How do you perform a neurological exam via telehealth? This page was designed to help you adapt the exam to this medium and still obtain the neurological information that you need.
To start, watch the 3 minute video below from the American Academy of Neurology for suggestion on how to perform a neurological examination via telehealth
Some key tips:
- Many aspects of a neurological screen can be performed via telehealth, but not all – such as vestibular exam, reflex assessment, altered muscle tone and subtle weakness or sensory deficits.
- It may be helpful to have a second person assist the patient with certain aspects of an assessment.
- Carefully observe the patient throughout and have patient repeat maneuvers a few times when needed or to provoke fatigue.
- To screen cranial nerves evaluate extraocular movements by having patients look in all directions, observe facial symmetry, shoulder shrug, and tongue protrusion
- Tremors may be observed visually.
- Check the finger to nose test for a cerebellar exam.
Sensory function
Assessment of sensory function is challenging in a telehealth exam. If another person is available to assist the patient, they may be instructed to perform light touch dermatomal assessment and compare sensation to the contralateral side or proximal to distal on same limb. You may ask the patient to draw a circle around the area that has altered sensation to get an idea of general distribution.
Motor system
In a telehealth assessment, functional tests (e.g. sit to stand, heel/toe walking, standing on one leg) can be helpful to identify issues with the motor system. If there is concern about red flags based on these functional tests and/or subjective information (e.g. balance issues, progressive or generalize lower extremity weakness, bowel or bladder changes) a more thorough in-person clinical assessment may be warranted.
Testing options for the cervical and lumbar spine myotomes are provided below as examples when manual resistance cannot be applied by the assessor. These tests are not validated and are provided as suggestions only.
Cervical Region:
Telehealth Assessment of Cervical Myotomes
| Myotome | Movement | Examples of Resistance Options |
|---|---|---|
| C4 | Shoulder elevation | Patient in standing holding approximately 1 kg weights in hands, vertically elevate shoulders. |
| C5 | Shoulder Abduction | Holding light weights (or soup cans), abduct shoulders to 90 with elbows extended. |
| C6 | Elbow flexion, wrist extension | Holding light weights in hand with elbow flexion at 90 and full pronation – perform wrist extension. |
| C7 | Elbow extension, wrist flexion | Elbow extension with elbow pointing to ceiling, stabilizing proximal arm with opposite hand (as required), and using a weight. OR Holding weights in hand with elbow flexed at 90 and full supination – perform wrist flexion. |
| C8 | Finger flexion, thumb extension/abduction | Hook flexed fingers (flexed DIP + PIP and extended MCPs) together and pull apart looking for asymmetry. OR Resisting thumbs against each other into extension or abduction, check for asymmetry. |
| T1 | Abduction and/or adduction of fingers | Open hands facing patient, press opposite abducted fingers (ulnar aspect of opposite little fingers in contact) against each other. OR Holding a folded piece of paper between the adducted little and ring fingers resist pulling the paper away. Look for asymmetry. |
| C8+T1 | Functional grip | Grip a water bottle or rolling pin – can the patient pull it out of the gripping hand with the unaffected hand? Do they feel a difference right and left? |
Adapted from: Inter-professional Spine Assessment and Education Clinics (ISAEC Operations), Low Back Rapid Access Clinic. Virtual Assessment and Education Toolkit. Toronto, ON: 2020.
Lumbar Region:
Telehealth Assessment of Lumbar Myotomes
| Myotome | Movement | Example of Resistance Options |
|---|---|---|
| L2 | Hip flexion | Patient standing with tested leg hip and knee flexed at 90 -90, hold for 5 secs OR Self-resisted hip flexion in sitting hold for 5 sec |
| L3 | Knee extension | Single leg sit to stand from chair OR Single leg squat checking for equality of depth, control R=L (ensure that patient is stabilized using a chair, counter etc. to prevent fall) OR Self-resisted knee extension with opposite leg in sitting, holding for 5 secs |
| L4 | Ankle dorsi flexion | Heel waking minimum 10 steps or self-resisted in sitting |
| L5 | Great toe extension, hip abduction | Self-resisted with hands. If patient can reach then instruct to bring foot up to opposite knee. Can also assess with hip abduction and resisted band or the presence or absence of Trendelenburg sign |
| S1 | Ankle plantar flexion | Single leg heel raises (5 full raises = 4/5, 10 raises = 5/5), toes walking 10 steps |
| Note: If appropriate, the single leg sit to stand is a reliable test for assessing L3, L4 (Quadriceps) strength in patients who present with radiculopathy. Fatigue testing can also be assessed for certain myotomes (i.e. number of repetitive single limb heel raises to assess S1 function) | ||
Adapted from: Inter-professional Spine Assessment and Education Clinics (ISAEC Operations), Low Back Rapid Access Clinic. Virtual Assessment and Education Toolkit. Toronto, ON: 2020.