The Virtual Neurological Examination

COVID-19 has heralded a new digital era in medicine where remote clinics are the new standard and are poised to become the new normal. When it comes to virtual medical history taking, a telemedicine portal does not really require a new approach and the same information as in a face-to-face setting can be obtained. However, this is not always the case for the physical examination and many signs and tests that are part of a routine examination are not suited to be performed remotely. The virtual neurological examination requires its own intricacies for which none of us have specifically been trained. In our VirtuEx, we have given an outline of what is feasible in a screening neurological examination reconciling practicality with a logical hierarchy in testing.

To get the most out of a VirtuEx, it is important that patients are informed before their appointment takes place on how to prepare. Ideally, via a letter or other form of communication, for example email, with comprehensive instructions should be sent out at least a week or two in advance. We have made a template letter that could be used to inform patients about their upcoming examination.

Although the functionalities of telemedicine portals might evolve, the majority of the current platforms do not allow screen sharing. Therefore, a more thorough assessment of eye sight needs to be done asynchronously. The most widespread application for this purpose is the Eye Handbook application which is free to download from the Apple or Google Play apps stores. When providing the patient with adequate instructions, the tests can be performed at home before the clinic appointment takes place. The Eye Handbook tests that are most informative and compatible with self-evaluation are the Near Vision Cards, Red Screen Bilateral and Amsler grids. We have deliberately not included Ishihara’s Test for colour deficiency as it is unreliable whether a patient with a deficit will judge his performance correctly.

Asynchronous examination instructions for patients:

- Before starting:

* Test your eyes under normal room lighting used for reading

* Wear eyeglasses you normally wear for reading (even if you wear only store-bought reading glasses)

During the remote clinic appointment, the clinician will ask you the result of the following Eye Handbook tests:

- Vision Test - Near Vision Cards

* Position yourself at 35 cm or 14 inches from the screen

* Cup your hand over one eye while testing the other eye

* Try to read the letters/numbers on your screen starting from biggest symbols and moving towards the smaller ones

* When you cannot read the letters/numbers anymore, look at the

right side of the screen and answer the following question:

What is the fraction that is indicated on the right side of your screen?

* Switch to the other eye and repeat.

- Red screen bilateral:

* Cup your hand over one eye while testing the other eye.

* Look at the red rectangle and answer the following question:

Can you see the bright red colour?

* Switch to the other eye and repeat.

* Look at the red rectangle and answer the following question:

Can you see the bright red colour?

Is there a difference in appearance or brightness compared to the other eye?

- Amsler Grids

* Position yourself at 35 cm or 14 inches from the screen

* Cup your hand over one eye while testing the other eye.

* Keep your eye focused on the dot in the centre of the grid and answer these questions:

Do any of the lines in the grid appear wavy, blurred or distorted?

Do all the boxes in the grid look square and the same size?

Are there any "holes" (missing areas) or dark areas in the grid?

Can you see all corners and sides of the grid (while keeping your eye on the central dot)?

* Switch to the other eye and repeat.

This is the most straightforward part of the virtual examination and is very similar to a face-to-face setting. The patient needs to position the smartphone, laptop or other device with the camera vertically on a desk and sit comfortably on a chair approximately half a metre away from the camera. The upper limb tests are self-explanatory, especially as the examiner can demonstrate the necessary movements (e.g. finger rolling test). The tests were selected based on their ability to detect proximal or distal weakness. However, this does not allow the thorough examination of muscle strength that is required for radiculopathies or neuromuscular diseases. Others have suggested that tendon reflexes can be evaluated remotely by self-testing or by an assistant using finger tapping, however, we do not consider this practical as tendon reflexes require training and a certain level of skill to perform and interpret correctly. In addition, this test strategy is intrinsically hampered by the fact that patients cannot be fully relaxed while testing. For cerebellar testing, finger-nose testing and thumb-index finger tapping are straightforward. Sensation testing with a tissue or a toothpick can indicate a proximo-distal gradient or lateralized differences.

Mental state screen

1. When appropriate: Attention span and concentration

Orientation in person, time and space

Episodic and working memory

Praxis - cleaning teeth or combing hair

Language

2. When appropriate: Repetition

Naming

Reading

Strength – Upper Limbs

3. Ability to raise the arms above one's head

4. Holding arms in supination, fingers adducted and closed eyes

5. Finger rolling test

6. Ability to completely bury the distal phalanx when making a fist.

7. When appropriate: Sustained abduction of the arms for up to 120 seconds.

Sensation

8. Self-administered sensation in both arms with a cotton swab or tissue

9. When appropriate: Self-administered sensation in both legs with a cotton swab or tissue

10. When appropriate: Self-administered sensation in all four limbs with a toothpick or a cold object

Cerebellar function

11. Finger-nose-test

12. Tapping thumb and index finger

13. When appropriate: Turning hands in alternating movements

14. When appropriate: Foot tapping and heel stomping

15. When appropriate: Rapid toe wiggling

Extrapyramidal function

16. When appropriate: Inspection for rest and action tremor

17. When appropriate: Inspection for decrement when finger tapping

To facilitate positioning during the second part, we have implemented the ‘one-index-finger-rule’ which is crucial for the reproducibility of the examination. From our experience, this rule is an easy indicator for patients on how close they exactly need to be in front of the camera and simultaneously allows clinicians to examine cranial nerve functions in great detail. The most challenging test of part two is observing pupillary constriction which requires specific instructions. The patient has to keep his flashlight lateral to the eye of interest with the light source at the level of the pupil. Next, the patient needs to slowly turn the light source inwards until the examiner asks to stop. This cue should be given at the point where the iris is completely visible. Pupillary constriction can now easily be observed after eye closure and opening. For convergence testing, the patient will need a pen. This test cannot be executed with the patient using his finger as his hand will obscure the view for the clinician. The pen needs to be moved between the upper border of the camera and the glabella while instructing the patient to focus on the tip of the pen. For saccade testing, it is necessary that the patient touches his ear with his index finger and moves the finger forward until it becomes visible for him. Subsequently, the clinician needs to ask the patient to quickly move his eye between the finger and the camera which allows him/her to evaluate saccade accuracy and velocity. To assess palatal movements, the patient needs to place himself at one index finger’s distance from the camera and his chin with his flashlight at the corner of his mouth shining the light inwards. In this position, the visibility of palatal movements is optimal. Although others have suggested confrontation visual fields can be done remotely, this is unlikely to yield reliable information as the patient’s screen size is typically relatively small impeding testing of visual field extremes.

Cranial nerve II:

1. When appropriate: Colour vision, visual acuity, central vision with Eye Handbook Application

Cranial nerve III-IV-VI:

2. Pupils: Close eyes for 5 seconds to evaluate pupillary reaction

3. Inspection of the eye: ptosis, ocular alignment

4. Ocular movements:

Versions: Ask patient to look in all directions of gaze with their head still

Convergence testing

Saccades

When appropriate: Ductions

When appropriate: VOR testing

When appropriate: Sustained upgaze for 30-60 seconds

Cranial nerve V

5. Self-administered facial sensation with a cotton swab or tissue

6. When appropriate: Self-administered facial sensation with a toothpick or a cold object

Cranial nerve VII

7. Inspection of facial symmetry, nasolabial fold flattening

8. Ask the patient to show their teeth, close their eyes and raise their eyebrows/frown

Cranial nerve VIII

9. Ask patient to rub their finger in either ear

Cranial nerves IX

10. Ask the patient to say ‘aaaah’ and inspect uvula and palatal position and movement

Cranial nerve XI

10. Ask the patient to shrug his shoulders and inspect symmetry

Cranial nerve XII

11. Ask the patient to stick out the tongue and to move the tongue rapidly from side to side

12. Ask the patient to click the tongue

13. When appropriate: Inspect for atrophy and/or fasciculations

For this part, it is paramount that the patient positions the camera vertically on the floor. If the camera is positioned obliquely at for example a 100° angle with the floor, the patient will need to be too far away from the camera to get his feet in the picture. The baseline position should be the closest position where you can see both feet and the legs until at least knee-level. This will be approximately half a metre in front of the camera. Standing and hopping on either leg are self-explanatory. To observe the gait of the patient, he will need to walk preferably 3 meters away from the camera. As it is necessary for Romberg’s test to capture truncal movements, we ask the patient to stop at the most distant point in the room and turn towards the camera. For the remainder of the examination, the patient needs to go back to his original position and turn 90°. This lateral position allows observing if tandem gait is executed correctly and whether heel or toe walking is possible.

Strength – Lower Limbs

Gait and balance

From a frontal camera viewpoint:

1. Standing on either leg

2. Hopping on either leg three times

3. Walking & turning (3m / 25ft)

4. Romberg’s test

5. When appropriate: squatting

From a lateral camera viewpoint (90° turn to the right):

6. Tandem gait

7. Walk on heels and toes