This document summarizes how to assess muscle strength through physical examination of different muscle groups. It provides instructions on positioning and resisting the patient's movements to test individual muscles. For each muscle or group, it identifies the main peripheral nerve, segmental spinal nerve supply, and recommended tests of strength. The assessment covers muscles of the shoulder, arm, forearm, hand, trunk, and hip and lower limb.

1. MOTOR SYSTEM EXAMINATION (Strength ) Moderator – Dr. V.K. GOEL Presenter- Dr. Harmeet Riyait

2. POWER OF MUSCLES QUICK ASSESSMENT – 1. Patient working 2. Standing up from lying & sitting position 3. Dressing or undressing 4. Lightly jumping or hopping

3. STRENGTH OF INDIVIDUAL MUSCLES Q.1. Is the muscle as strong as might be expected (bearing in mind the build & age of both patient & examiner)? Q.2. Is it as strong as same muscle on other side? Q.3. What is the degree of weakness if any? Q.4. Is the weakness constant or variable?-does it improve on rest or on encouragement? Q.5. Is there any painful condition? Q.6. Are the actions the patients is known to be able to carry out compatible with any apparent weakness demostrated?

4. Quantitative assessment of weakness 5. Normal power 4. The muscle, though able to make its full normal movement, is overcome by resistance. 3. The muscle is able to make its normal movement against gravity, but not against additional resistance. 2. The muscle can only make, its normal movement when the limb is so positioned that gravity is eliminated. There is a visible or palpable flicker of contraction, but no resultant movement of limb or joint. 0. Total paralysis. Note – 4+ against strong resistance 4 against moderate resistance 4- against mild resistance

5. SEGMENTAL NERVE SUPPLY PERIPHERAL NERVE SUPPLY ACTION OF THE MUSCLE METHOD OF TESTING - EXPOSED - POSITION - PALPATE - COMPARE

6. MUSCLES OF SHOULDER GIRDLE & SCAPULA Test – The patient flexes his elbow, holds the elbow to his side and then attempts to turn the fore arm backwards against resistance Peripheral Nerve – Suprascapular Mains Segmental Supply – C5 INFRA SPINATUS Test – Ask the patient to abducted from 30º to 60º the arm against examiner resistance Peripheral Nerve – Circumflex Main Segmental Supply - C5 DELTOID Test – The patient tries to initiate abduction of the arm from the side against resistance Peripheral Nerve – Suprascapular Main Segmental Supply – C5 SUPRA SPINATUS

7. If seratous anterior is weak, scapular medial borden will become prominent – winging of scapula Test Push the wall by his hands keeping elbow extended Main Seg supply C5C6C7 P. Nerve – N. to serratus anterior SERRATUS ANTERIOR Test-2 Strech the arm out infront & than to clasp the hands together while examiner endeavour to hold them apart Test-1 Placing the hand on hip and pressing in wards Main Seg supply C5C6C7 P. Nerve – Lat. & medial pectoral N. PECTORALIS MAJOR

8. Test-2 Resist the patient’s attempt to adduct the arm when abducted to above 90º Test-1 While palpating the muscle, ask the patient to cough Main Seg supply C7 P. Nerve –Nerve to L. Dorsi LATISSIMUS DORSI

9. RHOMBOIDS SEGMENTAL SUPPLY C5 PERIPHERAL NERVE NV TO RHOMBOIDS METHOD ASK THE PATIENT TO PLACE HIS HANDS ON HIP AND TRY TO FORCE HIS ELBOW BACKWARDS.

10. Trapezius Spinal accessory nerve Upper part-ask the patient to shrug his shoulders while you try to press them from behind. Lower part – ask the patient to approximate his shoulder blades.

11. MUSCLES OF ELBOW JOINT Test – Pt. attempts to extend the elbow against resistance Peripheral Nerve – Radial Mains Segmental Supply – C7 TRICEPS Test – Pt. pronates the forearm and draws the thumb towards the nose against resistance Peripheral Nerve – Radial Main Segmental Supply - C5C6 BRACHIORADIALIS Test – Pt. flexes his elbow against resistance, the forearm being supinated Peripheral N. – Musculo cutaneous Main Segmental Supply – C5 BICEPS

12. MUSCLES OF FOREARM & WRIST JOINT Peripheral Nerve - Ulnar Mains Segmental Supply – C8 FLEXOR CARPI ULNARIS Test – Examiner resist the patient attempt to flex the wrist towards the radial side Peripheral Nerve – Median Mains Segmental Supply – C6C7 FLEXOR CARPI RADIALS Test – Examiner attempt to flex the patients extended fingers at metacarpophalangeal joints Peripheral Nerve – Radial Main Segmental Supply -C7 EXTENSOR DIGITORUM Test – Pt. holds the fingers partialy extended and dorsiflexes the wrist towards the radial side against resistance Peripheral N. – Radial Main Segmental Supply – C6C7 EXTENSOR CARPI RADIALIS LONGUS

13. MUSCLES OF THUMB Test – Patients attempt to extend the thumb while the examiner attempts to flex it at the interphalangeal joint Peripheral Nerve – Radial Mains Segmental Supply – C8 EXTENSOR POLLICIS LONGUS Test – Pt. attempts to extend the thumb while the examiner attempts to flex it at MCP joint Peripheral Nerve – Radial Main Segmental Supply - C8 EXTENSOR POLLICIS BREVIS Test – Pt. attempts to maintain his thumb in abduction against the examiner resistance Peripheral N. – Radial Main Segmental Supply – C8 ABDUCTOR POLLICIS LONGUS

14. Test – Patient attempt to flex the distal phalanx of the thumb against the patient resistance (Hold the proximal phalanx) Peripheral Nerve – Median Mains Segmental Supply – C8 FLEXOR POLLICIS LONGUS Test – Ask the patient to abduct the thumb in a plane at right angle to the palmar aspect of index finger against the resistance of examiner thumb Peripheral Nerve – Median Main Segmental Supply - T1 ABDUCTOR POLLICIS BREVIS Test – Pt. attempts to touch the little finger with the thumb Peripheral N. – Median Main Segmental Supply – T1 OPPONENS POLLICIS

15. Adductor pollicis T1 ULNAR NERVE The patient attempts to hold a piece of paper between the thumb and the palmar aspect of forefinger.

16. MUSCLES OF HAND & FINGERS Pt. Tries to Adduct the fore finger against resistance Pt. Tries to abduct the fore finger against resistance Peripheral nerve ulnar Main Seg supply T1 IST DORSAL INTEROSSI & IST PALMAR INTROSSI B. Interossi – Pt. attemps to keep the fingers abducted against resistance A. Lumbricals – Pt. Tries to flex the extended fingers at the MCP Joints Median – Lumbical I & II Ulnar – lumbrical III & IV & interossi Main Seg supply C8 T1 LUMBRICAL & INTEROSSI

17. thank you Test – Back of hand is placed on the table & little finger abducted against resistance (sign of ulnar N. lesion) P. N. – Ulnar Mains Segmental Supply – T1 ABDUCTOR DIGITI MINIMI Test – Pt. Flexes the terminal phalanx of the fingers against resistance, the middle phalanx being supported P. N. – Median Ist & IInd Ulnar IIIrd & IVth Main Segmental Supply - C8 FLEXOR DIGITORUM PROFUNDUS Test – Pt. flexes the finger at the proximal inter phalangel joint against resistance (examiners fingers placed on middle phalanx) Peripheral N. – Median Main Segmental Supply – C8 FLEXOR DIGITORUM SUBLIMIS

18. Muscles of the TRUNK EXTENSORS OF THE SPINE SUPPLIED BY ALL SEGMENTS THROUGH POSTERIOR RAMI OF SPINAL NERVES TEST– The patient lies on his face and then attempts to raise his shoulders off the bed.

19. Intercostals T1-T12 Through intercostal nerves Observe the movements of the ribs on expiration and inspiration and the movements of the muscles in the intercostal spaces.

20. Abdominal muscles T5- L1 Intercostal, ilioinguinal and iliohypogastric nerves The patient lies on his back and attempts to raise his head against light resistence. Watch movement of the umbilicus. Beevor’s sign -with paralysis of the lower segment the umbilicus moves upwards but when upper segment is affected, umbilicus is pulled downwards.

21. Ask the patient to sit up in bed from the supine position without the aid of arms. Inability to do so indicates severe weakness of the muscles of abdomen and the hip flexors. Babinski’s rising up sign –in spastic paralysis of the leg the affected limb will rise first, but in hysterical paralysis this does not occur.

22. Diaphragm C3,4,5 Phrenic nerve Simple bedside test- ask the patient to take a deep breath and to count slowly. Most people can easily get to 20 or more with a single breath. Inability of the patient to breathe easily when lying flat  sometimes presents as difficulty sleeping.

23. Hip joint and lower limb

24. Hip flexion L2L3 nerve roots --the femoral nerve ask the patient to lie down and raise each leg separately while the examiner resists. . This tests the iliopsoas muscles

25. Hip extension instruct the patient to press down on the examiner's hand which is placed underneath the patient's thigh. This tests the gluteus maximus Inferior gluteal nerve [l4,L5] Observe the pt standing from a low chair

26. Hip adduction place your hands on the inner thighs of the patient and asking them to bring both legs together. This tests the adductors of the medial thigh. the L2, L3 and L4 nerve roots.

27. Hip abduction place your hands on the outer thighs and asking the patient to move their legs apart. This tests the gluteus maximus and gluteus minimus. Abduction of the hip is mediated by the L4, L5 and S1 nerve roots.

28. Knee flexion hold the knee from the side and applying resistance under the ankle and instructing the patient to pull the lower leg towards their buttock as hard as possible. This tests the hamstrings. L5 and S1 nerve roots via the sciatic nerve.

29. Knee extension place one hand under the knee and the other on top of the lower leg to provide resistance. Ask the patient to "kick out" or extend the lower leg at the knee.This tests the quadriceps muscle. L3 and L4 nerve roots via the femoral nerve.

30. Ankle dorsiflexion Hold the top of the ankle and have the patient pull their foot up towards their face as hard as possible.This tests the muscles in the anterior compartment of the lower leg. L4 and L5 nerve roots via the peroneal nerve Ask the patient to walk on heels

31. Ankle plantarflexion Holding the bottom of the foot, ask the patient to "press down on the gas pedal" as hard as possible. This tests the gastrocnemius and soleus muscles S1 and S2 nerve roots via the tibial nerve. Ask the patient to walk on toes

32. Extension of great toe Ask the patient to move the large toe against the examiner's resistance "up towards the patient's face". The EHL muscle is almost completely innervated by the L5 nerve root.

33. Summary- upper limb Small ms of hand. T1 Finger flexors C8 Triceps Finger extension, elbow extension C7 supinator Elbow flexion (semipronated) C6 Biceps Shoulder abduction, elbow flexion C5 REFLEX MOVEMENTS ROOT

34. Pronator test Ask the patient to hold his arms out in front with his palms facing upwards and to close his eyes tightly. One arm pronates and drifts downwards  indicates weakness on that side . Both arms drift downwards  b/l weakness Arm rises  cerebellar disease Fingers continuously move up and down (pseudoathetosis)- deficit of joint position sense .

35. Lower limb Ankle reflex Hip extension, knee flexion, plantar flexion. S1 Dorsiflexion of foot, inv & eversion of ankle, extn of great toe. L5 Knee reflex Knee extension L3, L4 Hip flexion L1, L2 Reflex Movement Root

36. Thank you