Here in this ppt we have motor system examination in details.. it also include stance & gait...Slides are prepared from dejong's neurology with few pictures from the internet.. hope its helpful..

1. EXAMINATION OF THE MOTOR SYSTEM
DR BISWA RANJAN PATRA
RESIDENT OF MEDICINE
P.G.I.M.E.R & DR RML HOSPITAL
NEW DELHI

2. WHY DO WE DO A MOTOR SYSTEM EXAMINATION
▪ Cardinal symptoms and signs which prompt a motor system examination:
1. Weakness
2. Imbalance
3. In-coordination
4. As a part of CNS examination

3. OUTLINE
• Anatomy
• Inspection and Palpation
• Tone and Power
• Reflexes
• Posture and abnormal movements
• Coordination
• Stance and gait

4. ANATOMY

5. ▪ COMPONENTS
1. CORTICOSPINAL / CORTICOBULBAR
2. EXTRAPYRAMIDAL SYSTEM
3. NEUROMUSCULAR UNIT

6. ORGANIZATION OF MOTOR SYSTEM

7. CORTICOSPINAL AND CORTICOBULBAR
▪ Corticobulbar (corticonuclear) fibers:
▪ Originate in the region of the sensorimotor cortex, where the face is represented.
They pass through the posterior limb of the internal capsule and the middle portion
of the crus cerebri to their targets, the somatic and brachial efferent nuclei in the
brain stem.
▪ Corticospinal tract:
▪ Originates in the remainder of the sensorimotor cortex and other cortical areas. It
follows a similar trajectory through the brain stem and then passes through the
pyramids of the medulla (hence, the name pyramidal tract), decussates, and
descends in the lateral column of the spinal cord.

9. EXTRAPYRAMIDAL SYSTEM
▪ Clinical phenomena of patients with disorders of extrapyramidal system are
different than those with pyramidal.
▪ Principal component is basal ganglia and its connections.

10. BASAL GANGLIA
▪ Components
1. Globus Pallidus
2. Putamen
3. Caudate
4. Substantia Nigra
5. Subthalamic Nucleus

13. FUNCTIONS OF BASAL GANGLIA
▪ Voluntary movement
▪ Initiation of movement
▪ Change from one pattern to other
▪ Programming and correcting movement while in progress (thalamocortical circuts)
▪ Postural control
▪ Righting reflex
▪ Automatic associated movement (walking)
▪ Control of muscle tone
▪ Reticulospinal
▪ Vestibulospinal

14. NEUROMUSCULAR UNIT

15. MUSCLE VOLUME & CONTOUR

16. ▪ Muscle volume and contour may be appraised by inspection, palpation, and
measurement.
▪ INSPECTION- compare symmetric parts, for any flattening, hollowing or bulging of
the muscles masses
- face,shoulder & pelvic girdle, palmar surface of hand, thenar and hypothenar
eminence, interossous muscles
▪ PALPATION- assess muscle bulk, contour & consistency- semielastic and regain their
shape at once when compressed
▪ MEASUREMENTS- made from fixed points and compared bilaterally (10 cm
above/below olecranon, 18cm above, 10 cm below tibial tuberosity)

19. MUSCLE TONE

20. MUSCLE TONE
▪ It is the resistance to passive motion due to inherent attributes of muscles-
viscosity, elasticity, extensibility
▪ Resting muscle tone is greatest in antigravity muscles that maintain the body in
erect posture
▪ It is by interplay by the gamma motor neuron loop in spinal cord segment &
descending influences from higher motor centres
▪ Loss of impulses from the supraspinal pathways that normally inhibit lower reflex
centers usually causes an increase in tone

21. EXAMINATION OF TONE
UPPER LIMBS
▪ Undulating flexion-extension movement at wrist & elbow joint
▪ Supination pronation of forearm- PRONATOR CATCH- in spaticity
▪ Hand dropping test- look for checking movements
LOWER LIMBS
▪ Rolling of limbs- floppy side to side movements / ankle & foot move in a piece
▪ Passive flexion, extension of hip, knee & ankle
▪ Brisk flexion of knee joint upwards- heel slides / leg rises all in one
▪ Leg dropping test- normal checking movements

22. ▪ PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that
progressively diminishes in range and usually disappears after six or seven
oscillations
▪ In extrapyramidal rigidity, there is a decrease in swing time but usually no
qualitative change in the response.
▪ In spasticity, there may be little or no decrease in swing time, but the movements
are jerky and irregular- zigzag pattern
▪ HEAD DROPPING TEST- Normally head drops rapidily into examiners hand.
in extrapyramidal rigidity- delayed/slow gentle dropping, rigidity affecting flexors

23. ▪ SPACTICITY- greater in one group of muscle than other (not uniform throughout the
range of movement), varies with the speed of movement (velocity dependent)
CLASP-KNIFE, PRONATER CATCH (spacticity of pronator muscles)
▪ LEAD-PIPE RIGIDITY/ PLASTIC- equal resistance in both agonist & antagonist,
independent of the rate of movement
▪ COGWHEEL RIGIDITY- jerky quality to hypertonicity, the jerky quality of the
resistance may be due to tremor superimposed on lead-pipe rigidity

24. MOTOR STRENGTH AND POWER

25. ▪ Strength evaluation requires:-
-judgment of force exerted in either initiating or resisting movement (MAJOR
CRITERIA)
-observation/ palpation of either the contraction of the muscle belly or
movements of its tendon
▪ Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant
inter & intraexaminer variability
▪ For more quantitative determinations various dynamometers, myometers, and
ergometers are available

26. ▪ The strength examination assesses primarily voluntary, or active, muscle
contraction rather than reflex contraction.
▪ Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
▪ In most disease processes, both are equally affected, and the two methods can be
used interchangeably

27. Misleads
 Extrapyramidal disease- rigidity/ bradykinesia
 Hyperkinesia / ataxia
 Speed – hypo/hyperthyroidism, depression
 Motor impersistence- apraxia
 Loss/impairment of movement- pain, swelling, spasm, fractures, dislocations,
ankylosis, contractures
▪ Passive movements to assess range of motion are necessary before strength
evaluation

28. ▪ In COMA, assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides.
▪ HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the
supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released

29. STRENGTH SCALES

30. ▪ Variability in muscle power, size, gender, body built affect examiners as well as
patients
▪ STRENGTH MISMATCH
▪ General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
▪ The small hand muscles are best examined by matching them against the
examiner’s like muscle
▪ The gastrocnemius muscles are normally so powerful it is virtually useless to
examine them using hand and arm strength

31. PATTERN OF WEAKNESS
▪ Generalized weakness- involves both sides of the body, more or less symmetrically,
truly generalized weakness involve bulbar motor functions
▪ Lesion can be in spinal cord/peripheral nerves/Nm junction/myopathy
▪ Spinal cord disease involve muscles preferentially innervated by CST, neuropathy
(distal>proximal) , myopathy & Nm junction (proximal>distal)
▪ Focal weakness- hemiparesis, monoparesis, diplegia (weakness of like parts
bilaterally)

33. NONORGANIC WEAKNESS
▪ HOOVER (AUTOMATIC WALKING) SIGN
Hoover’s sign is absence of the expected associated movement
- flexion/extension counter movement (hip)
- adduction/adduction (hip)
- abduction/abduction (hip)
▪ Muscle tone is normal/ decreased & usually vary from time to time

34. UMN v/s LMN
▪ Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
▪ UMN Lesions- Pyramidal lesions disrupt movements; any muscle that participates
in the movement will be weakened, regardless of its specific lower motor neuron
innervation
▪ In contrast, LMN lesions involve muscles innervated by a specific structure, such as
a nerve root or peripheral nerve

35. MUSCLES OF THE NECK
▪ Principal neck movements are flexion, extension (retraction), rotation (turning), and
lateral bending (tilting, abduction)
▪ Except for the sternocleidomastoid (SCM) and trapezius, it is not possible to
examine them individually
▪ The spinal accessory nerve, along with the second, third, and fourth cervical
segments, supplies both muscles
▪ SCM is a flexor and rotator of the head and neck; the trapezius retracts the neck and
draws it to one side.

39. ▪ The neck flexion test consists of measuring the time the supine patient can keep
the head raised with the chin on the chest
▪ Most patients can keep their head in this position for at least 1 minute
▪ Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor
or extensor weakness

41. THE SCAPULA
▪ Elevate- upper fibers of trapezius, levator scapulae
▪ Depression- lower fibers of trapezius, pectoralis minor, subclavius
▪ Retraction- rhomboids, middle fibers of trapezius
▪ Protraction- serratius anterior, pectoralis minor
▪ Examination of the rhomboids is important in the differentiation of C5
radiculopathy from upper trunk brachial plexopathy

42. Dorsal scapular nerve C4/5
Retraction of scapula
The rhomboids can be tested by
having the patient, with hand on
hip, retract the shoulder against
the examiner’s attempt to push
the elbow forward
RHOMBOIDS

43. Cranial XI C2,3,4
Upper fibers- shrug
Middle fibers-retract
On retraction of the shoulder
against resistance, the middle
fibers of the muscle can be seen
and palpated
TRAPEZIUS

44. Long thoracic nerve- C5,7
Protraction of scapula
The patient pushes against a wall
with his arms extended horizontally
in front of him; normally, the
medial border of the scapula
remains close to the thoracic wall.
SERRATIUS
ANTERIOR

45. WINGING OF SCAPULA
▪ Weakness of either the serratus anterior or the trapezius
▪ Trapezius retracts during abduction of the arm, serratus anterior functions during
forward elevation
▪ Trapezius winging- patient bend forward at the waist so the upper body is parallel to
the ground, then raise the arms to the sides, as if beginning a swan dive
▪ Serratus anterior- trying to elevate the arm in front/protract scapula against
resitance
▪ Muscular dystrophies- facioscapulohumeral (FSH) dystrophy, there is often
weakness of all the shoulder girdle muscles, with prominent scapular winging,
typically bilateral

46. For demonstrating winging of
scapula due to weakness in
trapezius
SWAN DIVE
POSTURE

47. THE GLENOHUMERAL JOINT
▪ Abduct- supraspinatus, deltoid, trapezius, serratus anterior
▪ Adduct- pectoralis major, latismus dorsi
▪ Flexion- pectoralis major, anterior fibres of deltoid
▪ Extension-posterior fibres of deltoid, lattismus dorsi
▪ Internal rotation- subscapularis, teres major
▪ External rotation- infraspinatus, teres minor

48. Suprascapular nerve C5,6
Contraction of the muscle fibers
can be felt during early stages of
abduction of the arm
SUPRASPINATUS

49. Axilliary nerve C5,6
Abduction 15 to 90 degrees
The patient attempts to abduct his
arm against resistance; the
contracting deltoid can be seen and
palpated.
DELTOID

50. Lateral & medial pectoral nerve
C5-T1
Contraction of the muscle can be
seen and felt during attempts to
adduct the arm against resistance
PECTORALIS
MAJOR

51. Thoracodorsal nerve, C6-8
Adducts, extends, medially rotates
shoulder
On adduction of the horizontally
and laterally abducted arm against
resistance, the contracting muscle
fibers can be seen and palpated.
LATTISMUS DORSI

52. THE ELBOW
▪ Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
▪ Extension- triceps,anconeus
▪ Supination- Biceps (strongest when forearm is flexed & pronated)
Supinator (acts through all degrees of flexion & supination)
Brachioradialis (forearm extended & pronated)
▪ Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed & supinated)

53. Musculocutaneous nerve C5,6
Flexion, supination
On attempts to flex the forearm
against resistance, the contracting
biceps muscle can be seen and
palpated
BICEPS BRACHII

54. Radial nerve C5,6
Flexion, supinator, pronator
On flexion of the semipronated
forearm (thumb up) against
resistance, the contracting muscle
can be seen and palpated.
BRACHIORADIALIS

55. Radial nerve C6,7,8
Extension of elbow joint
On attempts to extend the partially
flexed forearm against resistance,
contraction of the triceps can be
seen and palpated.
TRICEPS

56. A. On attempts to supinate the extended forearm against resistance, the contracting brachioradialis
can be seen & Palpated
B. supinate the flexed forearm against resistance, the contracting biceps can be seen & palpated
C. On pronation of the forearm against resistance, contraction of the Pronator Teres can be seen
and palpated.

57. THE WRIST
▪ Flexion- FCR, FCU
▪ Extension- ECRL,ECRB,ECU
▪ Adduction (ulnar flexion)- ECU
▪ Abduction (radial flexion)- ECRL,ECRB

58. FCR,FCU palpated ECRL,ECU palpated

59. FINGERS
▪ Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei & lumbricals flex MCP and extend IP joints
GRIP POWER
▪ Making a fist requires flexion of the fingers at all joints (MCP,IP,Thumb)
▪ It is not very useful in assessing upper extremity motor function
▪ Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST
innervated and are not likely to be weak with a mild CST lesion

60. FINGER FLEXORS
FDP-The patient resists attempts to extend the
distal phalanges while the middle phalanges
are fixed.
FDS- The patient resists attempts to straighten
the fingers at the first Interphalangeal (IP) joint

61. EDC- With hand outstretched and IP joints held in extension, the patient resists the examiner’s
attempt to flex the fingers at the (MCP) joints
Lumbricals & Interossei- Extension of the middle and distal phalanges, the patient attempts to
extend the fingers against resistance while the MCP joints are fixed

62. THUMB MUSCLE
▪ Forearm muscle- APL- abduct thumb & extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
▪ Thenar muscle- APB,OP,FLB
Palmar abduction by APL & APB muscles
Radial abduction by APL & EPB muscles
Opposition- OP,ODM

63. FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixed
EPL- The patient attempts to resist passive flexion of the thumb at the IP joint; the tendon can be seen and
palpated.
EPB-The patient attempts to resist passive flexion of the thumb at the MCP joint; the tendon can be seen and
palpated.

64. Radial abduction of the thumb.
The patient attempts to abduct the thumb in
the same plane as that of the palm; the
tendon of the APL can be seen and palpated
Palmar abduction of the thumb. The patient
attempts, against resistance, to bring the
thumb to a point vertically above its original
position.

65. OP- The patient attempts, against resistance, to touch the tip of the little finger with the thumb
ODM-The patient attempts to move the extended little finger in front of the other fingers and toward the
thumb
Palmar interossei - Adduction of the fingers. The patient attempts to adduct the fingers against resistance

66. MUSCLES OF ABDOMEN
▪ Rectus abdominis, pyramidalis, transverse abdominis & oblique (external & internal)
▪ BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad
when the patient raises the head or attempts a sit-up

67. T7-T12 intercostal nerves
The recumbent patient attempts to
raise his head against resistance
Flexors of spine also involved
ABDOMINAL
MUSCLES

68. THE HIP JOINT
▪ Flexors- iliopsoas, rectus femoris, Sartorius, tensor fascia lata
▪ Extensors- gluteus maximus
▪ Abductors- gluteus medius, minimus, TFL
▪ Adductors- adductor magnus,longus, brevis
▪ Internal/medial rotator- hip abductor muscles- gluteus medius, minimus, TFL
▪ External/lateral rotator- gluteus maximus, obturator internus & externus

71. Femoral nerve L2-4
The patient attempts to flex the thigh
against resistance; the knee is flexed
and the leg rests on the examiner’s
arm
With legs fixed they flex the trunk and
pelvis forward
Normal hip flexors cannot be
overcome by an examiner using hand
and arm strength from an arm’s length
away
LEG DRIFT- U/L CST lesion- flexed hip,
extended knee- 45 degree, drift
downward
FLEXORS OF THIGH

72. Inferior gluteal nerve L5-S2
The patient, lying prone with the leg
flexed at the knee, attempts to
extend the thigh against resistance;
contraction of the gluteus maximus
and other extensors can be seen and
palpated
Having the knee flexed minimizes any
contribution from the hamstrings
Lying in side & extending hip/ stand
upright from a stooped position
GOWERS MANEUVER- using his
hands to “climb up the legs”
Seen in muscular dystrophies with
marked weakness of hip extensors
EXTENSORS OF
THIGH

73. Superior gluteal nerve L4-S1
TRENDELENBURG’S SIGN
Exacerbated pelvic swing during
the stance phase as the pelvis on
the side of the swing leg drops
downwards
Bilateral- pelvic waddle/
WADDLING GAIT
ABDUCTION OF
THIGH AT HIP

75. Obturator nerve. L2-4
A.Magnus- Sciatic N carrying L4/5
The recumbent patient attempts
to adduct the extended leg against
resistance; contraction of the
adductor muscles can be seen and
palpated
ADDUCTORS OF
THIGH AT THE HIP

76. Superior gluteal nerve L4-S1
The patient, lying prone with the
leg flexed at the knee, attempts to
carry the foot laterally against
resistance, thus rotating the thigh
medially
Preferentially CST innervated
muscle
EXTERNAL/LATERAL ROTATION
G Maximus inferior gluteal nerve
Rotate medially with flexed knee
INTERNAL/MEDIAL
ROTATION

77. THE KNEE JOINT
▪ Flexion- hamstring muscles (biceps femoris, semimembranosus, semitendinosus)
The hamstrings also act as powerful hip extensors
▪ Extensors- Quadriceps femoris
(rectus femoris, vastus lateralis,medialis,intermedius)

78. Sciatic nerve L5,S1 S2
The prone patient attempts to
maintain flexion of the leg while
the examiner attempts to extend it;
the tendon of the biceps femoris
can be palpated laterally and the
tendons of the semimembranosus
and semitendinosus, medially.
LEG DRIFT /LEG SIGN OF BARRE
Prone, both knee flexed at 45
degree from horizontal, with CST
lesion involved leg will sink
FLEXION AT THE
KNEE

79. Femoral nerve L2-4
The supine patient attempts to extend
the leg at the knee against resistance;
contraction of the quadriceps femoris
can be seen and palpated.
EXTENSION AT
KNEE

80. The quadriceps is very powerful.
It is capable of generating as much as
1,000 pounds of force—three times
more than the hamstrings
The quadriceps is so powerful it is
nearly impossible to overcome in the
normal adolescent or adult except by
taking extreme mechanical advantage.
A sometimes useful technique for
testing knee extension is the
“BARKEEPER’S HOLD,” a hold usually
applied to the elbow to controlunruly
patrons

81. THE ANKLE JOINT
▪ Plantarflexion- gastrocnemius, soleus
▪ Dorsiflexion/extension- tibialis anterior EDL, EHL
▪ Inversion- tibialis posterior (platarflexed), tibialis anterior (dorsiflexed)
▪ Eversion- peronei longus, brevis, tertius, EDL

82. Tibial nerve S1-S2
The patient attempts to plantarflex
the foot at the ankle joint against
resistance; contraction of the
gastrocnemius and associated muscles
can be seen and palpated.
Very powerful muscles, mechanical
advantage need to be taken with long
lever
Patient stand on tiptoe
PLANTARFLEXION
OF THE FOOT

83. Deep peroneal nerve L4-L5
The patient attempts to dorsiflex
the foot against resistance;
contraction of the tibialis anterior
can be seen and palpated.
Patient standing on heels raising
toe
STEPPAGE GAIT exaggerated
flexion at hip & knee to clear
ground
Audible double slap
Also in sensory ataxia
DERSIFLEXION/
EXTENSION OF
THE FOOT

84. Tibialis posterior. Tibial nerve L5-S1
The patient attempts to raise the
inner border of the foot against
resistance; the tendon of the tibialis
posterior can be seen and palpated
just behind the medial malleolus.
INVERSION OF THE
FOOT

85. P longus, brevis- superficial peroneal
nerve L5L5S1
P tertius- deep peroneal nerve
The patient attempts to raise the
outer border of the foot against
resistance; the tendons of the
peronei longus and brevis can be
seen and palpated just above and
behind the lateral malleolus.
EVERSION OF THE
FOOT

86. MUSCLES OF FOOT & TOES
▪ The function of individual foot and toe muscles is not as clearly defined as in the
hand
▪ Extension (dorsiflexion)- EDL, EDB, EHL, EHB
▪ Flexion (plantarflexion)

87. Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes
against resistance, the tendons of
the extensors digitorum and
hallucis longus and the belly of the
extensor digitorum brevis can be
seen and palpated.
DORSIFLEXION OF
TOES

88. PRONATOR DRIFT (BARRE’S SIGN)
▪ In mild CST lesion with normal strength
▪ Upper extremity outstretched to front, palms up, eyes closed, hold for 20-30
seconds
▪ Normally palm flat,elbow straight, if any deviation its similar bilaterally
▪ Slight pronation, without downward drift, of the dominant arm (pseudodrift) is not
abnormal
▪ In mild CST lesion- pronation of hand, flexion of the elbow (due to weakness of CST
innervated muscles i.e extensors,supinators abductors)
▪ Similarly leg drift

89. With mild drift, there is slight pronation of the hand and slight flexion of the elbow on the abnormal
side.
With more severe drift, there is more prominent pronation and obvious flexion of the elbow, and there
may be downward drift of the entire arm

90. ▪ Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
▪ Cerebellar disease may cause drift to some degree, but the movement is outward
and usually slightly upward.
▪ In parietal lobe lesions, there may be “updrift,” with the involved arm rising
overhead without the patient’s awareness
▪ Other useful maneuvers include examination of forearm roll, finger roll, and rapid
alternating movements
▪ Thumb rolling was more sensitive (88%) than pronator drift (47%), forearm rolling
(65%), or index finger rolling (65%)

91. UPDRIFT due to a parietal lobe lesion with loss
of position sense
ARM ROLL- the involved extremity tends to
have a lesser excursion, abnormal extremity
remain relatively fixed (‘’posted‘’)

92. REFLEXES

93. DTR/MSR (MUSCLE STRETCH REFLEX)
▪ A reflex is an involuntary response to a sensory stimulus
▪ When a normal muscle is passively stretched, its fibres resist the stretch by
contracting
▪ Stretch reflex are important in maintaining erect posture

94. GRADES OF DTRS
▪ 0 = absent;
▪ 1+ (or +) = present but diminished
▪ 2+ (or ++) = normal
▪ 3+ (or +++) = increased but not necessarily to a pathologic degree (fast
normal/unsustained clonus)
▪ 4+ (or ++++) = markedly hyperactive, pathologic, often with extrabeats or
accompanying sustained clonus

95. •A technique involving isometric
contraction of other muscles for up to
10 seconds that may increase reflex
activity.
•Tell the patient to pull just before
you strike the tendon
REINFORCEMENT

96. •The patient's arm should be
partially flexed at the elbow with
palm down.
• Place your thumb or finger
firmly on the biceps tendon.
Observe flexion at the elbow,
and watch for and feel the
contraction of the biceps
muscle.
EXAGGERATED- spread of
reflexogenic area
accompanying flexion of wrist,
fingers & adduction of thumb
BICEPS REFLEX
(C5,C6)

97. The patient may be sitting or
supine.
The arm is placed midway
between flexion and extension
and may be rested
Strike the triceps tendon above
its insertion to olecranon
process
•Watch for contraction of the
triceps muscle and extension at
the elbow.
INVERTED TRICEPS JERK
Flexion of elbow due to damage to
afferent arc of triceps reflex
TRICEPS REFLEX
(C6,C7)

98. •The patient's hand should rest on the
abdomen or the lap, with the forearm
partly pronated.
•Strike the radius with the point or flat
edge of the reflex hammer, about 1 to 2
inches above the wrist.
•Watch for flexion of elbow with variable
supination
•EXAGGERATED associated flexion of
wrist and fingers with adduction of
forearm
•INVERTED SUPINATOR REFLEX
•Afferent limb impaired
•Twitch of the flexors of the hand and
fingers without flexion and supination of
the elbow
BRACHIORADIALIS/
SUPINATOR REFLEX (C5,C6)

99. •The patient may be either sitting or
lying down as long as the knee is
flexed.
•Briskly tap the patellar tendon just
below the patella.
•Note contraction of the quadriceps
with extension at the knee.
•WESTPHAL SIGN - Absence of
patellar reflex
•INVERTED PATELLAR REFLEX
•Tapping causes contraction of
hamstrings and flexion of knee
•Lesion in efferent limb
KNEE REFLEX
(L2,3,4)

101. •If the patient is sitting, dorsiflex
the foot at the ankle. Persuade
the patient to relax.
•Strike the Achilles tendon.
•Watch and feel for plantar
flexion at the ankle. Note also
the speed of relaxation after
muscular contraction.
ANKLE REFLEX
(PRIMARILY S1)

103. SUPERFICIAL SPINAL REFLEXES
How elicited

104. •Lightly but briskly stroke each
side of the abdomen, above (T8,
T9, T10) and below (T10, T11,
T12) the umbilicus.
•Note the contraction of the
abdominal muscles and
deviation of the umbilicus
toward the stimulus
ABDOMINAL REFLEX

105. •With an object such as a key or the
wooden end of an applicator stick
•Knees must be extended
•Stroke the lateral aspect of the sole (S1/
sural nerve sensory disribution ) from the
heel to the ball of the foot at deliberate
pace
•Usually stopping at MTP joint
•If no response stimulus should continue
along the metatarsal pad from the little toe
medially stopping short of base of the great
toe
Far medial stimulation may actually elicit a
plantar grasp response, causing the toes to
flex strongly
•Note movement of the big toe, normally
plantar flexion with flexion of small toes
THE PLANTAR
REFLEX (L5,S1)

106. PATHOLOGICAL REFLEXES
▪ Pathologic reflexes are responses not generally found in the normal individual
▪ Many are exaggerations and perversions of normal muscle stretch and superficial
reflexes.
-Spread of reflex results in the recruitment into the movement of muscles not
normally involved, classified as “associated movements,”
▪ Some are related to postural reflexes or primitive defence reflexes that are
normally suppressed by cerebral inhibition
▪ Responses normally seen in the immature nervous system of infancy, then
disappear only to reemerge later in the presence of disease
▪ Most are seen in CST lesions/ frontal lobe disease

107. PATHOLOGICAL REFLEXES OF LOWER LIMBS
▪ More constant, more easily elicited, more reliable, and more clinically relevant than
those in the upper limbs
▪ Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes

108. BABINSKI SIGN
▪ Babinski reflex is part of primitive flexion reflex (withdrawl reflex) & is normally
present in infancy
▪ It is the pathological variant of the plantar reflex
▪ Babinski response: Instead of the normal flexor response, dorsiflexion of the great
toe precedes all other movement. This is followed by spreading and extension of
the other toes (fanning/abduction), by marked dorsiflexion of the ankle, and by
flexion withdrawal of the hip and knee. It is pathognomonic of an UMN lesion
(TRIPLE FLEXION RESPONSE)
▪ BRISSAUD’S REFLEX- contraction of the tensor fascia lata causing slight internal
rotation at the hip and more rarely abduction of the hip
▪ The Brissaud reflex may be useful in the rare patient whose great toe is missing
▪ The response may be bilateral and is then called the crossed flexor reflex

110. ▪ The Chaddock sign is elicited by
stimulating the lateral aspect of the
foot, not the sole, beginning about
under the lateral malleolus near the
junction of the dorsal and plantar skin,
drawing the stimulus from the heel
forward to the small toe
▪ It produces less withdrawal than
plantar stimulation
▪ Oppenheim sign is usually elicited by
dragging the knuckles heavily down
the anteromedial surface of the tibia
from the infrapatellar region to the
ankle

111. ▪ Voluntary withdrawal rarely causes dorsiflexion of the ankle, and there is usually
plantar flexion of the toes (reflex v/s voluntary withdrawl)
▪ Occasionally, withdrawal makes it impossible to be certain whether the toe was
truly extensor or not (equivocal plantar responses)
▪ Some patients have no elicitable plantar response, in which case the plantars are
said to be mute or silent
▪ Toe extension may occasionally fail to occur because of disruption of the lower
motor neuron innervation to the EHL (e.g., radiculopathy, peroneal nerve palsy,
peripheral neuropathy, amyotrophic lateral sclerosis [ALS])
▪ With pes cavus and high-arched feet, the response is difficult to evaluate because of
fixed dorsiflexion of the toe

112. PATHOLOGICAL REFLEX OF UPPER EXTREMITIES
▪ They are less constant, more difficult to elicit, and usually less significant
diagnostically than those found in the lower extremities
▪ They primarily fall into two categories:
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses
occur only with lesions above the C5 or C6 segment of the cervical spinal cord

113. FRONTAL RELEASE SIGNS
▪ Normally present after birth and in infancy, disappear after the maturation of CST
▪ GRASP/FORCED GRASPING REFLEX- stimulation of skin of palmar surface between
thumb & forefinger leads to involuntary flexor response of the fingers and hand
▪ PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles
causing wrinkling of the skin of the chin with slight retraction in response to
scratching or stroking the palm of the ipsilateral hand (thenar eminence)
▪ SNOUT- is puckering and protrusion of the lips in response to pressing firmly
backward on the philtrum of the upper lip
▪ SUCK- stimulation of the perioral region is followed by sucking movements of the
lips, tongue, and jaw
▪ ROOTING- when the lips, mouth, and even head deviate toward a tactile stimulus
delivered beside the mouth/cheek

114. HOFFMANN & TROMNER SIGN (Pathological Wartenberg)
Wrist dorsiflexed fingers partially flexed, hold partially extended middle finger and give fick to nail
of middle finger.
Response- flexion & adduction of the thumb with flexion of index finger sometimes flexion of other
fingers as well

115. CLONUS
▪ Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
▪ Occurs at ankle, knee, wrist
▪ Unsustained (transient, exhaustible, or abortive) symmetric ankle clonus may occur
in normal individuals with physiologically fast DTRs.
▪ Sustained clonus is never normal
▪ MECHANISM- alternating stretch reflexes (muscle spindle/ Golgi tendon,
agonist/antagonist)

116. Knee ankle moderate flexion, quick
dorsiflexion and maintain slight
pressure
Response- rhythmic alternating
flexions and extensions of the ankle
PATELLAR- leg extended, relaxed.
Downward thrust, rhythmic up-down
movements
WRIST/FINGERS- sudden passive
extension of wrist or fingers
ANKLE CLONUS

117. ABNORMAL MOVEMENTS

119. EXAMINATION
• Observe casually during history:
– Any involuntary movements and their distribution
– Blink frequency
– Excessive sighing
• Cognitive assessment
orthostatic hypotension
• Gait,
• Eye movement (range & speed)
• Tone, power, coordination, plantars

120. OBSERVATION
• Rhythmic vs. arrhythmic
• Sustained vs. nonsustained
• Paroxysmal vs. Nonparoxysmal
• Slow vs. fast
• Amplitude
At rest vs. action
• Patterned vs. non-patterned
• Combination of varieties of movements
Supressibility

121. RHYTHMIC
• Tremor
• Dystonic tremor
• Dystonic myorhythmia
• Myoclonus (segmental)
• Myoclonus (oscillatory)
• Moving toes/fingers
• Periodic movements of sleep
• Tardive dyskinesia
ARRTHYMIC
• Akathitic movements
• Athetosis
• Ballism
• Chorea
• Dystonia
• Hemifacial spasm
• Hyperekplexia
• Arrhythmic myoclonus
• Tics

122. PAROXYSOMAL
• Tics
• PKD
• Sterotypies
• Akathic movements
• Moving toes
• Myorhythmia
CONTIGOUS
• Abdominal dyskinesias
• Athetosis
• Tremors
• Dystonic postures
• Myoclonus, rhythmic
• Myokymia
• Tic status

123. TREMORS
• An oscillatory, typically rhythmic and
regular movement that affects one or
more body parts
• Produced by rhythmic alternating or
simultaneous contractions of agonists
and antagonists
• Distinction between rest, postural,
action or with intention or task
specific
Better appreciated by placing a sheet of
paper on the outstreched finger
Alcohol,nicotine,caffeine,amphetamines,
ephedrine
Enhanced PT- hyperthyroidism

124. ASTERIXIS (NEGATIVE
MYOCLONUS)
Inability to sustain normal muscle tone
In metabolic encephalopathy, hepatic
The lapse in postural tone may cause
the hands to suddenly flop downward,
then quickly recover, causing a slow and
irregular flapping motion
FOOTFLAP- inability to keep the foot
dorsiflexed
Unilateral asterixis occur in focal brain
lesion involving contralateral thalamus

125. TICS
Quick irregular but repetitive movements
UNVOLUNTARY- abnormal movement, the
patient has some degree of awareness &
movement is in response to the urge of
some compelling inner force
akathisia, restlessleg

126. HEMIFACIAL SPASM
(HFS)
Involuntary twitching/ contraction of
the facial muscles on one side of the
face
Injury to facial nerve, tumor or blood
vessel compressing the facial nerve,
bells palsy
Stimulation of facial nerve causing it to
misfire making facial muscle contraction
MC cause AICA compressing at the
origin in brainstem

127. CHOREA (GR. DANCE)
characterized by involuntary, irregular, purposeless,
random, and nonrhythmic hyperkinesias
movements are spontaneous, abrupt, brief, rapid,
jerky, and unsustained
Individual movements are discrete, but they are
variable in type and location, causing an irregular
pattern of chaotic, multiform, constantly changing
movements that seem to flow from one body part
to another
Present at rest increase with activity/emotion
One extremity/ hemichorea/ generalised
Piano playing movements/ MILKMAID GRIP
MOTOR IMPERSISTENCE

128. ATHETOSIS (WITHOUT
FIXED POSITION)
Slower, more sustained, and larger in
amplitude than those in chorea
Involuntary, irregular, coarse, somewhat
rhythmic, and writhing or squirming in
character
Characterized by any combination of
flexion, extension, abduction, pronation,
and supination, often alternating and in
varying degrees
Athetosis – chorea overlap

129. DYSTONIA
Spontaneous, involuntary, sustained
muscle contractions that force the
affected parts of the body into
abnormal movements or postures,
sometimes with contraction of agonists
and antagonists

130. HEMIBALISMUS
Wild flinging ballistic movements (rapid
& forceful) usually unilateral
Can be
BIBALLISMUS/PARABALLISMUS/
MONOBALLISMUS
Lesions in contralateral basal ganglia
(subthalamic nuclei)
Disinhibition of the motor thalamus and
the cortex
Severe hemichorea v/s hemiballismus

131. FASICULATIONS
Fasciculations are fine, rapid, flickering
or vermicular twitching movements due
to contraction of a bundle, or fasciculus,
of muscle fibres
Seen in MND, other LMN lesions-
radiculopathy, peripheral neuropathy,
chronic deenervating process
Also seen by the administration of
cholinergic drugs (eg.pyridostigmine)

132. COORDINATION

133. CLINICAL MANIFESTATION OF CEREBELLAR
DYSFUNCTION
▪ Dyssynergia- decomposition of movements
▪ Dysmetria- hypermetria, hypometria- past ponting
▪ Agonist – Antagonist incoordination – dysdiadochokinesia, loss of checking
movements , rebound phenomenon
▪ Tremor – intention tremors
▪ Hypotonia – pendular knee jerks
▪ Dysarthria – scanning speech
▪ Nystagmus
▪ Posture & gait- deviation/ swaying , broad based gait

134. FINGER–TO-NOSE TEST/ FINGER-NOSE-FINGER TEST
THINGS TO LOOK FOR- INTENTION TREMOR, DYSMETRIA, DYSSYNERGIA, ATAXIA

135. the patient is asked to place the heel of one
foot on the opposite knee, tap it up and
down on the knee several times, push the
point of the heel (not the instep) along the
shin in a straight line to the great toe, and
then bring it back to the knee.
The patient with cerebellar disease is likely
to raise the foot too high, flex the knee too
much, and place the heel down above the
knee.
The excursions along the shin are jerky and
unsteady.
SENSORY ATAXIA- difficulty locating the
knee with the heel, groping around for it;
there is difficulty keeping the heel on the
shin, and it may slip off to either side while
sliding down the shin
HEEL- SHIN TEST

136. RAPIDLY ALTERNATING MOVEMENTS
▪ Patient is asked to alternatively supinate & pronate his hands/ alternate opening &
closing of fist, touching tip of his thumb with the tip of each finger rapidly in
sequence
▪ Any movement involving reciprocal innervation and alternate action of agonists and
antagonists can be used
▪ Due to impairment of the reciprocal relationship between agonist and antagonist
one movement cannot be followed quickly by its opposite movements

137. IMPAIRED CHECK & REBOUND PHENOMENON
▪ Impairment of the reciprocal relationship between agonist and antagonist
▪ Absence of REBOUND PHENOMENON/ IMPAIRED CHECKING is seen

138. DEVIATION & PAST POINTING
▪ In labyrinthine disease or with a cerebellar hemispheric lesion, the arm will deviate
to the involved side on the return track, more so with the eyes closed
▪ This deviation is called PAST PONTING
▪ The pattern of deviation is different in vestibular as opposed to cerebellar past
pointing
▪ In vestibular disease, past pointing occurs with both upper extremities toward the
involved side; in unilateral cerebellar disease, past pointing occurs toward the side
of the lesion, but only in the ipsilateral arm.

139. CEREBELLAR DRIFT
▪ Cerebellar lesion may also cause a drift of the outstretched upper extremities
▪ With cerebellar drift, the arm drifts mainly outward, either at the same level,
rising, or less often sinking

140. STATION & GAIT

141. ROMBERG SIGN
▪ When proprioception is disturbed, the patient may be able to stand with eyes open
but sways or falls with eyes closed
▪ The Romberg sign is used primarily as a test of proprioceptive, not cerebellar,
function

142. EXAMINATION OF GAIT
▪ Width of gait- normal 2 inches between two medial malleoli during the stride phase
▪ Forefoot clearance
▪ Stride length- short in extrapyramidal disease
▪ Movement of hip- excessive-myopathy, tilting- trendelenburg
▪ Tandem walking
▪ Turning

143. HEMIPLEGIC GAIT

144. FESTINATING GAIT

145. CEREBELLAR/ ATAXIC GAIT

146. STAMPING/ STOMPING GAIT

147. DIPLEGIC / CEREBRAL PALSY GAIT

148. MYOPATHIC / WADDLING GAIT

149. STEEEPAGE GAIT