This document summarizes the steps for performing a thorough motor system examination. It outlines how to inspect muscles for wasting, deformities, involuntary movements, and trophic changes. It describes how to assess muscle tone, power, coordination, reflexes, and gait. Abnormal findings are defined, including pathological reflexes like Babinski's sign. The exam involves a full evaluation of muscle and nerve function in the upper and lower limbs as well as the trunk.

1. neurology
Motor system Examination
Dr mohamed rizk khodair
lecturer of neurology
October 6 university
Mohamedrizk.med@edu.edu.eg
‫والجراحة‬ ‫الطب‬ ‫كلية‬

2. The motor system evaluation is divided into the following
Inspection :
Body positioning
Muscle waste ( wasting or hypertrophy )
Involuntary movements, fasciculation .
Skeletal deformities
Trophic changes

3. Body positioning :

4. Muscle wasting
Distribution :
Focal or generalized (proximal or distal)
Unilateral or bilateral
Symmetrical or not

5. Muscle wasting
pseudo hypertrophy

6. Skeletal deformities
Look for skeletal deformities : pes cavus , scoliosis

7. Muscle inspections
Fasciculation : examine the bulky muscle
Trophic changes

8. Muscle inspections
abnormal movements
• Distribution
• Rest , postural or action
• Frequency
• Amplitude
• Rhythmic or not
• What increase or decrease them

9. Assessment of muscle tone
A: upper limbs :
Shoulder : Gower’s method
Elbow : passive flexion and extension
Wrist : shaking , passive flexion and extension
B: lower limbs :
Hip : rolling
Knee : hooking , passive flexion and extension
Ankle : shaking , passive flexion and extension

10. Abnormal muscle tone
• Hypotonia
• Hypertonia : Spasticity , rigidity (cogwheel & lead pipe )
• Dystonia
• Myotonia
• Catatonia
• Stiffness ( meningeal irritation , stiff person syndrome )

11. Muscle power
• Power or strength is tested comparing the patient’s strength against your
own
• Compare one side to the other
• Grade strength using the medical research council scale

12. Upper limb
1. Shoulder ( adduction , abduction , flexion, extension, lateral rotators, medial rotators, serratus
anterior )
2. Elbow ( flexion and extension )
3. Wrist ( flexion and extension )
4. Hand ( thumb, interossesi, lumbricals )

13. Lower limb
1. Hip : flexion , extension, abduction, adduction
2. Knee : flexion , extension
3. Ankle : dorsiflexion , plantarflexion ,inversion , eversion
Don’t forget the trunk muscle ( abdominal and back muscle )

14. Gait abnormality

15. Coordination :
Upper limb
• With opened and closed eyes : finger to nose , finger to finger test , finger to doctor’s test
• Dysdiadokokinesia : inability to perform rapid alternating movement (pronation and supination )
• Rebound phenomenon : with sudden release of flexed elbow
• Buttoning or unbuttoning test : earliest sign
Lower limb :
• With opened and closed eye : heel to knee test.
• Standing : swaying truncal ataxia
• Walking along straight line
• Romberg sign

16. You must continue searching for all signs of
cerebellum
• Eye : nystagmus
• Speech staccato
• Neck : nodding
• Buttoning and non buttoning
• Rebound phenomenon
• Heel toes walking

17. Reflexes
Deep reflexes :
Upper limb ( Biceps reflex c5,6 , Brachioradialis reflex c5,6, Triceps reflex c6,7,
Supraspinatus reflex ,Finger reflex )
Lower limb ( knee reflex, ankle reflex, patellar reflex, adductor reflex )
Superficial reflexes
Planter reflexes ( babiniski method ,chaddok ,baradah openhinme , Gordon , Schaefer)
Abdominal reflexes, cremastric reflex , gluteal reflex , anal reflexes

18. Rate the reflex with following scale:
1. Sustained clonus 5+
2. Very brisk , hyperreflexia with clonus 4+
3. Brisker or more reflexive than normally 3+
4. Normal +2
5. Low normal or diminished 1+
6. A reflex that only elicited with reinforcement 0.5

19. Reflexes

20. Superficial reflexes

21. Abdominal reflex

22. Trömner reflex Mayer reflex
Reflexes: Pathological
Hoffman's sign (reflex): hold the patients partially extended middle finger by
your index finger and thumb, then flick it sharply by other hand followed by
sudden release~ flexion of the thumb (&adduction) and other fingers .
Tromner sign: hold the patients partially extended middle finger, letting the
hand dangle, then with the other hand flick the finger pad (similar response to
Hoffmann sign).
Wartenberg's thumb adduction sign : examiner links his flexed fingers with
patients' flexed fingers, then both flex their fingers further against each other's
resistance -> normally, thumb extends, while in pyramidal tract lesions ->
thumb adducts & flexes.

23. Frontal release signs (FRS):
• They are normally present in the developing nervous system, but disappear with maturation, and include palmomental
reflex (PMR), grasp, snout, sucking, head retraction and others.
• They occur with severe diffuse frontal lobes lesions e.g., dementias, diffuse encephalopathy, or head injury.
Guide to Neurological Examination
1. Grasp (forced grasping) reflex: gentle touching patients palm or trying to extend patients fingers - > patients' finger
flexion.
3.Palmomental reflex (PMR), or palm-chin reflex: scratching the palm of the ipsilateral hand especially thenar eminence ~
contraction of the mentalis and orbicularis oris ~ wrinkling of the chin with slight retraction of mouth.
It is exaggerated with frontal lobe lesions.
4. The orbicularis oris (snout): pressing firmly backward on the philtrum of the upper lip ~ puckering and protrusion of the
lips.
5. The sucking reflex).

24. Lower-Limb Pathologic Reflexes:
1. Babinski sign : the most important of pathological reflexes.
2. Flexion plantar responses:
- Plantar grasp reflex: similar to grasp reflex.
- Plantar muscle reflex: comparable to finger flexor reflex
- Rossolimo's sign: tapping the ball of foot or plantar surface of toes ~
plantar flexion.
3. Crossed extensor reflex: stimulation of the foot or leg on one side ~
flexion of that leg with extension of the other leg (with severe myelopathy).
4. Extensor thrust response: pressure applied to the foot of the passively flexed leg causes reflex extension.
5. The mass reflex (of Riddoch) : with severe myelopathy, stimulation below the spinal level -> massive
response, including leg flexion, abdominal wall contractions, evacuation of the bladder and bowel, sweating,
reflex erythema, pilomotor responses, and hypertension ± priapism and ejaculation.

25. The typical reflex pattern with UMNL is exaggerated DTRs, lost superficial
reflexes, and emergence of pathologic reflexes.

26. Reflexes: Pathological Postural Reflex
• Flexion withdrawal reflex:
• Decorticated:
• Decerebrated:

27. Thank you
Mohamedrizk.med@edu.edu.eg