Teaching the Neurological Examination in a Rapidly Evolving Clinical Climate

Abstract

The neurological examination remains the essence of neurology. It allows symptoms to be assessed, diagnoses to be made, and dynamic functions to be followed. Skill in the neurological examination has faced increasing challenges from the encroachment of diagnostic imaging, but has maintained its clinical utility. It has also encountered the battle for the precious time within a medical curriculum. This review considers how the neurological examination can best be taught into the future. It does so by considering factors related to the examination, the learner, the teacher, and the modern clinical environment.

Approach to Neuropathic Pain

“…Briefly, upper motor neuron signs, cranial nerve abnormalities, movement disorder abnormalities, cortical signs, cognitive deficits, and spinal sensory levels suggest a CNS lesion or disease, while lower motor neuron signs and focal sensory or motor abnormalities in peripheral nerve distributions suggest a PNS lesion or disease. 12,13,61 Additionally, both central and peripheral NP present with an obligate nature (i.e., the pain symptoms must occur in the body region corresponding to the distribution of the somatosensory nervous system injury). 14,17,33,62,63 Here, we emphasize key parts of the neurological examination for the evaluation of NP.…”

“…Normally, the knee will flex easily and the heel will drag up the bed; if there is spasticity, resistance to knee flexion will cause the foot to lift off the bed. 17,61,64 Reflexes may be abnormal in patients with NP. Brisk reflexes suggest a central process, while diminished reflexes suggest a peripheral process.…”

“…A clinical pearl is to compare reflexes in the contralateral limb to determine if there are relative differences that may be pathologic rather than attempting to grade an isolated reflex on an absolute scale of diminished, normal, and brisk. 61 A detailed sensory examination helps elucidate which elements of the PNS are involved including large (vibration and proprioception) and small (pinprick and temperature sensation) nerve fibers. 12,13,[19][20][21]65 There can be significant variability in the sensory examination secondary to inconsistent patient responses and reproducibility of sensory stimulus input.…”

The Shadow-Side of the Neurological Evaluation

“…A few general medical 2 and neurological journals [3][4][5][6][7] aim to teach neurological evaluation but the themes addressed are either particularly specific or more appropriate for specialists rather than for residents. Over the past 35 years, teaching neurology to the medical students and the neurology residents of my institution, I became aware that, besides their learning of "what must be taught "compulsorily" which may be read in any neurological textbook, many important aspects that remain "in the shadow" of the classic neurological symptoms and signs, should be addressed.…”

Flipping the classroom in neurological bedside teaching: a prospective controlled study

“…Bedside teaching is an essential part of medical education with a fundamental importance in fostering the casebased application of theoretical knowledge and acquiring of practical skills, including hypothesis-driven examination techniques and clinical reasoning [1,2]. These aspects are particularly important for teaching Neurology and the Neurological Exam (NE) [3]. However, there are several challenges that need to be met.…”