Neurological Examination Motor System Prof. Dr. Hülya Apaydın Nöroloji AB Dalı

Cortically Originated Movement I. Motor Tract (corticospinal tractus) Extrapyramidal System (basal ganglia) Cerebellum Praxis Circuits II. Motor Tract : Alpha motor neurons of spinal cord Neurons of the brainstem cranial nerve nuclei Peripheral nerve Neuromuscular junction Muscle

Motor Function

Nervous System Examination

Terminology Used to Describe Muscle Weakness Terminology Definition -plegia (suffix) Paralysis of a muscle or a limb( 0/5) -paresis (suffix) Weakness less severe than complete paralysis (1/5 to 4/5) Hemiparesis and hemiplegia Weakness of the arm and leg on one side of the body Quadriparesis and quadriplegia Weakness of both arm and both legs Paraparesis and paraplegia Weakness of both legs

Grading Motor Strength Grade 0/5 No muscle movement 1/5 Visible 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

Some Diagnostically Relevant Function of the Major Regions Some 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, balance Spinal cord Motor and sensory function of the body and extremities, bowl and bladder control Nerve root Motor and sensory function in territory of nerve root Peripheral 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 Neurological Disease at Different Major Locations Characteristic Symptoms and Signs Suggestive of Localization to This Region Cognitive dysfunction, speech and language dysfunction, hemiparesis, hemisensory loss, visual field deficits, headache, upper motor neuron signs Hemiparesis, hemisensory loss, headache, upper motor neuron signs Diplopia, dysarthria, nausea, vomitting, vertigo Alterations in level of consciousness Ataxia of gait or extremities Unilateral or bilateral weakness or sensory loss Crossed hemiparesis (e.g.,weakness on one side of the face and the opposite side of the body) Crossed hemisensory loss (e.g.,numbness on one side of the face and the opposite side of the body) Upper motor neuron signs Dysarthria, nausea, vomitting, vertigo Headache General Location Brain (hemispheric cortex) Brain (deep hemisphere) Brainstem Cerebellum

Characteristic Symtomps and Signs of Neurological Disease at Different Major Locations (continue) General Location Spinal cord Nerve root Peripheral nerve Neuromuscular junction Muscle Characteristic Symptoms and Signs Suggestive of Localization to This Region Bilateral weakness and sensory loss Bowl and bladder dysfunction Brown-Sequard syndrome Upper motor neuron signs Radiating pain corresponding to a nerve root distribution Numbness or weakness in a nerve root distribution Diminish reflex (lower motor neuron signs) in teritory of nerve root Distal paresthesias, sensory loss, or weakness Diminish distal reflexes (distal lower motor neuron signs) Waxing and waning weakness, dysarthria, dysphagia, ptosis, diplopia Weakness (usually proximal)

Common Neurological Symptoms Headache Visual Disorder Loss of Consciousness Speech Disorder Motor Disorder Inco-ordination Weakness Involuntary movement Sensory Disorder Sphincter Disorder Lower Cranial Nerve Disorder Mental Disorder

Motor Observation Involuntary Movements Chorea Fasciculation Athetosis Ballismus Myoclonus Tetanus Fasciculation Myotonia Cramp Tremor

Fasciculation

Rippling muscle disease

Myotonia

Muscle Symmetry Left to Right Proximal vs. Distal Atrophy Pay particular attention to the hands, shoulders, and thighs, hip. Gait

Muscle Tone Ask the patient to relax. Flex and extend the patient's fingers, wrist, and elbow. Flex and extend patient's ankle and knee. There is normally a small, continuous resistance to passive movement. Observe for decreased (flaccid) or increased (rigid/spastic) tone.

Muscle 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 Grade 0/5 No muscle movement 1/5 Visible 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

Squeeze two of your fingers "grip" Finger abduction 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

Pronator Drift Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed. (drift into pronation) Instruct the patient to keep the arms still while you tap them briskly downward

Reflexes Deep 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

Tendon Reflex Grading Scale Absent 1+ or + Hypoactive 2+ or ++ Reflexes should be graded on a 0 to 4 "plus" scale: Absent 1+ or + Hypoactive 2+ or ++ "Normal" 3+ or +++ Hyperactive without clonus 4+ or ++++ Hyperactive with clonus

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) Have the patient sit or lie down with the knee flexed. 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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Clonus If 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) 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 exam Finger to nose testing: With the patient seated, position your index finger at a point in space in front of the patient. Instruct the patient to move their index finger between your finger and their nose. Reposition your finger after each touch. Then test the other hand. Interpretation: The patient should be able to do this at a reasonable rate of speed, trace a straight path, and hit the end points accurately. Missing the mark, known as dysmetria, may be indicative of disease.

Cerebellar exam Rapid Alternating Finger Movements: Ask the patient to touch the tips of each finger to the thumb of the same hand. Test both hands. Interpretation: The movement should be fluid and accurate. Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease.

Cerebellar exam Rapid Alternating Hand Movements: Direct the patient to touch first the palm and then the dorsal side of one hand repeatedly against their thigh. Then test the other hand. Interpretation: The movement should be performed with speed and accuracy. Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease.

Cerebellar exam Heel to Shin Testing: Direct the patient to move the heel of one foot up and down along the top of the other shin. Then test the other foot. Intepretation: The movement should trace a straight line along the top of the shin and be done with reasonable speed.

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

Cerebellar disease