Outline•Anatomy•Inspection and Palpation•Posture and abnormal movements•Tone and Power•Reflexes•Coordination•Stance and gait
MOTOR PATHWAYSCorticobulbar (corticonuclear) fibers:originate in the region of the sensorimotor cortex,where the face is represented. They pass throughthe posterior limb of the internal capsule and themiddle portion of the crus cerebri to their targets,the somatic and brachial efferent nuclei in thebrain stem.
Corticospinal tract: originates in theremainder of the sensorimotor cortex and othercortical areas. It follows a similar trajectory throughthe brain stem and then passes through thepyramids of the medulla (hence, the namepyramidal tract), decussates, and descends in thelateral column of the spinal cord.
Inspection and PalpationLook for:•any asymmetry, inspecting both proximallyand distally.•any deformities such as clawing of thehands or pes cavus.•wasting or hypertrophy, fasciculation andinvoluntary movements.•Palpate muscles to assess their bulk.
Causes of Muscle wasting•Lower motor neurone lesions, peripheralnerve section•Longstanding or developmental uppermotor neurone damage disuse atrophy ofmuscle groups•Muscle disorders•Rheumatoid arthritis•Cachexia
Posture and Abnormal MovementsAsk the patient to hold the arms outstretched with the eyesclosed:• Pyramidal drift describes a tendency for the hand to moveupward and supinate if the hands are held outstretched in apronated position (palms downward), or to pronatedownward if the hands are held in supination.• Cerebellar drift is generally upward, with excessiverebound movements if the hand is suddenly displaceddownward by the examiner.• Parietal drift is an outward movement on displacing theulnar border of the supinated hand.
TONE•Muscular tone refers to the state of muscletension or contraction•For clinical purposes, it is the resistance feltby the examiner when moving a jointpassively through its range of movement.
Examination sequence•Ask the patient to lie supine on the examination couch, relax and gofloppy.•Passive movements of the joints should be through as full a range aspossible and both slowly and quickly.•In the upper limb hold the patients hand as if shaking hands, using yourother hand to support the patients elbow. Then rotate the forearm, flex andextend the wrist, elbow and shoulder, varying the speed and direction.•With the lower limb begin by rolling or rotating the leg from side to side,then briskly lift the knee into a flexed position.•Knee clonus: with the patient relaxed and the knee extended, sharplypush with your thumb and forefinger above the patella towards the foot,sustaining the pressure for a few seconds.•Ankle clonus: support the patients leg with both the knee and ankleresting in 90° flexion. Briskly dorsiflex and partially evert the foot andsustain the pressure
Common abnormalities•Hypotonia: decreased muscle tone•Hypertonia: increased muscle tone.There are two principal types of hypertonia: spasticity rigidity
Power•Muscle power is tested for groups of musclesmoving various joints.•Strength of individual muscle groups is testedby comparing them with examiner‟s ownstrength•Before testing power always look fortenderness and contracture of muscles andjoints•Fix the proximal joints to avoid movements byuninvolved muscles.
MRC Scale for grading muscle powerGrade 0 Complete paralysisGrade 1 A flicker of contraction onlyGrade 2 Power detectable only when gravity isexcluded by postural adjustmentGrade 3 Limb can be held against gravity but notresistanceGrade 4 Limb can be held against gravity and someresistanceGrade 5 Normal power
Examination sequence•Test the power of individual muscle groupsin both limbs alternately to compare.•Ask the patient to contract a group ofmuscles to maintain a position and resistyour attempt to displace the limb (isometrictesting).•Ask the patient to put the joint through amovement while you try to oppose the action(isotonic testing).
Muscles of Shoulder Girdle & ScapulaSupraspinatus:•Main Segmental Supply –C5, C6•Nerve supply-SuprascapularNerve•Action: Shoulder abduction•Test: The patient rests thearm down by the side. Gripat the elbow and resistabduction
Deltoid•Main Segmental Supply - C5•Peripheral Nerve – Circumflex•Action: Shoulder abduction, extension•Test: The patient abducts arms with elbowsbent. Press down on the upper arms
Infraspinatus(C5, Suprascapular)•Action: ShoulderExternal rotation•Test: The patient reststhe arm down by hisside with the forearmpointing anteriorly at 90°to the arm. Resistexternal rotation of theshoulder
Pectoralis major(sternocostal head)•Nerve supply: Medial andlateral pectoral; C6, C7, C8•Causes shoulder adduction•Test: The patient brings thearm just a little away from theside. Hold at th elbow andresist shoulder adduction.Observe the musclecontracton the anterior chest wall
Pectoralis major(Clavicular head)•Nerve Supply: Lateralpectoral N.; C5, C6•Shoulder flexion•The patient brings thearm up laterally with theforearm pointingsuperiorly. Hold at theelbow and resistshoulder flexionforwards.
Rhomboids•Nerve Supply: Dorsalscapular N.; C4, C5•Shoulder internal rotation•Test: The patient brings thehand to the small of theback with the palm facingposteriorly. Press againstthe palm of the patientshand to resist movement ofthe hand posteriorly.
Serratus anterior•Long thoracic C5, C6, C7•Stabilization of scapula•Test: The patient brings thehands anteriorly to pushagainst a vertical wall. Inparalysis, the free medialedge of the scapula wings„posteriorly away from the ribcageWinging of scapula
Latissimus dorsi•Thoracodorsal N.; C6,C7, C8•Shoulder adduction•The patient brings thearm up laterally tohorizontal. Hold at theelbow and resist shoulderadduction. Observe themuscle contract on theside of the chest wall
ElbowBiceps brachii•Musculocutaneous N.;C5, C6•Elbow flexion•The patient flexes theelbow with the forearmsupinated. Hold the wrist,stabilize at the elbow andresist flexion
Triceps•Radial N.; C6, C7, C8•Elbow extension•The patient holds thearm out with the elbowhalf-extended. Hold atthe wrist, stabilize at theelbow and resistextensionTesting Long headTesting whole muscle
Brachioradialis•Radial N.; C5, C6•Elbow flexion•The patient flexes theelbow with the forearmmid-pronated. Hold thewrist, stabilize at theelbow and resist flexion.Observe the musclebelly along forearm.
Forearm: Supinator•Radial N.; C6, C7•Forearm supination•Grasp the patient in ahandshake with thepatients elbow extendedand resist supination.
Pronator teres•Median N.; C6, C7•Forearm pronation•Grasp patient in ahandshake with hiselbow extended and resistpronation.
Wrist and HandExtensor carpi radialis longus•Radial N.; C5, C6•Wrist extension and abduction•The patient cocks the wrist up.Press over the dorsum of thehand at the second metacarpalhead and resist extension andabduction of the wrist. Stabilizewith the other hand at the baseof the forearm near the wrist
Extensor carpi ulnaris•Posterior interosseousN.; C7, C8•Wrist extension andadduction•The patient cocks thewrist up. Press over thedorsum of the hand at thefifth metacarpal head andresist extension andadduction of the wrist.Stabilize with your otherhand at the base of theforearm near the wrist.
Flexor carpi radialis•Median N.; C6, C7•Wrist flexion and abduction•Hold the fingers of your handagainst the upturned palmaraspect of the patients secondmetacarpal head and resistwrist flexion and abduction,stabilizing at the dorsalforearm with your other hand.Observe the flexor tendon atthe wrist
Flexor carpi ulnaris•Ulnar N.; C7, C8, T1•Wrist flexion and adduction•Hold the fingers of your handagainst the patients upturnedhand at the hypothenareminence and resist wristflexion and adduction,stabilizing at the dorsalforearm. Observe the tendonover the ulnar border of thewrist.
Flexor digitorum longus•Median N; C7, C8, T1•Causes Finger flexion•Stabilize the patientsproximal phalanxbetween your thumband finger and use afinger of your otherhand to resist flexion ofthe proximal inter-phalangeal joint
Flexor digitorum profundus I, II•Anterior interosseousN.; C7, C8•Finger flexion•Stabilize the patientsindex middle phalanxbetween your thumband finger and resistfinger flexion by pullingagainst the flexed distalphalanx.
Flexor digitorum profundus III, IV•Ulnar N.; C7, C8•Finger flexion•As for Flexor digitorumprofundus I, II, but withthe patients little finger
Flexor pollicis longus•Anterior interosseousN.; C7, C8•Thumb flexion•The patient flexes thethumb at the inter-phalangeal joint. Pressagainst the distalphalanx and resistflexion at this joint.
Abductor pollicis brevis•Median N.; C8, T1•Thumb abduction•The patient holds the palmupward and brings histhumb away from his handat 90° to the palm. Holdyour thumb against the sideof the patients thumb andresist abduction. Observethe thenar eminence.
Opponens pollicis•Median N•Opposition of the thumb•The patient should tryto touch the tip of thelittle finger with thethumb, against yourresistance.
First dorsal interosseous•Ulnar N.; C8, T1•Index finger abduction•The patient holds thehand out palmdownwards with thefingers apart. Hold yourfinger against the sideof the index finger andresist abduction
Testing the grip•C7, C8, T1•Ask the patient to squeezetwo of your fingers as hardas possible and not let themgo. You should normallyhave difficulty removingyour fingers from thepatients grip. Test bothgrips simultaneously witharms extended or in the lap.
Lumbricals•Lateral median and medialulnar, C8, T1•Phalanges extension•Stabilize the patientsmetacarpophalangeal joint inhyperextension by pressingyour finger against the palmarsurface of the middle phalanxso that the long extensorscannot act, and resistextension of the distal phalanx
HipIliopsoas•Spinal branches andfemoral N.; L1, L2, L3•Hip flexion•The patient flexes the thighat the hip near 90°. Resistthis by pressing on theanterior aspect of the thighjust proximal to the knee.
Gluteus maximus•Inferior gluteal N.; L5, S1,S2•Hip extension•The patient lies supine withlegs extended. Slightly flexthe hip by placing your handunder the knee. Ask thepatient to extend the hip tosupport the weight of thepelvis off the couch.
Hip adductors•Oburator N.; L2, L3, L4•Hip adduction•The patient lies supinewith legs extended. Resistadduction of the hip bypressing against themedial surface of theknee, stabilizing with yourother hand against theside of the pelvis.
Gluteus medius and tensorfasciae latae•Superior gluteal N.; L4, L5,S1•Hip abduction•The patient lies supine withlegs extended. Resistabduction of the hip bypressing against the lateralsurface of the knee,stabilizing with your handagainst the opposite side ofthe pelvis.
Knee-Quadriceps•Femoral N.; L2, L3, L4•Knee extension•The patient lies supine withlegs extended. Use onehand to lift the patients legfrom underneath the knee toabout 20°knee flexion andask the patient to extend theknee, resisting with yourother hand over the patientslower shin.
Hamstrings•Knee flexion•Sciatic N.; L5, S1, S2•The patient lies supinewith the knee flexed at90°. Hold the leg at theankle and resist pullingof the heel in towardsthe buttock.
Ankle and footGastrocnemius•Tibial N.; S1, S2•Ankle extension•The patient lies supinewith legs extended andplantar-flexing the foot.Hold the foot at themetatarsal heads andresist plantar-flexion.
Tibialis anterior•Deep peroneal N.; L4,L5•Ankle dorsiflexion•The patient lies supinewith legs extended andthe foot dorsi-flexed.Hold the foot over thedorsal surface and resistdorsi-flexion.
Tibialis posterior•Tibial N.; L4, L5•Ankle inversion•Hold the patients footmedially at the firstmetatarsal and resistinversion.
Peronei (longus and brevis)•Superficial peroneal N.;L5, S1•Ankle eversion•Hold the patients footlaterally at the fifthmetatarsal and resisteversion
Extensor hallucis longus•Deep peroneal N.; L5,S1•Great toe extension•The patient dorsiflexes thedistal phalanx of the greattoe. Press against thedorsal surface of the distalphalanx to resistdorsiflexion.
Extensor digitorum brevis•Deep peroneal N.; L5, S1•Toe extension•The patient dorsiflexes theproximal phalanges of thetoes and attempts to spreadthe toes. Alternatively, pressagainst the dorsal surfaces ofthe middle phalanges.Observe and palpate themuscle belly 4 cm distal to thelateral malleolus.
Flexor digitorum longus•Tibial N.; L5, S1, S2•Toe flexion•Hold the patients toeswith your fingers overthe plantar surfaces andresist flexion.
General Instructions•Encourage the patient to relax, then position the limbsproperly and symmetrically.•Hold the reflex hammer loosely between your thumb andindex finger so that it swings freely in an arc within thelimits set by your palm and other fingers.•With your wrist relaxed, strike the tendon briskly using arapid wrist movement. Your strike should be quick anddirect, not glancing.•Note the speed, force, and amplitude of the reflexresponse and grade the response using the scale below.Always compare the response of one side with the other.
Scale For Grading Reflexes
Reinforcement•A technique involvingisometric contraction ofother muscles for up to10 seconds that mayincrease reflex activity.•Tell the patient to pulljust before you strikethe tendon.
The Biceps Reflex (C5, C6)•The patients arm should bepartially flexed at the elbowwith palm down.• Place your thumb or fingerfirmly on the biceps tendon.•Strike with the reflex hammerso that the blow is aimeddirectly through your digittowards the tendon.•Observe flexion at the elbow,and watch for and feel thecontraction of the bicepsmuscle.
The Triceps Reflex (C6, C7)•The patient may be sitting orsupine. Flex the patients armat the elbow, with palm towardthe body, and pull it slightlyacross the chest.• Strike the triceps tendonabove the elbow. Use a directblow from directly behind it.•Watch for contraction of thetriceps muscle and extensionat the elbow.
If you have difficultygetting the patient torelax, try supportingthe upper arm asillustrated. Ask thepatient to let the armgo limp, as if it were“hung up to dry.” Thenstrike the tricepstendon.
The Supinator or BrachioradialisReflex (C5, C6)•The patients hand shouldrest on the abdomen or thelap, with the forearm partlypronated.•Strike the radius with thepoint or flat edge of thereflex hammer, about 1 to 2inches above the wrist.•Watch for flexion andsupination of the forearm.
The Knee Reflex (L2, L3, L4)•The patient may beeither sitting or lyingdown as long as theknee is flexed.•Briskly tap the patellartendon just below thepatella.•Note contraction of thequadriceps withextension at the knee.
The Ankle Reflex (primarily S1)•If the patient is sitting,dorsiflex the foot at theankle. Persuade thepatient to relax.•Strike the Achilles tendon.•Watch and feel for plantarflexion at the ankle. Notealso the speed ofrelaxation after muscularcontraction.
Ankle clonus•Support the knee in a partlyflexed position. With your otherhand, dorsiflex and plantar flex thefoot a few times while encouragingthe patient to relax, and thensharply dorsiflex the foot andmaintain it in dorsiflexion.Look andfeel for rhythmic oscillationsbetween dorsiflexion and plantarflexion.• In most normal people, the ankledoes not react to this stimulus.
Superficial spinal reflexes
Abdominal Reflexes•Lightly but briskly strokeeach side of theabdomen, above (T8, T9,T10) and below (T10,T11, T12) the umbilicus.•Note the contraction ofthe abdominal musclesand deviation of theumbilicus toward thestimulus.
The plantar reflex (L5, S1)•With an object such as a key or the wooden end of anapplicator stick, stroke the lateral aspect of the sole fromthe heel to the ball of the foot, curving medially across theball.•Note movement of the big toe, normally plantar flexion.•Babinski response: Instead of the normal flexorresponse, dorsiflexion of the great toe precedes all othermovement. This is followed by spreading and extension ofthe other toes, by marked dorsiflexion of the ankle, and byflexion withdrawal of the hip and knee. It is pathognomonicof an UMN lesion.
CoordinationTo assess coordination, observe thepatients performance in:•Rapid alternating movements•Point-to-point movements•Gait and other related body movements•Standing in specified ways
Rapid Alternating Movements•Ask the patient to tap your palm with thetips of the fingers of one hand, alternately inpronation and supination, as fast aspossible.•In cerebellar disease, one movementcannot be followed quickly by its oppositeand movements are slow, irregular, andclumsy. This abnormality is calleddysdiadochokinesis.
Point-to-Point MovementsFinger-to-nose Test•Ask the patient to touch the point of the nose and then thetip of your finger, held at arms length in front of thepatients face, using their index finger.•Ask the patient to repeat the test with the eyes closed.
Heel-shin testAsk the patient to place one heel on the opposite knee, andthen run it down the shin to the big toe. Note the smoothnessand accuracy of the movements. Repetition with the patientseyes closed tests for position sense. Repeat on the otherside.
GaitAsk the patient to:•Walk across the room or down the hall, then turn, andcome back. Observe posture, balance, swinging of thearms, and movements of the legs.•Walk heel-to-toe in a straight line (tandem walking).•Walk on the toes, then on the heels•Hop in place on each foot in turn•Do a shallow knee bend, first on one leg, then on theother.•Rising from a sitting position without arm support andstepping up on a sturdy stool.
Tandem walking Hopping
StanceThe Romberg Test:This is mainly a test of position sense. Thepatient should first stand with feet togetherand eyes open and then close both eyes for30 to 60 seconds without support. Note thepatients ability to maintain an uprightposture. Normally only minimal swayingoccurs.
Test For Pronator Drift•The patient should stand for 20 to 30 seconds with both arms straightforward, palms up, and with eyes closed. A person who cannot standmay be tested for a pronator drift in the sitting position.•Now, instructing the patient to keep the arms up and eyes shut, tap thearms briskly downward. The arms normally return smoothly to thehorizontal position.