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Henry Rogers
Henry Rogers

Bickerstaff Neurological Examination in Clinical Practice: The Ultimate Resource for Neurologists (Free Pdf)

Bickerstaff Neurological Examination Pdf Free Download

Neurological examination is a vital skill for any clinician who deals with patients with neurological disorders. It is a systematic way of assessing the function and integrity of the nervous system, from the brain to the spinal cord and peripheral nerves. Neurological examination can help to establish a diagnosis, monitor the progression of a disease, evaluate the response to treatment, and prognosticate the outcome.

Bickerstaff Neurological Examination Pdf Free Download

However, neurological examination is not a simple or straightforward task. It requires a thorough knowledge of neuroanatomy, neurophysiology, and neuropathology, as well as a keen observation, logical reasoning, and clinical judgment. Moreover, neurological examination can vary depending on the setting, the patient's condition, and the examiner's preference and experience.

Therefore, it is essential for clinicians to learn from experts who have mastered the art and science of neurological examination. One such expert is Dr. John A. Bickerstaff, who developed his own method of neurological examination that has been widely used and taught for over half a century. In this article, we will introduce you to Bickerstaff neurological examination, its history, principles, techniques, recording, interpretation, applications, limitations, and future prospects. We will also provide you with a link to download a free pdf version of his book "Bickerstaff's Neurological Examination in Clinical Practice".


Dr. John A. Bickerstaff was born in 1919 in England. He studied medicine at Oxford University and served as a medical officer in the Royal Air Force during World War II. After the war, he pursued his interest in neurology and became a consultant neurologist at St. Thomas' Hospital in London. He also held academic positions at King's College Hospital Medical School and Guy's Hospital Medical School.

Bickerstaff was fascinated by neurological examination and devoted his career to teaching and refining it. He published his first book "The Technique of Neurological Examination" in 1955, which was based on his lectures and demonstrations to medical students and junior doctors. He revised and expanded his book several times over the years, incorporating new findings and feedback from his colleagues and students. The sixth edition of his book was published in 1997 under the title "Bickerstaff's Neurological Examination in Clinical Practice". It has been translated into many languages and remains a classic reference for neurologists worldwide.


Bickerstaff neurological examination is based on four main principles:

  • The examination should be tailored to the patient's condition and complaint. There is no need to perform every test on every patient. The examiner should focus on the relevant parts of the nervous system that are likely to be affected by the patient's problem.

  • The examination should be systematic and logical. The examiner should follow a consistent order of examining different parts of the nervous system, starting from higher cerebral functions (such as mental status, speech, memory) to lower ones (such as cranial nerves, motor system, sensory system). The examiner should also compare both sides of the body for symmetry and look for signs of localization (such as hemiparesis or hemisensory loss).

  • The examination should be objective and accurate. The examiner should use standardized and validated tests and scales to measure the patient's neurological function. The examiner should also avoid bias and subjective interpretation of the findings. The examiner should report what he or she observes, not what he or she thinks or infers.

  • The examination should be dynamic and interactive. The examiner should engage the patient in a friendly and respectful manner, explain the purpose and procedure of each test, and provide feedback and encouragement. The examiner should also observe the patient's behavior, mood, attitude, and cooperation throughout the examination.


Bickerstaff neurological examination consists of several techniques that cover different aspects of the nervous system. Here is a brief overview of some of the main techniques:

Examination of higher cerebral functions

This technique assesses the patient's mental status, speech, memory, intelligence, and other cognitive functions. It includes tests such as:

  • Orientation: asking the patient about his or her name, age, date, time, place, and situation.

  • Attention: asking the patient to spell a word backwards or to subtract serial sevens from 100.

  • Memory: asking the patient to recall three words after a few minutes or to repeat a short story.

  • Language: asking the patient to name objects, follow commands, read, write, and repeat phrases.

  • Calculation: asking the patient to perform simple arithmetic problems.

  • Praxis: asking the patient to perform skilled movements such as brushing teeth or combing hair.

  • Gnosis: asking the patient to recognize objects by sight, touch, smell, or sound.

  • Executive functions: asking the patient to solve problems, plan actions, or switch tasks.

  • Abstract thinking: asking the patient to explain proverbs or similarities and differences between words.

  • Judgment: asking the patient to evaluate hypothetical situations or moral dilemmas.

Examination of cranial nerves

This technique assesses the function of the 12 pairs of cranial nerves that emerge from the brainstem and control various sensory and motor functions of the head and neck. It includes tests such as:

  • Olfactory nerve (I): asking the patient to identify different smells with each nostril.

  • Optic nerve (II): testing the patient's visual acuity, visual fields, color vision, pupillary reactions, and fundoscopy.

  • Oculomotor nerve (III), trochlear nerve (IV), and abducens nerve (VI): testing the patient's eye movements in different directions, convergence, accommodation, and eyelid position.

  • Trigeminal nerve (V): testing the patient's facial sensation in three divisions (ophthalmic, maxillary, and mandibular), corneal reflex, jaw jerk reflex, and jaw movements.

  • Facial nerve (VII): testing the patient's facial expression in different emotions, taste sensation in anterior two-thirds of tongue, lacrimation, salivation, and stapedius reflex.

  • Vestibulocochlear nerve (VIII): testing the patient's hearing acuity, lateralization of sound (Weber test), comparison of air and bone conduction (Rinne test), and vestibular function (caloric test).

  • Glossopharyngeal nerve (IX) and vagus nerve (X): testing the patient's taste sensation in posterior one-third of tongue, gag reflex, palatal movement, voice quality, and swallowing.

  • Accessory nerve (XI): testing the patient's shoulder shrug and head turn against resistance.

  • Hypoglossal nerve (XII): testing the patient's tongue movements in different directions and for atrophy or fasciculations.

Examination of motor system

This technique assesses the function of the motor cortex, corticospinal tract, spinal cord, peripheral nerves, neuromuscular junctions, and muscles. It includes tests such as:

  • Tone: feeling the resistance of the patient's muscles to passive movement at different joints.

  • Power: grading the strength of the patient's muscles on a scale of 0 to 5 against gravity and resistance.

  • Coordination: observing the accuracy and smoothness of the patient's voluntary movements such as finger-nose test or heel-shin test.

  • Gait: observing the pattern and stability of the patient's walking on different surfaces and in different directions.

Reflexes: eliciting and grading the deep tendon reflexes (such as biceps reflex or knee jerk) and superficial reflexes (such as abdominal reflex or plant 71b2f0854b


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