Physiotherapy assessment of cranial nerve examination
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Physiotherapy assessment of cranial nerves
Cranial nerve examination is part of a neurological screen in physiotherapy, especially after stroke, traumatic brain injury, concussion, dizziness, facial weakness, suspected central nervous system pathology, or unexplained balance problems.
Preparation
- Explain the assessment and obtain consent.
- Ensure the patient uses their usual glasses and hearing aids.
- Compare right and left sides throughout.
- Observe first: facial symmetry, eyelid position, speech, swallowing, head posture, involuntary eye movements, and use of mobility aids.
- Stop and seek urgent medical review if there is an acute new deficit, particularly diplopia, dysphagia, facial weakness, unequal pupils, sudden visual loss, severe headache, or new ataxia.
| Cranial nerve | Main function | Physiotherapy screening test | Abnormal findings / relevance |
|---|---|---|---|
| I Olfactory | Smell | With eyes closed, identify a familiar, non-irritant odour such as coffee or soap, one nostril at a time. | Usually omitted unless there is relevant head trauma, frontal-lobe concern, or reported loss of smell. Do not use irritants such as ammonia. |
| II Optic | Vision | Ask about visual clarity; check reading of suitable print, visual fields by confrontation, and ability to detect fingers in each quadrant. | Field loss can affect walking safety, obstacle avoidance, reading, and falls risk. |
| III Oculomotor | Most eye movements, pupil constriction, eyelid elevation | Observe eyelid position and pupil size. Assess pupil response to light if within scope. Test eye tracking. | Ptosis, diplopia, unequal pupils, impaired gaze, or poor visual tracking. New pupil asymmetry with headache or reduced consciousness needs urgent escalation. |
| IV Trochlear | Downward and inward eye movement | Included with eye-movement testing. Ask whether double vision occurs when looking down, such as on stairs. | Diplopia on downward gaze can affect stair negotiation and mobility. |
| V Trigeminal | Facial sensation and mastication | Test light touch over forehead (V1), cheek (V2), and jaw (V3), comparing sides. Palpate masseter/temporalis while patient clenches teeth. | Altered facial sensation or weak jaw clench. Corneal reflex is generally not a routine physiotherapy test. |
| VI Abducens | Lateral eye movement | Test with H-pattern or tracking a target horizontally and vertically, keeping head still. | Failure to abduct eye, horizontal diplopia, nystagmus. Important in vestibular and balance assessment. |
| VII Facial | Facial expression; taste anterior tongue | Inspect face at rest. Ask patient to raise eyebrows, close eyes tightly, smile, show teeth, puff cheeks, and frown. | Whole-side facial weakness suggests a peripheral pattern; lower facial weakness with preserved forehead movement may suggest a central pattern. Check ability to close eye fully and protect cornea. |
| VIII Vestibulocochlear | Hearing and balance | Screen hearing with finger rub or whisper, one ear at a time. In dizziness, observe spontaneous/gaze-evoked nystagmus, gait, balance, and consider vestibular assessment within competence. | Hearing asymmetry, vertigo, nystagmus, imbalance, nausea. Acute vestibular symptoms plus focal neurological signs require urgent referral. |
| IX Glossopharyngeal | Pharyngeal sensation, swallowing contribution | Listen to voice quality, ask about choking/coughing with food or fluids, and observe swallowing only if appropriate. | Wet/gurgly voice, cough after swallowing, nasal regurgitation, dysphagia. Refer promptly to speech and language therapy or medical team. Do not routinely elicit gag reflex. |
| X Vagus | Palatal movement, voice, swallowing | Ask patient to say “ah”; observe palate elevation and uvula position. Listen for hoarseness or nasal speech. | Palatal asymmetry, hoarseness, weak cough, swallowing difficulty. Aspiration risk needs escalation. |
| XI Accessory | Sternocleidomastoid and trapezius | Shoulder shrug against resistance. Turn head against resistance to each side. | Shoulder droop or weakness, difficulty with cervical control and upper-limb function. |
| XII Hypoglossal | Tongue movement | Ask patient to protrude tongue and move it side-to-side. Observe for deviation, wasting, or fasciculations. | Tongue deviation, dysarthria, impaired bolus control, possible swallowing difficulty. |
Eye movement test: practical method for CN III, IV and VI
- Position the target about 30-50 cm from the patient.
- Ask the patient to keep their head still and follow the target with the eyes only.
- Move the target in an H-pattern.
- Observe for:
- Reduced range of eye movement
- Diplopia
- Nystagmus
- Loss of smooth pursuit
- Head movement used to compensate
- Ask, “Do you see one image or two?” and identify the gaze direction provoking diplopia.
Harrison's recommends a minimum neurological cranial-nerve screen that includes visual fields, pupils, extraocular movements, and facial movements; it also advises grouping CN III, IV and VI because of their shared ocular-motor role. Harrison's Principles of Internal Medicine, 22e, Cranial Nerve Examination section.
Documentation example
Cranial nerve screen: CN II visual fields grossly intact to confrontation. Pupils equal and reactive. Extraocular movements full; no diplopia or nystagmus. Facial sensation and facial movements symmetrical. Hearing grossly intact to finger rub bilaterally. Voice clear; no reported dysphagia. Palate elevates symmetrically. Shoulder shrug and head rotation strong and equal. Tongue protrudes midline.
Key physiotherapy implications
- Visual-field loss or diplopia: assess transfers, mobility, stair safety, scanning strategies, and falls risk.
- Vestibular signs: distinguish possible peripheral vestibular presentation from central warning signs.
- Facial weakness: eye protection, communication, eating/drinking concerns, and appropriate referral.
- Bulbar signs, CN IX, X, XII: treat as swallowing and airway-safety concerns, not simply as an exercise issue.
- CN XI weakness: consider scapular position, neck pain, shoulder function, and upper-limb rehabilitation.
A recent systematic-review search did not identify evidence that changes the standard bedside cranial-nerve screen; the core approach remains clinical observation, side-to-side comparison, and prompt escalation of acute focal deficits.
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