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Monthly Archives: June 2014

Neurological Examination

A neurological examination, also called a neuro exam, is an evaluation of a person’s nervous system that can be completed in the doctor’s office. It may be performed with instruments, such as lights and reflex hammers, and usually does not cause any pain to the patient. The nervous system consists of he brain, spinal cord, and the nerves from these areas. There are many aspects of this examination, including an assessment of motor and sensory skills, balance and coordination, mental status (the patient’s level of awareness and interaction with the environment), reflexes and functioning of the nerves. The extent of the examination depends on many factors, including the initial problem that the patient is experiencing, the age of the patient and the condition of the patient.

Why is a neurological examination performed?

A complete and thorough evaluation of a person’s nervous system is important if there is any reason to think there may be an underlying problem, or during a complete physical. Damage to the nervous system can cause problems in daily functioning. Early identification may help to identify the cause and decrease long-term complications. A complete neurological examination may be performed:

– During a routine physical

– Following any type of trauma

– To follow the progression of a disease

– If the person has any of the following complaints:

– Headaches

– Blurry Vision

– Change in behaviour

– Fatigue

– Change in balance or coordination

– Numbness or tingling in the arms or legs

– Decrease in movement of the arms or legs

– Injury to the head, neck or back

– Fever

– Seizures

– Slurred Speech

– Weakness

– Tremor

What is done during a neurological assessment?

During a neurological assessment, the doctor will “test” the functioning of the nervous system. The nervous system is very complex and controls many parts of the body. The nervous system consists of the brain, spinal cord, 12 nerves that come from the brain, and the nerves that come from the spinal cord. The circulation to the brain, arising from the arteries in the neck, is also frequently assessed. In infants and younger children, neurological examination includes the measurements of the head circumference. The following is an overview of some of the areas that may be tested and evaluated during a neurological examination:

Mental Status: Mental Status(the patients level of awareness and interaction with the environment) may be assessed by conversing with the patient and establishing his or her awareness of person, place and time. The person will also be observed for clear speech and making sense while talking. This is usually done by the patients doctor just by observing the patient during normal interactions.

Motor function and balance: This may be tested by having the patient push and pull against the doctors hands with his or her arms and legs. Balance may be checked by assessing how the person stands and walks or having the patient stand with his or hers eyes closed while being gently pushed to one side or the other. The patient joints can also be checked simply by passive (performed by the doctor) and active (performed by the patient)movement.

Sensory Examination: The patients doctor may also perform a sensory test that checks his/her ability to feel. This may be done by using different instruments: dull needles, tuning forks, alcohol swabs, or other objects. The doctor may touch the patients legs, arms, or other parts of the body and have him/her identify the sensation (for example, hot or cold, sharp or dull).

Newborn and infant reflexes: There are different types of reflexes that may be tested. In newborns and infants, reflexes called infant reflexes (or primitive reflexes) are evaluated. Each of these reflexes disappears at a certain age as the infant grows.

These reflexes include:

     Blinking: An infant will close his/her eyes in response to bright lights.

     Babinski reflex: As the infants foot is stoked, the toes will extend upward.

     Crawling: If the infant is placed on his/her abdomen, he or she will make crawling      motions.

     Moro’s Reflex: A quick change in the infants position will cause the infant to throw the arms outwards, open the hands and throw back the head.

     Palmar and plantar grasp: The infants fingers or toes will curl around a finger placed in the area.

Reflexes in the older child and adult: These are usually examined with the use of a reflex hammer. The reflex hammer is used at different points on the body to test numerous reflexes, which are noted by the movement that the hammer causes.

Evaluation of the nerves of the brain: There are 12 main nerves of the brain, called the cranial nerves. During a complete neurological examination, most of these nerves are evaluated to help determine the functioning of the brain.



Hammer toes arise when the smaller toes of the foot become bent and prominent. The four smaller toes of the foot are much like the same fingers in the hand. Each has three bones (Phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (Metatarsals) and it is this area that is often referred to as the ball of the foot.

Generally, these bones and joints are straight. A hammertoe occurs when the toes become bent at the first interphalangeal joint, making the toe prominent. This can affect any number of the lesser toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, callouses or corns can form over the joints or at the tip of the toe.

What causes Hammertoes?

There are many different reasons but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and/or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.

In some instances trauma (either direct injury or overdoing from walking or sport) can predispose to hammertoes. Patients who have other medical conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?

It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity. It is common for patients to wear shoes that are too small and this can predispose to the problem.

At the start of deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint can become fixed or rigid. This can then affect the joint at the ball of the foot and, in severe cases, the joint capsule ruptures (tears) so that the joint becomes dislocated and the toe sits up in the air.

What are the most common symptoms?

– Deformity/prominence of toe

– Pain

– Redness around the joints

– Swelling around the joints

– Corn/Callous

– Difficulty in shoes with deformity of the shoe upper

– Difficulty in walking

– Stiffness in the joints of the toe

How is it recognised?

Clinical examination a detailed history allow diagnosis. X-Rays are often not required but can help to evaluate the extent of the deformity and the degree of arthritis within the joint.

There are several things that you can try to reduce the pain:

– Wear good fitting shoes with a deep toe box

– Avoid high heels

– Use a toe prop to straighten the toe if its still mobile

– Wear a protective pad over the toe

– See a podiatrist

What will a podiatrist do?

If simple measures do not reduce your symptoms, there are other options:

– Advise appropriate shoes

– Advise exercises if the toes are still mobile

– Show you how to strap the toe in a corrected position

– Provide a splint or protection

– Consider prescribing orthotics

– Advise on surgery

The way in which your foot loads during walking can place increased stress on the ball of the foot and cause increased toe activity. Special shoe inserts (orthotics) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the ball of the foot.

Will this cure the problem?

If the deformity is mobile, then this may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then orthotics will not cure the problem but may reduce the associated symptoms.

Indications for Orthotics

Foot Orthotics are specially designed shoe inserts that help support the feet and improve foot posture. People who have chronic foot or leg problems that interfere with the health and functioning of their feet may be prescribed orthotics by their podiatrist. For example, someone prone to calluses can have the pressure of their body weight redistributed across their feet with the support of custom-fitted shoe inserts. Athletes may also wear orthotics to help correct foot problems that can hinder their performance.

Conditions treated with Orthotics

Some of the foot and lower limb problems that can be successfully treated in the long term with Orthotics include:

– Corns and Calluses

– Foot Ulceration

– Tendonitis

– Reoccurring ankle sprains

– Recurrent stress fractures of foot and leg bones

– Heel pain

– Front-of-knee pain (Pattellofemoral Syndrome)

– Some hip and low back pains (particularly those made worse by long periods of walking or standing).

Orthoses are individually designed

Orthotics are designed to address the patients particular foot problems. The various types of orthotics can include:

– Functional Foot (customised kinetic) orthotics  – to offer all the features below, including postural adjustment.

– Prefabricated Orthotics – these devices can be customised by a podiatrist to provide relief for a specific problem.

– Cushioning Orthotics – to offer extra shock absorption to the foot.

– Pressure relief Orthotics – to remove pressure spots (that could be responsible for complaints such as corns and calluses) by redistributing the person’s body weight across the sole of the foot.

Prescribing Orthotics

When prescribing your orthotics, your podiatrist will consider various factors, including:

– Existing foot problems (such as corns and calluses)

– Foot structure and function

– Biomechanical considerations, including posture and walking pattern

– Type of footwear commonly worn

– Occupation (such as whether your job involves standing up for long periods of time)

– Lifestyle Factors (such as preferred sports)

Assessment for Orthotics

If foot orthotics are considered necessary, a comprehensive understanding of your foot function will be required. This may be done by examining your foot, including the rang of motion of your foot joints, the strength of the muscles in your feet, and the position of the bones in your feet when you stand. Your walking pattern will be assessed in detail (on a flat surface, a treadmill, or by repeating the activity that triggers your pain).

Long-term treatment with Orthotics

Orthotics will usually be prescribed with other therapies, such as a program of stretching and strengthening exercises to improve your posture and alignment. These exercises are generally developed by the podiatrist in consultation with you and started at the time of the orthotic prescription.

Other Physical therapies may include:

– Ultrasound

– Mobilisation

– Manipulation

– Taping and strapping

For people with diabetic foot ulcers, wound cleaning and dressings are provided, as well as pressure-relieving Orthoses to improve the rate of healing.

You may need to visit your podiatrist after your Orthoses are fitted to make sure they are working properly. In some cases, small adjustments to the shoe inserts are need. Your podiatrist will devise an ongoing treatment plan to help you manage your foot problems long term.