motor assessment

1. Motor Examination

2. • Contents
• Muscle Tone
• Reflex
• Primitive reflex
• Muscle Strength Assessment
• Grip Strength, Pinch Strength
• Voluntary Control Assessment

3. Muscle Tone
• Tone is defined as resistance of muscle to passive stretch or
elongation.
• Perform passive movement of the limb being tested maintain firm
and constant manual contact.
• Normal  Limb moves easily, therapist is able to alter direction and
speed without any resistance
• Hypertonic  Limb feels stiff and resistant to movement (increased
above normal resting levels)
• Hypotonic  Limb feel heavy and unresponsive (decreased below
normal resting levels)
• dystonia impaired or disordered tonicity

4. • Hypertonia :
• Spasticity
• Rigidity
• Dystonia
• Hypotonia-

5. Spasticity Rigidity
Increased muscle tone (hypertonia) Increased muscle tone (hypertonia)
Motor disorder characterized by resistance catch and release,
mid range or end range.
Hypertonic state characterized by resistance throughout
ROM.
Velocity dependent
As speed of passive movement is increased  increase in
resistance to passive movement
Velocity independent
Resistance to passive movement is constant
Lesion of Pyramidal tracts (corticospinal tract) Lesion of extrapyramial system
Only one group of muscles are affected
(In chronic stages both agonist and antagonist are affected
but one group is always stronger)
Both agonist and antagonist muscle have increased tone
(equal variation)

6. Rigidity types :
1. Lead pipe rigidity – constant resistant throughout range
2. Cog wheel rigidity – Alternate letting go & increasing
resistance to movement
3. Decorticate rigidity – trunk and LL in extension & UL in
flexion (corticospinal tract at level of diencephalon
above superior coliculus)
4. Decerebrate rigidity – trunk and limb in full extension
(corticospinal lesion in brainstem between superior
colliculus & vestibular nucleus)
Additional signs include :
 Clonus : Rhythmical contraction of muscle or group of
muscle in response to sudden, passive and sustained
stretching of spastic muscle
Ankle clonus-
Jaw clonus
Wrist clonus
Additional signs include :
 Tremor
 Bradykinesia
 Postural instability

10. • Dystonia :
• Prolonged involuntary movement disorder characterized by twisting repetitive
movements and increased muscle tone
• Hypotonia/flaccidity :
• Decreased or absent muscle tone
• Resistance to passive movement is diminished
• Stretch reflex diminished or absent
• Hyperextensibility of joints is common. & limbs are easily moved(floppy)
• Seen in LMN lesion
• Acute UMN lesion produces temporary hypotonia : known as spinal shock or cerebral
shock
• Which is commonly followed by Typical UMN signs

11. • Comparison should made between upper and lower extremity and
right and left extremities.
• Symmetrical/asymmetrical

12. EXAMINATION OF TONE
• An examination of tone consists of- (1) initial observation of resting posture and
palpation
(2) passive motion testing, and
(3) active motion testing.
• Initial observation- of the patient can reveal abnormal posturing of the limbs or
body. Careful inspection should be made regarding the position of the limbs,
trunk, and head.
• Palpation- of the muscle belly may yield additional information about the resting
state of muscle. Consistency, firmness, and turgor should all be examined.
Hypotonic muscles will feel soft and flabby, whereas hypertonic muscles will feel
taut and harder than normal.
• Passive motion testing reveals information about the responsiveness of muscles
to stretch. Because these responses should be examined in the absence of
voluntary control, the patient is instructed to relax, letting the therapist support
& move the limb

14. • Clonus- a phasic stretch response, is examined using a quick stretch
stimulus that is then maintained
• eg- ankle clonus is tested by sudden dorsiflexion of the foot and
maintaining the foot in dorsiflexion. he presence of a clasp-knife
response should also be noted

15. Clinical rating scale for tone
• 0  No response (Flaccidity)
• 1+  Decreased response (Hypotonia)
• 2+  Normal response
• 3 + Exaggerated response (mild o moderate hypertonia)
• 4+  Sustained response (Severe hypertonia)

16. • If spasticity is present :
• Modified Ashworth Scale
• Tardieu Scale
Special Tests In the lower limbs, spasticity can be examined using the
pendulum test
-the patient is positioned in supine with knees flexed over the end of a table.
-the examiner passively extends the knee fully against gravity and then allows
the leg to drop and swing like a pendulum
-. A normal and hypotonic limb will swing freely for several oscillations. In
patients with quadriceps or hamstring spasticity, the leg is resistant to full
extension and when dropped swings for only a few repetitions. It quickly
returns to the initial dependent starting position

17. Modified Ashworth Scale
0  No increase in muscle tone
1  Slight increase in muscle tone, manifested by a catch and release or
by minimal resistance at the end of the range of motion when the
affected part(s) is moved in flexion or extension
1+  Slight increase in muscle tone, manifested by a catch, followed by
minimal resistance throughout the remainder (less than half) of the
ROM
2  More marked increase in muscle tone through most of the ROM,
but affected part(s) easily moved
3  Considerable increase in muscle tone, passive movement difficult
4  Affected part(s) rigid in flexion or extension

18. Tardieu Scale
• The purpose of these scales is to quantify spasticity by assessing the
muscle's response to different stretch velocities and by determining the
spasticity angle .
• Tardieu scale has been utilized in the following populations: stroke, spinal
cord injury, multiple sclerosis, cerebral palsy, traumatic brain injury,
pediatric hypertonia and central nervous system lesions
• A standard goniometer will be utilized to measure R2 and R1. The patient
will be in testing position according to the muscle to be tested. The
stretching velocity of V1 and V3 will be applied to measure R2 and R1,
respectively. The quality of muscle reaction will be graded at the
stretching velocity of V3 as well. The difference between R2 and R1 will
be the measure of the dynamic component of spasticity.
• Measurements are taken in 3 velocity
• V1 : As slow as possible slower than natural drop of the limb segment under gravity
• V2 : Speed of limb segment falling under gravity
• V3 : As far as possible, faster than the rate of natural drop of the limb segment falling
under gravity
• Responses are recorded as X/Y
• X  0 to 5 rating
• Y  angle at which response noted

19. Spasticity angle-
R1-angle of catch seen at velocity V2 or V3
R2- full range of motion achieved when muscle is at rest & tested at V1
velocity
• 0 :- No resistance throughout the course of passive movement
• 1 :- Slight resistance throughout the course of passive movement, no
clear catch at precise angle
• 2 :- Clear catch at precise angle, interrupting the passive movement
followed by release
• 3 :- Fatigable clonus with less than 10 sec when maintaining the
pressure and appearing at the precise angle
• 4 :- Unfatiguable clonus with more than 10 sec when maintaining the
pressure and appearing at the precise angle
• 5 :- Joint is immovable

20. Reflex Testing
• Superficial Reflexes
• Deep tendon Reflexes

21. • Superficial Reflexes :
• Abdominal reflexes
• Plantar reflexes

22. • Plantar Reflex (S1-S2) :
• Stimulation  stroking the plantar surface of foot on lateral aspect from heel to ball of big
toe
• Normal Response  PF of toes and foot
• Babinski positive  Extension of great toe and fanning of other toes

23. • Abdominal Reflex (T8-T12):
• Stimulation  In supine position slight stroke is applied to abdomen from periphery
towards umbilicus (separately to each 4 quadrant)
• Normal Response  Localized contraction of the stimulated quadrant of the umbilicus
• Abnormal  Absence of muscle contraction under stimulation

25. • Interpretation
• IN muscle disease : Normal / Absent
• In NMJ : Normal
• In PNI : Normal
• UMN : Absent/ Decreased
• Extrapyramidal : Normal/ slightly increased
• Cerebellar : Normal

26. Deep Tendon Reflex
• A reflex is an involuntary, predictable and specific response to a
stimulus dependent on an intact reflex arc.
• Following DTR are checked commonly
• Jaw
• Biceps
• Brachioradialis
• Triceps
• Knee jerk
• Ankle jerk

27. Clinical rating scale for DTR :
• Grade 0  Absent  No visible muscle contraction on
reinforcement
• Grade 1+  Hyporeflexia/diminished Slight reflex with little or no
joint movement.
• Grade 2+  Normal/average  Typical reflex
• Grade 3+  Hyperreflexia/Exaggerated  Brisk reflex with
moderate joint movement
• Grade 4+  Abnormal (hyperreflexia)  Very brisk reflex, abnormal,
clonus

28. • Biceps jerk (C5-C6 musculocutaneous nerve)
• Stimulation  With the arm relaxed and the forearm slight pronated and
midway between flexion and extension, the examiner places thumb on biceps
tendon
• Response contraction of
the biceps muscle with flexion
of the elbow

29. • Triceps Jerk (C7-C8)
• Stimulation  The arm is placed midway between flexion and extension, and may
be rested in the patient's lap or on the examiner's hand tapping the triceps tendon
just above its insertion
• Response  contraction
of the triceps muscle with
extension of the elbow

30. • Brachiradialis reflex (C5-C6)
• Stimulation  Tapping just above the styloid process of the radius with the
forearm in semiflexion and semipronation
• Response  flexion of the elbow, with variable supination

31. The Patellar Reflex (Quadriceps Reflex, Knee Jerk) (L2,3,4)
• Stimulation  Sharp tap over the pattelar tendon
• Response  contraction of the quadriceps femoris muscle, with
resulting extension of the knee

32. • The Achilles Reflex (Ankle Jerk) (S1-S2)
• Stimulation  striking the Achilles tendon just above its insertion on the
calcaneus.
• Response  contraction of the gastrocnemius, soleus causes plantar flexion of
the foot at the ankle

33. Interpretation :
• Muscle pathology : Decreased parallel to reduced muscle strength
• NMJ : Normal to decreased parallel to reduced muscle strength
• Peripheral nerve : Diminished or absent
• Spinal cord : hypoactive at level of lesion and hyperactive below the
level of lesion
• Cortico spinal tract : Hyperactive on contralateral side
• Extrapyramidal : Usually Normal
• Cerebellar : pendular

34. Primitive & tonic reflex
• Primitive and tonic reflexes are present during infancy as a stage in normal
development and become integrated by the CNS at an early age
• Patients who exhibit these reflexes typically present with extensive brain
damage (e.g., stroke, TBI) and other UMN signs
• CLASSIFICATION-
Automatic reflexes
Spinal reflexes
Brain stem reflexes
Midbrain reflexes
Cortical reflexes

40. Spinal cord reflex

42. Sucking reflex
TESTING POSITION: supine lying
STIMULUS: initiates when roof of an infant's mouth is touche the nipple or
finger
RESPONSE: infant will automatically start sucking the nipple or finger>
ONSET: birth(32 weeks of pregnancy)
INTEGRATED: 4 months

45. • Flexor withdrawal
Stimulus- Noxious stimulus (pinprick) to sole of foot. Tested in supine
or sitting position
Response- Toes extend, foot dorsiflexes, entire LE flexes uncontrollably.
Onset: 28 weeks of gestation.
Integrated: 1–2 months

46. Extensor withdrawal

51. ATNR (asymmetric tonic neck reflex)

55. Negative supporting response

60. Cortical reflex
They are highly integrated & complex mechanism which are automatic response to
changes in posture & movement aimed to restore balance

62. Muscle bulk
• Atrophy the loss of muscle bulk (wasting), occurs as a result of the loss of
functional mobility (disuse atrophy), LMN disease (neurogenic atrophy), or
protein-calorie malnutrition
• Disuse atrophy is evident after periods of inactivity, developing in weeks or
months. It is generally widespread and affects antigravity muscles to a
greater extent.
• Neurogenic atrophy accompanies LMN injury (e.g., peripheral nerve injury,
spinal root injury) and occurs rapidly, generally within 2 to 3 weeks. Atrophy
is also accompanied by other signs of LMN injury (e.g., decreased or absent
tone or decreased or absent DTRs, fasciculations, weak or absent voluntary
movement
Examination of Muscle Bulk- the therapist should visually inspect the muscle
symmetry and shapes, comparing and contrasting their size and contour
• Muscles that look flat or concave are indicative of atrophy. Comparisons
should be made between and within limbs. Is the atrophy unilateral or
bilateral?
• Palpation at rest and during muscle contraction is used to determine muscle
tension. Girth measurements or volumetric displacement measures (e.g.,
hands or feet) can be used to confirm visual inspection findings.

63. Muscle Strength Examination
• MMT of b/l UL, LL and trunk
• Performed if VC grading is > or equal to 4
• Grip strength and pinch strength assessment  by dynamometer

65. • In patients with peripheral sensorimotor neuropathy (e.g., chronic diabetic
neuropathy) or acute motor neuropathy (e.g., Guillain-Barré), strength losses
are typically greater in distal segments (i.e., foot and ankle) than proximal
with involvement of more proximal segments as the disease progresses
• Documentation of strength and power changes should include a
determination of the specific muscles and body segments tested and tests
used; the type and degree of changes present (e.g., paresis, paralysis)

66. Voluntary Control Assessment (brunnstrom
approach)
• Criteria for voluntary control assessment
• Presence of spasticity
• Positive babinski’s sign
• Presence of synergy patterns
• Quality of performance in any position is the criteria of scoring i.e. the degree of
isolation
• Mid range of motion is usually selected as it is the most functional range &
easiest for a muscle group to work
• Chosen position must be in antigravity position to assess the muscle power of
function

67. Voluntary control grades
• 0 –no contraction
• 1- flicker of contraction
• 2- half range of motion in pattern
• 3- full range of motion in pattern
• 4- initial half in isolation and latter half in pattern
• 5-full ROM in isolation but goes in pattern on resistance
• 6-full ROM in isolation with resistance