Motor Examination
Motor system:
The motor system is the part of the nervous system
concerned initiation, coordination & control of skeletal muscle
activity
The motor system consist of:
Cortical motor areas
Subcortical structures e.g. basal ganglia
cerebellum, brain stem nuclei
Descending motor tracts
Cranial and spinal motor nerves
Skeletal muscles
Types of skeletal muscle contraction
1. The muscle contracts voluntary via orders from motor cortex
through corticospinal tracts.
2- The muscle contracts involuntary via reflex like stretch reflex
• There are stimulatory and inhibitory pathways affecting
the stretch reflex
• The sum of these pathways is inhibitory
• i.e. HIGHER CENTRES HAVE INHIBITORY EFFECT
ON STRECH REFLEX
Why perform motor system examination
• To evaluate the function of all components of the motor
system.
• To detect the presence of any neurological abnormality.
• To localize the abnormality which later on confirmed by
the investigations.
Examination of motor system includes:
1 • Muscle state
2 • Muscle tone
3 • Muscle power
4 • Superficial reflexes
5 • Deep reflexes
6 • Gait
7
• Involuntary movement
Muscle state
Procedure:
• Examination is done by inspection
• The patient should be sufficiently undressed (good exposure)
• Observe the rounding of the deltoid, the prominence of biceps,
triceps, quadriceps and muscles of the hand
• Compare left to right , proximal to distal (bilateral)
• Take in consideration the age, sex and physical fitness.
Muscle state
Observation:
• Average
• Hypertrophy
Physiological or true (symmetrical, the muscle
increased in bulk with proportional strength)
Pathological (pseudohypertrophy) ,the muscle
increased in bulk with diminished strength e.g. muscle
dystrophies
• Atrophy
Upper motor neuron lesion
Lower motor neuron lesion
Diabetic neuropathy
Disuse atrophy
Atrophy due to LMNL > UMNL
Why?
1- Loss of both active and passive muscle contractions
2- Loss of trophic factors secreted by nerves
• If : the right limb the left
So
Either:
• Left side is atrophied or
• Right side is pathologically hypertrophied (Pseudohypertrophy)
e.g. In some muscle diseases e.g. (Myopathy)
• How to differentiate between them?
VIA POWER
Muscle tone
• It is continuous mild degree of contraction caused by
continuous stretch of the muscle.
• It is the resistance of the muscle to passive stretch.
• Not seen by eye because:
– Not all motor neurons in the muscle are contracting
– Alternating motor neurons
Muscle tone
Procedure
• Ask the patient to relax completely
• Flex and extend the tested joint and compare to the
other side.
• Feel the muscle resistance offered to passive
stretch
Muscle tone
Observation:
• Normotonia
• Hypertonia ( chronic upper motor neuron lesion )
Spasticity (clasp knife) increased resistance at the
beginning of movement only
Rigidity increase resistance through the movement
either
Interrupted (cogwheel)
Continous (lead-pipe)
• Hypotonia
Lower motor neuron lesion
Acute stage of upper motor neuron lesion
Chorea
Cerebellar ataxia
Muscle power
Procedure
• It is the resistance to active movement
• Fix the joint proximal to the tested joint
• Ask the patient to perform movement while the
examiner resists the patient movement
Muscle power
• Ask the patient to extend and raise both
arms in front of him his palms facing
upwards and to keep his arms in place
while he close his eyes and count to 10.
• Normally their arms will remain in place.
• If there is weakness there will be a
positive pronator drift, in which the affected
arm will pronate and fall.
Muscle power
Abductors of the fingers
Ask the patient to keep the
fingers abducted against your
resistance
Adductors of the fingers
Ask the patient to hold a piece of
paper between his fingers against
your resistance
Muscle power
Hand grip
Test the grip (c7,c8 and T1)
ask the patient to squeeze two of
your fingers as hard as possible
and not let them go.
You should have difficulty in
removing your fingers from the
patient's grip
Muscle power
Wrist extension
Ask the patient to dorsiflexed his
wrist against your resistance
Wrist Flexion
Ask the patient to flex his wrist
against your resistance
Muscle power
Elbow flexion (biceps
muscle)
Ask the patient to flex his elbow
against your resistance
Elbow extension (triceps
muscle)
Ask the patient to extend his
elbow against your resistance
Muscle power
Serratus anterior
Ask the patient to push the wall by
his hands keeping elbow extended
If serratus anterior is weak, scapular
medial border will become prominent
( winging of scapula)
Deltoid
Ask the patient to abducted from 30º
to 60º the arm against examiner
resistance
Muscle power
Examination of trapizus
muscle
Ask the patient to elevate his
shoulder against your resistance
Examination of sternomastoid
muscle
Ask the patient to look to one side
against your resistance
Muscle power
Abdominal muscles
Ask the patient to lie on his
back and try to raise his head
against your resistance
Muscle power
Ankle plantarflexion
Holding the bottom of the foot, ask the
patient to press down against your
resistance
Ankle dorsiflexion
Ask the patient to dorsiflex the ankle
against your resistance
Muscle power
Knee flexion
Hold the knee from the side and
applying resistance under the ankle and
ask the patient to flex his knee against
your resistance
Knee extension
Place one hand under the knee and the
other on top of the lower leg to provide
resistance and ask the patient to extend
the knee against your resistance
Muscle power
Hip flexion
ask the patient to lie down and raise
each leg separately against your
resistance
Hip extension
Ask the patient to press down on the
examiner's hand which is placed underneath
the patient's thigh against your resistance
Muscle power
Hip adduction
Place your hands on the inner
thighs of the patient and ask him to
bring both legs together
Hip abduction
Place your hands on the outer
thighs and asking the patient to
move their legs apart
Muscle power
Observation
• Impaired strength (paresis)
• Absence of strength (plegia = paralysis)
• Scoring muscle strength
0 = No movement
+1 = Flicker movement
+2 = Movement with gravity eliminated
+3 = Movement against gravity only
+4 = Full movement against some resistance
+5 = Full movement against full resistance
Superficial reflexes
• Induced by stimulation of surface receptors
in skin or mucous membrane.
• All superficial reflexes are lost in UMNL &
LMNL.
• Planter reflex is modified with UMNL and not
lost.
Planter reflex
• Center: S1 & S2
• Response: planter flexion
of all toes
Planter reflex
• Modified planter reflex (+ve Babinisk’s sign):
Occur with UMNL
Complete: fanning of the outer 4 toes &
dorsiflexion of big toe
Partial: either fanning of the outer 4 toes (area 6
lesion ) or dorsiflexion of big toe (area 4 lesion )
• False positive Babiniski's sign:
Deep sleep Anesthesia
Coma Infant below 1 year
• Lost in LMNL
Planter Normal response False positive Babinisk's
(planter flexion of all toes) sign ( Infant below 1 year)
Positive Babinisk’s sign:
Dorsiflexion of big toe &
fanning of the outer 4 toes
Deep reflexes
• Deep reflexes (tendon jerks):
It is reflex rapid contraction in the muscle in response
to sudden taping on its semi stretched tendon
It is the clinical application of dynamic stretch reflex
It is done by Sudden Single strike on a semistreched
exposed tendon
it is called JERK because it involves contraction of all
motor units
Reflex hummer
Deep reflexes
Biceps jerk:
• Center: C5,C6
• Response: rapid flexion of
the limb
Deep reflexes
Triceps jerk:
• Center: C6,C7
• Response: rapid extension of
the limb
Deep reflexes
KNEE JERK:
• Center: L2,L3,L4
• Response: contraction of the
quadriceps muscle and
extension of the knee
Deep reflexes
Ankle jerk:
• Center: S1,S2
•Response: contraction of
gastrocnemius & soleus muscle
producing planter flexion
Deep reflexes
Observation:
• Normal reflexes
• Hyperreflexia
Chronic upper motor neuron lesion
Anxiety and nervousness
Tetany
Hyperthyroidism
• Hyporeflexia
Hypothyroidism
Neocerebellum syndrome (pendular knee jerk)
Chorea
• Areflexia
Lower motor neuron lesion
Deep reflexes
Grading of deep reflexes
•0 No response
• +1 Hyporeflexia
• +2 Normal reflexes
• +3 Hyperreflexia
• +4 Hyperreflexia with clonus
Jandrassik’s manoeuver
• It is reinforcement manoeuver
done to increase the response of
the spinal reflexes by elevating
the excitatory level of the spinal
cord
• It distract the attention of the
patient leading to removal of any
cortical inhibitory impulses
Abnormal involuntary movement
• Tremors
Resting: e.g. pill rolling movement in parkinsonism
Intention: with voluntary movement in cerebellar lesion
Fine : senility, anxiety and thyrotoxicosis
• Chorea: irregular purposeless rapid jerks due to lesion in
corpus striatum specially the caudate nucleus
• Athetosis: very slow twisting (worm-like) movement due to
lesion in lentiform nucleus specially globus pallidus
• Hemiballismus: remarkable violent (ballistic) movements of
the limbs due to lesion of subthalamus
Gait
Gait
Walk across room Heel to toe walking Hop in place
Observation
• Normal: the balance is easy, arm swing freely at the side
& turns are accomplished smoothly
• Abnormal
Spastic: the leg moves in an arc of circle out and
forward (circumduction) with dragging of the toe in
unilateral UMNL
Steppage: the feet are lifted high then brought down
on the floor to avoid dragging of the toe in LMNL (foot
drop)
Shuffling: short shuffling steps with decreased arm
swinging, the patient taking flexion attitude in
Parkinson's disease
Drunken : staggering, unsteady, wide based gait with
tendency to fall to the affected side in cerebellar
lesion
Lower motor Upper motor
neuron lesion neuron lesion
Muscle tone Flaccid paralysis Spastic paralysis
Deep reflex Absent Increased
Babniski’s sign Absent Present
Atrophy Marked Less result from
diuse
Fasciculation and May be present absent
fibrillation
Do you have
any questions?
? ?
Thank you
