Neurological Examination: What Is Your Physio Testing?
A neurological examination is an important part of a physiotherapy assessment when symptoms suggest that the nervous system may be involved.
This might include symptoms such as pins and needles, numbness, weakness, altered sensation, changes in coordination or pain travelling into an arm or leg.
The purpose of the examination is not simply to determine whether a nerve is "pinched". It helps your physiotherapist understand how well different parts of the nervous system are functioning and whether your symptoms are more likely to be coming from a nerve root, peripheral nerve, spinal cord or another structure.
This can be particularly useful when assessing conditions involving lower back pain with symptoms that travel into the buttock, leg or foot.
Why Would a Physiotherapist Perform a Neurological Examination?
The nervous system carries information between the brain, spinal cord and the rest of the body.
Nerves help control:
- Muscle contraction and strength.
- Sensation, including touch, temperature and pain.
- Reflexes.
- Coordination and movement.
If a nerve pathway is irritated or compressed, one or more of these functions may change.
For example, irritation of a nerve root in the lower back may produce leg pain, tingling, numbness or weakness. A similar process in the neck may produce symptoms into the shoulder, arm or hand.
Importantly, symptoms such as pain or pins and needles do not automatically mean there is serious nerve damage. The neurological examination helps determine whether there are objective changes in nerve function and whether further investigation is required.
What Does a Neurological Examination Include?
A basic neurological examination usually looks at three main areas:
- Motor function: How well different muscles can produce force.
- Sensation: Whether areas of the skin feel normal and symmetrical.
- Reflexes: How the nervous system responds to a specific stimulus.
Your physiotherapist may also assess nerve sensitivity, coordination, balance or other neurological signs depending on your symptoms.
How Is Muscle Strength Tested?
Muscle testing helps assess the motor component of the nervous system.
Your physiotherapist may ask you to perform specific movements while they apply resistance. Different movements can provide information about different nerve roots and peripheral nerves.
For example, the assessment may compare:
- Hip strength from side to side.
- Knee extension or knee bending strength.
- Ankle or big-toe movement.
- Shoulder, elbow, wrist or hand strength.
We are generally looking for meaningful differences between sides, unexpected weakness or a pattern that corresponds with the person's symptoms.
Strength testing is particularly useful because weakness caused by pain can look different from weakness associated with altered nerve function.
How Is Sensation Tested?
The sensory examination looks at how well signals from the skin are being transmitted through the nerves towards the spinal cord and brain.
A simple screening assessment may involve lightly touching corresponding areas on both sides of the body and asking whether the sensation feels the same.
Your physiotherapist may test particular areas of the arm or leg because different regions of the skin are supplied by different nerves and nerve roots.
We may be interested in whether an area feels:
- Normal.
- Less sensitive than the opposite side.
- Numb.
- Unusually sensitive.
- Tingly or altered.
If a sensory change is found, further testing can sometimes help clarify the pattern.
What Is a Dermatome?
A dermatome is an area of skin that receives much of its sensory information from a particular spinal nerve root.
Dermatome maps help clinicians interpret patterns of numbness or altered sensation.
For example, sensory changes around the thumb may raise different considerations from sensory changes around the little finger. Similarly, numbness along the outside of the lower leg may suggest involvement of a different nerve pathway from numbness on the inside of the ankle.
These maps are useful, but real human anatomy varies. Sensory patterns do not always follow a perfectly neat textbook distribution, which is why they need to be interpreted alongside the rest of the examination.
Why Does a Physio Test Your Reflexes?
Reflex testing gives us another way to assess the integrity of the nervous system.
The familiar "knee jerk" is one example of a deep tendon reflex.
When the patellar tendon just below the kneecap is tapped with a reflex hammer, it briefly stretches the quadriceps muscle. Sensory information travels into the spinal cord and a rapid motor response is sent back to the muscle, producing a small knee extension movement.
Other commonly tested reflexes include:
- The Achilles reflex at the ankle.
- The biceps reflex at the elbow.
- The triceps reflex.
- The brachioradialis reflex around the forearm.
The size of a reflex varies naturally between people. What is often more useful is looking at the overall pattern and whether there is a meaningful difference between the two sides.
What Does an Absent or Reduced Reflex Mean?
A reduced reflex can sometimes indicate altered function somewhere along the nerve pathway involved in that reflex.
However, a reduced or even absent reflex does not automatically mean there is a serious problem.
Some healthy people naturally have small reflexes, and reflexes can become more difficult to elicit with age or depending on how relaxed someone is during the test.
That is why reflexes should never be interpreted in isolation.
A finding becomes more meaningful when it fits with other features such as weakness, sensory changes, pain distribution or other neurological signs.
What About Nerve Tension Tests?
Your physiotherapist may also perform tests that progressively load parts of the nervous system.
Examples include the straight leg raise or slump test for symptoms affecting the lower limb, and upper-limb neurodynamic tests for symptoms affecting the arm.
These tests can help assess the sensitivity of neural tissues and determine whether particular movements reproduce someone's familiar symptoms.
It is important to distinguish nerve sensitivity from nerve damage. A nerve can be sensitive to movement or loading without showing objective loss of strength, sensation or reflex function.
Does a Disc Bulge Always Cause Nerve Symptoms?
No.
Disc bulges are common findings on scans, including in people who have no pain at all.
In some situations, a disc can irritate or compress a nearby nerve root and contribute to symptoms such as radiating pain, altered sensation or weakness.
However, seeing a disc bulge on an MRI does not automatically prove that it is responsible for someone's symptoms.
The scan needs to make sense alongside the clinical examination.
This is especially relevant when assessing lower back pain. Imaging findings, symptoms and neurological examination findings all need to be interpreted together rather than relying on the scan alone.
What Is the Difference Between Radicular Pain and Radiculopathy?
These terms are often used interchangeably, but they describe slightly different things.
Radicular pain refers to pain associated with irritation of a spinal nerve root. This can produce pain travelling into an arm or leg.
Radiculopathy implies measurable changes in nerve function, such as:
- Muscle weakness.
- Altered sensation.
- Reduced reflexes.
Someone can therefore experience nerve-related pain without necessarily having neurological loss on examination.
Why Do Physios Compare Both Sides?
Many neurological tests are interpreted by comparing one side of the body with the other.
This is because there is normal variation between individuals.
A particular reflex or muscle grade may be completely normal for one person but potentially significant in another if there is a clear side-to-side difference that matches their symptoms.
Comparing both sides gives the physiotherapist a better understanding of what is normal for that individual.
When Are Neurological Symptoms More Concerning?
Most episodes of radiating pain, tingling or nerve irritation are not medical emergencies.
However, some neurological changes require more urgent medical assessment.
Seek prompt medical attention if you experience:
- Rapidly worsening or substantial muscle weakness.
- New difficulty walking or controlling your legs.
- Loss of bladder or bowel control.
- Numbness around the saddle or genital area.
- Significant loss of coordination.
- Symptoms affecting both arms or both legs unexpectedly.
- Sudden neurological symptoms such as facial weakness, speech difficulty or severe loss of coordination.
These symptoms can have causes outside the scope of routine musculoskeletal physiotherapy and may require urgent medical investigation.
Does an Abnormal Neurological Test Mean I Need a Scan?
Not always.
Some nerve-related conditions improve without imaging or surgery.
The decision to investigate further depends on the overall clinical picture, including:
- The severity of the symptoms.
- Whether weakness or sensory loss is present.
- Whether symptoms are stable, improving or worsening.
- How long symptoms have been present.
- Whether there are any concerning neurological signs.
If further assessment is appropriate, your physiotherapist can discuss whether review by your GP, specialist or further imaging may be useful.
What If Nerve-Related Pain Has Been Present for a Long Time?
Persistent pain does not necessarily mean that a nerve is continuing to be damaged.
When symptoms have been present for a long time, pain can become influenced by a much broader combination of factors including physical capacity, sensitivity of the nervous system, sleep, activity, stress and previous experiences with pain.
This is why ongoing symptoms sometimes require a broader approach than simply looking for one structural problem on a scan.
You can read more about our approach to longer-lasting symptoms on our Chronic Pain page.
Why Is a Neurological Examination Useful?
A neurological examination provides another layer of information during the assessment of neck pain, lower back pain and symptoms travelling into the arms or legs.
It can help distinguish between:
- Local muscle or joint pain.
- Nerve irritation.
- Changes in nerve function.
- Problems that may need further investigation.
Perhaps most importantly, it helps put symptoms into context.
Pins and needles do not automatically mean nerve damage. A disc bulge does not automatically mean a nerve is compressed. And an unusual reflex does not mean very much without considering the rest of the examination.
The neurological examination is one part of the bigger picture, helping us understand what may be contributing to your symptoms and what the most appropriate next step should be.
