2.2 Neurological Examination

A systematic neurological examination establishes a baseline, localizes lesions, and tracks recovery. The NPTE tests the selection, administration, and interpretation of the standard tools.

Deep Tendon Reflexes (DTR)

Asymmetry between sides is more meaningful than the absolute grade—always compare limbs. Key reflex roots: biceps and brachioradialis C5-C6, triceps C7, patellar (knee jerk) L3-L4, Achilles (ankle jerk) S1-S2. A diminished knee jerk with anterior-thigh weakness points to an L3-L4 problem; a diminished ankle jerk with plantarflexion weakness points to S1.

Glasgow Coma Scale (GCS)

The GCS quantifies consciousness, especially after TBI, by summing three components:

Total 3-15. Interpretation: 13-15 mild, 9-12 moderate, 3-8 severe TBI (intubation is typically considered at GCS <=8). The motor sub-score distinguishes two ominous postures: decorticate (GCS motor 3) is abnormal flexion of the upper extremities, indicating a lesion above the red nucleus; decerebrate (GCS motor 2) is abnormal extension of all extremities, indicating a lower brainstem lesion and carrying a worse prognosis. Remember: deCORticate flexes toward the CORe; decerebrate extends.

Balance Assessment

Berg Balance Scale (BBS)

The BBS is a 14-item performance scale, each item scored 0-4, for a maximum of 56. Lower scores indicate higher fall risk (commonly: 41-56 low risk, 21-40 medium, 0-20 high). The minimal detectable change is roughly 4-5 points, so a smaller change may be measurement noise.

Romberg Test

The Romberg isolates proprioception. The patient stands feet-together with eyes open, then closed. A positive Romberg = loses balance only with eyes closed, meaning vision was compensating for impaired proprioception (dorsal-column dysfunction). If the patient sways with eyes open, the problem is not purely proprioceptive—it may be cerebellar, vestibular, or motor.

Timed Up and Go (TUG)

The patient rises from a chair, walks 3 m, turns, returns, and sits. Roughly <10 s is typical; >12-14 s flags increased fall risk; >20 s suggests dependence for mobility and need for assistance.

Coordination and Spasticity

Cerebellar dysfunction produces characteristic errors:

Cerebellar vs. basal-ganglia dysfunction: cerebellar lesions cause intention tremor (worse with movement), dysmetria, and ataxia (e.g., cerebellar stroke, MS); basal-ganglia disorders cause a resting tremor (better with movement), rigidity, and bradykinesia (e.g., Parkinson disease).

Modified Ashworth Scale (MAS) for spasticity

Choosing the Right Outcome Measure

The NPTE often asks which tool best fits a clinical question, so match the measure to the construct. For static and functional standing balance and fall risk in older or neurologic patients, the Berg Balance Scale is the workhorse. For mobility and fall risk with a quick screen, the Timed Up and Go is fast and functional. To isolate proprioceptive balance specifically, use the Romberg. For dynamic gait and the ability to modify walking under cognitive and head-movement challenges, the Dynamic Gait Index or Functional Gait Assessment is appropriate.

For spasticity, the Modified Ashworth Scale grades the catch on passive movement, while the Tardieu adds a velocity component.

Interpreting Change Over Time

A score in isolation is less useful than a score compared to a baseline and to the measure's minimal detectable change (MDC). If a patient's Berg improves by three points but the MDC is around four to five, the change may be measurement error rather than true improvement. Conversely, a change that exceeds the MDC and the minimal clinically important difference reflects real, meaningful progress and supports continuing the current plan of care. The exam expects you to recognize when a difference is meaningful versus noise, and to re-test the same way you tested at baseline so the comparison is valid.

Sensory and Tone Examination Pearls

A complete neuro exam also screens sensation systematically—light touch, pinprick (pain), proprioception, and vibration—because the modality lost localizes the lesion (dorsal column versus spinothalamic). When testing tone, move the limb at varying speeds: spasticity is velocity-dependent (the catch worsens with faster movement) and distinguishes an UMN picture from rigidity, which is velocity-independent and seen in basal-ganglia disorders. Documenting both the modality of sensory loss and the velocity-dependence of tone gives you the data the exam expects you to interpret into a localization and a plan.