Article In Brief
Over the years, the neurologic exam has not changed vastly as a tool for diagnosis. But new technologies, testing capabilities, and improved imaging modalities have enabled neurologists to confirm their findings from the exam.
While the value and method of conducting a neurologic exam has not changed much over the last 20 years, the strength and availability of imaging plus the introduction of telehealth have added new tools to compare findings.
“The way we teach the neurologic exam to medical students and residents today is the same way we did it 20, 30 years ago when I was a resident and when I was a medical student,” said Ralph F. Józefowicz, MD, FAAN, professor of neurology and medicine and the associate chair for education in the department of neurology at the University of Rochester School of Medicine and Dentistry. “The reason [for that] is it’s organized, and it’s been used for decades and it’s really very accurate.”
The neurologic exam has seven parts: mental status, cranial nerves, motor system, reflexes, sensory system, coordination, and station and gait.
“The exam is generally performed in that order, and it’s tailored to the patient’s complaints,” Dr. Józefowicz said. “If a patient presents with confusion, you’ll do more of an extensive mental status exam.”
In a typical exam, Dr. Józefowicz wants to hear the patient’s history first and then conduct the physical checkup, after which he generally has an idea about the source of the patient’s issue. Neurologists also may rely on information patients provide in questionnaires that can help screen for conditions such as depression, said Fraser Moore, MD, associate professor in the department of neurology and neurosurgery at McGill University, an associate member of the McGill Institute of Health Sciences Education, and director of the McGill Adult Neurology residency program.
“In general, if you take a good history, by the end of the history, you’ll know exactly what’s going on most of the time,” Dr. Józefowicz said. “Sometimes the history will give you a differential: Is this something in the [central nervous system] or the [peripheral nervous system]? And the exam will be able to differentiate. But it really boils down to the history and the physical, and typically you are 90 percent accurate.”
Dr. Moore believes neurologists spend more time with patients than the average physician, and especially more than other specialists, in part because they ask so many questions when taking a history.
Douglas J. Gelb, MD, PhD, FAAN, a clinical professor of neurology and associate chair of education in the department of neurology at University of Michigan Medical School, agreed that neurologists rely on the physical exam more than almost every other type of doctor.
“The nervous system has many more parts than a lot of the other systems,” he said. “If you’re a cardiologist and you think somebody might have a problem with their heart, there’s a limited part of the body that you look at, whereas neurologists, even if we’ve decided it’s a neurologic problem, that could be in the brain, the spinal cord, the peripheral nerves, the muscles, or the regions connecting those things. And if we don’t want to just do a whole set of tests that are unnecessary—and be misled by incidental abnormalities that have no clinical significance—then we’ve got to do something to refine our thoughts about where the problem is before we start ordering tests.”
While the main components of the neurologic exam have remained the same, Dr. Gelb said, many of the subtleties involved in it—things his own teachers prided themselves on—hardly come up in training today. And other tests have evolved.
“There is a test that’s done for patients with dizziness called the head impulse test that I don’t remember anyone doing when I was in training,” Dr. Gelb said. “There are subtle tests of sensory function that people did a lot more in the past, and a lot of residents these days are barely learning how to do them.”
The process of conducting an emergency neurologic exam has evolved, however.
“For stroke, back when I was training it was kind of a point of pride to be able to figure out where in the nervous system the stroke was located based purely on the history and exam. These days, time is of the essence. Trainees are taught to forgo a really detailed exam in the acute setting,” Dr. Gelb said, adding that they instead screen patients using the NIH Stroke Scale. “[The scale] is the basis for all of the therapeutic trials that have been done, and that—together with the results of tests like a CT-angiogram, which didn’t even exist until relatively recently—is what they use to make urgent treatment decisions.” Experience plays a role in exams as well. “The way I do the examination today is certainly more nuanced,” Dr. Józefowicz said. “And I know what I’m looking for and am better able to find it.”
Advances in Imaging
After neurologists take a patient’s history and conduct the physical exam, the patient may undergo imaging, which Dr. Józefowicz pointed to as one aspect of the neurologic exam that has changed in recent decades.
“At least now we can confirm our localization much more quickly with imaging studies,” he said. “In the old days, you had to have brain cutting,” which took place during an autopsy and let a pathologist see where the patient’s lesions had been.
Before CT scans came on the scene, neurologists relied on X-rays of the skull, pneumoencephalograms, and angiogram. CT scans had just come out when Dr. Józefowicz was a medical student, and while they were a medical breakthrough, he said, they were still somewhat crude.
“The CT scans of today are 100 times better than the ones 40 years ago,” he said, adding that the same can be said for MRI.
But neurologists should try to localize what troubles the patient ahead of conducting imaging, and that is why the neurologic exam and patient history are so important, according to Dr. Moore.
“We have better imaging [today], and it’s more available, too, but the problem with that is you really need to know what you need to image before you can do that,” he said.
The need for imaging depends on the neurologic disorder in question, as not every condition leads to imaging abnormalities or requires those tests, Dr. Józefowicz said. Conditions such as stroke, multiple sclerosis, and brain tumors, however, are associated with imaging abnormalities, he added, and the results could confirm a doctor’s initial diagnosis or send it in a different direction.
New modalities exist today as well, Dr. Józefowicz added. For example, diffusion-weighted imaging (DWI), which uses differences in Brownian motion to generate signal contrast, can tell within a few minutes whether a patient has had a stroke. And susceptibility-weighted imaging (SWI), which provides a unique contrast by using tissue magnetic susceptibility differences, can tell whether microhemorrhages have occurred in the brain.
“We really have a lot of advances in MR imaging,” Dr. Józefowicz said.
The availability of CT and MRI machines also has improved. Where some specialized care hospitals might have had them 20 years ago, they are more widely available today, at least in North America and Europe, Dr. Moore said. And integrating those images with institutions’ computer systems means doctors no longer need to wait to review physical films; they can pull up images on a computer to show their patients during the visit, pointed out Lyell K. Jones Jr., MD, FAAN, professor of neurology at Mayo Clinic in Rochester, MN.
Other Advances
The laboratory tests done during a neurologic evaluation have advanced as well, particularly blood and cerebrospinal fluid tests that can lead to a diagnosis that 20 years ago may have remained a mystery, Dr. Jones said.
“Especially in the last 10 years, there’s been an explosion of biomarker discovery,” he said. “For example, we can identify many more antibodies in the blood or spinal fluid as specific signs of neurological autoimmunity.”
Wearable technologies that provide medical feedback—not just smartwatches and activity trackers but also more sophisticated devices—do not yet play a role in the neurologic exam, but neurologists expect to see more of them one day.
“More and more people have a smartwatch that can detect atrial fibrillation,” Dr. Moore said. “If you have a person who had a stroke, you could try and get the data from the watch.”
He cautioned that those devices have not been systematically studied, so their reliability remains in question. Recently, however, Dr. Moore spoke with an engineering student trying to produce a type of wearable technology to help patients with Parkinson’s disease detect when “they’re in their on or off period”; it’s that type of technology that he could see becoming more common in the next few years.
Dr. Jones noted that some wearables already are used for patient assessments. Neurologists specializing in sleep disorders have used actigraphy to measure patients’ movements for a long time. And he expects that wearable technology could one day augment other diagnostic tests, like electrophysiology studies.
“There are some things that we might not see coming; for example, analyzing data sources that might seem unconventional,” Dr. Jones said. “We have a group here that is using machine learning, a type of artificial intelligence, to analyze speech patterns to tell if a person has a variety of [neurologic conditions].”
Taking and recording notes from exams, meanwhile, has advanced with the introduction of new technologies. While some doctors still take notes by hand, Dr. Moore said, many more clinics and hospitals are switching to electronic medical records (EMR).
“Along with that, you probably see more places that use a template for the exam and a person recording each part as appropriate,” he said.
Over the last 20 years, the EMR has moved from being used by some to now most neurologists, according to Dr. Jones. But in some ways, EMR has made clinical work less efficient, he added, calling EMR a “mixed blessing and curse.” Different EMR systems exist, and a lot of interoperability hurdles persist, Dr. Jones said.
“In general, if you take a good history, by the end of the history, you’ll know exactly what’s going on most of the time. Sometimes the history will give you a differential: Is this something in the [central nervous system] or the [peripheral nervous system]? And the exam will be able to differentiate. But it really boils down to the history and the physical, and typically you are 90 percent accurate.”—DR. RALPH F. JÓZEFOWICZ
“Especially in the last 10 years, there’s been an explosion of biomarker discovery. For example, we can identify many more antibodies in the blood or spinal fluid as specific signs of neurological autoimmunity.”—DR. LYELL K. JONES
“Many physicians are not fans of EMRs,” he said, but he has observed its benefits, such as in a recent meeting with a patient from another part of the country. “While I was meeting with him, I could bring up our EMR and review his clinic notes from the referring neurologist. It was extremely helpful. So, that capability has been really beneficial.”
The Expansion of Telemedicine
Like other specialties, neurology made the shift to telemedicine in recent years, helped in part by COVID-19-related limitations.
“The pandemic was a moment in time where probably 10 years of change happened within a couple of months in terms of doing virtual assessments,” Dr. Jones said. “When the pandemic started, a group here led by Dr. Chris Boes developed a template for doing a neurologic exam via telemedicine because at that time we didn’t know how long we would be doing that.”
While telemedicine offered neurologists a new way to examine patients, it does have limits. The process of taking a patient’s history does not change, Dr. Józefowicz said, nor do certain aspects of the physical exam, such as evaluating a patient’s mental status. Other parts can involve having patients complete various tasks as the doctor watches.
“You can probably do about half of the neurologic exam over telehealth,” Dr. Józefowicz said.
One of the aspects of the neurologic exam that clinicians use most—the reflex test using the reflex hammer—is almost impossible to do over telemedicine, Dr. Gelb said.
“Unless you can talk the patient or a family member through how to check reflexes, you just have to completely abandon” that part of the test, he said. “We can get a pretty good sense of how people walk by video as long as they’ve set up their video space appropriately.”
Telehealth also has opened new doors for job opportunities for neurologists. Dr. Józefowicz noted he has a colleague in Rochester whose practice involves conducting teleneurology exams around the country. Those exams may have limitations, Dr. Józefowicz said, but they can provide much-needed patient visits in an era when some doctor’s offices have months-long waiting lists for exams.
“People realize now that telehealth benefits people who don’t live close by [a doctor],” Dr. Moore said. “They don’t have to spend a half day or a day traveling into an appointment.”
A lot of teleneurology involves examinations by proxy, with neurologists connecting with physicians or physician assistants, according to Dr. Józefowicz.
“For example, at an emergency department in a small community hospital, the physician there will then consult with a neurologist via teleneurology,” he said. “So, it’s not just direct from the neurologist to the patient.”
Conducting follow-up exams with patients via telehealth is becoming increasingly common, Dr. Moore said. Dr. Józefowicz believes every new patient needs to be seen in person, but he may see established patients he knows well over telehealth—something other neurologists have continued, too.
“MRIs and blood tests aside, the bedside clinical examination is still our most useful diagnostic tool in neurology,” Dr. Jones said. “There was a lot of concern in our field about that dislocation between the neurologist and the patient. Now we’re all back and seeing patients [in person], but some of us have kept [telehealth visits] where it makes sense, especially for follow-up visits. We’re certainly doing more virtual care than in 2019.”
“There is a test that’s done for patients with dizziness called the head impulse test that I don’t remember anyone doing when I was in training. There are subtle tests of sensory function that people did a lot more in the past, and a lot of residents these days are barely learning how to do them.”—DR. DOUGLAS J. GELB
Looking Ahead
Most neurology resident programs also include a teleneurology curriculum, Dr. Józefowicz said.
“For medical students, they’re probably introduced to the concept, but you would not expect a medical student, after learning the technology and then graduating from medical school, to start doing telemedicine visits,” he said. “They don’t have the skills. So, I think it’s important for them to sort of learn about the concepts, but it’s not something they would be doing right away.”
When he sees others teach the neurologic exam to students or junior residents, Dr. Moore finds “the same kind of emphasis on the importance of the exam and doing specific techniques a specific way.” Overall, the neurologic exam seems like a perfect example of, “If it isn’t broke, don’t fix it.”
“The neurologic exam has really not changed because it was developed years ago and is very accurate when it’s performed by a skilled neurologist,” Dr. Józefowicz said. “Certain diagnostic testing, including neurologic imaging, has enhanced the field, and it improves the exam because you can compare your findings with the imaging results in real time.”
Disclosures
None of the neurologists had any disclosures.
