neurologic assesment

Neurologic Assessment

Maria Carmela L. Domocmat, RN, MSN
Instructor, Nursing Health Assessment
School of Nursing
Northern Luzon Adventist College

Nervous System Anatomy: Review

6/26/2011 2

http://sciencecity.oupchina.com.hk/biology/student/glossary/img/peripheral_nervous_system.jpg

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The right cerebral hemisphere controls movement of the left side of
the body.
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The cerebellum processes input from other areas of the brain, spinal cord
and sensory receptors to provide precise timing for coordinated, smooth
movements of the skeletal muscular system. A stroke affecting the
cerebellum may cause dizziness, nausea, balance and coordination
problems.
http://health.allrefer.com/pictures-images/cerebellum-function.html
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Neurologic Assessment:
OVERVIEW

Neurologic System Assessment

Organized into 5 major areas:
1. Mental Status
2. Cranial Nerves
3. Sensory System
4. Motor System & Cerebellar
5. Reflexes

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Mental Status and Level of
Consciousness
Observe the following:
• LOC
• posture and body movements
• dress, grooming and hygiene
• facial expression
• speech
• mood, feelings, and expressions
• thought processes and perceptions
• cognitive abilities
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Cranial Nerves
• I (olfactory)
• II (optic)
• III (oculomotor), IV (trochlear), VI (abducens)
• V (trigeminal)
• VII (facial)
• VIII acoustic/vestibulocochlear)
• IX (glossopharyngeal), X (vagus)
• XI (spinal accessory)
• XII (hypoglossal)
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Motor and cerebellar systems
assess condition and movement of muscles
evaluate balance
assess coordination

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Sensory Systems
• assess light touch, pain, and temperature
sensations
• test vibratory sensations
• sensitivity to position
• tactile discrimination (fine touch)

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Reflexes

• deep tendon
reflexes • superficial
o biceps reflexes
o brachioradialis o plantar
o triceps o abdominal reflex
o patellar o cremasteric
• Achilles reflex

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Tests for meningeal irritation or
inflammation
• Neck mobility
• Brudzinski’s sign
• Kernig’s sign

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MENTAL STATUS AND
LEVEL OF
CONSCIOUSNESS
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Observe the following
• LOC
• posture and body movements
• dress, grooming and hygiene
• facial expression
• speech
• mood, feelings, and expressions
• thought processes and perceptions
• cognitive abilities
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• Decorticate posture is • Decerebrate posture is an
an abnormal posturing that abnormal body posture that
involves involves
• rigidity, flexion of the arms, • arms and legs being held
• clenched fists, straight out,
• extended legs (held out • toes being pointed
straight). downward,
• arms are bent inward toward • head and neck being arched
the body backwards.
• wrists and fingers bent and • muscles are tightened and
held on the chest. held rigidly.
http://www.nlm.nih.gov/medlineplus/ency/article/003300.htm
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6/26/2011 http://loyaldavis.com/images/dec_1.jpg 26

For children under 5, the verbal response
criteria are adjusted as follow
SCORE 2 to 5 YRS 0 TO 23 Mos.

5 Appropriate words or phrases Smiles or coos appropriately

4 Inappropriate words Cries and consolable

Persistent inappropriate crying
3 Persistent cries and/or screams
&/or screaming

2 Grunts Grunts or is agitated or restless

1 No response No response

http://www.unc.edu/~rowlett/units/scales/glasgow.htm

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CRANIAL NERVES

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I (olfactory)
o abnormal finding:
inability to smell : neurogenic anosmia, olfactory
tract lesion, tumor or lesion of frontal lobe
loss of smell: congenital, nasal dse, smoking, use
of cocaine

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CN II (optic)
o visual acuity – both far and near
o confrontation test
o asses retina using ophthalmoscope
o OD – R eye; OS – L eye; OU - both eyes

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CN II (optic)
o normal finding:
round red reflex
optic disc – 1.5 mm; round or slightly oval; well-
defined margins,creamy pink
paler physiologic cup
retina – pink

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CN II (optic)
o abnormal finding:
blurred optic disc margins; dilated, pulsating veins
- Papilledema (swelling of optic nerve) – due to
increased ICP from tumor or hemorrhage
optic atrophy – brain tumors

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III (oculomotor), IV (trochlear), VI
(abducens)
o (a) inspect margin of eyelids
o (b) extraocular muscles
o (c) pupillary response to light

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CN III, IV, VI
o normal finding:
(a) eyelid covers abt 2 mm of iris
(b) eyes move smooth, coordinated motion in all
directions
(c) bilateral constriction

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CN III, IV, VI
o abnormal finding:
(a) ptosis (drooping of eyelids) – myasthenia
gravis
(b) abnormal eye movements
• nystagmus (rhythmic oscillation of the eyes) -
cerebellar disorder
• limited eye movement – increased ICP
• paralytic strabismus – paralysis of oculomotor, trochlear
or abducens nerves

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Nystagmus video

6/26/2011 Maria Carmela L. Domocmat, RN, MSN 36

CN III, IV, VI
(c) dilated pupil (6-7 mm) – oculomotor
nerve paralysis
Argyll Robertson pupils – CNS syphilis,
meningitis, brain tumor, alcoholism

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Argyll Robertson pupils

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CN III, IV, VI
constricted, fixed pupils – narcotics abuse, damage
to pons
unilaterally dilated pupil unresponsive to light or
accommodation – damage to CN III
constricted pupil unresponsive to light or
accommodation – lesions of the SNS (sympathetic
nervous sys)

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CN V (trigeminal)
o motor function
o sensory function :

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CN V (trigeminal)
o motor function
temporal and master muscles contraction
(Note: may be difficult to perform and evaluate
in client without teeth)

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CN V (trigeminal)
o sensory function :
sharp or dull sensation and light touch on
forehead, chin and cheeks
• safety pin, paper clip, or cut tongue depressor; wisp
of cotton
corneal reflex (blinking reflex)
(Note: may be absent or reduced in clients who
wear contact lenses)

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Corneal refle

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CN V
o normal finding:
temporal and masseter muscles contract bilaterally
correctly identifies sharp or dull, light touch

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CN V
o abnormal finding:
inability to identify – lesions in trigeminal nerve,
lesions in spinothalamic tract or posterior columns
absent corneal reflex – lesions of CN V, lesions of
motor part of CN VII

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CN VII (facial)
o motor function
o sensory function

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CN VII (facial)
o motor function
smile, frown, wrinkle forehead, show teeth, puff out
cheeks, purse lips, raise eyebrows, close eyes tightly
against resistance

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CN VII (facial)
o sensory function
taste test – anterior 2/3 of tongue – salt, sugar, or
lemon juice

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CN VII
o abnormal finding:
inability to close eyes, wrinkle forehead, or raise
forehead along with paralysis of lower part of face
on affected side – Bell’s palsy (peripheral injury to
CN VII)
paralysis of lower part of face on opposite side
affected - central lesions that affects the upper
motor neurons ex: CVA

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Bell’s palsy


CN VIII acoustic/vestibulocochlear)
o hearing: acoustic/ cochlear
Whisper, Weber, Rinne tests

balance: vestibular

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CN VIII
o abnormal finding:
vibratory sound lateralizes to good ear –
sensorineural loss
AC is greater than BC but not twice as long

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CN IX (glossopharyngeal),
CN X (Vagus)
uvula and soft palate
gag reflex
ability to swallow

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CN IX & X
o abnormal finding:
soft palate does not rise – bilateral lesion of CN X
unilateral rising of soft palate, deviation of uvula to
normal side –unilateral lesion CN X
dysphagia or hoarseness – lesion CN IX or X

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CN XI (spinal accessory)
o trapezius muscle - shrug shoulders against
resistance
o sternocleidomuscle – turn head against
resistance

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CN XI
o abnormal finding:
asymmetric, drooping of shoulders – paralysis or
muscle weakness due to neck injury or torticollis
atrophy with fasciculations – peripheral nerve dse

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Torticollis

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Atrophy with fasciculations

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CN XII (hypoglossal)
o strength and mobility tongue
o protrude tongue, move to side against resistance,
put back in mouth

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CN XII
o normal finding: symmetric and smooth, bilateral
strength
o abnormal finding:
atrophy with fasciculations – peripheral nerve dse
deviation to affected side – unilateral lesion

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MOTOR AND
CEREBELLAR SYSTEMS
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Condition and movement of muscles
o size and symmetry muscle grps
o strength and tone
o note unusual involuntary movement (i.e,
fasciculations, tics, tremors)

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o normal finding
muscles- fully developed
symmetric size (bilateral sides may vary 1 cm from
each other)
relaxed muscles contract voluntarily; show mild,
smooth resistance to passive movement
equally strong against resistance, without flaccidity,
spasticity, rigidity
no fasciculations, tics, tremors
elderly –hand tremor or dyskinesia (repetitive
movements of lips, jaw, tongue)
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o abnormal finding
muscle atrophy – dses of lower motor neurons or
muscle disorders
soft, limp, flaccid muscles
fasciculations - muscle twitching
tics – twitch of face, head or shoulders – stress,
neurologic disorder
tremors – rhythmic, oscillating movements –
Parkinson’s dse, cerebellar dse, multiple sclerosis (with
movement), hyperthyroidism, anxiety

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Fasciculations


Tics


Tremors


o abnormal finding
unusual bizarre face, tongue, jaw, lip
movements – chronic psychosis, long term
use of psychotropic drugs
slow, twisting movements in extremities and
face – cerebral palsy
brief, rapid, irregular, jerky movements (at
rest) - Huntington’s chorea

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Balance, Gait
o walk normally
o tandem walk – heel-to-toe walk
o romberg test
o hop with one foot
o elderly – may be difficult to perform

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o normal finding:
steady gait, opposite arms swing
maintains balance with little difficulty
elderly – may be very difficult
(-) Romberg test - erect with minimal swaying
hops without losing balance

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o abnormal finding
(+) Romberg test – swaying, moving feet apart to
prevent fall – dse of posterior columns, vestibular
dysfunction, cerebellar disorders

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Coordination
Point-to-point
Rapid Alternating Movements (RAM)

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o Point-to-point
finger-to-nose test
Finger- nose- to-finger
heel-to-shin test
Note: dominant side may be more coordinated than
nondominant side

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http://cloud.med.nyu.edu/modules/pub/neurosurgery/coordination.html

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Rapid Alternating Movements
(RAM)
Thumb to Fingers
Hands on Lap

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Rapid Alternating Movements
(RAM)
normal finding:
• elderly – may be difficult – bcoz decreased reaction
time and flexibility
abnormal finding:
• inability to perform – cerebellar dse, upper motor neuron
weakness, extrapyramidal dse
• dysdiadochokinesia -

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Dysdiadochokinesia
impairment of the ability to make movements
exhibiting a rapid change of motion that is caused by
cerebellar dysfunction

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SENSORY SYSTEM

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Light Touch, Pain, and Temperature Sensations
Vibratory sensations
Proprioception (sensitivity to position)
Tactile discrimination (fine touch)

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Light Touch, Pain, and Temperature
Sensations
scatter stimuli – distal and proximal parts of all
extremities and trunk to cover most of dermatomes

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Dermatomes

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o abnormal finding
anesthesia – absence of touch sensation
hypesthesia – decreased sensitivity to touch
hyperesthesia –increased sensitivity to touch
analgesia – absence of pain sensation
hypalgesia – decreased sensitivity to pain
hyperalgesia – increased sensitivity to pain

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• Vibratory sensations
o tuning fork – bony surface fingers or big toe
o usually decreased by 70

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• Proprioception (sensitivity to position)
o Note: if position sense is intact distally, then it is
intact proximally
o normal finding
some – sense position of great toe may be reduced
o abnormal finding
inability to identify directions – posterior column dse,
peripheral neuropathy (e.g., diabetes, chronic alcohol
abuse)

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Tactile discrimination (fine touch)
Tests for lesions of the sensory cortex
Stereognosis
Point Locations
Graphestesia
Two-Point Discrimination
Extinction

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http://cloud.med.nyu.edu/modules/pub/neurosurgery/sensory.html


REFLEXES

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Deep tendon reflexes
o biceps
o brachioradialis
o triceps
o patellar

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Biceps reflex
elicited by placing your thumb on the biceps
tendon and striking your thumb with the reflex
hammer and observing the arm movement.
Repeat and compare with the other arm.

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Briceps reflex

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Brachioradialis reflex
striking the brachioradialis tendon directly
with the hammer when the patient's arm is
resting.
Strike the tendon roughly 3 inches above
the wrist.
Note the reflex supination. Repeat and
compare to the other arm.
The biceps and brachioradialis reflexes are
mediated by the C5 and C6 nerve roots.
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Brachioradialis reflex

http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg

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Triceps reflex
strike the triceps tendon directly with the
hammer while holding the patient's arm with
your other hand.
Repeat and compare to the other arm
.The triceps reflex is mediated by the C6 and C7
nerve roots, predominantly by C7.

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Triceps reflex

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Patellar reflex
With the lower leg hanging freely off the edge of the bench, the knee jerk is
tested by striking the quadriceps tendon directly with the reflex hammer.
Repeat and compare to the other leg.The knee jerk reflex is mediated by the
L3 and L4 nerve roots, mainly L4.
Insult to the cerebellum may lead to pendular reflexes. Pendular reflexes are
not brisk but involve less damping of the limb movement than is usually
observed when a deep tendon reflex is elicited. Patients with cerebellar injury
may have a knee jerk that swings forwards and backwards several times. A
normal or brisk knee jerk would have little more than one swing forward and
one back. Pendular reflexes are best observed when the patient's lower legs
are allowed to hang and swing freelly off the end of an examining table.

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Patellar reflex

http://cloud.med.nyu.edu/modules/pub/neurosurgery/reflexes.html
http://www.brown.edu/Courses/Bio_160/Projects2000/Polio/Reflexcopy.jpg


Ankle reflex
elicited by holding the relaxed foot with one
hand and striking the Achilles tendon with the
hammer and noting plantar flexion. Compare to
the other foot.The ankle jerk reflex is mediated
by the S1 nerve root.

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Plantar or Achilles

http://www.beltina.org/pics/achilles_tendon.jpg
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Rate the reflex with the following scale:

5+ Sustained clonus

4+ Very brisk, hyperreflexive, with clonus

3+ Brisker or more reflexive than normally.

2+ Normal

1+ Low normal, diminished

0.5+ A reflex that is only elicited with reinforcement

0
6/26/2011 No response 105

http://www.wrongdiagnosis.com/bookimages/8/2546.png

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deep tendon reflexes are graded as
follows:
0 = no response; always abnormal
1+ = a slight but definitely present
response; may or may not be normal
2+ = a brisk response; normal
3+ = a very brisk response; may or may
not be normal
4+ = a tap elicits a repeating reflex
(clonus); always abnormal

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Superficial reflexes
o Plantar reflex
o Abdominal reflex
o Cremasteric reflex

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Plantar reflex
The plantar reflex (Babinski) is tested by coarsely
running a key or the end of the reflex hammer up
the lateral aspect of the foot from heel to big toe.

Normal finding : toe flexion.
Abnormal finding:
(+) Babinski's sign - toes extend and separate
indicative of an upper motor neuron lesion affecting
the lower extremity in question.
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Plantar reflex

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Abdominal reflex

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Abdominal reflex

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Cremasteric reflex

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Cremasteric reflex

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Hoffman response
elicited by holding the patient's middle finger between the
examiner's thumb and index finger.
Ask the patient to relax their fingers completely. Once the
patient is relaxed, using your thumbnail press down on the
patient's fingernail and move downward until your nail "clicks"
over the end of the patient's nail.
Repeat this maneuver multiple times on both hands.
Normal finding: nothing occurs.
Abnormal finding:
(+) Hoffman's response - other fingers flex transiently after the "click".
indicative of an upper motor neuron lesion affecting the upper extremity
in question.
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Hoffman response

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Hoffmann's sign, which is elicited by flicking the distal phalanx of the long
finger.
A negative response, as shown here, is no motion of the thumb.
A positive response is flexion of the thumb at the interphalangeal joint.
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Maria Carmela
http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg L. Domocmat, RN, MSN

Test of Clonus
Test clonus if any of the reflexes appeared
hyperactive. Hold the relaxed lower leg in your
hand, and sharply dorsiflex the foot and hold it
dorsiflexed. Feel for oscillations between flexion
and extension of the foot indicating clonus.
Normally nothing is felt.

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Tonus video

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