Neurological Neurological ExaminationExamination

Motor SystemMotor System

Prof. Dr. Hülya Prof. Dr. Hülya ApaydınApaydın

Nöroloji AB DalıNöroloji AB Dalı

CCortically ortically OOriginated riginated MovementMovement

I. Motor Tract (corticospinal tractus)I. Motor Tract (corticospinal tractus) Extrapyramidal System (basal ganglia)Extrapyramidal System (basal ganglia) CerebellumCerebellum Praxis CircuitsPraxis Circuits II. Motor Tract : II. Motor Tract : Alpha motor neurons of spinal cordAlpha motor neurons of spinal cord Neurons of the brainstem cranial nerve nucleiNeurons of the brainstem cranial nerve nuclei Peripheral nervePeripheral nerve Neuromuscular junctionNeuromuscular junction MuscleMuscle

Motor Function

Nervous System Nervous System ExaminationExamination

Terminology Used to Describe Terminology Used to Describe Muscle WeaknessMuscle Weakness

Terminology DefinitionTerminology Definition-plegia-plegia (suffix) (suffix) Paralysis of a muscle or a limb( 0/5)Paralysis of a muscle or a limb( 0/5)

-paresis -paresis (suffix) Weakness less severe than complete (suffix) Weakness less severe than complete paralysiparalysiss

(1/5 to 4/5)(1/5 to 4/5)

Hemiparesis and hemiplegia Weakness of the arm and Hemiparesis and hemiplegia Weakness of the arm and leg on oneleg on one

side of the bodyside of the body

Quadriparesis and quadriplegia Weakness of both arm and Quadriparesis and quadriplegia Weakness of both arm and both legsboth legs

Paraparesis and paraplegia Weakness of both legsParaparesis and paraplegia Weakness of both legs

Grading Motor Strength Grading Motor Strength GradeGrade

0/0/55

No muscle movementNo muscle movement

1 /1 /55

Visible muscle movement, Visible muscle movement, but no movement at the but no movement at the jointjoint

2 /2 /55

Movement at the joint, but Movement at the joint, but not against gravitynot against gravity

3 /3 /55

Movement against gravity, Movement against gravity, but not against added but not against added resistanceresistance

4 /4 /55

Movement against Movement against resistance, but less than resistance, but less than normalnormal

5/5/55

Normal strengthNormal strength

Some Diagnostically Relevant Function of the Major Some Diagnostically Relevant Function of the Major Regions Regions

RegionRegion Some major function of the regionSome major function of the region

Brain (hemispheric cortex )

Thought, language, memory, visual perception of contralateral space, contralateral motor and sensory function

Brain (deep cerebral hemisphere )

Contralateral motor and sensory function

Brainstem Eye movements, motor and sensory function of face and body, alertness, sensation of nausea, coordination of extremities, balance

Cerebellum Coordination of extremities, balanceSpinal cord Motor and sensory function of the body and extremities,

bowl and bladder controlNerve root Motor and sensory function in territory of nerve rootPeripheral nerve (or cranial nerve)

Motor and sensory function in territory of nerve or cranial nerve

Neuromuscular junction

Motor function of extremities, eye movements, swallowing, breathing

Muscle Motor function

Characteristic Symtomps and Signs of Characteristic Symtomps and Signs of Neurological Disease at Different Major Neurological Disease at Different Major

LocationsLocations

General LocationGeneral Location

Brain (hemispheric Brain (hemispheric cortex)cortex)

Brain (deep Brain (deep hemisphere)hemisphere)

BrainstemBrainstem

CerebellumCerebellum

Characteristic Symptoms and Signs Suggestive Characteristic Symptoms and Signs Suggestive of Localization to This Regionof Localization to This Region

Cognitive dysfunction, speech and language dysfunction, Cognitive dysfunction, speech and language dysfunction, hemiparesis, hemisensory loss, visual field deficits, hemiparesis, hemisensory loss, visual field deficits, headache, upper motor neuron signsheadache, upper motor neuron signs

Hemiparesis, hemisensory loss, headache, upper motor Hemiparesis, hemisensory loss, headache, upper motor neuron signsneuron signs

Diplopia, dysarthria, nausea, vomitting, vertigoDiplopia, dysarthria, nausea, vomitting, vertigoAlterations in level of consciousnessAlterations in level of consciousnessAtaxia of gait or extremitiesAtaxia of gait or extremitiesUnilateral or bilateral weakness or sensory lossUnilateral or bilateral weakness or sensory lossCrossed hemiparesis (e.g.,weakness on one side of the Crossed hemiparesis (e.g.,weakness on one side of the

face and the opposite side of the body)face and the opposite side of the body)Crossed hemisensory loss (e.g.,numbness on one side of Crossed hemisensory loss (e.g.,numbness on one side of

the face and the opposite side of the body)the face and the opposite side of the body)Upper motor neuron signsUpper motor neuron signs

Ataxia of gait or extremitiesAtaxia of gait or extremitiesDysarthria, nausea, vomitting, vertigoDysarthria, nausea, vomitting, vertigo HeadacheHeadache

Characteristic Symtomps and Signs of Characteristic Symtomps and Signs of Neurological Disease at Different Major Neurological Disease at Different Major

Locations (continue)Locations (continue) General General

LocationLocation

Spinal cordSpinal cord

Nerve rootNerve root

Peripheral nervePeripheral nerve

Neuromuscular Neuromuscular junctionjunction

MuscleMuscle

Characteristic Symptoms and Signs Suggestive of Characteristic Symptoms and Signs Suggestive of Localization to This RegionLocalization to This Region

Bilateral weakness and sensory lossBilateral weakness and sensory loss

Bowl and bladder dysfunctionBowl and bladder dysfunction

Brown-Sequard syndromeBrown-Sequard syndrome

Upper motor neuron signsUpper motor neuron signs

Radiating pain corresponding to a nerve root distributionRadiating pain corresponding to a nerve root distribution

Numbness or weakness in a nerve root distributionNumbness or weakness in a nerve root distribution

Diminish reflex (lower motor neuron signs) in teritory of Diminish reflex (lower motor neuron signs) in teritory of nerve rootnerve root

Distal paresthesias, sensory loss, or weaknessDistal paresthesias, sensory loss, or weakness

Diminish distal reflexes (distal lower motor neuron signs)Diminish distal reflexes (distal lower motor neuron signs)

Waxing and waning weakness, dysarthria, dysphagia, ptosis, Waxing and waning weakness, dysarthria, dysphagia, ptosis, diplopiadiplopia

Weakness Weakness (usually(usually proximal) proximal)

Common Neurological Common Neurological SymptomsSymptoms

HeadacheHeadache Visual DisorderVisual Disorder Loss of ConsciousnessLoss of Consciousness Speech DisorderSpeech Disorder Motor DisorderMotor Disorder

Inco-ordinationInco-ordination WeaknessWeakness Involuntary movementInvoluntary movement

Sensory DisorderSensory Disorder Sphincter DisorderSphincter Disorder Lower Cranial Nerve DisorderLower Cranial Nerve Disorder Mental DisorderMental Disorder

Motor Observation

•Involuntary Movements

• Fasciculation• Myotonia• Cramp• Tremor

• Chorea • Athetosis • Ballismus • Myoclonus • Tetanus

Fasciculation

Myotonia Myotonia

•Muscle Symmetry

•Left to Right

•Proximal vs. Distal

•Atrophy

•Pay particular attention to the hands, shoulders, and thighs, hip.

•Gait

Muscle Tone

1. Ask the patient to relax. 2. Flex and extend the

patient's fingers, wrist, and elbow.

3. Flex and extend patient's ankle and knee.

4. There is normally a small, continuous resistance to passive movement.

5. Observe for decreased (flaccid) or increased (rigid/spastic) tone.

Muscle toneMuscle tone

Muscle Strength

Test strength by having the patient move against your resistance.

• Always compare one side to the other.

• Grade strength on a scale from 0 to 5 "out of five"

Grading Motor Strength GradeGrading Motor Strength Grade

0/5 No muscle movement

1/5Visible muscle movement, but no movement at the joint

2/5 Movement at the joint, but not against gravity

3/5 Movement against gravity, but not against added resistance

4/5 Movement against resistance, but less than normal

5/5 Normal strength

Flexion at the elbow C5, C6, biceps

Extension at the elbow C6, C7, C8, triceps

Extension at the wrist C6,C7, C8, radial n

Squeeze two of your fingers "grip"

C7, C8,T1

Finger abduction C8, T1, ulnar nerve

Opposition of the thumb C8,T1, median n

Flexion at the hip L2, L3, L4, iliopsoas

Adduction at the hips L2, L3, L4, adductors

Abduction at the hips L4, L5, S1, gluteus medius and minimus

Extension at the hips S1, gluteus maximus

Extension at the knee

L2, L3, L4, quadriceps

Flexion at the knee L4, L5, S1, S2, hamstrings

Dorsiflexion at the ankle

L4, L5

Plantar flexion S1

Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed.

Pronator Drift

Instruct the patient to keep the arms still while you tap them briskly downward

(drift into pronation)

ReflexesReflexesDeep Tendon Reflexes

The patient must be relaxed and positioned properly before starting. Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response. Reflexes can be reinforced by having the patient perform isometric contraction of other muscles

0 Absent

1+ or + Hypoactive

2+ or ++ "Normal"

3+ or +++ Hyperactive without clonus

4+ or ++++ Hyperactive with clonus

Tendon Reflex Grading Scale Reflexes should be graded on a 0 to 4 "plus" scale:

Biceps reflex (C5, C6) 1.The patient's arm should be partially flexed at the elbow with the palm down. 2.Place your thumb or finger firmly on the biceps tendon. 3.Strike your finger with the reflex hammer. 4.You should feel the response even if you can't see it.

Triceps reflex (C6, C7)

1.Support the upper arm and let the patient's forearm hang free.

2.Strike the triceps tendon above the elbow with the broad side of the hammer.

3.If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest.

Brachioradialis reflex (C5, C6) 1.Have the patient rest the forearm on the abdomen or lap. 2.Strike the radius about 1-2 inches above the wrist. 3.Watch for flexion and supination of the forearm

Knee reflex (L2,3,4)1.Have the patient sit or lie down with the knee flexed. 2.Strike the patellar tendon just below the patella. 3. Note contraction of the quadriceps and extension of the knee

Ankle rerflex (S1, S2)

1.Dorsiflex the foot at the ankle.

2.Strike the Achilles tendon.

3.Watch and feel for plantar flexion at the ankle.

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ClonusIf the reflexes seem hyperactive, test for ankle clonus: ++ 1.Support the knee in a partly flexed position. 2.With the patient relaxed, quickly dorsiflex the foot. 3.Observe for rhythmic oscillations.

Abdominal (T8, T9, T10, T11, T12)

1.Use a blunt object such as a key or tongue blade.

2.Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12).

3.Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.

Plantar Response (Babinski)Plantar Response (Babinski)

1.Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.

2.Note movement of the toes, normally flexion (withdrawal).

3.Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.

Gait

Ask the patient to: 1. Walk across the room, turn and come back 2. Walk heel-to-toe in a straight line 3. Walk on their toes in a straight line 4. Walk on their heels in a straight line 5. Hop in place on each foot 6. Do a shallow knee bend 7. Rise from a sitting position

Paraplegia

Neuropathic

GOWER’S SIGN

Cerebellar examCerebellar exam Finger to nose testing:Finger to nose testing:

With the patient seated, position your index finger With the patient seated, position your index finger at a point in space in front of the patient.at a point in space in front of the patient.

Instruct the patient to move their index finger Instruct the patient to move their index finger between your finger and their nose.between your finger and their nose.

Reposition your finger after each touch.Reposition your finger after each touch. Then test the other hand.Then test the other hand.

Interpretation: The patient should be able to do Interpretation: The patient should be able to do this at a reasonable rate of speed, trace a this at a reasonable rate of speed, trace a straight path, and hit the end points accurately. straight path, and hit the end points accurately. Missing the mark, known as dysmetria, may be Missing the mark, known as dysmetria, may be indicative of disease.indicative of disease.

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Cerebellar examCerebellar exam

Rapid Alternating Finger Movements:Rapid Alternating Finger Movements: Ask the patient to touch the tips of each Ask the patient to touch the tips of each

finger to the thumb of the same hand.finger to the thumb of the same hand. Test both hands.Test both hands.

Interpretation: The movement should Interpretation: The movement should be fluid and accurate. Inability to do be fluid and accurate. Inability to do this, known as dysdiadokinesia, may this, known as dysdiadokinesia, may be indicative of cerebellar disease.be indicative of cerebellar disease.

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Cerebellar examCerebellar exam Rapid Alternating Hand Movements:Rapid Alternating Hand Movements:

Direct the patient to touch first the Direct the patient to touch first the palm and then the dorsal side of one palm and then the dorsal side of one hand repeatedly against their thigh.hand repeatedly against their thigh.

Then test the other hand.Then test the other hand. Interpretation: The movement Interpretation: The movement

should be performed with speed and should be performed with speed and accuracy. Inability to do this, known accuracy. Inability to do this, known as dysdiadokinesia, may be as dysdiadokinesia, may be indicative of cerebellar disease. indicative of cerebellar disease.

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Cerebellar examCerebellar exam Heel to Shin Testing:Heel to Shin Testing:

Direct the patient to move the heel of one Direct the patient to move the heel of one foot up and down along the top of the other foot up and down along the top of the other shin.shin.

Then test the other foot.Then test the other foot. Intepretation: The movement should Intepretation: The movement should

trace a straight line along the top of the trace a straight line along the top of the shin and be done with reasonable speed. shin and be done with reasonable speed.

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Cerebellar examCerebellar exam Realize that other organ system problems can Realize that other organ system problems can

affect performance of any of these tests. If, for affect performance of any of these tests. If, for example, the patient is visually impaired, they example, the patient is visually impaired, they may not be able to see the target during finger may not be able to see the target during finger to nose pointing. Alternatively, weakness due to to nose pointing. Alternatively, weakness due to a primary muscle disorder might limit the a primary muscle disorder might limit the patient's ability to move a limb in the fashion patient's ability to move a limb in the fashion required for some of the above testing. Thus, required for some of the above testing. Thus, other medical and neurological conditions must other medical and neurological conditions must be taken into account when interpreting be taken into account when interpreting cerebellar test results.cerebellar test results.

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Cerebellar diseaseCerebellar disease