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Handbook of Clinical Neurology 2019Clinical evaluation of neurologic disorders in the elderly requires seeking a thorough history and performing an age-appropriate neurologic examination with special... (Review)
Review
Clinical evaluation of neurologic disorders in the elderly requires seeking a thorough history and performing an age-appropriate neurologic examination with special attention to changes that occur with normal aging. The history should be obtained from the patient as well as collateral sources close to the patient to ensure accuracy and should include contextual elements such as medical history, social, economic, and psychological background, as well as an assessment of current functional state beyond activities of daily living. The safety of the patient, including the presence of physical, psychological, and financial threats, should be addressed during the interview. The neurological examination in older adults may need to be modified to circumvent disabilities such as hearing and visual impairment. Some elements of the neurological examination are expected to be affected by the process of aging, including pupillary reactivity, presbyopia, difficulty with ocular pursuit and up-gaze, reduced or absent distal reflexes, slower motor speed, and reduced ability to tandem walk, among others. In addition to a screening neurological assessment, evaluation of older adults with a particular complaint may require additional interview queries and examination manoeuvres. Common symptoms in the elderly include cognitive difficulties, balance and gait disorders, tremors, and neuropathy. A specialized approach to patients with cognitive difficulties must include assessment of each cognitive domain, including attention, executive function, learning and memory, perceptual-motor function, and social cognition. Balance and gait are essential parts of the neurological examination, and in patients with a history of falls or mobility issues, should become a central part of the evaluation. In patient with tremors, careful observation of the tremor quality (amplitude, frequency, and alleviating/exacerbating factors such as rest, movement, and posture) can aid diagnosis. Evaluation of neuropathy includes determining modality (numbness, tingling, pain, and weakness) and the distribution of symptoms in order to localize the site of nerve injury, which can be supplemented with nerve conduction studies/electromyography, to guide further diagnostic workup and treatment. A combination of detailed history and examination often will suggest a likely underlying neurodegenerative disorder and guide further diagnostic workup to establish a specific diagnosis.
Topics: Aged; Aged, 80 and over; Female; Humans; Male; Nervous System Diseases; Neurologic Examination
PubMed: 31753158
DOI: 10.1016/B978-0-12-804766-8.00005-4 -
American Family Physician Jan 2020Although the prevalence of muscle weakness in the general population is uncertain, it occurs in about 5% of U.S. adults 60 years and older. Determining the cause of... (Review)
Review
Although the prevalence of muscle weakness in the general population is uncertain, it occurs in about 5% of U.S. adults 60 years and older. Determining the cause of muscle weakness can be challenging. True muscle weakness must first be differentiated from subjective fatigue or pain-related motor impairment with normal motor strength. Muscle weakness should then be graded objectively using a formal tool such as the Medical Research Council Manual Muscle Testing scale. The differential diagnosis of true muscle weakness is extensive, including neurologic, rheumatologic, endocrine, genetic, medication- or toxin-related, and infectious etiologies. A stepwise approach to narrowing this differential diagnosis relies on the history and physical examination combined with knowledge of the potential etiologies. Frailty and sarcopenia are clinical syndromes occurring in older people that can present with generalized weakness. Asymmetric weakness is more common in neurologic conditions, whereas pain is more common in neuropathies or radiculopathies. Identifying abnormal findings, such as Chvostek sign, Babinski reflex, hoarse voice, and muscle atrophy, will narrow the possible diagnoses. Laboratory testing, including electrolyte, thyroid-stimulating hormone, and creatine kinase measurements, may also be helpful. Magnetic resonance imaging is indicated if there is concern for acute neurologic conditions, such as stroke or cauda equina syndrome, and may also guide muscle biopsy. Electromyography is indicated when certain diagnoses are being considered, such as amyotrophic lateral sclerosis, myasthenia gravis, neuropathy, and radiculopathy, and may also guide biopsy. If the etiology remains unclear, specialist consultation or muscle biopsy may be necessary to reach a diagnosis.
Topics: Adult; Aged; Aged, 80 and over; Diagnosis, Differential; Humans; Muscle Weakness; Muscles; Muscular Diseases; Neurologic Examination; Neurology
PubMed: 31939642
DOI: No ID Found -
American Family Physician Apr 2015Stroke can be categorized as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Awakening with or experiencing the abrupt onset of focal neurologic... (Review)
Review
Stroke can be categorized as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Awakening with or experiencing the abrupt onset of focal neurologic deficits is the hallmark of the diagnosis of ischemic stroke. The most common presenting symptoms of ischemic stroke are speech disturbance and weakness on one-half of the body. The most common conditions that can mimic a stroke are seizure, conversion disorder, migraine headache, and hypoglycemia. Taking a patient history and performing diagnostic studies will usually exclude stroke mimics. Neuroimaging is required to differentiate ischemic stroke from intracerebral hemorrhage, as well as to diagnose entities other than stroke. The choice of neuroimaging depends on availability of the method, the patient's eligibility for thrombolysis, and presence of contraindications. Subarachnoid hemorrhage presents most commonly with sudden onset of a severe headache, and noncontrast head computed tomography is the imaging test of choice. Cerebrospinal fluid inspection for bilirubin is recommended if subarachnoid hemorrhage is suspected in a patient with a normal computed tomography result. Public education about common presenting stroke symptoms may improve patient knowledge and clinical outcomes.
Topics: Cerebrospinal Fluid; Diagnosis, Differential; Humans; Neuroimaging; Neurologic Examination; Patient Education as Topic; Practice Guidelines as Topic; Risk Factors; Stroke
PubMed: 25884860
DOI: No ID Found -
Neurologic Clinics Aug 2014Myopathies are a heterogeneous group of disorders that can be challenging to diagnose. This review provides a diagnostic approach based predominantly on the clinical... (Review)
Review
Myopathies are a heterogeneous group of disorders that can be challenging to diagnose. This review provides a diagnostic approach based predominantly on the clinical history and neurologic examination. Laboratory testing that can be used to confirm the suspected diagnosis based on this pattern recognition approach is also discussed. Careful consideration of the distribution of muscle weakness and attention to common patterns of involvement in the context of other aspects of the neurologic examination and laboratory evaluation should assist the clinician in making a timely and accurate diagnosis and can sometimes minimize the expense of further testing.
Topics: Humans; Medical History Taking; Muscular Diseases; Neurologic Examination
PubMed: 25037080
DOI: 10.1016/j.ncl.2014.04.008 -
Journal of Neurophysiology Jul 2019Although many studies have reported on tests of the vestibular system a valid and reliable, evidence-based screening battery for easy clinical use remains elusive. Many... (Review)
Review
Although many studies have reported on tests of the vestibular system a valid and reliable, evidence-based screening battery for easy clinical use remains elusive. Many screening tests attempt to assess the vestibulo-ocular reflex. Therefore, head shaking, the Dix-Hallpike maneuver, the supine roll test, and head impulse tests are discussed. Other tests address the spatial orientation functions of the vestibular system, such as the Bucket Test and the Fukuda Stepping test. Still, other tests are based on the known correlates with balance skills, both static and dynamic, such as tandem walking and the modern variation of the Romberg test, the modified Clinical Test of Sensory Interaction and Balance. This review provides a critical overview of the literature on some of these tests and their value for clinical use and in epidemiological studies.
Topics: Eye Movements; Gait; Humans; Neurologic Examination; Orientation, Spatial; Postural Balance; Reflex, Vestibulo-Ocular; Vestibular Diseases
PubMed: 30995137
DOI: 10.1152/jn.00819.2018 -
Neurology Jan 2013Current criteria for the clinical diagnosis of pathologically confirmed corticobasal degeneration (CBD) no longer reflect the expanding understanding of this disease and...
Current criteria for the clinical diagnosis of pathologically confirmed corticobasal degeneration (CBD) no longer reflect the expanding understanding of this disease and its clinicopathologic correlations. An international consortium of behavioral neurology, neuropsychology, and movement disorders specialists developed new criteria based on consensus and a systematic literature review. Clinical diagnoses (early or late) were identified for 267 nonoverlapping pathologically confirmed CBD cases from published reports and brain banks. Combined with consensus, 4 CBD phenotypes emerged: corticobasal syndrome (CBS), frontal behavioral-spatial syndrome (FBS), nonfluent/agrammatic variant of primary progressive aphasia (naPPA), and progressive supranuclear palsy syndrome (PSPS). Clinical features of CBD cases were extracted from descriptions of 209 brain bank and published patients, providing a comprehensive description of CBD and correcting common misconceptions. Clinical CBD phenotypes and features were combined to create 2 sets of criteria: more specific clinical research criteria for probable CBD and broader criteria for possible CBD that are more inclusive but have a higher chance to detect other tau-based pathologies. Probable CBD criteria require insidious onset and gradual progression for at least 1 year, age at onset ≥ 50 years, no similar family history or known tau mutations, and a clinical phenotype of probable CBS or either FBS or naPPA with at least 1 CBS feature. The possible CBD category uses similar criteria but has no restrictions on age or family history, allows tau mutations, permits less rigorous phenotype fulfillment, and includes a PSPS phenotype. Future validation and refinement of the proposed criteria are needed.
Topics: Age of Onset; Aged; Basal Ganglia; Cerebral Cortex; Cognition Disorders; Databases, Factual; Family Health; Female; Humans; Language Disorders; Male; Middle Aged; Neurodegenerative Diseases; Neurologic Examination; Phenotype; Retrospective Studies
PubMed: 23359374
DOI: 10.1212/WNL.0b013e31827f0fd1 -
American Family Physician Apr 2019Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external... (Review)
Review
Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established. Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.
Topics: Athletic Injuries; Brain Concussion; Disease Management; Humans; Neurologic Examination; Sports Medicine
PubMed: 30932451
DOI: No ID Found -
Pain Physician Jul 2018Although sacroiliac joint dysfunction (SIJD) is generally regarded as a source of lumbar pain, its anatomical position and the absence of a diagnostic 'gold standard'...
BACKGROUND
Although sacroiliac joint dysfunction (SIJD) is generally regarded as a source of lumbar pain, its anatomical position and the absence of a diagnostic 'gold standard' lead to difficulties at examination and differential diagnosis. However, since sacroiliac (SI) joint blocks only provide information about pathologies of joint origin and since SIJD developing secondary to pathologies in structures around the joint can be missed. Provocation and palpation tests also need to be used in diagnosis.
OBJECTIVES
The purpose of this study was to examine the reliability of clinical examination and provocation tests used in the diagnosis of SIJD.
STUDY DESIGN
Retrospective analysis of prospectively collected data.
SETTING
Outpatient physical medicine and rehabilitation clinic.
METHODS
One hundred and seventeen patients presenting with lumbar and/or leg pain and diagnosed with SIJD through clinical evaluation were included in the study. Range of lumbar joint movement, pain location and specific tests used in the diagnosis of SIJD were evaluated. Positivity in 3 out of 6 provocation tests was adopted as the criterion.
RESULTS
75.2% of patients were female and 24.8% were male. Mean age was 46.41 ± 10.45 years. A higher level of females was determined in ender distribution. SIJD was determined on the right in 52.6% of patients and on the left in 47.4%. When SI joint provocation tests were analyzed individually, the highest positivity, in 91.4% patients diagnosed with SIJD, was in the FABER test. The lowest positivity, in 56.4% of patients, was determined in the Ganslen test. The same patients were assessed by the same clinician at 2 different times. In these data, the simple consistence, kappa and PABAK coefficient values of all tests were close to 1 and indicating good agreement. The thigh thrust (POSH) and sacral thrust tests exhibited very good agreement with a kappa coefficient of 0.90 and a PABAK coefficient of 0.92, while the FABER test exhibited good agreement with a kappa coefficient of 0.78 and a PABAK coefficient of 0.92.
LIMITATION
Agreement between different observers was not evaluated, and also no comparison was performed with SI joint injection, regarded as a widely used diagnostic technique.
CONCLUSION
The anatomical position of the SI joint and the lack of a diagnostic 'gold standard' make the examination and diagnosis of SIJD difficult. Most SI joint clinical tests have limited reliability and validity on their own, while a multitest regimen consisting of SI joint pain provocation tests is a reliable method, and these tests can be used instead of unnecessary invasive diagnostic SI joint procedures.
KEY WORDS
Dysfunction, lumbar, sacroiliac joint, provocation test, sacroiliac joint pain, pain pattern.
Topics: Adult; Diagnosis, Differential; Female; Humans; Low Back Pain; Male; Middle Aged; Neurologic Examination; Pain Measurement; Palpation; Reproducibility of Results; Retrospective Studies; Sacroiliac Joint
PubMed: 30045603
DOI: No ID Found -
BMC Musculoskeletal Disorders Feb 2017Lumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate... (Review)
Review
BACKGROUND
Lumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate treatment of patients resulting in poor health outcomes, exacerbating this already debilitating condition. This review evaluated 12 primary diagnostic accuracy studies that specifically assessed the performance of various individual and grouped clinical neurological tests in detecting nerve root impingement, as established in the current literature.
METHODS
Eight electronic data bases were searched for relevant articles from inception until July 2016. All primary diagnostic studies which investigated the accuracy of clinical neurological test (s) in diagnosing lumbar radiculopathy among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the 'Quality Assessment of Diagnostic tests Accuracy Studies' criteria.
RESULTS
A total of 12 studies which investigated standard components of clinical neurological examination of (sensory, motor, tendon reflex and neuro-dynamics) of the lumbo-sacral spine were included. The mean inter-observer agreement on quality assessment by two independent reviewers was fair (k = 0.3 - 0.7). The diagnostic performance of sensory testing using MR imaging as a reference standard demonstrated a sensitivity (confidence interval 95%) 0.61 (0.47-0.73) and a specificity of 0.63 (0.38-0.84). Motor tests sensitivity was poor to moderate, ranging from 0.13 (0.04-0.31) to 0.61 (0.36-0.83). Generally, the diagnostic performance of reflex testing was notably good with specificity ranging from (confidence interval 95%) 0.60 (0.51-0.69) to 0.93 (0.87-0.97) and sensitivity ranging from 0.14 (0.09-0.21) to 0.67 (0.21-0.94). Femoral nerve stretch test had a high sensitivity of (confidence interval 95%) 1.00 (0.40-1.00) and specificity of 0.83 (0.52-0.98) while SLR test recorded a mean sensitivity of 0.84 (0.72-0.92) and specificity of 0.78 (0.67-0.87).
CONCLUSIONS
There is a scarcity of studies on the diagnostic accuracy of clinical neurological examination testing. Furthermore there seem to be a disconnect among researchers regarding the diagnostic utility of lower limb neuro-dynamic tests which include the Straight Leg Raise and Femoral Nerve tests for sciatic and femoral nerve respectively. Whether these tests are able to detect the presence of disc herniation and subsequent nerve root compression or hyper-sensitivity of the sacral and femoral plexus due to mechanical irritation still remains debatable.
Topics: Humans; Intervertebral Disc Degeneration; Intervertebral Disc Displacement; Low Back Pain; Lumbar Vertebrae; Neurologic Examination; Radiculopathy; Sacrum
PubMed: 28231784
DOI: 10.1186/s12891-016-1383-2 -
Developmental Medicine and Child... Mar 2016The Hammersmith Infant Neurological Examination (HINE) has been proposed as one of the early neurological examination tools for the diagnosis of cerebral palsy (CP). The... (Review)
Review
The Hammersmith Infant Neurological Examination (HINE) has been proposed as one of the early neurological examination tools for the diagnosis of cerebral palsy (CP). The aim of the present study was to critically review the existing literature and our experience with the use of the HINE in infants at risk of CP. The published papers confirm that the HINE can play an important role in the diagnosis and prognosis of infants at risk of developing CP, and provide information on aspects of neurological findings impaired in different forms of CP and brain lesions.
Topics: Cerebral Palsy; Early Diagnosis; Humans; Infant; Neurologic Examination
PubMed: 26306473
DOI: 10.1111/dmcn.12876