Do you ever wonder, “did anyone else see that?” We find those red flags sometimes, don’t we? We see something odd in a physical exam and it completely changes our perspective on the patient. The key to seeing it, though, is to look for it.
You may be thinking, “another thing I need to add to my very limited time with the patient… great.” But I have great news for you! This can be done quickly and easily. You don’t have to do in-depth coverage of every single neurological deficit, but you can cover a lot of bases and get a baseline without dedicating a huge amount of time. This can lead you to go a little deeper later if you need to. But, this big piece here is that you’ll never know it’s an issue if you never look for it.
We now know that COVID-19 presents with any number of strange symptoms depending on which entry point the virus utilizes. This may include neurological symptoms such as loss of taste or smell, headaches, or other neurological signs that we discuss at length in this post. But, this screen isn’t just relevant for COVID-19 patients. Like I said before, I started educating on this years ago, way before COVID-19 was even a thing. If you have patients you see for any reason and they have a history of neurological events or conditions (old CVA, TIAs, old TBI, old CHI, peripheral nerve injury, seizure disorders), or even some neurocardiological-endocrine conditions like diabetes, you’ll want to get a neurological baseline in place. You can look back at this to see if they have made progress or are showing new symptoms for some reason!
The big tagline here is: You don’t know where the patient is at if you don’t know where they started. You can’t be calling in the physician to report neurological findings if you have no basis for comparison. Even strokes leave residual deficits that magnify under odd conditions. This doesn’t mean the person is having a stroke, as you’ll see later.
From Neck Pain to TIA in a the Twitch of a Finger
For example, I saw a patient at home with severe neck pain. Her cervical spine assessment showed that she could not rotate her head in either direction while seated, so I did a neurological screen. She was mildly confused, her blood pressure was high, and she was living alone. Some minor coordination tests didn’t look right and she had a (+) Hoffman’s sign. ***my eyes widen*** I dug a little deeper and found that she was completely unable to dissociate her upper body from her lower body. She was having TIAs and quickly losing neuromotor coordination. Her neck pain was a result of high blood pressure (instead of a headache) and her inability to dissociate her movements.
She wasn’t the only (+) Hoffman’s sign I’ve seen, either. I spent a long time learning about neurocardiological function from a patient who had sustained a brain injury in a car accident. Her midbrain shearing injury resulted in disruption of her ability to control her blood pressure which was leading to falls and emergency visits for excessive hypertension. My first clue that her hypertension wasn’t typical was that (+) Hoffman’s sign, which lead to an in-depth discussion of her medical history and revealed the TBI. She had moved and no longer had the same medical team, so no one was aware of this, and she hadn’t even told her home care nurse who was struggling to get her enough fast-acting medication to control her hypertension. But I never would have found that Hoffman’s sign if I hadn’t been screening for it.
Tone, Strength, Sensation, Synergies, Coordination, Posture, and Balance all need to be assessed as part of the neurological screening. And to top it all off, let’s throw in a cranial nerve exam. The only way I remembered all the things I needed to do for a neurological baseline assessment was to create an acronym. This is really generic, but it allows me to cover each of the important items and directs me toward where I need to dig a little deeper. Some of these things can also be observed simultaneously if you are looking for them. So, I came up with T.S.S.S.C.P.B. (“T, Triple S, CPB”) Just the first letter of each of these items. This helps keep me on track and ensures I don’t miss something I need to do. It may not work for you. I realize it’s a bit odd but it got me an A on my practical in school and I’ve been using it ever since! Yes, I do this at EVERY evaluation. Why not? It takes five minutes and it clears so many red flags.
Tone: Assessed with strength as in any typical MMT assessment using the bicep and tricep and/or hamstring and quad in seated. Remember, tone is resistance of a muscle to a passive stretch. Like I said, this is only a screen, so if there is a less common tonal presentation or it only presents in a different position, I won’t find it here.
Strength: Assessed as typical MMT as with any orthopedic examination. I also do reflexes here since I tend to already have them seated for quad and can easily assess brachioradialis, tricep, and plantarflexors. Since I already have their hands and feet, I also check UMN signs here. I focus on the big ones: Hoffman’s, Clonus, Babinski…
Here is a great video of how to quickly assess some upper motor neuron signs, like that Hoffman’s sign I talked about:
Sensation: Screened with light touch and deep pressure during positioning for MMT and other tests, but also screened using proprioceptive testing of the hallux. For screening purposes, if the most distal segment is intact, I assume that all above segments are intact (except in the case of diabetes or other stocking/glove disturbances).
Synergy: Observed during normal movements or assessed when needed, like in the case I mentioned above where the patient could not rotate her cervical spine bilaterally.
Coordination: Assessed using finger opposition, visual targeting, AND in the lower extremity using the heel to shin slide, usually just before MMT.
Posture: Assessed in seated and standing as part of any normal evaluation, but intensive attention paid to symmetry and posture during active movements. (Looking specifically for things like associated movements or signs of Pusher)
Balance: Gotta have that standardized test in there. Remember to choose something challenging. I always tell my patients, “If I’m not challenging you, I’m not going to change you.” Some of my favorites include the Function in Sitting Test (FIST), the Dynamic Gait Index (DGI), and the Balance Evaluations Systems Test (BESTest). Take your pick from what works best in your setting and for your population.
After doing this neurological screen, I tend to get a lot of comments like, “No one has ever done any of those things before. What do they mean?” Which gives me a great opportunity for patient education. Sometimes I get comments like, “My neurologist does those things, too,” from a patient’s family member, which strengthens my patient-provider relationship because they know that I know what I’m doing.
Once you get the hang of it and do it a few times, this comes really fast. Keep in mind that this is a SCREEN, so no, it’s not perfect, and it’s probably not what the neurologist does, and it won’t answer every single diagnostic question. But that’s not the point of a screen.
I cannot even put a number to the neurological signs I have picked up with this screen that warranted further investigation. Have you ever found neurological signs that completely altered the course of treatment for your patient? Tell me your story in the comments!
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The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.