COMMENTARY

Tips for Conducting a Virtual Neurologic Exam

Stephen Krieger, MD; Erin Staker

Disclosures

October 28, 2020

This transcript has been edited for clarity.

Stephen Krieger, MD: Hi. I'm Dr Stephen Krieger, a neurologist at the Corinne Goldsmith Dickinson Center for Multiple Sclerosis at Mount Sinai in New York. I'm here today with my collaborator Erin to show you how we do a neurologic examination over video. Erin, thanks so much for joining us.

Erin Staker: Thanks for having me.

Krieger: Neurology, of course, is a very hands-on field. We prioritize the neurologic examination to give us crucial clinical information about our patients. Many of us have been doing this remotely by virtual health throughout the months of 2020. We've developed techniques to try to accomplish many of the things that we need to do in the neurologic exam over video, which is a challenge because we don't have the use of our usual tools at our disposal, like tuning forks and reflex hammers. But we have come up with ways of filling that in with certain other props that I think provide useful information.

When I set up a video visit with one of my patients, I'll ask them to have three props on hand: a hair tie or a rubber band to look at upper-extremity strength, a cell phone with a flashlight that we'll use for cranial nerves and pupil responses, and something cold that came out of the fridge recently to look for temperature sensations.

I like to do the neuro exam basically in two parts. Firstly, there's the closeup part, where we're going to look at cranial nerves and the upper extremities. Second, I ask my patients to set up in a place where they can adjust the camera so that we can see them stand and walk in order to assess gait, balance, and things of that nature. So that's what we will do now in this video.

We start with the cranial nerves. The patient leans in real close to the camera so their face fills the screen. I then have them look with their eyes all the way to the right, all the way to the left, back to the middle, straight up, and then down and back, before sitting back again.

One of the changes we have to do here is to ask for movements through verbal instructions rather than by following my finger, because people can't look at the finger on the screen and move their eyes at the same time as we would able to in person.

We then turn to pupil responses, for which we're going to use the phone flashlight prop. The patient leans in real close again, so their face fills the screen, and looks right at the camera. The patient holds the light up to one eye so you can look at the pupil and then to the other eye, and then back and forth again. The patient can then sit back and relax.

So, again, we're looking for pupillary responses to light. As a multiple sclerosis specialist, I'm always focused on such things as an afferent pupillary defect, which could be seen using that test.

Let's turn to some of the other cranial nerves. I then ask the patient to raise their eyebrows up high and then down. Then I ask them to smile big. To look at facial sensations, I have them take two fingers on one hand and touch the side of the forehead and then the other side, to see if that feels about the same on both sides. Then I ask them to use the two fingers to feel the cheek on one side and then the other, as well as the chin on one side and then the other, to see if they also feel the same on both sides. Of course, we're relying on patient self-report here, but typically people are pretty sensitive to any loss of facial sensation.

We're also going to rely on self-report for hearing. I ask the patient to take a couple of fingers on one hand and rub it by their ear to tell us whether it sounds normal and about the same on both sides. For patients wearing headphones, I'll ask whether my voice sounds about the same on both sides. But without headphones, this is a good screening test for hearing loss.

Next we move on to lower cranial nerves, at which point I ask the patient to take out the cell phone light one more time. The patient leans in close again, opens their mouth wide, tilts the head back a little bit, and says "ahh." We can look for tongue being midline and the uvula rising. When well-lit by the phone's flashlight, we can see that just fine over video.

Then I ask the patient to shrug, with shoulders up high, and then relax them. Can they flex their neck all the way up and then their chin all the way down, without experiencing any numbness? This completes the basic cranial nerve examination.

Now, we turn to upper extremities. It can be challenging to measure strength, so we want to look for other ways of gauging the power examination in neurology. I start with having the patient place their hands up in front of them flat, like they're carrying a tray or a pizza. I ask them to close their eyes and then take the pointer finger on one hand and touch their nose, followed by the same motion with their other hand. The patient then opens their eyes and brings their arms up over the head.

Next, we can look for other tests of motor strength in the upper extremities. One thing that I like is looking for orbiting, whereby the patient takes their arms and makes rolling motions over each other, followed by the same motion in the reverse direction. Here we're looking for asymmetry, with one arm orbiting the other.

To continue with a strength exam and motor dexterity, the patient is asked to separately touch each finger on both hands to their thumb.

Finally, for hand strength, we use our next prop, which is our rubber band or hair tie. This is placed around the fingers just above the bottom knuckle. Patients are asked to spread that band or tie wide, back and forth, on both hands. Again, I'm looking here for symmetry in terms of how easily that task is for the patient to accomplish. It should feel the same on both sides.

Now let's turn to some other coordination tests. In the office, we would do finger, nose, finger. Here we're going to do nose, camera, nose. The patient touches their nose and then reaches out toward the camera back and forth bunch of times, nice and quick. The same test is done on the other hand as well. We can really look at how accurately we're coming to the target — which is of course, thankfully, a very small spot on the device they're using. That is good for the upper extremities in motor and coordination.

Let's turn to sensation in the upper extremities. For this will need our third prop, which is a cooled object from the fridge. I ask them to take that and place it on the back of one hand to confirm that it feels cool. They then repeat this test on the other hand. It should feel roughly the same on both sides of the hands. The object doesn't have to be freezing cold, but anything that has a bit of a chill to it can give us information about temperature sensation.

We then turn to the second part of the exam, which is going to be the full-length shot where we're going to look at standing, leg strength, and balance. The patient is asked to adjust the camera view so that we can see them standing. I like to tell my patients at the beginning that we're going to need a space that allows for us to watch them stand and walk, so that they can try to have that in place up front.

We start with balance, with the patient standing with their feet together and eyes closed. We're looking, of course, for stance and making sure we don't have any unusual sway. We can't do a formal Romberg test, but this is a good indicator. Then patient then turns and has a nice, normal walk to a point behind them, in order for us to get a good look at walking and stance.

They then walk back to the camera on their heels with toes pointing in the air, which allows us to do some challenge gait tasks, confirming that the toe elevation is maintained. They then swing around and go the other way, on their toes with heels in the air. This is another gait challenge test looking at plantar strength and balance.

Then to finish the balance testing, the patient walks back to the camera, one foot right in front of the other, as if on a balance beam. Of course, if you're concerned at all about a patient's balance or their abilities to do this, you want to make sure they're doing it in a safe way at home with something to grab onto if necessary.

There are then two more tests of leg strength. I see whether they can stand on one leg for a moment, with one leg held in the air. They then place the leg down, and repeat this with the other leg held in the air. This gives us a sense of leg strength and balance.

Finally, there's one last challenge task for leg strength. I ask the patient to do one full squat and then come back up, which allows us to look at leg strength and extensor strength.

Hopefully, we've demonstrated for you some tips and ways of doing the neurologic exam as a virtual telehealth examination. Erin, thank you so much for participating, and thanks to all of you for watching.

For a more humorous take on virtual neurology, check out Dr Krieger's recent piece in Practical Neurology.

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