness.
- Truncal ataxia.
Basal ganglia
Relevant features include:
- Bradykinesia.
- Chorea and athetosis.
- Finger tap and/or toe tap to identify dysrhythmia or amplitude decrement.
- Doorknob turning, finger flicking.
Tests of posture, stance and gait
Relevant features include:
- Romberg test, which we discuss elsewhere.
- Posture (e.g., hunched, stooped).
- Stance (e.g., normal or wide-based).
- Pull test (e.g., for Parkinson’s disease).
- Gait (e.g., stride length, heel strike, number of steps in turning, arm swing, tandem gait).
- Fukuda-Unterberger stepping test. The diagnostic utility of this test is limited, as we discuss elsewhere.
Cranial nerves
Examination of the cranial nerves is important for nearly every subdiscipline of neurology, including otoneurology.
CN I (olfactory)
This does not usually offer much diagnostic utility in otoneurology. Occasionally clinicians may elect to examine this during the assessment for idiopathic Parkinson’s disease or COVID-19.
CN II (optic)
Relevant techniques include:
- Ophthalmoscope examination to evaluate optic nerve head, and limited retinal assessment.
- Assessment of visual acuity and confrontation visual field testing are occasionally helpful.
CN III (oculomotor), IV (trochlear) and VI (abducens)
Ocular motor examination can be helpful, including:
- Assessment for spontaneous nystagmus. This is more easily identified with video oculography (VOG).
- Cover-uncover test to identify phorias/tropias.
- Bielschowsky test. Building on earlier observations by Albrecht Nagel (Nagel 1871), Franz Bruno Hofmann and Alfred Bielschowsky (Hofmann and Bielschowsky 1900) articulated a test for diagnosing superior oblique palsy (Bielschowsky 1950 (1934-1935)). This was later combined by Marshal Parks (Parks 1958) and Eugene Helveston (Parks and Helveston 1970) into a 3-step test for identifying which extraocular muscle palsy is responsible for an acquired hypertropia. The sensitivity and specificity of this examination technique have been questioned (Lee et al. 2018; Manchandia and Demer 2014).
- Assessment for end-gaze nystagmus. This is more easily identified with video oculography (VOG). We discuss this elsewhere.
- Assessment for internuclear ophthalmoplegia (INO), which we discuss elsewhere. This term was first introduced by Jean Lhermitte (Lhermitte 1922), further characterized by Anton Lutz (Lutz 1923), and pathologically confirmed by William Spiller (Spiller 1924). This is more easily identified with binocular video oculography (VOG).
- Assessment of convergence/divergence (e.g., for progressive supranuclear palsy and some other parkinsonian syndromes).
CN V (trigeminal):
- Identification of sensory deficits in the distribution of the trigeminal nerve is important, but not particularly useful for otoneurological diseases.
- Occasionally, identification of conductive hyperacusis (bone conduction superior to air conduction on the Rinne test) may suggest an impaired tensor tympani reflex (mediated by a branch of the trigeminal nerve).
CN VII (facial):
- Looking for asymmetry from upper/lower motor neuron weakness. Rarely, testing taste may be helpful (e.g., in Ramsay Hunt syndrome), or middle ear disease that disrupts the chorda tympani.
- Occasionally, identification of conductive hyperacusis (bone conduction superior to air conduction on the Rinne test) may suggest an impaired stapedial reflex (mediated by a branch of the facial nerve).
CN VIII (auditory): Bedside hearing tests.
- Finger rub test, whisper test, etc., which we discuss elsewhere.
- Weber’s test (Weber 1834), which we discuss elsewhere.
- Rinne’s test (Rinne 1855), which we discuss elsewhere.
CN VIII (vestibular):
Relevant techniques include:
- Bedside vestibular tests, such as:
- Assessment of spontaneous nystagmus.
- Head impulse testing.
- Tests with simple equipment, such as:
- Ophthalmoscope test.
- Dynamic visual acuity testing.
CN IX (glossopharyngeal):
- Poorly coordinated function in the strained speech that can occur in some cerebellar disorders.
CN X (vagus):
- Evaluation for palatal tremor (e.g., in oculopalatal tremor, formerly known as oculo-palatal myoclonus).
CN XI (spinal accessory):
- Evaluation for weakness (shoulder shrug, head turn).
CN XII (hypoglossal):
- Evaluation for dysarthria.
Face-to-face ocular motor examination for asymmetry in vestibular tone
Relevant techniques include:
- Evaluation for spontaneous nystagmus (Pavlin-Premrl et al. 2015), which we discuss elsewhere. This is more easily identified with video oculography (VOG).
- Evaluation for head shaking nystagmus, which we discuss elsewhere. This is more easily identified with video oculography (VOG).
- Head impulse testing at the bedside, which we discuss elsewhere.
Face-to-face ocular motor examination for benign paroxysmal positional vertigo (BPPV)
Relevant techniques include:
- Dix-Hallpike maneuver. The diagnostic utility of this maneuver is enhanced when performed using video oculography (VOG).
- Supine roll test. The diagnostic utility of this maneuver is enhanced when performed using video oculography (VOG).
Tests feasible with standard bedside equipment
- Handheld monocular otoscope, which we discuss elsewhere.
- Ophthalmoscope. This is useful for:
- Ophthalmoscope test of the vestibular-ocular reflex (Kheradmand and Zee 2012; Zee 1978).
- Optic nerve head edema.
- Limited retinal pathology. Better assessment of the retina can be obtained at the bedside with tools such as the PanOptic (McComiskie et al. 2004; Petrushkin et al. 2012), but this is not as widely available.
- Stethoscope. Mostly to evaluate for cardiac arrhythmias, which we discuss elsewhere.
- Sphygmomanometer. Mostly to evaluate for orthostatic hypotension, which we discuss elsewhere.
- Tuning fork for:
- Pallesthesia.
- Weber’s test and Rinne’s test (mentioned above).
- Ankle audition (Verrecchia et al. 2023), useful for semicircular canal dehiscence, which we discuss elsewhere.
Summary
Clinician develop their own routines for physical examination, adjusting according to a patient’s history, and any identified positive findings. We have reviewed a series of physical examination techniques, including several that tend to be more focused on identifying otoneurological disease.
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